Module 6
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Module 6: Individual Differences: Personality and Psychopathology
Monday, June 17 – Sunday, June 23

Required Reading/Viewing:

Principles of Psychology, Chapters 12 and 13 (Pages 502-516; 521-538; 549-563; 568-572)

Module 6 online content

Discussions:	
Module 6 Discussion

Initial responses due Thursday, June 20, 9:00 AM ET
Two peer response due Sunday, June 23, 9:00 AM ET
Leader response due Tuesday, June 25, 9:00 AM ET
Assignments:	None
Assessments:	None
Live Classrooms:	Monday, June 17, 7:30–9:00 PM ET
Activity:	Complete Module 6 Review and Reflect, due Monday, June 24, 11:59 PM ET
Welcome to Module 6

cas_ps101_19_su2_mtompson_mod6 video cannot be displayed here. Videos cannot be played from Printable Lectures. Please view media in the module.

Learning Objectives

Describe the epidemiology of mental health disorders, including overall prevalence of disorders, the most common disorders, and overall differences between men and women.
List symptoms of schizophrenia.
List symptoms of depression.
List symptoms of mania.
Describe the vulnerability-stress model and give examples of particularly important types of stressors for depression.
List three providers of mental health services and the differences in their training.
Describe three major approaches to the treatment of mental health disorders.
Compare and contrast the legal notions of “competence” and “insanity.”
Abnormal Psychology
Defining Mental Disorders

In this area of psychology, we are interested in understanding how mental disorders display themselves, how they emerge, what factors determine them, and how to best treat them.

A psychological disorder, or mental disorder, is a pattern of behavioral and psychological symptoms that either (a) impairs one’s ability to function in important areas of life AND/OR (b) causes significant distress. I want you to remember this definition. One can be “odd” and certainly not have a mental disorder. It needs to be a pattern of behavior, and it needs to involve impairment in functioning or significant distress (or both).

cover of the DSM book
The DSM-5 is the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, a book published by the American Psychiatric Association (APA) that lists current diagnoses of psychological disorders and describes them. It’s helpful in that it provides a common language to help professionals communicate and provides guidelines for making diagnoses. It helps convey information between professionals and it helps us study mental disorders by operationalizing them for research.

Epidemiology of Mental Disorders

So how common are mental disorders? Well, there’ve been a number of large epidemiologic studies. An epidemiologic study investigates how prevalent (how common) a problem is in a particular population or society and what some of the risk factors might be (at a population level). There are many large epidemiological studies to examine heart disease, diabetes, and many other health conditions. There have also been some large epidemiologic studies of mental disorders in a number of countries. So here are some surprising findings from those studies. First, mental disorders are quite prevalent. Approximately 50% of people will experience a mental health disorder in their lifetimes. Do you find this surprising? There’s such a range of mental health problems, substance use problems (including what we used to call addictions), depression, anxiety, and a host of others. It should be noted that available data suggest that rates of mental health disorders went UP during the COVID-19 pandemic. Please click on the image below to see clearly the extent of some mental health problems in the United States.

Please click the image to view the complete infographic.
Source: NAMI
At least in the United States addictions are among the most common, as are depression and anxiety. Schizophrenia, which I’ll talk about more about later, is a much less common mental health problem. Second, most people with a mental health problem about 80% do not receive any treatment from a mental health professional! That’s a lot of people. So why don’t people get treatment?  Well, here are some reasons:

Many people may recover on their own without help. They may not be seriously debilitated and they will get better over time. After all, if you think about a lot of illnesses, how often do you not seek treatment and just “wait it out”? Many of us have had “flu-like symptoms” and not gone to the doctor; we then got better over time. This can be true of mental health disorders too (at least more mild forms). Maybe you also seek help from people in your life who can provide support, guidance, and input, and these all help in your recovery.
On the other hand, we know that many mental health disorders can be chronic, and people may need help even though they don’t seek it out. One reason they don’t seek it out may be because of a “pull yourself up by your bootstraps” attitude, which is particularly prevalent in America. The idea here is that you need to “tough it out,” just fix it yourself, or “get over it.” Sadly, this attitude leads people to suffer in silence and keeps people from reaching out for help that could lead them to recover more quickly.
Stigma can also be a really big problem. Mental health problems are often perceived as a personal flaw or sign of weakness, and people may be ashamed to seek help for their problems. There’s a lot of stigma in our society. Some years ago research was done to look at mental health stigma and television programming. Interestingly, evaluating prime time television programs yielded two types of characters who have mental health problems and frequently show up in storylines. The first is the helpless individual (e.g., think about the homeless woman who gets murdered early in an episode of Law & Order). The second, and perhaps more problematic, character is the dangerous mentally ill murderer (think of many old movies). These are pretty negative stereotypes that don’t really encourage people to acknowledge their mental health challenges and seek help! Nor are these stereotypes accurate! Unfortunately, these stereotypes can often be associated with discrimination. In recent years, laws have come on the books to forbid discrimination against people with mental health problems, and I think this is a good thing.
One thing we do know is that men and women may differ in the prevalence of certain kinds of mental health problems. In general, women have higher rates of depression and anxiety, and men have higher rates of alcohol and drug problems. This is not to say that women can’t have drug and alcohol problems and that men can’t have anxiety and depression! Both certainly can have each (and possibly both), but the relative prevalence differs between men and women.

Past year prevalence of any mental illness among US Adults (2017)
* All other groups are non-Hispanic or Latino
** NH/OPI = Native Hawaiian/Other Pacific Islander
***AI/AN = American Indian/Alaska Native
Source: NAMI
So let’s talk about some specific mental health problems.

Schizophrenia

Schizophrenia is often what people think about when they think of mental illness. Schizophrenia is a severe mental illness in which individuals experience a number of symptoms. Let’s talk about some of those symptoms. Symptoms of schizophrenia are generally divided into two categories: positive symptoms and negative symptoms.

Positive Symptoms

What are positive symptoms? By positive symptoms we don’t mean good symptoms, rather positive symptoms are excesses or additions to normal experience.

Hallucinations are odd perceptual experiences. Hallucinations can occur in many of our perceptual systems. In visual hallucinations, people see things that aren’t really there. They may have visions. I used to work with children who had schizophrenia, which is a very rare condition in childhood. Some of these children would complain of images in their environment, the presence of people who weren’t there, and other odd visions. In olfactory hallucinations, people smell things that aren’t there, including odd odors. Now usually these odors are not pleasant, like roses; they’re more likely to be awful things, like feces. One of the things we’ve learned about olfactory hallucinations is that they may be signs of a brain tumor. So, if someone came into the emergency room with olfactory hallucinations, it might be best for the doctors to give them a brain scan to make sure they didn’t have a brain tumor. In tactile hallucinations, people often feel like there is something crawling on their skin or touching them in some way. Tactile hallucinations have been known to occur in people who are using a lot of amphetamines. So maybe they’re taking speed to get high and they begin to experience these tactile hallucinations, reporting that they have the sensation that insects are crawling on their skin. In auditory hallucinations, people hear things that aren’t there. They may hear people talking to them or about them; they may hear noises or conversations that don’t exist. Auditory hallucinations are the most common type of hallucinations in schizophrenia. I can remember many patients I saw over the years. I remember one who startled me in the middle of our conversation when he turned around and screamed, “Shut up, Mary!” at something behind him. Clearly he was hearing a very bothersome voice (auditory hallucination), which he was then able to describe to me.
Delusions are false beliefs. I used to work at a Veterans Administration hospital and interview people with schizophrenia. I also traveled all over Los Angeles when I was completing my doctoral dissertation research, and I interviewed many individuals with schizophrenia about their experiences. I was particularly interested in understanding their relationships with their family members, as I’m a person who is interested in how families cope with mental illness. I heard individuals with schizophrenia describe some pretty interesting delusions. I remember one man who believed that he was the only one of the world who could impregnate women. He believed that everyone was jealous of him because of this ability. So he was also paranoid about other people’s intentions, thinking they were out to harm him. I remember another man who wore a hat on his head and lined it with aluminum foil because he believed that aliens were trying to change his thoughts using radio waves. The aluminum foil was meant to keep the radio waves out of his head. I remember another man who I saw in therapy who believed that his thoughts were broadcast to other people around him and they could hear what he was thinking. He was very concerned that they heard his negative thoughts about others, and he felt a great deal of shame.
Thought disorder. Individuals with schizophrenia may have difficulties thinking, and their communications may be severely disorganized. At its worst we refer to this as word salad—where words are just thrown around in a random way that make it impossible for the listener to understand what the individual is communicating. I remember times when I would interview a patient for an hour, walk out of the session, and ask myself, “What’s wrong with me today? I just can’t seem to understand what’s going on.” What was really going on is that I had just spent an hour trying to understand a very thought-disordered patient.
Disorganized behavior. Individuals with schizophrenia may behave in ways that appear bizarre to many of us. They may put objects in odd places and engage in repetitive nonsensical behavior. I remember a mentally ill man on the street who had fashioned a very bizarre-looking hat out of a trash can top and was walking along attracting quite a bit of attention from passersby.
The positive symptoms of schizophrenia are also what we refer to as psychosis. Psychosis does not only occur among individuals with schizophrenia but can be evident in a number of other disorders. So if someone shows up in the emergency room with these positive symptoms, an ER psychiatrist may have a number of questions. First, is the person using drugs that result in these symptoms? By doing a toxicology screen (from blood and/or urine), the physician can determine if drugs might be the cause. An individual who has been using a lot of amphetamines or cocaine, among other drugs, may show many of the positive symptoms of schizophrenia. Second, the person may be having psychotic symptoms as a result of bipolar disorder or severe depression, and we will talk about these a bit later. By conducting an in-depth history of the psychotic and other symptoms, when they began to show themselves, and how the problems began to emerge, a psychiatrist or ER physician may be able to determine if there is another mental health problem that might explain these symptoms. Third, these positive symptoms could be a result of another type of neurological problem. For example, untreated syphilis can lead to brain deterioration with symptoms that look a lot like psychosis. Diagnosis can be tricky!!

