Chapter 11: Problems in the Development of Human Potential
Dissociative disorders have captured the public’s imagination as the result of several popular books and movies. The disorders are characterized by a disconnect between an individual’s immediate experience and memory of the past. The major dissociative disorders listed in DSM-5 include dissociative identity disorder, dissociative amnesia, and depersonalization disorder.
Dissociative identity disorder is characterized by two or more distinct, integrated personalities appearing at different times. Each personality can exist in isolation from the others, with little or no memory of the other’s existence. Dissociative amnesia is usually a temporary disorder affecting episodic (i.e., autobiographical) memory. It is the most common of the dissociative disorders. Depersonalization disorder is often described as an “out-of-body experience.” You realize it is not true, but feel as though you are watching yourself.
Until the transition to emprically-validated procedures in medicine, Freud’s psychodynamic model was prevalent in psychiatry and still influential in clinical psychology. Multiple personality disorders, amnesia, and out-of-body experiences make wonderful plot lines. The Bird’s Nest (Jackson, 1954), The Three Faces of Eve (Thigpen & Cleckley, 1957), and Sybil (Schreiber, 1973) describe the lives of individuals that fit the DSM criteria for dissociative identity disorder. These books and the movies they spawned (Lizzie, for The Bird’s Nest) were released when the Freudian influence on psychiatry was at its peak. Each told the story of relentless and insightful psychiatrists probing the early childhood experiences of individuals appearing to have different personalities at different times. Eventually, some source of childhood abuse was identified, the person was “cured” and lived happily ever after.
At best, Freud and others, basing their explanations of the causes of maladaptive behavior on uncontrolled case history evidence, offer hypotheses to be tested. No one ever tested Freud’s oedipal conflict interpretation of Little Han’s fear of horses by having a father threaten a child to see if the child projected fear onto another animal. In Chapter 5, we described Watson’s demonstration of the classical conditioning of a fear response to white rats in Little Albert. Watson felt that known, basic learning principles, could account for fear acquisition. He questioned the plausibility of Freud’s interpretation of the development of Little Hans’ fear. Direct and indirect classical conditioning procedures have been found to be effective in producing and eliminating anxiety, fears, and phobias.
Despite the convincing and exciting portrayals of dissociative disorder patients and the therapeutic process, there is now reason to question the Freudian assumptions underlying the narratives. After a comprehensive literature review, it was concluded that there was no credible data supporting the conclusion that dissociative disorders or amnesia result from childhood trauma as opposed to injuries to the brain or disease (Kihlstrom, 2005). The actual person that Sybil was based upon admitted that she faked the symptoms. Analyses of the transcripts of the therapeutic sessions resulted in a very different interpretation of her case and dissociative identity disorders in general (Lynn & Deming, 2010). Recent experimental evidence suggests that sleep deprivation may be an underlying cause of dissociative symptoms. It has been demonstrated that extreme dissociative symptoms can result from a single night’s deprivation of sleep (Giesbrecht, Smeets, Leppink, Jelicic, & Merckelbach, 2007). In another study, half of the patients meeting the criteria for dissociative disorders improved after normalization of their sleep patterns (van der Kloet, Giesbrecht, Lynn, Merckelbach, & de Zutter, 2012; Lynn, Berg, Lilienfeld, Merckelbach, Giesbrecht, Accardi, & Cleere, 2012). It may not be fascinating or provocative, but an effective way to avoid or treat dissociative disorders may be to get a good night’s sleep.
Somatic Symptom and Related Disorders
The diagnosis of somatic symptom disorder is based on the presence of severe medical symptoms (e.g., blindness, loss of the ability to move a hand, etc.) with no indication of a biological cause. The diagnosis of illness anxiety disorder is based on debilitating anxiety resulting from real or imagined health concerns. Health becomes the focus of one’s existence. This often results in spending long periods of time conducting research on a symptom or disease. In the past, such symptoms were described as psychosomatic or hypochondriasis, but these terms are now considered trivializing and demeaning and have been dropped from recent DSM editions. The problem of diagnosing a disorder based on the absence of biological symptoms is recognized as problematic (Reynolds, 2012). DSM-5 emphasizes the presence of behavioral symptoms such as repeated verbalizations or reports of obsessive thinking about health concerns or excessive time spent conducting research regarding medical concerns. As with anxiety and depressive disorders, the most effective treatment for somatic symptom disorders is cognitive-behavior therapy; medications may be prescribed in extreme or unsuccessful cases (Sharma & Manjula, 2013).
