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

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

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

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

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

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

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

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

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

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

Table 12–1 PERSPECTIVES ON PSYCHOLOGICAL DISORDERS

Standards/Values Measures

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

diathesis Biological predisposition.

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

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

The Prevalence of Psychological Disorders How common are mental disorders?

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

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

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

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

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

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

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

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

Major Depressive Disorder

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

30 35 40 45

Bipolar 2.6%

Post-Traumatic Stress Disorder 3.5%

Attention-Deficit Hyperactivity Disorder (ADHD) 4.1%

6.7%

Specific Phobias 8.7%

All Mood Disorders 9.5%

All Anxiety Disorders 18.1%

Schizophrenia 1.1%

Obsessive-Compulsive Disorder 1.0%

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

Watch PTSD 911 at www.mypsychlab.com

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

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

Table 12–2 DIAGNOSTIC CATEGORIES OF DSM-IV-RT

Category Example

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence

Mental retardation, learning disorders, autistic disorder, attention-deficit/hyperactivity disorder.

Delirium, Dementia, and Amnestic and Other Cognitive Disorders

Delirium, dementia of the Alzheimer’s type, amnestic disorder.

Mental Disorders Due to a General Medical Condition

Psychotic disorder due to epilepsy.

Substance-Related Disorders Alcohol dependence, cocaine dependence, nicotine dependence. Schizophrenia and Other Psychotic Disorders Schizophrenia, schizoaffective disorder, delusional disorder. Mood Disorders Major depressive disorder, dysthymic disorder, bipolar disorder. Anxiety Disorders Panic disorder with agoraphobia, social phobia, obsessive-compulsive disorder, post-

traumatic stress disorder, generalized anxiety disorder. Somatoform Disorders Somatization disorder, conversion disorder, hypochondriasis. Factitious Disorders Factitious disorder with predominantly physical signs and symptoms. Dissociative Disorders Dissociative amnesia, dissociative fugue, dissociative identity disorder, depersonalization

disorder. Sexual and Gender-Identity Disorders Hypoactive sexual desire disorder, male erectile disorder, female orgasmic disorder,

vaginismus. Eating Disorders Anorexia nervosa, bulimia nervosa. Sleep Disorders Primary insomnia, narcolepsy, sleep terror disorder. Impulse-Control Disorders Kleptomania, pyromania, pathological gambling. Adjustment Disorders Adjustment disorder with depressed mood, adjustment disorder with conduct disturbance. Personality Disorders Antisocial personality disorder, borderline personality disorder, narcissistic personality

disorder, dependent personality disorder.

Answers:1. supernatural.2. genetic.3. Insanity.4. (T).5. (F).6. (F).

CHECK YOUR UNDERSTANDING

1. It is likely that people in early societies believed that ________ forces caused abnormal behavior. 2. There is growing evidence that ________ factors are involved in mental disorders as diverse

as schizophrenia, depression, and anxiety. 3. ________ is a legal term that is not the same thing as mental illness.

Indicate whether the following statements are true (T) or false (F): 4. The line separating normal from abnormal behavior is somewhat arbitrary. 5. About two-thirds of Americans are suffering from one or more serious mental disorders

at any given time. 6. The cognitive view of mental disorders suggests that they arise from unconscious conflicts,

often rooted in childhood.

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MOOD DISORDERS How do mood disorders differ from ordinary mood changes?

Most people have a wide emotional range; they can be happy or sad, animated or quiet, cheerful or discouraged, or overjoyed or miserable, depending on the circumstances. In some people with mood disorders, this range is greatly restricted. They seem stuck at one or the other end of the emotional spectrum—either consistently excited and euphoric or consistently sad—regardless of life circumstances. Others with mood disorders alternate between the extremes of euphoria and sadness.

Depression How does clinical depression differ from ordinary sadness?

The most common mood disorder is depression, a state in which a person feels over- whelmed with sadness. Depressed people lose interest in the things they normally enjoy. Intense feelings of worthlessness and guilt leave them unable to feel pleasure. They are tired and apathetic, sometimes to the point of being unable to make the simplest decisions. Many depressed people feel as if they have failed utterly in life, and they tend to blame themselves for their problems. Seriously depressed people often have insomnia and lose interest in food and sex. They may have trouble thinking or concentrating—even to the extent of finding it difficult to read a newspaper. In fact, difficulty in concentrating and subtle changes in short-term memory are sometimes the first signs of the onset of depres- sion (Janice Williams et al., 2000). In extreme cases, depressed people may be plagued by suicidal thoughts or may even attempt suicide (C. T. S. Kumar, Mohan, & Ranjith, 2006). The earlier the age of onset of depressive symptoms, the greater the likelihood that suicide may be attempted (A. H. Thompson, 2008).

Clinical depression is different from the “normal” kind of depression that all people experience from time to time. Only when depression is long lasting and goes well beyond the typical reaction to a stressful life event is it classified as a mood disorder (American Psy- chological Association, 2000). (See “Applying Psychology: Recognizing Depression.”)

DSM-IV-TR distinguishes between two forms of depression: Major depressive disor- der is an episode of intense sadness that may last for several months; in contrast, dysthymia involves less intense sadness (and related symptoms), but persists with little

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depression A mood disorder characterized by overwhelming feelings of sadness, lack of interest in activities, and perhaps excessive guilt or feelings of worthlessness.

APPLY YOUR UNDERSTANDING

1. You are talking to a friend whose behavior has you concerned. She says, “Look, I’m happy, I feel good about myself, and I think things are going well.” Which viewpoint on mental health is reflected in her statement?

a. society’s view b. the individual’s view c. the mental health professional’s view d. Both (b) and (c) are true.

2. A friend asks you, “What causes people to have psychological disorders?” You respond, “Most often, it turns out that some people are biologically prone to developing a particular disorder. When they have some kind of stressful experience, the predisposition shows up in their behavior.” What view of psychological disorders are you taking?

a. psychoanalytic model b. cognitive model c. behavioral model d. diathesis–stress model

Answers:1. b.2. d.

L E A R N I N G O B J E C T I V E S • Explain how mood disorders differ from

ordinary mood changes. List the key symptoms that are used to diagnose major depression, dysthymia, mania, and bipolar disorder. Describe the causes of mood disorders.

• Describe the factors that are related to a person’s likelihood of committing suicide. Contrast the three myths about suicide with the actual facts about suicide.

mood disorders Disturbances in mood or prolonged emotional state.

major depressive disorder A depressive disorder characterized by an episode of intense sadness, depressed mood, or marked loss of interest or pleasure in nearly all activities.

dysthymia A depressive disorder where the symptoms are generally less severe than for major depressive disorder, but are present most days and persist for at least 2 years.

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relief for a period of 2 years or more. Depression is two to three times more prevalent in women than in men (Inaba et al., 2005; Kessler et al., 2003; Nolen-Hoeksema, 2006).

Children and adolescents can also suffer from depression. In very young children, depression is sometimes difficult to diagnose because the symptoms are usually different than those seen in adults. For instance, in infants or toddlers, depression may be manifest as a “failure to thrive” or gain weight, or as a delay in speech or motor development. In school-age children, depression may be manifested as antisocial behavior, excessive worry- ing, sleep disturbances, or unwarranted fatigue (Kaslow, Clark, & Sirian, 2008).

One of the most severe hazards of depression, as well as some of the other disorders described in this chapter, is that people may become so miserable that they no longer wish to live.

Recognizing Depression

From time to time, almost everyonegets “the blues.” Failing a major exam,breaking up with a partner, even leav- ing home and friends to attend college can all produce a temporary state of sadness. More significant life events can have an even greater impact: The loss of one’s job or the loss of a loved one can produce a sense of hopelessness about the future that feels very much like a slide into depres- sion. But in all of these instances, either the mood disorder is a normal reaction to a real problem or it passes quickly.

At what point do these normal responses evolve into clinical depression? The DSM- IV-RT provides the framework for making this distinction. First, clinical depression is characterized by depressed mood or by the loss of interest and pleasure in usual activities, or both. Clinicians also look for significant impairment or distress in social, occupational, or other important areas of functioning. People suffering from depres- sion not only feel sad or empty, but also have significant problems carrying on a normal lifestyle. Clinicians also look for other explanations. Could symptoms be due to substance abuse or medication side effects? Could they be the result of a med- ical condition such as hypothyroidism (the inability of the thyroid gland to produce an adequate amount of its hormones)? Could the symptoms be better interpreted as an intense but otherwise normal reaction to life events?

If the symptoms do not seem to be explained by the preceding causes, clini- cians make a diagnosis of major depressive disorder according to the DSM-IV-TR, which specifies that at least five of the fol- lowing symptoms—including at least one of the first two—are present:

1. Depressed mood: Does the person feel sad or empty for most of the day, most every day, or do others observe these symptoms?

2. Loss of interest in pleasure: Has the person lost interest in performing normal activities, such as working or going to social events? Does the per- son seem to be “just going through the motions” of daily life without deriving any pleasure from them?

3. Significant weight loss or gain: Has the person gained or lost more than 5% of body weight in a month? Has the per- son lost interest in eating or com- plained that food has lost its taste?

4. Sleep disturbances: Is the person hav- ing trouble sleeping? Conversely, is the person sleeping too much?

5. Disturbances in motor activities: Do others notice a change in the person’s activity level? Does the person just “sit around” or, conversely, behave in an agitated or unusually restless manner?

6. Fatigue: Does the person complain of being constantly tired and having no energy?

7. Feelings of worthlessness or excessive guilt: Does the person express feelings such as “You’d be better off without me” or “I’m evil and I ruin everything for everybody I love”?

8. Inability to concentrate: Does the per- son complain of memory problems (“I just can’t remember anything anymore”) or the inability to focus attention on simple tasks, such as reading a newspaper?

9. Recurrent thoughts of death: Does the person talk about committing suicide or express the wish that he or she were dead?

If you or someone you know well seems to have these symptoms, that per- son should consult a doctor or mental health professional. When these symp- toms are present and are not due to other medical conditions, a diagnosis of major depression is typically the result, and appropriate treatment can be prescribed. As you will learn in Chapter 13, “Thera- pies,” appropriate diagnosis is the first step in the effective treatment of psychological disorders.

Source: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Associ- ation, 2000.

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Suicide What factors are related to a person’s likelihood of committing suicide?

Each year in the United States, approximately one suicide occurs every 17 minutes, making it the 11th leading cause of death (Centers for Disease Control, 2006; Holloway, Brown, & Beck, 2008). In addition, half a million Americans receive hospital treatment each year for attempted suicide. Indeed, suicides outnumber homicides by five to three in the United States. The suicide rate is much higher among Whites than among minorities (Centers for Disease Control, 2006). Compared to other countries, the suicide rate in the United States is below average (the highest rates are found in eastern European countries) (Curtin, 2004). More women than men attempt suicide, but more men succeed, partly because men tend to choose violent and lethal means, such as guns.

Although the largest number of suicides occurs among older White males, since the 1960s suicide attempt rates have been rising among adolescents and young adults (Figure 12–2). In fact, adolescents account for 12% of all suicide attempts in the United States, and in many other countries suicide ranks as either the first, second, or third leading cause of death in that age group (Centers for Disease Control and Prevention, 1999; Zalsman & Mann, 2005). We cannot as yet explain the increase, though the stresses of leav- ing home, meeting the demands of college or a career, and surviving loneliness or broken romantic attachments seem to be particularly great at this stage of life. Although external problems such as unemployment and financial strain may also contribute to personal problems, suicidal behavior is most common among adolescents with psychological prob- lems. Several myths concerning suicide can be quite dangerous:

Myth: Someone who talks about committing suicide will never do it. Fact: Most people who kill themselves have talked about it. Such comments should

always be taken seriously.

Myth: Someone who has tried suicide and failed is not serious about it.