I particularly like the painting below. It was done by someone with the experience of psychosis. It uses all sorts of wonderful colors, but also notice all the eyes. It really has a disturbing and paranoid sort of feel, doesn’t it?

Songs of Schizophrenia

xalinea
Negative Symptoms

What are negative symptoms? By negative symptoms we don’t mean bad symptoms (although, in honesty, most of these are not good for the individual dealing with them!); what we mean is an absence of typical or normal behavior. Some examples of negative symptoms include:

Flat affect. By affect we mean emotional expression. In flat affect an individual lacks the normal range of emotional expressiveness, and their response may appear "off." For example, an individual with flat affect may appear to have little emotional reaction when discussing something very painful. This is not to say that they do not feel normal emotions but rather that they lack the ability to convey these in their expressions.
Alogia. This refers to a “poverty of speech”; the individual may talk very little or talk for some time but say very little.
Avolition. Individuals with schizophrenia may have difficulty initiating and persisting in activities and show little motivation. They may sit for hours doing very little. They may show very poor self-care, including lack of bathing and changing clothes.
In order for schizophrenia to be diagnosed the symptoms have to be present for at least six months (unless adequately treated earlier). So the very diagnostic criteria for schizophrenia include the assumption that it is rather chronic as an illness.

I’d like you to take a look at this video and see what you notice in terms of the positive symptoms and the negative symptoms in this gentleman.

schizophrenia symptoms video coverPlease click on the image to go directly to the Annenberg website to view this video.
Source: Annenberg Learner

Epidemiology of Schizophrenia

How common is schizophrenia? Large-scale epidemiologic studies suggest that approximately 1% of the world’s population meets the diagnostic criteria for schizophrenia. So while somewhat rarer than other mental disorders, a large number of people worldwide are impacted by this disorder (over 3.2 million in the United States). It is slightly more common in men than in women. Interestingly, rates of this disorder vary somewhat between countries, but schizophrenia is seen in all cultures. I think this speaks to some profound biological underlying causes.

What is the course of schizophrenia? Onset is when the illness first begins, and course is what happens over time to these symptoms in the life of someone living with schizophrenia. First, schizophrenia typically tends to emerge, or has its onset, in the late teens or early adult years. It can have a much earlier onset. In fact, as I noted above, one of the research studies that I worked on as a graduate student was to conduct follow-up interviews of children who had been diagnosed with schizophrenia prior to age 11. This childhood onset-type of schizophrenia is exceedingly rare. It can also show up in a person's 20's or 30's. Second, once diagnosed, schizophrenia tends to be rather chronic. The goal of treatment is to reduce psychotic symptoms; improve the individual’s engagement in life and his/her functioning in social, occupational, and other domains; and help him/her avoid further psychotic periods. In general, people who work to help individuals living with schizophrenia talk about the 1/3 - 1/3 - 1/3 rule—that’s the idea that approximately one third of those diagnosed with schizophrenia will mostly recover, another one third will improve but have some chronic symptoms, and one third tend not to recover much of their previous functioning. One observation, though, has been that many people with schizophrenia do tend to improve as they enter the later parts of their lives. The psychotic symptoms of schizophrenia tend to “burn out.”

You might find it interesting to step yourself through this epidemiology and risk factors quiz about schizophrenia. You'll need to click on the image to go to the site (don't worry, the answers to the questions follow each question.)

by Brian Miller, MD, PhD, MPH, Modern Medicine Network
Deinstitutionalization

woman walking inside brain mazeDeinstitutionalization, Its Causes, Effects, Pros and Cons
One societal factor that has very profoundly influenced the lives of people living with schizophrenia is deinstitutionalization. Deinstitutionalization is the movement to shift people from living in long-term mental hospitals to living in communities. This process began in the 1960s. The idea here was a noble one—to provide care within communities to those living with mental illness. By establishing community mental health centers and “sheltered workshop” employment opportunities, the government could help produce more humane living conditions for those with mental illness and reduce the burden of cost associated with these long-term mental hospitals. Believe me, these long-term hospitals were pretty bleak and depressing places! Unfortunately, during the Reagan administration the federal government support for these community-based programs was reduced and block grants were made to states to administer these programs. These programs were subsequently highly underfunded, leading to a real shortage of mental health treatment in community settings. So what’s been the result of this?

First, the largest provider of treatment in this country is the penal system. Jails and prisons provide more mental health care than any other setting. Unfortunately, this doesn’t work so well. Individuals often go to jail (maybe due to bizarre behavior in public, trespassing due to homelessness, etc.), are finally able to get some medication (minimal treatment) for their mental health disorders, and are then unable to continue this treatment after getting out of jail. So this leads to inconsistent treatment for many of the most vulnerable individuals with mental illness. In addition, jail is a seriously stressful place to spend time, and this stress can make mental health problems much worse. Second, there are few resources in communities to assist people with mental health problems to get adequate treatment. The states were unable to provide adequate resources through block grants and those grants ended. Even people who are very interested in seeking treatment cannot always get it. Opportunities for job training are really limited as well. Third, there has been an increase in the number of homeless mentally ill individuals living on our streets in America. If you go to places like New York City’s Port Authority Bus Terminal, or to our own South Station you will see many homeless individuals who are suffering from mental health disorders, schizophrenia chief among them, who are begging on the streets. I’d like to think that as a society we could do better for some of our most vulnerable citizens!

Factors Contributing to Schizophrenia

What might be the causes of schizophrenia? Well, it’s not generally helpful to talk about the “cause” because it’s likely that many things contribute to the development and maintenance of schizophrenia. I’d rather focus on “contributing factors.” Let’s go through some of these.

Vulnerability-Stress Disorders

Schizophrenia is one of a number of disorders that we refer to as vulnerability-stress disorders. In a vulnerability-stress disorder, an individual has a “vulnerability” that is likely biological in nature. As an example of another type of medical condition that is a vulnerability-stress disorder, think about heart disease. Individuals with heart disease have a vulnerability to acquire plaque in their arteries, and this plaque restricts blood flow and increases pressure on the heart’s pumping capacity. This vulnerability to form plaque may be genetic. However, even if you have a vulnerability, you may not show the disorder unless you are exposed to certain types of stress. Stress that contributes to heart disease includes smoking, ingestion of high cholesterol foods, physical inactivity, and overeating. Vulnerability + Stress = disorder (heart disease). One of the ways that we treat vulnerability-stress disorders is to use medication to treat the vulnerability, and psychological interventions (therapy) to improve the stress piece. In heart disease, doctors may prescribe statin medications to reduce cholesterol (vulnerability) and dietary changes and exercise to reduce biological stress.

deptiction of the Stress-vulnerability model
Source: Pachani, N. (2015). Stronger connections: Family stress, violence, and mental health. International Journal on Women Empowerment, 1, 45–47. DOI: 10.29052/2413-4252.v1.i1.2015.45-47.
So, what might be some of the contributing vulnerability and stress factors in schizophrenia?

Genetics
A number of methods have been developed over the years to study the role of genetics in mental health (and other) disorders. I will first describe how we do these studies and then tell you about the results for schizophrenia.