Feeding and Eating Disorders
The developmental distinction between feeding and eating disorders has been relaxed somewhat in DSM-5. The feeding disorders, rumination, the regurgitation of food after consumption, and pica, the consumption of culturally disapproved, non-nutritious substances (e.g., ice, dirt, paper, chalk, etc.), are now recognized as occurring in all age groups (Blinder, Barton, & Salama, 2008). The previous diagnosis, feeding disorder of infancy and childhood, has been renamed avoidant/restrictive food intake disorder, a broad category applying across the age span (Bryant-Waugh, Markham, Kreipe, & Walsh, 2010).
Direct learning techniques have been used to successfully treat rumination and pica disorders. Rewarding normal eating and punishing the initiation of rumination by placing a sour or bitter tasting substance on the tongue has been found effective in suppressing rumination (Wagaman, Williams, & Camilleri, 1998). Another procedure found to be effective is to teach individuals to breathe from their diaphragm while eating (Chitkara, van Tilburg, Whitehead, & Talley, 2006). Pica disorders have been treated using classical conditioning by pairing the inappropriate substance with a sour or bitter taste. Differential reinforcement procedures in which appropriate eating is followed by presentation of toys but inappropriate eating is not, in addition to time-out procedures, have also been effective treatments with normal individuals (Blinder, Barton, & Salama, 2008) and those with developmental disabilities (McAdam, Sherman, Sheldon, & Napolitano, 2004).
In past DSM editions, anorexia nervosa and bulimia were the only diagnosable psychiatric eating disorders. Women between the ages of 15 and 19 comprise 40% of those diagnosed with these two disorders (Hoek, & van Hoeken, 2003). Binge eating disorder was added as a diagnosable disorder in DSM-5 (Wonderlich , Gordon, Mitchell, Crosby, & Engel, 2009).
Anorexia nervosa is defined in DSM-5 by: 1) low body weight relative to developmental norms; 2) either the expressed fear of weight gain or presence of overt behaviors designed to interfere with gaining weight (e.g., excessive under-eating or extremely intense exercise sessions); and 3) a distorted body image (American Psychiatric Association, 2013; Attia & Walsh, 2007).
Anorexia is an insidious and potentially life-threatening disorder. A comprehensive review of 32 studies evaluating the effects of cognitive behavioral procedures alone, medicine alone, and both combined, was inconclusive. Although cognitive behavioral procedures appeared effective for those attaining a normal weight (i.e., preventing relapse), it was not clear that they were effective in helping individuals gain weight in the first place (Bulik, Berkman, Brownley, Sedway, & Lohr, 2007). The treatment results for bulimia nervosa are clearer and better. Bulimia is a disorder characterized by consumption of large quantities of food in a short time (i.e., binging) followed by attempts to lose weight through extreme measures such as induced vomiting or consuming laxatives (i.e., purging). Those diagnosed with binge eating disorder do not engage in purging. In comparison to anorexia, the diagnosis of bulimia or binge eating disorder can be more difficult because the majority of individuals remain close to their recommended weight (Yager, 1991). A review of randomized, controlled studies evaluating cognitive-behavioral therapy, interpersonal therapy, and medical treatment concluded that although not effective with all individuals, cognitive-behavioral procedures are still the initial treatment of choice (Walsh, Wilson, Loeb, Devlin, Pike, Roose, Fleiss, & Waternaux, 1997). Follow-up studies attempted to determine the predictive factors for an effective treatment outcome. Those exhibiting more severe symptoms and greater impulsivity were more likely to drop out of treatment. In addition, it was found that individuals remaining in treatment and requiring more than six sessions to reduce purging were unlikely to profit from additional cognitive-behavioral treatment. Those with a prior history of substance abuse were also less likely to profit from treatment. Medications were sometimes helpful in treating those not successful with cognitive-behavioral treatment approaches (Agras, Crow, Halmi, Mitchell, Wilson, & Kraemer, 2000; Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000; Wilson, Loeb, Walsh, Labouvie, Petkova, Liu, & Waternaux, 1999).
