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Psychological
Disorders
The Courage to Wake Up Every Morning
ill Garrett was a freshman scholarship recipient at Johns Hopkins University when he began to hear strange voices
inside his head. Those voices told him profoundly disturbing things: that he was stupid and fat, that soap and sham-
poo were toxic, that his father had poisoned the family dog, and that his grandmother was putting human body parts
in his food. Bill withdrew into this terrifying inner world. Eventually, he was diagnosed with schizophrenia, a disorder
characterized by disturbed thought. Failing in his classes, this previously excellent student (and track and lacrosse
star) was forced to return home.
Bill’s mother understood her son’s experience when she found herself at a support group for families of individuals with
schizophrenia. At one point, surrounded by 10 people all speaking to her at once, she was overwhelmed by the confusing
cacophony. Afterward she told her son, “You have to be the most courageous person. You wake up every morning”
(M.Park, 2009). Bill had told her that sleep was his only escape from the ceaseless terror of hearing those voices.
At home, Bill was constantly faced with evidence of his previous successes. Looking at his trophies and awards, he
said, “Mom, I was on top of the world. Now I’m in the gutter.” His mother, however, has encouraged him to think of
his disorder not as a sign of failure but as an opportunity to use the gifts he still possesses—symbolized by those
past accomplishments—to fi ght for the rights and well-being of individuals who, like him, fi nd their lives turned
upside-down by psychological disorders.
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Defining and Explaining Abnormal Behavior // 441
This chapter explores the meaning of the word abnormal as it relates to psychology. We
examine various theoretical approaches to understanding abnormal behavior and survey
the main psychological disorders. We delve into how stigma plays a role in the lives of
individuals struggling with psychological disorders, and we consider how even dif cult,
troubled lives remain valuable and meaningful.
What makes behavior “abnormal”? The American Psychiatric Association (2001, 2006)
de nes abnormal behavior in medical terms: a mental illness that affects or is manifested
in a person’s brain and can affect the way the individual thinks, behaves, and interacts
with others. Abnormal behavior may also be de ned by three criteria that distinguish it
from normal behavior: Abnormal behavior is deviant, maladaptive , or personally
distressful over a relatively long period of time. Only one of these criteria needs to be
present for a behavior to be labeled “abnormal,” but typically two or all three are present.
Three Criteria of Abnormal Behavior
Let’s take a close look at what each of the three characteristics of abnormal behavior entails:
Abnormal behavior is deviant . Abnormal behavior is certainly atypical or statistically
unusual. However, Alicia Keys, Hope Solo, and Mark Zuckerberg are atypical in many
of their behaviors, and yet we do not categorize them as abnormal. We do often consider
abnormal
behavior
Behavior that is
deviant, mal-
adaptive, or per-
sonally distressful
over a relatively
long period of
time.
1
Defi ning and Explaining
Abnormal Behavior
Accomplished individuals such as singer-songwriter Alicia Keys, champion soccer goalkeeper Hope Solo, and Facebook CEO Mark Zuckerberg are atypical
but not abnormal. However, when atypical behavior deviates from cultural norms. it often is considered abnormal.
EXPERIENCE IT!
Normal vs. Abnormal
Behavior
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442 // CHAPTER 12 // Psychological Disorders
atypical behavior abnormal, though, when it deviates from what is
acceptable in a culture. A woman who washes her hands three or
four times an hour and takes seven showers a day is abnormal
because her behavior deviates from culturally acceptable norms.
Abnormal behavior is maladaptive . Maladaptive behavior interferes
with one’s ability to function effectively in the world. A man who
believes that he can endanger others through his breathing may go to
great lengths to isolate himself from people for what he believes is their
own good. His belief negatively affects his everyday functioning; thus, his
behavior is maladaptive. Behavior that presents a danger to the person or
those around him or her is also considered maladaptive (and abnormal).
Abnormal behavior is personally distress ful over a long period of
time. The person engaging in the behavior  nds it troubling. A
woman who secretly makes herself vomit after every meal may
never be seen by others as deviant (because they do not know
about it), but this pattern of behavior may cause her to feel intense
shame, guilt, and despair.
Culture, Context, and the Meaning
of Abnormal Behavior
Because culture establishes the norms by which people evaluate their own and others’
behaviors, culture is at the core of what it means to be normal or abnormal (Ago-
rastos, Haasen, & Huber, 2012). In evaluating behavior as normal or abnormal,
culture matters in complex ways (Sue & others, 2013). Cultural norms provide
guidance about how people should behave and what behavior is healthy or
unhealthy. Importantly, however, cultural norms can be mistaken. One only
has to watch an episode of Mad Men to recognize that at one time cigarette
smoking was not only judged to be an acceptable habit but also promoted as
a healthy way to relax. The point is, de nitions of normal change as society
changes.
Signi cant, too, is the fact that cultural norms can be limiting, oppressive, and preju-
dicial (Potter, 2012). Individuals who  ght to change the established social order some-
times face the possibility of being labeled deviant—and even mentally ill. In the late
nineteenth and early twentieth centuries, for instance, women in Britain who dem-
onstrated for women’s right to vote were widely viewed to be mentally ill. When
a person’s or a group’s behavior challenges social expectations, we must open
our minds to the possibility that such actions are in fact an adaptive response
to injustice. People may justi ably challenge what everyone thinks is true and
may express ideas that seem strange. They should be able to make others
feel uncomfortable without being labeled abnormal.
Further, as individuals move from one culture to another, interpretations
and evaluations of their behavior must take into account the norms in their
culture of origin (Bourque & others, 2012; John & others, 2012). His-
torically, people entering the United States from other countries were
examined at Ellis Island, and many were judged to be mentally impaired
simply because of differences in their language and customs.
Cultural variation in what it means to be normal or abnormal makes it
very dif cult to compare different psychological disorders across different
cultures. Many of the diagnostic categories we trace in this chapter primar-
ily re ect Western (and often U.S.) notions of normality, and applying
these to other cultures can be misleading and even inappropriate (Agorastos,
Haasen, & Huber, 2012). Throughout this chapter, we will see how culture
in uences the experience of psychological disorders.
Consider, for instance,
that a symptom of one of Sigmund
Freud’s most famous patients,
Anna O., was that she was not
interested in getting married.
Spend 15 to 20 minutes observing an
area with a large number of people,
such as a mall, a cafeteria, or a
stadium during a game. Identify and
make a list of behaviors you would
classify as abnormal. How does your
list of behaviors compare with the
defi nition of abnormal provided
above? What would you change in
the list if you were in a different
setting, such as a church, a bar, or a
library? What does this exercise tell
you about the meaning of abnormal?
Context matters! If
the woman who washes her hands
three or four times an hour and
takes repeated showers works in
a sterile lab with toxic chemicals
or live viruses, her behavior
might be quite adaptive.
Which of these three
qualities—deviation from what is
acceptable, maladaptiveness, and
personal distress—do you think
is
most important
to calling
a behavior abnormal? Why?
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Defining and Explaining Abnormal Behavior // 443
Theoretical Approaches
to Psychological Disorders
What causes people to develop a psychological disorder, that is, to behave in deviant,
maladaptive, and personally distressful ways? Theorists have suggested various approaches
to this question.
THE BIOLOGICAL APPROACH The biological approach attributes psychologi-
cal disorders to organic, internal causes. This perspective primarily focuses on the brain,
genetic factors, and neurotransmitter functioning as the sources of abnormality.
The biological approach is evident in the medical model , which describes psycho-
logical disorders as medical diseases with a biological origin. From the perspective of
the medical model, abnormalities are called “mental illnesses ,” the af icted individuals
are “patients ,” and they are treated by “doctors.
THE PSYCHOLOGICAL APPROACH The psychological approach emphasizes
the contributions of experiences, thoughts, emotions, and personality characteristics in
explaining psychological disorders. Psychologists might focus, for example, on the in u-
ence of childhood experiences, personality traits, learning experiences, or cognitions in
the development and course of psychological disorders.
THE SOCIOCULTURAL APPROACH The sociocultural approach emphasizes
the social contexts in which a person lives, including gender, ethnicity, socioeconomic
status, family relationships, and culture. For instance, poverty is related to rates of psy-
chological disorders (Jeon-Slaughter, 2012; Rosenthal & others, 2012).
The sociocultural perspective stresses the ways that cultures in uence the understand-
ing and treatment of psychological disorders. The frequency and intensity of psycho-
logical disorders vary and depend on social, economic, technological, and religious
aspects of cultures (Matsumoto & Juang, 2013). Some disorders are culture-related, such
as windigo, a disorder recognized by northern Algonquian Native American groups that
involves fear of being bewitched and turned into a cannibal.
Importantly, different cultures may interpret the same pattern of behaviors in very dif-
ferent ways. When psychologists look for evidence of the occurrence of a particular dis-
order in different cultures, they must keep in mind that behaviors associated with a
disorder might not be labeled as illness or dysfunction within a particular cultural context.
Cultures might have their own interpretations of these behaviors, so researchers must probe
whether locals ever observe these patterns of behavior, even if they are not considered
illness (Draguns & Tanaka-Matsumi, 2003). For example, in one study researchers inter-
viewed a variety of individuals in Uganda to see whether dissociative disorders, including
dissociative identity disorder (which you might know as multiple personality disorder),
existed in that culture (Van Duijl, Cardeña, & de Jong, 2011). They found that while most
dissociative disorders were recognizable to Ugandans, the local healers consistently labeled
what Westerners consider dissociative identity disorder as a spirit possession.
THE BIOPSYCHOSOCIAL MODEL Abnormal behavior can be in uenced by
biological factors (such as genes), psychological factors (such as childhood experiences),
and sociocultural factors (such as gender). These factors can operate alone, but they often
act in combination with one another.
To appreciate how these factors work together, let’s back up for a moment. Consider
that not everyone with a genetic predisposition to schizophrenia develops the disorder.
Similarly, not everyone who experiences childhood neglect develops depression. More-
over, even women who live in cultures that strongly discriminate against them do not
always develop psychological disorders. Thus, to understand the development of psycho-
logical disorders, we must consider a variety of interacting factors from each of the
domains of experience.
medical model
The view that psychological
disorders are medical
diseases with a biological
origin.
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444 // CHAPTER 12 // Psychological Disorders
Sometimes this approach is called biopsychosocial. From the biopsychosocial perspec-
tive, none of the factors considered is necessarily viewed as more important than another;
rather, biological, psychological, and social factors are all signi cant ingredients in pro-
ducing both normal and abnormal behavior. Furthermore, these ingredients may combine
in unique ways, so that one depressed person might differ from another in terms of the
key factors associated with the development of the disorder.
Classifying Abnormal Behavior
To understand, prevent, and treat abnormal behavior, psychiatrists and psychologists have
devised systems classifying those behaviors into speci c psychological disorders. Clas-
sifying psychological disorders provides a common basis for communicating. If one
psychologist says that her client is experiencing depression, another psychologist under-
stands that a particular pattern of abnormal behavior has led to this diagnosis. A clas-
si cation system can also help clinicians predict how likely it is that a particular disorder
will occur, which individuals are most susceptible to it, how the disorder progresses, and
what the prognosis (or outcome) for treatment is (Birgeg á rd, Norring, & Clinton; Skodol,
2012a, 2012b).
Further, a classi cation system may bene t the person suffering from psychological
symptoms. Having a name for a problem can be a comfort and a signal that treatments
are available. On the other hand, of cially naming a problem can also have serious
negative implications for the person because of the potential for creating stigma, a mark
of shame that may cause others to avoid or to act negatively toward an individual. Being
diagnosed with a psychological disorder can profoundly in uence a person’s life because
of what the diagnosis means with respect to the person and his or her family and larger
social world. We discuss stigma further at the end of this chapter.
THE DSM-IV CLASSIFICATION SYSTEM In 1952, the American Psychiatric
Association (APA) published the  rst major classi cation of psychological disorders in
the United States, the Diagnostic and Statistical Manual of Mental Disorders. Its current
version, the DSM-IV (APA, 1994), was introduced in 1994 and revised in 2000,
producing the DSM-IV-TR (text revision) (APA, 2000). DSM-V is due in 2013.
Throughout the development of the DSM, the number of diagnosable disor-
ders has increased dramatically. The  rst DSM listed 112 disorders; the
DSM-IV-TR includes 374.
The DSM-IV classi es individuals on the basis of  ve dimen-
sions, or axes, that take into account the individual’s history
and highest level of functioning in the previous year.
The system’s creators meant to ensure that the indi-
vidual is not merely assigned to a psychologi-
cal disorder category but instead is characterized
in terms of a number of factors. The  ve axes of
DSM-IV are:
Axis I: All diagnostic categories except person-
ality disorders and mental retardation
Axis II: Personality disorders and mental retardation
Axis III: General medical conditions
Axis IV: Psychosocial and environmental problems
Axis V: Current level of functioning
Axes I and II are concerned with the classi cation of psycho-
logical disorders. Figure 12.1 describes the major categories of these
disorders. Axes III through V may not be needed to diagnose a psy-
chological disorder, but they are included so that the person’s overall
DSM-IV
The Diagnostic
and Statistical
Manual of Mental
Disorders, Fourth
Edition; the ma-
jor classifi cation
of psychological
disorders in the
United States.
The
DSM-I
V
was the work
of more than 200 mental health
professionals, including more
women, ethnic minorities, and
non-psychiatrists than
any previous version.
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Defining and Explaining Abnormal Behavior // 445
Include disorders that appear before adolescence, such as attention deficit hyperactivity disorder, autism,
and learning disorders (stuttering, for example).
Disorders usually first diagnosed in
infancy, childhood, or adolescence
and communication disorders
Major Categories of
Psychological Disorders
Description
Axis I Disorders
Axis II Disorders
Characterized by motor tension, hyperactivity, and apprehensive expectations/thoughts. Include
generalized anxiety disorder, panic disorder, phobic disorder, obsessive-compulsive disorder, and
post-traumatic stress disorder.
Anxiety disorders
Occur when psychological symptoms take a physical form even though no physical causes can
be found. Include hypochondriasis and conversion disorder.
Somatoform disorders
Characterized by the individual’s deliberate fabrication of a medical or mental disorder, but not
for external gain (such as a disability claim).
Factitious disorders
Involve a sudden loss of memory or change of identity. Include the disorders of dissociative amnesia,
dissociative fugue, and dissociative identity disorder.
Dissociative disorders
Consist of mental disorders involving problems in consciousness and cognition, such as
substance-induced delirium or dementia related to Alzheimer disease.
Delirium, dementia, amnesia, and
other cognitive disorders
Disorders in which there is a primary disturbance in mood; include depressive disorders and bipolar
disorder (which involves wide mood swings from deep depression to extreme euphoria and agitation).
Mood disorders
Disorders characterized by distorted thoughts and perceptions, odd communication, inappropriate
emotion, and other unusual behaviors.
Schizophrenia and other psychotic
disorders
Include alcohol-related disorders, cocaine-related disorders, hallucinogen-related disorders, and other
drug-related disorders.
Substance-related disorders
Include anorexia nervosa, bulimia nervosa, and binge eating disorder.Eating disorders
Consist of primary sleep disorders, such as insomnia and narcolepsy (see Chapter 4), and sleep disorders
due to a general medical condition.
Sleep disorders
Include kleptomania, pyromania, and compulsive gambling.Impulse control disorders not
elsewhere classified
Characterized by distressing emotional or behavioral symptoms in response to an identifiable stressor.Adjustment disorders
Low intellectual functioning and an inability to adapt to everyday life (see Chapter 7).
Mental retardation
Develop when personality traits become inflexible and maladaptive. Include antisocial
personality disorder and borderline personality disorder.
Personality disorders
Include relational problems (with a partner, sibling, and so on), problems related to abuse or neglect
(physical abuse of a child, for example), or additional conditions (such as bereavement, academic
problems, religious or spiritual problems).
Other conditions that may be a focus
of clinical attention
Consist of three main types of disorders: gender-identity disorders (person is not comfortable
with identity as a female or male), paraphilias (person has a preference for unusual sexual acts to
stimulate sexual arousal), and sexual dysfunctions (impairments in sexual functioning).
Sexual and gender identity disorders
FIGURE 12.1 Main Categories of Psychological Disorders in the DSM-IV The DSM-IV provides a way for mental health professionals and
researchers to communicate with one another about these well-de ned psychological disorders.
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446 // CHAPTER 12 // Psychological Disorders
life situation is considered. Axis III information helps to clarify whether symptoms may
be rooted in physical illness. On Axis V, the clinician evaluates the highest level of adap-
tive functioning the person has attained in the preceding year in social, occupational, or
school activities.
CRITIQUES OF THE DSM-IV A number of criticisms of the DSM-IV have been
voiced (Frances & Widiger, 2012; Robbins & others, 2012; Trull & others, 2012). Most
controversial is the fact that the manual classi es individuals based on their symptoms,
using medical terminology in the psychiatric tradition of thinking about mental disorders
in terms of disease (Oltmanns & Emery, 2013). This emphasis implies that the abnor-
malities have an internal cause that is relatively independent of environmental factors
(Kring & others, 2007). So, even though researchers have begun to shed light on the
complex interaction of genetic, neurobiological, cognitive, and environmental factors in
psychological disorders, the DSM-IV continues to re ect the medical model (APA, 2006).
That said, some biological factors, such as brain processes and pathways, also are not
adequately re ected in DSM-IV categories (Robbins & others, 2012).
Another criticism is that the DSM-IV focuses strictly on pathology and problems.
Critics argue that emphasizing strengths as well as weaknesses might help to destigma-
tize labels such as “schizophrenic.” Indeed, professionals avoid such labels, using what
is called people- rst language . Bill Garrett, whom you met in the chapter-opening
vignette, is a “person with schizophrenia,” not a “schizophrenic.” Identifying a person’s
strengths can be an important step toward maximizing his or her ability to contribute to
society (Compton & Hoffman, 2013; Roten, 2007).