One way to study genetics and mental health disorders is to see whether it runs in families—family history studies. Compared to individuals without schizophrenia, do individuals who are diagnosed with schizophrenia have more family members diagnosed with schizophrenia? The answer seems to be yes. However, just because something runs in families doesn’t mean it’s genetic. Families also transmit ways of coping, traditions, health habits, and many other things.
A second way to study genetics and mental health disorders is to look at adoption studies. For example, if an individual’s biological mother has schizophrenia but that individual is raised by an adoptive family without a history of schizophrenia, will that individual still be at higher risk for the development of schizophrenia? In general the answer seems to be a qualified yes.
A third way to study genetics and mental health disorders is to use twin studies. There are two types of twins. Monozygotic twins, also known as identical twins, form when the initial fertilized egg splits into two, forming two perfectly identical individuals. Monozygotic twins share 100% of their genes; they are always the same biological sex. Dizygotic twins, also known as fraternal twins, form from two different sets of eggs and sperm that happened to be fertilized at the same time and share the womb. Dizygotic twins share about 50% of their genes; they can be the same sex or opposite sexes. Indeed, dizygotic twins share no more genetic material than do regular siblings. So, if a trait (like a mental illness) is genetically determined, monozygotic twins should be more likely to share this trait than should dizygotic twins. We call this concordance—when one twin has it and the other one does as well. The concordance rate is the percentage of twin pairs that shares the trait. In schizophrenia, if one sibling in a monozygotic twin pair has schizophrenia, the likelihood the other one has it is about 46% (that’s the concordance rate). However, if one sibling in a dizygotic twin pair has schizophrenia, the likelihood the other will have it is about 14%. This is strong evidence that genetics contribute to the vulnerability to schizophrenia. On the other hand, it also clearly illustrates that schizophrenia is not 100% genetically determined. If that was the case, then the concordance rate for monozygotic twins would be 100%! It is far from 100%, at only 46%.
So we know that genetics may play a role but it certainly isn’t the only factor involved.

Abnormal Brain Chemistry colored picture of brain
Source: Schizophrenia.com
One of the leading theories about the causes of schizophrenia is known as the dopamine hypothesis. This hypothesis is that excesses in the activity of the neurotransmitter dopamine in the brain may be responsible for many of the symptoms of schizophrenia. What is the evidence for this hypothesis? First, drugs that increase dopamine activity in the brain, including cocaine and amphetamines, can produce the symptoms that we see in schizophrenia. Second, antipsychotic drugs that are used to reduce the symptoms of schizophrenia are typically ones that reduce or block dopamine in the brain. However, several of the new drugs used to treat schizophrenia do not directly affect dopamine, calling into question some of the assumptions of the dopamine hypothesis. There are so many neurotransmitter systems in the brain that work together, and indeed, there are many subtypes of the dopamine receptor! Understanding the neurochemistry of schizophrenia is a big job.

Environmental Factors
There is certainly evidence that early environmental factors may shape the vulnerability to schizophrenia. Here are two that might be really important:

Forceps
Problems during delivery of the baby may increase risk of schizophrenia. One birth complication is the use of forceps. Forceps were used to grip the baby’s head and help slide him or her from the birth canal. A forceps delivery could leave bruises on the child’s head. Remember that in this period of development, the skull is very soft and the brain very vulnerable. Forceps delivery may have led to lasting and subtle neural damage and vulnerability. Forceps are used far less frequently now than they once were.
Another really fascinating theory is that schizophrenia may be caused by prenatal exposure to influenza. Several large studies have been done, primarily in the Nordic countries. Why is this? Because these countries typically have socialized medicine and have very good records of health across the lifespan. By looking at these records, researchers were able to identify that individuals with schizophrenia were more typically born during the winter and spring, when influenza is far more common. Deeper research revealed that children whose mothers had influenza during the second trimester of the pregnancy were more likely to develop schizophrenia than those whose mothers did not. This suggests that exposure to influenza may have shaped vulnerability (somewhere in the brain) to develop schizophrenia. What’s interesting to me is that this vulnerability is typically “silent” until symptoms emerge late in adolescence or early in adulthood.
You might wonder why the symptoms tend not to emerge until that time, particularly if the vulnerability is already in place. You may remember from our discussion of biology and behavior that during adolescence many synaptic connections are “pruned away.” During childhood you have many ways of doing a task, but by adolescence you become increasingly specialized in how your brain works. While this makes your brain faster and more efficient, it also means that you are less able to recover from injury and less able to compensate when things go wrong. Perhaps the vulnerability to schizophrenia is always there, but it is only “uncovered” during this process of pruning.
Stressors
Stressful life events may play a role in the emergence of schizophrenia, and they certainly play a role in exacerbating symptoms over time. You can see how being a homeless person with schizophrenia is particularly bad, given a lack of consistent access to medical care for the mental health condition and an excess of stressful life circumstances.

Recreational drug use may play a particular role as a stressor in schizophrenia. Stimulant drugs (cocaine, amphetamines) and hallucinogens (PCP, marijuana) may be particularly problematic for people with schizophrenia.

Family conflict and high levels of family member criticism are also a stressor for some people with schizophrenia. I think it’s important to note that most family members are unprepared to know how to manage schizophrenia, and mental health professionals should include them in a comprehensive treatment plan, as they are often left trying to navigate a very complicated mental health system and figure out how to respond to some pretty confusing symptoms. Families can be one of the greatest sources of support and solace to their family member living with schizophrenia, but they also need help and support to do this. Mental health professionals can also help families learn to communicate with their mentally ill relatives in supportive and helpful ways.

Reprise: Vulnerability-Stress Model

Let’s think back for minute to the vulnerability-stress model. If we want to effectively treat individuals with schizophrenia, our best bet is to try to address both vulnerability and stress. Using psychiatric medications, we can treat the vulnerability. Using therapy to enhance coping among individuals with schizophrenia and their family members, using job training to increase skills, and helping individuals and families access social support, we can help reduce the stress. The idea here is to treat the vulnerability AND the stress.

So let’s move on to a different set of disorders.

Mood Disorders

In the DSM-5, mood disorders involve major disruptions in mood, thoughts, and behavior. These include both unipolar depression and bipolar disorder. I’m going to spend a bit of time talking about each.


What is a Mood Disorder?

Unipolar Depression

Unipolar depression is one of the most common forms of mental health problems out there. We call it unipolar, because there is only one “pole” of mood and that is low mood (depression). In a moment I will contrast this with bipolar disorder where there are low mood periods but also periods of heightened mood.

most common types despression in America
Source: Healthline
The most common type of unipolar depression is what we call major depressive disorder. Now, as you hear some of the symptoms, you may think to yourself, “I’ve had that.” Perhaps you have, as, I noted before, it’s pretty common. However, most of us have experienced at least some of these symptoms some of the time. The difference in major depressive disorder is that the symptoms are more intense, last longer, and are associated with greater disruption in one’s life.

Emotional symptoms. Major depressive disorder includes low mood, persistent sadness, and a lack of pleasure. We refer to this lack of pleasure as anhedonia, and it can be a severe symptom. Many people with anhedonia report being unable to enjoy most normal activities, like a good movie, an interesting conversation, or a tasty meal.
Behavioral symptoms. Individuals with major depressive disorder tend to withdraw from many activities that they once found pleasurable and to express much less interest. They may have a downcast expression and frequently criticize themselves in interacting with others.
Cognitive symptoms. Individuals with major depressive disorder will often report difficulty thinking and concentrating (cognitive impairment), and their thoughts about themselves, the world, and the future may be quite negative. They may believe that they're worthless and may feel excessively guilty about many things they both have and haven’t done. In its very severe forms, major depressive disorder includes psychotic symptoms (e.g., delusions that one is evil, hearing voices talking about one’s worthlessness). Most worrying for those of us who are mental health professionals, many individuals with major depressive disorder think about suicide and some attempt suicide (approximately 10%).
Physical symptoms. Individuals with major depressive disorder often have trouble sleeping. Many experience initial insomnia—that is a difficulty in falling asleep at night. Inidividuals with initial insomnia will report that they lie awake in bed for hours trying to fall asleep. Others experience middle insomnia, where they are up for several hours during the night unable to get back to sleep. Others experience terminal insomnia, where they awaken far earlier than they would like, and, while still exhausted, are unable to sleep and get up and start their day because they just can’t get back to sleep. Some individuals with major depressive disorder (a more unusual presentation) experience hypersomnia—sleeping much more than normal. In addition to these sleep disturbances, those with major depressive disorder often complain of severe exhaustion, fatigue, and low energy. They may also have changes in their appetite. Typically, individuals lose their appetites, their interest in food, and experience weight loss, but some (less typically) will report increased appetite and weight gain.
I’d like to show you a video of a woman in a moderate major depressive episode. She describes her symptoms of depression, her physical changes (including problems with sleep and appetite), and a suicide attempt that she made several years previously. I particularly like the role of the mental health professional here, as she compassionately questions about particular symptoms. You will also note how the woman suffering from depression talks about the impact of depression on her relationships. We know that depression can profoundly and negatively impact relationships—romantic relationships, parental relationships, and many others. I invite you to take a look.


University of Nottingham, Psychiatric Interviews for Teaching: Depression


So, major depressive disorder is a collection of symptoms that form what we call a syndrome. Major depressive disorder is extremely costly to society due to its treatment, impact on worker absenteeism and lost productivity, and suicide-related costs; estimates for the year 2010 were for over $200 billion in costs in the United States alone. In addition, the sheer amount of human suffering is incalculable.