Promising preliminary results have been obtained with the direct learning procedure, cue-exposure. Binging and purging were reduced in 22 adolescents diagnosed with bulimia who were resistant to other procedures. This was achieved by systematically exposing the adolescents to the specific environmental cues which triggered their binging and purging (Martinez-Mallén, Castro-Fornieles, Lázaro, Moreno, Morer, Font, Julien, Vila, & Toro, 2007). Cue-exposure is an extinction procedure. By repeatedly presenting the specific stimuli without permitting eating to occur, the strength of the cravings produced by these cues is reduced. A recent review describes innovative variations on cue-exposure including virtual reality procedures (Koskina, A., Campbell, L., & Schmidt, U. (2013). Virtual reality techniques have been found effective in simulating idiosyncratic cues, eliciting strong cravings for food in individuals diagnosed with bulimia. Such realism improves the effectiveness of cue-exposure procedures conducted in clinical settings (Gutierrez-Moldanado, Ferrer-Garcia, & Riva, G., 2013; Ferrer-Garcia, Gutierrez-Moldanado, & Pla, 2013).
We previously saw that a poor night’s sleep could lead to severe psychiatric symptoms. Research has also demonstrated that good sleep habits result in improved health and psychological functioning (Hyyppa & Kronholm, 1989). Worldwide, approximately 30 percent of adults report difficulty initiating or maintaining sleep or experiencing poor sleep quality. Six percent meet the DSM-IV-TR criteria for insomnia disorder of having such symptoms occur at least three times a week and last for at least one month (Roth, 2007).
A National Institute of Health Conference concluded that cognitive-behavioral procedures were at least as effective as medications for treating insomnia and had the advantage of improvements continuing after the procedures were terminated. In addition, learning-based procedures do not pose the risk of undesirable side-effects (NIH, 2005). These conclusions are consistent with the results of several experimental studies and literature reviews (Edinger & Means, 2005; Jacobs, Pace-Schott, Stickgold, & Otto, 2004; Morin, Colecchi, Stone, Sood, & Brink, 1999). A review of six randomized, controlled trials concluded that the computerized self-help administration of cognitive- behavioral procedures was mildly effective and worthy of consideration as a minimally invasive initial approach to treatment (Cheng & Dizon, 2012).
Richard Bootzin (1972) developed an early learning-based approach to the treatment of insomnia based on the principles of stimulus control. Now known as the Bootzin Technique, it requires implementing the following procedures:
- Go to bed only when you are sleepy
- Use the bed only for sleeping
- If you are unable to sleep, get up and do something else; return only when you are sleepy; if you still cannot sleep, get up again. The goal is to associate your bed with sleeping rather than with frustration. Repeat as often as necessary throughout the night.
- Set the alarm and get up at the same time every morning, regardless of how much or how little sleep you’ve had.
- Do not nap during the day (Bootzin, 1972).
There is a substantial amount of empirical support for the effectiveness of stimulus control procedures in addressing insomnia (Bootzin & Epstein, 2000, 2011; Morin & Azrin, 1987, 1988; Morin, Bootzin, Buysse, Edinger, Espie, & Lichstein, 2006; Morin, Hauri, Espie, Spielman, Buysse, & Bootzin, 1999; Riedel, Lichstein, Peterson, Means, Epperson, & Aguillarel, 1998; Turner & Ascher, 1979). Given the documented success of self-help approaches, the Bootzin Technique is certainly worth trying if you ever experience sleep problems.
In Chapter 4, we described Masters and Johnson’s (1966) proposed four-phase human sexual-response cycle consisting of an excitement phase, followed by a plateau, then orgasm, and then a calming phase in which the ability to become excited again is gradually reinstated (see Figure 4.4). A sexual dysfunction refers to a consistent problem occurring during one of the first three phases of normal sexual activity. When occurring during the first stage, problems are defined as sexual desire disorders. When occurring during the second stage, they are defined as sexual arousal disorders, and when during the third phase, as orgasm disorders (e.g., erectile dysfunction and premature ejaculation in men).
DSM-5 diagnoses of sexual disorders require durations of at least six months. Sexual desire and performance can be influenced by a multitude of factors including: other psychiatric conditions (e.g., anxiety, depression, etc.); hormonal irregularities (estrogen for women, testosterone for men); aging; fatigue (one more reason for maintaining good sleep habits); medications (e.g, SSRI anti-depressants); and relationship problems. Treatment for sexual dysfunctions can include individual or couples counseling, hormone replacement therapy, prescription of medications, or in extreme cases, implantation of surgical devices.
