12Paraphilic Disorders, SexualDysfunctions, and Gender D.docx

12
Paraphilic Disorders, Sexual
Dysfunctions, and Gender
Dysphoria
© Ikon Images/Corbis
Chapter Objectives
After reading this chapter, you should be able to do the
following:
• Identify sexual behavior that is considered to be disordered.
• Name the various types of sexual dysfunctions.
• Explain how people with sexual dysfunctions can be helped.
• Explain how or if sexual dysfunctions can be prevented.
• Describe the etiology and treatment of gender dysphoria.
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© 2018 Bridgepoint Education, Inc. All rights reserved. Not for
resale or redistribution.
326

Although sex is healthy, important, and worth discussing, it is
not always a topic that is talked
about openly. However, what to do, how to do it, and who to do
it with are the central top-
ics of movies, books, television shows, magazine articles,
newspaper reports, popular music,
Internet sites, and advertisements. Despite this avalanche of
information, society’s attitudes
toward sex remain conflicted and confused. Are some sex
practices signs of mental illness?
What is normal, anyway?
Because of people’s seemingly endless fascination
with the topic, sex is the subject of a huge amount
of professional literature. This chapter focuses on
three aspects of this literature: paraphilic disor-
ders, sexual dysfunctions, and gender dysphoria, as
described in the DSM–5. The chapter is divided into
three main sections. The first deals with the para-
philias (unusual sexual desires or acts), the second
examines sexual dysfunction (difficulties in per-
forming sexual acts), and the third section discusses
gender dysphoria (discomfort with one’s assigned
sex role).
Although the focus of the chapter is on sexual
behavior, it is wrong to think about these prob-
lems as somehow separable from other aspects of a
person’s life. As you will see, an individual’s sexual
behavior is influenced by his or her genetic back-
ground, medical condition, personal history, use of
substances, psychological state (especially the pres-
ence of anxiety or depression), and the prevailing
cultural norms. To show how these factors come
together to influence both normal and problematic
sexual behavior, this chapter tells the story of four

people: Peter Hall, Anne Lawrence, and Anne’s two sons, Jared
and Luke. Through a series of
tragic circumstances, the lives of these four people intersected
and were changed forever. We
will begin with the case of Peter Hall.
Ray Fisher/Getty
Hugh Hefner, the publisher of Playboy
magazine (shown here in his earlier
years), has been a recognizable symbol
of sexual identity in Western culture.
The Case of Peter Hall: Part 1
Peter Hall was born with a silver spoon in his mouth. His
successful stockbroker father
sent him to elite private schools, and his mother made sure that
he received the best music
lessons. Each summer, he went on trips to the cultural capitals
of Europe. Now in his late
40s, Peter speaks five languages, drives a Jaguar sports car, and
owns a yacht and three
homes. He is a familiar figure at art galleries and chairs the
museum board. Charming and
urbane, Peter is especially well known for his charity work with
underprivileged boys. Not
only does he sponsor sports teams and camps, but he has also
looked after wayward youths.
He has provided them with emotional and financial support;
some have even lived in one of
his homes. So, imagine the shock to the community when Peter
was arrested and charged
with child sexual assault. The following document displays a
newspaper account of the case
against Hall.

(continued)
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327
Newspaper Story Describing the Arrest of Peter Hall
Chair of Museum Board Arrested for Child Sexual Assault
by Ron Nicks
Businessman Peter Hall, aged 48, was arrested by Metro Police
and charged with seven
counts of child sexual assault. Hall had been under investigation
since police were
approached by Mrs. Anne Lawrence, a divorced schoolteacher
from Ross River. She claimed
that Hall had sexually abused her sons, Jared, now aged 13, and
Luke, aged 10, and that the
abuse had gone on for a year.
“At first, I thought Peter was the best thing that ever happened
to my boys. Their father
abandoned us, and I had to raise them alone. They needed a
father figure, and I thought Peter
was it.”
According to their mother, Jared and Luke met Hall last summer
at the beach. They were

admiring Hall’s classic antique surfboard when he struck up a
conversation with the
boys. Later that afternoon, he invited Anne and her sons to his
beachfront apartment for
refreshments. In the apartment, the boys played with Hall’s vast
collection of video games
and listened to his music CDs. They made plans to get together
again the next day. After
the summer, their relationship continued. On the weekends that
Hall used the beachfront
apartment, the boys were invited to join him. Often, their
mother accompanied them.
“I went to his apartment many times,” says Anne. “I always
found Peter pleasant and
entertaining. He was so refined and cultured. I thought we were
friends. Jared and Luke
adored Peter, and he treated them like the sons he never had. He
introduced them to opera
and classical music. I thought he was the ideal father.”
Anne first began to suspect something was wrong when she
found drugs (later identified as
amphetamines) in Jared’s drawer. She went to Hall for help. He
offered to pay for counseling
and to enroll Jared in a special program for substance using
teenagers. Because the program
was located near his city home, Hall offered to have Jared live
with him. What Hall neglected
to tell Anne was that he was the source of Jared’s
amphetamines. Jared moved in with Hall,
and Anne visited him on many weekends. Instead of improving
with treatment, however,
Jared seemed to get worse. According to Anne, he often seemed
“dazed and strung out.”

“One night I got a call from Peter telling me that Jared was
‘very sick.’ I hurried to Hall’s
home. I knew something was seriously wrong when I saw the
police car parked outside. I ran
inside. There was Jared, just lying there, unconscious from what
turned out to be an overdose
of sleeping pills. We got him to the hospital and had his
stomach pumped. When he awoke, he
told me that he had tried to kill himself to get away from Peter,
who not only used him for sex
but also made him have sex with Peter’s friends.”
Anne soon learned that Jared was not Hall’s only victim; Luke
had also been involved. The
police investigation turned up five other boys who claimed that
they, too, had been Hall’s
victims. Police inspector Philip Langton, who led the
investigation, searched Hall’s home
after the arrest. “We found amphetamines and hundreds of
photographs of naked boys, some
as young as 5 years old. There were many computer games,
toys, and videos—everything
young boys might like. Hall’s home computer was full of photos
of boys, as well as contacts
and connections to pedophile sites around the world.”
Hall faces trial next March.
See appendix for full case study.
The Case of Peter Hall: Part 1 (continued)
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328
Section 12.1 Paraphilic Disorders (Paraphilias)
12.1 Paraphilic Disorders (Paraphilias)
A breakthrough in research on sex occurred in the
1940s when Alfred Kinsey (1894–1956) and his col-
leagues used surveys to paint a statistical portrait
of the sexual behavior of 18,000 American men and
women (Kinsey, Pomeroy, & Martin, 1948; Kinsey,
Pomeroy, Martin, & Gebhard, 1953). Many of their
findings were surprising, at least at the time. Prac-
tices that were considered rare and harmful (mas-
turbation, for instance) were actually found to be
quite common. Since then, we have come to recog-
nize that what constitutes acceptable sexual behav-
ior is largely a function of cultural mores. Activities
considered normal in one time and place may be
prohibited in another (Giami, 2015). Nevertheless,
independent of time and culture, we have been able
to determine certain sexual behaviors that qualify
as psychological disorders.
According to the DSM–5, the paraphilic disorders
are characterized by intense sexual fantasies about,
and urges to have (a) sex with nonhuman objects
(bras or panties, for example), (b) sex that involves
suffering on the part of oneself or one’s partner, or
(c) sex with children. The person need not act out
these fantasies to receive the diagnosis, although
many do (American Psychiatric Association [APA],
2013). Although the DSM–5 describes only a small
number of paraphilias, it contains an “unspecified” category

that may include dozens, per-
haps hundreds, more (Schewe, 1997). It seems that just about
anything, from scuba diving
suits to toilet seats, can become imbued with erotic
significance. Despite their diverse range,
all paraphilias share a central characteristic—in every case,
sexual behavior has been discon-
nected from a loving, consensual relationship with another
adult. This category would be
used, for example, in situations in which the clinician is
confident that a paraphilia is present
and causes distress or impairment (recall the maladaptive
behavioral perspective discussed
in Chapter 1), but there is insufficient diagnostic information
present to determine the type
of paraphilia (Krueger & Kaplan, 2015).
Almost all people with paraphilias are male (Handy & Meston,
2016; Konrad, Welke, & Opitz-
Welke, 2015). Here is one possible explanation: Males may be
more aware of their sexual arousal
because they experience erections and have noticeable changes,
whereas women may be aroused
but may not report it because they experience sexuality
differently and without obvious physical
changes like an erection (Handy & Meston, 2016; Konrad,
Welke, & Opitz-Welke, 2015). Another
possible explanation is that women might not be attending to
their genital responses and/or
might be unable to accurately perceive their genital responses,
thus lacking interoceptive aware-
ness when genital arousal occurs (Handy & Meston, 2016).
Regardless, some researchers believe
that the reason(s) behind the significant gender split remain
unknown (Konrad et al., 2015). It is
unusual for a female to meet the diagnostic criteria for any of

the paraphilias other than masoch-
ism (for which they still represent the minority; APA, 2013).
Bettman/Getty
The work of Alfred Kinsey during the
1940s challenged commonly held ideas
about American sexual behavior.
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329
Diagnosis
The main characteristics of the DSM–5 paraphilic disorders are
summarized in this section.
To qualify for one of these diagnoses, a person must have
fantasies and urges that last at
least six months. During this period, people need not restrict
themselves solely to paraphilic
fantasies or sex; they can engage in other types of sexual
behavior as well. In most cases,
however, paraphilias (more often, several paraphilias) become
the person’s dominant form
of sexual expression. Like compulsions, paraphilic disorders
consume much of people’s lives
(Guay, 2009). Individuals may engage in their paraphilia every
day, sometimes several times
each day. Some collect fetishistic objects (for example, shoes or
bras) or photographs depict-

