2 reaction papper

bookchapter1-2.pdf

Home >Psychology homework help >2 reaction papper

C h a p t e r O u t l i n e

understanding psychopathology What Is a Psychological Disorder? The Science of Psychopathology Historical Conceptions of Abnormal Behavior

the Supernatural tradition Demons and Witches Stress and Melancholy Treatments for Possession Mass Hysteria Modern Mass Hysteria The Moon and the Stars Comments

the Biological tradition Hippocrates and Galen The 19th Century The Development of Biological Treatments Consequences of the Biological Tradition

the psychological tradition Moral Therapy Asylum Reform and the Decline of Moral

Therapy Psychoanalytic Theory Humanistic Theory The Behavioral Model

the present: the Scientific Method and an integrative approach

1 Abnormal Behavior in Historical Context

Je rr

y C

oo ke

/S ci

en ce

S ou

rc e

50443_ch01_ptg01_hr_002-031.indd 2 28/09/16 2:43 PM

Understanding PsychoPathology 3

student learning outcomes*

• Explain why psychology is a science with the primary objectives of describing, understanding, predicting, and controlling behavior and mental processes (APA SLO 1.1b) (see textbook pages 4–7, 25–27)

• Use basic psychological terminology, concepts, and theories in psychology to explain behavior and mental processes (APA SLO 1.1a) (see textbook pages 3–6, 9–14, 16–21, 23–27)

• Summarize important aspects of history of psychology, including key figures, central concerns, methods used, and theoretical conflicts (APA SLO 1.2c) (see textbook pages 9–27)

• Identify key characteristics of major content domains in psychology (e.g., cognition and learning, developmental, biological, and sociocultural) (APA SLO 1.2a) (see textbook pages 4–6, 13–21, 25–27)

• See APA SLO 1.1b listed above • Incorporate several appropriate levels of complexity

(e.g., cellular, individual, group/system, society/cultural) to explain behavior (APA SLO 2.1c) (see textbook pages 8–9, 12–16, 18–27)

Describe key concepts, principles, and overarching themes in psychology

Develop a working knowledge of the content domains of psychology

Use scientific reasoning to interpret behavior

Understanding Psychopathology Today you may have gotten out of bed, had breakfast, gone to class, studied, and, at the end of the day, enjoyed the company of your friends before dropping off to sleep. It probably did not occur to you that many physically healthy people are not able to do some or any of these things. What they have in common is a psychological disorder, a psychological dysfunction within an individual asso- ciated with distress or impairment in functioning and a response that is not typical or culturally expected. Before examining exactly what this means, let’s look at one individual’s situation.

Judy, a 16-year-old, was referred to our anxiety disorders clinic after increasing episodes of fainting. About 2 years earlier, in Judy’s first biology class, the teacher had shown a movie of a frog dissection to illustrate various points about anatomy.

This was a particularly graphic film, with vivid images of blood, tissue, and muscle. About halfway through, Judy felt a bit lightheaded and left the room. But the images did not

Judy... The Girl Who Fainted at the Sight of Blood

leave her. She continued to be bothered by them and occa- sionally felt slightly queasy. She began to avoid situations in which she might see blood or injury. She stopped looking at magazines that might have gory pictures. She found it difficult to look at raw meat, or even Band-Aids, because they brought the feared images to mind. Eventually, anything her friends or parents said that evoked an image of blood or injury caused Judy to feel lightheaded. It got so bad that if one of her friends exclaimed, “Cut it out!” she felt faint.

Beginning about 6 months before her visit to the clinic, Judy actually fainted when she unavoidably encountered something bloody. Her family physician could find nothing wrong with her, nor could several other physicians. By the time she was referred to our clinic, she was fainting 5 to 10 times a week, often in class. Clearly, this was problematic for her and disruptive in school; each time Judy fainted, the other students flocked around her, trying to help, and class was interrupted. Because no one could find anything wrong with her, the principal finally concluded that she was being manipulative and suspended her from school, even though she was an honor student.

* Portions of this chapter cover learning outcomes suggested by the American Psychological Association (2013) in their guidelines for the undergraduate psychology major. Chapter coverage of these outcomes is identified above by APA Goal and APA Suggested Learning Outcome (SLO).

(Continued next page)

50443_ch01_ptg01_hr_002-031.indd 3 28/09/16 2:43 PM

4 CHAPTER 1 abnormal behavior in h istor ical context

What Is a Psychological Disorder? Keeping in mind the real-life problems faced by Judy, let’s look more closely at the definition of psychological disorder: or prob- lematic abnormal behavior: It is a psychological dysfunction within an individual that is associated with distress or impair- ment in functioning and a response that is not typical or culturally expected (see E Figure 1.1). On the surface, these three criteria may seem obvious, but they were not easily arrived at and it is worth a moment to explore what they mean. You will see, impor- tantly, that no one criterion has yet been developed that fully defines a psychological disorder.

Psychological dysfunction Psychological dysfunction refers to a breakdown in cognitive, emo- tional, or behavioral functioning. For example, if you are out on a date, it should be fun. But if you experience severe fear all evening and just want to go home, even though there is nothing to be afraid of, and the severe fear happens on every date, your emotions are not functioning properly. However, if all your friends agree that the person who asked you out is unpredictable and dangerous in some way, then it would not be dysfunctional for you to be fearful and avoid the date.

A dysfunction was present for Judy: She fainted at the sight of blood. But many people experience a mild version of this reaction (feeling queasy at the sight of blood) without meeting the criteria

for the disorder, so knowing where to draw the line between normal and abnormal dysfunction is often difficult. For this rea- son, these problems are often considered to be on a continuum or a dimension rather than to be categories that are either present or absent (McNally, 2011; Stein, Phillips, Bolton, Fulford, Sadler, & Kendler, 2010; Widiger & Crego, 2013). This, too, is a reason why just having a dysfunction is not enough to meet the criteria for a psychological disorder.

distress or impairment That the behavior must be associated with distress to be classi- fied as a disorder adds an important component and seems clear: The criterion is satisfied if the individual is extremely upset. We can certainly say that Judy was distressed and even suffered with her phobia. But remember, by itself this criterion does not define problematic abnormal behavior. It is often quite normal to be dis- tressed—for example, if someone close to you dies. The human condition is such that suffering and distress are very much part of life. This is not likely to change. Furthermore, for some disorders, by definition, suffering and distress are absent. Consider the per- son who feels extremely elated and may act impulsively as part of a manic episode. As you will see in Chapter 7, one of the major difficulties with this problem is that some people enjoy the manic state so much they are reluctant to begin treatment or stay long in

Judy was suffering from what we now call blood– injection– injury phobia. Her reaction was quite severe, thereby meeting the criteria for phobia, a psychological disorder character- ized by marked and persistent fear of an object or situation. But many people have similar reactions that are not as severe when they receive an injection or see someone who is injured, whether blood is visible or not. For people who react as severely as Judy, this phobia can be disabling. They may avoid certain careers, such as medicine or nursing, and, if they are so afraid of needles and injections that they avoid them even when they need them, they put their health at risk. •

E FIgUre 1.1 The criteria defining a psychological disorder.

Psychological disorder

Psychological dysfunction

Distress or impairment

Atypical response

Distress and suffering are a natural part of life and do not in them- selves constitute a psychological disorder.

E ni

gm a/

A la

m y

S to

ck P

ho to

50443_ch01_ptg01_hr_002-031.indd 4 28/09/16 2:43 PM

Understanding PsychoPathology 5

treatment. Thus, defining psychological disorder by distress alone doesn’t work, although the concept of distress contributes to a good definition.

The concept of impairment is useful, although not entirely satisfactory. For example, many people consider themselves shy or lazy. This doesn’t mean that they’re abnormal. But if you are so shy that you find it impossible to date or even interact with people and you make every attempt to avoid interactions even though you would like to have friends, then your social functioning is impaired.

Judy was clearly impaired by her phobia, but many people with similar, less severe reactions are not impaired. This difference again illustrates the important point that most psychological disorders are simply extreme expressions of otherwise normal emotions, behaviors, and cognitive processes.

atypical or not culturally expected Finally, the criterion that the response be atypical or not culturally expected is important but also insufficient to determine if a disorder is present by itself. At times, something is considered abnormal because it occurs infrequently; it deviates from the average. The greater the deviation, the more abnormal it is. You might say that someone is abnormally short or abnormally tall, meaning that the person’s height deviates substantially from average, but this obviously isn’t a definition of disorder. Many people are far from the average in their behavior, but few would be considered disordered. We might call them talented or eccen- tric. Many artists, movie stars, and athletes fall in this category. For example, it’s not normal to wear a dress made entirely out of meat, but when Lady Gaga wore this to an awards show, it only enhanced her celebrity. The late novelist J. D. Salinger, who wrote The Catcher in the Rye, retreated to a small town in New Hampshire and refused to see any outsiders for years, but he continued to write. Some male rock singers wear heavy makeup on stage. These people are well paid and seem to enjoy their careers. In most cases, the more productive you are in the eyes of society, the more eccentricities society will tolerate. Therefore, “deviating from the average” doesn’t work well as a definition for problematic abnormal behavior.

Another view is that your behavior is disordered if you are vio- lating social norms, even if a number of people are sympathetic to your point of view. This definition is useful in considering impor- tant cultural differences in psychological disorders. For example, to enter a trance state and believe you are possessed reflects a psychological disorder in most Western cultures but not in many other societies, where the behavior is accepted and expected (see Chapter 6). (A cultural perspective is an important point of refer- ence throughout this book.) An informative example of this view is provided by Robert Sapolsky (2002), the prominent neuroscientist who, during his studies, worked closely with the Masai people in East Africa. One day, Sapolsky’s Masai friend Rhoda asked him to bring his vehicle as quickly as possible to the Masai village where a woman had been acting aggressively and had been hearing voices. The woman had actually killed a goat with her own hands. Sapolsky and several Masai were able to subdue her and transport her to a local health center. Realizing that this was an opportunity to learn

more of the Masai’s view of psychological disorders, Sapolsky had the following discussion:

“So, Rhoda,” I began laconically, “what do you suppose was wrong with that woman?”

She looked at me as if I was mad. “She is crazy.” “But how can you tell?” “She’s crazy. Can’t you just see from how she acts?” “But how do you decide that she is crazy? What did

she do?” “She killed that goat.” “Oh,” I said with anthropological detachment, “but

Masai kill goats all the time.” She looked at me as if I were an idiot. “Only the men

kill goats,” she said. “Well, how else do you know that she is crazy?” “She hears voices.” Again, I made a pain of myself. “Oh, but the Masai

hear voices sometimes.” (At ceremonies before long cattle drives, the Masai trance-dance and claim to hear voices.) And in one sentence, Rhoda summed up half of what any- one needs to know about cross-cultural psychiatry.

“But she hears voices at the wrong time.” (p. 138)

We accept extreme behaviors by entertainers, such as Lady Gaga, that would not be tolerated in other members of our society.

S te

ve G

ra ni

tz /G

et ty

Im ag

50443_ch01_ptg01_hr_002-031.indd 5 28/09/16 2:43 PM

6 CHAPTER 1 abnormal behavior in h istor ical context

a rating of 4 would indicate continual and severe symptoms (Beesdo-Baum, et al., 2012; LeBeau, Bogels, Moller, & Craske, 2015; LeBeau et al., 2012). These concepts are described more fully in Chapter 3, where the diagnosis of psychological disor- ders is discussed.

For a final challenge, take the problem of defining a psycho- logical disorder a step further and consider this: What if Judy passed out so often that after a while neither her classmates nor her teachers even noticed because she regained consciousness quickly? Furthermore, what if Judy continued to get good grades? Would fainting all the time at the mere thought of blood be a dis- order? Would it be impairing? Dysfunctional? Distressing? What do you think?

The Science of Psychopathology Psychopathology is the scientific study of psychological disorders. Within this field are specially trained professionals, including clin- ical and counseling psychologists, psychiatrists, psychiatric social workers, and psychiatric nurses, as well as marriage and family therapists and mental health counselors. Clinical psychologists and counseling psychologists receive the Ph.D., doctor of philosophy, degree (or sometimes an Ed.D., doctor of education, or Psy.D., doctor of psychology) and follow a course of graduate-level study lasting approximately 5 years, which prepares them to conduct research into the causes and treatment of psychological disorders and to diagnose, assess, and treat these disorders. Although there is a great deal of overlap, counseling psychologists tend to study and treat adjustment and vocational issues encountered by rela- tively healthy individuals, and clinical psychologists usually con- centrate on more severe psychological disorders. Also, programs in professional schools of psychology, where the degree is often a Psy.D., focus on clinical training and de-emphasize or elimi- nate research training. In contrast, Ph.D. programs in universities integrate clinical and research training. Psychologists with other specialty training, such as experimental and social psychologists, concentrate on investigating the basic determinants of behavior but do not assess or treat psychological disorders.

A social standard of normal has been misused, however. Con- sider, for example, the practice of committing political dissidents to mental institutions because they protest the policies of their government, which was common in Iraq before the fall of Saddam Hussein and now occurs in Iran. Although such dissident behav- ior clearly violated social norms, it should not alone be cause for commitment.

Jerome Wakefield (1999, 2009), in a thoughtful analysis of the matter, uses the shorthand definition of harmful dysfunction. A related concept that is also useful is to determine whether the behavior is out of the individual’s control (something the person doesn’t want to do) (Widiger & Crego, 2013; Widiger & Sankis, 2000). Variants of these approaches are most often used in current diagnostic practice, as outlined in the fifth edition of the Diag- nostic and Statistical Manual (American Psychiatric Association, 2013), which contains the current listing of criteria for psycho- logical disorders (Stein et al., 2010). These approaches guide our thinking in this book.

an accepted definition In conclusion, it is difficult to define what constitutes a psycholog- ical disorder (Lilienfeld & Marino, 1995, 1999)—and the debate continues (Blashfield, Keeley, Flanagan, & Miles, 2014; McNally, 2011; Stein et al., 2010; Spitzer, 1999; Wakefield, 2003, 2009; Zachar & Kendler, 2014). The most widely accepted definition used in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) describes behavioral, psychological, or biological dysfunctions that are unexpected in their cultural context and associated with present distress and impairment in functioning, or increased risk of suffering, death, pain, or impairment. This definition can be useful across cultures and subcultures if we pay careful atten- tion to what is functional or dysfunctional (or out of control) in a given society. But it is never easy to decide what represents dysfunction, and some scholars have argued persuasively that the health professions will never be able to satisfactorily define disease or disorder (see, for example, Lilienfeld & Marino, 1995, 1999; McNally, 2011; Stein et al., 2010; Zachar & Kendler, 2014). The best we may be able to do is to consider how the apparent disease or disorder matches a “typical” profile of a disorder—for example, major depression or schizophrenia—when most or all symptoms that experts would agree are part of the disorder are present. We call this typical profile a prototype, and, as described in Chapter 3, the diagnostic criteria from DSM-5 found through- out this book are all prototypes. This means that the patient may have only some features or symptoms of the disorder (a mini- mum number) and still meet criteria for the disorder because his or her set of symptoms is close to the prototype. But one of the differences between DSM-5 and its predecessor, DSM-IV, is the addition of dimensional estimates of the severity of spe- cific disorders in DSM-5 (American Psychiatric Association, 2013; Regier, Narrow, Kuhl, & Kupfer, 2009; Helzer, Wittchen, Krueger, & Kraemer, 2008). Thus, for the anxiety disorders, for example, the intensity and frequency of anxiety within a given disorder such as panic disorder is rated on a 0 to 4 scale where a rating of 1 would indicate mild or occasional symptoms and

Some religious behaviors may seem unusual to us but are culturally or individually appropriate.

ak e1

15 0/

Fo to

lia L

50443_ch01_ptg01_hr_002-031.indd 6 28/09/16 2:43 PM

Understanding PsychoPathology 7

see whether they work. They are accountable not only to their patients but also to the government agencies and insurance companies that pay for the treatments, so they must demon- strate clearly whether their treatments are effective or not. Third, scientist-practitioners might conduct research, often in clinics or hospitals, that produces new information about disorders or their treatment, thus becoming immune to the fads that plague our field, often at the expense of patients and their families. For example, new “miracle cures” for psy- chological disorders that are reported several times a year in popular media would not be used by a scientist-practitioner if there were no sound scientific data showing that they work. Such data flow from research that attempts three basic things: to describe psychological disorders, to determine their causes, and to treat them (see E Figure 1.3). These three categories compose an organizational structure that recurs throughout this book and that is formally evident in the discussions of specific disorders beginning in Chapter 5. A general overview of them now will give you a clearer perspective on our efforts to understand abnormality.

clinical description In hospitals and clinics, we often say that a patient “presents” with a specific problem or set of problems or we discuss the presenting problem. Presents is a traditional shorthand way of indicating why the person came to the clinic. Describing Judy’s presenting problem is the first step in determining her clinical description, which represents the unique combination of behav- iors, thoughts, and feelings that make up a specific disorder. The word clinical refers both to the types of problems or disorders that you would find in a clinic or hospital and to the activities connected with assessment and treatment. Throughout this text are excerpts from many more individual cases, most of them from our personal files.

Clearly, one important function of the clinical description is to specify what makes the disorder different from normal behav- ior or from other disorders. Statistical data may also be relevant.

For example, how many people in the population as a whole have the disorder? This figure is called the prevalence of the dis- order. Statistics on how many new cases occur during a given period, such as a year, represent the incidence of the disorder. Other statistics include the sex ratio—that is, what percentage of males and females have the disorder—and the typical age of onset, which often differs from one disorder to another.

Psychiatrists first earn an M.D. degree in medical school and then specialize in psychiatry during residency training that lasts 3 to 4 years. Psychiatrists also investigate the nature and causes of psychological disorders, often from a biological point of view; make diagnoses; and offer treatments. Many psychiatrists emphasize drugs or other biological treatments, although most use psychosocial treatments as well.

Psychiatric social workers typically earn a master’s degree in social work as they develop expertise in collecting information relevant to the social and family situation of the individual with a psychological disorder. Social workers also treat disorders, often concentrating on family problems associated with them. Psychi- atric nurses have advanced degrees, such as a master’s or even a Ph.D., and specialize in the care and treatment of patients with psychological disorders, usually in hospitals as part of a treat- ment team.

Finally, marriage and family therapists and mental health counselors typically spend 1 to 2 years earning a master’s degree and are employed to provide clinical services by hospitals or clin- ics, usually under the supervision of a doctoral-level clinician.

the scientist-Practitioner The most important development in the recent history of psy- chopathology is the adoption of scientific methods to learn more about the nature of psychological disorders, their causes, and their treatment. Many mental health professionals take a scientific approach to their clinical work and therefore are called scientist-practitioners (Barlow, Hayes, & Nelson, 1984; Hayes, Barlow, & Nelson-Gray, 1999). Mental health practitio- ners may function as scientist-practitioners in one or more of three ways (see E Figure 1.2). First, they may keep up with the latest scientific developments in their field and therefore use the most current diagnostic and treatment procedures. In this sense, they are consumers of the science of psychopathology to the advantage of their patients. Second, scientist-practitioners evaluate their own assessments or treatment procedures to

E FIgUre 1.2 Functioning as a scientist-practitioner.

Consumer of science • Enhancing the practice

Evaluator of science • Determining the effectiveness of the practice

Creator of science • Conducting research that leads to new procedures useful in practice

Mental health

professional

Ke vi

n Pe

te rs

on /P

ho to

di sc

/G et

ty Im

ag es

E FIgUre 1.3 Three major categories make up the study and discussion of psychological disorders.

Studying psychological

disorders

Focus

Clinical description

Causation (etiology)

Treatment and outcome

50443_ch01_ptg01_hr_002-031.indd 7 28/09/16 2:43 PM

8 CHAPTER 1 abnormal behavior in h istor ical context

disorders is so important to this field, we devote an entire chapter (Chapter 2) to it.

Treatment, also, is often important to the study of psy- chological disorders. If a new drug or psychosocial treatment is successful in treating a disorder, it may give us some hints about the nature of the disorder and its causes. For example, if a drug with a specific known effect within the nervous system alleviates a certain psychological disorder, we know that some- thing in that part of the nervous system might either be causing the disorder or helping maintain it. Similarly, if a psychologi- cal treatment designed to help clients regain a sense of control over their lives is effective with a certain disorder, a diminished sense of control may be an important psychological component of the disorder itself.

As you will see in the next chapter, psychopathology is rarely simple. This is because the effect does not necessarily imply the cause. To use a common example, you might take an aspirin to relieve a tension headache you developed during a grueling day of taking exams. If you then feel better, that does not mean that the headache was caused by a lack of aspirin. Nevertheless, many people seek treatment for psychological disorders, and treatment can provide interesting hints about the nature of the disorder.

In addition to having different symptoms, age of onset, and possibly a different sex ratio and prevalence, most disorders follow a somewhat individual pattern, or course. For example, some disorders, such as schizophrenia (see Chapter 13), follow a chronic course, meaning that they tend to last a long time, sometimes a lifetime. Other disorders, like mood disorders (see Chapter 7), follow an episodic course, in that the individual is likely to recover within a few months only to suffer a recur- rence of the disorder at a later time. This pattern may repeat throughout a person’s life. Still other disorders may have a time-limited course, meaning the disorder will improve without treatment in a relatively short period with little or no risk of recurrence.

Closely related to differences in course of disorders are dif- ferences in onset. Some disorders have an acute onset, mean- ing that they begin suddenly; others develop gradually over an extended period, which is sometimes called an insidious onset. It is important to know the typical course of a disorder so that we can know what to expect in the future and how best to deal with the problem. This is an important part of the clini- cal description. For example, if someone is suffering from a mild disorder with acute onset that we know is time limited, we might advise the individual not to bother with expensive treatment because the problem will be over soon enough, like a common cold. If the disorder is likely to last a long time (become chronic), however, the individual might want to seek treatment and take other appropriate steps. The anticipated course of a disorder is called the prognosis. So we might say, “the prognosis is good,” meaning the individual will probably recover, or “the prognosis is guarded,” meaning the probable outcome doesn’t look good.

The patient’s age may be an important part of the clini- cal description. A specific psychological disorder occurring in childhood may present differently from the same disorder in adulthood or old age. Children experiencing severe anxiety and panic often assume that they are physically ill because they have difficulty understanding that there is nothing phys- ically wrong. Because their thoughts and feelings are differ- ent from those experienced by adults with anxiety and panic, children are often misdiagnosed and treated for a medical disorder.

We call the study of changes in behavior over time develop- mental psychology, and we refer to the study of changes in abnor- mal behavior as developmental psychopathology. When you think of developmental psychology, you probably picture researchers studying the behavior of children. We change throughout our lives, however, and so researchers also study development in adolescents, adults, and older adults. Study of abnormal behav- ior across the entire age span is referred to as life-span develop- mental psychopathology. The field is relatively new but expanding rapidly.

causation, treatment, and etiology outcomes Etiology, or the study of origins, has to do with why a disorder begins (what causes it) and includes biological, psychological, and social dimensions. Because the etiology of psychological

Children experience panic and anxiety differently from adults, so their reactions may be mistaken for symptoms of physical illness.

un g

C hu

ng C

hi h

/S hu

tt er

st oc

k. co

50443_ch01_ptg01_hr_002-031.indd 8 28/09/16 2:43 PM

the sUPernatUral tradit ion 9

The Supernatural Tradition For much of our recorded history, deviant behavior has been considered a reflection of the battle between good and evil. When confronted with unexplainable, irrational behavior and by suffering and upheaval, people have perceived evil. In fact, in the Great Persian

In the past, textbooks emphasized treatment approaches in a general sense, with little attention to the disorder being treated. For example, a mental health professional might be thoroughly trained in a single theoretical approach, such as psychoanalysis or behavior therapy (both described later in the chapter), and then use that approach on every disorder. More recently, as our science has advanced, we have developed spe- cific effective treatments that do not always adhere neatly to one theoretical approach or another but that have grown out of a deeper understanding of the disorder in question. For this reason, there are no separate chapters in this book on such types of treatment approaches as psychodynamic, cognitive behavioral, or humanistic. Rather, the latest and most effec- tive drug and psychosocial treatments (nonmedical treatments that focus on psychological, social, and cultural factors) are described in the context of specific disorders in keeping with our integrative multidimensional perspective.

We now survey many early attempts to describe and treat abnormal behavior and to comprehend its causes, which will give you a better perspective on current approaches. In Chapter 2, we examine exciting contemporary views of causation and treatment. In Chapter 3, we discuss efforts to describe, or classify, abnormal behavior. In Chapter 4, we review research methods—our systematic efforts to discover the truths underlying description, cause, and treatment that allow us to function as scientist-practitioners. In Chapters 5 through 15, we examine specific disorders; our discussion is organized in each case in the now familiar triad of description, cause, and treatment. Finally, in Chapter 16 we examine legal, professional, and ethical issues relevant to psychological dis- orders and their treatment today. With that overview in mind, let us turn to the past.

Historical Conceptions of Abnormal Behavior For thousands of years, humans have tried to explain and con- trol problematic behavior. But our efforts always derive from the theories or models of behavior popular at the time. The purpose of these models is to explain why someone is “acting like that.” Three major models that have guided us date back to the beginnings of civilization.

Humans have always supposed that agents outside our bodies and environment influence our behavior, think- ing, and emotions. These agents—which might be divini- ties, demons, spirits, or other phenomena such as magnetic fields or the moon or the stars—are the driving forces behind the supernatural model. In addition, since the era of ancient Greece, the mind has often been called the soul or the psyche and considered separate from the body. Although many have thought that the mind can influence the body and, in turn, the body can influence the mind, most philosophers looked for causes of abnormal behavior in one or the other. This split gave rise to two traditions of thought about abnormal behav- ior, summarized as the biological model and the psychological model. These three models—the supernatural, the biological, and the psychological—are very old but continue to be used today.

Part A Write the letter for any or all of the following definitions of abnormality in the blanks: (a) societal norm violation, (b) impairment in functioning, (c) dysfunction, and (d) distress.

1. Miguel recently began feeling sad and lonely. Although still able to function at work and fulfill other responsi- bilities, he finds himself feeling down much of the time and he worries about what is happening to him. Which of the definitions of abnormality apply to Miguel’s situation? _____________

2. Three weeks ago, Jane, a 35-year-old business executive, stopped showering, refused to leave her apartment, and started watching television talk shows. Threats of being fired have failed to bring Jane back to reality, and she continues to spend her days staring blankly at the television screen. Which of the definitions seems to describe Jane’s behavior? ______________

Part B Match the following words that are used in clinical descriptions with their corresponding examples: (a) presenting problem, (b) prevalence, (c) incidence, (d) prognosis, (e) course, and (f) etiology.

3. Maria should recover quickly with no intervention necessary. Without treatment, John will deteriorate rapidly. ________________

4. Three new cases of bulimia have been reported in this county during the past month and only one in the next county. ______________

5. Elizabeth visited the campus mental health center because of her increasing feelings of guilt and anxiety. _________________

6. Biological, psychological, and social influences all contribute to a variety of disorders. ______________

7. The pattern a disorder follows can be chronic, time- limited, or episodic. _________

8. How many people in the population as a whole suffer from obsessive-compulsive disorder? ____________

Concept Check 1.1

50443_ch01_ptg01_hr_002-031.indd 9 28/09/16 2:43 PM

10 CHAPTER 1 abnormal behavior in h istor ical context

Empire from 900 to 600 b.c., all physical and mental disorders were considered the work of the devil (Millon, 2004). Barbara Tuchman, a noted historian, chronicled the second half of the 14th century, a particularly difficult time for humanity, in A Distant Mirror (1978). She ably captures the conflicting tides of opinion on the origins and treatment of insanity during that bleak and tumultuous period.

