Psychopathology Midterm

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Psychopathology:

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The study of mental illness, distress, and mental disorder in an attempt to distinguish the boundaries between normal and abnormal behavior. The aims of psychopathology are to better understand the true nature of disorder to more effectively treat and prevent mental illness.

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Epidemiology:

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The study of the patterns, causes,and effects of health and disease in populations. Studied through the examination of incidence and prevalence rates.

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Developmental psychopathology:

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(from the notes) Macroparadigm, study of the origins and course of individual patterns of behavioral maladaptation whatever the age, cause, and how complex the developmental patterns may be. Incorporates time so has to account for patterns of behavior in multiple arenas. (from articles) The study of children’s normal and abnormal functioning at all stages of development with an emphasis on both the normal processes of change and adaptation, the abnormal reactions to stress or adversity, and the relationship between the two.

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Incidence:

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A measure of the risk of developing a new condition within a specified period of time, rate of occurrence of new cases.

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Prevalence:

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The number of people with a disorder or condition in a given population at a specific time, either a point in time or over a period of time.

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Point Prevalence:

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The rate of prevalence at a specific point in time rather than over a period.

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Lifetime Prevalence:

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The rate of prevalence over a lifetime rather than at a specific point in time.

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Behavior genetics:

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An interdisciplinary field studying the effects of genetics and hereditary factors on behavior.

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Molecular genetics:

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The study of genes and their structures at the molecular level. This field helps us understand how genes are formed, how they mutate, and how disorders can be heritable. Also helps define what genes are related to certain disorders, and how genes and environment can potentially interact.

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Etiology:

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The underlying causes of a disorder, in our case of a mental disorder.

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Remittance:

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To reduce in intensity, or to go into remission.

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Concordance:

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Similarity between twins with respect to the presence or absence of a trait or disorder.

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Proband:

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A person suffering from a particular disorder and is used as a starting point for measuring the genetic effect of that disorder within a family.

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Nosology:

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The classification of diseases and when used in psychology it is the classification of mental disorders

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Reliability:

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The ability of a test/measure to produce similar results every time the test is carried out. A tests consistency over time.

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Validity:

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Is the ability of a test to measure what it was intended to measure. Generally, tests that are valid are also reliable

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Construct validity:

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How well a scale measures the theorized psychological scientific construct it is designed to measure.

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Clinical selection bias:

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The increased comorbidity rates in clinical settings, as individuals with multiple disorders are more likely to seek treatment than individuals with only one disorder.

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Comorbidity:

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The presence of more than one diagnosis occurring in an individual at the same time. There are four different types: comorbidity (the development of disorder B may be specifically related to the presence of disorder A), prognostic (disorder A may be a risk factor for disorder B), pathogenic (disorder B may be a secondary complication of disorder A), and correlated liabilities (disorder A and B have overlapping etiologic properties).

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Homotypic continuity:

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manifestations stay the same, underlying developmental processes change

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Heterotypic continuity:

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underlying developmental processes stays the same over time but manifestations do not

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Equifinality:

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a number of risk factors lead to the same outcome

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Multifinality:

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a particular adverse event leads to the multiple outcomes

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Describe the 5 axes in the DSM-IV?

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Axis I: Clinical disorders (including major mental disorders, learning disorders, and substance use disorders, ex: depression, anxiety, bipolar, ADHD)
Axis II: Personality disorders, mental retardation, developmental disorders (ex: paranoid personality disorder, intellectual disabilities)
Axis III: Physical condition (includes medical conditions and physical disorders, ex: brain injury)
Axis IV: Psychosocial stressors (checklist)
Axis V: Global Assessment of Functioning scores (scores range from 0 to 100, subjective rating of social, occupational, and physiological functioning)

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What might be an alternative to categorical systems?

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Dimensional models offer an alternative to categorical systems. While categorical systems are based on a “yes/no” approach to diagnosis, dimensional systems involve at least three ordinal values (i.e. mild/moderate/severe) or a continuous score along a dimension. These dimensions are empirically based and are derived through multivariate statistics. The debate about dimensional versus categorical approaches should not be guided by which model is “right,” as any dimensional system can be made categorical and visa versa. This is useful for the utility of diagnostic systems in determining treatment.

