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Learning Objectives

After reading this chapter, you should be able to:

Explain what psychoactive substances are.

Explain why psychoactive substances are so popular.

Analyze the potential dangers of using psychoactive substances.

Explain how substance-related disorders are treated.

Discuss ways that substance-related disorders can be prevented.

4 Substance-Related and Addictive Disorders

Lee O’dell/Hemera/Thinkstock

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4.1 Psychoactive Substances: Some Basic Information Chemicals that alter moods or behavior have been used for thousands of years by people from just about every culture and society. This chapter is concerned with why so many people use these psychoactive substances, the problems such substances can cause, how to help people who want to stop using substances, and how to prevent people from taking them up in the first place. Psychoactive substances—chemicals that alter our moods or behavior —touch every aspect of modern life; they affect the way we live, work, relax, and die. In the United States, the total cost of substance abuse in 2016 (the most recent year for which estimates are available) was more than $400 billion in lost workplace productivity (in part due to premature mortality), health care expenses, law enforcement and other criminal justice costs (for example, drug-related crimes), and losses from motor vehicle crashes (U.S. Department of Health and Human Services [USDHHS], 2016). Furthermore, about three quarters of the costs associated with alcohol use were due to binge drinking, and about 40% of those costs were paid by the government, emphasizing the huge cost of alcohol misuse to taxpayers (USDHSS, 2016). This value represents both the use of resources to address health and crime consequences as well as the loss of potential productivity from disability, death, and withdrawal from the workforce.

There is no precise boundary between social drinking and alcohol abuse. Like many psychological problems, substance-related disorders are often just extreme cases of common behaviors. How common? Recent data reported by the Center for Behavioral Health Statistics and Quality (CBHSQ, 2015) reveal that slightly more than half of Americans aged 12 or older (139.7 million, or 52.7%) reported some amount of alcohol use. This refers to general use of alcohol—a beer with pizza or a glass of wine at dinner, for example. A bit more than two out of every five people aged 12 or older (60.9 million, or 40%) participated in binge drinking at least once in the past 30 days (CBHSQ, 2015). For males, binge drinking is defined as the consumption of five or more alcoholic drinks in a row on at least one occasion during the preceding two-week period; for females, it refers to the consumption of four or more drinks during that time period (Bartel et al., 2017). The rates in 2009 and 2010 were similar (23.7%). Finally, heavy drinking was reported by 6.2% of the population aged 12 or older, or 16.3 million people (CBHSQ, 2015).

More disturbingly, data provided by the National Survey on Drug Use and Health (NSDUH) showed that in 2014, “17 million persons aged 12 or older were classified with an alcohol use disorder. This represented 6.4 percent of the population” (CBHSQ, 2015).

Psychoactive substances form a spectrum. At one end are everyday substances, such as the caffeine found in coffee, soft drinks, and tea. At the other end of the spectrum are illicit and potentially dangerous substances, such as opiates (for example, heroin). A variety of other substances lie between these two extremes.

Robert Jones presents an interesting example of an individual who may—or may not—have a drinking problem. Let’s meet him before we continue.

The Case of Robert Jones: Part 1

Robert (or Bob as he prefers to be called) is a 48-year-old African American male who has been married for 30 years to Paula. He has two children, aged 16 and 5. When Bob came to us, he was well dressed, presented pleasantly and appropriately, and had a friendly demeanor. He was not entirely sure why he was sent to the clinic, but he was sure that it was a mistake.

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“I’ve got no idea what’s going on here. The cops stopped me one night after work. Both were African Americans, and they knew me. They’ve seen me in town, at church. They told me I was weaving all over the road, and they wanted to make sure I was okay. Of course I was okay! I’ve been driving for over 30 years and never had an accident, never had a ticket! They asked me twice if I’d been drinking. I don’t drink, well, not that much anyway. They thought I was drunk! Would I drive drunk? I’ve got two kids, one a teenager who’ll be driving soon herself. I told them no, and then they asked me to step out of the car as they wanted me to do some things for them . . . .”

Bob continued his story for us during his initial intake interview. “This was so insane! I’ve got a graduate degree. I’m an upstanding citizen. The cops asked me to walk a straight line, to touch the tip of my nose with the index finger of each of my hands. That wasn’t good enough! Then they asked me if I’d been drinking— again—and then they asked me to blow into a tube in this little machine. I wasn’t sure I needed to do this, but I’d heard if you refuse to do this you’re immediately arrested. Where’s the ‘innocent until guilty’ here?” Bob decided that he’d better go along with the officers’ request and he did, but he complained the whole time. The end result was shocking to him, to say the least: “They said I was drunk! My . . . BAR . . . or something like that [we corrected him and explained that this was his blood alcohol concentration (BAC)] was .20.”

BAC refers to the percentage of alcohol that is in the body as compared to the total blood supply. A BAC of 0.08 is equivalent to about four drinks consumed per hour for an average-sized individual.

“That meant zip to me, so they told me it seemed like I’d had about 10 drinks. 10 drinks! That’d make me a rummy, a lush! I only drink beer anyway. 10 beers in one hour! That’d kill me much less anyone else!”

We confirmed the BAC results on Bob’s paperwork, sent to us by his probation officer. She sent him to us as part of his plea bargain in order to avoid jail time. Bob believed that he had no reason to be in our office. “Why don’t you concentrate on the real problems out there—the murderers, lying politicians, and the drunks that kill people while driving—huh? I’m a hardworking family man; I don’t belong in here with the winos and the loony tunes.” We pointed out the conditions of his probation and gave him the option to leave. Bob thought about this for a while and then finally stood up to leave.

Click here (https://media.thuze.com/MediaService/MediaService.svc/constellation/book/Get- zfeld.3794.18.1/{misc}casestudies_ch04.pdf) for full case study.

Because the DSM–5 includes many substance-related disorders, it is not possible to review each one here. Instead, this chapter emphasizes the common features of psychoactive substance use by focusing on the four substances most frequently used by American college students: caffeine, nicotine, alcohol, and cannabis (marijuana). Let’s start by surveying the physical and psychological effects of each of these substances.

Caffeine

If you need proof that practically everyone uses psychoactive substances at one time or another, just consider caffeine. It is practically everywhere. The only way you can avoid it is to shun coffee, tea, Red Bull, many popular soft drinks, cocoa, and chocolate. Even then, you may not succeed because caffeine is also found in headache, diet,

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and cold medications. Today, coffee remains the world’s most popular source of caffeine (see Figure 4.1 for other common sources).

Figure 4.1: Common sources of caffeine

Source: D a t a D a t a f ro m f ro m C o n s u m e r C o n s u m e r R e p o r t s , R e p o r t s , “ W h a t “ W h a t C a f f e i n e C a f f e i n e C a n C a n D o D o f o r f o r Yo u Yo u a n d a n d t o t o Yo u , ” Yo u , ” Consumer Reports on Health, 9( 1 9 9 7 ) ,( 1 9 9 7 ) , p p . p p . 9 7 , 9 7 , 9 9 – 1 0 1 , 9 9 – 1 0 1 , a s a s a p p e a r i n g a p p e a r i n g i n i n S . S . S c h w a r t z , S c h w a r t z , Abnormal Psychology: A Discovery Approach. M o u n t a i n M o u n t a i n Vi e w, Vi e w, C A : C A : M a y fie l d M a y fie l d P u b l i s h i n g P u b l i s h i n g C o m p a n y, C o m p a n y, 2 0 0 0 , 2 0 0 0 , F i g u re F i g u re 6 . 1 , 6 . 1 , p . p . 2 3 8 . 2 3 8 .

ActionAction Caffeine belongs to a class of chemicals called stimulants, whose main psychoactive effect is to make us more alert. Within 45 to 60 minutes after you drink a cup of coffee or munch on a chocolate bar, caffeine is absorbed from the stomach and the intestines. Once in the bloodstream, it causes blood pressure, pulse rate, and stomach acid production to increase. In the nervous system, caffeine acts as an antagonist to the neuroinhibitor adenosine (Kaster

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As with substances administered through a needle, our bodies react physiologically to nicotine within a matter of seconds.

et al., 2015). Antagonists are chemicals that reduce the potency of other chemicals. In contrast, agonists are chemicals that increase the potency of other chemicals (for example, fluoxetine [Prozac] is a serotonin agonist). Caffeine is also a powerful diuretic because it increases the excretion of liquid from the body.

HealthHealth Effects Effects Although it is widely used and generally regarded as safe, caffeine may still have adverse effects on health (de Mejia & Ramirez-Mares, 2014). For example, it increases the production of stomach acid, which may worsen digestive disorders and can cause acid reflux (“heartburn”). Insomnia, poor sleep, and anxiety are other potential results of overuse of caffeine. Excessive continual coffee consumption can also lead to bone loss, increased blood pressure, and lower bone density, meaning that fractures are more likely (Chaudhary, Grandner, Jackson, & Chakravorty, 2016; de Mejia & Ramirez-Mares, 2014). Some researchers, however, found that coffee consumption does not lead to ulcers or acid reflux (Papakonstantinou et al., 2016).

PsychologicalPsychological Effects Effects Because caffeine is a stimulant, many people consume drinks containing it to combat drowsiness, increase alertness, and boost energy. Paradoxically, many people also consume caffeine to relax. It is possible that the relaxing effect of caffeine is not the result of its chemical action but of expectancies (what people expect when they use a drug or substance) and social reinforcements. If we expect caffeine to be relaxing, it probably will be.

Nicotine

Nicotine is the primary psychoactive ingredient in tobacco, a plant that has grown in the Americas for centuries. Let’s look at a few statistics to put tobacco use into perspective. Although tobacco usage has decreased over the past few years, in 2015 nearly 25.3% of high school students used some type of tobacco product, including 13% who reported currently using at least two or more tobacco products (Singh, 2016). Among current high school users, smokeless tobacco was the product used most often during the past month (42%), followed by cigarettes (31.6%). Not surprisingly, e-cigarettes were used by about 15.5% of those surveyed (Neff et al., 2016). Cigar smoking was also common among high school students, at about 13.1% (Neff, Spiker, & Truant, 2015; Singh, 2016).

ActionAction Nicotine is a powerful stimulant, so toxic that it has been used as a natural insecticide. A small amount instantly kills a variety of insects. In humans, nicotine is one of the fastest acting psychoactive substances. Within seconds of a smoker’s puffing on a cigarette, nicotine reaches the smoker’s brain (Benowitz, 1996). It activates specific receptors in the midbrain that produce increased arousal. The end result is similar to the one produced by caffeine—smoking makes people more alert and less drowsy.

HealthHealth Effects Effects Carbon monoxide, the poisonous gas found in automobile exhaust

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emissions, is also present in cigarette smoke. It reduces the smoker’s oxygen supply, thereby affecting the heart and other circulatory organs. The organic chemicals suspended in smoke droplets, known as tar, contain several known carcinogens, or substances that can cause cancer. Many other dangerous substances, such as formaldehyde (a well- known carcinogen) and nitric oxide (a poisonous gas), are also found in tobacco smoke.

The effects of smoking on health have been known for decades. In 1948, researchers began a prospective study of more than 5,000 people living in Framingham, Massachusetts. Their aim was to identify the factors that contribute to heart disease. The now-famous Framingham Heart Study revealed a number of risk factors (characteristics, genetic or otherwise, that seem to be associated with an increased risk of disease onset or recurrence). Somewhat unexpectedly, at least at the time, high among those risk factors was smoking (Dawber, 1980). The Framingham study was the first evidence that tobacco smoking was related to heart disease. It was followed by a study of 8,000 men of Japanese descent, which found that smoking is also a risk factor for stroke (Abbott, Yin, Reed, & Yano, 1986). Smokers have three times as many strokes as people who have never smoked. A 34-year follow-up of the Framingham study shows a continuing association between smoking and a range of diseases years after smoking ceases (Freund, Belanger, D’Agostino, & Kannel, 1993).

In addition to heart disease and stroke, smoking is a risk factor in respiratory diseases such as bronchitis and emphysema (Rigotti, 2013), in stomach ulcers, and in diseases of the mouth (Sood et al., 2014). Exposure to the smoke of other people’s cigarettes, pipes, and cigars (known as passive smoking) is also a health risk, especially for young children (Czogala et al., 2014). These researchers estimated that passive smoking kills more than 600,000 people worldwide every year, an astonishingly high figure (Czogala et al., 2014).

According to the World Health Organization (WHO), tobacco is the second leading cause of death around the globe. WHO estimates that 12% of all deaths among adults aged 30 or older are smoking related, which comes out to about 5 million people each year. This number is expected to grow to 8 million by 2030. Half of all smokers will die from their tobacco use (WHO, 2012). In 2015, WHO estimated that over 1.1 billion people smoked tobacco (WHO, 2012).

Although smoking is directly related to stroke, heart disease, diabetes, chronic obstructive pulmonary disease (COPD), and 12 types of cancer (Carter et al., 2015; Farsalinos et al., 2016), the best known link is the relationship between smoking and lung cancer (Carter et al., 2015).

PsychologicalPsychological Effects Effects Despite nicotine’s arousing effects, most smokers, like most coffee drinkers, claim that they smoke to relax. Some research suggests that smoking may actually increase stress levels (Parrott, 2000). Other studies reveal that smoking is relaxing and that smoking increases under stressful circumstances (Hughes, 2005). As with coffee drinking, the relaxing effects of cigarette smoking may be, at least in part, the result of expectancies and social reinforcement.

Personality may play a role in nicotine use. Despite the well-known health risks, millions of people continue to smoke. Hans Eysenck (1991) suggested that this phenomenon may be partly explained as a behavioral expression of the personality trait of extroversion. According to Eysenck, extroverts are born with low levels of arousal. The experience of low arousal is perceived as unpleasant, so extroverts continuously seek stimulation—and smoking is a source of stimulation. Not all extroverts smoke, of course. There are other ways to raise arousal; some may drink lots of coffee. However, once extroverts start smoking (because of peer pressure, rebelliousness, or for some other reason), they are likely to continue because smoking provides the stimulation they crave (Hakulinen et al., 2015). In 2015, e-cigarettes were the most commonly used tobacco product among middle (5.3%) and high (16.0%) school

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students (Singh, 2016). During 2011–2015, significant increases in current use of e-cigarettes and hookahs occurred among middle and high school students. This finding is bothersome, but what is interesting is that the current use of conventional tobacco products such as cigarettes and cigars decreased during that timeframe. Many people falsely believe that e-cigarettes are healthier for you, and although ads may imply that this is the case, it is not true (Callahan-Lyon, 2014).

Nicotine, as a stimulant, belongs to the same class of substances as amphetamines, cocaine, and MDMA, which is also known as ecstasy or Molly (see Table 4.1).

Table 4.1: Examples of stimulants (other than caffeine and nicotine)

Name Description

Amphetamine A synthetic (manufactured) compound that comes in legal prescription versions and illegal street versions, such as “speed.” Amphetamine powder can be inhaled (“snorted”) or injected. Amphetamines enhance neurotransmitter concentration, especially norepinephrine and dopamine. This increased concentration produces alertness and arousal. Originally intended as an asthma medication, amphetamines still have several medical uses. For example, drugs such as dextroamphetamine (Adderall) and methylphenidate (Ritalin) may be prescribed for people with attention-deficit/hyperactivity disorder (discussed in Chapter 11); and because they suppress appetite, they are sometimes used as diet aids. Large doses of amphetamines can also be fatal.

Cocaine Derived from the South American coca plant, cocaine, or coke, comes in several forms and was once an ingredient in Coca-Cola (Musto, 1992). Cocaine produces stimulatory effects similar to those produced by amphetamines. Also like amphetamines, cocaine can be injected, snorted, or smoked in forms known as free-base and crack. Cocaine acts to enhance the action of dopamine and other neurotransmitters, thereby increasing arousal while producing a variety of psychological effects including (after prolonged use) paranoia, anxiety, panic attacks, and even a psychotic disorder (Yudofsky, Silver, & Hales, 1993). Withdrawal does not seem to produce symptoms unless cocaine use extends over a considerable period, usually defined as six months or longer (Gawin & Kleber, 1992). Similar to amphetamines, cocaine can be fatal in large doses (Harlow & Swint, 1989). In 2010, about 1 million people had cocaine dependence in the United States (NSDUH, 2011).

MDMA MDMA (3, 4-methylenedioxymethamphetamine), also known as ecstasy, is technically a stimulant but is often considered to be a hallucinogen as it produces hallucinogenic effects. This drug is often used in clubs and at raves as it provides users with a boost in energy that allows them to go on dancing for extended time periods. MDMA has no medicinal effects and can lead to many physical problems, including increased blood pressure and heart rate, which can lead to cardiac arrest (Ksir, Hart, & Oakley, 2008). The popular nickname Molly (slang for “molecular”) often refers to the supposedly “pure” crystalline powder form of MDMA, usually sold in capsules. Sometimes the capsule is “cut” with another substance (meaning that another substance in addition to MDMA is added in, often without the user’s or buyer’s knowledge). Other stimulants include cocaine, ketamine, methamphetamine, over-the-counter cough medicine, and synthetic cathinones (“bath salts”).

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Males are more likely to be binge drinkers than females, partly because women have less of the enzyme ADH (alcohol dehydrogenase) that helps break down alcohol in the stomach.

Alcohol

Alcohol (known more accurately as ethanol) is the second most commonly used psychoactive substance in the United States and perhaps in the world. It is estimated that 2 billion people worldwide use alcohol (WHO, 2011). Globally, 45% of the world’s population has never consumed alcohol (35% of men and 55% of women).

Alcohol is found in wine, liquor, spirits, beer, cider, and many cold medications. Unlike smoking, alcohol use is positively correlated with educational attainment. College graduates drink more than those who ended their education after high school (although college students with low marks drink more than high-performing students; Ansari, Stock, & Mills, 2013; Quinn & Fromme, 2011). International comparisons suggest considerable cross-cultural variability in alcohol consumption depending on availability and cultural prohibitions (Erol & Karpyak, 2015; WHO, 2014).

In all ethnic groups, males are much more likely than females to be binge drinkers, although women appear to be closing the gap (Erol & Karpyak, 2015). This also puts women at risk for other drug use, where they also seem to be catching up to men (Clinkinbeard & Barnum, 2015). Even so, the gap between men and women still exists. Why might that be? First, blood levels of alcohol build up more quickly in women than in men of the same size because women have less of the enzyme—known as

alcohol dehydrogenase (ADH)—that helps break down alcohol in the stomach before it enters the bloodstream (Erol & Karpyak, 2015). Note, however, that Erol and Karpyak (2015) also found some reports that suggested this is not the case. Second, many women do not drink when they are pregnant because of the now well-known fact that alcohol can cause birth defects (Landgraf, Nothacker, Kopp, & Heinen, 2013).

ActionAction Chemically, alcohol is a depressant. It lowers arousal and makes people drowsy (Yi, 1991). Some of the other depressants included in the DSM–5 are described in Table 4.2.

Alcohol exerts a variety of effects on the central nervous system, but one of its most important is to reduce inhibition, which is controlled by the GABA neurotransmitter system (GABA stands for gamma-amino butyric acid; the “gamma” is typically abbreviated with the Greek letter for gamma). The result is that drinkers lose some degree of self-control. Alcohol dilates blood vessels, decreases blood pressure, lowers heart rate, and slows respiration. Although small amounts of alcohol are exhaled as vapor by the lungs, which can be measured by roadside Breathalyzers, most of the ingested alcohol goes to the liver, where it is gradually broken down (metabolized) and excreted. The average person can metabolize about one “standard drink”—the equivalent of one 12-ounce glass of beer, one 5-ounce glass of wine, or 1 ounce of 90-proof liquor—per hour. (We will discuss the BAC a bit later in this chapter.) Neither drinking black coffee nor splashing cold water on one’s face makes any difference in the rate at which alcohol is metabolized; there is no quick way to sober up.

HealthHealth Effects Effects

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Drinking moderate amounts of alcohol, especially red wine, may reduce the likelihood of coronary heart disease (Chiva-Blanch, Arranz, Lamuela-Raventos, & Estruch, 2013). However, chronic use of alcohol can damage the heart and just about every other organ in the body (Shield, Parry, & Rehm, 2014; WHO, 2014). Alcohol irritates the digestive system, causing inflammation and bleeding. Prolonged and intensive use of alcohol can turn the liver into nonfunctioning, fibrous tissue. This syndrome is known as cirrhosis. A very high blood alcohol level can be fatal, although most people become unconscious before drinking enough to cause death.

Heavy drinking during pregnancy can put a fetus at risk of developing fetal alcohol syndrome (FAS), which is marked by intellectual disabilities, hyperactivity, facial deformities, and growth deficiencies of internal organs and the body’s systems (Caputo, Wood, & Jabbour, 2016; Landgraf et al., 2013). A classification known as fetal alcohol spectrum disorders (FASD) includes FAS, partial FAS, alcohol-related neurodevelopmental disorder, and alcohol- related birth defects (Landgraf et al., 2013). Even when they consume the same amount of alcohol, African American women and female members of certain Native American tribes are more likely to have children with FAS than are members of other groups (Caetano, Vaeth, Chartier, & Mills, 2014). Their increased vulnerability appears to be the result of genetic differences in alcohol metabolism (Caetano et al., 2014; Gordis, 1991).

PsychologicalPsychological Effects Effects Moderate amounts of alcohol make most people feel talkative and relaxed. Even though drinkers may relax, even modest amounts of alcohol can affect cognition (Starkey & Charlton, 2014). After a few drinks, we concentrate on only the immediate and the most obvious cues in our environment, ignoring complexities and long-term consequences. For example, you may feel like talking back to a professor or to your supervisor at work, but a sober consideration of the consequences will probably inhibit you from actually saying anything. Under the influence of alcohol, however, you may not consider the long-term consequences and just lash out. This narrowing of focus to the immediate is called alcoholic myopia (Fairbairn & Sayette, 2013). This can lead to having unprotected sex and inappropriate, even dangerous, acts of aggression (Giancola, 2015; Kiene, Simbayi, Abrams, & Cloete, 2016), for example.

As the amount of alcohol in the bloodstream builds, vision becomes blurred, hearing grows less acute, and motor control begins to break down. It is these effects that make drinking and driving so dangerous. Indeed, alcohol was associated with around 29% of all automobile accident fatalities in 2015 (National Highway Traffic Safety Administration [NHTSA], 2016).

The level of cognitive and motor impairment produced by alcohol depends on its concentration in the blood. Concentrations below 0.05% of blood by volume usually produce feelings of relaxation, with minimal cognitive or motor effects. Higher concentrations affect judgment and motor coordination. Figure 4.2 shows the relationship between blood alcohol concentration (BAC) and body weight.

Figure 4.2: Approximate blood alcohol concentration (BAC) and body weight

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Source: P. P. M . M . I n s e l I n s e l & & W. W. T. T. R o t h , R o t h , Core Concepts in Health, 1 0 t h 1 0 t h e d . e d . M o u n t a i n M o u n t a i n Vi e w, Vi e w, C A : C A : M a y fie l d M a y fie l d P u b l i s h i n gP u b l i s h i n g C o m p a n y, C o m p a n y, 2 0 0 0 , 2 0 0 0 , p . p . 2 5 4 . 2 5 4 . R e p r i n t e d R e p r i n t e d b y b y p e r m i s s i o n . p e r m i s s i o n .

Not only is judgment affected by alcohol, but so are the attributional processes required to interpret and control emotions (Giancola, 2013). For example, alcohol makes some people feel sexually aroused. Because their judgment

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is impaired, they may interpret innocent signs as indicating that another person feels the same way. Couple this with disinhibition, and it is not surprising that people influenced by alcohol may do things they would never do while sober. It is primarily alcohol’s disinhibiting effect that makes people believe that it is “stimulating,” even though it is a depressant. Excessive disinhibition can sometimes lead to aggression (Giancola, 2013). Aggression, combined with impaired judgment, makes alcohol a factor in child abuse (Freisthler & Gruenewald, 2013), as well as in many suicides (Borges et al., 2017). See Table 4.2 for a summation of depressants other than alcohol.

Table 4.2: Depressants other than alcohol

Name Description

Sedatives, hypnotics (sleep-inducing drugs), and anxiolytics (antianxiety drugs)

Barbiturates (Seconal, Nembutal, and others) were first used in 19th-century Germany as sleeping aids. Benzodiazepines (e.g., Valium) are considered safer than barbiturates. The main effect of all sedative and anxiolytic drugs is to depress bodily functions. At low doses, these drugs are calming and promote sleep, but they can affect memory and interfere with psychosocial functioning (Warneke, 1991). The abrupt cessation of any of these drugs after prolonged use can cause neurological symptoms, including seizures. Because alcohol, sedatives, and anxiolytics all affect the GABA system (McKim, 1991), mixing alcohol and these drugs produces a strong and potentially deadly effect (Fils-Aime, 1993).

Opioids Opioid is the general term for substances derived from the opium poppy plant. Known as opiates or narcotics, these include opium, morphine, and heroin; synthetic variants, such as methadone; and naturally occurring brain substances, such as beta-endorphins (Jaffe, 1991). All opioids are habit-forming. Although they may produce a brief feeling of elation, opioids are depressants (Barinaga, 1992). There is also evidence that opioids reduce the functioning of the immune system, thereby lowering resistance to disease.

Cannabis

Cannabis is actually a short name for Cannabis sativa, a type of hemp plant that produces several psychoactive substances. Marijuana (also known as pot, weed, and many other names) is a mixture of the dried shredded flowers and leaves of the plant. Hashish is a sticky resin obtained from cannabis flowers. Cannabis users usually roll the substance into a cigarette known as a joint or smoke it in a pipe.

The psychoactive ingredient in marijuana is delta-9-tetrahydrocannabinol, usually called THC. Ordinary marijuana contains about 3% THC, but some types can contain 20 times as much. At such high doses, THC can produce distorted sensations and perceptions (hallucinations). Technically, this makes cannabis a hallucinogen, but, as previously noted, the DSM–5 classifies it in a separate category because perceptual distortions do not always accompany cannabis intoxication. Several hallucinogens are described in Table 4.3.

Table 4.3: Common hallucinogenic substances

Name Description

MDMA Widely known as ecstasy, MDMA has both hallucinogenic and amphetamine-like stimulating qualities. MDMA destroys neurons, especially those containing dopamine. It

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not only produces hallucinations but also a loss of motor control (Fischer, Lankford, & Galea, 1995).

