There are some similarities between anorexics and bulimics and some differences.

Both rend to be females who come from successful, middle-class or upper middle-class families in which food is emphasized. Both use purge methods such as vomiting. The two eating disorders can overlap: some anorexics occasionally show binge eating. However, there are differences. Bulimics may be overweight or of approximately normal weight, are often extroverted, and are interested in sex (Rosen han & Seligman, 1984). Finally, bulimics are ashamed of their primary trait, binge eating, whereas anorexics are proud of their major symptom, weight loss. Box 15.8 describes a bulimic individual. The media have played up the idea that bulimia is epidemic among college women. One survey revealed that while 41% of non college working women reported at least one case of binge eating, the figure was 69% for college women. However, only 1% of the non college women and 5% of college women showed the other indicators of bulimia: depression, self-depreciation, fears of inability to control eating, and self-induced vomiting on a weekly basis (Science News, July 27, 1985). Apparently Box 15.8 The Man Who Vomits on Demand Despite a well-paying job as an engineer, Gary is always in financial trouble. The reason is obvious. His daily food bill exceeds $50 on weekdays and rises to $100 on the weekend. Lunch might consists of a dozen McDonalds hamburgers, five jumbo orders of fries, four chocolate shakes, and several single-portions of apple pie. Gary knew every all you can eat place in town, and their personnel knew him. He would fill a tray with chicken, fish, various vegetables, and several desserts, then retire to a table, gorge himself, go to the bathroom for relief, and return to refill his tray. Soon he was banned by the managers of all such establishments. A trip to the grocer in preparation for an evening meal would result in the purchase of potatoes by the pound, mayonnaise by the jar, club soda by the quart (it helped him vomit), and pretzels by the bag. Gary would surround himself with food, newspapers, a TV blaring his favorite program, and, of course, bowls and bowls of food. Many trips to the bathroom for vomiting and to the kitchen to replenish his bowls were often followed by another excursion to the grocery store. By the time Gary finally showed up for therapy, he could vomit at will, without using his finger. He described himself as successful on the job and tending to work best alone. Several promotions and raises supported his claim. He was also chronically worried about becoming flabby, although he was actually a little below weight for his age and height To supplement vomiting as a means of remaining thin, he regularly swam 85 Laps against the clock in the Olympic-size pool at the local YMCA. True to his tendency to set high standards for himself, his day was ruined if his lap time was slow. Such frustrations invariably led to an especially intense binge. Source: Based on an actual case reported by Oltmanns, Neale, & Davison. Used with permission (1986).

 binge eating and the resultant self-hatred, as well as damage to the digestive tract and teeth, are sources of misery for some women and at least a few men, but full- blown bulimia probably does not characterize even a substantial minority of college women. Mood Disorders Unlike anxiety-based disorders, dissociative reactions, personality psychophysiologic disorders, individuals classified in this category cannot function disorders, and

without some kind of intervention on their behalf. This section considers disorders so incapacitating that victims may need hospitalization and will almost certainly need medication, psychotherapy, or both. Here, for the first time, we consider psychosis withdrawal from reality. Major Depression The term mood disorder implies drastic fluctuations varying from normal feelings to elation or to depression, or some combination of these. Depression is involved in most mood disorders but not the kind that is common to us all, (discussed in Chapter 12), but rather in what the DSM IJI-R defines as major depression a serious variety of depression in which victims suffer one or more episodes of feeling sad, guilty, worthless and listless. By definition, a major depressive episode lasts for at least two weeks. It may be accompanied by poor appetite with weight loss as well as loss of interest in sex and usual activities. Depressed people can show contrasting symptoms. Some show a tendency to insomnia while others tend to oversleep. Some feel restlessness; others report being sluggish and fatigued. In addition many display an inability to reason, concentrate, or make decisions. Preoccupation with thoughts of death and suidde is common. Delusions, ideas that are unsupported by reality, and ballucintions, perceptions that do not correspond to any physical stimulus, may be present. Delusions and hallucinations are the major indexes of psychosis. People suffering from major depression tend to feel that they have sinned and are therefore worthless. They take no pleasure in any activity and can list a large number of imagined character flaws. In some extreme cases, people with major depression lapse into a kind of stupor in which they remain immobile and unresponsive. Bipolar Disorder Elation is at the other end of the mood-swing cycle from depression. Bipolar disorder, formerly called manic-depressive psychosis, includes symptoms of both

major depression and maniaa predominately elated or high mood. Maniacal people talk at a rate that would make an auctioneer proud. Grand thoughts about their own superior talents and imagined accomplishments race through their heads. Their supercharged state makes them highly distractible and unable to sleep. While in this condition maniacal people often become involved in activities with painful consequences, such as buying sprees, sexual indiscretions, foolish business ventures, and reckless driving. Mania is so rare that it may be hard to imagine. Perhaps the hallmark of this condition is extraordinary energy that yields feats of sustained activity beyond the capability of normal people. Box 15.9 describes a manic episode and shows that psychotic people can do what normal people can only imagine. There are three varieties of bipolar disorder: bipolar disordermanic, bipolar disorder depressed, and bipolar disordermixed. One of these three labels is applied in a given case, depending on whether the most current display of symptoms is characterized by mania, depression or a combination of both, respectively. A current display of depression would be regarded as bipolar depressed, if there has been at least one display of mania in the past. Likewise, a current display of mania would be classed as bipolar manic if depression has occurred in the past. By contrast bipolar mixed involves alternating displays of mania and depression separated by a few days or even hours. Mood disorders are among the more treatable of the psychotic dysfunctions. Bipolar disorder is often successfully treated with the drug lithium carbonate, and major depression frequently responds well to imipramine and other antidepressant drugs (Goldstein et a!., 1986). However, some evidence suggests that the talk therapies, those designed to restructure thinking about self and personal relationBox 15.9 Tarzan in a Hospital Gown Upon being committed to a psychiatric hospital by his wife, the young scientist seemed at first to be merely elated. He spoke of getting into high gear and soon demonstrated what he meant He leaped to a window sill and dared anyone to get him down! When confined to a room, he disassembled a bed and used its parts to pound the walls while he yelled and sang. After a spontaneous hula dance, he continued his unruly behavior the entire night The next morning he was even more energetic. He broke the overhead light with a shoe, then tore the window guard from its mountings. After ripping up his gown, he fashioned a loincloth and declared himself Tarzan, complete with jungle cries. He shrieked that he had tasted tiger blood and that he was the man for his bosss lob. Following this outburst, he made amorous comments to the nurses, accused them of flirting with him, and then proclaimed my body is not for sale at any Price. Source: Based on a case reported in Morgan and King (1966)...