ing their preferred paraphilic interest. Although some
paraphiliacs are loners who keep their
sexual behavior hidden, others are social enough to join interest
groups of fellow paraphiliacs
who meet either in person or on the Internet. They may share
paraphilic objects or informa-
tion, and, in some notorious cases of pedophilia, they may even
share victims.
Exhibitionist Disorder
The DSM–5 defines exhibitionist disorder as
exposing one’s genitals to a stranger, sometimes
accompanied by masturbation (APA, 2013). The
desire to expose one’s genitals in public is often
seen as a compulsive behavior. Affected individu-
als (“flashers”) may be trying to shock the observer,
and they often succeed. In some cases, exhibition-
ism may involve the fantasy that the stranger will
find the display sexually arousing. The disorder
is usually found among teenage and young adult
males who grew up in sexually repressive homes
and have little experience with women.
Fetishistic Disorder
The use of nonliving objects, such as shoes, bras,
underpants, or leather clothing, in fantasy or
directly to achieve sexual gratification, is called
fetishistic disorder or, more commonly, fetishism.
Some individuals have extensive fetish collections
that they have purchased or, in some cases, stolen.
They may masturbate while fondling the object, or
they may ask their partners to don the object dur-
ing sex. The fetishistic object is not just a stimulant
(many men are attracted by women in high heels and sheer
stockings); it is detached from

the female and sexually stimulating on its own. For people with
fetishism, sex is impossible
without the fetish. Using objects specifically designed for
sexual stimulation (vibrators, for
example) is not considered a sign of fetishism. Fetishism begins
in puberty and tends to last
a lifetime (APA, 2013).
Photodisc/Thinkstock
Exhibitionism, or exposing one’s geni-
tals to a stranger, is the most common
sexual offense punishable by law.
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330
Frotteuristic Disorders
Frottage is French for “rub,” and frotteuristic disorder involves
touching or rubbing up
against nonconsenting individuals, usually in crowded places.
Typically, the individual gets
behind a person in a crowd and rubs his or her genitals against
the person’s buttocks or
fondles the person with his or her hands. This behavior may be
accompanied by fantasies of
a sexual relationship with the individual. Most perpetrators run
away as soon as the victim
reacts. The behavior is most common in males aged 15–25

(APA, 2013).
Pedophilic Disorder (Pedophilia)
Fantasizing about or engaging in sex with prepu-
bescent children is termed pedophilic disorder
or, more commonly, pedophilia. According to the
DSM–5, pedophiles must be at least five years older
than their victims (APA, 2013). Pedophiles, who
seem to be exclusively male, generally focus on
children younger than age 13. Most pedophiles pre-
fer females, but some prefer males, and others are
aroused by both (Hughes, 2007). Pedophiles may be
sexually attracted only to children (exclusive type)
or to both children and adults (nonexclusive type).
Most are satisfied to fantasize about sex with chil-
dren or to collect child pornography. Because this
subgroup of pedophiles never acts out their fanta-
sies, they typically do not get into trouble with the
law (possession or distribution of child pornogra-
phy is a crime, however). Among pedophiles who
do engage in sex with children, some fondle them
or masturbate in front of them. Others engage in
sexual intercourse with children, sometimes using
force to achieve their ends.
Pedophiles rationalize their behavior as “educat-
ing” the child or giving the child sexual pleasure, or
they allege that the child seduced them. Pedophiles
may limit their activities to their own children
(incest) or to others they know, or they may prey on
strangers (Choi, Choo, Choi, & Woo, 2015). In gen-
eral, pedophiles will usually prey on children they know, and
within a short distance of where
the pedophile lives. This may include extended family members
who live nearby (Krueger &
Kaplan, 2008). Some seek occupations (such as teaching) that

bring them into contact with
children. Pedophiles may physically threaten their victims to
prevent disclosure, as well as
provide gifts (toys, access to adult-themed video games like
Call of Duty, and so on) to keep
the child quiet, as well as to coerce the child to participate in
the abusive situation. Pedophilic
disorder usually begins in puberty and is highly resistant to
punishment or treatment. (See
Part 2 of Peter Hall’s case in the appendix.)
Alexander Koerner/Getty
In 1977, French-Polish film director
Roman Polanski was arrested and
charged with unlawful sexual inter-
course with a minor, then 13-year-old
Samantha Geimer.
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331
Sexual Sadism Disorder
Fantasizing about inflicting or actually inflicting suf-
fering or humiliation on another for sexual satisfac-
tion is called sexual sadism disorder (APA, 2013).
The term sadism is derived from the name of the
Marquis de Sade (1740–1814), who wrote about

his need to inflict humiliation and pain on others.
Sadistic behaviors include whipping, torturing, cut-
ting, beating, pinching, and spanking. Some people
with sexual sadism find masochistic partners; oth-
ers impose their desires on unwilling partners. Sex-
ual sadism inflicted on nonconsenting partners is a
criminal offense. The severity of sadistic acts tends
to increase over time and, when associated with
antisocial personality disorder, may lead to rape
or even murder (Chan & Beauregard, 2016). Serial
“lust murders,” in which men rape, often mutilate,
and then deliberately kill their female victims, may
be an extreme form of sexual sadism. Note, however,
that neither rape nor murder is a paraphilia. Both
seem motivated as much by hate and aggression as
by lust, as the accompanying Highlight makes clear
regarding rape.
Pantheon/Superstock
The Marquis de Sade, namesake of the
term sadism, had written extensively of
his need to inflict pain and humiliation
on others.
Highlight: Rape Is Not Sex
The previous definition of rape included only penile/vaginal
penetration achieved against
a person’s will by menace or force, or when the victim cannot
give consent (because of
intellectual disability, illness, intoxication, or being
unconscious or comatose). Early in 2012
the Federal Bureau of Investigation (FBI) changed the
definition to make the term more
inclusive and more accurate. Most important, the phrase “carnal
knowledge of a female

forcibly and against her will” was removed. Now males and
females can be victims or
perpetrators. The new definition states, in part:
The penetration, no matter how slight, of the vagina or anus
with any body
part or object, or oral penetration by a sex organ of another
person, without
the consent of the victim . . . . The revised definition includes
any gender of
victim or perpetrator, and includes instances in which the victim
is incapable
of giving consent because of temporary or permanent mental or
physical
incapacity, including due to the influence of drugs or alcohol or
because of age.
The ability of the victim to give consent must be determined in
accordance
with state statute. Physical resistance from the victim is not
required to
demonstrate lack of consent. (FBI, 2012, p. 1)
Rape should be differentiated from sex with a minor, which is
sometimes called statutory
rape. Sex with a minor is always a crime, even when both
parties consent to the sex.
(continued)
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332
Sexual Masochism Disorder
Sex involving real or imagined humiliation and suffering
inflicted upon the self is described
as sexual masochism disorder (APA, 2013). Females may
fantasize about being held down
and raped, for example. Males may stick themselves with pins
or give themselves electric
shocks while masturbating. When partners are involved,
masochistic acts include whipping,
bondage, and being urinated on. Some couples carry out
elaborate sex rituals involving fetish-
istic objects, such as leather-studded belts. Most of the time,
physical damage is avoided, but,
in some cases, masochists’ desire to feel pain can lead to
serious injury or even death. For
instance, some people may deprive themselves of oxygen by
hanging from a noose or putting
a plastic bag over their heads (hypoxyphilia or asphyxiophilia).
The goal is to achieve enough
oxygen depletion to enhance sexual arousal (Coluccia et al.,
2016).
The accompanying Highlight addresses the question of whether
sexual sadism and sexual
masochism should be considered DSM–5 disorders.
Because many rapes are not reported, it is difficult to know how
often rape occurs, but we
do know that it is fairly common. In addition to any physical
injury they suffer, rape victims
may feel vulnerable, guilty, and depressed. The aftereffects of
rape may include a negative

attitude toward sex, an anxiety disorder, substance abuse, or all
three. In addition, victims
whose cases come to trial must endure humiliating questioning
from defense lawyers, who
attempt to demonstrate that the victim somehow provoked the
attack (Campbell, 1998).
Considerable psychological and community support is expended
each year helping rape
victims to reestablish their lives (Sacco, 2014).
Even though nonconsenting sex is a criterion for the paraphilic
disorders (APA, 2013), rape
is not considered a paraphilia because it is not primarily a
sexual act. Although rape involves
sexual penetration, rapists may not have erections or reach
orgasm during their attack. They
seem to be motivated not by sex but by the need to dominate,
degrade, and subjugate their
victims (Jamel, 2014). This is why rapes often include sadistic
acts. Victims have had their
breasts burned with cigarettes, their genitals mutilated, and, in
extreme cases, they have
been murdered.
According to one study, prevalence rates coming out of studies
on university campuses range
from 6% to 41% of college students being victims of attempted
or completed rape (Jordan,
2014). When looking only at sexual assault, a more recent study
found that prevalence rates
of sexual assault were about 23% among first-year students
(Conley et al., 2017). Regardless
of the statistics, any percentage is too high.
What should you do if you or someone you know is a victim of
rape? Most universities and

colleges have a counseling center and/or a crisis hotline where
you can report rape, either as
a victim yourself or if a friend is a victim. In addition, you can
visit http://rapecrisis.com/, a
comprehensive website that also lists a 24-hour hotline: 210-
349-7273. The website also has
an online feature through which you can talk to counselors.
The Violence Against Women Act was reauthorized in 2013. It
mandates services for all
victims of domestic violence, sexual assault, dating violence
and stalking, including but not
limited to Native women, immigrants, LGBT victims, college
students and youth, and public
housing residents (Sacco, 2014). This is an important piece of
legislation as it states that
violence against any woman is considered a crime, no matter
her race or ethnic background.
Highlight: Rape Is Not Sex (continued)
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http://rapecrisis.com/
333
Transvestic Disorder
Cross-dressing for sexual pleasure by heterosexual males is
called transvestic disorder