What is the prevalence of major depressive disorder? Over 17 million people (around 7% of the adult population) in the United States had a major depressive episode in 2017. About two thirds of these individuals were estimated by the National Institute of Mental Health (NIMH) as having severe impairment with their major depressive disorder. The age group with the highest rate of major depressive episodes was those aged 18 to 25 (around 13%). Interestingly, rates of major depressive disorder are low during childhood and approximately equal between boys and girls. Rates began to rise around the onset of puberty, and the rate for girls increases more rapidly than for boys. A recent review suggested that by the end of puberty, the rate of major depression for girls is almost three times the rate for boys, and a ratio of about 2 female:1 male persists throughout much of the rest of adult life.

What are some other kinds of depressive disorders? I’m going to mention a few others:

Persistent depressive disorder used to be called dysthymia. This is a kind of depression that sticks around for a long time (years) and waxes and wanes. Those with persistent depressive disorder can go through intense periods of major depression and less intense periods (often referred to as dysthymia). This kind of depression can be hard to treat and can have a major impact on people’s health, quality of life, and productivity.
Premenstrual dysphoric disorder is a depressive disorder in which symptoms occur in women around their monthly menstrual cycles.
Disruptive mood dysregulation disorder is a mood disorder that includes depression and irritability. People with this disorder can really have a hard time in relationships. Two other subtypes (what we call specifiers) of major depressive disorder include:
Seasonal pattern. In this pattern of major depression, symptoms typically emerge in the fall and may be intense during the winter months, but improve in the spring and summer. I think we can all relate to this a little bit, as those winter months are tough. But the person with the seasonal pattern of major depression experiences these mood symptoms very intensely. We think that the reason for the seasonal pattern has to do with exposure to daylight. You don’t see a lot of the seasonal pattern near the equator (where the length of the days doesn’t differ much between winter and summer), but it is increasingly common as one heads north. In places like Alaska, Russia, and the Nordic countries, the seasonal pattern of major depression is quite common. These are areas of the world that have very short days and limited exposure to sunlight during the winter months. It turns out that one of the best treatments for the seasonal pattern of depression is light therapy. In light therapy, the person suffering from the major depressive disorder (seasonal pattern) gets up in the morning and sit in front of a lightbox (that puts out a certain intensity of light) for a period of time each day. Use of the lightbox can greatly improve the depressive symptoms of the seasonal pattern.
Postpartum depression. This is a major depressive disorder occurring during the pregnancy and postpartum periods that can have a profound effect on a new mother’s ability to parent her infant; this has become a problem that is increasingly a focus of attention for obstetricians and pediatricians. Getting treatment for mothers with depression is a high priority for their own health and well-being and that of their infants.
Bipolar Disorder

Let’s talk about a different kind of mood disorder—bipolar disorder. Individuals with bipolar disorder experience periods of major depressive disorder, but they also experience periods of what we call mania. Here are some of the symptoms of mania:

Emotional symptoms. During a mania, an individual may experience extreme euphoria (happiness), excitement, and, sometimes, irritability.
Behavioral symptoms. During a mania, an individual has a high level of energy, may start many new activities, and may have many new ideas. They may seem very speeded up, walking faster, thinking very rapidly, and speaking very quickly. Individuals lack judgment and may engage in high-risk activities.
Cognitive symptoms. During a mania, an individual often has heightened self-esteem, grandiose ideas, and an inability to focus or attend, as attention is highly distractible. Grandiose ideas can become delusional with the person thinking that they are very special, extraordinary, brilliant. I remember a patient in the hospital thinking he was Jesus Christ and another thinking he was the president of the United States.
Physical symptoms. During a mania, an individual often sleeps little, perhaps only a few hours a night. Despite this lack of sleep, they feel highly energetic. This lack of sleep that occurs during mania (where the individual feels no need to sleep and yet has a high level of energy) should be distinguished from the lack of sleep that occurs during a major depressive episode (where the individual is desperate to sleep and chronically exhausted).
Let’s take a look at someone who is experiencing a manic episode—it’s pretty dramatic. What do you notice?


University of Nottingham: Psychiatric Interviews for Teaching: Mania


I’ve worked a lot with families of individuals with bipolar disorder, and I can say that manias are terrifying for families. While manic, an individual may engage in reckless behavior that destroys their lives. I remember a gentleman I worked with who came out of the hospital to find that he had lost his job, lost his license to practice law, lost his wife (she left him), lost his home, and owed the IRS $25,000. Here he was, a man in his mid-40s having to move in with his parents, all as a result of his severe manic episode. His parents were very glad that he hadn’t done anything more dangerous or damaging!

Individuals with bipolar disorder may cycle from mania to depression and back again. Others may have long periods of normality between episodes of mania or depression (what we call euthymic periods).

Interestingly, at the beginning of a manic episode people may be very productive, feel great and get a lot done, but as the episode progresses the behavior becomes more deteriorated, less focused, increasingly damaging and pointless. The beginning of the episode is what we call hypomania, and many people with bipolar disorder wish that they could return to that hypomanic state.

Types of Bipolar Disorder

In bipolar I disorder individuals experiences both major depressive episodes and full manias. In bipolar II disorder an individual experiences major depressive episodes and only the hypomanias. I remember a woman I saw in therapy when I was on my internship. She had been in the hospital for nine months, having experienced a severe major depressive episode and survived three suicide attempts. She had bipolar II disorder. Although she was improved when she was discharged from the hospital, her major depressive disorder was still clearly evident and she had suicidal thoughts. I remember seeing her once when she was hypomanic and the contrast between that and her usual state was striking. I walked in the room and she announced my arrival, told me how fabulous I looked, and informed me how wonderful she felt. This hypomania lasted about two weeks. Then she was back to her more chronic depressive state.

Another type of bipolar disorder is what we call cyclothymia. In cyclothymia an individual experiences mild depressed periods and hypomanias but does not have full manias or full major depressive episodes. It’s lots of ups and downs—this pattern is also very hard on relationships.

Epidemiology and Course of Bipolar Disorder

What is the prevalence of bipolar disorder? There have been a number of international and national studies done that estimate the rate of bipolar disorder. These indicate that approximately 1% of the U.S. population meets criteria for bipolar I disorder; and another approximately 1.5% of the US population meets criteria for bipolar II disorder. It appears that the gender distribution for bipolar disorder is approximately equal between men and women. It also appears that bipolar disorder occurs in most countries. Like schizophrenia, there is likely a strong biological component.

What is the course of bipolar disorder? The first episode of mania typically occurs in the person’s early 20s. For most people (greater than 90%), bipolar disorder is recurrent. Very few people have one manic episode and never have another. Some people have long periods of time between episodes of depression and mania, while others can have what is called rapid cycling, which includes four or more episodes in a given year. The recurrent nature of bipolar disorder speaks to the need for people to get treatment.

Reprise: Vulnerability-Stress Disorder (This Time for Mood Disorders)

So, what causes these mood disorders? I think here the vulnerability-stress model is an important one. Here’s what we know about some of the key vulnerability factors:

Genetics

There is a lot of evidence to suggest that genetics play a role in mood disorders. This evidence is drawn from family, twin, and adoption studies. It is likely that people inherit a genetic predisposition (vulnerability) to develop a mood disorder, and this is particularly true for bipolar disorder. Bipolar disorder definitely runs in families.

I worked on a study in which we compared a family treatment to an individual treatment for people who had been discharged from the hospital following a manic episode. Part of what we did was called psychoeducation—we helped families understand the symptoms, causes, course, and treatments for bipolar disorder. During the psychoeducation we talked about how bipolar disorder runs in families, and I was amazed at how many families told us about multiple members who had a history of manic episodes.
Twin studies suggest that among monozygotic twins, if one member has bipolar disorder there is a 70% likelihood the other will as well (high concordance rate); among dizygotic twins the concordance rate is 25%. These data really suggest a strong genetic component to bipolar disorder. On the other hand, while there is evidence that major depressive disorder may have some genetic roots, the data is far less compelling than in bipolar disorder. Still, genetics clearly contributes to the vulnerability for mood disorders.
Neurotransmitter Systems

As we consider the biology and behavior section at the beginning of the semester, we have strong reason to believe that disruptions in neurotransmitters may be involved in depression. Norepinephrine, dopamine, and serotonin (and probably others) appear to be involved. Certainly, we have evidence that medications that change both serotonin (SSRIs—see biology section) and norepinephrine (tricyclic antidepressants) can positively impact depression. Lithium is a common treatment for bipolar disorder, and while the mechanisms underlying its effectiveness are not fully understood, it appears to reduce glutamate (another neurotransmitter) and change the balance of excitatory and inhibitory influences in the brain. So we certainly have evidence that neurotransmitter systems are involved. These are likely to be connected to the genetic influences—as genes influence the function of our neurobiological systems. A tendency for disruption of neurotransmitter systems may also be a vulnerability contributing to mood disorders.

