ROD A.

MARTIN
•
NADIA MAIOLINO

CHAPTER

6 SensorSpot/Vetta/Getty Images

Dissociative and Somatic Symptom

and Related Disorders
LEARNING OBJECTIVES
AFTER READING THIS CHAPTER, STUDENTS WILL BE ABLE TO:
Describe the symptoms and clinical features of the major dissociative disorders.
Compare and contrast two competing theories of the etiology of dissociative identity disorder.
Describe the symptoms and clinical features of the major somatic symptom and related disorders.
Explain how biological, psychological, and social-environmental factors can work together to cause
somatic symptom and related disorders.
Discuss the goals and methods of contemporary psychological treatments for somatic symptom and
related disorders.

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 Kathy is 35 years old and has been in and out of the mental health system for approximately
15 years. Her previous therapists have given her a number of diagnoses, including generalized
anxiety disorder and borderline personality disorder. During an initial assessment, her current
psychotherapist learned that Kathy had an extensive history of sexual abuse perpetrated by her
father and grandfather. Kathy told the therapist that when she was a child she often felt like a
robot, and described herself as feeling “dead from the neck down” when she was repeatedly raped
by these family members. The psychologist noted that there were sizable gaps in Kathy’s memory
of her psychosocial history and that she was better able to recount her history on some days com-
pared to others. Her therapist also began to notice dramatic changes in Kathy’s appearance from
one day to the next. For example, on one day she would be dressed provocatively, wearing a great
deal of makeup, and on other days she would be dressed conservatively, with little makeup and
her hair pulled into a bun. The psychologist decided to work with Kathy to help her cope with her
history of sexual abuse, beginning very slowly by helping her build her trust until she felt comfort-
able in the therapy sessions. After a year of working together, Kathy felt comfortable enough with
her psychologist to tell her about the other personalities she experiences, something she had not
been able to do previously.

***

Casey is a 30-year-old man who is very afraid that he might die of cancer, as his mother did sev-
eral years ago. He has made frequent visits to different doctors, complaining of a pain in his left
leg. He began checking for lumps in his leg several times a day and reading about cancer on the
internet. He went to the emergency room complaining of pain in his leg, thinking this a sure sign
that a tumour was growing. After conducting several tests, the doctors found nothing wrong with
his leg, and reported that he was in excellent physical condition. After a year without a diagno-
sis, Casey found that he was experiencing chest pain in addition to the pains in his leg. He went
to the emergency room three times, certain that he was dying of a vicious cancer that had now
spread to his lungs. Each time, the doctors assured him that, although his pains might be real,
they could find no physical cause. Casey decided that the doctors were simply not competent
enough to find his disease. He became increasingly frustrated and began to stay at home as
much as he could to learn more about his perceived condition and to chat with cancer patients on
Facebook and Twitter. His relationships with family and friends have become strained, and he is
becoming increasingly socially isolated.

Kathy’s and Casey’s cases are clinical examples of two fas- beliefs that they have a serious illness, resulting in exces-
cinating groups of disorders known as the dissociative and sive anxiety and dysfunction. As a group, the somatic symp-
somatic symptom and related disorders. Kathy has one of tom and related disorders include conditions involving
the most severe types of dissociative disorders, dissociative bodily symptoms associated with significant distress and
identity disorder, in which an individual’s sense of self is impairment.
fragmented and resembles two or more personality states. As Many clinicians and researchers believe that these dis-
a group, the dissociative disorders include a wide range of orders result from maladaptive ways of coping with extreme
symptoms that involve severe disruptions in consciousness, stress. However, as we will see, there is a great deal of debate
memory, and identity (Kihlstrom, 2005). Casey has somatic among experts concerning the nature and causes of these
symptom disorder, in which people have long-standing disorders. Although a large body of clinical literature of case

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 Dissociative and Somatic Symptom and Related Disorders 129

studies and observational reports has accumulated over more described in some detail the usefulness of hypnosis in the
than a century, more systematic research has only begun to treatment of such patients. The book consisted primarily of
accumulate in recent years, and our knowledge about these case studies of female patients suffering from dissociation,
two groups of disorders is still quite limited. most of whom had been sexually abused. Several of these
Although the dissociative and somatic symptom and patients also suffered from somatic symptom and related
related disorders are classified as two separate diagnostic disorders. For example, the first case described “Anna O,” a
categories in DSM-5, they are strongly linked historically 21-year-old woman treated by Breuer who developed visual
and share common features. In early versions of the DSM, and hearing problems, total paralysis of both legs and her
these groups of disorders were classified together with the right arm, partial paralysis of her left arm, a nervous cough,
anxiety disorders under the general category of neuroses. and periods of disturbed consciousness in which she seemed
It was assumed that anxiety was the predominant underly- to be quite a different person. The classic Freudian view of
ing feature in the etiology of these disorders, whether or somatic symptom and dissociative disorders began with such
not anxiety could be observed overtly. With DSM-III, how- cases and was modified over several years. Freud eventually
ever, the classification of psychological disorders shifted in began to doubt the accuracy of his patients’ retrospective
emphasis from etiology to observable behaviour, a trend reports of traumatic sexual abuse and decided instead that
even more evident in DSM-5. This shift resulted in the dis- their memories of trauma were fantasized and not real. He
sociative and somatic symptom disorders being separated believed that dissociation and other intrapsychic defences
into two groupings independent of the anxiety disorders, developed in order to protect individuals from their unac-
due to their different symptom presentations. ceptable sexual impulses, not from real traumatic memories.
Freud also viewed conversion symptoms as expressions of
unconscious psychological conflicts. He suggested that “con-
version” of anxiety to more acceptable physical symptoms
Historical Perspective relieved the pressure of having to deal directly with the conflict.
The dissociative disorders and some of the somatic symp- This avoidance of conflict was termed primary gain, and was
tom disorders were once viewed as expressions of hysteria. viewed as the primary reinforcement maintaining the somatic
Dating back to ancient Greece, hysteria was a term used to symptoms. Freud also recognized that hysterical symptoms
describe a symptom pattern characterized by emotional could help a patient avoid responsibility and gain attention and
excitability and physical symptoms (e.g., convulsions, paral- sympathy, referring to these reinforcements as secondary gains of
yses, numbness, loss of vision) in the absence of any evident the symptoms. The term secondary gain is still commonly used
physiological cause. Hippocrates believed that these symp- today to refer to the benefits a patient may either unknowingly
toms were caused in women by a wandering womb (hysteros). or knowingly seek by adopting the sick role.
He thought the womb was like an animal that desired to
reproduce; if it remained inactive for too long, it became
angry and wandered around the body, blocking the channels
of respiration and causing illness (Merskey, 1995).
With the rise of Christianity, organic theories of hysteria
were replaced by supernatural explanations: dissociation and
related complaints were now seen as the result of demonic
possession, and exorcism was the favoured treatment (Ross,
1989). Only after the decline in acceptance of possession as
an explanation for abnormal behaviour did more psycho-
logically based theories develop. Over time, the components
of hysteria were examined as separate processes, and many
of the pioneers of modern psychological theories, such as
Alfred Binet, Jean-Martin Charcot, and Carl Jung, wrote
about dissociative and somatizing processes. Pierre Janet, a
French philosophy professor who trained with Charcot, was
the first to systematically study the concept of dissociation,
which he viewed as a pathological breakdown in the nor-
The Granger Collection

mal integration of mental processes, occurring as a result of

exposure to traumatic experiences (van der Kolk & van der
Hart, 1989).
Around the same time, Josef Breuer and Sigmund
Freud, in their classic 1895 publication Studies in Hysteria,
posited that trauma, often of a sexual nature, was a pre-
“Anna O” (Bertha Pappenheim; 1859–1936) developed a bizarre
disposing factor for hysteria and established a relation- range of physical and psychological symptoms. Her case was influ-
ship between dissociation and hypnotic-like states. They ential in the development of Freud’s ideas.

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 130 Chapter 6

The study of dissociation has followed a particularly of psychological functioning, such as identity, memory, con-
interesting course through history. After a peak of interest sciousness, emotion, sensorimotor functioning, and behav-
in the last two decades of the nineteenth century, interest iour (Spiegel et al., 2011). Normally, there is a unity in our
in dissociative processes dropped off exponentially during consciousness that gives rise to our sense of self. We know
the early part of the twentieth century (Goettman, Greaves, who we are. We know our names, where we live, and what we
& Coons, 1994). This decrease in interest has been attrib- do for a living. But for individuals with dissociative disorders,
uted to many factors, including the rise of behaviourism these simple aspects of daily living are bizarrely disturbed
and biological approaches within psychology, which did not and remain unintegrated, so that a coherent sense of self does
allow for the study of internal states such as consciousness not always exist.
(Ross, 1996). However, a resurgence of interest in dissocia- Dissociation itself is not necessarily a pathological pro-
tive processes took place from the 1970s to the 1990s. This cess. In fact, a certain degree of dissociation can be harmless
renewal of interest was shaped by several events, including and, in some cases, even adaptive (Barlow & Freyd, 2009).
the publication of popular accounts of cases of multiple If you have ever become lost in a daydream or become so
personality, the inclusion of dissociative identity disorder absorbed in a book or movie that you forgot about your sur-
in the DSM-III (published in 1980), and new research into roundings and the passage of time, you have had a mild dis-
consciousness and hypnosis (Hilgard, 1986). More recently, sociative experience. Dissociative experiences of this sort are
though, interest in dissociative disorders appears to have commonly reported in the general population (Gershuny
waned once again, with the annual number of scientific pub- & Thayer, 1999; Ross, 1996). If normal functioning is not
lications on this topic dropping in the first few years of the impaired by these occasional lapses and if the person can
twenty-first century to only about 25 percent of its peak “snap out of it,” there is no concern about pathological disso-
level in the 1990s (Pope, Barry, Bodkin, & Hudson, 2006). ciation. However, a problem exists when the person is unable
Many researchers now believe that dissociative disorders to control these drifts of consciousness or behaviour and they
were overdiagnosed in recent decades when they enjoyed a affect his or her ability to function in everyday life.
brief “bubble” of fashion that has now declined. Others attest There are also fairly stable individual differences in the
that this research area is “alive and relatively healthy,” draw- degree to which individuals tend to have dissociative experi-
ing attention to ongoing investigations that continue to be ences: some people dissociate more frequently than others
conducted on the dissociative disorders despite markedly (Carlson, Yates, & Sroufe, 2009). Dissociative tendency is
diminished interest (Boysen & VanBergen, 2013a, p. 441). related to other personality traits such as hypnotizability and
absorption. Research by Waller, Putnam, and Carlson (1996)
BEFORE MOVING ON indicates that dissociative experiences fall into two groups.
The first group involves mild, non-pathological forms of
Why were dissociative and somatic symptom and related dissociation, such as absorption and imaginative involve-
disorders traditionally grouped together in early diagnostic ment, that are normally distributed on a continuum across
systems, and why were they divided into separate diagnostic the general population. The second group involves more
groups with the publication of DSM-III? severe, pathological types of experiences, such as amnesia,
derealization, depersonalization, and identity alteration,
that do not normally occur in the general population and
Dissociative Disorders that form a discrete category or taxon.
The three major dissociative disorders classified in
Dissociative disorders are characterized by severe mal- DSM-5 will be discussed in this chapter: dissociative amne-
adaptive disruptions or alterations of identity, memory, and sia (which includes dissociative fugue as a subtype), deper-
consciousness that are experienced as being beyond one’s sonalization/derealization disorder, and dissociative identity
control. The defining symptom of these disorders is disso- disorder (formerly known as multiple personality disorder).
ciation, the lack of normal integration of one or more aspects Table 6.1 outlines the characteristics of these three disorders.

TABLE 6.1 TYPES OF DISSOCIATIVE DISORDERS

Disorder Description Comments
Dissociative amnesia Inability to recall important personal infor- Includes dissociative fugue, a rare condition in
mation which individuals unexpectedly leave home and
may turn up in a distant city with no memory of
their past.
Dissociative identity disorder Presence of two or more personality states Formerly known as multiple personality disor-
der. The classic case is The Three Faces of Eve
(Thigpen & Cleckley, 1957).
Depersonalization/derealization disorder Feeling of being detached from oneself and Depersonalization experienced for a short period
one’s physical and social environment of time is very common and not pathological.

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 Dissociative and Somatic Symptom and Related Disorders 131

FOCUS
Repressed Memory or False Memory?
6.1 At the age of 23, Alana sought help from a therapist ing brain regions and neurochemicals responsible for memory
because of feelings of depression and difficulty estab- functions (Bremner, 2001).
lishing meaningful relationships. After several sessions However, critics of the trauma–repression hypothesis
of therapy involving the use of hypnosis to help her recall have noted that it is based on the faulty assumption that the
her early relationship with her father, Alana remembered, in a mind records memories of childhood accurately, and that these
vague way at first but subsequently in increasing detail, that her recorded memories can be repressed and then recovered at a
father had sexually abused her during her childhood. She was later time through psychotherapy or hypnosis. These assump-
shocked but learned from her therapist that these traumatic tions are contradicted by a considerable amount of memory
memories had been repressed so that she could survive in her research indicating that most experiences are not recorded as
family for all these years. Although Alana had been somewhat with a video camera, but are distorted by various life events
distant from her father, she had not remembered this abuse for (Paris, 1996). Furthermore, most memories are far from factu-
17 years. She confronted her parents, and both her father and ally correct. In fact, as Loftus (1993) has pointed out, experi-
her mother vehemently denied any sexual abuse. With support mentally implanted false memories, once they are accepted as
from her therapist, Alana took her accusation to the police, true by participants, are reported as fact with enormous convic-
who, after some investigation, charged her father with sexual tion and are often embellished over time.
abuse. A further complicating factor is that it is generally not
Alana’s father claimed total innocence. After he was possible to establish the accuracy of a recovered traumatic
charged, he consulted a lawyer and learned about false mem- memory. Over the past decade, a growing number of functional
ory syndrome (Loftus & Davis, 2006), a proposed condition in magnetic resonance imaging (fMRI) studies have attempted to
which people are induced by therapists to remember events that determine whether differences between true and false memo-
never occurred. Loftus and other researchers posit that some ries can be detected by means of brain scans (e.g., Baym
therapists unwittingly implant these memories by using leading & Gonsalves, 2010). Despite promising results, the available
questions and repeated suggestion while patients are under hyp- evidence is far from conclusive (see Schacter & Loftus, 2013).
nosis. Several experiments have been conducted to demonstrate At present, there is no objective way to determine whether a
the existence of illusory or distorted memories and the idea that memory elicited in psychotherapy is true or false, aside from cor-
false memories can successfully be produced. For example, a roborating evidence, which is often not available. On the other
study by Loftus and Pickrell (1995) showed that adults could be hand, there is considerable evidence that hypnosis can implant
convinced that they had been lost for an extended period of time highly detailed but untrue memories.
when they were about five years old, after a trusted companion The highly controversial issue of repressed memory is not
was recruited to “plant” this memory. likely to be resolved soon. Because false memories can be cre-
On the other side of this debate, proponents of recov- ated through strong repeated suggestions, therapists need to
ered memory therapy point to research evidence indicating be very careful about making suggestions of early abuse when
that early traumatic experiences can cause selective disso- patients do not raise the topic themselves. On the other hand,
ciative amnesia (Gleaves, 1996; Kluft, 1999), although crit- it is also possible that people who have experienced extreme
ics have noted methodological weaknesses in these studies abuse or trauma could have dissociated these memories from
(Kihlstrom, 2005). The concept of repressed memory derives awareness. Advocates on both sides of this issue agree that clini-
from Freudian theory, which suggests that very traumatic events cal research needs to focus on identifying the conditions under
can be entirely forgotten in order to protect the child from the which the implantation of false memories is likely and to define
severe anxiety associated with the event. Research examining markers that indicate real traumatic amnesia. In the meantime,
the effects of stress on the neurobiology of memory supports mental health professionals must be extremely careful not to
a link between trauma and amnesia. Studies have shown that cause unnecessary suffering to either victims of actual trauma
extreme stress can have long-term effects on memory, by alter- or victims falsely accused as abusers. ●

Similar to other diagnostic classes in DSM-5, there is also an PREVALENCE

“other specified dissociative disorder” category to aid in the Not surprisingly, dissociation is more common among psy-
description of clinically significant symptoms that do not chiatric patients than the general population. Studies of the
meet diagnostic criteria for any of the above disorders. One prevalence of dissociative disorders in adult psychiatric inpa-
presentation that could be specified is “identity disturbance tient populations suggest that as many as 15 to 21 percent of
due to prolonged and intense coercive persuasion,” which inpatients in Canada have some kind of dissociative disorder
could follow from acts of torture or brainwashing (APA, (Horen, Leichner, & Lawson, 1995; Ross, Anderson, Fleisher,
2013, p. 306). By contrast, the “unspecified dissociative disor- & Norton, 1991). A study of adult outpatients at an inner-
der” category applies when there is insufficient information city psychiatric facility found that as many as 29 percent met
to specify why syndromes do not meet diagnostic criteria for the criteria for diagnosis of a dissociative disorder (Foote,
any of the major dissociative disorders.

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 132 Chapter 6

Smolin, Kaplan, Legatt, & Lipschitz, 2006). To determine the from home (fugue derives from the Latin word meaning
prevalence of dissociative disorders in the general popula- “flight”). Some individuals travel thousands of miles from
tion, Johnson and colleagues (2006) conducted structured their home before they recall their personal history. The
clinical interviews with a representative sample of 658 adults fugue is usually brief in duration, lasting from a few days to
from New York State. They found that 9.1 percent of these a few weeks, but there are rare cases where the individual
individuals could be diagnosed with dissociative disorders, disappears for a prolonged period of time. The behaviour of
including 0.8 percent with depersonalization/derealization individuals presenting with dissociative fugue is not all that
disorder, 1.8 percent with dissociative amnesia, 1.5 percent unusual; they are able to function reasonably well and may
with dissociative identity disorder, and 5.5 percent with dis- even successfully adopt a new identity and occupation if the
sociative disorder not otherwise specified. No cases of dis- disorder is prolonged. Dissociative fugue may end either
sociative fugue were found in this sample. There were no abruptly or gradually with persistent confusion or amnesia
differences between men and women in the prevalence of about identity. Often, those who have recovered from the
these disorders, and they were slightly more common in disorder report no memory of what occurred during the
younger than in older adults. This study also found high rates fugue state.
of comorbidity with other psychological disorders, including Our understanding of dissociative fugue is limited,
anxiety, bipolar, depressive, and personality disorders. largely due to the fact that it is so rare and because most of
these patients do not present for treatment (Coons, 1998).
Precipitating factors include life stressors, such as severe
marital and financial distress. Accordingly, the incidence
Dissociative Amnesia of dissociative fugue has been reported to increase dur-
The primary symptom of dissociative amnesia is the inabil- ing times of greater stress, such as during war or following
ity to recall significant personal information in the absence a natural disaster. Dissociative fugue is relatively common
of organic impairment. Typically, this amnesia occurs fol- in dissociative identity disorder, and comorbid diagnoses of
lowing a traumatic event, such as an automobile accident or depressive and bipolar disorders and substance abuse are
battlefield experiences during wartime. Afflicted individu- also frequently found (APA, 2013; Coons, 1999).
als usually have no memory of the precipitating traumatic
event; and may be unable to recall their own name, occupa-
BEFORE MOVING ON
tion, and other autobiographical information, even though
they may still retain general knowledge of world events, Amnesia can also result from brain damage due to various
such as the name of the current prime minister of Canada. causes (e.g., car accident, Alzheimer’s disease). How might
There is a large degree of variability concerning the chro- clinicians distinguish between these types of organic amne-
nicity and reoccurrence of amnestic episodes, as well as sia and dissociative amnesia?
the level of functional impairment associated with cases of
dissociative amnesia. In most instances, the amnesia remits
spontaneously within a few days after the person is in a safe Depersonalization/Derealization
environment, and may only be detected once memories are
recovered. In other cases, amnesia can be more chronic,
Disorder
recurrent, and debilitating. Depersonalization/derealization disorder is a dissocia-
Five patterns of memory loss characteristic of dissocia- tive disorder in which the individual has persistent or recur-
tive amnesia are described in DSM-5, including (1) localized rent experiences of depersonalization and/or derealization.
amnesia, wherein the person fails to recall information from Depersonalization is a condition in which individuals have
a very specific time period (e.g., the events immediately sur- a distinct sense of unreality and detachment from their
rounding a trauma); (2) selective amnesia, wherein only parts of own thoughts, feelings, sensations, actions, or body. Fleet-
the trauma are forgotten while other parts are remembered; ing experiences of depersonalization are relatively common,
(3) generalized amnesia, wherein the person forgets all per- with approximately half of the general population report-
sonal information from his or her past; (4) continuous amnesia, ing such symptoms, often during times of stress (Reutens,
wherein the individual forgets information from a specific Nielsen, & Sachdev, 2010). As a symptom, depersonaliza-
date until the present; and (5) systematized amnesia, wherein tion can also occur in several different disorders. In fact, it is
the individual only forgets certain categories of information, the third most commonly reported clinical symptom among
such as certain people or places. The latter three patterns of psychiatric patients, after depression and anxiety. Deper-
memory loss are less common, usually associated with more sonalization/derealization disorder is diagnosed only when
significant psychopathology, and are more commonly asso- severe depersonalization is the primary problem, and when
ciated with a diagnosis of dissociative identity disorder. the symptoms are persistent and cause clinically significant
Dissociative Fugue is included in DSM-5 as a subtype impairment or distress. Individuals with this disorder expe-
of dissociative amnesia. Dissociative fugue is an extremely rience recurrent episodes of depersonalization, in which
rare type of amnesia for autobiographical information that is they feel as though they are living in a dream, observing
so profound that individuals also travel unexpectedly away their own mental processes or body from the outside, or as

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 Dissociative and Somatic Symptom and Related Disorders 133

if time is moving slowly. They commonly describe feeling fails to take out the trash. For most of us, it is not difficult to
like a robot that is able to respond to their environment, but juggle these multiple roles or identities and adopt the behav-
without feeling connected to their actions (Simeon, 2009). iour most appropriate to a particular setting. We remain
Derealization is similar to depersonalization, but it conscious of these shifts and, no matter how many differ-
involves feelings of unreality and detachment with respect ent roles we must play within a particular day, we continue
to one’s surroundings rather than the self. Individuals who to have the experience of being a single person with one
have this symptom experience other people or objects in consciousness.
their environment as unreal, dreamlike, foggy, or distant. Dissociative identity disorder (DID) (formerly known
They may even have subjective visual distortions in which as multiple personality disorder) is one of the most controversial
they see objects as distorted, blurred, flattened, or larger or and fascinating disorders recognized in clinical psychology.
smaller than they actually are. This unusual disorder is diagnosed when the patient pres-
Unlike the other dissociative disorders, depersonaliza- ents with two or more distinct personality states, wherein a
tion/derealization disorder is not characterized by memory disruption of identity is indicated by discontinuities in one’s
impairment or identity confusion. This disorder typically sense of self and corresponding changes in psychological
begins in adolescence and tends to be chronic in nature. High functioning (e.g., altered emotional displays and behaviour).
rates of comorbidity with anxiety, depression, personality The presence of alternative personality states leads to recur-
disorders, and other dissociative disorders have been found rent gaps in memory for everyday events, trauma, and/or
(Simeon, Knutelska, Nelson, & Guralnik, 2003). Laboratory important autobiographical information. The DSM-5 diag-
research suggests that individuals with depersonalization/ nostic criteria for DID are listed in Table 6.2.
derealization disorder have reduced emotional reactivity to In classic examples of DID, alternative personality
stressful or emotionally arousing stimuli (Sierra et al., 2002; states resemble different identities or personalities that peri-
Simeon, Guralnik, Knutelska, Yehuda, & Schmeidler, 2003; odically intrude into the consciousness and assume control
Stanton et al., 2001), as well as cognitive disruptions in per- of a person’s behaviour. Historically, in DID, one of the per-
ceptual and attentional processes (Guralnik, Giesbrecht, sonality states is identified as the “host,” whereas subsequent
Knutelska, Sirroff, & Simeon, 2007). Neuroimaging research personality states are identified as alters. Each of the “per-
has begun to identify specific brain regions involved in the sonalities” is distinct and presents with different memories,
experience of depersonalization/derealization. For example, personal histories, and mannerisms. Different alters may
the inferior longitudinal fasciculus (ILF) may be critical for identify themselves as men or women, as adults or children,
integrating visual and emotional information, since damage or more rarely as animals. Some researchers have reported
to this area has been associated with diminished responses to differences between alters in eyeglass prescriptions, EEG
emotionally evocative images (Fischer et al., 2016). patterns, allergies, and other physical parameters (Nijenhuis
& den Boer, 2009). Although the number of alters can range
from one additional personality state to more than a thou-
sand, the average number appears to be somewhere between
Dissociative Identity Disorder 10 and 16 (Acocella, 1999; Coons, 1998).
We all wear many hats or play different roles. For example, The process of changing from one personality to
many of us could describe ourselves as students, siblings, another has been referred to as switching. Switching often
Canadians, employees, partners, or spouses. In addition, it occurs in response to a stressful situation, such as an argu-
is not unusual to behave quite differently depending on the ment with a spouse, or physical or sexual abuse, and may
role we are playing. For example, you might appear to be also occur if the therapist makes a request while the individ-
a more patient person when dealing with difficult custom- ual is hypnotized. The switch may or may not be dramatic
ers at your job than you are at home when your roommate enough to grab the attention of others, and may involve eye

TABLE 6.2 DSM-5 DIAGNOSTIC CRITERIA FOR DISSOCIATIVE IDENTITY DISORDER

A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experi-
ence of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by
related alterations in affect, behaviour, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs
and symptoms may be observed by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with
ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: in children, the symptoms are not bet-
ter explained by imaginary playmates or other fantasy play.
E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behaviour during alcohol
intoxication) or another medical condition (e.g., complex partial seizures).
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. (Copyright © 2013). American Psychiatric Association.
All Rights Reserved.

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 134 Chapter 6

blinking or eye rolling (Coons, 1998). The presence of a new

alter may also lead to a change in the tone of voice, demean-
Etiology
our, or posture of the individual. Our knowledge of the causes of the dissociative disorders is
In contrast to previous versions of DSM, the diagnos- minimal compared to many other clinical disorders, such as
tic criteria in DSM-5 are more flexible and emphasize less depressive and anxiety disorders. As noted previously, this
dramatic presentations of DID. Individuals are no longer issue has generated a great deal of debate, particularly with
required to display distinct “identities” that appear to “take regard to the etiology of DID. Two competing explanatory
control” of behaviour in order to receive a diagnosis of this models have been proposed: the trauma model and the socio-
disorder. Instead, it is recognized that alternative person- cognitive model (also referred to as the fantasy model). The
ality states may vary according to their level of overtness, trauma model, which is a diathesis-stress formulation, has a
and signs of identity disturbance may be quite subtle. For long history and continues to be widely accepted by many
example, the emergence of an alternative personality state clinicians and researchers (Dalenberg et al., 2012, 2014;
could correspond with the sudden occurrence of emo- Gleaves, 1996; Ross, 1997). According to this model, dissocia-
tions or behaviours that individuals find perplexing and tive disorders are a result of severe childhood trauma, includ-
not within their control. DSM-5 acknowledges that highly ing sexual, physical, and emotional abuse, accompanied by
overt personality states are more likely to occur in so-called personality traits that predispose the individual to employ
“possession-form” cases of DID, which “typically manifest as dissociation as a defence mechanism or coping strategy. Ini-
if a ‘spirit’, supernatural being, or outside person has taken tially, dissociation may be an adaptive response to traumatic
control, such that the individual begins speaking or acting in events that helps individuals cope with their trauma. For a
a distinctly different manner” (APA, 2013, p. 293). chronically abused child, for example, dissociation offers
The average age at diagnosis of DID is 29 to 35 years a means of escape when no other means is possible. If the
and this disorder is diagnosed three to nine times more fre- child can escape into a fantasy world and become somebody
quently in women than in men (APA, 2000). Self-destructive else and if this escape blunts the physical and emotional pain
behaviour is common among people with DID, including temporarily, he or she will likely do it again. However, this
self-inflicted burns, wrist slashing, and overdosing. About defence mechanism is no longer adaptive when it is main-
75 percent of patients with DID have a history of suicide tained as a habitual way of coping throughout adulthood.
attempts and more than 90 percent report recurrent sui- Not all people who are abused as children or who
cidal thoughts (Ross, 1997). DID is chronic by nature and experience other types of trauma develop dissociative dis-
patients often spend six to seven years seeking help from a orders. According to the trauma model, certain personality
variety of therapists for other problems, such as depression traits, such as high hypnotizability, fantasy proneness, and
or anxiety, before they are diagnosed with the disorder. Not openness to altered states of consciousness, may represent
surprisingly, given the severity of this condition, patients a diathesis, predisposing some individuals to develop dis-
with DID often have multiple diagnoses, including depres- sociative experiences in the face of trauma. These person-
sion, post-traumatic stress disorder, borderline personality ality traits themselves do not lead to dissociative disorders
disorder, substance abuse disorders, eating disorders, and (Rauschenberger & Lynn, 1995). However, they may increase
various anxiety disorders (Rodewald, Wilhelm-Gossling, the risk that people who undergo severe trauma will develop
Emrich, Reddemann, & Gast, 2011). The clinical picture is dissociative processes to cope with this trauma. In contrast,
complex, and these patients have developed a reputation for people who are low in dissociative tendencies may develop
being notoriously difficult to treat. Once diagnosed, most anxious, intrusive thoughts rather than a dissociative reac-
specialists in the area agree that several years of therapy are tion (Kirmayer, Robbins, & Paris, 1994).
required before integration of the host and alter personali- There may also be a genetic heritability component to
ties is possible (Kluft, 2001). these personality traits that makes some individuals more vul-
There is a great deal of debate among mental health nerable to dissociative disorders. Some studies comparing iden-
professionals about the prevalence of DID, and even about tical and fraternal twins have found that genetic factors account
the legitimacy of this diagnosis. Only about 200 cases of dis- for approximately 50 percent of the variance in dissociative
sociative identity disorder were reported in the entire world symptoms (Becker-Blease et al., 2004; Jang, Paris, Zweig-Frank,
literature prior to 1980 (Greaves, 1980). Over the next two & Livesley, 1998). There is also evidence for heritability of the
decades, however, diagnoses of this disorder increased expo- related traits of hypnotizability, absorption, and fantasy prone-
nentially. By 1986, it was estimated that 6000 cases had been ness (Morgan, 1973; Tellegen et al., 1988). However, at least one
diagnosed in North America (Coons, 1986), and many thou- study has failed to find evidence for heritability of pathological
sands more appeared in subsequent years. Recently, however, dissociative tendencies (Waller & Ross, 1997).
the number of diagnoses has dropped precipitously (Pope Some researchers have advanced the notion that
et al., 2006). This dramatic rise and fall in prevalence has attachment theory can also help to explain why some peo-
led some practitioners to believe that the disorder was over- ple are more vulnerable to dissociative disorders (Harari,
diagnosed in highly suggestible people by well-intentioned Bakermans-Kranenburg, & van Ijzendoorn, 2007; Liotti,
but overly zealous clinicians. This view will be explored fur- 2009). According to attachment theory, sensitive respond-
ther in the next section. ing by the parent to an infant’s needs results in a child who

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 Dissociative and Somatic Symptom and Related Disorders 135

demonstrates secure attachment, developing the skills and of clinicians who are strong believers in the legitimacy of
confidence necessary to relate to others later in adult life. this diagnosis, whereas many other clinicians who work
The lack of such sensitive responding by the caregiver results with severely disturbed and abused patients never encoun-
in insecure attachment, wherein children lack confidence in ter it (Boysen & VanBergen, 2013b). These arguments have
relations with others. One type of insecure attachment style led to a considerable amount of skepticism about the trauma
observed in infants has been labelled the “disorganized pat- model of DID among many mental health professionals. Sur-
tern,” which is characterized by inconsistent, contradictory veys of psychiatrists in Canada and the United States at the
behaviours when faced with stress, including stereotypical beginning of the twenty-first century showed that less than
and anomalous movements or postures, freezing, and trance- one-quarter of these clinicians believed that DID has strong
like states. Attachment researchers have noted similarities scientific validity (Lalonde, Hudson, Gigante, & Pope, 2001;
between these behaviours and dissociative states, and have Pope, Oliva, Hudson, Bodkin, & Gruber, 1999).
proposed that disorganized attachment may be a risk factor A critical issue dividing these two theories is whether or
for the development of pathological dissociation in adult life not DID actually develops in childhood as a result of abuse.
(Liotti, 2009; Main & Morgan, 1996). Disorganized attach- Proponents of the socio-cognitive model point out that DID
ment by itself does not necessarily lead to the development is usually diagnosed in adults and almost never observed
of dissociative disorders, but when individuals with this during childhood, when it is supposed to begin (Piper &
attachment style also experience overwhelming trauma, they Merskey, 2004a).
may be particularly vulnerable to developing a dissociative Although a number of mental health professionals con-
disorder (Lieberman, Chu, van Horn, & Harris, 2011). tinue to question the legitimacy of DID as a psychiatric
In contrast to the trauma model, the socio-cognitive diagnosis (Paris, 2012), others vehemently disagree (Brand,
model represents a very different etiological position Loewenstein, & Spiegel, 2013; Martinez-Taboas, Dorahy,
that is taken by many mental health professionals who do Sar, Middleton, & Krüger, 2013). The debate between trauma
not accept DID as a legitimate disorder (Lynn et al., 2014; and socio-cognitive models continues and, if anything,
Piper & Merskey, 2004a; Spanos, 1994, 1996). Nick Spanos, is more contentious than ever. Proponents of the trauma
who was a professor of psychology at Carleton University model point to a considerable amount of research evidence
in Ottawa, was a leading proponent of this model of DID. linking dissociative disorders with a history of trauma. In a
According to this perspective, multiple personality is a form widely cited meta-analysis, Dalenberg and colleagues (2012)
of role-playing in which individuals come to construe them- reported a moderately strong relationship between trauma
selves as possessing multiple selves and then begin to act in and dissociation, even when the analysis was restricted to
ways consistent with their own or their therapist’s concep- studies that relied on objective indicators of trauma. Addi-
tion of the disorder. Spanos (1996) did not suggest that these tionally, provocative results of prospective studies suggest
individuals were faking or malingering their illness, but did that highly aversive events are linked to later experiences of
assert that it is entirely possible to alter a person’s personal dissociation (Dalenberg et al., 2012).
history so that it is consistent with the belief that he or she Critics of the trauma model respond by citing several
has DID. Spanos believed that therapists’ leading questions, methodological flaws and inconsistencies in research used to
cues, and other demand characteristics play an important support this model (Lynn et al., 2014). Many relevant stud-
role in the generation and maintenance of this disorder. ies that document severe childhood physical and/or sexual
Harold Merskey, a psychiatrist and professor emeritus abuse are based on adult patients’ retrospective reports,
at the University of Western Ontario, has also championed which are very difficult to corroborate (Kihlstrom, 2005). In
this view (Merskey, 1992; Piper & Merskey, 2004a, 2004b). addition, more robust studies utilizing prospective designs
Merskey (1992) argued that DID is an iatrogenic (literally and well-corroborated cases of trauma have at times failed
meaning “caused by treatment”) condition, which means that to find the expected relationship between trauma and dis-
it is largely caused by therapists themselves during the course sociation (Lynn et al., 2014). Another source of information
of therapy. While treating emotionally troubled individuals has been studies that contrast diagnosed cases of DID with
by means of hypnosis, therapists may plant suggestions in individuals feigning symptoms of this disorder. A systematic
their patients that they have multiple personalities. Highly review conducted by Boysen and VanBergen (2014) suggests
hypnotizable patients, who have grown up in a culture in that there is a lack of meaningful differences between these
which stories of DID are widely reported in the media, may two groups, lending support to the socio-cognitive model.
then develop the symptoms of DID as a learned social role. However, these authors also cite several methodological
In support of this view, Merskey (1992) pointed to the sharp flaws limiting the interpretability of research in this area.
increase in diagnosed cases of DID following the release of
films that portrayed this disorder, such as The Three Faces of BEFORE MOVING ON
Eve and Sybil. Furthermore, until approximately 20 years
ago, the diagnosis of DID appeared to be limited to North The trauma model and the socio-cognitive model represent
America, and was quite rare in many other parts of the world two very different ways of explaining DID. What types of
before increasing global media attention. In addition, most evidence have been used to support each of these
explanations?
cases of DID have been reported by a relatively small number

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 136 Chapter 6

APPLIED CLINICAL CASE

Dissociative Amnesia with Fugue on national television, pleading for someone to recognize him.
Within hours, a woman telephoned from Olympia, Washington,
On September 10, 2006, a man appeared in the emergency saying that he was her fiancé, Jeff Ingram, a 40-year-old man
room of a hospital in Denver, Colorado, in obvious distress. He originally from Canada. He had disappeared after leaving on a
said he did not know his name or where he came from. Since trip to visit his parents in northern Alberta, and his family and
waking up on the sidewalk with no memory of his previous life, friends had been searching frantically for him for nearly two
he had been wandering the streets in confusion. Doctors at the months. When he was reunited with his fiancée and family, Jeff
hospital diagnosed him with dissociative fugue, and over the fol- did not recognize them, and six months later he still had no
lowing weeks they tried unsuccessfully to recover his memory by memory of his past, although he and his fiancée were making
means of hypnosis and sodium amytal (truth serum) treatments. plans for their wedding. The mystery of how he ended up in
After more than six weeks with no improvement, he appeared Denver was never solved.

Treatment traumatic childhood abuse (Kluft, 1999). However, others

have criticized the use of hypnosis in this patient population
PSYCHOTHERAPY because of the potential of retrieving confabulated memo-
Most psychotherapies for dissociative disorders focus on ries and personalities.
helping patients resolve emotional distress associated with
past traumas and learn more effective ways of coping with MEDICATION
stress in their lives (Harper, 2011). Treatment of DID tends Medication is generally not useful in the direct treatment of
to be a quite prolonged and arduous process, going through the dissociative disorders (Somer, Amos-Williams, & Stein,
a series of stages leading to the eventual integration of the 2013). However, psychopharmacology may be helpful in
various personalities (Kluft, 1999). The first stage of therapy treating comorbid disorders, such as depression and anxi-
involves the establishment of a trusting, safe environment ety. “Truth serum” or sodium amytal, a barbiturate causing
for the patient to discuss emotionally charged memories drowsiness, has sometimes been used to help the individual
of past trauma. The next stage begins by helping patients recall previously forgotten memories or identify additional
develop new coping skills that will be required when dis- alters. However, other psychotherapies are typically used at
cussions of past history of abuse take place. Agreements for the same time because the chemical does not always work or
open communication between alters may be necessary to the individual does not remember what was reported while
establish these new patterns of responding to stress. Therapy under the influence of this drug.
can then focus on remembering and grieving the abuse that
the patient experienced at the hands of those who should
have protected him or her. Once the patient develops more NEUROSURGICAL TREATMENTS
effective coping strategies and has reached a certain level of Emerging evidence points to the effectiveness of repetitive
acceptance of his or her past history of abuse, therapy can transcranial magnetic stimulation (rTMS) in the treatment
move on to the final stage: integration of the personalities. of dissociative disorders, particularly in cases of deperson-
Here the goal is for the alters to merge into a single person- alization/derealization disorder. This noninvasive proce-
ality or at least a group of alters that are working together dure involves the generation of a magnetic field at the level
and are aware of each other. of the scalp using a metal coil, which in turn influences the
Recent research on the effectiveness of psychotherapy for electrical activity in nearby regions of the brain. A recent
dissociative disorders includes a large-scale naturalistic study study of patients with depersonalization/derealization dis-
of patients who received therapy in the community for DID order reported that 20 sessions of rTMS to the right ventro-
(Brand et al., 2013). Main findings included lower levels of lateral prefrontal cortex significantly improved symptoms of
dissociation, depression, general distress, and post-traumatic depersonalization in six out of seven cases (Jay et al., 2016).
stress disorder symptoms at the 30-month follow-up. Despite However, the results also suggest that general symptoms of
these promising results, it should be emphasized that very lit- dissociation are relatively unaffected by this procedure.
tle systematic research has been conducted to date, and most
of the existing studies on the effectiveness of psychotherapy
for dissociative disorders have methodological flaws. Somatic Symptom and Related
HYPNOSIS Disorders
Hypnosis has been a popular treatment method for many The word somatic derives from the Greek soma, meaning
clinicians working with patients with DID to confirm the “body.” The somatic symptom and related disorders
diagnosis, to contact alters, and to uncover memories of are a group of disorders in which individuals present with

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 Dissociative and Somatic Symptom and Related Disorders 137

TABLE 6.3 SOMATIC SYMPTOM AND RELATED DISORDERS

Disorder Description
Somatic symptom disorder One or more somatic symptoms (e.g., chronic pain, fatigue) that are distressing or cause
significant disruption of daily life, accompanied by disproportionate concerns about seri-
ousness, anxiety, and/or excessive time and energy devoted to health concerns; a diag-
nosed medical illness may or may not be present
Illness anxiety disorder Preoccupation, anxiety, and worry about having or acquiring a serious illness in the
absence of significant somatic symptoms and despite the fact that thorough evaluation
fails to identify a serious medical condition
Conversion disorder Symptoms affecting voluntary motor or sensory functions (e.g., blindness, paralysis, loss
of feeling) that are incompatible with recognized neurological or medical conditions
Psychological factors affecting other The individual has a medical condition (e.g., asthma, heart disease, diabetes) that is
medical conditions adversely affected by psychological or behavioural factors (e.g., anxiety exacerbating
asthma symptoms, stressful work environment causing high blood pressure)
Factitious disorder Faking or inducing symptoms of illness to gain sympathy, medical care, and attention
(e.g., taking excessive laxatives, contaminating urine samples, intentionally injuring
oneself)

physical symptoms suggestive of medical illnesses, along on bodily concerns. The major diagnoses are somatic symptom
with significant psychological distress and functional disorder, illness anxiety disorder, conversion disorder, psychological
impairment. The physical symptoms can take a number factors affecting other medical conditions, and factitious disorder
of different forms. In dramatic cases, they involve substan- (see Table 6.3). In this chapter, we will discuss each of these
tial impairment of a sensory or muscular system, such as except psychological factors affecting other medical condi-
a loss of vision or paralysis in one arm. In other disorders, tions, which is the focus of Chapter 7.
individuals become unduly preoccupied with the belief
that they may have a serious disease; and become disabled
by constant worry, anxiety, and excessive time and energy PREVALENCE
devoted to their health concerns. Not surprisingly, individ- Because these disorders in DSM-5 represent a major recon-
uals with these disorders tend to view themselves as hav- ceptualization of the diagnostic group formerly called the
ing a medical disease or illness rather than a psychological somatoform disorders, little prevalence information is avail-
disorder, and they are much more likely to seek help from able to date. To obtain an estimate of their prevalence, we
a physician in general medicine than from a psychologist need to extrapolate from existing studies using the previ-
or psychiatrist. ous somatoform diagnoses. For example, the newly defined
In earlier versions of the DSM, these disorders were somatic symptom disorder subsumes the previous diagnosis
called somatoform disorders and an important criterion for of somatization disorder as well as most cases of hypochon-
diagnosis was that the bodily complaints of these individuals driasis. Past epidemiological studies assessing the prevalence
did not have a physiological basis or medical explanation. of somatization disorder found an average prevalence of
Instead, it was assumed that these symptoms were caused by 0.4 percent in the general population, whereas the preva-
psychological factors such as early traumatic experiences or lence of hypochondriasis was about 5 percent (Creed &
unresolved emotional distress. Because of the implication Barsky, 2004). The prevalence of somatic symptom disor-
that their physical symptoms were “all in their head,” many der is therefore likely to be about 5 percent as well. Since
patients viewed these diagnoses as demeaning and pejora- the DSM-5 diagnosis of illness anxiety disorder comprises
tive. These disorders have therefore been reconceptualised a smaller subset of hypochondriasis, the prevalence of this
in DSM-5 so that medically unexplained symptoms are no disorder is likely to be somewhat less than 5 percent. Epi-
longer such a central criterion for diagnosis. They may be demiological findings suggest that conversion disorder is
present to varying degrees, particularly in conversion dis- rarely found in the general population, with the estimated
order, but they are not necessary for a diagnosis of somatic prevalence being lower than 0.1% (Akagi & House, 2001).
symptom and related disorders. Thus, an individual could However, this disorder appears to be more common in neu-
have a diagnosed medical condition and still meet the cri- rological treatment settings; a recent study conducted in Iran
teria for one of these disorders. The key point is that psy- found that 8.2% of patients referred to an outpatient epi-
chological factors are causing excessive worry, distress, and lepsy clinic have non-epileptic seizures with no identifiable
impairment, or are contributing to the onset or severity of organic basis (Asadi-Pooya, Emami, & Emami, 2014). The
the medical condition. prevalence of factitious disorder is largely unknown due to
The somatic symptom and related disorders comprise inherent difficulties in studying this disorder. However, one
several disorders, all of which involve a predominant focus investigation conducted within a pediatric hospital setting

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 138 Chapter 6

reported that approximately 1.8% of persons involved

in patient cases qualified for a diagnosis of this disorder
(Ferrara et al., 2013).

Conversion Disorder
Conversion disorder, also called functional neurological symp-
tom disorder, is the most dramatic of the somatic symptom
and related disorders. Individuals with this disorder have a
loss of functioning in a part of their body that appears to be
due to a neurological or other medical cause, but without
any underlying medical abnormality to explain it. They may
have motor deficits such as paralysis or localized weakness,
impaired coordination or balance, inability to speak, diffi-
culty swallowing or the sensation of a lump in the throat, and
urinary retention. Behaviour resembling seizures or convul-
sions may also occur. In other cases, individuals have sensory
deficits such as loss of touch or pain sensation, double vision,
blindness, or deafness. Psychological factors, such as conflict
or stress, are presumed to be associated with the onset or
exacerbation of the condition. Patients with conversion dis-
order often have other diagnosable psychological disorders,
such as depression and anxiety (Aybek, Kanaan, & David,
2008; Stone, Warlow, & Sharpe, 2010).
Careful medical evaluation of these patients is always
essential to ensure that a genuine medical condition is not
misdiagnosed as a conversion disorder. Indeed, DSM-5 A B
criteria stipulate that this disorder can be diagnosed only
after thorough medical testing provides clear evidence that FIGURE 6.1 Glove Anaesthesia
the symptoms are not compatible with a neurological dis- People with glove anaesthesia lose sensation in the entire hand (A),
ease. In the past, a number of studies suggested that many not the area affected by the ulnar nerve which is where the loss
people diagnosed with conversion disorder were actually would be expected to a person with nerve damage (B).
suffering from a medical condition that diagnostic tests
could not identify. For example, early studies found that
one-quarter to one-half of all patients thought to have con- Another indicator that symptoms are likely due to
version disorders ultimately were diagnosed with medical conversion disorder is when they are clearly inconsis-
conditions (Slater & Glithero, 1965). However, growing tent with known physiological mechanisms. A classic
evidence indicates that rates of misdiagnosis have improved example is glove anaesthesia. This involves a loss of all
substantially over recent decades, likely due to improved sensation (e.g., touch, temperature, and pain) through-
knowledge and diagnostic techniques (Stone et al., 2005, out the hand, with the loss sharply demarcated at the
2009). For instance, a follow-up study of neurology outpa- wrist (see Figure 6.1A) rather than following a pattern
tients reported that a potential organic cause of medically consistent with the sensory innervation of the hand and
unexplained symptoms was later discovered in only 0.4% of forearm (Figure 6.1B). Another classic sign that was pre-
cases (Stone et al., 2009). viously thought to identify conversion symptoms was
In making a diagnosis of conversion disorder, clini- la belle indifférence, a nonchalant lack of concern about
cians often look for particular signs that help to distinguish the nature and implications of one’s symptoms. However,
these symptoms from those with an organic origin (Daum, recent research indicates that this is found in only a minor-
Hubschmid, & Aybek, 2014). For example, electroencepha- ity of cases and it does not reliably distinguish between
lographic recordings might show that a patient’s seizures are conversion symptoms and symptoms of organic disease
not accompanied by the distinctive brainwave activity seen in (Stone, Smyth, Carson, Warlow, & Sharpe, 2006).
epilepsy (Marchetti, Kurcgant, Neto, Von Bismark, & Fiore, Several studies have employed brain imaging tech-
2009). Patients may also show inconsistencies over time (e.g., niques such as fMRI to examine the brain regions involved
inadvertently moving a “paralyzed” limb when attention in conversion disorders (see Ejareh dar & Kanaan, 2016).
is directed elsewhere) or unusual symptom patterns (e.g., These studies suggest that conversion symptoms result from
unusual head movements during seizures). A careful physical a dynamic reorganization of the brain circuits that link voli-
exam may indicate substantial strength in muscles that have tion, movement, and perception, leading to an inhibition of
supposedly been immobilized for a long time. normal cortical activity (Black, Seritan, Taber, & Hurley,

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 Dissociative and Somatic Symptom and Related Disorders 139

2004). Interestingly, these mechanisms are not observed in factors might contribute to their illness or disability, and
individuals who are instructed to feign conversion symp- they become quite upset at the suggestion to see a psychol-
toms, suggesting that individuals with conversion disorders ogist or psychiatrist.
are not simply faking their symptoms. Patients with somatic symptom disorder often describe
As discussed earlier, prior to the publication of DSM- their problems in a colourful or exaggerated manner, but
III, conversion and dissociative disorders were grouped without specific factual information. Their accounts can be
together under the concept of hysteria. Some experts have very persuasive and potentially expose them to danger as a
suggested that conversion disorder might best be viewed as result of invasive or risky diagnostic procedures (e.g., X-ray
a form of dissociative disorder (Brown, Cardena, Nijenhuis, examinations or invasive probes), surgery, hospitalization,
Sar, & van der Hart, 2007). According to this view, conversion side effects from potent medications, or treatment by several
disorders involve a process of dissociation in which there is physicians at once, perhaps leading to complicated or even
a lack of integration between conscious awareness and sen- hazardous care (Woolfolk & Allen, 2010). Multidisciplinary
sory processes or voluntary control over physical symptoms. assessment is often required. On the one hand, physicians
This argument is supported by findings that individuals with need to test for the possible presence of medical condi-
conversion disorders also frequently meet the criteria for tions for which there can be vague, multiple, and confusing
diagnoses of dissociative disorders, tend to have high scores somatic symptoms (e.g., systemic lupus, multiple sclerosis,
on measures of dissociative experiences and hypnotizability, or chronic parasitic disease). On the other hand, psycholo-
and frequently have a history of childhood abuse and trauma gists need to assess emotional, cognitive, behavioural, and
(Roelofs et al., 2002; Yayla et al., 2015). social issues.
These patients are often prone to periods of anxiety
and depression that they cannot express or cope with adap-
BEFORE MOVING ON
tively (Löwe et al., 2008). In addition, these individuals often
When diagnosing a conversion disorder, what steps should be report histories of substance abuse and personality disorders
taken by a clinician to rule out possible physiological causes (Bornstein & Gold, 2008; Noyes et al., 2001).
for the symptoms? Individuals with somatic symptom disorder often dis-
play an excessive sensitivity to relatively minor bodily symp-
Somatic Symptom Disorder toms. The patient may be alarmed by his or her heartbeat,
breathing, or sweating; become apprehensive about a small
Somatic symptom disorder is a new diagnosis in DSM-5, sore; or worry about a minor cough. These symptoms are
which subsumes the former somatization disorder as well as attributed to some serious disease and serve to confirm the
most individuals who would previously have been diag- patient’s fears that an illness is indeed present, resulting in a
nosed with hypochondriasis. Individuals with somatic symp- great deal of time spent thinking about the meaning, authen-
tom disorder typically have multiple, recurrent somatic ticity, or etiology of the somatic experiences. If you have
symptoms such as pain, fatigue, nausea, muscle weakness, read Chapter 5 on anxiety disorders, you may have noticed
numbness, or indigestion. These symptoms, which may or a similarity between somatic symptom disorder and panic
may not be due to a diagnosed medical disease or illness, disorder, in that both disorders involve excessive concern
must be very distressing to the individual and result in sig- with and misinterpretation of bodily symptoms (Deacon &
nificant disruption of daily life. Individuals with this disor- Abramowitz, 2008). A difference, however, is that those with
der have a great deal of anxiety about their health, worry panic disorder typically fear immediate symptom-related
excessively about their symptoms, and devote excessive disasters that might occur during the panic attack itself,
time and energy to thinking about them. Their personal whereas individuals with somatic symptom disorder focus
identity may become wrapped up with their perceived on the long-term process of illness and disease.
physical illnesses, and they may restrict their activities, Pain is one of the most frequent bodily symptoms asso-
avoiding social events, frequently taking sick days from ciated with somatic symptom disorder. In previous versions
work, and even quitting work completely and staying at of DSM, pain disorder was a separate diagnosis, but in DSM-5
home on disability. it has been subsumed within somatic symptom disorder,
Not surprisingly, these individuals frequently go to and affected individuals receive the diagnosis of somatic
the doctor to seek medical treatment for their bodily con- symptom disorder with predominant pain. Pain as a con-
cerns. Sometimes a medical examination leads to the dis- sequence of injury or disease is a very common experience.
covery of a genuine illness or disease, but the individual’s Fortunately, it is usually self-limiting, and most sources of
level of anxiety and functional impairment continues to pain can be identified and eliminated. However, pain can
far exceed what is normal or realistic for their particular also be extraordinarily severe and distressing, and it can per-
health problem. More often, however, no serious medi- sist long beyond the span of time one would expect neces-
cal problem is found, but these individuals are not reas- sary for damaged tissue to heal. These experiences of pain
sured and may become resentful that the doctor is not are not infrequent. An epidemiological survey of 18 coun-
taking their symptoms seriously enough. Patients also tend tries suggests that between 37 and 41 percent of the general
to strongly resist suggestions that psychological or social population suffers with chronic or recurrent pain of varying

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 140 Chapter 6

bodily symptoms and are primarily concerned with the idea

that they are ill, whereas those with somatic symptom disor-
der have significant symptoms such as pain and may actually
have a diagnosed medical illness.
People with illness anxiety disorder tend to be highly
anxious about their health and become easily alarmed about
illness-related events, such as hearing that a friend has
Rubberball/Mike Kemp/Getty Images

become ill or watching a health-related news story on TV.

They tend to examine themselves frequently (e.g., taking
their temperature or examining their throat in a mirror), and
they search the internet excessively to research their sus-
pected disease. Illness becomes central to their self-identity,
affecting their daily activities, and a major focus of their con-
versations with friends and family. Like those with somatic
symptom disorder, these individuals are far more likely to
People with somatic symptom and related disorders often become seek help from a general medical practitioner than from a
frustrated with physicians and embark on an intense search for the psychologist or psychiatrist, and they tend to become quite
drug or device that will solve their problems. upset when it is suggested that they might benefit from psy-
chological intervention. To be diagnosed with this disorder,
the illness preoccupation must have been present for at least
severity (Tsang et al., 2008). When pain persists beyond
six months, although the particular illness that is feared may
its expected time span, a patient can often benefit from a
have changed during that time.
consideration of the role of psychosocial factors. Pain is an
Since anxiety is the predominant symptom of this dis-
individual and subjective experience, and both its onset and
order, some researchers believe that illness anxiety disorder
course are known to be affected by a number of psychologi-
would be more appropriately categorized as an anxiety dis-
cal factors, including stress, anxiety, and depression. These
order than a somatic symptom disorder (Olatunji, Deacon, &
psychological dimensions of pain establish an important
Abramowitz, 2009).
role for psychologists in understanding and controlling pain
(Wiech & Tracey, 2009).
Overall, the DSM-5’s reconceptualization of somatic BEFORE MOVING ON
symptom disorder has been met with resistance from some
If you were suffering from a somatic symptom disorder, how
researchers and clinicians who fear that changes will result might you identify any secondary gains that might be rein-
in greater stigmatization of individuals with legitimate forcing the disorder?
medical conditions, such as chronic pain (Katz, Rosenbloom,
& Fashler, 2015). Now that this disorder can be diagnosed
within the context of physical illness, there is concern that Factitious Disorder
individuals with medical issues will be over-diagnosed with
Individuals with factitious disorder (also called Munchau-
mental disorders (Frances & Chapman, 2013). However,
sen syndrome) deliberately fake or generate the symptoms
findings of a recent study indicate that the DSM-5 diag-
of illness or injury to gain medical attention. For example,
nostic criteria are more restrictive than previously thought.
they might surreptitiously take excessive amounts of laxa-
Claassen-van Dessel and colleagues (2016) reported that
tives, contaminate urine samples with fecal matter, or inject
fewer patients with medically unexplained symptoms were
cleaning fluids into their skin to make it appear that they
diagnosed with a somatic symptom disorder when assess-
have a serious illness. Besides physical symptoms, factitious
ment was based on DSM-5 criteria (45.5%) compared to
disorders can involve faking psychiatric symptoms, such as
DSM-IV requirements for somatoform disorders (92.9%).
hallucinations or delusions. A recent analysis of 372 stud-
ies suggests that most patients choose to self-induce illness
Illness Anxiety Disorder or injury, rather than falsely report or simulate symptoms
(Yates & Feldman, 2016). To be diagnosed with this disor-
Illness anxiety disorder is another new diagnosis in DSM-5, der, there must not be any obvious external rewards for this
which applies to a subset of the individuals who would previ- behaviour, such as receiving insurance money, evading mili-
ously have been diagnosed with hypochondriasis. People with tary service, or avoiding an exam. Instead, the motivation
illness anxiety disorder are preoccupied with the fear that of these individuals seems to be to gain sympathy, care, and
they may have a serious medical disease, despite the fact that attention that accompany the sick role. A particularly trou-
thorough medical examination reveals that there is nothing bling variant of this disorder is factitious disorder imposed
seriously wrong with them. The main difference between on another, in which an individual falsifies illness in another
this disorder and somatic symptom disorder is that individu- person, most commonly the person’s own child. The news
als with illness anxiety disorder do not have any significant media occasionally report tragic cases of mothers producing

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 Dissociative and Somatic Symptom and Related Disorders 141

life-threatening symptoms in their children, such as inject- of dysfunctional beliefs about illness leads an individual to
ing them with a noxious substance or smothering them with become attentionally biased to misinterpret information in a
a pillow to induce unconsciousness. Needless to say, this dis- self-alarming and personally threatening manner. Distorted
order is typically associated with a significant level of psy- and catastrophic interpretation of bodily symptoms produces
chological distress and impairment. anxiety and uncertainty, which prompts a person to engage
in various safety-seeking behaviours. Specifically, individuals
with health-related anxiety often avoid illness-related infor-
mation, frequently check symptoms, and repeatedly seek help
Etiology from medical professionals to receive reassurance regarding
The somatic symptom and related disorders are a rather dis- their concerns (Hadjistavropoulos, Craig, & Hadjistavro-
parate group of disorders that have little in common except poulos, 1998). It is proposed that these behaviours impede
the fact that they all involve bodily symptoms in one way corrective learning about a patient’s health and reinforce dys-
or another. In view of the heterogeneity of these disorders, functional beliefs about illness, thereby completing a vicious
it is likely that somewhat different etiological processes are cycle and maintaining anxiety (Abramowitz et al., 2007).
involved in each of them. Traditional psychoanalytic explana- Individual differences in various personality traits, such
tions proposed that these disorders resulted from conversion as negative affectivity and emotion regulation deficits, have
of the anxiety associated with unconscious conflicts and unac- also been proposed as contributors to the development of
ceptable sexual drives into somatic symptomatology and dis- somatic symptom and related disorders (e.g., Zunhammer,
tress. However, this view is not widely held today. Kirmayer Eberle, Eichhammer, & Volker, 2013). As we have seen,
and Looper (2007) have proposed an integrative biopsycho- recent research also suggests that many people with conver-
social model to explain the development of somatic symptom sion disorders, like people with dissociative disorders, are
and related disorders. According to this theory, a number of highly hypnotizable (Roelofs et al., 2002), and that conver-
physiological, psychological, and social factors may interact sion symptoms result from spontaneous self-hypnosis, in
in a series of vicious cycles, with different somatic symptom which sensory or motor functions are split off from con-
disorders resulting from different patterns of interaction. sciousness in reaction to extreme stress.
Although genetic factors likely have some role in the Early life experiences and social learning also likely play
development of somatic symptom and related disorders a role in the etiology of somatic symptom and related dis-
(Kendler et al., 1995), more is known about the influence of orders. A good deal of evidence has been offered for a rela-
physiological factors. For example, chronic stress produces acti- tionship between trauma and these disorders. A significant
vation of the hypothalamic-pituitary-adrenal (HPA) axis, pro- degree of childhood physical or sexual abuse or other severe
ducing high levels of cortisol, which can adversely affect the childhood adversity has been reported in many patients
immune system and also produce feelings of fatigue, pain, and with somatic symptom and related disorders (Şar, Akyüz,
general malaise (Kirmayer & Looper, 2007). These feelings in Kundakçı, Kızıltan, & Doğan, 2004).
turn can cause individuals to perceive themselves as having Individuals who report medically unexplained symp-
a physical illness when they are actually experiencing stress. toms in adulthood often also report early experiences of
Cognitive factors also seem to play an important role illness and/or observing serious illness in others (Hotopf,
in the development of these disorders. We all experience Wilson-Jones, Mayou, Wadsworth, & Wessely, 2000). From a
many bodily sensations arising from various aches and pains, social learning perspective, children observe and internalize
common viral infections, and feelings of apprehension or the health-related opinions and behaviours of close others,
dysphoria arising from stressful life experiences. However, such as how parents perceive illness and respond to bodily
individuals with somatic symptom disorders spend substan- symptoms (Marshall, Jones, Ramchandani, Stein, & Bass,
tial time monitoring their bodies and thus they are more 2007). Moreover, illness-related behaviours and the “sick
likely to notice the various changes that take place. People role” can be positively reinforced by the care, concern, and
with these disorders also tend to interpret bodily sensa- attention received from others, and negatively reinforced by
tions in a distorted manner, magnifying their seriousness or allowing the individual to avoid burdensome work activities
importance and attributing them to serious illnesses, lead- or uncomfortable social situations. This does not mean that
ing to increased distress and further physiological arousal individuals with these disorders are consciously faking their
(Barsky, 1992; Vervoort et al., 2006). symptoms to obtain rewards, but rather that people learn to
Abramowitz, Deacon, and Valentiner (2007) have pro- adopt roles as a result of their reinforcement history.
posed a cognitive-behavioural model of health anxiety
that encapsulates many of the previously described cogni-
tive mechanisms and bears resemblance to models of other Treatment
anxiety-related disorders. They theorize, as others have
(Salkovskis, 1996; Salkovskis & Warwick, 1986), that we all MEDICATION
develop beliefs and attitudes about our physical well-being Existing research suggests that antidepressant medication
through personal experiences with illness and informa- is likely helpful for addressing primary symptoms of these
tion from others about their experiences. The development disorders (Somashekar, Jainer, & Wuntakal, 2013). However,

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 142 Chapter 6

the evidence supporting its efficacy is low in quality, and the The cognitive-behavioural approach to treating somatic
number of adverse effects reported in the available studies symptom and related disorders involves restructuring mor-
is concerning (Kleinstäuber et al., 2014). Future research bid thoughts and preoccupations, and works to bring dys-
is necessary to evaluate the utility of medication for the functional behaviour patterns under control. Many reviews
somatic symptom disorders. However, identification and of the existing research indicate that cognitive-behavioural
treatment of comorbid anxiety and depressive disorders is therapy (CBT) is an effective method for treating patients
a vital part of treatment, for which pharmacotherapeutic with these disorders. For example, Olatunji and colleagues
interventions are often prescribed. (2014) conducted a meta-analysis to examine the effective-
ness of CBT for hypochondriasis/health anxiety, based
PSYCHOTHERAPY on the previously discussed cognitive-behavioural model
(Abramowitz et al., 2007). Patients who were randomly
Generally, treatment of the somatic symptom and related
assigned to CBT exhibited diminished symptoms of health
disorders has shifted away from traditional psychodynamic
anxiety and also depression at post-treatment and follow-up
therapy, which viewed somatic symptoms as masked expres-
compared to those who received a control treatment, which
sions of psychological conflict and focused on helping indi-
often consisted of routine medical care or being placed on
viduals acquire insight into the origins of their difficulties.
a waitlist for CBT (Olatunji et al., 2014). Unfortunately,
Current treatments focus on the cognitive, affective, and
despite the fact that effective cognitive-behavioural treat-
social processes that maintain excessive or inappropriate
ments have been developed for several somatic symptom
behaviour (Woolfolk & Allen, 2007). Because patients with
and related disorders, many patients do not seek psycho-
somatic symptom and related disorders are usually very
logical treatment, insisting that their problems are physical,
reluctant to view their symptoms as having a psychologi-
even after extensive medical testing indicates otherwise.
cal cause, establishing a co-operative therapeutic environ-
ment is crucial when treating these disorders. Simon (2002)
notes the important features of developing such an environ-
ment, including establishing the position that all symptoms BEFORE MOVING ON
are “real” and distressing, negotiating a mutually acceptable
treatment goal (e.g., tolerance of reasonable uncertainty In recent years, clinicians and researchers have begun to
about health), shifting attention from somatic symptoms to conceptualize somatic symptom disorder as a form of anxiety
life stresses or affective states that may provoke or exacer- disorder. How might cognitive-behavioural methods for treat-
ing anxiety disorders be applied to the treatment of somatic
bate symptoms, and focusing on symptom management and
symptom disorder?
rehabilitation rather than medical diagnosis and cure.

CANADIAN RESEARCH CENTRE

Dr. Laurence J. Kirmayer

Dr. Kirmayer is a professor of psychiatry at the way that cultural factors influence
McGill University, where he is the direc- the symptomatology and treatment of
tor of the Division of Social and Transcul- psychological disorders. A major focus of
tural Psychiatry and editor-in-chief of the his research is on mental health, healing,
journal Transcultural Psychiatry. Follow- and resilience among Indigenous peoples
ing undergraduate studies in physiologi- in Canada and other countries.
cal psychology, he obtained a doctorate Dr. Kirmayer’s research has made
Courtesy Dr. Laurence J. Kirmayer

in medicine at McGill and completed a particular contributions to our under-

residency in psychiatry at the University standing of somatization and disso-
of California, Davis. Since childhood, he ciation, both of which are key issues
has had a strong interest in cultural diver- in cultural psychiatry. His studies of
sity and identity, and this has profoundly somatization in primary health care
influenced his approach to understanding have led to the development of an
and treating psychological disorders. He influential theoretical model of somatic
is now an internationally renowned clini- symptom disorder as illness behaviour
cian and researcher in cultural psychia- triggered by psychosocial stress and
try, a field that cuts across anthropology, emotional distress, emphasizing the
sociology, and other social sciences. He role of causal attributions and inter- medicine, and dissociation continues to
has authored numerous research articles personal processes. His interest in dis- be a topic of interest in his more recent
and co-edited several books on this topic. sociation stems from his earlier work cross-cultural research on trauma and
Dr. Kirmayer is particularly interested in with clinical hypnosis in behavioural healing processes.

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 Dissociative and Somatic Symptom and Related Disorders 143

SUMMARY
● Dissociative disorders are characterized by severe ● In conversion disorder, symptoms are observed in vol-
disturbances or alterations of identity, memory, and untary motor or sensory functions (e.g., paralysis or
consciousness. seizures) that suggest neurological or other medical eti-
● The primary symptom of dissociative amnesia is the ologies, but these cannot be confirmed by medical tests.
inability to recall significant personal information, usu- ● Somatic symptom disorder involves one or more somatic
ally of a traumatic or stressful nature, in the absence of symptoms (e.g., chronic pain, fatigue) that are distressing
organic impairment. or cause significant disruption of daily life, accompanied
● Dissociative fugue is an extremely rare subtype of disso- by disproportionate concerns about seriousness, anxiety,
ciative amnesia in which individuals forget who they are and/or excessive time and energy devoted to health
and suddenly and unexpectedly travel away from their concerns; a diagnosed medical illness may or may not be
home. present.
● The key feature of depersonalization/derealization dis- ● People with illness anxiety disorder have long-standing
order is a persistent feeling of unreality and detachment fears, suspicions, or convictions about a serious disease,
from one’s self or surroundings, often described as feel- despite medical reassurance that the disease is not present.
ing like one is in a dream. ● According to the integrative biopsychosocial model
● Dissociative identity disorder (DID) is diagnosed when (Kirmayer & Looper, 2007), somatic symptom and
the patient presents with two or more distinct personal- related disorders result from a series of vicious cycles
ity states, wherein various symptoms indicate a disrup- involving physiological, psychological, and social factors.
tion in sense of self and sense of agency. ● Physiological factors include stress-related increases
● According to the trauma model, DID results from a in cortisol, which can adversely affect immunity and
combination of (1) severe childhood trauma, including produce feelings of fatigue, pain, and general malaise,
sexual, physical, and emotional abuse; and (2) particu- causing individuals under stress to perceive themselves
lar personality traits that predispose the individual to as having a physical illness.
employ dissociation as way of coping with that trauma. ● Psychological factors include excessive attention to and
Although dissociation may initially be an adaptive way misattribution of bodily symptoms, somatic amplifica-
of coping with traumatic events, it becomes maladap- tion, and high levels of health anxiety.
tive when it is maintained as a habitual way of coping ● Social factors include early childhood abuse and social
throughout adulthood. learning comprising both positive and negative rein-
● In contrast, proponents of the socio-cognitive model forcement of illness behaviours and the “sick role.”
argue that DID is an iatrogenic condition that results ● Establishing a co-operative therapeutic relationship
from well-intentioned but misguided therapists inadver- between therapist and patient is a particular challenge
tently planting suggestions in the minds of their patients and a vital first step in psychotherapy for somatic symp-
that they have multiple personalities. Highly hypnotiz- tom and related disorders.
able patients may then develop the symptoms of DID as
● Identification and treatment of comorbid anxiety and
a learned social role.
depressive disorders is also important.
● Individuals with somatic symptom and related disorders
● Cognitive interventions for somatic symptom and
complain about bodily symptoms suggestive of medical
related disorders involve restructuring dysfunctional
illnesses, along with significant psychological distress
thoughts, interpretations, and preoccupations relating to
and functional impairment.
bodily symptoms and illness.

