psychopathology week 7 onwards

1. • Prevalence 2. Biological Influences • Genetic contributions 3. Numerous genes on several chromosomes involved

1. Previously thought to be very rare, but this is not the case -1 in 50-68 school-aged children meet criteria -More commonly diagnosed in males • Gender ratio: 5:1 -IQ interaction -38% show intellectual disabilities - Interaction with IQ 1. Children with higher IQs who learn to speak before age 6 have the best outcomes 2. Tend to not need residential care, may even attend university and get a job - stilkl impairments in social interactions 2. -Heritability estimates as high as 80% -An identical twin has a 47-90% chance of having ASD if the other twin has ASD -For non-twin siblings, if one child has ASD, the chance of having a second child having ASD is 20% -Even if siblings do not meet criteria for ASD, they will likely show some deficits in social communication and interactions 3. • A deletion on Chromosome 16 was associated with ASD in 3 samples

1.Many people report that cocaine or marijuana enhances sex- ual pleasure. Although little is known about the effects of mari- juana across the range of use, it is unlikely that chemical effects increase pleasure. 2. Nicotine is similarly associated with impaired sexual perfor- mance. One report from Mannino, Klevens, and Flanders (1994), 3. Psychological contributions For years, most sex researchers and therapists thought the prin- cipal cause of sexual dysfunctions was anxiety (see, for example, Kaplan, 1979; Masters & Johnson, 1970). While evaluating the role of anxiety and sexual functioning in our own laboratory, we dis- covered it was not that simple. In certain circumstances, anxiety increases sexual arousal (Barlow, Sakheim, & Beck, 1983). We designed an experiment in which the same group of young, sexu- ally functional men viewed erotic films under three conditions. Before viewing the film, all participants were exposed to a harm- less but somewhat painful electric shock to the forearm.

1. Rather, in those individuals who report some enhancement of sexual pleasure (and many don't), the effect may be psychological in that their attention is focused more completely and fully on sensory stimulation (Buffum, 1982), a factor that seems to be an important part of healthy sexual func- tioning. If so, imagery and attentional focus can be enhanced with nondrug procedures such as meditation, in which a person practices concentrating on something with as few distractions as possible. 2. studying more than 4,000 male army veterans, found that cigarette smoking alone was associated with increased erectile dysfunction after controlling for other factors, such as alcohol and vascular disease (Wincze et al., 2008). Similarly, a more recent study found that nicotine used before viewing an erotic film was associated with reduced erectile response to the film for men ( 3. We then attempted to replicate the kinds of performance anxiety that males might experience during a sexual interaction. In the first condi- tion, which served as a control condition, the participants were told to relax and enjoy the film and that there was no chance of shock. In the second condition, participants were told there was a 60% chance they would receive the shock at some time while relax and enjoy the film and that there was no chance of shock. In the second condition, participants were told there was a 60% chance they would receive the n the third condition, most closely paralleling the types of per- formance anxiety that some individuals might experience, the same group of participants were told there was a 60% chance they would receive a shock if they did not achieve the average level of erection achieved by the previous par- ticipants (contingent shock threat). No shocks were delivered during the view- ing of the erotic films in any of the con- ditions, although participants believed they might be administered.

1. Substance Use Disorders — Diagnostic Criteria - 11 different criteria , ieither usin 2. dont meet criteria

1. Take in larger amounts or for longer than intended -Unsuccessful efforts to reduce use or quit -Spending a lot of time getting, using, or recovering; Lot of time getting th eg.10 hours a week , could be spending a lot of time doing other healthy and productive things 1. Some drugs may produce obvious physiological cravings (e.g., heroin), others won't (e.g., marijuana) because perhaps more mild in nature and , more attentional focus on cues of drug paraphanelia but not physical sensations -role disruption at work, home or school; 1. Calling into work sick becausd eof hangovers, -Continued use despite social/ interpersonal problems -Continued use despite physical or psychological problems -Reduction in social, occupational, or recreational activities -Using in physically hazardous situations;1. Erring in driving after alcohol use; PHYSICALLY HAZARDEUS SIUATIONS , -tolerance -withdrawal 2. 1. If an individual doesn't have goals to reduce use, they don't meet some criteria (e.g., take in larger amounts or longer than intended), they have to have uncesuccessdul efforts, if no efforts then don't meet criteris

1. A far more common male orgasmic disorder is premature ejaculation, ejaculation that occurs well before the man and his partner wish it to (Althof, 2006; Polonsky, 2000; Wincze, 2009; Wincze & Weisberg, 2015), defined as approximately 1 minute after penetration in DSM-5 (see DSM Table 10.4). Consider the rather typical case of Gary. 2. Sexual Pain Disorder A sexual dysfunction specific to women refers to difficulties with penetration during attempted intercourse or significant pain during intercourse. This disorder is called genito-pelvic pain/ penetration disorder. For some women, sexual desire is present, and arousal and orgasm are easily attai 3. But the most usual presentation of this disorder is referred to as vaginismus,

1. The frequency of premature ejaculation seems to be quite high. In the U.S. survey, 21% of all men met criteria for premature ejaculation, making it the most common male sexual dysfunction (Laumann et al., 1999; Serefoglu & Saitz, 2012). This difficulty is also a presenting complaint in as many as 60% of men who seek treatment for sexual dysfunction ( -men also present with erectile dysfunction as their major problem.) In one clinic, premature ejaculation was the principal complaint of 16% of men seeking treatment (Hawton, 1995). Although DSM-5 specifies a duration of less than approxi- mately 1 minute, it is difficult to define "premature." An adequate length of time before ejaculation varies from individual to individ- ual. Patrick and colleagues (2005) found that men who complain of premature ejaculation ejaculated 1.8 minutes after penetration, compared with 7.3 minutes in individuals without this complaint. A perceived lack of control over orgasm, however, may be the more important psychological determinant of premature ejacu- lation (Wincze et al., 2008).2 2. ed, but the pain during attempted intercourse is so severe that sexual behavior is dis- rupted. In other cases, severe anxiety or even panic attacks may occur in anticipation of possible pain during intercourse. 3. n which the pelvic muscles in the outer third of the vagina undergo involuntary spasms when intercourse is attempted (Binik et al., 2007; Kleinplatz et al., 2013). The spasm reaction of vaginismus may occur during any attempted penetration, includ- ing a gynecological exam or insertion of a tampon (Beck, 1993; Bradford & Meston, 2011). Women report sensations of "ripping, burning, or tearing during attempted intercourse" (Beck, 1993, p. 384). Consider the case of Jill.

1. Several findings lend some support to the theory of differential hormone exposure in utero. One is the observation that individuals with homosexual orientations have a 39% greater chance of being non-right handed (left handed or mixed handed) than those with heterosexual orientations (Lalumière, Blanchard, & Zucker, 2000), although these findings were not replicated in a later study 2. Some were pleased with the biologi- cal interpretation, because people could no longer assume as they used to in past decades that gays had made a "morally depraved" choice of supposedly "deviant" arousal patterns. Others, however, noted how quickly some members of the public, particularly in past decades, pounced on the implication that something was biologically wrong with individuals with homosexual arousal pat- terns, assuming that someday the abnormality would be detected in the fetus and prevented, perhaps through genetic engineering. Do such arguments over biological causes sound familiar? Think back to studies described in Chapter 2 that attempted to link complex behavior to particular genes.

1. There is also the finding that gay/bisexual men are significantly shorter and lighter than hetero- sexual men, though no differences were found for women (Bogart, 2010). Another is the intriguing findings that heterosexual males and masculine ("butch") lesbians tend to have a longer fourth ("ring") finger than index (second) finger but that heterosexual females and gay males show less of a difference or even have a longer index finger than f 2. In almost every case, these studies could not be replicated, and investigators fell back on a model in which genetic contributions to behavioral traits and psychological disorders come from many genes, each mak- ing a relatively small contribution to a vulnerability. This general- ized biological vulnerability then interacts in a complex way with various environmental conditions, personality traits, and other contributors to determine behavioral patterns. We also discussed reciprocal gene-environment interactions in which certain learn- ing experiences and environmental events may affect brain struc- ture and function and genetic expression.

1. Psychosocial treatments Among the many advances in our knowledge of sexual behavior, none was more dramatic than the publication in 1970 by William Masters and Virginia Johnson of Human Sexual Inadequacy. The procedures outlined in this book literally revolutionized sex ther- apy by providing a brief, direct, and reasonably successful thera- peutic program for sexual dysfunctions. Underscoring again the common basis of most sexual dysfunctions, a similar approach to therapy is taken with all patients, male and female, with slight variations depending on the specific sexual problem (for exam- ple, premature ejaculation or orgasmic disorder). 2. imary goal is to eliminate psychologically based performance anxiety (refer back to Figure 10.5). To accomplish this, Masters and Johnson introduced sensate focus and nondemand pleasuring. 3.At this point, arousal should be reestablished and the couple should be ready to attempt intercourse. So as not to proceed too quickly, this stage is also broken down into parts. For example, a couple might be instructed to attempt the beginnings of pen- etration; that i

1. This intensive program involves a male and a female therapist to facilitate com- munication between the dysfunctional partners. (Masters and Johnson were the original male and female therapists.) Therapy is conducted daily over a 2-week period. The actual program is quite straightforward. In addition to providing basic education about sexual functioning, altering deep-seated myths, and increasing communication, the clinicians' 2. In this exercise, couples are instructed to refrain from intercourse or genital caressing and simply to explore and enjoy each other's body through touching, kissing, hugging, massaging, or similar kinds of behavior. In the first phase, nongenital pleasuring, breasts and genitals are excluded from the exercises. After successfully accomplishing this phase, the couple moves to genital pleasuring but with a ban on orgasm and intercourse and clear instructions to the man that achieving an erection is not the goal. 3.e depth of penetration and the time it lasts are only gradually built up, and both genital and nongenital plea- suring continue. Eventually, full intercourse and thrusting are accomplished. After this 2-week intensive program, recovery was reported by Masters and Johnson for the vast majority of more than 790 sexually dysfunctional patients, with some differences in the rate of recovery depending on the disorder. Close to 100% of individuals with premature ejaculation recovered, whereas the rate for more difficult cases of lifelong generalized erectile dys- function was closer to 60%.

1. Cluster C: Obsessive-Compulsive Personality Disorder • Prevalence 2. Characteristics 3. • Causal factors 4. Cluster C: Obsessive-Compulsive Personality Disorder • Treatment 5. Duane is a 35-year-old man who was recently admitted to a correctional centre after an incidence of domestic violence. His wife had danced with another man at a party after he refused to dance with her. Shortly afterwards, they left the party and he accused her of sleeping with other men. Duane had long suspected and repeatedly accused his wife of cheating, despite giving her little opportunity to do so. He wouldn't let her work or go out on her own. He also had a history of suspecting others were out to get him. For example, if he found a scratch on his car, he believed that someone had done it on purpose. Duane believed that others could not be trusted nor should they be relied upon. He firmly believes that the world is coming to an end, and as a result, has been prepping a fallout shelter. --Which PD does this description most closely match? 59

1. 2% overall -Slightly more common in men 2. - Lack of research - Different from hoarding because their hoarded possessions are kept very orderly 3. • Modest genetic contribution 4. - If cant change perfectionsism , Targets rumination, procrastination, feelings of being inadequate\ - Poor evidence that treatment works for people with severe perfectionism 5. Q1. Ppd

1. CISGENDER: A 2. GENDER EXPERIENCES: T 3.AFAB/PFAB: 4. AMAB/PMAB: 5. GENDER DYSPHORIA:

1. A term used to describe people whose gender is the same as what was presumed for them at birth (male or female). 'Cis' is a Latin term meaning 'on the same side as'. 2. rans, transgender, gender diverse, cis and cisgender are all experiences of gender and are distinct from male, female and non-binary gender identities. 3. Assigned female at birth/Presumed female at birth. 4. Assigned male at birth/Presumed male at birth. 5. he distressor unease sometimes experiencedfrom being misgendered and/or when someone's gender and body personally don't feel connected or congruent. Many trans and gender diverse people do not experience gender dysphoria at all, and if they do,may cease with access to gender affirming healthcare and/or peer support. -With or without the presence of gender dysphoria, being trans and/or gender diverse is not a mental illness. Gender dysphoria does not equal being trans or gender diverse.

1. Cluster C: Dependent Personality Disorder 2. • Prevalence

1. A. A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: -Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. -Needs others to assume responsibility for most major areas of his or her life. -Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.) -Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy). -Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. -Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. -Urgently seeks another relationship as a source of care and support when a close relationship ends. -Is unrealistically preoccupied with fears of being left to take care of himself or herself. 2. 1% overall More common in women

1.Cluster B: Antisocial Personality Disorder criteria 2. Cluster B: Antisocial Personality Disorder • Prevalence

1. A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following: -Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest. -Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. -Impulsivity or failure to plan ahead. -Irritability and aggressiveness, as indicated by repeated physical fights or assaults. -Reckless disregard for safety of self or others. -Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. -Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. B. The individual is at least age 18 years - Cannot give diagnosis prior to 18yo but have to exhibit symptos before C. There is evidence of conduct disorder with onset before age 15 years. D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder. 2, • Prevalence -2-3% overall -3% in males -1% in females -Could be as high as a 5:1 ratio

1. Cluster B: Histrionic Personality Disorder criteria 2. • Prevalence

1. A. A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: -Is uncomfortable in situations in which he or she is not the center of attention. -Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior. -Displays rapidly shifting and shallow expression of emotions. -Consistently uses physical appearance to draw attention to self. -Has a style of speech that is excessively impressionistic and lacking in detail. -Shows self-dramatization, theatricality, and exaggerated expression of emotion. -Is suggestible (i.e., easily influenced by others or circumstances). -Considers relationships to be more intimate than they actually are;- Self-centred , vain shallow which maybe why criteria 8 2.- 1% - MAY BE More common in women? - Lack of research so not really many causal factors

1. Cluster C: Avoidant Personality Disorder criteria 2, • Prevalence

1. A. A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: -Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection. -Is unwilling to get involved with people unless certain of being liked and socua -Shows restraint within intimate relationships because of the fear of being shamed or ridiculed. -Is preoccupied with being criticized or rejected in social situations. -Is inhibited in new interpersonal situations because of feelings of inadequacy. -Views self as socially inept, personally unappealing, or inferior to others. -Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing. 2. 2-3% overall -More common in women 1. Anxiety/social anxiety more common in women

1. ASD criteria

1. A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by all of the following, currently or by history (examples are illustrative, not exhaustive; see text): 1.Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. reduced sharing of interests, emotions or affect 2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.§ ., eye-contact, gestures, misunderstanding or not using facial expressions 3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.§ no interest in friendship, absence of interest in having peers

1. that sexual orientation is malleable or changeable over time, at least for some people (Mock & Eibach, 2012). Dr. Lisa Diamond has studied women over time (longitudinal studies) and discovered that interpersonal and situational factors exert a substantial influence on women's patterns of sexual behavior and sexual identities, a finding much less true for men 2. In any case, the simple one-dimensional claims that homo- sexuality is caused by a gene or that heterosexuality is caused by healthy early developmental experiences will continue to appeal to certain segments of the general population 3. An Overview of Sexual Dysfunctions Before we describe sexual dysfunction, it's important to note that the problems that arise in the context of sexual interactions may occur in both heterosexual and homosexual relationships. Inability to become aroused or reach orgasm seems to be as common in homosexual as in heterosexual relationships, but we discuss them in the context of heterosexual relationships, which are the majority of cases we see in our clinic. Of the different stages in the sexual response cycle,

1. Among women who initially identified themselves as heterosexual, lesbian, bisexual, or "unla- beled," after 10 years more than two thirds of women had changed their identity label a few times. When women changed their sexual identities, they typically broadened rather than narrowed their potential range of attractions and relationships. Why is this true for women but not so much for men? Researchers don't know for certain, but these innovative longi- tudinal studies have already taught us a lot about the origins of sexual orientation. 2. either explana- tion is likely to be proved correct. Almost certainly, biology sets certain limits within which social and psychological factors affect development. Scientists will ultimately pin down biological con- tributions to the formation of sexual orientation—both heterosex- ual and homosexual—and the environment and experience will be found to powerfully influence how these patterns of potential sexual arousal develop 3.hree of them—desire, arousal, and orgasm (see E Figure 10.2)—are each associated with specific sexual dysfunc- tions. In addition, pain can become associated with sexual func- tioning in women, which leads to an additional dysfunction.

1. Most of these girls met criteria for childhood gender dysphoria disorder or came very close to it. At a follow up, when these girls (now women) averaged 25 years of age, only three met criteria for gender dysphoria

1. Another six reported bisexual/ homosexual behavior; eight more would have homosexual fantasies but not behavior. The remaining eight women were heterosexual (Drummond, Bradley, Peterson-Badali, & Zucker, 2008). This finding of only a very loose relationship between gender- nonconforming behavior and later sexual development is not unique to American culture. For example, similar relationships between early gender-nonconforming behavior and later development exist among the Fa'afafine, a group of males with homosexual orientation in the Pacific Islands country of Samoa (Bartlett & Vasey, 2006). And even in strict Muslim societies where

1. Causes of Substance Use Disorders 2. Biological Causes • Genetic component seems likely

1. Biological influences Psychological influences Sociocultural influences - Positive attitude and expectatipons abiut the drug experimentation regular use heavy use addiction 1. Some people skip heavy use, or regress backwards through flow, some don't need heavy use to become addicted 2. • Greater concordance between identical twins than fraternal twins for substance use disorders -Genetic factors seem to play a similar role for all drugs of abuse -Drugs are taken to avoid the bad feelings associated with withdrawal -Drugs affect the "pleasure pathway/reward pathway"

1. Gender Differences Although both men and women tend toward a monogamous (one partner) pattern of sexual relationships, gender differences in sexual behavior do exist, and some of them are quite dramatic. Most recently, Petersen and Hyde (2010) reported a sophisticated esults from hundreds of studies examin- ing gender differences in sexual attitudes and behaviors. Their findings will be reviewed in the following paragraphs. 2. Why women masturbate less frequently than men puzzles sex researchers, particularly when other long-standing gender differ- ences in sexual behavior, such as the probability of engaging in premarital intercourse, have virtually disappeared 3.Another continuing gender difference is reflected in the inci- dence of casual sex, attitudes toward casual premarital sex, and pornography use, with men expressing more permissive attitudes and behaviors than women

1. One com- mon finding among sexual surveys is a much higher percentage of men than women report that they masturbate (self-stimulate to orgasm; Oliver & Hyde, 1993; Peplau, 2003; Petersen & Hyde, 2010). When Richters and colleagues (2014) surveyed Australian adults, they also found this discrepancy (72% of men versus only 42% of women reported masturbating in the past year). An earlier study had shown that masturbation was not related to later sexual functioning; that is, whether individuals mastur- bated or not during adolescence had no influence on whether they had experienced intercourse, the frequency of intercourse, the number of partners, or other factors reflecting sexual adjustment 2. One traditional view accounting for dif- ferences in masturbatory behavior is that women have been taught to associate sex with romance and emotional intimacy, whereas men are more interested in physical gratification. But the dis- crepancy continues despite decreases in gender-specific attitudes toward sexuality. A more likely reason is anatomical. Because of the nature of the erectile response in men and their relative ease in providing sufficient stimulation to reach orgasm, masturbation may simply be more convenient for men than for women. This may explain why gender differences in masturbation are also evi- dent in primates and other animals 3. earak, 2014). The most current term for casual sex, particularly among college students, is "hooking up," which refers specifically to a range of physically intimate behaviors outside of a committed relationship (Owen, Rhoades, Stanley, & Fincham, 2010). Studies of "hooking up" demonstrate similar findings to older studies of casual sex, in that it is often precipitated by alcohol, and women are less likely to consider it a positive experience than men (Olmstead, Pasley, & Fincham, 2013; Strokoff, Owen, & Fincham, 2014). For example, Owen & Fincham (2011) found that greater alcohol use leads to greater engagement in "friends with benefits" relationships (a par- ticular type of "hooking up" that involves an ongoing nonromantic relationship), and this was especially true for women. Interestingly, even when women deliberately engage in casual sex, having a greater number of pa

1. medical treatments A variety of pharmacological and surgical techniques have been developed in recent years to treat sexual dysfunction, almost all focusing on male erectile disorder. The drug Viagra, introduced in 1998, and similar drugs such as Levitra and Cialis, introduced subsequently, are the best known. We look at the four most popu- lar procedures: oral medication, injection of vasoactive substances directly into the penis, surgery, and vacuum device therapy. Before we begin, note that it is important to combine any medical treat- ment with a comprehensive educational and sex therapy program to ensure maximum benefit. In 1998, the drug sildenafil (trade name Viagra) was intro- duced for erectile dysfunction. 2. e categorized as fair for 29% who reported adequate erection but satisfaction from 4 to 6, and unsatisfactory for 39% with inad- equate erection and satisfaction rated as 0 to 3. Thus, erections were sufficiently firm for intercourse in 61% of the men, consistent with other studies, but only 32% rated the results as at least good, suggesting the need for, perhaps, additional drug or psychological treatment.

1. pproval from the Food and Drug Administration occurred early in 1998, and results from several clinical trials suggested that between 50% and 80% of a large num- ber of men benefit from this treatment (Conti, Pepine, & Sweeney, 1999; Goldstein et al., 1998) in that erections become sufficient for intercourse, compared with approximately 30% who benefit from placebo. Results are similar with Cialis and Levitra (Carrier et al., 2005). As many as 30% of men may suffer severe headaches as a side effect, however, particularly at higher doses (Rosen, 2000, 2007; Virag, 1999), and reports of sexual satisfaction are not opti- mal. For example, Virag (1999) evaluated a large number of men treated with Viagra and found that 32% of the men were successful if success was defined as an erection sufficient to engage in inter- course and satisfaction of at least 7 on the 0-to-10 scal 2. If men are particularly anxious about sex, results are not as good with the drug (Rosen et al., 2006). Also, the large majority of men stop using the drug after a trial of several months or a year, indicating less than satisfactory long-term results (Rosen, 2007). To address this issue, Bach, Barlow, and Wincze (2004) evaluated the addition of cognitive-behavioral treatment (CBT) to treatment with Viagra. Results were encouraging because couples reported greater satisfaction and increased sexual activity after combined drug therapy and CBT, compared with a period when only the drug was used.

1.social and cultural contributions The model of sexual dysfunction displayed in Figure 10.5 helps explain why some individuals may be dysfunctional at the present time but not how they became that way. Although it is not known for sure why some people develop problems, many people learn early that sexuality can be negative and somewhat threatening, and the responses they develop reflect this belief. Donn Byrne and his colleagues call this negative cognitive set erotophobia. They have demonstrated that erotophobia 2.Laumann and colleagues (1999), in the U.S. sex survey, found a substantial impact of early traumatic sexual events on later sexual functioning, particularly in women. 3. In addition to generally negative attitudes or experiences asso- ciated with sexual interactions, a number of other factors may contribute to sexual dysfunction. Among these, the most com- mon is a marked deterioration in close interpersonal relationships (Burri, Spector, & Rahman, 2013; Jiann, Su, Yu, Wu, & Huang, 2009; Wincze, Bach, & Barlow, 2008; Wincze & Weisberg, 2015). It is difficult to have a satisfactory sexual relationship in the context of growing dislike for a partner. O

1. presumably learned early in childhood from families, religious authorities, or others, seems to predict sexual difficulties later in life (Byrne & Schulte, 1990). Thus, for some individuals, sexual cues become associated early with negative affect. In other cases, both men and women may experience specific negative or traumatic events after a period of relatively well-adjusted sexuality. These negative events might include sudden failure to become aroused or actual sexual trauma such as rape, as well as early sexual abuse. 2.For example, if women were sexually victimized by an adult before puberty or were forced to have sexual contact of some kind, they were approximately twice as likely to have orgasmic dysfunction as women who had not been touched before puberty or forced to have sex at any time. For male victims of adult-child contact, the probability of experiencing rectile dysfunction is more than 3 times greater than if they had not had the contact. Interestingly, men who admitted sexually assaulting women are 3.5 times as likely to report erectile dysfunc- tion as those who did not. Thus, traumatic sexual acts of all kinds have long-lasting effects on subsequent sexual functioning, in both men and women, sometimes lasting decades beyond the occur- rence of the original event (Hall, 2007; Meston & Lorenz, 2013). Such stressful events may initiate negative affect, in which individ- uals experience a loss of control over their sexual response cycle, throwing them into 3. Finally, it is also important to feel attractive yourself. Koch, Mansfield, Thurau, and Carey (2005) found that the more a woman perceived herself as less attractive than before, the more likely she was to have sexual problems. Kelly, Strassberg, and Kircher (1990) found that anorgasmic women, in addition to displaying more negative attitudes toward mastur- bation, greater sex guilt, and greater endorsement of sex myths, reported discomfort in telling their partners what sexual activi- ties might increase their arousal or lead to orgasm, such as direct clitoral stimulation. Poor sexual skills might also lead to frequent sexual failure and, ultimately, lack of desire. For example, men with erectile dysfunction report a greatly restricte

1. Treatment Goal of biological treatments: 2. Stimulant medications 3. § Drugs potentially increase risk of substance abuse

1. reduce impulsivity and hyperactivity, improve attention 2. -(methylphenidate) -Examples include Ritalin, Dexedrine, Adderall -Drugs appear to work by interacting with the dopamine system 80% of children with ADHD are prescribed stimulants -Numerous studies show these drugs are better than placebo and other active treatments in the short-term -But long-term may be no better than other active treatments May increase risk for later substance abuse—not clear § Long-term for medications may not be better than other active treatments (including psychological) better than placebo not better than other active treatements 3. · Perhaps give drugs which don't target dopamine system - Strattera? Strattera does not producw elation in high doses · But may not be effectivge for a child as much as Ritalin · Symptoms of adhd can lead to substanc use so if we give stimulat that is related to elation in high doses then quite easy to lean how to abuse ythose substances

1. Based on "desistence" statistics, some experts suggest an approach of "watchful waiting" 2. Treatment of Gender Dysphoria Social affirmations 3. Legal affirmation

1. see if a child is "correctly" transgender before administering treatment • Enforcement of traditional gender roles • Rejection of a child's desires, such as pronoun and name use, or prevention of counter-stereotypical modes of dress 1. Watchful waiting involves rejection of ch8lds desires like incorrect pronounds, so further didstress for child 2. So why should we pathologise an individual who ahas internalised the stigma for non-conformity' 2. -Least invasive and adaptable -Correct pronoun and name use -Clothing and hairstyles '- Spcial affirmations , most aadaptable to indovodual contexts 3. • Legal change of name and/or gender marker on documentation, e.g. drivers license • In NSW there are more stringent requirements to change a sex/gender marker • Evidence of specific surgeries are needed to change a birth certificate - nsw mor stringebt than federal need gnder reaffirmation surgeries but for feds don't need the durgery and can register an X or non-binary identity - Sex Reassignment Surgery

1.linical description Like amphetamines, in small amounts cocaine increases alert- ness, produces euphoria, increases blood pressure and pulse, and causes insomnia and loss of appetite. Remember that Danny snorted (inhaled) cocaine when he partied through the night with his friends. He later said the drug made him feel powerful and invincible—the only way he really felt self-confident. The effects of cocaine are short lived; for Danny they lasted less than an hour, 2.ey were originally thought to have permanent brain damage, although recent research suggests that the effects are less dramatic than first feared (Buckingham- Howes, Berger, Scaletti, & Black, 2013; Schiller & Allen, 2005). Some work suggests that m 3.statistics Worldwide, almost 5% of adults report using cocaine at some point in their lives, and in the United States, more than 1.5 million people (0.6% of U.S. population) report using cocaine, including crack-cocaine, each year.

1. snort repeatedly to keep himself up. During these binges, he often became paranoid, experiencing exaggerated fears that he would be caught or that someone would steal his cocaine. Such paranoia—referred to as cocaine-induced paranoia—is com- mon among persons with cocaine use disorders, occurring in two thirds or more (Daamen et al., 2012). Cocaine also makes the heart beat more rapidly and irregularly, and it can have fatal consequences, depending on a person's physical condition and the amount of the drug ingested. We saw that alcohol can damage the developing fetus. It has also been suspected that the use of cocaine (especially crack) by pregnant women may adversely affect their babies. Crack babies appear at birth to be more irritable than normal babies and have long bouts of high-pitched crying. 2.orn to mothers who have used cocaine during pregnancy may have decreased birth weight and decreased head circumference, and are at increased risk for later behavior problems (Richardson, Goldschmidt, & Willford, 2009). Complicating the evaluation of children born to mothers who use cocaine is that their mothers almost always used other substances as well, including alcohol and nicotine. Many of these children are raised in disrupted home environments, which fur- ther complicates the picture (Barthelemy et al., 2016). Continuing research should help us better understand the negative effects of cocaine on children. 3.8 to 25 are about twice as likely to use cocaine compared with other age groups. Also, men are twice as likely to use cocaine as women (SAMHSA, 2014). Black individuals account for close to half of admissions to emergency rooms for cocaine-related problems (47%), followed by Caucasian individuals (37%) and Hispanic individuals (10%). Also, men were twice as likely as women to be in the emergency room (SAMHSA, 2011). Approximately 17% of cocaine users have also used crack cocaine (a crystallized form of cocaine that is smoked) (Closser, 1992). One estimate is that about 0.1% of people in the United States have tried crack and that an increasing proportion of the abusers seeking treatment are young, une

1. 1. Gene-environment interaction 2. other causes 3, Cluster B: Antisocial Personality Disorder • Highly comorbid

1. § Monoamine Oxidase A gene (MAOA) used to breakdown neurotransmitters (norepinephrine, dopamine, serotonin) · These neurotransmitters are impacted by maltreatment -Candidate gene: Monoamine Oxidase A gene (MAOA gene) • MAOA gene is involved in breaking down neurotransmitters Low MAOA activity + maltreatment = ↑ risk of ASPD High MAOA activity + maltreatment = ↓ risk of ASPD Low MAOA activity + NO maltreatment = ↓ risk ofASPD 2. Modest genetic transmission • Low family income • Having a young mother • Being raised in a single-parent household • Conflict between parents • Delinquent sibling • Neglect • Large family size • Harsh discipline • Delinquent peers • Physical/sexual abuse 3. with substance use• Does a common factor lead to both? • They seem to share common genetic vulnerabilities • Environmental factors may determine which disorder develops

1. schizophrenia criteria

1. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated with antispsychotic medication ). At least one of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional expression or avolition). B. Since onset, level of functioning in work, interpersonal functioning, or self-care is markedly below level achieved prior to onset C. C. Persistence for at least 6 months, which includes at least one month of Criterion A symptoms and may include prodromal or residual periods, in which only 1 negative symptom or two Criterion A symptoms are present in an attenuated form D. Schizoaffective and depressive or bipolar disorder with psychotic features have been ruled out E. Symptoms are not attributable to the physiological effects of a substance or another medical condition F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to other required symptoms of schizophrenia, are also present for at least one month. - D, E AND F is to make sure evrry other psoossible disorder and making sure thay are 100% positivr

1.turn of some arousal at a 3-month follow up prompted us to ask Tony if anything unusual was happening in his life. He confessed that his marriage had taken a turn for the worse, and sexual rela- tions with his wife had all but ceased. A period of marital therapy restored the therapeutic gains (see Figure 10.7). Several years later, after his daughter's therapist decided she was ready, she and Tony resumed a nonsexual relationship, which they both wanted. 2. atients are taught to recog- nize the early signs of temptation and to institute a variety of self- control procedures before their urges become too strong. Evidence on the effects of psychological treatments for sexual offenders is decidedly mixed at this time. For sexual offenders who have come into contact with the legal system, including those who are incarcerated (obviously a very severe group), the results are modest at best in terms of preventing later occurrences of offend- ing (termed recidivism).

1. Two major areas in Tony's life needed treatment: deviant (incestuous) sexual arousal and marital problems. Most individu- als with paraphilic arousal patterns need a great deal of attention to family functioning or other interpersonal systems in which they operate (Fagan et al., 2002; Rice & Harris, 2002). In addition, many require intervention to help strengthen appropriate desired patterns of arousal. In orgasmic reconditioning, patients are instructed to masturbate to their usual fantasies but to substitute more desirable ones just before ejaculation. With repeated prac- tice, patients should be able to begin the desired fantasy earlier in the masturbatory process and still retain their arousal. This tech- nique, first described by Gerald Davison (1968), has been used with some success in a variety of settings (Brownell et al., 1977; Maletzky, 2002). 2.mpered because of the substantially dif- ferent methods and procedures in accessing recidivism rates. But several large surveys following up sexual offenders for a period of 4 to 5 years indicate reductions in sexual recidivism (that is, reof- fending) among patients who have received psychological treat- ments of up to 11% to 20% over what would be expected with the usual and customary treatment, with cognitive-behavioral programs proving to be the most effective in reducing recidivism (Hanson et al., 2002; Lösel & Schmucker, 2005). On the other hand, a large study from the state of California with participants who were incarcerated for their sexual offense showed very lit- tle effect of any intervention in rates of sexual or violent offend- ing over an 8-year follow-up period after these individuals were released (Marques, Wiederanders, Day, Nelson, & van Ommeren, 2005). Recent

1. orm certain tasks may also be impaired. More seriously, two types of organic brain syndromes may result from long-term heavy alcohol u 2. The effects of alcohol abuse extend beyond the health and well- being of the drinker. Fetal alcohol syndrome (FAS) is now gener- ally recognized as a combination of problems that can occur in a 3. Despite a national history of heavy alco- hol use, most adults in the United States characterize themselves as light drinkers or abstainers. On the other hand, about half of all Americans over the age of 12 report being current drinkers of alcohol, and there are considerable differences among people from different racial and ethnic backgrounds (see E Figure 11.3; SAMHSA, 2012).

1. a and Wernicke- Korsakoff syndrome. Dementia, (or neu- rocognitive disorder), which we discuss more fully in Chapter 15, involves the general loss of intellectual abilities and can be a direct result of neurotoxicity or "poisoning of the brain" by excessive amounts of alcohol (Ridley, Draper, & Withall, 2013). Wernicke-Korsakoff syndrome results in confusion, loss of muscle coordination, and unintelligible speech (Isenberg-Grzeda, Kutner, & Nicolson, 2012); it is believed to be caused by a deficiency of thiamine, a vitamin metabolized poorly by heavy drinkers. 2. r drank while she was pregnant. These prob- lems include fetal growth retardation, cognitive deficits, behavior problems, and learning difficulties (Douzgou et al., 2012). In addi- tion, children with FAS often have characteristic facial features. We metabolize alcohol with the help of an enzyme called alcohol dehydrogenase (ADH) (Schuckit, 2009b, 2014a). Three different forms of this enzyme have been identified (beta-1, beta-2, and beta-3 ADH). Among children 3. inking is lowest among Asians (40.0%). About 63 million Americans (24.6%) over the age of 18 report binge drinking (typically four or more drinks for women and five or more drinks for men over the span of 2 hours) in the past month— an alarming statistic (SAMHSA, 2013). Again, there are racial dif- ferences, with Asians reporting the lowest level of binge drinking (12.4%) and Caucasians (24.0%) and Hispanics or Latinos (24.1%) reporting the highest. Age seems to also be important given that peak lifetime alcohol use happens around late teens to early ado- lescence. In surveys across 100 four-year universities and colleges, about 36% of respondents said they had gone on a binge of heavy drinking once in the preceding 2 weeks (Johnston, O'Malley, Bach- man, & Schulenberg, 2012). Unfortunately, this binge drinking tre

1, Diagnostic Issues In early editions of the DSM, alcoholism and drug abuse weren't treated as separate disorders. Instead, they were categorized as "sociopathic personality disturbances"—a forerunner of the current antisocial personality disorder we discuss in Chapter 2. SM-5 removed the previous symptom that related to substance-related legal problems and added a symp- tom that indicates the presence of craving or a strong desire to use the substance (Dawson et al., 2012). These distinctions help clarify the problem and focus treatment on the appropriate aspect of the disorder. 3. Symptoms of other disorders can complicate the substance use disorder picture significantly. For example, do some people take drugs to excess because they are depressed, or does drug use and its consequences (for example, loss of friends, job) create depression? Researchers estimate that almost three quarters of the people in addiction treatment centers have an additional psychiatric disorder, with mood disorders

1. akness, and the influence of genetics and biology was hardly acknowledged. A separate cat- egory was created for substance abuse disorders in DSM-III, in 1980, and since then we have acknowledged the complex biologi- cal and psychological nature of the problem. The DSM-5 term substance-related disorders include 11 symp- toms that range from relatively mild (e.g., substance use results in a failure to fulfill major role obligations) to more severe (e.g., occupational or recreational activities are given up or reduced because of substance use). 2. anny would be considered to have a cocaine use disor- der in the severe range because of the tolerance he showed for the drug, his use of larger amounts than he intended, his unsuccessful attempts to stop using it, and the activities he gave up to buy it. His pattern of use was more pervasive than simple abuse, and the diagnosis provided a clear picture of his need for help. 3. (such as major depression) observed in more than 40% and anxiety disorders and posttraumatic stress disorder seen in more than 25% of the cases (Dawson et al., 2012; Lieb, 2015). Substance use might occur concurrently with other disorders for several reasons. Substance-related disorders and anxiety and mood disorders are highly prevalent in our society and may occur together so often just by chance. Drug intoxication and withdrawal can cause symptoms of anxiety, depression, and psychosis. Dis- orders such as schizophrenia and antisocial personality disorder are highly likely to include a secondary problem of substance use. Because substance-related disorders can be so complicated, DSM-5 tries to define when a symptom is a result of substance use and when it is not.

1/ Phases of Schizophrenia Prodromal: 2. Active/Acute: 3. Residual:

1. arly stage often not recognized until after the illness has progressed 1. 1-2y before serious symptoms 2. 85% experience prodromal 3. Less severe 4. Still have unusual symptoms § Ideas of reference, magical thinking, imaoprment of functioning, low energy Delusions, isolation, depressive symptoms, lack of initiative but nmot as severe as acute phase 5. Not as severe 2. : this phase is the most visible as people experience the positive symptoms of psychosis 1. (delusions and/or hallucinations) 3. a period when individuals have fewer obvious symptoms, but some symptoms are still present 1. Fewer obvious (positive) symptoms, but negative symptoms often remain (negative througj all phases but positive in acute phase only)

1.antagonist treatments We described how many psychoactive drugs produce euphoric effects through their interaction with the neurotransmitter systems in the brain. What would happen if the effects of these drugs were blocked so that the drugs no longer produced the pleasant results? Would people stop using the drugs? Antagonist drugs block or counteract the effects of psychoactive drugs, and a variety of drugs that seem to cancel out the effects of opiates have been used with people dependent on a variety of substances. The most often pre- scribed opiate-antagonist drug, naltrexone, has had only limited success with individuals who are not simultaneously participating in a structured treatment program (Krupitsky & Blokhina, 2010). When it is given to a person who is dependent on opiates, it pro- duces immediate withdrawal symptoms, an extremely unpleasant effect. A person must be free from these withdrawal symptoms completely before starting 2.versive treatment In addition to looking for ways to block the euphoric effects of psychoactive drugs, clinicians in this area may prescribe drugs that make ingesting the abused substances extremely unpleas- ant. The expectation is that a person wh

1. because it removes the euphoric effects of opiates, the user must be highly motivated to continue treatment. Acamprosate also seems to decrease cravings in people dependent on alcohol, and it works best with highly motivated people who are also participating in psychosocial inter- ventions (Kennedy et al., 2010). The brain mechanisms for the effects of this drug are not well understood (Oslin & Klaus, 2009). Overall, naltrexone or the other drugs being explored are not the magic bullets that would shut off the addict's response to psy- choactive drugs and put an end to dependence. They do appear to help some drug abusers handle withdrawal symptoms and the crav- ings that accompany attempts to abstain from drug use; antagonists may therefore be a useful addition to other th 2.a by-product of alcohol, and the resulting buildup of acetaldehyde causes feelings of ill- ness. People who drink alcohol after taking Antabuse experience nausea, vomiting, and elevated heart rate and respiration. Ideally, Antabuse is taken each morning, before the desire to drink arises. Unfortunately, noncompliance is a major concern, and a person 3.Both Antabuse for alcohol abuse and silver nitrate for cigarette smoking have generally been less than successful as treat- ment strategies on their own, primarily because they require that people be extremely motivated to continue taking them outside the supervision of a mental health professional. 4.use cardiac arrest or seizures, these drugs are gradually tapered off to minimize dangerous reactions. In addi- tion, sedative drugs (benzodiazepines) are often prescribed to help minimize discomfort for people withdrawing from other drugs, such as alcohol (Sher, Martinez, & Littlefield, 2011).

1. Thought broadcasting: 2. Persecution: 3. Erotomatic: 4. Jealous: 5. Somatic: 6. Negative Symptoms 7. • Avolition:

1. believing that others can know what one is thinking 2. believing that someone is harming or trying to harm oneself or loved ones;§ Paranoia that someone wants to harm self or loved ones 3.believing that another person is in love with the individual 4. believing that one's spouse or lover is unfaithful 5. believing that one's bodily function or appearance is grossly abnormal also another one § other onesBelieving those around you have been replaced by imposte and alsoBelieving an external force controls their feelings or behavioursrs and also 6. • Behavioural deficits in motivation, pleasure, social closeness and emotional expression - Considered to be core feature of schizophrenia because they last beyond acute episodes 7. inability to initiate and persist in activities • More motivated by goals that reduce boredom as opposed to those about autonomy, building skills, knowledge, etc 1. motivated by goals which reduce boredom, but not goals related to autonomy, knowledge, skill building like going to uni

1. - CBT - may work better than other treatments depending on age-group and drug 2. Prevention Programs: Universal, selective, indicated Universal programs target the whole population

1. eaches behaviours that make relapse less likely • Address distorted cognitions • Identify negative consequences;1. that not worlomh in their best interest • Increase motivation to change • Identify high risk situations • Reframe relapse • Failure of coping skills, not person 1. failure of coping, not failure of person, normalise it - Cbt works slghtly better beyt depends on age group and drug 2. - going into schools 1. Small effect size, significant social cost savings § Every $1 spent on prevention saves society between $2-$20 2. D.A.R.E. program ineffective - emphasizes zero-tolerance (so attracted to message rather than actual effectiveness) § May even increase drug use

1. After these results were published, specialty sexuality clin- ics based on the pioneering work of Masters and Johnson were established around the country to administer these new treatment techniques. Subsequent research revealed that many of the struc- tural aspects of the program did not seem necessary. For example, one therapist seems to be as effective as two (LoPiccolo, Heiman, Hogan, & Roberts, 1985), 2.Sex therapists have expanded on and modified these pro- cedures over the years to take advantage of recent advances in knowledge (see, for example, Bradford & Meston, 2011; Rosen, 2007; Weiner & Avery-Clark, 2014; Wincze, 2009; Wincze et al., 2008). Results with sex therapy for erectile dysfunction indicate that as many as 60% to 70% of the cases show a positive treatment outcome for at least several years, although results are mixed and there may be some slipping after that 3. serted in the vagina without thrusting. If arousal occurs too quickly, the penis is withdrawn and the squeeze tech- nique is employed again. In this way, the man develops a sense of control over arousal and ejaculation.

1. eeing patients once a week seems to be as effective as seeing them every day (Heiman & LoPiccolo, 1983). It has also become clear in the succeeding decades that the results achieved by Masters and Johnson were better than those achieved in clinics around the world using similar procedures. Reasons for this are not entirely clear. One possibility is that they were highly motivated because patients had to take at least 2 weeks off and fly to St. Louis to meet with Masters and Johnson. 2. or better treatment of specific sexual dysfunctions, sex thera- pists integrate specific procedures into the context of general sex therapy. For example, to treat premature ejaculation, most sex therapists use a procedure developed by Semans (1956), some- times called the squeeze technique, in which the penis is stimu- lated, usually by the partner, to nearly full erection. At this point, the partner firmly squeezes the penis near the top where the head of the penis joins the shaft, which quickly reduces arousal. These steps are repeated until (for heterosexual partners) eventually the 3. Reports of success with this approach over the past 20 years suggest that 60% to 90% of men benefit, but the success rates drop to about 25% after 3 years or more of follow up (Althof, 2007; Malavige & Jayawickrema, 2015; Polonsky, 2000). Gary, the 31-year-old sales representative, was treated with this method, and his wife was cooperative during the procedures. Brief marital therapy also persuaded Gary that his insecurity over his perception that his wife no longer found him attractive was unfounded. After treatment, he reduced his work hours somewhat, and the couple's marital and sexual relations improved.

1. An overview of the DSM-5 categories of the sexual dysfunc- tions we examine is in Table 10.3. As you can see, both males and females can experience parallel versions of most disorders, which take on specific forms determined by anatomy and other gender-specific characteristics. However, two disorders are sex specific: Premature (early) ejaculation occurs only in males, and 2. 80% of these couples reported that their marital and sexual relations were happy and satisfying. Surprisingly, 40% of the men reported occasional erectile and ejaculatory difficulties, and 63% of the women reported occasional dysfunctions of arousal or orgasm. 3.ndeed, the best predictor of sexual distress among these women were deficits in general emotional well-being or emo- tional relations

1. enito-pelvic pain/penetration disorder—which includes diffi- culties with penetration during intercourse due in many cases to painful contractions or spasms of the vagina—appears only in females. Sexual dysfunctions can be either lifelong or acquired. Lifelong refers to a chronic condition that is present during a person's entire sexual life; acquired refers to a disorder that begins after sexual activity has been relatively normal. In addition, -be generalized, occurring every time the individual attempts sex, or they can be situational, occurring with some partners or at certain times but not with other partners or at other times. 2. ut the crucial finding was that these dysfunctions did not detract from the respondents' overall sexual satisfaction. In another study, only 45% of women experiencing difficulties with orgasm reported the issue as problematic (Fugl-Meyer & Sjogren Fugl-Meyer, 1999). Bancroft, Loftus, and Long (2003) extended this analysis in a survey of close to 1,000 women in the United Sta 3. hips with the partner during sexual relations, not lack of lubrication or orgasm. These studies indicate that sexual satisfaction and occasional sexual dysfunction are not mutually exclusive categories (Bradford & Meston, 2011; Graham, 2010). In the context of a healthy relationship, occasional or partial sex- ual dysfunctions are easily accommodated. But this does raise problems for diagnosing sexual dysfunctions. Should a sexual problem be identified as a diagnosis when dysfunction is clearly present but the person is not distressed about it (Balon, Segraves, & Clayton, 2007; Zucker, 2010)? In DSM-5, the symptoms must clearly cause clinically significant distress in the individual or in the couple.

1. We now turn to the individual substances themselves, their effects on our brains and bodies, and how they are used in our society. We have grouped the substances into six general categories. • Depressants: 2. Other drugs of abuse: Other substances that are abused but do not fit neatly into one of the categories here include in- halants 3. Depressants Depressants primarily decrease central nervous system activity. Their principal effect is to reduce our levels of physiological arousal and help us relax. 4. or hundreds of years, Europeans drank large amounts of beer, wine, and hard liquor. When they came to North America in the early 1600s, they brought their con- siderable thirst for alcohol with them. In the United States dur- ing the early 1800s, consumption of alcohol (mostly whiskey) was more than 7 gallons per year for every person older than 15. This is more than three times the current rate of U.S. alcohol use (Smith, 2008; Rorabaugh, 1991). Alcohol is produced when certain yeasts react with sugar and water and fermentation takes place.

1. ese substances result in behavioral seda- tion and can induce relaxation. They include alcohol (ethyl alcohol) and the sedative and hypnotic drugs in the families of barbiturates (for example, Seconal) and benzodiazepines (for example, Valium, Xanax). 2. Other drugs of abuse: Other substances that are abused but do not fit neatly into one of the categories here include in- halants ( 3. cluded in this group are alcohol and the sedative, hypnotic, and anxiolytic drugs, such as those pre- scribed for insomnia (see Chapter 8). These substances are among those most likely to produce symptoms of physical dependence, tolerance, and withdrawal. We first look at the most commonly used of these substances—alcohol—and the alcohol-related dis- orders that can result. 4. Historically, we have been creative about fermenting alcohol from just about any fruit or veg- etable, partly because many foods contain sugar. Alcoholic drinks have included mead from honey, sake from rice, wine from palm, mescal and pulque from agave and cactus, liquor from maple syrup, liquor from South American jungle fruits, wine from grapes, and beer from grains (Lazare, 1989).

1.Fetishistic Disorder In fetishistic disorder, a person is sexually attracted to nonliving objects. There are almost as many types of fetishes as there are objects, although women's undergarments and shoes are popular (Darcangelo, 2008; Kafka, 2010). 2.In one U.S. city for several months, bras hung out on a woman's backyard clothesline disappeared. The women in the neighbor- hood soon began talking to each other and discovered that bras were missing from every clothesline for blocks around. A police stakeout caught the perpetrator, who turned out to have a strong fetish for brassieres. As another example of fetishistic behavior 3.Voyeuristic and Exhibitionistic Disorders 4. Although prevalence is unknown (Murphy & Page, 2008), in a random sample of 2,450 adults in Sweden, 31% re

1. etishistic arousal is associated with two classes of objects or activities: (1) an inanimate object or (2) a source of specific tactile stimulation, such as rubber, particularly clothing made out of rubber. Shiny black plastic is also used (Bancroft, 1989; Junginger, 1997). Most of the 2. related to tactile stimulation, it is relatively common for a urolo- gist to be called to the emergency room to remove surgically a long thin object, such as a pencil or the arm of an eyeglass frame, from a man's urethra. Men who insert such objects think that par- tially blocking the urethra in this way can increase the intensity of ejaculation during masturbation. If the entire object slips into the penis, however, major medical intervention is required. 3.Voyeuristicdisorderisthepracticeofobserving,tobecomearoused, an unsuspecting individual undressing or naked. Exhibitionistic disorder, by contrast, is achieving sexual arousal and gratification by exposing genitals to unsuspecting strangers (Långström, 2010). Consider the case of Robert. -Remember that anxiety actually increases arousal under some circumstances. Many voyeurs just don't get the same satisfaction from attending readily available strip shows at a local bar. Exhi- bitionistic disorder is often associated with lower levels of educa- tion, but not always. Note again that the thrilling element of risk is an important part of exhibitionistic disorder. 4.ident of being sexually aroused by exposing their genitals to a stranger, and 7.7% reported at least one incident of being sex- ually aroused by spying on others having sex (Långström & Seto, 2006). To meet diagnosis for exhibitionistic disorder, the behavior must occur repeatedly and be compulsive or out of control.

1. WEEK 9 Gambling 2. Psychoactive substance 3. Substance use 4. Polysubstance use 5. Substance intoxication 6. Terms and Definitions Substance abuse 7. Substance dependence

1. first non-substance addictive disorder in DSM Drugs such as alcoghol drugs, 2.Alters mood, behaviour, or both 3. • Taking moderate amounts of a substance in a way that doesn't interfere with functioning 4. • Using multiple substances 5. • Physical reaction to a substance (e.g., being drunk);- mood changes,, impaired jusgement being drunk) 6. • Use that interferes with life functioning • Pre-DSM-5term • A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by one (or more) symptom(s), occurring any time in a 12-month period § One or more symptoms within 12-month period § Set symptoms differs from substance depencedcne (pre dsm 5 term) 7. • Pre-DSM-5term • A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) symptom(s), occurring any time in a 12-month period

1, Similarly, another sophisticated survey found that nearly 9% of women and 10% of men reported some homosexual attractions or behavior. For adolescents, 5% of male teenagers and 11% of female teenagers report some homosexual behavior, albeit mostly in addition to hete 2. One study from Britain (Johnson, Wadsworth, Wellings, Bradshaw, & Field, 1992) and one from France (Spira et al., 1992) surveyed sexual behavior and practices among more than 20,000 men and women in each country. The results were surprisingly similar to those reported for U.S. men. 3. Another interesting set of data counters the many views we have of sexuality among older adults. Sexual behavior can continue well into old age, even past 80 for some people. Table 10.1 presents the percentage by age group of older individuals in a community sample who were sexually active and continuing to have sexual intercourse (Lindau et al., 2007).

1. percent of men and women reported that they were neither heterosexual, homosexual, nor bisexual, indicating that current categories may not fully capture the true range of sexual orientations (Chandra, et al., 2011). For example, recent descriptors used by some people include asexual (having a lack or low levels of sexual attraction to others or desire for sex) and pansexual (experiencing sexual, romantic, physical, and/or spiritual attraction for members of all gender identities/expressions), among others (Killerman, 2016). 2.More than 70% of the respondents from all age groups in the British and French studies reported no more than one sexual partner during the past year. Women were somewhat more likely than men to have had fewer than two partners. Only 4.1% of French men and 3.6% of British men reported ever having had a male sexual partner, and this figure drops to 1.5% for British men if we consider only the past 5 years. Almost certainly, the percentage of males engaging exclu- sively in homosexual behavior would be considerably lower. The consistency of these data across three countries suggests strongly 3. Notably, 38.5% of men and 16.7% of women aged 75 to 85 were sexually active. Reasons for the discrepancy between men and women are not clear, although given the earlier mortality of men, many older women lack a suit- able partner; it is also possible that some women are married to men in an older age bracket. Many older women also indicated that sex was "not at all important" and generally reported less interest in sex than their male counterparts. Decreases in sexual activity are mostly correlated with decreases in general mobility and various disease processes and consequent medication, which may reduce arousal. -the speed and intensity of vari- ous vasocongestive responses decrease with age. A large study of older individuals around the world, aged 40 to 80, found men were generally more satisfied with their sexuality than women, particu- larly in non-Western countries, and that good physical and mental health, as well as a good relationship with a partner, were the best predictors of sexual well-being

1. Chronic illness can also indirectly affect sexual functioning. For example, it is not uncommon for individuals who have had heart attacks to be wary of the physical exercise involved in sexual activity to th' 2.. 4; Jackson, Rosen, Kloner, & Kostis, 2006). A major physical cause of sexual dysfunction is prescription medication. Drug treatments for high blood pressure, called anti- hypertensive medications, in the class known as beta-blockers, including propranolol, may contribute to sexual dysfunction. Selective-serotonin reuptake inhibitor (SSRI) antidepressant medications and other antidepressant and antianxiety drugs may also interfe 3. y, some patients also abused alcohol. There is also the misconception that alcohol facilitates sexual arousal and behavior. What actually happens is that alcohol at low and moderate levels reduces social inhibitions so that people feel more like having sex (and perhaps are more willing to request it; Wiegel,

1. point of preoccupation. They often become unable to achieve arousal despite being assured by their physicians that sexual activity is safe for them (Cooper, 1988). Also, coronary artery disease and sexual dysfunction commonly coexist, and it is now recommended that men presenting with erectile dysfunction should be screened for cardiovascular disease 2. th sexual desire and arousal in both men and women (Balon, 2006; Kleinplatz et al., 2013). A number of these drugs, particularly the psychoactive drugs, may dampen sexual desire and arousal by altering levels of certain subtypes of sero- tonin in the brain. Sexual dysfunction—specifically low sexual desire and arousal difficulties—is the most widespread side effect of the antidepressant SSRIs, such as Prozac ( as many as 80% of individuals who take these medications may experience some degree of sexual dysfunction, although estimates closer to 50% seem more reliable (Balon, 2006; Clayton, Croft, & Handiwala, 2014; Montejo-Gonzalez et al., 1997). Some people are aware that alcohol suppresses sexual arousal, but they may not know that most other drugs of abuse, such as cocaine and heroin, also produce widespread sexual dysfunc- tion in frequent users and abusers, both male and female. 3. Physically, alcohol is a central nervous system suppressant, and for men to achieve erection and women to achieve lubrication is more difficult when the central nervous system is sup- pressed (Schiavi, 1990). Chronic alcohol abuse may cause perma- nent neurological damage and may virtually eliminate the sexual response cycle. Such abuse may lead to liver and testicular damage, resulting in decreased testosterone levels and related decreases in sexual desire and arousal. This dual effect of alcohol (social disin- hibition and physical suppression) has been recognized since the time of Shakespeare: "It provokes the desire, but it takes away the performance" (Macbeth, II, iii, 29). Chronic alcoholism can also cause fertility problems in both men and women (Malatesta & Adams, 2001). Fahrner (1987) examined the prevalence of sexual dysfunction among male alco- holics and found that 75% had erectile dysfunction, low sexual desire, and premature or delayed ejaculation.

1. Incentive sensitization theory 2. Delayed Discounting

1. • Craving (wanting) and liking • Drug cues and drug response 1. Sensitivity to cues induces craving/wanting (internal , external cues, so the bong used, or the location), the nevironments , surrounded by the parphanelia, great length to get the drug, so over time liking decreases but craving increases 2. That's why the want to end ut doesn't lead to quitting § When people seek help for the drug, they crave it but don't even like it anymore § Drug addict gets more dopamine hit from paraphernalia vs. drug itself, whereas non-drug addicts get more dopamine from drug itself vs. paraphernalia § So drug cues drive drug ise 1. Greater craving predicts higher relapse rates - central component of addiction 2. - 1 DOLLOR NOW OR 10 DOLLARS LATER: Value of immediate rewards over delayed rewards;1. Individuals who seek immediate gratification most likely to become addicts

1/ Terms and Definitions • Substance use disorder (prior two disorders merged into this disorder),1. still use substance abuse, it's a non-diagnostic term 2. • Physiological dependence 3. • Addiction

1. • DSM-5 term -At least two symptoms in the last year that interfered with his/her life or bother him/her a great deal -Can develop even if an individual is not using the drug for intoxicating purposes § Can occur even if drug isn't used for intoxication purposes e.g, could take sadatives for insomnia as prescribed , so mnot seeking to intoxicate, but can still become addicted 2. Tolerance: Needing more of a drug to obtain the same effects -Withdrawal: Physically responding negatively when a drug is no longer taken 3.. Sometimes defined by physiological dependence -Sometimes defined by drug-seeking behavior (e.g., spending too much money on substance) - or harmful drug-seeking behaviour (spend too much money on it, denying the unpleasant effects but sill taling it)

1. Difference between GD and SUDs • Prevalence 2. • Diagnosticthresholds 3. Comorbidity

1. • Gambling Disorder: 1-2% lifetime (0.05%-1% past year) • AUD: 30.3% lifetime (8.5% past year) • DUD: 10.3% lifetime (2.0% past year) - Way less than alcohol (30%) and drug (10%) disorders due to harder-to-meet criteria 2. - Gambling 1. Mild: 4-5 sx 2. Moderate: 6-7 sx 3. Severe: 8-9 sx - Substance use 1. Mild: 2-3 sx 2. Moderate: 4-5 sx 3. Severe: 6-11 sx 3. - Up to 96% of persons with gambling disorder meet criteria for another disorder!! 1. Compared to 75-80% with drugs/alcohol - Lifetime rates in descending order 1. Alcohol disorder: 73% 2. Drug use disorder: 38% 3. Mood disorder 49-56% 1. Anxiety disorder: 41-60%

1. Biological Influences Enlarged ventricles are common 2. Prefrontal cortex 3. Environmental Influences Stress

1. • Suggests a loss of brain cells • However, may not be specific to schizophrenia (e.g., bipolar with psychotic features) • However, not all with schizophrenia evidence enlarge ventricles 2. -Reduction in grey matter and overall volume of prefrontal cortex -Less activation of the prefrontal cortex -Less activation relates to greater severity of negative symptoms 3. § Delivery issues (high ratesof these in scixophrenic, complications may reduce oxygen to brain , so could resilt in schizophrenia) § Starvation; ww2, famine; drastic increase in rates f scizophrenia § Maternal infections during pregnancy · E.g., having the flu higher in delivering children that might dvelop schizophrenia, tiny relayoonship, some say 2nd and some say 3rd trimester § Cannabis use · Increased risk of schizophrenia if one has family history of mental illness · So reccommende dtose with family history to stay away from cannabis · Intensifies positive symptoms, depression, poor functioning with those who already have have schizophrenia § Low SES · Relationship may be bidirectional - schizophrenic people may have low SES due to their illness, not that their low SES is causing their illness; less access o healthcare and healthy environment

1. Anorexia Nervosa prevalence 2. • Demographics 3. Binge-Eating & Obesity 4.What else contributes to obesity?

1. • Western countries: 0.9-1.9% Characteristics - Fear of gaining weight; severe restriction of food - Distorted image of self 2. -Typically begins in early to mid-teens -Traditionally thought of as a disorder for "Caucasian females in high- income Western countries", but... -recent data show that the Westernisation of thin beauty ideals has led to increasing rates of anorexia nervosa in some Asian countries - While typically a white, Western, female disorder, has spread to other countries - Begin in earoly to mid treens 2. Contributes to obesity, and thus, binge eating treatments need to focus on weight reduction in addition to controlling binges And yet, only 7-19% of obese individuals binge eat 4. Night eating Consumption of a high-fat, energy-dense diet Genetics Physiology Psychological characteristics1

1. Characteristics 2. Causes

1. •Not the same thing as psychopathy Antisocial PD = heavy emphasis on observable behaviours (Lying, getting into fights, failing to honour financial obligations) Psychopathology = more emphasis on personality traits • Superficial charm, lack of empathy, manipulativeness -A lot overlap between the two constructs -APSD is more inclusive and reflects a lot of criminality -Psychopathy is narrower -Some say the reliability of the ASPD diagnosis comes at the expense of validity;1. Greater emphasis on observable behaviours increases reliability, but perhaps doesn't measure anything validly (not intende at what we're getting at) - perhaps psychopathy alone is a sufficient diagnosis 2. A fair amount of research has been done on ASPD - Genetic transmission 1. Impulsivity, aggression, low anxiety, temperament, hyperactivity, attention

1. Schizophrenia Prevalence 2. Characteristics 3. Most suffer moderate-to-severe impairment 4.Life expectancy is less than average 5. Causes of Schizophrenia 6. Biological Influences Genetic risk is the main driver for the development of schizophrenia

1. • About 1% of the population will develop schizophrenia • Equally common in males and females -Can emerge at any time • Typical onset in late adolescence or early adulthood • Childhood cases are extremely rare but not unheard of 2. Leads to significant morbidity Chronic 3. Only 21.5% employed over a 12mos period -85% are dependent on government assistance -42%-63% will abuse drugs and alcohol Many will experience stigma 4. More likely to die from any cause than the general population -5% will die by suicide 5. - Biology and Environment; both interact 1. Biology plays the largest role 6. • Accounts for about 81% of the risk • But don't forget that genes do their work via the environment • 1. Likely polygenetic; Multiple genes are likely involved Risk increases with genetic relatedness • E.g., having a twin with schizophrenia incurs greater risk than having an uncle with schizophrenia;§ E.g., more likely to have it if you have an identical twin with schizophrenia (~45%) than an uncle or aunt (~2-4%) • Negative symptoms seem to have a stronger genetic component than do positive symptoms

1. The Acute Effects of Illicit Drugs • Sedative, Hypnotic, and Anxiolytic Drugs 2. • Amphetamines 3. • Opioids 4. • Cannabis 5. The Long-term Effects of Illicit Drugs • Sedative, Hypnotic, and Anxiolytic Drugs 6. • Amphetamines 7. • Opioids 8. • Cannabis

1. • Acts on GABA receptors to produce tranquilising effects 2.• Acts on norepinephrine to influence arousal, attention, and mood 3.• Acts on enkephalins and endorphins to produce pain relief and induce euphoria 4. • Acts on cannabinoid receptors to influence pleasure, memory, thinking, concentration, movement, coordination, and sensory and time perception 5. • Memory problems (maybe dementia) and depression 6. • Paranoia, hallucinations, malnutrition, reduced immunity, mood swings, heart and kidney problems 7. • Constipation, sleep-disordered breathing, fractures, hypothalamic- pituitary-adrenal dysregulation 8. -Psychosis;§ More likely if one has history of family mental illness -Chronic coughing, wheezing, sputum production, and acute bronchitis -Using regularly as a teen may impair thinking, memory, and learning functions

1. 1. Adopted studies 2, Biological Influences • Dopamine hypothesis 3. But theory is too simplistic—many neurotransmitters are likely involved

1. • Adoptees have a high risk for developing schizophrenia if a biological parent has schizophrenia, but risk is lower than for children raised by their biological parent with schizophrenia • Healthy environment is a protective factor § Adopted child more likely than general population to have schizophrenia if biological parent has schizophrenia, but decreased risk if placed in home with non-schizophrenic parent Protective role of childhood healthy environment 2. Schizophrenia if partially caused by overactive dopamine • Drugs that increase dopamine result in schizophrenic- like behavior § behaviour and positive/disorganised symptoms • Drugs that decrease dopamine reduce schizophrenic- like behavior -PET and SPECT studies show that excess dopamine drives positive and disorganized symptoms 3. • Glutamate • NMDA • GABA

1. Sociocultural Causes • Societal attitudes about drug use 2. Integrative Model 3. Integrative Model for Substance Use Disorders

1. • Alcohol is the most used drug in most countries, but.... Australia, Europe and Argentina have some of the highest rates of per capita alcohol use -North and South America generally have moderate rates of alcohol use -Africa and Asia tend to have lower rates of alcohol use 2. Multiple Sources • Genetics • Neurobiology • Associative Learning • Cognitive Factors • Environmental Factors -Equifinality; • A disorder may arise from multiple and different paths 3. exposure to drug leads to use and psychosocial stressors and substance use disorder then addiction all impacted by psychological influences (positive and negative reinforcement, cognitive influences) and bio influences (sensitivity to drug, rate of metabolism , base levels of arousal eg. antisocial personality disorder, mood or anxiety disorders)

1. First championed by Jellinek more than 50 years ago, this view continues to influence the way people view and treat the disorder (Jellinek, 1946, 1952, 1960). Unfortunately, Jellinek based his model of the progression of alcohol use on a now famous but faulty study (Jellinek, 1946), which we briefly review. In 1945, the newly formed self-help organization Alcoholics Anonymous (AA) sent out some 1,600 surveys to its members ask- ing them to describe symptoms related to drinking, such as feel- ings of guilt or remorse and rationalizations about their actions, and to note when these 2.Despite these and other problems, Jellinek agreed to analyze the data, and he developed a four-stage model for the progression of alcoholism based on this limited information (Jellinek, 1952). According to his model, individuals go through a prealcoholic stage (drinking occasionally with few serious consequence 3.Similarly, a study tracking alcohol use onset and later use found that those who started drinking at age 11 or earlier were at higher risk for chronic and severe alcohol use disorders (Guttmannova et al., 2011). A third study followed 636 male inpatients in an alcohol rehabilitation center (Schucki

1.nalizations about their actions, and to note when these reactions first occurred. Only 98 of the almost 1,600 surveys were returned, however. As you know, such a small response could seriously affect data interpretation. A group of 98 may be different from the group as a whole, so they may not represent the typical person with alcohol problems. Also, because the responses were retrospective (participants were recalling past 2. a prodromal stage (drinking heav- ily but with few outward signs of a problem), a crucial stage (loss of control, with occasional binges), and a chronic stage (the primary daily activities involve getting and drinking alcohol). Attempts by other researchers to confirm this progression of stages have not been successful (Schuckit, Smith, Anthenelli, & Irwin, 1993). It appears instead that the course of a severe alcohol use disor- der may be progressive for most people. For example, early use of alcohol may predict later abuse. A study of almost 6,000 lifetime drinkers found that drinking at an early age—from ages 11 to 14— was predictive of later alcohol-related dis 3. uring their 30s, the men had more serious problems, such as regular blackouts and signs of alcohol withdrawal. By their late 30s and early 40s, these men demonstrated long-term serious consequences of their drinking, which included hallucinations, withdrawal convulsions, and hepatitis or pancreatitis. This study suggests a common pat- tern among people with chronic alcohol abuse and dependence, one with increasingly severe consequences. This progressive pat- tern is not inevitable for everyone who abuses alcohol, although we do not as yet understand what distinguishes those who are and those who are not susceptible (Krenek & Maisto, 2013).