It is rare, but sometimes an individual believes their actual gender is different from what they appear to be. This can result in aversion to one’s own body, anxiety, and extreme unhappiness (i.e., dysphoria). A subtle change in DSM-5 was from the term, gender identity disorder, to gender dysphoria. The initial term implied that a problem existed when one felt they were a different gender than the sex assigned at birth. The latter term indicates that this is a problem only when it causes extreme unhappiness and interferes with daily functioning. The evidence suggests that once one establishes a sexual identity as male or female, whether or not it is consistent with one’s hormonally-determined sex, it cannot be altered through counseling (Seligman, 1993, pp. 149-150). All that can be done to reduce psychological distress is to perform sexual reassignment surgery and hormone replacement therapy in accord with the individual’s self-defined sex (Murad, Elamin, Garcia, Mullan, Murad, Erwin, & Montori, 2010). DSM-5 indicates that subsequent to successful reduction in dysphoria, there may still be the need for treatment to facilitate transition to a new lifestyle.
Disruptive, Impulse-Control, and Conduct Disorders
The chapter on disruptive, impulse-control, and conduct disorders is new to DSM-5. It integrates disorders involving emotional problems and poor self-control that appeared in separate chapters in prior DSM editions, including; oppositional defiant disorder, intermittent explosive disorder, conduct disorder, kleptomania, and pyromania. Diagnosis of oppositional defiant disorder depends upon the frequency and intensity of behaviors frequently characteristic of early childhood and adolescence including: actively refusing to comply with requests or rules; intentionally annoying others; arguing; blaming others for one’s mistakes; being spiteful or seeking revenge. Learning-based procedures have been found to be the most effective treatment for oppositional defiant disorder (Eyberg, Nelson, & Boggs, 2008).
The DSM-5 lists the following criteria for intermittent explosive disorder in children at least six years of age:
- Recurrent outbursts that demonstrate an inability to control impulses, including either of the following:
- Verbal aggression (tantrums, verbal arguments or fights) or physical aggression that occurs twice in a weeklong period for at least three months and does not lead to destruction of property or physical injury, or
- Three outbursts that involve injury or destruction within a year-long period
- Aggressive behavior is grossly disproportionate to the magnitude of the psychosocial stressors
- The outbursts are not premeditated and serve no premeditated purpose
- The outbursts cause distress or impairment of functioning, or lead to financial or legal consequences (American Psychiatric Association, 2013).
There is evidence for the effectiveness of SSRIs in alleviating some of the symptoms of intermittent explosive disorder (Coccaro, Lee, & Kavoussi, 2009). Overall, however, experimental outcome studies indicate that cognitive-behavioral treatment including relaxation training, cue-exposure to situational triggers, and modifying problematic thought patterns is generally more effective than medication (McCloskey, Noblett, Deffenbacher, Gollan, & Coccaro, 2008).
Conduct disorders are more serious and problematic than the other impulse-control disorders. They are defined by “a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated” (American Psychiatric Association 2013). Diagnostic criteria require that three or more of the following occur within the span of a year:
Aggression to people and animals
- often bullies, threatens, or intimidates others
- often initiates physical fights
- has used a weapon that can cause serious physical harm to others (e.g., abat, brick, broken bottle, knife, gun)
- has been physically cruel to people
- has been physically cruel to animals
- has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
- has forced someone into sexual activity
Destruction of property
8. has deliberately engaged in fire setting with the intention of causing serious damage
9. has deliberately destroyed others’ property (other than by fire setting)
Deceitfulness or theft
10. has broken into someone else’s house, building, or car
11. often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)
12. has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
Serious violations of rules
13. often stays out at night despite parental prohibitions, beginning before age 13 years
14. has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
15. is often truant from school, beginning before age 13 years(American Psychiatric Association 2013).
The diagnosis for conduct disorder distinguishes between childhood-onset and adolescent-onset types. The former requires that at least one of the criteria occur prior to the age of ten. The distinction is also made between severity levels. The conduct disorder is considered mild if there are few problems beyond those required to meet the criteria and only minor harm results. The disorder is considered moderate if the number of problems and harm done is between the levels required for mild and severe. Severe conduct disorder consists of many problems beyond those required to meet the criteria resulting in extreme harm (American Psychiatric Association, 2013).