Among the proposed changes for the DSM-V, expected in May 2013, are (APA, 2012):
A new category, behavioral addictions , with one main disorder: gambling
A new category, binge eating disorder, and improved diagnostic criteria for anorexia
nervosa and bulimia nervosa
A new category, mood dysregulation , among mood disorders
Improved diagnostic criteria for identifying adolescents and adults most at risk for
suicide
A new category, risk syndromes , to help mental health professionals make earlier
diagnoses of some disorders, such as dementias and psychoses
A change in the terminology: mental retardation to intellectual disability
Elimination of 4 or 5 of the 10 categories of personality disorders
Some of these proposed revisions have come under  re (Skodol, 2012a, 2012b) . The
criticisms include (Frances & Widiger, 2012):
Diagnostic in ation, with too many new categories that do not yet have consistent
research support and would lead to a signi cant increase in the number of people
being labeled as having a mental disorder
Concern that some of the proposed new categories, such as mood dysregulation, will
increase what is already an overuse of antipsychotic drugs in treating children
Lower thresholds for some existing categories—such as attention de cit hyperactivity
disorder (ADHD), generalized anxiety disorder, and post-traumatic stress disorder—
that would add to the already very high rates of such disorders
However, labels such as those described by the DSM-IV and those proposed for the
DSM-V are based on the idea that psychological disorders are real and often medically
treatable. Some individuals have questioned this very assumption. Over 50 years ago, in
his book The Myth of Mental Illness, psychiatrist Thomas Szasz argued that psycho-
logical disorders are not illnesses and are better labeled “problems of living.” Szasz said
that it makes no sense to refer to a person’s problems of living as “mental illness” and
to treat him or her through a medical model. To consider these issues in the context of
an increasingly common psychological disorder, see Challenge Your Thinking.
attention defi cit hyperactivity
disorder (ADHD)
One of the most common
psychological disorders of
childhood, in which individ-
uals show one or more of
the following: inattention,
hyperactivity, and impulsivity.
EXPERIENCE IT!
Attention Defi city and
Hyperactivity Disorder
(ADHD)
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Defining and Explaining Abnormal Behavior // 447
Challenge
YOUR THINKING
P
erhaps no diagnosis is more
controversial these days than
attention de cit hyperactivity
disorder (ADHD), in which individuals,
prior to the age of 7, show one or
more of the following symptoms:
inattention, hyperactivity, and impul-
sivity. Chances are you know some-
one who suffers from ADHD. You
might even have it yourself.
ADHD is one of the most common
psychological disorders of childhood,
with diagnoses skyrocketing in re-
cent years. In 1988 just 500,000
cases of ADHD were diagnosed, but
by 2007, that number had jumped to
4 million per year (Bloom & Cohen, 2007). In 2010, 10.4 million
children were diagnosed with ADHD (Gar eld & others, 2012). Al-
though experts previously thought that most children “grow out”
of ADHD, more recent evidence suggests that as many as 70 per-
cent of adolescents (Sibley & others, 2012) and 66 percent of
adults (Asherson & others, 2010) who were diagnosed as children
continue to experience ADHD symptoms. Many professionals be-
lieve that adult ADHD should be recognized as a psychological
disorder in its own right (Kooij & others, 2010), and changing the
age for diagnosis with ADHD is one of the proposed revisions for
the DSM-V.
The sheer number of ADHD diagnoses has prompted specula-
tion that psychiatrists, parents, and teachers are in fact labeling
normal childhood behavior as psychopathology (Morrow & others,
2012). One reason for concern about overdiagnosing ADHD is
that the form of treatment in well over 80 percent of cases is psy-
choactive drugs, including stimulants such as Ritalin and Adderall
(Gar eld & others, 2012). Animal research has shown that in the
absence of ADHD, exposure to such stimulants can predispose
individuals to later addiction problems (Leo, 2005). Those who
question the diagnosis of ADHD in children  nd it equally problem-
atic in adults (Marcus, Norris, & Coccaro, 2012). These scholars
argue that the spread of ADHD is primarily a function of over-
pathologizing normal behavior, confusing ADHD for other disor-
ders, and aggressive marketing by pharmaceutical companies
(Moncrieff & Timimi, 2010).
A recent study sheds some light on the controversy. Child psy-
chologists, psychiatrists, and social workers were sent vignettes
of cases of children in which symptoms were described (Brüchmiller,
Margraf, & Schneider, 2012), and were asked to diagnose the
children. Some of the descriptions  t the diagnostic criteria for
ADHD, but others lacked key features of the disorder. In addition,
in the case vignettes, the researchers varied whether the child
was identi ed as male or fe-
male. The dependent variable
was whether these profession-
als gave a diagnosis of ADHD
toa case. The results showed
that participants overdiagnosed
ADHD, giving an ADHD diagnosis
to cases that speci cally lacked
important aspects of the disor-
der about 17 percent of the
time. Further, regardless of
symptoms, boys were two times
more likely than girls to receive
such a diagnosis. An important
lesson from this study is that
professionals must be vigilant in
their application of diagnostic criteria as they encounter different
cases. The results also demonstrate how even professionals can
fall prey to certain biases.
Certainly, individuals who experience ADHD have symptoms
that make adjustment dif cult, so it is critical that diagnosis of
the disorder be accurate. Children diagnosed with ADHD are at
heightened risk of dropping out of school, teen pregnancy, and
antisocial behavior (Barkley & others, 2002; von Polier, Vloet, &
Herpertz-Dahlmann, 2012). Adolescents and adults with ADHD
symptoms are more likely to experience dif culties at work,
while driving a car, and in interpersonal relationships; they
arealso more likely to have substance abuse problems (Chang,
Lichtenstein, & Larsson, 2012; Kooij & others, 2010; Sibley &
others, 2012).
ADHD is not the only controversial diagnosis; nor is this psycho-
logical disorder the only one given a great deal of attention by phar-
maceutical companies (Mash &
Wolfe, 2013). Drug companies
commonly fund research that
focuses on a disease model of
psychological disorders. Clearly,
psychological disorders are
“real” in the sense that they lead
to objectively negative outcomes
in people’s lives. The controversy
over ADHD is a reminder of the
important role of psychology re-
search in clarifying and de ning
diagnostic categories. Indeed,
the aim of the profession is to
avoid inappropriately labeling,
misdiagnosing, and mistreating
people who are already suffering.
Does
Everyone
Have ADHD?
What Do You Think?
Would ADHD be as contro-
versial if the treatment did
not involve drugs? Why or
why not?
Do you think ADHD would be
diagnosed as often as it is
ifdrugs were not readily
available for its treatment?
If a teacher suggested that
your child be tested for
ADHD, what would you do?
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448 // CHAPTER 12 // Psychological Disorders
Before we begin our survey of various psychological disorders, a word of caution. It
is very common for individuals who are learning about psychological disorders to
recognize the symptoms and behaviors of disorders in themselves or in people around
them. Keep in mind that only trained professionals can diagnose a psychological disorder.
1. All of the following are characteristics
of abnormal behavior except
A. it is typical.
B. it causes distress.
C. it is maladaptive.
D. it is deviant.
2. The medical model interprets psycho-
logical disorders as medical diseases
with a/an
A. environmental origin.
B. sociocultural origin.
C. biological origin.
D. biopsychosocial origin.
3. Mental retardation is classified on
_________ of the DSM-IV.
A. Axis I
B. Axis II
C. Axis III
D. Axis IV
APPLY IT 4. Since she was a little girl,
19-year-old Francesca has believed that
whenever she walks through a doorway, she
must touch the doorframe 12 times and si-
lently count to 12 or else her mother will
die. She has never told anyone about this
ritual, which she feels is harmless, similar
to carrying a lucky charm. Which of the
following is true of Francesca’s behavior?
A. Francesca’s behavior is abnormal only
because it is different from the norm. It
is not maladaptive, nor does it cause her
distress.
B. Francesca’s behavior fits all three charac-
teristics of abnormal behavior.
C. Francesca’s behavior is maladaptive, but
it is not abnormal because she does not
feel personal distress over her ritual.
D. Francesca’s behavior does not fit any of
the characteristics of abnormal behavior.
Think about how you felt before a make-or-break exam or a big presentation—or perhaps
as you noticed police lights  ashing behind your speeding car. Did you feel jittery and
nervous and experience tightness in your stomach? These are the feelings of normal
anxiety, an unpleasant feeling of fear and dread.
In contrast, anxiety disorders involve fears that are uncontrollable, disproportionate
to the actual danger the person might be in, and disruptive of ordinary life. They feature
motor tension ( jumpiness, trembling), hyperactivity (dizziness, a racing heart), and
apprehensive expectations and thoughts. In this section we examine  ve types of anxiety
disorders:
Generalized anxiety disorder
Panic disorder
Phobic disorder
Obsessive-compulsive disorder
Post-traumatic stress disorder
Generalized Anxiety Disorder
When you are worrying about getting a speeding ticket, you know why you are anxious;
there is a speci c cause. Generalized anxiety disorder is different from such everyday
feelings of anxiety in that sufferers experience persistent anxiety for at least 6 months
and are unable to specify the reasons for the anxiety (Freeman & Freeman, 2012). Peo-
ple with generalized anxiety disorder are nervous most of the time. They may worry
about their work, relationships, or health. That worry can also take a physical toll and
cause fatigue, muscle tension, stomach problems, and dif culty sleeping.
What is the etiology of generalized anxiety disorder? ( Etiology means the causes or
signi cant preceding conditions.) Among the biological factors are genetic predisposi-
tion, de ciency in the neurotransmitter GABA, and respiratory system abnormalities
anxiety disorders
Disabling (uncontrollable
and disruptive) psychologi-
cal disorders that feature
motor tension, hyperactivity,
and apprehensive expecta-
tions and thoughts.
generalized anxiety disorder
Psychological disorder
marked by persistent anxi-
ety for at least 6 months,
and in which the individual
is unable to specify the
reasons for the anxiety.
2
Anxiety Disorders
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Anxiety Disorders // 449
(Boschen, 2012). The psychological and sociocultural factors include having
harsh (or even impossible) self-standards, overly strict and critical parents,
automatic negative thoughts when feeling stressed, and a history of uncontrol-
lable traumas or stressors (such as an abusive parent).
Panic Disorder
Much like everyone else, you might sometimes have a speci c experience that sends you
into a panic. For example, you work all night on a paper, only to have your computer
crash before you saved your last changes, or you are about to dash across a street just
when you see a large truck coming right at you. Your heart races, your hands shake, and
you might break into a sweat.
In a panic disorder , however, a person experiences recurrent, sudden onsets of
intense terror, often without warning and with no speci c cause. Panic attacks can
produce severe palpitations, extreme shortness of breath, chest pains, trembling,
sweating, dizziness, and a feeling of helplessness (Oral & others, 2012). People
with panic disorder may feel that they are having a heart attack or going to die.
During a panic attack, the brain registers fear as areas of the fear network
of the limbic system, including the amygdala and hippocampus, are activated
(Holzschneider & Mulert, 2011). Charles Darwin, the scientist who proposed the
theory of evolution, suffered from intense panic disorder (Barloon & Noyes, 1997).
Southern cooking icon Paula Deen and former NFL running back Earl Campbell also
have dealt with this disorder.
What is the etiology of panic disorder? The-
ories of the origins of panic attack take into
account biological, psychological, and socio-
cultural factors (Pilecki, Arentoft, & McKay,
2011). In terms of biological factors, individu-
als may have a genetic predisposition to the
disorder (Bayoglu & others, 2012). Of particu-
lar interest to researchers are genes that direct
the action of neurotransmitters such as norepi-
nephrine (Buttenschøn & others, 2011) and
GABA (Thoeringer & others, 2009). Another
brain chemical, lactate , which plays a role in
brain metabolism, has been found to be elevated
in individuals with panic disorder (Maddock &
others, 2009). Further, experimental research
has shown that increasing lactate levels can pro-
duce panic attacks (Reiman & others 1989).
Other research points to the involvement of a
wider range of genes and bodily systems, impli-
cating genes involved in hormone regulation
(Wilson, Markie, & Fitches, 2012) and responses
to stress (Esler & others, 2009).
With respect to psychological in uences,
learning processes, as described in Chapter 5,
are one factor that has been considered in panic
disorder. Classical conditioning research has
shown that learned associations between bodily
cues of respiration and fear can play a role in
panic attacks (Acheson, Forsyth, & Moses,
2012). Interestingly, carbon dioxide (CO
2
) has
been found to be a very strong conditioned
panic disorder
Anxiety disorder
in which the indi-
vidual experi-
ences recurrent,
sudden onsets of
intense terror, of-
ten without warn-
ing and with no
specifi c cause.
Recall from Chapter 2 that
GABA is the neurotransmitter
that inhibits neurons from
firing—it’s like the brain’s brake
pedal. Problems with GABA are
often implicated in anxiety
disorders.
A
panic attack
can be
a one-time occurrence. People
with
panic disorder
have
recurrent attacks that
sometimes cause them to be afraid
to even leave their homes, a
condition called
agoraphobia.
Many experts interpret Edvard Munch’s painting The Scream as an expression
of the terror brought on by a panic attack.
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450 // CHAPTER 12 // Psychological Disorders
stimulus for fear, suggesting that humans may be biologically prepared to learn
an association between high concentrations of CO
2
and fear (Acheson, Forsyth,
& Moses, 2012; De Cort & others, 2012; Nardi & others, 2006; Schenberg,
2010). Thus, some learning researchers have suggested that at the heart of
panic attacks are the learned associations between CO
2
and fear (De Cort &
others, 2012).
In addition, the learning concept of generalization may apply to panic attack. Recall
that in classical conditioning, generalization means showing a conditioned response (in
this case, fear) to conditioned stimuli other than the particular one used in learning.
Research shows that individuals who suffer from panic attacks are more likely to display
overgeneralization of fear learning (Lissek & others, 2010). Why might those who
suffer from panic attacks be more likely to show stronger and more generalized
fear associations? One possibility is that the biological predispositions as well as
early experiences with traumatic life events may play a role in setting the stage
for such learning (Pilecki, Arentoft, & McKay, 2011).
In terms of sociocultural factors, in the United States, women are twice
as likely as men to have panic attacks (Altemus, 2006). Possible reasons
include biological differences in hormones and neurotransmitters (Altemus,
2006; Fodor & Epstein, 2002). Compared to men, women are more likely
to complain of distressing respiratory experiences during panic attacks
(Sheikh, Leskin, & Klein, 2002). Interestingly, a recent study showed that
healthy women are more likely to experience panic-related emotions when
exposed to air enriched with CO
2
(Nillni & others, 2012).
Research also suggests that women may cope with anxiety-provoking
situations differently than men do, and these differences may explain the gen-
der difference in panic disorder (Schmidt & Koselka, 2000; Viswanath & others,
2012). Panic attack has been observed in a variety of cultures, though there are
some cultural differences in the experience of these attacks (Agorastos, Haasen, &
Huber, 2012). For instance, in Korea, panic attacks are less likely to include a fear of
dying than is the case in other societies (Weissman & others, 1995).
Phobic Disorder
Many people are afraid of spiders and snakes; indeed, thinking
about letting a tarantula crawl over one’s face is likely to give
anyone the willies. It is not uncommon to be afraid of particular
objects or speci c environments such as extreme heights. For most
of us, these fears do not interfere with daily life. Some of us,
however, have an irrational, overwhelming, persistent fear of a
particular object or situation—an anxiety disorder called a phobic
disorder (phobia) . Whereas individuals with generalized anxiety
disorder cannot pinpoint the cause of their nervous feelings, indi-
viduals with phobias can.
A fear becomes a phobia when a situation is so dreaded that
an individual goes to almost any length to avoid it. As with any
anxiety disorder, phobias are fears that are uncontrollable, dis-
proportionate, and disruptive. A snake phobia that keeps a city-
dweller from leaving his apartment is clearly disproportionate to
the actual chances of encountering a snake. John Madden—
former NFL coach, recently retired football commentator, and
successful video game consultant—has a famous fear of  ying
that led him to take a bus to the games that he broadcast.
Anxiety is a universal emotion, and phobias have been found
in many cultures. Culture, though, may play a role in the object of
phobic disorder
(phobia)
Anxiety disorder
characterized by
an irrational,
overwhelming,
persistent fear
ofa particular
object or
situation.
An earlier explanation
of panic attack was called the
suffocation false alarm
theory.
Can you see why it
was initially proposed?
Whenever you encounter
gender differences in this
discussion, ask yourself whether
men or women might be more
likely
to report
having problems
or
to seek treatment.
Research on psychological disorders
is often based on individuals who
have reported symptoms or
sought help. If men are less likely
to report symptoms or seek
treatment, the data may
underestimate the occurrence of
psychological disorders in men.
“Stephen’s fear of heights is particularly bad today.”
Used by permission of CartoonStock, www.CartoonStock.com.
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Anxiety Disorders // 451
a particular phobia. For example, koro is a phobia that is found in Malaysia and Indonesia,
and some forms also appear in South China and parts of Africa. This phobia involves abject
terror among men that their genitals are shrinking into their bodies (Agorastos, Haasen, &
Huber, 2012). Koro is often accompanied by a strong terror that one is going to die.
Another phobic disorder, social phobia , is an intense fear of being humiliated or embar-
rassed in social situations (Pull, 2012). Singers Carly Simon and Barbra Streisand have dealt
with social phobia. Social phobia is recognized in many cultures, but it appears in a differ-
ent form in collectivistic cultures. In Japan and Korea, for instance, social phobia often
involves being afraid not of doing something embarrassing but of insulting or harming
another person (Agorastos, Haasen, & Huber, 2012). Researchers have found that East
Asians are more likely to have social anxiety than North Americans (Hsu & others, 2012).
Phobias usually begin in childhood (National Institute of Mental Health, 2008) and
come in many forms. Figure 12.2 labels and describes a number of phobias.
What is the etiology of phobic disorder? Genes appear to play a role in social
phobia (Reich, 2009). Researchers have proposed that there is a neural circuit
for social phobia that includes the thalamus, amygdala, and cerebral cortex
(Damsa, Kosel, & Moussally, 2009). Also, a number of neurotransmitters
may be involved in social phobia, especially serotonin (Nash & Nutt, 2005).