ships, are just as successful as drugs (Bower, 1986a). A combination of talk and drugs works best Some professionals also claim that depressed people benefit from electroconvulsive shock therapy low voltage electricity applied to the skull. All of these methods are discussed later in this chapter. Although depression is often set off by disastrous life events such as loss of a career, some of its forms may oe inherited. Recent studies of the Amish, members of a religious denomination who tend to marry within a small select community, indicate that bipolar disorder may run in families (Kolata, 1986). Whether bipolar disorder is inherited or not, it is possible that the basic disorder is depression and that the elation associated with mania may be an attempt to offset or suppress the underlying depression. Suicide, killing oneself, is not separately classified in the DSM III but is mentioned as a possible accompaniment to depression. This topic has basically been covered in Chapter 12. The characteristics of youth suicide overlap greatly with those of suicide in general. Only a few general characteristics are considered here. Attempts are most common among individuals in the late 20s to mid 40s and among women in general. Completed suicides occur most often among people 65 and above and among men in general (Goldstein et a!., 1986). There are around 25,000 suicides in the U.S. each year. Two sociological aspects deserve brief mention. Suicide rates are elevated during economic recession, probably in relation to high unemployment at these times (Schaefer, 1986). By contrast, suicide rate decrease during wartime (Schaefer, 1986). Delusional (Paranoid) Disorder This variety of paranoid disorder is psychotic-like and may be less treatable than mood disorders. However, people who suffer from it may be more likely to at least get by without treatment, compared to mood disorders. In the terms of DSM Ill-R, delusional (paranoid) disorder is evidenced when an individual shows persistent persecutory delusions or delusional jealousy, but the delusions are not bizarre and hallucinations are virtually absent. Unlike paranoid schizophrenics discussed laterpeople afflicted with delusional disorder may seem normal, since their delusions have at least some degree of plausibility. Examples in this category include individuals who believe that God takes the advice they offer Him during prayer, persons who find evidence for sexual infidelity in almost everything their spouses say and do, those who think that some vital organ, such as the liver, is failing, despite evidence to the contrary, and those who believe a famous person is in love with them. Induced Psychotic Disorder This abnormal pattern is listed in DSMIII-R under Psychotic Disorders Not Elsewhere Classified. Such treatment is informative. It implies that this form of paranoia is rare and not vell understood, relative to disorders covered so far In induced psychotic

disorder (shared paranoid disorder), formerly called folie a deux, the paranoid delusions of one member of a close relationship are adopted by the other member. A husband may serve as a model of paranoia for his wife, or a man may accept the persecutory beliefs of his brother. An example in this category involves an individual who wrote a psychological professional on behalf of himself and a companion. Dear Dr. , I have a neighbor who owns and operates a ultrasonic machine. The transducer is projected toward us. . . This neighbor has tried at various times to kill us but we have always managed to run from our apartment (Kisker, 1964, p. 368). The letter was written in clear, grammatically correct English. It evidenced a systematic delusion of long duration centering on attempts by a neighbor to kill the writer and his companion by use of modern technology. The paranoid ended the letter by specifying certain elaborate equipment that would be needed to thwart the evil neighbor, but indicated with dismay that it would cost around $1350. Who has money like that nowadays to spend on such a thing? *p. 3681. Schizophrenia Of all the psychoses, schizophrenia is perhaps the most baffling, frustrating, and serious. It is less treatable than anxiety or mood disorders, more incapacitating than most cases of personality disorder, and probably as poorly understood as multiple personality. The DSM III-R criteria for schizophrenia revolve around distortions of thought, behavior, and feelings. Schizophrenics display scrambled thought and speech, warped emotions, and bizarre behavior. They may with draw so completely that they enter a comalike state called catatonia. Their delusions often focus on being controlled or persecuted by something or someone, and they may believe that their thoughts are being broadcast to the world. Schizophrenics may report that thoughts are being inserted into their consciousness or being plucked from it. Delusions with religious themes are fairly common. Some schizophrenics claim to regularly communicate with God. Grandiose delusions such as being king of the world are also reported. Auditory hallucinations are more common than other varieties: schizophrenics report hearing voices commenting on their behavior or communicating with one another. They may also hear words out of nowhere. Because schizophrenia literally means splitting of the mind, it is often confused with multiple personality (Rosenhan & Seligman, 1984). In fact, the two disorders are quite distinct. Each of an individuals multiple personalities can relate to reality, but a person in the midst of a schizophrenic episode is generally unable to relate. Schizophrenia occurs in from 1 to 4% of the U.S. population (something in the order of 2 to 10 million victims). Among some subpopulations, such as college students, the incidence may be greater (Rosenhan & Seligman, 1984). Generally, the disorder first appears before the age of 45, with men showing symptoms earlier than women. The poor are especially hard hit by schizophrenia. Types of Schizophrenia