(Balon, 2016). Most often, transvestic fetishists masturbate
while wearing women’s clothes.
Individuals may begin by wearing one article of women’s
clothing, usually underwear, and
stop there. Alternatively, they may progress to wearing an entire
outfit and makeup. The
behavior usually begins in childhood or adolescence and
continues through adulthood and
even through marriage. Cross-dressing by gay males (drag
queens) to entertain an audience
is not an example of transvestic fetishism. Some individuals
find cross-dressing calming, even
when no sex is involved. They may seek to live as women and
may even have their sex surgi-
cally reassigned. In general, however, cross-dressing by males
who believe they are really
females is not a form of fetishism but rather indicates gender
dysphoria (discussed later in
this chapter).
Voyeuristic Disorder
Sexual fulfillment and excitement gained by watching
unsuspecting people disrobe or engage
in sex is called voyeuristic disorder. Watching people who know
they are being observed is
not considered a paraphilia (APA, 2013). Usually, men
masturbate while “peeping” or later as
they recall what they have seen. In severe cases, this is the
person’s only form of sex. It begins
Highlight: Should Sexual Sadism and Sexual Masochism
Disorder Be DSM–5 Diagnostic Categories?
We have spent the entire length of the book discussing mental
disorders, and how to
define abnormal behavior. There is one area that remains quite

controversial: Are we as
psychologists, and students, able to state with conviction that
sexual sadism disorder and
sexual masochism disorder are diagnosable? This question has
led to much debate in the
field, and outside of it. For example, Handy and Meston (2016)
note that paraphilic fantasies
are common in college-age students as well as in the general
population. This is especially
true for sadism and masochism or, to use as the authors’ term,
BDSM (standing for “bondage
& discipline/dominance & submission/sado-masochism”).
Handy and Meston found that
more than 60% of male college students fantasized about sadism
and bondage, while more
than 50% of female college students reported having had sexual
fantasies in which they
submitted to force or intrusive thoughts about being sexually
victimized. It seems that what
we are diagnosing appears to be occurring in the statistical
majority of the population, which
contradicts the statistical frequency definition of abnormal
behavior.
An opposing viewpoint is posited by Konrad, Welke, and Opitz-
Welke (2015), who note that
in an empirical analysis conducted by Robertson and Knight
(2015), it was discovered that
sadism and psychopathy consistently predicted sexual and
nonsexual violence. In addition,
serial sex offenders were more likely to engage in sexual
masochism (Konrad et al., 2015).
Not surprisingly, we are presenting to you opposing
perspectives. Suppose a patient came
to you asking for help to “get over” his love of being a sexual

masochist. How would you
handle this? Would you diagnose him with sexual masochism
disorder? Are we discussing
paraphilias, lifestyle choices, sexual preferences, or something
else? These are just a few
more questions for you to think about.
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334
in late adolescence; it cannot be diagnosed before age 18, since
the DSM–5 states that there is
“substantial difficulty in differentiating it from age-appropriate
puberty-related sexual curi-
osity and activity” (APA, 2013, p. 688). The course of the
disorder varies based on the age of
the individual (APA, 2013).
Unspecified Paraphilic Disorder
The DSM–5 category of unspecified paraphilic disorder
encompasses a mixed collection of sex-
ual behaviors and interests including making obscene phone
calls; having sex with corpses
or animals; deriving sexual pleasure from enemas; and
partialism, which is an intense sexual
attraction to a specific body part, most often breasts or
buttocks.

It is difficult to know how frequently paraphilias occur because
people with paraphilic dis-
orders rarely seek clinical assistance (Burgan, 2010). The
limited data that are available as
to prevalence come mainly from surveys of people who have
been convicted of sex crimes—
which is hardly a representative sample of the general
population. Convicted sex criminals
are not even a representative sample of people with paraphilias
because most paraphilias are
not illegal.
Another reason it is difficult to obtain accurate prevalence
estimates is that paraphilic behav-
ior may be masked by other diagnoses. For example, some
people engage in paraphilic behav-
ior only when intoxicated by alcohol or drugs, whereas others
display paraphilic behavior
only during psychotic episodes. These individuals will normally
be diagnosed with substance
intoxication or psychosis, respectively; their paraphilic
behavior may never be officially
recorded. Although it may be a difficult clinical judgment to
make, people who deliberately
use substances to …
Government business relations
PA 315
Chapter 10
Agenda
Privatization
Entrepreneurial strategy
Public entrepreneur

Examples
Negative: redevelopment projects in San Bernardino
Positive: Victoria Gardens
Privatization
Simply stated, privatization involves reliance on the private
sector, to one degree or another, in providing goods and
services to citizens that otherwise might be provided directly by
governments.
In California, focus on privatization due to several factors:
Budgetary problems - many governments have focused on
exploring ways to provide public services more efficiently,
thereby reducing their costs to taxpayers and freeing up
available public funds for other needs
Maintain and improve the quality of services
Drivers of privatization
Ideology – government should be limited –
“That government is best which governs least” ~ Henry David
Thoreau.
Also, Senator Rand Paul stated, “We don’t need bigger
government. We need to shrink the size of government.”
Greed and Corruption – Humanity at its worst.
Temptation to transfer lucrative government services to a
private business to ensure votes, personal gain, campaign
contributions, etc.
Economic – officials seek to offload their responsibilities to
private business who have the ability to efficiently reduce costs
by lowering wages, reducing service levels, and raise revenues
without public scrutiny.
History – Public utilities such as gas, water, electricity, and
sanitation serves are provided to citizens nationally through a
combination of public, private, and quasi-public entities.
Communication services such as telephone, television, and

transportation were developed by private organizations with
some government assistance but they remain heavily regulated
to ensure services are available to all citizens.
Effectiveness – the idea that running services as a business
ensures effectiveness (Charter Schools)
Reduction in liability – The usage of private contractors can
reduce the government’s liability for certain duties. Example –
in 2012, there were 113,491 employees of defense contractors in
Afghanistan compared to about 90,000 American soldiers.
2011 – more contractors died than soliders
Examples of government privatization
Adoption services
Animal control/shelters
Campgrounds
Daycare centers
Fire services
Garbage and waste management
Janitorial services
Medical insurance
Municipal water supply
Schools
Prisons and jails
Road maintenance
Toll roads/bridges
Utilities
Personnel management
Nursing homes
Museums
Employment training
Renewals of drivers license
Street cleaning
Telephone services

Landfills
Liability insurance
Privatization methods
Competitive bidding – government entity decides which
services to transfer and oversees a process where private
companies bid to provide the service.
Vouchers – citizens, which government assistance, choose
between public and private providers. Examples: education,
insurance (Medicare/Medical), daycare services
Asset sales – governments at all levels sell property and assets
to commercial entities such local police departments auctioning
off recovered and unclaimed property, to office buildings and
lands no longer needed by government
Advantages
Lower Taxes. Wexford County, Michigan privatized its
emergency medical service in 1994, resulting in an
improvement in service, reduction in administrative services,
and lower costs, saving county taxpayers more than $300,000 in
the first year alone.
Increased Efficiency. North of Boston, a privately owned and
operated incinerator, turns garbage into energy for 20 towns
with a combined population of more than a half-million
residents. The towns now pay only $22 per ton to have their
garbage taken away, compared to $100 per ton that is charged
by the government-operated landfill.
Improved Effectiveness. Wexford County, Michigan privatized
the operation of its animal shelter, following a State of
Michigan inspection where cages were found to be
unsatisfactory and in need of immediate replacement.
Lack of Political Influence. According to U.S. District Attorney
for the Northern District of Illinois Patrick Fitzgerald, “Illinois

roads were made more dangerous when state employees issued
drivers’ licenses to truck drivers in exchange for bribes,
intended to finance campaign contributions to former Governor
George Ryan’s political warchest.” Transferring responsibility
to a private entity with adequate supervision eliminates the
likelihood that officials will meddle in the provision of
services.
Proponents for privatization presume that government entities
are always less efficient than for-profit organizations – a
presumption that is simply not true. For example, Medicare’s
cost of administration as a percentage of claim dollars paid is
considerably less than any private insurer – less than 2%
historically, according to the Congressional Budget Office.
While there is much truth to the many claims of the abuse of
privatization and the problems that often accompany it,
opponents fail to recognize that governments cannot provide all
things to all people. Citizens have an insatiable desire for
services, especially if someone else is picking up the tab. At the
same time, taxpayers are increasingly reluctant to raise taxes to
support even critical services. As a consequence, government
officials ranging from local municipalities to the Federal
Government are forced to find other sources of revenue, cut
costs, and ration services.
7
Disadvantages
Higher Costs for the Public. Privatization often raises costs for
the public and governments.
In reviewing the proposed privatization of the Milwaukee Water
Works, the nonprofit consumer group Food & Water Watch
reports that the private water service would cost 59% more than

public water service.
Declines in Service Quality. What steps can be taken to make
sure that the desired quality of privatized services is provided
and maintained?
Atlanta, Georgia canceled a 20-year contract to run its drinking
water system due to tainted water and poor service.
City of Chicago sold its parking meters operation to a private
firm in 2008, parking rates have jumped to $6.50 per hour with
additional increases built-in for the next five years, causing a
drop in downtown small business sales due to visitors refusing
to pay the high rates. Mayor Rahm Emmanuel ordered an
independent audit of the contract after receiving unsubstantiated
charges of almost $30 million from the private contractor.
Limited Flexibility. Privatization can bind the hands of
policyholders for years.
The Chicago parking meter contract sold to a Morgan Stanley
group is for 75 years
Chicago Skyway Toll Bridge System was leased to a private
company for 99 years.
Indianapolis also sold its parking meter operation for 50 years
The State of Indiana sold control of a toll road for 75 years.
Corruption and Fraud. Privatization opens the doors to
unscrupulous behavior by politicians and businessmen.
The Washington Post reported the finding of the Inspector
General that $450,000 in payments made to former Republican
congresswoman Heather Wilson by four government contractors
did “not meet even minimum standards” for federal payments,
including an absence of any details about actual services
provided. The contractor reimbursed the Energy Department for
the payments.
Opponents of privatization point out that commercial entities
have a primary purpose to make a profit, often targeting a goal
in excess of 10% pretax. According to them, it is illogical that

profits can be reached in every case of privatization by
eliminating waste; it is far more likely that service levels will
be reduced or costs cut by lowering manpower or salary levels.
While there are reasons to justify privatization of some
government services, they claim returning savings to taxpayers
by privatization is unlikely.
Opponents of privatization claim that privatization is simply a
scheme to divert taxpayer dollars to create long-term revenue
streams and profits for corporations. The Public Interest, a
resource center dedicated to “ensuring that public contracts with
private entities are transparent, fair, well-managed, and
effectively monitored,” as well as meeting the needs of the
community, lists a number of potential drawbacks to
privatization:
8
The process by which governments remove, reduce, or simplify
restrictions on business and individuals in order to (in theory)
encourage the efficient operation of markets.
Positive example
Deregulation of the airline industry in the 1970s
Negative example
California energy crisis
https://www.pbs.org/wgbh/pages/frontline/shows/blackout/calif
ornia/timeline.html
Forms of Privatization: Deregulation