Natural (plant- derived) substances

Psilocybin (found in certain mushrooms), DMT (from the bark of the South American virola tree), mescaline (a cactus derivative), and other naturally occurring hallucinogens produce varying degrees of cognitive distortions depending on their concentration and on users’ expectations. (People who expect to see changing colors or bright lights are more likely to experience these sensations than those without such expectations.)

LSD Lysergic acid diethylamide is one of the most powerful hallucinogens. The physical effects of LSD are similar to those of stimulants: increased heart rate and blood pressure, loss of appetite, sleeplessness, and dry mouth. LSD’s psychological effects depend on the amount ingested, individual differences, expectations, and the social context. Typical reactions include rapid mood swings, distortions in time, and hallucinations. Sensations become confused, and some people claim to “hear” colors and “see” sounds (a phenomenon known as synesthesia). People who find such sensory experiences frightening label their experience a “bad trip” (American Psychiatric Association [APA], 2000).

PCP Because its profile of psychological effects differs from those of LSD and MDMA, the DSM–5 puts phencyclidine (PCP) in a different category. Yet PCP is also a powerful hallucinogen. Widely known as angel dust, PCP was developed in the 1950s as a surgical anesthetic. However, many people given PCP had hallucinations.

Cannabis is one of the oldest crops cultivated by human beings (see Grinspoon & Bakalar, 1993, for one example of a detailed history of marijuana). Ten-thousand-year-old clay pots unearthed in Taiwan were found to have strands of hemp fiber in their decorations. For centuries, and until fairly recently, hemp fiber was a major source of rope, canvas, paper, and cloth (the first Levi’s jeans were made of hemp).

ActionAction Within a few minutes of inhaling cannabis smoke, users experience dry mouth, rapid heartbeat, some loss of coordination, and slower reaction times. Blood vessels in the eyes expand, and blood pressure rises. Once in place, THC stimulates chemical reactions that produce the euphoria that users experience when they smoke cannabis.

HealthHealth Effects Effects Many people use cannabis regularly with little obvious effect on their health. In fact, the most common physiological effects reported by cannabis users are feelings of thirst and hunger (“the munchies”). However, cannabis smoke contains many of the same ingredients as tobacco, so cannabis smoking can result in the same respiratory problems that cigarette smoking causes: cough, increased susceptibility to colds, and lung disease. In fact, because cannabis smokers try to keep the smoke in their lungs as long as possible, smoking a marijuana joint may actually have a greater effect on respiratory health than smoking a cigarette. Cannabis also increases blood pressure and heart rate, so it may have particularly negative effects on people with heart or circulatory diseases (Hall & Degenhardt, 2013; Owen, Sutter, & Albertson, 2014; Volkow, Baler, Compton, & Weiss, 2014).

Over the past few years, many regular users of marijuana have either demonstrated marijuana abuse or become physiologically dependent, meaning they develop a tolerance for it and demonstrate irritability and restlessness when

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they stop using (Hasin et al., 2015). The long-term effects of cannabis smoking on the pulmonary-respiratory system are not as clear (Hall & Degenhardt, 2013). The 2014 National Survey on Drug Use and Health provides the following statistics: “Marijuana was the illicit drug with the highest rate of past-year dependence or abuse in 2014, followed by pain relievers and cocaine. Of the 7.1 million persons aged 12 or older classified with illicit drug dependence or abuse in 2014, 4.2 million had marijuana or hashish dependence or abuse (representing 1.6 percent of the total population aged 12 or older, and 63.0 percent of all those classified with illicit drug dependence or abuse), 1.9 million persons had pain reliever dependence or abuse, and about 913,000 persons had cocaine dependence or abuse” (CBHSQ, 2015).

MedicalMedical Marijuana Marijuana Usage Usage According to the National Institute on Drug Abuse (NIDA, 2017), medical marijuana refers to using the whole, unprocessed marijuana plant or its basic extracts to treat symptoms of illness and other conditions. The U.S. Food and Drug Administration (2017) has not recognized or approved the marijuana plant as medicine. THC can increase appetite and reduce nausea, which are extremely important for chemotherapy patients. THC may also decrease pain, inflammation (swelling and redness), and muscle control problems. These problems may also be treated with opioids, which can become physiologically addicting. Although the marijuana plant is still not FDA approved as of this writing, its potential medicinal usages require further research so that we can ascertain if (and how) this plant can have medicinal value.

PsychologicalPsychological Effects Effects The psychological effects of cannabis are highly variable. They depend on the amount of THC ingested, the expectations of the individual, and the social context. Some people feel nothing at all when they smoke marijuana. Most report feeling lazy, relaxed, and mildly elated (a state usually summarized as feeling “stoned”). Distorted perceptions (sights, sounds, time, and touch) have also been reported (Hadland, Knight, & Harris, 2016). Occasionally, cannabis users experience sudden feelings of anxiety and have paranoid thoughts (Hadland et al., 2016). A 2016 meta-analysis estimated that cannabis use is statistically associated, in a dose-dependent manner, with an increased risk of the development of psychotic disorders, which might include schizophrenia (Marconi, Di Forti, Lewis, Murray, & Vassos, 2016). Dose-dependent refers to a relationship in which a change in the amount, intensity, or duration of exposure to marijuana is associated with a change in risk of a specified outcome, in this case an increased risk of developing psychotic disorders.

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4.2 Why Are Psychoactive Substances So Popular? Why do we use psychoactive substances? According to ethologists, scientists who observe natural behavior in humans and animals, substance use is a “displacement” activity, something done in place of another behavior. For example, psychoanalysts view smoking as a way of obtaining oral gratification, a displacement for the breast. Such simple explanations, however, hardly do justice to the complex web of factors controlling substance use.

Perhaps the most obvious reason for using a substance is to change our state of consciousness. If we need to get started in the morning or if we are having trouble concentrating on our work, a cup of coffee or a cigarette may help. Similarly, when we are tense, alcohol or cannabis may help us to relax. In other words, we use psychoactive substances to produce specific psychological effects.

Although they are important, the psychological effects of substances are only part of the story. Substance use is the complex result of several interacting factors: exposure and availability, reinforcement, expectancies, social and cultural context, and biological variables.

Modeling, Exposure, and Availability

Before we can use a substance, we must first know that the substance exists and, second, have access to it. In the case of caffeine, modeling is almost universal. Parents, friends, practically everyone uses caffeine in one form or another. Alcohol use is also widely modeled. Children can readily identify the smell of alcohol (beer, wine, or whiskey), and many associate alcohol with adults or with unpleasant results (Jayne & Valentine, 2017).

Because we see so many people using caffeine, alcohol, and nicotine, often in happy surroundings, and because these substances are heavily promoted in the media and by peers, it is not surprising that most of us decide to give at least one of them a try. Contrast the familiarity and availability of caffeine, nicotine, and alcohol with our knowledge of and access to amphetamines. Amphetamines are also stimulants, but they are not as widely used. Few of us see our parents or friends using them, and they can be obtained legally only with a doctor’s prescription. In addition, marijuana is legal in some countries but not in others. Therefore, people who have been exposed to marijuana will be more familiar with it and its usage than will those who live in countries where marijuana is illegal. Medical marijuana usage remains part of the national debate in the United States.

Reinforcement

Modeling and availability might determine which substances we are most likely to try, but other factors determine whether we will keep using those we do try. One of the most important factors is the positive reinforcement we get from changing our mental state through the use of a substance (Posner, Amira, Algaze, Canino, & Duarte, 2016). These changes in mental state are perceived as pleasurable because they stimulate the brain’s “pleasure center,” the part of the brain that gives rise to subjectively pleasant feelings (Olds, 1956; Wise, 2013). Although the exact location of the pleasure center is a matter of debate, it seems to be closely related to the dopamine system (Wise, 2013). One of the reasons that people continue to use substances is to experience the reinforcing feelings produced when substances stimulate the brain’s pleasure center (see Figure 4.3).

Figure 4.3: The chemical process of dependence on nicotine

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Source: Adapted from S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 6.4, p. 86.

The reasons for using a substance may change over time. Consider cigarette smoking, for instance. Most of the time, people find their first experience unpleasant. The first few cigarettes may cause coughing, dizziness, nausea, even vomiting. It is amazing that anyone would wish to repeat the experience, especially since most adolescents know the health risks before they light up their first cigarette, though they typically underestimate the risk involved (Ambrose et al., 2014). Yet many go on to become smokers. One reason is peer group acceptance. Teenagers whose siblings or friends smoke are more likely to begin smoking than are those with no peers to emulate or impress (Huang et al., 2014). Because smoking is followed by peer approval, as well as by desired changes in mental state, it is reinforced. Exactly the same group dynamics reinforce the use of alcohol, cannabis, and other substances. Social reinforcement is an important determinant of substance use because substances are an integral part of social activity.

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In addition to positive reinforcement, negative reinforcement (escape from an aversive state) also plays an important role in substance use. Feeling tired or unable to concentrate is an unpleasant feeling. If a cigarette or a cup of coffee dissipates our fatigue and makes us more alert, we will be reinforced to try the same “cure” again the next time we feel tired or distracted. Similar negative reinforcement comes from substances that reduce feelings of anxiety and depression (SAMHSA, 2016).

Expectancies

Expectancies also influence usage (Harrell et al., 2015). How can a substance like nicotine, which increases blood pressure, pulse rate, and arousal, help people relax and fall asleep? We have discussed part of the answer; increases in arousal are reinforcing for low-arousal people, and stimulants affect the brain’s pleasure center, releasing pleasurable endorphins, chemicals in the body that inhibit pain and produce pleasure. But there is another factor ​- operating as well—cognitive expectancies. If we believe that a cup of tea will help us to sleep or that a cigarette will help us relax, then they probably will have these effects even though both tea and cigarettes contain stimulants. These expectancies about the effects of substances are the result of direct experience with a substance as well as exposure to parents, peers, and the media (Chisolm, Manganello, Kelleher, & Marshal, 2014).

Social and Cultural Context

As stated, the reinforcement produced by peer group acceptance is an important determinant of substance use, but economic factors are also related to substance use (Karriker-Jaffe, 2013). For instance, people in lower socioeconomic classes have higher substance abuse rates (Andrabi, Khoddam, & Leventhal, 2017; Karriker-Jaffe, 2013). Substance use is a particularly serious problem for some ethnic groups. Therefore, understanding substance use, and helping people with substance-related problems, requires sensitivity to the ways in which cultural norms affect substance-related behavior (Otiniano-Verissimo, Grella, Amaro, & Gee, 2014).

Biological Variables and Individual Differences

Some people may be genetically vulnerable to suffer from drug abuse (Palmer et al., 2015). If they are exposed to certain substances, people with such predispositions are more likely than others to use again. For example, genetics certainly play a role in alcohol use (Verhulst, Neale, & Kendler, 2015). A possible mechanism for a predisposition to alcoholism is the dopamine 2 (D2) gene found on chromosome 11 (Bühler et al., 2015; Mbarek et al., 2015). About 66% of excessive alcohol users (people whose alcohol use has caused them problems) carry this gene, whereas it is present in only 20% of the rest of the population. The existence of the D2 gene does not mean that some people are born “alcoholics.” Other genes may be connected to substance-related disorders (see Bühler et al., 2015). Chromosomes 4 and 12 have also been implicated (Bühler et al., 2015; Mbarek et al., 2015). In addition, an individual with a D2 gene might never drink because of religious reasons, choice, a preexisting medical condition, or for some other reason. The same gene is also associated with other substances, including nicotine and opioids, and with compulsive binge eating and gambling (Bühler et al., 2015; Clarke et al., 2014; Gyllai et al., 2014; Kessler, Hutson, Herman, & Potenza, 2016; Lobo et al., 2015; Schulte, Grilo, & Gearhardt, 2016).

Some people with the D2 gene may never develop substance-related problems because they have also inherited competing dispositions that counteract the effects of D2. For example, as many as half of all people of Asian descent lack one of the enzymes that helps break down alcohol in the liver. When they drink alcohol, they experience an

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“alcohol-flush syndrome” that includes a blushing red skin, dizziness, and nausea (Newman et al., 2013). The alcohol-flush syndrome may be unpleasant enough to prevent affected people from drinking, even if they have inherited the D2 gene.

It is important to note that one third of problem drinkers do not have the D2 gene. This suggests that there may be two different types of people who develop problems with alcohol: (a) those with the D2 gene and a family history of excessive drinking, who develop alcohol-related problems early in life, and (b) those without the gene, whose drinking problems develop late in life and whose social and occupational functioning is only mildly affected (Schuckit & Smith, 1996; Yoshino & Kato, 1996). Drinking in the second group seems mainly affected by environmental factors (exposure, social reinforcement), whereas drinking in the first group may be influenced more by genetics.

The United States’ Opioid Epidemic

In 2015 (the latest year for which data are available), 12.5 million people misused prescription opioids (USDHHS, 2017). Of those, 2.1 million people misused prescription opioids for the first time, and 2 million people had prescription opioid use disorder. In addition, 33,091 people died from overdosing on opioids, including 15,281 whose deaths were attributed to overdosing on commonly prescribed opioids, an inordinately high number. In 2013, the opioid epidemic cost the United States $78.5 billion (USDHHS, 2017). These numbers are increasing yearly, indicating the existence of a significant opioid epidemic, and one that is not going away soon. The USDHHS notes that the misuse and abuse of prescription medications in the United States remains high, but few people are aware of the extent of the problem. As we will discuss later, the best methods to address the problems of misuse and abuse are increased education and prevention. We need to determine why the abuse rate continues to increase, and how we can educate preteens and teenagers about the dangers of these substances. Perhaps then we will see the opioid abuse rate and the resulting death toll decrease.

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4.3 Potential Problems of Sustained Substance Use The average American consumes 200 mg of caffeine per day, the equivalent of two strong cups of brewed coffee. Of course, many people consume much more. High caffeine consumption can induce caffeine intoxication, which is marked by restlessness, excitement, an inability to sleep, flushed face, muscle twitching, and in especially severe cases, rambling speech, heart rate abnormalities, and agitation (APA, 2013). Very large doses can even be fatal. Alcohol and cannabis also produce well-documented intoxication syndromes (APA, 2013).

You may know people who show no signs of intoxication even after consuming significant amounts of alcohol and wonder why these people seem immune to its intoxicating effects. The answer is tolerance (the lessening of the body’s response to a drug after continued use). As a result of tolerance, individuals using a drug will find that they begin to need greater and greater amounts in order to achieve the same effects as before, or even to achieve a lesser effect. Three beers may be enough to produce intoxication in a nonuser, whereas a much larger amount may have little or no effect on a habitual beer drinker. People can develop tolerance to most (but not all) substances.

How much substance users consume, and how often, is determined partly by the amount of a substance in the user’s body. For example, smokers adjust their habit to maintain a certain level of nicotine in their bodies. If the amount of nicotine falls below the desired level, smokers may become irritable, restless, distractible, and hungry (Soyster, Anzai, Fromont, & Prochaska, 2016). These symptoms are known as nicotine withdrawal (APA, 2013). The DSM–5 also contains diagnostic criteria for alcohol withdrawal, which is marked by tremor, sweating, nausea, and anxiety. In severe cases, people withdrawing from alcohol may experience disturbances in consciousness, including hallucinations (known as delirium tremens, or the DTs). Withdrawal symptoms may be so severe that people continue using a substance just to avoid the symptoms. In such cases, substance use is being maintained by a form of negative reinforcement.

Substance Use Versus Substance Abuse

Substance use, by itself, is not a psychological disorder. Substances present a psychological problem only when they produce adverse consequences. Consuming a glass of wine with dinner does not lead to adverse consequences for most people; thus, it is not a sign of a psychological disorder. In contrast, drinking to the point of intoxication and missing classes several times a week for a number of weeks could be a sign of what the DSM–5 refers to as a substance use disorder.

The DSM–IV–TR had separate categories for substance abuse and substance dependence. Substance dependence criteria included tolerance and withdrawal as well as loss of control (the feeling that once an individual began using a substance, he or she was unable to stop, even if intending to do so). The DSM–5 combined both categories into a new category: substance use disorder (APA, 2013). This new category codes the substance use disorder on a spectrum using the following specifiers: mild, moderate, and severe. In addition, the criterion that the individual had to have recurrent legal problems in order to qualify for the old substance abuse diagnosis has been eliminated from the DSM–5 (APA, 2013). It is now also somewhat more difficult to “qualify” for substance use disorder. To qualify for the DSM–IV–TR substance abuse diagnosis, an individual had to satisfy minimally one criterion. In the DSM–5, the individual must satisfy minimally two or more criteria. For the moderate subcategory, an individual must satisfy minimally four or more criteria, as opposed to satisfying three or more for the old substance dependence disorder.

Perhaps more important, a new criterion was added to the DSM–5 regarding substance use disorder: craving, or a strong desire or urge to use a substance (APA, 2013). Craving implies physiological dependence which can lead to

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loss of control as well as intoxication.

Substance Dependence

Chronic substance abuse or misuse may lead to a substance use disorder. The DSM–5 uses the term dependence rather than addiction because the latter has pejorative connotations and, according to APA, has an uncertain definition (APA, 2013). According to the DSM–5, all categories of substances except caffeine can produce a substance use disorder.

Once a substance use disorder forms (meaning that the individual may have developed a dependence on that substance), people begin to organize their lives around satisfying their craving. The chronic use of substances may also change body chemistry because many substances replace the body’s natural chemicals. When substances are discontinued, the body takes a while to restart its natural production. In the interim, the person experiences withdrawal symptoms.

Not all substances produce physical signs of tolerance and withdrawal. The opposite is also true: Tolerance and withdrawal can exist without the craving for a substance that marks dependence.

Scientists once thought that people who abuse alcohol enter an inevitable downward spiral in which they become increasingly dependent (Jellinek, 1946), but we now know that alcohol abuse does not necessarily lead to dependence, or a substance use disorder (Wise & Koob, 2014). What is still not entirely clear is why some alcohol abusers become dependent, whereas others do not (Sobell & Sobell, 1993; Vaillant & Hiller-Sturmhofel, 1997). It is important to emphasize that dependence is much the same disorder whatever the substance involved. Dependence on multiple substances is known as polysubstance dependence, a common pattern among many substance-dependent individuals (Connor, Gullo, White, & Kelly, 2014).

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4.4 Overcoming Substance Use Disorders Substance use is often a difficult pattern to break. Even people who are highly motivated to quit may not necessarily succeed. This section illustrates the problems people face in overcoming a substance use disorder and maintaining recovery and offers some proposed solutions. Because the use of nicotine and alcohol is so common, the main focus of this section is on these two substances, but the discussion also shows how lessons learned from helping people give up common substances may be applied to less frequently used substances.

Practically all treatment programs for substance dependence combine several different methods, a strategy known as multimodal treatment. The general idea is to wean people away from a substance; help them manage their craving; and give them the skills necessary to cope with social stress, anxiety, and other potential causes of substance abuse.

Stages in Overcoming Substance Use Disorders

As summarized in Figure 4.4, people with a substance use disorder are thought to go through a series of stages in the process of recovery from substance dependence. This model was originally put forward by Prochaska and DiClemente (1983), to describe the process of quitting smoking, but it is applicable to practically any substance (see also Kougiali, Fasulo, Needs, & Van Laar, 2017). From not even thinking about ceasing substance use and not thinking that they have a substance dependence (the precontemplation stage), people move through the contemplation stage, in which they are thinking about ceasing usage and are beginning to think that they have a substance dependence, to the action stage, in which they actually quit. In the final stage, maintenance, they consolidate their treatment gains and attempt to avoid relapse. Most psychological treatment programs are aimed at the action stage, and the majority also address maintenance issues. (Click here (https://media.thuze.com/MediaSer- vice/MediaService.svc/constellation/book/Getzfeld.3794.18.1/{misc}casestudies_ch04.pdf) and see Part 2 of Robert Jones’s case.)

Figure 4.4: Lichtenstein and Glasgow’s stages of giving up a substance

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Source: Adapted from S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 6.6, p. 261.

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Detoxification

Once the action stage is reached, the first step in many treatment programs is detoxification, removal of the substance from the body. Smokers must stop smoking; alcohol-dependent people must stop drinking; heroin users must stop injecting or snorting.

To minimize withdrawal symptoms and maximize the probability that an individual will continue treatment, detoxification is usually a gradual process (Sachdeva, Choudhary, & Chandra, 2015). Sometimes, people undergoing detoxification may be prescribed anxiolytics and antidepressants to help with the stress of the withdrawal process (Sachdeva et al., 2015). Care must be taken, however, to limit the use of these drugs to ensure that people do not give up one substance only to start using another. Residential facilities (hospitals, drug treatment centers) often provide the safest environment for people undergoing withdrawal. However, inpatient treatment is more expensive than outpatient treatment, and there is little evidence that the extra expense necessarily produces better outcomes (Sachdeva et al., 2015). Most detoxifications today occur on an outpatient basis (Sachdeva et al., 2015). Inpatient treatment will offer better continuity for the patients, especially if they begin their treatment in a hospital. It also keeps the patient in an alcohol-free environment, lessening the relapse possibility. In addition, one study demonstrated that relapse rates are high for those patients who do not receive a treatment follow-up to detoxification (Polydorou & Kleber, 2008).

Detoxification does not, by itself, constitute a treatment. Many substance-dependent people go through cycles of detoxification followed by abuse and dependence followed by detoxification again (McKay & Hiller-Sturmhoefel, 2011). To break this cycle, clinicians may prescribe a medication to block the action of the substance.

People who are dependent on alcohol (an alcohol use disorder) may be prescribed a drug called Antabuse. If they take Antabuse and then consume alcohol, they will become quite ill—their hearts will race, they will vomit violently, and they may break out in soaking sweats. In theory at least, people who take Antabuse will stop drinking alcohol to avoid becoming ill (Soyka et al., 2017). Unfortunately, these aversive treatments rely on the person actually taking the Antabuse. A person who wants to drink without becoming sick needs only to stop taking the Antabuse—and that is just what many people do (Winslow, Onysko, & Hebert, 2016).

Substance Replacement and Maintenance

Some forms of substance use disorder may be so addictive that users settle for replacing a dangerous substance with a less dangerous one that they can stay on indefinitely. This is known as maintenance treatment. The most common drug maintenance program involves substituting the synthetic opioid methadone for the more dangerous opioid heroin (D’Aunno, Pollack, Frimpong, & Wuchiett, 2014). Methadone needs to be taken once a day, requiring either a daily trip to a clinic or take-home dosages. Although maintenance treatment may help some people wean themselves off heroin, it is almost certain that participants in such programs will become dependent on methadone (McCance- Katz & Kosten, 2005). Methadone maintenance is still the primary treatment approach for opioid disorders, even as buprenorphine (Subutex) and naltrexone (Vivitrol) have become more widely used (D’Aunno et al., 2014).

Highlight: Celebrities and Substance Use Disorder

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Prince passed away from an overdose in 2016.

The list of famous people and celebrities who have died as a result of a substance use disorder is lengthy and continues to expand. In May 2017, Chris Cornell, Soundgarden’s frontman, killed himself by hanging. A recovering drug addict, he was taking the anxiolytic lorazepam (Ativan) and may have overdosed. Prince died of a drug overdose in 2016. Prince had espoused clean living and to many people’s knowledge did not smoke, drink, or use illicit substances. Michael Jackson overdosed on propofol (Diprivan) as well as various anxiolytics. Amy Winehouse, a British singer and songwriter, was just 27 when she died of alcohol poisoning. What is it about being famous (or in Jackson’s, Prince’s, and, to a lesser extent, Cornell’s cases, music superstars) that could lead these individuals to develop a substance use disorder? Perhaps the pressures of fame, touring, and always being in the public eye led them to develop significant anxiety, and they saw alcohol and substance misuse as a way to cope with the anxiety.

How about you? When you have a bad day, perhaps failing an exam for which you knew the material cold, how do you handle it? Do you say, “I need a drink,” and then have one . . . or three? Is this a normal way to alleviate stress? After all, alcohol has been around since the beginning of recorded history, and besides, what is so terrible about having a beer after a long and difficult day?

For Cornell, Jackson, and the others, perhaps the media’s never-ending stream of photos, information, and gossip led to their deaths, since famous people are in the public eye every waking moment. Maybe it was the pressure of performing, or of coming up with new songs and albums, that created their problems. Or perhaps the music world attracts individuals who are prone to addiction: the addiction of fame, performing live, making millions of dollars at a young age, and being admired for their music and voices. Maybe these pressures, and the fear of losing everything quickly, led them to illicit substances.

We can only presume that these very talented individuals were suffering silently, perhaps burdened by their fame, and sought a way to disconnect, even for a short while. Sadly, if this is the case, the brief respite from reality and stress that substances provided became an addiction, leading eventually to their deaths.

Self-Help Groups

Self-help groups have a long history in the treatment of substance dependence. Alcoholics Anonymous (AA), for example, has been offering a self-help program around the world since 1935 (Nathan, 1993). Al-Anon is a related organization that provides support for the families of people dependent on alcohol (Timko, Young, & Moos, 2012). There are similar programs, such as Narcotics Anonymous, for people dependent on opioids and other substances (Miller, Gold, & Pottash, 1989). The AA program usually progresses through a series of 12 steps (see the accompanying Highlight). Alcohol-dependent people must first acknowledge their dependency, must then put their trust in a spiritual being (“a power greater than ourselves”), and must make amends to people whom they have harmed (Pagano et al., 2013). Because people are not randomly assigned to AA or a control group, it is not possible to conduct controlled clinical trials on the effectiveness of AA.