Demons and Witches One strong current of opinion put the causes and treatment of psychological disorders squarely in the realm of the supernatu- ral. During the last quarter of the 14th century, religious and lay authorities supported these popular superstitions, and society as a whole began to believe more strongly in the existence and power of demons and witches. The Catholic Church had split, and a sec- ond center, complete with a pope, emerged in the south of France to compete with Rome. In reaction to this schism, the Roman Church fought back against the evil in the world that it believed must have been behind this heresy.

People increasingly turned to magic and sorcery to solve their problems. During these turbulent times, the bizarre behavior of people afflicted with psychological disorders was seen as the work of the devil and witches. It followed that individuals possessed by evil spirits were probably responsible for any misfortune experi- enced by people in the local community, which inspired drastic action against the possessed. Treatments included exorcism, in which various religious rituals were performed in an effort to rid the victim of evil spirits. Other approaches included shaving the pattern of a cross in the hair of the victim’s head and securing suf- ferers to a wall near the front of a church so that they might benefit from hearing Mass.

The conviction that sorcery and witches are causes of madness and other evils continued into the 15th century, and evil contin- ued to be blamed for unexplainable behavior, even after the found- ing of the United States, as evidenced by the Salem, Massachusetts, witch trials in the late 17th century, which resulted in the hanging deaths of 20 women.

Stress and Melancholy An equally strong opinion, even during this period, reflected the enlightened view that insanity was a natural phenomenon, caused by mental or emotional stress, and that it was curable (Alexander & Selesnick, 1966; Maher & Maher, 1985a). Mental depression and anxiety were recognized as illnesses (Kemp, 1990; Schoeneman, 1977), although symptoms such as despair and lethargy were often identified by the church with the sin of acedia, or sloth (Tuchman, 1978). Common treatments were rest, sleep, and a healthy and happy environment. Other treatments included baths, ointments, and various potions. Indeed, during the 14th and 15th centuries, people with insanity, along with those with physical deformities or disabilities, were often moved from house to house in medieval villages as neighbors took turns caring for them. We now know that this medieval practice of keeping people who have psycho- logical disturbances in their own community is beneficial (see Chapter 13). We return to this subject when we discuss biological and psychological models later in this chapter.

During the Middle Ages, individuals with psychological disorders were sometimes thought to be possessed by evil spirits and exorcisms were attempted through rituals.

D E

A P

IC TU

R E

L IB

R A

R Y

/G et

ty Im

ag es

In the 14th century, one of the chief advisers to the king of France, a bishop and philosopher named Nicholas Oresme, also suggested that the disease of melancholy (depression) was the source of some bizarre behavior, rather than demons. Oresme pointed out that much of the evidence for the existence of sorcery and witchcraft, particularly among those considered insane, was obtained from people who were tortured and who, quite under- standably, confessed to anything.

These conflicting crosscurrents of natural and supernatural explanations for mental disorders are represented more or less strongly in various historical works, depending on the sources consulted by historians. Some assumed that demonic influences were the predominant explanations of abnormal behavior during the Middle Ages (for example, Zilboorg & Henry, 1941); others believed that the supernatural had little or no influence. As we see in the handling of the severe psychological disorder experienced by late-14th-century King Charles VI of France, both influences were strong, sometimes alternating in the treatment of the same case.

50443_ch01_ptg01_hr_002-031.indd 10 28/09/16 2:44 PM

the sUPernatUral tradit ion 11

Treatments for Possession With a perceived connection between evil deeds and sin on the one hand and psychological disorders on the other, it is logical to conclude that the sufferer is largely responsible for the disor- der, which might well be a punishment for evil deeds. Does this sound familiar? The acquired immune deficiency syndrome (AIDS) epidemic was associated with a similar belief among some people, particularly in the late 1980s and early 1990s. Because the human immunodeficiency virus (HIV) is, in Western societies, most prevalent among individuals with homosexual orientation, many people believed it was a divine punishment for what they considered immoral behavior. This view became less common as the AIDS virus spread to other segments of the population, yet it persists.

Possession, however, is not always connected with sin but may be seen as involuntary and the possessed individual as blameless. Furthermore, exorcisms at least have the virtue of being relatively painless. Interestingly, they sometimes work, as do other forms of faith healing, for reasons we explore in subsequent chapters. But what if they did not? In the Middle Ages, if exorcism failed, some authorities thought that steps were necessary to make the body uninhabitable by evil spirits, and many people were subjected to confinement, beatings, and other forms of torture (Kemp, 1990).

Somewhere along the way, a creative “therapist” decided that hanging people over a pit full of poisonous snakes might scare the evil spirits right out of their bodies (to say nothing of terrifying the people themselves). Strangely, this approach sometimes worked; that is, the most disturbed, oddly behaving individuals would suddenly come to their senses and experi- ence relief from their symptoms, if only temporarily. Naturally, this was reinforcing to the therapist, so snake pits were built in many institutions. Many other treatments based on the hypoth- esized therapeutic element of shock were developed, including dunkings in ice-cold water.

Mass Hysteria Another fascinating phenomenon is characterized by large-scale outbreaks of bizarre behavior. To this day, these episodes puzzle historians and mental health practitioners. During the Middle Ages, they lent support to the notion of possession by the devil. In Europe, whole groups of people were simultaneously com- pelled to run out in the streets, dance, shout, rave, and jump

In the summer of 1392, King Charles VI of France was under a great deal of stress, partly because of the divi- sion of the Catholic Church. As he rode with his army to the province of Brittany, a nearby aide dropped his lance with a loud clatter and the king, thinking he was under attack, turned on his own army, killing several prominent knights before being subdued from behind. The army immediately marched back to Paris. The King’s lieutenants and advisers concluded that he was mad.

During the following years, at his worst the King hid in a corner of his castle believing he was made of glass or roamed the corridors howling like a wolf. At other times, he couldn’t remember who or what he was. He became fearful and enraged whenever he saw his own royal coat of arms and would try to destroy it if it was brought near him.

The people of Paris were devastated by their leader’s apparent madness. Some thought it reflected God’s anger, because the King failed to take up arms to end the schism in the Catholic Church; others thought it was God’s warning against taking up arms; and still others thought it was divine punishment for heavy taxes (a conclusion some people might make today). But most thought the King’s mad- ness was caused by sorcery, a belief strengthened by a great drought that dried up the ponds and rivers, causing cattle to die of thirst. Merchants claimed their worst losses in 20 years.

Naturally, the King was given the best care available at the time. The most famous healer in the land was a 92-year-old physician whose treatment program included moving the King to one of his residences in the country where the air was thought to be the cleanest in the land. The physician prescribed rest, relaxation, and recreation. After some time, the King seemed to recover. The physi- cian recommended that the King not be burdened with the responsibilities of running the kingdom, claiming that if he had few worries or irritations, his mind would gradually strengthen and further improve.

Unfortunately, the physician died and the insanity of King Charles VI returned more seriously than before. This time, however, he came under the influence of the conflicting crosscurrent of supernatural causation. “An unkempt evil- eyed charlatan and pseudo-mystic named Arnaut Guilhem was allowed to treat Charles on his claim of possessing a book given by God to Adam by means of which man could overcome all affliction resulting from original sin” (Tuchman, 1978, p. 514). Guilhem insisted that the King’s malady was caused by sorcery, but his treatments failed to bring about a cure.

A variety of remedies and rituals of all kinds were tried, but none worked. High-ranking officials and doctors of the university called for the “sorcerers” to be discovered and punished. “On one occasion, two Augustinian friars, after getting no results from magic incantations and a liquid made

Charles VI... The Mad King from powdered pearls, proposed to cut incisions in the King’s head. When this was not allowed by the King’s council, the friars accused those who opposed their recommendation of sorcery” (Tuchman, 1978, p. 514). Even the King himself, during his lucid moments, came to believe that the source of madness was evil and sor- cery. “In the name of Jesus Christ,” he cried, weeping in his agony, “if there is any one of you who is an accom- plice to this evil I suffer, I beg him to torture me no longer but let me die!” (Tuchman, 1978, p. 515). •

50443_ch01_ptg01_hr_002-031.indd 11 28/09/16 2:44 PM

12 CHAPTER 1 abnormal behavior in h istor ical context

to spread to those around us (Hatfield, Cacioppo, & Rapson, 1994; Ntika, Sakellariou, Kefalas, & Stamatpoulou, 2014; Wang, 2006). If someone nearby becomes frightened or sad, chances are that, for the moment, you also will feel fear or sadness. When this kind of experience escalates into full-blown panic, whole communities are affected (Barlow, 2002). People are also suggestible when they are in states of high emotion. Therefore, if one person identifies a “cause” of the problem, others will probably assume that their own reactions have the same source. In popular language, this shared response is sometimes referred to as mob psychology. Until recently, it was assumed that victims had to be in contact with each other for the contagion to occur, as were the girls described above in the adjacent classrooms. But lately there are document- ed cases of emotion contagion occurring across social networks, raising the possibility that episodes of mass hysteria may increase (Bartholomew, Wessely, & Rubin, 2012; Dimon, 2013)

The Moon and the Stars Paracelsus, a Swiss physician who lived from 1493 to 1541, rejected notions of possession by the devil, suggesting instead that the movements of the moon and stars had profound effects on people’s psychological functioning. Echoing similar thinking in ancient Greece, Paracelsus speculated that the gravitational effects of the moon on bodily fluids might be a possible cause of mental disorders (Rotton & Kelly, 1985). This influential theory inspired the word lunatic, which is derived from the Latin word luna, mean- ing “moon.” You might hear some of your friends explain some- thing crazy they did one night by saying, “It must have been the full moon.” The belief that heavenly bodies affect human behavior still exists, although there is no scientific evidence to support it (Raison, Klein, & Steckler, 1999; Rotton & Kelly, 1985). Despite much ridicule, millions of people around the world are convinced that their behavior is influenced by the stages of the moon or the positions of the stars. This belief is most noticeable today in followers of astrology, who hold that their behavior and the major events in their lives can be predicted by their day-to-day relation- ship to the position of the planets. No serious evidence has ever confirmed such a connection, however.

Comments The supernatural tradition in psychopathology is alive and well, although it is relegated, for the most part, to small religious sects in this country and to primitive cultures elsewhere. Members of organized religions in most parts of the world look to psychology and medical science for help with major psychological disorders; in fact, the Roman Catholic Church requires that all health- care resources be exhausted before spiritual solutions such as exorcism can be considered. Nonetheless, miraculous cures are sometimes achieved by exorcism, magic potions and rituals, and other methods that seem to have little connection with modern science. It is fascinating to explore them when they do occur, and we return to this topic in subsequent chapters. But such cases are relatively rare, and almost no one would advocate supernatural treatment for severe psychological disorders except, perhaps, as a last resort.

around in patterns as if they were at a particularly wild party late at night (still called a rave today, but with music). This behavior was known by several names, including Saint Vitus’s Dance and tarantism. It is most interesting that many people behaved in this strange way at once. In an attempt to explain the inexplicable, several reasons were offered in addition to possession. One rea- sonable guess was reaction to insect bites. Another possibility was what we now call mass hysteria (Veith, 1965). Consider the following example.

Modern Mass Hysteria One Friday afternoon, an alarm sounded over the public address system of a community hospital, calling all physicians to the emer- gency room immediately. Arriving from a local school in a fleet of ambulances were 17 students and 4 teachers who reported dizzi- ness, headache, nausea, and stomach pains. Some were vomiting; most were hyperventilating.

All the students and teachers had been in four classrooms, two on each side of the hallway. The incident began when a 14-year-old girl reported a funny smell that seemed to be com- ing from a vent. She fell to the floor, crying and complaining that her stomach hurt and her eyes stung. Soon, many of the students and most of the teachers in the four adjoining class- rooms, who could see and hear what was happening, experi- enced similar symptoms. Of 86 susceptible people (82 students and 4 teachers in the four classrooms), 21 patients (17 students and 4 teachers) experienced symptoms severe enough to be evaluated at the hospital. Inspection of the school building by public health authorities revealed no apparent cause for the reac- tions, and physical examinations by teams of physicians revealed no physical abnormalities. All the patients were sent home and quickly recovered (Rockney & Lemke, 1992).

Mass hysteria may simply demonstrate the phenomenon of emotion contagion, in which the experience of an emotion seems

In hydrotherapy, patients were shocked back to their senses by appli- cations of ice-cold water.

Source: U.S. National Library of Medicine

50443_ch01_ptg01_hr_002-031.indd 12 28/09/16 2:44 PM

the b iological tradit ion 13

humoral theory of disorders. Hippocrates assumed that normal brain functioning was related to four bodily fluids or humors: blood, black bile, yellow bile, and phlegm. Blood came from the heart, black bile from the spleen, phlegm from the brain, and choler or yellow bile from the liver. Physicians believed that dis- ease resulted from too much or too little of one of the humors; for example, too much black bile was thought to cause melan- cholia (depression). In fact, the term melancholer, which means “black bile,” is still used today in its derivative form melancholy to refer to aspects of depression. The humoral theory was, perhaps, the first example of associating psychological disorders with a “chemical imbalance,” an approach that is widespread today.

The four humors were related to the Greeks’ conception of the four basic qualities: heat, dryness, moisture, and cold. Each humor was associated with one of these qualities. Terms derived from the four humors are still sometimes applied to personality traits. For example, sanguine (literal meaning “red, like blood”) describes someone who is ruddy in complexion, presumably from copious blood flowing through the body, and cheerful and optimistic, although insomnia and delirium were thought to be caused by excessive blood in the brain. Melancholic means depres- sive (depression was thought to be caused by black bile flooding the brain). A phlegmatic personality (from the humor phlegm) indicates apathy and sluggishness but can also mean being calm under stress. A choleric person (from yellow bile or choler) is hot tempered (Maher & Maher, 1985a).

Excesses of one or more humors were treated by regulating the environment to increase or decrease heat, dryness, moisture, or cold, depending on which humor was out of balance. One reason King Charles VI’s physician moved him to the less stressful coun- tryside was to restore the balance in his humors (Kemp, 1990). In addition to rest, good nutrition, and exercise, two treatments were developed. In one, bleeding or bloodletting, a carefully measured

amount of blood was removed from the body, often with leeches. The other was to induce vomiting; indeed, in a well-known treatise on depression published in 1621, Anatomy of Melancholy, Robert Burton recommended eating tobacco and a half-boiled cabbage to induce vomiting (Burton, 1621/1977). If Judy had lived 300 years ago, she might have been diagnosed with an illness, a brain disorder, or some other physical problem, perhaps related to excessive humors, and been given the proper medical treatments of the day: bed rest, a healthful diet, exercise, and other ministrations as indicated.

In ancient China and throughout Asia, a similar idea existed. But rather than “humors,” the Chinese focused on the move- ment of air or “wind” throughout the body. Unexplained mental disorders were caused by blockages of wind or the presence of cold, dark wind (yin) as opposed to warm, life- sustaining wind (yang). Treatment involved restoring proper flow of wind through vari- ous methods, including acupuncture.

The Biological Tradition Physical causes of mental disorders have been sought since early in history. Important to the biological tradition are a man, Hippocrates; a disease, syphilis; and the early consequences of believing that psychological disorders are biologically caused.

Hippocrates and galen The Greek physician Hippocrates (460–377 b.c.) is considered to be the father of modern Western medicine. He and his asso- ciates left a body of work called the Hippocratic Corpus, writ- ten between 450 and 350 b.c. (Maher & Maher, 1985a), in which they suggested that psychological disorders could be treated like any other disease. They did not limit their search for the causes of psychopathology to the general area of “dis- ease,” because they believed that psychological disorders might also be caused by brain pathology or head trauma and could be influenced by heredity (genetics). These are remarkably astute deductions for the time, and they have been supported in recent years. Hippocrates considered the brain to be the seat of wisdom, consciousness, intelligence, and emotion. Therefore, disorders involving these functions would logically be located in the brain. Hippocrates also recognized the importance of psychological and interpersonal contributions to psychopathology, such as the sometimes-negative effects of family stress; on some occasions, he removed patients from their families.

The Roman physician Galen (approximately a.d. 129–198) later adopted the ideas of Hippocrates and his associates and developed them further, creating a powerful and influential school of thought within the biological tradition that extended well into the 19th century. One of the more interesting and influential legacies of the Hippocratic-Galenic approach is the

Emotions are contagious and can escalate into mass hysteria.

A P

Im ag

es /H

at em

M ou

ss a

50443_ch01_ptg01_hr_002-031.indd 13 28/09/16 2:44 PM

14 CHAPTER 1 abnormal behavior in h istor ical context

syphilis Behavioral and cognitive symptoms of what we now know as advanced syphilis, a sexually transmitted disease caused by a bac- terial microorganism entering the brain, include believing that everyone is plotting against you (delusion of persecution) or that you are God (delusion of grandeur), as well as other bizarre behav- iors. Although these symptoms are similar to those of psychosis— psychological disorders characterized in part by beliefs that are not based in reality (delusions), perceptions that are not based in reality (hallucinations), or both—researchers recognized that a subgroup of apparently psychotic patients deteriorated steadily, becoming paralyzed and dying within 5 years of onset. This course of events contrasted with that of most psychotic patients, who remained fairly stable. In 1825, the condition was designated a disease, general paresis, because it had consistent symptoms (pre- sentation) and a consistent course that resulted in death. The rela- tionship between general paresis and syphilis was only gradually established. Louis Pasteur’s germ theory of disease, developed in about 1870, facilitated the identification of the specific bacterial microorganism that caused syphilis.

Of equal importance was the discovery of a cure for general paresis. Physicians observed a surprising recovery in patients with general paresis who had contracted malaria, so they deliberately injected other patients with blood from a soldier who was ill with malaria. Many recovered because the high fever “burned out” the syphilis bacteria. Obviously, this type of experiment would not be ethically possible today. Ultimately, clinical investigators dis- covered that penicillin cures syphilis, but with the malaria cure, “madness” and associated behavioral and cognitive symptoms for the first time were traced directly to a curable infection. Many mental health professionals then assumed that comparable causes and cures might be discovered for all psychological disorders.

John P. grey The champion of the biological tradition in the United States was the most influential American psychiatrist of the time, John P. Grey (Bockoven, 1963). In 1854, Grey was appointed superintendent of the Utica State Hospital in New York, the larg- est in the country. He also became editor of the American Journal of Insanity, the precursor of the current American Journal of Psychiatry, the flagship publication of the American Psychiatric Association (APA). Grey’s position was that the causes of insanity were always physical. Therefore, the mentally ill patient should be treated as physically ill. The emphasis was again on rest, diet, and proper room temperature and ventilation, approaches used for centuries by previous therapists in the biological tradition. Grey even invented the rotary fan to ventilate his large hospital.

Under Grey’s leadership, the conditions in hospitals greatly improved and they became more humane, livable institutions. But in subsequent years they also became so large and impersonal that individual attention was not possible.

In fact, leaders in psychiatry at the end of the 19th century were alarmed at the increasing size and impersonality of

Hippocrates also coined the word hysteria to describe a concept he learned about from the Egyptians, who had identi- fied what we now call the somatic symptom disorders. In these disorders, the physical symptoms appear to be the result of a medical problem for which no physical cause can be found, such as paralysis and some kinds of blindness. Because these disorders occurred primarily in women, the Egyptians (and Hippocrates) mistakenly assumed that they were restricted to women. They also presumed a cause: The empty uterus wan- dered to various parts of the body in search of conception (the Greek word for “uterus” is hysteron). Numerous physical symptoms reflected the location of the wandering uterus. The prescribed cure might be marriage or, occasionally, fumiga- tion of the vagina to lure the uterus back to its natural loca- tion (Alexander & Selesnick, 1966). Knowledge of physiology eventually disproved the wandering uterus theory; however, the tendency to stigmatize dramatic women as hysterical continued unabated well into the 1970s, when mental health professionals became sensitive to the prejudicial stereotype the term implied. As you will learn in Chapter 6, somatic symptom disorders (and the traits associated with them) are not limited to one sex or the other.

The 19th Century The biological tradition waxed and waned during the centu- ries after Hippocrates and Galen but was reinvigorated in the 19th century because of two factors: the discovery of the nature and cause of syphilis and strong support from the well-respected American psychiatrist John P. Grey.

Bloodletting, the extraction of blood from patients, was intended to restore the balance of humors in the body.

N at

io na

l L ib

ra ry

o f

M ed

ic in

50443_ch01_ptg01_hr_002-031.indd 14 28/09/16 2:44 PM

the b iological tradit ion 15

that the shock also made him “strangely elated” and wondered if it might be a useful treatment for depression (Finger & Zaromb, 2006, p. 245).

Independently in the 1920s, Hungarian psychiatrist Joseph von Meduna observed that schizophrenia was rarely found in individuals with epilepsy (which ultimately did not prove to be true). Some of his followers concluded that induced brain seizures might cure schizophrenia. Following suggestions on the possible benefits of applying electric shock directly to the brain—notably, by two Italian physicians, Ugo Cerletti and Lucio Bini, in 1938—a surgeon in London treated a depressed patient by sending six small shocks directly through his brain, produc- ing convulsions (Hunt, 1980). The patient recovered. Although greatly modified, shock treatment is still with us today. The con- troversial modern uses of electroconvulsive therapy are described in Chapter 7. It is interesting that even now we have little knowl- edge of how it works.

During the 1950s, the first effective drugs for severe psychotic disorders were developed in a systematic way. Before that time, a number of medicinal substances, including opium (derived from poppies), had been used as sedatives, along with countless herbs and folk remedies (Alexander & Selesnick, 1966). With the discovery of Rauwolfia serpentine (later renamed reserpine) and another class of drugs called neuroleptics (major tranquilizers), for the first time hallucinatory and delusional thought pro- cesses could be diminished in some patients; these drugs also controlled agitation and aggressiveness. Other discoveries included benzodiazepines (minor tranquilizers), which seemed to reduce anxiety. By the 1970s, the benzodiazepines (known by such brand names as Valium and Librium) were among the most widely prescribed drugs in the world. As drawbacks and side effects of tranquilizers became apparent, along with their limited effectiveness, prescriptions decreased somewhat (we discuss the benzodiazepines in more detail in Chapters 5 and 11).

Throughout the centuries, as Alexander and Selesnick point out, “The general pattern of drug therapy for mental illness has been one of initial enthusiasm followed by disappointment” (1966, p. 287). For example, bromides, a class of sedating drugs, were used at the end of the 19th century and beginning of the 20th century to treat anxiety and other psychological disorders. By the 1920s, they were reported as being effective for many serious psychological and emotional symptoms. By 1928, one of every five prescriptions in the United States was for bromides. When their side effects, including various undesirable physical symptoms, became widely known, and experience began to show that their overall effectiveness was relatively modest, bromides largely disap- peared from the scene.

Neuroleptics have also been used less as attention has focused on their many side effects, such as chronic tremors and shaking. However, the positive effects of these drugs on some patients’ psychotic symptoms of hallucinations, delusions, and agitation revitalized both the search for biological contributions to psy- chological disorders and the search for new and more powerful drugs, a search that has paid many dividends, as documented in later chapters.

mental hospitals and recommended that they be downsized. It was almost 100 years before the community mental health movement was successful in reducing the population of mental hospitals with the controversial policy of deinstitu- tionalization, in which patients were released into their com- munities. Unfortunately, this practice has as many negative consequences as positive ones, including a large increase in the number of chronically disabled patients homeless on the streets of our cities.

The Development of Biological Treatments On the positive side, renewed interest in the biological origin of psychological disorders led, ultimately, to greatly increased under- standing of biological contributions to psychopathology and to the development of new treatments. In the 1930s, the physi- cal interventions of electric shock and brain surgery were often used. Their effects, and the effects of new drugs, were discovered quite by accident. For example, insulin was occasionally given to stimulate appetite in psychotic patients who were not eating, but it also seemed to calm them down. In 1927, a Viennese physician, Manfred Sakel, began using increasingly higher dosages until, finally, patients convulsed and became temporarily comatose (Sakel, 1958). Some actually recovered their mental health, much to the surprise of everybody, and their recovery was attributed to the convulsions. The procedure became known as insulin shock therapy, but it was abandoned because it was too dangerous, often resulting in prolonged coma or even death. Other methods of producing convulsions had to be found.

Benjamin Franklin made numerous discoveries during his life with which we are familiar, but most people don’t know that he discovered accidentally, and then confirmed experimentally in the 1750s, that a mild and modest electric shock to the head produced a brief convulsion and memory loss (amnesia) but otherwise did little harm. A Dutch physician who was a friend and colleague of Franklin tried it on himself and discovered

In the 19th century, psychological disorders were attributed to mental or emotional stress, so patients were often treated sympathetically in a restful and hygienic environment.

O ld

P ap

er S

tu di

os /

A la

m y

S to

ck P

ho to

50443_ch01_ptg01_hr_002-031.indd 15 28/09/16 2:44 PM

16 CHAPTER 1 abnormal behavior in h istor ical context

The Psychological Tradition It is a long leap from evil spirits to brain pathology as the cause of psychological disorders. In the intervening centuries, where was the body of thought that put psychological development, both normal and abnormal, in an interpersonal and social context? In fact, this approach has a long and distinguished tradition. Plato, for example, thought that the two causes of maladaptive behavior were the social and cultural influences in one’s life and the learn- ing that took place in that environment. If something was wrong in the environment, such as abusive parents, one’s impulses and emotions would overcome reason. The best treatment was to reed- ucate the individual through rational discussion so that the power of reason would predominate (Maher & Maher, 1985a). This was very much a precursor to modern psychosocial treatment approaches to the causation of psychopathology, which focus not only on psychological factors but also on social and cultural ones. Other well-known early philosophers, including Aristotle, also emphasized the influence of social environment and early learn- ing on later psychopathology. These philosophers wrote about the importance of fantasies, dreams, and cognitions and thus anticipated, to some extent, later developments in psychoanalytic thought and cognitive science. They also advocated humane and responsible care for individuals with psychological disturbances.

Moral Therapy During the first half of the 19th century, a strong psychosocial approach to mental disorders called moral therapy became influ- ential. The term moral actually referred more to emotional or psy- chological factors rather than to a code of conduct. Its basic tenets included treating institutionalized patients as normally as possible in a setting that encouraged and reinforced normal social interac- tion (Bockoven, 1963), thus providing them with many opportuni- ties for appropriate social and interpersonal contact. Relationships were carefully nurtured. Individual attention clearly emphasized positive consequences for appropriate interactions and behavior, and restraint and seclusion were eliminated.

As with the biological tradition, the principles of moral therapy date back to Plato and beyond. For example, the Greek Asclepiad Temples of the 6th century b.c. housed the chronically ill, including those with psychological disorders. Here, patients were well cared for, massaged, and provided with soothing music. Similar enlightened practices were evident in Muslim countries in the Middle East (Millon, 2004). But moral therapy as a sys- tem originated with the well-known French psychiatrist Philippe Pinel (1745–1826) and his close associate Jean-Baptiste Pussin (1746–1811), who was the superintendent of the Parisian hospital La Bicêtre (Gerard, 1997; Zilboorg & Henry, 1941).

When Pinel arrived in 1791, Pussin had already instituted remark- able reforms by removing all chains used to restrain patients and instituting humane and positive psychological interventions. Pussin persuaded Pinel to go along with the changes. Much to Pinel’s credit, he did, first at La Bicêtre and then at the women’s hospital Salpétrière, where he invited Pussin to join him (Gerard, 1997; Maher & Maher, 1985b; Weiner, 1979). Here again, they instituted a humane and socially facilitative atmosphere that produced “miraculous” results.

Consequences of the Biological Tradition In the late 19th century, Grey and his colleagues ironically reduced or eliminated interest in treating mental patients, because they thought that mental disorders were the result of some as-yet- undiscovered brain pathology and were therefore incurable. The only available course of action was to hospitalize these patients. Around the turn of the century, some nurses documented clini- cal success in treating mental patients but were prevented from treating others for fear of raising hopes of a cure among family members. In place of treatment, interest centered on diagnosis, legal questions concerning the responsibility of patients for their actions during periods of insanity, and the study of brain pathol- ogy itself.