One form of privatization is deregulation, which refers to the
process by which governments remove, reduce, or simplify
restrictions on business and individuals in order to (in theory)
encourage the efficient operation of markets. Deregulation has
been often pursued by government as an economic development
strategy. The impact of deregulation is often mixed. There are
positive examples, such as the deregulation of the airline
industry in the 1970s. However there are also negative
examples, such as the California energy crisis in the 1990s.
Detailed descriptions of the examples can be found in your
assigned reading for this class.
Privatization goes beyond economic development purpose.
There are many forms of privatization not aiming at economic
development, but they provide opportunities for firms to do
business with government.
9
California energy crisis 2001
The hiring of private-sector firms or nonprofit organizations to
provide goods or services for the government.
e.g., Defense contracts
Contracting out is the predominant form of privatization in the
US.
Forms of Privatization: Contracting out
The most popular form of privatization in the United States is
contracting out, the hiring of private-sector firms or nonprofit
organizations to provide goods or services for the government.

For example, defense contracts from government have largely
encouraged the development of the arms industry in the nation.
In addition to military products and service, government also
contracts out many services, such as waste collection, human
service, social services, and so on.
11
(sometimes referred to as a joint venture) a contractual
arrangement formed between public- and private-sector partners
that can include a variety of activities that involve the private
sector in the development, financing, ownership, and operation
of a public facility or service.
Public-Private PartnershipS
Public-private partnerships (PPP or P3) are contractual
arrangements between public and private-sector entities. They
typically involve a government agency contracting with a
business or non-profit entity to renovate, construct, operate,
maintain, and/or manage a facility or system, in whole or in
part, that provides a public service. Such joint ownership often
enables larger projects, public land assembly powers, and/or
public backing. Government pays part of the expenses for its
portion of large projects through a variety of the above
mechanisms.
12
Public Private partnerships - Pros
Better infrastructure solutions
Each participant does what it does best
Faster project completions and reduced delay
Use of time-to-completion as a measure of performance and

therefore of profit
Public-private partnership's return on investment
Innovative design and financing approaches become available
when the two entities work together
Risks are fully appraised early on to determine project
feasibility
The private partner can serve as a check against unrealistic
government promises or expectations
Operational and project execution risks are transferred from the
government to the private participant
Private has more experience in cost containment
May include early completion bonuses that further increase
efficiency
Increasing the efficiency of the government's investment
Allows government funds to be redirected to other important
socioeconomic areas
P3s reduces government budgets and budget deficits
High-quality standards are better obtained and maintained
throughout the life cycle of the project
Public-private partnerships that reduce costs potentially can
lead to lower taxes.
https://www.thebalancesmb.com/public-private-partnership-
pros-and-cons-844713
Public private partnerships - cons
Every public-private partnership involves risks for the private
participant, who reasonably expects to be compensated for
accepting those risks. This can increase government costs.
When there are only a limited number of private entities that
have the capability to complete a project, such as with the
development of a jet fighter, the limited number of private
participants that are big enough to take these tasks on might
limit the competitiveness required for cost-effective partnering.
Profits of the projects can vary depending on the assumed risk,
the level of competition, and the complexity and scope of the

project.
If the expertise in the partnership lies heavily on the private
side, the government is at an inherent disadvantage. For
example, it might be unable to accurately assess the proposed
costs.
https://www.thebalancesmb.com/public-private-partnership-
pros-and-cons-844713
Privatization of Prisons PROS
1. Privatized prisons tend to be able to be run at lower costs.
There is a greater emphasis on cost management in a private
organization than there is through public service. Public
servants also tend to make more money in salary in the
corrections field than private workers do. Through cost-cutting
and a 50% reduction in wages that a private institution can
provide, it becomes easier to house the amount of inmates that
need to be contained.
2. Privatized prisons tend to be run more efficiently.
Profitability is certainly an issue, but so is the overall
efficiency of the prison. Better medical care and prisoner
management through rehabilitation can occur because the entire
process of the prison has been streamlined. When there isn’t as
much red tape that must be cut through in order to get
something done, everyone benefits.
3. Privatized prisons can lead to a better overall recidivism
performance.
With financial incentives in place, privatized prisons have a
reason to make sure that prisoners get the help that they need.
This tends to lead to safer conditions, better living conditions,
and more effective rehabilitation programs. Whenever financial
rewards are tied to recidivism rates in a community, the
privatized prison will lower the rates of crime.

CONS
1. There can be a lack of transparency.
Public institutions are required by the laws of most jurisdictions
to be completely transparent in their activities. Privatized
institutions, on the other hand, don’t necessarily have that same
provision. When it comes to the management of prisoners,
transparency is extremely important. There is no other way to
determine if prisoners are being treated fairly then through a
transparent system of policies.
2. There is a risk of dependency.
If just one or two companies are relied upon to provide prison
needs, then those companies can begin to dictate the terms and
conditions of their contracted agreements to their advantage.
The public institution will have no choice but to pay those costs
because they have stepped away from their role in the prison
system and the result might be higher costs.
3. Money becomes a priority.
If the prison starts losing money, what is going to happen to the
prisoners? There’s a good chance that the quality of food for the
living conditions will be reduced in order for profitability to be
achieved once again.
Prison privatization
https://www.youtube.com/watch?v=QWqs_igPIBI&feature=yout
u.be
Question
Should all government services be privatized? Should any? If
so, which ones?
What are the potential advantages and disadvantages of
privatizing correction services (prisons)?
What are the social implications of privatizing correction
services.

18
Entrepreneurial Strategy
19
Economic Development Strategies
Entrepreneurial strategies:
Adoption of policies that promise to increase public revenue,
focusing on new firm and technology development – creative
and innovate ways to increase revenue
A “demand-side” approach – advocates use of government
spending and growth in the money supply to stimulate the
demand for goods and services
Typical tools:
business and innovation assistance centers,
technology and business parks,
venture financing companies,
one-stop business information centers,
technology transfer programs,
workforce development programs,
export promotion programs, etc.
20
20
ES seeks to improve the capacity of local firms and/or

specifically targets entrepreneurs and growth-producing
economic sectors.
Offer to all firms alike
Demand Side - economic theory that advocates use of
government spending and growth in the money supply to
stimulate the demand for goods and services and therefore
expand economic activity
What are the key characteristics of a public entrepreneur?
21
21
• Collaborating and networking. Collaboration is fundamental to
the public entrepreneur – they seek to build partnerships for
change across government, business, and society.
Working across systems – public entrepreneurs see themselves
as part of a system rather than just an organization or public
department.
Building narratives for change – Entrepreneurs persuade,
influence, and sell. They influence behavior, social innovation
and persuade colleagues – administrators, politicians, and
citizens. Even though public servants are risk averse they are
willing to take chances.
Leveraging new resources – finding new ways of financing
public service and development. Example – pooling budgets,
looking for public-private partnerships
Focusing on Outcomes – Public entrepreneurship is about doing

whatever it takes to get the right outcome, even if it means
abandoning traditional public servant mindsets
Adapting and learning – What do most entrepreneurs have in
common? They are all willing to take risks. A motto for
entrepreneurs – Fail quickly, Fail Fast, and Fail Cheaply!
Public entrepreneurs are not dealing with their own money
though – So, they must take into consideration not only the
human factor but the financial cost as well.
Disadvantages related to public entrepreneurship.
Entrepreneurial economic development projects entail high
risk; a project failure would lead to huge financial public loss
City of San Bernardino joined the private sector via a baseball
team and real estate development firm to build a stadium. Idea
was to generate activity in the city.
Public-private partnerships in economic development blur the
lines between public and private goals.
Partnerships do not always bring together the best of both the
public and private sectors – can lead to confusing roles
Public sector selects projects based on profitability and is not
always concerned with social worthy but unprofitable projects
Socially beneficial such as affordable housing, community
center, libraries, and public parks
Entrepreneurial City
Features of Entrepreneurial City
React to globalization
Cities pursue innovative strategies to maintain or enhance the
city’s economic competitiveness in global economy
Operationalize entrepreneurialism
Cities use explicit formulated, real and reflexive strategies to
pursue active entrepreneurialism
Establish an entrepreneurial business climate

Cities market themselves as entrepreneurial and adopt
entrepreneurial discourse
Partner with private sector
actively partnering with the private sector in launching
“homegrown” economic development projects
Entrepreneurial city:
Acting like private co.
Undertake high risk project
Using innovative financing mechanisms (TIF, facility naming
rights, lottery games, special license plates)
23
Critique of Economic Development Implementation: San
Bernardino
Baseball Stadium
Background
The need of a new stadium
Fierce competition among jurisdictions for sports team
Previous loss of a team to a new stadium in Rancho Cucamonga
Chamber of Commerce aggressively promoting a new stadium
The project:
$18m funded by tax allocation bonds
Lease agreement: profit to team owner and expense to public
None of the original predicted economic impacts materialized
Vacant lots
High maintenance cost
The problems:
Original expenses were manipulated so little profit was
available to the city – 18 million funded through tax allocation
bonds and was much higher than the projected 13 million
None of the original predicted economic impacts materialized.

