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1 Introduction to Abnormal Psychology

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Learning Objectives

After reading this chapter, you should be able to:

• Define abnormal behavior.

• Discuss the history of mental illness.

• Identify the major theorists and theoretical orientations in psychology.

• Discuss the DSM–5.

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Section 1.1 How Do We Define Abnormal Behavior?

1.1 How Do We Define Abnormal Behavior? If you were to poll a random sample of average people, most would say that they know abnor- mal behavior when they see it. They might assess at-a-glance someone’s behavior as strange, odd, or sick, and they would quickly give reasons for their assessment. Let’s look at an exam- ple of potentially odd behavior that will illustrate this point.

You are walking in your neighborhood on a gorgeous summer afternoon, listening to your favorite songs on your smartphone. Suddenly, without warning, a man runs out from behind the bushes across the street. This wouldn’t usually catch your eye, but you notice that this man has no clothes on. He is running frantically while trying to cover himself with his hands, all the while looking behind him. Before you know it, the man disappears around the corner. Was the man’s behavior abnormal? Do you think he is likely to present a danger to himself or, more important, to other people? Answering questions like these helps practicing psycholo- gists to achieve one of their goals: to ascertain whether an individual’s behavior is abnormal, and to ascertain whether their behavior presents a danger to the individual or to others.

Three Perspectives of Abnormality Psychopathology refers to the study of the causes and development of psychiatric disorders. Many practitioners in the mental health professions (psychologists, social workers, counsel- ors, and psychiatrists, to name a few) agree that it is extremely difficult to arrive at a universal definition of abnormal behavior (Gelo, Vilei, Maddux, & Gennaro, 2015). They agree in gen- eral about what the term means, but they often use different perspectives to define it. Three perspectives commonly used by psychologists are the statistical frequency perspective (behavior is abnormal according to the statistics), the social norms perspective (behavior is abnormal according to the standards set by society), and the maladaptive perspective (behavior is abnormal because it interferes with the individual’s ability to function on a daily basis). Each perspective has its own usefulness and limitations, as discussed in the following sections.

The Statistical Frequency Perspective The statistical frequency perspective labels behavior as abnormal if the behavior exists in (or is exhibited by) only a minority of the population. This definition thus calls behaviors that are numerically rare abnormal. The majority of the “normal” population would fall into the middle range of a bell-shaped curve (when split in half the left side of the curve is a mirror image of the right side). As one moves away from the middle range in either direction, the per- son could be classified as being statistically more extreme and therefore as behaving abnor- mally (Helzer & Hudziak, 2002). An immediate problem with this definition: A person who falls on an extreme end of the frequency distribution would be considered abnormal based on the statistical frequency definition (falling into about 2.2% of the population), but he or she indeed might not be abnormal. Consider a gifted scientist or musician. Mozart, a prodigy, would be considered abnormal based on this definition, as would Einstein.

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Section 1.1 How Do We Define Abnormal Behavior?

A few presumptions here need to be examined. First, this perspective presumes that the gen- eral population’s behavior is considered to be normal. However, what is considered normal today wasn’t necessarily considered normal a hundred years ago, and what’s normal in New York City might not be considered all that normal in New Delhi. For example, consider the following routine: Someone wakes up, eats breakfast, goes to work, has lunch, goes home, eats dinner, spends some time with family, watches television, and then goes to bed. This is a routine that many working adults in the United States follow on a daily basis. Therefore, the general population would consider this to be normal behavior.

So what would you then make of the following: Instead of going to work every day and fol- lowing the previously outlined routine, an individual goes to the beach at 8 a.m. and lies on a blanket until the sun sets, each and every day? Or what about this possibility: A man goes to the beach with a blanket and a guitar, sits on the boardwalk, strums away while singing folk songs, and has a sign asking for handouts as he has lost his job due to a bad economy. Is this considered normal behavior based on current standards in the United States? Or is this behavior crossing over to abnormal behavior?

What about the man described earlier who ran naked from behind bushes? Do people usually run through the streets naked anywhere in the United States? And if the statistical perspec- tive tells us that this is extremely uncommon behavior, does that automatically mean that the individual’s behavior must be abnormal?

The Social Norms Perspective The social norms perspective states that behavior is abnormal if it deviates greatly from accepted social standards, values, or norms. Norms are spoken and unspoken rules for proper conduct. These are established by a society over time and are subject to changes over time. Two types of norms used to assess whether behavior is abnormal are legal norms and psy- chological norms. Legal norms tend to dictate how individuals should behave in the realm of their civic surroundings and with regard to their friends and neighbors. In other words, a legal norm is a mandatory rule of social behavior that is established by the state. If someone is labeled a criminal, his or her behavior violates legal norms as determined by that society. For example, the naked running man described earlier may be demonstrating abnormal behavior based on legal norms, since he could be arrested for indecent exposure.

Behaviors, thoughts, and emotions are also considered to be abnormal if they violate the norms set out by psychologists. Psychological disorders are categorized in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM–5), published by the American Psy- chiatric Association (described in more detail later in this chapter). The psychological norms perspective would involve using diagnostic criteria in the DSM–5 to determine if the pattern of such behaviors is likely to point to a mental disorder. For example, Michael Jackson was surely one of the most famous individuals in the world. However, he demonstrated unusual, perhaps odd, and maybe even abnormal behaviors at times. He often wore surgical masks when he was out in public. Perhaps more unusual was how he dressed his children when they went out. He would often cover his children’s faces or heads with blankets, Halloween-style masks,

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Section 1.1 How Do We Define Abnormal Behavior?

burqas, or disguises. Are these behaviors abnormal? It would likely seem so to many observ- ers. However, what if Jackson had a phobia about germs and was afraid of being exposed to cold viruses or other pathogens? What if he had a compromised immune system and there- fore needed to keep his face covered? Perhaps he covered his children’s faces to protect them from kidnappers, since he was an instantly recognizable and very wealthy pop star. Do these latter explanations now make Jackson’s behaviors more rational and therefore not abnormal?

The Maladaptive Perspective The statistical frequency perspective views behavior as abnormal if it occurs with statistical infrequency relative to the general population. A person can function, and might be consid- ered very talented, if his or her behavior is statistically infrequent, like Mozart or Michelan- gelo. The maladaptive perspective, while seemingly similar to the statistical frequency per- spective, views behavior as abnormal if it interferes with the individual’s ability to function in life or in society. By this we mean the ability to work, take care of oneself, and have normal social interactions. Do you think the naked running man is able to function in everyday life? Can you even make these kinds of judgments without knowing much about him? If nothing else, you can say that this naked individual appears to be somewhat unusual. However, is his behavior abnormal or indicative of mental illness? Let’s look at another example.

There is a woman in your neighborhood whom you see often. She works a regular 9-to-5 job, but you notice that it takes her a while to leave for work. You have noticed that she engages in some rather “unusual” yet regular routines before she finally heads off. You notice that it takes her a long time to leave the house. She goes back inside at least five or six times, disappears for a few minutes, and then returns outside. She locks her door, then returns at least four times to make sure it’s locked. When she finally gets in her car and drives off, she returns a few minutes later to ensure the garage door is closed. You also notice that when she finally leaves for good, the time is 10 a.m. Based on the maladaptive perspective, this woman’s behaviors interfere with her everyday life. She is able to function, but her daily rituals make her late for work every day. She has extreme difficulty leaving the house until she is absolutely certain that all the doors are locked and that her gas oven and range are turned off (we will discuss behaviors like this in more detail in Chapter 3,which covers obsessive-compulsive and related disorders).