Fact: Any suicide attempt means that the person is deeply troubled and needs help immediately. A suicidal person will try again, picking a more deadly method the second or third time around.

Myth: Only people who are life’s losers— those who have failed in their careers and in their personal lives—commit suicide.

Fact: Many people who kill themselves have prestigious jobs, conventional families, and a good income. Physicians, for example, have a suicide rate several times higher than that for the general population; in this case, the tendency to suicide may be related to their work stresses.

People considering suicide are overwhelmed with hopelessness. They feel that things cannot get better and see no way out of their difficulties. This perception is depression in the extreme, and it is not easy to talk someone out of this state of mind. Telling a suicidal person that things aren’t really so

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Figure 12–2 Gender and race differences in the suicide rate across the life span. The suicide rate for White males, who commit the largest number of suicides at all ages, shows a sharp rise beyond the age of 65. In contrast, the suicide rate for African American females, which is the lowest for any group, remains relatively stable throughout the life span. Source: From Suicide and Life-Threatening Behavior by E. K. Moscicki. Copyright © 1995 by Guilford Publi- cations, Inc. Reprinted by permission of Copyright Clearance Center on behalf of the publisher.

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bad does no good; in fact, the person may only view this as further evidence that no one understands his or her suffering. But most suicidal people do want help, however much they may despair of obtaining it. If a friend or family member seems at all suicidal, getting professional help is urgent. A community mental health center is a good starting place, as are the national suicide hotlines.

Mania and Bipolar Disorder What is mania, and how is it involved in bipolar disorder?

Another mood disorder, which is less common than depression, is mania, a state in which the person becomes euphoric or “high,” extremely active, excessively talkative, and easily distracted. People suffering from mania may become grandiose—that is, their self-esteem is greatly inflated. They typically have unlimited hopes and schemes, but little interest in realistically carrying them out. People in a manic state sometimes become aggressive and hostile toward others as their self-confidence grows more and more exaggerated. At the extreme, people going through a manic episode may become wild, incomprehensible, or violent until they collapse from exhaustion.

The mood disorder in which both mania and depression are present is known as bipolar disorder. In people with bipolar disorder, periods of mania and depression alternate (each lasting from a few days to a few months), sometimes with periods of normal mood in between. Occasionally, bipolar disorder occurs in a mild form, with moods of unrealistically high spirits followed by moderate depression. Research sug- gests that bipolar disorder is much less common than depression and, unlike depres- sion, occurs equally in men and women. Bipolar disorder also seems to have a stronger biological component than depression: It is more strongly linked to heredity and is most often treated with drugs (Hayden & Nurnberger, 2006; Konradi et al., 2004; Serretti & Mandelli, 2008).

Causes of Mood Disorders What causes some people to experience extreme mood changes?

Mood disorders result from a combination of risk factors although researchers do not yet know exactly how these elements interact to cause a mood disorder (Moffitt, Caspi, & Rutter, 2006).

Biological Factors Genetic factors can play an important role in the development of depression (Haghighi et al., 2008; Zubenko et al., 2003) and bipolar disorder (Badner, 2003; Serretti & Mandelli, 2008). Strong evidence comes from studies of twins. (See Chapter 2, “The Biological Basis of Behavior.”) If one identical twin is clinically depressed, the other twin (with identical genes) is likely to become clinically depressed also. Among fraternal twins (who share only about half their genes), if one twin is clinically depressed, the risk for the second twin is much lower (McGuffin, Katz, Watkins, & Rutherford, 1996). In addition, genetic researchers have recently identified a specific variation on the 22 chro- mosome that appears to increase an individual’s susceptibility to bipolar disorder by influ- encing the balance of certain neurotransmitters in the brain (Hashimoto et al., 2005; Kuratomi et al., 2008).

A new and particularly intriguing line of research aimed at understanding the cause of mood disorders stems from the diathesis–stress model. Recent research shows that a diathesis (biological predisposition) leaves some people particularly vulnerable to certain stress hormones. Adverse or traumatic experiences early in life can result in high levels of those stress hormones, which in turn increases the likelihood of a mood disorder later in life (Bradley et al., 2008; Gillespie & Nemeroff, 2007).

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mania A mood disorder characterized by euphoric states, extreme physical activity, excessive talkativeness, distractedness, and sometimes grandiosity.

bipolar disorder A mood disorder in which periods of mania and depression alternate, sometimes with periods of normal mood intervening.

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Psychological Factors Although a number of psychological factors are thought to play a role in causing severe depression, in recent years, researchers have focused on the contribution of maladaptive cognitive distortions. According to Aaron Beck (1967, 1976, 1984), during childhood and adolescence, some people undergo wrenching experiences such as the loss of a parent, severe difficulties in gaining parental or social approval, or humiliating criticism from teachers and other adults. One response to such experience is to develop a negative self-concept—a feeling of incompetence or unworthiness that has little to do with reality, but that is maintained by a distorted and illogical interpretation of real events. When a new situation arises that resembles the situation under which the self- concept was learned, these same feelings of worthlessness and incompetence may be acti- vated, resulting in depression. Considerable research supports Beck’s view of depression (Alloy, Abramson, & Francis, 1999; Alloy, Abramson, Whitehouse, et al., 1999; Kwon & Oei, 2003). Therapy based on Beck’s theories has proven quite successful in treating depression. (See Chapter 13, “Therapies.”)

Social Factors Many social factors have been linked with mood disorders, particularly difficulties in interpersonal relationships. In fact, some theorists have suggested that the link between depression and troubled relationships explains the fact that depression is two to three times more prevalent in women than in men (National Alliance on Mental Illness, 2003), because women tend to be more relationship oriented than men are in our society (Ali, 2008; Pinhas, Weaver, Bryden, Ghabbour, & Toner, 2002). Yet, not every person who experiences a troubled relationship becomes depressed. As the systems approach would predict, it appears that a genetic predisposition or cognitive distortion is necessary before a distressing close relationship or other significant life stressor will result in a mood disorder (Wichers et al., 2007).

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Person–Situation The Chicken or the Egg? It is sometimes difficult to tease apart the relative contribution of the person’s biological or cognitive tendencies and the social situation. People with certain depression-prone genetic or cognitive tendencies may be more likely than others to encounter stressful life events by virtue of their personality and behavior. For example, studies show that depressed people tend to evoke anxiety and even hostility in others, partly because they require more emo- tional support than people feel comfortable giving. As a result, people tend to avoid those who are depressed, and this shunning can intensify the depression. In short, depression- prone and depressed people may become trapped in a vicious circle that is at least partly of their own creation (Coyne & Whiffen, 1995; Pettit & Joiner, 2006). ■

cognitive distortions An illogical and maladaptive response to early negative life events that leads to feelings of incompetence and unworthiness that are reactivated whenever a new situation arises that resembles the original events.

CHECK YOUR UNDERSTANDING

Indicate whether the following statements are true (T) or false (F):

1. ________ People with a mood disorder always alternate between the extremes of euphoria and sadness.

2. ________ More men attempt suicide, but more women actually kill themselves. 3. ________ Most psychologists now believe that mood disorders result from a combination

of risk factors. 4. ________ Mania is the most common mood disorder.

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ANXIETY DISORDERS How does an anxiety disorder differ from ordinary anxiety?

All of us are afraid from time to time, but we usually know why we are fearful, our fear is caused by something appropriate and identifiable, and it passes with time. In the case of anxiety disorders, however, either the person does not know why he or she is afraid, or the anxiety is inappropriate to the circumstances. In either case, the person’s fear and anxiety just don’t seem to make sense.

As shown in Figure 12–1, anxiety disorders are more common than any other form of mental disorder. Anxiety disorders can be subdivided into several diagnostic categories, including specific phobias, panic disorder, and other anxiety disorders, such as generalized anxiety disorder, obsessive–compulsive disorder, and disorders caused by specific trau- matic events.

Specific Phobias Into what three categories are phobias usually grouped?

A specific phobia is an intense, paralyzing fear of something that perhaps should be feared, but the fear is excessive and unreasonable. In fact, the fear in a specific phobia is so great that it leads the person to avoid routine or adaptive activities and thus interferes with life functioning. For example, it is appropriate to be a bit fearful as an airplane takes off or lands, but people with a phobia about flying refuse to get on or even go near an airplane. Other common phobias focus on animals, heights, closed places, blood, needles, and injury. Almost 10% of people in the United States suffer from at least one specific phobia.

Most people feel some mild fear or uncertainty in many social situations, but when these fears interfere significantly with life functioning, they are considered to be social pho- bias. Intense fear of public speaking is a common form of social phobia. In other cases, simply talking with people or eating in public causes such severe anxiety that the phobic person will go to great lengths to avoid these situations.

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anxiety disorders Disorders in which anxiety is a characteristic feature or the avoidance of anxiety seems to motivate abnormal behavior.

APPLY YOUR UNDERSTANDING

1. Bob is “down in the dumps” most of the time. He is having a difficult time dealing with any criticism he receives at work or at home. Most days he feels that he is a failure, despite the fact that he is successful in his job and his family is happy. Although he participates in various activities outside the home, he finds no joy in anything. He says he is constantly tired, but he has trouble sleeping. It is most likely that Bob is suffering from

a. clinical depression. b. generalized anxiety disorder. c. depersonalization disorder. d. somatoform disorder.

2. Mary almost seems to be two different people. At times, she is hyperactive and talks nonstop (sometimes so fast that nobody can understand her). At those times, her friends say she is “bouncing off the walls.” But then she changes: She becomes terribly sad, loses interest in eating, spends much of her time in bed, and rarely says a word. It is most likely that Mary is suffering from

a. dissociative identity disorder. b. depression. c. bipolar disorder. d. schizophrenia.

Answers:1. a.2. c.

L E A R N I N G O B J E C T I V E S • Explain how anxiety disorders differ from

ordinary anxiety. Briefly describe the key features of phobias, panic disorders, generalized anxiety disorder, and obsessive–compulsive disorder.

• Describe the causes of anxiety disorders.

specific phobia Anxiety disorder characterized by an intense, paralyzing fear of something.

social phobias Anxiety disorders characterized by excessive, inappropriate fears connected with social situations or performances in front of other people.

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Agoraphobia is much more debilitating than social phobia. This term comes from Greek and Latin words that literally mean “fear of the marketplace,” but the disorder typi- cally involves multiple, intense fears, such as the fear of being alone, of being in public places from which escape might be difficult, of being in crowds, of traveling in an automo- bile, or of going through tunnels or over bridges. The common element in all of these situ- ations seems to be a great dread of being separated from sources of security. Some sufferers are so fearful that they will venture only a few miles from home; others will not leave their homes at all.

For example, consider the accomplished author, composer, pianist, and educator Allen Shawn, who wrote in his memoir:

I don’t like heights, I don’t like being on the water. I am upset by walking across parking lots or open parks or fields where there are no buildings. I tend to avoid bridges, unless they are on a small scale. I respond poorly to stretches of vastness but do equally badly when I am closed in, as I am severely claustrophobic. When I go to a theater, I sit on the aisle. I am pet- rified of tunnels, making most train travel as well as many drives difficult. I don’t take sub- ways. I avoid elevators as much as possible. I experience glassed-in spaces as toxic, and I find it very difficult to adjust to being in buildings in which the windows don’t open. I don’t like to go to enclosed malls; and if I do, I don’t venture very far into them . . . . In short, I am afraid both of closed and of open spaces, and I am afraid, in a sense, of any form of isolation. (Shawn, 2007, p. xviii)

Panic Disorder How does a panic attack differ from fear?

