It was 1:00 a.m. and Malcolm was driving home to North Dakota for his sister’s wedding. It was snowing heavily, and the roads were icy; he was driving as fast as he safely could, but the trip had already taken two hours longer than it normally would. As Malcolm was fiddling with the radio dial, he looked up to see a huge semitrailer swerving dangerously in front of him. Malcolm pumped his brakes, but his car began to spin toward the trick, which was not facing him head-on. Malcolm leaned on the steering wheel and swerved into the ditch. His small car crashed into a fence by the ditch, but fortunately he suffered no physical injuries. Malcolm’s hear was pounding, and he had never been so frightened in his life. Since his near-fatal accident, Malcolm cannot travel in a car. Simple contemplating a short drive fills him with panic and dread. In short, Malcolm has developed a phobia.
1. Complete the following table:
2. Why would Malcolm’s fear-provoking experience develop into a long-term phobia?
APA Citation Required
3. Describe how Malcolm’s phobia could develop into a generalized anxiety disorder.
APA Citation Required
Exercise #1: Malcolm Name:
Patricia is obsessed with counting rituals, and specifically with the number 3. Although she is not distressed when, for example, her dishes sit unwashed on the counter, Patricia does feel compelled to order them in groups of three – three places in a stack, three glasses lined in a row, etc. Patricia answers the telephone only after the third ring, and must buy three of any item on her grocery list. She also checks compulsively, always in increments of three. For example, she is not satisfied that her front door is locked until she turns the key three times, counting, “one-two-three” aloud.
1. Provide evidence in the boxes below regarding how we would consider Patricia’s behavior abnormal:
How is her behavior deviant?
How does her behavior cause distress?
How is her behavior dysfunctional?
2. Provide three more response prevention homework assignments for Patricia in addition to the one already given:
a. Buy only one of each item on the grocery list
Exercise #2: Patricia
Sarah is a 23-year-old female who works as a pediatric nurse. At 3:00 a.m. one night, Sarah finished her shift and walked to her car in the parking garage adjacent to the hospital. As Sarah approached her car, she heard footsteps behind her. Before she was able to react, she was thrown down and pinned to the cement floor by a man with a stocking mask over his face. Brandishing a knife, the attacker threatened to kill Sarah if she made any noise or attempted to fight or run. She was brutally raped and knocked unconscious. When she regained consciousness several minutes later, the perpetrator had fled the scene. Sarah drove home in a state of shock, and managed to call a close friend, who immediately drove her to the emergency room.
1. Four types of symptoms Sarah might manifest if she developed a stress disorder are listed below as a – d. In the spaced provided list two examples of each symptom specific to Sarah:
a. Re-experiencing the Traumatic Event:
Sarah has nightmares in which she “relives” the rape
Sarah often imagines that she hears the footsteps of her attacker when she goes outside
Clara, the proprietor of a popular in on the beach, was quite busy one fateful June day. The inn was at full capacity with 60 guests – all of whom seemed to be making requests at the same time for more towels and pillows, extra room keys, and use of the fax machine. Clara managed to get through dealing with an angry guest, Mr. Barnes, who demanded to have a “bigger room facing the ocean”, and then decided it would be an ideal time to escape the chaos and obnoxious guests by running to the bank to make a deposit.
Standing in line, Clara became lost in her thoughts about the big dinner that evening at the inn. She heard a scream behind her, and turned to see four men wearing Richard Nixon masks and carrying guns. The gunmen shot out the cameras on the walls and ordered everyone to drop to the floor. One of them threatened to shoot all of the bank tellers if any of them activated the alarm. Face down on the floor, Clara shut her eyes and silently prayed. She was so frightened that she had trouble breathing. Suddenly, more shots were fired and Clara felt a man falling on top of her. She opened her eyes to see the man all bloody and writhing on the floor next to her. Clara screamed, for which she received a sharp kick to the shoulder and a threat that if she didn’t “shut the fuck up”, she would “be next”. The next few minutes were a blur. Clara heard the gunmen running shortly before the police swarmed into the bank.