KEY TERMS
alters (p. 133) depersonalization/derealization disorder dissociative amnesia
conversion disorder (p. 138) (p. 132) (p. 132)

depersonalization derealization (p. 133) dissociative disorders (p. 130)

(p. 132) dissociation (p. 130) dissociative fugue (p. 132)

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 144 Chapter 6

dissociative identity disorder (DID) iatrogenic (p. 135) somatic symptom disorder (p. 139)
(p. 133) illness anxiety disorder (p. 140) somatic symptom disorder with predominant
factitious disorder imposed on another la belle indifférence (p. 138) pain (p. 139)
(p. 140) switching (p. 133)
repressed (p. 131)
factitious disorder (p. 140) trauma model (p. 134)
socio-cognitive model (p. 135)
false memory syndrome (p. 131)
somatic symptom and related disorders
glove anaesthesia (p. 138) (p. 136)
hysteria (p. 129)

M06_DOZO8871_06_SE_C06.indd 144 17/10/17 2:33 PM

 JOSHUA A. RASH
•
KENNETH M. PRKACHIN
•
GLENDA C. PRKACHIN
•
TAVIS S. CAMPBELL

CHAPTER

7 Sebastian Kaulitzki/Shutterstock

Psychological Factors Affecting

Medical Conditions
LEARNING OBJECTIVES
AFTER READING THIS CHAPTER, STUDENTS WILL BE ABLE TO:
Describe the history of the study of medical conditions linked to psychological/behavioural factors and
differentiate the fields contributing to it.
Articulate the concept of a “mechanism” and describe four biologically plausible pathways in which
psychological factors or behaviours contribute to “physical” disease.
Explain what is meant by “psychological stress,” distinguish three different approaches to conceptual-
izing it, and describe how it is measured and studied.
Describe the disease processes resulting in gastric ulcer and coronary heart disease.
Explain the psychosocial processes thought to contribute to infectious, ulcer, and coronary disease,
using evidence from empirical studies.
Characterize psychological/behavioural treatment techniques used with people suffering from psycho-
physiological disorders and explain how they relate to the psychosocial etiological mechanisms identi-
fied in this chapter.

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 George, a 32-year-old high school music teacher, was referred for psychological evaluation by his
family physician. For 16 months, George had been consulting his doctor about chest pains that
had caused him great anxiety. He was convinced he was having a heart attack. Within the last
year, George had consulted his doctor 37 times and had undergone extensive medical tests, none
of which had provided an explanation for his symptoms. Although there was no unusual history of
heart problems in his family and he was normal weight for his height, George was a smoker, sat
most of the day at work and did not exercise regularly.

Psychological evaluation revealed a man who was obviously distressed over his physical condition,
but whose agitation extended beyond that. George readily expressed grievances with other people
in his life: his principal for being demanding and incompetent, his wife for her sexual aloofness,
his father for his coolness, and numerous other individuals or classes of individuals for a litany of
reasons. He described his daily life as “going all out.” He was up at 5:00 a.m., at work for early
band practice, and usually finished at 6:30 each night. On his way home, he would pick up a six-
pack of beer and a sandwich to eat on the fly. Once at home, he would prepare his lessons for the
next day, finish the six-pack, and go to sleep.

George was an effective music teacher. His bands were always competitive in provincial cham-
pionships and for the preceding two years had been judged the best in the province. Yet these
achievements gave George no pleasure; he was always preoccupied with the deficiencies in his
students’ performances.

George’s case is representative of many people who are (Harrington, 2008). For example, Cannon (1942) discussed
referred for psychological or psychiatric evaluation. The the phenomenon of voodoo death. A member of a culture
presenting problem (recurrent chest pain) is ordinar- in which voodoo is practised may die as a consequence of
ily dealt with in clinical medicine, yet there are behav- learning that he or she has been cursed. Cannon attrib-
ioural (drinking, smoking, being sedentary), psychological uted this phenomenon to physiological processes elicited
(inability to experience pleasure, hard-driven, hostile, and by extreme threat and fear. As Western medicine evolved
agitated), and social (isolation) characteristics that seem during the first half of the twentieth century, diminishing
relevant to the symptoms he is experiencing. Moreover, attention was paid to these ideas. However, advances in
a substantial scientific literature suggests that George’s scientific methods, combined with the emergence of inter-
symptoms may be explained, at least in part, by psycho- disciplinary approaches, often involving the simultaneous
logical and behavioural variables that were identified in his examination of psychological and physiological variables,
psychological evaluation. Perhaps even more importantly, led to a powerful rebirth of the field toward the end of the
there is reason to believe that psychological therapies twentieth century.
that target the psychological and behavioural character- In the early years of psychopathology, this field of study
istics George has displayed may alleviate his distress and came to be referred to as psychosomatic medicine and the health
enhance his physical health. problems as psychosomatic disorders. People often incorrectly
use this term to describe imaginary illnesses, or the experi-
ence of symptoms (headaches, for example) with no known
Historical Perspective pathophysiological cause. Yet the disorders in question
involve identifiable disturbances in bodily structures and
This chapter focuses on the role of psychological factors in functions and are in no way feigned. The term also implies
physical illness. The idea that psychological processes can a dualistic view of mind and body as separate entities, sub-
affect bodily states, even to the extent of producing physical ject to different laws. To avoid such implications, in DSM-II
disease, has a long history in Western intellectual tradition (American Psychiatric Association [APA], 1968) the termi-
and may be even more deeply embedded in other cultures nology was changed to psychophysiological disorders.

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 Psychological Factors Affecting Medical Conditions 147

For many years, there was a set of “classic psychosomatic prevention of disease—for example, the use of psychological
disorders,” such as gastrointestinal ulcers, ulcerative colitis, techniques to control pain in patients undergoing medical
hypertension (high blood pressure), asthma, and arthritis. procedures, or interventions to improve a person with dia-
These disorders were probably considered together for a betes an ability to control his or her blood glucose or adhere
number of reasons. First, because evidence available at the to complex medical regimens. The broader term, health
time could not identify a specific pathophysiological cause, psychology, refers to any application of psychological meth-
dualistic thinking suggested that the roots of the disorders ods and theories to understand the origins of disease, individ-
must be psychological. Second, there was evidence suggest- ual responses to disease, and the determinants of good health.
ing distinct psychological features in patients suffering from In this chapter, we shall highlight a number of key concepts,
these disorders. Such thinking could be seen in early work of findings, and issues that health psychology has contributed
psychodynamically oriented theorists who posited specific to the study of psychopathology, focusing on those disorders
psychological etiologies for each of the classic psychoso- that reflect the impact of psychophysiological variables.
matic disorders. For example, Helen Flanders Dunbar (1935)
theorized that specific disorders were the natural conse-
BEFORE MOVING ON
quence of specific emotions and personality traits. The psy-
choanalyst Franz Alexander (1950) argued that the causes of The Greeks and their descendants in the Western intellec-
classic psychosomatic disorders lay in characteristic intrap- tual tradition viewed disease as a consequence of the imbal-
ersonal conflicts. According to this theory, people who were ance of four bodily fluids (blood, phlegm, and yellow and
prone to high blood pressure had a chronic sense of rage, black bile), excesses in any of which were thought to be cor-
but inhibited its expression. Consequently, they appeared related with particular temperaments. Traditional Chinese
unassertive and overly compliant. This conflict was thought medicine attributes certain diseases to imbalance of the life
forces Yin and Yang. In thinking about contemporary views
to have physiological consequences that led to clinical dis-
of psychophysiological disorders, people sometimes see par-
ease. The specific symptomatology was seen as symbolic of
allels with these and similar conceptions. How do you think
the underlying conflict. Such ideas persist to this day. For current conceptualizations are likely to differ from these ear-
example, there is considerable evidence that the experience lier ideas?
or expression of anger contributes to the pathophysiology of
heart disease (Chida & Steptoe, 2009; Myrtek, 2007; Smith
et al., 2008).
In the late 1970s, a new perspective emerged from the Diagnostic Issues
realization that many, perhaps all, disease states are influ- DSM-5 specifies the diagnostic criteria for a group of
enced directly or indirectly by social and psychological Somatic Symptom and Related Disorders. Within this broad
factors. The psychiatrist George Engel (1977) argued that grouping of conditions is a specific category: psychological
the biomedical model of disease should be expanded to a factors affecting other medical conditions. People who suffer or
“biopsychosocial” model (see Chapter 2). Engel’s argument experience medical conditions apart from mental disorders,
was based on evidence that psychological characteristics but whose medical conditions are evidently affected in one
and societal forces must be invoked to explain the origins of of several ways by psychological factors, are given this diag-
many diseases and the nature of health. nosis under the DSM-5 principles. To be diagnosed with
At about the same time, psychologists uncovered psychological factors affecting another medical condition
increasing evidence of the important role that psychological requires the presence of a diagnosed medical condition. The
factors and behaviour play in health and illness. For exam- key criterion for this diagnosis is evidence that the medical
ple, health care around the world began to incorporate the condition is adversely affected by some identifiable psycho-
idea that pain is in large part a psychological phenomenon logical or behavioural factor. DSM-5 specifies four ways in
(Melzack & Wall, 1982) and can be treated using psycho- which a psychological or behavioural factor might be ruled
logical techniques (Fordyce, 1976). A number of behaviours, in. One way is that the identified factor has influenced the
for example, smoking, poor diet, and lack of exercise, had course of the condition. This requires evidence that there
already been identified as increasing risk of disease. Inter- is a correlation between the occurrence of the psychologi-
est intensified as it became understood that such risk factors cal or behavioural factor on the one hand and the develop-
were the major determinants of the leading causes of death ment, exacerbation of, or delay of recovery from the medical
in Western societies. Behavioural therapy techniques offered condition on the other. Another is that the psychological or
apparently successful methods for controlling such behav- behavioural factor interferes with the treatment of the medi-
iours. Increasing evidence justified the belief that other psy- cal condition; something that is frequently observed when
chological variables, such as stress and characteristic styles patients do not adhere to a prescribed course of treatment,
of behaviour, were also associated with physical disease. for example. A third way is if an identifiable psychological or
All of these developments converged in a new branch behavioural factor poses an additional risk to the health of
of psychology called behavioural medicine, or health psy- the individual. This would be the case for a person with can-
chology. Behavioural medicine usually refers to applica- cer who persists in smoking cigarettes. Finally, this diagnos-
tion of the methods of behaviour change to the treatment or tic category can be ruled in when an identified psychological

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 148 Chapter 7

or behavioural factor influences the pathophysiology of the because of the close temporal association between her anxi-
disorder. It is this latter circumstance that most of this chap- ety symptoms and the onset of her heart attack. Comorbid
ter is devoted to. An exclusion criterion specifies that the generalized anxiety disorder would also be diagnosable.
psychological or behavioural factors at issue are not better Under the DCPR, Cindy would qualify for illness denial
explained by some other recognized mental disorder, such that would supplement DSM-5 diagnosis and be used to aid
as major depressive disorder. Clinicians employing this diag- case conceptualization and treatment planning.
nosis must specify the severity of the condition on a scale
ranging from “mild” to “extreme.” A mild disorder would be
BEFORE MOVING ON
one in which the medical risk to the patient is increased; for
example, when a patient with high blood pressure is incon- Imagine Mark, an adolescent boy with asthma, which is a
sistent in his or her use of medication. An extreme disorder chronic and occasionally fatal respiratory illness that causes
would be one in which there is imminent risk to the patient’s the airways to constrict, leading to the inability to breathe.
survival; for example, a patient who is experiencing pain in Now consider the DSM-5 criteria that must be met in order
the chest and arm, crushing sensations, and perspiration, to justify use of this disorder. What might be some of the
ignores these symptoms. psychological factors that contribute to Mark’s asthmatic
The International Classification of Diseases - 10 condition?
(ICD-10; currently undergoing revision with an expected
release date for ICD-11 of 2018) also specifies a category
“psychological or behavioural factors affecting disorders or diseases Psychosocial Mechanisms
classified elsewhere.” This category allows for the classification
psychological factors that increase the risk of suffering, dis- of Disease
ability, or death, and represent a focus of clinical attention. What are the mechanisms by which psychological factors
Similar to DSM-5, these factors may influence the course or might influence body systems? To answer this, we must
treatment of the medical condition, by affecting treatment understand the ways in which body tissues may be affected
adherence or care seeking, or by influencing the underlying by behaviours and psychological processes. For the purposes
pathophysiology and precipitating or exacerbating symptoms. of this discussion, behaviour is a discrete and potentially
While informative, it has been argued that the category observable act, such as eating, being physically active, exer-
of psychological factors affecting other medical condi- cising, smoking cigarettes, and so on. A psychological process is
tions lacks specificity and results in virtually no impact on not observable directly, but may be inferred reasonably on
clinical practice (Fava & Wise, 2007). It is important to note the basis of other phenomena that are. For example, we can-
that alternative diagnostic systems have been developed to not see another’s depression, but we can see evidence—in
supplement DSM-based classification of psychological fac- facial expression, in the way the individual speaks, in changes
tors that affect medical conditions and provide operational in sleeping, and even in responses to a questionnaire—that
tools that may better inform clinical practice. One such allows us to infer with some confidence that depression is
system is the Diagnostic Criteria for Psychosomatic Research present.
(DCPR) that was introduced in 1995 by an international Psychological influences on body tissues can be the
group of investigators (Fava, Freyberger et al., 1995). The effects of behaviours, particularly if those behaviours are
DCPR encompasses 12 psychosomatic syndromes, four of repeated frequently over weeks, months, or years. For exam-
which (alexithymia, type A behaviour, demoralization, and ple, there is no longer any reasonable doubt that the effects
irritable mood) refer to the domain of psychological factors of smoking are deadly. This is not because the act of smoking
affecting medical conditions (Fabbri, Fava, Sirri, & Wise, is inherently pathogenic, but because it repeatedly exposes
2007; Sirri & Fava, 2013). body tissues to tar and nicotine, which are known causes of
Imagine a 55-year-old woman, Cindy, who has recently disease. There are many other examples of behaviours that
suffered a myocardial infarction (heart attack) resulting promote disease by exposing body tissue to pathogenic sub-
from underlying atherosclerosis. She is a partner in a law stances. Conversely, there are also behaviours that have ben-
firm and has a recent history of uncontrollable and rumi- eficial effects, for example, exercise.
native worry, sleep loss, fatigue, and restlessness, meeting Pathological influences on body tissues can also be
the criteria for generalized anxiety disorder. In the past a consequence of psychological processes. A host of such
year, these symptoms have diminished her job performance, influences have been postulated, ranging from percep-
leading to considerable conflict with her firm’s other part- tual schemata (the ways in which people characteristically
ners. The symptoms of chest pain and shortness of breath interpret experience) to emotions (Hereafter, we will use
that indicated the onset of her heart attack occurred right the term psychosocial variables to refer to this broad class of
after a partners’ meeting in which she had had to defend influences). How could such influences affect body tissue?
herself against other partners’ criticisms of her handling of Three body systems are responsive to psychosocial vari-
her caseload. Under DSM-5, Cindy would qualify for the ables: the endocrine system, the autonomic nervous system,
diagnosis of a psychological factor affecting another medical and the immune system. Although we will discuss them sep-
condition, the other condition being myocardial infarction, arately, all three interact with the brain and with each other.

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 Psychological Factors Affecting Medical Conditions 149

Female Pineal gland

Hypothalamus

Pituitary gland

Parathyroid glands
Male
Thyroidglands

Thymus

Adrenal glands

Encyclopaedia Britannica/UIG/REX/Shutterstock
Pancreas

Kidneys

Testes

Ovaries

FIGURE 7.1 The Endocrine System

THE ENDOCRINE SYSTEM Hypothalamus

The endocrine system consists of organs that manufacture

hormones and, when the occasion is right, secrete them into
the bloodstream. Hormones are biologically active sub-
stances that circulate in the blood until they reach a “target”
organ such as the heart, the liver, or the bones, where they
will cause certain changes. Figure 7.1 displays some of the
endocrine organs in the human body.
Several endocrine organs are known to be highly Anterior
pituitary
responsive to psychosocial variables. Perhaps the best known Thyroid
is the hypothalamic-pituitary-adrenal (HPA) axis (an axis is
Gonad
a system of several organs that act together in a cascade of
effects). This system, depicted in Figure 7.2, begins with the
hypothalamus, a brain structure that controls a large number
of body functions and is responsive to psychosocial influ- Adrenal cortex
ences. When activated it can cause the pituitary gland, with
which it is connected by nerve fibres, to secrete a substance
called adrenocorticotropic hormone (ACTH) into the cir-
Alila/123RF

culation. The targets for ACTH are the cells in the adrenal
cortex, the outer layer of the adrenal glands, located above
the kidneys. When these tissues are stimulated they secrete
a well-known “stress” hormone, the glucocorticoid cortisol, FIGURE 7.2 The HPA Axis

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 150 Chapter 7

into the circulation. Cortisol is a highly active hormone that aroused, it tends to produce changes that prepare the body
produces a variety of effects. It suppresses inflammation, for vigorous action, such as increased blood pressure, heart
mobilizes glucose from the liver, increases cardiovascular rate, and perspiration and decreased digestive activity. Many
tone, produces immune system changes, and inhibits other of the effects of the sympathetic system would be danger-
endocrine structures (Herman, Prewitt, & Cullinan, 1996). ous if they were prolonged. For example, sustained increases
These features of glucocorticoid response are a defence in blood pressure could damage brain or vascular tissues.
mechanism. In the short term they promote immediate sur- The parasympathetic branch can “apply the brakes” to such
vival and inhibit unnecessary activity. However, they are changes to return the body to a more quiescent state that is
maladaptive when prolonged or exaggerated. In particular, within the body’s tolerance. This is somewhat of an oversim-
there is evidence that glucocorticoids suppress immune plification, however, as many of the daily changes in physi-
system function, enhance the development of atheroscle- ological processes may result from an increase or decrease
rosis (discussed later), and contribute to neuronal damage in parasympathetic or sympathetic arousal. For example,
in the brain (Becker, Breedlove, Crews, & McCarthy, 2002; momentary fluctuations in heart rate are often due to either
Chrousos & Kino, 2007; Miller, Chen, & Zhou, 2007) in a decreased parasympathetic (resulting in increased heart
way that may contribute to the intellectual decline associ- rate) or increased parasympathetic (resulting in decreased
ated with dementia. It is also increasingly recognized that heart rate) influences on the sino-atrial node of the heart.
cortisol released during stress plays an important role in the Similarly, increased and decreased myocardial contrac-
development of abdominal obesity, a major risk factor for tility (changes in the ability to produce force during the
cardiovascular disease (see below). Fat cells in the abdomi- contraction of the heart) are associated with increased and
nal region have a high concentration of receptors for glu- decreased sympathetic nervous system activation of the left
cocorticoids. When activated by glucocorticoid release, this ventricle of the heart. The level of activity of such systems is
has the effect, among other things, of activating enzymes determined by the relative balance of input from the sympa-
that increase the storage of fat within these cells (Bjorntorp, thetic and parasympathetic systems.
2001). Complicating the matter, cortisol also plays a role in In comparison to endocrine effects, which rely on the
increasing the production of fat cells (Warne & Dallman, bloodstream to convey hormones to target organs, ANS
2007). These and other known effects of cortisol release effects are rapid because they are based on the speed of
implicate the HPA axis in a wide variety of disease states. nervous conduction. The sympathetic system itself, how-
ever, is part of a second endocrine subsystem whose effects
involve release of hormones into the bloodstream: the
THE AUTONOMIC NERVOUS SYSTEM sympathetic-adrenal medullary (SAM) axis. Nerve fibres from
The second major body system that is responsive to psycho- the sympathetic system stimulate the cells of the inner
social influences is the autonomic nervous system (ANS; see region of the adrenal gland, the adrenal medulla, to secrete
Chapter 2). Most people have found themselves perspir- the hormones epinephrine and norepinephrine (also known
ing before some important event like an examination, or as adrenalin and noradrenalin). These belong to a broader
blushing after doing something embarrassing. Most people class of hormones known as catecholamines. When they
are also aware of body changes that take place during other are released into the bloodstream, epinephrine and norepi-
emotional states: the heart pounding, butterflies in the stom- nephrine circulate to a variety of target organs where they
ach, dryness in the mouth, and so on. Many of these immedi- can have powerful effects. Most of us are aware of these: we
ate changes result from the activity of the ANS. The term refer to exciting events as producing an “adrenalin rush” and
autonomic comes from the same root as “autonomous,” and describe risk-takers as “adrenalin junkies.” Such descriptions
reflects the belief that this system operates outside of con- convey the idea that catecholamines increase energy and
sciousness and control. Although this is not totally correct, activate the body. Notice that the effects are complementary
ordinarily it is true that we have little awareness or direct to the direct effects of the sympathetic system.
control of the ANS. Refer back to Figure 2.2 on page 31 for
a diagram of the main structures in this system. As described
in Chapter 2, the ANS consists of two anatomically distinct THE IMMUNE SYSTEM
parts. The sympathetic branch consists of nerve fibres that ema- A third mechanism that is responsive to psychosocial factors
nate from the thoracic and lumbar (or middle) regions of the is the immune system. The immune system comprises a net-
spinal cord and make contact with several organs: the heart, work of cells and organs that defends the body against exter-
the stomach, blood vessels, and so on. Notice, however, that nal, disease-causing forces (e.g., bacteria, viruses, fungi) or
most organs that are innervated by the sympathetic system internal pathogens (e.g., cancerous cells) known as antigens.
are also innervated by the parasympathetic branch, whose fibres The immune system performs this function through the com-
emanate from the cranial and sacral (or end) regions of the plex actions of a variety of white blood cells (Guyton, 1991).
spinal cord. Immune cells are produced and stored in several organs,
For many of the organs that are innervated by both, including the thymus gland, the lymph nodes, the bone mar-
the sympathetic and parasympathetic systems tend to act row, and the small intestines. They exert their effects as they
as accelerator and brakes. When the sympathetic system is circulate in the bloodstream. As shown in Figure 7.3, there are

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 Psychological Factors Affecting Medical Conditions 151

Cell-Mediated
Immunity
Thymus
gland T
T-cell
T K

Killer
lymphocytes T-cells

T M

Memory
T-cells

Present
invaders
T D
H

Delayed
Lymphokines

P
Bone Nonspecific to T- and hypersensitivity
marrow Immunity B-cells T-cells
cells

Regulate
Granulocytes and
monocytes T H

Helper
T-cells

T S

Regulate
Suppressor
T-cells

Antibody-Mediated
“Humoral” Immunity
Bursa-like
structure BB-cell
Plasma
cells A
Antibodies
lymphocytes (IgG, IgM, IgA,
IgD, IgE)

BM

Memory
B-cells
FIGURE 7.3 The Immune System
Source: Sarafino, E. P. (1997). Reprinted with permission of John Wiley & Sons, Inc.

three general categories of immune response, nonspecific, cellu- of other types of T-cells. One group of these, the so-called
lar, and humoral, each of which depends on different cell types killer (K) T-cells, attack foreign or mutated cells directly. Sup-
and courses of action. In nonspecific immune responses, pressor T-cells inhibit the actions of both the helper cells and
circulating white cells, called granulocytes and monocytes, the natural killer cells, thereby providing a negative feed-
identify invading antigens (an antigen is a substance that is back mechanism to control the immune episode and prevent
recognized as foreign to the body) and destroy them by a it from continuing indefinitely. In the course of an immune
process of engulfing and digesting called phagocytosis. Cel- episode, certain T-cells become permanently altered and are
lular immunity is based on the action of a class of blood cells transformed into memory T-cells, which are stored in the body
called T-lymphocytes. The “T” designation refers to their in anticipation of the next time it needs to counter the same
site of production, the thymus gland. Cellular immunity threat. This process is responsible for our “building up immu-
results from a complex cascade of actions of various types of nity” to certain kinds of microbes. In this way, we may become
T-lymphocytes. In an initial episode of invasion by a foreign sick with a particular disease, such as chicken pox, only once.
substance, an antigen is presented to T-lymphocytes by other And, of course, it is this process that is taken advantage of
cells, called macrophages (the antigen is recognized as such when people are vaccinated against infectious diseases.
by biochemical markers on its cell surface). This causes the In humoral immunity, invading antigens are also pre-
T-cells to proliferate (reproduce) and then circulate in the sented by macrophages to B-lymphocytes (“B” stands for
body. Several other types of T-cells participate in an immune bursa, an organ in which such cells are produced in birds; in
episode. Helper T-cells secrete substances called lymphokines humans they come from the liver and bone marrow; Guyton,
(e.g., the interleukins, interferon) that control the responses 1991). This causes the B-cells to reproduce, a process that is

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 152 Chapter 7

reinforced by lymphokine secretion from the helper T-cells.

Some of the activated B-cells remain as memory B-cells. Others
The Psychology of Stress
go on to be plasma cells, secreting antibodies called immuno- The mechanisms identified thus far help us to understand
globulins that neutralize antigens by clumping, rupturing, or some of the physiological processes that can mediate dis-
presenting them to phagocytic cells. ease. But how might they be activated by psychological
In the 1980s, scientists became aware that the immune influences? The study of psychological stress has provided
system responds to psychosocial influences, giving rise to the answers.
new field of psychoneuroimmunology, the study of mind– Stress has become one of the most pervasive ideas in
brain–immune system interactions (Ader, Felten, & Cohen, psychology. Most of us implicitly understand the term. As
2001; Kendall-Tackett, 2010). For example, exposure of people you are reading this text, you may be cramming for final
to acute stressors, such as making them perform an extempora- exams, the outcome of which may have an important influ-
neous speech, consistently produces changes such as increased ence on the rest of your life. If so, you know something about
numbers of natural killer and suppressor T-cells and reduced stress. As discussed in Chapter 5, post-traumatic stress dis-
T-cell proliferation (Cohen & Herbert, 1996). Cohen and order can result from extreme stress; depression may also
colleagues (1992) studied immune function in Cynomolgus sometimes be caused or exacerbated by events that most
(macaque) monkeys exposed to stable or unstable social condi- of us would call stressful (see Chapters 8 and 16). In the
tions. Blood samples taken from animals exposed to social dis- case that opened this chapter, one of the salient features of
ruption (by changing the monkeys in the experimental colony George’s life was that he was constantly “on edge,” largely
every month) showed impairment of the ability of T-cells to because of his own attributes.
proliferate, indicating a suppression of immune system func- How can we understand the impact of stress on health?
tioning. Interestingly, impaired immune functioning was most The term stress has been used to refer to (1) a stimulus, or a
pronounced in animals that showed less affiliative behaviour, property of the external world, (2) a response; or (3) to a trans-
such as contacting or grooming other animals, suggesting that action that mediates stimulus and response.
such social behaviours have important stress-modifying effects. The earliest views on stress emphasized its role as a
There have been many demonstrations of similar effects response, particularly as a set of physiological changes.
of psychological conditions in humans (Herbert & Cohen, Eminent University of Montreal physiologist Hans Selye
1993). For example, Zakowski, McAllister, Deal, and Baum (1956) was the father of the stress concept. His theory
(1992) exposed healthy people to either an emotionally neu- emerged from early studies of the effects of an ovarian
tral film (of African landscapes) or a film depicting unpleas- extract in rats. He noticed, at first, that animals treated
ant surgical procedures such as amputation. They collected with regular injections of an extract showed characteris-
blood samples periodically during exposure to and recovery tic changes: enlarged adrenal glands, degenerated immune
from the stressor. The ability of lymphocytes taken from system organs, and ulcers in their stomach linings. To his
the blood samples to proliferate in response to an immune surprise, however, rats injected with a simple saline solu-
challenge was measured. The results indicated a decrease tion showed the same changes! Legend has it that Selye was
in proliferation of the lymphocytes taken from participants a bit of a klutz at injecting rats, and his clumsiness caused
shown the gruesome film, compared with an increase among the observed reactions. To his credit, he realized that the
participants shown the neutral film (see Focus box 7.1 for critical determinant of the effects he observed must have
a discussion of the effects of marital conflict on immunity). been something common to both conditions, namely change,
Cohen and Herbert (1996) have described three path- unpleasantness, and a need to adapt. Later experiments con-
ways through which psychosocial variables can influence firmed that physiological changes could be produced by a
immune activity: (1) by the direct action of the central ner- wide variety of conditions involving both physical and psy-
vous system on organs and structures of the immune system, chological challenges. Integrating the results of many exper-
(2) as a secondary consequence of the hormonal changes iments and observations, Selye proposed that they reflected
discussed above, and (3) by changes in behaviour (e.g., poor a common underlying process, which he called stress.
dietary habits) that reflect personal characteristics or adap- Selye proposed that stress was a consequence of adap-
tations to changing life conditions. tation to demands placed on the body and argued that
it followed a natural trajectory. In the first phase, alarm,
the body mobilizes its defences. If the challenge persists,
BEFORE MOVING ON the body then enters the resistance phase, during which
The bodily changes mediated by the endocrine, autonomic,
it actively copes with the challenge through immune and
and immune systems are the products of evolution. Evolved neuroendocrine changes. In the short term, these adaptive
characteristics are generally adaptive—they contribute to responses enhance the body’s ability to ward off threats. If
survival of the individual and reproductive advantage. How- the challenge persists, however, exhaustion follows: energy
ever a process that contributes to the development of early is depleted and resistance can no longer be maintained. At
disease and death could hardly support either advantage. this point, the characteristic tissue changes described above
How could the responses produced by neuroendocrine, auto- occur and the organism may succumb to a disease of adapta-
nomic, or immune systems be both adaptive and pathogenic? tion, such as an ulcer. This general adaptation syndrome

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 Psychological Factors Affecting Medical Conditions 153

Putting It All Together:

FOCUS Stress, Marriage, Physiological Changes, and Health
7.1 Advances in research and technology have made it pos- participants’ knowledge. The samples were stored and then
sible to study the effects of stress in realistic human tested for a variety of pituitary and adrenal hormones. The
contexts. One of the most interesting examples is the study findings revealed interesting changes associated with the
of stress and physiology in the context of marital relationships. behaviours displayed by the participants during the conflict
Marriage is obviously one of the most important of human rela- interviews. Some couples engaged in high levels of hostile
tionships. It is entered into by a majority of people, it is a source behaviour during the interviews, such as criticizing, inter-
of great pleasure for many, but it can also be a source of pro- rupting, and disapproving; others did not. Among couples
found emotional distress. Virtually all marriages have points of who displayed these high rates of hostile behaviour, epineph-
tension; and issues of dominance, control, and social status. This rine, norepinephrine, and ACTH levels tended to be elevated
has led investigators to study what happens psychologically and during conflict or to remain high after conflict; in contrast,
physiologically to couples during difficult marital situations. To do changes indicative of less arousal or enhanced recovery char-
this kind of research, investigators identify couples who are will- acterized the couples who displayed lower levels of hostility.
ing to participate in controlled observations in a laboratory. Typi- The researchers suggested that this profile of changes is con-
cally, they are asked to discuss specific topics for a designated sistent with downregulation, or reduced effectiveness, of the
period of time. Of greatest interest is what happens during con- immune system, which may play a role in long-term health
flict, so the researchers must find a way of inducing it. To do so, consequences. More recently, Kiecolt-Glaser and colleagues
the couple may be interviewed or given questionnaires to identify (2005) showed that the expression of hostility in marital inter-
areas of disagreement (e.g., finances, friendships). These points actions was associated with slower wound healing and a profile
of disagreement then become the focus of discussion during the of inflammatory cytokine release that is known to promote a
experiments. To evaluate the emotional tone of the discussions, variety of age-related chronic conditions, including cardiovas-
participants are videotaped and the tapes are coded for different cular disease, diabetes, and some cancers.
types of emotional behaviour. These studies demonstrate the value of investigating mean-
Malarkey, Kiecolt-Glaser, Pearl, and Glaser (1994) stud- ingful interpersonal relationships using rigorous observational
ied 90 newlywed couples in this manner. Participants were and biological methods. Clearly, specific behavioural processes
admitted to a hospital research unit for a 24-hour period. that occur during marital conflict are associated with a range
Husband and wife had catheters implanted in their arms. of biological consequences. Although the studies by themselves
The catheters were connected to plastic tubing that allowed do not establish etiology, they do add detailed knowledge that
nurses to draw samples of blood periodically without the advances our understanding of disease mechanisms. ●

(GAS) was the first formal description and definition of a process of psychophysical scaling (marriage served as the
stress. Note that, according to this model, stress is inferred standard against which all other changes were assessed and
from a set of bodily changes; that is, it is defined by a was assigned an arbitrary change value of 50). Implicit in this
response. Note, as well, that by this definition any event that approach is the idea that stress is a property of the environ-
can bring about the characteristic set of changes is a stressor. ment—that is, a stimulus.
This implication of the “stress as response” perspective has Scores of studies have shown that experiencing such
been controversial. events increases the likelihood of psychological disor-
Others have taken the position that stress may be ders and physical diseases (Holmes & Masuda, 1974).
viewed as a kind of stimulus. Even in the GAS model, it Nevertheless, the approach has also been sharply criticized.
is implicit that some event must take place to set off adap- One criticism is that there is tremendous variability in the
tation effects. Perhaps it would be helpful to character- outcomes of studies examining prospective associations
ize those events, or their psychological consequences, as between life event stress and health outcomes, with a sizable
stress. In another well-known line of research, investigators minority demonstrating no clear association. Another con-
have attempted to characterize the stimuli that elicit stress cern is that major events are not representative of the com-
through identifying more or less universally challenging mon sources of stress in our lives. Kanner, Coyne, Schaefer,
events. The earliest and most famous of these attempts was and Lazarus (1981) suggested that people’s day-to-day lives
the Social Readjustment Rating Scale by Holmes and Rahe are more affected by smaller events, or “hassles,” such as
(1967). These investigators developed a list of life events that troubling thoughts about the future, too many responsibili-
required change. These events, such as death of a spouse, ties, or fear of rejection. They developed a scale to assess the
divorce, trouble with the law, all the way through to minor frequency of such events and how upsetting people found
inconveniences such as holiday stress and traffic infractions, them. There is some evidence that a measure of the intensity
were rated according to expert consensus of the relative of hassles predicts symptoms of physical illness (Weinberger,
degree of threat they entailed and assigned points through Hiner, & Tierney, 1987).

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 154 Chapter 7

Neither the stress-as-response nor the stress-as- to an end and the person continues to evaluate subsequent
stimulus approach has been embraced by contemporary events. If the individual concludes that there is an element
students. Defining stress by its physiological dimension of threat, secondary appraisals then take place, character-
forces us to consider very different processes as identical. For ized by the question: “Can I do anything?” The individual
example, your heart rate will increase if you are frightened may have a number of options available, such as seeking the
or if you walk up a flight of stairs. If we view stress only as a advice of a physician or trying to discern what will be on
set of physiological responses, we are at risk of glossing over the final examination. Such approaches have been termed
fundamental distinctions and of paying insufficient attention problem-focused coping because they attempt to identify and
to other determinants of physiological responses. Defining rectify the threat. Alternatively, the individual may focus on
stress as a stimulus is equally inadequate because people mollifying the bad feelings associated with the perception of
vary dramatically in what stimuli or events provoke physi- threat. Such emotion-focused coping might involve engaging in
ological arousal or subjective distress. For example, divorce diverting thoughts or activities or taking drugs to induce a
is probably a disturbing event for most people; yet for some different-feeling state. The individual will then evaluate the
it may be liberating. It is essential to take into account the effectiveness of such coping activities. If the individual con-
individual’s perspective when accounting for stress and its cludes that his or her coping is effective, stress will be min-
effects. imized. If not, the appraisal of threat will be reconfirmed.
This view, which has been articulated forcefully Thus, the transactional model views stress as emanating
by Richard Lazarus and his colleagues (e.g., Lazarus & from the balance between primary and secondary appraisals
Folkman, 1984), is called the transactional model of of threat and coping, respectively.
stress. It conceives of stress as a property of neither stimu- The transactional model is popular and has intuitive
lus nor response, but rather as an ongoing series of trans- appeal. However, we must ask how it helps account for the
actions between an individual and his or her environment. relation between psychosocial factors and bodily processes
Central to this formulation is the idea that people constantly that contribute to disease states. The first answer to this
evaluate what is happening to them. The eminent stress question is empirical. The transactional model grew out
researcher Robert Sapolsky (1994, pp. 1–2) provides the of evidence that the way a person perceives a potentially
following example: threatening event plays an important role in the physiologi-
cal response to it. In a series of classic studies, Lazarus and
It’s two o’clock in the morning and you’re lying in
colleagues demonstrated this by measuring autonomic reac-
bed. You have something immensely important and
tions to films that many people would find gruesome or
challenging to do the next day . . . You have to get
uncomfortable to watch. In one study, people watched a film
a decent night’s rest, but you’re still wide awake. . .
depicting a coming-of-age rite among Australian Aborigines
[S]omewhere around two-thirty, when you’re lying
(Speisman, Lazarus, Mordkoff, & Davidson, 1964). In this
there clammy and hyperventilating, an entirely
film, young males undergo a procedure called subincision,
new, disruptive chain of thoughts will no doubt
in which the underside of the penis is cut open in public
intrude. Suddenly, . . . you begin to contemplate that
and without pain relief. People who view this film often
nonspecific pain you’ve been having in your side,
show substantial autonomic arousal. However, people shown
that sense of exhaustion lately, that frequent head-
this film after instructions based on an “intellectualization”
ache. The realization hits you—I’m sick, fatally
(emphasizing the importance of the ritual in its cultural con-
sick! . . . When it’s two-thirty on those mornings, I
text and minimizing the discomfort of the ceremony) or a
always have a brain tumor. They’re very useful for
“denial” strategy (downplaying the pain) showed less arousal
that sort of terror, because you can attribute every
than people whose instructions accentuated the discom-
conceivable nonspecific symptom to a brain tumor
fort and risks of the ritual. Thus, the way that one appraises
and convince yourself it’s time to panic.
events can modify the physiological response to them. Such
In the transactional model, such evaluations are called findings have a direct implication for intervention: if one can
appraisals. Appraisals can take different forms, but one of manipulate the way people make stress-related appraisals,
the most critical is the appraisal of threat (see Chapter 5 for then presumably one can alter physiological responses to
a discussion of appraisal as an element in the development treat or prevent stress-related disease.
of anxiety). When faced with an event that may have adap- A second answer to the practical utility of the transac-
tational significance, such as the experience of symptoms of tional model is that it can help us organize the way we think
illness or a final examination worth half of your grade, it is about psychosocial influences on disease. Shortly, we will
as if the individual poses the following question: “Is this a review evidence that social conditions, personality charac-
threat to me?” (Note the italics. Lazarus’s view is that such teristics, emotions, and perceptions are associated with dis-
appraisals may occur quite unconsciously so that they can ease states. Many of these variables are thought to exert their
be described only metaphorically). This evaluative process effects through the processes proposed within the transac-
is called primary appraisal, and it sets the stage for further tional model. The model, then, encourages us to ask such
events that may or may not lead to stress. If the individual questions as “How would having a supportive social network
concludes that the event poses no threat, the process comes affect appraisal or coping processes?” or “What are the likely

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 Psychological Factors Affecting Medical Conditions 155

consequences of a particular coping process to a depressed a gradient of occupational and income status from cleri-
person?” An organizing model that guides thinking about cal workers at the bottom end to administrators at the top.
the processes elicited by potentially threatening conditions The study established the importance of social status as an
can be very valuable. influence on health and suggested that its effects are subtle
and pervasive. For one thing, 40- to 64-year-old men in the
lowest-status positions were between three and four times
Psychosocial Factors more likely to die in a 10-year period than men in the high-
est positions. This was not just a difference between the
That Influence Disease highest- and the lowest-status individuals; there was a gradi-
Beginning with Selye’s work, hundreds of studies of the ent to this effect that applied across the range of social status
effects of stress on bodily responses and health outcomes (see Figure 7.4). This observation is extremely important. It
have been done. For example, Boscarino (1997) studied implies that whatever is responsible for the differences var-
approximately 1400 Vietnam War–era United States Army ies quantitatively; there is no “threshold” below which one
veterans approximately 17 years after their service. Respon- observes high mortality and above which one observes low
dents were divided into those who had high and those who mortality. Moreover, as Evans (1994) has pointed out, none
had low levels of combat exposure. Veterans with high of the people in the Whitehall study would be considered
combat exposure had higher rates of circulatory, digestive, to be impoverished. Thus, something other than material
musculoskeletal, nervous system, respiratory, and infec- deprivation must be responsible for the differences. One
tious diseases over the follow-up interval than those with suggestion as to what that might be comes from Sapolsky’s
low combat exposure. These differences remained even (1995) studies of baboons.
after the influence of potentially confounding variables was In baboons, social status can be assessed by observ-
taken into account. In a more recent analysis of these veter- ing such things as which animals will defer to others when
ans, Boscarino (2008) showed that those who met the criteria competing for food, avoid eye contact, or make submissive
for post-traumatic stress disorder were more than twice as gestures. The physiological correlates of social status can
likely to have died from heart disease some three decades be studied by analyzing blood samples. Dominant and sub-
after their wartime experience. Exposure to combat is one missive baboons differ on a number of measures (Sapolsky,
of the most stressful experiences humans can undergo; con- 1989). Dominant males show reduced concentrations of
sequently, these findings provide strong evidence for long- cortisol, higher levels of high-density lipoprotein choles-
term effects of stress on a variety of health outcomes. The terol (the so-called good cholesterol that is associated with
effects can be quite complex, however, and other variables reduced risk of heart disease in humans), lower blood pres-
can play mediating roles. Of the mediating variables studied sure, and higher levels of circulating lymphocytes than sub-
to date, social status, controllability, and social support are missive baboons under resting conditions. In other words,
three of the most important. dominance is associated with changed neuroendocrine, auto-
nomic, and immune profiles. When stressed, for example in

SOCIAL STATUS
Social status refers to an individual’s relative position in
Administrative
a social hierarchy. Many human systems are organized 15
hierarchically—some people occupy high positions that Professional/executive
accord them status and power, others occupy low positions, Clerical
Ten-Year Mortality (%)

and most fall somewhere in between. Social status may be

Other
represented by economic status, occupational prestige, dom-
10
inance within a social group, or comparable variables. Dif-
ferences in social status are also observed in other species,
where they may be studied with respect to their implications
for human differences. Sapolsky (1990), for example, has
studied stress responses among baboons, a species organized 5
in distinct dominance hierarchies.
The influence of social status on health should come
as no surprise. Marmot and colleagues (Marmot, 1986;
Marmot, Kogevinas, & Elston, 1987; Marmot & Theorell,
0
1988) have reported on one of the most extensive studies to
All Causes Coronary Non-coronary
address this issue. The Whitehall study collected informa-
Heart Heart
tion on the habits and health of 10 000 British civil servants
Disease Disease
over approximately 20 years (Whitehall is the district in
London that houses the British government’s main offices). FIGURE 7.4 Mortality in Whitehall
Participants in the Whitehall study could be ordered along Source: Marmot & Mustard (1994, p. 206).

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 156 Chapter 7

40 Men Women
Many Many
Few Few
Andrew Macaskill/Wildlife Pictures Online

30

All cause deaths (%)

20

10
The big adult male is demonstrating his dominance. Baboons make
good subjects for the effects of status because their hierarchies
are clearly marked and fairly consistent. In this way, these animals
resemble members of highly structured human hierarchies, such as
feudal systems and the civil service. 0
30–49 50–59 60–69
a fight, dominant baboons show a larger response on many Ages at intake
of these parameters, but a faster return to resting conditions,
suggesting that they are better at recovering from provoca- FIGURE 7.5 Deaths from All Causes among Residents of
tion. There is a parallel between these findings and further Alameda County over Nine Years
observations that have been made of the Whitehall civil Participants who had many social connections were more likely to be
servants. Marmot and Theorell (1988) found that although alive at follow-up than participants who had few social connections.
all grades of civil servants showed elevated blood pressure Source: Based on Berkman, L. F., & Syme, S. L. (1979). Social networks, host resistance,
and mortality: A nine-year follow-up study of Alameda County residents. American Journal
during the workday, the blood pressures of administrators of Epidemiology, 109, 186–204.

dropped significantly more than that of lower-grade workers

when they went home. indicated that social support was associated with a 50 per-
Thus, social status may have an effect on longevity cent reduction in risk of mortality (Holt-Lunstad, Smith
through some of the stress-related physiological effects with & Layton, 2010). This effect was consistent across age, sex,
which it correlates. These effects, in turn, probably depend and initial health status, and was strongest among continu-
on other psychosocial factors. ous measures of complex social integration. The beneficial
effect of social support was comparable in magnitude to the
SOCIAL SUPPORT well-known harmful effect of smoking.
Although the effects of social support have been well
One psychosocial variable that has been consistently
documented, the reasons for these effects are unclear.
related to health status is social support: the extent to which
Certainly, one possibility is that social support may be
an individual feels connected to other people in meaning-
associated with material support in times of stress. Social
ful ways. It is usually assessed by asking people about the
support may also provide a means of discovering or testing
number of others with whom they have frequent contact,
coping strategies or a way of altering stress appraisals, as
whether there is anyone they feel comfortable confid-
suggested by the transactional model. For example, Shelley
ing in, and so on. The classic study of social support was
Taylor’s research (Taylor, 2006; Taylor et al., 2000) suggests
performed in Alameda County, California. Berkman and
that humans evolved affiliative neurocircuitry that activates
Syme (1979) investigated the health outcomes of some
during times of stress and prompts social-approach behav-
7000 residents, followed for nine years. At the beginning
iour as a coping mechanism. This has been termed the
of the study, participants responded to a questionnaire that
tend-and-befriend response to stress and is more common
assessed their social ties with other people by asking ques-
among females.
tions about marital status, interpersonal relationships, and
involvement in community organizations. At follow-up,
through an intensive process of investigating health records PERSONALITY
and death certificates, researchers discovered that there Personality represents a psychosocial variable associated
were significantly fewer deaths among people with many with the aetiology, development, and progression of medical
social affiliations—people who were highly “connected” conditions. Alexithymia is a personality characteristic origi-
with others—than among people with few connections nally introduced to describe a cognitive-affective pattern
(see Figure 7.5). Social support appears to be associated of behaviour frequently observed in patients with so-called
with effects on a remarkably wide range of health indica- psychosomatic disorders. The salient features of alexithymia
tors. A review of data from more than 300 000 individuals include: (1) difficulty identifying and describing subjective

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 Psychological Factors Affecting Medical Conditions 157

feelings, (2) difficulty distinguishing between feelings and

bodily sensations of emotional arousal, (3) constricted ima-
Disease States and Psychosocial
ginal capacities, and (4) externally oriented cognitive style Factors
(Taylor et al., 2000). Alexithymia has been linked to an
increased risk and a worsened prognosis of several medi- Psychosocial factors have been considered as possible con-
cal conditions, including cardiovascular disease, cancer, and tributors to many diseases. To illustrate the range of such
gastrointestinal disorders (De Vries et al., 2012; Lumley, contributions and the nature of thinking in this field, we
Neely, & Burger, 2007; Porcelli et al., 2003; Tolmunen et al., will focus on three disease states: infectious disease, gastric
2010). Type A personality is another psychosocial factor that ulcers, and cardiovascular disease.
affects medical conditions. We will return to some of these
issues elsewhere in this chapter. For now it is time to turn to INFECTIOUS DISEASE
some specific disease states.
Case Notes
BEFORE MOVING ON
Sarah is a student in her first year of medical school. It is
It is almost impossible to follow health stories in the media her fifth year at university. She is a competitive athlete, in
without coming upon an article or report of a study that sug- very good health, and careful to watch her diet. She had
gests that stress is a causal factor for some disorder or other. just finished a gruelling set of exams and was on an air-
Reports of this nature seem to surface almost monthly. This
plane flying home for Christmas break when she noticed
raises the question of whether the role of stress in health and
the first symptoms of what she recognized as the flu. By
illness may be oversold. When a concept becomes so perva-
sive and all-encompassing, many scientists become skeptical the start of the next day, she was experiencing full-blown
about whether it has any meaning at all. Do you think the symptoms: high temperature, aches and pains, a deep
stress concept has been oversold? In what areas do you think cough, and a runny nose. Sarah, who is not used to being
it has value, and in what areas might it be useless? What sick, was amazed by the intensity of her bout with the flu.
kinds of evidence do you think it is important to be able to She totally lacked energy and was barely able to make it
see before we conclude that stress plays a role in the onset or out of bed on Christmas morning. Eventually, her symp-
development of a disorder? toms improved, but there were residual effects when she
returned to university after the break.

Although we all know that they are caused by infection,

many people attribute infectious diseases like colds or the
flu to the stresses and strains of daily life. Furthermore, the
symptoms of some infectious diseases, like genital herpes,
often seem to be exacerbated (made worse or made to flare
up) during periods of emotional turmoil. What is the evi-
dence that such casual observations may be valid?
Several studies have examined whether stressful life
conditions predict or increase the likelihood of infec-
tious diseases (Cohen & Herbert, 1996). In one of the
most intriguing, Cohen, Tyrrell, and Smith (1993) exposed
healthy individuals to nasal drops containing respiratory
viruses or uninfected saline. Participants were quarantined
for seven days after experimental exposure, and during this
time indicators of infection were measured, including sever-
ity of cold symptoms, immune system markers of infec-
tion taken from nasal fluids, and measurements of mucous
nasal tissue (using the weight of used facial tissues!). Prior
to the study, participants were assessed with respect to the
Age fotostock/Superstock

number of stressful life events that had occurred to them in

the previous 12 months, the perceived stressfulness of their
lives, and current negative emotions. Those with higher per-
ceived stress and negative affect (the tendency to experience
unpleasant emotions) were indeed more likely to have clini-
Employees with high-demand jobs and unpredictable, berating
cal evidence of a cold and to show “hard” immune system
bosses are prone to miss work due to illness. changes indicative of infection than were subjects with lower

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 158 Chapter 7

stress. The underlying mechanism by which psychological

stress might increase susceptibility to infection is unknown, Jack did not get that option. The morning before they
but may reflect the functioning of the HPA axis. were due back, Jack and his wife set out to drive home,
In a more detailed study of the contribution of stress but had to pull the car over after about an hour because
to infectious diseases (Cohen et al., 1998), volunteers were Jack was experiencing extreme pain and vomiting blood.
infected with rhinovirus (“common cold”) drops and then He was taken to the nearest hospital, diagnosed with
followed to determine whether they became symptomatic. In a perforated ulcer, and told he was lucky to be alive.
addition, they underwent an extensive interview about their Although he recovered well following hospitalization
experience with life stressors in the last year. Participants and changes to his diet, Jack’s marriage did not thrive.
who had experienced distinct stressors lasting one month or He and his wife divorced after a few years. He would
more had a higher likelihood of developing a cold than those later confide that the months and weeks leading up to
whose stressors lasted less than a month. Long-standing dif- the wedding were full of conflict for him due to, among
ficulties associated with work (particularly unemployment other things, his ambivalence about getting married. He
or underemployment) and with interpersonal relationships directly attributed the cause of his ulcer to his psycho-
(such as marital difficulties or grudges) were the main stress- logical condition at the time.
ors that predicted cold symptoms.
There have been several studies of psychological influ-
ences on diseases mediated by the herpes viruses, such as If you were asked to name a disease-state affected by emo-
genital herpes, cold sores, and mononucleosis (Chida & Mao, tion, there is a good chance that ulcers would come to mind.
2009). Once introduced, herpes infections remain in the body The association has been long established in the public con-
in a latent state, manifesting clinical disease only occasion- sciousness, perhaps because we are very aware of the influence
ally. Hoon and colleagues (1991) studied herpes symptoms in of emotional states on the gut. Most of us have experienced
college students and reported that symptom recurrence was discomfort in the stomach during emotionally charged times,
associated with variations in psychological stress. so it is not difficult to believe that emotional distress may lead
It is natural to suspect that such stress effects on infec- to disease of the gut. Good-quality statistics on ulcers are dif-
tious diseases must be mediated by influences of stress on the ficult to obtain. However, a survey of a broadly representative
immune system. For example, Glaser and colleagues (1994) sample of 1036 Canadian adults suggested that approximately
measured the presence of antibodies to Epstein-Barr virus dur- 1 percent of the population experienced ulcer-like symptoms
ing a baseline period and during fall and spring examinations in the preceding year (Tougas, Chen, Hwang, Liu, & Eggleston,
among medical students known to be infected. Both examina- 1999). Indeed, the ulcer was one of Franz Alexander’s “clas-
tion periods were associated with increases in antibodies to the sic” psychosomatic disorders. As we shall see, there is some
virus, indicating its reactivation. However, we still lack clear truth to these preconceptions. However, ulcers also illustrate
understanding of the immune mechanisms responsible. the complexity of disease processes, because it is now gener-
ally accepted that they have a bacteriological cause. We are left
ULCER with the need to sort out the implications for understanding
the role of psychosocial determinants of ulcer disease.
First of all, what is an ulcer? A gastric ulcer is an erosion
Case Notes of the lining of the stomach or duodenum. Ulcers can be
life-threatening when they perforate, but even when they do
not they can produce excruciating pain. The events leading
One Sunday morning, Jack awakened with a peculiar
to an ulcer are thought to involve an interaction between the
burning sensation in his stomach. He didn’t think much
stomach’s own digestive juices and its natural defence mech-
of it and attributed it to having overdone things the night
anisms. The digestive juices, one of which is hydrochloric
before. He skipped breakfast, as he was inclined to do,
acid, are produced and secreted in the stomach in order
and spent a typical Sunday morning watching football.
to digest food. They are highly corrosive to living tissue,
The aching increased to such a point that the normally
including the stomach itself, which is normally protected by
stoic Jack began complaining to his family. After a late
a mucosal lining. Ulcers occur when the digestive fluids pen-
lunch, it got better. Throughout the next two weeks, the
etrate the lining, thus leaving the stomach, or duodenal wall,
burning pain returned periodically, but not every day, so
defenceless against their corrosive action.
Jack really did not think much was amiss. If he had, it
What role might psychosocial factors play in such
would not have made much difference, because Jack was
lesions? Here we are left to piece together lines of informa-
getting married that month and did not have time to think
tion from clinical observations, epidemiological studies, and
about it anyway. A few weeks later the wedding took place,
experiments in animals and humans. Clinicians have long
and Jack and his wife departed on their honeymoon.
observed that stressful life circumstances are associated with
Over the next two weeks, however, the stomach pains the development of ulcers in their patients. Alexander (1950)
grew worse, and Jack promised himself that he would argued that a very specific, though unconscious, psychologi-
see a doctor as soon as he got home. As it turned out, cal conflict involving an unsatisfied desire for love was the
main cause. This desire, symbolized by food, was thought to

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 Psychological Factors Affecting Medical Conditions 159

produce a state of chronic readiness to eat, which would lead human stressors, it has the advantage of reliability and gives
to breakdown of the stomach lining and consequent disease investigators the opportunity to investigate some of the
by continually stimulating the physiological accompaniments mechanisms that are responsible for ulcers.
of digestion. Appropriate treatment involved psychoanalysis Such research has indicated that various brain regions
geared toward uncovering the underlying conflict. There is lit- involved in the regulation of emotional states are crucial for
tle empirical support for this theory, and its influence is mostly the development of restraint-induced ulcers. Peter Henke of
of historical interest. However, other observations suggest psy- St. Francis Xavier University, for example, showed that direct
chological processes that may be more clearly involved. manipulation of the central nucleus of the amygdala by electri-
Several studies have reported associations between pro- cal stimulation increases gastric ulceration (Henke, 1988, 1992),
foundly stressful life conditions and ulcers (Levenstein, 2000). whereas other manipulations, such as electrical stimulation of
For example, during the German bombardment of London areas of the hippocampus that, in turn, affect the amygdala, are
in the Second World War, rates of hospitalization for perfo- associated with reductions in ulceration due to restraint stress
rated ulcers were observed to increase significantly (Spicer, (Henke, 1990). Such findings establish the importance of brain
Stewart, & Winser, 1944). Prospective epidemiological inves- regions in determining whether or not ulceration will occur
tigations have shown that there is a significant increase in risk during stress. Moreover, the particular brain regions impli-
of development of peptic ulcer associated with measures of cated are known to be key structures involved in emotional
life stress (Levenstein, 2000; Levenstein, Kaplan, & Smith, states. For example, LeDoux (2000) has shown that the amyg-
1995). For example, Levenstein and colleagues (Levenstein dala plays a critical role in the emotion of fear. The amygdala
et al., 2015) evaluated the association between life stress and is known to influence bodily responses to stress by activating
ulcers in a sample of 3379 Danish adults who were followed neurosecretory cells of the hypothalamus, thereby eliciting
for more than 10 years. Individuals who scored in the highest neuroendocrine and autonomic responses. For these reasons,
tertile for life stress were more than twice as likely to develop it seems very unlikely that the association of threat appraisal,
ulcers relative to individuals in the lowest tertile. Further, the gastric ulceration, and the amygdala is coincidental.
risk was independent of H. pylori infection, indicating a strong Perhaps the most elegant studies implicating psychologi-
psychosocial mechanism. cal factors in the development of ulcers were reported in the
There have also been advances in our understanding of late 1960s and early 1970s by Jay Weiss of Rockefeller Uni-
psychological aspects of ulcers, which follow from the under- versity. Weiss was interested in separating the physical and
standing that the brain is an important regulator of the stomach psychological aspects of stress. The stressor he employed
and gut through autonomic and neuroendocrine mechanisms was electric shock delivered to rats’ tails by an electrode. In
described earlier. We know, for example, that during stress- one study (Weiss, 1970), the shock was predicted by a warn-
induced sympathetic arousal, blood flow is diverted away from ing signal (a beeping tone). Another group was exposed to
the stomach lining to the skeletal muscles. It has been sug- both shocks and tones, but the events occurred at random so
gested that this may decrease the effectiveness of the mucosal that the tones did not reliably predict the shocks. Yet another
lining of the stomach in protecting it against digestive juices, group was exposed to identical environmental conditions, but
since blood vessels within that lining are thought to play a role no tones or shocks. Examinations of the stomachs of these
in the deactivation of gastric fluids (Pinel, 1997). animals indicated that the unshocked rats had very little
Hypersecretion of digestive acid appears to be an impor- stomach ulceration; rats that were exposed to shocks without
tant factor contributing to the development of ulcers. Stud- warning showed extensive stomach ulceration. The interest-
ies have shown that psychological distress is associated with ing finding was that rats that were shocked after a warning
increased secretion of gastric acids, and that patients with tone showed degrees of ulceration only slightly higher than
duodenal ulcers respond to laboratory stressors with greater the unshocked rats. Note that rats in the two shock conditions
quantities of acid secretion than healthy controls (Levenstein, received the identical number and intensity of shocks; the only
2000). Another factor is slow, rhythmic contractions of the factor that could have explained why one group had more
stomach that are different from the more frequent rhyth- lesions than the other was the predictability of the stressor.
mic contractions associated with the feeding cycle (Weiner, For decades, it was commonly accepted that ulcers
1996). When such contractions occur in rats, gastric erosions were often a consequence of stress. But in 1982, Australian
develop (Garrick et al., 1989). Although this association has physicians Barry Marshall and Robin Warren hypothesized
not been observed in humans, the animal observations make that ulcers were a consequence of a gut infection resulting
the argument for stress as a factor in ulcer disease more plau- from hardy, corkscrew-shaped bacterium called helicobacter
sible (see Focus box 7.2 for a discussion of causal inference). pylori (see Marshall, 2001). Desperate to prove this theory,
What is the evidence that stress can cause ulcers in ani- Marshal took some H. pylori from the gut of a person with
mals? Since Selye’s original observations, several methods ulcers and drank it! As the days passed, he developed gas-
have been used to demonstrate that manipulations of stress tritis, the precursor to an ulcer, proving that the bacterium
can produce ulcers. One common method is to restrain was an underlying cause of ulcers. It is now understood that
experimental animals by wrapping them tightly in a tube or H. pylori attacks the lining of the stomach, allowing acid
some other device. Restrained animals reliably show more through and leading to ulcers. It might be tempting, there-
gastric ulceration than do controls (Brodie, 1971). Although fore, to conclude that stress plays no role in ulcer formation,
this procedure does not provide a very realistic model of but the issue is probably more complicated. For example,

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 160 Chapter 7

FOCUS
Inferring Causality in Health Psychology
7.2 Is there a will to live? Does stress cause cancer? Does a of establishing precedence is the longitudinal study, in which a
particular kind of personality make one likely to become large group of people are evaluated for psychological or behav-
arthritic? While there is increasing acceptance of the con- ioural features and are then followed up, years or decades later,
tribution of psychological factors to illness and disease, many to determine whether they have developed a disease.
people, including health psychologists, continue to be skeptical. Several influential longitudinal studies have helped to
How do we begin to sort out reasonable answers to such questions? establish precedence for psychological variables. For example,
As explained in Chapter 4, the gold standard for establish- in the Harvard Mastery of Stress Study (Funkenstein, King,
ing causality is the experimental study in which an investigator & Drolette, 1957), students enrolled at Harvard University in
manipulates one possible causal variable while holding all other 1952, 1953, and 1954 underwent an extensive battery of
variables constant, and observes the effects on an outcome. In interviews, questionnaires, and psychological stress tests. Later
the health sciences it is often difficult, for practical or ethical investigations of the health status of these individuals indicated
reasons, to meet the strictures of the experimental method. The that participants who experienced high anxiety during psycho-
development of a disease such as rheumatoid arthritis, for exam- logical stress testing and participants who perceived their par-
ple, may occur over many years, and this is difficult to study in a ents to be uncaring were at substantially higher risk of a variety
laboratory. Similarly, it would obviously be unethical to conduct of illnesses 35 years later (Russek & Schwartz, 1997).
a study in which people were exposed to severe stress in order to The final criterion relates to the logic of explanation. There
establish the role of stress in disease. must be both a biologically and a psychologically plausible
Epidemiological and correlational research (discussed in mechanism linking a characteristic to the disease or illness
Chapter 4) can fill in some of the gaps. Hill (1965; see also outcome. Animal models or analogue studies are often used
Young, 1998) has outlined a number of criteria that may be to investigate possible mechanisms (American Psychosomatic
applied to evaluate whether a psychological variable plays a Society, 1996). For example, Anisman and his colleagues (Sklar
causal role. A basic criterion is association; the psychological & Anisman, 1979) at Carleton University have conducted stud-
variable is more likely to be present when the disease is pres- ies to clarify the processes by which stress might affect can-
ent than when the disease is not present. The case that there cer. To do this, they manipulated stressful experiences and
is a meaningful relationship is further supported by consistency observed their effects on growth of malignant tumours that they
across numerous studies and strength of association; that is, the had experimentally implanted in mice. Of course, the variables
variability in a psychological variable accounts for a great deal of manipulated in mice are not much like the stresses that humans
the variability in an outcome. Yet none of these criteria show that experience, and mice are not humans. We must be very careful
the relationship is one of cause and effect. The fourth criterion, when generalizing from one species to another. However, it may
precedence, requires evidence that the alleged cause existed be possible through such studies to illuminate the forces that
before the outcome developed. A common but expensive means affect human disease. ●

while it is estimated that most of the world’s population said that that role is exclusive. As Weiner (1996) has pointed
are infected with H. pylori, most of those infected will never out, antibodies to the bacterium have also been found in the
develops ulcers. This suggests the possibility of a more com- serum of healthy controls. According to Levenstein (2000),
plex association between bacterial infection and stress that only 20 percent of people who test positive for the bacterium
contributes to the ultimate expression of ulcers. show evidence of ulcer. Similarly, a review of 25 randomized
While studies of restraint and other forms of stress have controlled trials (n=5555) assessing the effect of H. pylori
helped to map the neural pathways that may be implicated eradication on the resolution of ulceration reported equivo-
in stress effects, there has been relatively little research in cal results (Du et al., 2016). Therefore, the mere presence of
recent years extending these concepts to ulcer disease in H. pylori is not sufficient to produce disease. The bacterium
humans. So far, our knowledge of stress and its psychosocial also appears in association with a number of other diseases,
determinants has had little effect on the treatment or pre- calling into question its specificity of action. Finally, patients
vention of ulcers. have been shown to improve even though the infection has
Considerable excitement was aroused in the medi- not been eliminated.
cal community by the discovery of a bacterium, Helicobacter The discovery of a bacterial agent is in no way inconsis-
pylori, now believed to play the primary role in the gene- tent with the findings that implicate psychological conditions.
sis of ulcers (Rathbone & Healey, 1989). The bacterium is As the diathesis-stress model emphasizes, psychological fac-
present in the stomachs of large proportions of individuals tors, such as stress, may lead a person to be more vulnerable
with ulcer disease and antibodies to it are present in their to the influence of a physical agent. Bosch and colleagues
serum. Moreover, treatment with drugs to eliminate H. pylori (2000) have provided evidence that psychological stress may
produces improvement in affected patients (Graham et al., play an important role in the effects of H. pylori itself. Saliva
1992). Does this discovery mean that stress is no longer rel- was collected from healthy young men before, during, and
evant to ulcer disease? Not at all. Although H. pylori plays an after they watched a video depicting bloody dental proce-
important role in the genesis of ulcer disease, it cannot be dures. The saliva samples were then purified in a laboratory

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 Psychological Factors Affecting Medical Conditions 161

APPLIED CLINICAL CASE

John Candy
John Candy was a Canadian success story. A member of the

Theo Westenberger/Paramount/Kobal/REX/Shutterstock
famous Second City comedy troupe, he was popular for his char-
acterizations of public and imaginary figures on the television
program SCTV. He parlayed his early successes into a career in
movies, appearing in such successful films as Stripes; Planes,
Trains and Automobiles; and Uncle Buck. On March 4, 1994, at
43 years of age, Candy died suddenly from a heart attack caused
by a coronary embolism. He was well known for being overweight.
A smoker, he also had a strong history of heart disease in his fam-
ily (his father died in his thirties from heart disease). Candy was
aware of his risk and had made attempts both to lower his weight
and to quit smoking. We will never know for certain whether other
psychological variables may have played a role in his death. What
is certain is that he lived a pressured lifestyle, and it is rumoured
that, at the time of his death, he was working hard to advance his
career after some critical disappointments.

dish and exposed to H. pylori. In this way, the researchers considered two sides of the same coin. Statistics for 2011
were able to determine the adhesion of H. pylori; that is, the indicate that, in Canada, 60 910 people died of heart dis-
effectiveness with which the bacterium establishes the first ease or stroke, accounting for 25 percent of deaths that year
stage in the process of infection. Adhesion of H. pylori more (Statistics Canada, 2014). Raw mortality, however, does not
than doubled in the saliva samples taken during stress expo- tell the whole story. Cardiovascular diseases are responsible
sure, thus suggesting that stressful conditions may play a for more potential years of life lost (PYLL)—a measure
role in the effectiveness of the microbe. More recently, Guo calculated by subtracting age of death from an individual’s
and colleagues (2009) have shown in mice that the stress of life expectancy—than any other cause except cancer and
observing another mouse in distress enhances the ability accidents. Cardiovascular disease also causes significant suf-
of H. pylori to colonize gastric tissue, probably through the fering and disability among survivors. Techniques for early
influence of glucocorticoid receptors. identification and treatment have increased the chances of
Based on the proportion of participants in well- survival, and advances in rehabilitation have also improved
controlled studies who provided no evidence of psycho- the prospects for recovery. Nevertheless, many people who
social vulnerability factors and evidence of the excess live with cardiovascular disease face diminished abilities,
of stressors among ulcer patients relative to controls, anxiety, and suffering, and their families must also adjust to
Levenstein (2000) has estimated that psychosocial variables the consequences of the disease.
are probably involved in 30 to 65 percent of cases. As dis- As a result of high rates of morbidity and mortality, car-
cussed in this and earlier chapters, interactions between diovascular disease has been the focus of intensive research,
mind and body are complex, and there is rarely one single and a great deal has been learned about it. This knowledge
factor that accounts for any condition. Thus, ulcer disease has paid off in a dramatic decline in death rates, which have
represents, in Levenstein’s (2000, p. 176) terms, “[t]he very dropped by almost 50 percent since the 1950s. As part of
model of a modern etiology.” this research, the behavioural and psychological processes
related to developing, triggering, and recovering from car-
diovascular disease have been well studied.
CARDIOVASCULAR DISEASE
Diseases of the vascular system—the heart and the blood CARDIOVASCULAR DISEASE PROCESSES To understand
vessels—are the leading causes of death and disability in how psychosocial variables may contribute to cardiovascular
Western societies. The two disease states that account for disease, you need a basic understanding of the disease pro-
most of these deaths are ischemic heart disease, in which cess. The cardiovascular system provides nutrients and oxy-
blood supply to the heart becomes compromised, lead- gen, the basic requirements for life, to all tissues of the body
ing to myocardial infarction (heart attack), and stroke, and serves as a highway for the elimination of waste products.
in which the blood supply to the brain is interrupted, lead- To do this, the heart acts as a pump, delivering blood, with its
ing to death of neural tissue. The disease processes under- various constituents—platelets, plasma, and so on—through
lying both end points are sufficiently similar that they are an extensive branching network of arteries, arterioles,

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 162 Chapter 7

capillaries, venules, and veins called the vasculature. The of the autonomic nervous system that one of its targets is
blood vessels consist of an opening, or lumen, and layers of the cardiovascular system. Sympathetic and parasympa-
cells that serve as the “tubing.” The control of blood supply thetic fibres can affect both cardiac output and peripheral
within this closed system is intricate. It is helpful to think resistance. Activation of the sympathetic system affecting
of a water pumping system, wherein the heart is the pump beta-adrenergic receptors on the heart will speed up its
and the vasculature is a hose. As the heart pumps, the blood rate, producing an increase in cardiac output and, con-
constituents are distributed through the tubing in cycles that sequently, in blood pressure. Activation of other compo-
correspond to the pumping action. The peak of the wave of nents of the sympathetic system affecting alpha-adrenergic
blood flow corresponds to the contraction of the left ventricle receptors can cause constriction of the blood vessels, again
of the heart. This is the main chamber that pumps blood into yielding an increase in blood pressure. Activity of the
the major arteries of the body at a point during the cardiac parasympathetic system opposes these effects. Complex
cycle that is called systole. However, when the pump is at rest, feedback mechanisms, involving blood pressure recep-
at a point in the cardiac cycle termed diastole, blood will still tors located in the carotid artery, allow the hypothalamus
be flowing, albeit at a much reduced pressure. The pressure to regulate blood pressure. In this way, the brain is always
of the blood flowing through the vasculature is commonly adjusting output and resistance to maintain blood pressure
measured in your doctor’s office with the use of a sphygmoma- within certain limits.
nometer (blood pressure cuff) and expressed in two numbers: Recall, as well, that the neuroendocrine system also
systolic blood pressure/diastolic blood pressure, in terms influences the cardiovascular system. In particular, release
of the number of millimetres of mercury (mm Hg) displaced of the catecholamines, epinephrine and norepinephrine,
by the measurement device (e.g., 120/70 mm Hg). from the adrenal medulla reinforces the changes produced
Persisting with the pump and hose analogy, we can see by sympathetic nervous system arousal, producing increased
that the pressure within the hose will be influenced by two heart rate, peripheral resistance, and blood pressure. In addi-
factors. The first is simply the amount of liquid being pushed tion to these effects, however, note that the catecholamines
into the hose with each beat of the pump; the more liquid, are distributed to the heart and vasculature by circulating
the greater the pressure, everything else being equal. Think through the bloodstream. Catecholamines can thereby not
of what happens with a garden hose when you turn the faucet only affect the ongoing activity of the heart and vasculature,
up to “full blast.” The more you open the faucet, the greater but also interact with blood constituents, such as the blood
the pressure and the farther the water will spray. The second cells, and the cells lining vessel walls. Thus, these two physi-
is the diameter of the tubing. What happens if you squeeze a ological systems, both of which are regulated by the brain
garden hose (see Figure 7.6)? The pressure of the fluid within and consequently responsive to psychological influences, are
increases and the spray will be longer. Much the same thing ideally located to exert an ongoing influence on the system
happens when the diameter of the blood vessels is narrowed. in which cardiovascular disease takes place.
Thus, blood pressure is a consequence of two major variables:
cardiac output (the amount of blood pumped by the heart) CARDIOVASCULAR RISK FACTORS Deaths due to myo-
and total peripheral resistance (the diameter of the blood cardial infarction can result from disturbances in the normal
vessels). Cardiac output is itself determined by two other pumping rhythm of the heart (arrhythmias) or from com-
variables: the rate at which the heart beats (commonly mea- promised supply of blood to the heart itself. These proximal
sured in beats per minute) and the amount of blood ejected causes of death, as well as stroke, are influenced primarily by
on each beat (stroke volume). an underlying disease state called atherosclerosis, a buildup
This excursion into the physiology of the cardiovas- of deposits, known as plaques, on the walls of the blood vessels
cular system is important because it allows us to begin to (see Figure 7.7). The growth of atherosclerotic plaques can
explain the mechanisms through which psychological fac-
tors can affect disease processes. Recall from our discussion
ATHEROSCLEROSIS

