Program Evaluation: Benefits and Concerns of Stakeholders
psychology eighth edition
Thomas F.
olTmanns Washington University in St. Louis
RobeRT e.
emeRy University of Virginia
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Library of Congress Cataloging-in-Publication Data
Oltmanns, Thomas F. Abnormal psychology \ Thomas F. Oltmanns, Washington University in St. Louis, Robert E. Emery, University of Virginia.—Eighth edition. pages cm ISBN 978-0-205-97074-2 1. Psychology, Pathological. 2. Mental illness. I. Emery, Robert E. II. Title. RC454.O44 2014 616.89—dc23
2013037915
10 9 8 7 6 5 4 3 2 1
To Gail, Josh, Sara, Billy, Presley, Riley, and Kinley—T.F.O.
To Kimberly, Maggie, Julia, Bobby, Lucy, and John—R.E.E.
brief 1 examples and definitions of abnormal behavior 1 2 causes of abnormal behavior 24 3 treatment of psychological disorders 52 4 classification and assessment of abnormal behavior 77 5 Mood disorders and Suicide 105 6 anxiety disorders and obsessive-compulsive disorder 143 7 acute and posttraumatic Stress disorders, dissociative disorders,
and Somatic Symptom disorders 174
8 Stress and physical health 206 9 personality disorders 231 10 feeding and eating disorders 262 11 Substance-related and addictive disorders 284 12 Sexual dysfunctions, paraphilic disorders, and gender
dysphoria 318
13 Schizophrenia Spectrum and other psychotic disorders 348 14 neurocognitive disorders 379 15 intellectual disabilities and autism Spectrum disorders 404 16 psychological disorders of childhood 435 17 adjustment disorders and life-cycle transitions 465 18 Mental health and the law 489
iii
brief
iv
Preface xii about the authors xix
1 examples and definitions of abnormal behavior 1 Overview 2
Recognizing the Presence of a Disorder 4
Defining Abnormal Behavior 5 Harmful Dysfunction 6
Mental Health Versus Absence of Disorder 7
Culture and Diagnostic Practice 7
THINKING CRITICALLY about DSM-5: Revising an Imperfect manual 7
CRITICAL THINKING matters: Is sexual addiction a meaningful Concept? 9
Who Experiences Abnormal Behavior? 10 Frequency in and Impact on Community Populations 11
Cross-Cultural Comparisons 13
The Mental Health Professions 14
Psychopathology in Historical Context 15 The Greek Tradition in Medicine 15
The Creation of the Asylum 16
Worcester Lunatic Hospital: A Model Institution 16
Lessons from the History of Psychopathology 17
Methods for the Scientific Study of Mental Disorders 18 The Uses and Limitations of Case Studies 18
ReSeARCH methods: Who must Provide scientific evidence? 19
Clinical Research Methods 20
getting HeLp 21
summary 21 the big picture 22 key terms 23
2 causes of abnormal behavior 24 Overview 25
Brief Historical Perspective 26 The Biological Paradigm 26
The Psychodynamic Paradigm 27
THINKING CRITICALLY about DSM-5: Diagnosis and Causes of mental Disorders 28
The Cognitive-Behavioral Paradigm 29
The Humanistic Paradigm 30
The Problem with Paradigms 30
Systems Theory 31 Holism 31
Causality 31
ReSeARCH methods: 33 Correlations: Does a Psychology major make you smarter? 33
Developmental Psychopathology 33
Biological Factors 34 The Neuron and Neurotransmitters 34
Neurotransmitters and Psychopathology 35
mind–body Dualism 35
Major Brain Structures 36
Cerebral Hemispheres 38
Psychophysiology 38
Behavior Genetics 39
Psychological Factors 42 Human Nature 42
CRITICAL THINKING matters: Do Vaccinations Cause autism? 43
Temperament 44
Emotions 45
Learning and Cognition 45
The Sense of Self 46
Stages of Development 46
Social Factors 48 Close Relationships 48
Gender and Gender Roles 48
Prejudice, Poverty, and Society 49
getting HeLp 50
summary 50 the big picture 51 key terms 51
3 treatment of psychological disorders 52 Overview 53 Four Views of Frances 54
Biological Treatments 55 Psychopharmacology 55
THINKING CRITICALLY about DSM-5: Diagnosis and Treatment 56
Electroconvulsive Therapy 57
Psychosurgery 58
Psychodynamic Psychotherapies 58 Freudian Psychoanalysis 58
ConTenTs v
Ego Analysis 60
Psychodynamic Psychotherapy 60
Cognitive-Behavior Therapy 60 Systematic Desensitization 61
Other Exposure Therapies 61
Aversion Therapy 61
Contingency Management 61
ReSeARCH methods: The experiment: Does Treatment Cause Improvement? 62
Social Skills Training 63
Cognitive Techniques 63
Beck’s Cognitive Therapy 63
Rational–Emotive Therapy 63
“Third-Wave” CBT 64
Humanistic Therapies 64 Client-Centered Therapy 64
A Means, Not an End? 64
Research on Psychotherapy 65 Does Psychotherapy Work? 65
CRITICAL THINKING matters: are all Therapies Created equal? 66
The allegiance effect 68
Psychotherapy Process Research 69
ethnic minorities in Psychotherapy 70
Couple, Family, and Group Therapy 72 Couple Therapy 72
Family Therapy 73
Group Therapy 73
Prevention 74
Specific Treatments for Specific Disorders 74
getting HeLp 75
summary 75 the big picture 76 key terms 76
4 classification and assessment of abnormal behavior 77 Overview 78
Basic Issues in Classification 80 Categories Versus Dimensions 80
From Description to Theory 80
Classifying Abnormal Behavior 81 The DSM-5 System 81
labels and stigma 82
Criteria for obsessive-Compulsive Disorder 83
Culture and Classification 83
Evaluating Classification Systems 85 Reliability 85
ReSeARCH methods: Reliability: agreement Regarding Diagnostic Decisions 85
Validity 86
THINKING CRITICALLY about DSM-5: scientific Progress or Diagnostic Fads? 87
Problems and Limitations of the DSM-5 System 88
Basic Issues in Assessment 90 Purposes of Clinical Assessment 90
Assumptions About Consistency of Behavior 91
Evaluating the Usefulness of Assessment Procedures 91
CRITICAL THINKING matters: The barnum effect and assessment Feedback 92
Psychological Assessment Procedures 92 Interviews 92
Observational Procedures 94
Personality Tests and Self-Report Inventories 96
Projective Personality Tests 99
Biological Assessment Procedures 100 Brain Imaging Techniques 100
getting HeLp 102
summary 103 the big picture 103 key terms 104
5 Mood disorders and Suicide 105 Overview 106
Symptoms 109 Emotional Symptoms 109
Cognitive Symptoms 110
Somatic Symptoms 110
Behavioral Symptoms 111
Other Problems Commonly Associated with Depression 111
Diagnosis 111
THINKING CRITICALLY about DSM-5: Depression or Grief Following a major loss? 112
Criteria for major Depressive episode 113
Criteria for Diagnosis of manic episode 114
Course and Outcome 116 Depressive Disorders 116
Bipolar Disorders 116
Frequency 117 Incidence and Prevalence 117
Risk for Mood Disorders Across the Life Span 117
Gender Differences 118
Cross-Cultural Differences 118
Causes 119 Social Factors 119
Psychological Factors 121
Biological Factors 122
Integration of Social, Psychological, and Biological Factors 127
vi ConTenTs
ReSeARCH methods: analogue studies: Do Rats Get Depressed, and Why? 127
Treatment 128 Depressive Disorders 128
Cognitive Therapy 128
Bipolar Disorders 130
CRITICAL THINKING matters: Do antidepressant Drugs Cause Violent behavior? 131
Electroconvulsive Therapy 132
Seasonal Mood Disorders 132
Suicide 132 Classification of Suicide 133
Frequency of Suicide 135
Causes of Suicide 136
Common elements of suicide 137
Treatment of Suicidal People 138
getting HeLp 139
summary 140 the big picture 141 key terms 141
6 anxiety disorders and obsessive-compulsive disorder 143
Overview 144
Symptoms of Anxiety Disorders 145 Anxiety 145
Excessive Worry 146
Panic Attacks 147
Phobias 147
Diagnosis of Anxiety Disorders 147 Criteria for Panic Disorder 148
THINKING CRITICALLY about DSM-5: splitting Up the anxiety Disorders 149
Course and Outcome 150
Frequency of Anxiety Disorders 151 Prevalence 151
Comorbidity 151
Gender Differences 151
Anxiety Disorders Across the Life Span 151
Cross-Cultural Comparisons 152
Causes of Anxiety Disorders 152 Adaptive and Maladaptive Fears 152
Social Factors 153
Psychological Factors 154
Biological Factors 156
Treatment of Anxiety Disorders 158 Psychological Interventions 158
Biological Interventions 160
ReSeARCH methods: statistical significance: When Differences matter 161
Obsessive-Compulsive and Related Disorders 162 Symptoms of OCD 163
Diagnosis of OCD and Related Disorders 165
Course and Outcome of OCD 167
Frequency of OCD and Related Disorders 168
Causes of OCD 168
Treatment of OCD 169
CRITICAL THINKING matters: Can a strep Infection Trigger oCD in Children? 169
getting HeLp 171
summary 171 the big picture 172 key terms 172
7 acute and posttraumatic Stress disorders, dissociative disorders, and Somatic Symptom disorders 174
Overview 175
Acute and Posttraumatic Stress Disorders 175 Symptoms of ASD and PTSD 176
Diagnosis of ASD and PTSD 177
Criteria for Posttraumatic stress Disorder 178
Criteria for acute stress Disorder 179
The Trauma of sexual assault 180
Frequency of Trauma, PTSD, and ASD 181
Causes of PTSD and ASD 182
Prevention and Treatment of ASD and PTSD 184
Dissociative Disorders 186 Hysteria and the Unconscious 187
CRITICAL THINKING matters: Recovered memories? 188
Symptoms of Dissociative Disorders 189
Diagnosis of Dissociative Disorders 190
Frequency of Dissociative Disorders 192
THINKING CRITICALLY about DSM-5: more on Diagnostic Fads 192
Causes of Dissociative Disorders 194
ReSeARCH methods: Retrospective Reports: Remembering the Past 195
Treatment of Dissociative Disorders 196
Somatic Symptom Disorders 196 Symptoms of Somatic Symptom Disorders 196
Diagnosis of Somatic Symptom Disorders 197
Criteria for Illness anxiety Disorder 198
Frequency of Somatic Symptom Disorders 199
Causes of Somatic Symptom Disorders 200
Treatment of Somatic Symptom Disorders 202
getting HeLp 203
summary 204 the big picture 204 key terms 205
ConTenTs vii
8 Stress and physical health 206 Overview 207
Defining Stress 208 Stress as a Life Event 209
Stress as Appraisal of Life Events 210
Symptoms of Stress 210 Tend and befriend: The Female stress Response? 211
Psychophysiological Responses to Stress 211
Coping 213
Health Behavior 214
CRITICAL THINKING matters: Resilience 214
Illness as a Cause of Stress 217
Diagnosis of Stress and Physical Illness 217
THINKING CRITICALLY about DSM-5: Is the Descriptive approach Too literal sometimes? 217
Psychological Factors and Some Familiar Illnesses 218 Cancer 218
Criteria for Psychological Factors affecting other medical Conditions 218
Acquired Immune Deficiency Syndrome (AIDS) 219
Pain Disorder 220
Sleep-Wake Disorders 220
Cardiovascular Disease 221 Symptoms of CVD 222
Diagnosis of CVD 222
Frequency of CVD 222
Causes of CVD 222
ReSeARCH methods: longitudinal studies: lives over Time 223
Prevention and Treatment of CVD 226
getting HeLp 228
summary 229 the big picture 229 key terms 230
9 personality disorders 231 Overview 232
Symptoms 234 Social Motivation 234
Cognitive Perspectives Regarding Self and Others 235
Temperament and Personality Traits 235
Context and Personality 237
Diagnosis 237 Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders 238
CRITICAL THINKING matters: Can Personality Disorders be adaptive? 238
Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders 239
Cluster C: Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders 241
A Dimensional Perspective on Personality Disorders 241
THINKING CRITICALLY about DSM-5: Is a Dimensional model Too Complicated? 243
Frequency 245 Prevalence in Community and Clinical Samples 245
Gender Differences 246
Stability of Personality Disorders over Time 246
Culture and Personality 247
ReSeARCH methods: Cross-Cultural Comparisons: The Importance of Context 248
Schizotypal Personality Disorder (SPD) 249 Symptoms 249
Criteria for schizotypal Personality Disorder 250
Causes 250
Treatment 250
Borderline Personality Disorder (BPD) 251 Impulse Control Disorders 252
Symptoms 252
Criteria for borderline Personality Disorder 253
Causes 253
Treatment 254
Antisocial Personality Disorder (ASPD) 255 Symptoms 256
Criteria for antisocial Personality Disorder 256
Causes 257
Treatment 259
getting HeLp 259
summary 260 the big picture 261 key terms 261
10 feeding and eating disorders 262 Overview 263
eating Disorders in males 264
Symptoms of Anorexia 265 Significantly Low Weight 265
Fear of Gaining Weight 266
Disturbance in Experiencing Weight or Shape 266
Amenorrhea 266
Medical Complications 266
Struggle for Control 266
Comorbid Psychological Disorders 266
viii ConTenTs
Symptoms of Bulimia 267 Binge Eating 268
Inappropriate Compensatory Behavior 268
Excessive Emphasis on Weight and Shape 268
Comorbid Psychological Disorders 269
Medical Complications 269
Diagnosis of Feeding and Eating Disorders 269
THINKING CRITICALLY about DSM-5: Is binge eating a mental Disorder? Is obesity? 269
Criteria for anorexia nervosa 270
Criteria for bulimia nervosa 271
Frequency of Anorexia and Bulimia 271 Standards of Beauty 272
CRITICAL THINKING matters: The Pressure to be Thin 273
Age of Onset 273
Causes of Anorexia and Bulimia 274 Social Factors 274
Psychological Factors 275
Biological Factors 277
Integration and Alternative Pathways 277
Treatment of Anorexia 278 Course and Outcome of Anorexia Nervosa 278
Treatment of Bulimia 279 Cognitive Behavior Therapy 279
Interpersonal Psychotherapy 279
Antidepressant Medications 279
ReSeARCH methods: Psychotherapy Placebos 280
Course and Outcome of Bulimia Nervosa 280
Prevention of Eating Disorders 280
getting HeLp 282
summary 282 the big picture 283 key terms 283
11 Substance-related and addictive disorders 284 Overview 285
Symptoms 287 Alcohol 289
Tobacco 290
Amphetamine and Cocaine 291
Opiates 292
Sedatives, Hypnotics, and Anxiolytics 293
Cannabis 294
Hallucinogens and Related Drugs 294
Diagnosis 295 Brief History of Legal and Illegal Substances 295
DSM-5 296
Course and Outcome 297
Criteria for alcohol Use Disorder 297
Other Disorders Commonly Associated with Addictions 298
Frequency 298 Prevalence of Alcohol Use Disorder 299
Prevalence of Drug and Nicotine Use Disorders 300
Risk for Addiction Across the Life Span 301
CRITICAL THINKING matters: should Tobacco Products be Illegal? 301
Causes 302 Social Factors 302
Biological Factors 303
Psychological Factors 306
Integrated Systems 307
ReSeARCH methods: studies of People at Risk for Disorders 307
Treatment 308 Detoxification 308
Medications During Remission 308
Self-Help Groups: Alcoholics Anonymous 309
Cognitive Behavior Therapy 310
Outcome Results and General Conclusions 311
Gambling Disorder 312
THINKING CRITICALLY about DSM-5: Is Pathological Gambling an addiction? 312
Symptoms 313
Diagnosis 314
Frequency 314
getting HeLp 315
summary 315 the big picture 316 key terms 317
12 Sexual dysfunctions, paraphilic disorders, and gender dysphoria 318
Overview 319 Brief Historical Perspective 321
Sexual Dysfunctions 321 Symptoms 321
Diagnosis 323
ReSeARCH methods: hypothetical Constructs: What Is sexual arousal? 325
Frequency 327
Causes 328
Treatment 330
CRITICAL THINKING matters: Does medication Cure sexual Dysfunction? 332
Paraphilic Disorders 332 Symptoms 333
ConTenTs ix
Diagnosis 333
THINKING CRITICALLY about DSM-5: Two sexual Problems That Did not become new mental Disorders 339
Frequency 340
Causes 340
Treatment 341
Gender Dysphoria 343 Symptoms 343
Frequency 344
Causes 344
Treatment 345
getting HeLp 345
summary 346 the big picture 346 key terms 347
13 Schizophrenia Spectrum and other psychotic disorders 348 Overview 349
Symptoms 351 Positive Symptoms 352
Negative Symptoms 353
First-Person account of Delusional beliefs 353
Disorganization 354
Diagnosis 355 DSM-5 355
Criteria for schizophrenia 356
Subtypes 356
CRITICAL THINKING matters: Why Were the symptom-based subtypes of schizophrenia Dropped from DSM-5? 357
Related Psychotic Disorders 357
Course and Outcome 358
Frequency 359 Gender Differences 359
Cross-Cultural Comparisons 360
Causes 360 Biological Factors 360
Social Factors 366
Psychological Factors 367
ReSeARCH methods: Comparison Groups: What Is normal? 369
Interaction of Biological and Environmental Factors 369
The Search for Markers of Vulnerability 370
THINKING CRITICALLY about DSM-5: attenuated Psychosis syndrome Reflects Wishful Rather Than Critical Thinking 370
Treatment 372 Antipsychotic Medication 372
Psychosocial Treatment 374
getting HeLp 376
summary 377 the big picture 378 key terms 378
14 neurocognitive disorders 379 Overview 380
Symptoms 383
Delirium 383
Criteria for Delirium 383
Major Neurocognitive Disorder 384
memory Changes in normal aging 385
Diagnosis 388
Brief Historical Perspective 388
Specific Types of Neurocognitive Disorder 389
Criteria for major neurocognitive Disorder 389
CRITICAL THINKING matters: how Can Clinicians establish an early Diagnosis of alzheimer’s Disease? 390
Frequency of Delirium and Major Neurocognitive Disorders 394
Prevalence of Dementia 394
ReSeARCH methods: Finding Genes That Cause behavioral Problems 395
Prevalence by Subtypes of Neurocognitive Disorder 396
Cross-Cultural Comparisons 396
Causes 396 Delirium 396
Neurocognitive Disorder 396
Treatment and Management 399 Medication 399
THINKING CRITICALLY about DSM-5: Will Patients and Their Families Understand “mild” neurocognitive Disorder? 400
Environmental and Behavioral Management 401
Support for Caregivers 401
getting HeLp 402
summary 402 the big picture 403 key terms 403
15 intellectual disabilities and autism Spectrum disorders 404 Overview 405
Intellectual Disabilities 405 Symptoms of Intellectual Disabilities 407
Criteria for Intellectual Disability (Intellectual Developmental Disorder) 407
ReSeARCH methods: Central Tendency and Variability: What Do IQ scores mean? 408
Diagnosis of Intellectual Disabilities 410
Frequency of Intellectual Disabilities 411
x ConTenTs
Causes of Intellectual Disabilities 411
Treatment: Prevention and Normalization 416
eugenics: our history of shame 417
Autism Spectrum Disorder 419 Symptoms of ASD 420
Diagnosis of ASD 424
Frequency of ASD 425
Criteria for autism spectrum Disorder 425
THINKING CRITICALLY about DSM-5: how Far out on the autism spectrum? 426
Causes of ASD 427
Treatment of ASD 428
CRITICAL THINKING matters: The bogus Treatment Called Facilitated Communication 429
getting HeLp 432
summary 433 the big picture 433 key terms 434
16 psychological disorders of childhood 435 Overview 436
Externalizing Disorders 437 Symptoms of Externalizing 437
Diagnosis of Externalizing Disorders 439
Criteria for attention-Deficit/hyperactivity Disorder 440
What are learning Disabillities? 441
Criteria for oppositional Defiant Disorder 442
Frequency of Externalizing 442
Criteria for Conduct Disorder 443
Causes of Externalizing 443
ReSeARCH methods: samples: how to select the People We study 444
Treatment of Externalizing Disorders 448
CRITICAL THINKING matters: aDhD’s False Causes and Cures 452
Internalizing and Other Disorders 454 Symptoms of Internalizing Disorders 454
Diagnosis of Internalizing and Other Childhood Disorders 456
THINKING CRITICALLY about DSM-5: Disruptive mood Dysregulation Disorder 457
Frequency of Internalizing Disorders 458
Treatment of Internalizing Disorders 461
getting HeLp 462
summary 463 the big picture 463 key terms 464
17 adjustment disorders and life-cycle transitions 465 Overview 466
Symptoms 467
Diagnosis 468
Criteria for adjustment Disorder 468
The Transition to Adulthood 469 Symptoms of the Adult Transition 470
Diagnosis of Identity Conflicts 471
Frequency of Identity Conflicts 471
Causes of Identity Conflicts 472
Treatment During the Transition to Adult Life 472
Family Transitions 472 Symptoms of Family Transitions 473
Diagnosis of Troubled Family Relationships 474
THINKING CRITICALLY about DSM-5: Do Psychological Problems Reside within Individuals? 475
Frequency of Family Transitions 476
Causes of Difficulty in Family Transitions 476
ReSeARCH methods: Genes and the environment 477
Treatment During Family Transitions 478
CRITICAL THINKING matters: a Divorce Gene? 478
The Transition to Later Life 480 Symptoms 481
Reliving the Past 483
Diagnosis of Aging 485
Frequency of Aging 485
Causes of Psychological Problems in Later Life 486
Treatment of Psychological Problems in Later Life 487
getting HeLp 487
summary 488 the big picture 488 key terms 488
18 Mental health and the law 489 Overview 490 Expert Witnesses 491
Free Will Versus Determinism 492
Rights and Responsibilities 492
Mental Illness and Criminal Responsibility 492 The Insanity Defense 492
Competence to Stand Trial 495
The “battered Woman syndrome” Defense 496
Sentencing and Mental Health 498
THINKING CRITICALLY about DSM-5: Thresholds Can be a matter of life or Death 499
Civil Commitment 500 A Brief History of U.S. Mental Hospitals 500
Libertarianism Versus Paternalism 500
Involuntary Hospitalization 501
CRITICAL THINKING matters: Violence and mental Illness 502
ConTenTs xi
ReSeARCH methods: base Rates and Prediction: Justice blackmun’s error 503
The Rights of Mental Patients 504
Deinstitutionalization 506
Mental Health and Family Law 507 Child Custody Disputes 508
Child Abuse 509
Professional Responsibilities and the Law 511 Professional Negligence and Malpractice 511
Confidentiality 512
getting HeLp 513
summary 513 the big picture 514 key terms 514
Glossary 515
References 525
Credits 561
name Index 564
subject Index 573
xii
Emotional suffering touches all of our lives at some point in time. Psychological problems affect many of us directly and all of us indirectly—through our loved ones, friends, and the strangers whose troubled behavior we cannot ignore. Abnormal psychology is not about “them.” Abnormal psychology is about all of us.
Abnormal psychology is also about scientific inquiry. In this eighth edition of our text, once again, we bring both the science and the personal aspects of abnormal psychology to life. We answer pressing intellectual and human questions as accu- rately, sensitively, and completely as possible, given the pace of new discoveries. Throughout this book, we offer an engaging yet rigorous treatment of abnormal psychology, highlighting both the latest research and theory and the urgent needs of the people behind the disorders.
Why Do you need This new edition? • DSM-5! The eighth edition of Abnormal Psychology is com-
pletely updated with information from the recently published DSM-5. We delayed our revision for a few months, so we could do more than just add tables of DSM-5 diagnostic criteria. You will find a great many DSM-5 tables, of course. But you will also see a discussion of the conceptual, practical, and political debates about DSM-5 integrated throughout the text.
• Thinking Critically About DSM-5 is a new feature that appears in every chapter. We teach students about DSM-5. Then we encourage the students to think deeply about the pros and cons of this diagnostic system. How does DSM-5 deal with dimensions versus categories in defining abnormal behavior? Is autism really best viewed as a spectrum disorder? What argu- ments lie behind DSM-5’s decision to include new diagnoses like binge eating disorder and hoarding disorder? Has DSM-5 taken the descriptive approach too far, for example, grouping diagnoses like anorexia nervosa and pica together because both involve eating? What does DSM-5 say about the causes and treatment of mental disorders?
• We include hundreds of new studies about DSM-5 and dozens of other topics. Psychological science is dynamic, ever-changing, and ever-growing. Our textbook grows with the field, bring- ing to life both the exciting process of discovery and important new findings about disorders and their causes and effective treatment. This eighth edition is at the cutting edge, because we have culled the best and most important new research from thousands of studies to include hundreds of new ones here.
• How can a student new to abnormal psychology learn to think critically about such a broad, important topic? We guide you
in your learning—and in critical thinking—with “The Big Picture” a set of probing questions that open each chapter. “The Big Picture” orients you to key issues and themes cov- ered in the relevant chapter. Each chapter ends with “The Big Picture Revisited,” returning to the key issues, briefly summa- rizing the central point, and directing you to pages where you can find a discussion of the details. You may have been ask- ing yourself these kind of critical questions, but if in case you weren’t, we show you how to keep the big picture in mind.
• We focus on the forest and the trees. Abnormal Psychology is about real people. We bring the human side of psychology problems to life with a series of new Speaking Out videos that we edited personally. We promise that these videos will make you think and make you feel, too. We also have included more on the human side of psychological problems with new and updated case studies, as well as updated “Getting Help” fea- tures that offer practical advice for you and your loved ones.
• You will find that Abnormal Psychology introduces you to new concepts from the frontiers of understanding interactions between genes and the environment. For example, are you a “dandelion” who can survive in most any environment, or instead are you a fragile “orchid” who will wither under harsh conditions but bloom gloriously in the right environment?
• You will find new and updated discussions of treatments that work. Do we at last have an effective treatment for adolescents with anorexia nervosa? Read our discussion of the “Maudsley method” in Chapter 10.
• We do not shy away from controversy, because we all can learn from facing the issues squarely. “Sexual addiction” seems to be epidemic. Is this a mental disorder? We draw you into the latest issues, research, and debates in Chapter 12. Or speaking of epi- demics, what about the purported “epidemic of autism”? We not only take you through the misguided (and largely resolved) con- troversy about vaccines and autism, but also discuss how much current controversy about the autism “epidemic” stems from much broader criteria used to diagnose autism spectrum disorder.
DSM-5 Is here and Intergrated everywhere in This eighth edition! Much anticipated and at long last, DSM-5 was published in May 2013. The new version of the Diagnostic and Statistical Manual includes many changes. A great many of the revisions incorporated into DSM-5 are a step forward. Others, well, not so much. . . .
We eagerly awaited the final publication of the DSM-5, as did other mental health professionals and textbook authors. We were
PReFaCe xiii
curious to see what much-discussed and debated changes made it into the final DSM-5, and what diagnoses and diagnostic criteria remained the same. Naturally, we wanted our eighth edition of Abnormal Psychology to include DSM-5, so that students and instruc- tors could have up-to-date information on this very influential diagnostic system. Yet, we made a decision not to rush this revision. Why? We wanted to do more than just include tables with new, DSM-5 diagnostic criteria. We wanted to integrate and evaluate DSM-5 into the fabric of every chapter. As a result, we might not be the first textbook published to be able to proclaim that we include DSM-5. We think it’s better to be able to say that the eighth edition of our text includes, integrates, and evaluates DSM-5 in a thorough, careful, and critical way.
Of course, you will find a great many tables of DSM-5 diag- nostic criteria in this text. But you will find much more. The most visible addition is our brand-new feature, Thinking Critically About DSM-5. Appearing in every chapter, Thinking Critically About DSM-5 asks and answers questions like these: How does the DSM- 5’s categorical diagnostic system deal with dimensional variations in abnormal (and normal) behavior? Is autism really best viewed as a spectrum disorder? What arguments—scientific, political, and practical—lie behind DSM-5’s decision to include new diagnoses like binge eating disorder and temper dysregulation disorder? Has DSM-5 taken the descriptive approach too far, too literally group- ing diagnoses together based solely on appearance (such as pica and anorexia nervosa)? What does (and doesn’t) DSM-5 say about the causes and treatment of mental disorders—and why?
Our goal in writing the Thinking Critically About DSM-5 features was, first, to teach students about the DSM-5, and, second, to help students think about DSM-5. We want students to understand the principles behind classification and diagnosis in general. We want them to grapple with the conceptual and empirical uncertainties concerning particular disorders. We also want students to recognize at least some of the practical and political agendas that influence what, in the context of our culture and times, we decide is or isn’t a mental disorder.
These ambitious goals require more than DSM-5 tables and new features. So, we also integrated various diagnostic and con- ceptual controversies about DSM-5 throughout every chapter. Of course, we updated the text specifically for DSM-5. But in fact, we have highlighted the theoretical issues behind various diagno- ses in every edition of our text. We are proud to note that many contemporary controversies surrounding the DSM-5 have been highlighted in our text for a long time. To offer just one exam- ple: Should abnormal behavior be classified along dimensions or into categories? This issue has been a key theme of Oltmanns and Emery, Abnormal Psychology, since the first edition. Questions like this are not just about the DSM-5. Debates about topics like dimensions versus categories are about critical thinking in gen- eral. Consider this question: Where does an instructor set cutoffs, turning the dimension of test score averages into the category of letter grades? Now, that’s a debate about dimensions and catego- ries that a student can understand!
Critical Thinking Abnormal Psychology is all about critical thinking. We believe that critical thinking is essential for science, for helping those in need, and for the intellectual and personal development of our stu- dents. Today’s students are overwhelmed with information from all kinds of media. Critical thinking is indispensible, so students can distinguish between information that is good, bad, or ugly (to borrow a phrase from our favorite Western movie). We want students to think critically about abnormal psychology—and everything else.
We encourage the readers of Abnormal Psychology to be inquiring skeptics. Students need to be skeptical in evaluating all kinds of claims. We help them to do so by teaching students to think like psychological scientists. Yet, we also want students to be inquiring, to be skeptical not cynical. Pressing human needs and fascinating psychological questions make it essential for us to seek answers, not just explode myths.
In this eighth edition of our text, we emphasize critical thinking in several ways. As noted, we include the new feature, Thinking Critically About DSM-5. We also refined our chapter opening feature, “The Big Picture,” to link even more tightly with our chapter ending, “The Big Picture: Critical Thinking Review.” “The Big Picture” draws students into each chapter by posing common yet critical questions about key substantive top- ics. The questions also orient the student to conceptual themes about the substance and the methods of abnormal psychology. Then, at the end of each chapter, we have a section called “The Big Picture: Critical Thinking Review,” which summarizes key, big-picture questions and includes handy page references for review purposes.
We also have continued to revise and expand our “Critical Thinking Matters” discussions, which are found in every chapter. These features address some timely, often controversial, and always critically important topics, for example, the purported link between vaccines and autism (see Chapter 2). Critical think- ing matters because psychological problems matter deeply to those who suffer and to their loved ones. Good research tells us—and them—which treatments work, and which ones don’t, as well as what might cause mental illness, and what doesn’t. Critical thinking matters because students in abnormal psychol- ogy surely will not remember all the details they learn in this course. In fact, they shouldn’t focus exclusively on facts, because data will change with new scientific developments. But if stu- dents can learn to think critically about abnormal psychology, the lesson will last a lifetime and be used repeatedly, not only in understanding psychological problems, but also in every area of their lives.
Our “Critical Thinking Matters” features help students to think about science, about pseudo-science, and about themselves. For example, in Chapter 2 we address the mistaken belief, still pro- moted widely on the Internet and in the popular media, that mer- cury in widely used measles/mumps/rubella (MMR) vaccinations
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in the 1990s caused an epidemic of autism (and perhaps a host of other psychological problems for children). “Critical Thinking Matters” outlines the concerns of the frightened public, but goes on to point out (1) the failure to find support for this fear in numer- ous, large-scale scientific studies; (2) the scientific stance that the burden of proof lies with the proponents of any hypothesis, includ- ing speculations about MMR; (3) the widely ignored fact that 10 of the original 13 authors who raised the theoretical possibility publicly withdrew their speculation about autism and MMR; (4) the fact that the findings of legal actions, sadly, do not necessarily reach conclusions consistent with scientific knowledge; and (5) recent discrediting of the scientists, journal article, and legal findings that originally “supported” this false claim. As we discuss in Chapter 15, moreover, the apparent epidemic of autism very likely resulted from increased awareness of the disorder and loosened criteria for diag- nosing autism, not from an actual increase in cases.