Other Considerations Let’s consider several other factors used to classify abnormal behavior. First, is a person’s behavior endangering the individual or other people? Often this is not the case. The idea that individuals who have a mental illness are dangerous or violent people, like Adam Lanza, Omar Mateen, or Charles Manson, is simply not true (see the accompanying Highlight). Most indi- viduals with a mental illness are not dangerous, and of those who are, most are more likely to pose a threat to themselves than to others.

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Section 1.1 How Do We Define Abnormal Behavior?

Highlight: How Would We Categorize Mass Shooters?

By definition, a school shooting is a form of mass shooting involving a gun attack on an educational institution, such as a school or university. The U.S. Secret Service defines them as shootings in which schools are “deliberately selected as the location for the attack” (Vossekuil, Fein, Reddy, Borum, & Modzeleski, 2004, p. 4). Let’s use the Newtown, Connecticut shooting as an example. On December 14, 2012, Adam Lanza, age 20, entered the Sandy Hook Elementary School in Newtown, and fatally shot 20 children who were 6 or 7 years old, as well as six adult staff members. Prior to driving to the school, Lanza shot and killed his mother at their Newtown home. As first responders arrived at the scene, Lanza killed himself by shooting himself in the head. This was the deadliest mass shooting at a high school or grade school in U.S. history and at the time was the third-deadliest mass shooting by a single person in U.S. history. What could cause a 20-year-old to murder his mother, then drive to an elementary school and murder 20 young children? A report issued by the Connecticut State’s Attorney’s Office (Sedensky, 2013) concluded that Lanza acted alone and planned his actions, but none of the evidence collected provided any indication as to why he did so, or why he targeted the school. This leads to many questions, many of which remain unanswered. Colleagues and I are often asked how we would categorize someone like Lanza.

How about Omar Mateen? On June 12, 2016, Mateen, a 29-year-old security guard, killed 49 people and wounded 53 others in a terrorist attack/hate crime inside Pulse, a gay nightclub in Orlando, Florida. Pulse was hosting Latin Night and most of the victims were Latino. At the time, it was both the deadliest mass shooting by a single shooter and the deadliest act of violence against LGBT people in U.S. history. While not a school shooting, this incident was somewhat easier to classify. Regardless, what would cause someone to enter a nightclub where people go to dance and to have fun, and systematically murder 49 patrons? Is this someone who has a mental illness? How about Lanza, who was previously diagnosed with Asperger’s syndrome as well as obsessive-compulsive disorder? Just because we have agreed-upon models to help us define abnormal behavior does not mean we can always explain its causes or the reasons some people do certain things. We also need to exercise caution. When a clear explanation for an individual’s behavior is lacking, does this mean we should not provide treatment to the individual?

Balkis Press/Sipa USA/AP Photos On June 12, 2016, Omar Mateen killed 49 people and wounded 53 in an attack on Pulse, a gay nightclub in Orlando, Florida.

(continued)

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Section 1.1 How Do We Define Abnormal Behavior?

Another consideration is whether the individual’s behavior is causing him or her distress. Not all abnormal behavior causes stress to the individual. In many cases, the individual’s family or loved ones are more distressed than the individual is. This makes it especially important for the family to be involved in as many aspects of treatment as possible. For example, suppose you have a friend who finds it impossible to dispose of old newspapers. The papers are piling up around his house, eventually making it difficult to enter certain rooms and creating a fire hazard. You ask him about this, and he says he “needs to keep them” in case he must refer to an article for his job as a Wikipedia editor. He appears not to be bothered by his actions, yet he becomes uncomfortable when you start to gather up some of the papers for removal. Thus, his behavior is not causing him stress, but trying to change his behavior does create stress.

Finally, we must consider factors such as the duration, the age of onset, and the intensity of the behavior(s). By duration, we mean the length of time the troublesome behaviors have existed. By age of onset, we mean the age at which the troublesome behaviors first become noticeable. This is especially important, since some mental illnesses cannot be diagnosed until an individual has reached a certain age, or cannot be diagnosed once an individual has passed a certain age. By intensity, we mean how extreme the behaviors in question are.

So, where does our naked running man fit? Let’s see if more information about him helps to clear up the picture. This man is a sophomore at a major university in the United States. He is a psychology major and has made the dean’s list, a status granted only to the best students.

Highlight: How Would We Categorize Mass Shooters? (continued)

According to Swanson, McGinty, Fazel, and Mays (2015), the media reports of mass shootings by “disturbed” individuals stimulate the public’s interest. These often sensationalistic reports reinforce the popular belief that mental illness frequently results in violence, usually gun violence. Swanson and colleagues (2015) concluded that epidemiological studies (which examine the incidence of disease) show that the large majority of people with serious mental illnesses are never violent. An APA Panel of Experts report stated that people with serious mental illness commit only a small proportion of firearm-related homicides (Webster & Vernick, 2013). The issue of gun violence cannot be resolved solely by focusing on serious mental illness (typically meaning disorders such as schizophrenia and bipolar I disorder) (Webster & Vernick, 2013). In other words, there is no significant correlation between gun violence and serious mental illness (Cornell & Guerra, 2013). However, mental illness is strongly associated with increased risk of suicide, which accounts for over half of U.S. firearm-related fatalities (Swanson et al., 2015).

As you read this textbook, think about the issues raised here and about how you would react if you discovered that some mental conditions, or actions, do not have easy, if any, explanations.

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Section 1.1 How Do We Define Abnormal Behavior?

When you looked more closely at the man, you saw that he was wearing only sneakers, which enabled him to run faster. The sneakers had the university’s logo on the sides. Is this enough information for you to reach a conclusion about his behavior?

Psychologists often have to make judgments based on what they see on the surface or in an individual’s overt behaviors. These are behaviors that are open and detectable by whoever observes them (Reber & Reber, 2001, p. 500). In other words, these are behaviors that we can see on the surface and therefore measure. Let’s look at some other facts about the naked run- ning man: He was running because he had been skinny-dipping in a backyard pool and was discovered by the homeowners. He also had a camcorder set up to record his escapades. Does this help?

Now do you think this man’s behavior is abnormal based on the aforementioned perspec- tives? Is skinny-dipping in someone else’s pool statistically frequent? Does it conform to social norms? Do you think it interferes with the man’s ability to function at his university? Does the man’s skinny-dipping in a stranger’s pool present a danger to himself or to others? Perhaps a bit more information would help. The man was skinny-dipping and recording his feat because he was pledging a fraternity at his university. This was part of a “hazing” ritual. The man had to prove he performed his escapade and therefore filmed it. As you learn more about the man, you discover that he is extremely reserved, painfully shy, and generally withdrawn in many social situations.

Perhaps he is just what David Weeks and Jamie James (1995) call eccentric. Those labeled as eccen- tric have odd or unusual habits but do not have a mental illness. Weeks and James published a work called Eccentrics: A Study of Sanity and Strangeness, in which they examined eccentrics throughout his- tory. They concluded that the eccentrics’ thought patterns are not disrupted and their behavior doesn’t typically cause them distress; in fact, most eccentrics may take pleasure in being an “original.” Perhaps you yourself have some odd or unusual habits, or perhaps you know someone who does. Albert Einstein could be classified as eccentric. He picked up cigarette butts off the street and smoked them in order to circumvent his doctor’s ban on buying tobacco for his pipe. He also would use his sailboat on windless days because he enjoyed a challenge. Oscar Wilde, the famous novelist, was another famous eccentric. While studying at Oxford University, Wilde would walk through the streets with a lobster on a leash, in addition to engaging in other odd behaviors.