1.Tobacco-Related Disorders When you think of addicts, what image comes to mind? Do you see dirty and disheveled people huddled on an old mattress in an aban- doned building, waiting for the next fix? Do you picture business- people huddled outside a city building on a rainy afternoon furtively smoking cigarettes? Both these images are accurate, because the nicotine in tobacco is a psychoactive substance that produces pat- terns of dependence, tolerance, and with 2.DSM-5 does not describe an intoxication pattern for tobacco- related disorders. Rather, it lists withdrawal symptoms, which include depressed mood, insomnia, irritability, anxiety, difficulty concentrat- ing, restlessness, and increased appetite and weight gain. Nicotine in small doses stimulates the central nervous system; it can relieve stress and improve mood. But it can also cause high blood pressure and increase the risk of h 3.Nicotine is inhaled into the lungs, where it enters the blood- stream. Only 7 to 19 seconds after a person inhales the smoke, the nicotine reaches the brain. Nicotine appears to stimulate specific receptors—nicotinic acetylcholine receptors (nAChRs)—in the midbrain reticular formation and the l

1.obacco-related disorders—comparable to those of the other drugs we have dis- cussed so far (Litvin, Ditre, Heckman, & Brandon, 2012). In 1942, the Scottish physician Lennox Johnson "shot up" nicotine extract and found after 80 injections that he liked it more than cigarettes and felt deprived without it (Kanigel, 1988). This colorless, oily liquid—called nicotine after Jean Nicot, who introduced tobacco to the French court in the 16th century—is what gives smoking its pleasurable qualities. The tobacco plant is indigenous to North America, and Native Americans cultivated and smoked the leaves centuries ago. Today, about 20% of all people in the United States smoke, which is down from the 42.4% who were smokers in 196 2.disease and cancer (Litvin et al., 2012). High doses can blur your vision, cause confusion, lead to convul- sions, and sometimes even cause death. Once smokers are depen- dent on nicotine, going without it causes withdrawal symptoms. If you doubt the addictive power of nicotine, consider that the rate of relapse among people trying to give up drugs is equivalent among those using alcohol, heroin, and cigarettes (see E Figure 11.5). Nicotine is inhaled into the lungs, where it enters the blood- stream. Only 7 to 19 seconds after a person inhales the smoke, the nicotine reaches the brain. 2.oughout the day in an effort to keep nicotine at a steady level in the bloodstream (see E Figure 11.6; Dalack, Glassman, & Covey, 1993). Some evidence also points to how maternal smoking can predict later substance-related disorders in their children, but this appears to be an environmental (e.g., home environment) rather than biological influence (D'Onofrio et al., 2012). Smoking has been linked with signs of negative affect, such as depression, anxiety, and anger

1.Cocaine is in the same group of stimulants as amphetamines because it has similar effects on the brain. The "up" seems to come primarily from the effect of cocaine on the dopamine system. Look at E Figure 11.4 to see how this action occurs. Cocaine enters the bloodstream and is carried to the brain. There the cocaine mol- ecules block the reuptake of dopamine. As you know, neurotrans- mitters released at the synapse stimulate the next neuron and then are recycled back to the original neuron. 2.our highly competitive and complex technological society, this would be a dream come true. But, as you probably realize, such temporary benefits have a high cost. Cocaine fooled us. Addiction does not resemble that of many other drugs early on; typically, peo- ple find only that they have a growing inability to resist taking more (Weiss & Iannucci, 2009). Few negative effects are noted at first; how- ever, with continued use, sle

1.ocaine seems to bind to places where dopamine neurotransmitters reenter their home neuron, blocking their reuptake. The dopamine that cannot be mains in the synapse, causing repeated stimulation of the next neuron. This stimulation of the dopamine neurons in the "pleasure pathway" (the site in the brain that seems to be involved in the experience of pleasure) causes the high asso- ciated with cocaine use. As late as the 1980s, many felt cocaine was a wonder drug that produced feelings of euphoria without being addictive (Weiss & Iannucci, 2009). Such a conservative source as the Comprehensive Textbook of Psychiatry in 1980 indicated that "taken no more than two or three times per week, cocaine creates no serious problems" (Grinspoon & Bakalar, 1980). Just imagi 2.leep is disrupted, increased tolerance causes a need for higher doses, paranoia and other negative symptoms set in, and the cocaine user gradually becomes socially isolated. Chronic use may result in premature aging of the brain (Ersche, Jones, Williams, Robbins, & Bullmore, 2012). Again, Danny's case illustrates this pattern. He was a social user for a number of years, using cocaine only with friends and Eventually, he had more frequent episodes of excessive use or binges, and he found himself increasingly craving the drug between binges. After the binges, Danny would crash and sleep. Cocaine withdrawal isn't like that of alcohol. Instead of rapid heartbeat, tremors, or nausea, withdrawal from cocaine produces pronounced feelings of apathy and boredom. Think for a minute how dangerous this type of withdrawal is. First, you're bored with every- thing and find little pleasure from the everyday activities of work or relationships. The one that can "bring you back to life" is cocaine. As you can imagine, a particularly vicious cycle develops: Cocaine is abused, withdraw

1. Men, how- ever, were more likely to report several binges in the 2-week period (White & Hingson, 2014; Presley & Meilman, 1992). The same survey found that students with a grade point average of A had no more than 3 drinks per w 2.Outside the United States, rates of alcohol use problems and dependence vary widely. The prevalence of alcohol use disor- ders in 2004 as measured by the World Health Organization was highest in eastern European countries 3. Progression Remember that Danny went through periods of heavy alcohol and drug use but also had times when he was relatively "straight" and did not use drugs. Similarly, many people with an alcohol use disorder fluctuate between drinking heavily, drinking "socially" without negative effects, and being abstinent (not drinking) (McCrady, 2014).

1.olic drinks per week (Presley & Meilman, 1992). Overall, these data point to the popularity and pervasiveness of drinking in our society (Donath et al., 2012). We know that not everyone who drinks develops an alcohol use disorder. Researchers estimate, however, that more than 16.6 million adults ages 18 and older meet criteria for an alco- hol use disorder and the same is true of 697, 000 adolescents ages 12 to 17 (SAMHSA, 2013). Life- time prevalence rates for alcohol use disorders, meaning a person met criteria for an alcohol use disorder at some point in his or her life, are more than 29% (Grant 2.t 13%, South Korea at 13.5%, and Thailand at 11%. The prevalence for alcohol use disorders in 2004 was lowest in Northern Africa (e.g., in Libya at 0.05%) and the Middle East (e.g., in Afghanistan at 0.2%) (World Health Organization, 2004). Such cultural differences can be accounted for by different attitudes toward drinking, the avail- ability of alcohol, physiological reactions, and family norms and patterns. 3. It seems that about 20% of people with severe alcohol dependence have a spontaneous remission (they are able to stop drinking on their own) and do not reexperience problems with drinking. It used to be thought that once problems arose with drink- ing they would become steadily worse, following a predictable downward pattern as long as the person kept drinking (Sobell & Sobell, 1993). In other words, like a disease that isn't treated properly, alcoholism will get progressively worse if left unc

1.Many people who use psychoactive substances experience a crash after being high. If people reliably crash, why don't they just stop taking drugs? One explanation is given by Solomon and Corbit in an interesting integration of both the positive and the negative reinforcement processes (Solomon, 1980; Solomon & Corbit, 1974). The opponent-process theory holds that an increase in positive feelings will be followed shortly by an increase in negative feelings. Similarly, an increase in negative feelings will be followed by a period of positive feelings (Ray, 2012). Athletes often report feeling depressed after finally attaining a long-sought goal. 2/Researchers have also looked at substance abuse as a way of self-medicating for other problems (Bailey & Baillie, 2012). If peo- ple have difficulties with anxiety, for example, they may be attracted to barbiturates or alcohol because of their anxiety-reducing quali- ties. In one study, researchers were successful in treating a group of cocaine addicts who had ADHD with methylphenidate (Ritalin) (Dursteler et al., 2015; Levin, Evans, Brooks, & Garawi, 2007). They had hypothesized that these individuals used cocaine to help focus their 3.Cognitiv

1.ponent-process theory claims that this mechanism is strengthened with use and weakened by disuse. So a person who has been using a drug for some time will need more of it to achieve the same results (tolerance). At the same time, the negative feelings that follow drug use tend to intensify. For many people, this is the point at which the motivation for drug taking shifts from desiring the euphoric high to alleviating the increasingly unpleasant crash. Unfortunately, they come to believe that the best remedy is more of the same drug. People who are hung over after drinking too much alcohol are often advised to have "the hair of the dog that bit you" (that is, have another drink). The sad irony here is that the very drug that can make you feel so bad is also the one thing that can take away your pa 2.Once their ability to concentrate improved with the methylphenidate, the users reduced their use of cocaine. arch is just beginning to outline the complex interplay among stressors, negative feelings, other psychological disorders, and negative reactions to the drugs themselves as causative factors in psychoactive drug use. 3.ada in grades 7 to 11 were ques- tioned each year for three years about their thoughts about alco- hol and marijuana use (Fulton, Krank, & Stewart, 2012; Young, 2013). Included were instructions for them to list 3 or 4 things they expected would happen if they used a particular substance. Positive expectancies about the effects of alcohol or marijuana use predicted who was more likely to use and increase their use of these drugs three years later. These results suggest that adoles- cents may begin drinking or using other drugs partly because they believe these substances will have positive effects

1. n order to reach out to these individuals, efforts are under way to put in place routine screenings for substance use problems in settings such as doc- tor's offices, hospital emergency rooms, and even in college and university health clinics. This community-wide approach is an important part of identifying difficulties and bringing treatment to those in need (Tucker, Murphy, & Kertesz, 2011). 2.Biological Treatments There have been a variety of biologically based approaches designed primarily to change the way substances are experi- enced. In other words, scientists are trying to find ways to pre- vent people from experiencing the pleasant highs associated with drug use or to find alternative substances that have some of the positive effects (for example, reducing anxiety) without their addictive properties. Table 11.2 lists the current recommended medical treatments for many of the more intractable substance dependence problems.

1.iscuss the treatment of substance-related disorders as a group because treatments have so much in common. For example, many programs that treat people for dependence on a variety of substances also teach skills for coping with life stressors. Some biological treatments focus on how to cancel out the effects of the ingested substances. We discuss the obvious differences among substances as they arise.

1.Disorders When we left Danny, he was in jail, awaiting the legal outcome of being arrested for vehicular manslaughter. At this point in his life, Danny needs more than legal help; he needs to free himself from his addiction to alcohol and cocaine. And the first step in his recovery has to come from him. Danny must admit he needs help, that he does indeed have a problem with drugs, and that he needs others to help him overcome his chronic dependence. The personal motivation to work on a drug problem appears to be important but not necessarily essential in the treatment of sub- stance abuse (National Institute on Drug Abuse [NIDA], 2009). Unfortunately, although Danny's arrest seemed to shock him into realizing how serious his problems had become, he was not ready to confront them head-on. He spent many hours researching how the antidepressant medication he was also taking could have caused the deadly accident and did not own up to his drug use as the cause. Treating people who have substance-related disorders is a dif- ficult task. 2.1. No single treatment is appropriate for all individuals. 2. Treatment needs to be readily available. 3. Effective treatment attends to multiple needs of

1.keep people hooked, the outlook for those who are dependent on drugs is often not positive. You will see in the case of heroin dependence, for example, that a best-case scenario is often just trading one addiction (heroin) for another (methadone). And even people who successfully cease taking drugs may feel the urge to resume drug use all their lives. Treatment for substance-related disorders focuses on multiple areas (Higgins et al., 2014). The National Institute on Drug Abuse recommends 13 principles of effective treatment for illicit drug abuse based on more than 35 years of research (NIDA, 2009) (see Table 11.1). Sometimes the first step is to help someone through the withdrawal process; typically, the ultimate goal is abstinence. In other situations, the goal is to get a person to maintain a certain level of drug use without escalating its intake, and sometimes it is geared toward preventing exposure to drugs. Because substance abuse arises from so many influences, it should not be surprising that treating people with su 3. 4. An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person's changing needs. 5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness (i.e., 3 months or longer). 6. Counseling (individual and/or group) and other behavioral thera- pies are critical components of effective treatment for addiction. 7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. 8. Addicted or drug-abusing individuals with coexisting mental disor- ders should have both disorders treated in an integrated way. 9. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. 10. Treatment does not need to be voluntary to be effective. 11. Possible drug use during treatment must be monitored continuously. 12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection. 13.

1.Prevention Adolescents are at high risk for drug addiction due to their higher rates of experimentation with drugs. When done right, education about drugs' risks can lead to decreases in drugs of abuse (e.g., ecstacy and tobacco) (Volkow & Warren, 2015). However, over the past few years, the strategies for preventing substance abuse and dependence have shifted from education-based approaches (for example, teaching s 2.ear of consequences, rewards for commitments not to use drugs, and strategies for refusing offers of drugs. Unfortunately, several extensive evaluations suggest that this type of program may not have its intended effects (Pentz, 1999). Fortunately, more comprehensive programs that involve skills training to avoid or resist social pressures (such as peers) and environmental pressures (such as media portrayals of drug use) can be effective in prevent- ing drug abuse among some. For example, one large-scale longi- tudinal study used a community-based intervention strategy to reduce binge drinking and alcohol-related injuries (for example, car crashes and assaults) 3.(for example, how drug use is portrayed in the media) to effect significant prevention results (Newton, Conrod

1.ldren that drugs can be harm- ful) to more wide-ranging approaches, including changes in the laws regarding drug possession and use and community-based interventions (Sher et al., 2011). Many states, for example, have implemented education-based programs in schools to try to deter students from using drugs. The widely used Drug Abuse Resistance Education (DARE) program encourages a "no drug use" messag 2.beverage service (that is, not serving too much alcohol to bar patrons), limit alco- hol access to underage drinkers, and increase local enforcement of drinking and driving laws to limit access to alcohol. People's self-reports of drinking too much and drinking and driving were fewer after the intervention, as were alcohol-related car accidents and assaults. These types of comprehensive programs may need to be replicated across communities and extended to 3.mplementing this sort of intervention is beyond the scope of one research investigator or even a consortium of researchers col- laborating across many sites. It requires the cooperation of gov- ernmental, educational, and even religious institutions. We may need to rethink our approach to preventing drug use and abuse (Newton et al., 2012).

1.Defining Gender Dysphoria Gender dysphoria must be distinguished from transvestic fetish- ism, a paraphilic disorder (discussed earlier) in which individuals, usually males, are sexually aroused by wearing articles of clothing associated with the opposite sex. Th 2.gender dysphoria occurs in the context of a DSD, this should be specified when making a diagnosis. But most individuals with gender dysphoria have no demonstrated physical abnormalities. (We return to the issue of DSD later.) Finally, gender d 3.woman trapped in a man's body or have any desire to be a woman, or vice versa. Note also, as the DSM-5 criteria do, that gender iden- tity is independent of sexual arousal patterns (APA, 2013; Savin- Williams, 2006). For example, a transwoman (a biological [natal] male with a strongly experienced feminine gender identity) may be sexually attracted to females. Similarly, Eli Coleman and his associates (

1.le role, but the primary purpose of cross-dressing is sexual gratification. In the case of gender dysphoria, the primary goal is not sexual gratification but rather the desire to live life openly in a manner consistent with that of the other gender. Gender dysphoria can also occur among individuals with dis- orders of sex development (DSD), formerly known as intersexu- ality or hermaphroditism who are born with ambiguous genitalia associated with documented hormonal or other physical abnor- malities. Depending on their particular mix of characteristics, individuals with DSDs are usually "assigned" to a specific sex at birth, sometimes undergoing surgery, as well as hormonal treat- ments, to alter their sexual anatomy. 2.ysphoria must be distinguished from the same-sex arousal patterns of a male who sometimes behaves effeminately, or a woman with same-sex arousal patterns and masculine mannerisms. Such an individual does not feel like a 3.ported on nine transmen in which the individuals were sexually attracted to men. Thus, heterosexual women before surgery were gay men after sur- gery. Chivers and Bailey (2000) compared a group of transmen who were attracted to men (a rare occurrence) with a group of transmen who were attracted to women (the usual pattern) both before and after surgery. They found the groups did not differ in the strength of their gender identity (as males), although the lat- ter group was more sexually assertive and, understandably, more interested in surgery to create an artificial penis.

1. interaction of Psychological and Physical Factors Having reviewed the various causes, we must now say that sel- dom is any sexual dysfunction associated exclusively with either psychological or physical factors (Bancroft, 1997; Rosen, 2007; Wiegel et al., 2006; Wincze & Weisburg, 2015). More often, there is a subtle combination of factors. To take a typical example, a young man, vulnerable to developing anxiety and holding to a certain number of sexual myths (the social contribution), may experience erectile failure unexpectedly after using drugs or alcohol, as many men do (the biological contribution). He will anticipate the next sexual encounter with anxiety, wondering if the failure might happen again. This combination of experience and apprehension activates the psychological sequence depicted in Figure 10.5, regardless of whether he's had a few drinks. 2.Treatment of Sexual Dysfunction Unlike most other disorders discussed in this book, one surpris- ingly simple treatment is effective for a large number of individu- als who experience sexual dysfunction: education.

1.n summary, socially transmitted negative attitudes about sex may interact with a person's relationship difficulties and predis- positions to develop performance anxiety and, ultimately, lead to sexual dysfunction. From a psychological point of view, it is not clear why some individuals develop one dysfunction and not another, although it is common for several dysfunctions to occur in the same patient. Possibly, an individual's specific biological predispositions interact with psychological factors to produce a specific sexual dysfunction. 2. Ignorance of the most basic aspects of the sexual response cycle and intercourse often leads to long-lasting dysfunctions (Bach, Wincze, & Barlow, 2001; Wincze et al., 2008; Wincze & Weisberg, 2015). Consider the case of Carl, who recently came to our sexuality clinic. 2. n the case of hypoactive sexual desire disorder, a marked dif- ference within a couple often leads to one partner being labeled as having low desire. For example, if one partner is quite happy with sexual relations once a week but the other partner desires sex every day, the latter partner may accuse the former of hav- ing low desire and, unfortunately, the former partner might agree. Facilitating better conditions often resolves these misunderstand- ings. Fortunately, for people with this and more complex sexual dysfunctions, treatments are now available, both psychosocial and medical. A

1.Class Discussion What are the biological and environmental factors that can lead to substance addiction? Are some drugs more addictive than others? 2.- What are the biological and environmental factors that can lead to substance addiction? 3.Are some drugs more addictive than others?

1.- craving, seeking and using drugs affect everu organ system, changes the way the brain looks and functions - when no longer uhigh, don't feel anything; nothing changes, everuything stull the same , jhunfry sleepy, brain dead - depressed; taking -- .drygs and rdrink it changes how you fwell, may make you less anciuous and experiencinh that then young people want to do it more - Develop a tolerance for it , meed more of it go get the same effect - The more risk factors indivisual have, the more taking drugs leads to an addiction 2.- Genetics, family history, peer pressure and social environment ; some drugs more addicting than other - Nicotine also classified as a substance use - 4 times jmmore likely to develop abuse if family history - Severe cases of withdrawal; life threatening, delirium, hallucinations. Seizures, palpitations, can still be fatal if not treated - Many treatments work despite having different bames - High relapsre rate of treatments, psych treatments not linkely to work longer than 12. Onths - Medication helsps symptoms but noit cureit 3.- Yes becuae of their chemical makup and the different dopamine releaes

1. Predictors of Nicotine Dependence 2. ; Illicit Drugs (2016)

1.-Smoking at an early age -Mood disorders -Anxiety disorders -Personality disorders -Illicit substance use disorders -Being unmarried -Low education attainment -Low SES 2.• Meth, hallucinogen, and synthetic cannabinoid use decreased -57% of meth users are those who use ice -Cocaine is at the highest level in the past 15 years -Common reasons for use: enhance experiences, improve mood, stop feeling unhappy -15.1% drive under the influence -1 in 10 were the victim of illicit drug-related harm -Unemployed people more likely than employed people to use cannabis and meth/ amphetamines -Homosexual/ bisexual individuals have the highest rates of use (42%)

1. Causes of Sexual Dysfunction Individual sexual dysfunctions seldom occur in isolation. Usually, a patient referred to a sexuality clinic complains of a wide assortment of sexual problems, although one may be of most concern (Rosen, 2007; Wincze, 2009). 2. us, this man suffered simultane- ously from erectile dysfunction, premature ejaculation, and low sexual desire. Because of the frequency of such combinations, we discuss the causes of various sexual dysfunctions together, reviewing briefly the biological, psychological, and social contributions and specifying causal factors thought to be associated exclusively Biological contributions A number of physical and medical con-ditions contribute to sexual dysfunc-tion (Basson, 2007; Bradford & Meston,2011; Rosen, 2007; Wincze et al., 2008;Wincze & Weisburg, 2015). Althoughthis is not surprising, most patients,and even many health professionals, are,unfortunately, unaware of the connec-tion. 3. Vascular disease is a major cause of sexual dysfunction, because erections in men and vaginal engorgement in women depend on adequate blood flow.

1.45-year-old man referred to our clinic had been free of problems until 10 years earlier, when he was under a great deal of pressure at work and was preparing to take a major career-related licens- ing examination. He began experiencing erectile dysfunction about 50% of the time, a condition that had progressed to approximately 80% of the time. In addition, he reported that he had no control over ejaculation, often ejaculating before pene- tration with only a semi-erect penis. Over the past 5 years, he had lost most interest in sex and was coming to treatment only at his wife's insistence. 2. Neurological diseases and otherconditions that affect the nervous sys-tem, such as diabetes and kidney dis-ease, may directly interfere with sexualfunctioning by reducing sensitivity inthe genital area, and they are a commoncause of erectile dysfunction in males(Rosen, 2007; Wincze, 2009; Wincze& Weisburg, 2015). Feldman and col-leagues (1994) reported that 28% ofmen with diabetes experienced com-plete erectile failure and other studieshave replicated these high prevalencerates ( 3. The two relevant vascular problems in men are arterial insufficiency (constricted arteries), which makes it difficult for blood to reach the penis, and venous leakage (blood flows out too quickly for an erection to be maintained; Wincze & Weisburg, 2015).

1. ADHD has been thought to involve brain damage, and this notion is reflected in the previous use of labels such as "minimal brain damage" or "minimal brain dys- function" (Ross & Pelham, 1981). The rapid advances in scan- ning technology now permit us to see just how the brain may be involved in this disorder. A great deal of research on the structure and the function of the brain for children with this disorder has been conducted over the past few years. In general, researchers now know that the overall volume of the brain in those with this disorder is slightly smaller (3% to 4%) than in children without this disorder (Barkley, 2015a 2.ts the association. The theory that food additives such as artificial colors, flavorings, and preserva- tives are responsible for the symptoms of ADHD has been highly controversial. Feingold (1975) presented this view, along with rec- ommen

1.A number of areas in the brains of those with ADHD appear affected, especially those involved in self-organizational abilities (Valera, Faraone, Murray, & Seidman, 2007). These changes seem less pronounced in persons who received medication (Taylor, 2012). In fact, a number of studies now point to a "growth enhancing effect" of stimulant medication, suggesting that brain development progresses in a more typical fashion in children receiving medication for ADHD versus those who do not (Frodl & Skokauskas, 2012; Rubia et al., 2014). A variety of toxins such as allergens and food additives have been considered as possible causes of ADHD over the years, although little evidence suppo 2.s for eliminating these substances as a treatment for ADHD. As a result, hundreds of thousands of families put their children on the Feingold diet, despite arguments by some that the diet has little or no effect on the symptoms of ADHD (Barkley, 1990; Kavale & Forness, 1983). Some large-scale research now suggests that there may be a small but measurable impact of arti- ficial food colors and additives on the behavior of young children (Hurt & Arnold, 2015). One study found that 3-year-old and 8- to 9-year-old children who consumed typical amounts of preserva- tives (sodium benzoate) and food colorings had increased levels of hyperactive behaviors (inattention, impulsivity, and overactivity) (McCann et al., 2007). Other research now points to the possible role of toxins such as the pesticides found

1.Cross-cultural research establishes the relatively universal nature of the five dimensions—although there are individual differences across cultures (Valchev et al., 2013; Carlo, Knight, Roesch, Opal, & Davis, 2014). One study examined Big Five traits in high school students across six different cultures and found, for example, that young adults in Turkey reported higher levels of conscientiousness and extraversion than those in China, whereas students in Taiwan repo 2.Personality Disorder Clusters DSM-5 divides the personality disorders into three groups, or clusters; this will probably continue until a strong scientific basis is established for viewing them differently (American Psychiatric Association, 2013) (see Table 12.1). The cluster division is based on resemblance. 3.Statistics and Development Because many people with these problems do not seek help on their own as do those with many of the other DSM-5 disorders, gath- ering information about the prevalence of personality disorders is difficult and therefore varies a great deal. An important population survey suggests that as many as 1 in 10 adults in the United States may have a diagnosable personality disorder (Lenzenweger

1.A number of researchers are trying to determine whether people with person- ality disorders can also be rated in a meaningful way along the Big Five dimensions and whether the system will help us better under- stand these disorders (Costa & McCrae, 2013). 2.Cluster A is called the odd or eccentric cluster; it includes paranoid, schizoid, and schizotypal personality dis- orders. Cluster B is the dramatic, emotional, or erratic cluster; it consists of antisocial, borderline, histrionic, and narcissistic per- sonality disorders. Cluster C is the anxious or fearful cluster; it includes avoidant, dependent, and obsessive-compulsive person- ality disorders. We follow this order in our review. 3. inical settings versus surveying the general population—even those not seeking assistance (Torgersen, 2012). Similarly, gender differences in the disorders—for example, more women were diag- nosed with borderline personality disorder and more men identi- fied with antisocial personality disorder—are highly variable when surveying the general population. There may be several reasons for these differences in diagnoses, including bias in diagnoses and dif- ferences in help-seeking behavior and tolerance of behavior in a cul- ture. We discuss several of these concerns later in the chapter. Personality disorders were thought to originate in childhood and continue into the adult years (Cloninger & Svakic, 2009). More sophisticated analyses suggest that personality disorders can remit over time (Zanarini, Frankenburg, Hennen & Silk, 2006, 2014); however, they may

1. and was bitterly dis- appointed and depressed over his behavior. Occasionally, a child molester is abusive and aggressive, sometimes killing the victims; in these cases, the disorder is often both sexual sadism and pedo- philia. But most child molesters are not physically abusive. Rarely is a child physically forced or injured. From the molester's per- spective, no harm is done because there is no physical force or threats. 2.Paraphilic disorders are seldom seen in women and were thought to be absent in women for many years, with the possible exception of sadomasochistic practices. But in recent years, several reports have appeared describing individual cases or small series of cases (Davis, 2014; Seto, 2009). Now estimates suggest that approximately 5% to 10% of all sexual offenders are women (Cortoni & Gannon, 2011; Logan, 2009; Wiegel, 2008). For example, Federoff, Fishell, and Federoff (1999) have reported 12 cases of women with paraphilic disorders seen in their clinic. Although some women h

1.Child molesters often rationalize their behavior as "lov- ing" the child or teaching the child useful lessons about sexual- ity. The child molester almost never considers the psychological damage the victim suffers, yet these interactions often destroy the child's trust and ability to share intimacy. Child molesters rarely gauge their power over the children, who may participate in the molestation without protest yet be frightened and unwilling. Often children feel responsible for the abuse because no outward force or threat was used by the adult, and only after the abused children 2.4 presented with exhibitionism, and 3 presented with sadomasoch- istic tendencies. Female sexual offenders are often treated similarly to male sexual offenders; however, recent work suggests that more attention is needed to understand the differences between these offenders and the best ways to treat them (Cortoni & Gannon, 2016). To take several examples, one heterosexual woman was con- victed of sexually molesting an unrelated 9-year-old boy while she was babysitting. It seems she had touched the boy's penis and asked him to masturbate in front of her while she watched religious pro- grams on television. It is not unusual for individuals with paraphilic disorders to rationalize their behavior by engaging in some other practices that they consider to be morally correct or uplifting at the same time, a practice sometimes referred to as "moral cleansin -sionally, drive her truck through the neighborhood, where she would attempt to befriend cats and dogs by offering them food. She would then place honey or other food substances on her genital area so that the animals would lick her. As with most people with para- philic disorders, the woman was horrified by this activity and was seeking treatment to eliminate it

1.The evidence for cannabis tolerance is contradictory. Chronic and heavy users report tolerance, especially to the euphoric high (Mennes, Ben Abdallah, & Cottler, 2009); they are unable to reach the levels of pleasure they experienced earlier. However, evidence also indicates "reverse tolerance," when regular users experience more pleasure from the drug after repeated use. Major signs of withdrawal do not usually occur with cannabis. 2.ese cannabis-derived products are prescribed for chemotherapy-induced nausea and vomiting, HIV-associated anorexia, neuropathic pain in multiple sclerosis, and cancer pain. 3.Most cannabis users inhale the drug by smoking the dried leaves in marijuana cigarettes; others use preparations such as hashish, which is the dried form of the resin in the leaves of the female plant. Marijuana contains more than 80 varieties of the chemicals called cannabinoids, which are believed to alter mood and behavior. The most common of these chemicals includes the tetrahydrocannabinols, otherwise known as THC. An exciting finding in the area of cannab

1.Chronic users who stop taking the drug report a period of irritability, restless- ness, appetite loss, nausea, and difficulty sleeping (Jager, 2012). Controversy surrounds the use of cannabis for medicinal pur- poses. However, there appears to be an increasing database docu- menting the successful use of cannabis and its by-products for the symptoms of certain diseases. In Canada and 24 states including Washington, D.C., cannabis products are available for medical use, including an herbal cannabis extract (Sativex—delivered in a nasal spray), dronabinol (Marinol), nabilone (Cesamet), and the herbal form of cannabis that is typically smoked 2.nfortunately, marijuana smoke may contain as many carcino- gens as tobacco smoke, although one long-term study that fol- lowed more than 5,000 men and women over 20 years suggested that occasional use does not appear to have a negative effect on lung functioning (Pletcher et al. 3.search was that the brain makes its own version of THC, a neurochemical called anandamide after the Sanskrit word ananda, which means "bliss" (Sedlak & Kaplin, 2009; Volkow, Baler, Compton, & Weiss, 2014). Subsequent research points to several other naturally-occurring brain chemi- cals including 2-AG (2-arachidonylglecerol), noladin ether, virod- hamine, and N-arachidonoyldopamine (Mechoulam & Parker, 2013; Piomelli, 2003). Scientists continu

1.reatment People with schizotypal personality disorder who request clinical help often seek assistance due to anxiety or depression . Relatedly, the presence of schizotypal personality disorder significantly increases the risk for developing major depressive disorder even years later (Skodol et al., 2011). Treatment includes some of the medical and psychological treatments for depression (Cloninger & Svakic, 2009; Mulder, Frampton, Luty, & Joyce, 2009). 2.Cluster B Personality Disorders People diagnosed with the Cluster B personality disorders— antisocial, borderline, histrionic, and narcissistic—all have behav- iors that have been described as dramatic, emotional, or erratic. These personality disorders are described next.Antisocial Personality Disorder People with antisocial personality disorder are among the most puzzling of the individuals a clinician will see in a practice and are characterized as having a history of failing to comply with social norms. They perform actions most of us would find unacceptable, such as stealing from friends and family. They also tend to be irre- sponsible, impulsive, and deceitfu

1.Controlled studies of attempts to treat groups of people with schizotypal personality disorder are few. There is now grow- ing interest in treating this disorder, however, because it is being viewed as a precursor to schizophrenia (McClure et al., 2010). One study used a combination of approaches, including antipsychotic medication, community treatment (a team of support profession- als providing therapeutic services), and social skills training, to treat the symptoms experienced by individuals with this disorder. Researchers found that this combination of approaches either reduced their symptoms or postponed the onset of later schizo- phrenia (Nordentoft et al., 2006). The idea of treating younger per- sons who have symptoms of schizotypal personality disorder with some combination of antipsychotic medication, cognitive behav- ior therapy, and social skills training in order to avoid the onset of schizophrenia is proving to be a promising prevention strateg 2.of people with psychopathy (a subgroup of persons with antisocial personality disorder that we outline later in the chapter), describes them as "social predators who charm, manipulate, and ruthlessly plow their way through life, leaving a broad trail of broken hearts, shattered expectations, and empty wallets. Completely lacking in conscience and empathy, they selfishly take what they want and do as they please, violating social norms and expectations without the slightest sense of guilt or regret" (Hare, 1993, p. xi). Although first identified as a "medical" problem by Philippe Pinel at the start of the nineteenth century (1801/1962), descriptions of individuals with these antisocial tendencies can be found in ancient stone texts found in Mesopotamia dating as far back as 670 B.C. (Abdul-Hamid & Stein, 2012). Just who

1.ly 1% to 7% of individuals who have sex reassignment surgery and were reached for follow-up later regret having the surgery to some extent (Bancroft, 1989; Byne et al., 2012; Dhejne, Öberg, Aryer, & Landén, 2014; Johansson et al., 2010; Lundstrom, Pauly, & Walinder, 1984). This is unfor- tunate, because the surgery is irreversible. Also, as many as 2% attempt suicide after surgery, a rate much higher than the rate for the general population. One problem may be incorrect diagnosis and assessment. 2. treatment of gender nonconformity in children Even more controversial is the treatment of gender-nonconforming children. On the one hand, some segments of society, particularly in more traditionally tolerant areas of the country such as San Francisco and New York, are becoming more open to gender vari- ations in both children and adults. In some schools, children are being allowed and even encouraged to dress and appear in gender- nonconforming ways on the assumption that this gives freer rein to who they "really are

1.For example, one study of 186 Dutch psychia- trists reporting on 584 patients presenting with gender dysphoria revealed little consensus on diagnostic features or the minimum age at which sex reassignment surgery is safe. Rather, the decision seemed to rest on personal preferences of the psychiatrist (Campo, Nijman, Merckelbach, & Evers, 2003). These assessments are complex and should always be done at highly specialized gende -Predictors of regret in addition to misdiagnosis include the presence of comorbid diagnoses such as alcohol use and psy- chosis, and poor family support (Byne et al., 2012). Nevertheless, surgery has made life worth living for many people who suffered the effects of existing in what they felt to be the wrong body with rates of satisfaction in recent years averaging about 90 2. ndeed, one study suggests that gender non-conforming children, who presented themselves according to their gender identity in everyday life exhibit cogni- tions more consistent with their expressed gender than their natal sex (Olson, Key, & Eaton, 2015). On the other hand, Skidmore and colleagues (2006) examined whether gender nonconformity was related to psychological distress in a community-based sample of gay men and lesbians. Gender nonconformity was measured by self-reports of childhood gender nonconformity, as well as ratings of current behavior. The researchers found that gender noncon- formity was related to psychological distress (depression, anxiety), but only for gay men and not for lesbians. M

1.agonist substitution Increased knowledge about how psychoactive drugs work on the brain has led researchers to explore ways of changing how they are experienced by people who are dependent on them. One method, agonist substitution, involves providing the person with a safe drug that has a chemical makeup similar to the addictive drug (therefore the name agonist). 2.ddiction to cigarette smoking is also treated by a substitution process. The drug—nicotine—is provided to smokers in the form of gum, patch, inhaler, or nasal spray, which lack the carcinogens included in cigarette smoke; the dose is later tapered off to lessen withdrawal from the drug. In general, these replacement strategies successfully help people stop smoking, although they work best with psychological therapy (Carpenter et al., 2013; Hughes, 2009). People must be taught how to use the gum properl

1.Methadone is an opiate agonist that is often given as a heroin substitute (Schwartz, Brooner, Montoya, Currens, & Hayes, 2010). Methadone is a synthetic narcotic devel- oped in Germany during World War II when morphine was not available for pain control; it was originally called adolphine after Adolph Hitler (Martínez-Fernández, 2002). Although it does not give the quick high of heroin, methadone initially provides the same analgesic (pain reducing) and sedative effects. When users develop a tolerance for methadone, however, it loses its analgesic and sedative qualities. Because heroin and methadone have cross-tolerance, meaning they act on the same neurotransmitter receptors, a heroin addict who takes methadone may become addicted to the methadone instead, but this is not always the case (Maremmani et al., 2009). Research suggests that when addicts combine methadone with counseling, many reduce their use of heroin and engage in less criminal activity (Schwartz et al., 2009). A newer agonist—buprenorphine—blocks the effects of opiates and seems to encourage better compliance than w 2.successfully quit smoking become dependent on the gum itself (Etter, 2009). The nicotine patch requires less effort and provides a steadier nicotine replacement (Hughes, 2009). Another medical treatment for smoking—bupropion (Zyban)—is also commonly prescribed, under the trade name Wellbutrin, as an antidepressant. This drug curbs the cravings without being an agonist for nicotine (rather than helping smokers trying to quit by making them less depressed). All of these medical treatments have roughly the same effectiveness in helping people quit smok- ing, with a 6-month a

1. Psychological Causes • Personality 2. Sociocultural Causes Exposure to drugs is a prerequisite for drug use 3. Family 4. • Peers

1.Neuroticism is linked to substance use through negative reinforcement motives(avoidance of negative affect from anxiety and depression or aversive tatses ) -Disinhibitory personality traits 1. (impulsivity, sensation seeking) § Positive reinforcement motives (adding of pleasure) linked to substance use through positive reinforcement motives 2. • Regulating advertising reduces alcohol/tobacco use • Increased alcohol outlet density and extended alcohol trading hours increases alcohol use• Taxing alcohol and cigarettes reduces use 3. Parent support, involvement, modelling and monitoring, good parent-child relationship quality is associated with less alcohol/drug use Teens whose parents supply them with alcohol are more likely to experience alcohol harms 1. who don't use alcohol themselves less loley to se 1. Teens who get alcohol from parents more likely to experience alcohol harms (2-3y after parents giving alcohol), to revent dirnking behind back but predicted long-twrm use than parents who doidt 4. • Alcohol/tobacco use greatest among those whose peers use these drugs1. More likely to use if peers are using 2. Perhaps correlational - we seek out likeminded people

1.Transvestic Disorder In transvestic disorder, sexual arousal is strongly associated with the act of (or fantasies of) dressing in clothes of the opposite sex, or cross-dressing (Blanchard, 2010; Wheeler, Newring, & Draper, 2008). Consider the case of Mr. M. 2.Interestingly, the wives of many men who cross-dress have accepted their husbands' behavior and can be quite supportive if it is a private matter between them. Docter and Princ 3/This specifier is very controversial because the "sexual confu- sion" experienced by Ron overlaps to some degree with gender dysphoria (described below), and some think this confusion is bet- ter captured by the concept of gender dysphoria.

1.Note that Mr. M. was in the Marine Corps before he joined the police force. It is not unusual for males who are strongly inclined to dress in female clothes to compensate by associating with so-called macho organizations. Some of our cross-dressing patients have been associated with various paramilitary organi- zations. Nevertheless, most individuals with this disorder do not seem to display any compensatory behaviors. The same survey in Sweden mentioned earlier found 2.8% of men and 0.4% of women reported at least one episode of transvestistic disorder (Långström & Zucker, 2005) The 3% prevalence rate in males, while a rough estimate, is generally accepted (APA, 2013). 2. 60% of more than 1,000 men with transvestistic dis- order were married at the time of the survey. Some people, both married and single, join cross-dressing clubs that meet periodically or subscribe to newsletters devoted to the topic. If sexual arousal is primarily focused on the clothing itself the diagnostic criteria require a specification "with fetishism." Research suggests that transvestism of this type is indistinguishable from other fetishes in most respects (Freund, Seto, & Kuban, 1996). Another speci- fier for transvestism describes a pattern of sexual arousal associ- ated not with clothing itself but rather with thoughts or images of oneself as a female. 3.ndeed, there is a somewhat greater risk that individuals with this paraphilic disor- der will develop gender dysphoria and request transition through sex reassignment surgery (Blanchard, 2010; Lawrence, 2013). But as one can see in the case of Ron/Rhonda, gender dysphoria was not a major component of his presentation, and he did not once consider surgical sex reassignment. Rather, he was very strongly sexually aroused by thoughts and images of himself as a woman.

1. SEX CHARACTERISTICS:

1.Physical parts of the body that are relatedto body development/regulationand reproductive systems. Primary sex characteristics are gonads, chromosomes, genitals and hormones. Secondary sex characteristics emerge at puberty and can include the development of breast tissue, voice pitch, facial and pubic hair etc. The term 'sex characteristics' is more accurate than 'biological sex', 'biologically male' or 'biologically female'. Physical organs, hormones and chromosomes should not be gendered as male or female, the gendering of body parts is a significant sourceof stigma, discrimination and pathologisation.

1.oking but later resume report that feelings of depression or anxiety were responsible for the relapse (Kahler, Litvin Bloom, Leventhal, & Brown, 2015). Due to this association between smok- ing and symptoms of depression and anxiety, relapse may be espe- cially higher for women as compared to men, because women more than men tend to have these symptoms 2.Caffeine-Related Disorders Caffeine is the most common of the psychoactive substances; esti- mates indicate that upwards of 85% of the U.S. population has at least one caffeinated beverage per day. (Mitchell, Knight, Hockenberry, Teplansky, & Hartman, 2014). Called the "gentle stimulant" because it is thought to be the least harmful of all addictive drugs, caffeine can still lead to problems similar to that of other drugs (e.g., interfer- ing with social and wo 3.t can make you feel jittery and can cause insomnia. Because caffeine takes a relatively long time to leave our bodies (about 6 hours), sleep can be disturbed if the caffeine is ingested in the hours close to bedtime.

1.Severe depression is found to occur significantly more often among people with nicotine dependence. Does this mean that smok- ing causes depression or depression causes smoking? There is a com- plex and bi-directional relationship between cigarette smoking and n other words, being depressed increases your risk of becoming dependent on nicotine, and at the same time, being dependent on nicotine will increase your risk of becoming depressed. Genetic studies suggest that a genetic vulnerabil- ity combined with certain life stresses may combine to make you vul- nerable to both a nicotine use disorder and depression (e.g., Edwards & Kendler, 2012). 2.found in tea, coffee, many soda drinks, and cocoa products. High levels of caffeine are added to the "energy drinks" that are widely consumed in the United States today but are banned in some European countries (including France, Denmark, and Norway) due to health concerns (Price, Hilchey, Darredeau, Fulton, & Barrett, 2010; Thorlton, Colby & Devine, 2014). As most of you have experienced firsthand, caffeine in small doses can elevate your mood and decrease fatigue. In larger 3.is effect is especially pronounced among those already suffer- ing from insomnia (Byrne et al., 2012). As with the other psychoactive drugs, people react variously to caffeine; some are sensitive to it, and others can con- sume relatively large amounts with little effect. Research suggests that moderate use of caffeine (a cup of coffee per day) by pregnant women does not harm the developing fetus (Loomans et al., 2012). DSM-5 includes caffeine usedisorder—defined problematic caffeineuse that causes significant impairmentand distress—as a condition for fur-ther study (American Psychiatric Asso-ciation, 2013). As

1.Hallucinogen-Related Disorders On a Monday afternoon in April 1943, Albert Hoffmann, a sci- entist at a large Swiss chemical company, prepared to test a newly synthesized compound. He had been studying derivatives of ergot, a fungus that grows on diseased kernels of grain, and sensed that he had missed something important in the 25th compound of the lysergic acid series 2.LSD (d-lysergic acid diethylamide), sometimes referred to as "acid," is the most common hallucinogenic drug. It is produced synthetically in laboratories, although naturally occurring deriva- tives of this grain fungus (ergot) have been found historically. In Europe during the Middle Ages, an outbreak of illnesses occurred as a result of people's eating grain that was infected with the fun- gus. One version of this illness—later called ergotism—constricted the flo 3.eople during that decade (Parrott, 2012). The late Timothy Leary, at the time a Harvard University research professor, first used LSD in 1961 and immediately began a movement to have every child and adult try the drug and "turn on, tune in, and drop out." There are a number of other hallucinogens, some occurring naturally in a variety of plants: psiloc

1.at he thought was an infinitesi- mally small amount of this drug, which he referred to in his notes as LSD-25, he waited to see what subtle changes might come over him as a result. Thirty minutes later, he reported no change, but some 40 minutes after taking the drug, he began to feel dizzy and had a noticeable desire to laugh. Riding his bicycle home, he hal- lucinated that the buildings he passed were moving and melting. By the time he arrived home, he was terrified he was losing his mind. Hoffmann was experiencing the first recorded "trip" on LSD (Jones, 2009). 2.gs and eventually resulted in gangrene and the loss of limbs. Another type of illness resulted in convulsions, delirium, and hallucinations. Years later, scientists connected ergot with the illnesses and began studying versions of this fungus for possible benefits. This is the type of work Hoffmann was engaged in when he discovered LSD's hallucino- genic properties. LSD largely remained in the laboratory until the 1960s, when it was first produced illegally for recreational use. However, the Central Intelligence Agency (CIA) tested LSD as a "truth serum" during interrogations though the agency abandoned their efforts after several serious incidents and no evidence of truth (Lee & Shlain, 1992). The mind-altering effects of the drug suited the social effort to reject established culture and enhanced the search for enlightenment that characterized the mood and behavior of 3.imethyltryptamine (DMT) (found in the bark of the Virola tree, which grows in South and Central America); and mescaline (found in the peyote cactus plant). Phencyclidine (or PCP) is snorted, smoked, or injected intravenously, and it causes impulsivity and aggressiveness. The DSM-5 diagnostic criteria for hallucinogen intoxication are similar to those for cannabis: perceptual changes such as the subjective intensification of perceptions, depersonalization, and hallucinations. Physical symptoms include pupillary dilation, rapid heartbeat, sweating, and blurred vision (American Psychiatric Association, 2013). Many users have written about hallucinogens, and they describe a variety of experiences. In one well-designed placebo-controlled study of hallucinogens, researchers at Johns

1As with several other disorders we've discussed, researchers are looking for endophenotypes, those basic deficits—such as spe- cific attentional problems—characteristic of ADHD. The goal is to link these deficits to specific brain dysfunctions. Not surprisingly, specific areas of current interest for ADHD are the brain's attention system, working memory fun 2.e strong genetic influence in ADHD does not rule out any role for the environment (Ficks & Waldman, 2009). In one of a growing number of gene-environment interaction studies of ADHD, for example, researchers found that children with a spe- cific mutation involving the dopamine system (called the DAT1 genotype) were more likely to exhibit the symptoms of ADHD if their mothers smoked during pregnancy (Kahn, Khoury, Nichols, & Lanphear, 2003; Russell, Ford, Williams, & Russell, in press). Prenatal smoking seemed to interact with this genetic predisposi- tion to increase the risk for hyperactive and i

1.attentiveness, and impul- sivity. Researchers are now trying to tie specific genetic defects to these cognitive processes to make the link between genes and behavior. Some research indicates that poor "inhibitory control" (the ability to stop responding to a task when signaled) may be common among both children with ADHD and their unaffected family members (siblings and parents) and may be one genetic marker (an endophenotype) for this disorder (Goos, Crosbie, Payne, & Schachar, 2009; Nikolas & Nigg, 2015). 2.esearch is now pointing to additional environmental factors, such as maternal stress and alcohol use, and parental mar- ital instability and discord, as involved in these gene-environment interactions (Barkley, 2015a; Ficks & Waldman, 2009). The association between ADHD and maternal smoking is one of the more consistent findings in this area. In addition, a variety of other pregnancy complications (for example, maternal alcohol consumption and low birth weight) may play a role in increas- ing the chance that a child with a genetic predisposition for ADHD will display the symptoms characteristic of this disorder (Barkley, 2006c). Unfortunately, many of the studies in this area confound socioeconomic and genetic factors (for example, there is an increased likelihood of smoking among women who also have low socioeconomic status or are under other stressors) (Russell et al., in press).

1.Comorbidity Looking at Table 12.2 and adding up the prevalence rates across the personality disorders, you might conclude that up to 25% of all peo- ple are affected. In fact, the percentage of people in the population with a personality disorder is likely closer to 10% (Huang et al., 2009; Lenzenweger et al., 2007). What accounts for this discrepancy? A major concern with the personality disorders is that people tend to be diagnosed with more than one. The term comorbidity historically describes the condition in which a person has multiple diseases (Caron & Rutter, 1991). A fair amount of disagreement is ongoing 2.Cluster A Personality Disorders 3.Paranoid Personality Disorder Although it is probably adaptive to be a little wary of other people and their motives, being too distrustful can interfere with mak- ing friends, working with others, and, in general, getting through daily interactions in a functional way. People with paranoid per- sonality disorder are excessively mistrustful and suspicious of others, without any justification.

1.bout whether the term should be used with psychological disorders because of the frequent overlap of different disorders (Skodol, 2005). In just one example, Zimmerman, Rothschild, and Chelminski (2005) conducted a study of 859 psychiatric outpatients and assessed how many had one or more personality disorders. Table 12.4 shows the odds that a person with a particular personality disorder would also meet the criteria for other disorders. For example, a person iden- tified with borderline personality disorder is also likely to receive diagnoses of paranoid, schizotypal, antisocial, narcissistic, avoidant, or dependent personality disorders. 2.Three personality disorders—paranoid, schizoid, and schizotypal— share common features that resemble some of the psychotic symp- toms seen in schizophrenia. These odd or eccentric personality disorders are described next. 3.They assume other people are out to harm or trick them; therefore, they tend not to confide in others. Consider the case of Jake.

1/There appears to be an inverted U-shaped relation between arousal and performance, the Yerkes-Dodson curve, which suggests people with either high or low levels of arousal tend to experience negative affect and perform poorly in many situations, whereas individuals with intermediate levels of arousal tend to be relatively content and perform satisfactorily in most situations. 2.According to the fearlessness hypothesis, psychopaths possess a higher threshold for experiencing fear than most other individu- als (Lykken, 1957, 1982). In other words, things that greatly fright- en the rest of us have little effect on the psychopath (Syngelaki, Fairchild, Moore, Savage, & Goozen, 2013). Remember that Ryan was unafraid of going alone to dangerous neighborhoods to buy drugs. According to proponents of this hypothesis, the fearless- ness of the psychopath gives rise to all the other major features of the syndrome. 3.u think about the behavior of psychopaths, the pos- sible malfunctioning of these systems is clear. An imbalance between the BIS and the reward system may make the fear and anxiety produced by the BIS less apparent and the positive feelings associated with the reward system more pro

1.ccording to the underarousal hypothesis, the abnormally low levels of cortical arousal characteristic of psychopaths are the primary cause of their antisocial and risk-taking behav- iors; they seek stimulation to boost their chronically low levels -s means that Ryan lied, took drugs, and dug up graves to achieve the same level of arousal we might get from talking on the phone with a good friend or watching television. Several researchers have examined childhood and adolescent psychophysiological predictors of adult antisocial behavior and criminality. Raine, Venables, and Williams (1990), for example, assessed a sample of 15 year olds on a variety of autonomic and central nervous system variables. They found that future crimi- nals had lower skin conductance activity, lower heart rate during rest periods, and more s 2.have tried to connect what we know about the workings of the brain with clinical observations of people with antisocial personality disorder, especially those with psychopa- thy. Several theorists have applied Jeffrey Gray's (1987) model of brain functioning to this population (Fowles, 1988; Quay, 1993). According to Gray, three major brain systems influence learning and emotional behavior: the behavioral inhibition system (BIS), the reward system, and the fight/flight system. Two of these sys- tems, the BIS and the reward system, have been used to explain the behavior of people with psychopathy. The BIS is responsible for our ability to stop or slow down when we are faced with impend- ing punishment, nonreward, or novel situations; activation of this system leads to anxiety and frustration. The BIS is thought to be located in the septohippocampal syste 3.Theorists have proposed that this type of neurobiological dysfunction may explain why psychopaths aren't anxious about committing the antisocial acts that char- acterize their disorder. Researchers continue to explore how differences in neu- rotransmitter function (for example, serotonin) and neurohor- mone function (for example, androgens such as testosterone and the stress neurohormone cortisol) in the brains of these individu- als can explain the callousness, superficial charm, lack of remorse, and impulsivity that characterize people with

1.sychological and social dimensions What goes on in the mind of a psychopath? In one of several studies of how psychopaths process reward and punishment, Newman, Patterson, and Kosson (1987) set up a card-playing task on a computer; they provided five-cent rewards and fines for correct and incorrect answers to psychopathic and nonpsy- chopathic criminal offenders. The game was constructed so that at first players were rewarded about 90% of the time and fined only about 10% of the time. Gradually, the odds changed until the probability of getting a reward was 0%. Despite feedback that reward was no longer forthcoming, the psychopaths continued to play and lose, while those without psychopathy stopped play- ing. As a result of this and other studies, the researchers hypoth- esized that once psychopaths set their sights on a reward goal, they are less likely than nonpsychopaths to be deterred despite signs the goal is no longer achievable (Dvorak-Bertscha, Curtin, Rubinstein, & Newman, 2009). 2.Although little is known about which environmental fac- tors play a direct role in causing antisocial personality disorder and psychopathy (as opposed to childhood conduct disorders), evidence from

1.gain, considering the reckless and daring behavior of some psychopaths (robbing banks with- out a mask and getting caught immediately), failure to abandon an unattainable goal fits the overall picture. Gerald Patterson's influential work suggests that aggression in children with antisocial personality disorder may escalate, partly as a result of their interactions with their parents (Granic & Patterson, 2006; Patterson, 1982). He found that the parents often give in to the problem behaviors displayed by their children. For example, a boy's parents ask him to make his bed and he refuses. One parent yells at the boy. The boy yells back and becomes abu- sive. At some point, his interchange becomes so aversive that the parent stops fighting and walks away, thereby ending the fight but also letting the son not make his bed. Giving in to these problems results in short-term gains for both the parent (calm is restored in the house) and the child (he gets what he wants), but it results in continuing problems. The child has learned to continue fighting and not give up, and the parent learns that the only way to "win" is to withdraw all demands. This "coercive family process" combines with other factors, such as genetic influences, 2.tiology of criminality and perhaps antisocial personality disorder. For example, in the adoption study by Sigvardsson, Cloninger, Bohman, and von Knorring (1982), low social status of the adoptive parents increased the risk of non- violent criminality among females. Like children with conduct disorders, individuals with antisocial personality disorder come from homes with inconsistent parental discipline

1.o not tell us directly whether abuse and neglect cause later bor- derline personality disorder. In an important study, researchers followed 500 children who had documented cases of childhood physical and sexual abuse and neglect and compared them in adulthood with a control group (no history of reported abuse or neglect) (Widom, Czaja, & Paris, 2009). 2.Symptoms of borderline personality disorder have been observed among people who have gone through rapid cultural changes. The problems of identity, emptiness, fears of abandon- ment, and low anxiety threshold have been found in child and adult immigrants (Laxenaire, Ganne-Vevonec, & Streiff, 1982; Skhiri, Annabi, Bi, & Allani, 1982). These observations further support the possibility that prior trauma may, in some individu- als, lead to borderline personality disor

1.ignificantly more abused and neglected children went on to develop borderline personal- ity disorder compared with controls. This finding is particularly significant for girls and women because girls are 2 or 3 times more likely to be sexually abused than boys (Bebbington et al., 2009). It is clear that a majority of people who receive the diagnosis of borderline personality disorder have suffered terrible abuse or neglect from parents, sexual abuse, physical abuse by others, or a combination of these (Ball & Links, 2009). For those who have not reported such histories, some research is examining just how they could develop borderline personality disorder. For example, factors such as temperament (emotional nature, such as being impulsive, irritable, or hypersensitive) or neurological impair- ments (being exposed prenatally to alcohol or drugs) and how they interact with parental styles may account for some cases of borderline personality disorder (Graybar & Boutilier, 2002). 2.at a history of childhood trauma, including sexual and physical abuse, occurs in people with other disorders, such as schizoid personality disorder, somatic symptom disorder (see Chapter 6), panic disorder (see Chapter 5), and dis- sociative identity disorder (see Chapter 6). In addition, a portion of individuals with borderline personality disorder have no appar- ent history of such abuse (Cloninger & Svakic, 2009). Although childhood sexual abuse and physical abuse and neglect seem to play an important role in the etiology of borderline personality disorder (Zanarini & Wedig, 2014), neither appears to be neces- sary or sufficient to produce the syndrome.

1.This gene-environment interaction was demonstrated most clearly by Cadoret, Yates, Troughton, Woodworth, and Stewart (1995), who studied adopted children and their likelihood of developing conduct problems. If the children's biological parents had a history of antisocial personality disorder and their adoptive 2.neurobiological influences A great deal of research has focused on neurobiological influ- ences that may be specific to antisocial personality disorder. One thing seems clear: 3.arousal theories The fearlessness, seeming insensitivity to punishment, and thrill- seeking behaviors characteristic of those with antisocial per- sonality disorder (especially those with psychopathy) sparked interest in what neurobiological processes might contribute to these unusual reactions.

1.ilies exposed them to chronic stress through marital, legal, or psychiatric problems, the children were at greater risk for conduct problems. Again, research shows that genetic influence does not necessarily mean certain disorders are inevitable. Genetic research on conduct disorder points to an interaction between genetic and environmental influences, such as academic difficulty, peer prob- lems, low family income, neglect, and harsh discipline from par- ents (Beaver, Barnes, May, & Schwartz, 2011; Kendler, Aggen, & Patrick, 2013; Silberg, Maes, & Eaves, 2012; Knopik et al., 2014). 2.General brain damage does not explain why some people become psychopaths or criminals; these individuals appear to score as well on neuropsychological tests as the rest of us (Hart, Forth, & Hare, 1990). Such tests are designed to detect only significant damage in the brain, however, and will not pick up subtle changes in chemistry or structure that could affect behavi 3.Early theoretical work on people with antisocial personality disorder emphasized two hypotheses: the underarousal hypothesis and the fearlessness hypothesis. According to the underarousal hypothesis, psychopaths have abnormally low levels of cortical arousal (Sylvers, Ryan, Alden,

1. amphetamines At low doses, amphetamines can induce feelings of elation and vigor and can reduce fatigue. You feel "up." After a period of eleva- tion, however, you come back down and "crash," feeling depressed or tired. Amphetamines are manufactured in laboratories; they were first synthesized in 1887 and later used as a treatment for asthma and as a nasal decongestant (Carvalho et al., 2012). Because amphetamines also reduce appetite, some people take them to lose weight. Adolph Hitler, partly because of his other physical mala- dies, became addict 2.vDSM-5 diagnostic criteria for intoxication in amphetamine use disorders include significant behavioral symptoms, such as euphoria or affective blunting (a lack of emotional expres- sion), changes in sociability, interpersonal sensitivity, anxiety, tension, anger, stereotyped behaviors, impaired judgment, and impaired social or oc

1.ilots, and some college students trying to "pull all-nighters" use amphetamines to get an extra energy "boost" and stay awake. Amphetamines are prescribed for people with narcolepsy, a sleep disorder characterized by excessive sleepiness (discussed in Chapter 8). Some of these drugs (Ritalin, Adderall) are even given to children with attention-deficit/hyperactivity dis- order (ADHD) (discussed in Chapter 14). Amphetamies too are being misused for their psychostimulant effects. One large study found that almost two thirds of college students in their fourth year had been offered illegal p 2.n addition, physi- ological symptoms occur during or shortly after amphetamine or related substances are ingested and can include heart rate or blood pressure changes, perspiration or chills, nausea or vomit- ing, weight loss, muscular weakness, respiratory depression, chest pain, seizures, or coma. Severe intoxication or overdose can cause hallucinations, panic, agitation, and paranoid delusions (Carvalho et al., 2012). Amphetamine tolerance builds quickly, making it doubly dangerous. Withdrawal often results in apathy, prolonged periods of sleep, irritability, and depression. Periodically, certain "designer drugs" appear in local mini- epidemics. An amphetamine called methylene-dioxymetham- phetamine (MDMA), first synthesized in 1912 in Germany, was used as an appetite suppressant (McCann & Ricaurte, 2009). Rec- reational use of this drug, now commonly called Ecstasy, rose sharply in the late 1980

1.Narcissistic Personality Disorder We all know people who think highly of themselves—perhaps exaggerating their real abilities. They consider themselves some- how different from others and deserving of special treatment. In narcissistic personality disorder, this tendency is taken to its extreme. In Greek mythology, Narcissus was a youth who spurned the love of Echo, so enamored was he of his own beauty. He spent his days admiring his own image reflected in a pool of water. Psychoanalysts, including Freud, used the term narcissistic to describe people who show an exaggerated sense of self-importance and are preoccupied with receiving attention (Ronningstam, 2012). Consider the case of Willie. 2.causes and treatment We start out as infants being self-centered and demanding, which is part of our struggle for survival. Part of the socialization pro- cess, however, involves teaching children empathy and altruism. Some writers, including Kohut (1971, 1977), believe that narcis- sistic personality disorder arises largely from a profound failure by the parents of modeling empathy early in a child's develop- ment. As a consequence, the child remains fixated at a self- centered, grandiose stag

1.inical description People with narcissistic personality disorder have an unreason- able sense of self-importance and are so preoccupied with them- selves that they lack sensitivity and compassion for other people (Caligor, Levy, & Yeomans, 2015; Ronningstam, 2012). They aren't comfortable unless someone is admiring them. Their exagger- ated feelings and their fantasies of greatness, called grandiosity, create a number of negative attributes. They require and expect a great deal of special attention—the best ting space in front of the movie theater. They also tend to use or exploit others for their own interests and show little empathy. When confronted with other successful people, they can be extremely envious and arrogant. And because they often fail to live up to their own expectati 2.including greater emphasis on short-term hedonism, individualism, com- petitiveness, and success. According to Lasch, the "me generation" -produced more than its share of individuals with narcissistic personality disorder. Indeed, reports confirm that narcissistic personality disorder is increasing in prevalence (Huang et al., 2009). However, this appar- ent rise may be a consequence of increased interest in and research on the disorder. 3.ognitive therapy strives to replace their fantasies with a focus on the day-to-day pleasurable experienc- es that are truly attainable. Coping strategies such as relaxation training are used to help them face and accept criticism. Help- ing them focus on the feelings of others is also a goal. Because individuals with this disorder are vulnerable to severe depressive episodes, particularly in middle age, treatment is often initiated for the depression. It is impossible to draw any conclusions, how- ever, about the impact of such treatment on the actual narcissistic personality disorder.