Real People We want students to think critically about disorders and to be sensi- tive to the struggles of individuals with psychological problems. As scientist-practitioners, we see these dual goals not only as compat- ible, but also as essential. One way that we underscore the personal nature of emotional problems is in our “Getting Help” features found in every chapter. In “Getting Help,” we directly address the personal side of psychological disorders and try to answer the sorts of questions that students often ask us privately after a lecture or during office hours. The “Getting Help” sections give responsible, empirically sound, and concrete guidance on such personal topics as
• What treatments should I seek out for a particular disorder? (See Chapters 2, 6, 10, and 12)
• What can I do to help someone I know who has a psychologi- cal problem? (See Chapters 5, 9, 10, and 16)
• How can I find a good therapist? (See Chapters 3, 5, and 12)
• Where can I get reliable information from books, the Internet, or professionals in my community? (See Chapters 1, 5, 7, and 11)
• What self-help strategies can I try or suggest to friends? (See Chapters 6, 11, and 12)
Students can also find research-based information on the effectiveness and efficacy of various treatments in Chapter 3, “Treatment of Psychological Disorders,” and in the “Treatment” headings near the end of every disorder chapter. We cover treat- ment generally at the beginning of the text but in detail in the context of each disorder, because different treatments are more or less effective for different psychological problems.
“speaking out” Videos One of the best ways to understand the needs of the people behind the disorders is to hear their stories in their own words. We worked in consultation with Pearson and NKP Productions
to produce (and expand) a video series called Speaking Out: Interviews with People Who Struggle with Psychological Disorders. The earlier cases in the Speaking Out series were intro- duced with previous editions of our book. We have added four new cases, addressing the following problem areas: gender dys- phoria, nonsuicidal self-injury, dissociative amnesia, and binge eating disorder. These interviews give students a window into the lives of people who in many ways may not be that different from anyone else, but who do struggle with various kinds of mental disorder. As before, the new video cases also include a segment called “A Day in the Life,” which features interviews with friends and family members who discuss their relationships, feelings, and perspectives. We introduce students to each of these people in the appropriate chapters of our book, using their photos and a brief description of relevant issues that should be considered when viewing the video cases. The full versions of the interviews are available to instructors either on DVD or on MyPsychLab.com (www.mypsychlab.com).
We are especially proud of the Speaking Out videos and view them as a part of our text, not as a supplement, because we were intimately involved with their production. As with the original series, we screened the new video cases, helped to construct and guide the actual interviews, and gave detailed feedback on how to edit the films to make the disorders real for students and fit closely with the organization and themes in our eighth edition.
new Research The unsolved mysteries of abnormal psychology challenge all of our intellectual and personal resources. In our eighth edition, we include the latest “clues” psychological scientists have unearthed in doing the detective work of research, including references to hundreds of new studies. But the measure of a leading-edge textbook is not merely the number of new references; it is the number of new studies the authors have reviewed and evaluated before deciding which ones to include and which ones to discard. For every new reference in this edition of our text, we have read many additional papers before selecting the one gem to include. Some of the updated research and perspectives in this edition include:
• Updated discussion regarding the general definition of mental disorders, as employed in DSM-5, and new estimates regarding the number of mental health professionals delivering services (Chapter 1)
• Enhanced coverage of gene–environment interactions (includ- ing “orchids” versus “dandelions”) and failures to replicate the effects of specific genes (Chapter 2)
• New evidence on what makes placebos “work,” on disseminating evidenced-based treatments, and “3rd wave” CBT (Chapter 3)
• Revised discussion of the reliability of diagnosis, based on new evidence from the DSM-5 field trials (Chapter 4)
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• New mention of premenstrual dysphoric disorder (a category added to DSM-5), and new discussion of evidence regarding the increase in military suicides, which have received consider- able attention in the popular media (Chapter 5)
• Addition of material on hoarding disorder (another new diag- nostic category added to DSM-5) and expanded coverage of the diagnostic features and prevalence of obsessive-compulsive symptoms and spectrum disorders, which are now listed sepa- rately from anxiety disorders in DSM-5 (Chapter 6)
• Further consideration of resilience in response to trauma, questions about secondary trauma, and new questions about somatoform and dissociative disorders (Chapter 7)
• New research on cultural differences in social support, religion, and coping, and the daily experience of pain (Chapter 8)
• Careful explanation of the two approaches to classification of personality disorders that are now included in DSM-5 as well as the similarities and distinctions between them (Chapter 9)
• Questions and new information about binge eating disor- der and obesity; latest evidence on redefining, treating (the Maudsley method), and preventing eating disorders; up-to-date consideration of women’s portrayal in the media (Chapter 10)
• New evidence regarding the frequency of overdose deaths attributed to opioid pain-killers, which has increased dramati- cally in recent years as well as expanded coverage of gambling disorder, which is now listed with Substance-Related and Addictive Disorders in DSM-5 (Chapter 11)
• Discussion of the revised approach to the definition and clas- sification of paraphilic disorders (Chapter 12)
• Careful consideration of the proposed diagnostic construct “Attenuated Psychosis Syndrome,” including its potential ben- efits as well as likely negative consequences (Chapter 13)
• Explanation of the change to neurocognitive disorders as the overall diagnostic term for this chapter as well as the deletion of the term amnestic disorder (Chapter 14)
• More questions about the autism spectrum, the so-called epi- demic of autism, and estimates of the prevalence of autism spectrum disorder (Chapter 15)
• Questions about the DSM-5’s elimination of childhood disor- ders; updated discussion of adolescent depression, antidepres- sants, suicide risk; careful consideration of the new diagnosis and the issues behind it, disruptive mood dysregulation disor- der (Chapter 16)
• Further consideration of “relational diagnoses,” complicated grief, and psychological pain (Chapter 17)
• Discussion of how diagnostic thresholds are a matter of life and death in the case of intellectual disabilities; new material on advanced psychiatric directives (Chapter 18)
still the Gold standard We see the most exciting and promising future for abnormal psy- chology in the integration of theoretical approaches, professional specialties, and science and practice, not in the old, fractured competition among “paradigms,” a split between psychology and psychiatry, or the division between scientists and practitio- ners. We view integration as the gold standard of any forward- looking abnormal psychology text, and the gold standard remains unchanged in the eighth edition of our textbook.
Integrating Causes and Treatment For much of the last century, abnormal psychology was domi- nated by theoretical paradigms, a circumstance that reminds us of the parable of the seven blind men and the elephant. One blind man grasps a tusk and concludes that an elephant is very much like a spear. Another feels a leg and decides an elephant is like a tree, and so on. Our goal from the first edition of Abnormal Psychology has been to show the reader the whole elephant. We do this through our unique integrative systems approach, in which we focus on what we know today rather than what we used to think. In every chapter, we consider the latest evidence on the multiple risk factors that contribute to psycho- logical disorders, as well as the most effective psychological and biomedical treatments. Even if science cannot yet paint a picture of the whole elephant, we clearly tell the student what we know, what we don’t know, and how psychologists think the pieces might fit together.
Pedagogy: Integrated Content and Methods We also continue to bring cohesion to abnormal psychology—and to the student—with pedagogy. Each disorder chapter unfolds in the same way, providing a coherent framework with a consistent chapter outline. We open with an Overview followed by one or two extended Case Studies. We then discuss Symptoms, Diagnosis, Frequency, Causes, and, finally, Treatment.
Abnormal psychology is not only about the latest research, but also about the methods psychologists use (and invent) in order to do scientific detective work. Unlike any other text in this field, we cover the scientific method by offering brief “Research Methods” features in every single chapter. Teaching methods in the context of content helps students appreciate the importance of scientific procedures and assumptions, makes learning research methods more manageable, and gives the text flexibility. By the end of the text, our unique approach allows us to cover research methods in more detail than we could reasonably cover in a single, detached chapter. Many of our students have told us that the typical research methods chapter seems dry, difficult, and—to our great disappointment—irrelevant. These problems never arise with our integrated, contextualized approach to research methods.
Abnormal psychology also is, of course, about real people with real problems. We bring the human, clinical side of abnormal psychology alive with detailed “Case Studies.” The case studies take
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the reader along the human journey of pain, triumph, frustration, and fresh starts that is abnormal psychology. The cases help stu- dents to think more deeply about psychological disorders, much as our own clinical experience enriches our understanding. (We both have been active clinicians as well as active researchers throughout our careers.) In extended cases near the beginning of each chapter, in briefer cases later, and in first-person accounts throughout, the student sees how ordinary lives are disrupted by psychological problems—and how effective treatment can rebuild shattered lives. The case studies also make the details and complexity of the sci- ence concrete, relevant, and essential to the “real world.”
Sometimes a study or problem suggests a departure from current thinking or raises side issues that deserve to be examined in detail. We cover these emerging ideas in features identified by the topic at hand. One example of an emerging issue we discuss in this way is whether the female response to stress might be to “tend and befriend” rather than fight or flight (Chapter 8). Other topics include the common elements of suicide (Chapter 5) and a system for classifying different types of rapists (Chapter 12).
supplements Package MyPsychLab for Abnormal Psychology MyPsychLab is an online homework, tutorial, and assessment program that truly engages students in learning. It helps students better prepare for class, quizzes, and exams—resulting in better performance in the course. It provides educators a dynamic set of tools for gauging individual and class performance. To order the eighth edition with MyPsychLab, use ISBN 0205997945.
VIRTUAL CASE STUDIES
Virtual Case Studies offers you a science-based, interactive simulation where you can learn how a number of risk factors and protective factors could impact disorder development in a virtual person. As you progress through the simulation you will not act as the character or as a clinician, but will be able to inde- pendently explore a variety of different behaviors, events, and outcomes that one who suffers from a disorder could potentially encounter. There are no right or wrong selections, as exploring the impact of both risk and protective factors in the life of the character will provide valuable insights into the experience of a disorder along a continuum. The following Virtual Case Studies are available at mypsychlab.com:
Anxiety Disorders Mood Disorders Eating Disorders Substance Use Disorders
SPEAkING OUT: INTERVIEWS WITH PEOPLE WHO STRUGGLE WITH PSyCHOLOGICAL DISORDERS
This set of video segments allows students to see firsthand accounts of patients with various disorders. The interviews were
conducted by licensed clinicians and range in length from 8 to 25 minutes. Disorders include major depressive disorder, obsessive- compulsive disorder, anorexia nervosa, PTSD, alcoholism, schizophrenia, autism, ADHD, bipolar disorder, social phobia, hypochondriasis, borderline personality disorder, and adjustment to physical illness. These video segments are available on DVD or through MyPsychLab.
Volume 1: ISBN 0-13-193332-9 Volume 2: ISBN 0-13-600303-6 Volume 3: ISBN 0-13-230891-6
INSTRUCTOR’S MANUAL (ISBN 0205979742)
A comprehensive tool for class preparation and management, each chapter includes learning objectives, a chapter outline, lec- ture suggestions, discussion ideas, classroom activities, discussion questions, and video resources. Available for download on the Instructor’s Resource Center at www.pearsonhighered.com.
TEST BANk (ISBN 0205979777)
The Test Bank has been rigorously developed, reviewed, and checked for accuracy, to ensure the quality of both the ques- tions and the answers. It includes fully referenced multiple- choice, short answer, and concise essay questions. Each question is accompanied by a page reference, difficulty level, skill type (factual, conceptual, or applied), topic, a learning objective, and a correct answer. Available for download on the Instructor’s Resource Center at www.pearsonhighered.com.
MyTest (ISBN 0205982395) A powerful assessment-generation program that helps instructors easily create and print quizzes and exams. Questions and tests can be authored online, allowing instructors ultimate flexibility and the ability to efficiently manage assessments anytime, anywhere. Instructors can easily access existing questions and edit, create, and store questions using a simple drag-and-drop technique and word-like controls. Data on each question provide information on difficulty level and the page number of corresponding text discussion. For more information, go to www.PearsonMyTest. com.
LECTURE POWERPOINT SLIDES (ISBN 0205982409)
The PowerPoint slides provide an active format for presenting concepts from each chapter and feature relevant figures and tables from the text. Available for download on the Instructor’s Resource Center at www.pearsonhighered.com.
ENHANCED LECTURE POWERPOINT SLIDES WITH EMBEDDED VIDEOS (ISBN 0205982379)
The lecture PowerPoint slides have been embedded with select Speaking Out video pertaining to each disorder chapter, enabling instructors to show videos within the context of their lecture. No Internet connection is required to play videos.
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POWERPOINT SLIDES FOR PHOTOS, FIGURES, AND TABLES (ISBN 0205982417)
Contain only the photos, figures, and line art from the textbook. Available for download on the Instructor’s Resource Center at www.pearsonhighered.com.
(ISBN 0205979807)
CourseSmart textbooks online is an exciting choice for students looking to save money. As an alternative to purchasing the print textbook, students can subscribe to the same content online and save up to 60 percent off the suggested list price of the print text. With a CourseSmart eTextbook, students can search the text, make notes online, print out reading assignments that incorpo- rate lecture notes, and bookmark important passages for later review. For more information or to subscribe to the CourseSmart eTextbook, visit www.coursesmart.com.
acknowledgments Writing and revising this textbook is a never-ending task that fortunately is also a labor of love. This eighth edition is the culmination of years of effort and is the product of many people’s hard work. The first people we wish to thank for their important contributions to making this the text of the future, not of the past, are the following expert reviewers who have unselfishly offered us a great many helpful suggestions, both in this and in previous editions: John Dale Alden, III, Lipscomb University; John Allen, University of Arizona; Hal Arkowitz, University of Arizona; Jo Ann Armstrong, Patrick Henry Community College; Gordon Atlas, Alfred University; Deanna Barch, Washington University; Catherine Barnard, Kalamazoo Community College; Thomas G. Bowers, Pennsylvania State University, Harrisburg; Stephanie Boyd, University of South Carolina; Gail Bruce-Sanford, University of Montana; Ann Calhoun-Seals, Belmont Abbey College; Caryn L. Carlson, University of Texas at Austin; Richard Cavasina, California University of Pennsylvania; Laurie Chassin, Arizona State University; Lee H. Coleman, Miami University of Ohio; Bradley T. Conner, Temple University; Andrew Corso, University of Pennsylvania; Dean Cruess, University of Pennsylvania; Danielle Dick, Washington University; Juris G. Draguns, Pennsylvania State University; Sarah Lopez-Duran; Nicholas Eaton, Stony Brook University; William Edmonston, Jr., Colgate University; Ronald Evans, Washburn University; John Foust, Parkland College; Dan Fox, Sam Houston State University; Alan Glaros, University of Missouri, Kansas City; Ian H. Gotlib, Stanford University; Irving Gottesman, University of Virginia; Mort Harmatz, University of Massachusetts; Marjorie L. Hatch, Southern Methodist University; Jennifer A. Haythornwaite, Johns Hopkins University; Holly Hazlett-Stevens, University of Nevada, Reno; Brant P. Hasler, University of Arizona; Debra
L. Hollister, Valencia Community College; Jessica Jablonski, University of Delaware; Jennifer Jenkins, University of Toronto; Jutta Joormann, University of Miami; Pamela Keel, Florida State University; Stuart Keeley, Bowling Green State University; Lynn Kemen, Hunter College; Carolin Keutzer, University of Oregon; Robert Lawyer, Delgado Community College; Marvin Lee, Tennessee State University; Barbara Lewis, University of West Florida; Mark H. Licht, Florida State University; Freda Liu, Arizona State University; Roger Loeb, University of Michigan, Dearborn; Carol Manning, University of Virginia; Sara Martino, Richard Stockton College of New Jersey; Richard D. McAnulty, University of North Carolina–Charlotte; Richard McFall, Indiana University; John Monahan, University of Virginia School of Law; Tracy L. Morris, West Virginia University; Dan Muhwezi, Butler Community College; Christopher Murray, University of Maryland; William O’Donohue, University of Nevada–Reno; Joseph J. Palladino, University of Southern Indiana; Demetrios Papageorgis, University of British Columbia; Ronald D. Pearse, Fairmont State College; Brady Phelps, South Dakota State University; Nnamdi Pole, Smith College; Seth Pollak, University of Wisconsin; Lauren Polvere, Concordia University; Melvyn G. Preisz, Oklahoma City University; Paul Rasmussen, Furman University; Rena Repetti, University of California, Los Angeles; Amy Resch, Citrus College; Robert J. Resnick, Randolph- Macon College; Karen Clay Rhines, Northampton Community College; Jennifer Langhinrichsen-Rohling, University of South Alabama; Patricia H. Rosenberger, Colorado State University; Catherine Guthrie-Scanes, Mississippi State University; Forrest Scogin, University of Alabama; Josh Searle-White, Allegheny College; Fran Sessa, Penn State Abington; Danny Shaw, University of Pittsburgh; Heather Shaw, American Institutes of Research; Brenda Shook, National University; Robin Shusko, Universities at Shady Grove and University of Maryland; Janet Simons, Central Iowa Psychological Services; Patricia J. Slocum, College of DuPage; Darrell Smith, Tennessee State University; Randi Smith, Metropolitan State College of Denver; George Spilich, Washington College; Cheryl Spinweber, University of California, San Diego; Bonnie Spring, The Chicago Medical School; Laura Stephenson, Washburn University; Xuan Stevens, Florida International University; Eric Stice, University of Texas; Alexandra Stillman, Utah State University; Joanne Stohs, California State, Fullerton; Martha Storandt, Washington University; Milton E. Strauss, Case Western Reserve University; Amie Grills-Taquechel, University of Houston; Melissa Terlecki, Cabrini College; J. Kevin Thompson, University of South Florida; Julie Thompson, Duke University; Frances Thorndike, University of Virginia; Robert H. Tipton, Virginia Commonwealth University; David Topor, Harvard Medical School; Gaston Weisz, Adelphi University and University of Phoenix Online; Douglas Whitman, Wayne State University; Michael Wierzbicki, Marquette University; Joanna Lee Williams, University of Virginia; Ken Winters, University of Minnesota; Eleanor Webber, Johnson State College; Craig Woodsmall,
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McKendree University; Robert D. Zettle, Wichita State University; Anthony Zoccolillo, Rutgers University.
We have been fortunate to work in stimulating academic environments that have fostered our interests in studying abnormal psychology and in teaching undergraduate students. We are particularly grateful to our colleagues at the University of Virginia: Eric Turkheimer, Irving Gottesman (now at the University of Minnesota), Mavis Hetherington, John Monahan, Joseph Allen, Dan Wegner, David Hill, Jim Coan, Bethany Teachman, Amori Mikami (now at the University of British Columbia), Cedric Williams, and Peter Brunjes for extended and ongoing discussions of the issues that are considered in this book. Many other colleagues at Washington University in St. Louis have added an important perspective to our views regarding important topics in this field. They include Arpana Agrawal, Deanna Barch, Ryan Bogdan, Danielle Dick (now at Virginia Commonwealth University), Bob Krueger (now at the University of Minnesota), Randy Larsen, Tom Rodebaugh, Martha Storandt and Renee Thompson. Close friends and colleagues at Indiana University have also served in this role, especially Dick McFall, Rick Viken, Mary Waldron, and Alexander Buchwald. Many undergradu- ate and graduate students who have taken our courses also have helped to shape the viewpoints that are expressed here. They are too numerous to identify individually, but we are grateful for the intellectual challenges and excitement that they have provided over the past several years.
Many other people have contributed to the text in important ways. Jutta Joormann provided extremely helpful suggestions with regard to Chapter 5; Bethany Teachman and members of
her lab group offered many thoughtful comments for Chapter 6; Nnamdi Pole gave us extensive feedback and suggestions for Chapter 7. Pamela Keel offered a thorough, detailed, and insight- ful review of Chapter 10, along with dozens of excellent sugges- tions for change. Deanna Barch has been an ongoing source of information regarding issues discussed in Chapter 13. Kimberly Carpenter Emery did extensive legal research for Chapter 18. Danielle Dick contributed substantial expertise regarding devel- opments in behavior genetics and gene identification meth- ods. Martha Storandt and Carol Manning provided extensive consultation on issues related to dementia and other cognitive disorders. Jennifer Green provided important help with library research. Finally, Bailey Ocker gave us both indispensible help with research, manuscript preparation, and photo research— thank you, Bailey, we never would have finished on time or as well without you!
We also would like to express our deep appreciation to the Pearson team who share our pride and excitement about this text and who have worked long and hard to make it the very best text. Major contributors include Amber Chow, Acquisitions Editor; Jeremy Intal, Marketing Manager; Shelly Kupperman, Project Manager; Annemarie Franklin, Program Manager; Pam Weldin, Media Project Manager; Kate Cebik, Photo Researcher.
Finally, we want to express our gratitude to our families for their patience and support throughout our obsession with this text: Gail and Josh Oltmanns, and Sara, Billy, Presley, Riley, and Kinley Baber; and Kimberly, Julia, Bobby, Lucy, and John Emery and Maggie and Mike Strong. You remain our loving sources of motivation and inspiration.
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—Tom Oltmanns —Bob Emery
xix xix
about the Thomas F. olTmanns is the Edgar James Swift Professor of
Psychology in Arts and Sciences and
professor of psychiatry at Washington
University in St. Louis, where he is
also director of Clinical Training in
Psychology. He received his B.A. from
the University of Wisconsin and his
Ph.D. from Stony Brook University.
Oltmanns was previously professor of
psychology at the University of Virginia
(1986 to 2003) and at Indiana University
(1976 to 1986). His early research
studies were concerned with the role
of cognitive and emotional factors in schizophrenia. With grant sup-
port from NIMH, his lab is currently conducting a prospective study
of the trajectory and impact of personality disorders in middle-aged
and older adults. He has served on the Board of Directors of the
Association for Psychological Science and was elected president of the
Society for Research in Psychopathology, the Society for a Science of
Clinical Psychology and the Academy of Psychological Clinical Science.
Undergraduate students in psychology have selected him to receive out-
standing teaching awards at Washington University and at UVA. In 2011,
Oltmanns received the Toy Caldwell-Colbert Award for distinguished
educator in clinical psychology from the Society for Clinical Psychology
(Division 12 of APA). His other books include Schizophrenia (1980), written
with John Neale; Delusional Beliefs (1988), edited with Brendan Maher;
and Case Studies in Abnormal Psychology (9th edition, 2012), written with
Michele Martin and Gerald Davison.
Robert e. emeRy is professor of psychology and direc-
tor of the Center for Children, Families,
and the Law at the University of
Virginia, where he also served as direc-
tor of Clinical Training for nine years. He
received a B.A. from Brown University
in 1974 and a Ph.D. from SUNY at Stony
Brook in 1982. His research focuses
on family conflict, children’s mental
health, and associated legal issues,
particularly divorce mediation and
child custody disputes. More recently,
he has become involved in genetically
informed research of selection into and the consequences of major
changes in the family environment. Emery has authored over 150 sci-
entific articles and book chapters. His awards include Distinguished
Contributions to Family Psychology from Division 43 of the American
Psychological Association, a Citation Classic from the Institute for Scientific
Information, an Outstanding Research Publication Award from the
American Association for Marriage and Family Therapy, the Distinguished
Researcher Award from the Association of Family and Conciliation Courts,
and several awards and award nominations for his three books on divorce:
Marriage, Divorce and Children’s Adjustment (2nd edition, 1998, Sage
Publications); Renegotiating Family Relationships: Divorce, Child Custody,
and Mediation (2nd edition, 2011, Guilford Press); and The Truth About
Children and Divorce: Dealing with the Emotions So You and Your Children
Can Thrive (2006, Plume). Emery currently is associate editor of Family
Court Review, and he is principal investigator of a major grant from
NICHD. In addition to teaching, research, and administration, he maintains
a limited practice as a clinical psychologist and mediator.
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1
examples and definitions of abnormal behavior
2 CHAPTER 1 examples and definitions of abnormal behavior
The big picture learning objectives
1.1 What is the difference between normal and abnormal behavior?
1.2 How does culture influence the definition of mental disorders?
1.3 How does the impact of mental disorders compare to that of
other health problems?
1.4 Who provides help for people with mental disorders?
1.5 Why do scientific methods play such an important role in psychology’s approach to the study of mental disorders?
Just as each of us will be affected by medical problems at some point during our lives, it is also likely that we, or someone we love, will have to cope with that aspect of the human experience known as a disorder of the mind.
Overview The symptoms and signs of mental disorders, including such phe- nomena as depressed mood, panic attacks, and bizarre beliefs, are known as psychopathology. Literally translated, this term means pathology of the mind. Abnormal psychology is the application of psychological science to the study of mental disorders.
In the first four chapters of this book, we will look at the field of abnormal psychology in general. We will look at the ways in which abnormal behaviors are broken down into categories of mental disorders that can be more clearly defined for diagnostic purposes, and how those behaviors are assessed. We will also dis- cuss current ideas about the causes of these disorders and ways in which they can be treated.
This chapter will help you begin to understand the qualities that define behaviors and experiences as being abnormal. At what point does the diet that a girl follows in order to perform at her peak as a ballerina or gymnast become an eating disorder? When does grief following the end of a relationship become major de- pression? The line dividing normal from abnormal is not always clear. You will find that the issue is often one of degree rather than exact form or content of behavior.
The case studies in this chapter describe the experiences of two people whose behavior would be considered abnormal by mental health professionals. Our first case will introduce you to a person who suffered from one of the most obvious and disabling forms of mental disorder, known as schizophrenia. Kevin’s life had been relatively unremarkable for many years. He had done well in school, was married, and held a good job. Unfortunately, over a period of several months, the fabric of his normal life began to fall apart. The transition wasn’t obvious to either Kevin or his family, but it eventually became clear that he was having serious problems.
A Husband’s Schizophrenia with Paranoid Delusions Kevin and Joyce Warner (not their real names*) had been mar- ried for eight years when they sought help from a psychologist for their marital problems. Joyce was 34 years old, worked full time as a pediatric nurse, and was six months pregnant with her first child. Kevin, who was 35 years old, was finishing his third year working as a librarian at a local university. Joyce was extremely worried about what would happen if Kevin lost his job, especially in light of the baby’s imminent arrival.
Although the Warners had come for couples therapy, the psychologist soon became concerned about certain eccentric
Mental disorders touch every realm of human experience; they are part of the human experience. They can disrupt the way we think, the way we feel, and the way we behave. They also affect relation- ships with other people. These problems often have a devastating impact on people’s lives. In countries such as the United States, men- tal disorders are the second leading cause of disease-related disabil- ity and mortality, ranking slightly behind cardiovascular conditions and slightly ahead of cancer (Lopez et al., 2006). The purpose of this book is to help you become familiar with the nature of these disorders and the various ways in which psychologists and other mental health professionals are advancing knowledge of their causes and treatment.
Many of us grow up thinking that mental disorders happen to a few unfortunate people. We don’t expect them to happen to us or to those we love. In fact, mental disorders are very com- mon. At least two out of every four people will experience a seri- ous form of abnormal behavior, such as depression, alcoholism, or schizophrenia, at some point during his or her lifetime. When you add up the numbers of people who experience these prob- lems firsthand as well as through relatives and close friends, you realize that, like other health problems, mental disorders affect all of us. That is why, throughout this book, we will try to help you understand not only the kind of disturbed behaviors and think- ing that characterize particular disorders, but also the people to whom they occur and the circumstances that can foster them.
Most importantly, this book is about all of us, not “them”— anonymous people with whom we empathize but do not identify.
*Throughout this text we use fictitious names to protect the identities of the people involved.
1
examples and definitions of abnormal behavior CHAPTER 1 3
aspects of Kevin’s behavior. In the first session, Joyce described one recent event that had precipitated a major argument. One day, after eating lunch at work, Kevin had experienced sharp pains in his chest and had difficulty breathing. Fearful, he rushed to the emergency room at the hospital where Joyce worked. The physician who saw Kevin found nothing wrong with him, even af- ter extensive testing. She gave Kevin a few tranquilizers and sent him home to rest. When Joyce arrived home that evening, Kevin told her that he suspected that he had been poisoned at work by his supervisor. He still held this belief.
Kevin’s belief about the alleged poisoning raised serious con- cern in the psychologist’s mind about Kevin’s mental health. He decided to interview Joyce alone so that he could ask more ex- tensive questions about Kevin’s behavior. Joyce realized that the poisoning idea was “crazy.” She was not willing, however, to see it as evidence that Kevin had a mental disorder. Joyce had known Kevin for 15 years. As far as she knew, he had never held any strange beliefs before this time. Joyce said that Kevin had always been “a thoughtful and unusually sensitive guy.” She did not at- tach a great deal of significance to Kevin’s unusual belief. She was more preoccupied with the couple’s present financial concerns and insisted that it was time for Kevin to “face reality.”
Kevin’s condition deteriorated noticeably over the next few weeks. He became extremely withdrawn, frequently sitting alone in a darkened room after dinner. On several occasions, he told her that he felt as if he had “lost pieces of his thinking.” It wasn’t that his memory was failing, but rather he felt as though parts of his brain were shut off.
Kevin’s problems at work also grew worse. His supervisor in- formed Kevin that his contract would definitely not be renewed. Joyce exploded when Kevin indifferently told her the bad news. His apparent lack of concern was especially annoying. She called Kevin’s supervisor, who confirmed the news. He told her that Kevin was physically present at the library, but he was only com- pleting a few hours of work each day. Kevin sometimes spent long periods of time just sitting at his desk and staring off into space and was sometimes heard mumbling softly to himself.
Kevin’s speech was quite odd during the next therapy session. He would sometimes start to speak, drift off into silence, then re- establish eye contact with a bewildered smile and a shrug of his shoulders. He had apparently lost his train of thought completely. His answers to questions were often off the point, and when he did string together several sentences, their meaning was some- times obscure. For example, at one point during the session, the psychologist asked Kevin if he planned to appeal his supervisor’s decision. Kevin said, “I’m feeling pressured, like I’m lost and can’t quite get here. But I need more time to explore the deeper side. Like in art. What you see on the surface is much richer when you look closely. I’m like that. An intuitive person. I can’t relate in a lin- ear way, and when people expect that from me, I get confused.”
Kevin’s strange belief about poisoning continued to expand. The Warners received a letter from Kevin’s mother, who lived in another city 200 miles away. She had become ill after going out
for dinner one night and mentioned that she must have eaten something that made her sick. After reading the letter, Kevin became convinced that his supervisor had tried to poison his mother, too.
When questioned about this new incident, Kevin launched into a long, rambling story. He said that his supervisor was a Vietnam veteran, but he had refused to talk with Kevin about his years in the service. Kevin suspected that this was because the supervisor had been a member of army intelligence. Perhaps he still was a member of some secret organization. Kevin suggested that an agent from this organization had been sent by his supervi- sor to poison his mother. Kevin thought that he and Joyce were in danger. Kevin also had some concerns about Asians, but he would not specify these worries in more detail.
Kevin’s bizarre beliefs and his disorganized behavior con- vinced the psychologist that he needed to be hospitalized. Joyce reluctantly agreed that this was the most appropriate course of action. She had run out of alternatives. Arrangements were made to have Kevin admitted to a private psychiatric facility, where the psychiatrist prescribed a type of antipsychotic medication. Kevin seemed to respond positively to the drug, because he soon stopped talking about plots and poisoning—but he remained withdrawn and uncommunicative. After three weeks of treatment, Kevin’s psychiatrist thought that he had improved significantly. Kevin was discharged from the hospital in time for the birth of their baby girl. Unfortunately, when the couple returned to con- sult with the psychologist, Kevin’s adjustment was still a major concern. He did not talk with Joyce about the poisonings, but she noticed that he remained withdrawn and showed few emotions, even toward the baby.
When the psychologist questioned Kevin in detail, he admit- ted reluctantly that he still believed that he had been poisoned. Slowly, he revealed more of the plot. Immediately after admission to the hospital, Kevin had decided that his psychiatrist, who hap- pened to be from Korea, could not be trusted. Kevin was sure that he, too, was working for army intelligence or perhaps for a counterintelligence operation. Kevin believed that he was being interrogated by this clever psychiatrist, so he had “played dumb.” He did not discuss the suspected poisonings or the secret organi- zation that had planned them. Whenever he could get away with it, Kevin simply pretended to take his medication. He thought that it was either poison or truth serum.
Kevin was admitted to a different psychiatric hospital soon after it became apparent that his paranoid beliefs had expanded. This time, he was given intramuscular injections of antipsychotic medication in order to be sure that the medicine was actually taken. Kevin improved considerably after several weeks in the hospital. He acknowledged that he had experienced paranoid thoughts. Although he still felt suspicious from time to time, won- dering whether the plot had actually been real, he recognized that it could not really have happened, and he spent less and less time thinking about it.
4 CHAPTER 1 examples and definitions of abnormal behavior
Recognizing the Presence of a Disorder Some mental disorders are so severe that the people who suffer from them are not aware of the implausibility of their beliefs. Schizophrenia is a form of psychosis, a general term that refers to several types of severe mental disorders in which the person is considered to be out of contact with reality. Kevin exhibited several psychotic symptoms. For example, Kevin’s firm belief that he was being poisoned by his supervisor had no basis in reality. Other disorders, however, are more subtle variations on normal experience. We will shortly consider some of the guidelines that are applied in determining abnormality.