With regard to psychological factors, learning theorists consider phobias
learned fears (Vriends & others, 2012). Perhaps, for example, the individual with
the fear of falling off a building experienced a fall from a high place earlier in life
and therefore associates heights with pain (a classical conditioning explanation). Alterna-
tively, he or she may have heard about or watched others who
demonstrated terror of high places (an observational learning
explanation), as when a little girl develops a fear of heights
after sitting next to her terri ed mother and observing her
clutch the handrails, white-knuckled, as the roller coaster
creeps steeply uphill.
Obsessive-Compulsive
Disorder
Just before leaving on a long road trip, you  nd yourself
checking to be sure you locked the front door. As you pull
away in your car, you are stricken with the thought that you
Systematic
desensitization, described in
Chapter 13, involves the application
of learning principles to the
unlearning
of phobias.
Acrophobia Fear of high places
Aerophobia Fear of flying
Ailurophobia Fear of cats
Algophobia Fear of pain
Amaxophobia Fear of vehicles,
driving
Arachnophobia Fear of spiders
Astrapophobia Fear of lightning
Cynophobia Fear of dogs
Gamophobia Fear of marriage
Hydrophobia Fear of water
Melissophobia Fear of bees
Mysophobia Fear of dirt
Nyctophobia Fear of darkness
Ophidiophobia Fear of nonpoisonous
snakes
Thanatophobia Fear of death
Xenophobia Fear of strangers
FIGURE 12.2 Phobias This  gure features examples of phobic disorder—an anxiety disorder characterized by irrational and overwhelming fear of a particular
object or situation.
“I gotta go—we’re discussing my compulsive
communications disorder.”
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452 // CHAPTER 12 // Psychological Disorders
As long as the person
performs the ritual, she never
finds out that the terrible
outcome doesn’t happen. The
easing of the anxiety exemplifies
negative reinforcement
(having something bad taken away
after performing a behavior).
forgot to turn off the coffeemaker. Going to bed the night before an early  ight, you
check your alarm clock a few times to be sure you will wake up on time. These are
examples of normal checking behavior.
In contrast, the anxiety disorder known as obsessive-compulsive disorder (OCD)
features anxiety-provoking thoughts that will not go away and/or urges to perform repet-
itive, ritualistic behaviors to prevent or produce some future situation. Obsessions are
recurrent thoughts, and compulsions are recurrent behaviors. Individuals with OCD dwell
on their doubts and repeat their routines sometimes hundreds of times a day (Yap, Mogan,
& Kyrios, 2012). The most common compulsions are excessive checking, cleansing, and
counting. Game show host Howie Mandel has coped with OCD, as have soccer star
David Beckham, singer-actor Justin Timberlake, and actress Jessica Alba. Obsessive-
compulsive symptoms have been found in many cultures, and culture plays a role in the
content of obsessive thoughts or compulsive behaviors (Matsunaga & Seedat, 2011).
An individual with OCD might believe that she has to touch the doorway
with her left hand whenever she enters a room and count her steps as she walks.
If she does not complete this ritual, she may be overcome with a sense of fear
that something terrible will happen (Victor & Bernstein, 2009).
What is the etiology of obsessive-compulsive disorder? In terms of biologi-
cal factors, there seems to be a genetic component (Alonso & others, 2012;
Angoa-Perez & others, 2012). Also, brain-imaging studies have suggested
neurological links for OCD (Hou & others, 2012; Stern & others, 2012). One
neuroscienti c analysis is that the frontal cortex or basal ganglia are so active in
OCD that numerous impulses reach the thalamus, generating obsessive thoughts or
compulsive actions (Rotge & others, 2009).
In one study, fMRI was used to examine the brain activity of individuals with OCD
before and after treatment (Nakao & others, 2005). Following effective treatment, a
number of areas in the frontal cortex showed decreased activation. Interestingly, the
amygdala, which is associated with the experience of anxiety, may be smaller in indi-
viduals with OCD compared to those who do not have the disorder (Atmaca & others,
2008). Low levels of the neurotransmitters serotonin and dopamine likely are involved
in the brain pathways linked with OCD (Goljevscek & Carvalho, 2011; Soomro, 2012).
In terms of psychological factors, OCD sometimes occurs during a period of life stress
such as that surrounding the birth of a child or a change in occupational or marital sta-
tus (Uguz & others, 2007). According to the cognitive perspective, what differentiates
individuals with OCD from those who do not have it is the ability to turn off negative,
intrusive thoughts by ignoring or effectively dismissing them (Leahy, Holland, & McGinn,
2012; C. Williams, 2012).
Post-Traumatic Stress Disorder
If you have ever been in even a minor car accident, you may have had a nightmare or
two about it. You might have even found yourself reliving the experience for some time.
This normal recovery process takes on a particularly devastating character in post-
traumatic stress disorder. Post-traumatic stress disorder (PTSD) is an anxiety disorder
that develops through exposure to a traumatic event that overwhelms the person’s abili-
ties to cope (Beidel, Bulik, & Stanley, 2012). The symptoms of PTSD vary but include:
Flashbacks in which the individual relives the event. A  ashback can make the person
lose touch with reality and reenact the event for seconds, hours, or, very rarely, days.
A person having a  ashback—which can come in the form of images, sounds, smells,
and/or feelings—usually believes that the traumatic event is happening all over again
(Brewin, 2012).
Avoiding emotional experiences and avoiding talking about emotions with others.
Reduced ability to feel emotions, often reported as feeling numb, resulting in an inabil-
ity to experience happiness, sexual desire, or enjoyable interpersonal relationships.
obsessive-
compulsive
disorder (OCD)
Anxiety disorder
in which the indi-
vidual has anxiety-
provoking
thoughts that will
not go away and/
or urges to per-
form repetitive,
ritualistic behav-
iors to prevent or
produce some
future situation.
post-traumatic stress
disorder (PTSD)
Anxiety disorder that devel-
ops through exposure to a
traumatic event, a severely
oppressive situation, cruel
abuse, or a natural or an
unnatural disaster.
EXPERIENCE IT!
Obsessive-Compulsive
Disorder
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Anxiety Disorders // 453
The Psychological Wounds of War
P
TSD has been a concern for soldiers who have served in Iraq and Afghanistan
(Klemanski & others, 2012; Yoder & others, 2012). In an effort to prevent
PTSD, the U.S. military gives troops stress-management training before deployment
(Ritchie & others, 2006). Branches of the armed forces station mental health profes-
sionals in combat zones around the world to help prevent PTSD and to lessen the
effects of the disorder (Rabasca, 2000). These measures appear to be paying off:
Researchers have found that PTSD sufferers from the Iraq and Afghanistan wars are gen-
erally less likely to be unemployed or incarcerated and more likely to maintain strong
social bonds following their term of service than veterans of earlier wars (Fontana &
Rosenheck, 2008).
Historically, the stigma associated with psychological disorders has been especially
strong within the military ranks, where struggling with a psychological problem is
commonly viewed as a sign of weakness or incompetence (Warner & others, 2011). Yet
individuals engaged in combat are at considerable risk of developing PTSD, and the disor-
der can profoundly affect their lives. A survey of almost 3,000 soldiers who had just
returned from the Iraq War revealed that 17 percent met the criteria for PTSD (Hoge & others,
2007). This fi gure is likely an underestimate given the stigma linked to psychological disorders in
the military.
In 2008, military psychologist John Fortunato suggested that veterans with PTSD ought to
be eligible for the Purple Heart, the prestigious military decoration awarded to those who have
been physically wounded or killed in combat (Schogol, 2009). Awarding PTSD sufferers the
Purple Heart, Fortunato argued, would not only acknowledge their sacrifi ce but also reduce the
stigma attached to psychological disorders. That year, the military did consider whether PTSD
sufferers in its ranks ought to be awarded the Purple Heart. However, the Pentagon decided
against awarding the Purple Heart to military personnel with PTSD on the grounds that the
disorder is not limited to victims of physical trauma from enemy fi re but also can affect
eyewitnesses (Schogol, 2009). Still, the fact that the top brass considered the possibility
suggests that the military is becoming more aware of the serious problems facing those who
are traumatized while serving their country in combat.
PSYCHOLOGY IN OUR WORLD
Excessive arousal, resulting in an exaggerated startle response or an inability to
sleep.
Dif culties with memory and concentration.
Feelings of apprehension, including nervous tremors.
Impulsive outbursts of behavior, such as aggressiveness, or sudden changes in lifestyle.
PTSD symptoms can follow a trauma immediately or after months or even years (Solomon
& others, 2012). Most individuals who are exposed to a traumatic event experience some
of the symptoms in the days and weeks following exposure (National Center for PTSD,
2012). However, not every individual exposed to the same event develops PTSD (Brewin
& others, 2012; Nemeroff & others, 2006).
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454 // CHAPTER 12 // Psychological Disorders
1. Sudden episodes of extreme anxiety or
terror that involve symptoms such as
heart palpitations, trembling, sweat-
ing, and fear of losing control are
characteristic of
A. generalized anxiety disorder.
B. post-traumatic stress disorder.
C. obsessive-compulsive disorder.
D. panic disorder.
2. Which of the following is true of
post-traumatic stress disorder?
A. It is caused by panic attacks.
B. It is the natural outgrowth of
experiencing trauma.
C. It involves fl ashbacks.
D. The symptoms always occur
immediately following a trauma.
3. Intense fear of something that provokes
an individual’s efforts to avoid the
feared stimulus is a defining
characteristic of
A. post-traumatic stress disorder.
B. phobic disorder.
C. panic disorder.
D. generalized anxiety disorder.
APPLY IT! 4. Lately Tina has noticed
that her mother appears to be overwhelmed
with worry about everything. Her mother
has told Tina that she is having trouble
sleeping and experiencing racing thoughts
of all the terrible things that might happen
at any given moment. Tina’s mother is
showing signs of
A. panic disorder.
B. obsessive-compulsive disorder.
C. generalized anxiety disorder.
D. post-traumatic stress disorder.
3
Mood Disorders
Mood disorders are psychological disorders in which there is a primary disturbance of
mood ( mood refers to a prolonged emotion that colors the individual’s entire emotional
state). This mood disturbance can include cognitive, behavioral, and somatic (physical)
symptoms, as well as interpersonal dif culties. In this section we examine the two main
types of mood disorders—depressive disorders and bipolar disorder—and consider a
tragic correlate of these disorders: suicide.
Depressive Disorders
Everyone feels blue sometimes. A romantic breakup, the death of a loved one, or a
personal failure can cast a dark cloud over life. Sometimes, however, a person might
feel unhappy and not know why. Depressive disorders are mood disorders in which
mood disorders
Psychological
disorders—the
main types of
which are de-
pressive disor-
ders and bipolar
disorder—in
which there is a
primary distur-
bance of mood:
prolonged emo-
tion that colors
the individual’s
entire emotional
state.
depressive disorders
Mood disorders in which
the individual suffers from
depression—an unrelenting
lack of pleasure in life.
Researchers have examined PTSD associ-
ated with various experiences (Harder & oth-
ers, 2012). These include combat and
war-related traumas (Khamis, 2012), sexual
abuse and assault (S. Y. Kim & others, 2012),
natural disasters such as hurricanes and earth-
quakes (Sezgin & Punamaki, 2012), and
unnatural disasters such as plane crashes and
terrorist attacks (Luft & others, 2012).
Clearly, one cause of PTSD is the traumatic
event itself (Risbrough & Stein, 2012). How-
ever, because not everyone who experiences the
same traumatic life event develops PTSD, other
factors, aside from the event, must in uence a
person’s vulnerability to the disorder (Gabert-
Quillen & others, 2012). These include a his-
tory of previous traumatic events and conditions,
such as abuse and psychological disorders
(Canton- Cortes, Canton, & Cortes, 2012), cultural
background as in the case of traumatized refugees (Hinton & others, 2012), and genetic
predisposition (Mehta & Binder, 2012; Skelton & others, 2012).
Prior to deployment, U.S. troops receive stress-management training aimed
at helping to prevent PTSD and other disorders that might be triggered by
the high-stress conditions of war.
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Mood Disorders // 455
This painting by Vincent Van Gogh, Portrait of
Dr. Gachet, refl ects the extreme melancholy
that characterizes the depressive disorders.
the individual suffers from depression , an unrelenting lack of plea-
sure in life. The severity of depressive disorders varies. Some indi-
viduals experience what is classi ed as major depressive disorder,
whereas others are given the diagnosis of dysthymic disorder, a more
chronic depression with fewer symptoms than major depression
(Wasserman, 2012)
A variety of cultures have recognized depression, and studies have
shown that across cultures depression is characterized as involving an
absence of joy, low energy, and high levels of sadness (Dritschel &
others, 2011; Kahn, 2012). Moreover, culture may in uence the ways
individuals describe their experience. For instance, people from Eastern
cultures may be less likely to talk about their emotional states, and
more likely to describe depressive symptoms in terms of bodily feelings
and symptoms, than those from Western cultures (Draguns & Tanaka-
Matsumi, 2003). Depressive disorders are common, and many success-
ful individuals have been diagnosed with depression. They include
musicians Sheryl Crow and Eric Clapton, actors Drew Barrymore,
Halle Berry, and Jim Carrey, artist Pablo Picasso, astronaut Buzz Aldrin
(the second moon walker), famed American architect Frank Lloyd
Wright, and J. K. Rowling, the author of the Harry Potter series.
Major depressive disorder (MDD) involves a signi cant depres-
sive episode and depressed characteristics, such as lethargy and hopelessness, for at least
two weeks. MDD impairs daily functioning, and the National Institute of Mental Health
(NIMH) has called it the leading cause of disability in the United States (NIMH, 2008).
Ten symptoms (at least  ve of which must be present during a two-week period) de ne
a major depressive episode:
Depressed mood most of the day
Reduced interest or pleasure in all or most activities
Signi cant weight loss or gain or signi cant decrease or interest in appetite
Trouble sleeping or sleeping too much
Psychomotor agitation or retardation
Fatigue or loss of energy
Feeling worthless or guilty in an excessive or inappropriate manner
Problems in thinking, concentrating, or making decisions
Recurrent thoughts of death and suicide
No history of manic episodes (periods of euphoric mood)
Dysthymic disorder (DD) is a mood disorder that is generally more chronic and has
fewer symptoms than MDD. The individual is in a depressed mood for most days for at
least two years as an adult or at least one year as a child or adolescent (NIMH, 2012).
To be classi ed as having dysthymic disorder, the individual must not have experienced
a major depressive episode, and the two-year period of depression must not have been
broken by a normal mood lasting more than two months. Two or more of these six
symptoms must be present:
Poor appetite or overeating
Sleep problems
Low energy or fatigue
Low self-esteem
Poor concentration or dif culty making decisions
Feelings of hopelessness
What are the causes of depressive disorders? A variety of biological, psychological,
and sociocultural factors have been implicated in their development.
major depressive
disorder (MDD)
Psychological
disorder involv-
ing a major de-
pressive episode
and depressed
characteristics,
such as lethargy
and hopeless-
ness, for at least
two weeks.
dysthymic disorder (DD)
Mood disorder that is gen-
erally more chronic and has
fewer symptoms than major
depressive disorder.
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456 // CHAPTER 12 // Psychological Disorders
BIOLOGICAL FACTORS Genetic in uences play a role in depression (Goenjian
& others, 2012; Sabunciyan & others, 2012). In addition, speci c brain structures are
involved in depressive disorders. For example, depressed individuals show lower levels
of brain activity in a section of the prefrontal cortex that is involved in generating actions
(Duman & others, 2012) as well as in regions of the brain associated with the perception
of rewards in the environment (Howland, 2012). A depressed person’s brain may not
recognize opportunities for pleasurable experiences.
Depression also likely involves problems in neurotransmitter regulation. Recall that
neurotransmitters are chemicals that carry impulses from neuron to neuron. For smooth
brain function, neurotransmitters must ebb and  ow, often in harmony with one another.
Individuals with major depressive disorder appear to have too few receptors for the
neurotransmitters serotonin and norepinephrine (Houston & others, 2012; H. F. Li &
others, 2012). Some research suggests that problems in regulating a neurotransmitter
called substance P might be involved in depression (Munoz & Covenas, 2012). Substance
P is thought to play an important role in the psychological experience of pain (Sacerdote
& Levrini, 2012).
PSYCHOLOGICAL FACTORS Psychological explanations of depression have
drawn on behavioral learning theories and cognitive theories. One behavioral view of
depression focuses on learned helplessness , which, as we saw in Chapter 5, involves an
individual’s feelings of powerlessness after exposure to aversive circumstances over
which the person has no control. Martin Seligman (1975) proposed that learned helpless-
ness is a reason that some people become depressed. When individuals cannot control
their stress, they eventually feel helpless and stop trying to change their situations. This
helplessness spirals into hopelessness (Becker-Weidman & others, 2009).
Cognitive explanations of depression focus on the thoughts and beliefs that con-
tribute to this sense of hopelessness (Britton & others, 2012; Jarrett & others, 2012).
Psychiatrist Aaron Beck (1967) proposed that negative thoughts re ect self-defeating
beliefs that shape depressed individuals’ experiences. These habitual negative thoughts
magnify and expand depressed persons’ negative experiences (Lam, 2012). For exam-
ple, a depressed individual might overgeneralize about a minor occurrence—say, turn-
ing in a work assignment late—and think that he or she is worthless. A depressed
person might view a minor setback such as getting a D on a paper as the end of the
world. The accumulation of such cognitive distortions can lead to depression (T. W.
Lee & others, 2011).
The way people think can also in uence the course of depression. Depressed indi-
viduals may ruminate on negative experiences and negative feelings, playing them
over and over again in their minds (Nolen-Hoeksema, 2011). This tendency to rumi-
nate is associated with the development of depression as well as other psychological
problems such as binge eating and substance abuse (Cowdrey & Park, 2012; Kuhn &
others, 2012).
Another cognitive view of depression focuses on people’s attributions—their
attempts to explain what caused something to happen (Seidel & others, 2012). Depres-
sion is thought to be related to a pessimistic attributional style. In this style, individu-
als regularly explain negative events as having internal causes (“It is my fault I failed
the exam”), stable causes (“I’m going to fail again and again”), and global causes
(“Failing this exam shows that I won’t do well in any of my courses”). Pessimistic
attributional style means blaming oneself for negative events and expecting the negative
events to recur (Abramson, Seligman, & Teasdale, 1978). This pessimistic style can
be contrasted with an optimistic attributional style, which is essentially its opposite.
