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Essay-questions-final
Abnormal Psychology (Concordia University)
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1. Describe the human sexual response cycle and then describe one example of a male
and female sexual dysfunction. Be sure to explain where the dysfunction occurs in the
cycle.
(Draw the cycle)
The human sexual response cycle refers to the sequence of emotional and physical
changes that occur as a person becomes sexually aroused and participates in sexually
stimulating activities. It consists of the desire phase, arousal stage, plateau phase, orgasm
phase an resolution phase. In the desire phase, sexual urges occur in response to sexual
cues or fantasies. The arousal stage is a subjective sense of sexual pleasure and
physiological signs of sexual arousal. For example, in males there is penile tumescence
(increased flow of the blood into the penis) and in females, vasocongestion (blood pools
in the pelvic area) leading to vaginal lubrication and breast tumescence (erect nipples).
The plateau phase is a brief period that occurs before orgasm. The orgasm phase in
males consists of feelings of the inevitability of ejaculation, which is followed by
ejaculation. In the female orgasm, contractions of the walls of the lower third of the
vagina are present. The resolution phase occurs particularly in men where a decrease in
arousal occurs after orgasm.
The three stages of the sexual response cycle, desire, arousal and orgasm, are each
associated with specific sexual dysfunctions. Additionally, pain can become associated
with sexual functioning in women, which leads to an additional dysfunction.
An example of a male sexual dysfunction is erectile disorder. Erectile disorder is a
specific disorder of arousal. The problem here is not desire, many males with erectile
disorder have frequent sexual urges and fantasies and strong desire to have sex. Their
problem is in becoming aroused displayed by a marked difficulty in obtaining an erection
during sexual activity or maintaining and erection until the completion of sexual activity
or a marked decrease in erectile rigidity. It is important to note that men are usually more
impaired by arousal problems than women because the inability to achieve and maintain
an erection makes intercourse difficult or impossible. Additionally, it is unusual for a
man to be completely unable to achieve an erection; partial erection is usually the
problem. Male erectile disorder is the most common problem for which men seek help
(50%).
An example of a female sexual dysfunction is female orgasmic disorder. Female
orgasmic disorder is present when there is a marked delay in orgasm, infrequency of
orgasm, absence of orgasm or a reduced intensity of orgasmic sensations. An inability to
achieve an orgasm despite adequate sexual desire and arousal is commonly seen in
women and less commonly seen in men. Approximately 50% of women do not achieve
orgasm with every sexual encounter, unlike most men, who tend to experience orgasm
more consistently. Thus, an inability to reach orgasm is the most common complaint
among women who seek therapy for sexual problems.
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2. Discuss the psychosocial causes of Paraphilias. How do these theories relate to/inform
psychosocial treatments of Paraphilias?
(Draw the model of the paraphila development)
Psychosocial Causes:
Case histories help identify the psychosocial factors thought to contribute to the
development of paraphilic disorders by providing hypotheses that can then be tested by
controlled scientific observations.
In many cases, an inability to develop adequate social relations with the appropriate
people for sexual relationships seems to be associated with developing inappropriate
sexual outlets. However, it is difficult to determine cause and effect.
Secondly, the presence of disordered relationships in childhood and adolescence may
result in deficits in healthy sexual development. However, many people with deficient
sexual and social skills do not develop deviant patterns of arousal.
Additionally, forbidden or early sexual experiences (accidental or vicarious) in childhood
or adolescence may play a role. For example a man who has his first sexual experience
while “peeping”. However, many of us do not find our early experiences reflected in our
sexual patterns.
Another factor may be the nature of the person’s early sexual fantasies. For example, in a
famous study, the researchers demonstrated that sexual arousal could become associated
with a natural object (e.g. a boot) if the object was repeatedly presented while the
individual was sexually aroused. Thus, the development of unwanted sexual arousal may
be simply due to an operant conditioning paradigm where early fantasies that are
repeatedly reinforced through the very strong sexual pleasure associated with
masturbation. Before an individual with a pedophilic or sadism disorder ever acts on his
behavior, he may fantasize about it hundreds of times while masturbating. This may
explain why paraphilic disorders are almost exclusively seen in males. Men masturbate
and orgasm more frequently than women.