Emil Kraepelin (1856–1926) was the dominant figure dur- ing this period and one of the founding fathers of modern psy- chiatry. He was extremely influential in advocating the major ideas of the biological tradition, but he was little involved in treatment. His lasting contribution was in the area of diagno- sis and classification, which we discuss in detail in Chapter 3. Kraepelin (1913) was one of the first to distinguish among various psychological disorders, seeing that each may have a different age of onset and time course, with somewhat differ- ent clusters of presenting symptoms, and probably a different cause. Many of his descriptions of schizophrenic disorders are still useful today.

By the end of the 1800s, a scientific approach to psychological disorders and their classification had begun with the search for biological causes. Furthermore, treatment was based on humane principles. There were many drawbacks, however, the most unfor- tunate being that active intervention and treatment were all but eliminated in some settings, despite the availability of some effec- tive approaches. It is to these that we now turn.

For thousands of years, humans have tried to understand and control abnormal behavior. Check your understanding of these historical theories and match them to the treatments used to “cure” abnormal behavior: (a) bloodletting; induced vomiting; (b) patient placed in socially facilitative environ- ments; and (c) exorcism; burning at the stake.

1. Supernatural causes; evil demons took over the victims’ bodies and controlled their behaviors. _____________

2. The humoral theory reflected the belief that normal functioning of the brain required a balance of four bodily fluids or humors. ______________

3. Maladaptive behavior was caused by poor social and cultural influences within the environment. ______________

Concept Check 1.2

50443_ch01_ptg01_hr_002-031.indd 16 28/09/16 2:44 PM

the Psychological tradit ion 17

recognized that moral therapy worked best when the number of patients in an institution was 200 or fewer, allowing for a great deal of individual attention. After the Civil War, enormous waves of immigrants arrived in the United States, yielding their own popu- lations of mentally ill. Patient loads in existing hospitals increased to 1,000 or 2,000, and even more. Because immigrant groups were thought not to deserve the same privileges as “native” Americans (whose ancestors had immigrated perhaps only 50 or 100 years earlier!), they were not given moral treatments even when there were sufficient hospital personnel.

A second reason for the decline of moral therapy has an unlikely source. The great crusader Dorothea Dix (1802–1887) campaigned endlessly for reform in the treatment of insanity. A schoolteacher who had worked in various institutions, she had firsthand knowledge of the deplorable conditions imposed on patients with insanity, and she made it her life’s work to inform the American public and their leaders of these abuses. Her work became known as the mental hygiene movement.

In addition to improving the standards of care, Dix worked hard to make sure that everyone who needed care received it, including the homeless. Through her efforts, humane treatment became more widely available in U.S. institutions. As her career drew to a close, she was rightly acknowledged as a hero of the 19th century.

After William Tuke (1732–1822) followed Pinel’s lead in England, Benjamin Rush (1745–1813), often considered the founder of U.S. psychiatry, introduced moral therapy in his early work at Pennsylvania Hospital. It then became the treatment of choice in the leading hospitals. Asylums had appeared in the 16th century, but they were more like prisons than hospitals. It was the rise of moral therapy in Europe and the United States that made asylums habitable and even therapeutic.

In 1833, Horace Mann, chairman of the board of trustees of the Worcester State Hospital, reported on 32 patients who had been given up as incurable. These patients were treated with moral therapy, cured, and released to their families. Of 100 patients who were viciously assaultive before treatment, no more than 12 continued to be violent a year after beginning treatment. Before treatment, 40 patients had routinely torn off any new clothes provided by attendants; only 8 continued this behavior after a period of treatment. These were remarkable statistics then and would be remarkable even today (Bockoven, 1963).

Asylum reform and the Decline of Moral Therapy Unfortunately, after the mid-19th century, humane treatment declined because of a convergence of factors. First, it was widely

In 1822 at an annual town meeting, the town of Nantucket, a small island 30 miles off the coast of Massachusetts, voted to build a permanent town poor farm and asylum (Gavin, 2003). After the War of 1812, Nantucket had pros- pered from trade as well as from the beginning of the great whaling era and the citizens wanted to take care of the less fortunate. Inspired by more modern beliefs at the time about the treatment of insanity, it was decided to place the asylum away from town in an area where residents could work pro- ductively in a pleasant and restful rural setting with fresh air, individual attention, and the availability of productive activities. As was characteristic of those days, asylums also cared for the poor and the elderly. Since misuse of alcohol was considered the principal cause of poverty, moving the asylums as far away from taverns as possible seemed logical and was another reason for locating the asylum in the coun- try. But more importantly, both alcohol abuse and insanity were considered curable after word reached the island of the very positive results from moral therapy at McLean Asylum near Boston. Thus, it was arranged for residents of the asy- lum to engage principally in agricultural labor, producing vegetables, eggs, and dairy products or working outside in the wheat and rye fields or with the livestock. The elderly or those unable to work outside of the asylum were pro- vided with productive work in their room such as weaving. Consistent with the tenets of moral therapy, it was thought

that a majority of the inmates might recover under the bene- fits of this healthy and restorative atmosphere. And the poor farm was well run and profitable for the town!

After building the asylum, town officials appointed a Board of Overseers, responsible leaders of Nantucket, who immedi- ately became concerned about the number of people visiting the asylum and poor farm presumably to gawk at the insane. In a further effort to protect the residents, the town passed an ordinance restricting visits only to those who applied in writ- ing and offered a good reason for visiting. Unfortunately, in the winter of February 1844, the structure burned to the ground. Despite heroic efforts of many townspeople, ten inmates were killed and the structure was destroyed.

Eventually a new asylum was built, but by this time it housed only the sick and elderly who could no longer care for themselves. By that time, the new state asylum for the insane had opened far from the island and the removal of people suffering from insanity to this large (and impersonal) state institution was seen as desirable. New policies were adopted for cases of poverty (presumably those not suffering from addiction of some kind) that included maintaining the poor in their dwellings and providing them with sufficient (but minimal) materials and resources to see them through. A new town “poor department” was created for this purpose. Thus did moral therapy rise and fall in a small rural town in New England, reflecting the tenor of the time (Gavin, 2003).

Asylums And Poor FArms in rurAl AmericA

50443_ch01_ptg01_hr_002-031.indd 17 28/09/16 2:44 PM

18 CHAPTER 1 abnormal behavior in h istor ical context

sat down in front at a concert? If so, you have something in com- mon with the patients of Franz Anton Mesmer (1734–1815) and with millions of people since his time who have been hypnotized. Mesmer suggested to his patients that their problem was caused by an undetectable fluid found in all living organisms called “animal magnetism,” which could become blocked.

Mesmer had his patients sit in a dark room around a large vat of chemicals with rods extending from it and touching them. Dressed in flowing robes, he might then identify and tap various areas of their bodies where their animal magnetism was blocked while suggesting strongly that they were being cured. Because of his rather unusual techniques, Mesmer was considered an oddity and maybe a charlatan, strongly opposed by the medical establish- ment (Winter, 1998). In fact, none less than Benjamin Franklin put animal magnetism to the test by conducting a brilliant experiment in which patients received either magnetized water or nonmag- netized water with strong suggestions that they would get better. Neither the patient nor the therapist knew which water was which, making it a double-blind experiment (see Chapter 4). When both groups got better, Franklin concluded that animal magne- tism, or mesmerism, was nothing more than strong suggestion (Gould, 1991; McNally, 1999). Nevertheless, Mesmer is widely regarded as the father of hypnosis, a state in which extremely sug- gestible subjects sometimes appear to be in a trance.

Many distinguished scientists and physicians were interested in Mesmer’s powerful methods of suggestion. One of the best known, Jean-Martin Charcot (1825–1893), was head of the Salpétrière Hospital in Paris, where Philippe Pinel had introduced psychological treatments several generations earlier. A distin- guished neurologist, Charcot demonstrated that some techniques of mesmerism were effective with a number of psychological disorders, and he did much to legitimize the fledgling practice of hypnosis. Significantly, in 1885 a young man named Sigmund Freud came from Vienna to study with Charcot.

After returning from France, Freud teamed up with Josef Breuer (1842–1925), who had experimented with a some- what different hypnotic procedure. While his patients were in the highly suggestible state of hypnosis, Breuer asked them to describe their problems, conflicts, and fears in as much detail as they could. Breuer observed two extremely important phenomena during this process. First, patients often became extremely emotional as they talked and felt quite relieved and improved after emerging from the hypnotic state. Second, seldom would they have gained an understanding of the rela- tionship between their emotional problems and their psycho- logical disorder. In fact, it was difficult or impossible for them to recall some details they had described under hypnosis. In other words, the material seemed to be beyond the awareness of the patient. With this observation, Breuer and Freud had “discovered” the unconscious mind and its apparent influence on the production of psychological disorders. This is one of the most important developments in the history of psychopathol- ogy and, indeed, of psychology as a whole.

A close second was their discovery that it is therapeutic to recall and relive emotional trauma that has been made unconscious and to release the accompanying tension. This release of emotional material became known as catharsis. A fuller understanding of

Unfortunately, an unforeseen consequence of Dix’s heroic efforts was a substantial increase in the number of mental patients. This influx led to a rapid transition from moral therapy to custodi- al care because hospitals were inadequately staffed. Dix reformed our asylums and single-handedly inspired the construction of numerous new institutions here and abroad. But even her tireless efforts and advocacy could not ensure sufficient staffing to allow the individual attention necessary to moral therapy. A final blow to the practice of moral therapy was the decision, in the middle of the 19th century, that mental illness was caused by brain pathol- ogy and, therefore, was incurable.

The psychological tradition lay dormant for a time, only to reemerge in several different schools of thought in the 20th century. The first major approach was psychoanalysis, based on Sigmund Freud’s (1856–1939) elaborate theory of the structure of the mind and the role of unconscious processes in determining behavior. The second was behaviorism, associated with John B. Watson, Ivan Pavlov, and B. F. Skinner, which focuses on how learning and adap- tation affect the development of psychopathology.

Psychoanalytic Theory Have you ever felt as if someone cast a spell on you? Have you ever been mesmerized by a look across the classroom from a beautiful man or woman, or a stare from a rock musician as you

Dorothea Dix (1802–1887) began the mental hygiene movement and spent much of her life campaigning for reform in the treatment of the mentally ill.

ve re

tt H

is to

ric al

/S hu

tt er

st oc

k. co

50443_ch01_ptg01_hr_002-031.indd 18 28/09/16 2:44 PM

the Psychological tradit ion 19

serious chronic illness that led to his death. Throughout his illness, Anna O. had cared for him; she felt it necessary to spend endless hours at his bedside. Five months after her father became ill, Anna noticed that during the day her vision blurred and that from time to time she had difficulty moving her right arm and both legs. Soon, additional symptoms appeared. She began to expe- rience some difficulty speak- ing, and her behavior became unpredictable. Shortly thereaf- ter, she consulted Breuer.

In a series of treatment ses- sions, Breuer dealt with one symptom at a time through hypnosis and subsequent “talking through,” tracing each symp- tom to its hypothetical causation in circumstances surrounding the death of Anna’s father. One at a time, her “hysterical” ail- ments disappeared, but only after treatment was administered for each respective behavior. This process of treating one behavior at a time fulfills a basic requirement for drawing scientific conclu- sions about the effects of treatment in an individual case study, as you will see in Chapter 4. We will return to the fascinating case of Anna O. in Chapter 6.

Freud took these basic observations and expanded them into the psychoanalytic model, the most comprehensive theory yet constructed on the development and structure of our personali- ties. He also speculated on where this development could go wrong and produce psychological disorders. Although many of Freud’s views changed over time, the basic principles of mental function- ing that he originally proposed remained constant through his writings and are still applied by psychoanalysts today.

Although most of it remains unproven, psychoanalytic theory has had a strong influence, and it is still important to be familiar with its basic ideas; what follows is a brief outline of the theory. We focus on its three major facets: (1) the structure of the mind and the distinct functions of personality that sometimes clash with one another; (2) the defense mechanisms with which the mind defends itself from these clashes, or conflicts; and (3) the stages of early psychosexual development that provide grist for the mill of our inner conflicts.

the structure of the mind The mind, according to Freud, has three major parts or func- tions: the id, the ego, and the superego (see E Figure 1.4). These terms, like many from psychoanalysis, have found their way into our common vocabulary, but although you may have heard them, you may not be aware of their meaning. The id is the source of our strong sexual and aggressive feelings or energies. It is, basi- cally, the animal within us; if totally unchecked, it would make us all rapists or killers. The energy or drive within the id is the

the relationship between current emotions and earlier events is referred to as insight. As you shall see throughout this book, par- ticularly in Chapters 5 and 6 on anxiety and somatic symptom disorders, the existence of “unconscious” memories and feelings and the importance of processing emotion-filled information have been verified and reaffirmed.

Freud and Breuer’s theories were based on case observations, some of which were made in a surprisingly systematic way for those times. An excellent example is Breuer’s classic description of his treatment of “hysterical” symptoms in Anna O. in 1895 (Breuer & Freud, 1895/1957). Anna O. was a bright, attractive young woman who was perfectly healthy until she reached 21 years of age. Shortly before her problems began, her father developed a

Franz Anton Mesmer (1734–1815) and other early therapists often used hypnosis and/or strong suggestions to cure their patients.

E ric

h Le

ss in

g/ A

rt R

es ou

rc e,

N Y

Jean Charcot (1825–1893) studied hypnosis and influenced Sigmund Freud to consider psychosocial approaches to psychological disorders.

Josef Breuer (1842–1925) worked on the celebrated case of Anna O. and, with Sigmund Freud, developed the theory of psychoanalysis.

M ar

y E

va ns

P ic

tu re

L ib

ra ry

/A la

m y

S to

ck P

ho to

B et

tm an

n/ G

et ty

Im ag

50443_ch01_ptg01_hr_002-031.indd 19 28/09/16 2:44 PM

20 CHAPTER 1 abnormal behavior in h istor ical context

often referred to as the executive or manager of our minds. If it mediates successfully, we can go on to the higher intellectual and creative pursuits of life. If it is unsuccessful and the id or superego becomes too strong, conflict will overtake us and psychological disorders will develop. Because these conflicts are all within the mind, they are referred to as intrapsychic conflicts. Now think back to the case of Anna O., in which Breuer observed that patients cannot always remember important but unpleasant emo- tional events. From these and other observations, Freud concep- tualized the mental structures described in this section to explain unconscious processes. He believed that the id and the superego are almost entirely unconscious. We are fully aware only of the secondary processes of the ego, which is a relatively small part of the mind.

defense mechanisms The ego fights a continual battle to stay on top of the warring id and superego. Occasionally, their conflicts produce anxiety that threatens to overwhelm the ego. The anxiety is a signal that alerts the ego to marshal defense mechanisms, unconscious protective processes that keep primitive emotions associated with conflicts in check so that the ego can continue its coordinating function. Although Freud first conceptualized defense mechanisms, it was his daughter, Anna Freud, who developed the ideas more fully.

We all use defense mechanisms at times—they are sometimes adaptive and at other times maladaptive. For example, have you ever done poorly on a test because the professor was unfair in the grading? And then when you got home you yelled at your younger brother or perhaps even your dog? This is an example of the defense mechanism of displacement. The ego adaptively decides that expressing primitive anger at your professor might not be in your best interest. Because your brother and your dog don’t have the authority to affect you in an adverse way, your anger is dis- placed to one of them. Some people may redirect energy from conflict or underlying anxiety into a more constructive outlet such as work, where they may be more efficient because of the redirec- tion. This process is called sublimation.

More severe internal conflicts that produce a lot of anxiety or other emotions can trigger self-defeating defensive processes or symptoms. Phobic and obsessive symptoms are especially common self-defeating defensive reactions that, according to Freud, reflect an inadequate attempt to deal with an internally dangerous situation. Phobic symptoms typically incorporate elements of the danger. For example, a dog phobia may be connected to an infantile fear of castra- tion; that is, a man’s internal conflict involves a fear of being attacked and castrated, a fear that is consciously expressed as a fear of being attacked and bitten by a dog, even if he knows the dog is harmless.

Defense mechanisms have been subjected to scientific study, and there is some evidence that they may be of potential import in the study of psychopathology (Vaillant, 1992; 2012). For example, Perry and Bond (2012, 2014) noted that reduction in unadaptive defense mechanisms, and strengthening of adaptive mechanisms such as humor and sublimation, correlated with psychological health. Thus, the concept of defense mechanisms—coping styles, in contemporary terminology—continues to be important to the study of psychopathology.

libido. Even today, some peo- ple explain low sex drive as an absence of libido. A less impor- tant source of energy, not as well conceptualized by Freud, is the death instinct, or thanatos. These two basic drives, toward life and fulfillment on the one hand and death and destruction on the other, are continually in opposition.

The id operates according to the pleasure principle, with an overriding goal of maximizing pleasure and eliminating any associated tension or conflicts. The goal of pleasure, which is particularly prominent in child- hood, often conflicts with social rules and regulations, as you shall see later. The id has its own characteristic way of process- ing information; referred to as the primary process, this type

of thinking is emotional, irrational, illogical, filled with fantasies, and preoccupied with sex, aggression, selfishness, and envy.

Fortunately for all of us, in Freud’s view, the id’s selfish and sometimes dangerous drives do not go unchecked. In fact, only a few months into life, we know we must adapt our basic demands to the real world. In other words, we must find ways to meet our basic needs without offending everyone around us. Put yet another way, we must act realistically. The part of our mind that ensures that we act realistically is called the ego, and it operates according to the reality principle instead of the pleasure prin- ciple. The cognitive operations or thinking styles of the ego are characterized by logic and reason and are referred to as the sec- ondary process, as opposed to the illogical and irrational primary process of the id.

The third important struc- ture within the mind, the superego, or what we might call conscience, represents the moral principles instilled in us by our parents and our culture. It is the voice within us that nags at us when we know we’re doing something wrong. Because the purpose of the superego is to counteract the potentially dan- gerous aggressive and sexual drives of the id, the basis for conflict is readily apparent.

The role of the ego is to mediate conflict between the id and the superego, juggling their demands with the reali- ties of the world. The ego is

M ar

y E

va ns

P ic

tu re

L ib

ra ry

/A la

m y

S to

ck P

ho to

Bertha Pappenheim (1859– 1936), famous as Anna O., was described as “hysterical” by Breuer.

A P

Im ag

Sigmund Freud (1856–1939) is considered the founder of psychoanalysis.

50443_ch01_ptg01_hr_002-031.indd 20 28/09/16 2:44 PM

the Psychological tradit ion 21

associated with oral fixation include depen- dency and passivity or, in reaction to these tendencies, rebelliousness and cynicism.

One of the more controversial and fre- quently mentioned psychosexual conflicts occurs during the phallic stage (from age 3 to age 5 or 6), which is characterized by early genital self-stimulation.

This conflict is the subject of the Greek tragedy Oedipus Rex, in which Oedipus is fated to kill his father and, unknowingly, to marry his mother. Freud asserted that all young boys relive this fantasy when genital self-stimulation is accompanied by images of sexual interactions with their mothers. These fantasies, in turn, are accompanied by strong feelings of envy and perhaps anger

toward their fathers, with whom they identify but whose place they wish to take. Furthermore, strong fears develop that the father may punish that lust by removing the son’s penis—thus, the phenomenon of castration anxiety. This fear helps the boy keep his lustful impulses toward his mother in check. The battle of the lustful impulses on the one hand and castration anxiety on the other creates a conflict that is internal, or intrapsychic, called the Oedipus complex. The phallic stage passes uneventfully only if several things happen. First, the child must resolve his ambiva- lent relationship with his parents and reconcile the simultaneous anger and love he has for his father. If this happens, he may go on to channel his libidinal impulses into heterosexual relationships while retaining harmless affection for his mother.

The counterpart conflict in girls, called the Electra complex, is even more controversial. Freud viewed the young girl as wanting to replace her mother and possess her father. Central to this pos- session is the girl’s desire for a penis, so as to be more like her father and brothers—hence the term penis envy. According to Freud, the

Examples of defense mechanisms are listed below (APA, 2000a):

Denial: Refuses to acknowledge some aspect of objective reality or subjective experience that is apparent to others

Displacement: Transfers a feeling about, or a response to, an object that causes discomfort onto another, usually less-threatening, object or person

Projection: Falsely attributes own unacceptable feelings, impulses, or thoughts to another individual or object

Rationalization: Conceals the true motivations for actions, thoughts, or feelings through elaborate reassuring or self- serving but incorrect explanations

Reaction formation: Substitutes behavior, thoughts, or feelings that are the direct opposite of unacceptable ones

Repression: Blocks disturbing wishes, thoughts, or experiences from conscious awareness

Sublimation: Directs potentially maladaptive feelings or impulses into socially acceptable behavior

Psychosexual stages of development Freud also theorized that during infancy and early childhood we pass through a number of psychosexual stages of development that have a profound and lasting impact. This makes Freud one of the first to take a developmental perspective on the study of abnormal behavior, which we look at in detail throughout this book. The stages—oral, anal, phallic, latency, and genital— represent distinctive patterns of gratifying our basic needs and satisfying our drive for physical pleasure. For example, the oral stage, typically extending for approximately 2 years from birth, is characterized by a central focus on the need for food. In the act of sucking, necessary for feeding, the lips, tongue, and mouth become the focus of libidinal drives and, therefore, the principal source of pleasure. Freud hypothesized that if we did not receive appropriate gratification during a specific stage or if a specific stage left a particularly strong impression (which he termed fixation), an individual’s personality would reflect the stage throughout adult life. For example, fixation at the oral stage might result in excessive thumb sucking and emphasis on oral stimulation through eating, chewing pencils, or bit- ing fingernails. Adult personality characteristics theoretically

Illogical; emotional; irrational

Logical; rational

Conscience Moral

principles

Reality principle

Pleasure principle

Type of thinking Driven by

Intrapsychic conflicts

Superego

Ego Mediator

E FIgUre 1.4 Freud’s structure of the mind.

Im ag

no /H

ul to

n A

rc hi

ve /G

et ty

Im ag

Anna Freud (1895–1982), here with her father, contributed the concept of defense mechanisms to the field of psychoanalysis.

50443_ch01_ptg01_hr_002-031.indd 21 28/09/16 2:44 PM

22 CHAPTER 1 abnormal behavior in h istor ical context

own schools of thought. Jung, rejecting many of the sexual aspects of Freud’s theory, introduced the concept of the collective unconscious, which is a wisdom accumulated by society and culture that is stored deep in individual memories and passed down from generation to generation. Jung also suggested that spiritual and religious drives are as much a part of human nature as are sexual drives; this emphasis and the idea of the collective unconscious continue to draw the attention of mystics. Jung emphasized the importance of enduring personality traits such as introversion (the tendency to be shy and withdrawn) and extrover- sion (the tendency to be friendly and outgoing).

Adler focused on feelings of inferiority and the striving for superiority; he created the term inferiority complex. Unlike Freud, both Jung and Adler also believed that the basic quality of human nature is positive and that there is a strong drive toward self- actualization (realizing one’s full potential). Jung and Adler believed that by removing barriers to both internal and external growth the individual would improve and flourish.

Others took psychoanalytical theorizing in different directions, emphasizing development over the life span and the influence of culture and society on personality. Karen Horney (1885–1952) and Erich Fromm (1900–1980) are associated with these ideas, but the best-known theorist is Erik Erikson (1902–1994). Erikson’s greatest contribution was his theory of development across the life span, in which he described in some detail the crises and conflicts that accompany eight specific stages. For example, in the last of these stages, the mature age, beginning about age 65, individuals review their lives and attempt to make sense of them, experienc- ing both satisfaction at having completed some lifelong goals and despair at having failed at others. Scientific developments have borne out the wisdom of considering psychopathology from a developmental point of view.

Psychoanalytic Psychotherapy Many techniques of psychoanalytic psychotherapy, or psycho- analysis, are designed to reveal the nature of unconscious mental processes and conflicts through catharsis and insight. Freud developed techniques of free association, in which patients are instructed to say whatever comes to mind without the usual socially required censoring. Free association is intended to reveal emotionally charged material that may be repressed because it is too painful or threatening to bring into consciousness. Freud’s patients lay on a couch, and he sat behind them so that they would not be distracted. This is how the couch became the symbol of psy- chotherapy. Other techniques include dream analysis (still quite popular today), in which the therapist interprets the content of dreams, supposedly reflecting the primary-process thinking of the id, and systematically relates the dreams to symbolic aspects of unconscious conflicts. This procedure is often difficult because the patient may resist the efforts of the therapist to uncover repressed and sensitive conflicts and may deny the interpretations. The goal of this stage of therapy is to help the patient gain insight into the nature of the conflicts.

The relationship between the therapist, called the psychoanalyst, and the patient is important. In the context of this relationship as it evolves, the therapist may discover the nature of the patient’s

conflict is successfully resolved when females develop healthy het- erosexual relationships and look forward to having a baby, which he viewed as a healthy substitute for having a penis. Needless to say, this particular theory has provoked marked consternation over the years as being sexist and demeaning. It is important to remember that it is theory, not fact; no systematic research exists to support it.

In Freud’s view, all nonpsychotic psychological disorders resulted from underlying unconscious conflicts, the anxiety that resulted from those conflicts, and the implementation of ego defense mechanisms. Freud called such disorders neuroses, or neurotic disorders, from an old term referring to disorders of the nervous system.

later developments in Psychoanalytic thought Freud’s original psychoanalytic theories have been greatly modi- fied and developed in a number of different directions, mostly by his students or followers. Some theorists simply took one compo- nent of psychoanalytic theory and developed it more fully. Others broke with Freud and went in entirely new directions.

Anna Freud (1895–1982), Freud’s daughter, concentrated on the way in which the defensive reactions of the ego determine our behavior. In so doing, she was the first proponent of the modern field of ego psychology. Her book Ego and the Mecha- nisms of Defense (1946) is still influential. According to Anna Freud, the individual slowly accumulates adaptational capaci- ties, skill in reality testing, and defenses. Abnormal behavior develops when the ego is deficient in regulating such functions as delaying and controlling impulses or in marshaling appro- priate normal defenses to strong internal conflicts. In another somewhat later modification of Freud’s theories, Heinz Kohut (1913–1981) focused on a theory of the formation of self- concept and the crucial attributes of the self that allow an individ- ual to progress toward health, or conversely, to develop neurosis. This psychoanalytic approach became known as self-psychology (Kohut, 1977).

A related area that is quite popular today is referred to as object relations. Object relations is the study of how children incorporate the images, the memories, and sometimes the values of a person who was important to them and to whom they were (or are) emotionally attached. Object in this sense refers to these important people, and the process of incorporation is called intro- jection. Introjected objects can become an integrated part of the ego or may assume conflicting roles in determining the identity, or self. For example, your parents may have conflicting views on rela- tionships or careers, which, in turn, may be different from your own point of view. To the extent that these varying positions have been incorporated, the potential for conflict arises. One day you may feel one way about your career direction, and the next day you may feel quite differently. According to object relations theory, you tend to see the world through the eyes of the person incorpo- rated into your self. Object relations theorists focus on how these disparate images come together to make up a person’s identity and on the conflicts that may emerge.

Carl Jung (1875–1961) and Alfred Adler (1870–1937) were students of Freud who came to reject his ideas and form their

50443_ch01_ptg01_hr_002-031.indd 22 28/09/16 2:44 PM

the Psychological tradit ion 23

A major criticism of psychoanalysis is that it is basically unsci- entific, relying on reports by the patient of events that happened years ago. These events have been filtered through the experience of the observer and then interpreted by the psychoanalyst in ways that certainly could be questioned and might differ from one ana- lyst to the next. Finally, there has been no careful measurement of any of these psychological phenomena and no obvious way to prove or disprove the basic hypotheses of psychoanalysis. This is important because measurement and the ability to prove or dis- prove a theory are the foundations of the scientific approach.