Another type of anxiety disorder is panic disorder, characterized by recurring episodes of a sudden, unpredictable, and overwhelming fear or terror. Panic attacks occur without any reasonable cause and are accompanied by feelings of impending doom, chest pain, dizzi- ness or fainting, sweating, difficulty breathing, and fear of losing control or dying. Panic attacks usually last only a few minutes, but they may recur for no apparent reason. For example, consider the following description:

Minday Markowitz is an attractive, stylishly dressed 25-year-old art director for a trade mag- azine who comes to an anxiety clinic after reading about the clinic program in the newspa- per. She is seeking treatment for “panic attacks” that have occurred with increasing frequency over the past year, often 2 or 3 times a day. These attacks begin with a sudden intense wave of “horrible fear” that seems to come out of nowhere, sometimes during the day, sometimes waking her from sleep. She begins to tremble, is nauseated, feels as though she is choking, and fears that she will lose control and do something crazy, like run screaming into the street. (Spitzer, Gibbon, Skodol, Williams, & First, 2002, p. 202)

Panic attacks not only cause tremendous fear while they are happening, but also leave a dread of having another panic attack, which can persist for days or even weeks after the original episode. In some cases, this dread is so overwhelming that it can lead to the development of agoraphobia: To prevent a recurrence, people may avoid any circum- stance that might cause anxiety, clinging to people or situations that help keep them calm.

Other Anxiety Disorders How do generalized anxiety disorder and obsessive–compulsive disorder differ from specific phobias?

In the various phobias and in panic attacks, there is a specific source of anxiety. In contrast, generalized anxiety disorder is defined by prolonged vague but intense fears that are not attached to any particular object or circumstance. Generalized anxiety disorder perhaps

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agoraphobia An anxiety disorder that involves multiple, intense fears of crowds, public places, and other situations that require separation from a source of security such as the home.

panic disorder An anxiety disorder characterized by recurrent panic attacks in which the person suddenly experiences intense fear or terror without any reasonable cause.

generalized anxiety disorder An anxiety disorder characterized by prolonged vague but intense fears that are not attached to any particular object or circumstance.

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comes closest to the everyday meaning attached to the term neurotic. Its symptoms include the inability to relax, muscle tension, rapid heartbeat or pounding heart, apprehensiveness about the future, constant alertness to potential threats, and sleeping difficulties (Hazlett- Stevens, Pruitt, & Collins, 2009).

A very different form of anxiety disorder is obsessive–compulsive disorder (OCD). Obsessions are involuntary thoughts or ideas that keep recurring despite the person’s attempts to stop them, whereas compulsions are repetitive, ritualistic behaviors that a per- son feels compelled to perform (Shader, 2003). Obsessive thoughts are often horrible and frightening. One patient, for example, reported that “when she thought of her boyfriend, she wished he were dead”; when her sister spoke of going to the beach with her infant daughter, she “hoped that they would both drown” (Carson & Butcher, 1992, p. 190). Compulsive behaviors may be equally disruptive to the person who feels driven to perform them. Recall Jack, the engineer described at the beginning of the chapter, who couldn’t leave his house without double- and triple-checking to be sure the doors were locked and all the lights and appliances were turned off.

People who experience obsessions and compulsions often do not seem particularly anxious, so why is this disorder considered an anxiety disorder? The answer is that if such people try to stop their irrational behavior—or if someone else tries to stop them—they experience severe anxiety. In other words, the obsessive–compulsive behavior seems to have developed to keep anxiety under control.

Finally, two types of anxiety disorder are clearly caused by some specific highly stress- ful event. Some people who have lived through fires, floods, tornadoes, or disasters such as an airplane crash experience repeated episodes of fear and terror after the event itself is over. If the anxious reaction occurs soon after the event, the diagnosis is acute stress disorder. If it takes place long after the event is over, particularly in cases of military combat or rape, the diagnosis is likely to be posttraumatic stress disorder, discussed in Chapter 11, “Stress and Health Psychology” (Oltmanns & Emery, 2006).

Causes of Anxiety Disorders What causes anxiety disorders?

Like all behaviors, phobias can be learned. Consider a young boy who is savagely attacked by a large dog. Because of this experience, he is now terribly afraid of all dogs. In this case, a realistic fear has become transformed into a phobia. However, other phobias are harder to understand. As we saw in Chapter 5,“Learning,” many people get shocks from electric sock- ets, but almost no one develops a socket phobia. Yet snake and spider phobias are common. The reason seems to be that through evolution we have become biologically predisposed to associate certain potentially dangerous objects with intense fears (Hofmann, Moscovitch, & Heinrichs, 2004; Nesse, 2000; Seligman, 1971).

Psychologists working from the biological perspective point to heredity, arguing that we can inherit a predisposition to anxiety disorders (Bolton et al., 2006; Gelernter & Stein, 2009; Leonardo & Hen, 2006). In fact, anxiety disorders tend to run in families. Researchers have located some specific genetic sites that may generally predispose people toward anxiety disorders (Goddard et al., 2004; Hamilton et al., 2004). In some cases, spe- cific genes have even been linked to specific anxiety disorders, such as obsessive hoarding (Alonso et al., 2008).

Finally, we need to consider the role that internal psychological conflicts may play in producing feelings of anxiety. The very fact that people suffering from anxiety disorders often have no idea why they are anxious suggests that the explanation may be found in unconscious conflicts that trigger anxiety. According to this view, phobias are the result of displacement, in which people redirect their anxiety from the unconscious conflicts toward objects or settings in the real world. (See Chapter 11, “Stress and Health Psychology,” for a discussion of displacement.)

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obsessive–compulsive disorder (OCD) An anxiety disorder in which a person feels driven to think disturbing thoughts or to perform senseless rituals.

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PSYCHOSOMATIC AND SOMATOFORM DISORDERS What is the difference between psychosomatic disorders and somatoform disorders?

The term psychosomatic perfectly captures the interplay of psyche (mind) and soma (body), which characterizes these disorders. A psychosomatic disorder is a real, physical disorder, but one that has, at least in part, a psychological cause. As we saw in Chapter 11 (“Stress and Health Psychology”), stress, anxiety, and prolonged emotional arousal alter body chem- istry, the functioning of bodily organs, and the body’s immune system (which is vital in fighting infections). Thus, modern medicine leans toward the idea that all physical ailments are to some extent “psychosomatic.”

Psychosomatic disorders involve genuine physical illnesses. In contrast, people suffering from somatoform disorders believe that they are physically ill and describe symptoms that sound like physical illnesses, but medical examinations reveal no organic problems. Never- theless, the symptoms are real to them and are not under voluntary control (American Psychological Association, 2000). For example, in one kind of somatoform disorder, somatization disorder, the person experiences vague, recurring physical symptoms for which medical attention has been sought repeatedly but no organic cause found. Common complaints are back pain, dizziness, abdominal pain, and sometimes anxiety and depression.

One of the more dramatic forms of somatoform disorder involves complaints of paralysis, blindness, deafness, seizures, loss of feeling, or pregnancy. In these conversion

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L E A R N I N G O B J E C T I V E • Distinguish between psychosomatic

and somatoform disorders, somatization disorder, conversion disorders, hypochondriasis, and body dysmorphic disorder. Explain what is meant by the statement that “all physical ailments are to some extent psychosomatic.”

psychosomatic disorder A disorder in which there is real physical illness that is largely caused by psychological factors such as stress and anxiety.

CHECK YOUR UNDERSTANDING

1. According to the psychoanalytic view, anxiety results from ________ ________. 2. The belief that we inherit the tendency to develop some phobias more easily than others

argues that these phobias are ________ ________. Indicate whether the following statements are true (T) or false (F):

3. ________ The fear in a specific phobia often interferes with life functions. 4. ________ People who experience obsessions and compulsions appear highly anxious. 5. ________ Research indicates that people who feel that they are not in control of stressful

events in their lives are more likely to experience anxiety than those who believe that they have control over such events.

Answers:1. unconscious conflicts.2. prepared responses.3. (T).4. (F).5. (T).

APPLY YOUR UNDERSTANDING

1. Barbara becomes intensely fearful whenever she finds herself in crowds or in public places from which she might not be able to escape easily. It is most likely that Barbara is suffering from

a. generalized anxiety disorder. b. panic disorder. c. agoraphobia. d. acute stress disorder.

2. A combat veteran complains of insomnia. If he does fall asleep, he often has horrible nightmares that involve killing and blood. He may be doing something normal—for example, riding a bicycle through a park—when frightening memories of war come upon him as a result of some normal stimulus, like the sound of a low-flying airplane. Given this information, you would suspect that he was suffering from

a. generalized anxiety disorder. b. posttraumatic stress disorder. c. panic disorder. d. obsessive–compulsive disorder. Answers:1. c.2. b.

somatoform disorders Disorders in which there is an apparent physical illness for which there is no organic basis.

somatization disorder A somatoform disorder characterized by recurrent vague somatic complaints without a physical cause.

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disorders, no physical causes appear, yet the symptoms are very real. Yet another somato- form disorder is hypochondriasis. Here, the person interprets some small symptom— perhaps a cough, a bruise, or perspiration—as a sign of a serious disease. Although the symptom may actually exist, there is no evidence that the serious illness does.

Body dysmorphic disorder, or imagined ugliness, is a recently diagnosed and poorly understood type of somatoform disorder. Cases of body dysmorphic disorder can be very striking. One man, for example, felt that people stared at his “pointed ears” and “large nos- trils” so much that he eventually could not face going to work, so he quit his job. Claudia, the woman described at the beginning of the chapter who displayed such concern about her hair, apparently was suffering from a body dysmorphic disorder. Clearly, people who become that preoccupied with their appearance cannot lead a normal life. Ironically, most people who suffer body dysmorphic disorder are not ugly. They may be average looking or even attractive, but they are unable to evaluate their looks realistically.

Somatoform disorders (especially conversion disorders) present a challenge for psy- chological theorists because they seem to involve some kind of unconscious processes. Freud concluded that the physical symptoms were often related to traumatic experiences buried in a patient’s past. Cognitive–behavioral theorists look for ways in which the symp- tomatic behavior is being rewarded. From the biological perspective, research has shown that at least some diagnosed somatoform disorders actually were real physical illnesses that were overlooked or misdiagnosed. Nevertheless, most cases of conversion disorder cannot be explained by current medical science. These cases pose as much of a theoretical chal- lenge today as they did when conversion disorders captured Freud’s attention more than a century ago.

conversion disorders Somatoform disorders in which a dramatic specific disability has no physical cause but instead seems related to psychological problems.

hypochondriasis A somatoform disorder in which a person interprets insignificant symptoms as signs of serious illness in the absence of any organic evidence of such illness.

body dysmorphic disorder A somatoform disorder in which a person becomes so preoccupied with his or her imagined ugliness that normal life is impossible.

CHECK YOUR UNDERSTANDING

Indicate whether the following statements are true (T) or false (F):

1. ________ Modern medicine leans toward the idea that all physical ailments are to some extent “psychosomatic.”

2. ________ People who suffer from somatoform disorders do not consciously seek to mislead others about their physical condition.

3. ________ Research has shown that at least some diagnosed somatoform disorders actually were real physical illnesses that were overlooked or misdiagnosed.

4. ________ Most cases of conversion disorder can be explained by current medical science.

Answers:1. (T).2. (T).3. (T).4. (F).

APPLY YOUR UNDERSTANDING

1. Bob is concerned about a few warts that have appeared on his arms. His doctor says that they are just warts and are not a concern, but Bob believes they are cancerous and that he will die from them. He consults another doctor and then another, both of whom tell him they are just normal warts, but he remains convinced they are cancerous and he is going to die. It appears that Bob is suffering from

a. hypochondriasis. b. a psychosomatic disorder. c. a somatoform disorder. d. a phobia.

2. John is a writer, but work on his latest novel has come to a halt because he has lost all feeling in his arm and his hand. His doctor can find no physical cause for his problem; however, there is no question that he no longer has feeling in his arm and that he can no longer hold a pencil or type on a keyboard. It seems likely that John is suffering from

a. body dysmorphic disorder. b. hypochondriasis. c. conversion disorder. d. dissociative disorder. Answers:1. a.2. c.