Optimists make external attributions for bad things that happen (“I did badly on the
test because it’s hard to know what a professor wants on the  rst exam”). They also
recognize that these causes can change (“I’ll do better on the next one”) and that they
are speci c (“It was only one test”). Optimistic attributional style has been related to
lowered depression and decreased suicide risk in a variety of samples (Rasmussen &
Wingate, 2012; Tindle & others, 2012).
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Mood Disorders // 457
Having a spouse, roommate, or
friend who suffers from depression can
increase the risk that an individual will
also become depressed (Coyne, 1976;
Joiner, Alfano, & Metalsky, 1992;
Ruscher & Gotlib, 1988). Such effects
are sometimes called contagion because
they suggest that depression can spread
from one person to another (Kiuru &
others, 2012). Of course, the term con-
tagion here is metaphorical. In fact,
research suggests that whether depres-
sion and anxiety are contagious depends
on the quality of interactions between
people. To read more about this topic
and its potential role in children’s psy-
chological health, see the Intersection.
SOCIOCULTURAL FACTORS
Individuals with a low socioeconomic
status (SES), especially people living
in poverty, are more likely to develop
depression than their higher-SES
counterparts (Boothroyd & others,
2006). A longitudinal study of adults
revealed that depression increased as
one’s standard of living and employ-
ment circumstances worsened (Lorant
& others, 2007). Studies have found
very high rates of depression in Native
American groups, among whom pov-
erty, hopelessness, and alcoholism are
widespread (Teesson & Vogl, 2006).
Women are nearly twice as likely
as men to develop depression (Yuan &
others, 2009). As Figure 12.3 shows,
this gender difference occurs in many
countries (Inaba & others, 2005). Inci-
dence of depression is high, too,
among single women who are the
heads of households and among young
married women who work at unsatis-
fying, dead-end jobs (Whiffen &
Demidenko, 2006). Minority women
also are a high-risk group for depres-
sion (Diefenbach & others, 2009).
Bipolar Disorder
Just as we all have down times, there are times when things seem to be going phe-
nomenally well. For individuals with bipolar disorder, the ups and downs of life
take on an extreme and often harmful tone. Bipolar disorder is a mood disorder
characterized by extreme mood swings that include one or more episodes of
mania, an overexcited, unrealistically optimistic state. A manic episode is like the
ipside of a depressive episode (Goldney, 2012). The person who experiences
bipolar disorder
Mood disorder
characterized by
extreme mood
swings that in-
clude one or
more episodes of
mania, an over-
excited, unrealis-
tically optimistic
state.
2.5
4.0
0
5 1015202530
Lifetime Rate per 100 People
Korea
4.5
6.5
Puerto Rico
3.5
8.5
United States
7.5
13.0
Edmonton, Canada
8.0
16.0
New Zealand
5.0
17.0
West Germany
6.5
19.0
Florence, Italy
11.0
22.0
Paris, France
14.0
24.0
Beirut, Lebanon
Males
Females
PSYCHOLOGICAL INQUIRY
FIGURE 12.3 Gender Differences in Depression Across Cultures
This graph shows the rates of depression for men and women in nine cultures (Weissman
& Olfson, 1995). > Which cultures have the highest and lowest rates of depression?
What might account for these differences? > Which cultures have the largest gender
difference in depression? What might account for these differences? > In order to be
diagnosed with depression, a person has to seek treatment for the disorder. How might
gender and culture in uence a person’s willingness to get treatment?
Another gender
difference to consider: Why
might men show lower levels of
depression than women?
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458 // CHAPTER 12 // Psychological Disorders
T
he role of friendships in chil-
dren’s and adolescents’ lives
is increasingly of interest to
developmental psychologists.
Among youth, friends are important to
self-esteem, well-being, and school
adjustment (Mendel & others, 2012;
Mora & Gil, 2012; Shany, Wiener, &
Assido, 2012). Still, some friends
may be better in uences than others.
A large body of evidence supports the
conclusion that hanging around with
friends who engage in problem behav-
iors such as delinquency and sub-
stance abuse increases the likelihood
of youth involvement in such behavior
(Giletta & others, 2012; Laursen &
others, 2012). But what about associating closely with individuals
who have psychological symptoms, like depression and anxiety,
that are not as likely to beevident in behavior? Might such symp-
toms also “rub off” on friends?
Before addressing that question, let’s clarify some terms. In
children, symptoms of psychological disorders are often catego-
rized as either externalizing or internalizing symptoms. External-
izing symptoms, commonly referred to as “acting out,” include
delinquency and aggression. Internalizing symptoms include
feelings of depression and anxiety. While research supports the
notion that externalizing symptoms are contagious (that is, they
spread from one friend to another), only recently have research-
ers addressed the possibility that internalizing symptoms might
be contagious as well. To put it concretely, can having a friend
who is depressed or anxious increase the likelihood that a
childor an adolescent will become depressed or anxious as
well? Research suggests the answer is yes (Prinstein, 2007;
Tompkins & others, 2011), and a recent study by Rebecca
Schwartz-Mette and Amanda Rose (2012) provides an explana-
tion for this effect.
These researchers proposed that depression and anxiety can
pass from one friend to another through the conversations friends
share. They examined a particular kind of social sharing called co-
rumination (Rose, 2002; Rose & Smith, 2009). Rumination is a
way of thinking that involves worrying about a topic without  nding
a resolution. When we ruminate, we might dwell on all the possi-
ble horrible consequences of some negative event or imagine
everything that might go wrong in the
future. Co-rumination is like that too,
but it involves engaging in a conversa-
tion with someone and making a neg-
ative event that the person is going
through seem even worse. When
friends co-ruminate, they focus on
problems, rehashing them repeatedly,
speculating on possible future prob-
lems, and emphasizing negative emo-
tions (Rose, 2002). Ironically, though
co-rumination can make both mem-
bers of a friendship feel pretty miser-
able, this kind of social sharing is
also related to friendship quality and
closeness (Rose, Carlson, & Waller,
2007). Perhaps because of this
closeness, co- rumination is associated with strong feelings of em-
pathetic distress, which occurs when one friend takes on the nega-
tive feelings of the other (Smith & Rose, 2011). If co-ruminating
allows one to share deeply in the emotional life of another, it
might well play a role in spreading depression or anxiety.
To explore this possibility, Schwartz-Mette and Rose (2012)
examined whether symptoms of depression and anxiety in one youth
predicted increases in these symptoms in that individual’s friends
and whether this contagion might be explained by the tendency to
co-ruminate. They surveyed several hundred children (third- and  fth-
graders) and adolescents (seventh- and ninth-graders) and their best
friends and found that having a friend who was feeling depressed
or anxious indeed predicted increases in feelings of depression or
anxiety six months later in all but the youngest boys. Further, co-
rumination was associated with contagion of anxiety for all but the
youngest boys in the study. For depression, co-rumination was asso-
ciated with the contagion of depression but only for adolescents.
This work shows that peer relation-
ships are a key factor to consider in
psychological dif culties among youth.
Friends are a vital resource, and
talking with friends is a primary chan-
nel by which we make sense of the
world. Research is now showing that
the quality of those conversations
may be an important element in
mental health.
Clinical and Developmental Psychology:
Can Kids “Catch” Depression and Anxiety?
INTERSECTION
\\
How do these results
match your experiences of
childhood friendship?
\\
Do some of your
present-day friends
co-ruminate over negative
events?
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Mood Disorders // 459
mania feels on top of the world. She has tremendous energy and might
sleep very little. A manic state also features an impulsivity that can
get the individual in trouble. For example, the sufferer might spend
his life savings on a foolish business venture.
Most bipolar individuals experience multiple cycles of depression
interspersed with mania, usually separated by six months to a year.
Unlike depressive disorders, which are more likely to occur in women,
bipolar disorder is equally common in women and men. Bipolar dis-
order does not prevent a person from being successful. Award-winning
actor Catherine Zeta-Jones, famed dancer and choreographer Alvin
Ailey, and actor-writer Carrie Fisher (Princess Leia) have been diag-
nosed with bipolar disorder.
What factors play a role in the development of bipolar disorder?
Genetic in uences are stronger predictors of bipolar disorder than of
depressive disorders (Pirooznia & others, 2012). An individual with
an identical twin who has bipolar disorder has a 70 percent probabil-
ity of also having the disorder, and a fraternal twin has a more than
10 percent probability (Figure 12.4). Researchers are zeroing in on
the speci c genetic location of bipolar disorder (Crisafulli & others,
2012; Pedroso & others, 2012).
Other biological processes are also a factor. Like depression, bipo-
lar disorder is associated with differences in brain activity. Figure 12.5
shows the metabolic activity in the cerebral cortex of an individual
cycling through depressive and manic phases. Notice the decrease in
metabolic activity in the brain during depression and the increase in
metabolic activity during mania (Baxter & others, 1995). In addition
to high levels of norepinephrine and low levels of serotonin, studies
show that high levels of the neurotransmitter
glutamate occur in bipolar disorder (Dhillin,
2012; Fountoulakis, 2012). These differ-
ences between depression and bipolar disor-
der have led to differences in treatment, as
we will see in Chapter 13.
Suicide
Thinking about suicide is not necessarily
abnormal. However, attempting or completing
the act of suicide is abnormal. Approximately
90 percent of individuals who commit suicide
are estimated to have a diagnosable mental
disorder (NIMH, 2008), and the most common
disorders among individuals who commit sui-
cide are depression and anxiety (Blanco & oth-
ers, 2012; Nauta & others, 2012). Depressed
individuals are also likely to attempt suicide
more than once (da Silva Cais & others, 2009).
Sadly, many individuals who, to the outside
eye, seem to be leading successful and ful ll-
ing lives have ended their lives through sui-
cide. Examples include poet Sylvia Plath,
novelist Ernest Hemingway, and grunge icon
Kurt Cobain (who committed suicide after life-
long battles with ADHD and bipolar disorder).
0
10
20
30
50
40
60
70
80
Identical
twins
Fraternal
twins
General
population
Percent risk of bipolar disorder
FIGURE 12.4 Risk of Bipolar
Disorder in Identical and Fraternal
Twins If One Twin Has the Disorder,
andin the General Population Notice how
much stronger the similarity of bipolar disorder is in
identical twins as compared with fraternal twins and
the general population. These statistics suggest a
strong genetic role in the disorder.
FIGURE 12.5 Brain Metabolism in Mania and Depression
PET scans of an individual with bipolar disorder, who is described as a rapid-cycler
because of how quickly severe mood changes occurred. (Top and bottom) The
person’s brain in a depressed state. (Middle) A manic state. The PET scans reveal
how the brain’s energy consumption falls in depression and rises in mania. The red
areas in the middle row re ect rapid consumption of glucose.
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460 // CHAPTER 12 // Psychological Disorders
According to the Centers for Disease Control and Prevention
(CDC), in 2010, 37,793 people in the United States committed
suicide, and suicide was the 10th-highest cause of death in the
country (CDC, 2012). There are twice as many suicides as
homicides in the United States, and the suicide rate increased
13 percent from 1999 to 2010 (Schmitz & others, 2012).
Research indicates that for every completed suicide, 8 to 25
attempted suicides occur (NIMH, 2008). Suicide is the third-
leading cause (after automobile accidents and homicides) of
death today among U.S. adolescents 13 through 19 years of
age (Murphy, Xu, & Kochanek, 2012). Even more shocking,
in the United States suicide is the third-leading cause of death
among children 10 to 14 years of age (CDC, 2007). Given these
grim statistics, psychologists work with individuals to reduce
the frequency and intensity of suicidal impulses. Figure 12.6
provides good advice on what to do and what not to do
if you encounter someone who is threatening suicide.
What might prompt an individual to end his or
her own life? Biological, psychological, and socio-
cultural circumstances can be contributing factors.
BIOLOGICAL FACTORS Genetic factors
appear to play a role in suicide, which tends to run
in families (Althoff & others, 2012). The Hemingways
are one famous family that has been plagued by sui-
cide. Five Hemingways, spread across generations, com-
mitted suicide, including the writer Ernest Hemingway and
his granddaughter Margaux, a model and actor. Similarly, in
2009, Nicholas Hughes—a successful marine biologist and the
son of Sylvia Plath, a poet who had killed herself—tragically
hanged himself.
Studies have linked suicide with low levels of the neu-
rotransmitter serotonin (Lyddon & others, 2012). Individuals
who attempt suicide and who have low serotonin levels are 10
times more likely to attempt suicide again than are attempters
who have high serotonin levels (Courtet & others, 2004). Poor
physical health, especially when it is chronic, is another risk
factor for suicide (Webb & others, 2012).
PSYCHOLOGICAL FACTORS Psychological factors that can contribute to sui-
cide include mental disorders and traumas such as sexual abuse (Wanner & others, 2012).
Struggling with the stress of a psychological disorder can leave a person feeling
hopeless, and the disorder itself may tax the person’s ability to cope with life’s
dif culties. Indeed, approximately 90 percent of individuals whocommit suicide
are estimated to have a diagnosable mental disorder (NIMH, 2008).
An immediate and highly stressful circumstance—such as the loss of a loved
one or a job,  unking out of school, or an unwanted pregnancy—can lead people to
threaten and/or to commit suicide (Videtic & others, 2009). In addition, substance abuse
is linked with suicide more today than in the past (Conner & others, 2012).
In research focusing on suicide notes, Thomas Joiner and his colleagues have found that
having a sense of belongingness or of being needed separates individuals who attempt sui-
cide from those who complete it (Joiner, 2005; Joiner, Hollar, & Van Orden, 2006; Joiner
& Ribeiro, 2011). Essentially, people who feel that someone will miss them or still need
them are less likely than others to complete a suicide (A. R. Smith & others, 2012).
SOCIOCULTURAL FACTORS Chronic economic hardship can be a factor in sui-
cide (Ferretti & Coluccia, 2009; Rojas & Stenberg, 2010). Cultural and ethnic contexts
What Not to Do
1. Don’t ignore
the warning signs.
2. Don’t refuse to
talk about suicide if
the person wants to
talk about it.
3. Don’t react with horror,
disapproval, or repulsion.
4. Don’t offer false reassurances
(“Everything will be all right”) or make judgments
(“You should be thankful for . . .”).
5. Don’t abandon the person after the crisis seems
to have passed or after professional counseling
has begun.
What to Do
1. Ask direct, straightforward questions in a calm
manner. For example, “Are you thinking about
hurting yourself?
2. Be a good listener and be supportive. Emphasize
that unbearable pain can be survived.
3. Take the suicide threat very seriously. Ask
questions about the person’s feelings, relation-
ships, and thoughts about the type of method to
be used. If a gun, pills, rope, or other means is
mentioned and a specific plan has been
developed, the situation is dangerous. Stay with
the person until help arrives.
4. Encourage the person to get professional help
and assist him or her in getting help.
If the person is willing, take
the person to a mental
health facility
or hospital.
FIGURE 12.6 When Someone Is Threatening
Suicide Do not ignore the warning signs if you think someone
you know is considering suicide. Talk to a counselor if you are
reluctant to say anything to the person yourself.
Note that people whose
parents committed suicide may be
more likely to consider suicide as
an option. So, environment
matters.
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Mood Disorders // 461
also are related to suicide attempts. In the
United States, adolescents’ suicide attempts
vary across ethnic groups. As Figure 12.7
illustrates, more than 20 percent of
American Indian/Alaska Native (AI/AN)
female adolescents reported that they had
attempted suicide in the previous year, and
suicide accounts for almost 20 percent of
AI/AN deaths in 15- to 19-year-olds
(Goldston & others, 2008). As the  gure
also shows, African American and non-
Latino White males reported the lowest
incidence of suicide attempts. A major risk
factor in the high rate of suicide attempts
by AI/AN adolescents is their elevated rate
of alcohol abuse.
Suicide rates vary worldwide; the low-
est rates occur in countries with cultural
and religious norms against ending one’s
own life. Among the nations with the highest suicide rates are several eastern European
nations—including Belarus, Bulgaria, and Russia—along with Japan and South Korea.
According to the World Health Organization (WHO), among the nations with the lowest
rates are Haiti, Antigua and Barbuda, Egypt, and Iran (WHO, 2009). Of the 104 nations
ranked by the WHO, the United States ranks 40th.
Research has also linked suicide to the culture of honor. Recall that in honor cultures,
individuals are more likely to interpret insults as  ghting words and to defend their
personal honor with aggression. One set of studies examined suicide and depression in
the United States, comparing geographic regions that are considered to have a culture of
honor (that is, southern states) with other areas. Even accounting for a host of other
factors, suicide rates were found to be higher in states with a culture of honor (Osterman
& Brown, 2011). The researchers also examined how regions compared in terms of the
use of prescription antidepressants and discovered that states with a culture of honor
also had lower levels of use of these drugs. It may be that in a culture of honor,
seeking treatment for depression is seen as a weakness or a mark of shame.
There are gender differences in suicide as well (Sarma & Kola, 2010).
Women are three times more likely than men to attempt suicide. Men, however,
are four times more likely than women to complete suicide (Kochanek & oth-
ers, 2004). Men are also more likely than women to use a  rearm in a suicide
attempt (Maris, 1998). The highest suicide rate is among non-Latino White men
ages 85 and older (NIMH, 2008).
0
4
8
12
16
20
24
Males Females
Suicide attempt rates (per 100)
NA/AN
AA/PI
African American
Non-Latino
White
Latino
FIGURE 12.7 Suicide Attempts by U.S. Adolescents from
Different Ethnic Groups Note that the data shown are for one-year rates of
self-reported suicide attempts. NA/AN Native Americans/Alaska Native; AA/PI
Asian American/Paci c Islander.
Men are
less
likely
than women to
report
being
depressed but are
more
likely to
commit
suicide. Clearly,
depression in men might be
underestimated.
1. To be diagnosed with bipolar disorder,
an individual must experience
A. a manic episode.
B. a depressive episode.
C. a manic episode and a depressive
episode.