Mental disorders are typically defined by a set of character- istic features; one symptom by itself is seldom sufficient to make a diagnosis. A group of symptoms that appear together and are assumed to represent a specific type of disorder is referred to as a syndrome. Kevin’s unrealistic and paranoid belief that he was being poisoned, his peculiar and occasionally difficult-to-under- stand patterns of speech, and his oddly unemotional responses are all symptoms of schizophrenia (see Chapter 13). Each symptom is taken to be a fallible, or imperfect, indicator of the presence of the disorder. The significance of any specific feature depends on whether the person also exhibits additional behaviors that are characteristic of a particular disorder.
The duration of a person’s symptoms is also important. Mental disorders are defined in terms of persistent maladaptive behaviors. Many unusual behaviors and inexplicable experiences are short lived; if we ignore them, they go away. Unfortunately, some forms of problematic behavior are not transient, and they eventually interfere with the person’s social and occupational functioning. In Kevin’s case, he had become completely preoc- cupied with his suspicions about poison. Joyce tried for several weeks to ignore certain aspects of Kevin’s behavior, especially his delusional beliefs. She didn’t want to think about the possibility that his behavior was abnormal and instead chose to explain his problems in terms of lack of maturity or lack of motivation. But as the problems accumulated, she finally decided to seek profes- sional help. The magnitude of Kevin’s problem was measured, in large part, by its persistence.
Impairment in the ability to perform social and occupa- tional roles is another consideration in identifying the presence of a mental disorder. Delusional beliefs and disorganized speech typically lead to a profound disruption of relationships with other people. Like Kevin, people who experience these symptoms will obviously find the world to be a strange, puzzling, and perhaps alarming place. And they often elicit the same reactions in other people. Kevin’s odd behavior and his inability to concentrate on his work had eventually cost him his job. His problems also had a negative impact on his relationship with his wife and his ability to help care for their daughter.
Kevin’s situation raises several additional questions about abnormal behavior. One of the most difficult issues in the field
centers on the processes by which mental disorders are identified. Once Kevin’s problems came to the attention of a mental health professional, could he have been tested in some way to confirm the presence or absence of a mental disorder?
Psychologists and other mental health professionals do not at present have laboratory tests that can be used to confirm defini- tively the presence of psychopathology because the processes that are responsible for mental disorders have not yet been discovered. Unlike specialists in other areas of medicine where many specific disease mechanisms have been discovered by advances in the bio- logical sciences, psychologists and psychiatrists cannot test for the presence of a viral infection or a brain lesion or a genetic defect to confirm a diagnosis of mental disorder. Clinical psychologists must still depend on their observations of the person’s behavior and descriptions of personal experience.
Is it possible to move beyond our current dependence on descriptive definitions of psychopathology? Will we someday have valid tests that can be used to establish independently the presence of a mental disorder? If we do, what form might these tests take? The answers to these questions are being sought in many kinds of research studies that will be discussed throughout this book.
Before we leave this section, we must also mention some other terms. You may be familiar with a variety of words that are commonly used in describing abnormal behavior. One term is in- sanity, which years ago referred to mental dysfunction but today is a legal term that refers to judgments about whether a person
People with schizophrenia are sometimes socially withdrawn and find social relationships to be puzzling or threatening.
examples and definitions of abnormal behavior CHAPTER 1 5
should be held responsible for criminal behavior if he or she is also mentally disturbed (see Chapter 18). If Kevin had murdered his psychiatrist, for example, based on the delusional belief that the psychiatrist was trying to harm him, a court of law might consider whether Kevin should be held to be not guilty by reason of insanity.
Another old-fashioned term that you may have heard is ner- vous breakdown. If we said that Kevin had “suffered a nervous breakdown,” we would be indicating, in very general terms, that he had developed some sort of incapacitating but otherwise un- specified type of mental disorder. This expression does not convey any specific information about the nature of the person’s prob- lems. Some people might also say that Kevin was acting crazy. This is an informal, pejorative term that does not convey specific information and carries with it many unfortunate, unfounded, and negative implications. Mental health professionals refer to psychopathological conditions as mental disorders or abnormal behaviors. We will define these terms in the pages that follow.
Defining Abnormal Behavior Why do we consider Kevin’s behavior to be abnormal? By what criteria do we decide whether a particular set of behaviors or emotional reactions should be viewed as a mental disorder? These are important questions because they determine, in many ways, how other people will respond to the person, as well as who will be responsible for providing help (if help is required). Many at- tempts have been made to define abnormal behavior, but none is entirely satisfactory. No one has been able to provide a consistent definition that easily accounts for all situations in which the con- cept is invoked (Phillips et al., 2012; Zachar & Kendler, 2007).
One approach to the definition of abnormal behavior places principal emphasis on the individual’s experience of personal dis- tress. We might say that abnormal behavior is defined in terms of subjective discomfort that leads the person to seek help from a mental health professional. However, this definition is fraught with problems. Kevin’s case illustrates one of the major reasons that this approach does not work. Before his second hospitalization, Kevin was unable or unwilling to appreciate the extent of his problem or the impact his behavior had on other people. A psychologist would say that he did not have insight regarding his disorder. The discom- fort was primarily experienced by Joyce, and she had attempted for many weeks to deny the nature of the problem. It would be useless to adopt a definition that considered Kevin’s behavior to be abnor- mal only after he had been successfully treated.
Another approach is to define abnormal behavior in terms of statistical norms—how common or rare it is in the general population. By this definition, people with unusually high levels of anxiety or depression would be considered abnormal because their experience deviates from the expected norm. Kevin’s para- noid beliefs would be defined as pathological because they are idiosyncratic. Mental disorders are, in fact, defined in terms of experiences that most people do not have.
This approach, however, does not specify how unusual the behavior must be before it is considered abnormal. Some condi- tions that are typically considered to be forms of psychopathology are extremely rare. For example, gender dysphoria, the belief that one is a member of the opposite sex trapped in the wrong body, affects less than 1 person out of every 30,000. In contrast, other mental disorders are much more common. Mood disorders affect 1 out of every 5 people at some point during their lives; alcohol- ism and other substance use disorders affect approximately 1 out of every 6 people (Kessler et al., 2005; Moffitt et al., 2010).
Another weakness of the statistical approach is that it does not distinguish between deviations that are harmful and those
Andy Warhol was one of the most influential painters of the 20th century. His colleague, Jean-Michel Basquiat, was also an extremely promising artist. His addiction to heroin, which led to a fatal overdose, provides one example of the destructive impact of mental disorders.
MypsychLab VIDEO CASE
Bipolar Disorder
FELIZIANO
“Depression is the worst part. My shoulders feel weighted down, and your blood feels warmer than it is. You sink deeper and deeper.”
Watch the Video Feliziano: Bipolar Disorder on MyPsychLab
As you watch the interview and the day-in- the-life segments, ask yourself what impact Feliziano’s depression and hypomania seem to have on his ability to function. Are these mood states harmful?
6 CHAPTER 1 examples and definitions of abnormal behavior
that are not. Many rare behaviors are not pathological. Some “abnormal” qualities have relatively little impact on a person’s adjustment. Examples are being extremely pragmatic or unusu- ally talkative. Other abnormal characteristics, such as excep- tional intellectual, artistic, or athletic ability, may actually confer an advantage on the individual. For these reasons, the simple fact that a behavior is statistically rare cannot be used to define psychopathology.
Harmful Dysfunction One useful approach to the definition of mental disorder has been proposed by Jerome Wakefield of Rutgers University (Wakefield, 2010). According to Wakefield, a condition should be considered a mental disorder if, and only if, it meets two criteria:
1. The condition results from the inability of some internal mechanism (mental or physical) to perform its natural func- tion. In other words, something inside the person is not work- ing properly. Examples of such mechanisms include those that regulate levels of emotion, and those that distinguish be- tween real auditory sensations and those that are imagined.
2. The condition causes some harm to the person as judged by the standards of the person’s culture. These negative conse- quences are measured in terms of the person’s own subjective distress or difficulty performing expected social or occupa- tional roles.
A mental disorder, therefore, is defined in terms of harmful dysfunction. This definition incorporates one element that is based as much as possible on an objective evaluation of perfor- mance. The natural function of cognitive and perceptual pro- cesses is to allow the person to perceive the world in ways that are shared with other people and to engage in rational thought and problem solving. The dysfunctions in mental disorders are assumed to be the product of disruptions of thought, feeling, communication, perception, and motivation.
In Kevin’s case, the most apparent dysfunctions involved fail- ures of mechanisms that are responsible for perception, thinking, and communication. Disruption of these systems was presumably responsible for his delusional beliefs and his disorganized speech. The natural function of cognitive and perceptual processes is to allow the person to perceive the world in ways that are shared with other people and to engage in rational thought and prob- lem solving. The natural function of language abilities is to allow the person to communicate clearly with other people. Therefore, Kevin’s abnormal behavior can be viewed as a pervasive dysfunc- tion cutting across several mental mechanisms.
The harmful dysfunction view of mental disorder recognizes that every type of dysfunction does not lead to a disorder. Only dysfunctions that result in significant harm to the person are con- sidered to be disorders. This is the second element of the defini- tion. There are, for example, many types of physical dysfunctions, such as albinism, reversal of heart position, and fused toes, that
clearly represent a significant departure from the way that some biological process ordinarily functions. These conditions are not considered to be disorders, however, because they are not neces- sarily harmful to the person.
Kevin’s dysfunctions were, in fact, harmful to his adjust- ment. They affected both his family relationships—his marriage to Joyce and his ability to function as a parent—and his perfor- mance at work. His social and occupational performances were clearly impaired. There are, of course, other types of harm that are also associated with mental disorders. These include subjec- tive distress, such as high levels of anxiety or depression, as well as more tangible outcomes, such as suicide.
The definition of abnormal behavior employed by the official Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association and currently in its fifth edition—DSM-5 (APA, 2013)—incorporates many of the factors that we have already discussed. This classification system is dis- cussed in Chapter 4. This definition is summarized in Table 1.1, along with a number of conditions that are specifically excluded from the DSM-5 definition of mental disorders (Stein et al., 2010).
The DSM-5 definition places primary emphasis on the con- sequences of certain behavioral syndromes. Accordingly, mental disorders are defined by clusters of persistent, maladaptive be- haviors that are associated with personal distress, such as anxiety or depression, or with impairment in social functioning, such as job performance or personal relationships. The official definition, therefore, recognizes the concept of dysfunction, and it spells out ways in which the harmful consequences of the disorder might be identified.
The DSM-5 definition excludes voluntary behaviors, as well as beliefs and actions that are shared by religious, political,
table 1.1 Defining Characteristics of Mental Disorders Features
1. A syndrome (groups of associated features) that is characterized by disturbance of a person’s cognition, emotion regulation, or behavior.
2. The consequences of which are clinically significant distress or disability in social, occupational, or other important activities.
3. The syndrome reflects a dysfunction in the psychological, biological, or developmental processes that are associated with mental functioning.
4. Must not be merely an expectable response to common stressors and losses or a culturally sanctioned response to a particular event (e.g., trance states in religious rituals).
5. That is not primarily a result of social deviance or conflicts with society.
Source: Based on Stein, D. J., Phillips, K. A., Bolton, D. D., Fulford, K. M., Sadler, J. Z., & Kendler, K. S. 2010. What is a mental/psychiatric disorder? From DSM-IV to DSM-V. Psychological Medicine, 40, 1759–1765.
examples and definitions of abnormal behavior CHAPTER 1 7
or sexual minority groups (e.g., gays and lesbians). In the 1960s, for example, members of the Yippie Party intentionally engaged in disruptive behaviors, such as throwing money off the balcony at a stock exchange. Their purpose was to challenge traditional values. These were, in some ways, maladaptive behaviors that could have resulted in social impairment if those involved had been legally prosecuted. But they were not dysfunctions. They were intentional political gestures. It makes sense to try to dis- tinguish between voluntary behaviors and mental disorders, but the boundaries between these different forms of behavior are dif- ficult to draw. Educated discussions of these issues depend on the consideration of a number of important questions (see Critical Thinking Matters on page 9).
In actual practice, abnormal behavior is defined in terms of an official diagnostic system. Mental health, like medicine, is an applied rather than a theoretical field. It draws on knowl- edge from research in the psychological and biological sciences in an effort to help people whose behavior is disordered. Men- tal disorders are, in some respects, those problems with which mental health professionals attempt to deal. As their activities and explanatory concepts expand, so does the list of abnormal behaviors. The practical boundaries of abnormal behavior are defined by the list of disorders that are included in the official Diagnostic and Statistical Manual of Mental Disorders. The cat- egories in that manual are listed inside the back cover of this book. The DSM-5 thus provides another simplistic, although practical, answer to our question as to why Kevin’s behavior would be considered abnormal: He would be considered to be exhibiting abnormal behavior because his experiences fit the description of schizophrenia, which is one of the officially recognized forms of mental disorder (see Thinking Critically About DSM-5).
Mental Health Versus Absence of Disorder The process of defining abnormal behavior raises interesting questions about the way we think about the quality of our lives when mental disorders are not present. What is mental health? Is optimal mental health more than the absence of mental dis- order? The answer is clearly “yes.” If you want to know whether one of your friends is physically fit, you would need to determine more than whether he or she is sick. In the realm of psychologi- cal functioning, people who function at the highest levels can be described as flourishing (Fredrickson & Losada, 2005; Keyes, 2009). They are people who typically experience many positive emotions, are interested in life, and tend to be calm and peaceful. Flourishing people also hold positive attitudes about themselves and other people. They find meaning and direction in their lives and develop trusting relationships with other people. Complete mental health implies the presence of these adaptive character- istics. Therefore, comprehensive approaches to mental health in the community must be concerned both with efforts to diminish the frequency and impact of mental disorders and with activities designed to promote flourishing.
Culture and Diagnostic Practice The process by which the Diagnostic and Statistical Manual is constructed and revised is necessarily influenced by cultural con- siderations. Culture is defined in terms of the values, beliefs, and practices that are shared by a specific community or group of people. These values and beliefs have a profound influence on opinions regarding the difference between normal and abnormal behavior (Bass et al., 2012).
The impact of particular behaviors and experiences on a person’s adjustment depends on the culture in which the person
THINKING CRITICALLY about DSM-5
Revising an Imperfect Manual
The official diagnostic manual for mental disorders is revised by the American Psychiatric Association on a regular basis, about once every 15 to 20 years. You might be surprised that the classification system changes so often, but these updates reflect the evolution of our understanding regarding these com- plex problems. Even more well-established and widely accepted classification systems change. You may remember when Pluto was removed from the list of planets, or recall that new elements have been added to the Periodic Table as a result of nuclear sci- ence. Classification systems change as knowledge expands.
The fifth and latest version, DSM-51, was published in 2013, an event surrounded by excitement as well as heated controversy.
More than a dozen workgroups concerned with specific disor- ders (e.g., mood disorders, psychotic disorders) were composed of expert researchers and clinicians who had been appointed to represent current knowledge in their respective areas. Each group produced a series of proposals that were subjected to public comments as well as field trials that were intended to generate data regarding the reliability of the new definitions. In the end, some experts considered the final product to be a major step forward while others viewed it as a serious step back (Kupfer & Regier, 2011; Frances & Widiger, 2012).
We have added a new feature, Thinking Critically About DSM-5, to each chapter in this text. These features are designed to
Continued
8 CHAPTER 1 examples and definitions of abnormal behavior
lives. To use Jerome Wakefield’s (1992) terms, “only dysfunc- tions that are socially disvalued are disorders” (p. 384). Con- sider, for example, the DSM-5 concept of female orgasmic disorder, which is defined in terms of the absence of orgasm accompanied by subjective distress or interpersonal difficulties that result from this disturbance (see Chapter 12). A woman who grew up in a society that discouraged female sexuality might not be distressed or impaired by the absence of orgasmic responses. According to DSM-5, she would not be considered to have a sexual problem. Therefore, this definition of abnor- mal behavior is not culturally universal and might lead us to consider a particular pattern of behavior to be abnormal in one society and not in another.
There have been many instances in which groups repre- senting particular social values have brought pressure to bear on decisions shaping the diagnostic manual. The influence of
cultural changes on psychiatric classification is perhaps no- where better illustrated than in the case of homosexuality. In the first and second editions of the DSM, homosexuality was, by definition, a form of mental disorder, in spite of arguments ex- pressed by scientists, who argued that homosexual behavior was not abnormal (see Chapter 12). Toward the end of the 1960s, as the gay and lesbian rights movement became more force- ful and outspoken, its leaders challenged the assumption that homosexuality was pathological. They opposed the inclusion of homosexuality in the official diagnostic manual. After extended and sometimes heated discussions, the board of trustees of the American Psychiatric Association agreed to remove homosexu- ality as a form of mental illness. They were impressed by nu- merous indications, in personal appeals as well as the research literature, that homosexuality, per se, was not invariably associ- ated with impaired functioning. They decided that, in order to
help you understand ways in which this diagnostic manual has evolved, criteria that are used to judge its progress, and issues that are most controversial following publication of its latest edi- tion. We don’t want you to accept the DSM-5 definitions simply because they were published on the authority of the American Psychiatric Association. On the other hand, we also don’t want you to reject the manual because everything in it isn’t perfect. Above all else, remember that DSM-5 is a handbook, not the Bible (Frances, 2012). There are no absolute truths to be found in the classification of mental disorders.
The debates about DSM-5 generate considerable emotion from people on both sides because changes in the manual affect so many people’s lives. Crucial economic resources are clearly at stake. Adding a diagnostic category can create or expand a market for specific treatments (e.g., medications to treat a new disorder may reap enormous profits) while also raising challeng- ing issues about whether insurance companies must pay for those treatments, whether schools will be expected to provide special services, and whether the government must pay disabil- ity claims. There are also pressures on the other side. Deleting an existing category, or narrowing the criteria that are used to define it, can create serious hardships for individuals and families who are then unable to find or afford suitable services upon which they depend. Mental health professionals, research scientists, and patient advocacy groups all play a crucial role in these debates.
Everyone agrees that the classification system must evolve, but what principles should guide this process of change? When
DSM-IV (APA, 1994) was being produced, the process was de- signed to be conservative. Changes were presumably allowed only when there was substantial evidence to support a shift in the diagnostic criteria for a particular disorder. A few years later, when discussions about DSM-5 began, the process was de- signed to be more open. Workgroups were encouraged to make changes that would bring the system in line with contemporary thinking, even if hard evidence was not available to indicate that the change was empirically justified. Reasonable arguments can be made for both approaches to the revision process. Ultimately, the value of these changing definitions will be judged by the outcomes. Are the new definitions meaningful? Can they be used to improve people’s lives?
In the midst of public debates about the DSM-5 process, another issue has taken center stage. What group is best po- sitioned to manage this system? The American Psychiatric As- sociation clearly owns DSM, having launched its original version in 1952. Given the fact that other mental health professions also play important roles in treating and studying mental disorders, does it make sense for this one organization to be the sole owner and manager of the classification system that governs so many aspects of our lives? Should decisions to change the system be guided, even in part, by the enormous economic benefits that have fallen to one professional organization? Some critics have argued that the classification system for mental disorders should be governed by some type of government or- ganization, such as the National Institutes of Health, rather than a profit-making professional association. This issue will undoubt- edly be debated and explored in coming years.
1Previous editions of the manual have been identified using roman numerals, e.g., DSM-III, DSM-IV. The current edition uses Arabic numerals in the hope that more frequent revisions of the text (e.g., DSM-5.1 and so on) can be produced easily and labeled clearly, much like updates to computer software packages.
examples and definitions of abnormal behavior CHAPTER 1 9
be considered a form of mental disorder, a condition ought to be associated with subjective distress or seriously impaired social or occupational functioning. The stage was set for these events by gradual shifts in society’s attitudes toward sexual behavior (Bullough, 1976; Minton, 2002). As more and more people came to believe that reproduction was not the main purpose of sexual behavior, tolerance for greater variety in human sexual- ity grew. The revision of the DSM’s system for describing sexual disorders was, therefore, the product of several forces, cultural as well as political. These deliberations are a reflection of the prac- tical nature of the manual and of the health-related professions.
Value judgments are an inherent part of any attempt to define “disorder” ( Sedgwick, 1981).
Many people think about culture primarily in terms of exotic patterns of behavior in distant lands. The decision regarding ho- mosexuality reminds us that the values of our own culture play an intimate role in our definition of abnormal behavior. These issues also highlight the importance of cultural change. Culture is a dynamic process; it changes continuously as a result of the ac- tions of individuals. To the extent that our definition of abnormal behavior is determined by cultural values and beliefs, we should expect that it will continue to evolve over time.
CRITICAL THINKING matters
Is Sexual Addiction a Meaningful Concept?
Stories about mental disorders appear frequently in the popular media. One topic that once again attracted a frenzy of media attention in 2010 was a concept that has been called “sexual addiction.” Tiger Woods, the top-ranked golfer in the world and wealthiest professional athlete in his- tory, confessed to having a series of illicit sexual affairs and announced that he would take an indefinite break from the pro- fessional tour. At the time, Woods was married to former Swed- ish model Elin Nordegren, who had given birth to their second child earlier that same year. More than a dozen women came forward to claim publicly that they had sexual relationships with Woods, and several large companies soon cancelled lucrative endorsement deals that paid him millions of dollars to endorse their products. Newspapers, magazines, and television programs sought interviews with professional psychologists who offered their opinions regarding Woods’ behavior. Why would this fabu- lously successful, universally admired, iconic figure risk his mar- riage, family, and career for a seemingly endless series of casual sexual relationships?
Many experts responded by invoking the concept of mental disorder, specifically “sexual addiction” (some called it “sexual compulsion,” and one called it the “Clinton syndrome” in refer- ence to similar problems that had been discussed in the midst of President Clinton’s sex scandal in 1998). The symptoms of this disorder presumably include low self-esteem, insecurity, need for reassurance, and sensation seeking, to name only a few. One expert claimed that 20 percent of highly successful men suffer from sexual addiction.
Most of the stories failed to mention that sexual addiction does not appear as an officially recognized mental disorder in DSM-5. That, by itself, is not an insurmountable problem. Disorders have come and gone over the years, and it’s possible that this one— or some version of it—might eventually turn out to be useful. In fact, the work group that revised the list of sexual disorders for DSM-5 did consider but ultimately rejected adding a new
category called “hypersexual disorder” (Reid et al., 2012) (see Thinking Critically About DSM-5 in Chapter 12). We shouldn’t ignore a new concept simply because it hasn’t become part of the official classification system (or accept one on faith, simply because it has). The most important thing is that we think criti- cally about the issues that are raised by invoking a concept like sexual addiction.
At the broadest possible level, we must ask ourselves “What is a mental disorder?” Is there another explanation for such thought- less and damaging behavior? Tiger Woods received several weeks of treatment for sexual addiction at a residential mental health facility. Has that treatment been shown to be effective for this kind of behavioral problem? Is it necessary? Does the diag- nosis simply provide him with a convenient excuse that might encourage the public to forgive his immoral behavior?
Another important question is whether sexual addiction is more useful than other similar concepts (Moser, 2011). For example, narcissistic personality disorder includes many of the same fea- tures (such as lack of empathy, feelings of entitlement, and a his- tory of exploiting others). What evidence supports the value of one concept over another? In posing such questions, we are not arguing for or against a decision to include sexual addiction or hypersexual disorder as a type of mental disorder. Rather, we are encouraging you to think critically.
Students who ask these kinds of questions are engaged in a process in which judgments and decisions are based on a care- ful analysis of the best available evidence. In order to consider these issues, you need to put aside your own subjective feelings and impressions, such as whether you find a particular kind of behavior disgusting, confusing, or frightening. It may also be necessary to disregard opinions expressed by authorities whom you respect (politicians, journalists, and talk-show hosts). Be skeptical. Ask questions. Consider the evidence from different points of view, and remember that some kinds of evidence are better than others.
10 CHAPTER 1 examples and definitions of abnormal behavior
Who Experiences Abnormal Behavior? Having introduced many of the issues that are involved in the definition of abnormal behavior, we now turn to another clinical example. The woman in our second case study, Mary Childress, suffered from a serious eating disorder known as bulimia nervosa. Her problems raise additional questions about the definition of abnormal behavior.
As you are reading the case, ask yourself about the impact of Mary’s eating disorder on her subjective experience and so- cial adjustment. In what ways are these consequences similar to those seen in Kevin Warner’s case? How are they different? This case also introduces another important concept associated with the way that we think about abnormal behavior: How can we identify the boundary between normal and abnormal behavior? Is there an obvious distinction between eating patterns that are con- sidered to be part of a mental disorder and those that are not? Or is there a gradual progression from one end of a continuum to the other, with each step fading gradually into the next?
A College Student’s Eating Disorder Mary Childress was, in most respects, a typical 19-year-old sopho- more at a large state university. She was a good student, in spite of the fact that she spent little time studying, and was popular with other students. Everything about Mary’s life was relatively normal—except for her bingeing and purging.
Mary’s eating patterns were wildly erratic. She preferred to skip breakfast entirely and often missed lunch as well. By the middle of the afternoon, she could no longer ignore the hunger pangs. At that point, on two or three days out of the week, Mary would drive her car to the drive-in window of a fast-food res- taurant. Her typical order included three or four double cheese- burgers, several orders of french fries, and a large milkshake (or maybe two). Then she binged, devouring all the food as she drove around town by herself. Later she would go to a private bathroom, where she wouldn’t be seen by anyone, and purge the food from her stomach by vomiting. Afterward, she returned to her room, feeling angry, frustrated, and ashamed.
Mary was tall and weighed 110 pounds. She believed that her body was unattractive, especially her thighs and hips. She was extremely critical of herself and had worried about her weight for many years. Her weight fluctuated quite a bit, from a low of 97 pounds when she was a senior in high school to a high of 125 during her first year at the university. Her mother was a “full-figured” woman. Mary swore to herself at an early age that she would never let herself gain as much weight as her mother had.
Purging had originally seemed like an ideal solution to the problem of weight control. You could eat whatever you wanted and quickly get rid of it so you wouldn’t get fat. Unfortunately, the vomiting became a vicious trap. Disgusted by her own behav- ior, Mary often promised herself that she would never binge and purge again, but she couldn’t stop the cycle.
For the past year, Mary had been vomiting at least once al- most every day and occasionally as many as three or four times a day. The impulse to purge was very strong. Mary felt bloated after having only a bowl of cereal and a glass of orange juice. If she ate a sandwich and drank a diet soda, she began to ruminate about what she had eaten, thinking, “I’ve got to get rid of that!” Usually, before long, she found a bathroom and threw up. Her excessive binges were less frequent than the vomiting. Four or five times a week she experienced an overwhelming urge to eat forbidden foods, especially fast food. Her initial reaction was usu- ally a short-lived attempt to resist the impulse. Then she would space out or “go into a zone,” becoming only vaguely aware of what she was doing and feeling. In the midst of a serious binge, Mary felt completely helpless and unable to control herself.
There weren’t any obvious physical signs that would alert someone to Mary’s eating problems, but the vomiting had begun to wreak havoc with her body, especially her digestive system. She had suffered severe throat infections and frequent, intense stomach pains. Her dentist had noticed problems beginning to develop with her teeth and gums, undoubtedly a consequence of constant exposure to strong stomach acids.
Mary’s eating problem started to develop when she was 15 years old. She had been seriously involved in gymnastics for sev- eral years, but eventually developed a knee condition that forced her to give up the sport. She gained a few pounds in the next month or two and decided to lose weight by dieting. Buoyed by unrealistic expectations about the immediate, positive benefits of a diet that she had seen advertised on television, Mary initially adhered rigidly to its recommended regimen. Six months later, after three of these fad diets had failed, she started throwing up as a way to control her intake of food.
Mary’s problems persisted after she graduated from high school and began her college education. She felt guilty and ashamed about her eating problems. She was much too embar- rassed to let anyone know what she was doing and would never eat more than a few mouthfuls of food in a public place, such as the dorm cafeteria. Her roommate, Julie, was from a small town on the other side of the state. They got along reasonably well, but Mary managed to conceal her bingeing and purging, thanks in large part to the fact that she was able to bring her own car to campus. The car allowed her to drive away from campus several times a week so that she could binge.
Mary’s case illustrates many of the characteristic features of bulimia nervosa. As in Kevin’s case, her behavior could be con- sidered abnormal not only because it fits the criteria for one of the categories in DSM-5 but also because she suffered from a dys- function (in this case, of the mechanisms that regulate appetite) that was obviously harmful. The impact of the disorder was great- est in terms of her physical health: Eating disorders can be fatal if they are not properly treated because they affect so many vital organs of the body, including the heart and kidneys. Mary’s social
examples and definitions of abnormal behavior CHAPTER 1 11
functioning and her academic performance were not yet seriously impaired. There are many different ways in which to measure the harmful effects of abnormal behavior.
Mary’s case also illustrates the subjective pain that is as- sociated with many types of abnormal behavior. In contrast to Kevin, Mary was acutely aware of her disorder. She was frus- trated and unhappy. In an attempt to relieve this emotional distress, she entered psychological treatment. Unfortunately, painful emotions associated with mental disorders can also in- terfere with, or delay, the decision to look for professional help. Guilt, shame, and embarrassment often accompany psychologi- cal problems and sometimes make it difficult to confide in an- other person, even though the average therapist has seen such problems many times over.
Frequency in and Impact on Community Populations Many important decisions about mental disorders are based on data regarding the frequency with which these disorders occur. At least 3 percent of college women would meet diagnostic criteria for bulimia nervosa (see Chapter 10). These data are a source of considerable concern, especially among those who are responsible for health services on college campuses.
Epidemiology is the scientific study of the frequency and distribution of disorders within a population (Gordis, 2008). Epidemiologists are concerned with questions, such as whether
How thin is too thin? Does this dancer suffer from an eating disorder? Some experts maintain that the differences between abnormal and nor- mal behavior are essentially differences in degree, that is, quantitative differences.
the frequency of a disorder has increased or decreased during a particular period, whether it is more common in one geographic area than in another, and whether certain types of people—based on such factors as gender, race, and socioeconomic status—are at greater risk than other types for the development of the disorder. Health administrators often use such information to make deci- sions about the allocation of resources for professional training programs, treatment facilities, and research projects.
Two terms are particularly important in epidemiological re- search. Incidence refers to the number of new cases of a disor- der that appear in a population during a specific period of time. Prevalence refers to the total number of active cases, both old and new, that are present in a population during a specific period of time (Susser et al., 2006). The lifetime prevalence of a disorder is the total proportion of people in a given population who have been af- fected by the disorder at some point during their lives. Some studies also report 12-month prevalence rates, indicating the proportion of the population that met criteria for the disorder during the year prior to the assessment. Lifetime prevalence rates are higher than 12-month prevalence rates because some people who had problems in the past and then recovered will be counted with regard to life- time disorders but not be counted for the most recent year.
LIFetIMe PreVALenCe AnD GenDer DIFFerenCes How prevalent are the various forms of abnormal behavior? The best data regarding this question come from a large-scale study known as the National Comorbidity Survey Replication (NCS-R) con- ducted between 2001 and 2003 (Kessler et al., 2005; Kessler, Merikangas, & Wang, 2007). Members of this research team interviewed a nationally representative sample of approximately 9,000 people living in the continental United States. Questions were asked pertaining to several (but not all) forms of mental disorder. The NCS-R found that 46 percent of the people inter- viewed received at least one lifetime diagnosis, with first onset of symptoms usually occurring during childhood or adolescence. This proportion of the population is much higher than many people expect, and it underscores the point that we made at the beginning of this chapter: All of us can expect to encounter the challenges of a mental disorder—either for ourselves or for some- one we love—at some point during our lives.
Figure 1.1 lists some results from this study using lifetime prevalence rates—the number of people who had experienced each disorder at some point during their lives. The most prevalent specific type of disorder was major depression (17 percent). Sub- stance use disorders and various kinds of anxiety disorders were also relatively common. Substantially lower lifetime prevalence rates were found for schizophrenia and eating disorders (bulimia and anorexia), which affects approximately 1 percent of the popu- lation. These lifetime prevalence rates are consistent with data re- ported by earlier epidemiological studies of mental disorders.
Although many mental disorders are quite common, they are not always seriously debilitating, and some people who qualify for a diagnosis do not need immediate treatment. The NCS-R
12 CHAPTER 1 examples and definitions of abnormal behavior
Clinical psychologists perform many roles. Some provide direct clinical ser- vices. Many are involved in research, teaching, and various administrative activities.