Individuals diagnosed with conduct disorder can be extremely destructive and dangerous. In a review of research, rates of conduct disorder ranged from 23% to 87% for incarcerated youth or those in detention facilities (Teplin, Abram, McClelland, Mericle, Dulcan, & Washburn, 2006). It is important to identify the predisposing factors and initiate treatment for conduct disorder as soon as possible. Deficits in intellectual functioning, verbal reasoning, and organizational ability are common (Lynam & Henry, 2001; Moffit & Lynam, 1994). Children and adolescents diagnosed with conduct disorder often live in dangerous neighborhoods under poor financial conditions with a single (possibly divorced) parent and deviant peers. Parental characteristics frequently include: criminal behavior; substance abuse; psychiatric disorders; unemployment; a negligent parenting style with low levels of warmth and affection, poor attachment, and inconsistent discipline (Granic & Patterson, 2006; Hinshaw & Lee, 2003).
Truancy or poor performance in school, frequent fights, or incidents of bullying can be early warning signs for conduct disorder. Medications have been unsuccessful as a treatment approach (Scott, 2008). The results of behavioral training, in which parents are taught to implement the basic principles of direct and indirect learning through instruction, observational learning, and guided practice, have been encouraging (Kazdin, 2010). Necessary skills include systematic and accurate observation of behavior, effective use of prompting, fading, and shaping techniques, and consistent administration of reinforcement, punishment, and extinction procedures (Breston & Eyberg, 1998; Feldman & Kazdin, 1995). Follow-up research has demonstrated treatment effects lasting as long as 14 years (Long, Forehand, Wierson, & Morgan, 1994). Despite the successes of behavioral parent training, it is severely under-utilized due to the lack of availability of a sufficient number of parent-trainers and logistic problems during its implementation. There is the hope that these needs can be addressed by taking advantage of different technologies. Videotapes of expert practitioners can be provided to assist in training. Videotapes of interactions between parents and children may be used to provide feedback on usage of behavioral techniques. Cell phones can be used to maintain communication between the professional staff and parents between meetings (Jones, Forehand, Cuellar, Parent, Honeycutt, Khavou, Gonzalez, & Anton, 2014). In the following chapter, we will describe a comprehensive, “multisystemic” approach to treating conduct disorder (Caron, Catron, Gallop, Han, Harris, Ngo, & Weiss, 2013; Henggeler, Melton, & Smith, 1992) as well as early intervention procedures designed to prevent the disorder from developing in the first place (Hektner, August, Bloomquist, Lee, & Klimes-Dougan, 2014).
Substance-Related and Addictive Disorders
The following drugs are considered addictive in DSM-5: alcohol, caffeine, cannabis (marijuana), hallucinogens (e.g., LSD), inhalants, opioids (pain killers), sedatives (tranquilizers), hypnotics (sleep inducers), stimulants (e.g., methamphetamine), cocaine, and tobacco (American Psychiatric Association, 2013). Our evolving understanding of the reward mechanisms involved in addictive disorders is an excellent example of the synergy between psychology and psychiatry. For example, the fact that gambling appears to activate the same brain reward mechanisms as drugs, resulted in its inclusion under substance use disorder in DSM-5.
Olds and Milner (1954) discovered that electrical stimulation of certain areas of a rat’s brain served as a powerful reinforcer for a rat’s bar-pressing behavior. Later it was discovered that manipulating the pulse of electrical stimulation produced behavioral effects similar to those resulting from different drug dosages; higher pulse rates acted like higher dosages. The effects were so powerful that rats preferred electrical stimulation to food and would continue to press the bar despite being starved (Wise, 1996)! In this respect, electrical brain stimulation acts in a manner similar to other addictive substances; the individual craves the substance despite self-destructive consequences. The same parts of the brain mediate the reinforcing effects of electrical stimulation and different drugs through the neurotransmitter dopamine (Wise, 1989, 1996).
Similar to autism and schizophrenia, the DSM-5 collapses across previous distinctions between types of substance abuse and addictive disorders and provides criteria for indicating severity. The diagnosis of substance use disorder encompasses the previous diagnoses of substance abuse and substance dependence. The severity of the disorder is based on the number of symptoms identified from the following list (2-3 = mild, 4-5 = moderate, six or more = severe):
- Taking the substance in larger amounts or for longer than the you meant to
- Wanting to cut down or stop using the substance but not managing to
- Spending a lot of time getting, using, or recovering from use of the substance
- Cravings and urges to use the substance
- Not managing to do what you should at work, home or school, because of substance use
- Continuing to use, even when it causes problems in relationships
- Giving up important social, occupational or recreational activities because of substance use
- Using substances again and again, even when it puts the you in danger
- Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance
- Needing more of the substance to get the effect you want (tolerance)
- Development of withdrawal symptoms, which can be relieved by taking more of the substance (American Psychiatric Association, 2013).