Normal artery Artery narrowed by plaque

HR (heart rate) × SV (stroke volume) = CO (cardiac output)

TPR (total
peripheral
resistance)
Roberto Biasini/123RF

Blood flow Atherosclerotic plaque

FIGURE 7.6 Plumbing Analogy for the Human
Cardiovascular System FIGURE 7.7 The Buildup of Atherosclerotic Plaque

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 Psychological Factors Affecting Medical Conditions 163

ultimately narrow the openings of arteries enough to com- increased for all four tasks, most dramatically during the
promise the blood supply to the heart or the brain, leading to anger interview. This study exemplifies a common method
myocardial infarction or stroke. for examining how psychological variables affect physiologi-
Atherosclerotic plaques are complex structures built up cal responses. Physiological functions such as heart rate or
from matter deposited on arterial linings over the course of a blood pressure are measured while people are exposed to an
lifetime: primarily lipids (blood fats, especially cholesterol), explicit, psychologically stressful provocation. Hundreds of
but also blood platelets and cell fibres. Autopsy studies have studies using this stress reactivity paradigm have shown
shown the development of atherosclerosis (atherogenesis) that many cardiovascular functions are responsive to chang-
as early as two years of age. Most people show signs of ath- ing psychological conditions.
erosclerosis by their thirties. These observations emphasize In 1984, David Krantz and Stephen Manuck formally
the long time frame over which the disease develops. Over hypothesized that the risk of cardiovascular disease increases
decades, subtle influences on the disease process can play with individual differences in cardiovascular reactivity;
an important role. On the other hand, the slow develop- that is, how much an individual’s cardiovascular function
ment of the disease process gives plenty of opportunity for changes in response to a psychologically significant stimulus.
prevention. The study of cardiovascular reactivity has provided some
But what do atherosclerotic plaques have to do with important insights. Commonly measured cardiovascular
behavioural or psychosocial variables? For one thing, indi- functions such as heart rate, blood pressure, and periph-
vidual health-related behaviours may contribute directly to eral resistance can be influenced readily by psychological
atherogenesis. Dietary factors, such as frequent consumption stressors (Turner, 1994), but so, too, can hormones like epi-
of fat and cholesterol, make lipids available for plaque for- nephrine, norepinephrine, and cortisol (Dimsdale & Ziegler,
mation. Smoking, too, is thought to play a role in athero- 1991; Kuhn, 1989). More subtle changes in the cardiovascu-
genesis. High blood cholesterol and cigarette smoking are lar system, such as the percentage of blood pumped by the
considered major modifiable risk factors for cardiovas- left ventricle during each beat (Ironson et al., 1992; Legault,
cular disease. Physical activity and exercise are protective Langer, Armstrong, & Freeman, 1995) and even abnormali-
factors that are thought to reduce risk of cardiovascular dis- ties in the motion of the heart’s chamber walls, can also be
ease, at least in part by preventing atherosclerotic buildup. produced by psychological stress (Rozanski et al., 1988).
Another potential source of atherogenesis lies in the effects Mills and Prkachin (1993), at the University of Waterloo,
of the ANS and endocrine regulatory mechanisms discussed even found that exposure to psychological stressors could
above. reverse the reduction in “stickiness” of blood platelets pro-
Blood pressure can vary substantially over the course duced by dietary supplements containing essential fatty
of a day. Large variations can cause turbulence in the blood acids.
vessels, particularly at points where they branch into smaller Manuck and colleagues (Manuck, Kaplan, Adams, &
vessels. This applies shear stress powerful enough to dam- Clarkson, 1989; Manuck, Kaplan, & Clarkson, 1983) have
age the cells of the vessel walls. According to one theory also provided experimental evidence that cardiovascular
of plaque formation, lipids, blood platelets, and other con- reactivity contributes to the development of atherosclerosis
stituents recruited to fix the walls become gathering spots in Cynomolgus monkeys raised in an experimental colony.
for other atherogenic material. Additionally, circulating cat- The monkeys were fed a high-cholesterol diet. Heart rate
echolamines may contribute to plaque formation by affect- was measured at rest and while the monkeys were threat-
ing the tendency of blood platelets to “stick” to one another. ened by a “monkey glove” that had previously been used
Yet another factor that contributes to risk of cardiovas- to capture them. At the end of each study, the researchers
cular disease is hypertension, a characteristically high level measured atherosclerotic deposits on the arteries supplying
of resting blood pressure (defined as a reading of more than the animals’ hearts. Monkeys that showed a higher increase
140/80 in a doctor’s office). Hypertension can result from a in heart rate in reaction to threat also showed significantly
variety of background causes, but in approximately 90 per- more atherosclerosis. In other work, Kaplan, Manuck, and
cent of cases it is “essential,” which means that a single cause colleagues have shown that socially disrupting primate colo-
cannot be identified. nies by repeatedly moving the monkeys between groups can
promote the development of atherosclerosis, even if the ani-
PSYCHOSOCIAL FACTORS IN CARDIOVASCULAR mals are not fed an atherogenic diet (Kaplan et al., 1983).
DISEASE The activity of the cardiovascular system is clearly David Spence and colleagues at the University of
and sometimes profoundly altered by psychosocial stim- Western Ontario found evidence that these findings gen-
uli. In one study, healthy young men were exposed to four eralize to humans. In a large sample of middle-aged men
standardized situations (Prkachin, Mills, Zwaal, & Husted, and women studied for several years, ultrasound imaging
2001). In one, they squeezed a hand dynamometer for five was used to measure plaque build up in the carotid arter-
minutes. In a second, they simply counted forward from the ies. The best predictor of worsening atherosclerosis over a
number “1.” In a third, they performed mental arithmetic, two-year period was the magnitude of systolic blood pres-
and in a fourth, they were interviewed about an event that sure increase during the Stroop colour–word conflict test,
had made them angry. Systolic and diastolic blood pressure in which participants must name the colour of ink in which

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 164 Chapter 7

a colour word is written (Barnett, Spence, Manuck, & Osler’s idea that the heart attack is associated with a
Jennings, 1997). Patients highly reactive to this particular particular type of personality remained dormant until it was
psychological stressor showed accelerated development of taken up in the mid-twentieth century by a pair of Ameri-
the disease process underlying heart attack and stroke. can cardiologists. Friedman and Rosenman (1959) hypoth-
Exaggerated cardiovascular reactivity likely results esized the existence of a pattern of behaviour that increases
in long-term erosive effects with the capacity to trigger risk of myocardial infarction and death. The pattern
acute cardiovascular events. Carroll and colleagues (2012) involved people who appeared to be “aggressively involved
examined the association between blood pressure reactiv- in a chronic . . . struggle to achieve more and more in less
ity in response to acute mental stress task and 16-year car- and less time, and if required to do so, against the oppos-
diovascular disease mortality among a sample of 431 men ing efforts of other things or other persons” (Friedman &
and women. Individuals scoring in the top quartile of blood Rosenman, 1974, p. 67). Friedman and Rosenman developed
pressure reactivity were more likely to die of cardiovascular an interview to identify people with this behaviour pattern,
disease over the subsequent 16 years of follow-up. This asso- which they termed Type A. This was an important advance
ciation was independent of age, sex, body-mass index (BMI), because it lent itself to systematic epidemiological investiga-
physical activity, long-standing chronic illness, and resting tions. In the landmark Western Collaborative Group Study,
blood pressure. Friedman, Rosenman, and others assessed the health and
The majority of research has investigated the phenom- health habits of more than 3000 people, who were fol-
enon of exaggerated cardiovascular reactivity with the pre- lowed systematically over the next eight and a half years
sumption that blunted reactivity (i.e., less change in heart (Rosenman et al., 1975). Mortality statistics revealed two
rate and blood pressure than would typically be expected important findings. First, people assessed as Type A were
during a given stressor) is benign or protective. Recent evi- approximately twice as likely to die from heart disease as
dence has challenged this presumption and indicated that people assessed as Type B (i.e., those who are more relaxed
blunted physiological reactivity is associated with a range of and calm). Second, the risk associated with Type A behav-
adverse behavioural and health outcomes, including depres- iour was independent of other risk factors for heart disease,
sion, obesity, addiction, smoking, and impulsivity (refer to such as smoking. This appeared to be the first clear identi-
Carroll et al., 2017, for a review). It is becoming increasing fication of a psychological characteristic that met conven-
clear that the association between health and cardiovascular tional criteria for designation as a “risk factor.”
reactivity forms an inverted U with blunted and exaggerated Not all studies, however, confirmed an association
reactivity being particularly problematic. between Type A behaviour and heart disease. Subsequent
The intensity of the response of the cardiovascular sys- evidence indicated that the risk exists in only some of
tem to stress is associated with cardiovascular disease, but so the components of the Type A pattern. Look at the vari-
is the extent to which elevations in blood pressure or heart ety of characteristics subsumed under the Type A label:
rate due to a stressor persists after the stressor is no longer hyperalertness, time urgency, job involvement, competitive-
present (i.e., cardiovascular recovery). A meta-analysis ness, and hostility. Do these components always go together?
of 41 studies evaluating cardiovascular responses to stress It is possible to imagine someone who is hyperalert but not
reported that delayed cardiovascular recovery (defined competitive, or time urgent but not hostile, isn’t it? Interest
as sustained cardiovascular activation above baseline lev- has shifted to identifying which components most directly
els during the post-stress recovery period) was associated affect risk of heart disease.
with an increase in risk for hypertension and cardiovascular Consistently, measures of hostility have been associ-
disease (Chida & Steptoe, 2010). It has been proposed that ated with symptoms of heart disease and death. Hecker,
delayed cardiovascular recovery may be sustained through Chesney, Black, and Frautschi (1988) reanalyzed data from
persistent activation of stress-related thoughts and emo- the Western Collaborative Group Study, including the Type
tions (Gerin et al., 2006). Research in our laboratory sup- A interviews, and determined that hostility was the main
ports this hypothesis, indicating that people who tend to characteristic accounting for increased risk of heart disease.
ruminate (i.e., experience repetitive and unwanted thoughts A number of studies using the Cook-Medley hostility scale
about the causes and consequences of stressful events) do (a questionnaire derived from the MMPI; Cook & Medley,
not adapt to a stressor that is repeated across multiple labo- 1954) have also documented this association. For example,
ratory testing sessions (Johnson et al., 2012). Barefoot and colleagues (1989) studied the health status of
118 lawyers who had been given the MMPI about 28 years
PSYCHOLOGICAL FACTORS IN CARDIOVASCULAR earlier when they were healthy young adults. High hostility
DISEASE The Canadian physician Sir William Osler, some- scores were associated with a significant increase in the like-
times referred to as the grandfather of behavioural medicine, lihood of death at follow-up.
was one of the earliest proponents of the modern era to draw Although not all studies have confirmed this associa-
attention to the association between styles of behaviour and tion, meta-analyses (e.g., Miller, Smith, Turner, Guijarro,
heart disease. He described the typical patient with atheroscle- & Hallet, 1996) support the conclusion that hostility and
rosis as a “ . . . keen and ambitious man, the indicator of whose related characteristics are a factor in cardiovascular morbid-
engine is always at ‘full speed ahead’” (Osler, 1910, p. 839). ity and mortality (Meta-analysis is a method of examining

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 Psychological Factors Affecting Medical Conditions 165

the findings of many studies as a whole. See Chapter 17 for

a fuller discussion).
Just what is this characteristic called hostility? The

Bruce Ayres/The Image Bank/Getty Images

words we use to describe psychological characteristics or
behaviours are imperfect and often fail to capture all their
nuances. In the case of hostility, the construct involves sev-
eral features. Barefoot (1992) emphasized three compo-
nents: affective features involving a tendency to respond to
situations with anger and contempt; a cognitive/attitudinal
dimension involving a tendency to view others with cyni-
cism and to impute bad intentions to them; and a behavioural
dimension involving direct and subtle aggressiveness and
antagonism. Consistent with this analysis, subscales of the
Cook-Medley scale measuring cynicism, hostile affect, and
According to recent studies, it is not this man’s stressful job and
aggressive responding predicted likelihood of early death in drive to get ahead that put him at risk so much as the hostility he
the study by Barefoot and colleagues (1989). is expressing.
How would hostility lead to health risk? What mecha-
nism would apply? In a comprehensive analysis, Timothy was poor. Both the psychosocial vulnerability and the trans-
Smith (1992) outlined five possible models: actional model derive support from studies showing that
Psychophysiological reactivity model: It suggests that hos- hostile people have fewer social supports and more stress-
tile people are at higher risk because they experience exag- ful life events than do non-hostile people (Hardy & Smith,
gerated autonomic and neuroendocrine responses during 1988; Smith & Frohm, 1985). Prkachin and Silverman (2002)
stress. provided support for the transactional model by showing
that hostile people are less likely than non-hostile people to
Psychosocial vulnerability model: It suggests that hostile engage in tension-defusing behaviour (e.g., social smiling)
people experience a more demanding interpersonal life than during stressful interactions. Finally, several studies have
do others. shown that hostile people smoke more, use alcohol more,
Transactional model: A hybrid of the first two models, pos- consume more calories, and engage in less exercise than
its that the behaviour of hostile individuals constructs, by non-hostile people (Smith, 1992).
its natural consequences, a social world that is antagonis- One relevant set of observations involves physiological
tic and unsupportive. Consequent interpersonal stress and response to anger. Studies have shown that recalled experi-
lack of social support increase the vulnerability of these ences of anger elicit distinct and powerful changes in the
people. cardiovascular system (Prkachin et al., 2001). Ironson and col-
leagues (1992) asked people to recall and describe an event
Health behaviour model: It suggests that hostile people that had made them angry, while measuring the proportion of
may be more likely to engage in unhealthy behaviours (e.g., blood ejected from the left ventricle by an imaging technique
smoking, drug use, high-fat diets) and less likely to engage in called radionuclide ventriculography. Decreased left ventricu-
healthy practices, such as exercise. lar ejection fraction (LVEF) is an indicator of compromised
A final theory: It is the link between hostility and poor cardiovascular function. LVEF decreased during anger recall
health outcomes is the result of a third variable, constitu- in coronary artery disease patients but not in healthy controls.
tional vulnerability, with which they are both associated. Evidence has increasingly emerged about the impor-
tance of another psychological characteristic—depression—
It is difficult to pick and choose among these alterna- in cardiovascular morbidity and mortality. Frasure-Smith,
tives because there is evidence to support each one. For Lesperance, and Talajic (1993), from McGill University,
example, several studies have supported the hypothesis studied more than 200 patients who had recently sur-
that hostile people show enhanced physiological arousal to vived a heart attack. When they had recovered sufficiently,
psychological stress. Interestingly, however, such responses patients were interviewed and categorized as depressed or
may occur only when the stressful conditions are relevant not according to modified DSM-III-R criteria. You might
to the hostility characteristic. For example, in one study wonder, wouldn’t anybody who has just had a heart attack
hostile participants differed from non-hostile participants be depressed? Indeed, sadness and worry are extremely
in their cardiovascular responses to a word-identification common in such circumstances, but people do vary in their
test only when they were also exposed to social harassment reactions. In this study, only 16 percent of patients met the
(Suarez & Williams, 1989). Prkachin, Mills, Kaufman, and DSM criteria for a major depressive disorder. The research-
Carew (1991) found that hostile participants showed a “slow ers followed up these patients six months later—an impor-
burn” effect. Unlike non-hostile people, their blood pressure tant milestone, because most deaths following a heart attack
increased gradually during a difficult computer task when occur within that time. Depression soon after the heart
they were led to believe erroneously that their performance attack was associated with a greater than fivefold increase

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 166 Chapter 7

in the risk of dying within six months, independent of other the heart associated with depression. Depression in cardiac
predictors such as disease severity and history of previous patients has been found to be associated with a number of
heart attack. Frasure-Smith and colleagues (1999) repeated changes in autonomic function, such as increased heart rate
this observation with a larger sample and a different method and decreased heart-rate variability that are themselves pre-
of assessing depression. They showed that the elevated risk dictors of complications of heart disease (Carney et al., 1995;
of mortality associated with depression was approximately Krittayaphong et al., 1997). Moreover, post-heart-attack
the same in men and women. patients whose depression responds favourably to drug ther-
In the years since the pioneering work of Frasure-Smith apy show increases, whereas patients whose depression does
and colleagues, many studies have investigated the rela- not respond favourably show decreases in heart-rate vari-
tionships among depression, heart disease, and death. ability (Khaykin et al., 1998).
Rugulies (2002) and Wulsin and Singal (2003) performed Greg Miller has provided evidence that depression may
meta-analyses of prospective studies of this relationship; affect the risk of heart disease and death through inflam-
that is, of studies that investigated the risk of developing matory mechanisms, which are increasingly understood as
heart disease among people who showed previous evidence fundamental contributors to atherogenesis (Libby, 2002).
of depression. These studies indicate that depression is In one study (Miller, Stetler, Carney, Freedland, & Banks,
associated with an approximate 60 percent increase in risk 2002), young, otherwise healthy but depressed individuals
of developing heart disease. Likewise, Barth, Schumacher, showed large elevations in C-reactive protein and interleu-
and Herrmann-Lingen (2004) performed a meta-analysis of kin 6 compared with controls. C-reactive protein and inter-
studies that have investigated outcomes of depression among leukin 6 are important because they mediate inflammation
patients who already have coronary heart disease. They and have been directly implicated in the development of
found that depression is associated with a twofold increase atherosclerosis. More recently, Miller and his colleagues
in risk of death within approximately two years among have shown that, in response to the acute stress of a mock job
people with heart disease (see also Kop & Plumhoff, 2011). interview, depressed people show impairments in the ability
Whooley and Wong (2013) have reviewed potential of their white blood cells to inhibit inflammatory processes
explanations of the impact of depression on cardiovascular (Miller, Rohleder, Stetler, & Kirschbaum, 2005).
disease. Two possible explanations—that the relationship As we have seen, research conducted over the last two
simply reflects the severity of cardiovascular disease (i.e., the decades has yielded an abundance of new information about
worse the heart condition, the more depressed the patient) the relationship between psychosocial variables and cardio-
or that the relationship is a consequence of toxic effects of vascular disease (for a comprehensive review, see Everson-
antidepressant medication—cannot be supported by the Rose & Lewis, 2005). This section has reviewed some of the
available evidence. Plausible pathways generally fall into psychological characteristics that are currently believed to
two categories: biological and behavioural factors. play a role in the development of heart disease and some of
Considerable evidence suggests that the associa- the mechanisms by which psychological variables may exert
tion between depression and cardiovascular disease can be their effect. Just how important are they? We know, for exam-
explained by behavioural factors, including physical activ- ple, that smoking and a poor diet increase risk for heart dis-
ity, medication non-adherence, and social isolation. The ease, and we know that physiological risk factors, such as high
prospective Heart and Soul Study evaluated whether behav- blood pressure and diabetes, also play a role. Surely these are
ioural factors explained the association between symp- much more important and powerful influences, are they not?
toms of depression and cardiovascular events in a sample In a massive investigation—the INTERHEART
of more than 1000 outpatients with stable coronary heart study—Salim Yusuf, of McMaster University, and a large
disease who were followed for nearly five years (Whooley team of co-investigators identified more than 15 000 people
et al., 2008). Patients with baseline depressive symptoms who had suffered their first heart attack, as well as almost
had a 50% greater rate of subsequent cardiovascular events. 15 000 controls. Participants were identified in 52 countries
Importantly, adjustment for physical activity, smoking, and on every inhabited continent. For each participant, the
medication non-adherence were associated with 32%, 10%, investigators performed measurements of a large number of
and 5% reductions in the strength of the association between known or suspected treatable risk factors, including smok-
depressive symptoms and cardiovascular events, respec- ing, dietary patterns, physical activity, blood constituents,
tively. The association between symptoms of depression and and psychosocial factors. Their measure of psychosocial
cardiovascular disease was eliminated after adjustment of all factors included self-reported stress at home (e.g., irritabil-
three health behaviours. Win and colleagues (2011) reported ity, anxiety, sleep loss), work stress, financial stress, major
a similarly strong mediating effect of physical activity on the life events, locus of control, and depression. The results of
association between symptoms of depression and cardiovas- the INTERHEART study (Yusuf et al., 2004) suggested
cular events in a sample of almost 6000 patients that better that nine risk factors—smoking, the apolipoprotein A/apo-
generalized to women and minorities. lipoprotein B ratio (a measure of blood lipids), high blood
The association between depression and cardiovascular pressure, diabetes, abdominal obesity, low consumption
disease might also be explained by biological factors, such as of fruits and vegetables, lack of consumption of moderate
alterations in autonomic and neuroendocrine regulation of amounts of alcohol, low physical activity, and psychosocial

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 Psychological Factors Affecting Medical Conditions 167

factors—accounted for more than 90 percent of the risk of Cognitive-behavioural techniques are also commonly
heart attack. The pattern of associations was generally com- used. They focus on helping the individual to identify
parable around the world and in both men and women. Of thinking styles that promote stress, such as negative self-
the nine risk factors, the three that had the greatest impact statements, and to devise new ways of thinking and acting
were raised blood lipids, smoking, and psychosocial factors, to counteract stress (see Chapter 17, and compare with the
in that order. In other words, the influence on cardiovascu- examples of cognitive-behavioural treatments described
lar disease of psychosocial variables such as those discussed in Chapters 5 and 8). Such methods are often informed by
in this chapter is substantial and important in public health Lazarus’s transactional model and can be seen as attempts to
terms. As research in this field has progressed, our ideas modify appraisal and coping processes.
about the manner in which such influences operate have Linden and Chambers (1994), of the University of
become more complex and more refined. We will no doubt British Columbia, reported a meta-analysis of stress man-
learn much more as the twenty-first century progresses. agement in the treatment of hypertension. Their results
indicated that stress management could be as effective
as the standard prescription drugs when the interven-
BEFORE MOVING ON tions were targeted and individualized to the patients’
Psychophysiological reactivity is a term that can be purely problems. More recently, Linden and Moseley (2006)
descriptive, in which case it simply refers to physiological reported a meta-analysis of controlled trials investigating
reactions to psychological stimuli. On the other hand, it is the effects of psychological treatments such as biofeed-
sometimes used to refer to a variable on which people dif- back and stress management for hypertension. Their results
fer characteristically, with some people being highly reac- indicated that such interventions do, in fact, produce sig-
tive, others not reactive at all, and most of us somewhere nificant reductions in systolic blood pressure. Interestingly,
in between. Describe how psychophysiological reactivity, in these researchers also concluded that interventions that
either sense of the term, helps to explain the origins of ulcer involve multiple components (e.g., biofeedback and stress
and cardiovascular diseases. management) or that are individualized based on a patient’s
specific psychological characteristics produce especially
BEFORE MOVING ON marked reductions.
A variety of treatment techniques have been developed
It is important to be able to see the connection between to address specific psychosocial variables. Most of this work
empirical findings and the conclusions they support. In this has been informed by a cognitive-behavioural, transactional
chapter, we have reviewed evidence that psychological fac-
perspective. Probably the best-known example is the Recur-
tors can contribute to the onset or exacerbation of infections,
rent Coronary Prevention Project (Friedman et al., 1986).
ulcers, and cardiovascular diseases. For each disease state,
pick one empirical study that has been covered and describe Patients who had suffered a heart attack were assigned to
how the evidence supports a role for psychological influ- one of two conditions. One was a standard cardiac counsel-
ences. You should also be able to describe some limitations ling intervention involving education about risks and risk
to the conclusions that can be drawn. factor control. In the other, patients also underwent inten-
sive counselling to change Type A behaviours. The Type A
counselling, which took place in group sessions over four
and a half years, included education about Type A behav-
Treatment iour; developing self-awareness about triggers of Type A
If psychosocial factors contribute to disease, it seems sen- behaviour; reducing time urgency, anger, and hostility; and
sible that psychological approaches would be useful in increasing patience and empathy. After three years, patients
treatment. A variety of such approaches have been devel- who had received the Type A counselling program showed
oped, with varied results. Broadly speaking, two classes a reduction in measured Type A behaviour. They also had
of intervention characterize work in this field: (1) generic just over half as many recurrences of cardiac events as the
approaches to the management of stress and related prob- control patients.
lems, and (2) interventions directed toward specific psy- Larger trials targeting psychosocial variables to reduce
chosocial variables thought to play a role in the etiology morbidity and mortality following cardiovascular disease
of disease. have not been universally supportive. The ENRICHD
Generic stress management programs attempt to (ENhancing Recovery In Coronary Heart Disease) trial
address either the physiological arousal response or the evaluated the effect of non-pharmacological treatment
behaviours and thought processes believed to play a role of depression on mortality and recurrent myocardial
in eliciting arousal. Relaxation training is often used to infarction (Berkman et al., 2003). Nearly 2500 patients
prevent or inhibit stress-induced sympathetic and neuro- with myocardial infarction and depression were enrolled
endocrine responses. Techniques range from teaching the and randomized to receive usual care or a median of
control of specific muscle groups to autogenic training, a 11 sessions of individually tailored cognitive behaviour
multi-faceted procedure that encourages people to invoke therapy for depression over the course of 6 months. Results
images of warmth and heaviness. were mixed. Although depression improved, there was no

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 168 Chapter 7

difference in morbidity and mortality between the two

groups. Follow-up analyses indicated that depression was
an independent risk factor for death following myocardial
infarction, despite the fact that the treatment of depression
was not associated with a decrease in this risk (Carney et al.,
2003). On possible confounding factor was the use of anti-

FatCamera/E+/Getty Images
depressant medication, which reached 20.6 percent in the
control group and 28 percent in the intervention group by
the end of follow-up. Interestingly, antidepressant medica-
tion use was associated with a significant reduction in risk
of morbidity or mortality (Berkman et al., 2003). Arguably,
it is important to treat depression following myocardial
infarction as doing so improves psychological outcomes
and makes it easier for the patients to adhere to medical Many people report that meditation or yoga reduces stress, which,
regimens necessary for survival. in turn, may help to alleviate stress-related medical problems.
Although it is possible that the specific skills tar-
geted in the Recurrent Coronary Prevention Project or in and on encouraging emotional communication (Billings
Ornish’s intensive lifestyle intervention program (Ornish et al., 1996). Undoubtedly, such experiences can contribute
et al., 1998) may be critically important for therapeutic ben- to the development of new ways of appraising and coping.
efits, it is worth noting that the interventions also address Emotional communication may also enhance the ability to
several other relevant psychosocial variables. In particu- “process” emotional experiences and promote new ways
lar, the programs emphasize and encourage social support. of interacting with others. There is evidence that all these
Indeed, as these types of intervention have evolved, they changes may play a role in promoting health and prevent-
have begun to place greater emphasis on group interaction ing disease.

CANADIAN RESEARCH CENTRE

Dr. Kim Lavoie

As important as it is to understand how smoking, diet, physical activity, adher-
psychosocial factors contribute to dis- ence) factors influence the devel-
ease, it is even more important to dis- opment and progression of chronic
cover ways of preventing, treating, or disease, including cardiovascular dis-
mitigating their negative effects. An ease, asthma, and chronic obstructive

Courtesy of Dr. Kim Lavoie

exemplary program of research into clini- pulmonary disease (COPD).
cal interventions in health psychology In her earlier work, Dr. Lavoie and
and behavioural medicine has been led colleagues investigated the impact of
by Dr. Kim Lavoie, Professor of Psychol- psychiatric disorders on patients with
ogy and Chair of Behavioural Medicine heart and lung disease. This research has
at Université du Québec à Montréal, highlighted the importance of screening
co-director of the Montreal Behavioural for and treating psychiatric disorders in
Medicine Centre, director of the Chronic patients who experience these chronic
Disease research division at Hôpital du diseases. For example, her research has of exercise stress tests among patients
Sacré-Coeur de Montreal, and Chair highlighted that 34 percent of adults with cardiovascular disease and comor-
of the Health Psychology and Behav- with asthma experience a psychiatric bid depression (Lavoie et al., 2004).
ioural Medicine Section at the Canadian disorder that worsens asthma control and Indices of exercise stress test perfor-
Psychological Association. Dr. Lavoie quality of life (Lavoie et al., 2005). Simi- mance were lower among patients with
and her colleagues have been involved larly, she has demonstrated that patients depression, and resulted in more false
in research that is focused on reduc- treated for COPD in an outpatient setting negative tests, cautioning the validity
ing chronic disease morbidity and who have a psychiatric disorder experi- of exercise stress testing among cardiac
mortality by understanding how psy- ence greater risk of COPD-exacerbations patients with depression.
chological (e.g., stress, anxiety, depres- (Laurin et al., 2009). Finally, Lavoie Dr. Lavoie and colleagues have more
sion, motivation) and behavioural (e.g., et al. evaluated the validity and reliability recently focused on the development and

M07_DOZO8871_06_SE_C07.indd 168 23/11/17 3:34 PM

 Psychological Factors Affecting Medical Conditions 169

implementation of evidence-based inter- to enhance a patient’s self-efficacy and arguably benefit the most from lifestyle
ventions designed to help patients with motivation for behaviour change using counselling about health behaviour
chronic disease reduce the frequency principles and techniques derived from change (i.e., cardiologists, respirolo-
of behaviours that are problematic to self-determination theory (Ryan & Deci, gists, and internists). If successful, this
health and increase the frequency of 2000) and motivational interviewing research will help generate a framework
those that are beneficial (i.e., health (Miller & Rollnick, 2013). In one such and methodology for training physi-
behaviour change). The development intervention, patients with poorly con- cians in a critically important yet often
and management of chronic diseases trolled asthma who were not using their neglected clinical skill that seeks to
(e.g., cardiovascular, COPD, asthma, inhaled corticosteroids as prescribed improve physician-patient communica-
cancer) are heavily influenced by behav- were randomized to receive four brief tion, optimize care, and improve chronic
iours, including smoking, poor diet, alco- (15 to 30 minute) motivational coun- disease outcomes.
hol consumption, physical activity levels, selling sessions (i.e., collaborative, Finally, Dr. Lavoie and colleagues
and medication non-adherence. Thus, person-centred counselling sessions for have developed a professional practice
behaviour and lifestyle interventions are strengthening a person’s motivation and network of Canadians who specialize
often first-line recommendations when commitment for change by exploring in health behaviour change and pro-
it comes to the prevention and manage- and resolving ambivalence) or usual care motion. She co-founded and chairs
ment of chronic diseases. Yet, behaviour (Moullec et al., 2014). Results indicated Can-Change: Canadian Network for
change is difficult to initiate and even that brief motivational counselling pro- Health Behaviour Change and Promo-
more challenging to maintain. Dr. Lavoie duced clinically relevant improvements tion (http://can-change.ca/). She also
has targeted health behaviour change in adherence to inhaled corticosteroids, regularly conducts workshops to train
from the perspective of the patient as symptoms of asthma, and increased health care providers in motivational
well as the health care provider. patients’ confidence in their ability to counselling. The work of Dr. Lavoie and
Changing one’s behaviour is a chal- control their asthma. her team is representative of research
lenging task. It has been suggested that In her most recent program of and practice in behavioural medicine.
there is no impending pharmaceutical research, Dr. Lavoie and colleagues It is multidisciplinary, involving the
discovery, surgical innovation, or gov- have received funds from the Canadian full spectrum of professionals who deal
ernmental policy change with greater Institutes for Health Research (CIHR) with cardiac and respiratory patients:
potential for reducing rates of morbidity to train health care providers in the cardiologists, respirologists, nurses,
and mortality than increasing the per- use of motivational communication to psychiatrists, physiatrists, psycholo-
centage of treatment plans that patients improve patient-provider communication gists, and rehabilitation workers. It
carry out as prescribed (Sabaté, 2003). and promote health behaviour change. addresses basic theoretical questions
Despite this call to action, there has This is a pan-Canadian study that spe- and practical outcomes. Finally, it is
been little guidance on how to motivate cifically targets specialist physicians oriented to important issues that affect
health behaviour change. Dr. Lavoie and whose practices involve treating the the lives patient with chronic diseases.
colleagues have designed interventions highest proportion of patients who could

SUMMARY
● There is a long history of attempts to explain the ● Psychological stress, a basic psychological process
origin of illness and disease by psychological processes. that stimulates physiological disease mechanisms, is
Advances in psychological and physiological methods complex and regulated by cognitive, personality, and
have lent a new credibility to these ideas. social variables that can enhance or diminish risk of
● The widespread influence of psychological factors on disease.
physical illness is recognized in DSM 5 by a distinct ● A number of disease states, including the common cold,
diagnostic category: Psychological Factors Affecting ulcers, and heart disease, can be understood, at least in
Other Medical Conditions. part, by examining psychological and psychophysiologi-
● Biologically plausible mechanisms for the occurrence of cal variables.
certain diseases exist in the physiological changes known ● Theory and findings in this area have contributed to the
to accompany psychological states. Such changes can be development of promising psychological treatments for
mediated in complex ways by the autonomic, neuroen- physical disorders.
docrine, and immune systems and their interactions.

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 170 Chapter 7

KEY TERMS
alarm (p. 152) general adaptation syndrome (GAS) psychoneuroimmunology (p. 152)
alexithymia (p. 156) (pp. 152-153) psychophysiological reactivity model
appraisals (p. 154) health behaviour model (p. 165) (p. 165)

arrhythmias (p. 162) health psychology (p. 147) psychosocial vulnerability model (p. 165)

atherogenesis (p. 163) humoral immunity (p. 151) resistance (p. 152)

atherosclerosis (p. 162) hypertension (p. 163) secondary appraisals (p. 154)

behavioural medicine (p. 147) ischemic heart disease (p. 161) stress reactivity paradigm (p. 163)

cardiac output (p. 162) longitudinal study (p. 160) stroke (p. 161)

cardiovascular reactivity (p. 163) modifiable risk factors (p. 163) systolic blood pressure/diastolic blood
myocardial infarction (p. 161) pressure (p. 162)
cardiovascular recovery (p. 164)
nonspecific immune responses (p. 151) total peripheral resistance (p. 162)
cellular immunity (p. 151)
potential years of life lost (PYLL) (p. 161) transactional model (p. 165)
constitutional vulnerability (p. 165)
primary appraisals (p. 154) Type A (p. 164)
dualistic (p. 146)
protective factor (p. 163) vasculature (p. 162)
exhaustion (p. 152)

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 DANIELLE MACDONALD
•
KATHRYN TROTTIER

CHAPTER

10 Elena Elisseeva/123RF

Eating Disorders
LEARNING OBJECTIVES
AFTER READING THIS CHAPTER, STUDENTS WILL BE ABLE TO:
Describe the symptoms of eating disorders and distinguish among anorexia nervosa, bulimia nervosa,
binge-eating disorder, other specified feeding or eating disorders, and an unspecified feeding or eating
disorder.
Identify the prevalence of eating disorders and illustrate how their prevalence has changed over time.
Distinguish between the physical/biological factors that are thought to contribute to the development
of eating disorders and those that are thought to be a consequence of eating disorders.
Outline the primary etiological factors that are involved in eating disorder symptomatology.
Compare and contrast biological treatment (i.e., medication), cognitive-behavioural therapy, and inter-
personal therapy in the treatment of bulimia nervosa.
Describe a prevention program that has been implemented to decrease the risk of developing an eating
disorder, and highlight the main findings of the program.

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 When Becky was 18 years old, her boyfriend broke up with her. Becky, who is now 19, had been
dating her boyfriend for two years. After the breakup she found herself feeling depressed, and her
self-esteem suffered greatly. Although she was of average weight, Becky thought she might feel
better about herself if she lost a bit of weight, so she began a strict diet. She cut out all added
fats such as butter and mayonnaise, desserts, and fried foods. After successfully losing three
kilos and receiving positive comments from her friends and family, Becky thought she might feel
even better about herself if she lost a bit more weight. In addition to cutting out foods high in
fat, Becky decided to restrict herself to eating fruit, vegetables, diet products, and white meat.
However, Becky’s weight loss did not seem to be improving her self-esteem, and one evening she
found herself home alone, feeling particularly down. She decided to allow herself one piece of
cake, but after eating it she felt as though she could not stop eating. She ate several pieces of
cake, a bag of chips, and half a bag of cookies. After finishing the food, she felt uncomfortably
full and anxious about having consumed so many calories and so much fat. She felt that she had
no choice but to vomit the food she had eaten.

In the following weeks, Becky found herself engaging in the same pattern of behaviour. Each
morning she made a pact with herself to stick to her diet, but in the evenings when she was
feeling tired, alone, and bad about herself, she often felt out of control and compelled to eat large
amounts of food, which she then felt she had to vomit. Eventually, Becky began to vomit even
normal portions of food that she ate during the day. Despite this, she did not lose any more weight
and felt worse about herself than before she began to diet.

Introduction and Historical context of a behaviour can be critical in determining how it is

perceived and interpreted (Miller & Pumariega, 2001).
Perspective In bulimia nervosa, individuals experience episodes of
binge eating in which they consume a large amount of food
Today, many people are familiar with the term eating disor- and feel out of control while they eat, often following a period
ders. However, even if you are familiar with the term, you of food restriction. After the binge, they try to compensate
may not be exactly sure what eating disorders are or why for what they have eaten, for example, by engaging in self-
they occur. There are many common misperceptions about induced vomiting, laxative use, fasting, or exercise. Bulimia
eating disorders, including that individuals with anorexia nervosa was also recognized as a mental health disorder only
nervosa are simply starving themselves on purpose, or that in the late twentieth century (Striegel-Moore, 1997), although
eating disorders are driven by issues of vanity. Many of these episodes of binge eating and compensatory behaviours have
misperceptions are rooted in outdated views of what eat- also been described throughout history (Bemporad, 1997).
ing disorders are and how they develop. Increasingly in the With the publication of the DSM-5 (APA, 2013), binge-
twenty-first century, mental health movements are focused eating disorder (BED) has been included as a stand-alone
on increasing accurate awareness and reducing stigma eating disorder. As in bulimia nervosa, recurrent episodes of
around mental health issues, including eating disorders. binge eating occur. However, unlike bulimia, regular, inap-
The eating disorder anorexia nervosa is characterized propriate compensatory behaviours to try to rid the body of
by food restriction that leads to a significantly low weight, calories are not present. Instead, the binge eating is associ-
relative to a person’s age, height, and sex, as well as a fear of ated with a variety of eating behaviours (e.g., eating rapidly,
gaining weight. Anorexia nervosa was first recognized as a eating until uncomfortably full, eating despite not being
mental health disorder in the late-twentieth century (Bruch, hungry, eating alone because of embarrassment) and feeling
1978), but its symptoms have been described for hundreds, or guilt or disgust about the binge eating.
even thousands of years (Bemporad, 1997). Interestingly, in In this chapter, we focus on eating disorders, including
the Middle Ages, behaviours that would today be described anorexia nervosa, bulimia nervosa, binge-eating disorder, and
as symptoms of anorexia were seen positively, as evidence of the other specified eating disorders (including purging disor-
religious asceticism. This demonstrates that the socio-cultural der and night-eating syndrome). In DSM-5, however, eating

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 Eating Disorders 231

Individuals with anorexia have an intense fear of gaining

weight, or of becoming fat. This fear is paradoxical, given that
they are in fact underweight. To maintain their low weight,
they restrict the amount of food they eat. This may begin with
a reduction in the total number of calories consumed over
the course of a day, and avoidance of foods that are high in
calories. However, the number of foods that are avoided often
grows to the extent that individuals develop a long list of “for-
bidden foods” that they refuse to eat. Individuals with anorexia
typically believe that eating feared or forbidden foods will
result in significant amounts of weight gain—they might even
believe that this weight gain will occur immediately after eat-
ing the food. A variety of other maladaptive or ritualistic eating
behaviours may also develop. For example, individuals may
begin eating foods in a set order (e.g., eating vegetables first
National Eating Disorder Information Centre

and leaving certain types of food on their plate, such as high-

protein foods, until last), dissecting food into small pieces, and
weighing food or fluids before consumption.
Some people with anorexia engage in excessive exercise
as a means of achieving weight loss. General restlessness is also
common, as well as pacing back and forth and standing rather
than sitting. This restlessness may be driven by a desire to burn
additional calories; however, it may also be a result of poor
nutrition and starvation. Some individuals with anorexia ner-
vosa reach and maintain their low body weight through food
This poster from the National Eating Disorder Information Centre in restriction and exercise. However, others also engage in purging
Toronto aims to dispel the myth that eating disorders are a choice. behaviours in order to achieve or maintain weight loss. Purg-
ing behaviours include self-induced vomiting, laxative abuse,
disorders are classified together with feeding disorders. The or abuse of enemas or diuretics. These purging behaviours,
feeding disorders include pica (eating non-food substances, which result in the direct evacuation of the stomach, bowels, or
such as dirt or paper), rumination disorder (repeatedly bladder, are distinct from other compensatory behaviours that
regurgitating food), and avoidant/restrictive food intake dis- can be used to prevent weight gain, such as fasting or excessive
order (ARFID). ARFID resembles anorexia nervosa in some exercise. Although purging behaviours can lead to some weight
ways: it is characterized by a feeding disturbance that leads loss, this is primarily due to dehydration (which itself has seri-
to being underweight and/or an inability to eat enough food ous medical consequences), as a substantial number of calories
to meet nutritional/energy needs. However, unlike anorexia are still absorbed by the body (Mehler, 2011).
nervosa, individuals do not perceive themselves as fat or have Many individuals who purge also engage in binge eating.
a distorted perception of their body weight or shape. From a clinician and researcher’s standpoint, it is important to
determine whether a patient is engaging in objective binge eat-
ing, or whether binges are subjective. Although both types of
Typical Characteristics binge eating are associated with a lack of control over eating,
the amounts of food consumed differ. An objective binge, as
ANOREXIA NERVOSA defined by the DSM-5, consists of eating a large amount of
Family and friends of individuals with anorexia nervosa may food (larger than most individuals would eat under similar cir-
find it difficult to understand why their loved ones are so cumstances) in a specific time period (e.g., less than two hours).
concerned with weight and shape despite their emaciated In contrast, if the individual is in fact eating small or normal
appearance. For those who are not familiar with the features of amounts of food during these episodes (such as one chocolate
anorexia, and the factors that typically underlie this disorder, bar), these would be considered subjective binge episodes.
it may be difficult to understand the struggle that individu- Anorexia nervosa involves not only a drive for weight loss
als with anorexia face. Parents are concerned about the seri- and a fear of gaining weight, but also a disturbance in body
ous consequences of their children being so underweight, and image. This disturbance may be manifested in several ways.
often encourage them to eat, as this will seemingly solve their Individuals with anorexia may have a disturbance in their
problems. As a result, conflicts with parents about eating are view of their body shape. This may be general body dissat-
common, and individuals with anorexia may hide or secretly isfaction, in which they view their overall weight or shape to
dispose of food, eat alone, or tell others that they have eaten be distressingly unacceptable, or may be dissatisfaction with
when in fact they have not. To be able to understand and treat particular body parts, such as their thighs or hips. Individuals
this disorder, it is important to recognize that there are a variety with anorexia often perceive their bodies or parts of their bod-
of underlying psychological factors associated with anorexia. ies to be much larger than they actually are. This disturbance

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 232 Chapter 10

in body image is often linked with low self-esteem, and indi- arrhythmias. The secretive nature of the binge/purge episodes,
viduals may use body weight or shape as one of their primary in conjunction with the fact that family and friends may not
methods of determining self-evaluation. Individuals with detect a problem, adds to the seriousness of bulimia given the
anorexia may be hypervigilant in assessing their bodies, and potentially severe medical complications that can arise.
may employ a variety of methods in their assessments, includ- During episodes of binge eating, foods that are high
ing repeated weighing, measuring body parts (e.g., measuring in calories are typically consumed, such as pizza, cake, ice
stomach or leg circumference), or constant checking their cream, and chips. During these episodes, more calories are
body shape in mirrors or other reflective surfaces. derived from fat, and less from protein, compared to caloric
Although the most striking feature of anorexia nervosa intake during non-binge eating episodes (Gendall, Sullivan,
is low body weight, other common features of this disor- Joyce, Carter, & Bulik, 1997). The foods consumed during
der may be less immediately apparent. These features may binge episodes are often considered to be “forbidden foods,”
concern cognitive, emotional, and physiological function- and are avoided during periods of dieting and food restric-
ing; and include social withdrawal, irritability, preoccupa- tion. This pattern of avoidance may set up a cycle of binge-
tion with food, and depression. However, it is important to ing and purging. After an episode of binge eating, there is a
note that while these features occur frequently in individuals feeling of physical discomfort (as a result of the large amount
with anorexia, many seem to be linked to the state of semi- of food consumed), in addition to feelings of guilt and worry
starvation that individuals with anorexia are in, as opposed to about weight gain. Many individuals with bulimia engage in
being a feature of the disorder itself. In other words, during self-induced vomiting after binge-eating episodes to relieve
or after recovery, once an individual with anorexia has gained this physical discomfort, as well as to compensate for their
some weight, many of these features may be less severe, or excessive intake in an attempt to prevent weight gain. After
may no longer be present. In the section on physical and psy- purging, they may begin another period of dieting or restric-
chological consequences of eating disorders, we will further tion, leaving them feeling hungry in addition to feeling guilt
examine this issue, taking into consideration research that and self-hatred about the purging behaviours. This becomes
shows that individuals who severely restrict their food intake a cyclical pattern of restriction, binge eating, and purging.
(but do not have an eating disorder) show many of the same In addition to dieting and food restriction, a number of
features that are present in anorexia nervosa. other factors may serve as cues for binge-eating episodes.
Heatherton and Baumeister (1991) proposed that episodes
of binge eating occur in an attempt to escape from high
BULIMIA NERVOSA levels of aversive self-awareness. According to this “escape
Bulimia nervosa is characterized by episodes of binge eating from self-awareness” model, individuals who binge eat tend
followed by compensatory behaviours designed to prevent to have high expectations of themselves, constantly monitor
weight gain. As in anorexia nervosa, individuals with bulimia themselves, and often fail to meet the high standards they
often have low self-esteem, and use weight and shape infor- set for themselves. Awareness of their failures leads to feel-
mation as their primary method of self-evaluation. Other ings of anxiety and depression and, as a result, individuals
features, such as social isolation and depression, are also become strongly motivated to escape from this negative state.
common in both anorexia and bulimia nervosa. In contrast Heatherton and Baumeister propose that binge eating occurs
to anorexia, however, individuals with bulimia are typically as a result of a shift in attention. More specifically, binge eat-
within the normal weight range. This, in conjunction with ing results from individuals shifting focus away from their
the fact that binge eating and compensatory behaviours are perceived failure to live up to high standards, and toward
often conducted in private, may make it harder for friends the behaviour and positive sensations associated with eat-
and family to detect the problem. ing. Additionally, people with bulimia typically experience
Individuals with bulimia engage in objective binge eating increased negative emotions directly preceding binge-eating
and, in order to prevent weight gain, engage in a variety of com- episodes. After binge eating and purging, negative emotions
pensatory behaviours. These compensatory behaviours may decrease, suggesting that binge eating and purging function
include fasting and excessive exercise, as well as purging. As to attenuate negative emotions (Smyth et al., 2007).
mentioned, purging behaviours such as vomiting and laxative Upon reviewing the features of anorexia and bulimia
abuse are relatively ineffective at producing significant weight nervosa, you might notice that many of them overlap. Indi-
loss, and much of the weight loss that occurs as a result of these viduals with anorexia and those with bulimia both tend to be
behaviours is simply due to dehydration. This, in part, accounts preoccupied with, and overvalue weight and shape, and have
for the fact that many individuals with bulimia are within the low self-esteem. Furthermore, like individuals with bulimia,
normal weight range—the purging and compensatory behav- some individuals with anorexia nervosa may engage in binge
iours they engage in may not be sufficient to produce weight eating as well as purging behaviours. What, then, is the dif-
loss, relative to the number of calories that are consumed ference between these groups? One of the primary differ-
(some of which are digested before purging begins). These ences between anorexia and bulimia is body weight; whereas
purging behaviours also have serious medical consequences, individuals with anorexia nervosa are always underweight by
which include, but are not limited to, damage to the teeth definition, individuals with bulimia are typically within their
from frequent vomiting, impaired renal function, hypokalemia normal weight range. Furthermore, although all individu-
(low potassium), and cardiovascular difficulties such as als with bulimia engage in binge eating and compensatory

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 Eating Disorders 233

behaviours, only some individuals with anorexia exhibit TABLE 10.1 PREVALENCE AND INCIDENCE OF
these behaviours. Hence, assessing body weight and eat- ANOREXIA NERVOSA, BULIMIA
ing behaviours can allow clinicians to differentiate between NERVOSA, AND BED
anorexia and bulimia nervosa. We will discuss the diagnostic
Lifetime Prevalence Incidence
features of both of these disorders and outline assessment
techniques for eating disorders later in this text. Females Males
Anorexia Nervosa

BINGE-EATING DISORDER White 0.64% 0.14% 8 per 100 000

population/year
BED, like bulimia nervosa, is characterized by regular binge
Latino 0.12% 0.03%
eating episodes. Unlike bulimia, however, episodes of inap-
propriate compensatory behaviours to prevent weight gain Asian 0.13% 0.07%
do not follow these binge eating episodes. People with BED African-American 0.12% 0.18%
experience significant distress about their binge eating. Some Bulimia Nervosa
other characteristics of individuals with BED include eating White 0.97% 0.08% 12 per 100 000
very rapidly, eating large amounts even when not hungry, population/year
eating alone because of embarrassment about the amount Latino 2.34% 1.73%
that they are eating, or feeling very guilty or disgusted after Asian 1.87% 1.14%
binge-eating episodes.
African-American 1.74% 0.90%
One of the first published cases of an individual with
Binge Eating Disorder
BED appeared in the late 1950s (Stunkard, 1959). Stunkard
observed a pattern of sporadic binge eating of large amounts White 1.91% 0.94% Unknown
of food, in addition to alternating periods of dieting and over- Latino 2.71% 1.54%
eating, in some obese individuals. He presented a case of a Asian 1.66% 0.84%
man who binged after arguments with his wife. This man African-American 2.22% 0.78%
would find himself buying large amounts of food at the gro-
Source: Based on Marques, L., Alegria, M., Becker, A. E., Chen, C. N., Fang, A.,
cery store and would be unable to control himself (i.e., stop Chosak, A., & Diniz, J. B. (2011). Comparative prevalence, correlates of impairment,
and service utilization for eating disorders across US ethnic groups: Implications for
eating) after starting to eat the food. After the binges, this indi- reducing ethnic disparities in health care access for eating disorders. International
vidual felt extremely distressed and experienced self-hatred. Journal of Eating Disorders, 44, 412-420. doi: 10.1002/eat.20787

His self-hatred was always focused on his eating, rather than

on the relationship disputes that often triggered the binge.
You may have noticed that there is some overlap with this lifetime. More recently, Marques and colleagues (2011)
man’s case and the “escape from self-awareness” model that examined the lifetime and 12-month prevalence of anorexia
you read about in the previous section on bulimia nervosa. nervosa, bulimia nervosa, and BED in more than 8000 par-
Although Stunkard’s original case of BED was an obese ticipants from four racial/ethnic groups and both genders in
male, BED and obesity are distinct but overlapping concepts. the United States (see Table 10.1). The results indicated that
Because large quantities of food are consumed during regu- White females were no more likely than other racial/ethnic
lar binges, with no regular use of inappropriate compensatory groups to have a lifetime eating disorder. For males, Latino
behaviours aimed at preventing weight gain, individuals with males were significantly more likely than White males to
BED are often overweight and are sometimes obese. How- have a lifetime history of bulimia, but otherwise there were
ever, some individuals with BED are within a normal weight no differences in prevalence rates between white men and
range. Research has shown that individuals with a diagnosis of men of other racial/ethnic groups (Marques et al., 2011).
BED who are not obese have similar concerns about eating, Research has also suggested that other specified feeding or
weight and shape, and similar levels of depression as those eating disorders (see the section Diagnosis and Assessment)
with BED who are obese (Dingemans & van Furth, 2012). are even more common than either anorexia or bulimia.
Furthermore, individuals with BED whose weight is not in Prior to the publication of DSM-5, these eating disorders
the obese range tend to be younger, suggesting that over time were estimated as having a prevalence rate of 2.37 percent
weight gain may occur if binge eating episodes continue over detected in a large community sample of adolescents and
the months or years. Although overvaluation of weight and young adults (Machado, Machado, Gonçalves, & Hoek,
shape is not a diagnostic criterion for BED, individuals with 2007). However, this other specified category included BED
BED have weight and shape concerns that are comparable to prior to DSM-5. Given, that BED is now a distinct eating
those with bulimia (Grilo, Masheb, & White, 2010). disorder category and the frequency threshold for a diagno-
sis of bulimia is now lower, the prevalence of other speci-
Incidence and Prevalence fied feeding and eating disorders has decreased somewhat
(Machado, Goncalves, & Hoek, 2013).
In a Canadian community sample, Garfinkel and colleagues There have been reports of an increase in the incidence
(1995) found that 1.1 percent of women and 0.1 percent of anorexia nervosa during the twentieth century (e.g., Hoek
of men had met criteria for bulimia at some point in their & van Hoeken, 2003; Currin, Schmidt, Treasure, & Jick, 2005).

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 234 Chapter 10

The incidence of bulimia nervosa also appears to have for anorexia nervosa or bulimia nervosa, and followed
increased since it was first described in the late 1970s, though these individuals for up to nine years after their entry into
rates may have peaked in the mid-1990s (Rosenvinge & Pet- the study (Keel, Dorer, Franko, Jackson, & Herzog, 2005).
tersen, 2015). Incidence rates for both disorders in the general Relapse occurred in 36% of women with anorexia nervosa
population appear to have stabilized and may have even who had achieved remission, and 35% of women with buli-
begun to decrease since the early 2000s, although incidence mia nervosa. Unfortunately, the high mortality rate in eating
rates in younger age groups—particularly younger women— disorders exists even among individuals who have received
remain far higher than in the general population (Hoek, 2006; treatment. For example, Herzog and colleagues (2000)
Rosenvinge & Pettersen, 2015). It is unclear to what extent report that all the participants who died during the course
the observed increases in the incidence of anorexia and buli- of their study (5.1% of the participants) had received indi-
mia throughout the twentieth century are a result of increased vidual psychotherapy and pharmacotherapy.
awareness and recognition, as opposed to actual increases in There is similar variability in course and outcome in
incidence (Wakeling, 1996). Regardless of whether the true samples of individuals with eating disorders who are not
incidence of anorexia nervosa has increased, there has been seeking treatment. To study the natural course of eating dis-
an increase in the incidence of registered cases (and, hence, an orders in the community, Keski-Rahkonen and colleagues
increased need for treatment facilities; Hoek & van Hoeken, examined the prevalence and course of eating disorders in
2003). Despite increased awareness, Hudson and colleagues the community in a large epidemiological study. In this study,
(2007) indicate that only about half of individuals with bulimia more than half of individuals with lifetime bulimia nervosa
nervosa have ever sought treatment for their eating disorder. and approximately two-thirds of individuals with lifetime
Hence, a large proportion of individuals who meet diagnostic anorexia nervosa were able to achieve and sustain remission
criteria for an eating disorder do not receive appropriate men- from their eating disorder within five years of the disorder’s
tal health care. onset (Keski-Rahkonen et al., 2007; Keski-Rahkonen et al.,
Binge eating disorder (BED) has only recently been added 2009). There were no differences in long-term outcomes
to the DSM-5 as a distinct eating disorder. As a result, inci- for either anorexia or bulimia nervosa based on whether or
dence data from large studies of the general population are not not the individual’s eating disorder had been detected by the
yet available. However, BED has a prevalence that is compara- health care system (although importantly, detection does not
ble or slightly higher than that of bulimia nervosa (Marques et necessarily mean that the individual received eating disorder
al., 2011). Furthermore, less than 40 percent of the individuals treatment). These findings suggest that over time, many indi-
who received a lifetime diagnosis of BED had received eating- viduals with eating disorders are able to make improvements.
disorder treatment (Kessler et al., 2013), which fits with the
findings already mentioned regarding low levels of treatment
BEFORE MOVING ON
received by individuals with anorexia or bulimia nervosa.
There remains a persistent stereotype that eating disorders
primarily affect white women, despite an increasing recog-
PROGNOSIS nition that eating disorders affect individuals from all races
Eating disorders have the highest mortality rate of all the psy- and genders. Why do you think this stereotype persists? How
might this stereotype affect men or people of colour who are
chiatric disorders (Agras et al., 2004). Recent meta-analytic
experiencing an eating disorder?
research estimates the mortality rates of eating disorders as
between 3.6% and 7.6% for anorexia nervosa, between 1.1%
and 2.4% for bulimia nervosa, and between 1.5% and 5.8% for
other eating disorders (Arcelus, Mitchell, Wales, & Nielsen, Diagnosis and Assessment
2011). The most common causes of death among individuals
with eating disorders are starvation and nutritional complica- DIAGNOSTIC CRITERIA
tions (e.g., electrolyte imbalance or dehydration), and suicide
(Neumärker, 2000). In fact, as many as one in five deaths in
individuals with anorexia are due to suicide (Arcelus et al., Case Notes
2011). Clearly, eating disorders are serious disorders.
It appears that there is a varied treatment response Rachel is a 34-year-old woman who works full time and
among individuals with eating disorders. On average, lives on her own in an apartment. Rachel has always
approximately 50% of adults with bulimia nervosa are able been quite thin, and her co-workers have commented to
to stop binge eating and purging with the current evidence- her that they wish they could have her figure. In order
based individual therapy. Of the other 50%, some show par- to maintain her slim figure, Rachel eats small portions,
tial improvements and others show no change at all in the avoids snacking, and always prepares her own food so
frequency of binge/purge episodes (Byrne, Fursland, Allen, that she knows what is in it. Although her co-workers
& Watson, 2011; Fairburn et al., 2009). In addition, relapse are friendly and sometimes go out together after work
rates are high for eating disorders. One study investigated for dinner and drinks, Rachel has never joined them.
relapse rates in a group of 240 women who sought treatment

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 Eating Disorders 235

minimally normal/expected (see Table 10.2). The DSM-5

She feels stressed by the idea of ordering at a restau- suggests that significantly low weight can be assessed by cal-
rant and eating in front of other people. She also doesn’t culating a body mass index (BMI)—weight in kilograms
want to disrupt her exercise routine, because she is divided by height in metres squared. The DSM-5 refers to
afraid that if she misses one day at the gym, she will the guidelines of the World Health Organization, indicating
fall into a negative spiral and stop exercising completely. that a BMI of 18.5 is considered to be the lower threshold
of a normal weight, and that those with a BMI of less than
Lately, some of Rachel’s friends have noticed that she
17 would be considered to have a significantly low weight.
has been losing weight and looking unwell. Her best
However, the DSM-5 also highlights that those with a BMI
friend recently spoke up about her concerns, and Rachel
between 17.0 and 18.5, and in certain cases even a BMI
confided to her that it has been difficult to eat normally
higher than 18.5 may also be considered to have a signifi-
and maintain her weight since her mother became ill and
cantly low weight, depending on their clinical history. Part of
passed away last year. She started eating even smaller
the difficulty in defining a “significantly low weight” is that
portions than before, and exercising more, during the
it is unreasonable to specify a single standard for minimally
stressful period of her mother’s illness. She feels bet-
normal weight that applies to all individuals – particularly
ter emotionally when she exercises, and has gradually
because “normal weight” may vary between men and women,
increased her exercise routine to one hour a day, five or
and during different age groups within adulthood. Another
six days per week. Although she has noticed her weight
reason why it is difficult to give a precise definition for low
loss, she still perceives her stomach and thighs as “too
weight is that most people who develop anorexia nervosa
big,” and she has found it difficult to eat more because
do so in adolescence when they are still growing, with the
she is concerned about gaining “too much” weight.
typical onset between ages 14 to 18. For these individuals, an
Her friend suggested that she go to her family doctor
indication of significantly low weight would be a failure to
to discuss some of her issues with weight and exercise.
make expected weight gain during a period of growth. Clini-
Rachel reluctantly agreed to do so, and was somewhat
cians are instructed to consider an individual’s body build
alarmed when she found out that she had developed
and weight history when determining whether an individual
low blood pressure, and that her irregular and missed
meets the low weight criterion for anorexia nervosa.
periods were likely connected with her low weight.
The second criterion is an intense fear of gaining weight
Her weight was taken at 49 kilograms, at a height of
or of becoming fat, or persistent behaviour that interferes
170 centimetres, giving her a body mass index of 17.
with weight gain, despite being at a significantly low weight.
Her doctor suggested that he could refer her to a psychi-
It is important to note that individuals with anorexia ner-
atrist specializing in eating disorders treatment, and she
vosa do not necessarily fear weight gain for aesthetic rea-
agreed to visit the psychiatrist for further assessment.
sons. Some individuals with anorexia may fear weight gain
because they fear losing some of the consequences of their
low weights that they view as beneficial. For example, many
ANOREXIA NERVOSA As you have already read, and can individuals with anorexia nervosa report that they fear gain-
observe in the above case example, the central feature of ing weight because they desire the emotional numbness that
anorexia nervosa is severe food restriction leading to a very is associated with being underweight.
low body weight. The DSM-5 defines this as the restriction Finally, in order to meet diagnostic criteria for anorexia,
of energy intake leading to a body weight that is less than an individual must have a distortion in the experience of his

TABLE 10.2 DSM-5 DIAGNOSTIC CRITERIA FOR ANOREXIA NERVOSA

A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, devel-
opmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for
children and adolescents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly
low weight.
C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation,
or persistent lack of recognition of the seriousness of the current low body weight.

Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior
(i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss
is accomplished primarily through dieting, fasting, and/or excessive exercise.

Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior
(i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. (Copyright © 2013), American Psychiatric Association.
All Rights Reserved.

