False sensory perceptions that often take the form of hearing voices are called ________.

Psychological Disorders12

Enduring Issues in Psychological Disorders Perspectives on Psychological Disorders • Historical Views of

Psychological Disorders • The Biological Model • The Psychoanalytic Model • The Cognitive–Behavioral

Model • The Diathesis–Stress Model

and Systems Theory

• The Prevalence of Psychological Disorders

• Mental Illness and the Law • Classifying Abnormal

Behavior

Mood Disorders • Depression • Suicide • Mania and Bipolar Disorder • Causes of Mood Disorders

Anxiety Disorders • Specific Phobias • Panic Disorder • Other Anxiety Disorders • Causes of Anxiety Disorders Psychosomatic and Somatoform Disorders Dissociative Disorders Sexual and Gender-Identity Disorders Personality Disorders

Schizophrenic Disorders • Types of Schizophrenic

Disorders • Causes of Schizophrenia Childhood Disorders Gender and Cultural Differences in Psychological Disorders • Gender Differences • Cultural Differences

O V E R V I E W

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Jack was a very successful chemical engineer known for themeticulous accuracy of his work. But Jack also had a “littlequirk.” He constantly felt compelled to double-, triple-, and even quadruple-check things to assure himself that they were done properly. For instance, when leaving his apartment in the morning, he occasionally got as far as the garage—but invariably he would go back to make certain that the door was securely locked and the stove, lights, and other appliances were all turned off. Going on a vacation was particularly difficult for him because his checking routine was so exhaustive and time-consuming. Yet Jack insisted that he would never want to give up this chronic checking. Doing so, he said, would make him “much too nervous.”

For Claudia, every day was more than just a bad-hair day. She was always in utter despair over how “hideous” her hair looked. She perceived some parts of it to be too long, and others to be too short. In her eyes, one area would look much too “poofy,” while another area would look far too flat. Claudia got up early each morning just to work on her hair. For about 2 hours she would wash it, dry it, brush it, comb it, curl it, straighten it, and snip away infinitesimal amounts with an expensive pair of hair-cutting scissors. But she was never satisfied with the

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results. Not even trips to the most expensive salons could make her feel content about her hair. She declared that virtually every day was ruined because her hair looked so bad. Claudia said that she desperately wanted to stop focusing on her hair, but for some reason she just couldn’t.

Jonathan was a 22-year-old auto mechanic whom everyone described as a loner. He seldom engaged in conversation and seemed lost in his own private world. At work, the other mechanics took to whistling sharply whenever they wanted to get his attention. Jonathan also had a “strange look” on his face that could make customers feel uncomfortable. But his oddest behavior was his assertion that he sometimes had the distinct feeling his dead mother was standing next to him, watching what he did. Although Jonathan realized that his mother was not really there, he nevertheless felt reassured by the illusion of her presence. He took great care not to look or reach toward the spot where he felt his mother was, because doing so inevitably made the feeling go away.

Cases adapted from J. S. Nevis, S. A. Rathus, & B. Green (2005). Abnormal Psychol-

ogy in a Changing World (5th ed.) Upper Saddle River, NJ: Prentice Hall.

ENDURING ISSUES IN PSYCHOLOGICAL DISORDERS As we explore psychological disorders in this chapter, we will again encounter some of the enduring issues that interest psychologists. A recurring topic is the relationship between genetics, neurotransmitters, and behavior disorders (mind–body). We will also see that many psychological disorders arise because a vulnerable person encounters a particularly stressful environment (person–situation). As you read the chapter, think about how you would answer the question “What is normal?” and how the answer to that question has changed over time and differs even today across cultures (diversity–universality). Consider also whether a young person with a psychological disorder is likely to suffer from it later in life and, conversely, whether a well-adjusted young person is immune to psychological dis- orders later in life (stability–change).

PERSPECTIVES ON PSYCHOLOGICAL DISORDERS How does a mental health professional define a psychological disorder?