1.Cannabis-Related Disorders Cannabis (marijuana) was the drug of choice in the 1960s and early 1970s. Although it has decreased in popularity, it is still the most routinely used illegal substance, with 5 to 15% of peo- ple in western countries reporting regular use (Jager, 2012). In the United States, 22.2 million individuals aged 12 or older used marijuana in the past 30 days (SAMHSA, 2014). Marijuana is the name given 2. ciating the subtleties of music. Perhaps more than any other drug, however, cannabis can produce different reactions in people. It is not uncommon for someone to report having no reac- tion to the first use of the drug; it also appears that people can "turn off " the high if they are sufficiently motivated (Jager, 2012). The feelin

1.is sativa). Cannabis grows wild throughout the tropical and temperate regions of the world, which accounts for one of its nicknames, "weed." As demonstrated by the following parable, people who smoke marijuana often experience altered perceptions of the world. -shall stroll in through the keyhole!" (Rowell & Rowell, 1939, p. 66) Reactions to cannabis usually include mood swings. Otherwise- normal experiences seem extremely funny, or the person might enter a dreamlike state in which time seems to stand still. Users often report heightened sensory experience seeing vivid colors, 2.eing produced by small doses can change to paranoia, hallucinations, and dizziness when larger doses are taken. High school-age marijuana smokers get lower grades and are less likely to graduate, although it is not clear if this is the direct result of cannabis use or concurrent other drug use (Jager, 2012). Research on frequent cannabis users suggests that impairments of memory, concentration, relationships with others, and employ- ment may be negative outcomes of long-term use (possibly lead- ing to cannabis use disorders), although some researchers suggest that some psychological problems precede usage—increasing the likelihood that someone will use cannabis (Heron et al., 2013; Macleod et al., 2004). The introduction of synthetic marijuana (referred to with a number of different names such as "fake weed," "K2" or "Spice" and marketed as "herbal incense") has caused alarm because in many pl

1.robably some of the most intriguing research we describe in this book involves using the techniques in brain imaging to see how psychological treatments influence brain function. One pilot study examined emotional reactions to upsetting photos (for example, pictures of women being attacked) in controls and in women with borderline personality disord 2.Histrionic Personality Disorder Individuals with histrionic personality disorder tend to be overly dramatic and often seem almost to be acting, which is why the term histrionic, which means theatrical in manner, is used. Consider the case of Pat. 3.ddition, they seek reassurance and approval constantly and may become upset or angry when others do not attend to them or praise them. People with histrionic personality disorder also tend to be impulsive and have great difficulty delay- ing gratification. The cognitive style associated with histrionic personality disor- der is impressionistic (Beck, Freeman, & Davis, 2007), character- ized by a tendency to view situations in global, black-and-white terms. Speech is often vague, lacking in detail, and characterized by exaggeration (

1.is study found that among the women who benefited from treat- ment, arousal (in the amygdala and hippocampus) to the upsetting photos improved over time as a function of treatment. No changes occurred in controls or in women who did not have positive treat- ment experiences. This type of integrative research holds enormous promise for our understanding of borderline personality disorder and the mechanisms underlying successful treatment. 2. clinical description People with histrionic personality disorder are inclined to express their emotions in an exaggerated fashion, for example, hugging someone they have just met or crying uncontrollably during a sad movie (Ferguson & Negy, 2014; Blashfield, Reynolds, & Stennett, 2012). They also tend to be vain, self-centered, and uncomfort- able when they are not in the limelight. They are often seductive in appearance and behavior, and they are typically concerned about their looks. (Pat, for example, spent a great deal of money on unusual jewelry and was sure to point it out to anyone who would listen. 3.or example, when Pat was asked about a date she had had the night before, she might say it was "amazing" but fail to provide more detailed information. The high rate of this diagnosis among women versus men raises questions about the nature of the disorder and its diagnostic criteria (Boysen, Ebersole, Casner, & Coston, 2014). As we first discussed in the beginning of this chapter, there is some thought that the features of histrionic personality disorder, such as over- dramatization, vanity, seductiveness, and overconcern with physi- cal appearance, are characteristic of the Western "stereotypical female" and may lead to an overdiagnosis among women. Sprock (2000) examined this important question and found some evi- dence for a bias among psychologists and psychiatrists to associate the diagnosis with women rather than men

1. reatment of disorders of sex development (intersexuality) As we noted, surgery and hormonal replacement therapy has been standard treatment for many individuals with DSDs who may be born with physical characteristics of both sexes in order to make their sexual anatomy match as closely to their assigned gender as possible. These procedures usually take place soon after birth. But in later years, gender dysphoria may also develop in these individuals, and, if it does, a similar sequence of treat- ment steps beginning with the least intrusive would be initi- ated as described above (Byne et al., 2012). Of course, treatment for gender dysphoria in any form has always been controversial and particularly so when a DSD is present. F 2.Fausto-Sterling suggests that an increasing number of pediatric endocrinologists, urologists, and psychologists are examining the wisdom of early genital surgery that results in an irrevers- ible gender assignment. Instead, health professionals may want to examine closely the precise nature of th

1.sto-Sterling, who suggests that there are actually five sexes: males; females; "herms," who are named after true hermaphrodites, or people born with both testes and ovaries; "merms," who are anatomi- cally more male than female but possess some aspect of female genitalia; and "ferms," who have ovaries but possess some aspect of male genitalia (Fausto-Sterling, 2000a, 2000b; 2015). She estimates, based on the best evidence available, that for every 1,000 children born, 17, or 1.7%, may be present with a DSD in some form. What Fausto-Sterling (2000b) and others have noted is that individuals in this group are often dissatisfied with sur- gery, much as Bruce was in the case we described. There have been instances in which doctors, upon observing anatomical sexual ambiguity after birth, treat it as an emergency and imme- diately perform surgery. 2.e DSD and consider sur- gery only as a last resort, and only when they are quite sure the particular condition will lead to a specific psychological gender identity. Otherwise, psychological treatments to help individuals adapt to their particular sexual anatomy, or their emerging gender experience, might be more appropriate.

1. ior to DSM-5, most disorders we discuss in this book were in Axis I of the DSM-IV-TR, which included the traditional disorders. The personality disorders were included in a separate axis, Axis II, because as a group they were seen as distinct. 2.Categorical and Dimensional Models Most of us are sometimes suspicious of others and a little paranoid, overly dramatic, too self-involved, or reclusive. Fortunately, these characteristics do not last long or are not overly intense; they haven't significantly impaired how we live and work. People with personal- ity disorders, however, display problem characteristics over extended periods and in many situations, which can cause great emotional pain for themselves, others, or both (Widiger, 2012). Their diffi- culty, then, can be seen as one of degree rather than kind; in other words, the problems of people with personality disorders may just be extreme versions of the problems many of us experience temporarily, such as being shy or suspicious (S

1.t was thought that the characteristic traits were more ingrained and inflexible in peo- ple who have personality disorders, and the disorders themselves were less likely to be successfully modified. With the changes made with DSM-5, these separate axes were eliminated, and now the per- sonality disorders are listed with the rest of the DSM-5 disorders (American Psychiatric Association, 2013). 2.The distinction between problems of degree and problems of kind is usually described in terms of dimensions instead of categories. The issue that continues to be debated in the field is whether personal- ity disorders are extreme versions of otherwise typical personality variations (dimensions) or ways of relating that are different from psychologically healthy behavior (categories) (Skodol, 2012). You can see the difference between dimensions and categories in every- day life. For example, we tend to look at gender categorically. Society generally views us as being in one category—"female"—or the other— "male." Yet many believe it is more accurate to look at gender in terms of dimensions. For example, we know that "male" and "female" may describe a range of choices in gender expression (e.g., personal grooming, attire, use of makeup and other body modifications). We could just as easily place people along a continuum of maleness and femaleness rather than in the absolute categories of male or female. We also often label people's size categorically, as tall, average, or short. But height, too, can be viewed dimensionally, in inches or centimet

1. Selective programs 2. Indicated programs 3. Rehearse Your Knowledge How does withdrawal influence drug use? Explain the incentive sensitization theory. Which personality characteristic is most associated with using drugs to obtain positive reinforcement? Explain the factors that influence whether drug use reduces negative affect. Discuss an integrative model for substance abuse. What is the difference between agonist substitution andantagonistic treatment? What is contingency management? How effective are drug treatments in general?

1.target groups at risk for developing substance abuse problems • Often more costly than universal programs because extensive screening is needed 2. target people already having problems • Basically its treatment provided to young people

1.esent biases on the part of the clinicians who make the diagnoses? Take, for example, a classic study by Maureen Ford and Thomas Widiger (1989), who sent fictitious case histo- ries to clinical psychologists for diagnosis. One case described a person with antisocial personality disorder, which is characterized by irresponsible and reckless behavior and usually diagnosed in males; the other case described a person with histrionic personal- ity disorder, which is characterized by excessive emotionality and attention seeking and more often diagnosed in females. The sub- ject was identified as male in some versions of each case and as female in others, although everything else was identical. As the graph in E Figure 12 2.This disorder may simply be the embodimentof extremely "feminine" traits (Chodoff, 1982);branding such an individual mentally ill, accord-ing to Kaplan, 3.different stages of the diagnostic process. Widiger and Spitzer (1991) point out that the criteria for the disorder may themselves be biased (criterion gender bias),

1.the antisocial personality dis- order case was labeled male, most psychologists gave the correct diagnosis. When the same case of antisocial personality disorder was labeled female, however, most psychologists diagnosed it as histrionic personality disorder rather than antisocial personal- ity disorder. In the case of histrionic personality disorder, being labeled a woman increased the likelihood of that diagnosis. Ford and Widiger (1989) concluded that the psychologists incorrectly diagnosed more women as having histrionic personality disorder. This gender difference in diagnosis has also been criticized by other authors (see, for example, Kaplan, 1983) on the grounds that histrionic personality disorder, like several of the other personal- ity disorders, is biased against females. As Kaplan (1983) points out, many of the features of histrionic personality disorder, such as overdramatization, vanity, seductiveness, andoverconcern with physical appearance, are char-acteristic of the Western "stereotypical female." 2.society's inherent biasagainst females. (See Table 12.3 for a humoroustake on a male version of a personality disorder.)Interestingly, the "macho" personality (Mosher &Sirkin, 1984), in which the individual possessesstereotypically masculine traits, is nowhere to befound in the DSM. 3.assessment measures and the way they are used may be biased (assessment gender bias). In gen- eral, the criteria themselves do not appear to have strong gender bias, although there may be some tendency for clinicians to use their own bias when using the criteria and therefore diagnose males and

1.Psychological Dimensions We have shown that the substances people use to alter mood and behavior have unique effects. The high from heroin differs sub- stantially from the experience of smoking a cigarette, which in turn differs from the effects of amphetamines or LSD. Nevertheless, it is important to point out the similarities in the way people mentally react to most of these substances. Positive reinforcement The feelings that result from using psychoactive substances are pleasurable in some way, and people will continue to take the drugs to recapture the pleasure. Research shows quite clearly that many drugs used and abused by humans also seem to be plea- surable to animals (Young & Herling, 1986). Laboratory animals will work to have their bodies injected with drugs such as cocaine, amphetamines, opiates, sedatives, and alcohol, which demon- strates that even without social and cultural influences these drugs are pleasurable. 2.negative reinforcement Most researchers have looked at how drugs help reduce unpleasant feelings through negative reinforcement. Many people are likely to initiate and continue drug use to escape from unpleasantness in their lives. In addition to the initial

1.research also indicates that to some extent all psycho- active drugs provide a pleasurable experience (Ray, 2012). In addi- tion, the social contexts for drug taking may encourage its use, even when the use alone is not the desired outcome. One study found that among volunteers who preferred not to take Valium, pairing money with pill taking caused participants to switch from a placebo to Valium (Alessi, Roll, Reilly, & Johanson, 2002). Posi- tive reinforcement 2This phenomenon has been explored under a number of different names, including tension reduction, negative affect, and self-medication, each of which has a somewhat different focus (Ray, 2012). One premise is that substance use becomes a way for users to cope with the unpleasant feelings that go along with life circum- stances. For example, one study of 1,252 U.S. Army soldiers return- ing home from Operation Iraqi Freedom found that those exposed to violent combat, human trauma, and having direct responsibility for taking the life of another person were at increased risk for risk- taking and for more frequent and greater alcohol use (Killgore et al., 2008; Stappenbeck, Hellmuth, 2.jor factor in predicting who would use alcohol and other drugs. However, they also found that adoles- cents who reported negative affect, such as feeling lonely, crying a lot, or being tense, were more likely than others to use drugs. The researchers further determined that the adolescents from both groups tended to use drugs as a way to cope with unpleasant feel- ings. This study and others (see, for example, Pardini, Lochman, & Wells, 2004) suggest that one contributing factor to adolescent drug use is the desire to escape from unpleasantness. It also sug- gests that to prevent people from using drugs we may need to address influences such as stress and anxiety, a strategy we discuss in our section on treatment.

1. In another study, Maletzky, Tolan, and McFarland (2006) found that among sexual offenders released from prison for whom medication was considered to be possibly useful, a subset who actually received the medication had signifi- cantly fewer subsequent sexual offences than a group who, for a variety of reasons, did not receive the medication.summary Based on evidence from a number of settings, evidence for the psychosocial treatment of paraphilic disorders is mixed, with more success reported in outpatient settings with presumably less severe, more stable patients. But most results are uncontrolled observations from a small number of clinical r 2.Gender Dysphoria What is it that makes you think you are a man? Or a woman? Clearly, it's more than your sexual arousal patterns or your anatomy. It's also more than the reactions and experiences of your family and society. The essence of your masculinity or femininity is a deep-seated per- sonal sense called gender identity or the gender you actually expe- rience. Gender dysphoria 3.f the natal sex is female but the xperienced gender (gender identity) is strongly male, the individual is typically referred to as a

1.research centers, and results may not be as good in other clinics and offices. In any case, as with treatment for sexual dysfunctions, psychosocial approaches to paraphilic disorders are not readily available out- side of specialized treatment centers. In the meantime, the outlook for most individuals with these disorders is bleak because para- philic disorders run a chronic course and recurrence is common. 2.is present if a person's physical sex (male or female anatomy, also called "natal" sex) is not consistent with the person's sense of who he or she really is or with his or her experienced er. While gender dysphoria can occur on a continuum (American Psychological Association [APA] Task Force of Gender Identity and Gender Variance, 2008; Cohen-Kettenis & Pfäfflin, 2010), at the extreme end of the continuum are individuals who reject their natal sex altogether and wish to change it. People with this disorder often feel trapped in a body of the wrong sex. 3.or "transman," and a natal male would be a transwoman. If the individual has made the transition to full time living in their experienced gender (by interacting with people in their daily lives in a consistent manner in their desired gender) and they are preparing for, or have undergone sex reassignment surgery then they are referred to as "posttransition," and this is specified in the diagnostic criteria for gender dysphoria

1.sychosocial Treatments Most biological treatments for substance abuse show some prom- ise with people who are trying to eliminate their drug habit. Not one of these treatments alone is successful for most people, how- ever (Schuckit, 2009b). Most research indicates a need for social support or therapeutic interven 2.npatient Facilities The first specialized facility for people with substance abuse problems was established in 1935, when the first federal narcotic "farm" was built in Lexington, Kentucky. Now mostly privately run, such facilities are designed to help people get through the ini- tial withdrawal period and to provide supportive therapy so that they can go back to their communities (Morgan, 1981). Inpatient care can be extremely expensive (Bender, 2004). The question arises, then, as to how 3.alcoholics anonymous and its Variations Without question, the most popular model for the treatment of substance abuse is a variation of the Twelve Steps program first developed by Alcoholics Anonymous (AA). Established in 1935 by two alcoholic professionals, William "Bill W." Wilson and Robert "Dr. Bob" Holbrook Smith, the foundation of AA is the notion that alcoholism is a disease and

1.sorder, a number of models and programs have been developed. Unfortunately, in no other area of psychology have unvalidated and untested methods of treatment been so widely accepted. A reminder: A program that has not been subject to the scrutiny of research may work, but the sheer number of people receiving services of unknown value is still cause for concern. We next review several therapeutic approaches that have been evaluated. 2.ective this type of care is compared with outpatient therapy that can cost 90% less. Research suggests there may be no difference between intensive residential setting pro- grams and quality outpatient care in the outcomes for alcoholic patients (Miller & Hester, 1986) or for drug treatment in general (NIDA, 2009). Although some people do improve as inpatients, they may do equally well in outpatient care that is significantly less 3.Central to the design of AA is its independence from the established medical community and the freedom it offers from the stigmatization of alcoholism (Denzin, 1987; Robertson, 1988). An important component is the social support it provides through group meetings. Since 1935, AA has steadily expanded to include almost 106,000 groups in more than 100 countries (White & Kurtz, 2008). In one survey, 9% of the adult population in the United States reported they had at one time attended an AA meeting (Room & Greenfield, 2006). The Twelve Steps of AA are the basis of its philosophy (see Table 11.3). In them, you can see the reliance on prayer and a belief in God.

1.Biological interventions The first types of medication used for children with ADHD were stimulants. Since the use of stimulant medication for children with ADHD was first described (Bradley, 1937), hundreds of stud- ies have documented the effectiveness of this kind of medication in reducing the core symptoms (hyperactivity, impulsiveness) of the disorder. It is estimated that 3.5% of the children living in the United States are being treated with medication for symptoms of ADHD (Zuvekas & Vitiello, 2012). Drugs such as methylpheni- date (Ritalin, Adderall) and several nonstimulant medications such as atomoxetine (Strattera), guanfacine (Tenex), and cloni- dine have proved helpful in reducing the core symptoms of hyper- activity and impulsivity and in improving concentration on tasks (Connor, 2015).

1.seemed paradoxical or contrary to expect that children would calm down after taking a stimulant. However, on the same low doses, children and adults with and without ADHD react in the same way. It appears that stimulant medications rein- force the brain's ability to focus attention during problem-solving tasks (Connor, 2006). Although the use of stimulant medications remains controversial, especially for children, most clinicians recommend them temporarily, in combination with psychoso- cial interventions, to he

1.most common treatment strategyfor children involves parent training (Scott,Briskman, & O'Connor, 2014; Presnall,Webster-Stratton, & Constantino, 2014;Patterson, 1986). Parents are taught to recog-nize behavior problems early and to use praiseand privileges to reduce problem behaviorand encourage prosocial behaviors. 2.revention We have seen a dramatic increase in the amount of research on prevention strategies focused on children at risk for later antisocial personality disorder. The aggressive behaviors of young children are remarkably stable, meaning that children who hit, insult, and threaten others are likely to continue these behaviors as they grow older. Unfortunately, these behaviors become more serious over time and, though some individuals become less aggressive after ado- lescence (Jennings & Reingle, 2012) are oftentimes early signs of the homicides and assaults seen among some adults (Wright, Tibbetts, & Daigle, 2015; Eron & Huesmann, 1990; Singer & Flannery, 2000). Approaches to change this aggressive course are being imple- mented mainly in school and preschool settings and empha- size behavioral supports for good behavior and skills training to improve social competence

1.reatmentstudies typically show that these types of pro-grams can significantly improve the behaviorsof many children who display antisocial behav-iors (Conduct Problems Prevention ResearchGroup, 2010). A number of factors, however,put families at risk either for not succeedingin treatment or for dropping out early; theseinclude cases with a high degree of family dys-function, socioeconomic disadvantage, highfamily stress, a parent's history of antisocialbehavior, and severe conduct disorder on thepart of the child 2.A number of types of these programs are under evaluation, and the results look promising. For example, research using parent training for young children (toddlers from 1 1⁄2 to 2 1⁄2 years) suggests that early intervention may be particularly help- ful (Shaw, Dishion, Supplee, Gardner, & Arnds, 2006). Aggres- sion can be reduced and social competence (for example, making friends and sharing) can be improved among young children, and these results generally are maintained over a few years (Conduct Problems Prevention Research, 2010; Reddy et al., 2009). One recent study found that the association between childhood con- duct disorder and adult antisocial behavior was weaker among those adolescents who participated in high school sports, pointing to the possible utility of activities that disrupt delinquent habits (Samek, Elkins, Keyes, Iacono, & McGue, 2015) It is too soon to assess the impact of targeted prevention programs on adult antiso- cial behaviors typically observed among people with this person- ality disorder

1.Impulsivity includes blurting out answers before questions have been completed and having trouble waiting turns. Either the first (inattention 2.Inattention, hyperactivity, and impulsivity often cause other problems that appear secondary to ADHD. Academic perfor- mance often suffers, especially as the child progresses in school. The cause of this poor performance is not known. It could be a result of inattention and impulsivity, and in some children this can be made worse by factors such as concurrent learning disabilities. Genetic research on both ADHD and learning disabilities sug- gests that they may share a common biological cause 3.statistics An important analysis of prevalence of ADHD suggests that the disorder is found in about 5.2% of the child populations across all regions of the world (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007). This finding of comparable rates of ADHD worldwide is important because debates continue to rage about the validity of ADHD as a real disorder. Some people believe that children who are just normally "active" are being misdiagnosed with ADHD. Previously, geographic differences were noted in the number of people diagnosed with this disorder.

1.the second and third (hyperactivity and impulsivity) set of symptoms must be present for someone to be diagnosed with ADHD (American Psychiatric Association, 2013). These different presentations are called subtypes, and they include the inattentive subtype (what some may call ADD, not- ing the absence of hyperactivity, although this is not an official diagnostic label), and the hyperactive/impulsive subtype. Other individuals meet criteria for both inattention and hyperactivity/ impulsivity, and these individuals are labeled with the combined subtype. 2. npopular and rejected by their peers (McQuade & Hoza, 2015). This, too, may be the result of genetic factors as well as environ- mental influences such as a hostile home environment and gene- environment interactions. For example, some research shows that having a specific genotype (i.e., a dopamine transporter— DAT1; and a serotonin transporter) and psychosocial distress can predict ADHD in children (Barkley, 2 3.dren were more likely to receive the label of ADHD in the United States than anywhere else. For example, an analysis of data from surveying parents over the phone suggests that 11% of children in the United States aged 4 to 17 were labeled with ADHD between 2011 and 2012 (Centers for Disease Control and Prevention, 2013). This higher number may suggest that it is being over-diagnosed in the United States. Based on these different rates of diagnosis, some have argued that ADHD in children is simply a cultural construct—meaning that the behavior of these children is typical from a developmental perspective, and it is Western society's intolerance (due to the loss of extended family support, pressure to succeed academically, and busy family life) that causes labeling ADHD as a disorder (Timimi & Taylor, 2004). The best data suggest, however, that from 5% to 7% of the worldwide population of children currently meet the criteria for ADHD and 3% to 5% have symptoms that significantly in

1. The results, presented in E Figure 10.4, indicate that the noncontingent shock threat condition increased sexual arousal compared with the no-shock threat con- trol condition. 2. These counterintuitive findings have some parallels outside the laboratory. In one unusual and startling report, Sarrel and Mas- ters (1982) described the ability of men to perform sexually under threat of physical harm. These men, the victims of gang rape by women, reported later that they had been able to achieve erections and repeatedly engage in intercourse despite being constantly threatened with knives and other weapons if they failed. Certainly they experienced extreme levels of anxiety, yet they reported that their sexual performance was not impaired.If anxiety does not necessarily decrease sexual arousal and performance, what does? A partial answer is distraction. I 3. Anxiety induced by shock threat ("You'll be shocked if you don't get aroused") did seem to reduce sexual

1/In an even more surpris- ing development, however, the contingent shock threat condition (in which partici- pants were told there was a 60% chance they would be shocked if they did not achieve adequate arousal) increased sexual response even more significantly than the no-shock threat control condition. Si 2.t, participants were asked to listen to a narrative through earphones while they watched an erotic film and were told that they would later have to report on the narrative to make sure they were listening. Sexually functional males demonstrated significantly less arousal based on penile strain gauge measurements when they were distracted by the narrative than when they were not distracted (Abrahamson, Barlow, Sakheim, Beck, & Athanasiou, 1985). To any male who has tried to concentrate on baseball scores or some other nonsexual event to reduce unwanted arousal, this result will come as no surprise. Males with erectile dysfunction in whom physical disease processes had been ruled out reacted somewhat differently from functional men to both shock threat and distraction condi- tions. 3,. ysfunctional. Remember that the reverse was true for the normally functioning males. By contrast, the kind of neutral dis- tracting conditions present in the experiment by Abrahamson and colleagues (1985) did not reduce arousal in those males who were dysfunctional. This discovery is puzzling. Two other findings from different experiments are important. One revealed that patients with erectile dysfunction consistently underreport their actual levels of arousal; that is, at the same level of erectile responses (as measured by the penile strain gauge), men who are dysfunctional report far less sexual arousal than do sexu- ally functional men (Sakheim et al., 1987). This result seems to be true for dysfunctional women as well

1. 1. Which psychological disorder has the highest lifetime prevalence? a) Obesity (not a psychological disorder) b) Anorexia Nervosa c) Bulimia Nervosa (Anorexia and Bulimia have similar prevalence - approx. 1%) d) Binge Eating Disorder (prevalence approx. 3%) 2. Which gender has highest rates of eating disorders? a) Females b) Males c) Females, except for Binge Eating Disorder where prevalence is equal for males and females d) Both males and females have equal prevalence rates 3. 3. What is NOT a symptom of Anorexia Nervosa? a) Disturbance in the way in which one's body weight or shape is experienced b) Intense fear of gaining weight or of becoming fat c) Restriction of energy intake relative to requirements, leading to a significantly low body weight d) Recurrent episodes of binge eating and purging (specifier)

d 2. a 3. d

1. Rehearse Your Knowledge What are the two ways that addiction is defined? What comprises physiological dependence? What effects to opioids produce? What kind of drugs are examples of depressants? Which drug does not have a substance use disorder in the DSM-5? Which drug does not have a substance intoxication disorder in the DSM-5? Which neurotransmitter is responsible for drug reward learning?

lols

1. Rehearse Your Knowledge Describe the various symptoms of ADHD Describe the symptoms of ASD Which disorders does the diagnosis of ASD in the DSM- 5 replace from the DSM-IV? Who is most at risk for developing ADHD? Who is most at risk for developing ASD? Discuss the aetiology of ADHD Discuss the aetiology of ASD Discuss the treatments for ADHD Describe treatment for ASD Do vaccines cause autism? Should the Feingold diet be used to treat ADHD? 33 Rehearse Your Knowledge Brandon is a 12-year old boy experiencing temper tantrums that are negatively affecting school performance. Brandon's mother reported that things had always been difficult but became worse recently. Brandon's teachers reported that he was academically capable, but had little ability to make friends, and rarely spoke in class. When interviewed alone, Brandon responded with mumbles when asked questions about his classmates, school, and family. But when asked about toy cars, Brandon lit up, and showed the examiner several cars he had in his backpack. Brandon did not make eye contact when talking to the examiner. When queried again about school, Brandon showed the examiner text messages on his phone that said things like "los

ASD

1. Henry was a great statistician. He was conscientious; attending to minute details. However, when working with others on projects, he would become quite upset if they couldn't keep up with him. He would become quite irritated with his staff if they did not follow elaborately constructed workplans and schedules. He would work many hours each day because he would spend an excessive amount of time planning out other people's work, which left him little time to do his own work. He was unable to acknowledge that there were equally good other ways to do things. At home, everything needed to be orderly and he would become quite upset if his family did not meet his standards. --Which PD does this description most closely match?

Q2. Ocpd

1. Juanita, aged 33, was seeking treatment for longstanding depression, suicidal thoughts, and loneliness. She had spent the past six months doing little else than watching TV in bed, eating junk food, and doing online shopping. Juanita had done well in school, but left university early due to her professors being idiots. She had held many entry level jobs since then, first feeling like her bosses were super amazing, but eventually finding them twisted and incompetent, which would result in her quitting or being fired due to inappropriate aggressive behaviour. This would leave her feeling terrible. Sometimes she would cut herself with a razorblade, just deep enough to draw blood. The blood fascinated her and made her feel alive, which reassured her of her existence. She felt the pain was real and deserved, much unlike her chronic feelings of emptiness. --Which PD does this description most closely match?

Q3 BPD

1. Sociocultural Predictors 2. Treatment 3. Treatment • Masters and Johnson's psychosocial intervention

1. -Rape or sexual abuse -Erotophobia: Associate sexuality with negative feelings, anxiety, or threat -Relationship problems- anger, poor communication -Long periods of abstinence -History of hurried sex 2. -Education alone can be surprisingly effective;- Focus on treating immediate causes of sexual dysfunction (spectator role, fear of performance) -Couples therapy when relationship problems exist -Communication training (likes/dislikes) 3. -Treatment is daily for 2 weeks -Goal is to eliminate performance anxiety and focus on the self -Education about sexual response, foreplay, etc. -Sensate focus and nondemand pleasuring;§ Sensate focus: Focus on physical sensation instead of anxiety § May also involve cognitive activities to reduce negative cognitions (e.g., body dissatisfaction, performance anxiety), maybe challenge cognitive dsisotortions -Sexual activity with the goal of focusing on sensations without trying to achieve orgasm

1. Rehearse Your Knowledge What are the main clinical differences between individuals with anorexia nervosa and those with bulimia nervosa? What features do anorexia nervosa and bulimia nervosa share in common? What kind of medical problems do individuals with eating disorders experience? What kind of psychological and social problems do individuals with anorexia nervosa experience due to self-inflicted starvation? Individuals from what diagnostic category often deny any problem exists? 2. Causes of Eating Disorders

lols 2. Biological influences Sociocultural influences Family influences Psychological and behavioural influences

1. Types of Intoxications 2. Types of Substance Withdrawals

-Alcohol Intoxication -Caffeine Intoxication -Cannabis Intoxication - Hallucinogen- Related Intoxication (PCP or other) -. Inhalant Intoxication -Opioid Intoxication -Sedative/ Hypnotic/ Anxiolytic Intoxication -Stimulant Intoxication -Other (or Unknown) Substance Intoxication - Also symptoms differ based on the drugs - Cannot be intoxicated on tobacco 2. Alcohol Withdrawal -Caffeine Withdrawal -Cannabis Withdrawal -Opioid Withdrawal -Sedative/ Hypnotic/ Anxiolytic Withdrawal -Stimulant Withdrawal -Tobacco Withdrawal -Other (or Unknown) Substance Withdrawal - Cannot have withdrawals on hallucinogens (PCP or other) or inhalants

1. Rehearse Your Knowledge What is gender dysphoria? Who is required to meet more symptoms, adults or children? Discuss the associated psychopathology associated with gender dysphoria. What treatment can be given to someone with gender dysphoria? And how does treatment vary by age? What factors might impact and bias research on gender dysphoria?

1

1.does our society view people who are dependent on drugs? This issue is of tremendous importance because it affects efforts to legislate the sale, manufacture, possession, and use of these substances. It also dictates how drug-dependent individuals are treated. Two views of substance-related disorders character- ize contemporary thought: the moral weakness and the disease models of dependence. According to the moral weakness model of chemical dependence, drug use is seen as a failure of self-control in the face of tempta 2.Cultural Dimensions Culture is a pervasive factor in the influence of drug use and treatment. For example, the extent to which and how well people 3.her hand, in certain cultures, including Korea, peo- ple are expected to drink alcohol heavily on certain social occa- sions (C. K. Lee, 1992). As we have seen before, exposure to these substances, in addition to social pressure for heavy and frequent use, may facilitate their abuse, and this may explain the high alcohol abuse rates in countries like Korea. This cultural influ- ence provides an interesting natural experiment when explor- ing gene-environmen

1,Propo- nents of this model see drug users as lacking the character or moral fiber to resist the lure of drugs. We saw earlier, for example, that the Catholic Church made drug use an official sin—an indication of its disdain. The disease model of physiological dependence, in contrast, assumes that drug use disorders are caused by an under- lying physiological cause; this is a biological perspective. Those who ascribe to this model think that just as diabetes or asthma can't be blamed on the afflicted individuals, neither should drug use disorders. AA and similar organizations see drug use disor- ders as an incurable disease over which the addict 2.w cultures (acculturation) can be either a source of strength or a stress that can impact drug use. Cultural factors such as machismo (male dominance in Latin cultures), marianismo (female Latin role of motherly nurturance and identifying with the Virgin Mary), spirituality, and tiu lien ("loss of face" among Asians, that can lead to shame for not living up to cultural expec- tations) are just a few cultural viewpoints that can affect drug use and treatment in either a positive or negative way (Castro & Nieri, 2010). In addition, when we examine a behavior as it appears in different cultures, it is necessary to reexamine what is considered abnormal (Kohn, Wintrob, & Alarcón, 2009). Each culture has its own preferences for acceptable psychoactive drugs, as well as its own prohibitions for substances it finds unacceptable. Keep in mind that in addition t 3.People of Asian descent are more likely to have the ALDH2 gene, which produces a severe "flushing" effect (reddening and burning of the face) after drink- ing alcohol. This flushing effect was thought to be responsible for a relatively low rate of drinking in the population (de Wit & Phillips, 2012). However, between 1979 and 1992—when increased drinking became socially expected—there was an increase in alcohol abuse (Higuchi et al., 1994). The protective In many cultures, alcohol is used as part of certain rituals, demonstrated in this photo of Masai elders drinking ceremonial beer. value of having the ALDH2 gene was dimin- ished by the change in cultural nor

1.n other words, a person could receive a diagnosis of one personality disorder at one point in time and then years later no longer meet the criteria for his original problem but now have characteristics of a second (or third) personality disor- der. Our relative lack of information about such important features of personality disorders as their developmental course is a repeat- ing theme. 2.People with borderline personality disorder are character- ized by their volatile and unstable relationships; they tend to have persistent problems in early adulthood, with frequent hospital- izations, unstable personal relationships, severe depression, and suicidal gestures. Individuals with borderline personality disorder die by suicide at a rate about 50 times higher than the general pop- ulation, with most research s 3.Gender Differences Men diagnosed with a personality disorder tend to display traits characterized as more aggressive, structured, self-assertive, and detached, and women tend to present with characteristics that are more submissive, emotional, and insecure

1,aps in our knowledge of the course of about half these disorders are visible in Table 12.2. One reason for this dearth of research is that many individuals do not seek treatment in the early developmental phases of their disorder but only after years of distress. This makes it difficult to study people with personal- ity disorders from the beginning, although a few research studie 2.suggesting that 8% to 10% of patients with this illness complete suicide (Gunderson, 2011; Björkenstam, Björkenstam, Holm, Gerdin, & Ekselius, 2015). On the bright side, their symptoms gradually improve if they survive into their 30s (Zanarini et al., 2006, 2014), although elderly individuals may still experience higher than average interpersonal difficulties (Powers, Gleason, & Oltmanns, 2013). People with antisocial personality 3.hat antisocial personality disorder is pres- ent more often in males and dependent personality disorder more often in females. Historically, histrionic and borderline personality disorders were identified by clinicians more often in women (Dulit, Marin, & Frances, 1993; Stone, 1993), but according to more recent studies of their prevalence in the general population, equal numbers of males and females may have histrionic and borderline personal- ity disorders (see Table 12.2). If this observation holds up in future studies, why have these disorders been predominantly diagnosed among females in general clinical practice and in other studies?

1.Schizotypal Personality Disorder People with schizotypal personality disorder are typically socially isolated, like those with schizoid personality disorder. In addition, they also behave in ways that would seem unusual to many of us, and they tend to be suspicious and to have odd beliefs (Rosell, Futterman, McMaster, & Siever, 2014; Chemerenski, Triebwasser, Roussos, & Siever, 2013). Schizotypal personality disorder is considered by some to be on a continuum (that is, on the same spectrum) with schizophrenia 2.People given a diagnosis of schizotypal personality disorder have psychoticlike (but not psychotic) symptoms (such as believing everything relates to them personally), social deficits, and sometimes cognitive impairments or paranoia (Kwapil & Barrantes-Vidal, 2012). These individuals are often considered odd or bizarre because of how they relate to other people, how they think and behave, and even how they dress. They have ideas of reference; for example, they may believe that somehow everyone on a passing city bus is talking about them, yet they may be able to acknowledge this is unlikely 3.Because persons with schizotypal personality disorder often have beliefs around religiou

1,evere disorder we discuss in the next chapter—but without some of the more debilitating symptoms, such as hallucinations and delusions. In fact, because of this close connection, DSM-5 includes this disorder under both the heading of a personality disorder and under the head- ing of a schizophrenia spectrum disorder (American Psychiatric Association, 2013). Consider the case of Mr. S. 2.et al., 2014). Again, as you will see in Chapter 13, some people with schizophrenia also have ideas of reference, but they are usually not able to "test reality" or see the illogic of their ideas. Individuals with schizotypal personality disorder also have odd beliefs or engage in "magical thinking," believing, for exam- ple, that they are clairvoyant or telepathic (Furnham & Crump, 2014). In addition, they report unusual perceptual experiences, including such illusions as feeling the presence of another person when they are alone. Notice the subtle but important difference between feeling as if someone else is in the room and the more extreme perceptual distortion in people with schizophrenia who might report there is someone else in the room when there isn't. Unlike people who simply have unusual interests or beliefs, those with schizotypal personality disorder tend to be suspicious and have paranoid thoughts, express little emotion, and may dress or behave in unusual ways (for example, wear many layers of clothing in the summertime or mumble to themselves) (Chemerinski et al., 2013). Prospective research on children who later develop schizo- typal personality disorder found that they tend to be passive and unengaged and are hypersensitive to criticism 3.perform on tests involving memory and learning, suggesting some damage in the left hemisphere (Siever & Davis, 2004). Other research, using magnetic resonance imaging, points to generalized brain abnor- malities in those with schizotypal personality disorder (Modinos et al., 2009; Lener et al., 2014).

1.antisocial and impulsive behavior—partly caused by the child's difficult temperament and impulsivity (Chronis et al., 2007; Kochanska, Aksan, & Joy, 2007)—alienates other children who might be good role models and attracts others who encourage an 2.treatment One of the major problems with treating people in this group is typical of numerous personality disorders: They rarely identify themselves as needing treatment. Because of this, and because they can be manipulative even with their therapists, most clini- cians are pessimistic about the outcome of treatment for adults who have antisocial personality disorder, and there are few docu- mented success stories (National Collaborating Centre for Mental Health, 2010). In general, therapists agree with incarcerating these people to deter future antisocial acts.

1,hese behaviors may also result in the child's dropping out of school and a poor occupational history in adulthood, which help create increasingly frustrat- ing life circumstances that further incite acts against society (Thomas, 2009). This is, admittedly, an abbreviated version of a complex sce- nario. The important element is that in this integrative model of antisocial behavior, biological, psychological, and cultural factors combine in intricate ways to create someone like Ryan. 2.Clinicians encourage iden- tification of high-risk children so that treatment can be attempted before they become adults (National Collaborating Centre for Mental Health, 2010; Thomas, 2009). One large study with vio- lent offenders found that cognitive behavior therapy could reduce the likelihood of violence 5 years after treatment (Olver, Lewis, & Wong, 2013). Importantly, however, treatment success was negatively correlated with ratings on the PCL-R for traits of "self- ish, callous, and remorseless use of others." In other words, the higher the score on this trait (which we have seen is related to psychopathy), the less successful th

1. Schizophreniform Disorder 2. Brief Psychotic Disorder 3. Schizoaffective Disorder

1. "Schizophrenia" that lasts between 1 - 6 months - freniform is diagnosis before 6 mothers - May progress onto schizophrenia if it lasts more than 6m-Associated with relatively good functioning - if doens not go on schizophrenia and if only acutely experience -Most patients resume normal lives 2. 1. Briefest duration of all psychotic disorders! -Positive symptoms of schizophrenia and/or disorganized speech or behaviour -Lasts less than 1 month -Briefest duration of all psychotic disorders -Typically precipitated by trauma or stress 3. "Schizophrenia" plus a major mood episode (manic or depressive) -Psychotic symptoms must also occur outside the mood disturbance for at least two weeks - weeks as somep people diunirng manic or depressige episodes may have psychotic symtpoms, spo need to isolate it 1. This is because manic/depressive episodes may themselves cause psychotic symptoms -Prognosis is similar for people with schizophrenia -Such persons do not tend to get better on their own - may need psychosocial treatment and medication

1. 2. Hyperactivity and impulsivity

1. (2) Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. -Often fidgets with or taps hands or feet or squirms in seat; with pens -Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). -Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.) -Often unable to play or engage in leisure activities quietly. Is often "on the go," acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with). -Often talks excessively. -Often blurts out an answer before a question has been completed (e.g., completes people's sentences; cannot wait for turn in conversation). -Often has difficulty waiting his or her turn (e.g., while waiting in line). in conversations or in general -Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing). B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities). D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder

1. paraphillif disorder - Whats an a =typical fetush

1. - The other category - Para meaning strong attractions and ohillia mean abnormal sexual behaviour - Fetishistic disorder l ; fekale undergarments, non-hgeniral body parts - Voyeuristic disorder; - Exhibitionistic; exposing gaenatila to unsoespecting people - Sadism - Only considered paraphilic disorder, if cause distress ot hatm Cars fetishes ; dpendsd on levekl of distress - Why is it delusional disorder and not fetishistic; as not only getting sexual arousal aout of it oits also committd relationshop, saying car receives enjoyment reather than just he receives enjoyment

Amanda was a 35-year old unemployed, woman with a high school education who wanted to live her life without taking drugs. At the time of the interview, she was using ecstasy three days per week on average, which was more frequently than she desired. She said that her ecstasy use would last several days to avoid withdrawal symptoms, such as increased depression, fatigue, and loss of appetite. Amanda reported that her ecstasy use was due to her reduced interest in socialising with others and depression, which she attributed to experiencing the death of loved ones and relationship difficulties with her boyfriend. She had tried multiple times to quit through going cold turkey or replacing her ecstasy use with oxycontin, which was obtained outside of a prescription. She was persistently concerned about her use, as she believed that her ecstasy use had exacerbated her longstanding history of depression and anxiety symptoms and that it significantly impacted upon her social and occupational functioning. She described receiving ecstasy on two to three occasions per week in exchange for sexual or criminal favours. She had several pending legal cases related to possession and fraud charges. Which

1. ****??MDMA is a synthetic drug that acts as a stimulant and hallucinogen. ... It produces an energizing effect, distortions in time and perception, and ...

1. Cluster A: Schizotypal Personality Disorder • Prevalence 2. Characteristics 3. Causal factors 4. • Treatment

1. - 1% - Males more than females 2. Better studied than other Cluster A disorders -Appears to be part of the schizophrenia spectrum 1. Recommendation to remove other cluster A disorders and keep this one due to lack of research on others 3.1. Genes - linked to schizophrenia § Occurs more in 1st degree relatives § Teens with schizotypal PD have greater chance of developing schizophrenia in adulthood 2. A separate ccause; Childhood maltreatment/trauma - not genetically related to schizophrenia § Applies more to men than women - Low SES 4. • Low doses of antipsychotics • SSRIs Address comorbid depression using CBT -Lack of RCTs

1. Recent Illicit Drug Use (Australia) 2. ANY 12-MONTH MENTAL DISORDER 3. In substance use disorders itself 4. - Most common disorders in any given uear

1. - 1st most common: Cannabis 1. 10% use cannabis in a year, 40% in a lifetime - 2nd most common: Pharmaceuticals/opiates 1. 3.5% in a year use pharmaceuticals for their intoxicating effects, pain relief - 3rd most common: Cocaine 1. 2.5% in a year - 4th most common: Ecstasy 2. - 20% in a year will experience a mental health disorder 1. 14.4% anxiety 2. 6.2% affective 3. 5.1% substance use 3. 1. 2.9% harmful alcohol use (not meeting dependence criteria) - Most common disorders in any given uear -alcohol dependence which is 1.4 and drug use disorders 1.4% 4. . 1. PTSD (6.4%) 2. . Social Phobia (4.7%) 3. Depressive episode (4.1%) 4. Alcohol harmful use (2.9%), in a harmful way but not si harmu to lead t dependence on drugs.

1. Substance Use Disorders (Australia) Demographics in Australia 2. The "Safe" Drugs (Australia); alcohol and smoking 3. DSM-5 Considerations

1. - 1st most likely: 16-24yo then 25-34 1. Gradually decreases with age, but likelhoof o anxiety disorders increase till 45 then decrease 2. 1. Involved in delinquent and victim in 40-50% of all murders, assaults, rapes 2. Involved in 67% domestic violence cases 3. 1% of babies have fetal alcohol spectrum disorders 4. Disrupted sleep - Smoking 1. Most preventable cause of disease 2. Children of smokers likely to suffer negative health effects than those of non-smokers 3. Disrupted sleep patterns, associated with dementia - Account for more health problems and mortality rate than all illegal drugs combined 3. DSM-IV considered substance abuse and substance dependence as separate diagnoses -DSM-5 combines these into one substance-related disorder and describes them as mild (2-3 criteria), moderate (4-5 criteria), or severe (6+ criteria) also Added "craving" and Removed "legal problems"

1, Alcohol in Australia;2016 National Drug Strategy Household Survey

1. - 80% drink occasionally - 17% overall and 26% in rural areas will drink over the risky lifetime drinking guideline (over 2+ stds per day) -26% of people living in remote or very remote areas exceeded the lifetime risky drinking guidelines -15.4% drink 11+/occasion, but 29% of those 18-24 y.o. -5.9% drink daily -48% of drinkers attempted to reduce their intake due to health concerns -1 in 6 put themselves or others at risk when under the influence -1 in 4 were the victim of alcohol-related harm

1. ABA; bf skinner

1. - ; behaviour changeabke through positive reinfprcement , and condeuwnces - of behavior behavior that is reinforcedm- tends to rewire us and becomes our - default behavior he also found that - behavior that is not reinforced will - dissipate over time - Skinner's research is commonly seen in - learn to walk talk and avoid picking up - 4:51 - hot things through repetitive training - 4:53 - from our parents or loved ones we learn - 4:56 - most of our basic life skills through - 4:58 - appetitive reinforcement reinforces are - 5:01 - essentially the outcomes of the rewards - 5:04 - or Consequences from our own behaviors - 5:07 - for example rewarding a child for - adult ABA therapy is a changing behavior - 5:40 - by looking at what is reinforcing the - 5:44 - behavior so things that happen after a

1. Predictors of Illicit Drug Dependence 2. Dopamine and Reward System

1. - Severe, chronic early life stress - Drugs/alcohol before adulthood - Cigarette use - Depression - Male - Low education/SES - High neuroticism - Conduct disorder 2. All drugs of abuse increase dopamine in the nucleus accumbens -This brain response helps us to learn which stimuli are associated with reward and increases our reward-seeking behaviour - Increase reward-seeking behaviour, what drigs and cues associated with rewards - Dopamine: Associative learning/reward learning

1. Treating Sexual Dysfunctions Read Conversation Article (Find on LEGANTO) https://theconversation.com/why-we-should-treat-depression- anxiety-and-sexual-dysfunction-together-24226 Should sexual dysfunction be a symptom of depression or anxiety disorders? Should sexual dysfunction be assessed when a person comes in for treatment for depression or anxiety? 2. - Slide; receleaiming female sexual desire

1. - if functijoning high anxiety all the tim eexpercting something to haopopen its ard to desire sexually , mindfulness is important' - Need to be assessed to see severitu of anxiety and edepressison or to improve ot - You can have sexual dysfcuntcion without depression and axiety so don't oiver pathologise them 2. - How do we know when it's a dysfunction versus when someone just doesn't like sex?(i.e., asexuality) , its when they are distresse

1. ; Gender Dysphoria - In relation to transgender sometimes, but related to agender, gender queer Children's criteria for transgenderism 2. CHOC VideoGENDER DYSPHORIA IN CHILDREN AND TEENS

1. - is more strict. It can be normal for children to play around with gender roles - Has to clcause clinicallay significant, marked distress - Its only when child;s feeling sdistressed or uncomnfortable wearing the clothes they wear 2. - CHOC practices gender affirming therapy - Some people unmatched with assigned gender at birth, or even gender non-conforming - Why trans? Genetics, culture - If parent starts wondering if child is trans or gender non-conforming- see wherrethey are coming from, not easy on themsekves pr the family - Try npt to change the ide aof child rather than sea can fix ethem , give them safety and security rather - Encouraging adolescents and children to feel comfortable expressing who they feel they are

1.Should we use the terms alcoholic / drug addict? We often hear the term "alcoholic" and "drug addict", but what do they mean? What do you think of when you hear these terms?

1. - labels assume the persons problem is what identoefies them - Say indovodal with alcoghol problem and substance use disorder - Tolerance and withdrawl symoptoms - Withdrawsl; physcically responding negatively when no longer taken - Tobacco does not have intocication disorder - Dopamine is the crvavung

1. by lookibg at what reinforces the behaviour can help change it,

1. - look at pricniples of behaviour, set up environ,enmtal antecedents for the behavopri, and if the behaviour we want shows up can expect to do it in futute - tiny goals ; bad socisll interactons to being toleant; it's a daily battele - teach child colours; if child keep picking red when its yellow, so move yellow apple closer to them , yhen give reinforcement like high five, edibe or praise, say that's a good thinking, so then expect correct answer next time - develop into more advanced skills , =start with little steps, get child where they need to be in ABA - doesn't

1. Clip 2 Anorexia 2. Class Discussion What causes or leads to the development of eating disorders? What other eating disorders were mentioned in the videos? What are their defining features? Why do females have higher prevalence rates than males? Do eating disorders and body image problems look different in males?

1. - more cutting back as much as possible, in denial don't thinj have oreivlem , maintains it , because society gives complenents when losing weight - When people say you look goof continuwa - Trash eat, nothing could stop 2. - Cross over to different ones ofver time, 25% of whose have bulimia had anorexia in the bast - Anorexia and bulimia difference - Bulimia ; undereating and overaeating cancels each t ] - In anorexia undereatong is a lot, leads to starvation - Eating disorder most culturally linked disorder , as countries nbecome westrnised, prevalence increases - Social media , trends in body image reinforces eating disorder - Now mgazines focus on male body image concerns ,like muscularity - Both men and women share fear of being fat however females drive for thinness and males drive for muscularity , so maybe underestimating eating disorders for men because we have poor measurements, how eating disorder is measured - 25% of those with eating sorsprders are males - -revalence of eating disorders for males is undersstimated as they are stigmatised to reach out for treatment - Sexuality issues for both genders

1.- disorders, symptoms, demographics, treatmenrs - don't focus on dsm changes too much- disorders, symptoms, demographics, treatmenrs - don't focus on dsm changes too much 2.Arturo is 32 and manages a popular bar. He has a few drinks at the end of each night shift, and goes out with colleagues a few times a month and gets drunk. He used stimulants sporadically when he was younger, mostly cocaine. In the past few years his stimulant use has become more frequent, and he now uses several times a week. It has caused financial strain as he needs more and more of the stimulants to get the same effect, and this caused many arguments with his wife. Though she is unaware of the extent of his substance use, they argue a lot about the time and money Arturo spends socialising, and the effect it has on his two young kids. Arturo has tried to cut down his use but has been unsuccessful due easy drug availability and the stress of his job, and is concerned that his wife may leave him if things don't improve. Discussion points: What disorder(s) do you think Arturo might have?What symptoms of Arturo's stand out to you?What other information would you like to know to be confident in your • 1. 2. 3. diag

1. - same criteria with one additition of cravings - be on drg without abusing it ; prescription drugs - physiological suyntpms depend on the substance and how strong additive it is, stimulant or depressant, ow one metabolises the substance 2. - stimulant use disorder ] - unsuccessdul attempts to quit, several times, tolerance, - moderate severity; 4-5 symptoms - may be ask about cravings, explore urges as well to check urges aren't severe 3. neurobiology, associative learning. cognitive factors, environmental factors - early life experiences affect the risk of developin - changes in dopanmine release result from the positive and negative reinforcement directly and indirectly - slide; eqofinality, different early life experiences, substance abuse, childhood abuse can lead to the same outcome and same psychological disordere

1. Cluster B: Borderline Personality Disorder • Prevalence 2. Cluster B: Borderline Personality Disorder • Comorbidity 3. • Suicide 4. TYPE OF ABISE

1. -1-2% overall -10% of outpatients -15-20% of inpatients -Female: male ratio = 3:1 ratio (old stats) -Female: male ratio = 1:1 ratio (current stats)\ 2. - Well researched - above all other PDs -80% meet criteria for major depression -10% meet criteria for bipolar disorder -67% meet criteria for substance use disorder -Often comorbid with schizotypal, narcissistic, and dependent personality disorder§ If personality styles are consistent and pervasive, how do they have multiple styles of personality? 3. 25% make at least one attempt -8-10% will end their lives by suicide - Suicidial trheats to seek attention and reduce abandonment , baut cannot think like this, tale theoir threats seriously 4. Emotional Abuse 79% in BPD and 51% in other -Physical Abuse 59% in BPD 34% -Sexual Abuse 61% in BPD in other pd 32%

1. Australian Standards of Care stipulate access of puberty blockers requires: 2. Treatment for Adults • WPATH (World Professional Association for Transgender Health) criteria are used

1. -A diagnosis of gender dysphoria -Fertility preservation counselling -Consent from a parent/guardian - Treatment specific to child's needs and environment - For afolescents not elligibke for surgwries, piberty blockers help prevent unwanted secondary sex characteristics -Prescription of puberty blockers during adolescence decreased lifetime odds of suicidal ideation among transgender individuals (N = 85 20,619, aged 18 to 36 years; 2020) 2.• No diagnosis required to access hormonal therapies • Medical gatekeeping can occur where the attitudes of the medical practitioner may impact how accessible the treatments are for individuals

1. Biological Influences • Neurobiological contributions 2. Public Service Announcement • Neurobiological influences

1. -Brains become significantly larger between the ages of two and four than those of non ASD individuals, but not all individuals with ASD have larger brains -Brain growth appears to slow abnormally in later childhood -Larger amygdala at ages 3 and 4 related to more social and communication difficulties at age 6 -Enlarged cerebellum associated with less exploration of surroundings § Neurons perhaps not pruned correctly for people with ASD - pruning helps us meet developmental milestones (older children frwer uneccessaru connections so may be why not happening for ASD children) -Low levels of oxytocin in individuals with ASD • Bonding and social memory 1. Low levels of oxytocin, perhaps leads to poor bonding and poor social memory; perhaps explaining the low interest in social interactions 2 • Vaccinations do NOT increase the risk of autism • A meta-analysis examining 1,256,407 did NOTsupport a link between vaccines and autism! • Health risk of not vaccinating is substantial

1. Substance Intoxication 2. Substance Withdrawal

1. -Development of reversible substance-specific problematic behavior due to the acute ingestion of a substance •Can occur without a substance-use disorder;1. , maybe domeone celebrates and gets too much alcohol, but only on that oparticilar occasion and perhaps forst time 2. -Development of a substance-specific problematic behavioural change, with physiological and cognitive components, that is due to cessation of or reduction in HEAVY and PROLONGED USE. - If someone drink firtnigtly and then one time drink 6-7 beers , don't call this withdrawal as it has to be heavu and prolonged use - Body ahad to become accustomed to the intake of drug so function differently so when not. Body has to readjust o before intake of drugs

1. Predictors of Alcohol Abuse 2. • Tobacco;2016 National Drug Strategy Household Survey

1. -Drinking at an early age -Low level of response to alcohol;1. Need higher doses for desired effects -Family history of alcohol use disorder;1. Seems to be genetic - 40% heritability (children of gfathers wo have alcohol problems) -Increased positive alcohol expectancies -High impulsivity -High novelty seeking 2. • People living in the lowest socioeconomic areas are more likely to smoke than people living in the highest socioeconomic area -14.9% current smokers -12.2% smoke daily -Smoke ~94 cigarettes/week -31% have tried electronic cigs, but only 4.4% currently use them -3 in 4 tried to reduce/quit smoking due to $$ or health problems -3 in 10 who try to quit were unsuccessful -1 in 3 have no plans to quit, but 42% may be motivated to change if their health deteriorates 1. Most common 18-24yo (7% use them) 2. Young people: Use due to curiosity 3. Old people: Use due to wanting to quit

1. Psychological Causes Mood alteration 2. Outcome expectancies influence use

1. -Drugs can increase positive affect and diminish negative affect 1. (more stressors ), placeoobo effect of think thyll relax us tjen it will -Increases in negative affect and negative life events predict drug use -Ability to reduce negative affect is influenced by abstinence and distraction 1. Moderating impact: § How distractive drug is, so if playing gam,e whilst usng drug then higher effect in decreasing negative affect § Abstinence: , drug use mor elikely to ndevcrease negative affect after abstinent for a while, Drug use after abstinence leads to greater decreases in negative affect, 1 month vs 2 weeks 2. -People use a drug not because it changes their mood, but because they think it does -Balanced placebo designs -Greater positive expectancies predict greater use and greater problems - one group receive alcoghol and otld, but other group told but don't receive it, both same effects 1. Drug will have the effect we expect, e.g., if we expect a drug to relax us, we will feel more relaxed by it 2. Positive expectancies predict greater use/greater problems 3. Balanced placebo design § Half of people receive alcohol, know they're consuming alcohol § Half of people don't receive alcohol, believe they're consuming alcohol · Can have the same effects as drinking alcohol!

1. Obesity WORLD-WIDE STATS 2. Clips 1 and 2 RESTRICTIVE EATING, ANOREXIA, BULIMIA, BINGE EATING;Think about what causes eating disorders

1. -Obesity has nearly tripled since 1975 -1.9 billion adults are overweight (39% of the population) -650 million adults are obese (13% of the population) -In 2016, more than 1.9 billion adults, 18 years and older, were overweight. Of these over 650 million were obese. -41 million children under the age of 5 are overweight or obese -Obesity contributes to Type 2 diabetes, cardiovascular disease, musculoskeletal disorders, some cancers 2. binge eating disorder - Lack of sleep, psych attributes - Painful childhood experience s cause it to develop, - Feel ashamed of it - Loss of brother - Sometimes not all at once , but its constand then negative self-evaluation afyer eating, guilty for the forst time then do it again - Meal plan is important - If treatment do wellthen overcomes\ - Social and anvironmental factos as well

1. Challenges 2. 5-Factor Model of (normal) Personality - OCEAN traits make up normal personality - Dimension/continuum of each factor Researchers unsure whether 5-factor PICTURE

1. -Overlapping features across disorders -Overlapping features across the categories -High comorbidity among the PDs -High comorbidity with other disorders -Symptoms are highly subjective -Misdiagnosis is common -Personality researchers generally agree that personality is dimensional, but can't agree on a dimensional system for PDs - Subjective symptoms - endorsing criteria may depend on how one interprets question (subjective criterion), so get different disorder depending on interpretation - Commonly misdiagnosed - Dsm5 watnted to follow 5 factor ,odel and get rid of 4 disorders, so countdnt agree on dimensional system for personality disorders , so things stayed relatively sa,e to dsm 4 2. 1. model should be used for personality disorders - 6 facets for each dimension (30 in total), different levels for each facet 1. If this is translated to measure personality disorders, there will be many more disorders than just 10 due to high number of combinations

1. The Acute Effects of Nicotine 2. The Long-term Effects of Nicotine

1. -Reaches the brain within 7-19 seconds (so addicted as, effects experienced quicly) -Influences nicotinic acetylcholine receptors -Increases energy -Improves mood Influences glutamate • Might help us remember that nicotine makes us feel good and increase desire to keep using it 1. May help us remember the good feeling of nicotine, remid sus desire of wanting to ise it 2. - Withdrawal 1. Insomnia, increased appetite, restlessness, trouble concentrating, anxiety, depression, irritability - Loss of taste/smell - Yellow teeth/decay, bad breath - Premature ageing - Poor immune response - Respiratory disorders - Cardiovascular disorders - Gastrointestinal disorders - Cancer 1. Also resistance to chemo and radiotherapy agents, less likely to recover fro it - 2/3 of long-term smokers die of smoking-related disease!

1. Treatment Behavioural Treatment 2. Preferred model 3. - Children with autism... - Parents just waiting to be formerly fiagnosed - Now just one diahgnosis ASD, used to be different subsets\ - Low functioning Aitism just a spectrum , some have only little

1. -Skill building -Reduce problem behaviors -Communication and language training -Increase socialization -Naturalistic teaching strategies;1. Incolve children in Naturalistic teaching environments and use naturalistic teaching strategies -Early intervention is critical - may "normalize" thefunctioning of the developing brain1. outcomes better if act early 2. • ABA + Special education at school focused communication + Family support - family support to manage extra hlel 3. - Children with autism... - Parents just waiting to be formerly fiagnosed - Now just one diahgnosis ASD, used to be different subsets\ - Low functioning Aitism just a spectrum , some have only little § Recoil from situations, intolerance of environments § Food sensitivity issues as very sensitive to taste and smell of foof - Beginning to acccpet diagnosis is wht helps

1. ROGD Controversy Expert view is that a "rapid onset gender dysphoria" 2. Diagnostic Controversy

1. -is empirically unsubstantiated -However, in public or media discussions ROGD is has been used to question the legitimacy of an adolescent's stated gender identity -Alternative explanations for apparent social contagion include that learning about other people's experiences (such as with gender dysphoria) can allow individuals to better recognise their own experiences - Known to , so don't use these terms uneccessarily - Learning abiut how gender works for other people allows binary and non-binary people to recognise their transgender experiences - Adolescenses may seem as they ahad rapid onset but actually recognition and naming of experiences that were previouslybunexplainable. 2. Stigma versus access to care - Disorders are social constructs whose criteri based on culture/context, - Shouldn't pathologise people for internalising society's stigma - could increase the stigma for normal childhood experiences 1. However, pathologising it allows for easier access to care due to insurance companies etc.

1. In addition to gender differences in sexual behavior, it also seems that there are differences in sexual behavior based on sexual orientation. 2. Cultural Differences What is normal in Western countries may not necessarily be nor- mal in other parts of the world (McGoldrick, Loonan, & Wohlsifer, 2007). The Sambia in PapuaNew Guinea believe semen is an 364 CHAPTER 10 sexual DysfuNctIoNs, ParaPhIlIc DIsorDers, aND GeNDer DysPhorIa Barlow, David, et al. Abnormal Psychology : An Integrative Approach, Cengage, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mqu/detail.action?docID=5776289. Created from mqu on 2022-05-09 10:31:49. essential substance for growth and development in young boys of the tribe. They also believe semen is not produced naturally; that is, the body is incapable of producing it spon- taneously.