Nevertheless, psychoanalytic concepts and observations have been valuable, not only to the study of psychopathology and psy- chodynamic psychotherapy but also to the history of ideas in Western civilization. Careful scientific studies of psychopathology have supported the observation of unconscious mental processes, the notion that basic emotional responses are often triggered by hidden or symbolic cues, and the understanding that memories of events in our lives can be repressed and otherwise avoided in a variety of ingenious ways. The relationship of the therapist and the patient, called the therapeutic alliance, is an important area of study across most therapeutic strategies. These concepts, along with the importance of various coping styles or defense mecha- nisms, will appear repeatedly throughout this book.

Many of these psychodynamic ideas had been in development for more than a century, culminating in Freud’s influential writ- ings (e.g., Lehrer, 1995), and they stood in stark contrast to witch trials and ideas of incurable brain pathology. In early years, the source of good and evil and of urges and prohibitions was con- ceived as external and spiritual, usually in the guise of demons confronting the forces of good. From the psychoanalytic point of view, we ourselves became the battleground for these forces, and we are inexorably caught up in the battle, sometimes for better and sometimes for worse.

Humanistic Theory We have already seen that Jung and Adler broke sharply with Freud. Their fundamental disagreement concerned the very nature of humanity. Freud portrayed life as a battleground where we are continually in danger of being overwhelmed by our darkest forces. Jung and Adler, by contrast, emphasized the positive, opti- mistic side of human nature. Jung talked about setting goals, look- ing toward the future, and realizing one’s fullest potential. Adler believed that human nature reaches its fullest potential when we contribute to the welfare of other individuals and to society as a whole. He believed that we all strive to reach superior levels of intellectual and moral development. Nevertheless, both Jung and Adler retained many of the principles of psychodynamic thought. Their general philosophies were adopted in the middle of the cen- tury by personality theorists and became known as humanistic psychology.

Self-actualizing was the watchword for this movement. The underlying assumption is that all of us could reach our highest potential, in all areas of functioning, if only we had the freedom to grow. Inevitably, a variety of conditions may block our actual- ization. Because every person is basically good and whole, most blocks originate outside the individual. Difficult living conditions

intrapsychic conflict. This is because, in a phenomenon called transference, patients come to relate to the therapist much as they did to important figures in their childhood, particularly their parents. Patients who resent the therapist but can verbalize no good reason for it may be reenacting childhood resentment toward a parent. More often, the patient will fall deeply in love with the therapist, which reflects strong positive feelings that existed earlier for a parent. In the phenomenon of countertransference, therapists project some of their own personal issues and feelings, usually positive, onto the patient. Therapists are trained to deal with their own feelings as well as those of their patients, whatever the mode of therapy, and it is strictly against all ethical canons of the mental health professions to accept overtures from patients that might lead to relationships outside therapy.

Classical psychoanalysis requires therapy four to five times a week for 2 to 5 years to analyze unconscious conflicts, resolve them, and restructure the personality to put the ego back in charge. Reduction of symptoms (psychological disorders) is relatively inconsequential because they are only expressions of underlying intrapsychic conflicts that arise from psychosexual developmental stages. Thus, eliminating a phobia or depressive episode would be of little use unless the underlying conflict was dealt with adequately, because another set of symptoms would almost certainly emerge (symptom substitution). Because of the extraordinary expense of classical psychoanalysis, and the lack of evidence that it is effective in alleviating psychological disorders, this approach is seldom used today.

Psychoanalysis is still practiced, particularly in some large cities, but many psychotherapists employ a loosely related set of approaches referred to as psychodynamic psychotherapy. Although conflicts and unconscious processes are still empha- sized, and efforts are made to identify trauma and active defense mechanisms, therapists use an eclectic mixture of tactics, with a social and interpersonal focus. Seven tactics that character- ize psychodynamic psychotherapy include (1) a focus on affect and the expression of patients’ emotions; (2) an exploration of patients’ attempts to avoid topics or engage in activities that hinder the progress of therapy; (3) the identification of patterns in patients’ actions, thoughts, feelings, experiences, and rela- tionships; (4) an emphasis on past experiences; (5) a focus on patients’ interpersonal experiences; (6) an emphasis on the ther- apeutic relationship; and (7) an exploration of patients’ wishes, dreams, or fantasies (Blagys & Hilsenroth, 2000). Two additional features characterize psychodynamic psychotherapy. First, it is significantly briefer than classical psychoanalysis. Second, psychodynamic therapists deemphasize the goal of personality reconstruction, focusing instead on relieving the suffering asso- ciated with psychological disorders.

comments Pure psychoanalysis is of historical interest more than current interest, and classical psychoanalysis as a treatment has been diminishing in popularity for years. In 1980, the term neurosis, which specifically implied a psychoanalytic view of the causes of psychological disorders, was dropped from the DSM, the official diagnostic system of the APA.

50443_ch01_ptg01_hr_002-031.indd 23 28/09/16 2:44 PM

24 CHAPTER 1 abnormal behavior in h istor ical context

systematic development of a more scientific approach to psycho- logical aspects of psychopathology.

Pavlov and classical conditioning In his classic study examining why dogs salivate before the presentation of food, physiologist Ivan Petrovich Pavlov (1849–1936) of St. Petersburg, Russia, initiated the study of classical conditioning, a type of learning in which a neutral stimu- lus is paired with a response until it elicits that response. The word conditioning (or conditioned response) resulted from an accident in translation from the original Russian. Pavlov was really talking about a response that occurred only on the condition of the pres- ence of a particular event or situation (stimulus)—in this case, the footsteps of the laboratory assistant at feeding time. Thus, “condi- tional response” would have been more accurate. Conditioning is one way in which we acquire new information, particularly infor- mation that is somewhat emotional in nature. This process is not as simple as it first seems, and we continue to uncover many more facts about its complexity (Bouton, 2005; Craske, Hermans, & Vansteenwegen, 2006; Lissek et al., 2014; Prenoveau, Craske, Liao, & Ornitz, 2013; Rescorla, 1988). But it can be quite automatic. Let’s look at a powerful contemporary example.

Psychologists working in oncology units have studied a phe- nomenon well known to many cancer patients, their nurses and physicians, and their families. Chemotherapy, a common treatment for some forms of cancer, has side effects including severe nausea and vomiting. But these patients often experience severe nausea and, occasionally, vomiting when they merely see the medical per- sonnel who administered the chemotherapy or any equipment asso- ciated with the treatment, even on days when their treatment is not delivered (Morrow & Dobkin, 1988; Kamen, et al., 2014; Roscoe, Morrow, Aapro, Molassiotis, & Olver, 2011). For some patients, this reaction becomes associated with a variety of stimuli that evoke people or things present during chemotherapy—anybody in a nurse’s uniform or even the sight of the hospital. The strength of the response to similar objects or people is usually a function of how similar these objects or people are. This phenomenon is called stim- ulus generalization because the response generalizes to similar stimuli. In any case, this partic- ular reaction is distressing and uncomfortable, particularly if it is associated with a variety of objects or situations. Psycholo- gists have had to develop specif- ic treatments to overcome this response (Mustian et al., 2011).

Whether the stimulus is food, as in Pavlov’s laboratory, or chemotherapy, the classical conditioning process begins with a stimulus that would elicit a response in almost anyone and requires no learning; no conditions must be present for the response to occur. For these

or stressful life or interpersonal experiences may move you away from your true self.

Abraham Maslow (1908–1970) was most systematic in describing the structure of personality. He postulated a hier- archy of needs, beginning with our most basic physical needs for food and sex and ranging upward to our needs for self- actualization, love, and self-esteem. Social needs such as friendship fall somewhere between. Maslow hypothesized that we cannot progress up the hierarchy until we have satisfied the needs at lower levels.

Carl Rogers (1902–1987) is, from the point of view of therapy, the most influential humanist. Rogers (1961) originated client- centered therapy, later known as person-centered therapy. In this approach, the therapist takes a passive role, making as few interpretations as possible. The point is to give the individual a chance to develop during the course of therapy, unfettered by threats to the self. Humanist theorists have great faith in the abil- ity of human relations to foster this growth. Unconditional pos- itive regard, the complete and almost unqualified acceptance of most of the client’s feelings and actions, is critical to the human- istic approach. Empathy is the sympathetic understanding of the individual’s particular view of the world. The hoped-for result of person-centered therapy is that clients will be more straight- forward and honest with themselves and will access their innate tendencies toward growth.

Like psychoanalysis, the humanistic approach has had a substantial effect on theories of interpersonal relationships. For example, the human potential movements so popular in the 1960s and 1970s were a direct result of humanistic theo- rizing. This approach also emphasized the importance of the therapeutic relationship in a way quite different from Freud’s approach. Rather than seeing the relationship as a means to an end (transference), humanistic therapists believed that relation- ships, including the therapeutic relationship, were the single most positive influence in facilitating human growth. In fact, Rogers made substantial contributions to the scientific study of therapist–client relationships.

Nevertheless, the humanistic model contributed relatively little new information to the field of psychopathology. One reason for this is that its proponents, with some exceptions, had little interest in doing research that would discover or create new knowledge. Rather, they stressed the unique, nonquantifiable experiences of the individual, emphasizing that people are more different than alike. As Maslow noted, the humanistic model found its greatest application among individuals without psychological disorders. The application of person-centered therapy to more severe psy- chological disorders has decreased substantially over the decades, although certain variations have arisen periodically in some areas of psychopathology.

The Behavioral Model As psychoanalysis swept the world at the beginning of the 20th century, events in Russia and the United States would eventu- ally provide an alternative psychological model that was every bit as powerful. The behavioral model, which is also known as the cognitive-behavioral model or social learning model, brought the

H ul

to n

A rc

hi ve

/G et

ty Im

ag es

Ivan Pavlov (1849–1936) identi- fied the process of classical conditioning, which is important to many emotional disorders.

50443_ch01_ptg01_hr_002-031.indd 24 28/09/16 2:44 PM

the Psychological tradit ion 25

reached for the rat, however, the experimenters made a loud noise behind him. After only five trials, Albert showed the first signs of fear if the white rat came near. The experiment- ers then determined that Albert displayed mild fear of any white furry object, even a Santa Claus mask with a white fuzzy beard. You may not think that this is surprising, but keep in mind that this was one of the first examples ever recorded in a laboratory of producing fear of an object not previously feared. Of course, this experiment would be considered unethi- cal by today’s standards, and it turns out Albert may have also had some neurological impairment that could have contributed to developing fear (Fridlund, Beck, Goldie, & Irons, 2012), but the study remains a classic one.

Another student of Watson’s, Mary Cover Jones (1896–1987), thought that if fear could be learned or classically conditioned in this way, perhaps it could also be unlearned or extinguished. She worked with a boy named Peter, who at 2 years, 10 months old was already quite afraid of furry objects. Jones decided to bring a white rabbit into the room where Peter was playing for a short time each day. She also arranged for other children, whom she knew did not fear rabbits, to be in the same room. She noted that Peter’s fear gradually diminished. Each time it diminished, she brought the rabbit closer. Eventually Peter was touching and even playing with the rabbit (Jones, 1924a, 1924b), and years later the fear had not returned.

the Beginnings of Behavior therapy The implications of Jones’s research were largely ignored for two decades, given the fervor associated with more psychoanalytic conceptions of the development of fear. But in the late 1940s and early 1950s, Joseph Wolpe (1915–1997), a pioneering psychiatrist from South Africa, became dissatisfied with prevailing psycho- analytic interpretations of psychopathology and began looking for something else. He turned to the work of Pavlov and became familiar with the wider field of behavioral psychology. He devel- oped a variety of behavioral procedures for treating his patients, many of whom suffered from phobias. His best-known tech- nique was termed systematic desensitization. In principle, it was similar to the treatment of little Peter: Individuals were gradually introduced to the objects or situations they feared so that their fear could extinguish; that is, they could test reality and see that nothing bad happened in the presence of the phobic object or scene. Wolpe added another element by having his patients do something that was incompatible with fear while they were in the presence of the dreaded object or situation. Because he could not always reproduce the phobic object in his office, Wolpe had his

reasons, the food or chemotherapy is called the unconditioned stim- ulus (UCS). The natural or unlearned response to this stimulus— in these cases, salivation or nausea—is called the unconditioned response (UCR). Now the learning comes in. As we have already seen, any person or object associated with the UCS (food or chemo- therapy) acquires the power to elicit the same response, but now the response, because it was elicited by the conditional or conditioned stimulus (CS), is termed a conditioned response (CR). Thus, the nurse associated with the chemotherapy becomes a CS. The nauseous sen- sation (upon seeing the nurse), which is almost the same as that experienced during chemotherapy, becomes the CR.

With unconditioned stimuli as powerful as chemotherapy, a CR can be learned in one trial. Most learning of this type, however, requires repeated pairing of the UCS (for example, chemotherapy) and the CS (for instance, nurses’ uniforms or hospital equipment). When Pavlov began to investigate this phenomenon, he substi- tuted a metronome for the footsteps of his laboratory assistants so that he could quantify the stimulus more accurately and, therefore, study the approach more precisely. What he also learned is that presentation of the CS (for example, the metronome) without the food for a long enough period would eventually eliminate the CR to the food. In other words, the dog learned that the metronome no longer meant that a meal might be on the way. This process was called extinction.

Because Pavlov was a physiologist, it was natural for him to study these processes in a laboratory and to be quite scientific about it. This required precision in measuring and observing relationships and in ruling out alternative explanations. Although this scientific approach is common in biology, it was uncommon in psychology at that time. For example, it was impossible for psychoanalysts to measure unconscious conflicts precisely, or even observe them. Even early experimental psychologists such as Edward Titchener (1867–1927) emphasized the study of introspection. Subjects sim- ply reported on their inner thoughts and feelings after experiencing certain stimuli, but the results of this “armchair” psychology were inconsistent and discouraging to many experimental psychologists.

Watson and the rise of Behaviorism An early American psychologist, John B. Watson (1878–1958), is considered the founder of behaviorism. Strongly influenced by the work of Pavlov, Watson decided that to base psychology on introspection was to head in the wrong direction; that psychol- ogy could be made as scientific as physiology, and that psychology needs introspection or other nonquantifiable methods no more than chemistry and physics do (Watson, 1913). This point of view is reflected in a famous quotation from a seminal article published by Watson in 1913: “Psychology, as the behaviorist views it, is a purely objective experimental branch of natural science. Its theo- retical goal is the prediction and control of behavior. Introspection forms no essential part of its methods” (p. 158).

Most of Watson’s time was spent developing behavioral psychology as a radical empirical science, but he did dabble briefly in the study of psychopathology. In 1920, he and a student, Rosalie Rayner, presented an 11-month-old boy named Albert with a harmless fluffy white rat to play with. Albert was not afraid of the small animal and enjoyed playing with it. Every time Albert

rc hi

ve s

of t

he H

is to

ry o

f A m

er ic

an P

sy ch

ol og

y/ U

ni ve

rs ity

o f A

kr on

Mary Cover Jones (1896–1987) was one of the first psycholo- gists to use behavioral tech- niques to free a patient from phobia.

50443_ch01_ptg01_hr_002-031.indd 25 28/09/16 2:44 PM

26 CHAPTER 1 abnormal behavior in h istor ical context

Skinner coined the term operant conditioning because behavior operates on the environment and changes it in some way. For example, the boy’s behavior affects his par- ents’ behavior and probably the behavior of other custom- ers. Therefore, he changes his environment. Most things that we do socially provide the context for other people to respond to us in one way or another, thereby provid- ing consequences for our behavior. The same is true of our physical environment, although the consequences may be long term (polluting the air eventually will poison us). Skinner preferred the term reinforcement to “reward” because it connotes the effect on the behavior. Skinner once said that he found himself a bit embarrassed to be talking continually about reinforcement, much as Marxists used to see class struggle everywhere. But he pointed out that all of our behavior is governed to some degree by reinforcement, which can be arranged in an endless variety of ways, in schedules of reinforcement. Skinner wrote a whole book on different schedules of reinforcement (Ferster & Skinner, 1957). He also believed that using punishment as a consequence is relatively ineffective in the long run and that the primary way to develop new behavior is to positively rein- force desired behavior. Much like Watson, Skinner did not see the need to go beyond the observable and quantifiable to establish a satisfactory science of behavior. He did not deny the influence of biology or the existence of subjective states of emotion or cognition; he simply explained these phenomena as relatively inconsequential side effects of a particular history of reinforcement.

The subjects of Skinner’s research were usually animals, mostly pigeons and rats. Using his new principles, Skinner and his disciples taught the animals a variety of tricks, including dancing, playing Ping-Pong, and playing a toy piano. To do this he used a procedure called shaping, a process of reinforcing successive approximations to a final behavior or set of behav- iors. For example, if you want a pigeon to play Ping-Pong, first you provide it with a pellet of food every time it moves its head slightly toward a Ping-Pong ball tossed in its direction. Gradually you require the pigeon to move its head ever closer to the Ping-Pong ball until it touches it. Finally, receiving the food pellet is contingent on the pigeon hitting the ball back with its head.

Pavlov, Watson, and Skinner contributed significantly to behavior therapy (see, for example, Wolpe, 1958), in which sci- entific principles of psychology are applied to clinical problems. Their ideas have substantially contributed to current psychologi- cal treatments and so are referred to repeatedly in this book.

patients carefully and systematically imagine the phobic scene, and the response he chose was relaxation because it was conve- nient. For example, Wolpe treated a young man with a phobia of dogs by training him first to relax deeply and then imagine he was looking at a dog across the park. Gradually, he could imagine the dog across the park and remain relaxed, experiencing little or no fear. Wolpe then had him imagine that he was closer to the dog. Eventually, the young man imagined that he was touching the dog while maintaining a relaxed, almost trancelike state.

Wolpe reported great success with systematic desensitiza- tion, one of the first wide-scale applications of the new science of behaviorism to psychopathology. Wolpe, working with fellow pioneers Hans Eysenck and Stanley Rachman in London, called this approach behavior therapy. Although Wolpe’s procedures are seldom used today, they paved the way for modern-day fear and anxiety reduction procedures in which severe phobias can be eliminated in as little as 1 day (see Chapter 5).

B. F. skinner and operant conditioning Sigmund Freud’s influence extended far beyond psychopathology into many aspects of our cultural and intellectual history. Only one other behavioral scientist has made a similar impact: Burrhus Frederic (B. F.) Skinner (1904–1990). In 1938 he published The Behavior of Organisms, in which he laid out, in a comprehensive manner, the principles of operant conditioning, a type of learning in which behavior changes as a function of what follows the behav- ior. Skinner observed early on that a large part of our behavior is not automatically elicited by a UCS and that we must account for this. In the ensuing years, Skinner did not confine his ideas to the laboratories of experimental psychology. He ranged far and wide in his writings, describing, for example, the potential applications of a science of behavior to our culture. Some best-known exam- ples of his ideas are in the novel Walden Two (Skinner, 1948), in which he depicts a fictional society run on the principles of oper- ant conditioning. In another well-known work, Beyond Freedom and Dignity (1971), Skinner lays out a broader statement of prob- lems facing our culture and suggests solutions based on his own view of a science of behavior.

Skinner was strongly influenced by Watson’s conviction that a science of human behavior must be based on observable events and relationships among those events. The work of psycholo- gist Edward L. Thorndike (1874–1949) also influenced Skinner. Thorndike is best known for the law of effect, which states that behavior is either strengthened (likely to be repeated more fre- quently) or weakened (likely to occur less frequently) depending on the consequences of that behavior. Skinner took the simple notions that Thorndike had tested in the animal laboratories, using food as a reinforcer, and developed them in a variety of complex ways to apply to much of our behavior. For example, if a 5-year-old boy starts shouting at the top of his lungs in a restaurant, much to the annoyance of the people around him, it is unlikely that his behavior was automatically elicited by a UCS. Also, he will be less likely to do it in the future if his parents scold him, take him out to the car to sit for a bit, or consistently reinforce more appropriate behavior. Then again, if the parents think his behavior is cute and laugh, chances are he will do it again.

B et

tm an

n/ G

et ty

Im ag

B. F. Skinner (1904–1990) studied operant conditioning, a form of learning that is central to psychopathology.

50443_ch01_ptg01_hr_002-031.indd 26 28/09/16 2:44 PM

the Present: the sc ient if ic method and an integrat ive aPProach 27

structure of the brain, sometimes permanently. In other words, our behavior, both normal and abnormal, is the product of a continual interaction of psychological, biological, and social influences.

The view that psychopathology is multiply determined had its early adherents. Perhaps the most notable was Adolf Meyer (1866–1950), often considered the dean of American psychiatry. Whereas most professionals during the first half of the century held narrow views of the cause of psychopathology, Meyer stead- fastly emphasized the equal contributions of biological, psycho- logical, and sociocultural determinism. Although Meyer’s ideas had some proponents, it was 100 years before the wisdom of his advice was fully recognized in the field.

By 2000, a veritable explosion of knowledge about psycho- pathology was occurring. The young fields of cognitive science and neuroscience began to grow exponentially as we learned more about the brain and about how we process, remember, and use information. At the same time, startling new findings from behavioral science revealed the importance of early experience in determining later development. It was clear that a new model was needed that would consider biological, psychological, and social influences on behavior. This approach to psychopathology would combine findings from all areas with our rapidly growing understanding of how we experience life during different devel- opmental periods, from infancy to old age. In 2010, the National Institute of Mental Health (NIMH) instituted a strategic plan to support further research and development on the interre- lationship of these factors with the aim of translating research findings to front-line treatment settings (Cuthbert, 2014; Insel, 2009; Sanislow, Quinn, & Sypher, 2015). In the remainder of this book, we explore the reciprocal influences among neuroscience, cognitive science, behavior science, and developmental science and demonstrate that the only currently valid model of psycho- pathology is multidimensional and integrative.

comments The behavioral model has contributed greatly to the understand- ing and treatment of psychopathology, as is apparent in the chapters that follow. Nevertheless, this model is incomplete and inadequate to account for what we now know about psychopathol- ogy. In the past, there was little or no room for biology in behav- iorism, because disorders were considered, for the most part, environmentally determined reactions. The model also fails to account for development of psychopathology across the life span. Recent advances in our knowledge of how information is pro- cessed, both consciously and subconsciously, have added a layer of complexity. Integrating all these dimensions requires a new model of psychopathology.

The Present: The Scientific Method and an Integrative Approach As William Shakespeare wrote, “What’s past is prologue.” We have just reviewed three traditions or ways of thinking about causes of psychopathology: the supernatural, the biological, and the psy- chological (further subdivided into two major historical compo- nents: psychoanalytic and behavioral).

Supernatural explanations of psychopathology are still with us. Superstitions prevail, including beliefs in the effects of the moon and the stars on our behavior. This tradition has little influence on scientists and other professionals, however. Biological, psychoana- lytic, and behavioral models, by contrast, continue to further our knowledge of psychopathology, as you will see in the next chapter.

Each tradition has failed in important ways. First, scientific methods were not often applied to the theories and treatments within a tradition, mostly because methods that would have pro- duced the evidence necessary to confirm or disprove the theories and treatments had not been developed. Lacking such evidence, many people accepted various fads and superstitions that ulti- mately proved to be untrue or useless. New fads often superseded truly useful theories and treatment procedures. King Charles VI was subjected to a variety of procedures, some of which have since been proved useful and others that were mere fads or even harmful. How we use scientific methods to confirm or disconfirm findings in psychopathology is described in Chapter 4. Second, health pro- fessionals tend to look at psychological disorders narrowly, from their own point of view alone. Grey assumed that psychological disorders were the result of brain disease and that other factors had no influence. Watson assumed that all behaviors, including disordered behavior, were the result of psychological and social influences and that the contribution of biological factors was inconsequential.

In the 1990s, two developments came together as never before to shed light on the nature of psychopathology: (1) the increas- ing sophistication of scientific tools and methodology, and (2) the realization that no one influence—biological, behavioral, cognitive, emotional, or social—ever occurs in isolation. Literally, every time we think, feel, or do something, the brain and the rest of the body are hard at work. Perhaps not as obvious, however, is that our thoughts, feelings, and actions inevitably influence the function and even the

Match the treatment with the corresponding psychological theory of behavior: (a) behavioral model, (b) moral therapy, (c) psychoanalytic theory, and (d) humanistic theory.

1. Treating institutionalized patients as normally as pos- sible and encouraging social interaction and relation- ship development. ____________

2. Hypnosis, psychoanalysis-like free association and dream analysis, and balance of the id, ego, and superego. ____________

3. Person-centered therapy with unconditional positive regard. ____________

4. Classical conditioning, systematic desensitization, and operant conditioning. ___________

Concept Check 1.3

50443_ch01_ptg01_hr_002-031.indd 27 28/09/16 2:44 PM

exorcism to rid the body of the supernatural spirits. Biological treatments typically emphasize physical care and the search for medical cures, especially drugs. Psychological approaches use psy- chosocial treatments, beginning with moral therapy and including modern psychotherapy.

p Sigmund Freud, the founder of psychoanalytic therapy, offered an elaborate conception of the unconscious mind, much of which is still conjecture. In therapy, Freud focused on tapping into the mysteries of the unconscious through such techniques as cathar- sis, free association, and dream analysis. Although Freud’s follow- ers veered from his path in many ways, Freud’s influence can still be felt today.

p One outgrowth of Freudian therapy is humanistic psychology, which focuses more on human potential and self-actualizing than on psychological disorders. Therapy that has evolved from this ap- proach is known as person-centered therapy; the therapist shows almost unconditional positive regard for the client’s feelings and thoughts.

p The behavioral model moved psychology into the realm of science. Both research and therapy focus on things that are measurable, including such techniques as systematic desensitization, reinforce- ment, and shaping.

The Present: The Scientific Method and an Integrative Approach

p With the increasing sophistication of our scientific tools, and new knowledge from cognitive science, behavioral science, and neu- roscience, we now realize that no contribution to psychological disorders ever occurs in isolation. Our behavior, both normal and abnormal, is a product of a continual interaction of psychological, biological, and social influences.

Understanding Psychopathology p A psychological disorder is (1) a psychological dysfunction within an individual that is (2) associated with distress or impairment in functioning and (3) a response that is not typical or culturally ex- pected. All three basic criteria must be met; no one criterion alone has yet been identified that defines the essence of abnormality.

p The field of psychopathology is concerned with the scientific study of psychological disorders. Trained mental health professionals range from clinical and counseling psychologists to psychiatrists and psychiatric social workers and nurses. Each profession requires a specific type of training.

p Using scientific methods, mental health professionals can function as scientist-practitioners. They not only keep up with the latest findings but also use scientific data to evaluate their own work, and they often conduct research within their clinics or hospitals.

p Research about psychological disorders falls into three basic categories: description, causation, and treatment and outcomes.

The Supernatural, Biological, and Psychological Traditions

p Historically, there have been three prominent approaches to abnormal behavior. In the supernatural tradition, abnormal behavior is attributed to agents outside our bodies or social environment, such as demons, spirits, or the influence of the moon and stars; although still alive, this tradition has been largely replaced by biological and psychological perspectives. In the biological tradition, disorders are attributed to disease or biochemical imbalances; in the psychological tradition, abnor- mal behavior is attributed to faulty psychological development and to social context.

p Each tradition has its own way of treating individuals who suffer from psychological disorders. Supernatural treatments include

Summary

28 CHAPTER 1 abnormal behavior in h istor ical context

50443_ch01_ptg01_hr_002-031.indd 28 28/09/16 2:44 PM

sUmmary 29

Key Terms Answers to Concept Checks psychological disorder, 3 phobia, 4 abnormal behavior, 4 psychopathology, 6 scientist-practitioner, 7 presenting problem, 7 clinical description, 7 prevalence, 7 incidence, 7 course, 8 prognosis, 8 etiology, 8 exorcism, 10 psychosocial treatment, 16 moral therapy, 16 mental hygiene movement, 17 psychoanalysis, 18 behaviorism, 18 unconscious, 18 catharsis, 18 psychoanalytic model, 19 id, 19 ego, 20 superego, 20 intrapsychic conflicts, 20 defense mechanisms, 20

psychosexual stages of development, 21

castration anxiety, 21 neurosis (plural neuroses), 22 ego psychology, 22 self-psychology, 22 object relations, 22 collective unconscious, 22 free association, 22 dream analysis, 22 psychoanalyst, 22 transference, 23 psychodynamic

psychotherapy, 23 self-actualizing, 23 person-centered therapy, 24 unconditional positive

regard, 24 behavioral model, 24 classical conditioning, 24 extinction, 25 introspection, 25 systematic desensitization, 25 behavior therapy, 26 reinforcement, 26 shaping, 26

1.1 Part A 1. d; 2. b, c

Part B 3. d; 4. c; 5. a; 6. f; 7. e; 8. b

1.2 1. c; 2. a; 3. b

1.3 1. b; 2. c; 3. d; 4. a

50443_ch01_ptg01_hr_002-031.indd 29 28/09/16 2:44 PM

1930–1968

1500s: Paracelsus suggests that the moon and the stars, not possession by the devil, affect people’s psychological functioning.