D. a dysthymic episode.
2. All of the following are a symptom of
major depressive disorder except
A. fatigue.
B. weight change.
C. thoughts of death.
D. substance use.
3. A true statement about suicide and
gender is that
A. women are more likely to attempt
suicide than men.
B. men are more likely to attempt
suicide than women.
C. men and women are equally likely to
attempt suicide.
D. men and women are equally likely to
complete suicide.
APPLY IT! 4. During his first two col-
lege years, Barry has felt “down” most of
the time. He has had trouble concentrating
and difficulty making decisions. Sometimes
he is so overwhelmed with deciding on his
major and struggling to focus that he feels
hopeless. Otherwise, Barry is doing fairly
well; he has no problems with loss of ap-
petite or sleeping, and in general his en-
ergy level is fine. Which of the following is
most likely to be true of Barry?
A. Barry is suffering from major depressive
disorder.
B. Barry is entering the depressive phase of
bipolar disorder.
C. Barry has dysthymic disorder.
D. Barry is experiencing the everyday blues
that everyone gets from time to time.
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462 // CHAPTER 12 // Psychological Disorders
4
Eating Disorders
For some people, concerns about weight and body image become a serious, debilitating
disorder (Lock, 2012a; Wilson & Zandberg, 2012). For such individuals, the very act of
eating is an arena where a variety of complex biological, psychological, and cul-
tural issues are played out, often with tragic consequences.
A number of famous people have coped with eating disorders, including
Princess Diana, Ashley Judd, Paula Abdul, Mary-Kate Olsen, and Kelly
Clarkson. Eating disorders are characterized by extreme disturbances in
eating behavior—from eating very, very little to eating a great deal. In this
section we examine three eating disorders—anorexia nervosa, bulimia ner-
vosa, and binge eating disorder.
Anorexia Nervosa
Anorexia nervosa is an eating disorder that involves the relentless pursuit of thinness
through starvation. Anorexia nervosa is much more common in girls and women than
boys and men and affects between 0.5 and 3.7 percent of young women (NIMH, 2011).
The American Psychiatric Association (2005) lists these main characteristics of anorexia
nervosa:
Weight less than 85 percent of what is considered normal for age and height, and
refusal to maintain weight at a healthy level.
An intense fear of gaining weight that does not decrease with
weight loss.
A distorted body image (Stewart & others, 2012). Even when
individuals with anorexia nervosa are extremely thin, they never
think they are thin enough. They weigh themselves frequently,
take their body measurements often, and gaze critically at them-
selves in mirrors.
Amenorrhea (lack of menstruation) in girls who have reached
puberty.
Over time, anorexia nervosa can lead to physical changes, such
as the growth of  ne hair all over the body, thinning of bones and
hair, severe constipation, and low blood pressure (NIMH, 2011).
Dangerous and even life-threatening complications include damage
to the heart and thyroid. Anorexia nervosa is said to have the high-
est mortality rate (about 5.6 percent of individuals with anorexia
nervosa die within 10 years of diagnosis) of any psychological dis-
order (Hoek, 2006; NIMH, 2011).
Anorexia nervosa typically begins in the teenage years, often
following an episode of dieting and some type of life stress
(Fitzpatrick, 2012). Most individuals with anorexia ner-
vosa are non-Latino White female adolescents or young
adults from well-educated middle- and upper-income
families (Darcy, 2012; Dodge, 2012). They are often
high-achieving perfectionists (Forbush, Heatherton, &
Keel, 2007). Obsessive thinking about weight and
compulsive exercise are also related to anorexia nervosa
(Hildebrandt & others, 2012).
anorexia nervosa
Eating disorder that involves
the relentless pursuit of
thinness through starvation.
Disorders of eating can
vary across cultures. In Fiji,
a disorder known as
macake
involves
poor appetite and refusing to eat.
Very high levels of social concern meet
this refusal, and individuals with
macake are strongly motivated to
start eating and
enjoying food again.
Individuals with
anorexia nervosa lack personal
distress over their symptoms.
Recall that personal distress
over one’s behavior is just one
aspect of the definition
of abnormal.
Uruguayan model Eliana Ramos posed
for the camera in her native country.
Tragically, the super-thin Ramos died at
age 18 in February 2007, two years
after this picture was taken, reportedly
from health problems associated with
anorexia nervosa.
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Eating Disorders // 463
Bulimia Nervosa
Bulimia nervosa is an eating disorder in which an individual
(typically female) consistently follows a binge-and-purge eating pat-
tern. The individual goes on an eating binge and then purges by
self-induced vomiting or the use of laxatives. Most people with
bulimia nervosa are preoccupied with food, have a strong fear
of becoming overweight, and are depressed or anxious
(Birgegárd, Norring, & Clinton, 2012). Because bulimia nervosa
occurs within a normal weight range, the disorder is often dif cult to
detect. A person with bulimia nervosa usually keeps the disorder a secret
and experiences a great deal of self-disgust and shame.
Bulimia nervosa can lead to complications such as a chronic sore throat,
kidney problems, dehydration, and gastrointestinal disorders (NIMH, 2011). The
disorder is also related to dental problems, as persistent exposure to the stomach
acids in vomit can wear away tooth enamel.
Bulimia nervosa typically begins in late adolescence or early adulthood (Levine,
2002). The disorder affects between 1 and 4 percent of young women (NIMH, 2011).
Like those with anorexia nervosa, many young women who develop bulimia nervosa
are highly perfectionistic (Lampard & others, 2012). At the same time, they tend
to have low levels of self-ef cacy (Bardone-Cone & others, 2006). In other
words, these are young women with very high standards but very low con dence
that they can achieve their goals. Impulsivity, negative emotion, and obsessive-
compulsive disorder are also related to bulimia (Roncero, Perpina, & Garcia-
Soriano, 2011). Bulimia nervosa is associated, too, with a high incidence of
sexual and physical abuse in childhood (Lo Sauro & others, 2008).
Anorexia Nervosa and Bulimia Nervosa:
Causes and Treatments
What is the etiology (cause) of anorexia nervosa and bulimia nervosa? For many years
researchers thought that sociocultural factors, such as media images of very thin women
and family pressures, were the central determinants of these disorders (Le Grange &
others, 2010). Media images that glorify extreme thinness can indeed in uence women’s
body image, and emphasis on the thin ideal is related to anorexia nervosa and bulimia
nervosa (Carr & Peebles, 2012). However, as powerful as these media messages might
be, countless females are exposed to media images of unrealistically thin women, but
relatively few develop eating disorders. Many young women embark on diets, but com-
paratively few of them develop eating disorders.
Eating disorders occur in cultures that do not emphasize the ideal of thinness,
although the disorders may differ from Western descriptions. For instance, in Eastern
cultures, individuals can show the symptoms of anorexia nervosa, but they lack the fear
of getting fat that is common in North Americans with the disorder (Pike, Yamamiya,
& Konishi, 2011).
Since the 1980s, researchers have increasingly probed the potential biological under-
pinnings of these disorders, examining in particular the interplay of social and biological
factors. Genes play a substantial role in both anorexia nervosa and bulimia nervosa (Lock,
2012b). In fact, genes in uence many psychological characteristics (for example, perfec-
tionism, impulsivity, obsessive-compulsive tendencies, and thinness drive) and behaviors
(restrained eating, binge eating, self-induced vomiting) that are associated with anorexia
nervosa and bulimia nervosa (Mikolajczyk, Grzywacz, & Samochowiec, 2010; Schur,
Heckbert, & Goldberg, 2010). These genes are also factors in the regulation of serotonin,
and problems in regulating serotonin are related to both anorexia nervosa and bulimia
nervosa (Capasso, Putrella, & Milano, 2009).
bulimia nervosa
Eating disorder in which an
individual (typically a girl or
woman) consistently follows
a binge-and-purge eating
pattern.
Dentists and dental
hygienists are sometimes the
first to recognize the signs of
bulimia nervosa.
Although much more
common in women, bulimia can
also affect men. Elton John has
described his struggles with
this eating disorder.
B
B
(t
yp
te
occurs
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464 // CHAPTER 12 // Psychological Disorders
Even as biological factors play a role in the emergence of eating disorders, eating
disorders themselves affect the body, including the brain. Most psychologists believe that
while social factors and experiences may play a role in triggering dieting, the physical
effects of dieting, bingeing, and purging may change the neural networks that then sus-
tain the disordered pattern, in a kind of vicious cycle (Lock, 2012b).
Although anorexia and bulimia nervosa are serious disorders, recovery is possible
(Fitzpatrick, 2012; Treasure, Claudino, & Zucker, 2010). Anorexia nervosa may require
hospitalization. The  rst target of intervention is promoting weight gain, in extreme cases
through the use of a feeding tube. A common obstacle in the treatment of anorexia ner-
vosa is that individuals with the disorder deny that anything is wrong. They maintain
their belief that thinness and restrictive dieting are correct and not a sign of mental ill-
ness (Wilson, Grilo, & Vitousek, 2007). Still, drug therapies and psychotherapy have
been shown to be effective in treating anorexia nervosa, as well as bulimia nervosa
(Hagman & Frank, 2012; Wilson & Zandberg, 2012).
Binge Eating Disorder
Binge eating disorder (BED) is characterized by recurrent episodes of consuming large
amounts of food during which the person feels a lack of control over eating (Birgegárd,
Norring, & Clinton, 2012). Unlike an individual with bulimia nervosa, someone with
BED does not try to purge. Most individuals with BED are overweight or obese (Carrard,
der Linden, & Golay, 2012).
Individuals with BED often eat quickly, eat a great deal when they are not hungry,
and eat until they are uncomfortably full. They frequently eat alone because of embar-
rassment or guilt, and they feel ashamed and disgusted with themselves after overeating.
BED is the most common of all eating disorders—affecting men, women, and ethnic
groups within the United States more similarly than anorexia nervosa or bulimia nervosa
(Azarbad & others, 2010). An estimated 2 to 5 percent of Americans will suffer from
BED in their lifetime (NIMH, 2011).
BED is thought to characterize approximately 8 percent of individuals
who are obese. Unlike obese individuals who do not suffer from BED, binge
eaters are more likely to place great value on their physical appearance,
weight, and body shape (Grilo, Masheb, & White, 2010). The complications
of BED are those of obesity more generally, including diabetes, hyperten-
sion, and cardiovascular disease.
Binge Eating Disorder:
Causes and Treatments
Researchers are examining the role of biological and psy-
chological factors in BED. Genes play a role (Akkermann
& others, 2012), as does dopamine, the neurotransmitter
related to reward pathways in the brain (C. Davis & others,
2010). The fact that binge eating often occurs after stressful
events suggests that binge eaters use food to regulate their
emotions (Wilson, Grilo, & Vitousek, 2007). The areas of the
brain and endocrine system that respond to stress are overactive
in individuals with BED (Lo Sauro & others, 2008), and this
overactivity leads to high levels of circulating cortisol, the
hormone most associated with stress. Individuals with BED may
be more likely to perceive events as stressful and then seek to
manage that stress by binge eating.
binge eating disorder (BED)
Eating disorder character-
ized by recurrent episodes
of eating large amounts of
food during which the per-
son feels a lack of control
over eating.
Unlike individuals with anorexia nervosa or bulimia
nervosa, most people with binge eating disorder are
overweight or obese.
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Dissociative Disorders // 465
Little research has examined the sociocultural factors in BED. One study examined
whether exposure to U.S. culture might increase the risk of developing BED (Swanson
& others, 2012). The results showed that Mexicans who immigrated to the United States
and Mexican Americans were more likely to develop BED than were Mexicans who lived
in Mexico, controlling for a variety of factors (Swanson & others, 2012).
Just as treatment for anorexia nervosa  rst focuses on weight gain, some believe that
treatment for BED should  rst target weight loss (DeAngelis, 2002). Others argue that
individuals with BED must be treated for disordered eating per se, and they insist that
if the underlying psychological issues are not addressed, weight loss will not be success-
ful or permanent (de Zwaan & others, 2005; Hay & others, 2009).
1. The main characteristics of anorexia ner-
vosa include all of the following except
A. absence of menstrual periods after
puberty.
B. distorted image of one’s body.
C. strong fears of weight gain even as
weight loss occurs.
D. intense and persistent tremors.
2. A person with bulimia nervosa typically
A. thinks a lot about food.
B. is considerably underweight.
C. is a male.
D. is not overly concerned about gain-
ing weight.
3. The most common of all eating
disorders is
A. bulimia nervosa.
B. anorexia nervosa.
C. binge eating disorder.
D. gastrointestinal disease.
APPLY IT 4. Nancy is a first-year
straight- A premed major. Nancy’s roommate
Luci notices that Nancy has lost a great
deal of weight and is extremely thin. Luci
observes that Nancy works out a lot, rarely
finishes meals, and wears bulky sweaters all
the time. Luci also notices that Nancy’s
arms have fine hairs growing on them, and
Nancy has mentioned never getting her
period anymore. When Luci asks Nancy
about her weight loss, Nancy replies that
she is very concerned that she not gain the
“freshman 15” and is feeling good about
her ability to keep up with her work and
keep off those extra pounds. Which of the
following is the most likely explanation for
what is going on with Nancy?
A. Nancy likely has bulimia nervosa.
B. Despite her lack of personal distress
about her symptoms, Nancy likely has
anorexia nervosa.
C. Nancy has binge eating disorder.
D. Given Nancy’s overall success, it seems
unlikely that she is suffering from a
psychological disorder.
Have you ever been on a long car ride and completely lost track of time, so that you
could not even remember a stretch of miles along the road? Have you been so caught
up in a daydream that you were unaware of the passage of time? These are examples of
normal dissociation. Dissociation refers to psychological states in which the person feels
disconnected from immediate experience.
At the extreme of dissociation are individuals who persistently feel a sense of
disconnection. Dissociative disorders are psychological disorders that involve a
sudden loss of memory or change in identity. Under extreme stress or shock, the
individual’s conscious awareness becomes dissociated (separated or split) from
previous memories and thoughts (Espirito-Santo & Pio-Abreu, 2009). Individu-
als who develop dissociative disorders may have problems putting together dif-
ferent aspects of consciousness, so that experiences at different levels of awareness
might be felt as if they are happening to someone else (Dell & O’Neil, 2007).
Psychologists believe that dissociation is a way of dealing with extreme stress
(Brand & others, 2012). Through dissociation the individual mentally protects his or her
conscious self from the traumatic event. Dissociative disorders often occur in individuals
who also show signs of PTSD (Lanius & others, 2012). Both psychological disorders
are thought to be rooted, in part, in extremely traumatic life events (Foote & others,
2006). The notion that dissociative disorders are related to problems in pulling together
emotional memories is supported by  ndings showing lower volume in the hippocampus
and amygdala in individuals with dissociative disorders (Vermetten & others, 2006). The
hippocampus is especially involved in consolidating memory and organizing life experi-
ence into a coherent whole (Spiegel, 2006).
dissociative
disorders
Psychological
disorders that
involve a sudden
loss of memory
or change in
identity due to
the dissociation
(separation) of
the individual’s
conscious aware-
ness from previ-
ous memories
and thoughts.
5
Dissociative Disorders
In dissociative
disorders, consciousness (see
Chapter 4) is split off from
experience—the “stream of
consciousness” is disrupted.
Hypnosis is often used to treat
dissociative disorders.
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466 // CHAPTER 12 // Psychological Disorders
Dissociative disorders are perhaps the most controversial of all diagnostic cat-
egories, with some psychologists believing that they are often mistakenly diag-
nosed (Freeland & others, 1993) and others arguing that they are underdiagnosed
(Sar, Akyuz, & Dogan, 2007; Spiegel, 2006). Three kinds of dissociative dis-
orders are dissociative amnesia, dissociative fugue, and dissociative identity
disorder.
Dissociative Amnesia and
Dissociative Fugue
Recall from Chapter 6 that amnesia is the inability to recall important events (Markow-
itsch & Staniloiu, 2012). Amnesia can result from a blow to the head that produces
trauma in the brain. Dissociative amnesia is a type of amnesia characterized by extreme
memory loss that stems from extensive psychological stress. People experiencing dis-
sociative amnesia remember everyday tasks like how to hail a cab and use a phone. They
forget only aspects of their own identity and autobiographical experiences.
One case of dissociative amnesia involved a 28-year-old married woman who had
given birth to her sixth child four months before (Tharoor & others, 2007). After she
delivered the child, her family noticed that she did not acknowledge her newborn as her
own baby and that she had neither a recollection of having given birth nor a sense of
her own identity. She took care of the baby as advised by her family members but main-
tained a belief that although she had been pregnant, she had not given birth. Under the
in uence of sodium pentothal (a narcotic sometimes called “truth serum” because it
renders people talkative and likely to share information), the young mother eventually
described how she had not wanted to continue her sixth pregnancy, but her spouse, who
lived in another country, had refused to consent to an abortion. She described herself as
exhausted by the pregnancy. Eventually, through hypnosis and memory exercises, the
woman recovered autobiographical memory for her identity as well as for the expe-
rience of having given birth.
Dissociative fugue ( fugue means “ ight”) is a dissociative disorder in
which the individual not only develops amnesia but also unexpectedly travels
away from home and sometimes assumes a new identity. What makes dissocia-
tive fugue different from dissociative amnesia is this tendency to run away.
A recent case of dissociative fugue involved the disappearance of a middle-
school teacher in New York City. Twenty-three-year-old Hannah Upp disappeared
while out for a run on August 28, 2008 (Marx & Didziulis, 2009). She had no wal-
let, no identi cation, no cell phone, and no money. Her family, friends, and roommates
posted  yers around the city and messages on the Internet. As days went by, they
became increasingly concerned that something terrible had happened. Finally,
Hannah was found  oating face down in the New York harbor on September
16, sunburned and dehydrated but alive. She remembered nothing of her expe-
riences. To her, it felt like she had gone out for a run and 10 minutes later was
being pulled from the harbor. To this day, she does not know what event might
have led to her dissociative fugue, nor does she remember how she survived
during her two-week disappearance.
Dissociative Identity Disorder
Dissociative identity disorder (DID) , formerly called multiple personality disorder, is the
most dramatic, least common, and most controversial dissociative disorder. Individuals with
this disorder have two or more distinct personalities or identities (Belli & others, 2012).