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Benefits of the diagnostic system include:

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1. it would be easy to incorporate into existing systems 2. it allows us to maintain the clinical utility of the DSM (such as providing common names for disorders) 3. it better conveys the severity of impairment or distress 4. it would increase reliability by integrating assessment and addressing subclinical problems 5. it can account for time, as repeated measures would capture more domains of functioning and illuminate patterns over time 6. and it would provide standard assessment systems because scores would be based on standardized questions, which would be useful for cross site work.

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Problems with a diagnostic system include:

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1. it doesn’t correct all measurement error issues 2. it does not address issues of comorbidity 3. it would be difficult to incorporate latent models, which look at patterns of response rather than individual responses 4. and it would not contain a nosology of vulnerability.

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Briefly describe the history of attempts to classify mental illness.

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The goal of attempting to classify mental illness was to eliminate confusion by providing a common language for the field, especially for clinicians and researchers. Both DSM I and II were constructed by a committee of clinical experts
1952: DSM I
106 disorders, 3 categories (organic brain disorder, mental deficiency, functional disorder)
very subjective, based on clinical experiences
1968: DSM II: less psychodynamic influence
1980: DSM III: attempt at including more research findings so that it would more scientific and less subjective
1987: DSM III R: more research included, more explicit criteria included to clarify some of the confusion in the DSM III classifications, homosexuality taken out, psychodynamic mostly gone
1994: DSM IV
2000: DSM IVTR: categorical approach, revised to keep up with ICD, multidiaxial with 5 axes
DSM V: work started in 1999 and is still a work in progress

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To what extent and in what way is knowledge of normal child development relevant to our understanding of psychopathology across the lifespan?

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By understanding normal child development, there is more focus on the continuities and discontinuities of origins and course of individual patterns of behavioral adaptations. Taking a developmental approach to psychopathology takes into account time, age of onset and course of developmental patterns across time and a variety of multiple domains. A developmental approach also helps frame the understanding of what is normal and abnormal development.

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When you see a heritability coefficient of .80, what does it mean and what information remains unknown?

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Heritability is a population statistic that tells us the portion of a trait that is accounted for by genetics. An easy equation to help us make sense of heritability coefficients is h2 (squared) + c2 + e2 = 100% of the variance in a trait, where h2 is heritability, c2 is shared environment, and e2 is nonshared environment. This means that a heritability coefficient of .8 tells us that genes account for 80% of how a trait expresses itself and that they other 20% is accounted for by some combination between shared and nonshared environment.

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Please describe the concept of behavioral maladaptation.

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The concept of behavioral maladaptation comes from developmental psychopathology and refers to talking about behavior as a result of organization and as being inseparable from its context. Behavior problems are ordered reactions to the type of disorganized environment that occurs after adverse events. Behavioral maladaptations are the result of successive interactions of the person with their environment. Pathology is not something a child has, it is a pattern of adaptation reflecting the totality of the developmental context to that point. (Sroufe article)

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How does the concept of patterns of adaptation impact assessment and treatment of mental health problems?

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Adaptation implies that changes in a situation or context results in changes in the individual in an effort to adapt to something. Given that individual development is an adaptive system, relationships between early and later behavior needs to be considered in the context of continuity. Assessment and treatment of mental health problems must account for these situational or contextual changes. Specific investigation of typical patterns of adaptation or normative development will guide the assessment of atypical patterns of adaptation that result in psychopathology. Within this investigation, researchers must focus on threats (e.g., behaviors, genetic predispositions, environmental influences) to typical or optimal adaptation and incorporate the assessment of these threats in longitudinal studies. This method affords researchers the opportunity to gauge developmental pathways associated with psychopathology while measuring differences in the manifestation of disorder based on adaptive changes over a given period of time. Measuring behavior before and after these changes throughout development will inform treatment programs. TREESSS. Thus, the concept of patterns of adaptation requires an approach to assessment and treatment that assumes continuity of mental health problems with associated adaptive changes throughout the duration of the disorder. As a result, assessment must include longitudinal measurements before and after these adaptive changes to inform treatment protocol.
*Mention treatment and subsequent reassessment to effectively measure patterns of adaptation/maladaptation

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Describe the different designs used to examine genetic influence on psychopathology? What questions do they address?

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Family Studies, Adoption/Twin Studies, Linkage/Association Studies, Interaction Studies

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Family Studies:

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designs that investigate whether relative risk is apparent in a certain family’s genealogy. This design examines the presence of certain genetic disorders throughout a family. Primarily, it address whether or not a disorder is familial or not by measuring it’s prevalence in the pedigree of an individual.