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DISSOCIATIVE DISORDERS What do dissociative disorders have in common?

Dissociative disorders are among the most puzzling forms of mental disorders, both to the observer and to the sufferer. Dissociation means that part of an individual’s personality appears to be separated from the rest. The disorder usually involves memory loss and a complete, though generally temporary, change in identity. Rarely, several distinct personal- ities appear in one person.

Loss of memory without an organic cause can occur as a reaction to an extremely stressful event or period. During World War II, for example, some hospitalized soldiers could not recall their names, where they lived, where they were born, or how they came to be in battle. But war and its horrors are not the only causes of dissociative amnesia. The person who betrays a friend in a business deal or the victim of rape may also forget, selectively, what has happened. Total amnesia, in which people forget everything, is rare, despite its popularity in novels and films. Sometimes an amnesia victim leaves home and assumes an entirely new identity; this phenomenon, known as dissociative fugue, is also very unusual.

In dissociative identity disorder, commonly known as multiple personality disorder, several distinct personalities emerge at different times. In the true multiple personality, the various personalities are distinct people with their own names, identi- ties, memories, mannerisms, speaking voices, and even IQs. Sometimes the personalities are so separate that they don’t know they inhabit a body with other “people.” At other times, the personalities do know of the existence of other “people” and even make dis- paraging remarks about them. Typically, the personalities contrast sharply with one another, as if each one represents different aspects of the same person—one being the more socially acceptable, “nice” side of the person and the other being the darker, more uninhibited or “evil” side.

The origins of dissociative identity disorder are still not understood (Dell, 2006). One theory suggests that it develops as a response to childhood abuse (Lev-Wiesel, 2008). The child learns to cope with abuse by a process of dissociation—by having the abuse, in effect, happen to “someone else,” that is, to a personality who is not con- scious most of the time. The fact that one or more of the multiple personalities in almost every case is a child (even when the person is an adult) seems to support this idea, and clinicians report a history of child abuse in more than three-quarters of their cases of dissociative identity disorder (Kidron, 2008; C. A. Ross, Norton, & Wozney, 1989).

Other clinicians suggest that dissociative identity disorder is not a real disorder at all, but an elaborate kind of role-playing—faked in the beginning and then perhaps gen- uinely believed by the patient (Lilienfeld & Lynn, 2003; H. G. Pope, Barry, Bodkin, & Hudson, 2006). Some intriguing biological data show that in at least some patients, how- ever, the various personalities have different blood pressure readings, different responses to medication, different allergies, different vision problems (necessitating a different pair of glasses for each personality), and different handedness—all of which would be diffi- cult to feign. Each personality may also exhibit distinctly different brain-wave patterns (Dell’Osso, 2003; Putnam, 1984).

A far less dramatic (and much more common) dissociative disorder is depersonalization disorder, in which the person suddenly feels changed or different in a strange way. Some people feel that they have left their bodies, whereas others find that their actions have suddenly become mechanical or dreamlike. This kind of feeling is especially common during adolescence and young adulthood, when our sense of ourselves and our inter- actions with others change rapidly. Only when the sense of depersonalization becomes a long-term or chronic problem or when the alienation impairs normal social func- tioning can this be classified as a dissociative disorder (American Psychological Associa- tion, 2000).

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dissociative amnesia A disorder characterized by loss of memory for past events without organic cause.

dissociative fugue A disorder that involves flight from home and the assumption of a new identity with amnesia for past identity and events.

dissociative identity disorder (Also called multiple personality disorder.) Disorder characterized by the separation of the personality into two or more distinct personalities.

L E A R N I N G O B J E C T I V E • Explain what is meant by dissociation.

Briefly describe the key features of dissociative amnesia, dissociative fugue, dissociative identity disorder, and depersonalization disorder.

depersonalization disorder A dissociative disorder whose essential feature is that the person suddenly feels changed or different in a strange way.

When she was found by a Florida park ranger, Jane Doe was suffering from amnesia. She could not recall her name, her past, or how to read and write. She never regained her mem- ory of the past.

dissociative disorders Disorders in which some aspect of the personality seems separated from the rest.

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SEXUAL AND GENDER-IDENTITY DISORDERS What are the three main types of sexual disorders?

Sexual dysfunction is the loss or impairment of the ordinary physical responses of sexual function (see Figure 12–3). In men, this usually takes the form of erectile disorder or erectile dysfunction (ED), the inability to achieve or maintain an erection. In women, it often takes the form of female sexual arousal disorder, the inability to become sexually excited or to reach orgasm. (These conditions were once called “impotence” and “frigidity,” respectively, but pro- fessionals in the field have rejected these terms as too negative and judgmental.) Occasional problems with achieving or maintaining an erection in men or with lubrication or reaching orgasm in women are common. Only when the condition is frequent or constant and when enjoyment of sexual relationships becomes impaired should it be considered serious.

CHECK YOUR UNDERSTANDING

1. ________ ________ usually involve memory loss and a complete—though generally temporary—change in identity.

2. Clinicians report a history of ________ ________ in over three-quarters of their cases of dissociative identity disorder.

3. Dissociative disorders, like conversion disorders, seem to involve ________ processes.

Answers:1. dissociative disorders.2. child abuse.3. unconscious.

APPLY YOUR UNDERSTANDING

1. A person who was being interrogated by the police confessed on tape to having committed several murders. When the alleged killer was brought to trial, his lawyers agreed that the voice on the tape belonged to their client. But they asserted that the person who confessed was another personality that lived inside the body of their client. In other words, they claimed that their client was suffering from

a. depersonalization disorder. b. dissociative identity disorder. c. conversion disorder. d. body dysmorphic disorder.

2. You are reading the newspaper and come across a story of a young man who was found wandering the streets with no recollection of who he was, where he came from, or how he got there. You suspect that he is most likely suffering from

a. depersonalization disorder. b. dissociative amnesia. c. conversion disorder. d. body dysmorphic disorder. Answers:1. b.2. b.

L E A R N I N G O B J E C T I V E • Identify the three main types of sexual

disorders that are recognized in the DSM-IV-TR.

sexual dysfunction Loss or impairment of the ordinary physical responses of sexual function.

erectile disorder (or erectile dysfunction) (ED) The inability of a man to achieve or maintain an erection.

female sexual arousal disorder The inability of a woman to become sexually aroused or to reach orgasm.

Diversity–Universality What’s Normal? Ideas about what is normal and abnormal in sexual behavior vary with the times, the indi- vidual, and, sometimes, the culture. Throughout the late 20th century, as psychologists became more aware of the diversity of “normal” sexual behaviors, they increasingly nar- rowed their definition of abnormal sexual behavior. Today the DSM-IV-TR recognizes only three main types of sexual disorders: sexual dysfunction, paraphilias, and gender-identity disorders. We will discuss each of these in turn. ■

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orgasmic disorders Inability to reach orgasm in a person able to experience sexual desire and maintain arousal.

sexual desire disorders Disorders in which the person lacks sexual interest or has an active distaste for sex.

Figure 12–3 Sexual dysfunction in the United States. This graph shows the incidence of the most common types of sexual dysfunction in men and women, by age group. Source: Data from National Health and Social Life Survey published in Journal of the American Medical Association, February 1999, reported in USA Today, May 18, 1999, p. 7D.

18–29 30–39 40–49 50–59

Ages

Women’s problems Men’s problems

010203040 0 10 20 30 40

Lack interest in sex 32% 32%

30% 27%

26% 28%

22% 23%

27% 24%

17% 17%

16%

19% 18%

21% 27%

21% 15%

13% 8%

11% 11%

14% 13%

15% 17%

7% 7%

9% 9%

10% 8% 9%

19%

7% 9% 11%

18%

30% 32%

28% 31%

17% 19%

14%

Lack interest in sex

Unable to achieve orgasm Unable to achieve orgasm

Sex not pleasurable Sex not pleasurable

Anxious about performance Anxious about performance

Trouble lubricating Trouble with erections

Pain during sex Climax too early

The incidence of ED is quite high, even among otherwise healthy men. In one survey, 25% of 40- to 70-year-old men had moderate ED. Less than half the men in this age group reported having no ED (Lamberg, 1998). Fortunately, new medications popularly known as Viagra, Levitra, and Cialis are extremely effective in treating ED (S. B. Levine, 2006; Meston & Frohlich, 2000).

Although Viagra appears to help most male patients overcome ED, it is of little value unless a man is first sexually aroused. Unfortunately, some men and women find it difficult or impossible to experience any desire for sexual activity to begin with. Sexual desire disorders involve a lack of interest in sex or perhaps an active distaste for it. Low sexual desire is more common among women than among men and plays a role in per- haps 40% of all sexual dysfunctions (R. D. Hayes, Dennerstein, Bennett, & Fairley, 2008; Warnock, 2002). The extent and causes of this disorder in men or women is difficult to analyze. Because some people simply have a low motivation for sexual activity, scant interest in sex is normal for them and does not necessarily reflect any sexual disorder (Meston & Rellini, 2008).

Other people are able to experience sexual desire and maintain arousal but are unable to reach orgasm, the peaking of sexual pleasure and the release of sexual tension. These people are said to experience orgasmic disorders. Male orgasmic disorder—the inability to ejaculate even when fully aroused—is rare yet seems to be becoming increasingly common as more men find it desirable to practice the delay of orgasm. Masters and Johnson (1970)

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attributed male orgasmic disorder primarily to such psychological factors as traumatic experiences. The problem also seems to be a side effect of some medications, such as cer- tain antidepressants. This difficulty is considerably more common among women than among men (see Figure 12–3).

Among the other problems that can occur during the sexual response cycle are premature ejaculation, a fairly common disorder that the DSM-IV-TR defines as the male’s inability to inhibit orgasm as long as desired, and vaginismus, involuntary muscle spasms in the outer part of a woman’s vagina during sexual excitement that make inter- course impossible. Again, the occasional experience of such problems is common; the DSM-IV-TR considers them dysfunctions only if they are persistent and recurrent (Hunter, Goodie, Oordt, & Dobmeyer, 2009).

A second group of sexual disorders, known as paraphilias, involves the use of uncon- ventional sex objects or situations to obtain sexual arousal. Most people have unusual sex- ual fantasies at some time, which can be a healthy stimulant of normal sexual enjoyment. However, fetishism—the repeated use of a nonhuman object such as a shoe or underwear as the preferred or exclusive method of achieving sexual excitement—is considered a sexual disorder (Darcangelo, Hollings, & Paladino, 2008). Most people who practice fetishism are male, and the fetish frequently begins during adolescence (Fagan, Lehne, Strand, & Berlin, 2005). Fetishes may derive from unusual learning experiences: As their sexual drive devel- ops during adolescence, some boys learn to associate arousal with inanimate objects, per- haps as a result of early sexual exploration while masturbating or because of difficulties in social relationships (Bertolini, 2001).

Other unconventional patterns of sexual behavior are voyeurism, watching other peo- ple have sex or spying on people who are nude; achieving arousal by exhibitionism, the exposure of one’s genitals in inappropriate situations, such as to strangers; frotteurism, achieving sexual arousal by touching or rubbing against a nonconsenting person in situa- tions like a crowded subway car; and transvestic fetishism, wearing clothes of the opposite sex for sexual excitement and gratification. Sexual sadism ties sexual pleasure to aggres- sion. To attain sexual gratification, sadists humiliate or physically harm sex partners. Sexual masochism is the inability to enjoy sex without accompanying emotional or physi- cal pain. Sexual sadists and masochists sometimes engage in mutually consenting sex, but at times sadistic acts are inflicted on unconsenting partners, sometimes resulting in serious injury or even death (Purcell & Arrigo, 2006).