Surrounding vacant lots
Spillover effects never materialized
High maintenance cost; the facility cost the city over $30,000 a
year
Eventually signed over to private sector owners at a large loss;
today, moderately successful as an island of activity.
Turned over to Arrowhead (Arrowhead Credit Union Park);
turned over to San Manuel Tribe and renamed San Manuel
Stadium in 2012
24
--We will use SB for our examples: tough row to hoe because it
has not had natural dynamics leading to redevelopment (as we
saw in coastal cities)
stadium: poor deal but at least functioning, discuss how much
spillover there has been (little); originally expenses were
manipulated so that there was little profit to share; renegotiated
in 2002 with the renaming but still financially weak:
--Chamber member: expectation: annual attendance of over
200,000; spillover effect (restaurant, downtown)
--$18m funded by tax allocation bonds (1996), higher than
projection $13m
Lease agreement: profit to team owner and expense to public,
Initial 10 year lease gave team owners parking fees, 2/3 of net
profits from all concessions including non-sporting events, City
received certain percentage of net profits from ticket sales,
stadium cost controlled by team owners who charge very high
--None of the original predicted economic impacts materialized
Surrounded by Vacant lots

High maintenance cost: simply maintaining the facility costs the
EDA $30,000 per year.
--Turned over to Arrowhead (Arrowhead Credit Union Park)
25
Spillover effects?
26
Positive Examples in San Bernardino
Norton Air Force Base
The former Norton Air Force Base, now known as San
Bernardino International Airport, has been transformed into a
flourishing business complex where huge modern buildings
have replaced military structures. Selected to close in 1988 and
finally closed in 1995
In 1990, a joint powers authority called the Inland Valley
Development Agency (IVDA) was formed to oversee
redevelopment of the non-aviation portion of the former Norton

Air Force Base.
10,700 full time jobs restored in the region as a result of the
economic development efforts at the former Norton Air Force
Base
An additional 5,000 indirect jobs culminating in nearly $1.9
billion of economic output
After years of revitalization and infrastructure improvements in
and around the former base, it has now surpassed the direct jobs
lost by the base’s closure in 1994
The base reuse area includes the San Bernardino International
Airport and the adjacent land designated as Alliance California,
which is home to Fortune 100 and 500 firms, as well as
international and local businesses that have invested and
continued to invest in growing their operations.
SBIA is a Foreign Trade Zone - offering federal tax incentives
to businesses locating there and allows for California tax credits
to qualifying businesses operating there.
Major projects
Stater Bros’ distribution center
Pep Boys’ facility
Mattel
Kohl’s
Amazon
Commercial airport – to Mexico
US Customs and Border Protection
US Forest Service
Foreign-Trade Zones (FTZ) are secure areas under U.S.
Customs and Border Protection (CBP) supervision that are
generally considered outside CBP territory upon activation.
Located in or near CBP ports of entry, they are the United

States' version of what are known internationally as free-trade
zones.
27
City of Rancho Cucamonga
Incorp. Nov. 1977
38.3 square miles
Population is
approximately 176,000
Top 10 fastest growing cities with a population of 100,000 or
more in the U.S.
29
RC home to Empire Lakes golf course that annually hosts the
PGA Nationwide Golf Tour. In addition, the city also has a
6,500 seat stadium, home to the Quakes, the Class “A” baseball
team affiliate of the Calif. Angels. Other
shopping/entertainment venues nearby include the Calif.
Speedway and the Ont. Mills Mall. Low crime rate, excellent
schools. Median House Price – 415,000

Rancho Cucamonga Family
Median Income - $79,973
Median Age – 32.2 years
Education – High School graduate or higher 91.1% –B.A. or
graduate degrees 33.2 %.
Over 45% of new residents have worked in management or the
professions.
30
Last bullet point – since 1990, over 45% of the city’s new
residents have worked in management or the professions.
(Source Census: 1990 & 2000)
Victoria Gardens
A Rancho Cucamonga Success Story
210 Fwy.
15 Fwy.
Day Creek Blvd.
Victoria Gardens
Base Line Rd.
Foothill Blvd.

32
Reasons Why Area Lacked Development
Lack of Infrastructure – streets, storm drains, utilities - $45
million estimated cost
Multiple property owners – no one could afford to develop
ahead of others
Market demand was low
Lack of interest from high end retailers
33
Victoria Gardens
The 175-acre project - shops, restaurants, a movie theater,
office space, and a variety of civic uses on a street grid
Idea was to transform the city’s civic identity and create a new
focal point in Rancho Cucamonga
It was to appear as if the project had evolved over time from a
small grouping of agricultural buildings to a lively, small town
main street – mix of buildings
Public and Private Investment
Public/private partnership among Forest City Commercial
Development, the Lewis Group of Companies, and the Rancho
Cucamonga Redevelopment Agency
Agency owned land valued at $27 million
Agency built parking structures - $12 million
Contributed $2 million for public street to serve Cultural Center
Agency wanted a “placemaking” development
Total development cost was approximately $234 million,

including $188 million direct private costs,
Developer participated in public financing for infrastructure –
130 million construction loan
Placemaking is a multi-faceted approach to planning, designing,
and managing public spaces. Rancho wanted to not only focus
on economic development programs and attract and retain
businesses but they wanted to create a sense of community.
They were looking to attrazct talented residents by offering a
center of innovation and creativity.
35
Return on Public Investment
Promissory Note from Developer to Agency for $13 million
Participation in profits in 4th year
Estimated rate of return on the Agency’s investment exceeds
16.5% = $167 million in revenues over a 30 year period.
Sales tax annually at $3 million and growing
Property tax annually at $2.5 million and growing
Public Safety facility on site at no cost to City
Additional Benefits
Upscale shopping & restaurant choices
for two-county region
Over 3,000 new full and part time jobs were created with a
payroll exceeding $50 million a year
PLACEMAKING– first pedestrian friendly, open air mixed use
design configuration in the Inland Empire

Catalyst for additional
development: 1,350 new homes; 800,000 square feet of
additional retail and additional sales tax
Catalyst For Retail Development
Victoria Gardens
Foothill Blvd.
Base Line Rd.
Arrow Rt.
Rochester Blvd.
I-15
I-210
Victoria Gateway Center 113,000 s.f.
Foothill Crossing 300,000 s.f.
Day Creek Blvd.
Bass Pro Shops
Tourist Destination
First Store in CA.

2-3 Million Visits Annually
Foothill Crossing
Sears Grand 180,000 s.f.
Foothill Blvd.
Arrow Rt.
I-15 Fwy.
Day Creek Blvd.
Victoria Gateway Center By Regency Development
Foothill Blvd.
Base Line Rd.
Rochester Blvd.
I-15
Day Creek Blvd.
REI 23,500 s.f.
Circuit City 34,000 s.f.
Look at Me Now
Experience Gained
From the city’s perspective, the project has been very
successful, generating in excess of $5 million in sales and

property taxes annually. The estimated internal rate of return on
the Rancho Cucamonga Redevelopment Agency’s
Furthermore, the project has spurred the development of
500,000 square feet of other retail space on adjacent parcels.
The town center approach as well as the tenant mix required for
Victoria Gardens’ success was risky given the retail forms that
persisted in the Inland Empire. In the end, the novelty of the
project’s configuration translated into a competitive advantage.
Leasing was initially challenging, but after a critical mass of
tenants was obtained, leasing additional tenants became much
easier.
The vast majority of Victoria Gardens’ retail space is single
story; in retrospect, Forest City might have considered
incorporating residential units over the retail uses.
Only time will tell how the project’s seemingly incremental
design ages. One major benefit …
8 Schizophrenia Spectrum and Other Psychotic Disorders
Marcus Butt/Ikon Images/SuperStock
Chapter Objectives
After reading this chapter, you should be able to do the
following:
• Describe and explain how schizophrenia is diagnosed.
• Describe and explain what causes schizophrenia.
• Describe and explain how schizophrenia is treated.
• Describe the other schizophrenia spectrum and psychotic
disorders and differentiate them from

schizophrenia.
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214
Section 8.1 The Genesis of Schizophrenia
Schizophrenia is among the most catastrophic of all
psychological disorders, with a lifetime
prevalence ranging from about 0.3% to 0.7% (American
Psychiatric Association [APA], 2013)
and about 2.5 million cases in the United States alone (Lambert
& Kinsley, 2005). This means
that approximately 1 of every 100 people in the world suffers
from schizophrenia during his
or her lifetime (Lindenmayer & Khan, 2012; Long et al., 2014).
One meta-analysis shows the
worldwide lifetime prevalence at 0.48% (Simeone, Ward,
Phillip, Collins, & Windish, 2015).
According to the National Institute of Mental Health (2010), an
estimated 24 million people
worldwide are afflicted with the disorder. It typically strikes
young adults, who may suffer for
decades as schizophrenia wrecks their social relationships,
impairs their thinking and health,
and robs them of the ability to enjoy life. Schizophrenia also
represents a massive drain on
society’s resources. Many patients cannot work, many require
public assistance, and most
require expensive treatment (Wu et al., 2005). Faced with

numerous difficulties, not only psy-
chological and behavioral but also economic, many individuals
with schizophrenia attempt
suicide (at least 25% to 50% may attempt it, and about 4% to
13% may successfully complete
it; Lee, Lee, Koo, & Park, 2015). These tragic deaths add to the
guilt and pain already borne
by the families of individuals with schizophrenia. However,
with proper intervention, family
involvement in treatment, better education (especially through
mass media), and perhaps
most important, early identification, many individuals with
schizophrenia can lead meaning-
ful lives.
Schizophrenia falls under the category of schizophrenia
spectrum disorders. The other disor-
ders in this category are discussed later in this chapter. The
signs and symptoms of schizo-
phrenia are not simply more extreme forms of everyday
behavior, as with anxiety, depressive,
or bipolar and related disorders. Some of the symptoms
associated with schizophrenia are
rarely, if ever, encountered in daily life. Still, it is important to
remember that no matter how
bizarre their behavior, people with schizophrenia are human
beings who experience love,
hurt, joy, grief, and all the other human emotions and feelings.
To help us keep in mind the
human side of the tragedy that is schizophrenia, this chapter
refers frequently to the story of
Jennifer Plowman. Let’s begin with Part 1 of her case study.
8.1 The Genesis of Schizophrenia
We can all identify with people who are depressed or anxious.
Most of us have been there

ourselves, in the sense that at some time or another we have all
experienced the “blues” or
felt nervous and worried about events occurring in our daily
lives. There is nothing baffling or
impenetrable about depression, or anxiety, or even mania.
Schizophrenia is different. Schizo-
phrenia is not a personality disorder (these will be discussed in
Chapter 9), and as discussed
in Chapter 5, it is definitely not a dissociative disorder, such as
dissociative identity disorder.
People with schizophrenia behave in ways that most of us find
incomprehensible. They may
believe that other people can read their thoughts or that friends
and neighbors are engaged in
elaborate plots against them. In different historical periods,
people who have displayed these
behaviors have been given pejorative labels such as “mad,”
“crazy,” “insane,” and “lunatic,” but
such behaviors can be more accurately and appropriately
categorized as symptoms of a group
of disorders known as the psychoses, disorders characterized by
gross distortions of reality.
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215
The Case of Jennifer Plowman: Part 1