1300s: Superstition runs ram- pant, and mental disorders are blamed on demons and witches; exorcisms are performed to rid victims of evil spirits.

1400s: Enlightened view that insanity is caused by mental or emotional stress gains momentum, and depression and anxiety are again regarded by some as disorders.

1400–1800: Bloodletting and leeches are used to rid the body of unhealthy fluids and restore chemical balance.

1793: Philippe Pinel introduc- es moral therapy and makes French mental institutions more humane.

1825–1875: Syphilis is dif- ferentiated from other types of psychosis in that it is caused by a specific bacterium; ulti- mately, penicillin is found to cure syphilis.

200 c.e.: Galen suggests that normal and abnormal behav- iors are related to four bodily fluids, or humors.

400 b.c.: Hippocrates sug- gests that psychological disor- ders have both biological and psychological causes.

400 b.c.–1875

400 b.c. 1500s 1825–18751300s

Timeline of Significant events

1968: DSM-II is published.1938: B. F. Skinner publishes The Behavior of Organisms, which describes the principles of operant conditioning.

1930: Insulin shock therapy, electric shock treatments, and brain surgery begin to be used to treat psychopathology.

1958: Joseph Wolpe effectively treats patients with phobias using systematic desensitiza- tion based on principles of behavioral science.

1952: The first edition of the Diagnostic and Statistical Manual (DSM-I) is published.

1950: The first effective drugs for severe psychotic disorders are developed. Humanistic psychology (based on ideas of Carl Jung, Alfred Adler, and Carl Rogers) gains some acceptance.

1946: Anna Freud publishes Ego and the Mechanisms of Defense.

1943: The Minnesota Multiphasic Personality Inventory is published.

1930 1943 1950 1968

N at

io na

l L ib

ra ry

o f

M ed

ic in

B et

tm an

n/ G

et ty

Im ag

no /H

ul to

n A

rc hi

ve /G

et ty

Im ag

Th e

Im ag

e W

or ks

50443_ch01_ptg01_hr_002-031.indd 30 28/09/16 2:44 PM

1848–1920

1980–20131990s: Increasingly sophisti- cated research methods are developed; no one influence— biological or environmental—is found to cause psychological disorders in isolation from the other. 2000: DSM-IV-TR is published.

1994: DSM-IV is published. 2013: DSM-5 is published.1987: DSM-III-R is published.

1980: DSM-III is published.

1904: Ivan Pavlov receives the Nobel Prize for his work on the physiology of digestion, which leads him to identify conditioned reflexes in dogs.

1848: Dorothea Dix success- fully campaigns for more humane treatment in U.S. mental institutions.

1854: John P. Grey, head of New York’s Utica Hospital, believes that insanity is the result of physical causes, thus de-emphasizing psychological treatments.

1870: Louis Pasteur develops his germ theory of disease, which helps identify the bac- terium that causes syphilis.

1913: Emil Kraepelin classifies various psychological disorders from a biological point of view and publishes work on diagnosis.

1920: John B. Watson experi- ments with conditioned fear in Little Albert, using a white rat.

1895: Josef Breuer treats the “hysterical” Anna O., leading to Freud’s development of psychoanalytic theory.

1848 1920

1980

1870

1990s 2000 2010

1900

ve re

tt H

is to

ric al

/S hu

tte rs

to ck

.c om

1900: Sigmund Freud pub- lishes The Interpretation of Dreams.

A P

Im ag

to ck

M on

ta ge

M ar

y E

va ns

P ic

tu re

L ib

ra ry

/A la

m y

S to

ck P

ho to

H ul

to n

A rc

hi ve

/G et

ty Im

ag es

50443_ch01_ptg01_hr_002-031.indd 31 28/09/16 2:44 PM

C H A P T E R O U T L I N E

One-Dimensional versus Multidimensional Models

What Caused Judy’s Phobia? Outcome and Comments

Genetic Contributions to Psychopathology

The Nature of Genes New Developments in the Study of Genes

and Behavior The Interaction of Genes and the Environment Epigenetics and the Nongenomic

“Inheritance” of Behavior

Neuroscience and Its Contributions to Psychopathology

The Central Nervous System The Structure of the Brain The Peripheral Nervous System Neurotransmitters Implications for Psychopathology Psychosocial Influences on Brain Structure

and Function Interactions of Psychosocial Factors and

Neurotransmitter Systems Psychosocial Effects on the Development

of Brain Structure and Function Comments

Behavioral and Cognitive Science Conditioning and Cognitive Processes Learned Helplessness Social Learning Prepared Learning Cognitive Science and the Unconscious

Emotions The Physiology and Purpose of Fear Emotional Phenomena The Components of Emotion Anger and Your Heart Emotions and Psychopathology

Cultural, Social, and Interpersonal Factors Voodoo, the Evil Eye, and Other Fears Gender Social Effects on Health and Behavior Global Incidence of Psychological Disorders

Life-Span Development Conclusions

2 An Integrative Approach to Psychopathology

ho to

gr ap

he e.

eu /S

hu tt

er st

oc k.

co m

50443_ch02_ptg01_hr_032-073.indd 32 28/09/16 5:29 PM

One-D imens iOnal versus mult iD imens iOnal mODels 33

we still encounter this type of thinking occasionally, but most scien- tists and clinicians believe abnormal behavior results from multiple influences. A system, or feedback loop, may have independent inputs at many different points, but as each input becomes part of the whole, it can no longer be considered independent. This perspective on cau- sality is systemic, which derives from the word system; it implies that any particular influence contributing to psychopathology cannot be considered out of context. Context, in this case, is the biology and behavior of the individual, as well as the cognitive, emotional, social, and cultural environment, because any one component of the system inevitably affects the other components, forming a complex network. This is a multidimensional model.

What Caused Judy’s Phobia? From a multidimensional perspective, let’s look at what might have caused Judy’s phobia (see E Figure 2.1).

Behavioral Influences The cause of Judy’s phobia might at first seem obvious. She saw a movie with graphic scenes of blood and injury and had a bad reaction to it. Her reaction, an unconditioned response, became associated with situations similar to the scenes in the movie, depending on how similar they were. But Judy’s reaction reached such an extreme that even hearing someone say “Cut it out!” evoked queasiness. Is Judy’s phobia a straightforward case of clas- sical conditioning? It might seem so, but one puzzling question arises: Why didn’t the other kids in Judy’s class develop the same phobia? As far as Judy knew, nobody else even felt queasy.

Biological Influences We now know that more is involved in blood–injection–injury pho- bia than a simple conditioning experience, although, clearly, con- ditioning and stimulus generalization contribute. We have learned

Student LearnIng OutcOmeS*

• Identify basic biological, psychological, and social components of behavioral explanations (e.g., inferences, observations, operational definitions, interpretation) (APA SLO 2.1a) (see textbook pages 33–35, 62–65)

• Incorporate several appropriate levels of complexity (e.g., cellular, individual, group/system, society/cultural) to explain behavior (APA SLO 2.1C) (see textbook pages 42–58, 60, 65–70)

Use scientific reasoning to interpret psychological phenomena. This outcome applies to APA SLO indicators 1.1a & 1.1C

Develop a working knowledge of the content domains of psychology.

* Portions of this chapter cover learning outcomes suggested by the American Psychological Association (2013) in its guidelines for the undergraduate psychology major. Chapter coverage of these outcomes is identified above by APA Goal and APA Suggested Learning Outcome (SLO).

One-Dimensional versus Multidimensional Models To say that psychopathology is caused by a physical abnormality or by conditioning is to accept a linear or one-dimensional model, which attempts to trace the origins of behavior to a single cause. A linear causal model might hold that schizophrenia or a phobia is caused by a chemical imbalance or by growing up surrounded by overwhelming conflicts among family members. In psychology and psychopathology,

R emember Judy from Chapter 1? We knew she suffered from blood–injection–injury phobia but we did not know why. Here, we address the issue of causation. This chapter examines

the specific components of a multidimensional integrative approach to psychopathology (see E Figure 2.1). Biological dimen- sions include causal factors from the fields of genetics and neu- roscience. Psychological dimensions include causal factors from behavioral and cognitive processes, including learned helplessness, social learning, prepared learning, and even unconscious processes (in a different guise than in the days of Sigmund Freud). Emotional influences contribute in a variety of ways to psychopathology, as do social and interpersonal influences. Finally, developmental influ- ences figure in any discussion of causes of psychological disorders. You will become familiar with these areas as they relate to psycho- pathology and learn about some of the latest developments relevant to psychological disorders. But keep in mind what we confirmed in the previous chapter: No influence operates in isolation. Each dimension—biological or psychological—is strongly influenced by the others and by development, and they weave together in various complex and intricate ways to create a psychological disorder.

Here, we explain briefly why we have adopted a multidimen- sional integrative model of psychopathology. Then we preview various causal influences and interactions, using Judy’s case as background. After that, we look more deeply at specific causal influences in psychopathology, examining both the latest research and integrative ways of viewing what we know.

50443_ch02_ptg01_hr_032-073.indd 33 28/09/16 5:29 PM

34 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

a lot about this phobia (Antony & Barlow, 2002; Ritz, Meuret, & Ayala, 2010; van Overveld, de Jong, & Peters, 2011). Physiologically, Judy experienced a vasovagal syncope, which is a common cause of fainting. Syncope means “sinking feeling” or “swoon” caused by low blood pressure in the head. When she saw the film, she became mildly distressed, as many people would, and her heart rate and blood pressure increased accordingly, which she probably did not notice. Then her body took over, immediately over-compensating by decreasing her vascular resistance, lowering her heart rate and, eventually, lowering her blood pressure too much. The amount of blood reaching her brain diminished until she lost consciousness.

A possible cause of the vasovagal syncope is an overreaction of a mechanism called the sinoaortic baroreflex arc, which compensates for sudden increases in blood pressure by lowering it. Interestingly, the tendency to overcompensate seems to be inherited, a trait that may account for the high rate of blood–injection–injury phobia in families. Do you ever feel queasy at the sight of blood? If so, chanc- es are your mother, your father, or someone else in your immedi- ate family has the same reaction. In one study, 61% of the family members of individuals with this phobia had a similar condition, although somewhat milder in most cases (Öst, 1992). You might think, then, that we have discovered the cause of blood–injury– injection phobia and that all we need to do is develop a pill to reg- ulate the baroreflex. But many people with rather severe syncope reaction tendencies do not develop phobias. They cope with their reaction in various ways, including tensing their muscles whenever they are confronted with blood. Tensing the muscles quickly raises

blood pressure and prevents the fainting response. Furthermore, some people with little or no syncope reaction develop the phobia anyway (Öst, 1992). Therefore, the cause of blood–injection–injury phobia is more complicated than it seems. If we said that the pho- bia is caused by a biological dysfunction (an overactive vasovagal reaction probably because of a particularly sensitive baroreflex mechanism) or a traumatic experience (seeing a gruesome film) and subsequent conditioning, we would be partly right on both counts, but in adopting a one-dimensional causal model we would miss the most important point: To cause blood–injection–injury phobia, a complex interaction must occur between emotional, cog- nitive, social, biological, and behavioral factors. Inheriting a strong syncope reaction definitely puts a person at risk for developing this phobia, but other influences are at work as well.

emotional Influences Judy’s case is a good example of biology influencing behavior. But behavior, thoughts, and feelings can also influence biology, some- times dramatically. What role did Judy’s fear and anxiety play in the development of her phobia, and where did they come from? Emotions can affect physiological responses such as blood pres- sure, heart rate, and respiration, particularly if we know rationally there is nothing to fear, as Judy did. In her case, rapid increases in heart rate caused by her emotions may have triggered a stron- ger and more intense baroreflex. Emotions also changed the way she thought about situations involving blood and injury and

Behavioral Influences

• Conditioned response to sight of blood: similar situations–even words–produce same reaction.

• Tendency to escape and avoid situations involving blood.

Causes

Biological Influences

• Inherited overreactive sinoaortic baroreflex arc.

• Vasovagal syncope: heart rate and blood pressure increase, body overcompensates.

• Light-headedness and queasiness. • Judy faints.

Social Influences

Judy’s fainting causes disruptions in school and home: • Friends and family rush to help her. • Principal suspends her. • Doctors say nothing is physically wrong.

Emotional and Cognitive Influences

• Fear of fainting, worrying about health

E FigUre 2.1 Judy’s case.

50443_ch02_ptg01_hr_032-073.indd 34 28/09/16 5:29 PM

One-D imens iOnal versus mult iD imens iOnal mODels 35

motivated her to behave in ways she didn’t want to, avoiding all situations connected with blood and injury, even if it was impor- tant not to avoid them. As we see throughout this book, emotions play a substantial role in the development of many disorders.

Social Influences We are all social animals; by our very nature we tend to live in groups such as families. Social and cultural factors make direct contributions to biology and behavior. Judy’s friends and fam- ily rushed to her aid when she fainted. Did their support help or hurt? Her principal rejected her and dismissed her problem. What effect did this behavior have on her phobia? Rejection, particu- larly by authority figures, can make psychological disorders worse than they otherwise would be. Then again, being supportive only when somebody is experiencing symptoms is not always helpful because the strong effects of social attention may actually increase the frequency and intensity of the reaction.

developmental Influences One more influence affects us all—the passage of time. As time passes, many things about ourselves and our environments change in important ways, causing us to react differently at different ages. Thus, at certain times we may enter a developmental critical period when we are more or less reactive to a given situation or influ- ence than at other times. To go back to Judy, it is possible she was previously exposed to other situations involving blood. Important questions to ask are these: Why did this problem develop when she was 16 years old and not before? Is it possible that her susceptibil- ity to having a vasovagal reaction was highest in her teenage years? It may be that the timing of her physiological reaction, along with viewing the disturbing biology film, provided just the right (but unfortunate) combination to initiate her severe phobic response.

Outcome and Comments Fortunately for Judy, she responded well to brief but intensive treat- ment at one of our clinics, and she was back in school within 7 days. Judy was gradually exposed, with her full cooperation, to words,

images, and situations describing or depicting blood and injury, while a sudden drop in blood pressure was prevented. We began with something mild, such as the phrase “Cut it out!” By the end of the week Judy was witnessing surgical procedures at the local hospital.

Judy required close therapeutic supervision during this pro- gram. At one point, while driving home with her parents from an evening session, she had the bad luck to pass a car crash, and she saw a bleeding accident victim. That night, she dreamed about bloody accident victims coming through the walls of her bedroom. This experience made her call the clinic and request emergency intervention to reduce her distress, but it did not slow her prog- ress. (Programs for treating phobias and related anxiety disorders are described more fully in Chapter 5. It is the issue of etiology or causation that concerns us here.)

As you can see, finding the causes of abnormal behavior is a complex and fascinating process. Focusing on biological or behav- ioral factors would not have given us a full picture of the causes of Judy’s disorder; we had to consider a variety of other influences and how they might interact. A discussion in more depth follows, examining the research underlying the many biological, psycho- logical, and social influences that must be considered as causes of any psychological disorder.

Theorists have abandoned the notion that any one factor can explain abnormal behavior; they favor an integrative model. Match each of the following scenarios to its most likely influ- ence or influences: (a) behavioral, (b) biological, (c) emo- tional, (d) social, and (e) developmental.

1. The fact that some phobias are more common than others (such as fear of heights and snakes) and may have contributed to the survival of the species in the past suggests that phobias may be genetically prewired. This is evidence for which influence? ______________

2. Jan’s husband, Jinx, was an unemployed jerk who spent his life chasing women other than his wife. Jan, happily divorced for years, cannot understand why the smell of Jinx’s brand of aftershave causes her to become nau- seated. Which influence best explains her response? ______________

3. Nathan, age 16, finds it more difficult than his 7-year- old sister to adjust to his parents’ recent separation. This may be explained by what influences? ______________

4. A traumatic ride on a Ferris wheel at a young age was most likely to have been the initial cause of Juanita’s fear of heights. Her strong emotional reaction to heights is likely to maintain or even increase her fear. The initial development of the phobia is likely a result of ______________ influences; however, ______________ influences are likely perpetuating the phobia.

Concept Check 2.1

People who experience the same traumatic event will have different long-term reactions.

N ic

ho la

s K

am m

/A FP

/G et

ty Im

ag es

50443_ch02_ptg01_hr_032-073.indd 35 28/09/16 5:29 PM

36 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

The Nature of genes We have known for a long time that each normal human cell has 46 chromosomes arranged in 23 pairs. One chromosome in each pair comes from the father and one from the mother. We can see these chromosomes through a microscope, and we can sometimes tell when one is faulty and predict what problems it will cause.

The first 22 pairs of chromosomes provide programs or direc- tions for the development of the body and brain, and the last pair, called the sex chromosomes, determines an individual’s sex. In females, both chromosomes in the 23rd pair are called X chromo- somes. In males, the mother contributes an X chromosome but the father contributes a Y chromosome. This one difference is respon- sible for the variance in biological sex. Abnormalities in the sex chromosomal pair can cause ambiguous sexual characteristics (see Chapter 10).

The DNA molecules that contain genes have a certain struc- ture, a double helix that was discovered only a few decades ago. The shape of a helix is like a spiral staircase. A double helix is two spirals intertwined, turning in opposite directions. Located on this double spiral are simple pairs of molecules bound together and arranged in different orders. On the X chromosome, there are approximately 160 million pairs. The ordering of these base pairs influences how the body develops and works.

A dominant gene is one of a pair of genes that strongly influ- ences a particular trait, and we need only one of them to deter- mine, for example, our eye color or hair color. A recessive gene, by contrast, must be paired with another (recessive) gene to deter- mine a trait. Otherwise, it won’t have any effect. Gene dominance occurs when one member of a gene pair is consistently expressed over the other (for example, a brown-eyed gene is dominant over a blue-eyed gene). When we have a dominant gene, using Men- delian laws of genetics we can predict fairly accurately how many offspring will develop a certain trait, characteristic, or disorder, depending on whether one or both of the parents carry that domi- nant gene.

Most of the time, predictions are not so simple. Much of our development and, interestingly, most of our behavior, our per- sonality, and even our intelligence are probably polygenic—that

genetic Contributions to Psychopathology What causes you to look like one or both of your parents or, per- haps, your grandparents? Obviously, the genes you inherit are from your parents and from your ancestors before them. Genes are long molecules of deoxyribonucleic acid (DNA) at various locations on chromosomes, within the cell nucleus. Ever since Gregor Mendel’s pioneering work in the 19th century, we have known that physi- cal characteristics such as hair color and eye color and, to a cer- tain extent, height and weight are determined—or at least strongly influenced—by our genetic endowment. Other factors in the envi- ronment influence our physical appearance, however. To some extent, our weight and even our height are affected by nutritional, social, and cultural factors. Consequently, our genes seldom deter- mine our physical development in any absolute way. They do pro- vide some boundaries to our development. Exactly where we go within these boundaries depends on environmental influences.

Although this is true for most of our characteristics, it is not true for all of them. Some of our characteristics are strongly deter- mined by one or more genes, including natural hair color and eye color. A few rare disorders are determined in this same way, includ- ing Huntington’s disease, a degenerative brain disease that appears in early to middle age, usually the early 40s. This disease has been traced to a genetic defect that causes deterioration in a specific area of the brain, the basal ganglia. It causes broad changes in personal- ity, cognitive functioning, and, particularly, motor behavior, includ- ing involuntary shaking or jerkiness throughout the body. We have not yet discovered a way to environmentally influence the course of Huntington’s disease. Another example of genetic influence is a dis- order known as phenylketonuria (PKU), which can result in mental retardation. This disorder, present at birth, is caused by the inability of the body to metabolize (break down) phenylalanine, a chemical compound found in many foods. Like Huntington’s disease, PKU is caused by a defect in a single gene, with little contribution from oth- er genes or the environmental background. PKU is inherited when both parents are carriers of the gene and pass it on to the child. For- tunately, researchers have discovered a way to correct this disorder: We can change the way the environment interacts with and affects the genetic expression of this disorder. Specifically, by detecting PKU early enough (which is now routinely done), we can simply restrict the amount of phenylalanine in the baby’s diet until the child devel- ops to the point where a normal diet does not harm the brain, usually 6 or 7 years of age. Disorders such as PKU and Huntington’s disease, in which cognitive impairment of various kinds is the prominent characteristic, are covered in more detail in Chapters 14 and 15.

Except for identical twins, every person has a unique set of genes unlike those of anyone else in the world. Because there is plenty of room for the environment to influence our development within the constraints set by our genes, there are many reasons for the development of individual differences.

What about our behavior and traits, our likes and dislikes? Do genes influence personality and, by extension, abnormal behav- ior? This question of nature (genes) versus nurture (upbringing and other environmental influences) is age-old in psychology, and the answers beginning to emerge are fascinating. Before discuss- ing them, let’s review briefly what we know about genes and about environmental factors.

A normal female has 23 pairs of chromosomes.

B io

-P ho

to A

ss oc

ia te

s/ S

ci en

ce S

ou rc

50443_ch02_ptg01_hr_032-073.indd 36 28/09/16 5:29 PM

genet ic cOntr ibut iOns tO psychOpathOlOgy 37

et al., 2011; Plomin & Davis, 2009; Rutter, 2006; Rutter et al., 2006; Thapar & McGuffin, 2009). In Chapter 4, we look at the actual methods that scientists use to study the influence of genes. Here, our interest is in what they are finding.

New Developments in the Study of genes and Behavior Scientists have now identified, in a preliminary way, the genetic contribution to psychological disorders and related behavioral patterns. The best estimates attribute about half of our enduring personality traits and cognitive abilities to genetic influence (Rutter, 2006). For example, McClearn and colleagues (1997) compared 110 Swedish identical twin pairs, at least 80 years old, with 130 same-sex fraternal twin pairs of a similar age and found heritability estimates for specific cognitive abilities, such as memory or ability to perceive spatial relations, ranged from 32% to 62%. This work built on earlier important twin studies, with different age groups showing similar results (for example, Bouchard, Lykken, McGue, Segal, & Tellegen, 1990). Furthermore, a study of more than 1,200 twins spanning 35 years confirmed that during adulthood (from early adulthood to late middle age) genetic factors deter- mined stability in cognitive abilities, whereas environmental fac- tors were responsible for any changes (Lyons et al., 2009). In other studies, the same heritability calculation for personality traits such as shyness or activity levels ranges between 30% and 50% (Bouchard et al., 1990; Kendler, 2001; Loehlin, 1992; Rutter, 2006; Saudino & Plomin, 1996; Saudino, Plomin, & DeFries, 1996).

It has also become clear that adverse life events such as a “chaotic” childhood can overwhelm the influence of genes (Turkheimer, Haley, Waldron, D’Onofrio, & Gottesman, 2003). For example, one member of a set of twins in the Lyons and colleagues (2009) study showed marked variability or change in cognitive abili- ties if his or her environment changed dramatically from the other twin’s because of some stressful event such as death of a loved one.

For psychological disorders, the evidence indicates that genetic factors make some contribution to all disorders but account for less than half of the explanation. This means that if one of a pair of

is, influenced by many genes, each contributing only a tiny effect, all of which, in turn, may be influenced by the environment. The same is true for psychiatric disorders (Geschwind & Flint 2015). And because the human genome—an individual’s complete set of genes—consists of more than 20,000 genes (U.S. Department of Energy Office of Science, 2009), polygenic interactions can be quite complex. For this reason, most genetic scientists now use sophis- ticated procedures such as quantitative genetics and molecular genetics that allow them to look for patterns of influence across many genes (Kendler, 2011, 2013; Kendler, Jaffee, & Roemer, 2011; Plomin & Davis, 2009; Rutter, Moffitt, & Caspi, 2006). Quantita- tive genetics basically sums up all the tiny effects across many genes without necessarily telling us which genes are responsible for which effects. Molecular genetics focuses on examining the actual structure of genes with increasingly advanced technologies such as DNA microarrays; these technologies allow scientists to analyze thousands of genes at once and identify broad networks of genes that may be contributing to a particular trait (Kendler, 2011; Plomin & Davis, 2009). Such studies have indicated that hundreds of genes can contribute to the heritability of a single trait (Hariri et al., 2002; Plomin et al., 1995; Rutter et al., 2006). It is very important to understand how genes work. Genes exert their influ- ences on our bodies and our behavior through a series of steps that produce proteins. Although all cells contain our entire genetic structure, only a small proportion of the genes in any one cell are “turned on” or expressed. In this way, cells become specialized, with some influencing liver function and others affecting person- ality. What is interesting is that environmental factors, in the form of social and cultural influences, can determine whether genes are “turned on” (Cole, 2011). To take one example, in studies with rat pups, researchers have found that the absence of normal maternal behavior of “licking and grooming” prevents the genetic expres- sion of a glucocorticoid receptor that modulates stress hormones. This means rats with inadequate maternal care have greater sen- sitivity to stress (Meaney & Szyf, 2005). There is evidence that a similar model may be relevant in humans (Dickens, Turkheimer, & Beam, 2011; Hyman, 2009). We present more examples later in the chapter when we discuss the interaction of genes and the envi- ronment. The study of gene expression and gene–environment interaction is the current frontier in the study of genetics (Kendler

Scientists can now isolate DNA for study. A DNA molecule, which contains genes, resembles a double spiral, or helix.

og da

nh od

a/ S

hu tt

er st

oc k.

co m

W ill

& D

en i M

ci nt

yr e/

S ci

en ce

S ou

rc e

50443_ch02_ptg01_hr_032-073.indd 37 28/09/16 5:29 PM

38 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

identical twins has schizophrenia, there is a less-than-50% likeli- hood that the other twin will also have schizophrenia (Gottesman, 1991). Similar or lower rates exist for other psychological disor- ders (Kendler & Prescott, 2006; Rutter, 2006).

Behavioral geneticists have reached general conclusions in the past several years on the role of genes and psychological disor- ders relevant to this chapter’s discussion of integrative approaches to psychopathology. First, specific genes or small groups of genes may ultimately be found to be associated with certain psychologi- cal disorders, as suggested in several important studies described later. But as discussed earlier, much of the current evidence sug- gests that contributions to psychological disorders come from many genes, each having a relatively small effect (Flint, 2009; Rutter, 2006). It is extremely important that we recognize this probability and continue to make every attempt to track the group of genes implicated in various disorders. Advances in gene mapping, molecular genetics, and linkage studies help with this difficult research (for example, Gershon Kelsoe, Kendler, & Watson, 2001; Hettema, Prescott, Myers, Neale, & Kendler, 2005). In linkage studies, scientists study individuals who have the same disorder, such as bipolar disorder, and also share other features, such as eye color; because the location of the gene for eye color is known, this allows scientists to attempt to “link” known gene locations (for eye color, in this example) with the possible location of a gene contributing to the disorder (Flint, 2009; see Chapter 4).

Second, as noted earlier, it has become increasingly clear that genetic contributions cannot be studied in the absence of inter- actions with events in the environment that trigger genetic vul- nerability or “turn on” specific genes (Kendler et al., 2011; Rutter, 2010). It is to this fascinating topic that we now turn.