Finally, an incredibly high sex drive has been observed in individuals with paraphilic
disorders. For example, it is not uncommon for these individuals to masturbate 3-4 times
a day. The very act of trying to suppress unwanted emotionally charged thoughts and
fantasies seem to have the paradoxical effect of increasing their frequency and intensity.
Psychosocial Treatment:
The theories previously stated help establish several psychosocial treatment procedures
for decreasing unwanted arousal. Most treatments are behavior therapy procedures aimed
at changing the associations and context from arousing and pleasurable to neutral. Covert
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desensitization, orgasmic reconditioning and relapse prevention are all psychosocial
treatments for paraphilic disorders.
In covert desensitization, the individual is requested to imagine harmful or dangerous
consequences that are associated with the unwanted behavior and arousal. The notion
here is that the patient’s arousal patterns are undesirable because of their long-term
consequences, but the immediate pleasure they provided and strong reinforcement,
overcomes any thoughts of possible harm or danger that might arise in the future. During
6-8 sessions, the therapist narrates dramatic scenes and the patient is then instructed to
imagine them every day until all arousal disappears. For example, a father who is
sexually attracted to his daughter, would be guided through scenes where he is discovered
by his wife, family members or priest
In orgasmic reconditioning, patients are instructed to masturbate to their usual fantasies
but to substitute more desirable ones just before ejaculation. With repeated practice,
subjects should be able to begin the desired fantasy earlier in the masturbatory process
and still retain their arousal.
Finally, patients need to be provided with coping skills to prevent slips or relapse. In
Relapse prevention patients are taught to recognize the early sign of temptation and to
implement a variety of self-control procedures before their urges become too strong.
It is important to note that it has been difficult to assess the success of these treatments
and it is thus unclear how effective these psychosocial procedures are at reducing
paraphilic disorders.
3. Discuss the different treatments for Substance-Use Disorders. Use one disorder as an
example.
Treating individuals who have a substance-related disorder is a difficult task because of
the combination of influences that often work together to keep people hooked. Thus, the
outlook for those who are dependent on drugs is often not very positive. Treatment of
substance-related disorders focuses on several areas, which will be demonstrated by using
alcohol use disorder as an example.
However, it is first important to not that the personal motivation to work on a drug
problem appears to be important but not necessarily essential in the treatment of
substance abuse, and substance abusers arrive at treatment at different stages of readiness
to change their substance use behavior. A specific psychological technique called
motivational enhancement therapy (MET), has been developed to help individuals
with substance use disorder increase their motivation to change and move toward a stage
where they are ready to work on modifying their problematic substance use behavior.
Biological treatment:
Increased knowledge about how psychoactive drugs work on the brain has led researchers
to explore ways of changing how they are experiences by people who are dependent on
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them. Biological treatments for substance abuse include agonist substitution, which
involves providing the person with a safer drug that has a chemical makeup similar to the
addictive drug, antagonist treatments, which block or counteract the effects of
psychoactive drugs, and aversive treatments that make ingesting the abused substances
extremely unpleasant. Specifically to individuals with alcohol use disorder, a relatively
new serotonin antagonist drug called ondansetron is being studied. This drug may
modulate some of the behavioral effects of alcohol, may decrease alcohol consumption,
and may be particularly helpful for people who developed alcoholism at or before their
early 20s. The most commonly known aversive treatment, disulfiram (Antabuse), is
used with people who are alcohol dependent. People who drink alcohol after taking
Antabuse experience nausea, vomiting, and elevated heart rate and respiration.
Individuals are required to take Antabuse each morning, before the desire to drink wins
out. However, unfortunately, noncompliance is a major concern and a person who skips
the Antabuse for a few days is able to resume drinking. Thus, Antabuse has generally
been less than successful as a treatment strategy on its own because it requires people to
be extremely motivated to continue taking it outside the supervision of a mental health
professional.
Other biological treatments such as medication (e.g. SSRIs) are now being tested for
their potential therapeutic properties, especially for alcohol dependence.
Psychosocial treatments
For most abusers, none of the biological treatments alone are successful and the majority
of research indicates a need for social support or therapeutic intervention. Because so
many people need help to overcome their substance disorder, a number of models and
programs have been developed.
Inpatient treatment facilities are designed to help substance dependent people get
through the initial withdrawal period and to provide supportive therapy so they can go
back to their communities. However, inpatient care is expensive and it may not be more
effective than outpatient therapy.