After waiting what seemed like hours, Clara was checked out by a doctor and then interviewed by police. She was finally allowed to return to the inn – six hours after she left for what she thought would be a brief errand. For the next two weeks, Clara felt as if she were in a fog and had difficulty remembering details about the traumatic event she had experience.
1. Using Clara’s incident, apply a description of the pattern of forgetting that would illustrate the kinds of amnesia listed:
a. Localized Amnesia:
Clara is able to recall her hectic day at the inn, including her run-in with Mr. Barnes, but can’t remember a thing about being in the bank. She can recall everything after waking up at the inn the day after the robbery. b. Selective Amnesia:
c. Continuous Amnesia:
d. Dissociative Fugue:
Exercise #4: Clara
Saul is a 59-year-old grocery store owner, who through 40 years of hard work, has made his store the biggest in town. He has accomplished this in spite of stiff competition from national chain stores. He has always taken great pride in beating them. Saul has earned the respect of his customers and employees alike. But profits have been down for a few years – a situation he blames on his advancing age. He decides to sell his store when one of the chains offers him a good price. He and his wife retire to the coast of Maine.
Saul enjoys retirement for about a week, and then starts to complain of feeling “empty”. He tries improving his golf game, but quits when his wife and others consistently beat him at the sport. He finds himself drinking more alcohol than ever before. He had wanted to take up sailing, but decides not to, figuring he is too old. Within six months of retirement, he is doing little more than watching television, drinking and going to bed early every night.
Apply the Cognitive Therapy explanation of unipolar depression to this case study:
a. Phase One: Increasing Activities & Elevating Mood
List some of the rewards for positive behavior Saul received as a store owner:
What pleasurable events could be reintroduced for Saul to improve his mood?
b. Phase Two: Challenging Automatic Thoughts
What one thought would you challenge in Saul’s thinking process?
What homework would you give to Saul at this phase? c. Phase Three: Identifying negative thinking & biases
Which of Saul’s activities in retirement causes this downward spiral of negative automatic thinking?
Outline for Saul how his negative bias or automatic thinking is affecting his retirement. Exercise #5: Saul
1. Sheldon repeatedly engages in high-risk activities such as drinking and driving, and mixing alcohol and drugs. When his girlfriend pleads with him to stop the dangerous behavior, Sheldon usually retorts with statements like “You wouldn’t care if I died, anyway” and “It would serve you right if I did kill myself one of these days”.
2. After her suicide attempt by drug overdoes, Jackie stated the following to a hospital psychiatric nurse: “I had thought about killing myself on and off for weeks. I would have a really bad day and almost do it, but then I’d feel a little better the next day and decide not to. Today was a really, really bad day – the worst”.
3. Six-year old Marianne is devastated after seeing her family dog, Jo-Jo, killed by a car in front of her house. Her parents try to comfort her by telling her that Jo-Jo is happy in heaven, but later she runs into the busy street and is nearly hit by an oncoming truck. When Marianne’s parents ask why she did what she did, she replies, “I wanted to go to heaven to make sure Jo-Jo is okay”.
4. Antonio is a 72-year-old man who is suffering from advanced bone cancer. Certain that his last days will be filled with intolerable pain, Antonio asphyxiates himself in his car.
Complete the following table by describing the characteristics of Shneidman’s four categories of people who attempt or commit suicide. Then, read through the case examples provided and match each with the most appropriate category.
Exercise #6: Suicide (Sheldon, Jackie, Marianne, and Antonio)
Characteristics of Case relating to description of Category
Rita has sought treatment for her mysterious physical symptoms from six medical professionals at four hospitals. Her symptoms include a sensation of numbness that “travels” across her scalp and face, frequent abdominal pain, and paralysis of her legs. The last doctor she visited could find no organic (physical) basis for her condition, even after an extensive series of tests, and finally advised Rita to seek psychotherapy. Although she initially resisted, Rita decided that she had better do what the doctor advised or she might not be able to receive further medical services from the hospital
1. Complete the following table by writing in the names of the therapeutic techniques used to address the physical symptoms of Somatic Symptom Disorder described in the textbook, as well as sample statements you might use for each technique if you were the therapist.
Exercise #7: Rita
Sample Therapeutic Statement
“Rita, I notice that you walked very quickly into my office today. It’s just wonderful that you’ve been able to suppress the paralysis.”