The interaction of genes and the environment In 1983, the distinguished neuroscientist and Nobel Prize winner Eric Kandel speculated that the process of learning affects more

than behavior. He suggested that the very genetic structure of cells may change as a result of learning if genes that were inactive or dormant interact with the environment in such a way that they become active. In other words, the environment may occasion- ally turn on certain genes. This type of mechanism may lead to changes in the number of receptors at the end of a neuron, which, in turn, would affect biochemical functioning in the brain.

Although Kandel was not the first to propose this idea, he pro- vided convincing evidence to support it. Most of us assume that the brain, like other parts of the body, may well be influenced by environmental changes during development. But we also assume that once maturity is reached, the structure and function of our internal organs and most of our physiology are set or, in the case of the brain, hard-wired. The competing idea is that the brain and its functions are plastic, subject to continual change in response to the environment, even at the level of genetic structure. Now there is additional strong evidence supporting that view (Dick, 2011; Kendler et al., 2011; Landis & Insel, 2008; Robinson, Fernald, & Clayton, 2008).

With these new findings in mind, we can now explore gene– environment interactions as they relate to psychopathology. Two models have received the most attention: the diathesis–stress model and reciprocal gene–environment model (or gene– environment correlations).

the diathesis–Stress model For years, scientists have assumed a specific method of interaction between genes and environment. According to this diathesis– stress model, individuals inherit tendencies to express certain traits or behaviors, which may then be activated under conditions of stress (see E Figure 2.2). Each inherited tendency is a diathesis, which means, literally, a condition that makes someone susceptible to developing a disorder. When the right kind of life event, such as a certain type of stressor, comes along, the disorder develops. For example, according to the diathesis–stress model, Judy inherited a tendency to faint at the sight of blood. This tendency is the diathesis, or vulnerability. It would not become prom- inent until certain environ- mental events occurred. For Judy, this event was the sight of an animal being dissected when she was in a situation in which escape, or at least closing her eyes, was not acceptable. The stress of seeing the dissec- tion under these condi- tions activated her genetic tendency to faint. Together, these factors led to her developing a disorder. If she had not taken biology,

Genetic contributions to behavior are evident in twins who were raised apart. When these brothers were finally reunited, they were both firefighters, and they discovered many other shared characteristics and interests.

Th om

as W

an st

al l/T

he Im

ag e

W or

C ar

l F ris

to n

of S

tic hm

an M

ed ca

l E qu

ip m

en t

Eric Kandel won the Nobel Prize in Medicine for learning on bio- logical functioning among other accomplishments.

ST A

N H

O N

D A

/G et

ty Im

ag es

50443_ch02_ptg01_hr_032-073.indd 38 28/09/16 5:29 PM

genet ic cOntr ibut iOns tO psychOpathOlOgy 39

she might have gone through life without ever knowing she had this tendency, at least to such an extreme, although she might have felt queasy about minor cuts and bruises. You can see that the dia- thesis is genetically based and the stress is environmental but that they must interact to produce a disorder.

We might also take the case of someone who inherits a vul- nerability to alcoholism, which would make that person sub- stantially different from a close friend who does not have the same tendency. During college, both engage in extended drink- ing bouts, but only the individual with the so-called addictive genes begins the long downward spiral into alcoholism. The friend doesn’t. Having a particular vulnerability doesn’t mean you will necessarily develop the associated disorder. The smaller the vulnerability, the greater the life stress required to produce the disorder; conversely, with greater vulnerability, less life stress is required. This model of gene–environment interactions has been popular, although, in view of the relationship of the environment to the structure and function of the brain, it is greatly oversimplified.

This relationship was demonstrated in an elegant way in a landmark study by Caspi and colleagues (2003). These inves- tigators studied a group of 847 individuals in New Zealand who had undergone a variety of assessments for more than two decades, starting at the age of 3. They also noted whether the participants, at age 26, had been depressed during the past year. Overall, 17% of the study participants reported that they had experienced a major depressive episode during the prior year, and 3% reported that they felt suicidal. But the crucial part of the study is that the investigators also identified the genetic makeup of the individuals and, in particular, a gene that pro- duces a substance called a chemical transporter that affects the transmission of serotonin in the brain, called the 5-HTT gene. Serotonin, one of the neurotransmitters we will talk about later in the chapter, is particularly implicated in depression and relat- ed disorders. But the gene that Caspi and colleagues were study- ing comes in two common versions, or alleles: the long allele and the short allele. There was reason to believe, from prior work with animals, that individuals with at least two copies of the long allele (LL) were able to cope better with stress than individuals with two copies of the short allele (SS). Because the investigators have been recording stressful life events in these

individuals most of their lives, they were able to test this rela- tionship. In people with two S alleles, the risk for having a major depressive episode doubled if they had at least four stressful life events, compared with participants experiencing four stressful events who had two L alleles. But the interesting finding occurs when we look at the childhood experience of these individuals. In people with the SS alleles, severe and stressful maltreatment during childhood more than doubled their risks of depression in adulthood compared with those individuals carrying the SS alleles who were not maltreated or abused (63% versus 30%). For individuals carrying the LL alleles, on the other hand, stressful childhood experiences did not affect the incidence of depression in adulthood; 30% of this group became depressed whether they had experienced stressful childhoods or not. (This relationship is shown in E Figure 2.3.) Therefore, unlike this

Life events (stressor)

Stressor: long bouts of

drinking in college

Person #1 becomes alcoholic

Person #2 doesn’t become alcoholic

Diathesis: genetic

tendency to become alcoholic

Disorder

Genetic vulnerability (diathesis)

Alcoholism

E FigUre 2.2 In the diathesis–stress model, the greater the underlying vulnerability, the less stress is needed to trigger a disorder.

.20

.30

.40

.50

.60

.70

No maltreatment

P ro

b ab

ili ty

o f

m aj

o r

d ep

re ss

io n

e p

is o

d e

Probable maltreatment

Severe maltreatment

Two short alleles One short allele, one long allele Two long alleles

Key: SS SL LL

= = =

E FigUre 2.3 Interaction of genes and early environment in producing adult major depression. (Reprinted, with permission, from Caspi, A., Sugden, K., Moffitt, T. E., Taylor, A., Craig, I. W., Harrington, H., et al. (2003). Influence of life stress on depression: Moderation by a polymorphism in the 5-HTT gene. Science, 301, 386–389,© 2003 AAAS.)

50443_ch02_ptg01_hr_032-073.indd 39 28/09/16 5:29 PM

40 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

SS group, depression in the LL allele group seems related to stress in their recent past rather than childhood experiences. This study was very important in demonstrating clearly that neither genes nor life experiences (environmental events) can solely explain the onset of a disorder such as depression. It takes a complex interaction of the two factors.

Other studies have replicated or supported these findings (Binder, 2008; Karg, Burmeister, Shedden, & Sen, 2011; Kilpatrick et al., 2007; Mercer et al., 2012; Rutter et al., 2006). For example, in the Kilpatrick et al. (2007) study on the development of post- traumatic stress disorder (PTSD), 589 adults who experienced the Florida hurricanes of 2004 were interviewed and DNA was collected to examine genetic structure. Individuals with the same genetic makeup (SS) that signaled vulnerability in the Caspi and colleagues (2003) study were also more likely to develop PTSD after the hurricanes than those with the LL alleles. But another factor played a role as well. If individuals had a strong network of family and friends (strong social support), they were protected from developing PTSD even if they had the vulnerable genetic makeup and experienced a trauma (the hurricane). High-risk individuals (high hurricane exposure, SS alleles, and low social support) were at 4.5 times the risk of developing PTSD, as well as depression.

Also, in a study of the same group of New Zealand individuals by the investigators who carried out the study described earlier, Caspi et al. (2002) found that a different set of genes from those associated with depression seems to contribute to violent and anti- social behavior in adults. But again, this genetic predisposition occurs only if the individuals were maltreated as children. That is, some children who were maltreated turned out to be violent and antisocial as adults, but they were four times more likely to do their share of rape, robbery, and assault if they had a certain genetic makeup than were those who didn’t have the genetic makeup. These studies require replication. In fact, subsequent research sug- gests that it is not just any one genetic variation that makes people susceptible to stress or other environmental influences (Risch et. al., 2009; Goldman, Glei. Lin, & Weinstein, 2010). A larger net- work of genes almost certainly plays a role in the development of depression and other disorders. These and subsequent studies,

however, do provide powerful, if preliminary, support for the gene–environment interaction model that had only indirect sup- port until this time (Uher, 2011).

the gene–environment correlation model With additional study, psychologists have found the web of interre- lationships between genes and environment to be even more com- plex. Some evidence now indicates that genetic endowment may increase the probability that an individual will experience stressful life events (see Kendler, 2006, 2011; Rutter, 2006, 2010; Saudino, Pedersen, Lichtenstein, McClearn, & Plomin, 1997; Thapar & McGuffin, 2009). For example, people with a genetic vulnerability to develop a certain disorder, such as blood–injury–injection pho- bia, may also have a personality trait—let’s say impulsiveness— that makes them more likely to be involved in minor accidents that would result in their seeing blood. In other words, they may be accident prone because they are continually rushing to com- plete things or to get to places without regard for their physical safety. These people, then, might have a genetically determined tendency to create the very environmental risk factors that trigger a genetic vulnerability to blood–injury–injection phobia.

This is the gene–environment correlation model or recipro- cal gene–environment model (Jaffee, 2011; Kendler, 2011; Thapar & McGuffin, 2009) (see E Figure 2.4). Some evidence indicates that it applies to the development of depression, because some people may tend to seek out difficult relationships or other cir- cumstances that lead to depression (Eley, 2011). This did not seem to be the case in the New Zealand study described earlier (Caspi et al., 2003), however, because stressful episodes during adulthood occurred with about the same frequency in the SS and the LL groups. McGue and Lykken (1992) have even applied the gene–environment correlation model to some fascinating data on the influence of genes on the divorce rate. For example, if you and your spouse each have an identical twin, and both identical twins have been divorced, the chance that you will also divorce increases greatly. Furthermore, if your identical twin and your parents and your spouse’s parents have been divorced, the chance that you will divorce is 77.5%. Conversely, if none of your family members on

Situations involving seeing blood

Genetic tendency to develop blood–injection–injury phobia

Tendency toward impulsiveness—attracts situations that might involve blood

Blood–injection–injury phobia

Situations involving seeing blood

Blood–injection–injury phobia

Person A has genetic vulnerability to develop blood–injection–injury phobia.

Person B does not have genetic vulnerability to develop blood–injection–injury phobia.

E FigUre 2.4 Reciprocal Gene–Environment Model

50443_ch02_ptg01_hr_032-073.indd 40 28/09/16 5:29 PM

genet ic cOntr ibut iOns tO psychOpathOlOgy 41

either side has been divorced, the probability that you will divorce is only 5.3%.

This is the extreme example, but McGue and Lykken (1992) demonstrated that the probability of your divorcing doubles over the probability in the population at large if your fraternal twin is also divorced and increases sixfold if your identical twin is divorced. Why would this happen? Obviously, no one gene causes divorce. To the extent that it is genetically determined, the ten- dency to divorce is almost certainly related to various inherited traits, such as being high-strung, impulsive, or short-tempered, that make someone hard to get along with (Jockin, McGue, & Lykken, 1996). Another possibility is that an inherited trait makes it more likely you will choose an incompatible spouse. To take a simple example, if you are passive and unassertive, you may well choose a strong, dominant mate who turns out to be difficult to live with. You get divorced but then find yourself attracted to another individual with the same personality traits, who is also difficult to live with. Some people would simply attribute this kind of pattern to poor judgment. Nevertheless, there’s no doubt that social, interpersonal, psychological, and environmental fac- tors play major roles in whether we stay married, and it’s quite possible that our genes contribute to how we create our own environment.

epigenetics and the Nongenomic “inheritance” of Behavior To make things a bit more interesting but also more complicated, a number of reports suggest that studies to date have overemphasized the extent of genetic influence on our personalities, our tempera- ments, and their contribution to the development of psychologi- cal disorders (Mill, 2011). This overemphasis may be partly the result of the manner in which these studies have been conducted (Moore, 2001; Turkheimer & Waldron, 2000). Several intriguing lines of evidence have come together in recent years to buttress this conclusion.

For example, in their animal laboratories, Crabbe, Wahlsten, and Dudek (1999) conducted a clever experiment in which three types of mice with different genetic makeups were raised in vir- tually identical environments at three sites, the home universities of the behavioral geneticists just named. Each mouse of a given type (for example, type A) was genetically indistinguishable from all other mice of that type at each of the universities. The experimenters went out of their way to make sure the environ- ments (for example, laboratory, cage, and lighting conditions) were the same at each university. For example, each site had the same kind of sawdust bedding that was changed on the same day of the week. If the animals had to be handled, all of them were handled at the same time by experimenters wearing the same kind of glove. When their tails were marked for identification, the same type of pen was used. If genes determine the behavior of the mice, then mice with virtually identical genetic makeup (type A) should have performed the same at all three sites on a series of tests, as should have type B and type C mice. But the results showed that this did not happen. Although a certain type of mouse might perform similarly on a specific test across all

three sites, on other tests that type of mouse performed differ- ently. Robert Sapolsky, a prominent neuroscientist, concluded, “genetic influences are often a lot less powerful than is commonly believed. The environment, even working subtly, can still mold and hold its own in the biological interactions that shape who we are” (Sapolsky, 2000, p. 15).

In another fascinating program of research with rodents (Cameron et al., 2005; Francis, Diorio, Liu, & Meaney, 1999; Weaver et al., 2004), the investigators studied stress reactivity and how it is passed through generations, using a powerful experi- mental procedure called cross-fostering, in which a rat pup born to one mother is assigned to another mother for rearing. They first demonstrated, as had many other investigators, that mater- nal behavior affected how the young rats tolerated stress. If the mothers were calm and supportive, their rat pups were less fear- ful and better able to tolerate stress. But we don’t know if this effect results from genetic influences or from being raised by calm mothers. This is where cross-fostering comes in. Francis et al. (1999) took some newly born rat pups of fearful and easily stressed mothers and placed them for rearing with calm moth- ers. Other young rats remained with their easily stressed moth- ers. With this interesting scientific twist, Francis et al. (1999) demonstrated that calm and supportive behavior by the mothers could be passed down through generations of rats independent of genetic influences, because rats born to easily stressed mothers but reared by calm mothers grew up more calm and supportive. The authors concluded,

These findings suggest that individual differences in the expression of genes in brain regions that regulate stress reactivity can be transmitted from one generation to the next through behavior. . . . The results . . . suggest that the mechanism for this pattern of inheritance involves differ- ences in maternal care. (p. 1158)

In subsequent studies from this group (Cameron et al., 2005), the investigators demonstrated that the maternal behavior had lastingly altered the endocrine response to stress by affecting gene expression. But this effect only occurred if the rat mother was calm and nurturing during the rat pups’ first week of life. After that, it didn’t matter. This highlights the importance of early expe- rience on behavior.

Other scientists have reported similar results (Anisman, Zaharia, Meaney, & Merali, 1998; Harper, 2005). For example, Suomi (1999), working with rhesus monkeys and using the cross-fostering strategies just described, showed that if geneti- cally reactive and emotional young monkeys are reared by calm mothers for the first 6 months of their lives, the animals behaved in later life as if they were nonemotional and not reactive to stress at birth. In other words, the environmental effects of early parenting seem to override any genetic contribution to be anx- ious, emotional, or reactive to stress. Suomi (1999) also demon- strated that these emotionally reactive monkeys raised by “calm, supportive” parents were also calm and supportive when raising their own children, thereby influencing and even reversing the genetic contribution to the expression of personality traits or temperaments.

50443_ch02_ptg01_hr_032-073.indd 41 28/09/16 5:29 PM

42 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

Strong effects of the environment have also been observed in humans. For example, Tienari et al. (1994) found that children whose parents had schizophrenia and who were adopted away as babies demonstrated a tendency to develop psychiatric disorders (including schizophrenia) themselves only if they were adopted into dysfunctional families. Those children adopted into func- tional families with high-quality parenting did not develop the disorders. Thus, it is probably too simplistic to say the genetic contribution to a personality trait or to a psychological disorder is approximately 50%. We can talk of a heritable (genetic) con- tribution only in the context of the individual’s past and present environment (Dickens et al., 2011).

In support of this conclusion, Suomi (2000) demonstrated that for young monkeys with a specific genetic pattern associated with a highly reactive temperament (emotional or susceptible to the effects of stress), early maternal deprivation (disruptions in mothering) will have a powerful effect on their neuroendocrine functioning and their later behavioral and emotional reactions. For animals not carrying this genetic characteristic, however, maternal deprivation will have little effect, just as was found in the New Zealand study in humans by Caspi et al. (2003), and it is likely this effect will be carried down through the generations. But, as noted above in the example of genetic influences on cog- nitive abilities (Turkheimer et al., 2003), extremely chaotic early environments can override genetic factors and alter neuroendo- crine function to increase the likelihood of later behavioral and emotional disorders (Dickens et al., 2011; Ouellet-Morin et al., 2008).

How does this work? Although the environment cannot change our DNA, it can change the gene expression. It seems that genes are turned on or off by cellular material that is located just outside of the genome (“epi,” as in the word epigenetics, means on or around) and that stress, nutrition, or other factors can affect this epigenome, which is then immediately passed down to the next generation and maybe for several generations (Arai, Li, Hartley, & Feig, 2009; Mill, 2011). The genome itself isn’t changed, so if the stressful or inadequate environment disappears, eventu- ally the epigenome will fade. These new conceptualizations of the role of genetic contributions as only constraining environmental influences have implications for preventing unwanted personal- ity traits or temperaments and even psychological disorders. That is, it seems that environmental manipulations, particularly early in life, may do much to override the genetically influenced ten- dency to develop undesirable behavioral and emotional reactions. Although current research suggests that environmental influ- ences, such as peer groups and schools, affect this genetic expres- sion, the strongest evidence exists for the effects of early parenting influences and other early experiences (Cameron et al., 2005; Mill, 2011; Ouellet-Morin et al., 2008).

Nowhere is the complexity of the interaction of genetic and environmental influences more apparent than in the famous cases of Chang and Eng, a pair of conjoined identical twins born to parents living in Thailand in 1810 (known as Siam at the time) who were joined at the chest. These individuals, who were suc- cessful entertainers and traveled around the world performing at exhibitions, were the source of the name “Siamese twins.” What is important for our purposes here is that these identical twins

obviously shared identical genes, as well as nearly identical envi- ronments throughout their lives. Thus, we would certainly expect them to behave in similar ways when it comes to personality fea- tures, temperaments, and psychological disorders. But everybody who knew these twins noted that they had distinct personalities. Chang was prone to moodiness and depression, and he finally started drinking heavily. Eng, on the other hand, was more cheer- ful, quiet, and thoughtful (Moore, 2001).

In summary, a complex interaction between genes and the environment plays an important role in every psychological dis- order (Kendler, et al., 2011; Rutter, 2006, 2010; Turkheimer, 1998). Our genetic endowment does contribute to our behavior, our emo- tions, and our cognitive processes and constrains the influence of environmental factors, such as upbringing, on our later behav- ior, as is evident in the New Zealand study (Caspi et al., 2003) and its later replications. Environmental events, in turn, seem to affect our very genetic structure by determining whether certain genes are activated or not (Kendler, 2011; Landis & Insel, 2008). Furthermore, strong environmental influences alone may be suf- ficient to override genetic diatheses. Thus, neither nature (genes) nor nurture (environmental events) alone, but rather a complex interaction of the two, influences the development of our behavior and personalities.

Determine whether these statements relating to the genetic contributions of psychopathology are true (T) or false (F).

1. _____________ The first 20 pairs of chromosomes program the development of the body and brain.

2. _____________ No individual genes have been identi- fied that cause any major psychological disorders.

3. _____________ According to the diathesis–stress model, people inherit a vulnerability to express certain traits or behaviors that may be activated under certain stress conditions.

4. _____________ The idea that individuals may have a genetic endowment to increase the probability that they will experience stressful life events and there- fore trigger a vulnerability is in accordance with the diathesis–stress model.

5. _____________ Environmental events alone influence the development of our behavior and personalities.

Concept Check 2.2

Neuroscience and its Contributions to Psychopathology Knowing how the nervous system and, especially, how the brain works is central to any understanding of our behavior, emotions, and cognitive processes. This is the focus of neuroscience. To

50443_ch02_ptg01_hr_032-073.indd 42 28/09/16 5:29 PM

neurOscience anD its cOntr ibut iOns tO psychOpathOlOgy 43

comprehend the newest research in this field, we first need an overview of how the brain and the nervous system function. The human nervous system includes the central nervous system, con- sisting of the brain and the spinal cord, and the peripheral nervous system, consisting of the somatic nervous system and the auto- nomic nervous system (see E Figure 2.5).

The Central Nervous System The central nervous system processes all information received from our sense organs and reacts as necessary. It sorts out what is relevant, such as a certain taste or a new sound, from what isn’t, such as a familiar view or ticking clock; checks the memory banks to determine why the information is relevant; and implements the right reaction, whether it is to answer a simple question or to play a Mozart sonata. This is a lot of exceedingly complex work. The spinal cord is part of the central nervous system, but its primary function is to facilitate the sending of messages to and from the brain, which is the other major component of the central ner- vous system (CNS) and the most complex organ in the body. The brain uses an average of 140 billion nerve cells, called neurons, to control our thoughts and action. Neurons transmit information throughout the nervous system.

It is important to understand what a neuron is and how it works. The typical neuron contains a central cell body with two kinds of branches. One kind of branch is called a dendrite. Den- drites have numerous receptors that receive messages in the form of chemical impulses from other nerve cells, which are converted into electrical impulses. The other kind of branch, called an axon, transmits these impulses to other neurons. Any one nerve cell may have multiple connections to other neurons. These connections are called synapses. The brain has billions of nerve cells, more than 100 billion by some estimates, and trillions of synapses; so you can see how complicated the system becomes, far more complicated than the most powerful computer that has ever been built (or will be for some time). Inspired by the Human Genome Project, the White House announced in 2013 the BRAIN initiative (the acronym stands for Brain Research through Advancing Innovative Neurotechnologies). The goal of this highly ambitious project is to revolutionize our understanding of the human brain, which orga- nizes every facet of our existence.

The smallest building blocks of the brain are the neurons that form a highly complex network of information flow. Within each neuron, information is transmitted through electrical impulses, called action potentials, traveling along the axon of a neuron. The end of an axon is called a terminal button. Neurons are not actually connected directly to each other. There is a small space through which the impulse must pass to get to the next neuron. The space between the terminal button of one neuron and the dendrite of another is called the synaptic cleft. What happens in this space is of great interest to psychopatholo- gists. The biochemicals that are released from the axon of one neuron and transmit the impulse to the dendrite receptors of another neuron are called neurotransmitters, which are chemi- cals stored in vesicles in the terminal buttons (see E Figures 2.6 and 2.12). These were mentioned briefly when we described the genetic contribution to the depression in the New Zealand study

(Caspi et al., 2003). Only in the past several decades have we begun to understand their complexity. Now, using increasingly sensitive equipment and techniques, scientists have identified many types of neurotransmitters.

In addition to neurons, there is another type of cell that com- prises the nervous system—glia (or glial) cells. Even though these cells outnumber neurons by a ratio of about 10 to 1, for many years they were little studied because scientists believed that they were passive cells that merely served to connect and insulate neu- rons (Koob, 2009). More recently, scientists have discovered that glia actually play active roles in neural activity (Eroglu & Barres, 2010). It is now known that there are different types of glia cells with several specific functions, some of which serve to modulate neurotransmitter activity (Allen & Barres, 2009; Perea & Araque, 2007). Better understanding the role of glia cells in neurotrans- mitter processes is an important new area of research. To date, however, the most advanced neuroscience research in psychopa- thology focuses on neurons.

Major neurotransmitters relevant to psychopathology include norepinephrine (also known as noradrenaline), serotonin, dopa- mine, gamma-aminobutyric acid (GABA), and glutamate. You will see these terms many times in this book. Some neurotransmit- ters are excitatory, because they increase the likelihood that the connecting neuron will fire, whereas other neurotransmitters are inhibitory because they decrease the likelihood that the connect- ing neuron will fire. Some neurons can receive input from both excitatory and inhibitory neurotransmitters.

Excesses or insufficiencies in some neurotransmitters are associated with different groups of psychological disorders. For

The central nervous system screens out information that is irrelevant to the current situation. From moment to moment we notice what moves or changes more than what remains the same.

D av

id -Y

ou ng

W ol

ff /P

ho to

E di

t D

av id

-Y ou

ng W

ol ff

/P ho

to E

di t

50443_ch02_ptg01_hr_032-073.indd 43 28/09/16 5:29 PM

44 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

Peripheral Nervous System

Somatic (blue): Controls voluntary muscles and conveys sensory information to the central nervous system Autonomic (red): Controls involuntary muscles Sympathetic: Expends energy Parasympathetic: Conserves energy

Corpus callosum

Cerebral cortex

Cerebellum

Thalamus Hypothalamus

Pituitary gland Pons

Medulla

Central Nervous System (brown) Brain Spinal cord

Nervous system

Brain Spinal cord Autonomic nervous system (ANS)

Somatic nervous system

Peripheral nervous system (PNS)

Central nervous system (CNS)

Parasympathetic division

Sympathetic division

Corpus callosum

Cerebral cortex

Cerebellum

Thalamus Hypothalamus Pituitary gland

Pons

Medulla

example, reduced levels of GABA were initially thought to be associated with excessive anxiety (Costa, 1985). Early research (Snyder, 1976, 1981) linked increases in dopamine activity to schizophrenia. Other early research found correlations between depression and high levels of norepinephrine (Schildkraut, 1965) and, possibly, low levels of serotonin (Siever, Davis, & Gorman, 1991). However, more recent research, described later in this chapter, indicates that these early interpretations were too sim- plistic. In view of their importance, we return to the subject of neurotransmitters shortly.

The Structure of the Brain Having an overview of the brain is useful because many structures described here are later mentioned in the context of specific dis- orders. One way to view the brain (see E Figure 2.7) is to see it in two parts—the brain stem and the forebrain. The brain stem is the lower and more ancient part of the brain. Found in most animals, this structure handles most of the essential automatic functions, such as breathing, sleeping, and moving around in a coordinated way. The forebrain is more advanced and evolved more recently.

50443_ch02_ptg01_hr_032-073.indd 44 28/09/16 5:29 PM

neurOscience anD its cOntr ibut iOns tO psychOpathOlOgy 45

Interaction of neuro- transmitter with receptor, exciting or inhibiting post- synaptic neuron

Postsynaptic neuron

Transport of neurotransmitter down axon

Synthesis of neurotransmitter and formation of vesicles

Cell body

Release of neurotransmitter

Reuptake of neuro- transmitter to be recycled

Separation of neurotransmitter molecules from receptors

5 Vesicles without neurotransmitter transported back to cell body

Forebrain

Optic nerve

Olfactory bulb

Hindbrain Midbrain

Some anatomists even consider the thalamus and hypothalamus to be parts of the forebrain.

At the base of the forebrain, just above the thalamus and hypo- thalamus, is the limbic system. Limbic means border, so named because it is located around the edge of the center of the brain. The limbic system, which figures prominently in much of psy- chopathology, includes such structures as the hippocampus (sea horse), cingulate gyrus (girdle), septum (partition), and amygdala (almond), all of which are named for their approximate shapes. This system helps regulate our emotional experiences and expres- sions and, to some extent, our ability to learn and to control our impulses. It is also involved with the basic drives of sex, aggres- sion, hunger, and thirst.

The basal ganglia, also at the base of the forebrain, include the caudate (tailed) nucleus. Because damage to these structures is involved in changing our posture or twitching or shaking, they are believed to control motor activity. Later in this chapter, we review some interesting findings on the relationship of this area to obses- sive-compulsive disorder.