There are four basic varieties of schizophrenia, discussed here roughly in order from most to least severe. However, each has other distinguishing characteristics that I will point Out. Disorganized Type In the disorganized type of schizophrenia, formerly called hebephrenia, thoughts and emotions are rather completely disorganized, or thoughts and emotions may be blunted or inappropriate. Unlike other types of schizophrenics and psychotics, disorganized schizophrenics do not have systematic or organized delusions, such as those built around a religious theme. Their emotions can be so inappropriate that they will laugh when told a loved one has died and cry in response to a joke. In short, people with disorganized type schizophrenia have scrambled thoughts and feelings that typically do not conform to a consistent pattern. Catatonic Type The catatonic type is distinguished by the possible presence of a stuporous state, catatonia, and by marked negativism manifested in resistance to others and to reality itself. Victims react very little to environmental events and may refuse to talk. Negativism apparently underlies catatonia (Carson et aL, 1988). In one actual mild case, if the patient was being led by the hand in one direction, she would habitually pull away in the opposite direction. In severe cases, patients who are generally catatonic have been known to attack hospital personnel while in an agitated state. Catatonics will sometimes seem totally oblivious of surroundings, apparently unaware of events such as the presence of nude patients or of inmates who are insulting them. However, those who eventually improve can recall these events. Apparently they were attending to reality but refused to respond to it. So determined is the resistance to reality that, in one case, a catatonic leaned against a radiator until burned to the bone and never flinched. Some catatonics have been known to assume pretzel-like postures and resist attempts by strong-armed orderlies to unravel them. Paranoid Type The paranoid type is distinguished by delusions of persecution or grandiosity being king of the worldand by hallucinations with persecutory or grandiose content. Individuals in this category tend to be less emotionally or cognitively distorted than disorganized or catatonic schizophrenics. Also, their delusions and hallucinations are more likely to revolve around a single theme such as religious persecution. For example, there are cases on record of individuals who assumed the identity of Christ. All of these people could talk and think coherently and defend their

delusions. If confronted with the fact that Christ died two thousand years ago schizophrenic Christ would simply assert, Im resurrected. 6

Undifferentiated Type The undifferentiated type might be thought of as a depository for all those case that do not fit into the other categories of schizophrenia. The DSM IJ1-R descriptior includes delusions, hallucinations, incoherence, and disorganized behavior that doe not qualify the victim for an other type of the disorder. These people are delusiona as well as cognitively and emotionally deranged, but they do not show catatoni states, paranoid delusions, or the thoroughly scrambled emotions of the disorganize type. Box 15.10 depicts an undifferentiated case. Notice the relatively low level o severity compared to the other types. Despite the relative lack of severity, or perhap. because of it, the general characteristics of schizophrenia are clearly illustrated confused thinking and speech, delusions, deranged emotions (bland in this case), anc hallucinations. Box 15.10 The Woman Who Attained Immortality Margaret, the 39-year-old mother of a 7-year-old boy and a 4-year-old girl, was forced by her husband to enter a psychiatric hospital under threat of police intervention. Ray, to whom she had been married for eight years, had tolerated her bizarre behavior, but his patience ran out when she insisted on keeping the children home from school to read the BibIe I seems that Margaret had seen the sign of the cross in the kitchen sinkactually a knife lying acro&s a forkand experienced a revelation. She had sinned in marrying Ray, whom she did not love, and in having children in a loveless marriage. As punishment God had made her immortal so that she would suffer marital discord forever. Confirmation of this belief caine when she saw an old episode of The Honeymooners in which Ralph and Alice were, as usual, yelling at each other. Surely this is what God had in mind for her for theres to fher life When she noticed that the childrens pupils were fixed in size (actually iey were not), she came to realize that they were also immortal and thus doomed to suffer their unhappy lives forever. During the usual initial psychiatric interview, Margaret was emotionally bland and expressionless. She spoke in a monotone but largely made sense, despite occasional lapses of attention and unresponsiveness to questions. When asked whether she was afraid when she realized that she was immortal, she replied, No. You see, the sun to me ..is the sun to people, but its God to me. When I book up the sun, its God, not the sun anymore. See what I mean? God took over my life because I didnt deserve to live it my selL I ve got to get out of here so that l can b closer to Him. ....: Sowce: Based on a case renorted inOltmans et at. (1986) Used with permission.

Theories of Causation

Over the years, schizophrenia has been attributed to many different causes. It has been thought to be learned from deviant parents or acquired by exposure to a distorted social environment, such as that existing in the criminal underworld, a prison or a concentratioi camp (Rosenhan & Seligman, 1984). More recently a number of biological hypotheses have been advancecL Basically, many psychiatrists and psychologists see schizophrenia as inherited and due to a chemical imbalance, such as the overabundance f the neurotransmitter dopamine (a neurotransmitter is a chemical by which impulses are transmitted between nerve cells). Studies of identical twins and biochemical research seem to support this point of view. Unfortunately, biological hypotheses about schizophrenia come in and out of fashion. At one point, the evidence seems to support the contention that schizophrenia is inherited, at another it does not (Rosenhan & Seligman, 1984). Discoveries of biochemicals cause great excit ement until it is realized that direct evidence of their involvement in schizophrenia is hard to obtain (Goldstein et al., 1986). In recent years the pos.sibility that schizophrenia might be caused by a virus has received a great deal of attention (Bower, 1985c). Only time will tell whether this hypothesis has any validity. Organic Mental Syndromes and Disorders Disorders discussed thus far may involve physiological problems ranging from inherited deficiencies to abnormal levels of certain neurotransmitters. However, in no case was the suspected physical source of the problem directly observed. Organic brain disorders involve some sort of deteckzble dysfunction of the brain or some physiological process. Victims of organic disorders are frequently more severely incapacitated than those with other disorders and may be especially difficult to treat. Some brain deficiencies are brought on by damage due to rumors or injury. Damage can also be caused by destruction of brain tissue associated with sclerosis (hardening or blockage) of arteries in or leading to the brain. Organic brain disorders may also be related to disease (for example, syphilis), or the use of drugs such as alcohol or heroin. The symptoms of organic disorders greatly overlap with those of other disorders. Consequently, organic disorders are suspected only if symptoms are especially severe, if memory and intellectual functioning are influenced, and if motor responses are affected (for example, the individual has difficulty controlling hand movements). The presence of these three characteristics allows psychologists and psychiatrists to rule out the other DSM III categories considered earlier.