M10_DOZO8871_06_SE_C10.indd 235 25/10/17 5:56 PM

 236 Chapter 10

or her body and/or undue significance of body weight. Such TABLE 10.3 DSM-5 DIAGNOSTIC CRITERIA FOR
distortions can include (1) a disturbance in perception of BULIMIA NERVOSA
body weight or shape, such that the individual perceives her-
A. Recurrent episodes of binge eating. An episode of binge
self as weighing more than she does or being larger than she
eating is characterized by both of the following:
is; alternatively, she may recognize that she is underweight 1. Eating, in a discrete period of time (e.g., within any
but may perceive a particular body part as being larger than 2-hour period), an amount of food that is definitely larger
it actually is; (2) lack of recognition of the seriousness of her than what most individuals would eat in a similar period
current (low) weight; or (3) determining self-worth based of time under similar circumstances.
primarily on body weight or shape. This last criterion refers 2. A sense of lack of control over eating during the episode
to the tendency for individuals with anorexia (and other eat- (e.g., a feeling that one cannot stop eating or control
ing disorders) to evaluate themselves generally based on their what or how much one is eating).
typically negative view of their bodies. In order to assess this, B. Recurrent inappropriate compensatory behaviors in order
Canadian researchers Geller, Johnson, and Madsen (1997) to prevent weight gain, such as self-induced vomiting; mis-
use of laxatives, diuretics, or other medications; fasting; or
developed the Shape and Weight-Based Self-Esteem Inven-
excessive exercise.
tory (SAWBS) that measures the importance of weight and
C. The binge eating and inappropriate compensatory behaviors
shape to self-esteem relative to other factors (e.g., personal- both occur, on average, at least once a week for 3 months.
ity, relationships, career/school, and so on). Another Cana- D. Self-evaluation is unduly influenced by body shape and
dian research group has developed a self-report measure weight.
of weight-based self-esteem called the Weight-Influenced E. The disturbance does not occur exclusively during episodes
Self-Esteem Questionnaire (WISE-Q). The WISE-Q mea- of anorexia nervosa.
sures the influence of weight on how individuals with eat- Source: Reprinted with permission from the Diagnostic and Statistical Manual
ing disorders feel about themselves in various domains of of Mental Disorders, Fifth Edition. (Copyright © 2013), American Psychiatric
Association. All Rights Reserved.
self-evaluation (Trottier, McFarlane, Olmsted, & McCabe,
2013). It appears that for individuals with eating disorders,
feelings about their weight influence how they feel about
other, unrelated domains of self-evaluation (e.g., morality,
behaviours. Compensatory behaviours consist of any behav-
performance at work or school). Research with the WISE-Q
iours meant to “get rid of ” or “make up for” the binge,
found that when weight influences how individuals feel
including self-induced vomiting; use of laxatives, diuretics,
about themselves in domains that realistically should not be
or other medications; strict dieting; or vigorous exercise to
linked to weight/shape (e.g., school performance), relapse
prevent weight gain (see Table 10.3). In addition, the self-
following intensive eating disorder treatment is more likely
evaluation of individuals with bulimia is overly influenced
(McFarlane, Olmsted, & Trottier, 2008).
by body shape and/or weight. You might notice that this cri-
The DSM-5 subtypes anorexia into restricting type
terion is the same as one of the three criteria for anorexia
and binge-eating/purging type for both research and clini-
nervosa, reflecting the distortion in the experience and sig-
cal purposes. Restricting type individuals attain their
nificance of body weight in these individuals. Whereas this
extremely low body weights through strict dieting and,
criterion is a central component of the diagnostic criteria
sometimes, excessive exercise. Binge-eating/purging type
for bulimia nervosa, it is one of three alternative criteria for
individuals not only engage in strict dieting (and possibly
anorexia nervosa. The third criterion requires that episodes
excessive exercise) but also regularly engage in binge eat-
of binge eating and compensatory behaviours occur, on aver-
ing and/or purging behaviours. The distinction between
age, at least once a week for three months. Individuals who
restricting and binge-eating/purging subtypes is impor-
fail to meet the criteria for frequency or duration, but who
tant for research and clinical purposes for several reasons.
are nonetheless regularly having episodes of binge eating
Binge eating and/or purging behaviours are often directly
and compensatory behaviour, are still considered to have an
addressed in treatment and have a variety of physical conse-
eating disorder but are not diagnosed with bulimia (see the
quences that may require medical attention. There may also
section on other specified feeding or eating disorders).
be differences between these groups with respect to their
ability to regulate and manage negative emotions and impul- BINGE EATING DISORDER Binge-eating disorder (BED)
sive behaviours (Peat, Mitchell, Hoek, & Wonderlich, 2009). involves recurrent episodes of binge eating, as in bulimia
The binge-eating/purging subtype also has a poorer prog- nervosa, but these individuals do not engage in inappropri-
nosis than the restricting subtype (Peat et al., 2009). When ate compensatory behaviours. In addition to the presence of
conducting research, it is important to describe exactly what regular binge eating, individuals must report at least three
and whom you are studying. The subtypes allow researchers of the following features associated with binge-eating epi-
to describe their participants more precisely. sodes: eating very rapidly; eating until uncomfortably full;
eating large amounts of food even when not hungry; eating
BULIMIA NERVOSA The DSM-5 defines bulimia nervosa alone because of embarrassment about the amount of food
as an eating disorder characterized by recurrent episodes of consumed; and feeling disgusted, depressed, or guilty after
objective binge eating and inappropriate use of compensatory binges. The binge eating episodes must occur, on average,

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 Eating Disorders 237

TABLE 10.4 DSM-5 DIAGNOSTIC CRITERIA FOR and anxiety compared to individuals who are obese but do
BINGE EATING DISORDER not have a BED diagnosis (Fandiño et al., 2010).
A. Recurrent episodes of binge eating. An episode of binge
eating is characterized by both of the following: OTHER SPECIFIED/UNSPECIFIED FEEDING OR EATING
1. Eating, in a discrete period of time (e.g., within any DISORDER Although the concept of an eating disorder is
2-hour period) an amount of food that is definitely larger typically equated with anorexia, bulimia, and BED, there
than what most people would eat, in a similar period of is another category of eating disorder (other specified/
time under similar circumstances. unspecified feeding or eating disorder) that was previously
2. A sense of lack of control over eating during the episode identified as more common than either anorexia or bulimia
(e.g., a feeling that on cannot stop eating or control what nervosa in community and outpatient settings (Fairburn &
or how much one is eating). Bohn, 2005). Even in a large Canadian tertiary care centre,
B. The binge-eating episodes are associated with three (or
which provides specialized intensive treatment, 40 percent
more) of the following:
of the individuals who received treatment had a diagnosis of
1. Eating much more rapidly than normal.
2. Eating until feeling uncomfortably full.
an eating disorder that did not meet the criteria for anorexia
3. Eating large amounts of food when not feeling physically or bulimia nervosa (Rockert, Kaplan, & Olmsted, 2007).
hungry. In the publication of DSM-5, several changes were
4. Eating alone because of feeling embarrassed by how made to the criteria for eating disorders that were expected
much one is eating. to reduce the frequency of individuals who are diagnosed
5. Feeling disgusted With oneself, depressed, or very guilty under this “other” category (Keel, Brown, Holm-Denoma,
afterward. & Bodell, 2011). These changes include the addition of BED
C. Marked distress regarding binge eating is present. as a stand-alone eating disorder, a decrease in the frequency
D. The binge eating occurs, on average, at least once a week of binge eating needed for a diagnosis of bulimia nervosa,
for 3 months.
and removing a criterion for amenorrhea for the diagnosis
E. The binge eating is not associated with the recurrent use of
of anorexia nervosa. Indeed, these changes have reduced the
inappropriate compensatory behavior as in bulimia nervosa
and does not occur exclusively during the course of bulimia
proportion of individuals with eating disorders classified
nervosa or anorexia nervosa in this “other” category (Vo, Accurso, Goldschmidt, & Le
Grange, 2016).
Source: Reprinted with permission from the Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition. (Copyright © 2013), American Psychiatric The category of “other specified feeding or eating dis-
Association. All Rights Reserved.
order” encompasses eating disorders of clinical severity that
do not meet the specific criteria for anorexia, bulimia, or
BED (see Table 10.5). In some individuals, the eating dis-
order resembles the full syndromes of anorexia, bulimia, or
at least once per week for three months. Finally, significant BED but does not quite meet full DSM-5 diagnostic criteria
distress about binge eating must be present. (e.g., the case of someone who meets all of the criteria for
The publication of DSM-5 represents the first time that bulimia nervosa but engages in binge/purge episodes, on
BED has been recognized as a stand-alone, specified eating average, less than once a week). In other individuals, the psy-
disorder (as it was previously classified under disorders for chopathological features of the eating disorder combine in
further study [see Table 10.4]). There has been some dis- a different way than in one of these three disorders, but are
agreement among researchers as to whether BED is itself a nevertheless clinically significant.
discrete disorder or whether it is a type of bulimia. Some Purging disorder is included in the category of “other
researchers have suggested that BED should be classified as specified feeding or eating disorder,” (OSFED) and is char-
a subtype of bulimia because both disorders have binge eat- acterized by the use of inappropriate compensatory behav-
ing as a central feature. However, a review of the research on iours (such as vomiting or laxative use) in the absence of
BED has helped to resolve some of the debate about whether binge eating by individuals who are within the normal
this disorder could be considered as a stand-alone eating weight range. Night-eating syndrome has also been added
disorder, by demonstrating that BED appears to be distinct to this category. Night-eating syndrome is characterized
from the other eating disorders, and that there is notable by repeated nocturnal eating (but not binge eating, which
psychopathology and significant impairments in quality of would be better accounted for by BED), which causes sig-
life associated with BED (Wonderlich, Gordon, Mitchell, nificant distress and/or impairment in functioning. Both
Crosby, & Engel, 2009). Importantly, although many indi- purging disorder and night-eating syndrome lack sufficient
viduals with BED are obese, this is not a requirement for the research to be classified as distinct eating disorders, although
diagnosis of BED. Conversely, not all individuals who are a growing body of evidence suggests that both conditions
obese have regular binge-eating episodes: Approximately represent pathological eating behaviour that is associated
20 to 45 percent of individuals who are obese and attend- with significant reductions in quality of life (Keel & Striegel-
ing a weight-loss clinic have symptoms of BED (Brewerton, Moore, 2009; Striegel-Moore, Franko, & Garcia, 2009).
1999). Individuals with BED report higher levels of eating Finally, there is the “unspecified feeding or eating disorder”
disorder psychopathology, and higher levels of depression category, which applies to individuals with eating disorder

M10_DOZO8871_06_SE_C10.indd 237 25/10/17 5:56 PM

 238 Chapter 10

TABLE 10.5 DSM-5 DIAGNOSTIC CRITERIA FOR OTHER SPECIFIED FEEDING OR EATING DISORDER

This category applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant
distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for
any of the disorders in the feeding and eating disorders diagnostic class. The other specified feeding or eating disorder category is used
in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any
specific feeding and eating disorder. This is done by recording “other specified feeding or eating disorder” followed by the specific rea-
son (e.g., “bulimia nervosa of low frequency”).
Examples of presentations that can be specified using the “other specified” designation include the following:
1. Atypical anorexia nervosa: All of the criteria for anorexia nervosa are met, except that despite significant weight loss, the indi-
vidual’s weight is within or above the normal range.
2. Bulimia nervosa (of low frequency and/or limited duration): All of the criteria for bulimia nervosa are met, except that the binge eat-
ing and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than 3 months.
3. Binge-eating disorder (of low frequency and/or limited duration): All of the criteria for binge-eating disorder are met, except that the
binge eating occurs, on average, less than once a week and/or for less than 3 months.
4. Purging disorder: Recurrent purging behavior to influence weight or shape (e.g., self-induced vomiting; misuse of laxatives, diuret-
ics, or other medications) in the absence of binge eating.
5. Night eating syndrome: Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive
food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better explained
by external influences such as changes in the individual’s sleep-wake cycle or by local social norms. The night eating causes
significant distress and/or impairment in functioning. The disordered pattern of eating is not better explained by binge-eating
disorder or another mental disorder, including substance use, and is not attributing to another medical disorder or to an effect of
medication.
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. (Copyright © 2013), American Psychiatric Association.
All Rights Reserved.

symptoms that cause distress and/or impairment, but do not and between bulimia and BED. Someone with the binge-
meet criteria for any of the specified eating disorders. eating/purging type of anorexia may differ from someone
with bulimia only with respect to whether his or her weight
is significantly below what is expected for his or her height
DIAGNOSTIC ISSUES and age. Similarly, it can be difficult to determine whether
DIFFERENTIAL DIAGNOSIS As is the case with the diag- some individuals engage in inappropriate behaviours to
nosis of all mental disorders, when diagnosing an eating compensate for binges.
disorder, psychiatrists and psychologists must consider and For example, imagine the case of an individual who
rule out other possible causes for the patient’s symptoms. For reports regular binge-eating episodes, and who exercises as
example, in the case of someone with a probable diagnosis well. To determine whether a diagnosis of bulimia nervosa
of anorexia or bulimia nervosa, it is important to establish would be appropriate, it is critical to determine whether the
that the symptoms are not due to a medical condition. Sev- exercise represents an inappropriate compensatory behav-
eral medical conditions cause significant weight loss (e.g., iour. To determine whether exercise is severe enough to be
gastrointestinal disease, acquired immune deficiency syn- considered “excessive” or inappropriate, the DSM-5 sug-
drome), and some even involve disturbed eating behaviour gests that it should be interfering significantly with impor-
(e.g., Kleine-Levin syndrome, a sleep disorder characterized tant activities or occurring at inappropriate times or in
by excessive sleep alternating with disinhibited behaviour, appropriate settings, or the patient should be continuing to
such as compulsive overeating). It is also important to rule exercise despite injury or medical complications. The exer-
out major depressive disorder, as it may involve either severe cise should also be directly connected to the binge-eating
weight loss or overeating. However, individuals experiencing episodes, with the purpose of preventing weight gain, to be
these other disorders and conditions will not exhibit the over considered a compensatory behaviour.
concern with weight and/or shape that is characteristic of
eating disorders and they will not engage in inappropriate VALIDITY OF DIAGNOSTIC CRITERIA AND CLASSIFICA-
compensatory behaviours, as in bulimia nervosa. TION Because there can be small distinctions between eat-
Once a psychiatrist or psychologist has determined that ing disorder categories, some researchers (e.g., Van der Ham,
an individual has an eating disorder, he or she must then Meulman, Van Strien, & Van Engeland, 1997) have proposed
determine which eating disorder the person has. Unlike other that eating disorders be conceptualized on a spectrum, rather
disorders, such as anxiety disorders, it is not possible to have than as separate diagnostic categories. In other words, they
more than one eating disorder at the same time. Some of suggest that the eating behaviours and other psychopathol-
the important distinctions to be made are between bulimia ogy of individuals with eating disorders exist on a spectrum
nervosa and the binge-eating/purging type of anorexia, of severity. On a spectrum of binge eating, for example, it

M10_DOZO8871_06_SE_C10.indd 238 25/10/17 5:56 PM

 Eating Disorders 239

has been proposed that BED be the least severe and bulimia numerical ratings of the frequency and severity of eating
with the presence of purging behaviours as the most severe disorder symptoms such as binge eating and compensatory
pathology (Hay & Fairburn, 1998). behaviours, and also provides normative data on dietary
Support for the spectrum view of eating disorders restraint, and eating, weight, and shape concerns. Conduct-
comes from the fact that many individuals move from one ing a diagnostic interview for an eating disorder involves
diagnostic category to another (and even back again) across gathering a great deal of information from the individual
time. As many as three-quarters of individuals with an ini- being assessed. The interviewer must gather information
tial diagnosis of anorexia nervosa cross over into the other not only about the current and past frequency and severity
subtype of anorexia or into bulimia nervosa. In contrast, few of dietary restriction, binge eating, purging, and exercise,
individuals who begin with bulimia cross over into anorexia but also about distorted attitudes and beliefs about weight,
(Eddy et al., 2008). Fairburn, Cooper, and Shafran (2003) have shape, and eating; weight history; and current and past
pointed out that eating disorder diagnoses tend to change menstrual function (for post-menarchal females). The inter-
in a systematic way over the lifespan. In mid-adolescence, view should also assess the patient’s interpersonal function-
eating disorders most typically resemble anorexia nervosa, ing and potential factors that may have contributed to the
whereas the eating disorders of late adolescence and early development and/or maintenance of the eating disorder, as
adulthood tend to resemble bulimia nervosa. Furthermore, well as the patient’s level of available social support.
in a study of individuals with bulimia nervosa, there was An additional goal of diagnostic interviews for eating
evidence that individuals with a history of anorexia nervosa disorders is typically to assess for the presence and absence
had lower BMIs and smaller waist and hip circumferences of other psychological disorders, as other disorders are often
than individuals with bulimia without a history of anorexia present in individuals with eating disorders. Some of the dis-
(Vaz, Guisado, & Peñas-Lledó, 2003). Individuals who have orders that are often assessed for are substance use disorders,
crossed over from anorexia to bulimia nervosa also remain at mood disorders, anxiety disorders, obsessive compulsive
risk of relapsing back to anorexia (Eddy et al., 2008). These disorder, post-traumatic stress disorder, and personality
findings suggest that subclinical features or unique charac- disorders.
teristics of anorexia may remain in individuals who cross Another important component of eating disorders
over from anorexia to bulimia nervosa, supporting the spec- assessment is a medical examination that can determine
trum view of eating disorders. the presence of any physical and/or medical complications
Many researchers continue to express reservations associated with eating disorders. These complications will
about the limitations of the classification system used for eat- be addressed in greater detail in the following section. It is
ing disorders in the DSM-5, and some are looking ahead and important to assess for the medical consequences of eating
considering possible approaches for the DSM-6 that could disorders, as they should be addressed and monitored as part
improve the clinical utility of diagnostic criteria for eating of treatment. Furthermore, for some patients, knowledge of
disorders (Fairburn & Cooper, 2011). One approach that is the physical and medical complications of their eating disor-
gaining traction is the National Institute of Mental Health’s ders can motivate them to pursue recovery.
(NIMH) Research Domain Criteria (RDoC) approach (see A final component of many assessments is the admin-
Chapter 3), which argues that instead of studying mental istration of self-report questionnaires to complement the
health disorders based on discrete (and potentially arbi- information gathered through the clinical interview. One
trary) categorical classifications, the best approach may be to of the most frequently used self-report questionnaires
examine core underlying features that characterize men- with individuals with eating disorders is the Eating Disor-
tal disorders more broadly (e.g., emotion regulation defi- der Inventory, which assesses eating disorder attitudes and
cits; NIMH, 2016). Nevertheless, despite the emergence of behaviours (Garner, Olmsted, & Polivy, 1983). Question-
alternative approaches and some of the controversy that has naires measuring symptoms of depression, general psycho-
surrounded the changes to the criteria for eating disorders pathology, quality of life or impairment, and social support
in the DSM-5 (and in particular, the addition of BED as a are also often administered.
stand-alone eating disorder), some researchers have found
support for the validity of the DSM-5 criteria for eating dis-
orders (e.g., Keel, Brown, Holm-Denoma, & Bodell, 2011). Physical and Psychological
Complications
ASSESSMENT There are numerous serious medical, psychological, and
Assessment for diagnostic purposes and to guide treatment behavioural effects of eating disorders. In a review of the
planning is usually conducted using a structured or semi- literature, Agras (2001) indicated that across all the eating
structured interview. Many researchers and clinicians use disorder subtypes, individuals experience reduced quality of
the Eating Disorder Examination (EDE) (Fairburn, Coo- life and their social relationships are negatively affected. In
per, & O’Connor, 2008) to aid their assessments. The EDE individuals with anorexia, some of the physical and medi-
is a structured clinical interview for diagnosing eating cal complications that may develop include osteoporosis,
disorders that has good reliability and validity. It provides cardiovascular problems (including lowered heart rate and

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 240 Chapter 10

low blood pressure), decreased fertility, lethargy, dry skin, conducted by Franklin, Schiele, Brozek, and Keys (1948)
dry hair and hair loss, and heightened sensitivity to cold. has allowed insight into the physical and emotional conse-
Lanugo, a fine downy hair, may grow on the body in order to quences of semi-starvation and weight loss, both of which
maintain body warmth. Amenorrhea, the absence of at least may be present in eating disorders. A group of American
three consecutive menstrual periods, often occurs in women conscientious objectors during the Second World War
of childbearing age with anorexia nervosa. Both cognitive agreed to participate in a study on semi-starvation in lieu of
and emotional functioning can also be affected, such as dif- military service. This study was initially conducted to gain
ficulties concentrating and increases in irritability. Severe, insight into how to best renourish civilians in Europe who
potentially fatal medical conditions can arise in anorexia, had starved during the war; however, it has also provided
which are typically attributed to semi-starvation, as well as critical insights in the field of eating disorders. The par-
to the purging behaviours that are sometimes present. These ticipants were healthy, normal-weight males who restricted
include impaired renal function and cardiac arrhythmia. their eating and engaged in regular physical activity over the
In individuals with bulimia, as well as the binge/purge course of 24 weeks in order to lose approximately 25 percent
subtype of anorexia nervosa, dental problems (such as erosion of their initial body weight. This food restriction and weight
of tooth enamel) often develop due to the presence of stom- loss had both psychological and physiological consequences
ach acid during self-induced vomiting. Similarly, individu- for the participants. The semi-starvation led to decreases
als who self-induce vomiting may exhibit Russell’s sign in heart rate, increases in emotional instability (includ-
(scrapes or calluses on the backs of hands or knuckles). ing depression and irritability), difficulty concentrating,
Electrolyte imbalance, particularly hypokalemia (low potas- decreased sex drive, and lethargy. Many participants also
sium), can occur in individuals with bulimia due to frequent exhibited dry skin and hair and increases in hair loss. Almost
vomiting or laxative use. This imbalance can lead to prob- all of the participants demonstrated an increased focus on
lems with cardiovascular and renal functioning (including food, with food becoming the primary topic of conversation.
gastric rupture and cardiac arrhythmias), which can be fatal. This increased focus on food continued even after the period
As in anorexia, emotional functioning may also be affected. of food restriction ended, during the rehabilitation period
Furthermore, research indicates that individuals who binge for weight restoration. However, at the end of the 12-week
eat are more likely to exhibit comorbid substance abuse rehabilitation period, there was improvement in many of the
(e.g., Root et al., 2010). Additional medical problems and symptoms, and the values for the symptoms had returned to
complications can arise from drug and alcohol abuse, pos- near-normal levels 20 weeks after ending the semi-starvation
ing further difficulties for individuals with eating disorders period. The similarity between these symptoms and those
who already have an elevated risk of mortality (Conason, present in the eating disorders is striking. This suggests that
Klomek, & Sher, 2006). The physical consequences of BED malnutrition may lead to several of the symptoms present in
are similar to those associated with obesity, and include an eating disorders, and that some of these symptoms may be
elevated risk of type 2 diabetes, cardiovascular disease, and alleviated with improved eating and weight restoration.
sleep apnea (pauses in breathing, or very shallow breathing,
during sleep).
One complication involved in studying the physical and BEFORE MOVING ON
psychological symptoms of eating disorders is distinguish- Which conceptualization of eating disorders do you prefer—
ing between whether a factor is a cause or a consequence of the categorical view (i.e., the current diagnostic categories)
the eating disorder. For example, malnutrition may exagger- or the spectrum view? What are some of the advantages and
ate certain symptoms of personality disorders, so it can be disadvantages of the current method of classification?
difficult to determine whether, in the absence of malnutri-
tion, apparent personality disturbances are in fact present in
an individual who has been diagnosed with an eating dis-
order. To investigate whether personality disorders endure Etiology
after recovery from an eating disorder, or are mainly present
during the course of an eating disorder, Matsunaga and col- GENETIC AND BIOLOGICAL THEORIES
leagues (2000) assessed a group of patients who had recov- Despite strong social pressures to be thin and widespread
ered from their eating disorders for at least a year. These body dissatisfaction among young women, eating disorders
researchers demonstrated that although treatment for eating remain relatively rare. This, in conjunction with the fact
disorders seems to attenuate the symptoms of personality that there appears to be a heritable component to eating
disorders, there does indeed seem to be a link between eat- disorders, highlights the possibility that biological factors
ing disorders and personality disorders, even after recovery. play a role in the etiology of eating disorders (Kaye, 2008).
This suggests that personality disorders are not merely a The rate of eating disorders in relatives of individuals with
consequence of the disorder. anorexia nervosa is four-and-a-half times higher than in
Without conducting prospective longitudinal studies, it relatives of a healthy comparison group (Strober, Freeman,
can be difficult to distinguish between the causes and conse- Lampert, Diamond, & Kaye, 2000). Reviews of twin studies,
quences of eating disorders. However, a seminal early study family studies, and molecular genetic studies have suggested

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 Eating Disorders 241

that genetics play a significant role in the development of levels, may also account, in part, for the observed gender
eating disorders. A review of high-quality twin studies indi- differences in the prevalence of eating disorders. Research-
cated that 48 to 76% of the variance in anorexia nervosa, 50 ers at McMaster University suggest that gender differences
to 83% of the variance in bulimia nervosa, and 41% of the in the serotonergic system may make women more suscep-
variance in BED is accounted for by genetic factors (Striegel- tible to the development of an eating disorder, as females are
Moore & Bulik, 2007). Although in recent years numerous more susceptible to dysregulation in the serotonin system
genetic studies on eating disorders have emerged, many dif- than are males (Steiner, Lepage, & Dunn, 1997). For exam-
ferent genes have been investigated with few replications, ple, it appears that dieting alters brain serotonin function in
which limits our knowledge about the specific influence of women, but not in men (Walsh, Oldman, Franklin, Fairburn,
genes on eating disorders (Klump & Gobrogge, 2005). & Cowen, 1995). Biological changes occurring at puberty
Dysfunctional neurotransmitter activity has also been may also contribute to the development of eating disor-
investigated as another possible contributor to the devel- ders through secondary mechanisms (rather than directly
opment of an eating disorder. In particular, a link between influencing the development of eating disorders). Eating
serotonin levels and feeding/satiety has been established, disorders typically develop during late puberty, or shortly
and researchers have suggested that a dysregulation of the thereafter. Some researchers have postulated that the hor-
serotonin system is involved in the pathophysiology of eat- monal changes associated with puberty in females may acti-
ing disorders (e.g., Brewerton, 1995). Indeed, individuals vate the development of disordered eating, either directly or
with anorexia and bulimia demonstrate signs of serotonin indirectly (e.g., hormone levels influence body fat composi-
dysregulation (e.g., Kaye, Gendall, & Strober, 1998). For tion or eating behaviour, which in turn increases the risk for
example, it appears that anorexia nervosa is associated with disordered eating; Klump et al., 2006). However, until more
reduced serotonin activity (specifically, reduced density of research is conducted, it is premature to draw conclusions
serotonin transporters in women with anorexia nervosa as about the causal role of gender differences in biological
compared to healthy controls; Bruce, Steiger, Ng Yin Kin, & functioning in the development of eating disorders.
Israel, 2006). It is important to note that the association that has been
Further support for the role of serotonin functioning in established between serotonin functioning and eating disor-
eating disorders comes from research conducted by Robert ders should be interpreted with caution. As you read ear-
Levitan and colleagues (2001) at the University of Toronto. lier in the chapter, it can be difficult to distinguish between
To extend the research demonstrating that individuals with factors that may cause eating disorders and factors that are
eating disorders have disturbances in their serotonin sys- a consequence of the eating disorder. Part of the difficulty
tem, Levitan and colleagues studied polymorphism of the in establishing the role of serotonin in the development of
serotonin 1B receptor gene in individuals with bulimia to eating disorders is the correlational nature of the studies
determine if any association existed between this measure investigating serotonin function in individuals with eating
and BMI. They demonstrated that this association does disorders. It is possible that alterations of serotonergic sys-
exist—polymorphism of the serotonin 1B receptor gene was tems in individuals with eating disorders may simply be a
associated with a lower minimum lifetime BMI (minimum function of low weight (in anorexia) or malnutrition associ-
lifetime BMI was assessed by determining patients’ lowest ated with the eating disorder (Wolfe, Metzger, & Jimerson,
weight since age 17, along with patients’ height, to calcu- 1997). However, researchers studying serotonin functioning
late BMI). Hence, individuals with bulimia who exhibited in individuals who had a history of bulimia nervosa and were
a particular expression of the serotonin 1B receptor gene no longer symptomatic, compared with individuals with
reported having a lower minimum BMI than individuals current bulimia nervosa and healthy controls, found that
with bulimia with different expressions of this gene. These serotonin transporter densities were lower than controls in
findings support the possible role of genetic factors (in par- both individuals with active and remitted bulimia nervosa
ticular, serotonin receptor genes) in bulimia. However, as (Steiger et al., 2005). Steiger and colleagues suggest that
Klein and Walsh (2004) point out, it is unlikely that eating serotonergic dysregulation may be a trait that increases the
disorders stem from polymorphism of one gene in particular. risk of developing bulimia. Further research is necessary in
It is more likely that sets of genes, interacting with particular order to conclude that serotonin dysregulation is a contribu-
environmental factors, are implicated in the development of tor to the development of eating disorders, as opposed to a
eating disorders. lasting consequence of these disorders.
Clearly, the development of eating disorders is a com-
plex process that is not the result of the presence of merely BEFORE MOVING ON
one biological factor. These genetic or biological factors,
however, may interact with other factors to precipitate the Earlier in the chapter, you read about some of the physical
development of eating disorders. Although it seems that gen- consequences of eating disorders. Compare and contrast
der differences in eating disorders are in part attributable to these physical symptoms, which are thought to be a conse-
socio-cultural factors (which are addressed in the next sec- quence of malnutrition associated with eating disorders, with
the genetic/biological factors that are thought to contribute
tion), it is also possible that gender differences in biologi-
to the development of eating disorders.
cal factors, such as serotonergic functioning and hormonal

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 242 Chapter 10

FOCUS
Thin Ideal Media Images Make Women Feel Bad, Right?
10.1 A great deal of research has sought to demonstrate appearance satisfaction and increased thin ideal internalization
a relation between thin ideal media images and dis- result (e.g., Tiggeman & Polivy, 2010).
ordered eating behaviours and/or attitudes. A recent Although the majority of studies have found negative
meta-analysis showed that exposure to media images pro- effects of thin ideal media exposure, some studies have failed to
moting the thin ideal is correlated with higher body dissatis- find any significant effects (e.g., Champion & Furnham, 1999)
faction, restrictive eating behaviours, and symptoms of anorexia or have found positive effects on self-perceptions (e.g., Joshi,
and bulimia nervosa in women (Ferguson, 2013). The effects Herman, & Polivy, 2004). Furthermore, the recent meta-analysis
for women overall were small but statistically significant. How- described earlier showed that although there were small effects
ever, when samples of women were subdivided into high versus for women, there were few effects for men or for the general
low pre-existing body dissatisfaction, the relationship between population (Ferguson, 2013), suggesting that gender is likely
media images and body dissatisfaction was much stronger for an important factor to consider in understanding the relation-
those women who already had body image concerns (Ferguson, ship between thin media images and body dissatisfaction. It
2013). Additionally the relation between different types of media is likely that a number of studies finding no significant effects
consumption (e.g., television, magazines, music videos) appears have gone unpublished due to the fact that it can be difficult to
to relate to degree of body dissatisfaction in similar ways (Fergu- publish a study with null results. One potential reason why so
son, 2013). However, correlational studies cannot demonstrate many studies have found negative effects of thin media exposure
that exposure to thin body images causes body dissatisfaction is that women may believe that they should feel worse about
and other eating disorder–related symptoms. It seems just as themselves after viewing these stimuli. In a qualitative interview
likely that individuals who are already dissatisfied with their study, adolescent girls reported that the portrayal of thin models
bodies seek out these images. In response to this problem, a in the media was the major force in creating body dissatisfac-
number of experimental studies have manipulated exposure to tion (Wertheim, Paxton, Schutx, & Muir, 1997). If participants
thin ideal media figures and measured the corresponding effects believe that viewing idealized media images should make them
on body dissatisfaction and other self-perception measures. feel worse about themselves, then they are likely to respond in a
The literature suggests that thin media images do have an negative way to such images when simply asked how the images
adverse effect on the body dissatisfaction of some young women. make them feel.
Indeed, a meta-analysis of the literature (Grabe, Ward, & Shibley One Canadian study directly addressed the issue of these
Hyde, 2008) found that exposure to thin ideal images was asso- demand characteristics in this area of research. Mills, Polivy,
ciated with higher levels of body dissatisfaction and thin ideal Herman, and Tiggeman (2002) demonstrated that when demand
internalization among women compared with exposure to con- characteristics are present (in that participants were aware that
trol images. Negative effects were even found on eating beliefs their responses to the media images were the topic of interest to
and behaviours. The authors pointed out that it is very concern- the experimenters), dieters report feeling more depressed follow-
ing that brief experimental exposures to thin ideal images can ing exposure to idealized images. However, when demand char-
affect beliefs about eating, dieting, and purging. Additionally, acteristics were minimized, chronic dieters rated their current
women with pre-existing body image issues were more adversely body sizes as thinner following exposure to idealized images.
affected by thin media stimuli presented in research studies The results of this study suggest that rather than using models
than were women who were relatively satisfied with their bodies as standards of comparison, dieters identified with these thin
(Groesz, Levine, & Murnen, 2002). ideal images and were inspired by them or engaged in a posi-
These frequently observed negative effects of exposure tive fantasy in response to them. These findings may help to
to idealized media images are typically explained using social explain why many women not only voluntarily expose themselves
comparison theory. Studies finding negative effects of idealized to thin ideal media images but also seem to enjoy looking at
media images generally assume that participants are using the them. Even in the cases where thin ideal media images have
thin models as standards of comparison for determining self- immediate positive effects, they may have adverse effects in
evaluations. In line with this hypothesis, studies have shown that the long term because positive inspirational effects may encour-
when young women engage in upward social comparisons with age dieting, which may worsen self-esteem and body satisfaction
fashion models on the dimension of attractiveness, decreased in the long run. ●

PSYCHOLOGICAL THEORIES body size of the “ideal” woman. From 1959 to 1988, Miss
SOCIO-CULTURAL FACTORS According to the socio- America contestants and Playboy centrefolds became progres-
cultural model of eating disorders, these disorders are (to at sively thinner (Garner, Garfinkel, Schwartz, & Thompson,
least some extent) a product of the increasing pressures for 1980; Wiseman, Gray, Mosimann, & Athrens, 1992; see
women in Western society to achieve an ultra-slim body. Figure 10.1). Wiseman and colleagues found that most of these
The mass media are a ubiquitous source of thin ideal images models weighed less than 85 percent of what would have been
(see Focus box 10.1). Research has shown that in the last half considered normal for their age and height—meaning that
of the twentieth century, there was a steady decrease in the they met the criteria of low body weight for anorexia nervosa.

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 Eating Disorders 243

100 Average Body Weight

92 Playboy
91 Miss America
90
Percentage Expected Weight

89
88
87
86
85
84
83
82
81
80

59 61 63 65 67 69 71 73 75 77 79 81 83 85 87
Year

FIGURE 10.1 Average Percentage of Expected Weight of Playboy Centrefolds (1959–1978) and Miss America
Contestants (1979–1988)
Source: Republished with permission of John Wiley & Sons, from Cultural Expectations of Thinness in Women: An Update, International Journal of Eating Disorders, Vol. 11, No. 1,
pp. 85–89. 1992; permission conveyed through Copyright Clearance Center, Inc.

Another study examined Playboy centrefolds up to 1999 turn, increase the risk for eating disorder psychopathol-
(Sypeck et al., 2006). The results suggest that although the ogy. Recently, there has been a shift in the ideal female
Playboy models remained underweight, their weights appear body presented by the media, such that the women are
to have stabilized during the last two decades of the twenti- now presented as both extremely thin and extremely toned
eth century. The most recent of these studies looked at both (Grogan, 2008). Homan (2010) investigated the longitudi-
American and German Playboy centrefolds between 1980 and nal impact of idealization of these athletic ideal images
2011 (Hergovich & Sussenbach, 2015). Although the models’ and found that it predicted change in compulsive exercise
weights stayed stable, on average their bust sizes decreased over the seven-month study period but not body dissat-
and their bodies became more androgynous (i.e., less cur- isfaction or dieting. In contrast, thin ideal internalization
vaceous) overall. This change was more pronounced in the predicted change in all three outcomes. Importantly,
American sample. Thus, in addition to an overall thin ideal there may also be important racial/ethnic differences in
body weight, the ideal body shape for women has become ideal body preferences. In particular, although European-
increasingly less curvaceous over time, particularly in the American women tend to prefer thin, athletic body types,
United States (Hergovich & Sussenbach, 2015). African American women may endorse more curvy ideal
Internalization of these thin media images is believed body sizes (Overstreet, Quinn, & Agocha, 2010). Latina
to be a causal risk factor for the development of an eat- women may simultaneously endorse both the dominant thin
ing disorder (Thompson & Stice, 2001). Internalization of ideal, as well as a more curvy ideal body type (Viladrich,
the thin ideal involves affirming the desirability of socially Yeh, Bruning, & Weiss, 2009).
sanctioned ideals and engaging in behaviours to achieve It is interesting that while the ideal body size for women
the ideals (Heinberg, Thompson, & Stormer, 1995). Thin has been getting thinner, women are actually becoming
ideal internalization is believed to lead directly to body heavier. According to the Women’s Health Surveillance
dissatisfaction (because the cultural ideal is unattainable Report commissioned by Health Canada, the prevalence
for most women) and dieting. Both of these variables, in of being overweight among women increased from 19% in

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 244 Chapter 10

30 1985
Morrow, Hrabosky, & Perry, 2004), and is also prevalent
among adolescent girls (Lawler & Nixon, 2011). For exam-
1991 ple, in a sample of 129 adolescent girls between the ages
25 of 12 and 19, 80 percent reported a desire to change their
1994/1995
Percentage of Respondents

body size (Lawler & Nixon, 2011). This body dissatisfac-

2000/2001
tion encourages many girls and women to diet in an effort
20
to change their weight or shape. In fact, dieting has become
so prevalent that it, too, has been described as “normal”
15 for young women (Polivy & Herman, 1987). The question
remains, however, why given that almost all women are
exposed to socio-cultural pressures to be thin, and many
10 develop body dissatisfaction and engage in dieting behav-
iours, far fewer go on to develop eating disorders (Polivy &
Herman, 2004).
5

BEFORE MOVING ON
0
Overweight Obese
Under what conditions do you think thin ideal media images
Year of Survey are more likely to have negative effects on young women?
How do you think these images might affect older women or
FIGURE 10.2 Percentage of Female Canadians Aged 20
men?
to 64 Considered Overweight and Obese
Source: Physical activity and obesity in Canadian women. In Canadian Institute for Health
Information, Women’s Health Surveillance Report. 2003.
FAMILY FACTORS The family has been identified as an
important influence in the development of eating disorders.
1985 to 26% in 2000/2001, and the prevalence of obesity It can provide cultural transmission of pathological values or
among women increased from 7% to 14% during the same be a stressor on its own (by being a source of miscommunica-
time period (Bryan & Walsh, 2004; see Figure 10.2). More tion or conflict, or through lack of emotional support). It can
recently, the Canadian Community Health Survey found also be a protective factor by providing support, identity, and
that the prevalence among women of being overweight or comfort. The way in which families communicate cultural
obese was 30% and 23%, respectively, in 2004. The preva- ideas about thinness can potentially contribute to the devel-
lence of being overweight or obese among men has similarly opment of eating disorders (e.g., Haworth-Hoeppner, 2000;
increased. Strober et al., 2000). When the family environment is criti-
There also appears to be an increasing discrepancy cal or coercive, or weight/shape and appearance are promi-
between the average man and the “ideal” man as depicted in nent themes in the household, the risk of eating disorders
the media, such that the ideal man is becoming more mus- increases (Haworth-Hoeppner, 2000).
cular, whereas the average man is developing more body fat Family factors such as parental attitudes about weight
(Spitzer, Henderson, & Zivian, 1999). However, pressure to and shape, and unhealthy eating behaviours in the home may
obtain the ideal body appears to be greater for women than also have a role in increasing eating disorder risk. For exam-
for men. According to the socio-cultural model of eating ple, mothers who make comments about weight and shape, or
disorders, the greater prevalence of eating disorders among who engage in dieting behaviours may inadvertently commu-
women than among men is a result of the greater pressure on nicate these feelings and behaviours to their daughters, who
women to obtain the “ideal” body. Nonetheless, research sug- often emulate them (Coffman, Balantekin, & Savage, 2016;
gests that men are indeed susceptible to the potential effects Smolak, Levine, & Schermer, 1999). Additionally, children in
of exposure to idealized male media images (Pritchard & families that focus on physical attractiveness and weight may
Cramblitt, 2014). A meta-analysis of published experimental be more likely to develop an eating disorder, especially chil-
literature suggests that exposure to muscular male fashion dren who are particularly sensitive to family expectations and
models leads men to feel worse about their bodies (Bartlett, values (Davis, Shuster, Blackmore, & Fox, 2004).
Vowels, & Saucier, 2008). There is also evidence that expo- Children of mothers who themselves have eating disor-
sure to these images is related to negative psychological (e.g., ders may be at particular risk for developing eating problems.
depression) and behavioural (e.g., excessive exercise) out- Some of this risk may be genetically inherited, and some of
comes. We further address some of the factors that may play the risk may be transmitted via modelling. For example, the
a role in gender differences in eating disorders later in this children of mothers who have eating disorders report greater
chapter. weight and shape concerns and more dietary restraint than
Our society’s obsession with thinness for women is so children whose mothers do not have eating disorders (Stein
widespread that a moderate degree of body dissatisfaction et al., 2006). A mother’s own eating disorder may also affect
has been normative among women for some time (Cash, her ability to determine how to best feed her child, which

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 Eating Disorders 245

may result in feeding her child in a more restrictive manner (Polivy & Herman, 2002). Longitudinal studies have indi-
than women without eating disorders (Reba-Harrelson et al., cated that these sorts of factors may predict the development
2010). Shared vulnerability to negative affect may also help of eating disorders before they appear in a given individual
to explain the increased risk of eating disorders in the chil- (Thompson & Stice, 2001).
dren of mothers with eating disorders. For example, the chil- Individuals may try to compensate for these problems
dren of mothers with eating disorders may be more likely by trying to construct an identity focused on weight, shape,
to experience symptoms of depression and anxiety (Reba- and excessive control of one’s body, to help create a sense
Harrelson et al., 2010), which suggests a shared vulnerability of self. This reliance on one’s weight and shape, however,
towards negative emotions. can make one more vulnerable to eating problems in the
face of threats to this identity. For example, experiences that
PERSONALITY/INDIVIDUAL FACTORS A number of per- appear to be unrelated to weight and shape (e.g., feelings of
sonality traits appear to characterize patients with eating ineffectiveness in other areas) may be mislabelled or misin-
disorders, both before and during their eating disorder, and terpreted as “feeling fat” (McFarlane, Urbszat, & Olmsted,
some individual difference variables may be influential in 2011). Clinical observations suggest the extent to which an
the development of the pathology. Personality research is, individual’s identity can be influenced by an eating disor-
of necessity, correlational in nature, so it is not possible to der, and how difficulties in treatment can arise as a result of
conclude that these differences are what cause the develop- this identification with the disorder (e.g., Bulik & Kendler,
ment of an eating disorder, but the distinctions are nonethe- 2000). There is evidence that individuals with anorexia
less suggestive. or bulimia have more negative (and fewer positive) self-
Personality traits such as perfectionism, obsessiveness, schemas than do control individuals without a history of
neuroticism, negative emotionality, avoidance of harm, and mental disorders (Stein & Corte, 2007). Self-schemas, in
general avoidance characterize both patients with anorexia turn, are associated with body dissatisfaction, as individu-
nervosa and those with bulimia nervosa (Cassin & von als who have fewer positive self-schemas are more likely to
Ranson, 2005). In addition, individuals with anorexia nervosa report higher body dissatisfaction. This research supports
are often characterized by high levels of constraint, persever- the notion that identity impairments are associated with
ation and rigidity, and low levels of novelty seeking, whereas eating-disordered symptomatology (Stein & Corte, 2007).
individuals with bulimia nervosa often exhibit high impulsiv- Dieting, and the embracing of society’s idealization
ity, novelty and sensation seeking, and characteristics over- of thinness for women that dieting reflects, has itself been
lapping with borderline personality disorder (Cassin & von implicated as a precipitating factor in eating disorders, espe-
Ranson, 2005). These traits tend to be present both during cially binge eating (Polivy & Herman, 2002). Despite this,
the disorder and after recovery (Fairburn et al., 1999; Kaye it is clear that very few of the millions of people who are
et al., 1998; Lilenfeld et al., 2000). Some personality charac- chronic dieters will go on to develop an eating disorder. Sim-
teristics common to eating disorders, such as perfectionism, ilarly, some sports and activities that place extreme emphasis
are found in family members of individuals with eating dis- on appearance, body shape, or leanness (such as gymnastics
orders who do not themselves have any symptoms of eating or ballet dancing) are associated with increased risk for eat-
disorders (Lilenfeld et al., 2000). A review that included pro- ing disorders (Bratland-Sanda & Sundgot-Borgen, 2013).
spective studies suggested that the presence of these personal- Thus, certain personality and behavioural patterns appear
ity factors increases the risk of developing an eating disorder to be contributors to the development of eating disorders,
(Lilenfeld, Wonderlich, Riso, Crosby, & Mitchell, 2006). though none of these is a perfect predictor.
Other individual differences have been studied as pos-
sible risk factors contributing to the development of eating MATURATIONAL ISSUES As children develop into ado-
disorders. These include characteristics such as low self- lescence, physical maturation causes increasing sex differ-
esteem, identity problems, depressive affect, and poor body ences such that males begin to become more muscular, and
image, as well as behaviours undertaken in connection with females become more curvaceous. This pushes males toward
some of these, including dieting and participation in exer- the masculine ideal body shape, but for females, pubertal
cising or sports that emphasize the body (Polivy, Herman, development involves adding body fat, which takes girls
Mills, & Wheeler, 2003). further away from the thin ideal female figure (Striegel-
Low self-esteem is present in many mental disorders, Moore, 1993). It may not be a coincidence, then, that eat-
not only eating disorders. For example, low self-esteem is ing disorders are most likely to appear around the time of
often linked to depression. Low self-esteem and identity puberty, at the same time that girls develop feelings of body
diffusion may result from traumatic experiences such as dissatisfaction and start to diet to lose weight because their
sexual, physical, or emotional abuse, although such negative level of body fat is increasing. The idealization of a thin body
life experiences are not necessary precursors to the devel- shape by the surrounding culture may push adolescent girls
opment of an eating disorder. In general, having a negative toward dangerous dieting practices and a rejection of one’s
body image, being a chronic dieter, and having low self- own body shape that contribute, in susceptible individuals,
esteem, depression, and identity problems all seem to be risk to the development of eating disorders (Polivy & Herman,
factors associated with the development of eating disorders 2002; Stice, 2002).

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 Eating Disorders 247

APPLIED CLINICAL CASE

Sheena Carpenter her eating disorder increased in severity over time and she devel-
oped many complications, including depressed mood, erosion of
Sheena Carpenter was a young woman who struggled with anorexia her tooth enamel, low electrolytes, and seizures. Her heart, liver,
nervosa up until the time of her death due to starvation at the age and brain were all damaged. At the time of her death, Sheena
of 22. After learning about Sheena’s eating disorder, Sheena’s weighed only 22.67 kilos.
mother, Lynn, sought treatment for her daughter but ran into a Sheena’s eating disorder was not just about pursuing thin-
number of roadblocks: few available treatment resources were ness. Sheena revealed that she had been sexually abused as a
available, and her daughter’s motivation to recover was low and child and she experienced intrusive memories related to this. She
transient. also had a very close but difficult relationship with her mother.
At age 14, Sheena went to a modelling agency where she was After Sheena’s death, Lynn and two of her friends began work on
told that she would be more photogenic if she had a thinner face. establishing a not-for-profit support centre for people with eating
In the years that followed, the first signs of her eating disorder disorders in Toronto called Sheena’s Place. Sheena’s Place offers
emerged—she wore baggy clothes to hide her dropping weight, group therapy to people in the community with eating disorders,
and she became obsessed with food. By the age of 18, Sheena’s with the goal of providing hope and support. Sheena’s Place has
weight had dropped to less than 35 kilos, and her mother discov- grown tremendously since its inception, offering more than 45
ered that Sheena was inducing vomiting. Over the course of her support groups to people with eating disorders. Other similar sup-
disorder Sheena was, at times, able to make progress—on two port centres can be found in Canada—including Danielle’s Place,
occasions she was able to gain 9 kilos. However, for the most part, also in Ontario, and Jessie’s Hope Society in British Columbia.

bulimia nervosa, however, research indicates that the treat- images were distorted toward perceptions of overweight
ment response does not appear to differ for male and female (Betz, Mintz, & Speakmon, 1994). Hence, it is possible that
patients (Shingleton, Thompson-Brenner, Thompson, Pratt, males are more protected than females against the develop-
& Franko, 2015). Furthermore, it appears that male patients ment of eating disorders, given their different types of weight
can be treated effectively in a setting that is composed pri- and shape concerns and less frequent dieting behaviours.
marily of females (Woodside & Kaplan, 1994). However, this factor alone cannot account for the develop-
A recent review of the literature on eating disorders in ment of eating disorders, given that eating disorders are so
males (Jones & Morgan, 2010) suggests that similar factors rare despite the fact that body dissatisfaction is so widespread.
influence the risk of developing eating disorders in men and There seem to be some protective factors operating for
women, and that the main factors that could explain the gen- males; yet, there are still cases of eating disorders in males.
der discrepancy are unresolved. Eating disorders may occur Are there certain groups of males that may be more suscep-
more frequently in women because the strength, or preva- tible to developing eating disorders? Some evidence suggests
lence, of certain risk factors (such as socio-cultural factors) is that gay males may have a greater risk than heterosexual
higher than for men. For example, Andersen and DiDomenico males for developing eating disorders. Men who identify
(1992) found that for every diet-related article or advertise- as gay are more likely than heterosexual males to be preoc-
ment in men’s magazines, there were 10.5 in women’s maga- cupied with their body size and shape (Strong, Williamson,
zines. Of course, the fact that women are exposed to more Netemeyer, & Geer, 2000) and appear to have a higher prev-
diet-related material than men cannot solely account for why alence of eating disorder symptoms than heterosexual males
more women develop eating disorders. After all, if this were (Feldman & Meyer, 2007). Furthermore, researchers have
the case, we would expect to see a higher prevalence of eat- indicated that men seeking treatment for an eating disorder
ing disorders in women, given that the majority of women in are disproportionately likely to identify as gay. For example,
Western societies are exposed to this type of material. Carlat and colleagues (1997) indicated that 41% of the male
Within non-clinical populations, there is also evidence eating disorder patients they treated identified as hetero-
that women are disproportionately affected by weight and sexual, whereas 27% identified as gay or bisexual, and 32%
shape concerns. For example, non–eating-disordered males identified as asexual. In contrast, there do not appear to be
have less appearance investment and less body image preoc- any differences between heterosexual and lesbian or bisexual
cupation compared to non–eating-disordered females (Cash, women with regard to the prevalence of eating disorders
Morrow, Hrabosky, & Perry, 2004). Nevertheless, body dissat- (Feldman & Meyer, 2007; Strong et al., 2000).
isfaction in non-clinical men is receiving increasing research However, the increased risk of eating disorders within
attention. Research suggests that both heterosexual and gay gay males is not ubiquitous. In two studies on eating-
men prefer a lean but muscular body type (Tiggemann, disordered populations that included control groups
Martins, & Kirkbride, 2007), whereas women tend to prefer (Mangweth et al., 1997; Olivardia, Pope, Mangweth, &
a thin body type (Tiggemann & Lynch, 2001). Similarly, the Hudson, 1995), men with eating disorders were not more
reported body images of college males tended to be distorted likely to identify as gay, compared to men without eat-
toward perceptions of underweight, whereas females’ body ing disorders. Hence, given the inconsistent findings, it is

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 248 Chapter 10

premature to conclude that there is a strong association shape leads to excessive dietary restriction, which leaves
between sexual orientation and eating disorders in males. the individual both psychologically and physiologically
In fact, research investigating disordered eating in both susceptible to episodes of binge eating. Purging and other
heterosexual-identified and gay-identified males demon- excessive means of controlling body weight or shape serve
strated that when males’ levels of body dissatisfaction and to compensate for binge eating but also maintain binge eat-
self-esteem were statistically controlled for, there was no ing by reducing the individual’s anxiety about weight gain
significant association between sexual orientation and eat- and by disrupting learned hunger and satiety cues. Episodes
ing disorder symptomatology (Hospers & Jansen, 2005). of binge eating and inappropriate compensatory behaviours
This suggests that body dissatisfaction (as opposed to sexual worsen self-esteem, thereby leading to more dietary restraint
orientation) plays a more central role in the development of and thus more binge eating (Fairburn, 2002).
eating disorders in males. Individual CBT for bulimia nervosa typically involves
three stages that span approximately 20 weeks. In the first
stage, the focus is on establishing a regular pattern of eating.
Treatment This is accomplished through psychoeducation about the
BIOLOGICAL TREATMENTS connection between restricting food intake and binge eating,
and teaching patients to use behavioural strategies (e.g., meal
Bulimia nervosa has been treated with antidepressant medi-
planning, distraction, stimulus control) to eat three meals
cation, namely tricyclic antidepressants and selective sero-
and two snacks daily without compensating. Self-monitoring
tonin reuptake inhibitors. The rationale for treating bulimia
is also used to help patients normalize their eating and iden-
with these drugs is that depressive symptoms are common
tify triggers for symptoms. The second stage involves a con-
in these patients, and, in addition, serotonin is believed to
tinued focus on normalized eating, especially with respect
play a role in binge eating. Meta-analyses, which systemati-
to eliminating dieting. This stage also focuses on teach-
cally and quantitatively review available research evidence,
ing problem-solving skills and identifying and modifying
suggest that, overall, fluoxetine (Prozac) leads to a moderate
dysfunctional thoughts and beliefs (especially about body
initial improvement in binge eating and purging symptoms
weight and shape). The third stage focuses on strategies for
in non-underweight individuals with eating disorders. How-
maintaining change and preventing relapse (Fairburn, 2008;
ever, only a small minority of patients remit from their eat-
Fairburn, Marcus, & Wilson, 1993).
ing disorder using these drugs, and most patients continue
Fairburn and his colleagues have also proposed
to meet diagnostic criteria (Narash-Eisikovits, Dierberger,
a cognitive-behavioural theory of the maintenance of
& Westen, 2002). Furthermore, meta-analyses have revealed
anorexia (Fairburn, Shafran, & Cooper, 1998). They suggest
that treatment with antidepressants is inferior to cognitive-
that the central feature of anorexia nervosa is an extreme
behaviour therapy (CBT; described in the next section) at
need to control eating and that, in Western society, a ten-
reducing frequency of bingeing and purging, depression, and
dency to determine self-worth based on body weight and
distorted eating-related attitudes (Whittal, Agras, & Gould,
shape is superimposed on the need for control. However,
1999). When CBT is added to antidepressant treatment,
relatively few studies have examined the efficacy of CBT for
antidepressant medication is better than when it is used
anorexia nervosa using randomized controlled trial meth-
alone (Narash-Eisikovits et al., 2002), but not better than
odology. Research in this area is limited by small sample
CBT on its own (Wilson, 1993). Preliminary evidence exists
sizes and relatively high dropout rates (Bulik et al., 2007),
for other second-generation antidepressants (trazodone and
as well as by a sizeable proportion of non-randomized stud-
fluvoxamine), an anticonvulsant (topiramate), and a tricyclic
ies (Galsworthy-Francis & Allen, 2014). A recent systematic
antidepressant (desipramine). However, replication for all of
review of the literature indicated that CBT appears to be
these medications is required.
helpful in reducing treatment drop-out, improving treat-
Unfortunately, attempts to treat anorexia nervosa with
ment adherence, increasing weight, improving eating dis-
pharmacological agents have not been successful. Neither
order symptoms, and reducing relapse (Galsworthy-Francis
antidepressants, antipsychotics, nor any other class of drugs
& Allen, 2014). However, overall, CBT did not consistently
has been found to lead to significant weight gain, improve
outperform the comparison treatments (Galsworthy-Francis
distorted attitudes or beliefs, or supplement inpatient pro-
& Allen, 2014), indicating that CBT may not work as well
grams (Bulik, Berkman, Brownley, Sedway, & Lohr, 2007).
for anorexia compared to bulimia nervosa.
Fairburn and colleagues have also proposed a transdi-
PSYCHOLOGICAL TREATMENTS agnostic theory and treatment of eating disorders (Fairburn,
COGNITIVE-BEHAVIOUR THERAPY (CBT) More than 60 2008; Fairburn et al., 2003; see Figure 10.3). This theory argues
randomized controlled trials of treatments for bulimia that anorexia, bulimia, BED, and OSFED have similar under-
nervosa have been conducted. On the basis of this research, lying psychopathological processes and maintaining factors
CBT is considered the leading evidence-based treat- and therefore can be treated using similar CBT interventions.
ment for bulimia and is widely accepted as the treatment Consequently, CBT for eating disorders has been adapted
of choice among clinicians (Fairburn, 2008; Whittal et al., so that it is relevant and can be applied to all individuals
1999). According to the cognitive-behavioural model of the with eating disorders, regardless of their specific diagnosis.
maintenance of bulimia, overvaluation of body weight and This adapted form of CBT has been called “CBT enhanced

M10_DOZO8871_06_SE_C10.indd 248 25/10/17 6:18 PM

 Eating Disorders 249

DYSFUNCTIONAL SCHEME FOR SELF-EVALUATION

Over-evaluation of eating, shape, Over-evaluation of achieving

and weight and their control “PERFECTIONISM”

CORE LOW SELF-ESTEEM

LIFE

Strict dieting and other

weight-control behaviour

(Achieving in
other domains)
Binge eating Low weight
MOOD
INTOLERANCE
Compensatory “Starvation
vomiting/laxative syndrome”
misuse

FIGURE 10.3 A Schematic Representation of the “Transdiagnostic” Theory of the Maintenance of Eating Disorders.
Source: Republished with permission of Elsevier Inc., from Cognitive behaviour therapy for eating disorders: A transdiagnostic theory and treatment. Behaviour Research and Therapy, 41,
509-528 and 2003; permission conveyed through Copyright Clearance Center, Inc.

for eating disorders (CBT-E)” (Cooper & Fairburn, 2011; INTERPERSONAL THERAPY To date, only one other treat-
Fairburn, 2008). Preliminary research shows that this ment has shown effects on symptoms of bulimia that are
enhanced CBT is an effective treatment for a variety of comparable to those of CBT. In interpersonal therapy (IPT),
eating disorder diagnoses (e.g., Byrne et al., 2011; Fairburn the focus is on maladaptive personal relationships and ways
et al., 2009, 2013, 2015). of relating to others, because difficulties in these areas are
thought to contribute to the development and maintenance of
eating disorders (Birchall, 1999). In IPT, the major job of the
therapist is to identify which problem area is relevant to the
patient—grief, role transitions, interpersonal role disputes,
or interpersonal deficits—and to work to improve the client’s
functioning in that area. IPT differs from CBT in that it does
not directly target eating-disordered attitudes and behaviours.
Fairburn and his colleagues developed interper-
sonal therapy for bulimia nervosa to serve as a compari-
son treatment to CBT for the purpose of a research trial
(Fairburn, Jones, Peveler, Hope, & O’Connor, 1993). In a
well-conducted study, Fairburn and his colleagues found
that patients with bulimia who received CBT experi-
enced more than a 90% reduction in bingeing and purg-
ing one year after treatment. Nearly 40% of the patients
had ceased binge eating and compensatory symptoms
National Eating Disorder Information Centre

altogether. What was surprising was the finding that IPT

produced effects equivalent to CBT at one-year follow-
up, although CBT was somewhat better at the conclusion
of treatment. In another study, 220 patients with bulimia
nervosa were randomly assigned to receive either CBT or
IPT (Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000).
These researchers found that 45% in the CBT group and
8% in the IPT group abstained from binge-eating and
purging symptoms at the end of treatment. Similarly, CBT
led to larger reductions in dietary restraint than did IPT
This is one of several public service announcements sponsored by (see Figure 10.4). However, at one-year follow-up there
the National Eating Disorder Information Centre in Toronto. were no significant differences between CBT and IPT,

M10_DOZO8871_06_SE_C10.indd 249 25/10/17 5:56 PM

 250 Chapter 10

0.0
CBT
–0.5 IPT

Change in Dietary Restraint

–1.0

–1.5

–2.0

–2.5

–3.0
0 2 4 6 8 10 12 14 16 18 20
Weeks

FIGURE 10.4 CBT versus IPT in the Treatment of Bulimia Nervosa

Source: Based on Agras, Walsh, Fairburn, Wilson & Kraemer (2000). A Multicenter Comparison of Cognitive-Behavioral Therapy and Interpersonal Psychotherapy for Bulimia Nervosa,
Archives of General Psychiatry, Vol. 57, pp. 459–466.

with individuals who received IPT continuing to improve Some individuals with eating disorders seek nutritional
after the end of treatment. Most recently, enhanced CBT counselling as a stand-alone intervention. For example,
and IPT were compared in another well-designed study in a community sample of women with bulimia nervosa,
that supported the prior findings that CBT outperformed 37 percent of the women who had sought some treatment
IPT at post-treatment. Like the previous studies, the IPT for their eating disorder had visited a dietitian (Mond, Hay,
patients continued to improve after the end of treatment, Rodgers, & Owen, 2007).
although in this study, CBT continued to outperform IPT
at the end of the follow-up period (Fairburn et al., 2015). FAMILY THERAPY Various forms of family therapy have
Although CBT is still considered the preferred treatment been employed in the treatment of eating disorders, par-
for bulimia nervosa because it reduces symptoms relatively ticularly anorexia nervosa. The specific interventions used
quickly, IPT also appears to be an efficacious option. vary depending on the specific model of family therapy;
however, in general, family therapy focuses on stresses
NUTRITIONAL THERAPY AND MEAL SUPPORT When within the family as a whole rather than on individuals, and
a patient has anorexia nervosa, the first priority should be places responsibility for recovery on both the client and her
to restore body weight to a minimal healthy level. This is relatives. The Maudsley approach is a specific, evidence-
primarily important for medical stability. However, many based family therapy for adolescents with eating disorders.
of the symptoms of anorexia nervosa are due to the effects This approach involves an initial focus on recruiting par-
of starvation. Weight restoration can alleviate many of ents to engage actively in managing the patient’s weight
these symptoms, including cognitive impairments. Relat- gain (where relevant) and eating. No attention is paid to
edly, some degree of weight restoration may be required to the cause of the disorder or to factors that do not directly
facilitate participation in psychotherapy. Both nutritional affect the task of normalized eating. As eating improves and
counselling and meal support are important components weight approaches normal levels, the therapist helps the
of treatment programs for eating disorders. Meal support is family to return control of eating to the adolescent. Only
common in intensive treatment programs and involves pro- when eating and weight are no longer central to family
viding emotional support and coaching during or after meals concerns does the therapist turn to more general adoles-
and helping individuals to decrease eating-related rituals cent issues independent of the eating disorder (Lock & le
(e.g., Leichner, Hall, & Calderon, 2005). Researchers at the Grange, 2005). The available evidence supports the use of
British Columbia Children’s Hospital have developed meal family-based therapy for the treatment of adolescents with
support training materials for parents of children and ado- eating disorders. A recent meta-analysis found that over-
lescents with eating disorders. These materials have been all, although family-based therapy and individual therapy
well received by the families, and are being used by clinicians appear to perform similarly at the end of treatment for ado-
to help involve families in the treatment process (Cairns, lescents with eating disorders, those who received family
Styles, & Leichner, 2007). Nutritional counselling involves therapy did better during the follow-up period (Couturier,
learning about what constitutes a normal meal, appropri- Kimber, & Szatmari, 2013). In contrast, family therapy has
ate portion sizes, and nutritional requirements and the not been shown to be an effective stand-alone treatment
regulation of weight (American Dietetic Association, 2006). for adults.

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 Eating Disorders 251

SELF-HELP Self-help manuals that seek to disseminate PREVENTION

information about eating disorders and strategies for over- Interventions for eating disorders are predominantly
coming bulimia and BED have been developed in response therapeutic. In other words, researchers and clinicians
to the fact that therapists who specialize in eating disorders have focused on developing and providing therapies for
are in short supply and that large numbers of individuals with individuals who have already developed eating disorders.
eating disorders do not seek treatment. The majority of these However, some researchers have investigated whether
manuals are based on cognitive-behavioural principles. Self- providing preventive intervention programs can decrease
help manuals can be used in several ways, including (1) for the presence of risk factors for the development of eat-
provision of an accessible form of information for individuals ing disorders, and ultimately prevent disordered eating
who might not otherwise have access to expert help, or who behaviours. One such program, Healthy Schools–Healthy
may feel too embarrassed to seek treatment; (2) in conjunc- Kids, was applied universally to all Grade 6 and 7 students
tion with guidance by a non-specialist professional such as who participated in the study. This program, developed
a nurse or family doctor; (3) as the first step in a stepped- in Toronto by Gail McVey and her colleagues (McVey,
care approach to treatment delivery, with only those who Tweed, & Blackmore, 2007), randomly assigned four
require further treatment going on to more intensive (and schools to either an intervention condition or a control
thus more costly) treatments; (4) for administration to patients (no intervention) group for comparison. The interven-
who are on waiting lists for intensive treatment; and (5) for tion lasted throughout the school year and incorporated
facilitation of therapist-administered CBT (Carter, 2002). a variety of approaches, including in-class curriculum,
Published studies of self-help interventions for bulimia a “Girl Talk” peer support group, parent education, and
nervosa and BED indicate that they are efficacious. In a posters, video, and play presentations relating to teas-
randomized controlled trial conducted at Toronto General ing, peer pressure, size acceptance, and healthy eating.
Hospital, Carter and colleagues (2003) examined the efficacy Participants who received the intervention experienced
of two unguided self-help treatments for bulimia nervosa: decreases in internalization of the thin ideal between
a CBT manual and a nonspecific interpersonal treatment baseline and post-intervention, which were maintained
manual. They found equivalent significant reductions in at the six-month follow-up, and a decrease in disordered
frequency of bingeing and vomiting in both of the self-help eating from baseline to post-intervention. In contrast,
groups (these reductions did not occur in the control group). those in the control condition experienced decreases in
Carter and Fairburn (1998) compared the relative effective- thin ideal internalization during the study period, but
ness of guided and unguided self-help for BED in a random- their scores returned to baseline values at the six-month
ized controlled trial. Participants assigned to the unguided follow-up. These findings suggest that the intervention
self-help group followed a CBT manual for a period of was successful, particularly in reducing internalization of
12 weeks. Those in the guided self-help group followed the socio-cultural ideal.
the same treatment manual for the same period of time but Other programs have focused their preventive inter-
also received six to eight brief support sessions with a non- ventions on individuals who have been identified as high
specialist facilitator. Both self-help treatments resulted in risk for the development of eating disorders. In one study,
statistically significant and equivalent reductions in binge 480 women between the ages of 18 and 30 who reported
eating. There was a similar pattern of results for eating- having high levels of concern about their weight were
disordered attitudes. randomly assigned to either a waitlist control group or an
Self-help treatments are just beginning to be applied internet-based prevention program that used cognitive-
to anorexia. One study examined the efficacy of cognitive- behavioural strategies aimed at decreasing body dissat-
behavioural guided self-help compared to a waiting list isfaction and weight concerns (Taylor et al., 2006). The
control group before admission to an inpatient unit. Results eight-week-long structured program involved partici-
showed that duration of inpatient treatment was significantly pants logging in once a week to the program, reading new
shorter among participants who received guided self-help material, and participating in online discussion groups.
(Fichter, Cebulla, Quadflieg, & Naab, 2008). It is unlikely Participants in the intervention condition reported larger
that self-help will turn out to be an efficacious stand-alone decreases in weight concerns, eating pathology, and drive
treatment for anorexia given that individuals typically for thinness after the eight-week program compared to
require high levels of support and guidance to make the those in the control group, and these effects remained
behavioural and attitudinal changes necessary for recovery. one year after the end of the program. The success of
internet-based prevention programs is promising, as this
type of program may make it easier for individuals who
BEFORE MOVING ON are at risk for developing an eating disorder to access
support.
What are the main differences between the different psy- To further investigate the effectiveness of prevention
chological treatment approaches (i.e., CBT, IPT, and fam-
programs and to determine whether certain factors improve
ily therapy)? What approach would you recommend to an
the success of an intervention, a meta-analysis evaluated
18-year-old woman diagnosed with bulimia, and why?
the effectiveness of 38 eating disorder prevention programs,

M10_DOZO8871_06_SE_C10.indd 251 25/10/17 5:56 PM

 252 Chapter 10

CANADIAN RESEARCH CENTRE

Eating Disorder Program, University Health Network (Toronto, Ontario)

Established in 1983, the University for recovery-oriented practice. This ori- “best practice” culture, it is neces-
Health Network’s Eating Disorder Pro- entation differentiates the traditional sary to conduct research on the effec-
gram (EDP) is the largest intensive treat- approach of “clinical recovery,” which tiveness of the different treatments
ment centre in Canada for adults with focuses on the remission of symptoms, offered, and on how to improve treat-
anorexia nervosa, bulimia nervosa, and from “personal recovery,” which recog- ment outcomes. A core theme underly-
other specified feeding and eating disor- nizes that individuals can improve their ing the research at the EDP is a focus
ders. Individuals from across the province quality of life and reach valued goals, on improving treatments so that they
of Ontario can utilize intensive eating even if they continue to experience symp- better meet the needs of the patients.
disorder treatment through the program. toms of their clinical disorder (Roberts One innovative current project, funded
In addition to providing high quality treat- & Boardman, 2013). Recovery-oriented by the Ontario Mental Health Founda-
ment, the EDP conducts clinical research treatments recognize that each person is tion, is examining the efficacy of an
aimed at evaluating the effectiveness a unique individual, and helps patients integrated treatment combining CBT
of and improving treatments, as well as work toward personal goals and build for eating disorders and CBT for post-
developing new innovative treatments for more meaningful lives as an integral part traumatic stress disorder, for patients
individuals with eating disorders. of their mental health care (Roberts & who are experiencing both of these
A multidisciplinary team provides Boardman, 2013). Consistent with this problems simultaneously. Eating disor-
clinical care for individuals in the pro- approach, in 2017 the University Health der symptoms and PTSD symptoms may
gram. This team is co-led by Dr. Marion Network EDP redesigned their treatment interact with and maintain one another
Olmsted, a clinical psychologist, and services in line with three core patient- (Trottier et al., 2016), and this proj-
Dr. Patricia Colton, a psychiatrist. Other care principles: (1) providing flexible, ect is investigating whether the needs
members of the clinical team include individualized care, (2) providing con- of patients with this symptom profile
psychologists, psychiatrists, occupational tinuity of care and seamless transition are better met when both disorders are
therapists, dietitians, social workers, men- among all three levels of care (inpatient, addressed concurrently. The result of a
tal health clinicians, nurse practitioners, day treatment, and outpatient), and (3) pilot study of this intervention are prom-
and nurses. Each discipline and indi- helping patients make improvements that ising (Trottier, Monson, Wonderlich,
vidual brings specialized experience and they can maintain in the long-term. The & Olmsted, 2017), and a randomized
expertise to the team (e.g., dietitians offer redesigned program not only focuses on controlled trial examining the efficacy
knowledge about nutrition, whereas the reducing and eliminating eating disorder of this integrated treatment compared
psychologists have extensive training in symptoms but also focuses on helping to standard eating disorder treatment
psychological assessment and research). patients build a life outside of treatment is currently underway. Another cur-
Moreover, team members across disci- that will support their recovery. rent project aims to deliver an adjunc-
plines also share similar roles, such as As a training site within a teach- tive substance-use intervention prior
facilitating therapy groups. The psycho- ing hospital that is fully affiliated with to intensive eating disorder treatment
therapy provided in the program includes the University of Toronto, the EDP also in order to better meet the needs of
behavioural interventions (e.g., skills for provides specialized training across dis- patients with co-occurring substance
normalizing eating patterns, interrupt- ciplines as one of its mandates. Practi- use disorders. Other research in this
ing bingeing and purging, and emotion cum students from various disciplines, centre has focused on examining
regulation), psychoeducation, cognitive psychology and psychiatry residents, and the effectiveness of intensive treat-
strategies, and cognitive-behavioural inter- postdoctoral fellows, often complete spe- ment (Olmsted, McFarlane, Trottier, &
ventions targeting interpersonal problems cialized clinical and/or research training Rockert, 2013) and elucidating pre-
(Olmsted et al., 2010). at the EDP. dictors of relapse after intensive treat-
In 2015, the Mental Health Com- The EDP aims to provide the best ment (Olmsted, MacDonald, McFarlane,
mission of Canada published guidelines clinical care possible. To maintain this Trottier, & Colton, 2015).

all of which included a control comparison group (Stice therefore they may engage more in these programs than do
& Shaw, 2004). More than 50 percent of the interventions those individuals with fewer concerns (Stice & Shaw, 2004).
resulted in significant decreases in at least one risk factor for
eating pathology (such as body dissatisfaction). Furthermore, BEFORE MOVING ON
programs that selected high-risk participants produced
larger decreases in body dissatisfaction, dieting, and eating What are some of the advantages and disadvantages of pre-
pathology than did universally applied programs. One pos- vention programs that are targeted toward high-risk groups
sible explanation for this is that high-risk participants may (as opposed to universally applied)? Do you think more
schools should implement eating disorder prevention pro-
be more motivated by the intervention programs because
grams? Why or why not?
they experience more weight/shape-related distress, and

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 Eating Disorders 253

SUMMARY
● Eating disorders have been described throughout his- these eating disorders resemble the full syndromes of
tory, and were not always seen as evidence of maladjust- anorexia, bulimia nervosa or binge-eating disorder, and
ment. Although eating disorders have become relatively in other individuals the psychopathological features of
common in modern Western societies, reports of food the eating disorder combine in a somewhat different
restriction and periods of binge eating and purging are way. Purging disorder and night-eating syndrome are
not new. two examples of an “other specified feeding or eating
● According to the DSM-5, the central feature of disorder.”
anorexia nervosa is the restriction of food intake, ● There appears to have been an increase in the preva-
leading to a significantly low weight (i.e., a weight that lence of eating disorders over the last several decades
is less than minimally normal, or expected, for age of the twentieth century, although it is unclear to what
and height). Individuals with anorexia have an intense extent the increase is due to an enhanced awareness
fear of gaining weight or becoming fat, or exhibit about eating disorders. The prevalence of eating dis-
behaviour that interferes with weight gain. They often orders in Canada is similar to the prevalence in other
believe that eating feared or forbidden foods will Western countries.
result in significant amounts of weight gain. Individu- ● Assessment for diagnostic purposes and to guide treat-
als with anorexia nervosa typically achieve and main- ment planning is usually conducted using a structured
tain their low body weight through food restriction or semi-structured interview. Conducting a diagnostic
and exercising (and are classified as “restricting type”). interview for an eating disorder involves gathering infor-
However, some individuals with anorexia also engage mation about current and past frequency and severity
in binge eating and/or purging behaviours. These of dietary restriction, bingeing, purging, and exercise,
individuals are classified as “binge-eating/purging as well as distorted attitudes and beliefs about weight,
type.” Anorexia nervosa also typically involves shape, and eating, weight history, and current and past
disturbed attitudes and beliefs related to body weight menstrual function (where relevant). Clinicians and
and shape, or a lack of recognition of the seriousness researchers often use the Eating Disorder Examination
of the low body weight. to gather this information.
● Bulimia nervosa is characterized by episodes of binge ● Eating disorders are multi-determined. They are very
eating and engaging in compensatory behaviours to complex disorders, and one factor alone does not pro-
prevent weight gain. Individuals with bulimia nervosa duce an eating disorder in any given individual. Our
often have low self-esteem and use weight and shape society’s preference for thinness may lead to body
as a primary method of self-evaluation. Other features, dissatisfaction and dieting. In vulnerable individuals,
such as social isolation and depression, are also com- these factors may precipitate an eating disorder. Factors
mon in both anorexia and bulimia nervosa. However, such as low self-esteem, family dynamics, trauma, and
in contrast to anorexia nervosa, individuals with early maturation may leave an individual susceptible
bulimia are typically within the normal weight range. to developing an eating disorder. Genetic and biologi-
According to the DSM-5, episodes of binge eating and cal predispositions may also contribute to developing
compensatory behaviours must occur, on average, at an eating disorder. Although integrative models and
least once a week for three months for a diagnosis of theories attempt to address the complexity of eating
bulimia nervosa. disorders and the many identified etiological factors,
● Binge-eating disorder, like bulimia nervosa, involves they have not yet provided predictive power sufficient
regular binge-eating episodes that occur at least once to identify the individuals most likely to develop eating
a week for three months. However, there are no inap- disorders.
propriate compensatory behaviours to prevent weight ● There have been few controlled studies of treatments
gains that occur after the binges. Although individuals for anorexia nervosa. Weight restoration to a minimal
with BED are often overweight or obese, it is possible healthy level is of primary importance. There is some
to be within the normal-weight range. Individuals evidence that CBT can be beneficial in producing
with BED experience significant distress about their weight gain, improving eating disorder psychopathology,
binge eating, and there are disturbed eating behav- and preventing relapse in adults, and that family therapy
iours and thoughts that are associated with the binge is a good option for adolescents. Although antidepres-
eating. sant medication has not been shown to be effective in the
● The DSM-5 also acknowledges eating disorders of clini- treatment of anorexia nervosa, it is helpful in the treat-
cal severity that do not meet current diagnostic criteria. ment of bulimia nervosa. However, research suggests
These eating disorders are classified as “other speci- that antidepressants such as Prozac are inferior to CBT
fied feeding or eating disorders.” In some individuals, in the treatment of bulimia nervosa. CBT is considered

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 254 Chapter 10

the treatment of choice for bulimia nervosa and BED. programs that target “high-risk” participants (such as
Nevertheless, IPT produces equivalent effects over the women with high levels of body dissatisfaction) pro-
longer term. duced larger decreases in body dissatisfaction, dieting,
● Research on the prevention of eating disorders is and eating pathology than did universally applied
emerging, with some promising results. Prevention programs.

KEY TERMS
amenorrhea (p. 240) bulimia nervosa (p. 230) purging (p. 231)
anorexia nervosa (p. 230) Eating Disorder Examination (EDE) (p. 239) restricting type (p. 236)
binge eating/purging type (p. 236) lanugo (p. 240) risk factors (p. 246)
binge eating disorder (BED) (p. 230) maintenance factors (p. 246) Russell’s sign (p. 240)
body mass index (BMI) (p. 235) objective binge (p. 231)

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 DAVID C. HODGINS
•
MAGDALEN SCHLUTER

CHAPTER

11 Wragg/E+/Getty Images

Substance-Related
and Addictive Disorders
LEARNING OBJECTIVES
AFTER READING THIS CHAPTER, STUDENTS WILL BE ABLE TO:
Explain how substance-related disorders are defined and diagnosed.
Understand and describe the effects, etiology, and treatment approaches related to alcohol use
disorders.
Comprehend trends in the prevalence of substance use in Canada.
Identify the psychological and physiological effects of various substances of abuse.
Describe similarities between substance use disorders and disordered gambling.
Describe the most common treatment approaches for various substance use disorders and disordered
gambling.

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 At age 39, Gareth found himself in group therapy describing how he had lost his job and almost
lost his life. When he thought back to how it had all begun, he found it difficult to pinpoint when
using drugs and alcohol ceased to be fun and a social activity and began to be necessary to main-
tain day-to-day functioning. Somehow, he had gone from having the world by the tail as an execu-
tive at a software company to living in a treatment facility, wondering if he would ever be able to
stay off drugs and rebuild his life.