One of the most serious paraphilias is pedophilia, which according to DSM-IV-TR is defined as engaging in sexual activity with a child, generally under the age of 13. Child sex- ual abuse is shockingly common in the United States. Pedophiles are almost invariably men under age 40 who are close to the victims rather than strangers (Barbaree & Seto, 1997). Although there is no single cause of pedophilia, some of the most common explanations are that pedophiles cannot adjust to the adult sexual role and have been interested exclu- sively in children as sex objects since adolescence; they turn to children as sexual objects in response to stress in adult relationships in which they feel inadequate; or they have records of unstable social adjustment and generally commit sexual offenses against children in response to a temporary aggressive mood. Studies also indicate that the majority of pedophiles have histories of sexual frustration and failure, low self-esteem, an inability to cope with negative emotions, tend to perceive themselves as immature, and are rather dependent, unassertive, lonely, and insecure (L. J. Cohen & Galynker, 2002; Mandeville- Norden & Beech, 2009).

Gender-identity disorders involve the desire to become—or the insistence that one really is—a member of the other sex. Some little boys, for example, want to be girls instead. They may reject boys’ clothing, desire to wear their sisters’ clothes, and play only with girls and with toys that are considered “girls’ toys.” Similarly, some girls wear boys’ clothing and play only with boys and “boys’ toys.” When such children are uncomfortable being a male or a female and are unwilling to accept themselves as such, the diagnosis is gender-identity disorder in children (Zucker, 2005).

The causes of gender-identity disorders are not known. Both animal research and the fact that these disorders are often apparent from early childhood suggest that biological

premature ejaculation Inability of man to inhibit orgasm as long as desired.

vaginismus Involuntary muscle spasms in the outer part of the vagina that make intercourse impossible.

fetishism A paraphilia in which a nonhuman object is the preferred or exclusive method of achieving sexual excitement.

paraphilias Sexual disorders in which unconventional objects or situations cause sexual arousal.

voyeurism Desire to watch others having sexual relations or to spy on nude people.

Repeated use of nonhuman objects, such as shoes, underwear, or leather goods, as the preferred or exclusive method of achieving sexual excitement is known as fetishism.

exhibitionism Compulsion to expose one’s genitals in public to achieve sexual arousal.

frotteurism Compulsion to achieve sexual arousal by touching or rubbing against a nonconsenting person in public situations.

transvestic fetishism Wearing the clothes of the opposite sex to achieve sexual gratification.

sexual sadism Obtaining sexual gratification from humiliating or physically harming a sex partner.

sexual masochism Inability to enjoy sex without accompanying emotional or physical pain.

pedophilia Desire to have sexual relations with children as the preferred or exclusive method of achieving sexual excitement.

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gender-identity disorders Disorders that involve the desire to become, or the insistence that one really is, a member of the other biological sex.

gender-identity disorder in children Rejection of one’s biological gender in childhood, along with the clothing and behavior that society considers appropriate to that gender.

PERSONALITY DISORDERS Which personality disorder creates the most significant problems for society?

In Chapter 10, “Personality,” we saw that despite having certain characteristic views of the world and ways of doing things, people normally can adjust their behavior to fit different sit- uations. But some people, starting at some point early in life, develop inflexible and mal- adaptive ways of thinking and behaving that are so exaggerated and rigid that they cause serious distress to themselves or problems to others. People with such personality disorders range from harmless eccentrics to cold-blooded killers.

One group of personality disorders, schizoid personality disorder, is characterized by an inability or desire to form social relationships and have no warm or tender feelings for others. Such loners cannot express their feelings and appear cold, distant, and unfeeling. Moreover, they often seem vague, absentminded, indecisive, or “in a fog.” Because their withdrawal is so complete, persons with schizoid personality disorder seldom marry and may have trouble holding jobs that require them to work with or relate to others (American Psychological Association, 2000).

CHECK YOUR UNDERSTANDING

Match each of the following terms with the appropriate description:

1. _______ pedophilia

2. _______ gender-identity disorder

3. _______ female sexual arousal disorder

4. _______ paraphilias

a. The inability for a woman to become sexually excited or to reach orgasm.

b. Involve the use of unconventional sex objects or situations to obtain sexual arousal.

c. Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child.

d. The desire to become—or the insistence that one really is—a member of the other biological sex.

Answers:1. c.2. d.3. a.4. b.

APPLY YOUR UNDERSTANDING

1. Viagra and similar drugs have become best sellers because they provide temporary relief from

a. erectile disorder. b. paraphilias. c. generalized anxiety disorder. d. body dysmorphic disorder.

2. A man is arrested for stealing women’s underwear from clotheslines and adding them to the large collection he has hidden in his home. He says that he finds the clothing sexually exciting. It would appear that he is suffering from

a. erectile disorder. b. gender-identity disorder. c. pedophilia. d. fetishism. Answers:1. a.2. d.

personality disorders Disorders in which inflexible and maladaptive ways of thinking and behaving learned early in life cause distress to the person or conflicts with others.

schizoid personality disorder Personality disorder in which a person is withdrawn and lacks feelings for others.

L E A R N I N G O B J E C T I V E • Identify the distinguishing

characteristic of personality disorders. Briefly describe schizoid, paranoid, dependent, avoidant, narcissistic, borderline, and anti-social personality disorders.

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factors, such as prenatal hormonal imbalances, are major contributors. Research suggests that children with gender-identity disorder have an increased likelihood of becoming homosexual or bisexual as adults (Wallien & Cohen-Kettenis, 2008).

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People with paranoid personality disorder often see themselves as rational and objec- tive, yet they are guarded, secretive, devious, scheming, and argumentative. They are suspi- cious and mistrustful even when there is no reason to be; they are hypersensitive to any possible threat or trick; and they refuse to accept blame or criticism even when it is deserved.

A cluster of personality disorders characterized by anxious or fearful behavior includes dependent personality disorder and avoidant personality disorder. People with dependent personality disorder are unable to make decisions on their own or to do things indepen- dently. Rather, they rely on parents, a spouse, friends, or others to make the major choices in their lives and usually are extremely unhappy being alone. In avoidant personality dis- order, the person is timid, anxious, and fearful of rejection. It is not surprising that this social anxiety leads to isolation, but unlike the schizoid type, the person with avoidant per- sonality disorder wants to have close relationships with others.

Another cluster of personality disorders is characterized by dramatic, emotional, or erratic behavior. People with narcissistic personality disorder, for example, display a grandiose sense of self-importance and a preoccupation with fantasies of unlimited suc- cess. Such people believe that they are extraordinary, need constant attention and admira- tion, display a sense of entitlement, and tend to exploit others. They are given to envy and arrogance, and they lack the ability to really care for anyone else (American Psychological Association, 2000).

Borderline personality disorder is characterized by marked instability in self- image, mood, and interpersonal relationships. People with this personality disorder tend to act impulsively and, often, self-destructively. They feel uncomfortable being alone and often manipulate self-destructive impulses in an effort to control or solidify their per- sonal relationships.

One of the most widely studied personality disorders is antisocial personality disorder. People who exhibit this disorder lie, steal, cheat, and show little or no sense of responsibil- ity, although they often seem intelligent and charming at first. The “con man” exemplifies many of the features of the antisocial personality, as does the person who compulsively cheats business partners, because she or he knows their weak points. Antisocial personali- ties rarely show any anxiety or guilt about their behavior. Indeed, they are likely to blame society or their victims for the antisocial actions that they themselves commit. As you might suspect, people with antisocial personality disorder are responsible for a good deal of crime and violence.

Approximately 3% of American men and less than 1% of American women suffer from antisocial personality disorder. It is not surprising that prison inmates show high rates of personality disorder, with male inmates having a rate as high as 60% (Moran, 1999). Not all people with antisocial personality disorder are convicted criminals, however. Many manipulate others for their own gain while avoiding the criminal justice system.

Antisocial personality disorder seems to result from a combination of biological predis- position, difficult life experiences, and an unhealthy social environment (Gabbard, 2005; Moffitt, Caspi, & Rutter, 2006). Some findings suggest that heredity is a risk factor for the later development of antisocial behavior (Fu et al., 2002; Lyons et al., 1995). Research sug- gests that some people with antisocial personalities are less responsive to stress and thus are more likely to engage in thrill-seeking behaviors, such as gambling and substance abuse, which may be harmful to themselves or others (Pietrzak & Petry, 2005; Patrick, 1994). Another intriguing explanation for the cause of antisocial personality disorder is that it arises as a consequence of anatomical irregularities in the prefrontal region of the brain dur- ing infancy (Boes, Tranel, Anderson, & Nopoulos, 2008; A. R. Damasio & Anderson, 2003).

Some psychologists believe that emotional deprivation in early childhood predisposes people to antisocial personality disorder. The child for whom no one cares, say psycholo- gists, cares for no one. Respect for others is the basis of our social code, but when you can- not see things from another person’s perspective, behavior “rules” seem like nothing more than an assertion of adult power to be defied.

Family influences may also prevent the normal learning of rules of conduct in the preschool and school years. A child who has been rejected by one or both parents is not likely to develop adequate social skills or appropriate social behavior. Further, the high

paranoid personality disorder Personality disorder in which the person is inappropriately suspicious and mistrustful of others.

avoidant personality disorder Personality disorder in which the person’s fears of rejection by others lead to social isolation.

dependent personality disorder Personality disorder in which the person is unable to make choices and decisions independently and cannot tolerate being alone.

narcissistic personality disorder Personality disorder in which the person has an exaggerated sense of self-importance and needs constant admiration.

borderline personality disorder Personality disorder characterized by marked instability in self-image, mood, and interpersonal relationships.

antisocial personality disorder Personality disorder that involves a pattern of violent, criminal, or unethical and exploitative behavior and an inability to feel affection for others.

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incidence of antisocial behavior in people with an antisocial parent suggests that antisocial behavior may be partly learned and partly inherited. Once serious misbe- havior begins in childhood, there is an almost predictable progression: The child’s conduct leads to rejection by peers and failure in school, followed by affilia- tion with other children who have behav- ior problems. By late childhood or adolescence, the deviant patterns that will later show up as a full-blown antisocial personality disorder are well established (J. Hill, 2003; T. M. Levy & Orlans, 2004). Cognitive theorists emphasize that in addition to the failure to learn rules and develop self-control, moral development

may be arrested in children who are emotionally rejected and inadequately disciplined (K. Davidson, 2008; Soyguet & Tuerkcapar, 2001).

Causation

We have offered a number of different theories about the cause of antiso-cial personality disorder, all supported by research. Think about eachof these theories and try to answer the following questions: • To what extent do the different perspectives conflict? To what extent do they

support one another?

• What kind of evidence—what kinds of research studies—is offered in sup- port of each theory?

• Which theory would be most useful from a clinical, or treatment, point of view? Which would be most likely to spawn further research?

• Why do different theoretical perspectives exist?

CHECK YOUR UNDERSTANDING

Match the following personality disorders with the appropriate description:

1. _______ schizoid personality disorder

2. _______ paranoid personality disorder 3. _______ dependent personality disorder 4. _______ avoidant personality disorder 5. _______ borderline personality disorder

a. shows instability in self-image, mood, and relationshps

b. is fearful and timid c. is mistrustful even when there is no reason d. lacks the ability to form social relationships e. is unable to make own decisions

Answers:1. d.2. c.3. e.4. b.5. a.

APPLY YOUR UNDERSTANDING

1. John represents himself as a stockbroker who specializes in investing the life savings of elderly people, but he never invests the money. Instead, he puts it into his own bank account and then flees the country. When he is caught and asked how he feels about financially destroying elderly people, he explains, “Hey, if they were stupid enough to give me their money, they deserved what they got.” John is most likely suffering from ________ personality disorder.

a. dependent b. avoidant c. antisocial d. borderline

2. Jennifer is a graduate student who believes that her thesis will completely change the way that scientists view the universe. She believes that she is the only person intelligent enough to have come up with the thesis, that she is not sufficiently appreciated by other students and faculty, and that nobody on her thesis committee is sufficiently knowledgeable to judge its merits. Assuming that her thesis is not, in fact, revolutionary, it would appear that Jennifer is suffering from ________ personality disorder.

a. paranoid b. narcissistic c. borderline d. antisocial

Answers:1. c.2. b.