When is a person’s behavior abnormal? This is not always easy to determine. There is no doubt about the abnormality of a man who dresses in flowing robes and accosts pedestri- ans on the street, claiming to be Jesus Christ, or a woman who dons an aluminum-foil hel- met to prevent space aliens from “stealing” her thoughts. But other instances of abnormal behavior aren’t always so clear. What about the three people we have just described? All of them exhibit unusual behavior. But does their behavior deserve to be labeled “abnormal”? Do any of them have a genuine psychological disorder?

The answer depends in part on the perspective you take. As Table 12–1 summarizes, society, the individual, and the mental health professional all adopt different perspectives

L E A R N I N G O B J E C T I V E S • Compare the three perspectives on

what constitutes abnormal behavior. Explain what is meant by the statement “Identifying behavior as abnormal is also a matter of degree.” Distinguish between the prevalence and incidence of psychological disorders, and between mental illness and insanity.

• Describe the key features of the biological, psychoanalytic, cognitive–behavioral, diathesis–stress, and systems models of psychological disorders.

• Explain what is meant by “DSM-IV-TR” and describe the basis on which it categorizes disorders.

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when distinguishing abnormal behavior from normal behavior. Society’s main standard of abnormality is whether the behavior fails to conform to prevailing ideas about what is socially expected of people. In contrast, when individuals assess the abnormality of their own behavior, their main criterion is whether that behavior fosters a sense of unhappiness and lack of well-being. Mental health professionals take still another perspective. They assess abnormality chiefly by looking for maladaptive personality traits, psychological dis- comfort regarding a particular behavior, and evidence that the behavior is preventing the person from functioning well in life.

These three approaches to identifying abnormal behavior are not always in agree- ment. For example, of the three people previously described, only Claudia considers her own behavior to be a genuine problem that is undermining her happiness and sense of well-being. In contrast to Claudia, Jack is not really bothered by his compulsive behavior (in fact, he sees it as a way of relieving anxiety); and Jonathan is not only content with being a loner, but he also experiences great comfort from the illusion of his dead mother’s presence. But now suppose we shift our focus and adopt society’s perspective. In this case, we must include Jonathan on our list of those whose behavior is abnormal. His self-imposed isolation and talk of sensing his mother’s ghost violate social expecta- tions of how people should think and act. Society would not consider Jonathan normal. Neither would a mental health professional. In fact, from the perspective of a mental health professional, all three of these cases show evidence of a psychological disorder. The people involved may not always be distressed by their own behavior, but that behav- ior is impairing their ability to function well in everyday settings or in social relation- ships. The point is that there is no hard and fast rule as to what constitutes abnormal behavior. Distinguishing between normal and abnormal behavior always depends on the perspective taken.

Identifying behavior as abnormal is also a matter of degree. To understand why, imag- ine that each of our three cases is slightly less extreme. Jack is still prone to double-checking, but he doesn’t check over and over again. Claudia still spends much time on her hair, but she doesn’t do so constantly and not with such chronic dissatisfaction. As for Jonathan, he only occasionally withdraws from social contact; and he has had the sense of his dead mother’s presence just twice over the last 3 years. In these less severe situations, a mental health pro- fessional would not be so ready to diagnose a mental disorder. Clearly, great care must be taken when separating mental health and mental illness into two qualitatively different cate- gories. It is often more accurate to think of mental illness as simply being quantitatively dif- ferent from normal behavior—that is, different in degree. The line between one and the other is often somewhat arbitrary. Cases are always much easier to judge when they fall at the extreme end of a dimension than when they fall near the “dividing line.”

Table 12–1 PERSPECTIVES ON PSYCHOLOGICAL DISORDERS

Standards/Values Measures

Society Orderly world in which people assume responsibility for their assigned social roles (e.g., breadwinner, parent), conform to prevailing mores, and meet situational requirements.

Observations of behavior, extent to which a person fulfills society’s expectations and measures up to prevailing standards.

Individual Happiness, gratification of needs. Subjective perceptions of self-esteem, acceptance, and well-being. Mental health professional

Sound personality structure characterized by growth, development, autonomy, environmental mastery, ability to cope with stress, adaptation.

Clinical judgment, aided by behavioral observations and psychological tests of such variables as self-concept; sense of identity; balance of psychic forces; unified outlook on life; resistance to stress; self-regulation; the ability to cope with reality; the absence of mental and behavioral symptoms; adequacy in interpersonal relationships.

