EXAM 3 (Ch. 14, )

expressed emotion

the general level of criticism, disapproval, hostility, and intrusiveness expressed in a family. people recovering from schizophrenia are considered more likely to relapse if their families rate high in expressed emotion.

dopamine hypothesis

the theory that schizophrenia results from excessive activity of the neurotransmitter dopamine

multicultural factors: research neglect

-ACCORDING TO THE CURRENT CRITERIA of DSM-5, a pattern diagnosed as a personality disorder must "deviate markedly from the expectations of the individual's culture" (APA, 2013). Given the importance of culture in this diagnosis, and given the enormous clinical interest in personality disorders, it is striking how little multicultural research has been conducted on these problems. Clinical theorists have suspicions but little compelling evidence that there are cultural differences in this realm -The lack of multicultural research is of special concern with regard to borderline personality disorder, the pattern characterized by extreme mood fluctuations, outbursts of intense anger, self-injurious behavior, fear of abandonment, feelings of emptiness, problematic relationships, and identity confusion, because many theorists are convinced that gender and other cultural differences may be particularly important in both the development and diagnosis of this disorder -As you read earlier, around 75 percent of all people who receive a diagnosis of borderline personality disorder are female (Skodol, 2017, 2016). Although it may be that women are biologically more prone to the disorder or that diagnostic bias is at work, this gender difference may instead be a reflection of the extraordinary traumas to which many women are subjected as children (Daigre et al., 2015). Recall, for example, that the childhoods of some people with borderline personality disorder are filled with emotional trauma, victimization, violence, and abuse, at times sexual abuse. It may be, a number of theorists argue, that experiences of this kind are prerequisites to the development of borderline personality disorder, that women in our society are particularly subjected to such experiences, and that, in fact, the disorder should more properly be viewed and treated as a special form of posttraumatic stress disorder (Kulkarni, 2017; Sherry & Whilde, 2008; Hodges, 2003). In the absence of systematic research, however, alternative explanations like this remain untested and corresponding treatments undeveloped. In a related vein, given the childhood experiences that typically precede borderline personality disorder, some multicultural theorists believe that the disorder may actually be a reaction to persistent feelings of marginality, powerlessness, and social failure (Sherry & Whilde, 2008; Miller, 1999, 1994). That is, the disorder may be attributable more to social inequalities (including sexism, racism, or homophobia) than to psychological factors. Given such possibilities, it is most welcome that a few multicultural studies of borderline personality disorder have been conducted over the past decade (Skodol, 2017; De Genna & Feske, 2013). In these undertakings, researchers assessed the prevalence of the personality disorder in diverse clinical populations (Meaney et al., 2016; Trull et al., 2010; Chavira et al., 2003). They found that Hispanic American individuals qualified for a diagnosis of borderline personality disorder more often than non-Hispanic white American or African American individuals did. Could it be that Hispanic Americans generally are more likely than other cultural groups to display this disorder, and—if so—why? Questions of this kind underline once again the need for more multicultural research into personality disorders

financial and emotional costs of schizophrenia

-25% attempt suicide; 5% die -increased risk of physical illness -more frequently found in lower-SES groups -poor people in the U.S. are more likely than wealthy people to experience schizophrenia

famous insanity defense cases

-Although the plea of not guilty by reason of insanity is used infrequently, some of the most famous cases in history have featured this defense strategy. You have already read about the cases of John Hinckley (see page 581) and Andrea Yates (see page 431). Here are some other famous insanity defense cases: 1977 In Michigan, Francine Hughes poured gasoline around the bed where her husband, Mickey, lay in a drunken stupor. Then she lit a match and set him on fire. At her trial she explained that he had beaten her repeatedly for 14 years and had threatened to kill her if she tried to leave him. The jury found her not guilty by reason of temporary insanity, making her into a symbol for many abused women across the nation. 1978 David "Son of Sam" Berkowitz, a serial killer in New York City, explained that a barking dog had sent him demonic messages to kill. Although two psychiatrists assessed him as psychotic, he was found guilty of his crimes. Long after his trial, he said that he had actually made up the delusions. 1979 Kenneth Bianchi, one of the pair known as the Hillside Strangler, entered a plea of not guilty by reason of insanity but was found guilty along with his cousin of sexually assaulting and murdering women in the Los Angeles area in late 1977 and early 1978. He claimed that he had multiple personalities. 1980 In December, Mark David Chapman murdered John Lennon. Chapman later explained that he had killed the rock music legend because he believed Lennon to be a "sell-out." Pleading not guilty by reason of insanity, he also described hearing the voice of God and compared himself with Moses. Chapman was convicted of murder. 1992 Jeffrey Dahmer, a 31-year-old mass murderer in Milwaukee, was tried for the killings of 15 young men. Dahmer drugged some of his victims, performed crude lobotomies on them, and dismembered their bodies and stored their parts to be eaten. Despite a plea of not guilty by reason of insanity, the jury found him guilty as charged. He was beaten to death by another inmate in 1995. 1994 On June 23, 1993, twenty-four-year-old Lorena Bobbitt cut off her husband's penis with a 12-inch kitchen knife while he slept. During her trial, defense attorneys argued that after years of abuse by John Bobbitt, his wife suffered a brief psychotic episode and was seized by an "irresistible impulse" to cut off his penis after he raped her. In 1994, the jury found her not guilty by reason of temporary insanity. She was committed to a state mental hospital and released a few months later. 2011 In 2002, Brian David Mitchell abducted a 14-year-old teenager named Elizabeth Smart from her home and held her until she was rescued nine months later. After years of trial delays, Mitchell was tried for kidnapping in 2010. He pleaded not guilty by reason of insanity, saying that he was acting out delusions ("revelations from God") when he committed this crime. The jury found him guilty of kidnapping in 2011 and sentenced him to life in prison without parole. 2015 In 2012, James Holmes, a 25-year-old neuroscience doctoral student, entered a cinema in Aurora, Colorado, and opened fire on the moviegoers, killing 12 and wounding 20. In the months after his arrest, Holmes, who had no prior criminal record, tried to kill himself three times. Although Holmes pleaded not guilty by reason of insanity, a jury found him guilty of murder in 2015 and sentenced him to life in prison without parole. 2017 In 2014 two 12-year-old girls stabbed a classmate multiple times, saying they were trying to appease and impress Slender Man, a mythical "boogie man" whom a number of Internet users report seeing and fearing in their everyday lives. In separate 2017 trials, each of the assailants pleaded guilty to attempted intentional homicide, but in each case they were further deemed to have been mentally ill at the time of the attack and were assigned to extended treatment in a mental hospital rather than imprisonment.

criminals commitment and insanity during commission of a crime

-Consider once again the case of John Hinckley. Was he insane at the time he shot the president? If insane, should he be held responsible for his actions? On June 21, 1982, fifteen months after he shot four men in the nation's capital, a jury pronounced Hinckley not guilty by reason of insanity. Hinckley thus joined Richard Lawrence, a house painter who shot at Andrew Jackson in 1835, and John Schrank, a saloonkeeper who shot former president Teddy Roosevelt in 1912, as a would-be assassin who was found not guilty by reason of insanity. -Although most Americans were shocked by the Hinckley verdict, those familiar with the insanity defense were not so surprised. In this case, as in other federal court cases at that time, the prosecution had the burden of proving beyond a reasonable doubt that the defendant was sane. Many state courts placed a similar responsibility on the prosecution. To present a clear-cut demonstration of sanity can be difficult, especially when the defendant has exhibited bizarre behavior in other areas of life. A few years after the Hinckley verdict, Congress passed a law making it the defense's burden in federal cases to prove that defendants are insane, rather than the prosecution's burden to prove them sane. Around 75 percent of state legislatures have since followed suit (Gandhi & Prabbu, 2017). It is important to recognize that "insanity" is a legal term (Hallevy, 2017). That is, the definition of "insanity" used in criminal cases was written by legislators, not by clinicians. Defendants may have mental disorders but not necessarily qualify for a legal definition of insanity. Modern Western definitions of insanity can be traced to the murder case of Daniel M'Naghten in England in 1843. M'Naghten shot and killed Edward Drummond, the secretary to British prime minister Robert Peel, while trying to shoot Peel. Because of M'Naghten's apparent delusions of persecution, the jury found him to be not guilty by reason of insanity. The public was outraged by this decision, and their angry outcry forced the British law lords to define the insanity defense more clearly. This legal definition, known as the M'Naghten test, or M'Naghten rule, stated that having a mental disorder at the time of a crime does not by itself mean that the person was insane; the defendant also had to be unable to know right from wrong. The state and federal courts in the United States adopted this test as well. -In the late nineteenth century some state and federal courts in the United States, dissatisfied with the M'Naghten rule, adopted a different test—the irresistible impulse test. This test, which had first been used in Ohio in 1834, emphasized the inability to control one's actions. A person who committed a crime during an uncontrollable "fit of passion" was considered insane and not guilty under this test. For years state and federal courts chose between the M'Naghten test and the irresistible impulse test to determine the sanity of criminal defendants. For a while a third test, called the Durham test, also became popular, but it was soon replaced in most courts. This test, based on a decision handed down by the Supreme Court in 1954 in the case of Durham v. United States, stated simply that people are not criminally responsible if their "unlawful act was the product of mental disease or mental defect." This test was meant to offer more flexibility in court decisions, but it proved too flexible. Insanity defenses could point to such problems as alcoholism or other forms of substance abuse and conceivably even headaches or ulcers, which were listed as psychophysiological disorders in DSM-I -In 1955 the American Law Institute (ALI) formulated a test that combined aspects of the M'Naghten, irresistible impulse, and Durham tests. The American Law Institute test held that people are not criminally responsible if at the time of a crime they had a mental disorder or defect that prevented them from knowing right from wrong or from being able to control themselves and to follow the law. For a time the new test became the most widely accepted legal test of insanity. After the Hinckley verdict, however, there was a public uproar over the "liberal" ALI guidelines, and people called for tougher standards. Partly in response to this uproar, the American Psychiatric Association recommended in 1983 that people should be found not guilty by reason of insanity onlyif they did not know right from wrong at the time of the crime; an inability to control themselves and to follow the law should no longer be sufficient grounds for a judgment of insanity. In short, the association was calling for a return to the M'Naghten test. This test now is used in all cases tried in federal courts and in about half of the state courts. The more liberal ALI standard is still used in the remaining state courts, except in Idaho, Kansas, Montana, and Utah, which have more or less done away with the insanity plea altogether. People suffering from severe mental disorders in which confusion is a major feature may not be able to tell right from wrong or to control their behavior. It is therefore not surprising that more than 80 percent of defendants who are acquitted of a crime by reason of insanity qualify for a diagnosis of schizophrenia or another form of psychosis (Melton et al., 2017, 2007; Steadman et al., 1993). The majority of these acquitted defendants have a history of past hospitalization, arrest, or both. About half who successfully plead insanity are white, and 86 percent are male. Their mean age is 32 years. The crimes for which defendants are found not guilty by reason of insanity vary greatly, although approximately 70 percent are violent crimes of some sort. At least 15 percent of those acquitted are accused specifically of murder -WHAT CONCERNS ARE RAISED BY THE INSANITY DEFENSE? Despite the changes in the insanity criteria, criticism of the insanity defense continues (Perlin, 2017; Greene & Heilbrun, 2013; Pouncey & Lukens, 2010). One concern is the fundamental difference between the law and the science of human behavior. The law assumes that individuals have free will and are generally responsible for their actions. Several models of human behavior, in contrast, assume that physical or psychological forces act to determine the individual's behavior. Inevitably, then, legal definitions of insanity and responsibility will differ from those suggested by clinical research. A second criticism points to the uncertainty of scientific knowledge about abnormal behavior. During a typical insanity defense trial, the testimony of defense clinicians conflicts with that of clinicians hired by the prosecution, and so the jury must weigh the claims of "experts" who disagree in their assessments. Some people see this lack of professional agreement as evidence that clinical knowledge in some areas may be too incomplete to be allowed to influence important legal decisions. Others counter that the field has made great strides—for example, developing several psychological scales to help clinicians discriminate more consistently between the sane and insane as defined by the M'Naghten standard (Melton et al., 2017, 2007; Xue et al., 2015; Rogers, 2008). Even with helpful scales in hand, however, clinicians making judgments of legal insanity face a problem that is difficult to overcome: They must evaluate a defendant's state of mind during an event that took place weeks, months, or years earlier. Because mental states can and do change over time and across situations, clinicians can never be entirely certain that their assessments of mental instability at the time of the crime are accurate. Perhaps the most common criticism of the insanity defense is that it allows criminals to escape punishment. Granted, some people who successfully plead insanity are released from treatment facilities just months after their acquittal. Yet the number of such cases is quite small (Melton et al., 2017, 2007; Steadman et al., 1993; Callahan et al., 1991). According to surveys, the public dramatically overestimates the percentage of defendants who plead insanity, guessing it to be 30 to 40 percent, when in fact it is less than 1 percent. Moreover, only a minority of these defendants fake or exaggerate their psychological symptoms, and only 26 percent of those who plead insanity are actually found not guilty on this basis. In all, less than 1 of every 400 defendants in the United States is found not guilty by reason of insanity (see PsychWatch). It is also worth noting that in 80 percent of those cases in which defendants are acquitted by reason of insanity, the prosecution has agreed to the appropriateness of the plea. -During most of U.S. history, a successful insanity plea amounted to the equivalent of a long-term prison sentence. In fact, on average, treatment in a mental hospital resulted in confinement that was twice as long as imprisonment for the same crime would have brought (Perlin, 2017). Because hospitalization resulted in little if any improvement, clinicians were reluctant to predict that the offenders would not repeat their crimes -Today, however, offenders are being released from mental hospitals earlier and earlier. This trend is the result of the increasing effectiveness of drug therapy and other treatments in institutions, the growing reaction against extended institutionalization, and more emphasis on patients' rights (Gowensmith et al., 2017; Slovenko, 2011, 2009, 2004). In 1992, in the case of Foucha v. Louisiana, the U.S. Supreme Court clarified that the only acceptable basis for determining the release of hospitalized offenders is whether or not they are still "insane"; they cannot be kept indefinitely in mental hospitals solely because they are dangerous. Some states are able to maintain control over offenders even after their release from hospitals. Adopting a procedure called "outpatient commitment," the states may insist on community treatment, monitor the patients closely, and rehospitalize them if necessary (Gowensmith et al., 2017; Norko et al., 2016). WHAT OTHER VERDICTS ARE AVAILABLE? Over the past four decades, at least 20 states have added another verdict option—guilty but mentally ill. Defendants who receive this verdict are found to have had a mental illness at the time of their crime, but the illness was not fully related to or responsible for the crime. The option of guilty but mentally ill enables jurors to convict a person they view as dangerous while also suggesting that the individual receive needed treatment. Defendants found to be guilty but mentally ill are given a prison term with the added recommendation that they also undergo treatment if necessary. After initial enthusiasm for this verdict option, legal and clinical theorists have increasingly found it unsatisfactory. According to research, it has not reduced the number of not guilty by reason of insanity verdicts, and it often confuses jurors (Bartol & Bartol, 2015; Frierson et al., 2015). In addition, as critics point out, appropriate mental health care is supposed to be available to all prisoners anyway, regardless of the verdict (Binswanger & Elmore, 2016). That is, the verdict of guilty but mentally ill may differ from a guilty verdict in name only. Some states allow still another kind of defense, guilty with diminished capacity, in which a defendant's mental dysfunction is viewed as an extenuating circumstance that the court should take into consideration in determining the precise crime of which he or she is guilty (ABA, 2017; Slovenko, 2011). The defense lawyer argues that because of mental dysfunction, the defendant could not have intended to commit a particular crime. The person can then be found guilty of a lesser crime—of manslaughter (unlawful killing without intent), say, instead of murder in the first degree (planned murder). The famous case of Dan White, who shot and killed Mayor George Moscone and City Supervisor Harvey Milk of San Francisco in 1978, illustrates the use of this verdict -Because of possible miscarriages of justice, many legal experts have argued against the "diminished capacity" defense. A number of states have even eliminated it, including California shortly after the Dan White verdict -WHAT ARE SEX-OFFENDER STATUTES? Since 1937, when Michigan passed the first "sexual psychopath" law, a number of states have placed sex offenders in a special legal category (Sanders, 2016; Perillo et al., 2014). These states believe that some of those who are repeatedly found guilty of sex crimes have a mental disorder, so the states categorize them as mentally disordered sex offenders. People classified in this way are convicted of a criminal offense and are thus judged to be responsible for their actions. Nevertheless, mentally disordered sex offenders are sent to a mental health facility instead of a prison. In part, such laws reflect a belief held by many legislators that such sex offenders are psychologically disturbed. On a practical level, the laws help protect sex offenders from the physical abuse that they often receive in prison society. Over the past two decades, however, most states have been changing or abolishing their mentally disordered sex offender laws, and at this point only a handful still have them. There are several reasons for this trend. First, the state laws often declare that in order to be classified as a mentally disordered sex offender, the person must be a good candidate for treatment, another judgment that is difficult for clinicians to make, especially for this population (Marshall & Marshall, 2016; Marshall et al., 2011). Second, there is evidence that racial bias often affects the use of the mentally disordered sex offender classification. From a defendant's perspective, this classification is considered an attractive alternative to imprisonment—an alternative available to non-Hispanic white Americans much more often than to members of racial and ethnic minority groups. Non-Hispanic white Americans are twice as likely as African Americans or Hispanic Americans who have been convicted of similar crimes to be granted mentally disordered sex offender status. But perhaps the primary reason that mentally disordered sex offender laws have lost favor is that state legislatures and courts are now less concerned than they used to be about the rights and needs of sex offenders, given the growing number of sex crimes taking place across the country (Feldman, 2017; Sanders, 2016), particularly ones in which children are victims. In fact, in response to public outrage over the high number of sex crimes, 21 states and the federal government have instead passed sexually violent predator laws (or sexually dangerous persons laws) (MHA, 2017). These relatively new laws call for certain sex offenders who have been convicted of sex crimes and have served their sentence in prison to be removed from prison before their release and committed involuntarily to a mental hospital for treatment if a court judges them likely to engage in further "predatory acts of sexual violence" as a result of "mental abnormality" or "personality disorder" (MHA, 2017; Perillo et al., 2014). That is, in contrast to the mentally disordered sex offender laws, which call for sex offenders to receive treatment instead of imprisonment, the sexually violent predator laws require certain sex offenders to receive imprisonment and then, in addition, be committed for a period of involuntary treatment. The constitutionality of the sexually violent predator laws was upheld by the Supreme Court in the 1997 case of Kansas v. Hendricks by a 5-to-4 margin.

personality rediscovered, the reconsidered

-DURING THE FIRST HALF OF the twentieth century, clinicians believed deeply in the unique, enduring patterns we call personality, and they tried to define important personality traits. They then discovered how readily people can be shaped by the situations in which they find themselves, and a backlash developed. The concept of personality seemed to lose legitimacy, and for a while it became almost an obscene word in some circles. The clinical category of personality disorders went through a similar rejection. When psychodynamic and humanistic theorists dominated the clinical field, neurotic character disorders—a set of diagnoses similar to today's personality disorders—were considered useful clinical categories, but their popularity declined as other models grew in influence. During the past 25 years, serious interest in personality and personality disorders has rebounded. In case after case, clinicians have concluded that rigid personality traits do seem to pose special problems, and they have developed new objective tests and interview guides to assess these disorders, setting in motion a wave of systematic research (Clarkin et al., 2018). So far, only the antisocial and borderline personality disorders have received much study. However, with DSM-5 now considering a new—dimensional—classification approach for possible use in the future, additional research is likely to follow. This may allow clinicians to better answer some pressing questions: How common are the various personality disorders? How useful are personality disorder categories? How effective is a dimensional approach to diagnosing these disorders? And which treatments are most effective? In short, DSM-5's proposal of a dimensional classification approach eventually may lead to major changes in the field's understanding, diagnosis, and treatment of personality disorders. Now that clinicians have rediscovered personality disorders, they must determine the most appropriate ways to think about, explain, and treat them.