The most popular treatment of substance abuse is the 12-step program developed by
Alcoholics Anonymous (AA) in 1935, which takes an abstinence approach to drug
abuse. AA is founded on the notion that alcoholism is a disease and alcoholics must
acknowledge their addiction to alcohol and its destructive power over them. The
addiction is seen as more powerful than any individual and therefore they must look to a
higher power to help them over come their shortcoming. Central to AA is its
independence from the established medical community and the freedom it offers from the
stigmatization of alcoholism. An important component is the social support it provides
through group meetings. Since participants attend meetings anonymously and only when
they feel the need to, conducting systematic research on the effectiveness of AA has been
especially difficult and studies have shown mixed results.
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Researchers have questioned the total abstinence goal of AA and have offered an
alternative approach, harm reduction. The harm reduction approach recognizes that
substance use occurs in society and its primary goal is to minimize the harm associated
with substance. Some believe that some substance abusers (notably alcohol) may be
capable of becoming social users without resuming their abuse of these drugs. The notion
of teaching people controlled drinking is extremely controversial. One study by Mark
and Linda Sobell assigned alcohol dependent individuals to either a program that taught
them how to drink in moderation or to a group that was abstinence oriented. At a 2-year
follow-up, participants in the controlled drinking group were functioning well 85% of the
time, whereas those in the abstinence group were doing well only 42% of the time.
However, some of the men in both groups had serious relapses and required
rehospitalization and some were incarcerated. Thus, controlled drinking may be a viable
alternative to abstinence for some alcohol abusers. In the United Kingdom and Canada
controlled drinking is more widely accepted than in the United States. More recent
research has shown controlled drinking to be at least as effective as abstinence, but that
neither treatment is successful for 70-80% of patients over the long term.
Most comprehensive treatment programs aimed at helping people with substance abuse
and dependence problems have several different component treatments thought to boost
the effectiveness of the “treatment package”.
In aversion therapy, a conditioning model, substance use is paired with something
extremely unpleasant such as a brief electric shock or feelings of nausea. For example, an
alcoholic might be offered a drink of alcohol and receive a painful shock when the glass
reaches his/her lips. The goal here is to counteract the positive associations of substance
use with negative associations. The negative associations can also be made by imagining
unpleasant scenes in a technique called covert sensitization.
In contingency management the clinician and patient together select the behaviors that
the client needs to change and decide on the reinforcers that will reward reaching certain
goals, for example money or small retail items.
An other package of treatments is the community reinforcement approach. Several
different facets of the drug problem are assessed. First, a spouse, friend or relative who is
not a substance user is recruited to participate in relationship therapy in order to help the
abuser improve his/ her relationships with other important people. Second, clients are
taught how to identify the antecedents and consequences that influence their drug taking.
For example, if they are likely to drink alcohol with certain friends, patients are taught to
recognize the relationship and encouraged to avoid the associations. Third, patients are
given assistance with employment, education, finances, or other social service areas that
may help reduce their stress. Fourth, new recreational options help the person replace
substance use with new activities. There is currently strong empirical support for the
effectiveness of this approach with alcohol users.
The relapse prevention treatment directly addresses the problem of relapse. The model
developed by Alan Marlatt looks at the learned aspects of dependence and sees relapse as
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a failure of cognitive and behavioral coping skills. Therapy involved helping people
remove any ambivalence about stopping their drug use by examining their beliefs about
the positive aspects of the drug (“There’s noting like the numbing aspect of alcohol”) and
confronting the negative consequences of its use (“I fight with my wife when I’m
drunk”). High risk situations are identified and strategies are developed to deal with
potentially problematic situations as well as with the craving that arises from abstinence.
As previously stated, relapse rates for alcohol users are extremely high, thus, incidents of
relapse are dealt with as occurrences from which the person can recover. For instance,
instead of looking on these episodes as inevitably leading to drug use, people in treatment
are encouraged to see them as episodes brought on by temporary stress or a situation that
can be changed. Research on this technique suggests that it may be particularly effective
for alcohol problems.
4.Using examples from the chapters covered in this exam, describe how three disorders
fit the definition/meet criteria of a psychological disorder
5. Define Personality Disorders and the personality disorder clusters. In addition,
describe one personality disorder and its best available treatment.