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Adoption/Twin Studies:

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designs that determine if a disorder is influenced by genes and examines its heritability. Twin Studies use the difference between identical (MZ) and fraternal (DZ) twin correlations in order to estimate the degree of genetic influence on a trait. Adoption Studies use the difference between biological parent child correlations and adoptive parent child correlations to estimate the genetic influence on a trait.

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Linkage/Association Studies:

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association studies give us a specific location based upon a theory driven hypothesis, while linkage studies give us a place to start looking. This design also examines the presence of genetic markers, segments of DNA that can be cut and characterized by known enzymes and then sequenced for genetic variation. If a particular marker is associated with a particular disorder, then we can reasonably conclude that a gene contributing to that disorder is nearby.

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Interaction Studies:

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designs that help illustrate the role of the environment on psychopathology.This approach examines the influence of genes on environmental attributes, the influence of those environmental attributes on genes and how interactions of biological, psychological, and sociocultural influences contribute to the manifestation of psychopathology

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What are some of the general limitations of heritability studies?

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It can be difficult to narrow down a disorder to certain genes since environment plays such a prominent role, even with monozygotic twins. Adoption studies can help mitigate this, but it is still difficult to account for environment. Although small, there is a chance mutations could also screw up the heritability (either by introducing it, or removing the disorder). They can work nicely for genetically linked disorders, but are more problematic for disorders without a genetic component, or related to several different genes leading to a predisposition. Even if we narrow down a disorder to specific genes, those genes may or may not be expressed at different times of development, making it difficult to determine how relevant those genes really are and to predict the likelihood that they will make a difference. Heritability estimates change over the course of development so depending on when the measure is taken it could be an over or underestimate.

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Are externalizing disorders culturally bound syndromes? Please describe what is meant by culturally bound, and provide evidence for your position

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Arguably yes or no. Culturally bound means that something is seen and relevant only in a specific culture. Externalizing disorders could be seen as culturally bound since different cultures view different behaviors as problematic. However, it could be argued that they are universal since, as was mentioned in class, some cultures define problematic behaviors in similar ways. What seems more likely is that externalizing disorders per se are not culturally bound, but how they manifest varies by culture.

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Describe some of the ways that environmental influences could moderate or alter the importance of genetic effects.

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Genes and environment interact to determine what characteristics will be made manifest in an individual. Genetic effects may seem insurmountable in many cases but environment can have a large effect to either improve outcomes or exacerbate problems. In the past there was a question of whether environment had any effect at all, now it is simply a question of how much effect it has. In his article Raulin differentiates between shared environmental influences and non shared environmental influences. He says that research has found that non shared environmental influences play a major role in the etiology of most mental disorders and personality traits. This basically means that if a person is specifically treated badly by a parent, they are more likely to suffer the effects of that environment than are two siblings that are exposed to a highly anxious parent. However, environmental influences can be used and manipulated to improve outcomes for children that might be genetically predisposed to certain disorders. That is to say that effective parenting, a caring community, teaching cognitive and self regulation skills can all to taught to increase resilience and assuage the effects of a possible genetic predisposition to things such as stress or anxiety.

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What are the strengths of a categorical approach?

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1. Allows for effective communication across the field
2. It provides categories that are understandable to lay people
3. It makes clinical decision making simpler and allows for easy insurance reimbursement
4. It doesn't bury rare disorders within a broader dimension

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What are the weaknesses of a categorical approach?

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1. Difficult to determine the appropriate boundaries both within and between categories
2. Increased rates of comorbidity
3. Increased measurement error
4. Decreased interrater reliability
5. Due to yes/no setup of the categories leaves minimal room for error
6. Loss of potentially valuable information about severity and duration (beyond that which is required for the diagnosis
7. Exclusion criteria cause you to lose the flavor of what's really going on

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What are some concerns about the DSM and other categorical approaches?