1. . For example, in one study using U.S. college students (Oswalt & Wyatt, 2013), researchers found that men who identi- fied "unsure" had more partners than those who identified as gay, bisexual, or heterosexual and that heterosexual men had fewer partners than gay, bisexual, and "unsure" men. On the other hand, women who identified as bisexual had more partners than women who identified with other orientations. What happened to the sexual revolution? Where are the effects of the "anything goes" attitude toward sexual expression and fulfill- ment that supposedly began in the 1960s and 1970s? Clearly there has been some change. The double standard has disappeared, in that most women no longer feel constrained by a stricter and more conservative social standard of sexual conduct. The sexes are defi- nitely drawing together in their attitudes and behavior, although some differences in attitudes, core beliefs, and behavior remain. 2.Therefore, all young boys in the tribe, beginning at approximately age 7, become semen recipients by engaging exclusively in homosexual oral sex with teenage boys. Only oral sexual practices are permitted; masturbation is forbidden and absent. Early in adolescence, the boys switch roles and become semen providers to younger boys. Heterosexual relations and

1.- Added craving as a diagnostic criteria 2. - Removed legal problems as diagnostic criteria

1. 1. Added based on multidisciplinary research, craving central to distinction , key criterion for determining thse with SUD 2. May be a key to helping people overcome SUD 2. 1. Didn't map onto unidimensional model; all croteria mapped onto both dependenca and ise except legal problems 2. Was not very helpful, as people who had legal problems usually also had a host of other symptoms anyway so wanst need ed to identify the indovodials § Individuals still met criteria for substance use disorder with this legal problems criteria removed

1. Criterion in the gender dysphoria diagnosis for children have been critiqued as one reason that children have not been given access to treatment 2. Diagnostic Controversy for Children

1. 1. Critcisism for study on children points toward the inclusion of criteria related t contersteriytpicla play and peers, criteria allow geneder dyspjoraig=diagnoses to be given to feminine or tom boys , so a broaf group of gender nonconformi g children may be diagnosed with gender dysphoria even when some of them do not displau yje ncistencye of gender , which is more reflective in adolescence 2. Follow-up studies show a large proportion of gender dysphoric children to "desist" in their gender dysphoria during adolescence or adulthood -Other research has indicated children who fit criterion A1 are most likely to persist in gender dysphoria Some children may be engaging in counter stereotypical activities but are experiencing distress due to social stigma for nonconformity Research may not properly identify children who are likely to persist due to ongoing cultural stigma around gender nonconformity

1. - Unspecified substance disorder 2. Substance Use Disorders;Course Specifiers 3. - In a controlled community 4. On maintenance therapy 5. - Severity

1. 1. Impaired functioning but ; Don't meet full criteria as number 2 meets criteria for SUD(only meet one criteria) 2. - Remission 1. Early remission (3-11m) 2. Sustained remission (12m+) 1. No criteria must be met during this time except for craving for both above § Craving may never stop; When someone stops using, the associative learning (negative reinforcement) between cue-drug isn't extinguished 3. 1. in rehab and don't have access to drugs, so maybe explaining wgy in early remission 4. - On maintenance therapy (opioids, tobacco) 1. Taking a substitute 5. -Mild (2-3 sx) -Moderate (4-5 sxs) -Severe (6+ sxs)

1. - Male hypoactive sexual desire disorder 2. Premature Ejaculation 3. - Female sexual interest disorder

1. 1. Lacking interest in sex and fantasising 2. Clinician should consider age, sociocultural factors, etc. 2. 1. reached within 1 minute of vaginal penetration, and before it is desired to be reached 2. Diagnosis can be given in non-vaginal penetration situations, but time is not specified 3. 1. Lacking interest in sex, reduced arousal, characterised by 3+ listed symptoms - Female orgasmic disorder - Life long aor aquired - Transcietnt symptoms of these are really common (like whils grieving or stresdful siuations would be nlornal) - Not explained by depression, anxiety , severe relationshop problem or ptsd

1. - Severity: Mild/moderate/severe/extreme 2. Bulimia Nervosa • Prevalence 3. Age of onset g 4. Most have comorbid psychological disorders 5. Bulimia Nervosa • Key Features

1. 1. Mild if 1-3 compensatory behaviours 2. Moderate 4-7 compensatory behaviours 3. Severe 8-13 compensatory behaviours 4. Extreme 14+ compensatory behaviours 2. • 1% overall • 1.5% for women • 0.5% for men 3. enerally between 21-24 years of age (women) 4. • 50 to 70% have met criteria for a mood disorder at some point • 80% have met criteria for an anxiety disorder at some point, commonly PTSD, Social Phobia, or OCD • Nearly 2 in 5 people abuse substances 5. -Binges may involve up to 4,800 calories -Foods consumed are often high in sugar, fat, or carbohydrates -Most individuals are within 10% of normal body weight -Compensatory behaviors - designed to "make up for" binge eating -Purging: Self-induced vomiting, diuretics or laxatives -Non-purging: Excessive exercise, fasting or food restriction -Most are overly concerned with body shape -Fear of gaining weight -Guilt, shame, or regret 25-30% attempt suicide, but rate of suicide is not higher than the general population

1. - Sex Reassignment Surgery 2. Treatment for Gender Dysphoria 3. 1. Conflict between affirming identity or encouraging cisgender behaviour

1. 1. Must be psychologically/socially stable and live as desired gender for years first 2. 75% report satisfaction 3. F2M adjust better than M2F - Hormone therapues prescribe dby GP, - Treatment of intersexuality 1. Surgery at birth § May cause gender dysphoria 2. -Treatment plans should be devised with the specific needs of the client in mind -Match specific gender dysphoria experiences to relevant treatment, e.g. social transition for social related dysphoria -Mix of treatments are often appropriate 3. - Treatment specific to child's needs and environment - For afolescents not elligibke for surgwries, piberty blockers help prevent unwanted secondary sex characteristics - For adults don't need diagnosis , just prescribe by gp - The criteria reference body and mind experienced son need to match the treatment to experience, if desire to be treated as another genderm, then social and legal transition may be better

1. Gambling Disorder Comparison with Substance-Use Disorders - Similarities with other substance-use disorders 2. - Unique to gambling disorder 3. - Unique to substance-use disorder

1. 1. Tolerance 2. Loss of control 3. Withdrawal 4. Negative consequences; risked or lost a significant relationship, educational or work-related opportunity because of gambling 5. Fixation; preoccupation with gambling-related thoughts such as reliving past gambling experiences, planning future experiences, or strategising ways to fund gambling behaviour; just as with alcohol; its excessive time, spent ibraining, using, or recovering from alcohol 2. 1. Negative affect; gambling in response to negative effect 2. Chasing losses; follows gambling losses by retiring another day to recoup money 3. Lying 4. Bailouts; depends on others for money to alleviate desperate financial situations caused by gambling 3. 1. Hazardous situations

1. Combined bio-psycho-social treatments 2. Public Service Announcement • Treatment 3. Autism Spectrum Disorder Label is new to DSM-5 Encompasses several disorders previously classified as

1. 1. e.g., medication + behavioural treatments) § Perhaps superior to medication or behavioural treatments alone in short-term · More research needed for long term outcomes 2. • Although additives in food may influence ADHD symptoms for a subset of children • Most children do not respond positively to the Feingold diet! • Also no evidence that refined sugar contributes to ADHD 1. No evidence that refined sugar contributes to ADHD 2. Not that helpful 3. "pervasive developmental disorders" - As not differ from each other only in the severity of symptoms • Including: • Autistic disorder • Asperger's disorder • Childhood disintegrative disorder • Rett syndrome

WEEK 11 1. - schizophrenia

1, - Slide; schizophrenia - Wring in head; paranoid of people, being afraid of people saying and doing thgs, projecting own issues to others, psychosis , traying to take Valium to calm down - Hear people;'s thoughts, screaming , voices , visions of violence, hallucinating blood down walls uring exams, seeing mutilated faces of loved ones - Voices punisjh them if they tell someone - Deny the problem, affecting finances, shelter, appetiute, stpop eating and drinking - Not untuil close to death that f=he realised something was wrong - Did not smoke too much feed; stigma . everyone think just taking drugs - Why it happened to me? Genetic (similar to father's experiences, predisposed to be at risk)genes for scizoaffective disorder and emnvironmental factors (brth drayma, stressful periods, CSA) - Lost identity, hope, purpose, a rwadon to get out of bed after diagnosis - Marriage broke - whoa re your voices, no voiceds tdue to medication controlling them, no voices, some have deceased voices, voices of unborn children (came to life), male and female voices; abuse with posh accent, say the most embarrassing and vile things that only oneslelf would nknow; no one else could have come upn with the script - Face revolting you're evil, food is poisoned , you stuoid, idiot, little shithead, kill herself now, people in ambulance hoping to murder herl voices get louder until they oblige, - Learn how to manage iit - Is government out to get you; centrelink

1. • Prevalence 2. Characteristics; 2 types and its causes 3. • Treatment

1, 1% overall -Might be more common in men 2. 1. Vulnerable: Act narcissistic but also are ashamed don't believe it 1. Childhood abuse 2. Intrusive, controlling, cold parenting 2. Grandiose: Act and believe narcissistically 1. Parental overevaluation perhaps leads to grandiosity 3. Focus on grandiosity, lack of empathy, unrealistic thinking -Emphasize realistic goals and coping skills for dealing with criticism -Little evidence treatment is effective

1. intoxication Our physiological reaction to ingested substances—drunkenness or getting high—is substance intoxication. 2. substance use disorders Defining substance use disorders by how much of a substance is ingested is problematic. For example, is drinking two glasses of wine in an hour abuse? Three glasses? Six? Is taking one injection of heroin considered abuse? The fifth edition of the Diagnostic and Statistical Manual (DSM-5) (American Psychiatric Association, 2013) defines substance use disorders in terms of how significantly the use interferes with the user's life. 3. Danny seems to fit this definition of a disorder. His inability to complete a semester of community college was a direct result of drug use. Danny often drove while drunk or under the influence of other drugs, and he had already been arrested twice. Danny's use of multiple substances was so relent- less and pervasive that he would probably be diag- nosed with severe forms of the disorders. Substance use disorder is usually described as addiction. Although we use the term addiction

1, For a person to variables interact,including the type of drug taken, the amount tlogi- cal reaction. For many of the substances we discuss here, intoxication is experienced as impaired judgment, mood changes, and low- ered motor ability (for example, problems walking or talking). 2.ob, or relationships with others, and put you in physically dangerous situations (for example, while driving) you would be considered to have a disorder. Some evidence suggests that drug use can predict later job outcomes. In one study, researchers controlled for factors such as educa- tional interests and other problem behavior, and still found that repeated hard drug use (using one or more of the following: amphetamines, barbiturates, crack, cocaine, PCP, LSD, other psychedelics, crystal meth, inhalants, heroin, or other narcotics) predicted poor job outcomes after college 3. utinely when we describe people who seem to be under the control of drugs, there is some disagreement about how to define addiction (Rehm et al., 2013; Edwards, 2012). In order to meet criteria for a disorder, a person must meet criteria for at least two symptoms in the past year that interfered with his/her life or bothered him/her a great deal. When a person has four or five symptoms, he or she is considered to fall in the moderate range. A severe substance use disorder would be someone like Danny that has six or more symptoms. Symptoms for substance use disorders can include a physiological depen- dence on the drug or drugs, meaning the use of increasingly greater amounts of the drug to experience the same effect (tolerance), and a negative physical response when the substance is no lo

1. Slide particular treatments 2. Anna • Anna is a 38-year-old divorced woman who works in an administrative position for a large federal agency. She is well-established in her career and has several close friends with whom she enjoys spending time. She comes to you following years of unsuccessful attempts to get appropriate treatment for her binge eating. She reports a prior experience with counseling during college after she experienced a sexual assault. She shared with her counselor her concerns about binge eating but the counselor told her that they needed to remain focused on working through issues directly related to the sexual assault. Embarrassed for having brought up her binge eating behavior, she waited years to seek help again and, when she did on two other occasions, it was recommended that she meet with a dietitian to "learn how to eat healthily." She explains to you that she needs help with binge eating and that it's not a matter of knowledge - "I know what to do. I just can't do it. I cannot control my eating." She describes a pattern where she works hard to "get on track" with her eating but finds it difficult to maintain. She is 5'4"and weighs 180 lbs. She first starte

1, For bing e eating cbt and and onterpersonal therapy 2.excessively eats and hard to maintain, difficulty to control - Need to know if anna is engaging in compensatory strategies to rule out bulimia , how frequent is the binges - Learn about ipbringing - Needs help with relapse prevention , explore family and social support

1. Antipsychotics (AKA neuroleptics) • First-generation medications 2. Extrapyramidal adverse effects are common 3. • Second-generation medications 4., • Compliance with medication is often a problem

1, e.g. chlorpromazine, haloperidol 1. Reduce positive, disorganised symptoms (don't treat negative ) § As they Block D2 dopamine receptors (which have no effect on negative symptms) § Not a cure, but functioning will be better § Balance in that too mucygh medication isn't prodicimg he same amoint of symptoms as wthey were having wjen of schizophrenia symptoms 2. § Commonly experience extrapyramidal adverse effects · Parkinson-like symptoms: Drooling, tremors, muscular rigidity · Tardive Dyskinesia: Mouth muscles involuntary sucking/lip-smacking; permanent, no getting over it § Functioning rarely completely improves § Must start on lowest possible dose and balance benefit of taking them & side-effect• 3. e.g. aripiprazole, clozapine, olanzapine, risperidone -Mechanism of action differs from first-generation meds side effects -Weight gain -Sedation 4. 1. Aversion to side effects 2. Can't afford as low ses, on gov. assistance 3. Poor doctor-client relationship as cognoive and TOM deficits, also contribute to nit take medicaicaiojm

1. Treatment Behavioral treatment for children 2. Parent training to learn reinforcement system, 3. Adults:

1, • Reinforcement programs increase appropriate behaviors, decrease inappropriate behaviors • May also involve parent training · Punishment not effective! Only works when punisher is around and can lead to aggression so used as last respor · Reinforcement schefule; Getting up every dat at same time, brush alone , · May use token system for completing chores, not being disruptive for a certain period of time, etc. · Goal at the end is to cash in 80% of tokens at the end of the day so constant reinforcement and keep some to save up 2. § how to decreade punishment and reward posiytive behaviour , reward child; eg, if talking on phone for 3 kinutes, reward child for no t interrupting you, som parents think that this may increase symptoms due to giving them more attention however not turue so we get then to test these ideas out ; get them ti make a practice phone call • Intensive programs *might* be as effective as stimulant medication in the short-term§ term (don't come with risk of ncreasing tisksubstance abuse) 3. § Cognitive behavioural therapy to increase attention/organisation

1.Overview of Neurodevelopmental Disorders Almost all disorders described in this book are developmental disor- ders in the sense that they change over time. Most disorders originate in childhood, although the full presentation of the problem may not manifest itself until much later. Disorders that show themselves early in life often persist as the person grows older, so the term childhood disorder may be misleading. Because the developmental disorders in this group are all believed to be neurologically based, DSM-5 catego- 2. hildhood is considered particularly important, because the brain changes signifi- cantly for several years after birth; this is also when critical developments occur in social, emotional, cognitive, and other important competency areas. These changes mostly follow a pattern: The child develops one skill before acquiring the next, and subsequent skills often build upon one another. Although this pattern of change is only one aspect of development, it is an important concept at this point because it implies that any disruption in the development of early skills will, by the very nature of this sequential process, disrupt the develop- ment of later skills.

1,izes them as neurodevelopmental disorders (American Psychiatric Association, 2013). In this chapter, we cover those disorders that are revealed in a clinically significant way during a child's developing years and are of concern to families and educators. Remember, how- ever, that these difficulties often persist through adulthood and are typically lifelong problems, not problems unique to children. Again, a number of difficulties and, indeed, distinct disorders begin in childhood. In certain disorders, some children are fine except for difficulties with talking. Others have problems relating to their peers. Still other children have a combination of conditions that signif- icantly hinder their development, as illustrated by the case o 2.ctrum disorder suffer from a disrup- tion in early social development, which prevents them from developing important social relationships, even with their parents (Durand, 2014). From a developmental perspective, the absence of early and meaningful social relationships has serious consequences. Children whose motivation to interact with others is disrupted may have a more difficult time learn- ing to communicate; that is, they may not want to learn to speak if other people are not important to them. Researchers don't know whether a disruption in communication skills is a direct outcome of the disorder or a by-product of disrupted early social development.

1. hildren with ADHD are first identified as different from their peers around age 3 or 4; their parents describe them as active, mischievous, slow to toilet train, and oppositional (Taylor, 2012). The symptoms of inattention, impulsivity, and hyperactivity become increasingly obvious during the school years. Despite the perception that children grow out of ADHD, their problems usu- ally continue: it is estimated that about half of the children with ADHD have ongoing difficulties through adulthood (McGough, 2005). Over time, children with ADHD se 2.ections. They are also more likely to have driving difficulties, such as crash- es; to be cited for speeding; and to have their licenses suspended (Barkley, 2015b; Fabiano & Schatz, 2015). What happens to children and ado- lescents with ADHD as they become adults? Rachel Klein and her colleagues followed up on more than 200 boys with this disorder and reported on their status 33 years later ( 3.Diagnosing children with ADHD is complicated. Several other DSM-5 disorders, also found in children, appear to overlap significantly with this disorder. Specifically, oppositional defiant disorder (ODD), conduct disorder, and bipolar disorder all have c

1,r time, children with ADHD seem to be less impulsive, although inattention persists. During adolescence, the impulsivity manifests itself in different areas; for example, teens with ADHD are at greater risk for pregnancy and contracting sexually transmitted 2/tatus 33 years later (Klein et al., 2012). When compared with a group with- out ADHD, the majority of these men (84%) were employed but in jobs with significantly lower positions than the comparison group. They also had 2.5 fewer years of education and were much less likely to hold higher degrees. These men were also more likely to be divorced and to have substance use problems and antisocial personality disorder (Klein et al., 2012). In addition, the effects of their tendency to be impulsive may account for their increased risk of dis- playing risky driving, having a sexually transmitted disease, increased chance of having a head injury, and more emergency department admis- sions (Ramos Olazagasti et al., 2013). In short, although the mani- festations of ADHD change as people grow older, m 3.mpulsivity and hyperactivity observed in children with ADHD can manifest themselves in some of these symptoms. Similarly, conduct disorder—which, as you saw in Chapter 12, can be a precursor to antisocial person- ality disorder—is also observed in many children with ADHD (Toth et al., 2016). Bipolar disorder—which, you will recall from Chapter 7, is one of the mood disorders—also overlaps signifi- cantly with ADHD (Pliszka, 2015). This overlap can complicate diagnosis in these children.

1,Other Drugs of Abuse A number of other substances are used by individuals to alter sensory experiences. These drugs do not fit neatly into the classes of substances we just described but are nonetheless of great con- cern because they can be physically damaging to those who ingest them. We briefly describe inhalants, steroids, and a group of drugs commonly referred to as designer drugs. Inhalants include a variety of substances found in volatile solvents—making them available to breathe into the lungs directly. Some common inhalants that are used abusively include spray paint, hair spray, paint thinner, gasoline, amyl nitrate, nitrous oxide ("laughing gas 2.Users build up a tolerance to the drugs, and withdrawal—which involves sleep disturbance, trem- ors, irritability, and nausea—can last from 2 to 5 days. Unfortu- nately, use can also increase aggressive and antisocial behavior, and long-term use can damage bone marrow, kidneys, liver, lung, nervous system, and the brain (for example, leading to cognitive impairment for t

1,ry-cleaning fluid, and spot remover (Ridenour & Howard, 2012). Inhalant use is highest during early adolescence, ages 13 to 14, especially in those in correctional or psychiatric institutions. Additionally, higher rates of inhalant use are found among Native Americans and Caucasians, as well as those who live in rural or small towns, come from disadvantaged backgrounds, have higher levels of anxiety and depression, and show more impulsive and fearless temperaments (Garland, How- ard, Vaughn, & Perron, 2011; Halliburton & Bray, 2016). These drugs are rapidly absorbed into the bloodstream through the lungs when inhaled from containers or The high associated with the use of inhalants resembles hat of alcohol intoxication and usually includes dizziness, slurred speech, lack of coordination, euphoria, and lethargy (American Psychia 2. user and for infants born to mothers who use while pregnant) (Ford, Sutter, Owen, & Albertson, 2014). If users are startled, this can cause a cardiac event that can lead to death (called "sudden sniffing death") (Ridenour & Howard, 2012). Anabolic-androgenic steroids (more commonly referred to as steroids or "roids" or "juice") are derived from or are a syn- thesized form of the hormone testosterone (Pope & Kanayama, 2012). The legitimate medical uses of these drugs focus on people with asthma, anemia, breast cancer, and males with inad

1. causes and treatment Extensive research on the genetic, neurobiological, and psycho- social contributions to schizoid personality disorder remains to be conducted. In fact, very little empirical research has been published on the nature and causes of this disorder (Triebwasser et al., 2012). Childhood shyness is reported as a precurso 2.It is rare for a person with this disorder to request treatment except in response to a crisis such as extreme depression or los- ing a job (Kelly et al., 2007). Therapists often begin treatment by pointing out the value in social relationships 3.The therapist takes the part of a friend or significant other in a technique known as role-playing and helps the patient prac- tice establishing and maintaining social relationships (Skodol & Gunderson, 2008).

1,schizoid personality disorder. It may be that this per- sonality trait is inherited and serves as an important determi- nant in the development of this disorder. Abuse and neglect in childhood are also reported among individuals with this disor- der (Lobbestael, Arntz, & Bernstein, 2010; Carr, Keenleyside, & Fitzhenry, 2015). Research over the past several decades points to biological causes of autism (a disorder we discuss in more detail in Chapter 14), and research demonstrates significant overlap in the occurrence of autism spectrum disorder and schizoid personality disorder (Lugnegård, Hallerbäck, & Gillberg, 2012; Hummelen, Pedersen, Wilberg, & Karterud, 2014; Coolidge, Marle, Rhoades, Monaghan, & Segal, 2013; Vannucchi et al., 2014). It is possible that a biological dysfunction found in both autism and schizoid personality disorder combines with early learning or early problems with interpersonal relationships to produce the social deficits that d 2.erson with the disorder may even need to be taught the emotions felt by others to learn empathy (Skodol & Gunderson, 2008). Because their social skills were never established or have atrophied through lack of use (Caballo, Salazar, Irurtia, Olivares, & Olivares, 2014), people with schizoid personality disorder often receive social skills training 3.ype of social skills training is helped by identifying a social network—a person or people who will be supportive (Bender, 2005). Outcome research on this type of approach is unfortunately quite limited, so we must be cautious in evaluating the effectiveness of treatment for people with schizoid personality disorder.

1.obvious question is how these genes func- tion when it comes to addiction—a field of research called func- tional genomics (Demers, Bogdan, & Agrawal, 2014; Khokhar, Ferguson, Zhu, & Tyndale, 2010). Genetic factors may affect how people experience and metab- olize certain drugs, which in turn may partly determine who will or will not become regular users (Volkow & Warren, 2015). Just to illustrate how complex these relationships can be, research has found that certain genes are associated with a greater likelihood of heroin addiction in Hispanic and African American populations (Nielsen et al., 200 2.neurobiological influences In general, the pleasurable experiences reported by people who use psychoactive substances partly explain why people continue to use them. In behavioral terms, people are positively reinforced for using drugs. But what mechanism is responsible for such experi- ences? Studies indicate the brain appears to have a natural "plea- sure pathway" that mediates our experience of reward. All abused substances seem to affect this internal reward center in the same way as you experience pleasure from certain foods or from sex (Ray, 2012). In other words, what psychoactive

1,ther research points out that a pharmaco- logical treatment for alcohol use disorder—naltrexone (an opioid antagonist)—may be most effective with individuals who have a particular genetic variant in their opioid receptors (the OPRM1 gene) (Ray, 2012). In other words, your genetics may not only influence whether you develop a substance-related disorder but also help predict which treatments may be effective in reducing these problems. 2.uman brain is still subject to debate. It is believed that the dopaminergic system and its opioid-releasing neurons known as MOP-r receptors are involved. Opioids have an agonist effect at MOP-r receptors, which are spread throughout the central nervous system and are encoded by mu opioid recep- tor gene of OPRM1. This means opioids encourage more produc- tion of the brains' own opioids. The pleasure center of reward that keeps opioid users using is made up of MOP-r receptors mostly found in ventral and dorsal striatal areas and is highly influenced by the downstream activation of the dopaminergic mesocortico- limbic and nigrostriatal systems (Berridge & Kringelbach, 2015; Borg et al., 2015).

1.Expectations appear to change as people have more experience with drugs, although their expectations are similar for alcohol, nicotine, cannabis, and cocaine (Simons, Dvorak, & Lau-Barraco, 2009; Young, 2013). Some evidence points to positive exp 2.Once people stop taking drugs after pro- longed or repeated use, powerful urges called "cravings" can interfere with efforts to remain off these drugs 3.Social Dimensions Exposure to psychoactive substances is a necessary prerequisite to their use and possible abuse, as previously discussed. You could probably list a number of ways people are exposed to these substances—through friends, through the media, and so on. Research on the consequences of cigarette advertising, for exam- ple, suggests the effects of media exposure may be more influential than peer pressure in determining whether teens smoke (Jackson, Brown, & L'Engle,

1,ving you will feel good if you take a drug—as an indirect influence on drug problems. In other words, what these beliefs may do is increase the likelihood you will take certain drugs, which in turn will increase the likelihood that prob- lems will arise. 2.udes cravings as one of the cri- teria for diagnosing a substance-related disorder. If you've ever tried to give up ice cream and then found yourself compelled to have some, you have a limited idea of what it might be like to crave a drug. These urges seem to be triggered by factors such as the availability of the drug, contact with things associated with drug taking (for example, sitting in a bar), specific moods (for example, being depressed), or having a small dose of the drug. For example, one study used a virtual real- ity apparatus to simulate visual, auditory, and olfactory (an alcohol-dipped tissue) cues (Lee et al., 2009) for alcohol-dependent adults. The participants could choose among kinds of alco- holic beverages (e.g., r alcohol under these conditions (Lee et al., 2009). This type of technology may make it easier for clinicians to assess poten- tial problem areas for clients, which can then be targeted to help keep them from relapsing. Research is under way to determine how cravings may work in the brain and if certain medications can be used to reduce thes 3.large study, 820 adolescents (ages 14-17) were studied to assess what factors influenced the age at which they would have their first drink of alcohol (Kuperman et al., 2013). This study found several factors predicted early alcohol use including when their best friends started drink- ing, whether their family was at high risk for alcohol dependence, and the presence of behavior problems in these children. Research suggests that drug-addicted parents spend less time monitoring their children than parents without drug problems (Dishion,Patterson,&Reid,1988)andthatthisisanimportant contribution to early adolescent substance use (Kerr, Stattin, & Burk, 2010). When parents do not provide appropriate supervision, their children tend to develop friendships with peers who supported drug use (Van Ryzin, Fosco, & Dishion, 2012). Children influenced by drug use at home may be expose

1. Indigo •Indigo is a 16 year old high school student. She has always been a high achiever, both in her school work and extracurricular activities. She was teased quite a lot in primary school, with comments about her appearance and weight leading her to start dieting. She lost quite a bit of weight, and has been quite underweight for the last couple of years. Despite this, she still feels 'fat' and is very afraid of putting on weight as she would feel like a failure. In the past she reduced her weight by skipping meals and exercising for hours at a time. In the last few months she has found it more difficult to limit her meals, and has had periods where she hasn't been able to stop herself from eating. She was so upset by this that she vomited up the 'excess' food afterwards. The constant effort to control her weight has been very difficult to manage and Indigo has found herself feeling increasingly worried about her weight, her school work, her friends, and being able to achieve her life goals. Discussion points: What disorder(s) do you think Indigo might have? What symptoms stand out to you?What other information would you like to know to be confident in your diagnosis? What if we

1. - Anorexia with current binge purge subtype - Why is it not bulimia? - Because shes still significantly underweight - In anorexia subjective of how a "lot" of food would be , think its excessive - However binge eating is eating excessive amounts disporoportionate to normal portion - Anorexic people, can move from eundereating to bing eating (still less than in binge eatong and bulimia);- So indogo has past restricting subtype but now binge/purge subtype - Fear of failure, perfectionist tendencies to do with ideal body type , no amount of weight loss is good enough, always striving to be perfect

1. Bulimia Nervosa Characteristics 2. treatment 3. Treatment for anorexia

1. - Binging and purging - Usually within a normal weight range due to over-eating and then compensating - Distorted body image - Sometimes the only thing distinguishing between bulimia and anorexia is whether one's BMI is below normal Symptoms - Not sure about c or d or e Onset - Early adulthood 2. • Aim is to develop more typical eating patterns • CBT 3. • Two-step process: • Help the person to gain weight • Help with long- term maintenance of weight gain • CBT • Family therapy

1. Binge Eating Disorder Characteristics 2. Prevalence 3. Demographics 4. Causes 5. Treatment 6. Difference between anorexia and bulimia

1. - Binging without purging - Usually higher BMI than those without disorders - Usually concerns with body image, although that isn't in DSM-V criteria 2. - 1.4% in middle-class and high-income countries - 5-30% of obese people; maybe 7-19% in other studies 3. - More common in females 4. - Night eating - High-fat, energy-dense diet - Genetics & physiology 5. - Need to focus on weight reduction as well as controlling/reducing binges - CBT & IPT 6. - Difference between anorexia and bulimia is inderweifht and anorexia is under vmi 17 - But both have inappropriate ecompensatory strategoes to keep wreight under control but also both influsenced by body ideals - Interpersonal and family therapy for binge eating

1. Treatment in general videos. 2. Jefferson house

1. - CBT with aim of developing normal eating patterns\ - Nurses, nutritionist , losts of collaborative , structured treatment - Could be psychoeducation , discussion with peers or individual therapist - Self-monitoring , interperdonal /behavioural experiments , journaling - Write what contributes to the negatibe feeling of their body then challenge the distortions - Behaviours ; avoid beach or pool\ - Frst steop is ti rec ognise problems of thoughts or behaviours - Treatments need to help change what patients do , change their behaviours rather than root causes and understanding, sometimes change first then understand - Each patient meets full team everyday, same team , if hospital focus on relapse prevention, focus on eating meals in different social settings 2. - patients spend the night after hospital program, realworld home like - Parents and family important to involve them - Patients don't often feel ready for treatment, but this ambivalence is a cardinal symptom of anorexia - As patients change their behaviour, they become more motivated for recover

1. An Overview of Personality Disorders 2. Slide; Personality 3. shortcoming of dsm5 personality disorders

1. - Cluster A 1. Paranoid, schizoid, schizotypal - Cluster B 1. Antisocial, borderline, histrionic, narcissistic - Cluster C 1. Avoidant, dependent, obsessive-compulsive 2. - Personality equates to sense of self, characyeristic traits, cping styles, and how we interact in social environments - Emerges in child hood and crystallises in adolescence and young adltjood - Hard to solidiyfy sense of self - Most personalities tailored to fit situations and societies, so flexibly interact wiothithers and fit woth work 1. Personality disorders entail rigid, poorly adaptable personalities, lower therir c=quakity of lifw or others oaround them 3. - Few science-based theories due to poor research and unsatisfactory measures (poor validity and reliability of instruments assessing the personality disorders )

1. Four categories of sexual disorders

1. - Desire 1. Male hypoactive sexual desire disorder 2. Female sexual interest/arousal disorder - Arousal 1. Male erectile dysfunction 2. Female sexual interest/arousal disorder - Orgasm 1. Male premature ejaculation 2. Male delayed ejaculation 3. Female orgasmic disorder - Pain 1. Female genito-pelvic pain/penetration disorder

1. Prevention • Prevention 2. Rehearse Your Knowledge Describe the positive symptoms of schizophrenia Describe the negative symptoms of schizophrenia Describe the disorganised symptoms of schizophrenia What are the different phases of schizophrenia? Describe how the brain has been implicated in schizophrenia Describe the environmental factor implicated in the development of schizophrenia Which group of symptoms do first-generation antipsychotics best treat? What are the potential side-effects associated with first- generation antipsychotics? Which drug seems to be the most effective treatment for individuals with schizophrenia? How can psychosocial treatments help schizophrenia? 35

1. - If one can identify at-risk children or prodromal phase, can engage early intervention to reduce the negative impact of subsequent schizophrenia (while not avoiding schizophrenia itself), as later diagnoses acan rduce this • Identify at-risk children • Relatives of individuals with schizophrenia • Foster supportive, stable environmentssocial skills training; etc • Offer additional treatment at prodromal stages, including social skills training

1. ADHD Video 2. - Impulsive; doesn't think about consequences 3. Kyle been on ritaline since 2 ;

1. - Easy distraction - Acts as if driven by motot; trouble at school, hard to control her by parent, affects the way she thinks and behaves - Adhd affects managing and organising thought part not working - Impulsive; doesn't think about consequences 2. - Caused by underactive brain regions - hyperactivity tries to kickstart underactive regions, constantly seek stimulation; restarting gear to keep it from stalling - Highenergy - 1/25 children have ADHD, one in every classroom in new Zealand - No concept for danger ; climb trees more capable of , run out into road, run away when upset - Violent towards brother; in play, still ot acceptable, need to learn social etiquette - Can cause aggression - Ritalin similar to cocaine - can help reduce hyperactive behaviour but often not eliminate it; hopefully see some improvement 3. - controversial to prescribe to really young children ,m but has issues , had started a fire, clibing dangerously injuries , drove mim's car, is very aggressive and violent - Fdaughter emabarassed to go anywhere cause brother - Taking kyle to reassess ; sitting at table for 2 or 3 hours is really hars, brain cant stop for long enough - medication - Can persist into adulthood but may be more subtle; more abd more adults treated ] - Dominated by symptoms, still senses being different; takes Ritalin anyway - Doesn't know where to start for things - Several things at onece and doesn't finish, difficukty in paying attention, interferes with every sphere , - Can live whole lives without knowibf thet have ADHD, as confused with a lack of discipline - Inability to pay attention or prioritise tasks

1. Treatment effects 2. Contingency management 3. Community reinforcement approaches may be quite helpful

1. - Effectiveness similar between inpatient/outpatient programs, outpatient much cheaper - Alcoholics Anonymous (AA) probably helpful v1. The more one is engaged, the more their benefit 2. "Smart Recovery" - same philosophy without the religious side - Controlled use potentially just as effective as abstinence?, better outcomes in abstinence? But some went ino use heavily again , but didn't look at abstinence groip so possibky same effectsv 2.-improves outcomes in the short-term 1. Client and clinician work together rewarding different behaviours (smaller to larger, first dollar tofor clean uringe then 2000) 2. Once reward contingency ceased, stops working 3. Can be expensive to reward clients 3. 1. Supportive communities - social support, help with stressors (employment, medical bills, skills)

1. Stanislav Stanislav is 19 year old and works in sales. He has always been a fairly normal weight, but he has never been very confident about his appearance. In high school he felt self-conscious compared to many of his friends, particularly those who were more muscular than him. He increased his exercise, started lifting weights and tried to stick to a healthy diet. Despite his efforts he feels like he needs better muscle definition and is very concerned about losing muscle mass, or putting on fat. He feels like if he was more muscular he would be happier with himself, and have the confidence to date more. He dislikes going out to eat with his friends as they often want to eat unhealthy food or junk food. He tries to avoid these foods as sometimes when he starts eating them he feels like he can't stop, and will eat a very large amount of food in secret. When he does this he feels disgusted, guilty and out of control, and then will exercise for hours to 'burn it off', take caffeine pills to try to suppress his appetite, and take diuretics to reduce water weight. Discussion points: What disorder(s) do you think Stanislav might have? What symptoms stand out to you? What other information

1. - Hes not underweight so its bulimia - He rightfullyg thinks it's a lot of food, so restricting but still eatng m,ore than the normal portion and underweight despite wanting to get muscular - Need to establish frequency of binges to be confident in diagnoses; - Food control strategies less effective than in anorexia - We'd want to know how much and how often he's eating - When someone has anorexia because of restrictive food controls, their body cant really old muscle, but males think they could be tonned

1. While watching think about how you define gender vs. sex. What might be some of the difficulties LGBTIQ+ individuals experience? 2.Sex vs Gender vs Gender Identity

1. - Lot of people didn't know till late - Body envy, not in desiring sexual way - Gynacologist to deal with women - Society pressures to get married, have kids - Isolated in sociery, cops , fear if being killee, not getting job, disowned, thrown out pf hospital - Early on in transition askedm which toilets . - Disabled toilets, so gender neutral - Genserr identity experessed through pronounds, clothes - tra uma from medical community - drag queen is performative and dressing up - changing names, rhinoplasty , needs to be signed off by posychaitrist, psychologist and doctor, sometimes need to meey criteria for transitioming , starting hormones 2. -Sex is a label—male or female—assigned at birth by doctor based on the genitals you are born with and the chromosomes you have. -But "biological sex" doesn't really capture everything that can happen -Intersex--When someone's sexual and reproductive anatomy doesn't seem to fit the typical definitions of female or male -Gender—its social and legal status—its about how society expects people to act, based on their sex, and these expectations vary across cultures -Gender identity—is how you feel on the inside and how you express yourself on the outside -Most people feel male or female, but -Some people feel masculine female or feminine male -Some people feel neither male or female—genderqueer, gender variant, gender fluid -Cisgender—when assigned sex and gender identity are matched up -Transgender—when people feel that their assigned sex is of the other gender - Gender: Social and cultural, legal status; expectations of you based on gender roles - Gender identity: How you feel on the inside and express self on the outside - If someone born with chromostome type, then sometimes genatilaia mutilated and doesn't find out till later when vagina with no periof - Body dysmorphia; vould be har , breast , beard

1. Positive Symptoms • Excesses and distortions • Hallucinations 2. • Delusions 3. Grandiose delusions: 4. Ideas of reference: 5. • Thought insertion: 6. • Thought withdrawal:

1. - Mostly present during acute schizophrenic episodes Sensory experiences in the absence of any relevant stimulation from the environment -Auditory hallucinations more common than visual • Hearing one's thoughts spoken by another voice • Hearing voices arguing • Hearing voices comment on one's behaviour1. Hallucination can occur for any sense . Auditory hallucinations more common than others can also involve othe senses; skin sensations when not veing touched § May hear thoughts spoken by someone else, voices arguing, voices commenting on self 3. 74% of people with schizophrenia have auditory hallucinations 2.• Beliefs contrary to reality and firmly held despite disconfirming evidence 1. 65% may suffer from delusions 3. exaggerated sense of self- importance;· Believe you can move the wind with your hands 4. reading personal significance into the trivial activities of others· E.g., Believe TV is talking to you 5. believing that one's thoughts are not their own, but have been inserted by an external force§ ; aliens 6. believing one's thoughts have been taken from their minds elien

1. Drug Categories Depressants 2. Stimulants 3. Opiates 4. Hallucinogens

1. Induce behavioural sedation and relaxation Slow down CNS, tranquilising effects, -Alcohol, sedatives, barbituates, anxiolytics/benzodiazapines 2. Speed up CNS;• Increase alertness, mood, and activity • Amphetamines, crystal meth, cocaine, nicotine, caffeine 3. • Produce analgesia and euphoria • Heroin, opium, codeine, morphine 4. • Alter sensory perception ;1. produce delusions as well • Cannabis, LSD, PCP - Categories not clear-cut and mutually exclusive , e.g., PCP is an hallucinogen but also has stimulant properties

1. Gender Dysphoria Debate • Should Gender Dysphoria be a diagnosis in the DSM? Think about the advantages and disadvantages, purpose of the diagnosis, stereotypes and assumptions faced by people who meet criteria for gender dysphoria. Split up into 2 teams: Affirmative and Negative. You must have 2 speakers on each team. 5 minutes preparation Each team is allowed max. 4 minutes to present your argument PLEASE be respectful and avoid stigmatising others PLEASE listen to your classmates and be open to different ideas

1. - Must only be diagnosed if it causes clinically significant distress - Advantages: 1. Aids communication 2. Organises information 3. Helps inform research and treatments, raises awareness, easier to fund research on observable behaiviour, on actual actual diagnoses , insurance civer 4. Hope to clients; shprtened road to transitioning 5. Affirming it for them as a real thing, justified anxiety, experience and distress being validated, legitimisnhg ,re 6. Connects to them to community and other people -In general, diagnoses can provide these advantages: Aids communication, Organises information, Helps direct research & treatment, Gives clients hope - Disadvantages: 1. Stigmatising 2. May think they need go be fixed , 3. Maybe discriminated against 4. Identity invalidated by supposed mental illness 5. Pejoriatiuvr , bias - Gender nonconfirnming, non-binary , they/them not disorder, but if called a girl and they fewl like a boy and that's distressing that's when they start Pejorative / stigmatising, May bias & restrict information gathering

1. Neurodevelopmental Disorders 2. - 6 Disorders

1. - Neurologically based - Shown during earlydevelopmental years (concern to parents and educators) , often persist into adulthood so not rewally childhood disorders - Skill development usually occurs in stages - Brain changes rapidly, in social , emotional and cognitive development - One skill before developing mew skill 1. If one stage disrupted, development of later skills disrupted, so lifelong consequences in socialness and interpersonal relationships - Delayed does not necessarily mean abnormal behaviour, just that they are delayed in reaching a milestone 2. 1. Intellectual disabilities 2. Communication disorders 3. Autism spectrum 4. Attention-Defecit/Hyperactivity Disorder 5. Specific Learning Disorder 6. Other Neurodevelopmental Disorders

1. Big Five Dimensions for Disordered Personalities? 2. paranoid personality disorder

1. - No pathological version of openness - Corresponding Pathology: 1. Disinhibition (from conscientiousness) 2. Extreme introversion (from extraversion) 3. Antagonism (from agreeableness) 4. Negative affectivity (from neuroticism) - So hard to fit neatly in 10 disordr s 2. A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: -Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her. -Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. -Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her. -Reads hidden demeaning or threatening meanings into benign remarks or events. -Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights). -Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. -Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.

1. Two Developmental Pathways 2. Cluster B: Antisocial Personality Disorder • ASPD is the result of multiple interacting factors 3. Treatment

1. - Oppositional defiant disorder conduct disorder ASPD 1. ODD by age 6, CD age 9, ASPD age 18 - OR ADHD + conduct disorder ASPD 1. Perhaps due to restlessness, inattentiveness, impulsivity which are symptoms of ASPD 2.-Genetic propenseties for a difficult temperament, hyperactivity, attentional difficulties, etc -Environmental risks Inadequate parenting -Disrupted family bonds -Poverty -Deviant peers -Poor relationships with peers, teachers, partners, employers 3. -Few seek treatment on their own -Antisocial behavior is predictive of poor prognosis -Emphasis is placed on prevention and rehabilitation -Often incarceration is the only viable alternative -May need to focus on practical (or selfish) consequences (e.g., if you assault someone you'll go to prison)

1. Juan • 1. 2. 3. • Juan is a 47 year old personal trainer. He has been married for 15 years, and reports a sound relationship with his wife with no outstanding difficulties in the marriage. Over the past 2 years, Juan has reported experiencing periods of a few weeks at a time of feeling low energy, feeling things in his life were no longer exciting, and not enjoying things he would normally enjoy - including engaging in sexual activity with his wife. Over these 2 years he would frequently refuse to have sex with his wife, and would often wait until she was asleep before joining her in bed. Discussion points: What disorder(s) do you think Juan might have?What symptoms stand out to you?What other information would you like to know to be confident in your diagnosis?

1. - Poassibly MDD AND male hypoactuve sexual desire disorder , dfeelomh low energy , no longer ezceiting, consisder age , sociaocultutal factors - Reduced onterest, in sex ,could be depression and recurrent episodes major depressive disorder as persistend dd is 2 years without a break (several things lin life no longer getting enjoyment out of ), so sex is ot the only activity noy enjoy, so rule oyt ther causeso of lack of interest in sex, so does he enjoy sex when depression. Alleviates , sor does moy enoy even when its gone - So depressipn possibly full cuprirt - If does not alleviate after depessio. Theb diagised with sexial disorder

1. Cluster B: Borderline Personality Disorder criteria

1. A. pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: -Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) -A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation;§ Extremes of idealising and devaluing the other (love them or hate them) -Identity disturbance: markedly and persistently unstable self-image or sense of self. -Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) -Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. -Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). -Chronic feelings of emptiness. -Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). -Transient, stress-related paranoid ideation or severe dissociative symptoms§ of psychosis (out of contact with rality ), hallucinations, paranoid ideas, severe dissociation 1. 75% have cognitive symptoms

1. Carlos a 19-year old uni student presented for help with academic difficulties. Since starting uni he had been unable to manage his schedule and was failing assessments. He said that he found it difficult to stay focused while reading and listening to lectures and often became distracted by other things going on. He complained of feeling restless. When queried, Carlos reported that he had often been in trouble at school for not following instructions, not doing his homework, getting out of his seat, losing things, not waiting his turn, and not listening. --Which disorder might Carlos meet criteria for?

1. ADHD

1. The Development of Sexual Orientation In studying the development of sexual orientation, the recent emphasis is on the breadth and variety of sexual arousal patterns within otherwise normal and adaptive sexual expression. This was not always the case. Until the 1970s, many forms of sexual expres- sion, including homosexuality, were considered pathological. 2.Some reports suggest that there may be a genetic component to sexual orientation as homosexuality runs in families (Bailey & Benishay, 1993), and concordance for homosexuality is more common among identical twins than among fraternal twins or natural siblings 3. Other reports indicate that homosexuality and also gender atypical behavior during childhood is associated with differential exposure to hormones, particularly atypical androgen levels in utero

1. After homosexuality was eliminated as a diagnosis, many societies began to reevaluate the nature and origins of consensual sexual behavior in adults, but because of the "taboos" on sexual research by government granting agencies and other funding sources, this inquiry is still in its infancy. Most of the research to date has occurred in the context of the development of homosexual arousal patterns. 2. ared in approximately 50% of identical twins, compared with 16% to 22% of fraternal twins. Approximately the same or a slightly lower per- centage of nontwin brothers or sisters were gay (Bailey & Pillard, 1991; Bailey, Pillard, Neale, & Agyei, 1993; Whitnam, Diamond, & Martin, 1993). Other studies on the causes of homosexual behav- ior reveal that in men, genes account for approximately 34% to 39% of the cause, and in women, 18% to 19%, with the remainder accounted for by environmental influences (Långström, Rahman, Carlström, & Lichtenstein, 2010). 3. adue, Green, & Hellman, 1984; Hershberger & Segal, 2004) and that the actual structure of the brain might be different in individuals with homo- sexual as compared with heterosexual arousal patterns

1. Types of Disorders look at slides

1. Alcohol Use Disorder -Cannabis Use Disorder -Hallucinogen- Related Disorder (PCP or other) -Inhalant Use Disorder -Opioid Use Disorder -Sedative/ Hypnotic/ Anxiolytic Use Disorder -Stimulant Use Disorder (amphetamine, cocaine, or other) -Tobacco Use Disorder -Other (or unknown) Substance Use Disorder -Other XX- induced Disorder;1. steroids, (drugs don't fit into those other categories) - Other (or unknown)-induced disorder (substance or medication induced disorders -Unspecified Substance Use Disorder - Not enough research to suggest caffeine can produce the symptoms outlined in the diagnostic criteria - Other (or unknown) 1. Depressive , anxiety and psychotic disorders

1, In addi- tion, in years past, some women were not as concerned as men about experiencing intense pleasure during sex as long as they could consummate the act; this is generally no longer the case. It is unusual for a man to be completely unable to achieve an erection. More typical is a situation like Bill's, where full erections are possible during masturbation and partial erections occur dur- ing attempted intercourse, but with insufficient rigidity to allow penetration. The prevalence of erectile dysfunction is startlingly high and increases with age. 2. The prevalence of female interest and arousal disorders is somewhat more difficult to estimate because many women still do not consider absence of arousal to be a problem, let alone

1. Although data from the U.S. survey indicate that 5% of men between 18 and 59 fully meet a stringent set of criteria for erectile dysfunction (Laumann et al., 1999), this figure certainly underestimates the prevalence because erectile dysfunc- tion increases rapidly in men after age 60. Rosen, Wing, Schneider, and Gendrano (2005) reviewed evidence from around the world and found that 60% of men 60 and over suffered from erectile dysfunction. Data from another study (shown in E Figure 10.3) suggest that at least some impairment is present in approximately 40% of men in their 40s and 70% of men in their 70s (Feldman, Goldstein, Hatzichristou, Krane, & McKunlay, 1994; Kim & Lipshultz, 1997; Rosen, 2007); incidence (new cases) increases dramatically with age, with 46 new cases reported each year for every 1,000 men in their 60s (Johannes et al., 2000). Erectile disor- der is easily the most common problem for which men seek help, accounting for 50% or more of the 2. e U.S. survey reports a prevalence of 14% of females experiencing an arousal disorder (Laumann et al., 1999). A more recent study (Rosen et al., 2014) reported a prevalence of 7.4%. Because disorders of desire, arousal, and orgasm often overlap, it is difficult to estimate precisely how many women with spe- cific interest and arousal disorders present to sex clinics

1.More recent research has also found that gender nonconformity is associated with lower levels of psychological well-being, but it has not found the same interaction with sexual orientation (Rieger & Savin-Williams, 2012); thus more research is needed in this area. 2.gender-nonconforming boys defeminize as they reach adult- hood, perhaps because of persistent social pressure from their family and peers. Also, interventions exist to alter gender- nonconforming behavior in young children to avoid the ostracism and scorn these children encounter in most school settings (e.g

1. Although only a minority of gay men report gender non- conformity as boys; research indicates that many of these 2.build resilience in children who exhibit gender- nonconforming behavior by strengthening their relationships with peers and caregivers, increasing their sense of self-control, and increasing their sense of belonging within a community or culture (Allan & Ungar, 2014). Thus, society is faced with a dilemma that requires more research. Should the free expression of gender nonconformity be encouraged knowing that, in most parts of world, gender non- conformity will make for difficult social adaptation leading to substantial psychological distress for decades to come, particu- larly since the gender nonconformity is unlikely to persist into adolescence or adulthood?

1. Thus, social and cultural factors seem to affect later sexual functioning. John Gagnon has studied this phenomenon and constructed an important concept called script theory of sexual functioning, according to which we all operate by following "scripts" that reflect social and cultural expectations and guide our behavior 2. Cultural scripts may also contribute to the type of sexual dysfunction reported. In India, for example, Verma, Khaitan, and Singh (1998) reported that 77% of a large number of male patients in a sexuality clinic in India reported difficulties with premature ejaculation.

1. overing these scripts, both in individuals and across cultures, will tell us much about sexual functioning. For example, a person who learns that sex- uality is potentially dangerous, dirty, or forbidden is more vulner- able to developing sexual dysfunction later in life. This pattern is most evident in cultures with restrictive attitudes toward sex (McGoldrick et al., 2007). For example, vaginismus is relatively rare in North America but is considerably more prevalent in Ireland, Turkey, and Iran (Doğan, 2009; Farnam, Janghorbani, Merghati- Khoei, & Raisi, 2014; McGoldrick et al., 2007). 2. In addition, 71% of male patients complained of being extremely concerned about nocturnal emissions ("wet dreams") associated with erotic dreams. The authors note that this focus on problems with ejaculation is most likely the result of a strong culturally held belief in India that loss of semen causes depletion of physical and mental energy. It is also interesting that out of 1,000 patients presenting to this clinic, only 36 were female, most likely reflecting the devaluation of sexual experiences for females for religious and social reasons in India. Even in our own culture, certain socially communicated expectations and attitudes may stay with us despite our relatively enlightened and permissive attitude toward sex. Barbara Andersen and her colleagues (see, for example, Cyranowski et al., 1999) have demonstrated that being emotional and self-conscious about sex (having a negative sexual self-schema, described earlier in the chapter) may later lead to sexual difficulties under stressful situations. The

1.ate in adolescence, the boys are expected to marry and begin exclusive heterosexual activity. And they do, with no exceptions (Herdt, 1987; Herdt & Stoller, 1989). By con- trast, the Munda of northeast India require adolescents and chil- dren to live together. 2. n about half of more than 100 societies surveyed worldwide, premarital sexual behavior is culturally accepted and encouraged; in the remaining half, premarital sex is unacceptable and discouraged (Bancroft, 1989; Broude & Greene, 1980). In terms of sex in midlife, both in the context of a marriage and not, there are also different attitudes towards and engagement in sex- ual behavior even among Americans.

1. But in this group, both male and female children live in the same setting, and the sexual activity, con- sisting mostly of petting and mutual masturbation, is all hetero- sexual (Bancroft, 1989). Even within Western cultures, there are some variations. Schwartz (1993) surveyed attitudes surrounding the first pre- marital experience of sexual intercourse in nearly 200 female undergraduates in the United States and compared them with a similar sample in Sweden, where attitudes toward sexuality are somewhat more permissive. The average age at the time of first intercourse for the woman and the age of her partner are presented in Table 10.2, as well as the age the women thought it would be socially acceptable in their culture for them to have sexual inter- course. Acceptable perceived ages for both men and women were significantly younger in Sweden—and unlike the United States, roughly equal—but few other differences existed, with one striking exception: 73.7% of Swedish women and only 56.7% of American women used some form of contraception during their first sexual intercourse, a significant difference. 2. For example, a large survey of multi-ethnic middle-aged women in the United States found that Chinese and Japanese women were less likely than Caucasian women to report sex as very important, while African-American women were more likely to do so (Cain et al., 2003). Moreover, of those who had sex in the past 6 months, Hispanic women were less likely to cite "for pleasure" as their reason for doing so compared with other ethnic groups. Thus, what is normal sexual behavior in

1. C,D, AND E 2. Autism Spectrum Disorder • Specify current level of severity

1. C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. D. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level. 1. Intellectual disabilities may co-occur § For both disorders, social communication has to be lower than level associated with intellectual disability 2. 1. Level 1: Requiring support § Symptoms noticeable without support due to social defficits and inflexikle behaviour 2. Level 2: Requiring substantial support § Symptoms may still be noticeable with support § E.g., inflexibility etc., inflexible behaviour , inability to cope interfere with variety of contexts 3. Level 3: Requiring very substantial support - Severe deficits, only interacting owth thers ti get their needs met , vrry inflexible behaviours and extreme difficuktu coping with change § Rarely interact with others and un unusual way § Interferes with all areas of life functioning

1. Characteristics 2. • Causal factors 3. • Treatment

1. Characteristics - Relatively well researched - Similar to schizoid PD due to being characterised by social isolation 1. Key difference is one wants relationships, the other doesn't (schizoid) - An extreme version of social phobia 1. Very few cases of APD aren't comorbid with social phobia - Link to schizophrenia? More common in those with relatives who have schizophrenia 2, 1. Inherited fear of negative evaluation (diathesis) § Stress can trigger this (gene-environment interaction) - Emotional abuse - Rejection - Humiliation from parents - Common in relatievs with schizopjrenia 3.• Similar to that of social phobia - Building social skills, facing anxiety-provoking situations - Similar to social phobia treatment

. In some cultures, individuals with a different gender expe- rience are often accorded the status of "shaman" or "seer" and treated as wisdom figures. A shaman is almost always a male adopting a female role (see, for example, Coleman, Colgan, & Gooren, 1992). Stoller (1976) reported on two contemporary feminized Native American men who were not only accepted but also esteemed by their tribes for their expertise in healing rituals. 2.Causes Research has yet to uncover any specific biological contributions to gender dysphoria or alternative gender experience for that matter, although it seems likely that a biological predisposition will be discovered. Coolidge, Thede, and Young (2002) estimated that genetics contributed abou 3.Early research suggested that, as with sexual orientation, slightly higher levels of testosterone or estrogen at certain criti- cal periods of development might masculinize a female fetus or feminize a male fetus (see, for example, Keefe, 2002). Variations in hormonal levels could occur naturally or because of medica- tion that a pregnant mother is taking. Scientists have studied girls 5 to 12 with an intersex condition known as congenital adrenal hyperplasia (CAH).

1. Contrary to the respect accorded these individuals in some cul- tures, social tolerance for them remains relatively low in Western =lthough that is changing particularly as individuals such as Kaitlyn Jenner and Chaz Bono forthrightly and openly discuss gender dysphoria. In recent years, actors such as Laverne Cox, books such as "Becoming Nicole", and movies such as The Danish Girl, have also begun to raise awareness about gender 2.62% to creating a vulnerability to experience gender dysphoria in their twin sample. Thirty-eight percent of the vulnerability came from nonshared (unique) envi- ronmental events. A study from the Netherlands twin registry suggested that 70% of the vulnerability for cross-gender behav- ior (behaving in a manner consistent with the opposite natal sex) was genetic as opposed to environmental, but this behavior is not the same as gender identity, which was not measured (as explained later) (van Beijsterveldt, Hudziak, & Boomsma, 2006 3.Compared with groups of girls and boys without CAH, the CAH girls were masculine in their behavior, but there were no dif- ferences in gender identity. Thus, scientists have yet to establish a link between prenatal hormonal influence and later gender identity, although it is still possible that one exists. Structural differences in the area of the brain that controls male sex hor- mones have also been observed i

1.Delusional Disorder 2. Differential Diagnosis

1. Key feature—delusions -Does NOT include other positive symptoms or negative or disorganized symptoms -Functioning is generally not impaired beyond the impact of believing the delusion - when behaving in accordance with delusion, that will impair their functioning n=but other areas not really omlpactive - Better prognosis than schizophrenic patients as impairement less pervasive -Prognosis is better than with schizophrenia 2. -Psychotic symptoms can occur as part of other mental disorders -Psychotic symptoms can occur as a result of substance use -Psychotic symptoms can occur as a result of some medications -Psychotic symptoms can occur as a result of some medical conditions -Thus you can't just look at the symptom You need to look at everything else going on with the person - People with schizophrenia have highest rates of stigma - Lengthy, detailed assessment to rule out alternative explanations for symptoms

1. Virtually all men and women studied by Mosher and col- leagues and Chandra and colleagues were sexually experienced, with vaginal intercourse a nearly universal experience, even for those who had never been married. 2. (2011) also engaged in oral sex, but only 35.8 and 30.7 percent, respectively, had ever engaged in anal sex, a particularly high-risk behavior for AIDS transmis- sion. Slightly more troublesome is an earlier finding by Billy and colleagues (1993) that 23.3% of men had had sex with 20 or more partners, which is another high-risk behavior. Then again, more than 70% had had only 1 sexual partner during the previous year, and fewer than

1. Even by age 15, over a quarter of males and females have engaged in vaginal intercourse, and the prevalence rate increases steadily with the age of individuals. In the overall sample, 81.3 percent of men and 80.1 percent of women in 2. 10% had had 4 or more partners during the same period. The Chandra and colleagues study (2011) reports similar figures, with 21.4% of men having sex with 15 or more partners during their lifetime (compared with 8.3% of women). Also, only 6.0% of men and 2.9% of women reported 4 or more partners during the past year. The overwhelming majority of the men in the Mosher and colleagues study (2005) had engaged exclusively in heterosexual behavior (sex with the opposite sex), with only 6.5 percent of adult men having ever engaged in any homosexual behavior (sex with the same sex). In this sample, 92 percent of men reported being attracted only to females, 3.9 percent mostly to females, 1.0 percent to both males and females, and 2.2 per- cent were attracted only to males, with similar numbers reported

1. Disorders are socially constructed, reflecting the politics and values of particular contexts

1. Example: homosexuality was considered a disorder until the DSM- III, when changes occurred in societal views, legal frameworks, and development of human rights laws -Some experts suggest gender identity disorder replaced homosexuality to allow the continued pathologisation of gender variance Criterion in the gender dysphoria diagnosis for children have been critiqued as one reason that children have not been given access to treatment Gay females seen as masculine and gay males seen as feminine

1. Causal Factors 2. 1. Similar to other drugs of abuse

1. GD's heritability is within this range at 0.50-0.60 -The proportion of variability due to genetic factors ranges from 0.39 for hallucinogens to 0.72 for cocaine -Heritablerisktendstobenonspecificandsharedacross substances and GD • Impulsivity and negative affect;1. Via impulsivity, neuroticism (negative affect) 2. • Environmental contributions to the variability in risk for developing GD account for 38%-65% • childhood maltreatment • parental gambling behavior • cultural acceptance of gambling • convenience of gambling establishments1. (reduce acceptance to reduce gambong

1, NON-BINARY: 2.TRANSITION/GENDER AFFIRMATION:

1. Genders that sit outside of the female and male binary are often called non-binary. This includes people whose gender is not exclusively female or male. A person might identify solely as non-binary, or relate to non-binary as an umbrella term and consider themselves genderfluid, genderqueer, trans masculine, trans feminine, agender, bigender, or something else. 2. he personal process or processesa trans or gender diverse person determines is right for them in order to live as their defined gender and so that society recognises this. Transition may involve social, medical/surgical and/or legal steps that affirm a person's gender. Affirming gender doesn't mean changing gender, 'having a sex change' or 'becoming a man or a woman', and transition isn't the same as being trans. A trans or gender diverse person who hasn't medically or legally affirmed their gender is no less the man, woman or non-binary person they've always been.

1. Sexual Desire Disorders Three disorders reflect problems with the desire or arousal phase of the sexual response cycle. Two of these disorders are characterized by little or no interest in sex that is causing significant distress in the individual or couple. 2. male Hypoactive sexual desire disorderand Female sexual interest/arousal disorder Males with hypoactive sexual desire disorder and females with sexual interest/arousal disorder have little or no interest in any type of sexual activity. It is difficult to assess low sexual desire, and a great deal of clinical judgment is required (Leiblum, 2010; Segraves & Woodard, 2006; Wincze, Bach, & Barlow, 2008; Wincze, 2009; Wincze & Weisberg, 2015). You might gauge it by frequency of sex- ual activity—say, less than twice a month for a married couple. Or you might determine whether someone ever thinks about sex or has sexual fantasies.

1. In males, this disorder is called male hypoactive sexual desire disorder. In females, low sexual interest is almost always accompanied by a diminished ability to become excited or aroused by erotic cues or sexual activity. Thus, deficits in interest or the ability to become aroused in women is combined in a disorder called female sexual interest/arousal disorder 2. en there is the person who has sex twice a week but really doesn't want to and thinks about it only because his wife is on his case to live up to his end of the marriage and have sex more often. This individual might have no desire, despite having frequent sex. Consider the cases of Judy and Ira and of Mr. and Mrs. C. Judy and Ira... A Loving Marriage? udy, a married woman in her late 20s, reached a clinic staff member on the phone and reported that she thought his case to live up to his end of the marriage and have sex more often. This individual might have no desire, despite having frequent sex. Consider the cases of Judy and Ira and of Mr. and Mrs. C.

SEX READING 1. r? Again, it depends. Current views tend to be quite tolerant of a variety of sexual expressions, even if they are unusual, unless the behavior is associated with a sub- stantial impairment in functioning or involves nonconsenting individuals such as children. Two kinds of sexual behavior meet this definition. 2. altogether is gender dysphoria

1. In paraphilic disorders, the relatively new term for sexual deviation, sexual arousal occurs primarily in the context of inappropriate objects or individuals. Philia refers to a strong attraction or liking, and para indicates the attraction is abnormal. Paraphilic arousal patterns tend to be focused rather narrowly, often precluding mutually consenting adult partners, even if desired. In actuality, paraphilic disorders have little to do with sexual dysfunctions except for the fact that they both involve sexual behavior. For this reason, paraphilic dis- orders now comprise a separate category of disorders in DSM-5. Another condition that has been separated from sexual disorders 2. In gender dysphoria there is incon- gruence and psychological distress and dissatisfaction with the gender one has been assigned at birth (boy or girl). The disorder is not sexual but rather a disturbance in the person's sense of being a male or a female. Before describing these three conditions, we return to our initial question, "What is normal sexual behavior?" to gain an important perspective, particularly on sexual dysfunc- tions and paraphilic disorders. We spend a bit more time on what is "normal" in this chapter, compared to other chapters since so many misconceptions exist. Determining the prevalence of sexual practices accurately requires careful surveys that randomly sample the population. In a scientifically sound survey, Mosher, Chandra, and Jones (2005) reported data from 12,571 men and women in the United States ages 15 to 44, as part of the National Survey of Family Growth by the Centers for Disease Control and Prevention (CDC). These data are presented in E Figure 10.1. The participants were interviewed, which is more reliable than having them fill out a questionnaire, and the responses were analyzed in detail. I

1. Characteristics 2, • Treatment 3. Cluster B: Narcissistic Personality Disorder criteria

1. Lack of research -Causal factors - unknown - Perceived as self-centred, vain, over-reactive 2. - Focus on attention seeking and its long-term negative consequences - Focus on problem interpersonal behaviours - Little evidence that treatment is effective 3. A. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: -Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). -Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. -Believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions). -Requires excessive admiration. -Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations). -Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends). -Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others. -Is often envious of others or believes that others are envious of him or her. -Shows arrogant, haughty behaviors or attitudes.

1. Cluster B: Borderline Personality Disorder More research has been done on BPD than any other PD Causal factors 2. • Treatment

1. Modest genetic transmission1. Neuroticism, impulsivity not disorder inherited probablu just the traits - Childhood maltreatment 1. BPD linked to much higher rates of childhood maltreatment than other PDs 2. Maltreatment is a general psych vulnerability risk factor - contributes to many disorders - Childhood abuse - Poverty -Marital discord - Fighting parents or separated parents - Parental substance abuse - Family violence 2. Antidepressants widely used, but little evidence to support their use—might help with comorbid depression- (not BPD itself) -Dialectical behaviour therapy; -Focus on dual reality of acceptance of difficulties and need for change -Focus on interpersonal effectiveness -Focus on distress tolerance to decrease reckless/self-harming behavior - (DBT) is the number 1 treatment 1. Acceptance of negative affect without self-destructive/maladaptive behaviour 2. Problem-focussed, hierarchy of goals § Prioritise reducing suicidal, self-interest behaviour; increasing social skills 3. Learn interpersonal effectiveness 4. Regulation of emotions and tolerance of distress - DBT evidenced to work!

1. A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period: - A: Must meet 4 of 9 symptoms 2. note

1. Need to gamble with increasingly amounts of $$ to achieve excitement -Restless or irritable when attempting to cut down/stop -Unsuccessful efforts to cut down/stop -Often preoccupied with gambling thoughts -Often gambles when distressed -After losing $$, returns to get even -Lies to conceal the extent of gambling involvement -Has jeopardized relationships, educational, or career opportunities -Relies on others for $$ to relieve desperate financial situation B. The gambling behavior is not better explained by a manic episode. 2. 1. Note: Drug use disorders have 11 criteria and only need to meet 2 (which is why gambling less prevalence)

1. 5-Factor Model of Personality 2. Personality Disorders 3. Prevalence

1. OCEAN - Dimension/continuum of each factor 1. Researchers unsure whether 5-factor model should be used for personality disorders - 6 facets for each dimension (30 in total) 1. If this is translated to measure personality disorders, there will be many more disorders than just 10 due to high number of combinations 2. -A persistent pattern of emotions, cognitions, and behavior that results in enduring emotional distress for the person affected and/or for others and may cause difficulties with work and relationships -Pervasive and inflexible traits -Stable -Maladaptive -Ego-syntonic: Unlike other disorders, often feel consistent with one's identity; don't feel treatment is necessary - Symptoms feel consistent with one's personality/identity and individual may not want treatment, if do seek disorder, its a disorder that's a consequence of the personality one like anxiety , or forced into treatmemnt - Develop slowly over time, choose through different ones 3. •Develop slowly over time -10-12% of the population meet criteria for a PD - Unreliable measures9different test-retest reliability so wrong as personalitu meant to be stable -Grouped into 3 clusters Cluster A - odd or eccentric cluster (4%) Cluster B - dramatic, emotional, erratic cluster (4%) Cluster C - fearful or anxious cluster (7%) - Research shows that these clusters are perhaps not clear-cut, disorders don't necessarily belong together

1. By contrast, results from a large number of studies suggest that no gender differences are currently apparent in attitudes about homosexuality (generally acceptable), the experience of sexual satisfaction (important for both), or attitudes toward mas- turbation (generally accepting). 2. Although they are decreasing, differences still exist between men and women in sexual behavior and attitudes toward sexuality (Peplau, 2003; Petersen & Hyde, 2010). For example, differences seem to exist in patterns of sexual arousal (Chivers, Rieger, Latty, & Bailey, 2004; Samson & Janssen, 2014). Men are more specific and narrow in their patterns of arousal.

1. Small-to-moderate gender dif- ferences were evident in attitudes toward premarital intercourse when the couple was engaged or in a committed relationship (with men more approving than women) and in attitudes toward extramarital sex (sex outside of the marital relationship, which men also approved of more than women). As in the British and French studies, the number of sexual partners and the frequency of intercourse were slightly greater for men, and men were slightly younger at age of first sexual intercourse. Examining trends from 1943 to 1999, we find that almost all existing gender differences became smaller over time, especially in regard to attitudes toward premarital sex. Specifically, only 12% of young women approved of premarital sex in 1943, compared with 73% in 1999. The figures for men were 40% in 1943 and 79% in 199 ore recently, in the late 1990s and after 2000, investigators have noted a decrease in number of sexual partners and a tendency to delay sexual intercourse among adolescent boys, perhaps due to a fear of AIDS. Few changes over this time period were noted for adolescent girls 2. That is, heterosexual men are aroused by female sexual stimuli but not male sexual stimuli. For gay men, it's the opposite. Men with gender dysphoria (dis- cussed later) who had surgery to become female retained this specificity (attracted to males but not females). Females, on the other hand, whether heterosexual or lesbian, experience arousal to both male and female sexual stimuli, demonstrating a broader, more general pattern of arousal.