According to the DSM 5, a personality disorder is a persistent pattern of emotions,
cognitions, and behavior that results in enduring emotional distress for the person
affected and/or for other and may cause difficulties with work and relationships.
Individuals with personality disorders may not feel any subjective distress, however, and
it may be acutely felt by others because of the actions of the person with the disorder.
Personality disorders take on a chronic course, they originate in childhood and continue
through adulthood. More sophisticated analyses suggest that personality disorders can
remit over time, however, they may be replaced by other personality disorders. Since
these chronic problems affect personality, they pervade every aspect of a person’s life.
For example, if an individual is overly suspicious (a sign of paranoid personality
disorder), this trait will affect almost everything he does including employment,
relationships and where the individual lives. A suspicious individual may change jobs
frequently if he believes co-workers conspire against him, he may not be able to sustain a
lasting relationship if he cant trust anyone and he may move often if he suspects his
landlord is out to get him.
The DSM-5 divides the personality disorders into three groups or “clusters”, which is
based on the resemblance of the disorders. Cluster A is called the “odd” or “eccentric”
cluster and includes paranoid, schizoid and schizotypal personality disorders. Cluster B is
the “dramatic”, or “emotional”, or “erratic” cluster and consists of antisocial, borderline,
histrionic, and narcissistic personality disorders. Montreal researchers have found that all
four disorders in this cluster are characterized by elevated impulsivity. Cluster C is the
“anxious” or “fearful” cluster and includes avoidance, dependent and obsessivecompulsive personality disorders. Findings from a research group in Spain suggest that
an overactive behavioral inhibition system may be the core underlying vulnerability for
Cluster C personality disorders.
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Individuals with dependent personality disorder rely on others to make ordinary
decisions as well as important ones, which results in an unreasonable fear of
abandonment. This personality disorder belongs to the Cluster C, anxious/ fearful
personality disorders because the interpersonally dependent behavior is motivated by
anxiety (e.g. fear of abandonment). To not be rejected by others, these individuals may
sometimes agree with other people when their own opinions differ. They have a strong
desire to obtain and maintain supportive and nurturing relationships, which may lead to
submissiveness, timidity, and passivity. Additionally, people with this disorder may have
feelings of inadequacy, may be sensitive to criticism, and have a need for reassurance, in
which they respond to by clinging to relationships. Having a sociotropic personality trait
is relevant to the etiology of dependent personality disorders. Sociotropy refers to a
personality orientation involving a strong investment in positive social interactions.
Very little research exists on the effectiveness of treatments for dependent personality
disorder. Individuals with dependent personality disorder may seem like ideal patients
because of their attentiveness and eagerness to give their responsibility to the therapist.
However, that submissiveness negates one of the major goals of therapy, which is to
make the person more independent and personally responsible. Therefore, therapy
progresses gradually as the patient develops confidence in his/her ability to make
decisions independently. There is a particular need for care that the patient does not
become overly dependent on the therapist.
6. Describe the biological, psychological, and social causes of Schizophrenia. Be sure to
use at least one well described example of each type of cause (biological, psychological,
social), by reporting studies that support each claim.
Schizophrenia is an extremely complex disorder and there are many biological,
psychological and social causes for this disorder.
Biological Causes
Research on the genetic influences of schizophrenia clearly illustrates the enormous
complexity of genetic influences on behavior. By looking at family studies, twin studies
and adoption studies, one can safely say that genes are responsible for making some
individuals vulnerable to schizophrenia. Additionally neurobiological influences and
abnormal brain structures have been noted in schizophrenia.
Family Studies:
A German researcher (Frenz Kallman), examined family members of more than 1000
persons diagnosed with schizophrenia in a Berlin psychiatric hospital. Kallman showed
that the severity of the parent’s disorder influenced the likelihood of the children having
schizophrenia. Thus, the more severe the parent’s schizophrenia, the more likely the
children were to develop it also. Additionally, he showed that all forms of schizophrenia
were seen within the families. Thus, you may inherit a general predisposition for
schizophrenia that manifests in the same form or a different one from that of your parent.
More recent research has suggested that families that have a member with schizophrenia
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are not just at risk for schizophrenia or all psychological disorders but there seems to be
an increase familial risk for a spectrum of psychotic disorders related to schizophrenia.