2 4 6 8 10 12 14 16 180
Anorexia nervosa
Bulimia nervosa
Schizophrenia
Obsessive-compulsive disorder
Bipolar disorder
Panic disorder
Posttraumatic stress disorder
Drug abuse
Alcohol abuse
Major depression
Lifetime Prevalence (percent)
figure 1.1 Frequency of Mental Disorders in the Community Lifetime prevalence rates for various mental disorders (NCS-R data). Courtesy of Thomas F. Oltmanns and Robert E. Emery.
investigators assigned each case a score with regard to severity, based on the severity of symptoms as well as the level of occupa- tional and social impairment that the person experienced. Aver- aged across all of the disorders diagnosed in the past 12 months, 40 percent of cases were rated as “mild,” 37 percent as “moder- ate,” and only 22 percent as “severe.” Mood disorders were the most likely to be rated as severe (45 percent) while anxiety disor- ders were less likely to be rated as severe (23 percent).
Epidemiological studies such as the NCS-R have consistently found gender differences for many types of mental disorder: Major
depression, anxiety disorders, and eating disorders are more com- mon among women; alcoholism and antisocial personality are more common among men. Some other conditions, such as bipolar disor- der, appear with equal frequency in both women and men. Patterns of this sort raise interesting questions about possible causal mecha- nisms. What conditions would make women more vulnerable to one kind of disorder and men more vulnerable to another? There are many possibilities, including factors such as hormones, patterns of learning, and social pressures. We will discuss gender differences in more detail in subsequent chapters of this book.
examples and definitions of abnormal behavior CHAPTER 1 13
CoMorbIDIty AnD DIseAse burDen Most severe disorders are concentrated in a relatively small segment of the population. Often these are people who simultaneously qualify for more than one diagnosis, such as major depression and alcoholism. The presence of more than one condition within the same period of time is known as comorbidity (or co-occurrence). Six percent of the people in the NCS-R sample had three or more 12-month disorders, and 50 percent of those cases were rated as being “se- vere.” While mental disorders occur relatively frequently, the most serious problems are concentrated in a smaller group of people who have more than one disorder. These findings have shifted the emphasis of epidemiological studies from counting the absolute number of people who have any kind of mental disorder to mea- suring the functional impairment associated with these problems.
Mental disorders are highly prevalent, but how do we mea- sure the extent of their impact on people’s lives? And how does that impact compare to the effects of other diseases? These are important questions when policymakers must establish priorities for various types of training, research, and health services (Eaton et al., 2012).
Epidemiologists measure disease burden by combining two factors: mortality and disability. The common measure is based on time: lost years of healthy life, which might be caused by pre- mature death (compared to the person’s standard life expectancy) or living with a disability (weighted for severity). For purposes of comparison among different forms of disease and injury, the
disability produced by major depression is considered to be equivalent to that associated with blindness or paraplegia. A psy- chotic disorder such as schizophrenia leads to disability that is comparable to that associated with quadriplegia.
The World Health Organization (WHO) sponsored an am- bitious study called the Global Burden of Disease Study, which used these measures to evaluate and compare the impact of more than 100 forms of disease and injury throughout the world (Lo- pez et al., 2006). Although mental disorders are responsible for only 1 percent of all deaths, they produce 47 percent of all dis- ability in economically developed countries, such as the United States, and 28 percent of all disability worldwide. The combined index (mortality plus disability) reveals that, as a combined cat- egory, mental disorders are the second leading source of disease burden in developed countries (see Figure 1.2). Investigators in the WHO study predict that, relative to other types of health problems, the burden of mental disorders will increase by the year 2020. These surprising results strongly indicate that mental disor- ders are one of the world’s greatest health challenges.
Cross-Cultural Comparisons As the evidence regarding the global burden of disease clearly doc- uments, mental disorders affect people all over the world. That does not mean, however, that the symptoms of psychopathology and the expression of emotional distress take the same form in all cultures. Epidemiological studies comparing the frequency of
figure 1.2 Comparison of the Impact of Mental Disorders and other Medical Conditions on People’s Lives Disease burden in economically developed countries measured in disability-adjusted life years (DALYs). Source: Murray, CJLM, Lopez, AD, eds. 1996. The Burden of Global Disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Vol. 1. Cambridge, MA: Harvard University Press.
0 5 10 15 20
Self-in�icted injuries (suicide)
Posttraumatic stress disorder
Panic disorder
Obsessive-compulsive disorder
Bipolar disorder
Schizophrenia
Major depression
All drug use
All infectious and parasitic disease
All alcohol use
All respiratory conditions
All malignant disease (cancer)
All mental disorders, including suicide
All cardiovascular conditions
Listed by Illness Category
Listed by Speci�c Mental Disorder
Percent of Total Burden
14 CHAPTER 1 examples and definitions of abnormal behavior
mental disorders in different cultures suggest that some disorders, such as schizophrenia, show important consistencies in cross-cul- tural comparisons. They are found in virtually every culture that social scientists have studied.
Other disorders, such as bulimia, are more specifically as- sociated with cultural factors, as revealed by comparisons of prevalence in different parts of the world and changes in prev- alence over generations. Almost 90 percent of bulimic patients are women. Within the United States, the incidence of bulimia is much higher among university women than among working women, and it is more common among younger women than among older women. The prevalence of bulimia is much higher in Western nations than in other parts of the world. Furthermore, the number of cases increased dramatically during the latter part of the twentieth century (Keel & Klump, 2003). These patterns suggest that holding particular sets of values related to eating and to women’s appearance is an important ingredient in establishing risk for development of an eating disorder.
The strength and nature of the relationship between culture and psychopathology vary from one disorder to the next. Several general conclusions can be drawn from cross-cultural studies of psychopathology (Draguns & Tanaka-Matsumi, 2003), including the following points:
• All mental disorders are shaped, to some extent, by cultural factors.
• No mental disorders are entirely due to cultural or social factors.
• Psychotic disorders are less influenced by culture than are nonpsychotic disorders.
• The symptoms of certain disorders are more likely to vary across cultures than are the disorders themselves.
We will return to these points as we discuss specific disorders, such as depression, phobias, and alcoholism, throughout this book.
The Mental Health Professions People receive treatment for psychological problems in many different settings and from various kinds of service providers. Specialized mental health professionals, such as psychiatrists, psy- chologists, and social workers, treat fewer than half (40 percent) of those people who seek help for mental disorders (Kessler & Stafford, 2008). Roughly one-third (34 percent) are treated by primary care physicians, who are most likely to prescribe some form of medication. The remaining 26 percent of mental health services are delivered by social agencies and self-help groups, such as Alcoholics Anonymous.
Many forms of specialized training prepare people to provide professional assistance to those who suffer from mental disorders. Table 1.2 presents estimated numbers of different types of mental health professionals currently practicing in the United States. The overall number of professionals who provide mental health services expanded dramatically during the past two decades, with most
of this growth occurring among nonphysicians (Robiner, 2006). Most of these professions require extensive clinical experience in addition to formal academic instruction. In order to provide di- rect services to clients, psychiatrists, psychologists, social workers, counselors, nurses, and marriage and family therapists must be li- censed in their own specialties by state boards of examiners.
Psychiatry is the branch of medicine that is concerned with the study and treatment of mental disorders. Psychiatrists com- plete the normal sequence of coursework and internship training in a medical school (usually four years) before going on to receive specialized residency training (another four years) that is focused on abnormal behavior. By virtue of their medical training, psy- chiatrists are licensed to practice medicine and therefore are able to prescribe medication. Most psychiatrists are also trained in the use of psychosocial intervention.
Clinical psychology is concerned with the application of psychological science to the assessment and treatment of mental disorders. A clinical psychologist typically completes five years of graduate study in a department of psychology, as well as a one-year internship, before receiving a doctoral degree. Clinical psycholo- gists are trained in the use of psychological assessment procedures and in the use of psychotherapy. Within clinical psychology, there are two primary types of clinical training programs. One course of study, which leads to the Ph.D. (doctor of philosophy) degree, involves a traditional sequence of graduate training with major emphasis on research methods. The other approach, which culmi- nates in a Psy.D. (doctor of psychology) degree, places greater em- phasis on practical skills of assessment and treatment and does not require an independent research project for the dissertation. One can also obtain a Ph.D. degree in counseling psychology, a more applied field that focuses on training, assessment, and therapy.
Social work is a third profession that is concerned with help- ing people to achieve an effective level of psychosocial function- ing. Most practicing social workers have a master’s degree in social work. In contrast to psychology and psychiatry, social work is based
table 1.2 Estimated Number of Clinically Trained Professionals Providing Mental Health Services in the United States Profession number
Psychiatrists 30,000
Clinical Psychologists 93,000
Mental Health and Substance Abuse Social Workers 115,000
MH Counselors and Marriage and Family Therapists 156,000
Psychiatric Nurses 18,000
Psychosocial Rehabilitation Providers 100,000
Sources: United States Department of Labor; Bureau of Labor Statistics.
examples and definitions of abnormal behavior CHAPTER 1 15
less on a body of scientific knowledge than on a commitment to action. Social work is practiced in a wide range of settings, from courts and prisons to schools and hospitals, as well as other social service agencies. The emphasis tends to be on social and cultural factors, such as the effects of poverty on the availability of educa- tional and health services, rather than on individual differences in personality or psychopathology. Psychiatric social workers receive specialized training in the treatment of mental health problems.
Like social workers, professional counselors work in many dif- ferent settings, ranging from schools and government agencies to mental health centers and private practice. Most are trained at the master’s degree level, and the emphasis of their activity is also on providing direct service. Marriage and family therapy (MFT) is a multidisciplinary field in which professionals are trained to provide psychotherapy. Most MFTs are trained at the master’s level, and many hold a degree in social work, counseling, or psychology as well. Although the theoretical orientation is focused on couples and family issues, approximately half of the people treated by MFTs are seen in individual psychotherapy. Psychiatric nursing is a rapidly growing field. Training for this profession typically involves a bachelor’s degree in nursing plus graduate level training (at least a master’s degree) in the treatment of mental health problems.
Another approach to mental health services that is expanding rapidly in size and influence is psychosocial rehabilitation (PSR). Professionals in this area work in crisis, residential, and case man- agement programs for people with severe forms of disorder, such as schizophrenia. PSR workers teach people practical, day-to-day skills that are necessary for living in the community, thereby reducing the need for long-term hospitalization and minimizing the level of dis- ability experienced by their clients. Graduate training is not required for most PSR positions; three out of four people providing PSR ser- vices have either a high school education or a bachelor’s degree.
It is difficult to say with certainty what the mental health professions will be like in the future. Boundaries between pro- fessions change as a function of progress in the development of therapeutic procedures, economic pressures, legislative action, and courtroom decisions. This has been particularly true in the field of mental health, where enormous changes have taken place over the past few decades. Reform is currently being driven by the pervasive influence of managed care, which refers to the way that services are financed. For example, health insurance compa- nies typically place restrictions on the types of services that will be reimbursed, as well as the specific professionals who can pro- vide them. Managed care places a high priority on cost contain- ment and the evaluation of treatment effectiveness. Legislative issues that determine the scope of clinical practice are also very important. Many psychologists are pursuing the right to prescribe medication (Fox et al., 2009). Decisions regarding this issue will also have a dramatic impact on the boundaries that separate the mental health professions. Ongoing conflicts over the increasing price of health care, priorities for treatment, and access to services suggest that debates over the rights and privileges of patients and their therapists will intensify in coming years.
One thing is certain about the future of the mental health professions: There will always be a demand for people who are trained to help those suffering from abnormal behavior. Many people experience mental disorders. Unfortunately, most of those who are in need of professional treatment do not get it (Kessler et al., 2005; Ormel et al., 2008). Several explanations have been proposed. Some people who qualify for a diagnosis may not be so impaired as to seek treatment; others, as we shall see, may not rec- ognize their disorder. In some cases, treatment may not be avail- able, the person may not have the time or resources to obtain treatment, or the person may have tried treatments in the past that failed (see Getting Help at the end of this chapter.)
Psychopathology in Historical Context Throughout history, many other societies have held very different views of the problems that we consider to be mental disorders. Before leaving this introductory chapter, we must begin to place contempo- rary approaches to psychopathology in historical perspective.
The search for explanations of the causes of abnormal behav- ior dates to ancient times, as do conflicting opinions about the etiology of emotional disorders. References to abnormal behavior have been found in ancient accounts from Chinese, Hebrew, and Egyptian societies. Many of these records explain abnormal be- havior as resulting from the disfavor of the gods or the mischief of demons. In fact, abnormal behavior continues to be attributed to demons in some preliterate societies today.
the Greek tradition in Medicine More earthly and less supernatural accounts of the etiology of psy- chopathology can be traced to the Greek physician Hippocrates (460–377 b.c.e.), who ridiculed demonological accounts of illness and insanity. Instead, Hippocrates hypothesized that abnormal behavior, like other forms of disease, had natural causes. Health depended on maintaining a natural balance within the body, spe- cifically a balance of four body fluids (which were also known as the four humors): blood, phlegm, black bile, and yellow bile. Hippocrates argued that various types of disorders, including psy- chopathology, resulted from either an excess or a deficiency of one of these four fluids. The specifics of Hippocrates’ theories obviously have little value today, but his systematic attempt to uncover nat- ural, biological explanations for all types of illness represented an enormously important departure from previous ways of thinking.
The Hippocratic perspective dominated medical thought in Western countries until the middle of the nineteenth cen- tury (Golub, 1994). People trained in the Hippocratic tradition viewed “disease” as a unitary concept. In other words, physicians (and others who were given responsibility for healing people who were disturbed or suffering) did not distinguish between mental disorders and other types of illness. All problems were considered to be the result of an imbalance of body fluids, and treatment
16 CHAPTER 1 examples and definitions of abnormal behavior
procedures were designed in an attempt to restore the ideal bal- ance. These were often called “heroic” treatments because they were drastic (and frequently painful) attempts to quickly reverse the course of an illness. They involved bloodletting (intentionally cutting the person to reduce the amount of blood in the body) and purging (the induction of vomiting), as well as the use of heat and cold. These practices need to be part of standard medi- cal treatments well into the nineteenth century (Starr, 1982).
the Creation of the Asylum In Europe during the Middle Ages, “lunatics” and “idiots,” as the mentally ill and intellectually disabled were commonly called, aroused little interest and were given marginal care. Most people lived in rural settings and made their living through agricultural ac- tivities. Disturbed behavior was considered to be the responsibility of the family rather than the community or the state. Many people were kept at home by their families, and others roamed freely as beggars. Mentally disturbed people who were violent or appeared dangerous were often imprisoned with criminals. Those who could not subsist on their own were placed in almshouses for the poor.
In the 1600s and 1700s, “insane asylums” were established to house the mentally disturbed. Several factors changed the way that society viewed people with mental disorders and reinforced the relatively new belief that the community as a whole should be responsible for their care (Grob, 2011). Perhaps most impor- tant was a change in economic, demographic, and social condi- tions. Consider, for example, the situation in the United States at the beginning of the nineteenth century. The period between 1790 and 1850 saw rapid population growth and the rise of large cities. The increased urbanization of the American population was accompanied by a shift from an agricultural to an industrial economy. Lunatic asylums—the original mental hospitals—were created to serve heavily populated cities and to assume responsi- bilities that had previously been performed by individual families.
Early asylums were little more than human warehouses, but as the nineteenth century began, the moral treatment movement led to improved conditions in at least some mental hospitals. Founded on a basic respect for human dignity and the belief that humanistic care would help to relieve mental illness, moral treat- ment reform efforts were instituted by leading mental health pro- fessionals of the day, such as Benjamin Rush in the United States, Philippe Pinel in France, and William Tuke in England. Rather than simply confining mental patients, moral treatment offered support, care, and a degree of freedom. Belief in the importance of reason and the potential benefits of science played an impor- tant role in the moral treatment movement. In contrast to the fatalistic, supernatural explanations that had prevailed during the Middle Ages, these reformers touted an optimistic view, arguing that mental disorders could be treated successfully.
Many of the large mental institutions in the United States were built in the nineteenth century as a result of the philosophy of moral treatment. In the middle of the 1800s, the mental health
advocate Dorothea Dix was a leader in this movement. Dix argued that treating the mentally ill in hospitals was both more humane and more economical than caring for them haphazardly in their communities, and she urged that special facilities be built to house mental patients. Dix and like-minded reformers were successful in their efforts. In 1830, there were only four public mental hospitals in the United States that housed a combined total of fewer than 200 patients. By 1880, there were 75 public mental hospitals, with a total population of more than 35,000 residents (Torrey, 1988).
The creation of large institutions for the treatment of mental patients led to the development of a new profession—psychiatry. By the middle of the 1800s, superintendents of asylums for the insane were almost always physicians who had experience in the care of people with severe mental disorders. The Association of Medical Superintendents of American Institutions for the Insane (AMSAII), which later became the American Psychiatric Associa- tion (APA), was founded in 1844. The large patient populations within these institutions provided an opportunity for these men to observe various types of psychopathology over an extended pe- riod of time. They soon began to publish their ideas regarding the causes of these conditions, and they also experimented with new treatment methods (Grob, 2011).
Worcester Lunatic Hospital: A Model Institution In 1833, the state of Massachusetts opened a publicly supported asylum for lunatics, a term used at the time to describe people with mental disorders, in Worcester. Samuel Woodward, the asy- lum’s first superintendent, also became the first president of the AMSAII. Woodward became very well known throughout the United States and Europe because of his claims that mental dis- orders could be cured just like other types of diseases. We will
This 16th century illustration shows sick people going to the doctor who attempts to cure their problems by extracting blood from them using a leech. The rationale for such treatment procedures was to restore the proper balance of bodily fluids.
examples and definitions of abnormal behavior CHAPTER 1 17
describe this institution and its superintendent briefly because, in many ways, it became a model for psychiatric care on which other nineteenth-century hospitals were built.
Woodward’s ideas about the causes of disorders represented a combination of physical and moral considerations. Moral factors focused on the person’s lifestyle. Violations of “natural” or conven- tional behavior could presumably cause mental disorders. Judgments regarding the nature of these violations were based on the prevailing middle class, Protestant standards that were held by Woodward and his peers, who were almost invariably well-educated, white males. After treating several hundred patients during his first 10 years at the Worcester asylum, Woodward argued that at least half of the cases could be traced to immoral behavior, improper living condi- tions, and exposure to unnatural stresses. Specific examples included intemperance (heavy drinking), masturbation, overwork, domestic difficulties, excessive ambition, faulty education, personal disap- pointment, marital problems, excessive religious enthusiasm, jeal- ousy, and pride (Grob, 2011). The remaining cases were attributed to physical causes, such as poor health or a blow to the head.
Treatment at the Worcester Lunatic Hospital included a blend of physical and moral procedures. If mental disorders were often caused by improper behavior and difficult life circum- stances, presumably they could be cured by moving the person to a more appropriate and therapeutic environment, the asylum. Moral treatment focused on efforts to reeducate the patient, fostering the development of self-control that would allow the person to return to a “healthy” lifestyle. Procedures included oc- cupational therapy, religious exercises, and recreation. Mechanical restraints were employed only when considered necessary.
Moral treatments were combined with a mixture of physi- cal procedures. These included standard heroic interventions, such as bleeding and purging, which the asylum superintendents had learned as part of their medical training. For example, some symptoms were thought to be produced by inflammation of the brain, and it was believed that bleeding would restore the natu- ral balance of fluids. Woodward and his colleagues also employed various kinds of drugs. Patients who were excited, agitated, or violent were often treated with opium or morphine. Depressed patients were given laxatives.
Woodward claimed that “no disease, of equal severity, can be treated with greater success than insanity, if the remedies are applied sufficiently early.” He reported that the recovery rates at the Worcester hospital varied from 82 percent to 91 percent be- tween 1833 and 1845. His reports were embraced and endorsed by other members of the young psychiatric profession. They fu- eled enthusiasm for establishing more large public hospitals, thus aiding the efforts of Dorothea Dix and other advocates for public support of mental health treatment.
Lessons from the History of Psychopathology The invention and expansion of public mental hospitals set in motion a process of systematic observation and scientific inquiry that led directly to our current system of mental health care. The
creation of psychiatry as a professional group, committed to treat- ing and understanding psychopathology, laid the foundation for expanded public concern and financial resources for solving the problems of mental disorders.
There are, of course, many aspects of nineteenth-century psy- chiatry that, in retrospect, seem to have been naive or misguided. To take only one example, it seems silly to have thought that mas- turbation would cause mental disorders. In fact, masturbation is now taught and encouraged as part of treatment for certain types of sexual dysfunction (see Chapter 12). The obvious cultural bi- ases that influenced the etiological hypotheses of Woodward and his colleagues seem quite unreasonable today. But, of course, our own values and beliefs influence the ways in which we define, think about, and treat mental disorders. Mental disorders cannot be defined in a cultural vacuum or in a completely objective fash- ion. The best we can do is to be aware of the problem of bias and include a variety of cultural and social perspectives in thinking about and defining the issues (Mezzich et al., 2008).
The other lesson that we can learn from history involves the importance of scientific research. Viewed from the perspective of contemporary care, we can easily be skeptical of Samuel Wood- ward’s claims regarding the phenomenal success of treatment at the Worcester asylum. No one today believes that 90 percent of seriously disturbed, psychotic patients can be cured by currently available forms of treatment. Therefore, it is preposterous to as- sume that such astounding success might have been achieved at the Worcester Lunatic Hospital. During the nineteenth century, physicians were not trained in scientific research methods. Their optimistic statements about treatment outcome were accepted, in large part, on the basis of their professional authority. Clearly, Woodward’s enthusiastic assertions should have been evaluated with more stringent, scientific methods.
Unfortunately, the type of naive acceptance that met Wood- ward’s idealistic claims has become a regrettable tradition. For the past 150 years, mental health professionals and the public alike have repeatedly embraced new treatment procedures that have
An engraving of the Massachusetts Lunatic Asylum as it appeared in 1835.
18 CHAPTER 1 examples and definitions of abnormal behavior
been hailed as cures for mental disorders. Perhaps most notorious was a group of somatic (bodily) treatment procedures that was introduced during the 1920s and 1930s (Valenstein, 1986). They included inducing fever, insulin comas, and lobotomy, a crude form of brain surgery (see Table 1.3). These dramatic procedures, which have subsequently proved to be ineffective, were accepted with the same enthusiasm that greeted the invention of large public institutions in nineteenth-century America. Thousands of patients were subjected to these procedures, which remained widespread until the early 1950s, when more effective pharma- cological treatments were discovered. The history of psycho- pathology teaches us that people who claim that a new form of treatment is effective should be expected to prove it scientifically (see Research Methods on page 19).
Methods for the Scientific Study of Mental Disorders This book will provide you with an introduction to the scientific study of psychopathology. The application of science to questions regarding abnormal behavior carries with it the implicit assump- tion that these problems can be studied systematically and objec- tively. Such a systematic and objective study is the basis for finding order in the frequently chaotic and puzzling world of mental dis- orders. This order will eventually allow us to understand the pro- cesses by which abnormal behaviors are created and maintained.
Clinical scientists adopt an attitude of open-minded skepti- cism, tempered by an appreciation for the research methods that are used to collect empirical data. They formulate specific hypoth- eses, test them, and then refine them based on the results of these tests. For example, suppose you formulated the hypothesis that people who are depressed will improve if they eat more than a cer- tain amount of chocolate every day. This hypothesis could be tested in a number of ways, using the methods discussed throughout this book. In order to get the most from this book, you may have to set aside—at least temporarily—personal beliefs that you have already
acquired about mental disorders. Try to adopt an objective, skepti- cal attitude. We hope to pique your curiosity and share with you the satisfaction, as well as perhaps some of the frustration, of searching for answers to questions about complex behavior problems.
The Uses and Limitations of Case Studies We have already presented one source of information regarding mental disorders: the case study, an in-depth look at the symp- toms and circumstances surrounding one person’s mental distur- bance. For many people, our initial ideas about the nature and potential causes of abnormal behavior are shaped by personal ex- perience with a close friend or family member who has struggled with a psychological disorder. We use a number of case studies in this book to illustrate the symptoms of psychopathology and to raise questions about their development. Therefore, we should consider the ways in which case studies can be helpful in the study of psychopathology, as well as some of their limitations.
A case study presents a description of the problems experi- enced by one particular person. Detailed case studies can provide an exhaustive catalog of the symptoms that the person displayed, the manner in which these symptoms emerged, the developmen- tal and family history that preceded the onset of the disorder, and whatever response the person may have shown to treatment ef- forts. This material often forms the basis for hypotheses about the causes of a person’s problems. For example, based on Mary’s case, one might speculate that depression plays a role in eating disorders. Case studies are especially important sources of information about conditions that have not received much attention in the literature and for problems that are relatively unusual. Dissociative iden- tity disorder and gender dysphoria are examples of disorders that are so infrequent that it is difficult to find groups of patients for the purpose of research studies. Much of what we know about these conditions is based on descriptions of individual patients.
Case studies also have several drawbacks. The most obvious limitation of case studies is that they can be viewed from many different perspectives. Any case can be interpreted in several
table 1.3 Somatic Treatments Introduced and Widely Employed in the 1920s and 1930s Name Procedure Original Rationale
Fever therapy Blood from people with malaria was injected into psychiatric patients so that they would develop a fever.
Observation that symptoms sometimes disappeared in patients who became ill with typhoid fever
Insulin coma therapy
Insulin was injected into psychiatric patients to lower the sugar content of the blood and induce a hypoglycemic state and deep coma.
Observed mental changes among some diabetic drug addicts who were treated with insulin
Lobotomy A sharp knife was inserted through a hole that was bored in the patient’s skull, severing nerve fibers connecting the frontal lobes to the rest of the brain.
Observation that the same surgical procedure with chimpanzees led to a reduction in the display of negative emotion during stress
Note: Lack of critical evaluation of these procedures is belied by the unusual honors bestowed upon their inventors. Julius Wagner-Jauregg, an Austrian psychiatrist, was awarded the Nobel Prize in 1927 for his work in developing fever therapy. Egaz Moniz, a Portuguese psychiatrist, was awarded the Nobel Prize in 1946 for introduction of the lobotomy.
examples and definitions of abnormal behavior CHAPTER 1 19
ways, and competing explanations may be equally plausible. Consider, for example, Abraham Lincoln, who suffered through periods of profound depression throughout his adult life. Some historians have argued that Lincoln’s mood disorder can be traced to the sudden death of his mother when he was 9 years old ( Burlingame, 1994). The impact of this tragic experience was later intensified by several other losses, including the deaths of two of his four sons. Heredity may also have played a role in the
origins of Lincoln’s depression. Some of Lincoln’s cousins were apparently also depressed, and neighbors recalled that Lincoln’s father “often got the blues.” Speculation of this sort is intriguing, particularly in the case of a man who played such an important role in the history of the United States. But we must remember that case studies are not conclusive. Lincoln’s experience does not indicate conclusively whether the loss of a parent can increase a person’s vulnerability to depression, and it does not prove that
RESEARCH methods
Who Must Provide Scientific Evidence?
Scientists have established a basic and extremely important rule for making and testing any new hypothesis: The scien-tist who makes a new prediction must prove it to be true. Scientists are not obligated to disprove other researchers’ asser- tions. Until a hypothesis is supported by empirical evidence, the community of scientists assumes that the new prediction is false.
The concepts of the experimental hypothesis and the null hy- pothesis are central to understanding this essential rule of science. A hypothesis is any new prediction, such as the idea that eating chocolate can alleviate depression, made by an in- vestigator. Researchers must adopt and state their experimental hypothesis in both correlational studies and experiments (dis- cussed in Research Methods in Chapters 2 and 3). In all scientific research, the null hypothesis is the alternative to the experi- mental hypothesis. The null hypothesis always predicts that the experimental hypothesis is not true, for example, that eating chocolate does not make depressed people feel better. The rules of science dictate that scientists must assume that the null hypothesis holds until research contradicts it. That is, the burden of proof falls on the scientist who makes a new prediction, and offers an experimental hypothesis.
These rules of science are analogous to rules about the burden of proof that have been adopted in trial courts. In U.S. courtrooms, the law assumes that a defendant is innocent until proven guilty. Defendants do not need to prove their innocence; rather, prose- cutors need to prove the defendant’s guilt. Thus, the null hypoth- esis is analogous to the assumption of innocence, and the burden of proof in science falls on any scientist who challenges the null hypothesis, just as it falls on the prosecutor in a court trial.
These rules in science and in law serve important purposes. Both are conservative principles designed to protect the field from false assertions. Our legal philosophy is, “It is better to let 10 guilty people go free than to punish one innocent person.” Scien- tists adopt a similar philosophy—that false “scientific evidence” is more dangerous than undetected knowledge. Because of these safeguards, we can be reasonably confident when an experimen- tal hypothesis is supported or when a defendant is found guilty.
We can easily apply these concepts and rules to claims that were made for the effectiveness of treatment methods such as lobotomy. In this example, the experimental hypothesis is that severing the nerve fibers that connect the frontal lobes to other areas of the brain will result in a significant decrease in psychotic symptoms. The null hypothesis is that this treatment is no more effective than having no treatment at all. According to the rules of science, a clinician who claims to have discovered a new treat- ment must prove that it is true. Scientists are not obligated to prove that the assertion is false, because the null hypothesis holds until it is rejected.
The value of this conservative approach is obvious when we con- sider the needless suffering and permanent neurological dys- function that was ultimately inflicted upon thousands of patients who were given lobotomies or subjected to fevers and comas during the 1940s (Valenstein, 1986). Had surgeons assumed that lobotomies did not work, many patients’ brains would have been left intact. Similar conclusions can be drawn about less in- vasive procedures, such as institutionalization, medication, and psychotherapy. These treatments are also associated with costs, which range from financial considerations—certainly important in today’s health care environment—to the disappointment brought about by false hopes. In all these cases, clinicians who provide mental health services should be required to demon- strate scientifically that their treatment procedures are both effective and harmless (Chambless et al., 2006; Dimidjian & Hollon, 2010).
There is one more similarity between the rules of science and the rules of the courtroom. Courtroom verdicts do not lead to a judgment that the defendant is “innocent,” but only to a decision that she or he is “not guilty.” In theory, the possibility remains that a defendant who is found “not guilty” did indeed commit a crime. Similarly, scientific research does not lead to the conclusion that the null hypothesis is true. Scientists never prove the null hypothesis; they only fail to reject it. The reason for this position is that the philosophy of knowledge, epistemology, tells us that it is impossible ever to prove that an experimental hy- pothesis is false in every circumstance.
20 CHAPTER 1 examples and definitions of abnormal behavior
genetic factors are involved in the transmission of this disorder. These questions must be resolved through scientific investigation.
The other main limitation of case studies is that it is risky to draw general conclusions about a disorder from a single example. How can we know that this individual is representative of the disorder as a whole? Are his or her experiences typical for people with this disorder? Again, hypotheses generated on the basis of the single case must be tested in research with larger, more repre- sentative samples of patients.
Clinical research Methods The importance of the search for new information about men- tal disorders has inspired us to build another special feature into this textbook. Each chapter includes a Research Methods feature that explains one particular research issue in some detail. The Re- search Methods feature in this chapter, for example, is concerned with the null hypothesis, the need to consider not only that your hypothesis may be true, but also that it may be false. A list of the issues addressed in Research Methods throughout this textbook appears in Table 1.4. They are arranged to progress from some of the more basic research methods and issues, such as correlational and experimental designs, toward more complex issues, such as gene identification and heritability.
We decided to discuss methodological issues in small sec- tions throughout the book, for two primary reasons. First, the problems raised by research methods are often complex and chal- lenging. Some students find it difficult to digest and comprehend
Many people lead successful lives and make important contributions to society in spite of their struggles with mental disorder. For example, Abraham Lincoln suffered episodes of severe depression.
table 1.4 List of Research Methods Featured in This Book Chapter topic
1 Who Must Provide Scientific Evidence?
2 Correlations: Does a Psychology Major Make You Smarter?
3 The Experimental Method: Does Therapy Cause Improvement?
4 Reliability: Agreement Regarding Diagnostic Decisions
5 Analogue Studies: Do Rats Get Depressed, and Why?
6 Statistical Significance: When Differences Matter
7 Retrospective Reports: Remembering the Past
8 Longitudinal Studies: Lives over Time
9 Cross-Cultural Comparisons: The Importance of Context
10 Psychotherapy Placebos: Controlling for Expectations
11 Studies of People at Risk for Disorders
12 Hypothetical Constructs: What Is Sexual Arousal?
13 Comparison Groups: What Is Normal?
14 Finding Genes That Cause Behavioral Problems
15 Central Tendency and Variability: What Do IQ Scores Mean?
16 Samples: How to Select the People We Study
17 Heritability: Genes and the Environment
18 Base Rates and Prediction: Justice Blackmun’s Error
an entire chapter on research methods in one chunk, especially at the beginning of a book. Thus, we have broken it down into more manageable bites. Second, and perhaps more important, the methods we discuss generally make more sense and are easier to understand when they are presented in the context of a clinical question that they can help answer. Our discussions of research methods are, therefore, introduced while we are explaining con- temporary views of particular clinical problems.