Science and Society/SuperStock Eccentrics exhibit odd or unusual hab- its, yet do not have a mental illness. Albert Einstein may be considered an eccentric or an “original” for displaying peculiar habits.

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

1.2 A History of Theoretical Orientations for Abnormal Behavior

Imagine this: It is a few thousand years ago, and your friend is planning to attend a regularly occurring event that he is eagerly anticipating. Your friend talks about looking forward to the occasion, as it is a form of socialization for him. The government sanctions the event and sup- ports it as a way of pleasing its citizens and giving back to them. Your friend then mentions that he would like you to come along to see how exciting the event is. You arrive and see that the arena contains at least 80,000 screaming people. You naturally wonder why everyone is yelling and why they seem so excited. All of the people are standing. You even see a “royal box” where dignitaries are sitting. At the end of the event, your friend asks you, “Well, what did you think?” You reply that you have never seen anything like it and love what you saw. You then ask when you can attend the next performance.

Does any of this seem unusual or abnormal? What if you now knew that you were in ancient Rome attending gladiator fights and seeing prisoners being torn to pieces by lions? These events were considered to be a normal form of entertainment in ancient Rome, but if we tried to stage such an event in the United States in 2017, you can imagine the consequences and outrage. Thus, what constitutes abnormal behavior depends in part on society’s definitions of what is normal, which can change over time. Humans have demonstrated abnormal behav- ior for at least, by this author’s account, a few thousand years. The gladiator fights were not considered unusual in their time, but they are now considered to be unusual and, by many people, repulsive.

Ancient Times The earliest explanations for mental illness seem to have been that the afflicted were pos- sessed by evil spirits or demons (an idea that some people still believe today). Skulls dating back to 6500 BCE have been discovered with holes bored into them (see Figure 1.1), which are an indication of trepanning (also known as trephining). The belief seems to have been that the holes would allow the evil spirits to leave the “possessed” person. In later medieval societies, exorcisms were performed, usually by a specially trained priest. This was a non- invasive way to drive the demons or evil spirits from the possessed person or a place, often a house. These became more common in the 1600s. Exorcisms, although rare, are still per- formed today.

The first physiology-based explanations for mental illness were provided in ancient Greece by Hippocrates (460–377 BCE), the father of modern medicine. Hippocrates viewed abnor- mal behavior—and physical illnesses in general—as having internal causes. Specifically, he believed that the body contained four fluids, or humors (yellow bile, black bile, blood, and phlegm), that must be kept in adequate balance to maintain health (it must be noted that the theory was wrong about the cause of diseases). His prescriptions for the ill included rest, proper diet, sobriety, and exercise, strategies that are still recommended today. Hippocrates also believed that if you took care of your body, your mind would stay well.

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

The Middle Ages and the Renaissance The Middle Ages occurred from approximately the fifth to the fifteenth centuries. Many peo- ple adopted the perspective that demons were causing mental illnesses in certain people. The views held by the ancient Greeks and Romans, who saw physiological causes of mental illnesses, lost favor. Plagues were common in the Middle Ages, and exorcisms reemerged as a form of “treatment” for mental illnesses. An important concept emerged during these times: the idea that evil supernatural forces were to blame for the individual’s mental illness. Oddly enough, this in effect removed some of the responsibility of “getting sick” or of “being sick” from the mentally ill.

During the Renaissance (around 1400–1700), the treatment of the mentally ill improved sig- nificantly. The mentally ill were viewed as having “sick” minds; therefore, their minds needed to be treated along with their bodies. A more significant event occurred during the early part of the Renaissance: the creation of asylums. Even though the name asylum connotes bad feel- ings and scenes of patient abuse today, this was not how they were run at their founding. Their sole purpose was to treat the mentally ill in a humane fashion. They soon became over- crowded, however, and the treatment turned to punishment and torture. One of the most famous asylums was London’s Bethlehem Hospital, founded in 1247 as a hospital for the poor.

Figure 1.1: Trepanning

Note the holes bored into the skull.

Skull

Trephine

Hole made by trepanning

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

In the early 1400s, it began to be used to house the mentally ill. During the 16th century, Bethlehem Hospital was used solely to house the criminally insane. Did you know that the term bedlam comes from Bethlehem Hospital? Bethlehem Hospital was called “Bethlem” for short, and Londoners pronounced it “bedlam.” The term bedlam even- tually became associated with the chaotic condi- tions within the hospital’s own walls, with mental illness, and with a place or situation where mass confusion reigns (New Advent, n.d.).

Two Important Mental Health Reformers: 1700s–1800s Philippe Pinel (1745–1826) was one of the early reformers in the proper treatment of individu- als with mental illnesses. Pinel, a Frenchman, advocated that they be treated with sympathy, compassion, and empathy and not with beatings and torture. Dorothea Dix (1802–1887) helped to establish many state mental hospitals in the United States during her nationwide campaign

to reform treatments of the mentally ill. She was directly responsible for laws that aimed to reform treatment of this population.

Psychoanalytic Theory: 1890s–1930s Although trephination dates back thousands of years, the history of abnormal psychology can realistically be traced to 1895, when Sigmund Freud (1856–1939), in collaboration with Josef Breuer (1842–1925), published his first book, Studies in Hysteria. (The first book Freud wrote alone was The Interpretation of Dreams, published in 1900.) Freud, a neurologist, was initially a researcher who studied the reproductive systems of eels. In 1885, just before he married, he obtained a grant to go to Paris to see the famous neurologist Jean Martin Char- cot (1825–1893). Charcot specialized in the study of hysteria and susceptibility to hypnosis. From his time with Charcot, Freud realized the power that the mind could have over the body, and he returned from Paris determined to make a name for himself in the field of hypnosis. After experimenting with hypnosis on his patients, Freud abandoned this form of treatment as it proved ineffective for many of them. He favored treatment in which the patient talked through his or her problems, which he termed psychoanalysis.

Breuer, a Viennese physician, treated patients who suffered from hysteria. Breuer’s patients told him that they had physical illnesses. However, after examination, he discovered that they had no physical symptoms. Breuer discovered that in some cases his patients’ symp- toms eased or disappeared once they discussed the past with him in a safe environment with- out censure and while under hypnosis. Breuer and Freud discussed their ideas, and Freud expanded on them and created psychoanalytic theory, thus leading to an entire movement

Time Life Pictures/Contributor/Getty Images An inmate at Bethlehem Hospital, where the mentally ill were held in inhumane conditions.

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

that is still popular today. Freud’s basic tenet was that unconscious processes, motives, and urges are at the core of all of our behaviors and difficulties.

How did Freud view abnormal behavior? He saw adult human behavior as resulting from a combination of the components of what he termed the psyche, which consisted of three parts: the id, the ego, and the superego (see Figure 1.2). The id is the primitive part of the personality that houses our unconscious desires, wishes, and basic innate drives such as sex and aggression. If these drives are not satisfied, or if the unconscious desires come into con- sciousness, anxiety can result. The id is the only piece of the psyche that is present at birth. The ego, which is partially conscious and is the second part of the psyche, does its best to control the id by trying to “convince” it to delay gratification until a reasonable solution to the drive reduction is found. The id does not listen, as it needs to be satisfied immediately regardless of the consequences. The ego develops when a child is between 1½ and 3 years old. Eventually the superego, the final part of the psyche, develops when a child is between 3 and 6 years old and enables the individual to feel guilt and have a conscience. The superego is also partially conscious, and it helps the ego to control the id’s desires. Even if the id’s urges are controlled by the ego and the superego, its desires still exist, driving behavior. Because these desires are so strong, they cause anxiety if they are unmet. According to psychoanalytic theory, this can lead to abnormal behavior.