Cognitive Factors

We often think of biological factors as a vulnerability, but cognitive factors can be as well. You may remember when we talked about the self-serving bias? I mentioned that it is a bias to attribute our successes (e.g., doing well on a test) to internal causes (“hey, I’m super smart!”) and our failures (e.g., failing a test) to external/situational causes (“I had a terrible night’s sleep,” “the exam wasn’t fair”). I also noted that it is turned upside down in depressive disorders—success is attributed to external causes (“I’m sure it was just an easy exam”) but failure is attributed to internal causes (“I really am not very competent,” “I’m stupid”). People at risk for depression may have a tendency to have global, stable, internal attributions for negative events. Global means it impacts everything; stable means it will always be like this; and internal means it is a part of you. For example, you end a relationship and think, “I’m just bad at relationships!” Oh no! Being bad at relationships is global (it affects all relationships), stable (you’re likely to stay that way), and it’s internal (you are the problem). Ugh! Not a healthy way to think. People with depression may also have other dysfunctional thoughts, including catastrophizing (“I got a C on this exam, so I’ll never be a successful person”). If a person has a tendency to think in these ways, he or she is more at risk for depression. So these negative thought patterns can be a cognitive vulnerability to depression.

What about on the stress side? We know that life stress can contribute strongly to depression.

Loss

Loss (of someone you love, of career aspirations, of status, etc.) is a big stressor. Death of one’s mother by age 9 is a big stressor that increases risk for depression. Losing a parent often involves multiple losses and changes that can intensify its impact.

Interpersonal Stress

We also know that interpersonal stress is a BIG factor. In one study a researcher friend of mine decided to investigate whether a negative event in marriage could lead to a major depressive episode in women who had NO history of previous depression. She recruited a sample of women who had a negative marital event in the last few months (e.g., found out their spouse was having an affair, had been told he’d like to end the marriage, been physically attacked by their spouse, etc.), and she followed up with them after 6 months. Fully 38% of these women had developed a major depressive episode!

woman with head in her hands
We can think of negative life events as falling into two categories: Fateful or independent life events are things that just happen to you—lightning strikes, getting caught in a flood, death of a loved one; and dependent life events are stressors that you contribute to—relationship conflict, losing a job, ending a relationship. It turns out that dependent (and particularly interpersonal) stress is a big factor in depression.
One model used to help understand the relationship between depression and stress is the stress-generation model. This is the idea that stress contributes to depression and symptoms of depression (like social withdrawal, irritability) contribute to more stress—like a big vicious cycle. As a therapist, the point here is not to blame depressed people but to understand how to get out of this bad cycle!!
Surprisingly, perhaps, positive life events can contribute to manic episodes in bipolar disorder. You may think that positive life events are all good, but they have a downside. Many of the positive things that happen to us are very stressful—they require us to make serious adjustments to our lives! Think about going to college, getting married, having a baby—these are all good things, but they are also seriously stressful. The person with bipolar disorder may be more likely to have a manic episode following one of these positive events, particularly if it means a major change to one’s schedule. Individuals with bipolar disorder must really pay attention to maintaining regular sleep-wake cycles. What if the person with bipolar disorder gets a promotion at work and needs to do more international travel that involves changing time zones a lot? If I were this person's therapist, I would make sure we talked a lot about this as a high-risk time (for mania) and work on strategies for minimizing that risk (e.g., regular sleep times, negotiating at work for particular travel schedules).
Stress is all around us! Figuring out how to navigate it, take care of oneself, limit stress, and cope with it are essential in the treatment of mood disorders.

The vulnerability-stress model, although not the only model, can be an important framework for understanding many medical and psychiatric conditions.

Let’s move on to treatment!

Do You Remember?

Test your memory by matching the terms to their definitions.


Treatment
Treatment Introduction

ripples on surface of blue water
I often have students ask me questions about therapy and other mental health treatment, so for this section I decided to organize it as a series of questions and answers!

Question 1: Why Do People Seek Therapy?

People seek therapy for several reasons.

They have a psychological disorder and are looking for help to address it. Say, for instance, that Bob has panic attacks on a regular basis and is increasing unwilling to go places for fear of having another panic attack. He seeks out therapy to help reduce the panic attacks and get back into life. As another example, Mary has a problem with alcohol use and seeks a therapist to help her reduce or stop drinking. In both cases, these individuals are seeking help for a psychological disorder.
They have difficulty in a relationship. Say Aisha and Allen are married, frequently fight, and are unsure if they want to start a family. They may seek out therapy to help them figure out how to communicate better, to improve their relationship, and to more effectively plan their future. As another example, Omar and Maria have a four-year-old daughter who is very challenging and has frequent tantrums, and they are having trouble figuring out how to parent this child. They seek therapy to help them work on parenting skills and strategies; going together helps them “get on the same page” with effective parenting. In both cases, they are seeking treatment for relationship problems.
They are going through a life transition. Say Hans is just about to graduate from college and is unsure what direction he wants to take in his career; he goes to therapy to help him explore his goals, priorities, and options. As another example, Alia is a 70-year-old woman whose husband of 45 years recently passed away after a long illness; although not depressed, she is struggling with how to reorganize her life and move forward. She seeks therapy for support and to help her explore how she will cope with this enormous life change. In both cases, the individuals are going through huge life transitions.
Question 2: Who Are Treatment Providers?

There are several different types of treatment providers for mental health services; although this is not an exhaustive list, it includes some of the most common. I’ll tell you who they are, their training, and the typical kind of work they do.

Who Provides Treatment?
Clinical Psychologist—A clinical psychologist has an academic degree (PhD, PsyD, ED), has supervised clinical training, completes an internship and has to be licensed within a state to practice independently. Clinical psychologists make diagnoses, administer and interpret psychological testing, do research, and deliver psychotherapy services. I completed my PhD at UCLA where I had extensive clinical training, completed an internship at the UCLA Medical Center, and was licensed as a Health Service Provider in the Commonwealth of Massachusetts.

Psychiatrist—A psychiatrist has a medical degree (MD, DO), including completing rotations in a number of areas of medicine during medical school, a three-year residency specifically in psychiatry, and possibly additional specialty training in a fellowship. For example, one of my favorite child psychiatrists at Boston Children’s Hospital completed his medical training at Tufts University School of Medicine, his residency in general psychiatry at the Boston VA and Tufts, and got fellowship training specifically in child psychiatry through Tufts Medical Center. The kinds of work psychiatrists do include making diagnoses, providing psychotherapy, prescribing medications and other biological treatments, and doing research.

Social Worker—For people who want to directly help others, this can be a terrific degree and typically takes only two years. Social workers have a Master of Social Work (MSW) degree, complete an internship, and are licensed. They work in a variety of settings, including schools, hospitals, prisons/jails, child protective services, outpatient clinics . . . the list goes on. They often do case management, helping coordinate care for people with complex needs, and therapy, including with families.

Marriage/Family Therapist and Mental Health Counselor—These roles differ from state to state. Individuals in these roles may have a Master’s degree with specialized training; they may work with families, with individuals struggling with addiction, etc. Depending on the state, they may be individually licensed or they may work under the supervision of a clinical psychologist, psychiatrist, or licensed clinical social worker (LCSW).

Question 3: Who Is Involved in the Therapy Process?

Typically, individuals come alone to see therapists on an outpatient basis—this is the most common therapy model.

Members of a couple may meet together with a therapist.

Families can also be the participants—I often do therapy with families and they come in all constellations! Families can be two participants (e.g., a mother and son, father and daughter, etc.), three (e.g., two parents and a child), or more (e.g., parents, several children, grandparents, etc.). In doing family therapy I sometimes include particular members in some, but not all, sessions.

Groups of unrelated individuals can also very productively attend sessions together. There are groups for people struggling with addiction, working on parenting, recovering from loss or bereavement, confronting cancer or other medical challenge, etc. Although individuals may be very different in many ways, they share a common challenge or experience. When I was on internship, I lead (with a psychiatrist) a group for people who were living with bipolar disorder. It was very useful to participants as it allowed them a forum to hear about others’ experiences, solve common challenges, and consider how to best manage their bipolar disorder. Veterans Administration Hospitals often have groups for veterans who are living with Post-Traumatic Stress Disorder resulting from combat-exposure. Those who have also been in war are able to understand the combat experience and its impact. It really helps to feel there are others who understand your experience!

Question 4: What Kinds of Treatments Are There?