civil commitment

-Every year in the United States, large numbers of people with mental disorders are involuntarily committed to treatment. Typically they are committed to mental institutions, but 46 states also have some form of outpatient civil commitment laws that allow patients to be forced into community treatment programs (TAC, 2017; Miller & Hanson, 2016; Zilber, 2016). Canada and Great Britain have similar laws. Civil commitments have long caused controversy and debate. In some ways the law provides more protection for people suspected of being criminals than for people suspected of being psychotic (Strachan, 2008; Burton, 1990). WHY COMMIT? Generally our legal system permits involuntary commitment of individuals when they are considered to be in need of treatment and dangerous to themselves or others. People may be dangerous to themselves if they are suicidal or if they act recklessly (for example, drinking a drain cleaner to prove that they are immune to its chemicals). They may be dangerous to others if they seek to harm them or if they unintentionally place others at risk. The state's authority to commit disturbed people rests on its duties to protect the interests of the individual and of society: the principles of parens patriae and police power. Under parens patriae ("parent of the country"), the state can take action to protect patients from self-harm, including through involuntarily hospitalizing them. Conversely, police power allows the state to take steps to protect society from a person who is dangerous. WHAT ARE THE PROCEDURES FOR CIVIL COMMITMENT? Civil commitment laws vary from state to state. Some basic procedures, however, are common to most of these laws. Often family members begin commitment proceedings. In response to a son's psychotic behavior and repeated assaults on other people, for example, his parents may try to persuade him to seek admission to a mental institution. If the son refuses, the parents may go to court and seek an involuntary commitment order. If the son is a minor, the process is straightforward. The Supreme Court, in the case of Parham v. J. R. (1979), has ruled that a hearing is not necessary in such cases, as long as a qualified mental health professional considers commitment necessary. If the son is an adult, however, the process is more involved. The court usually will order a mental examination and allow the person to contest the commitment in court, often represented by a lawyer. -The Supreme Court has ruled that before an individual can be committed, there must be "clear and convincing" proof that he or she is mentally ill and has met the state's criteria for involuntary commitment. The ruling does not suggest what criteria should be used (Hille, 2017). That matter is still left to each state. But, whatever the state's criteria, clinicians must offer clear and convincing proof that the person meets those criteria. When is proof clear and convincing, according to the court? When it provides 75 percent certainty that the criteria of commitment have been met. This is far less than the near-total certainty ("beyond a reasonable doubt") required to convict people of committing a crime. EMERGENCY COMMITMENT Many situations require immediate action; no one can wait for commitment proceedings when a life is at stake. Consider, for example, an emergency patient who is suicidal or hearing voices demanding hostile actions against others. He or she may need immediate treatment and round-the-clock supervision. If treatment could not be given in such situations without the patient's full consent, the consequences could be tragic. Therefore, many states give clinicians the right to certify that certain patients need temporary commitment and medication. In past years, these states required certification by two physicians (not necessarily psychiatrists in some of the states). Today states may allow certification by other mental health professionals as well. The clinicians must declare that the state of mind of the patients makes them dangerous to themselves or others. By tradition, the certifications are often referred to as two-physician certificates, or 2 PCs. The length of such emergency commitments varies from state to state, but three days is often the limit (Hedman et al., 2016). Should clinicians come to believe that a longer stay is necessary, formal commitment proceedings may be initiated during the period of emergency commitment. WHO IS DANGEROUS? In the past, people with mental disorders were actually less likely than others to commit violent or dangerous acts. This low rate of violence was apparently related to the fact that so many such people lived in institutions. As a result of deinstitutionalization, however, hundreds of thousands of people with severe disturbances now live in the community, and many of them receive little, if any, treatment. Some are indeed dangerous to themselves or others. -It is important to be clear that, according to research, the vast majority of people with mental disorders (90 percent) are in no way violent or dangerous, and only a small percentage of all violent acts (3 percent) are committed by people with mental disorders (HHS, 2017; Frances, 2016; Beckett, 2014). That said, recent studies do suggest that people with severe mental disorders are somewhat more likely than the general population to perform violent behaviors (Miller & Hanson, 2016; Beckett, 2014). The disorders with the strongest relationships to violence are severe substance use disorder, impulse control disorder, antisocial personality disorder, and psychotic disorders (Bonnet et al., 2017; Moore & Pfaff, 2017; Alniak et al., 2016). Of these, substance use disorder appears to be the single most influential factor. For example, schizophrenia compounded by substance use disorder has a stronger relationship to violence than schizophrenia alone does. -A determination of dangerousness is often required for involuntary civil commitment. But can mental health professionals accurately predict who will commit violent acts? Research suggests that psychiatrists and psychologists are wrong more often than right when they make long-term predictions of violence (Galán et al., 2018; Miller & Hanson, 2016; Mills et al., 2011). Most often they overestimate the likelihood that a patient will eventually be violent. Their short-term predictions—that is, predictions of imminent violence—tend to be more accurate (Fazel et al., 2017; O'Shea & Dickens, 2016). Researchers are now working, with some success, to develop new assessment techniques that use statistical approaches and are more objective in their predictions of dangerousness than are the subjective judgments of clinicians -WHAT ARE THE PROBLEMS WITH CIVIL COMMITMENT? Civil commitment has been criticized on several grounds (Miller & Hanson, 2016; Winick, 2008). First is the difficulty of assessing a person's dangerousness. If judgments of dangerousness are often inaccurate, how can one justify using them to deprive people of liberty? Second, the legal definitions of "mental illness" and "dangerousness" are vague. The terms may be defined so broadly that they could be applied to almost anyone an evaluator views as undesirable. Indeed, many civil libertarians worry about involuntary commitment being used to control people, as is often done in countries ruled by authoritarian governments, where mental hospitals house people with unpopular political views. A third problem is the sometimes questionable therapeutic value of civil commitment. Research suggests that many people committed involuntarily do not respond well to therapy. -On the basis of these and other arguments, some clinicians suggest that involuntary commitment should be abolished (Miller & Hanson, 2016; McSherry & Weller, 2010). Others, however, advocate finding a more systematic way to evaluate dangerousness when decisions are to be made about commitment (Miller & Hanson, 2016; Heilbrun & Erickson, 2007). Some suggest instituting a process of risk assessment that would arrive at statements such as, "The patient is believed to have X likelihood of being violent to the following people or under the following conditions over Y period of time." Proponents argue that this would be a more useful and appropriate way of deciding where and how people with psychological disorders should be treated. TRENDS IN CIVIL COMMITMENT The flexibility of the involuntary commitment laws probably reached a peak in 1962. That year, in the case of Robinson v. California, the Supreme Court ruled that imprisoning people who suffered from substance use disorders might violate the Constitution's ban on cruel and unusual punishment, and it recommended involuntary civil commitment to a mental hospital as a more reasonable action. This ruling encouraged the civil commitment of many kinds of "social deviants," and many such individuals found it difficult to obtain release from the hospitals to which they were committed. During the late 1960s and early 1970s, reporters, novelists, civil libertarians, and others spoke out against the ease with which so many people were being unjustifiably committed to mental hospitals. As the public became more aware of these issues, state legislatures started to pass stricter standards about involuntary hospital commitment, and, as mentioned earlier, many launched outpatient commitment programs in which courts may order people with severe mental disorders into community treatment (Miller & Hanson, 2016). In turn, rates of involuntary hospital commitment declined, and release rates rose. Fewer people are institutionalized through civil commitment procedures today than in the past.

treatments for dependent personality disorder

-In therapy, people with dependent personality disorder usually place all responsibility for their treatment and well-being on the clinician. Thus a key task of therapy is to help patients accept responsibility for themselves (Bressert, 2017; Colli et al., 2014). Because the domineering behaviors of a spouse or parent may help foster a patient's symptoms, some clinicians suggest couple or family therapy as well, or even separate therapy for the partner or parent (Lebow & Uliaszek, 2010; Nichols, 2004). Treatment for dependent personality disorder can be at least modestly helpful. Psychodynamic therapy for this pattern focuses on many of the same issues as therapy for depressed people, including the transference of dependency needs onto the therapist (Svartberg & McCullough, 2010). Cognitive-behavioral therapists combine behavioral and cognitive interventions to help the clients take control of their lives. On the behavioral end, the therapists often provide assertiveness training to help the individuals better express their own wishes in relationships (Bressert, 2017; Farmer & Nelson-Gray, 2005). On the cognitive end, the therapists also try to help the clients challenge and change their assumptions of incompetence and helplessness (Bressert, 2017; Borge et al., 2010; Beck et al., 2004). Antidepressant drug therapy has been helpful for people whose personality disorder is accompanied by depression (Skodol, 2016; Fava et al., 2002). As with avoidant personality disorder, a group therapy format can be helpful because it provides opportunities for the client to receive support from a number of peers rather than from a single dominant person (Bressert, 2017; Perry, 2005). In addition, group members may serve as models for one another as they practice better ways to express feelings and solve problems

law in psychology: how do the legislative and judicial systems influence mental health care

-Just as clinical science and practice have influenced the legal system, so the legal system has had a major impact on clinical practice. First, courts and legislatures have developed the process of civil commitment, which allows certain people to be forced into mental health treatment. Although many people who show signs of mental disturbance seek treatment voluntarily, a large number are not aware of their problems or are simply not interested in undergoing therapy. For such people, civil commitment procedures may be put into action. -Second, the legal system, on behalf of the state, has taken on the responsibility of protecting patients' rights during treatment. This protection extends not only to patients who have been involuntarily committed but also to those who seek treatment voluntarily, even on an outpatient basis.

explanations for obsessive-compulsive personality disorder

-Most explanations of obsessive-compulsive personality disorder borrow heavily from those of obsessive-compulsive disorder, despite the doubts concerning a link between the two disorders. As with so many of the personality disorders, psychodynamic explanations dominate and research evidence is limited. Freudian theorists suggest that people with obsessive-compulsive personality disorder are anal retentive. That is, because of overly harsh toilet training during the anal stage, they become filled with anger, and they remain fixated at this stage. To keep their anger under control, they persistently resist both their anger and their instincts to have bowel movements. In turn, they become extremely orderly and restrained; many become passionate collectors. Other psychodynamic theorists suggest that any early struggles with parents over control and independence may ignite the aggressive impulses at the root of this personality disorder -Cognitive-behavioral theorists have little to say about the origins of obsessive-compulsive personality disorder, but they do propose that illogical thinking processes help keep it going (Paast et al., 2016; Weishaar & Beck, 2006; Beck et al., 2004). They point, for example, to dichotomous thinking, which may produce rigidity and perfectionism. Similarly, they note that people with this disorder tend to misread or exaggerate the potential outcomes of mistakes or errors

protecting patients' rights

-Over the past two decades, court decisions and state and federal laws have significantly expanded the rights of patients with mental disorders, in particular the right to treatment and the right to refuse treatment (Miller & Hanson, 2016; OPA, 2016; Lepping & Raveesh, 2014). HOW IS THE RIGHT TO TREATMENT PROTECTED? When people are committed to mental institutions and do not receive treatment, the institutions become, in effect, prisons for the unconvicted. To many patients in the late 1960s and the 1970s, large state mental institutions were just that, and some patients and their attorneys began to demand that the state honor the patients' right to treatment. In the landmark case of Wyatt v. Stickney, a suit on behalf of institutionalized patients in Alabama in 1972, a federal court ruled that the state was constitutionally obligated to provide "adequate treatment" to all people who had been committed involuntarily. Because conditions in the state's hospitals were so terrible, the judge laid out goals that state officials had to meet, including more therapists, better living conditions, more privacy, more social interactions and physical exercise, and a more proper use of physical restraint and medication. Other states have since adopted many of these standards -Another important decision was handed down in 1975 by the Supreme Court in the case of O'Connor v. Donaldson. After being held in a Florida mental institution for more than 14 years, Kenneth Donaldson sued for release. Donaldson repeatedly had sought release and had been overruled by the institution's psychiatrists. He argued that he and his fellow patients were receiving poor treatment, were being largely ignored by the staff, and were allowed little personal freedom. The Supreme Court ruled in his favor, fined the hospital's superintendent, and said that such institutions must review patients' cases periodically. The justices also ruled that the state cannot continue to institutionalize people against their will if they are not dangerous and are capable of surviving on their own or with the willing help of responsible family members or friends. To help protect the rights of patients, Congress passed the Protection and Advocacy for Mentally Ill Individuals Act in 1986. This law set up protection and advocacy systems in all states and U.S. territories and gave public advocates who worked for patients the power to investigate possible abuse and neglect and to correct those problems legally -In more recent years, public advocates have argued that the right to treatment also should be extended to the tens of thousands of people with severe mental disorders who are repeatedly released from hospitals into communities ill-equipped to care for them. Many such people have no place to go and are unable to care for themselves, often winding up homeless or in prisons (Allison et al., 2017; MIP, 2017). A number of advocates are now suing federal and state agencies throughout the country, demanding that they fulfill the promises of the community mental health movement (see Chapter 15). HOW IS THE RIGHT TO REFUSE TREATMENT PROTECTED? During the past two decades, the courts have also decided that patients, particularly those in institutions, have the right to refuse treatment. The courts have been reluctant to make a single general ruling on this right because there are so many different kinds of treatment, and a general ruling based on one of them might have unintended effects. Therefore, rulings usually target one specific treatment at a time. Most of the right-to-refuse-treatment rulings center on biological treatments. These treatments are easier to impose on patients without their cooperation than psychotherapy, and they often are more hazardous. For example, state rulings have consistently granted patients the right to refuse psychosurgery, the most irreversible form of physical treatment—and often the most dangerous. Some states have also acknowledged a patient's right to refuse electroconvulsive therapy (ECT), the treatment used in many cases of severe depression (see Chapter 8). However, the right-to-refuse issue is more complex with regard to ECT than to psychosurgery. ECT is very effective for many people with severe depression, but it can cause great upset and can also be misused. Today many states grant patients—particularly voluntary patients—the right to refuse ECT (Miller & Hanson, 2016; OPA, 2016). Usually a patient must be informed fully about the nature of the treatment and must give written consent to it. A number of states continue to permit ECT to be forced on committed patients, whereas others require the consent of a close relative or other third party in such cases. In the past, patients did not have the right to refuse psychotropic medications. As you have read, however, many psychotropic drugs are very powerful, and some produce effects that are unwanted and dangerous. As these harmful effects have become more apparent, some states have granted patients the right to refuse medication (Dunlop & Pinals, 2016; OPA, 2016). Typically, these states require physicians to explain the purpose of the medication to patients and obtain their written consent. If a patient's refusal is considered incompetent, dangerous, or irrational, the state may allow it to be overturned by an independent psychiatrist, medical committee, or local court. However, the refusing patient is supported in this process by a lawyer or other patient advocate (OPA, 2016). WHAT OTHER RIGHTS DO PATIENTS HAVE? Court decisions have protected still other patient rights over the past several decades. Patients who perform work in mental institutions, particularly private institutions, are now guaranteed at least a minimum wage. In addition, according to a court decision, patients released from state mental hospitals have a right to aftercare and to an appropriate community residence, such as a group home. And, more generally, people with psychological disorders should receive treatment in the least restrictive facility available. If an inpatient program at a community mental health center is available and appropriate, for example, then that is the facility to which they should be assigned, not a mental hospital -THE "RIGHTS" DEBATE Certainly, people with psychological disorders have civil rights that must be protected at all times. However, many clinicians express concern that the patients' rights rulings and laws may unintentionally deprive these patients of opportunities for recovery. Consider the right to refuse medication. If medications can help a patient with a severe mental disorder to recover, doesn't the patient have the right to that recovery? If confusion causes the patient to refuse medication, can clinicians in good conscience delay medication while legal channels are being cleared? -Despite such legitimate concerns, keep in mind that the clinical field has not always done an effective job of protecting patients' rights. Over the years, many patients have been overmedicated and received improper treatments. Furthermore, one must ask whether the field's present state of knowledge justifies clinicians' overriding of patients' rights. Can clinicians confidently say that a given treatment will help a patient? Can they predict when a treatment will have harmful effects? Since clinicians themselves often disagree, it seems appropriate for patients, their advocates, and outside evaluators to also play key roles in decision making.

treatments for avoidant personality disorder

-People with avoidant personality disorder come to therapy in the hope of finding acceptance and affection. Keeping them in treatment can be a challenge, however, for many of them soon begin to avoid the sessions. Often they distrust the therapist's sincerity and start to fear his or her rejection (Skodol & Bender, 2016). Thus, as with several of the other personality disorders, a key task of the therapist is to gain the person's trust (Skodol, 2016; Colli et al., 2014). Beyond building trust, therapists tend to treat people with avoidant personality disorder much as they treat people with social anxiety disorder and other anxiety disorders. Such approaches have had at least modest success (Bernecker et al., 2017; Kikkert et al., 2016; Lampe, 2016). Psychodynamic therapists try to help clients recognize and resolve the unconscious conflicts that may be operating (Guina, 2016; Leichsenring & Salzer, 2014). Cognitive-behavioral therapists help them change their distressing beliefs and thoughts, carry on in the face of painful emotions, and improve their self-image (Lampe, 2016; Rees & Pritchard, 2013). They also provide social skills training and exposure treatments that require people to gradually increase their social contacts (Kampmann et al., 2016). Group therapy formats, especially groups that follow cognitive and behavioral principles, have the added advantage of providing clients with practice in social interactions (Balje et al., 2016; Bressert, 2017; Herbert et al., 2005). Antianxiety and antidepressant drugs are sometimes useful in reducing the social anxiety of people with the disorder, although the symptoms may return when medication is stopped

criminal commitment and incompetence to stand trial

-Regardless of their state of mind at the time of a crime, defendants may be judged to be mentally incompetent to stand trial. The competence requirement is meant to ensure that defendants understand the charges they are facing and can work with their lawyers to prepare and conduct an adequate defense (Hallevy, 2017; Reisner et al., 2013). This minimum standard of competence was specified by the Supreme Court in the case of Dusky v. United States (1960). -The issue of competence is most often raised by the defendant's attorney, although prosecutors, arresting police officers, and even the judge may raise it as well (Roesch, 2016; Reisner et al., 2013). When the issue of competence is raised, the judge orders a psychological evaluation, usually on an inpatient basis (see Table 19-1). As many as 60,000 competency evaluations are conducted in the United States each year (Faubion, 2016; Bartol & Bartol, 2015). Approximately 20 to 25 percent of defendants who receive such an evaluation are found to be incompetent to stand trial. If the court decides that the defendant is incompetent, he or she is typically assigned to a mental health facility until competent to stand trial -A famous case of incompetence to stand trial is that of Jared Lee Loughner. On January 8, 2011, Loughner went to a political gathering at a shopping center in Tucson, Arizona, and opened fire on 20 persons. Six people were killed and 14 injured, including U.S. representative Gabrielle Giffords. Giffords, the apparent target of the attack, survived, although she was shot in the head. After Loughner underwent five weeks of psychiatric assessment, a judge ruled that he was incompetent to stand trial. It was not until 18 months later, after extended treatment with antipsychotic drugs, that Loughner was ruled competent to stand trial. In November 2012, he pleaded guilty to murder and was sentenced to life imprisonment. Sometimes, incompetence rulings can continue even longer. In another famous case, a man named Russell Weston entered the U.S. Capitol building in 1998, apparently seeking out then-House Majority Whip Tom DeLay, among others, and shot two police officers to death. In 1999, Weston, who had stopped taking medications for his severe psychosis, was found incompetent to stand trial and sent to a psychiatric institution. In 2001, a judge ruled that he should be forced to take medications again, but even with such drugs Weston continued to have severe symptoms and to this day remains incompetent to stand trial for the 1998 shootings. Many more cases of criminal commitment result from decisions of mental incompetence than from verdicts of not guilty by reason of insanity (Roesch, 2016; Roesch et al., 2010). However, the majority of criminals currently institutionalized for psychological treatment in the United States are not from either of these two groups. Rather, they are convicted inmates whose psychological problems have led prison officials to decide they need treatment, either in mental health units within the prison or in mental hospitals -It is possible that an innocent defendant, ruled incompetent to stand trial, could spend years in a mental health facility with no opportunity to disprove the criminal accusations against him or her. Some defendants have, in fact, served longer "sentences" in mental health facilities awaiting a ruling of competence than they would have served in prison had they been convicted. Such a possibility was reduced when the Supreme Court ruled, in the case of Jackson v. Indiana (1972), that an incompetent defendant cannot be indefinitely committed. After a reasonable amount of time, he or she should either be found competent and tried, set free, or transferred to a mental health facility under civil commitment procedures. Until the early 1970s, most states required that mentally incompetent defendants be committed to maximum security institutions for the "criminally insane." Under current law, however, the courts have more flexibility. In fact, when the charges are relatively minor, such defendants are often treated on an outpatient basis, an arrangement often called jail diversion because the disturbed person is "diverted" from jail to the community for mental health care

law and mental health

-TWO SOCIAL INSTITUTIONS HAVE a particularly strong impact on the mental health profession: the legislative and judicial systems. These institutions—collectively, the legal field—have long been responsible for protecting both the public good and the rights of individuals. Sometimes the relationship between the legal field and the mental health field has been friendly, and those in the two fields have worked together to protect the rights and meet the needs of troubled people and of society at large. At other times they have clashed, and one field has imposed its will on the other. -This relationship has two distinct aspects. On the one hand, mental health professionals often play a role in the criminal justice system, as when they are called upon to help the courts assess the mental stability of people accused of crimes. They responded to this call in the Hinckley case, as you will see, and in thousands of other cases. This aspect of the relationship is sometimes termed psychology in law; that is, clinical practitioners and researchers operate within the legal system. On the other hand, there is another aspect to the relationship, called law in psychology. The legislative and judicial systems act upon the clinical field, regulating certain aspects of mental health care. The courts may, for example, force some people to enter treatment, even against their will. In addition, the law protects the rights of patients. The intersections between the mental health field and the legal and judicial systems are collectively referred to as forensic psychology (Ryan, 2016). Forensic psychologists or psychiatrists (or related mental health professionals) may perform such varied activities as testifying in trials, researching the reliability of eyewitness testimony, or helping police profile the personality of a serial killer on the loose.