Source: From “A Tripartite Model of Mental Health and Therapeutic Outcomes with Special Reference to Negative Effects on Psychotherapy” by H. H. Strupp and S. W. Hadley, American Psychologist, 32 (1977), pp. 187–196. Copyright © 1977 by American Psychological Association.

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Psychological Disorders 393

Historical Views of Psychological Disorders How has the view of psychological disorders changed over time?

The place and times also contribute to how we define mental disorders. Thousands of years ago, mysterious behaviors were often attributed to supernatural powers and madness was a sign that spirits had possessed a per- son. As late as the 18th century, the emotionally dis- turbed person was thought to be a witch or to be possessed by the devil. Exorcisms, ranging from the mild to the hair raising, were performed, and many people endured horrifying tortures. Some people were even burned at the stake.

By the late Middle Ages, there was a move away from viewing the mentally ill as witches and possessed by demons, and they were increasingly confined to public and private asylums. Even though these institu- tions were founded with good intentions, most were little more than prisons. In the worst cases, inmates were chained down and deprived of food, light, or air in order to “cure” them.

Little was done to ensure humane standards in mental institutions until 1793, when Philippe Pinel (1745–1826) became director of the Bicêtre Hospital in Paris. Under his direction, patients were released from their chains and allowed to move about the hospital grounds, rooms were made more comfortable and sanitary, and questionable and violent medical treatments were abandoned (James Harris, 2003). Pinel’s reforms were soon fol- lowed by similar efforts in England and, somewhat later, in the United States where Dorothea Dix (1802–1887), a schoolteacher from Boston, led a nationwide campaign for the humane treatment of mentally ill people. Under her influence, the few existing asylums in the United States were gradually turned into hospitals.

The basic reason for the failed—and sometimes abusive—treatment of mentally dis- turbed people throughout history has been the lack of understanding of the nature and causes of psychological disorders. Although our knowledge is still inadequate, important advances in understanding abnormal behavior can be traced to the late 19th and 20th cen- turies, when three influential but conflicting models of abnormal behavior emerged: the biological model, the psychoanalytic model, and the cognitive–behavioral model.

The Biological Model How can biology influence the development of psychological disorders?

The biological model holds that psychological disorders are caused by physiological mal- functions often stemming from hereditary factors. As we shall see, support for the biologi- cal model has been growing rapidly as scientists make advances in the new interdisciplinary field of neuroscience, which directly links biology and behavior (see Chapter 2,“The Biolog- ical Basis of Behavior”).

For instance, new neuroimaging techniques have enabled researchers to pinpoint regions of the brain involved in such disorders as schizophrenia (Kumra, 2008; Ragland, 2007) and antisocial personality (Birbaumer et al., 2005; Narayan et al., 2007). By unravel- ing the complex chemical interactions that take place at the synapse, neurochemists have spawned advances in neuropharmacology leading to the development of promising new psychoactive drugs (see Chapter 13,“Therapies”). Many of these advances are also linked to the field of behavior genetics, which is continually increasing our understanding of the role

In the 17th century, French physicians tried various devices to cure their patients of “fantasy and folly.”

biological model View that psychological disorders have a biochemical or physiological basis.

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of specific genes in the development of complex disorders such as schizophrenia (Horiuchi et al., 2006; Tang et al., 2006; Ying-Chieh Wang et al., 2008) and autism (Kuehn, 2006; Losh, Sullivan, Trembath, & Piven, 2008).

Although neuroscientific breakthroughs are indeed remarkable, to date no neu- roimaging technique can clearly and definitively differentiate among various mental dis- orders (Callicott, 2003; Sarason & Sarason, 1999). And despite the availability of an increasing number of medications to alleviate the symptoms of some mental disorders, most drugs can only control—rather than cure—abnormal behavior. There is also some concern that advances in identifying the underlying neurological structures and mecha- nisms associated with mental illnesses may interfere with the recognition of equally impor- tant psychological causes of abnormal behavior (Dudai, 2004; Widiger & Sankis, 2000). Despite this concern, the integration of neuroscientific research and traditional psycholog- ical approaches to understanding behavior is taking place at an increasingly rapid pace, and will undoubtedly reshape our view of mental illness in the future (Lacy & Hughes, 2006; Westen, 2005).