1. Treatment • Psychosocial Treatment 2. Family therapies 3. Social skills training + Family therapy 4. Cognitive remediation 5. • Psychosocial Treatment• Token economies on inpatient units 6. Case Management 7.Vocational rehabilitation

1. Social skills training 2. § Psychoeducation § Avoid blaming someone/the individual for their schizophrenia § Communication, problem-solving training § Expanding social network 3. 1. Combining social skills with family therapy gives best prognosis than one treatment alone 4. 1. Computer-based training of attention, memory, problem-solving § Improves executive functioning 5. 1. Token economies in inpatient units which reward adaptive behaviour; if engahhing in social omyteratcions, they can cash tokemns in for prizes 6. § Connect people with services across medical and psychological fields they need , range of services they need , as they have lower life exprctancu so truing to improve thois tsatistica nd increase quality of life -Connect people with the services they need -Hold together and coordinate the range of medical and psychological services that individuals need 7.Aim to help people get employed, give them guidance o rcounseeling with some work experience

1. Medical Examination Human sexuality clinicians routinely inquire about medical con- ditions that affect sexual functioning. A variety of drugs, includ- ing some commonly prescribed for hypertension, anxiety, and depression, often disrupt sexual arousal and functioning. Recent surgery or concurrent medical conditions must be evaluated for their impact on sexual functioning; often the surgeon or treat- ing physician may not have described possible side effects, or the patient may not have told the physician that a medical procedure or drug has affected sexual functioning 2. Psychophysiological Assessment Many clinicians assess the ability of individuals to become sex- ually aroused under a variety of conditions by taking psycho- physiological measurements while the patient is either awake or asleep. In men, penile erection is measured directly, using, for example, a penile strain gauge developed in our clinic (Barlow, Becker, Leitenberg, & Agras, 1970) 3. The comparable device for women is a vaginal photople- thysmograph, developed by James Geer and his associates (Geer, Morokoff, & Greenwood, 1974; Prause & Janssen, 2006; Rosen & Beck, 1988).

1. Some males with specific sexual dysfunctions such as erectile disorder have already visited a urologist—a physician specializing in disorders of the genitals, bladder, and associated structures—before coming to a sexual- ity clinic, and many females already have visited a gynecologist. These specialists may check levels of sexual hormones necessary for adequate sexual functioning and, in the case of males, evaluate vascular functioning necessary for an erectile response. 2. As the penis expands, the strain gauge picks up the changes and records them on a poly- graph. Note that participants are often not aware of these more objective measures of their arousal; that is, their self-report of how aroused they are differs from the objective measure, and this discrepancy increases or decreases as a function of the type of sexual problem they have. Measuring penile rigidity is also important in cases of erectile dysfunction, because large erections with insufficient rigidity will not be adequate for intercourse (Wiegel et al., 2002) 3.This device, which is smaller than a tampon, is inserted by the woman into her vagina. A light source at the tip of the instrument and two light-sensitive photoreceptors on the sides of the instrument measure the amount of light reflected back from the vaginal walls. Because blood flows to the vaginal walls during arousal, the amount of light passing through them decreases with increasing arousal. Typically in our clinic, individuals undergoing physiological assessment view an erotic videotape for 2 to 5 minutes or, occasion- ally, listen to an erotic audiotape (see, for example, Bach, Brown, & Barlow, 1999; Weisburg, Brown, Wincze, & Barlow, 2001). The patient's sexual responsivity during this time is assessed psycho- physiologically using the strain gauge or photoplethysmograph just described. Patients also report subjectively on the amount of sexual arousal they experience. This assessment allows the clinician to carefully observe the conditions under which arousal is possible for the patient.

1. Paraphilic Disorders: Clinical Descriptions If you are like most people, your sexual interest is directed to other physically mature adults (or late adolescents), all of whom are capable of freely offering or withholding their consent. But what if you are sexually attracted to something or somebody other than another adult, such as animals (particularly horses and dogs; Williams & Weinberg, 2003) or a vacuum cleaner? (Yes, it does happen!) Or what if your only means of obtaining sexual satisfaction is to commit a brutal murder? 2. in the beginning of the chapter, these disorders of sexual arousal, if they cause distress or impairment to the individual, or cause personal harm, or the risk of harm to others are called paraphilic disorders. It is important to note that DSM-5 does not consider a paraphilia a disorder unless it is associated with distress and impairment or harm or the threat of harm to others. 3. urthermore, it is not uncommon for individuals with paraphilic disorder to also suffer from comorbid mood, anxiety, and substance abuse disorders (Kafka & Hennen, 2003; Krueger & Kaplan, 2015; Raymond, Coleman, Ohlerking, Christenson, & Miner, 1999). Although paraphilic disorders

1. Such patterns of sexual arousal and countless others exist in a large number of individuals, causing untold human suffering both for them and, if their behavior involves other people, for their victims. As 2. Thus, unusual patterns of sexual attraction are not considered to be sufficient to meet criteria for a disorder. This is a controversial change in DSM-5 (see DSM Controversies box on page 399). Over the years, we have assessed and treated a large number of individuals with paraphilias and paraphilic disorders, ranging from the slightly eccentric and sometimes pitiful cases to some of the most dangerous killer-rapists encountered anywhere. As noted above, there are many harmless aberrations, such as some fetishistic arousal patterns (see next section), which harm no one, are not distressful or impairing, and therefore do not meet crite- ria for a disorder. We begin by describing briefly the major types of paraphilic disorders, using in all instances cases from our own files. As with sexual dysfunctions, it is unusual for an individual to have just one paraphilic pattern of sexual arousal (Bradford & Meston, 2011; Krueger & Kaplan, 2015; Laws & O'Donohue, 2008; Seto, Kingston, & Bourget, 2014). Many of our patients may present with two 3. s transvestic disorder (cross- dressing, discussed later), seem relatively common (Bancroft, 1989; Mason, 1997). You may have been the victim of frotteuristic disorder in a large city, typically on a crowded subway or bus. (We mean really crowded, with people packed in like sardines.) In this situation, women have been known to experience more than the usual jostling and pushing from behind. What they dis- cover, much to their horror, is a male with a frotteuristic arousal n rubbing against them until he is stim- ulated to the point of ejaculation. Because the victims cannot escape easily, the frotteuristic act is usually successful

1. Attention-Deficit/Hyperactivity Disorder • Course of ADHD 2. Causes of ADHD 3. Biological Influences • Genetic contributions

1. Sxs usually appear around age 3 to 4 65-80% continue to have sxs during adolescence -Half of children with ADHD continue to have sxs as adults, but only 15% may continue to have the dx• -Lower education, lower SES, change jobs frequently, substance use, divorce -Impulsivity decreases, but inattention remains -Brain development progresses in a more typical fashion in children receiving medication for ADHD versus those who do not 2. Biological influences -Environmental influences 3. • Heritability estimates as high as 80% A number of candidate genes have been identified , most notable are those genes associated with dopamine • DAT1 - dopamine transporter gene • Dopamine receptors DRD4 and DRD5 § Dopamine receptors and transporeter geneGenes associated with dopamine are only linked to ADHD when in combination with environmental factors (prenatal nicotine use, alcohol use, etc.) · Dopamine receptors DRD4 and DRD5 · Dopamine transmitter DAT1 -Norepinephrine, GABA, and serotonin also implicated

1. exual development. However, the anabolic action of these drugs (that can produce increased body mass) has resulted in their illicit use by those wishing to try to improve their physical abilities by increasing muscle bulk. Steroids can be taken orally or through injection, and some estimates suggest that approximately 2% to 6% of males will use the drug illegally at some point in their lives (Pope & Kanayama, 2012). Users sometimes administer the drug on a schedule of several weeks or months followed by a break from its use—ca 2.Another class of drugs—dissociative anesthetics—causes drowsiness, pain relief, and the feeling of being out of one's body (Domino & Miller, 2015; Javitt & Zukin, 2009). Some- times referred to as designer drugs, this growing group of drugs was originally developed by pharmaceutical companies to tar- get specific disease 3.but feared growing list of related substances that includes 3,4-methelenedioxyethamphetamine (MDEA, or Eve), and 2-(4-bromo-2,5-dimethoxy-phenyl)-ethylamine (BDMPEA, or Nexus) (Wu et al., 2009). Their ability to heighten a person's auditory and visual perception, as well as the senses of taste and touch, has been incorporated into the

1. cycling"—or combine several types of steroids— called "stacking." Steroid use differs from other drug use because the substance does not produce a desirable high but instead is used to enhance performance and body size. Dependence on the substance therefore seems to involve the desire to maintain the performance gains obtained rather than a need to re-experience an altered emotional or physical state. Research on the long-term effects of steroid use seems to suggest that mood disturbances are common (for example, depression, anxiety, and panic attacks) (Pope & Kanayam 2.. It was only a matter of time before some began using the developing technology to design "recreational drugs." We have already described one of the more common illicit designer drugs—MDMA, street names of Ecstasy or Molly—in the section on stimulants. This am 3. scene is ketamine (street names include K, Special K, and Cat Valium), a dissociative anesthetic that produces a sense of detachment, along with a reduced awareness of pain (Wolff, 2012). Gamma-hydroxybutyrate (GHB, or liquid Ecstasy) is a central nervous system depressant that was marketed in health food stores in the 1980s as a means of stimulating muscle growth. Users report that, at low doses, it can produce a state of relaxation and increased tendency to verbalize but that at higher doses or with alcohol or other drugs it can result in seizures, severe respira- tory depression, and coma. These drugs taken at high doses may be especially dangerous for the developing teenager brain due to their high toxicity, which may cause irreversible memory loss and other cognitive problems

1. other words, although alcohol seems to loosen our tongues and makes us more sociable, it makes it difficult for neurons to communicate with one another (Joslyn, Ravindranathan, Brush, Schuckit, & White, 2010). For example, there is some 2. The long-term effects of heavy drinking are often severe. Withdrawal from chronic alcohol use typically includes hand tremors and, within several hours, nausea or vomiting, anxiety, transient hallucinations, agitation, insomnia, and, at its most extrem 3. Whether alcohol will cause organic damage depends on genetic vulner- ability, the frequency of use, the length of drinking binges, the blood alcohol levels attained during the drinking peri- ods, and whether the body is given time to recover between binges.

1. d below) that the genes responsible for communication between neurons may also be responsible for individual differences in response to alcohol. The glutamate system is under studyfor its role in the effects of alcohol. Incontrast to the GABA system, the glu-tamate system is excitatory, helpingneurons fire. It is suspected to involvelearning and memory, and it may be theavenue through which alcohol affects ourcognitive abilities. Blackouts, the loss ofmemory for what happens during intoxi-cation, may result from the interaction ofalcohol with the glutamate system. Theserotonin system also appears to be sen- 2. withdrawal delirium (or delirium tremens—the DTs), a condition that can produce frightening hallucinations and body tremors. The devastating experience of delirium tremens can be reduced with adequate medical treatment (Schuckit, 2014b). 3. king include liver disease, pancreatitis, cardiovascular disorders, and brain damage. Part of the folklore concerning alco- hol is that it permanently kills brain cells (neurons). As you will see later, this may not be true. Some evidence for brain damage comes from the experiences of people who are alcohol dependent and experience blackouts, seizures, and hallu- cinations. Memory and the ability to per- form certain tasks m

1. Gender affirmative surgery and transition

1. decreased the prevalence of suicidal ideation among transgender individuals in the UK (n=307; 2014) • Trans-related factors related to suicidal included experiences of gender dysphoria, confusion and denial of gender, fears around transition, treatment delays and refusal from medical practitioners - Trans people higher risk at associated psyhopathology but maybe to do woth stoigma and access to treatment -• A meta-analysis (N= 4,913 transgender people) indicated that internalised transnegativity was related to depression, anxiety, and suicidal ideation (2021)

1. Orgasm Disorders The orgasm phase of the sexual response cycle can also become disrupted in one of several ways. As a result, either the orgasm occurs at an inappropriate time or it does not occur. An inability to achieve an orgasm despite adequate sexual desire and arousal is commonly seen in women and less com- monly seen in men. Males who achieve orgasm only with great difficulty or not at all meet criteria for a condition called 2. An inability to reach orgasm is the most common complaint among women who seek therapy for sexual problems. 3. In the U.S. survey, approximately 8% of men report having delayed ejaculation or none during sexual interactions (Laumann et al., 1999). Men seldom seek treatment for this condition. It is

1. delayed ejaculation. In women the condition is referred to as female orgasmic disorder 2. though the U.S. survey did not estimate the prevalence of female orgas- mic disorder specifically, approximately 25% of women report significant difficulty reaching orgasm (Heiman, 2000; Laumann et al., 1999), although estimates vary widely (Graham, 2010). The problem is equally present in different age groups, and unmarried women were 1.5 times more likely than married women to expe- rience orgasm disorder. In diagnosing this problem, it is neces- sary to determine that the women "never or almost never" reach orgasm (Wincze & Weisberg, 2015). This distinction is important because only approximately 20% of all women reliably experience regular orgasms during sexual intercourse (Graham, 2010; Lloyd, 2005). Therefore, approximately 80% do not achieve orgasm with every sexual encounter, unlike most men, who tend to experi- ence orgasm more consistently. 3. ternative forms of stimulation and that this condition is accom- modated by the couple (Apfelbaum, 2000). Some men who are unable to ejaculate with their partners can obtain an erection and ejaculate during masturbation. Occasion- ally men suffer from retrograde ejaculation, in which ejaculatory fluids travel backward into the bladder rather than forward. This phenomenon is almost always caused by the effects of certain drugs or a coexisting medical condition and should not be con- fused with delayed ejaculation.

1.ambling Disorder Gambling has a long history—for example, dice have been found in Egyptian tombs (Greenberg, 2005). It is growing in popularity in this country, and in many places it is a legal and acceptable form of entertainment. Perhaps as a result, gambling disorder affects an increasing number of people, with a lifetime estimate of approxi- mately 1.9% of adult Americans (Ashley & Boehlke, 2012). Research suggests that among pathological gamblers, 14% have lost at least one job, 19% have declared bankruptcy, 32% have been arrested, and 21% have been incarcerated (Gerst 2.arch) show strong similarities in the biological origins of gambling disorders and substance use disorders. In one study, brainimaging technology (echoplanar functional magnetic resonance imaging) was used to observe brain function while gamblers observed videotapes of other people gambling (Potenza et al., 2003). A decreased level of activity was observed in those regions of the brain that are involved in impulse regulation when compared with controls, suggesting an interaction between the environmental cues to gamble and the brain's response (which may be to decrease the ability to

1. e DSM-5 criteria for gambling disorder set forth the associated behaviors that characterize people who have this addictive disorder. These include the same pattern of urges we observe in the other substance-related disorders. Note too the parallels with substance dependence, with the need to gamble increasing amounts of money over time and the "withdrawal symptoms" such as restlessness and irritability when attempting to stop. These parallels to substance-related disorders led to the recategorization of gambling disorder as an "Addictive Disorder" in DSM-5 (Denis, Fatséas, & Auriacombe, 2012). There is a growing body of research on the nature and treat- ment of gambling disorder. For example, work is under way to explore the biological origins of the urge to gamble among patho- logical gamblers. Research in this area and others (e.g., genetic 2.suggesting an interaction between the environmental cues to gamble and the brain's response (which may be to decrease the ability to resist these cues). Studies have found that the ventromedial prefrontal cortex and orbitofrontal cortex ("the executive parts" of the brain) do not function as normal in those with gambling disorder. Poor impulse control and risky decisions are both processes that involve ventromedial prefrontal cortex and those individuals with higher problems in these areas also show poorer response to treatment and higher relapse rates (Yau, Yip, & Potenza, 2015). Treatment of gambling problems is difficult. Those with gambling disorder exhibit a combination of characteristics— including denial of the problem, impulsivity, and continuing optimism ("One big win will cover my losses!")—that

1. Lawrence (2005) studied 232 transwomen both before and after surgery and found that the majority (54%) were mostly het- erosexual (attracted to women) before the surgery. 2.Gender dysphoria resulting in a rejection of natal sex is rel- atively rare. The estimated prevalence in natal males is between 5 and 14 per 1,000 and for natal females between 2 and 3 per 1,000 (American Psychiatric Association, 2013; 2015), occurring approximately 3 times more frequently in natal males than in natal females

1. hat only 25% remained attracted to women after surgery, thus making them technically gay. This latter group may constitute a distinct subset of transwomen with a different pattern of devel- opment called autogynephilia, in which gender dysphoria begins with a strong and specific sexual attraction to a fantasy of oneself (auto) as a female (gyne). This fantasy then progresses to a more comprehensive all-encompassing experienced gender as a female. Individuals in this subgroup of biological males were not effemi- nate as boys but became sexually aroused while cross-dressing and to fantasies of themselves as women. Over time, these fanta- sies progress to becoming a woman (Bailey, 2003; Carroll, 2007; Lawrence, 2013). This distinction is controversial, but it is sup- ported by research (Carroll, 2007; see p. 379). 23.merican Psychological Association, 2008; Judge, O'Donovan, Callaghan, Gaoatswe, & O'Shea, 2014; Sohn & Bosinski, 2007). Many countries now require a series of legal steps to change gender. In Germany, between 2.1 and 2.4 per 100,000 in the popu- lation took at least the first legal step of changing their first names in the 1990s; in that country, the male:female ratio of people with gender dysphoria is 2.3:1 (Weitze & Osburg, 1996). Since 2006 in New York City, people may choose to alter the natal sex listed on their birth certificates following surgery.

1. clinical description Apparent stimulation is the initial effect of alcohol, although it is a depressant. We generally experience a feeling of well-being, our inhibitions are reduced, and we become more outgoing. This is because the inhibitory centers in the brain are initially depressed—or slowed. 2. effects Alcohol affects many parts of the body (see E Figure 11.1). After it is ingested, it passes through the esophagus (1 in Figure 11.1) and into the stomach (2), where small amounts are absorbed. From there, most of it travels to the small intestine (3), where it is easily absorbed into the bloodstream. 3. Most substances we describe in this chapter, including can- nabis, opiates, and tranquilizers, interact with specific recep- tors in the brain cells. The effects of alcohol, however, are more complex. Alcohol influences a number of neuroreceptor systems, which makes it difficult to study (Ray, 2012). For example, the gamma-aminobutyric acid (GABA) system, which we discussed in Chapters 2 and 5, seems to be particularly sensitive to alcohol. GABA, as you will recall, is an inhibitory neurotransmitte

1. ith continued drinking, however, alco- hol depresses more areas of the brain, which impedes the ability to function properly. Motor coordination is impaired (staggering, slurred speech), reaction time is slowed, we become confused, our ability to make judgments is reduced, and even vision and hearing can be negatively affected, all of which 2. circulatory system distributes e body, where it contacts every major organ, including the heart (4). Some of the alcohol goes to the lungs, where it vaporizes and is exhaled, a phenomenon that is the basis for the breathalyzer test that measures levels of intoxica- tion. As alcohol passes through the liver (5), it is broken down or metabolized into carbon dioxide and water by enzymes (Maher, 1997). E Figure 11.2 shows how much time it takes to metabo- lize one to four drinks, with the dotted line showing when driv- ing becomes impaire 3. of the neuron it attaches to. Because the GABA system seems to affect the emotion of anxi- ety, alcohol's antianxiety properties may result from its interaction with the GABA system. Also, when GABA attaches to its receptor, chloride ions enter the cell and make it less sensitive to the effects of other neurotransmitters. Alcohol seems to reinforce the move- ment of these chloride ions; as a result, the neurons have difficult

1. Lifelong female orgasmic disorder may be treated with explicit training in masturbatory procedures (Bradford & Meston, 2011). For example, Greta was still unable to achieve orgasm with manual stimulation by her husband, even after proceeding through the basic steps of sex therapy. At this point, following certain stan- dardized treatment programs for this problem (see, for example, Heiman, 2000; Heiman & LoPiccolo, 1988), Greta and Will pur- chased a vibrator and Greta was taught to let go of her inhibitions by talking out loud about how she felt during sexual arousal, even shouting or screaming if she wanted to. In the context of appro- priate genital pleasuring and disinhibition exercises, the vibrator brought on Greta's first orgasm.\ 2. ple, the woman gradually inserts the man's penis. These exercises are carried out in the context of genital and nongenital pleasuring so as to retain arousal. Close attention must be accorded to any increased fear and anxiety that may be associated with the process, which may trigger memories of early sexual abuse that may have contributed

1. ith practice and good commu- nication, the couple eventually learned how to bring on Greta's orgasm without the vibrator. Although Will and Greta were both delighted with her progress, Will was concerned that Greta's screams during orgasm would attract the attention of the neigh- bors! Summaries of results from a number of studies suggest 70% to 90% of women will benefit from treatment, and these gains are stable and even improve further over time (Fruhauf et al., 2013; Heiman, 2007; Heiman & Meston, 1997; Segraves & Althof, 1998). To treat vaginismus and pain related to penetration in genito- pelvic pain/penetration disorder, the woman and, eventually, the partner gradually insert increasingly larger dilators at the woman's pace. After the woman (and then the partner) 2. These procedures are highly successful, with a large majority of women (80% to 100%) overcoming vaginismus in a relatively short period (Binik et al., 2007; Leiblum & Rosen, 2000; ter Kuile et al., 2007; ter Kuile, Melles, de Groot, Tuijnman-Raasveld, & van Lankveld, 2013). A variety of treatment procedures have also been developed for low sexual desire (see, for example, Pridal & LoPiccolo, 2000; Wincze, 2009; Wincze & Weisberg, 2015). At the heart of these treatments are the standard reeducation and communication phases of traditional sex therapy with, possibly, the addition of masturbatory training and exposure to erotic material. Each case may require individual strategies. Remember Mrs. C., who was sexually abused by her cousin? Therapy involved helping the couple understand the impact of the repeated, unwanted sexual experiences in Mrs. C.'s past and to approach sex so that Mrs. C. was more comfortable with foreplay. She gradually lost the idea that once sex was started she had no control. She and her husband worked on starting and stopping sexual encounters.

1. • Anhedonia: 2. Asociality: 3. Alogia: 4. • Affective flattening/Blunted affect: 5.Disorganised Symptoms • Disorganised speech

1. lack of pleasure• Reduction in anticipatory pleasure not consummatory pleasure- Anhedonia: Lack of pleasure; sdepressive people do this ; if ask individual might experience eating cake , they say wont look forward to it, so labut will enjoy it if pyt in font of them 2, lack of interest in social interactionswish to spend time alone 3. significant reduction of speech 4. lack of emotional expression1. Flat voice, not look at people when speaking 5. • Erratic speech and emotions that prevents listeners from understanding. • Loose associations: ideas which are disjointed by still related • Derailment: ideas so disorganized there appears to be no meaningful connections

1. pter. Problems of sexual interest or desire used to be considered marital rather than sexual difficulties. Since the recognition in the late 1980s of low sexual desire as a distinct disorder, however, increasing numbers of couples present to sex therapy clinics with one of the partners reporting this problem (Kleinplatz, Moser, & Lev, 2012; Leiblum, 2010; Pridal & LoPiccolo, 2000). Best esti- mates suggest that more than 50% of patients who come to sex- uality clinics for help complain of low sexual desire or interest (Leiblum 2010; Pridal & LoPiccolo, 2000). 2. Sexual Arousal Disorders Erectile disorder is a specific disorder of arousal. The problem here is not desire. Many males with erectile dysfunction have fre- quent sexual urges and fantasies and a strong desire to have sex. 3. The old and somewhat derogatory terms for male erectile dis- order and female interest and arousal difficulties are impotence and frigidity, but these are imprecise labels that do not identify the specific phase of the sexual response in which the problems are localized.

1. n many clinics, it is the most common presenting complaint of women; men present more often with erectile dysfunction (Hawton, 1995). The U.S. survey confirmed that 22% of women and 5% of men suffer from low sexual interest (hypoactive sexual disorder in man). But in a larger international survey, as many as 43% of women reported this problem (Laumann et al., 2005). For men, the prevalence increases with age; for women, it decreases with age (DeLamater & Sill, 2005; Fileborn, et al., 2015; Laumann, Paik, & Rosen, 1999). Schreiner-Engel and Schiavi (1986) noted that patients with this disorder rarely have sexual fantasies, seldom masturbate (35% of the women and 52% of the men never masturbated, and most of the rest in their sample masturbated no more than once a month), and attempt intercourse once a month or less. 2. Their problem is in becoming physically aroused: For females who are also likely to have low interest, deficits in arousal are reflected in an inability to achieve or maintain adequate lubrication 3. A man typically feels more impaired by his problem than a woman does by hers. Inability to achieve and maintain an erection makes intercourse difficult or impossible. Women who are unable to achieve vaginal lubrication, however, may be able to compensate by using a commercial lubricant (Leiblum 2010; Wincze, 2009). In women, arousal and lubrication may decrease

1.causes Important information about the genetics of ADHD is beginning to be uncovered (Barkley, 2015a). Researchers have known for some time that ADHD is more common in families in which one person has the disorder. For example, the relatives of children with ADHD have been found to be more likely to have ADHD them- selves than would be expected in the general population (Fliers et al., 2009). It is important to note that these families display a 2.Most attention to date focuses on genes associated with the neurochemical dopamine, although norepinephrine, serotonin, and gamma-aminobutyric acid (GABA) are also implicated in the cause of ADHD. More

1. n psychopathology in general, including conduct disorder, mood disorders, anxiety disorders, and substance abuse (Barkley, 2015a). This research and the comorbidity in the children them- selves suggest that some shared genetic deficits may contribute to the problems experienced by individuals with these disorders (Brown, 2009). ADHD is considered to be highly influenced by genetics. Envi- ronmental influences play a relatively small role in the cause of the disorder when compared with many other disorders we discuss in this book. As with other disorders, researchers are finding that multiple genes are responsible for ADHD (Nikolas & Burt, 2010). In its simplest form, we tend to think of genetic "problems" in terms of having genes turned off (not making proteins) when they should be turned on and vice versa. Research on ADHD (and on other disorders) is finding that in many cases, however, mutations occur that either create extra copies of a gene on one chromosome or result in the deletion of genes (called copy number variants— CNVs) (Martin, O'Donovan, Thapar, Langley, & Williams, 2015). Because our DNA is structured to function with corresponding or matching pairs of genes on each chromosome, the additions or deletions of one or more genes res 2/ally, there is strong evidence that ADHD is associated with the dopamine D4 receptor gene, the dopamine transporter gene (DAT1), and the dopamine D5 receptor gene. DAT1 is of particular interest because methylphe- nidate (Ritalin)—one of the most common medical treatments for ADHD—inhibits this gene and increases the amount of dopamine available (Davis et al., 2007; de Azeredo et al., 2014). Such research helps us understand at a microlevel what might be going wrong and how to design new interventions.

1. There was also some hope that Viagra would be useful for dysfunction in postmenopausal women, but results were disap- pointing (Bradford & Meston, 2011; Kaplan et al., 1999). Now interest has centered on a new drug, flibanserin, as a possible treatment for hypoactive sexual desire in women. 2. For some time, testosterone (Schiavi, White, Mandeli, & Levine, 1997) has been used to treat erectile dysfunction. But although it is safe and has relatively few side effects, only negligible effects on erectile dysfunction have been reported (Forti, Corona, Vignozzi, & Maggi, 2012; Mann et al., 1996). Some urologists teach patients to inject vasodilating drugs such as papaverine or prostaglandin directly into the penis when they want to have sexu- al intercourse.

1. ndeed initial research findings suggest that this medication may be effective since there is preliminary evidence for increases in sexual desire and reduced distress associated with hypoactive sexual desire in women, (DeRogatis et al., 2012; Katz et al., 2013). These findings are also very controversial since the data show that the effects of what has been called "pink Viagra" are very modest so as to be relatively unnoticeable for many women leading some to question whether pharmaceutical companies may be misleading the public in order to cash in on a sexual enhancement drug for women giv- en the enormous profits associated with Viagra and similar drugs for men 2. drugs dilate the blood vessels, allowing blood to flow to the penis and thereby producing an erection within 15 minutes that can last from 1 to 4 hours (Rosen, 2007; Segraves & Althof, 1998). Because this procedure is a bit painful (although not as much as one might think), a substantial number of men, usually 50% to 60%, stop using it after a short time. In one study, 50 of 100 patients discontinued papaverine for various reasons (Lakin, Montague, Vanderbrug Medendorp, Tesar, & Schover, 1990; Segraves & Althof, 1998). A soft capsule that contains papav- erine (called MUSE [Medical Urethral System for Erections]) can be inserted directly into the urethra, but this is somewhat painful, is less effective than injections, and remains awkward and artifi- cial enough to preclude wide acceptance (Delizonna, Wincze, Litz, Brown, & Barlow, 2001). Insertion of penile prostheses or implants has been a surgical option for almost 100 years; only recently have they become good enough to approximate normal sexual func- tioning.

1. In an impressive series of studies, Barbara Andersen and her colleagues have assessed gender differences in basic or core beliefs about sexual aspects of one's self. These core beliefs about sexual- ity are referred to as "sexual self-schemas." Specifically, in a series of studies (Andersen & Cyranowski, 1994; Andersen, Cyranowski, & Espindle, 1999; Cyranowski, Aarestad, & Andersen, 1999), Andersen and colleagues demonstrated that women tend to report the experi- ence of passionate and romantic feelings as an integral part of their sexuality, as well as an openness to sexual experience. 2. Peplau (2003) summarizes research to date on gender differences in human sexuality as highlighting four

1. substantial number of women, however, also hold an embarrassed, conserva- tive, or self-conscious schema that sometimes conflicts with more positive aspects of their sexual attitudes. Men, on the other hand, evidence a strong component of feeling powerful, independent, and aggressive as part of their sexuality, in addition to being passionate, loving, and open to experience. Also, men do not generally possess negative core beliefs reflecting self-consciousness, embarrassment, or feeling behaviorally inhibited 2. themes: (1) men show more sexual desire and arousal than women; (2) women emphasize committed relationships as a context for sex more than men; (3) men's sexual self-concept, unlike women's, is characterized partly by power, independence, and aggression; and (4) women's sexual beliefs are more "plastic" in that they are more easily shaped by cultural, social, and situational factors. For exam- ple, women are more likely to change sexual orientation over time (Diamond, 2007; Diamond et al., 2011; Mock & Eibach, 2012) or may be more variable in frequency of sex, alternating periods of high frequency with low frequency if a sexual partner leaves.

1. reclaiming sexual desire

1. talk avbiyt it

1. d that can be bent by the male into correct position for inter- course and maneuvered out of the way at other times. In a more popular procedure, the male squeezes a small pump that is surgically implanted into the scrotum, forcing fluid into an inflatable cylinder and thus producing an erection. A newer penile prosthetic device is an inflatable rod that contains the pumping device, which is more convenient than having 2. summary Treatment programs, both psychosocial and medical, offer hope to most people who suffer from sexual dysfunctions. Unfortunately, such programs are not readily available in many locations because few health and mental health professionals are trained to apply them, although the availability of drugs for male erectile dysfunc- tion is widespread.

1. ual functioning or assuring satisfaction in most patients (Gregoire, 1992; Kim & Lipshultz, 1997); they are now generally used only if other approaches don't work. On the other hand, this procedure has proved useful for men who must have a cancerous prostate removed, because this surgery often causes erectile dysfunction, although newer "nerve-sparing" sur- geries lessen the effect to some extent (Ramsawh, Morgentaler, Covino, Barlow, & DeWolf, 2005). Another approach is vacuum device therapy, which works by creating a vacuum in a cylinder placed over the penis. The vacuum draws blood into the penis, which is then trapped by a specially designed ring placed around the base of the penis. Although using the vacuum device is rather awkward, between 70% and 100% of users report satisfactory erections, particu- larly if psychological sex therapy is ineffective 2. urther, government agencies such as the NIH have been slow to fund research dedicated to understand- ing sexual dysfunctions and their treatments since any research focused on sex has occasionally proved to be controversial among some members of Congress serving on oversight committees for NIH funding. Psychological treatment of sexual arousal disor- ders requires further improvement, and treatments for low sexual desire are largely untested. Most treatments are still intrusive and clumsy, although drugs such as Viagra and Levitra exhibit some success for erectile dysfunction. New medical developments including medications, topical creams, and gene therapy are under investigation as potential treatments, but research on these inter- ventions is just beginning.

1. Assessing and Treating Paraphilic Disorders In recent years, researchers have developed sophisticated meth- ods for assessing specific patterns of sexual arousal (Ponseti et al., 2012; Wincze, 2009; Wincze & Weisberg, 2015). This devel- opment is important in studying paraphilic disorder because sometimes even the individual presenting with the problem is not fully aware of what caused arousal. An individual once came in to our clinic complaining of uncontrollable arousal to open- toed white sandals worn by women. He noted that he was irre- sistibly drawn to any woman wearing such sandals and would follow her for miles. These urges occupied much of his summer. 2. Psychological Treatment A number of treatment procedures are available for decreas- ing unwanted arousal. Most are behavior therapy procedures directed at changing the associations and context from arousing and pleasurable to neutral 3. ke hours. You know what Father X must be thinking as he stands there staring at you. You are embarrassed and wantto say something, but you can't seem to find the right words. You realize that Father X can no longer respect you as he once did. Father X finally says, "I don't understand this; th

1. ubsequent objective assessment revealed that the sandal itself had no erotic value for this individual; rather, he had a strong sexual attraction to women's feet, particularly moving in a cer- tain way. He had no reason to hide this fact; it was just that he did not realize it himself. Using the model of paraphilic disorders described pre- viously, we assess each patient not only for the presence of paraphilic arousal but also for levels of desired arousal to adults, for social skills, and for the ability to form relationships. Tony had no problems with social skills: He was 52 years old, reasonably happily married, and generally compatible with his second wife. His major difficulty was his continuing strong, incestuous at 2.One procedure, carried out entirely in the imagination of the patient, called covert sensitization, was first described by Joseph Cautela (1967; see also Barlow, 2004). In this treatment, patients associate sexually arousing images in ion with some reasons why the behavior is harm- ful or dangerous. Before treatment, the patient knows about these reasons, but the immediate pleasure and strong reinforcement the sexual activity provides is enough to overcome any thoughts of possible harm or danger that might arise in the future. This pro- cess is what happens in much unwanted addictive behavior, where the short-term pleasure outweighs the long-term harm, including bulimia. In imagination, harmful or dangerous consequences can be associated quite directly with the unwanted behavior and arousal in a powerful and emotionally meaningful way. One of the most powerful negative aspects of Tony's behavior was his embarrassment over the thoug 3.During six or eight sessions, the therapist narrates such scenes dramatically, and the patient is then instructed to imagine them daily until all arousal disappears. The results of Tony's treatment are presented in E Figure 10.7. "Card-sort scores" are a measure of how much Tony wanted sexual interactions with his daugh- ter in comparison with his wish for nonsexual fatherly interac- tions. His incestuous arousal was largely eliminated after 3 to 4 weeks, but the treatment did not affect his desire to interact with his daughter in a healthier manner.

1. Although there are no data on the prevalence of vaginismus in community samples, best estimates are that it affects 6% of women (Bradford & Meston, 2011). 2. Assessing Sexual Behavior There are three major aspects to the assessment of sexual behavior (Wiegel, Wincze, & Barlow, 2002): 3. Interviews All clinicians who conduct interviews for sexual problems should be aware of several useful assumptions (Wiegel et al., 2002; Wincze, 2009). For example, they must demonstrate to the patient through their actions and interviewing style that they are comfortable talking about these issues. Because many patients do not know the various clinical terms professionals use to describe the sexual response cycle and various aspects of sexual behavior, clinicians must always be prepared to use the vernacu- lar (language) of the patient, realizing also that terms vary from person to person. The following are examples of the questions asked in semis- tructured interviews in our sexuality clinic:

1. wenty-five percent of women who report suffering from some sexual dysfunction experience vagi- nismus, according to Crowley, Richardson, and Goldmeir (2006). Because vaginismus and the experience of pain during intercourse overlap quite a bit in women, these conditions have been combined in DSM-5 into genito-pelvic pain/penetration disorder (Binik, 2010; Bradford & Meston, 2011; Payne et al., 2005). Results from the U.S. survey indicate that approximately 7% of women suffer from one or the other type of sexual pain disorder, with higher proportions of younger and less educated women reporting this problem (Laumann et al., 1999). Somewhat higher estimates of 15% of women in North America reporting recurring pain during intercourse have been reported in DSM-5 2. Interviews, usually supported by numerous questionnaires because patients may provide more information on paper than in a verbal interview A thorough medical evaluation, to rule out the variety of med- ical conditions that can contribute to sexual problems A psychophysiological assessment, to directly measure the physiological aspects of sexual arousal 3. How would you describe your current interest in sex?Do you avoid engaging in sexual behavior with a partner? Do you have sexual fantasies?How often do you currently masturbate?How often do you engage in sexual intercourse?How often do you engage in mutual caressing or cuddling without intercourse?Have you ever been sexually abused or raped or had a negative experience associated with sex? A clinician must be careful to ask these questions in a manner that puts the patient at ease. During an interview lasting approxi- mately 2 hours, the clinician also covers nonsexual relationship issues and physical health and screens for the presence of addi- tional psychological disorders. When possible, the partner is interviewed concurrently. Patients may volunteer in writing some information they are not ready to talk about, so they are usually given a variety of ques- tionnaires that help reveal sexual activity and attitudes toward sexuality.

1. 1. Rule out conduct disorder or oppositional defiant disorder 2. Attention-Deficit/Hyperactivity Disorder • Specify whether: 3. Attention-Deficit/Hyperactivity Disorder • Prevalence

1. § Often comorbidity between these, so can have multiple diagnosis, but ensure that ADHD symptoms not entirely caused by separate diagnosis (just make sure they aren't capabole of getting symptoms on their own if so then conduct or ODD) 2. 1. Combined presentation: Both A1 and A2 met? 2. Predominantly inattentive: A1 met, A2 not 3. Predominantly hyperactive/impulsive: A2 met, A1 not 3. • Occurs in approximately 5% of school-aged children throughout the world • In general population (including adults), 5 to 11% meet criteria • ADHD most commonly diagnosed in the United States -Prevalence differences could be the result of children getting a diagnosis that isn't warranted due to a limited assessment -May also be due to some individuals preferring to diagnosis ADHD rather than oppositional defiant disorder or conduct disorder 1. diagnosis in US however conduct and ODD less prevalence here; maybe some cultural differences , § Perhaps due to limited assessment in US; need thorough 2or 3 hour diagnoses; need a lot of neuropsych testing, paediatrician 20 minute ppointment not enough § Perhaps misdiagnosis of conduct disorder or ODD , as these 2 stigmatising thye give adhd • Gender differences: Boys outnumber girls 3:1;1. Perhaps due to girls having less disruptive symptoms; so maybe not getting explicitly diagnosed as much

1. • High expressed emotion 2.. Diathesis-Stress Model 3. Treatment

1. § may lead to schizo intense symptoms or other way around · High expressed emotions: Critical comments, hostility, emotional over-involvement · 10% of schizo in low sexpressed emotion hmes relapse after being hosputalised after schizof[phrenia compared with 58% of those released into highe o Schizophrenic patient more likely to relapse if living in a high expressed emotional home compared to low expressed emotional home · So this os a stressor that leads to difficult encironment · Perhaps also bidirectional relationship · Can intensify schizophrenic symptoms 2. § Huge genetic, biological component which interacts with environment; both are needed 3. Often includes a combo of short-term hospital stays, medication, and psychosocial treatment - Best way to treat someone is combine these

1.From the DSM5 website: 2. Sexual dysfunction is not all that uncommon

1. • "It is important to note that gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition." 2. Lacked interest in sex f: 26-43% M; 13-28% Inability to reach orgasm F18-41% M9-21% Orgasm reached too quickly F8-26% M12-31% Pain during sex F9-32% M3-12% Sex not pleasurable F17-36% M8-17% Trouble lubricating F16-38% M; NA Trouble maintaining or achieving an erection F. NA M. 13-28% - 11-23% meet criteria for disorder of the 43% whon have the symtpms - Transciet symptoms nor,s, but disorder neds to be at leadst 6 monhs and clinically dieeffirent distress - Most common for men is orgasm reached too quickly, followed by lacking interest in sex tied with inability to maintain erection

1. Cluster A: Schizoid Personality Disorder • Prevalence 2. Characteristics 3. Causal factors 4.Treatment 5. Cluster A: Schizotypal Personality Disorder criteria

1. • 1% • More common in males than females 2. - Poorly studied! These people don't sign up for research often - Great overlap with autism (interpersonal aloofness) - May precede psychotic illness 3. - Genes - Impairment in affiliative (relational) system (similar with autism) 4. -Focus on the value of interpersonal relationships -Build empathy and social skills -Lack of RCTs;1. unsure if treatments benefit anyone 5. A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: -Ideas of reference (excluding delusions of reference);1. Seeing things as being about them when they aren't (but not often to the point of being entirely delusional) -Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations). -strange or usual Unusual perceptual experiences, including bodily illusions. -Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped). -Suspiciousness or paranoid ideation. -Inappropriate or constricted affect. -Behavior or appearance that is odd, eccentric, or peculiar. -Lack of close friends or confidants other than first-degree relatives. -Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self. A. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.

1. • Prevalence 2. Characteristics 3. Causal factors 4. Treatment 5. schizoid personality disorder

1. • 1-2% • Female: male = 1:1 2. Not well studied - Rarely is paranoia as bad as being psychotic, although may have transient psychotic symptoms during distress 3. • Modest genetic transmission • Parental neglect/abuse • Exposure to violent adults as children • Traumatic brain injury • Chronic cocaine use 4. • Cognitive therapy to counter negativistic thinking • Lack of RCTs;1. No randomised control trials, unsure if effective 5. A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: -Neither desires nor enjoys close relationships, including being part of a family. -Almost always chooses solitary activities. -Has little, if any, interest in having sexual experiences with another person. -Takes pleasure in few, if any, activities. -Lacks close friends or confidants other than first-degree relatives. -Appears indifferent to the praise or criticism of others. Shows emotional coldness, detachment, or flattened affectivity. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition.

1. • Neurobiological correlates of ADHD 2. Environmental Influences • The role of toxins 3. • Family factors

1. • Smaller brain volume • Inactivity of the frontal cortex and basal ganglia • Abnormal frontal lobe development and functioning • Smaller brain volume• Inactivity of the frontal cortex and basal ganglia § ALL AREAS ASSOCIATED WITH DOPAMINE 2. • Lead;§ small degree of symptoms • Food additives (e.g., dyes, pesticides) may play very small role in hyperactive/impulsive behavior among children • Maternal smoking increases risk § and perhaps alcohol use; not every mother who smokes has adhd kid and also the opposite § Toxins have very small effect 3. • Parent-child relationship interacts with neurobiological factors to influence sx expression • Parents of kids with ADHD give more commands and have more negative interactions with their kids • This is in part due to the child's sx • Fathers who have a dx of ADHD tend to be less effective parents · Extreme adhd symptims lead to increase in negative interatciosn · Parents give more commands and more negative interactions · Fathers with ADHD are less effective parents but leads to negative interactions with kids

1. The Acute Effects of Alcoho 2. The Long-term Effects of Alcohol

1. • Influences numerous neuroreceptor systems -• GABA • Might be responsible for anti-anxiety properties;1. Inhibitory, makes receptors less receptive to other transmitters by binding to the re, oversymulate pathways so reduce anxiety -Glutamate decreased • Might be responsible for cognitive dysfunction 1. Excitatory ; helps neuron fire 2. Involved in learning and memory, 3. Alcohol causes memory loss and blackouts -Serotonin • Might be responsible for improved mood and alcohol cravings 2. • Withdrawal;- Hand tremors, nausea, vomiting, anciety , • Delirium tremens;1. Severe alcohol withdrawal symptoms § Shaking, hallucinations, confusion § Starts 2-5 days after last drink § Can be fatal -Liver disease -Pancreatitis -Cardiovascular disorders -Brain damage • Dementia (general kloss of intellectual abilities) • Wernicke-Korsakoff Syndrome (§ Confusion, muscle problems, vision problems, mental activity loss § May progress to coma and death)

1. characteristics and causal factors 2. • Treatment 3. • Cluster C: Obsessive-Compulsive Personality Disorder criteria

1. • Lack of research -Small to moderate genetic contribution -Authoritarian and overprotective parents 2.- No advice, no known treatment which works - Anxiety and depression will be treated instead which is a consequence of the PD 3. A. A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: -Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. -Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met). -Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity). -Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).;(black and white thinking) -Is unable to discard worn-out or worthless objects even when they have no sentimental value. -Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. -Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. -Shows rigidity and stubbornness.

1. Causes of Gender Dysphoria 2. ROGD Controversy Recent study proposing a "Rapid Onset Gender Dysphoria" (ROGD) 3. The study has been extensively critiqued:

1. • No clear biological causes identified, but likely has genetic component -Studies have found that 62 to 70% of variance in gender expression is explained by genetics -Exposure to certain hormones in the womb (e.g., higher levels of testosterone may masculinize a female fetus) - Some critigued the interest in cause s asv that may sparlk the desire to prevent gender dysphoria and formation of transgender identities 2. Claimed a social contagion effect driving gender dysphoria among some adolescents due to a higher prevalence of gender dysphoria in some adolescent peer groups 3. Recruitment methods • Only parents (not the adolescents);- Parents required to self-specifiyif their children satisfied the criteria for the gender dysohoria diagnosis • Parents filled in DSM criteria • Recruitment from three websites known as places that encouraged parents to not believe their children's transgender identity -Statistics did not align with interpretation and inferences -A revised version of the study published that revises inferences to place less emphasis on the causes of gender dysphoria

1. Treatment 2. Rehearse Your Knowledge Anthony is a 26 year old male. He had been betting on sports games for the past five years. Over the past year, he had begun to lose more money than he could afford. He had gradually increased the frequency and bets he placed. When le lost, he placed he larger bets, convinced the odds would be in his favour next time. When he won, he felt immense excitement and would continue to play, convinced he was on a winning streak. He was relying on his girlfriend, who was younger and supporting herself while attending university, to provide him with food and rent money. She had grown quite unhappy over the past year due to his gambling behaviour, but as much as we wanted to stop gambling, Anthony found that he not able to. If he went a day without placing a bet, he became quite restless, feeling like he was missing out. Recently, she had left him so he was now seeking treatment to stop. How many symptoms does Anthony meet? Which severity specifier would you give him?

1. • Similar to CBT for substance use High relapse rates -Outcomes might be improved when family relationship problems are addressed

1. Class Discussion • What are some examples of positive versus negative psychotic symptoms related to substance use? 2. urden of substance use disorders Which drugs account for the greatest economic burden:Alcohol, tobacco, or illicit substances?

1.- Early intervention; earlier you can provide treastemen - Identify those whi at risk; famlily history , prodermal symptoms, can be similar to depression symptions. Anxiety , a drop in functioning in a school settojh - 12-25 start to exhibit these symptoms; more pronounced between 16-20 - Look at screening them if at risk - Work out what level their psychosis at - What interventions to prevemy them developing firther - Positive psychotic symptoms; added not many , hallucinations, delusions - Nehative psychoyoic sympotoms; loss of motivation and cognitive symotoms, stop being social, loss of faceial expressions,mute - Provide them with lots of psychoeducation - Antipsychotic medication ; monitor how they dowith low dose; gradually increase it depending on the response - Cannabis; increases the risk of psychosis amnd psychotic disorders - Cannabis can express genetic makeup of schizophrenia; increases psychotic symptoms 2.Economic costs associated with licit and illicit drug use in 2004-05 amounted to $56.1 billion calculated based on costs related to healthcare, production in the workplace/home, road accidents, crime, etc) Tobacco accounted for 56% comprising ($31.5 billion) Alcohol accounted for 27% ($15.3 billion) Illicit drugs accounted for 15% ($8.2 billion)

1.Class Discussion • What might make CBT effective for substance use disorders? Think about each component of CBT. 2.Evidence-Based Treatments: All forms of CBT

1.- Specific gioals, managing urges to drink and smoke, kearnt these have truggers; arguinmh with wife, hanging with Charlie, negative feedback from boss, so learnt to avoid these and leave - Next reqward himself - What we think affects how we feel wihich drives his behaviours, when he thinks he sucks, he fulls bad then goes for a drink - Assertive communication skills - Positibe relationshio s - Ruth followed him and did therapy as well - Frank more confident in urges, and slowing his thoughts - Beliefs and what associated with the drink if someone come in with alcoholism; learn tiggers as well fpocus secificallky on its alcohol and alcohol-relwated cognitions, bhevaiour , problema and social networks around alcoholic - 12 sessions ; 1 session a week , an hour long 2.Behavioural Couples Therapy, recovery planning, guided self-change, smoking cessation with weight gain prevention, motivational interviewing, recovery plan ing, contingency management, relapse prevention

1.- Slide; clip 4 gambing disorders clip 2.- Now change din 2014 now it's an addiction; simila r behavioural syotms, neurla substrates - Failue to filfil makor role obligatoons ; 3.Gambingl;

1.- Spend all her earning sin gambiling - Borrowing money from friends, lie about wjat she was doinf - Cash out 4000$ of checques of friends parents - Thought she would drive into oncoming traffic ' - Irrresistable cravings ; performed gambling despite negative consequencies - Putting something of value at risk inhopes of getting something of freater value - Lot of people can gamble but not experience the addiction - But 4-6 million get problems in - Pathaological disorder ; prsistant and reciurent gambling behaviour leading to clinically significant distress; used to be problem of impulse control Dsm 5 classified ampling with pyro and kleptomania 2.- For gambiling the same criteria; have they jeoperdised the roles - Drugs; persiostent dieseire unseucceddsuful efforts to cut down - In gambinkg; rrpeated unsuccessdul efforts to - Persistence in behaviojr despite negative consequences 3.- do they experience tolerance or withdrawal; evidence suggests they do ; everuone heart rte increased when playing the game ; rush of excitement , heart rate of gambler squicly camd down more quiclklyb agfter stopping , reflecting tolwracnce - Gambelers tend to need to gamble larger amouts of money ti feel the sam rush - Withdrawal; 91% expressed cravings and reported headaches,. Insomnia, shakin ; physiological symptoms - Similarities between them

1. criterion B

1.B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text): 1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).§ repeating phrases, idiosyncratic phrases 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).§ rigid thinking patterns , distress form small changes in the environment , rigid greeting rituals, dsasm food everyday 3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). 4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). § More (hyper ) or under(hypo)

1.e of you who have experienced headaches, drowsiness, and a generally unpleasant mood when denied your morning cof- fee have had the withdrawal symptoms characteristic of this drug (Meredith et al., 2013). 2.Opioid-Related Disorders The word opiate refers to the natural chemicals in the opium poppy that have a narcotic effect (they relieve pain and induce sleep). In some circumstances, they can cause opioid-related disorders. The broader term opioids refers to the family of substances that includes natural opiates, synthetic variations (heroin, methadone, hydrocodone, oxycodone), and the comparable substances that occur naturally in the brain (enkephalins, beta-endorphins, and dynorphins) (Borg et al., 2015). References to the use of opium as a medicine date back more than 3,500 years (Strain, Lofwall, & Jaffe, 2009). In The Wizard of Oz, the Wicked Witch of the West puts Dorothy, Toto, and the Cowardly Lion to sleep by poisoning poppies in a field that is on the way to Oz, a literary allusion to the opium poppies u 3.rate and alcohol withdrawal can be even more distressing, however. Even so, people who cease or reduce their opi- oid intake begin to experience symptoms within 6 to 12 ho

1.Caffeine's effect on the brain seems to involve the neuromodulator adenosine and, to a lesser extent, the neurotransmitter dopamine (Juliano, Ferré, & Griffiths, 2015). Caffeine seems to block adenosine reuptake. Adenosine plays an important role on the release of dopamine and glutamate in the striatum, which may explain the elation and increased energy that come with caffeine use 2.to produce morphine, codeine, and heroin. Just as the poppies lull Dorothy, the Cowardly Lion, and Toto, opiates induce euphoria, drowsiness, and slowed breathing. High doses can lead to death if respiration is completely depressed. Opi- ates are also analgesics, substances that help relieve pain. People are sometimes given morphine before and after surgery to calm them and help block pain. Withdrawal from opioids can be so unpleasant that people may continue to use these drug 3. years with 4.13 million people over the age of 12 reporting non- medical use (SAMHSA, 2014). One survey found that 12.3% of high school seniors reported using opioids (e.g., hydrocodone, oxycodone) for nonmedical reasons (McCabe, West, Teter, & Boyd, 2012). Illicit use of opioid-containing prescription was the second most common type of illicit drug use in 2014 after marijuana. This rise in opioid use over the past decade has been deemed an opioid epidemic and public health crisis in the United States. The rise is particularly problematic because 1.9 million met criteria for opioid use disorder in 2013 (SAMHSA, 2014). Additionally, the increase in number of deaths due to illicit opioid use was the leading cause of death for drug users in 2013, a 360% increase from 1999 (Centers for Disease Control, National Center for Health Statistics, 2014). Research also suggests that individuals who first became addicted to prescription pain medication transitioned to using heroin (Muhuri, Gfroerer & Davies, 2013). People who use opiates face risks beyond addiction and the threat of overdose. Because these Because these drugs are usually injected intravenously, users are at increased risk for other chronic life-threatening illness such as Hepatitis C and HIV infection and therefore AIDS (

1. Treatment Treatment is available for gender dysphoria in specialty clinics around the world, although much controversy surrounds 2.sex reassignment surgery To qualify for surgery at a reputable clinic, individuals must live in the desired gender for 1 to 2 years so that they can be sure they want to change sex. They also must be stable psychologically, financially, and socially. In transwomen, hormones are admin- istered to promote gynecomastia (the growth of breasts) and the development of other secondary sex characteristics. Facial hair is typically removed through electrolysis. If the individual is satisfied with the events of the trial period, the genitals are removed and a vagina is constructed.

1.Carroll, 2007; Meyer-Bahlburg, 2010). For adults requesting full sex transition treatment guidelines from both the American Psychiatric Association and the American Psychological Association have now been published (American Psychological Association, 2015; Byne et al., 2012). The treatment guidelines published by the American Psychological Association (2015) highlight the diversity of problems facing gender- nonconforming individuals and encourage therapists to take a holistic view of these patients (i.e., helping to build resilience, working within existing family structures, and collaborating with other care providers). Recommendations from the American Psychiatric Association guidelines, when addressing adult patients with gender dysphoria more specifically, begin with the least intrusive step of full psychological evaluation and education before proceeding to partially reversible steps such as administra- tion of gonadal hormones to bring about desired secondary sex characteristics. The final nonreversible step is to alter anatomy physically to be consistent with gender identity through sex reas- signment surgery. 2.transmen, an artificial penis is typically constructed through plastic surgery, using sections of skin and muscle from elsewhere in the body, such as the thigh. Breasts are surgically removed. Genital surgery is more difficult and complex in natal females. Estimates of satisfaction with surgery indicate predomi- nantly successful adjustment (between 75% and 100% generally satisfied) among those who could be reached for follow ups, with transmen generally adjusting better than transwomen

1. nical description Individuals with schizoid personality disorder seem neither to desire nor to enjoy closeness with others, including romantic or sexual relationships. As a result, they appear cold and detached and do not seem affected by praise or criticism. One of the changes in DSM-IV-TR from previous versions was the recognition that at least some people with schizoid personality disorder are sensitive to the opinions of others but are unwilling or unable to express this emotion.

1.For them, social isolation may be extremely painful. Unfortunately, homelessness appears to be prevalent among peo- ple with this personality disorder, perhaps as a result of their lack of close friendships and lack of dissatisfaction about not having a sexual relationship with another person (Rouff, 2000; Angstman & Rasmussen, 2011). The social deficiencies of people with schizoid personality disorder are similar to those of people with paranoid personality disorder, although they are more extreme. As Beck and Freeman (1990, p. 125) put it, they "consider themselves to be observ- ers rather than participants in the world around them." They do not seem to have the unusual thought processes that character- ize the other disorders in Cluster A (Cloninger & Svakic, 2009) (see Table 12.6). For example, people with paranoid and schizo- typal personality disorders often have ideas of reference, mistaken beliefs that meaningless events relate just to them. In contrast, those with schizoid personality disorder share the social isolation, and constricted affect (showing neither positive nor negative emotion) seen in people with paranoid personality disorder. You will see in Chapter 13 that this distinction among psychotic-like symptoms is important to understanding people with schizophrenia, some of whom show the "positive" symptoms (actively unusual behaviors such as ideas of reference) and others only the "negative" symptoms (the more passive manifestations of social isolation or poor rapport with others).

1. Treatment of Gender Dysphoria Medical treatment Gender affirmation surgeries 2. Hormone therapies 3. Treatment for Children 4. Treatment for Adolescents

1.Genital reconfiguration, facial surgery, vocal surgery -In Australia, people often have to travel interstate to access expert care 2. Hormone replacement therapies (HRT): masculinising and feminising hormones -Hormone blockers (or puberty blockers): prevent the release of hormones and can delay the onset of puberty 3. Social transition most appropriate -Schools can be an important place to ensure an affirmative environment - Common, may not lead to dysphoria - May lead to negative social experiences 4. -Puberty and development of secondary sex characteristics can be a source of dysphoria -Puberty blockers can delay the onset of puberty (and are also prescribed for cisgender children with early onset puberty) -Hormone replacement therapies (HRT) not medically applicable until later adolescence or adulthood -Surgeries only accessible in adulthood

1.tudies suggest that those who are more likely to engage with AA tend to have more severe alcohol use problem and seem to be more committed to abstinence (McCrady & Tonigan, 2015). Thus, AA can be an effective treatment for highly motivated peo- ple with alcohol dependence. Research to date has not shown how AA compares t 2.controlled use One of the tenets of AA is total abstinence; recovering alcohol- ics who have just one sip of alcohol are believed to have "slipped" until they again achieve abstinence. Some researchers question this assumption, however, and believe at least a portion of abusers of several substances (notably alcohol and nicotine) may be capa- ble of becom

1.However, preliminary evidence shows that AA can be helpful for individuals seeking to achieve total abstinence and may be more cost effective than other treat- ments. Researchers are still trying to understand exactly why AA and the 12-step program work, but it seems that social support plays an important role (McCrady & Tonigan, 2015). Some individuals have a more mixed experience with AA and this includes agnostics and atheists, women, and minority groups (McCrady & Tonigan, 2015). Other groups now exist (e.g., Ratio- nal Recovery, Moderation Management, Women for Sobriety, SMART Recovery) for individuals w 2. oholism treatment field, the notion of teaching people controlled drinking is extremely controversial, partly because of a classic study showing partial success in teaching severe abusers to drink in a limited way (Sobell & Sobell, 1978). The participants were 40 male alcoholics in an alcoholism treat- ment program at a state hospital who were thought to have a good prognosis. The men were assigned either to a program that taught them how to drink in moderation (experimental group) or to a group that was abstinence oriented (control group). The researchers, Mark and Linda Sobell, followed the men for more than 2 years, maintaining contact with 98% of them. During the second year after treatment, those who participated in the con- trolled drinking group were functioning well 85% of the time, whereas the men in the abstinence group were reported to be doing well only 42% of the time. Although results in the two groups differed significantly, some men in both groups suffered serious relapses and required rehospitalization and some were incarcerated

1.bwasser, Chemerinski, Roussos, & Siever, 2013). It is certainly true that people are not always benevolent and sincere, and our interactions are sometimes ambiguous enough to make other people's intentions unclear. Looking too closely at what other people say and do can sometimes lead you to misinterpret them. Cultural factors have also been implicated in paranoid per- sonality disorder. Certain groups of people, such as prisoners, refugees, people with hearing impairments, and older adults, are thought to be particularly susceptible because of their unique experiences ( 2.treatment Because people with paranoid personality disorder are mistrustful of everyone, they are unlikely to seek professional help when they need it, and they have difficulty developing the trusting relation- ships necessary for successful therapy 3.Schizoid Personality Disorder Do you know someone who is a "loner"? Someone who would choose a solitary walk over an invitation to a party? A person who comes to class alone, sits alone, and leaves alone? Now, magnify this preference for isolation many times over and you can begin to grasp the impact of schizoid personality disorder (Hopwood & Thomas, 2012)

1.Imagine how you might view other people if you were an immigrant who had dif- ficulty with the language and the customs of your new culture. Such innocuous things as other people laughing or talking quietly might be interpreted as somehow directed at you. The late musi- cian Jim Morrison of The Doors described this phenomenon in his song "People Are Strange" (1967): "People are strange, / When you're a stranger, / Faces look ugly, / When you're alone." 2.Establishing a meaningful therapeu- tic alliance between the client and the therapist therefore becomes an important first step (Bender, 2005). When these individuals finally do seek therapy, the trigger is usually a crisis in their lives— such as Jake's threats to harm strangers—or other problems such as anxiety or depression, not necessarily their personality disorder -Therapists try to provide an atmosphere conducive to devel- oping a sense of trust (Bender, 2005). They often use cognitive therapy to counter the person's mistaken assumptions about oth- ers, focusing on changing the person's beliefs that all people are malevolent and most people cannot be trusted (Beck, Davis, & Freeman, 2015). Be forewarned, however, that to date there are no confirmed demonstrations that any form of treatment can signifi- cantly improve the lives of people with paranoid personality dis- order. A survey of mental health professionals indicated that only 11% of therapists who treat paranoid personality disorder thought these indivi 3.with this personality disorder show a pat- tern of detachment from social relationships and a limited range of emotions in interpersonal situations. They seem aloof, cold, and indifferent to other people. The term schizoid is relatively old, hav- ing been used by Bleuler (1924) to describe people who have a tendency to turn inward and away from the outside world. These people were said to lack emotional expressiveness and pursued vague interests. Consider the case of Mr. Z

1.of mystical experiences (for example, deeply felt positive mood), and even 14 months later many rated the experience as having a spiritual significance (Griffiths, Richards, Johnson, McCann, & Jesse, 2008). More research is needed to explore how these types of drugs work with increased specificity, and this research may also tell us how our brains process experiences such as personal mean- ing and spirituality (TylŠ, Páleníček, & Horáček, 2014). Tolerance develops quickly to a number of hallucinogens, including 2.porary effect of the drug and it will wear off in a few hours (Parrott, 2012). Hallucinogens seem to affect the brain in diverse and non- specific ways, meaning by affecting multiple different receptors at one time in opposing ways. It is thought that this broad impact on brain receptors may lead to consciousness expanding experienced by some (Passie & Halpern, 2015). Most of these drugs bear some resemblance to neurotransmitters; LSD, psilocybin, lysergic acid amide, and DMT are chemically similar to serotonin; mescaline resembles norepinephrine; and a number of other hallucinogens we have not discussed are similar to acetylcholine.

1.LSD, psilocybin, and mescaline (hallucinogen use disorders) (Passie & Halpern, 2015). If taken repeatedly over a period of days, these drugs lose their effectiveness. Sensitiv- ity returns after about a week of abstinence, however. For most hallucinogens, no withdrawal symptoms are reported. Even so, a number of concerns have been expressed about their use. One is the possibility of psychotic reactions. Stories in the popular press about people who jumped out of windows because they believed they could fly or who stepped into moving traffic with the mistaken idea that they couldn't be hurt have provided for sensational reading, but little evidence suggests that using hal- lucinogens produces a greater risk than being drunk or under the influence of any other drug. People do report having "bad trips"; these are the sort of frightening episodes in which clouds turn into threatening monsters or deep feelings of paranoia take over. Usually someone on a bad trip can be "talked down" 2.silocybin, for example, seems to increase serotonin as an agonist at 5HT2A/C and 5HT1A receptors to produce hallucinogenic effects but the remaining neural activity is less understood and it seems that psi- locybin may also impact dopamine receptors. Recent fMRI stud- ies show activation in "resting state networks" that are typically activated during a resting state or introspection, as well as net- works that increase focused attention. Alternation and activation of these two networks typically happens during states like medi- tation or psychosis. Research in human and animal laboratory studies shows no short-term or long-toxicity, meaning one's body processes the substances without incurring any harm to organs including the brain. This may be in part why some researchers are exploring psilocybin as a "model" for psychosis as well as a sub- stance with possible therapeutic potent

1. Causes of Paraphilic Disorders Although no substitute for scientific inquiry, case histories often provide hypotheses that can then be tested by controlled scientific observations. Let's return to the cases of Robert and Tony to see if their histories contain any clues.\ 2.Many people with defi- cient sexual and social skills do not develop deviant patterns of arousal, however. Early experience seems to have an effect that may be quite accidental.

1.These cases remind us that deviant patterns of sexual arousal often occur in the context of other sexual and social problems. Undesired kinds of arousal may be associated with deficiencies in levels of "desired" arousal with consensual adults; this was certainly true for both Tony and Robert, whose sexual relationships with adults were incomplete. In many cases, an inability to develop adequate social relations with the appropriate people for sexual relationships seems to be associated with a developing of inap- propriate sexual outlet 2.ony's early sexual experiences just happened to be of the type he later found sexually arousing. Many individuals with pedophilic disorder also report being abused themselves as chil- dren, which turns out to be a strong predictor of later sexual abuse by the victim (Fagan et al., 2002; Nunes, Hermann, Malcom, & Lavoie, 2013). Robert's first erotic experience occurred while he was "peeping." But many of us do not find our early experiences reflected in our sexual patterns. Another factor may be the nature of the person's early sexual fantasies. For example, Rachman and Hodgson (1968; see also Bancroft, 1989) demonstrated that sexual arousal could become associated with a neutral object—a boot, for example—if the boot was repeatedly presented while the individual was sexu- ally aroused.