At first, Gareth drank to keep up with his co-workers and business clients, many of whom regularly
had “liquid lunches.” Although he didn’t really like the way alcohol made him feel in the after-
noon, he soon found that a little of “the hair of the dog that bit you” at the bar after work helped
him to feel better for the drive home. He also found alcohol more pleasing at parties and was able
to drink more without getting drunk.

At a party held by a business associate, Gareth was introduced to cocaine, which gave him the
energy for extended parties and alleviated the hangovers he often experienced after a night of
drinking. He was also amazed by the way that cocaine improved his concentration, energy, and
creativity. When high on cocaine he could work longer hours without taking a break, and he began
to feel as if he could accomplish anything he set his mind to. The only drawback was the cost of
the cocaine, but he could handle even that because he was doing so well in his job.

As he began to use cocaine more frequently, Gareth found that he often needed alcohol or “down-
ers” to help him relax and fall asleep in the evenings. His physician was willing to prescribe ben-
zodiazepines when Gareth explained that he was in a high-pressure job and had trouble sleeping
because he worked odd hours and travelled to different time zones. Of course, the benzodiazepine
and alcohol use at night meant he was often groggy in the morning and needed cocaine to help
him function. His co-workers began to notice changes in Gareth’s personality and decreased pro-
ductivity. Gareth was in danger of losing his job.

One night, this cycle of abuse caught up with Gareth. He had been drinking with some custom-
ers right after work and came home at about 7:00 p.m. Tired, he decided to skip dinner and have
a nap but could not sleep, so he took a couple of sleeping pills and had another stiff drink. The
combination of benzodiazepines and a considerable amount of alcohol on an empty stomach
resulted in a loss of consciousness. When his wife got home around 8:00 p.m., she found him
asleep on the sofa and could not awaken him. She immediately phoned 911, and help arrived in
time. The interview in the emergency room later that evening revealed the drug roller coaster that
Gareth was on. His physician and wife insisted that he go directly to a treatment facility and he
agreed.

Historically, virtually every culture has employed some the immediate effects of these substances are usually pleas-
legally or socially sanctioned drugs to alter moods or states ant, history is full of accounts of the devastating long-term
of consciousness. In our culture, the most widely used impact of addictive substances.
substances are alcohol, tobacco, and caffeine, all of which The latest version of the DSM (APA, 2013) reintro-
are legal and (at least to some extent) socially acceptable. duced as a formal diagnostic concept the term “addiction,”
Many people begin their day with a cup of tea or coffee. which was not used in DSM-III or IV. Substance use disor-
Other people include a cigarette. Parties and other social ders are now contained in a section titled Substance-related
events for adults almost always include alcohol. Although and Addictive Disorders. Part of this decision was related

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 Substance-Related and Addictive Disorders 257

to the recognition that behaviours other than substances

are associated with similar effects for affected individuals,
Diagnosis and Assessment
including impairment of control, and continued drive to use DIAGNOSING SUBSTANCE USE
despite clear negative consequences. As part of the plan- DISORDERS
ning for the DSM-5, the research on a number of behaviours What the general public commonly refers to as alcohol-
such as sex, work, shopping, and gaming was reviewed. Ulti- ism and drug addiction are formally termed substance use
mately, gambling disorder was the only behaviour that had disorders in the DSM-5. Substances of abuse are divided into
sufficient depth of research to be included at this time. This 10 classes: alcohol; caffeine; cannabis; hallucinogens; inhal-
chapter ends with a description of the current understand- ants; opioids; sedatives, hypnotics, and anxiolytics; stimulants;
ing of gambling and gambling disorder. tobacco; and other or unknown substances. An individual can
receive a diagnosis for one or more of these classes (e.g., alcohol
use disorder, opioid use disorder). In general, substance use disorder
Historical Perspective refers to recurrent use of one of these specific substances that
Alcohol and drug use have been around longer than leads to adverse consequences. The disorder ranges in sever-
recorded history. Mead, an alcoholic beverage naturally ity from mild to moderate to severe, depending on the num-
formed by the fermentation of honey, was probably the first ber of problem indicators. The 11 indicators apply to most
alcohol that humans consumed. The ancient Egyptians were classes of substances, with a few minor exceptions (e.g., with-
known for their drinking, and wine was extensively used by drawal symptoms are not part of inhalant use disorder; there
the Hebrews. is no caffeine use disorder). Table 11.1 describes the indica-
Opium derivatives were once widely used in Asian cul- tors for alcohol use disorder as an example.
tures, as well as in ancient Greece and Rome. Therapeutically,
they were taken to relieve pain or induce sleep; however, the TABLE 11.1 DSM-5 DIAGNOSTIC CRITERIA FOR
euphoria that these drugs produced resulted in their wide- ALCOHOL USE DISORDER
spread use to enhance pleasure. In the Andes, for thousands A. A problematic pattern of alcohol use leading to clinically
of years, native populations occasionally chewed the leaf of significant impairment or distress, as manifested by at least
the coca plant to relieve fatigue and increase endurance. The two of the following, occurring within a 12-month period
flower of the peyote cactus has long been used by Indigenous 1. Alcohol is often taken in larger amounts or over a longer
people in South and Central America as part of religious cer- period than was intended.
emonies. The chemical contained in this flower was valued 2. There is a persistent desire or unsuccessful efforts to
cut down or control alcohol use.
for its ability to alter consciousness and results in hallucina-
3. A great deal of time is spent in activities necessary to
tions similar to those caused by LSD.
obtain alcohol, use alcohol, or recover from its effects.
The effects of substance abuse were particularly grim 4. Craving, or a strong desire or urge to use alcohol.
as the Europeans colonized North and South America. 5. Recurrent alcohol use resulting in a failure to fulfill
Alcohol, in the form of beer, was widely consumed, in part major role obligations at work, school, or home.
because of the poor quality of drinking water. The tavern 6. Continued alcohol use despite having persistent or
became the hub of social activity in the colonies and alco- recurrent social or interpersonal problems caused or
hol was an integral part of all social and festive occasions. exacerbated by the effects of alcohol.
Consumption levels were extremely high by current stan- 7. Important social, occupational, or recreational activities
dards, even among children. When North American Indig- are given up or reduced because of alcohol use.
enous people were introduced to European brandy, they 8. Recurrent alcohol use in situations in which it is physi-
cally hazardous.
discovered a means of being transported into a strange new
9. Alcohol use is continued despite knowledge of having a
world of experience. In an inebriated state, people commit-
persistent or recurrent physical or psychological problem
ted crimes and acts of self-destruction previously unheard that is likely to have been caused or exacerbated by alcohol.
of (Douville & Casanova, 1967). A hunter might trade his 10. Tolerance, as defined by either of the following:
entire winter’s catch of furs for a jug or two of whisky, lead- a. A need for markedly increased amounts of alcohol to
ing to misery and starvation. As a final insult, liquor reduced achieve intoxication or desired effect.
resistance to many imported diseases (Eccles, 1959). b. A markedly diminished effect with continued use of
South American cultures suffered similar effects. Prior the same amount of alcohol.
to the arrival of the Spanish, alcohol was consumed only col- 11. Withdrawal, as manifested by either of the following:
lectively, as part of religious ceremonies. A few years after a. The characteristic withdrawal syndrome for alcohol
the conquest, Indigenous people commonly used alcohol to (refer to Criteria A and B of the criteria set for alcohol
withdrawal, pp. 499–500).
escape from the confusion of their disrupted world (Bethell,
b. Alcohol (or a closely related substance, such as a
1984). There was also a striking increase in the use of coca
benzodiazepine) is taken to relieve or avoid with-
leaf in the Andes. Formerly used only with the permission drawal symptoms.
of the Inca king or his governor, coca became indispensable
Source: Reprinted with permission from the Diagnostic and Statistical Manual
for Quechua mine workers because it enabled them to work of Mental Disorders, Fifth Edition. (Copyright © 2013). American Psychiatric
Association. All Rights Reserved.
almost without eating (Bethell, 1984).

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 258 Chapter 11

There are four general groupings of indicators: impair- to achieve the same effect. Individuals suffering from
ment of control over use, social impairment, risky use, and withdrawal experience unpleasant and sometimes dangerous
pharmacological criteria. Impairment of control includes symptoms, such as nausea, headache, or tremors when the
taking the substance in greater amounts or for longer than addictive substance is removed from the body. These physi-
intended. For example, a man may plan to stop for a quick ological events are a result of the changes that the body has
drink at the neighbourhood pub on his way home for dinner undergone in order to adapt to the continued presence of the
but end up spending a few hours drinking. In the traditional drug. Specific drugs have predictable groups of symptoms
concept of alcoholism, impairment of control was referred typically characterized by overactivity of the physiologi-
to as loss of control. Behavioural psychologists have dem- cal functions that were suppressed by the substance and/or
onstrated that contingencies, rewards, and punishments can depression of the functions that were stimulated by the sub-
influence the use of a substance even in the most affected stance. Additional ingestion of the specific drug, or one that is
individuals, which suggests that control is impaired but not closely related, will alleviate these symptoms. Of course, this
entirely lost. Other indicators of impairment of control (see is part of the vicious circle that maintains dependence.
indicators 2, 3, and 4 in Table 11.1) are multiple unsuccess- In addition to the substance use disorders, a number of
ful attempts to cut down or stop, spending a great deal of substance-induced disorders are associated with each of
time obtaining the substance or recovering from its effects, the 10 drug classes, including intoxication, withdrawal, and
and experiencing a strong craving for the substance. The other substance- or medication-induced mental disorders
social impairment indicators (indicators 5, 6, and 7) refer (e.g., psychotic, bipolar, depressive, anxiety, and sleep disor-
to a failure to fulfill major role obligations at work, home, or ders). As the name implies, these disorders are sets of symp-
school; continued use despite clear negative consequences toms that are caused by the heavy use of specific substances
on relationships; and the reduction of other involvements to and they generally resolve when the person stops using the
give priority to using the substance. For example, a person substance.
might stay away from an otherwise desirable party if smok-
ing is not allowed. Others may eat only in restaurants where
alcohol is served. A woman may have previously been active POLYSUBSTANCE USE DISORDER
in a hiking club but have shifted to spending weekend after- Research into the short-term and long-term effects of sub-
noons with friends at a local pub. stance use and abuse is plagued by the issue of polysub-
The risky use indicators (8 and 9) are used in situations stance abuse, the simultaneous misuse or dependence upon
in which it might be hazardous, such as driving or operating two or more substances. In fact, concurrent dependence
machinery, and in which there is continued use despite the appears to be the rule rather than the exception. For exam-
clear indication that use is causing or exacerbating physical ple, 80 percent of individuals with alcohol use disorders
or psychological problems (e.g., headaches, depression). also smoke cigarettes, and many are likely addicted to both
The pharmacological dependence indicators (Weinberger, Funk, & Goodwin, 2016). Research has shown
(10 and 11) are tolerance and withdrawal. Tolerance means that more than half of cocaine users are dependent on alco-
that the person needs increased amounts of the substance hol (Higgins, Budney, Bickel, Foerg, & Badger, 1994), and

FOCUS
Back to the Future: Addiction in the DSM-5
11.1 A number of significant changes in how we con- other drugs is “Substance-related and Addictive Disorders.”
ceptualize substance use disorders are contained in However, the term addiction is not used in either labelling or
the DSM-5 (APA, 2013). One major change is in ter- describing the disorders. Instead, the more neutral “substance
minology. Since the third edition, the term substance use disorder” has been adopted.
dependence has been used to avoid more pejorative terms like Another change is related to the broadening of the section
alcoholic and addict. In the DSM-IV-TR, dependence referred to to include non-substance-related addictions, often referred to
both psychological and physiological aspects of reliance on sub- as behavioural addictions. At this point, only one behavioural
stances. However, the term was confusing—as in other arenas, addiction is sufficiently well studied and understood to be
tolerance refers to a physiological dependence, which may or included in the DSM-5: gambling disorder.
may not be related to addiction. For example, an individual pre- Close consideration was given to including internet gam-
scribed pain medications after surgery quickly develops physical ing addiction as a formal diagnosis as well. However, because
tolerance and typically will experience physiological withdrawal research support is limited, a set of tentative diagnostic criteria
when the medication is discontinued. However, the individual are included in the DSM-5 appendix as a way of encouraging fur-
does not show any signs of addiction, such as use of the drug to ther study. It is expected that other behavioural addictions, such
manage feelings or compulsive use. In the DSM-5 we revert to as sex addiction and work addiction, will also be candidates for
the use of the term addiction and drop the use of dependence. future DSM editions. ●
The name for the section of the DSM that includes alcohol and

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 Substance-Related and Addictive Disorders 259

Any Alcohol Use: 59%

Any Cigarette Smoking: 11%

Alcohol Use only:

27%
No Drug
Use: 35%
Alcohol & Cigarettes
Cigarettes
only: <1%
smoking only:
<0.5%
Alcohol, Cigarettes,
Cannabis Use only:
3%

Use of all 4:
Alcohol & Cannabis
6%
Use only: 11% Alcohol & Other
Drug Use only: 5%

Alcohol, Cannabis &

Other Drug Use only:
6%
Cannabis Use Other Drug Use
only: <1% only: 3%

Any Cannabis Use: 29% Any Other Drug Use: 21%

Notes: (1) based on a random half sample of secondary students (n=3, 171); (2) “Other Drug Use” refers to use of at least one of 17 drugs: synthetic
cannabis (”spice,” “K2”), inhalants, LSD, mushrooms/mescaline, jimson weed, salvia divinorum, cocaine, crack, methamphetamine, heroin, ecstasy,
mephedrone (”bath salts”), tranquillizers/sedatives, (NM), modafinil (NM), prescription opioid pain relievers (NM), ADHD drugs (NM), and
over-the-counter cough/cold medication; (3) not all combinations are presented, therefore the percentages shown do not total to 100%.

FIGURE 11.1 The Overlap of Alcohol, Cannabis, and Other Drug Use in the Past Year, Ontario Student Drug Use
Survey 2015 (Grades 7 to 12)
Source: Adapted from Drug use among Ontario students, 1977-2011: Detailed OSDUHS findings (CAMH Research Document Series No. 32). Toronto, ON: Center for Addiction and
Mental Health

more than half of all amphetamine users also abuse benzodi- no students smoke cigarettes exclusively, and 3 percent use
azepines (Darke, Ross, & Cohen, 1994). Opioid addicts often any other drug exclusively.
abuse alcohol, cocaine, and benzodiazepines, and illicit use There are a number of health and treatment concerns
of opioids such as heroin are augmented with legal prescrip- related to polysubstance abuse. Combining drugs is physi-
tion opioids such as oxycodone (Oxycontin), codeine, mor- cally dangerous because they are often synergistic. That is,
phine, and hydrocodone (Vicodin; Fischer, Cruz, & Rehm, the combined effects of the drugs exceed or are significantly
2006). Sometimes the pattern is that of concurrent, alter- different from the sum of their individual effects. For exam-
nating use. To prevent the excessive excitement, irritabil- ple, mixing alcohol and barbiturates or opioids can depress
ity, and insomnia associated with chronic amphetamine use, central nervous system (CNS) functioning to a much greater
addicts will often consume barbiturates when they want to degree than any of these substances alone. Amphetamines and
“come down” or sleep. Later, amphetamines will be used to other stimulants, when combined with alcohol, cause physi-
reduce the sedative effects or morning drowsiness caused by cal damage greater than the damage that would be caused
the barbiturates. Polysubstance abuse appears to be on the by the drugs if they were taken separately (Comer, 1997).
rise and is more common in young people (Newcomb, 1994). To complicate matters, individuals with a history of poly-
In a study of Ontario high school students (Boak, Hamilton, substance abuse are likely to have more diagnosable
Adlaf, & Mann, 2015), more than six in ten reported using mental problems than individuals who abuse only one
alcohol, tobacco, cannabis, or another illicit drug in the past substance (Moss, Goldstein, Chen, & Yi, 2015). In DSM-5,
year. Figure 11.1 depicts the overlap of substance use. It abuse of each substance is diagnosed separately so that each
appears that alcohol is the most common element of involve- person is likely to have multiple diagnoses. When treat-
ment in other substance use. A very small proportion of stu- ment is considered, the drug that presents the more imme-
dents use cannabis exclusively (less than 1 percent), almost diate threat to health (e.g., opioids, cocaine, alcohol) tends

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 260 Chapter 11

to overshadow others (e.g., smoking, marijuana). However, were first called “spirits,” is believed to have been discovered
it is not clear which substance use disorder or other men- in Arabia. In addition to the Egyptians and the Hebrews,
tal disorder should be treated first, or whether all should be there is ample evidence that the Greeks enjoyed wine, and
treated at the same time. later Roman emperors were notorious for their insobriety. It
is reported that the people who met Christopher Columbus
in the Caribbean had their own form of beer, and the distilla-
Case Notes tion of whisky was commonplace in Ireland by ce 1500, and
occurred on a large scale in America by the eighteenth cen-
tury. Alcohol was not used by Indigenous Canadians until
“When did things start to fall apart?” thought Marianne. the French brought brandy and the British brought rum
Certainly, the car accident had a lot to do with it. She from Europe.
could still vividly remember that evening five years ago. Concern for overuse of alcohol and attempts to regu-
She was to have gone to Florida with Luc that week, late its consumption date back to earliest recordings of
but he told her he wanted to end their relationship. So its use. All attempts to suppress alcohol in Europe and
instead she drove the five hours to Toronto to take a com- America from the fourteenth to the twentieth century have
puter graphics course. Driving home after three gruelling failed. In the United States, Prohibition came into effect
days, she fell asleep at the wheel and crashed into a wall in 1920, and did effectively reduce overall alcohol intake.
of rock. She awoke in the hospital with a fractured spine. Partial or complete prohibition was also introduced into
Fortunately, she was able to walk again. Three weeks later, the majority of Canadian provinces around the same time.
she went back to an empty home and a long recuperation. However, there was widespread disrespect for the laws,
The medications provided by the hospital helped to con- leading to the growth of organized crime and bootlegging
trol the pain and let her sleep. Combined with alcohol, (illegal production and sale). Much of the bootlegging
she discovered, they worked even better. The alcohol also originated in Canada and was directed to the United States.
dulled her nagging worries about the future. Concern about this lawlessness, as well as an appreciation
of the revenues to be gained by taxing liquor sales, led to
Eventually, her injuries healed and she again found the repeal of Prohibition soon after the Great Depression
employment. She managed to stop taking the pain medi- began. As might be expected, there was a gradual increase in
cation, but kept on drinking. Alcohol dulled her back alcohol consumption; per capita consumption equalled pre-
pain, and it made her feel good. She fell into the habit of Prohibition levels by the end of the Second World War, and
having a few drinks alone at home each night, often fall- continued to rise until it peaked in 1980–1981. Consump-
ing asleep in front of the television. She often resolved tion dropped between 1981 and the late 1990s but has again
not to drink that night, but the loneliness and back pain begun to rise. Generally, the greater the economic wealth of
were too much to bear without alcohol. She convinced a country, the greater the proportion of the population that
herself she was not really an alcoholic because she drinks and the greater the average consumption is (World
never drank during the day and was never really drunk. Health Organization, 2014a).
Nevertheless, her concentration was off, her work began
to suffer, and her social life dwindled. She finally real-
ized that she had a problem and made inquiries about CANADIAN CONSUMPTION PATTERNS
professional services but, as yet, was too ashamed and
In 2015, 15 154 Canadians aged 15 and older were inter-
frightened to admit that she needed help.
viewed about their alcohol use by telephone using a
random-digit dialing survey method (Health Canada, 2016).
This bi-yearly survey was launched in 2013 and is similar
BEFORE MOVING ON to earlier surveys. In the recent survey, approximately four
out of every five Canadians (77%) reported drinking alcohol
How does the conceptualization of substance use disorders
in the past 12 months, and 10% had never imbibed alcohol.
in DSM-5 differ from that of previous conceptualizations?
These figures are slightly lower than those in a 2004 sur-
vey, which found that 79% had consumed alcohol in the past
12 months. The rate of past-year drinking is higher for men
Alcohol than for women (81% versus 73%).
People who drank alcohol in the past year can be
HISTORY OF USE divided into four categories according to the frequency
Alcohol has been called the “world’s number one psycho- of drinking and the number of drinks consumed (see
active substance” (Ray & Ksir, 1990). By 6400 bce, people Table 11.2 for a definition of a standard drink). The larg-
had discovered how to make alcohol in the form of beer and est groups of drinkers are classified as light infrequent
berry wine. The distillation process, in which the fermented drinkers (less than weekly and fewer than five drinks per
solution containing alcohol is heated and the vapours are occasion) at 36%, and light frequent drinkers (more than
collected and condensed in liquid form again to create what weekly and fewer than five drinks per occasion) at 32%.

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 Substance-Related and Addictive Disorders 261

FOCUS
Canada’s Indigenous People
11.2 Issues related to substance misuse in Canada’s Indig- interventions and sprit-centred approaches that include cer-
enous people are a significant social concern and are emony, traditions, and indigenous languages (Health Canada,
perceived by their leadership to be the top challenge 2011b). The goal is to provide individually based treatments in
for community wellness (First Nations Information Gover- the context of overall community healing. An excellent example
nance Committee, 2012). Substance effects are complicated by is Alkali Lake in British Columbia:
high unemployment, inadequate housing, poor access to health
services, and education and economic marginalization. Among In reaction to high rates of alcohol addiction, with nearly
First Nation adults, rates of heavy drinking were reported by two- all of the community seen as dependent, the community
thirds of individuals aged 30 to 49. In contrast to the general engaged in an ongoing healing process to transform health
population, heavy drinking did not decline after young-adulthood; and social conditions, promote individual and community
significant declines were only observed after age 60. Adolescent wellness, and revitalize traditional teachings and practices.
suicide rates are much higher than the national adolescent rate. Guided by continued leadership, commitment and support,
It appears that fetal alcohol spectrum disorders (FASD) are much this process started with one sober person and expanded
more prevalent and tobacco and injection drug use are also partic- to 95 percent of community members indicating that they
ular concerns among First Nations populations (Shields, 2000). were clean and sober. Throughout the process, sober com-
Over the last 30 years, an increasingly organized network munity members worked to eliminate the bootlegging of
of residential and community treatment centres, which provide alcohol through collaboration with the RCMP. As well, a
culturally based services and support, have been developed as voucher system was established with stores in Williams
part of a National Native Alcohol and Drug Abuse Program. Orig- Lake for food and other necessities, where some of the
inally they were based upon the Alcoholics Anonymous model community’s heaviest drinkers received these in place of
but over time they have incorporated cognitive-behavioural social assistance funds. (Health Canada, 2011b, p 21) ●

About 5% are heavy infrequent drinkers (less than weekly post-secondary education are also more likely to be current
and five or more drinks per occasion) and 4% are heavy drinkers. However, those with the least education and those
frequent drinkers (more than weekly and five or more out of work reported the heaviest drinking (Canadian Cen-
drinks per occasion). tre on Substance Abuse, 2004a).
Young adults are more likely to drink and to drink heav- Low-risk drinking guidelines have been established by
ily; consumption peaks in the mid-twenties, then decreases. the Canadian Centre on Substance Abuse and endorsed by
About 83 percent of young adults aged 20 to 24 drink dur- many professional organizations (e.g., the Canadian Medical
ing the course of a year, compared to 59 percent of youth Association, the Canadian Paediatric Society, and the Coun-
aged 15 to 19. Single people are more likely to be both casual cil of Chief Medical Officers of Health) to provide an indica-
and heavy drinkers; high-income earners and those with a tion of the upper limits on drinking so that drinking is not likely

TABLE 11.2 CONVERTING ALCOHOLIC BEVERAGES INTO STANDARD DRINKS

Beverage (% alcohol) Usual Bottle Size Standard Drinks Usual Serving Number of Standard Drinks
in a Usual Serving
Beer (5%) 340 mL (12 oz) 1.0 340 mL (12 oz) 1.0
Wine (12%) 750 mL (26.4 oz) 5.3 140 mL (5 oz) 1.0
1000 mL (35.2 oz) 7.0

1500 mL (52.8 oz) 10.6

Fortified wine (18%) 750 mL (26.4 oz) 7.5 85 mL (3 oz) 1.0

Spirits (40%) 340 mL (12 oz) 8.0 43 mL (1.5 oz) 1.0
710 mL (25 oz) 16.6

1135 mL (40 oz) 26.6

Wine coolers (5–7%) 340 mL (12 oz) 1.0–1.4 340 mL (12 oz) 1.0–1.4
variable sizes from

750 mL to 2 L

Pre-mixed liquor bever- 340 mL (12 oz) 1.0–1.4 340 mL (12 oz) 1.0–1.4
ages (5–7%)
Source: Hodgins, D. C., & Diskin, K. M. (2003). Alcohol Problems. In M. Nerson & S. M. Turner (Eds.), Diagnostic Interviewing (3rd ed.). New York: Springer.

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 262 Chapter 11

TABLE 11.3 CANADA’S LOW-RISK DRINKING HIGH-RISK DRINKING Alcohol researchers suggest that
GUIDELINES there is a direct relationship between the overall level of con-
Drinking is a personal choice. If you choose to drink, these
sumption within a population and the number of people suf-
guidelines can help you decide when, where, why, and how. fering alcohol use disorder. Moreover, there is a relationship
between an individual’s consumption and that person’s risk.
Guideline 1
Reduce your long-term health risks by drinking no more than:
The Alcohol Use Disorders Identification Test (AUDIT;
10 drinks a week for women, with no more than 2 drinks a day Babor, de la Fuente, Saunders, & Grant, 1992), a 10-question
most days. screening tool, is often administered to estimate risk level
15 drinks a week for men, with no more than 3 drinks a day (see Table 11.4). The AUDIT was originally developed by
most days. the World Health Organization for use in a cross-cultural
Set aside non-drinking days each week, so you do not develop comparison of brief treatments for alcohol problems. The
the habit of drinking. items were developed to minimize cultural differences in
Guideline 2 alcohol use and attitudes. The AUDIT has become widely
Reduce your risk of injury and harm by drinking no more than 3 used in surveys of prevalence in different populations, such
drinks (for women) and 4 drinks (for men) at any one time. as medical patients, students, employees, and the general
Plan to drink in a safe environment. Stay within the weekly limits population.
outlined in Guideline 1. Validation studies of the AUDIT indicate that different
Guideline 3 cut-off scores are needed for different populations. For the
Do not drink when you are driving a vehicle or using machinery general population, a cut-off of 8 is typically used to indicate
and tools; taking medicine or other drugs that interact with high-risk drinking. The AUDIT was used in a 2004 Cana-
alcohol; doing any kind of dangerous (extreme) physical activity;
dian national study. Among past-year–drinking Canadians,
living with mental or physical health problems; living with
17% of adults were identified as high risk. The proportion
alcohol dependence; pregnant or planning to be pregnant;
responsible for the safety of others; making important decisions
of men was 25% and of women was 9%. More than 30% of
those under age 25 were high-risk drinkers compared with
Guideline 4
only 5% of people aged 65 and older (Canadian Centre on
If you are pregnant, planning to become pregnant, or will soon
begin breastfeeding, the safest choice is to drink no alcohol at all.
Substance Abuse, 2004a). The AUDIT was also used in the
most recent survey of Ontario high school students (Boak et
Guideline 5
al., 2015). High-risk drinking was reported by 20% of stu-
If you are a child or youth, you should delay drinking until
your late teens. Alcohol can harm the way your brain and body
dents in Grades 7 to 12.
develop. Ask your parents for guidance and follow the local
alcohol laws. If you are drinking, plan ahead and stay in control.
Source: Based on Butt, P., Beirness, D., Cesa, F., Gliksman, L., Paradis, C., &
Stockwell, T. (2011). Alcohol and Health in Canada: A Summary of Evidence and
Guidelines for Low-Risk Drinking. Ottawa, ON: Canadian Centre on Substance Abuse.

to lead to physical impairment (see Table 11.3). According to

low-risk drinking guidelines, daily alcohol intake should not
exceed two drinks for women and three drinks for men, and
weekly intake should not exceed 10 drinks for women and 15
drinks for men (Butt et al., 2011).
Lebrecht Music and Arts Photo Library/Alamy Stock Photo

Surveys have also been conducted of university students

across Canada (Adlaf, Demers, & Gliksman, 2005). Overall
90% of all university students had consumed alcohol at some
point in their lives. Eighty-six percent reported drinking in the
past 12 months. The rates of drinking were highest in Quebec
and the Atlantic provinces (89.7% and 85.6%, respectively),
and were lowest in British Columbia (78.5%). Although they
represented the highest number of drinkers, students from
Quebec universities reported the lowest average weekly intake.
University students are also more likely to consume
larger quantities on a single occasion, known as “binge
drinking.” In the survey of university students, 18.5 percent
reported drinking five or more drinks twice per month or
more. Male students reported drinking more often and more The devastation wrought by alcohol addiction is not a new thing.
heavily than female students, and students living on their This woodcut captures the misery suffered by the addicted in
own or in residence drank more than those living at home. eighteenth-century London.

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 Substance-Related and Addictive Disorders 263

TABLE 11.4 ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT)

Circle the number that comes closest to your actions during the past year.
1. How often do you have a drink containing alcohol?
Never (0) 2 to 3 times a week (3)
Monthly or less (1) 4 or more times a week (4)
2 to 4 times a month (2)
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2 (0) 7 to 9 (3)
3 or 4 (1) 10 or more (4)
5 or 6 (2)
3. How often do you have five or more drinks on one occasion?
Never (0) Weekly (3)
Less than monthly (1) Daily or almost daily (4)
Monthly (2)
4. How often during the past year have you found that you were not able to stop drinking once you had started?
Never (0) Weekly (3)
Less than monthly (1) Daily or almost daily (4)
Monthly (2)
5. How often during the last year have you failed to do what was normally expected from you because of drinking?
Never (0) Weekly (3)
Less than monthly (1) Daily or almost daily (4)
Monthly (2)
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
Never (0) Weekly (3)
Less than monthly (1) Daily or almost daily (4)
Monthly (2)
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
Never (0) Weekly (3)
Less than monthly (1) Daily or almost daily (4)
Monthly (2)
8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
Never (0) Weekly (3)
Less than monthly (1) Daily or almost daily (4)
Monthly (2)
9. Have you or someone else been injured as a result of your drinking?
No (0)
Yes, but not in last year (2)
Yes, during the last year (4)
10. Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggested you cut down?
No (0)
Yes, but not in last year (2)
Yes, during the last year (4)
Scoring: Each answer is weighted from 0 to 4 as indicated in the brackets. Please note that questions 9 and 10 are scored 0, 2, or 4.
A score of 8 or more indicates that a harmful level of alcohol consumption is likely.
Source: Reprinted from The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care (2nd ed.). © World Health Organization, Babor, T. F., & Higgins Biddle, J.
Copyright (2002).

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 264 Chapter 11

EFFECTS a lower proportion of body fat mean that a woman will usu-
Ethyl alcohol is the effective chemical compound in alco- ally have a higher BAL (and therefore be more intoxicated)
holic beverages. It reduces anxiety, produces euphoria, and than a man of the same body weight consuming the same
creates a sense of well-being. It also reduces inhibitions, quantity of alcohol (Frezza et al., 1990; National Institute on
which adds to the perception that alcohol enhances social Drug Abuse, 1992).
and physical pleasure, sexual performance, power, and social
assertiveness. SHORT-TERM EFFECTS The effects of alcohol vary with
Yet it appears that some of the short-term effects of the level of concentration of the drug (yes, it is a drug) in the
ingesting small amounts of alcohol are as strongly related bloodstream. In addition, alcohol has what is termed a bipha-
to the expectations of the effects of alcohol as they are to sic effect. At lower doses, the effect of alcohol is stimulating,
its chemical action on the body. In an interesting body of resulting in pleasant feelings. At higher doses, alcohol acts
research, participants were told falsely that their drink con- as a depressant, and many may experience dysphoria. High
tained alcohol. These individuals were found to behave more doses can also produce unconsciousness and death. Because
aggressively (Lang, Goeckner, Adessor, & Marlatt, 1975), alcohol depresses CNS function, rapid ingestion of a large
report greater sexual arousal (Wilson & Lawson, 1976), and amount of alcohol can inhibit respiration and cause death.
report less performance-related anxiety (Abrams, Kushner, Fortunately, alcohol usually causes vomiting or unconscious-
Medina, & Voight, 2001) than participants who were not led to ness before most people reach this level of intoxication.
believe they were consuming alcohol. Environmental cues and Alcohol causes deficits in eye–hand coordination, which
personality can also mediate this effect (Quigley & Leonard, can be seen at BALs as low as 0.01 (alcohol only makes you
2006). One study found that individuals with high disposi- think you are the best pool player), and drowsiness shows
tional aggressivity were more likely to behave aggressively up on vigilance tasks at levels of 0.06. A 40% decrease in
when administered the placebo drink compared to individuals steadiness, as measured by the amount of swaying, is evi-
with low aggressivity (Giancola, 2002). It would appear that in dent at a BAL of 0.06. Decreased visual acuity and decreased
some individuals, expectations regarding alcohol’s effects are sensitivity to taste, smell, and pain are evident at BALs as
more potent than the actual physical responses. low as 0.08. Furthermore, at BALs of 0.08 to 0.1, reaction
Unlike most orally ingested psychoactive substances, time slows by about 10%, performance on standard intel-
alcohol does not require digestion to enter the bloodstream. ligence tests falls, memory is poorer, and perception of time
Since ethanol is water-soluble, it can pass directly into the is altered. (Five minutes seems like eight—an interesting
blood from the stomach, although most of it is absorbed challenge to the adage “Time flies when you’re having fun.”)
from the small intestine. The bloodstream quickly carries it Alcohol begins to affect driving performance at about 0.05,
to the CNS. The rate and peak level of absorption depend and the curve starts to rise sharply at about 0.08, the legal
on how quickly the alcohol gets through the stomach and limit of impairment in many jurisdictions. At the same time
into the intestine. If alcohol is consumed on a full stomach, that objective measures show poorer performance, the loss of
such as with a meal, passage to the intestine is more gradual inhibition often gives people increased confidence in their
than when consumed on an empty stomach. abilities (Tiplady, Franklin, & Scholey, 2004).
Once the alcohol reaches the blood supply, it travels Not surprisingly, this increased confidence and impaired
throughout the body and enters most tissues. Alcohol level performance can easily result in accidents. According to
is usually expressed as a percentage of blood. For example, the Traffic Injury Research Foundation (2014), approxi-
if there are 80 millilitres of alcohol in 100 000 millilitres mately 17% of Canadians reported that they had driven
of blood, blood alcohol level (BAL) is 0.08%. Approxi- after consuming alcohol in the past 30 days. This number
mately 95% of alcohol is removed by the liver at essentially has decreased from the 25% who reported this behaviour
a constant rate of 7 to 8 millilitres of ethanol per hour. The in 2010. More than 5% of drivers reported having driven at
remaining 5% of alcohol is excreted by the lungs, which is some point in the year before the survey when they were
what Breathalyzers measure to estimate BAL. Thirty mil- likely over the legal limit, and 38% of these drivers admitted
lilitres of liquor, 150 millilitres of wine, and one beer have to driving with passengers in the vehicle.
equivalent absolute alcohol content of 15 millilitres. If rate Drinking large amounts of alcohol quickly, particu-
of intake equals rate of metabolism, then BAL will remain larly on an empty stomach, can cause memory blackouts,
stable. If more than a single standard drink is consumed an interval of time for which the person cannot recall key
every two hours, then BAL will climb. Because alcohol does details or entire events. Blackouts are much more common
not distribute much into fatty tissues, an 80-kilogram leaner among social drinkers than previously thought. Among uni-
person will have a lower BAL than an 80-kilogram less versity students, the reported prevalence of blackouts is typ-
lean person who drinks the same amount of alcohol. The ically around 50 percent (Wetherill & Fromme, 2016). Types
leaner person has more fluid volume in which to distribute of events forgotten include participation in a wide range of
the alcohol. Alcohol is further broken down in the stomach potentially dangerous events, including driving, unprotected
by the enzyme alcohol dehydrogenase, and women have sex, and vandalism (White, Jamieson-Drake, & Swartz-
significantly less of this enzyme. The lower levels of alcohol welder, 2002). Women and men were equally likely to report
dehydrogenase in women and the fact that men tend to have blackouts in this survey, despite the fact that women drank

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 Substance-Related and Addictive Disorders 265

less often and less heavily, which is likely related to the gen- esophagus, stomach, liver, lung, pancreas, colon, and rectum.
der differences in the metabolism of alcohol just described. Finally, the effects of alcohol and nicotine are compounded
Alcohol is often considered a good way to get a good night’s to increase cancers of the oral region (Gunzerath, Faden,
sleep. Although alcohol may cause mild sedation and help Zakhari, & Warren, 2004; Longnecker, 1994).
a person fall asleep, it suppresses the rapid eye movement Heavy alcohol use has been associated with damage
(REM) phase of the sleep cycle. Lighter drinking suppresses to the heart muscle (cardiomyopathy), high blood pres-
REM for the first part of the night, but REM will rebound, sure, and strokes. On the other hand, there is consistent
or increase, in the latter part of the night to compensate. evidence that moderate alcohol consumption is related to a
With heavier drinking, REM is suppressed throughout the lower incidence of coronary heart disease. This finding has
night. This irregular sleep pattern impedes the restorative prompted discussions of a possible protective factor. The
effect of sleep, leading to significant daytime sleepiness. suggestion is that consuming one to two drinks of alcohol per
The adverse symptoms of “the morning after the night day may raise HDL cholesterol (“good cholesterol”), which
before” are familiar to many, but not well understood. The in turn increases blood flow through the coronary vessels
symptoms of hangovers range from nausea, fatigue, headache, (Di Castelnuovo et al., 2006).
thirst, depression, and anxiety to general malaise, and it is It has been a popular belief that consumption of alcohol
possible that these symptoms are a result of withdrawal from permanently kills brain cells, and research has demonstrated
the short-term or long-term addiction to alcohol. This notion that the brains of individuals who abuse alcohol demonstrate
is supported by the popularly recommended cure of “the hair tissue reduction, particularly in the hypothalamus and thala-
of the dog that bit you.” This remedy of taking an alcoholic mus. One result of this is Wernicke-Korsakoff syndrome,
drink to cure a hangover may appear to minimize the symp- a chronic disease characterized by an inability to form
toms, but it really only spreads them out. An analgesic for the new memories and a loss of contact with reality. However,
headache, and rest and time, are probably the wisest “cures.” research is conflicting and there is some evidence of brain
The extreme thirst that accompanies a hangover is axon regrowth in the cortex following an extended period of
related to alcohol’s ability to cause the fluid inside the body’s abstinence (Bates, Bowden, & Barry, 2002).
cells to move outside the cells, causing cellular dehydra-
tion. In addition, the diuretic effect that causes the body FETAL ALCOHOL SPECTRUM DISORDER The relation-
to excrete more fluid than is taken in (an effect that can be ship between maternal drinking and birth defects was first
quite inconvenient in certain circumstances) contributes to called fetal alcohol syndrome (FAS) in 1973, and described
the increase in thirst. Finally, the nausea and stomach upset a pattern of facial dysmorphology, growth retardation, and
result because alcohol is a gastric irritant. In addition, the CNS dysfunction (Jones & Smith, 1973). More broadly, the
accumulation of acetaldehyde, a by-product of the metabo- varieties of impact resulting from exposure to prenatal alco-
lism of alcohol, is quite toxic, which contributes to the nau- hol fall under the umbrella term fetal alcohol spectrum disorder
sea and headache. The fatigue experienced the next day can (FASD) and include FAS, partial FAS, alcohol-related neu-
often be attributed to alcohol’s interference with normal rodevelopmental disorder, and alcohol-related birth defects
sleep patterns and the increased level of activity during the (see Chapter 14).
revelry of the evening before.
SOCIAL EFFECTS OF ALCOHOL MISUSE In a general sur-
LONG-TERM EFFECTS Alcohol is ubiquitous in our soci- vey conducted by Statistics Canada (Health Canada, 2010a),
ety and is therefore rarely considered a dangerous drug. In respondents (ages 15+) were asked whether their drink-
fact, it is a favourite part of many social activities. However, ing had adversely affected their friendships and social life,
chronic alcohol consumption is related to many diseases. physical health, happiness, financial situation, home life or
Because alcohol travels though the body in the bloodstream, marriage, work or studies, legal situation, learning abilities,
it comes in contact with every organ, directly or indirectly or housing in the previous 12 months. About 5.7 percent of
affecting every part of the body. Factors related to the sever- individuals reported at least one of these harms in the past
ity of damage include an individual’s genetic vulnerability, year, with men being more than twice as likely as women to
the frequency and duration of drinking, and the severity and report harm. These data illustrate some of the direct social
spacing of binges (Gutjahr, Gmel, & Rehm, 2001). Alcohol is consequences of alcohol abuse.
high in calories and, therefore, heavy drinkers often reduce According to a Canadian Centre for Substance Abuse
their food intake or, alternatively, experience increased body study (Rehm, Baliunas, Brochu, Sarnocinska-Hart, & Taylor,
fat and weight gain (the “beer belly”). Not only are these 2006), alcohol use costs Canadians a staggering $14.6 billion a
calories of little nutritional value, but alcohol also interferes year in increased health care, law enforcement, and reduced
with the absorption of nutrients in food that is eaten. Con- productivity (see Table 11.5 for a breakdown of the ways in
sequently, severe malnutrition and related tissue damage can which alcohol, tobacco, and illicit drugs impose costs on the
result. Prolonged alcohol use, with concomitant reduced Canadian economy). This cost has likely increased since 2002;
protein intake, is damaging to the endocrine glands, the pan- For instance, the cost of hospitalizations alone for substance
creas, and especially the liver. Alcohol has also been asso- use disorders in 2011 was an estimated $267 million, over half
ciated with cancers of the mouth, tongue, pharynx, larynx, of which was from alcohol (Young, & Jesseman, 2014).

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 266 Chapter 11

TABLE 11.5 THE SOCIAL COSTS OF TOBACCO, ALCOHOL, AND ILLEGAL DRUGS IN CANADA, 2002
(in millions of dollars)
Tobacco Alcohol Illegal drugs Total TAD
1. Direct health care costs: total 4360.2 3306.2 1134.6 8800.9
1.1 Morbidity:
acute care hospitalization 2551.2 1458.6 426.37 4436.2
psychiatric hospitals — 19.6 11.5 31.2
1.2 inpatient specialized treatment — 754.9 352.1 1107.1
1.3 outpatient specialized treatment — 52.4 56.3 108.7
1.4 ambulatory care: physician fees 142.2 80.2 22.6 245.0
1.5 family physician visit 306.3 172.8 48.8 527.9
1.6 prescription drugs 1360.5 767.6 216.8 2344.9
2. Direct law enforcement costs — 3072.2 2335.5 5407.8
2.1 police — 1,898.8 1432.0 3330.7
2.2 courts — 513.1 330.6 843.7
2.3 corrections (including probation) — 660.4 573.0 1233.4
3. Direct costs for prevention and research 78.1 53.0 16.5 147.6
3.1 research 9.0 17.3 8.6 34.9
3.2 prevention programs 69.1 33.9 7.9 110.9
3.3 salaries and operating funds — 1.8 — 1.8
4. Other direct costs 87.0 996.1 79.1 1162.2
4.1 fire damage 86.5 156.5 — 243.0
4.2 traffic accident damage — 756.9 67.0 823.9
4.3 losses associated with the workplace 0.5 17.0 6.6 24.1
4.3.1 EAP & health promotion programs 0.5 17.0 4.2 21.7
4.3.2. drug testing in the workplace N/A — 2.4 2.4
4.4 administrative costs for transfer payments 0.0 65.8 5.4 71.3
4.4.1 social welfare and other programs — 4.3 — 4.3
4.4.2. workers’ compensation — 61.5 5.4 66.9
5. Indirect costs: productivity losses 12 470.9 7126.4 4678.6 24 275.9
5.1 due to long-term disability 10 536.8 6,163.9 4408.4 21 109.1
5.2 due to short-term disability (days in bed) 24.4 15.9 21.8 62.0
5.3 due to short-term disability (days with reduced activity) 36.2 23.6 0.1 59.8
5.4 due to premature mortality 1873.5 923.0 248.5 3045.0
Total 16 996.2 14 554.0 8244.3 39 794.4
Total per capita (in $) 541 463 262 1267
Total as % of all substance-related costs 42.7 36.6 20.7 100.0
TAD: Tobacco, Alcohol, and Illegal Drugs; N/A: not applicable “–”: not available; EAP: Employee Assistance Programs
Categories in italics are sub-categories of immediate prior category.
Source: Reproduced with permission from the Canadian Centre on Substance Use and Addiction.

In particular, drinking and driving has been recognized ETIOLOGY

as a major social problem. It is estimated that in 2002, 8100 The average age at which Canadians start drinking is
Canadians lost their lives as a result of alcohol consumption. 14.8 years and has gradually increased over the past two
The largest alcohol-related cause of death was liver cir- decades (Boak et al., 2015). Alcohol is advertised on tele-
rhosis, followed by motor vehicle accidents and suicide. In vision and radio, and in magazines. It is available in every
addition, there were an estimated 196 000 hospital admis- community, and we are encouraged to imbibe at most social
sions related to alcohol, the largest number being caused by gatherings. There is no stigma attached to drinking alco-
accidental falls, followed by alcohol dependence and motor hol; in fact, people are often pressed to explain why they
vehicle accidents.

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 Substance-Related and Addictive Disorders 267

are abstaining. With such extensive social influence, why having the disorder personally. Although vulnerable, many
do only some people become dependent on alcohol, while such offspring do not develop alcohol problems and many
others do not? There has been extensive research into the people with alcohol use disorders do not have affected
etiology and maintenance of alcohol use disorder, and many parents. Undoubtedly, environmental factors and personal
of these theories have been adopted for other types of sub- choice play significant roles in the development or avoid-
stance use disorders, so some generalization is possible. ance of problems with alcohol.

GENETIC FACTORS It is an accepted fact that alcohol use NEUROBIOLOGICAL INFLUENCES Biological marker
disorders run in families but, as we have seen in other chap- studies attempt to show that alcohol use disorder is inherited
ters (see Chapter 4), this does not disentangle the genetic by establishing an association between it and other inher-
and environmental influences. Twin studies have confirmed ited characteristics (see also discussions of linkage analysis
that male monozygotic twins are more similar than dizygotic in Chapters 8 and 9). Biological processes of individuals
twins in their tendencies to develop problems with alcohol with alcohol use disorder, of non-problem drinkers, and of
abuse and dependence (Agrawal & Lynskey, 2008). The con- children of both are compared to determine markers of vul-
cordance rate for male monozygotic twins has been found to nerability to alcohol. One such marker is brain wave activ-
range from 26 to 77% across studies, compared to a range ity that can be measured by electroencephalographic (EEG)
of 12 to 54% for male dizygotic twins (McGue, 1999). The techniques. Sons and daughters of alcohol dependent fathers
results for studies of females are more variable, with about have more elevation of resting-state beta wave activity than
half of the available studies showing a significant genetic do children of non-affected fathers (Rangaswamy et al., 2004).
effect. The concordance rate for female monozygotic twins Evoked potentials have also been implicated. These are brief
has been found to range from 25 to 32%, compared to a changes in EEG responses to external stimuli, such as flashes
range of 5 to 24% for female dizygotic twins (McGue, 1999). of light or loud sounds. The P300 response occurs about
However, these studies fall prey to the criticisms mentioned 300 milliseconds after the presentation of a stimulus and is
in Chapter 4. Adoption studies (also explained in Chapter 4) believed to indicate an individual’s attentional abilities. Sons
show a similar pattern of consistent results for men but vari- and daughters of parents with alcohol use disorder consis-
able results for women (Gelernter & Kranzler, 2009). tently show smaller P300 amplitudes elicited in a variety
Twin and adoption studies provide evidence for a of tasks than do offspring of non-alcoholic parents (Hill &
genetic contribution to the development of alcohol disorders, Steinhauer, 1993; Iacono, Malone, & McGue, 2003). A simi-
particularly for men, but what exactly is inherited? Given lar pattern was found in individuals with alcohol use disor-
the complexity of alcohol problems, it is unlikely that only der who were no longer drinking (Porjesz & Begleiter, 1997).
one or two of the up to 100 000 genes composing humans are Importantly, longitudinal studies show that a reduced P300
responsible. Instead, it is likely that multiple genes and pat- response predicts the early onset of alcohol problems (Hill,
terns of genes are important. Research has focused on genes Shen, Lowers, & Locke, 2000). Taken together, these findings
involved in the sensitivity of receptor sites for a number of suggest that beta activity and P300 amplitude reflect herita-
neurotransmitters that form part of the reward system of ble components for risk of alcohol abuse and are appropriate
the brain. Genes associated with the GABAergic, dopami- vulnerability markers.
nergic, glutamatergic, serotonergic, opioid, and cholinergic Neurotransmitter s such as GABA (gamma-
systems have been implicated in the susceptibility to alcohol aminobutyric acid), beta-endorphin, and serotonin are other
dependence (Gilpin & Koob, 2008). However, the relation- potential markers for alcohol use disorders. For example, low
ship between these systems and alcohol use is complex, and levels of serotonin have been associated with alcohol-related
precisely how environmental factors moderate these genetic characteristics such as impulsivity, aggression, antisocial
susceptibilities still needs to be understood. behaviour, reward processing, and alcohol craving in both
Another genetic factor that may be involved in alcohol animals and humans (Hayes & Grenshaw, 2011). However,
use disorders is the ability to metabolize alcohol. Alcohol is serotonin operates in a complex manner, with more pro-
broken down in the liver into a by-product called acetalde- cesses involved than simply serotonin level; these include
hyde, which is further broken down by the enzyme aldehyde sensitivity and density of receptors, variation in rate of
dehydrogenase. If acetaldehyde builds up, it causes serious metabolism and reuptake of serotonin in the synaptic cleft,
illness. In certain individuals—particularly those of Asian dietary intake of amino acids, and the cell’s recent firing his-
descent—aldehyde dehydrogenase seems to be absent, tory (Neumeister et al., 2006). Serotonin is not yet a practi-
resulting in unpleasant physiological responses including cal marker for alcohol use disorder, in part because serotonin
cutaneous flushing (i.e., facial flushing) and palpitations, levels are difficult to measure (Tabakoff & Hoffman, 1991),
perspiration, and headache. These effects provide a biologi- and its precise role in addiction is still being determined.
cal upper limit on alcohol consumption, which reduces the In addition to neurological influences, heart rate related
risk for development of alcohol abuse (Iyer-Eimerbrink & to the consumption of alcohol has also been studied. Men
Nurnberger, 2014). with relatives who have alcohol use disorder show larger
It is important to note that being a son or daughter of increases in heart rate (Finn, Zeitouni, & Pihl, 1990). In addi-
someone with an alcohol use disorder does not predetermine tion, those with the greatest increases in heart rate were more

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 268 Chapter 11

inclined to drink alcohol regularly (Pihl & Peterson, 1991). It These expectancies begin to develop in childhood by
has been suggested that heart rate increase is a measure of observing adult drinking behaviours and media portray-
sensitivity to the stimulating properties of alcohol, and may als of positive alcohol-related experiences. While tension
be viewed as an index of reward (Brunelle et al., 2004). reduction is a factor in problem drinking for many people,
Although each of the aforementioned biological mark- it does not explain all problem drinking behaviour (Young,
ers has shown interesting relationships to alcohol use disor- Oei, & Knight, 1990). The alcohol expectancy theory pro-
der, none has so far been found clinically useful in diagnosing poses that drinking behaviour is largely determined by the
substance abuse or in predicting which individuals will grow reinforcement that an individual expects to receive from
up to have alcohol problems. Like the genetic factors dis- it. Among the expectancies identified by a group of social
cussed earlier, at the present time, these biological markers drinkers were that alcohol positively transforms experiences,
might be considered indications of a vulnerability and merit enhances both social and physical pleasure and sexual per-
further investigation. formance and experience, increases power and aggression,
alters personal characteristics and improves social skill, and
PSYCHOLOGICAL FACTORS While one clear profile of an reduces tension (Goldman, Del Boca, & Darkes, 1999). Nev-
addictive personality has not been established, certain per- ertheless, most of these subjective experiences are a func-
sonality characteristics seem to be associated with alcohol tion of expectation and attitude and not a drug effect. In
use disorder. The strongest association is with the trait of fact, alcohol’s pharmacological effects can have the opposite
behavioural disinhibition. People with alcohol-use prob- effect of expectation in regard to tension reduction, mood,
lems tend to have greater difficulty inhibiting behavioural sexual performance, and social skills.
impulses (McGue, 1999; Lawrence, Luty, Bogdan, Sahakian, In support of the expectancy theory, priming positive
& Clark, 2009); They tend to be more rebellious, more alcohol expectancies has been found to increase subsequent
impulsive, more aggressive, and more willing to take risks alcohol consumption in heavy drinkers (Stein, Goldman, &
than individuals without alcohol problems. The severity of Del Boca, 2000). Additionally, individuals with alcohol-use
the alcohol abuse also appears to be positively associated disorder and heavy social drinkers are more likely than non-
with the level of impaired inhibitory control over behaviour problem drinkers to believe that alcohol use will result in
(Lawrence et al., 2009). These differences predate the onset positive outcomes (Leeman, Kulesza, Stewart, & Copeland,
of the alcohol problems and have been observed as early as 2012). Longitudinal research with adolescents also sup-
age three (Caspi, Moffit, Newman, & Silva, 1996). Interest- ports the impact of alcohol expectancy on future drinking
ingly, behavioural disinhibition may be related to serotonin behaviour; Positive expectancies of alcohol effects predict
deficiency (Sachs et al., 2013), which, as we mentioned earlier, higher levels of subsequent alcohol use (Smith, Goldman,
might be a vulnerability marker for alcohol-use problems. Greenbaum, & Christiansen, 1995).
A second trait that has been shown to be associated Learning and experience also play a role in the develop-
with alcoholism is negative emotionality or neuroticism. ment of tolerance for alcohol and other drugs. Dr. Shep Siegel
Negative emotionality is the tendency to experience psy- from McMaster University originated a line of research that
chological distress, anxiety, and depression. Research shows demonstrated that drug tolerance is partially conditioned
that affected individuals are more likely to have this ten- to the environment in which the substance is used. Tradi-
dency than are non-affected individuals (McGue, Slutske, tionally, tolerance was considered to be related entirely to
& Iacono, 1999). However, longitudinal data do not provide biological process, a cellular adaptation to the substance.
evidence that this tendency predates the onset of alcohol use Using animal models, Siegel and others demonstrated that
and subsequent alcohol problems (Chassin, Flora, & King, through the principles of classical conditioning, cues in the
2004). One study found that negative emotionality was asso- environment can become conditioned stimuli to the effects
ciated with a more rapid escalation to alcohol-use problems of drug use. These cues cause the individual to anticipate the
among adolescents following the onset of drinking (Colder, drug effects so that when the drug is actually administered
Campbell, Ruel, Richardson, & Flay, 2002). Negative emo- the effects are diminished. Over time, as conditioning con-
tionality appears more likely to be a consequence of alcohol tinues, the drug effects diminish to a greater extent. Toler-
use disorder (Sher, Trull, Bartholow, & Vieth, 1999) than a ance, or the need for a greater amount of drug for the same
risk factor. effect, is greatest when the conditioned environmental cues
Several theories have been proposed to explain alco- are present. This behavioural tolerance effect accounts for
hol misuse. The tension-reduction, or anxiety-relief, the observation that heroin addicts can use a larger amount
hypothesis suggests that drinking is reinforced by its abil- of heroin in their typical environment (where tolerance is
ity to reduce tension, anxiety, anger, depression, and other greatest) but can fatally overdose when they use the same
unpleasant emotions. However, support for this hypothesis amount in a novel environment (Siegel, 2016).
is inconsistent, probably because alcohol has variable effects
on tension, depending on how much is consumed, and only SOCIO-CULTURAL FACTORS Alcohol use is influenced by
certain individuals experience stress reduction after ingest- social and cultural factors such as family values, attitudes,
ing alcohol. It also appears that the subjective effects of and expectations that have been passed on from generation
alcohol depend largely on the expectancies of the drinker. to generation. It seems that people who are introduced to

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 Substance-Related and Addictive Disorders 269

drinking as a rite of passage in an environment in which episodic heavy drinking in parents predicts earlier and
excessive drinking is socially accepted (and, indeed, encour- heavier adolescent drinking (Vermeulen-Smit et al., 2012).
aged by peer pressure) face an increased risk of developing A longitudinal study of alcohol experiences among Cana-
alcohol problems. In some subcultures, an individual’s use dian adolescents found that the perceived intensity of paren-
of chemicals is seen as a sign of maturity, and this adoles- tal drinking predicted adolescent alcohol use one year later
cent peer subculture may encourage repeated episodes of (Van Der Vorst et al., 2013). However, one longitudinal study
substance abuse. Social learning also influences expectancies found no clear link between parental drinking during child-
and, as we have seen, individuals with positive expectan- hood and drinking behaviour nine years later (Van Damme
cies are most likely to be the heaviest drinkers. Cultural and et al., 2015). Children of parents who drink no alcohol also
familial traditions and attitudes toward alcohol use combine tend to the extremes of drinking behaviour, either drinking
to influence the individuals’ expectations of the effects of heavily or not at all (Lawson, Peterson, & Lawson, 1983).
alcohol and their drinking patterns. The exact etiology of alcohol use disorder has yet to
Evidence for cultural influence on drinking patterns be resolved, but many researchers agree that it is a multide-
can be found in comparisons of alcohol problems in different termined disorder influenced by biological, psychological,
countries. While the consumption of alcohol is worldwide, and sociological factors. Evidence for a genetic contribu-
the patterns of alcohol abuse differ from country to coun- tion to the development of alcohol use disorder is strong,
try. In France, where daily drinking is common, individuals but it cannot explain why some people with family histo-
with alcohol use disorder are usually steady drinkers who ries of alcohol problems do not develop drinking problems.
rarely show a loss of control and are prone to physical disor- Nor does it account for the fact that most of the people who
ders rather than social disruptions. Although daily drinking develop these disorders do not have family histories of these
is also acceptable in Italy, drinking is usually restricted to problems. Individuals develop expectations about alcohol,
mealtime and consumption is limited, and there is a much must choose to use alcohol, and decide on the way it will
lower rate of disorder there than in France. In England, be used. The individual with biological and/or psychologi-
Ireland, and North America, problems are often manifested cal vulnerabilities may respond to social influences and per-
by bouts of extremely heavy drinking and often associated sonal stressors in a manner that promotes the development
with loss of control and disastrous social consequences. In of drinking problems. Different combinations of risk factors
Muslim countries, where consumption of alcohol is discour- and environmental liabilities create multiple paths to the
aged on religious grounds, alcohol misuse may be limited development of alcohol use disorders.
(Karam, Maalouf, & Ghandour, 2004).
Drinking patterns in the home also influence an indi-
vidual’s use of alcohol. Adolescents’ drinking tends to mir- TREATMENT
ror that of their parents. If parents use alcohol to cope with Alcohol and other drug abuse have probably been around for
stressful situations or associate heavy drinking with celebra- as long as the drugs themselves. Early admonitions against
tion, children will likely adopt the same attitudes. In general, the overuse of alcohol were of a moral nature, and those who

APPLIED CLINICAL CASE

Robert Downey Jr.

Robert John Downey Jr. is a Golden Globe Award–winning and
Academy Award–nominated actor who also became infamous
Junji Kurokawa/AP Photo/CP Images

for a period of alcohol and other drug abuse during the 1990s.
Although he continued his acting career during that time, he
was frequently in the news for drug-related incidents that led to
arrest, incarceration, and mandated substance abuse treatment.
Downey relapsed often and dramatically. In 1999 he explained
to a judge: “It’s like I have a loaded gun in my mouth and my fin-
ger’s on the trigger, and I like the taste of the gunmetal” (Reaves,
2001). Over the years, Downey has appeared in more than 70
movies and on various television shows, including Saturday Night
Live. He has also been arrested on numerous occasions, spent a
year in state prison, and is well known for falling asleep in his probation for Downey, instead of incarceration. Since then, he
neighbour’s bed while under the influence. In 2001, he was fired says he is drug-free and has garnered acclaim for his leading
from the popular television show Ally McBeal after being arrested role in the popular Iron Man movies. He attributes his recov-
while on parole for suspicion of being under the influence of ery to family therapy, 12-step programs, meditation, yoga, and
drugs. A newly established drug court mandated treatment and kung fu (Wilde, 2003).

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 270 Chapter 11

lacked the fortitude to resist temptation were punished. A 25 years, there has been a move toward the use of outpatient
more liberal view of alcohol and other drug use arose dur- treatments from the routine use of the standardized 28-day
ing the Second World War, when many soldiers engaged in inpatient program. However, efforts to identify specifically
substance abuse. A number of treatment approaches have which type of individual does best in which type of approach
been developed for alcohol use disorder, each with its own have met with limited success. Generally, treatments are
proponents and some evidence of effectiveness. In Canada, focused on abstinence, meaning that they help the person to
there are just over 1000 treatment programs. The differing stop drinking completely (see Focus box 11.3).
patterns of alcohol abuse suggest that there are various con-
tributors to alcohol use disorder, and it may be that some RESIDENTIAL TREATMENT: THE MINNESOTA MODEL
treatments, or combination of treatments, are better suited The most common residential treatment for alcohol use
for some people under some conditions. Over the past disorder is a multimodal approach advocating a 12-step

FOCUS
Non-abstinence Drinking Goals in Treatment
11.3 Originally, controlled-drinking research was used to having a stronger belief in one’s ability to moderate drinking
test the critical hypotheses of the popular disease con- (Saladin & Santa Ana, 2004). Individuals who self-select non-
cept of alcoholism (Pattison, Sobell, & Sobell, 1977). abstinence programs also tend to have fewer alcohol-related
Mark and Linda Sobell (researchers who worked for many problems and symptoms of dependence (Humphreys & Klaw,
years at the Centre for Addiction and Mental Health in Toronto) 2001). Humphreys (2003) argues that groups such as Mod-
studied a program for teaching alcoholics to drink in moderation eration Management, which allow goal choice, extend the tra-
in comparison with an abstinence-oriented program similar to ditional treatment system by attracting people who would not
Alcoholics Anonymous (Sobell & Sobell, 1973, 1976). Partici- attend traditional treatment. Allowing a choice of goals within
pants in the study were 40 male alcoholics in a treatment pro- treatment systems may be one effective way to increase the
gram who were thought to have a good prognosis. Overall results numbers of people willing to enter alcohol treatment. It is esti-
over more than two years of follow-up indicated that individuals mated that as few as 10 percent of individuals with alcohol use
in the controlled-drinking group were functioning well for 85 disorders attend treatment. More flexibility in goals may appeal
percent of the days, as compared to 42 percent of the days for to a wider range of people with alcohol use disorders.
the abstinence group. Most professionals advise that abstinence is the appropriate
These results were challenged in a subsequent paper. treatment goal for drinkers who have had a long history of heavy
Pendery, Maltzman, and West (1982) reported that they had con- drinking, where drinking has come to be a pervasive and integral
tacted the men in the Sobell study 10 years later and found that part of their lifestyle, or for those who have suffered serious con-
only one of the men in the controlled-drinking group continued to sequences. However, if they are unwilling to accept abstinence
maintain a pattern of controlled drinking; four had died from alco- as a treatment goal, they may benefit from treatment aimed at
hol-induced problems. This re-evaluation made headlines. The harm reduction (Addiction Research Foundation, 1992).
Sobells were charged with scientific misconduct and ethical viola- What are the implications of assuming the “wrong” goal for
tions. However, these charges were later refuted by several inde- an individual? A small group of treatment studies have randomly
pendent investigative committees. Pendery and colleagues (1982) assigned individuals to either abstinence or non-abstinence
had not provided follow-up data on the abstinence group—who, it drinking goals (Adamson & Sellman, 2001; Ambrogne, 2002).
turned out, had fared no better than the controlled-drinking group. These studies comparing drinking goals do not find differences
This controversy has created lasting mistrust between proponents in outcome, which suggests that it is not harmful to allow indi-
and opponents of controlled-drinking programs. viduals to attempt to moderate their drinking instead of abstain-
A number of other lines of evidence point to the viability of ing. Ambrogne (2002) identified 12 studies that consistently
non-abstinence treatment goals for some people with alcohol use found that some patients were able to sustain non–problematic
problems (Hodgins, 2005). First, as early as the 1940s, follow-up drinking after treatment over follow-up periods of one to eight
studies of alcoholics have revealed that a proportion of patients, years. In fact, there may be an advantage to allowing patients to
albeit a small group, describe successful and sustained non- make their own goal choice. Goals change over time, and treat-
abstinence outcomes over follow-up periods of one to eight years ment can provide experiences that will encourage patients to
(Ambrogne, 2002). The most widely cited of these studies is the reconsider and revise their initial goals. In one Canadian study
Rand report from the mid-1980s that provided a follow-up of a that allowed goal choice among people with severe alcohol
large national U.S. sample of patients from abstinence-oriented dependence, participants choosing moderation initially tended
inpatient alcohol treatment programs. Remarkably, about to change their goal to abstinence over time, presumably as
18 percent of patients were described as drinking moderately and a result of lack of success with moderation (Hodgins, Leigh,
problem-free after four years (Polich, Armor, & Braiker, 1981). Milne, & Gerrish, 1997). Choice of abstinence with this group of
Second, patient characteristics have been found to predict patients ultimately predicted better outcome at one-year follow-
success with non-abstinence outcomes. These include younger up. In short, the appropriateness of a goal will declare itself over
age, relatively better social and psychological stability, employ- time, and usually in short order. ●
ment, being female, having less severe alcohol dependence, and

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 Substance-Related and Addictive Disorders 271

Alcoholics Anonymous philosophy. This model views alco- dehydrogenase, resulting in a buildup of acetaldehyde
hol use disorder as a disease and is termed the Minnesota in the body. Like people who naturally lack this enzyme,
model because it was popularized by the well-known people who drink alcohol after taking Antabuse experience
Hazelden treatment program in that state. For people who increased heart rate, nausea, vomiting, and other unpleasant
show signs of withdrawal, treatment begins in a hospital or effects. Patients are instructed to take the medication each
detoxification clinic under medical supervision, and often morning, before the desire to drink becomes overwhelming.
includes prescription drugs. Following detoxification treat- The goal is to deter the individual from drinking, but once
ment for the physical dependence, treatment of the psy- again compliance is a major hurdle. It is common to have
chological dependence begins. This component includes a family member administer Antabuse to the affected indi-
education about the consequences of alcohol use and abuse, vidual as part of a treatment program. This approach has the
individual counselling for psychological issues, and group added advantage of helping the family member regain trust
therapy to improve interpersonal skills. Abstinence is the in the individual’s resolve to not drink.
goal, since it is assumed that people with the alcoholism “dis-
ease” will never be able to drink in a controlled way. Partici-
MUTUAL SUPPORT GROUPS
pants are usually required to attend Alcoholics Anonymous
meetings and encouraged to keep going after treatment to Alcoholics Anonymous. Alcoholics Anonymous (AA) works
address the danger of relapse. Despite the popularity of the with more alcoholics worldwide than any other treatment
Minnesota model, the effectiveness of the approach has not organization. AA does not use professionally trained staff; it
been rigorously evaluated. is a self-help group, “a fellowship of men and women who
share their experience, strength, and hope with each other
PHARMACOTHERAPY Medication has been used in the that they may solve their common problem and help oth-
treatment of alcohol use disorder to assist in detoxification, ers to recover from alcoholism” (AA Grapevine, Inc., New
to reduce the pleasurable effects associated with drinking, York, cited in Rivers, 1994, p. 268). AA got its start in 1935 in
and to produce nausea when alcohol is consumed. To make a popular Protestant religious following, the Oxford Move-
detoxification more bearable, benzodiazepines (tranquiliz- ment. The movement, dedicated to redeeming humankind
ers) have been administered to alcoholics as a first step in through striving for absolute good, consisted of small groups
treatment. Since these medications mimic some of the effects that met weekly for prayer, worship, and discussion. Two
of alcohol, they minimize the effects of withdrawal. Doses members, physician Dr. Bob and stockbroker Bill W. had
are gradually decreased as withdrawal symptoms abate. been trying unsuccessfully to quit drinking, and found the
Medication can also be prescribed as a method of fellowship of the group helpful. They invited more and more
reducing the immediate gratification that accompanies problematic drinkers into the group, and when the meetings
drinking. Naltrexone, an opioid antagonist drug, targets the became too large, they broke away and founded Alcoholics
neurotransmitters that mediate alcohol’s effects on the brain Anonymous.
and “blocks” the pleasurable effects of alcohol. In addition, it The AA treatment is based on a disease model, and
helps to reduce the sensation of craving. Studies have shown the goal is complete abstinence. AA members believe that
that naltrexone, in combination with psychosocial treat- there is no cure for alcoholism; there are only alcoholics
ment, does help some alcohol abusers abstain from alcohol who drink and alcoholics who do not drink (in recovery).
use, particularly those who are finding it difficult to initiate They believe that they are powerless to control their drink-
abstinence (Killeen et al., 2004; Chick et al., 2000). Acam- ing and must rely on a “Higher Power” to help them. Mem-
prosate is another drug that can be used to reduce craving bers are encouraged to attend meetings often and regularly,
for alcohol and to reduce distress during early abstinence. as social support is central to the program, and to follow
It is an agonist drug that facilitates the inhibitory action of the “12 steps” of recovery (see Table 11.6). Members who
the neurotransmitter GABA at its receptors. Studies con- have stayed sober for a period of time serve as sponsors for
ducted in Europe show that use of Acamprosate in com- newcomers. There are more than 65 000 AA groups in the
bination with psychosocial treatment doubles the number United States and Canada, and more than 100 000 meetings
of people who are successfully abstainers (Swift, 2003). A are held each week all over the world. Many of the groups
meta-analysis of acamprosate and naltrexone effectiveness comprise specific types of individuals such as women,
suggested that acamprosate may be particularly effective in LGBTQ , smokers, non-smokers, and so forth. Active mem-
abstinence treatment while naltrexone may be more effec- bers will often attend more than one group in addition to
tive with controlled drinking (Carmet, Angeles, Ana, & their “home” group.
María, 2004). These medications have the potential to play AA is an effective treatment for some, and many people
an important adjunctive role in alcohol treatment. However, credit it with saving their lives. Others find it difficult to
success depends on the compliance of the individual, which embrace because of its reliance on spirituality and its adop-
has been a significant concern with these drugs. tion of the disease model. Only a few research evaluations of
Another medication approach is to make the experi- AA’s effectiveness exist, mostly observing the effects when
ence of drinking extremely aversive. Antabuse (disulfiram) attendance is coerced (e.g., legally mandated by the courts
blocks the action of the metabolizing enzyme acetaldehyde or employers). Results have not been favourable, although

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 272 Chapter 11

TABLE 11.6 THE 12 STEPS OF ALCOHOLICS behavioural interventions attempt to condition an aversive
ANONYMOUS response to alcohol by pairing alcohol with an unpleasant
1. We admitted we were powerless over alcohol—that our
stimulus. For example, the sight, smell, and taste of alco-
lives had become unmanageable. hol may be presented while the alcoholic is nauseated and
2. Came to believe that a Power greater than ourselves
vomiting as a result of taking an emetic drug. Theoretically,
could restore us to sanity. over time the sensation of nausea should be elicited by the
3. Made a decision to turn our will and our lives over to the
presence of alcohol without the emetic drug (a conditioned
care of God as we understood Him. response), and the previously positive associations with
4. Made a searching and fearless moral inventory of our-
drinking become negative. Even though a number of theo-
selves. retically sound procedures have been used, aversion therapy
5. Admitted to God, to ourselves, and to another human
alone has had limited success, although it can be combined
being the exact nature of our wrongs. with other treatments (Costello, 1975; Nietzel, Winett,
6. Were entirely ready to have God remove all these defects
Macdonald, & Davidson, 1977).
of character. Other behavioural treatments are based on operant
7. Humbly asked Him to remove our shortcomings.
conditioning principles (see Chapter 2). Contingency man-
agement has been used to manipulate reinforcement con-
8. Made a list of all persons we had harmed, and became
willing to make amends to them all.
tingencies for alcohol use. Contracts between patients and
treatment programs may be established that specify rewards
9. Made direct amends to such people wherever possible,
except when to do so would injure them or others.
(or punishments) contingent on small steps toward sobriety.
Contingency management appears to help clients main-
10. Continued to take personal inventory and when we were
wrong promptly admitted it.
tain abstinence, and thus, may enhance the effectiveness
of treatment (Prendergast, Podus, Finney, Greenwell, &
11. Sought through prayer and meditation to improve our
conscious contact with God as we understood Him, pray-
Roll, 2006). A more comprehensive operant program is the
ing only for knowledge of His will for us and the power to Community Reinforcement Approach (CRA; Azrin, 1976).
carry that out. A spouse, friend, or relative who is not a substance user is
12. Having had a spiritual awakening as the result of these recruited to participate in the program; both participants
steps, we tried to carry this message to alcoholics, and to learn behavioural coping skills and how to develop contin-
practice these principles in all our affairs. gency contracts. They learn to identify antecedents to drink-
Source: The Twelve Steps and Twelve Traditions. Used by permission from
ing, the circumstances in which drinking is most likely, social
Alcoholics Anonymous World Services, Inc. reinforcers, and the consequences of drinking. They are
also taught how to arrange reinforcement contingencies to
reward sobriety rather than reinforce drinking. Finally, this
comprehensive intervention program also helps alcohol-
the intent of AA is that attendance is voluntary (McCrady,
ics to develop new recreational options that do not involve
Horvath, & Delaney, 2003). Follow-up studies of alcoholics
alcohol and reduce stress through improvements in practical
post-treatment show that those who choose to attend AA
areas of life, such as employment, finances, and education.
have better outcomes than those who do not attend. More
Behavioural self-management is a treatment approach
rigorous evaluation has been conducted on 12-step facilita-
that teaches people with alcohol use disorder to manage
tion, which involves the use of professionals in encouraging
their own drinking through behavioural contracting, restruc-
AA attendance with positive results (McCrady et al., 2003).
turing of thoughts about drinking, and having individuals
A number of mutual support groups have been devel-
recognize the patterns in their drinking. This approach has
oped to support individuals who do not affiliate with the
been offered in groups, in individual format, and in the form
spiritual aspect of the AA groups. These groups empha-
of self-help workbooks. It has strong research support, par-
size personal responsibility and rationality as important in
ticularly for individuals with less severe alcohol problems
recovery. Women for Sobriety and SMART Recovery (Self-
(Miller, Wilbourne, & Hettema, 2003), and it has been used
Management and Recovery Training) support abstinence
with the goals of both complete abstinence and moderated
from alcohol and other drugs. Moderation Management
drinking.
helps individuals to moderate their drinking versus stopping
completely.
Relapse Prevention. Whether the goal of treatment for
PSYCHOLOGICAL TREATMENTS alcohol use disorder is complete abstinence or moderated
drinking, the long-term results of most programs are disap-
Behavioural Treatment. The behavioural approach treats pointing. Most treated individuals eventually relapse and
problem drinking as a learned behaviour. Alcohol, an develop problems with alcohol again. Relapse prevention
unconditioned stimulus, elicits unconditioned responses in treatment aims to avoid relapses if possible, and to manage
the form of pleasant physical reactions. Alcohol becomes a relapse if and when it occurs (Marlatt & Gordon, 1985).
associated with these pleasant responses (see Chapter 2 for Relapse is seen as a failure of a person’s cognitive and behav-
an explanation of conditioning theory). Therefore, some ioural coping skills to cope with life’s problems. Maladaptive

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 Substance-Related and Addictive Disorders 273

behaviour is seen as a result of self-defeating thoughts and partner is trained to reward sobriety rather than reinforce
self-deception that can bring about “inadvertent” slips. drinking.
Apparently innocent decisions based on distorted beliefs can
chain together to create circumstances that increase the risk BRIEF INTERVENTIONS Brief interventions are one to
of drinking. The relapse prevention techniques attempt to three sessions in length, offering time-limited and specific
help individuals identify these distorted beliefs and replace advice regarding the need to reduce or eliminate alcohol
them with adaptive ones. High-risk situations are identified consumption. These interventions can be offered opportu-
for each individual and strategies are developed to deal with nistically in settings where the individual is seeking help for
them. For example, if a person has a history of drinking in a related problem. For example, a family physician might
response to interpersonal conflict, that person can be taught raise the issue of alcohol use in patients with gastrointestinal
to recognize the early stages of an argument and talk issues problems or abnormal liver functioning tests, or an emer-
over more calmly, or to leave and go for a walk before ten- gency room nurse may approach victims of motor vehicle
sions mount too high. People are taught to view lapses not accidents involving alcohol. Alternatively, brief interven-
as overwhelming failures that will inevitably lead to more tions can be offered to individuals with “concerns” about
drinking, but as temporary occurrences brought on by a spe- their alcohol use but who are reluctant to seek more formal
cific situation, from which a person can recover. Evaluations treatment. One such program, called the Drinker’s Check-up,
have shown relapse prevention to be useful in treating alcohol allows individuals to get feedback on their drinking behav-
use disorder (Miller et al., 2003; Witkiewitz & Marlatt, 2004). iours. Of the treatment approaches for alcohol problems
that have been empirically evaluated, brief interventions are
among those that have the largest and strongest support.
Marital and Family Therapy. An individual’s pattern of sub-
Particularly effective are brief approaches that focus
stance abuse is unavoidably linked to close social relation-
on the individual’s motivation to make changes in his or her
ships, though not necessarily caused by these relationships.
drinking (Miller et al., 2003). Motivational interviewing is
In family and marital therapy, the relationship, rather than
an approach that can be used with clients who present with
the problem drinker, is seen as the patient. Family therapy
varying levels of readiness to change their behaviour. In a
focuses on issues of interaction and the notion that a family
non-confrontational, accepting manner, the therapist helps
unit attempts to maintain equilibrium. Established patterns
the client to identify and freely discuss both the pros and
of interaction and resistance to change can inadvertently
cons of his or her alcohol use. Motivational interviewing is
support alcohol abuse by one member of the family. Fam-
considered to be a client-centred, semi-directive technique
ily members may have established roles for themselves that
wherein the therapist works to increase the client’s aware-
are defined by the substance abuse and have become so
ness of the problems and create a discrepancy between
enmeshed in the drinking problem that they actually pre-
behaviours and goals. The therapist supports the client’s
vent changes in the abuse pattern. Such people are described
self-efficacy and autonomy to move toward change. Motiva-
as codependents. Even if there is no codependency, marital
tional interviewing can be used as part of brief interventions
conflict, such as spousal nagging about drinking, can stimu-
or as an adjunct for more comprehensive treatments.
late bouts of heavy drinking.
In a family with someone with an alcohol use disorder,
the alcohol abuse often overshadows other existing or poten- BEFORE MOVING ON
tial problems. In a sense, the abuser becomes a scapegoat.
What causes one person to develop an alcohol problem, while
When the individual stops drinking, other troubling issues
another does not?
might develop or become evident. For example, a potentially
depressed spouse may manage the depression by dealing
with the problem of an alcoholic spouse. When this diversion
is no longer available, the depression may unfold. Children
Barbiturates and Benzodiazepines
in such families often try to be “extra good” and supportive There are a number of drugs considered to be depressants
during the drinking phase, and may react to a parent’s quit- because they inhibit neurotransmitter activity in the
ting by acting out. Family members may have reduced their CNS. We have seen that alcohol is one of these sub-
communication because of fear of causing the alcoholic to stances, although it was not developed for this purpose. In
become violent or drink more, and the communication may the DSM-5, the depressant drugs other than alcohol are
remain subdued after cessation of drinking. Each of these grouped together as sedative, hypnotic, or anxiolytic drugs,
areas provides potential targets of therapeutic interventions based upon their typical prescribed use as sedatives, sleeping
in the families of alcoholics. medications, and anti-anxiety medications. Barbituric acid,
Behavioural marital therapies adapted for treatment produced in 1903, was one of the first drugs developed as a
of couples in which one partner has an alcohol problem are treatment for anxiety and tension and later for sleep. Since
among the approaches with the strongest empirical support. then, there have been many derivatives of this sedative-
This approach is focused on teaching communication skills hypnotic drug, including those with the brand names Sec-
and increasing the levels of positive reinforcement in the onal, Tuinal, Nembutal, and Fiorinal. Barbiturates were
relationship. As with the CRA approach, the non-alcoholic widely prescribed until the 1940s, when their addictive

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 274 Chapter 11

potential became known. Barbiturates are commonly known personality changes and serious impairments of memory
as “downers,” or according to the colour of their brand name and judgment.
versions (e.g., “blues,” “yellow jackets,” and “red birds”).
Now, another group of drugs belonging to the sedative- DEPENDENCY
hypnotic class called benzodiazepines (e.g., Valium, Librium,
Tolerance to barbiturates develops rapidly. With regular use,
Xanax, Ativan) are more frequently prescribed for sleep and
increasingly higher doses are needed to achieve sedative
anxiety problems. Although these are generally thought of
effects. Tolerance to the benzodiazepines typically develops
as safer alternatives to barbiturates, they too can be addict-
much more slowly than tolerance to barbiturates. A user with
ing if misused. Barbiturates and benzodiazepines are odour-
high tolerance to barbiturates or benzodiazepines attempt-
less, white, crystalline compounds, usually taken as tablets
ing to abstain abruptly may experience extreme withdrawal
or capsules. Long-acting forms are available for prolonged
reactions including delirium, convulsions, sleep disruptions,
sedation. Shorter-acting versions, used to treat insomnia, are
and other symptoms similar to those experienced with alco-
thought to be more addicting.
hol withdrawal.