There are many different types of treatments. The type of treatments used will depend on the assumptions made about the nature of the problem—after all, we want to help folks address their concerns. Therapists can come from a variety of theoretical perspectives about the nature of the problems and that influences what they then choose to do. Here are some perspectives:

Treatment

Biomedical Treatments

Biomedical treatments make the assumption that biological factors are important in the problem. This does not assume that biological factors are the only factors involved, but that they are important factors all the same. We’ve talked about a number of biomedical treatment approaches throughout the semester. For example, lithium is a treatment for bipolar disorder. Although it is not exactly clear how lithium works, there is evidence that it both treats manic episodes and reduces the likelihood of manic episodes occurring in the future—a preventive effect. It also appears that lithium can reduce risk of suicide in bipolar disorder, and that’s important. As another example, antipsychotic drugs, which typically work through reducing dopamine, seemed to be effective in reducing the positive symptoms of schizophrenia. As another example, antidepressant medications (tricyclic antidepressants and SSRIs) are helpful in the treatment of depression and a number of other conditions. New treatments are being developed, such as transcranial magnetic stimulation. These medications and other biological treaments all make the assumption that biological processes in the brain are disrupted in these forms of mental illness. The medications are used to change these neurological processes.

Psychological Treatments

Psychological treatments assume that psychological and/or environmental factors are important in the problem. There are a number of different kinds of perspectives on psychological problems, and these perspectives guide treatment. Let’s talk about several of these perspectives and how they influence the clinician's approach to treatment.

Perspectives

Psychoanalytic

The psychoanalytic perspective makes the assumption that psychological problems are a result of internal, unconscious conflict. The goal of psychoanalytic psychotherapy is to make the unconscious conscious. That is, if a person can understand the underlying factors motivating their behavior and, through their relationship with the therapist, resolve some of these conflicts, they may be able to make different choices and live in a different kind of way in relationship to both themselves and others. Some of the strategies that psychoanalytic psychotherapists use include free association (asking patients to report whatever comes into their minds) and dream interpretation.

Behavioral

The behaviorists make a different set of assumptions. They assume that the source of problems is inappropriate conditioning. Their goal therefore is to extinguish undesirable behavior and to shape new, more adaptive behavior. By using what we know about classical and operant conditioning, they can use a variety of techniques to change behavior, including exposure, different reinforcement schedules, etc. Many parent training approaches use this behavioral approach to help parents develop new, more adaptive strategies as they raise their children. They may focus on helping parents reinforce the behaviors they want to see, ignore mild negative behaviors (promoting extinction of those behaviors), improve communication, and use more effective and consistent punishment strategies.

Cognitive

Cognitive therapists make a different set of assumptions. They assume that the way we think about the world, our expectations and our beliefs, are the source of psychological problems. For instance, the depressed person may see the world in an overly negative way, catastrophizing and focusing on only the most negative aspects of situations. Sometimes depressed people have a tendency to see themselves, the world, and the future in a negative light. As another example, people who have anxiety may tend to overestimate the threat in their environment. The goal of the cognitive therapist is to replace negative beliefs, perceptions, and assumptions with more realistic and adaptive ideas. The cognitive therapist may help their client explore and track their own thoughts and assumptions, collect information on how realistic those thoughts and assumptions are, and try out new ways of thinking.

These are just a sampling of some of the strategies that therapists may use to help their clients/patients.


Why Cognitive Behavior Therapy
Question 5: How Successful Is Therapy?

Now you may wonder how useful therapy actually is. Does it help people get better? You may be surprised at how difficult this question is to answer. How do we go about answering this question?

Randomized Clinical Trial

One way we do this is through what’s called a randomized clinical trial or RCT. In an RCT, participants are randomly assigned to different treatments.

In the most traditional RCT, participants are randomly assigned to either the treatment or the control group.
There’s a number of reasons to include a control group. But what are we controlling for? Different kinds of control groups can answer different kinds of questions. Here are some reasons why people get better that we can control for in an RCT:
Natural course of the problem. Some people just get better simply through the passage of time. As I’ve noted in class previously, most of us, even if we don’t get treatment, will recover from, say, a bad cold or the flu eventually. We call this spontaneous remission—sometimes folks just get better on their own. By including a no treatment control group we can account for the fact that some people will spontaneously remit.
Expectations. Our expectations can be very powerful. Sometimes people get better just knowing that they’re getting help (or think they’re getting help). The placebo control group helps us take into account these expectations. A placebo is a “sugar pill” with no real therapeutic properties. Let’s say, for example I want to compare my newly synthesized drug (Drug X) for the treatment of panic disorder to a placebo. The question I’m answering here is: Does my new drug do a better job in controlling panic than the patient’s expectations (based on the fact that they are getting something)? If my drug is helpful, I will see that it reduces panic attacks more than the placebo.
Comparative effectiveness. I can also do a different kind of RCT which answers a different kind of question. In this case I can compare my new drug to an established treatment. The question here is really, is my new drug any better than what already exists? After all, if my new treatment doesn’t do as well as the old treatment, maybe it’s not all that great. On the other hand, if it is AS GOOD as the old treatment, I then want to see if works better for certain types of patients. This is what we call comparative effectiveness.
Meta-Analysis

We have hundreds of randomized clinical trials that have been done examining treatments for all sorts of psychological problems. What is a researcher or clinician supposed to conclude from all of this? Let’s say I was a therapist, and I wanted to see what the best treatment was for social anxiety disorder. I did a literature search and found hundreds of studies! What am I supposed to do? How do I know what works best? Well, this is where meta-analysis comes in. Meta-analysis allows us to pool results from lots of different clinical trials (RCTs) so that we can look at trends and come to conclusions.

What do meta-analyses of psychotherapy reveal?

First, it looks like psychotherapy is significantly better than no treatment. I’m certainly glad to see that this is the case!
Second, those who get therapy appeared to be better off than about 80% of those who don’t get therapy.
Third, results are generally pretty quick with 50% improving significantly by eight weeks and 75% by six months.
Fourth, the effects can be enduring. However, there’s a caveat here. Many studies only follow patients for short periods of time (less than a year), so we don’t have enough good data on how long they can have an impact.
Fifth, interestingly we are seeing more and more evidence that psychotherapy can be associated with changes in brain chemistry. Changing the way we think and behave in the world can have powerful impact on the functioning of the human brain.
Question 6: Is One Type of Therapy Better Than Others?

You might wonder if one form of therapy is better than others. Unfortunately, some types of treatments have not undergone very much testing in randomized clinical trials, so it’s a little hard to answer this question. However, those meta-analyses that have looked at this question have found, perhaps surprisingly, that there does not appear to be a lot of difference between different forms of therapy. In fact some meta-analyses have found little or no difference! There may be a variety of reasons for this.

empathy
One reason is that many therapies have common treatment elements that are helpful. One common element of treatment is what we call the therapeutic relationship or therapeutic alliance. This is the idea that having a caring and trusting relationship with a therapist and being able to examine problems and concerns can be a very powerful intervention on its own; the therapeutic relationship has been shown to account for a large proportion of improvement in psychotherapy. Therapy can also provide a corrective learning experience. People in therapy learn new ways of thinking about problems, approaching the world, and coping with difficult situations. That experience can powerfully impact self-efficacy in a variety of situations. This can be true for a number of therapies.

Certain characteristics of therapists predict better outcomes for clients in psychotherapy. For example, clients do better when their therapists are warm, sensitive, responsive, and caring. None of this sounds particularly surprising, does it? Sometimes a “match” between the race/ethnicity of the therapist and client can be helpful, as the therapist may be perceived by the client as more able to understand their experience, but this is certainly not always true. It is crucial that therapists are respectful of cultural differences, as this is an important predictor of how well people do in psychotherapy. Therapists should be open and respectful, carefully listen to their client’s perspective, and be able to talk about the client’s particular experiences and concerns.

Client characteristics may also impact the likelihood of treatment success. Certain kinds of clients are more likely to do well in treatment. Those who are motivated, committed, and willing to try new strategies are more likely to gain from therapy. Again, not too surprising! However, sometimes clients don’t come to therapy on their own. Sometimes individuals are court-ordered to seek treatment, and this doesn’t tend to predict a very good outcome. When you’re being forced by the court to come to treatment, you’re not really coming on your own, and may be less motivated to get help. Another time when clients don’t come on their own is when their family members pressure them. I’ve worked with child and adolescent clients, and many of them are being pushed by their parents to come to therapy! They don’t really want to be there (even when the parents were right to send them!). For the therapist, the key in those situations is to really make a connection with the child (therapeutic relationship) and help them to see that they can get something they want out of therapy (e.g., getting their parents to let up, getting along better with peers, etc.). This can be kind of tricky.


Characteristics of the environment may be very important in predicting treatment success. Having a supportive family improves outcomes and treatment, even if the family is never involved in the treatment itself! One can see how that could be the case. If you were getting therapy for some challenging psychological problem, and your parents encouraged and supported that choice, you can see how that would be helpful. Another predictor of doing well in therapy is having a stable living environment. We find that it’s often hard for people who are homeless to benefit from therapy. I think of this from the perspective of Maslow’s hierarchy of needs. It’s really hard to focus on higher goals (getting better in therapy) when one is simply trying to find food, a safe place to sleep, and protection from bad weather and other threats. Sometimes the most important thing in working with homeless people is to help them find a safe and stable living situation first; after that they can work more effectively in therapy. In the case of trauma, it is important that the individual no longer be exposed to the trauma itself. So for example, let’s say that a woman has experienced domestic violence and has symptoms of PTSD; the first thing would be to make sure she is no longer threatened with that violence, and then psychotherapy can focus on treating the symptoms of her PTSD.