Figure 1.2: Freud’s theory of personality

Freud compared personality to an iceberg. A small part is conscious, a somewhat larger part is preconscious (available to conscious awareness with some mental effort), and the largest part of personality is unconscious (unavailable to the individual without massive psychoanalytic effort).

Source: Reprinted from Steven Schwartz and James Johnson, Psychopathology of childhood: A clinical-experimental approach, p. 13, Pergamon Press, 1985, with permission from Elsevier.

Unconscious

Preconscious

Conscious

Ego Superego

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

Freud and his followers also looked at abnormal behavior in other ways. For example, Freud saw depression as anger turned inward. He maintained that everyone has self-destructive tendencies, but that they usually remain repressed. Repression is an ego defense mechanism that operates unconsciously. Repression keeps certain ideas, impulses, and memories from reaching consciousness. If these ideas were to surface, they would produce anxiety and guilt, among other feelings. However, when individuals are unable to express their anger appropri- ately and turn it inward as a form of self-punishment, this can lead to depression.

Behaviorism: 1910s–1940s Freud’s explanations for abnormal behavior varied somewhat according to an individual’s diagnosis; however, the explanations of two American psychologists, John B. Watson (1878– 1958) and B. F. Skinner (1904–1990), stayed the same regardless of the individual or the diagnosis. These two posited that something in the environment is always reinforcing an indi- vidual’s aberrant behavior(s). In other words, the causal factors are outside of the individual. Behaviorists believe that only observable and scientifically measurable behaviors are worth studying and investigating. Some behaviorists go to more of an extreme, stating that only physiological responses matter; consciousness and any mental states are not worth examin- ing, as they do not exist. (They have often been called radical behaviorists.) Let’s consider an example: A child is often disruptive in class, screaming and throwing objects. That child is usually sent to the principal’s office for subsequent punishment. It turns out that the child loves the attention he gets when he is removed from class, as he has no friends and is also ignored at home by his father. His acting out is reinforced by the attention he gets in the class- room and by getting sent to the principal’s office. Perhaps you can think of some celebrities whose behaviors are reinforced by environmental actions (gaining more attention and noto- riety). Effective treatment, therefore, always relies on the manipulation of the environment in order to change the individual’s behavior. In the case of someone suffering from depression, for example, Skinner would try to discover what environmental factors were sustaining the depressive symptoms and then help the patient to eliminate those reinforcers, with little to no emphasis on the person’s thoughts, unconscious desires, and so on.

Cognitive Behaviorism: 1950s–1970s Cognitive behaviorism is a psychotherapeutic method that alters distorted attitudes by identifying and replacing negative and inaccurate thoughts, which will therefore lead to behavioral changes. Albert Ellis (1913–2007) took a somewhat unique approach to defin- ing and treating abnormal behavior. He believed that people become depressed and develop other mental illnesses because of faulty thinking. For example, Ellis said that some people set themselves up to fail because of “musterbation.” This means that you create a series of men- tal “musts” that are virtually impossible to satisfy, such as “I must always do well in all of my performances and always win the praise and approval of others. If not, I’m a failure.” This is an unrealistic expectation, and when it’s not met, the individual gets depressed and anxious or develops other problems. Ellis defined an ABC model that refers to the three components of how people experience and interpret events in either a faulty or a healthy manner. In this model, A is the activating event or adversity, B is the belief that follows, and C is the conse- quence. For example, let’s look at a woman who receives a negative work evaluation (this is the A, activating event or adversity). She then believes that she is a failure (the B, or belief ).

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

The end result (or C, consequence) is that the woman now feels anxious and depressed. Ellis created rational emotive behavior therapy (REBT) to treat people with problems resulting from such faulty thinking. It works by helping patients to replace their irrational responses to events (the B, or belief ) with a more healthy and rational interpretation (such as, in the case of the poor job review, “I tried my best” or “I’m still learning and will get better”). REBT works well in treating anxiety disorders and some mood disorders (such as some depressive disorders); it does not work well with lower-functioning individuals or with those who are not very verbal (or verbally astute).

Albert Bandura (b. 1925) created social learning theory, also known as modeling. Bandura postulated that people could learn by observing the behavior of others—whether in real life, on television, or in the movies—and then copying, or modeling, those behaviors. Modeling is a powerful form of learning. How did you learn to read, ride a bicycle, or use a computer? Likely through modeling. Therefore, abnormal behavior is easy to explain from a modeling perspective. The individual sees a model demonstrate a behavior and either get rewarded or get punished for it. If the model is rewarded for the behavior, the observer may think, “Hmm, he got rewarded, maybe I should do the same.” Then the observer copies what she sees and demonstrates the behavior. This may seem (and is, to a degree) rather simplistic, but, in addi- tion to biological factors, it might help to explain why certain behaviors run in families. For example, if an individual was abused as a child, he or she is more likely to be an abuser as an adult.

Aaron Beck (b. 1921) developed the cognitive perspective theory to examine the causes of unipolar depression, known just as depression to most people; this depression has one “pole” or dysfunctional mood state. These individuals have no history of mania and revert to a normal mood state when the depression lifts. Bipolar disorder has two poles and two dys- functional mood states—a manic state and depression. The cognitive perspective attributes abnormal behavior to faulty thinking—that is, to seeing life’s events in a negative fashion. Having these negative thoughts will lead to negative behavior, which can lead to unipolar depression. According to Beck, depression develops in childhood and adolescence because of what he calls negative schemas, or the tendency to see the world pessimistically or nega- tively. A schema is defined as the fundamental way in which people process information, typi- cally about themselves (Dozois & Rnic, 2015). Individuals acquire these negative schemas for a variety of reasons: for example, the death of a parent, repeated social rejection by peers, or one tragedy after another. These schemas are activated whenever the individual experiences a new situation that is similar to the conditions in which the negative schemas were learned. Beck also notes that these individuals are prone to misinterpreting reality. Thus, they think irrationally and may believe that they are responsible for all of their family’s ills, that they are totally worthless, and so on. They may end up seeing themselves as hopeless and their chances of future success as limited or nonexistent.

These negative schemas and their accompanying cognitive distortions support the negative triad. Beck explained this in the following fashion: First, the person maintains a negative view of himself or herself (“Everything I touch is ruined.”). The person also maintains a negative view of the environment (“No one could possibly get along with these roommates.”). Finally, the person has a negative view of the future and sees things as hopeless (“No matter what I do, things will always turn out bad for me, so it is really hopeless to even try.”). Individuals who follow this triad set themselves up for failure, and most likely depression, by adopting these schemas. If they experience stress or disappointment, the likelihood of becoming depressed

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

increases. In effect, the individual’s negative thoughts lead to negative behaviors (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979).