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Highlight: Some Thoughts on Alcoholics Anonymous (AA)

Chances are excellent that you have heard of Alcoholics Anonymous, or AA, sometimes called Friends of Bill W. on cruise ships and elsewhere (Bill Wilson, along with Dr. Bob Smith, founded AA). You may have some preconceived notions: that AA is for a bunch of drunks, that it’s an excuse to drink anonymously, that it’s only for men or ex-Navymen, that it’s only for alcoholics, that it espouses religion and if you’re not religious you cannot attend, or that it’s only for older people. All of these statements are unequivocally false. AA welcomes everyone: all genders and people of any ethnic, racial, or religious background, usually without an age floor (the lowest age allowed, within reason, of course). One does not need to have a substance use disorder to attend. Open meetings are for people who want to learn about AA and for those who think they may have a substance use disorder or misuse a substance—in both cases, alcohol. Typically these meetings include a speaker who relates his or her story to the audience. The attendees may take turns discussing their connection to the night’s story or theme. Closed meetings are for those who have, or think they have, a substance use disorder. Typically these meetings have a leader who discusses a theme, speaks to how the theme relates to himself or herself, and then goes around a table or the room to ask others what the theme means to them. There is never pressure to participate, nor to pay (meetings are free). A contribution “hat” may be passed, but it’s not mandatory to give. Most important, last names and even last initials are never used; the entire meeting is anonymous. Finally, although the 12 steps process has a religious overtone, AA itself is not a religious entity. According to the organization’s website, “A.A.’s Twelve Steps are a group of principles, spiritual in their nature, which, if practiced as a way of life, can expel the obsession to drink and enable the sufferer to become happily and usefully whole.”

As noted previously, AA and its relatives Al-Anon and Narcotics Anonymous have seemed to be effective in helping people to stay sober and clean. Many clinicians use these groups as a treatment adjunct (an addition to psychotherapy), and patients seem to appreciate feeling as though they are not alone.

AA is a worldwide organization and is still going strong after more than 80 years. What are your views on AA? Did you believe some of the myths shared at the beginning of this feature? Would you ever consider going to an open meeting to observe and learn?

Quoted text from www.aa.org (http://www.aa.org) .

Relapse Prevention

Most substance abuse treatment programs have high relapse rates. For example, practically all quit-smoking programs are successful at first, but after a time, 70% to 80% of participants begin smoking again. Some treatment programs attempt to improve on this by training people to deal with the potential causes of relapse before they occur. The main factor influencing relapse prevention and treatment efficacy seems to be treatment length. Longer,

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repeated, and more intense treatments produce better results than brief treatments (McKay & Hiller-Sturmhoefel, 2011). (Click here (https://media.thuze.com/MediaService/MediaService.svc/constellation/book/Get- zfeld.3794.18.1/{misc}casestudies_ch04.pdf) and see Part 3 of Robert Jones’s case.)

Treatment of Substance Use Disorder (Substance Dependence): State of the Art

Despite the best efforts of generations of psychologists, substance dependence remains difficult to treat. An 11-year follow-up study showed that 10.2% of men treated for heroin dependence were dead, 24.8% continued to use heroin, 46.6% were currently in treatment, and about 22% were involved with criminal activity (Teesson et al., 2015). More recent data reveal that, in the United States, the number of persons aged 12 or older needing treatment for an alcohol use problem was 18.0 million (6.9% of the population aged 12 or older; NSDUH, 2013). Even though the NSDUH report does not discuss the difficulty of preventing alcohol abuse or dependence relapse, practitioners and individuals with an alcohol abuse or dependence problem know the difficulty of maintaining recovery. In short, no single program seems to work for everyone.

Substance dependence is often associated with other psychological disorders (Lai, Clearly, Sitharthan, & Hunt, 2015). It is often difficult to determine whether substance abuse is the cause of another psychological disorder or its result, or both (Lai et al., 2015). In most cases, however, it is necessary to treat any serious psychological disorders before people can moderate their use of substances. The problems of mentally ill chemical abusers (MICAs) are especially severe, according to one study (Kutcher, Kachur, Marton, Szalai, & Jaunkalns, 1992). MICAs, who are most often young males, are generally poor, homeless, sickly, and likely to get into legal difficulties.

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4.5 Prevention of Substance-Related Disorders Although they vary in their specifics, all clinical-based programs for substance dependence focus on the individual. The social forces maintaining substance abuse—peer pressure, lack of knowledge, advertising (in the cases of nicotine and alcohol), and legal restrictions—are rarely addressed. Clinical programs are also expensive; they involve multiple sessions, and only limited numbers of people can be treated at one time. In contrast, prevention programs have the potential to save money because keeping disorders from developing is usually cheaper than treating disorders after they develop. Prevention programs may benefit the most people who are unable to access or afford clinical treatment.

Legal Restrictions

Perhaps the most straightforward approach to the primary prevention of substance abuse and dependence is to use the legal system. However, because legal restrictions on exposure to drugs have had limited success, public health authorities have argued that restricting access might be a more effective means of preventing substance abuse (Stockings et al., 2016).

One approach to restricting access is to ban substance use in certain settings. Smoking, which was once common in offices, restaurants, planes, and theaters, is now prohibited in most public areas. As the number of places where smoking is permitted decreases, smokers have fewer opportunities to pursue their habit. Thus, making smoking inconvenient may reduce its prevalence (Stockings et al., 2016).

Health Education Programs

Although people who use substances are usually aware of the health risks, they tend to believe that these risks apply more to other people than to themselves (Gibbons, McGovern, & Lando, 1991). This feeling of invulnerability, which applies to adults as well as adolescents (Quadrel, Fischhoff, & Davis, 1993), may explain why people continue to use dangerous substances even when they know they are harmful (Gibbons, Kingsbury, & Gerrard, 2012). The main value of health warnings (such as the surgeon general’s warning on cigarette packages or television commercials that talk about the perils of drug use) is in moving those who use substances from the precontemplation to the contemplation stage of the quitting process, at which point other, more powerful interventions take over.

Specific Educational Programs

Global educational programs provide information about substances, but they do not address the factors that maintain substance use: peer pressure, mood changes, advertising, avoidance of withdrawal, and stress reduction. Specific educational interventions designed to teach those at risk how to resist these influences and temptations, and how to deal with stress and withdrawal, may have a greater chance of succeeding (Ksir et al., 2008).

Worksite Programs

As their name suggests, worksite programs are delivered to workers, and sometimes their families, at their places of employment. With the cooperation of employers, workers are given time off to attend these programs and may even be rewarded for success. In an attempt at secondary prevention, some employers also use chemical tests to screen

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employees for substance use. However, such programs raise certain ethical problems involving consent and disclosure of purpose (Forrest, 1997).

Highlight: Substance Use on the Big Screen

Do these titles sound familiar: Arthur, Fast Times at Ridgemont High, Harold and Kumar Go to White Castle? They are all Hollywood comedies that have as a central theme excessive alcohol or drug usage. In each film (and in far too many others to mention), the excessive usage is portrayed in a comedic fashion. To be sure, these films are quite funny, as comedies should be. But what kinds of messages do they send to the general public who watches them? In Fast Times, Sean Penn’s character, Spicoli, is perpetually stoned; the same is true for Kumar in that film series. Arthur is virtually always intoxicated.

Should the general public be laughing at individuals who, if they came into a psychologist’s office, would most likely be diagnosed with a substance use disorder? Is being perpetually stoned or drunk something that is funny, or is it dangerous? More important, let’s presume that the majority of the population does not understand what a substance use disorder is, and that these films (and similar television shows) are their primary exposure to the disorder. How could we make audiences understand that these comedic portrayals are fictitious, and that a real substance use disorder is not funny at all, but instead presents a risk to the person’s life, as well as to loved ones, family members, and innocent people, especially if the person chooses to drive while intoxicated?

An important component of a helping professional’s job is being an educator. We need to continue to educate the public about what a substance use disorder is, about how it truly presents itself, and, most important, that the situations and characters seen in movies, while amusing, are designed to make us laugh and are not accurate portrayals of the facts.

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Chapter Summary

Psychoactive Substances: Some Basic Information Practically everyone has used a psychoactive substance at some time in their lives. These substances form a spectrum, from those that are commonly used, such as caffeine, to highly dangerous drugs such as heroin and other opioids. Caffeine, nicotine, alcohol, and cannabis are the four psychoactive substances most commonly used by American college students. Caffeine is found in many drinks, as well as in headache, diet, and cold medications. Nicotine is the psychoactive ingredient in tobacco. Alcohol is found in wine, beer, spirits, and many medications. And cannabis is a type of hemp plant whose leaves may be ingested in a variety of ways. Caffeine and nicotine are stimulants; they combat drowsiness, increase alertness, and help produce energy. Alcohol is a depressant, which slows body processes and induces sleep. Cannabis has a variety of stimulant and depressant effects. It also has the potential to produce sensory and cognitive distortions. Although caffeine and nicotine may be dangerous to one’s health in large doses, they have not been linked to any specific illness. At higher doses, alcohol can cause serious health problems, and cannabis smoke may be as dangerous as cigarette smoke. Although both caffeine and nicotine are stimulants, many people claim to find them relaxing. This may be a reflection of their ability to enhance the body’s natural opioids. Relaxation may also be the result of cognitive expectancies and social reinforcement. A third possibility is that some personality types (extroverts) are chronically underaroused, a state they find unpleasant. Because stimulants increase their arousal to “normal” levels, they find these substances produce pleasant feelings.

Why Are Psychoactive Substances So Popular? People begin to use substances such as nicotine, alcohol, and opioids partially because of social conformity. Certain personality traits—extroversion, for example—may also encourage people to use substances.

Potential Problems of Sustained Substance Use Using substantial amounts of many substances can result in intoxication. Chronic use of substances may also produce tolerance, forcing users to continually increase the amount they consume to achieve the same effect. When one has a substance dependence, abruptly ceasing a habitually used substance can produce the unpleasant symptoms characteristic of withdrawal.

Overcoming Substance Use Disorder First, the person must decide to change. Next comes an active attempt to change. Finally, the new behavior must be maintained.

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Most psychological interventions are aimed at the action stage; many also target the maintenance stage. Practically all treatment programs aimed at substance abuse and dependence are multimodal (they combine several treatment methods). Sometimes, replacing one substance with another, less dangerous one (replacing cigarettes with nicotine patches, for example) can assist the treatment process. In addition to positive treatments, aversive conditioning has also been widely used to help people who are dependent on substances.

Prevention of Substance-Related Disorders Public health interventions have the potential to reach many more people at much less cost than psychological interventions. Although they may be valuable in getting people to think about quitting, outright prohibition and global educational programs have not proved successful in reducing substance dependence. Worksite programs and self-help strategies have the potential to help many people give up substances.

Critical Thinking Questions 1. Let’s assume that you are a regular coffee, tea, or cola drinker. How difficult would it be for you to quit

drinking “cold turkey,” that is, to stop drinking these beverages completely, with no treatment interventions? 2. Some people believe that a substance use disorder (substance dependence) is a moral flaw and is the fault of

the dependent individual—that is, the individual can stop whenever he or she likes. What are your views on this perspective?

3. The chapter notes that some psychoactive substances cannot lead to physiological dependence. Discuss your views on this.

4. Alcoholics Anonymous (AA) has been around for more than 80 years, and, in spite of no solid research support, the organization seems to be successful. How can a self-help group where no therapy is provided help people stay sober and straighten out their lives?

5. Discuss your views on using psychoactive substances like methadone to treat opioid dependence. 6. We have mentioned elsewhere that psychotropic medications such as anxiolytics can be used to treat

psychiatric disorders. It is possible to become dependent on some of these medications. What is your perspective on this? Is helping to treat a condition worth the risk of dependence?

Key Terms

agonist A chemical that increases the potency of other chemicals.

alcohol (ethanol) The second most commonly used psychoactive substance in the United States.

alcohol dehydrogenase (ADH) An enzyme that breaks down alcohol in the stomach and the liver.

alcoholic myopia

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Narrowing of focus to the immediate.

antagonist A chemical that reduces the potency of other chemicals.

binge drinking Consumption, for a male, of five or more alcoholic drinks in a row on at least one occasion during a two-week period; for a female, it is four or more drinks.

caffeine A stimulant; the most commonly used psychoactive substance in the United States.

cannabis Marijuana or pot; a type of hemp plant that produces several psychoactive substances such as marijuana and hashish.

craving A strong desire or urge to use a substance.

delirium tremens (the DTs) A symptom of alcohol withdrawal, which can include hallucinations, disorientation, insomnia, physical discomfort, shaking, and nausea.

depressant A psychoactive substance that lowers arousal and makes people drowsy.

detoxification Removal of a substance from the body, usually done in an inpatient setting.

endorphins Chemicals in the body that inhibit pain and produce pleasure.

ethologists Scientists who observe natural behavior in humans and animals.

expectancies What people expect when they use a drug or substance.

extroversion A personality trait ​commonly found in people born with low levels of arousal. The experience of low arousal is perceived as unpleasant, so extroverts continuously seek stimulation.

fetal alcohol syndrome (FAS) A disorder marked by intellectual disabilities, hyperactivity, facial deformities, heart defects, and organ malfunctions due to the mother’s excessive alcohol consumption during pregnancy.

hallucinogen A psychoactive substance that produces distorted sensations and perceptions (hallucinations).

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lysergic acid diethylamide (LSD) A very powerful hallucinogen.

mentally ill chemical abusers (MICAs) Individuals, often young males, generally poor, homeless, sickly, and likely to get into legal difficulties, who misuse chemical substances.

multimodal treatment Programs that combine several different methods to cure substance dependence.

nicotine A psychoactive substance found in cigarettes; it acts quickly and is addictive.

polysubstance dependence Dependence on multiple substances.

psychoactive substances Chemicals that alter a person’s moods or behavior.

risk factors Characteristics, genetic or otherwise, that seem to be associated with an increased risk of disease onset or recurrence.

stimulants Substances whose main psychoactive effects are to increase alertness.

substance use disorder (substance dependence) A condition in which the individual has a recurring pattern of ​substance-related difficulties. The more ​criteria the individual satisfies, the more likely the individual is physiologically ​dependent on that substance.

THC (delta-9-tetrahydrocannabinol) The psychoactive ingredient in marijuana.

tolerance The body’s response to a drug wherein it takes more (sometimes less) of a psychoactive substance to achieve the same effect.

withdrawal The physiological effects suffered by an individual once a psychoactive substance has been removed from the body.

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Chapter Objectives

After reading this chapter, you should be able to do the following:

Describe the stages of the normal sleep cycle.

Know and describe the main differences between the major sleep-wake disorders.

Understand the main ways to treat sleep disorders.

Know and describe the main feeding disorders.

Know and describe the major differences between anorexia nervosa, bulimia nervosa, and binge-

7 Sleep-Wake and Eating Disorders

fpwing/iStock/Thinkstock

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eating disorder.

Describe some of the methods used to treat eating disorders.

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7.1 An Introduction to Sleep-Wake Disorders: The Normal Sleep Cycle We sleep close to 3,000 hours per year, which means that we spend about one third of our lives asleep. However, according to the National Sleep Foundation (2017), about 40% of people in the United States don’t get enough sleep, and lack of proper sleep can lead to health problems (Depner, Stothard, & Wright, 2014; Liu, 2016; Schochat, Cohen-Zion, & Tzischinsky, 2013).

The normal human sleep cycle consists of four different stages of sleep, one of which involves rapid eye movement (REM) and three of which do not (non-REM, or NREM, sleep). The cycle begins with NREM Stage 1, which begins shortly after you fall asleep. In this stage, which lasts from 1 to 10 minutes, you are lightly asleep. However, you can quickly and somewhat easily return to being fully awake. Although you are asleep, you may wake up from this stage feeling like you didn’t sleep at all. The next stage is NREM Stage 2. This stage lasts about 20 minutes and is characterized by a slowing heart rate and a decrease in body temperature. You spend about 45% of your sleep time in NREM Stage 2 sleep. Your body reduces its activity to prepare you to go into a deep sleep, and it becomes harder to wake you up. Typically, NREM Stages 1 and 2 are referred to as light sleep. NREM Stage 3 comes next. This stage is the combination of what was previously separated into Stage 3 and 4 sleep and typically starts 35 to 45 minutes after falling asleep. Your brain waves slow down and become larger. In this stage, you will sleep through most potential sleep disturbances (noises and movements) without showing any reaction. If by some chance you actually wake up during NREM Stage 3 sleep, there is a good chance that you will feel disoriented for the first few minutes. Sometimes this stage is referred to as “slow-wave sleep” or “delta sleep.”

The final stage of a normal sleep cycle is called REM Stage 4. The first REM sleep stage lasts around 10 minutes and usually happens after having been asleep at least 90 minutes. Your eyes move rapidly in all directions during REM sleep, almost as though you are watching a movie. Typically, REM stages get longer and longer as the night goes by. Dreams (and nightmares) usually happen during the last REM stage, which can last an hour and is the deepest. This stage is also known as “paradoxical sleep.” One reason for this: Even though your brain is quite active during the stage, most of your muscles are paralyzed (Chieh, 2015).

The two main types of sleep disorders are the dyssomnias (irregularities or abnormalities in the amount, quality, or timing of sleep) and the parasomnias (sleep disturbances that result from unusual or abnormal events that occur when one is asleep, typically during the night). Psychological factors can play an important role in these disorders. Parasomnias can occur during both REM and NREM sleep. Somnambulism (sleepwalking) and enuresis (bedwetting) occur during the REM stage. We will describe the major sleep-wake disorders in the next two sections.

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Insomnia affects nearly 50% of the U.S. population every year.

7.2 Dyssomnias Dyssomnias are disorders that affect the initiation or maintenance of sleep, which includes nighttime wakefulness, or excessive sleepiness. They include insomnia disorder, hypersomnolence disorder, narcolepsy, breathing-related sleep disorders, and circadian rhythm sleep-wake-disorders.

Insomnia Disorder

Insomnia involves a disturbance in the amount, quality, or timing of sleep that occurs at least three nights per week for at least 3 months (American Psychiatric Association [APA], 2013). The most common sleep-wake disorder is insomnia, called insomnia disorder in the DSM–5. Insomnia disorder is characterized by difficulty falling asleep, maintaining sleep, or not feeling rested after normal amounts of sleep, occurring at least three nights per week for at least three months (American Psychiatric Association [APA], 2013). Difficulty maintaining sleep is defined in the DSM–5 as having frequent awakenings or problems returning to sleep after awakening. Overall, about one third of all adults report some symptoms of insomnia, and about 6% to 10% meet the diagnostic criteria for insomnia disorder (APA, 2013; Morin & Jarrin, 2013). The National Sleep Foundation estimates that almost 50% of the U.S. population experiences some symptoms of insomnia during a given year (Morin & Jarrin, 2013). Typically these individuals go through the day quite sleepy and may have difficulty performing tasks, especially those that require memory and recall. This can also be dangerous as individuals may get sleepy while driving. Insomnia might be a result of the individual being under too much stress and being unable to cope, or perhaps being depressed or anxious. Insomnia can occur only on some nights but not others, or it can have a more chronic pattern, lasting weeks to many months, or even lasting a lifetime after onset.

Hypersomnolence Disorder (Hypersomnia)

Hypersomnolence disorder is characterized by excessive sleepiness even though the individual may have slept at least seven hours (this qualifies as a lot of sleep for many people these days). If a person has slept for more than nine hours per day and does not feel refreshed, this qualifies as hypersomnolence. To qualify for the diagnosis, this problem must occur at least three times a week for at least three months. Typically, the individual will have difficulty getting out of bed or may take frequent daily naps. Unlike insomnia, which occurs twice as often in women (Pallesen, Sivertsten, Nordhus, & Bjorvatn, 2014; Taylor, Bramoweth, Grieser, Tatum, & Roane, 2013), hypersomnolence occurs more frequently in men (Billiard & Sonka, 2016).

Narcolepsy

What if an individual quickly and unexpectedly falls asleep and goes directly into REM sleep? Narcolepsy is marked

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by sudden and repeated “attacks” of REM, or dream-state, sleep that may be accompanied by a brief loss of muscle tone, called cataplexy. The individual might fall asleep during a conversation or an important presentation, or might fall asleep without warning while driving. Like the other dyssomnias already discussed, the individual must have, minimally, episodes three times per week for at least three months. Narcolepsy tends to be rare, affecting about 0.02% to 0.04% of the population (APA, 2013; Partinen et al., 2014). It seems that the sudden REM sleep attacks may be set off by strong emotional events such as extreme excitation, happiness, or anger. In addition, it is now known that narcolepsy is caused by an orexin (hypocretin) deficiency (APA, 2013). Orexin, also called hypocretin, is a neurotransmitter that regulates and is involved with arousal, wakefulness, and appetite. The most common form of narcolepsy, involving cataplexy, is caused by a lack of hypocretin in the brain due to destruction of the cells that produce it.

Breathing-Related Sleep Disorders

Breathing-related sleep disorders are caused by sleep-related breathing difficulties that lead to excessive sleepiness or insomnia. Individuals who suffer from these disorders have interrupted sleep many times during the night and do not feel rested even when they get more than the typical amount of sleep (eight hours). These disorders are subdivided into obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation. In obstructive sleep apnea hypopnea, the individual may stop breathing for as long as 30 seconds many times during the night, with minimally five obstructive apneas or hypopneas per hour of sleep. This may occur hundreds of times during the night, but the victim is unaware that it is occurring. Typically the individual is significantly overweight and will be a loud snorer. Obstructive sleep apnea hypopnea is associated with obesity, or being minimally 30 pounds overweight, as defined by the National Institutes of Health (Drager, Toreiro, Polotsky, & Lorenzi-Filbo, 2013), and may also be associated with increasing age (Franklin & Lindberg, 2015). Obstructive sleep apnea hypopnea can also be associated with trauma (Tamanna, Parker, Lyons, & Ullah, 2014), and it can lead to increased blood pressure and may lead to a stroke. Typically, this disorder is more common in males (Peppard et al., 2013).

Central sleep apnea is the occurrence of at least five central apneas per hour of sleep. It needs to be diagnosed via polysomnography. Polysomnography, also called a sleep study, records the individual’s brain waves, blood oxygen level, heart rate and breathing, as well as eye and leg movements. Polysomnography usually is done at a sleep disorders unit within a hospital or at a sleep center. Typically this is done at night so that the test can record the individual’s nighttime sleep patterns, but it can be performed during the day to accommodate those who work at night. An important function of this test is that it can be used to help adjust the treatment plan for an individual who has already been diagnosed with a sleep disorder (Mayo Clinic, 2017).

Finally, in sleep-related hypoventilation, which also must be diagnosed via polysomnography, the individual has decreased respiration while asleep, as demonstrated by elevated carbon dioxide levels (APA, 2013).

Circadian Rhythm Sleep-Wake-Disorders

Circadian rhythm sleep-wake disorders refers to a series of sleep-wake problems in which individuals have difficulty sleeping at the times required for work, school, or other aspect of their lives. Typically this occurs when individuals do shift work; they may work two normal days in a row, then work three days during the night (Wright, Bogan, & Wyatt, 2013). The sleep disturbance leads to excessive sleepiness, insomnia, or both (APA, 2013). One easy way to treat this disorder, at least in theory, is to encourage the individual to get a job that has consistent working hours.

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Etiology

Insomnia disorder can have a variety of causes. First, people who have insomnia disorder may not become sleepy until much later at night because their body temperature doesn’t drop enough for them to fall asleep (Miller et al., 2015). Drug and alcohol usage can also contribute to insomnia disorder, as can changes in light, noise, or temperature. Psychological factors can also play a role, specifically stressful events occurring during the day (LeBlanc et al., 2007). Individuals may also misperceive how much sleep they need. In addition, they may not fully appreciate how disruptive interrupted sleep is. Insomnia disorder can also be a learned behavior. For example, the individual may associate the bed and bedroom with negative thoughts or feelings related to frustrations falling asleep; therefore, bedtime sets off anxiety reactions (Stepanski, 2006).

Breathing-related sleep disorders can also contribute to insomnia disorder. Another etiological factor may be our always-on world—when most of us spend large amounts of time using smartphones and other electronic devices.

One interesting causal factor can be daytime naps—a common way that people try to make up for lost sleep at night. These naps can interrupt sleep the next night as the body’s natural rhythms are upset. In addition, a person may think that daytime naps are a good way to compensate for lost sleep and so may anticipate the naps and, subsequently, be unable to fall asleep or have sleep disruptions at night.

Some of the sleep-wake disorders run in families, which is not a causal factor, as such, but might offer a research direction in the future (Gehrman, Keenan, Byrne, & Pack, 2015). In fact, some research has shown that 39% of people who had hypersomnolence disorder had a family history of it (Guilleminault & Pelayo, 2000). Narcolepsy may also run in families (Ohayon, 2016).

Treatment

The most commonly used medical treatments for sleep-wake disorders that include insomnia involve prescribing medications, specifically the benzodiazepines or related medications. These medications include zolpidem (Ambien) and zaleplon (Sonata), two examples of short-acting drugs. Longer-lasting drugs include flurazepam (Dalmane), a benzodiazepine. Short-acting drugs are often preferred as they will have stopped working by morning and will not produce daytime drowsiness. These drugs do have negative effects though. Benzodiazepines can cause excessive sleepiness and can lead the individual to become dependent on them. They are also designed for short-term use; long-term use can lead to dependence. Ambien, in particular, has been documented to cause sleepwalking-related problems in some people (Pagel, 2014), and nocturnal eating episodes in others (Pagel, 2014; Paulke, Wunder, & Toennes, 2015).

Stimulants such as amphetamine or Ritalin are often prescribed for narcolepsy or hypersomnolence disorder (Lopez, Arnulf, Drouot, Lecendreux, & Dauvilliers, 2017). For breathing-related sleep disorders, such as obstructive sleep apnea hypopnea, weight loss is often strongly recommended, but individuals given this advice are typically unsuccessful at conquering their disorder because they often fail to lose weight or maintain weight loss (Sanders & Givelber, 2006). Mechanical devices to improve breathing during sleep, or to reposition the tongue or jaw during sleep, have also been tried, again typically with little success because of the discomfort these methods produce. One assistive mechanical device, which is quite cumbersome, is called a continuous positive airway pressure (CPAP) machine. A CPAP machine delivers just enough air pressure to a mask to keep the upper airway passages open while the user is asleep, thus assisting breathing and making sleep apnea and poor sleep less likely. This can also be used to prevent very loud snoring, a result of sleep apnea as well as of being morbidly obese (Qaseem, Barry, Denberg,

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Owens, & Shekelle, 2013).

Simple environmental treatments (altering the environment to make changes in the individual’s behaviors) for sleep disorders include making bedtimes several hours later than normal and using bright light to help fool the brain into thinking it’s earlier than normal, known as phototherapy (Dagan, Borodkin, & Ayalon, 2006).