Research findings are not the end of the road, either. The fact that someone has managed to collect and present data on a particular topic does not mean that the data are useful. We want you to learn about the problems of designing and interpreting re- search studies so that you will become a more critical consumer of scientific evidence. If you do not have a background in research design or quantitative methods, the Research Methods features will familiarize you with the procedures that psychologists use to test their hypotheses. If you have already had an introductory course in methodology, they will show you how these problems are handled in research on abnormal behavior.
examples and definitions of abnormal behavior CHAPTER 1 21
getting HELp
Many students take an abnormal psychology class, in part, to understand more about their own problems or the problems of friends or family members. If you are considering whether you want to get help for yourself or for someone you know, these Getting Help sections should give you a head start in finding good therapists and effective treatments.
Of course, psychology is not just about problems. If you are won- dering if you need help, if you are just curious about the problems people can have, or even if you are skeptical or disinterested, you will definitely learn more about yourself and others from this course and by studying psychology in general. That is what makes the subject so fascinating! But when the topic is abnormal psy- chology, you should be warned in advance about two risks.
The first is the “medical student’s syndrome.” As medical stu- dents learn about new illnesses, they often “develop” the symp- toms of each successive disease they study. The same thing can happen when studying abnormal psychology. In fact, because many symptoms of emotional disorders share much in common with everyday experiences, students of abnormal psychology are even more likely to “discover” symptoms in themselves or oth- ers. (“Gee, I think maybe I have an anxiety disorder.” “He is so self-absorbed; he has a personality disorder.”) We all are fright- ened about experiencing illness and abnormality, and this fear can make us suggestible. So try to prepare yourself for bouts of the medical student’s syndrome. And remember that it is normal to experience mild versions of many of the symptoms you will read about in this text.
Our second warning is much more serious. If you are genu- inely concerned about your own problems or those of a loved one, you probably have or will consult various “self-help”
resources—books, Web sites, or perhaps groups online or of- fline. Do not accept uncritically the treatment programs they may suggest. You probably know that not everything you hear or read is true, and psychological advice is no exception.
Misleading, inaccurate, or simply wrong information is a particu- lar problem in abnormal psychology for three reasons. First, to be honest, as you will learn throughout this course, psychologi- cal scientists simply do not know the causes of or absolutely effective treatments for many emotional problems. Second, people who have emotional problems, and those who have loved ones who have emotional problems, often are desperate to find a cure. Third, some well-meaning—and some unscrupu- lous—people will provide authoritative-sounding “answers” that really are theories, speculations, or distortions.
How can you know what information is accurate and what infor- mation is inaccurate? We have worked hard to bring you the most recent scientific information in this text. In addition to the detailed information we present in each chapter, we give you practical tips including recommended self-help books and Web sites in these Getting Help sections in each chapter. Two general resources you might want to explore now are Martin Seligman’s book, What You Can Change and What You Can’t (2007), and the homepage of the National Institute of Mental Health: www.nimh.nih.gov. But we don’t want you to rely only on this book or other authorities. We want you to rely on your own critical thinking skills, especially when it comes to getting help for yourself or someone you care about. Remember this: There is an army of scientists out there trying to solve the problems of emotional disorders, because, like us, they want to help. Breakthrough treatments that really are breakthrough treatments will not be kept secret. They will be an- nounced on the front page of newspapers, not in obscure books or remote Web sites.
Mental disorders are quite common. At least 50 percent of all men and women will experience a serious form of abnormal behavior, such as depression, alcoholism, or schizophrenia, at some point during their lives.
Mental disorders are defined in terms of typical signs and symptoms rather than identifiable causal factors. A group of symptoms that appear together and are assumed to represent a specific type of disorder is called a syndrome. There are no definitive psychological or biological tests that can be used to confirm the presence of psychopathology. At present, the diagnosis of mental disorders depends on observations of the person’s behavior and descriptions of personal experience.
No one has been able to provide a universally accepted defini- tion of abnormal behavior. One useful approach defines mental disorders in terms of harmful dysfunction. The official classifi- cation system, DSM-5, defines mental disorders as a group of
Summary1
22 CHAPTER 1 examples and definitions of abnormal behavior
1.1 What is the difference between normal and abnormal behavior? While the line between normal and abnormal is not always obvious, several important considerations help to clarify the distinction . . . (see pages 5–6).
1.2 How does culture influence the definition of mental disorders? Social and political forces influence the extent to which certain kinds of experience are considered to be pathological . . . (see pages 7–8).
1.3 How does the impact of mental disorders compare to that of other health problems? Mental disorders are responsible for almost half of all disability in economically developed countries, ranking second in total disease burden behind cardiovascular disease . . . (see page 13).
1.4 Who provides help for people with mental disorders? Many different forms of training can prepare people for professional careers in the delivery of mental health services . . . (see page 14).
1.5 Why do scientific methods play such an important role in psychology’s approach to the study of mental disorders? The hallmark of psychology as an academic discipline is the use of rigorous scientific methods to test the validity of alternative hypotheses regarding issues such as the causes and treatment of men- tal disorders . . . (see page 18).
critical thinking review
The big picture
persistent maladaptive behaviors that result in personal distress or impaired functioning.
Various forms of voluntary social deviance and efforts to express individuality are excluded from the definition of mental disor- ders. Political and religious actions, and the beliefs on which they are based, are not considered to be forms of abnormal behavior, even when they seem unusual to many other people. Nevertheless, culture has an important influence on the process of defining psychopathology.
The scientific study of the frequency and distribution of disor- ders within a population is known as epidemiology. The global burden of mental disorders is substantial. Some severe forms of abnormal behavior, such as schizophrenia, have been observed in virtually every society that has been studied by social scien- tists. There are also forms of psychopathology—including eating disorders—for which substantial cross-cultural differences have been found.
Many forms of specialized training prepare people to provide professional help to those who suffer from mental disorders. A psychiatrist is licensed to practice medicine and is there- fore able to prescribe medication. A clinical psychologist has received graduate training in the use of assessment pro- cedures and psychotherapy. Most psychologists also have
extensive knowledge regarding research methods, and their training prepares them for the integration of science and practice.
Throughout history, many societies have held different ideas about the problems that we consider to be mental disorders. Although the earliest asylums were little more than human ware- houses, the moral treatment movement introduced improved conditions in some mental hospitals. The creation of large insti- tutions for mental patients led to the development of psychiatry as a profession. These physicians, who served as the superinten- dents of asylums, developed systems for describing, classifying, and treating people with various types of mental disorders. Their efforts led to the use of scientific methods to test these new ideas.
A person who proposes a new theory about the causes of a form of psychopathology, or someone who advocates a new form of treatment, should be expected to prove these claims with scientific evidence. The burden of proof falls on the clinical scientist who offers a new prediction. In other words, the null hypothesis (the alternative to the experimental hypothesis) is assumed to be true until it is contradicted by systematic data. Individual case studies do not provide con- clusive evidence about the causes of, or treatments for, mental disorders.
examples and definitions of abnormal behavior CHAPTER 1 23
key terms abnormal psychology 2 case study 18 clinical psychology 14 comorbidity 13
culture 7 epidemiology 11 hypothesis 19 harmful dysfunction 6
incidence 11 null hypothesis 19 prevalence 11 psychiatry 14
psychopathology 2 psychosis 4 social work 14 syndrome 4
2
causes of abnormal behavior
causes of abnormal behavior CHAPTER 2 25
2 The Big Picture learning objectives
2.1 What is the biopsychosocial model and why do we need it?
2.2 What does “correlation does not mean causation” mean?
2.3 How is “mental illness caused by a chemical imbalance
in the brain” an example of reductionism?
2.4 Are scientists likely to discover a gene
that causes mental disorders?
2.5 How do social and psychological factors
contribute to emotional problems?
2.6 Is abnormal behavior really all about
labeling and role playing?
What causes abnormal behavior? We all want an answer to this ques- tion. People suffering from emotional problems, and their loved ones, may be desperate for one. Some “experts” will offer a ready re- sponse, pointing to the trauma of abuse, poor parenting, a “broken brain,” or other handy explanations. Unfortunately, such simple ac- counts are almost certainly wrong. Trauma, upbringing, and biology all may contribute to different mental disorders, but most emotional problems appear to result from a combination of various biological, psychological, and social influences. And the truth is that we do not know the specific cause of most emotional disorders. What we have is an unsolved mystery, and psychological scientists have much detec- tive work to do. In this chapter, we introduce you to psychology’s hard evidence, working theories, and hot leads in pursuit of answers to this compelling mystery.
Overview You may be distressed to learn that the cause, or etiology, of most abnormal behavior is unknown. In fact, you may have read or heard popular accounts with headlines like, “Depression Found in the Brain!” Our reaction to such breathless stories is: We know depression is in the brain. Of course, it is exciting that
neuroscientists are identifying specific brain regions and chemi- cals involved in mental illnesses. But scientists often cannot answer basic “chicken or egg” questions like: Do chemical im- balances in the brain cause depression? Or do trying experiences cause depression—and changes in brain chemistry that reflect de- pression? Media accounts about what causes abnormal behavior typically are oversimplified—and often misleading. They “solve” the mystery in today’s headline, but retract it on the back page the next day.
Some scientists also claim to have solved the mystery. Throughout much of the twentieth century, many psychologists vowed allegiance to one of the four broad theories of abnormal behavior—the biological, psychodynamic, cognitive-behavioral, and humanistic paradigms. A paradigm is a set of shared as- sumptions that includes both the substance of a theory and be- liefs about how scientists should collect data and test hypotheses. Thus, the four paradigms disagreed not only about what causes abnormal behavior, but also about how to prove each theory.
Most psychological scientists today suspect that abnormal behavior is caused by a combination of biological, psychological, and social factors (Kendler & Prescott, 2006). Biological contri- butions range from brain chemistry to genetic predispositions. Psychological contributions range from troubled emotions to distorted thinking. Social and cultural contributions range from conflict in family relationships to sexual and racial bias. In short, contemporary research is guided by the biopsychosocial model, an effort to integrate evidence on these broad contributions to mental disorders.
In this chapter, we briefly review the four traditional para- digms and explain how integrated approaches have emerged to replace them. We also introduce a number of biological, psycho- logical, and social processes that appear to contribute to emo- tional problems. In later chapters, we return to these concepts when discussing specific psychological disorders. As we do in ev- ery chapter, we begin our investigation with a case study. Most cases, including the following one, come from our own therapy files.
Meghan’s Many Hardships At the age of 14, Meghan B. attempted to end her life by taking approximately 20 Tylenol® capsules. Meghan took the pills after an explosive fight with her mother over Meghan’s grades and a boy she was dating. Meghan was in her room when she impul- sively took the pills, but shortly afterward she told her mother what she had done. Her parents rushed Meghan to the emer- gency room, where her vital signs were closely monitored. As the crisis was coming to an end, Meghan’s parents agreed that she should be hospitalized to make sure that she was safe and to be- gin to treat her problems.
Meghan talked freely during the 30 days she spent on the adolescent unit of a private psychiatric hospital. Most of her com- plaints focused on her mother. Meghan insisted that her mother was always “in her face,” telling her what to do and when and
26 CHAPTER 2 causes of abnormal behavior
how to do it. Her father was “great,” but he was too busy with his job as a chemical engineer to spend much time with her.
Meghan also had long-standing problems in school. She barely maintained a C average despite considerable efforts to do better. Meghan said she didn’t care about school, and her mother’s insistence that she could do much better was a major source of conflict between them. Meghan also complained that she had few friends, either in or outside of school. She described her classmates as “straight” and said she had no interest in them. Meghan was obviously angry as she described her family, school, and friends, but she also seemed sad. She often denounced her- self as “stupid,” and she cried about being a “reject” when dis- cussing why no friends, including her boyfriend, came to see her at the hospital.
Mrs. B. provided details on the history of Meghan’s prob- lems. Mr. and Mrs. B. could not have children of their own, and they adopted Meghan when she was 2 years old. According to the adoption agency, Meghan’s birth mother was 16 years old when she had the baby. Meghan’s biological mother was a drug user, and she haphazardly left the baby in the care of friends and relatives for weeks at a time. Little was known about Meghan’s biological father except that he had had some trouble with the law. Meghan’s mother had known him only briefly.
After a six-month legal investigation, Meghan’s mother agreed to give her up for adoption. Meghan came to live with Mr. and Mrs. B. shortly thereafter.
Mrs. B. happily doted on her daughter. She said that Mr. B. was a loving father, but agreed with Meghan that he was rarely at home. Meghan seemed fine until first grade, when teachers began to complain about her. She disrupted the classroom with her restlessness, and she did not complete her schoolwork. In second grade, a school psychologist suggested that Meghan was a “hyperactive” child who also had a learning disability. Her pediatrician recommended medication. Mrs. B. was horrified by the thought of medication or of sending Meghan to a “resource room” for part of the school day. Instead, she redoubled her ef- forts at parenting.
Meghan’s grades and classroom behavior remained accept- able as long as Mrs. B. consulted repeatedly with the school. Mrs. B. noted with bitterness, however, that the one problem that she could not solve was Meghan’s friendships. The daughters of Mrs. B.’s friends and neighbors were well behaved and excellent students. Meghan did not fit in, and she never got invited to play with the other girls.
Mrs. B. was obviously sad when discussing Meghan’s past, but she became agitated and angry when discussing the present. She was very concerned about Meghan, but she wondered out loud if the suicide attempt had been manipulative. Mrs. B. said that she had had major conflicts with Meghan ever since Meghan started middle school. Meghan would no longer work with her mother on her homework for the usual two hours each night. She began arguing about everything from picking up her room to her boyfriend, an 18 year old whom Mrs. B. abhorred. Mrs. B.
complained that she did not understand what had happened to her daughter. She clearly stated, however, that whatever it was, she would fix it.
What was causing Meghan’s problems? Her case study sug- gests many possibilities. Some difficulties seem to be a reaction to a mother whose attentiveness at age 8 seems intrusive at age 14. We could also trace some of her troubles to anger over her failures in school or rejection by her peers. However, Meghan’s problems seem bigger than this. Surely she was affected by the physical abuse, inconsistent love, and chaotic living arrangements during the first, critical years of her life. But could those distant events account for her current problems? What about biological con- tributions? Did her birth mother’s drug abuse affect Meghan as a developing fetus? Was Meghan a healthy, full-term newborn? Given her biological parents’ history of troubled behavior, could Meghan’s problems be partly genetic? We do not have easy an- swers to these questions, but we can tell you how psychological scientists are seeking to answer them.
Brief Historical Perspective The search for explanations of the causes of abnormal behavior dates to ancient times. But it was not until the nineteenth and early twentieth centuries that three major scientific advances oc- curred. One was the discovery of the cause of general paresis, a severe mental disorder that eventually ends in death. The second was the work of Sigmund Freud, a thinker who had a profound influence on abnormal psychology and Western society. The third was the emergence of a new academic discipline called psychology.
The Biological Paradigm The discovery of the cause of general paresis (general paralysis) is a remarkable and historically important example of the biologi- cal paradigm, which looks for biological abnormalities that cause abnormal behavior, for example, brain diseases, brain injuries, or genetic disorders. General paresis is caused by syphilis, a sexually transmitted disease. We know this as a result of over a century of research—some good and some bad.
In 1798, John Haslam, a British physician, distinguished general paresis from other forms of “lunacy” based on its symp- toms, which include delusions of grandeur, cognitive impairment (dementia), and progressive paralysis. (General paresis has an un- remitting course and ends in death after many years.) The diag- nosis inspired a search for the cause of the disorder, but it took scientists more than 100 years to solve the mystery.
The breakthrough began with the recognition that many people with general paresis had contracted syphilis earlier in their lives. Yet, researchers still questioned this linkage. For example, in 1894, the French syphilis expert, Jean Fournier, found that only 65 percent of patients with general paresis reported a his- tory of syphilis. How could syphilis cause the disorder if a third
causes of abnormal behavior CHAPTER 2 27
of patients never contracted it? But three years later, Austrian– German psychiatrist Richard von Krafft-Ebing attempted to inoculate patients with general paresis against syphilis. No one became infected when exposed to the inoculation’s mild form of the disease. There could be only one explanation: All of the patients had been infected with syphilis previously. Fournier’s statistic, based on imperfect self-reports, was wrong.
Soon thereafter, scientists identified the type of bacteria (called a spirochete) that causes syphilis. Postmortem examinations revealed that the spirochete had invaded and destroyed parts of patients’ brain. In 1910, Paul Ehrlich, a German microbiologist, developed an arsenic-containing chemical that destroyed the spirochete and prevented general paresis. (Unfortunately, the drug worked only if the patient was treated in the early stages of infection.) Later, sci- entists learned that syphilis could be cured by another new drug, penicillin—the first antibiotic. General paresis was virtually elimi- nated when antibiotics became widely available after World War II.
The dramatic discovery of the cause of general paresis pro- moted hopes that scientists could use similar methods to uncover biological causes for other mental disorders. Broadly, the medical
method involves accurate diagnosis as the first step (see Thinking Critically about DSM-5 on p. 28). The second step is identifying a specific biological cause. The third is developing treatments that prevent, eliminate, or alter the cause. Unfortunately, specific bio- logical causes have been identified only for a few cognitive disorders (see Chapter 14) and about half of all cases of intellectual disabil- ity (see Chapter 15). Will the future bring similar discoveries for depression, bipolar disorder, schizophrenia, perhaps even substance abuse? Some scientists hope to identify specific genes and brain pro- cesses that cause these disorders. Others believe that we will never discover a single cause, because so many factors are involved in the development of psychological disorders (Kendler & Prescott, 2006).
Like most psychologists, we agree more with the second group of scientists than the first. Specific biological causes, many genetic, probably will be discovered for a small percentage of mental disor- ders. Yet, we expect the great majority of cases of abnormal behav- ior to defy simple explanation. Like heart disease and cancer, most mental disorders appear to be “lifestyle diseases” that are caused by a combination of biological, psychological, and social influences.
The Psychodynamic Paradigm The psychodynamic paradigm, an outgrowth of Sigmund Freud’s (1856–1939) theories, asserts that abnormal behavior is caused by unconscious mental conflicts that have roots in early child- hood experience. Freud was trained in Paris by Jean Charcot (1825–1893), a neurologist who used hypnosis to treat hysteria. Hysteria is characterized by unusual physical symptoms in the
German microbiologist Paul Ehrlich (1854–1915) developed arsphena- mine, an arsenic-based treatment for syphilis that prevented general paresis. He won the Nobel Prize for Medicine.
Sigmund Freud arriving in Paris with his friend, Marie Bonaparte, Princess of Greece and Denmark, and U.S. Ambassador William Bullitt.
28 CHAPTER 2 causes of abnormal behavior
Freud concluded that hysterical patients did not fake or con- sciously associate their physical symptoms with emotional dis- tress. Instead, he suggested that their psychological conflicts were unconsciously “converted” into physical symptoms. His conclu- sion about the peculiar problem of hysteria led Freud to theorize
absence of physical impairment. For example, “hysterical blind- ness” is the inability to see, but the blindness is not caused by an organic dysfunction. Hysteria appears to have been common in Freud’s time, although the diagnosis is controversial today (see Chapter 7).
Thinking CriTiCally about DSM-5
Diagnosis and Causes of Mental Disorders
You know that many physical illnesses are diagnosed based on their cause. Strep throat (caused by streptococcal in-fection) is one familiar example. Given your experience with problems like strep throat, you may be surprised to learn that most psychological problems are not diagnosed based on their cause.
The DSM-5, in fact, explicitly does not attempt to diagnose mental disorders based on what is, or might be, causing the problem. Instead, the system takes a descriptive approach to classifying abnormal behavior, grouping psychological problems into categories based on similarities in how people act and what they report about their inner experiences. There are many good reasons why DSM-5 follows a descriptive approach. One reason is that experts simply do not know what causes most mental dis- orders, as we have discussed. (This is also true for many physical disorders: Think cancer.) A second reason is that the descriptive approach helps professionals to agree about the presence or absence of an emotional problem. Agreement is more formally known as the reliability of a diagnosis (see Chapter 4). In a very real sense, the descriptive approach of DSM-5 gives mental health professionals a common language for talking about mental illness.
Does this mean that DSM-5 reveals nothing about causation? No. Some diagnoses have some etiological validity, which simply means the diagnosis reveals something about causation (see Chapter 4). We know that there is a very strong genetic contri- bution to attention-deficit/hyperactivity disorder, for example, even though we do not know what genes are involved (see Chapter 16). For a few other conditions, a specific causal factor is a part of the diagnosis itself. For example, drinking too much is part of the definition of alcoholism, and you cannot have post- traumatic stress disorder without first experiencing a trauma. Finally, scientists have discovered a specific cause for a minority of psychological disorders, particularly some forms of dementia (see Chapter 14) and various intellectual disabilities (formerly called mental retardation).
The intellectual disabilities may be a model for the future diag- nosis of mental disorders. A century ago, diagnosing intellectual disabilities was similar to diagnosing mental disorders today. Causation was largely unknown. But over the last 100 years, sci- entists have identified specific causes for about 60 percent of all
cases of intellectual disability, which has a great many different causes (see Chapter 15). Future researchers similarly may iden- tify subtypes of today’s “same” DSM-5 disorder, differentiating subtypes based on known causation (e.g., perhaps a single gene causes a small percentage of cases of depression or schizophre- nia, a subtype not recognized today).
Another possibility is that future versions of the DSM will be structured in a completely different way from the DSM-5, for example, based on new knowledge about normal function- ing. As we have said, the field of abnormal psychology is in the predicament of diagnosing abnormal behavior—not normal behavior—in the absence of a definition of “normal.” Affective neuroscientist Jaak Panksepp (Panksepp & Biven, 2012) argues, for example, that the diagnosis of mental disorders should be based on knowledge about evolved, basic affects observed in the behavior of all mammals, including humans that are being confirmed in the “archaeology” of neuroscience. Along these lines, we might speculate that one such (future) diagnosis might be “fight or flight” anxiety. (Fight or flight is observed across many animals, for example, a cat confronted by a dog can ei- ther flee up a nearby tree or lash out with claws extended.) In addition to the logic of evolution and mounting evidence from neuroscience, such a classification has clinical implications not suggested by today’s DSM-5 diagnosis of anxiety disorders. Like a cat facing a barking dog, some anxious people get very angry when they feel “cornered.” More generally these people seem to have an exaggerated fight or flight response, ready to run or attack, even in the face of relatively minor challenges.
We are fascinated by affective neuroscience—and think the field may well help psychology to begin to develop its “periodic table” of basic elements. We also recognize that both affective neuroscience and acceptance of its principles are in their early stages, and there are good reason for the DSM to move cau- tiously. In fact, the DSM once classified mental disorders based on “causation,” including a long list of “neuroses” wrongly presumed to be caused by the unconscious conflicts of psycho- analytic theory. Thus, for the present and foreseeable future, we understand and support the descriptive approach of DSM-5. The method has many advantages, but you should know that DSM-5 diagnoses provide little information about the specific causes of most mental disorders.
causes of abnormal behavior CHAPTER 2 29
mothers’ lover: They identify with their fathers. Freud hypoth- esized that girls, unlike boys, do not desire their opposite gender parent sexually. Instead, girls confront the electra complex, yearn- ing for something their fathers have and they are “missing”—a penis. This is the Freudian notion of “penis envy.”
It is not difficult to criticize these ideas as far-fetched, overly sexualized, and sexist. We also can (and do) criticize psychoana- lytic theory on scientific grounds. Still, Freud offered many in- novative ideas about unconscious mental processes, conflicts between biological needs and social rules, psychological defenses, and more. Even today, some psychoanalysts insist on interpreting Freud literally. We believe that Freud would have criticized such unchanging interpretations. After all, he often revised his own ideas. In this spirit, we view Freud’s theories as metaphors that are more valuable in the abstract than in their specifics.
The Cognitive-Behavioral Paradigm Like the biological and psychodynamic paradigms, the foun- dations of the cognitive-behavioral paradigm, which views ab- normal behavior as a product of learning can be traced to the nineteenth century, specifically to 1879, when Wilhelm Wundt
that many psychological processes are unconscious. This assump- tion served as the impetus behind his elaborate psychoanalytic theory, a term that refers specifically to Freud’s theorizing. The broader term psychodynamic theory includes not only Freudian theory but also the revisions of his followers (see Chapter 3).
Psychoanalytic theory is complicated and historically important, so we describe it in some detail here. You should know, however, that college students today are much more likely to learn about Freud’s ideas in English departments than in psy- chology courses! Eighty-six percent of classes on psychoanalysis on U.S. campuses are taught outside of psychology departments (Shulman & Redmond, 2008). Why? The theory is a rich source of theorizing—and weak on science.
Psychoanalytic theory divides the mind into three parts: the id, the ego, and the superego. The id is present at birth and houses biological drives, such as hunger, as well as two key psy- chological drives: sex and aggression. In Freudian theory, the id operates according to the pleasure principle—the impulses of the id seek immediate gratification and create discomfort or unrest until they are satisfied. Thus, in Freud’s view, sexual or aggressive urges are akin to biological urges, like hunger.
The ego is the part of the personality that must deal with the realities of the world as it attempts to fulfill id impulses as well as perform other functions. Thus, the ego operates on the reality principle. According to Freud, the ego begins to develop in the first year of life, and it continues to evolve, particularly during the preschool years. Unlike id impulses, which are primarily uncon- scious, much of the ego resides in conscious awareness.
The third part of the personality is the superego, which is roughly equivalent to your conscience. The superego contains so- cietal standards of behavior, particularly rules that children learn in their preschool years from trying to be like their parents. Freud viewed the superego’s rules as efforts to govern the id’s sexual and aggressive impulses, with the ego mediating between the two. Freud called conflict between the superego and the ego moral anxiety, and conflict between the id and the ego neurotic anxiety.
Freud suggested that the ego protects itself from neurotic anxiety by utilizing various defense mechanisms, unconscious self-deceptions that reduce conscious anxiety by distorting anxiety-producing memories, emotions, and impulses. For example, the defense of projection turns the tables psychologically. When you use projection, you project your own feelings on to someone else: “I’m not mad at you. You’re mad at me!” A list of some of the more familiar defenses can be found in Table 2.1. Many of these terms are now a part of everyday language, testimony to Freud’s influence on Western culture.
Freud viewed early childhood experiences, especially related to forbidden topics, as shaping personality and emotional health. His theory of psychosexual development argued that different stages of child development are defined by sexual conflicts (see Table 2.5 on page 47). For example, Freud’s oedipal conflict suggests that boys harbor sexual desire for their mothers. Freud argued that boys resolve this impossible impulse by becoming like their
table 2.1 Some Freudian Defense Mechanisms Denial Insistence that an experience, memory,
or need did not occur or does not exist. For example, you completely block a painful experience from your memory.
Displacement Feelings or actions are transferred from one person or object to another that is less threatening. For example, you kick your dog when you are upset with your boss.
Projection Attributing one’s own feelings or thoughts to other people. For example, a husband argues that his wife is angry at him when, in fact, he is angry at her.
Rationalization Intellectually justifying a feeling or event. For example, after not getting the offer, you decide that a job you applied for was not the one you really wanted.
Reaction formation
Converting a painful or unacceptable feeling into its opposite. For example, you “hate” a former lover, but underneath it all you still really love that person.
Repression Suppressing threatening material from consciousness but without denial. For example, you “forget” about an embarrassing experience.
Sublimation Diverting id impulses into constructive and acceptable outlets. For example, you study hard to get good grades rather than giving in to desires for immediate pleasure.
30 CHAPTER 2 causes of abnormal behavior
The U.S. psychologist John B. Watson (1878–1958) was an in- fluential proponent of applying learning theory to human behavior. Watson argued for behaviorism, suggesting that observable behavior was the only appropriate subject matter for the science of psychology because, he argued, thoughts and emotions cannot be measured ob- jectively. However, very important research, including therapies we discuss in Chapter 3, has shown the importance of cognitive pro- cesses in learning. Thus, “cognitive” joined “behavioral.” True to their historical roots, cognitive-behavior therapists value and have pro- moted psychological research in many areas of abnormal psychology.
The Humanistic Paradigm The humanistic paradigm argues that human behavior is the prod- uct of free will, the view that we control, choose, and are respon- sible for our actions. This stance is a reaction against determinism, the scientific assumption that human behavior is caused by po- tentially knowable factors (a position held by the other three par- adigms). Because free will, by definition, is not predictable, it is impossible to determine the causes of abnormal behavior accord- ing to the humanistic paradigm. For this reason, the approach perhaps is best considered as an alternative philosophy, not as an alternative psychological theory.
The humanistic paradigm is also distinguished by its explic- itly positive view of human nature. Humanistic psychologists blame abnormal behavior on society, not on the individual, whom they see as inherently good (see Table 2.2). The term humanistic is appealing, but we should be clear about this: All psychologists are humanists in the sense that their ultimate goal is to improve the human condition.
The Problem with Paradigms The historian and philosopher Thomas Kuhn (1962) showed how paradigms can both direct and misdirect scientists. Paradigms can tell us how to find answers, but sometimes the guidance can be a hindrance. The idea that paradigms can guide or blind us is illustrated by the following enigma, written by Lord Byron:
(1832–1920) began the science of psychology at the University of Leipzig. Wundt’s substantive contributions to psychology were limited, but he made a profound contribution by introducing the scientific study of psychological phenomena, especially learning.
Two prominent early scientists who made lasting substantive contributions to learning theory and research were the Russian physiologist Ivan Pavlov (1849–1936) and the U.S. psycholo- gist B. F. Skinner (1904–1990). These scientists articulated the principles of classical conditioning and operant conditioning— concepts that continue to be central to psychology today.
In his famous experiment, Pavlov (1928) rang a bell when he fed meat powder to dogs. After repeated trials, the sound of the bell alone elicited salivation. This illustrates Pavlov’s theory of classical conditioning. Classical conditioning is learning through association, and involves four key components. There is an unconditioned stimulus (the meat powder), the stimulus that automatically produces the unconditioned response (salivation). A conditioned stimulus (the bell) is a neutral stimulus that, when repeatedly paired with an unconditioned stimulus, comes to produce a conditioned response (salivation). Extinction gradually occurs once a conditioned stimulus no longer is paired with an unconditioned stimulus. Eventually, the conditioned stimulus no longer elicits the conditioned response.
Skinner’s (1953) operant conditioning asserts that behavior is a function of its consequences. Specifically, behavior increases if it is rewarded, and it decreases if it is punished. In his numerous studies of rats and pigeons in his famous “Skinner box,” Skinner identified four different, crucial consequences. Positive reinforcement is when the onset of a stimulus increases the frequency of behavior (e.g., you get paid for your work). Negative reinforcement is when the cessation of a stimulus increases the frequency of behavior (you give in to a nagging friend). Punishment is when the onset of a stimulus decreases the frequency of behavior (you are quiet after a teacher’s scolding); and response cost is when the cessation of a stimulus decreases the fre- quency of behavior (you stop talking back when your parents take away your allowance). Extinction results from ending the association between a behavior and its consequences as in classical conditioning.
table 2.2 Comparison of Biological, Psychodynamic, Cognitive-Behavioral, and Humanistic Paradigms Topic Biological Psychodynamic Cognitive-Behavioral Humanistic
Inborn human nature Competitive, but some altruism
Aggressive, sexual Neutral—a blank slate Basic goodness
Cause of abnormality Genes, neurochemistry, physical damage
Early childhood experiences
Social learning Frustrations of society
Type of treatment Medication, other somatic therapies
Psychodynamic therapy
Cognitive-behavior therapy
Nondirective therapy
Paradigmatic focus Bodily functions and structures
Unconscious mind Observable behavior Free will
causes of abnormal behavior CHAPTER 2 31
the natural world. Systems theory also offers an important per- spective on the causes of abnormal behavior, one that we adopt throughout this text. Systems theory includes the biopsychosocial model and elements of each of the four paradigms, but it also highlights the need to understand the ecology of human behav- ior. Several key concepts deserve explanation.
Holism A central principle of systems theory is holism, the idea that the whole is more than the sum of its parts. Holism is a familiar but important concept. Holistic medicine, for example, focuses not just on physi- cal illness, but on health, psychological, and social needs. Similarly, a holistic approach to abnormal behavior views mental illness in the context of the individual’s personality, including their strengths, and more broadly, in the interpersonal and societal contexts.
The holistic approach contrasts with its scientific counterpoint, reductionism. Reductionism attempts to understand problems by focusing on smaller and smaller units, suggesting that the small- est (or most molecular) account is the “true” cause (Kagan, 2007; Valenstein, 1998). From this perspective, the Higgs boson (the “God Particle”) provides the ultimate explanation in physics, and neuro- chemistry offers the ultimate explanation of abnormal behavior.