There arc many organic disorders, and most are relatively rare. Accordingly, only two example types are covered in mis section. The first involves brain tumors. Charles Whitman was a student at the Universiw of Texas. Friends reported that he became increasingly more suspicious and hostile over time. He was known to carry guns in his car and threatened to use them on motorists. Finally, his hostility peaked and he killed his mother and wife, after writing in his diary that the world was not a fit place to live. He then climbed to the top of a tower on the University of Texas campus and fired on passers-by. Whitman shot 44 people, killing 14 before police ambushed him (Valenstein, 1973). An autopsy revealed that he suffered from a malignant brain tumor in an area that may control aggression. Although the case is controversial, the Texas Tower murders provide an illustration of the possibility that brain tumors may generate abnormal behavior. Perhaps the most frustrating and well known of the organic disorders is Aitheimers disease, destruction of brain tissue that is involved in the production of

the neurotransmitter acetyicholine. It was once confused with senility, a broad and overused category of intellectual and memory deficiencies found in some elderly people. In the early stages of Alzheimers, the major symptom is inability to remember information that was once on the tip of the tongue. Liter, personality changes may occur. People who suffer from Alzheimers disease may become irritable and difficult to live with. They may be given to sudden outhursts of cursing. Social inhibitions may dissolve and afflicted individuals may make comments about people to their faces that are insulting or even vicious. Still later, family members may be mistaken for friends and events occurring only a few minutes ago may be forgotten as if they had not happened. Finally, victims may become incoherent and unable to care for their simplest needs. There is as yet no cure for this tragic disease. There are many good books available on abnormal psychology, but Carson, Butcher, and Colemans text has been outstanding for the longest period (Abnormal Psychology and Modern L/: Scott-Foresman, 1988). Those who wish to learn more about psychiatric diagnosis should see the DSM II! citations in the references. How Abnormalities Are Treated The two main categories of treatment for abnormal behaviors are biological therapies and psychological therapies. Biological Therapies Biological therapies range from psychosurgery (altering portions of the brain that control emotions) through electroconvulsive shock treatment (in which electric current is sent through the brain) to the use of psychoactive drugs. The discovery of new and apparently effective drug therapies for mental patients during the 1960s enabled some mental patients to be kept functioning in the outside world. The three basic classes of psychoactive drugs and well-known examples of each are listed in Table 15.1 along with their common side effects. Minor Tranquilizers and Drugs for Mild Depression There is no question that minor tranquilizers and drugs for nonpsychotic depression represent advances in the treatment of anxiety problems and mild depression. When used occasionally and in moderation they have helped many people get through difficult periods. They do, however, have harmful side effects, and abuse of these agents is widespread. Diazepam (Valium) may be the most widely prescribed single drug. Many patients may rake valium and other drugs in this mild category for years believing that they are not addictive. Former First Lady Betty Ford is among the many

10

Americans who are or were addicted to Valium (Ford used the potentially deadly combination of alcohol and Valium). While there are 350,000 heroin addicts in the U.S., there are approximately 3 million people addicted to Valium. These numbers are witness to the fact that legal drug use and abuse has surpassed use of illegal street drugs (Schimelpenig, 1980). Major Tranquilizers and Antidepressants Before major tranquilizers were available, schizophrenia and some other psychoses seemed to be untreatable. People with these disorders were doomed to a lifetime in mental hospitals. With drug treatment, many can function reasonably well within the mental hospital setting and some can actually livc near-normal lives on the outside (Goldstein et a!., 1986). Drugs have been especially effective in the treatment of bipolar disorder and other forms of depression (Rosenhan & Seligman, 1984). Side effects have been reduced through the use of lower dosages. Still, these drugs do not cure the disorders for which they are prescribed; rather they relieve symptoms

11

In fact, the word cure may not be applicable, because whether the psychoses and other serious psychiatric disorders are diseases is still being debated (Carson et al., 1988). Moreover, the dangers associated with major tranquilizers and some antidepressants should not be taken lightly. One of the most debilitating is tardive dyskinesia, involuntary muscular movements most noticeable in the face. The sucking, lip- smacking, and tongue thrusting characteristics of tardive dyskiriesia are disfiguring and irreversible (Rosenhan & Seligman, 1984). Ironically, the only known treatment for these symptoms is to administer more of the drugs that caused the problem in the first place (Coleman et aL, 1984). More alarming is fact that major tranquilizers can sometimes be lethal (Bower, 1986b). Neuroleptic malIgnant syndrome is associated with fever, severe muscle rigidity, elevated blood pressure, elevated heart rate, and clouded consciousness that can lapse into delirium, stupor, inability to talk, and coma. This disorder occurs in about 1% of those taking major tranquilizers, about one-fifth of whom die of respiratory, cardiovascular, or kidney failure. Although low, this death rate is a significant risk compared to that for other drugs. In addition, the premature excitement over drugs has led to the wholesale release of institutionalized mental patients without a provision fo the supervision that drug therapy requires. This has created problems both for the patients and for the larger society. A significant percentage of street people (estimates range from to 1/3) are believed to have been released from mental hospitals or clinics under the assumption that drugs would allow them to function in the real world. These developments suggest it is time to rethink the acsumption that supplying seriously disturbed people with psychoactive drugs and no other help will allow them to function adequately outsice an institution. Electroconvulsive (Shock) Therapy Although it is no longer controversial that minor tranquilizers, major tranquilizers, antidepressants and other psychotropic drugs can help people with psychological problems, the same cannot be said for some other biologically based treatments. Electroconvulsive therapy (ECT)the production of brain seizures by passing electrical current through the brainwas once in widespread use and is still advocated by some professionals, especially for severe depression. General anesthesia and muscle relaxants are now used to prevent painful muscle spasms. Patients are unconscious while the shock is administered, but no one knows whether they have subconscious discomfort during shocks or unpleasant side effects that they cannot describe afterward. Many report confusion and disorientation after treatment and some refuse further shocks (Fisher, 1985). Some depressed patients appear to improve after shock therapy, though critics of the procedure suggest that patients may get better so they will not have to suffer through another shock session. One reason for concern about ECT is its unscientific origin. In 1933 an Italian physician Ugo Cerletti witnessed the slaughtering of hogs. Metal tongs were clamped to the temples of the animals 12