The Society of Clinical Psychology website for evidence-based practices lists behavioral marital (couples) therapy as having strong research support for alcohol use disorders. Cognitive therapy and contingency management procedures, in which individuals receive “prizes” for clean laboratory samples, have been effective in treating mixed substance use disorders. A separate website of evidence-based practices for substance use disorders is maintained by the University of Washington Alcohol and Drug Abuse Institute (http://adai.uw.edu/ebp/). It lists behavioral self-control training and harm reduction approaches as being effective with adults (including college students) experiencing drinking problems. The Brief Alcohol Screening and Intervention for College Students (BASICS) harm reduction approach will be described in the following chapter (Denerin & Spear, 2012; Dimeff, Baer, Kivlahan, & Marlatt, 1998; Marlatt, 1996; Marlatt, Baer, & Larimer, 1995).
The diagnosis of neurocognitive disorders is based on clinical and behavioral observations made during adulthood. Due to the similarity in names, it is inevitable that neurodevelopmental and neurocognitive disorders will be confused. Although these disorders are both suspected to be the result of impairments in the brain or central nervous system, their effects are at opposite ends of the lifespan and are in opposite directions. Neurodevelopmental disorders, occurring early in life, interfere with normal, age-appropriate cognitive and social development. Neurocognitive disorders are diagnosed later in life when there is deterioration in healthy cognitive functioning impacting on customary daily activities. When deterioration is extreme, as in Alzheimer’s disease, the individual may be unable to maintain an independent lifestyle.
Unlike prior DSM editions, DSM-5 includes the diagnosis of mild as well as severe versions of different neurocognitive disorders based on the underlying medical condition (when known). The listed medical conditions include: Alzheimer’s disease;frontotemporal disorder;disorder with Lewy bodies; vascular disorder;traumatic brain injury; substance or medication-induced disorders; HIV infection; Prion disease; Parkinson’s disease; and Huntington’s disease. The neural and brain damage resulting from the major neurocognitive disorders result in discouraging prognoses and limited to non-existent treatment options. For example, currently existing medications can only slow down, not halt the worsening symptoms of Alzheimer’s disease (e.g., severe memory loss). It is not possible to reverse the physical damage and learning-based approaches have not proved effective in improving cognitive functioning.
A paraphilia is the experience of intense sexual arousal under non-normative conditions. The DSM-5 diagnosis of paraphilic disorder represents a change from how paraphilia was treated in the past. In prior editions, diagnosis was based on the occurrence of non-normative feelings and actions. The DSM-5 criteria require that, in addition, the feelings and behavior must cause distress or harm to oneself or others. The eight listed disorders include: exhibitionistic disorder (i.e., exposing oneself to strangers), fetishistic disorder (i.e., sexual arousal to unusual objects such as shoes); frotteuristic disorder (i.e., rubbing oneself against another individual without their consent); pedophilic disorder (i.e., sexual attraction to children); sexual masochism disorder (i.e., sexual behavior resulting in bodily harm to oneself); sexual sadism disorder (sexual behavior resulting in bodily harm to another non-consenting individual); transvestic disorder (i.e., sexual arousal resulting from dressing in the clothes of the opposite sex); and voyeuristic disorder (i.e., spying on individuals engaged in private activities).
The World Federation of Societies of Biological Psychiatry published guidelines for the biological treatment of paraphilia (Thibaut, De La Barra, Gordon, Cosyns, & Bradford, 2010). The goals of treatment included control of paraphilic fantasies, urges, behaviors, and distress. Cognitive-behavioral therapy was recommended along with six stages of pharmacologic treatment based upon the intensity of the individual’s fantasies, the level of success attained with a less powerful drug, and the risk for potential harm. It has been found that the combination of learning-based procedures and drugs was more effective than either alone (Hall, & Hall, 2007). In extreme instances, it is recommended that drugs or surgery that totally suppresses sexual urges be considered (Thibaut, De La Barra, Gordon, Cosyns, & Bradford, 2010).