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SCHIZOPHRENIC DISORDERS How is schizophrenia different from multiple-personality disorder?

Schizophrenic disorders are severe conditions marked by disordered thoughts and com- munications, inappropriate emotions, and bizarre behavior that lasts for months or even years (E. Walker & Tessner, 2008). People with schizophrenia are out of touch with reality, which is to say that they are psychotic.

People with schizophrenia often suffer from hallucinations, false sensory perceptions that usually take the form of hearing voices that are not really there. (Visual, tactile, or olfactory hallucinations are more likely to indicate substance abuse or organic brain dam- age.) They also frequently have delusions—false beliefs about reality with no factual basis—that distort their relationships with their surroundings and with other people. Typ- ically, these delusions are paranoid: People with schizophrenia often believe that someone is out to harm them. Because their world is utterly different from reality, people with schizo- phrenia usually cannot live a normal life unless they are successfully treated with medica- tion. (See Chapter 13, “Therapies.”) Often, they are unable to communicate with others, since their words are incoherent when they speak.

Types of Schizophrenic Disorders Disorganized schizophrenia includes some of the more bizarre symptoms of schizophre- nia, such as giggling, grimacing, and frantic gesturing. People suffering from disorganized schizophrenia show a childish disregard for social conventions and may urinate or defecate at inappropriate times. They are active, but aimless, and they are often given to incoherent conversations.

In catatonic schizophrenia, motor activity is severely disturbed. People in this state may remain immobile, mute, and impassive. They may behave in a robotlike fashion when ordered to move, and they may even let doctors put their arms and legs into uncomfortable positions that they maintain for hours. At the opposite extreme, they may become exces- sively excited, talking and shouting continuously.

Paranoid schizophrenia is marked by extreme suspiciousness and complex delusions. People with paranoid schizophrenia may believe themselves to be Napoleon or the Virgin Mary, or they may insist that Russian spies with laser guns are constantly on their trail because they have learned some great secret. As they are less likely to be incoherent or to look or act “crazy,” these people can appear more “normal” than people with other schizo- phrenic disorders when their delusions are compatible with everyday life. They may, how- ever, become hostile or aggressive toward anyone who questions their thinking or delusions. Note that this disorder is far more severe than paranoid personality disorder, which does not involve bizarre delusions or loss of touch with reality.

Finally, undifferentiated schizophrenia is the classification developed for people who have several of the characteristic symptoms of schizophrenia—such as delusions, hallucina- tions, or incoherence—yet do not show the typical symptoms of any other subtype of the disorder.

Causes of Schizophrenia Because schizophrenia is a very serious disorder, considerable research has been directed at trying to discover its causes (Keshavan, Tandon, Boutros, & Nasral- lah, 2008; Williamson, 2006). Many studies indicate that schizophrenia has a genetic component (Gottesman, 1991; Hashimoto et al., 2003; P. Lichtenstein et al., 2009). People with schizophrenia are more likely than other people to have children with schizophrenia, even when those children have lived with adoptive parents since early in life. If one identical twin suffers from schizophrenia, the chances are almost 50% that the other twin will also develop this disorder. In

L E A R N I N G O B J E C T I V E S • Describe the common feature in all

cases of schizophrenia. Explain the difference between hallucinations and delusions. Briefly describe the key features of disorganized, catatonic, paranoid, and undifferentiated schizophrenia.

• Describe the causes of schizophrenic disorders.

psychotic Behavior characterized by a loss of touch with reality.

schizophrenic disorders Severe disorders in which there are disturbances of thoughts, communications, and emotions, including delusions and hallucinations.

delusions False beliefs about reality that have no basis in fact.

hallucinations Sensory experiences in the absence of external stimulation.

disorganized schizophrenia Schizophrenic disorder in which bizarre and childlike behaviors are common.

catatonic schizophrenia Schizophrenic disorder in which disturbed motor behavior is prominent.

paranoid schizophrenia Schizophrenic disorder marked by extreme suspiciousness and complex, bizarre delusions.

undifferentiated schizophrenia Schizophrenic disorder in which there are clear schizophrenic symptoms that do not meet the criteria for another subtype of the disorder.

Neuroimaging techniques, such as this PET scan, often reveal important differences between the brains of people with schizophre- nia and normal volunteers. Still, neuroimaging does not provide a decisive diagnostic test for schizophrenia.

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fraternal twins, if one twin has schizophrenia, the chances are only about 17% that the other twin will develop it as well.

Considerable research suggests that biological predisposition to schizophrenia may involve the faulty regulation of the neurotransmitters dopamine and glutamate in the central nervous system (R. Murray, Lappin, & Di Forti, 2008; Paz, Tardito, Atzori, & Tseng, 2008). Some research also indicates that pathology in various structures of the brain may contribute to the onset of schizophrenia (Killgore, Rosso, Gruber, & Yurgelun-Todd, 2009; Lawrie, McIntosh, Hall, Owens, & Johnstone, 2008). Other studies link schizophrenia to some form of early pre- natal infection or disturbance (Bresnahan, Schaefer,

Brown, & Susser, 2005; Winter et al., 2008). Despite these findings however, no laboratory tests to date can diagnose schizophrenia on the basis of brain or genetic abnormalities alone.

Studies of identical twins have also been used to identify the importance of environ- ment in causing schizophrenia. Because identical twins are genetically identical and because half of the identical twins of people with schizophrenia do not develop schizophrenia themselves, this severe and puzzling disorder cannot be caused by genetic factors alone. Environmental factors—ranging from disturbed family relations to taking drugs to biological damage that may occur at any age, even before birth—must also fig- ure in determining whether a person will develop schizophrenia. Finally, although quite different in emphasis, the various explanations for schizophrenic disorders are not mutu- ally exclusive. Genetic factors are universally acknowledged, but many theorists believe that only a combination of biological, psychological, and social factors produces schizo- phrenia (van Os, Rutten, & Poulton, 2008). According to systems theory, genetic factors predispose some people to schizophrenia; and family interaction and life stress activate the predisposition.

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Genius and Mental Disorders

Jean-Jacques Rousseau allegedly was paranoid. Mozart composed hisRequiem while under the delusion that he was being poisoned. Van Gogh cutoff his ear and sent it to a prostitute. Schopenhauer, Chopin, and John Stuart Mill were depressed. Robert Burns and Lord Byron apparently were alcoholics. Virginia Woolf suffered from bipolar disorder throughout her entire adult life.

• Do you think that creative people in general are more likely than others to suffer from psychological problems? What leads you to believe as you do?

• What evidence would you need to have in order to answer this question in a scientific way?

CHECK YOUR UNDERSTANDING

Indicate whether the following statements are true (T) or false (F):

1. ________ Schizophrenia is almost the same thing as multiple personality disorder. 2. ________ Psychotic symptoms, or loss of contact with reality, are indicators that a person

suffers from disorders other than schizophrenia. 3. ________ Studies indicate that a biological predisposition to schizophrenia may be inherited. 4. ________ Laboratory tests can be used to diagnose schizophrenia on the basis of brain

abnormalities.

Answers:1. (F).2. (F).3. (T).4. (F).

APPLY YOUR UNDERSTANDING

1. The book A Beautiful Mind is about John Nash, a mathematical genius. In young adulthood, he became convinced that people were spying on him and hunting him down. He searched for secret codes in numbers, sent bizarre postcards to friends, and made no sense when he spoke. On the basis of this description, it seems most likely that he was suffering from

a. disorganized schizophrenia. b. catatonic schizophrenia. c. undifferentiated schizophrenia. d. paranoid schizophrenia.

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Psychological Disorders 417

CHILDHOOD DISORDERS Why do stimulants appear to slow down hyperactive children and adults?

Children may suffer from conditions already discussed in this chapter—for example, depression and anxiety disorders. But other disorders are either characteristic of children or are first evident in childhood. The DSM-IV-TR contains a long list of disorders usually first diagnosed in infancy, childhood, or adolescence. Two of these disorders are attention- deficit hyperactivity disorder and autistic disorder.

Attention-deficit hyperactivity disorder (ADHD) was once known simply as hyperactivity. The new name reflects the fact that children with the disorder typically have trouble focusing their attention in the sustained way that other children do. Instead, they are easily distracted, often fidgety and impulsive, and almost constantly in motion. This disorder affects about 5% of all school-age children worldwide (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007), about 4% of adults in the United States (Kessler et al., 2006), and is much more common in males than females. Research suggests that ADHD is present at birth, but becomes a serious problem only after a child starts school (Monastra, 2008). The class setting demands that children sit quietly, pay attention as instructed, follow directions, and inhibit urges to yell and run around. The child with ADHD simply cannot conform to these demands.

We do not yet know what causes ADHD, but considerable evidence indicates biological factors play an important role (Monastra, 2008; Nigg, 2005). Neuroimaging studies, for example, reveal individuals with ADHD display altered brain functioning when presented with tasks that require shifting attention. The deficiency appears to involve the frontal lobe (see Chapter 2, “The Biological Basis of Behavior”), which normally recruits appropriate regions of the brain to solve a problem. In people with ADHD, however, the frontal lobe sometimes activates brain centers unrelated to solving a problem (Konrad, Neufang, Hanisch, Fink, & Herpertz-Dahlmann, 2006; Mulas et al., 2006; Murias, Swanson, & Srinivasan, 2007).

Family interaction and other social experiences may be more important in preventing the disorder than in causing it (C. Johnston & Ohan, 2005). That is, some exceptionally competent parents and patient, tolerant teachers may be able to teach “difficult” children to conform to the demands of schooling. Although some psychologists train the parents of children with ADHD in these management skills, the most frequent treatment for these children is a type of drug known as a psychostimulant. Psychostimulants do not work by “slowing down”hyperac- tive children; rather, they appear to increase the children’s ability to focus their attention so that they can attend to the task at hand, which decreases their hyperactivity and improves their aca- demic performance (Duesenberg, 2006; Gimpel et al., 2005). Unfortunately, psychostimulants often produce only short-term benefits; and their use and possible overuse in treating ADHD children is controversial (LeFever, Arcona, & Antonuccio, 2003; Marc Lerner & Wigal, 2008).

A very different and profoundly serious disorder that usually becomes evident in the first few years of life is autistic disorder. Autistic children fail to form normal attachments to parents, remaining distant and withdrawn into their own separate worlds. As infants, they may even show distress at being picked up or held. As they grow older, they typically

L E A R N I N G O B J E C T I V E • Describe the key features of attention-

deficit hyperactivity disorder and autistic spectrum disorder including the difference between autism and Asperger syndrome.

attention-deficit hyperactivity disorder (ADHD) A childhood disorder characterized by inattention, impulsiveness, and hyperactivity.

Answers:1. d.2. c.

psychostimulant Drugs that increase ability to focus attention in people with ADHD.

autistic disorder A childhood disorder characterized by lack of social instincts and strange motor behavior.

2. Your roommate asks you what the difference is between “hallucinations” and “delusions.” You tell her

a. hallucinations involve false beliefs, while delusions involve false sensory perceptions.

b. hallucinations occur primarily in schizophrenic disorders, while delusions occur primarily in dissociative disorders.

c. hallucinations involve false sensory perceptions, while delusions involve false beliefs.

d. there is no difference; those are just two words for the same thing.

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do not speak, or they develop a peculiar speech pattern called echolalia, in which they repeat the words said to them. Autistic children typically show strange motor behavior, such as repeating body movements endlessly or walking constantly on tiptoe. They don’t play as normal children do; they are not at all social and may use toys in odd ways, constantly spin- ning the wheels on a toy truck or tearing paper into strips. Autistic children often display the symptoms of retardation (LaMalfa, Lassi, Bertelli, Salvini, & Placidi, 2004), but it is hard to test their mental ability because they generally don’t talk (Dawson, Soulières, Gernsbacher, & Mottron, 2007). The disorder lasts into adulthood in the great majority of cases.