Martin Seligman (b. 1942), a professor of psychology at the University of Pennsylvania (where Beck also taught), was inspired by Beck’s work and developed a theory of learned helplessness as it applies to depression. Again, keep in mind that even though we are spe- cifically discussing depression, these theories can explain other mental illnesses, but not all. In Seligman’s view, individuals develop depression, or perhaps anxiety disorders, because they see themselves as helpless to control the reinforcers in their environment, and there- fore the environment itself; they cannot make positive changes in their lives. If individuals

are consistently experiencing bad incidents (for example, they might say that they are having a bad month), Seligman would say that eventually the individuals will resign themselves to the negativity as “fate.” Avoidance and escape behaviors then dis- appear and individuals see themselves as helpless to escape, prisoners of their environments and of their situations. Seligman and his colleagues later revised this theory and renamed it the reformu- lated helplessness theory.

The original theory had two major problems. First, it did not distinguish between cases in which out- comes are uncontrollable for all people (called universal helplessness) and cases in which they are uncontrollable only for some people (called personal helplessness). Second, the theory did not explain when helplessness is general and when it is specific, or when it is chronic and when it is acute. The reformulation was based on a revised concept of attribution theory (Abramson, Seligman, & Teas- dale, 1987; Taube-Schiff & Lau, 2008). According to this revision, once people perceive that they lack control over outcomes, they attribute their helpless- ness to a cause. This cause can be stable or unstable, global or specific, and internal or external.

Humanism: 1950s Carl Rogers (1902–1987) created the client- or person-centered approach. Rogers believed in the innate goodness of all people, and in the ability of all people to grow and to lead con- structive lives. Rogers theorized that dysfunction begins in infancy. Children who receive unconditional positive regard—when one person is completely accepting toward another person—from their parents early in life will grow up to become constructive and productive adults, even though they will have flaws. They will realize that they and their contributions are valued even with these flaws. In Rogerian therapy, clients attempt to look at themselves

4X5 Collection/SuperStock According to the reformulated help- lessness theory, some individuals develop depression or anxiety because they see themselves as prisoners of fate, unable to control their negative situations or environment.

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

as being valuable worthwhile human beings. Those who have low self-esteem may be seen as being incongruent, or experiencing a mismatch between their idealized self-image and their true self-image. When this occurs, anxiety and other issues result, and it is the therapist’s job, first, to be a model of congruence and empathize with the client. Then, the therapist will help the individual become congruent and to effectively feel better about himself or herself. See Table 1.1 for a summary of the main theories and theorists in the history of psychology.

Table 1.1: The main theories and theorists in the history of psychology

Theorist Theory Explanation

Sigmund Freud (1856–1939)

Psychoanalytic theory Individuals develop neuroses because of their unresolved conflicts (repressed id impulses surfacing and overwhelming the ego and superego) and because of prob- lems occurring during childhood.

Albert Bandura (1925–)

Social learning theory Individuals learn based on what they observe others (models) do in the world.

Albert Ellis (1913–2007)

Rational emotive behavior therapy Individuals develop disorders because of faulty thinking.

Aaron Beck (1921–)

Cognitive perspective Individuals develop depression in child- hood and adolescence because of the tendency to see the world negatively.

Martin Seligman (1942–)

Theory of learned helplessness Individuals develop disorders because they see themselves as helpless to control the environment around them. They therefore “give up” trying to change their situation and “grin and bear it.”

Carl Rogers (1902–1987)

Humanism Dysfunction begins in infancy. Children who receive unconditional positive regard— when one person is completely accept- ing toward another person—from their parents early in life will grow up to become constructive and productive adults, even though they will have flaws.

The Diathesis-Stress Model Next we will look at a model that straddles the two categories of cognitive and biological theories. The diathesis-stress model contends that behaviors are a product of both genet- ics (biology) and environmental stressors. This is an interactionist model, which means that it views abnormal behavior as originating from a combination of genetic predisposition(s) (the diathesis) that are set off, or “turned on” (like a light switch), by environmental stressors (Holmes & Rahe, 1967).

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

We can examine this concept more closely by using an example. Many psychologists accept that schizophrenia runs in families and, therefore, that it has a genetic component. However, this does not guarantee that individuals born into a family with a history of mental illness will have the disorder; it just means that they are more vulnerable to developing it, or perhaps another mental illness. They are essentially born with this gene “switched off,” and stress from the environment may or may not eventually “turn on” the gene. For example, let’s look at a young adult with a genetic predisposition for schizophrenia who uses illicit substances such as marijuana and heroin. Soon after the drugs’ effects have worn off, she begins to demon- strate schizophrenic behaviors and thoughts. This demonstrates how the environment (the stress) turns on the diathesis (the genetic predisposition). If this individual has strong sup- port systems, the diathesis is less likely to trigger the switch, and the illness is less likely to be expressed. This is a useful theory for the following reason: It removes some of the responsi- bility from individuals for contracting their illnesses. It is not their fault, not a character flaw; it is just the fact that they were born with this genetic predisposition.

Biological Models: Late 1800s–Early 1900s Emil Kraepelin (1856–1926) was a German research scientist who was indirectly responsible for the foundation that eventually led to the creation of the Diagnostic and Statistical Manual series. He also posited the concept that physical factors were responsible for mental illnesses. If this latter concept sounds familiar to you, it is. Hippocrates espoused these ideas more than two thousand years earlier.

Another important event occurred in 1897: the sexually transmitted disease syphilis was found to have led to general paresis, an incurable physical disorder that has both physical and mental symptoms (Hogebrug et al., 2013). A German neurologist, Richard von Krafft- Ebing (1840–1902), was responsible for this discovery. This was important because syphilis sufferers demonstrated delusions of grandeur, which can be a sign of a mental illness. This was a critical discovery because now there was medical evidence that physical illnesses could mimic symptoms of mental illnesses and, more important, that physiological factors were, at the least, somehow involved with some if not all the mental disorders known at that time.

Biological Models: Early 1900s–1940s The concept that biology was somehow involved in mental illness led to biological treatment methods, many of which were seen as unsuccessful or perhaps inhumane. Lobotomies are a type of psychosurgery (surgery for a psychological purpose) that destroys brain tissue to change a person’s behavior. The person’s nerves that connect the frontal lobes to the parts of the brain that control emotions are severed, supposedly calming their behavioral outbursts. Unfortunately, the individual often entered a vegetative state and was basically unresponsive to stimulation and to people (Collins & Stam, 2015). For obvious reasons, lobotomies are no longer performed.

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

Electroconvulsive therapy (ECT), also known as electroshock therapy, and often referred to as shock treatment, is a psychiatric treatment in which seizures are electrically induced in patients to provide relief from psychiatric illnesses, mostly for unipolar depression (Krish- nan, 2016). The procedure is typically performed in a hospital, on either an outpatient or an inpatient basis. You will learn about ECT in Chapter 6, but for the moment note that ECT was often used initially to quiet agitated patients, which was not its intended use.

Finally, insulin shock therapy, also known as insulin coma therapy (ICT), was a form of psychiatric treatment in which patients were repeatedly injected with large doses of insulin to produce daily comas over several weeks. The concept, again, was that an agitated person would be calmed once he or she came out of the coma (Gibson, 2014). Of course, the risk here is evident: What if the patient does not come out of the coma? ICT is also not used today.

The field of psychology reached a major milestone in the early 1950s when Henri Laborit (1914–1955) introduced the drug chlorpromazine (known by its trade name Thorazine). This medication was initially used to tranquilize surgical patients, but Laborit noticed that it also managed to calm patients without putting them to sleep. Since patients with schizo- phrenia often exhibit perpetual agitated behavior, Laborit proposed using the drug to treat schizophrenic disorders. Many psychiatrists thought that his idea had no merit and stood by the practices of using electroshock therapy or psy- chotherapy to treat serious mental illnesses. How- ever, a fellow surgeon informed his brother-in-law, the psychiatrist Pierre Deniker, about this possible use of Thorazine. Deniker became interested and ordered some to try on his most agitated, uncontrol- lable patients. The results stunned Deniker and his colleagues, as patients who needed to be restrained or who were uncommunicative were now open to communication and could be left unsupervised. The field of psychopharmacology (the study of the effect of drugs on the mind and behavior) was unof- ficially born, and the nature of mental illness treat- ment was changed forever.