Twin Studies:
Twin studies have shown that both genes and environment play a role in the development
of schizophrenia. Identical twins share 100% of genes and 100% of their environment
while fraternal twins share 50% of genes and 100% of their environment. If the
environment is solely responsible for schizophrenia we would expect little difference
between identical and fraternal twins. In contrast, if only genetic factors are relevant, both
identical twins would always have schizophrenia and the fraternal twins would both have
it about 50% of the time. Research on twin studies indicates that the truth is somewhere
in the middle, we see a difference between identical twins and fraternal (environment)
twin and identical twins do not always both have the disorder (genes).
More interestingly, identical quadruplets all of whom have schizophrenia have been
studied extensively. The “Genain” quadruplets represent the complex interaction between
genetics and the environment. All four women shared the same genetic predisposition
and were all brought up in the same particularly dysfunctional household. However, the
time of onset for schizophrenia, the symptoms and diagnoses, the course of the disorder
and their outcomes differed significantly from sister to sister. The case of the Genain
quadruplets revels an important consideration in studying genetic influences on behavior,
unshared environments. Even identical siblings can have very different prenatal and
family experiences and can therefore be exposed to varying degrees of biological and
environmental stress. This unusual case demonstrates that even sibling who are very
close in every aspect of their lives can still have considerably different experiences
physically and social as they grow up, which may result in vastly different outcomes.
Adoption Studies:
The largest adoption study was conducted in Finland. The data from this study support
the idea that schizophrenia represents a spectrum of related disorders, all of which
overlap genetically. If an adopted child had a biological mother with schizophrenia,
he/she had about a 5% chance of having the disorder (compared with about only 1%
chance in the general population). However, if the biological mother had schizophrenia or
one of the related psychotic disorders (e.g. delusional disorder, schizophreniform
disorder), the risk that the adopted child would have one of these disorders rose to about
22%. Thus, even when raised away from their parents, children of parents with
schizophrenia have a much higher chance of having the disorder themselves. Moreover,
there appears to be a protective factor if these children are brought up in healthy,
supportive homes. A gene-environment interaction was observed in this study where a
good home environment reduces the risk of schizophrenia.
Neurobiological influences:
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The question whether schizophrenia involves a malfunctioning brain has lead to a great
deal of research focusing on the brain. One controversial theory of the cause of
schizophrenia involved the neurotransmitter dopamine. Research on antipsychotic
medications has suggested that the dopamine system may be too active in individuals
with schizophrenia. Firstly, antipsychotic drugs (neuroleptics) that are often effective in
treating people with schizophrenia are dopamine antagonists; they partially block the
brain’s use of dopamine. These drugs can produce negative side effects similar to those in
Parkinson’s disease, which is a disorder known to be due to insufficient dopamine.
Secondly, the drug L-dopa, a dopamine agonist used to treat people with Parkinson’s
disease, produces schizophrenia-like symptoms in some people. Thirdly, amphetamines,
which also activate dopamine, can make psychotic symptoms worse in some people with
schizophrenia. Thus, when drugs that are known to increase dopamine (agonists) are
administered, there is an increase in schizophrenic behavior and when drugs that are
known to decrease dopamine activity (antagonists) are used, schizophrenic symptoms
tend to diminish. Taking all these observations into account, researchers theorized that
schizophrenia in some people was attributable to excessive dopamine activity.
Despite these observations, some evidence is inconsistent with the dopamine theory.
Firstly, some people with schizophrenia do not respond to dopamine antagonists.
Secondly, when neuroleptics are taken, symptoms take days or weeks to subside. Lastly,
these drugs are only partly helpful in reducing the negative symptoms (e.g. flat affect,
anhedonia) of schizophrenia.
Brain structure:
Evidence for neurological damage in people with schizophrenia comes from a number of
observations. Brain damage or dysfunction may cause or accompany schizophrenia,
although no single site is probably responsible for the whole range of symptoms.
Researchers have noted that individuals with schizophrenia show larger lateral and third
ventricals. However, larger ventricals is not seen in everyone who has schizophrenia.
Enlarged ventricles are observed more often in men than women. Additionally, ventricals
seem to enlarge in proportion to age and to the duration of the schizophrenia. Moreover,
enlarged ventricles may be related to susceptibility and vulnerability of schizophrenia.
One study showed that both the affected and unaffected siblings had enlargement of the
third ventricle compared with controls.