"personality disorder--trait specified": DSM-5's proposed dimensional approach

-The "Big Five" approach to personality disorders has received considerable study, and some theorists would like it to be used as the official classification approach in the United States and around the world. Instead, the framers of the ICD (the classification system used in most countries outside the United States) and the DSM (the classification system used in the United States) have each developed their own dimensional approach for classifying personality disorders, and they plan to use those approaches in their future editions. Indeed, as you read earlier, the DSM-5 framers have already included a detailed description of their proposed dimensional approach in DSM-5, so that it can be examined by clinicians and studied and tested by researchers -DSM-5's proposed dimensional approach to personality disorders begins with the notion that people whose traits significantly impair their functioning should receive a diagnosis called personality disorder—trait specified (PDTS) (APA, 2013). When assigning this diagnosis, clinicians would also identify and list the problematic traits and rate the severity of impairment caused by them. According to the proposal, five groups of problematic traits would be eligible for a diagnosis of PDTS: negative affectivity, detachment, antagonism, disinhibition, and psychoticism. Negative Affectivity People who display negative affectivity experience negative emotions frequently and intensely. In particular, they exhibit one or more of the following traits: emotional lability (unstable emotions), anxiousness, separation insecurity, perseveration (repetition of certain behaviors despite repeated failures), submissiveness, hostility, depressivity, suspiciousness, and strong emotional reactions (overreactions to emotionally arousing situations). Detachment People who manifest detachment tend to withdraw from other people and social interactions. They may exhibit any of the following traits: restricted emotional reactivity (little reaction to emotionally arousing situations), depressivity, suspiciousness, withdrawal, anhedonia (inability to feel pleasure or take interest in things), and intimacy avoidance. You'll note that two of the traits in this group—depressivity and suspiciousness—are also found in the negative affectivity group. Antagonism People who display antagonism behave in ways that put them at odds with other people. They may exhibit any of the following traits: manipulativeness, deceitfulness, grandiosity, attention seeking, callousness, and hostility. Hostility is also found in the negative affectivity group. Disinhibition People who manifest disinhibition behave impulsively, without reflecting on potential future consequences. They may exhibit any of the following traits: irresponsibility, impulsivity, distractibility, risk taking, and imperfection/disorganization. Psychoticism People who display psychoticism have unusual and bizarre experiences. They may exhibit any of the following traits: unusual beliefs and experiences, eccentricity, and cognitive and perceptual dysregulation (odd thought processes and sensory experiences). -If a person is impaired significantly by any of the five trait groups, or even by just 1 of the 25 traits that make up those groups, he or she would qualify for a diagnosis of personality disorder—trait specified. In such cases, the diagnostician would indicate which traits are impaired. Consider, for example, Lucas, the unhappy 42-year-old assistant graphics programmer described on page 501. As you'll recall, Lucas meets the criteria for a diagnosis of dependent personality disorder under DSM-5's current categorical approach, based largely on his lifetime of extreme dependence on his father, mother, sisters, friends, and coworkers. Using the alternative dimensional approach presented in DSM-5, a diagnostician would instead observe that Lucas is significantly impaired by several of the traits that characterize the negative affectivity trait group. He is, for example, greatly impaired by "separation insecurity." This trait has prevented him from ever living on his own, marrying his girlfriend, disagreeing with his father, advancing at work, and broadening his social life. In addition, Lucas seems to be impaired significantly by the traits of "submissiveness," "anxiousness," and "depressivity." Given this picture, his therapist might assign him a diagnosis of personality disorder—trait specified, with problematic traits of separation insecurity, submissiveness, anxiousness, and depressivity. According to this dimensional approach, when clinicians assign a diagnosis of personality disorder—trait specified, they also must rate the degree of dysfunction caused by each of the person's traits, using a five-point scale ranging from "little or no impairment" (Rating = 0) to "extreme impairment" (Rating = 4). Consider Lucas once again. He would probably warrant a rating of "0" on most of the 25 traits listed in the DSM-5 proposal, a rating of "3" on the traits of anxiousness and depressivity, and a rating of "4" on the traits of separation insecurity and submissiveness. Altogether, he would receive the following cumbersome, but informative, diagnosis: Diagnosis: Personality Disorder—Trait Specified Separation insecurity: Rating 4 Submissiveness: Rating 4 Anxiousness: Rating 3 Depressivity: Rating 3 Other traits: Rating 0 This dimensional approach to personality disorders may indeed prove superior to DSM-5's current categorical approach. Thus far, however, it has caused its own stir in the clinical community. Many clinicians believe that the proposed changes would give too much latitude to diagnosticians—allowing them to apply diagnoses of personality disorder to an enormous range of personality patterns. Still others worry that the requirements of the newly proposed system are too cumbersome or complicated. Thus a number of researchers are currently conducting studies to clarify the merits and drawbacks of the proposed system (Anderson et al., 2018, 2016; Rojas & Widiger, 2016). Only time and continued research will determine whether the alternative system is indeed a useful approach to the classification and diagnosis of personality disorders.

malpractice suits

-The number of malpractice suits against therapists has risen sharply in recent years. Claims have been made against clinicians in response to a patient's attempted suicide, sexual activity with a patient, failure to obtain informed consent for a treatment, negligent drug therapy, omission of drug therapy that would speed improvement, improper termination of treatment, and wrongful commitment (Pope & Vasquez, 2016; Sher, 2015; Reich & Schatzberg, 2014). Studies suggest that malpractice suits, or the fear of them, can have significant effects on clinical decisions and practice, for better or for worse

explanations for avoidant personality disorder

-Theorists often assume that avoidant personality disorder has the same causes as anxiety disorders—such as early traumas, conditioned fears, upsetting beliefs, or biochemical abnormalities. However, with the exception of social anxiety disorder, research has not clearly tied the personality disorder directly to the anxiety disorders (Herbert, 2007). Psychodynamic and cognitive-behavioral explanations of avoidant personality disorder are the most popular among clinicians. Psychodynamic theorists focus mainly on the general feelings of shame and insecurity that people with avoidant personality disorder have (Guina, 2016; Svartberg & McCullough, 2010). Some trace the shame to childhood experiences such as early bowel and bladder accidents. If parents repeatedly punish or ridicule a child for having such accidents, the child may develop a negative self-image. This may lead to the child's feeling unlovable throughout life and distrusting the love of others. Similarly, cognitive-behavioral theorists believe that harsh criticism and rejection in early childhood may lead certain people to assume that others in their environment will always judge them negatively. These people come to expect rejection, misinterpret the reactions of others to fit that expectation, discount positive feedback, and generally fear social involvements—setting the stage for avoidant personality disorder (Lampe, 2015; Weishaar & Beck, 2006). In several studies, when participants with this disorder were asked to recall their childhood, their descriptions supported both the psychodynamic and cognitive-behavioral predictions (Carr & Francis, 2010; Herbert, 2007). They remembered, for example, feeling criticized, rejected, and isolated; receiving little encouragement from their parents; and experiencing few displays of parental love or pride -Cognitive-behavioral theorists also suggest that most people with avoidant personality disorder fail to develop effective social skills, a failure that helps maintain the disorder. In support of this position, several studies have found social skills deficits among people with avoidant personality disorder (Moroni et al., 2016; Kantor, 2010; Herbert, 2007). Most of the theorists agree, however, that these deficits first develop as a result of the individuals avoiding so many social situations

dependent personality disorder

-a personality disorder characterized by a pattern of clinging and obedience, fear of separation, and an ongoing need to be taken care of -they are clinging and obedient, fearing separation from their parent, spouse, or other person with whom they are in a close relationship. They rely on others so much that they cannot make the smallest decision for themselves -It is normal and healthy to depend on others, but those with dependent personality disorder constantly need assistance with even the simplest matters and have extreme feelings of inadequacy and helplessness. Afraid that they cannot care for themselves, they cling desperately to friends or relatives. As you observed previously, people with avoidant personality disorder have difficulty initiating relationships. In contrast, people with dependent personality disorder have difficulty with separation. They feel completely helpless and devastated when a close relationship ends, and they quickly seek out another relationship to fill the void. Many cling persistently to relationships with partners who physically or psychologically abuse them (Leemans & Loas, 2016; Loas et al., 2015, 2011). Lacking confidence in their own ability and judgment, people with this disorder seldom disagree with others and allow even important decisions to be made for them (Bressert, 2017; Gore & Widiger, 2015). They may depend on a parent or spouse to decide where to live, what job to have, and which neighbors to befriend. Because they so fear rejection, they are overly sensitive to disapproval and keep trying to meet other people's wishes and expectations, even if it means volunteering for unpleasant or demeaning tasks -Many people with dependent personality disorder feel distressed, lonely, and sad; often they dislike themselves. Thus they are at risk for depressive, anxiety, and eating disorders (Bornstein, 2012, 2007). Their fear of separation and their feelings of helplessness may leave them particularly prone to suicidal thoughts, especially when they believe that a relationship is about to end (Bornstein, 2012; Kiev, 1989). Surveys suggest that fewer than 1 percent of the population experience dependent personality disorder (APA, 2013; Sansone & Sansone, 2011). For years, clinicians have believed that more women than men display this pattern, but some research suggests that the disorder is just as common in men

obsessive-compulsive personality disorder

-a personality disorder marked by sushi an intense focus on orderliness, perfectionism, and control that the person loses flexibility, openness, and efficiency -Their concern for doing everything "right" impairs their productivity -When faced with a task, he and others who have obsessive-compulsive personality disorder may become so focused on organization and details that they fail to grasp the point of the activity. As a result, their work is often behind schedule (some seem unable to finish any job), and they may neglect leisure activities and friendships. People with this personality disorder set unreasonably high standards for themselves and others. Their behaviors extend well beyond the realm of conscientiousness. They can never be satisfied with their performance, but they typically refuse to seek help or to work with a team, convinced that others are too careless or incompetent to do the job right. Because they are so afraid of making mistakes, they may be reluctant to make decisions (Wheaton & Pinto, 2017). They also tend to be rigid and stubborn, particularly in their morals, ethics, and values. They live by a strict personal code and use it as a yardstick for measuring others. They may have trouble expressing much affection, and their relationships are sometimes stiff and superficial (Cain et al., 2015). In addition, they are often stingy with their time or money. Some cannot even throw away objects that are worn out or useless (Riddle et al., 2016; APA, 2013). According to surveys, as many as 7.9 percent of the adult population display obsessive-compulsive personality disorder, with white, educated, married, and employed people receiving the diagnosis most often (APA, 2013; Sansone & Sansone, 2011). Men are twice as likely as women to display the disorder -Many clinicians believe that obsessive-compulsive personality disorder and obsessive-compulsive disorder are closely related. Certainly, the two disorders share a number of features, and many people who suffer from one of the disorders meet the diagnostic criteria for the other disorder (Starcevic & Brakoulias, 2017; Gordon et al., 2016). However, it is worth noting that people with the personality disorder are more likely to suffer from either major depressive disorder, an anxiety disorder, or a substance use disorder than from obsessive-compulsive disorder (Brakoulias et al., 2017; APA, 2013). In fact, researchers have not consistently found a specific link between obsessive-compulsive personality disorder and obsessive-compulsive disorder

restricted (blunted and flat) affect

-show less emotion than most people -avoidance of eye contact -immobile, expressionless face -blunted affect, flat affect

brief psychotic disorder

-various psychotic symptoms, such as delusions, hallucinations, disorganized speech, restricted or inappropriate affect, and catatonia -less than 1 month

the "big five" theory of personality and personality disorders

A large body of research conducted with diverse populations consistently suggests that the basic structure of personality may consist of five "supertraits," or factors—neuroticism, extroversion, openness to experiences, agreeableness, and conscientiousness (Chapman et al., 2017; Morton et al., 2016). Each of these factors, which are frequently referred to as the "Big Five," consists of a number of subfactors. Anxiety and hostility, for example, are subfactors of the neuroticism factor, while optimism and friendliness are subfactors of the extroversion factor. Theoretically, everyone's personality can be summarized by a combination of these supertraits. One person may display high levels of neuroticism and agreeableness, medium extroversion, and low conscientiousness and openness to experiences. In contrast, another person may display high levels of agreeableness and conscientiousness, medium neuroticism and extroversion, and low openness to experiences. And so on -Many proponents of the Big Five model have argued further that it would be best to describe all people with personality disorders as being high, low, or in between on the five supertraits and to drop the use of personality disorder categories altogether (Song & Shi, 2017; Glover et al., 2011; Lawton et al., 2011). Thus a particular person who currently qualifies for a diagnosis of avoidant personality disorder might instead be described as displaying a high degree of neuroticism, medium degrees of agreeableness and conscientiousness, and very low degrees of extroversion and openness to new experiences. Similarly, a person currently diagnosed with narcissistic personality disorder might be described in the Big Five approach as displaying very high degrees of neuroticism and extroversion, medium degrees of conscientiousness and openness to new experiences, and a very low degree of agreeableness

technology and mental health

AS YOU HAVE SEEN THROUGHOUT this book, today's ever-changing technology has had significant effects—both positive and negative—on the mental health field, and it will undoubtedly affect the field even more in the coming years. Our digital world provides new triggers for the expression of abnormal behavior. The maladaptive functioning of many persons with gambling disorder, for example, has been exacerbated by the ready availability of Internet gambling (see page 379). Similarly, the Internet, texting, and social networking are now used frequently by those who wish to stalk or bully others, express sexual exhibitionism, pursue pedophilic desires, or satisfy other paraphilic disorders (see pages 403, 514). And, in the opinion of many clinicians, constant texting, tweeting, and Internet browsing may help shorten people's attention spans and establish a foundation for attention problems. Beyond providing new triggers for abnormal behavior, research indicates that today's technology also is helping to produce new psychological disorders. As you read in Chapter 12, one such pattern is Internet use disorder, a problem marked by excessive and dysfunctional levels of texting, tweeting, networking, Internet browsing, e-mailing, blogging, online shopping, or online pornographic use (McNicol & Thorsteinsson, 2017) (see page 380). The framers of DSM-5 have suggested that this disorder be considered for possible inclusion in future revisions of the DSM. Similarly, the Internet has brought a new exhibitionistic feature to certain kinds of abnormal behavior. For example, as you read in Chapter 9, a growing number of people now use social networking to post videos of themselves engaging in self-cutting or suicidal acts, acts that traditionally had been conducted in private (see pages 253-254). There is also a growing recognition among clinical practitioners and researchers that even everyday social networking can contribute to psychological dysfunction. In addition to its many virtues, social networking may, according to research, provide a new venue for peer pressure and social anxiety in some adolescents (Houston, 2016; Nesi & Prinstein, 2015). It may, for example, cause some people to develop fears that others in their network will exclude them socially. Similarly, clinicians worry that social networking may lead shy or socially anxious people to withdraw from valuable face-to-face relationships. As you have read throughout this textbook, the face of clinical treatment has also expanded in our fast-moving digital world. Telemental health, the use of various technologies to deliver mental health services without the therapist being physically present, is now common (Comer et al., 2017; Maheu et al., 2017). It takes such forms as long-distance therapy between clients and therapists using videoconferencing (see page 65), therapy offered by computer programs (see page 20), treatment enhanced by the use of video game-like avatars and other virtual reality experiences (see page 169), and Internet-based support groups (see pages 20, 74). In addition, of the hundreds of thousands of new apps created over the past five years, a number are devoted to helping people relax, cheer up, or track their shifting moods and thoughts (see page 225). And many computer exercise programs—cognitive and physical—have been developed with the goal of improving both mental health (particularly, cognitive functioning and mood) and physical health Similarly, numerous websites now offer useful mental health information, enabling people to better inform themselves, their friends, and their family members about psychological problems and treatment options (see page 20). Unfortunately, along with this wealth of online information comes considerable misinformation about psychological problems and their treatments, offered by persons and sites that are far from knowledgeable or noble. The issue of quality control is also a major problem for Internet-based therapy, support groups, and the like, and there are now numerous antitreatment networks, such as the pro-suicide and pro-Ana networks you read about in Chapters 9 and 11, that try to guide people away from seeking help for their psychological problems Clearly, the growing impact of technological change on the mental health field presents formidable challenges for clinicians and researchers alike. Few of the technological applications discussed throughout this book are well understood, and few have been subjected to comprehensive research. Yet, as we mentioned earlier, the relationship between technology and mental health is growing precipitously. It behooves everyone in the field to understand this growth and its implications.

bringing mental health services to the workplace

According to numerous surveys, work is by far the leading source of stress for people (AIS, 2017). Over 40 percent of workers find their jobs very stressful and believe them to be bad for their mental health and general health (AIS, 2017, Harvard School of Public Health, 2016; Pazzanese, 2016). Stressed-out workers report that the primary causes of their upsets are excessive workload (46 percent of workers), people and personnel issues (28 percent), difficulties balancing work with home life (20 percent), and lack of job security (6 percent) (AIS, 2017). All this stress not only affects the home life and personal functioning of employees. It also impairs performance and productivity in the workplace. Stress and mental health problems are the third leading cause of work absences, behind minor sicknesses and back and neck pain (ONS, 2017). Keeping in mind that job stress often contributes to medical problems such as high blood pressure and cardiovascular issues, 60 percent of absences from work can be traced, directly or indirectly, to stress and related mental health issues (AIS, 2017; Harvard School of Public Health, 2016). Altogether, it is estimated that businesses in the United States lose $30 billion to lost work days and $12 billion to extra health care expenses (Harvard School of Public Health, 2016; Pazzanese, 2016; White, 2015). Furthermore, studies find that stress at work contributes to poorer productivity and more accidents, employee mistakes, employee departures, insurance costs, and worker compensation expenses For both humane and financial reasons, many employers try to address the work-related stress and other mental health needs of their employees. Two common approaches, provided by about half of employers, are employee assistance programsand stress reduction programs (Harvard School of Public Health, 2016; Richmond et al., 2016; Waehrer et al., 2016). Employee assistance programs are mental health services made available by a place of business. They are run either by mental health professionals who work directly for a company or by outside mental health agencies. Stress-reduction and problem-solving programs are workshops or group sessions in which mental health professionals teach employees techniques for coping, solving problems, and handling and reducing stress. As you read in Chapter 3, one of today's most common such techniques is mindfulness training, offered by around one-third of employers (see pages 65-66). Stress-reduction programs are just as likely to be aimed at high-level executives as at assembly-line workers. Often employees are required to attend such programs, and they are given time off from their jobs to do so. Businesses believe that employee assistance and stress reduction programs save them money in the long run by preventing psychological problems from interfering with work performance and by reducing employee insurance claims, a notion that has been supported in various studies (Richmond et al., 2016; Waehrer et al., 2016). And, for their part, at least half of workers agree that they need help learning how to manage stress

what ethical principles guide mental health professionals?