Specific Therapies for Specific Problems

So, there’s not so much evidence that therapies differ in their impact . . . Wait a minute though . . . Is this really the right question? After all, why should one type of treatment work well for all kinds of problems? Maybe a better question is, “What type of treatment works for what type of person with what type of problem under what types of conditions with what type of therapist?” Wow!! That’s a pretty complicated question. But maybe it’s really the question we need to be asking. So let’s look at some specific treatments for specific types of problems. These are some that have shown to be helpful through research.

Family Psychoeducational Treatment for Schizophrenia

As I noted before, most families have no idea what to do when one of their members begins showing symptoms of schizophrenia. Why would they? This family psychoeducational treatment helps family members to understand the symptoms, risk factors, course, and treatment of schizophrenia and to develop specific skills for more effectively communicating with, solving problems with, and seeking help for their family member. There have been a large number of studies that have shown that this treatment not only leads to patients with schizophrenia having fewer symptoms but also helps reduces family stress and family members’ sense of burden from the illness. It’s a great treatment.

Exposure Therapy for Phobias

This goes back a long way. If you have a phobia of, say, dogs, your best bet is to get exposure therapy. You can get a psychoanalytic therapy that may help you understand how you came to have this phobia, but the real way to get rid of the phobia is exposure therapy. This treatment works well and generally very quickly. People who do exposure therapy for phobias can go through two strategies. One is a gradual exposure. What we do there is create fear hierarchy—a list of all the situations that may make one afraid and a rating of how afraid one is in each of these situations. You can see how this works in the attached fear hierarchy for a snake phobia. Now, in gradual exposure we start at the bottom of the list (the least feared items) and work toward the top. There is also something called intensive exposure, where one starts toward the top. I tend to think that most people prefer the gradual exposure approach. Think about how you would want to treat a fear that you might have—gradual or intensive exposure? I think I might tend to go for gradual exposure . . . .

Example of Fear Hierarchy for Snake Phobia
Feared Item	Fear Rating	Exposure
Sounds of Hissing	3	Make/find a recording and listen to it repeatedly
Hearing the word "snake"	3	Again, listen to a recording repeatedly
Reading articles in the newspapers or on the internet about snake behavior	4	Find brief articles and read repeatedly
Seeing worms	4	Go to a bait shop and buy some
Seeing pictures of snakes	6	Go on the internet and finds tons of images
Watching a movie with snakes in it	7	Watch Raiders of the Lost Ark, an old movie containing lots of snakes
Seeing garden snakes	8	Go to a pet store that sells snakes
Going to a reptile house at a zoo	9	Go to the zoo
Holding a snake	10	Find a place that does this

Treating Arachnophobia
Cognitive Therapy for Depression and Anxiety

This kind of treatment has been shown to work very well. We often think of it now not as cognitive therapy exclusively but what will call cognitive behavioral therapy (CBT). Take a look at this slide, as it illustrates a CBT model for depression. It makes the assumption that cognitive factors (e.g., negative assumptions, interpretations, etc.) and behavioral factors (e.g., irritability, self-criticism in social situations, social withdrawal) can contribute to depression. Then depression can make these cognitive and behavioral factors worse—the classic vicious cycle. Similar models examine the cognitive and behavioral factors that perpetuate anxiety. The CBT therapist intervenes at both the behavioral level and at the cognitive level. This treatment has been shown to be effective in a range of studies with a range of age groups for a wide range of depression and anxiety problems.

cognitive therapy model
Interpersonal Therapy for Depression

You may wonder why there are so many treatments for depression. It’s because of the terrible toll depression takes on people’s lives. Well, interpersonal therapy focuses on the relationship between depressive symptoms and interpersonal stressors. By helping people focus on developing skills for dealing with and finding solutions for interpersonal problems, this model can be super helpful for people with depression. It may be that some people do better in interpersonal therapy and others better in cognitive behavioral therapy (people have different preferences for therapy).

Interoceptive Exposure for Panic Disorder

In panic disorder, individuals who experience panic attacks become increasingly afraid of the possibility of a panic attack occurring. Panic attacks involve a variety of symptoms, including increased heart rate, difficulty catching one’s breath, sweating palms, tingly sensations, and fear of passing out, becoming ill, or dying. A panic attack can be so terrifying that the individual heads to the emergency department. Once a person has had a panic attack, they may become more sensitive to physical sensations. For example, their heart may begin to beat faster, and they then interpret this as a sign of an impending panic attack. Of course, this makes them anxious, which makes their heart beat faster. Oh no, it all escalates until an actual panic attack occurs! Then they are all the more fearful! So part of what happens with panic attacks is that fear leads to physiological arousal, which is interpreted as a sign of a panic attack, and then it becomes a panic attack. Ugh! The point of the interoceptive exposure is to teach people about this escalation process, expose them to the physiological symptoms, and help them to recognize that these symptoms are nothing to be feared. It sounds a little bit crazy, but it works beautifully. The data is very strong for interoceptive exposure in the treatment of panic disorder. In fact, I’m proud to say that Dr. David Barlow, my colleague here at Boston University, was the person who developed this treatment! It’s pretty much the recommended treatment for people who are suffering from panic disorder.

Question 7: What Are Some of the Changes in Therapy Over the Years?

Psychotherapy has changed a lot over the years, and I'd like to point out several important changes.

line drawing of head 
Source:Pixaby: Elisa Riva
Technical Eclecticism

What in the world does this mean? Well it means that many therapists today integrate strategies from many theoretical perspectives. For example, they may use particular techniques to help engage clients in treatment, may use other techniques to help clients understand the nature of their problems, and may use still other techniques to specifically reduce particular kinds of behavior. There’s an upside to this technical eclecticism. By using more strategies and having a broader perspective, we may be able to treat people more effectively. On the downside, it’s important to have an overall strategy for treatment and not just to go from one thing to another to another (like a bag of tricks).

More Use of Medications

There has been a strong increase in the number of prescriptions for psychiatric medications over the last few decades. The upside here is that many individuals who might not have sought treatment from psychologists or psychiatrists may seek treatment through their primary care doctors. The use of medications makes treatment more accessible to a larger population. The downside though is potentially a big one. The ease of prescribing medications may mean that individuals will receive prescriptions without adequate assessment of the problem and adequate follow-up. As an example, what if a woman came to a primary care doctor and said to him, “I’m feeling depressed after my husband of 50 years recently passed away”? The doctor might say, “Oh, here’s a prescription for an antidepressant.” I would argue that this approach fails to really address the needs of this woman who has just experienced a major devastating life stressor! Sometimes we really need to think about the factors that contribute to psychological problems and how we can best help patients. As another example of a downside, there has been a large increase in the number of “off-label” medications prescribed to young children. We don’t really know if these strong medications help children’s behavior, nor do we know their long-terms effects and side effects!

Shorter Duration of Treatment

Insurance companies and other stakeholders have pushed for shorter and shorter treatment. Your insurance company may only approve a short-term treatment for a particular type of problem. On the one hand, this can be very beneficial (the upside), as sometimes we get more done when we have less time. It’s also the case that many people don’t want a long-term treatment; they want to come in and address their problems and go on their way. However, the downside is that some problems require longer term treatment.

The Biggest Recent Changes

I would say that the two biggest changes in treatment for mental health problems in recent years are an increasing emphasis on evidence-based care and a move toward personalized medicine.

Evidence-based care is the idea that we should only use treatments for which there is positive data about their efficacy. We need to know what works, and we should use what works. Now the upside here is that it’s correct! We shouldn’t be using treatments just because they “feel good” or sound logical, we should have evidence of their effectiveness. On the other hand, we don’t always know what works for particular problems, during particular developmental periods, and for particular individuals.

Personalized medicine is the idea that we need to determine what is the right treatment for particular individuals. Much work is currently being done through the National Institute of Mental Health to try to understand how to better match treatments to particular individuals.

Molecule body concept of the human DNA
Legal Issues
Mental Illness and the Legal System

Take a look at these three pictures, in turn. Do you recognize these people?

Michael McDermott	Andrea Yates	John Hinckley Jr. 
The individuals are Michael McDermott, Andrea Yates, and John Hinckley Jr. What do these folks have in common? Well, they all committed terrible crimes and they all used the defense of “not guilty by reason of insanity.” I will discuss the other two later, but I’d like to focus on John Hinckley for the moment.