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1. Lack of empirically supported categories
2. Excessive comorbidity: rates as high as 60% for some disorders and it is the rule/norm for kids
3. Boundary disputes: based on the comorbidity rates, among other things, we likely have arbitrary cutoffs. Look at disorders such as mixed anxiety and depression, social phobia vs. avoidant personality disorder, and schizoaffective disorder vs. major depression. Are these diagnoses on the same spectrum and we are just drawing the boundaries incorrectly or are they on a dimension we aren't categorizing?
4. Measurement error: there is very low interrater reliability amongst diagnoses
5. Loss of potentially useful clinical information: we only get information about duration and severity in as much as they are required by the diagnostic criteria so we lose a lot of valuable information.
6. Fails to account for development: the DSM doesn’t account for symptom change over the course of time or for a lifetime perspective on diagnosis and stressors. DSM also provides a limited ability to address etiology and developmental history.
7. Fails to account for context: when we don't look at disorders in context it can cause us to make erroneous assumptions about what is happening, failing to factor context into treatment can also make success more difficult.
8. Culturally bound: are some of our diagnoses culturally bound (recurrent locality specific patterns of abnormal and distressing behavior)? Questions the appropriateness of the DSM in other cultures.
9. Overly influenced by the medical model: a view which sees disorders as discrete and arising from a singular cause.

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What is Harmful Dysfunction?

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Wakefield (1992) argued for Harmful Dysfunction as way of defining disorders. He argued that past abuses in diagnoses necessitated a more specific and scientific definition rooted in evolutionary biology. Wakefield defined “dysfunction” as impairment in the ability of a biological structure to accomplish the function it was designed to perform. He defined “harmful” as a value term referring to the consequences of a dysfunction. Wakefield’s approach was that understanding the original function of a biological structure was necessary to determining if it was working or not. He believed that classifying disorders in this manner would improve the reliability and validity of the DSM.

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What are the problems inherent in this definition of disorder?

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Lillenfeld and Marino (1999) outlined four major problems in this definition of disorder: 1. a mental disorder can be a failure in a function that is not naturally selected (i.e. dyscalcula), so the Harmful Dysfunction model fails to deal with the issue of cultural exaptations. 2. the cutoff at which dysfunction is defined is arbitrary, 3. dysfunction is not definitional criteria, 4. and that this model adopts a categorical approach as opposed to a dimensional approach.

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How can Harmful Dysfunction be useful?

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Despite these issues with the Harmful Dysfunction model of disorder, it is a useful definition in that it attempts to rigorously define the concept of a disorder. The Harmful Dysfunction model raises some important questions about the relationship between biological and psychological dysfunction that may continue to be addressed through research on human genetics. The Harmful Dysfunction model, while flawed, attempts to remove subjective criteria from the definition of disorder.

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What is a Roschian Prototype?

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Lillenfeld & Marino (1999) proposed Roschian Prototypes as an alternative to Harmful Dysfunction for defining disorder. They argued that disorders lack defining features and that assigning them to categories is thus arbitrary. They proposed that disorders be diagnosed based on similarity to a Roschian Prototype. These prototypes would be developed based on consensus and real world experience, which they argued would make them more reliable and valid. They also argued that an important strength of this model is that disorders are socially determined and that decisions come down to whether the disorder requires treatment or not. (See first two paragraphs of Harmful Dysfunction question)

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How can the Roschian Prototype work against the Harmful Dysfunction perspective?

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Roschian Prototypes work against the Harmful Dysfunction model in that they argue that disorders lack defining features, whereas Wakefield argued for very specific definitional criteria of disorder. Additionally, Roschian prototypes acknowledge the cultural biases involved in defining disorder and incorporate this issue into their diagnostic criteria, whereas Wakefield attempts to eliminate the influence of cultural bias by utilizing an evolutionary biological perspective.

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How can the Roschian Prototype work with the Harmful Dysfunction perspective?

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Roschian Prototypes might work with the Harmful Dysfunction perspective in that different disorders may be addressed more adequately by different theories. For example, certain disorders may be more readily traced back to problems in biological functioning, especially as our technology improves in this area. However, other disorders may not adequately be addressed by this model, and thus a Roschian approach might be more well suited to approaching the diagnosis of these disorders.

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What are the various perspectives on defining mental disorder? What are the benefits/advantages and disadvantages of each perspective?

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Based on Fowler’s outline on Widiger & Sankis (2000). Refer back to previous questions on categorical, dimensional, HD, Roschian as other ways to define mental disorders 1. Normal vs. abnormal functioning. 2. Cultural relativity perspective. Harmful dysfunction/dyscontrolled maladaptivity

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The normal vs. abnormal functioning

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DSM IV definition of a mental disorder: “must currently be considered a manifestation of a behavioral, psychological or biological dysfunction in the individual.”
Advantages: provides a definition
Disadvantages: 1. Relies on indicators of distress or impairment instead of defining what is maladaptive behavior and what is true psychopathology 2. Epidemiological research shows increase in prevalence rates but this may be due to social/political factors or diagnostic criteria of DSM 3. Role of pharmacological agents/drug therapy