DISCUSSIONS OF THE LEGAL AND mental health systems may sometimes give the impression that clinicians as a group are uncaring and are considerate of patients' rights and needs only when they are forced to be. This, of course, is not true. Most clinicians care greatly about their clients and strive to help them while at the same time respecting their rights and dignity (Pope & Vasquez, 2016, 2011). In fact, clinicians do not rely exclusively on the legislative and court systems to ensure proper and effective clinical practice. They also regulate themselves by continually developing and revising ethical guidelines for their work and behavior. Many legal decisions do nothing more than place the power of the law behind these already existing professional guidelines. Each profession within the mental health field has its own code of ethics. The code of the American Psychological Association (2017, 2010, 2002) is typical. This code, highly respected by other mental health professionals and public officials, includes specific guidelines: Psychologists are permitted to offer advice in self-help books, on DVDs, on television and radio programs, in newspapers and magazines, through mailed material, and in other places, provided they do so responsibly and professionally and base their advice on appropriate psychological literature and practices. Psychologists are bound by these same ethical requirements when they offer advice and ideas online, whether on individual Web pages, blogs, bulletin boards, or chat rooms. Internet-based professional advice has proved difficult to regulate, however, because the number of such offerings keeps getting larger and larger and so many advice-givers do not appear to have any professional training or credentials. Psychologists may not conduct fraudulent research, plagiarize the work of others, or publish false data. During the past 30 years cases of scientific fraud or misconduct have been discovered in all of the sciences, including psychology. These acts have led to misunderstandings of important issues, taken scientific research in the wrong direction, and damaged public trust. Unfortunately, the impressions created by false findings may continue to influence the thinking of both the public and other scientists for years. Psychologists must acknowledge their limitations with regard to patients who are disabled or whose gender, ethnicity, language, socioeconomic status, or sexual orientation differs from that of the therapist. This guideline often requires psychotherapists to obtain additional training or supervision, consult with more knowledgeable colleagues, or refer clients to more appropriate professionals. Psychologists who make evaluations and testify in legal cases must base their assessments on sufficient information and substantiate their findings appropriately.If an adequate examination of the individual in question is not possible, psychologists must make clear the limited nature of their testimony. Psychologists may not participate or assist in torture—acts in which severe pain, suffering, or degradation is intentionally inflicted on people. This guideline was added to the code of ethics in 2017, a year after an APA-sponsored report revealed that, over a period of several years, the APA had aided and advised the Department of Defense and the Central Intelligence Agency in the development of "enhanced interrogation" techniques (that is, torture-based questioning) and had adjusted professional guidelines to allow psychologist involvement in such interrogations (see Trending). Psychologists may not take advantage of clients and students, sexually or otherwise.This guideline relates to the widespread social problem of sexual harassment, as well as the problem of therapists who take sexual advantage of clients in therapy. The code specifically forbids a sexual relationship with a present or former therapy client for at least two years after the end of treatment—and even then such a relationship is permitted only in "the most unusual circumstances." Furthermore, psychologists may not accept as clients people with whom they have previously had a sexual relationship. Research has clarified that clients may suffer great emotional damage from sexual involvement with their therapists (Pope & Vasquez, 2016, 2011; Pope & Wedding, 2014). How many therapists actually have a sexual relationship with a client? On the basis of various surveys, reviewers have estimated that 4 to 5 percent of today's therapists engage in some form of sexual misconduct with patients, down from 10 percent more than a decade ago. Although the vast majority of therapists do not engage in sexual behavior of any kind with clients, their ability to control private feelings is apparently another matter. In surveys, more than 80 percent of therapists reported having been sexually attracted to a client, at least on occasion (Pope & Vasquez, 2016, 2011; Pope & Wedding, 2014). Although few of these therapists acted on their feelings, most of them felt guilty, anxious, or concerned about the attraction. Given such issues, it is not surprising that sexual ethics training is given high priority in many of today's clinical training programs. Psychologists must adhere to the principle of confidentiality. All of the state and federal courts have upheld laws protecting therapy confidentiality (Fisher, 2016, 2013). For peace of mind and to ensure effective therapy, clients must be able to trust that their private exchanges with a therapist will not be repeated to others (Skodol & Bender, 2016). There are times, however, when the principle of confidentiality must be compromised (Middleman & Olson, 2017; Pope & Vasquez, 2016, 2011). A therapist in training, for example, must discuss cases on a regular basis with a supervisor, and clients must be informed that such discussions are taking place. A second exception arises in cases of outpatients who are clearly dangerous. The 1976 case of Tarasoff v. Regents of the University of California, one of the most important cases to affect client-therapist relationships, concerned an outpatient at a University of California hospital. He had confided to his therapist that he wanted to harm his former girlfriend, Tanya Tarasoff. Several days after ending therapy, the former patient fulfilled his promise. He stabbed Tanya Tarasoff to death. Should confidentiality have been broken in this case? The therapist, in fact, felt that it should. Campus police were notified, but the patient was released after some questioning. In their suit against the hospital and therapist, the victim's parents argued that the therapist should have also warned them and their daughter that the patient intended to harm Ms. Tarasoff. The California Supreme Court agreed: "The protective privilege ends where the public peril begins." The current code of ethics for psychologists thus declares that therapists have a duty to protect—a responsibility to break confidentiality, even without the client's consent, when it is necessary "to protect the client or others from harm." Since the Tarasoffruling, most states have adopted the California court rulings or similar ones, and a number have passed "duty to protect" bills that clarify the rules of confidentiality for therapists and protect them from certain civil suits (Middleman & Olson, 2017; Knoll, 2015). Many such bills further rule that therapists must also protect people who are close to a client's intended victim and thus in danger. A child, for example, is likely to be at risk when a client plans to assault the child's mother.

jury consultation

During the past 30 years, more and more lawyers have turned to clinicians for psychological advice in conducting trials (Gomez, 2016; Crouter, 2015). A new breed of clinical specialists, known as "jury specialists," has evolved. They advise lawyers about which potential jurors are likely to favor their side and which strategies are likely to win jurors' support during trials. The jury specialists make their suggestions on the basis of surveys, interviews, analyses of jurors' backgrounds and attitudes, and laboratory simulations of upcoming trials. However, it is not clear that a clinician's advice is more valid than a lawyer's instincts or that the judgments of either are particularly accurate

in what other ways do the clinical and legal fields interact?

Mental health and legal professionals may influence each other's work in other ways as well. During the past 25 years, their paths have crossed in four key areas: malpractice suits, professional boundaries, jury consultation, and psychological research of legal topics.

serial murderers: madness or badness?

Over the course of a decade, between 2003 and 2014, an eccentric history buff named Charles Severance killed three individuals in Alexandria, Virginia. Severance shot the victims—people he had never met—in their homes, simply because they were relatively affluent. In his private journals, the murderer had repeatedly expressed a desire to kill the local elite—members of the ruling class, as he put it. He was convicted of these crimes and sentenced to life in prison in 2016, joining a growing list of serial killers who have fascinated and horrified the public over the years: Bruce Ivins ("anthrax killer"), Theodore Kaczynski ("Unabomber"), Ted Bundy, David Berkowitz ("Son of Sam"), Albert DeSalvo ("Boston Strangler"), John Wayne Gacy ("Killer Clown"), Jeffrey Dahmer ("Milwaukee Cannibal"), Dennis Rader ("BTK killer"), and more By definition, serial killers commit a series of murders (3 or more) in separate incidents over an extended period of time. They are different from mass killers, whom you read about in Chapter 16—individuals who murder four or more people at a single time, usually in a single location (see page 483). The FBI estimates that there are between 25 and 50 serial killers at large in the United States at any given time (FBI, 2017, 2014). Worldwide, 4,500 such killers have been identified since the year 1900 (Aamodt, 2016, 2014). Each serial killer follows his or her own pattern, but many of them appear to have certain characteristics in common (FBI, 2017, 2014; Johnston, 2017; Becker, 2016). The majority—but certainly not all—are non-Hispanic white males between 30 and 45 years old, of average to high intelligence, seemingly clean-cut, smooth-talking, attractive, and skillful manipulators. Close to half of serial killers seem to have severe personality disorders (FBI, 2017, 2014; Becker, 2016; Hickey, 2015). Lack of conscience and an utter disregard for people and the rules of society—key features of antisocial personality disorder—are typical. Narcissistic thinking is quite common as well. Feelings of being special may even give the killers an unrealistic belief that they will not get caught (Kocsis, 2008; Wright et al., 2006). Often it is this sense of invincibility that leads to their capture. Sexual dysfunctions, paraphilic disorders, and fantasies also seem to play a part (FBI, 2017, 2014; Becker, 2016). Studies have found that vivid fantasies, often sexual and sadistic, may help drive the killer's behavior. Some clinicians also believe that the killers may be trying to overcome general feelings of powerlessness by controlling, hurting, or eliminating those who are momentarily weaker. A number of the killers were abused as children—physically, sexually, and/or emotionally. Law enforcement agencies and behavioral researchers have gathered an impressive body of statistical information about serial killings and killers in recent years. This data is often of help to criminal investigators as they seek to capture these repeat perpetrators of particularly heinous acts. At the same time, it would be inaccurate to say that clinical theorists understand why serial killers behave as they do.

professional boundaries

Over the past 25 years, the legislative and judicial systems have helped change the boundaries that distinguish one clinical profession from another. In particular, they have given more authority to psychologists and blurred the lines that once separated psychiatry from psychology. A growing number of states, for example, are ruling that psychologists can admit patients to the state's hospitals, a power previously held only by psychiatrists. In 1991, with the blessing of Congress, the Department of Defense (DOD) started to reconsider the biggest difference of all between the practices of psychiatrists and psychologists—the authority to prescribe drugs, a role previously denied to psychologists. The DOD set up a trial training program for Army psychologists. Given the apparent success of this trial program, the American Psychological Association later recommended that all psychologists be allowed to pursue extensive educational and training programs in prescription services and receive certification to prescribe medications if they pass. New Mexico, Louisiana, Illinois, Iowa, Idaho, and the U.S. territory of Guam now do grant prescription privileges to psychologists who receive special pharmacology training As the action by the American Psychological Association suggests, the legislative and judicial systems do not simply take it upon themselves to interfere in the affairs of clinical professionals. Professional associations of psychologists, psychiatrists, and social workers actually lobby in state legislatures across the country for laws and decisions that may increase the authority of their members, a further demonstration of the way the mental health system interacts with other sectors of our society.

treatment for obsessive-compulsive personality disorder

People with obsessive-compulsive personality disorder do not usually believe there is anything wrong with them. They therefore are not likely to seek treatment unless they are also suffering from another disorder, most frequently an anxiety disorder or depression, or unless someone close to them insists that they get treatment (Bartz et al., 2007). Because of this, therapists often feel as though they must "win over" and engage the clients in the therapy process (Colli et al., 2014). People with obsessive-compulsive personality disorder often respond well to psychodynamic or cognitive-behavioral therapy (Smith et al., 2017; Kikkert et al., 2016; Weishaar & Beck, 2006). Psychodynamic therapists typically try to help these clients recognize, experience, and accept their underlying feelings and insecurities, and perhaps take risks and accept their personal limitations (Bressert, 2016). Cognitive therapists focus on helping the clients to change their dichotomous—"all or nothing"—thinking, perfectionism, indecisiveness, procrastination, and chronic worrying (Bressert, 2016). A number of clinicians report that people with obsessive-compulsive personality disorder, like those with obsessive-compulsive disorder, respond well to SSRIs, the serotonin-enhancing antidepressant drugs; however, researchers have yet to study this issue fully

explanations for dependent personality disorder

Psychodynamic explanations for dependent personality disorder are very similar to those for depression (Svartberg & McCullough, 2010). Freudian theorists argue, for example, that unresolved conflicts during the oral stage of development can give rise to a lifelong need for nurturance, thus heightening the likelihood of a dependent personality disorder (Bornstein, 2012, 2007, 2005). Similarly, object relations theorists say that early parental loss or rejection may prevent normal experiences of attachmentand separation, leaving some children with fears of abandonment that persist throughout their lives (Caligor & Clarkin, 2010). Still other psychodynamic theorists suggest that, to the contrary, many parents of people with this disorder were overinvolved and overprotective, thus increasing their children's dependency, insecurity, and separation anxiety -Cognitive-behavioral theorists point to both behavioral and cognitive factors in their explanation of dependent personality disorder. In the behavioral realm, they propose that parents of people with dependent personality disorder unintentionally rewarded their children's clinging and "loyal" behavior, while at the same time punishing acts of independence, perhaps through the withdrawal of love. Alternatively, some parents' own dependent behaviors may have served as models for their children (Bornstein, 2012, 2007). In the cognitive realm, the theorists identify two maladaptive attitudes as further helping to produce and maintain this disorder: (1) "I am inadequate and helpless to deal with the world," and (2) "I must find a person to provide protection so I can cope." Dichotomous (black-and-white) thinking may also play a key role: "If I am to be dependent, I must be completely helpless," or "If I am to be independent, I must be alone." Such thinking prevents sufferers from making efforts to be autonomous

positive symptoms of schizophrenia

Symptoms of schizophrenia that seem to be excesses of, or bizarre additions to, normal thoughts, emotions, or behaviors. -"pathological excesses," or bizarre additions, to a person's behavior -delusions, disorganized thinking and speech, heightened perceptions and hallucinations, and inappropriate affect are the ones most often found in schizophrenia

the person within the profession

THE ACTIONS OF CLINICAL RESEARCHERS and practitioners not only influence and are influenced by other forces in society but also are closely tied to their personal needs and goals (see InfoCentral). You have seen that the human strengths, imperfections, wisdom, and clumsiness of clinical professionals may affect their theoretical orientations, their interactions with clients, and the kinds of clients with whom they choose to work. You have also seen how personal leanings may sometimes override professional standards and scruples and, in extreme cases, lead clinical scientists to commit research fraud and clinical practitioners to engage in sexual misconduct with clients. Surveys of the mental health of therapists have found that as many as 84 percent report having been in therapy at least once (Pope & Vasquez, 2016; Bearse et al., 2014; Pope & Wedding, 2014). Their reasons are largely the same as those of other clients, with relationship problems, depression, and anxiety topping the list. And, like other people, therapists often are reluctant to acknowledge their psychological problems. It is not clear why so many therapists have psychological problems. Perhaps it is because their jobs are highly stressful; research suggests that therapists often experience some degree of job burnout (BPS, 2016). Or perhaps therapists are simply more aware of their own negative feelings or are more likely to pursue treatment for their problems. Alternatively, people with personal concerns may be more inclined to choose clinical work as a profession. Whatever the reason, clinicians bring to their work a set of psychological issues that may, along with other important factors, affect how they listen and respond to clients. The science and profession of abnormal psychology seek to understand, predict, and change abnormal functioning. But we must not lose sight of the fact that mental health researchers and clinicians are human beings, living within a society of human beings, working to serve human beings. The mixture of discovery, misdirection, promise, and frustration that you have encountered throughout this book is thus to be expected. When you think about it, could the study and treatment of human behavior really proceed in any other way?

within a larger system

The effects of this larger system on an individual's psychological needs can be positive or negative, like a family's impact on each of its members. When the system protects a client's rights and confidentiality, for example, it is serving the client well. When economic, legal, or other societal forces limit treatment options, cut off treatment prematurely, or stigmatize a person, the system is adding to the person's problems. Because of the enormous growth and impact of the mental health profession in our society, it is important that we understand the profession's strengths and weaknesses. As you have seen throughout this book, the field has gathered much knowledge, especially during the past several decades. What mental health professionals do not know and cannot do, however, still outweighs what they do know and can do. Everyone who turns to the clinical field—directly or indirectly—must recognize that it is young and imperfect. Society is vastly curious about behavior and often in need of information and help. What we as a society must remember, however, is that the field is still unfolding.AT ONE TIME, CLINICAL RESEARCHERS and professionals conducted their work largely in isolation. Today their activities have numerous ties to the legislative, judicial, and economic systems, and to technological forces as well. One reason for this growing interconnectedness is that the clinical field has reached a high level of respect and acceptance in our society. Clinicians now serve millions of people in many ways. They have much to say about almost every aspect of society, from education to ecology, and are widely looked to as sources of expertise. When a field becomes so prominent, it inevitably affects how other institutions are run. It also attracts public scrutiny, and various institutions begin to keep an eye on its activities. When people with psychological problems seek help from a therapist, they are entering a complex system consisting of many interconnected parts. Just as their personal problems have grown within a social structure, so will their treatment be affected by the various parts of a larger system—the therapist's values and needs, legal and economic factors, societal attitudes, technological changes, and yet other forces. These many forces influence clinical research as well.

psychology in law: how to do clinicians influence the criminal justice system

To arrive at just and appropriate punishments, the courts need to know whether defendants are responsible for the crimes they commit and capable of defending themselves in court. If not, it would be inappropriate to find defendants guilty or punish them in the usual manner. The courts have decided that in some instances people who suffer from severe mental instability may not be responsible for their actions or may not be able to defend themselves in court, and so should not be punished in the usual way. Although the courts make the final judgment as to mental instability, their decisions are guided to a large degree by the opinions of mental health professionals. When people accused of crimes are judged to be mentally unstable, they are usually sent to a mental institution for treatment, a process called criminal commitment.Actually there are several forms of criminal commitment. In one, people are judged mentally unstable at the time of their crimes and so innocent of wrongdoing. They may plead not guilty by reason of insanity (NGRI) and bring mental health professionals into court to support their claim. When people are found not guilty on this basis, they are committed for treatment until they improve enough to be released (Gowensmith et al., 2017). In a second form of criminal commitment, people are judged mentally unstable at the time of their trial and so are considered unable to understand the trial procedures and defend themselves in court. They are committed for treatment until they are competent to stand trial. Once again, the testimony of mental health professionals helps determine the defendant's psychological functioning. These judgments of mental instability have stirred many arguments. Some people consider the judgments to be loopholes in the legal system that allow criminals to escape proper punishment for wrongdoing. Others argue that a legal system simply cannot be just unless it allows for extenuating circumstances, such as mental instability. The practice of criminal commitment differs from country to country. In this chapter you will see primarily how it operates in the United States. Although the specific principles and procedures of each country may differ, most countries grapple with the same issues, concerns, and decisions that you will read about here.

the economics of mental health

You have already seen how economic decisions by the government may influence the clinical field's treatment of people with severe mental disorders. For example, the desire of the state and federal governments to reduce costs was an important consideration in the country's deinstitutionalization movement, which contributed to the premature release of hospital patients into the community. Economic decisions by government agencies may affect other kinds of clients and treatment programs as well. As you read in Chapter 15, government funding for services to people with psychological disorders has risen sharply over the past five decades, from $1 billion in 1963 to around $152 billion today (SAMHSA, 2017, 2014). Around 28 percent of that money is spent on prescription drugs, but much of the rest is targeted for income support, housing subsidies, and other such expenses rather than direct mental health services. The result is that government funding for mental health services is, in fact, insufficient. People with severe mental disorders are hit hardest by the funding shortage. The number of people on waiting lists for community-based services grew from 200,000 in 2002 to 393,000 in 2008, and that number has increased still more over the past decade, according to individual state reports (Morris, 2017; NCBH, 2017; Daly, 2010). Government funding currently covers 63 percent of all mental health services, leaving a mental health expense of tens of billions of dollars for individual patients and their private insurance companies (SAMHSA, 2017, 2014). This large economic role of private insurance companies has had a significant effect on the way clinicians go about their work. As you'll remember from Chapter 1, to reduce their expenses, most of these companies have developed managed care programs, in which the insurance company determines which therapists clients may choose from, the cost of sessions, and the number of sessions for which a client may be reimbursed (Bowers et al., 2016). These and other insurance plans may also control expenses through the use of peer review systems, in which clinicians who work for the insurance company periodically review a client's treatment program and recommend that insurance benefits be either continued or stopped. Typically, insurers require reports or session notes from the therapist, often including intimate personal information about the patient As you also read in Chapter 1, many therapists and clients dislike managed care programs and peer reviews (Decker, 2016; Lustig et al., 2013). They believe that the reports required of therapists breach confidentiality, even when efforts are made to protect anonymity, and that the importance of therapy in a given case is sometimes difficult to convey in a brief report. They also argue that the priorities of managed care programs inevitably shorten therapy, even if longer-term treatment would be advisable in particular cases. The priorities may also favor treatments that offer short-term results (for example, drug therapy) over more costly approaches that might yield more promising long-term improvement (Bowers et al., 2016). As in the medical field, there are disturbing stories about patients who are prematurely cut off from mental health services by their managed care programs. In short, many clinicians fear that the current system amounts to regulation of therapy by insurance companies rather than by therapists. Yet another major problem with insurance coverage in the United States—whether managed care or other kinds of insurance programs—is that reimbursements for mental disorders are, on average, lower than those for physical disorders, placing people with psychological difficulties at a significant disadvantage (McGuire, 2016; Sipe et al., 2015). As you have read, the federal government tried to address this problem from 2008 through 2016 (see pages 16-18). In 2008 Congress passed a parity law that mandated equal insurance coverage for mental and physical problems, and in 2014 the mental health provisions of the Affordable Care Act ("Obamacare") expanded the reach of the earlier bill. If, however, efforts in Congress to change or repeal the Affordable Care Act eventually succeed, it is possible that the federal mandates for parity in mental health insurance coverage will, likewise, be discontinued.