Transcript of a Commitment Hearing for Jennifer Plowman
COUNTY COURT
COURT TRANSCRIPT
Marion County
Presiding: Hon. Richard Harding
JUDGE: You are requesting that your daughter, Jennifer, be
involuntarily committed to
University Hospital? Are you represented by legal counsel?
ANNE PLOWMAN: No, Your Honor. I can’t afford a lawyer.
JUDGE: I can see that you receive public assistance.
ANNE PLOWMAN: I do not want my daughter to wait for
public assistance. Jenny refuses to
go to the hospital on her own, and she desperately needs help.
JUDGE: Why do you say this?
ANNE PLOWMAN: Jenny has not left the house for days. She
has not washed or changed her
clothes. She just sits in her room. Sometimes I hear her talking
to herself. Other times I can
hear her laughing and swearing. Jenny says that she cannot
come out of her room because
people can read her thoughts. Your Honor, she desperately
needs help.
JUDGE: Has she threatened you or anyone else?
ANNE PLOWMAN: No.

JUDGE: Has she harmed herself?
ANNE PLOWMAN: She won’t wash or change her clothes.
JUDGE: But has she tried to hurt herself, cut herself, or
something similar?
ANNE PLOWMAN: No. She says that there is nothing wrong
with her.
JUDGE: I do not want to deprive Jenny of her liberty unless
there is some good reason. Jenny
is a 21-year-old adult. If she is not dangerous to herself or
anyone else, then she should
choose for herself whether she needs treatment.
ANNE PLOWMAN: Please, Your Honor. I’m so worried. Isn’t
there something you can do to
help?
JUDGE: Perhaps we can talk her into going voluntarily into
University Hospital. If not, I will
commit her, but only for 72 hours so that she may be examined
by Mental Health Services.
Once I receive their report, I will decide how to proceed.*
*Note: The requirements for involuntary commitment vary from
state to state. In general,
they include the presence of a mental illness, dangerous
behavior toward self or others, grave
disability, and the need for treatment. A person can be
involuntarily committed for 72 hours
and must be released if there are no reason(s) to retain the
individual.

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216
Emil Kraepelin (1856–1926) devised a classification system for
psychotic conditions. After
examining a group of hallucinating and delusional patients, he
distinguished between two
types of psychotic disorders. In the first type, serious mental
symptoms began in adolescence
or early adulthood and followed a deteriorating course. In the
second type, symptoms fol-
lowed a cyclical course in which periods of remission alternated
with psychotic episodes.
Kraepelin named the cyclic psychosis manic-depressive
disorder. Kraepelin called the continu-
ously deteriorating psychosis dementia praecox (translated from
Latin, means “premature
dementia”). Kraepelin believed that the deterioration he
observed in dementia praecox was
the result of a progressive organic brain syndrome that began
early in life.
In contrast to Kraepelin, Swiss psychiatrist Eugen Bleuler
(1857–1939) rejected the idea that
the course of a disorder, alone, could ever distinguish one
psychosis from another. Bleuler pre-
ferred to classify psychological disorders on the basis of their

characteristic signs and symp-
toms, rather than on their course and outcome (Bleuler,
1911/1952). The DSM–5 adopted
Bleuler’s approach.
Bleuler proposed that the name dementia
praecox be replaced with schizophrenia,
a term derived from the Greek words for
“split” (schizo) and “mind” (phrene). It is
important not to confuse Bleuler’s concept
of schizophrenia with dissociative identity
disorder (formerly called multiple person-
ality disorder, as discussed in Chapter 5).
Bleuler’s “split” was not among personali-
ties but among cognitions within a single
personality. In schizophrenia, thoughts
become split (disconnected) from one
another. People race from one idea to the
next, often with no obvious connection.
Bleuler believed that a “loosening of asso-
ciative threads” among cognitions was the
common link among a set of heterogeneous
disorders that he loosely grouped together
and called the “schizophrenias.”
Bleuler’s symptoms for schizophrenia
included hallucinations (sensory experi-
ences in the absence of external stimuli),
delusions (unsubstantiated beliefs), odd
motor movements, and bizarre behavior.
For example, individuals with schizophre-
nia might walk around in public wearing a
lion’s pelt in the middle of summer and talk-
ing to themselves, or they might sit in the
middle of a busy street beating the ground

Vlue/iStock/Thinkstock
The term schizophrenia derives from the Greek
words for “split” (schizo) and “mind” (phrene)
in order to demonstrate the disconnected, or
split, thoughts that occur within the mind.
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217
with drumsticks. They might be combative or easily agitated.
Bleuler always referred to “the
schizophrenias” rather than simply to “schizophrenia.” He
insisted on the plural because he
believed that several different but related disorders were
responsible for psychotic behav-
ior. Although this chapter uses the more common singular term
schizophrenia, Bleuler was
undoubtedly correct; schizophrenia is far from a homogeneous
diagnostic category.
Signs and Symptoms
The DSM–5 diagnostic criteria for schizophrenia are relatively
narrow (see Table 8.1). Yet,
despite this narrowing, there is no single symptom or set of
symptoms that describes all
people with schizophrenia. The schizophrenic syndrome is
heterogeneous (mixed or var-
ied or different; homogeneous means “the same”) in the

presentation of symptoms, course,
response to treatment, and outcome. These differences among
people may mean that Bleuler
was correct: Schizophrenia is not a single disorder but a
syndrome or series of disorders with
different etiologies and outcomes (Cuesta & Peralta, 2016).
In addition to schizophrenia, the DSM–5 describes seven other
psychotic disorders, each of
which shares some characteristics with schizophrenia (see Table
8.2).
Table 8.1 Main DSM–5 diagnostic criteria for schizophrenia
A. Characteristic symptoms: two (or more) of the following,
each present for a significant portion of time
during a one-month period (or less if successfully treated). At
least one of these must be (1), (2), or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech (frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (diminished emotional expression or
avolition)
B. For a significant portion of the time since the onset of the
disturbance, level of functioning in one or more
major areas, such as work, interpersonal relations, or self-care
are markedly below the level achieved
prior to the onset (or when the onset is in childhood or
adolescence, failure to achieve expected level of
interpersonal, academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least six
months. This six-month period must include
at least one month of symptoms (or less if successfully treated)

that meet criterion A (active-phase
symptoms) and may include periods of prodromal or residual
symptoms. During these prodromal or
residual periods, the signs of the disturbance may be manifested
by only negative symptoms or two or
more symptoms listed in criterion A present in an attenuated
form (for example, odd beliefs or unusual
perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder
with psychotic features have been ruled out
because either (1) no major depressive or manic episodes have
occurred concurrently with the active-
phase symptoms; or (2) if mood episodes have occurred during
active-phase symptoms, they have been
present for a minority of the total duration of the active and
residual periods.
E. The disturbance is not due to the direct physiological effects
of a substance (for example, a drug of abuse
or a medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a
communication disorder of childhood onset
[see Chapter 11], the additional diagnosis of schizophrenia is
made only if prominent delusions or
hallucinations, in addition to the other required symptoms of
schizophrenia, are also present for at least
a month (or less if successfully treated).
Source: APA (2013, p. 99).
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218
At first glance, it might appear to the untrained eye that all
schizophrenia spectrum and other
psychotic disorders are similar, if not almost identical. After
all, most, if not all, include hal-
lucinations and delusions among their diagnostic criteria.
However, this is not the case. The
accompanying Highlight briefly examines two disorders that
appear similar to schizophrenia
but are not.
Although the DSM–5 contains diagnostic criteria for each of the
schizophrenia spectrum and
other psychotic disorders, researchers have tended to neglect the
other disorders in favor
of schizophrenia. For this reason, this chapter focuses on
schizophrenia, although the other
disorders are mentioned when appropriate.
Positive Versus Negative Symptoms
Schizophrenic symptoms are divided into two main categories:
positive and negative. In this
context, positive and negative do not mean good or bad. Instead
they mean the presence (posi-
tive) or absence (negative) of something. Positive symptoms
reflect an excess or distortion
of normal cognitive and emotional functions; negative
symptoms reflect a reduction or loss
of normal functions. The most common positive symptoms are
delusions, hallucinations, dis-

organized speech and thinking, inappropriate affect, and bizarre
motor movements. The neg-
ative symptoms are loss of initiative, lack of emotional
expression, and impoverished speech.
Although the distinction between positive and negative
symptoms may have some practical
value in predicting who will respond to treatment, it is a rather
crude dichotomy (Velligan
et al., 1997). Positive symptoms can occur in people who have
major depressive disorder,
Table 8.2 Main DSM–5 psychotic disorders
Schizophrenia: A psychotic disturbance lasting more than six
months that includes one or more of the
following: delusions, hallucinations, disorganized speech, or
odd movements.
Schizophreniform disorder: A disorder with symptoms similar
to schizophrenia but with a shorter duration
(between one and six months).
Schizoaffective disorder: A combination of a mood disorder and
symptoms similar to those found in
schizophrenia.
Delusional disorder: A disorder characterized by at least one
month of delusions that are not bizarre in
character and with none of the other symptoms of
schizophrenia.
Brief psychotic disorder: A disturbance in which psychotic
symptoms last for less than one month.
Psychotic disorder due to another medical condition: A