and they were jolted with 125 volts. They fell into convulsive unconsciousness and were stabbed to death in that condition. Supposedly it spared them pain. Cerletti immediately became excitedly curious about the possibk effects of electricity applied to the brains of humans. He put in a call to the Roni police, asking them to be on the look-out for a suitable subject. Soon an unfortunat vagrant was delivered and fitted with two large electrodes fixed on his head. Eight) volts for .2 seconds caused the vagrant to jolt and his body to stiffen, but he remainec conscus. When Cerletti and an assistant began to discuss the ethical and practica; implications of applying more shock, the vagrant suddenly became coherent anc exclaimed Not another one! Its deadly! (p. 21). Undeterred, the two experimenters commenced to administer 110 volts for .2 seconds. Unfortunately no one seems to know the fate of the vagrant, but it was not severe enough to prevent the birth ol ECT. Neither did an erroneous assumption by initial users concerning why ECT works call its use into question (Coleman et al., 1984). In fact, to this day even those who claim that ECT works cannot say why (Fisher, 1985). Critics of ECU note that some of its side effects last for days, notably loss of memory for events that occurred days, weeks, or months prior to treatment. Permanent memory loss has also occurred; after an unusual 50 treatments one man could not remember people he had known for years. There have also been reports of cognitive (intellectual) impairment, loss of creativity, permanent destruction of nerve cells, and rare cases of death (Bower, 1985e; Fisher, 1985). Other critics object to ECU because it is sometimes administered without patients consent (Szasz, 1983) and has been misused (it has been used as punishment: a 13-year-old retarded girl received ECU after she was caught masturbating; Fisher, 1985). Despite all these objections, ECU has its defenders and continues to be used on between 60,000 and 100,000 people annually (Bower, 1985e). Evidence indicates that its harmful side effects might at least be lessened and its benefits retained if weaker current is applied to only one side of the brain (Fisher, 1985). Also, logically, ECU might be a reasonable last resort treatment for severely depressed patients who have not responded to other treatments and who are in danger of killing themselves. P.sythosurgeiy Compared to psychosurgerydestroying certain areas of the brain that affect emotionsECU is only moderately controversial. Psychosurgery actually grew out of animal research. During the mid1930s a couple of American researchers presented a paper at a neurological conference (reported in Valenstein, 1973). A Portuguese neurologist, Antonio E. Moniz, arose from the audience to express curiosity about the report that formerly violent monkeys became tranquil following psychosurgery. Much to the horror of the researchers, Moniz asked if the operation might have similar effects on humans. They assured him it should not be tried. Unflinchingly, Moniz preceded to perform some 20 psychosurgeries. His reward was the Nobel Prize for medicine (1949), the only one ever awarded for psychiatry. Shortly thereafter, the operation, popularly known as the prefrontal lobotomy, came to the United States. American physician Walter Freeman used a version of it on some 3500 patients. He drove an ice pick like device up through the eye socket of the skull just above the eye and moved it about 13

more or less at random (local anesthetic was used; brain tissue is generally not pain sensitive; Valenstein, 1973). An estimated 70,000 similar operations were performed in the United States and Great Britain from the 1930s to the 1950s, many of them in physicians offices. Over the years, the operation has become more sophisticated. Precise instruments now allow rather exact destruction of small areas of the brain, sometimes by means of electrical current (Chorover, 1974). Nevertheless, critics contend that even these more sophisticated operations violate known facts about the brain. Researchers now know hat the brain is not necessarily a collection of compartments, each with a specific function (eating) that can be removed without harm to other functions. Rather, brain areas and their functions may be closely related so that removal of one area cripples the functions of other connected areas. The animal research that originally suggested psychosurgery is consistent with this notion about the interconnectedness of brain parts: the surgically tranquilized monkeys were intellectually devastated (one repeatedly put a cigarette into its mouth, lighted end first). An actual case of psychosurgery illustrates the problems with assuming that destroying a small area of the brain removes one function for example, capability for aggressionwithout harming other functions (Chorover, 1974). Thomas R., a bright young engineer, with several patents to his name was accused by his wife of attacking her and their children during uncontrollable fits of rage. He also was labeled paranoid after he charged that his wife was having an affair with a neighbor. Although Thomas R repeatedly refused to allow emotional elements of his brain to be destroyed with electricity transmitted through deeply implanted electrodes, his surgeons persuaded him to undergo the operation. They reported no postoperative aftereffect more serious than temporary impotence. However, an opponent of psychosurgery, psychiatrist Peter R Breggin, followed up the case of Thomas R It was discovered that there was no good evidence that the young man was prone to rages before the operation, nor did he cause trouble when hospitalized before the implantation operation. He wrote his mother that the operation was science fiction. After the electrodes destroyed part of his brain, it was immediately evident that Thomas was delusional, socially confused, and unable to function normally. He never worked steadily again and has been in and out of hospitals as well as jails ever sinceon one occasion he was arrested for fighting. By the way, while Thomas R was undergoing psychosurgery, his wife filed for divorce and eventually married the neighbor. Other objections to psychosurgery revolve around human rights. One critic of psychiatry, psychiatrist Thomas Szasz, believes that all psychiatric procedures, most especially psychosurgery, should not be performed unless patients who are fully informed desire it and consent to it (Szasz, 1977). He contends that no form of coercion or persuasion should be used. Despite these several objections, lack of evidence for the effectiveness of psychosurgery, and its outlaw status in several countries (including the Soviet Union), it is still legal in the United States (Black, 1977; Mark, 1974). In fact, it is still being performed (Jenike, 1989).