DRUG READING 1. moking cigarettes, drinking alcohol, and using illegal drugs are all related to these disorders, and they are responsible for astronomical financial costs and the tragic waste of hundreds of thousands of human lives each year. In this chapter, we explore substance-related 2.Perspectives on Substance-Related and Addictive Disordersv the general population (12 years or older) are believed to use illegal drugs (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013). Many U.S. presiden- tial administrations have declared various "wars on drugs," but the problem remains. The Roman Catholic Church issued a universal catechism in 1992 that officially declared drug abuse and drunk driving to be sins (Riding, 1992). Yet from the drug-related deaths of rock stars Jimi Hendrix and Janis Joplin in 1970 to contempo- rary celebrities such as Michael Jackson, Whitney Houston, and Amy Winehouse, drug use continues to negatively impact the lives of many. And stories such as these not only are about the rich and famous but are retold in every corner of our society. 3.Levels of Involvement Although each drug described in this chapter has unique effects, there are similari

1.These disorders have cursed us for centuries and continue to affect how we live, work, and play. Equally disruptive to the people affected, impulse-control disor- ders represent a number of related problems that involve the inability to resist acting on a drive or temptation. Included in this group are those who cannot resist aggressive impulses or the impulse to steal, for example, or to set fires. 2. e case of Danny, who has the disturbing but common habit of alcohol use disorder, and several substance use disorders. 3. rm substance refers to chemical compounds that are ingested to alter mood or behavior. Psychoactive substances alter mood, behavior, or both. Although you might first think of drugs such as cocaine and heroin, this definition also includes more commonplace legal drugs such as alcohol, the nicotine found in tobacco, and the caffeine in coffee, soft drinks, and chocolate. As you will see, these so-called safe drugs also affect mood and behavior, they can be addictive, and they account for more health problems and a greater mortal- ity rate than all illegal drugs combined. 4. ost of you reading this chapter probably use some sort of psychoactive substance occa- sionally. Drinking a cup of coffee in the morning to wake up or smoking a cigarette and having a drink with a friend to relax are examples of substance use, as is the occasional ingestion of illegal drugs such as cannabis, cocaine, amphetamines, or barbiturates.

1. Many of these problems characterize the presumably more severe incarcerated population mentioned above. Nevertheless, other groups using similar treatment procedures have achieved comparable success rates (Abel, 1989; Becker, 1990; Fagan et al., 2002). Therapist knowledge and expertise seem to be important in successfully carrying out these treatments to prevent future sexual offenses among patients. Judith Becker used the procedures described previously in a program for adolescent sexual offenders in an inner-city setting (see, for example, Becker, 1990; Morenz & Becker, 1995). Results indicate that a relatively low 10% of those who completed treat- ment had committed further sex crimes. 2.Drug Treatments The most popular drug used to treat individuals with paraphilic disorders is an antiandrogen called cyproterone acetate (Bradford, 1997; Assumpção, Garcia, Garcia, Bradford, & Thibaut, 2014; Seto, 2009). This "chemical castration" drug eliminates sexual desire and fantasy by reducing testosterone levels dramatically, but fantasies and arousal return as soon as the drug is removed. A second drug is medroxyprogesterone (Depo-Provera is the injectable form), a

1.These findings were important both because many adolescent offenders carry the AIDS virus and literally are putting their victims' lives in danger and because the recidivism rate of sexual offenders without treat- ment is high (see, for example, Hanson, Steffy, & Gauthier, 1993; Nagayama Hall, 1995), just as it is for all pleasurable but unde- sirable behavior, including substance abuse. More recently, an important study found that intervening with aggressive, victim- izing, or highly inappropriate sexual behavior in children aged 5 to 12 with a CBT was effective in preventing sexual offending once they reached adolescence and adulthood 10 years later compared to a group receiving play therapy (Carpentier, Silovsky, & Chaffin, 2006). Only 2% of children receiving CBT had future sexual offenses. 2. These drugs may be useful for dangerous sexual offenders who do not respond to alternative treatments or to temporarily suppress sexual arousal in patients who require it, but it is not always successful. In an earlier report of the Maletzky series (1991), only 8 of approxi- mately 5,000 patients required the drug because they showed no response whatsoever to psychological treatments. Rösler and Witztum (1998) report successful "chemical castration" of 30 men with severe long-standing paraphilic disorders using triptorelin, which inhibits gonadotropin secretion in men. This drug appears to be somewhat more effective than the other drugs mentioned here with fewer side effects, based on this one study. Of course, the drug is only effective if taken regularly, but most individuals, facing prison as the alternative, are highly motivated to comply with treatment

3.1.n other words, those individu- als who tend not to develop the slurred speech, staggering, and other sedative effects of alcohol use are mor 2.). Numerous studies have found that many people who commit such violent acts as murder, rape, and assault are intoxicated at the time of the crime (Rossow & Bye, 2012). We hope you are skeptical of this type of correlation. Just because drunkenness and violence over- lap does not mean that alcohol will necessarily make you violent. Laboratory studies sh 3.Sedative-, Hypnotic-, or Anxiolytic-Related Disorders The general group of depressants also includes sedative (calm- ing), hypnotic (sleep-inducing), and anxiolytic (anxiety-reducing) drugs (Bond & Lader, 2012). These drugs include barbiturates and benzodiazepines. Barbiturates (which include Amytal, Seconal, and Nembutal) are a family of sedative drugs first syn- thesized in Germany in 1882 (Cozanitis, 2004). They were pre- scribed to help people sleep and replaced such drugs as alcohol and opium. Barbiturates were widely prescribed by physicians during the 1930s and 1940s, before their addictive properties were fully understood. By the 1950s, they were among the drugs most abused by adults

1.This is of particular concern given the trend to mix highly caffein- ated energy drinks with alco- hol (McKetin, Coen, & Kaye, 2015). This combination of drinks can reduce the sedative effect of alcohol, which may increase the likelihood of later 2.Whether a person behaves aggres- sively outside the laboratory, however, probably involves a number of interrelated factors, such as the quantity and timing of alcohol consumed, the person's history of violence, expectations about drinking, and what happens to the individual while intoxicated. Alcohol does not cause aggression, but it may increase a person's likelihood of engaging in impulsive acts and it may impair the abil- ity to consider the consequences of acting impulsively (Bye, 2007). Given the right circumstances, such im 3. od and Drug Administration ruled that they are not appropriate for reducing the tension and anxiety resulting from everyday stresses and strains, an estimated 85 mil- lion prescriptions are written for benzodiazepines in the United States each year (Olfson, King, & Schoenbaum, 2015). In general, benzodiazepines are considered much safer than barbiturates, with less risk of abuse and dependence. Reports on the misuse of Rohypnol, however, show how dangerous even some benzodiaze- pine drugs can be. Rohypnol (otherwise known as "forget-me-pill," "roofenol," "roofies," "ruffies") gained a following among teenag- ers in the 1990s because it has the same effect as alcohol without the telltale odor.

1.ne study tested how people with and without borderline personality dis- order could correctly identify the emotion of a face that was morphing on screen (changing slowly from a neutral expression to an emotional expression such as anger) and found those with borderline personality disorder were more accurate than controls In one study, the emotion "shame" was explored in people with this disorder (Rusch et al., 2007). For example, people were given the following scenario: You attend your coworker's housewarming party and you spill red wine on a new cream-colored carpet, but you think no one notices. Participants are then asked to say which of the following four reactions they would have: "You would wish you were anywhere but at the party." (indicating shame proneness) • "You would stay late to help clean up the stain after the party." (guilt proneness) • "You think your coworker should have expected some accidents at such a big party." (detachment) • "You would wonder why your coworker chose to serve red wine with the new light carpet." (externalization) (p 2.Cognitive factors in borderline personality disorder are just beginning to be explored. Here, the questions are, just how

1.This study found that women with borderline personality dis- order (no men were included in this study) were more likely to report shame than healthy women and women with social phobia. Importantly, the researchers also found that this elevated tendency to experience shame was associated with low self-esteem, low quality of life, and high levels of anger and hostility (Rusch et al., 2007). Shame has also been found to be related to self-inflicted injury (for example, cutting) in this population (Wiklander et al., 2012). This incorporation of shame in interpreting certain situations has also been observed in children and youth with characteristics of borderline per' 2. borderline personality disorder remembered more of these words despite being instructed to for- get them. This preliminary evidence for a memory bias may hold clues to the nature of this disorder and may someday be helpful in designing more effective treatment (Winter, Elzinga, & Schmahl, 2013; Baer, Peters, Eisenlohr-Moul, Geiger, & Sauer, 2012). An important environmental risk factor in a gene-environment interaction explanation for borderline personality disorder is the possible contribution of early trauma, especially sexual and physi- cal abuse. Numerous studies show that people with this disorder are more likely to report abuse than are healthy individuals or those with other psychiatric conditions

1.evelopmental influences As children move into adulthood, the forms of antisocial behav- iors change—from truancy and stealing from friends to extor- tion, assaults, armed robbery, or other crimes. Fortunately, clinical lore, as well as scattered empirical reports (Robins, 1966), suggest that rates of antisocial behavior begin to decline rather markedly around the age of 40 2.n integrative model How can we put all this information together to get a better understanding of people with antisocial personality disorder? Remember that the research just discussed sometimes involved people labeled as having antisocial personality disorder but at other times included people labeled as psychopathic or even crim- inals. Whatever the label, it appears these people have a genetic vulnerability to antisocial behaviors and personality traits. As you have seen, genetics may lead to differences in neurotransmitter and neurohormone (dopamine and serotonin) function that influences aggressiveness, as well as differences in neurohormone (cortisol) function that affects the way people deal with stress; these brain differences may lead to personality traits such as callousness, impulsivity, and aggressive

1.are, McPherson, and Forth (1988) provided empirical support for this phenomenon. They examined the conviction rates of male psychopaths and male nonpsychopaths who had been incarcer- ated for a variety of crimes. The researchers found that between the ages of 16 and 45 the conviction rates of nonpsychopaths remained relatively constant. In contrast, the conviction rates of psychopaths remained relatively constant up until about 40, at which time they decreased markedly (see E Figure 12.2). Why antisocial behavior often declines around middle age 2One potential gene-environment interaction may be seen in the role of fear conditioning in children. If you remember back 2.hapter 1 and Chapter 5, we discussed how we learn to fear things that can harm us (for example, a hot stove) through the pairing of an unconditioned stimulus (e.g., heat from burner) and a conditioned stimulus (e.g., parent's warning to stay away), resulting in avoidance of the conditioned stimulus. But what if this conditioning is somehow impaired and you do not learn to avoid things that can harm you? An important study looked at whether abnormal responses to fear conditioning as a young child could be responsible for later antisocial behavior in adults 3.hich suggests that these children had problems in this area of the brain (Sterzer, 2010). These findings may point to a mechanism by which genetic influences (leading to damage in the amygdala) interact with environmental influ- ences (learning to fear threats) to produce adults who are rela- tively fearless and therefore engage in behaviors that cause harm to themselves and others. Biological influences further interact with other environ- mental experiences such as early childhood adversity. In a family that may already be under stress because of divorce or substance abuse, there may be an interaction style that encour- ages antisocial behavior on the part of the child

1.ndividual differences in the way people respond to alcohol. Understanding these response dif- ferences is important because they may help explain why some people continue to use drugs until they acquire a dependence on them, whereas others stop before this happens. A number of studies compare individuals with and without a family history of alcoholism (Gordis, 2000). 2.One current line of research involves analyzing the brain wave patterns of people at risk for developing alcoholism. This research is studying the sons of people with alcohol problems because of their own increased likelihood of having alcohol problems. Par- ticipants are asked to sit quietly and listen for a particular tone. When they hear the tone, they are to signal the researcher. During this time, their

1.concluded that, compared with the sons of nonalcoholics, the sons of alcoholics may be more sensitive to alcohol when it is first ingested and then become less sensitive to its effects as the hours pass after drinking. This find- ing is significant because the euphoric effects of alcohol occur just after drinking but the experience after several hours is often sad- ness and depression. People who are at risk for developing alco- holism (in this case, the sons of alcoholics) may be better able to appreciate the initial highs of drinking and be less sensitive to the lows that come later, making them ideal candidates for continued drinking. In support of this observation, follow-up research over a 10-year period found that those men who tended to be less sensi- tive to alcohol also ten 2.rain waves are monitored and a particular pattern emerges called the P300 amplitude. Approximately 300 millisec- onds (the origin of the "P300" designation) after the tone is pre- sented, a characteristic spike in brain waves occurs that indicates the brain is processing this information. In general, researchers find this spike is lower among those with a family history of alco- holism (Tapert & Jacobus, 2012). Is this brain wave difference somehow connected to the rea- sons people later develop a dependence on alcohol, or is it just a marker or sign that these individuals have in common but is not related to their drinking? One piece of evidence that argues against the P300 differ

1.n many cases, the types of norm violations that an adult would engage in— irresponsibility regarding work or family—appear as younger versions in conduct disorder, such as truancy from school or running away from home. Some children w 2.genetic influences Family, twin, and adoption studies all suggest a genetic influ- ence on both antisocial personality disorder and criminality (Reichborn-Kjennerud et al., 2015; Checknita et al., 2015; Ficks & Waldman, 2014; Delisi & Vaughn, 2015; Kendler et al., 2014). For example, in a classic study, Crowe (1974) examined children whose mothers were felons and who were later adopted by other families

1.conduct disorder do feel remorseful about their behavior, which is why DSM-5 included the qualifier "with a callous-unemotional presenta- tion" in order to better differenti- ate these two groups. -tremendous amount of interest in studying a group that causes a great deal of harm to society. Research has been con- ducted for a number of years, and so we know a great deal more about antisocial personality disorder than about most of the other personality disorders. 2.pared them with adopted children of normal mothers. All were separated from their mothers as newborns, minimizing the possibility that environmental factors from their biological fami- lies were responsible for the results. Crowe found that the adopted offspring of felons had significantly higher rates of arrests, convic- tion, and antisocial personality than did the adopted offspring of normal mothers, which suggests at least some genetic influence on criminality and antisocial behavior. Crowe found something else quite interesting, however: The adopted children of felons who themselves later became crimi- nals had spent more time in interim orphanages than either the adopted children of felons who did not becom -ildren of normal mothers. As Crowe points out, this suggests a gene-environment interaction; in other words, genetic factors may be important only in the presence of certain environ- mental influences (alternatively, certain environmental influences are important only in the presence of certain genetic predispo- sitions). Genetic factors may present a vulnerability, but actual development of criminality may require environmental factors, such as a deficit in early, high-quality contact with parents or par- ent surrogates.

1.s effects are described by users in a variety of ways: Ecstasy makes you "feel happy" and "love everyone and everything"; "music feels better" and "it's more fun to dance"; "You can say what is on your mind without worrying what others will think" (Levy, O'Grady, Wish, & Arria, 2005, p. 1431). Recent years have also seen a rise in a variation of MDMA called "Molly" that has been marketed as a purified powder in capsules instead of the pressed pills of Ecstasy (National Institute of Drug Abuse, 2013). A purified, crystallized form of amphetamine, called meth- amphetamine (commonly referred to as "crystal meth" or "ice"), is ingested through smoking. 2.mphetamines stimulate the central nervous system by enhanc- ing the activity of norepinephrine and dopamine. Specifically, amphetamines help the release of these neurotransmitters and block 3. cocaine The use and misuse of drugs wax and wane according to societal fashion, moods, and sanctions. Cocaine replaced amphetamines as the stimulant of choice in the 1970s (Jaffe, Rawson, & Ling, 2005). Cocaine is derived from the leaves of the coca plant, a flow- ering bush indigenous to South America. In his essay "On Coca" (1885/1974, p. 60), a yo

1.drug causes marked aggressive ten- dencies and stays in the system longer than cocaine, making it partic- ularly dangerous. This drug gained and dropped in popularity since it was invented in the 1930s, although its use has now spread wider than before (Maxwell & Brecht, 2011). However enjoyable these vari- ous amphetamines may be in the short term, the potential for users to become dependent on them is extremely high, with great risk for long-term difficulties. Some research also shows that repeated use of MDMA can cause lasting memory problems ( 2. reuptake, thereby making more of them available throughout the system (Carvalho et al., 2012). Too much amphetamine—and therefore too much dopamine and norepinephrine—can lead to hallucinations and delusions. As we see in Chapter 13, this effect has stimulated theories on the causes of schizophrenia, which can also include hallucinat 3.atin Americans have chewed coca leaves for centuries to get relief from hunger and fatigue (Daamen, Penning, Brunt, & Verster, 2012). Cocaine was introduced into the United States in the late 19th century; it was widely used from then until the 1920s. In 1885, Parke, Davis & Co. manufactured coca and cocaine in 15 forms, including coca-leaf cigarettes and cigars, inhalants, and crystals. For people who couldn't afford these products, a cheaper way to get cocaine was in Coca-Cola, which up until 1903 con- tained a small amount

1. number of years ago, we determined in our sexuality clinic that certain rapists do closely fit definitions of paraphilic disorder and could probably better be described as sadists, a finding that has since been confirmed (McCabe & Wauchope, 2005; Quinsey, 2010; Seto et al., 2012). We constructed two audiotapes on which were described 2. Among the rapists we were evaluating, a subgroup seemed to be particularly aroused when force and acts of cruelty were involved. To assess this reaction more completely, we put together a third audiotape consisting of aggression and assault without any sexual content. A number of individuals displayed strong sexual arousal to nonsexual aggressive themes, as well as to rape, and little or no arousal to mutually enjoyable intercourse. 3.Pedophilic Disorder and Incest Perhaps the most tragic sexual deviance is sexual attraction to chil- dren (or young adolescents generally aged 13 years or younger), called pedophilia (Blanchard, 2010; Seto, 2009, 2012). People around the world have become more aware of this problem fol- lowing the well-publicized scandal in the Catholic Church, where priests, many of whom undoubtedly met criteria for pedophilic 4.pornogra

1.e constructed two audiotapes on which were described (1) mutually enjoyable sexual intercourse and (2) sexual intercourse involving force on the part of the male (rape). Each tape was played twice for selected listeners. The nonrapists became sexually aroused to descriptions of mutually consenting intercourse but not to those involving force. Rapists 2. Nevertheless, he was convicted of multiple assaults and rapes and was about to begin a life sentence in a closely guarded area of the maximum-security state prison. Realizing his behavior was hopelessly out of control, he was eager to get there. He reported that all his waking hours were spent ruminating uncontrollably on sadistic fantasies. He knew he was going to spend the rest of his life in prison, probably in solitary confinement, but he hoped there was something we could 3. used children repeatedly, only to be transferred to another church and repeat these offences. Individuals with this pattern of arousal may be attracted to male children, female chil- dren, or both. In one survey, as many as 12% of men and 17% of women reported being touched inappropriately by adults when they were children (Fagan, Wise, Schmidt, & Berlin, 2002). A more recent study estimated the preva- lence of sexual abuse before age 18 to be 10.14% (Pérez-Fuentes et al., 2013). Approximately 90% of abusers are male, and 10% are female (Fagan et al., 2002; Seto, 2009). Much as with adult rape, as many as 40% to 50% of sexual offend- ers do not have pedophilic arousal patterns and do not meet criteria for pedophilic disorder. Rather, their offenses are associated with bru- tal antisocial and aggressive opportun 4.lthough pedophilia and incest have much in common, victims of pedophilic disorder tend to be young children, and victims of incest tend to be girls beginning to mature physi- cally (Rice & Harris, 2002). By using penile strain gauge measures, Marshall, Barbaree, and Christophe (1986) and Marshall (1997) demonstrated that incestuous males are, in general, more aroused by adult women than are males with pedophilic disorder, who tend to focus exclusively on children. Thus, incestuous relations may have more to do with availability and interpersonal issues ongoing in the famil

1.With some training, clinicians are able to gather information from interviews with a person, along with material from significant oth- ers or institutional files (for example, prison records), and assign the person scores on the checklist, with high scores indicating psychopathy (Hare & Neumann, 2006). The Cleckley/Hare criteria focus primarily on underlying personality traits (for example, being self-centered or manipula- tive). Earlier versions of the DSM criteria for antisocial personal- ity focused almost entirely on observable behaviors (for example, "impulsively and repeatedly changes employment, residence, or sexual partners"). 2.antisocial Personality disorder and criminality Although Cleckley did not deny that many psychopaths are at greatly elevated risk for criminal and antisocial behaviors, he did emphasize that some have few or no legal or interpersonal difficul- ties. In other words, some psychopaths are not criminals and some do not display outward aggressiveness that was included in the DSM-IV-TR criteria for antisocial personality disorder. What sepa- rates many in this group from those who get into trouble with the law may be their intelligence quotient (IQ). In a cla

1.framers of the previous DSM criteria felt that trying to assess a personality trait—for example, whether someone was manipulative—would be more difficult than deter- mining whether the person engaged in certain behaviors, such as repeated fighting. The DSM-5, however, moved closer to the trait- based criteria and includes some of the same language included in Hare's PCL-R (e.g., callousness, manipulativeness, and deceit- fulness). Unfortunately, research on identifying persons with antisocial personality disorder suggests that this new definition reduces the reliability of the diagnosis (Regier et al., 2013). Addi- tional work will be needed to improve the reliability of this diag- nosis while m 2.to be at high risk for later delinquent behavior, 16% did indeed have run-ins with the law by the age of 15, and 84% did not. What distinguished these two groups? In general, the at-risk children with lower IQs were the ones who got in trouble. This suggests that having a higher IQ may help protect some people from developing more serious problems, or it may at least prevent them from getting caught. 2.Wanted: charming, aggressive, carefree people who are impulsively irresponsible but are good at handling people and at looking after number one. Widom found that her sample appeared to possess many of the same characteristics as imprisoned psychopaths; for example, a large percentage of them received low scores on questionnaire measures of empathy and socialization, and their parents tended to have higher rates of psychopathology, including alcoholism. But many of these individuals had stable occupations and had managed to stay out of prison. Widom's study, although lacking a control group, shows that at least some individuals with psy- chopathic personality traits avoid repeated contact with the legal system and may even function successfully in society.

1. The same thing is now happening with sexual orientation. For example, neither Bailey and colleagues (1999) nor Rice, Anderson, Risch, and Ebers (1999) in later studies could replicate the report suggesting a specific gene for homosexuality (Hamer et al., 1993). Most theoretical models outlining these complex interactions for sexual orientation imply that there may be many pathways to the development of heterosexuality or homosexuality and that no one factor—biological or psychological—can predict the outcome (Bancroft, 1994; Brakefield et al., 2014; Byne & Parsons, 1993).

1.e of the more intriguing findings from the twin studies of Bailey and his colleagues is that approximately 50% of the identi- cal twins with exactly the same genetic structure, as well as the same environment (growing up in the same house), did not have the same sexual orientation (Bailey & Pillard, 1991). Also intrigu- ing is the finding in a study of 302 gay males that those growing up with older brothers are more likely to be gay, whereas having older sisters, or younger brothers or sisters, is not correlated with later sexual orientation. This study found that each additional older brother increased the odds of being gay by one third. This finding, which has been replicated several times and is referred to as the "fraternal birth order hypothesis," may suggest the impor- tance of environmental influences (Blanchard, 2008; Blanchard & Bogaert, 1996, 1998; Cantor, Blanchard, Paterson, & Bogaert, 2002). Although the mechanism has not been definitively identi- fied, some research has implicated the importance of the mother's immunological response to Y-linked proteins

1. Boys are 2 to 3 times more likely to be diagnosed with ADHD than girls, and this discrepancy increases for children being seen in clinics (Owens, Cardoos, & Hinshaw, 2015; Spencer, Biederman, & Mick, 2007). 2.This focuson boys may have been the result of theiractive and disruptive behaviors, whichcaused concern among families and school personnel and there- fore prompted research into the nature, causes, and treatment of these problems. More boys displayed these behaviors, which made it easier to find participants to study. But did this almost singular focus on boys result in ignoring how young girls experience this disorder?

1.e reason for this gen- der difference is largely unknown. It may be that adults are more tolerant of hyper- activity among girls, who tend to be less active than boys with ADHD. Boys tend to be more aggressive, which will more likely result in attention by mental health professionals (Rucklidge, 2010). Girls with ADHD, on the other hand, tend to display more behaviors referred to as "internalizing"—specifically, anxiety and depression (Owens et al., 2015). The higher prevalence of boys iden-tified as having ADHD has led some toquestion whether the DSM-5 diagnosticcriteria for this disorder are applicable togirls. Here is the quandary: Most researchover the past several decade 2.oncern is being raised by some psychologists, including Kathleen Nadeau (a clinical psychologist who specializes in girls with ADHD), who argues that more research is needed on ADHD in girls: "Girls experience significant struggles that are often over- looked because their ADHD symptoms bear little resemblance to those of boys" (Crawford, 2003, p. 28). She says that girls with ADHD were neglected because their symptoms differ so dramati- cally from boys' symptoms, although to date there is little firm evi- dence for these differences (Owens et al., 2015). Just as researchers are now exploring ADHD among adults, in addition to children, more research is now addressing the relative lack of research on girls and women.

1.an integrative model Although there is no currently accepted integrative model for this disorder, it is tempting to borrow from the work on anxiety dis- orders to outline a possible view. If you recall from Chapter 5, we describe the "triple vulnerability" theory (Barlow, 2002; Suárez, Bennett, Goldstein, & Barlow, 2008). The first vulnerability (or diathesis) is a generalized biological vulnerability. We can see the genetic vulnerability to emotional reactivity in people with bor- derline personality disorder and how this affects specific brain function. 2.treatment In stark contrast to individuals with antisocial personality disor- der, who rarely acknowledge requiring help, those with borderline personality disorder appear quite distressed and are more likely to seek treatment even than people with anxiety and mood disorders (Bender et al., 2014; Ansell, Sanislow, McGlashan, & Grilo, 2007). Reviews of research on the use of medical treatment for people with this disorder suggest that symptomatic treatment can some- times be helpful. 3.riority in treatment is first given to those behaviors that may result in harm (suicidal behaviors), then those behaviors that interfere with therapy

1.econd vulnerability is a generalized psychological vulnerability. In the case of people with this personality disorder, they tend to view the world as threatening and to react strongly to real and perceived threats. The third vulnerability is a specific psy- chological vulnerability, learned from early environmental experi- ences; this is where early trauma, abuse, or both may advance this -When a person is stressed, his or her biologi- cal tendency to be overly reactive interacts with the psychological tendency to feel threatened. This may result in the outbursts and suicidal behaviors commonly observed in this group. This prelim- inary model awaits validation and further research. 3.e validation of others, sometimes by visu- alizing themselves not reacting to criticism (Lynch & Cuper, 2012). Results from a number of studies suggest that DBT may help reduce suicide attempts, dropouts from treatment, and hospital- izations (Linehan et al., 2015; Linehan & Dexter-Mazza, 2008; McMain, Guimond, Streiner, Cardish, & Links, 2013). A follow up of 39 women who received either dialectical behavior therapy or general therapeutic support (called "treatment as usual") for 1 year showed that, during the first 6 months of follow up, the women in the DBT group were less suicidal, less angry, and better adjusted socially (Linehan & Kehrer, 1993). Another study examined how treating these individuals with DBT in an inpatient setting (a psy- chiatric hospital) for approximately 5 days would improve their outcomes (Yen, Johnson, Costello, & Simpson, 2009). The partici- pants improved in a number of areas, such as with a reduction in depression, hopelessness, anger expression, and dissoc

1. with the result that the brains are comparatively more feminine. But it isn't clear whether this is a cause or an effect. At least some evidence suggests that gender identity firms up between 18 months and 3 years of age (Ehrhardt & Meyer-Bahlburg, 1981; Money & Ehrhardt, 1972) and is 2. Richard Green, a pioneering researcher in this area, has stud- ied boys who behave in feminine ways and girls who behave in masculine ways, investigating what makes them that way and following what happens to them (Green, 1987). 3. Other factors, such as excessive attention and physical contact on the part of the mother, may also play some role, as may a lack of male playmates during the early years of socialization. These are just some factors identified by Green as characteristic of gender- nonconforming boys. Remember that as-yet-undiscovered bio- logical factors may also contribute to the spontaneous display of cross-gender behaviors and interests. F

1.ed after that. But newer studies suggest that possible preexisting biological factors have already had their impact. One interesting case illustrating this phenomenon was originally reported by Green and Money (1969), who described the sequence of events that occurred in the case of Bruce/Brenda. There do seem to be other case studies of children whose gender was reassigned at birth who adapted successfully (see, for example, Gearhart, 1989), but it certainly seems that biology expressed itself in Bruce's case. 2.f behav- iors and attitudes is referred to as gender nonconformity (see, for example, Skidmore, Linsenmeier, & Bailey, 2006). Green discov- ered that when most young boys spontaneously display "feminine" interests and behaviors, they are typically discouraged by most families, and these behaviors usually cease. Boys who consistently display these behaviors are not discouraged, however, and are sometimes encouraged. 3.For example, one recent study found that exposure to higher levels of fetal testosterone was asso- ciated with more masculine play behavior in both boys and girls during childhood (Auyeng et al., 2009). In following up with these boys, however, Green discovered that few seem to develop the gen- der incongruence. The most likely outcome is the development of homosexual preferences, but even this particular sexual arousal pattern seems to occur exclusively in only approximately 40% of the gender-nonconforming boys. Another 32% show some degree of bisexuality, sexual attraction to both their own and the opposite sex. Looking at it from the other side, 60% were functioning het- erosexually. These results were replicated in subsequent prospective studies of boys (Zucker, 2005). Girls with gender-nonconforming behavior are seldom studied, because their behavior attracts much less attention in Western soci

1. treatment. Pathological gamblers often experience cravings similar to people who are substance dependent (Grant, Odlaug, & Schreiber, 2015). Treatment is often similar to substance dependence treatment, and there is a parallel Gambler's Anonymous that incorporates the same 12-step program we discussed previously. However, the evidence of effectiveness for Gambler's Anonymous suggests that 70% to 90% drop out of these programs and that the desire to quit must be present before intervention (Ashley & Boehlke, 2012). Cognitive-behavioral interventions help reduce the symptoms of gambling disorder. Brief

1.een found to help and both are recommended. Given the higher rates of impulsivity of those with these disorder and thus their high dropout rates from treatment, more research is starting to compare the brief versions to the full course ones (Grant et al., 2015). In addition to gambling disorder being included under the heading of "Addictive Disorders," DSM-5 includes another potentially addictive behavior "Internet Gaming Disorder" as a condition for further study (American Psychiatric Association, 2013). There are indications that some individuals are so preoccupied with online games (sometimes in a social context with other players) that a similar pattern of tolerance and withdrawal develops (Petry & O'Brien, 2013). The goal of including this potentially new category of addictive behavior is to encourage additional research on its nature and treatment. DSM 5 TABLE 11.10

1.treatment In contrast to the scarcity of research into most other personality disorders, there are a number of well-controlled studies on approaches to therapy for people with avoidant personality disor- der (Leahy & McGinn, 2012). 2.Dependent Personality Disorder We all know what it means to be dependent on another person. People with dependent personality disorder, however, rely on others to make ordinary decisions as well as important ones, which results in an unreasonable fear of abandonment. Consider the case of Karen. .linical description Individuals with dependent personality disorder sometimes agree with other people when their own opinion differs so as not to be rejected (Bornstein, 2012). Their desire to obtain and maintain supportive and nurturant relationships may lead to their other behavioral characteristics, 3.causes and treatment We are all born dependent on other people for food, physical pro- tection, and nurturance. Part of the socialization process in most cultures involves helping us live independently (Bornstein, 1992). It was thought that such disruptions as the early death of a parent or neglect or rejection by caregivers could cause people to grow up fearing ab

1.ehavioral intervention techniques for anxiety and social skills problems have had some success (e.g., Borge et al., 2010; Emmelkamp et al., 2006). Because the prob- lems experienced by people with avoidant personality disorder resemble those of people with social phobia, many of the same treatments are used for both groups (see Chapter 5). Therapeutic alliance—the collaborative connection between therapist and client—appears to be an important pre 2. g submissiveness, timidity, and passivity. People with this disorder are similar to those with avoid- ant personality disorder in their feelings of inadequacy, sensitiv- ity to criticism, and need for reassurance. However, people with avoidant personality disorder respond to these feelings by avoid- ing relationships, whereas those with dependent personality disor- der respond by clinging to relationships (Disney, 2013; Bornstein, 2012). It is important to note that in certain cultures (e.g., East Asian Confucianism) dependence and submission may be viewed as a desired interpersonal state (Chen, Nettles, & Chen, 2009). 3.factors underlying this genetic influence and how they interact with environmental influences (Sanislow et al., 2012). The treatment literature for this disorder is mostly descrip- tive; little research exists to show whether a particular treatment is effective (Borge et al., 2010; Paris, 2008). On the surface, because of their attentiveness and eagerness to give responsibility for their problems to the therapist, people with dependent personality disor- der can appear to be ideal patients. That very submissiveness, how- ever, negates one of the major goals of therapy, which is to make the person more independent and personally responsible (Leahy & McGinn, 2012). Therapy therefore progresses gradually as the patient develops confidence in his ability to make decisions inde- pendently (Beck et al., 2007

1.causes Despite its long history, little research has been done on the causes or treatment of histrionic personality disorder. The ancient 2.reatment Although a great deal has been written about ways of helping people with histrionic personality disorder, little of the research demonstrates success (Cloninger & Svakic, 2009). Some therapists have tried to modify the attention-getting behavior. Kass, Silvers, and Abrams (1972) worked with five women, four of whom had been hospitali

1.ek philosophers believed that many unexplainable problems of women were caused by the uterus (hysteria) migrating within the body (Abse, 1987; Ussher, 2013). As you have seen, however, histrionic personality disorder also occurs among men. One hypothesis involves a possible relationship with antisocial personality disorder. Evidence suggests that histrionic personality and antisocial personality co-occur more often than chance would account for. Lilienfeld and colleagues (1986), for example, found that roughly two-thirds of people with a histrionic personality also met criteria for antisocial personality disorder. The evidence for this association has led to the suggestion (see, for example, Cloninger, 1978; Lilienfeld, -g condition may be predisposed to exhibit a predomi- nantly histrionic pattern, whereas males with the underlying con- dition may be predisposed to exhibit a predominantly antisocial pattern. Whether this association exists remains a controversial issue, however, and further research on this potential relationship is needed (Dolan & Völlm, 2009; Salekin, Rogers, & Sewell, 1997), particularly given that borderline personality disorder has also been concep 2.ed with five women, four of whom had been hospitalized for suicide attempts and all of whom were later diagnosed with histrionic personality disorder. The women were rewarded for appropriate interactions and fined for attention- getting behavior. The therapists noted improvement after an 18-month follow up, but they did not collect scientific data to con- firm their observation. A large part of therapy for these individuals usually focuses on the problematic interpersonal relationships. They often manipu- late others through emotional crises, using charm, sex, seductive- ness, or complaining (Beck et al., 2007). People with histrionic personality disorder often need to be shown how the short-term gains derived from this interactional style result in long-term costs, and they need to be ta

1.correct aspects of the person's life that might contribute to sub- stance use or interfere with efforts to abstain. First, a spouse, friend, or relative who is not a substance user is recruited to participate in relationship therapy to help the abuser improve relationships with other important people. Second, clients are taught how to identify the antecedents and c 2.Obstacles to successful treatment for substance use and dependence include a lack of personal awareness that one has a problem and an unwillingness to change. An increasingly com- mon intervention approach that directly addresses these needs is referred to as Motivational Enhancement Therapy (MET) (NIDA, 2009). MET is based on the work of Miller and Rollnick (2012), who proposed that behavior change in adults is more likely with empathetic and optimistic counseling (the therapist understands the client's perspective and believes that he or she can change) and a focus on a p 3. ognitive-behavioral therapy (CBT) is an effective treatment approach for many psychological disorders (see Chapter 5, for example) and it is also one of the most well designed and studied approaches for treating substance dependence (Granillo, Perron

1.equences that influence their drug taking. For example, if they are likely to use cocaine with certain friends, clients are taught to recognize the relationships and encouraged to avoid the associations. Third, clients are given assistance with employment, education, finances, or other social service areas that may help reduce their stress. Fourth, new recreational options help the person replace substance use with new activities. There is now strong empirical support for the effectiveness of this approach with alcohol and cocaine abusers (Higgins et al., 2014). 2.ection with the client's core values (for example, drinking and its consequences interferes with spending more time with family). By reminding the client about what he or she cherishes most, MET intends to improve the individual's belief that any changes made (e.g., drinking less) will have positive outcomes (e.g., more family time) and the individual is therefore more likely to make the recommended changes. MET has been used to assist individuals with a variety of substance use problems, and it appears to be a useful component to add to psychological treatment 3.Therapy involves helping people remove any ambivalence about stopping their drug use by examining their beliefs about the positive aspects of the drug ("There's nothing like a cocaine high") and confronting the negative consequences of its use ("I fight with my wife when I'm high"). High-risk situations are identified ("having extra money in my pocket"), and strategies are developed to deal with poten- tially problematic situations, as well as with the craving that arises from abstinence. Incidents of relapse are dealt with as occurrences from which the person can recover; instead of looking on these episodes as inevitably leading to more drug use, people in treat- ment are encouraged to see them as episodes brought on by tem- porary stress or a situation that can be changed.

1. of the way people are diagnosed with the DSM, the personality disorders—like most other disorders—end up being viewed in categories. You have two choices—either you do ("yes") or you do not ("no") have a disorder. For example, either you have antisocial personality disorder or you don't. DSM diagnoses don't rate how dependent you are; if you meet the criteria, you are labeled as having dependent personality disorder. There is no "somewhat" when it comes to personality disorders. 2.olleagues (Widiger & Simonsen, 2005; Widiger & Trull, 2007; Widiger, 2011) have argued for decades that such a system would have at least three advantages over a purely categorical system: (1) It would retain more information about each individual, (2) it would be more flexible because it would permit both categorical and dimensional differentiations among individuals, and (3) it would avoid the often arbitrary decisions involved in assigning a person to a diag- nostic category. Currently, there is an alternative model of person- ality disorders included in the section on "emerging measures and models" in DSM-5 that

1.ere are advantages to using categorical models of behavior, the most important being their convenience. With simplification, -One is that the mere act of using catego- ries leads clinicians to reify them; that is, to view disorders as real "things," comparable to the realness of an infection or a broken arm. Some argue that personality disorders are not things that exist but points at which society decides a particular way of relating to the world has become a problem. There is the important unresolved issue again: Are personality disorders just an extreme variant of normal personality, or are they distinctly different disorders? Some had proposed that the DSM-5 personality disorders sec- tion be replaced or at least supplemented by a dimensional model (South et al., 2011; Widiger, 2012) in which individuals would not only be given categorical diagnoses but also would be rated on a series of personality dimensions. Widiger and 2.functioning. It remains to be seen how this alternative model will be used in the future. Although no general consensus exists about what the basic per- sonality dimensions might be, there are several contenders (South et al., 2011). One of the more widely accepted is called the five-factor model, or the "Big Five," and is taken from work on normal person- ality (Hopwood & Thomas, 2012; McCrae & Costa Jr., 2008). In this model, people can be rated on a series of personality dimensions, and the combination of five components describes why people are so different. The five factors or dimensions are extroversion (talkative, assertive, and active versus silent, passive, and reserved); agreeable- ness (kind, trusting, and warm versus hostile, selfish, and mistrust- ful); conscientiousness (organized, thorough, and reliable versus careless, negligent, and unreliable); neuroticism (even-tempered versus nervous, moody, and temperamental); and openness to expe- rience (imaginative, curious, and creative versus shallow and imper- ceptive) (

1.Obsessive-Compulsive Personality Disorder People who have obsessive-compulsive personality disorder are characterized by a fixation on things being done "the right way" (Diedrich & Voderholzer, 2015). Although many might envy their persistence and dedication, this preoccupation with details pre- vents them from completing much of anything. Consider the case of Daniel. 2. An intriguing theory suggests that the psychological profiles of many serial killers point to the role of obsessive-compulsive personality disorder. Ferreira (2000) notes that these individuals do not often fit the definition of someone with a severe mental illness—such as schizophrenia—but are "masters of control" in manipulating their victims. 3,At the other end of the behavioral spectrum, it is also common to find obsessive-compulsive personality disorder among gifted children, whose quest for perfectionism can be quite debilitating (Nugent, 2000). causes and treatment There seems to be a moderate genetic contribution to obsessive- compulsive personality disorder (Gjerde et al., 2015; Cloninger & Svakic, 2009

1.ersonality disorder seems to be only distantly related to obsessive-compulsive disorder, one of the anxiety disorders we described in Chapter 5 (Samuels & Costa, 2012). People like Daniel tend not to have the obsessive thoughts and the com- pulsive behaviors seen in the like-named obsessive-compulsive disorder. Although people with the anxiety disorder sometimes show characteristics of the personality disorder, they show the characteristics of other personality disorders as well (for example, avoidant, histrionic, or dependent) (Melca, Yücel, Mendlowicz, de Oliviera-Souza 2.Their need to control all aspects of the crime fits the pattern of people with obsessive-compulsive personality disorder, and some combination of this disorder and unfortunate childhood experiences may lead to this disturbing behavior pattern. Obsessive-compulsive personality disorder may also play a role among some sex offenders—in particular, pedophiles. Brain-imaging research on pedophiles suggests that brain functioning in these individuals is similar to those with obsessive-compulsive personality disorder (Schiffer et al., 3. Some people may be predisposed to favor structure in their lives, but to reach the level it did in Daniel may require parental reinforcement of conformity and neatness. Therapy often attacks the fears that seem to underlie the need for orderliness (Pinto, 2015). These individuals are often afraid that what they do will be inadequate, so they procrastinate a essively ruminate about important issues and minor details alike. Therapists help the individual relax or use cognitive reap- praisal techniques to reframe compulsive thoughts. This form of cognitive-behavioral therapy—following along the lines of treat- ment for obsessive-compulsive disorder (see Chapter 5)—appears to be effective for people with this personality disorde

1.ultural factors not only influence the rates of substance abuse but also determine how it is manifested. Research indicates that alcohol consumption in Poland and Finland is relatively low, yet conflicts related to drink- ing and arrests for drunkenness in those countries are high compared with those in the Netherlands, which has about the same rate of alcohol consumption (Osterberg, 1986). Our discussion of expectancies may provide some insight into how the same amount of drink- ing can have d 2.An Integrative Model Any explanation of substance use disorders must account for the basic issue raised earlier in this chapter: Why do some people use drugs but not abuse them or become dependent? E Figure 11.8 illustrates how the multiple influences we have discussed may interact to account for this process. Access to a drug is a nec- essary but not a sufficient condition for abuse or dependence. Exposure has many sources, including the media, parents, peers, and, indirectly, lack of supervision. Whether people use a drug depends also on social and cultural expectations, some encour- aging and some discouraging, such as laws against possession or sale of the drug. The path from drug use to a

1.fects of alcohol use differ across cultures (for example, "Drinking makes me more aggressive" versus "Drink- ing makes me more withdrawn"); these dif- fering expectancies may partially account for the variations in the consequences of drinking in Poland, Finland, and the Nether- lands. Whether substance use is consid 2.ome individuals may inherit a greater sensi- tivity to the effects of certain drugs; others may inherit an ability to metabolize substances more quickly and are thereby able to toler- ate higher (and more dangerous) levels (Young-Wolff, Enoch, & Prescott, 2011). Other psychiatric conditions may indirectly put someone at risk for substance abuse. Antisocial personality dis- order, characterized by the frequent violation of social norms (see Chapter 12), is thought to include a lowered rate of arousa 3.e other side of this ability shows itself in drug addiction. With the continued use of substances such as alcohol, cocaine, or the other drugs we explore in this chapter, the brain reorganizes itself to adapt. Unfortunately, this change in the brain increases the drive to obtain the drug and decreases the desire for other nondrug experiences—both of which contribute to contin- ued use and relapse (Russo et al., 2010). It is clear that abuse and dependence cannot be predicted from one factor, be it genetic, neurobiological, psychological, or cul- tural. For example, some people with the genes common to many with substance abuse problems do not become abusers. Many people who experience the most crushing stressors, such as abject poverty or bigotry and violence, cope without resorting to drug use. There are different pathways to abuse, and we are only now beginning to identify their basic outlines. Once a drug has been used repeatedly, biology and cogni- tion conspire to create dependence. Co

1.clinical description At low doses, barbiturates relax the muscles and can produce a mild feeling of well-being. Larger doses can have results similar to those of heavy drinking: slurred speech and problems walking, 2.Stimulants Of all the psychoactive drugs used in the United States, the most commonly consumed are stimulants. Included in this group are caffeine (in coffee, chocolate, and many soft drinks), nicotine (in tobacco products such as cigarettes), amphetamines, and cocaine.

1.g, and working. At extremely high doses, the dia- phragm muscles can relax so much that they cause death by suffo- cation. Overdosing on barbiturates is a common means of suicide. Like the barbiturates, benzodiazepines are used to calm an individual and induce sleep. In addition, drugs in this class are prescribed as muscle relaxants and anticonvulsants (antiseizure medications) (Bond & Lader, 2012). People who use them for non- medical reasons report first feeling a pleasant high and a reduction of inhibition, similar to the effects of drinking alcohol. With con- tinued use, however, tolerance and dependence can develop. Users who try to stop taking the drug experience symptoms like those of alcohol withdrawal (anxiety, insomnia, tremors, and delirium). The DSM-5 criteria for sedative-, hypnotic-, and anxiolytic- related disorders do not differ substantially from those for alco- hol disorders. Both include maladaptive behavioral changes such as inappropriate sexual or aggressive behavior, variable moods, impaired judgment, impaired social or occupational funct 2. hen you got up this morn- ing. In contrast to the depressant drugs, stimulants—as their name suggests—make you more alert and energetic. They have a long history of use. Chinese physicians, for example, prescribed an amphetamine compound called ma-huang (Ephedra sinica) for more than 5,000 years for illnesses such as headaches, asthma, and the common cold (Fushimi, Wang, Ebisui, Cai, & Mikage, 2008). We describe several stimula

1. Or will psychological adjustment be more positive if gender nonconformity is allowed and facilitated? If research confirms that adjustment is more positive if individu- als find their own place on a gender continuum, then large-scale campaigns to alter social norms may well occur along the lines of the successful campaigns of the past several decades for gay rights, after a consensus developed in the 1970s that homosexuality was not a disorder. Research will continue on this important and inter- esting topic. Treatment guidelines developed by the American Psychiatric Association and the American Psychological Association for gen- der nonconformity in youth simply outl 2More recently, new treatment approaches have been devel- oped in some clinics for children who more clearly identify as transsexual. Given the irreversible nature of many treatments for gender dysphoria, treatment for these children needs to be administered with caution. One specialty clinic for these chil- dren at well-known Children's Hospital in Boston, has attracted attention for their treatment approach. In pre-pubescent chil- dren, first-line treatments include psychoeducation and therapy

1.givers to lessen gender dysphoria and decrease cross-gender behaviors and identification on the assumption that these behaviors are unlikely to persist anyway and the negative consequences of social rejec- tion could be avoided and that avoiding later intrusive surgery would be desirable. A second approach could be described as "watchful waiting" by letting expressed gender unfold naturally. This goal requires strong support from caregivers and the com- munity because of the potential social and interpersonal risks and lack of integration with peer groups. Yet a third approach advocates actively affirming and encouraging cross-gender iden- tification, but critics point out that gender nonconformity usu- ally does not persist and that taking this course would increase the likelihood of persistence. There is very little hard scientific information on which course would be the most beneficial for a given child. 2.clarify gender identity and navigate the complex social issues associated with cross-gender identification. In individu- als closer to puberty, psychotherapy is also recommended. How- ever, a medical intervention that blocks puberty is also available (if, after detailed assessment, it is determined that such treat- ment would be in the best interest of the patient based on the severity of the discordance between gender identity and natal sex as well as family and social considerations). This medication allows the adolescent time to continue exploring gender iden- tity issues without the added of stress of beginning puberty in a gender that is inconsistent with their identify (Tishelman et al., 2014). While this treatment has received some positive press in recent years, it still remains controversial in many parts of the United States.

1.Aspects of Personality Disorders What if a person's characteristic ways of thinking and behaving cause significant distress to the self or others? What if the person can't change this way of relating to the world and is unhappy? We might consider this person to have a personality disorder. Unlike many of the disorders we have already discussed, personality dis- orders are chronic; they do not come and go but originate in child- hood and continue throughout adulthood (Widiger, 2012). Because these chronic problems affect personality, 2.relationships (she may not be able to sustain a lasting rela- tionship if she can't trust anyone), and even where she lives (she may move often if she suspects her landlords are out to get her). A personality disorder is a persistent pattern of emotions, cog- nitions, and behavior that results in enduring emotional distress for the person affected and/or for others and may cause difficul- ties with work and relationships (American Psychiatric Association, 2013). DSM-5 notes that having a personality disorder may distress the affected person 3.DSM-5 lists 10 specific personality disorders. Although the pros- pects for treatment success for people who have

1.hey pervade every aspect of a person's life. For example, if a woman is overly suspicious (a sign of a possible paranoid personality disorder), this trait will affect almost everything she does, including her employment (sh 2.Individuals with personality disorders may not feel any subjective distress, however; indeed, it may in fact be others who acutely feel distress because of the actions of the person with the disorder. This is particularly common with antisocial personal- ity disorder, because the individual may show a blatant disregard for the rights of others yet exhibit no remorse (Hare, Neumann, & Widiger, 2012). In certain cases, someone other than the person with the personality disorder must decide whether the disorder is causing significant functional impairment, because the affected person often cannot make such a judgment. 3.gative for those diagnosed with per- sonality disorders, especially those (as you will see next) in Cluster A (the odd or eccentric cluster) and Cluster B (the dramatic, emotional, or erratic cluster) (Liebman & Burnette, 2013). Therapists especially need to guard against letting their personal feelings interfere with treatment when working with people who have personality disorders.

1. ingested (withdrawal) (Higgins, Sigmon, & Heil, 2014). Tolerance and withdrawal are physiological reactions to the chemicals being ingested. Have you ever experienced a headache when you didn't get your morning coffee? You were probably going through caf- feine withdrawal. I\ 2. Other symptoms that make up a substance use disorder include "drug-seeking behaviors." 3. It may seem counterintuitive, but dependence can be present without abuse.

1.hich a per- son can experience frightening hallucinations and body tremors (a condition described later in this chapter). Withdrawal from many substances can bring on chills, fever, diarrhea, nausea and vomiting, and aches and pains. Not all substances are physiologi- cally addicting, however. For example, you do not go through severe physical withdrawal when you stop taking LSD. Cocaine withdrawal has a pattern that includes anxiety, sleep changes, lack of motivation, and boredom (DSM-5; American Psychiatric Association, 2013), and withdrawal from cannabis includes such symptoms as irritability, nervousness, appetite change, and sleep disturbance (DSM-5). We return to the ways drugs act on 2. epeated use of a drug, a desperate need to ingest more of the substance (stealing money to buy drugs, standing outside in the cold to smoke), and the likelihood that use will resume after a period of abstinence are behaviors that define the extent of substance use disorders. Such behavioral reactions are different from the physiological respons- es to drugs we described before and are sometimes referred to in terms of psychological dependence. The previous version of the DSM considered substance abuse and substance dependence as separate diagnoses. The DSM-5 combines the two into the gen- eral definition of substance-related disorders based on research that suggests the two co-occur (American Psychiatric Association, 2013; Dawson, Goldstein, & Grant, 2012; O'Brien, 2011). Let's go back to the questions we started with: "Can you use drugs and not abuse them?" and "Can you abuse drugs and not become addicted to them?" The answer to the first question is yes. Some people drink wine or beer regularly without drinking to excess. And contrary to popular belief, some people use drugs such as heroin, cocaine, or crack (a form of cocaine) occasionally (for instance, several times a year) without abusing them ( 3.nt on the drug—build up a toler- ance and go through withdrawal if it is stopped—without abusing it (Flemming, 2010; Portenoy & Mathur, 2009). Later in this chapter, we discuss biological and psychosocial theories of the causes of substance-related disorders and why we have individualized reac- tions to these subst

1.here has been a rise in the use of synthetic cathi- nones ("bath salts") 3,4-methylenedioxypyrovalerone (MDPV), syn- thetic form of a stimulant found in the khat plant from East Africa and Saudi Arabi 2.Causes of Substance-Related Disorders People continue to use psychoactive drugs for their effects on mood, perception, and behavior despite the obvious negative con- sequences of abuse and dependence. We saw that despite his clear potential as an individual, Danny continued to use drugs to his detriment. Various factors help explain why people like Danny persist in using drugs. Drug abuse and dependence, once thought to be the result of moral weakness, are now understood to be influ- enced by a combi 3.Biological Dimensions In 2007, when American model and television personality Anna Nicole Smith died from an apparently accidental overdose of at least nine prescription medications—including methadone, Valium, and the sedative chloral hydrate—the unfortunate news created a media sensation. The tragedy was compo 4. Familial and genetic influences As you already have seen throughout this book, many psycho- logical disorders are influenced in important ways by genetics. Mounting evidenc

1.hiones are much stronger and though similar to stimulants, they have an excitatory or agitating effect that can include paranoia, delirium, hallucinations and panic attacks (Baumann et al., 2013). Use of all these drugs can result in toler- ance and dependence, and their increasing popularity among ado- lescents and young adults raises significant public health concerns. 2.al and psychosocial factors. Why do some people use psychoactive drugs without abusing or becoming dependent on them? Why do some people stop using these drugs or use them in moderate amounts after being depen- dent on them and others continue a lifelong pattern of dependence despite their efforts to stop? These questions continue to occupy the time and attention of numerous researchers througho 3., just months before, her only son Daniel had died, also from an apparent drug overdose. Did the son inherit a vulnerabil- ity to addiction from his mother? Did he pick up Anna Nicole's habits from living with her over the years? Is it just a coincidence that both mother and son were so involved with 4. jor twin study, the role of the environment, as well as the role of genetics, was examined in substance use problems. Researchers studied more than 1,000 pairs of male twins and ques- tioned them about their use of cannabis, cocaine, hallucinogens, sedatives, stimulants, and opiates (Kendler, Jacobson, Prescott, & Neale, 2003). The findings—which may have major implications for how we approach treatment and prevention—suggest that there are common genetic influences on the use of all of these drugs. Although it is clear that genetics plays an important role in substance-related disorders, specific genes and their influence on these disorder

1.nderstanding this type of developmental relationship is important for several reasons. Knowing what processes are dis- rupted will help us understand the disorder better and may lead to more appropriate intervention strategies. It may be impor- tant to identify children with attention-deficit/hyperactivity disorder, for example, because their problems with impul- sivity may interfere with their ability to create and mainta 2. ttention-Deficit/Hyperactivity Disorder Do you know people who flit from activity to activity, who start many tasks but seldom finish one, who have trouble concentrat- ing, and who don't seem to pay attention when others speak? These people may have attention-deficit/hyperactivity disorder (ADHD), one of the most common reasons children are referred for mental health services in the United States. The primary char- acteristics of such people include a pattern of inattention, such as being disorganized or forgetful about school or work-related tasks, or of hyperactivity and impulsivity. clinical description Danny has many characteristics of ADHD. Like Danny, people with this disorder have a great deal of difficulty sustaining their attention on a task or activity (

1.iendships, an important developmental consideration. Similarly, identifying a disorder such as autism spectrum disor- der at an early age is important for these children so that their social deficits can be addressed before they affect other skill domains, such as social communication. Too often, people see early and pervasive disruptions in developmental skills (such as you saw with Timmy) and expect a negative prognosis, with the problems predetermined and permanent. Remember, how- ever, that biological and psychosocial influences continuously interact with each other. Therefore, even for disorders such as attention-deficit/hyperactivity disorder and autism spectrum disorder that have clear biological bases, the presentation of the disorder is different for eac -One note of caution is appropriate here. There is real con- cern in the profession, especially among developmental psy- chologists, that some workers in the field may view aspects of normal development as symptoms of abnormality. For exam- ple, echolalia, which involves repeating the speech of others, was once thought to be a sign of autism spectrum disorder. When we study the development of speech in children without disorders, however, we find that repeating what someone else says is an intermediate step in language development. In chil- dren with autism spectrum disorder, therefore, echolalia is just a sign of relatively delayed language skills and not a symptom of their disorder (Roberts, 2014). Knowledge of development is important for understanding the nature of psychological disorders. 2. hildren with this disorder are often described as fidgety in school, unable to sit still for more than a few minutes. Danny's restlessness in his classroom was a considerable source of concern for his teacher and peers, who were frustrated by his impatience and excessive activity. In addition to hyperactivity and prob- lems sustaining attention, impulsivity—acting apparently with- out thinking—is a common complaint made about people with ADHD. For instance, during meetings at baseball practice, Danny often shouted responses to the coach's questions even before the coach had a chance to finish his sentence.

1.Borderline Personality Disorder People with borderline personality disorder lead tumultuous lives. Their moods and relationships are unstable, and usually they have a poor self-image. These people often feel empty and are at great risk of dying by their own hands. Consider the c 2.People with this personality disorder are often intense, going from anger to deep depression in a short time. Dysfunction in the area of emotion is sometimes considered one of the core features of borderline perso

1.linical description Borderline personality disorder is one of the most common per- sonality disorders observed in clinical settings; it is observed in every culture and is seen in about 1% to 2% of the general popu- lation (Torgersen, 2012). Claire's life illustrates the instability characteristic of people with borderline personality disorder. They tend to have turbulent relationships, fearing abandon- ment but lacking control over their emotions (Hooley, Cole, & Gironde, 2012). They often engage in behaviors that are suicidal, self-mutilative, or both, cutting, burning, or punching them- selves. Claire sometimes used her cigarette to burn her palm or forearm, and she carved her initials in her arm. As men -s mentioned previously, a significant proportion—nearly 10%—die by suicide 2. disorder (Linehan & Dexter-Mazza, 2008) and is one of the best predictors of suicide in this group (McGirr et al., 2009). The characteristic of instability (in emotion, interpersonal relationships, self-concept, and behavior) is seen as a core feature with some describing this group as being "stably unstable" (Hooley et al., 2012). This instability extends to impulsivity, which can be seen in their drug abuse and self-mutilation. Although not so obvious as to why, the self-injurious behaviors, such as cutting, some- times are described as tension-reducing by people who engage in these behaviors (McKenzie & Gross, 2014; Nock, 2010). Claire's empty feeling is also common; these people are some- times described as chronically bored and have difficulties with their own identities (Linehan & Dexter-Mazza, 2008). The mood disorders we discussed in Chapter 7 are common among people with borderline personality disorder; one study of inpatients with this disorder found that more than 80% also had major depression and approximately 10% had bipolar II disorder

1.clinical description Individuals with antisocial personality disorder tend to have long histories of violating the rights of others (Black, 2013; Hare et al., 2012). They are often described as being aggressive because they take what they want, indifferent to the concerns of other people. Lying and cheating seem to be second nature to them, and often they appear unable to tell the difference between the truth and the lies they make up to further their own goals. They show no remorse or concern over the sometimes devastating effects of their actions. Substance abuse is common in people with antisocial per- sonality disorder and appears to be a lifelong pattern among these individuals (Hasin et al., 2011). 2.Antisocial personality disorder has had a number of names over the years. Philippe Pinel (1801/1962) identified what he called manie sans délire (mania without delirium) to describe peo- ple with unusual emotional responses and impulsive rages but no deficits in reasoning ability (Charland, 2010). Other labels have included moral insanity, egopathy, sociopathy, and psychopathy. 3.defining criteria Hervey Cleckley (1941/1982), a psychiatrist who spent much of his career working with

1.long-term outcome for people with antisocial personality disorder is usually poor, regardless of gender (Black, 2013; Colman et al., 2009). One classic study, for example, followed 1,000 delinquent and nondelinquent boys over a 50-year period (Laub & Vaillant, 2000). Many of the delinquent boys would today receive a diagnosis of conduct disorder, which you will see later may be a precursor to antisocial personality disorder in adults. The delinquent boys were more than twice as likely to die an unnatural death (for example, accident, suicide, or homicide) as their nondelinquent peers, which may be attributed to factors such as alcohol abuse and poor self-care (for example, infections and reckless behavior). 2.A great deal has been written about these labels; we focus on the two that have figured most prominently in psychological research: psychopathy and DSM-5's antisocial personality disorder. There continues to be debate in the field if these really are two distinct disorders 3.Glibness/superficial charm Grandiose sense of self-worth Pathological lying Conning/manipulative Lack of remorse or guilt Callous/lack of empathy

1.egative responses by parents, teachers, and peers to the affected child's impulsivity and hyperactivity may contribute to feelings of low self-esteem, especially in children who are also depressed (Anastopoulos, Sommer, & Schatz, 2009). Years of con- stant remi 2.treatment of adHd Treatment for ADHD has proceeded on two fronts: psychosocial and biological interventions (Smith & Shapiro, 2015). Psychosocial treatments generally focus on broader issues such as improving aca- demic performance, decreasing disruptive behavior, and improving

1.los, Sommer, & Schatz, 2009). Years of con- stant reminders by teachers and parents to behave, sit quietly, and pay attention may create a negative self-image in these children, which, in turn, can negatively affect their ability to make friends, and these effects can last into adulthood (Murphy, 2015). Thus, the possible biological influences on impulsivity, hyperactivity, and attention, combined with attempts to control these children, may lead to rejection and consequent poor self-image. An inte- gration of the biological and psychological influences on ADHD suggests that both need to be addressed when designing effective treatments (Barkley, 2015c).

1.egative responses by parents, teachers, and peers to the affected child's impulsivity and hyperactivity may contribute to feelings of low self-esteem, especially in children who are also depressed (Anastopoulos, Sommer, & Schatz, 2009). Years of con- stant remi 2.treatment of adHd Treatment for ADHD has proceeded on two fronts: psychosocial and biological interventions (Smith & Shapiro, 2015). Psychosocial treatments generally focus on broader issues such as improving aca- demic performance, decreasing disruptive behavior, and improving 3.Psychosocial interventions Researchers recommend various behavioral interventions to help these children at home and in school (Pfiffner & DuPaul, 2015; Robin, 2015). In general, the programs set such goals as increasing the amount of time the child remains seated, the number of math papers completed, or appropriate play with peers. Reinforcement programs reward the child for improvements and, at times, pun- ish misbehavior with loss of rewards. Other parent education pro- grams teach families how to respond constructively to their child's behaviors and how to structure the child's day to help prevent dif- ficulties (e.g., Loren et al.

1.los, Sommer, & Schatz, 2009). Years of con- stant reminders by teachers and parents to behave, sit quietly, and pay attention may create a negative self-image in these children, which, in turn, can negatively affect their ability to make friends, and these effects can last into adulthood (Murphy, 2015). Thus, the possible biological influences on impulsivity, hyperactivity, and attention, combined with attempts to control these children, may lead to rejection and consequent poor self-image. An inte- gration of the biological and psychological influences on ADHD suggests that both need to be addressed when designing effective treatments (Barkley, 2015c). 2.cial skills. Typically, the goal of biological treatments is to reduce the children's impulsivity and hyperactivity and to improve their attention skills. Current thinking in this area points to using parent- and/or teacher-delivered behavioral interventions for young children before attempting medication (Subcommittee on Attention-Deficit/Hyperactivity D 3.cial skills training for these children, which includes teaching them how to interact appropri- ately with their peers, also seems to be an important treatment component (Watson, Richels, Michalek, & Raymer, 2015). For adults with ADHD, cognitive-behavioral intervention to reduce distractibility and improve organizational skills appears quite helpful (Knouse, 2015). Most clinicians typically recommend a combination of approaches designed to individualize treatments for those with ADHD, targeting both short-term management issues (decreasing hyperactivity and impulsivity) and long-term concerns (preventing and reversing academic decline and improv- ing social skills).

1. Another finding showed that inducing positive or negative mood by playing joyful or sad music directly affected sexual arousal, at least in normals, with sad music decreasin 2. we have to break the concept of performance anxiety into several components. One component is arousal, another is cognitive processes, and the third is negative affect (Wiegel et al., 2006; Wincze et al., 2008; Wincze & Weisburg, 2015). When confronted with the possibility of having sexual rela- tions, individuals who are dysfunctional tend to expect the worst and find the situation to be relatively negative and unpleasant (Weisburg et al., 2001; Wincze & Weisburg, 2015). As far as pos- sible, they avoid becoming aware of any sexual cues (and therefore are not aware of how aroused they are physically, thus underre- porting their arousal 3. dysfunctional sexual arousal (Barlow, 1986, 2002). These experi- ments demonstrate that sexual arousal is strongly determined by psychological factors, particularly cognitive and emotional fac- tors, that are powerful enough to determine whether blood flows to the appropriate areas of the body, such as the genitals, confirm- ing again the strong interaction of psychological a

1.lthough the original studies described above were carried out mostly with men because of the early avail- ability of the strain gauge measure, subsequent studies with women reveal a similar pattern of results (Bradford & Meston, 2006). How do we interpret this complex series of experiments to account for sexual dysfunction from a psychological perspective? 2. They also may distract themselves with negative thoughts, such as, "I'm going to make a fool of myself; I'll never be able to get aroused; she [or he] will think I'm stupid." We know that as arousal increases, a person's attention focuses more intently and consistently. But the person who is focusing on nega- tive thoughts will find it impossible to become sexually aroused. People with normal sexual functioning react to a sexual situ- ation positively. They focus their attention on the erotic cues and do not become distracted. When they become aroused, they focus even more strongly on the sexual and erotic cues, allow- ing themselves to become increasingly sexually aroused 3. performance demand" conditions, experi- ence positive affect, are not distracted by nonsexual stimuli, and have a good idea of how aroused they are. Individuals with sexual problems, such as erectile dysfunction in males, show decreased arousal during performance demand, experience negative affect, are distracted by nonsexual stimuli, and do not have an accu- rate sense of how aroused they are. This process seems to apply to most sexual dysfunctions, which, you will remember, tend to occur together, but it is particularly applicable to sexual arousal disorders (Wiegel et al., 2006). Though little is known about the psychological (or biologi- cal) factors associated with premature ejaculation (Althof, 2007; Bradford & Meston, 2011; Malavige & Jayawickrema, 2015; Weiner, 1996), the condition is most prevalent in young men and that excessive physiological arousal in the sympathetic nervous system may lead to rapid ejaculation. These observations suggest some men may have a naturally lower threshold for ejaculation; that is, they require less stimulation and arousal to ejaculate.