Each identity has its own memories, behaviors, and relationships. One identity dominates
at one time, another takes over at another time. Individuals sometimes report that a wall
of amnesia separates their different identities (Dale & others, 2009); however, research
dissociative amnesia
Dissociative disorder charac-
terized by extreme memory
loss that is caused by exten-
sive psychological stress.
dissociative fugue
Dissociative
disorder in which
the individual not
only develops
amnesia but also
unexpectedly
travels away from
home and as-
sumes a new
identity.
dissociative identity disorder
(DID)
Formerly called multiple
personality disorder, a dis-
sociative disorder in which
the individual has two or
more distinct personalities
or selves, each with its own
memories, behaviors, and
relationships.
T he study on dissociative
disorders in Uganda from
earlier in this chapter found
agreement among respondents
that dissociative states are
brought on by trauma.
Matt Damon’s character,
Jason Bourne, in the
Bourne
films is named after
Ansel
Bourne,
who in 1887 became
the first known real-life case
of dissociative fugue.
At one point during her
fugue, Hannah was approached by
someone who asked if she was the
Hannah everyone was looking for,
and she answered no.
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Dissociative Disorders // 467
suggests that memory does transfer across
these identities, even if the person believes
it does not (Kong, Allen, & Glisky, 2008).
The shift between identities usually occurs
under distress (Sar & others, 2007) but
sometimes can also be controlled by the
person (Kong, Allen, & Glisky, 2008).
A famous real-life example of disso-
ciative identity disorder is the “three
faces of Eve” case, based on the life of a
woman named Chris Sizemore (Thigpen
& Cleckley, 1957) (Figure 12.8). Eve
White was the original dominant personal-
ity. She had no knowledge of her second
personality, Eve Black, although Eve
Black had been alternating with Eve White
for a number of years. Eve White was
bland, quiet, and serious. By contrast, Eve
Black was carefree, mischievous, and
uninhibited. Eve Black would emerge at
the most inappropriate times, leaving Eve
White with hangovers, bills, and a reputa-
tion in local bars that she could not explain. During treatment, a third personality emerged:
Jane. More mature than the other two, Jane seems to have developed as a result of
therapy. More recently, former Heisman Trophy winner and legendary NFL running back
Herschel Walker (2008) revealed his experience with dissociative disorder in his book
Breaking Free: My Life with Dissociative Identity Disorder .
Research on dissociative identity disorder links a high rate of extraordinarily severe
sexual or physical abuse during early childhood to the condition (Ross & Ness, 2010).
Some psychologists believe that a child can cope with intense trauma by dissociating
from the experience and developing other alternate selves as protectors. Sexual abuse has
occurred in as many as 70 percent or more of dissociative identity disorder cases (Foote
& others, 2006); however, the majority of individuals who have been sexually abused do
not develop dissociative identity disorder. The vast majority of individuals with dissocia-
tive identity disorder are women. A genetic predisposition might also exist, as the dis-
order tends to run in families (Dell & Eisenhower, 1990).
Until the 1980s, only about 300 cases of dissociative identity disorder had ever been
reported (Suinn, 1984). In the past 30 years, hundreds more cases have been diagnosed.
Social cognitive approaches point out that diagnoses have tended to increase whenever the
popular media present a case, as in the miniseries Sybil and the Showtime drama United
States of Tara . From this perspective, individuals develop multiple identities through social
contagion. After exposure to these examples, people may be more likely to view multiple
identities as a real condition. Some experts believe, in fact, that dissociative identity dis-
order is a social construction —that it represents a category some people adopt to make
sense of their experiences (Spanos, 1996). Rather than being a single person with
many con icting feelings, wishes, and potentially awful experiences, the individual
compartmentalizes different aspects of the self into independent identities. In some
cases, therapists have been accused of creating alternate personalities. Encountering
an individual who appears to have a fragmented sense of self, the therapist may
begin to treat each fragment as its own “personality” (Spiegel, 2006).
Cross-cultural comparisons can shed light on whether dissociative identity disorder is
primarily a response to traumatic events or the result of a social cognitive factor like
social contagion. If dissociation is a response to trauma, individuals with similar levels
of traumatic experience should show similar degrees of dissociation, regardless of their
exposure to cultural messages about dissociation. In China, the popular media do not
commonly portray individuals with dissociative disorder, and professional knowledge of
the disorder is rare. One study comparing individuals from China and Canada (where
FIGURE 12.8 The Three Faces of Eve Chris Sizemore, the subject of the
1950s book and  lm The Three Faces of Eve, is shown here with a work she painted,
titled Three Faces in One.
Therapists and patients
are making
attributions
to
understand abnormal behavior.
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468 // CHAPTER 12 // Psychological Disorders
dissociative identity disorder is a widely publicized condition) found reports of traumatic
experience to be similar across groups and to relate to dissociative experiences similarly
as well (Ross & others, 2008), casting some doubt on the notion that dissociative expe-
riences are entirely a product of social contagion.
1. Dissociative identity disorder is associ-
ated with unusually high rates of
A. anxiety.
B. abuse during early childhood.
C. depression.
D. divorce.
2. Someone who suffers memory loss after
a psychological trauma is said to have
A. dissociative identity disorder.
B. dissociative fugue.
C. dissociative amnesia.
D. schizophrenia.
3. In cases of dissociative fugue, the
individual not only experiences amnesia
but also
A. has frequent thoughts of suicide.
B. takes on multiple different
identities.
C. refuses to leave his or her home.
D. travels away from home.
APPLY IT 4. Eddie often loses track of
time. He is sometimes late for appoint-
ments because he is so engrossed in what-
ever he is doing. While working on a term
paper in the library, he gets so caught up in
what he is reading that he is shocked when
he looks up and sees that the sun has set
and it is night. Which of the following best
describes Eddie?
A. Eddie is showing signs of dissociative
identity disorder.
B. Eddie is showing signs of dissociative
fugue.
C. Eddie is showing normal dissociative
states.
D. Eddie is at risk for dissociative amnesia.
Have you had the experience of watching a movie and suddenly noticing that the  lm
bears an uncanny resemblance to your life? Have you ever listened to a radio talk show
and realized that the host was saying exactly what you were just thinking? Do these
moments mean something special about you, or are they coincidences? For people with
schizophrenia, such experiences may take on special and personal meaning.
Schizophrenia is a severe psychological disorder that is characterized by highly dis-
ordered thought processes. These disordered thoughts are referred to as psychotic because
they are far removed from reality. The world of the person with schizophrenia is deeply
frightening and chaotic.
Schizophrenia is usually diagnosed in early adulthood, around age 18 for men and 25
for women. Individuals with schizophrenia may see things that are not there, hear voices
inside their heads, and live in a strange world of twisted logic. They may say odd things,
show inappropriate emotion, and move their bodies in peculiar ways. Often, they are
socially withdrawn and isolated.
It is dif cult to imagine the ordeal of people living with schizophrenia, who
comprise about half of the patients in psychiatric hospitals. The suicide risk
for individuals with schizophrenia is eight times that for the general population
(Pompili & others, 2007). For many with the disorder, controlling it means
using powerful medications to combat symptoms. The most common cause of
relapse is that individuals stop taking their medication. They might do so because
they feel better and believe they no longer need the drugs, they do not realize that
their thoughts are disordered, or the side effects of the medications are too unpleasant.
Symptoms of Schizophrenia
Psychologists generally classify the symptoms of schizophrenia as positive symptoms,
negative symptoms, and cognitive de cits (NIMH, 2008).
POSITIVE SYMPTOMS The positive symptoms of schizophrenia are marked by
a distortion or an excess of normal function. They are “positive” because they re ect
schizophrenia
Severe psycho-
logical disorder
characterized by
highly disordered
thought pro-
cesses; individu-
als suffering from
schizophrenia
may be referred
to as psychotic
because they are
so far removed
from reality.
6
Schizophrenia
Seeking treatment for
schizophrenia takes courage. It
requires that individuals accept
that their perception of the
world—their very sense of
reality—is mistaken.
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Schizophrenia // 469
something added above and beyond normal behavior. Positive symp-
toms of schizophrenia include hallucinations, delusions, thought disor-
ders, and disorders of movement.
Hallucinations are sensory experiences that occur in the absence of
real stimuli. Hallucinations are usually auditory—the person might com-
plain of hearing voices—or visual, and much less commonly they can
be experienced as smells or tastes (Bhatia & others, 2009). Culture
affects the form hallucinations take, as well as their content and sensory
modality—that is, whether the hallucinations are visual, auditory, or
manifest as smells or tastes (Bauer & others, 2011). Visual hallucinations
involve seeing things that are not there, as in the case of Moe Armstrong.
At the age of 21, while serving in Vietnam as a Marine medical corps-
man, Armstrong experienced a psychotic break. Dead Vietcong soldiers
appeared to talk to him and beg him for help and did not seem to real-
ize that they were dead. Armstrong, now a successful businessman and
a sought-after public speaker who holds two master’s degrees, relies on
medication to keep such experiences at bay (Bonfatti, 2005).
Delusions are false, unusual, and sometimes magical beliefs that
are not part of an individual’s culture. A delusional person might think
that he is Jesus Christ or Muhammad; another might imagine that her
thoughts are being broadcast over the radio. It is crucial to distinguish
delusions from cultural ideas such as the religious belief that a person
can have divine visions or communicate personally with a deity. Gen-
erally, psychology and psychiatry do not treat these ideas as delusional.
For individuals with schizophrenia, delusional beliefs that might
seem completely illogical to the outsider are experienced as all too
real. At one point in his life, Bill Garrett (from the chapter-opening
vignette) was convinced that a blister on his hand was a sign of gan-
grene. So strong was his belief that he tried to cut off his hand with a
knife, before being stopped by his family (M. Park, 2009).
Thought disorder refers to the unusual, sometimes bizarre thought processes that
are characteristic positive symptoms of schizophrenia. The thoughts of persons with
schizophrenia can be disorganized and confused. Often individuals with schizophrenia
do not make sense when they talk or write. For example, someone with schizophrenia
might say, “Well, Rocky, babe, happening, but where, when, up, top, side, over, you
know, out of the way, that’s it. Sign off.” These incoherent, loose word associations,
called word salad, have no meaning for the listener. The individual might also make
up new words (Kerns & others, 1999). In addition, a person with schizophrenia can
show referential thinking , which means giving personal meaning to completely ran-
dom events. For instance, the individual might believe that a traf c light has turned
red because he or she is in a hurry.
A nal type of positive symptom is disorders of movement. A person with schizo-
phrenia may show unusual mannerisms, body movements, and facial expressions. The
individual may repeat certain motions over and over or, in extreme cases, may become
catatonic. Catatonia is a state of immobility and unresponsiveness that lasts for long
periods of time (Figure 12.9).
NEGATIVE SYMPTOMS Whereas schizophrenia’s positive symptoms are charac-
terized by a distortion or an excess of normal functions, schizophrenia’s negative
symptoms re ect social withdrawal, behavioral de cits, and the loss or decrease
of normal functions. One negative symptom is at affect , which means the dis-
play of little or no emotion (LePage & others, 2011). Individuals with schizo-
phrenia also may be lacking in the ability to read the emotions of others
(Chambon, Baudouin, & Franck, 2006). They may experience a lack of positive
emotional experience in daily life and show a de cient ability to plan, initiate,
and engage in goal-directed behavior.
hallucinations
Sensory experi-
ences that occur
in the absence of
real stimuli.
delusions
False, unusual,
and sometimes
magical beliefs
that are not part
of an individual’s
culture.
referential thinking
Ascribing personal meaning
to completely random
events.
catatonia
State of immobil-
ity and unrespon-
siveness lasting
for long periods
of time.
at affect
The display of
little or no
emotion—a
common nega-
tive symptom of
schizophrenia.
FIGURE 12.9 Disorders of
Movement in Schizophrenia Unusual motor
behaviors are positive symptoms of schizophrenia.
Individuals may cease to move altogether (a state
called catatonia), sometimes holding bizarre
postures.
Because negative
symptoms are not as obviously
part of a psychiatric illness,
people with schizophrenia may be
perceived as lazy and unwilling to
better their lives.
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470 // CHAPTER 12 // Psychological Disorders
COGNITIVE SYMPTOMS Cognitive symptoms of schizophrenia include dif culty
sustaining attention, problems holding information in memory, and inability to interpret
information and make decisions (Sitnikova, Goff, & Kuperberg, 2009; Torniainen & oth-
ers, 2012). These symptoms may be subtle and are often detected only through neuropsy-
chological tests. Researchers now recognize that to understand schizophrenia’s cognitive
symptoms fully, measures of these symptoms must be tailored to particular cultural
contexts (Mehta & others, 2011).
Causes of Schizophrenia
A great deal of research has investigated schizophrenia’s causes, including biological,
psychological, and sociocultural factors involved in the disorder.
BIOLOGICAL FACTORS Research provides strong support for biological explana-
tions of schizophrenia. Especially compelling is the evidence for a genetic predisposition
(Tao & others, 2012). However, structural abnormalities and neurotransmitters also are
linked to this severe psychological disorder (Perez-Costas & others, 2012; Sugranyes &
others, 2012).
Heredity Research supports the notion that schizophrenia is at least partially due to
genetic factors (Vasco, Cardinale, & Polonia, 2012). As genetic similarity to a person
with schizophrenia increases, so does a person’s risk of developing schizophrenia, as
Figure 12.10 shows (Cardno & Gottesman, 2000). Such data strongly suggest that genetic
factors play a role in schizophrenia. Researchers are seeking to pinpoint the chromosomal
Relationship to Person with Schizophrenia
48%
17%
13%
9%
6%
6%
5%
4%
2%
2%
1%
0
5 1015202530 40455035
Percentage Risk of Developing Schizophrenia
General population
Nephews/nieces
Uncles/aunts
First cousins
Grandchildren
Half siblings
Siblings
Children
Fraternal twins
Identical twins
Parents
25% 2nd degree relatives
50% 1st degree relatives
100%
12.5% 3rd degree relatives
Genes shared
FIGURE 12.10 Lifetime Risk
of Developing Schizophrenia
According to Genetic
Relatedness As genetic relatedness to
an individual with schizophrenia increases,
so does the risk of developing schizophrenia.
> Which familial relationships have
the lowest and highest level of genetic
overlap? > What is the difference in
genetic overlap between identical twins
and non-twin siblings? > What is the
difference in risk of schizophrenia
between identical twins and
non-twin siblings?
PSYCHOLOGICAL INQUIRY
EXPERIENCE IT!
John Nash: A Beautiful
Mind
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Schizophrenia // 471
location of genes involved in susceptibility to schizophrenia (Crowley & others, 2012;
van Beveren & others, 2012).
Structural Brain Abnormalities Studies have found structural brain abnormali-
ties in people with schizophrenia. Imaging techniques such as MRI scans clearly show
enlarged ventricles in the brain (Rais & others, 2012). Ventricles are  uid- lled spaces,
and enlargement of the ventricles indicates the deterioration in other brain tissue. Indi-
viduals with schizophrenia also have a small frontal cortex (the area in which thinking,
planning, and decision making take place) and show less activity in this area than indi-
viduals who do not have schizophrenia (Cotter & others, 2002).
Still, the differences between the brains of healthy individuals and those with schizo-
phrenia are small (NIMH, 2008). Microscopic studies of brain tissue after death reveal
small changes in the distribution or characteristics of brain cells in persons with schizo-
phrenia. It appears that many of these changes occurred prenatally because they are not
accompanied by glial cells, which are always present when a brain injury occurs after
birth. It may be that problems in prenatal development such as infections (A. S. Brown,
2006) predispose a brain to developing schizophrenic symptoms during puberty and
young adulthood (Fatemi & Folsom, 2009).
Problems in Neurotransmitter Regulation An early biological explanation for
schizophrenia linked excess dopamine production to schizophrenia. The link between dopa-
mine and psychotic symptoms was  rst noticed when the drug L-dopa (which increases
dopamine levels) was given to individuals as a treatment for Parkinson disease. In addition
to relieving their Parkinson symptoms, L-dopa caused some individuals to experience dis-
turbed thoughts (Janowsky, Addario, & Risch, 1987). Furthermore, drugs that reduce psy-
chotic symptoms often block dopamine (Kapur, 2003). Whether it is differences in the
amount, the production, or the uptake of dopamine, there is good evidence that dopamine
plays a role in schizophrenia (Brito-Melo & others, 2012; Howes & others, 2012).
As noted in the chapters about states of consciousness (Chapter 4) and learning
(Chapter 5), dopamine is a “feel good” neurotransmitter that helps us recognize
rewarding stimuli in the environment. As described in the chapter on personality
(Chapter 10), dopamine is related to being outgoing and sociable. How can a neu-
rotransmitter that is associated with good things play a crucial role in the most dev-
astating psychological disorder?
One way to think about this puzzle is to view dopamine as a neurochemical mes-
senger that in effect shouts out, “Hey! This is important!” whenever we encounter oppor-
tunities for reward. Imagine what it might be like to be bombarded with such messages
about even the smallest details of life (Kapur, 2003). The person’s own thoughts might
take on such dramatic proportions that they sound like someone else’s voice talking
inside the person’s head. Fleeting ideas such as “It’s raining today because I didn’t bring
my umbrella to work” suddenly seem not silly but true. Shitij Kapur (2003) has suggested
that hallucinations, delusions, and referential thinking may be expressions of the indi-
vidual’s attempts to make sense of such extraordinary feelings.
A problem with the dopamine explanation of schizophrenia is that antipsychotic
drugs reduce dopamine levels very quickly, but delusional beliefs take much longer to
disappear. Even after dopamine levels are balanced, a person
might still cling to the bizarre belief that members of a powerful
conspiracy are watching his every move. If dopamine causes
these symptoms, why do the symptoms persist even after the
dopamine is under control? According to Kapur, delusions serve
as explanatory schemes that have helped the person make sense
of the random and chaotic experiences caused by out-of-control
dopamine. Bizarre beliefs might disappear only after experience
demonstrates that such schemes no longer carry their explana-
tory power (Kapur, 2003). That is, with time, experience, and
therapy, the person might come to realize that there is, in fact,
no conspiracy.