disturbance in which psychotic symptoms develop
directly from a medical condition, such as a seizure disorder
(epilepsy), migraine headaches, or multiple
sclerosis.
Substance/medication-induced psychotic disorder: A disorder in
which psychotic symptoms are the result of
substance abuse or exposure to a toxin.
Catatonia: A disorder in which the individual displays at least
three symptoms including stupor (no
psychomotor activity), waxy flexibility (slight resistance to a
professional’s attempt to change the
individual’s body position), and mutism (no or very little verbal
response).
Source: Reprinted with permission from the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition,
(Copyright
©2013), p. 99. American Psychiatric Association. All Rights
Reserved.
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219
bipolar I disorder, delusional disorder, and schizoaffective
disorder, among other conditions.
In schizophrenia, positive symptoms do not seem to be closely

related to one another. Some
people with schizophrenia have only one positive symptom;
others have many. Similarly, neg-
ative symptoms are not specific to schizophrenia (they are also
found in depressive, and bipo-
lar and related disorders). Approximately 60% of individuals
with schizophrenia exhibit pos-
itive symptoms such as hallucinations and delusions
(Lindenmayer & Kahn, 2006), whereas
approximately 41% display at least two negative symptoms
(Patel et al., 2015).
Delusions
Delusions are odd or unusual ways of thinking that lie outside
the realm of reality or do not
have rational explanations. To be considered a potential
symptom of schizophrenia, a delu-
sion must be contrary to a person’s background and must not be
held by members of the
person’s cultural or ethnic group. For example, members of a
cult who believe that the world
will come to an end on a certain date are probably not showing
signs of schizophrenia. By
Highlight: Differentiating Among Schizophrenia and
Schizoaffective and Delusional Disorders
In schizoaffective disorder the individual must have a major
mood episode (this means a
major depressive or manic episode) along with criterion A of
schizophrenia (delusions,
hallucinations, disorganized speech, negative symptoms, and/or
grossly disorganized or
catatonic behavior; see Table 8.1). In addition, the delusions or
hallucinations must be
present for at least two weeks while a depressive or manic

episode is not present. Third, the
manic or depressive episode must be present for most of the
total length of the active portion
of the mental illness (APA, 2013). In other words, the
individual must have symptoms of
schizophrenia as well as a major mood episode during the
illness, unlike schizophrenia,
where a major mood episode has not occurred with the active-
phase symptoms. In addition,
schizoaffective disorder is rather rare, affecting 0.3% of the
population, making it a third
as likely to occur as schizophrenia (APA, 2013). Although it is
difficult to differentiate
schizoaffective disorder from schizophrenia, one need only
assess if the criteria are being
met for a manic or a major depressive episode during the
majority of the active phase of the
illness. If so, then one is most likely seeing schizoaffective
disorder.
Delusional disorder differs from schizophrenia in one key
aspect: Criterion A for
schizophrenia has never been met. If hallucinations are present,
they are not a prominent
feature and are related to the delusion’s theme (for example, an
individual who constantly
hears voices saying that his or her every move is being closely
watched and recorded in
association with the delusion of persecution). In addition, the
individual’s functioning is
not very bizarre or odd. Also, if the individual has manic or
major depressive episodes, they
are brief. Delusional disorder is less common than
schizophrenia and is a bit rarer than
schizoaffective disorder, occurring in about 0.2% of the
population.

Perhaps the most important differentiation among these three
disorders is that
schizophrenia is the most debilitating of the three disorders,
oftentimes defying treatment
progress or success. Individuals with schizophrenia often end up
among the nation’s
homeless population.
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220
contrast, educated middle-class Americans who believe that
mice are scientifically advanced
aliens who were sent to colonize the Earth and destroy humanity
most probably are.
According to her mother, Jennifer Plowman believed that
“people” could “read her mind.” This
belief was explored by Dr. Stuart Berg, the psychologist who
evaluated Jennifer on her second
day in the hospital. Part of their discussion appears here.
The Case of Jennifer Plowman: Part 3
Transcript From an Interview Between Dr. Berg and Jennifer
Plowman
DR. BERG: Jenny, your mother says that you refused to leave

your house. How come?
JENNIFER: Come, lum, rum is a drink that sailors like.
DR. BERG: But, why did you refuse to go outside?
JENNIFER: I am fine. Why do I need to be here? The walls
protected me at home.
DR. BERG: From what?
JENNIFER: Selegonite cannot get out of lead. There is lead in
the bed and the walls and halls.
Outside, they can get through.
DR. BERG: Who can get through?
JENNIFER: They can hear my thoughts. Without the lead, they
leak out, and they can hear
them. I can hear them laughing. They find out what I am
thinking, and they laugh at their
success.
DR. BERG: You believe that lead in the walls of your house
keeps people from reading your
mind. While you are outside of the house, without the lead to
protect you, people will read
your thoughts and laugh when they manage to get what they
want.
JENNIFER: Yes. Like Superman. I know the secret because I
am a rocket scientist. I have flown
to space. I can develop new rockets that run on special minerals.
I am too smart for this place.
I should be at home.

Additional Transcript of Jennifer Plowman’s “Background
Chatter” at
Her Intake Interview
Men need sex. I have had sex 10,000 times. That window is in
the room because you want
patients to know the color of the world. I know the president.
He lives in town. I didn’t like
his movie. He just wants to win the Academy Award. His movie
is my life. I made a movie
once. It had lots of stars. The cameraman was my friend. The
sound technician was excellent.
Where are the mics and cameras hidden? Is this logomouth here
to get me nervous? My
father died last year, leer, jeer, tears on my pillow, pain in my
heart over you, what can I do?
There is nothing wrong with me, you know. I don’t know why I
am here. I’m fine.
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221
Although Jennifer’s delusions are relatively vague and
incoherent, this is not always the case
(Maher & Spitzer, 1993). For some individuals with
schizophrenia, delusions can be system-
atic, be elaborate, and have a common premise. Persecutory
delusions (also called paranoid
delusions) are beliefs held by people who insist that someone is

out to get them. Thought
insertion delusions (sometimes called delusions of influence)
are a category of delusion in
which people believe thoughts are being inserted into their
heads. Grandiose delusions,
when people believe they have some extraordinary talent or
power, are also relatively com-
mon. For example, they may think they can control the weather
or the stock market, or that
they are Christ or Bill Gates.
In Capgras syndrome, people believe that someone they know
has been replaced by a dou-
ble (Moschopoulos, Kaprinis, & Nimatoudis, 2016), and in
Cotard syndrome, the individual
believes he or she is dead (Cannas et al., 2017). Both of these
kinds of delusions are very rare.
Incorrect but plausible delusions (for example, “my assistant is
plotting to get my job”) may
also be seen in individuals with schizophrenia, but bizarre
delusions have greater diagnostic
value. The problem with plausible delusions is that they may
not be delusions at all. After all,
even delusional people can have enemies.
Interestingly, most people with schizophrenia find it difficult to
believe that others consider
their ideas hard to believe and perhaps even outlandish. They
cling to their beliefs even in the
face of compelling negative evidence.
Delusions vary in the extent to which they disrupt everyday
functioning. Some individuals
with schizophrenia are totally preoccupied with their odd
beliefs, whereas others are only
minimally impaired. In fact, you may never even know that

some people have delusions
because they are perfectly rational and can get along well
except when someone brings up the
subject of their delusion. For example, one person might believe
that she is a religious demi-
god, or perhaps Batwoman, who will save her city from being
overrun with crime. Another
might believe that he is a famous artist and paint, and display
his works on the sidewalk for all
to enjoy, even though to a trained eye they are just scrawls on
canvas. Something to consider:
Do these kinds of delusions pose a danger to the individual or to
others? Keep this question in
mind as we continue the discussion.
Hallucinations
We all have sensory illusions. If you’re alone
in your house at night, you may think you
hear a burglar when there is no one around.
Walking across campus, you think you hear
your name being called, and yet there is no
one there. These experiences do not mean
that you have schizophrenia. It is only your
imagination “playing tricks.” In contrast,
people who have schizophrenia consider
such sensory illusions quite real.
Hallucinations are perceptions that occur
without any external stimuli. Auditory hal-
lucinations, such as hearing external voices,
Thomas J Peterson/Exactostock-1672/SuperStock
Some individuals with schizophrenia believe
that people can read their minds, or insert
thoughts into their heads, common delusions.
To guard against this, they may cover their

head with tin foil.
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222
are the most common type, occurring in as many as 70% to 80%
of individuals with schizo-
phrenia (Chhabra et al., 2016; Gram-Henriksen, Raballo, &
Pamas, 2015). Different cultures
tend to produce different hallucinations: Visual, olfactory
(particularly rotten odors), and
tactile (touch) hallucinations (such as the feeling that bugs are
crawling under one’s skin)
are associated with schizophrenia in the United States (Bauer et
al., 2011; Larøi et al., 2014).
Another example of a culture-specific hallucination involves an
Amazonian people called the
Bororo. In this culture, the novice shaman is identified when he
has a dream of soaring high
above the earth, like a vulture, and seeing the fiery cloud of
smoke that indicates an attacking
illness (Larøi et al., 2014). To the person with active
schizophrenia, these voices, odors, and
sounds are not imaginary; they are real.
Imaging techniques have given researchers insight into what is
going on in the brains of people
when they hallucinate. One study found that the part of the

brain most active during schizo-
phrenic auditory hallucinations is the area responsible for
speech production, not the brain area
responsible for speech comprehension (Donata-Wolf et al.,
2011). This finding suggests that when
people with schizophrenia hallucinate, they are not “hearing”
voices in their brain but instead are
reporting their own thoughts. In effect, they are listening to
their own voices and thoughts and
cannot differentiate these from someone else talking to them
(Chhabra et al., 2016).
Disorganized Speech
As you can see from the earlier interview excerpts,
Jennifer Plowman’s speech was distinctly odd. She
made up words, such as selegonite (these are known
as neologisms). She also jumped from one topic to
the next, a phenomenon known as thought derail-
ment. Jennifer also linked words together according
to their sound, as in “come, lum, rum.” These sound-
based sequences are known as clang associations.
Like Jennifer, people with schizophrenia often give
irrelevant responses to questions, a phenomenon
known as tangentiality. When the disorganization
becomes extreme, the result is word salad, a mass
of disconnected words (for example, “I saw a rat
earlier yet it really smells in here yabba glick morch
blargh”). In contrast to Jennifer, many people with
schizophrenia speak very little; others are exces-
sively literal or concrete.
The incoherent speech produced by Jennifer, and
other people with schizophrenia, is often taken …