1/Sexual Sadism and Sexual Masochism Disorders Both sexual sadism and sexual masochism are associated with either inflicting pain or humiliation (sadism) or suffering pain or humiliation (masochism; Hucker, 2008; Krueger, 2010a, 2010b; Yates, Hucker, & Kingston, 2008), and becoming sexually aroused is specifically associated with violence and injury in these conditions (Seto, Lalumiere, Harris, & Chivers, 2012). Although Mr. M. was extremely concerned about his cross-dressing, he was also disturbed by another problem. T 2. sadistic rape After murder, rape is the most devastating assault one person can make on another. It is not classified as a paraphilic disorder because most instances of rape are better characterized as an assault by a male (or, quite rarely, a female) whose patterns of sexual arousal are not para- philic. Instead, many rapists meet criteria for antisocial personalit

1.maximize his sexual pleasure during inter- course with his wife, he had her wear a collar and leash, tied her to the bed, and handcuffed her. He sometimes tied himself with ropes, chains, handcuffs, and wires, all while he was cross-dressed. Mr. M. was concerned he might injure himself seriously. As a member of the police force, he had heard of cases and even investigated one him- self in which an individual was found dead, tightly and completely bound in harnesses, handcuffs, and ropes. In many such cases, something goes wrong and the individual accidentally hangs him- self, an event that should be distinguished from the closely related condition called hypoxiphilia, which involves self-strangulation to reduce the flow of oxygen to the brain and enhance the sensation of orgasm. It may seem paradoxical that someone has to either inflict or receive pain to become sexually aroused, but these types of cases are not uncommon 2. der (see Chapter 12) and may engage in a variety of antiso- cial and aggressive acts (Bradford & Meston, 2011; Davison & Janca, 2012; McCabe & Wauchope, 2005; Quinsey, 2010). Many rapes could be described as opportunistic, in that an aggressive or antisocial individual with a marked lack of empathy and disregard for inflicting pain on others (Bernat, Calhoun, & Adams, 1999) spontaneously took advantage of a vulnerable and unsuspecting woman. These unplanned assaults often occur during robberies or other criminal events. Rapes can also be motivated by anger and vindictiveness against specific women and may have been planned in advance (Hucker, 1997; McCabe & Wauchope, 2005; Rebocho & Silva, 2014; Quinsey, 2010).

1. A variety of procedures were used in a program of 3 to 4 months in a clinic devoted exclusively to this type of treatment. What makes the report notable is that Maletzky collected objective physiological outcome measures using the penile strain gauge described earlier with almost every partici- pant in the program, in addition to patients' reports of progress. In many cases, he also obtained corroborating information from families and legal authorities. In his follow up of these patients, Maletzky (2002) defined a treatment as successful when someone had 2.Men who rape had the lowest success rate among all offenders with a single diagnosis (75%), and individuals with multiple para- philic disorders had the lowest success rate of any group. Maletzky (2002) also examined factors associated with failure

1.ompleted all treatment sessions, (2) demonstrated no deviant sexual arousal on objective physiological testing at any annual follow-up testing session, (3) reported no deviant arousal or behavior at any time since treatment ended, and (4) had no legal record of any charges of deviant sexual activity, even if unsubstantiated. He defined as a treatment failure anyone who was not a success. Any offender who did not complete treatment for any reason was counted as a fail- ure, even though some may well have benefited from the partial treatment and gone on to recover. Using this criteria, from 75% to 95% of individuals, depending on the type of sexual offense (such as pedophilia, rape, or voyeurism), had a successful outcome. Maletzky's results were not derived from a scientifically controlled clinical trial, however. 2.Among the strongest predictors were a history of unstable social relationships, an unstable employment history, strong denial the problem exists, a history of multiple victims, and a situation in which the offender continues to live with a victim (as might be typical in cases of

1. One of the most powerful engines for developing unwanted arousal may be early sexual fantasies that are repeat- edly reinforced through the strong sexual pleasure associated with masturbation ( 2.on rare occasions, cases of women with paraphilic disorders do turn up (Cortoni & Gannon, 2011; Federoff et al., 1999; Ford & Cortoni, 2008; Hunter & Mathews, 1997; Logan, 2009), and a comprehensive national study of 175 female child sexual abusers exists (Wiegel, 2008). However, if early experiences contribute strongly to later sexual arousal patterns, then what about the Sambia males who practice exclusive homos 3.We have speculated elsewhere that activity this consuming may be related to the obsessional processes of obsessive-compulsive dis- order (Barlow, 2002). In both instances, the very act of trying to suppress unwanted, emotionally charged thoughts and fantasies seems to have the paradoxical effect of increasing their frequency and intensity (see Chapter 5). This process is also ongoing in peo- ple with eating disorders and addictions, when attempts to restrict strong addictive cravings lead to uncontrollable increases in the undesired behaviors.

1.ore an indi- vidual with a pedophilic or sadism disorder ever acts on his behavior, he may fantasize about it thousands of times while masturbating. Expressed as a clinical or operant-conditioning paradigm, this is another example of a learning process in which a behavior (sexual arousal to a specific object or activ- ity) is repeatedly reinforced through association with a pleasur- able consequence (orgasm). This mechanism may explain why paraphilic disorders are almost exclusively male disorders. The basic differences in frequency of masturbation between men and women that exist across cultures may contribute to the dif- ferential development of paraphilic disorders. 2.exual behavior during childhood and early adolescence and yet are exclusively heterosexual as adults? In such cohesive societies, the social demands or "scripts" for sexual interactions are stronger and more rigid than in our culture and thus may override the effects of early experiences (Baldwin & Baldwin, 1989). In addition, therapists and sex researchers who work with indi- viduals with paraphilic disorders have observed what seems to be an incredibly strong sex drive. It is not uncommon for some indi- viduals to masturbate three or four times a day. In one case seen in our clinic, a sadistic rapist masturbated approximately every half hour all day long, just as often as it was physiologically possible. 3.Psychopathologists are also becoming interested in the phe- nomenon of weak inhibitory control across these paraphilic dis- orders, which may indicate a weak biologically based behavioral inhibition system (BIS) in the brain (Ward & Beech, 2008) that might repress serotonergic functioning. (You may remember from Chapter 5 that the BIS is a brain circuit associated with anxiety and inhibition.) The model shown in E Figure 10.6 incorporates the factors thought to contribute to the development of paraphilic disor- ders.

1.Eating disorders are also common, par- ticularly bulimia (see Chapter 8): Approximately 25% of people with borderline personality disorder also have bulimia, 2.causes The results from numerous family studies suggest that borderline personality disorder is more prevalent in families with the disorder 3.Neuroimaging studies, designed to locate areas in the brain contributing to borderline personality disorder, point to the limbic network

1.p to 64% of the people with borderline personality disorder are also diagnosed with at least one substance use disorder (Zanarini et al., 1998). As with antisocial personality disorder, people with borderline personality disorder tend to improve during their 30s and 40s, although they may continue to have difficult 2.and somehow linked with mood disorders (Amad, Ramoz, Thomas, Jardri, & Gorwood, 2014). Studies of monozygotic (identical) and dizygotic (fraternal) twins indicated a higher concordance rate among monozygotic twins, further supporting the role of genet- ics in the expression of borderline personality disorder (Calati, Gressier, Balestri, & Serretti, 2013). The emotional reactivity that is a central aspect of borderline personality disorder has led researchers to look at this personal- ity trait for clues about inherited influences (endophenotypes). Important genetic studies are investigating genes associated with the neurochemical serotonin because dysfunction in this sys- tem has been linked to the emotional instability, suicidal behav- iors, and impulsivity seen in people with this diso 3.Significantly, this area in the brain is involved in emo- tion regulation and dysfunctional serotonin neurotransmission, linking these findings with genetic research. Low serotonergic activity is involved with the regulation of mood and impulsiv- ity, making it a target for extensive study in this group (Hooley et al., 2012). To further "zero in" on the nature of this disorder, it is nec- essary to refine the concept of emotional reactivity in borderline personality disorder. When asked about their experiences, people with this disorder will report greater emotional fluctuations and greater emotional intensity, primarily in negative emotions such as anger and anxiety (Dixon-Gordon et al., 2015; Chapman, Dixon-Gordon, Butler, & Walters, 2015; Linehan, 2015). Some research—using "morphing" technology—is looking at how sen- sitive these individuals are to the emotions of others.

1.clinical description The defining characteristic of people with paranoid personal- ity disorder is a pervasive unjustified distrust. Certainly, there may be times when someone is deceitful and "out to get you"; however, people with paranoid personality disorder are suspi- cious in situations in which most other people would agree their suspicions are unfounded. Even events that have nothing to do with them are interpreted as personal attacks (Bernstein & Useda, 2007; APA, 2013). 2.auses Evidence for biological contributions to paranoid personality disorder is limited. Some research suggests the disorder may be slightly more common among the relatives of people who have schizophrenia, although the association does not seem to be strong (Tienari et al., 2003). In other words, relatives of individuals with schizophrenia may be more likely to have paranoid personality disorder than people who do not have a relative with schizophre- nia. In general, there appears to be a strong role for genetics in paranoid personality disorder 3.Psychological contributions to this disorder are even less certain, although some interesting speculations have been made. Retrospec- tive research—asking people

1.people would view a neighbor's barking dog or a delayed airline flight as a deliberate attempt to annoy them. Unfortunately, such mistrust often extends to peo- ple close to them and makes meaningful relationships difficult. Imagine what a lonely existence this must be. Suspiciousness and mistrust can show themselves in a number of ways. People with paranoid personality disorder may be argumentative, may com- plain, or may be quiet. This style of interaction is communicated, sometimes nonverbally, to others, often resulting in discomfort among those who come in contact with them because of this volatility. These individuals are sensitive to criticism and have an excessive need for autonomy (APA, 2013). Having this disorder increases the risk of suicide attempts and violent beha 2.As you will see later with the other odd or eccentric personality disorders in Cluster A, there seems to be some relationship with schizophre- nia (Bolinskey et al., 2015), causing some to suggest eliminating it 3.people with this disorder to recall events from their childhood—suggests that early mistreatment or traumatic childhood experiences may play a role in the development of para- noid personality disorder (Iacovino, Jackson, & Oltmanns, 2014). Caution is warranted when interpreting these results because, clearly, there may be strong bias in the recall of these individuals who are already prone to viewing the world as a threat. Some psychologists point directly to the thoughts (also referred to as "schemas") of people with paranoid personal- ity disorder as a way of explaining their behavior. One view is that people with this disorder have the following basic mistaken assumptions about others: "People are malevolent and decep- tive," "They'll attack you if they get the chance," and "You can be okay only if you stay on your toes" (Lobbestael & Arntz, 2012). This is a maladaptive way to view the world, yet it seems to per- vade every aspect of the lives of these individuals. Although we don't know why they develop these

1.How do different drugs that affect different neurotransmit- ter systems all converge to activate the pleasure pathway, which is primarily made up of dopamine-sensitive neurons? Researchers are only beginning to sort out the answers to this question, but some surprising findings have emerged in recent years. For exam- ple, we know that amphetamines and cocaine act directly on the dopamine syste 2.This complicated picture is far from complete. We now under- stand that other neurotransmitters in addition to dopamine— including serotonin and norepinephrine—are also involved in the brain's reward system (Khokhar et al., 2010; Volkow & Warren, 2015). The coming years should yield interesting insights into the interaction of drugs and the brain. One aspect that awaits explana- tion is how drugs not only provide pleasurable experiences (posi- tive reinforcement) but also help remove unpleasant experiences such as pain, feelings of illness, or anxiety (negative reinforce- ment).

1.ple, the neurons in the brain's ventral tegmental area are kept from continuous firing by GABA neurons. (Remember that the GABA system is an inhibitory neurotransmitter system that blocks other neurons from sending information.) One thing that keeps us from being on an unending high is the presence of these GABA neurons, which act as the "brain police," or super- egos of the reward neurotransmitter system. Opiates (opium, morphine, heroin) inhibit GABA, which in turn stops the GABA neurons from inhibiting dopamine, which makes more dopamine available in the brain's pleasure pathway. Drugs that stimulate the reward center directly or indirectly include not only amphet- amine, cocaine, and opiates but also nicotine and alcoho 2.Aspirin is a negative reinforcer: We take it not because it makes us feel good but because it stops us from feeling bad. In much the same way, one property of the psychoactive drugs is that they stop people from feeling bad, an effect as powerful as making them feel good. With several drugs, negative reinforcement is related to the anxiolytic effect, the ability to reduce anxiety (discussed briefly in the section on the sedative, hypnotic, and anxiolytic drugs). Alcohol has an anxiolytic effect. The neurobiology of how these drugs reduce anxiety seems to involve the septal-hippocampal system (Ray, 2012), which includes a large number of GABA- sensitive neurons. Certain drugs may reduce anxiety by enhancing the activity of GABA in this region, thereby inhibiting the brain's normal reaction

1.The life of an opiate addict can be bleak. Research suggests that mortality rates in this population range from 6 to 20 times higher than the general population's. And, those individuals who do live face much hardship recovering from addiction with stable abstinence rates as low as 30% with most individuals undergo- ing many relapses. 2.amily and social support, employment, and opioid abstinence of at least five years (Hser et al., 2015). The high or "rush" experienced by users comes from activation of the body's natural opioid system. In other words, the brain already has its own opioids—

1.ven those that discontinue opioids often use alcohol and other drugs in their place (Hser, Evans, Grella, Ling, & Anglin, 2015). Results from a 33-year follow-up study of more than 80 opioid users in an English town highlight this pessimistic view (Rathod, Addenbrooke, & Rosenbach, 2005). At the follow up, 22% of opioid users had died—about twice the national rate of about 12% for the general population. More than half the deaths were the result of drug overdose, and several took their own lives. The good news from this study was that of those who sur- vived, 80% were no longer using opioids, and the remaining 20% were being treated with methadone. stence opioid use may be related to comorbid mental disorders and sexual or physical abuse. Long-term recovery has been shown to be associated with 2.ephalins and endorphins—that pro- vide narcotic effects (Ballantyne, 2012). Heroin, opium, morphine, and other opiates activate this system. The discovery of the natural opioid system was a major breakthrough in the field of psychophar- macology: Not only does it allow us to study the effects of addictive drugs on the brain, but it also has led to important discoveries that may help us treat people dependent on these drugs.

1.Identifying psychopaths among the criminal population seems to have important implications for predicting their future criminal behavior (Vitacco, Neumann, & Pardini, 2014). As you can imag- ine, having personality characteristics such as a lack of remorse and impulsivity can lead to difficulty staying out of trouble with the legal system. In general, most research has found that peo- ple who score high on measures of psychopathy commit crimes at a higher rate than those with lower scores and are at greater risk for more violent crimes and recidivism (repeating offenses) (e.g., Widiger, 2006), although some recent research has found psychopathy to be a less reliable predictor of criminality (Colins, Andershed, & Pardini, 2015). 2. conduct disorder It is important to note the developmen- tal nature of antisocial behavior. DSM-5 provides a separate diagnosis for chil- dren who engage in behaviors that violate society's norms: conduct disorder. It pro- vides for the designation of two subtypes; childhood-onset type (the onset of at least one criterion characteristic of CD prior to age 10 years) or adolescent-onset type (the absence of any criteria characteris- tic of CD prior to age 10 ye

1.view the literature on antisocial personality disorder, note that the people included in the research may be members of only one of the three groups (those with antisocial personality dis- order, psychopathy, and criminals) we have described. For example, genetic research is usually conducted with criminals because th -heir families are easier to identify than members of the other groups. As you now know, the criminal group may include people other than those with anti- social personality disorder or psychopa- thy. Keep this in mind as you read on. 2.n addi- tional subtype, new to the DSM-5, is called "with a callous-unemotional presentation" (Barry, Golmaryami, Rivera-Hudson, & Frick, 2012). This designation is an indi- cation that the young person presents in a way that suggests personality characteris- tics similar to an adult with psychopathy. Many children with conduct disorder— most often diagnosed in boys—become juvenile offenders and tend to become involved with drugs . Ryan fits into this category. More important, the lifelong pattern of antisocial behavior is evident because young children who display antisocial behavior are likely to continue these behaviors as they grow older (Black, 2013; Frick, 2012). Data from long-term follow-up research indicate that many adults with antisocial personality disorder or psy- chopathy had conduct disorder as children

1. cluster cPeople diagnosed with the next three personality disorders we highlight—avoidant, dependent, and obsessive-compulsive— share common features with people who have anxiety dis- orders. These anxious or fearful personality disorders are described next. Avoidant Personality Disorder As the name suggests, people with avoidant personality disorder are extremely sensitive to the opinions of others and although they desire social relationships, their anxiety leads them to avoid such association 2.linical description Theodore Millon (1981), who initially proposed this diagnosis, notes that it is important to distinguish between individuals who are asocial because 3.causes Some evidence has found that avoidant personality disorder is related to other subschizophrenia-related disorders, occur- ring more often in relatives of people who have schizophrenia (Fogelson et al., 2010, 2007). A number of theories have been proposed that integrate biological and psychosocial influences as the cause of avoidant personality disorder. Millon (1981), for example, suggests that these individuals may be born with a dif- ficult temperament or personality characteristics. As a result, their parents

1.xtremely low self-esteem—coupled with a fear of rejection—causes them to be limited in their friendships and dependent on those they feel comfortable with (Eikenaes, Pedersen, &Wilberg, 2015; Sanislow, da Cruz, Giano 2.apathetic, affectively flat, and relatively uninterested in interpersonal relationships (comparable to what DSM-5 terms schizoid personality disorder) and individuals who are asocial because they are interpersonally anxious and fearful of -rejection. It is the latter who fit the criteria of avoidant personality disorder (Millon & Martinez, 1995). These individuals feel chroni- cally rejected by others and are pessimistic about their future. 3.This rejection, in turn, may result in low self-esteem and social alienation, conditions that persist into adulthood. Limited support does exist for psycho- social influences in the cause of avoidant personality disorder. For example, Stravynski, Elie, and Franche (1989) questioned a group of people with avoidant personality disorder and a group of control participants about their early treatment by their par- ents. Those with the disorder remembered their parents as more rejecting, more guilt engendering, and less affectionate than the control group, suggesting parenting may contribute to the development of this disorder. Similarly, research has consistently found that these individuals are more likely to report childhood experiences of neglect, isolatio

1.Disorganised Symptoms • Disorganised behaviour 2. Cognition

1.• Inability to organize behaviour so that it conforms with community standards • Catonia: abnormality of movement that may involve repetitive or purposeless overactivity, - catalepsy (resistance to passive movement), or 1. try to move them Resistance to having limbs moved; passive movement -waxy flexibility (can move a person's limbs into positions that will be held for long periods)1. Can move limbs into a position that will be held for a long time 2. Cognitive deficits are common -Start prior to onset of schizophrenia -Worsen at the time of first presentation and then stabilise • Neurocognition • Attention, concentration, memory, speed of processing, executive functioning • Social cognition• Emotion recognition, theory of mind 1. mind (attribute mental states, emotions intents and desires of oneself or other people, impaores iability to recognise ones emotions or others, so hard to make social conncedtios)

1., Treatment Agonist substitution 2. Antagonistic treatment 3. • Aversive treatment

1.• Safe drug with a similar chemical composition as the abused drug • Examples include methadone and nicotine gum or patch§ Methadone has health impacts but reduces crime compared to heroin 2. • Drugs that block or counteract the positive effects of substances • Examples include naltrexone for opiate and alcohol problems 3. • Drugs that make use of substances extremely unpleasant • Examples include antabuse and silver nitrate 1. Antabuse/silver nitrate: Make intoxication cause vomiting, etc. § Works, but people may just stop taking the medication as they know that's what causes it

1. Central Features of ADHD 2. Attention-Deficit/Hyperactivity Disorder inattention bit

1/- Inattention - Overactivity - Impulsivity 2. A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2): (1) Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. -Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). -Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). -Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). -Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked). -Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). -Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). -Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). -Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). -Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

1.The controversy over the Sobell study still has a chilling effect on controlled drinking as a treatment of alcohol abuse in the United States. In contrast, controlled drinking is widely accepted as a treatment for alcoholism in the United Kingdom. Despite opposi- tion, research on this approach has been conducted in the ensuing years (e.g., Orford & Keddie, 2006; van Amsterdam & van den Brink, 2013) 2.component treatment Most comprehensive treatment programs aimed at helping peo- ple with substance use disorder have a number of components thought to boost the effectiveness of the "treatment package" (NIDA, 2009). We saw in our review of biological treatments that their effectiveness is increased when psychologically based therapy is added. In aversion therapy, which uses a conditioning model, substance use is paired with something extremely unpleas- ant, such as a brief electric shock or feelings of nausea. For exam- ple, a person might be offered a drink of alcohol and receive a painful shock when the glass reaches his lips. 3.ne component that seems to be a valuable part of therapy for substance use is contingency management (Higgins et al., 2014). Here, the clinician and the client

1the results seem to show that controlled drink- ing is at least as effective as abstinence but that neither treatment is successful for 70% to 80% of patients over the long term—a rather bleak outlook for people with alcohol dependence problems. 2.The goal is to coun- teract the positive associations with substance use with negative associations. The negative associations can also be made by imag- ining unpleasant scenes in a technique called covert sensitization (Cautela, 1966); the person might picture herself beginning to snort cocaine and be interrupted with visions of herself becoming violently ill (Kearney, 2006). 3.erhaps money or small retail items like CDs. In a study of cocaine abusers, clients received cash vouchers (up to almost $2,000) for having cocaine-negative urine specimens (Higgins et al., 2006). This study found greater abstinence rates among cocaine- dependent users with the contingency management approach and other skills training than among users in a more traditional counsel- ing program that included a 12-step approach to treatment. Another package of treatments is the community reinforcement approach (e.g., Campbell, Miele, Nunes, McCrimmon, & Ghitza, 2012). In keeping with the multiple influences that affect substance use, several facets of the drug problem are addressed to help id

1. Sexual Dysfunctions • Specifiers for sexual dysfunctions 2. male hypoactive sexual desire disorder criteria

1, - Lifelong vs. acquired - Generalised vs. situational;. Generalised: Not limited to partner, type of stimulation - Mild, moderate, or severe; Based on distress due to sexual dysfunction 2. A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. The judgment of deficiency is made by the clinician, taking into account factors that affect sexual functioning, such as age and general and sociocultural contexts of the individual's life. B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months. C. The symptoms in Criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition;- (e.g., severe relationship distress some is allowed, but is it abusive etc.?.), mental disorder, medication, medical condition

1. King Henry the 8th (England, ~1500s): 2. Homosexuality and American psychiatry 3. 1960s radical gay liberation movement "gay is good" 4. 1974:

1. (1491-1547)• Anal sex is punishable by death • In 1861, maximum penalty was reduced to 10 years imprisonment2 2. Kinsey's finding that homosexual behaviour was more common than previously believed;1. believed (as much as 10% of the population) -Trained psychologists could not differentiate test results from homosexual and heterosexual individuals 3. 1. Radical gay liberation 4. Finally, in 1974 homosexuality was removed from the DSM-II -DSM-III, DSM-IV, & DSM-IV-TR had sexual disorder not otherwise specified: persistent and marked distress about one's sexual orientation 1. DSM-III through to DSM-IV-TR has sexual disorder not otherwise specified: Distress about one's sexual orientation § An individual was called disordered if they internalised society's stigma about who they are

1. Prevalence 2. Female Orgasmic Disorder Anne is a 26-year old woman who sought treatment after her partner became concerned that she could not achieve an orgasm. Anne was quite happy with her relationship with Colin and enjoyed their sex life, although she too wished she could experience orgasms. Upon questioning, Anne reported that she feels anxious about letting go in the bedroom and fully relaxing. She reported that she has never felt quite comfortable with her body and has rarely masturbated.

1. - 17%-41% of women have trouble reaching orgasm - 2/3 of women have faked an orgasm, protect theor -psrtenrs ego and feelings - Disorder not lack of sexual enjoymet , no difference in sexual arousal or interest yet they are still having triuvke achieving an orgasm 2. For anne maybe some psych component contributing to not achieving orgask

1. prevalence 2. Male Hypoactive Sexual Desire Disorder John is a 45-year old man who has difficulty obtaining an erection when his wife initiates sex. John hasn't initiated sex with his wife in years and he wishes his wife would stop expecting him to have sex. John's wife is unhappy with their life in the bedroom and often asks John if he is having an affair because it isn't normal for a man to not want sex. John is not having an affair, rather he says he has no desire to have sex with his wife or anyone. He feels stressed at work and isn't as satisfied with his physical appearance as he was when he was 20 and exercising regularly. John feels he wouldn't be bothered by his lack of interest in sex if his wife weren't bothered by it.

1. - 5% of men 2. - Some stressors, body dissatidfaction could contribute , but not a symotom of sexyal dysfinction , - How significant stressor was, rile out adjustment disorder

1. 1830: Rev. Sylvester Graham - 2. Technology 3. STIs on the Rise

1. - Abstinence Theory 1. We are healthier when we're fit, eat plain foods, and abstain from sex 2. Believed bland food would decrease sexual urges - created graham crackers - Kellogg's: Cautioned parents to look for symptoms of children masturbating 1. Advocated for sewing foreskin together with wire and burning female clitoris 1. Also believed bland food would decrease sexual urges - created Kellogg's cornflakes, 39 telltale signs of masturbation dull eyes, confidence, sewed foreskin together for males, and femsles clitoris burned with acid 2. Now sexual inhibition seen as the problem 2. - Easy to access sexual content 3. - Increase of acceptance towards sex led to increase in STIs - 16% of Australians will have STI during lifetime; 4m people 1. Chlamydia increasing the most, perhaps due to being asymptomatic

1. - developmental considerations Because the overwhelming majority of cases begin in adoles- cence, it is clear that anorexia and bulimia are strongly related to development (Smith, Simmons, Flory, Annus, & Hill, 2007; Steiger et al., 2013). As pointed out in classic studies by Striegel- Moore, Silberstein, and Rodin (1986) and Attie and Brooks-Gunn (1995), differential patterns of physical development in girls and boys interact with cultural influences to create eating disorders. 2. - Causes of Eating - Disorders - As with all disorders discussed in this book, biological, psychological, and social factors contribute to the development of these serious eating disorders. - Social Dimensions - Levine and Smolak referred over 20 years ago (1996) to "the glo- rification of slenderness" in magazines and on television, where most females are thinner than the average American woman. Because overweight men are 2 to 5 times more common as television char- acters than overweight women, the message from the media to be thin is clearly aimed at women, and the message got through loud and clear and is still getting through. Grabe, Ward, and Hyde (2008), reviewing 77 studies, demonstrated a strong re

1. - After puberty, girls gain weight primarily in fat tissue, whereas boys develop muscle and lean tissue. As the ideal look in Western countries is tall and muscular for men and thin and prepubertal for women, physical development brings boys closer to the ideal and takes girls further away. Eating disorders, particularly anorexia nervosa, occasionally occur in children under the age of 11 (Walsh, 2010). In those rare cases of young children developing anorexia, they are likely to restrict fluid intake, as well as food intake, perhaps not understanding the difference (Gislason, 1988; Walsh, 2010). This is particularly danger- ous. Concerns about weight are somewhat less common in young children. Nevertheless, negative attitude toward being overweight emerges as early as 3 years of age, and more than half of girls age 6 to 8 would like to be thinner (Striegel-Moore & Franko, 2002). By 9 years of age, 20% of girls reported trying to lose weight, and by 14, 40% were trying to lose weight (Field 2. - Remember that anorexia and particu-larly bulimia are the most culturallyspecific psychological disorders yet iden-tified. What drives so many young peo-ple into a punishing and life-threateningroutine of semistarvation or purging?For many young women, looking goodis more important than being healthy.For young females in competitive envi-ronments, self-worth, happiness, andsuccess are largely determined by bodymeasurements and percentage of bodyfat, factors that have little or no correla-tion with personal happiness and successin the long run. The cultural imperativefor thinness directly results in dieting, the first dangerous step down the slippery slope to anorexia and bulimia. - Levine and Smolak referred over 20 years ago (1996) to "the glo- rification of slenderness" in magazines and on television, where most females are thinner than the average American woman. Because overweight men are 2 to 5 times more common as television char- acters than overweight women, the message from the media to be thin is clearly aimed at women, and the message got through loud and clear and is still getting through. Grabe, Ward, and Hyde (2008), reviewing 77 studies, demonstrated a strong relationship between exposure to media ima

1. - Biological Dimensions - Like most psychological disorders, eating disorders run in families and thus seem to have a genetic component ting disorders are 4 to 5 times more likely than the gen- eral population to develop eating disorders themselves, with the risks for female relatives of patients with anorexia higher (see, for example, Strober, Freeman, Lampert, Diamond, & Kaye, 2000). In important twin studies of bulimia by Kendler and colleagues (1991) and of anorexia by Walters and Kendler (1995), research- ers used structured interviews to ascertain the prevalence of the disorders among 2,163 female twins. In 23% of identical twin pairs, both twins had bulimia, as compared with 9% of fraternal twins. 2.- . In other words, a person might inherit a tendency to be emotionally responsive to stressful life events and, as one con- sequence, might eat impulsively in an attempt to relieve stress and anxiety (Kaye, 2008; Pearson, Wonderlich, & Smith, 2015; Strober, 2002). Klump and colleagues (2001) mention perfectionist traits, along with negative affect. This biological vulnerability might then interact with social and psychological factors to produce an eating disorder. Wade and colleag

1. - Because no adoption studies have yet been reported, strong sociocultural influences cannot be ruled out, and other studies have produced inconsistent results (Fairburn, Cowen, & Harrison, 1999). For anorexia, numbers were too small for precise estimates, but the disorder in one twin did seem to confer a significant risk for both anorexia and bulimia in the co-twin. Bulik and colleagues (2006), in a large twin study, estimated heritability at 0.56. Thus, the consensus is that genetic makeup is about half of the equation among causes of anorexia and bulimia ( nonspecific personality traits such as emotional instability and, perhaps, poor impulse control might be inherited 2. Biological processes are quite active in the regulation of eat- ing and thus of eating disorders, and substantial evidence points to the hypothalamus as playing an important role. Investigators have studied the hypothalamus and the major neurotransmitter systems—including norepinephrine, dopamine, and, particularly, serotonin—that pass throughit to determine whether some-thing is malfunctioning wheneating disorders occur (Kaye,2008; Vitiello & Lederhendler,2000). Low levels of serotoner-gic activity, the system mostoften associated with eatingdisorders

1. Cultural Differences Sambia of Papua New Guinea

1. - Belief that semen is important for growth, strength, spirituality - Belief that a lot of semen needed for pregnancy, and that semen needs replenishing, so needs yo be preserved or obtained elseqhwre; HOMOSECIAL - Belief that female body is unhealthy (period huts) - Young males practice semen exchange build up semen stores until they have their first child, and then homosexual behaviour stops • Rejecting homosexuality would be viewed as abnormal And yet in many other cultures this behaviour would be stigmatised as homosexual pedophilia 1. Fellatio 2. Penetration of younger boys - Having no homosexual behaviour is seen as abnormal for men, so still engage in theis even when enagage in wsex with females

1. - Anorexia Nervosa - Like Phoebe, the overwhelming majority of individuals with buli- mia are within 10% of their normal weight In contrast, individuals with anorexia nervosa (which literally means a "nervous loss of appetite"—an incorrect definition because appetite often remains healthy) differ in one important way from individuals with bulimia. They are so suc- cessful at losing weight that they put their lives in considerable danger. 2. - clinical description - AN is less common than BN but has oberolap - y individuals with bulimia have a history of anorexia; that is, they once used fasting to reduce their body weight below desirable levels (Fairburn & Cooper, 2014; Fairburn, Welch, et al., 1997). Although decreased

1. - Both anorexia and bulimia are characterized by a morbid fear of gaining weight and losing control over eating. The major difference seems to be whether the individual is successful at los- ing weight. People with anorexia are proud of both their diets and their extraordinary control. People with bulimia are ashamed of both their eating issues and their lack of control - ragic consequences of anorexia among young celebrities and within the modeling world have been well publicized in the media. In November 2010, 28-year-old French model and actress Isabelle Caro died, weighing 93 pounds. At 5 feet 5 inches, she had a BMI of 15.47 (16 is considered starvation). Around 2006, first Spain, then Italy, Brazil, and India, instituted bans on mod- els with BMIs 2. - . Many peo- ple lose weight because of a medical condition, but people with anorexia have an intense fear of obesity and relentlessly pursue thinness (Fairburn & Cooper, 2014; Hsu, 1990; Russell, 2009). As with Julie, the disorder most commonly begins in an adolescent who is overweight or who perceives herself to be. She then starts a diet that escalates into an obsessive preoccupation with being thin. - DSM-5 specifies two subtypes of anorexia nervosa. In the restricting type, individuals diet to limit calorie intake; in the binge- eating-purging type, they rely on purging. Unlike individuals with bulimia, binge-eating-purging anorexics binge on relatively small amounts of food and purge more consistently, in some cases each time they eat. Approximately half the individuals who meet criteria for anorexia engage in binge eating and purging (Fairburn & Cooper, 2014). Prospective data collected over 8 years on 136 individuals with anorexia reveal few differences between these two subtypes on severity of symptoms or personality (Eddy et al., 2002). At that time, fully 62% of the restricting subtype had begun bingeing or purging. Another study showed few differences between these subtypes and co-morbidity with anxiety disorders (Kaye et al., 2014). Thus, subtyping may not be useful in predicting the future course of the disorder but rather may reflect a certain phase or stage of anorexia, a finding confirmed in a more recent study (Eddy et al., 2008).

1. Anorexia Nervosa • Starvation Syndrome (Keys et al, 1950)

1. - Caused men to starve Weight loss and physical changes already noted, plus: -Personality/mood changes: Apathy, depression, tiredness, irritability, moodiness; poor concentration; narrowing of interests; loss of sexual interest; less spontaneity -Social changes: Deterioration in group spirit; reluctance to make group decisions or plan activities; social interaction became stilted; loss of interest in education/career activities -Food preoccupation: Preoccupation with food; collecting recipes; food planning; food rituals; dawdling over meals; increase in gum chewing, smoking, nail-biting

1. Female Sexual Interest/Arousal Disorder Cheryl is 35 years old. She rarely thinks about having sex, does not initiate sex with her husband, and wishes he would stop trying to have sex with her. Cheryl used to enjoy sex quite a bit, both before and after she was married. But now that she has had children, she feels that sex is not important. She has better things to do, like sleep, than have sex. However, even if she feels rested, she is uninterested in sex. When she does give into her husband, she doesn't feel any enjoyment no matter what he does in the bedroom. Afterwards, she may have even less interest in sex, if that were possible. She loves her husband, but doesn't feel any passion for him. She doesn't think she could feel passion for any man. Cheryl's husband is quite unsatisfied with their sex life and wants Cheryl to get help. Cheryl just wants her husband to have an affair so that he will stop asking her to have sex. 2. Erectile Disorder criteria

1. - Cheryl not bothered by it onely because of , ask husband to have affair 2. A. At least one of the three following symptoms must be experienced on almost all or all (approximately 75%-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts): - Marked difficulty in obtaining an erection during sexual activity. - Marked difficulty in maintaining an erection until the completion of sexual activity. - Marked decrease in erectile rigidity. B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months. C. The symptoms in Criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

1. demographic and onset 2. Paraphilic Disorders 3. Frotteuristic Disorder criteria

1. - Demographic: Males, mostly - Onset: Adolescence 1. However, sexual sadism/masochism tend to start early-adulthood - Issue: Should something be considered a disorder when distress is due to society's stigma? 2. -Fetishistic disorder -Voyeuristic disorder -Exhibitionistic disorder -Frotteuristic disorder -Transvestic disorder -Sexual sadism disorder -Sexual masochism disorder -Sadistic Rape -Pedophilic disorder -Other Specified Paraphilic Disorder -Unspecified Paraphilic Disorder 3. A. Over a period of 6 mos, recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person, as manifested by fantasies, urges, or behaviours B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

1. Psychological Predictors 2. Dave Barlow: Model of Functional and Dysfunctional Sexual Arousal

1. - Depression - Anxiety - Poor self-esteem - Uncomfortable environment for sex - Narrow attitudes about sex - Negative thoughts about sex - overDependence on routines 2 - There are explicit and implicit demands for sexual performance 1. Negative affect/expectancies mahy focus on public consequences of not perdorming, non erotic cues attentional problems increased autonomic arousal (anxiety) hyper-focus on distractions, not ne9ng attractive, other things to get done dysfunctional performance all leading to avoidance 2. Positive affect/expectancie and expectancies, accurate reportinhof arousal, perception of control attentional focus on erotic cues increased autonomic arousal (sexual arousal) increased efficient attention of erotic cues functional performance a;l leading to approach

1. Slide; Causes of Sexual Dysfunction 2. Spectator Role: 3. Biological Predictors

1. - Distal causes (religious orthodoxy, psychosexual trauma, homosexual inclination, inadequate counselling, excessive alcohol intake, physiological problems and sociocultural factors) lead to immediate dysfunction (spectator role and fears about performance0 leading to human sexual inadequacy 2. Paying too much attention to own experience rather than partner's experience, these come from socio ultural issues , that sex is bad dirty, if they've experiecnec secual abuse, all leading to focus on own experience , distak anteciedients lead yo thix 3. - Smoking - Heavy drinking and long-term drinking - Cardiovascular problems - Diabetes - Neurological diseases - Low physiological arousal - SSRI medications; help increase desire and arlousal , but ythey themselves tmay lead to sexual dysfunction - Antihypertensive medication - Drug use

1. - but they now may be leveling off with a 16.9% rate in 2008, 2010, and 2011 (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010; Ogden, Carroll, Kit, & Flegal, 2012; 2014; Ogden et al., 2016). Rates may be even dropping a bit in preschoolers (Ogeden et al., 2016; Pan, Blanck, Sherry, Dalenius, & Grummer-Strawn, 2012), indicat- ing, perhaps, that public education campaigns are just begin- ning to have an effect. If one looks at children and adolescents either overweight (above the 85th percentile in BMI) or obese, the rate is 30.4%. The stigma of obesity has a major impact on quality of life

1. - For example, most overweight individuals are subjected to prejudice and discrimination in college, at work, and in housing (Gearhardt et al., 2012). Further, the experience of weight discrimination is associated with increased mortality risk (Sutin, Stephan, & Terracciano, 2015). Ridicule and teasing in children may increase obesity through depression and binge - Obesity is not limited to North America. Rates of obesity in eastern and southern European nations are as high as 50% (Berghöfer et al., 2008; Bjorntorp, 1997; Ng et al., 2014), and the rate is greatly increasing in developing nations. In Japan, although still comparatively low, obesity rates in men have doubled since 1992 and have nearly doubled in young women - where the proportion of Chinese who are overweight increased from 6% to 8% in a 7-year period (Holden, 2005). Obesity is also the main driver of type 2 diabetes, which has reached epidemic status (Yach, Stuckler, & Brownell, 2006). Additional facts documenting the global epidemic of obe- sity and its consequences are presented in - where the proportion of Chinese who are overweight increased from 6% to 8% in a 7-year period (Holden, 2005). Obesity is also the main driver of type 2 diabetes, which has reached epidemic status (Yach, Stuckler, & Brownell, 2006). Additional facts documenting the global epidemic of obe- sity and its consequences are presented in

1. - Treatment of Eating Disorders - Only since the 1980s have there been treatments for bulimia; treatments for anorexia have been around much longer but were not initially well developed. Rapidly accumulating evidence indi- cates that at least one, and possibly two, psychological treatments are effective, particularly for bulimia nervosa. - Drug Treatments At present, drug treatments have not been found to be effective in the treatment of anorexia nervosa (see, for example, Crow, Mitchell, Roerig, & Steffen, 2009; Wilson & Fairburn, 2007).

1. - For example, one definitive study reported that fluoxetine (Prozac) had no benefit in preventing relapse in patients with anorexia after weight has been restored - there is some evidence that drugs may be useful for some people with bulimia, particularly during the bingeing and purging cycle. The drugs generally considered the most effective for bulimia are the same antidepressant medica- tions proven effective for mood disorders and anxiety disorders (Broft, Berner, & Walsh, 2010; Shapiro et al., 2007; Wilson & Fairburn, 2007). The Food and Drug Administration (FDA) in 1996 approved Prozac as effective for eating disorders. E researchers found the average reduc- tion in binge eating and purging was, respectively, 47% and 65% (Walsh, 1991; Walsh, Hadigan, Devlin, Gladis, & Roose, 1991). A more recent review (meta-analysis) suggested that selective serotonin reuptake inhibitors are helpful in the treat- ment of bulimia (Tortorella, Fabrazzo, Monteleone, Steardo, & Monteleone, 2014). However, although antidepressants are more effective than plac

1.Furthermore, emotional eating behavior (eating to relieve stress or anxiety) and binge eating frequencies peaked in the postovulatory phases of the menstrual cycle for all women whether they binged or not during other phases of their cycle. High levels of hormones at least partially accounted for these peaks. In

1. - In an interesting bit of theorizing, Klump and her colleagues, noting the strong associa- tion between the onset of bulimia and puberty, speculate that the onset of puberty and associated hormonal changes may "turn on" certain hormone responsive risk genes in women prone to binge eating to begin with because they possess these genetic patterns. If true, this would be another example of the kind of gene- environment interactions d f investigators do find a strong association between neuro- biological functions and eating disorders, the question of cause or effect remains. At present, the consensus is that some neuro- biological abnormalities do exist in people with eating disorders (e.g., Marsh et al., 2011; Mainz, Schulte-Rüther, Fink, Herpertz- Dahlmann, & Konrad, 2012) but that they may be aresultof semi- starvation or a binge-purge cycle rather than a cause, although they may well contribute to themaintenanceof the disorder once it is established. --**** They hypothesized that reduced levels of leptin, a hormone acting in the hypothalamus to produce feelings of fullness (and therefore keep people from over- eating) might be associated with excessive efforts to keep weight - **d therefore lead to increases in the reinforcing value of food and possibly binge eating. Contrary to their hypotheses, they found that patients with bulimia compared to control participants did not differ on leptin levels, which were therefore not signifi- cantly associated with the reinforcing value of food.

1. - mortality rate may increase to as much as 2% in hospitals where the surgery is done less often (usually few- er than 100 operations for a given surgeon), but the 30-day mor- tality rate averages about 1% and nearly 6% after 5 years (Omalu et al., 2007). There is some evidence that these rates are not differ- ent from severely obese individuals who do not have the surgery at the 5-year point (Livingston, 2007). Furthermore, if the surgery is successful, risk of death from obesity-related diseases such as diabetes is reduced substantially, as much as 90% in some stud- ies (Adams et al., 2007) This suggests that this surgery should not become routine until we know more about it (Livingston, 2012; Wolfe & Belle, 2014). 2.high-fat snacks. These programs also target reduction of sedentary habits in children and adolescents, such as viewing television, playing video games, and sitting in front of a computer. These programs may be more successful than with adults because parents are typically fully engaged in the program in a constructive way and provide constant and continuing support (Ludwig, 2012; Altman & Wilfey, 2015). This is important because many parents who are not part of structur

1. - In any case, surgeons typically require patients to exhaust all other treatment options and to undergo a thorough psychological assessment to ascertain whether they can adapt to the radically changed eating patterns required postsurgery (Kral, 2002; Livingston, 2010; Sarwer et al., 2004). New psychological programs have been designed specifically to prepare patients for this surgery and help them adapt following surgery (Apple, Lock, & Peebles, 2006). With these new programs, surgery may be the best bet for severely obese individuals, but only a small proportion of those eligible are getting the surgery, because of its controversial nature Turning to public health policy approach 2. Most of us recognize that eating is essential to our survival. Equally important is sleep, a still relatively mysterious process crucial to everyday functioning and strongly implicated in many psychological disorders. We turn our attention to this additional survival activity in an effort to understand

1. Distortions of body image in some males can also have tragic consequences. Olivardia, Pope, and Hudson (2000) have described a syndrome in men, particularly male weight lifters, that they initially termed "reverse anorexia nervosa."

1. - Men with this syndrome reported they were extremely concerned about looking small, even though they were muscular. Many of these men avoided beaches, locker rooms, and other places where their bodies might be seen. These men also were prone to using anabolic-androgenic steroids to bulk up, risking both the medi- cal and the psychological consequences of taking steroids. - ere prone to using anabolic-androgenic steroids to bulk up, risking both the medi- cal and the psychological consequences of taking steroids. Thus, although a marked gender difference in typical body image dis- tortion is obvious, with many women thinking they're too big and some men thinking they're too small, both types of distortion can result in severe psychological and physical consequences

1. - But given the substan- tial medical costs associated with obesity, particularly in lower- income groups, many public health professionals would judge that these incentives save the health care system and taxpayers far more money than they cost, particularly since other studies have shown the value of incentives on initial weight loss (John et al., 2011). The most successful programs are professionally directed behavior modification programs. A recent study suggested that the combination of restricted calorie intake, increased physical activity, and behavior therapy tends to lead to more weight loss than any of these components on their own (Wadden, Butryn, Hong, & Tsai, 2014). 2. Patients lose as much as 20% of their weight on very-low-calorie diets, which typically consist of 4 to 6 liquid meal replacement products, or "shakes," a day. At the end of 3 or 4 months, they are then placed on a low-calorie balanced diet. As with all weight-loss programs, patients typically regain up to 50% of their lost weight in the year following treatment (Ames, et al., 2014; Wadden & Osei, 2002). But more than half of them are able to maintain a weight loss of at least 5%, which is impor- tant in

1. - Other research has suggested that behav- ior modification programs are particularly effective if patients attend group maintenance sessions periodically in the year fol- lowing initial weight reduction ( - In a major study, Svetkey and colleagues (2008) randomly assigned 1,032 overweight or obese adults who had lost at least 10 pounds (4 kilograms) during a 6-month behavior modification program to one of three weight-loss maintenance conditions for 30 months: (1) once-a-month contact with a counselor to help them maintain their program (personal contact group), (2) a website they could log on to when they wanted to maintain their program (interactive technology group), and (3) a control comparison in which they were on their own (self-directed group). - Nevertheless, even these programs do not produce impressive results. Although participants lost 19 pounds (8 kilograms) on average during the initial 6-month program, individuals in the control group and the interactive technology group gained back approximately 12 pounds (5.2-5.5 kilograms), and those in the once-a-month contact group gained back approximately 9 pounds (4 kilograms) after 2.5 years. 2. - But more than half of them are able to maintain a weight loss of at least 5%, which is impor- tant in very obese people (Sarwer et al., 2004). Similarly, drug treatments that reduce internal cues signaling hunger may have some effect, particularly if combined with a behavioral approach targeting lifestyle change, but concerns about cardiovascular side effects have plagued these medications Finally, the surgical approach to extreme obesity—calledbariatric surgery— is an increasingly popular approach for individuals with a BMI of at least 40 (Adams et al., 2012; Courcoulas, 2012; Livingston, 2012; Arteburn & Fisher, 2014). This surgery has been performed on several celebrities, such as music producer/American Idoljudge Randy Jackson, and television personalities Sharon Osbourne and Al Roker. As noted earlier, 6.3% of the population in the United States now falls into this BMI of 40 or above category (Flegal et al., 2012). Up to 220,000 individuals received bariatric surgery in 2009 (American Society for Metabolic & Bariatric Surgery, 2010). Furthermore

1. Assessing Sexual Dysfunctions Assess 2. - Psychophysiological assessment 3. Medical evaluation 4. Sexual Dysfunctions in DSM MFEFPDGSOU

1. - Practitioner needs to be extremely comfortable with topic to not induce guilt, shame, anxiety in patient - Assess 1. Sexual attitudes 2. Behaviours 3. Sexual response cycle 4. Relationship issues 5. Psychological disorders 2. -Males—Penile plethysmograph/strain gauge (measures erection) -Females—Vaginal plethymograph/photoplethysmograph (measures blood flow to vagina) 3. Medication side effects -Physical conditions 4. -Male Hypoactive Sexual Desire Disorder -Female Sexual Interest/Arousal Disorder -Erectile Disorder -Female Orgasmic Disorder -Premature Ejaculation Disorder -Delayed Ejaculation Disorder -Genito-Pelvic Pain/Penetration Disorder;1. Only applies to women ,Men may experience pain too, but they rarely seek treatment for it, Not enough information to classify as disorder for men -Substance/ Medication-Induced Sexual Dysfunction -Other Specified Sexual Dysfunction -Unspecified Sexual Dysfunction

1. Binge Eating Disorder Specifiers: 2. Binge Eating Disorder • Prevalence 3. High comorbidity with 4. Binge Eating Disorder • Key Features 4. Binge Eating Disorder • Consequences

1. - Remission - Severity (same as BN) 2. -3.5% for women -2% for men -Higher rates in obese samples: 6.5%-8% - Onset: 30-50yo 3. anxiety disorders (65%), mood disorders (46-70%), and substance use disorders (23%) 4. -They have more concern about their weight or shape than overweight/obese pts without BED;- related to disorder themwlev more than regular individuals -A typical binge involves around 1,900 calories -Associated with being overweight or obese - Highly ritualistic patterns surrounding binge behaviour 5. -Physical discomfort and gastrointestinal distress -Shame, self-hatred, anxiety, and depression -Weight gain, obesity -Cardiovascular disease -High blood pressure -High cholesterol -High triglycerides -Adult-onset diabetes -Gout - Worse ss time goes on, sisolate themselves because of shame

1. Treatment 2. CBT-E (Fairburn, 2008) stage 1

1. - SSRIs 1. Seem to only be helpful for bulimia - Psychological treatments equally effective as each other, hard to become expert, lose opportunities to nmake money § CBT is preferred simply because it is the gold standard for other treatments, and we should focus our training on CBT above other treatments stick with CBT ghan below 1. Interpersonal psychotherapy 2. Family therapy; might be great for adolsscentg 2. - Establish foundations of treatment; achieve early change 1. Assess nature and severity 2. Jointly create personalised formulation - visualise transdiagnostic model, highlight how treatment targets mechanisms 3. Explain what treatment will involve 4. Establish real-time self-monitoring of thoughts, behaviours, context 5. Initiate in-session collaborative weighing, avod and excessive just as nad § Knowledge of weight is important for tracking recovery § Helps prevent excessive weighing outside of session 6. Provide psychoeducation

1. Pathways to Obesity 2. Treatment - Lifestyle modifications 3. Medications 4. Bariatric (gastric bypass) surgery

1. - Social pressure to be thin 1. body dissatisfaction dieting binge eating weight gain - Negative emotions 1. binge eating weight gain 2. 1. Diet 2. Exercise 3. Behavioural intervention § Reward system § Being held accountable 4. Average weight loss in lifestyle modification programs is only 3.2kg! § Not great by itself, but better than nothing 3. • Xenical • Lose up to 9% of baseline weight in a year § Problem: Requires limiting fat intake in order to take the medication (less than 40 grams of fat ad less than 12 g fat need ed foor one mean) · Eating more fat that this can cause very unpleasant side-effects 4. • Reduce the storage capacity of the stomach -And sometimes also shorten the length of the intestine so that less food can be absorbed -20kg-40kg weight loss 1. Reduces storage capacity of stomach (from football size to egg size!) 1. Surgery risk associated

1. nterestingly, widely available behavioral weight loss programs for obese patients with BED, such as Weight Watchers, have some positive effect on binging, but not nearly so much as CBT (Grilo, Masheb, Wilson, Gueorguieva, & White, 2011). 2. Fortunately, it appears that self-help procedures may be use- ful in the treatment of BED (Carter & Fairburn, 1998; Wilson & Zandberg, 2012). For example, CBT delivered as guided self-help was demonstrated to be more effective than a standard behavioral weight-loss program for BED both after treatment and at a 2-year follow up (Wilson, Wilfley, Agras, & Bryson, 2010), and this same program is effective when delivered out of a doctor's office in a primary care setting (Striegel-Moore et al., 2010). In view of these results, it would seem a self-help approach should probably be the first treatment offered for BED before engaging in more expen- sive and time-consuming therapist-led treatments.

1. - Some racial and ethnic differences are apparent in people with BED seeking treat- ment (Franko et al., 2012). African American participants tend to have higher BMI, and Hispanic participants have greater concerns with shape and weight than Caucasian participants. Thus, it would seem that tailoring treatment to these ethnic groups would be use- ful. Also, males may respond somewhat differently than females to treatment since one recent study demonstrated that men with lower shape/weight concerns responded well to brief treatments, whereas females with shape/weight concerns at any level of sever- ity, and men at more severe levels, all required l 2. - with bulimia, however, more severe cases may need the more intensive treatment delivered by a therapist, particularly cases with mul- tiple (comorbid) disorders in addition to BED, as well as low self- esteem (Wilson et al., 2010). Interestingly a recent report following up the Wilson and colleagues (2010) study indicated that rapid response (at least 70% reduction in binge eating by week 4) was a specific positive indicator of greater rates of remission compared to nonrapid responders up to two years later in the CBT guided self-help treatment but not in the IPT or the behavioral weight- loss group. - The authors suggest that since IPT was effective for both rapid and nonrapid responders, participants who do not show a ponse to CBT might be switched over to IPT. Matching treatment to individuals on the basis of their personal characteris- tics or patterns of responding (personalized medicine) is regarded by many as the next important step for improving success rates of our treatments

1. Specify whether: 2. Specify severity: mild, moderate, severe, extreme 3. bmi calculation 4. Only difference between someone with BN and AN 5. Anorexia Nervosa Prevalence 6. Age of onset 7. predominant demographic

1. - Subtype: Restricting or binge-purge 1. Restricting: Limit intake 2. Binge-purge: Try to limit intake (maybe without success) and also purge (underweight then anorexian , normal then nulimia) Specify if: in partial remission, in full remission 2. 1. Mild: BMI 17+ 2. Moderate: BMI 16-17 3. Severe: 15-16 4. Extreme: <15 5. Note: Normal is 18.5 - 25 § Although contextual factors should be considered (e.g., athletic, heavy muscles?) 3. weight(kf)/height(m)2 4. an significantly underweight 5. 1% for women 0.3% for men -More common among ballet students/performers (20%) 6. enerally between 16-20 years of age, but can occur in children 7. Majority are female and white -From middle- to upper-middle-class families -Develops in non-Western women after moving to Western countries or via the media 1. Contrast between cultures not minding extra weight and hating extra weight but then wathing tv American, developed thesze dsisordefs

1. - Preventing Eating Disorders Attempts are being made to prevent the development of eating disorders (Field et al., 2012; Stice, Rohde, Shaw, & Marti, 2012). If successful methods are confirmed, they will be important, because many cases of eating disorders are resistant to treatment, and most individuals who do not receive treatment suffer for years, in some cases all of their lives (Eddy et al., 2008). The development of eat- ing disorders during adolescence is a risk factor for a variety of additional problems and disorders during adulthood, including cardiovascular symptoms, chronic fatigue and infectious diseases, binge drinking and drug use, and anxiety and mood disorders (Field et al., 2012; Johnson, Cohen, Kasen, & Brook, 2002). Before implementing a prevention program, however, it is necessary to target specific behaviors to change. Stice, Shaw, and Marti (2007) concluded after a review of prevention programs that selecting girls age 15 or over and focusing on eliminating an exaggerated focus on body shape or weight and encouraging acceptance of one's body stood the best chance of success in preventing eat- ing disorders 2. - Obesity - As noted at the beginning of the chapter

1. - This finding is similar to results from prevention efforts for depression, where a "selective" approach of targeting high-risk individuals was most successful rather than a "universal" approach targeting everyone in a certain age range (Stice & Shaw, 2004). Using this selective approach, a program developed by Stice and colleagues (2012) called "Healthy Weight" was compared with just handing out educational material in 398 college women at risk for developing eating disorders because of weight and shape con- cerns. During 4 weekly hour-long group sessions with 6,210 par- ticipants, the women were educated about food and eating habits (and motivated to alter these habits using motivational enhance- ment procedures). - ealthy Weight" group compared with the comparison group, particularly for the most severely at risk women, and the effect was durable at a 6-month follow up. 2. - , Kruszon- Moran, Carroll, Fryar, & Ogden, 2016; Ogden et al., 2006). What is particularly disturbing is that this prevalence of obesity represents close to a tripling from 12% of adults in 1991. Medical costs for obesity and overweight are estimated at $147 billion, or 9.1% of U.S. health-care expenditures - At a BMI of 30, risk of mortality increases by 30%, and at a BMI of 40 or more, risk of mortality is 100% or more (Manson et al., 1995; Wadden, Brownell, & Foster, 2002). Because 6.3% of the adult population has a BMI over 40 (Flegal et al., 2012), a substantial number of people, perhaps 10 million or more in the United States alone, are in serious danger, and recent evidence indicates that this may be an underestimate (Stokes & Preston, 2015). Interestingly, in spite of overwhelming evidence pointing to the deleterious effects of obesity, some research is starting to suggest that the distribution of one's fat tissue is more important than BMI when it comes to predicting health outcomes, but more research is needed

1. - **Psychological Treatments - Until the 1980s, psychological treatments for people with eating disorders were directed at the patient's low self-esteem and dif- ficulties in developing an individual identity. Disordered patterns of family interaction and communication were also targeted for treatment. These treatments alone, however, did not have the effectiveness that clinicians hoped they might (see, for example, Minuchin et al., 1978; Russell, Szmukler, Dare, & Eisler, 1987). Short-term cognitive-behavioral treatments target problem eating behavior and associated attitudes about the overriding importance and significance of body weight and shape, and these strategies econd, noting the common concern with body shape and weight at the core of all eating disorders, the treatment has become "transdiagnostic" in that it is applicable with minor alterations to all eating disorder

1. - This is an important develop- ment because in DSM-IV, eating disorders, for the most part, were considered to be mutually exclusive. For example, according to DSM-IV guidelines, a person could not meet criteria for both anorexia and bulimia. But investigators working in this area dis- covered that features of the various eating disorders overlapped considerably (Fairburn, 2008; Keel, Brown, Holland, & Bodell, 2012). Furthermore, a large portion of patients, perhaps as many as 50% or more, who met criteria for a clinically severe eating disorder in DSM-IV did not meet criteria for anorexia or bulimia and were diagnosed with "eating disorder not otherwise specified" (eating disorder NOS) (Fairburn & Bohn, 2005). As described earlier in the chapter, some of these patients would now meet criteria for "binge eating disorder," which is included as a full- fledged diagnostic category in DSM-5. As noted above, these eating disorders have very similar causal influences, including similar inherited biological vulnerabilities, similar social influences (primarily cultural influences glorifying thinness), and a strong family influence toward perfectionism in all things. F n this treatment protocol, the essential components of cognitive- behavioral therapy (CBT) directed at causal factors common to all eating disorders are targeted in an integrated way. (Individu- als with anorexia and a very low weight—BMI of 17.5 or less— who would need inpatient treatment would be excluded until their weight was restored to an adequate level when they could then benefit from the program.)

1. - dietary restraint During World War II, in what has become a classic study, Keys and colleagues (Keys, Brozek, Henschel, Michelson, & Taylor, 1950) conducted a semistarvation experiment involving 36 con- scientious objectors who volunteered for the study as an alterna- tive to military service. For 6 months, these healthy men were given about half their former full intake of food 2.- Family influences - In the past, much has been made of the possible significance of fam- ily interaction patterns in cases of eating disorders. A number of clinicians and investigators in decades past (see, for example, Attie & Brooks-Gunn, 1995; Bruch, 1985; Humphrey, 1989; Minuchin, Rosman, & Baker, 1978) observed that the "typical" family of some- one with anorexia is successful, hard-driving, concerned about external appearances, and eager to maintain harmony. To accom- plish these goals, family members often deny or ignore conflicts or negative feelings and tend to attribute their problems to other people at the expense of frank communication among themselves (Fairburn, Shafran, & Cooper, 1999; Hsu, 1990).

1. - This period was followed by a 3-month rehabilitation phase, during which food was gradually increased. During the diet, the participants lost an average of 25% of their body weight. The results were carefully documented, particularly the psychological effects. - The investigators found that the participants became preoccu- pied with food and eating. Conversations, reading, and daydreams revolved around food. Many began to collect recipes and to hoard food-related items. If cultural pressures to be thin are as important as they seem to be in triggering eating disorders, then such disorders would be expected to occur where these pressures are particularly severe, which is just what happens to ballet dancers, who are under extraordinary pressures to be thin. 2. - some differences in inter- actions within the families of girls with disordered eating in comparison with control families. Basically, mothers of girls with disordered eating seemed to act as "society's messengers" in wanting their daughters to be thin, at least initially (Steinberg & Phares, 2001). They were likely to be dieting themselves and, gen- erally, were more perfectionistic than comparison mothers in that they were less satisfied with their families and family cohesion Whatever the preexisting relationships, after the onset of an eating disorder, particularly anorexia, family relationships can deteriorate quickly. Nothing is more frustrating than watching your daughter starve herself at a dinner table where food is plentiful. Educated and knowledgeable parents, includ- ing psychologists and psychiatrists with full understanding of the disorder, have reported resorting to physical violence

1. - medical consequences Chronic bulimia with purging has a number of medical conse- quences (Mehler, Birmingham, Crow, & Jahraus, 2010; Russell, 2009). One is salivary gland enlargement caused by repeated vom- iting, which gives the face a chubby appearance. 2. - associated Psychological disorders - An individual with bulimia usually presents with additional psy- chological disorders, particularly anxiety and mood disorders (Steiger et al., 2013; Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011; Sysko & Wilson, 2011). Results from a defini- tive national survey on the prevalence of eating disorders and associated psychological disorders found that 80.6% of individuals 66% of adolescents with bulimia presented with a co-occurring anxiety disorder when interviewed (Swanson et al., 2011). But patients with anxiety disorders, on the other hand, do not necessarily have elevated rates of eating disorders (Schwalberg, Barlow, Alger, & Howard, 1992). Mood disorders, particularly depression,

1. - This was notice- able with Phoebe. Repeated vomiting also may erode the dental enamel on the inner surface of the front teeth as well as tear the esophagus. More important, continued vomiting may upset the chemical balance of bodily fluids, including sodium and potas- sium levels. This condition, called an electrolyte imbalance, can result in serious medical complications if unattended, includ- ing cardiac arrhythmia (disrupted heartbeat), seizures, and renal (kidney) failure, all of which can be fatal. Surprisingly, young women with bulimia also develop more body fat than age- and weight-matched healthy controls (Ludescher et al., 2009), the very effect they are trying to avoid! Normalization of eating habits will quickly reverse the imbalance. Intestinal problems resulting from laxative abuse are also potentially serious; they can include severe constipation or permanent colon damage. Finally, some individu- als with bulimia have marked calluses on t 2. - also commonly co-occur with bulimia, with about 20% of bulimic patients meeting criteria for a mood disorder when interviewed, and between 50% and 70% meeting criteria at some point during the course of their disorder (Hudson et al., 2007; Swanson et al., 2011). For a number of years, one prominent theory suggested that eating disorders are simply a way of expressing depression. But most evidence indicates that depressionfollowsbulimia and may be a reaction to it (Brownell & Fairburn, 1995; Steiger et al., 2013). Finally, substance abuse commonly accompanies bulimia nervosa. For example, Hudson and colleagues (2007) reported that 36.8% of individuals with bulimia and 27% of individuals with anorexia were also substance abusers when interviewed, with even higher lifetime rates of substance abuse.

1. 1. Directed masturbation 2. Treatment • Erectile dysfunction

1. - Use of dilators for vaginismus, to have less pain when penis is inserted - Exposing people to erotic material for low sexual desire problems - Combination of strategies usually used! 2. 1. Viagra § Many side effects, e.g., frequent, and severe headaches 2. Vasodilating drug injections § Erection lasts 1-4 hours, may cause pain 3. Vacuum device therapy § Can feel awkward during sexual activity § 75% report this works, quite effective 1. Penile prosthesis or implants, for thse who have jas it removed - No medications are consistently helpful for sexual dysfunction in women

1. - Disordered Eating Patterns in Cases of Obesity There are two forms of maladaptive eating patterns in people who are obese. The first is binge eating, and the second isnight eat- ing syndrome(Lundgren, Allison, & Stunkard, 2012; Vander Wal, 2012). 2. - Causes Henderson and Brownell (2004) make a point that this obesity epidemic is clearly related to the spread of modernization. In other words, as we advance technologically, we are getting fat- ter. That is, the promotion of an inactive, sedentary lifestyle and the consumption of a high-fat, energy-dense diet is the larg- est single contributor to the obesity epidemic (Caballero, 2007; Levine et al., 2005).