The largest part of the forebrain is the cerebral cortex, which contains more than 80% of all neurons in the central nervous sys- tem. This part of the brain provides us with our distinctly human qualities, allowing us to look to the future and plan, to reason, and to create. The cerebral cortex is divided into two hemispheres. Although the hemispheres look alike structurally and operate relatively independently (both are capable of perceiving, thinking, and remembering), recent research indicates that each has differ- ent specialties. The left hemisphere seems to be chiefly responsible for verbal and other cognitive processes. The right hemisphere seems to be better at perceiving the world around us and creat- ing images. The hemispheres may play differential roles in specific

The lowest part of the brain stem, the hindbrain, contains the medulla, the pons, and the cerebellum. The hindbrain regulates many automatic activities, such as breathing, the pumping action of the heart (heartbeat), and digestion. The cerebellum controls motor coordination, and recent research suggests that abnormali- ties in the cerebellum may be associated with autism, although the connection with motor coordination is not clear (Courchesne, 1997; Lee et al., 2002; Fatemi et al., 2012; see Chapter 14).

Also located in the brain stem is the midbrain, which coordi- nates movement with sensory input and contains parts of the retic- ular activating system, which contributes to processes of arousal and tension, such as whether we are awake or asleep.

At the top of the brain stem are the thalamus and hypothal- amus, which are involved broadly with regulating behavior and emotion. These structures function primarily as a relay between the forebrain and the remaining lower areas of the brain stem.

50443_ch02_ptg01_hr_032-073.indd 45 28/09/16 5:29 PM

46 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

Thalamus

Caudate nucleus

Putamen (lateral)

Amygdala

Globus pallidus (medial)

Thalamus

Pineal gland

Tectum

Pons

Medulla

Tegmentum

Superior colliculus

Inferior colliculus

Midbrain

Posterolateral view of brain stem

Cingulate gyrus

Frontal lobe

Corpus callosum

Tissue dividing lateral ventricles

Cerebral cortex Parietal lobe

Occipital lobe

Superior and inferior colliculi Midbrain

Cerebellum

Central canal of spinal cord

Thalamus

Nucleus accumbens

Hypothalamus

Pituitary gland Pons

Medulla

Spinal cord

Cingulate gyrus

Anterior thalamic nuclei

Septal nuclei

Frontal lobe

Olfactory bulb

Amygdala

Mamillary bodies

Hippocampus

Parahippocampal gyrus (limbic lobe)

Fornix

50443_ch02_ptg01_hr_032-073.indd 46 28/09/16 5:29 PM

neurOscience anD its cOntr ibut iOns tO psychOpathOlOgy 47

psychological disorders. Each hemisphere consists of four sepa- rate areas, or lobes: temporal, parietal, occipital, and frontal (see E Figure 2.8). Each is associated with different processes. Of the first three areas, the temporal lobe is associated with recognizing various sights and sounds and with long-term memory storage, the parietal lobe is associated with recognizing various sensations of touch and monitoring body positioning, and the occipital lobe is associated with integrating and making sense of various visual inputs. These three lobes, located toward the back (posterior) of the brain, work together to process sight, touch, hearing, and other signals from our senses.

The frontal lobe is the most interesting from the point of view of psychopathology. The front (or anterior) of the frontal lobe is called the prefrontal cortex, and this is the area responsible for higher cognitive functions such as thinking and reasoning, plan- ning for the future, and long-term memory. This area of the brain synthesizes all information received from other parts of the brain and decides how to respond. It is what enables us to relate to the world around us and the people in it—to behave as social animals. When studying areas of the brain for clues to psychopathology, most researchers focus on the frontal lobe of the cerebral cortex, as well as on the limbic system and the basal ganglia.

The Peripheral Nervous System The peripheral nervous system coordinates with the brain stem to make sure the body is working properly. Its two major components

are the somatic nervous system and the autonomic nervous system. The somatic nervous system controls the muscles, so damage in this area might make it difficult for us to engage in any volun- tary movement, including talking. The autonomic nervous system includes the sympathetic nervous system and parasympathetic ner- vous system. The primary duties of the autonomic nervous system are to regulate the cardiovascular system (for example, the heart and blood vessels) and the endocrine system (for example, the pituitary, adrenal, thyroid, and gonadal glands) and to perform various other functions, including aiding digestion and regulating body temperature (see E Figure 2.9).

The endocrine system works a bit differently from other sys- tems in the body. Each endocrine gland produces its own chemi- cal messenger, called a hormone, and releases it directly into the bloodstream. The adrenal glands produce epinephrine (also called adrenaline) in response to stress, as well as salt-regulating hor- mones; the thyroid gland produces thyroxine, which facilitates energy metabolism and growth; the pituitary is a master gland that produces a variety of regulatory hormones; and the gonadal glands produce sex hormones such as estrogen and testosterone. The endocrine system is closely related to the immune system; it is also implicated in a variety of disorders. In addition to contributing to stress-related physical disorders discussed in Chapter 9, endo- crine regulation may play a role in depression, anxiety, schizo- phrenia, and other disorders (McEwen, 2013). Some studies have found, for example, that depressed patients may respond better to an antidepressant medication if it is administered in combination

Frontal lobe (planning of movements, recent memory, some aspects of emotions)

Precentral gyrus (primary motor cortex)

Central sulcus

Temporal lobe (hearing, advanced visual processing)

Prefrontal cortex

Olfaction

Vision Audition

Movement Somesthesis

(a) (b)

Motor Somesthetic

Visual

Auditory

Occipital lobe (vision)

Olfactory bulb

Postcentral gyrus (primary somatosensory cortex)

Parietal lobe (body sensations)

E FigUre 2.8 Some major subdivisions of the human cerebral cortex and a few of their primary functions. (Reprinted, with permission, from Kalat, J. W. (2009). Biological Psychology, 10th edition, © 2009 Wadsworth.)

50443_ch02_ptg01_hr_032-073.indd 47 28/09/16 5:29 PM

48 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

with a thyroid hormone (Nierenberg et al., 2006), or for some older depressed men coadministration of testosterone may enhance antidepressant effects (Pope, Cohane, Kanayama, Siegel, & Hudson, 2003). This interdisciplinary area of research is termed psychoneuroendocrinology and is a growing subfield.

Sympathetic and parasympathetic divisions of the autonomic nervous system operate in a complementary fashion. The sym- pathetic nervous system is primarily responsible for mobilizing the body during times of stress or danger by rapidly activating the organs and glands under its control. When the sympathetic division goes on alert, three things happen. The heart beats faster, thereby increasing the flow of blood to the muscles; respiration

increases, allowing more oxygen to get into the blood and brain; and the adrenal glands are stimulated. All three changes help mobilize us for action. When you read in the newspaper that a woman lifted a heavy object to free a trapped child, you can be sure her sympathetic nervous system was working overtime. This system mediates a substantial part of our “emergency” or “alarm” reaction, discussed later in this chapter and in Chapter 5.

One of the functions of the parasympathetic system is to bal- ance the sympathetic system. In other words, because we could not operate in a state of hyperarousal and preparedness forever, the parasympathetic nervous system takes over after the sympa- thetic nervous system has been active for a while, normalizing our

Vagus nerveHeart

Salivary glands

Lungs

Liver Spleen

Stomach

Pupil

Sympathetic outflow Parasympathetic outflow

Cranial nerves (12 pairs)

Postganglionic axons

Cervical nerves (8 pairs)

Thoracic nerves (12 pairs)

Lumbar nerves (5 pairs)

Sacral nerves (5 pairs)

Coccygeal nerve (1 pair)

Celiac ganglion

Pelvic nerve

(Most ganglia near spinal cord)

Preganglionic axons

Pancreas

Kidney Adrenal gland

Muscles that erect hairs

Bladder

Uterus

Genitals

Large intestine

Small intestine

E FigUre 2.9 The sympathetic nervous system (red lines) and parasympathetic nervous system (blue lines). (Reprinted, with permission, from Kalat, J. W. (2009). Biological Psychology, 10th edition, © 2009 Wadsworth.)

50443_ch02_ptg01_hr_032-073.indd 48 28/09/16 5:29 PM

neurOscience anD its cOntr ibut iOns tO psychOpathOlOgy 49

arousal and facilitating the storage of energy by helping the diges- tive process.

One brain connection implicated in some psychological dis- orders involves the hypothalamus and the endocrine system. The hypothalamus connects to the adjacent pituitary gland, which is the master or coordinator of the endocrine system. The pituitary gland, in turn, may stimulate the cortical part of the adrenal glands on top of the kidneys. As we noted previously, surges of epineph- rine tend to energize us, arouse us, and get our bodies ready for threat or challenge. When athletes say their adrenaline was really flowing, they mean they were highly aroused and up for the com- petition. The cortical part of the adrenal glands also produces the stress hormone cortisol. This system is called the hypothalamic– pituitary–adrenocortical axis, or HPA axis (see E Figure 2.10); it has been implicated in several psychological disorders and is mentioned in Chapters 5, 7, and 9. There is good evidence show- ing that a dysregulation of the HPA axis is linked to depression (Burke, Davis, Otte, & Mohr, 2005). A recent study by Gotlib and colleagues (2015) further suggests that a specific feature on

a chromosome, called a telomere, appears to moderate the effect of depression and cortisol. Telomeres are certain structures that cap the ends of chromosomes to protect the chromosome from deteriorating or getting entangled with neighboring chromo- somes. The study by Gotlib and colleagues found that daughters of depressed mothers had shorter telomeres than did daughters of never-depressed mothers. Moreover, shorter telomeres were associated with greater cortisol reactivity to stress. In the future, it might be possible to use such genetic information to find ways to prevent the development of depression in vulnerable people by identifying individuals with shorter telomeres and training them to be more resilient to stress.

This brief overview should give you a general sense of the structure and function of the brain and nervous system. New procedures for studying brain structure and function that involve photographing the working brain are discussed in Chapter 3. Here, we focus on what these studies reveal about the nature of psychopathology.

Neurotransmitters The biochemical neurotransmitters in the brain and nervous sys- tem that carry messages from one neuron to another continue to receive intense attention from psychopathologists (Bloom & Kupfer, 1995; LeDoux, 2002; Iverson, 2006; Iverson & Iverson, 2007; Nestler, Hyman, & Malenka, 2008). One good example is the role of the neurotransmitter serotonin in some studies of gene–environment interactions described earlier (e.g., Karg et al., 2011). This biochemical was discovered only in the past several decades, and only in the past few years have we developed the extraordinarily sophisticated procedures necessary to study them. One way to think of neurotransmitters is as narrow currents flow- ing through the ocean of the brain. Sometimes they run parallel with other currents, only to separate again. Often they seem to meander aimlessly, looping back on themselves before moving on. Neurons that are sensitive to one type of neurotransmitter cluster together and form paths from one part of the brain to the other.

These paths may overlap with the paths of other neurotrans- mitters, but, as often as not, they end up going their separate ways (Bloom, Nelson, & Lazerson, 2001; Dean, Kelsey, Heller, & Ciaranello, 1993). There are thousands, perhaps tens of thousands, of these brain circuits, and we are just beginning to discover and map them (Arenkiel & Ehlers, 2009). Neuroscientists have identi- fied several neural pathways that seem to play roles in various psy- chological disorders (Fineberg et al., 2010; LeDoux, 2002, 2015; Stahl, 2008; Tau & Peterson, 2010).

New neurotransmitters are frequently discovered, and existing neurotransmitter systems must be subdivided into separate clas- sifications. Estimates suggest that more than 100 different neu- rotransmitters, each with multiple receptors, are functioning in various parts of the nervous system (Borodinsky et al., 2004; Kalat, 2013; Sharp, 2009). Also, scientists are increasingly discovering additional biochemicals and gases that have certain neurotrans- mitter properties. Because this dynamic field of research is in a state of considerable flux, the neuroscience of psychopathology is an exciting area of study that may lead to new drug treatments among other advances. Research findings that seem to apply to

Pineal gland

Pituitary gland

Parathyroid glands

Adrenal gland

Liver

Kidney

Pancreas

Ovary (in female)

Placenta (in female during pregnancy)

Testis (in male)

Thyroid glands

Thymus

Hypothalamus

50443_ch02_ptg01_hr_032-073.indd 49 28/09/16 5:29 PM

50 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

psychopathology today may no longer be relevant tomorrow, how- ever. Many years of study will be required before it is all sorted out.

You may still read reports that certain psychological disorders are “caused” by biochemical imbalances, excesses, or deficiencies in certain neurotransmitter systems. For example, abnormal activ- ity of the neurotransmitter serotonin is often described as causing depression, and abnormalities in the neurotransmitter dopamine have been implicated in schizophrenia. Increasing evidence indi- cates that this is an enormous oversimplification, however. We are now learning that the effects of neurotransmitter activity are less specific. They often seem to be related to the way we process infor- mation (Harmer et al., 2009; Kandel, Schwartz, & Jessell, 2000; LeDoux, 2002; Sullivan & LeDoux, 2004). Changes in neurotrans- mitter activity may make people more or less likely to exhibit cer- tain kinds of behavior in certain situations without causing the behavior directly. In addition, broad-based disturbances in our functioning are almost always associated with interactions of the various neurotransmitters rather than with alterations in the activity of any one system (Fineberg et al., 2010; LeDoux, 2002; Stahl, 2008; Xing, Zhang, Russell, & Post, 2006). In other words, the currents intersect so often that changes in one neurotransmit- ter result in changes in the other, often in a way scientists have not yet been able to predict.

Research on neurotransmitter function focuses primarily on what happens when activity levels change. We can study this in several ways. We can introduce substances called agonists that effectively increase the activity of a neurotransmitter by mimicking its effects; substances called antagonists that decrease, or block, a neurotransmitter; or substances called inverse agonists that pro- duce effects opposite to those produced by the neurotransmitter. By systematically manipulating the production of a neurotrans- mitter in different parts of the brain, scientists are able to learn more about its effects. Most drugs could be classified as either agonistic or antagonistic, although they may achieve these results in a variety of ways. That is, these drug therapies work by either increasing or decreasing the flow of specific neurotransmitters. Some drugs directly inhibit, or block, the production of a neu- rotransmitter. Other drugs increase the production of competing biochemical substances that may deactivate the neurotransmit- ter. Yet other drugs do not affect neurotransmitters directly but prevent the chemical from reaching the next neuron by closing down, or occupying, the receptors in that neuron. After a neu- rotransmitter is released, it is quickly broken down and brought back from the synaptic cleft into the same neuron that released it. This process is called reuptake. Normally, the action of a neu- rotransmitter is fairly brief to ensure that the nervous system can quickly adjust to environmental changes and situational demands. Sometimes, psychological problems are associated with too much of a particular neurotransmitter in the synaptic gap, sometimes with too little. Some drugs work by blocking the reuptake pro- cess, thereby causing continued stimulation along the brain cir- cuit; other drugs work by stimulating or blocking the release of a neurotransmitter into the synaptic gap or by blocking the receptor of a neurotransmitter. Here we will focus on several classic neu- rotransmitters most relevant to psychopathology. Two types of neurotransmitters, monoamines and amino acids, have been most studied in regard to psychopathology. These are considered the

“classic” neurotransmitters because they are synthesized in the nerve. Neurotransmitters in the monoamine class include norepi- nephrine (also known as noradrenaline), serotonin, and dopamine. Amino-acid neurotransmitters include gamma-aminobutyric acid (GABA) and glutamate.

glutamate and gaBa Two major neurotransmitters affect much of what we do. Each of these substances is in the amino acid category of neurotransmit- ters. The first, glutamate, is an excitatory transmitter that “turns on” many different neurons, leading to action. A second type of amino acid transmitter is gamma-aminobutyric acid, or GABA for short, which is an inhibitory neurotransmitter. Thus, the job of GABA is to inhibit (or regulate) the transmission of information and action potentials. Because these two neurotransmitters work in concert to balance functioning in the brain, they have been referred to as the “chemical brothers” (LeDoux, 2002). Glutamate and GABA operate relatively independently at a molecular level, but the relative balance of each in a cell will determine whether the neuron is activated (fires) or not.

Another characteristic of these “chemical brothers” is that they are fast acting, as they would have to be for the brain to keep up with the many influences from the environment that require action or restraint. As is true for every neurotransmitter, over- or underactivity can cause some serious problems. Some people who like Chinese food and who are sensitive to glutamate may have experienced a few adverse reactions from a common additive in Chinese food referred to as MSG. MSG stands for monosodium glutamate and can increase the amount of glutamate in the body, causing headaches, ringing in the ears, or other physical symp- toms in some people. We return to some exciting new findings involving glutamate-specific receptors when we discuss new treat- ments for anxiety disorders in Chapter 5.

As noted earlier, GABA reduces postsynaptic activity, which, in turn, inhibits a variety of behaviors and emotions. GABA was discovered before glutamate and has been studied for a longer period; its best-known effect is to reduce anxiety (Charney & Drevets, 2002; Davis, 2002; Sullivan & LeDoux, 2004; Griebel & Holmes, 2013). Scientists have discovered that a particular class of drugs, the benzodiazepines, or minor tranquilizers, makes it easier for GABA molecules to attach themselves to the receptors of spe- cialized neurons. Thus, the higher the level of benzodiazepine, the more GABA becomes attached to neuron receptors and the calmer we become (to a point). Because benzodiazepines have certain addictive properties, clinical scientists are working to iden- tify other substances that may also modulate levels of GABA; these include certain natural ste- roids in the brain (Eser, Schule, Baghai, Romeo, & Rupprecht, 2006; Gordon, 2002; Rupprecht et al., 2009).

As with other neurotrans- mitter systems, we now know that GABA’s effect is not specific

Computer-generated model of GABA.

U ni

ve rs

ity o

f C

al ifo

rn ia

/L ew

is B

as te

r, Jr

. M .D

50443_ch02_ptg01_hr_032-073.indd 50 28/09/16 5:29 PM

neurOscience anD its cOntr ibut iOns tO psychOpathOlOgy 51

to anxiety but has a broader influence. The GABA system rides on many circuits distributed widely throughout the brain. GABA seems to reduce overall arousal somewhat and to temper our emotional responses. For example, in addition to reducing anxi- ety, minor tranquilizers have an anticonvulsant effect, relaxing muscle groups that may be subject to spasms. Drug compounds that increase GABA are also under evaluation as treatments for insomnia (Monti, Möhler, & Pandi-Perumal, 2010; Sullivan, 2012; Sullivan & Guilleminault, 2009; Walsh et al., 2008). Furthermore, the GABA system seems to reduce levels of anger, hostility, aggres- sion, and perhaps even positive emotional states such as eager anticipation and pleasure, making GABA a generalized inhibiting neurotransmitter, much as glutamate has a generalized excitatory function (Bond & Lader, 1979; Lader, 1975; Sharp, 2009). We are also learning that the GABA system is not just one system working in only one manner but is composed of a number of subsystems. Different types of GABA receptors seem to act in different ways, with perhaps only one of the subtypes having an affinity for the benzodiazepine component (D’Hulst, Atack, & Kooy, 2009; Gray, 1985; LeDoux, 2002, 2015; Sharp, 2009). Therefore, the conclusion that this system is responsible for anxiety seems just as out of date as concluding that the serotonin system is responsible for depres- sion (see the next section).

Serotonin The technical name for serotonin is 5-hydroxytryptamine (5HT). It is in the monoamine category of neurotransmitters, along with norepinephrine and dopamine, discussed next. Approximately six major circuits of serotonin spread from the midbrain, loop- ing around its various parts (Azmitia, 1978) (see E Figure 2.11).

Because of the widespread nature of these circuits, many of them ending up in the cortex, serotonin is believed to influence a great deal of our behavior, particularly the way we process informa- tion (Harmer, 2008; Merens, Willem Van der Does, & Spinhoven, 2007; Spoont, 1992). It was genetically influenced dysregulation in this system that contributed to depression in the New Zealand study described earlier (Caspi et al., 2003).

The serotonin system regulates our behavior, moods, and thought processes. Extremely low activity levels of serotonin are associated with less inhibition and with instability, impulsivity, and the tendency to overreact to situations. Low serotonin activity has been associated with aggression, suicide, impulsive overeat- ing, and excessive sexual behavior (Berman, McCloskey, Fanning, Schumacher, & Coccaro, 2009). These behaviors do not necessarily happen if serotonin activity is low, however. Other currents in the brain, or other psychological or social influences, may well com- pensate for low serotonin activity. Therefore, low serotonin activ- ity may make us more vulnerable to certain problematic behavior without directly causing it (as mentioned earlier). On the other end, high levels of serotonin may interact with GABA to counter- act glutamate (the same fact is emerging about other neurotrans- mitter systems).

To add to the complexity, serotonin has slightly different effects depending on the type or subtype of receptors involved. There are approximately 15 different receptors in the serotonin system (Olivier, 2015). Several classes of drugs primarily affect the serotonin system, including the tricyclic antidepressants such as imipramine (known by its brand name, Tofranil). How- ever, the class of drugs called selective-serotonin reuptake inhib- itors (SSRIs), including fluoxetine (Prozac) (see E Figure 2.12), affects serotonin more directly than other drugs, including the tricyclic antidepressants. SSRIs are used to treat a num- ber of psychological disorders, particularly anxiety, mood, and eating disorders. The herbal medication St. John’s wort, available in many drug- stores, also affects serotonin levels.

Thalamus

Cerebral cortex

Basal ganglia

Dorsal raphe nucleus

Midbrain

Cerebellum

E FigUre 2.11 Major serotonin pathways in the brain.

A positron emission tomography scan shows the distribution of sero- tonergic neurons.

J. J

am es

F ro

st , M

.D .,

P hD

./ Jo

hn s

H op

ki ns

U ni

ve rs

ity S

ch oo

l of

M ed

ic in

Computer-generated model of serotonin.

U ni

ve rs

ity o

f C

al ifo

rn ia

/L ew

is B

ax te

r Jr

. M .D

50443_ch02_ptg01_hr_032-073.indd 51 28/09/16 5:29 PM

52 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

norepinephrine A third neurotransmitter system in the monoamine class impor- tant to psychopathology is norepinephrine (also known as noradrenaline) (see E Figure 2.13). We have already seen that norepinephrine, like epinephrine (referred to as a catecholamine), is part of the endocrine system.

Norepinephrine seems to stimulate at least two groups (and probably several more) of receptors called alpha-adrenergic and beta-adrenergic receptors. Someone in your family may be taking a widely used class of drugs called beta-blockers, particularly if that person has hypertension or difficulties with regulating heart rate.

As the name indicates, these drugs block the beta-receptors so that their response to a surge of norepinephrine is reduced, which keeps blood pressure and heart rate down. In the central nervous system, a number of norepinephrine circuits have been identified. One major cir- cuit begins in the hindbrain, an area that controls basic bodily

Receptor Variation There are at least 15 different serotonin receptors, each associated with a different function.

F E

How Serotonin Drugs Work Prozac enhances serotonin’s effects by preventing it from being absorbed . Redux and fenfluramine (antiobesity drugs) cause the release of extra serotonin into the synapse . Unfortunately, these drugs have been recalled by the FDA for dangerous cardiovascular side effects (see Chapter 8).

How Neurotransmitters Work Neurotransmitters are stored in tiny sacs at the end of the neuron . An electric jolt makes the sacs merge with the outer membrane, and the neurotransmitter is released into the synapse . The molecules diffuse across the gap and bind receptors, specialized proteins, on the adjacent neuron . When sufficient neurotransmitter has been absorbed, the receptors release the molecules, which are then broken down or reabsorbed by the first neuron and stored for later use .

Prozac

Redux

Nerve signal

Receptor

Synapse

E FigUre 2.12 Manipulating serotonin in the brain.

Olfactory bulb

Hypothalamus

Amygdala Ventral noradrenergic bundle

Dorsal noradrenergic bundle

Cerebral cortex Corpus callosum

Thalamus

Locus coeruleus

Computer-generated model of norepinephrine.

U ni

ve rs

ity o

f C

al ifo

rn ia

/L ew

is B

as te

r, Jr

. M .D

50443_ch02_ptg01_hr_032-073.indd 52 28/09/16 5:29 PM

neurOscience anD its cOntr ibut iOns tO psychOpathOlOgy 53

functions such as respiration. Another circuit appears to influ- ence the emergency reactions or alarm responses (Charney & Drevets, 2002; Gray & McNaughton, 1996; Sullivan & LeDoux, 2004) that occur when we suddenly find ourselves in a dangerous situation, suggesting that norepinephrine may bear some relation- ship to states of panic (Charney et al., 1990; Gray & McNaughton, 1996). More likely, however, is that this system, with all its varying circuits coursing through the brain, acts in a more general way to regulate or modulate certain behavioral tendencies and is not directly involved in specific patterns of behavior or in psychologi- cal disorders.

dopamine Finally, dopamine is a major neurotransmitter that is in the monoamine class and that is also termed a catecholamine because of the similarity of its chemical structure to epineph- rine and norepinephrine. Dopamine has been implicated in the pathophysiology of schizophrenia (see E Figure 2.14) and dis- orders of addiction (Le Foll, Gallo, Le Strat, Lu, & Gorwood, 2009). Some research also indicates it may play a significant role in depression (Dunlop & Nemeroff, 2007) and attention deficit hyperactivity disorder (Volkow et al., 2009). Remember the wonder drug reserpine mentioned in Chapter 1 that reduced psychotic behaviors associated with schizophrenia? This drug and more modern antipsychotic treatments affect a number of neurotransmitter systems, but their greatest impact may be that they block specific dopamine receptors, thus lowering dopamine activity (see, for example, Snyder, Burt, & Creese, 1976). Thus, it was long thought possible that in schizophrenia

dopamine circuits may be too active. The recent develop- ment of second-generation antipsychotic drugs such as clozapine, which has only weak effects on certain dopa- mine receptors, suggests this idea may need revising. We explore the dopamine hypothesis in some detail in Chapter 13.

In its various circuits throughout specific regions of the brain, dopamine also seems to have a more general effect, best described as a switch that turns on various brain circuits possibly associ- ated with certain types of behavior. Once the switch is turned on, other neurotransmitters may then inhibit or facilitate emotions or behavior (Armbruster et al., 2009; Oades, 1985; Spoont, 1992; Stahl, 2008). Dopamine circuits merge and cross with serotonin circuits at many points and therefore influence many of the same behaviors. For example, dopamine activity is associated with exploratory, outgoing, pleasure-seeking behaviors (Elovainio, Kivimaki, Viikari, Ekelund, & Keltikangas-Jarvinen, 2005), and serotonin is associated with inhibition and constraint; thus, in a sense they balance each other (Depue, Luciana, Arbisi, Collins, & Leon, 1994).

Again, we see that the effects of a neurotransmitter—in this case, dopamine—are more complex than we originally thought. Researchers have thus far discovered at least five different recep- tor sites that are selectively sensitive to dopamine (Beaulieu & Gainetdinov, 2011). One of a class of drugs that affects the dopa- mine circuits specifically is L-dopa, which is a dopamine agonist (increases levels of dopamine). One of the systems that dopamine switches on is the locomotor system, which regulates ability to move in a coordinated way and, once turned on, is influenced by serotonin activity. Because of these connections, deficiencies in dopamine have been associated with disorders such as Parkinson’s disease, in which a marked deterioration in motor behavior includes tremors, rigidity of muscles, and difficulty with judgment. L-dopa has been successful in reducing some of these motor disabilities.

implications for Psychopathology Psychological disorders typically mix emotional, behavioral, and cognitive symptoms, so identifiable lesions (or damage) local- ized in specific structures of the brain do not, for the most part, cause the disorders. Even widespread damage most often results in motor or sensory deficits, which are usually the province of the medical specialty of neurology; neurologists often work with neu- ropsychologists to identify specific lesions. But psychopathologists have been focusing lately on the more general role of brain func- tion in the development of personality, with the goal of consider- ing how different types of biologically driven personalities might be more vulnerable to developing certain types of psychological disorders. For example, genetic contributions might lead to pat- terns of neurotransmitter activity that influence personality. Thus, some impulsive risk takers may have low serotonergic activity and high dopaminergic activity.