We have reached the end of the DSM-5 list of psychiatric disorders. To some extent, we can consider the list as progressing from disorders with a strong nature (i.e., underlying genetic) component, such as Down and Fragile X syndromes, to personality disorders that, as described in Chapter 9, are based on nature/nurture interactions. The DSM-5 describes ten specific diagnosable personality disorders divided into three clusters as follows:
Cluster A (odd disorders)
- Paranoid personality disorder: characterized by a pattern of irrational suspicion and mistrust of others, interpreting motivations as malevolent
- Schizoid personality disorder: lack of interest and detachment from social relationships, and restricted emotional expression
- Schizotypal personality disorder: a pattern of extreme discomfort interacting socially, distorted cognitions and perceptions
Cluster B (dramatic, emotional or erratic disorders)
- Antisocial personality disorder: a pervasive pattern of disregard for and violation of the rights of others, lack of empathy
- Borderline personality disorder: pervasive pattern of instability in relationships, self-image, identity, behavior and affects often leading to self-harm and impulsivity
- Histrionic personality disorder: pervasive pattern of attention-seeking behavior and excessive emotions
- Narcissistic personality disorder: a pervasive pattern of grandiosity, need for admiration, and a lack of empathy
Cluster C (anxious or fearful disorders)
- Avoidant personality disorder: pervasive feelings of social inhibition and inadequacy, extreme sensitivity to negative evaluation
- Dependent personality disorder: pervasive psychological need to be cared for by other people.
- Obsessive-compulsive personality disorder (not the same as obsessive-compulsive disorder): characterized by rigid conformity to rules, perfectionism and control (American Psychiatric Association, 2013).
Each distinct personality disorder consists of a characteristic style of rigid, maladaptive thinking and behaving. As such, personality disorders are less specific than other DSM disorders in their behavioral symptomology. It is relatively straightforward and non-controversial to describe the behaviors from which one infers hallucinations, delusions, mania, depression, anxiety, and so on, including even conduct disorder and paraphilic disorder. It is more subjective and controversial to describe an individual as paranoid, antisocial, histrionic, narcissistic, avoidant, or dependent.
There is an old joke about a medical student that “died from a misprint.” We probably all can admit to sometimes behaving in paranoid, antisocial, histrionic, or narcissistic, and so on, ways. Does that mean we have a “mental illness?” This highlights the point Szasz made with his phrase “the myth of mental illness.” Saying someone “has” paranoid personality disorder provides none of the valuable information of a medical diagnosis. It does not tell us about the etiology of the behavior, its prognosis, or an effective treatment strategy.
Figure 11.6 summarizes research evaluating the evidence for brain dysfunction and the response to biological and psychosocial (i.e., learning-based) treatments for individuals diagnosed with personality disorders (Tasman, Kay, Lieberman, First, & Maj, 2008). There is very little evidence for biological pathology underlying any personality disorder unrelated to schizophrenia. Only drugs related to other disorders (e.g., antipsychotics, antidepressants, and mood stabilizers) are recommended for treatment. Personality disorders have also proven resistant to learning-based approaches, including the usually effective cognitive-behavior therapy. This should not be surprising, given the pervasiveness of the disorder which by definition affects all aspects of a person’s functioning.
|Cluster||Evidence for Brain Dysfunction||Response to Biological Treatments||Response to Psychosocial Treatments|
|A||Evidence for relationship of schizotypal personality to schizophrenia; otherwise none known||Schizotypal patients may improve on antipsychotic medication; otherwise not indicated||Poor. Supportive psychotherapy may help|
|B||Evidence suggestive for antisocial and borderline personalities; otherwise none known||Antidepressants, antipsychotics, or mood stabilizers may help for borderline personality; otherwise not indicated||Poor in antisocial personality. Variable in borderline, narcissistic, and histrionic personalities|
|C||None known||No direct response. Medications may help with comorbid anxiety and depression||Most common treatment for these disorders. Response variable|
Figure 11.6 Response of patients with personality disorders to biological and psychosocial treatments (adapted from Tasman, Kay, Lieberman, First, & Maj, 2008).