In recent years, autistic disorder has come to be viewed as just one dimension of a much broader range of developmental disorders known as autistic spectrum disorder (ASD) (Dawson & Toth, 2006; Ming, Brimacombe, Chaaban, Zimmerman-Bier, & Wagner, 2008). Individuals with disorders in the autistic spectrum display symptoms that are simi- lar to those seen in autistic disorder, but the severity of the symptoms is often quite reduced. For example, high functioning children with a form of ASD known as Asperger syndrome may show difficulty interacting with other people, but may have little or no prob- lem with speech or intellectual development.

We don’t know what causes autism, although most theorists believe that it results almost entirely from biological conditions (Goode, 2004; Zimmerman, Connors, & Pardo-Villamizar, 2006). Some causes of mental retardation, such as fragile X syndrome (see Chapter 7, “Cognition and Mental Abilities”), also seem to increase the risk of autistic disorder. Recent evidence suggests that genetics also play a strong role in causing the disorder (Campbell, Li, Sutcliffe, Persico, & Levitt, 2008; Rutter, 2005), though no spe- cific gene or chromosome responsible for autistic disorder has yet been identified (Losh, Sullivan, Trembath, & Piven, 2008).

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CHECK YOUR UNDERSTANDING

Indicate whether the following statements are true (T) or false (F):

1. ________ ADHD is much more common in boys than in girls. 2. ________ Psychostimulants work by “slowing down” hyperactive children. 3. ________ Most theorists believe that autistic disorder results almost entirely from biological

conditions.

Answers:1. (T).2. (F).3. (T).

APPLY YOUR UNDERSTANDING

1. Marie is a 7-year-old who is easily distracted and who has great difficulty concentrating. While reading or studying, her attention will often be drawn to events going on elsewhere. She is fidgety, impulsive, and never seems to stop moving. She finds it almost impossible to sit quietly, pay attention, and follow directions. Marie is most likely suffering from

a. attention-deficit hyperactivity disorder. b. autistic disorder. c. echolalia. d. disorganized personality disorder.

2. Harry is a child who is usually distant and withdrawn. He doesn’t seem to form attachments with anyone, even his parents. He plays by himself. He rarely talks; when he does, it is usually to repeat what someone else just said to him. It is most likely that Harry is suffering from

a. attention-deficit hyperactivity disorder. b. autistic disorder. c. bipolar disorder. d. disorganized personality disorder.

Answers:1. a.2. b.

autistic spectrum disorder (ASD) A range of disorders involving varying degrees of impairment in communication skills, social interactions, and restricted, repetitive, and stereotyped patterns of behavior.

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Psychological Disorders 419

GENDER AND CULTURAL DIFFERENCES IN PSYCHOLOGICAL DISORDERS What are the differences between men and women in psychological disorders?

Gender Differences For the most part, men and women are similar with respect to mental disorders, but dif- ferences do exist. Many studies have concluded that women have a higher rate of psycho- logical disorders than men do, but this is an oversimplification (Cosgrove & Riddle, 2004; Hartung & Widiger, 1998; Klose & Jacobi, 2004). We do know that more women than men are treated for mental disorders. But this cannot be taken to mean that more women than men have mental disorders, for in our society, it is much more acceptable for women to discuss their emotional difficulties and to seek professional help openly (H. Lerman, 1996).

Moreover, mental disorders for which there seems to be a strong biological compo- nent, such as bipolar disorder and schizophrenia, are distributed fairly equally between the sexes. Differences tend to be found for those disorders without a strong biological component—that is, disorders in which learning and experience play a more important role. For example, men are more likely than women to suffer from substance abuse and antisocial personality disorder. Women, on the other hand, are more likely to suffer from depression, agoraphobia, simple phobia, obsessive–compulsive disorder, and som- atization disorder (Craske, 2003; Rosenfield & Pottick, 2005). These tendencies, coupled with the fact that gender differences observed in the United States are not always seen in other cultures (Culbertson, 1997), suggest that socialization plays a part in developing a disorder: When men display abnormal behavior, it is more likely to take the forms of drinking too much and acting aggressively; when women display abnormal behavior, they are more likely to become fearful, passive, hopeless, and “sick” (Rosenfield & Pottick, 2005).

One commonly reported difference between the sexes concerns marital status. Men who are separated, divorced, or who have never married have a higher incidence of mental disorders than do either women of the same marital status or married men. But married women have higher rates than married men. What accounts for the apparent fact that mar- riage is psychologically less beneficial for women than for men?

Here, too, socialization appears to play a role. For women, marriage, family relation- ships, and child rearing are likely to be more stressful than they are for men (Erickson, 2005; Stolzenberg & Waite, 2005). For men, marriage and family provide a haven; for women, they are a demanding job. In addition, women are more likely than men to be the victims of incest, rape, and marital battering. As one researcher has commented, “for women, the U.S. family is a violent institution” (Koss, 1990, p. 376).

We saw in Chapter 11 that the effects of stress are proportional to the extent that a person feels alienated, powerless, and helpless. Alienation, powerlessness, and helplessness are more prevalent in women than in men. These factors are espe- cially common among minority women, so it is not surprising that the prevalence of psychological disorders is greater among them than among other women (Laganà & Sosa, 2004). In addition, these factors play an especially important role in anxiety disorders and depression—precisely those disorders experienced most often by women (M. Byrne, Carr, & Clark, 2004; Kessler et al., 1994). The rate of depression among women is twice that of men, a difference that is usually ascribed to the more negative and stressful aspects of women’s lives, including lower incomes and the experiences of bias and physical and sexual abuse (American Psy- chological Association, 2006; Blehar & Keita, 2003).

In summary, women do seem to have higher rates of anxiety disorders and depression than men do; and they are more likely than men to seek

L E A R N I N G O B J E C T I V E • Describe the differences between men

and women in psychological disorders including the prevalence of disorders and the kinds of disorders they are likely to experience. Explain why these differences exist. Explain why “it is increasingly important for mental health professionals to be aware of cultural differences” in psychological disorders.

More women than men in the United States seek help for mental disorders, but this may not mean mental disorders are more prevalent in women. Women are more likely than men to seek help for a variety of problems, physical and mental.

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Cultural Differences As the U.S. population becomes more diverse, it is increasingly important for mental health professionals to be aware of cultural differences if they are to understand and diagnose dis- orders among people of various cultural groups. Many disorders occur only in particular cultural groups. For example, ataque de nervios—literally translated as “attack of nerves”— is a culturally specific phenomenon that is seen predominately among Latinos. The symp- toms of ataque de nervios generally include the feeling of being out of control, which may be accompanied by fainting spells, trembling, uncontrollable screaming, and crying, and, in some cases, verbal or physical aggressiveness. Afterwards, many patients do not recall the attack, and quickly return to normal functioning. Another example, taijin kyofusho (roughly translated as “fear of people”), involves a morbid fear that one’s body or actions may be offensive to others. Taijin kyofusho is rarely seen outside of Japan. Other cross-cul- tural investigations have found differences in the course of schizophrenia and in the way childhood psychological disorders are manifest among different cultures (Kymalainen & Weisman de Mamani, 2008; López & Guarnaccia, 2008; Weisz, McCarty, Eastman, Chaiyasit, & Suwanlert, 1997).

Prevalence of childhood disorders also differs markedly by culture. Of course, it is adults—parents, teachers, counselors—who decide whether a child is suffering from a psy- chological disorder, and those decisions are likely to be influenced by cultural expectations. For example, in a series of cross-cultural studies, Thai children were more likely to be referred to mental health clinics for internalizing problems, such as anxiety and depression, compared to U.S. children, who were more likely to be referred for externalizing problems, such as aggressive behavior (Weisz et al., 1997).

Diversity–Universality Are We All Alike? The frequency and nature of some psychological disorders vary significantly among the world’s different cultures (Halbreich & Karkun, 2006; López & Guarnaccia, 2000). This suggests that many disorders have a strong cultural component, or that diagnosis is somehow related to culture. On the other hand, disorders that are known to have a strong genetic component generally display a more uniform distribution across different cultures. ■

CHECK YOUR UNDERSTANDING

1. Mental disorders for which there seems to be a strong ______________ component are distributed fairly equally between the sexes.

2. More women than men are treated for mental disorders. Is this statement true (T) or false (F)? 3. There is greater cultural variation in those abnormal behaviors with strong genetic causes.

Is this statement true (T) or false (F)?

Answers:1. biological.2. (T).3. (F).

professional help for their problems. However, greater stress, due in part to socialization and lower status rather than psychological weakness, apparently accounts for this statis- tic. Marriage and family life, associated with lower rates of mental disorders among men, introduce additional stress into the lives of women, particularly young women (25 to 45); and in some instances this added stress escalates into a psychological disorder.

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Perspectives on Psychological Disorders biological model, p. 393 psychoanalytic model, p. 394 cognitive–behavioral model, p. 394 diathesis–stress model, p. 394 diathesis, p. 395 systems approach, p. 395 insanity, p. 396

Mood Disorders mood disorders, p. 398 depression, p. 398 major depressive disorder, p. 398 dysthymia, p. 398 mania, p. 401 bipolar disorder, p. 401 cognitive distortions, p. 402

Anxiety Disorders anxiety disorders, p. 403 specific phobia, p. 403 social phobias, p. 403 agoraphobia, p. 404 panic disorder, p. 404 generalized anxiety disorder,

p. 404 obsessive–compulsive disorder

(OCD), p. 405

Psychosomatic and Somatoform Disorders psychosomatic disorder, p. 406 somatoform disorders, p. 406 somatization disorder, p. 406 conversion disorders, p. 407 hypochondriasis, p. 407 body dysmorphic disorder, p. 407

Dissociative Disorders dissociative disorders, p. 408 dissociative amnesia, p. 408 dissociative fugue, p. 408 dissociative identity disorder,

p. 408 depersonalization disorder, p. 408

Sexual and Gender-Identity Disorders sexual dysfunction, p. 409 erectile disorder (or erectile

dysfunction) (ED), p. 409 female sexual arousal disorder,

p. 409 sexual desire disorders, p. 410 orgasmic disorders, p. 410 premature ejaculation, p. 411 vaginismus, p. 411 paraphilias, p. 411

fetishism, p. 411 voyeurism, p. 411 exhibitionism, p. 411 frotteurism, p. 411 transvestic fetishism, p. 411 sexual sadism, p. 411 sexual masochism, p. 411 pedophilia, p. 411 gender-identity disorders, p. 411 gender-identity disorder in

children, p. 411

Personality Disorders personality disorders, p. 412 schizoid personality disorder,

p. 412 paranoid personality disorder,

p. 413 dependent personality disorder,

p. 413 avoidant personality disorder,

p. 413 narcissistic personality

disorder, p. 413 borderline personality disorder,

p. 413 antisocial personality disorder,

p. 413

Schizophrenic Disorders schizophrenic disorders,

p. 415 psychotic, p. 415 hallucinations, p. 415 delusions, p. 415 disorganized schizophrenia,

p. 415 catatonic schizophrenia,

p. 415 paranoid schizophrenia,

p. 415 undifferentiated schizophrenia,

p. 415

Childhood Disorders attention-deficit hyperactivity

disorder (ADHD), p. 417 psychostimulant, p. 417 autistic disorder, p. 417 autistic spectrum disorder

(ASD), p. 418

PERSPECTIVES ON PSYCHOLOGICAL DISORDERS How does a mental health professional define a psychologi- cal disorder? Mental health professionals define a psychological disorder as a condition that either seriously impairs a person’s abil- ity to function in life or creates a high level of inner distress, or both. This view does not mean that the category “disordered” is always easy to distinguish from the category “normal.” In fact, it may be more accurate to view abnormal behavior as merely quanti- tatively different from normal behavior.