The frontal lobe appears to be less active in people with schizophrenia, a phenomenon
called hypofrontality. Neurobiological research by several Canadian teams has shown
that patients with schizophrenia perform poorly relative to comparison groups on
cognitive tasks known to be related to functioning of the frontal lobed. For example,
patients with schizophrenia performed more poorly than healthy control on the Wisconsin
Card Sorting Task, a test that requires planning and organization abilities. Hypofrontality
also seems to be associated with the negative symptoms of schizophrenia.
Other biological causes:
- The offspring of twins
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Linkage association studies
Common traits: smooth-pursuit eye movement
Schizo virus?
Psychological Causes:
The fact that one identical twin may develop schizophrenia and the other may not
suggests that schizophrenia involves something in addition to genes. Additionally, not all
individuals with schizophrenia have enlarged ventricles or hypofrontality. Thus, the
causal picture may be further complicated by psychological and social factors.
Stress:
Stress can affect the development of schizophrenia. It is important to discover how much
and what kind of stress makes a person with a predisposition for schizophrenia develop
the disorder itself. Researchers have studied the effects of a variety of stressors on
schizophrenia. Living in a large city is associated with an increased risk of developing
schizophrenia, thus suggesting that the stress of urban living may precipitate its onset.
Additionally stressful life events appear to precipitate the onset of the disorder. In one
study, researchers observed that healthy people who engaged in combat during a war
often display temporary symptoms that resemble those of schizophrenia. Moreover, in an
other study, individuals diagnosed with schizophrenia experienced a high number of
stressful life events in the three weeks just before they started showing sign of the
disorder. However, it is important to note that the retrospective nature of such research
creates problems. Each study relies on after-the-fact reports, collected after the person
showed signs of schizophrenia. There may be bias in such reports and they may therefore
be misleading.
One study used a prospective approach to examine the impact of stress on relapse. The
researchers identified 30 people with recent-onset schizophrenia and followed them for a
year. During the one-year assessment period, 11 of the 30 people had a significant
relapse, their symptoms returned or worsened. The study found that relapses occurred
when stressful life events increased during the previous month.
Social Causes:
Stress:
An other important area in the study of the impact of stress on schizophrenia is research
showing a significant negative correlation between social class and schizophrenia. There
is a significant tendency for individuals with schizophrenia to be found in the lowest
social classes. This finding has been replicated in a variety of cultures. There are two
possible explanations for this finding. First, the sociogenic hypothesis suggests that life in
the lower social classes is stressful and thus predisposing those from the lower social
classes to an increased likelihood of schizophrenia. Second, the social selection
hypothesis pertains to the adverse effects of schizophrenia on a person’s ability to hold a
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job. If the illness makes them less able to hold a job, individuals with schizophrenia may
experience a downward social drift into lower social classes. Although results have been
mixed, findings generally favor the social selection hypothesis.
Social support:
Social support appears to be a protective factor and improves the prognosis of
schizophrenia. A longitudinal study at the University of Ottawa showed that higher levels
of social support from non-family members in the social network predicted better
outcomes five years later among patients experiencing their first episode of
schizophrenia.
Families and Relapse:
Questions involving the role of family members has lead to a great deal of research on
how interactions within the family affect people who have schizophrenia. Recent work
has focused more on how family interactions contribute not to the onset of schizophrenia
itself but to relapse after initial symptoms are observed. A particular communication
styles called expressed emotion (EE) has been of focus. Brown and colleagues followed a
sample of people who had been discharged from the hospital after an episode of
schizophrenic symptoms. The researchers found that former patients who had limited
contact with their relatives did better than patients who spent longer period with their
families. Additionally, if the level of criticism (disapproval), hostility (animosity), and
emotional over involvement (intrusiveness) expressed by the families was high, patients
tended to relapse. Other studies have shown similar findings. If you have schizophrenia
and live in a family with high expressed emotion, you are 3.7 times more likely to relapse
than if you lived in a family with low expressed emotion.
Example of high expressed emotion: “I’ver tried to jolly him out of it and pestered him
into doing things”
Example of low expressed emotion: “I know its better for her to be on her own, to get
away from me and try to do things on her own”, “whatever she does suits me”
It is important to note that high expressed emotion may be a contributing factor and not a
cause of schizophrenia because EE levels differ worldwide and prevalence rates remain
stable.
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