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Cultural relativity perspective

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Authors say presence of mental disorder across culture can be empirically tested. Are disorders culturally bound or universal?
Disadvantages: 1. Comparisons to physical illness, we can apply how we look at physical illness with mental illness (e.g. high bp is always bad) 2. Different societies have different values 3. Questions the validity of construct of mental disorder and science of psychopathology
Advantages: has identified culture bound syndromes (e.g. ataques de nervioso)

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Harmful Dysfunction or dyscontrolled maladaptivity

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Based on evolutionary theory that disorder is inability of mechanism to function its naturally selected purpose
Advantage: scientifically based on evolutionary biology
Disadvantage: not compatible with other sociobiological models, does not consider the role of dyscontrol in psychological functioning. Mental disorders are dyscontrolled organismic impairments in psychological functioning (i.e. feelings, thoughts, behaviors over which normal person controls).

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Describe the types of continuity through which mental illness may be expressed?

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1. Phenomenological continuity 2. Typological continuity 3. Etiological continuity 4. Psychometric continuity

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Phenomenological continuity

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quantitative differences (e.g. mild, moderate, severe levels) of symptoms in people with and without disorders. To test for phenomenological continuity: multivariate stats

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Typological continuity

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look for subtypes, qualitative differences among subtypes. Lack of meaningful subtypes suggest continuity. To test for typological continuity: cluster analysis.

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Etiological continuity

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the degree to which milder forms of disorders is a risk for severe disorders suggests continuity. To test for etiological continuity: logistic regression

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Psychometric continuity

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the ability that a measure assesses the full range of a disorder. To test for psychometric continuity: item response theory

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What is comorbidity and why is it important to consider when attempting to classify mental illness?

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Comorbidity is the co occurrence of two or more disorders at the same time. When different disorders consistently present at the same time, it becomes difficult to tease apart whether or not the comorbid form is distinct from the individual forms. For example, is comorbid anxiety and depression different from just anxiety or just depression? Additionally, it suggests that we may have poorly defined borders between the illnesses (they are really the same thing), they could have common etiologies (caused by the same things), or they may predispose for one another (anxiety leads to depression and vice versa). Depending on which is the case, the solution is different, and we cannot easily tell which is the most likely answer.

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A policy maker approaches you for consultation on a mental health initiative she is interested in proposing to congress. Based on research she saw that autism has a heritability index of .85, the policy maker has concluded that autism is a genetic disorder. She wants to pull funding from an existing program that pairs autistic children with “environmental consultants” who assist in setting up structured social interaction for children in their homes and schools. The policy maker wants to reinvest this money in research to identify the genes for autism. What would you advise?

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This would be a bad idea. The high heritability rate for Autism helps us understand part of the etiology, but it does little to help with treatment. While it is important to potentially use genes as a sign that early intervention is needed, the intervention is still necessary since knowing the genes does not allow us to cure the disorder. Additionally, genes are only a part of the problem since environment interacts with genes to determine outcome, so discounting either would be problematic for treatment. Therefore, the best move is likely to continue investing in the environmental treatment methods, while also finding alternative sources of funding for the genetic research so we can take advantage of both.

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What is the developmental pathways (aka developmental hierarchy) model of antisocial behavior?

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talk about Moffit’s Dunedine study and the Zuid Holland study.

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Moffit’s Dunedine Multidisciplinary Health and Development Study

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this study looked at a highly representative sample over a period of more than 30 years and had a very high retention rate.

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Of the children that had antisocial behavior problems, there were four groups:

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1. Life course persistent offenders (LCP) 2. adolescence limited offenders (AP), 3. Abstainers (5%), 4. Recovery (8%)

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Life course persistent offenders:

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10%, “stable, pervasive, and extreme antisocial behavior in childhood plus extreme delinquent involvement in adolescence.” as adults, tend to specialize in serious offenses, display more serious symptoms of antisocial personality disorder, demonstrate greater violence, have poor work histories and lack job-skills, lack social bonds and job skills that might deter criminal behavior (supports “turning point theory”)

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Adolescence limited offenders (AP)

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26%: build pro social behaviors and academic skills in years before antisocial behavior. had better chances than LCP men to get good jobs & to “[benefit] from the reforming effects of a good woman”. were still in trouble in adulthood. showed biggest differences from other groups (incl. LCP) in impulsivity. may still be engaging in crime because of maturity gap (adulthood seen as beginning after 25 in more modern times)