How has the view of psychological disorders changed over time? In early societies, abnormal behavior was often attributed to supernatural powers. As late as the 18th century, the mentally ill were thought to be witches or possessed by the devil. In modern times, three approaches have helped to advance our understanding of abnormal behavior: the biological, the psychoanalytic, and the cognitive behavioral.

How can biology influence the development of psychologi- cal disorders? The biological model holds that abnormal behav- ior is caused by physiological malfunction, especially of the brain.

Researchers assume the origin of these malfunctions is often hereditary. Although neuroscientists have demonstrated that genetic/biochemical factors are involved in some psychological disorders, biology alone cannot account for most mental illnesses.

What did Freud and his followers believe was the underlying cause of psychological disorders? The psychoanalytic model orig- inating with Freud holds that abnormal behavior is a symbolic expres- sion of unconscious conflicts that generally can be traced to childhood.

According to the cognitive–behavioral model, what causes abnormal behavior? The cognitive–behavior model states that psy- chological disorders arise when people learn maladaptive ways of thinking and acting. What has been learned can be unlearned, however. Cognitive–behavioral therapists strive to modify their patients’ dys- functional behaviors and distorted, self-defeating thought processes.

Why do some people with a family background of a psycholog- ical disorder develop the disorder, whereas other family mem- bers do not? According to the diathesis–stress model, which integrates the biological and environmental perspectives, psycholog- ical disorders develop when a biological predisposition is triggered by stressful circumstances. Another attempt at integrating causes is the systems (biopsychosocial) approach, which contends psychological

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disorders are “lifestyle diseases” arising from a combination of bio- logical risk factors, psychological stresses, and societal pressures.

How common are mental disorders? According to research, 15% of the population is suffering from one or more mental disor- ders at any given point in time.

Is there a difference between “insanity” and “mental ill- ness”? Insanity is a legal term, not a psychological one. It is typi- cally applied to defendants who were so mentally disturbed when they committed their offense that they either did not know right from wrong or were unable to control their behavior.

Why is it useful to have a manual of psychological disorders? The current fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) provides careful descriptions of the symptoms of different disorders so that diagnoses based on them will be reliable and consistent among mental health professionals. The DSM-IV-TR includes little information on causes and treatments.

MOOD DISORDERS How do mood disorders differ from ordinary mood changes? Most people have a wide emotional range, but in some people with mood disorders, this range is greatly restricted. They seem stuck at one or the other end of the emotional spectrum, or they may alter- nate back and forth between periods of mania and depression.

How does clinical depression differ from ordinary sadness? The most common mood disorder is depression, in which a person feels overwhelmed with sadness, loses interest in activities, and dis- plays such other symptoms as excessive guilt, feelings of worthless- ness, insomnia, and loss of appetite. Major depressive disorder is an episode of intense sadness that may last for several months; in contrast, dysthymia involves less intense sadness but persists with little relief for a period of 2 years or more.

What factors are related to a person’s likelihood of commit- ting suicide? More women than men attempt suicide, but more men succeed. Suicide attempt rates among American adolescents and young adults have been rising. A common feeling associated with suicide is hopelessness, which is also typical of depression.

What is mania, and how is it involved in bipolar disorder? People suffering from mania become euphoric (“high”), extremely active, excessively talkative, and easily distracted. They typically have unlimited hopes and schemes, but little interest in realistically carrying them out. At the extreme, they may collapse from exhaustion. Manic episodes usually alternate with depression. Such a mood disorder, in which both mania and depression are alternately present and are sometimes inter- rupted by periods of normal mood, is known as bipolar disorder.

What causes some people to experience extreme mood changes? Mood disorders can result from a combination of bio- logical, psychological, and social factors. Genetics and chemical imbalances in the brain seem to play an important role in the development of depression and, especially, bipolar disorder. Cognitive distortions (unrealistically negative views about the self) occur in many depressed people, although it is uncertain whether these cause the depression or are caused by it. Finally, social factors, such as troubled relationships, have also been linked with mood disorders.

ANXIETY DISORDERS How does an anxiety disorder differ from ordinary anxiety? Normal fear is caused by something identifiable and the fear sub- sides with time. With anxiety disorder, however, either the person doesn’t know the source of the fear or the anxiety is inappropriate to the circumstances.

Into what three categories are phobias usually grouped? A specific phobia is an intense, paralyzing fear of something that it is unreasonable to fear so excessively. A social phobia is exces- sive, inappropriate fear connected with social situations or perfor- mances in front of other people. Agoraphobia, a less common and much more debilitating type of anxiety disorder, involves multiple, intense fears such as the fear of being alone, of being in public places, or of other situations involving separation from a source of security.

How does a panic attack differ from fear? Panic disorder is char- acterized by recurring sudden, unpredictable, and overwhelming experiences of intense fear or terror without any reasonable cause.

How do generalized anxiety disorder and obsessive–compul- sive disorder differ from specific phobias? Generalized anxiety disorder is defined by prolonged vague, but intense fears that, unlike phobias, are not attached to any particular object or circumstance. In contrast, obsessive–compulsive disorder involves either involun- tary thoughts that recur despite the person’s attempt to stop them or compulsive rituals that a person feels compelled to perform. Two other types of anxiety disorder are caused by highly stressful events. If the anxious reaction occurs soon after the event, the diagnosis is acute stress disorder; if it occurs long after the event is over, the diag- nosis is posttraumatic stress disorder.

What causes anxiety disorders? Psychologists with a biological perspective propose that a predisposition to anxiety disorders may be inherited because these types of disorders tend to run in fami- lies. Cognitive psychologists suggest that people who believe that they have no control over stressful events in their lives are more likely to suffer from anxiety disorders than other people are. Evolu- tionary psychologists hold that we are predisposed by evolution to associate certain stimuli with intense fears, serving as the origin of many phobias. Psychoanalytic thinkers focus on inner psychologi- cal conflicts and the defense mechanisms they trigger as the sources of anxiety disorders.

PSYCHOSOMATIC AND SOMATOFORM DISORDERS What is the difference between psychosomatic disorders and somatoform disorders? Psychosomatic disorders are ill- nesses that have a valid physical basis, but are largely caused by psy- chological factors such as excessive stress and anxiety. In contrast, somatoform disorders are characterized by physical symptoms without any identifiable physical cause. Examples are somatization disorder, characterized by recurrent vague somatic complaints without a physical cause, conversion disorder (a dramatic specific disability without organic cause), hypochondriasis (insistence that minor symptoms mean serious illness), and body dysmorphic dis- order (imagined ugliness in some part of the body).

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DISSOCIATIVE DISORDERS What do dissociative disorders have in common? In dissociative disorders, some part of a person’s personality or mem- ory is separated from the rest. Dissociative amnesia involves the loss of at least some significant aspects of memory. When an amne- sia victim leaves home and assumes an entirely new identity, the disorder is known as dissociative fugue. In dissociative identity disorder (multiple personality disorder), several distinct personali- ties emerge at different times. In depersonalization disorder, the person suddenly feels changed or different in a strange way.

SEXUAL AND GENDER-IDENTITY DISORDERS What are the three main types of sexual disorders? The DSM- IV-TR recognizes three main types of sexual disorders: sexual dys- function, paraphilias, and gender-identity disorders.

Sexual dysfunction is the loss or impairment of the ability to function effectively during sex. In men, this may take the form of erectile disorder (ED), the inability to achieve or keep an erection; in women, it often takes the form of female sexual arousal disor- der, the inability to become sexually excited or to reach orgasm. Sexual desire disorders involve a lack of interest in or an active aversion to sex. People with orgasmic disorders experience both desire and arousal but are unable to reach orgasm. Other problems that can occur include premature ejaculation—the male’s inability to inhibit orgasm as long as desired—and vaginismus—involun- tary muscle spasms in the outer part of a woman’s vagina during sexual excitement that make intercourse impossible.

Paraphilias involve the use of unconventional sex objects or situ- ations. These disorders include fetishism, voyeurism, exhibitionism, frotteurism, transvestic fetishism, sexual sadism, and sexual masochism. One of the most serious paraphilias is pedophilia, the engaging in sexual relations with children.

Gender-identity disorders involve the desire to become, or the insistence that one really is, a member of the other sex. Gender- identity disorder in children is characterized by rejection of one’s biological gender as well as the clothing and behavior society con- siders appropriate to that gender during childhood.

PERSONALITY DISORDERS Which personality disorder creates the most significant prob- lems for society? Personality disorders are enduring, inflexible, and maladaptive ways of thinking and behaving that are so exaggerated and rigid that they cause serious inner distress or conflicts with others. One group of personality disorders is characterized by odd or eccen- tric behavior. People who exhibit schizoid personality disorder lack the ability or desire to form social relationships and have no warm feelings for other people; those with paranoid personality disorder are inappropriately suspicious, hypersensitive, and argumentative. Another cluster of personality disorders is characterized by anxious or fearful behavior. Examples are dependent personality disorder (the inability to think or act independently) and avoidant personality dis- order (social anxiety leading to isolation). A third group of personal- ity disorders is characterized by dramatic, emotional, or erratic behavior. For instance, people with narcissistic personality disorder

have a highly overblown sense of self-importance, whereas those with borderline personality disorder show much instability in self-image, mood, and interpersonal relationships. Finally, people with antisocial personality disorder chronically lie, steal, and cheat with little or no remorse. Because this disorder is responsible for a good deal of crime and violence, it creates the greatest problems for society.

SCHIZOPHRENIC DISORDERS How is schizophrenia different from multiple-personality disor- der? In multiple-personality disorder, consciousness is split into two or more distinctive personalities, each of which is coherent and intact. This condition is different from schizophrenic disorders, which involve dramatic disruptions in thought and communication, inap- propriate emotions, and bizarre behavior that lasts for years. People with schizophrenia are out of touch with reality and usually cannot live a normal life unless successfully treated with medication. They often suffer from hallucinations (false sensory perceptions) and delusions (false beliefs about reality). Subtypes of schizophrenic disorders include disorganized schizophrenia (childish disregard for social con- ventions), catatonic schizophrenia (mute immobility or excessive excitement), paranoid schizophrenia (extreme suspiciousness related to complex delusions), and undifferentiated schizophrenia (charac- terized by a diversity of symptoms).

CHILDHOOD DISORDERS Why do stimulants appear to slow down hyperactive children and adults? DSM-IV-TR contains a long list of disorders usually first diagnosed in infancy, childhood, or adolescence. Children with attention-deficit hyperactivity disorder (ADHD) are highly dis- tractible, often fidgety and impulsive, and almost constantly in motion. The psychostimulants frequently prescribed for ADHD appear to slow such children down because they increase the ability to focus attention on routine tasks. Autistic disorder is a profound developmental prob- lem identified in the first few years of life. It is characterized by a failure to form normal social attachments, by severe speech impairment, and by strange motor behaviors. A much broader range of developmental dis- orders known as autistic spectrum disorder (ASD) is used to describe individuals with symptoms that are similar to those seen in autistic dis- order, but may be less severe as is the case in Asperger syndrome.

GENDER AND CULTURAL DIFFERENCES IN PSYCHOLOGICAL DISORDERS What complex factors contribute to different rates of abnor- mal behavior in men and women? Although nearly all psycholog- ical disorders affect both men and women, there are some gender differences in the degree to which some disorders are found. Men are more likely to suffer from substance abuse and antisocial personality disorder; women show higher rates of depression, agoraphobia, sim- ple phobia, obsessive–compulsive disorder, and somatization disor- der. In general, gender differences are less likely to be seen in disorders that have a strong biological component. This tendency is also seen cross-culturally, where cultural differences are observed in disorders not heavily influenced by genetic and biological factors. These gender and cultural differences support the systems view that biological, psy- chological, and social forces interact as causes of abnormal behavior.

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

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

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