Relaxation techniques, described in Chapter 3, have been used to successfully treat insomnia disorder (Zacharie, Lyby, Ritterband, & O’Toole, 2016). Stimulus control techniques have also been used with greater success in treating insomnia disorder (Harvey et al., 2014). In this technique, the individual is asked to use the bed for only two things: sleep and sex. This, of course, is easier said than done, as many people read, watch television, and also eat in bed. In effect, we ask the individual to redefine the purpose of the bed and the bedroom. Our constantly being connected to smartphones or tablets can also be a problem, especially before bedtime. Studies have shown that the light from screens in the evening alters sleepiness and alertness, and suppresses melatonin levels (Chang, Aeschbach, Duffy, & Czeisler, 2015). Reducing time spent using these lighted screens before bedtime might help decrease insomnia.

Finally, establishing a good sleep hygiene program, taking steps during the day and before bedtime to ensure a good night’s sleep, is also effective. Avoiding caffeine and nicotine well before bedtime, setting a regular bedtime for each night, and making sure the bedroom is the proper temperature each night are some of the preventive measures that seem to be effective (Irish, Kline, Gunn, Buysse, & Hall, 2015).

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7.3 Parasomnias The DSM–5 parasomnias include non–rapid eye movement sleep arousal disorders (sleep terror and sleepwalking types) and nightmare disorder.

Non–Rapid Eye Movement Sleep Arousal Disorders, Sleep Terror Type

Non-rapid eye movement sleep arousal disorder, sleep terror type is not related to nightmares (dreams arousing feelings of intense fear, horror, and distress) as sleep terror disorder occurs during NREM sleep, whereas nightmares occur during REM sleep. Typically sleep terrors affect children and cause them to awaken with a frighteningly loud scream. The child will have a rapid heart rate, be very upset, and often be sweating profusely. Typically, sleep terrors appear in children, disappear in adolescence, and affect up to 6% of children at one time or another (APA, 2013). Oddly enough, children do not recall sleep terrors (Tinuper, Bisuli, & Provini, 2012). Sleep terrors affect about 2% to 4% of adults (Carrillo-Solano, Leu-Semenescu, Golmard, Groos, & Arnulf, 2016).

Non–Rapid Eye Movement Sleep Arousal Disorders, Sleepwalking Type

Non-rapid eye movement sleep arousal disorders, sleepwalking type (sometimes called somnambulism when it recurs) is primarily a childhood disorder that, surprisingly to most people, occurs during NREM sleep (APA, 2013). It typically occurs during the first few hours of sleep (the first third of sleep). Affected individuals will usually leave their beds repeatedly during the night and walk around without being conscious of doing so or being able to recall doing so later, once awake. It is not dangerous to awaken a sleepwalker, but if left alone, the individual will typically return to bed. Statistics vary, but anywhere from 2% to 5% of children have repeated episodes (APA, 2013) and up to 40% of children may have at least one episode (APA, 2013). Stress and extreme fatigue may be related to sleepwalking (APA, 2013). Sleepwalking usually ends by the time a child reaches age 15. Like night terrors, this disorder affects about 2% to 4% of adults (Carrillo-Solano et al., 2016).

Nightmare Disorder

We mentioned nightmares earlier, but when do nightmares become nightmare disorder? According to the DSM–5, the extended and unfortunately well-remembered dreams of nightmare disorder usually have themes of “avoiding threats to survival, security, and physical integrity” and “generally occur during the second half of a major sleep episode” (APA, 2013, p. 404). Typically the individual will awaken rapidly and do so repeatedly following a nightmare. Nightmare disorder tends to affect women slightly more so than men (Sandman et al., 2013).

Etiology and Treatment

We still know little about the etiology and treatment of parasomnias (Owens & Mohan, 2016; Tinuper et al., 2012), and currently there are few recommended treatments for these disorders. One efficacious method used to treat and eliminate sleep terrors in children is scheduled awakenings, in which the parent is told to wake the child about 15 to 20 minutes before each sleep terror episode is expected to begin (Kuhn & Elliot, 2003; Mindell, Kuhn, Lewin, Meltzer, & Sadehet, 2006). The same method can be used with adults. Typically adults can go to a sleep disorders clinic, where their sleep patterns and behaviors can be observed and measured (for example, with an electroencephalograph, or EEG). Behavior modification techniques can be used, as well as psychotherapy to see if

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the nightmares have recurring themes. An efficacious method is for someone observing an individual having nightmares or night terrors to take notes and record the themes, if the individual can recall the nightmares or night terrors on waking (Owens & Mohan, 2016).

In sum, we still do not know a lot about sleep disorders, but we do know that many individuals in the United States do not get enough sleep, making problems more likely to occur. Research continues into these somewhat puzzling disorders.

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7.4 Feeding Disorders Like all animals, humans must eat regularly and properly in order to stay physically and psychologically healthy, to survive, and to thrive. Individuals who have a feeding or an eating disorder may eat too much in too short a timeframe, or they may eat too little and thus lose a significant amount of weight, becoming dangerously underweight for their height or age. (See the accompanying Highlight for a look at eating disorders in a modern context.) Alternatively, they may eat nonnutritive or nonfood substances, such as wood shavings or lead paint chips.

Highlight: Eating Disorders and the Internet

The possibilities are quite strong that you have heard of pro-anorexia (pro-ana) and pro-bulimia (pro-mia) websites. An Internet search will reveal a lot of them. What are these sites about? Generally speaking, they promote anorexia nervosa and bulimia nervosa as lifestyle choices as well as diet options. The creators of these sites see nothing wrong with these behaviors. For example, a 16-year-old blogger shared this piece of advice: “Wear a rubber band around your wrist and snap it when you want to eat. Food = pain.” Most people would agree that this statement promotes unhealthy, potentially lethal behavior. But what about the women who think this is normal? How can we hope to help them and provide treatment to them if they see these kinds of statements online, promoted as normalcy? These sites also equate amenorrhea as a measure of successful weight loss, whereas the DSM–IV–TR saw this as a diagnostic criterion for anorexia nervosa. Clearly there are different perspectives here.

Pro-mia websites are the same, except they focus on bulimia nervosa, not anorexia nervosa. Many people are not aware that such sites exist, yet once they view them, for the most part, they become disturbed by what they read. In the United States, freedom of speech is a fundamental right, but perhaps the creators of these kinds of sites should think about the consequences of the behaviors they are promoting. Some social media sites have attempted to ban or restrict such sites, but they usually just pop up elsewhere. What is your perspective?

Pica

Pica is an unusual eating disorder that occurs in people across socioeconomic groups, ages, and genders (Stiegler, 2005), although it may be more prevalent among women, children, and those of lower socioeconomic status (Delaney et al., 2015; Kelly, Shank, Bakalar, & Tanofsky-Kraff, 2014). The name pica comes from the Latin word for “magpie,” a bird known to eat practically anything. This is precisely the problem in pica. People with this disorder have been known to eat dirt, laundry starch, chalk, buttons, paper, cigarette butts, matches, sand, soap, toothpaste, and many other supposedly inedible substances. The main DSM–5 diagnostic criteria for pica appear in Table 7.1. Note that it is important to consider cultural practices when making this diagnosis. Members of cultures that sanction the consumption of odd substances, such as clay, are not suffering from a psychological disorder.

Table 7.1 DSM–5DSM–5 diagnostic criteria for pica

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A. Persistent eating of nonnutritive, nonfood substances over a period of at least one month. B. The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the

individual. C. The eating behavior is not part of a culturally supported or socially normative practice. D. If the eating behavior occurs in the context of another mental disorder (e.g., intellectual disability

[intellectual developmental disorder], autism spectrum disorder, schizophrenia) or medical condition (including pregnancy), it is sufficiently severe to warrant additional clinical attention.

Specify if: In remission: After full criteria for pica were previously met, the criteria have not been met for a sustained period of time.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©2013), pp. 329–330. American Psychiatric Association. All Rights Reserved.

The prevalence and cause of pica are unknown. Psychological theories tend to be vague (for example, “fixation at the oral stage of development”). Physiological explanations are not much better. Most are based on the idea that diet deficiencies (too little iron or zinc, for example) cause a craving for anything containing these missing minerals. Yet most of the items craved by people with pica do not actually supply the missing minerals.

Rumination Disorder and Avoidant/Restrictive Food Intake Feeding Disorder

The DSM–5 includes two other feeding disorders usually found in infants or young children: rumination disorder and avoidant/restrictive food intake feeding disorder. Rumination disorder is marked by regurgitation of food, whereas avoidant/restrictive disorder of infancy is manifested by inadequate eating. Both disorders are diagnosed only when there is no clear medical condition causing the symptoms, and little is known about the prevalence or etiology of either one (APA, 2013; Delaney et al., 2015).

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7.5 Eating Disorders What do Lady Gaga, Demi Lovato, Paula Abdul, Fiona Apple, Oprah, and the late Princess Diana have in common? All of these women had an eating disorder, in most cases bulimia nervosa (described later in this section). To their credit, many if not most of them have been or were open about their struggles.

Eating disorders refer to extreme disturbances in eating behavior. Two core features of eating disorders are an obsession with losing weight and a morbid fear of gaining weight. The hallmark characteristic of eating disorders is the desire for, and perhaps obsession with, getting thin or remaining thin. In this section we will examine the two most common eating disorders, anorexia nervosa and bulimia nervosa. Anorexia nervosa is marked by an obsessive and irrational fear of gaining weight, with a resultant major reduction in food intake (known as restriction), so much so that the individual loses a significant amount of body weight (APA, 2013). Those suffering from bulimia nervosa may be obsessed with maintaining weight by binging (out-of-control eating) and then using an inappropriate compensatory behavior (such as fasting or using laxatives) to prevent weight gain (APA, 2013).

We will also briefly examine binge-eating disorder (BED), which was first identified in the 1990s and was under further review in the DSM–IV–TR. This disorder has now been included as a diagnosis in the DSM–5 (APA, 2013). Individuals with BED experience marked distress as a result of their binging. However, binging is not then followed by inappropriate compensatory behaviors, defined as purging or restriction (that is, self-starvation) as it is with other eating disorders. (See the comparison of eating disorders in Figure 7.1).

Figure 7.1: Similarities and differences among eating disorders

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Source: A d a p t e d A d a p t e d f ro m f ro m S . S . S c h w a r t z , S c h w a r t z , Abnormal Psychology: A Discovery Approach. M o u n t a i n M o u n t a i n Vi e w, Vi e w, C A : C A : M a y fie l dM a y fie l d P u b l i s h i n g P u b l i s h i n g C o m p a n y, C o m p a n y, 2 0 0 0 , 2 0 0 0 , Ta b l e Ta b l e 1 2 . 6 , 1 2 . 6 , p . p . 5 4 3 . 5 4 3 .

In this chapter, we frequently focus on women when discussing anorexia nervosa and bulimia nervosa. We do so simply because these disorders overwhelmingly affect females; perhaps as many as 90% to 95% of individuals with anorexia nervosa and bulimia nervosa are female (Smink, van Hoeken, Oldehinkel, & Hoek, 2014). Data point to the lifetime prevalence of anorexia nervosa as ranging anywhere from 0.5% to 2% of the female population in Western countries; some researchers estimate that the prevalence is closer to 0.3% (Litmanen, Fröjd, Marttunen, Isomaa, & Kaltiala-Heino, 2017). Another study suggests that as many as 5% of women develop bulimia from ages 14 to 15 (Kjelsas, Bjornstrom, & Gotestam, 2004), and a more recent estimate puts the rate of bulimia in men at about one- tenth the rate in women (APA, 2013). This discrepancy leads researchers to hypothesize that gender and/or gender roles may somehow be involved in the development of eating disorders. It has also been hypothesized that hormones and estrogen levels may be involved (Getzfeld, 2006).

Eating disorders did not attract much research until the 1960s (Fairburn & Brownell, 2002; Striegel-Moore & Smolak, 2001). More important, anorexia nervosa and bulimia nervosa did not appear in the DSM until the DSM–III (APA, 1980). Due to the late acknowledgment of eating disorders in the research community, the scientific and research information that we have on bulimia and anorexia nervosa is somewhat limited. It is remarkable that we know as much as we do about these disorders given the relatively short period of time in which they have been scientifically investigated. Before we examine anorexia nervosa, let’s meet Paula Ames in Part 1 of her case study.

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The Case of Paula Ames: Part 1

Paula, a 31-year-old single Caucasian female, is an undergraduate student in liberal arts at a major university. Paula’s height is approximately 5’6” and she was initially reluctant to share her weight with her psychologist. Paula works as a waitress full time in order to pay her tuition and to make ends meet. Paula was pleasant during the sessions but often seemed rather tense and on edge. She kept checking her watch, and she wore long sleeves even though it was summer.

Excerpt From Transcript of Treatment Session Conducted by Dr. Brian Philipps With Paula Ames

Brian Philipps, Ph.D. Psychologist

Transcript of Treatment Session: Paula Ames

Client: Paula Ames

Therapist: Dr. Brian Philipps

DR. PHILIPPS: What brings you to therapy today, Paula?

PAULA: I need to finally shut certain people up, especially my Mom and my fiancé. They have really been driving me crazy about my eating. It’s not like I do anything odd; most women diet before their wedding. My wedding is in a few months, and I need to fit into my dress. I need to lose a few pounds, but I do like my food. I’m also not the biggest fan of crowds . . . I don’t do well in social situations . . . everyone always seems to be staring at me, so we are trying to keep the number of guests down.

DR. PHILIPPS: I would like to try and understand why your family and future husband might, as you say, be concerned about your eating. Would you be able to describe your diet for me?

PAULA: Well, I’m tall—5’6”—and I weigh . . . do you need to know exactly, because I can tell you exactly. Like, I know how to calculate accurately as I bought a very expensive scale. I weigh 92 pounds and that is too much. I want to be a beautiful bride, so I need to lose about maybe 5 more pounds to get into the best dress I can afford. This is my day, my fairytale. Cinderella wasn’t fat like I am. I look at my arms and see the flesh hanging off . . . blech.

DR. PHILIPPS: I see. And would you be able to describe your eating behaviors?

PAULA: I eat . . . What is it with you people? Food is not a problem for me. I told you I need to get to the proper size before my wedding. I’m a flabby Patty right now, and a flabby bride won’t do. My fiancé will leave me at the altar if I don’t lose a bit more.

DR. PHILIPPS: Could you perhaps be more specific about your eating behaviors? For example, what do your meals look like on a daily basis? How would you say you manage your weight?

PAULA: Manage my weight? Not real well as you can see. I eat normal meals, cereal at breakfast, sandwich for lunch, yogurt for dinner, maybe iceberg lettuce. Always drink water, as that’s the healthiest, or tea plain.

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No coffee or coffee specialty drinks. I need to keep my calories down, no more than 500 a day tops; 300 is much better, of course.* Sometimes I exercise to keep the weight off or to lose the weight. But I can handle food; it’s not a weird thing for me.

Click here (https://media.thuze.com/MediaService/MediaService.svc/constellation/book/Get- zfeld.3794.18.1/{misc}casestudies_ch07.pdf) for full case study.

*Note: The suggested calorie count for females is anywhere between 1,500 and 2,000 calories per day.

Anorexia Nervosa

Anorexia nervosa literally means “nervous loss of appetite,” though this is misleading as the individual usually maintains an appetite. Three DSM–5 criteria need to be met for a diagnosis of anorexia nervosa.

First, individuals must refuse to maintain their minimally normal body weight for their age, sex, developmental trajectory (expected height), and physical health. This is defined as a weight that is less than that which is minimally normal (in the DSM–IV–TR this was defined as body weight less than 85% of that expected for individuals of the same age and height; APA, 2013) or for children and adolescents, a weight that is less than is minimally expected of them (APA, 2013). The “85%” criterion was removed from the DSM–5.

Second, individuals must have an intense fear of gaining weight or becoming fat, even though they are obviously at a significantly low weight (APA, 2013). This is a crippling fear, perhaps obsessive in nature, that limits the individual’s life so much that he or she becomes completely focused on either not gaining any additional weight or perhaps trying to lose even more weight. Not only is there a heightened fear of weight gain, but the individual’s behavior ensures he or she will not gain weight. (See the accompanying Highlight.)

Highlight: Body Dissatisfaction

“Tell me what you don’t like about yourself”—this question opened every episode of Nip/Tuck, a television drama about plastic surgeons that ran from 2003 to 2010. Although the series slanted toward the bizarre, it made some important points about people and society in general. Wouldn’t every person asked this question be able to reel off a whole list of body dissatisfactions? Is there something wrong with not liking aspects of yourself? If you look at the data, you can see that the number of plastic surgeries increased by about 4% from 2015 to 2016 (from 1,715,224 total procedures to 1,780,987; American Society of Plastic Surgeons, 2017). The top three procedures were breast augmentation, liposuction, and nose reshaping (rhinoplasty). Evidently a large number of people in the United States do not like aspects of themselves.

Yet body dissatisfaction, paired with obsessions over celebrities such as the Kardashians, Taylor Swift, and so many others, can lead to devastating outcomes. Seeking surgery after surgery in the pursuit of mythical perfection—or developing unhealthy eating habits that can lead to a full-blown eating disorder—carries grave risks. Perhaps helping professionals can promote the concept that you are okay just the way you are, and that

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vadimguzhva/iStock/Thinkstock

People with the restricting type of anorexia nervosa become meticulous about the amount of food they eat on a daily basis.

it’s okay to be dissatisfied with a feature or two. It takes all kinds to make up the world, and not everyone can look alike. Maybe such an approach could lead to a decrease in eating disorders—and in unnecessary plastic surgeries as well.

The third criterion is the denial of the seriousness of the low body weight or a disturbance in how the individual experiences or perceives her or his weight or shape (APA, 2013). Individuals will usually see themselves as quite obese even though it is obvious to everyone else that they are seriously malnourished (Farrell, Lee, & Shafran, 2005). Denial appears to be a key component of eating disorders. This can be denial of the individual’s actual shape or denial of the seriousness of the problem.

The DSM–5 lists two subtypes of anorexia nervosa. The main difference between these two subtypes involves how individuals with anorexia nervosa manage to maintain their abnormally low weight, or how they continue to lose weight. The restricting type is characterized by individuals being meticulous, perhaps obsessive, about how much food they eat at a given time, and what their caloric intake is at each meal or on a daily basis. Typically, these individuals will first cut out sweets and other foods perceived as “fattening” (APA, 2013). Individuals do not regularly engage in binge-eating or purging behavior (APA, 2013). The binge-eating/purging type is characterized by individuals regularly engaging in binge-eating or purging behavior such as self-induced vomiting or the misuse of laxatives, diuretics, or enemas (APA, 2013). The individuals feel like they cannot control the binging behavior. Binges are typically smaller than those seen in individuals with bulimia, and purging happens more often

than it does with bulimia, typically after every meal (Agras, 1987). It has been estimated that about 50% of all individuals with anorexia nervosa binge and purge. Note also that for anorexia to be diagnosed with either subtype, the symptoms must be active for a period of at least three months (APA, 2013; Smink et al., 2014).

Eating disorders, particularly anorexia nervosa, are the most lethal of all of the mental disorders, including unipolar depression (Franko et al., 2013). In the past, some research demonstrated that approximately 20% of individuals with anorexia nervosa died from medical complications related to their disorder; at least 50% of these were suicides (Chavez & Insel, 2007; Mehler & Brown, 2014). Other studies state that the death rate from anorexia nervosa is approximately 2% to 6% (Kask et al., 2016; Suokas et al., 2013), although a certain percentage of those deaths were due to suicide. Getzfeld (1999) hypothesized that females with anorexia nervosa may be engaging in a form of suicide, slowly disappearing and wasting away. Psychologically, they are detached, focused solely on their body image and their weight, or lack thereof, and physically detaching themselves from life.

Bulimia Nervosa

Whereas anorexia nervosa affects between 0.5% and 2% of all women in Westernized countries (Ekern, 2014; Smink

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Stockbyte/Stockbyte/Thinkstock

One way individuals with bulimia nervosa eliminate the food consumed during binging is through excessive exercise, which often means exercising several hours every day.

et al., 2014; Stice, Burger, & Yokum, 2013), bulimia nervosa, literally “hunger of an ox,” affects between 2% and 5% of the population (Ekern, 2014). Bulimia nervosa is characterized by the individual eating an unusually large amount of food at a single sitting and then using inappropriate compensatory behavior(s) to rid the body of the excess calories. An individual suffering from bulimia nervosa will often binge on 3,000 to as many as 6,000 calories in a single sitting and then compensate by purging through vomiting or using laxatives, or by fasting (APA, 2013). Although the average calorie count for a binge, which might occur as often as 30 times per week, is about 3,400 calories, binges may reach as high as 10,000 calories. Consider that a McDonald’s Big Mac sandwich has 560 calories. A binge of approximately 3,000 calories is equivalent to eating about 5.5 Big Macs in one sitting; a binge of about 10,000 calories would be the same as consuming 18 Big Macs, also in one sitting.

Bulimia nervosa is diagnosed by using five DSM–5 criteria. First, these individuals must have recurrent episodes of binge eating (where they eat much more during a specific time period than most people would under similar circumstances [APA, 2013] and believe they have no control over this behavior). They feel that they cannot stop their eating or control what they are eating or how much they are eating.

Second, the individual must engage in recurrent inappropriate compensatory behaviors, which means they must engage in self-induced vomiting or misuse of diuretics (medications that increase urination), laxatives, or enemas. These are all examples of purging behaviors. The goal of a purge is to eliminate all of the food that was consumed during the prior binge. It is only a purge if the food is somehow forced out of the body by inappropriate compensatory behaviors. (A person who unintentionally vomits is not purging.) Inappropriate compensatory behaviors are behaviors designed to counterbalance and counteract the effects of the binge. They are designed to ensure that the individual with bulimia does not in fact gain any weight, but they also serve to give the individual the illusion of self- control. Their purging seems to alleviate any anxiety caused by the fear of gaining weight. Another way that the individual can eliminate the food is through fasting or exercising excessively, such as exercising at least three hours a day every day, presuming that he or she is not a professional athlete or in training for a competition such as the Olympics (APA, 2013). Some people call this behavior “exercise bulimia nervosa.” Unfortunately, the DSM–5 does not define the terms excessively or misuse, which can be problematic as it is left up to clinicians and psychologists to interpret these terms.

Third, the binging and purging, or other inappropriate compensatory behavior, must occur on average at least once per week over a three-month period. Fourth, the individual’s self-evaluation must be unduly influenced by their body weight and shape (APA, 2013). These people place extreme and excessive emphasis on body weight and shape to the point where it seems to become an obsession. (Obsessions were discussed in Chapter 3.) In fact, only about 3% of the women with bulimia in one dated study were not obsessed (our word) with their body’s weight and shape (Garfinkel, 1992).

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The fifth DSM–5 criterion states that bulimia nervosa does not occur solely during episodes of anorexia nervosa (APA, 2013). We must be able to distinguish between bulimia nervosa and anorexia nervosa, as treatment modalities differ significantly, especially the often recommended and/or required medical interventions.

The DSM–5 diagnostic criteria for bulimia nervosa are summarized in Table 7.2.

Table 7.2 DSM–5DSM–5 diagnostic criteria for bulimia nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is

definitely larger than most people would eat during a similar period of time and under similar circumstances.

2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain (e.g., self-induced vomiting; misuse of laxatives, diuretics, enemas, 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 three months.

D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©2013), p. 345. American Psychiatric Association. All Rights Reserved.

Binge-Eating Disorder (BED)

Binge-eating disorder (BED) involves binging episodes similar to those found in bulimia nervosa but without the inappropriate compensatory behaviors (for example, purging and self-starvation). In effect, the main, and some might say only, diagnostic criterion for BED is recurrent episodes of binge eating that occur on average at least once per week for three months, identical to the first criterion for bulimia nervosa. A critical difference between BED and bulimia nervosa is that the DSM–5 definition for BED does not include inappropriate compensatory behaviors being demonstrated by the individual, a criterion of bulimia nervosa (APA, 2010, 2013). In addition, BED cannot be comorbid with anorexia nervosa or bulimia nervosa (APA, 2013). The DSM–5 diagnostic criteria for BED are summarized in Table 7.3. (Which of the eating disorders do you think Paula Ames has? Click here (https://medi- a.thuze.com/MediaService/MediaService.svc/constellation/book/Getzfeld.3794.18.1/{misc}casestudies_ch07.pdf) and see Part 2 of her case.)

Table 7.3 DSM–5DSM–5 diagnostic criteria for binge-eating disorder

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (for example, within any two-hour period), an amount of food

that is definitely larger than most people would eat during a similar period of time and under similar circumstances.

2. A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating).

B. The binge-eating episodes are associated with three (or more) of the following:

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1. Eating much more rapidly than normal. 2. Eating until feeling uncomfortably full. 3. Eating large amounts of food when not feeling physically hungry. 4. Eating alone because of being embarrassed by how much one is eating. 5. Feeling disgusted with oneself, depressed, or very guilty after overeating.

C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least once a week for three months E. The binge eating is not associated with the recurrent use of inappropriate compensatory behaviors as in

bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Source: APA (2013, p. 350).

Etiologies of Eating Disorders

Researchers have uncovered several factors they believe influence the emergence of eating disorders in general, or anorexia nervosa or bulimia nervosa specifically, and developed theories to explain these factors.

SocioculturalSociocultural Factors Factors Unlike many of the disorders in this book, both bulimia nervosa and anorexia nervosa seem to occur most often within specific Westernized countries, specific age groups, specific social classes, and most commonly in females.

Eating disorders may now be crossing racial boundaries (Perez, Ohrt, & Hoek, 2016; Solmi, Hotopf, Hatch, Treasure, & Micali, 2016). However, eating disorders have been viewed as by-products of Western cultures where the media—including television, Internet, and movies—“shape” people’s opinions of how a healthy body should appear, which, in this case, means thin (Ferguson, Muñoz, Garza, & Galindo, 2013). Anorexia nervosa is more common in industrialized societies, especially in those societies where Western media influence is pronounced, and where female thinness is seen as an ideal (Pike, Hoek, & Dunne, 2014). In nonindustrialized societies, or in societies where Western influence is minimal, a more rounded figure is preferred. In addition, eating disorders manifest themselves during adolescence and young adulthood for a simple reason: Society expects females to be thin. These women may be internalizing this concept (Hoek, 2002; Hsu, 1990).