PREVALENCE
TREATMENT
The prevalence of prescription tranquilizer use in Canada
Treatment for sedative, hypnotic, or anxiolytic use disor-
has remained stable since 2008, with approximately 10%
ders can be very complicated and may require prolonged
of the general population, aged 15 years and older, report-
hospitalization. Treatment usually involves administering
ing use of prescription sedatives. In 2015, 13.5% of women
progressively smaller doses of the abused drug to mini-
and 7.3% of men reported using sedatives in the preceding
mize withdrawal symptoms. Many individuals experience
12 months. Abuse of tranquilizers is also fairly low in Canada.
abstinence syndrome, which is characterized by insomnia,
In the same national survey, only 0.3% of Canadians reported
headaches, aching all over the body, anxiety, and depression;
abusing sedatives in the preceding 12 months. In a survey
and which can last for months (Cambor & Millman, 1991). In
of Ontario high school students (Boak et al., 2015), non-
addition to the pharmacological interventions, psychological
medical use of tranquilizers (including benzodiazepines)
and educational programs are usually advised to treat barbi-
was 1.3% for males and 3.0% for females.
turate dependency. Narcotics Anonymous mutual support
groups, based on the same model as AA, have been set up in
EFFECTS most large Canadian cities.
The effects of barbiturates and benzodiazepines are simi-
lar except that the anxiolytic effects of the benzodiazepines
emerge at lower doses, making them the safer alternative. In Stimulants
small doses, these drugs cause mild euphoria. With larger
Stimulants are a class of drugs that have a stimulating or
doses, slurred speech, poor motor coordination, and impair-
arousing effect on the CNS and create their effects by influ-
ment of judgment and concentration occur. Initially, users
encing the rate of uptake of the neurotransmitters dopa-
may be combative and argumentative, but the larger dos-
mine, norepinephrine, and serotonin at receptor sites in the
ages eventually induce sleep. The behaviour observed at
brain. The increased availability of these neurotransmitters
this dosage is similar to that seen in alcohol intoxication.
affects the nucleus accumbens, which is a primary reward
In fact, DSM-5 criteria for sedative, hypnotic, or anxiolytic
centre in the brain. As a group, stimulants are the most
intoxication are very similar to those of alcohol intoxica-
commonly used and abused drugs. They include tobacco,
tion. Because they depress CNS function, very large doses
amphetamines, cocaine, and caffeine. Medications such as
of barbiturates lower respiration, blood pressure, and heart
Ritalin and Adderal that are used to treat attention deficit
rate to dangerous levels. The diaphragm muscles may relax
disorder fall into this drug class. In the DSM-5, tobacco and
excessively, causing suffocation. Coma is also a common out-
caffeine are classed separately from the stimulants because
come. Many people taking barbiturates and benzodiazepines
their effects differ.
are unaware that their effects are amplified when mixed with
other drugs. As an example, the combination of barbiturates
with alcohol causes a synergistic effect: the effect of the two TOBACCO
drugs is greater than the effects of the sum of the two drugs Tobacco use (in the form of cigarettes, snuff, chewing
taken separately. Alcohol greatly increases the sedative and tobacco, cigars, and pipes) constitutes one of the leading
toxic effects of the barbiturate—the effect that nearly killed public health concerns in Canada. The number of Canadian
Gareth in the chapter-opening case. This combination has deaths directly attributable to tobacco use is estimated to be
led to many deaths, both accidental and suicidal. approximately 21 percent of all deaths in the past decade
Chronic use of barbiturates or benzodiazepines can (Statistics Canada, 2012b). This number includes adult
cause what appears to be a constant state of alcohol intoxi- smoking-related diseases (e.g., lung cancer and emphy-
cation. Long-term use causes depression, chronic fatigue, sema), childhood illness linked to maternal smoking (e.g.,
mood swings, and paranoia. It may also result in dramatic respiratory illness), and deaths due to smoking-related fires.

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 Substance-Related and Addictive Disorders 275

Smoking prevention and cessation programs have become thought to contribute to its rewarding and addictive proper-
a priority for national health campaigns. Moreover, soci- ties (Benowitz, 1990).
ety bears major costs related to tobacco use. As shown in Although the short-term consequences of smoking are
Table 11.5, the costs to society related to tobacco are higher minimal, the long-term health risks associated with smoking
than the costs related to alcohol, and much higher than all are significant. Smoking has been implicated in the develop-
costs related to illicit drugs. ment of lung, esophagus, larynx, and other cancers; emphy-
Nicotine comes from the tobacco plant Nicotiniana taba- sema; respiratory illness; heart disease; and other chronic
cum, which is a member of the nightshade family. Indigenous conditions. Most of these illnesses are caused by the carbon
to South America, it is now grown in many places through- monoxide and other chemicals found in tobacco. Although
out the world. In Canada, it was originally grown by the many of the health risks associated with smoking can be
Petun, Neutral, and Huron tribes of southwestern Ontario, minimized 5 to 10 years after a person quits, lung dam-
who introduced it to French settlers. These colonists began age is often irreversible (Jaffe, 1995). The health hazards of
cultivating and trading tobacco as early as 1652. Commercial second-hand (or passive) smoke can be even more danger-
cultivation began in the 1800s, and Canada now ranks among ous. Because there is no filter for these substances, second-
the top 10 tobacco-producing countries. hand smoke contains greater concentrations of ammonia,
carbon monoxide, nicotine, and tar than the smoke inhaled
by the smoker. As a result, passive smoking is associated
PREVALENCE Smoking rates in Canada rose steadily in the
with significant health risks in non-smokers, including heart
1900s, peaking in the mid-1960s. It is estimated that in 2015,
disease, lung cancer, and childhood asthma.
13% of Canadians over the age of 12 currently smoked ciga-
Smoking during pregnancy is associated with problems
rettes (Statistics Canada, 2012a). This represents a decline
such as low birth weight, spontaneous abortion, stillbirth,
from 1965, when approximately 50% of Canadians smoked
and infant illness and disability. Women who smoke during
regularly, and from 2007, when 19% smoked. In 2010, 13%
pregnancy have double to triple the risk of having an under-
reported smoking daily, whereas 4% reported smoking occa-
weight baby and 12 times the risk of delivering prematurely.
sionally. More males (20%) reported smoking than females
An estimated 23 percent of women smoked during their last
(14%). Daily smokers smoked an average of 15.1 cigarettes per
pregnancy (Cui, Shooshtari, Forget, Clara, & Cheung, 2014).
day. There are at present more Canadians who have quit smok-
ing than there are current smokers. The decline in smoking
over time is likely due to increasing tobacco prices, antismok- DEPENDENCY Dependence produced by nicotine is
ing media campaigns, and smoking bans in public places such thought to be even greater than that produced by other
as restaurants, shopping malls, and buses (Wilson et al., 2012). addictive substances, including alcohol, cocaine, and caf-
Of particular concern to public health officials are the feine (see Table 11.7; West, 2006). Nicotine dependence
rates of smoking among people under age 20, and efforts have develops quickly, and although extremely large doses are
been made to restrict cigarette ads that specifically target required to produce intoxication, its behavioural effects
young people. The number of teen smokers rose in the 1990s are severe enough to classify many tobacco users as hav-
but has been steadily declining since 1997. However, tobacco ing a substance abuse disorder according to DSM-5 crite-
use is still common among Canadian youth. Data collected ria. Smokers become addicted not only because of nicotine’s
from the 2008 Canadian Youth Smoking Survey estimated mood-enhancing abilities, but to prevent the effects of with-
that 18.1% of males and 12.8% of females in Grade 12 were drawal, which can be quite severe.
tobacco users (Leatherdale & Burkhalter, 2011). Other high- So, with smoking, we have a situation that is extremely
risk groups for smoking include people with a lower formal conducive to dependence: heavy nicotine use does not cause
education, blue-collar workers, and Indigenous Canadians. intoxication or behavioural impairment, and it is legally
An estimated 59% of the First Nations population (Assem- available and relatively inexpensive. A person can smoke
bly of First Nations and First Nations Information Gover- all day and avoid the severe withdrawal symptoms—a per-
nance Committee, 2007) and 71% of the Inuit population fect recipe for addiction. People addicted to nicotine dis-
smoke (First Nations and Inuit Health Branch, 2004). play behaviours much like those of other substance abusers:
they often need a cigarette to start their day, they frequently
EFFECTS Nicotine is a CNS stimulant related to the smoke more than they anticipate, and they often spend a
amphetamines. It is an extremely potent chemical and the great deal of time looking for more cigarettes. Some smok-
ingestion of only a few drops, in its pure form, can cause ers change their social plans to have continuous access to
respiratory failure. Lower dosages can interfere with think- cigarettes. Furthermore, almost all smokers continue to
ing and problem solving, and can cause extreme agitation smoke despite the knowledge that they are seriously damag-
and irritability along with mood changes. However, the ing their health. There has been some suggestion that some
very small amount of nicotine present in a cigarette is not people are more sensitive to the effects of nicotine on dopa-
lethal and can increase alertness and improve mood. When minergic neurons, and thus become dependent more quickly
inhaled, nicotine enters the lungs and reaches the brain in (Morel et al., 2014). Certainly, people who begin to smoke
seconds. Similar to other addictive substances, it stimulates when they are teenagers tend to be more dependent than
the release of dopamine in the nucleus accumbens. This is those who start smoking in their twenties.

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 276 Chapter 11

TABLE 11.7 RELATIVE ADDICTIVENESS OF achieving lasting success. The majority quit smoking with-
COMMONLY USED SUBSTANCES AND out professional help. Others seek help in the form of widely
ACTIVITIES available self-help materials or through psychological and/
This table represents experts’ assessment of how easy it is to
or pharmacological treatments.
get hooked on various commonly used substances and activities
Psychological Treatments. Psychological interventions have
(both legal and illegal) and how difficult it is to stop using them.
The estimates represent the proportion of users who develop an
increasingly become conceptualized and organized as an inte-
addictive pattern at some point in their lives. grated system that includes a range of interventions varying
in terms of intensity. Examples include formal face-to-face
Drug/Activity Plausible Estimate of
“Addictive Potential”
psychological interventions, brief counselling provided by
health care professionals, telephone counselling, online sup-
Those with at least some usable data port groups for quitting, and provision of self-help materi-
Heroin High als for quitting. A review of the research on effectiveness of
Methadone High psychological treatments concluded that there is consistent
Nicotine High evidence that counselling is associated with modest smoking
Amphetamines Moderate cessation success (Schlam & Baker, 2013). The use of self-
help materials without counselling or medication is not effec-
Ecstasy Moderate
tive at improving quit rates (Ranney et al., 2006).
Cocaine Moderate
The psychological interventions designed to help
Alcohol Moderate people stop smoking are usually behavioural or cognitive
Marijuana Moderate in nature. As such, they typically help individuals develop
Benzodiazepines Moderate skills such as self-monitoring, goal setting, and reinforce-
Gambling Low ment. Some interventions attempt to reduce the pleasure
Those with little usable data experienced by smokers by forcing them to smoke far
more cigarettes than they would normally. The adverse
Inactivity Moderate
nature of these programs has probably contributed to their
Tasty food Moderate
lack of success (Sobell, Toneatto, & Sobell, 1990). Other
Barbiturates Low smoking cessation programs involve abrupt abstinence
Inhalants Low (“cold turkey”) or include a period of reduction before the
Gammahydroxybutyrate (GHB) Low individual quits for good.
Steroids Low
Stealing Low Pharmacological Treatments. Smoking cessation medica-
Violence Low tions fall under two main categories: over-the-counter nico-
Diving Low tine replacements and medications that are available only
Surfing Low
by prescription. Nicotine replacement in the form of gum,
lozenges, inhalers, or skin patches helps to reduce cravings
Fast driving Low
and other physiological withdrawal symptoms by maintain-
Exercise Very low ing a steady level of nicotine in the system. The idea is to
Sexual behaviours Very low break the behavioural habits associated with smoking while
Playing computer games Very low simultaneously reducing craving.
Chocolate Very low Prescription-only medications include bupropion
Self-harm Very low hydrochloride and varenicline tartrate. Both drugs work
by targeting receptors in the brain and do not deliver any
Caffeine Very low
nicotine to the body. Bupropion hydrochloride (Wellbutrin,
Watching TV Very low
Zyban) was originally prescribed as an antidepressant but
Work Very low was subsequently found to be effective in aiding smoking
Shopping Very low cessation. It works by reducing the severity of nicotine crav-
Source: Republished with permission of John Wiley & Sons, from Theories of Addiction, ings and withdrawal symptoms. Varenicline tartrate (Chan-
Robert West, 2002; permission conveyed through Copyright Clearance Center, Inc.
tix, Champix) is a prescription drug that works by reducing
cravings and decreasing the pleasurable effects of nicotine.
TREATMENT Despite greater restrictions on smoking There has been some evidence to suggest an association
in public places and ever-increasing knowledge about between varenicline and suicidal ideation. It is recommended
the health risks associated with smoking, it can be a diffi- that health care professionals and patients be very attentive
cult habit to break. Research in the United States shows to mood and behavioural changes when taking varenicline.
that most smokers want to quit and over half have tried to Success rates of pharmacological treatments are greatly
quit in the past year (Centers for Disease Control, 2011). enhanced when used in conjunction with psychological ther-
Most smokers make three or four quit attempts before apies (Alberta Alcohol and Drug Abuse Commission, 2004).

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 Substance-Related and Addictive Disorders 277

BEFORE MOVING ON
amphetamine use in Canada has declined markedly. In the
Canadian Centre on Substance Abuse (2004a) national sur-
Despite the relative addictiveness of tobacco, the prevalence vey, 6% of respondents (aged 15+) reported using amphet-
of smoking has decreased in recent years. What are some amines at some time in their life; Ecstasy use was reported
explanations for this trend? by 4%. Among high school students (Grades 9 to 12), 5.6%
of males and 5.1% of females reported ecstasy use in the past
year and 1.1% of both males and females reported meth-
AMPHETAMINES AND DESIGNER DRUGS amphetapine use, including crystal meth. Among students
Amphetamines and related drugs have effects on the body in Grades 7 to 12, 2.1% reported using an ADHD drug for
similar to those of the naturally occurring hormone adren- nonmedical purposes (Boak et al., 2015).
alin. The two most commonly abused forms of amphet-
amine are methamphetamine (with street names such as EFFECTS At low doses, amphetamines increase alertness
“speed” when injected, and “ice” or “crystal” when smoked and allow the user to focus attention effectively, offering
in a purified form) and dextroamphetamine (a legally pre- improved performance on cognitive tasks. Amphetamines
scribed medication sold under the name Dexedrine). Other also suppress appetite. At higher doses, they induce feelings
street names for these drugs are “bennies,” “uppers,” “glass,” of exhilaration, extroversion, and confidence, and at very
“crank,” and “pep pills.” Methylphenidate (Ritalin) is used high doses, restlessness and anxiety can occur.
to treat ADHD but can also be abused. Methylated amphet- Chronic amphetamine use is associated with feelings of
amines, referred to as designer drugs, have both stimulant fatigue and sadness, as well as periods of social withdrawal
and hallucinogenic properties. Methylene-dioxymetham- and intense anger. Repeated high doses can cause halluci-
phetamine (MDMA), known as “ecstasy” (or simply “E”), nations, delirium, and paranoia, a condition known as toxic
has had recent popularity, particularly among young peo- psychosis. To combat undesirable effects such as sleepless-
ple at raves. Methylene-dioxyamphetamine (MDA) and ness, many amphetamine users also become dependent upon
para-methoxyamphetamine (PMA) are other examples of depressant drugs such as tranquilizers, barbiturates, and
designer drugs. alcohol to induce sleep. This can lead to a roller coaster–like
Amphetamines were originally developed as a nasal vicious circle of drug use (Stein & Ellinwood, 1993).
decongestant and asthma treatment in the 1930s. It was dis- The physical effects of amphetamines include increased
covered that, in addition to shrinking mucous membranes or irregular heartbeat, fluctuations in blood pressure, hot or
and constricting blood vessels, they also increased alertness cold flashes, nausea, weakness, and dilation of pupils. Pro-
and concentration. Consequently, they were used to treat longed use usually leads to weight loss. At very high doses,
narcolepsy (a sleeping disorder) and later ADHD. Later, amphetamines can induce seizures, confusion, and coma.
the appetite-suppressant qualities of amphetamines also The periods of intense anger associated with prolonged
led to their use as a treatment for obesity. Currently, only amphetamine use might also contribute to the prevalence
dextroamphetamine (or Dexedrine, used in the treatment of of violent death in Canada such as suicides, homicides, and
ADHD) is legally manufactured in Canada. Other amphet- violent accidents (Gourlay, 2000).
amines and related drugs, referred to as “designer drugs,” The long-term effects of ecstasy have received consid-
are manufactured illegally in home laboratories. erable attention. Based on animal studies, there is a concern
that moderate or greater use can lead to permanent depletion
PREVALENCE The rate of amphetamine and other illicit
drug use in Canada is difficult to determine for several rea-
sons. First, unlike alcohol and tobacco (which can be mea-
sured by the standard drink or the cigarette), most drugs
have no accepted units of measurement. Moreover, because
most sales of such drugs are illegal, there are no consumer
records or indexes of availability. Consumers may not even
Janine Wiedel Photolibrary/Alamy Stock Photo

know what they are using. Because many are manufactured

in illegal laboratories, the contents vary considerably. For
example, the RCMP conducted an analysis of ecstasy tablets
seized at Vancouver raves (Royal Canadian Mounted Police,
2000). Only 24 percent of the tablets were pure MDMA; the
other tablets were mixtures of other substances with or with-
out MDMA. More than one-third contained no MDMA.
Thus, it is difficult to define and monitor addiction, or to
gauge the social impact of illicit drug use.
Between 1950 and 1970, stimulants were widely con-
sumed by truckers, athletes, students, and others wishing Crack, a fast-acting and highly addictive form of cocaine, is smoked
to increase alertness and enhance performance. Since then, with a special pipe.

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 278 Chapter 11

of serotonin. There have been reports of long-term neuro- it forms a crystallized substance (a “rock”), which is then
psychiatric problems in users, although the specific role of smoked. The process itself is potentially dangerous, because
ecstasy in producing these effects is unclear. the solvents are highly flammable. It is popular, however,
because of its cheapness, since the cocaine used need not be
DEPENDENCY Amphetamine tolerance and dependence as refined as cocaine for snorting. This method of ingestion
develops very quickly. The effects of amphetamines do not also increases the rate of metabolizing the drug and makes it
last long, and users often experience a post-high “crash” more addictive.
marked by feelings of fatigue, irritability, sadness, and crav- The short-term effects of cocaine appear soon after its
ing. Withdrawal from amphetamines also often causes peri- ingestion and dissipate very quickly. Crack is especially fast-
ods of apathy and prolonged sleeping. acting, and may wear off in a few minutes. In small amounts,
cocaine use in any form produces feelings of euphoria, well-
COCAINE being, and confidence. Users become more alert and talkative,
and experience reduced appetite and increased excitement
Cocaine comes from the Erythroxylon coca bush, indigenous and energy, due to the stimulation of the higher centres of the
to various areas in South America. Its stimulating effects CNS. It appears that these effects are primarily achieved by
have long been known to the people of these regions, who increasing the availability of dopamine at important neuronal
chew on the leaves to reduce fatigue and induce euphoria. sites in the brain. With high doses, the CNS is overstimulated,
Throughout the 1800s, cocaine was viewed as harmless; it leading to poor muscle control, confusion, anxiety, anger, and
was sold in cocaine-laced cigarettes, cigars, inhalants, and aggression. Continuous use may result in mood swings, loss
crystals, and was the principal ingredient in a variety of of interest in sex, weight loss, and insomnia. As with amphet-
commercial products, including Coca-Cola (Musto, 1992). amines, chronic use of cocaine can also lead to toxic psychosis
In 1911 cocaine use was restricted in Canada, and it is now experienced as delusions and hallucinations.
only occasionally used legally as a local anaesthetic for Physical symptoms of cocaine use include increased
minor surgeries. blood pressure and body temperature, as well as irregular
In the 1960s and 1970s, cocaine became a popular recre- heartbeat. Users may also experience chest pain, nausea,
ational drug. Due to the high cost, its use was generally lim- blurred vision, fever, muscle spasms, convulsions, and coma.
ited to those in middle- and upper-income groups. Recently, Death can occur because of cocaine’s impact on the brain
however, cocaine has fallen in price as cheaper forms such as centres that control respiration.
crack have been introduced.
Cocaine is usually sold on the street in powder form. PREVALENCE The restriction on cocaine use by the
This powder is often snorted, but can also be rubbed into Canadian government in the early 1900s led to a decline in its
the skin or mixed with water and injected. Another method use throughout the first half of the century. This decline coin-
of cocaine ingestion is called “freebasing” and involves cided with an increase in amphetamine use. When amphet-
purifying cocaine by heating it and smoking the residue. amine use waned in the 1950s and 1960s, cocaine’s popularity
(See Table 11.8 for a comparison of methods of taking sub- again increased (Addiction Research Foundation, 1997).
stances.) Crack is made by dissolving powdered cocaine in a In a 2015 survey, approximately 1 percent of Canadi-
solvent, combining it with baking soda, and heating it until ans reported having used cocaine or crack in the past year

TABLE 11.8 METHODS OF TAKING SUBSTANCES

Method Route Time to Reach Brain
Inhaling Drug in vapour form is inhaled through mouth and lungs into circula- 7 seconds
tory system.
Snorting Drug in powdered form is snorted into the nose. Some of the drug 4 minutes
lands on the nasal mucous membranes, is absorbed by blood vessels,
and enters the bloodstream.
Injection Drug in liquid form directly enters the body through a needle. 20 seconds (intravenous)
Injection may be intravenous or intramuscular (subcutaneous). 4 minutes (intramuscular)

Oral ingestion Drug in solid or liquid form passes through esophagus and stomach 30 minutes
and finally to the small intestines. It is absorbed by blood vessels in
the intestines.
Other routes Drugs can be absorbed through areas that contain mucous mem- Variable
branes. Drugs can be placed under the tongue, inserted anally and
vaginally, and administered as eyedrops.
Source: Reprinted with permission from Understanding Drugs of Abuse: The Processes of Addiction, Treatment, and Recovery, (Copyright ©2004). American Psychiatric Association.
All Rights Reserved.

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 Substance-Related and Addictive Disorders 279

(Health Canada, 2017). Among high school students, past OPIOIDS

year use of cocaine was 2.5 percent, with males and females Opioids (also known as narcotics) are a class of CNS depres-
equally likely to report use (Boak et al., 2015). sants—drugs whose main effects are the reduction of pain
and sleep inducement. Opium, the alkaloid from which opi-
DEPENDENCY Cocaine produces intense psychological
oids are derived, comes from the seeds of the opium poppy,
dependence and results in severe withdrawal symptoms.
which is indigenous to Asia and the Middle East. Natural
Cocaine users often feel a crash as the drug begins to wear
opiates (e.g., morphine, codeine) are refined directly from
off, which results in intense craving, depression, and para-
opium, whereas semi-synthetic opiates (e.g., heroin, oxyco-
noia, followed by fatigue. The craving for cocaine experi-
done) are derived from natural opiates. Synthetic opiates
enced during withdrawal gradually diminishes in intensity,
(e.g., methadone, Demerol, Percocet) are drugs manufac-
but can take more than a month to disappear completely
tured to have similar effects to those of the other opiates.
(Gawin & Kleber, 1986; Weddington et al., 1990).
Opioids can be taken as tablets, capsules, suppositories,
TREATMENT FOR AMPHETAMINE AND COCAINE ABUSE syrups, or in the form of an injection. In pure form, heroin
Treatment for stimulant abuse is complicated by several fac- appears as a white, odourless, bitter-tasting powder that can
tors. Stimulant users are likely to use other drugs to coun- also be snorted. Most heroin users, however, prefer to mix
teract some of the effects of the stimulants. As a result, many heroin with water and inject it to produce a more intense
are dependent on alcohol or other depressants, making it dif- high. This is known as “mainlining.”
ficult to decide which dependency to treat first. In addition, Heroin, the most commonly abused opioid, was
people who abuse more than one drug often have comor- originally introduced in 1898 as a replacement for mor-
bid mental disorders, and it is often difficult to determine phine and was viewed as relatively harmless. Not until
whether one of these conditions predates the other. the early 1900s was it discovered that heroin is even more
addictive than morphine. Morphine and codeine are the
Psychological Treatments. Psychological treatments for only naturally derived opioids in common clinical use in
stimulant abuse developed in the 1980s were often modelled North America. Morphine remains a mainstay of analge-
after the 12-step programs for alcohol. Intervention pro- sia for severe pain, such as that experienced by terminally
grams, which normally have abstinence as a goal, have also ill cancer patients, and codeine is present in many com-
focused on group therapy, individual counselling, and devel- mon medications, such as cough syrups and painkillers.
oping relapse prevention skills (McClellan, Arndt, Metzger, Although synthetic opiates are used frequently today as
Woody, & O’Brien, 1993). Cognitive-behavioural interven- analgesics, they can also produce dependence.
tions examine the thoughts and behaviours that precede and
maintain stimulant abuse (Joe, Dansereau, & Simpson, 1994). PREVALENCE
Recently, community outpatient contingency manage- In 2015 less than 1% of Canadians reported ever having
ment programs have become popular, in which individuals tried heroin (Health Canada, 2016). Among high school stu-
are rewarded with money and social outings if they remain dents in Ontario, 0.8% reported using it sometime in their
drug-free. There is some evidence that these programs are life and 0.7% reported using it in the past year. Rates have
superior to 12-step programs (Higgins et al., 1993). Among been generally low but have dropped in the past decade
individuals with mental disorders, contingency management (Boak et al., 2015).
is associated with significant reductions in drug use both Although the street use of heroin is not a major Cana-
during and following treatment, and reductions in psychiat- dian problem, the use of prescription forms of opioids by
ric symptoms (McDonell et al., 2013). Treatment programs Canadians is of considerable concern. Thirteen percent of
have also been developed that integrate the treatment of the Canadians aged 15 years and older reported using opioids
drug and comorbid mental health disorders. This integrated in the past year (Health Canada, 2016). Prevalence was not
approach is considered superior to sequential treatment of significantly different between males and females. Students
the various concerns. Cocaine Anonymous and Narcotics are also reporting high levels of use, with 10.0 percent of
Anonymous mutual support groups are also often recom- Ontario students in Grades 7 to 12 reporting past-year use
mended to complement the formal treatment program. (Boak et al., 2015).
Biological Treatments. Biological treatments are usually
used as adjuncts to psychological interventions for stimu- EFFECTS
lant abuse. Antidepressants may be prescribed to combat Opioids mimic the effects of endogenous opiates, or the
the depression that frequently occurs during withdrawal. body’s natural painkillers. Known as exogenous opiates,
In addition, drugs such as methylphenidate may be given narcotics affect receptor sites located throughout the body,
to reduce cravings. So far, studies have not found that these including the brain, spinal cord, and bloodstream. The nar-
medications alone improve outcomes (Gourlay, 2000; Miles cotics bind to receptor sites at these locations and, in turn,
et al., 2013). Again, they are probably most beneficial when reduce the body’s production of endogenous opiates. Thus,
used in conjunction with a good psychological treatment someone who stops using exogenous opiates may experience
program. increased pain sensitivity (Cambor & Millman, 1991).

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 280 Chapter 11

Heroin is perhaps the most addicting of all opiates, in causing death can occur. A major problem is that the impact of
part due to the sensations associated with using the drug. any dose can be difficult to determine. In fact, heroin addicts
About one minute after injecting heroin, the user experi- sometimes die from a dosage level that they had previously
ences an intense pleasurable rush. After this subsides, a tolerated. It appears that this is more likely to occur when the
euphoria characterized by dulled sensations and dream- drug is taken in an environment that is different from the one in
like sedation is produced, and the user may appear drunk. which the drug is usually taken, although it is not clear why this
Heroin also acts as an appetite suppressant, and even small is so (Szabo, Tabakoff, & Hoffman, 1994). In addition, because
doses can cause restlessness, nausea, and vomiting (Addic- heroin is produced in an uncontrolled manner and sold on
tion Research Foundation, 1997). the street, it is often cut with other drugs and its purity is dif-
At higher doses, heroin has extremely dangerous effects: ficult to determine. Many deaths have resulted when, for some
pupils constrict, the skin may turn blue and feel cold and unknown reason, the heroin that is sold at a street level is purer
clammy, breathing slows, and coma and respiratory depression than usual, so that the user unwittingly injects too high a dose.

FOCUS
The Fentanyl Crisis
11.4 Canada has seen a marked increase in the number of heroin addicts. Since then, several countries, including Canada,
fatal overdoses due to illicit fentanyl use. Fentanyl is have established increasingly organized needle exchange
a synthetic opioid that is up to 100 times more potent services. Canada has 30 needle exchange programs operating
than morphine. Alberta and British Columbia have been the across the country (Riley, 1994). These programs are often
most affected in this crisis but availability appears to be moving implemented along with counselling, education, and outreach
east across the country. Between 2009 and 2014, the rates of efforts attempting to encourage addicts to participate more fully
fentanyl-related deaths increased sevenfold overall and twenty- in treatment programs. Often the service is mobile, with a van
fold in Alberta (Canadian Centre on Substance Abuse, 2015). travelling to convenient meeting points with the addicts.
Exposure to fentanyl can occur from several sources. Heroin Research demonstrates that needle exchange programs
users may acquire fentanyl-laced Heroin, “fake oxy” tablets that accomplish their harm reduction goals. Users who attend pro-
are manufactured to resemble oxycodone, or purposefully seek grams compared to those who do not attend reduce their risk
out fentanyl (Jafari, Buxton, & Joe, 2015). behaviours and infection rates (Hurley, 1997) and are more
In an attempt to address this crisis, governments are mak- likely to attend treatment programs (United States Department
ing naloxone much more easily available to frontline workers of Health and Human Services, 2000).
such as fire fighters and paramedics and through pharamacies. Despite these positive effects, concerns about needle
For example, British Columbia initiated a Take Home Naloxone exchange programs continue to be voiced. Many are concerned
Program in 2012. Naloxone (Narcan) is a drug that blocks the about the risk to the public of providing extra needles to addicts.
effects of opioids, including depressed respiration and loss of However, no large public health risks have emerged. For exam-
consciousness, and is used to treat narcotic overdoses in emer- ple, the rate at which needles are turned in exceeds the rate
gency situations. The Take Home program educates opioid at which they are handed out in Vancouver (Vancouver Coastal
users and service providers in overdose prevention, recognition, Health, 2003). There is no evidence of an increase in needle
and response. In addition, sites involved in this program pro- stick accidents in public places such as playgrounds and parks.
vide prescriptions for naloxone to opioid users. This program There is also no evidence that drug dealers are drawn to areas
appears effective in reducing harms, including deaths, from with programs because of a perceived availability of clientele, or
opioid overdoses (Canadian Medical Association, 2014). Over that crime rates increase (Videnieks, 2003).
581 estimated opioid overdoses have been successfully reversed Perhaps the largest objections are to the harm reduction
(Deonarine, Amlani, Ambrose, & Buxton, 2016). philosophy itself. The harm reduction policy is sometimes seen
as supporting illicit drug use by providing drug use parapherna-
The Harm Reduction Approach lia. Due to these concerns, the U.S. federal government has a
Whereas treatment for drug abuse focuses on reducing or eliminat- constitutional ban on the use of federal funds to support needle
ing the use of the drug, harm reduction approaches focus on reduc- exchange programs and research on their effectiveness (Vernick,
ing the consequences of the use. Injection is often the preferred Burris, & Strathdee, 2003). In Canada, the police community
method of drug taking and many harm reduction approaches have has expressed concerns at times, although generally a posi-
focused on reducing consequences of this route of administra- tive working relationship between the police and programs has
tion. Among the other health risks of drug abuse, injection drug developed (Canadian Centre on Substance Abuse, 2004b). The
use puts the user at risk of contracting HIV or hepatitis C through establishment of needle exchange programs in Canadian prisons,
the use of contaminated needles or other injection equipment where injection drug use rates and rates of HIV and hepatitis C
such as spoons or containers. Users inject many times per day, so infection are far higher than those in the general population, has
the risk to the individual over time is high. In Vancouver, a study been more controversial. Despite their successful introduction in
of users found that 28 percent were HIV positive and 86 percent prisons in many other countries, there are currently no programs
were hepatitis C positive (Spittal et al., 1998). in Canadian correctional institutions (Canadian Centre on Sub-
In the 1980s, the Public Health Department in Rotterdam stance Abuse, 2004b). ●
began to distribute clean needles to a semi-organized group of

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 Substance-Related and Addictive Disorders 281

Chronic users may develop a number of physical con-

ditions. Chronic respiratory and pulmonary problems may
Cannabis
develop as a result of the effects of heroin on the respiratory
system. Case Notes
Endocarditis, an infection of the lining of the heart,
occurs as a result of the use of unsterilized needles. When Derek was 16 years old and in Grade 11, his older
The use of unsterilized injection equipment can also cause brother turned him on to grass, and he liked it. Derek
abscesses, cellulitis, liver disease, and brain damage. The began to smoke occasionally with his brother during the
risk of HIV infection among intravenous drug users is week. He could get marijuana for other kids from his
significant, although the introduction of needle exchange brother, which made him very popular.
programs seems to have been successful at reducing
the spread of HIV through needles (Gibson, Flynn, & Although Derek’s parents and brother had dropped out
Perales, 2001). of school early, Derek seemed academically gifted.
However, as his smoking became more frequent, his
work habits deteriorated and his attendance dropped.
DEPENDENCY Within a few months, he met suppliers who could pro-
The withdrawal symptoms associated with heroin and other vide him with cheaper marijuana and other drugs as
opioids are extremely severe and begin about eight hours well. Derek was now spending more time dealing than
after the last dose. Along with increased pain sensitivity, doing schoolwork, and he failed his year. But he was
the user may experience dysphoria, a dulling of the senses, earning as much in a day or two as his father did in a
anxiety, increased bodily secretions (runny eyes and nose), week of casual labour.
pupil dilation, fever, sweating, and muscle pain. Thirty-six By the end of the next school year, word of his services
hours after a dose, muscle-twitching, cramps, hot flashes, reached the ears of the principal. Derek’s apartment was
and changes in heart rate and blood pressure can occur, in raided and a sizable cache of drugs was seized. Derek
addition to sleeplessness, vomiting, and diarrhea. These was sentenced to 18 months in prison.
symptoms gradually diminish over a five to 10-day period.
Partly because of the intensity of these symptoms, relapse Upon release six months later, Derek was adamant about
of opioid abuse is extremely common (Addiction Research going straight. He returned to school and got a job wait-
Foundation, 1997). ing tables. But Grades did not come as easily as before,
the other students were all much younger, and the dou-
ble workload was tiring. He slowly slipped into seeing
TREATMENT some of his old acquaintances and smoking the odd
The treatment for opioid abuse typically involves the joint. When other students asked for drugs, he found it
use of medications. Drugs such as naltrexone act as opi- hard to refuse. Derek soon gave up his job and started
oid antagonists and help to alleviate initial symptoms of selling, and using, a variety of drugs.
withdrawal. Methadone, a heroin replacement, or a newer Derek was referred to one of the authors for a pre-
medication, buprenorphine/naloxone, are often used sentencing report after being found guilty of possession of
to reduce the craving after initial withdrawal symptoms a variety of drugs for the purpose of trafficking. This time,
have abated. Higher doses of these opioid antagonists are he was also charged with possession of a large number of
given in the early stages of treatment and are then grad- stolen goods, including a very expensive stereo system.
ually decreased. The medication is either tapered out Derek claimed he had received the goods as payment for
completely or is maintained at a steady dose to allow indi- drugs and did not know that they had been stolen.
viduals to improve their functioning in other areas of their
lives, such as employment and social relationships. Opioid
replacement therapy is associated with reduced criminal Marijuana and hashish come from the hemp plant
activity (Rastegar, Kawasaki, King, Harris, & Brooner, 2016) Cannabis sativa, indigenous to Asia but now grown in many
and reduced risk of HIV infection among intravenous drug parts of the world. The hemp plant was originally (and still
users (MacArthur et al., 2012). Most experts agree that is) cultivated for its strong fibres, which can be processed
medication therapy works best in conjunction with good into cloth and rope. However, its psychotropic and medicinal
individual and group psychological programs, as well as properties soon became known, and it was used for pleasure
ongoing peer support. as well as to treat rheumatism, gout, depression, and cholera.
Marijuana consists of the leaves and flowers of this plant,
which are dried and crushed. Hashish, made from the resin
BEFORE MOVING ON produced by the plant, is a much stronger form of cannabis.
Although both forms are most often smoked in cigarette
Why do opioids such as heroin and oxycodone have a high
form (called a “joint”) or in a pipe, they can also be chewed,
addictive potential?
added to baked goods, or prepared in a tea. Other names for

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 282 Chapter 11

marijuana and hashish are “pot,” “weed,” “grass,” “dope,” although it seems that this most often occurs when the
“reefer,” and “bud.” Cannabis does not fit into the usual clas- user has a pre-existing mental disorder. Individuals under
sification of drug groups. It generally has depressant effects, the influence of marijuana show deficits in complex motor
yet it increases the user’s heart rate like a stimulant. It can skills, short-term memory, reaction time, and attention.
also produce hallucinations when consumed in large doses, Physical effects include itchy, red eyes, and both increased
but this is not a usual effect. blood pressure and appetite (Wilson, Ellinwood, Mathew,
& Johnson, 1994). Cannabis has clear effects on ability to
PREVALENCE drive. Although detection of impairment is considerably
more complex than alcohol impairment, a standardized
Marijuana is the most commonly used and most widely
roadside assessment called the Drug Evaluation and Clas-
available illicit drug in Canada. In 2015, 37.5% of Canadi-
sification (DEC) program has been used throughout Canada
ans aged 15 and over reported using cannabis at least once
since 2008. DEC, which detects use of other psychoactive
in their lives and 12.3% reported using it in the year before
drugs in addition to cannabis, involves a series of coordina-
the survey (Health Canada, 2016). Rates were higher among
tion tests, an eye examination, behavioural observations, and
males and for younger adults, although prevalence of can-
toxicology analysis. Drug Recognition Experts (DREs) are
nabis use among females has increased. Rates of lifetime and
individuals trained and certified in conducting DEC evalu-
past-year use are lower than those reported in 2004, when
ations. Certification is essential because of the large number
the lifetime and past-year rates were 44.5% and 14.1%
and complexity of factors that need to be considered in each
respectively.
appraisal. A review of DEC evaluation studies found the
Among Canadian high school students in Grades 7 to 12,
overall accuracy of DEC evaluations of suspected impaired
21.3% reported use in the past year, with males and females
drivers to be greater than 80 percent (Beirness, LeCavalier,
equally likely to use. Daily use was reported by 2.1%. Use
& Singhal, 2007). An analysis of 1400 DEC evaluations con-
increases with each Grade from 7 to 12, with 37.2% of peo-
ducted in Canada revealed that DREs are extremely accu-
ple in Grade 12 reporting past-year use (Boak et al., 2015).
rate (95 percent) in detecting drivers who are impaired by
Although rates of cannabis use among adults appear
drugs (Beirness, Beasley, & LeCavalier, 2009).
to be rising, use among high school students have reduced
Long-term users often suffer greater lung problems
slightly since 1999 (Boak et al., 2015). Use among univer-
than tobacco smokers, including deterioration in the lin-
sity students is similar to that of Grade 12 students. A survey
ings of the trachea and bronchial tubes, which may be a
by researchers at the CAMH (Adlaf et al., 2005) found that
result of holding unfiltered smoke in their lungs for long
more than half (51%) of university students across Canada
periods of time. In addition, marijuana and hashish contain
reported using cannabis at some point in their lives. About a
much greater concentrations of some known carcinogens
third (32%) had used it during the past 12 months, and this
(e.g., benzopyrene) than does tobacco, and there is also
varied by region. Students in Quebec reported the highest
some evidence that chronic marijuana use can result in
rates of cannabis use in the previous 12 months (39%), fol-
fertility problems for both men and women.
lowed by the Atlantic provinces (37%), Ontario (33%), and
Some long-term users develop amotivational
British Columbia (30%). University students in the Prairie
syndrome, a continuing pattern of apathy, profound self-
provinces reported the lowest rates of cannabis use (19%).
absorption, detachment from friends and family, and
abandonment of career and educational goals. Reduced
EFFECTS motivation for goal-directed behaviour in cannabis users
The psychoactive effects of cannabis are caused primar- appears to be related to repeated doses of THC, supporting
ily by the chemical delta-9-tetrahydrocannabinol (THC). the hypothesis that THC can disrupt reward-based learning
Although the exact mechanisms by which THC exerts its (Lane & Cherek, 2002). However, it is not yet clear whether
influence are not fully understood, it appears that it acts cannabis use is a cause, consequence, or correlate of amotiva-
upon specific cannabinoid receptors in the body and mim- tion. Although the amotivational syndrome is thought to be
ics the effects of naturally occurring substances, including related to the alteration of brain function caused by chronic
the endogenous opiates (Bouaboula et al., 1993). The con- cannabis use (Musty & Kabak, 1995), it may also be related
centration of THC in marijuana and hashish has increased to depression in long-term users. There is evidence that
about fivefold since the 1960s and 1970s, making it difficult about 30 percent of regular cannabis users also have symp-
to measure accurately the effect of specific doses. toms of depression (American Psychiatric Association, 2000;
Cannabis involves mild changes in perception along Cambor & Millman, 1991). It is unclear whether depression
with enhancement of physical experiences. With relatively leads to increased cannabis consumption, or whether it is a
small doses, most users report feeling mildly euphoric and result of prolonged use. Among chronic users, cannabis itself
sociable. A sense of well-being and relaxation usually begins may be a significant motivator, causing other behaviours to
within minutes of ingesting the drug and lasts for two to be seen as less rewarding (Volkow et al., 2016).
three hours. Some people, however, find the drug stimulat- Regular use of cannabis has also been linked to increased
ing, and occasionally panic or anxiety is also experienced. At onset of psychosis (see Chapter 9) in numerous longitudi-
high doses, cannabis has been known to cause hallucinations, nal studies conducted over the past 30 years. More recent

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 Substance-Related and Addictive Disorders 283

attention has been given to whether this association is causal TREATMENT

(i.e., the use of cannabis specifically causes the psychotic Several factors complicate treatment of cannabis use dis-
symptoms), whether it reflects an underlying shared vulner- orders. Marijuana abuse often co-occurs with other mental
ability (i.e., people with a vulnerability to psychotic disorder disorders, including use of other substances, and cannabis
also have a vulnerability to the use of cannabis), or whether users rarely seek treatment for marijuana abuse (Copeland,
people with emerging psychotic disorder self-medicate Clement, & Swift 2014). Individuals who do seek treatment
these symptoms with cannabis. A recent review concluded have typically been using cannabis for over 10 years. Most
that the bulk of the research evidence suggests that the link individuals who abuse marijuana in Canada are placed in gen-
is causal but that a better understanding of who is most at eralized treatment programs, although there are also efforts to
risk is required (Gage, Hickman, & Zammit, 2016). develop cannabis-specific treatment approaches. A combina-
tion of motivational enhancement and cognitive-behavioural
THERAPEUTIC EFFECTS OF CANNABIS Cannabis has
therapy has the greatest evidence of success for individuals
been used in the treatment of several diseases, including
with marijuana dependence (Copeland et al., 2014; Stephens,
cancer, AIDS, and glaucoma. It has been shown that THC
Roffman, & Curtin, 2000). The high rate of relapse following
can help to alleviate nausea and encourage eating in cancer
treatment suggests a possible need for adjunctive pharmaco-
and AIDS patients. THC has been used to relieve pressure
therapy. However, are no currently accepted pharmacological
within the eyes in the treatment of glaucoma. Because it is
interventions available (Balter, Cooper, & Haney, 2014) and
both illicit and thought to be “bad for one’s health,” most
more research is needed on these medications.
jurisdictions do not currently allow marijuana consumption
for therapeutic use, even in extreme cases. However, as of
2001, the Canadian government changed regulations on the
possession and production of marijuana for medical pur-
Hallucinogens
poses so that those with a terminal illness, and those with Hallucinogens are drugs that change a person’s mental state
severe pain from medical conditions (including severe pain by inducing perceptual and sensory distortions or hallucina-
associated with multiple sclerosis, spinal cord injury, AIDS/ tions. They are also called psychedelics, which comes from the
HIV, severe arthritis, and epilepsy), can apply to the Office Greek words for “soul” and “to make manifest.” Hallucino-
of Cannabis Medical Access to possess the drug legally. All gens have been used in religious or spiritual ceremonies for
applications must be supported by declarations from medi- thousands of years. Many of these drugs are derived from
cal practitioners. Patients can also apply for a license to grow plants, but others are produced in the laboratory. There are
their own marijuana for the above purposes (Munroe, 2002). many kinds of hallucinogens, but the most well-known are
As of August 2016, the Canadian government changed lysergic acid diethylamide (LSD or “acid”), mescaline, and
regulations on the possession and production of cannabis for psilocybin (magic mushrooms). Methylene-dioxymetham-
medical purposes. Individuals with a medical need such as phetamine (MDMA) or ecstasy (described under “Amphet-
those with a terminal illness and those with severe pain from amines and Designer Drugs” earlier in this chapter) is
medical conditions can obtain authorization from a health sometimes included in this category as well.
care practitioner to access quality-controlled cannabis LSD was first discovered in 1938 by Swiss chemist
through a licensed producer, or register with Health Canada Albert Hoffman, who was investigating ergot—a fungus
to grow a small amount of their own for medical purposes that affects cereal plants such as wheat and rye. In 1943 he
(Health Canada, 2016). Legislation is pending to legalize use
generally as of July 2018, including the purchasing and cul-
tivation of small amounts.

DEPENDENCY
It has long been believed that cannabis is not addictive, but
there is recent recognition that regular use results in both
tolerance and withdrawal symptoms, although withdrawal
is milder than with other addictive substances. Symptoms
include irritability, nervousness and anxiety, loss of appetite,
restlessness, sleep disturbances, and anger/aggression (Budney,
Bettmann/Getty Images

Moore, Vandrey, & Hughes, 2003). Additionally, about one

in 20 Canadians report a cannabis-related concern, the most
common of which are impaired control over use, and strong
cravings for the drug (Canadian Centre on Substance Abuse,
2004a). According to a recent survey, lifetime prevalence of
cannabis use disorder (CUD) among Canadians aged 15 and
Timothy Leary was one of the leaders of a movement that extolled
older is 6.8 percent (Statistics Canada, 2012a). In the 12 months hallucinogens as part of a quasi-spiritual quest to expand con-
before the survey, 1.3 percent had a cannabis use disorder. sciousness and live life on a higher plane.

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 284 Chapter 11

accidentally ingested some of the compound he had isolated may lead to a risk of injury if there are extreme distortions
from this fungus, and subsequently had the first recorded in sense of distance, depth, or speed. PCP has effects that
“acid trip.” Later, he also extracted psilocybin from a mush- are more variable, and larger doses have been linked to con-
room called Psilocybe mexicana. vulsions, coma, and death. Individuals often purchase PCP
Hallucinogens can be ingested in capsule or tablet form, unknowingly under the guise of other drugs such as mescaline.
or as a liquid applied to small pieces of paper (e.g., stamps or One of the most frightening and inexplicable consequences
stickers) and then placed on the tongue. The effects of hallu- of hallucinogen use can be the occurrence of “flashbacks,”
cinogens usually begin within an hour of ingestion or sooner unpredictable recurrences of some of the physical or percep-
and last between six and 12 hours. Mescaline is found in the tual distortions experienced during a previous trip. DSM-5
head of the peyote cactus and is chewed or mixed with food includes a diagnosis called hallucinogen persisting perception dis-
or water. Psilocybin is also chewed or swallowed with water. order, which is applied if flashbacks cause significant distress or
Phencyclidine (PCP or “angel dust”) is a dissociative anaes- interfere with social or occupational functioning.
thetic that is typically smoked for its hallucinogenic proper-
ties. Ketamine (K or Special K), a close analogue to PCP, is DEPENDENCY
used as a veterinary anaesthetic. Recreationally, ketamine is
It is widely thought that hallucinogens have little addictive
injected, snorted, or taken orally. Salvia (Salvia divinorum) is a
potential, although they may induce psychological depen-
plant native to southern Mexico containing powerful psycho-
dence. Even heavy users of hallucinogens rarely consume
active chemical properties that lead to hallucinations. Salvia
the drug more than once every few weeks, partly due to the
was traditionally ingested by chewing the plant leaves but is
fact that tolerance develops within a few days of continuous
more commonly smoked.
use. When this occurs, a user no longer experiences the hal-
lucinogenic effects of the drug, although the physiological
PREVALENCE effects are still manifested. Abstinence from the drug for a
In Canada, the use of hallucinogens peaked in the 1960s. few days to a week lowers tolerance to normal levels. Hal-
According to the latest adult survey (Health Canada, 2016), lucinogens do not appear to cause noticeable withdrawal
13.1% reported using hallucinogens (including salvia) some- effects, even after long-term use.
time in their life, although use in the year before the survey Because hallucinogens do not appear to be addictive,
was rare (less than 1%). Use is slightly higher among high few programs have been developed specifically to treat
school students in Ontario than among Canadian adults, but hallucinogen dependence. Those that have been devel-
is also dropping. Past-year use of LSD was 1.5% and of sal- oped generally focus on addressing the user’s psychological
via was 2.2% (Boak et al., 2015). dependence on the drug.

EFFECTS
The subjective effects of hallucinogens depend on a number Gambling
of variables, including the personality of the user and the Social gambling has been part of many societies; it can be
amount of drug ingested. People’s expectations regarding recreational and provide exciting and exhilarating entertain-
the effects of hallucinogens appear to play a large role in ment. Gambling shares many characteristics with substance
determining their reaction. In addition, the setting in which use. Both generate short-lived pleasurable feelings and pro-
the hallucinogens are taken appears to be very important. vide relief from negative feelings, and both ultimately create
Users who feel uncomfortable or unsafe in their environ- cravings to repeat the behaviour. Both have the ability to alter
ment may experience anxiety and fear, which can sometimes mood and level of arousal and, arguably, to induce an altered
escalate into panic or psychotic-like episodes. A very small state of perception. Most Canadians are social gamblers.
number of individuals are left with a prolonged psychotic They limit the frequency of their gambling, and the time and
disorder long after the drug has worn off. money spent on gambling, and suffer no repercussions from
People taking hallucinogens report a number of sensory their gambling. However, there is another group of gamblers
experiences, including vivid visual hallucinations. Objects may who will “risk their reputation, their family’s security, their
waver, shimmer, or become distorted (e.g., limbs may appear life’s savings, their work, their freedom, or their safety on
very long). People commonly see colourful “halos” around the turn of a card, a roll of the dice, or the legs of a horse”
objects; moving objects leave visible trails. Users may also (Custer, 1982). They are preoccupied with gambling and
experience synesthesia, a transference of stimuli from one sense unable to resist despite staggeringly negative consequences.
to another, such as “hearing” colours or “feeling” sounds.
Hallucinogens have an excitatory effect on the CNS and
mimic the effects of serotonin by acting upon serotonin recep- PREVALENCE
tors in the brain stem and cerebral cortex. LSD, for example, In Canada, a large expansion in gambling opportunities
affects the sympathetic nervous system and causes dilated occurred in the 1990s when provincial governments began
pupils, increased heart rate, elevated blood pressure, and legalizing video lottery terminals (VLTs) and permanent casi-
increased alertness. Most hallucinogens are not physiologi- nos to supplement lottery, bingo, and horse racing gambling.
cally dangerous even in high doses. However, hallucinations Participation varies from province to province according to

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 Substance-Related and Addictive Disorders 285

availability, but overall about 80% of adults gamble. (Cana- co-occurring mental disorders and gambling problems; At
dian Partnership for Responsible Gambling, 2016). the University of Calgary, the authors of this text and col-
Lottery games appear to be the most popular form of leagues have developed brief treatment approaches using a
gambling, followed by instant win tickets and gambling at a motivational approach.
casino. Despite restrictions on gambling, a significant pro- Our brief treatment development work has three under-
portion of adolescents engage in gambling behaviour. The lying assumptions. First, many people recover from substance
2012–2013 Youth Gambling Survey found that 41.6 percent abuse and other addictions without the help of formal treat-
of adolescents had gambled in the previous three months ment. For example, it is clear that the most common pathway
(Elton-Marshall, Leatherdale, & Turner, 2016). Lifetime out for Canadians with an alcohol problem is “self-recovery”
prevalence was approximately 80 percent. (Cunningham & Breslin, 2004). We assume that this is also
true for people with gambling problems, and we know that
DEPENDENCY people will often not initiate the process of changing until they
have suffered significant problems for an extended period of
The issue of whether addiction can occur without the inges-
time (Hodgins & el-Guebaly, 2000). Second, as few as 10 percent
tion of a substance is a topic of lively debate. Some researchers
of problem gamblers, will attend formal treatment (Hodgins,
argue in favour of a physiological definition of dependence
Currie, & el-Guebaly, 2001). Third, the change strategies that
that requires neurophysiological changes in response to the
problem gamblers use (e.g., avoiding cues to gamble, self-instruc-
presence of a foreign substance, whereas others adhere to
tion) are similar to those used by individuals attending treatment
the psychological aspect of dependence. Certain individuals
(Hodgins & el-Guebaly, 2000).
are unable to control the frequency or amount of the behav-
Brief treatments that focus on motivational issues are
iour, much like individuals with substance use disorders.
effective for other addictive disorders (Miller & Rollnick, 2003),
Some pathological gamblers have such great difficulty quit-
can reach individuals not seeking treatment and foster the early
ting that they even experience withdrawal-like symptoms
use of recovery strategies without requiring that an individual
when attempting to stop. In fact, DSM-5 diagnostic criteria
attend a program. Our strategy has been twofold: we have
for gambling disorder were intentionally patterned after
incorporated practical information about recovery strategies
those for substance dependence, and the DSM-5 includes
into a brief self-help workbook and we have provided individu-
gambling disorder in the Substance-related and Addictive
als interested in using a self-help approach with brief telephone
Disorders section of the manual. It has been suggested that
support that focuses on their motivation to implement the
gambling and other addictive disorders are functionally
change strategies. The workbook focuses on self-assessment of
equivalent forms of behaviour that satisfy similar needs and
gambling behaviour, goal setting, strategies for not gambling,
that these behaviours may be regarded as cross-addictions.
and recovery maintenance (Hodgins & Makarchuk, 2002).
As a result, an addiction model of pathological gambling has
We have conducted a number of clinical trials of this
gained increasing acceptance among clinicians.
brief intervention (Hodgins, Currie, Currie, & Fick, 2009;
The Canadian Community Health Survey (Marshall &
Diskin & Hodgins, 2009). In one trial, we followed partici-
Wynne, 2003) provided a national perspective on gambling
pants for 24 months and found that those who received the
problems, including gambling disorder. Gambling was iden-
workbook–motivational intervention had better outcomes
tified as a problem or a potential problem for about 5 per-
than those who received the workbook only. About 37 per-
cent of the population. Risk factors for problem gambling
cent were abstinent from gambling, and an additional 40
included being male, being Indigenous, and having a low
percent had significantly reduced their expenditures on
level of education. Daily gamblers and VLT players were at
gambling (Hodgins, Currie, el-Guebaly, & Peden, 2004).
particularly high risk for problems. In contrast, lottery tick-
Web-based interventions also show promise in the
ets were associated with the smallest risk for problem gam-
treatment of disordered gambling. The wide availability of
bling (Marshall & Wynne, 2003).
the internet makes it a potentially useful tool for improv-
ing the accessibility of treatment services (Swan & Hodgins,
TREATMENT 2015). Promising results have been found with cognitive-
Canadian psychologists are widely recognized for their behavioural and brief treatment methods. For example,
contribution to the development of empirically based treat- Carlbring and colleagues (2012) found that internet-based
ments for problem gambling. Only a few years ago, little was CBT with additional minimal therapist contact significantly
known about how to best treat such individuals. Often, sub- reduced problem gambling; these gains were maintained at a
stance abuse treatment programs were slightly modified for three-year follow-up.
use with problem gamblers. Today, research groups across
the country are tackling the issue of developing gambling-
specific treatment approaches. Robert Ladouceur and his
group at Laval University have developed cognitive treat- BEFORE MOVING ON
ment programs. At McGill University, Jeffery Dereven-
sky and Rina Gupta are working on adolescent treatment What are the benefits of brief treatment, self-recovery, and
harm reduction approaches? What are some characteristics
approaches; Tony Toneatto and colleagues at the University
that gambling shares with substance use?
of Toronto are looking at the effectiveness of treatment for

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 286 Chapter 11

SUMMARY
● DSM-5 sets out the criteria for substance intoxica- ● In 2015 about 1.2 percent of Canadians reported having
tion and substance use disorders in the section called used cocaine or crack in the past year. The short-term
Substance-related and Addictive Disorders, which also effects of cocaine appear soon after its ingestion and
includes gambling disorder. wear off very quickly. Crack is especially fast-acting,
● Alcohol is the world’s number one psychoactive sub- and its effects may wear off in a few minutes. In small
stance, with almost 80 percent of Canadians reporting amounts, cocaine use in any form produces feelings of
drinking in the past year. Alcohol may result in posi- euphoria, well-being, and confidence. Continual use may
tive feelings in the short term, but over time it acts as result in mood swings, loss of interest in sex, weight loss,
a depressant. Alcohol causes deficits in coordination, and insomnia.
vigilance, and reaction time. These physical and psycho- ● Treatments for stimulant abuse developed in the 1980s
logical effects can result in negative consequences eco- were often modelled after the 12-step programs for alco-
nomically, socially, and medically. Treatment for alcohol hol. They include psychological (cognitive behavioural)
use disorders includes abstinence-based treatments and pharmacological (e.g., antidepressants) interventions.
(AA, Minnesota model), pharmacotherapy medication ● Opioids are a class of CNS depressant drugs whose main
(benzodiazepines, Naltrexone, Acamprosate, Antabuse), effects are the reduction of pain and sleep inducement.
and psychological treatments (behavioural interventions, Opioids mimic the effects of endogenous opiates, or the
relapse prevention, marital and family therapy, brief body’s natural painkillers. The illicit use of prescription
interventions). opioids is a significant concern in Canada. Since 2009,
● One of the major problems in treating substance abusers the number of opioid-related overdoses has increased
is the phenomenon of polysubstance abuse. Research has exponentially. The treatment for opioid abuse typically
demonstrated that concurrent dependence may be the involves the use of medications (naltrexone, methadone).
rule rather than the exception. In the DSM-5, an indi- ● In 2015, 37.5 percent of Canadians aged 15 and over
vidual can receive a diagnosis for each separate drug that reported using cannabis at least once in their lives and
is being abused. 12.3 percent reported using it in the year before the
● The use of tranquilizers (including barbiturates and survey. Cannabis involves mild changes in perception
benzodiazepines) is fairly low in Canada. Barbiturates along with enhancement of physical experiences. With
and benzodiazepines are considered depressants because relatively small doses, most users report feeling mildly
they inhibit neurotransmitter activity in the CNS. The euphoric and sociable. At high doses, cannabis has been
euphoria produced by small doses turns to poor motor known to cause hallucinations, although it seems that
coordination at higher doses, and can prove fatal in too this most often occurs when the user has a pre-existing
large a dose. Treatment usually involves pharmacologi- mental disorder. Most marijuana abusers in Canada are
cal treatment (progressively smaller doses of the abused placed in generalized treatment programs, although
drug) in combination with psychological and educational there are also efforts to develop cannabis-specific treat-
programs. ment approaches using a cognitive-behavioural treat-
● In 2015 it was estimated that 13 percent of Canadians ment model.
over the age of 14 smoked cigarettes. Nicotine is a CNS ● In 2015 approximately 13 percent of Canadian adults
stimulant. Lower dosages can interfere with thinking and reported using hallucinogens sometime in their life,
problem solving, and can cause extreme agitation and although use in the year before the survey was less
irritability along with mood changes. The small amount than 1 percent. People taking hallucinogens report a
of nicotine present in a cigarette is not lethal and can number of sensory experiences, including vivid visual
increase alertness and improve mood. Treatments for hallucinations. Hallucinogens have an excitatory effect
smoking cessation include psychological (behavioural or on the CNS and mimic the effects of serotonin by
cognitive) and pharmacological (nicotine replacement acting upon serotonin receptors in the brain stem and
and prescription medication) interventions. cerebral cortex. Because hallucinogens do not appear to
● Six percent of Canadians report having used amphet- be addictive, few programs have been developed specifi-
amines at least once in their life. Short-term effects of cally to treat hallucinogen dependence.
low dosages of amphetamines include increased alertness ● It is clear that alcohol, tobacco, and illicit drugs are a
and ability to focus attention. This may lead to enhanced major health hazard and cost our country billions of
cognitive performance. Higher dosages, preferred by dollars annually, in direct and indirect expenses. There
drug addicts, may produce feelings of exhilaration, but is evidence that educating communities has had some
restlessness and anxiety may also be present. Prolonged positive effects with alcohol and tobacco use, but there is
use may lead to paranoia, toxic psychosis, periods of a disturbing trend toward increased use of several illicit
chronic fatigue, or a “crash” when the drugs wear off. drugs, particularly by teenagers and young adults.