How do psychotropic medications (those that help individuals to handle psychiatric problems) gen- erally work? They increase or decrease levels of various neurotransmitters, brain chemicals presumed to be at either subnormal or super- normal levels in an individual with a mental illness (see Table 1.2 for a list of common neu- rotransmitters). Most frequently, psychotropic medications are used to increase levels of the neurotransmitters serotonin and norepinephrine, which have been implicated in a variety of mental illnesses. For example, serotonin deficiencies have been implicated in depression as well as in bulimia nervosa, and high dopamine levels have been tied to schizophrenia. We will discuss these associations in more detail in Chapters 6, 7, and 8, respectively.

Peter Sickles/SuperStock Research in the early 1950s revealed that drugs commonly used during medical procedures could also be used to treat mental illness.

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

The advent of psychotropic medications also led to other changes in treatment for the men- tally ill. For example, some of these individuals could now be released from inpatient units and be treated on an outpatient basis, freeing up facility beds and allowing the patients to lead more normal lives.

Today, a number of mental illnesses are treated with a combination of talk therapy and medi- cations. Medications work well (for some) in alleviating the symptoms of mental illnesses, but they do not eliminate all of the concerns that bring someone in for treatment. They also can produce side effects, some of which are quite significant, and certain classes of medications have addictive potential. Therefore, medications should not be viewed as panaceas or be used as the sole treatment for a mental illness; nevertheless, they should be used when advisable in conjunction with therapy.

A Quick Look at Another Option: Transcranial Magnetic Stimulation (TMS) Transcranial magnetic stimulation (TMS) is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression. TMS is typi- cally used when other depression treatments haven’t been effective. Typically, during a TMS session, an electromagnetic coil is placed against the scalp, near the patient’s forehead. The electromagnet delivers a magnetic pulse that stimulates nerve cells in the region of the brain hypothesized to be involved with mood control, specifically unipolar depression. The proce- dure itself is painless. In addition, and more interestingly, TMS may activate regions of the brain that have decreased activity in people with unipolar depression. Since treatment for unipolar depression involves delivering repetitive magnetic pulses, the procedure is often called repetitive TMS (rTMS). Even though researchers remain uncertain as to how rTMS works, the magnetic pulses appear to affect how this part of the brain is working, which in turn seems to ease unipolar depression symptoms and improve the patient’s mood (Taylor et al., 2017).

Table 1.2: Common neurotransmitters

Acetylcholine (ACH) Triggers muscle contractions; involved with muscle movement, memory, anger, and aggression.

Dopamine Involved with muscle movement, mood, motivation, and reward-seeking behav- ior; also involved with Parkinson’s disease; hypothesized to be involved with schizophrenia and bipolar disorder.

Gamma-amino butyric acid (GABA)

Involved with movement and anxiety; involved with anxiety disorders (too little causes anxiety) and seizure disorder.

Glutamate Involved with memory and learning; hypothesized to be involved with schizo- phrenia and some substance-related disorders.

Norepinephrine Involved with stress, alertness, arousal, and reward-seeking behavior; hypoth- esized to be involved with anxiety and mood disorders.

Serotonin Regulates mood, sex drive, appetite, body temperature, and sleep; involved with depression, eating disorders; may be involved with schizophrenia, bipolar disor- der, and anxiety disorders.

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Section 1.3 The DSM–5

1.3 The DSM–5 The classification system to which psychologists and other helping professionals refer when making diagnoses concerning mental health issues is the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM–5; APA, 2013). This manual has always been published by the American Psychiatric Association and covers all defined mental illnesses in both children and adults that were known at the time of publication. The book lists symptoms and signs that can help categorize the various illnesses. Symptoms are the patient’s subjective descrip- tion of the complaints that they may have, whereas signs are generally objective observations made by the diagnostician, from either an interview or some type of test given to the patient.

The Evolution of the DSM The DSM was first published in 1952 and has undergone several revisions since that time. The sole purpose of the DSM was to classify and provide a descriptive explanation for all known mental disorders. The first version was 132 pages long, listed 106 disorders, and offered concise descriptions of major psychiatric diagnoses. This inventory was an important advancement in the field of psychology and led to greater reliability of mental illness diagno- ses because all researchers began to use the same criteria. The second edition was published in 1968 and included 182 disorders, yet it was quite similar to the DSM–I. Both the DSM–I and DSM–II emphasized the psychodynamic (Freudian) perspective, yet the DSM–II included sociological and biological knowledge about each disorder as well.

The third edition of the DSM was published in 1980 and was 494 pages long—quite a bit longer than the first edition. This edition included many important changes. For example, it addressed the fact that the first two editions neglected extraneous factors, such as medical conditions, environmental concerns, and life stressors, that may play a part in the develop- ment of mental illnesses. The DSM–III, unlike the DSM–I and DSM–II, was based on scientific evidence. Its reliability was improved with the addition of explicit diagnostic criteria. In short, the third edition acknowledged that many disorders do not have a single cause but are trig- gered by the cumulative effect of multiple factors (Mayes & Horwitz, 2005).

The third edition also introduced a new multiaxial system in which disorders were evalu- ated on five different axes. Many of the disorders listed in the DSM–III have a high level of co-occurrence with other disorders. This is called comorbidity (Blashfield, Keeley, Flanagan, & Miles, 2014). However, the idea of comorbidity may not be accurate, per Meghani et al. (2013), who feel that many disorders could be a variation of a single underlying disorder, rather than being distinct conditions.

Because of some inconsistencies in the criteria of some disorders, the APA issued a revision of the DSM–III in 1987 and named it the DSM–III–R. This edition increased the coverage of psy- chopathologies. The next major revision of the DSM took place in 1994 with the publication of the DSM–IV, which had 943 pages and covered 373 different diagnoses. Additional revisions were published in 2000, including some corrections and updates to the content; this was called the DSM–IV–TR (Text Revision). The latest major revision, published in 2013, is called the DSM–5. It is about the same length as the preceding edition but fewer diagnoses are now included (approximately 265, according to a number of articles). Table 1.3 summarizes the DSM series up to and including the DSM–5. To give you an idea how diagnostic criteria appear in the DSM–5, refer to Table 1.4, which shows the diagnostic criteria for bulimia nervosa.

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Section 1.3 The DSM–5

Table 1.3: Summary of the DSM series from DSM–I through DSM–5

Version Year Published

Length/ # of Diagnoses Description/Changes

DSM–I 1952 132 pages/ 106 diagnoses

Concise descriptions of major psychiatric diagnoses.

DSM–II 1968 136 pages/ 182 diagnoses

Increased attention given to problems of children and adolescents with addition of behavior disorders of childhood–adolescence.

DSM–III 1980 494 pages/ 265 diagnoses

Addressed the role of extraneous factors that may play a role in mental illness, such as medical conditions and life stressors; introduced the new multiaxial system.

DSM–III–R 1987 567 pages/ 292 diagnoses

Increased coverage of psychopathologies.

DSM–IV 1994 943 pages/ 373 diagnoses

Included new clinically significant criteria in almost half the categories.