What does internalizing “thin is in” mean? What this means is that some women (and men) appear to be more vulnerable to mass media’s ideas of the ideal body shape and size, whereas others are less so. For men, this would be a shape that is lean yet muscular, with the so-called “six-pack” abdominal muscles made famous by Mike “The Situation” Sorrentino on the TV show The Jersey Shore or Zac Efron in the movie Baywatch (2017). For women, this would be a body that either has little body fat or else has impossible curves like Barbie, even in her newer, “more accurate” version. An individual’s ability to avoid developing a negative body image and negative self- statements, in addition to being able to avoid the pressure to either remain thin or to lose more weight, seems to be related to media exposure, how well the individual can handle environmental stressors, and the quality of the individual’s support systems (Stice, Schupak-Neuberg, Shaw, & Stein, 1994; Stice, Spangler, & Agras, 2001). (See the accompanying Highlight.)

Highlight: The Media, Anorexia Nervosa, and Bulimia Nervosa

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In 2016 Sports Illustrated chose three women to be cover models for its annual swimsuit issue, which many people argue promotes subtle sexuality and female objectification, and not swimsuits. Suppose you received all three issues and you were an adolescent female. You would soon see that Haley Clauson, a “supermodel,” is topless and is quite thin. Ronda Rousey, a mixed martial arts former champion, appears in body paint, totally nude underneath. Ashley Graham, a “plus sized” supermodel, appears in a two-piece swimsuit. Why is Graham, who by standard modeling criteria is overweight and perhaps obese, wearing a two-piece swimsuit, while the others, who are a lot thinner, are not? What does this convey about body image as well as what is considered normal? What would your reactions be if Graham were topless or nude, with her body parts tastefully covered? Could she appear in ESPN’s The Body Issue, where famous athletes from all sports appear nude? Which woman would a teenager be most likely to identify with? The media promote certain body types and shapes as being aesthetic, sexy, and “normal,” while promoting others stereotypically. How often do you see someone who has curves like Graham playing a romantic role, or a lead, for example? In many shows and movies, such actresses usually portray funny, sarcastic supporting characters. Why can’t they be considered “sexy” or their bodies be seen as normal?

PsychologicalPsychological Factors Factors Even though familial and sociocultural factors surely play some role in the development of eating disorders, a number of psychological factors have also been implicated in their etiologies. These include individuals striving for some kind of control in their lives, interoceptive awareness, separation problems, and body dissatisfaction.

StrivingStriving for for Control Control One trait that appears to be common among individuals with anorexia nervosa is that they tend to be perfectionists and have obsessive-compulsive tendencies. These individuals struggle for control and perfection in every part of their lives and, therefore, also with their bodies. The lack of eating can perhaps be viewed as a way to gain control over their lives and as a way to develop a sense of independence—an idea posited by Hilda Bruch (1973). Individuals may feel that their weight, and thus their appearance, is the only thing that they can control without parental or other outside influence or interference; anything less than perfection is considered to be a failure, especially by individuals with anorexia nervosa (Bruch, 1973; Pearlman, 2005).

InteroceptiveInteroceptive Awareness Awareness Interoceptive awareness refers to an individual’s awareness of internal cues, including emotional states and hunger (Khalsa et al., 2015; Lavender et al., 2014). Individuals with anorexia nervosa may be more in touch with their appearance than with the fact that they feel sad, angry, happy, or disgusted. Because of this, they don’t recognize certain internal cues, such as hunger pangs. Researchers have found that some women without a high level of interoceptive awareness cannot recognize when they are sated (Viken, Treat, Nosofsky, McFall, & Palmeri, 2002). Earlier research noted that a lack of interoceptive awareness was able to predict the development of eating disorders as much as two years into the future (Leon, Fulkerson, Perry, & Early-Zald, 1995).

BodyBody Dissatisfaction Dissatisfaction

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Body dissatisfaction is a key factor in both bulimia nervosa and anorexia nervosa. In both cases, the disorder is caused and perpetuated by the individuals wanting to change their bodies. However, individuals with anorexia nervosa are much more concerned with their appearance and are totally dissatisfied with their body shape, to the point of evidencing pathology. In other words, these individuals will continue to starve themselves even when their weight is dangerously low “just to lose a bit more” and to appear ever thinner. Individuals with bulimia, who may starve themselves as a method of staving off weight gain, will be of a normal weight or slightly overweight. They tend to be more concerned with pleasing others, are often more concerned with being attractive to others, and are more likely than individuals with anorexia nervosa to have sexual relationships (Striegel-Moore, Silberstein, & Rodin, 1993). Cultural influences in Western societies contribute to this body dissatisfaction by placing a very high value on a reed-thin body (Culbert, Racine, & Klump, 2015).

BiologicalBiological Factors Factors Like many of the psychological disorders, eating disorders seem to run in families and seem to have a genetic component (Culbert et al., 2015; Starr & Kreipe, 2014). In addition, low levels of serotonin activity have been linked to bulimia nervosa (e.g., Phillips et al., 2014; Starr & Kreipe, 2014), especially to binge eating of carbohydrates (Kaye et al., 2012). Serotonin is a neurotransmitter that is involved with information processing and coordination of motor skills, specifically movement. It is also involved with inhibition and restraint and helps to regulate aggression, sexual behaviors, and eating, which would include binging and purging. Irregular serotonin levels have been directly implicated in the etiology of unipolar depression (Gryglewski, Lanzenberger, Kranz, & Cumming, 2014) and in obsessive-compulsive disorder (Lissemore et al., 2014), both of which are sometimes comorbid with eating disorders (Cederlöf et al., 2015; Godart et al., 2015), although it is unclear which condition manifests first (Getzfeld, 1992). This link between eating disorders and unipolar depression and obsessive-compulsive disorder can be substantiated by the fact that antidepressants that work to increase serotonin activity in the brain will, in many instances, reduce and/or eliminate bulimic symptoms (Milano et al., 2013).

Some researchers believe that people with eating disorders have serotonin levels that are too high, and that this irregularity is present at birth (Kaye et al., 2005). By self-starvation or purging, the individual is, perhaps unconsciously, attempting to reduce these unusually high serotonin levels (Kaye et al., 2005).

TheThe Psychoanalytic Psychoanalytic Perspective Perspective Psychoanalysts believe that people with bulimia nervosa see their families as rejecting of them, and they often engage in arguments and conflicts, whereas individuals with anorexia nervosa may see their families as being overly close (Fornari et al., 1999). Bruch (2001), whose work in studying and treating eating disorders was groundbreaking, noted that a dysfunctional relationship between the mother and her child led to, among other things, a poor sense of independence and control, which eventually led to the child manifesting an eating disorder. She called this an ego deficiency in the child.

Bruch saw a dichotomy in how parents respond to their child’s needs. Effective parents feed their children when they are hungry, and comfort them when they are frightened, sad, or in pain. By contrast, ineffective parents do not properly attend to their children’s needs. For example, they might feel or determine that the child is hungry or in need of comforting while misinterpreting the child’s actual condition. They might feed the child when the child is in pain and needs comforting, or comfort the child instead of feeding him or her when the child is hungry. According to Bruch (1973), children raised in this fashion may be unaware of or confused about their internal needs (hunger, pain, and so on), leading to their being unable to correctly recognize and identify their emotions. Once children reach

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Hilde Bruch, a pioneer in the study and treatment of eating disorders.

adolescence, their desire to become more independent understandably, and predictably, increases, but they feel as though they are unable to do so. In effect, they demonstrate reaction formation: Because they feel helpless and that they lack control, they instead do the opposite, which is they seek out excessive control over their body and eating behaviors. There is some support for this hypothesis (for example, Holtom-Viesel & Allan, 2014), as well as for Bruch’s point that individuals who have an eating disorder misperceive their internal cues (Lavender et al., 2014). Keep her points in mind, especially when we discuss treatment modalities.

TheThe Behaviorist Behaviorist Perspective Perspective According to Bandura’s modeling theory (which states that a child who is interested in a model’s behavior and is able to reproduce it will indeed do so), parents may be the cause of eating disorders in their children. Per Bandura’s theory, children whose parents are on a diet will notice how preoccupied the parents are with their caloric intake and decide they too should get involved in this diet program. Additionally, parents may push their children to lose weight, whether to win a spot on the cheerleading team or simply to compete with the children’s thinner peers in school (Abraczinskas, Fisak, & Barnes, 2012). Recent research has also noted that mothers, fathers, and peers each played an important role in the development of girls’ bulimic symptoms by affecting their body dissatisfaction, which was related to later dieting behaviors, depressive symptoms, and bulimic symptoms (Blodgett-Salafia & Gondoli, 2010). The results suggested that peers were a stronger influence than mothers and fathers. (Click here (https://media.thuze.- com/MediaService/MediaService.svc/constellation/book/Getzfeld.3794.18.1/{misc}casestudies_ch07.pdf) and see Part 3 of Paula Ames’s case.)

Treatment of Anorexia Nervosa

Successful treatment for anorexia nervosa is rather limited (Hsu, 1990). In one study, approximately 10% to 20% of patients with anorexia nervosa remained at their pretreatment weight during their posttreatment follow-ups (Haliburn, 2005). What this means is that many patients with anorexia nervosa do not respond well to treatment, which often includes inpatient hospitalization. For those who do initially respond to treatment, recovery may not last (Richard, Bauer, & Kordy, 2005).

Anorexia nervosa treatment includes two goals. The first, most immediate goal is to get the individual to gain back a certain amount of weight and to attempt to normalize her eating pattern. In life-threatening cases, this may need to occur in an inpatient setting. This type of intervention is warranted if patients absolutely refuse to eat or if their weight is significantly below where it should be. This can lead to increased risk for cardiac arrest. If individuals refuse to eat, they would need to be force-fed via intravenous lines and/or via a tube down the throat. This can lead to an early treatment obstacle because the force-feeding may lead to distrust of treatment professionals, setting up an aversive condition. For a variety of reasons, not the least of which is to avoid setting up such a condition, treatment

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Treatment for anorexia nervosa is not always successful, which can often lead to patients being hospitalized so that necessary weight gain may be carefully monitored.

now typically occurs in an outpatient setting or in a day treatment hospital (see, for example, Raveneau et al., 2014).

One advantage of day treatment hospitals or, if the individual’s life is at risk, inpatient settings is that weight gain can be monitored carefully. The weight gain should be gradual, with a target of about two to three pounds per week, although this depends on the individual’s weight at treatment onset. In some instances, the individual might gain as much as a pound per day. There are several reasons the weight gain needs to be gradual and not sudden. Psychologically, rapid weight gain might scare the patient, and the patient might drop out of treatment, making the treatment goal act like a punishment. The APA (2000, 2013) also notes that if weight gain is rapid, the individual might suffer from constipation, abdominal pain, and bloating. The most commonly used weight restoration method is usually called a nutritional rehabilitation program. This includes nursing care, nutritional counseling, and a high-calorie diet to help the individual get back to normal eating and to help her gain weight (Leclerc et al., 2013). Typically, the calorie count will increase gradually until it reaches approximately 3,000 calories per day (Zerbe, 2010). These programs usually last from 8 to 12 weeks.

The second goal of treatment is to work on the psychological, social, and environmental issues that either may have caused or are somehow maintaining the disorder and thus interfering with recovery. Some of these issues include working with individuals to change their dysfunctional body image attitudes and working on the interpersonal problems they have in their lives (with, for example, family, friends, and significant others). The issue of loss of control of one’s eating is also addressed in therapy. Treatment is typically conducted through family therapy, self- help groups, or individual therapy.

Family therapy is most successful with adolescents who have had anorexia nervosa for less than three years, that is, with an early onset and a short duration (Rutherford & Couturier, 2007). The core problem is presumed to be the parents’ disagreement with, and perhaps denial of, the adolescent’s desire for autonomy. Mealtimes and thoughts about food and weight are typically dysfunctional within the individual’s family and are focused on in treatment. Family attitudes toward body shape, as well as any underlying conflicts, will be discussed. Typically, in family therapy, the therapist will work to get the individual out of the role of being a “sick” child and will work with the parents to confront their own issues and conflicts directly with each other and not through their children (Minuchin, Rosman, & Baker, 1978). One main goal is to get the family to work as a team to address the anorexic eating behaviors and to function better as a family unit in general. Whereas some studies note that family therapy appears to be one of the more successful treatment modalities for anorexia nervosa (Dare & Eisler, 2002; Lock & le Grange, 2005), many therapists will use this modality in combination with individual and group therapy as well as self-help groups.

Cognitive-BehavioralCognitive-Behavioral Therapy Therapy

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Cognitive-behavioral therapy (CBT) is often used in conjunction with other techniques previously mentioned to treat anorexia nervosa. Therapists may work with individuals to help them learn more appropriate ways to exercise control, as anorexia nervosa is often caused in part by an individual’s wanting to feel in control. The individual’s attitudes about food, eating, and weight would also be examined in therapy. Typically these individuals view food as an enemy. Therapists would work on what are called faulty cognitions, sometimes called irrational beliefs. These are irrational or false beliefs that result in self-defeating behavior(s) that the person demonstrates. The individual’s cognitions are so faulty that they obscure the truth; thus, the individual believes in the falsehoods. Individuals’ self- esteem ends up even more damaged and self-destructive behaviors become entrenched (see, for example, Fairburn & Cooper, 2014; Lask & Bryant-Waugh, 2000; McFarlane, Carter, & Olmsted, 2005).

PsychotropicPsychotropic Medications Medications Many professionals agree that medications should not be used in the treatment of anorexia nervosa because they tend to be rather ineffective (Watson & Bulik, 2013). Since many of these individuals are severely underweight, potential medication side effects could be more pronounced, leading to significant complications. Being malnourished or severely underweight can change the amount of medicine in the individual’s body. Too much or too little can be dangerous. For example, tricyclic antidepressants (TCAs) may lead to heart arrhythmias, which can lead to cardiac arrest. In fact, antidepressants, in general, seem to be ineffective in treating anorexia nervosa (Suárez-Pinilla et al., 2015).

Treatment of Bulimia Nervosa

The treatment of bulimia nervosa has been shown to have about a 40% success rate, defined as (a) eliminating or greatly reducing the cycle of binging followed by inappropriate compensatory behavior, (b) eating normally, and (c) maintaining a normal weight for the individual’s height and age (Isomaa & Isomaa, 2014). Isomaa and Isomaa (2014) also noted that in follow-up research years after treatment ended, up to 85% of those with bulimia nervosa have either fully or partially recovered. Approximately 30% to 50% will experience relapse (MacDonald, McFarlane, Dionne, David, & Olmsted, 2017). Treatment for bulimia nervosa is evidently much more effective than treatment for anorexia nervosa. There are two possible reasons for this. First, because bulimia nervosa is more common, more research has been done on its possible treatments. Antidepressants, especially the selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac) and sertraline (Zoloft) may reduce and/or eliminate the symptoms, especially when combined with CBT (Bernacchi, 2017; Starr & Kreipe, 2014). Second, treatment is more effective because, unlike in anorexia nervosa, death due to bulimia nervosa remains relatively rare (Keel & Mitchell, 1997).

The most pressing goal of treatment for bulimia is to extinguish the binge/purge cycles and to reestablish good eating habits, working under the assumption that, at one point, the individual exhibited healthy or “normal” eating habits. The long-term goal is to examine, and perhaps bring to the surface of the conscious mind, the root causes of the individual’s bulimic behaviors.

BehavioralBehavioral Therapy Therapy Typically, behavioral techniques are used in conjunction with other therapeutic techniques such as cognitive methods and supportive techniques (Bernacci, 2017). A common technique is to ask patients to keep a food diary, which documents their daily meals, what they eat, and any changes they note in their feelings of hunger or fullness. The

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Keeping a food diary allows individuals with bulimia to track patterns in their eating habits, which in turn can help uncover the source of the individuals’ bulimic behaviors.

most important result of keeping a food diary is that it allows patients to objectively look at their eating patterns and behaviors, something that many individuals with bulimia do not (or perhaps cannot) do. In addition, and perhaps more important, this method allows individuals to recognize emotional eating. In other words, are any emotions triggering an eating binge, and do individuals eat as a result of an uneasy emotion, or because they are truly hungry?

Cognitive-BehavioralCognitive-Behavioral Therapy Therapy Cognitive-behavioral therapy focuses on teaching ways to resist the binge/purge impulses and notice the warning signs (Wilson, 2005). Christopher Fairburn (1985), a major researcher in the field of bulimia, created a three-step approach to treat bulimia nervosa that has been successful and is often used by today’s helping professionals. The main goal in the three-step approach is to look at individuals’ eating behavior and to have them look at the consequences of binging. The helping professional examines the physical consequences of binging and purging with the patients and helps them understand how ineffective it is to use laxatives or vomit to control their weight. Dieting, especially extreme diets where the daily caloric intake is severely reduced, is also examined in either therapy or educational sessions. These can occur individually or in groups. Next, an eating plan is set up in which many small meals are eaten each day, with no more than three hours between any meals. This planned eating schedule will eliminate the bouncing back and forth between periods of overeating and purging, or restriction, that occur with bulimia nervosa (Fairburn, 1985).

Next, the helping professional will examine the dysfunctional cognitions, or beliefs, that the individuals have about their appearance and dieting behaviors. Cognitive restructuring, helping patients to recognize and change negative thoughts that lead to binging and subsequently purging,

may be used at this point. The helping professional works with the individuals to assist them as they discover these irrational thoughts and make plans to change these negative self-statements. Goals include raising the individuals’ self-esteem and helping them realize that they cannot be perfect all of the time.

Finally, the helping professional will prepare patients for potential relapses and how to handle them. They will also work with patients to help them develop realistic beliefs and expectations about eating and weight-related issues. Research has demonstrated that these techniques lead to the elimination of bulimic symptoms in at least one third to as many as two thirds of individuals with the disorder (Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000; Mitchell et al., 2002; Poulson et al., 2014).

InterpersonalInterpersonal Therapy Therapy Interpersonal therapy (IPT) may also be an effective treatment modality. IPT focuses on the individual’s current relationships, with particular focus on the family during weekly sessions over four to six months. Communication and problem-solving skills are worked on in order to improve individuals’ interpersonal relationships, and the focus is on what in their relationships led to the onset, maintenance, and relapse of bulimia nervosa (Bernacci, 2017; Kass, Rosenthal, Pottackal, & McGann, 2013; Tanofsky-Kraff, Shomaker, Young, & Wilfley, 2016). This therapeutic

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modality does not focus on the individual’s maladaptive eating behaviors but instead focuses on reducing interpersonal conflicts, especially within the individual’s family.

PsychotropicPsychotropic Medications Medications Research has shown significantly positive outcomes for the use of antidepressants in treating bulimia nervosa (Hay & Claudino, 2012; Starr & Kreipe, 2014). The antidepressants typically used are SSRIs such as fluoxetine (Prozac), which have fewer side effects than others, increasing the likelihood of medication compliance. Prozac is the only medication approved by the FDA to treat the binges and inappropriate compensatory behaviors (specifically, purges) of bulimia nervosa. Other SSRIs, such as sertraline (Zoloft), also have proven to be effective.

Treatment of Binge-Eating Disorder

A crucial component of making sure that individuals who diet do not regain the weight is to stop the binge eating (see, for example, Fisher et al., 2014). Cognitive-behavioral therapy and interpersonal therapy have both proved to be rather successful in treating BED (Amianto, Ottone, Daga, & Fassino, 2015; Brownley et al., 2016; Fisher et al., 2014; Grilo et al., 2014). Interestingly, using self-help procedures appears to be ineffective in the long-term in treating BED; more effective interventions are required (Fairburn & Murphy, 2015; Grilo et al., 2014). These results were similar to those for subjects who were in therapy groups. Another interesting study measured the effectiveness of Prozac in treating BED. Four experimental groups were formed: Prozac alone, placebo, CBT and Prozac, and placebo and CBT. Prozac alone, when compared with placebo alone, showed no significant difference in eliminating BED. When CBT was used in conjunction with Prozac and with placebo, both treatment modalities were more successful than Prozac alone or placebo alone. In fact, 73% of the subjects did not binge for one month after treatment concluded, which the researchers defined as remission (Ramacciotti et al., 2013). So, one can conclude that adding Prozac to CBT does not make the overall treatment more effective. (Click here (https://media.thuze.com/Medi- aService/MediaService.svc/constellation/book/Getzfeld.3794.18.1/{misc}casestudies_ch07.pdf) and see Part 4 of Paula Ames’s case.)

A more recent treatment modality for BED is the use of lisdexamfetamine dimesylate (Vyvanse), a stimulant used to treat attention-deficit/hyperactivity disorder in children aged 6 years or older and adults. It was approved to treat BED in 2015. Common side effects are dry mouth, constipation, insomnia, and increased heart rate. Since Vyvanse is a stimulant, there is the potential for abuse and/or dependence. Interestingly, the anticonvulsant topiramate (Topamax) has been found to reduce binge-eating episodes. Possible side effects include dizziness and kidney stones. Since Topamax is not an FDA-approved treatment for BED, if prescribed it will be off-label. This means that the psychiatrist can legally prescribe Topamax, but it has not been FDA approved to treat the condition for which it is being prescribed. What are your views on off-label prescribing?

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Chapter Summary

Sleep Disorders The two main types of sleep disorders are the dyssomnias and the parasomnias. Insomnia disorder is characterized by a difficulty falling asleep, maintaining sleep, or not feeling rested after normal amounts of sleep. Narcolepsy, a rare condition, is marked by sudden and repeated “attacks” of dream state (rapid eye movement, or REM) sleep that will also be accompanied by a brief loss of muscle tone, called cataplexy. In obstructive sleep apnea hypopnea, the individual may stop breathing for as long as 30 seconds many times during the night. This may occur hundreds of times during the night, and the victim is unaware that this is occurring. The parasomnias are characterized by sleep disturbances that result from unusual or abnormal events that occur during the night. Non–REM sleep arousal disorder, sleep terror type, which typically affects children and usually disappears in adolescence, is not related to nightmares, as sleep terrors occur during non-REM sleep. Non–REM sleep arousal disorder, sleepwalking type (called somnambulism when it is repeated), is primarily a childhood disorder, occurring during NREM sleep, that disappears around age 15.

Etiologies of Sleep-Wake Disorders Causes of insomnia may include a failure of the body temperature to drop enough for the individual to fall asleep; drug and alcohol use; changes in light, noise, or temperature; stressful events occurring during the day; fatigue; or a misperception of how much sleep is needed or of how disruptive interrupted sleep can be. Some of the sleep-wake disorders, including narcolepsy, run in families; however, this cannot be considered a causal factor. Sleep apnea may be associated with trauma.

Treatment of Sleep Disorders The most commonly used treatment for insomnia is medication, specifically the benzodiazepines (Dalmane) or related medications (such as Ambien). However, negative effects of benzodiazepines include excessive sleepiness and dependence. Short-acting drugs are often the preferred medication choice as they will have stopped working by morning and will not produce daytime drowsiness. Stimulants are often prescribed for narcolepsy or hypersomnia. For breathing-related sleep disorders, such as obstructive sleep apnea hypopnea, weight loss is often strongly recommended. Mechanical devices to improve breathing during sleep typically have little success because of the discomfort they produce. Simple environmental treatments include making bedtimes several hours later than normal or using bright light to fool the brain into thinking it’s earlier. Progressive relaxation techniques have been used with a limited amount of success. Stimulus control techniques, limiting bedroom activities to sleeping and having sex, have been used with

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greater success. Establishing a good sleep hygiene program is also effective. One method used to eliminate sleep terrors is scheduled awakenings.

Eating Disorders People with eating disorders suffer from extreme disturbances in eating behavior caused by an obsessive and irrational fear of gaining weight. The individual may have an obsessive and irrational fear of gaining weight (anorexia nervosa), or may be obsessed with maintaining their weight by binging and then using an inappropriate compensatory behavior to prevent weight gain (bulimia nervosa).

Anorexia Nervosa

Anorexia nervosa, a condition that can be quite lethal and appears most often in women, is defined as an eating disorder in which the individual refuses to maintain proper body weight and weighs less than the minimally normal amount for their height and age. Individuals with anorexia nervosa have an intense fear of gaining weight or becoming fat even though they are severely underweight, and they deny the seriousness of the problem or cannot properly perceive how their bodies appear. Anorexia nervosa has two subtypes: the restricting type, characterized by the individual (during the current episode) not regularly engaging in binge-eating or purging behavior, and the binge-eating/purging type, characterized by the individual (during the current episode) regularly engaging in binge-eating or purging behavior.

Bulimia Nervosa

In bulimia nervosa, individuals binge eat and then expel the food from their bodies, either through purging or nonpurging behavior. Binging is characterized by individuals eating an amount of food during a certain period of time that is significantly larger than what most would eat during that time period and under similar circumstances, and by those individuals feeling as though they lack control over their eating binges.

Binge-Eating Disorder (BED)

In binge-eating disorder (BED), the individual binges without using compensatory behaviors.

Etiologies of Eating Disorders One sociocultural factor associated with eating disorders that has been investigated is Western values and the influence of Western media on what should be the ideal body type. Psychological causal factors that have been researched include control issues, a lack of interoceptive awareness, separation problems from the family, and body dissatisfaction issues. Biological causal factors that have been investigated include improper serotonin levels, among other hypotheses.

Treatment of Anorexia Nervosa

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In treating anorexia nervosa, the immediate goal is to get affected individuals to gain back a certain amount of weight and to attempt to normalize their eating patterns. Interpersonal therapy, ideally using the family therapy modality, is also used, and cognitive-behavioral techniques seem to be somewhat successful. Medications are not recommended for treating anorexia nervosa, as none has been proven successful.

Treatment of Bulimia Nervosa The most pressing goal in treatment is to extinguish the binge/purge cycles and to reestablish good eating habits. The long-term goal is to examine, and perhaps bring to the surface of the conscious mind, the root causes of the individual’s bulimic behaviors. Standard modalities for treating bulimia include individual and family therapy, specifically cognitive- behavioral therapies and interpersonal behavior therapies. Antidepressants, specifically the SSRIs Prozac and Zoloft, have been proven to be quite successful in reducing the binge/purge cycles. Tricyclic antidepressants (TCAs) have also proven to be effective, but their side-effect profiles (and the potential for a lethal overdose) do not warrant their usage in lieu of SSRIs.

