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" Feminism o Are you a feminist? " Some answered "yes" to that question. Many answered "no." o Do you believe that men and women should be given equal social, legal, and economic opportunities, or should one gender have an advantage in these areas over the other? " I would bet that either all or very nearly all of you answered that both genders should be treated equally. o Feminism is the belief system that holds that women and men should be considered equal in terms of social, legal, and economic opportunities. If you believe that men and women should be given equal opportunities, then you are a feminist. o Men and woman are not given equal opportunities o Many people think that feminism means trying to make men less powerful than women. " She says in the interview that she isn't a feminist because she "think(s) the idea of 'raise women to power, take the men away from the power' is never going to work out because you need balance." " She's right about one thing, though. We need balance among the genders. Balance is another word for equality. Equality is the goal of feminism. " Historical Representations of Women and Men o How many women versus men do you remember reading about in history classes? o Aristotle believed that women couldn't develop fully as rational beings, and are more likely to be envious and to lie (and there are many other examples in philosophy). " Representations of Men and Women in Religion and Mythology o Adam was made in God's own image o He was given the curse of having to work to survive. o Eve was made from a part of a man o She was the one who led Adam to sin, and she has the curses of painful childbirth and having to obey her husband. (This assumes that women DON'T have to also work to survive!) " In Taoism's yin-yang symbol, yin (the black area) is feminine and yang (the white area) is masculine. " o Yin (female) also stands for ignorance, darkness, and evil. o Yang (male), on the other hand, represents light, intellect, and goodness. " In Hinduism, an unmarried woman or widow has no personal identity. A woman's identity is defined by her husband. o Hindu girls born in the "untouchable" class (poor) used to be given by their parents to temples to appease the gods by having sex with upper-caste men, and this still takes place in some areas. o I wonder who thought up that rule ... (Hint, it's the priests and upper-caste men.) " A few general themes emerge from an examination of how religion and mythology has viewed women throughout history: 1 - Women are evil sinners, like Eve, Mary Magdalene, yin, etc. 2 - Women are frightening witches, like Medusa. 3 - Women are pure and virtuous, like the Virgin Mary or the Earth Mother. " While some of these themes are positive and some are negative, overall they indicate that men are normal and women are different. This is called androcentrism, from the word androgen (a male hormone). " Despite these things, women tend to be more religious than men in nearly all cultures and religions. o Why do you think that is? " Language o Studies have shown that for the reader or listener, this conjures up thoughts of men, not of either gender. o master (sounds honorable) versus mistress (sounds like a woman that a man has on the side) o actor (a person who acts) versus actress (a female person who acts) o traditionally, the use of sir to address a superior officer of either gender in the military, although female officers are addressed as ma'am today o Women have often been invisible in language, with "he" or "his" used to refer to either sex. o Many masculine titles are sometimes seen as better or normal, such as: etc. o Masculine nouns are often used to refer to anyone. This is called the androcentric generic. " The Media o Less than 25% of front-page newspaper stories refer to women. o Women are about 25% of newspaper and magazine opinion columnists. o About 60-70% of actors in prime-time are male. (Note use of the word actors. What is this an example of?) o Coverage of women's sports is 6% of all sports coverage. o Women are less visible in the media: " About 65% of clip-art images are male. " Most video game characters are male. " Women are also less audible in the media: o Women are only 5% of all radio talk show hosts. o Between 70% and 90% of all advertisement voiceovers are male. " Women are less often shown working outside of the home: o Ads more often show men in work settings. o In TV shows, women characters' home lives are focused on more often than men's. o Teen girl magazines focus more on appearance and attracting boys than on career goals and independence. " Women of color are either underrepresented or shown in a biased way: o Black characters are more often in sitcoms than in dramas. o Other ethnic groups are less visible. For instance, Latinos are about 18% of the population but only 2% of prime-time TV characters and magazine advertisement models. " Lower-social-class women are also underrepresented or shown in a biased way: o Half of lower-income women in magazines are Black, but Black women make up much less than half of all poor women. o Black people are overrepresented in such daytime shows as Maury or Judge Judy. " Effects of Biased Representations o Do all of these things just reflect reality, or do they influence it? Both! o Women who are exposed to a TV ad that shows women in traditionally female roles reported much less self-confidence than women shown a TV ad depicting greater gender role flexibility. o Also, feminist attitudes (of both men and women) tend to decrease after watching stereotyped ads. " Common Stereotypes o Women are stereotypically seen as being gentle, compassionate, caring, and more concerned with relationships. This is called communion. " Men are stereotypically seen as being more concerned with self-interests, competitive, confident, leaders. This is called agency. " Components of Prejudice o Women are typically viewed as less competent than men. " This is especially true for males' views of women, but women also do this to each other and to themselves. " It is also especially true when you have little other information about a woman's qualifications, when the evaluator has expertise in the area, or when the woman acts in a stereotypically male way. o Women are typically viewed as more pleasant than men. " However, one group of women is viewed as less pleasant than men: female feminists. o Ambivalent sexism " This includes two competing types of sexism: hostile sexism and benevolent sexism. " Hostile sexism is blatant and easy to spot. It is an attitude that women should "know their place" and are not as valuable or deserving or strong as men are. " Benevolent sexism is more subtle. This type of sexism emphasizes a woman's special niceness or purity. The focus, though, is on how women are different from men. " Notice how these two components of ambivalent sexism fit nicely with the views of women in religion and mythology? " Men tend to score somewhat higher than women on benevolent sexism scales, and much higher than women on hostile sexism scales. " In countries with low gender equality (as measured by women's income compared to males and the percentage of high government posts held by women), rates of both types of sexism are higher. " In other words, both hostile sexism ("Women should know their place!") and benevolent sexism ("Women are pleasant and soft, and they must be protected by strong men.") serve the same purpose: to keep women disempowered. " Of course, men can also be unfairly viewed with sexist attitudes, too. " Sexist attitudes actually hurt those who hold them as well. A recent meta-analysis (Wong, Ho, Wang, & Miller, 2016) found that more sexist men (who see themselves as playboys or as having power over women) have more depression and anxiety and are less likely to get help for those conditions. o Discrimination " What country has the least gender discrimination? " It's not the US. " The Scandinavian countries of Sweden, Norway, Denmark, Iceland, and Finland have the least gender discrimination. " In those countries, the rates of women in Parliament are still only between 37% and 48%. (And this is by far the best in the world!) " This is up from between 24% and 39% just a few years ago, though! " In the US in 2018, women make up 23.6% of the 116th Congress (24 in the Senate, 102 in the House, 126 out of 535 total). " There is a slow upward trend here, though: o 110th Congress (elected in 2006) - 16.4% o 111th (2008) - 17.2% o 112th (2010) - 16.4% o 113th (2012) - 18.9% o 114th (2014) - 19.4% o 115th (2016) - 19.6% o 116th (2018) - 23.6% (this, our current congress, is also our most diverse ever by gender, ethnicity, religion, and sexual orientation) o Why is representation in government important? Watch these high school boys find out: Personal Consequences of Gender Stereotypes " Cognitive Errors o For instance, we tend to only notice information that supports our beliefs, leading to confirming of stereotypes in an upward spiral. This is the confirmation bias. o We tend to simplify and organize our world by making categories. This is necessary and adaptive. o The main way we categorize people is by gender. o However, there are a number of biases that often occur automatically when we categorize people. When we see a boy who isn't good at math, we don't remember this observation as well because it doesn't fit with our beliefs. When we see a girl who isn't good at math, though, this fits with and strengthens our expectations. " We also tend to see all males as similar, all females as similar, and males and females as very different. This creates a larger perceived gap than there may really be. This is called gender polarization. For instance, has anyone ever asked you to explain the behavior of someone of your gender by starting with "You're a girl..." (or "guy")? This assumes that all women (or men) are alike, when they clearly aren't. " Male experience is seen as the norm. This is androcentrism. For example, many studies have shown that men have more self-confidence than women. It was automatically concluded that since men are the norm, women suffer from low self-confidence. Why did we not conclude instead that women are the norm and men have over-inflated and delusional self-confidence? (This actually may be closer to the truth, it turns out!) " We also form biased judgments about abilities. We assume that a woman will be good at some things and a man at others. We tend to assume, for instance, that a woman would be better at soothing a crying baby and a man would be the one to go to if you need a tire changed. We all know consciously that both men and women are capable of either task, but our automatic, implicit expectations happen anyway. ▪ We make different attributions about women and men too. An attribution is an explanation we make about the causes of someone's behavior. ▪ We tend to attribute a woman's success to hard work. ▪ We tend to attribute a man's success to talent or ability. ▪ What's the implication of this? We believe that women have to work harder than men to achieve the same amount of success! o Behavior A self-fulfilling prophecy occurs when my expectations about someone can cause that person to meet those expectations. My expectation that my daughter won't do well in science can lead her to become pessimistic, leading to her not trying as hard to do well, leading to her not doing as well in science. o When we are made consciously aware of one of the categories in which we fit (e.g., gender, ethnicity, age, etc.) and that category has a stereotype regarding performance in a certain area, we tend to perform closer to the stereotype in that area. This is the stereotype threat. " In one study, Asian American women were split into three groups. All three groups completed the same difficult math test. " Before the math test, though, each group also completed one other questionnaire. " The first group completed a questionnaire about ethnicity. This made these women think consciously about the fact that they were of Asian descent. " The second group completed a questionnaire about gender. This made these women conscious of the fact that they were women. " The third group answered a demographic questionnaire that didn't emphasize belonging to any particular group. " Asians are supposed to be good at math, right? The Asian-American awareness group scored highest, getting 54% of the questions right on the test. " Women are supposed to be bad at math, right? The gender awareness group only got 43% right. " The no conscious focus group wound up right in the middle, with 49% right. " They all took the same test! " Individuals tended to perform closer to the stereotype of the group they consciously put themselves into. o One final note ... Androgyny (having characteristics of both genders) was once thought to be the healthiest way for men or women to be. " You know, like a man who cooks and cries at the end of The Notebook, or a woman who changes her own oil and likes Kevin James movies. " Just kidding, nobody likes Kevin James movies. " More recent research findings show us that androgyny is healthy, but not necessarily healthier than being more masculine or more feminine. " All are healthy ways to be, as long as gender roles aren't taken to an extreme. Emma Watson Speech- UN Feminism Speech He for she campaign- ending gender equality, this is the first campaign of its kind at the UN. Feminism is not MAN HATING.Women are chosing to not identify as feminists Feminists are not anti MEN MODULE TWO " Boys and Girls in Different Cultures o In US culture, would parents rather have a boy or a girl? " Today, there is no clear preference in our culture for one or the other gender when having a baby. o However, boys are strongly preferred in some countries. " For instance, there are strong preferences for boys in some parts of India, China (girls are sometimes called "maggots in the rice"), Korea, and the Zulu Nation of South Africa (where girls are "merely weeds"). o This leads in some cases to abortion, abandonment shortly after birth, or less thorough medical care for girl babies. o Right now in China, about 8 girls are born for every 10 boys. That's a big disparity! What are the long-term implications of this? o In part as a reaction to the problems that this gender disparity will cause (along with the fact that they won't have enough young people of either gender to take care of their aging population), in October 2015 the Chinese government dropped their one-child policy. Now, married couples in China can have two children. This will probably help to make baby girls be more valued, but we'll have to see what the research shows... " We tend to rate baby girls as weaker, more fine-featured, more delicate, and more feminine than boys, even when there's no measurable difference. " Social Learning Approach o Kids learn gender-appropriate behaviors through the social learning approach. o This includes experiencing the basic behavioral learning concepts of reward and punishment for different gender-related behaviors. Will this boy be scolded or laughed at for dressing up like a princess? Will this girl be bullied for having a short haircut and boyish clothes? o The social learning approach also includes modeling, or learning a behavior that we see someone else get reinforced for. " We're especially likely to imitate models who are more like us. " Thus, girls model after their mother figures, other girls, and female characters more often. The reverse is true for boys. o Cognitive Developmental Approach ◦ Kids create mental lists of characteristics that are typically male and typically female by watching males and females act. ◦ These gender schemas are also formed by hearing others talk about what girls and boys "should" or "shouldn't" do. ◦ For example, when my daughter was 4, she would always give me the blue toy and keep the red one for herself because "boys like blue and girls like red." Similarly, when my wife or I said we didn't want to do something, she would always ask, "Is it because girls (or boys) don't do that?" ◦ So, you can see that gender schemas (developed through the cognitive developmental approach) are beliefs about what makes a girl a girl and what makes a boy a boy. This is contrasted with the social learning approach, which affects gender-related behaviors like grooming, choice of activities, etc. ◦ Gender schemas become more complex and more flexible as we grow. ◦ After we develop a gender identity, or the realization that "I am a girl" or "I am a boy" (typically by age 1½ to 2½), gender schemas increase in importance. ◦ This used to be a controversy; some thought only the social learning approach was true and some thought only the cognitive developmental theory made sense. ◦ As with many of these either/or controversies throughout the history of psychology, we now see the answer as "both." ◦ Kids create their thoughts about gender through the cognitive developmental approach. ◦ A schema is a mental category in which we place things. ◦ Gender schemas are among first schemas to develop. ◦ The cognitive developmental approach works together with the social learning approach to form our knowledge about gender. o Biology ◦ Some research shows that preferences for girls' or boys' toys are at least partially hormonally determined. For example, girls with congenital adrenal hyperplasia (in which the adrenal glands are larger and more active than normal) have more testosterone in their systems before birth, and they tend to enjoy playing with boys' toys more than unaffected girls do, even if parents encourage them to play with girls' toys (Pasterski et al., 2005). " Parents o Parents' reactions to infants tend to be somewhat gender-stereotyped before parents know their infant's unique characteristics. " Parents react much more to a toddler's personality than to his or her gender, though. " Still, across cultures girls are more likely to be assigned "feminine" chores and boys "masculine" chores. " We often provide gender-specific toys. We also tend to discourage boys from playing with girls' toys more strongly than the reverse. " Men are more likely than women to encourage both girls and boys to play with stereotypically gender-appropriate toys. " Parents (of either gender) are also more likely to talk to daughters (rather than sons) about other people and about emotions. " When emotions are discussed, different ones are discussed with children of each gender. Boys most commonly discuss anger Girls are most commonly discussing fear and sadness A peer group is kids of about the same age " Peers tend to reject kids who act in a non-stereotypical fashion regarding gender. o Who gets it worse? Boys who act in a feminine way are treated more harshly than girls who act in a masculine way. o This means that peers believe that girls who act like boys aren't as bad as boys who act like girls. What's the implication here? o Masculine gender roles have a higher status, since a masculine girl is accepted more readily than a feminine boy is. " Peers also encourage gender segregation, which is a preference to play with kids of the same gender. o This begins by age three or four. o It increases in intensity until early adolescence, when the other gender becomes more interesting to many adolescents... o What implications does gender segregation have on modeling of gender-stereotyped behaviors? We only have peers of the same gender on which to model our behaviors! " Peers are prejudiced against kids of the other gender. o You know, boys are dirty, girls are icky, etc. o This may arise from rigid gender schemas that tell the kid that boys and girls are very different. " Peers treat girls and boys differently too. o Children (of either gender) tend to respond to girls based more on physical attractiveness. o What are the implications of this for girls' and boys' future attitudes about beauty? o School ◦ In many ways, schools tend to give messages that men are more important. ◦ For instance, higher proportions of principals are men while most teachers are women. ▪ In Florida in 2014 (the most recent data available), 9.3% of elementary school teachers were men, while 34.5% of principals were men (Florida Department of Education, 2017). ▪ Where do elementary school principals come from? They are promoted from the ranks of teachers! ▪ If female and male teachers had the same opportunities to get promoted, wouldn't men make up something close to 9.5% of principals? ▪ In 2013-2014, my kids' elementary school had 6.6% male teachers (one taught PE), and the principal and vice principal were both men (Florida Department of Education, 2015). They do a great job, but one message given here is that men are bosses and women aren't. ◦ Boys also tend to receive more positive feedback from teachers. ◦ Classroom activities are often chosen to appeal to boys. ◦ Females are often less prevalent in the books that are used in elementary schools. ◦ Black girls may also be less encouraged by their teachers to challenge themselves academically. ◦ The same is true of girls of any ethnicity from lower socioeconomic groups. ◦ Hopefully these trends will continue to improve, since most colleges that train teachers now include required courses about gender and ethnic diversity. ▪ At UCF in 2016-2017, EDF 2085 (Introduction to Diversity for Educators) and TSL 4240 (Issues in Second Language Acquisition) are required, along with six hours of electives with an international or diversity focus. o The Media ◦ Video games ▪ There are more male characters in video games, encouraging boys to play them and to develop computer and hand-eye coordination skills. ◦ Books ▪ The main characters in kids' picture books are males by a two to one ratio. ▪ Girls in books are more likely to need more help, while boys are more likely to be self-reliant. ▪ Research studies show that this can directly affect the self-esteem of kids who read these books. ▪ Some books try to show kids who behave in a non gender-stereotypical way, but these tend to be girls only. ▪ What does this tell kids about the relative importance of masculine and feminine characteristics? Like the messages kids get from peers, it seems like masculine is given a higher status than feminine is. Even in books with non-stereotypical kids, they often have gender-stereotypical parents. " Also, more mothers are shown than fathers overall. o TV " Boys are seen more often in kids' TV shows. " Stereotyped gender activities are also common. " Some antidotes to the effects of TV on kids' gender schemas include: " Limit kids' TV viewing. " Watch TV with your kids and discuss any gender-stereotyped behavior that is shown. " Look for and choose non-biased options to watch. " Kids and Gender Knowledge o As early as 6 months old, kids can tell the difference between a female and a male. " Kids can clearly explain the differences between the genders by the time they are 6 or 7 years old. " Kids in grade school tend to show strong stereotypes in preferences for: o toys that they like to play with o what girls/boys are "supposed" to like to play with o their own future occupations o attributions of personality characteristics to each gender (e.g., gentle, strong, etc.) (this last one is consistent across cultures) " Also across cultures, stereotypes about males are stronger than stereotypes about females. MODULE THREE " Adolescence o Adolescence is a transition phase between childhood and adulthood o Is it the worst of both worlds? " You have more responsibilities. " You don't yet have the experience with which to easily handle them, though. " You also don't get all of the rewards of adulthood yet. " Puberty o Puberty is the age at which a person becomes physically able to sexually reproduce. o This is the beginning of adolescence. o For girls, the range for the age of onset of puberty is ages 