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 Substance-Related and Addictive Disorders 287

● Social gambling is increasingly popular in Canada. repeat the behaviour. The DSM-5 diagnostic criteria for
Approximately 75 percent of Canadians engage in some gambling disorder were patterned after those for sub-
form of gambling. Gambling shares many characteristics stance dependence. Current treatment approaches for
with substance use including short-term pleasurable disordered gambling include cognitive-behavioural and
feelings, relief from negative feelings, and cravings to brief treatments that focus on motivational issues.

KEY TERMS
abstinence syndrome (p. 274) endogenous opiates (p. 279) pharmacological dependence (p. 258)
agonist drug (p. 271) ethyl alcohol (p. 264) polysubstance abuse (p. 258)
alcohol dehydrogenase (p. 264) exogenous opiates (p. 279) relapse (p. 272)
alcohol expectancy theory (p. 268) fetal alcohol syndrome (FAS) (p. 265) risky use (p. 258)
amotivational syndrome (p. 282) flashbacks (p. 284) social impairment (p. 258)
amphetamines (p. 277) gambling disorder (p. 285) stimulants (p. 274)
Antabuse (p. 271) hallucinogens (p. 283) substance-induced disorder (p. 258)
antagonist drug (p. 271) harm reduction approaches (p. 280) substance use disorders (p. 257)
behavioural disinhibition (p. 268) impairment of control (p. 258) tension-reduction (p. 268)
behavioural tolerance (p. 268) low-risk drinking guidelines (p. 261) THC (p. 282)
blackouts (p. 264) methadone (p. 281) tobacco (p. 274)
blood alcohol level (BAL) (p. 264) Minnesota model (p. 271) tolerance (p. 258)
brief intervention (p. 273) motivational interviewing (p. 273) toxic psychosis (p. 277)
buprenophrine / naloxone (p. 281) negative emotionality (p. 268) Wernicke-Korsakoff syndrome (p. 265)
cannabis (p. 281) nicotine (p. 275) withdrawal (p. 258)
depressants (p. 273) opioids (p. 279)

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 STEPHEN P. LEWIS
•
STEPHEN PORTER

CHAPTER

12 Marekuliasz/Shutterstock

The Personality Disorders

LEARNING OBJECTIVES
BY THE END OF THIS CHAPTER, STUDENTS WILL BE ABLE TO:
Differentiate between personality traits and disorders in accordance with the Diagnostic and Statistical
Manual (DSM-5).
Understand how personality disorders differ from other disorders that may have overlapping symptoms.
Identify the three clusters of personality disorders, and define each disorder.
Define and differentiate egosyntonic and egodystonic.
Differentiate between antisocial personality disorder and psychopathy.
Understand how obsessive-compulsive personality disorder (OCPD) differs from obsessive-compulsive
disorder (OCD).
Identify and summarize the four main etiological perspectives of personality disorders.

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 Bikram is 26 years old. He lives alone in Calgary but is supported by his parents after recently los-
ing his job. He spends most of his days alone on his computer or reading books about ghosts and
urban legends. His parents describe him as always being “different” and an “odd child.” They say
Bikram has an intense belief in paranormal activity; he says that he believes in the existence of
ghosts and claims to have seen them in the past. Bikram has difficulty forming relationships and
is very anxious in social settings. His anxiety does not wane when interacting with others, even in
situations in which he has familiarity (e.g., gatherings with family friends). Bikram is highly suspi-
ciousness of others and is very superstitious. He avoids walking under ladders and believes he is
cursed with “negative energy” for having broken a mirror when he was younger.

***

Amelie is 22 and was hospitalized in St. John’s following an episode of self-injury that warranted
medical attention. During her intake interview, it was found that she cut herself deeply in response to
intense and what she perceived as intolerable emotional pain that followed a break-up. During the time
she is hospitalized, Amelie shares with her doctors that she has cut herself since she was a teenager
and that she did this to “deal with” past childhood trauma. Specifically, she was abused by an uncle
when she was seven. She also indicates that she engages in a number of other high-risk behaviours,
including heavy drinking, binge-eating, and promiscuity. In her relationships, Amelie describes a
pattern of falling in love quickly with others but that this does not last long; she reports that none
of her relationships end well and she does not speak to any of her ex-partners, some of whom she
despises for the way they “abandoned me.” When asked about her emotional life, she described
herself as warm and caring; however, she also said that she has difficulty regulating her mood and
has intense mood swings. Sometimes she has angry outbursts in which she feels threatened and then
lashes out at others. She said this has resulted in getting fired from several jobs and losing friendships.
When she’s alone she describes a sense of not knowing who she is and feeling empty inside. She
sometimes feels as though she is “not there” and that she is watching herself from the outside.

***

James enjoyed a good upbringing in a well-to-do family in British Columbia. His family reports
that he was a likeable child, but that he lied frequently from a young age and was “like Jekyll and
Hyde,” changing from being friendly to aggressive in an instant. As he got older, he was seen as
charming and engaging, and was very popular with women. He became a musician in a rock band.
James has a long history of violence against both men and women. His pattern of violence is
diverse such that some of his violent acts were highly premeditated (including sexual assaults, an
attempted murder, and a robbery), while many others seemed spontaneous. In fact, he once put
his “friend” in a wheelchair over a poker hand. He is now an incarcerated serial rapist.

There are aspects of their personal style (or personal- (e.g., a mood or anxiety disorder). Yet, each is unable to
ity) that contribute to a range of difficulties for Bikram, function in a manner that is adaptive and flexible. Indeed,
Amelie, and James. In some cases (e.g., Amelie), the impact each seems to be dominated by a single main negative fea-
is personal distress. Interestingly, however, the personal- ture (eccentricity in Bikram’s case, instability in Amelie’s
ity of all of these individuals negatively affects their social case, and utter selfishness in the case of James) that domi-
interactions, or in the case of James, can cause serious nates his or her behaviour and thinking. All three people
harm to others. None of these individuals has any one of would very likely meet the diagnostic criteria for a person-
the other conditions identified in Section II of the DSM-5 ality disorder.

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 290 Chapter 12

The Concept of Personality the disorder (e.g., in borderline personality disorder, avoid-
ant personality disorder), they tend to also cause distress for
Disorder other people. For example, people with antisocial person-
ality disorder (ASPD) or narcissistic personality disorder
How would you describe your best friend? Your answer may see nothing wrong with themselves, or even believe that
will likely focus on his or her personality characteristics, other people have the problem. People with ASPD, in par-
or on the manner in which he or she consistently behaves, ticular, can wreak havoc on the lives of those around them
feels, and thinks. Perhaps your friend is friendly, outgoing, through persistent violence, lying, and manipulation.
confident, and charismatic. Or maybe your friend is shy, As a reader, you justifiably may ask why (and perhaps
quiet, and passive. All people display some consistency whether) we need to “pathologize” or diagnose a condition
in their behaviour, emotions, and thinking, and this con- that causes the affected person little distress. This is actually
sistency is the basis for describing people’s “personality.” a highly controversial issue. On the one hand, the field of
For instance, we readily describe people we know as being abnormal psychology does not wish to cause harm to a per-
meek or aggressive, friendly or hostile, kind or cruel, shy son through the stigma of a diagnostic label such as “person-
or outgoing, or sensitive or easygoing. There are countless ality disorder.” Further, we run the risk of circular logic with
adjectives used to describe people. And, many people will such labels by implying that they have some explanatory
exhibit variability in these characteristics. For example, power. For example, if we explain the destructive behaviour
you may usually be an outgoing, talkative person, but you of someone with ASPD as resulting from his or her condition
may feel great distress or even “clam up” during a public or “illness,” we are using circular reasoning (because we diag-
presentation. When we describe someone as having a per- nose the condition based on such behaviour). On the other
sonality characteristic we are referring to a feature that is hand, abnormal psychology seeks to classify these conditions
typically displayed over time and in various (but not nec- in order to aid in the prediction, diagnosis, and treatment of
essarily all) situations. These cross-situationally consis- behaviour. Psychopathy is a good example of a construct that
tent and persistent features are described by personality helps to predict behaviour. Knowing that criminal offenders
theorists as traits. People have different levels of various meet criteria for psychopathy allows us to predict that they
personality traits, the combination of which describes his are far more likely to perpetrate predatory violence than are
or her overall personality. The focus of this chapter is on their non-psychopathic counterparts. Moreover, three large-
patterns of highly maladaptive personality traits known as scale prospective longitudinal studies, known as the Chil-
personality disorders. dren in the Community Study of Developmental Course of
According to the DSM-5 “a personality disorder is an Personality Disorder (Cohen, Crawford, Johnson, & Kasen,
enduring pattern of inner experience and behavior that 2005), the Collaborative Longitudinal Personality Disor-
deviates markedly from the expectations of the individual’s ders Study (Skodol et al., 2005), and the McLean Study of
culture, is pervasive and inflexible, has an onset in adoles- Adult Development (Zanarini, Frankenburg, Hennen, Reich,
cence or early adulthood, is stable over time, and leads to & Silk, 2005), have been consistent in their conclusions that
distress or impairment” (APA, 2013, p. 645). While this defi- personality disorders represent a significant health problem
nition is similar to those found in most textbooks on person- for those with the condition (e.g., interpersonal conflicts, sui-
ality, it ignores the fact that most people’s behaviour is also cide attempts, violent/criminal behaviour) and in their asso-
modified by context. One feature of people with personal- ciation with extensive treatment use.
ity disorders, however, is that their personality is more rigid
and inflexible. It is displayed, to a large extent, indepen-
dently of context. In a given situation, their behaviour often BEFORE MOVING ON
seems highly inappropriate to most others. In some cases,
How does the DSM-5 define personality traits and personality
they may initially display appropriate behaviour but cannot
disorders? When do personality traits constitute a personal-
typically sustain it for long periods or when under stress. In ity disorder? How do personality disorders differ from other
fact, according to the DSM-5, personality traits constitute major mental disorders?
a personality disorder only when they are inflexible and lead
to distress or impairment. People with personality disorders
also show a far more restricted range of traits than do most This chapter reflects the current model for personal-
people. Whereas we would describe most people we know ity disorders advocated by the DSM-5 in Section II. The
well as having a variety of key traits (e.g., generous, friendly, DSM-5 provides six formal criteria in defining personality
ambitious), individuals with personality disorders are more disorders:
likely to be characterized by a single dominant, albeit dys-
functional, trait. ● Criterion A states that the pattern of behaviour must be
Other mental disorders, such as depression, schizo- manifested in at least two of the following areas: cognition,
phrenia, or anxiety disorders, are associated with subjective emotions, interpersonal functioning, or impulse control.
distress. That is, distress that primarily affects the person ● Criterion B requires that the enduring pattern of behav-
with the condition. Interestingly, however, while personality iour be rigid and consistent across a broad range of per-
disorders can certainly impact the individual afflicted with sonal and social situations.

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 The Personality Disorders 291

● Criterion C states that this behaviour should lead to for a general personality disorder but the key symptoms are
clinically significant distress in social, occupational, or not reflected in the existing personality disorders.
other important areas of functioning.
● Criterion D requires stability and long duration of BEFORE MOVING ON
symptoms, with onset in adolescence or earlier.
● Criterion E states that the behaviour cannot be What are the six criteria that define personality disorders?
accounted for by another mental disorder. Do the names of the three clusters of personality disorders
meaningfully depict the disorders they encompass? Which
● Criterion F requires that the behavioural patterns are disorders fall into which category? Should we group person-
not the result of substance use (e.g., drugs or alcohol) or ality disorders together? Why or why not? What are the two
of another medical condition. additional personality disorders that do not belong to a clus-
ter? Why do they exist?
DSM-5 lists the specific personality disorders accord-
ing to three broad clusters:
● Cluster A odd and eccentric disorders (paranoid, schizoid, Table 12.1 presents the clusters with characteristic
and schizotypal); features. While Clusters A and C appear to have enough
● Cluster B dramatic, emotional, or erratic disorders (antiso- features in common to make reasonably cohesive groups,
cial, borderline, histrionic, and narcissistic); and Cluster B seems somewhat heterogeneous and even confus-
ing (Frances, 1985). Perhaps this is one reason that personal-
● Cluster C anxious and fearful disorders (avoidant, depen-
ity disorders are a somewhat neglected diagnostic category.
dent, and obsessive-compulsive).
Although definitional problems concerning personality
In addition to these three clusters, the DSM addresses disorders should be acknowledged, the assessment of these
(a) personality change due to another medical condition and conditions represents an important issue in clinical and
(b) other specified personality disorder and unspecified personality forensic settings. For one thing, when someone has a per-
disorder. Personality change due to another medical condition is a sonality disorder it can greatly complicate the treatment of
persistent disturbance in personality that is the direct result other mental disorders. Part of the difficulty is that personal-
of a medical condition, such as a frontal lobe lesion. The ity disorders can disrupt the alliance between a therapist and
other specified personality disorder and unspecified personality dis- a client. In addition, personality disorders can sometimes be
order is a category provided to address two situations. In the mistaken for another mental disorder. For example, schizo-
first, the individual meets criteria for a general personality typal personality disorder shares features (although less
disorder and exhibits symptoms of a number of personality severe) with schizophrenia. Indeed, schizotypal personality
disorders, but the criteria for any single personality disorder disorder is also listed under “schizophrenia spectrum and
are not met. In the second, the individual might meet criteria other psychotic disorders” to aid with differential diagnosis.

TABLE 12.1 PERSONALITY DISORDERS LISTED IN DSM-5

Paranoid personality disorder is a pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent.
Schizoid personality disorder is a pattern of detachment from social relationships and a restricted range of emotional expression.
Schizotypal personality disorder is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and
eccentricities of behavior.
Antisocial personality disorder is a pattern of disregard for, and violation of, the rights of others.
Borderline personality disorder is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity.
Histrionic personality disorder is a pattern of excessive emotionality and attention seeking.
Narcissistic personality disorder is a pattern of grandiosity, need for admiration, and lack of empathy.
Avoidant personality disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
Dependent personality disorder is a pattern of submissive and clinging behavior related to an excessive need to be taken care of.
Obsessive-compulsive personality disorder is a pattern of preoccupation with orderliness, perfectionism, and control
Personality change due to another medical condition is a persistent personality disturbance that is judged to be due to the direct
physiological effects of a medical condition (e.g., frontal lobe lesion).
Other specified personality disorder and unspecified personality disorder is a category provided for two situations: 1) the individual’s
personality pattern meets the general criteria for a personality disorder, and traits of several different personality disorders are present,
but the criteria for any specific personality disorder are not met; or 2) the individual’s personality pattern meets the general criteria for a
personality disorder, but the individual is considered to have a personality disorder that is not included in the DSM-5 classification
(e.g., passive-aggressive personality disorder).
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. (Copyright © 2013). American Psychiatric Association.
All Rights Reserved.

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 292 Chapter 12

A wrong diagnosis could lead to the wrong treatment plan, Again though, these findings only provide a partial picture
or possibly a mistaken drug prescription. In addition, while of the range of personality disorders in Canada given the
the treatment of personality disorders has been traditionally narrow focus of the sample. It is clear that data concerning
viewed as difficult and the prognosis poor, the situation is the prevalence of these disorders in community samples in
improving with the development of more effective thera- Canada are greatly needed!
peutic approaches. Given the above, we often have to look to research
Studies investigating the prevalence of personality from other countries to get a sense of personality disorder
disorders have examined rates among inpatient, outpatient, rates. For example, a study conducted in the United States
and community populations. Depending on the sample and examined the lifelong prevalence of personality disorders
method of diagnosis, prevalence rates vary considerably. For in a community sample, with findings indicating that the
instance, relative to structured interviews, self-report mea- overall (lifetime) rate of personality disorders was 6.7%
sures will likely yield underestimates of ASPD because indi- (Zimmerman & Coryell, 1990). More specifically, rates across
viduals are reluctant to admit that they engage in antisocial the three clusters were 3.6% for Cluster A (with schizotypal
behaviours. Accordingly, the use of multi-method assess- being the most common), 2.7% for Cluster B (with antiso-
ment is relevant to broader diagnostic issues as well as to cial and histrionic being the most common), and 2.7% for
treatment and prediction issues. For example, Klein (2003) Cluster C (with dependent and obsessive-compulsive being
evaluated patients’ and informants’ (e.g., intimate partners, the most common). Studies in Europe tend to reveal some-
relatives, friends) reports of personality disorders in pre- what lower rates (Maier, Lichtermann, Klingler, Heun, &
dicting outcomes in a seven-and-a-half-year follow-up of Hallmayer, 1992). Comparisons of these and other findings
85 outpatients with major depression. Both patients’ and suggest that about 6 to 9 percent of the entire population,
informants’ reports uniquely predicted depressive symp- including community, hospitalized, and outpatient samples,
toms and global functioning at follow-up. Interestingly, only will have one or more personality disorders during their life
informants’ reports made an independent contribution to (Merikangas & Weissman, 1986). Samuels and colleagues
predicting social adjustment. This suggests that at least some (2002) had clinical psychologists assess personality disorders
patients with personality disorders may not be cognizant of in 742 adult participants living in Maryland. They found
the negative impact they have on those close to them. that the overall prevalence of all personality disorders was
Unfortunately, little research has examined the preva- 9 percent. The authors also examined various demographic
lence of personality disorders among the general Canadian characteristics associated with personality disorders.
population. While the Public Health Agency of Canada Cluster A disorders were most prevalent in men who had
(2002), has examined personality disorders among individ- never married. Cluster B disorders were most prevalent in
uals in institutional settings, these data have major limita- poorly educated men, and Cluster C disorders were most
tions because most people with personality disorders who common among those who had graduated from high school
are hospitalized are a risk to themselves or to others. In but who had never married (for a critique of this study see
contrast, most others go untreated or are treated in their Lenzenweger, Lane, Loranger, & Kessler, 2007).
community rather than in hospitals. Among both women Studies published in the Journal of Clinical Psychiatry and
and men, the highest rates of hospitalization for personality the Journal of Personality Disorders provide some of the high-
disorders in 1999 were among people between 15 and 44 est estimates of personality disorders to date. Conducted
years of age. More than three-quarters (78 percent) of all by the National Institute on Alcohol Abuse and Alcoholism
admissions were between these ages, and rates were higher and the National Institutes of Health, the first study focused
among women than men. In all age groups, personality dis- on a representative community survey of 43 000 American
orders were more likely to be a contributing rather than adults. The authors (Grant et al., 2004) estimated that from
the main factor determining length of stay in hospital. This 2001 to 2002, 14.8 percent of American adults (30.8 million)
is because personality disorders are associated with other met the diagnostic criteria for at least one DSM-IV-TR
conditions, such as suicidal behaviour, that lead to hospital- personality disorder. Overall, the risk of having avoidant,
ization. The average length of stay in hospitals due to per- dependent, and paranoid personality disorders was greater
sonality disorders was 9.5 days. for females than for males, whereas the risk of having ASPD
In another study, Séguin and colleagues (2006) con- was greater for males than for females. The authors found no
ducted psychological autopsies of 102 individuals who gender differences in risk for obsessive-compulsive, schizoid,
died by suicide in New Brunswick. A psychological autopsy or histrionic personality disorders. The authors of this study
is a research method used after someone dies by suicide also identified the following factors associating with having
and involves comprehensive (often structured) interviews a diagnosed personality disorder: being Native American
with others in the life of the deceased (e.g., partners, family, or Black; being a young adult; having low socio-economic
friends) as well as those involved in their health care to obtain status; and being divorced, separated, widowed, or never
detailed information about the deceased individual and what married. This study must be considered with caution, as it
might have contributed to the individual’s suicide. Findings has been criticized for relying on a new diagnostic inter-
from this study found that 52 percent of the cases involved view administered by laypersons instead of a well-validated
personality disorders, half of which were from Cluster B. interview by trained clinicians (Lenzenweger et al., 2007).

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 The Personality Disorders 293

Moreover, it is important to remember that viewing gender, (Drake & Vaillant, 1985), results from the National Comor-
ethnicity, or marital status as risk factors in themselves is bidity Survey Replication (Lenzenweger et al., 2007) sug-
problematic as it simplifies the nature of risk and provides gested that 39% of people with a personality disorder
little (if any) explanation or context to account for why these receive treatment for their mental health or substance abuse
factors associate with personality disorder risk. In the second difficulties. Those with Cluster B disorders sought treat-
study, based on a community sample of 644 children tracked ment the most (49.1%), followed by those with Cluster C
from early childhood through adolescence and into early disorders (29%) and Cluster A disorders (25%). Most of the
adulthood, Crawford and colleagues (2005) estimated the respondents sought treatment from general medical provid-
prevalence of any personality disorder to be 15.7 percent. As ers (19%), followed by psychiatrists (14%) or other mental
with the Samuels and colleagues (2002) study, however, the health professionals (17%).
Crawford and colleagues (2005) sample has been criticized An important distinction between personality disorders
for not being representative of the greater U.S. population and other DSM-5 disorders is that most individuals suffer-
(Lenzenweger et al., 2007). ing from major mental health difficulties (e.g., schizophrenia,
In an effort to address some of these methodological bipolar disorder) have far more impaired functioning than
limitations and present nationally representative estimates do most patients with personality disorders. An objec-
of clinician-diagnosed personality disorders in the gen- tive evaluation of people with personality disorders indi-
eral U.S. population, Lenzenweger and colleagues (2007) cates impaired life circumstances, but their actual abilities
examined the responses to questions from the International appear relatively intact compared to those with major men-
Personality Disorder Examination administered to 5692 tal disorders (Millon, 1996). Also, as mentioned earlier, for
participants. According to results from a sub-sample of more many people with personality disorder, their functioning is
than 200 participants who were administered the complete egosyntonic. That is, they do not view it as problematic. In
measure 5.7% met criteria for Cluster A disorders, 1.5% for contrast, most other mental disorders are generally consid-
Cluster B disorders, 6.0% for Cluster C disorders, and 9.1% ered egodystonic as they cause distress and are viewed as
for any personality disorder. Gender, race/ethnicity, family problematic by the individual. Intervention for those with
income, and marital status were not significantly related to personality disorders, then, must initially address the issue
any of the personality disorder measures. of motivation for treatment and treatment readiness.
Generally speaking, prevalence rates are higher among
those in inpatient versus outpatient settings. For example,
borderline personality disorder, the most commonly diag-
nosed personality disorder among patients in treatment, has Diagnostic Issues
been reported in 11% of outpatients and 19% of inpatients Personality disorders have traditionally presented more
(Widiger & Frances, 1989). Rates of ASPD vary depending diagnostic problems than most other mental disorders
on whether psychiatric patients or criminal offenders are because of the lower reliability of their diagnosis (Rogers,
surveyed. In psychiatric outpatients, the prevalence rates are Duncan, Lynett, & Sewell, 1994), their poorly understood
near 5%, but jump to 12 to 37% for psychiatric inpatients. In etiology (Marshall & Barbaree, 1984), and weaker treatment
prison populations, the rates range from 30 to 70% (Widiger efficacy (Kelly et al., 1992). With respect to diagnosis, two
& Rogers, 1989). indices of reliability are important. Inter-rater reliability—
Traditionally, personality disorders have been viewed as that is, the agreement between two raters—ranges from 0.86
distinct from other mental problems (e.g., major depression, to 0.97 for the personality disorders (Maffei et al., 1997).
schizophrenia). This is reflected in previous iterations of Test-retest reliability—that is, agreement in diagnosis over
the DSM (e.g., DSM-IV), where personality disorders were time—has traditionally been much weaker, ranging from
located in a distinct section from mood disorders, eating 0.11 to 0.57 (Zimmerman, 1994), although this seems to have
disorders, psychotic disorders, and most other conditions. been improving in recent years (see below).
This may, at least in part, explain why personality disorders There are, however, other challenges to the DSM’s
appear toward the end of Section II in the DSM-5 (despite definitions of personality disorder and questions of whether
their early onset considering the organization of Section II a “diagnosis” is even warranted. For example, Canadian
to temporally reflect development). Relative to personality researcher John Livesley and his colleagues (Livesley, 1986;
disorders, the so-called clinical disorders (e.g., schizophrenia, Livesley, Schroeder, Jackson, & Jang, 1994) have argued that
bipolar disorder) have more pronounced symptomatology personality disorders are better viewed as constellations
and have a greater likelihood of referral to mental health of traits, each of which lie along a continuum, rather than
professionals. This may also account for why the main clini- as disorders that people simply have or do not have. For
cal disorders in DSM-5 tend to be referred to as “mental example, one could view extreme levels of conscientious-
illnesses” when compared to personality disorders. Techni- ness (e.g., being very rigid, highly perfectionistic, miserly),
cally, however, they would all be mental illnesses by virtue of as involved in obsessive-compulsive personality disorder.
their inclusion in the DSM. This conceptualization of personality disorders as traits
Whereas older research indicated that 80% or more along a continuum is acknowledged in the DSM-5. It also
of people with personality disorders never seek treatment aligns with the manner by which personality traits tend to

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be conceived (i.e., viewed on a dimension). We discuss these Specifically, there was a gender bias in the criteria for BPD
issues in more detail toward the end of this text. In addi- and in the view that BPD manifests differently in men than
tion, as explained in the next section, others have suggested in women. Finally, this study concluded that this gender dif-
that the diagnostic criteria for some personality disorders ference in the symptoms of BPD was not reflected in the
are gender biased (Kaplan, 1983), or that their application DSM-IV criteria (the most recent version of the DSM at the
permits the gender biases of the diagnostician to influence time that the study was conducted); the DSM-5 criteria also
diagnosis (Ford & Widiger, 1989). do not address the symptoms characteristic of BPD in men.
There are, in fact, many problems with the notion of As another example, histrionic personality disorder
personality disorder that have not been resolved, and it has long been diagnosed more commonly in females than
is clear that further research is needed before a clearly in males (Reich, 1987), and studies asking participants to
defined set of criteria is developed. Nonetheless, most cli- rate the diagnostic criteria indicate that most people view
nicians agree that some people consistently show maladap- the features of the disorder as decidedly feminine (Sprock,
tive, inflexible, and restricted ways of behaving, feeling, and Blashfield, & Smith, 1990). In an interesting examination of
thinking that are best described as relating to personality. gender bias, Warner (1978) had 175 mental health profes-
In the end, it is not so much whether personality disorders sionals make a diagnosis after reading a case history. The
exist, but rather how they can be defined in a way that is patient was described as a woman in half of the cases and as
unbiased, reliable, and leads to effective treatment or predic- a man in the other half, but the case description remained
tion. Among the various diagnostic issues, researchers have the same. Of those clinicians who were given the “female”
identified gender and cultural bias in the diagnostic criteria case, 76 percent diagnosed the patient as suffering from a
as subjects of concern. These biases, it is suggested, contrib- hysterical personality disorder (the earlier name for histri-
ute to the broader problem of unsatisfactory reliability. onic personality disorder), while only 49 percent applied
that diagnosis when the patient was described as a man.
Ford and Widiger (1989) also examined these issues, but
GENDER AND CULTURAL ISSUES looked at gender bias both in the diagnostic criteria and in
An important consideration when making a DSM-5 diagno- the diagnosis of histrionic personality disorder. They found
sis is to ensure that the client’s functioning does not simply that, while the specific diagnostic criteria for histrionic per-
reflect normative responding in the client’s culture. As our sonality disorder were found with equal frequency among
populations become increasingly culturally diverse, clini- men and women, women were more likely to be diagnosed
cians might misdiagnose if they do not take adequate precau- with the disorder. In another study of histrionic personality
tions to determine whether certain attitudes and behaviours disorder, women were more commonly diagnosed, whereas
are appropriate for distinct cultures or societal subgroups. an epidemiological survey of more than 3000 community
For example, economically disadvantaged children living in adults revealed the same prevalence in males and females
inner cities may learn self-interested strategies in order to (2.2 percent) (Nestadt et al., 1990). This finding suggests
survive. These strategies may, in the eyes of a more privi- either bias in referrals to psychiatric clinics for people with
leged clinician, appear to reveal psychopathology, whereas histrionic features or gender bias in the application of the
in reality they are adaptive given the environmental context. diagnosis among those who are referred.
Similar concerns exist for gender biases in the diagnosis The gender biases witnessed in diagnosing personal-
of personality disorders. Sex role stereotypes may influence ity disorders have sometimes become “systemic,” such that
the clinician’s determination of the presence of personality large numbers of males or females are virtually excluded
disorders (Pantony & Caplan, 1991). For example, clinicians from a diagnosis category because of their gender. For
have been shown to be reluctant to diagnose males with example, psychopathy—one of the most harmful personal-
histrionic personality disorder and are unlikely to consider ity disorders, although not yet formally listed in DSM-5—is
females as having ASPD (Samuel & Widiger, 2009; Widiger diagnosed in approximately 15 to 25 percent of male fed-
& Spitzer, 1991). The emphasis on aggression in the criteria eral inmates in Canada (translating into thousands of men).
for ASPD may result in underdiagnosing in females because However, very few female federal inmates ever receive this
of gender differences in the prevalence and expression of classification because the Correctional Service of Canada
aggression. In addition, Henry and Cohen (1983) have sug- apparently views being female as largely incompatible with
gested that clinicians typically overdiagnose borderline being psychopathic, a belief that is not in accordance with
personality disorder (BPD) in women. For example, in one research. For example, Rutherford, Cacciola, and Alterman
study an average of 80 percent of people diagnosed with (1999) examined the prevalence of psychopathy in a group
BPD were women (Widiger & Trull, 1993). It is difficult to of 137 women seeking treatment for cocaine dependency.
know whether these results reflect a true gender difference The findings showed that 19 percent of the women scored in
in the occurrence of the disorder, or whether they reflect the moderate to high range on the Psychopathy Checklist–
inappropriately gender-biased criteria or application of Revised, 12 of whom were diagnosed with APD according
the criteria. A more recent study conducted by Boggs and to the DSM-IV. Clearly, psychopathy can occur in women,
colleagues (2005) discovered that the diagnosis of BPD in despite the reluctance—perhaps politically driven—of some
females (versus males) may be due to the criteria themselves. agencies to concur with the research.

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 The Personality Disorders 295

It is difficult to know whether differences in the preva- criteria for their initial diagnosis every month for a follow-
lence of personality disorders across genders and ethnic up period lasting two years. These findings are consistent
groups represent biases in diagnosis or reflect true differ- with those of two other large-scale longitudinal studies,
ences. One study looked at this issue by examining ratings of the Children in the Community Study of Developmental
both diagnosticians and the patients themselves. Grilo and Course of Personality Disorder (Cohen et al., 2005) and the
colleagues (2003) compared the distribution of borderline McLean Study of Adult Development (Zanarini et al., 2005),
(BPD), schizotypal (STPD), avoidant (APD), and obsessive- which found that personality disorders were not as enduring
compulsive (OCPD) disorders across three groups: Cauca- as was once thought.
sians, African-Americans, and Hispanics. The researchers
used both a clinician-administered diagnostic interview and
a self-report instrument. The results indicated higher rates COMORBIDITY AND DIAGNOSTIC
of BPD in Hispanic than in Caucasian and African-American OVERLAP
participants, and higher rates of STPD among African- One further problem with the diagnosis of personality dis-
Americans than Caucasians. Self-report data reflected the orders concerns their independence from each other as well
same patterns, suggesting that there may be true cultural dif- as other mental disorders. The terms comorbidity and overlap
ferences in the risk for certain disorders. are often used synonymously in the literature when, in fact,
they refer to two conceptually distinct features of diagnosis.
Comorbidity should be used to describe the co-occurrence
RELIABILITY OF DIAGNOSIS of two or more different diagnoses for one person. Overlap,
Concerns regarding cultural and gender insensitivity in on the other hand, refers to the similarity of symptoms in
diagnostic strategies underscore larger issues related to the two or more different disorders (i.e., some of the same crite-
reliability and validity of diagnosing personality disorders. ria apply to different diagnoses). Diagnostic criteria for dif-
These are not new concerns and they have governed revi- ferent conditions should be distinct, but for some personality
sions to the DSM since 1980. For instance, the early field disorders the criteria remain sufficiently vague or require
trials with DSM-III (APA, 1980) revealed rather poor reli- such significant inference by the clinician that overlap seems
ability for the personality disorders, suggesting that clini- likely. For example, narcissistic personality disorder (NPD)
cians often fail to agree on a particular diagnosis for a specific and antisocial personality disorder (ASPD) are both associ-
patient. However, the manner by which diagnoses are made, ated with a lack of empathy or concern for others.
and the time spent collating relevant diagnostic informa- Researchers have highlighted problems with overlap
tion (e.g., presence of symptoms, impact on functioning) between specific disorders. For example, in one study, 47
may contribute to better reliability. Indeed, it is likely that percent of those diagnosed with borderline personality dis-
most personality disorders can be reliably diagnosed given order (BPD) met the criteria for ASPD and 57 percent met
enough information and effort. Imagine if oncologists or car- the criteria for histrionic disorder (Widiger, Frances, & Trull,
diologists did not “have time” to diagnose cancer or heart 1987). A recent study found that schizotypal personality
disease reliably! Sometimes, the consequences of a missed disorder was associated with both borderline personality dis-
personality disorder can be as devastating. order and narcissistic personality disorder (Lentz, Robinson,
Notwithstanding issues regarding the reliability of & Bolton, 2010). Another example is a study that revealed
personality disorder diagnoses, the situation appears to be that psychopathic individuals with antisocial personality dis-
improving. Adding support for this are recent studies sug- order often show overlapping symptoms with both schizoid
gesting that personality disorder diagnoses may be becom- personality disorder and narcissistic personality disorder
ing more reliable. For example, Zanarini and colleagues (Coid & Ullrich, 2010). While some degree of co-occurrence
(2000) examined both the inter-rater and the test-retest reli- is expected with any condition, these rates are quite high and
ability of Axis I and II disorders using structured DSM-IV- raise questions about the nature of overlapping symptoms
based interviews. The results indicated at least “fair to good” across different personality disorders.
inter-rater reliability for all personality disorders diagnosed Comorbidity also exists between personality disorders
by experienced clinicians. In addition, all personality disor- and other mental disorders. A recent World Health Orga-
ders, except for narcissistic personality disorder and para- nization study estimated that worldwide, over half (51.2
noid personality disorder, showed “fair to good” test-retest percent) of individuals diagnosed with personality disor-
reliability. ders meet the criteria for at least one other mental disorder
A major goal of research examining the reliability of (Huang et al., 2009). A specific example is the comorbidity
personality disorders has been to determine their stability between borderline personality disorder and mood disor-
over time. Interestingly, it is possible that these conditions ders. This comorbidity has led to suggestions that border-
may not be as chronic as once believed (Bornovalova, Hicks, line disorder might better be classified as a mood disorder
Iacono, & McGue, 2009; Ericson, Tuvbald, Raine, Young- (Nakdimen, 1986), an issue which continues to be debated
Wolff, & Baker, 2011). For example, Skodol and colleagues (Tryer, 2009; Parker, 2014). Despite these issues, the Collab-
(2005) reported that fewer than one half of patients with a orative Longitudinal Personality Disorders Study (Skodol
personality disorder remained at or above the diagnostic et al., 2005) established that diagnostic criteria for the

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 296 Chapter 12

individual personality disorders related better with each inferiority were exhibiting a “social” disorder and coined the
other than with criteria from other personality disorders. term sociopath, reflecting the idea that the condition involved
This led these researchers to conclude that the diagnostic an “anti-society” view of life. Such views were eventually
criteria of each of the personality disorders show some dis- incorporated into the APA’s first edition of the DSM in 1952,
criminant validity. which described a “sociopathic personality disturbance,
antisocial reaction.”
The current conceptualization of psychopathy is
founded largely in the clinical observations of psychiatrist
Historical Perspective Hervey Cleckley. With a series of clinical case vignettes pre-
Historically, most attention on personality disorders has sented in his classic text The Mask of Sanity (1941), Cleckley
focused on what we now call antisocial personality disor- proposed that there are a number of defining characteris-
der, or the related condition psychopathy. The well-known tics of the disorder, including emotional, interpersonal, and
writings of Niccolò Machiavelli (1469–1527) advocated for behavioural elements. Cleckley observed that psychopaths
the use of unscrupulous, manipulative, amoral, and decep- were unresponsive to social control and behaved in a socially
tive behaviour in achieving power in politics and society inappropriate manner. Further, he described a profound
(Campbell, 2003). Based on his writings, the term machiavel- emotional deficit, such that deep emotion and anxiety were
lianism has become synonymous with callous, manipulative, missing in the psychopath. In fact, he theorized that a lack of
and deceptive personality characteristics (see Campbell, emotion was at the core of the disorder, with other symptoms
2003; Fehr, Samson, & Paulhus, 1992; Wilson, Near, & following from this emotional shallowness. For the past four
Miller, 1996). Machiavellianism, in addition to subclinical decades, Dr. Robert Hare and colleagues at the University
narcissism and subclinical psychopathy, comprise the “Dark of British Columbia have worked toward operationalizing
Triad”—a constellation of personality traits that are deemed Cleckley’s criteria for psychopathy, aimed at the generation
to be socially aversive (Paulhus & Williams, 2002). of a highly reliable diagnostic tool for researchers: the Psy-
One of the first written descriptions of the psychopathy chopathy Checklist (Hare, 1980), revised in 1991 and 2003
was by Pinel (1809), whose work was discussed in Chapter 1. (Psychopathy Checklist–Revised; Hare, 1991, 2003).
Pinel described a psychiatric condition associated primar-
ily with amorality rather than psychosis. He referred to this
condition as manie sans délire, or madness without delirium. Etiology
In such patients, he observed profound deficits in emotion
Aside from mentions of “hereditary taint” in prominent
but no apparent reasoning/intellectual dysfunction. Such
psychiatric texts (e.g., Krafft-Ebing, 1886/1939), little con-
patients were prone to stealing, violence, and lying, but
sideration was given to potential causes of personality dis-
seemed to have no other mental health difficulties.
orders in the nineteenth century (e.g., Porter, 1996). This
Similar to Pinel’s notion, British psychiatrist James
trend began to change with the development of the psycho-
Pritchard (1835) coined the term moral insanity to delineate
dynamic school and the publication of the first etiological
a mental condition characterized by an absence of morality,
theories of psychopathy in the 1920s (e.g., Partridge, 1928,
rather than the “madness” seen in other psychiatric patients.
1929). Theories related to the etiology of psychopathy con-
Like Pinel, Pritchard observed that while there clearly was
tinued during and after the 1940s, with contributions from
emotional dysfunction in such patients, their cognitive abili-
learning theorists (e.g., Schachter & Latane, 1964), psycho-
ties were intact. Pritchard (1835) further discussed how indi-
analysts (e.g., Arieti, 1963), and psychophysiologists (e.g.,
viduals suffering from moral insanity seemed to completely
Hare, 1970). In fact, in a 1967 bibliography (Hare & Hare,
disregard the moral, ethical, and cultural norms of society.
1967), 218 studies fell under the category of etiology—more
He thought that the “moral principles of the mind” were
than any other topic on psychopathy. Unfortunately, how-
“perverted or depraved” in these men. Koch (1891, as cited
ever, fewer efforts have focused on other personality disor-
in Millon, Simonsen, & Birket-Smith, 1998) objected to the
ders. Consequently, there are still no firm conclusions about
term moral insanity and gave the opinion that a more appro-
the factors that cause personality disorders. In what follows,
priate term would be psychopathic inferiority. In his view, the
we briefly cover the main current theories about the etiol-
condition of psychopathy stemmed from a type of biological
ogy of personality disorders. More detail is covered in the
abnormality that resulted in personality anomalies such as
section on specific disorders where there is more empirical
extreme selfishness. This conceptualization of psychopathy,
evidence (i.e., antisocial and borderline disorders).
with its focus on personality pathology, was more closely
aligned to the modern conceptualization of psychopathy
than were earlier views. PSYCHODYNAMIC VIEWS
Sociologists also took interest in the early part of the Psychoanalysts see personality disorders as resulting from
twentieth century. Not surprisingly, they saw social condi- disturbances in the parent–child relationship, particularly in
tions as critical. Accordingly, they replaced the term psycho- problems related to separation-individuation (Mahler, Pine,
path with the descriptor sociopath (Birnbaum, 1914). Partridge & Bergman, 1975). This refers to the process by which the
(1930) argued that individuals with this psychopathic child learns that he or she is an individual separate from the

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mother and other people and, as a result, acquires a sense Levy (2000) has argued that poor attachment bonds are an
of him- or herself as an independent person. Thus, accord- antecedent to violence and antisocial patterns in children.
ing to psychodynamic theorists, difficulties in this process The fact that personality disorders usually become obvi-
result in either an inadequate sense of self (e.g., borderline, ous during late adolescence when the demands for social
narcissistic, or histrionic personality disorders) or problems interaction become pre-eminent lends some support to the
in dealing with other people (e.g., avoidant or antisocial per- importance of attachment deficits in the origin of these dis-
sonality disorders). There is clear evidence that adults with orders. Consistent with these claims, Goldberg, Mann, Wise,
personality disorders are far more likely than other people and Segall (1985) found that patients with personality disor-
to have had difficult childhoods, including the loss of a par- ders typically described their parents as either uncaring or
ent through death, divorce, or abandonment (Pert, Ferriter, overprotective, or both.
& Saul, 2004; Robins, 1966) or parental rejection (McCord Finally, in a multi-site study, Battle and colleagues
& McCord, 1964; Russ, Heim, & Westen, 2003). This evi- (2004) examined the childhood histories of 600 patients
dence has also served to bolster other environmental theo- diagnosed with a personality disorder or major depressive
ries of personality disorders, particularly attachment theory disorder. The study confirmed that rates of childhood mal-
(Ainsworth & Bowlby, 1991) and learning-based theories treatment among individuals with personality disorders
(Turkat & Levin, 1984). are generally high (73 percent reporting abuse; 82 percent
reporting neglect). As expected, borderline personality dis-
order was more consistently associated with childhood abuse
ATTACHMENT THEORY and neglect than were other disorders. Of course, it is not
As with many mental disorders, dominant thinking on the possible to establish causation (only correlation) using this
nature/nurture debate has undergone dramatic shifts over approach. Nonetheless, these findings show the very high
time. During the 1990s, it became somewhat unfashionable prevalence of negative childhood experiences in those with
to explain personality pathology as being rooted in child- a personality disorder.
hood (Porter, 1996), with biology being seen by many as the
primary cause, especially for APSD and psychopathy (e.g.,
Hare, 1993; Livesley, Jang, & Vernon, 2003). More recently, COGNITIVE-BEHAVIOURAL
the Children in the Community Study of Developmental PERSPECTIVES
Course of Personality Disorder established that “PD symp- Cognitive-behavioural theorists have suggested a variety of
tom constellations identified in adulthood have their origins factors that may contribute to the emergence of personal-
in childhood” (Cohen et al., 2005, p. 481). ity disorders. Cognitive strategies or schemas (e.g., beliefs,
Many theorists are again turning to the role of early rela- assumptions, and attitudes) are said to develop early in life,
tionships in contributing to personality pathology in adult- and in individuals with personality disorders these schemas
hood. Attachment theory asserts that children learn how become rigid and inflexible (Beck, Freeman, & Davis, 2004;
to relate to others, particularly in affectionate ways, by the Shapiro, 1981; Young, 1999; Young, Klosko, & Weishaar,
way in which their parents relate to them. When the attach- 2003). Young defined negative schemas as broad and per-
ment bond between parents and the child is positive (i.e., the vasively maladaptive themes that people hold about them-
parents are loving, encouraging, and supportive), the child will selves and their relationships with others. Because they form
develop the skills and confidence necessary to relate effec- early in life as a result of damaging experiences (e.g., aban-
tively to others. The parent–child bond serves as a template donment), Young believed that negative schemas are famil-
for all later relationships (Bowlby, 1977). When this bond is iar. The views of new events become distorted to maintain
poor, children will lack confidence in relationships with oth- the validity of the schemas. People cope with their negative
ers (i.e., they will be afraid of rejection, and they will not have schemas in ways that may have been adaptive when they
the skills necessary for intimate relationships). This analysis were children trying to survive in a damaging environment
has been applied to various personality disorders (Links, 1992; (e.g., by surrendering or overcompensating), but they con-
Patrick, Hobson, Castle, & Howard, 1994), and empirical evi- tinue coping in this same manner into adulthood.
dence appears to support the role of disrupted attachments Linehan (1987, 1993; Linehan, Cochran, Kehrer, &
in the etiology of these disorders (Coons, 1994; Torgersen & Barlow, 2001) argued that people who develop borderline
Alnaes, 1992; West, Keller, Links, & Patrick, 1993). personality disorder come from families who consistently
Researchers at the University of British Columbia invalidate their childhood emotional experiences and over-
(Bartholomew, 1990; Dutton, Saunders, Starzomski, & simplify the ease with which life’s problems can be solved.
Bartholomew, 1994) have shown that if parent–child attach- Accordingly, they learn that the way to communicate and
ments are poor, the child will typically develop adult rela- get the attention of their parents (and, as a consequence,
tionship styles that are characterized by ambivalence, fear, to communicate with others) is through a display of major
or avoidance. Poor attachments typically lead to deficits in emotional outbursts. Linehan’s theory has been applied pri-
developing intimacy (Marshall, Hudson, & Hodkinson, 1993), marily to those with borderline personality disorder, but it
such that various maladaptive ways of dealing with interper- could apply to other personality disorders, particularly those
sonal relationships are likely (Marshall & Barbaree, 1984). in Cluster B (i.e., dramatic, emotional, or erratic disorders).

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Of course, parents may also model inappropriate per- schizophrenia. The authors examined whether such deficits
sonal styles themselves, and there is considerable evidence would also be found in patients with schizophrenia spectrum
that modelling is a powerful influence on children’s behav- personality disorders. They assessed prefrontal grey and
iour (Bandura, 1976). In addition, parents may inappro- white volumes using magnetic resonance imaging (MRI)
priately reward or punish behaviour and the expression of in a community sample of 16 individuals with schizotypal/
attitudes. Parents of children who engage in antisocial behav- paranoid personality disorder, 27 healthy control individu-
iour, for example, have been shown to reward or punish their als, and 26 psychiatric controls. The personality disorder
children non-contingently (Bauer & Webster-Stratton, 2007; group showed reduced prefrontal volume and poorer frontal
Snyder, 1977); that is, their responses are not related to the functioning compared to both other groups. More recently,
child’s behaviour. functional MRI (fMRI) studies on patients with borderline
personality disorder have begun to appear. These stud-
ies have mapped both the structure and the functioning of
BIOLOGICAL FACTORS the brains of people with borderline personality disorder
Biological accounts of personality disorders have been most while they engage in emotion-inducing tasks, such as recall-
thoroughly explored with ASPD, and we will discuss them ing emotional autobiographical events or viewing various
in more depth when we describe that disorder later in this emotional expressions on faces. The studies have implicated
chapter. Basically, however, biological theorists have claimed dysregulated responding of the prefrontal areas of the brain
that there is either brain dysfunction or a genetic or hormonal as well as fronto-limbic dysfunction in the form of overac-
basis for these conditions. Cloninger, Svrakic, and Przybeck tivation of the amygdala (Beblo et al., 2006; Minzenberg,
(1993), for example, proposed that specific disturbances Fan, New, Tang, & Siever, 2007; Schnell, Dietrich, Schnit-
in neurotransmitter systems in the brain characterize par- ker, Daumann, & Herpertz, 2007; Schnell & Herpertz, 2007;
ticular types of personality disorders. Similarly, Siever and Silbersweig et al., 2007).
Davis (1991) suggest that different biological processes are Examining concordance rates among twins provides
associated with four dimensions (i.e., cognitive-perceptual another approach to test the role of biology in personality
organization, impulsivity-aggression, affective stability, and disorders. Coolidge, Thede, and Jang (2001) investigated the
anxiety-inhibition) that together determine personality. In heritability of personality disorder features in 112 pairs of
this regard, disruptions in the biological underpinnings of 4- to 15-year-old twins, including 70 monozygotic and 42
these four factors might be expected to produce unique per- dizygotic twin pairs. The children’s parents provided infor-
sonality disorders. mation about the children’s features using a tool measuring
Although the evidence showing the value of these gen- 12 personality disorders according to the criteria in DSM-
eral theories is limited, there has been some support for IV-TR. The analyses showed that the median “heritability
biological factors in personality disorders (Depue, Luciana, coefficient” for the 12 scales was .75 (ranging from a high of
Arbisi, Collins, & Leon, 1994). The strongest support, as .81 for the dependent and schizotypal personality disorder
we will see, comes from research with antisocial personal- scales to .50 for the paranoid personality disorder scales).
ity theories. But more recent work also suggests the likeli- The results suggested that childhood personality disorders
hood of biological influences on other disorders, such as may have a substantial genetic component.
schizotypal personality disorder. Hans, Auerbach, Styr,
and Marcus (2004) examined lifetime major mental disor-
der and personality disorder diagnoses among 116 young SUMMARY OF ETIOLOGY
people (aged 12 to 22). Forty-one participants had a parent There are various theories regarding the causes of person-
with schizophrenia, 39 had a parent with a mental disorder ality disorders. In keeping with most other disorders, some
other than schizophrenia, and 36 had parents with no men- synthesis of these theories seems to make the most sense.
tal disorder. One central finding was that both schizophrenia There is clear correlational evidence of biological, family,
and schizotypal personality disorder occurred exclusively in and learning processes, and there is some (limited) sup-
children of parents with schizophrenia. Children of parents port for psychodynamic accounts. With respect to Cluster A
with schizophrenia also were at increased risk for avoidant disorders, the most prominent observations are genetic
personality disorder but not paranoid personality disor- links with both schizophrenia and mood disorders. Biologi-
der. These relationships were particularly strong for males. cal variables such as impaired eye-tracking, as measured by
These findings strongly suggest that there is a familial vul- smooth-pursuit eye movements, have also been investigated
nerability to schizophrenia spectrum disorders (especially as signs of biological bases for Cluster A disorders (Zemish-
schizotypal personality disorder) that is observable before lany, Siever, & Coccaro, 1988). For Cluster B disorders, the
adulthood. two etiological factors that have received the best support
Raine and colleagues (2002) took a different approach are biological factors and attachment problems. Investiga-
to examining biological correlates of personality disorders. tions of causal factors specifically with Cluster C disorders
Specifically, these researchers focused on a brain region have been very limited, despite the prevalence of the dis-
known as the prefrontal cortex. It was already known that orders (Morey, 1988). In general, causes of the personality
structural prefrontal deficits existed in some patients with disorders remain murky; longitudinal (lifespan) approaches

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 The Personality Disorders 299

are essential to resolve the lingering mysteries and are cur- link with schizophrenia has been proposed. Some research-
rently being conducted (see Cohen et al., 2005; Skodol et al., ers have even suggested that paranoid personality disorder
2005; Zanarini et al., 2005). may be a subtype of schizophrenia (Kendler, Masterson, &
Davis, 1985). A more common view is that paranoid PD is
a related disorder, or a “cousin” of schizophrenia. The main
BEFORE MOVING ON
difference in paranoid PD and paranoid schizophrenia is the
What are the four main perspectives used to explain the etiol- severity (e.g., in terms of bizarreness, extension) of people’s
ogy of personality disorders? Are there any definite causes paranoid beliefs. In schizophrenia, paranoid beliefs are suf-
of personality disorders? After reviewing each theory, which ficiently bizarre and ingrained that they are considered
perspective appears to be the most legitimate? Do certain “psychotic”— that is, a delusion. In paranoid PD, the indi-
theories seem more fitting for some personality disorders vidual’s paranoid beliefs are non-bizarre, within the realm
than others? Why or why not? of possibility, and pertain to general suspiciousness, even
though they are mistaken.
In a large-scale study among adolescents in New York,
The Specific Disorders paranoid PD was one of the four most persistent types of
personality disorder identified (Bernstein et al., 1993).
Two personality disorders have received the bulk of research Recent data also suggest that paranoid personality disorder
attention over the past several years: antisocial personality is one of the most commonly diagnosed personality disor-
disorder and borderline personality disorder. Accordingly, ders in community samples (Edens, Marcus, & Morey, 2009).
our primary focus will be on these, with briefer descriptions You might imagine that attempting to provide treatment to
of the remaining disorders. someone who distrusts everyone, including the clinician,
is very difficult. In fact, it is likely that only a very small
proportion of individuals with this disorder would seek or
Cluster A: Odd and Eccentric accept treatment.
Disorders
PARANOID PERSONALITY DISORDER SCHIZOID PERSONALITY DISORDER
Pervasive suspiciousness concerning the motives of other Individuals with this condition seem completely uninter-
people and a tendency to interpret what others say and do ested in having any sort of intimate involvement with others,
as personally meaningful in a negative way are the primary and they display little in the way of emotional responsive-
features of someone with paranoid personality disorder. ness. They come across as being detached, aloof, or self-
These individuals consistently misread the innocent actions absorbed. Individuals with schizoid PD rarely experience
or comments of others as being threatening or critical, and intense emotions and may be puzzled by the passions of oth-
they expect other people to exploit them. Consequently, ers. These individuals typically spend significant time alone
individuals with this disorder tend to be hypervigilant, and and can appear cold and indifferent toward others. In fact,
they take extreme precautions against potential threats from they seem not to enjoy relationships of any type, apparently
others. They believe that other people intend to hurt them, preferring to be alone. Unlike most of us, they avoid social
and they are reluctant to share anything personal for fear activities and do not seek or seem to desire sexual relations.
it might be used against them. In addition, they are typi- There seems to be little doubt that most do not have the
cally humourless and eccentric, and are seen by others as skills necessary for effective social interaction, but they also
hostile, jealous, and preoccupied with power and control. appear uninterested in acquiring such skills.
Not surprisingly, they have numerous problems in relation- There are several diagnostic concerns related to schizoid
ships; most people cannot tolerate their need to control and PD. For example, in some ways, this condition’s presentation
particularly their jealous and suspicious nature. Frequently, may mirror some of the negative symptoms (e.g., flat affect)
patients who are paranoid become socially isolated, and this observed in schizophrenia. Other issues have also been
seems only to add to their persecutory ideas. documented. Morey’s (1988) examination of the impact on
These features, identified both in the diagnostic crite- diagnostic practices of the changes from DSM-III to DSM-
ria and in clinical reports, have been confirmed in research. III-R revealed that the frequency of schizoid diagnoses
For example, compared with participants with no diagnosis, increased significantly (from 1.4 percent of patients to 11
individuals with paranoid PD experience far more paranoid percent). This was apparently due to a reduction in the fre-
thoughts throughout their life (Turkat & Banks, 1987), have quency of the diagnosis of schizotypal PD and a correspond-
greater difficulty dealing with ambiguity and are more sus- ing increase in diagnosing schizoid PD. Unfortunately, this
picious (Thompson-Pope & Turkat, 1988), and are more makes it difficult to compare research on schizoid PD con-
likely to misread social cues as evidence of hostility by oth- ducted before and after the publication of the DSM-III-R.
ers (Turkat, Keane, & Thompson-Pope, 1990). One of the main problems with this diagnostic category is
Since paranoid personality disorder occurs commonly that it has been the focus of little methodologically sound
among relatives of individuals with schizophrenia, a genetic research. As a consequence, little knowledge has since been

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 300 Chapter 12

offered about this disorder. Perhaps as a result of the changes & Meltzer, 1991). Overall, medication has positive, although
in previous diagnostic criteria, published studies frequently modest, effects (Gitlin, 1993). Controlled studies of psycho-
confound schizoid and schizotypal features, and do not, logical forms of treatment have not been reported. Unfor-
therefore, permit any definitive conclusions. More recently, tunately, the long-term prognosis for schizotypal PD is
data from the Children in the Community Study of Devel- generally poor.
opmental Course of Personality Disorder led Cohen and
colleagues (2005) to conclude that schizoid PD appeared
to be distinct from paranoid and schizotypal PD. They sug-
gested that schizoid PD may be more related to asocial dis-
Cluster B: Dramatic, Emotional,
orders such as Autism Spectrum Disorder. or Erratic Disorders
As noted earlier, the four disorders in Cluster B do not seem
SCHIZOTYPAL PERSONALITY DISORDER to have as much in common with each other as is implied by
their collective grouping. Whereas histrionic and borderline
The major presenting features of individuals with schizo-
disorders may be perceived as dramatic, it is hard to see what
typal personality disorder are eccentricity of thought and
this descriptor has to do with antisocial personality disorder.
behaviour. Much like Bikram from earlier in this chapter,
Indeed, except for a limited range of emotional expression
many are extremely superstitious and have thoughts that
among these individuals, none of the Custer B descriptors
are permeated by odd beliefs. For instance, individuals with
seem to fit those with ASPD. Hence, some suggest that those
this condition may engage in magical thinking and believe
with ASPD belong to a separate category of personality dis-
in paranormal phenomena (e.g., telepathy, clairvoyance); it
orders (Lykken, 1995).
is not uncommon for these individuals to see such skills in
themselves. The nature of their odd beliefs can turn others
away, which results in them being socially isolated. Such iso- ANTISOCIAL PERSONALITY DISORDER
lation may increase the likelihood for unusual thoughts and AND PSYCHOPATHY: A CONFUSION OF
perceptions, as there is little opportunity to check the accu- DIAGNOSES
racy of their cognitions. You were introduced to James at the beginning of this
Like paranoid PD, and to a lesser extent schizoid PD, chapter. People like James are among the most dangerous
this condition has some similarities with schizophrenia. individuals in society, as reflected by a consistently higher
However, the difference lies in the severity and quality of rate of criminal behaviour than other offenders throughout
the symptoms. Although their beliefs, perceptual experi- adulthood (e.g., Harpur & Hare, 1994; Porter, Birt, & Boer,
ences, speech, and behaviours are odd and they tend to iso- 2001). James’s personal style occurs often in individuals who
late them from others, they are not usually considered to be are diagnosed as having APD. On the surface, he is charming
so eccentric as to meet the criteria for delusional or hallu- and persuasive, but this masks a self-centred and, in his case,
cinatory psychotic experiences. There is, however, consid- criminal lifestyle. Not all patients with antisocial personali-
erable disagreement on this issue. For example, McGlashan ties commit crimes, although most of them who are so diag-
(1994) claimed that transient psychoses characterize these nosed by clinicians have a criminal record. This may simply
patients, and Kendler (1985) concluded that schizotypal PD reflect the fact that it is their criminal behaviour that brings
is simply a subtle form of schizophrenia. Research examin- them to the attention of psychiatrists or psychologists. How-
ing biological features has found strong similarities between ever, the behavioural features of ASPD do predispose these
patients with schizotypal PD and those with schizophrenia patients to crime, and unlawfulness is one of the examples
(Siever, 1985). In addition, many family members of patients that DSM-5 provides of the disregard that those with antiso-
with schizophrenia exhibit schizotypal symptoms (Kendler, cial personalities display toward others.
1985). More recent research has revealed that, while the
symptoms of schizotypal PD remain the same, the sever- DESCRIPTION OF THE DISORDER Individuals thus iden-
ity of the symptoms varies depending on sex and age tified have been referred to as psychopaths, sociopaths, or
(Fonseca-Pedrero, Lemos-Giráldez, Muñiz, García-Cueto, dyssocial personalities, with these terms sometimes being used
& Campillo-Álvarez, 2008; Paíno-Piñeiro, Fonseca-Pedrero, interchangeably. In fact, in correctional settings, the terms
Lemos-Giráldez, & Muñiz, 2008). These issues are addressed psychopathy and ASPD have been confused for decades. Many
in the DSM-5 in the Schizophrenia Spectrum and other Psychotic researchers and clinicians continue to use the concept of psy-
Disorders and Personality Disorders sections. chopathy rather than following DSM-5 criteria, or vice versa.
The literature regarding treatment of schizotypal per- However, it is important to recognize that ASPD and
sonality disorder mirrors the approach taken with etiology; psychopathy are not the same (e.g., Hart & Hare, 1997). Psy-
that is, the emphasis is on the schizophrenic-like features. chopathy incorporates a richer set of emotional, interper-
Low doses of antipsychotic drugs may relieve the cognitive sonal, and behavioural features than the DSM-5 definition of
problems and social anxiety experienced by these individu- ASPD, which chiefly focuses on observable behaviour. The
als (Goldberg et al., 1986); antidepressant medication has relatively few criteria reflecting emotional and interpersonal
also yielded positive effects (Markovitz, Calabrese, Schulz, processes in the diagnostic manual, as well as the results of

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 The Personality Disorders 301

studies (Rogers et al., 1994) comparing the DSM and other both behaviour and personality. Studies of the PCL-R have
measures of ASPD (e.g., PCL-R and the ICD-10 of the World revealed that two factors, personality traits and lifestyle
Health Organization, 1992), underscore this concern. How- instability, are necessary and sufficient for a diagnosis (Hare,
ever, there is some overlap between ASPD and psychopathy, Hart, & Harpur, 1991). Furthermore, the PCL-R emotional/
such that only a small proportion of individuals who qualify affective criteria (such as shallow affect) are highly reliable if
for a diagnosis of ASPD are psychopathic, whereas most indi- the rater has the appropriate training (e.g., Hare, 2003).
viduals who are psychopathic would qualify for an ASPD Unlike the other personality disorders, the essential
diagnosis (Hare, 2003; Hart & Hare, 1997). According to Coid feature of ASPD is a pervasive pattern of disregard for and
and Ullrich (2010) ASPD and psychopathy are in fact related, violation of the rights of others that begins in childhood
but that psychopathy is more severe than ASPD. In other or early adolescence and continues into adulthood. The
words, ASPD and psychopathy have an asymmetric relation- increasing reliance on behavioural indices of the disorder
ship. As such, we will consider ASPD and psychopathy to be introduced since DSM-II has raised concerns regarding the
related but separate entities in the following sections. relation of the diagnostic criteria to clinical conceptions of
The debate regarding the utility of differentiating con- the related construct of psychopathy (Hare et al., 1991). The
cepts of ASPD and psychopathy has led to some confusion. notion of psychopathy as a destructive constellation of per-
Central to this issue is whether the DSM criteria sufficiently sonality characteristics has a long history (as discussed ear-
reflect the personality domain of the disorder. Employing lier). Indeed, it was this clinical concept that originally led
essentially behavioural criteria may increase diagnostic reli- to the definition of ASPD. Again, it is important to highlight
ability, but may also yield a group of individuals who are that the DSM-5 criteria for ASPD are a highly reliable set
markedly variable in terms of personality traits (Blackburn, of indicators of a socially deviant lifestyle; however, they are
1992). The advantage of using the most widely accepted not the best criteria for tapping the core features of psychop-
measure of psychopathy—the Psychopathy Checklist– athy (e.g., shallow affect, lack of empathy), which are best
Revised (PCL-R; Hare, 1991, 2003)—is that it considers measured by the Psychopathy Checklist–Revised.

FOCUS
Paul Bernardo and Karla Homolka
12.1 Serial offenders who commit sexual assaults and/or rienced at the hands of Bernardo had reportedly left her like
homicides continue to be a major concern to the pub- a “concentration camp survivor,” and had contributed to her
lic. Paul Bernardo, known as the “Scarborough Rapist” involvement in the murders (Galligan, 1996).
and a diagnosed psychopath, sexually assaulted numerous However, the true extent of Homolka’s culpability in the
Ontario women over the course of several years in the early 1990s. murders was revealed in the videotapes that were later recovered.
Although he was a suspect in the investigation of the rapes, Her claims of being under her husband’s control—central to the
he was not arrested and his violence escalated until he—along plea bargain—appeared to be blatantly false (see Wrightsman
with his wife, Karla Homolka—raped and murdered three young & Porter, 2005). On the videotapes they had made of their vio-
women, including Homolka’s own sister. Bernardo and Homolka lence, these predatory offenders clearly derived enjoyment from
abducted two teenage girls separately and held them captive the suffering of the victims. It was reported that Homolka spoke
for several days and videotaped their actions while they repeat- with and sexually assaulted the victims with a smile on her
edly and brutally sexually assaulted them. After several days of face. As a student of psychology, how helpful do you think the
torture, the girls were murdered and their bodies were disposed descriptions provided by the mental health professionals were
of. When these callous crimes were revealed, the public was in helping the court make the right decisions? Did Homolka
outraged—all the more so because a woman was involved. In one successfully deceive the court? How does this case inform your
of the most notorious plea bargains in Canadian legal history, opinion of the reliability and validity of DSM disorders and the
Homolka entered into a deal with the Ontario Crown Attorney’s diagnostic process? ●
office on May 14, 1993, in which she agreed to plead guilty
to two counts of manslaughter in return for a 12-year sentence
(see Galligan, 1996). During the sentencing hearing, evidence
was presented that she had played a direct role in the drug-
ging, sexual assault, and death of her 15-year-old sister. Prior to
the plea bargain, Homolka had been assessed by several mental
health professionals. In March 1993, she had been admitted
into a hospital where she underwent lengthy evaluations by two
psychiatrists and two psychologists. The clinical reports include
numerous diagnoses and clinical descriptions, from stress,
anxiety, and depression to learned helplessness, post-traumatic
stress disorder, lack of affect, and other indicators of “battered
woman syndrome,” whereas little evidence was found for psy-
chosis or sexual deviance. The domestic violence she had expe-
Frank Gunn/CP Images Phil Snel/CP Images

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 302 Chapter 12

ANTISOCIAL PERSONALITY DISORDER (APD) The tained throughout their lifespan in one form or another. This
DSM-5 criteria for the diagnosis of APD include seven research also suggests the importance of familial/parental
exemplars reflecting the violation of the rights of others: factors and genetic features as risk factors for developing
nonconformity, callousness, deceitfulness, irresponsibility, ASPD. There have been two major systematic literature
impulsivity, aggressiveness, and recklessness. Sean Penn gave reviews (Miles & Carey, 1997; Rhee & Waldman, 2002) that
a remarkably accurate portrayal of ASPD in the movie Dead collectively analyzed a relatively large body of empirical
Man Walking. Reflecting a polythetic approach (meaning only studies on the genetic influences on antisocial and aggres-
a subset of symptoms or behaviours is required for a diagnosis, sive behaviour. Both of these reviews incorporated twin and
unlike most medical diagnoses), three or more of the above adoption studies in their analyses and both converged on the
symptoms must be met for the diagnosis to be applied. importance of genetics in the development of aggressive and
antisocial behaviour. This literature has yielded heritability
Prevalence. The DSM-5 reports lifetime prevalence rates estimates for measures of antisocial behaviour/aggression
for ASPD between 0.2% and 3.3% for both males and ranging from 44 to 72 percent (Blair, Peschardt, Budhani,
females. These results are comparable to the United States Mitchell, & Pine, 2006).
National Comorbidity Survey Replication (Lenzenweger et However, while a strictly biological explanation has been
al., 2007), which reported a prevalence rate of 0.6% in males found to be insufficient to account for the etiology of antiso-
and females combined. The incidence in forensic settings, as cial behaviour (Raine, 1993), such factors appear to interact
expected, is likely higher since criminal behaviour is a domi- with childhood experiences to produce criminality. There
nant feature of ASPD. appear to be neuropsychological markers that, in combina-
Estimates in Great Britain (Chiswick, 1992) indicate a tion with specific environmental circumstances (e.g., crimi-
prevalence rate of approximately 25 to 33% of patients in Spe- nogenic environment, poor parenting, neglect, and physical
cial Hospitals. This high number presumably occurs because abuse), interact to make children vulnerable to developing
criminals who are considered to have a psychiatric disorder an antisocial lifestyle and personality (Mealey, 1995).
are diverted to these Special Hospitals, whereas those who Finally, there are psychological explanations for ASPD
do not are simply imprisoned. Hare (1983, 1985) reported that focus on inadequate self-regulation. Lykken (1957), for
higher estimates in Canadian prisons using DSM-III-R, example, suggested that such individuals are essentially fear-
where approximately 40% of offenders were diagnosed as less. This fearlessness hypothesis claims that those with ASPD
having APD. Similar data from another correctional sample have a higher threshold for feeling fear than do other people.
were provided by Hart and Hare (1989), reflecting the rela- Events that make most people anxious (e.g., the expectation of
tive overdiagnosis using DSM-III criteria (50% incidence being punished) are thought to have little or no effect on those
of APD) compared with an early version of the Personality with ASPD. A recent study provided support for this hypothe-
Checklist (12.5% incidence of psychopathy). These rates are sis by confirming that there appears to be an attentional mecha-
slightly lower than estimates provided by Quebec researchers nism that reduces the fear response in individuals with ASPD
Côté and Hodgins (1990), who used yet another assessment (Dvorak-Bertsch, Curtin, Rubinstein, & Newman, 2009).
strategy, the Diagnostic Interview Schedule (Robins, Helzer, Despite this line of research, some social learning
Croughan, & Ratcliff, 1981). In a random sample of 495 male theorists have questioned the validity of the fearlessness
inmates, Côté and Hodgins diagnosed 61.5% as having APD hypothesis. For instance, Schmauk (1970) suggested that,
using the diagnostic interview criteria. since Lykken’s research (see Figure 12.1) and other studies

Etiology of APD. Several lines of investigation have been

1 2 3 4
pursued in an attempt to explain the following major char-
acteristics of persons with ASPD: callous disregard for oth-
ers, impulsivity and poor self-regulation, rule breaking and Red lights
criminality, and exploitation of others. Initially, social and
family factors were highlighted (Robins, 1966); here, the
view was that parental behaviours can influence the devel- Green lights
opment of antisocial functioning. This led to the applica-
tion of family systems approaches to treatment, in which
empirically determined risk factors are targeted within a Levers
family-centred model of service delivery (Henggeler &
Schoenwald, 1993). This multi-systemic therapy approach
has produced some promising outcome data (Borduin et al., FIGURE 12.1 Lykken’s Lever Apparatus to Test
1995) and this has further encouraged the idea that dis- Avoidance Learning
ruptive families are causal factors in the disorder. Moffitt’s Lykken (1957) devised this apparatus for his study of avoidance
learning in individuals with APD. The participants had to learn a
(1993) work on developmental trajectories indicates that a sequence of 20 correct lever presses.
minority of youth become involved in rule breaking and
Source: Based on Lykken, David T (1957). A study of anxiety in the sociopathic personality,
delinquent behaviour at an early age and that this is sus- The Journal of Abnormal and Social Psychology, Vol. 55(1), Jul 1957, 6-10.