We value the discoveries produced by reductionist approaches, but we also want you to appreciate that there are different levels of analysis for understanding psychological problems (physics, biol- ogy, medicine, etc.) (Hinde, 1992). Biological, psychological, and social views of abnormal behavior each use a different “lens”; one is a microscope, another a magnifying glass, and the third a tele- scope. No lens is “right.” They are just different. Each has value for different purposes. In fact, we can order all academic disciplines according to their level of analysis (Schwartz, 1982; see Table 2.3).
We can illustrate the importance of levels of analysis with a far-out example. Assume that three Martian scientists are sent to Earth to discover what causes those mysterious metallic vehicles to speed across the planet’s landmass. A Martian ecologist reports that the vehicles (called “automobiles”) move at different speeds based on the width of the black paths on which they are set, whether the paths are straight or curved, and the presence of something called “radar traps.” A Martian psychologist disagrees, noting that the speed of automobiles is determined by the age, gender, and mood of the individual who sits behind the wheel. A third scientist, a reductionist, laughs at the other two. The Martian physicist notes that the speed of automobiles ultimately is caused by a chemical process that occurs inside an outdated machine, the internal com- bustion engine. The process involves oxygen, fuel, and heat and results in mechanical energy. The Martian example illustrates that the most reductionistic, or molecular, explanation is not necessarily more (or less) accurate than the most broad, or molar, one.
Causality You may be a bit frustrated by the “Russian matreska doll” ap- proach of systems theory, with one explanation nested within
I’m not in earth, nor the sun, nor the moon. You may search all the sky— I’m not there. In the morning and evening— though not at noon, You may plainly perceive me, for like a balloon, I am suspended in air. Though disease may possess me, and sickness and pain, I am never in sorrow nor gloom; Though in wit and wisdom I equally reign I am the heart of all sin and have long lived in vain; Yet I ne’er shall be found in the tomb.
What is this poem about? The topic is not the soul or ghosts, life or shadows, or a dozen other possibilities. The topic is the letter i. (Suspended in air, the heart of all sin.) Why is the puzzle so dif- ficult to solve? Because most people assume that the solution lies in the content of the poem, not in its form. This illustrates how our assumptions (a paradigm) can lead us to overlook possible answers. Yet, paradigms can also open up new perspectives. Now that you have been able to adopt a new “paradigm”—to focus on the form, not the content of words—you can easily solve the following puzzle:
The beginning of eternity, the end of time and space, The beginning of every end, the end of every place.
The now obvious answer is the letter e. Like your initial approach to the brainteaser, the four para-
digms make assumptions about the causes of abnormal psychology that can be too narrow. The biological paradigm can overempha- size the medical model, the analogy between physical and psycho- logical illnesses. The psychodynamic paradigm can be unyielding in focusing on childhood experiences, unconscious conflicts, and interpreting Freud literally. The cognitive-behavioral paradigm can overlook the rich social and biological context of human behavior. Finally, the humanistic approach can be antiscientific. In short, each paradigm has weaknesses—and strengths. As with word puz- zles, the trick is knowing when to use a different approach.
Systems Theory Systems theory is an integrative approach to science, one that embraces not only the importance of multiple contributions to causality but also their interdependence. Systems theory has in- fluenced many sciences. For example, systems theory is basic to ecology, the study of the interdependence of living organisms in
32 CHAPTER 2 causes of abnormal behavior
another. This is understandable. Human beings are not very pa- tient with complicated explanations. Our orderly minds want to pinpoint a single culprit. We want to know the cause of cancer, the cause of heart disease, and the cause of mental illness.
But a question might help to unhinge you from this search for simplicity: What is the cause of automobile accidents? Car ac- cidents have many causes: excessive speed, drunk drivers, slippery roads, and worn tires. It would be fruitless to search for the cause of car accidents. The same is true for most mental disorders (and cancer and heart disease).
Equifinality and Multifinality Car accidents and abnor- mal behavior are examples of the principle of equifinality, which indicates that there are many routes to the same destination (or disorder). We use the term multiple pathways as a synonym for equifinality. The same disorder may have several different causes.
Equifinality has a mirror concept, multifinality, which says that the same event can lead to different outcomes. For example, not all abused children grow up with the same problems later in life. In fact, not all abused children have psychological problems as adults. Throughout the text, you will repeatedly see examples of equifinality and multifinality. The human psyche is indeed a very complex system.
thE diathEsis-strEss ModEl The diathesis-stress model is a common way of summarizing multiple influences on abnor- mal behavior. A diathesis is a predisposition toward developing a disorder, for example, an inherited tendency toward depression. A stress is a difficult experience, for example, the loss of a loved
table 2.3 Ordering Academic Disciplines by Level of Analysis level of analysis academic discipline
Beyond Earth Astronomy
Supranational Ecology, economics
National Government, political science
Organizations Organizational science
Groups Sociology
Organisms Psychology, ethology, zoology
Organs Cardiology, neurology
Cells Cellular biology
Biochemicals Biochemistry
Chemicals Chemistry, physical chemistry
Atoms Physics
Subatomic particles Subatomic physics
Abstract systems Mathematics, philosophy
Source: Based on G.E. Schwartz, 1982, “Testing the biopsychosocial model: The ultimate challenge facing behavioral medicine,” Journal of Consulting and Clinical Psychology, 50, 1040–1053.
“Boy, have I got this guy conditioned! Every time I press the bar down he drops a piece of food.”
© Robert E. Emery.
Like car accidents, mental illnesses have many causes, not one.
one through an unexpected death. The diathesis-stress model sug- gests that mental disorders develop when a stress is added on top of a predisposition (Zuckerman, 1999). But multiple stressors or risk factors may contribute to mental disorders (Belsky & Pluess, 2009). You should know, moreover, that the term risk factor refers to circumstances that are correlated with an increased likelihood of a disorder but do not necessarily cause it (see Research Methods).
rEciprocal causality We like to think of causes as a one- way street. But a systems approach emphasizes interdependency and reciprocal causality, mutual influences where “cause” and “effect” sometimes is a matter of perspective. Does the experi- menter cause the rat in a Skinner box to press the bar, or does the rat cause the experimenter to feed it? B. F. Skinner himself toyed with this question, as the accompanying cartoon illustrates (Skinner, 1956). As we search for explanations of mental disor- ders, we sometimes similarly need to shift perspectives, and ask, for example: Do troubled relationships cause mental disorders, or do trouble people make relationships difficult?
causes of abnormal behavior CHAPTER 2 33
developmental Psychopathology Developmental psychopathology is an approach to abnormal psychology that emphasizes change over time. The approach recognizes the importance of developmental norms—age-graded averages—to understanding influences on (and the definition of ) abnormal behavior (Cicchetti & Cohen, 1995; Rutter & Garmezy, 1983). Developmental norms tell us that a full-blown temper tantrum is normal at 2 years of age, for example, but that kicking and screaming to get your own way is abnormal at the age of 22. Development does not end at the age of 22, however, as predictable changes in both psychological and social experi- ences occur throughout adult life. Recognizing this, we devote an entire chapter (Chapter 17) to discussing the normal but
reSearCh methods
Correlations: Does a Psychology Major Make You Smarter?
The correlational study and the experiment (see Chapter 3) are two basic and essential research methods. In a correlational study, the relation between two factors (their co-relation) is studied systematically. For example, you might hypothesize that psychology majors learn more about research methods than biology majors. To support this hypothesis, you might simply argue your point, or you could rely on case studies—“I know more about research than my roommate, and she’s a biology major!”
If you were to conduct a correlational study, you would collect a large sample of both psychology and biology majors and com- pare them on an objective measure of knowledge of research methods. You would then use statistics to test whether research knowledge is correlated with academic major.
An important statistic for measuring how strongly two factors are related is the correlation coefficient. The correlation coef- ficient is a number that always ranges between −1 and +1. If all psychology majors got 100 percent correct on your test of research methods and all biology majors got 0 percent correct, the correlation between academic major and research knowl- edge would be 1. If all psychology and biology majors got 50 percent of the items correct, the correlation between major and knowledge would be zero. Two factors are more strongly correlated when a correlation coefficient has a higher absolute value, regardless of whether the sign is positive or negative.
Positive correlations (from 0.01 to 1) indicate that, as one factor goes up, the other factor also goes up. For example, height and weight are positively correlated, as are years of education and employment income. Taller people weigh more; educated people earn more money. Negative correlations (from −1 to −0.01) indicate that, as one number gets bigger, the other number gets smaller. For example, your course load and your free time are negatively correlated. The more courses you take, the less free time you have.
In this chapter, we discuss many factors that are correlated with and might cause psychological problems. Levels of neurotransmit- ters are positively correlated with some emotional problems (they are elevated in comparison to normal), and they are negatively cor- related with other types of emotional problems (they are depleted in comparison to normal). However, you should always remember that correlation does not mean causation. This is true for the corre- lation between major and research knowledge and for the correla- tion between neurotransmitters and mental health (Kagan, 2007).
We might want to conclude that X causes Y—depleted neu- rotransmitters cause depression. A correlation may result from causation, but there are always two alternative explanations: re- verse causality and third variables. Reverse causality indicates that causation could be operating in the opposite direction: Y could be causing X. Depression could be causing the depletion of neurotransmitters. The third variable problem indicates that a correlation between any two variables might be explained by their joint relation with some unmeasured factor—a third vari- able. For example, stress might cause both depression and the depletion of neurotransmitters.
So if you found that psychology majors know more about research methods, could you conclude that majoring in psychology caused this result? No! People who know more about research methods to begin with might become psychology majors (reverse causality). Or more intelligent people might both major in psychology and learn more about research methods (third variable).
As we discuss in Chapter 3, the experiment does allow scientists to determine cause and effect. However, it often is impractical or unethical to conduct experiments on psychological problems, while correlational studies can be conducted with far fewer practical or ethical concerns. Thus, the correlational method has the weakness that correlation does not mean causation, but the strength that it can be used to study many real-life circumstances.
psychologically trying changes that result from developmental transitions during adult life.
A developmental approach is also important for abnormal behavior itself. Many psychological disorders follow unique devel- opmental patterns. Sometimes there is a characteristic premorbid history, a pattern of behavior that precedes the onset of the disor- der. A disorder may also have a predictable course, or prognosis, for the future. Abnormal behavior is a moving picture of develop- ment and not just a diagnostic snapshot.
The remainder of this chapter has sections on biological, psy- chological, and social factors involved in the development of psy- chopathology. This basic material sets the stage for our more specific discussions of the causes of abnormal behavior in later chapters.
34 CHAPTER 2 causes of abnormal behavior
Biological Factors We begin our discussion of biological factors affecting mental functioning by considering the smallest anatomic unit within the nervous system—the neuron or nerve cell. Next, we consider the major brain structures and current knowledge of their primary behavioral functions. We then turn to psychophysiology, the ef- fect of psychological experience on the functioning of various body systems. Finally, we consider the broadest of all biological influences, the effect of genes on behavior.
In considering biological influences, it is helpful to note the dis- tinction between the study of biological structures and biological func- tions. The field of anatomy is concerned with the study of biological structures; the field of physiology investigates biological functions. Neu- roanatomy and neurophysiology are subspecialties within these broader fields that focus specifically on brain structures and brain functions. The study of neuroanatomy and neurophysiology is the domain of an exciting, multidisciplinary field of research called neuroscience.
The neuron and neurotransmitters Billions of tiny nerve cells—neurons—form the basic build- ing blocks of the brain. Each neuron has four major anatomic
figure 2.1 The neuron The anatomic structure of the neuron, or nerve cell. Source: © Pearson Education, Upper Saddle River, New Jersey.
Neurotransmitter
Axon Terminals
Synapse
Dendrite
Axon
Cell Body
Cell Nucleus
Axon terminal
Vesicles
Neuro- transmitters
Receptors Synapse
Reabsorption
figure 2.2 synaptic Transmission When an electrical nerve impulse reaches the end of a neuron, synaptic vesicles release neu- rotransmitters into the synapse. The chemical transmission between cells is complete when neurotransmitters travel to receptor sites on another neuron. Source: Keith Kasnot/National Geographic Stock.
components: the soma or cell body, the dendrites, the axon, and the axon terminal (see Figure 2.1). The soma—the cell body and largest part of the neuron—is where most of the neuron’s metabolism and maintenance are controlled and performed. The dendrites branch out from the soma; they serve the pri- mary function of receiving messages from other cells. The axon is the trunk of the neuron. Messages are transmitted down the axon toward other cells. Finally, the axon terminal is the end of the axon, where messages are sent out to other neurons (Barondes, 1993). Watch the Video The Anatomy of the Neuron on MyPsychLab
Within each neuron, information is transmitted as a change in electrical potential that moves from the dendrites and cell body, along the axon, toward the axon terminal. The axon termi- nal is separated from other cells by a synapse, a small gap filled with fluid. Neurons typically have synapses with thousands of other cells (see Figure 2.2).
Unlike the electrical communication within a neuron, in- formation is transmitted chemically across a synapse to other neurons. The axon terminal contains vesicles containing chemi- cal substances called neurotransmitters, which are released into the synapse and are received at the receptors on the dendrites
causes of abnormal behavior CHAPTER 2 35
or soma of another neuron. Different receptor sites are more or less responsive to particular neurotransmitters. Dozens of differ- ent chemical compounds serve as neurotransmitters in the brain. Serotonin and dopamine are two that are known to be particu- larly important for abnormal behavior. Watch the Video How Neurotransmitters Work on MyPsychLab
Not all neurotransmitters cross the synapse and reach the receptors on another neuron. The process of reuptake, or reabsorption, captures some neurotransmitters in the syn- apse and returns the chemical substances to the axon termi- nal. The neurotransmitter then is reused in subsequent neural transmission.
In addition to the neurotransmitters, a second type of chemical affects communication in the brain. Neuromodulators are chemicals that can influence communication among many neurons by affect- ing the functioning of neurotransmitters (Ciarnello et al., 1995). Neuromodulators often affect regions of the brain that are quite distant from where they were released. This occurs, for example, when stress causes the adrenal gland to release hormones that affect many aspects of brain functioning (as we discuss shortly).
neurotransmitters and Psychopathology Scientists have found neurotransmitter disruptions in some people with mental disorders. An oversupply of certain
Mind–Body Dualism
Some people mistakenly conclude that, because brain functions are correlated with having a psychological problem, this means that there is something wrong in the brain that causes the disorder. Certain regions of the brain “light up” with depression. This means that depression is a “brain disease,” right? Medications that affect brain chemistry lessen symptoms of depression. This means depression is caused by a “chemical imbalance in the brain,” right? Wrong—on both counts.
Much of this misguided thinking can be traced to the logical error formally known as dualism, the mistaken view that the mind and body are somehow separable. This wrong-headed reasoning has a long and undistinguished history. Dualism dates to the French philosopher René Descartes (1596–1650), who attempted to balance the dominant religious views of his times with emerging scientific reasoning. Descartes recognized the importance of human biology, but he wanted to elevate human spirituality beyond the brain. To balance scientific and religious beliefs, he argued that many human experiences result from brain function, but higher spiritual thoughts and feelings some- how exist apart from the body.
Descartes argued for a distinction—a dualism—between mind and body. But he was wrong. No psychological experience can exist apart from biology. Just like computer software cannot run without computer hardware, no psychological experience runs independently from the hardware of the brain (Turkheimer, 1998; Valenstein, 1998).
Even love has a biochemical explanation, a fact that Calvin ponders in the accompanying cartoon. If you are unpersuaded by Calvin, you may be convinced by a study. Images of married women’s brains show bigger responses to threat when a woman is hold- ing a stranger’s hand instead of her husband’s. Brain images also show a bigger response to threat when women are holding hands with husbands to whom they are less happily married (Coan, Schaefer, & Davidson, 2006). Like depression, anxiety, and other troublesome emotions (and all our thoughts and feelings), the “software” experience of love is represented in underlying brain “hardware.” Yet, love will still be love (not a brain disease) even after scientists identify the “chemical imbalance” that explains it. And as with love, depression (and other mental disorders) are not necessarily caused by a “broken brain” just because certain parts of the brain “light up” when people are depressed.
CALVIN AND HOBBES © Bill Watterson. Reprinted with permission of UNIVERSAL UCLICK. All rights reserved.
36 CHAPTER 2 causes of abnormal behavior
neurotransmitters is found in some cases, an undersupply in oth- ers, and disturbances in reuptake in still other cases. In addition, the density and/or sensitivity of receptors may play a role in some abnormal behavior.
Much research has investigated how drugs alter brain chemis- try, and in turn, affect symptoms. For example, medications that al- leviate some symptoms of schizophrenia block receptors sensitive to the neurotransmitter dopamine. This suggests that abnormalities in the dopamine system may be involved in schizophrenia (see Chap- ter 13). Evidence that effective treatments for depression inhibit the reuptake of the serotonin links a depletion of that neurotransmitter to mood disorders (see Chapter 5). As we discuss in the appropriate
Hand
Face
Motor cortex
Motor cortex
Cortex This wrinkled surface of the brain is only an eighth of an inch thick, but it is involved in many complex tasks, including memory, language, and perception. The cortex is divided into four lobes (right). Larger portions of the motor cortex (a part of the frontal lobe) are devoted to more active body parts such as the hands and face.
Frontal lobe Involved in movement, speech, reasoning, and aspects of emotion.
Parietal lobe Integrates sensory information; plays a role in spatial reasoning.
Temporal lobe Processes sound and smell, regulates emotions, and is involved in aspects of learning, memory, and language.
Occipital lobe Interprets visual information.
Corpus callosum Links the left and right hemispheres.
Thalamus Receives and integrates sensory information from sense organs and from higher brain structures.
Midbrain Involved in some movements, especially related to �ghting and sex.
Cerebellum Coordinates motor movements.
Pons Part of brain stem; involved in sleep, movement.
Pituitary gland Secretes hormones; connected to brain through the hypothalamus.
Hypothalamus Helps control basic biological urges like eating, drinking, and sex; regulates blood pressure and heart rate.
Planum temporale
Planum temporale Involved in understanding speech; usually much larger in the left hemisphere.
Dura Leathery covering over the brain.
Ventricles Filled with cerebrospinal �uid.
Cortex Its bulges (called gyri) and large grooves (called �ssures) greatly increase its surface area.
Limbic system A group of central brain structures that regulate emotion, basic learning, and basic behaviors.
Amygdala Part of the limbic system; contributes to some emotions.
Hippocampus Part of the limbic system; affects ability to learn; identi�es sensory information worth learning.
Healthy neuron
Ventricle
Asymmetry Many corresponding areas are larger in one hemisphere, especially in the cortex.
Brain stem Forms connections with spinal cord, allowing brain and body to communicate.
Medulla Part of brain stem; controls vital bodily functions, including heart rate, respiration, and blood pressure.
figure 2.3 The Healthy Brain Scientists are only beginning to discover how the healthy brain performs its complex functions. You should view this complex figure as a rough road map that will be redrawn repeatedly. Like a roadmap, you should not try to memorize the figure, but use it as a guide. You will appreciate more and more detail as you return to examine it repeatedly. Despite the continuing mysteries, increasingly sophisticated tools have allowed researchers to identify more and more of the functions performed by different areas of the brain. For example, the four lobes of the brain’s cortex play very different roles in thought, emotion, sensation, and motor movement (see top right of figure). Still, our incomplete knowledge of the healthy brain limits our understanding of brain abnormalities.
chapters, however, several neurotransmitters are likely to be involved in these and other mental disorders. Consistent with our discus- sion of levels of analysis, moreover, a biochemical difference does not necessarily mean that these problems are caused by “a chemical imbalance in the brain,” even though many people, including many mental health professionals, mistakenly leap to this conclusion (see box on Mind–Body Dualism on page 35).
Major Brain structures Neuroanatomists broadly divide the brain into the hindbrain, the midbrain, and the forebrain (see Figure 2.3). Basic bodily functions are regulated by the structures of the hindbrain, which
causes of abnormal behavior CHAPTER 2 37
include the medulla, pons, and cerebellum. Few forms of ab- normal behavior are linked with disturbances in the hindbrain.
Watch the Video Geography of the Brain on MyPsychLab
The midbrain is involved in the control of some motor ac- tivities, especially those related to fighting and sex. Much of the reticular activating system is located in the midbrain, although it extends into the pons and medulla as well. The reticular activating system regulates sleeping and waking. Damage to areas of the mid- brain can cause extreme disturbances in sexual behavior, aggres- siveness, and sleep, but such abnormalities typically result from specific brain traumas or tumors (Matthysse & Pope, 1986).
Stroke and the Motor Cortex A stroke commonly disrupts voluntary movement on one side of the body. The stroke shown at the right has affected the face and hand.
Diseased carotid artery
Diseased neuron
Middle cerebral artery
Planum temporale May be larger in right hemisphere in schizophrenia, unlike normal asymmetry.
Ventricles Larger than normal in schizophrenia.
Planum temporale
Beta amyloid protein
Atrophied tissue
“Senile plaque”
Hand
FaceUmbra
Umbra
Penumbra
Penumbra
Blood
Blockage
Tangle
STROKE
ALZHEIMER’S DISEASE
SCHIZOPHRENIA
Source: Keith Kasnot, Copyright National Geographic Image Collection.figure 2.3 (Continued) The unhealthy Brain Scientists have identified clear brain abnormalities only for some severe mental disorders. A stroke is caused by loss of blood supply to a region of the brain, and it kills off nearby cells (see Chapter 14). Cells die rapidly near the center of the damaged tissue, the umbra. Cells die less rapidly in the periphery, the penumbra, and may be saved by future medical advances. Alzheimer’s disease is a severe cognitive disorder associated with aging (see Chapter 14) that is characterized by atrophied brain tissue, “senile plaques” (caused by clumps of beta amyloid protein), and tangles of diseased or dead neurons. Schizophrenia is a very serious psychotic illness (see Chapter 13) that remains a mystery as a brain disorder, despite some promising leads. For example, among people with schizophrenia the ventricles often are enlarged, and asymmetries in the planum temporale may be reversed. Source: Keith Kasnot/National Geographic Stock.
Most of the human brain consists of the forebrain. The forebrain evolved more recently and is the site of most sensory, emotional, and cognitive processes. The forebrain is linked with the midbrain and hindbrain by the limbic system, which is made up of several struc- tures that regulate emotion and learning. Two important compo- nents of the limbic system are the thalamus and the hypothalamus. The thalamus receives and integrates sensory information from both the sense organs and higher brain structures. The hypothalamus controls basic biological urges, such as eating, drinking, and sexual activity. Much of the functioning of the autonomic nervous system (which we discuss shortly) is also directed by the hypothalamus.
38 CHAPTER 2 causes of abnormal behavior
Cerebral Hemispheres Most of the forebrain is composed of the two cerebral hemi- spheres. Many brain functions are lateralized, so that one hemi- sphere serves a specialized role as the site of specific cognitive and emotional activities. In general, the left cerebral hemisphere is in- volved in language and related functions, and the right cerebral hemisphere is involved in spatial organization and analysis.
The two cerebral hemispheres are connected by the corpus callosum, coordinates the different functions performed by the left and the right hemispheres. When we view a cross section of the forebrain, four connected chambers, or ventricles, become ap- parent. The ventricles are filled with cerebrospinal fluid, and they are enlarged in some psychological and neurological disorders.
The cerebral cortex is the uneven surface area of the fore- brain that lies just underneath the skull. It is the site of the control and integration of sophisticated memory, sensory, and motor func- tions. The cerebral cortex is divided into four lobes (see Figure 2.3). The frontal lobe, located just behind the forehead, controls a number of complex functions, including reasoning, planning, emotion, speech, and movement. The parietal lobe, located at the top and back of the head, receives and integrates sensory informa- tion and also plays a role in spatial reasoning. The temporal lobe, located beneath much of the frontal and parietal lobes, processes sound and smell, regulates emotions, and is involved in some aspects of learning, memory, and language. Finally, the occipital lobe, located behind the temporal lobe, receives and interprets vi- sual information.
Major Brain sTruCTurEs and PsyCHoPaTHology Only the most severe mental disorders have clearly been linked to abnormalities in neuroanatomy. In most cases, brain damage is extensive. For example, during a stroke, blood vessels in the brain rupture, cutting off the supply of oxygen to parts of the brain and killing surrounding brain tissue. This disrupts the functioning of nearby healthy neurons because the brain cannot remove the dead tissue (see Figure 2.3). Tangles of neurons are found in patients with Alzheimer’s disease, but the damage can be identified only during postmortem autopsies (see Figure 2.3). In patients with schizophrenia, the ventricles of the brain are enlarged, and asym- metries are also found in other brain structures (see Figure 2.3). Watch the Video Brain Damage in Alzheimer’s Disease on MyPsychLab
Neuroscientists have made dramatic breakthroughs in devel- oping instruments that allow us to observe the anatomic struc- ture of the living brain and record broad physiological processes. These imaging procedures are being used to study psychologi- cal disorders ranging from schizophrenia to learning disabilities; they are discussed in Chapter 4, along with other methods of psychological assessment.
At present, brain imaging is more exciting technically than practically for identifying biological causes of mental disorders. However, there is every reason to hope that brain imaging tech- niques will greatly improve our understanding of both normal and abnormal brain structure and function.
Hypothalmus Pituitary gland
Thyroid gland
Adrenal glands
Ovary (female)
Testis (male)
Gonads
Psychophysiology Psychophysiology is the study of changes in the functioning of the body that result from psychological experience. Some of these reac- tions are familiar. Psychophysiological responses include a pounding heart, a flushed face, tears, sexual excitement, and numerous other reactions. Such responses reflect a person’s psychological state, particu- larly the degree and perhaps the type of his or her emotional arousal.
EndoCrinE sysTEM Psychophysiological arousal results from the activity of two different communication systems within the body— the endocrine system and the nervous system. The endocrine system is a collection of glands found at various locations throughout the body. Its major components include the ovaries or testes and the pi- tuitary, thyroid, and adrenal glands (see Figure 2.4). Endocrine glands produce psychophysiological responses by releasing hormones into the bloodstream—chemical substances that affect the functioning of distant body systems and sometimes act as neuromodulators. The en- docrine system regulates some aspects of normal development, partic- ularly physical growth and sexual development. Parts of the endocrine system, particularly the adrenal glands, are also activated by stress and help prepare the body to respond to an emergency.
Certain abnormalities in the functioning of the endocrine system are known to cause psychological symptoms. For example, in hyperthyroidism, also known as Graves’ disease, the thyroid gland secretes too much of the hormone thyroxin, causing restlessness,
figure 2.4 The Endocrine system The glands that comprise the endocrine system, which affects physical and psychophysiological responses through the release of hormones into the bloodstream. Source: © Pearson Education, Upper Saddle River, New Jersey.
causes of abnormal behavior CHAPTER 2 39
agitation, and anxiety. Research on depression also suggests that en- docrine functioning sometimes contributes to causing this disorder.
Simulate the Experiment The Endocrine System in MyPsychLab
auTonoMiC nErvous sysTEM The basic system of com- munication within the body is the nervous system. The human nervous system is divided into the central nervous system, which includes the brain and the spinal cord, and the peripheral ner- vous system. The peripheral nervous system includes all connec- tions that stem from the central nervous system and innervate the body’s muscles, sensory systems, and organs.
The peripheral nervous system itself has two subdivisions. The voluntary, somatic nervous system governs muscular control, and the involuntary, autonomic nervous system regulates the functions of various body organs, such as the heart and stomach. The somatic nervous system controls intentional or voluntary ac- tions like scratching your nose. The autonomic nervous system is responsible for psychophysiological reactions—responses that occur with little or no conscious control.
The autonomic nervous system can be subdivided into two branches, the sympathetic and parasympathetic nervous systems. In general, the sympathetic nervous system controls activities as- sociated with increased arousal and energy expenditure, and the parasympathetic nervous system controls the slowing of arousal and energy conservation. Thus, the two branches work somewhat in opposition, which works to maintain homeostasis.
PsyCHoPHysiology and PsyCHoPaTHology Psycho- physiological overarousal and underarousal can contribute to abnormal behavior. For example, overactivity of the autonomic ner- vous system (a pounding heart and sweaty hands) has been linked to excessive anxiety. In contrast, chronic autonomic underarousal may explain some of the indifference to social rules and the failure to learn from punishment found in antisocial personality disorder. Psychophysiological assessment also can be a useful way of objec- tively measuring reactions to psychological events (see Chapter 4).
Behavior genetics Genes are ultramicroscopic units of DNA that carry information about heredity. Genes are located on chromosomes, chainlike structures found in the nucleus of cells. Humans normally have 23 pairs of chromosomes.
Genetics is the study of genes and their hereditary functions, a field that often focuses at the level of molecules. Behavior genetics traditionally studies broad genetic influences on normal and abnor- mal behavior, focusing on whether genes are more or less impor- tant in development (Plomin, DeFries, McClearn, & McGuffin, 2008; Rutter et al., 2001). However, many experts in genetics and behavior genetics are working together today in the hope of iden- tifying specific genes involved in normal and abnormal behavior (Kendler & Prescott, 2006; Kim-Cohen & Gold, 2009).
gEnoTyPEs and PHEnoTyPEs A basic principle of genetics is the distinction between genotypes and phenotypes. A genotype is an individual’s actual genetic structure. A phenotype is the
expression of a given genotype. Different genotypes can produce the same phenotypes. And the environment can affect a pheno- type, but experience does not change a genotype.
doMinanT and rECEssivE inHEriTanCE Genes have alternative forms known as alleles. Dominant/recessive inheritance occurs when a trait is caused by a single or autosomal gene that has only two alleles (e.g., A and a) and only one locus, a spe- cific location on a chromosome. Austrian monk Gregor Mendel (1822–1884) discovered this pattern in his famous studies of gar- den peas. (This form of genetic transmission is often called “Men- delian inheritance” in his honor.) The gene for color in Mendel’s peas had only two alleles, A (yellow, dominant) and a (green, recessive). Thus, three genotypes were possible: AA, aA (or Aa), and aa. Because A is dominant over a, however, both AA and aA plants were yellow, while aa plants were green. Thus, there are three genotypes, but only two phenotypes. Figure 2.5 illustrates patterns of inheritance for dominant and recessive disorders.
figure 2.5 dominant and recessive genetic disorders Patterns of transmission from parents to children for dominant (top figure) and recessive disor- ders (bottom figure). Note that the single gene (autosomal) disorder is either present or absent for both patterns of inheritance. Source: Based on Garone, Stephen. 1999. Genetics of Mental Disorders: A Guide for Students, Clinicians, and Researchers. Guilford Press.
Affected Father
Carrier Father
Unaffected Mother
Carrier Mother
Affected Son
(25%)
Unaffected Daughter
(25%)
Affected Daughter
(25%)
Unaffected Son
(25%)
Aa
Aa
Aa Aa
Aa aaaa
Affected Son
(25%)
Carrier Son
Carrier Daughter
Carrier (50%)
Unaffected (75%)
Unaffected Daughter
(25%)
AA Aa aaaA
aa
40 CHAPTER 2 causes of abnormal behavior
PolygEniC inHEriTanCE Dominant/recessive inheritance causes some rare forms of mental retardation (Plomin et al., 2008), but most mental disorders do not appear to be caused by a single gene. Instead, they are polygenic, that is, they are influenced by multiple genes (Gottesman, 1991)—and by the environment.
Polygenic inheritance is critical to how we think about ab- normal behavior. In contrast to the categorically different phe- notypes produced by a single gene (like yellow versus green), polygenic inheritance produces characteristics that fall along a dimension (like height). In fact, the distribution of a phenotype begins to resemble the normal distribution as more genes are in- volved (see Figure 2.6).
The distinction between categories and dimensions might seem a bit abstract, so let’s bring it down to earth with a familiar example. Test score averages are a dimension. Letter grades are different categories. We turn dimensions into categories by set- ting a cutoff. The cutoff can be critical, as you know if you ever ended up with an 89.9 average—and got a “B” for a letter grade. Like your professor, psychologists set cutoffs or thresholds for de- fining mental disorders.
All of this holds important implications for how we think about genes and abnormal behavior. We tend to think of emotional problems in terms of categories: A young woman is either depressed or not. We also tend to think of genes in terms of dominant and recessive inheritance: She either has the “gene for” depression or she doesn’t. However, both assumptions appear to be wrong.