9 to 14. The average age for the onset of puberty for girls is 12. o For boys, the range is from ages 10 to 17. o During puberty, secondary sex characteristics develop. " These are body parts that are related to reproduction, but aren't critical for it (breasts, pubic hair, etc.) o What happens to the body during puberty? " Girls become curvier (increase in body fat, especially in hips). " Both genders get to enjoy the pleasures of acne. " Also, both genders get hairier. " Body odor comes along as well. " Body Image o There is the same exaggeration here as in earlier years on the importance of female attractiveness. o Adolescent women are less satisfied with their bodies after looking at fashion magazines compared with looking at other magazines. " Physical appearance is the strongest predictor of self-worth in female adolescents. " For males, the strongest predictor of self-worth is athletic competence. " Adolescent girls who are athletes have higher self-esteem than other girls do. " Self-Esteem o Self-esteem can be defined as how much I like and value myself. o What is the difference between adolescent males and females on self-esteem? You may be surprised to find out that overall there is very little difference between the genders here. o The hardest time for girls, though, is the late teenage years. During this period, girls do have lower self-esteem than boys do. " This might be due to the interaction of years of the over-valuing of her appearance, along with a reduction in body satisfaction after exposure to media depictions of thin girls (such as in fashion magazines, among other places). " However, one group of adolescent females does not show this dip in self-esteem during the late teen years: Black adolescents. " One other group doesn't show this dip either: upper-class teen girls. Lower-class and middle-class girls do have a reduction in self-esteem during the later teens, though. " Boys' Self Image Can Be Molded and Constricted by Expectations Too! o Take a look at this Kickstarter promo video (Links to an external site.)Links to an external site. (4:49) for the documentary film The Mask You Live In, which explores boys' gender socialization and the ways that masculine expectations can affect them. " Since this video was made, the film has been completed and released. You can access it on several streaming services if you're interested. " How do Teen Boys and Girls Differ in Education and Career Goals? o Research shows that, especially in math and science, teachers may expect more from boys and give them more attention, may choose examples of interest to boys, and may give more encouragement to boys to pursue related careers. " Boys may tend to react negatively to girls interested in math or science, and research shows that few girls join related clubs. esearch shows that most science and math clubs in high schools don't have many female members. This science club has 6 of 13 members who are female, though. What was the case in your high school? o Girls do better in schools that: " emphasize gender, ethnic, and class equality " have high expectations for girls " encourage leadership in girls " have mentor programs o Today, 53% of college students are female. o Women also earn 51% of PhDs! This is a relatively new shift toward equality in higher education opportunity. o Only 42% of college teachers are women, though. " That percentage is actually much lower in the areas of science, math, and engineering. " Historically, there has often been a message that "girls aren't welcome" in these areas. " Awareness of this gender gap may be leading to changes, though. A recent study (Williams & Ceci, 2015) showed that hypothetical women applicants for STEM faculty positions (biology, engineering, and psychology) were preferred two to one over hypothetical male applicants. If this is true and if it continues, might this actually be a problematic over-correction? o Adolescent males and females tend to aspire to careers that are very similar in level of prestige. o Compared to males, adolescent females tend to be more likely to: " choose nontraditional careers that aren't stereotypically associated with their gender " be allowed to make their own career decisions free from parental pressure (boys get more pressure in this area) " seek out and gather needed information about their career choices " emphasize the importance of marriage and kids when considering a career path " Girls who aspire to high-prestige, nontraditional careers tend to: o get good grades o be independent, confident, assertive, emotionally stable, and satisfied with their lives (all characteristics that will come in handy in a professional career) o have feminist attitudes o have middle- or upper-class backgrounds o have moms who worked outside of the home o have a supportive family o have work experience during school " Research shows that due to the importance placed on having a boyfriend, girls who initially have high career goals may let go of their dreams, since "boys don't like smart girls." " Family o Most adolescents have a strong emotional bond and get along well with their parents, especially on big issues like values and politics. " Teen girls typically feel closer to their mothers than their fathers. " Parental acceptance of girls' various emotions continues to be greater than for boys at this age. " Teen girls' friendships may tend to be closer and more intimate than boys' friendships, but the research here is mixed. " Romance o After years of gender segregation, boys and girls now have to figure out how to interact. o Much of the information about the other gender comes from the media, which often portrays gender-stereotyped behavior. " The average heterosexual romance lasts 4 months, but the average length increases with age. " Boys are more likely to mention physical attractiveness when describing their girlfriends. " Girls, on the other hand, mention what they get from their relationships (like support and intimacy) when describing their boyfriends. " There are a lot of differences among girls in how having a boyfriend affects a girl's school performance and self-image. o Some girls forget themselves and their other responsibilities when they get a boyfriend, some can stay focused on things other than their boyfriend. " Lesbians report an average age of 11 when they became aware of being attracted to females. " A full 99% of lesbians said they have heard anti-gay remarks in school. o That's an amazingly large percentage. You almost never get numbers as high as that in surveys of any kind. " Most young lesbians tend to overcome these negative messages, though. Surveys show that 94% report being glad to be lesbian or bisexual. MODULE FOUR " Brain Structure o Joel et al. (2015) have found that there are some ways in which the brains of males and females tend to differ, for instance in the sizes of certain brain structures, the distribution of grey and white matter, the strengths of connections in certain areas, etc. o However, almost nobody (between 8% and 0%) has a brain that has only female (or male) characteristics, and these individuals would probably be considered psychologically unwell outliers. o In other words, there is no such thing as a "female brain" or a "male brain." o Instead, each of us has a unique mosaic of female and male brain characteristics. o On the other hand, since there are brain differences that are correlated with gender, research in this area might eventually help us explain why some psychological disorders are experienced by each gender differently or at different frequencies. o We'll explore these psychological disorder differences in the last 2/3 of this class. " Achievement Motivation and Success " In fear of success, there is no difference between the genders. o How does this compare with the stereotype? Are women thought to be more uncomfortable with success? " In self-confidence, there are some differences, though. o Men are a bit more self confident overall. o The differences in self-confidence between men and women are largest when people make public estimates of their abilities rather than private estimates. " This means that if a woman and a man are asked to publicly state, for instance, how confident they are that they would win a bet, the man would express quite a bit more confidence that he will win. The woman would express less confidence. " However, if each of those persons is asked to write down (so that there is not an audience) how confident they are that they will win the bet, something different happens. The man might be a little more confident than the woman, but not by much. " The presence of an audience seems to make men express more confidence, but not women. o Also, men's self-confidence tends to be more stable, while women's self-confidence is more variable based on feedback from others. " Does this mean that men are more self-secure (which has historically been the interpretation) or that women are more realistic and open to healthy self-examination? " Verbal Communication o Regarding talkativeness, the research is mixed, showing either no difference or, if anything, men talking more. Overall, though, there is no clear difference shown. ◦ Regarding interruptions, research suggests that men interrupt more than women do. ▪ However, it seems likely that this is actually a function of status instead of gender. ▪ On average, men have higher status in this culture than women do. That might account for men being more likely to interrupt. ▪ If this is the case, we would expect that a female boss would be more likely to interrupt her male subordinate and that the male subordinate would be less likely to interrupt his female boss. ◦ Who is more polite, men or women? ▪ There are actually few differences found between the genders in politeness. ◦ One interesting difference in language use between the genders is that women tend to use more hesitant phrases (such as "I'm not sure" or "I guess"). ▪ However, this is ONLY TRUE when a woman is talking to a man. This doesn't happen in woman-to-woman conversations. o Nonverbal Communication ◦ Women have smaller personal space zones than men do. ◦ There are also some differences between the genders in posture. ▪ Men tend to take up more physical space with their posture. ▪ legs apart ▪ arms moving away from the body more frequently more relaxed posture " In contrast, women tend to take up less physical space. o legs together o arms close to bodies o more rigid posture o Women tend to look at other people (of either gender) more. o People (of either gender) tend to look at women more. o Now is a good time to talk about subject variables and stimulus variables, because these concepts apply here. o A subject variable is a behavior that is affected by a quality of the person doing the behavior (the subject). o A stimulus variable is a behavior that is affected by a quality of the person to which the behavior is being done (the stimulus, or the thing that stimulates the behavior). o For instance, when I say that women tend to look at other people more, this is a subject variable. That's because the gender of the person doing the looking affects the looking behavior. In other words, my gender (male) makes me look at people less frequently. o When I say that people tend to look at women more, this is a stimulus variable because the gender of the person being looked at affects the looking behavior. When a woman and a man walk into my room, I'll be more likely to look at the woman because of her gender. This would be true no matter what my own gender was. o Here's another example. Let's imagine that there was a difference in politeness between the genders. (Remember, like I said above, there actually isn't a difference in politeness, but let's pretend that there is.) o If I said that people tend to be more polite to men than to women, that would be a... o stimulus variable. The gender of the person being spoken to determines how polite the speaker is. o If I said that women tend to be more polite than men, that would be a... o subject variable. The gender of the speaker determines how polite the speaker is. o Get it? o One final example. (Forgive me if I'm beating this to death, but this concept can be a bit tricky.) o Take another look at the example above of women being more likely to use hesitant phrases. Is this a subject variable or a stimulus variable? o It's actually BOTH. It's a subject variable because women use more hesitant phrases than men do. It's also a stimulus variable, though, because women only do this when they're talking to men. Thus, the genders of the speaker AND the person being spoken to determine the behavior. " One final difference in nonverbal communication is that women are moderately better at accurately decoding what other people's facial expressions really mean. o Altruism ◦ Altruism is providing help to someone in need without expecting a reward. ◦ You can wind up getting a reward after all, but to be altruistic you have to not expect one. ◦ There is no real difference between the genders in altruism; both men and women are about equally altruistic. o Nurturance ◦ Nurturance is giving care to someone younger or less able to care for himself or herself, like a baby, an older relative, a sick roommate, etc. ◦ Women rate themselves higher on nurturance. ◦ However, there is no objectively measurable difference between the genders in amount of nurturance actually given. o Empathy ◦ Empathy is understanding what someone else is feeling and feeling it with them. ◦ As with nurturance, women rate themselves higher on this but there is really no measurable difference. o Moral Judgments ◦ The stereotype is that women want to do what is right and compassionate, even if it's not technically by the rules. ▪ According to this stereotype, a female judge would be more likely to throw out a speeding ticket if the defendant showed that she had a spotless driving record before the ticket and was only speeding to get home to a sick child. ◦ The stereotype for men is that they want to do what is fair and by the rules, even if someone might be unfairly or unreasonably hurt. ▪ This stereotype would predict that a male judge would be more likely to let the ticket stand, because the law is the law. ◦ Research shows that there is actually a small but measurable difference between the genders in moral judgments that agree with the directions of these stereotypes. o Friendship ◦ Friendships of women and men are similar in most ways, such as in the degree of satisfaction with friendships and the value that each places on self-disclosure. ◦ However, there are some differences. ▪ Women value physical contact between friends more. ▪ Women self-disclose with friends slightly more. This is true even though both genders value self-disclosure equally. ▪ Women spend more time helping friends. Women blame friends less for their friends' problems. MODULE FIVE " Access discrimination is discrimination used in hiring, like rejecting well-qualified women applicants or offering less attractive positions than the one that was applied for because the applicant is a woman. " Access discrimination is stronger for women when an employer has strong gender-role stereotypes or when the employer is strongly religious. " It is also stronger for a woman when the job for which she is applying is more prestigious " o This is true even within the same employment field. o Treatment discrimination is differential treatment after hiring. o For instance, women earn 77% as much as men across ethnicities " For instance, here are average annual physician salaries after controlling for the doctors' ages, hours worked, and where they practice (Ly, Seabird, & Jena, 2016): " White male doctors - $253,000 " Black male doctors - $188,000 " White female doctors - $163,000 " Black female doctors - $152,000 " This pay discrepancy seems to be surprisingly well-tolerated, considering the fact that it's completely unfair. " One study asked participants to say how much they would ask for to do a hypothetical job. " Both men and women were given the same job description. For instance: answer phones, greet clients, schedule deliveries, manage customer files, track accounts and payments. " Men, on average, asked for $10.27 per hour. " Women asked for $7.48 per hour. " This was for the exact same job! " Notice how close those two numbers come to the 77% number that occurs in reality... " Actress Jennifer Lawrence, for one, is speaking out (Links to an external site.)Links to an external site. after it was revealed that she and other female stars get paid less than their male counterparts (via an email hack of movie studio Sony Pictures). Read her brief letter linked above. It's good. " Also, watch this video (2:08) with Kristen Bell. It's funny, yet statistically accurate. o One possible solution for the wage gap problem is wage transparency, or requiring all companies to publicly post the average salaries for men and women in each kind of job at the company (like Sony was forced to do via that email hack). This would permit the free market (via consumer purchasing choices) to take action on this information, putting economic and social pressure on companies to close the wage gap. o Going a bit further than this, Iceland has recently enacted a law requiring all businesses and government agencies to provide documentation annually to prove that they pay women and men equally for the same jobs and experience levels. Businesses have to pay a fine if they don't pay the genders equally. Even before this law, Iceland had the lowest economic gender gap in the world. They want to get rid of the gap completely. " The glass ceiling is the invisible barrier that keeps women and minorities from advancing past a certain level in a company. " The sticky floor, on the other hand, describes women in low-level jobs with little to no hope for promotion. Entry level workers such as receptionists, cashiers, waitresses, and housekeepers rarely even get the chance to bump into the glass ceiling. " The glass escalator, however, is a nice feature for men. Men in traditionally feminine jobs get promoted more easily than women do. Remember the example of male teachers being more likely to be promoted to principal? " Women are also more likely to receive negative job evaluations. " Often, women are excluded from networking opportunities too. " Sexual harassment (unwanted sexual advances) and heterosexism (bias against non-heterosexuals) are also prevalent in the workplace. " Traditionally female occupations (such as nurse, teacher, dental hygienist, daycare worker, etc.) tend to have lower pay than traditionally male occupations (such as doctor, principal, dentist, lawyer, etc.). " Many opponents of efforts to address the gender wage gap will point to this fact to deny the wage gap's existence, saying that women simply choose to work in lower-paying fields. " You can remind them that the wage gap exists even within individual professions or fields, however. " Traditionally male occupations tend to be considered more prestigious than typically-female careers. " The women in these traditionally male jobs tend to be similar to the men in those jobs. o high achieving o confident (though a little less so than the men in these jobs) o similar cognitive skills " Confident and assertive women in these jobs tend to get more negative reactions than more passive women do " Women in blue-collar jobs (such as auto mechanics, construction workers, factory workers, etc.) are also similar to the men in these jobs, but the women can often be held to stricter standards for performance than the men are. " Men perform between 30% and 40% of the household duties when both a husband and wife are employed. " Men have an average of 36 more free-time minutes a day after work and home duties than women do. " Both men and women seem to be generally OK with this, though women with husbands who do more around the home are happier with their marriages. " When differences in the division of housework duties are extreme, the woman is at greater risk of depression. " Today, 71% of moms are employed. " Moms also provide most of the child care (between 60% and 90%, depending on the study), although the division of this labor is improving over time. " Speaking of kids and employment, how does the U.S. compare with the rest of the world in the area of maternity and paternity leave when a child is born? Watch this video (2:19) to find out. " Role strain, which is the conflict between the demands of a job and the family, is very common. " However, employed women tend to be physically healthier than those who do not work outside of the home. " Employed women's self-esteem is also generally higher, and they have less risk of depression or anxiety. " Having both roles (employee and wife/mother) can actually provide a buffer; when things are stressful in one place, you can gain strength and confidence from your performance in the other one. " All of the above benefits of employment aren't true, though, for a woman in a low-paying or unrewarding job, with many kids, and with an unsupportive husband. In this case the job is just another stressor. MODULE SIX " Trends in Heterosexual Marital Relationships o Women report more positive emotions (happiness, satisfaction, enjoyment, etc.) related to their marriages than men do. o However, women also report more negative emotions (dissatisfaction, resentment, anger, etc.) related to their marriages than men do. o Women just seem to be more in tune with how they're feeling (whether good or bad) about their marriage. o Married women who are employed have more decision-making power within the marriage " In a traditional marriage, the husband makes most or all of the decisions and controls the money. " In an egalitarian marriage, both spouses share power equally. " Most marriages in the U.S. today are actually somewhere in between these two types. " When a marriage ends, the woman is more likely to be the one who initiates the divorce. " Divorce is one of most stressful changes a person can face. Depression and anger are common, but so is relief! " A woman's financial status is almost always worsened after a divorce, especially if she has kids (less than half of divorced dads pay mandated child support). " Research on Lesbians and Bisexual Women o Surveys show that the term lesbian is preferred to homosexual woman because the former emphasizes the non-sexual aspects of the relationship, too. o When the psychological health of lesbians is compared to that of straight women, no differences are found, except for lesbians having perhaps a little higher self-esteem and self-reliance. o The fact that lesbians face a higher risk of being the victim of hate crimes can, of course, reduce happiness, though. o Those who are more accepting of their own lesbian identities have higher self-esteem than those who aren't. o Though lesbians often create supportive social networks for themselves, they tend to be happier if their family and pre-outing friends accept them after they come out. o Lesbian couples are generally about as satisfied as straight couples, no more and no less. o Until recently, they still didn't get the same legal benefits as married heterosexual couples do in much of the U.S. " On January 6th, 2015, Florida became the 36th state to grant marriage rights to lesbian and gay couples. " Not long after that, on June 26, 2015, marriage rights were extended to same-sex couples in every state following the Supreme Court's Obergefell v. Hodges decision. " Lesbian and gay couples had already had this right across most of Europe for a while, though, so we're really just catching up with the rest of the developed world. " Regarding bisexual women, they show no differences in psychological adjustment or happiness when compared to lesbians or heterosexuals. " However, bisexual women can feel