Excess dopamine basically
tells the person that
everything
is important.
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472 // CHAPTER 12 // Psychological Disorders
PSYCHOLOGICAL FACTORS Psychologists used to explain schizophrenia as
rooted in an individual’s dif cult childhood experiences with parents. Such explanations
have mostly fallen by the wayside, but contemporary theorists do recognize that stress
may contribute to the development of this disorder. The diathesis-stress model
argues that a combination of biogenetic disposition and stress causes schizophrenia
(Meehl, 1962). ( Diathesis means “physical vulnerability or predisposition to a
particular disorder.”) For instance, genetic characteristics might produce schizo-
phrenia only when (and if) the individual experiences extreme stress.
SOCIOCULTURAL FACTORS A fascinating  nding on sociocultural fac-
tors in schizophrenia is a consistent difference in the course of schizophrenia over
time in developing versus developed nations. Speci cally, individuals with schizophrenia
in developing, nonindustrialized nations are more likely to show indications of recovery
over time compared to those in developed, industrialized nations (Bhugra, 2006; Jablensky,
2000; Myers, 2010). Whether measured in symptoms, disturbances in thought, or the
ability to engage in productive work, individuals in less developed countries appear to
do better than their counterparts in developed nations.
This difference is puzzling. Some experts argue that developing nations must be mis-
diagnosing more individuals or are better off than the label “developing” implies (Burns,
2009). Other commentators look to differences in cultural beliefs and practices to understand
these effects. For instance, it might be that in more developed nations (such as the United
States), there is not a very strong belief that individuals diagnosed with schizophrenia can
recover (Luhrmann, 2007). In addition, cultures vary in terms of their beliefs about and
responses to symptoms. In Chandigarh, India, for example, where some of the developing-
nation data were collected, visual hallucinations were not viewed as very different from
commonplace religious experiences (Luhrmann, 2007). Moreover, in developing nations,
families remained involved in individuals’ lives after diagnosis, and many families
lived in close-knit communities where care of their loved one was not so burden-
some (Hopper & Wanderling, 2000). The fact that culture matters to schizo-
phrenia highlights the role of cultural context in psychological disorders.
Consider that even if individuals with schizophrenia were found to share
some common brain characteristics, these similar brains would have differ-
ent experiences and different outcomes as a result of culture.
In developed nations, schizophrenia is strongly associated with pov-
erty, but it is not clear if poverty increases the likelihood of experiencing
the disorder (Luhrmann, 2007). Marriage, warm and supportive friends
(Jablensky & others, 1992; Wiersma & others, 1998), and employment are
related to better outcomes for people diagnosed with schizophrenia (Rosen
& Garety, 2005). At the very least, this research suggests that some individu-
als with schizophrenia enjoy marriage, productive work, and friendships (Drake,
Levine, & Laska, 2007; Fleischhaker & others, 2005; Marshall & Rathbone, 2006).
diathesis-stress
model
View of schizo-
phrenia empha-
sizing that a
combination of
biogenetic dis-
position and
stress causes
the disorder.
Recall that Moe
Armstrong experienced his first
symptoms during the extremely
stressful experience of the
Vietnam War.
If you have never met anyone with
schizophrenia, why not get to know
Moe Armstrong online? He has a blog
at www.moearmstrong.com/Site/
Welcome.html and a speech on
YouTube at www.youtube.com/
watch?v=p-_j1ZNKzsg.
1. A negative symptom of schizophrenia is
A. hallucinations.
B. at affect.
C. delusions.
D. catatonia.
2. Joel believes that he has superhuman
powers. He is likely suffering from
A. hallucinations.
B. delusions.
C. negative symptoms.
D. referential thinking.
3. The biological causes of schizophrenia
include
A. problems with the body’s regulation
of dopamine.
B. abnormalities in brain structure such
as enlarged ventricles and a small
frontal cortex.
C. both A and B
D. neither A nor B
APPLY IT 4. During a psychiatric hos-
pital internship, Tara approaches a young
man sitting alone in a corner, and they
have a short conversation. He asks her if
she is with the government, and she tells
him that she is not. She asks him a few
questions and walks away. She tells her
advisor later that what disturbed her about
the conversation was not so much what the
young man said, but that she had this feel-
ing that he just was not really there. Tara
was noticing the _________ symptoms of
schizophrenia.
A. positive
B. negative
C. cognitive
D. genetic
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Personality Disorders // 473
Imagine that your personality—the very thing about you that makes you you —is the core
of your life dif culties. That is what happens with personality disorders , which are
chronic, maladaptive cognitive-behavioral patterns that are thoroughly integrated into an
individual’s personality. Personality disorders are relatively common. In one study of a
representative U.S. sample, researchers found that 15 percent had a personality disorder
(Grant & others, 2004).
The DSM-IV lists 10 different personality disorders. Proposed changes to the classi-
cation of personality disorders in the DSM-V are radical (Millon, 2012; Skodol, 2012a,
2012b). They call for eliminating four or  ve of these personality disorders, such as
paranoid and histrionic, and deleting the disorders’ diagnostic criteria (Frances & Widiger,
2012; Skodol, 2012a, 2012b). Figure 12.11 shows the proposed personality disorder
categories for the DSM-V .
Here we survey the two personality disorders that have been the object of the greatest
study: antisocial personality disorder and borderline personality disorder. Both will likely
be kept in the DSM-V .
Antisocial Personality Disorder
Antisocial personality disorder (ASPD) is a psychological disorder characterized by
guiltlessness, law-breaking, exploitation of others, irresponsibility, and deceit. Although
they may be super cially charming, individuals with ASPD do not play by the rules, and
personality disorders
Chronic, maladaptive
cognitive-behavioral
patterns that are thoroughly
integrated into an
individual’s personality.
antisocial personality
disorder (ASPD)
Psychological disorder char-
acterized by guiltlessness,
law-breaking, exploitation
ofothers, irresponsibility,
and deceit.
7
Personality Disorders
Characteristics
Personality
Disorder
Antisocial
Guiltless law-breaking; manipulative, deceitful, callous, hostile, risk-taking,
impulsive, irresponsible behavior
Borderline Emotionally unstable and intense, impulsive, risk-taking, hostile, and anxious
individual; experiences fear of abandonment, depression, and internal feelings
of emptiness
Obsessive-
Compulsive
Rigid perfectionism and adherence to a strict moral code; experiences a great
deal of anxiety unless things are “just right” and may be obsessed with rules;
excessively stubborn, rigid, and moralistic (Note: This is not the same as the
anxiety disorder discussed earlier in this chapter.)
Avoidant Socially detached and withdrawn individual who avoids intimacy with others;
low levels of positive emotion, high levels of anxiety
Narcissistic
Unrealistic grandiose sense of self-importance, attention-seeking, difficulty
taking criticism, lack of empathy for others
Personality
Disorder Trait
Specified
Extreme trait profile, with personality traits contributing to problems in the self
(including sense of identity and self-direction) as well as in social relationships
Schizotypal
Eccentric beliefs, cognitive and perceptual distortions, unusual beliefs and
experiences, similar to delusions; emotionally restricted, socially withdrawn,
suspicious
FIGURE 12.11 Personality Disorder Diagnoses Proposed for the DSM-V The
newest version of the DSM might contain these seven personality disorders (American Psychiatric Association,
2012). Note how these descriptions make use of the personality traits presented in Chapter 10.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright ©
2000 American Psychiatric Association.
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474 // CHAPTER 12 // Psychological Disorders
they often lead a life of crime and violence. ASPD is far more common in men than in
women and is related to criminal behavior, vandalism, substance abuse, and alcoholism
(Cale & Lilienfeld, 2002).
The DSM-IV criteria for antisocial personality disorder include
Failure to conform to social norms or obey the law
Deceitfulness, lying, using aliases, or conning others for personal pro t or pleasure
Impulsivity or failure to plan ahead
Irritability and aggressiveness; getting into physical  ghts or perpetrating assaults
Reckless disregard for the safety of self or others
Consistent irresponsibility, inconsistent work behavior; not paying bills
Lack of remorse, indifference to the pain of others, or rationalizing; hurting or mis-
treating another person
Generally, ASPD is not diagnosed unless a person has shown persistent antisocial behav-
ior before the age of 15.
Although ASPD is associated with criminal behavior, not all individuals with ASPD
engage in crime, and not all criminals suffer from ASPD. Some individuals with ASPD can
have successful careers. There are antisocial physicians, clergy members, lawyers, and just
about any other occupation. Still, such individuals tend to be exploitative of others, and they
break the rules, even if they are never caught.
What is the etiology of ASPD? Biological factors include genetic,
brain, and autonomic nervous system differences. We consider these
in turn.
ASPD is genetically heritable (Nordstrom & others, 2012). Cer-
tain genetic characteristics associated with ASPD may interact with
testosterone (the hormone most associated with aggressive behavior)
to promote antisocial behavior (Sjoberg & others, 2008). Although
the experience of childhood abuse may be implicated in ASPD, there
is evidence that genetic differences may distinguish abused children
who go on to commit violent acts themselves from those who do
not (Caspi & others, 2002).
In terms of the brain, research has linked ASPD to low levels of
activation in the prefrontal cortex and has related these brain dif-
ferences to poor decision making and problems in learning
(Raine & others, 2000). With regard to the autonomic nervous
system, researchers have found that individuals with ASPD
are less stressed than others by aversive circumstances,
including punishment (Fung & others, 2005), and that they
have the ability to keep their cool while engaging in deception
(Verschuere & others, 2005). The underaroused autonomic ner-
vous system may be a key difference between adolescents who
become antisocial adults and those whose behavior improves during
adulthood (Raine, Venables, & Williams, 1990).
The term psychopath is sometimes used to refer to a subgroup
of individuals with ASPD (Pham, 2012). Psychopaths are remorse-
less predators who engage in violence to get what they want. Exam-
ples of psychopaths include serial killers John Wayne Gacy, who
murdered 33 boys and young men, and Ted Bundy, who confessed
to murdering at least 30 young women. Psychopaths tend to show
less prefrontal activation than normal individuals and to have struc-
tural abnormalities in the amygdala, as well as the hippocampus, the
brain structure most closely associated with memory (Weber & oth-
ers, 2008). Importantly, these brain differences are most pronounced
in “unsuccessful psychopaths”—individuals who have been arrested
John Wayne Gacy (top) and Ted Bundy
(bottom) exemplify the subgroup of
people with ASPD who are also
psychopathic.
Lack of autonomic
nervous system activity
suggests why individuals with
ASPD might be able to fool a
polygraph (lie detector).
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Personality Disorders // 475
for their behaviors (Yang & others, 2005). In contrast, “successful psychopaths”—
individuals who have engaged in antisocial behavior but have not gotten caught—are
more similar to healthy controls in terms of brain structure and function. However,
in their behavior, successful psychopaths demonstrate a lack of empathy and a will-
ingness to act immorally; they victimize others to enrich their own lives. Psychopaths
show de ciencies in learning about fear and have dif culty processing information
related to the distress of others, such as sad or fearful faces (Dolan & Fullam, 2006).
A key challenge in treating individuals with ASPD, including psychopaths, is their
ability to con even sophisticated mental health professionals. Many never seek therapy,
and others end up in prison, where treatment is rarely an option.
Borderline Personality Disorder
According to the DSM-IV, borderline personality disorder (BPD) is a pervasive pattern
of instability in interpersonal relationships, self-image, and emotions, and of marked
impulsivity beginning by early adulthood and present in various contexts. Individuals
with BPD are insecure, impulsive, and emotional (Hooley, Cole, & Gironde, 2012). BPD
is related to self-harming behaviors such as cutting (injuring oneself with a sharp object
but without suicidal intent) and also to suicide (Soloff & others, 1994).
The DSM-IV speci es that BPD is indicated by the presence of  ve or more of the
following symptoms:
Frantic efforts to avoid being abandoned
Unstable and intense interpersonal relationships characterized by extreme shifts
between idealization and devaluation
Markedly and persistently unstable self-image or sense of self
Impulsivity in at least two areas that are potentially self-damaging (for example,
spending, sex, substance abuse, reckless driving, and binge eating)
Recurrent suicidal behavior, gestures, or threats or self-mutilating behavior
Unstable and extreme emotional responses
Chronic feelings of emptiness
Inappropriate, intense anger or dif culty controlling anger
Temporary stress-related paranoia (a pattern of disturbed thought featuring delusions
of grandeur or persecution) or severe dissociative symptoms
Individuals with BPD are prone to wild mood swings and very sensitive to how
others treat them. They often feel as if they are riding a nonstop emotional roller-
coaster (Selby & others, 2009), and their loved ones may have to work hard to
avoid upsetting them. Individuals with BPD tend to see the world in black-and-
white terms, a thinking style called splitting. For example, they typically view
other people as either hated enemies with no positive qualities or as beloved,
idealized friends who can do no wrong.
Borderline personality disorder is far more common in women than men.
Women make up 75 percent of those with the disorder (Korzekwa & others,
2008; Oltmanns & Powers, 2012).
The potential causes of BPD are likely complex and include biological factors
as well as childhood experiences. The role of genes in BPD has been demonstrated
in a variety of studies and across cultures (Mulder, 2012). The heritability of BPD is
about 40 percent (Distel & others, 2008).
Many individuals with borderline personality disorder report experiences of childhood
sexual abuse, as well as physical abuse and neglect (Al-Alem & Omar, 2008; De
Fruyt & De Clercq, 2012). It is not clear, however, whether abuse is a primary
cause of the disorder (Trull & Widiger, 2003). Childhood abuse experiences
may combine with genetic factors in promoting BPD.
borderline personality
disorder (BPD)
Psychological disorder
characterized by a pervasive
pattern of instability in inter-
personal relationships, self-
image, and emotions, and
of marked impulsivity begin-
ning by early adulthood and
present in a variety of
contexts.
Their functioning
frontal lobes might help
successful psychopaths
avoid getting caught.
This would be a diathesis-
stress model explanation for BPD.
Movie depictions of BPD
include
Fatal Attraction,
Single White Female,
and
Obsessed.
Where these films
get it wrong is that they show
BPD as leading to more harm to
others than to the self.
EXPERIENCE IT!
Borderline Personality
Disorder
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476 // CHAPTER 12 // Psychological Disorders
Cognitive factors associated with BPD include a tendency to hold a set of irrational
beliefs (Leahy & McGinn, 2012). These include thinking that one is powerless and
innately unacceptable and that other people are dangerous and hostile (Arntz,
2005). Individuals with BPD also display hypervigilance: the tendency to be
constantly on the alert, looking for threatening information in the environment
(Sieswerda & others, 2007).
Up until 20 years ago, experts thought that BPD was untreatable. More
recent evidence, however, suggests that many individuals with BPD show
improvement over time—as many as 50 percent within two years of starting
treatment (Gunderson, 2008). One key aspect of successful treatment appears to
be a reduction in social stress, such as that due to leaving an abusive romantic
partner or establishing a sense of trust in a therapist (Gunderson & others, 2003).
To recognize the severe
toll of BPD on those suffering
from it (and on their families and
friends), in 2008 the U.S. House
of Representatives declared May
to be National Borderline
Personality Disorder
Awareness Month.
1. Individuals with ASPD
A. are incapable of having successful
careers.
B. are typically women.
C. are typically men.
D. rarely engage in criminal behavior.
2. People with BPD
A. pay little attention to how others
treat them.
B. rarely have problems with anger or
strong emotion.
C. tend to have suicidal thoughts or
engage in self-harming actions.
D. tend to have a balanced viewpoint of
people and things rather than to see
them as all black or all white.
3. All of the following are true of BPD except
A. BPD can be caused by a combination
of nature and nurture—genetic in-
heritance and childhood experience.
B. Recent research has shown that peo-
ple with BPD respond positively to
treatment.
C. A common symptom of BPD is impul-
sive behavior such as binge eating
and reckless driving.
D. BPD is far more common in men than
women.
APPLY IT 4. Your new friend Maureen
tells you that she was diagnosed with bor-
derline personality disorder at the age of
23. She feels hopeless when she considers
that her mood swings and unstable self-
esteem are part of her very personality.
Despairing, she asks, “How will I ever
change?” Which of the following statements
about Maureen’s condition is accurate?
A. Maureen should seek therapy and strive
to improve her relationships with others,
as BPD is treatable.
B. Maureen’s concerns are realistic, because
a personality disorder like BPD is
unlikely to change.
C. Maureen should seek treatment for BPD
because there is a high likelihood that
she will end up committing a criminal act.
D. Maureen is right to be concerned,
because BPD is most often caused by
genetic factors.
Putting a label on a person with a psychological disorder can make the disorder seem
like something that happens only to other people (Baumann, 2007). The truth is that
psychological disorders are not just about other people; they are about people, period.
Over 26 percent of Americans ages 18 and older suffer from a diagnosable psychologi-
cal disorder in a given year—an estimated 57.7 million U.S. adults (Kessler & others,
2005; NIMH, 2008). Chances are that you or someone you know will experience a
psychological disorder. Figure 12.12 shows how common many psychological disorders
are in the United States.
A classic and controversial study illustrates that labels of psychological disorder can
be “sticky”—hard to remove once they are applied to a person. David Rosenhan (1973)
recruited eight adults (including a stay-at-home mother, a psychology graduate student,
a pediatrician, and some psychiatrists), none with a psychological disorder, to see a
psychiatrist at various hospitals. These “pseudo-patients” were instructed to act normally
except to complain about hearing voices that said things like “empty” and “thud.All
eight expressed an interest in leaving the hospital and behaved cooperatively. Neverthe-
less, all eight were labeled with schizophrenia and kept in the hospital from 3 to 52 days.
None of the mental health professionals they encountered ever questioned the diagnosis
that was given to these individuals, and all were discharged with the label “schizophre-
nia in remission.” The label “schizophrenia” had stuck to the pseudo-patients and caused
the professionals around them to interpret their quite normal behavior as abnormal.
Clearly, once a person has been labeled with a psychological disorder, that label colors
how others perceive everything else he or she does.