phenothiazines

a group of antihistamine drugs that became the first group of effective antipsychotic medications -discovered in the 1950s

second-generation antipsychotic drugs

a relatively new group of antipsychotic drugs whose biological action is different from that of the first-generation antipsychotic drugs. also know as atypical antipsychotic drugs. -the newer drugs bind not only to D-2 dopamine receptors, like the first-generation antipsychotic drugs, but also to many D-1 receptors and to receptors for other neurotransmitters such as serotonin, glutamine, and GABA

avolition

a symptom of schizophrenia marked by apathy and an inability to start or complete a course of action

psychological research of legal topics

sychologists have sometimes conducted studies and developed expertise on topics of great importance to the criminal justice system. In turn, these studies influence how the system carries out its work. Psychological investigations of two topics, eyewitness testimony and patterns of criminality, have gained particular attention. EYEWITNESS TESTIMONY In criminal cases, testimony by eyewitnesses is extremely influential. It often determines whether a defendant will be found guilty or not guilty. But how accurate is eyewitness testimony? This question has become urgent, as a troubling number of prisoners (many on death row) have had their convictions overturned after DNA evidence revealed that they could not have committed the crimes of which they had been convicted. It turns out that more than 70 percent of such wrongful convictions were based in large part on mistaken eyewitness testimony (Innocence Project, 2017; Wise et al., 2014). Most eyewitnesses undoubtedly try to tell the truth about what or who they saw. Yet research indicates that eyewitness testimony can be highly unreliable, partly because eyewitnesses sometimes hold subtle biases and partly because most crimes are unexpected and fleeting and therefore not the sort of events remembered well (Carpenter & Krendl, 2016; Houston et al., 2013). During the crime, for example, lighting may be poor or other distractions may be present. Witnesses may have had other things on their minds, such as concern for their own safety or that of bystanders. Such concerns may greatly impair later memory In laboratory studies, researchers have found it easy to fool participants who are trying to recall the details of an observed event simply by introducing misinformation (Loftus, 2017; Rindal et al., 2017; Morgan et al., 2013). After a suggestive description by the researcher, stop signs can be transformed into yield signs, white cars into blue ones, and Mickey Mouse into Minnie Mouse. In addition, laboratory studies indicate that persons who are highly suggestible have the poorest recall of observed events (Liebman et al., 2002). As for identifying actual perpetrators, research has found that accuracy is heavily influenced by the method used in identification (Wixted & Wells, 2017; Bartol & Bartol, 2015). For example, police lineups, particularly ones conducted poorly, are not always reliable, and the errors that witnesses make when looking at lineups tend to stick (Miura & Itoh, 2016; Wixted et al., 2016; Wells et al., 2015, 2011). Researchers have also learned that the confidence of witnesses is not consistently related to accuracy (Wixted & Wells, 2017; Wise et al., 2014). Witnesses who are "absolutely certain" may be no more correct in their recollections than those who are only "fairly sure." Yet the degree of a witness's confidence often influences whether jurors believe his or her testimony (Loftus & Greenspan, 2017). Psychological investigations into the memories of eyewitnesses have not yet undone the judicial system's reliance on or respect for those witnesses' testimony. Nor should it. The distance between laboratory studies and real-life events is often great, and the findings from such studies must be applied with care. Still, eyewitness research has begun to make an impact. Instructions to jurors about the accuracy of eyewitness confidence may now be included in eyewitness cases (Cash & Lane, 2017; Safer et al., 2016). In addition, studies of hypnosis and of its ability to create false memories have led most states to prohibit eyewitnesses from testifying about events or details if their recall of the events was initially helped by hypnosis. PATTERNS OF CRIMINALITY A growing number of television shows, movies, and books suggest that clinicians often play a major role in criminal investigations by providing police with psychological profiles of perpetrators—"He's probably white, in his thirties, has a history of animal torture, has few friends, and is subject to emotional outbursts." The study of criminal behavior patterns and of profiling has increased in recent decades; however, it is not nearly as revealing or influential as the media and the arts would have us believe (Kapardis, 2017; Kocsis & Palermo, 2016, 2013). On the positive side, researchers have gathered information about the psychological features of various criminals, and they have indeed found that perpetrators of particular kinds of crimes—serial murder or serial sexual assault, for example—frequently share a number of traits and background features (see PsychWatch). But while such traits are often present, they are not always present, and so applying profile information to a particular crime can be wrong and misleading (Kapardis, 2017). Increasingly, police are consulting psychological profilers, and this practice appears to be helpful as long as the limitations of profiling are recognized A reminder of the limitations of profiling comes from the case of the snipers who terrorized the Washington, DC, area for three weeks in October 2002, shooting 10 people dead and seriously wounding 3 others. Most of the profiling done by FBI psychologists had suggested that the sniper was acting alone; it turned out that the attacks were conducted by a pair: a middle-aged man, John Allen Muhammad, and a teenage boy, Lee Boyd Malvo. Although profiles had suggested a young thrill-seeker, Muhammad was 41. Profilers had believed the attacker to be non-Hispanic white but neither Muhammad nor Malvo was white. The prediction of a male attacker was correct, but then again female serial killers are relatively rare.

biological explanation of antisocial personality disorder

-A wide range of studies suggest that biological factors play an important role in antisocial personality disorder -First, there are indications that people may inherit a biological predisposition to the disorder -For example, twin research has found that 67% of the identical twins of people with antisocial personality disorder also display the disorder themselves, in contrast to 31% of fraternal twins of people with the disorder -In a similar vein, some genetic research suggests that the disorder may be linked to particular genes -Biological researchers have found that antisocial people, particularly those who are highly impulsive and aggressive, have lower serotonin activity than other people -As you'll recall both impulsivity and aggression also have been linked to low serotonin activity in other kinds of studies, so the presence of this biological factor in people with antisocial personality disorder is not surprising -In related work, studies indicate that individuals with this disorder display deficient functioning in their prefrontal cortex and anterior cingulate cortex -Among other duties, these brain structures help people to plan and execute realistic strategies and to have personal characteristics such as sympathy, judgment, and empathy -These are, of course, all qualities found wanting in people with antisocial personality disorder. Similar research has found deficient functioning in the amygdala, hippocampus, and temporal cortex of people with this disorder, brain structure problems that may contribute to the individuals' inability to follow rules -A different line of biological research has found that research participants with this disorder often respond to warnings or expectations of stress with low brain and bodily arousal, such as slow autonomic arousal and slow EEG waves -It is believed that such underarousal in response to stress enables people with the disorder to readily tune out threatening or emotional situations and so be unaffected by them. This could help explain a phenomenon often observed by clinicians—that people with antisocial personality disorder seem to feel less anxiety than other people, and so lack a key ingredient for learning from negative life experiences or tuning in to the emotional cues of others -It could also be argued that because of their physical underarousal, people with antisocial personality disorder are more likely than other people to take risks and seek thrills -That is, they may be drawn to antisocial activity precisely because it meets an underlying biological need for more excitement and arousal -In support of this idea, as you read earlier, antisocial personality disorder often goes hand in hand with sensation-seeking behavior -These various biological factors may be tied together more closely than first meets the eye -Consistent with the field's increasing emphasis on dysfunctional brain circuits, many theorists now suspect that antisocial personality disorder is ultimately related to poor functioning by a brain circuit consisting of the prefrontal cortex, anterior cingulate cortex, amygdala, hippocampus, and temporal cortex, among other structures -Poor communication (that is, poor interconnectivity) between the structures in this circuit may produce chronic low reactions to stress by the two brain-body stress pathways—the sympathetic nervous system pathway and the hypothalamic-pituitary-adrenal pathway—leading, in turn, to a state of low arousal, weak stress reactions, poor empathy for the pain of others, and other features of antisocial personality disorder -Although enthusiasm for this circuit-centered explanation is growing, research regarding its specifics and merits has been limited to date

mass murders

-Clinical theorists and researchers have offered various theories about why individuals commit such murders, but enlightening research and effective interventions have been elusive -We know they involve, by definition, the murder of four or more people in the same location and at around the same time -FBI records also indicate that, on average, mass killings occur in the United States every two weeks, 75 percent of them feature a lone killer, 67 percent involve the use of guns, and most are committed by males -We also know that despite public perceptions, mass killings are not a new phenomenon. They have occurred—with regularity—for centuries -What is new, however, is the increasing frequency of mass public shootings (for example, schools, shopping malls, and workplaces) and the emergence of certain patterns of mass murder -Although specific issues vary from mass murder to mass murder—racial or religious hatred, for example—two general patterns are on the rise -In one pattern, so-called "pseudocommando" mass murders, the murderer "kills in public, often during the daytime, plans his offense well in advance, and comes prepared with a powerful arsenal of weapons. He has no escape planned and expects to be killed during the incident" -In another pattern, "autogenic" (self-generated) massacres, individuals kill people indiscriminately to fulfill a personal agenda -Theorists have suggested a number of factors to help explain pseudocommando, autogenic, and other mass killings, including the availability of guns, bullying behavior, substance abuse, the proliferation of violent media and video games, dysfunctional homes, and contagion effects -Moreover, regardless of one's position on gun control, media violence, or the like, almost everyone, including most clinicians, believe that mass killers typically suffer from a mental disorder -Which mental disorder? On this, there is little agreement -Each of the following has been suggested: --Antisocial, borderline, paranoid, or schizotypal personality disorder --Schizophrenia or severe bipolar disorder --Intermittent explosive disorder—an impulse-control disorder featuring repeated, unprovoked verbal and/or behavioral outbursts --Severe depression, stress, or anxiety -Although these and yet other disorders have been proposed, none has received clear support in the limited research conducted on mass killings. -On the other hand, several psychological variables have emerged as a common denominator across the various studies: severe feelings of anger and resentment, feelings of being persecuted or grossly mistreated, and desires for revenge -That is, regardless of which mental disorder a mass killer may display, he usually is driven by this set of feelings. -For a growing number of clinical researchers, this repeated finding suggests that research should focus less on diagnosis and much more on identifying and understanding these particular feelings.

integrative explanations for BPD

-In recent years, two explanations—the biosocial and the developmental psychopathology explanations—have examined how these various factors, particularly the psychological and biological factors, might intersect to more fully account for borderline personality disorder -As you will see, the two explanations are quite compatible and often overlap -According to the biosocial explanation (Neacsiu & Linehan, 2014), borderline personality disorder results from a combination of internal forces (for example, difficulty identifying and controlling one's emotions, social skill deficits, abnormal neurotransmitter activity) and external forces (for example, an environment in which a child's emotions are punished, ignored, trivialized, or disregarded). Parents may, for instance, misinterpret their child's intense emotions as exaggerations or attempts at manipulation rather than as serious expressions of unsettled internal states. According to the biosocial theory, if children have intrinsic difficulty identifying and controlling their emotions and if their parents teach them to ignore their intense feelings, they may never learn how properly to recognize and control their emotional arousal, how to tolerate emotional distress, or when to trust their emotional responses (Herpertz & Bertsch, 2014; Lazarus et al., 2014). Such children will be at risk for the development of borderline personality disorder. This theory has received some, but not consistent, research support -Note that the biosocial theory is similar to one of the leading explanations for eating disorders. As you saw in Chapter 11, pioneering theorist Hilde Bruch proposed that children whose parents do not respond accurately to the children's internal cues may never learn to identify cues of hunger, thus increasing their risk of developing an eating disorder (see pages 322-323). Small wonder that a large number of people with borderline personality disorder also have an eating disorder (Gabriel & Waller, 2014). Recall, for example, Dal's binge eating behaviors. Proponents of the other integrative explanation of borderline personality disorder, the developmental psychopathology explanation, build on and add details to the biosocial view. Like the biosocial theorists, developmental psychopathologists believe that internal and external factors intersect over the course of a person's life to help produce this disorder (Fonagy & Luyten, 2018, 2016; Lenzenweger & Depue, 2016; Tackett et al., 2016). While these theorists are interested in all such factors—from genetic to environmental—they believe that early parent−child relationships are particularly influential in the development of borderline personality disorder. Consistent with the psychodynamic model's object relations theorists, developmental psychopathologists contend that children who experience early trauma and abuse and whose parents are markedly inattentive, uncaring, confusing, threatening, and dismissive, are likely to develop a disorganized attachment style (Fonagy & Luyten, 2018, 2016). That is, their attachments to other people throughout life will parallel their problematic attachments to their parents and will be filled with anxiety, emotional instability, and inconsistency. In short, according to the developmental psychopathology explanation, individuals whose early childhoods are marked by traumas and dysfunctional attachments with their parents are likely to enter adulthood with a severely flawed capacity for healthy relationships—a disorganized attachment style—unless they are fortunate enough to further experience significant positive factors (positive genetic predispositions, positive life events, sensitive role models, opportunities to build resilience, and the like) that help counter their early negative experiences (Fonagy et al., 2017). Individuals who do not experience such positive factors are, say developmental psychopathologists, high risk candidates for borderline personality disorder. Studies repeatedly confirm that, on average, people with borderline personality disorder display a disorganized attachment style and have indeed experienced unfavorable parenting and early childhood traumas (Fonagy & Luyten, 2018, 2016; Beeney et al., 2017). In recent years, a number of theorists, particularly developmental psychopathologists, have also come to believe that the central psychological deficit in borderline personality disorder may be the person's inability to mentalize (Bateman & Fonagy, 2016, 2012, 2010). Mentalization refers to people's capacity to understand their own mental states and those of other people—that is, to recognize needs, desires, feelings, beliefs, and goals. When people mentalize effectively, they can better understand and predict the behaviors of other people, and they can react to others in appropriate and trusting ways. Many developmental psychopathologists suspect that persons subjected to early dysfunctional attachment relationships emerge from their childhood with a weakened ability to mentalize and, correspondingly, a poor ability to control their emotions, attention, thinking, and behavior (Quek et al., 2017; Fonagy & Luyten, 2018, 2016; Sroufe et al., 2005). They cannot accurately understand either their own or other people's underlying mental states. As one theorist has stated, a mind that repeatedly misinterprets itself is going to misinterpret others as well (Bateman & Fonagy, 2016, 2012, 2010). Several psychological disorders have been linked to poor mentalization skills, but those skills seem particularly flawed in people with borderline personality disorder, according to research (Badoud et al., 2018; Fonagy et al., 2017). The developmental psychopathology notions about borderline personality disorder have excited many in the clinical field, just as the perspective's explanations of other psychological disorders have aroused enthusiasm. Moreover, studies have found clear relationships between poor parent−child attachments and the development of disorganized attachment styles and between disorganized attachment styles and borderline personality disorders (Beeney et al., 2017; Bateman & Fonagy, 2016, 2012, 2010). However, it is not necessarily the case that early parent−child attachments are the primary factor in the development of this disorder. Nor is it clear that mentalization deficits are at the center of the disorder. Those important issues are currently being investigated in a range of studies

borderline personality disorder

-a personality disorder characterized by repeated instability in interpersonal relationships, self-image, and mood, and by impulsive behavior -these characteristics combine to make their relationships very unstable as well -people with borderline personality disorder swing in and out of very depressive, anxious, and irritable states that last anywhere from a few hours to a few days or more -their emotions seem to be always in conflict with the world around them -they are prone to bouts of anger, which sometimes result in physical aggression and violence -just as often, however, they direct their impulsive anger inward and inflict bodily harm on themselves -many seem troubled by deep feelings of emptiness -borderline personality disorder is a complex disorder, and it is fast becoming one of the more common conditions seen in clinical practice -as many as 85% of individuals with this syndrome also experience another psychological disorder at some point in their lives, most often major depressive disorder, PTSD, an eating disorder, bipolar disorder, and/or another personality disorder -their impulsive, self-destructive activities may range from alcohol and substance abuse to delinquency, unsafe sex, and reckless driving -many engage in self-injurious or self-mutilation behaviors, such as cutting or burning themselves or banging their heads -as you saw in Chapter 9, such behaviors typically cause immense physical suffering, but those with borderline personality disorder often feel as if the physical discomfort offers relief from their emotional suffering -it may serve as a distraction from their emotional or interpersonal upsets, "snapping" them out of an "emotional overload" -many try to hurt themselves as a way of dealing with their chronic feelings of emptiness, boredom, and identity confusion -scars and bruises also may provide them with a kind of concrete evidence of their emotional distress -suicidal threats and actions are also common -studies suggest that around 75 percent of people with borderline personality disorder attempt suicide at least once in their lives; as many as 10 percent actually die of suicide -it is common for people with this disorder to enter clinical treatment by way of the emergency room after a suicide attempt -people with borderline personality disorder frequently form intense, conflict-ridden relationships in which their feelings are not necessarily shared by the other person -they may come to idealize another person's qualities and abilities after just a brief first encounter -they also may violate the boundaries of relationships -thinking in dichotomous (black-and-white) terms, they quickly feel rejected and become furious when their expectations are not met; yet they remain very attached to the relationships -in fact, they have recurrent fears of impending abandonment and frequently engage in frantic efforts to avoid real or imagined separations from important people in their lives -sometimes they cut themselves or carry out other self-destructive acts to prevent partners from leaving -people with borderline personality disorder typically have dramatic identity shifts -because of this unstable sense of self, their goals, aspirations, friends, and even sexual orientation may shift rapidly -they may also occasionally have a sense of dissociation, or detachment, from their own thoughts or bodies -at times they may have no sense of themselves at all, leading to the feelings of emptiness described earlier -according to surveys, 5.9 percent of the adult population display borderline personality disorder -close to 75 percent of the patients who receive the diagnosis are women -the course of the disorder varies from person to person -in the most common pattern, the person's instability and risk of suicide peak during young adulthood and then gradually wane with advancing age -given the chaotic and unstable relationships characteristic of borderline personality disorder, it is not surprising that the disorder tends to interfere with job performance even more than most other personality disorders do

antisocial personality disorder

-a personality disorder marked by a general pattern of disregard for and violation of other people's rights -sometimes described as "psychopaths" or "sociopaths" -aside from substance use disorders, this is the disorder most closely linked to adult criminal behavior -DSM-5 stipulates that a person must be at least 18 years of age to receive this diagnosis; however, most people with antisocial personality disorder displayed some patterns of misbehavior before they were 15, including truancy, running away, cruelty to animals or people, and destroying property -people with antisocial personality disorder lie repeatedly; many cannot work consistently at a job; they are absent frequently and are likely to quit their jobs altogether -usually they are also careless with money and frequently fail to pay their debts -they are often impulsive, taking action without thinking of the consequences -correspondingly, they may be irritable, aggressive, and quick to start fights -many travel from place to place -recklessness is another common trait: people with antisocial personality disorder have little regard for their own safety or for that of others, even their children -they are self-centered as well, and are likely to have trouble maintaining close relationships -usually they develop a knack for gaining personal profit at the expense of other people -because the pain or damage they cause seldom concerns them, clinicians commonly say that they lack a moral conscience -they think of their victims as weak and deserving of being conned, robbed, or even physically harmed -surveys indicate that 3.6% of adults in the United States meet the criteria for antisocial personality disorder -the disorder is as much as four times more common among men than women -because people with this disorder are often arrested, researchers frequently look for people with antisocial patterns in prison populations -it is estimated that at least 35% of people in prison meet the diagnostic criteria for this disorder -among men in urban jails, the antisocial personality pattern has been linked strongly to past arrests for crimes of violence -the criminal behavior of many people with this disorder declines after the age of 40; some, however, continue their criminal activities throughout their lives -studies and clinical observations also indicate that people with antisocial personality disorder have higher rates of alcoholism and other substance use disorders than do the rest of the population -indeed, some research indicates that more than 80% of people with this personality disorder display a substance use disorder at some point in their lives -perhaps intoxication and substance misuse help trigger the development of antisocial personality disorder by loosening a person's inhibitions -perhaps this personality disorder somehow makes a person more prone to abuse substances -or perhaps antisocial personality disorder and substance use disorders both have the same cause, such as a deep-seated need to take risks -interestingly, drug users with the personality disorder often cite the recreational aspects of drug use as their reason for starting and continuing it -consistent with this risk-focused explanation, a number of people with antisocial personality disorder also display gambling disorder -in fact, the personality disorder is manifested by 23% of all people with gambling disorder -it appears that children with conduct disorder and an accompanying attention-deficit/hyperactivity disorder have a heightened risk of developing antisocial personality disorder -these two childhood disorders often bear similarities to antisocial personality disorder -like adults with antisocial personality disorder, children with a conduct disorder persistently lie and violate rules and other people's rights, and children with attention-deficit/hyperactivity disorder lack foresight and judgment and fail to learn from experience -intriguing as these observations may be, however, the precise connection between the childhood disorders and antisocial personality disorder has been difficult to pinpoint.

residual phase of schizophrenia

-return to prodromal-like levels -they may retain some negative symptoms, such as blunted emotion, but have a lessening of the striking symptoms of the active phase -although 25% or more of patients recovery completely from schizophrenia, the majority continue to have at least some residual problems from the rest of their lives

schizophreniform disorder

-various psychotic symptoms, such as delusions, hallucinations, disorganized speech, restricted or inappropriate affect, and catatonia -1 to 6 months -lifetime prevalence: 0.20%

psychosis

A state in which a person loses contact with reality in key ways. -Most commonly appears in schizophrenia -Their ability to perceive and respond to the environment becomes so disturbed that they may not be able to function at home, with friends, in school, or at work -They may have hallucinations (false sensory perceptions) or delusions (false beliefs), or they may withdraw into a private world -Taking LSD or abusing amphetamines or cocaine may also produce psychosis -So may injuries or diseases of the brain -So may other severe psychological disorders, such as major depressive disorder or bipolar disorder -Most commonly, however, psychosis appears in the form of schizophrenia -The term schizophrenia comes from the Greek words for "split mind."