Treatment of Binge-Eating Disorder Cognitive-behavioral therapy and interpersonal therapy have been successful in treating BED. Self-help procedures have not proven to be effective in the long term.

Critical Thinking Questions 1. A common treatment modality for insomnia disorder is prescribing medications to help the individual fall

asleep. One problem with these medications is that it is relatively easy to become addicted to them. Discuss your views on using medications to treat insomnia disorder, noting both positive and negative outcomes of using them.

2. Some of the parasomnias, like non–REM sleep arousal disorder with sleep terrors and non–REM sleep arousal disorder with sleepwalking, tend to disappear by adulthood. Discuss and explain some of the possible reasons for this.

3. Anorexia nervosa is a difficult disorder to comprehend. Give your perspective on what might cause adolescents to starve themselves to the point of death (in some instances), and discuss the most effective treatment methods for anorexia nervosa.

4. Bulimia nervosa is easier to understand and to treat than anorexia nervosa, and it is also more common. What might some of the reasons be for these differences?

5. BED is a new diagnosis in the DSM–5. Describe and discuss some reasons why BED is now a DSM–5 diagnostic category.

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Key Terms

anorexia nervosa An eating disorder in which the individual avoids consuming food due to an unrealistic fear of gaining weight, even though the individual is seriously underweight at present. It literally means “nervous loss of appetite.”

avoidant/restrictive disorder A feeding disorder characterized by inadequate eating.

binge eating Eating within a specific time period an amount of food that is significantly larger than most people would eat during that time period under similar circumstances; may range from 6,000 to upwards of 10,000 calories at one sitting.

binge-eating disorder (BED)

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Involves binging episodes similar to those found in bulimia nervosa but without the inappropriate compensatory behaviors (e.g., purging, self-starvation).

binge-eating/purging type A subtype of anorexia nervosa characterized by the individual, during the current episode, regularly engaging in binge-eating or purging behavior (that is, self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

body image How an individual thinks he or she appears to others.

breathing-related sleep disorders An illness caused by sleep-related breathing difficulties that lead to excessive sleepiness or insomnia. These disorders are subdivided into obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation.

bulimia nervosa An eating disorder characterized by the individual’s eating and then expelling the food from the body. The individual is deathly afraid of gaining weight. It literally means “hunger of an ox.”

cataplexy A brief loss of muscle tone that often accompanies narcolepsy.

central sleep apnea The occurrence of, minimally, five or more central apneas per hour of sleep.

circadian rhythm sleep-wake disorders A series of sleep-wake problems in which the individual has difficulty sleeping at the times required for their work, school, or other aspect of their lives.

cognitive restructuring A technique psychologists use to help their patients recognize and change negative thoughts that lead them to binge and subsequently purge, or to engage in other self-destructive behaviors.

continuous positive airway pressure (CPAP) A machine used in sleep apnea therapy. By delivering enough air pressure to a face mask, it keeps the upper airway passages open while the user is asleep.

diuretics Medications that increase urination and therefore have a tendency to dry someone out and perhaps lead to weight loss.

dyssomnias Irregularities or abnormalities in the amount, quality, or timing of sleep. Included in this category are disorders initiating or maintaining sleep, which includes nighttime wakefulness, or excessive sleepiness.

eating disorders Illnesses that occur when an individual suffers extreme disturbances in eating behavior caused by an obsessive and irrational fear of gaining weight.

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faulty cognitions Sometimes called irrational beliefs, these are irrational or false beliefs that result in self-defeating behavior(s), which can lead to self-destructive or maladaptive behaviors.

food diary A written record of a patient’s daily eating habits, food intake, and so on, that is to be shared with a clinician on a weekly basis. Ideally the food diary will also include binges, purges, and the patient’s feelings when he or she eats.

hypersomnolence disorder A sleep-wake disorder characterized by excessive sleepiness even though the individual may have slept at least seven to nine hours.

inappropriate compensatory behaviors Behaviors designed to counterbalance and counteract the effects of an eating binge. They are designed to ensure that the individual with bulimia does not in fact gain any weight; they also serve to help the individual regain self- control. The purging seems to alleviate any anxiety caused by the fear of gaining weight.

insomnia disorder An inability to sleep characterized by a difficulty falling asleep, maintaining sleep, or not feeling rested after normal amounts of sleep.

insomnia A disturbance in the amount, quality, or timing of sleep that occurs at least three nights per week for at least 3 months.

interoceptive awareness An individual’s awareness of his or her internal cues, including emotional states and hunger.

irrational beliefs Ways of thinking that can lead to self-destructive or maladaptive behaviors. One example would be the statement “I must be loved by everyone.” This is impossible, as no one person, real or fictitious, is loved by everyone.

narcolepsy A sleep disorder marked by sudden and repeated “attacks” of dream state (REM) sleep that will also be accompanied by a brief loss of muscle tone, called cataplexy.

nightmare disorder The frequent occurence of extended and well-remembered dreams that usually have themes of avoiding threats to survival, security, and physical integrity. These dreams usually occur during the second half of a major sleep episode.

nightmares Dreams that arouse feelings of intense fear, horror, and distress.

non–rapid eye movement sleep arousal disorder, sleep terror type A childhood disorder that occurs during NREM sleep. Sufferers experience sleep terrors and awaken screaming very loudly.

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non–rapid eye movement sleep arousal disorders, sleepwalking type Primarily a childhood disorder that occurs during NREM sleep, typically during the first few hours of sleep. Affected individuals will usually leave their beds repeatedly during the night and walk around without being conscious of doing so or being able to recall doing so later once awake.

obesity Being minimally 30 pounds overweight, as defined by the National Institutes of Health.

obstructive sleep apnea hypopnea A breathing-related sleep disorder during which the individual may stop breathing for as long as 30 seconds many times during the night.

orexin (hypocretin) A neurotransmitter that regulates and is involved with arousal, wakefulness, and appetite.

parasomnias Sleep disturbances that result from unusual or abnormal events that occur during the night.

pica A feeding disorder in which the individual will eat things such as dirt, laundry starch, and chalk.

polysomnography (sleep study) A test that records an individual’s brain waves, blood oxygen level, heart rate and breathing, as well as eye and leg movements in order to diagnose sleep disorders.

purge The elimination of all of the food that was consumed during a prior binge by an individual with anorexia or bulimia. It is only a purge if the food is somehow forced out of the body by inappropriate compensatory behaviors.

restricting type A subtype of anorexia nervosa characterized by the individual being meticulous, perhaps obsessive, about how much food he or she eats at a given time, and his or her caloric intake at each meal or on a daily basis. Such individuals do not regularly engage in binge-eating or purging behavior.

rumination disorder A feeding disorder marked by regurgitation of food.

sleep-related hypoventilation A sleep disorder in which the individual has decreased respiration while asleep as demonstrated by elevated carbon dioxide levels; diagnosed by polysomnography.

sleep terrors A sleep disorder (but not a DSM–5 diagnostic category) that typically affects children and causes them to awaken with a frighteningly loud scream; the child will have a rapid heart rate, be very upset, and often be sweating profusely. Children do not recall sleep terrors.

somnambulism Recurrence of sleepwalking episodes.

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Chapter Objectives

After reading this chapter, you should be able to do the following:

Understand the evolution of a personality disorder.

Understand the factors related to diagnosing personality disorder.

Dicuss the causes, symptoms, and treatment for Cluster A disorders.

Discuss the causes, symptoms, and treatment for Cluster B disorders.

Discuss the causes, symptoms, and treatment for Cluster C disorders.

9 Personality Disorders

Ingemar Edfalk/Blend Images/SuperStock

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When we describe people who prefer spending a quiet night at home to attending a party as “introverted” or when we call ace fighter pilots “brave,” we are implying that their behavior is caused by their personality traits. (Why do fighter pilots take to the sky? Because they are brave.) Such trait-based explanations of behavior have an intuitive appeal: They fit our beliefs about human nature. Some people are naturally shy; others, gregarious. Some are timid; others are brave. This is the “popular” meaning of personality. For this chapter, we will use a more scientific definition of personality. According to the DSM–5, the sum of an individual’s traits constitutes his or her personality, a set of “enduring patterns of perceiving, relating to, and thinking about the environment and oneself, which are exhibited in a wide range of important social and personal contexts” (American Psychiatric Association [APA], 2013, p. 647).

Experience tells us that there is at least some consistency to people’s behavior and that maladaptive personality traits can cause distress. The DSM–5 considers people with these maladaptive personality traits to have a personality disorder: an enduring pattern of inner experience and behavior that deviates markedly from the expectations of an individual’s culture. Although both the DSM–5 and the International Statistical Classification of Diseases and Related Health Problems (ICD-9-CM) include a diagnostic category for personality disorders, the idea that a personality can be disordered is steeped in controversy (Sutker, 1994; Widiger & Trull, 2007). For example, do career criminals really suffer from a personality disorder, or have they simply made a choice about how they wish to lead their lives? Experts have differing opinions on this issue. They also disagree about which personality traits are debilitating enough to constitute a disorder. Perhaps the fundamental problem with personality disorders is that they have so little in common. The personality disorders covered in the DSM–5 include excessive shyness, self- absorption, and schizophrenic-like behaviors, and there seems little logical, empirical, or theoretical justification for grouping such disparate “disorders” into a single category.

In contrast to clinical disorders such as schizophrenia, personality disorders are supposed to arise from enduring character traits. Taken to extremes, practically any personality trait can impair social functioning and create problems. Shy people may lead restricted social lives; those who are extremely aggressive may get into trouble with the law. Because any personality trait, taken to extremes, can produce difficulties in living, some psychologists prefer to conceptualize personality disorders as the unlucky result of falling at the extreme of some personality trait—too shy, too hostile, too self-centered, and so on (Wakefield, 2012).

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Ross Dolan/Glenwood Springs Post Independent/AP Images

Commonly, pyschopaths can be sociable, yet they often lack empathy. Serial killer Ted Bundy was often characterized as being charismatic and friendly.

9.1 Evolution of a Personality Disorder: From Psychopath to Antisocial Personality The idea that criminal behavior is inherited was a subject loathed by social reformers, who hoped to create a more caring society. What is the point of trying to improve the lot of disadvantaged people if their destiny is genetically predetermined? In the 19th century, however, social reformers were in the minority. Most professionals followed psychiatrist Emil Kraepelin, who said that criminal behavior was largely genetic in origin. Kraepelin grouped people who lied, cheated, committed crimes, and harmed others into a diagnostic category he called “constitutional psychopathic inferiority.” “Psychopaths” were people who behaved in an antisocial manner. The cause of their behavior was genetic (“constitutional”) and probably the result of some failure in evolutionary development (“inferiority”). Although Kraepelin admitted that individuals considered to be psychopaths in one culture—terrorists, for example—might be hailed as freedom fighters in another culture, he still believed that social causes were secondary to genetics in the etiology of antisocial behavior.

Over the years, Kraepelin’s category was shortened (by dropping “constitutional” and “inferiority”) to psychopath, defined as a person who lacks empathy, does not fear punishment, and will continue to break the law even if capture and punishment are likely. The first DSM, published in 1952, abandoned the term psychopath entirely. Instead, it referred to a sociopathic personality. This change in nomenclature signified the dominance of social theories of antisocial behavior: Criminals are made, not born.

Moral Insanity Revived

The term sociopath never entirely replaced psychopath. Indeed, psychopath was still a widely used diagnostic term when Hervey Cleckley published The Mask of Sanity in 1976. Cleckley’s psychopaths were antisocial people who appeared “normal,” even to professionals, but whose normality was really only a superficial “mask of sanity.” Beneath the surface, Cleckley argued, psychopaths were deeply disturbed.

Because of their mask of sanity, psychopaths initially make a good impression. They can be friendly, intelligent, and show no overt signs of a mental disorder. Yet they lead highly aberrant lives. They have dismal social relationships and disordered work histories, and they are often unreliable. On an impulse, they may give up a successful career to follow some momentary whim. Their projects, both legal and illegal, often turn out badly because, despite their intelligence, they fail to plan ahead. When confronted with evidence of their misbehavior, psychopaths first try to blame others. When this fails, they may admit their misdeeds and feign regret, but their remorse and concern for their victims are not genuine, and their misbehavior is often repeated. Punishment does not deter them. In fact, psychopathic people engage in antisocial behavior even when they are almost certain to be caught and punished. It is as if they cannot see the future. When they are apprehended, psychopaths remain self-centered. Some have even been known to ask employers for references after being fired for stealing.

The subject of this chapter’s case study, Eric Cooper, has many of the characteristics of Cleckley’s psychopaths.

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The Case of Eric Cooper: Part 1

Excerpt from the Assessment of Eric Cooper by the Court Psychologist

MUNICIPAL COURT

Psychological Assessment

Date: December 4, 2011

Client: Eric Cooper

Instruments

Minnesota Multiphasic Personality Inventory–2 (MMPI-2)

Thematic Apperception Test (TAT)

Wechsler Adult Intelligence Scale (WAIS-IV)

Psychopathy Checklist–Revised (PCL-R)

Clinical interview

Psychologist: Dr. Aaron Lusted

Referral: Judge Warren

Reason for Referral: Judge Warren requested this presentencing report on Eric Cooper, a 30-year-old man who has been previously convicted of several crimes, including robbery and assault.

Behavioral Observations: Although the client was cooperative and friendly, he rarely made direct eye contact. Also, despite his general good mood, he would swear out loud and pound the table whenever he missed any questions on the intelligence test. There were no signs of delirium or alcohol intoxication, and the client was able to complete all tests with little prompting. The client reported that he had tried to rob a bank, while drunk, in order to pay his bills. He expressed concern that a guard was hurt during the attempted robbery and said he was pleased that no permanent damage was done. He asked whether there was a cure for his problem but when asked what his problem was, he said, “Bad luck, mostly.”

Social History: [See Document 10.3, Social Work Report.]

Intellectual Assessment: The client’s scores on the WAIS-IV intelligence test place him in the above-average range of intelligence. His scores on the verbal scales were higher, in general, than his scores on the performance scale. This is not surprising in someone with the client’s educational achievement.

Personality Assessment: The validity scales of the MMPI-2 were all in the average range, indicating that the test profile could be safely interpreted. The main feature of the profile was an elevated score on the

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psychopathic deviate scale. The client’s responses revealed a self-centered person, whose own feelings always take precedence over those of other people, and a person who lacks empathy for the feelings and rights of others. He also has a strong tendency to act impulsively. . . . The client’s TAT responses reflected a preoccupation with violence—there were numerous references to death, blood, and corpses—but no mention about how the characters in the story might respond or be affected by the violence. It was as if the client could not imagine what might be going through the heads of his own characters. . . . The client’s responses to the PCL-R (which assesses manipulative behavior and impulsivity) were those found among people who have been labeled “psychopaths”—people who lack empathy and are likely to use violence to achieve their goals.

Based on the test results, behavioral observations, and my clinical interview, it appears that the client is a person who has little empathy for or understanding of other people. He thinks mainly of himself, his needs, and his feelings. He is prepared to use violence to meet his needs, no matter how simplistic or complex they may be. He will use violence if someone has something he needs (money or food or alcohol), or something he wants but cannot afford (an automobile). Because he lacks empathy, the client is almost certain to have trouble in personal relationships. In addition, his self-centered attitude as well as his impulsiveness and willingness to use violence are likely to bring him into continued conflict with the law.

Diagnostic Considerations: The client meets the DSM–5 criteria for antisocial personality disorder; he also meets many of the criteria for borderline personality disorder. In addition, he seems to have a pattern of substance abuse. He recently experienced stress from business problems, but his global functioning is only mildly impaired, and he is capable of a high level of psychological functioning.

Alcohol use disorder

Antisocial personality disorder

(possible borderline personality disorder as provisional secondary diagnosis)

Click here (https://media.thuze.com/MediaService/MediaService.svc/constellation/book/Get- zfeld.3794.18.1/{misc}casestudies_ch09.pdf) for full case study.

Cleckley’s Etiological Hypothesis: An Inability to Feel Emotions

For Cleckley, the failure to learn from experience was a central clue to the cause of psychopathic behavior. To explain why psychopathic people failed to profit from experience, Cleckley hypothesized that they are unable to experience normal emotions. They pretend to feel regret, affection, and fear, but they are really like actors, who simulate emotions they are not really experiencing. Because they do not feel anxiety about future punishment, psychopaths continue to commit antisocial acts for which they have been punished in the past (Crego & Widiger, 2015; Silverstein, 2007; Zuckerman, 1999).

DSM–IVDSM–IV Abandons Psychopathy

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The experimental data collected over the decades are remarkably consistent with Cleckley’s clinical observations (Hare, 1996; Hare & Neumann, 2006). People who meet his definition of a psychopath act on their immediate instincts and seem not to fear punishment. Not surprisingly, they are continuously in trouble. Despite these intriguing, and largely consistent, research findings, the DSM–IV abandoned both the term psychopath and the term sociopath, replacing them with antisocial personality disorder, which remains in the DSM–5. The DSM–IV deliberately replaced Cleckley’s psychopath—a clearly deviant person—with a diagnostic category that is so general it can accommodate practically anyone who behaves in an antisocial manner. Moreover, the new diagnostic criteria omit the hallmark of Cleckley’s concept of psychopathy—an inability to feel emotions.

Why the change? The main reason is the DSM–5’s attempt to make its diagnostic criteria as objective as possible. The DSM–5 criteria for antisocial personality disorder focus on observable behaviors (such as impulsivity) and omit those that refer to presumed etiologies (such as a failure to feel emotions). The hallmark of the DSM–5’s antisocial personality disorder is a flagrant disregard for the rights of other people. People with antisocial personality disorder are often irresponsible, impulsive, and untrustworthy. Although the objective criteria strived for in the DSM–5 are an improvement over the subjective diagnostic criteria sometimes used in the past, it is curious that such a consistent body of psychological research has had so little effect on modern diagnostic practice.

Because only three of seven criteria need be met for the diagnosis of antisocial personality disorder, the DSM–5 criteria can encompass the behaviors of, among others in no particular order, con artists, thieves, career criminals, charlatans, corrupt politicians, even devious used car salespeople. Because the category is so broad, it tells us remarkably little about a person’s behavior. People with an antisocial personality disorder can have markedly different demeanors. Some can be charming; others may be surly and aggressive. In other words, despite its status as a disorder of “personality,” the antisocial personality label tells us little about a person’s temperament; it is just a shorthand way of saying that a person engages in a habitual pattern of irresponsible behavior. Often, this behavior brings the person in contact with the law (Crego & Widiger, 2015). Nevertheless, it is important to note that an antisocial personality is not the equivalent of criminality. Not all criminals have a psychological disorder and not all people who have antisocial personality disorder are criminals (Crego & Widiger, 2015).

For a diagnosis of antisocial personality disorder, there must be evidence of a conduct disorder in childhood and an adult pattern of antisocial behavior that is evident by age 15. By insisting on such a lifelong pattern, the DSM–5 seems to have moved back in the direction of Kraepelin’s “constitutional psychopath,” who is either born antisocial or who develops such tendencies early in life. In practice, the initial onset of antisocial behavior is difficult to document (Ogloff, 2006). Objective information about a person’s childhood is rarely available, retrospective reports by others are often unreliable, and people suspected of being antisocial cannot be trusted to give an accurate history of their own lives. Despite these uncertainties, the idea that people who are “psychopathic” are different from birth, or at least early childhood, is sometimes used to argue that they cannot help their actions—that they are simply suffering from an illness.

Prevalence and Course of Antisocial Personality Disorder

Between 0.2% and 3.3% of the general population, mainly men, meet the DSM–5 criteria for antisocial personality disorder (APA, 2013; Zimmerman, Favrod, Trieu, & Pomini, 2005). Although the preponderance of men diagnosed with antisocial personality disorder may reflect a difference between the sexes, it may also be the result of stereotypical sex roles or of the clinician’s own biases (Castro, Carbonell, & Anestis, 2011). In our society, men are expected to be aggressive and to take more risks than women (see Figure 9.1). Men may be socially reinforced for

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behaving in ways consistent with at least some of the diagnostic criteria for antisocial personality disorder.

Figure 9.1: Are some cultures more antisocial than others?

In a cross-cultural study, teenagers were asked to write stories describing how imaginary characters would respond to various conflicts. About one third of the respondents from New Zealand, Australia, Northern Ireland, and the United States described violent responses, compared to less than one fifth of the subjects from Korea, Sweden, and Mexico.

Source: A d a p t e d A d a p t e d f ro m f ro m A rc h e r A rc h e r a n d a n d M c D o n a l d M c D o n a l d ( 1 9 9 5 ) , ( 1 9 9 5 ) , a s a s a p p e a r i n g a p p e a r i n g i n i n R . R . J . J . C o r n e r, C o r n e r, Abnormal Psychology, 6 t h 6 t h e d . e d . N e w N e w Yo r k : Yo r k : Wo r t h Wo r t h P u b l i s h e r s , P u b l i s h e r s , 2 0 0 7 , 2 0 0 7 , F i g u re F i g u re 1 6 . 3 , 1 6 . 3 , p . p . 4 7 3 . 4 7 3 . R e p r i n t e d R e p r i n t e d b y b y p e r m i s s i o n .p e r m i s s i o n .

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By the DSM–5’s definition, antisocial personality disorder usually has its origins in adolescence, but it may begin even earlier (APA, 2013; Krastins, Francis, Field, & Carr, 2014). In fact, poor impulse control and aggressiveness as a child are important predictors of antisocial personality disorder later in life (Krastins et al., 2014).

A typical sequence is for an impulsive prepubescent boy to be labeled as a “conduct problem” in school. In adolescence, the same boy is labeled “delinquent,” and in early adulthood, he is diagnosed as antisocial (Krastins et al., 2014). Girls usually show fewer problems before adolescence (Javdani, Sadeh, & Verona 2011). About 10% of children have conduct disorder; of that group, 75% are male (Nock, Kazdin, Hiripi, & Kessler, 2006). Those with conduct disorder are more likely to be diagnosed with antisocial personality disorder in later life (Krastins et al., 2014; Lahey, Loeber, Burke, & Applegate, 2005).

The highest prevalence of antisocial personality disorder is among men aged 25 to 44 years. In middle and old age, the incidence of antisocial personality disorder declines. It is not clear whether this means the disorder diminishes with age or whether people with antisocial personality disorder fail to live past middle age (Hare, McPherson, & Forth, 1998; Oltmanns & Balsis, 2011). We do know that many die young from suicide, homicide, accidents, and substance abuse (National Collaborating Centre for Mental Health, 2010).

Causes of Antisocial Personality Disorder

Many researchers do not believe that there is a gene that makes a person a criminal. The modern view is that genetics and environment both contribute to every type of behavior, including antisocial behavior. In this section, we will examine some of the ways in which heredity, biology, and experience interact to produce antisocial behavior (see Figure 9.2).

Figure 9.2: Risk factors for antisocial personality disorder

Source: F ro m F ro m S . S . S c h w a r t z , S c h w a r t z , Abnormal Psychology: A Discovery Approach. M o u n t a i n M o u n t a i n Vi e w, Vi e w, C A : C A : M a y fie l d M a y fie l d P u b l i s h i n gP u b l i s h i n g C o m p a n y, C o m p a n y, 2 0 0 0 , 2 0 0 0 , F i g u re F i g u re 1 0 . 3 , 1 0 . 3 , p . p . 4 3 7 . 4 3 7 .

GeneticsGenetics Considerable evidence points to a genetic element in antisocial behavior, particularly when the antisocial behavior includes aggression. This evidence includes a higher concordance for antisocial traits among identical siblings than among nonidentical siblings (National Collaborating Centre for Mental Health, 2010) and the finding that adopted

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children grow up to resemble their antisocial biological parents more than their non-antisocial adopted parents.

All of the simple explanations that have been offered to date (for instance, that antisocial behavior is the result of an extra male chromosome) have proved to be blind alleys (Harmon, Bender, Linden, & Robinson, 1998). All researchers agree that the mechanism by which antisocial behavior is inherited is likely to be complicated (National Collaborating Centre for Mental Health, 2010). One popular theory is that low levels of serotonin possibly contribute to violent antisocial behavior (National Collaborating Centre for Mental Health, 2010). A complication for this hypothesis is that some of the variables that affect serotonin levels may, by themselves, cause antisocial behavior. For example, disadvantaged people, whose diets are poor, may have low serotonin levels. Their poverty also puts them at high risk of engaging in antisocial behavior. Is it their low serotonin that causes their antisocial behavior, or is it their poverty? Perhaps it is both.

There is a pressing need to clarify the ways in which genes affect antisocial behavior. Opponents view genetic research as racially motivated, an attempt to redefine social problems in biological terms. They fear that genetic research will be used to stigmatize some minority groups as “born criminals.” Stigmatizing minorities is a danger, of course, but such an outcome can be avoided by properly educating the public about the meaning of genetic findings. Banning research on the genetics of antisocial personality disorder for political reasons would make it impossible for researchers to get a complete picture about how genetics and environment interact to produce antisocial behavior.

SensationSensation Seeking Seeking A hypothesis with a long history in psychology suggests that antisocial personality disorder is the result of low emotional arousal (Schoorl, 2015). The idea is that low arousal is an aversive state that people naturally try to escape. They do this by seeking the stimulation and excitement that comes from dangerous, often antisocial, behavior (Schoorl, 2015). Of course, stimulation seeking need not always lead to antisocial behavior. Successful businesspeople, mountain climbers, and even scientists may also crave stimulation, but their behavior is not antisocial. Clearly, sensation seeking alone is not a sufficient explanation for why some people develop antisocial personality disorder. We must also explain why such people seek stimulation in socially disapproved ways. One likely place to look is in early childhood family experiences.

FamilyFamily Dynamics Dynamics Psychodynamic theorists attribute antisocial and most other personality disorders to an absence of trust in other people (National Collaborating Centre for Mental Health, 2010). This loss of trust, which results from a lack of love during infancy, leads to emotional detachment. Children grow up unable to empathize with others; as a result, they become self-absorbed. The evidence for this view is the frequent finding of dysfunctional backgrounds in the histories of people with antisocial personality disorder (National Collaborating Centre for Mental Health, 2010). Again, however, there are many people who grow up with abuse who do not develop antisocial personality disorder, so family dynamics, on their own, are not a sufficient etiological explanation.