14

It has been argued that psychosurgery can be justified in cases where all else has failed and seizures or other brain dysfunction make life unbearable. Couple these criteria with consent by informed patients and psychosurgery may make sense in some rare cases. Unfortunately, no one can say how it is to be determined that all e lse has failed,life is unbearable, and the patient fully understands the implications of the operation and willingly consents. Psychological Therapies Unlikeb biological therapies, the psychological therapies have generated little controversy, perhaps because they lack the obvious moral and ethical implications of electricity applied to the brain, drug side effects, and the destruction of brain tissue. Part of the reason they are less controversial then psychological therapies is that they lack the structure and concreteness that would allow either benefit or harm to be confirmed by the scientific method. Nevertheless, there is growing evidence that psychological therapies work and little evidence that they harm people. Accordingly they are important alternatives to biological methods. Several forms of psychological therapy have already been discussed in chapters to which they are relevant: modeling, cognitive psychologist Kellys scientific approach to therapy, and Rogers clientcentered therapy (Chapter 5); assertiveness training and Ellis rational emotive therapy (Chapter 14); systematic desensitization, a behavioristic method, (Chapters 2 and 13); Skinners behavioristic approach (Chapter 5) and group therapy (Chapter 12). Freuds psychoanalystic method, other humanistic approaches, and some additional behavioristic techniques are discussed here. Psychoanalysis This system of psychological therapy is based on Freuds idea that problems often originate in childhood relations with parents. The psychoanalytic piocess frequently consists of attempting to bring repressed critical experiences and feelings relating to child/parent relationships into the conscious mind. The therapist controls sessions and serves as a pathfinder who guides the patient through the dark, dense forest of the unconscious to bring troublesome, repressed experiences into the sunlight. Although the therapist comes to know the forest well and can redirect a patient who becomes lost, it is the patient who must ultimately find the correct path to critical experiences and feelings, take it, and confront the dark mysteries at its end. Only then will she or he have insight, the sudden coming to grips with the repressed experiences and feelings that are the source of problems (for example, the experience of having seen parents in the act of sexual intercourse). To get at repressed experiences, psychoanalysts often direct patients to use free association expressing whatever thoughts are present while the mind is allowed to wonder freely. Free association is not ertirely free, in that therapist may sense when are oiito something imponant and stop them: I-fold it there. Why dont you pursue that thought for a minute. 15

As analysts assist patients n talking about themselves, they note resistance. unwillingness to talk about or otherwise pursue certain subjects. Patients who will no

talk about their mothers, for example, may have repressed feelings and experiences relating to them. There are other sources of clues to the unconscious. Transference occurs when feelings, attitudes, and orientations that are characteristic of a critical figure in a patients life are transferred to the therapist. Patients then begin to react to the therapist as they did or do to the critical figure, perhaps a parent. Transference informs the therapist that the critical figure might be involved in important repressed feelingsnd experiences. One problem with psychoanalysis is the expense in terms of time and money: sessions may run into the hundreds and last for years. Yet there is little evidence that psychoanalysis is better than other forms of talk therapy (Carson et al., 1988). Also troublesome is the observation that only relatively intelligent, articulate people who are not seriously disturbed seem to benefit from it. Still, for individuals whose problems may be general, such as chronic anxiety, and whose childhood situation was unusual, psychoanalysis may be the therapy of choice. Humanistic Therapies Basically, humanistic therapy assumes the essential worth of people and their ability to solve their own problems. Rogers client-centered therapy, for instance, is a straightforward method in which the empathy of the therapist and his or her willingness to unconditionally accept the worth of clients counts for more than formal training. Rogers assumes that peoples problems arise from failure to recognize and express important values, talents, and emotions; therefore, his brand of therapy may be most useful to people who find their lives meaningless and unfulfiuing. Another therapy in the humanistic category, Gestalt therapy, emphasizes the whole person and the need to consider relations between mind and body. It also focuses on relations among thoughts, feelings, and actions, as well as between self-awareness and self-acceptance. Its founder, Fritz Pens, considered that the mission of Gestalt therapy is to allow individuals to appreciate their individuality and to recognize that each aspect of themselves is inseparable from all other aspects (Perls, 1959). He taught clients to become aware of minute bodily feelings as well as global life goals. Perls sought to unify clients experiences so that their every aspect would be in tune with every other aspect. For example, a client may have feelings of anger toward a friend as part of love for that person. In turn, these mixed feelings toward the friend reflect feelings of anger with and love for self. Given these revelations, both positive and negative feelings toward the friend can be accepted and self-acceptance becomes more likely. A client may express this interrelatedness by saying of a friend, I love her, but I hate her because she is so much like me. . . all the best things about me and all the things I cant stand. Pens also taught clients to take responsibility for themselves. A 31-year-old client whose dependency on her mother precluded standing on her own feet was asked, Okay, can you talk as a 31 16

year-old to your mother? Can you be your age? The client replied firmly, Mother, I am 31 years old. Im quite capable of walking on my own