8
Combatting Stigma
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Combatting Stigma // 477
Labels of psychological disorder carry
with them a wide array of implications for
the individual. Is the person still able to be
a good friend? A good parent? A competent
worker? A signi cant concern for individu-
als with psychological disorders is the nega-
tive attitudes that others might have about
people struggling with mental illness (Phelan
& Basow, 2007). Stigma can be a barrier for
individuals coping with a psychological dis-
order, as well as for their families and loved
ones (Corrigan, 2007; Hinshaw, 2007). Neg-
ative attitudes about individuals with psy-
chological disorders are common in many
cultures, and cultural norms and values in u-
ence these attitudes (Abdullah & Brown,
2011). Fear of stigma can prevent individu-
als from seeking treatment and from talking
about their problems with family and friends.
Consequences
of Stigma
The stigma attached to psychological disor-
ders can provoke prejudice and discrimination
toward individuals who are struggling with these problems, thus complicating an already
dif cult situation. Having a disorder and experiencing the stigma associated with it can
also negatively affect the physical health of such individuals.
PREJUDICE AND DISCRIMINATION Labels of psychological disorders can be
damaging because they may lead to negative stereotypes, which play a role in prejudice.
For example, the label “schizophrenic” often has negative connotations such as “frightening”
and “dangerous.
Vivid cases of extremely harmful behavior by individuals with psychological disor-
ders can perpetuate the stereotype that people with such disorders are violent. For
example, Cho Seung-Hui, a 23-year-old college student, murdered 32 students and
faculty at Virginia Tech University in April 2007 before killing himself. The widely
reported fact that Cho had struggled with psychological disorders throughout his life
may have reinforced the notion that individuals with disorders are dangerous. In fact,
however, people with psychological disorders (especially those in treatment) are no
more likely to commit violent acts than the general population. Cho was no more
representative of people with psychological disorders than he was representative of
students at Virginia Tech.
Individuals with psychological disorders are often aware of the negative stigma attached
to these conditions and may themselves have previously held such negative attitudes.
Seeking the assistance they need may involve accepting a stigmatized identity (Thornicroft
& others, 2009; Yen & others, 2009). Even mental health professionals can fall prey to
prejudicial attitudes toward those who are coping with psychological disorders (Nordt,
Rossler, & Lauber, 2006). Improved knowledge about the neurobiological and genetic
processes involved in many psychological disorders appears to be a promising direction
for interventions to reduce such prejudice. Research shows that information about the role
of genes in these disorders reduces prejudicial attitudes (WonPat-Borja & others, 2012).
Among the most feared aspects of stigma is discrimination, or acting prejudicially
toward a person who is a member of a stigmatized group. In the workplace, discrimination
Anxiety Disorders
General anxiety disorder 6.8 3.1%
Panic disorder 6.0 2.7%
Phobic disorder 19.2 8.7%
PTSD 7.7 3.5%
Mood Disorders
Major depressive disorder 14.8 6.7%
Dysthymic disorder 3.3 1.5%
Bipolar disorder 5.7 2.6%
Schizophrenia 2.4 1.1%
Number of
U.S. Adults in a
Given Year (Millions)
Percentage
of U.S. Adults
FIGURE 12.12 The 12-Month Prevalence of the Most
Common Psychological Disorders If you add up the numbers in this
gure, you will see that the totals are higher than the numbers given in the text.
The explanation is that people are frequently diagnosed with more than one
psychological disorder. An individual who has both a depressive and an anxiety
disorder would be counted in both of those categories.
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478 // CHAPTER 12 // Psychological Disorders
against a person with a psychological disorder violates the law. The Americans with
Disabilities Act (ADA) of 1990 made it illegal to refuse employment or a promotion to
someone with a psychological disorder when the person’s condition does not prevent
performance of the job’s essential functions (Cleveland, Barnes-Farrell, & Ratz, 1997).
A person’s appearance or behavior may be unusual or irritating, but as long as that
individual is able to complete the duties required of a position, employment or promotion
cannot be denied.
PHYSICAL HEALTH Individuals with psychological disorders are more likely to
be physically ill and two times more likely to die than their psychologically healthy
counterparts (Gittelman, 2008; Kumar, 2004). They are also more likely to be obese, to
smoke, to drink excessively, and to lead sedentary lives (Kim & others, 2007; Lindwall
& others, 2007; Mykletun & others, 2007; Osborn, Nazareth, & King, 2006).
You might be thinking that these physical health issues are the least of their worries.
If people struggling with schizophrenia want to smoke, why not let them? This type of
thinking sells short the capacity of psychological and psychiatric treatments to help those
with psychological disorders. Research has shown that health-promotion programs can
work well for individuals with a severe psychological disorder (Addington & others,
1998; Chafetz & others, 2008). When we disregard the potential of physical health inter-
ventions for people with psychological disorders to make positive life changes, we reveal
our biases.
Overcoming Stigma
How can we combat the stigma of psychological disorders? One obstacle to changing
people’s attitudes toward individuals with psychological disorders is that mental illness
is often “invisible.” That is, sometimes a person we know can have a disorder without
our being aware. We may be unaware of many good lives around us that are being lived
under a cloud of psychological disorder, because worries about being stigmatized keep
the affected individuals from “coming out.” Thus, stigma leads to a catch-22: Positive
examples of individuals coping with psychological disorders are often missing from our
experience because those who are doing well shun public disclosure of their disorders
(Jensen & Wadkins, 2007).
A critical step toward eliminating stigma is to resist thinking of people with disorders
as limited by their condition. Instead, it is vital to recognize their strengths—both in
confronting their disorder and in carrying on despite their problems—and their achieve-
ments. By creating a positive environment for people with disorders, we encourage more
of them to become con dently “visible” and empower them to be positive role models.
When Milton Greek arrived at Ohio University in the 1980s as a young undergradu-
ate, he had an ambitious goal: “to discover a psychological code that people should live
by, to create world peace” (Carey, 2011a). He became known as a person with very
strange ideas. By his senior year, Milt was in a failing marriage and was convinced that
he had met God one day on the street and Jesus a few days later. Although he was a
lifelong atheist, his delusions took on a distinctive religious character. He believed the
Rapture would occur at any moment and that he himself was the anti-Christ. He heard
voices no one else did and saw things that were not there. Eventually diagnosed with
schizophrenia, Milt began taking medication and started to put his life back together.
While in graduate school, he stopped taking his medications when things seemed to be
going well, only to have a close friend give him a reality check. “When she used the
word ‘hallucination’ I knew it was true,” he said (Carey, 2011a).
Today Milt is a 49-year-old, happily married computer programmer. He takes medica-
tions to control his symptoms and seems again to have found a mission in life. This time
it is about making a difference in the lives of others by sharing his story as a man with
schizophrenia. Along with a small group of other people with serious psychiatric disor-
ders, Milt has “come out” and related his experiences to combat stigma, providing hope
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Summary // 479
for others who are suffering with psychological disorders and helping psychologists who
are interested in experiences like his.
After reading this chapter, you know that many admired individuals have dealt with
psychological disorders. Their diagnoses do not detract from their accomplishments. To
the contrary, their accomplishments are all the more remarkable in the context of the
challenges they have faced.
1. The percentage of Americans 18 years of
age and older who suffer from a diag-
nosable psychological disorder in a
given year is closest to
A. 15 percent.
B. 26 percent.
C. 40 percent.
D. 46 percent.
2. The stigma attached to psychological
disorders can have implications for
A. the physical health of an individual
with such a disorder.
B. the psychological well-being of an
individual with such a disorder.
C. other people’s attitudes and behav-
iors toward the individual with such
a disorder.
D. all of the above
3. Labeling psychological disorders can
lead to damaging
A. stereotyping.
B. discrimination.
C. prejudice.
D. all of the above
APPLY IT 4. Liliana has applied for a
job after graduation doing data entry for a
polling firm. During her second interview,
Liliana asks the human resources manager
whether the job’s health benefits include
prescription drug coverage, as she is on
anti-anxiety medication for generalized
anxiety disorder. Which of the following
statements is most applicable, legally and
otherwise, in light of Liliana’s request?
A. The human resources manager should
tell the hiring committee to avoid hiring
Liliana because she has a psychological
disorder.
B. It is illegal for the firm to deny Liliana
employment simply because she has a
psychological disorder.
C. Liliana should not have asked that ques-
tion, because she will not be hired.
D. Liliana must be given the job, or the
firm could face a lawsuit.
psychological, and sociocultural factors may contribute to the develop-
ment of panic disorder.
Phobic disorders involve an irrational, overwhelming fear of a par-
ticular object, such as snakes, or a situation, such as  ying. Obsessive-
compulsive disorder is an anxiety disorder in which the individual has
anxiety-provoking thoughts that will not go away (obsession) and/or
urges to perform repetitive, ritualistic behaviors to prevent or produce
some future situation (compulsion). Post-traumatic stress disorder
(PTSD) is an anxiety disorder that develops through exposure to trau-
matic events, sexual abuse and assault, and natural and unnatural disas-
ters. Symptoms include  ashbacks, emotional avoidance, emotional
numbing, and excessive arousal. A variety of experiential, psychologi-
cal, and genetic factors have been shown to relate to these disorders.
3 Mood Disorders
Two types of mood disorders are depressive disorders and bipolar disorder.
The depressive disorders include major depressive disorder and dys-
thymic disorder. In major depressive disorder, the individual experi-
ences a serious depressive episode and depressed characteristics such
aslethargy and hopelessness. Dysthymic disorder is generally more
chronic and has fewer symptoms than major depressive disorder.
Biological explanations of depressive disorders focus on heredity,
neurophysiological abnormalities, and neurotransmitter deregulation.
Psychological explanations include behavioral and cognitive perspec-
tives. Sociocultural explanations emphasize socioeconomic and ethnic
factors, as well as gender.
Bipolar disorder is characterized by extreme mood swings that
include one or more episodes of mania (an overexcited, unrealistic,
SUMMARY
1 Defi ning and Explaining
Abnormal Behavior
Abnormal behavior is deviant, maladaptive, or personally distressful.
Theoretical perspectives on the causes of psychological disorders include
biological, psychological, sociocultural, and biopsychosocial approaches.
Biological approaches to disorders describe psychological disorders
as diseases with origins in structural, biochemical, and genetic factors.
Psychological approaches include the behavioral, social cognitive, and
trait perspectives. Sociocultural approaches place emphasis on the larger
social context in which a person lives, including marriage, socioeco-
nomic status, ethnicity, gender, and culture. Biopsychosocial approaches
view the interactions among biological, psychological, and social factors
as signi cant forces in producing both normal and abnormal behavior.
The classi cation of disorders provides a shorthand for communica-
tion, allows clinicians to make predictions about disorders, and helps
them to decide on appropriate treatment. The Diagnostic and Statistical
Manual of Mental Disorders ( DSM ) is the classi cation system clini-
cians use to diagnose psychological disorders. Some psychologists con-
tend that the DSM-IV perpetuates the medical model of psychological
disorders, labels everyday problems as psychological disorders, and
fails to address strengths.
2 Anxiety Disorders
Generalized anxiety disorder is anxiety that persists for at least six
months with no speci c reason for the anxiety. Panic disorder involves
attacks marked by the sudden onset of intense terror. Biological,
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480 // CHAPTER 12 // Psychological Disorders
optimistic state). Most individuals with bipolar disorder go through
multiple cycles of depression interspersed with mania. Genetic
in uences are stronger predictors of bipolar disorder than depressive
disorder, and biological processes are also a factor in bipolar disorder.
Severe depression and other psychological disorders can cause indi-
viduals to want to end their lives. Theorists have proposed biological,
psychological, and sociocultural explanations of suicide.
4 Eating Disorders
Three eating disorders are anorexia nervosa, bulimia nervosa, and binge
eating disorder. Anorexia nervosa is characterized by extreme under-
weight and starvation. The disorder is related to perfectionism and
obsessive-compulsive tendencies. Bulimia nervosa involves a pattern
ofbinge eating followed by purging through self-induced vomiting. In
contrast, binge eating disorder involves binge eating without purging.
Anorexia nervosa and bulimia nervosa are much more common in
women than men, but there is no gender difference in binge eating
disorder. Although sociocultural factors were once thought to be primary
in explaining eating disorders, more recent evidence points to the role of
biological factors.
5 Dissociative Disorders
Dissociative amnesia entails memory loss caused by extensive
psychological stress. Dissociative fugue also involves memory loss,
but individuals with this disorder unexpectedly travel away from
home or work, sometimes assume a new identity, and do not remem-
ber the old one. In dissociative identity disorder, formerly called
multiple personality disorder, two or more distinct personalities are
present in the same individual.
6 Schizophrenia
Schizophrenia is a severe psychological disorder characterized by
highly disordered thought processes. Positive symptoms of schizophre-
nia are behaviors and experiences that are present in individuals with
schizophrenia but absent in healthy people; they include hallucinations
and delusions. Negative symptoms of schizophrenia are behaviors and
experiences that are part of healthy human life that are absent for those
with this disorder; they include  at affect and an inability to plan or
engage in goal-directed behavior.
Biological factors (heredity, structural brain abnormalities, and prob-
lems in neurotransmitter regulation, especially dopamine), psychologi-
cal factors (diathesis-stress model), and sociocultural factors may be
involved in schizophrenia. Psychological and sociocultural factors are
not viewed as stand-alone causes of schizophrenia, but they are related
to the course of the disorder.
7 Personality Disorders
Personality disorders are chronic, maladaptive cognitive-behavioral pat-
terns that are thoroughly integrated into an individual’s personality. Two
common types are antisocial personality disorder (ASPD) and border-
line personality disorder (BPD).
Antisocial personality disorder is characterized by guiltlessness, law-
breaking, exploitation of others, irresponsibility, and deceit. Individuals
with this disorder often lead a life of crime and violence. Psychopaths—
remorseless predators who engage in violence to get what they want—
are a subgroup of individuals with ASPD.
Borderline personality disorder is a pervasive pattern of instability in
interpersonal relationships, self-image, and emotions, and of marked
impulsivity beginning by early adulthood and present in a variety of
contexts. This disorder is related to self-harming behaviors such as
cutting and suicide.
Biological factors for ASPD include genetic, brain, and autonomic
nervous system differences. The potential causes of BPD are complex and
include biological and cognitive factors as well as childhood experiences.
8 Combatting Stigma
Stigma can create a signi cant barrier for people coping with a psycho-
logical disorder, as well as for their loved ones. Fear of being labeled
can prevent individuals with a disorder from getting treatment and from
talking about their problems with family and friends. In addition, the
stigma attached to psychological disorders can lead to prejudice and dis-
crimination toward individuals who are struggling with these problems.
Having a disorder and experiencing the stigma associated with it can
also negatively affect the physical health of such individuals.
We can help to combat stigma by acknowledging the strengths and
the achievements of individuals coping with psychological disorders.
By creating a positive environment for people with disorders, we
encourage them to be open about their struggles and to thrive, with
the result that they can become positive role models for others.
abnormal behavior, p. 441
medical model, p. 443
DSM-IV , p. 444
attention de cit hyperactivity
disorder (ADHD), p. 446
anxiety disorders, p. 448
generalized anxiety
disorder, p. 448
panic disorder, p. 449
phobic disorder (phobia), p. 450
obsessive-compulsive disorder
(OCD), p. 452
post-traumatic stress disorder
(PTSD), p. 452
mood disorders, p. 454
depressive disorders, p. 454
major depressive disorder
(MDD), p. 455
dysthymic disorder (DD), p. 455
bipolar disorder, p. 457
anorexia nervosa, p. 462
bulimia nervosa, p. 463
binge eating disorder (BED), p. 464
dissociative disorders, p. 465
dissociative amnesia, p. 466
dissociative fugue, p. 466
dissociative identity disorder
(DID), p. 466
schizophrenia, p. 468
hallucinations, p. 469
delusions, p. 469
referential thinking, p. 469
catatonia, p. 469
at affect, p. 469
diathesis-stress model, p. 472
personality disorders, p. 473
antisocial personality disorder
(ASPD), p. 473
borderline personality disorder
(BPD), p. 475
KEY TERMS
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Self-Test // 481
SELF-TEST
Multiple Choice
1. The name for a mark of shame that may
cause people to avoid, or act negatively
toward, an individual is
A. disfi gurement.
B. mortifi cation.
C. stigma.
D. prejudice.
2. Feeling an overwhelming sense of dread
and worry without a specifi c cause is
known as
A. obsessive-compulsive disorder.
B. generalized anxiety disorder.
C. phobic disorder.
D. panic disorder.
3. A characteristic of post-traumatic stress
disorder is
A. panic attacks.
B. an exaggerated startle response.
C. persistent nervousness about a variety
of things.
D. extreme fear of an object or place.
4. All of the following are a mood disorder
except
A. generalized anxiety disorder.
B. dysthymic disorder.
C. major depressive disorder.
D. bipolar disorder.
5. The diagnostic criteria for major depressive
disorder include the standard that a
depressive episode must last at least
A. one week.
B. two weeks.
C. two months.
D. two years.
6. Insistently focusing on being depressed is
characteristic of
A. catastrophic thinking.
B. a ruminative coping style.
C. dysthymic disorder.
D. learned helplessness.
7. The eating disorder that involves binge
eating followed by purging through self-
induced vomiting is
A. binge eating disorder.
B. bulimia nervosa.
C. anorexia nervosa.
D. compulsive eating disorder.
8. A dissociative disorder accompanied by
unexpected sudden travel is
A. dissociate disorder.
B. dissociative amnesia.
C. dissociative identity disorder.
D. dissociative fugue.
9. _____ symptoms of schizophrenia refl ect a
loss of normal functioning, while _______
symptoms refl ect the addition of abnormal
functioning.
A. Cognitive; behavioral
B. Behavioral; cognitive
C. Positive; negative
D. Negative; positive
10. Antisocial personality disorder is charac-
terized by _______, whereas borderline
personality disorder is characterized by
_______.
A. avoidance of impulsive behavior; avoid-
ance of physical aggression
B. avoidance of physical aggression;
avoidance of impulsive behavior
C. a tendency to harm oneself; violence
toward others
D. violence toward others; a tendency to
harm oneself
Apply It!
11. What is the diathesis-stress model? In the
text this model was applied to schizophre-
nia. Apply it to one eating disorder and
one anxiety disorder.
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