biological view of schizophrenia stats

-1% of the general population develops schizophrenia -the prevalence rises to 3% among second-degree relatives with the disorder--that is half-siblings, uncles, aunts, nephews, nieces, and grandchildren--and it reaches an average of 10% among first-degree relatives (parents, siblings, and children)

downward drift theory

-Although schizophrenia appears in all socioeconomic groups, it is found more frequently in the lower levels. -This has led some theorists to believe that the stress of poverty is itself a cause of the disorder. -However, it could be that schizophrenia causes its sufferers to fall from a higher to a lower socioeconomic level or to remain poor because they are unable to function effectively. -This is sometimes called the downward drift theory

psychodynamic explanation of antisocial personality disorder

-As with many other personality disorders, psychodynamic theorists propose that this one begins with an absence of parental love during infancy, leading to a lack of basic trust -In this view, some children—the ones who develop antisocial personality disorder—respond to the early inadequacies by becoming emotionally distant, and they bond with others through the use of power and destructiveness. -In support of the psychodynamic explanation, researchers have found that people with this disorder are more likely than others to have had significant stress in their childhoods, particularly in such forms as family poverty, family violence, child abuse, and parental conflict or divorce

catatonic posturing

-people assume awkward, bizarre positions for long periods of time -ex. they may spend hours holding their arms out at a 90 degree angle or balancing in a squatting position

delusions of control

-people believe their feelings, thoughts, and actions are being controlled by other people

delusions of grandeur

-people believe themselves to be great inventors, religious saviors, or other specially empowered persons

psychological explanations for BPD

-Because a fear of abandonment tortures so many people with borderline personality disorder, psychodynamic theorists have looked once again to early parental relationships to explain the disorder. Object relations theorists, for example, propose that an early lack of acceptance by parents may lead to a loss of self-esteem, increased dependence, and an inability to cope with separation (Huprich et al., 2017; Caligor & Clarkin, 2010; Gabbard, 2010). Research has found that this is consistent with the early childhoods of people with borderline personality disorder. In many cases, when they were children, their parents neglected or rejected them, verbally abused them, or otherwise behaved inappropriately (Skodol, 2017; Martín-Blanco et al., 2014). Their childhoods were often marked by multiple parent substitutes, divorce, death, or traumas such as physical or sexual abuse. Indeed, research suggests that early sexual abuse is a common contributor to the development of borderline personality disorder (Newnham & Janca, 2014; Huang, Yang, & Wu, 2010). Children who experience such abuse are four times more likely to develop the disorder than those who do not experience abuse (Zelkowitz et al., 2001). At the same time, it is important to recognize that the vast majority of people with histories of physical, sexual, or psychological abuse do not go on to develop borderline personality disorder

psychodynamic explanation of schizophrenia

-Fromm-Reichmann: Schizophrenogenic mothers (little research support) -believed cold or unnurturing parents may set schizophrenia in motion -mothers described as cold, domineering, and uninterested in their children's needs -these mothers may appear to be self-sacrificing but are actually using their children to meet their own needs -at once overprotective and rejecting, they confused their children and set the stage for schizophrenic functioning -called schizoprenogenic mothers -but majority of people with schizophrenia do not appear to have mothers who fit the schizophrenogenic descriptiontion -self theorists: biological deficiencies cause development of fragmented self

selfies: narcissistic or not?

-In the art world, people have been drawing self-portraits for centuries. In recent years, however, digital technology has ushered in the era of the selfie, a cousin to the self-portrait. Safe to say, just about every cell phone user has taken a selfie. In fact, more than 90 percent of all teens have now posted a photo of themselves online (SMA, 2017; Pew Research Center, 2014), and, according to some estimates, 93 million selfies are posted online every day (Whitbourne, 2016). These self-photos have created such a stir that the word "selfie" was elected "Word of the Year" by the Oxford English Dictionary a few years back. As the selfie phenomenon has grown, opinions about selfies have intensified (Diefenbach & Christoforakos, 2017). It seems like people either love them or hate them. This is true in the field of psychology as well. Some psychologists view taking selfies as a form of narcissistic behavior, while others view them more positively -First, the negative perspective. Many sociocultural theorists see a link between narcissistic personality disorder and "eras of narcissism" in society (Paris, 2014). They suggest that social values in society break down periodically, producing generations of self-centered, materialistic youth. Some of these theorists consider today's selfie generation a perfect example of a current era of narcissism. This theory has gained a large following, but it is not supported by research. Several teams of investigators have found no relationship at all between how many selfies people post and how high they score on narcissism personality scales (Etgar & Amichai-Hamburger, 2017; Alloway, 2014; Alloway et al., 2014). Other researchers have found that people who score high on narcissism scales do, on average, like to take selfies, but many such individuals do not (Kim et al., 2016; Whitbourne, 2016). Moreover, the vast majority of people who post selfies do not score especially high on narcissism scales. -This lack of support for the narcissism viewpoint does not mean that selfies, especially repeated selfie behaviors, are completely harmless. Sherry Turkle, an influential technology psychologist, believes that the near-reflexive instinct to photograph oneself may limit deeper engagements with the environment or prevent a full experience of events (Turkle, 2015, 2013; Eisold, 2013). Turkle also suggests that people who post an endless stream of selfies are often seeking external validation of their self-worth, even if that pursuit may not rise to a level of clinical narcissism. Psychologists also observe that posting too many "selfies" may alienate those who view the poster's social media profile (Miller, 2013). Studies have found, for example, that people often take a negative view of friends and family members who excessively post photos to their Facebook sites (Houghton, 2013). On the positive side, a number of psychologists believe that the criticisms and concerns about the selfie movement have been overstated. They agree with media psychologist Pamela Rutledge (2013) that, for the most part, selfies are an inevitable by-product of "technology-enabled self-expression." Rutledge contends that selfie behaviors are simply confusing to individuals of a predigital generation. Moreover, she concludes that the selfie trend can enhance explorations of identity, help identify one's interests, develop artistic expression, help people craft a meaningful narrative of their life experiences, and even reflect more realistic body images (for example, posting "selfies" without makeup). Indeed, several studies have supported these points and have also uncovered additional positive motives and effects of selfie taking (Christensen, 2017; Holiday et al., 2016; Kim et al., 2016). In short, like other technological trends you've read about, the selfie phenomenon has received mixed grades from psychology researchers and practitioners so far

treatments for BPD

-It appears that psychotherapy can eventually lead to some degree of improvement for people with borderline personality disorder (Livesley, 2017; Choi-Kain et al., 2016; McMain, 2015). It is, however, extraordinarily difficult for a therapist to strike a balance between empathizing with the borderline client's dependency and anger and challenging his or her way of thinking (Skodol, 2016; Goodman et al., 2014). The wildly fluctuating interpersonal attitudes of clients with the disorder can also make it difficult for therapists to establish collaborative working relationships with them. Moreover, clients with borderline personality disorder may violate the boundaries of the client-therapist relationship (for example, calling the therapist's emergency contact number to discuss matters of a less urgent nature) (Skodol, 2016; Colli et al., 2014). Traditional psychoanalytic therapy has not been effective with people with borderline personality disorder (Doering et al., 2010). The clients often experience the psychoanalytic therapist's reserved style and use of free association as suggesting disinterest and abandonment. The clients may also have difficulty tolerating interpretations made by psychoanalytic therapists and see them as attacks. On the other hand, contemporary psychodynamic approaches, particularly relational psychoanalytic therapy (see page 58), in which therapists take a more supportive posture and focus primarily on the therapist−patient relationship, have been more effective than traditional psychoanalytic approaches. In approaches of this kind, therapists work to provide an empathic setting within which borderline clients can explore their unconscious conflicts and pay attention to their central relationship disturbance, poor sense of self, and pervasive loneliness and emptiness (Cristea et al., 2017; Goodman et al., 2014; Gabbard, 2010, 2001). Research has found that relational psychoanalytic therapy and other contemporary psychodynamic treatments may help reduce suicide attempts, self-harm behaviors, and the number of hospitalizations, and bring at least some improvement to those with the disorder (Skodol, 2016; Clarkin et al., 2010, 2001; Doering et al., 2010). Over the past two decades, a new-wave cognitive-behavioral therapy for borderline personality disorder, called dialectical behavior therapy (DBT), has received considerable research support and is now considered the treatment of choice for people with borderline personality disorder (Robins et al., 2018; Rudge et al., 2018; Linehan et al., 2015, 2002, 2001). DBT, developed by psychologist Marsha Linehan, consists of weekly individual therapy and group skill-building sessions that last for approximately one year. While targeting all of the features of borderline personality disorder, DBT places special emphasis on clients' efforts at self-harm and/or suicide. The individual therapy sessions include many of the same behavioral and cognitive techniques that are applied to other disorders: homework assignments, psychoeducation, the teaching of coping and related skills, modeling by the therapist, clear goal setting, reinforcements for appropriate behaviors, mindfulness skill training, ongoing assessment of the client's behaviors and treatment progress, and collaborative examinations by the client and therapist of the client's ways of thinking -Although primarily cognitive-behavioral, the individual DBT sessions also borrow heavily from the humanistic and contemporary psychodynamic approaches, placing the client-therapist relationship itself at the center of treatment interactions, making sure that appropriate treatment boundaries are adhered to, and providing an environment of acceptance and validation of the client. Indeed, DBT therapists regularly empathize with their borderline clients and with the emotional turmoil they are experiencing; locate kernels of truth in the clients' complaints or demands; and examine alternative ways for them to address valid needs (Skodol, 2016). DBT clients also participate in social skill-building groups (Kramer, 2017; Roney & Cannon, 2014). In these groups, clients practice new ways of relating to other people in a safe environment and receive validation and support from other group members. DBT has received more research support than any other treatment for borderline personality disorder (Rudge et al., 2018; Livesley, 2017; Neacsiu & Linehan, 2014). Many clients who undergo DBT become more able to tolerate stress, develop more social skills, respond more effectively to life situations, and develop a more stable identity. They also display significantly fewer self-harm and suicidal behaviors and require fewer hospitalizations than those who receive other forms of treatment. In addition, they are more likely to remain in treatment and to report less anger, more social gratification, improved work performance, and reductions in substance abuse (Skodol, 2016; Linehan et al., 2015; Rizvi et al., 2011). Antidepressant, antibipolar, antianxiety, and antipsychotic drugs have helped calm the emotional and aggressive storms of some people with borderline personality disorder (Bridler et al., 2015). However, given the numerous suicide attempts by people with this disorder, some clinicians believe that the use of drugs on an outpatient basis is unwise (Gunderson, 2011). Most professionals believe that psychotropic drug treatment for borderline personality disorder should be used largely as an adjunct to psychotherapy approaches, and indeed many clients seem to benefit from a combination of psychotherapy and drug therapy

explanations for antisocial personality disorder

-Most explanations of antisocial personality disorder come from the psychodynamic, cognitive-behavioral, and biological models. -In fact, a number of factors have been linked to this disorder by researchers, but complete explanations have been elusive

cognitive-behavioral explanation of antisocial personality disorder

-On the behavioral side, many theorists have suggested that antisocial symptoms may be learned through principles of conditioning, particularly modeling, or imitation -As evidence, they point to the higher rate of antisocial personality disorder found among the parents and close relatives of people with this disorder -The modeling explanation is also supported by studies of friends and associates of people with antisocial personality disorder -For example, one investigation found that middle school students who were attracted to antisocial peers went on to engage in antisocial behavior themselves in order to gain acceptance -Other theorists have pointed to another principle of conditioning, operant conditioning, to help explain antisocial personality disorder -These theorists suggest that some parents unintentionally teach antisocial behavior by regularly rewarding a child's aggressive behavior -When the child misbehaves or becomes violent in reaction to the parents' requests or orders, for example, the parents may give in to restore peace -Without meaning to, they may be teaching the child to be stubborn and perhaps even violent -On the cognitive side, a number of theorists say that people with antisocial personality disorder hold attitudes that trivialize the importance of other people's needs -Such a philosophy of life, the theorists suggest, may be far more common in our society than people recognize. In another explanation that emphasizes cognitive functioning, some theorists propose that people with this disorder have genuine difficulty recognizing points of view or feelings other than their own

treatments for histrionic personality disorder

-People with histrionic personality disorder are more likely than those with most other personality disorders to seek out treatment on their own (Bressert, 2016). Working with them can be very difficult, however, because of the demands, tantrums, and seductiveness they are likely to deploy. Another problem is that these clients may pretend to have important insights or to change during treatment merely to please the therapist. To head off such problems, therapists must remain objective and maintain strict professional boundaries (Bressert, 2016; Colli et al., 2014). Cognitive-behavioral therapists have tried to help people with this disorder to change their belief that they are helpless and also to develop better, more deliberate ways of thinking and solving problems (Bressert, 2016; Beck & Weishaar, 2014; Weishaar & Beck, 2006). Psychodynamic therapy and various group therapy formats have also been used (Novais et al., 2015; Horowitz & Lerner, 2010). In all these approaches, therapists ultimately aim to help the clients recognize their excessive dependency, find inner satisfaction, and become more self-reliant. Clinical case reports suggest that each of the approaches can be useful. Drug therapy appears less successful except as a means of relieving the depressive symptoms that some patients have

catatonic rigidity

-people maintain a rigid, upright posture for hours and resist efforts to be moved

disorganized thinking and speech

-People with schizophrenia may not be able to think logically and may speak in peculiar ways -These difficulties, collectively called formal thought disorders, can cause the sufferer great confusion and make communication extremely difficult -Often such thought disorders take the form of positive symptoms (pathological excesses), as in loose associations, neologisms, perseveration, and clang -People who have loose associations, or derailment, the most common formal thought disorder, rapidly shift from one topic to another, believing that their incoherent statements make sense -A single, perhaps unimportant word in one sentence becomes the focus of the next -Some people with schizophrenia use neologisms, made-up words that typically have meaning only to the person using them -Others may have the formal thought disorder of perseveration, in which they repeat their words and statements again and again -Finally, some use clang, or rhyme, to think or express themselves -When asked how he was feeling, one man replied, "Well, hell, it's well to tell" -Another described the weather as "So hot, you know it runs on a cot" -Research suggests that some people may have disorganized speech or thinking long before their full pattern of schizophrenia unfolds

poverty of speech

-People with schizophrenia often have alogia, or poverty of speech, a reduction in speech or speech content. Some people with this negative kind of formal thought disorder think and say very little. Others say quite a bit but still manage to convey little meaning

explanations for narcissistic personality disorder

-Psychodynamic theorists more than others have theorized about narcissistic personality disorder, and they again propose that the problem begins with cold, rejecting parents (Miller et al., 2017; Roepke & Vater, 2014). They argue that some people with this background spend their lives defending against feeling unsatisfied, rejected, unworthy, ashamed, and wary of the world. They do so by repeatedly telling themselves that they are actually perfect and desirable, and also by seeking admiration from others. Object relations theorists—the psychodynamic theorists who emphasize relationships—interpret the grandiose self-image as a way for these people to convince themselves that they are totally self-sufficient and without need of warm relationships with their parents or anyone else (Miller et al., 2017; Celani, 2014). In support of the psychodynamic theories, research has found that children who are neglected and/or abused or who lose parents through adoption, divorce, or death are at particular risk for the later development of narcissistic personality disorder (Caligor & Petrini, 2016; Kernberg, 2010, 1992, 1989). Studies also show that people with this disorder do indeed earn relatively high shame and rejection scores on various scales and believe that other people are basically unavailable to them (Miller et al., 2017; Ritter et al., 2014). A number of cognitive-behavioral theorists propose that narcissistic personality disorder may develop when people are treated too positively rather than too negatively in early life. They hold that certain children acquire a superior and grandiose attitude when their "admiring or doting parents" teach them to "overvalue their self-worth," repeatedly rewarding them for minor accomplishments or for no accomplishment at all (Miller et al., 2017; Caligor & Petrini, 2016). Many sociocultural theorists see a link between narcissistic personality disorder and "eras of narcissism" in society (Paris, 2014). They suggest that family values and social ideals in certain societies periodically break down, producing generations of young people who are self-centered and materialistic and have short attention spans. Western cultures in particular, which encourage self-expression, individualism, and competitiveness, are considered likely to produce such generations of narcissism. In fact, one worldwide study conducted on the Internet found that respondents from the United States had the highest narcissism scores, followed, in descending order, by those from Europe, Canada, Asia, and the Middle East

sociocultural explanations for BPD

-Some sociocultural theorists suggest that cases of borderline personality disorder are particularly likely to emerge in cultures that change rapidly. As a culture loses its stability, they argue, it inevitably leaves many of its members with problems of identity, a sense of emptiness, high anxiety, and fears of abandonment. Family units may come apart, leaving people with little sense of belonging. Changes of this kind in society today may explain growing reports of the disorder

explanations for histrionic personality disorder

-The psychodynamic perspective was originally developed to help explain cases of hysteria (see Chapter 10), so it is no surprise that psychodynamic theorists continue to have a strong interest in histrionic personality disorder. Most psychodynamic theorists believe that as children, people with this disorder had cold and controlling parents who left them feeling unloved and afraid of abandonment (Novais et al., 2015; Horowitz & Lerner, 2010). To defend against deep-seated fears of loss, the children learned to behave dramatically, inventing crises that would require other people to act protectively -Cognitive-behavioral explanations look instead at the lack of substance and extreme suggestibility that people with histrionic personality disorder have (Novais et al., 2015; Blagov et al., 2007). Cognitive-behavioral theorists see these people as becoming less and less interested in knowing about the world at large because they are so self-focused and emotional. With no detailed memories of what they never learned, they must rely on hunches or on other people to provide them with direction in life. Some cognitive theorists also believe that people with this disorder hold a general assumption that they are helpless to care for themselves, and so they constantly seek out others who will meet their needs (Weishaar & Beck, 2006; Beck et al., 2004). Sociocultural, particularly multicultural, theorists believe that histrionic personality disorder is produced in part by cultural norms and expectations (Novais et al., 2015; Fowler et al., 2007). Until recent decades, our society encouraged girls to hold on to childhood and dependency as they grew up. The vain, dramatic, and selfish behavior of the histrionic personality may actually be an exaggeration of femininity as our culture once defined it. Similarly, some clinical observers claim that histrionic personality disorder is diagnosed less often in Asian and other cultures that discourage overt sexualization and more often in Hispanic American and Latin American cultures that are more tolerant of overt sexualization (Patrick, 2007; Trull & Widiger, 2003). Researchers have not, however, investigated this claim systematically

catatonic excitement

-people move excitedly, sometimes wildly waving their arms and legs

catatonic stupor

-people stop responding to their environment, remaining motionless and silent for long stretches of time

biological explanations for BPD

-There are indications that people may inherit a biological predisposition to develop borderline personality disorder, although the impact of this factor seems to be less influential for this disorder than for antisocial personality disorder. In twin research, for example, it has been found that 35 percent of the identical twins of people with borderline personality disorder also display the disorder themselves, in contrast to 19 percent of fraternal twins of people with the disorder (Skodol, 2017; Kendler et al., 2008; Torgersen et al., 2000). Similarly, research has revealed that close relatives of those with borderline personality disorder are five times more likely than the general population to have the same personality disorder (Amad et al., 2014). In a similar vein, some genetic research suggests that the disorder may be linked to particular genes (Agha et al., 2017). Beyond genetic studies, researchers have found that people with borderline personality disorder, particularly those who are most impulsive—individuals who attempt suicide or are very aggressive toward others—have lower brain serotonin activity (Skodol, 2017; Soloff et al., 2014). As you may recall from Chapters 7 and 9, low serotonin activity has been linked repeatedly to depression, suicide, aggression, and impulsivity -Borderline personality disorder also has been tied to abnormal activity and anatomy of certain brain structures, including the amygdala (hyperactive), hippocampus (underactive), prefrontal cortex (underactive), and other structures in the frontal lobes (Skodol, 2017; Ruocco & Carcone, 2016; Mitchell et al., 2014). The frontal lobes—located in the outermost layer of the brain—are comprised of numerous structures that collectively control our abilities to plan well, form accurate judgments, make good decisions, exercise self-control, and express our emotions properly. Many of today's theorists believe that the various structures mentioned above are members of a particular brain circuit and that the problems displayed by each structure actually reflect dysfunction throughout that entire brain circuit (Agha et al., 2017). Specifically, they believe that the structures in this circuit communicate poorly with each other (they have poor interconnectivity) for people with borderline personality disorder, leading to the frequent emotional outbursts, impulsive acts, wrong judgments, and bad decisions that characterize this disorder. As with the brain circuit explanation for antisocial personality disorder, research has not yet fully sorted out all of the specifics or possible merits of this explanation for borderline personality disorder, although numerous specific findings seem to point in this direction