(Pens, 1959, p. 165). People who have learned to be in tune with and accepting of their feelings and how these reiate to their needs and goals have taken the first step toward self-responsibility. A related humanistic approach, existenthi therapy, seeks to explore the meaning of existence by confrontations with lifes paradoxes such as love/hate, life/death, and free wilL/determinism (May, 1969). Attempting to understand death sheds light on the meaning of life. Clients are challenged to consider the purpose of their existence. They are asked to openly and honestly examine their current feelings and values. People who are able to fully appreciate the here and now and come to terms with it are able to grasp lifes meaning, however fleetingly. Being absorbed by the feelings of the moment frees one from the clutches of others expectations. In a nse, to be is to be in touch with ones innermost feelings by homing in on the external world of the moment. Difficulties with Gestalt and existential therapy revolve around the lack of standard procedures that can be taught to therapists and can be evaluated for effectiveness. In turn, the procedural problem is due to the abstract, vague nature of concepts underlying the therapy. The Gestalt and existential points of view are more philosophies than theories from which therapies can be derived. They will be most helpful to people who feel that their lives have lost meaning and their outcomes are not controlled by themselves. Behavioral Therapy Behavior therapy uses procedures developed by a number of learning psychologists to eliminate unwanted behavior or to condition desirable behavior. Its extensive coverage in this book attests its usefulness. Some forms of behavior therapy not discussed elsewhere are described briefly here. Extinction, elimination of the response after reinforcement no longer occurs, can be used in two different ways to deal with behavioral problems. First, in implosive therapy the client is asked to imagine frightening, anxiety-provoking, or upsetting situations so that anxious or fearful feelings can be experienced in a safe setting. Because the feared consequences do not occur, the feelings of dread are extinguishecL For example, a person who is afraid to get dirty because dirt has germs and germs kill people, could be asked to imagine being covered with dirt. When nothing bad happens as a result of being dirty, fearful responses are extinguished. Flooding also involves confronting a frightening situation to attain extinction, but the frightening circumstance is actually encountered rather than just imaginecL For example, a person who is afraid of dogs might be induced to enter a room containing a large, tame dog and experience that nothing bad happens.

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Aversion therapy involves associating some undesirable behavior with aversive (painful or unpleasant) stimulation. For example, heavy smokers have been induced to smoke very rapidly until they become ill so that smoking is associated with nausea.

Sexual offenders have been given electric shock as they are presented with pictures of people similar to their victims (for example, pictures of children shown to a pedophiliac). Psychotics have been shocked when they show bizarre behavior. Obviously there are ethical difficulties with this kind of therapy. It might be legitimately used when it is the only way to eliminate a behavior that is more destructive than the therapy (children have been shocked fot mutilating themselves when all else failed to eliminate the behavior). Behavior therapy can be extremely effective, but it has a limited range of application. It has little application in problems of self-esteem or hopelessness. Also, it is not useful with many psychotics because their lack of contact with reality precludes the appreciation of reinforcement. Effectivenvss of Psychological Therapies After many studies of psychological therapies compared with no treatment and with each other, it is clear that psychological therapies are definitely better than no treatment, but no type of psychological therapy is generally better than the others (Goldstein et al., 1986). It is also clear that a psychological therapy can be very effective if it is carefully selected to be appropriate for the problem and for the person with the problem (Carson et al., 1988). Psychological therapies have the drawback of being highly dependent on their practitioners. Since therapists are also human beings, racial bias, sexual bias, and even beautyism can affect their interactions with clients and therefore the outcome of treatment. The attitude toward the patient of the psychiatrist administering a drug or other biological therapy may also influence treatment effectiveness, but presumably to a lesser extent. Selecting a Therapist Although there may be cases in which electroconvulsive therapy and even psychosurgery might be justified, these treatments cannot be generally recommended. However, there are many cases that can be effectively treated with psychoactive drugs: severe depression, psychosis, and other disorders that have not responded to psychological therapies. Choosing a psychiatrist to administer drugs should involve an examination of professional credentials. All legitimate psychiatrists have an M.D. degree and have completed residencies in their specialty. It is worth checking where both were obtained and how long the individual has been in 18

practice. Psychiatrists who have been in business for a long time at the same location and who have degrees and residencies from established university hospitals are to be preferred. Obtain information about credentials and check them by calling the psychiatric department at the nearest university hospital.

It is also important to find a psychiatrist in whom one can place trust. If possible, it is important to ask others who have been served by the psychiatrist one is considering. Do not accept drug prescriptions thoughtlessly. As always, seeking a second opinion is good practice. Choosing a psychological therapist is an equally important decision. Credentials are a good place to start. Here selection is difficult compared to choosing a psychiatrist, because a wide variety of professionals practice psychologica! therapy. A clinical psychologist with a PhD degree is a wise choice. Call the nearest university psychology department to check credentials. People with masters degrees in psychology and people from other disciplines may also be helpful. In their case, it is best to consult a former client concerning their effectiveness. In every case, check whether the psychological professional under consideration is certified by the state and determine whether her or his degree is from a reputable univefsity. Finally, try a few sample sessions before making a final decision. For further informion on choosing a therapist see Goode (1988c). SUMMARY POINTS 1. Abnormality may be defined statistically, prognostically, or both. The standard source for definitions of psychological abnormalities is the Dzagnos& and Statistical Manual III (DSM I1I-R) of the American Psychiatric Association. 2. Generalized anxiety disorder has the symptoms of anxiety; panic disorder is characterized by intense anxiety attacks with symptoms such as breathlessness, choking, dizziness, and faintness. Obsessions are involuntary, recurring thoughts; compulsions are involuntary ritualistic behaviors. A phobia is a persistent, irrational fear that is out of proportion to its cause. 3. Somatoform disorders involve physical symptoms unrelated to any identifiable biological cause. In hypochondriasis there is a chronic fear of and complaint about a physical disorder although the symptoms do not match any particular disease. Conversion disorder involves the faithful mimicking of symptoms associated with some physical disorder that is not present. 4. Dissociative disorders, which allow satisfaction of needs without stress through the dissociating of acts and thoughts from the basic personality, include psychogenic amnesia and multiple personality.