But as best we can tell, there is no single “gene for” depres- sion or most any other known mental disorder. Instead, there appear to be multiple genes involved in the risk for different men- tal disorders, just as multiple genes affect height. And just like height, this means there is no clear genetic basis for drawing a line between normal and abnormal. People can be “really short,” “not really short,” “kind of short,” and so on. Similarly, because mental disorders are polygenic, people can be “really depressed,” “not re- ally depressed,” “kind of depressed,” and so on.
faMily inCidEnCE sTudiEs Behavior geneticists have de- veloped several methods for studying genetic contributions to behavior, including family incidence studies, twin studies, and adoption studies. Family incidence studies ask whether diseases “run in families.” Investigators identify normal and ill probands, or index cases, and tabulate the frequency with which other mem- bers of their families suffer from the same disorder. If a higher prevalence of illness is found in the family of an ill proband, this is consistent with genetic causation. The finding also is consistent with environmental causation, however, because families share environments as well as genes. Therefore, family incidence studies do not lead to firm conclusions about the role of genes versus the environment.
Twin sTudiEs Studies of twins, in contrast, can provide strong evidence about genetic and environmental contributions.
figure 2.6 single gene and Polygenetic inheritance Single genes produce phenotypes that differ qualitatively, as illustrated in the top panel. Multiple genes produce phenotypes that differ quantitatively. The distribution of traits approximates the normal curve as more genes are involved—as illustrated for only two genes in the bottom panel.
Fr eq
ue nc
y
AABB
AABb
AAbB
AaBB
aABB
AAbb
AaBb
aABb
aAbB
aaBB
AabB
Aabb
aAbb
aaBb
aabB
Aa
aA AAaa
Normal curve
Phenotype x Phenotype y
aabb
Monozygotic (MZ) twins are identical. One egg is fertilized by one sperm, and thus MZ twins have identical genotypes. Dizygotic (DZ) twins are fraternal. These twins are produced from two eggs and two sperm. Thus, like all siblings, DZ twins share an average of 50 percent of their genes, while MZ twins share 100 percent of their genes. Most MZ and DZ twin pairs are raised together in the same family. Thus MZ and DZ twins differ in their genetic similarity, but they are alike in their environmen- tal experiences.
The natural experiment of comparing MZ and DZ twins can reveal genetic and environmental contributions to behavior. For mental disorders, a key is the concordance rate for the two sets of twins. A twin pair is concordant when both twins either have the same disorder or are free from the disorder, for example, both suffer from schizophrenia. The twin pair is discordant when one twin has the disorder but the other does not, for example, one twin has schizophrenia but the co-twin does not.
Any differences between the concordance rates for MZ and DZ twins must be caused by genetics (assuming that MZ and DZ twin pairs experience similar environments). If a disorder is purely genetic, scientists should find a concordance rate of 100 percent for MZ twins and 50 percent for DZ twins (see Table 2.4). Test yourself. You should be able to explain why.
In contrast, similar concordance rates for MZ and DZ twins indicate environmental causation. This is true whether the con- cordance rates are both 0 percent, both 100 percent, or both anywhere in between. However, high versus low concordance rates reveal what kind of experiences are causal. High concor- dance rates point to the influence of the shared environment, experiences twins share in common, for example, growing up in
causes of abnormal behavior CHAPTER 2 41
table 2.4 Twin Studies: Implications of Different Findings Concordance for MZs versus dZs supports influence of Perfect Case1
MZ > DZ Genes MZ = 100%; DZ = 50%
MZ = DZ; both high Shared environment MZ = 100%; DZ = 100%
MZ = DZ; both low Nonshared environment MZ = 0%; DZ = 0%
1The identified influence explains everything in the perfect case. Actual concordance rates almost always fall between these extremes, thus providing an index of the relative contributions of genes, the shared environment, and/or the nonshared environment.
Robert Emery with identical twins he interviewed for a research project at the Twins Days Festival, the world’s largest gathering of twins.
poverty. If the shared environment explained all of the variance in a problem, the concordance rate would be 100 percent for both MZ and DZ twins (see Table 2.4).
What about low concordance rates? Low concordance rates point to the influence of the nonshared environment, experi- ences unique to one twin, for example, an abusive boyfriend or girlfriend. If the nonshared environment was entirely respon- sible for a problem, the concordance rate would be 0 for both MZ and DZ twins (see Table 2.4). As we have noted, however, abnormal behavior is not explained purely by genes, the shared environment, or the nonshared environment. Twin studies pro- vide useful estimates of the importance of each influence by yielding data in between the perfect scenarios summarized in Table 2.4.
adoPTion sTudiEs In adoption studies, people who were adopted are compared with their biological versus their adop- tive relatives (usually their parents) in terms of concordance for a disorder. If concordance is higher for biological than adoptive
relatives, then genetic factors are involved, because adopted chil- dren share their biological relatives’ genes but not their environ- ment. On the other hand, if children are more similar to their adoptive than to their biological relatives, then environment is causal, because adopted children share their adoptive relatives’ en- vironment but not their genes.
Think about the case of the adopted girl, Meghan, from the beginning of this chapter. Genetic influences are implicated if Meghan develops problems similar to her biological, but not adoptive, parents. On the other hand, environmental influences are causal if Meghan develops problems more similar to her adop- tive than her biological parents.
Adoption studies have some potential problems, for example, the fact that adoption placement can be selective. Still, you can be confident in the findings of behavior genetic research when adop- tion and twin studies produce similar results (Kendler & Prescott, 2006; Plomin et al., 2008).
gEnETiCs and PsyCHoPaTHology Genetic influences on mental disorders are pervasive, as you will learn in subsequent chapters. But traditional twin and adoption studies do not tell us what genetic mechanism is at work. When we read that twin studies reveal that a disorder is “genetic,” we may think there is “a gene for” depression, alcoholism, or hyperactivity. But such a conclusion is wrong.
Think about this: Criminal behavior is also “genetic,” as is divorce and political affiliation! (Concordance rates are higher for MZ than for DZ twins for all of these complex behaviors.) But no one thinks that people have a “crime gene,” a “divorce gene,” or a “Republican gene.” (We hope.) Behavior genetic research tells us that genes are important, but many genes appear to affect abnormal behavior, often in ways that are subtle and indirect. As we noted, geneticists and behavior geneticists are collaborating, and we may eventually identify specific genes involved in rare subtypes of certain mental disorders (as was discovered for rare in- tellectual disabilities; see Chapter 15). Even so, a large “multiply caused” group is likely to remain (as is also true for intellectual disabilities).
And unfortunately, people often misinterpret behavior genetic research (Dar-Nimrod & Heine, 2011; Kagan, 2007;
42 CHAPTER 2 causes of abnormal behavior
Rutter, Moffitt, & Caspi, 2006). One serious misinterpretation is that DNA is destiny. Genetic influences on abnormal behavior are predispositions, increased risks, not predestinations— inevitabilities (Faraone, Tsuang, & Tsuang, 1999).
It also is wrong to think that genetic characteristics cannot be modified. Even for intellectual disabilities with a known ge- netic cause, environmental experiences such as dietary restrictions or early intellectual stimulation can substantially increase IQ (Turkheimer, 1991). In short, the conclusion “It’s genetic” does not mean “It’s inevitable” or “It’s hopeless.”
Genetic influences on behavior are pervasive, but we want you to think critically and beyond familiar models of dominant and recessive inheritance. In fact, you should be skeptical of any- one who claims to have found “the” cause of any mental disorder (see Critical Thinking Matters).
gEnEs and THE EnvironMEnT Nature and nurture are not separate influences on behavior. Nature and nurture always work together (Li, 2003). You need to know two broad ways in which genes and the environment do this. The first is gene– environment interaction, genetic predispositions and environmen- tal experiences combining to produce more than their separate influ- ences. In fact, collaborating geneticists and behavior geneticists have identified specific genes that appear to produce abnormal behavior only under specific environmental circumstances, a very exciting area of research. But here is an important caution: Many studies of gene– environment interactions are not replicated in subsequent research (Risch et al., 2009). Of course, false leads are to be expected, when you combine a new field, 25,000 genes, innumerable potential ex- periences—and the complexity of human behavior. We know that genes and the environment work together; we are only beginning to discover how (Champagne & Mashoodh, 2009; Cole, 2009).
A second key concept is gene–environment correlation, the fact that our experience is correlated with our genetic makeup (Rutter et al., 2006). Anxious parents give children “anxious” genes and an anxious upbringing. Thrill-seeking, a genetically in- fluenced trait, also propels people into risky experiences. In short, experience is a genetically random. Anxious parenting, risk tak- ing, and probably most other experiences are correlated with our genetic makeup. This means that any link between an experience and a disorder may be explained by correlated genes, not by the experience itself (e.g., see Research Methods on page 33).
Psychological Factors We must begin our overview of psychological influences on abnormal behavior on a humbling note: We face the task of try- ing to explain abnormal behavior without a good understanding of normal behavior! Psychology does not have a widely accepted theory of personality, the essential traits that, taken as a whole, describe human behavior. This is a huge limitation, akin to describing circulatory diseases before agreeing about the normal structure and functions of blood, arteries, veins, and the heart! As
Harry Potter learned what it means to be wizard, yet psychologists do not agree about what defines normal human behavior. This makes the definition of abnormal (not normal) challenging.
a result, any listing of the psychological factors involved in men- tal disorders, including our own, is necessarily incomplete and perhaps controversial. Still, we can organize many psychologi- cal factors affecting mental health into six categories: (1) human nature, (2) temperament, (3) emotion, (4) learning and cognition, (5) our sense of self, and (6) human development.
Human nature What is human nature—psychological motivations that we share with other animals and others that are uniquely human? As you are well aware, this is a big question. Freud’s answer was that we have two basic drives, sex and aggression. In contrast, Watson suggested that we come into the world as blank slates—there is no human nature apart from experience. Today, psychologists are addressing questions about human nature in an exciting and con- troversial field of study called evolutionary psychology.
EvoluTionary PsyCHology Evolutionary psychology is the application of the principles of evolution to understanding the animal and human mind (Confer et al., 2009). Evolution- ary psychologists study species-typical characteristics—genetically influenced motivations that people share in common. Behavior
causes of abnormal behavior CHAPTER 2 43
CriTiCal Thinking matters
Do Vaccinations Cause Autism?
In 1998, the highly reputable British journal Lancet published a study by Dr. Andrew Wakefield and a dozen coauthors (1998). The authors speculated that the measles/mumps/rubella (MMR) vaccination might be responsible for 12 cases of autism they diagnosed. Autism is a severe psychological disorder that begins very early in life and is marked by extreme problems with communication, social interaction, and stereotyped behavior (see Xavier Video Case). The researchers did not analyze any sci- entific data, or study children who were vaccinated but did not develop autism. In fact, a skeptical editorial was published with the article (Chen & DeStefano, 1998).
None of these limitations prevented a subsequent tsunami of fear and claims that vaccinations cause autism. Warnings spread on television, radio, in print, and especially over the Internet. The U.S. Congress held hearings. The National Institutes of Health funded new research. Many parents refused to vacci- nate their children. This worried public health officials. Measles, mumps, and rubella are serious illnesses, and the MMR vaccina- tion not only protects the vaccinated child but helps keep these highly contagious diseases from spreading (Offit, 2010).
What does science say about the vaccination hypothesis? One Danish study of half a million children found no differences in the rate of autism between children who did and did not re- ceive the MMR vaccine containing the supposed autism causing agent, thimerosal (Hviid et al., 2003), as did a major study in the United Kingdom (Chen, Landau, & Sham, 2004) and two in Japan (Honda et al., 2005; Uchiyama et al., 2007). If this does not make you skeptical, consider this: 10 of the original 13 co- authors of the 1998 paper retracted their speculation (New York Times, March 4, 2004). Or consider this: In 2011, the prestigious Institute of Medicine concluded that evidence favors rejection of the hypothesis that MMR vaccine causes autism (Stratton, Ford, Rusch, & Clayton, 2011).
Misinformation, fear, and anger still abound even after public retractions and negative results for hundreds of thousands of children (versus speculations about 12). Search the Internet, and you will find many vehement assertions that MMR causes autism. With so much information on the Internet (and opinion masquer- ading as information), you have to be skeptical in evaluating all kinds of assertions—including your own! We want you to think critically in abnormal psychology and in life.
And here’s another reason to think critically: Lawyers. Thousands of parents are suing a special federal compensation court that awards money for injuries caused by vaccines. The court was established in 1988 in response to fears that the diphtheria- pertussis-tetanus (DPT) vaccine causes neurological damage, fears that experts now conclude were false (Sugarman, 2007).
Still, lawyers convinced some juries otherwise, and the legal costs led most manufacturers to stop making DPT. When the last man- ufacturer threatened to halt production, the U.S. government created the fund, fearing devastating public health consequences if children were no longer vaccinated (Sugarman, 2007).
In 2008, the court awarded money to the parents of Hannah Poling, who was diagnosed with autism. Hannah’s behavior de- teriorated rapidly around the time she was vaccinated. However, she also had a rare disorder of the mitochondria, the energy factories of cells. Mitochondrial disorders often surface follow- ing only a severe infection. An expert witness claimed that this is what happened to Hannah as a result of her multiple vaccina- tions, a claim that leading vaccine scientists note has no basis in science. Vaccines, in fact, may protect people with mitochondrial disorders by warding off serious infection (Offit, 2008).
Know this: Legal rulings are not scientific evidence. The law is about convincing a judge or jury that some allegation is true. Scientists must prove facts publicly and repeatedly. In fact, the same federal vaccine court has now rejected the idea that vac- cines cause autism in three specially selected test cases (New York Times, February 13, 2009).
And while we are on the topic of legal action, here’s another one: In 2010, Britain’s General Medical Council banned Dr. Andrew Wakefield from practicing medicine in his native country due to unprofessional conduct surrounding his vac- cine “research” (New York Times, May 24, 2010). Also in 2010, Lancet took the highly unusual step of withdrawing Wakefield et al.’s (1998) article. Why? Wakefield failed to disclose that his anti-MMR “research” was supported financially by lawyers su- ing manufacturers of the MMR vaccine—or that, in 1997, he had patented a new measles vaccine that might have replaced MMR (New York Times, February 2, 2010). Skeptical yet?
It is far easier to create false fears than to dispel them. In November 2010, the Web site of the National Institute of Child Health and Human Development read: “There is no con- clusive scientific evidence that any part of a vaccine or combi- nation of vaccines causes autism . . .” If you are paranoid, you can focus on the “conclusive” qualification. But science can never prove the negative. (Prove that those Martian scientists we discussed earlier did not write this textbook. You just can’t see them!) This is why the burden of proof rests upon any sci- entist who offers a hypothesis. If I speculate that vaccinations cause autism (or Martians write textbooks), I need to prove I am right. You do not need to prove me wrong. Skepticism is a basic rule of science. Until I show that my hypothesis is true, the community of scientists assumes it is false. Critical thinking matters.
44 CHAPTER 2 causes of abnormal behavior
geneticists, in contrast, study how genes influence individual dif- ferences, or what makes people different from one another. Evolu- tionary psychologists assume that animal and human psychology, like animal and human anatomy, evolved through natural selec- tion and sexual selection.
Natural selection is the process in which successful, inherited adaptations to environmental problems become more common over successive generations. The adaptation is selected by evolu- tion, because it increases inclusive fitness, the reproductive success of those who have the adaptation, their offspring, and/or their kin. For example, the large human brain, with its particularly large cerebral cortex, was selected by evolution because of the ad- aptations it enabled (e.g., the use of tools and weapons). Early humans with larger brains were more likely to survive and pass their adaptive genes on to more offspring.
Sexual selection improves inclusive fitness through increased access to mates and mating. Mating success can be increased by successful intrasexual competition, for example, a dominant male limits the mating opportunities of other males; or by successful intersexual selection, for example, a more brightly colored bird attracts more members of the opposite sex (Gaulin & McBurney, 2001; Larsen & Buss, 2002).
Evolutionary psychology seeks to understand how evolution shaped human behavior. Psychologists do not agree about the na- ture of human nature, but two qualities that belong at the top of anyone’s list are the need to form close relationships and the competition for dominance.
aTTaCHMEnT THEory The writings of British psychiatrist John Bowlby (1907–1990) greatly influenced psychologists’ views about the human need to form close relationships. The heart of Bowlby’s theory was the observation that infants form attachments early in life—special, selective bonds with their caregivers.
Bowlby based his approach, known as attachment theory, on findings from ethology, the study of animal behavior. Ethologists documented that close relationships develop between infants and caregivers in many species of animals. Human infants develop se- lective bonds to caregivers more slowly during the first year of life. These bonds, together with displays of distress when separated, keep infant and parent in close proximity. You can readily observe the result: Ducklings swim in line behind their mother; toddlers explore the world in an irregular orbit around a parent. From an evolutionary standpoint, proximity has survival value, because parents protect their offspring from danger. Attachment behavior is an inborn characteristic, a product of natural selection.
Attachment theory has generated much psychological re- search (Cassidy & Shaver, 2008). Particularly relevant to abnormal behavior are studies of insecure or anxious attachments, parent– child relationships that are a product of inconsistent and unre- sponsive parenting during the first year of life (Ainsworth et al., 1978). Anxious attachments can make children mistrustful, de- pendent, and/or rejecting in subsequent relationships, patterns that may continue into adult life. Attachment difficulties can be
Mammals form strong bonds between infants and caregivers. Disruptions in human attachments can contribute to abnormal behavior.
overcome (Rutter & Rutter, 1993), and research shows that sup- portive relationships promote mental health throughout the life span, not just early in life (Dykas & Cassidy, 2011).
doMinanCE The development of attachments, or more gen- erally of affiliation with other members of the same species, is one of the two broad categories of social behaviors studied by ethologists. The second is dominance, the hierarchical order- ing of a social group into more and less privileged members (Sloman, Gardner, & Price, 1989). Dominance hierarchies are easily observed in human as well as other animal social groups. Dominance competition is basic to sexual selection, and there- fore a prime candidate on our short list of species-typical hu- man qualities (Buss, 2009). Exciting, recent theorizing suggests that dominance motivation play a role in antisocial behavior, narcissism, and mania (Johnson, Leedom, & Muhtadie, 2012).
Additional motivations surely belong on psychology’s “peri- odic table” of human elements (Kenrick et al., 2010). Still, we are confident that attachment and dominance will rank high on the final list. Freud might agree. We view Freud’s basic drives, sex and aggression, as metaphors for the broader motivations of affiliation and dominance.
Temperament A key area of research on personality is the study of temperament, characteristic styles of relating to the world. Researchers generally
causes of abnormal behavior CHAPTER 2 45
that are older in evolutionary terms and more similar to brain structures found in other animals (who do not have humans’ large cortex). Thus, our feelings are more “basic” or primitive than our thoughts, which are controlled by the cerebral cortex, a more recent product of evolution (Shariff & Tracy, 2011). Cog- nition can regulate emotion, but we cannot wholly control our feelings intellectually (Panksepp & Biven, 2012). This fact often becomes an issue in treating abnormal behavior, as people may want to but cannot easily change their emotions.
learning and cognition Motivations, temperament, and emotions can be modified, at least to some degree, by learning. Earlier, we discussed classical and operant conditioning, two modes of learning that are essential to the development of normal and abnormal behavior. We know, for example, that classical conditioning can create new fears, and antisocial behavior can be maintained by positive reinforcement.
A third learning mechanism described by the U.S. psycholo- gist Albert Bandura of Stanford University (Bandura & Walters, 1963) is modeling, or learning through imitation, a process that you surely have observed many times. A particular concern for ab- normal behavior is when parents or other important adults model dysfunctional behavior for children, for example, excessive drinking.
Cognitive psychologists study other, more complex learning mechanisms such as attention, information processing, and mem- ory. In doing so, cognitive psychologists often draw analogies be- tween human thinking and computers, but the “human computer” apparently is programmed to make decision making more efficient but less objective (Kahneman, 2003). We routinely make cognitive errors not because we reason wrongly, but because we use short- hand calculations (heuristics) that require little effort and typically are accurate enough—but sometimes may be way off the mark.
Cognitive psychology has profoundly affected theorizing about the cause of mental disorders, as has the parallel field of social cognition—the study of how humans process information about the social world. The important concept of attribution
agree that temperament consists of five dimensions (McAdams & Pals, 2006; Zuckerman, 1991). The “big five” are (1) openness to ex- perience—imaginative and curious versus shallow and imperceptive; (2) conscientiousness—organized and reliable versus careless and negligent; (3) extraversion—active and talkative versus passive and re- served; (4) agreeableness—trusting and kind versus hostile and selfish; and (5) neuroticism—nervous and moody versus calm and pleasant. The acronym OCEAN (the first letter of each term) will help you to remember “the big five.” Individual differences in temperament are basic to understanding personality disorders (Chapter 9).
Emotions Emotions, internal feeling states, are essential to human expe- rience and to our understanding of mental disorders. We have hundreds of words for different feelings in the English language. What emotions are most essential? Researchers have used statisti- cal analysis to reduce our lexicon of feelings to six basic emotions:
• Love • Anger • Joy • Sadness • Surprise • Fear
This list can be pared further into two categories, positive emotions (the left column) and negative emotions (the right col- umn). Of course, negative emotions are most relevant to abnormal psychology, but differentiating between negative emotions is also a key. One recent study found that, among people who experienced intense negative emotions, those who could better describe their feelings consumed less alcohol than others who could only talk generally about being upset or feeling bad (Kashdan et al., 2010).
Emotions come to us without intention, effort, or desire. Emotions are controlled primarily by subcortical brain structures
The cartoon pokes fun at evolution and perhaps suggests a new break up line. © Carolita Johnson/The New Yorker Collection/www.cartoonbank.com
Evolution shapes behavior in animals and humans. Do humans compete for dominance, perhaps in more subtle ways than these stags compete?
46 CHAPTER 2 causes of abnormal behavior
argued that people develop many different role identities, vari- ous senses of self corresponding with actual life roles. A related, contemporary theory is that people have multiple relational selves, unique actions and identities linked with different significant relationships (Chen, Boucher, & Tapias, 2006).
Self-control—internal rules for guiding appropriate behavior—is another important part of the internal self. Self- control is learned through the process of socialization, where parents, teachers, and peers use discipline, praise, and their own example to teach children prosocial behavior and set limits on their anti- social behavior. Over time, these standards are internalized—that is, the external rules become internal regulations. The result is self-control (Maccoby & Mnookin, 1992).
Self-esteem, valuing one’s abilities, is another important and sometimes controversial aspect of our sense of self. The concept of self-esteem has been derided recently, partly in reaction to mis- guided school programs that urged raising children’s self-esteem as a cure to everything from school dropout to teen pregnancy (Swann, Chang-Schneider, & McClarty, 2007). High self-esteem appears to be as much a product of success as a cause of it; raising children’s self-esteem in isolation from actual achievement produces little benefit (Baumeister et al., 2003). Similarly, low self-esteem can result from psychological problems as well as cause them.
One final note: Our sense of self may be uniquely human, but there is still no dualism between mind and body. Like all psychological experiences, our sense of self is represented in the brain. In fact, the human sense of self may be localized in the frontal lobe. A terrible form of degenerative brain disease rap- idly damages the front lobe, and causes patients to lose much self-reflection and self-control (Levenson & Miller, 2007).
stages of development How people grow and change is of basic importance to normal and abnormal psychology. A key developmental concept is that psy- chological growth can be divided into developmental stages— periods of time marked by age and/or social tasks during which children or adults face common social and emotional challenges.
Two prominent theories of developmental stages are Freud’s theory of psychosexual development and Erikson’s theory of
illustrates this approach. Attributions are perceived causes, people’s beliefs about cause–effect relations. We are “intuitive scientists.” We routinely draw shorthand conclusions about cau- sality instead of examining things scientifically. If your boyfriend gets mad at you for “ditching” him at a party, for example, you are unlikely to examine his feelings objectively. Instead, you at- tribute his anger to some reasonable cause, perhaps his tendency to cling to you. Intuitive judgments are efficient because they re- quire little cognitive effort, but research shows that attributions often are inaccurate (Nisbett & Wilson, 1977; Wilson, 2002).
One cognitive theory suggests that automatic and distorted perceptions of reality cause people to become depressed (Beck et al., 1979). For example, people prone to depression may con- clude that they are inadequate based on a single unpleasant ex- perience. A successful treatment based on this theory encourages depressed people to be more scientific and less intuitive in evalu- ating conclusions about themselves (see Chapter 5). One contro- versy, however, is whether depressed people actually see the world all too accurately. Perhaps nondepressed people are the ones who make routine cognitive errors by seeing the world, and them- selves, in an unrealistically positive light (Taylor et al., 2003).
the sense of self We share emotions and motivations with other animals, and we share some information-processing strategies with computers. Per- haps our sense of self is uniquely human. The exact definition of self can be elusive, however, both in psychological theory and personally.
One influential idea is Erik Erikson’s (1968) concept of identity, an integrated sense of self. Erikson viewed identity as the product of the adolescent’s struggle to answer the question, “Who am I?” As we discuss in Chapter 17, Erikson urged young people to take some time and try new values and roles before adopting a single, enduring identity.
Other theorists argue that we do not have one identity but many “selves.” The psychologist George Kelly (1905–1967), for example, emphasized the identities linked with the different roles that people play in life. These include obvious roles such as being a daughter, a student, and a friend, as well as less obvious roles, such as being a “caretaker,” a “jock,” or “the quiet one.” Kelly
© Charles Barsotti/The New Yorker Collection/www.cartoonbank.com.
causes of abnormal behavior CHAPTER 2 47
table 2.5 Freud’s and Erikson’s Stage Theories of Development aGE1 0–1½ 1–3 2–6 5–12 11–20 18–30 25–70 65 on
freud oral anal phallic latency Genital
Oral gratification through breastfeeding. Meeting one’s own needs.
Learning control over environment and inner needs through toilet training.
Sexual rivalry with opposite- gender parent. Oedipal conflicts, penis envy, identification.
Not a stage, as psychosexual development is dormant during these ages.
Mature sexuality and formation of mutual heterosexual relationships.
Erikson Basic trust vs. Basic Mistrust
autonomy vs. shame and doubt
initiative vs. Guilt
industry vs. inferiority
identity vs. role confusion
intimacy vs. self- absorption
Generativity vs. stagnation
integrity vs. despair
Developing basic trust in self and others through feeding and care-taking.
Gaining a sense of competence through success in toileting and mastering environment.
Gaining parental approval for initiative rather than guilt over inadequacy.
Curiosity and eagerness to learn leads to a sense of competence or inadequacy.
Identity crisis is a struggle to answer question, “Who am I?”
Aloneness of young adult resolved by forming friendships and a lasting intimate relationship.
Success in work but especially in raising the next generation, or failure to be productive.
Satisfaction with the life one lived rather than despair over lost oppor- tunities.
1Ages are approximate, as indicated by overlap in age ranges
Intimate relationships can be a source of great social support or emotional distress.
psychosocial development. Freud highlighted the child’s internal struggles with sexuality as marking the various stages of develop- ment. In contrast, Erikson emphasized social tasks and the conflicts involved in meeting the demands of the external world. Erikson also suggested that development does not end with adolescence; rather, he proposed that development continues throughout the life span.
The key tasks, ages, and defining events of these two stage theories are summarized in Table 2.5. Note the differences
between the theories, but also note that both theorists used similar ages to mark the beginning and end of different stages. Other the- orists also have suggested that key developmental transitions occur around the ages of 1, 6, and 12. These are critical times of change for children.
Developmental transitions mark the end of one developmen- tal stage and the beginning of a new one—for example, the end of childhood and the beginning of adolescence. Developmental
48 CHAPTER 2 causes of abnormal behavior
of some major life experience (Rutter, 2007). If we find that MZ twins who divorce have more psychological problems than their married co-twins, we know that the difference is not due to genes. We also know that the difference is not caused by childrearing or other experiences that twins share. Why? Identical twins have identical genes and grow up in the same families. Any difference between them therefore must be caused by the nonshared environ- ment, their unique experiences, one of which is divorce in the pres- ent example. In fact, twin research suggests that divorce does cause some psychological problems both in children (D’Onofrio et al., 2007) and adults (Horn et al., in press; South & Krueger, 2008).
soCial rElaTionsHiPs Research also shows that a good rela- tionship with someone outside of the family is associated with bet- ter mental health among children (Landis, Gaylord-Harden, & Malinowski, 2007; Werner & Smith, 1992) and adults (Birditt & Antonucci, 2007; Reis, Collins, & Berscheid, 2000). A few things are critical about this social support—the emotional and practical assistance received from others. Significantly, one close relationship can provide as much support as many relationships. The greatest risk comes from having no social support. In addition, it is much worse to be actively rejected than to be neglected. Especially among children, it is far worse to be “liked least” than not to be “liked most” by your peers (Coie & Kupersmidt, 1983). Finally, neuro- science and psychological evidence shows the depression and anger that come from being ostracized, ignored, or excluded (Williams & Nida, 2011).
Once again, the association between abnormal behavior and the relationship troubles may have several causes. For some, peer rejection may cause emotional difficulties. In other cases, the lack of a close relationship may be a consequence of abnormal behav- ior. Finally, social support may help some people to cope more successfully with preexisting emotional problems.
gender and gender roles Gender and gender roles, expectations regarding the appropri- ate behavior of males or females, can dramatically affect our be- havior. Some gender differences are determined by genetics and hormones, but socially prescribed gender roles also exert a strong influence on our behavior (Maccoby, 1998).
Gender roles may influence the development, expression, or stigma of psychopathology. Some theorists suggest, for example, that women’s traditional roles foster dependency and helpless- ness, which accounts for the considerably higher rates of depres- sion among women (Nolen-Hoeksema, 1990). Others argue that gender roles may not cause abnormal behavior, but influence how psychopathology is expressed. For example, social expectations may allow women to become depressed when confronted with adversity, whereas men’s roles dictate that they “carry on” or perhaps sooth their inner turmoil with alcohol or drugs. Finally, recent research shows that more stigma is attached to gender-typical emotional problems. People view depression in women and alcohol abuse in men as more controllable than the converse (depression in men,
transitions are often a time of turmoil. As we are forced to learn new ways of thinking, feeling, and acting, stressful developmental transitions may worsen or contribute to abnormal behavior. They can also be extremely challenging psychologically, as we discuss in detail in Chapter 17.
Social Factors At a broader level of analysis, abnormal behavior can be under- stood in terms of social roles, behavior that, like a role in a play, is shaped by social “scripts.” In fact, labeling theory asserts that emo- tional disorders themselves are enactments of prescribed social roles (Rosenhan, 1973). Labeling theory suggests that people’s ac- tions conform to the expectations created by the label, a process termed the self-fulfilling prophesy (Rosenthal, 1966).
There is little doubt that expectations affect behavior, but la- beling alone offers a limited understanding of much abnormal behavior. For example, how could labeling someone “schizo- phrenic” cause severe hallucinations, delusions, and life disrup- tions? (On the other hand, labeling a child a “troublemaker” may play a key role in the development of antisocial behavior.) The roles we play in life—including roles shaped by gender, race, so- cial class, and culture—help to shape who we become. But psy- chopathology is much more than a social role.
Potential social influences on abnormal behavior are numer- ous, including interpersonal relationships, social institutions, and cultural values. We can offer a few key examples here, including close relationships, gender roles, ethnicity, prejudice, and poverty.
Close relationships Researchers consistently find that relationship problems, particularly conflict and anger in close relationships, are associated with various emotional disorders (Beach et al., 2006; Miklowitz, Otto, & Frank, 2007). Do troubled relationships cause abnormal behavior, or do an individual’s psychological problems cause relationship difficulties?
MariTal sTaTus and PsyCHoPaTHology The association between marital status and psychopathology is a good example of the cause–effect dilemma. The demographics of the U.S. family have changed greatly over the last few decades. Cohabitation before marriage is frequent, many children are born outside of marriage, and almost half of all marriages end in divorce (Bramlett & Mosher, 2001). In part because of the uncertainty created by these rapid changes, researchers have carefully studied the psychological conse- quences of alternative family structures for children and adults.
Marital status and psychological problems clearly are corre- lated. Children and adults from divorced or never-married fami- lies have somewhat more psychological problems than people from always-married families (Amato, 2010; Emery, Shim, & Horn, 2012; Waite & Gallagher, 2000; Whisman, Sheldon, & Goering, 2000). But does marital status cause these problems?
In order to better address the question of causality, researchers are now comparing twins (or their children) who differ in terms
causes of abnormal behavior CHAPTER 2 49
links the prejudice experienced by gays and lesbians to an increased risk for mental health problems (Meyer, 2003).
Poverty is linked with many stressors (Evans & Kim, 2012), including exposure to gruesome traumas. One researcher found that 12 percent of school–aged children living in a Washington, DC, neighborhood reported seeing a dead body in the streets out- side their homes (Richters, 1993). Poverty also increases exposure to chemical toxins, such as the lead found in old, chipped paint and automotive exhaust fumes (Evans, 2004). When ingested at toxic levels, lead can damage the central nervous system.
We recognize that society and culture influence abnormal be- havior even more broadly. Our lives, our education, and even our science are embedded within our culture. Societal practices, be- liefs, and values help to shape the definition of abnormal behav- ior and the scientific enterprise that attempts to uncover its roots.
alcohol abuse in women), and as a result, they are less sympathetic and less inclined to offer help (Wirth & Bodenhausen, 2009).