rejection from both the heterosexual and lesbian cultures, with lesbians viewing them as partially rejecting their lesbian nature. " Singlism is bias toward women who haven't ever married, especially once they reach their thirties. o Is the reaction to unwed, middle-aged women different from the reaction toward unwed, middle-aged men? " There are some advantages to being single, though. o freedom to do what you want when you want o privacy at home " Of course, there are disadvantages too. o loneliness o Noah's Ark syndrome: Many social events are designed for couples. " attending a wedding " going out to eat " cruises " going to the movies " etc. MODULE SEVEN " Gender and Mental Illness o Gender (or sex) can influence mental disorders in 3 ways: " sometimes only one sex or the other can get a disorder For instance, no biological man has ever had premenstrual dysphoric disorder. And no biological woman has ever had erectile disorder, either. " one gender can be at greater risk for some disorders, such as depression " or each gender can have different symptoms for the same disorder A boy with ADHD would be bouncing off of the walls, but this girl with ADHD just looks bored. o In this class we will be looking at only those mental disorders for which there is a difference between the genders. o We will also be looking at the ways that the differences between women and men (that we learned in Modules 1 through 6) might relate to or even explain these gender differences in mental disorders. o Bipolar Disorder ◦ Bipolar disorder involves cycling between bouts of depressive episodes and manic episodes. ▪ A manic episode is an extremely elevated mood that (while this sounds good) causes the person more problems than it's worth. ◦ Compared with men, women cycle between mania and depression more rapidly. ◦ Women with bipolar disorder are also more likely to experience mixed features, in which the symptoms of depression and mania are experienced simultaneously. ▪ This sounds confusing (or even impossible), but it is actually very common. If mixed features are being experienced, then the person could feel (for instance) mostly manic (full of energy, feeling powerful, impatience, having a flood of ideas that seem brilliant to you) but with a few symptoms of depression (like excessive guilt) at the same time. ◦ Compared with men with bipolar disorder, women with bipolar disorder also experience more depressive symptoms, more anxiety symptoms, tend to drink alcohol more, and are at increased risk of also developing an eating disorder. o Premenstrual Dysphoric Disorder ◦ As mentioned above, this is a disorder that only women can get. ◦ Premenstrual dysphoric disorder happens during the week before menses and starts to improve a few days after the period starts. Symptoms include mood swings, irritability, depression, tension, concentration problems, fatigue, feeling out of control, and bloating " Major Depressive Disorder o The technically proper way to categorize major depressive disorder is to classify it as unipolardepression. This is in contrast to bipolar disorder, which includes both poles (high and low) of mood. o For major depressive disorder to be diagnosed, a person must experience one or more majordepressive episodes (described below). " For a diagnosis of depression, there also must be no history of any manic or hypomanic episodes - that is, none of the highs of bipolar disorder. " If a person who experiences a major depressive episode has ever had a manic or hypomanic episode, then the person has bipolar disorder and not major depressive disorder. o To qualify as a major depressive episode, five or more of these symptoms must be present for at least two weeks: 1. depressed mood* 2. anhedonia*, which is a lack of enjoyment in things (an = without, hedonism = pleasure) 3. weight loss or weight gain (5% of body weight in a month) or increase or decrease in appetite 4. insomnia or hypersomnia (sleeping way too much and yet never feeling rested) 5. psychomotor agitation (e.g., pacing; constant wringing of the hands; being unable to sit still; or constantly pulling or rubbing your skin, clothes, or other things) or psychomotor retardation (e.g., slowed speech, thought, and movements of the body; lengthy pauses before you reply to someone; softer speech; less frequent speech or even muteness; decreases in the inflection of speech; having fewer things to talk about); these changes have to be noticeable by other people, not just something that the person notices herself or himself 6. fatigue 7. feelings of worthlessness or excessive guilt 8. poor concentration or indecisiveness 9. recurrent thoughts of death, thoughts of suicide without a plan, thoughts of suicide with a plan, or a suicide attempt (these four suicidal behaviors are arranged in this list in increasing order of severity, by the way) o *Of the five or more symptoms that are present, at least one has to be either (1) depressed mood or (2) anhedonia. o Again, major depressive disorder is diagnosed when a person experiences one or more major depressive episodes and has never experienced a manic or hypomanic episode. " Remember, a major depressive (or manic or hypomanic) episode is not a diagnosis; it's like a large, multipart symptom that's made up of other, smaller symptoms (those nine things listed above). o Three of these nine symptoms are most indicative of a more severe case of depression: " (5) psychomotor agitation or psychomotor retardation " (7) feelings of worthlessness or excessive guilt if these are so strong that they are delusional (such as, "I am so worthless that nobody in the world likes me.") " (9) suicidal thoughts or behavior o Women are more likely to experience suicidal thoughts. o However, men are more likely to die from suicide. o Huh? This is because men tend to choose more effective ways to attempt suicide (i.e., guns for men, pills for women). " Persistent Depressive Disorder o Persistent depressive disorder is mild depression (that is, with fewer than five of those nine symptoms) lasting at least two years. ◦ In DSM-IV, this disorder was known as dysthymic disorder or dysthymia. ◦ Episodes of major depressive disorder may be superimposed on persistent depressive disorder. ▪ That is, you can be mildly depressed all the time for years (persistent depressive disorder) and also have periodic bouts of full-blown depression. After the bout of full depression is over, you go back to feeling mildly depressed again. ▪ This is called double depression. o Facts About Major Depressive and Persistent Depressive Disorders ◦ The overall prevalence of these disorders in the US is 7%. ◦ These disorders are seen 1.5 to 3 times as often in females as in males. ▪ Is this because women are more attuned to their feelings so they are simply more likely to notice and report depression? ▪ Probably not, because this finding is consistent even when outside observers measure people's symptoms, rather than relying on self-report. Women are still diagnosed 1.5 to 3 times more frequently in this way. ▪ However, when a list of male-specific symptoms is used (i.e., anger, aggression, irritability, substance abuse, risk-taking, hyperactivity), the differences in prevalence between the genders vanish. ▪ This suggests that our list of symptoms for depression may actually be estrocentric (rather than androcentric) - based on female as normative! ▪ Another way of looking at this is that our list of symptoms may have been devised under the assumption that depression is mostly a woman's issue, since symptoms that are mainly experienced by depressed males aren't on the list. ◦ For women with depression, substance abuse is common, as are anxiety disorders, eating disorders, and borderline personality disorder. ◦ The prevalence of depression decreases with age. ▪ Did you expect it to increase? ▪ Why does it decrease? ▪ Older persons tend to be less likely to report depression, since there was more of a stigma with that disorder when they were younger. ▪ Also, the older you get, the more coping skills you develop, so you tend to get happier as you age. (Yay!) ▪ Finally, people with depression have a shorter life expectancy. That means that there are fewer depressed old people in part because they have already died. ◦ Many people with depressive disorders don't get treatment. ▪ Sometimes, there is simply no access to treatment due to financial or transportation issues. ▪ Also, some people tend to believe that they "should be able to get over it." That's true for normal sadness, but depression is a medical condition that might need medical treatment. Depression can and often does resolve itself, but it often leaves scars on a person's self-image. " Biological Causes o Genetics " You are 2 to 4 times more likely to get depression if you have a close relative with depression. " The same is true for bipolar disorder, but there is no crossing of this tendency between depression and bipolar. If depression runs in your family, you're at no greater risk for developing bipolar disorder, and vice versa. " This suggests that there are different biological mechanisms at work in depression and bipolar disorder, rather than both being versions of the same disorder as we used to believe. " This is one reason that in DSM-5, depression and bipolar disorder are in separate sections. In DSM-IV, they were both categorized in the same section: mood disorders. " Depression is about 40% caused by heredity for women and 20% caused by heredity for men. " One implication of this is that the environment plays a larger role in depression for men. " The genetic predisposition for depression or bipolar disorder is multi-factorial (many genes interact to produce a predisposition); there is not a single gene for depression or bipolar. " However, the personality trait of neuroticism is the largest single genetic factor underlying the depressive and bipolar disorders. Of the Big Five personality traits (OCEAN), neuroticism (N) is most strongly related to depression. The same is true if we use the Big Six (HEXACO) instead, but neuroticism (N) is called emotionality (E) in that model. o Neurotransmitters " Depression and bipolar are largely caused by the action of the monoamine neurotransmitters (which are norepinephrine, serotonin, and to a lesser extent dopamine) in the limbic system. " In general, too much of these neurotransmitters causes mania, and too little causes depression. " Mood is affected when you have imbalances in: " the production of neurotransmitters (i.e., too much or not enough of the neurotransmitter is being made in the presynaptic neuron) " the release of neurotransmitters (i.e., either too much or too little is released into the synapse) " the degradation of neurotransmitters (i.e., once they are released into the synapse, they are broken down either too quickly or too slowly by the enzyme monoamine oxidase) " the reuptake of neurotransmitters (i.e., once they're released into the synapse, the neurotransmitter molecules are re-absorbed back into the pre-synaptic cell either too quickly or too slowly) " the number of neurotransmitter receptors on the postsynaptic neuron (either too many or too few) " the sensitivity of the neurotransmitter receptors on the postsynaptic neuron (either too sensitive or not sensitive enough) " We can see that for each of these six ways that things can go wrong, either mania or depression can result, depending on whether too much or too little neurotransmitter activity happens. o Brain structure " For depression, there are some structural changes to the brain that can be linked directly to specific symptoms: " Lower activity in the prefrontal cortex leads to a reduction in goal-directed behavior. " Lower activity in the anterior cingulate leads to anhedonia. " A smaller and less active hippocampus is related to memory loss. " An enlarged amygdala results in rumination on (obsessively thinking about) depressing things. o For those with depression, fMRIs show dysfunctions in the brain areas that process emotions and reward seeking. o With treatment, each of the above brain changes returns to normal. o These changes in brain structure can be caused either by your experiences or your genes. " Hormones o Excessive hormone production activity in the hypothalamic-pituitary-adrenal (HPA) axis is associated with sadness and suicide risk. " Cortisol (the stress hormone) is in chronic excess during depression. This affects monoamine functioning and leads to extreme emotional responses to even minor stressors. " Environmental Causes o Early childhood stress (like abuse, neglect, or poverty) is correlated with the neurobiological abnormalities of depression. " Can we assume, then, that childhood abuse or other stresses cause these brain abnormalities? " NO!!!! " It's worth saying it again. No, we can't assume that a bad childhood causes changes in the brain, even though the two are correlated. " This is because correlation does not prove causation! " It's entirely possible that the reverse is true: These brain abnormalities might tend to be inherited in families, and the abnormalities might cause parents to abuse or neglect their kids or be more likely to be poor. " Alternatively, a child born with these depression-causing brain abnormalities might have behavior or attitude issues too, which cause her or him to have worse relationships with caregivers, leading to a stressful childhood. o Early childhood stress is strongly related to the depressive and bipolar disorders. " There are countless other possibilities too, since correlation does not prove causation! " Bad experiences in childhood that are numerous and of different kinds are the strongest risk factors. " In non-human animals, the lack of maternal care in early childhood causes brain abnormalities, and subsequent supportive maternal care reduces them. Even in humans, these two things (childhood neglect and brain abnormalities) are correlated. (We can't assume causation in humans, though, because we can't ethically experiment on human infants by intentionally neglecting one randomly-selected group of kids and comparing them to a control group. It's considered ethical to experiment on non-human animals this way, though. Do you agree?) " Smothering or overprotective parenting also increases a kid's risk of these disorders. " The risk for girls is greatest when they change from one level of school to another. o As evidence for this, in school districts that have kindergarten through 8th grade in a single primary school, a girl's risk for depression increases as she enters the 9th grade. o In districts with middle schools that are 7th through 9th grade, though, the risk for girls increases when they leave elementary school to enter the 7th grade. " As we've already learned, women with husbands who help out less around the house are at greater risk for depression too. Perhaps surprisingly, only men (not women) have increased risk for depression following marital separation or divorce " Psychological Causes o Depression is caused by a reduction in reinforcers. For instance, when you lose a friend, you become depressed because the positive attention that this friend used to give you is no longer present. o Depression is also caused by the reinforcement of depressive behaviors (such as crying or self-downing statements) by sympathy and attention. o From the perspective of behaviorism: We need to feel comforted and supported when we're sad, even when we're depressed. Compassion and support are double-edged swords, however. If I get more attention when I cry and talk down about myself, and if attention is a reinforcer for me, I'm going to cry and down myself more. " Repeated, uncontrollable negative life events can also lead to learned helplessness, when the person simply gives up trying to make things better. " If I keep trying and failing to find a way to catch up on my bills (or find more supportive friends, or get out of an abusive relationship, or whatever), eventually I'll start believing (often erroneously) that nothing I do makes any difference and I'll stop trying. " This leads to depression. " Often a new client will come to me with depression and in a state of learned helplessness. " Usually, together we find options and strategies to reduce or solve the problems or (at the very least) respond to them differently, reducing the client's depression. o From a cognitive perspective: " Beck's cognitive triad: Depressed persons have negative views of themselves, the world, and the future. " Then the person depressed by the cognitive triad commits other thinking errors like automatically focusing on the negative side of things. " Reformulated learned helplessness: Persons who tend to attribute bad things to causes that are internal, stable, and global experience learned helplessness and hopelessness. " That is, "It's my fault that things suck, I can't change myself, and it's not just part of me that's broken it's my whole life. " It's called "reformulated" learned helplessness because the original kind of learned helplessness is a behavioral concept, caused by a persistent lack of reinforcers for adaptive behaviors. " Here, though, it's been reformulated to include a cogni

WMH

Module 8 " Depression During Pregnancy o If a woman is already depressed while she's pregnant (that is, prepartum), there are greater risks of: " complications during pregnancy or delivery " the baby having low birth weight " premature birth " This is different from postpartum depression (see below). " Postpartum Blues o The postpartum blues are a brief (roughly the first 10 days after birth) feeling of sadness, crying, insomnia, irritability, anxiety, and feeling overwhelmed. " This is different from postpartum depression (see below). " It's also pretty normal, since about 50% of new mothers go through this. " Postpartum Depression o Postpartum depression is full blown depression (at least five of the nine symptoms: sadness, anhedonia, appetite changes, sleep problems, psychomotor changes, fatigue, guilt, concentration problems, suicidal thoughts) plusone more symptom: lack of interest in the baby " Severe anxiety is also common during postpartum depression, including symptoms up to full-blown panic attacks. " Postpartum depression usually begins within 6 months of birth, but the official DSM-5 diagnosis says that symptoms must start during pregnancy or within 4 weeks of birth. " Half of the time the depression starts before delivery, which isn't technically postpartum. " That's why the DSM-5 term for postpartum depression is major depressive disorder with peripartum onset. o The prefix "peri" means "around," so peripartum means a little while before or after birth. " We'll just refer to it by its common name: postpartum depression. " It typically lasts many months. " About 3% to 6% of new mothers experience postpartum depression. " Postpartum depression is more likely if the mother is stressed or if she lacks social support. " One recent study showed that depressive symptoms in new dads also increased by 68%, so it might be that postpartum depression isn't a strictly female condition after all. " Actress Hayden Panettiere spoke out about her experiences with postpartum depression on the September 28, 2015 episode of Live with Kelly and Michael: "There's a lot of misunderstanding - there's a lot of people out there that think that it's not real, that it's not true, that it's something that's made up in their minds, that 'Oh, it's hormones.' They brush it off. It's something that's completely uncontrollable. It's really painful and it's really scary, and women need a lot of support." " Her character on the TV show Nashville was written to have postpartum depression, too. " Greater risk of postpartum depression if the mother- is under 20 years old, abuses alcohol, smokes, takes illegal substances, didn't plan the pregnancy or doesn't want the baby, had a mood disorder or anxiety prior to the pregnancy (eg; depression), has something stressful happen to her during the pregnancy, has difficult pregnancy, difficult labor or emergency delivery, premature delivery, baby with an illness or abnormality, close familt member who has anxiety or depression, poor relationship with baby's dad, is unmarried, financial problems, little support from family, friends, or significant other, suicide attempt, poor support from parents in childhood, miscarriage or stillbirth. " Since childbirth is a time of significant change for a woman, the ways a new mother adjusts to these changes can contribute to (or help prevent) depression. " Physical Changes After Childbirth o Often after childbirth, women experience changes in muscle tone and difficulty losing the weight gained during pregnancy. " Women also frequently experience fatigue after giving birth and for several weeks afterward " There is often soreness and pain in the perineal area (the area around the birth canal). " Physical recovery after a Cesarean delivery usually takes even more time than after a vaginal delivery. o By the way, a recent meta-analysis (Hoxha et al., 2017) found that for-profit hospitals are 1.41 times more likely to deliver using a C-section than are non-profit hospitals, independent of characteristics of the mother. According to the authors, money seems to be the motivating factor here... " Common Emotional Changes After Childbirth o These emotional changes can be caused by life changes that happen as a consequence of having a baby and/or hormonal changes related to the pregnancy and birth. o Note: The emotional changes listed below can sometimes be linked to hormones, but postpartum depression itself does not seem to be hormonally caused. o Common emotional changes after childbirth include: " feelings of loss of your old identity Want to make a quick trip to the store? Better make sure that all of your provisions and supplies are restocked. " feeling overwhelmed with the new responsibilities of motherhood " feeling stressed from changes in your routine " feeling mentally fatigued because of disrupted sleep patterns or a lack of free time " feeling doubts about your ability to be a good mother " feeling less sexually or physically attractive " feeling guilty due to an unrealistic need to be a perfect mom " The pressure to be the perfect mom can be exacerbated by things like this pic from Instagram. This is a post from model Gisele Bundchen sharing the magic of motherhood. She forgot to post the tantrum that the kid probably had right before this picture and the kid perhaps throwing up on her chest right after. We can be trapped by the belief that what people show us via social media is the way their lives are all of the time, and feel guilty because ours aren't that perfect or awesome. " Causes of Postpartum Depression o Though hormones are often blamed, there is not actually strong empirical evidence for this. o However, levels of hormones produced by the thyroid (a small gland in the neck that helps regulate how the body stores and uses energy from food) may also decline after childbirth. " Low levels of thyroid hormones can mimic symptoms of depression. " A simple blood test can tell if depression is psychological or due to thyroid problems. " The treatment for this type of depression is taking synthetic thyroid hormone medicine. " Effects of Postpartum Depression o There are some indications that postpartum depression in a mother can cause a baby to have: " delays in language development " problems with mother-child bonding " behavior problems " increased frequency of crying " Treatments for Postpartum Depression o Fortunately, there are several types of antidepressant medications that may be safely given to breastfeeding mothers, including nortriptyline (Pamelor), paroxetine (Paxil), and sertraline (Zoloft). o What about the use of antidepressants duringpregnancy rather than afterward? " A recent publication in the online preview version of