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5. An inability to relate normally to others in the usual fashion is basic to all personality disorders, including paranoid personality, passive-aggressive personalit , schizoid personality, and avoidant personality. Compulsive personality disorder involves more generalized symptoms than does obsession/compulsion. People with dependent personality disorder passively submit to the care and control of another person. 6. Histrionic personality disorder involves dramatic emotional expressions and excessive seeking of attention; narcissistic personality is characterized by a grandiose sense of self-importance and claims of entitlement; antisocial 1. personality includes exploitative behavior, impulsivity, inability to plan ahead and lack of conscience. 7. Psychophysiologic disorders, which involve harmful mind/body interactions, may include essential hypertension and peptic ulcers, smoking, asthma, and tension and migraine headaches. 8. Anorexia nervosa involves drastic curtailment of food intake, often accompanied by use of laxatives and excessive exercising, because of a fear of obesity that persists even when weight is far below normal. Bulimia is a syndrome of alternate binging and purging. 9. Major depression s characterized by sadness, sleep irregularity, poor apretite, and feelings of, worthlessness; in bipolar disorder, symptoms of major depression are interspersed with episodes of wild, high behavior called mania. Mood disorders are among the more treatable of the psychoses. 10. Delusional disorder is characterized by delusions of persecution and grandiosity, but the scrambled thinking and emotions of schizophrenia are absent and delusio are relatively plausible. In induced psychotic disorder, one person in a close relationship develops a delusion that the other then adopts. 11. Schizophrenia may be characterized by bizarre thoughts, grandiose or persecutory delusions, hearing voices, scrambled speech, blunted emotions, and catatonic states. It afflicts from 1% to 4% of the U.S. population. It may be categorized as disorganized, catatonic, paranoid, or undifferentiated. 12. . Organic mental syndromes involve some sort of detectable brain dysfunction usually accompanied by memory, intellectual, and motor problems. Alzheimers disease is a form of organic mental syndrome that may be related to a lack of the neurotransmitter acetylcholine. 13. The three categories of psychoactive drugs are minor tranquilizers, major tranquilizers, and antidepressants, all with side effects. 14. Electrocoiwulsive therapy is highly controversial, but may be effective for relieving depression; in psychosurgery, areas of the brain thought to be involved in harmful emotions, such as aggressiveness, are destroyed. The method has been condemned by many psychological professionals. 15. The psychological therapies, which have few harmful consequences and appear to be effective include psychoanalysis, gestalt therapy, existential therapy, and behavioral techniques such as extinction through implosive therapy or flooding. Aversion therapy entails the association of undesired behavior with aversive stimulation. 20

KEY CONCEPTS Abnormality Anxiety Phobia Dissociative disorders Statistical Generalized anxiety Somatoform disorders Psychogenic amnesia Prognostic disorder Hvpochondriasis Psychogenic fugue DSM III Panic disorder Conversion disorder Multiple personality Anxiety-based disorders Obsessive-compulsive Personality disorders disorder liraiioid personahty Passive aggres.sive personality Schizoid personality Avoidant personality Obses.sive-compu Isive personal it) Passive-dependent personal it) Narcissistic personality Antisocial personality Psychophvsiologic disorders Anorexia nerosa Buliniia nervosa Mood disorders Major depression Bipolar disorder Delusional (paranoid) disorder Induced psychotic disorder Schizophrenia Disorgan i/ed Catatonic Paranotd Undifferentiated

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Organic syndromes and disorders Aixheimers disease Biological therapies Psychoactive drugs Minor tranquilizers Major tranquilizers Antidepres.sants Tardive dyskinesia Electroconvulsive therapy (ECT) Psychosurgery Psychological therapies Psychoanalysis Insight Free association Resistance Transference Humanistic therapy Existential therapy Behavioral therapy Extinction Implosion Flooding Aversive therapy Selecting a Therapist Health psychology REVIEW QUESTIONS 1. Can you come up with additional meanings of abnormal? 2. Can you relate obsessive-compulsive disorder to normal obse&sive and compulsive behaviors? 3. What kinds of conversion disorder symptoms are most likely to fr i1 physicians? 22

4. wy is multiple personality so interesting to the public? 5. Can you construct a personaliw that shows overlap EXAMPLE MULTIPLE CHOICE QUESTIONS with all personality disorder categories? 6. Besides male runners, what other types might h closet anorexics? 7. Can you list three disorders that overlap with schizo phrenia? 8. Can you speculate on the most abused psychoactiv drug of the future? 9. What will it take to make psychosurgery safe am effective? 1. A panic disorder attack usually lasts a. hours b. minutes c. days d. months 2. Closet hypochondriacs a. live in closets b. are more severely affected than the usual kind c. describe symptoms to only a few d. arc afraid of illness 3. The man with 27 personalities and who was killed by a beer a. was retarded b. had God as one of his personalities c. had no female personalities d. had personalitie who were lawyers, language experts and music fans 4. Hermann GOering was apparently not a. histrionic b. narcis,sistic c. antisocial d. schizophrenic 5. Like most ariorexics Noralynn was a. an exerciser b. unintelligent c. interested in sex d. lazy 6. Catatonic schizophrenics are a. silly b. coherent c. negative d very alert

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7.ECTIS a. not currently practiced b. controversial c. highly effective d. banned in the United States 8. Psychoactive drugs are a. ineffective b. banned in the United States c. effective for depression d. cures e 9. Insight is associated with a.. psycho2nalysis b. humanistic therapy c. behavior therapy d. existenial therapy 10. In general, psychological therapies a. do not work b. work, some better than others c. work d. may or may not work Oi 6 ag qL 9 --- p-c z qt

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