Some believe that androgyny—the possession of both “female” and “male” gender-role characteristics—is the answer to the problems associated with being either overly “feminine” or overly “masculine.” Others embrace traditional gender roles. We do not address this value conflict in this text, although we do consider gender differences in the prevalence of various psy- chological disorders. When appropriate, we also interpret gen- der differences in terms of the roles played by men and women.
Prejudice, Poverty, and society Prejudice and poverty are broad social influences on psycho- logical well-being in the United States today (Cox, Abramson, Devine, & Hollon, 2012). We consider these two factors together because they are so commonly linked in American life. In 2009, 9.3 percent of white families were living below the poverty level, compared with 22.7 percent of black, 22.7 percent of Latino, and 9.4 percent of Asian families. Race and poverty are also closely linked to marital status. Among African Americans, 8.6 percent of married families lived in poverty compared to 36.7 percent of families headed by single women. Among whites, the comparable rates were 5.4 percent married versus 27.3 percent single women; 16.0 percent versus 38.8 percent for Hispanics; and 7.9 versus 16.9 for Asians (U.S. Census Bureau, 2012).
Poverty affects a disproportionate number of African Americans, but the experiences of American blacks and whites differ in many ways. African Americans have endured a history of slavery and discrimination, and racial prejudices undermine physical and mental health (Clark et al., 1999). Of course, African Americans are not the only targets of prejudice. For example, extensive evidence
Socially prescribed gender roles exert a strong influence on our behavior and perhaps on the development, expression, and consequences of psychopathology.
MyPsychlab ViDeO CaSe
Autism
XAVIER
“He is now talking, which was a blessing.”
Watch the Video Xavier: Autism on MyPsychLab
As you watch the video, observe Xavier’s communication struggles and odd behavior, and keep in mind that he is functioning pretty
well in comparison to many children with autism.
50 CHAPTER 2 causes of abnormal behavior
The biological, psychodynamic, cognitive-behavioral, and humanistic approaches to understanding the causes of abnormal behavior are alternative paradigms, and not just alternative theo- ries. Biological approaches emphasize causes “within the skin.” Psychodynamic theory highlights unconscious processes. Cognitive- behavioral viewpoints focus on observable, learned behavior. The humanistic paradigm argues that behavior is a product of free will.
Abnormal behavior is best understood in terms of the biopsycho- social model, the combination of different biological, psychologi- cal, and social factors. systems theory is a way of integrating dif- ferent contributions to abnormal behavior. Its central principle is holism, the idea that the whole is more than the sum of its parts.
Biological factors in abnormal behavior begin with the neuron, or nerve cell. Communication between neurons occurs when the axon terminals release chemical substances called neurotransmitters into the synapse between nerve cells. Disrupted communication among neurons, particularly disruptions in the functioning of various neu- rotransmitters, is involved in several types of abnormal behavior, although you should be cautioned against mind–body dualism.
The brain is divided into three subdivisions: the hindbrain, the mid- brain, and the forebrain. Because of the rudimentary state of our knowledge about the brain, only the most severe mental disorders have been clearly linked with abnormalities in neuroanatomy.
Psychophysiology involves changes in the functioning of the body that result from psychological experiences. Psychophysiological arousal is caused by the endocrine system and the nervous system. Endocrine glands release hormones into the bloodstream that regulate some aspects of normal development as well as some responses to stress. The auto- nomic nervous system is the part of the central nervous system that is responsible for psychophysiological reactions.
Most forms of abnormal behavior are polygenic—that is, caused by more than one gene. While genes are involved in most
Summary2
getting helP
The problems that you study in abnormal psychology can touch your life in a very personal way. At one time or an-other, you, someone in your family, or one of your close friends will likely experience a psychological problem. If so, we hope you will seek and find meaningful help. What can you do if you think you may want to get help?
A good place to start is to talk frankly with someone you trust— a friend, a family member, a mental health professional, maybe a professor. Taking this step can be difficult, but you will surely be relieved once you have opened up a little. In fact, this may be the end of your search. With the aid of a little perspective, you may be reassured that what you thought were “crazy” feelings or concerns are pretty normal.
Normal? Yes. We mean it when we say that there is not a high wall dividing normal from abnormal behavior. Negative emotions are part of everyday life. Most of us experience mild to moder- ate levels of anxiety, sadness, and anger fairly often. In fact, these emotions are often adaptive. These feelings can energize us to cope with the challenges in our lives. So, maybe all you re- ally need is the understanding and perspective of a caring friend or relative, or of an objective third party.
Recognizing where you are in your life may also help you to achieve a little perspective. The late teens and early
twenties—the age of many people taking this class—are fre- quently at a time of uncertainty and self-doubt. It is quite com- mon for young people to question their goals, beliefs, values, friendships, sexuality, family relationships, and almost every- thing else. If this sounds like you, you may want to read ahead in Chapter 17, which discusses many of the challenges of the transition to adult life. You also may want to look at Chapter 17 if you are a nontraditional student, because we also discuss many other common but trying developmental transitions throughout the adult life span. Times of change and challenge can be very exciting, but they also can be very distressing and lonely.
What should you do if you do not feel better after talking with someone you trust? We suggest that you consider consulting a mental health professional. This is a good next step whether you think you are suffering from a psychological problem, are not sure, or simply want help with some normal but distressing life experience. We know that there can be a stigma about seeing a therapist, but we strongly believe that the stigma is wrong. Mental health problems are incredibly common, and a therapist, or maybe your family doctor, can offer you an informed perspec- tive and some good treatment alternatives. We give suggestions about how to go about finding a reliable mental health profes- sional in the Getting Help section of Chapter 3.
causes of abnormal behavior CHAPTER 2 51
mental illnesses, the fact that a psychological disorder has a genetic component does not mean that it is inevitable.
Psychology has not developed a list of its core components. Some promise toward this goal is offered by evolutionary psychology, the application of the principles of evolution to our understanding of the animal and human minds. Two basic psy- chological motivations seen in humans and other animals are the formation of attachments and competition for dominance.
Temperament is an individual’s characteristic style of relating to the world, and researchers agree on the “big five” dimensions of temperament.
Emotions are internal feeling states that come to us without intention, effort, or desire. Emotional disruptions are at the core of many mental disorders.
key terms attachments 44 attributions 46 autonomic nervous system 39 behavior genetics 39 biopsychosocial model 25 cerebral cortex 38 cerebral hemispheres 38 chromosomes 39 classical conditioning 30 concordance rate 40 correlational study 33 correlation coefficient 33 defense mechanism 29 developmental
psychopathology 33 developmental stages 46 diathesis 32
dizygotic (DZ) twins 40 dominance 44 dualism 35 ego 29 emotions 45 endocrine system 38 evolutionary psychology 42 extinction 30 gender roles 48 genes 39 gene–environment
correlation 42 gene–environment
interaction 42 genotype 39 hormones 38 hypothalamus 37
id 29 identity 46 lateralized 38 limbic system 37 modeling 45 monozygotic (MZ) twins 40 neurons 34 neurotransmitters 34 nonshared environment 41 operant conditioning 30 paradigm 25 phenotype 39 polygenic 39 premorbid history 33 probands 40 prognosis 33 psychoanalytic theory 29
psychophysiology 38 receptors 34 reductionism 31 reuptake 35 reverse causality 33 risk factors 32 self-control 46 shared environment 41 social support 48 stress 32 superego 29 synapse 34 systems theory 31 temperament 44 third variable 33 ventricles 38
Learning mechanisms include classical conditioning, operant conditioning, modeling, and human cognition and contribute to both normal and abnormal behavior.
The sense of self is a uniquely human quality that may also play a role in causing emotional problems.
The idea of developmental stages not only charts the course of normal development, against which abnormal behavior must be compared, but it also highlights the important issue of develop- mental transitions.
Social support from people other than family members can be an important buffer against stress. Gender roles may influence the development, expression, or consequences of psychopathol- ogy. Race and poverty are also broad social influences on psy- chological well-being.
2.1 What is the biopsychosocial model and why do we need it? Paradigms can tell us how to find answers, but sometimes the guid- ance can be a hindrance . . . (see page 30).
2.2 What does “correlation does not mean causation” mean? A correlation may result from causation, but there are always two alternative explanations: reverse causality and third variables . . . (see page 33).
2.3 How is “mental illness caused by a chemical imbalance in the brain” an example of reductionism? This means depression is caused by a “chemical imbalance in the brain,” right? Wrong . . . (see page 35).
2.4 Are scientists likely to discover a gene that causes mental disorders? . . . there is no single “gene for” depression or most any other known mental disorder . . . (see page 40).
2.5 How do social and psychological factors contribute to emotional problems? . . . any listing of the psychological factors involved in mental disor- ders, including our own, is necessarily incomplete and likely to be controversial . . . (see page 42).
2.6 Is abnormal behavior really all about labeling and role playing? The roles we play in life—including roles shaped by gender, race, social class, and culture—help to shape who we become. But psycho- pathology is much more than a social role . . . (see page 48).
critical thinking review
The Big Picture
3
treatment of psychological disorders
treatment of psychological disorders CHAPTER 3 53
3 The Big Picture learning objectives
3.1 What do treatments for psychological problems look like?
3.2 How did Freud influence psychotherapy?
3.3 What is cognitive-behavior therapy?
3.4 Does psychotherapy work?
3.5 What is the placebo effect? How do placebos work?
3.6 Is it important to “click” with your therapist?
Many people seek psychological help when battling bulimia, de- pression, anxiety, or other psychological problems. Others consult a professional when struggling with relationships, or searching for a happier, more meaningful life. Can treatment help? Does it matter if you see a psychiatrist, clinical psychologist, social worker, or coun- selor? Should you look for someone who specializes in your particu- lar problem? Should you try medication? What should you expect a therapist to do and say? How can “talking” help?
Overview What can help? Few questions in abnormal psychology are more important than this one. We use psychological science to explore answers to this essential question in this chapter. However, we continue to ask, “What helps?” throughout the text, because re- search shows that different treatments work better for different disorders (Barlow, 2008; Nathan & Gorman, 2007).
One treatment that can help is psychotherapy, the use of psychological techniques and the therapist–client relationship to produce emotional, cognitive, and behavior change. We can de- fine psychotherapy generally, but it can be a challenge to be more specific. One complication is that adherents to different paradigms offer very different treatments (Prochaska & Norcross, 2006). Mental health professionals often ask one another, “What is your
theoretical orientation?” The answer is supposed to be “biological,” “psychodynamic,” “cognitive-behavioral,” or “humanistic,” an indi- cation of the therapist’s preferred treatment approach.
Today, most mental health professionals describe them- selves as eclectic, meaning they use different treatments for different disorders (Bechtoldt et al., 2001). We embrace the eclectic approach, as long as clinicians use research to select the most effective treatment (Baker, McFall, & Shoham, 2008; Chambless & Ollendick, 2000). That is, the practice of psycho- therapy must be evidenced-based. Research may support alter- native treatments, based on either therapy outcome, how well a treatment works, or therapy process, what makes therapy work (Kazdin, 2008).
Evidence-based treatment is the scientific—and practical— approach to therapy. Unfortunately, some therapists fail to edu- cate their clients about evidence-based treatments. Yet, there is an even bigger problem: Most people with psychological problems do not get any help. Over one in 10 people in the United States get some kind of mental health treatment, and rates of receiving help have increased in recent decades. Yet, two-thirds of people with a diagnosable mental disorder still do not receive treatment (Kessler et al., 2005).
We introduce treatment with the following case study. As you read, ponder what you think might be wrong with this young woman and what might help her. After the case, we discuss how different therapists might treat her using a bio- logical, psychodynamic, cognitive-behavioral, or humanistic approach.
Why Is Frances Depressed? Frances was a 23-year-old woman when she first sought treat- ment. She had been depressed for almost three years, with peri- ods of relative happiness or deeper despair. When she came into therapy, her depression was severe. She had little appetite, had lost 10 pounds over the previous six weeks, and her erratic sleep- ing patterns were worse than usual. She awoke around 2 or 3 a.m. every night, tossed in bed for several hours, and finally fell asleep again near dawn.
Frances reported feeling profoundly depressed about herself, her new marriage, and life in general. She admitted to occasional thoughts of suicide, but she could never commit the act. She felt that she “lacked the courage” to take her own life. Frances also said that she lacked motivation. She withdrew from her hus- band and the few friends she had, and she frequently called in sick at work. Frances’s reported symptoms were consistent with her careless dress, frequent bouts of crying, and slowed speech and body movements.
Frances said she had a happy childhood. She had not known depression until the current episode began in her last year in col- lege. At first, she convinced herself that she was only suffering from “senior year syndrome.” She wasn’t sure what to do with her life. Secretly, she longed to move to New York and finally break out and do something exciting. But when she told her parents
54 CHAPTER 3 treatment of psychological disorders
about her plans, her mother begged Frances to return home. She insisted that the two of them needed to have fun together again after four long years with Frances away at school. Frances returned home.
Shortly after moving home, Frances realized that her difficul- ties were much more serious than she had thought. She found herself intermittently screaming at her doting mother and being “super-nice” after feeling guilty about losing her temper. Fran- ces thought that her erratic behavior toward her mother was all her fault. She described her mother as “a saint.” Her mother ap- parently agreed. In both their minds, Frances was a failure as a daughter.
Frances described her mother as giving, but some of her comments about her were far from glowing. She said she was her mother’s best friend. When asked if her mother was her best friend, Frances began to cry.
She felt like her mother’s infant, her parent, or even her hus- band, but not her friend and certainly not like her grown daughter.
Frances had little to say about her father. She pictured him drinking beer, eating meals, and falling asleep in front of the television.
Throughout the time she lived at home, Frances’s depres- sion only deepened. After a year of living with her parents, she married her high school sweetheart. Frances felt pressured to get married. Both her future husband and her mother insisted that it was time for her to settle down and start a family. Frances had hoped that marriage might be the solution to her problems. The excitement of the wedding added to this hope. But after the mar- riage, Frances said that things were worse—if that were possible.
Frances’s husband was a young accountant who reminded Frances of her father. He didn’t drink but spent most of his brief time at home working or reading in his study. She said they had little communication, and she felt no warmth in her marriage. Her husband often was angry and sullen, but Frances said she couldn’t blame him for feeling that way. His problem was being married to
her. She wanted to love him, but she never had. She was a failure as a wife. She was a failure in life.
The theme of self-blame pervaded Frances’s descriptions of her family. She repeatedly noted that, despite their flaws, her par- ents and her husband were good and loving people. She was the one with the problem. She had everything that she could hope for, yet she was unhappy. One reason she wanted to die was to ease the burden on them. How could they be happy when they had to put up with her foul moods? When she talked about these things, however, Frances’s tone of voice often sounded more angry than depressed.
Four Views of Frances How might Frances’s problems be viewed through the lens of the four paradigms? Biological, psychodynamic, cognitive-behavioral, and humanistic therapists all would note her depressed mood, self-blame, and troubled relationships. However, therapists work- ing within these different paradigms would evaluate Frances and approach treatment in very different ways (see Table 3.1).
Biological therapies approach mental illness by drawing an analogy with physical illness. Thus, a biologically oriented psychi- atrist or psychologist would focus first on making a diagnosis of Frances’s problems. This would not be difficult because Frances’s symptoms paint a clear picture of depression. The therapist also would take note of Frances’s description of her father, who seems chronically depressed. Perhaps a genetic predisposition runs in her family.
A biologically oriented therapist would sympathize with Frances’s interpersonal problems but would not blame either Frances or her family for their troubles. Rather, the therapist would blame something that neither Frances nor her family members could control: depression. It is exhausting to deal with someone who is constantly agitated and depressed. In the end,
table 3.1 Comparison of Biological, Psychodynamic, Cognitive-Behavioral, and Humanistic Treatments Topic Biological Psychodynamic Cognitive-Behavioral Humanistic
Goal of treatment Alter biology to relieve psychological distress
Gain insight into defenses/unconscious motivations
Learn more adaptive behaviors/cognitions
Increase emotional awareness
Primary method Diagnosis, medication Interpretation of defenses
Instruction, guided learning, homework
Empathy, support, exploring emotions
Role of therapist Active, directive, diagnostician
Passive, nondirective, interpreter (may be aloof)
Active, directive, nonjudgmental, teacher
Passive, nondirective, warm, supporter
Length of treatment Brief, with occasional follow-up visits
Usually long term; some new short-term treatments
Short term, with later “booster” sessions
Varies; length not typically structured
treatment of psychological disorders CHAPTER 3 55
the therapist might explain that depression is caused by a chemi- cal imbalance in the brain, recommend medication, and schedule follow-up appointments to monitor the effects of the medication on Frances’s mood.
A psychodynamic therapist would also note Frances’s depres- sion but likely would focus on her defensive style. The therapist might view Frances’s justification of her parents’ and husband’s behavior as a form of rationalization. The therapist would also see a pattern of denial in Frances’s refusal to acknowledge the im- perfections of her loved ones and their failure to fulfill her needs. When Frances says that she is a burden on her family, a psycho- dynamic therapist might wonder if she was projecting onto them her own feelings of being burdened by her mother’s demands and her husband’s indifference.
A psychodynamic therapist probably would not challenge Frances’s defenses early in therapy but instead begin by exploring her past. The goal would be to illuminate patterns in Frances’s internal conflicts, unconscious motivations, and defenses. Sooner or later, the psychodynamic therapist would confront Frances’s defenses in order to help her gain insight into her hidden resent- ment toward her mother, longing for a relationship with her father, and unfulfilled fantasies about marriage.
A cognitive-behavior therapist might note many of the same issues in Frances’s life. Rather than focusing on defense mechanisms and the past, however, the therapist would hone in on Frances’s cognitive and behavioral patterns now. Frances’s self-blame—her pattern of attributing all of her interpersonal difficulties to herself—would be seen as a cognitive error. Her withdrawal from pleasing activities and unassertiveness also might be seen as contributing to her depression. In compari- son to a psychodynamic therapist, a cognitive-behavior thera- pist would be far more directive in discussing these topics. For example, he or she would tell Frances that her thinking was distorted and causing her depression.
The therapist also would make direct suggestions to teach Frances new ways of thinking, acting, and feeling. The thera- pist might encourage Frances to blame others appropriately, not just herself, for relationship problems and urge her to try out new ways of relating to her mother, father, and husband. The therapist would want Frances to play an active role in this pro- cess by completing homework—activities outside the therapy, for example, writing about her anger or actually confronting her mother and husband. A cognitive-behavior therapist would ex- pect Frances’s depressed mood to begin to lift once she learned to assert herself and no longer blame herself for everything that went wrong.
A humanistic therapist would also note Frances’s depression, self-blame, and unsatisfactory relationships. A more prominent focus, however, would be her lack of emotional genuineness—her inability to “be herself ” with other people and within herself. The therapist would explore Frances’s tendency to bury her true feel- ings. The goal would be to help Frances recognize how she really feels.
In therapy, the humanistic therapist would be nondirective about discussion but would continually focus on underlying emotions. Initially, the therapist might simply empathize with Frances’s feelings of sadness, loneliness, and isolation. Over time, he or she might suggest that Frances had other feelings that she did not express, including frustration and guilt over her moth- er’s controlling yet dependent style, and anger at her husband’s and father’s self-centeredness. The humanistic therapist might tell Frances that all of her conflicting feelings were legitimate and encourage Frances to “own” them. The therapist would not directly encourage Frances to act differently. Instead, Frances might make changes in her life as a result of her increased emotional awareness.
These approaches to treating Frances are very different, but you may wonder if a therapist could use the best aspects of each one (see Thinking Critically About DSM-5 on p. 56). In fact, psy- chologists often integrate elements of different approaches when working to find more effective treatments. One straightforward example is when psychotherapy is combined with medication, al- though most people who take antidepressants do not get therapy— and the number who do is declining (Olfson & Marcus, 2009). Before considering how approaches can be integrated, however, we first need to elaborate on their differences.
Biological Treatments The history of the discovery of the cause and cure of general pare- sis illustrates the hope and the methods of the medical model (see Chapter 2). First, a diagnosis is developed and refined. Second, clues are put together like pieces of a puzzle that eventually fit together to identify a specific cause. Third, scientists experiment with ways to prevent or eliminate the specific cause until they find an effective treatment. These are not simple steps. It took a century to diagnose general paresis, discover that syphilis caused it, and develop antibiotics to cure syphilis and prevent general paresis.
Today, scientists often search for biological treatments with- out knowing a disorder’s specific cause. These treatments focus on symptom alleviation, reducing the dysfunctional symptoms of a disorder but not eliminating its root cause (Valenstein, 1998). Happily, numerous medications have been discovered since the 1950s, and particularly since the 1980s, that offer effective symp- tom alleviation.
Psychopharmacology Psychopharmacology is the use of medications to treat psycho- logical disturbances. There are many psychotropic medications, chemical substances that affect psychological state, used to treat various mental disorders (see Table 3.2 on p. 57). Some medications, for example, antianxiety drugs, produce rapid changes in think- ing, mood, and behavior. Others, such as antidepressants, have more subtle influences that build up gradually over time. Still other psychotropic drugs affect people with mental disorders very
56 CHAPTER 3 treatment of psychological disorders
differently from the way they affect someone who is functioning normally. Antipsychotic medications help to eliminate delusions and hallucinations among people suffering from schizophrenia, but the same medications would disorient most people and send them into a long, groggy sleep.
Psychopharmacology has grown dramatically in recent de- cades, too much, perhaps. In the United States, prescriptions for psychostimulants, used to treat inattentive and hyperactive behav- ior, tripled for preschoolers during the 1990s (Zito et al., 2000).
Today, one in 20 children takes medication for mental health issues (Glied & Frank, 2009). Prescriptions for antidepressants doubled in the last decade (Olfson & Marcus, 2009). In fact, antidepressants are prescribed more often than any medication (passing drugs that lower blood pressure in 2005) (Cherry et al., 2007). A leading U.S. managed care organization for prescrip- tion drugs reported that 21 percent of adult women were taking an antidepressant, as were almost half as many men (Medico, 2011). Even antipsychotics are used with surprising frequency.
Thinking CriTiCally about DSM-5
Diagnosis and Treatment
DSM-5 is the official list of mental disorders. What does the manual say about how various disorders should be treated? Nothing. In fact, developers of the manual ex- plicitly did not attempt to detail the best treatments for various mental disorders. The Web site describing the development of the new diagnostic system says, “DSM-5 is intended to be a man- ual for assessment and diagnosis of mental disorders and will not include information or guidelines for treatment for any disorder.”
Why does the DSM-5 not contain information about treatment? There are two broad reasons. First, as we detail in Chapter 4, the developers of the manual are primarily concerned with the reli- ability of the DSM-5, the extent to which different mental health experts reach the same diagnosis, not the manual’s validity or value for different purposes, including its value for identifying the best treatments. Second, considerable controversy exists about the best treatments for various mental disorders. Is a given mental disorder best treated with medication or psycho- therapy, and if the answer is therapy, what form of psychother- apy is most effective?
The American Psychiatric Association, which publishes the DSM-5, also develops and publishes “Clinical Practice Guidelines” for various mental disorders. At the time we were writing this, guidelines for 14 disorders were published on the organization’s Web site, http://www.psych.org/practice/clinical-practice- guidelines. The American Psychiatric Association developed these guidelines by appointing panels of experts who reviewed the literature, reached various conclusions about treatment, and eventually published the guidelines after seeking extensive feedback from researchers, practitioners, and others. Even more rigorous methods will be used to develop future guidelines, for example, formal surveys will be used to obtain feedback on the conclusions and recommendations reached by panels of experts.
A group of psychologists has taken a different approach to list- ing the most effective therapies for mental disorders, by identi- fying “empirically supported treatments” for different disorders.
As we were writing this, the Web site of the clinical psychology division of the American Psychological Association listed empiri- cally supported treatments for 11 different mental disorders http://www.apa.org/divisions/div12/cppi.html. The Web site identifies a single committee as developing all of these 11 lists, although various experts have published different versions of the lists using the same name, “empirically supported treatments” (Woody, Weisz, & McClean, 2005).
So where is the controversy? Pretty much everywhere. For example, even though the list of empirically supported treat- ments is published by its clinical psychology division, a resolu- tion adopted by the entire American Psychological Association offers a set of statements touting the general effectiveness of psychotherapy (while indicating that practice guidelines will be developed in the future). http://www.apa.org/about/policy/ resolution-psychotherapy.aspx This statement defines psycho- therapy and the disorders for which psychotherapy is effective very broadly, whereas the list of empirically supported therapies is very specific to given disorders and dominated by cognitive- behavior therapies. The American Psychiatric Association’s guidelines tend to emphasize medication, while the American Psychological Association’s statement claims that psychotherapy is more effective than medication in the long run. (Recall that psychiatrists can prescribe medication, while clinical psycholo- gists generally cannot.)
Mental health professionals need to do a better job of reach- ing consensus about the most effective treatments for different disorders by working together across professions and truly striv- ing for objectivity. And people seeking mental health care—and students in Abnormal Psychology classes—need to be smart consumers who think critically about the (differing) conclusions reached by experts. We help you hone your critically think skills throughout the text. In particular, we take you through the pros and cons of different treatments for different disorders in every chapter.
treatment of psychological disorders CHAPTER 3 57
Two antipsychotic medications, Abilify and Seroquel, were the fifth and sixth most prescribed medications in 2011—often used for the questionable purpose of treating anxiety or depression (New York Times, September 25, 2012).
We review different psychotropic medications in relevant chapters later in the text. For now, you should note a few gen- eral points. First, medication often is an effective and safe treat- ment. Second, psychotropic medications do not cure underlying causes, but symptom alleviation still is extremely important. Where would we be without pain relievers, which offer only symptom relief? Third, many psychotropic drugs must be taken for a long time. Because the medications do not produce a cure, patients may need to keep taking the drug—for months, years, or sometimes for a lifetime. Fourth, all medications have side effects, some of which are very unpleasant. Partly for this reason, many patients do not take their medication as prescribed, and they may experience a relapse as a result. Fifth, most psycho- tropic medications are prescribed by primary care physicians, not psychiatrists (Mojtabai & Olfson, 2008). Finally, we worry, despite the benefits of psychopharmacology, that Americans are perhaps too eager to find a pill to solve all their problems (Barber, 2008).
Electroconvulsive Therapy
Medication is the most common biological treatment, but it is not the only one. Electroconvulsive therapy (ECT) involves deliberately inducing a seizure by passing electricity through the brain. In 1938, the technique was discovered by Italian physi- cians Ugo Cerletti and Lucio Bini, seeking to cure schizophrenia. At the time, schizophrenia was erroneously thought to be rare among people who had epilepsy. Could epileptic seizures some- how prevent the disorder? A bizarre source gave Cerletti and Bini an idea about how to test this hypothesis. When visiting a slaugh- terhouse, they observed electric current being passed through the brains of animals, producing a convulsion (and unconsciousness for slaughter). With this inspiration, the two physicians devel- oped a modified electroconvulsive technique as an experimental treatment for schizophrenia. ECT failed in this goal, but today ECT can be effective for severe depressions that do not respond to other treatments (UK ECT Review Group, 2003).
Typically, ECT involves a series of 6 to 12 sessions over the course of a few weeks. Approximately 100 volts of electric cur- rent is passed through a patient’s brain in order to cause a convul- sion. In bilateral ECT, electrodes are placed on the left and right
table 3.2 Major Categories of Medications for Treating Psychological Disorders Therapeutic Use
Chemical Structure or Psychopharmacologic Action
Example
Generic Name Trade Name
Antipsychotics (also called major tranquilizers or neuroleptics)
Phenothiazines Thioxanthenes Butyrophenones Rauwolfia alkaloids Atypical neuroleptics
Chlorpromazine Thiothixene Haloperidol Reserpine Clozapine
Thorazine Navane Haldol Sandril Clozaril
Antidepressants Tricyclic antidepressants (TCAs) Monoamine oxidase inhibitors (MAOIs) Selective serotonin reuptake inhibitors (SSRIs) Atypical antidepressants
Amitriptyline Phenelzine Fluoxetine Bupropion
Elavil Nardil Prozac Wellbutrin
Psychomotor stimulants
Amphetamines Other
Dextroamphetamine Methylphenidate
Dexedrine Ritalin
Antimanic Metallic element Anticonvulsants
Lithium carbonate Carbamazepine
Eskalith Tegretol
Antianxiety (also called minor tranquillizers)
Benzodiazepines Triazolobenzodiazepine
Diazepam Alprazolam
Valium Xanax
Sedative hypnotic Barbiturates Benzodiazepines
Phenobarbital Triazolam
Halcion
Antipanic Benzodiazepines SSRIs
Alprazolam Paroxetine
Xanax Paxil
Antiobsessional TCA SSRIs
Clomipramine Fluvoxamine
Anafranil Luvox
58 CHAPTER 3 treatment of psychological disorders
temples, and the current passes through both brain hemispheres. In unilateral ECT, the current is passed through only one side of the brain, the nondominant hemisphere.
Unilateral ECT produces less retrograde amnesia—loss of memory of past events, a disturbing side effect of ECT (Lisanby et al., 2000). Unfortunately, unilateral ECT is less effective than bilateral ECT. Similarly, low-dose ECT (just enough current to produce a seizure) is less effective but causes fewer memory im- pairments than high-dose ECT (2.5 or more times the minimal current) (Sackheim, Prudic, & Devanand, 2000; UK ECT Re- view Group, 2003). Thus, effectiveness must be weighed against increased side effects.
Books and movies such as One Flew over the Cuckoo’s Nest highlight past misuses of ECT. Today, however, ECT is employed infrequently and cautiously. Side effects can be serious and can include memory loss and even death in rare cases. Still, ECT can be very useful in treating severe depressions, especially when pa- tients do not respond to other treatments.
Psychosurgery Psychosurgery, the surgical destruction of specific regions of the brain, is another biological treatment with a checkered history. Egas Moniz (1874–1955), a Portuguese neurologist, introduced psychosurgery in 1935. He performed a procedure called pre- frontal lobotomy, irrevocably severing the frontal lobes of the brain. In 1949, Moniz won the Nobel Prize for his work. But his treatment was subsequently discredited because of its limited benefits and frequent, often severe, side effects, including exces- sive tranquility, emotional unresponsiveness, and even death.
American neurologist Walter Freeman performed almost 3,500 loboto- mies, often severing the frontal lobes by knocking an instrument through the back of the eye socket. Today, lobotomy is completely discredited, but refined neurosurgery may play a role in treating severe disorders that do not respond to other treatments.
Moniz himself was shot and paralyzed by one of his lobotomized patients, a sad testament to the unpredictable outcome of the procedure.
Prefrontal lobotomies are a thing of the past, but as the popular movie Shutter Island reminded viewers, thousands of pre- frontal lobotomies were performed around the world—between 10,000 and 20,000 in the United States alone. Today, very precise psychosurgeries may be used to treat severe affective or anxiety disorders—when all other treatments have failed. For example, cingulotomy, lesioning pinpointed regions of the cingulate cor- tex, may help very severe cases of obsessive–compulsive disorder (Mashour, Walker, & Martuza, 2005). Still, the irreversibility of brain damage makes psychosurgery a very rarely used procedure. Perhaps the future will bring effective refinements (Dougherty & Rauch, 2007).
Psychodynamic Psychotherapies Psychodynamic psychotherapies seek to uncover inner conflicts and bring them into conscious awareness. All are an outgrowth of Freudian theory, which emphasizes the importance of gaining insight into complex, unconscious conflicts.
Freudian Psychoanalysis An early influence on Freud’s “talking cure” was Joseph Breuer (1842–1925), who used hypnosis to induce troubled patients to talk freely about problems in their lives. Upon awakening from a hypnotic trance, many patients reported relief from their symp- toms. Breuer assumed that pent-up emotion was responsible for his patients’ psychological problems, and he attributed their improvement to catharsis, the release of previously unexpressed feelings.
Freud collaborated with Breuer early in his career, and he temporarily adopted the hypnotic method. But Freud soon con- cluded that hypnosis was unnecessary to encourage open expres- sion. Instead, Freud simply told his patients to speak freely about whatever thoughts crossed their mind. This method, called free association, became a cornerstone of Freud’s famous treatment, psychoanalysis.
Unlike Breuer, Freud did not see catharsis as an end in itself. The true benefit of free association was that it revealed aspects of the unconscious mind. Freud found clues to his patients’ uncon- scious desires in their unedited speech. Freud also believed that information about the unconscious revealed in dreams, when defenses presumably are weak, and by slips of the tongue (now called “Freudian slips,” for example, saying “sin” when you meant to say “sex”). Thus, free association, dreams, and slips of the tongue are all Freudian “windows into the unconscious.”
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