the Journal of the American Medical Association (Boukhris, Sheehy, Mottron, & Bérard, 2015) has indicated that the use of antidepressants by pregnant women increases the risk that the child will be born with autism spectrum disorder (ASD). " Other authors (Salcedo, 2015) note, however, that maternal depression increases the risk of ASD in children, so it may be the disorder and not the treatment that increases risk. " Also, the risk increases from less than 1% without antidepressants to less than 2% if the mother takes antidepressants while pregnant, so the difference in risk is not staggering. " Basically, the science is still being settled on this topic. " Puerperal Psychosis o Postpartum psychosis (or puerperal psychosis, puerperal meaning "relating to childbirth or the period immediately following") can also occur. o Symptoms may include: " hallucinations " Hallucinations are usually auditory (hearing things) and are only rarely visual (seeing things). " Hallucinations can actually involve any sense, though, even smell, touch, and taste. " Sometimes hallucinations during puerperal psychosis can include command hallucinations in which a voice tells the mother to kill the baby. " delusions " Delusions are beliefs that are very strongly held but are false and irrational. " Puerperal psychosis may include the delusion that the baby is possessed. " feeling confused " rapid mood swings " attempts by the mother to hurt herself or the baby o This condition is very rare, though, being found in only 1 to 2 out of every 1,000 births. o It usually begins in the first 2 weeks after childbirth. o The odds of this disorder increase if the mom has a family history of bipolar disorder. o Women who have a history of bipolar disorder, depression, or schizoaffective disorder (which is a mixture of psychotic symptoms like hallucinations and delusions with mood symptoms like sadness and anhedonia) have a higher risk too. o If a woman has one episode of puerperal psychosis, her chances of having another one with the next baby are between 30% and 50%. " Superfetation o Superfetation isn't actually a psychological disorder, but it's interesting. o Superfetation is a second pregnancy that happens during a menstrual cycle that begins after an already established pregnancy (Tuppen, Fairs, de Chazal, & Konje, 1999). o That is, a woman is pregnant, has sex, and gets pregnant again! o She has two babies in her womb at the same time, but they're about a month apart in age. o You didn't know that could happen, did you? o This is, of course, extremely rare. It has only been documented a few times. MODULE 9 NOTES " Autism Spectrum Disorder o In DSM-5 the single diagnosis of autism spectrum disorder (ASD) has replaced and now covers all of these disorders from DSM-IV: " autism " Asperger's syndrome - social and nonverbal communication issues, intense interest in a few topics; often very intelligent " One UCF student applied to Harvard for grad school and said on his application that he had Asperger's syndrome. " The school replied, "You'll feel right at home, everyone else here has it too." " Rett's disorder - develop normally until 1 to 3 years old, then lose motor, intellectual, and social skills; often includes compulsive hand-wringing Rett's disorder almost only happens to girls because it involves the X chromosome. " childhood disintegrative disorder - develop normally until 2 to 4 years old, then lose language and motor skills o Symptoms of ASD include: " (1) problems with communication or social interaction, such as: " (a) problems with nonverbal communication A person with ASD has trouble with such nonverbal skills as making eye contact, since this is uncomfortable for him or her to do. This image shows where a person with ASD was looking (purple line and circles) while watching a video of this man talking. Notice that the person with ASD never looked directly at the man's eye. Compare this with where a person without ASD looked (red line and circles). " (b) a lack of social or emotional reciprocity, meaning that the person can't manage the normal back-and-forth of a conversation and doesn't bond over shared interests or emotions " (c) trouble maintaining relationships because they can't adjust their behavior to the social situation and tend to not be particularly interested in other kids If you watch Sherlock (the BBC version), do the previous two symptoms remind you of Sherlock Holmes? He claims that he's a high functioning sociopath (which he probably is), but he would probably be diagnosed with ASD. " (2) repetitive behaviors, which must include at least two of these: " (a) repetitive movements or speech " Repetitive movements might include rocking back and forth. This young boy, Michael, rocks back and forth to comfort himself. Watch from about 0:40 to about 1:40 or so. Notice also how he takes a while to respond to his mother's voice. " Repetitive speech might include echolaliawhich is compulsively repeating whatever someone else says. Oft-repeated phrases are a common form of repetitive speech too. On my flight back from Phoenix after watching the 2014 Fiesta Bowl we had some turbulence. During the turbulence the five year old kid behind me made a veryloud "aaaahhhhh" noise. Dad would calmly say, "It's time to be quiet now," and the kid would reply "OK, DAD" in an adorably snarky tone. About five seconds later, the "aaaahhhhh" noise was repeated, dad would say his phrase, and the kid would make his reply. This cycle continued throughout the 15 minutes of the turbulence. It became ... not adorable. " (b) obsession with routines or rituals, such as compulsively lining things up For instance, a child with ASD might be obsessed with the vacuum cleaner (an object) or might obsessively memorize the scientific names of all of the dinosaurs (a subject). I had a cousin who did that. " (d) either being too reactive or not reactive enough to sensory input o Most people with ASD have lower intelligence, but they can also have high intelligence. o Girls make up 20% of those with ASD, but girls with ASD are more likely to have lower intelligence " One possible explanation for this is that some girls with normal or high IQ have undiagnosed ASD, but since quiet girls aren't as noticeable as quiet boys their ASD isn't documented. o We're sometimes hearing in the media about an "autism epidemic," but the overall prevalence of ASD is only about 1%. " Attention Deficit/Hyperactivity Disorder o This disorder is seen in about 5% of kids. Did you expect more based on media coverage of the disorder? o It's also seen in about 2.5% of adults. o Only about 1/3 of those with ADHD are female. o Girls are more likely to have the attention deficit type without any hyperactivity, while boys are more likely to have both hyperactivity and problems with maintaining attention. o One study showed that 23% of girls (but not boys) with the combined type of ADHD (that is, with both attention problems and hyperactivity) attempted suicide while 51% of girls (not boys) engaged in cutting or burning behaviors. o One other difference between the genders is that boys with ADHD show more physical aggression, while girls with ADHD show more social and relational aggression. " Enuresis o Enuresis is wetting the bed or urinating in your clothes. o To be diagnosed as enuresis, the "accidents" have to happen at least two times per week over a period of at least 3 months. o Also, the kid must be at least 5 years old, an age at which she or he should reasonably be able to control urination. o There is only one gender difference for this disorder: Girls tend to have diurnal (during the day) enuresis, while boys have nocturnal(during the night) enuresis. o That is, girls wet their pants, and boys wet the bed. " Conduct disorder involves aggression to people or animals, property damage, lying, stealing, and/or serious rule violations (such as skipping school, sneaking out at night, etc.). " Kleptomania o Kleptomania is the recurrent inability to resist the impulse to steal something that you don't need, but not for the purpose of selling it. o You steal not for the value of the object, but for the thrill of stealing. o There is increasing tension right before you steal and intense pleasure or relief while you're stealing. o Of those with kleptomania, 75% are female. o Personality ◦ Personality can be defined as ways of acting, thinking, believing, and feeling that are stable across time and situations. ◦ A personality disorder, then, is a long-standing pattern of maladaptive (ineffective) behaviors, thoughts, beliefs and feelings. ▪ There are 10 personality disorders, organized into three distinct clusters, which we will cover briefly over the next three pages. ◦ Clients with these disorders often come to treatment for other symptoms (like depression, substance abuse, relationship issues, etc.) that are caused by their personality disorders rather than seeking treatment for their personality disorders themselves. ▪ This is because these people don't see their personality disorder symptoms as maladaptive. ▪ To them, the unreasonable ways that they act, think, believe, and feel seem normal and reasonable. Otherwise they wouldn't act, think, believe, and feel those ways. ◦ As a consequence of the clients not thinking that their personalities are a problem, and due to the fact that personalities are (by definition) stable and not easily changeable, the personality disorders are very hard to successfully treat in counseling. ◦ The overall prevalence of all personality disorders is between 9% and 15%. o General Criteria for All Personality Disorders ◦ To be diagnosable as any of the 10 personality disorders, the symptoms must meet all of these six criteria: ▪ 1 - There is an enduring pattern of inner experience and behavior that deviates markedly from cultural expectations in two or more of these four areas: cognition (thoughts), affectivity (feelings), interpersonal functioning, and/or impulse control. ▪ 2 - The pattern is inflexible and happens across different kinds of situations. ▪ 3 - The symptoms cause the person distress or some kind of impairment in functioning. ▪ This requirement is in just about all DSM-5 diagnoses. If you have all of the symptoms of a mental disorder but those symptoms aren't causing you any problems, then you don't actually have the disorder. ▪ 4 - The pattern of symptoms is stable and has been present at least since early adulthood. ▪ This is because personalities aren't temporary things. ▪ A personality is who you are, and this doesn't change much over a lifetime. ▪ If a person develops symptoms of a personality disorder for the first time later in life, then this is not a personality disorder. ▪ In such a case, some other mental disorder would have to be diagnosed. ▪ 5 - The symptoms are not actually being caused by some other mental disorder. ▪ 6 - Also, the symptoms are not caused by a drug, medical illness, or physical injury. ◦ In addition to these six criteria, each of the 10 personality disorders has its own specific criteria that must be met. We will cover some of those in Module 10b. o Notes About Personality Disorders ◦ The specific diagnostic criteria of the different personality disorders are sometimes hard to differentiate. ▪ For instance, was stealing an ex's iPad an act of revenge (consistent with borderline personality disorder), a cry for attention (consistent with histrionic personality disorder), or just a crime (consistent with antisocial personality disorder)? ◦ There is a lot of comorbidity between the personality disorders and with other mental disorders. ▪ This means that if a person has a personality disorder, she or he probably has other mental disorders (e.g., substance dependence, depression, another personality disorder, etc.) as well. ▪ These two or more disorders are co-morbid, since the disorders (or morbidity) happen together. ◦ For these reasons, the most common personality disorder diagnosis is actually other specified personality disorder, which is a "none of the above" catch-all diagnosis used when a client has symptoms from several personality disorders but does not meet full criteria for any single disorder. The symptoms of the personality disorders often diminish over time (especially in old age) as the negative consequences of the person's behaviors and thinking patterns are finally seen and accepted by the person. o Cluster A ◦ The Cluster A personality disorders are called the odd-eccentric personality disorders. ◦ These personality disorders include some of the symptoms of schizophrenia, but with one difference: Reality contact remains mostly intact. ▪ In other words, people with these types of personality disorders have very strange ways of thinking and behaving, but they're not experiencing severe delusions ("Aliens are controlling my brain!!") or hallucinations ("In fact, I see one right there!!"). ◦ The Cluster A personality disorders are more prevalent in families with a history of schizophrenia, so it does seem that these personality disorders are related to schizophrenia. o Paranoid Personality Disorder ◦ Someone with paranoid personality disorder would have pervasive distrust and suspiciousness of other people. ◦ Other people's motives are consistently interpreted as evil and with the intent to harm the person. This kind of personality disorder is more common in men than in women. The picture on the left is of actor Randy Quaid in the movie Independence Day (1996). In that movie, Quaid played Russell Casse, a pilot who believed that he had been abducted and sexually experimented on by aliens. The picture on the right is a mug shot of Quaid and his wife, Evi. The couple sought (but were refused) asylum in Canada for protection against "Hollywood star whackers" who allegedly target and kill movie stars. There is no actual evidence that star whackers exist, or that these two are being targeted. They refuse to use any credit cards or computers so that they can stay off the grid and not be as easily tracked. They were arrested in 2009 for refusing to pay a $10,000 hotel bill. They probably suffer from paranoid personality disorder (just like Randy's character did in the movie) Another example of a character with paranoid personality disorder is Mad-Eye Moody from the Harry Potter films (although he was usually right to be paranoid). " Schizoid Personality Disorder o A person with schizoid personality disorder would: " experience a sense of detachment in social relationships " have a narrow range of emotions that she or he could express " be uninterested in forming relationships with other people " be described as "cold and humorless" " not be able to even understand the emotions that other people experience, much less experience them himself or herself o This disorder is slightly more common in men and may cause more social problems in men than in women. Milton Waddams (left) from the movie Office Space (1999) and Argus Filch from the Harry Potter movies are characters that would probably be diagnosed with schizoid personality disorder. o Schizotypal Personality Disorder ◦ If you had schizotypal personality disorder, you would: ▪ have some pretty significant deficits in your interpersonal and social skills ▪ For instance, you wouldn't be good at making small talk, and many of the nonverbal cues that people rely on to relate to others would be completely confusing to you. ▪ be very uncomfortable with close relationships, even though you would want to have them ▪ Note that you want to have friends, but because of your odd and unusual ways many people would rather avoid you. ▪ This is different from schizoid personality disorder, in which friendships aren't even desired. ▪ behave eccentrically, in ways that make others see you as odd ▪ have unusual thoughts that others would also consider odd ▪ perceive things in unique (yes, odd) ways ◦ This personality disorder is also more common in men. Do you notice a pattern in the gender distribution of the Cluster A personality disorders? Here are Luna Lovegood (left) and Professor Trelawney (right) from Harry Potter. Even if you're not familiar with those books or movies, you can see that these two people dress and act in strange, flamboyant ways. As a result, Luna didn't have many friends and was often bullied and picked on. Most of the other professors didn't care for Professor Trelawney either. o Cluster B ◦ The personality disorders in Cluster B are known as the dramatic-emotional personality disorders. ◦ Persons with these disorders tend to have relationships that are superficial and/or dramatic in nature, a tendency to act without thinking, and/or a tendency toward violence. o Antisocial Personality Disorder ◦ People with antisocial personality disorder tend to: ▪ not care about other people's rights ▪ violate those rights freely ▪ lie ▪ con others to get what they want ▪ not feel at all bad about doing these bad things Common terms to describe someone with antisocial personality disorder are psychopath and sociopath. People who don't place any value at all on the needs or lives of other people, such as Hannibal Lecter from Silence of the Lambs or Voldemort from Harry Potter, would have antisocial personality disorder. o Nearly half of the men and a quarter of the women in jail have this disorder (Fazel & Danesh, 2002). o The job with the highest proportion of those with antisocial personality disorder is... CEO. " Bernie Madoff (left) was an executive who ran the largest Ponzi scheme in the history of the US, losing $500 billion client dollars. The money lost included funds from such charities as the Gift of Life Bone Marrow Foundation and Steven Spielberg's Wunderkinder Foundation, which supports veterans' organizations. Many of the charities whose money Madoff promised to invest (but instead stole, reinvested in risky schemes, and lost) had to close down. Madoff knew that what he was doing was illegal and would cost these people and organizations their money, but he did it anyway because he has antisocial personality disorder. In 2009, he was sentenced to 150 years in prison for these crimes. More recently, investor Martin Shkreli bought the rights to a lifesaving drug used to fight rare infections caused by immune deficiencies and hiked the price from $13.50 per pill to $750.00 per pill. Because he could. Because this is the only drug available to save some people's lives, and he figured that they would pay anything for it. He's in federal prison today because of unrelated fraud convictions, so that's good news. ◦ The prevalence of this disorder in the general population is about 1%, but the prevalence among bosses and supervisors (of any kind) is 4%. ▪ Does this explain some of your former (or current) bosses? ◦ This diagnosis is much more common in men, although it might be underdiagnosed in women because of the emphasis in the diagnosis on aggression. It's possible that women with antisocial personality disorder express it in other ways. o Borderline Personality Disorder ◦ Borderline personality disorder causes people to have: ▪ very unstable relationships ▪ a self-image that is unstable and based primarily on the person's (ever-shifting) beliefs about what others think about her or him ▪ highly unstable and unpredictable emotions a tendency toward impulsive behaviors A person with borderline personality disorder has weak interpersonal boundaries. This person has a hard time separating her personal space from that of others. As a result, her self-image fluctuates from moment to moment to match your view of her, whatever that is. Thus, when you love her, she feels good and worthy of love. When you reject her, she feels worthless. o Of those with borderline personality disorder, 75% are women. o Because women experience this disorder more often, we'll learn more about it in Module 10b. " The movie Fatal Attraction (1987) shows a classic case of borderline personality disorder. The female character is calm and happy while her affair with the married man is going strong, but once he tries to break it off she freaks out and tries to kill him. This is because if he doesn't want her, she is worthless. Feeling worthless is an intolerable experience for humans, so this causes her to lash out. " Pat (right) from Silver Linings Playbook (2012) has borderline personality disorder (among other diagnoses). This disorder is on display when he refuses to accept that his marriage is over and semi-stalks his ex-wife (not shown). Jennifer Lawrence (left) plays his new love interest, who also struggles with mental health issues. She won an Oscar for that role. Bellatrix Lestrange from Harry Potter might have borderline personality disorder since she is very impulsive and her self-image seems to fluctuate along with the amount and type of attention that Voldemort pays to her. o Histrionic Personality Disorder ◦ A person with histrionic personality disorder: ▪ is excessively emotional, yet the emotions tend to be superficial rather than deeply felt ▪ wants to always be the center of attention, achieving this by being dramatic or seductive ▪ talks in ways that are superficial and lacking in detail ▪ tends to be seen as self-centered and shallow This disorder is also more common in women, so we'll take a closer look at it in Module 10b. As seen here, Miley Cyrus tends to dress, dance, act, and talk with one goal in mind: making you pay attention to her. She probably has histrionic personality disorder. Also, the dance performance depicted above with Miley and Robin Thicke appears to be where Beetlejuice came from, but that's just a theory . Miley's superficial speech and thinking style can be seen in this quote. When asked in an interview for W Magazine (February 3, 2014) what motivated her to become involved in a foundation that works to ensure that everyone has access to safe drinking water, she replied, "I think water's, like, a really important thing." You don't say. ilderoy Lockhart from Harry Potter also has histrionic personality disorder. He's always on the lookout for a camera or a microphone to capture his awesomeness. He fabricated stories of his bravery and power and published them in several books. When asked to provide details about inconsistencies in those stories, he gives vague answers that lack detail. o Narcissistic Personality Disorder ◦ Narcissistic personality disorder can be seen in a person who: ▪ has a grandiose self-image, acting like he is better than everyone else ▪ has fantasies that he is better than anyone else when it's not possible to pull this illusion off in real life ▪ needs constant admiration ▪ completely lacks empathy for others ▪ has a sense of entitlement, which makes sense since he is better than everyone else (according to him) ▪ is very arrogant ◦ This is the person who says (or thinks), "If they would just put me in charge of (fill in the blank), I'd solve all of these problems easily," even though nobody else really believes that this person has a clue. Between 50% and 75% (depending of the study) of those with this disorder are male. For instance, Ron Burgundy (left, from Anchorman) thinks that he is pretty much completely awesome. Dolores Umbridge (from Harry Potter, in pink) thinks that she can do whatever she wants no matter who it hurts because she's the only one who knows what's best. Both of these characters have narcissistic personality disorder. " Cluster C o The personality disorders in this group are the anxious-fearful personality disorders. o People with these disorders tend to be overly worried about criticism and/or abandonment. " Avoidant Personality Disorder o Avoidant personality disorder brings with it: " pretty intense social inhibition " feelings of inadequacy " strong fears of being criticized or shamed " a self-image as one who is socially inferior to others and not as good at social interactions as other people are o This disorder seems to be evenly split between