ModelingModeling and and Media Media Many lifelong habits, including antisocial ones, are first developed in childhood. For this reason, a childhood spent with criminal models is an ideal training ground for children to learn antisocial behavior (Paris, 2001). More often, however, exposure to antisocial behavior is not direct, but through the media. Children see crimes, including violent ones, on television, in the movies, and of course on the Internet; they can even “perpetrate” a pretend form of

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Ingemar Edfalk/Blend Images/SuperStock

Does violence in the media contribute to childhood violence? Researchers have conducted numerous studies on this topic, but the results have not pinpointed an exact cause.

violence by playing computer games.

Certainly, some evidence indicates that the number of hours spent watching media violence is a predictor of aggression, both in children and later in life (Coker et al., 2015). But it is only one of many predictors, and not a very strong one at that. The correlation between aggression among males and the time spent watching violent television programs in the United States is 0.25. In Australia it is 0.13, and in Finland, 0.22 (correlations can range from 1.0 to –1.0; numbers such as those here are not significant because they are too weak to have statistical significance; Huesmann, Moise, & Podolski, 1997). These correlations are too small to explain or predict violence on their own (Barrett, 1997). Perhaps aggressive kids are more likely to watch violent videos and play violent computer games. To make things even more complicated, there are strong counterexamples to the relationship between media violence and actual violence. Japan, for instance, is famous for its violent pornographic comics and gory

cartoons, yet it has a much lower incidence of violent crime than other countries (NationMaster, 2017).

The evidence boils down to this: Violence in the media is not a sufficient explanation for childhood violence. Censorship of media violence may reduce violence among some susceptible children (at the risk of violating everyone else’s right to free speech), but it is unlikely to eliminate what is really a complicated social problem that has multiple causes.

Treatment of Antisocial Personality Disorder

Few adults with antisocial behavior seek treatment, and even fewer are motivated to change. In general, treatments tend to be ineffective (National Collaborating Centre for Mental Health, 2010). The most common “treatment” for people with antisocial personality disorder is incarceration in a correctional facility. But incarceration is notoriously unsuccessful at rehabilitating most individuals, and repeat offenses are common. Psychological treatment does not usually thrive in involuntary settings such as prisons, yet there have been controlled studies showing the effectiveness of behavior therapy and behavioral staff training programs in reducing antisocial behavior, especially violence, by persons in institutions (Brazil, Van Dongen, Maes, Mars, & Baskin-Sommers, 2016). Clinicians have also had some success in reducing violence using antipsychotic and antidepressant medications, but more evidence is needed (Brazil et al., 2016). Given the difficulties encountered in treating antisocial personality disorder after it is established, some psychologists have emphasized prevention instead (National Collaborating Centre for Mental Health, 2010). Prevention programs are usually aimed at children and adolescents from high-risk backgrounds (abused children, children in single-parent families, and children from marginal neighborhoods). These programs include parent training and school-based counseling programs, among others.

Highlight: The Slender Man Stabbings

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On May 31, 2014, a horrific case shocked the relatively small city of Waukesha, Wisconsin. Two 12-year-old girls, Anissa Weier and Morgan Geyser, lured their best friend, 12-year-old Payton (Bella) Leutner, into the woods after a birthday sleepover at Geyser’s house. Weier and Geyser allegedly stabbed Leutner 19 times, purportedly to impress the fictional character Slender Man. By sacrificing Leutner, they believed that their families and they would be spared the Slender Man’s fatal wrath. After being stabbed, Leutner crawled to a road and lay on a sidewalk where a cyclist found her and called 911. She was rushed to a hospital, at which point she was close to death. Miraculously she recovered after being hospitalized for six days and later returned to school.

How could two 12-year-old girls, who were raised in evidently loving households where they did not lack basic needs, stab their best friend and leave her for dead? What could have led them to do such a thing? Although the case has a spectacular aspect to it that made major news headlines, an examination of some of the released facts provides a clearer picture of what might have occurred. Geyser purportedly had mental health issues since she was a very young child, according to her mother. What is not widely known is that her father has schizophrenia, currently in remission as of this writing. Weier was bullied extensively in school and would be drawn to unusual, often bizarre websites while withdrawing in her room.

Still, do these few facts (there are many others, of course) help to explain how two young girls could find themselves facing at least 60 years in prison? More relevant to the facts presented in this chapter, what if one or both also had premorbid indicators (warning signs) of a personality disorder? Neither girl can be diagnosed with a personality disorder because they are not yet 18. But does the inability to diagnose them prevent us from properly treating the girls? It seems not, as Geyser is in an inpatient psychiatric unit under court order, after being diagnosed with early-onset schizophrenia, and is doing reasonably well. Weier’s trial concluded in September 2017. A jury determined that she was mentally ill at the time of the attack, so Weier will avoid prison. Her attorney, Maura McMahon, said during closing arguments that Weier was lonely and depressed after her parents divorced and she latched onto Geyser. Once they became friends, they became obsessed with Slender Man, developing a condition called shared delusional disorder. Although not a DSM–5 diagnosis (the term in the DSM–5 is delusional symptoms in partner of individual with delusional disorder), this means that Weier ended up believing the Slender Man delusions that Geyser kept telling her about. The defense argued that Geyser’s delusions provided content for Weier’s delusions. This decision means that Weier will be sent to a psychiatric hospital rather than prison. A plea agreement states that she has to spend at least three years at a hospital before further determination is made. Geyser’s trial was scheduled to begin in October 2017 but in late September, she reached a plea deal. The terms of the deal state that Geyser will be evaluated by doctors, and based on the doctors’ testimony a judge will determine how long she will remain in a state mental hospital.

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Anissa Weier (left) and Morgan Geyser (right) developed shared delusional disorder and believed that they were being threatened by a fictional bogeyman called Slender Man.

This case raises many interesting questions: Why can’t we diagnose someone under age 18 with a personality disorder, even when it seems likely the signs and symptoms are present? Can we help someone who believes that fictions like Slender Man are real and who will go as far as attempting to kill another person? Although we can hypothesize that since Geyser’s father has schizophrenia, she may have inherited its diathesis, what about Weier? Is this the behavior of two misguided 12 year olds? Why didn’t anyone pick up on Geyser’s warning signs earlier, before it was too late? Or Weier’s? Would you be able to work with someone who has difficulty separating fantasy from reality, not knowing the difference between “right” and “wrong”? How important is it to stop bullying once it is detected? For the moment, these questions must remain hypotheses to a case that, sadly, has echoes in many school shootings and other tragic incidents, in which bullying and other possible premorbid indicators of a future personality disorder, or other kind of mental illness, are missed, downplayed, or ignored.

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9.2 Diagnosing Personality Disorders All personality disorders begin to become apparent during adolescence or early on in adulthood, although some do not make their first appearance until adulthood (APA, 2013). Once these disorders appear, they change little over the years, and they affect behavior in numerous situations.

Some personality disorders—antisocial personality disorder, for example—do not normally cause the individuals who have them personal distress. Instead, other people, especially their victims, feel the anguish. In such cases, diagnosis depends not on the self-perceptions of the individuals concerned but on the effects of their behavior on others. This is not unusual in abnormal psychology.

Categories Versus Dimensions

Because each of us can be described by noting where we fall on one or more personality traits, or “dimensions,” some psychologists have advocated a dimensional approach to diagnosing personality disorders. Instead of employing the “exclusional” diagnostic categories of the DSM–5—a person either meets the diagnostic criteria for a personality disorder or does not meet them—the dimensional approach to diagnosis describes people using a standard set of personality dimensions. The DSM–5 includes the dimensional model in Section III, “Emerging Measures and Models.” This section includes proposed diagnostic criteria for this new model. Perhaps this model will replace the current personality disorders model in the DSM’s next revision (see the accompanying Highlight).

Highlight: Personality Disorder Trait Specified (PDTS)

The APA (2013) has come up with an alternative dimensional approach to be considered in a possible DSM–5 update. A core component of this approach is the diagnosis of personality disorder trait specified (PDTS). Individuals would receive this diagnosis if one or more of their traits significantly impaired their functioning in everyday life. Psychologists and other helping professionals would identify and list the traits that were impaired, as well as rate the severity of the impairment. The five groups of traits are as follows:

Negative affectivity: People who display this trait have and experience negative emotions frequently and intensely. They will demonstrate at least one of the following traits: emotional lability (unstable emotions), anxiousness, separation insecurity, submissiveness, hostility, perseveration (repeating certain behaviors despite repeated failures from prior attempts), depression, suspiciousness, and restricted affectivity (lack of affect). Detachment: These people often avoid social interactions, often withdrawing from them. They will demonstrate one of the following traits: withdrawal, intimacy avoidance, anhedonia (inability to feel pleasure or get pleasure from pleasurable things), depression, restricted affectivity, and suspiciousness. Antagonism: These individuals will behave in ways that will put them in confrontation with others. They will demonstrate one of the following traits: manipulativeness, deceitfulness, grandiosity, attention seeking, callousness, and hostility. Disinhibition: These individuals behave impulsively without reflecting on potential future consequences. They will demonstrate one of the following traits: irresponsibility, impulsivity,

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distractibility, risk taking, and lack of rigid perfectionism. Psychoticism: These individuals have unusual and bizarre experiences. They will demonstrate one of the following traits: unusual beliefs and experiences, eccentricity, and cognitive and perceptual dysregulation (odd or unusual thought processes or sensory experiences) (APA, 2013).

An individual would qualify for a PDTS diagnosis if he or she has significant impairment in any of these five groups of traits, or in only one of the traits listed in any of the groups. As mentioned earlier, this approach and diagnosis are currently in review for the next revision of the DSM–5. What is your opinion about this dimensional approach?

The advantage of the dimensional approach is that it avoids pigeonholing people into narrow categorical boxes, thereby allowing them to be described in richer and more complex ways. Over the years, several attempts have been made to develop dimensional systems for describing personality (Cloninger, Bayon, & Przybeck, 1997; Widiger & Trull, 2007). These have not had wide consensus because psychologists have not been able to agree on which personality dimensions to use for this purpose (Widiger, 1991). One more widely accepted model is the five-factor model. People are rated on the following dimensions, and the combination determines the reasons why we are all so different: extroversion, agreeableness, conscientiousness, neuroticism, and openness to experience (Costa & McCrae, 2005; Goldberg, 1993).

Types of Personality Disorders

Following the DSM–5, this chapter divides the personality disorders into three clusters. Cluster A includes the paranoid, schizoid, and schizotypal personality disorders. Individuals who fall into Cluster A appear odd or eccentric. Cluster B includes the antisocial, borderline, histrionic, and narcissistic personality disorders. Individuals in Cluster B are dramatic, emotional, and erratic. Cluster C includes the avoidant, dependent, and obsessive- compulsive personality disorders. Individuals in Cluster C are anxious and fearful. It is not uncommon for the same person to be simultaneously diagnosed with personality disorders from more than one cluster (APA, 2016; Phillips & Gunderson, 1996; Skodol, 2005).

The precise number of personality disorders and the names of these disorders have varied from one version of the DSM to the next. Although the DSM–5 has settled on the 10 personality disorders listed in Table 9.1, keep in mind that these disorders represent only a sample of the total number of potential personality disorders.

Table 9.1 DSM–5DSM–5 personality disorders

Diagnostic term Primary personality characteristics

Cluster A

Paranoid personality Distrust and suspicion of others, poor social relations

Schizoid personality Restricted range of emotions and unstable relationships

Schizotypal personality Eccentric behavior, including cognitive distortions

Cluster B

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Antisocial personality Disregard of the rights of other people

Borderline personality Unstable relationships, poor self-image, impulsivity

Histrionic personality Excessive emotional display and the pursuit of attention

Narcissistic personality Grandiose feelings of superiority

Cluster C

Avoidant personality Socially sensitive, inhibited, feelings of inadequacy

Dependent personality Submissive and needing the care of others

Obsessive-compulsive personality Preoccupation with order and control

Diagnostic Reliability

Clinicians have difficulty deciding which personality disorder diagnosis is appropriate for which individual. The problem is that the same diagnostic criteria can be applied to supposedly different disorders. Clinicians have no trouble agreeing that a person has poor social relations (one of the diagnostic criteria), but they do not agree about whether a person with poor social relations should be classified as having a borderline, schizoid, or avoidant personality disorder (each of which is marked by the same criterion—poor social relations). Therefore, diagnostic reliability (the consistency of a measuring device, here referring to the DSM–5) is rather poor. Similarly, hostility (another of the diagnostic criteria) is easy to recognize, but of little discriminatory value because it is a feature of more than half the personality disorders.

Also, given the overlapping diagnostic criteria, it is not surprising that, as mentioned earlier, there is high comorbidity among personality disorders (APA, 2013). In fact, choosing between two or more personality disorders may be so difficult that clinicians may find it easier to simply give people both diagnoses.

Diagnostic Validity

The predictive value of the personality and impulse-control disorders is somewhat uncertain. Here we would examine validity, that is, does the DSM–5 measure what it claims to measure? In addition, does the DSM–5 have eternal validity, meaning do the diagnostic criteria generalize to many individuals? Knowing that someone has a personality disorder tells us little about how different personalities develop. Predicting how a person will behave in any situation requires that we understand not only the person’s personality but also the social situation in which the behavior takes place (Sherman et al., 2015).

Diagnostic Biases

Clinicians must be on the alert for potential biases in themselves when making any diagnosis, but personality disorders lend themselves to diagnostic biases. For example, dependence, submissiveness, and allowing one’s life to be directed by a spouse are all signs of a dependent personality disorder. However, they are also traits encouraged in females by many societies. If women adopt the dependent social role expected by their social group, are we really justified in calling their behavior a personality disorder? And gender biases are not the only ones that clinicians must avoid. Unless clinicians are careful, their evaluation of other people may also be biased by their own beliefs about or

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perceptions of social class, ethnicity, age, and education. As discussed in the following sections on specific personality disorders, each of these variables can bias clinical judgments about who is suffering from a personality disorder.

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9.3 Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders Cluster A personality disorders are marked by eccentricity, not to the point of losing touch with reality, but enough for the individual to be perceived by others as odd. The disorders included in Cluster A all share at least a superficial similarity with schizophrenia. Indeed, Cluster A personality disorders have sometimes been construed as milder versions or precursors of schizophrenia (Via et al., 2016). There is considerable overlap among the Cluster A personality disorders, making it difficult for clinicians to differentiate among them (APA, 2013; Via et al., 2016).

Paranoid Personality Disorder

People with paranoid personality disorder lack trust in others and constantly fear that their friends may be disloyal or unfaithful. Consequently, people with paranoid personality disorder avoid revealing their thoughts and feelings. Often, others perceive them as being hypersensitive. Those with this disorder may interpret even innocuous events (omission of their name from a roster, for example) as a sign that others are plotting against them. Any offers of assistance are taken as criticisms that the person is unable to cope on his or her own. Because they react to these perceived insults with anger, people with paranoid personality disorder are perceived by others as hostile.

At one time, paranoid personality disorder was viewed as a milder form of schizophrenia, but there are important differences between the two conditions. In contrast to people with schizophrenia, those with paranoid personality disorder do not have delusions, hallucinations, or other forms of thought disorder (APA, 2013). Instead, they are characterized mainly by their suspicion of other people. Today, most clinicians believe that paranoid personality disorder is at best only a distant member of schizophrenia spectrum and other psychotic disorders (Triebwasser, Chemerinski, Roussos, & Siever, 2013).

Sometimes, several people with paranoid personality disorder band together into groups with others who share their paranoid beliefs. Of course, seemingly “paranoid” people may have real enemies, so this diagnosis should not be applied lightly to political or economic refugees or to people whose backgrounds may have actually included conspiracies and prejudice. Some critics have argued that paranoid personality disorder should have been removed from the DSM–5, as there is not enough empirical data to support its inclusion (Triebwasser et al., 2013).

EtiologyEtiology Paranoid personality disorder first becomes apparent in childhood and seems to occur more often in males than females (APA, 2013). It affects between 0.5% and 4.4% of the general population (APA, 2013; O’Connor, 2008; Triebwasser et al., 2013). Because both traumatic brain injury and substance abuse may produce paranoid symptoms, care should be taken to exclude both possibilities when making the diagnosis (Gauba, Thomas, Balhara, & Deshpande, 2016).

TreatmentTreatment Few people with paranoid personality disorder seek psychological treatment; they are too suspicious of therapists. Those who do find their way into treatment may receive psychodynamic psychotherapy, cognitive-behavioral therapy, and medication. Unfortunately, none of these approaches to treatment have met with much success (Triebwasser et al., 2013).

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Schizoid Personality Disorder

Schizoid personality disorder consists mainly of negative rather than positive symptoms. As was discussed in Chapter 8, positive and negative do not refer to “good” and “bad” aspects. Rather, positive symptoms refer to something added to an individual’s behaviors or personality (like a delusion), whereas negative symptoms refer to an absence of something or some kind of behavior that typically is present (for example, proper hygiene or speech). That is, the defining feature of schizoid personality disorder is not a delusion, obsession, or thought disorder—it is the lack of social relationships (Triebwasser, Chemerinski, Roussos, & Siever, 2012). People with schizoid personality disorder prefer solitary pursuits and spend much of their time alone (see the accompanying Highlight). They have flat affect (a limited range of emotions) and are indifferent toward the opinions of others. Because of their social isolation, people with schizoid personality disorder are socially inept and appear self-absorbed, cold, and aloof (Triebwasser et al., 2012).

Highlight: Veronica’s Sunday

Veronica is a 32-year-old woman who works during the week as a security guard at a bank. This excerpt from a letter written by Veronica’s sister, with whom she lives, to their mother, is a description of a typical Sunday in the life of this woman with a schizoid personality disorder:

Dear Mom,

I hope you are well, and over your cold. I am doing OK, but I’m worried about Veronica. I have been keeping a close eye on her as you suggested, but she seems to be getting even more withdrawn. Let me tell you about Sunday. Veronica got up at 8:30 and switched on the television. She watched for an hour while still in bed. She then had some juice and coffee while watching a news show on television. At around 10:30, she fed Kat [the cat]. She sat and watched the cat eat for a while and then spent 45 minutes washing and ironing her clothes. She organized her drawers and then had a shower and got dressed. By this time, it was noon. Her next activity was to sit on a chair directly in front of a window and read the newspaper that we get delivered. After about an hour of this, Veronica once again turned on the television. She watched a talk show, and then she went outside for a walk. When she returned home, she ate a tiny dinner and watched television until late, when she fell asleep. She did not utter a word to me, or anyone else, all day. . ..

To keep schizophrenia and schizoid personality disorder separate, the DSM–5 rules out schizoid personality disorder in people with schizophrenia (or any other psychotic disorder). It is also important that diagnosticians consider a person’s social situation. For example, the diagnosis of schizoid personality disorder is inappropriate for people who have recently migrated from one culture to another. Although immigrants may show the signs of a schizoid personality disorder (immigrants often take a while to settle into their new surroundings), it would be unwise to make a diagnosis until they have had the opportunity to adjust to their new environment. Finally, the diagnosis should be reserved for people in distress, not for people who prefer and adjust well to living as “loners.”

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Mrk movie/Marka/SuperStock

Some people have diagnosed Batman with schizoid personality disorder due to his solitary tendencies and aloof persona.

EtiologyEtiology Although the term simple schizophrenia was once used to describe people with schizoid personality disorder, it, like paranoid personality disorder, is probably only a distant (at best) member of the spectrum of schizophrenia-related disorders (Fulton & Winokur, 1993; Laulik, Chou, Browne, & Allam, 2013; Maier, Lichtermann, Minges, & Heun, 1994). Schizoid personality disorder is no more common among the relatives of people with schizophrenia than it is among the relatives of people without schizophrenia. Like paranoid personality disorder, it is more likely to be found among the relatives of depressed people than of schizophrenic people.

Psychodynamic (and most behavioral) theorists blame rejecting and abusive parents for causing their offspring to shun other people (Laulik et al., 2013; Sperry, 2003). The trouble with this hypothesis is that precisely the same etiology is applied to paranoid personality disorder. What psychodynamic theorists do not explain is why some rejected children withdraw and develop a schizoid personality disorder, whereas others react with anger and become paranoid. Based on the restricted range of affect often displayed by people with schizoid personality disorder, cognitive theorists have hypothesized that their symptoms are the result of some deficit in processing emotional information (Smith, 2006; Triebwasser et al., 2012).

TreatmentTreatment People with schizoid personality disorder rarely seek treatment; they are too disengaged from others to care and too threatened by close relationships to get involved in psychotherapy (Mittal, Kalus, Bernstein, & Siever, 2007; Triebwasser et al., 2012). Those who do find their way into treatment usually suffer from some associated condition, such as substance abuse or depression. For those who receive treatment, psychoanalytic therapy focuses on working through the trauma produced by early rejection, whereas cognitive-behavioral therapy attempts to teach people the social skills they need to interact with others. There have been case reports of successful psychological treatment of schizoid personality disorder in young people (Gooding, 2016; Herlihy, 1993), but, for most people, psychotherapy has produced only limited success (Belcher et al., 1995) and medications have not proved much better (Gooding, 2016; Koenigsberg et al., 2002).

Schizotypal Personality Disorder

Like people with schizoid personality disorder, those with schizotypal personality disorder are loners who are unable to form relationships with other people or are uninterested in doing so. They prefer solitary activities to those involving others, and, like people with schizoid personality disorder, they are often perceived as cold and unemotional. There are also similarities between schizotypal personality disorder and paranoid personality disorder. Both disorders are marked by suspicion of the motives of others and by ideas of reference, the belief that unrelated comments and events pertain to those with the disorder.

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Clearly, the schizotypal personality disorder shares symptoms with both the schizoid and the paranoid personality disorders, but it differs in an important respect: Schizotypal personality disorder is hypothesized to be related to, and like, schizophrenia (Koenigsberg et al., 2005; Thames & Lilienfeld, 2015). People with schizotypal personality disorder have peculiar thoughts, rambling speech, odd appearance, and eccentric behaviors. Put simply, schizotypal personality disorder seems to be a mild form of schizophrenia that occurs in approximately 0.6% to 3.9% of the population (APA, 2013; Bollini & Walker, 2007; Rosell et al., 2014; Thames & Lilienfeld, 2015).

EtiologyEtiology Because of the similarity between schizotypal disorder and the schizophrenia spectrum of disorders, researchers have tried to apply the diathesis-stress etiological model of schizophrenia to schizotypal personality disorder. Certainly, the diathesis appears to be similar. Schizotypal personality disorder is most commonly found in families with schizophrenic relatives (Thames & Lilienfeld, 2015), and people with schizotypal personality disorder exhibit attentional deficits similar to those seen in people with schizophrenia (Bollini & Walker, 2007; Thames & Lilienfeld, 2015). The similarities between the two disorders do not end there. Both schizophrenia and schizotypal personality disorder have also been linked to higher than average levels of dopamine as well as to enlarged brain ventricles (Bollini & Walker, 2007; Fervaha & Remington, 2013).

TreatmentTreatment As it is with schizophrenia, psychotherapy is of limited value in schizotypal personality disorder (Ewing, Falk, & Otto, 1996; Ryan, Macdonald, & Walker, 2013). The most successful treatment approaches mirror those used in schizophrenia—skills training (McKay & Neziroglu, 1996; Ryan et al., 2013) and antipsychotic medication (Bollini & Walker, 2007; Ryan et al., 2013). See Table 9.2 for a comparison of Cluster A personality disorders and schizophrenia.

Table 9.2 Comparison of Cluster A personality disorders and schizophrenia on selected characteristics

Disorder Characteristics

Negative symptoms (e.g., blunt affect)

Paranoid ideas

Family members with schizophrenia

Positive symptoms (e.g., thought disorder)

Schizophrenia Yes Yes Yes Yes

Cluster A Personality Disorders

Paranoid personality disorder

Yes

Schizoid personality disorder

Yes Yes

Schizotypal personality disorder

Yes Yes Yes

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9.4 Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders People with Cluster B personality disorders tend to be self-absorbed. They find it difficult to empathize with others because they spend so much time and energy on themselves. In addition, they exaggerate the importance of everything that happens to them, usually in a theatrical and overly dramatic way. Because of their excessive self- concern and melodramatics, people with Cluster B personality disorders find it difficult to establish and maintain interpersonal relationships (APA, 2013). Antisocial personality disorder has already been discussed, so this section focuses on the remaining three Cluster B disorders: borderline, histrionic, and narcissistic personality disorders.

Borderline Personality Disorder

Clinicians and researchers who work from different paradigms have used the term borderline in several different ways: (a) to refer to people whose behavior fell at some hypothetical border between “neurotic” mood disorders and psychotic ones, (b) as a general term for the symptoms caused by mild brain damage, and (c) to describe people whose poor social relations are marked by manipulative suicide attempts (Gunderson, Zanarini, & Kisiel, 1995; Ogden & Prokott, 2013; Tyrer, 1994).

In an attempt to give systematic meaning to the term borderline, the DSM–5 has chosen to emphasize instability and impulsivity. According to the DSM–5, people with borderline personality disorder are insecure because they have a morbid fear of abandonment. They want to form close relationships, and, initially at least, they succeed. But their need for attention and reassurance eventually becomes too overwhelming and their relationships break down. This is a recurring cycle—other people begin as perfect friends and evolve into enemies; there is no in-between. This tendency to categorize people as entirely good or entirely bad is known in psychoanalytic circles as “splitting.”

When relationships deteriorate, people with borderline personality disorder may threaten to harm themselves just to keep the connection going. If this does not work (and it rarely does), they may actually carry out their threats by mutilating or even killing themselves (Ogden & Prokott, 2016; Sherry & Whilde, 2008). In addition to self-harm, people with borderline personality disorder may engage in various forms of imprudent behavior—reckless driving, unsafe sex, gambling, and substance abuse (Schub & Kornusky, 2016; Sherry & Whilde, 2008). Indeed, their moods tend to swing widely depending on the state of their interpersonal relationships. When these are going well, they may be elated, friendly, and good company. When their relationships are going badly, they become depressed, sullen, and aggressive.