2. Come up with a short story and explanation regarding Rita’s situation if you were a cognitive psychologist. For example, Rita’s physical symptoms are rooted in her coping with the loss of her father recently. She is struggling to convey her depression . . . 3. Come up with a short story and explanation regarding Rita’s situation if you were a behavioral psychologist. For example, Rita’s physical symptoms are rooted in her coping with the loss of her father recently. She is struggling to convey her depression . . .
Josie S. is a 15-year-old female who was referred to the City Hospital’s Department of Psychiatry because she is believed to be suffering from anorexia nervosa. Josie 5 feet 6 inches tall. In the last six months, her weight has dropped 59 pounds, from 142 to 83 pounds. She appears emaciated and is physically weak. Josie reached menarche at age 11 but has not had a period in 16 weeks. Her parents state that although they really wanted Josie to lose some weight “because she was too big to wear all the nice clothes” they bought for her, they are now concerned because she is refusing to eat meals at home. Josie reports that she feels fine and “doesn’t understand all the fuss because I am still a fat pig.”
Exercise #8: Josie S. Name:
City Hospital – Department of Psychiatry
Treatment Plan for: Josie S.
Diagnosis: Anorexia Nervosa, restrictive type
Weight restoration and resumption of normal eating patterns
Treatment Strategy #1
Medical/Biological approaches: If Josie’s life is threatened, use tube and intravenous feedings and/or antidepressant drugs to help restore her weight.
Treatment Strategy #2
Treatment Strategy #3
Supportive nursing care:
Treatment dimension: Address broader psychological and family issues
Treatment Strategy #1
Self-exploration/insight approach: Help Josie express her need for independence and control in more appropriate ways; help Josie learn to recognize and trust her internal sensations and feelings.
Treatment Strategy #2
Treatment Strategy #3
Margaret is a full-time college student, holds a part-time job, and is also on the cross-country team. While competing in a track meet one week ago, Margaret started her race feeling good and full of energy. At the 1-mile mark, however she felt a wrenching pain in her hamstring muscle. She pushed herself to run, but had to drop out of the race as she approached the 2-mile mark. Margaret felt exhausted, and the pain in her leg was excruciating. After being examined by a physician, Margaret learned that in addition to tearing several ligaments, she had tested positive for amphetamines. She confessed to her coach that she had been using increasing amounts of Dexedrine in order to maintain the energy she needed to keep up with the demands of her life.
Exercise #9: Margaret Name:
1. Using the concepts of tolerance and dependence, how would you explain Margaret’s increased amphetamine use and subsequent injuries?
Glenn started using alcohol at age 15. Always rather shy and socially awkward, he found that drinking helped him “loosen up” enough to interact with his peers, who he had avoided in the past. By age 18, Glenn was known as a real “partyer”. He drank nearly every day and often experienced blackouts. Glenn managed to get into college but dropped out at the end of his first semester because his grades were so poor. He got a job at a convenience store but was fired for coming to work intoxicated. Depressed and broke, Glenn asked an acquaintance if he could :crash” at his place until he found another job. It turned out that the acquaintance sold heroin. Glenn continued his heavy drinking, and within three months of moving in, he was also hooked on heroin. He tried to quit, but whenever his roommate brought out his drug paraphernalia, Glenn would succumb to an overpowering urge to shoot up. The fact that he would become depressed, anxious, and physically ill after going without heroin for even a day or two, made it even more difficult to quit.
2. How would each of the follow behavioral theories explain Glenn’s increasing heroin and alcohol use? Provide an example of what you would do for therapy.
a. Operant conditioning theory:
b. Classical conditioning theory:
Richard, 23 years old: In high school, Richard was an average student. After graduation from High School, he entered the army . . . Richard remember the period . . . after his discharge from the army . . . as one of the worst in his life . . . Any, even remote, anticipation of disappointment was able to provoke attacks of anxiety in him . . .