The Psychoanalytic Model What did Freud and his followers believe was the underlying cause of psychological disorders?

Freud and his followers developed the psychoanalytic model during the late 19th and early 20th centuries. (See Chapter 10, “Personality.”) According to this model, behavior disorders are symbolic expressions of unconscious conflicts, which can usually be traced to childhood. The psychoanalytic model argues that in order to resolve their problems effectively, people must become aware that the source of their problems lies in their childhood and infancy.

Although Freud and his followers profoundly influenced both the mental health disci- plines and Western culture, only weak and scattered scientific evidence supports their psy- choanalytic theories about the causes and effective treatment of mental disorders.

The Cognitive–Behavioral Model According to the cognitive–behavioral model, what causes abnormal behavior?

A third model of abnormal behavior grew out of 20th-century research on learning and cognition. The cognitive–behavioral model suggests that psychological disorders, like all behavior, result from learning. For example, a bright student who believes that he is acade- mically inferior to his classmates and can’t perform well on a test may not put much effort into studying. Naturally, he performs poorly, and his poor test score confirms his belief that he is academically inferior.

The cognitive–behavioral model has led to innovations in the treatment of psycholog- ical disorders, but the model has been criticized for its limited perspective, especially its emphasis on environmental causes and treatments.

The Diathesis–Stress Model and Systems Theory Why do some people with a family history of a psychological disorder develop the disorder, whereas other family members do not?

Each of the three major theories is useful in explaining the causes of certain types of disor- ders. The most exciting recent developments, however, emphasize integration of the vari- ous theoretical models to discover specific causes and specific treatments for different mental disorders.

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psychoanalytic model View that psychological disorders result from unconscious internal conflicts.

cognitive–behavioral model View that psychological disorders result from learning maladaptive ways of thinking and behaving.

The cognitive–behavioral view of mental dis- orders suggests that people can learn—and unlearn—thinking patterns that affect their lives unfavorably. For example, an athlete who is convinced she will not win may not practice as hard as she should and end up “defeating herself.”

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Psychological Disorders 395

One promising integrative approach is seen in the diathesis–stress model (McKeever & Huff, 2003; L. A. Schmidt, Polak, & Spooner, 2005). This model suggests that a biological predisposition called a diathesis must combine with a stressful circum- stance before the predisposition to a mental disorder is manifested (S. R. Jones & Ferny- hough, 2007).

The systems approach, also known as the biopsychosocial model, examines how bio- logical risks, psychological stresses, and social pressures and expectations combine to pro- duce psychological disorders (Fava & Sonino, 2007; Weston, 2005). According to this model, emotional problems are “lifestyle diseases” that, much like heart disease and many other physical illnesses, result from a combination of risk factors and stresses. Just as heart disease can result from a combination of genetic predisposition, personality styles, poor health habits (such as smoking), and stress, psychological problems result from several risk factors that influence one another. In this chapter, we follow the systems approach in exam- ining the causes and treatments of abnormal behavior.

diathesis Biological predisposition.

systems approach View that biological, psychological, and social risk factors combine to produce psychological disorders. Also known as the biopsychosocial model of psychological disorders.

Mind–Body Causes of Mental Disorders Throughout this chapter, as we discuss what is known about the causes of psychological disorders, you will see that biological and psychological factors are intimately connected. For example, there is strong evidence for a genetic component in some personality disor- ders as well as in schizophrenia. However, not everyone who inherits these factors develops a personality disorder or suffers from schizophrenia. Our current state of knowledge allows us to pinpoint certain causative factors for certain conditions, but it does not allow us to completely differentiate biological and psychological factors. ■

The Prevalence of Psychological Disorders How common are mental disorders?

Psychologists and public-health experts are concerned with both the prevalence and the incidence of mental health problems. Prevalence refers to the frequency with which a given disorder occurs at a given time. If there were 100 cases of depression in a popu- lation of 1,000, the prevalence of depression would be 10%. The incidence of a disorder refers to the number of new cases that arise in a given period. If there were 10 new cases of depression in a population of 1,000 in a single year, the incidence would be 1% per year.