DSM–IV–TR 2000 943 pages/ 373 diagnoses

Some information updated.

DSM–5 2013 947/ 265 diagnoses

Some significant changes. For example, Asperger’s syndrome was dropped, and obsessive-compulsive and related disorders have their own chapter. The multiaxial system was removed. Moved from a categorical model, in which symptoms are based on a checklist format, to a dimensional model, in which symptoms are organized on a spectrum from mild to severe.

Source: Adapted from Andreasen and Black (2006).

How Do We Use the DSM–5? The DSM–5 describes mental disorders and their symptoms and gives statistics and gender breakdowns for each disorder. This common diagnostic and classification system enables psychologists and other helping professionals to communicate with each other about specific disorders, regardless of specialty area. Communicating a diagnosis about a patient to another mental health professional in a succinct manner is important in trying to get the patient the help that he or she needs (Lilienfeld, Smith, & Watts, 2013). Using a standardized method of diagnosis leads to a better understanding of disorders and, as a consequence, better treat- ment. For issues regarding self-diagnosis, see the accompanying Highlight.

There must be a high degree of reliability when a standardized classification system is used. Reliability refers to the consistency of the diagnostic system. Interrater reliability means that a test will have the same or similar results when used by different people.

The validity of a classification system, that is, the measurement or accuracy of the information in the diagnostic categories, is also clearly important. In other words, does the test measure or predict what it is supposed to? If it does, then we can say that the assessment technique is valid. For example, does an intelligence test really measure intelligence? It may measure “book smarts” but not “street smarts,” which is a type of intelligence.

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Section 1.3 The DSM–5

Table 1.4: How the DSM–5 summary table appears for bulimia nervosa

DSM–5 Diagnostic Criteria for Bulimia Nervosa (307.51)

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2 hour period), an amount of food that is definitely

larger than most people would eat during a similar period of time under similar circumstances. 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or

control what or how much one is eating). B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomit-

ing; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for

3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Specify if: In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time. In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time. Specify current severity: The minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability. Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week. Moderate: An average of 4–7 episodes of inappropriate compensatory behaviors per week. Severe: An average of 8–13 episodes of inappropriate compensatory behaviors per week. Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.

Source: American Psychiatric Association (APA, 2013, p. 345).

Highlight: Do I Have a Mental Illness?

Have you ever felt sad or lonely and sat down in front of the television with a pint of ice cream to make yourself feel better? Did you feel like throwing up afterward? Does this mean that you have bulimia nervosa? Does it mean you are depressed? If you are like many students, you may be tempted to self-diagnose your own behaviors as you learn about the disorders described in the remainder of this book.

It may be that you are neither bulimic nor depressed, but you may have another condition: medical student syndrome (sometimes called medical school syndrome), wherein medical students often begin to believe that they are suffering from the disease they are studying. Consider that everyone overeats at some point in their lives, and everyone has days, perhaps many in a row, when they feel blue or depressed. We are all human and, like all humans, we have good days and bad days, and the bad days may sometimes include behaviors that could be mistaken for mental illness symptoms. However, rest assured that the diagnostic criteria in the DSM–5 (American Psychiatric Association [APA], 2013) require, in most instances, a duration of several months to at least two years before any diagnosis can be made. If your behaviors are brief and occur only occasionally, you are probably acting “normally” and have little to worry about. You will learn more about symptoms and diagnosis of disorders in later chapters. If after reading more, you still think you may be suffering from mental illness, by all means, we encourage you to seek help. One resource is the National Alliance on Mental Illness (http://www.nami.org/).

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Section 1.3 The DSM–5

The number of disorders now listed in the DSM–5 may make it easier to diagnose more indi- viduals as having disorders. Although this results in several more types of mental illnesses, they are more distinct from each other now than they were several years ago. Nevertheless, the problem remains: How do you diagnose someone who meets only three of the four required symptoms of a disorder? For example, someone who is anxious also commonly suffers from depression. That means that this particular individual will now have two different diagnostic labels—not just a single one that may encompass both aspects of the individual’s disorder.

It is important to note that the DSM-5 is not immune from social and political influence. Some observers in the field believe that the most recent revisions align more with what the major drug companies want to see, thus leading to more medications being prescribed (as discussed in Frances, 2012). For more on the DSM–5 and its contexts, see the accompanying Highlight.

Highlight: Removing Disorders From the DSM

Did you know that until the DSM–III was published in 1980, homosexuality was considered to be a mental illness or disorder? The DSM task force decided to eliminate homosexuality in December 1973; this took place with the seventh printing of the DSM–II in 1974. Technically, however, homosexuality was not completely removed (that is, not mentioned at all) until the DSM–III was published. Also, did you know that Asperger’s syndrome (a pervasive developmental disorder that is a higher functioning form of autism) has now been reclassified as an autism spectrum disorder? If nothing else, these changes show how our views of what constitutes mental illness, how it is defined, and what each diagnosis entails, have changed over the years. What are your views on this subject?

The Medical Model All mental illnesses described in the DSM–5 are seen as having similar symptoms in common within each diagnostic category and subcategory (APA, 2013). For example, all individuals suffering from bulimia nervosa will demonstrate binging behaviors as well as recurrent inap- propriate compensatory behaviors (self-induced vomiting, abuse of laxatives, fasting, and so on). The mental illnesses listed in the DSM–5 are seen as being similar to physical diseases (that is, all influenzas have the same general symptoms, all bronchial pneumonias have simi- lar symptoms), hence, the term medical model. In addition, there is thought to be a physi- ological basis or cause for the individual’s problem(s). Those who endorse the medical model consider symptoms to be visible signs of the physical disorder. Therefore, if symptoms are grouped together and classified into a disorder such as bulimia nervosa, the true cause can eventually be discovered and appropriate physical treatment administered. The behaviors that one demonstrates (hallucinations, depressed mood, fear of heights, and so on) are con- sidered to be symptoms of a mental illness. The symptoms are clustered together to define various mental illnesses. When psychologists attempt to diagnose a new patient, they will look at symptoms and see into which DSM–5 category the symptoms fit. This is critical because it allows the helping professions to have a common language in which to communicate.

Many students, when they first encounter the DSM–5, have the following reaction: “Well, where does this book tell me how to treat this complicated disorder?” The DSM–5 does not

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Chapter Summary

include treatment information; it is only, as its title states, a diagnostic manual that describes the disorders. Psychologists and others in the helping professions learn how to treat mental illnesses by direct practice, classwork, and, of course, studying and reading. We will discuss how to treat the most commonly presented mental illnesses in the remainder of this book.

What DSM–5 Disorders Are Covered in This Book? It is impossible to address all 265 DSM–5 disorders in the space of this book. We will cover the following main categories of mental disorders, as listed in the DSM–5:

• Trauma and stressor-related disorders (including posttraumatic stress disorder) • Anxiety and obsessive-compulsive disorders • Substance-related and addictive disorders • Dissociative disorders and somatic symptom and related disorders • Depressive and bipolar disorders • Sleep-wake, feeding, and eating disorders • Schizophrenia spectrum disorders • Personality disorders • Neurocognitive disorders • Neurodevelopmental disorders • Sexual dysfunctions, paraphilic disorders, and gender dysphoria disorders

Chapter Summary

How Do We Define Abnormal Behavior? • The statistical frequency perspective labels behavior as abnormal if it occurs rarely

in relation to the behavior of the general population. • The social norms perspective considers behavior to be abnormal if the behavior

deviates greatly from accepted social standards, values, or norms. • The maladaptive perspective views behavior as abnormal if it interferes with the

individual’s ability to function in life or in society.