Approximately two years after his return to civilian life, Richard left his job because he became overwhelmed by these feelings of lack of confidence in himself, and he refused to go look for another one. He stayed home most of the day. His mother would nag him that he was too lazy and unwilling to do anything. He became slower and slower in dressing and undressing and taking care of himself. When he went out of the house, he felt compelled “to give interpretations” to everything he looked at. He did not know what to do outside the house, where to go, where to turn. If he saw a red light at a crossing, he would interpret it as a message that he should not go in that direction. If he saw an arrow, he would follow the arrow interpreting it as a sign sent by God that he should go in that direction. Feeling lost and horrified, he would go home and stay there, afraid to go out because going out meant making decisions or choices that he felt unable to make. He reached the point where he stayed home must of the time. But even at home, he was tortured by his symptoms. He could not act; any motion that he felt like making seemed to him an insurmountable obstacle, because he did not know whether he should make it or not. He was increasingly afraid of doing the wrong thing. Such fears prevented him from dressing, undressing, eating, and so forth. He felt paralyzed and lay motionless in bed. He gradually became worse, was completely motionless, and had to be hospitalized . . .
Being undecided, he felt blocked, and often would remain mute and motionless, like a statue, even for days.
Exercise #10: Richard Name:
In this exercise you will put yourself in the place of the therapist assigned to design a token economy program for Richard. Use your knowledge of the deficits and excesses of behavior that people with the disorder exhibit to complete a list of target behaviors that could be rewarded, set the daily reward in numbers of TEs (token exchanges), and complete the list of reinforcement that Richard could purchase with his tokens.
City Hospital Department of Psychiatry
Treatment plan for
Changing from Pajamas to a different set of clothes TE = 1 per day
Having a face to face conversation with a nurse TE = 1 per day
Candy bars & Soda (TE = 2)
Belinda T. is a 27-year-old woman who decided to seek therapy from Dr. Platt, an established and highly regarded clinician. During the initial interview, Belinda told Dr. Platt the following: “Things have been getting worse and worse for me. Even when it seems like I’m having a good day, suddenly something goes wrong and I get depressed, or so mad that I see red. [1} A few nights ago I smashed every glass plate in the house and kicked my dog so hard that I had to take him to the vet.  The next day I felt so horrible that I drank until I passed out. I get to feeling really awful and alone, like I’m a big nothing inside. Sometimes I cut my arms and stomach with a razor.  When I feel the pain and see the blood, I get a rush . . . almost like I feel more “real.”  This therapy is my last change; if it doesn’t work, I may as well just give up and die”.
Dr. Platt agreed to work with Belinda in therapy and made a provisional diagnosis of borderline personality disorder. After her first therapy session, Belinda told her friends that Dr. Platt was “the most wonderful person in the world,” and that she had never met anyone with such understanding and compassion. She said that she was certain Dr. Platt could help her. But just five sessions later, Belinda confronted Dr. Platt by saying, “You are an unfeeling, incompetent bitch! You are the one who needs a shrink.”  Dr. Platt responded by asking, “I wonder if some of your anger is about my being on vacation last week?” Belinda confirmed Dr. Platt’s hypothesis by angrily claiming that Dr. Platt had deserted her and no longer cared about her.  Sobbing, Belinda rolled up her sleeve and revealed several new cuts on her arm. “Look at what you made me do! Please don’t leave me along again; I can’t stand it. The next time you cancel a session, I might kill myself.” 
Exercise #11: Belida Name:
Each of the numbered statements in this case relate to a particular characteristic of people who suffer from borderline personality disorder. Match each statement with the characteristics (a – g) that follow:
 _________  ________  __________  __________  _________  _________  ________
Anger is expressed in aggressive, violent behavior outward
Fearing desertion, manipulative behavior such as suicidal threats is used to maintain relationships
Anger is expressed and directed inward through self-destructive and self-mutilating behaviors
Vacillation occurs between overidealizing and devaluing others in relationships
Dramatic, often sudden shifts in mood are common
Rage and extreme disappointment are felt when expectations, particularly about others “being there” at all times in a relationship, are not met
Self-destructive and self-mutilating behavior can serve to relieve chronic feelings of boredom and emptiness and to validate “personhood”.
Exercise #12: Odd Personality Disorders Name:
“Odd” Personality Disorders
With the grid below, check the features that you think fit into each category listed.