1. - We discussed BED earlier in the chapter, but it is important to note that only a minority of patients with obesity, between 7% and 19%, present with patterns of binge eating. - More interesting is the pattern of night eating syndrome that occurs in between 6% and 16% of obese individuals seeking weight-loss treatment but in as many as 55% of those with extreme obesity seeking bariatric surgery (discussed later; Colles & Dixon, 2012; Lamberg, 2003; Sarwer, Foster, & Wadden, 2004; Stunkard, Allison, & Lundgren, 2008). In the morning, however, they are not hungry and do not usually eat breakfast. These individuals do not binge during their night eating and seldom purge. Occa- sionally, nonobese individuals will engage in night eating, but the behavior is overwhelmingly associated with being overweight or obese (Gallant, Lundgren, & Drapeau, 2012; Lundgren et al., 2012; Striegel-Moore et al., 2010). Notice the relationship of night eating syndrome with increasing levels of obesity inEFigure 8.8 (Colles, Dixon, & O'Brien, 2007). This condition is not the same as the nocturnal eating syndrome described later in the chapter in the section about sleep disorders. 2.- Kelly Brownell (2003; Brownell et al., 2010) notes that in our modern society, individuals are continually exposed to heavily advertised, inexpensive fatty foods that have low nutritional value. as the "toxic environment" (Schwartz & Brownell, 2007). He notes that the best example of this phenomenon comes from a classic study of the Pima Indians from Mexico. A portion of this tribe of Indians migrated to Arizona relatively recently. Examining the result of this migration, Ravussin, Valencia, Esparza, Bennett, and Schulz (1994) determined that Arizona Pima women consumed 41% of their total calories in fat on the average and weighed 44 pounds on average more than Pima women who stayed in Mexico, who consumed 23% of their calories from fat. Because this relatively small tribe retains a strong genetic similarity, it is likely that the "toxic environment" in the more modern United States has con- tributed to the obesity epidemic among the Arizona Pima women.

1. Specify if: 2. Sexual Sadism Disorder 3. Sexual Masochism and Sadism Disorders Examples include

1. - With asphyxiophilia, is why kept in dsm 5 Arousal by restricting breathing 2. A. Over a period of at least 6 months, recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors. B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 3. physical bondage, blindfolding, spanking, whipping, electric shocks, cutting, humiliation (being urinated or defecated on, being forced to wear a collar like a dog or put on display naked), taking the role of a slave and submitting to orders and commands'- slave vs. master, whipping, cutting, humiliation - Diagnosis usually occurs in personal or relationship distress

1. - An Integrative Model - Although the three major eating disorders are identifiable by their unique characteristics, and the specific diagnoses have some valid- ity, it is becoming increasingly clear that all eating disorders have much in common in terms of causal factors. It may be more useful to lump the eating disorders into one diagnostic category, sim- ply noting which specific features occur, such as dietary restraint, bingeing, or purging. R - ndividuals with eating disor- ders may have some of the same biological vulnerabilities (such as being highly responsive to stressful life events) as individuals with anxiety disorders (Kendler et al., 1995; Klump et al., 2014; Rojo, Conesa, Bermudez, & Livianos, 2006). Anxiety and mood disor- ders are also common in the families of individuals with eating

1. - and negative emotions, along with "mood intolerance," seem to trigger binge eating in many patients. In addition, as you will see, drug and psychological treatments with proven effectiveness for anxiety disorders are also the treat- ments of choice for eating disorders. Indeed, we could conceptual- ize eating disorders as anxiety disorders focused exclusively on a fear of becoming overweight. In any case, it is clear that social and cultural pressures to be thin motivate significant restriction of eating, usually through severe dieting. Remember, however, that many people, including adolescent females, go on strict diets, but only a small minority develops eating disorders, so dieting alone does not account for the disorders. It is also important to note that the social interac- tions in high-achieving families play at least some role. An empha- sis in these families on looks and achievement, and perfectionistic tendencies, may help establish strong attitudes about the overrid- ing importance of physical appearance to popularity and success, attitudes reinforced in peer groups. These attitudes result in an exaggerated focus on body shape and weight. Finally, there is the question of why a small minority of individuals with eating dis- orders can control their intake through dietary restraint, result- ing in alarming weight loss (anorexia), whereas the majority are unsuccessful at losing weight and compensate in a cycle of binge- ing and purging (bulimia; Eddy et al., 2002; Eddy et al., 2008). These differences, at least initially, may be determined by biol- ogy or physiology, such as a genetically determined disposition to be somewhat thinner initially.

1. - Immigrants to the United States in general more than doubled their prevalence of obesity from 8% to 19% after at least 15 years of living in this country ( - n average, genetic contributions may constitute a smaller portion of the cause of obe- sity than cultural factors, but it helps explain why some people become obese and some don't when exposed to the same envi- ronment. For example, genes influence the number of fat cells an individual has, the likelihood of fat storage, saiety, and, most likely, activity levels 2. - Treatment - The treatment of obesity is only moderately successful at the indi- vidual level (Bray, 2012; Ludwig, 2012), with somewhat greater long-term evidence for effectiveness in children compared to adults (Sarwer et al., 2004; Waters et al., 2011). Treatment is usually organized in a series of steps from least intrusive to most intrusive depending on the extent of obesity. The first step is usually a self- directed weight-loss program in individuals who buy a popular diet book. The most usual result is that some individuals may lose some weight in the short term but almost always regain that weight (Mann, Tomiyama, & Ward, 2015). Furthermore, these books do l

1. - because it takes a "toxic" environment to turn on these genes. Physiological processes, particularly hormonal regulation of appe- tite, play a large role in the initiation and maintenance of eating and vary considerably from individual to individual ( - Psychological processes of emotional regulation (for example, eating to try to cheer yourself up when you're feeling down), impulse control, attitudes and moti- vation toward eating, and responsiveness to the consequences of eating are also impor- tant (Blundell, 2002; Stice, Presnell, Shaw, & Rohde, 2005). In some lower income groups, particularly African American communities, unhealthy eating and drink- ing in readily available fast food outlets actually does seem to reduce stress, but with damaging physical consequences 2. - ). The Atkins diet did seem safe in these studies, contrary to some previous assumptions about car- bohydrate restrictions. - The next step is commercial self-help programs such as Weight Watchers and Jenny Craig. Weight Watchers reports that, in 2014, more than 800,000 people attended more than 36,000 meetings weekly around the world (Weight Watchers International, 2014). These programs stand a better chance of achieving some success, at least compared with self-directed programs (Jakicic et al., 2012; Johnston, Rost, Miller-Kovach, Moreno, & Foreyt, 2013; Wing, 2010). In an earlier study (Heshka et al., 2003) among members who successfully lost weight initially and kept their weight off for at least 6 weeks after completing the program, between 19% and 37% weighed within 5 pounds of their goal weight at least 5 years after treatment (Lowe, Miller-Kovach, Frie, & Phelan, 1999; Sarwer et al., 2004). But this means that up to 80% of individuals, even if they are initially successful, are not successful in the long run

1. - anorexia nervosa In anorexia, the most important initial goal is to restore the patient's weight to a point that is at least within the low-normal range (American Psychiatric Association, 2010b). If body weight is below approximately 75% of the average healthy body weight for a given individual, or if weight has been lost rapidly and the individ- ual continues to refuse food, inpatient treatment is recommended (Schwartz, Mansbach, Marion, Katzman & Forman, 2008; Russell, 2009) because severe medical complications, particularly acute cardiac failure, could occur if weight is not restored immediately. I 2. - Restoring weight, although often a difficult task, is probably the easiest part of treatment. Clinicians who treat patients in dif- ferent settings, as reported in a variety of studies, find that at least 85% will be able to gain weight. The gain is often as much as a half- pound to a pound a day until weight is within the normal range. Knowing they cannot leave the hospital until their weight gain is adequate is often sufficient to motivate adolescents with anorexia (Agras, Barlow, Chapin, Abel, & Leitenberg, 1974). Julie gained about 18 pounds during her 5-week hospital stay. We

1. - difficult task, is probably the easiest part of treatment. Clinicians who treat patients in dif- ferent settings, as reported in a variety of studies, find that at least 85% will be able to gain weight. The gain is often as much as a half- pound to a pound a day until weight is within the normal range. Knowing they cannot leave the hospital until their weight gain is adequate is often sufficient to motivate adolescents with anorexia (Agras, Barlow, Chapin, Abel, & Leitenberg, 1974). Julie gained about 18 pounds during her 5-week hospital stay. Weight gain is very important, since starvation induces loss of gray matter and hormonal dysregulation in the brain (Mainz et al., 2012), changes that are reversible when normal weight is restored. - anorexia nervosa 2. - Second, attitudes toward body shape and image distor- tion are discussed at some length in family sessions. Unless the therapist attends to these attitudes, individuals with anorexia are likely to face a lifetime preoccupation with weight and body shape, struggle to maintain marginal weight and social adjust- ment, and be subject to repeated hospitalization. Family therapy directed at the goals mentioned above seems effective, particu- larly with young girls (less than 19 years of age) with a short his- tory of the disorder (Eisler et al., 2000; Lock, le Grange, Agras, & Dare, 2001). Until recently, the long-term results of treatment for anorexia have been more discouraging than for bulimia, with substantially lower rates of full recovery than for bulimia over a 7.5-year period (Eddy et al., 2008; Herzog et al., 1999). But this may be changing. - In a recent important clinical trial, 121 adoles- cents with anorexia received 24 sessions of either family-based -- In a recent important clinical trial, 121 adoles- cents with anorexia received 24 sessions of either family-based - atment (FBT) in which the parents became intimately involved in the treatment program with a focus on facilitating weight gain, or individual psychotherapy. At treatment conclusion, 42% met criteria for remission in the FBT condition and 49% at a one year follow up, compared with 23% at both points in time in the individual psychotherapy condition (Lock et al., 2010). A subse-

1. - Bulimia Nervosa - You are probably familiar with bulimia nervosa from your own experience or a friend's. It is one of the most common psychologi- cal disorders on college campuses. - clinical description - The hallmark of bulimia nervosa is eating a larger amount of food—typically, more junk food than fruits and vegetables—than most people would eat under similar circumstances (Fairburn & Cooper, 1993; 2014). Patients with bulimia readily identify with this description, even though the actual caloric intake for binges varies significantly from person to person (Franko, Wonderlich, Little, & Herzog, 2004). Just as important as the amount of food eaten is that the eating is experienced as out of control (Fairburn & Cooper, 2014; Sysko & Wilson, 2011), a criterion that is an integral part of the definition of binge eating. Another important criterion is that the individual attempts tocompensate

1. - individual attempts to compensate for the binge eating and potential weight gain, almost always by purging techniques. Techniques include self-induced vomiting immediately after eating, as in the case of Phoebe, and using laxatives (drugs that relieve constipation) and diuret- ics (drugs that result in loss of fluids through greatly increased frequency of urination). Some people use both methods; others attempt to compensate in other ways. Some exercise excessively (although rigorous exercising is more usually a characteristic of anorexia nervosa; Davis and colleagues (1997), found that 57% of a group of patients with bulimia nervosa exercised exces- sively while 81% of a group with anorexia did). Others fast for long periods between binges. Bulimia nervosa was subtyped in DSM-IV-TR into purging type (e.g., vomiting, laxatives, or diuretics) or nonpurging type (e.g., exercise and/or fasting). But the non- purging type has turned out to be quite rare, accounting for only 6% to 8% of patients with bulimia (Hay & Fairburn, 1998; Striegel- Moore et al., 2001). Furthermore, these studies found little evidence of any differences between purging and nonpurging types of bulimia,

1. Paraphilic Disorders • Nature of paraphilic disorders 2. Paraphilia is only considered disordered when the individual: 3. Paraphilic Disorders • If a person feels guilty and ashamed about a paraphilia because 4. Paraphilic Disorders stats

1. - misplaced sexual attraction and arousal -Focused on inappropriate people or objects -Often multiple paraphilic patterns of arousal -Manifest in fantasies, urges, arousal or behaviors 2. • Experiences clinically significant distress or impairment OR • Acts on urges with a nonconsenting person - Like transvestic dsorder , not hurrying anuone but ashamed so need diagnosis? 3. they have internalised society's stigma about the behaviour - does this warrant a diagnosis - even when their behaviour does not inflict on others? 4. - Few reliable prevalence statistics; not a lo of structured clinical intervies, legal repercussions 1. Focussing on crime statistics likely underestimates prevalence - High comorbidity among paraphilias - High comorbidity with anxiety, mood, substance use

1. - associated Psychological disorders As with bulimia nervosa, anxiety disorders and mood disor- ders are often present in individuals with anorexia (Agras, 2001; Russell, 2009; Sysko & Wilson, 2011), with rates of depression 2.- Binge-Eating Disorder Beginning in the 1990s, research focused on a group of individuals who experience marked distress because of binge eating but donotengage in extreme compensatory behaviors and therefore cannot be diagnosed with bulimia (Castonguay, Eldredge, & Agras, 1995; Fairburn et al., 1998). These individuals have binge-eating disor- der (BED). After classification inDSM-IVas a disorder needing further study, BED is now included as a full-fledged disorder inDSM-5(Wonderlich, Gordon, Mitchell, Crosby, & Engel, 2009). Evidence that supports its elevation to disorder status includes somewhat different patterns of heritability compared with other eating disorders

1. - obsessive-compulsive disorder (OCD) (see Chapter 5; Cederlöf et al., 2015; Keel et al., 2004; Kaye et al., 2014). In anorexia, unpleasant thoughts are focused on gaining weight, and individuals engage in a variety of behaviors, some of them ritualistic, to rid themselves of such thoughts. Future research will determine whether anorexia and OCD are truly similar or simply resemble each other. Substance abuse is also common in individuals with anorexia nervosa 2. - somewhat different patterns of heritability compared with other eating disorders (Bulik et al., 2000), as well as a greater likeli- hood of occurring in males and a later age of onset. There is also a greater likelihood of remission and a better response to treatment in BED compared with other eating disorders - Individuals who meet preliminary criteria for BED are often found in weight-control programs. For example, Brody, Walsh, and Devlin (1994) studied mildly obese participants in a weight- control program and identified 18.8% who met criteria for BED. t criteria (see, for example, Spitzer et al., 1993). But Hudson and colleagues (2006) concluded that BED is a disor- der caused by a separate set of factors from obesity without BED and is associated with more severe obesity. The general consensus is that about 20% of obese individuals in weight-loss programs engage in binge eating, with the number rising to approximately 50% among candidates for bariatric surgery (surgery to correct severe or morbid obesity). Fairburn, Cooper, Doll, Norman, and O'Connor (2000) identified 48 individuals with BED and were able to prospectively follow 40 of them for 5 years. The prognosis was relatively good for this group, with only 18% retaining the full diagnostic criteria for BED at a 5-year follow-up.

. - Major Types of Eating Disorders - Although some disorders we discuss in this chapter can be deadly, many of us are not aware they are widespread among us. They began to increase during the 1950s or early 1960s and have spread insidiously over the ensuing decades. In bulimia nervosa, out-of- control eating episodes, or binges, are followed by self-induced vomiting, excessive use of laxatives, or other attempts to purge (get rid of) the food. In anorexia nervosa, the person eats only mini- mal amounts of food or exercises vigorously to offset food intake so body weight sometimes drops dangerously. In binge-eating disorder, individuals may binge repeatedly and find it distressing, but they do not attempt to purge the food. The chief characteristic of these related disorders is an overwhelming, all-encompassing drive to be thin. Of the people with anorexia nervosa who are fol- lowed over a sufficient period, up to 20% die as a result of their disorder, with slightly more than 5% dying within 10 years From 20% to 30% of anorexia 2. - Eating disor- ders tend to occur in a relatively small segment of the population. More than 90% of the severe cases are young females who live in a socially

1. - population (Agras, 2001; Arcelus, Mitchell, Wales, & Nielsen, 2011; Chavez & Insel, 2007). Suicide attempts are very common among people with eating disorders, affecting between 30% to 40% of patients at least once during their lifetime ( - Between 1975 and 1986, the referral rates for anorexia rose slowly, but the rates for bulimia rose dramatically—from virtually none to more than 140 per year. Similar findings have been reported from other parts of the world (Hay & Hall, 1991; Lacey, 1992), although more recent surveys suggest that rates for bulimia may be leveling off or even beginning to drop from highs reached in the 1990s (Keel, Heatherton, Dorer, Joiner, & Zalta, 2006). Nevertheless, a large-scale population survey (Hudson, Hiripi, Pope, & Kessler, 2007) continues to show a higher prevalence of eating disorders in younger age groups born between 1972 and 1985 than for older age groups, particularly for bulimia. 2. - e very specificity of these disorders in terms of sex and age is unparalleled and makes the search for causes all the more interesting. In these disorders, unlike most others, the strongest contributions to etiology seem to be sociocultural rather than psy- chological or biological factors. 3. - But this table is useful for most people and is in use around the world. In this chapter, we focus on serious undernourish- ment (BMI less than 18.5), as well as obesity (BMI 30 or greater). - e more overweight someone is at a given height, the greater the risks to health (Convit, 2012). These risks are widespread and involve greatly increased prevalence of cardiovascular disease, dia- betes, hypertension, stroke, gallbladder disease, respiratory disease, muscular skeletal problems, and hormone-related cancers (Convit, 2012; Flegal, Graubard, Williamson, & Gail, 2005; Henderson & Brownell, 2004). And more recent evidence indicates that these risks may be even greater than previously thought (Stokes & Preston, 2015). Obesity is included in this chapter, because it is produced by the consumption of a greater number of calories than are expended in energy.

1. - They assumed from the study that these friendship cliques are significantly associated with individual body image concerns and eating behaviors. In other words, if your friends tend to use extreme dieting or other weight-loss techniques, there is a greater chance that you will, too (Hutchinson & Rapee, 2007). A recent, more definitive study con- cludes that while young girls do tend to share body image concerns, endship cliques do not necessarily cause these atti- tudes or the disordered eating that follows. Rather, adolescent girls s 2. Why does dieting cause weight gain? Cottone and colleagues (2009) began feeding rats junk food, which the rats came to love, instead of a boring diet of pellets. They then withdrew the junk food but not the pellets.

1. - simply tend to choose friends who already share these attitudes (Rayner, Schniering, Rapee, Taylor, & Hutchinson, 2012). Nevertheless, any attempts to treat eating disorders must take into account the influence of the social network in maintaining these attitudes. - horrence of fat can have tragic consequences. In one early study, toddlers with afflu- ent parents appeared at hospitals with "failure to thrive" syndrome, in which growth and devel- opment are severely retarded - equate nutrition. In each case, the parents had put their young, healthy, but somewhat chubby toddlers on diets in the hope of preventing obesity at a later date (Pugliese, Weyman-Daun, Moses, & Lifshitz, 1987). Mothers who have anorexia restrict food intake in not only themselves but also their children, sometimes to the detriment of their children's health (Russell, 2009). 2. - Based on observations of brain function com- pared with rats who never had junk food, it was clear that these rats became extremely stressed and anxious. Furthermore, the "junk food" rats began eating more of the pellets than the control group; which then seemed to relieve the stress. Thus, repeated cycles of "dieting" seems to produce stress-related withdrawal symptoms in the brain, much like other addictive substances, resulting in more eating than would have occurred without dieting. - ping an eating disorder were already binge eating and purging, were eating in secret, expressed a desire to have an empty stomach, were preoccupied with food, and were afraid of losing control over eating.

1. - Statistics - Clear cases of bulimia have been described for thousands of years (Parry-Jones & Parry-Jones, 2002), but bulimia nervosa was rec- ognized as a distinct psychological disorder only in the 1970s Among those who present for treatment, the overwhelming majority (90% to 95%) of individuals with bulimia are women. 2. Among women, adolescent girls are most at risk.

1. - with bulimia have a slightly later age of onset, and a large minority are predominantly gay males or bisexual (Matthews- Ewald, 2014; Rothblum, 2002). For example, Carlat, Camargo, and Herzog (1997) accumulated information on 135 male patients with eating disorders who were seen over 13 years and found that 42% were either gay males or bisexual, a far higher rate of eating disorders than found in heterosexual males (Feldman & Meyer, 2007). Male athletes in sports that require weight regulation, such as wrestling, are another large group of males with eating disorders More recent studies suggest the incidence among males is increasing (Dominé, Berchtold, Akré, Michaud, & Suris, 2009) with one study showing 0.8% of a large group of males having at least some of the symptoms of bulimia with another 2.9% having at least some of the symptoms of BED (Field et al., 2014). Interestingly, the gender imbalance in bulimia was not always present. Historians of psychopathology note that for hundreds 2. - A prospec- tive 8-year survey of 496 adolescent girls reported that more than 13% experienced some form of eating disorder by the time they were 20 (Stice, Marti, Shaw, & Jaconis, 2009; Stice et al., 2013). In another elegant prospective study, eating-related problems of 1,498 freshmen women at a large university were studied over the 4-year college experience. Only 28% to 34% had no eating- related concerns. But 29% to 34% consistently attempted to limit their food intake because of weight/shape concerns; 14% to 18% engaged in overeating and binge eating; another 14% to 17% com- bined attempts to limit intake with binge eating; and 6% to 7% had pervasive bulimic-like concerns.

1. Specifiers 2. Characteristics 3. - Some rationalise behaviour

1. --exclusive type (attracted only to children) or nonexclusive type --sexually attracted to males --sexually attracted to females --sexually attracted to both -Specify if: Limited to incest 2. -In some cases, pedophilic urges are limited to incest (i.e., young members of one's own family);1. May be a difference between incestuous and non-incestuous paedophilia -Incestuous males may be aroused by adult women -Male pedophiles are usually not aroused by adult women;- non-incestuous paedophiles less likely to be aroused by adult women -Generally molest children they know -Physically force rarely used as they violate trust of the victim 3. • E.g., consider pedophilic activity to be an act of affection or a teaching experience • Often engage in other moral compensatory behavior;- doing good deeds to make up for not

1. Causes of Paraphilia Disorders 2. Conditioning 3. Theory: In restrictive household,

1. -2/3 of sex offenders have a history of child sexual abuse -Heightened impulsivity combined with poor emotion regulation -Hostile attitudes and lack of empathy toward women (related to nonconsensual behaviours with women) -Cognitive distortions (e.g., the woman wants me to see her undress, the child wants me to teach him about sex, she deserved to be taught a lesson 1. justifying behaviours, "they wanted it") -High sex drives;. Some cases will masturbate as frequently as they possibly can, every 30nminuytd 2. • Stimuli and sexual fantasies present during masturbation may become paired with sexual arousal 3. 1. In restrictive household, one's own young body is paired with masturbation (as there is nothing to masturbate to), so then lead to m=buen turned on oto young babies as an adult § May also explain other types of paraphilic disorders § However, may not be correct. E.g., Sambians don't engage in homosexual behaviours after marriage (but perhaps still think about them?)

1. Bulimia Nervosa • Consequences 2. Anorexia Nervosa

1. -Less lethal than anorexia nervosa BUT twice the mortality rate found in comparably aged peers without BN -Purging methods can result in severe medical problems -Erosion of dental enamel, mouth ulcers -Swollen salivary glands that lead to a puffy face -Electrolyte imbalance -Kidney failure, cardiac arrhythmia, seizures, intestinal problems, permanent colon damage -also menstruation loss???check "One common medical complication of anorexia nervosa is cessation of menstruation (amenorrhea), which also occurs relatively often in bulimia." "If vomiting is part of the anorexia, electrolyte imbalance and resulting cardiac and kidney problems can result, as in bulimia." 2. A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

1, Family Factors 2. Psychological Factors 3. Behavioural Factors • Dieting 4. Eating Disorders are Multiply Determined

1. -Parents with distorted perception of food and eating may restrict children's intake too (e.g., put chubby toddlers on unnecessary diets) -Perfectionistic parents -Families of individuals with anorexia are often: -High achieving with high expectations -Concerned with external appearances -Overly motivated to maintain harmony > leads to poor communication and denial of problems -Highly critical of family members' shape, weight, and eating 2. Internalized the thin ideal -Negative body image Perfectionism -Negative emotionality;- when feel bad become overl self-citical -Distress intolerance;- ; m,ore inclined to engage in compensatory beaviours g help feeling sad -Heightened sensitivity to rewards 3. Behavioural Factors - Dieting; lead to hunger , an lead to bibges due to setpoint byond what we need to energy expendutior 5. psych, bio and social influences -bio are -inherited vulnerability (unseat\

1. - ; Avoidant/Restrictive Food Intake Disorder RFID 2. specified disorders

1. 1. Persistent failure to meet food or energy needs 2. May be due to disinterest, avoidance of sensation, concern of consequences 2. - Other Specified Feeding or Eating Disorder and Unspecified Feeding and Eating Disorder 1. Used to categorise eating disorder when not meeting full criteria for anything else 2. Other Specified: Used when one understands why someone doesn't meet full criteria 3. Unspecified: Used when it is unknown why someone doesn't meet full criteria

1. - Substance/medication-induced sexual dysfunction 2. Other Specified Sexual Dysfunction 3. Unspecified Sexual Dysfunction 4. TABLE SLIDE 17 WEEK8 CATEGORy of dysfunction; Sexual interest, desire, and arousal 5. Orgasm 6. sexual pain

1. 1. When symptoms are experienced due to substance exposure/withdrawal 2. Must be due to a medication where sexual dysfunction is a known side effect 2. 1. Experience dysfunction which causes impairment, but not all criteria are met for a disorder 3. 1. When it is not known why the individual doesn't meet criteria - needs further assessment - Pain ojly fr mfemale sperhaps because males don't seek treatment 2. females-Female sexual interest arousal disorder males -Male hypoactive sexual desire disorder -Erectile disorder 5. Female orgasmic disorder -for males its -Premature ejaculation disorder -Delayed ejaculation disorder 6. Genito-pelvic pain/penetration disorder for females

1. - Criticisms of the cycle 2. Not always the case.... Symptoms of sexual dysfunction among 20,000 individuals for at least 2 of the past 12 mos

1. 1. Women report desire stage happens at same time as arousal, and 1/3 of women report arousal stage happens before desire stage 2. Men's subjective and biological arousal go hand-in-hand penis more aroused as self-repotrt of arousal goes up; women have less correlation between biological (blood moving; swelling) and sexual arousal (mental state) Sexual dysfunction common 2. • 43% of women • 31% of men 1. Reported some dusfunction on one of the stages - Problems with arousal/ejaculation -Another study found 40% of men had some difficulty with erection/ejaculation, 63% of women had problems with arousal/orgasm -Disorders only made when symptom cause distress/impairment • 11-23% of women reported both dysfunction and distress

1. bulimia nervosa criteria

1. 2. A. Recurrent episodes of binge eating. An episode is characterized by: 1. Eating, in a discrete period of time, an amount of food that is definitely larger than what most other individuals who eat in a similar period of time under similar circumstances 2. A sense of lack of control over eating during the episode B. Recurrent inappropriate compensatory behavior in order to prevent weight gain;such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur on average at least once a week for 3 months D. Self-evaluation is unduly influenced by body shape and weight E. Disturbance does not occur exclusively during anorexia Specifiers: in partial remission;After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time. , in full remission; After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time. Specify severity: mild, moderate, severe, extreme

1. Prevalence 2. Sadistic Rape 3. Pedophilic Disorder criteria

1. 5-10% of people may engage in some S&M so not all that "abnormal" -Diagnosis usually occurs in the context of personal or relationship distress- Usually one partjner with masogish and other sadism 2. Some rapists are sadists, but most are not -Most rapists do not show paraphilic patterns of arousal -Rapists tend to show sexual arousal to violent sexual and non-sexual material 3. A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger). B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty. The individual is at least age 16 years and at least 5 years older than the child or children in C. Criterion A. Note: Do not include an individual in late adolescence involved in an ongoing sexual relationship with a 12- or 13-year-old.

1. erectile disorder prevalence 2, Erectile Disorder Gary has sought treatment at a sex therapy clinic because he has difficulty maintaining an erection when having sex with his wife. He experiences initial interest in having sex, but then quickly loses interest almost immediately upon entering his wife. He did not have this issue when he first started dating his wife. During his interview, Gary admitted that he and his wife do not communicate well and that he feels they spent too much time together. He doesn't know how to tell her that he wants to spend more time with his friends and this causes him stress. 3. Female Orgasmic Disorder

1. 50-60% of men may experience at least occasional erectile dysfunction -Prevalence increases with age 2. - mstressor going on in , pick out main sumptoms of these disorders, rule out factors also known as contributors ti these priblems so don't want to not give them diagnosis due to not getting treatment 3. A. Presence of either of the following symptoms and experienced on almost all or all (approximately 75%-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts): -Marked delay in, marked infrequency of, or absence of orgasm. -Markedly reduced intensity of orgasmic sensations. B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months. C. The symptoms in Criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

1. Gender Dysphoria (Adolescents and Adults)

1. A. A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months' duration, as manifested by at least two of the following: 1. A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics). 2. A strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one's experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics). 3. A strong desire for the primary and/or secondary sex characteristics of the other gender. 4. A strong desire to be of the other gender (or some alternative gender different from one's assigned gender). 5. A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender). 6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender). -B. The condition is associated with clinically significant distress or impairment in social, occupational, or other areas of functioning

1. Delayed Ejaculation Disorder criteria 2. prevalence

1. A. Either of the following symptoms must be experienced on almost all or all occasions (approximately 75%-100%) of partnered sexual activity (in identified situational contexts or, if generalized, in all contexts), and without the individual desiring delay: -Marked delay in ejaculation. -Marked infrequency or absence of ejaculation. B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months. C. The symptoms in Criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/ medication or another medical condition. 2. • Affects <1% of all adult males

1. Female Sexual Interest/Arousal Disorder criteria 2. prevalence

1. A. Lack of or significantly reduced sexual interest/arousal, as manifested by 3+ of the following: - Absent/reduced sexual activity - Absent/reduced sexual/erotic thoughts or fantasies - No/reduced initiation of sexual activity, and typically unreceptive to a partner's attempt to initiate - Absent/reduced sexual excitement/pleasure during sexual activity in 75-100% of sexual encounters - Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues - Absent/reduced genital or nongenital sensations during sexual activity in 75-100% of sexual encounters C. The symptoms have persisted for a minimum duration of approximately 6 mos. D. The symptoms cause clinically significant distress in the individual. E. The symptoms are not better accounted for by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition. 2. - 24-43% of women may experience disinterest in sex for multiple months - Unsure what 6m+ prevalence is

1. Exhibitionistic Disorder criteria 2.Specify if: 3. Characteristics

1. A. Over a period of 6 mos, recurrent and intense sexual arousal from the exposure of one's genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviours B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 2. --sexually aroused by exposing genitals to prepubertal children -- sexually aroused by exposing genitals to physically mature individuals --sexually aroused by exposing genitals to prepubertal children and physically mature individuals 3. -Element of thrill and risk is necessary for sexual arousal -Desire to shock the individual -Most masturbate during the exposure - Might be a compulsion 1. Repeated exposure in the same place at the same time of day 2. Feel remorseful afterwards, similar to OCD, in ocd though anciety before

1. Transvestic Disorder criteria 2, Specify if: 3. Characteristics 4. Sexual Masochism Disorder criteria

1. A. Over a period of at least 6 months, recurrent and intense sexual arousal from cross-dressing, as manifested by fantasies, urges, or behaviors. B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 2. --with fetishism -- with autogynephilia;1. Arousal by thoughts/images of self as female 3. - Individuals are usually married, and spouse knows of behaviour - Rarely involves non-consent - ***Rarely involves impairment, so why is it a disorder 4. A. Over a period of at least 6 months, recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges, or behaviors. B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

1. Genito-Pelvic Pain/Penetration Disorder criteria 2. prevalence

1. A. Persistent or recurrent difficulties with one (or more) of the following: - Vaginal penetration during intercourse. - Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts. -Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration. -Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration. B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months. C. The symptoms in Criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of a severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition. 1. Must go through extensive medical examination to make sure its noy lack of lubrication or not n=infection that's causeing it 2, The prevalence of genito-pelvic pain/penetration disorder is unknown. However, approximately 15% of women in North America report recurrent pain during intercourse

1. Binge Eating Disorder

1. A. Recurrent episodes of binge eating. An episode is characterized by: 1. Eating, in a discrete period of time, an amount of food that is definitely larger than what most other individuals who eat in a similar period of time under similar circumstances 2. A sense of lack of control over eating during the episode B. Binge eating is associated with 3 or more: 1. Rapid eating 2. Eating until uncomfortably full 3. Eating when not physically hungry 4. Eating alone due to embarrassment 5. Feelings of disgust/guilt/depression afterwards;- Maybe highly ritualistic oatterbs, watch something, get to supermarke C. Marked distress regarding the binge eating D. Binge eating occurs on average at least 1 day/week for 3 months E. No AN or BN or inappropriate compensatory behavior

1. Model for the Development of Paraphilia Disorders 2. Treatment of Paraphilia Disorders

1. Accidental or vicarious sexual associations, possible inadequate development consensual adult arousal patterns, possible inadequate development of appropriate social skills for relating to adults or even possible inadequate development of appropriate social skills for relating to adults all could come together to get inappropriate sexual fantasies repeatedly associated with masturbatory activities and strongly reinforced - Inhibition of undesired fantasies, arousal and behavuoiurs may increase thoughts, fantasies, behaviours -all lead to paraphilia 2. -Studies have been restricted to sex offenders and haven't used control groups or studied long-term effects;- is it better than doijng nothing is the control group bit -Many aren't motivated for treatment • Might help to encourage them to focus on the legal ramifications of their behaviour

1. Eating Disorder 2.DSM-5 Feeding and Eating Disorders 3. - Pica 4. Rumination Disorder

1. Eating Disorder: Disturbed pattern of eating impacting health or functioning Symptoms - Excessive exercise - Weight preoccupation - Abnormal electrolyte levels - Fear of gaining weight - Large food intake - Anxiety/avoidance of eating 2.-Pica -Rumination Disorder -Avoidant/Restrictive -Food Intake Disorder -Anorexia Nervosa -Bulimia Nervosa -Binge Eating Disorder -Other Specified Feeding or Eating Disorder -Unspecified Feeding and Eating Disorders 3. 1. Eating of non-food , non-nutritive substances 2. Vary with age, like paper, soap, haie , paint, coal 4. 1. Repeated regurgitation of food § Rechewed, re-swallowed, spit-out § Must be present for at least 1 month and not due to another medical condition

1. 2003: 2. Incwst 3. Current Statistics Masturbation 4. Sexual activity can and does last past age 80 5. Current Statistics - Homosexuality 6. - Penetration

1. Homosexual acts became legal 2. 1. A taboo in nearly all cultures across time § Perhaps evolutionarily adaptive 2. Not taboo in ancient Egypt where pharaohs married within the family to keep blood untainted, also maybe cause its evolutionary malaadaptive, more likely to develop defects to get 3. • M = 72% report ever masturbating • F = 42% report ever masturbating 4. • Age 75 to 85 -M = 38.5% active -F = 16.7% active 5. 1. 6% of men report homosexual behaviour in lifetime 2. 12% of women report homosexual behaviour 6. 1. Over half have had sex by 18-19 2. Over 80-85% have had sex by 20-24

1. Stage Four:

1. Maintain the changes obtained; minimise the risk of relapse -Maintain the changes obtained • Identify what problems remain • Jointly devise a specific plan for maintaining progress -Minimise the risk of relapse • Identify future "at risk" times • Being underweight • Devise a plan for dealing with setbacks 1. Reflection on what has been learnt 2. Addressing still-present problems 3. Structuring environment to prevent relapse, whay they are going to do when o back to own environ,ent § Support system, etc.

1. Characteristics 2. Fetishistic Disorder criteria 3. Specify: 4. Characteristics

1. Often occurs in crowds and/or confining situations from which the other person cannot escape • Examples: Crowded elevator or subway Not well studied 2. A. Over a period of at least 6 months, recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body part(s), as manifested by fantasies, urges, or behaviors. B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The fetish objects are not limited to articles of clothing used in cross-dressing (as in transvestic disorder) or sex toys devices specifically designed for the purpose of tactile genital stimulation (e.g., vibrator). 3. -body part(s), nonliving object(s), other 4. The presence of the fetish is strongly preferred or even necessary for sexual arousal -Examples may include rubber, hair, feet, objects such as shoes

1. Family Factors 2. Psychological Factors

1. Our families may feed us to comfort us and show us love -Social contagion • We may pick up the eating patterns of those we love - and attitudes/beliefs 2. -High fat / High carbohydrate foods comfort us when we are distressed -When rats are given a diet of cafeteria food—chocolate, cheesecake, bacon, sausage—they rapidly gain weight -They also drastically reduce how much rat chow they eat -They experience down-regulation of activity in brain reward circuits -In conditions of punishment, they continue to eat the cafeteria food 1. Insensitivity to punishment - continue to eat cafeteria food despite electric floor - More and more to satisyfy reward, tolerance increases b(exactoy what jappense with drug abuse) - Food may be addictive. Insensitivity to punishment and other-reward

1. Overweight and Obesity 2. Consequences of Overweight and Obesity 3. Causes of Overweight and Obesity

1. Overweight = BMI between 25-29 -Obese = BMI 30+ -Increasing more rapidly in children/teens -Obesity also growing rapidly in developing countries -Mortality rate close to that associated with smoking - In 2015, over 60% of people were overweight/obese in Australia 2.1. 5th leading rate of global deaths -Cardiovascular diseases -Diabetes Musculoskeletal disorders Childhood obesity • Breathing difficulties • Increased risk of fractures; osteoarthritis;- Childhood obesity increases risk of adult obesity - In childhood: in risk of • Hypertension • Early markers of cardiovascular disease • Insulin resistance • Psychological effects 3. Biological influences Sociocultural influences Family influences Psychological and behavioural influences

1. Phase I: 2. Phase II: 3. Phase IIIA: 4. Phase IIIB: 5. • Squeeze technique 6. • Masturbatory training

1. Refrain from intercourse and genital caressing— simply explore and enjoy kissing, hugging, massaging, etc § learning what eah iher likes 2. Genital pleasuring, but orgasm and intercourse or banned§ , ease people into it 3. Begin penetration—limit depth and time—continue with nongenital pleasuring § ease them into it 4. Resume full intercourse and thrusting 36 1. Many experience benefits of this treatment! 5. - Squeeze technique to help with premature ejaculation 6. - Masturbatory training to help with female orgasm disorder

1. Biological Factors 2. Sociocultural Factors

1. Relatives of people with eating disorders are 4-5x more likely to develop an eating disorder -Not clear what is inherited -May be nonspecific traits like emotional instability or impulsivity -Low levels of serotonergic activity often found in eating disorders;- could be cionsequence rather than cause of earing disorders -We may have biologically-driven set points for weight, going below these set points will increase hunger, which may drive uncontrollable binging 1. Unsure if due to low tryptophan (ingredient for serotonin) in diet, or biological - Set-Point Theory: All born with a point at which we should weigh. Going under this set-point increases hunger (leading to uncontrollable urges to eat), leass gto BN OR BED 2. -Media portrayals: thinness linked to success, happiness -Social pressures toward thinness in higher socioeconomic backgrounds -Cultural emphasis on dieting -Standards of ideal body size - Looking at models promoting AN

1. Stage Two: 2. Stage Three:

1. Review progress; identify emerging barriers to change; design -Whilst continuing with the strategies and procedures introduced in Stage One ... -Review progress and compliance with treatment -Identify emerging barriers to change -Review the formulation -Decide whether to use the "broad" form of CBT-E • Focused: Core default version of the treatment • Broad: Includes additional modules to address mood intolerance, clinical perfectionism, low self-esteem, and major interpersonal problems -Design Stage Three 2. Address the main maintaining mechanisms Whilst continuing with the strategies and procedures introduced in Stage One, address the main maintaining mechanisms operating in the individual patient's case... • Focused version of CBT-E • Over-evaluation of shape and weight • Over-evaluation of control over eating • Dietary restraint;§ Dietary restraint (intention to restrict food, regardless of success) and restriction (limiting amount/type of food) • Dietary restriction • Being underweight • Event-related changes in eating

1. Although DSM-5 criteria specify only "significantly low" body weight 15% below that expected, one study suggests that BMI averages close to 15.8 by the time treatment is sought (Be 2. AN- medical consequences

1. Shaw, Witt, & Lowe, 2013). Another key criterion of anorexia is a marked disturbance in body image. When Julie looked at herself in the mirror, she saw something different from what others saw. They saw an emaciated, sickly, frail girl in the throes of semistarva- tion. Julie saw a girl who still needed to lose at least a few pounds from some parts of her body. For Julie, her face and buttocks were the 2. common medical complication of anorexia nervosa is cessa- tion of menstruation (amenorrhea), which also occurs relatively often in bulimia (Crow, Thuras, Keel, & Mitchell, 2002). This feature can be an objective physical index of the degree of food restriction, but is inconsistent because it does not occur in all cases (Franko et al., 2004). Because of this inconsistency, amenorrhea was dropped as a diagnostic criterion in DSM-5 (Attia & Roberto, 2009; Fairburn & Cooper, 2014). Other medical signs and symp- toms of anorexia include dry skin, brittle hair or nails, and sensi- tivity to or intolerance of cold temperatures. Also, it is relatively common to see lanugo, downy hair on the limbs and cheeks. Cardiovascular problems, such as chronically low blood pressure and heart rate, can also result. If vomiting is part of the anorexia, electrolyte i

1. Specifier

1. Specify if: with a disorder of sex development -Specify if: Posttransition: The individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen—namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male; mastectomy or phalloplasty in a natal female).

1. Bulimia Nervosa, Binge-Eating Disorder, and Anorexia Nervosa 2. Statistics and Course for Eating Disorders 3. auses of Eating Disorders

1. There are three prevalent eating disorders. In bulimia nervosa, dieting results in out-of-control binge-eating episodes that are often followed by purging the food through vomiting or other means. In binge-eating disorder, a pattern of binge eating is not followed by purging. Anorexia nervosa, in which food intake is cut dramatically, results in substantial weight loss and sometimes dangerously low body weight. 2. Bulimia nervosa and anorexia nervosa are largely confined to young women in developed countries who are pursuing a thin body shape that is culturally mandated and biologically inappro- priate, making it extremely difficult to achieve. p Without treatment, eating disorders become chronic and can, on occasion, result in death. 3. Inadditiontosocioculturalpressures,causalfactorsincludepos- sible biological and genetic vulnerabilities (the disorders tend to run in families), psychological factors (low self-esteem), social anxiety (fears of rejection), and distorted body image (relatively normal-weight individuals view themselves as fat and ugly).

1. Diagnostic Crossover of Eating Disorders Common to switch between: also may go in order 2. Rehearse Your Knowledge Gemma presents as underweight (BMI = 16.5). She says that "there is nothing more important than being thin" and that any gain in weight would be "devastating". She eats barely anything and exercises intensively in order to lose weight. When asked whether she was still menstruating, she responded that whilst her periods were "light" they are still regular. • What diagnosis best fits Gemma? 3. Rehearse Your Knowledge Thomas is distressed about his loss of control around eating. Over the last 4 months, he has experienced episodes he describes like "going into a frenzy" and eats excessive amounts of food. Last night he reported having consumed an entire 4L container of ice-cream and most of a packet of Tim-Tams. Recently these episodes have become more frequent, occurring around 3-4 times per week. • What diagnosis best fits Thomas? 4. Rehearse Your Knowledge For the last 3 months Susie has become preoccupied with food and her weight. Whilst she eats 3 meals per day, she has many rules with what she can and cannot eat, and vomits after every meal. Her eating behaviour ha

1. between Anorexia Nervosa, restricting and Anorexia Nervosa, binge-eating/purging -between Anorexia Nervosa, binge-eating/purging and Bulimia Nervosa -between Bulimia Nervosa and Binge Eating Disorder - AN restricting must cross over to AN binge-eating/purging before it becomes BN or BED - Bn and bed; compensation in former - An goes to subtupe of binge eating before going to BN - ****Underlying mechanism for all disorders? Symptoms depend on context? All individuals excessively co cerned about body shaoee and weight 2. AN restricting subtype 3. probs BED 4. BN

WEEK 81. Note: Reliable prevalence estimates' 2. Historically speaking 3. Sexuality History 1940s: Kinsey & team 4.- 1960s: Masters & Johnson 5. Kaplin a

1. difficult to determine due to poor reliability in clinical interviews, interviews in abnormal populations, and general lack of research, don't teally tralk about it, research dne in small populations 2. - We know veru little about sexual behaviour , np relaiable instruments - Very personal 3. - conducted interviews if people aboit sexulauty 4. 1. observed masturbation and intercourse § Sexual response cycle - psych treatment for dysfunctions which is still used 5. 1. added to sexual response cycle, encouraged sex, researched new treatments § Later modified statement to say you need to be safe during sex § But be very cautious as sex might kill us , § Don't forget these names - Normal or abnormal depends on culture and time period

1. United States meta-analysis (2019): e 2. Associated Psychopathology Results should be viewed in context of publication year Systematic review of individuals with a gender dysphoria diagnosis (N= 577; years 2000-2014)

1. estimated 0.39% - 2.7% of population • Lower estimates from studies with adults • Higher estimates from studies with adolescents • Differing prevalence estimates may be due to factors such as treatment accessibility or social stigma preventing transition Large life expectancy differences • 2014 US report indicated the life expectancy for a transgender woman was 35 years of age - Requesting X on passport or requesting name change shows that women are much more likely to ask for these things 2. • 53.2% had a lifetime Axis I disorder • Mood disorders (42.1% lifetime) • Anxiety disorders (26.8% lifetime) • No systematic differences between men and women Depression among young people aged 12-29 (50.6% transgender, 20.6% cisgender; N=360);- Half of trans youth as depressed, n=but only 1/5th of cisgender

1. Thus, the principal focus of this protocol is on the distorted evaluation of body shape and weight, and maladaptive attempts to control weight in the form of strict dieting, possibly accompanied by binge ea 2. - Binge-eating disorder - Early studies adapting CBT for bulimia to obese binge eaters were quite successful (Smith, Marcus, & Kaye, 1992). To take one exam- ple, Agras, Telch, Arnow, Eldredge, and Marnell (1997) followed 93 obese individuals with BED for 1 year and found that immedi- ately after treatment with CBT, 41% of the participants abstained from bingeing and 72% binged less frequently. After 1 year, binge eating was reduced by 64%, and 33% of the group refrained from bingeing altogether. Importantly, those who had stopped binge eating during CBT maintained a weight loss of approximately

1. overeating such as purging, laxative misuse, etc. Fairburn refers to this treatment as cognitive-behavioral therapy- enhanced (CBT-E) 2. - 9 pounds over this 1-year follow-up period; those who continued to binge gained approximately 8 pounds. Thus, stopping binge eat- ing is critical to sustaining weight loss in obese patients, a finding consistent with other studies of weight-loss procedures - to results with bulimia, it appears that IPT is every bit as effective as CBT for binge eating. Wilfley and colleagues (2002) treated 162 overweight or obese men and women with BED with either CBT or IPT and found comparable results from each treatment. Fully 60% refrained from bingeing at a 1-year follow-up. But, in a study examining the effectiveness of the anti- depressant drug Prozac compared with CBT for BED, Prozac was ineffective (compared with placebo) and Prozac did not add any- thing to CBT when the two treatments were combined (Grilo, Masheb, & Wilson, 2005). The positive results from CBT were reasonably durable at follow up 1 year later (Grilo et al., 2012). If individuals began to respond rapidly to CBT treatment (by the 4th week), the response was particularly good, both short term and long term

1. adolescents, with the most definitive study appearing in 2007 (Hudson et al., 2007). These results from the National Comorbid- ity Survey reflect lifetime and 12-month prevalence, not only for the three major eating disorders described here but also for "sub- threshold" BED, where binge eating occurred at a high-enough frequency but some additional criteria, such as "marked distress" regarding the binge eating, were not met. Therefore, the disor- der did not meet the diagnostic "threshold" for BED. 2. The median age of onset for all eating-related disorders occurred in a narrow range

1. the study was conducted prior to the publication of DSM-5, the 3-month duration required for BED (or subthreshold BED), found in DSM-5, rather than the 6 months required in DSM-IV-TR, was used. Finally, if binge eating occurred at least twice a week for 3 months—even if it was just a symptom of the four other disor- ders in Table 8.2 rather than a separate condition— the case was listed under "Any binge eating." This latter category provides an overall picture of the prevalence of binge eating. These data are all presented in Table 8.2. As you can see, lifetime prevalence was consistently 2 to 3 times greater for females, with the exception of subthreshold BED. This sex ratio reflects a somewhat higher pro- portion of males than found in other samples, but it agrees with data from the study mentioned above by Field and colleagues, (2014) showing that some binge eating symptoms are relatively common in males. No 12-month cases of anorexia were found in this sample, but a large study in Finland based on a telephone sur- vey found a higher lifetime prevalence of anorexia of 2.2%, and half those cases had not been detected in the health-care system (Keski-Rahkonen et al., 2007) 2. - 18 to 21 years (Hudson et al., 2007), which is consistent with more recent findings (Stice et al., 2013). For anorexia, this age of onset was fairly consistent, with younger cases tending to begin at age 15, but it was more common for cases of bulimia to begin as early as age 10, as it

1. Specify if 2. Children who are more insistent in their beliefs 3. Prevalence • What is your gender?• New Zealand high school students:

1. with a disorder of sex development;1. E.g., being born with two genders 2. - beliefs are more likely to be transgender as adults - In boys and girls/ strong focus o sex , doenst recognise current gender - Cross gender term references the fact that focus on physiological sex - Matching gender criteria good wording as not icused on child physiological sex as all other criteria is - Criteria strong focus on esex but ehen are fpcused on sexperiences these criteria do have capacity to recognise non-binary genders 3. • 1.2% transgender, 2.5% not sure, 1.7% I don't understand the question - ~1% or less are transgender

1. • Most have comorbid psychological disorders 2. Anorexia Nervosa • Key Features 3. Anorexia Nervosa • Consequences

1. • 70% are depressed at some point • Sexual dysfunction is common • Higher than average rates of OCD and substance abuse (purging type) • Individuals are 18x more likely to die by suicide than their same aged peers;1. Higher than MDD 2. Often begins with dieting -Disturbance in the way in which one's body weight or shape is experienced -Often avoid eating in front of other people;1. May dispose of food secretly 2. Cut food into tiny pieces -Many deny having a problem 3. -Mortality rate is 5x higher than the mortality rate for similarly aged females -Starving body borrows energy from internal organs, leading to organ damage including cardiac damage > can cause heart attack -Electrolyte imbalance -Amenorrhea -Sensitivity to cold temps -Lanugo -Dry skin, brittle hair and nails -low bp, heart palpitations , heart failure - Amenorrhea (loss of period) - Sensitive to cold temperatures fue to lack of fat - Lanugo (fuzzy hair over body) -osteoporosis, fractures -low potassium , magnesium and sodium -bruise easily, yellow skin -fertility issues, higher risk of miscarriage, low birthwightbaby , ppd, c-section

1.Gender dysphoria and transgender people GenderDysphoria: 2. Binary and Nonbinary experiences

1. • Community : gendered experiences (e.g. social or bodily experiences) incongruent with current gender • Professional: When a person experiences distress resulting from incongruence between current gender and assigned gender at birth -Not all transgender people experience gender dysphoria (as described in the DSM or community definitions) -Gender dysphoria is not required in order for an individual to have a transgender identity - Prior to DSM-V, there was transsexualism and gender identity disorder 2. -The term transgender is flexible and descriptive -Binary transgender experiences are when an individuals' gender fall within the binary of man or woman -Non binary transgender experiences are when an individuals' gender does not conform to the man/woman binary • e.g. gender fluid, gender queer, agender, and many other ways to describe gender identities - Need more specific info to describe ondividuals' experiences - Other individuals may identify as outside of man or woman - Hold personal meaning for client, so important sto see how they asceobe it to their personal experiences

1. Brief History • DSM-III (1980) and DSM-IV (1994) 2. DSM 5 (2013), 3. First diagnosis in DSM-III of transsexualism

1. • Gender variance included in the diagnoses of transsexualism and gender identity disorder of childhood 2.criteria adapted from previous diagnoses and renamed as gender dysphoria to reduce stigma -Historically, gender variance has been considered pathological with treatment aims to re-align gender with physiological sex - Up until 20 years ago, transgender phenomena considered pathological;1. Climcic received criticism as hormones and surgeries used as solutions so instead offered psychotherapies , or reality testing due to vew that gener variabce as pathological (nit supported by experts) DSM-III 1. Thought it required psychotherapy and reality testing - gender reassignment strongly admonished 2. Dompartatively todyay treatment is best to have reaffirming qualities either for transition or in general -However, gender clinics in have provided medical transition care since the 1960s in the United States and 1970s in Australia -No straightforward history of how gender dysphoria in understood and treated 3.1. under class of psychosexual disorders 2. Aim to keep definitions similar across genders, but feminist mental health professionals campaigned to have them slightly separate - DSM-IV 1. Criteria became the same for boys and girls 2. Could only be labelled with the disorder if one had clinical distress or impairment

1. Aversion therapy 2. Covert sensitization 3. Orgasmic reconditioning 4. Treatment of Paraphilia Disorders • Medications 5. Depo-Provera:

1. • Pair their paraphilic fantasies with an aversive stimulus 2. • Imagine aversive consequences to form negative associations with deviant (e.g., pedophilic) behavior 3. - masturbation to appropriate (adult) stimuli - Data: Aversion therapy doesn't work when aversive stimuli removed (found in studies of alcoholism); no evidence to support covert sensitisation 4. § Desires and fantasies reduced drastically, but return when not taking drug 5. reduces testosterone and thus sex drive (usually used as birth control for women) 1. Some take medication to avoid prison -Most useful for dangerous sexual offenders; some take the drug to avoid going to prison

1. Elements of satisfaction 2. Abnormality • What is "normal" vs. "abnormal" sexual behavior? Need to consider: 3. Sexual Response cycle DAPOR

1. • Women = More likely to seek demonstrations of love, intimacy • Men = More likely to focus on arousal 1. Sexual inactivity usually due to health reasons - Satisfaction (on average) 2. • Normative facts and statistics • Cultural considerations • Gender differences in sexual behavior and attitudes 3. 1. Desire phase § Sexual cue/fantasy lead to sexual urges 2. Arousal phase § Subjective sense of pleasure /physiological signs of arousal § Blood flows into penis (penal tumescence)/vagina(vasocongestion leading to vaginal lubrications and breast tumescence (erect nipples) 3. Plateau phase § Brief period before orgasm 4. Orgasm phase § Men: Feeling inevitable ejaculation § Females: Contraction of vaginal walls of the lower 3rd of the vagina 5. Resolution phase § Men: Decrease in arousal § Women: Sometimes decrease in arousal, however, often can have multiple orgasm

1. Biological Factors 2. Sociocultural Factors

1.- Genes account for 30% of obesity cases - Hormones 1. Leptin (produced by fat cells): When body fat decreases, leptin production decreases, food intake stimulated insensitive to lepton § Genetic abnormality where people don't produce leptin, leading to insatiable appetite morbid obesity § Giving leptin to overweight people doesn't usually help stop eating · Overweight people may instead be insensitive to leptin · Also there are thin people who are leptin resistant - so there must be something else interacting with leptin here 1. Ghrelin (produced by stomach): Increase in levels when stomach empty, stimulates food intake 2. We live in a culture that provides ready access to high- fat, high-sugar foods - reafy made quicker and cheaper tasther than fruits or vegetables -Time pressure -When people are given free access to food, they eat 150% more than their energy requirements!

1. for 5 years. About a third improved to the point where they no longer met diagnostic criteria each year, but another third who had improved previously relapsed. Between 50% and 67% exhibited serious eating disorder symptoms at the end of each year of the 5-year study, indicating this disorder has a relatively poor prognosis. In a follow-up study, Fairburn, Stice, and colleagues. (2003) reported that the strongest predictors of persistent bulimia were a history of childhood obe- sity and a continuing overemphasis on the importance of being thin. 2. - cross-cultural considerations We have already discussed the highly culturally specific nature of anorexia and bulimia. A particularly striking finding is that these disorders develop in immigrants who have recently moved to Western countries (Anderson-Fye, 2009). One of the more interesting classic studies is Nasser's survey of 50 Egyptian women in London universities and 60 Egyptian women in Cairo universities (Nasser, 1988).

1.- In addition, individuals tend to retain their bulimic symp- toms instead of shifting to symptoms of other eating disorders Similarly, once anorexia develops, its course seems chronic— although not so chronic as bulimia, based on data from Hudson and colleagues (2007), particularly if it is caught early and treated. But individuals with anorexia tend to maintain a low BMI over a long period, along with distorted perceptions of shape and weight, indicating that even if they no longer meet criteria for anorexia they continue to restrict their eating 2. - There were no instances of eating disorders in Cairo, but 12% of the Egyptian women in England had developed eating disorders. Mumford, Whitehouse, and Platts (1991) found comparable results with Asian women liv- ing in the United States. - The prevalence of eating disorders varies somewhat among most North American minority populations, including African Americans, Hispanics, Native Americans, and Asians. Earlier surveys revealed that African American adoles- cent girls have less body dissatisfaction, fewer weight concerns, a more positive self-image, and perceive themselves to be thinner than they are, compared with the attitudes of Caucasian adoles- cent girls (Celio, Zabinski, & Wilfley, 2002). - reenberg and LaPorte (1996) observed in an experiment that young white males preferred somewhat thinner figures in women than African American males, which may contribute to the somewhat lower incidence of eating disorders in African American women. But a more recent survey suggests some of these ethnic differences may be changing. Marques and colleagues (2011) found that the prevalence of eating disorders is now more similar among non-Hispanic whites, African American, Asian American, and Hispanic females. Eating disorders are generally more common among Native Americans than other ethnic groups (Crago, Shisslak, & Estes, 1997

1. - Psychological Dimensions - Clinical observations over the years have indicated that many young women with eating disorders have a diminished sense of personal control and confidence in their own abilities and talents (Bruch, 1973, 1985; Striegel-Moore, Silberstein, & Rodin, 1993; Walters & Kendler, 1995). This may manifest as strikingly low self- esteem (Fairburn, Cooper, & Shafran, 2003). They also display more perfectionistic attitudes, perhaps learned or inherited from their families, which may reflect attempts to exert control over important events in their lives Shafran, Lee, Payne, and Fairburn (2006) artificially raised per- fectionistic standards in otherwise normal women by instructing them to pursue the highest possible standards in everything they did for the next 24 hours. These instructions caused them to eat fewer high-calorie foods, to restrict their eating, and to have more regret after eating than women told to just do the minimum for 24 hours.

1.- This occurred even though eating was not specifically men- tioned as part of pursuing the "highest standards." Perfectionism alone, however, is only weakly associated with the development of an eating disorder, because individuals must consider themselves overweight and manifest low self-esteem before the trait of perfec- tionism makes a contribution (Vohs, Bardone, Joiner, Abramson, & Heatherton, 1999). But when perfectionism is directed to distorted perception of body image, a powerful engine to drive eating dis- order behavior is in place Women with eating disorders are intensely preoccupied with how they appear to others (Fairburn, Stice, et al., 2003; Smith et al., 2007). They also perceivethemselves as frauds, consideringfalse any impressions they makeof being adequate, self-sufficient,or worthwhile. - pecific distortions in perception of body shape change often, depending on day-to-day experience. McKenzie, Williamson, and Cubic (1993) found that women with bulimia judged that their bodies were larger after they ate a candy bar and soft drink, where- as the judgments of women in control groups were unaffected by snacks. - Another important observation is that at least a subgroup of these patients has difficulty tolerating any negative emotion (mood intolerance) and may binge or engage in other behaviors, such as self-induced vomiting or intense exercise, in an attempt to regulate their mood (reduce their anxiety or distress by doing something they think will help them avoid being fat) tigated reaction to food cues in women with bulimia and a normal comparison group who had been food deprived. They discovered that women with buli- mia, when hungry, had more intense negative emotional reactions (distress, anxiety, and depression) when viewing pictures of food and subsequently ate more at a buffet, presumably to decrease their anxiety and distress and make themselves feel better, even though this overeating would cause problems in the long run.

1. terms , which have the most variation Gender and sex Gender, sex, transgender, and cisgender Typicaluseinpsychology 2. Transgenderortrans*: 3. Gender/sexassignedatbirth: 4. Cisgender: 5. Gender role 6. Transgender

1.- entangles in ciltural ways • Gender: the social role an individual occupies • Sex: physiological characteristics that correspond to the binary groups of male and female 2. an umbrella term for individuals whose gender assigned at birth is different to their current gender 3. the gender/ sex given to a child based on physiological sex 4. atermdescribingindividualwhosecurrentgender aligns with their gender assigned at birth 66 5. - Behaviour, attitude, personality traits which are culturally associated with a particular gender - Biological sex and gender identity is usually consistent 6. - Describes someone whose gender identity doesn't match assigned sex 1. May be opposite gender, or gender which falls outside binary - Theby are often used as the sample that receieves the gender dysphoria diagnosis

1. Premature Ejaculation Disorder criteria 2. prevalence

1.A, A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it. Note: Although the diagnosis of premature (early) ejaculation may be applied to individuals engaged in nonvaginal sexual activities, specific duration criteria have not been established for these activities. 1. vaginal' penetration because that's where research has been done; disorder can still be given to other forms of penetration, diagnosis can also be applied g those noyt vaginal presentation, and don't know how short is too short of a time , as men do ejacuate with in 5 minutes if entering nto vagina Slightly dofferent than other sexual dusfunction B. The symptom in Criterion A must have been present for at least 6 months and must be experienced on almost all or all (approximately 75%-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts). C. The symptom in Criterion A causes clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition. 2. Affects 21% of all adult males at least occasionally, but only 3% meet diagnostic criteria -Most common in younger, inexperienced males 27

1. Gender Dysphoria (Children)

1.A. A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months' duration, as manifested by at least six of the following (one of which must be Criterion A1): 1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one's assigned gender). 2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing. 3. A strong preference for cross-gender roles in make-believe play or fantasy play. 4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender. 5. A strong preference for playmates of the other gender. 6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities. 7. A strong dislike of one's sexual anatomy. 8. A strong desire for the primary and/or secondary sex characteristics that match one's experienced gender. B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

1. Voyeuristic Disorder criteria 2. Voyeuristic Disorder

1.A. Over a period of at least 6 months, recurrent and intense sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity, as manifested by fantasies, urges, or behaviors. B. The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The individual experiencing the arousal and/or acting on the urges is at least 18 years of age. 2. -Risk associated with "peeping" may intensify sexual arousal; - Arousal associated with risk of getting caught, arousal not present if person knows they are being watched; -Someone undressing for the voyeur's benefit is not gratifying -Orgasm is achieved by masturbation, either while watching or later while remembering the peeping

1. Treatment of Eating Disorders 2. Obesity

1.Several psychosocial treatments are effective, including cognitive- behavioral approaches combined with family therapy and interpersonal psychotherapy. Drug treatments are less effective at the current time. 2. Obesity is not a disorder in DSM but is one of the more dangerous epidemics confronting the world today. -Cultural norms that encourage -eating high-fat foods combine with genetic and other factors to cause obesity, which is difficult to treat. Professionally directed behavior modification programs emphasizing diet and exercise are moderately successful, but prevention effort in the form of changes in government policy on nutrition seem the most promising.

1.causes Historically, the word schizotype was used to describe people who were predisposed to develop schizophrenia (Meehl, 1962; Rado, 1962). Schizotypal personality disorder is viewed by some to be one phenotype of a schizophrenia genotype. 2.arrantes-Vidal, 2012). The idea of a relationship between schizotypal personality dis- order and schizophrenia arises partly from the way people with the disorders behave. Many characteristics of schizotypal person- ality disorder, including ideas of reference, illusions, and para- noid thinking, are similar but milder forms of behaviors observed among people with schizophrenia. Genetic research also seems to support a relationship. 3.Cognitive assessment of people with this disorder points to mild-to-moderate decrements in their ability

1.genotype is the gene or genes that make up a particular disorder. Depending on a variety of other influences, however, the way you turn out—your phenotype—may vary from other persons with a similar genetic makeup. Some people are thought to have "schizophrenia genes" (the genotype) yet, because of the relative lack of biological influ- ences (for example, prenatal illnesses) or environmental stresses (for example, poverty, maltreatment), some will have the less 2.amily, twin, and adoption studies have shown an increased prevalence of schizotypal personality dis- order among relatives of people with schizophrenia who do not also have schizophrenia themselves (Siever & Davis, 2004). These studies also tell us, however, that the environment can strongly influence schizotypal personality disorder. Some research suggests that schizotypal symptoms are strongly associated with childhood maltreatment among men, and this childhood maltreatment seems to result in posttraumatic stress disorder (PTSD) symptoms (see Chapter 5) among wome 3.

1. Rehearse Your Knowledge -Define sexual dysfunction. -Compare and contrast the symptoms of the dysfunctions of sexual desire, arousal, and orgasm in men and women. -Describe the phases of Masters and Johnson's sensate focus treatment -Describe the potential causes sexual dysfunction. -How do we decide if a sexual behaviour or lack thereof is a dysfunction?

1lols

1. Transdiagnostic View of EDs;Basic Formulation of Bulimia Nervosa diagram!!!! 2. Basic Formulation of Binge Eating Disorder 3. Basic Formulation of Anorexia Nervosa 4. Transdiagnostic View of EDs • What is striking is diagnostic crossover AND the similarity between the disorders DIAGRAM

overvaluation of shape and weight and their control to strict dieting; non-compensatory weight-control behaviour to binge eating to compensatory vomiting/laxative misuse or back to strict dieting and overvaluation -events and associated mood change also has an influence' 2. Dissatisfaction with shape and weight and there control goes to intermittent dieting -or binge eating goes to intermittent dieting or dissatisfaction -events and associated mood change has an influence 3. overvaluation gies to strict dieting and compensatory behaviour, to significantly low weight(preoccupation with eating, social withdrawal,, heightened fullness, heightened obsessionally) also can go back up 4. • Overvaluation of weight and shape • Controlling eating influences self-evaluation