the genders. People with avoidant personality disorder, like comic strip character Charlie Brown and Harry Potter's Neville Longbottom, tend to feel socially awkward and generally inadequate. o Dependent Personality Disorder ◦ A person with dependent personality disorder: ▪ has such a strong need to be taken care of that she will cling to even unhealthy relationships and submit to being mistreated, all to avoid being left behind ▪ usually can't make a decision without getting a lot of advice from others, although it's generally preferred if someone else makes the decision for her ▪ jumps right into a new relationship as soon as one ends; this person is almost never single ▪ is afraid that she just can't take care of herself This one is also more common in women, so we'll look more closely at it in Module 10b. Bob (left) from the movie What About Bob (1991) is so afraid to be out of contact with his therapist (right) that he shows up at his therapist's vacation house and won't go away. o Obsessive-Compulsive Personality Disorder ◦ Obsessive-compulsive personality disorder leads to: ▪ being preoccupied with orderliness, perfection, and control ▪ losing flexibility, efficiency, and productivity because of this obsession with perfection ▪ preoccupation with rules and organization ▪ rarely or never having fun because you're always working ▪ refusing to delegate tasks because others can't do it as well as you can, and anything less than perfection is just not acceptable ▪ stubbornness ◦ This personality disorder is, of course, closely related to obsessive-compulsive disorder, but they are distinct disorders. ▪ Obsessive-compulsive disorder involves intrusive thoughts (obsessions) and involuntary, repetitive behaviors (compulsions). ▪ Obsessive-compulsive personality disorder is more of a broad approach to life in which control is the most important thing. ◦ It sounds like a person with this personality disorder would be a good employee because of his focus on getting things just right, but the person's perfection usually results in work that is too slow to keep up with real-world demands, so they often struggle at most kinds of jobs. About 2/3 of those with this disorder are men. Angela Martin (from the TV show The Office) has obsessive-compulsive personality disorder. She's obsessed with whether or not everyone follows the rules, she is extremely neat and orderly, and she never has any fun. Hermione from Harry Potter probably started out on her way to developing obsessive-compulsive personality disorder, but she loosened up through her friendships with Harry and Ron. o Borderline Personality Disorder ◦ Caution: Some of the images below are pretty graphic. ◦ The term borderline was originally used to describe persons who were on the borderline between neurosis (i.e., common psychological issues like anxiety and depression) and psychosis (i.e., more serious disorders that involve a break with reality, like schizophrenia) and were hard to treat. ◦ Borderline personality disorder is found in 2% of adults. ◦ That makes this disorder more common than bipolar disorder or schizophrenia. ◦ This disorder is a little more commonly diagnosed in Latinos/Latinas, Black people, and people in lower socioeconomic groups. o Diagnostic Criteria ◦ Borderline personality disorder (BPD) is a pervasive pattern of unstable mood, relationships, and self-image combined with a tendency toward impulsive behaviors, and must include 5 or more of these symptoms: ▪ (1) frantic, panicked efforts to avoid being abandoned (the abandonment can be either real or imagined) ▪ (2) a pattern of relationships that are both intense and unstable ▪ These relationships tend to vacillate between idealizing and demonizing the other person. ▪ (3) a very unstable self-image ▪ (4) impulsive behaviors in at least 2 different areas of life (e.g., work, finances, personal care, relationships, physical safety, etc.) that could be harmful to the person ▪ Examples include risky sex, drug use, binge eating, over-spending, reckless driving, gambling, etc. (5) repeated suicide attempts, threats of suicide, or self-mutilation Repeated self-cutting is commonly done by those with BPD to distract themselves from their internal pain, among other reasons that can vary from person to person. For instance, another common reason given for self-cutting is that it reaffirms the person's ability to feel something. " (6) strong and intense emotional reactions, known as affective instability " (7) feeling chronically empty " (8) anger that is unreasonably intense or hard for the person to control " (9) becoming paranoid or dissociating when under stress " Dissociation is the temporary separation of one part of your mental functioning from the other parts. " For instance, if you've ever been driving and arrived at your destination without really remembering how you got there, you experienced dissociation. " In this case, the part of your brain that handles driving temporarily separated from your consciousness, probably because you were distracted by something or very tired. " This kind of dissociation is normal and very common. " More serious dissociations can involve feeling like you're not real, or feeling like you're viewing reality but that it doesn't seem real, as if you're watching a movie. " Characteristics of Borderline Personality Disorder o There is a typical interaction pattern between someone with BPD and another person: " The person with BPD has some kind of interaction with someone else. " During the interaction, the person with BPD feels unloved, criticized, threatened, or in some way rejected. " As a result, the person with BPD feels urges to cut or kill herself. " These urges are often accompanied by thoughts such as, "I'll show you!" " The person with BPD self-mutilates, threatens suicide, or actually attempts suicide. " The other person appeases or comforts the person with BPD to get her to stop hurting herself. " And... repeat. o The relationships of people with BPD tend to be intense but stormy, frequently switching from idealization to devaluation and back again. " For instance, I once had a student who, in the first 30 minutes of the first class of a semester, raised her hand and told me that I was the best teacher ever. " She asked if I would be willing to come and speak at an organization with which she was involved. " I thanked her and suggested that we talk about this after class. " From the way that she so quickly idealized me, I knew at that point that she had BPD, and that she would cause me trouble before the semester ended. " Sure enough, by the end of the semester she was sending me angry and demeaning emails. " You see, I gave some of her assignments low grades. " She disagreed with the grades (which was her right and privilege), and she angrily asked me to explain to her why points were taken off. " I did so, clearly delineating how each point was deducted. " She could not argue with my reasoning, so she attacked me personally. " She felt irrationally personally rejected by the low grades that I gave her, so she switched from idealizing me to degrading me. " This is a hallmark of BPD. o Some people with BPD describe feeling a "desperate emptiness" that leads them to cling tightly to new relationships. o People with this disorder often misinterpret innocent actions as rejection or abandonment. " For example, if his friend cancels plans because her babysitter got sick, or if his therapist reschedules an appointment, or if he asks you to hang out but you already had plans, the person with BPD would feel abandoned and rejected and would probably lash out either at himself or at the other person. o Frequently, they manipulate people or situations to gain support or make themselves look good, because they absolutely have to look good in the eyes of others. " This is because the person with BPD has no self-image other than her belief about what you think of her. " For her, if you think she's awesome, then she is. If you think that she's bad, then she is. " There is no stable self-image that exists independent of others' opinions. o Often they can experience out of control emotions, with intense episodes of anger, depression, anxiety, jealousy, or other emotions that may last minutes or hours. o One consequence of their unstable self-concept is that they can experience splitting, which is periods of extreme self-doubt alternating with periods of grandiose self-importance. " For the person with BPD, there are no gray areas regarding his value as a person. " He is either perfect or completely worthless. " Because he sees himself this way, he also sees you this way. " That's why the person with BPD tends to idealize or devalue others. o As a result of the lack of stable self-image, there tends to be frequent changing of long-term goals, jobs, friends, values, and even sexuality. o In fact, one common pattern is the tendency to self-destruct right when an important goal is about to be reached. o People with BPD usually have histories of self-injury, especially cutting and burning. Common places to cut or burn are the upper arm/shoulder, thigh, and abdomen. These are places where wounds are easy to conceal with clothing. The woman on the right also has anorexia nervosa, which commonly co-occurs with BPD. o Sometimes they dissociate while they are harming themselves, cutting themselves while on mental auto-pilot and not remembering doing so, and even being surprised at how much time has passed or how much blood there is once they come-to. o Suicide attempts are relatively common among those with BPD. o A full 75% of those with BPD make at least one suicide attempt! o However, these attempts are almost never (intentionally) successful: Only 8-10% of those with BPD die by suicide. o Of course, that's still a very high death rate for a psychological disorder. o The main (but not only) reason for suicide attempts by those with BPD is to gain attention from those who have rejected them. o This is why most suicide attempts by those with BPD fail; they don't want to die, they just want you to pay attention to them. o Most people who meet criteria for BPD also meet criteria for at least one other personality disorder. o Co-occurring diagnoses of depression, bipolar disorder, substance dependence, eating disorders, ADHD, and PTSD are also common. " Causes of Borderline Personality Disorder o If you have a close relative with BPD you are 5 times more likely to have it as well. o BPD also tends to run in families with high rates of mood disorders, substance abuse, and antisocial personality disorder, so there may be some connection among these disorders. o The main cause of BPD is poor early relationships with caregivers. " For instance, an enmeshed parent/child relationship may lead to encouragement of dependence and punishment of a kid's attempts at individuation. " As a result, the child never learns to differentiate her view of herself from others' views of her. " Later, when she perceives that you're rejecting her, she rejects herself, leading to self-punishment (via self-mutilation, suicide attempts, self-sabotage of her goals, etc.) Enmeshment happens when two people are too close. As a result, each person becomes confused about what are his attitudes and what are the attitudes of the other person. A child in an enmeshed relationship with a parent fails to develop a stable sense of self. " More directly abusive or neglectful parenting can also lead to BPD. " About 75% of those with BPD were sexually abused in childhood. " That's a huge percentage! " The loss of a parent early in childhood (through death or other forms of abandonment) is also a risk factor for BPD. " Overall, either enmeshment, abuse, or abandonment leads to this poorly developed view of the self and others: "If they reject me then I reject me!" " Such black and white views of self leads to similar views of others (as either all good or all bad, with no gray areas). o People with BPD are more likely to have: " greater reactivity of the amygdala (which processes all emotional stimuli and assigns emotions to whatever situation you're experiencing) " decreased activity in the prefrontal cortex (which is the brain's "stop sign" that keeps us from acting impulsively) " low levels of serotonin (which also results in impulsivity) " reatment for Borderline Personality Disorder o The primary treatment for BPD is dialectical behavior therapy (DBT). " A dialectic happens when two people with different beliefs have a discussion, identify those basic points on which they agree, and then move forward in the conversation from that point, resulting in a change in belief for one or both parties. " Dialectical behavior therapy, then, involves the counselor meeting the client where she is but then pushing the client to change those beliefs (e.g., "You must love me!") and behaviors (e.g., self-cutting) that aren't rational or effective. " The goals of DBT are to help the client learn: " a more realistic and positive sense of self " how to effectively regulate emotions and solve problems " to let go of dichotomous (black/white, either/or) thinking " The client learns to monitor her self-talk, recognizing and challenging self-downing thoughts and black-and-white evaluations. " The client also learns assertiveness skills to get interpersonal needs met in healthy way, instead of through manipulation. " The most important thing is for the counselor to respond differently than others typically do when the counselor is idealized or rejected in order to force the client to change the manipulative approach that works with other people. " This kind of treatment is actually pretty effective, but only as long as the client stays in treatment. " Usually, once a new romantic relationship is begun, the client feels "GREAT!" again, so she drops out of therapy. o Medications are also prescribed to treat BPD. " Antidepressant drugs are sometimes used to relieve the person's depression. " As a nice side benefit, the SSRIs also help with reducing impulsivity. " Antipsychotic drugs are sometimes prescribed if dissociation or paranoia are present. " Unfortunately, though, the use of medication doesn't seem to increase recovery rates for BPD. o Histrionic Personality Disorder ◦ The historical roots of this diagnosis lie with cases of hysterical neurosis that were described by Sigmund Freud. ◦ In hysterical neurosis, the person experiences a real neurological symptom (such as dizziness, numbness, trouble breathing, etc.) that has a psychological cause but no biological cause. ◦ What Freud called hysterical neurosis is now called functional neurological symptom disorder in DSM-5 (or conversion disorder in DSM-IV). ◦ Histrionic personality disorder (HPD) has about a 2% prevalence in the population. o Diagnostic Criteria ◦ HPD is a pervasive pattern of attention-seeking and overly dramatic emotions, and must include 5 or more of these symptoms: ▪ (1) being uncomfortable when you're not the center of attention ▪ (2) behaving in inappropriately sexually seductive or provocative ways ▪ (3) having emotions that shift rapidly and are shallow rather than deeply felt ▪ (4) using your looks to get attention ▪ (5) speaking in ways that lack detail or are overly impressionistic (that is, acting on your initial impression of something instead of seeking all of the facts or calmly reasoning through things) ▪ (6) expressing emotions in ways that are exaggerated or theatrical ▪ (7) being easily suggestible (that is, easily influenced by the suggestions of others or by current circumstances) ▪ (8) a tendency to consider relationships to be more intimate than they really are (like squealing and running to hug a distant acquaintance when you run into her) ◦ Watch these two videos to see symptoms of HPD displayed. ▪ In the first video (7:44), Rifqa Bary, a teenager from Ohio with Muslim parents, talks about her conversion to Christianity. ▪ Notice how in the first video Rifqa seems to say things in anticipation of their impact rather than from internal feeling. The more reaction she gets from her audience the more she puts into it. She also seems suggestible, repeating stuff that she has heard others say rather than creating and expressing her own ideas. " In the second video (6:49), Rifqa is being interviewed by Channel 9 in Orlando. By this time she had run away from home to escape the threats of her parents who were allegedly enraged because she converted to Christianity. " She ran away to be with an Orlando pastor (Blake Lorenz) and his wife (Beverly), whom she met on Facebook. In the second video, Blake is the man with his arm around Rifqa. " In the second video, notice how she shows suggestibility. " For instance, she again seems to be repeating phrases she's heard ("Let it be so!" "I'm a follower of God, Jesus, the true living Jesus!") without any sincere feelings behind them. " Another example of suggestibility is the fact that she ran away to Florida because she met this pastor who suggested it via a prayer meeting on Facebook. (!) " She also is impressionistic: "He was about to beat me with it." What does "about to beat me with it" mean? Did he raise his hand in anger, but not strike her? In Rifqa's mind, this is converted from "he almost wanted to hit me but he didn't" to "he was about to beat me with it." " Another example of her being impressionistic: "I rode on a bus for 27 hours... to 30 hours..." Can you imagine the number of hours of this bus trip increasing with each telling of this story? " Another example: "Hundreds of cases that were killed by their dad back home" (in Sri Lanka). " Sri Lanka is a primarily Buddhist country. " She said that a teacher offered to take her in because of the abuse that she was getting, but this teacher was interviewed and said that she wasn't aware of any of this. The teacher was only worried about the parties that Rifqa was having when her parents were away. " Rifqa also claimed that her dad would kill her if he found out that she was a cheerleader. " When the Ohio Department of Children and Families investigated her parents' home, the investigators found this picture on the family's fireplace mantle. " Investigators also found a permission slip for her to be a cheerleader signed by ... her father. " Blake and Beverly Lorenz (the pastor and his wife) were subsequently fired by their church. Blake was audio recorded claiming that the church's board of directors was "demonically possessed." His wife was recorded expressing shock and disbelief that the board could even fire them, noting that she and her hubby are "college educated." It sounds like there may be some narcissistic personality disorder going on here. I find in my own professional experience that those with personality disorders tend to be attracted into the orbits of others with these disorders. o Causes of Histrionic Personality Disorder ◦ In fact, little is known about the causes of HPD. ◦ This disorder runs in families, but we're unsure if this is because of genetics or family dynamics. ◦ It's probably some of both. ◦ Why are the majority of those diagnosed with this disorder women? ◦ Could it be that HPD behaviors are more noticeable in women because attention-seeking and sexual aggressiveness are less accepted from women? That's at least a possibility to be explored. ◦ One current controversy with this disorder is the possibility that it is actually the same disorder as antisocial personality disorder (i.e., psychopaths), but with exaggerated feminine qualities instead of masculine ones. o Treatment for Histrionic Personality Disorder ◦ From a psychodynamic perspective, HPD can be treated by helping the client uncover repressed emotions and needs and express these in more healthy ways. ◦ A cognitive therapy approach would focus on helping the client identify the faulty, irrational beliefs that underlie his or her behaviors. ▪ For example, a strongly held, irrational belief such as "I'm nothing if I'm not being noticed" could be a cause of HPD. ▪ A cognitive therapist would help clients re-train themselves to accept that they don't need the approval or attention of others. ▪ The therapist would do this by having the client repeat in her head over and over again (say, 10 times in a row, with emphasis, three times a day) something that is both rational and the exact opposite of the irrational belief. ▪ One possibility would be something like, "I am OK and I have no need for others' attention or approval!" The client would say this in her head, vigorously and energetically, as if she's trying to convince an audience of an important truth. ▪ With sufficient repetition, this new rational belief would eventually overwrite and replace the old, irrational one, and symptoms would diminish. ◦ Unfortunately, there is not a lot of data on the effectiveness of counseling for HPD. ◦ This is because HPD clients often lose interest in treatment. The client is especially likely to drop out of treatment when the client enters into a new romantic relationship. o Dependent Personality Disorder ◦ The prevalence of dependent personality disorder (DPD) is below 1%. ◦ However, prevalence rates are higher based on people's self-report compared to diagnosis by professionals. ◦ This means that some people think that they are overly dependent, even when they wouldn't be diagnosed as such. ◦ In fact, the prevalence rate for DPD is as much as 6% when it is self-diagnosed. The actual prevalence rate is less than 1%, though. o Diagnostic Criteria ◦ DPD is the pervasive and excessive need to be taken care of that results in being clingy, submissive, and fearing separation from significant others, and must include 5 or more of these symptoms: (1) trouble making decisions without a lot of advice and assurance Someone with DPD would need another person to decide for her whether or not she should bring an umbrella today, or what she should wear today. " (2) needing others to take responsibility for most major areas of your life " For instance, often a parent will be relied on to decide where to live, what job to have, how to parent, what friends to have, etc. " (3) a reluctance to disagree with someone because you're afraid that that person would leave you or reject you if you did " Also the person would tend to not get reasonably or justifiably angry at someone who wrongs him if he believes that he needs that person's support. " (4) trouble starting new projects on your own " This is because of a lack of self-confidence, not because of a lack of motivation. " (5) going to excessive lengths to get nurturance or support from others " Often the person with DPD will volunteer for things she doesn't want to do or will even tolerate being abused. " 6) being uncomfortable when you're alone because you fear that you can't take care of yourself " (7) urgently seeking a new relationship when one relationship ends " (8) preoccupation with fears of being left to take care of yourself " Characteristics of Dependent Personality Disorder o A person with DPD will deny her or his own needs, thoughts, and feelings to avoid displeasing others. o He will submit to unreasonable demands, allowing himself to be exploited, all to avoid rejection. o People with DPD have increased risks of being physically, sexually, and emotionally abused. o They tend to receive any criticism as proof of their unworthiness, easily losing faith in themselves. o Social interactions are usually limited to a small circle of friends and (primarily) family on whom they feel dependent. o DPD can cause problems at work due to a lack of decision-making skills as well as a lack of initiative. o Depression, anxiety, and other personality disorders have high comorbidity with DPD. " Causes of Dependent Personality Disorder o This disorder, too, runs in families, but we're unsure exactly what roles genes and environment play. o Experiencing chronic illness during childhood may increase your risk