Aaron Beck, a psychiatrist and one of the first practitioners of cognitive-behavioral therapy, modified and lengthened the procedures to improve their applicability to personality disorders. He adopted some of the features of Freud’s traditional psychodynamic therapy, addressing thinking patterns developed during childhood as well as interpersonal styles resulting from relationships with one’s parents. Treatment was conducted over extended time periods and could last more than a year. In contrast to psychodynamic therapy, the individual would be expected to play a more active role in defining the nature of the problem, formulating treatment goals, and assessing treatment effectiveness. Homework was assigned to practice thinking and behavioral skills, developed during meetings with the therapist, in the home and work environments (Beck & Freedman, 1990). There is some evidence for the effectiveness of long-term psychodynamic and cognitive-behavioral approaches to treating personality disorders (Leichsenring & Leibing, 2003). Early cognitive-behavioral approaches focused on a narrow range of thinking patterns (e.g., specific thoughts related to one’s depression or anxiety). Jeffrey Young employed cognitive procedures to address schemas (see Chapter 7), the more organized and expansive thought patterns characteristic of personality disorders (McGinn & Young, 1994). Relationships between maladaptive schemas, the Big Five personality factors, and perceived parenting styles in adolescents have been identified (Muris, 2006; Young, Klosko, & Weishaar, 2003). A recent multi-center outcome study found schema-focused therapy more effective than clarification-oriented cognitive therapy or non-cognitive therapy for the treatment of personality disorders (Bamelis, Evers, Spinhoven, & Arntz, 2014).
Watch the following video for a description of schema therapy:
Nature/Nurture and Maladaptive Behavior
Acceptance and application of the scientific method was responsible for the technological transformations we have witnessed in our physical environment over the past four centuries. Our changing understanding of the complimentary roles psychiatry and psychology can play in the treatment of behavioral disorders stems from the acceptance of scientific evidence-based practice in both disciplines. Research findings point to the limitations of biologically-based treatments (e.g., drugs) and for the need for “talking therapies” (i.e., cognitive behavioral therapies for specific and stylistic thinking patterns). Talking can achieve just so much, however. It has been found that inclusion and completion of homework assignments is essential to the success of cognitive-behavioral procedures (Burns & Spangler, 2000; Garland & Scott, 2002; Ilardi & Craighead, 1994; Kazantzis, Deane, & Ronan, 2000). In the following chapter we will discuss the role of self-efficacy, the belief that one can accomplish a task, in the success of behavioral interventions (Bandura, 1977b).
The hope is that research will uncover the specific neurological underpinnings of cognitive, emotional, and behavioral symptoms. Psychiatric researchers are recommending transition from DSM, symptom-based diagnosis, to classifying disorders based on findings in neuroscience and genetics (Insel, Cuthbert, Garvey, Heinssen, Pine, Quinn, Sanislow, & Wang, 2010). The National Institute of Mental Health has launched the Research Domain Criteria (RDoC) project with the goal of transitioning to a diagnostic system incorporating genetics, imaging, and cognitive science. Psychiatry would then more resemble other medical subfields which define pathological conditions on the basis of their etiology as opposed to symptomology.
There have already been surprising and important findings changing our understanding of DSM disorders. Five disorders have unexpectedly been found to share common genes. High genetic correlations exist between schizophrenia and bipolar disorder. Moderate correlations exist between schizophrenia and major depressive disorder, bipolar disorder and major depressive disorder, and ADHD and major depressive disorder (Cross-Disorder Group of the Psychiatric Genomics Consortium, 2013). There is the possibility that shared genes result in similar pathological mechanisms, having implications with respect to treatment. For example, one of the shared genes known to be involved in the regulation of calcium affects emotion, thinking, attention, and memory (Cross-Disorder Group of the Psychiatric Genomics Consortium, 2013).
Behavioral neuroscience offers another promising approach to understanding and treating DSM disorders. It has been found that those with diagnosed disorders perform poorly on the Iowa Gambling Task (IGT) in comparison to non-diagnosed individuals (Mukherjee & Kable, 2014). The IGT is a standardized task in which individuals must select from four different decks of cards. Payoffs are higher when selections are only made from two of the decks. Over extended trials, non-diagnosed individuals eventually adopt this strategy whereas those with DSM disorders do not (Bechara, Damasio, Damasio, & Anderson, 1994). There do not appear to be differences between types of disorders, suggesting that difficulties in making value-based decisions are fundamental to psychiatric disorders. The parts of the brain (frontal cortex and amygdala, among others) involved in performing the IGT appear to be the same as those impaired in diagnosed populations. Performing well on the IGT requires long-term processing of the results of decision-making. It is hoped that future research may be able to determine if specific components of the decision-making process are problematic in different disorders, potentially leading to more prescriptive psychological and psychiatric treatments (Mukherjee & Kable, 2014).