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Abstainers

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5%. defined as having no more than 1 antisocial problem at any assessment, high self-constraint became adaptive in adulthood, least problem behaviors, tended to be in happy marriages, delaying children, and highest status jobs

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Recovery

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8%. challenge theory because antisocial behavior starts in childhood and should follow a “chain of cumulative disadvantage”. found that true recovery was rare as many were “low level chronic offenders” by adulthood. suffered internalizing forms of psychopathology and tended to be social isolates (this may have been a “protective factor” in adolescence)

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These groups were found to be

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consistent across the genders even though occurrence of antisocial behaviors was much higher in males and the percentages above represent that of male cohorts only

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Zuid Holland Study.

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This study was key in showing the connections between Oppositional Defiance Disorder (ODD), Conduct Disorder (CD) and Antisocial Personality Disorder (APSD). It seems that disruptive problems such as ODD lead to anxiety and depression problems. Problems such as ADHD lead to both ODD and anxiety and depression problems. ODD also leads to CD which is a precursor to Antisocial personality disorder. There seems to be a lot of comorbidity in these and that results in the idea of them being hierarchically related. They are related but distinct lines of evidence those diagnosed with CD have ODD but there is less comorbidity in the national sample so comorbidity in community sample probably due to the fact that people coming in really need help. Second line of evidence: latent class analysis shows the two are separate constructs.

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What are the implications of the developmental pathways (aka developmental hierarchy) model of antisocial behavior in terms of presentation of symptoms?

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The implications of these findings and how symptoms are presented are that there needs, early, sustained and persistent intervention. Probably at the point of ODD in childhood.

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Should substance use be included in the DSM V criteria of conduct disorder? Provide an argument with evidence for why or why not? How would doing so impact the prevalence of conduct disorder and treatments? Rationale for Yes

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research by Biglan, Dick, and Kendler. 50% of variability in substance use is explained by genes while heritability for conduct problems is low so substance abuse would be a better predictor. And the older children get the bigger the role of genes in expressing substance abuse. The effect of the environment is greater at a younger age so this once again calls for early intervention. Another reason is that substance abuse is so highly correlated with Conduct disorder.
Should substance use be included in the DSM V criteria of conduct disorder? Provide an argument with evidence for why or why not? How would doing so impact the prevalence of conduct disorder and treatments? Rationale for No

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It might introduce racial biases based on variability in use of certain drugs. It could also bias results in terms of whether people live in urban areas or in rural areas because studies found that the genetic effects or propensity to alcoholism were higher in urban settings. This would mean that prevalence of conduct disorders would seem higher in urban settings that in rural settings. Similarly, female adolescents were more susceptible to environmental influences when it came to substance use. So if conduct disorder were higher among substance abusers, prevalence of conduct disorders would increase among females.

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Theorize how life choices like being in a romantic relationship function to protect people with elevated risk for substance abuse?

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Family and environmental factors have been found to heavily influence psychoactive substance use in childhood and adolescence. However, persistent use in adulthood may be more associated with genetic predispositions. Kendler et al., 2008 found that effects of environmental influences tend to persist until at least early 30’s. In addition, changes occurring during adolescent development may also alter environmental (e.g., neighborhood) effects on genetic susceptibility in adulthood. (Dick et al., 2009). Thus, life choices, including the decision to engage in a romantic relationship especially during adolescence, may alter the effects of a genetic predisposition to engage in substance abuse. The emotional support and security experienced in romantic relationships may serve as a protective factor for substance use especially in individuals with an elevated risk associated with genetic makeup. Conversely, involvement in romantic relationships in which one partner is an avid substance user may exacerbate their romantic partner’s elevated genetic susceptibility to substance use. A number of factors associated with the choice to engage in romantic relationships may alter the gene by environment interaction that is attributed to the development of persistent substance use.

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What is the causal mechanism involved in this protective function?

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Thus, the causal mechanism involved is the interaction of environmental influences and genetic predispositions or susceptibility to substance use. By environmental influences being particularly influential early in life, certain life choices (especially during adolescence) may alter any potential genetic effects. Engaging in romantic relationships could potentially protect individuals with an elevated risk for substance abuse by providing them with a social environment that does not encourage (or actually discourages) substance use early in life. This decision could possibly prevent the development of a desire to engage in subsequent substance use even when elevated risk exists.