5 Dissociative Disorders and Somatic Symptom and Related
Disorders
Roman Barelko/Hemera/Thinkstock
Learning Objectives
After reading this chapter, you should be able to:
• Differentiate between dissociative and somatic symptom and
related disorders.
• Describe what roles are played by unconscious thoughts and
feelings in causing these disorders.
• Describe how helping professionals treat dissociative
disorders.
• Differentiate among the different treatment methods, and
theoretical perspectives, of dissociative identity
disorder.
• Describe how helping professionals treat somatic symptom
and related disorders.
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122
Dissociative Disorders and Somatic Symptom and Related
Disorders

If anyone knows what it’s like to be paralyzed and still have
feelings it’s me. I
could use a few moments of oblivion. (Dr. Christian Troy to Dr.
Liz Cruz, Nip/
Tuck)
Sigmund Freud believed that everyday memory lapses might be
caused by the repression of
troubling thoughts and feelings. By using examples from typical
life situations, Freud hoped
to demonstrate that repression is not an abnormal process but
rather the ego’s routine way
of defending itself against unacceptable thoughts and impulses.
He maintained that every-
day memory lapses and slips of the tongue obey the same
psychological principles, and are
explainable by the same theories, as psychological disorders.
The difference between them is
one of degree. Repression, a normal psychological process,
causes a mental disorder when it
becomes so pervasive that it interferes with either occupational
or social functioning. This is
consistent with one of the recurrent themes of this book—an
acknowledgment of the conti-
nuity between normal and abnormal behavior.
Over the years, theorists have challenged many of Freud’s
views, but the idea that uncon-
scious thoughts and emotions can produce psychological
disorders still seems to prevail
when it comes to the DSM–5 categories discussed in this
chapter—dissociative disorders and
somatic symptom and related disorders.
Although they are the most written about, and indeed

fascinating, psychological disorders,
we know surprisingly little about the etiology and treatment of
the dissociative disorders and
somatic symptom and related disorders. Dissociative disorders
derive their name from their
main symptom—the “disassociation” of the personality.
(Dissociation here refers to the sepa-
ration between the personality and the body. That is, the body is
physically there while the
mind is elsewhere.) Our personalities are the totality of our
inner experiences and our behav-
iors. Normally, the various parts of our personalities are glued
together by our memories.
In the dissociative disorders, our memories and sometimes our
identities become detached
(dissociated) from one another. We may forget the past or, in
some cases, even who we are.
Somatic symptom and related disorders are marked by physical
symptoms that mimic those
produced by disease (somatic means “similar to the body”).
They differ from the stress-related
organic disorders discussed in Chapter 2 in that people with
somatic symptom and related
disorders have no obvious physical illness. Instead, the
symptoms are viewed as physical
manifestations of psychological (usually unconscious)
problems. The absence of a physical
illness also differentiates the dissociative disorders from
organic brain disorders and syn-
dromes that produce similar symptoms (these brain disorders are
discussed in Chapter 10).
Although there are no obvious physical reasons for their
symptoms, you should not conclude
that people suffering from somatic symptom and dissociative

disorders are deliberately fak-
ing. People with dissociative disorders have real memory losses,
and people with somatic
symptom and related disorders really do believe that they are
physically ill, are about to fall
ill, or are physically deformed. People who intentionally
pretend to be sick are classified as
either malingering (pretending to be sick to avoid commitments
or to gain some advantage)
or suffering from a factitious disorder (in which people feign
illness for no personal gain other
than attention).
Following Freud’s early work, the dissociative and somatic
symptom and related disorders
were originally classified together as neuroses. The DSM–5
places them into separate chapters
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123
Dissociative Disorders and Somatic Symptom and Related
Disorders
(as did the DSM–IV and DSM–IV–TR) because of their rather
different clinical appearance. Here
they are grouped together because of the apparent role played
by unconscious processes in
all three categories of disorder. Factitious disorder is also
included because its superficial

similarity to somatic symptom and related disorders presents
clinicians with an important
diagnostic challenge.
Let’s examine the case of Helen Fairchild, a woman whose lost
past appears to have returned
to haunt her.
The Case of Helen Fairchild: Part 1
Dr. Dorothy McLean’s Assessment and Preliminary Treatment
Plan
for Helen Fairchild
Reason for Referral: Helen Fairchild was self-referred. She says
that she is distracted, has no
sexual desire, sometimes feels that life is not real, and has no
memory of parts of her past.
Behavioral Observations and Brief History: Helen Fairchild, a
27-year-old female, reports
feeling distressed for the past few months. Her husband of
seven years left her three
months ago and moved in with his administrative assistant.
Helen says that she never had
much interest in sex and found little enjoyment in intimacy.
Since her husband left, Helen
has developed recurrent stomachaches, dizziness, hot flushes,
and headaches. She sought
medical advice, but no physical cause was identified. Her
family doctor prescribed painkillers
for her headaches. She denies any illness or substance use.
Helen has found it difficult to concentrate and has been having
trouble at work. She has not
been completing tasks, has been missing appointments, and
sometimes has missed whole

days of work. On several occasions, she found herself driving in
the country when she was
supposed to be at work. On these occasions, she was unable to
recall how she had gotten to
the country or what she had done during the preceding hours.
She finds this loss of memory
distressing, especially since she also has few memories of her
childhood. Sometimes she feels
that life is not “real” and that she is simply “playing a role.”
She says that she feels as if she is
standing outside herself, watching herself go through the
motions of everyday life.
Helen was carefully dressed and groomed. Although she seemed
quiet, she was not weepy,
nor did she seem particularly anxious. Although she was
responsive to questions, she would
lapse into silence and from time to time had to be prompted to
respond. In general, she
seemed to be a mildly depressed woman with a variety of
physical complaints coupled with
feelings of unreality and memory loss.
Diagnostic Considerations: Helen seems to be mildly depressed,
but she also has distinct signs
of dissociative disorders, such as depersonalization and
amnesia. It is premature to make any
specific diagnosis, but the following are possibilities:
Dissociative amnesia (rule out with dissociative fugue)
Depersonalization/derealization disorder
Somatic symptom disorder
Major depressive disorder
(continued)

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124
Section 5.1 Dissociative Disorders
5.1 Dissociative Disorders
We will begin this section by examining amnesia (memory loss
associated with psychologi-
cal trauma) and fugue (when a person not only develops
amnesia but also moves away from
home and perhaps even adopts a new identity). We will then
examine depersonalization/
derealization disorder. People with this disorder feel as if their
body parts have changed in
size, or they may have the impression that they are outside their
bodies, viewing themselves
from a distance. Finally, we will look at dissociative identity
disorder, formerly known as mul-
tiple personality disorder. In this disorder, two or more separate
identities recurrently come
forward to take charge of a person’s behavior. Each identity has
its own characteristic person-
ality, habits, and memories.
Amnesia and Fugue
As Freud demonstrated, having memory slips is common. We all
forget things: items on shop-
ping lists, telephone numbers, birthdays, and anniversaries.
However, when memory gaps
are too great to blame on ordinary forgetfulness—when a person

cannot recall important
life events or even who she or he is, and when memory loss is
associated with psychological
trauma—then dissociative amnesia (psychogenic memory loss)
may be suspected (Bailey
& Brand, 2017).
There are two main types of amnesia. An inability to form new
memories is known as antero-
grade (forward) amnesia. Sufferers can remember events that
occurred before a traumatic
experience, but new events are forgotten shortly after they
occur. For example, a person may
remember everything that occurred before an automobile
accident but not after the accident.
The Case of Helen Fairchild: Part 1 (continued)
No medical reason has been uncovered for memory loss,
headache, and stomachache; could
be signs of a somatic symptom disorder
Preliminary Treatment Plan: Before treatment progresses, Helen
needs to be referred to
a medical doctor. This is to rule out any possible neurological
causes of her condition.
Although Helen’s problems may be a reaction to her husband’s
infidelity and abandonment,
there are some troubling and puzzling aspects to this case.
Helen has no interest in sex, and
she has unexplained gaps in her childhood memories. She also
seems to have “blank” periods
when she cannot recall where she was or what she was doing.
Putting these together, it may
be possible that Helen has repressed sex-related childhood
memories that have led her to

fear sex. One possibility may be childhood sexual abuse. This
would be consistent with her
stomachache, which could be a “body memory” of what
happened to her. Her dissociative
symptoms may arise from the same source. Therapy will be
targeted at uncovering evidence
for such early abuse. Free association and hypnosis may help
her to recover these memories.
If such evidence is uncovered, Helen will be enrolled in a
support group for trauma
survivors. She will also need to confront her abuser.
get83787_05_c05_121-144.indd 124 2/16/18 4:40 PM
125
Section 5.1 Dissociative Disorders
Each day, the person awakes believing that the accident took
place the day before. Retrograde
(backward) amnesia is exactly the opposite; events that took
place before a traumatic event
are forgotten. A person may not recall anything that happened
before an automobile accident
while remembering events that occurred after the accident.
Almost all cases of dissociative
amnesia are of the retrograde type.
In more severe cases, memory loss is generalized.

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