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 The Personality Disorders 303

used an electric shock as a form of punishment, the findings Newman and his colleagues have described the pathol-
might only be relevant to shocks and other forms of physi- ogy of psychopaths (as measured by the PCL-R) as due
cal punishment. Schmauk pointed out that, as children, indi- primarily to information processing deficiencies (Wallace,
viduals with ASPD appear to have been exposed to severe Schmitt, Vitale, & Newman, 2000). Through a series of labo-
physical punishment from their parents or guardians that ratory and process-based investigations, they concluded that
was frequently not contingent upon their behaviour. As a psychopaths suffer from a generalized information process-
result, Schmauk suggested that these individuals might have ing deficiency involving the automatic directing of attention
learned to be either indifferent to physical punishment or to stimuli that are peripheral to ongoing directed behaviour.
oppositional to such attempts at controlling them. Opposi- That is, once engaged in reward-based behaviour, the psy-
tional behaviour has been thoroughly examined in children chopath is less likely to attend to other cues to modulate
(Campbell, 1990) and refers to a tendency to do the oppo- his or her ongoing response. In contrast, the antisocial and
site of what is being asked of the person. In the present case, criminal behaviour exhibited by those with ASPD involves
oppositional behaviour would result in the punished behav- schema-based deficits. These deficits comprise antisocial
iour showing an increase rather than the expected decrease. schemas and cognitive distortions not requiring automatic
To test this idea, Schmauk repeated Lykken’s study attentional cueing. Such research supports the idea that psy-
but employed three different kinds of punishments: physi- chopathy and ASPD are different diagnoses implying differ-
cal (electric shocks), tangible (participants lost money for ent etiology, intervention, and prognosis.
errors), and social (reprimands by the experimenter for
errors). With electric shocks as punishments, Schmauk rep- Course and Prognosis of APD. Robins and Regier (1991)
licated Lykken’s findings, and he obtained similar results reported that the average duration of ASPD, from the onset
with the social punishments. That is, in response to both of the first symptom to the end of the last, was 19 years. This
types of punishments, individuals with APD performed remittance over time of symptoms has been described as the
poorly relative to their counterparts. However, when the burnout factor, with the expectation being that symptoms will
APD group lost money for pressing the wrong lever, they disappear by the fourth decade of life. However, Arboleda-
quickly learned to avoid the shocked levers and, in fact, did Florez and Holley (1991) have presented data refuting the
so more successfully than had their counterparts under any view that there is burn out among individuals with ASPD.
of the punishment conditions (see Figure 12.2). Schmauk These conflicting data are confusing and it is hard to make
concluded that individuals with APD were differentially sense of them. Correctional Service Canada researchers
responsive to different kinds of punishment as a result of Porporino and Motiuk (1995) found that in the context of
early learning experiences, rather than completely fearless comorbid ASPD and substance, the post-release perfor-
or unresponsive to all punishment. mance is poorer than in those offenders who have only one
of these disorders.
Psychopaths
Normal controls Treatment for APD. Reviews of treatment efficacy for patients
0.55 with APD have been generally pessimistic (Reid & Gacono,
2000; Suedfeld & Landon, 1978). Many of the early studies,
however, suffered from poor methodology. As pointed out by
0.50
Paul Gendreau (1996) of the University of New Brunswick,
Mean Avoidance Learning

programs delivered in previous decades did not reflect con-

0.45 temporary knowledge of effective treatment programs for
resistant clients, so it may be premature to discount the poten-
tial for modifying the destructive behaviours of these clients.
0.40 Attrition from treatment programs is also high, and this has
proved to be predictive of subsequent reoffending. Lastly, in
substance abuse treatment, individuals with ASPD fare more
0.35
poorly than do other patients (Alterman & Cacciola, 1991).
Surprisingly, therapeutic hope has not vanished. Approxi-
0.30 mately two-thirds of psychiatrists think that individuals with
ASPD are sometimes treatable (Tennent, Tennent, Prins, &
Bedford, 1993). Despite a poor response to hospitalization,
prognosis is improved for these clients if there is a treatable
Physical Tangible Social
anxiety or depressive feature to their behaviour (Gabbard &
Punisher Coyne, 1987) or if they can be convinced to form an effective
FIGURE 12.2 Effects of Different Types of Punishment therapeutic alliance (Gerstley et al., 1989). According to cur-
on Psychopaths rent views, treatment should be aimed at symptom reduction
and behaviour management rather than at a cure (Quinsey,
Source: Based on Schmauk, F. J. (1970) Punishment, arousal, and avoidance learning in
sociopaths. Journal of Abnormal Psychology, 76, 325-335. Harris, Rice, & Cormier, 2006).

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 304 Chapter 12

Treatment of other resistant clients suggests a of 82 studies examining persistent sexual offending
responsivity factor. That is, treatment must be responsive (n = 29 450 sexual offenders) and found that the major pre-
(or matched) to a particular patient’s needs and interper- dictors of future sexual offences by both adolescents and
sonal style. Poor treatment performance may, in part, be adults were an antisocial orientation and deviant sexual pref-
caused by an intervention that is of insufficient intensity erences. An antisocial orientation was also a major predictor
(Gendreau, 1996), viewed by patients as irrelevant (Miller & of future non-sexual violent offences. Interestingly, many of
Rollnick, 1991), or seen as involuntary (Gabbard & Coyne, the variables traditionally targeted in sexual offender treat-
1987). Several of these issues have been specifically consid- ment programs (e.g., psychological distress) showed little
ered in the context of the provision of treatment, yet they or no relation with future sexual offences. Conceptualizing
remain untested hypotheses. Researchers at the Oak Ridge treatment as a management strategy rather than as a cure is
Mental Health Centre in Ontario (Rice, Harris, & Quinsey, perhaps a more helpful framework and likely protects clini-
1996) have pointed out that treatment programs vary for cians from undue optimism. Further, targeting responsivity
these clients according to the extent that either personal- factors (i.e., those factors that are related to the antisocial
ity or criminality is emphasized, and yet a problems-based behaviour) may yield enhanced treatment efficacy, but this
approach would appear to enhance compliance and efficacy. remains an empirical question.
Many of the more recent developments in treatment
programs for criminal populations have involved significant PSYCHOPATHY Although psychopathy is not listed in the
contributions from Canadian researchers in forensic hospi- DSM-5, an enormous amount of research has been devoted
tals (e.g., Quinsey et al., 2006) and in prisons (e.g., Serin & to the disorder in the past two decades, probably more than
Kuriychuk, 1994). While treatment targets for these samples to APD, or all other personality disorders combined. Psycho-
have sometimes obscured the distinction between crimi- paths are a distinctive subgroup of offenders best described
nality and antisocial personality, they typically include a by their unique interpersonal and affective disposition. They
focus on some combination of aggressive and antisocial atti- are egocentric, deceptive, callous, manipulative individuals
tudes and beliefs, impulsivity or poor self-regulation, social who lack remorse and emotional depth. Readers interested in
skills, anger, assertiveness, substance abuse, empathy, prob- viewing a film depiction of a psychopath might consider The
lem solving, and moral reasoning (Serin & Preston, 2001). Last King of Scotland, in which Forest Whitaker plays the role of
For many of these targets, there are structured program Ugandan dictator Idi Amin. Whitaker effectively conveys the
materials; however, the technology to measure treatment superficially charming, charismatic, and grandiose qualities
gains remains relatively unsophisticated. Furthermore, the of the disorder that are often used to mask a selfish, deceitful,
overreliance on self-report assessment methods is problem- callous, and antisocial lifestyle. He received the Best Actor
atic in a population in whom honesty is suspect. award at the 79th Academy Awards for his portrayal of Amin.
Another strategy for managing antisocial or acting-out Psychopaths commit a disproportionate amount of anti-
behaviour, particularly in closed settings, has been pharmaco- social and violent behaviour in society, extending to both
therapy. Short-term use of psychopharmocological agents is nonsexual and sexual violence (Hart & Hare, 1997; Porter
most often used to manage difficult or threatening behaviour. et al., 2000). In addition to their aggression and violence,
However, the side effects of long-term drug use and prob- psychopaths are chronic deceivers, often but not always
lems of noncompliance have been noted in forensic patients lying for instrumental reasons such as to escape punishment.
(Harris, 1989). While short-term use of antipsychotic, anti- Häkkänen-Nyholm and Hare (2009) revealed that offenders
anxiety, and sedative medications is not uncommon, symptom with high PCL-R scores are more likely to deny charges or
alleviation is rarely sustained, and patients are typically pro- claim self-defence. These offenders are also likely to be con-
vided with no new skills to improve their ability to deal with victed of a less serious crime than the one they committed,
future situations. For some patients, medication may reduce be granted an appeal of their sentence, and be granted unde-
arousal level sufficiently for them to participate more fully in served conditional release. Psychopathic non-sex offenders
cognitive-behavioural treatment (Rice & Harris, 1993). were the most successful at garnering conditional release,
but even the psychopathic sex offenders were more success-
Summary of ASPD. While the DSM-5 criteria for ASPD ful than non-psychopathic non-sex offenders (Porter, ten
are simplified and reliable, these criteria have not served to Brinke, & Wilson, 2009). They are “users” of others, in their
bridge the conceptual differences between divergent views attempts to obtain money, drugs, sex, or power (e.g., Hart &
regarding the preferred diagnostic criteria or the assessment Hare, 1997; Porter & Woodworth, 2007; Woodworth & Porter,
of these clients. It is important to note that alternatives to the 2002). Many psychopaths are con artists with a long history
diagnostic criteria, such as the PCL-R and ICD-10, may yield of frauds and scams; some even become cult leaders, corrupt
better assessments, in the view of experienced clinicians. politicians, or successful corporate leaders, before their fre-
Currently, treatment initiatives can be only partly quent downfall (e.g., Babiak & Hare, 2006).
guided by theory (Rice & Harris, 1997b; Serin & Preston, Not only are psychopaths successful scam artists, they
2001). Prognosis even after treatment remains relatively also appear to have a heightened ability to discern vulnerable
poor for patients with ASPD. For example, Hanson and individuals from non-vulnerable individuals. To successfully
Morton-Bourgon (2005) collectively analyzed the results dupe someone, it is important to target an individual who is

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 The Personality Disorders 305

easy to manipulate. There are many characteristics associated offender is likely to commit future violent behaviour (e.g.,
with vulnerability, including low self-esteem, low assertive- Harris, Rice, & Quinsey, 1993; Hemphill, Hare, & Wong,
ness, and increased depression and anxiety (Egan & Perry, 1998; Rice & Harris, 1997a; Salekin, Rogers, & Sewell, 1996).
1998). Psychopaths have demonstrated a keen ability to detect For example, Canadian researchers Serin and Amos (1995)
these signs of vulnerability among others in a number of stud- found that psychopaths were about five times more likely
ies. Book, Quinsey, and Langford (2007) found that psycho- than their counterparts to engage in violent reoffending
pathic individuals were better able than are non-psychopaths within five years of their release from prison. Although the
to sense a lack of assertiveness after simply viewing a two- prevalence of psychopathy in civil psychiatric patients is low
minute video of a vulnerable target. In another study, research- compared to that among criminal offenders (e.g., Douglas,
ers found that psychopaths were able to detect vulnerability Ogloff, Nicholls, & Grant, 1999), a consideration of psychop-
based on gait and non-verbal cues alone (Wheeler, Book, & athy still helps to predict future aggression in this popula-
Costello, 2009). Finally, in another investigation, it was found tion. Skeem and Mulvey (2001) examined future violence in
that men who possessed a high number of psychopathic traits 1136 psychiatric patients from the MacArthur Violence Risk
had nearly perfect recall of sad and unsuccessful females who Assessment project, and found that PCL-R scores predicted
are likely to be highly vulnerable (Wilson, Demetrioff, & future serious violence, despite a low base rate (8 percent).
Porter, 2008). It is unknown at this time how psychopaths Not only do psychopaths commit more violence, they
detect vulnerability in others, but the authors of this chapter commit particularly heinous violence. Williamson, Hare, and
are currently investigating this phenomenon. Wong (1987) found that psychopaths’ violent crimes were
It is important to note that diagnostic strategies other more likely to have a motive of material gain (45.2%) than
than those outlined in DSM-5 are gaining prominence in were non-psychopaths’ (14.6%). Further, non-psychopaths
the forensic literature. For example, the PCL-R (Hare, 1991) (31.7%) were more likely to display high levels of emotion
enjoys international popularity as both a research instrument in their offences than were psychopaths (2.4%). Cornell and
and a clinical tool (e.g., Hemphill & Hare, 2004). Psychopa- colleagues (1996) found that offenders who had committed at
thy, as measured by the PCL-R, is characterized by 20 criteria least one previous act of instrumental (planned with an exter-
scored from 0 to 2 for a maximum score of 40. As recom- nal goal) violence had higher PCL-R scores than offenders
mended in the manual, a minimum score of 30 is the cut-off who had only committed acts of reactive violence. In addi-
for classifying psychopathy. The PCL-R score is highly reli- tion, psychopaths adhere to the selective impulsivity theory
able over time and has a high level of validity according to (Juodis, Starzomski, Porter, & Woodworth, 2012). That is, they
much research (e.g., Fulero, 1995; Stone, 1995). Increasingly, are not out of control, but are able to quickly weigh the pros
the PCL-R is used in assessments to inform judicial decisions, and cons of their actions. They will act impulsively only if
principally because of its predictive validity in terms of recid- the consequences are worth the risk. Woodworth and Porter
ivism (i.e., the commission of new criminal offences follow- (2002) examined the relationship between psychopathy and
ing some previous involvement in the criminal justice system) homicide. In a sample of 125 incarcerated homicide offend-
(Douglas, Vincent, & Edens, 2007; Serin & Brown, 2000). ers from two Canadian federal institutions, psychopaths were
Despite the definitional differences between ASPD and more likely to have engaged in “cold-blooded” predatory
psychopathy, little distinction has been made between ASPD homicides (93.3%) than were non-psychopathic offenders
and psychopathy in the legal system (Lyon & Ogloff, 2000). (48.4%). Research has revealed that psychopaths are likely to
Some authors (e.g., Harding, 1992) suggest that the reluc- commit a number of other violent crimes including spousal
tance to use the term psychopathic stems from its pejorative abuse (Shaw & Porter, 2012) and rape (Porter et al., 2001).
connotations. Psychopathy, however, is a resilient term that In addition to committing more cold-blooded violence,
has enjoyed a relative resurgence in use in correctional and psychopaths may even enjoy inflicting the violence. Research
forensic settings (Hare, 2003). In the media, psychopathy has has addressed the possible link between psychopathy and
been prominent in descriptions of infamous offenders such sadistic interests. Holt, Meloy, and Stack (1999) found that
as Clifford Olson and Paul Bernardo. Such sensationalism, sadistic traits were more common in violent psychopaths
however, does little to inform the public or clinicians regard- than in violent non-psychopaths. Further, there is a modest
ing the disorder, as many or most psychopaths are not serial correlation (.21 to .28) between PCL-R scores and deviant
rapists or murderers. Many “white-collar psychopaths” are sexual arousal (e.g., Barbaree, Seto, Serin, Amos, & Preston,
successful in business or politics (e.g., Babiak & Hare, 2006). 1994). A team of Canadian researchers (Porter, Woodworth,
Earle, Drugge, & Boer, 2003) examined the relation between
Psychopathy and Aggression. As outlined by Porter and PCL-R scores and the types of aggression evidenced dur-
Porter (2007), researchers have established a strong link ing the crime in a sample of 38 Canadian sexual murder-
between psychopathic traits and aggression or violence in ers. Homicides committed by psychopaths showed a higher
both adult offenders and psychiatric patients. Porter, Birt, and level of both gratuitous and sadistic violence than did
Boer (2001) found that psychopaths incarcerated in Cana- homicides perpetrated by non-psychopathic offenders. In
dian correctional institutions had perpetrated an average of fact, most psychopaths (82.4 percent) had committed sadis-
more than seven violent crimes, nearly twice the average tic acts on their victims, compared to 52.6 percent of the
of their counterparts. This link helps us predict whether an non-psychopaths.

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Prevalence of Psychopathy. Hare (1996, 2003) estimates that that the impulsive aggression of psychopaths may be linked
1 percent of the population is psychopathic (meaning that we to serotonergic hypofunctioning in combination with a high
have more than 300 000 psychopaths in Canada). However, it dopamine activity. Despite these compelling findings, the
is very difficult, if not impossible, to conclusively determine data are correlational, and much more research is required to
the prevalence of psychopathy in the community. Imagine establish whether such biological correlates are causal factors.
psychopaths receiving a survey questionnaire in which they Three relatively recent studies have reported important
are asked whether they lack remorse, lie frequently, are cal- data on the genetic contributions to psychopathy. Blonigen,
lous individuals, and so on. The researcher is unlikely to Carlson, Krueger, and Patrick (2003) had 353 male adult
receive many honest responses! twins complete a self-report measure of psychopathic traits
However, there is a wealth of research to allow conclu- and found moderate levels of heritability for the subscales
sions about the prevalence of psychopathy in forensic popu- measuring affect-related traits of the disorder. Blonigen,
lations. In federal correctional settings, approximately 15 Hicks, Krueger, Patrick, and Iacono (2005) examined 626
to 25 percent of inmates are psychopaths, according to the pairs of 17-year-old male and female twins and found sig-
PCL-R (e.g., see Hare, 2003). Rates of psychopathy among nificant heritability on measures of fearless dominance and
Canadian offenders also appear to vary according to security impulsive antisocial behaviour. Viding, Blair, Moffitt, and
level, with psychopaths being overrepresented in maximum- Plomin (2005) published data on 3500 twin pairs of children
security prisons (Wong, 1984). from the Twins Early Development Study. These research-
Research with female inmate samples (outside Canada) ers indexed the callous and unemotional component of
indicates a base rate of psychopathy of 9 to 31 percent (e.g., psychopathy at age seven and found significant group heri-
Kennedy, Hicks, & Patrick, 2007; Vitale, Smith, Brinkley, & tability and no environmental influence on this component
Newman, 2002; Warren et al., 2003). of psychopathy. Such findings have led some researchers to
argue that there is a stronger genetic cause as opposed to
Etiology of Psychopathy. There has been an abundance of social cause of psychopathy (Blair et al., 2006).
etiological theories concerning psychopathy, ranging from As with most mental disorders, it is unlikely that biol-
evolutionary (Lalumière, Harris, & Rice, 2001; Mealey, 1995; ogy tells the whole story of how psychopathy develops.
Quinsey, 1995) and neurobiological (Raine, Lencz, Bihrle, Almost certainly, environmental factors play a role. More
LaCasse, & Colletti, 2000) explanations to environmental than 40 years ago, McCord and McCord (1964) argued that
models involving early childhood trauma or maltreatment there is an association between early emotional deprivation
(McCord & McCord, 1964; Porter, 1996). However, at pres- (i.e., parental neglect, erratic punishment) and psychopathic
ent, the data are primarily correlational in nature and it is characteristics in adulthood. There are some data to speak
not possible to offer a definitive causal account. to their claim. Weiler and Widom (1996) found that chil-
Biological theorists have observed that psychopaths tend dren who were abused or neglected went on to have higher
to differ from non-psychopaths in terms of their underlying PCL-R scores than matched controls who had not been mal-
biological functioning and neurological processing. Psycho- treated. Using a retrospective design, Marshall and Cooke
paths are insensitive to the emotional content of information, (1995, 1999) found that psychopaths had experienced a more
especially language (Hancock, Woodworth, & Porter, 2011; negative upbringing (e.g., poor discipline, emotional abuse/
Willamson, Harpur, & Hare, 1991) and emotional pictorial neglect) and negative school experience than had non-
information (Christianson et al., 1996). The limited exist- psychopaths. More recently, Campbell, Porter, and Santor
ing neuroimaging studies implicate brain abnormalities in (2004) examined the criminal, clinical, and psychosocial cor-
psychopaths. Such abnormalities have been identified in the relates of psychopathy in a sample of 226 incarcerated ado-
prefrontal cortex, hippocampus, angular gyrus, basal ganglia, lescents. Only 9.4 percent of the sample showed a high level
and amygdala (e.g., Abbott, 2001; Blair, 2001, 2003; Brower of psychopathic traits. Thirty-three percent of the sample
& Price, 2001; Deeley et al., 2006; De Oliveira-Souza et al., had a history of experiencing physical abuse and 50 percent
2008; Kiehl et al., 2004; Mitchell, Colledge, Leonard, & Blair, had a history of non-parental living arrangements such as
2002; Stevens, Charman, & Blair, 2001; Yang et al., 2005). For foster care. High psychopathy scores in these adolescents
example, because of an apparent dysfunction of the amyg- were associated with both the experience of physical abuse
dala, psychopathic individuals appear to use alternative and disrupted living arrangements.
(primarily cognitive) means of processing emotional material Porter (1996) has suggested that there are in fact two
to compensate for the absence of appropriate limbic input pathways that can lead to the development of psychopa-
(which normally provides prompt information about the thy. In the case of fundamental psychopathy, the disorder is the
affective characteristics of stimuli). inevitable result of a biological (probably polygenic) predis-
Neurotransmitters have also been implicated in psy- position within the individual that hinders the development
chopathic behaviour. Soderstrom, Blennow, Manhem, and of affective bonds. In the case of secondary psychopathy, the
Forsman (2001) found that PCL-R scores were predicted by development of the disorder is heavily dependent on and the
lower 5-HIAA concentrations (a metabolite of serotonin) and result of negative environmental experiences during the for-
high catecholaminergic activity (HVA) in the cerebral spinal mative years of childhood, such as extreme neglect or abuse.
fluid of violent forensic inpatients. The authors concluded With secondary psychopathy, the profound affective deficit

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 The Personality Disorders 307

may be the result of the individual’s ability to detach him- or also more likely to have symptoms and diagnoses of conduct
herself from his or her emotions, as opposed to an inability disorder, narcissistic personality disorder, and oppositional
to actually experience emotions, as is the case with funda- defiant disorder (e.g., Murrie & Cornell, 2000). In addition,
mental psychopathy. More recent research has generated such adolescents have been found to score high on measures
some evidence in support of this existence of, and distinc- of impulsivity (Stanford, Ebner, Patton, & Williams, 1994)
tion between, primary and secondary psychopaths (Skeem, and sensation seeking (Vitacco, Rogers, Neumann, Durrant,
Johansson, Andershed, Kerr, & Louden, 2007). Further, & Collins, 2000). Research conducted in Canada revealed
another recent study that used a large sample of inmates that psychopathy has a moderate to high level of stability,
found support for dissociation as a mediator between child- with behavioural and interpersonal factors having the great-
hood maltreatment and higher PCL-R scores measuring est stability (Lee, Klaver, Hart, Moretti, & Douglas, 2009).
an impulsive and antisocial lifestyle (Poythress, Skeem, &
Lilienfeld, 2006). Thus, it is possible that psychopathy may Treatment of Psychopaths. One of the key requirements for
have its roots in biological predispositions and/or environ- successful psychological treatment is motivation on the part of
mental experiences, depending on the individual. the client. Not surprisingly, observations on the effectiveness
of treatment with psychopaths have not been encouraging
Course and Prognosis of Psychopathy. Like all personality (Hare, 1998; Lösel, 1998; Rice, 1997; Rice, Harris, & Cormier,
disorders, psychopathy is typically a lifelong condition. Pre- 1992). For example, Richards and colleagues (2003) evalu-
cursors to psychopathy emerge early in childhood as “cal- ated the role of psychopathy in treatment outcome in a large
lous/unemotional” traits (Frick, 2006; Frick, Bodin, & Barry, sample of adult female offenders. Psychopaths showed poorer
2000; Frick & Ellis, 1999; Lynam, 2002), which map closely response to substance abuse treatment in terms of noncom-
onto adult psychopathic traits (Frick, 2002; Munoz & Frick, pliance, violent and disruptive rule violations, avoidance of
2007; Salekin & Frick, 2005). As outlined by Campbell and urinalysis testing, poor treatment attendance, and low thera-
colleagues (2004; Hare & Neumann, 2009), although the pist progress ratings. Using a sample of adult male offenders,
existence of psychopathy in adults is generally accepted, Hobson, Shine, and Roberts (2000) found that higher PCL-R
the appropriateness of diagnosing psychopathy in children scores were associated with a higher incidence of misbehav-
and youths is much more controversial, with a host of ethical iours (e.g., lying, verbal outbursts) in a treatment group.
concerns. Nonetheless, it is important to focus on the pres- Despite the huge obstacles, some researchers remain
ence of psychopathic traits in this group, given their asso- optimistic that an effective intervention strategy with
ciations with specific patterns of future antisocial behaviour psychopathic individuals can be devised with further
(Forth, Kosson, & Hare, 2003). research. Skeem, Monahan, and Mulvey (2002), for example,
Campbell and colleagues (2004) note that adolescents found that longer involvement in outpatient treatment (at
with a high level of psychopathic traits are more likely to least seven sessions) reduced the risk of violence among psy-
have an earlier onset of conduct problems and to present chopathic individuals discharged from a non-forensic inpa-
with a greater variety and severity of delinquent behaviours tient setting when compared to those who received less than
(e.g., Smith, Gacono, & Kaufman, 1997). Such adolescents are seven sessions of treatment.

APPLIED CLINICAL CASE

Sophie’s Experience emotions and cognitions, especially those that follow stressful
events such as arguments with others. In addition to this, she
Sophie, now 25 years-old, was admitted to a hospital inpatient learned how to better tolerate distress, self-soothe when upset
unit following an overdose that occurred following a heated argu- and feeling alone, and to mindfully meditate. Due to her diffi-
ment with her boyfriend who she thought was leaving her. She culties communicating her feelings with others and her tendency
has significant difficulty being alone and fears being abandoned. for angry outbursts, she has also learned how to more effectively
Sophie has a history of emergency room visits due to self-injury; communicate her feelings with others. After a year of DBT, Sophie
she has been frequently brought to the hospital by her boyfriend reports only cutting herself on a few occasions and not at all in the
or friends. Sophie reports cutting or burning herself fairly regu- past several months. This represents a significant decrease from
larly to cope with anxiety and traumatic flashbacks since she was the time before her hospitalization. She also reports getting along
12 years old. She also reports feeling chronically empty and unsure better with friends and family and has not overdosed or attempted
of who she is as a person. Sophie reports being sexually abused as suicide at all since starting treatment. Although her relationship
a child by a neighbour and then bullied as an adolescent. Following with her boyfriend ended soon after her hospitalization, Sophie
a comprehensive diagnostic assessment, Sophie was diagnosed has managed to come to terms with this loss; she was able to
with borderline personality disorder. Upon release from hospital, use cognitive restructuring techniques to challenge her initial view
she began taking part in outpatient dialectical behaviour therapy that he abandoned her. While she still struggles with feelings of
(DBT). While in treatment Sophie learned how to identify different emptiness she has learned to better tolerate these experiences.

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 308 Chapter 12

Any way you look at it, adult psychopaths represent from those with lived BPD experience and interviews from
a unique group of offenders who can be expected to be experts in the field, including Marsha Linehan and Otto
resistant to treatment. According to leading researchers, Kernberg. The video can be watched on YouTube: www.you-
programs should focus on changing and managing behav- tube.com/watch?v=967Ckat7f98.
iour rather than on changing the core personality traits In addition to the aforementioned risky behaviours,
of the psychopath (Quinsey et al., 2006; Wong & Hare, is not uncommon for individuals with BPD to engage in
2005). Behaviourist techniques (e.g., token economies) that non-suicidal self-injury (NSSI; APA, 2013)—the purpose-
are strictly defined and implemented by institutional staff ful damaging of a person’s own body without lethal intent
have shown some success within institutions; however, the (Klonsky, Muehlenkamp, Lewis, & Walsh, 2011). Indeed,
gains observed within institutions may not generalize to the one BPD diagnostic criterion involves engagement in NSSI
community for many of those who are eventually released (e.g., self-cutting, burning), suicidal ideation, or suicidal
(Quinsey et al., 2006). Intense supervision in the form of behaviour, including suicide attempts. Rates of NSSI among
probation or parole is often necessary, and in some extreme those meeting criteria for BPD can be as high as 70 percent
cases preventive detention is warranted (i.e., long-term/ (APA, 2013), and are especially high in adolescent popula-
indeterminate incarceration) (Quinsey et al., 2006). Treat- tions (for a recent review, see Kaess, Brunner, & Chanen,
ment providers must be especially careful not to be deceived 2014). In addition to NSSI, most who have BPD report sui-
into perceiving progress when they are really observing a cidal ideation and many have attempted suicide. Tragically,
performance worthy of an Academy Award. about 8 to 10 percent of individuals with BPD die by suicide
(APA, 2013). For these reasons, it is critical that treatment
of BPD incorporate ongoing comprehensive risk assessment
BEFORE MOVING ON
and safety planning.
What are the key differences between psychopathy and anti- Individuals diagnosed with BPD commonly experience
social personality disorder? If you were to see a client in a emotional instability. They tend to be more emotionally
forensic setting, what symptoms or behaviours would you reactive to stressors and have difficulty regulating emo-
look for to differentiate between the two? What tools would tions (e.g., sadness, anger) when they occur. Understandably,
you use to aid in your diagnosis? emotional instability can translate into major relationship
difficulties. For example, individuals with BPD can be emo-
tionally volatile and argumentative with others (e.g., roman-
BORDERLINE PERSONALITY DISORDER tic partners, family). This can result in frequent conflicts and
Borderline personality disorder (BPD) may be one of the tumultuous, short-lived relationships. The relationships of
most poorly named personality disorders. Historically, individuals with BPD can be further impacted by the man-
the diagnostic label was meant to describe a person on the ner by which they alternate between idealizing and devalu-
border between neurosis and psychosis. Many laypersons ing their partners.
assume that the term refers to someone on the “border” of At the same time, individuals with BPD also seem
psychosis or “going crazy,” which is not typically the case. unable to tolerate being alone and can become desperate
Most people with BPD do not experience psychotic symp- about relationships. For example, they may go to extreme
toms and such views are arguably pejorative and contribute lengths (e.g., making suicidal threats) to avoid being alone.
to stigma. Indeed, there is a significant stigma associated It is important to avoid jumping to conclusions about what
with BPD; we discuss this further in the text that follows. this may connote. While these actions may be viewed as
attention-seeking and manipulative, which may make sense
DESCRIPTION OF BORDERLINE PERSONALITY DISOR- on the surface, it is important to consider these responses
DER Borderline personality disorder (BPD) can generally in the proper context. For example, such extreme reactions
be characterized by instability across various domains of often stem from difficulty knowing how to effectively regu-
personality functioning. Specifically, the hallmark features late intense feelings, fears of abandonment (which may be
of BPD are: (a) fluctuations in and difficulty regulating emo- rooted in childhood experiences), and how to appropriately
tions, (b) an unstable sense of one’s identity, (c) instability in communicate with others.
social relationships, and (d) impulsive behaviour. For exam- In addition to the typical symptoms of BPD, there are
ple, in response to intense negative emotions (e.g., anxiety, also several associated features that may or may not be pres-
sadness, anger), which are perceived as intolerable, individu- ent in all patients with the disorder. For example, individuals
als who have BPD may engage in a range of impulsive and with BPD may blame their relationship problems on others
potentially harmful acts, such as excessive spending, reckless instead of accepting any personal responsibility, and they
driving, promiscuity, and binge-eating. Unsurprisingly, this may also attempt to undermine their achievements when
can have significant consequences for those with BPD and they have nearly succeeded in reaching their goals (such
those in their lives (e.g., romantic partners, family). For an as dropping out of university shortly before graduation). In
excellent overview of BPD and its treatment, you might wish addition, some people with BPD experience psychotic-like
to watch Back From the Edge a documentary developed by the symptoms or even dissociation during times of stress. These
New York Presbyterian Hospital. It includes several stories symptoms are not usually sufficiently severe to require an

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 The Personality Disorders 309

additional diagnosis but nevertheless affect these individu- women being diagnosed with BPD 75% of the time (APA,
als’ functioning (APA, 2013). 2013). Recall, however, there are a number of consider-
ations (e.g., biases in gender expectations) that may account
BPD AND SELF-INJURY: AN IMPORTANT DISTINCTION for this.
Historically, NSSI has been viewed as a prominent feature, Another issue that has generated a fair bit of debate
and at times, even an indicator of BPD. On the one hand, this concerns the utility of a BPD diagnosis among adolescents.
is perhaps unsurprising. As noted, rates of NSSI among those While some suggest that BPD is reasonably stable over time
with BPD are high (APA, 2013), particularly among adoles- (Barasch, Frances, Hurt, Clarkin, & Cohen, 1985), Stone
cents with BPD (Kaess et al., 2014). However, it is important (1993) reported that, of patients diagnosed with BPD as
to note that NSSI is neither sufficient nor necessary for a emerging adults, only one quarter still meet diagnostic cri-
BPD diagnosis (APA, 2013; Glenn & Klonsky, 2013; Lewis & teria by middle age. This begs the question of when a BPD
Heath, 2015). Not all who meet BPD criteria will self-injure. diagnosis should be made. Adding to this debate is whether
Moreover, most who self-injure do not have BPD (for reviews we can reliably make a diagnostic decision about individuals
see Lewis & Heath, 2015; Klonsky et al. 2011). whose personality is arguably still developing. Other major
According to a growing line of research, including stud- reasons against BPD being diagnosed in adolescents pertain
ies by researchers at the University of British Columbia, to some of its key features, including affective instability or
NSSI can be meaningfully distinguished from BPD (Glenn identity, both of which are normative experiences for many
& Klonsky, 2013) and BPD symptoms (Klonsky & Olino, young people. Others have expressed concern that render-
2008). Interestingly, there is also a growing body of litera- ing a diagnosis so early may have longer-term stigmatizing
ture suggesting that NSSI may constitute its own diagnostic effects thereby shaping how others view and ultimately, how
category within the DSM—namely, NSSI disorder (APA, clinicians treat these individuals (see Chanen & McCutheon,
2013). Part of the rationale behind this effort is to avoid con- 2008; Kaess et al., 2014).
flating NSSI and BPD. Moreover, there is growing evidence Despite these concerns, a number of recent empirical
indicating that NSSI disorder is not only distinct from other studies have indicated that a BPD diagnosis in adolescence can
conditions but that many of its proposed diagnostic features be reliability and validly made (Chanen, Jovev, McCutcheon,
can be reliably and validly assessed (for a review see Selby, Jackson, & McGorry, 2008; Miller, Muehlenkamp,
Kranzler, Fehling, & Panza, 2015). & Jacobson, 2008). According to a Canadian study, this can
Another key issue warranting discussion is how others occur among youth as young as 12 to 14 years of age (Glenn
may view NSSI and those who enact it. It is not uncommon & Klonsky, 2013). Furthermore, some evidence suggests that
for NSSI and many other BPD behaviours to be viewed both adolescent and adult BPD have a similar stability in
as attention-seeking. In fact, as pointed out by Canadian course—at least after two years (Chanen, Jackson, McGorry,
researchers, such views about NSSI specifically are com- Allot, Clarkson, & Yuen, 2004). In addition, there may be
mon in across lay and clinical contexts (e.g., Lewis, Mahdy, incremental validity in the provision of a BPD diagnosis
Michal, & Arbuthnott, 2014; Muehlenkamp, Claes, Quigley in adolescents over and above other forms of mental dis-
et al., 2013). These views are unhelpful in several ways. Not order (Kaess, von Ceumern-Lindenstjerna, Parzer, Chanen
only do they fuel an unhelpful and often stigmatizing dis- et al., 2012; Chanen, Jovev, & Jackson, 2007). Perhaps
course about why people self-injure but these views are also the most compelling argument, however, stems from the
inconsistent with the voluminous body of scholarly work disorder-specific treatment of BPD and that early interven-
on NSSI. Indeed, NSSI is rarely—if ever—an attention- tion in adolescents is beneficial (e.g., Chanen & McCutheon,
seeking act. In a review of the literature by Klonsky from the 2013; Kaess et al., 2014). That is, when identified early
University of British Columbia, the most commonly cited enough with BPD, individuals tend to respond well to
reason for NSSI is to obtain relief from negative emotions BPD-specific treatments that may have prophylactic (i.e.,
that are perceived as painful and intolerable (see Klonsky, preventative) effects over the long-term.
2007). As discussed above, context when understanding
behaviour is important. If we take into account the intense ETIOLOGY OF BPD The etiology of BPD has been debated
and at times volatile emotional experiences of those who for many years, with the different views emphasizing child-
BPD, and their inability to know how to effectively chan- hood experiences, biological factors, psychodynamic pro-
nel or cope with these feelings, it is perhaps unsurprising cesses, and social learning. Certainly, the evidence strongly
that NSSI is used to obtain momentary relief from these implicates disruptions in the family of origin and childhood
experiences. It makes sense, then, that emotion regulation abuse and neglect as very significant factors in the devel-
constitutes a central focus of treating BPD, and NSSI (see opment of borderline personality disorder (Links, 1992;
Linehan, 1993; Klonsky et al., 2011). Marziali, 1992). Patients with BPD typically recall their
parents as either neglectful (Paris & Frank, 1989) or abusive
PREVALENCE, STABILITY, AND DIAGNOSTIC ISSUES (Bryer, Nelson, Miller, & Krol, 1987). Briere and Zaidi
BPD has a lifetime occurrence in approximately 2% of the (1989), in a study of 100 females seen at an emergency ser-
population (but may be as high as 5.9%). As noted earlier, vice, found that females who had been sexually abused dur-
BPD may be more common in women than in men, with ing their childhood were five times more likely to be given

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 310 Chapter 12

a diagnosis of BPD than were female patients who had not may be the result of environmental rather than genetic fac-
been sexually abused. Caution should be exercised here, tors. Torgersen (1984) found no support for a genetic contri-
however, to not assume causality; past abuse is a non-specific bution to the development of either BPD or schizotypal PD
risk factor for myriad mental health difficulties (e.g., PTSD, in a study of Norwegian twins, but the number of partici-
depression)—not just BPD. pants was very small.
Despite problems with determining the accuracy of Linehan’s (1987, 1993) biosocial theory describes BPD
traumatic childhood recollections (e.g., Loftus, 2003; Porter, primarily as dysfunction of the emotion regulation system.
Yuille, & Lehman, 1999), the findings to date suggest that According to the theory, people with BPD have a biologi-
attachment problems with parents may be an etiological cally predisposed difficulty in regulating their own emo-
factor in BPD. Patients with BPD have significant difficul- tions. Individuals who are biologically vulnerable may
ties with adult relationships, and this may be understood to include those who experience emotional reactions more
result from a fear of, or ambivalence about, intimacy. People intensely, those who are more sensitive to various emotional
who have problems with adult intimacy are considered to stimuli, or those who take longer to return to a baseline level
have developed these difficulties as a result of poor parent– of emotional arousal after an emotional reaction. This vul-
child attachments (Berman & Sperling, 1994), which fail nerability interacts with exposure to a pervasively invalidat-
to instill the self-confidence and skills necessary for effec- ing environment (i.e., one that minimizes, rejects, blames,
tive intimacy (Bartholomew, 1989) and fail to provide an or attributes pejorative characteristics to an individual’s
adequate template for adult intimate relationships (Bowlby, responses) to result in an emotionally dysregulated system
1988). For example, many adults who as children had poor that is believed to underlie the aforementioned symptoms.
relationships with their parents have an interpersonal style Treatment for BPD is often challenging because the etiology
that is described as anxious ambivalent. These adults often of the disorder is still largely unclear (Paris, 2009).
harbour intense fears of abandonment but they strongly
desire intimacy with others and, consequently, persistently TREATMENT OF BPD Dialectical behaviour therapy
seek out romantic partners. However, once they begin to get (DBT), developed by Marsha Linehan (Linehan & Heard,
close to their partner, they become anxious and begin to back 1992), has attracted major international attention in the
away from the relationship. While they desire closeness, they treatment of BPD. Originally developed as a treatment for
appear to be afraid of it. This is precisely the relationship women who engaged in self-injury and suicidal behaviours
style that characterizes borderline patients. The features of (Robins & Chapman, 2004), the approach has been tailored
BPD may then be seen as attempts to adjust to their desire to patients with BPD, although its application has been
for, but distrust of, intimacy. expanding. One of the main features of this approach is
Murray (1979) has suggested an association between the acceptance by the therapist of the patient’s maladaptive
minimal brain dysfunction and the development of BPD. and at times self-destructive behaviours (Linehan, et al.,
He proposed that the distorting effects of minimal brain 2001). In addition, several standard behavioural procedures
dysfunction on perceptual processes may interfere with are used, such as exposure treatment for the external and
effective parent–child relationships and that these effects internal cues that evoke distress, skills training (e.g., dis-
may continue to disrupt relationships throughout the lifes- tress tolerance, mindfulness, interpersonal effectiveness),
pan. According to Murray, confused perceptions, emotional contingency management (i.e., use of positive reinforce-
instability, and poor impulse control typical of minimal brain ment for desired behaviour), and cognitive restructuring.
dysfunction may lead to BPD behaviour. A recent study The dialectical process describes “both the coexisting
that examined the brains of individuals with BPD revealed multiple tensions and the thought processes and styles
that these individuals have significantly reduced right hip- used and targeted in the treatment strategies” (Linehan &
pocampal volumes compared to healthy participants (Sala Heard, 1992, p. 249).
et al., 2011). A similar study found that individuals with BPD According to Robins and Chapman (2004), DBT is the
also have reduced volumes of grey matter in the dorsolateral only outpatient psychotherapy that has been shown to be
prefrontal cortex (DLPFC) (Brunner et al., 2010). The hip- effective with patients with BPD. Linehan and colleagues
pocampus and the DLPFC both play a pivotal role in the (1991) compared the treatment outcome of 22 female
sustaining and controlling (or lack thereof) of impulsive and patients with BPD assigned to DBT with 22 patients who
aggressive behaviour (Bellani et al., 2010; Sala et al., 2011). were provided with “treatment as usual.” At the end of one
Research investigating this claim has generally supported year of treatment, those assigned to DBT had made fewer
the idea that a subset of individuals with BPD have soft neu- suicide attempts and had spent less time in hospital than
rological signs (Marziali, 1992), but the evidence is far from those allocated to the other treatment program. An impor-
convincing at this time. tant additional observation was that while only 17 percent
Available evidence suggests a relatively high incidence of the patients treated with DBT dropped out, almost 60
of BPD features in the first-degree relatives of patients with percent of the other group withdrew prior to treatment ter-
BPD (Links, 1992); this has been taken by some to suggest mination. Although both groups displayed less depression
familial transmission of the disorder (Baron, Risch, Levitt, & and hopelessness after treatment, there were no group dif-
Gruen, 1985). Of course, familial transmission of a disorder ferences on these measures.

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 The Personality Disorders 311

Linehan and colleagues (2006) reported the results of

a two-year randomized controlled trial (101 women) for
suicidal behaviours and BPD comparing DBT to therapy
provided by experts. Compared to the therapy provided by

Classic Image/Alamy Stock Photo

the experts not using DBT, patients who received DBT were
half as likely to make a suicide attempt, made fewer visits to
psychiatric emergency departments, required less hospital-
ization for suicidal thoughts, and were less likely to drop out
of treatment. A more recent study with a Canadian sample
compared the effectiveness of DBT to general psychiatric
management among individuals with BPD (McMain et al.,
2009). The results of this study demonstrate that both DBT According to Greek myth, the beautiful youth Narkissos fell in love
and general psychiatric management significantly reduced with his own reflection in a spring; to punish him for his excessive
common symptoms of BPD, including psychological dis- self-love, the gods transformed him into the flower called the
tress, degree of suicidal ideation and behaviour, and health narcissus.
care utilization (Linehan et al., 2001).
is the staple characteristic of these individuals. If you were to
BEFORE MOVING ON have a conversation with someone who has NPD, you would
quickly get the impression of “me me me,” with every topic
What are the four main areas of instability in BPD? What somehow being turned to the person’s own greatness. They
are the most common reasons for non-suicidal self-injury? Do are so preoccupied with their own interests and desires that
you think that BPD should be diagnosed in adolescent popu- they typically have difficulty feeling any concern for others;
lations? Why or why not? What do you think is the strongest
this can mirror the empathy deficit seen in ASPD or psy-
theory to explain the development of BPD?
chopathy. However, unlike these latter conditions, individu-
als with NPD are easily hurt by any perception that their
HISTRIONIC PERSONALITY DISORDER greatness is not being recognized. Similarly, their self-esteem
is readily shattered by negative feedback from others, pre-
People with histrionic personality disorder (HPD) can some-
sumably because they desire only admiration and approval.
times be “the life of the party.” Indeed, attention-seeking
This is commonly referred to as the narcissistic paradox. The
behaviours tend to characterize people with this disorder. In
self-absorption of these patients frequently leads to an obses-
fact, there seems to be little that someone with HPD will
sion with unrealistic fantasies of success. They expect, and
not do to solicit attention. They are overly dramatic in their
demand, to be treated as “special.” This, coupled with a lack
emotional displays, self-centred, and constantly attempting
of empathy, leads them to exploit others to serve their own
to be the centre of attention. They may dress provocatively
needs. Like those with HPD, the actions of those with NPD
and be overly sexual in inappropriate contexts such as a job
alienate others. Thus, these individuals are frequently lonely
interview. The flamboyant displays of individuals with HPD
and unhappy. When frustrated or slighted, they can become
are apparently intended to make others focus on them, as
vengeful and verbally or physically aggressive.
they seem unable to tolerate being ignored. Indeed, they
Ronningstam and Gunderson (1990) claim that research
may become quite annoyed if another person in a group
has validated these features as characteristic of NPD. How-
setting receives more attention than they do. These indi-
ever, while Morey (1988) reported a remarkable increase
viduals may also over-react to what others would normally
(from 6.2 percent of patients to 22 percent) in the application
consider insignificant events. Their insincerity and shal-
of the diagnosis from DSM-III to DSM-III-R, others found
lowness, however, make it difficult for them to hold other
no cases of NPD in a sample of 800 community participants
people’s attention for long. As a consequence, they typically
(Zimmerman & Coryell, 1990). When NPD is diagnosed,
have few friends. Because of their strong need for attention,
there is considerable overlap with BPD (Morey, 1988).
they tend to be very demanding and inconsiderate, and not
Although encountering an individual with NPD is rare,
surprisingly, their relationships are often short-lived and
one of the authors of this chapter recently experienced the
tumultuous. Again, as a result of their need to be the centre
behaviour of a narcissist while completing a practicum in a
of attention, these individuals are often flirtatious, and seem
forensic setting. During the brief consultation, the individual
unable to develop any degree of deep intimacy in relation-
displayed all the characteristic personality traits associated
ships. Their behaviour causes considerable distress to them-
with narcissistic personality disorder, including grandiosity,
selves and to others with whom they become involved.
egocentricity, and an elevated sense of self-importance. Spe-
cifically, the individual paid very little attention to the profes-
NARCISSISTIC PERSONALITY DISORDER sional during the interview. While this individual was being
Patients who are narcissistic are grandiose and consider them- questioned about a previous offence and his current progress,
selves to have unique and outstanding abilities. They have an he assumed superiority and spoke in a condescending manner
exaggerated sense of self-importance; indeed, egocentricity to the interviewer. Further, the individual spent the majority of

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 312 Chapter 12

the consultation answering text messages on his phone; when fears cause many problems for individuals with APD, includ-
he did acknowledge the professional, he was extremely patron- ing disrupted interpersonal relationships as well as severely
izing. By behaving in this way, the individual revealed his restricted job options, academic pursuits, and leisure activi-
strong feelings of superiority and high levels of egocentricity. ties. Their avoidance of intimacy also distresses other people
With the increasing popularity of the internet and social who may wish to form a close relationship with them.
media, research has begun to focus on the types of individu- People with more avoidant personality styles have been
als most likely to use these media outlets. One such study documented in the literature well before their inclusion in the
revealed that a high degree of narcissism was related to context of APD. For instance Karen Horney (1945) noted that
increased overall internet use (Mehdizadeh, 2010). Specifi- there were people who found interpersonal relationships of
cally, narcissistic individuals used social networking sites to any kind to be such an intolerable strain that “solitude becomes
promote themselves and were most likely to change their primarily a means of avoiding it” (p. 73). Millon (1969) was
photos, write status updates, and write notes. A similar study the first to use the term avoidant personality to describe people
discovered that individuals who possess a high number of who actively avoided social interactions. He suggested that
narcissistic traits displayed more self-promoting and sexy children rejected by their parents would lack self-confidence
images of themselves on their Facebook profiles (DeWall, and would, as a consequence, avoid others for fear of further
Buffardi, Bonser, & Campbell, 2011). Although personality rejection (Millon, 1981). This notion fits with the extensive
disorders are characterized as egosyntonic, a recent review of literature on parent–child attachments and the consequences
narcissism across a wide range of traits revealed that individ- of parental rejection for adult relationships. While some chil-
uals high in narcissism are often aware that others perceive dren with poor parental bonds develop an anxious/avoidant
them less favourably than they perceive themselves, that they relationship style, others grow up to be so afraid of intimate
are able to make positive first impressions that eventually relationships that they become avoidant of any depth in what-
deteriorate, and that they do appear to have some insight into ever relationships they form. These are just the characteristics
their narcissistic traits (Carlson, Vazire, & Oltmanns, 2011). that identify avoidant personality clients.
Some researchers found considerable overlap between
BEFORE MOVING ON avoidant personality disorder and dependent disorder (e.g.,
Trull, Widiger, & Frances, 1987) while others have reported
What are the general themes of each of the three personality overlap with BPD (Morey, 1988), previously described.
disorder clusters? Define each of the DSM-5 personality dis- There is also a problem differentiating avoidant disorder
orders and explain some of the key symptoms. How are histri- and social phobia. Indeed, there is considerable overlap
onic personality disorder and narcissistic personality disorder
between these conditions (Turner, Beidel, Dancu, & Keys,
different? How are they similar?
1991) with some researchers indicating they only differ in
symptom severity (Cox, Pagura, Stein, & Sareen, 2009; Holt,
Cluster C: Anxious and Fearful Heimberg, & Hope, 1992).

Disorders
DEPENDENT PERSONALITY DISORDER
Although avoidant and dependent personality disorders
People with this condition appear to be afraid to rely on
appear to share anxieties and fears as primary features,
themselves to make decisions. They seek advice and direc-
obsessive-compulsive personality disorder seems to be char-
tion from others, need constant reassurance, and seek out
acterized more by a preoccupation with orderliness and rules.
relationships in which they can adopt a submissive role. Not
Again, there seems to be little value in clustering these disor-
only do they allow other people to assume responsibility for
ders in the same category. Information regarding etiology and
important aspects of their lives, but also seem to desperately
effective intervention specific to these disorders is sparse.
need to do so. They seem unable to function independently,
and typically ask their spouse or partner to decide what job
AVOIDANT PERSONALITY DISORDER they should seek or what clothes they should purchase; they
Avoidant personality disorder (APD) is characterized by a tend to defer to others for most, if not all, of the decisions
pervasive pattern of avoiding interpersonal contacts and an in their lives. Individuals with dependent personality disor-
extreme sensitivity to criticism and disapproval. Individuals der (DPD) subordinate their needs to those of other people,
with APD tend to avoid intimacy with others, although they even people they hardly know. This may lead to involvement
clearly desire affection (unlike schizoid personality disorder). in abusive relationships or destroy relationships with part-
As a result, they frequently experience terrible loneliness. ners who could be beneficial to them.
While social discomfort and a fear of negative evaluation Reich (1990) observed that the relatives of male patients
are commonly experienced, the fundamental fear of those with this disorder were likely to experience depression,
with APD is social rejection. These individuals restrict social whereas the relatives of female dependents were more likely
interactions to those they trust not to denigrate them; how- to have panic disorder. Relatedly, individuals with panic
ever, even with these people, they refrain from getting too disorder have been found to have comorbidity with various
close for fear of ultimate rejection. Understandably, these personality disorders, including DPD (Johnson, Weissman,

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 The Personality Disorders 313

& Klerman, 1990). As discussed earlier, it is critical to con-

BEFORE MOVING ON
sider cultural context when diagnosing personality disor-
ders. This is especially true with DPD, which is arguably How does obsessive-compulsive personality disorder differ
the most culture-laden of the personality disorders. Specifi- from obsessive-compulsive disorder? What differences would
cally, DPD is rooted in the individualistic culture of North you expect to see in the symptoms of clients with each of
America, but is not as prevalent in collectivist cultures these disorders, and how would their treatment plans differ?
(Chen, Nettles, & Chen, 2009).

Treatment
OBSESSIVE-COMPULSIVE PERSONALITY
DISORDER There are numerous obstacles to providing effective treat-
ment to clients with personality disorders. As Gorton and
Major features of obsessive-compulsive personality disorder Akhtar (1990) observed, two important factors make it dif-
(OCPD) include inflexibility and a desire for perfection. It is ficult to evaluate treatment with the personality disorders:
the centrality of these two features, and the absence of obses- (1) many of these patients are not themselves upset by their
sional thoughts and compulsive behaviours, that distinguish characteristic personality style and so do not seek treat-
this personality disorder from obsessive-compulsive disor- ment, and (2) the dropout rates from treatment among these
der (discussed in Chapter 5). Preoccupation with rules and patients is extremely high. Because individuals with person-
order makes these patients rigid and inefficient as a result of ality disorders have difficulties in their relationships, this
focusing too much on the details of a problem. Individuals understandably translates into difficulties forming and main-
with OCPD also attempt to ignore feelings, since they con- taining a strong therapeutic alliance in therapy. For some
sider emotions to be unpredictable. They tend to be moralis- clients, the treatment context itself is a barrier to treatment.
tic and judgmental, which can contribute to difficulty when For example, treatment provided to an individual with ASPD
dealing with other individuals. or psychopathy tends to be court-ordered or provided in
Knock, knock, knock, Penny? A popular example of a tele- prison. This is likely not the best environment for developing
vision character with many features of OCPD is Dr. Sheldon a trusting therapeutic alliance. In addition, many individuals
Cooper, played by Emmy winner Jim Parsons, on The Big with personality disorders have problems maintaining focus
Bang Theory. Sheldon demonstrates many of the traits asso- on the therapeutic process between sessions. Even when the
ciated with OCPD, including a preoccupation with details, focus in treatment is on another condition, those patients
lists, rules, and order (i.e., his strict adherence to eating who also have a personality disorder do more poorly (Reich
specific take-out meals depending on the day of the week), & Green, 1991). In recent years, however, far more effort has
rigidity and stubbornness (i.e., his insistence that he is the been devoted to developing treatment programs specifically
only individual who is allowed to sit on the left side of the for these patients, although to date outcome data are limited.
couch), and his unreasonable insistence that others submit According to Sperry (2003), five basic premises are essen-
exactly to his way of doing things (i.e., the roommate agree- tial to achieving effective treatment outcomes with patients
ment). Although Sheldon has never been officially diag- diagnosed with a personality disorder: (1) these disorders are
nosed with OCPD, and often claims on the show “I’m not best conceptualized in a way that considers both biological
crazy. My mother had me tested,” he does provide an excel- and psychological factors, and the more effective treatment
lent example of several of the behaviours that would often will reflect this approach, (2) before treatment, it is important
characterize OCPD. to assess the individual’s amenability to treatment, (3) effec-
Since the DSM-III-R, very little research has been tive treatment is flexible and tailored to the individual client,
published on OCPD. The exception to this is the research (4) the lower the level of treatability in the client, the more
alluded to above that distinguishes OCPD and OCD. Stud- the therapist must combine multiple treatment approaches,
ies using objective measures have found a clear indepen- and (5) the basic goal of treatment should be to help the client
dence between these two conditions. However, when using improve in his or her overall level of functioning. Now, we
projective techniques or clinical interviews, co-occurrence discuss some of the major approaches used in the treatment
of the two disorders has been reported (Cawley, 1974; Slade, of personality disorders. These are consistent with Sperry’s
1974). In fact, in one study found that other personality dis- recommendations, and include (1) object-relations therapy,
orders (e.g., avoidant, dependent, schizotypal PDs) were (2) cognitive-behavioural approaches, and (3) medication.
more likely to co-occur with OCD than was OCPD (Joffe,
Swinson, & Regan, 1988). More recently, researchers have
revealed that OCPD is not phenomenologically different OBJECT-RELATIONS THERAPY
from OCD, and that OCPD is simply a marker of obsessive- Leading proponents of an object-relations approach have
compulsive severity (Lochner et al., 2011). Furthermore, been Kernberg (1975) and Kohut (1977). In their view, treat-
Garyfallos and colleagues (2010) discovered a high rate of ment should be aimed at correcting the flaws in the self
comorbidity between OCD and OCPD and suggested that that have resulted from unfortunate formative experiences
individuals with both of these disorders should constitute a (e.g., childhood abuse or neglect). The relationship between
subtype of OCD. patient and therapist serves as a vehicle for confronting, in a

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 314 Chapter 12

supportive way, the patient’s defences and distortions. This Canadian therapist Ariel Stravynski and his colleagues
process is slow and, if successful, produces gradual changes. (Stravynski, Lesage, Marcouiller, & Elie, 1989) have applied
Thus, treatment is seen as necessarily long term. In the behavioural approaches employing social skills training
only controlled evaluation of this approach, Stevenson and and desensitization to the problems of patients with avoid-
Meares (1992) treated 30 patients with BPD, and followed ant personality disorder. However, the benefits of these
them up for one year. At follow-up, 30 percent of the patients programs have not been evaluated at long-term follow-up,
no longer met DSM criteria for BPD. Single-case reports and Alden (1989) observed that most of the treated patients
of similar treatment programs for NPD have also yielded remained socially uncomfortable.
encouraging results (Kinston, 1980), but more extensive and
more rigorous evaluations are required to determine the
PHARMACOLOGICAL INTERVENTIONS
true value of this approach.
Patients with BPD have been treated using a variety of
pharmacotherapy treatments, including antidepressants
COGNITIVE-BEHAVIOURAL APPROACHES (e.g., SSRIs, tricyclics, MAOIs), mood stabilizers (e.g., lith-
Dr. Aaron Beck and his colleagues have extended his cogni- ium carbonate), anxiolytics (e.g., anti-anxiety medications),
tive analyses to the personality disorders and suggested that opiate antagonists, and neuroleptics. These pharmaco-
treatment must correct the cognitive distortions of these logical agents have varying degrees of effectiveness (APA,
patients in order to be successful (Beck Davis, & Freeman, 2001). Overall, patients with BPD have been successfully
2015). Beck’s treatment is directed at challenging the core treated with some level of success when using medications
beliefs that are thought to underlie the difficulties that peo- such as amitriptyline (an antidepressant), thiothixene and
ple with personality disorders experience. This approach is olanzapine (both antipsychotics), and carbamazepine and
referred to as cognitive restructuring, and is the basis for lamotrigine (both anticonvulsants). Depending on symptom
change, along with skills training and behavioural practices presentations, some people with BPD may be differentially
(see Chapter 17). To date, however, adherents of this prom- responsive to either antipsychotic or antidepressant medi-
ising approach have not produced controlled evaluations. cations. For instance, in one study, researchers found that
This appears to be at least partly explained by the relatively antipsychotics were most effective among individuals with
recent development of this approach and the claim by Beck BPD who also displayed psychotic-like features (Goldberg
and colleagues (1990) that, unlike the application of cog- & colleagues, 1986). In another study, antidepressants were
nitive therapy to other difficulties (e.g., major depression), found to yield significant improvements for those with BPD
treatment of personality disorders will take far longer. and major depression (Cole et al., 1984). Finally, Reich and
Schema therapy, developed by Jeffrey Young (Young, colleagues (2009) found that anticonvulsants were effective
1999; Young et al., 2003), involves a cognitive-behavioural at reducing affective instability and impulsivity in individu-
approach to the treatment of personality disorders; however, als with BPD.
it also incorporates gestalt, object-relations, and psychody- As for other personality disorders, Goldberg and
namic treatment techniques while placing a heavy emphasis colleagues (1986) found low doses of thiothixene to be
on clients’ early difficult life experiences and on their cur- beneficial for those with schizotypal PD. These individu-
rent therapeutic relationship. A review of treatment efficacy als also seem to respond to antidepressants (Markovitz
for personality disorders suggests that CBT significantly et al., 1991); however, the benefits of any medications
reduces symptoms and enhances outcomes for all the person- with this personality disorder are modest at best (Gitlin,
ality disorders (Matusiewicz, Hopwood, Banducci, & Lejeuz, 1993). Medication has been used with those with ASPD
2010). A randomized trial of schema-focused therapy (SFT) for short-term management of problematic and threaten-
versus transference-focused therapy (TFT) for 88 patients ing behaviour. However, long-term side effects, lack of
with severe BPD symptomatology demonstrated that SFT symptom alleviation, and noncompliance indicate that
patients had a significantly lower dropout rate compared to this approach has, at best, a modest impact. In combina-
TFT patients over three years (27 percent versus 50 percent) tion with other intervention strategies, however, it may
and that SFT patients showed greater improvements on all prove helpful.
clinical and quality-of-life measures administered compared
to TFT patients (Giesen-Bloo et al., 2006).
BEFORE MOVING ON
Dialectical Behaviour Therapy (DBT), described above
and also rooted in CBT, has been adapted for use with a vari- Many patients who have a personality disorder do not believe
ety of conditions beyond BPD (e.g., eating disorders, atten- that there is anything wrong with them. Do these patients
tion deficit/hyperactivity disorder, depression). However, exhibit egosyntonic or egodystonic symptoms? Considering
little is known about its efficacy with these conditions (Robins the various forms of treatments that are available, which
& Chapman, 2004). Similarly, even though its use has been would be most effective for dealing with this type of patient,
expanded, to date no work on the application of DBT to other and how would you attempt to deal with his or her resistance?
personality disorders has been published despite reason to How might this method differ from treatment of other major
mental illnesses (e.g., schizophrenia, bipolar disorder)
believe it may have utility for other personality disorders.

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 The Personality Disorders 315

CANADIAN RESEARCH CENTRE

Dr. Robert Hare

Dr. Robert Hare is emeritus profes- Center (CASMIRC), and is a member of
sor of psychology, University of British the FBI Serial Murder Working Group.
Columbia, where he has taught and con- He was also a member of the advisory

Photo by Scott McCall. Courtesy of Dr. Robert Hare

ducted research for some 35 years, and panel established by Her Majesty’s Prison
president of Darkstone Research Group Service to develop new programs for the
Ltd., a forensic research and consulting treatment of psychopathic offenders. His
firm. He has devoted most of his academic current research on psychopathy includes
career to the investigation of psychopa- assessment issues, developmental fac-
thy, examining its nature, assessment, tors, neurobiological correlates, risk for
and implications for mental health and recidivism and violence, and the develop-
criminal justice. He is the author of sev- ment of new treatment and management
eral books, including Without Conscience: strategies for psychopathic offenders.
The Disturbing World of the Psychopaths More recently, Dr. Hare has extended
Among Us, and more than 100 scientific the theory and research on psychopathy
articles on psychopathy. He developed the to the business and corporate world with
Psychopathy Checklist–Revised (PCL-R) the development of the B-Scan-360, an
and co-authored its derivatives, the Psy- instrument used to screen for psycho-
chopathy Checklist: Screening Version, pathic traits and behaviours. Psychology; the Isaac Ray Award, pre-
the Psychopathy Checklist: Youth Version, Dr. Hare continues to lecture widely sented by the American Psychiatric
the Antisocial Process Screening Device, on psychopathy and on the use and mis- Association and the American Academy
and the P-Scan (for use in law enforce- use of the PCL-R in the mental health and of Psychiatry and Law for Outstand-
ment). Dr. Hare’s assessment tools are criminal justice systems. Among his most ing Contributions to Forensic Psychiatry
used in every developed country. In recent awards are the Silver Medal of the and Psychiatric Jurisprudence; and the
addition to his extensive research activi- Queen Sophia Centre in Spain; the Cana- B. Jaye Anno Award for Excellence
ties, he consults with many law enforce- dian Psychological Association Award for in Communication, presented by the
ment agencies, including the FBI and Distinguished Applications of Psychol- National Commission on Correctional
the RCMP, sits on the Research Advisory ogy; the American Academy of Foren- Health Care. He was also made an affili-
Board of the FBI Child Abduction and sic Psychology Award for Distinguished ate member of the International Criminal
Serial Murder Investigative Resources Applications to the Field of Forensic Investigative Analysis Fellowship.

The Future of Personality Disorders in the DSM. Although In addition to the removal of four of the personality
the DSM-5 was published in 2013, the APA already is con- disorders, a change to the way in which clinicians diagnose
sidering changes to the personality disorders section for personality disorders also has been proposed. Since the first
future versions. Specifically, the DSM-5 includes a proposal version of the DSM, the diagnosis of personality disorders,
for a new method of assessing personality disorders in Sec- much like all conditions, has been categorical; individu-
tion III, Emerging Measures and Models. There are a num- als have to meet a certain number of the criteria to reach
ber of reasons for the personality disorders to be revised, the cut-off to be diagnosed with a personality disorder.
including the excessive co-occurrence of personality disor- The proposed change is to shift to a hybrid dimensional-
ders and comorbidity among various clinical disorders, the categorical model for personality disorders and personal-
poor temporal stability of diagnoses, and the use of arbitrary ity disorder assessment. This shift will involve a completely
thresholds for diagnosis (Bornstein, 2011). After a thorough new method for diagnosis, replacing the categorical method
review of the personality disorder literature, the workgroup with a measure of self- and interpersonal functioning, as
responsible for suggesting amendments to the diagnosis of well as a continuum of personality traits. Clinicians will
personality disorders decided that four of the current per- have to assess a client’s overall personality functioning by
sonality disorders should be removed from the DSM com- assessing self-functioning, characterized by impairments
pletely: schizoid personality disorder, histrionic personality in identity and self-direction, and interpersonal function-
disorder, paranoid personality disorder, and dependent per- ing, characterized by impairments in empathy and intimacy.
sonality disorder. To account for the personality disorders Similar to the current model, clinicians must also assess
that will be removed, a “Personality Disorder Trait Speci- whether the client possesses the pathological personality
fied” (PDTS) category has been proposed. traits associated with the personality disorder in question.

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 316 Chapter 12

It is expected that this shift to a dimensional-categorical BEFORE MOVING ON

model will reduce the amount of concurrent personality
disorders and comorbidity with other major mental ill- Considering what you now know about personality disorders,
nesses (Samuel, Lynam, Widiger, & Ball, 2011). While the what do you think of the hybrid model proposed for future
proposed revisions to the model of personality disorders versions of the DSM? Do you agree with the proposed dele-
were not accepted for the first version of the DSM-5, this tions of four of the current personality disorders? Why or why
not? Do you think personality disorders should be conceptu-
model is currently being tested and will likely be imple-
alized using a more dimensional approach? Why or why not?
mented in future versions of the DSM.

SUMMARY
● Personality disorders comprise maladaptive personality as well as overlap among these disorders. Further, many
traits. All people have relatively consistent characteris- have argued that the diagnostic criteria reflect cultural
tics that make up their personality. Personality disorders and gender bias, although this is not conclusive.
are distinguished from normal personality traits by being ● The essential feature of ASPD is a pervasive, ongoing
rigid, maladaptive, and monolithic. People with person- disregard for the rights of others. Special diagnostic
ality disorders typically have many intact abilities but issues and confusion over prevalence and research out-
have impaired functioning (especially socially) because comes arise because ASPD is similar in some respects
of their disorder. Personality disorders (i.e., psychopathy to the related construct of psychopathy. The latter, as
or APD) were first clearly described in the early nine- measured by PCL-R, focuses on core emotional and
teenth century. The present set of personality disorders interpersonal processes as well as behaviour, whereas the
first appeared in DSM-III as Axis II, separate from the DSM-5 criteria for ASPD are largely behavioural. Social
Axis I “clinical” disorders. While the same set of person- and family factors have been cited as etiological factors
ality disorders is included in the DSM-5, the multi-axial for ASPD; there is some support for genetic factors as
system is no longer used in the current version of the well. Studies have shown that psychopaths are at high
DSM, and the personality disorders are now included in risk for future violence and that treatment outcomes are
Section II of the manual. generally poor. BPD is characterized by fluctuations in
● Personality disorders are more rigid and often more mood (emotional instability), an unstable sense of iden-
difficult to treat than are other major mental disorders. tity, instability in relationships, and behavioural instabil-
Other mental disorders (e.g., schizophrenia, bipolar ity (impulsivity). Diagnostic criteria are still debated for
disorder) are primarily considered to be egodystonic several disorders. Disruptions in the family of origin are
because they cause distress and are viewed as problem- the most common etiological explanation. Treatment for
atic by the individual sufferer. Personality disorders personality disorders in general is difficult to evaluate,
are often considered to be egosyntonic. In fact, most because many patients never seek treatment. Among
individuals diagnosed with personality disorders do not the main approaches used those rooted in cognitive-
report experiencing any distress in interpersonal rela- behavioural theory, though medications are also used.
tions or daily functioning (with exceptions, of course, There are few well-controlled studies of any treatments
e.g., borderline personality disorder, avoidant personality for most of these disorders.
disorder). It is often the family and friends of an indi- ● Obsessive-compulsive personality disorder and the
vidual with a personality disorder who seek help for the more commonly known obsessive-compulsive disor-
individual, because those closest to the individual most der are distinct constructs. OCD can be found in the
often feel the effects of personality disorders. Obsessive-Compulsive and Related Disorders section,
● The DSM-5 lists 10 disorders, grouped into three clus- whereas OCPD is listed under the Personality Disorders.
ters: odd and eccentric disorders (paranoid, schizoid, These disorders can be distinguished by the symptoms
schizotypal); dramatic, emotional, or erratic disorders displayed; due to these differences, OCD and OCPD
(antisocial, borderline, histrionic, narcissistic); and require different interventions.
anxious and fearful disorders (avoidant, dependent, ● Etiological explanations have focused on psychodynam-
obsessive-compulsive). It also lists two other disorders: ics, attachment theory, cognitive-behavioural perspectives,
“Personality change due to another medical condition” and, most recently, biological factors such as genetics,
and “other specified personality disorder and unspeci- neurotransmitters, or brain dysfunction. Unfortunately, the
fied personality disorder.” Personality disorder diagnoses majority of the data are correlational. Of the 10 DSM-5
tend to have lower reliability than those of other major disorders, APD has received the bulk of research attention
mental disorders, and there is considerable comorbidity due to the harm caused by those with the disorder.

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 The Personality Disorders 317

● The DSM-5 includes two chapters on the personality specified. The DSM-5 authors have also proposed to
disorders, the first in Section II and the second in Sec- change the model used to diagnose personality disorders
tion III. The criteria set forth in Section II are those from categorical to a hybrid dimensional-categorical
that are currently being implemented. The chapter in model. This shift will involve a completely new method
Section III proposes drastic revisions to the personality for diagnosis, replacing the categorical method with a
disorders chapter, including abolishing four of the exist- measure of self and interpersonal functioning, as well as
ing personality disorders (schizoid personality disorder, a continuum of personality traits. It is unknown when
histrionic personality disorder, paranoid personality this new model of assessing personality traits will be
disorder, and dependent personality disorder), as well implemented but it will likely be included in revisions of
as adding a new diagnosis of personality disorder trait the DSM-5.

KEY TERMS
anxious ambivalent (p. 310) egodystonic (p. 293) polythetic (p. 302)
attachment theory (p. 297) egosyntonic (p. 293) prevalence (p. 292)
clusters (p. 291) emotional responsiveness (p. 299) psychological autopsy (p. 292)
cognitive restructuring (p. 314) fearlessness hypothesis (p. 302) psychopaths (p. 300)
comorbidity (p. 295) instability (p. 308) responsivity factor (p. 304)
delusions (p. 299) oppositional behaviour (p. 303) sociopaths (p. 300)
dialectical behaviour therapy (p. 310) overlap (p. 295) suspiciousness (p. 299)
eccentricity (p. 300) personality disorders (p. 290) traits (p. 290)

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