In 2005, the National Institute of Mental Health conducted a survey finding that 26.2% or approximately 57.7 million Americans were suffering from a mental disorder. While only about 6% were regarded as having a serious mental illness, almost half the peo- ple (45%) suffering from one mental disorder also met the criteria for 2 or more other mental disorders (Kessler, Chiu, Demler, & Walters, 2005). Notably, mental disorders are the leading cause of disability in the United States for people between the ages of 15 and 44 (The World Health Organization, 2004). Figure 12–1 shows the prevalence for some of the more common mental disorders among adult Americans. As shown in Figure 12–1, anxi- ety disorders are the most common mental disorder followed by mood disorders. (All of these are described in detail later in this chapter.)

More recently diagnostic interviews with more than 60,000 people in 14 countries around the world showed that over a 1-year period, the prevalence of moderate or serious psychological disorders varied widely from 12% of the population in the Americas to 7% in Europe, 6% in the Middle East and Africa, and just 4% in Asia (World Health Organization [WHO] World Mental Health Survey Consortium, 2004).

diathesis–stress model View that people biologically predisposed to a mental disorder (those with a certain diathesis) will tend to exhibit that disorder when particularly affected by stress.

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Mental Illness and the Law Is there a difference between being “mentally ill” and being “insane”?

Particularly horrifying crimes have often been attributed to mental disturbance, because it seems to many people that anyone who could commit such crimes must be “crazy.” But to the legal system, this presents a problem: If a person is truly “crazy,” are we justi- fied in holding him or her responsible for criminal acts? The legal answer to this ques- tion is a qualified yes. A mentally ill person is responsible for his or her crimes unless he or she is determined to be insane. What’s the difference between being “mentally ill” and being “insane”? Insanity is a legal term, not a psychological one. It is typically applied to defendants who were so mentally disturbed when they committed their offense that they either lacked substantial capacity to appreciate the criminality of their actions (to know right from wrong) or to conform to the requirements of the law (to control their behavior).

When a defendant is suspected of being mentally disturbed or legally insane, another important question must be answered before that person is brought to trial: Is the person able to understand the charges against him or her and to participate in a defense in court? This issue is known as competency to stand trial. The person is exam- ined by a court-appointed expert and, if found to be incompetent, is sent to a mental institution, often for an indefinite period. If judged to be competent, the person is required to stand trial.

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Figure 12–1 Prevalence of selected mental disorders in the United States. A 2005 survey by the National Institute of Mental Health found that approximately 26.2%, or about 57.7 million Americans suffer from a mental disorder. The prevalence among adult Americans for a few of the more common mental disorders is shown here. Source: National Institute of Mental Health (2005).

0

Major Depressive Disorder

5 10 15 2520 Number of American Adults (in millions)

30 35 40 45

Bipolar 2.6%

Post-Traumatic Stress Disorder 3.5%

Attention-Deficit Hyperactivity Disorder (ADHD) 4.1%

6.7%

Specific Phobias 8.7%

All Mood Disorders 9.5%

All Anxiety Disorders 18.1%

Schizophrenia 1.1%

Obsessive-Compulsive Disorder 1.0%

insanity Legal term applied to defendants who do not know right from wrong or are unable to control their behavior.

Watch PTSD 911 at www.mypsychlab.com

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Classifying Abnormal Behavior Why is it useful to have a manual of psychological disorders?

For nearly 40 years, the American Psychiatric Association (APA) has issued a manual describing and classifying the various kinds of psychological disorders. This publication, the Diagnostic and Statistical Manual of Mental Disorders (DSM), has been revised four times. The DSM-IV-TR (American Psychiatric Association, 2000) provides a complete list of mental disorders, with each category painstakingly defined in terms of significant behavior patterns (see Table 12–2). The DSM has gained increasing acceptance because its detailed criteria for diagnosing mental disorders have made diagnosis much more reli- able. Today, it is the most widely used classification of psychological disorders. In the remainder of this chapter, we will explore some of the key categories in greater detail.