of developing this disorder. A child who is chronically ill might learn to view himself as being unable to adequately take care of himself. o Children with separation anxiety disorder also have a greater risk for developing DPD. This child has separation anxiety disorder. She panics when she believes that her mother is leaving her presence. ◦ From a cognitive perspective, the strong, irrational belief that "I am needy and weak" often underlies this disorder. o Treatment for Dependent Personality Disorder ◦ Unlike with other personality disorders, persons with dependent personality disorder often seek treatment because they know that they are being used and abused. ◦ A psychodynamic counselor would seek to help the client gain insight into early experiences with caregivers that led to adulthood feelings of over-dependence. ◦ Behavioral therapy would involve the use of systematic desensitization to help the client become more comfortable with making decisions. ▪ This would involve teaching the client how to relax herself when a very small decision is made, and then progressing to bigger and bigger decisions as each successive step becomes comfortable. A humanistic/person-centered counselor would give the client unconditional positive regard (UPR) and acceptance to naturally foster the growth of the client's s Module 11 " Anxiety o Maladaptive anxiety (versus adaptive and healthy fear) has at least one of these qualities: " Concerns are unrealistic rather than reasonable based on the available evidence. " The amount of fear is out of proportion to the actual threat. " The fear remains after the threat passes, rather than subsiding when the threat ends. " The fear is in anticipation of a possible but unlikely threat (as opposed to a threat that is likely to actually happen). o Anxious kids are at greater risk for developing anxiety disorders later in life. o This is especially true if parents make it worse by: " being overprotective " being controlling of their children " being intrusive into the private lives of their kids " being anxious themselves " catastrophizing things by blowing negative events out of proportion " being overly critical of their children " not expressing enough warmth toward their kids " dying when the child is young o Overall, for every male that has an anxiety disorder, two females have one. " Panic Disorder o Panic disorder is a pattern of recurrent and unexpected panic attacks. o A panic attack is a period of intense fear or discomfort with 4 or more of these symptoms coming on abruptly: " heart palpitations or racing heart " sweating " shaking " shortness of breath " feeling of choking " chest pain " nausea " dizziness or feeling faint " chills or hot flushes " paresthesias (numbness or tingling) " derealization (things don't seem real) or depersonalization (like I'm watching myself from outside myself) (these two are examples of dissociation, which we learned about in Module 10b) " fear of losing control/going crazy " fear of dying o A panic attack may be in response to some frightening or startling environmental trigger, or it may come on completely at random. o As many as 40% of young adults have occasional panic attacks, so these symptoms are pretty common. o Panic disorder is twice as common in women. o The prevalence of panic disorder rises sharply for females right after puberty. o There are a variety of possible causes of panic disorder: " It is possible to inherit a genetic predisposition toward panic disorder, perhaps experienced as mild anxiety that is felt just about all of the time. " One possible cause of panic disorder is neurotransmitter imbalances, especially imbalances of norepinephrine in the locus ceruleus (which leads to panic attacks) and serotonin in the amygdala (which causes chronic anxiety) ▪ Other neurotransmitters and hormones may be involved too. ▪ Being hypersensitive to bodily sensations (like when your heart skips a beat or when you can't catch your breath) can increase your risk for panic disorder. ▪ Bodily hypersensitivity includes: ▪ (1) paying very close attention to bodily sensations, even subconsciously ▪ (2) interpreting them in a negative way, and ▪ (3) catastrophic thinking ("I can't breathe! I'm going to die!") ▪ Another possible cause is a poorly regulated fight or flight system, meaning that your fight or flight system sometimes starts without provocation and then runs wild. ▪ The integrated model of panic disorder is one well-supported model of the cause of this disorder that connects all of these possible causes together: The diagram above shows the integrated model of panic disorder. Here we see that an inherited genetic predisposition toward anxiety is expressed biologically as imbalances in neurotransmitters. The genetic vulnerability and neurotransmitter imbalances lead the person to be hypersensitive to bodily sensations. As a result, when something in the body feels odd (such as a skipped heartbeat or shortness of breath), the person begins to feel anxiety in anticipation of a panic attack. Ironically, this anxiety actually brings on the panic attack. If the person has panic attacks in specific places (such as at the store), panic attacks can be mentally associated with those places. The person might then begin to fear and avoid going out of the house, leading to agoraphobia. ◦ Treatments for panic disorder are quite effective. ▪ Biological treatments include: ▪ antidepressants, but one problem is that the side effects of these medicines can actually mimic a panic attack when the medications are first begun or when they are stopped antianxiety medications in the benzodiazepine category such as Xanax and Klonopin Benzodiazepines such as Xanax and Klonopin are very effective at relieving anxiety. Unfortunately, they're also very addictive. " Cognitive-behavioral treatments include: " relaxation exercises " keeping a thought diary to find catastrophizing thoughts that cause anxiety " actually inducing a panic attack in the counselor's office to explore the catastrophizing thoughts that happen before and during an attack " coaching the client in using relaxation skills during an actual panic attack in the counselor's office " challenging the client's irrational beliefs that are causing unnecessary anxiety " systematic desensitization to anxiety triggers " This involves practicing relaxation as you're exposed to more and more frightening situations. " Agoraphobia o Agoraphobia (literally meaning "fear of the marketplace") is anxiety about being in places from which it would be difficult or embarrassing to escape or in which you might not be able to get help if you have a panic attack. o It includes the intense fear of at least two of these five things that relate to fearing either that "I can't get out of here!" or "Help isn't available!": " (1) using public transportation Any of these public transportation options would be terrifying for someone with agoraphobia. " (2) being in an open space Being in a wide open space like an empty parking lot or a long bridge might also be terrifying. " (3) being in an enclosed space Enclosed public spaces like grocery stores or movie theaters are also seen as frightening. " (4) standing in line or being in a crowd Going to Disney or Universal would not be a fun time for someone with agoraphobia. ▪ (5) being away from home alone ◦ Overall, less than 1% of the population suffers from agoraphobia.

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◦ This disorder is twice as common in women. ◦ Agoraphobia usually begins within 1 year of the onset of frequent anxiety symptoms such as generalized anxiety, social phobia, panic attacks, etc. ◦ If a person gets this disorder, it usually starts in her mid to late twenties. ◦ Risk factors include: ▪ a general tendency to be nervous ▪ having experienced some kind of serious trauma or abuse ▪ growing up with parents who showed too little warmth or too much overprotectiveness ▪ inherited genetic risk (since this cause of this disorder is 61% genetic and 39% environmental) ◦ When you think of agoraphobia you think of a person who never leaves the home, but only 1/3 of those with this disorder are completely homebound. ◦ Instead, a person with agoraphobia may tolerate going outside, but with great misery. ◦ It usually makes leaving the home easier for the person if he has someone he trusts with him, but his family is likely to eventually get tired of chaperoning him everywhere. ◦ Drugs and alcohol are often used to cope, but these things can actually increase anxiety symptoms over the long term. ◦ Treatment for agoraphobia is often successful, and usually involves the use of both medications and therapy. ▪ The medications prescribed for agoraphobia are the SSRIs and the benzodiazepines. ▪ A cognitive therapist would focus on challenging the client's catastrophic irrational beliefs (like "I can't get out of here!" or "Help isn't available!" or "It's horrible and intolerable to feel scared!"). ▪ A behavioral therapist would teach the client a breathing and relaxation exercise called progressive muscle relaxation (PMR), in which the client learns to tense and relax each part of the body in succession while breathing deeply. ▪ PMR works to relieve symptoms of agoraphobia because it is impossible for the state of relaxation and the emotion of anxiety to exist simultaneously in the human body. ▪ Thus, if you can learn to force your body into relaxation, you can push feelings of anxiety out. ▪ A behaviorist would also use systematic desensitization to gradually acclimate the client to feared situations. ▪ Early stages of systematic desensitization would have the client imagining going outside while using her PMR skills to relax herself. Once she can be relaxed while imagining going outside, she can move on to face something scarier. ▪ Middle stages of systematic desensitization may involve the counselor accompanying the client when going outside or to a crowded store, helping the client use PMR to relax. ▪ Toward the later stages, the client would be able to go outside by herself and practice using PMR to become relaxed. ▪ For many with agoraphobia, the first few counseling sessions are often held at home or via phone or Skype, later moving to the counselor's office as the client's symptoms get better. o Specific Phobia ◦ A specific phobia is an intense fear or anxiety about a specific situation or thing. ◦ As with all DSM-5 diagnoses, though, you don't have a specific phobia unless your symptoms cause significant distress. ◦ This means that if you're very afraid of something (such as snakes) but this fear doesn't cause you problems in your day-to-day life (that is, you can go about your typical day without intense fear or without avoiding doing things that you want or need to do), you don't have a specific phobia. ◦ There are five types of specific phobia: " (1) animal Snakes and spiders are common animal phobias, but any living thing can be tied to this kind of phobia. " (2) natural environment Heights, water, and storms are examples of natural environment phobias. " (3) blood-injection-injury A person with the blood-injection-injury type of phobia would not respond well to any of these things. " (4) situational Enclosed spaces such as elevators, an airplane, or an underground tunnel are examples of situations about which people might have phobias. The miner in the tunnel creeps me out more than a little bit, personally. " (5) other The other category can include anything else about which a person is terrified. Examples include loud noises or situations that might lead to choking (such as eating in a restaurant). o The typical response to being exposed to a phobia is autonomic arousal: Blood pressure rises, breathing quickens, pupils dilate, adrenaline is pumped into the blood stream, etc. o The typical response to the blood-injection-injury type of phobia is actually the opposite of the response to the other types, though. " When someone with the blood-injection-injury type of phobia sees blood, his blood pressure drops and he faints. o The average person with a specific phobia actually has three of them, so it's unusual to have only one. o Two thirds of those with phobias are female. o However, the prevalence is the same for both genders for one type of phobia: the blood-injection-injury type. o Social Anxiety Disorder ◦ Social anxiety disorder is the strong fear of social situations or situations in which the person is expected to perform in some way, when it is possible that other people might pass negative judgments on the person. ▪ Feared judgments from others might include weak, stupid, boring, anxious, unlikable, dirty, or anything else that is negative. ◦ Basically, the client is terrified that he or she will act in a way that is embarrassing. ◦ Examples of things that would be feared and avoided include meeting new people, simple conversations, being observed while eating, giving a speech, talking to a cashier, etc. ◦ This disorder is twice as common in women. ◦ However, men are more likely than women to fear two specific social circumstances: dating and wetting themselves. ◦ The overall prevalence of this disorder is 7%. ◦ It tends to develop between the ages of 8 and 15. ◦ There are a variety of possible causes: ▪ From a behavioral perspective, experiencing something humiliating might lead to a connection between social situations and humiliation. For instance, being chronically bullied might lead to social anxiety disorder. ▪ Biologically, tendencies toward social inhibition tend to be inherited, and your risk increases if these inherited tendencies are paired with receiving bad parenting. ▪ Cognitively speaking, the cause of social anxiety disorder would be beliefs such as "I must be perfect" or "I must be liked by everyone all the time," along with the assumption that rejection is inevitable. ▪ Cognitive psychology would also identify a tendency to focus on your mistakes and react to them with harsh self-judgment as a cause of social anxiety disorder. ▪ From the cognitive perspective, people with social anxiety disorder also tend to be very attuned to negative social cues, sometimes even seeing them when they're not there. ▪ When a (real or imagined) negative social cue is perceived ("She looks bored with me."), it is also interpreted in self-defeating ways ("I'm completely undesirable!"). ◦ Depending on the assumptions made about its cause, treatments for social anxiety disorder vary: ▪ Biologically, the benzodiazepines and the antidepressants are often prescribed to help those with social anxiety disorder. ▪ A cognitive therapist would (as always) focus on helping the client let go of the irrational beliefs that keep her afraid ("It's horrible if someone sees me fail!") and replace them with more rational ones ("It's bad if someone sees me fail, but it's definitely not horrible. After all, I'll live!"). ▪ A behavioral therapist would use systematic desensitization to help the client become comfortable with social situations. ▪ Flooding, which is exposing a client to a feared situation like in systematic desensitization, but intensely and all at once, is as effective as systematic desensitization but it's not often used. ▪ In the case of social anxiety disorder, flooding might involve making the client go to a party with strangers and make small talk all night without leaving. ▪ The teaching of social skills (like how to make small talk, what kinds of eye contact and facial expressions to make, etc.) is also an effective behavioral technique to help people become less anxious about social situations. ▪ Another very effective behavioral treatment is modeling, which involves observing other people with social anxiety disorder successfully facing their fears. For instance, Katy Perry (left) would not be a very good model to help someone with social anxiety disorder reduce her fears. This is because while it's true that Katy Perry isn't afraid of social situations, she has been outgoing all of her life. To be effective, a model has to be similar to the client but a little bit better at the target behavior than the client. Thus, a better model for someone with social anxiety disorder would be Australian Olympic swimmer Susie O'Neill (right), who has social anxiety disorder yet was able to overcome her fears to compete in the Olympics. o Generalized Anxiety Disorder ◦ As opposed to having acute, specific anxieties (like a fear of heights or of social situations), a person with generalized anxiety disorder is anxious all the time and in most situations. ◦ This disorder is twice as common in women. ◦ The focus of the person's worry may shift frequently, and the person may tend to worry about many different things. ◦ For instance, the person may be worried all day for several days about an upcoming test. Once that test is over, his worry would not go away; it would just shift to focus on his bills or his relationship or something else. ◦ The causes of generalized anxiety disorder are generally conceived via the cognitive and biological perspectives. ▪ Cognitively, the person's thoughts tend to be constantly focused on threat at both the conscious and subconscious levels. ▪ The person often believes that worrying can actually prevent bad things from happening. ▪ That is, the person would literally believe, "If I don't worry about my mom's health, she'll get sick." Even if the person knew that this was irrational, he would not easily be able to let this kind of belief go. The risks (of bad things happening) would be too great. ▪ Reformulated learned helplessness (see Module 7 Notes 4) can also play a part. ▪ Biologically, a deficiency of the neurotransmitter GABA (gamma aminobutyric acid) is implicated in generalized anxiety disorder. ▪ The job of GABA is to prevent some neurons from firing at the wrong time. ▪ With too little GABA, these neurons fire when they're not supposed to, leading to anxiety when there is really nothing to be worried about. ◦ Generalized anxiety disorder can be effectively treated using cognitive-behavioral and biological techniques. ▪ From the cognitive-behavioral perspective (side note: cognitive counseling and behavioral counseling are often used together, with very good results), a counselor would want to: ▪ help clients confront and (to whatever extent possible) solve the main issues about which they're worried. (This one's more behavioral in nature since it's teaching the client new behaviors to do.) ▪ challenge clients' catastrophizing thoughts that are causing their worry (cognitive). ▪ help clients develop new strategies to cope with their problems (such as assertiveness or problem-solving skills) and with their anxious emotions (such as journaling, exercise, deep breathing, etc.). (This one's also behavioral since new behaviors are being taught.) ▪ Biologically, the benzodiazepines and the antidepressants are often prescribed. " Fortunately, there is also a different type of medication called BuSpar that helps with generalized anxiety disorder and is less addictive than the benzodiazepines. o These disorders are related to the anxiety disorders, but they are categorized separately from the anxiety disorders in the DSM-5. In DSM-IV all of these disorders were in the anxiety disorder section. o Obsessive-Compulsive Disorder ◦ A person with obsessive-compulsive disorder (OCD) has obsessions, compulsions, or both. ◦ An obsession is a thought (an idea or mental image) or an impulse (an urge to do something) that won't go away, comes into your mind without you wanting it to, and causes you some kind of distress. ◦ A compulsion is a repetitive behavior (like washing your hands or checking that the door is locked) or a mental act (like repeating a word over and over or reading every sign that you see in its entirety) that a person feels she absolutely has to perform either to make her anxiety go away or to prevent something bad from happening. ◦ A person with OCD won't necessarily carry out all of these obsessive impulses (such as to hurt a child or to yell at someone), but the person can be wracked with guilt and anxiety for even having them come to mind. ◦ Pregnant women and new moms are at increased risk for OCD. ▪ Usually, OCD is experienced by new or expecting moms as one specific kind of obsession: intrusive, repeated, and unwanted thoughts about harming her baby. ▪ These impulses are mostly never acted on, but you can imagine the guilt that such a mother would feel for even thinking them. ◦ When it comes to compulsions, women are more likely to experience the need for compulsive cleaning. ◦ Men are more likely to have compulsions related to the need for symmetry, as well as obsessions involving forbidden (often sexual or violent) thoughts. The designer of the DVD cases for the TV series Monk (a character who suffers from severe OCD) is both brilliant and a little bit evil. Thanks to the reversed design of the box for seventh season, symmetry is impossible to achieve with these cases. o Body Dysmorphic Disorder ◦ A person with body dysmorphic disorder would be obsessed with one or more perceived flaws in his or her physical appearance, even though other people can't see this supposed imperfection or (if it can be seen) they don't think it's a big deal. If you looked at this woman with body dysmorphic disorder, you would see her as shown in the picture at left. When she sees herself, however, she sees flaws and imperfections that nobody else can see. She literally sees flaws that aren't there; she's not fishing for compliments by pretending to feel ugly. This woman is Bethany Storro. She threw acid on her face because, "In the mirror, I saw a distorted monster." "I held it up to my face and I could feel it burning through my skin," Storro said. "Like, melting into my face. And I was just, I was so happy." She has since received counseling and her body dysmorphic disorder symptoms are much improved. ◦ Females and males tend to be preoccupied mostly with the same body parts, with one exception: Men are more likely to focus on imperfections in their genitals (size, curvature, etc.). ◦ A special type of body dysmorphic disorder called muscle dysphoria occurs almost exclusively in men. Excessive weightlifting leading to the grotesque musculature seen on this man is a symptom of body dysmorphic disorder. It is likely that he still thinks that his arms are too small. ◦ Of people with this disorder, women are much more likely than men to also have an eating disorder at the same time. o Hoarding Disorder ◦ Hoarding disorder causes people to have trouble getting rid of things because of a feeling that the things will be needed one day, or as a way to avoid the emotional distress that they feel when they get rid of things. ◦ Compared to men, women are more likely to have the "with excessive acquisition" subtype of this disorder, which involves compulsive shopping. This woman with hoarding disorder can't stop herself from buying shoes. o Trichotillomania ◦ Trichotillomania involves compulsively pulling out your hair over and over again, even if you want to stop People with trichotillomania will have bald patches on various parts of their bodies because the hair in those spots is repeatedly pulled out. If they don't pull their hair when they feel compelled to do so, anxiety will build up to intolerable levels. The anxiety is relieved only when the hair is pulled out. ◦ This disorder is seen in women 10 times as often as in men. ◦ Symptoms tend to have an onset at puberty and tend to get worse during changes in hormones such as during menstruation and menopause, so hormonal causes are implicated. o Excoriation Disorder ◦ Excoriation disorder is very similar to trichotillomania, but instead of hair pulling it involves compulsively picking at your skin over and over until sores are created. A full 75% of those with this disorder are female. o As with the obsessive-compulsive and related disorders, the