A History of Theoretical Orientations for Abnormal Behavior • During ancient times, mental illness was explained as the presence of evil spirits

within the body of the ill person. One method for treating mental illness was trepan- ning, in which a small instrument was used to bore holes in the skull to allow the evil spirits to leave the “possessed” person.

• Hippocrates noted a connection between abnormal behavior and internal, physi- ological causes.

• Sigmund Freud and Josef Breuer noticed that some of their patients presented physi- ological symptoms while having no physiological problems. Freud realized that one way to help these individuals was via psychoanalysis, or talk therapy.

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Chapter Summary

• Freud’s theory includes the ideas of repression and the psyche, which consists of the id, the ego, and the superego; this theory emphasizes the importance of examining people’s unconscious minds.

• B. F. Skinner and John Watson believed that abnormal behavior was environmentally caused, as an individual’s behavior was reinforced in the environment, therefore making it more likely to recur.

• Albert Ellis, Albert Bandura, Aaron Beck, and Martin Seligman believed that a per- son’s thoughts (irrational, maladaptive, or otherwise) lead to, or cause, a person’s aberrant or abnormal behaviors. Bandura believed that a person learns abnormal behaviors by watching others perform them, and then the individual reproduces (or “models”) what he or she sees.

• Carl Rogers believed that all humans are innately good and that problems arise when an individual is incongruent, that is, experiencing a mismatch between his or her idealized self-image and his or her true self-image.

• The diathesis-stress model posits that abnormal behavior originates from a combi- nation of genetic factors (the diathesis) triggered or “turned on” (like a light switch) by environmental stressors.

• Biological models view mental illness as having biological origins, specifically neurotransmitter levels being too low or too high. In these models, medications are often used to treat mental illnesses.

The DSM–5 • The DSM–5 describes mental disorders, their signs and symptoms, and gives statis-

tics and gender breakdowns for each disorder. • Comorbidity means that disorders seem to “go together” or appear at the same time

in the same individual. • The medical model views all mental illnesses described in the DSM–5 as having simi-

lar symptoms in common within each diagnostic category and subcategory.

Critical Thinking Questions 1. What criteria would you use to determine whether someone’s behavior is abnormal

or not? 2. Discuss whether social norms should be used to diagnose mental illness. 3. What are your views on the reasons people carry out mass shootings? What could

lead someone like Adam Lanza to murder more than 20 young children? 4. Behaviorists like Skinner focus on the present, not on the past or on a person’s

upbringing. How successful would this approach be in psychotherapy, and why? 5. Which of the theories mentioned in this chapter do you think best explains the ori-

gins of mental illness? Why? 6. What are your views on Rogers’s concept of innate goodness? Do you think people

are innately good or bad? 7. Give your perspectives on the use of ECT. Additionally, discuss whether TMS is a

viable treatment modality. 8. What are the pros and cons of using medications to treat mental illnesses?

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Chapter Summary

Key Terms ABC model A model of three components of how we experience and interpret events: A, the activating event or adversity; B, the belief that follows; and C, the consequence.

age of onset The age at which the trouble- some behaviors first become noticeable.

behaviorists Psychologists who believe that only observable and scientifically mea- surable behaviors are worth studying and investigating.

bipolar disorder A disorder with two poles and two dysfunctional mood states—a manic state and a depressed state.

cognitive behaviorism A psychotherapeu- tic method that alters distorted attitudes by identifying and replacing negative and inac- curate thoughts, which will therefore lead to behavioral changes.

cognitive perspective theory Aaron Beck’s theory that abnormal behavior is caused by faulty thinking such as viewing life events in a negative fashion.

comorbidity When one or more disorders co-occur or overlap.

diathesis-stress model A model that con- tends behaviors are a product of both genet- ics (biology) and environmental stressors.

duration The length of time the trouble- some behaviors have existed for a patient.

eccentric Individuals who have odd or unusual habits but do not have a mental illness.

ego A partially conscious part of the psyche (which develops when an infant is between 1½ and 3 years old) that seeks to control the id by “convincing” it to delay gratifica- tion until a reasonable solution to the drive reduction is found.

electroconvulsive therapy (ECT) Also known as electroshock therapy, and often referred to as shock treatment; a psychiatric treatment in which seizures are electrically induced in patients to provide relief from psychiatric ill- nesses, mostly for unipolar depression.

general paresis An incurable physical disorder that has both physical and mental symptoms.

id The primitive part of the personality, present from birth, that houses our uncon- scious desires, wishes, and our basic innate drives such as sex and aggression.

insulin shock therapy (insulin coma therapy) A form of psychiatric treatment in which patients were repeatedly injected with large doses of insulin to produce daily comas over several weeks; this would pre- sumably calm agitated patients.

intensity How extreme the behaviors in question are.

learned helplessness Seligman’s theory that individuals develop depression or anxi- ety disorders because they see themselves as helpless to control their environments.

legal norms Rules for behavior based on society’s laws.

lobotomies A type of psychosurgery (surgery for a psychological purpose) that destroys brain tissue to change a person’s behavior.

maladaptive perspective Behavior is deemed abnormal if it interferes with the individual’s ability to function.

medical student syndrome The syndrome in which medical students begin to believe they are suffering from the disease they are studying.

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Chapter Summary

modeling The idea that we can learn by observing the behavior of others.

negative schema A view of the world that is negative or pessimistic. Beck believed this to be the cause of depression.

neurotransmitters Brain chemicals; they are presumed to be at subnormal or super- normal levels in individuals with mental disorders.

norms Spoken and unspoken rules for proper conduct that are established by a society over time and are subject to change over time.

overt behaviors Behaviors that are on the surface or clearly visible to others.

psyche In Freudian theory, this consists of three parts: the id, the ego, and the superego.

psychoanalytic theory The set of con- cepts wherein individuals develop neuro- ses because of their unresolved conflicts, repressed id impulses surfacing and over- whelming the ego and the superego, and problems that occurred during childhood.

psychological norms Rules for behavior as codified in the DSM–5.

psychopathology The study of the causes and development of psychiatric disorders.

psychopharmacology The study of the treatment of mental illnesses with drugs and medication.

reformulated helplessness theory A revised version of the helplessness theory that differentiates between universal and personal helplessness, as well as between helplessness that is general or specific.

repetitive TMS (rTMS) A treatment for unipolar depression that involves deliver- ing repetitive magnetic pulses to the brain’s nerve cells.

repression An ego defense mechanism that operates unconsciously to keep certain ideas, impulses, and memories from reach- ing consciousness.

social norms perspective Behavior is deemed abnormal according to the stan- dards set by society.

statistical frequency perspective Behav- ior is deemed abnormal because it occurs rarely or in only a small minority of the population.

superego The final part of the psyche; it develops when a child is between 3 and 6 years old and enables the individual to feel guilt and have a conscience. The superego is partially conscious and helps the ego to control the id’s desires.

transcranial magnetic stimulation (TMS) A noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression.

trepanning A process in which a small instrument is used to bore holes into the skull; the purpose may have been to release evil spirits from an afflicted person.

unconditional positive regard When one person is completely accepting toward another person. Rogers believed that people who receive unconditional positive regard from their parents early in life will grow up to become constructive and productive adults.

unipolar depression Known just as depression to most people; this depression has one “pole” or dysfunctional mood state.

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