treatments for antisocial personality disorder

-Treatments for people with antisocial personality disorder are typically ineffective -Major obstacles to treatment include the individual's lacking a conscience, a desire to change, or respect for therapy -Most of those in therapy have been forced to participate by an employer, their school, or the law, or they come to the attention of therapists when they also develop another psychological disorder -Some cognitive-behavioral therapists try to guide clients with antisocial personality disorder to think about moral issues and about the needs of other people -However, research has not found this approach to be particularly helpful -In a similar vein, a number of hospitals and prisons have tried to create a therapeutic community for people with this disorder, a structured environment that teaches responsibility toward others -Some patients seem to profit from such approaches, but it appears that most do not -In recent years, clinicians have also used psychotropic medications, particularly antipsychotic drugs, to treat people with antisocial personality disorder -However, research has not found medication to be consistently useful in addressing the overall antisocial pattern

catatonia

-a pattern of extreme psychomotor symptoms, found in some forms of schizophrenia, which may include catatonic stupor, rigidity, or posturing -around 10% of people with schizophrenia experience some degree of catatonia -individuals with other severe psychological disorders, such as major depressive disorder or bipolar disorder, may also experience these symptoms

avoidant personality disorder

-a personality disorder characterized by consistent discomfort and restraint in social situations, overwhelming feelings of inadequacy, and extreme sensitivity to negative evaluation -They are so fearful of being rejected that they give no one an opportunity to reject them—or to accept them either -At the center of this withdrawal lies not so much poor social skills as a dread of criticism, disapproval, or rejection. They are timid and hesitant in social situations, afraid to say something foolish or to embarrass themselves by blushing or acting nervous. Even in intimate relationships they express themselves very carefully, afraid of being shamed or ridiculed. People with this disorder believe themselves to be unappealing or inferior to others. They exaggerate the potential difficulties of new situations, so they seldom take risks or try out new activities. They usually have few or no close friends, though they actually yearn for intimate relationships, and frequently feel depressed and lonely. As a substitute, some develop an inner world of fantasy and imagination -Avoidant personality disorder is similar to social anxiety disorder (see Chapter 5), and many people with one of these disorders also experience the other (Eikenaes et al., 2016, 2013; Lampe, 2016). The similarities include a fear of humiliation and low confidence. Some theorists believe that there is a key difference between the two disorders—namely, that people with social anxiety disorder primarily fear social circumstances, while people with the personality disorder tend to fear close social relationships. Other theorists, however, believe that the two disorders reflect the same core of psychopathology and should be combined. At least 2.4 percent of adults have avoidant personality disorder, men as frequently as women (NIMH, 2017; APA, 2013; Sansone & Sansone, 2011). Many children and teenagers are also painfully shy and avoid other people, but this is usually just a normal part of their development

schizotypal personality disorder

-a personality disorder characterized by extreme discomfort in close relationships, odd forms of thinking and perceiving, and behavioral eccentricities -anxious around others, they seek isolation and have few close friends. some feel intensely lonely -the disorder is more severe than the paranoid and schizoid personality disorders -these symptoms may include ideas of reference—beliefs that unrelated events pertain to them in some important way—and bodily illusions, such as sensing an external "force" or presence -a number of people with this disorder see themselves as having special extrasensory abilities, and some believe that they have magical control over others -examples of schizotypal eccentricities include repeatedly arranging cans to align their labels, organizing closets extensively, or wearing an odd assortment of clothing -the emotions of these individuals may be inappropriate, flat, or humorless -people with schizotypal personality disorder often have great difficulty keeping their attention focused -correspondingly, their conversation is typically digressive and vague, even sprinkled with loose associations -they tend to drift aimlessly and lead an idle, unproductive life -they are likely to choose undemanding jobs in which they can work below their capacity and are not required to interact with other people -surveys suggest that 3.9% of adults—slightly more males than females—display schizotypal personality disorder

DSM-5 diagnosis of schizophrenia

-symptoms of the disorder continue for 6 months or more -people have active symptoms for at least one of those months and show a deterioration from previous levels of functioning -several schizophrenia-like disorder in DSM-5 are called schizophrenia spectrum disorders (schizophreniform disorder; schizoaffective disorder) -there must be a deterioration in the person's work, social relations, and ability to care for him or herself -in 80-85% of cases, the disorder is dominated by positive symptoms, such as delusions, hallucinations, and certain formal thought disorders (sometimes called Type I schizophrenia) -in 15-20% of cases the individual displays mostly negative symptoms (sometimes called Type II schizophrenia) -Type I patients generally seem to have been better adjusted prior to their disorder, to have later onset of symptoms, and to be more likely to show improvement

heightened perceptions and hallucinations

-the perceptions and attention of some people with schizophrenia seem to intensify -the persons may feel that their senses are being flooded by all the sights and sounds that surround them -this makes it almost impossible for them to attend to anything important -laboratory studies repeatedly have found problems of perception and attention among people with schizophrenia -in one early study, participants were instructed to listen for a particular syllable recorded against an ongoing background of speech -as long as the background speech was kept simple, participants with and without schizophrenia were equally successful at picking out the syllable in question; but when the background speech was made more distracting, those with schizophrenia became less able to identify the syllable -in many studies, people with schizophrenia have also demonstrated deficiencies in smooth pursuit eye movement, weaknesses that may be related again to attention problems -when asked to keep their head still and track a moving object back and forth with their eyes, research participants with schizophrenia tend to perform more poorly than those without schizophrenia -the various perception and attention problems that people with schizophrenia have may develop years before the onset of the actual disorder -it is also possible that such problems further contribute to the memory impairments that are common to many people with schizophrenia -another kind of perceptual problem in schizophrenia consists of hallucinations, perceptions that a person has in the absence of external stimuli -people who have auditory hallucinations, by far the most common kind in schizophrenia, hear sounds and voices that seem to come from outside their heads -the voices may talk directly to the hallucinator, perhaps giving commands or warning of dangers, or they may be experienced as overheard -research suggests that people with auditory hallucinations actually produce the nerve signals of sound in their brains, "hear" them, and then believe that external sources are responsible -one line of research has measured blood flow in Broca's area, the region of the brain that helps people produce speech -the investigators have found more blood flow in Broca's area while patients are having auditory hallucinations -a related study instructed six men with schizophrenia to press a button whenever they had an auditory hallucination -PET scans revealed increased activity near the surfaces of their brains, in the tissues of the auditory cortex, the brain's hearing center, when they pressed the button -hallucinations can also involve any of the other senses -tactile hallucinations may take the form of tingling, burning, or electric-shock sensations -somatic hallucinations feel as if something is happening inside the body, such as a snake crawling inside one's stomach -visual hallucinations may produce vague perceptions of colors or clouds or distinct visions of people or objects -people with gustatory hallucinations regularly find that their food or drink tastes strange, and people with olfactory hallucinations smell odors that no one else does, such as the smell of poison or smoke -hallucinations and delusional ideas often occur together

schizoid personality disorder

-a personality disorder in which a personal persistently avoids social relationships and shows little emotional expression -they persistently avoid and are removed from social relationships and demonstrate little in the way of emotion -like people with paranoid personality disorder, they do not have close ties with other people. the reason they avoid social contact, however, has nothing to do with paranoid feelings of distrust or suspicion; it is because they genuinely prefer to be alone -often described as "loners," make no effort to start or keep friendships, take little interest in having sexual relationships, and even seem indifferent to their families. they seek out jobs that require little or no contact with others. -when necessary, they can form work relations to a degree, but they prefer to keep to themselves. -many live by themselves as well. -not surprisingly, their social skills tend to be weak. -if they marry, their lack of interest in intimacy may create marital or family problems -people with schizoid personality disorder focus mainly on themselves and are generally unaffected by praise or criticism -they rarely show any feelings, expressing neither joy nor anger -they seem to have no need for attention or acceptance; are typically viewed as cold, humorless, or dull; and generally succeed in being ignored -this disorder is present in 3.1% of the adult population -men are slightly more likely to experience it than are women, and men may also be more impaired by it

histrionic personality disorder

-a personality disorder in which an individual displays a pattern of excessive emotionality and attention seeking. once called hysterical personality disorder. -typically described as "emotionally charged," their exaggerated moods and neediness can complicate life considerably -People with histrionic personality disorder are always "on stage," using theatrical gestures and mannerisms and grandiose language to describe ordinary everyday events. Like chameleons, they keep changing themselves to attract and impress an audience, and in their pursuit they change not only their surface characteristics—according to the latest fads—but also their opinions and beliefs. In fact, their speech is actually scanty in detail and substance, and they seem to lack a sense of who they really are. Approval and praise are their lifeblood; they must have others present to witness their exaggerated emotional states. Vain, self-centered, demanding, and unable to delay gratification for long, they overreact to any minor event that gets in the way of their quest for attention. Some make suicide attempts, often to manipulate others -People with histrionic personality disorder may draw attention to themselves by exaggerating their physical illnesses or fatigue (Kayhan et al., 2016). They may also behave very provocatively and try to achieve their goals through sexual seduction. Most obsess over how they look and how others will perceive them, often wearing bright, eye-catching clothes. They exaggerate the depth of their relationships, considering themselves to be the intimate friends of people who see them as no more than casual acquaintances. Often they become involved with romantic partners who may be exciting but who do not treat them well. This disorder was once believed to be more common in women than in men, and clinicians long described the "hysterical wife" (Novais et al., 2015; Anderson et al., 2001). Research, however, has revealed gender bias in past diagnoses (APA, 2013). When evaluating case studies of people with a mixture of histrionic and antisocial traits, clinicians in several studies gave a diagnosis of histrionic personality disorder to women more than men. Surveys suggest that 1.8 percent of adults have this personality disorder, with males and females equally affected

narcissistic personality disorder

-a personality disorder marked by a broad pattern of grandiosity, need for admiration, and lack of empathy -Convinced of their own great success, power, or beauty, they expect constant attention and admiration from those around them -In the Greek myth, Narcissus died enraptured by the beauty of his own reflection in a pool, pining away with longing to possess his own image. His name has come to be synonymous with extreme self-involvement, and indeed people with narcissistic personality disorder have a grandiose sense of self-importance. They exaggerate their achievements and talents, expecting others to recognize them as superior, and often appear arrogant. They are very choosy about their friends and associates, believing that their problems are unique and can be appreciated only by other "special," high-status people. Because of their charm, they often make favorable first impressions, yet they can rarely maintain long-term relationships -people with narcissistic personality disorder are seldom interested in the feelings of others. They may not even be able to empathize with such feelings (Bressert, 2016; Marcoux et al., 2014). Many take advantage of other people to achieve their own ends, perhaps partly out of envy; at the same time they believe others envy them. Though grandiose, some react to criticism or frustration with bouts of rage, humiliation, or embitterment (Miller et al., 2017; Caligor & Petrini, 2016). Others may react with cold indifference. And still others become extremely pessimistic and filled with depression (Gore & Widiger, 2016). They may have periods of zest that alternate with periods of disappointment -As many as 6.2 percent of adults display narcissistic personality disorder, up to 75 percent of them men (Caligor & Petrini, 2016; APA, 2013). Narcissistic-type behaviors and thoughts are common and normal among teenagers and do not usually lead to adult narcissism

paranoid personality disorder

-a personality disorder marked by a pattern of extreme distrust and suspiciousness of others -diagnosed when a person has unjustified suspicious that others are harming him or her, has persistent unfounded doubts about the loyalty of friends, reads treating meanings into benign events, persistently hears grudges, and has recurrent unjustified suspicions about the faithfulness of life partners -their trust in their own ideas and abilities can be excessive -they find "hidden" meanings, which are usually belittling or treating, in everything -remain cold and distant -although inaccurate and inappropriate, their suspicions are not usually delusional; the ideas are not so bizarre or so firmly held as to clearly remove the individuals from reality -people with this disorder are critical of weakness and fault in others, particularly at work. they are unable to recognize their own mistakes, thought, and are extremely sensitive to criticism. -they often blame others for the things that go wrong in their lives, and they repeatedly bear grudges -as many as 4.4% of adults experience this disorder, which is apparently more common in men than in women

personality

-a set of uniquely expressed characteristics that influence our behaviors, emotions, thoughts, and interactions -personality traits are our particular characteristics that lead us to react in fairly predictable ways as we move through life -yet our personalities are also flexible and we learn from experience. as we interact with our surroundings, we try out various responses to see which feel better and which are more effective. this is a flexibility that people who suffer from a personality disorder usually do not have

delusions

-a strange false belief firmly held despite evidence to the contrary -ideas that they believe wholeheartedly but that have no basis in fact -the deluded person may consider the ideas enlightening or may feel confused by them -some people hold a single delusion that dominates their lives and behavior; others have many delusions -there are 4 types of delusions: delusions of persecution, delusions of reference, delusions of grandeur, and delusions of control

personality disorder

-an enduring, rigid pattern of inner experience and outward behavior that repeatedly impairs a person's sense of self, emotional experiences, goals, capacity for empathy, and/or capacity for intimacy -people with personality disorders display an enduring, rigid pattern of inner experience and outward behavior that impairs their sense of self, emotional experiences, goals, capacity for empathy, and/or capacity for intimacy -personality traits are much more extreme and dysfunctional than those of most other people in their culture, leading to significant problems and psychological pain for themselves or others -symptoms of personality disorders last for years and typically become recognizable in adolescence or early adulthood, although some start during childhood -these disorders are among the most difficult psychological disorders to treat -many people with the disorders are not even aware of their personality problems and daily to trace their difficulties to their maladaptive style of thinking and behaving -surveys indicate around 15% of all adults in the U.S. display a personality disorder t some point in their lives -it is common for a person with a personality disorder to also suffer from another disorder, a relationship called comorbidity -research indicates that the presence of a personality disorder complicates a person's chances for a successful recovery from other psychological problems -DSM-5 identifies 1- personality disorders, broken down into 3 clusters -these 10 personality disorders are each characterized by a group of problematic personality symptoms -the DSM's listing of 10 distinct personality disorders is called a categorical approach -this kind of approach assumes that (1) problematic personality traits are either present or absent in people, (2) a personality disorder is either displayed or not displayed by a person, and (3) a person who suffers from a personality disorder is not markedly troubled by personality traits outside of that disorder -these assumptions are frequently contradicted in clinical practice -the symptoms of th personality disorders listed in DSM-5 overlap so much that clinicians often find it difficult to distinguish one disorder from another, resulting in frequently disagreements about which diagnosis is correct for a person with a personality disorder -this lack of agreement has raised serous questions about the validity (accuracy) and reliability (consistency) of the 10 DSM-5 personality disorder categories -many theorists have challenged the use a of a categorical approach to personality disorder and believe that personality disorders differ more in degree than in type of dysfunction and should instead by classified by the severity of personalty traits rather than by the presence of absence of specific traits--a procedure called a dimensional approach -in a dimensional approach, each trait is seen as varying along a continuum extending from nonproblemattc to extremely problematic -people with a personality disorder are those who display extreme degrees of problematic traits=degrees not commonly found in the general population

negative symptoms of schizophrenia

-are those that seem to be "pathological deficits," characteristics that are lacking in a person -poverty of speech, blunted and flat affect, loss of volition, and social withdrawal are commonly found in schizophrenia -such deficits greatly affect one's life and activities -restricted affect: showing less emotion than most people; avoiding eye contact; immobile, expressionless face

explanations for schizotypal personality disorder

-because the symptoms of schizotypal personality disorder so often resemble those of schizophrenia, researchers have hypothesized that similar factors may be at work in both disorders -investigators have found that schizotypal symptoms, like schizophrenic patterns, are often linked to family conflicts and to psychological disorders in parents -they have also learned that defects in attention and short-term memory may contribute to schizotypal personality disorder, just as they apparently do to schizophrenia -for example, research participants with either disorder perform poorly on backward masking, a laboratory test of attention that requires a person to identify a visual stimulus immediately after a previous stimulus has flashed on and off the screen -people with these disorders have a hard time shutting out the first stimulus in order to focus on the second -finally, researchers have linked schizotypal personality disorder to some of the same biological factors found in schizophrenia, such as high activity of the neurotransmitter dopamine, enlarged brain ventricles, smaller temporal lobes, and loss of gray matter -there are indications that these biological factors may have a genetic basis -although these findings do suggest a close relationship between schizotypal personality disorder and schizophrenia, the personality disorder also has been linked to disorders of mood -around 2/3rds of people with schizotypal personality disorder also suffer from major depressive disorder or bipolar disorder at some point in their lives -relatives of people with depression have a higher than usual rate of schizotypal personality disorder, and vice versa -thus, at the very least, this personality disorder is not tied exclusively to schizophrenia

sociocultural views of schizophrenia

-believe that multicultural factors, social labeling, and family dysfunction all contribute to schizophrenia -research has yet to clarify what the precise causal relationships might be

"odd" personality disorders

-consists of paranoid, schizoid, and schizotypal personality disorders -people with these disorders typically have odd or eccentric behaviors that are similar to but not as extensive as those seen in schizophrenia, including extreme suspiciousness, social withdrawal, and peculiar ways of thinking and perceiving things -such behaviors usually leave a personal isolated -some clinicians believe these personality disorders are related to schizophrenia -in fact, schizotypal personality disorder is listed twice in the DSM-5 as one of the schizophrenia spectrum disorders and as one of the personality disorders -people with an odd-cluster personality disorder often quality for an additional diagnosis of schizophrenia or have close relatives with schizophrenia -clinicians have not been so successful in determining the causes of symptoms of odd-cluster personality disorders or how to read them -people with these disorders rarely seek treatment

delusions of persecution

-delusions of persecution are the most common in schizophrenia -people with such delusions believe they are being plotted or discriminated against, spied on, slandered, threatened, attacked, or deliberately victimized

inappropriate affect

-emotions that are unsuited to the situation -they may smile when making a somber statement or upon being told terrible news, or they may become upset in situations that should make them happy -they may also undergo inappropriate shifts in mood -during a tender conversation with his wife, for example, a man with schizophrenia suddenly started yelling obscenities at her and complaining about her inadequacies -in at least some cases, these emotions may be merely a response to other features of the disorder -consider a woman with schizophrenia who smiles when told of her husband's serious illness -she may not actually be happy about the news; in fact, she may not be understanding or even hearing it -she could, for example, be responding instead to another of the many stimuli flooding her senses, perhaps a joke coming from an auditory hallucination

psychotic disorder due to another medical condition

-hallucinations, delusions, or disorganized speech caused by a medical illness or brain damage -no minimum length

substance/medication-induced psychotic disorder

-hallucinations, delusions, or disorganized speech caused directly by a substance, such as an abused drug -no minimum length

biological views of schizophrenia

-inheritance and brain activity play key roles in development of schizophrenia -genetic factors (diathesis-stress perspective) have research support (1) relatives of people with schizophrenia (2) twins with schizophrenia (3) people with schizophrenia who are adopted (4) direct genetic research and molecular biology -biochemial abnormalities: dopamine hypothesis --certain neurons using dopamine fire too often, producing symptoms of schizophrenia --messages traveling from dopamine-sending neurons to dopamine receptors on to other neurons, particularly to the D-2 receptors, may be transmitted too easily or too often --this theory is based on the effectiveness of antipsychotic medications --schizophrenia may be related to abnormal activity or interactions of both dopamine and other neurotransmitters, rather than to abnormal dopamine activity alone -dysfunctional brain structures and circuitry -studies suggest that a dysfunctional brain circuit may lead to schizophrenia -this circuit includes the prefrontal cortex, hippocampus, amygdala, thalamus, striatum, and substantia nigra, among other structures -dysfunctional brain structures and circuitry --brain circuit structures function and interconnect in problematic ways that are collectively unique to this disorder --newer research suggests the schizophrenia-related circuit may be two distinct sub circuits whose various structures sometimes overlap --abnormal neurotransmitter activity is now seen as part of a broader circuit dysfunction that can propel people toward schizophrenia -viral problems --exposure to viruses before birth triggers a passed-on immune response that interrupts fetal brain development -evidence --animal model investigations --links involving late winter births and mother influence exposure -consistent with explanations that point to viral infections and immune system reactions, researchers have found that microglia are especially active in the brains of people with schizophrenia. Microglia are brain immune cells that provide a first line of defense against brain infections and inflammation