On March 30, 1981, John Hinckley Jr. attempted to assassinate President Ronald Reagan. He ended up wounding Reagan, a police officer, a secret service agent, and Reagan’s press secretary, James Brady. Brady was seriously wounded and remained disabled by his injuries until he died 33 years later. Indeed, James Brady and his wife Sarah Brady became major advocates for gun control and were instrumental in the passing of legislation to restrict handguns and assault weapons. (You may have heard of the “Brady Bill.”)

Back to Hinckley … he was charged with 13 felonies; however, at his trial in June 1982, he was declared “not guilty by reason of insanity.” His legal team mounted an insanity defense and he won. He had a number of diagnoses over the years with schizophrenia being prominent among them. He was obsessed with the actress Jodie Foster, stalked her, and apparently tried to kill Reagan in an attempt to impress her. After the verdict, he was transferred from prison to a locked ward at Saint Elizabeth's Hospital in Washington, DC.

The Hinckley case lead to a backlash against the notion of the insanity defense, with some states abolishing it, including Idaho, Montana, and Utah. Many people, including editorial writers, expressed the view that the insanity defense meant that you could try to kill the president and get away with it. As a result of this public outcry, the U.S. Congress passed the Insanity Defense Reform Act of 1984. This act narrowed the rules for considering a defendant’s mental illness in federal criminal courts in the United States, including restricting the testimony of expert witnesses, narrowing the definition of “insanity,” placing the burden of proof on the defendant, and requiring “clear and convincing evidence.”

Today we are going to review some history of the ideas of insanity in legal contexts, contrast the ideas of “insanity” and “competence,” and consider some common assumptions about the insanity defense. So let’s get started!

When Is a Person Considered Legally Insane?

In the insanity defense, the defendant’s lawyer argues that her client should be declared “not guilty by reason of insanity." Well, first of all, “insanity” is a legal, not a psychiatric, term. If you look through the index of the DSM-5 you will not find a diagnosis of insanity or any criteria for defining it. Psychiatrists don’t “treat” insanity. It’s only considered within a legal context. Certainly, some psychiatrists are hired to talk during a trial about the defendant’s state of mind, but they are not making a psychiatric diagnosis of “insanity.”

Because it is a legal term, it varies by jurisdiction—the federal courts have one definition, and state courts may differ from both federal courts and from courts in other states.

Two ideas are relevant here:

Cognitive insanity is the notion that the person was insane at the time of the crime because, due to mental disorder or defect, they didn’t understand the nature of their actions and didn’t recognize that what they did was wrong. As an example, let’s say that a person was in the middle of a severe episode of schizophrenia and attacked someone who they thought was trying to kill them (even though it was absolutely not the case). At the time of the crime, due to this severe psychiatric illness, the person didn’t understand that their actions were wrong or inappropriate.
Irresistible impulse is different. Irresistible impulse is the idea that a person is in such an emotional state that they are unable to control their actions. As an example, let’s say a man comes home to find his wife in bed with her lover; he is so distraught that he impulsively kills them both. You could say he had an irresistible impulse as a function of his emotional state.
In most jurisdictions, cognitive insanity has to be demonstrated for a successful insanity defense; irresistible impulse will not do for an insanity defense. Over the years the insanity defense has narrowed and is primarily based on cognitive insanity.
Changes to the Law
The Insanity Defense Reform Act of 1984, signed into law on October 12, 1984, was the first comprehensive federal legislation governing the insanity defense and the disposition of individuals suffering from a mental disease or defect who are involved in the criminal justice system. The more significant provisions:

significantly modified the standard for insanity previously applied in the federal courts;
placed the burden of proof on the defendant to establish the defense by clear and convincing evidence;
limited the scope of expert testimony on ultimate legal issues;
eliminated the defense of diminished capacity;
created a special verdict of "not guilty only by reason of insanity," which triggers a commitment proceeding; and
provided for federal commitment of persons who become insane after having been found guilty or while serving a federal prison sentence.
~ Insanity Defense Reform Act of 1984
Some of the important aspects of insanity definitions here are that:

It refers to one’s state of mind at the time of the crime.
In the 1984 reforms, it specifies that it is due to “mental disease or defect.”
It certainly emphasizes cognitive insanity.
So How Does Insanity Differ From Competence?

These are two very different legal issues! Listen to the YouTube clip below about the trial of a Michigan man.


Competence refers to a defendant’s state of mind at the time they are defending themselves in a court of law. Can they understand the charges against them? Can they participate in their own defense? If a person is not competent to stand trial, they may have to wait until a time when they are competent to go before a judge or jury.


Planned Parenthood Gunman Incompetent to Stand Trial

Defendants must have the capacity to understand, reason, and appreciate as it relates to specific content areas.

Competency to assist counsel
Understanding of criminal charges
Understanding of the implications of being a defendant
Understanding of the adversarial nature of the proceedings
Understanding of the role of defense counsel, prosecutor, judge, and jury
Ability to work with attorney and relate pertinent information
Decisional competency
Ability to make important decisions that arise in the course of adjudication: how to plead, consider plea agreements, strategy of defense
It is possible to be competent to stand trial but have been legally insane at the time of the crime. Take, for example, the hypothetical case of the individual who, due to severe mental illness, was unable to understand that what he did was wrong at the time he did it. Perhaps after the crime was committed, he was able to receive appropriate treatment and his symptoms remitted. He is now competent to stand trial but may still mount an insanity defense arguing that at the time of the crime he was legally insane.

It is also possible to have been fully NOT insane at the time of the crime but be incompetent to stand trial. Let’s say someone committed an armed robbery and knew full well what they were doing and the nature of wrongfulness of this act. This person clearly could NOT mount an insanity defense! However, in the weeks after the crime was committed, they had a terrible accident and head injury, resulting in severe memory problems. This person may now be unable to understand the charges against them and are therefore incompetent to stand trial, even though they were certainly not insane at the time of the crime.

So competence and insanity are very different ideas from a legal perspective.

Does the Insanity Defense Allow People to “Get Away with Murder”?

Some people object to the insanity defense because they believe it keeps people from being held responsible for their actions and that many people try to use it to get “off the hook” for their crimes. So what does research tell us?

First of all, the insanity defense is used very rarely. An insanity defense is mounted in less than 1% of felony cases! That’s not very many. After all, with changes to the insanity defense, including the narrower definition and the need for “clear and convincing evidence” in many jurisdictions, it’s not an easy defense to mount! So, no, not a lot of folks are using it. And, that leads to the next point.

Second of all, when it is used it is often not effective. Only in 25% of cases where an insanity defense is used is it successful. Most of the time, in 75% of cases, the insanity defense is not successful. So, if it is successful, does that mean the person just goes on their way? No . . . that leads to the next point.

Third, often when an insanity defense is successful, the person still spends a LONG TIME in confinement. A person may be sent to a long-term hospital to address the reasons for the insanity (often, mental illness). In fact, some studies show that the length of confinement may be longer following a successful insanity plea than if the person had been found guilty and served their time in prison.

Here’s a video that describes a recent case where the insanity defense was used. You can see how complicated the issues can be.

side shot of Dunwoody
Dunwoody Trial: The Insanity Defense

By the way, Hemy Neuman lost on his insanity defense and was declared guilty of murder.

What Happened to These Three Defendants?

So, what happened to Michael McDermott, Andrea Yates and John Hinckley Jr.?


Michael McDermott worked at Edgewater Technologies in Wakefield, MA. Angry over problems with his employer, he entered his workplace with a high capacity weapon and shot and killed seven coworkers. However, his insanity defense didn’t work out for him. He was found guilty of all seven murders, sentenced to seven consecutive life sentences, and will die in prison.


Andrea Yates was severely depressed and diagnosed with “post-partum psychosis” after the birth of her fifth child. After being in the hospital she was discharged to her home and her husband was told not to leave her alone with the children. However, he did, and she drowned all five of her children in the bathtub—an absolutely horrible and tragic act. Although her defense team mounted an insanity defense, it was unsuccessful, and she was found guilty of capital murder and sentenced to life in prison. However, five years later, when it was discovered that one of the prosecution’s expert witnesses had given false testimony, she was retried and was found not guilty by reason of insanity. She has been a patient at Kerrville State Hospital in Texas since 2007. Although she has the opportunity in recent years to be reviewed for possible release, she has chosen not to do so but rather to not contest her stay in the hospital and to continue her treatment.


John Hinckley’s defense team mounted an insanity defense; he won. However, he spent the next 17 years full-time at Saint Elizabeth's Hospital in Washington DC, despite having no demonstrable symptoms of his schizophrenia for years. In 1999 he began to have some visits to his parents’ home in suburban Virginia; over time the length of these visits was expanded. In 2016, he was discharged from Saint Elizabeth's to live with his elderly parents. He had significant restrictions on his activities but was released from Saint Elizabeth’s Hospital. In June 2022, after 41 years, he was granted full release.

Review and Reflect

For this last Review and Reflect activity, please take this time to think back to the beginning of the course and all that you have learned. Use that reflection to respond to the set of questions listed below.