trauma- and stressor-related disorders are similar in many ways to the anxiety disorders but are given their own category in DSM-5. o Posttraumatic Stress Disorder ◦ Posttraumatic stress disorder (PTSD) includes all of these things: ▪ A person is exposed to a traumatic event (either by it happening to the person, by seeing it, by learning about it, or by dealing with the aftermath of it) that involves death, serious injury, sexual violence, or the threat of these things. ▪ This leads to the event being persistently re-experienced through troubling memories, dreams, feeling like it's re-occurring (dissociation), or psychological or physiological distress when reminded of the event. ▪ The person also avoids reminders of the event like the place that it happened or things that are reminiscent of the trauma. ▪ Negative changes in thinking or emotions are also experienced, including amnesia for all or part of the traumatic event, negative beliefs about yourself or the world, exaggerated blaming of yourself or others, unpleasant emotions (like horror or shame) about the event, anhedonia, feelings of alienation from others, or inability to feel pleasant emotions. ▪ Exposure to the traumatic event also leads to increased biological arousal which is expressed as angry outbursts, self-destructive behavior, hypervigilance, an intense startle response, concentration problems, and/or sleep problems. ▪ Finally, these symptoms must last for at least one month for PTSD to be diagnosed. ◦ PTSD is a common response to things like natural disasters, abuse, war, traumas, etc. In 2014, photographer Devin Mitchell travelled around the U.S. for his senior thesis project. He documented the varied lives of veterans by composing portraits that were semi-surreal. He would make connections with the vets, join them in their homes, and let the vets compose their own portraits by picking their props, poses, costumes, and who would be with them in the photos. Mitchell said he began to see how therapeutic this whole process was for the vets. He called his photo collection the Veteran Vision Project. ◦ The severity of PTSD can range from mild to immobilizing. ◦ Women are more likely to experience PTSD and their symptoms tend to last longer, probably because women are more likely to be victims of sexual and relationship violence. ◦ If an entire population is exposed to a stressor like a natural disaster, though, there is no difference in the prevalence of PTSD between the genders in the exposed community. o Acute Stress Disorder ◦ Acute stress disorder is basically the same thing as PTSD. ◦ The main difference between the two disorders is that the duration of acute stress disorder is between 3 days and 1 month. ◦ If the symptoms continue after a month, then the diagnosis would be changed from acute stress disorder to PTSD. Like PTSD, acute stress disorder is also more prevalent among women, but this difference may be due in part to differences in the neurobiology of the stress response between the genders. Module 12 Notes o DSM-5 Symptoms of Substance Use Disorder ◦ For substance use disorder to be diagnosed, a person has to experience two or more of these symptoms at any time over 12 consecutive months: ▪ (1) often use more of the substance than intended, or for a longer period of time than intended ▪ (2) try unsuccessfully to limit use of the substance ▪ (3) spend a lot of time either getting, using, or recovering from the use of the substance (e.g., hangovers) ▪ (4) cravings for the substance ▪ (5) use of the substance results in the repeated failure of the person to meet obligations ▪ (6) the person continues to use the substance despite it causing persistent interpersonal problems such as arguing or losing friends ▪ (7) important social, job, or fun activities are given up or reduced ▪ (8) repeatedly using the substance in dangerous situations, such as while driving or while watching children ▪ (9) continuing to use the substance despite knowing that it's contributing to physical (e.g., weight loss or breathing problems) or psychological (e.g., depression or anxiety) problems ▪ (10) tolerance, which is either needing more substance to get high or getting less high with the same amount of substance ▪ (11) withdrawal, which is either having withdrawal symptoms (like headaches, shaking, irritability, etc.) when you don't use the substance or using the substance to avoid having those symptoms o What is Substance Use Disorder? ◦ Substance use disorder is synonymous with addiction. ◦ Does any use of a drug mean that a person is addicted? No. ◦ What defines addiction is not so much the amount used, but more the effects of the use and whether or not it's continued after the effects are felt. For example, if I stick my finger in a light socket and get shocked, I'm probably going to stop doing that. But if I continue to do so, I am demonstrating addiction. Addiction may show itself in rationalizations, like trying to figure out ways to keep sticking my finger in the outlet but to avoid the shock. ◦ The prevalence of substance use over the past year for US adults varies widely by drug: ▪ cocaine - 1.8% ▪ heroin - 0.3% ▪ prescription medications used other than as prescribed - 7.1% ▪ nicotine - 15.1% (for cigarettes, plus another 7% for smokeless tobacco and vaping) ▪ hallucinogens (like acid or mushrooms) - 1.8% ▪ alcohol - 71.0% ▪ inhalants (like sniffing glue or other chemicals) - 0.7% ▪ pot - 13.5% ▪ The lifetime prevalence of pot use in the US is 44%. In other words, about 44% of Americans will use pot at least once in their lifetimes. Worldwide, the prevalence of pot use over the past year is only 2.5%, so over five times as many Americans smoke pot as compared to citizens of the rest of the world. o Biological Causes ◦ Any mind-altering drug that is susceptible to abuse (e.g., alcohol, pot, cocaine, Xanax, etc.) directly and intensely activates the brain's reward system. ◦ Those people who are low in self-control might be more vulnerable to addiction. o Behavioral Causes ◦ From the behavioral perspective, the high that you get from a drug is a positive reinforcer. The feeling of euphoria that is produced by a drug is a strong positive reinforcer. This feeling is a reinforcer because the feeling causes more of the behavior (taking the drug) to happen in the future. This feeling is a positive reinforcer because the feeling of euphoria is a pleasant new thing that you didn't have before and that you are getting as a result of the behavior. ◦ As drug use continues and increases (due to continued positive reinforcement), tolerance develops. ◦ When you don't use the drug, you experience bad feelings (physical or emotional), which is withdrawal. ◦ So you use the drug to get rid of these feelings, which leads to negative reinforcement of drug use. This woman is feeling achy, nauseous, and depressed because she is experiencing withdrawal. If she drinks or uses in order to feel better, her drug use would be negatively reinforced when her withdrawal symptoms went away. The removal of the withdrawal symptoms would be a reinforcer because feeling better causes more of the behavior (taking the drug) to happen in the future. This is identical to the reinforcing nature of the euphoria that comes with drug use. However, the removal of withdrawal symptoms is a negative (rather than positive) reinforcer because it involves losing something unpleasant (aches, nausea, depression) that you had before the behavior. ◦ But why don't the negatives of drug use like hangovers, cost, relationships, etc. (which are punishers for drug use) make people stop? ◦ This is because the reinforcers (the high or the avoidance of withdrawal symptoms) are immediate, while the punishers happen later. Immediate consequences are always more powerful than ones that happen long after a behavior is done. The buzz that this woman gets right now is a much more powerful control on her smoking behavior than the coughing up of phlegm tomorrow morning will be. o Cognitive Causes ◦ You may have heard this and wondered if it is true, but it is: Addiction is a disease. ◦ Like any disease, it affects the functioning of an organ. ◦ The organ that is affected by addiction is the brain. ◦ Since the brain creates our thoughts, addiction is a disease of thought. ◦ Major thought distortions associated with addiction include: ▪ denial toward self - "I can control it," "I'm only hurting myself, I'm not hurting anyone else," etc. ▪ denial toward others - hiding your use from others, social isolation and withdrawal, etc. ▪ rationalization - "I don't have a problem because I'm not as bad as that person (yet)," "You made me drink with your nagging," "I can't deal with these emotions," "I only use because I want to and not because I'm addicted, so I could stop any time," etc. o Becoming Addicted ◦ Everyone has a line. ◦ Once that line is crossed, you have become addicted to the pleasant alteration of consciousness that comes with getting high. ◦ Everyone also has a bar. ◦ That bar is made up of three things: genetic predisposition to addiction stress during your upbringing and in your current life substance use ◦ If your bar reaches your line, you become addicted. Here, we have a person's bar reaching the level of addiction. This person's combination of genetic vulnerability, stressful experiences, and substance use was enough to cause the thinking changes in the brain that lead to compulsive substance use. ◦ If your bar does not reach your line, you do not become addicted. This is Angela's bar. Her bar does not reach the level of addiction because she has little genetic vulnerability, not a lot of stress, and only uses drugs in moderation. ◦ With enough substance use, though, the bar of addiction might still be reached. If Angela used more and more, she would eventually become addicted even if her life was stress-free and she had no family history of addiction. ◦ The three components of one person's bar can be of very different sizes from someone else's. This is Julia's bar. Because addiction runs in her family and she has a moderately stressful life, she became addicted the very first time she used a substance. Some addicts describe realizing "This is it! This is what my life has been missing!" the moment they first use their drug of choice, whether that drug be alcohol, cocaine, or any other mind-altering substance. ◦ It's important to note that once the line of addiction is reached, you are addicted to all mind-altering substances. That is, if you drink a lot and become an alcoholic, you can't safely use pot or some other drug. This is because the mind is at least in part addicted to the euphoria of an altered state of consciousness, not just to one specific drug. ◦ One other thing to remember is that different substances fill up the "substance use" portion of your bar more quickly than others. The more addictive a substance is, the less of its use will be needed to cause addiction. In other words, a shot of heroin adds a whole lot more to your bar than a shot of whiskey does. o Smoking ◦ Men are more likely to smoke cigarettes than women. ◦ However, the difference in smoking prevalence is actually quite small between the ages of 12 and 17. ◦ One big reason that girls of this age smoke almost as much as boys do is that smoking is a great way to reduce your appetite. ◦ Girls this age often smoke as a form of weight control. o Alcohol ◦ In the overall population, the prevalence of alcohol use in men is three times more than for women. ◦ Among college students, though, the numbers are much more similar between the genders. ◦ About 80% of all college students drank during the past year. ◦ The percentage of college women who drank during the past year (81.3%) is actually a little higher than for the men (79.0%), though. ◦ For college students, 41% of women and 49% of men binge drank at least once over the last two weeks. ◦ A drinking binge is defined as 4 drinks or more for a woman, or 5 drinks or more for a man. ◦ A binge is only 4 drinks for a woman (versus 5 for a man) because of a woman's lower percentage of body water (due to the higher percentage of fat). ◦ Having less water in the body means that a given amount of a drug would have a higher concentration in a woman's body than in a man's, since there is less water for the drug to be dissolved in. ◦ Which categories of college students drink the most? ▪ freshmen ▪ White students ▪ members of sororities and fraternities ▪ athletes This is Shelby Turnier, former ace pitcher for the UCF softball team. I'm NOT SAYING THAT SHE DRINKS OR DOESN'T DRINK!!!!! I just used her picture as an example of an athlete. Also, UCF has an excellent softball program, so Go Knights! o Illegal Drugs ◦ Of those who use drugs illegally, about 37% are women. ◦ Men tend to use illegal street drugs like cocaine and meth. ◦ Women tend to abuse prescription drugs. Women who use drugs illegally tend to abuse prescription pain medications like OxyContin (left) or anti-anxiety medications like Valium (right). A woman's higher percentage of body fat also means that drugs that bind to fat (like pot) stay in her system longer than they would for a man. o Recovery from Substance Abuse Disorder ◦ Recovery from addiction seems to require two things: The desire to stop (motivation) and the ability to stop (skills). ◦ The stages of change model is a useful way of thinking about how people change unhealthy behavior habits like addictions. ▪ In the precontemplation stage, the person is in denial ("I don't have a problem!") or is aware that there is a problem but is not interested in addressing it. ▪ In the contemplation stage, the person is considering the pros and cons of using versus the pros and cons of changing, along with the considerable effort that it will take to change. ▪ In the preparation stage, the person has made a commitment to change and is ready to take action. ▪ In the action stage, the person is doing new things (like counseling, AA meetings, avoiding bars, exercising, etc.) to change addictive behaviors. ▪ In the maintenance stage, the person is continuing to practice the new behaviors that were learned in the action stage. ◦ Usually a person will go back and forth between stages of change, rather than proceeding through them in a linear manner. ◦ Some people who become addicted apparently already have the skills that are needed to stop and can stop and stay stopped on their own when they decide to (which is called spontaneous remission). ◦ However, most people who become addicted need help learning new skills along with some kind of accountability to keep using them, since addiction constantly works against the person. ◦ This is because since addiction is a disease of thought, a person in addiction or in early recovery can't always trust that his or her thinking is rational. o Self-Help Organizations ◦ Alcoholics Anonymous (AA) was the first peer self-help organization for addiction. ◦ AA was established in 1935 in Akron, Ohio when stockbroker Bill W. and surgeon Dr. Bob (both alcoholics) met and helped each other to stay sober by just talking to each other. Then the two of them used what worked for them to help others stay sober as well. Bill W. (left) and Dr. Bob (right) were the founders of AA. They aren't referred to by their full names because of the "anonymous" part of Alcoholics Anonymous. They wanted people to feel safe coming to their meetings without feeling stigmatized about their alcoholism, so anonymity was promised. ◦ The founders of AA examined the process that was working for them and broke it into 12 Steps. ◦ They wrote the book Alcoholics Anonymous (also known as "The Big Book") to describe what they did to get and stay sober. This is the AA logo. The equilateral triangle relates to the three parts of the solution (unity, recovery, and service) as well as to a three part disease (physical, mental, and spiritual). The circle is used to represent wholeness. ◦ Today, the 12 Steps of AA have been adapted to apply to many other addictions too, including other drugs, overeating, gambling, hoarding, spending money, sex, and work. ◦ AA and other 12-Step programs recommend that you get a mentor (called a sponsor), work through the 12 Steps, and completely abstain from any mind-altering substances (all of them, not just the one that has caused you problems). ◦ Despite the warning to stay away from all mind-altering substances, though, you would be shocked at how much nicotine and caffeine (which are also mind-altering substances) are consumed at 12-Step meetings... ◦ Peer self-help meetings provide opportunities for people to learn the skills they need to stay sober, such as how to manage their emotions without drinking or using, how to resist urges to get high or to drink, how to avoid unhealthy people and situations, how to have healthy relationships, etc. ◦ These meetings also offer accountability for your actions (or lack thereof), since your sponsor and the other members of your group will expect to see action and results from you. ◦ Non 12-Step peer self-help programs like SMART and Rational Recovery use a cognitive psychology approach to learning how to stay sober, avoiding the spirituality that is involved in 12-Step approaches. o Substance Abuse Counseling ◦ Mental health counseling for substance use disorders begins with an assessment of the level of severity of the client's problem. ◦ Once it is clear how serious the person's addiction is, the client should be offered the least intensive kind of treatment that meets the client's needs, so that more treatment than necessary isn't given. ◦ There are several levels of substance abuse treatment that are intended to meet the needs of different levels of addiction. From least intensive to most intensive, they are: ▪ outpatient treatment - 1 or 2 group sessions per week and one individual session every week or two ▪ intensive outpatient treatment - 2 to 5 group sessions per week and one or more individual session per week ▪ day treatment - the client lives at home like normal but goes to a treatment facility five days a week for eight hours of counseling per day ▪ half-way house - the client lives in a group home, goes to work, and attends counseling and self-help meetings when not at work ▪ inpatient treatment - the client lives at a hospital-like facility without leaving for several weeks or months, receiving counseling and self-help meetings throughout the day ◦ All levels of treatment usually involve random drug testing, and they often incorporate self-help meetings. o Medications for Substance Abuse Treatment ◦ Antabuse is a medicine that interferes with the body's breakdown of alcohol, causing nausea and other unpleasant symptoms when alcohol is consumed. If you take Antabuse, drinking won't be pleasant for you. As a result, unpleasant things (nausea) rather than pleasant things (a buzz) will be paired with drinking. This makes the drinking behavior decrease in frequency over time. However, if you really want to drink today, you can just skip your Antabuse pill and drinking won't make you sick. This means that you still have to want to get sober. ◦ Naltrexone is an opiate antagonist, meaning that it binds with opioid receptors in the brain to prevent opiates like heroin and pain medications from binding to those receptors. This prevents the drugs from having any mind-altering effects, so the positive reinforcement is prevented. Naltrexone ◦ BuSpar is sometimes prescribed to help relieve the long-term symptoms of alcohol withdrawal (especially anxiety). ◦ The SSRIs also help relieve withdrawal symptoms. ◦ Methadone is an opiate that is prescribed for daily use to relieve withdrawal symptoms for opiates. Methadone is usually taken in liquid form. Over time, the amount of methadone that is prescribed is slowly decreased, so that the body gradually becomes accustomed to not having any opiates. This can be an effective way to help people get off heroin or pain pills, but only if they commit to decreasing their methadone dose over time. Unfortunately, some people stay on methadone for a long time, merely substituting one addiction for another. Some critics of methadone treatment note that the clinics that prescribe methadone have a motivation to keep people on the drug. ◦ Suboxone is a newer and (possibly/hopefully?) less addictive drug to manage opiate withdrawal that might be safer than methadone. Suboxone Module 13 Notes: 1 - Anorexia Nervosa o The Importance of Physical Appearance ◦ People do things every day to make themselves look better. ▪ dress in fashionable clothes ▪ style their hair ▪ put on makeup ▪ trim their beards or mustaches ▪ exercise ▪ watch what they eat ◦ Sometimes people do more uncommon things to make themselves look better. ▪ breast implants ▪ pec implants ▪ liposuction ▪ Botox ◦ On rare occasions, the drive to look good can get out of control. ◦ One possible outcome of this drive to look good is an eating disorder, although the eating disorders can also have other causal factors besides wanting to look a certain way. o Anorexia Nervosa ◦ This woman, who suffered from anorexia nervosa, weighed 49 pounds after walking 12 hours every day. ◦ You are probably aware of some famous people who may have battled anorexia nervosa. From left to right: a fashion model, Nicole Richie (before and after), and Mary Kate Olsen (before and after) From left to right: Lindsay Lohan (after and before), Hilary Duff before, and Hilary Duff after probably suffering from anorexia ◦ You probably think that you know the difference between anorexia and bulimia. ◦ You're probably wrong. :-) ◦ We'll find out below. ◦ A diagnosis of anorexia nervosa requires the presence of all three of these symptoms: ▪ (1) taking in too little food leading to significantly low body weight ▪ The DSM-IV-TR defined "significantly low body weight" as weighing less than 85% of the normal weight for your age, height, and gender. ▪ The DSM-5 instead classifies the severity of anorexia nervosa based on the person's body mass index (BMI). ▪ BMI equals a person's weight (in kg) divided by his or her height squared (in m2). ▪ For example, a woman of average height (5' 4" or 1.62m) who weighs 130 lbs (59 kg) would have a BMI of 59 / (1.62)2 = 22.5. ▪ The normal range for BMI is between 18.5 and 24.9. ▪ For someone with anorexia, BMI would have to be 18.49 or below. ▪ Mild anorexia includes a BMI of 17.0 to 18.49. ▪ Moderate anorexia includes a BMI of 16 to 16.99. ▪ Severe anorexia includes a BMI of 15 to 15.99. ▪ Extreme anorexia includes a BMI below 15. ▪ However, low body weight is only one of three required symptoms. A very skinny person does not have anorexia unless she or he also has the other two symptoms, which are ... ▪ (2) an intense fear of gaining weight ▪ (3) a disturbance in the way that you perceive your body weight or body shape A person with anorexia nervosa would literally see fat where other people see normal or even too thin. The disturbance in the way that the body is perceived can also include viewing your weight or body shape as unreasonably important to your self-image. ◦ There are two types of anorexia nervosa. ▪ The restricting type includes using dieting, fasting, or using way too much exercise in order to control weight, but the person doesn't engage in any binges or purges. ▪ This is what people usually think of when they think of anorexia. ▪ The binge-eating purging type includes regular bingeing on food and/or purging your body to get rid of food. ▪ This is what people usually think of when they think of bulimia, not anorexia! ▪ In fact, bingeing and purging can happen during either anorexia or bulimia. ▪ We'll learn exactly what a binge is and what a purge is in the next section. ▪ We'll also learn what exactly separates anorexia from bulimia (since it's not the presence or absence of binges and purges). ◦ In the binge-eating purging type of anorexia, Russell's sign (calluses on the knuckles) is often seen because your teeth hit your knuckles when you use your finger to make yourself vomit. ◦ The belief underlying anorexia is "I believe I'm good and worthwhile only when I have complete control over my eating and when I'm losing weight." Notice that it's not good enough just to be thin. There is no final, satisfying weight goal that can be reached because you feel that you have to constantly be losing weight, getting thinner. This is true no matter how thin you already are. ◦ Weight loss is viewed as an extraordinary achievement and a sign of great self-discipline. ◦ People with anorexia may think that they're fat, or they may know that they're skinny but think that certain specific parts of their bodies are fat, especially the belly, butt, and thighs. The belly, butt, and thighs are often areas of obsessive focus for someone with anorexia. The young woman on the right is unhappy because she doesn't have a thigh gap. ◦ The lack of adequate nutrition will make a person with anorexia chronically fatigued, yet the person will remain driven to keep up with a grueling exercise and work/school schedule. People with anorexia tend to be highly driven. They must always push themselves (at work, at school, or in the gym) to be better and better. ◦ Amenorrhea, or the temporary ending of a woman's menstrual cycle, is common. This happens because the body thinks that there is not enough food available in the environment to sustain it. In such circumstances, it is evolutionarily advantageous to not produce offspring. Thus, the starving woman with anorexia becomes temporarily infertile. Amenorrhea was actually one of the required diagnostic criteria for anorexia nervosa in DSM-IV-TR (but only for women). ◦ A person with anorexia will often develop elaborate rituals related to control over eating and food. A person with anorexia might express her desire to maintain control over food by always arranging her food in a specific pattern on her plate, cutting the food into very small pieces, obsessively collecting recipes that she will never cook or eat, or compulsively hoarding food that is never consumed. ◦ The overall prevalence of this disorder is only about 0.4%. ◦ Of those with anorexia, 90% to 95% are female. ◦ The disorder usually begins between the ages of 15 and 19. ◦ Anorexia is often preceded by a stressful event, like going off to college or a devatating breakup. Young women going off to college are at increased risk for developing anorexia nervosa. ◦ It is more common in Whites than in any other ethnic group. ◦ Health risks of anorexia include: loss of bone density (which may not be completely reversible) heart failure kidney damage decreased immune system functioning stomach expansion or even rupturing The swollen belly of a person who is starving is called Kwashiorkor, and it's caused by a lack of protein. This protein deficiency prevents the body from effectively managing bodily fluids. As a result, these fluids pool in the belly. It's a tragically ironic twist that a person with anorexia can develop Kwashiorkor, see his or her belly growing, and then feel even more compelled to starve as a result. ◦ A person with the restricting type of anorexia tends to be more in denial that there is a problem. ◦ Most people with this type recover from the disorder within 5 years, but for some this condition remains chronic. ◦ The binge/purge type tends to include more problems with mood swings, drug use, and self-mutilation, and is more likely to be chronic rather than (relatively) short-lived like the restricting type. ◦ About 5% of those with anorexia die from the disorder, either through starvation (basically, the heart eats itself), other medical problems, or suicide. Module 13 Notes: 2 - Bulimia Nervosa and a New Eating Disorder o Bulimia Nervosa ◦ Bulimia nervosa is diagnosed when all five of these symptoms are present: ▪ (1) recurrent binge eating ▪ A binge is eating much more in a short time (say, a few hours) than most would under similar circumstances, along with a lack of control over eating during the binge. ▪ Dissociation is common during binges, after which the person may be shocked to discover how much was eaten. ▪ (2) recurrently doing inappropriate things to make up for the bingeing ▪ This can include purging, which is doing something to get food or fluids out of your body quickly. Ways to purge include making yourself vomit, using laxatives, using diuretics (which make your body get rid of fluids faster through frequent urination), and enemas (which quickly clean out your lower digestive tract). ▪ Inappropriate things to make up for the bingeing can also include two strategies other than purges: fasting and excessive exercise. ▪ Thus there are six main ways to show symptom #2: induced vomiting, laxatives, diuretics, enemas, fasting, and excessive exercise. The first four in that list are considered purges, the last two are not. ▪ (3) Binges and purges (or fasting or excessive exercise) happen at least one time a week for at least three months. ▪ In fact, the severity of the disorder is classified based on how often the binges and purges occur. ▪ Mild is an average of 1 to 3 episodes per week. ▪ Moderate is an average of 4 to 7 episodes per week. ▪ Severe is an average of 8 to 13 episodes per week. ▪ Extreme is an average of 14 or more episodes per week. ▪ (4) Feelings about yourself are greatly influenced by your weight or body shape. ▪ (5) The criteria for anorexia nervosa are not met. ◦ The key distinction between anorexia and bulimia, then, is that in bulimia no gross distortions of body image are present. ◦ In other words, a person with bulimia sees the same thing that other people see when she looks at herself in the mirror, while a person with anorexia sees fat that nobody else can see. ◦ If criteria are met for both anorexia and bulimia at the same time, then according to symptom #5 only anorexia is diagnosed. ◦ For both disorders, self-esteem is based largely on being thin. ◦ People with this disorder are also 90% to 95% female. ◦ The overall prevalence is about 1%. ◦ A person with bulimia typically has a body that is normal to slightly overweight. ▪ For anorexia to be diagnosed, a person's BMI must be below the normal range (i.e., less than 18.5). ▪ A person with bulimia, on the other hand, tends to have a BMI of between 18.5 and 30 or so. ▪ A person with bulimia can be very thin, but this is not usually the case. ◦ Binges are usually done in secret, as the person is ashamed of the behavior. ◦ A binge usually consists of between 2000 and 3000 calories, but sometimes it can be up to 5000 or 6000 calories. ◦ If a person binges more than once during a single day, over 10,000 calories can be consumed. Remember, most people consume about 1200-2000 calories per day in total. ◦ The person often tends to avoid high calorie foods in general when a binge is not happening. ◦ However, during a binge a person might eat several burgers, several orders of fries, a couple of milkshakes, six donuts, and a bag of Oreos. A binge might include a single person eating this much food over a span of a few hours. This is about 6000 calories. ◦ The frequent vomiting that often accompanies bulimia can rot your teeth. ◦ A female with bulimia often experiences irregular periods or amenorrhea, just like in anorexia. ◦ Russell's sign (calluses on the knuckles) is also commonly seen in bulimia. ◦ Bulimia is easy for a person to hide if the person belongs to a group that values exercise. People who are involved with activities that require regular exercise and an emphasis on watching your weight (such as gymnastics, track, dance, cheerleading, wrestling, etc.) can easily hide their bulimia since their compensatory behaviors (i.e., frequent exercise) seem normal for their situation. ◦ Bulimia usually begins between the ages of 15 to 29. ◦ This disorder can cause electrolyte imbalances due to frequent fluid loss, leading to heart failure. ◦ Often the esophagus is torn by the frequent vomiting. ◦ Bulimia tends to be a chronic condition rather than short-lived. o Binge Eating Disorder ◦ Binge eating disorder is a new diagnosis in DSM-5. ◦ This disorder involves out of control binges without any purges or other behavior to make up for the binges. A person with this disorder tends to be morbidly obese. Module 13 Notes: 3 - Causes of the Eating Disorders o Biological Causes ◦ Eating disorders tend to run in families; they have a strong genetic component. ◦ The presence of an eating disorder is correlated with disruptions in the control of appetite and satiation in the hypothalamus. ◦ Since this is only a correlation, though, we don't know for sure if the changes in the hypothalamus cause the eating disorders or if they are caused by the eating disorders. o Social Causes ◦ Our culture's beauty ideal has become thinner over time. From left to right, images of female physical perfection for the ancient Greeks (Aphrodite), America in the 1920s, and America in the 1940s. These women are much larger than most of the models, actresses, and singers of today. These four images are composites of all of the Playboy centerfolds for each month for four different decades. In other words, each image is the combination of 120 images, one per month for 10 years. The pinkish-tanish blotches are the models' bodies. The composite body from the 1960s (far left) is larger than the one from the 1970s (near left). The bodies in the 1980s (near right) and the 1990s (far right) get progressively smaller still. Women's Ideal Body Types Throughout History (Links to an external site.) Links to an external site. Take a look at this video (3:10) that breaks down how the beauty ideal has changed over history. ◦ Recently in some parts of the world, in order to combat this trend toward unhealthy thinness, laws have been passed that require fashion models to be examined by a physician before each fashion show. If a model's BMI isn't in the normal range, the model can't step onto the runway. In Madrid, Spain and Milan, Italy models are not allowed to work if their BMI is less than 18. In Israel a model's BMI has to be at least 18.5. In France, a law was recently passed that requires every model to have a certification from a doctor that she or he is of a healthy weight. The law was changed from "BMI of at least 18" to "healthy weight as certified by a doctor" because BMI was criticized as an inaccurate way to judge health. ◦ How does this thin beauty ideal affect kids? ▪ One study showed that 42% of 1st and 3rd graders said that they wished that they were thinner. ▪ The same study found that 81% of 10 year-olds are afraid of beingf at. These girls might already feel shame about their bodies. ◦ All of the eating disorders have become more common over the last 50 years, mainly in Western countries. ◦ One kind of mindset protects a woman from getting these disorders: Not buying into the thin ideal. ◦ For kids, athletes in weight-dependent sports (like gymnastics or wrestling) are at greater risk for developing eating disorders. ◦ However, non-elite athletes (that is, kids who are not training for elite competitions like the Olympics) in non-weight dependent sports (like soccer and basketball) are at less risk for eating disorders than are those in the general population. ◦ Eating disorders are more prevalent in middle- and upper-income families. ◦ Fortunately, there seems to be a recent cultural trend toward embracing women with normal to larger body shapes. Kelly Clarkson (left) is a superstar who has a normal body. Raven Simone (center) seems to have embraced her larger body shape. Charlotte Church (right) is an opera singer who refused to lose weight when her agent told her that she needed to be thin in order to benefit her career. Adele (left) has carved out super-stardom without making her body look like a Barbie doll. Jennette McCurdy (center) is a former Nickelodeon star who seems proud of her curves. Lena Dunham (right) celebrates her normal-looking body by being naked on TV. A lot I've heard that Meghan Trainor (left) is all about that bass. Elle King (center) doesn't have your typical pop singer's body. Rebel Wilson (right) is funny, talented, and not ashamed of her body shape. Jennifer Lawrence sums it up beautifully. o Psychological Causes ◦ Binges are so satisfying because they temporarily relieve painful emotions like depression, guilt, anxiety, relationship problems, etc. ◦ Cognitively, the eating disorders are caused by: the overvaluation of appearance (e.g., "Thinness will bring me popularity, which will bring happiness!") perfectionism low self-esteem a belief that I must conform to other people's wishes rigid evaluations of yourself and others ◦ A major psychological perspective that does a good job of explaining the eating disorders is family dynamics, which looks at the ways that family members interact with each other and how these interactions affect each individual in the family. The eating disorders are more common in "good girls" who are high achieving, dutiful, and strongly want to please their parents. The parents of those with eating disorders tend to be over-controlling, place an unreasonably high value on the compliance and achievement of their children, and don't allow their children to express negative feelings like anger, sadness, or discouragement. Enmeshment between parents and children with eating disorders is very common. If you will recall from Module 10b, when a relationship between two people is enmeshed the interpersonal boundaries that separate "me" from "you" are weak and easily crossed. For example, if I can't stand it when you are angry with me, this is because we are enmeshed and the interpersonal boundaries that separate "your anger" from "me" aren't strong. I can't distinguish between "you have a negative opinion of me right now" from my own self-image, so I feel like I am horrible when you think badly of me. An enmeshed parent sees the child as an extension of the self rather than as a separate individual with needs, desires, preferences, opinions, emotions, etc. Enmeshed parents, then, only attend to their needs rather than to their child's. This means that the kid never learns to identify and accept her or his own needs because those needs are always ignored or dismissed. Instead, the child learns to monitor other people to figure out what the other people want and then comply with the needs of others. The eating disorders may tend to develop in adolescence because this is the age when we're supposed to become independent, but the person feels incapable of separating from an enmeshed relationship with parents. The person with an eating disorder feels rage at the over-controlling nature of his or her parents. The control that the person gains over eating helps to make up for that lack of control in the parental relationship. The person's weight loss or lack of eating also makes the parents concerned about the welfare of their child, which is felt as power over both the self and the family. Families of those with eating disorders tend to be similar to the families of those with depression and anxiety, but the mothers in families with eating disorders tend to focus a lot on the weight of their daughters. A full 82% of kids with eating disorders come from families that were on a family-wide diet. Another sign of an enmeshed relationship is abuse, and 80% of those with eating disorders were physically or sexually abused as a kid. As a result of the abuse, these unconscious drives can often be found in those who were abused as children: Those with binge eating disorder tend to overeat for the purpose of making themselves unattractive so that they are no longer a target for those who would sexually abuse them. Women with anorexia tend to lose their female characteristics (i.e., breasts, curves, menses) and want to become invisible so that abusers will no longer notice them. The theme for those with bulimia is try to gain control over their bodies in response to the lack of control over the abuse that happened in the past. Overall, the key issue for those with eating disorders is control. Module 13 Notes: 4 - Treatments for the Eating Disorders o Treatments ◦ Whenever an eating disorder starts, emotional growth stops. ◦ This is because instead of facing and learning how to cope with difficult emotions, relationship issues, or other situations, the person avoids these learning opportunities by focusing on food. ◦ Because of this, the person doesn't learn any coping skills for relationships or emotions. ◦ In fact, adult clients with eating disorders who are in inpatient treatment facilities often begin to dress like tweens or teenagers, carry stuffed animals, become more playful, and stop wearing makeup. Once her food-related coping mechanism is taken away from her, a woman with an eating disorder in an inpatient treatment facility will probably begin to dress, think, and act like someone who is the age at which her eating disorder began since this is when her emotional growth stopped. o Treatments for Anorexia ◦ Anorexia tends to be resistant to treatment due to the client's need for control. ◦ The client sees the need for counseling as unwelcome evidence that the client lacks self-control, so the counselor must work extra hard to gain and maintain the client's trust. ◦ For severe cases of anorexia, hospitalization and forced feeding are often necessary before counseling can begin. ◦ Unfortunately, this begins treatment with some pretty severe damage to the client's trust for the counselor, who forced the client into the hospital. ◦ A cognitive therapist would work to build the client's self-awareness of and trust in the client's own feelings. ◦ A behavioral therapist would set up a system for the client to earn rewards for weight gain. A behavioral therapist might create a chart like this to keep a visual record of the client's progress in gaining weight. If a certain weight is reached (72.5 pounds, for instance), the client might be given a reward such as more free recreation time, a very powerful motivator for a hospitalized client. ◦ A family systems therapist would work to identify and change the interpersonal interaction patterns within the family that are supporting the client's eating disorder. ◦ Treatment for anorexia often takes many years, with mixed results. o Treatments for Bulimia ◦ For a person with bulimia, the need for control tends to be related to coping with emotions. ◦ That is, if I can't control how I feel emotionally, I'll control what goes into and out of my body instead. ◦ If a cognitive-behavioral counselor was treating a person with bulimia, the counselor would: ▪ ask the client to monitor and write down the thoughts that accompany eating and purging ▪ talk about these thoughts and challenge them where they are irrational ▪ teach the client healthy eating habits, such as what a healthy portion is, what "full" feels like, how to tolerate being full, etc. Treatment for bulimia is actually very effective and usually only lasts between 10 and 20 sessions. Module 14 Notes o Brief Psychotic Disorder ◦ Brief psychotic disorder is diagnosed when one or more of these symptoms is experienced: ▪ (1) delusions ▪ (2) hallucinations ▪ (3) disorganized speech Disorganized speech includes things like: derailment, which is frequently wandering off the topic of conversation tangential speech, in which one topic leads to another one that is only barely related to the first topic (that is, the person goes off on a tangent) word salad, which is incomprehensible speech that just sounds like random words The person in this video (1:19) demonstrates disorganized speech. Note that from one sentence to the next (or even within a single sentence), he jumps between topics that are kind of related, but not really (tangential speech). Sometimes he seems to just speak random words (word salad). ▪ (4) grossly disorganized or catatonic behavior ▪ Disorganized behavior includes things like sudden outbursts of laughter or yelling, or bizarre behaviors like strange dancing when it's just not time to dance. ▪ Catatonic behaviors include: not doing what someone asks you to do (like handing me a pen), which is called negativism rigidly holding your body in an unusual posture mutism, which is being verbally non-responsive when you're spoken to stupor, which is being physically non-responsive when you're pushed or touched excessive movements (like head shaking or arm waving) with no apparent cause It's important to note that these catatonic behaviors aren't done intentionally. They aren't a case of a person consciously deciding to be defiant. Normal interpersonal interactions just aren't processed correctly in the brain of a person with schizophrenia, so the person acts strangely. If you can choose whether or not to be mute, you're not psychotic. This video (3:31) demonstrates a number of catatonic behaviors. ◦ One thing to note about these four symptoms is that if a person only has one of them, the symptom would have to be either #1, #2, or #3 for the disorder to be diagnosed. ◦ That is, if the person shows symptom is #4 (grossly disorganized or catatonic behavior), at least one more symptom would also have to be shown for it to be brief psychotic disorder. ◦ An episode of brief psychotic disorder lasts between 1 day and 1 month. ◦ Symptoms have to completely go away for an episode to be considered over. ◦ If symptoms last for more than one month, the diagnosis switches from brief psychotic disorder to schizophrenia (which we'll cover next). ◦ Women are twice as likely to experience brief psychotic disorder. o Schizophrenia ◦ A diagnosis of schizophrenia is given if two or more of these symptoms are experienced for at least 1 month: ▪ (1) delusions ▪ (2) hallucinations ▪ (3) disorganized speech ▪ (4) grossly disorganized or catatonic behavior ▪ (5) negative symptoms ▪ A negative symptom is something that is not present but should be. ▪ This is in contrast to positive symptoms, which are things that are present but should not be. ▪ Symptoms 1 through 4 are positive symptoms, because the person is doing or experiencing things that are unusual, such as hearing voices or holding an odd posture. ▪ Negative symptoms include: showing little to no facial expressions having flat speech that lacks normal inflections having a lack of nonverbal communication (like hand movements) when talking not engaging in any self-directed behaviors, which is called avolition (a = without, volition = will) engaging in little or no speech, known as alogia (a = without, logos = speech) anhedonia a lack of interest in interpersonal relationships, called asociality ◦ Just like with brief psychotic disorder, at least one of the two or more symptoms has to be #1, #2, or #3 for schizophrenia to be diagnosed. ◦ The typical age at onset for schizophrenia is later for women (late 20s) than for men (early to mid-20s). ◦ Women are also much more likely to experience even later onset of schizophrenia (in middle age), which is almost unheard of in men. ◦ Women have more affect (mood) symptoms (like laughing at odd times, depression, anxiety), while men have more negative symptoms. ◦ Women with this disorder tend to show better social functioning than men with this disorder. o Schizoaffective Disorder ◦ This is schizophrenia plus a mood disorder, either depression or bipolar. This disorder is more common in women, but only the depressive type. o Dissociative Amnesia ◦ If you will recall from Module 10b (when we talked about borderline personality disorder), dissociation is the temporary separation of one part of your mental functioning from the other parts. ◦ In addition to dissociative amnesia, the dissociative disorders category in DSM-5 also includes dissociative identity disorder, which most people incorrectly refer to as "multiple personality disorder." ◦ Dissociative amnesia happens when you can't