EtiologyEtiology There is considerable overlap between the symptoms of antisocial personality disorder and those of borderline personality disorder. There are some differences as well. Although people with both diagnoses are impulsive, reckless, unable to form stable relationships, and often hostile, borderline personality is also associated with a morbid fear of abandonment.

Borderline personality disorder occurs in anywhere from 1.6% to 5.9% of the general population (APA, 2013; Sherry & Whilde, 2008), with about 75% being female. As we have seen, sex differences in the incidence of a disorder can have many explanations. In the case of borderline personality disorder, social factors, especially sex role expectations, seem to play an important part (Becker, 1997; Hoertel et al., 2014). Through the process of socialization, similar etiological factors wind up producing somewhat different disorders. For instance, it is possible that the underlying causes of antisocial and borderline personality disorders are similar but that women are socialized

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to be more frightened of being alone and to turn their aggression inward in the form of suicidal gestures rather than outward toward others (Hoertel, Peyre, Wall, Limosin, & Blanco, 2014; Paris, 1997). Of course, social roles change from one society to another, so it is important to keep in mind that practically all of the research and clinical reports concerning borderline personality disorder come from developed countries such as the United States. Traditional societies, such as those found in developing countries, have different sex roles. For example, in some societies, women are almost guaranteed supportive relationships through a network of mutual family and community obligations. Perhaps this is the reason such societies have a low incidence of borderline personality disorder (Paris, 1996; Paris & Lis, 2012).

Borderline personality disorder has been attributed to parental loss or abuse in childhood (Ogden & Prokott, 2016; Sansone, Levitt, & Sansone, 2005) or to posttraumatic stress later in life (Ogden & Prokott, 2016; Zlotnick, 1997). In both cases, psychological trauma is thought to produce a fear of further loss and a subsequent fear of abandonment (Ogden & Prokott, 2016; Sherry & Whilde, 2008). Although this seems a plausible theory, it is hardly specific to borderline personality disorder. Parental loss and abuse are found in the backgrounds of many psychological disorders. A similar lack of specificity may be found in the various biological explanations offered for borderline personality disorder—genetics, low levels of serotonin (Norra et al., 2003; Ogden & Prokott, 2016), thyroid dysfunction (Klonoff & Landrine, 1997; Sinai et al., 2015), and brain structures either being unusually small or being overactive or underactive (Donegan et al., 2003; Visintin, Voci, Pagotto, & Hewstone, 2016); all occur in other disorders as well.

TreatmentTreatment There have been many attempts to develop treatments for borderline personality disorder, but none has proved especially successful. Psychoanalytic psychotherapy concentrates on analyzing the transference relationship that develops between patient and therapist. That is, in psychoanalysis, it is essential to establish a patient-analyst relationship in which the patient responds to the analyst as though the analyst is or was an important figure (for example, father, mother) in the patient’s life. The goal of treatment is to use the transference relationship as a model to show people the way in which they undermine their interpersonal relationships (Gabbard et al., 1994; Horwitz, 1996; Stoffers et al., 2013). A strong patient-therapist transference may also help people with borderline personality disorder to learn to trust others. As you can imagine, however, building a transference relationship and analyzing a client’s interpersonal functioning is difficult with people whose relationships are characteristically turbulent. Following their usual pattern, patients with borderline personality disorder begin by idealizing the therapist as a potential savior and later, through splitting, turn this completely around so that the therapist becomes a money- seeking charlatan. In such cases, analyzing the transference relationship takes some time, with many regressions along the way (Bender & Oldham, 2005; Stoffers et al., 2013).

Although cognitive-behavioral therapy may assist people with borderline personality disorder to lead more effective lives (Stoffers et al., 2013; Waldo & Harman, 1998), people with this disorder may find it difficult to complete a course of therapy. They may drop out of treatment at the first sign (real or imagined) that the therapist is neglecting them. To help such clients follow through with treatment, clinicians may first try to increase a client’s emotional stability. For example, emotional awareness training, in which people with borderline personality disorder are given practice in recognizing their emotions (as well as those being experienced by others) and then taught ways to control their emotions, may help clients to cope with the stress of cognitive and behavioral interventions (Oldham, 2006; Stoffers et al., 2013). Therapists, too, must make certain adjustments. For example, they must learn to deal with the manipulative behavior of clients who are hypersensitive to criticism and are always imagining that they are being rejected.

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People with histrionic personality disorder desire to be the center of attention.

Cognitive-behavioral therapists may employ a multimodal treatment strategy known as dialectical behavior therapy. This approach combines group and individual therapy, supportive counseling, and a behavioral contract (usually an agreement not to harm oneself) with skill training aimed at improving and maintaining relationships (Linehan & Dexter-Mazza, 2008; Stoffers et al., 2013). Support may also be given to friends and family members who need to learn what to expect and how to deal with a person who has a borderline personality disorder (Gale, 2016).

In addition to psychological treatment, the entire spectrum of psychoactive drugs has been used to treat borderline personality disorder, usually in conjunction with some form of psychological therapy (Ogden & Prokott, 2016; Soloff, 2005). The most effective drugs are antidepressants (especially the SSRIs), which seem to reduce the impulsivity, depression, and rage that destroy relationships (Binks et al., 2006; Ogden & Prokott, 2013).

Histrionic Personality Disorder

Histrionic personality disorder is a direct descendant of the 19th-century concept of hysteria. People with this disorder do not have conversion symptoms, though. They are mainly motivated by the need to be the center of attention (Bates, 2016; Skodol, 2005). To gain the notice they crave, people with this disorder may act seductively, dress in eccentric clothes, or act in a loud and boisterous fashion. People with a histrionic personality disorder actively seek compliments and are easily upset by criticism. Because of their melodramatic displays, histrionic people are viewed as shallow and phony.

EtiologyEtiology Histrionic personality disorder appears to have a prevalence of 1.84% to 3% in the general population (APA, 2013; Bates, 2016; O’Connor, 2008) and affects men and women equally (Bates, 2016; O’Connor, 2008).

TreatmentTreatment Although people with histrionic personality disorder may seek treatment, they make difficult clients. They tend to use the therapeutic environment as another opportunity to “be on center stage” and present exaggerated versions of their problems (Bates, 2016; Gutheil, 2005). Group treatment is generally not possible for people with histrionic personality disorder because of their need to monopolize the therapist’s attention. Nor are histrionic people good candidates for insight-oriented therapy (self-awareness and understanding of the influence of the past on their present behavior); they find it impossible to accept any but their own interpretations of their behavior. Perhaps the best therapeutic approach is to concentrate on helping people with this disorder to separate important problems from trivial ones, and to teach them how to pay attention to others. There are no specific drug treatments for histrionic personality disorder, although drugs may be used to treat any comorbid disorders (such as major depressive disorder; Bates, 2016; Grossman, 2004).

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Narcissistic Personality Disorder

According to Greek mythology, Narcissus was a boy of legendary beauty who fell in love with his own reflection in the waters of a pond. He stared at his reflection until he wasted away to a flower. From this story, Freud derived the word narcissistic, meaning a person who is consumed with self-love. Freud’s use of the term has evolved into the DSM–5 diagnosis of narcissistic personality disorder. People with this disorder are characterized by their strong sense of superiority. They consider themselves to be important and demand special treatment. People with this disorder are often rude because they view rules and common courtesy as meant for others (Kealy, Goodman, Rasmussen, Weiderman, & Ogrodniczuk, 2017; Miller, Campbell, & Pilkonis, 2007). Like people with histrionic personality disorder, narcissistic people crave attention. They dream of achieving positions that will gain them the power and attention they seek. More often, however, narcissistic people exaggerate their own successes and envy the achievements of others. Beneath the surface, narcissistic people are so plagued by self-doubt that, even when they have reached a goal, they remain unsatisfied because success never brings them the level of adulation they desire.

EtiologyEtiology In psychodynamic terms, narcissism starts in childhood. We are all narcissistic as children because the world seems to revolve around us. When we are hungry, someone feeds us; when we are cold, someone always caters to our needs. One of the most important tasks facing children during the process of socialization is learning that there are other people in the world, with their own feelings and needs. Learning to empathize with others is a skill that develops through childhood and the teenage years, so we must be wary of applying the DSM–5 criteria to young people (APA, 2013). However, by early adulthood, a narcissistic personality disorder should become clear. Once such a disorder develops, it tends to be ongoing (Bates & Neff, 2017; Ronningstam, 1998). Narcissistic personality disorder affects about 0% to 6.2% of the general population (APA, 2013), mainly males.

TreatmentTreatment Both psychodynamic and cognitive-behavioral approaches to the treatment of narcissistic personality disorder focus attention on helping people to become more realistic in their goals and to find satisfaction and fulfillment in the normal events of daily life (Beck, Freeman, & Davis, 2004; Kealy et al., 2017). Training in recognizing and empathizing with the emotions of others is an important adjunct goal of treatment. As in many other personality disorders, drugs may be used to treat some symptoms or for comorbid disorders (Bateman, Gunderson, & Mulder, 2015; Joseph, 1997).

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9.5 Cluster C: Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders The disorders in Cluster C share the characteristics of fearfulness and worry (Alpert et al., 1997; Laulik et al., 2013). In contrast to the anxiety disorders, however, Cluster C personality disorders tend to have an earlier onset, no clear cause, and a stable lifelong course (O’Donohue, Fowler, & Lilienfeld, 2007). Cluster C disorders include avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. Research support for the various etiological hypotheses is very limited. At the same time, treatments for these disorders appear to be modestly to moderately helpful—considerably better than for other personality disorders.

Avoidant Personality Disorder

People with avoidant personality disorder are shy and socially uncomfortable. Unlike people with schizoid personality disorder, people with avoidant personality disorder would prefer to be sociable, but they avoid social contact because they fear embarrassment and criticism. In practice, it is difficult to separate avoidant personality disorder from social phobia (Prerost, 2016; Ralevski et al., 2005). When social anxiety is long-standing, the diagnoses are probably interchangeable. Because shyness and social reticence are developmentally appropriate for young children (and because some cultural groups encourage social timidity for one or both sexes), a client’s age and culture should be taken into account when making this diagnosis (APA, 2013). Avoidant personality disorder occurs in around 2.4% of the general population, and it affects men and women in equal numbers (APA, 2013; O’Connor, 2008; Prerost, 2016). It is often found in conjunction with the diagnosis of unipolar depression (APA, 2013; Prerost, 2016). Cognitive-behavioral treatments aimed at reducing social anxiety can also help people with avoidant personality disorder to lead fuller lives (Beck, 2016; Emmelkamp et al., 2006).

EtiologyEtiology Avoidant personality disorder is similar to social anxiety disorder in a number of ways, and may be comorbid with it (see, for example, Eikenaes et al., 2013). Both disorders present with a fear of humiliation and low self-confidence. However, there appears to be a key difference between the two disorders: People with social anxiety disorder mainly fear social circumstances, whereas people with avoidant personality disorder fear close social relationships (Lampe & Sunderland, 2013). Others believe that the two disorders are very similar and therefore should be combined (Eikenaes et al., 2013).

TreatmentTreatment One of the main issues with treating individuals with avoidant personality disorder is keeping them in treatment. This should not be a surprise, as many of the patients begin to avoid the sessions. This is not necessarily resistance but is based on the patient’s not trusting the clinician, and fearing being rejected by the clinician. An important aspect of treatment is therefore for the clinician to gain the patient’s trust (Colli et al., 2014; Leichsenring & Salzer, 2014). Typically, clinicians will treat avoidant personality disorder the same way they treat social anxiety disorder, and the success rate is usually moderate to good (Kantor, 2010; Porcerelli et al., 2007). As you might expect, psychodynamic therapists try to help the patients recognize and resolve their unconscious conflicts (Leichsenring & Salzer, 2014). Cognitive therapists, among other aspects, will work with patients to help them change their upsetting, irrational beliefs and thoughts, carry on in the face of painful emotions, and improve their self-image (Beck et al., 2004; Rees & Pritchard, 2013). Behavioral therapists will provide social skills training as well as exposure therapy, gradually requiring patients to increase their day-to-day interpersonal interactions (Herbert, 2007). Group therapy can be

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especially successful, as it provides the patient a chance to practice interpersonal interactions in a safe environment (Herbert et al., 2005).

Dependent Personality Disorder

People with dependent personality disorder have a strong need to be taken care of by someone else, preferably someone important (Bornstein, 2005; Disney, 2013; Skodol, 2005). To fulfill this need, they tend to be submissive to the demands of their chosen caretaker, acting, at times, as if they were helpless to look after themselves. Like people with histrionic personality disorder, those with dependent personality disorder have a strong need for approval. However, dependent people are timid, whereas histrionic people actively seek attention. Like people with borderline personality disorders, dependent people worry about being abandoned. Instead of reacting with rage, however, dependent people become submissive. Finally, both avoidant and dependent personality disorders are characterized by feelings of inadequacy, but avoidant people tend to withdraw, whereas dependent people seek to develop relationships with people who can care for them.

Dependent personality disorder affects anywhere from 0.6% to 2.5% of the general population (APA, 2013; Grant et al., 2004). The DSM–5 asserts that the disorder affects both sexes with only a small bias toward females (APA, 2013). This sex difference probably reflects the cultural stereotype of the dependent woman. Because young children are expected to be dependent and because some cultural groups foster dependent behavior among females, caution should be taken in applying this diagnosis to children or to members of some cultural groups (APA, 2013).

EtiologyEtiology Although the precise causes of dependent personality disorder are not known, it is thought to begin with a fearful temperament (a genetic disposition) that evokes overprotectiveness from parents (Disney, 2013; Sperry, 2003). Illness in childhood, abandonment, and traumatic loss can produce a similar overprotectiveness. Children may resent this attitude but may learn to submit rather than challenge their parents.

TreatmentTreatment Few people seek treatment for dependent personality disorder. However, some may find their way into therapy for an associated anxiety or depressive disorder (Disney, 2013; Skodol, Gallaher, & Oldham, 1996). In psychodynamic treatment, the therapist uses the transference relationship first to form a bond with the client and then to teach the person how to separate. The idea is that, through the transference experience, the person will learn more effective modes of relating to others (Disney, 2013; Sperry, 2003). Cognitive therapists try to help their dependent clients to recognize the faulty cognitions that produce their lack of self-confidence (Disney, 2013; Freeman, 2002). Behavioral therapists use assertiveness training to enhance self-esteem by providing dependent clients with a nonsubmissive mode of relating to others. Relaxation training may also be helpful in reducing anxiety. Although people with this disorder usually go along with their therapist’s treatment suggestions (they are submissive people, after all), they are still difficult to treat because of their need for constant reassurance.

Long-term treatment is probably not a good idea with dependent people because it may make them overly dependent on their therapist. Support and self-help groups could be useful places for clients to practice new skills learned in therapy (provided, of course, that clients participate in the group and do not simply let others do all the talking). Drugs may be prescribed for the anxiety and depression often experienced by people with dependent personality

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Felix Ungar (left) of TheThe Odd Odd Couple Couple is a notorious neat freak, always mopping, cleaning, and picking up dust bunnies. He is always immaculately dressed. Does he have OCPD?

disorder (Disney, 2013; Fava et al., 2002), but care should be taken because clients may use drug overdoses as a way of manipulating other people.

Obsessive-Compulsive Personality Disorder

It is rather easy, based on the name among other aspects, to confuse obsessive-compulsive disorder (OCD) with obsessive-compulsive personality disorder. OCD behaviors fall along a continuum from relatively mild to severe (Stein & Hollander, 1997; Vorstenbosch et al., 2012). Obsessive- compulsive personality disorder (OCPD) behaviors fall at the mild end of the continuum. People who have this disorder do not display true obsessions or even severe compulsions. Instead, they are characterized by a perfectionistic attitude toward daily life (APA, 2013). People with this disorder try to maintain a rigid control over their routines and, when possible, the behavior of other people. They accomplish the latter by insisting on a tight adherence to rules and schedules. They feel that their approach to all matters is the only correct one, and they tend to deny that other people might have reasonable alternative views. Not surprisingly, they are viewed by others as moralistic, rigid, and stubborn. The disorder seems to be more common among white, educated, married males and has a prevalence in the community of about 2.1% to 7.9% (APA, 2013; Bartz, Kaplan, & Hollander, 2007).

EtiologyEtiology As for many of the personality disorders, research on the etiology of OCPD is limited. A number of theories link OCPD with OCD even though there may in fact be little similarity between the two conditions. As you might expect, Freudian concepts are heavily represented.

Freudian theorists suggest that people with OCPD are anal retentive. This is due to very strict toilet training by the individual’s parents during the anal stage. Therefore, they become anal retentive and fixated in the anal stage. They develop a lot of anger, which is repressed; in order to control this anger and stay in control, they withhold their feces. The end result is that they become extremely orderly and restrained (Millon, 2011). Cognitive theorists, as you might guess, believe that illogical and irrational thinking maintains OCPD (Beck et al., 2004; Weishaar & Beck, 2006).

TreatmentTreatment People with OCPD do not usually believe there is anything wrong with them. Because of this they are not likely to seek treatment unless they are also suffering from a comorbid condition. This is often an anxiety disorder or unipolar depression. They may seek treatment if a close friend or family member insists on it (Bartz et al., 2007). Part of the treatment process, therefore, might involve the clinician’s trying to establish rapport and trying to convince the patient to stay in treatment (Colli et al., 2014).

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In therapy, Freudians would try to help patients recognize and accept their insecurities and personal limitations. Cognitive therapists would again focus on helping patients to change their irrational, all-or-nothing thinking, as well as their perfectionism, procrastination, and chronic worrying. The response rate to both modalities is usually quite good (Svartberg & McCullough, 2010; Weishaar & Beck, 2006).

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Chapter Summary

Evolution of a Personality Disorder Personality disorders constitute distinct diagnostic categories; a person either meets the criteria for a personality disorder or does not meet them. Alternatively, people may be described by where they fall on a variety of personality dimensions. The dimensional approach provides richer descriptions and avoids pigeonholing people into narrow categories. Unfortunately, there are many possible personality dimensions, and no one knows which ones are appropriate for describing people.

Diagnosing Personality Disorders Clinicians often disagree about personality disorder diagnoses because of overlapping criteria. Borderline, schizoid, and avoidant personality disorders are all marked by poor social relations. To make diagnosis easier, clinicians often simply give people more than one personality-disorder diagnosis. In some cases, personality-disorder diagnostic criteria reflect cultural and gender stereotypes.

Antisocial Personality Disorder The hallmark of antisocial personality disorder is a flagrant disregard for the rights of other people. The disorder is found mainly in males, it affects between 0.2% and 3.3% of the population, and its incidence decreases with age. Like much human behavior, antisocial personality disorder begins in childhood, especially among children from abusive or discordant families. Few people with antisocial personality disorder are motivated to seek treatment.

Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders Cluster A personality disorders are marked by eccentricity, not to the point of losing touch with reality, but sufficient for the individual to be perceived by others as odd. Psychological treatments for Cluster A disorders mirror those used in schizophrenia—social skill training and antipsychotic medication.

Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders People with Cluster B personality disorders are self-absorbed. They find it difficult to empathize with others, and they exaggerate the importance of everything that happens to them in a theatrical and overly dramatic way. Because of their excessive self-concern and melodramatics, people with Cluster B disorders find it difficult to establish and maintain interpersonal relationships. These disorders are difficult to treat but may sometimes respond to therapy, particularly a mixture of psychodynamic and cognitive-behavioral treatment. Drugs are also used in treatment but mainly for associated conditions or specific symptoms.

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Cluster C: Avoidant, Obsessive-Compulsive, and Dependent Personality Disorders The disorders in Cluster C share many characteristics with the anxiety disorders, such as fearfulness and worry, and they tend to co-occur with depression. Cluster C personality disorders tend to have no clear cause and a stable lifelong course.

Critical Thinking Questions 1. Personality disorders are chronic and difficult to treat. What makes these disorders so difficult to treat? 2. Antisocial personality disorder appears to be associated with criminal tendencies or behaviors. Discuss the

possible connection between the two. 3. Narcissistic personality disorder was under consideration for removal from the DSM–5 as a diagnostic

category. Discuss some possible reasons for this consideration. 4. Individuals with a Cluster B personality disorder often do not come into treatment voluntarily. Let’s assume

you had someone with antisocial personality disorder in treatment who hated being there. How would you go about treating him or her?

5. Imagine that your coworker has a narcissistic personality disorder. What types of issues do you think you might encounter in working with him or her?

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Key Terms

antisocial personality disorder A Cluster B disorder; the key characteristic is a flagrant disregard for the rights of other people. People with antisocial personality disorder are often irresponsible, impulsive, and untrustworthy.

avoidant personality disorder A Cluster C disorder; people with avoidant personality disorder are shy and socially uncomfortable. They would prefer to be sociable, but they avoid social contact because they fear embarrassment and criticism.

borderline personality disorder A Cluster B disorder; people with borderline personality disorder are insecure because they have a morbid fear of abandonment. They tend to be self-injurious and have short-term, intense interpersonal relationships.

dependent personality disorder

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A Cluster C disorder; people with this disorder have a strong need to be taken care of by someone else, preferably someone important. They tend to be submissive to the demands of their chosen caretaker, acting, at times, as if they were helpless to look after themselves.

dialectical behavior therapy A treatment approach for borderline personality disorder that combines group and individual therapy, supportive counseling, and behavioral contracting with skill training aimed at improving and maintaining relationships.

dimensional approach This system for diagnosing personality disorders describes people using a standard set of personality dimensions.

histrionic personality disorder A Cluster B disorder; these individuals are motivated mainly by the need to be the center of attention. People with this disorder may act seductively, dress in eccentric clothes, or act in a loud and boisterous fashion.

narcissistic personality disorder A Cluster B disorder; these individuals have a strong sense of superiority. Those with the disorder consider themselves to be important and demand special treatment, and they are often rude because they view rules and common courtesy as meant for others.

obsessive-compulsive personality disorder A Cluster C disorder; people who have this disorder are characterized by a perfectionistic attitude toward daily life. They try to maintain a rigid control over their routines and, when possible, the behavior of other people.

paranoid personality disorder A Cluster A disorder; individuals with the disorder avoid revealing their thoughts and feelings and may interpret even innocuous events as a sign that others are plotting against them.

personality The sum of an individual’s traits.

personality disorder An enduring pattern of inner experience and behavior that deviates markedly from the expectations of an individual’s culture.

personality disorder trait specified (PDTS) A personality disorder currently under consideration for inclusion in a future DSM–5 revision. Individuals would receive this diagnosis if one or more of their traits significantly impaired their functioning in everyday life.

psychopath A person who lacks empathy, does not fear punishment, and will continue to break the law even if capture and punishment are likely.

schizoid personality disorder A Cluster A disorder; people with this disorder have negative rather than positive symptoms. The defining feature of schizoid personality disorder is not a delusion, obsession, or thought disorder—it is the lack of social relationships.

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schizotypal personality disorder A Cluster A disorder; those with this disorder are considered “loners” who are unable to form relationships with other people or are uninterested in doing so. They are often perceived as cold and unemotional.

shared delusional disorder Not a DSM–5 diagnosis (the DSM–5 term is delusional symptoms in partner of individual with delusional disorder); refers to a condition in which an individual’s delusions provide content for another person, thus fostering that person’s delusions.

transference relationship In psychoanalysis, establishing a patient-analyst relationship in which the patient responds to the analyst as though the analyst is or was an important figure (for example, father, mother) in the patient’s life.

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CASE STUDY

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GARY (BIPOLAR DISORDER)

CASE STUDY DETAILS Gary is a 19-year-old who withdrew from college after experiencing a manic

episode during which he was brought to the attention of the Campus Police (“I

took the responsibility to pull multiple fire alarms in my dorm to ensure that

they worked, given the life or death nature of fires”). He had changed his

major from engineering to philosophy and increasingly had reduced his sleep,

spending long hours engaging his friends in conversations about the nature of

reality. He had been convinced about the importance of his ideas, stating

frequently that he was more learned and advanced than all his professors. He

told others that he was on the verge of revolutionizing his new field, and he

grew increasingly irritable and intolerant of any who disagreed with him. He

also increased a number of high-risk behaviors – drinking and engaging in

sexual relations in a way that was unlike his previous history. At the present

time, he has returned home and his been placed on a mood stabilizer (after a

period of time on an antipsychotic), and his psychiatrist is requesting

adjunctive psychotherapy for his bipolar disorder. The patient’s parents are

somewhat shocked by the diagnosis, but they acknowledge that Gary had early

11/20/20, 11'09 PMGary (bipolar disorder) | Society of Clinical Psychology

Page 3 of 4https://div12.org/case_study/gary-bipolar-disorder/

problems with anxiety during pre-adolescence, followed by some periods of

withdrawal and depression during his adolescence. His parents are eager to be

involved in treatment, if appropriate.

SYMPTOMS Alcohol Use

Depression

Elevated Mood

Impulsivity

Irritability

Mania/Hypomania

Mood Cycles

Risky Behaviors

DIAGNOSES AND RELATED TREATMENTS

1. BIPOLAR DISORDER (HTTPS://WWW.DIV12.ORG/DIAGNOSIS/BIPOLAR- DISORDER/)

The following treatments have empirical support for individuals with Bipolar

Disorder (https://www.div12.org/diagnosis/bipolar-disorder/):

Cognitive Therapy (CT) for Bipolar Disorder

11/20/20, 11'09 PMGary (bipolar disorder) | Society of Clinical Psychology

Page 4 of 4https://div12.org/case_study/gary-bipolar-disorder/

(https://www.div12.org/treatment/cognitive-therapy-ct-for-bipolar-

disorder/)

Family Focused Therapy (FFT) for Bipolar Disorder

(https://www.div12.org/treatment/family-focused-therapy-fft-for-

bipolar-disorder/)

Interpersonal and Social Rhythm Therapy (IPSRT) for Bipolar Disorder

(https://www.div12.org/treatment/interpersonal-and-social-rhythm-

therapy-ipsrt-for-bipolar-disorder/)

Psychoeducation for Bipolar Disorder

(https://www.div12.org/treatment/psychoeducation-for-bipolar-

disorder/)

Systematic Care for Bipolar Disorder

(https://www.div12.org/treatment/systematic-care-for-bipolar-

disorder/)

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