loss of volition

-loss of motivation or directedness -feeling drained of energy and interest in normal goals -inability to start or follow through on a course of action -ambivalence: conflicted feelings about most things

psychomotor symptoms

-many move relatively slowly -awkward moments, repeated grimaces, and odd gestures -movements seem to have a magical quality -symptoms may take extreme forms, collectively called catatonia

explanations for schizoid personality disorder

-many psychodynamic theorists, particularly object relations theorists, propose that schizoid personality disorder has its roots in an unsatisfied need for human contact -parents of people with this disorder, like those of people with paranoid personality disorder, are believed to have been unaccepting or even abusive of their children -whereas people with paranoid symptoms react to such parenting chiefly with distrust, those with schizoid personality disorder are left unable to give or receive love -they cope by avoiding all relationships -cognitive-behavioral theorists propose, not surprisingly, that people with schizoid personality disorder suffer from deficiencies in their thinking -their thoughts tend to be vague, empty, and without much meaning, and they have trouble scanning the environment to arrive at accurate perceptions -unable to pick up emotional cues from others, they simply cannot respond to emotion -as this theory might predict, children with schizoid personality disorder develop language and motor skills very slowly, whatever their level of intelligence

diagnosing schizophrenia

-many researchers believe that a distinction between Type I and Type II schizophrenia helps predict the course of the disorder -Type I schizophrenia is dominated by positive symptoms -Type II schizophrenia is dominated by negative symptoms

social labelling and schizophrenia

-many sociocultural theorists believe that the features of schizophrenia are influenced by the diagnosis itself -in their opinion, society assigns the label "schizophrenic" to people who fail to conform to certain norms of behavior -once the label is assigned, justified or not, it becomes a self-fulfilling prophecy that promotes the development of many schizophrenic symptoms

family dysfunction and schizophrenia

-many studies suggest that schizophrenia, like a number of other mental disorders, if often linked to family stress -parents of people with schizophrenia often (1) display more conflict, (2) have more difficulty communicating with one another, and (3) are more critical of and overinvovled with their children than other parents -people who are trying to recover from schizophrenia are almost 4 times more likely to relapse if the live with such a family (high expressed emotion) than if they live with one low in expressed emotion -it is also the case that people with schizophrenia greatly disrupt family life -in doing so, they themselves may help produce the family problems that clinicians and research continue to observe

psychological and sociocultural models lag behind in schizophrenia

-most clinical theorists now believe that schizophrenia is caused by a combination of factors, though researchers have been far more successful in identifying the biological influences than the psychological and sociocultural ones -while biological investigations have closed in on specifically genes, abnormalities in brain biochemistry and brain circuits, and even viral infections, most of the psychological and sociocultural research has been able to cite only general factors, such as the roles of family conflict and diagnostic labelling

treatments for schizotypal personality disorder

-most therapists agree on the need to help these clients "reconnect" with the world and recognize the limits of their thinking and their powers -therapists may thus try to set clear limits—for example, by requiring punctuality—and work on helping the clients recognize where their views end and those of the therapist begin -other therapy goals are to increase positive social contacts, ease loneliness, reduce overstimulation, and help the individuals become more aware of their personal feelings -cognitive-behavioral therapists further combine cognitive and behavioral techniques to help people with schizotypal personality disorder function more effectively -using cognitive interventions, they try to teach clients to evaluate their unusual thoughts or perceptions objectively and to ignore the inappropriate ones -therapists may keep track of clients' odd or magical predictions, for example, and later point out their inaccuracy -when clients are speaking and begin to digress, the therapists might ask them to sum up what they are trying to say -in addition, specific behavioral methods, such as speech lessons, social skills training, and tips on appropriate dress and manners, have sometimes helped clients learn to blend in better with and be more comfortable around others -antipsychotic drugs have been given to people with schizotypal personality disorder, again because of the disorder's similarity to schizophrenia -in low doses the drugs appear to have helped some people, usually by reducing certain of their thought problems

3 clusters of personality disorders

-one closer, marked by odd or eccentric behaviors, consists of the paranoid, schizoid, and schizotypal personality disorders -a second cluster features dramatic behavior and consists of the antisocial, borderline, histrionic, and narcissistic personality disorders -the final cluster features a high degree of anxiety and includes the avoidant, dependent, and obsessive-compulsive personality disorders

treatments for paranoid personality disorder

-people with paranoid personality disorder do not typically see themselves as needing help, and few come to treatment willingly -many who are in treatment view the role of patient as inferior and distrust and rebel against their therapists. Thus it is not surprising that therapy for this disorder, as for most other personality disorders, has limited effect and moves very slowly -object relations therapists—the psychodynamic therapists who give center stage to relationships—try to see past the patient's anger and work on what they view as his or her deep wish for a satisfying relationship -self-therapists—the psychodynamic clinicians who focus on the need for a healthy and unified self—try to help clients reestablish self-cohesion (a unified personality), which they believe has been lost in the person's continuing negative focus on others -cognitive-behavioral therapy has also been used to treat people with paranoid personality disorder. on the behavioral side, therapists help clients to master anxiety-reduction techniques and to improve their skills at solving interpersonal problems. on the cognitive side, therapists guide the clients to develop more realistic interpretations of other people's words and actions and to become more aware of other people's points of view -antipsychotic drug therapy seems to be of limited help

social withdrawal

-people with schizophrenia may withdraw from their social environment and attend only to their own ideas and fantasies -because their ideas are illogical and confused, the withdrawal has the effect of distancing them still further from reality -social withdrawal seems also to lead to a breakdown of social skills, including the ability to recognize other people's needs and emotions accurately

symptoms of schizophrenia

-positive symptoms (excesses of thought, emotion, and behavior) -negative symptoms (deficits of thought, emotion, and behavior) -psychomotor symptoms (unusual movements or gestures) -depends on the period if you're more dominated by positive or negative symptoms -around half of those with schizophrenia have significant difficulties with memory and other kinds of cognitive functioning

structures that comprise this schizophrenia-related circuit

-prefrontal cortex, hippocampus, amygdala, thalamus, striatum, and substantia nigra, among other brain regions -in cases of schizophrenia the structures function and interconnect in problematic ways that are, collectively, unique to this disorder

multicultural factors and schizophrenia

-rates of schizophrenia appears to differ between racial and ethnic groups -as many as 2.1% of African Americans receive a diagnosis of schizophrenia, compared with 1.4% of non-Hispanic white Americans. -research also suggests that African Americans with schizophrenia are overrepresented in state hospitals, 48% of those with a diagnosis of schizophrenia are African American, although only 16% of the state population is African American -one possibility for this is African Americans are more prone to develop schizophrenia. -another is that clinicians from majority groups are unintentionally biased in their diagnoses of African Americans or misread cultural differences as symptoms of schizophrenia -yet another explanation for the difference between African Americans and non-Hispanic white Americans may lie in the economic sphere -on average, African Americans are more likely to be poor, when economic differences are controlled for, the prevalence rates of schizophrenia become closer for the two racial groups -consistent with the economic explanation is the finding that Hispanic Americans, who also tend to be economically disadvantaged, appear to be more likely to be diagnosed with schizophrenia than non-Hispanic white Americans, although their diagnostic rate is not as high as that of African Americans. -it also appears that schizophrenia differs from country to country in key ways -although the overall prevalence of this disorder is stable (around 1%) in countries across the world, the course and outcome of the disorder may vary considerably -according to a study by the WHO, the 25 milling schizophrenic patients who live in developing countries have better recovery rates than schizophrenic patients in Western and other developed countries -the schizophrenic patients from the developing countries were more likely than those in the developed countries to recovery from their disorder and less likely to have continuous or episodic symptoms, to have impaired social functioning, or to require heavy antipsychotic drugs or hospitalization -some clinical theorists believe that these differences partly reflect genetic differences from population to population. however, other s argue that the psychosocial environments of developing countries tend to be more supportive and therapeutic than those of developed countries, leading to more favorable outcomes for people with schizophrenia -in developing countries, for example, there may be more family and social support for people with schizophrenia, more relatives and friends bailable to help care for such people, and less judgmental, critical, and hostile attitudes toward people with schizophrenia

biological relatives of an adoptee and schizophrenia

-researchers have repeatedly found that the biological relatives of adoptees with schizophrenia are more likely than their adoptive relatives to develop schizophrenia or another schizophrenia spectrum disorder

genetic studies and schizophrenia

-researchers have run studies of genetic linkage and molecular biology to pinpoint the possible genetic factors in schizophrenia -studies have identified possible gene defects on chromosomes 1, 2, 6, 8, 10, 13, 15, 18, 20, and 22, and on the X chromosome, each of which may help predispose a person to develop this disorder -it may be that different kinds of schizophrenia are linked to different genes -it's most likely that schizophrenia, like a number of disorders, is a polygenic disorder, caused by a combination of gene defects

course of schizophrenia

-schizophrenia usually first appears between the late teens and mid-thirties -three phrases: prodromal, active, residual -each phase of the disorder may last for days or years -a fuller recovery from schizophrenia is more likely in people who functioned quite well before the disorder (had good premorbid functioning); whose initial disorder is triggered by stress, come on abruptly, or develops during middle age; and who receive early treatment (preferably during the pronominal phase) -relapses are apparently more likely during times of life stress

viral problems and schizophrenia

-some investigators suggest that the brain abnormalities may result from exposure to viruses before birth -perhaps a viral infection triggers an immune system response in the mother, is passed on to the developing fetus, enters his or her brain, and interrupts proper brain development -some evidence is circumstantial, such as the finding that an unusually large number of people with schizophrenia are born during the late winter -the late winder brith rate among people with schizophrenia is 5-8% higher than among other people; this could be because of an increase in fetal or infant exposure to viruses at that time of the year -more direct evidence comes from studies showing that mothers of people with schizophrenia were more likely to have been exposed to the influenza virus during pregnancy than were mothers of people without schizophrenia

schizophrenia and twins

-studies have found that if one identical twin develops schizophrenia, there is a 48% chance that the other twin will do so as well -if the twins are fraternal, on the other hand, the second twin has approximately a 17% chance of developing the disorder

prodromal phase of schizophrenia

-symptoms are not yet obvious, but the person is beginning to deteriorate -beginning of deterioration; mild symptoms -person may withdraw socially, speak in vague or odd ways, develop strange ideas, or express little emotion

active phase of schizophrenia

-symptoms become apparent -sometimes this phrase is triggered by stress or trauma in the person's life

treatments for schizoid personality disorder

-their social withdrawal prevents most people with schizoid personality disorder from entering therapy unless some other disorder, such as alcoholism, makes treatment necessary -clients are likely to remain emotionally distant from the therapist, seem not to care about their treatment, and make limited progress at best -cognitive-behavioral therapists have sometimes been able to help people with this disorder experience more positive emotions and more satisfying social interactions -on the cognitive end, their techniques include presenting clients with lists of emotions to think about or having them write down and remember pleasurable experiences -on the behavioral end, therapists have sometimes had success teaching social skills to such clients, using role-playing, exposure techniques, and homework assignments as tools -group therapy is apparently useful when it offers a safe setting for social contact, although people with schizoid personality disorder may resist pressure to take part -as with paranoid personality disorder, drug therapy seems to offer limited help

explanations for paranoid personality disorder

-theories proposed to explain paranoid personality disorder have received little systematic research -psychodynamic theories, the oldest of these explanations, trace the pattern to early interactions with demanding parents, particularly distant, rigid fathers and over controlling, rejecting mothers (you will see that psychodynamic explanations for almost all the personality disorders begin the same way--with repeated mistreatment during childhood and lack of love) -according to one psychodynamic view, some people come to view their environment as hostile as a result of their parents' persistently unreasonable demands. they must always be on alert because they cannot trust others, and they are likely to develop feelings of extreme anger. they also project these feelings onto others and, as a result, feel increasingly persecuted. -some cognitive-behavioral theorists suggest that people with paranoid personality disorder generally hold broad maladaptive assumptions, such as "people are evil" and "people will attack you if given the chance." -biological theorists propose that paranoid personality disorder has genetic causes -a widely reported study that looked at self-reports of suspiciousness in 3,810 Australian twin pairs found that if one twin was excessively suspicious, the other had an increased likelihood of also being suspicious -one again, however, it is important to note that such similarities between twins might also be the result of common environmental experiences

developmental psychopathology view of schizophrenia

-theorists contend that the road to schizophrenia begins with a genetically inherited predisposition to the disorder--a predisposition that is expressed by the dysfunctional brain circuit -theorists further argue that this genetic predisposition may eventually lead to schizophrenia if, over the course of an individual's development, he or she experiences significant life stressors, difficult family interactions, and/or other negative environmental factors -a diathesis-stress relationship at work with schizophrenia: that is, people with a biological predisposition to this disorder will develop it if they further experience significant life stress or other negative events -two key points: 1. schizophrenia typically begins to unfold long before the actual onset of the disorder in young adulthood. developmental psychopathology researchers have found that such people also tend to be more socially withdrawn, disagreeable, and disobedient, and to have more motor difficulties, throughout their early development. some of those early problems seem to result largely from the individual's inherited predisposition, but, according to research, they may also be due to repeated experiences of childhood stress, family dysfunction, and/or difficult social interactions 2. one of the key ways that a dysfunctional brain circuit may adversely affect the functioning of people who later become schizophrenic is through the circuit's impact on the operation of the hypothalamic-pituitary-adernal (HPA) stress pathway. whenever we are stressed, the brain's tho-thalamus actives this brain-body pathway, leading, in turn, to the secretion of cortisol and other stress hormones and to a broad experience of arousal. developmental psychopathology reserachers have found that dysfunction by the schizophrenia-related brain circuit leads to repeated overreactions by the HPA pathway in the face of stress. such chronic overreactions leave individuals highly sensitive to and unsettled by stressors throughout their development. the individuals become all the more inclined to later develop schizophrenia in the face of stress. -developmental psychopathology researchers and other investigators have further discovered that an overreactive HPA stress pathway and chronic stress reactions lead to the development of a dysfunctional immune system, characterized by heightened inflammation throughout the brain. thus it is not surprising that numerous studies conducted over the past several years have found signifiant immune system problems and chronic inflammation throughout the brains of people with schizophrenia.

explanations for borderline personality disorder

-theorists have pointed to a range of possible psychological, biological, and sociocultural factors in their explanations of borderline personality disorder -over the past several years, there have been productive efforts to determine how such factors may interact to produce this disorder

delusions of reference

-they attach special and personal meaning to the actions of others or to various objects or events -Richard, for example, interpreted arrows on street signs as indicators of the direction he should take

"dramatic" personality disorders

-this cluster includes the antisocial borderline, histrionic, and narcissistic personality disorders -the behaviors of people with these problems are so dramatic, emotional, or erratic that it is almost impossible for them to have relationships that are truly giving and satisfying -these personality disorders are more commonly diagnosed than the others -however, only the antisocial and borderline personality disorders have received much study, partly because they create so many problems for other people -the causes of the disorders, like those of the odd personality disorders, are not well understood -treatments range from ineffective to moderately effective

"anxious" personality disorders

-this cluster includes the avoidant, dependent, and obsessive-compulsive personality disorders -people with these patterns typically display anxious and fearful behavior -although many of the symptoms of these personality disorders are similar to those of the anxiety and depressive disorders, researchers have not found direct links between this cluster of those disorders -research support for the various explanations is very limited -at the same time, treatments for these disorders appear to be modestly to moderately helpful--considerably better than for other personality disorders

conclusion biological views of schizophrenia

-together, the biochemical, brain circuit, and viral findings are shedding much light on the mysteries of schizophrenia -at the same time, it's important to recognize that many people who have these biological abnormalities never develop schizophrenia -that is because biological factors merely set the stage for schizophrenia, while key psychological and sociocultural factors must be present for the disorder to appear

cognitive-behavioral explanation of schizophrenia

-two explanations of how and why people develop schizophrenia: operant conditioning and misinterpretations -the operant explanation of schizophrenia begins with the general observation that most people in life become quite proficient at reading and responding to social cutes--that is, other people's smiles, frowns, and comments. people who respond to such cues in a socially acceptable way are better able to satisfy their own emotional needs and reach their goals. some people, however, are not reinforced for their attention to social cues, either because of unusual circumstances or because important figures in their lives are socially inadequate. as a result, they stop attending to such cues and focus instead on irrelevant cues such as the brightness of light in a room, a bird flying above, or the sound of a word rather than its meaning. as they attend to irrelevant cues more and more, their responses become increasingly bizarre. because the bizarre responses are rewards with attention or other types of reinforcement, they are likely to be repeated again and again. -operant conditioning: circumstantial support; more recently viewed as a partial explanation -the misinterpretation explanation begins by accepting the biological position that the brains of people with schizophrenia are actually producing strange and unreal sensations--sensations triggered by biological factors--when they have hallucinations and related perceptual experiences. according to the cognitive-behavioral explanation, however, when the individuals attempt to understand their unusual experiences, more features of their disorder emerge. when first confronted by voices or other troubling sensations, these people turn to friends and relatives. naturally, the friends and relatives deny the reality of the sensations, and eventually the sufferers conclude that the others are trying to hide the truth. they begin to reject all feedback, and some develop beliefs (delusions) that they are being persecuted. in short, according to this theory, people with schizophrenia take a "rational path to madness." this process of drawing incorrect and bizarre conclusions (delusions) may be helped along by a cognitive bias that many people with schizophrenia have--a tendency to jump to conclusions -misinterpreting unusual sensations: no direct research support

schizophrenia dx checklist

1. For 1 month, individual displays two or more of the following symptoms much of the time:(a) Delusions(b) Hallucinations(c) Disorganized speech(d) Very abnormal motor activity, including catatonia(e) Negative symptoms 2. At least one of the individual's symptoms must be delusions, hallucinations, or disorganized speech. 3. Individual functions much more poorly in various life spheres than was the case prior to the symptoms. 4. Beyond this 1 month of intense symptomology, individual continues to display some degree of impaired functioning for at least 5 additional months.

personality disorder dx checklist

1. individual displays a long-term, rigid, and wide-ranging pattern of inner experience and behavior that leads to dysfunction in at least two of the following realms: cognition, emotion, social interactions, and impulsivity 2. the individuals pattern is significantly different from ones usually found in his or her culture 3. individual experiences significant distress or impairment

schizophrenia

A psychotic disorder in which personal, social, and occupational functioning deteriorate as a result of strange perceptions, disturbed thought processes, unusual emotions, and motor abnormalities. -1 of 100 experience schizophrenia during lifetime -21 million worldwide; 3.6 million in the U.S. -Equally distributed between men and women -Average age at onset: 23 for men; 28 for women

treatment for narcissistic personality disorder

Narcissistic personality disorder is one of the most difficult personality patterns to treat because the clients are unable to acknowledge weaknesses, to appreciate the effect of their behavior on others, or to incorporate feedback from others (Tanzilli et al., 2017; Ronningstam, 2017). The clients who consult therapists usually do so because of a related disorder such as depression (Caligor & Petrini, 2016). Once in treatment, the clients may try to manipulate the therapist into supporting their sense of superiority (Skodol & Bender, 2016). Some also seem to project their grandiose attitudes onto their therapists and develop a love-hate stance toward them (Colli et al., 2014; Shapiro, 2004). Psychodynamic therapists seek to help people with this disorder recognize and work through their basic insecurities and defenses (Bressert, 2016; Diamond & Meehan, 2013). Cognitive-behavioral therapists, focusing on the self-centered thinking of such individuals, try to redirect the clients' focus onto the opinions of others, teach them to interpret criticism more rationally, increase their ability to empathize, and change their all-or-nothing notions (Caligor & Petrini, 2016; Weishaar & Beck, 2006; Beck et al., 2004). None of the approaches have had clear success, however

antipsychotic drugs

drugs that help correct grossly confused or distorted thinking

schizoaffective disorder

marked symptoms of both schizophrenia and a major depressive episode or a manic episode -6 months or more

delusional disorder

persistent delusions that are not bizarre and not due to schizophrenia; persecutory, jealous, grandiose, and somatic delusions are common -1 month or more -lifetime prevalence 0.10%

Approximately 1 of every 100 people in the world suffers from ________ during his or her lifetime. An estimated 21 million people worldwide are afflicted with it, including 3.6 million in the United States. Equal numbers of men and women experience the disorder. The average age of onset for men is 23 years, compared with 28 years for women.

schizophrenia

People with this disorder are much more likely to attempt suicide than the general population. It is estimated that as many as 25 percent of people with _______ attempt suicide and 5 percent die from suicide. Given this high risk, it is strongly recommended that patients with ______ receive thorough suicide risk assessments during treatment and when they are discharged from treatment programs. In addition, people with the disorder have an increased risk of physical—often fatal—illness. On average, they live 10 to 20 fewer years than other people.

schizophrenia; schizophrenia