Computer-generated model of dopamine.

U ni

ve rs

ity o

f C

al ifo

rn ia

/L ew

is B

as te

r, Jr

. M .D

Basal ganglia

Prefrontal cortex

Mesostriatal system

Substantia nigra

Ventral tegmental area

Mesolimbocortical system

E FigUre 2.14 Two major dopamine pathways. The mesolimbic system is apparently implicated in schizophrenia; the path to the basal ganglia contributes to problems in the locomotor system, such as tardive dyskinesia, which sometimes results from use of neuroleptic drugs. (Adapted from Kalat, J. W. (2009). Biological Psychology, 10th edition, © 2009 Wadsworth.)

50443_ch02_ptg01_hr_032-073.indd 53 28/09/16 5:30 PM

54 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

Procedures for studying images of the functioning brain have been applied to a number of disorders, including obsessive- compulsive disorder (OCD). Individuals with this severe anxiety- based disorder (described in Chapter 5) suffer from intrusive, frightening thoughts—for example, some patients may fear that they might have become contaminated with deadly germs and will poison their loved ones if they touch them. To prevent this drastic consequence, they engage in compulsive rituals such as frequent washing to try to scrub off the imagined poison. A number of investigators have found intriguing differences between the brains of patients with OCD and the brains of other people. Although the sizes and structures of the brains are the same, patients with OCD have increased activity in the part of the frontal lobe of the cerebral cortex called the orbital surface (Chamberlain et al., 2008; Harrison et al., 2013). Increased activity is also present in the cin- gulate gyrus and, to a lesser extent, in the caudate nucleus, a cir- cuit that extends from the orbital section of the frontal area of the cortex to parts of the thalamus. Activity in these areas seems to be correlated; that is, if one area is active, the other areas are also. These areas contain several pathways of neurotransmitters, and one of the most concentrated is serotonin.

Remember that one of the roles of serotonin seems to be to moderate our reactions. Eating behavior, sexual behavior, and aggression are under better control with adequate levels of sero- tonin. Research, mostly on animals, demonstrates that lesions (damage) that interrupt serotonin circuits seem to impair the abil- ity to ignore irrelevant external cues, making the organism overac- tive. Thus, if we were to experience damage or interruption in this brain circuit, we might find ourselves acting on every thought or impulse that enters our heads.

Thomas Insel (1992) described a case originally reported by Eslinger and Damasio (1985) of a man who had been successful as an accountant, husband, and father of two before undergoing surgery for a brain tumor. He made a good recovery from sur- gery and seemed to be fine, but in the following year his business failed and he separated from his family. Although his scores on IQ tests were as high as ever and all his mental functions were intact, he was unable to keep a job or even be on time for an appoint- ment. What was causing all these problems? He was engaging in

lengthy and uncontrollable compulsive rituals. Most of his days were consumed with washing, dressing, and rearranging things in the single room where he lived. In other words, he had classic obsessive-compulsive symptoms. The area of his brain damaged by removal of the tumor was a small area of his orbital frontal cortex.

This information seems to support a biological cause for psy- chopathology—in this case, OCD. You might think there is no need to consider social or psychological influences here. But Insel and other neuroscientists interpret these findings cautiously. First, this case involves only one individual. Other individuals with the same lesion might react differently. Also, brain-imaging stud- ies are often inconsistent with one another on many important details. Sometimes pinpointing the increased or decreased activity is difficult because brains differ in their structure, just as bodies and faces do. Also, the orbital frontal cortex is implicated in other anxiety disorders and maybe other emotional disorders (Gansler et al., 2009; Goodwin, 2009; Sullivan & LeDoux, 2004), so the dam- age in this area of the brain may just increase negative affect more generally rather than OCD specifically. Therefore, more work has to be done, and perhaps technology has to improve further, before we can be confident about the relation of the orbital frontal cortex to OCD. It is possible that activity in this area may simply be a result of the repetitive thinking and ritualistic behavior that char- acterizes OCD, rather than a cause. To take a simple analogy, if you were late for class and began running, massive changes would occur throughout your body and brain. If someone who did not know that you had just sprinted to class then examined you with brain scans, your brain functions would look different from those of the brain of a person who had walked to class. If you were doing well in the class, the scientist might conclude, wrongly, that your unusual brain function “caused” your intelligence. It is also impor- tant to note that today, neuroscientists focus much more on the connectivity between certain brain areas (the brain circuitry) than the activity of any particular brain region that might be associated with a specific mental disorder (e.g., Whitfield-Gabrieli et al., in press).

Psychosocial influences on Brain Structure and Function At the same time that psychopathologists are exploring the causes of psychopathology, whether in the brain or in the environment, people are suffering and require the best treatments we have.

Sometimes the effects of treatment tell us something about the nature of psychopathology. For example, if a clinician thinks OCD is caused by a specific brain function or dysfunction or by learned anxiety to scary or repulsive thoughts, this view would determine choice of treatment, as we noted in Chapter 1. Directing a treat- ment at one or the other of these theoretical causes of the disorder and then observing whether the patient gets better will prove or disprove the accuracy of the theory. This common strategy has one overriding weakness. Successfully treating a patient’s particular feverish state or toothache with aspirin does not mean the fever or toothache was caused by an aspirin deficiency, because an effect does not imply a cause. So the reasons why a problem develops in the first place (the initiating factors) are not necessarily the same as

Brain function is altered in people with OCD, but it normalizes after effective psychosocial treatment.

U ni

ve rs

ity o

f C

al ifo

rn ia

/L ew

is B

as te

r, Jr

. M .D

50443_ch02_ptg01_hr_032-073.indd 54 28/09/16 5:30 PM

neurOscience anD its cOntr ibut iOns tO psychOpathOlOgy 55

the reasons why her problem still persists (the maintaining factors). In order to treat the problem effectively, it is typically more impor- tant to know and target the maintaining factors than the initiating factors (e.g., particular experiences from the past that might have initiated the problem). Nevertheless, this line of evidence gives us some hints about causes of psychopathology, particularly when it is combined with other, more direct experimental evidence.

If you knew that someone with OCD might have a somewhat faulty brain circuit, what treatment would you choose? Maybe you would recommend brain surgery, or neurosurgery. Neurosurgery to correct severe psychopathology (sometimes called “psychosur- gery”) is an option still chosen today on occasion, particularly in the case of OCD when the suffering is severe and other treatments have failed (Aouizerate et al., 2006; Bear, Fitzgerald, Rosenfeld, & Bittar, 2010; Denys et al., 2010; Greenberg, Rauch, & Haber, 2010; see also Chapter 5). For the accountant described previously, the removal of his brain tumor seems to have inadvertently eliminated an inhibitory part of the brain circuit implicated in OCD. Precise surgical lesions might dampen the runaway activity that seems to occur in or near this particular area of the brain triggering the OCD symptoms. This result would probably be welcome if all other treatments have failed, although psychosurgery is used seldom and has not been studied systematically.

Nobody wants to do surgery if less intrusive treatments are available. To use the analogy of a television set that has developed the “disorder” of going fuzzy, if you had to rearrange and recon- nect wires on the circuit board every time the disorder occurred, the correction would be a major undertaking. Alternatively, if you could simply push some buttons on the remote and elimi- nate the fuzziness, the correction would be simpler and less risky. The development of drugs affecting neurotransmitter activity has given us one of those buttons. We now have drugs that, although not a cure or even an effective treatment in all cases, do seem to be beneficial in treating OCD. As you might suspect, most of them act by increasing serotonin activity in one way or another.

But is it possible to get at this brain circuit without either sur- gery or drugs? Could psychological treatment be powerful enough to affect the circuit directly? The answer seems to be yes. To take one of the first examples, Lewis R. Baxter and his colleagues used brain imaging on patients who had not been treated and then took an additional, important scientific step (Baxter et al., 1992). They treated the patients with a cognitive-behavioral therapy known to be effective in OCD called exposure and response prevention (described more fully in Chapter 5) and then repeated the brain imaging. In a remarkable finding, widely noted in the world of psychopathology, Baxter and his colleagues discovered that the brain circuit had been changed (normalized) by a psychologi- cal intervention. The same team of investigators then replicated the experiment with a different group of patients and found the same changes in brain function (Schwartz, Stoessel, Baxter, Martin, & Phelps, 1996). In other examples, investigating teams noted changes in brain function after successful psychological treatment for depression, PTSD, obsessive-compulsive disor- der, panic disorder, social anxiety disorder, specific phobias, and schizophrenia (Barsaglini, Sartori, Benetti, Pettersson-Yeo, & Mechelli, 2014). A review of the evidence suggests that, depending on the disorder, psychotherapy results in either a normalization of

abnormal patterns of activity, the recruitment of additional areas, which did not show altered activation prior to treatment, or both. One study showed that as little as two hours of intense exposure- based therapy for specific phobia changed brain function dramati- cally, and these effects persisted six months later (Hauner, Mineka, Voss, & Paller, 2012).

The study of placebo effects offers another window on psycho- logical factors directly affecting brain function. Remember that it is common for inactive placebo medications, which are just sugar pills, or other “sham” (inactive) treatments to result in behavioral and emotional changes in patients, presumably as a result of psy- chological factors such as increasing hope and expectations or con- ditioning effects (discussed later in the chapter) (Brody & Miller, 2011). Several recent studies have examined the conditions under which placebos are active. For example, one study administered medications for either pain or anxiety after surgery by means of an infusion pump that was either in plain view of the patients or was hidden behind a screen (Colloca, Lopiano, Lanotte, & Benedetti, 2004). Even though the same dosage of medicine was administered, the effect was consistently greater when patients knew they were receiving the drug because they could see the pump working com- pared with when the pump was hidden behind a screen. No pla- cebos were actually given in this study, but the difference in effects between knowing and not knowing whether the drug was given was considered a good estimate of the placebo effect. In another study, patients with irritable bowel syndrome (see Chapter 9) received a sham treatment (acupuncture) that was not designed to be effective. The treatment was administered either imperson- ally or in the context of a warm therapeutic interpersonal relation- ship. The impersonal administration produced better results than no treatment, (even though there was no active ingredient in the treatment) but the addition of a strong relationship added sub- stantially to the therapeutic benefit (Kaptchuk et. al., 2008). But how and why do placebos work?

In an intriguing study, Leuchter, Cook, Witte, Morgan, and Abrams (2002) treated patients with major depressive disorder with either antidepressant medications or placebo medications. Measures of brain function showed that both antidepressant medications and placebos changed brain function but in some- what different parts of the brain, suggesting different mechanisms of action for these two interventions, at least in the treatment of depression. Placebos alone are not usually as effective as active medication, but every time clinicians prescribe pills, they are also treating the patient psychologically by inducing positive expec- tation for change, and this intervention changes brain function. Petrovic, Kalso, Petersson, and Ingvar (2002), in an important study, also examined how placebo pills (in other words, psycho- logical factors) can change brain function in the context of treating pain. Normal participants were administered (with their consent) a harmless but painful condition in which their left hand was sub- jected to intense heat. These participants were informed that two potent analgesics (pain-reducing medications) would be used in the experiment. In fact, one of these drugs was an opioid, and the other was a placebo. Opioid-based drugs are used routinely in medical settings to relieve severe pain. Each participant experi- enced the painful stimulus under three conditions: (1) under the influence of an opioid drug, (2) under the influence of a placebo

50443_ch02_ptg01_hr_032-073.indd 55 28/09/16 5:30 PM

56 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

pill that the patient assumed was an opioid-based drug, and (3) with no drug (pain only). All participants experienced each condition multiple times, while brain-imaging procedures moni- tored their brain functioning (see Chapter 3) during administra- tion of the painful stimulus. Whereas both the placebo drug and the opiate drug reduced pain to less than the level with no drug, the surprising results indicated that, unlike the study on depres- sion above, both treatments activated overlapping (although not identical) regions in the brain, primarily within the anterior cin- gulate cortex and the brain stem. These areas were not activated during the pain-only condition. Thus, it appears that the anterior cingulate cortex is at least in part responsible for control of the pain response in the brain stem and that cognitive expectations of pain relief created by the placebo condition may cause these brain circuits to be turned on. It would seem that psychological fac- tors are another button on the remote with which we can directly change brain circuits. In a follow-up study, the authors compared the mechanisms of the effect of opioids versus placebo on the brain in more detail and found that the opioid-rich areas of the anterior cingulate cortex were more extensively activated during opioid as compared with placebo analgesia, whereas placebo analgesia was more dependent on a neocortical top-down influence (Petrovic et al., 2010). In general, the literature suggests that multiple brain systems and neurochemical modulators, including opioids and dopamine, seem to be involved in the placebo effect on pain per- ception (Wager, & Atlas, 2015).

A final intriguing area of research is exploring the specific ways in which drug or active psychological treatments work (as opposed to placebos) in terms of changes in brain function. Are the changes in brain function similar or different as a function of drug or psychological treatment? Kennedy et al. (2007) treated individuals with major depressive disorder with either a psycho- logical treatment, cognitive-behavioral therapy (CBT), or the anti- depressant drug venlafaxine. Although some brain changes were similar among the three treatment groups, complex differences were also noted, primarily in the way in which CBT facilitated changes in thinking patterns in the cortex that, in turn, affected the emotional brain. Sometimes this is called a “top down” change because it originates in the cortex and works its way down into the lower brain. Drugs, on the other hand, often seem to work more in a “bottom up” manner, reaching higher areas of the cortex (where thinking occurs) last. Because we know that some people respond better to psycho- logical treatments, and others respond better to drugs, this research provides hope that we will one day be able to choose the best treat- ments or better combine treatments based on an analysis of the individual’s brain function. Our team has been able to use brain imaging as a tool to predict psychotherapy response (Doehrmann et al., 2013; Whitfield-Gabrieli, 2016). The results showed that greater activa- tion in certain brain areas involved in emotion processing and greater connectivity between higher cortical areas with the amygdala predict better outcome after CBT for social anxiety

disorder. In the next step, this method could be used to predict whether a particular patient will respond better to pharmacother- apy or psychotherapy. For example, if researchers find that greater (or weaker) connectivity between the amygdala and prefrontal brain areas predict better treatment response to CBT but worse response to drug therapy, this information could then be used to match patients to the most promising treatment option for this particular patient. This is an example for precision medicine (i.e., tailoring the treatment to the individual patient in order to opti- mize therapy outcome).

interactions of Psychosocial Factors and Neurotransmitter Systems Several experiments illustrate the interaction of psychosocial fac- tors and brain function on neurotransmitter activity, with impli- cations for the development of disorders. Some even indicate that psychosocial factors directly affect levels of neurotransmitters. In one classic experiment, Insel, Scanlan, Champoux, and Suomi (1988) raised two groups of rhesus monkeys identically except for their ability to control things in their cages. One group had free access to toys and food treats, but the second group got these toys and treats only when the first group did. In other words, members of the second group had the same number of toys and treats but could not choose when they got them. In any case, the monkeys in the first group grew up with a sense of control over things in their lives and those in the second group didn’t.

Later in their lives, all these monkeys were administered a ben- zodiazepine inverse agonist, a neurochemical that has the oppo- site effect of the neurotransmitter GABA; the effect is an extreme burst of anxiety. (The few times this neurochemical has been administered to people—usually scientists administering it to one another—the recipients have reported the experience, which lasts only a short time, to be one of the most horrible sensations they had ever endured.) When this substance was injected into the monkeys, the results were interesting. The monkeys that had been raised with little control over their environment ran to a corner of their cage where they crouched and displayed signs of severe anxiety and panic. But the monkeys that had a sense of control

Rhesus monkeys injected with a specific neurotransmitter react with anger or fear, depending on their early psychological experiences.

Th om

as In

se l/1

98 6

st ud

y/ N

at io

na l I

ns tit

ut e

of M

en ta

l H ea

lth

50443_ch02_ptg01_hr_032-073.indd 56 28/09/16 5:30 PM

neurOscience anD its cOntr ibut iOns tO psychOpathOlOgy 57

behaved quite differently. They did not seem anxious. Rather, they seemed angry and aggres- sive, even attacking other mon- keys near them. Thus, the same level of a neurochemical sub- stance, acting as a neurotrans- mitter, had different effects, depending on the psychologi- cal and environmental histories of the monkeys.

The Insel and colleagues (Insel, Scanlan, Champoux, & Suomi, 1988) experiment is an early example of a significant interaction between neurotrans- mitters and psychosocial factors. Other experiments suggest that psychosocial influences directly affect the functioning and per- haps even the structure of the central nervous system. Scien-

tists have observed that psychosocial factors routinely change the activity levels of many of our neurotransmitter systems (Barik et al., 2013; Cacioppo et al., 2007; Marinelli & McCutcheon, 2014; Sandi & Haller, 2015).

In another remarkable example of the complex interaction among psychosocial factors, brain structure, and brain function as reflected in neurotransmitter activity, Yeh, Fricke, and Edwards (1996) studied two male crayfish battling to establish dominance in their social group. When one of the crayfish won the battle and established dominance, the scientists found that serotonin made a specific set of neurons more likely to fire. In the animal that lost the battle, serotonin made the same neurons less likely to fire. Thus, unlike the Insel et al. (1988) experiment, where monkeys were injected with a neurotransmitter, Yeh and colleagues (1996) discovered that naturally occurring neurotransmitters have dif- ferent effects depending on the previous psychosocial experience of the organism. Furthermore, this experience directly affects the structure of neurons at the synapse by altering the sensitiv- ity of serotonin receptors. The researchers also discovered that the effects of serotonin are reversible if the losers again become dominant. Similarly, Suomi (2000) demonstrated in primates that early stressful experiences produced deficits in serotonin (as well as other neuroendocrine changes) in genetically susceptible indi- viduals, deficits that did not occur in the absence of early stress.

In another example, Berton and colleagues (2006) discov- ered, much to their surprise, that putting into a cage big mice that then proceeded to “bully” a smaller mouse produced changes in the mesolimbic dopamine system of the smaller mouse. These changes were associated with the smaller mouse wanting no part of other mice under any circumstances. The small mouse chose to become a recluse. Interestingly, the mesolimbic system is ordinar- ily associated with reward and even addiction. But in this case, certain chemicals that produce new learning and other positive changes in other parts of the brain, specifically brain development neurotrophic factor (BDNF; a protein that is involved in learning

by stimulating growth of new neurons), were turned on in the mesolimbic dopamine system by a psychological experience— bullying—such that the mesolimbic dopamine system had dif- ferent effects on the mouse than it usually does because of the mouse’s unique experience. That is, the “bullying” experience produced BDNF, which changed the usual functioning of the mesolimbic dopamine system from facilitating reinforcement and even addiction to facilitating avoidance and isolation. More recent research implicates glucocorticoid receptors located on dopami- nergic neurons specifically in facilitating and maintaining this social aversion (Barik et al., 2013).

Psychosocial effects on the Development of Brain Structure and Function It also seems that the structure of neurons themselves, including the number of receptors on a cell, can be changed by learning and experience during development (Clemenson, Deng, & Gage, 2015; Kandel, Dudai, & Mayford, 2014) and that these effects on the central nervous system continue throughout our lives (Cameron et al., 2005; Spinelli et al., 2009; Suárez et al., 2009). We are now beginning to learn how this happens (Clemenson et al., 2015; Kolb, Gibb, & Robinson, 2003; Kolb & Whishaw, 1998; Miller, 2011). For example, William Greenough and his associates, in a series of classic experiments (Greenough, Withers, & Wallace, 1990), studied the cerebellum, which coordinates and controls motor behavior. They discovered that the nervous systems of rats raised in a rich environment requiring a lot of learning and motor behavior develop differently from the nervous systems in rats that were couch potatoes. The active rats had many more connec- tions between nerve cells in the cerebellum and grew many more dendrites. In a follow-up study, Wallace, Kilman, Withers, and Greenough (1992) reported that these structural changes in the brain began in as little as 4 days in rats, suggesting enormous plas- ticity in brain structure as a result of experience. Similarly, stress during early development can lead to substantial changes in the functioning of the HPA axis (described earlier in this chapter) that, in turn, make primates more or less susceptible to stress later in life (Barlow, 2002; Coplan et al., 1998; Gillespie & Nemeroff, 2007; Spinelli et al., 2009; Suomi, 1999). It may be something similar to this mechanism that was responsible for the effects of early stress on the later development of depression in genetically susceptible individuals in the New Zealand study described earlier (Caspi et al., 2003). More recent experiments with monkeys indicate that housing monkeys in larger groups increases the amount of gray matter in several parts of the brain involved in social cognition. This turns out to be very important since social cognition, includ- ing such skills as being able to interpret facial expressions and ges- tures and successfully predicting what others might be likely to do, makes one more successful socially and, in monkeys, increases one’s social ranking (Sallet et al., 2011). Even more intriguing, some recent studies have suggested increased gray matter density in several temporal lobe regions of the brain in people who have larger Facebook networks. Of course, these findings are only cor- relational at present (Kanai, Bahrami, Roylance, & Rees, 2012).

So, we can conclude that early psychological experience affects the development of the nervous system and thus determines

Thomas Insel, the leading investigator in the monkey study, conducts research on the interaction of neurotrans- mitters and psychosocial fac- tors at the National Institute of Mental Health where he is now Director.

Th om

as In

se l

50443_ch02_ptg01_hr_032-073.indd 57 28/09/16 5:30 PM

58 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

vulnerability to psychological disorders later in life. It seems that the very structure of the nervous system is constantly changing as a result of learning and experience, even into old age, and that some of these changes become permanent (Kolb, Gibb, & Gorny, 2003; Barlow, Ellard, Sauer Zavala, Bullis, & Carl, 2014 ). This plasticity of the central nervous system helps us adapt more read- ily to our environment. These findings will be important when we discuss the causes of anxiety disorders and mood disorders in Chapters 5 and 7.

Comments The specific brain circuits involved in psychological disorders are complex systems identified by pathways of neurotransmitters traversing the brain. The existence of these circuits suggests that the structure and function of the nervous system play major roles in psychopathology. But other research suggests the circuits are strongly influenced—perhaps even created—by psychological and social factors. Furthermore, both biological interventions, such as drugs, and psychological interventions or experience seem capable of altering the circuits. Therefore, we cannot consider the nature and cause of psychological disorders without examining both bio- logical and psychological factors. We now turn to an examination of psychological factors.

Behavioral and Cognitive Science Enormous progress has been made in understanding behavioral and cognitive influences in psychopathology. Some new informa- tion has come from the rapidly growing field of cognitive science, which is concerned with how we acquire and process information and how we store and ultimately retrieve it (one of the processes involved in memory). Scientists have also discovered that we are not necessarily aware of a great deal of what goes on inside our heads. Because, technically, these cognitive processes are uncon- scious, some findings recall the unconscious mental processes that are so much a part of Sigmund Freud’s theory of psychoanalysis (although they do not look much like the ones he envisioned). A brief account of current thinking on what is happening during the process of classical conditioning will start us on our way.

Conditioning and Cognitive Processes During the 1960s and 1970s, behavioral scientists in animal labo- ratories began to uncover the complexity of the basic processes of classical conditioning (Bouton, 2005; Bouton, Mineka, & Barlow, 2001; Eelen & Vervliet, 2006; Meyers & Davis, 2002; Mineka & Zinbarg, 1996, 1998). Robert Rescorla (1988) concluded that sim- ply pairing two events closely in time (such as the meat powder and the metronome in Ivan Pavlov’s laboratories) is not what’s important in this type of learning; at the least, it is a simple sum- mary. Rather, a variety of judgments and cognitive processes

William Greenough and his associates raised rats in a complex envi- ronment that required significant learning and motor behavior, which affected the structure of the rats’ brains. This supports the role of psychological factors in biological development.

W ill

ia m

G re

en ou

gh /U

ni ve

rs ity

o f

lll in

oi s

Check your understanding of the brain structures and neu- rotransmitters. Match each with its description below: (a) frontal lobe, (b) brain stem, (c) GABA, (d) midbrain, (e) serotonin, (f) dopamine, (g) norepinephrine, and (h) cere- bral cortex.

Concept Check 2.3

1. Movement, breathing, and sleeping depend on the ancient part of the brain, which is present in most animals. ______________

2. Which neurotransmitter binds to neuron receptor sites, inhibiting postsynaptic activity and reducing overall arousal? ______________

3. Which neurotransmitter is a switch that turns on various brain circuits? ______________

4. Which neurotransmitter seems to be involved in our emergency reactions or alarm responses? ___________

5. This area contains part of the reticular activating sys- tem and coordinates movement with sensory output. ______________

6. Which neurotransmitter is believed to influence the way we process information, as well as to moderate or inhibit our behavior? ______________

7. More than 80% of the neurons in the human central nervous system are contained in this part of the brain, which gives us distinct qualities. ______________

8. This area is responsible for most of our memory, think- ing, and reasoning capabilities and makes us social animals. ______________

50443_ch02_ptg01_hr_032-073.indd 58 28/09/16 5:30 PM

behaviOral anD cOgnit ive sc ience 59

combine to determine the final outcome of this learning, even in lower animals such as rats.

To take just one simple example, Pavlov would have predicted that if the meat powder and the metronome were paired, say, 50 times, then a certain amount of learning would take place. But Rescorla and others discovered that if one animal never saw the meat powder except for the 50 trials following the metro- nome sound, whereas the meat powder was brought to a second animal many times between the 50 times it was paired with the metronome, the two animals would learn different things; that is, even though the metronome and the meat powder were paired 50 times for each animal, the metronome was less meaningful to the second animal (see E Figure 2.15). Put another way, the first ani- mal learned that the sound of the metronome meant meat powder came next; the second animal learned that the meat sometimes came after the sound and sometimes without the sound. That two different conditions produce two different learning outcomes is a commonsense notion, but it demonstrates, along with many far more complex scientific findings, that basic classical (and operant) conditioning paradigms facilitate the learning of the relationship among events in the environment.

This type of learning enables us to develop working ideas about the world that allow us to make appropriate judgments. We can then respond in a way that will benefit, or at least not hurt,

us. In other words, complex cognitive processing of information, as well as emotional processing, is involved when conditioning occurs, even in animals.

Learned Helplessness Along similar lines, Martin Seligman and his colleague Steven Maier, also working with animals, described the phenomenon of learned helplessness, which occurs when rats or other animals encounter conditions over which they have no control (Maier & Seligman, 1976). If rats are confronted with a situation in which they receive occasional foot shocks, they can function well if they learn they can cope with these shocks by doing something to avoid them (say, pressing a lever). But if the animals learn their behavior has no effect on their environment—sometimes they get shocked and sometimes they don’t, no matter what they do—they become “helpless”; in other words, they give up attempting to cope and seem to develop the animal equivalent of depression.

Seligman drew some important conclusions from these obser- vations. He theorized that the same phenomenon may happen with people who are faced with uncontrollable stress in their lives. Subsequent work revealed this to be true under one important condition: People become depressed if they “decide” or “think” they can do little about the stress in their lives, even if it seems

12 1 2 39

10 11

4 567

12 1 2

39 10

4 567

Meat always comes with sound.

Unconditioned stimulus

Neutral stimulus

Contiguity only

Meat comes with and without sound.

Contiguity and random

Unconditioned stimulus

Neutral stimulus

= ?

E FigUre 2.15 Robert Rescorla’s experiment that showed contiguity—pairing a neutral stimulus and an unconditioned stimulus—does not result in the same kind of conditioning. The dog in the contiguity-only group (top panel) experiences the usual conditioning procedure: Pairing a tone and meat causes the tone to take on properties of the meat. For the dog in the contiguity-and-random group, the meat appeared away from the tones, as well as with it, making the tone less meaningful.

P ho

to s:

G et

ty Im

ag es

A m

er ic

an Im

ag es

In c/

D ig

ita l V

is io

n/ G

et ty

Im ag

es A

m er

ic an

Im ag

es In

c/ G

et ty

Im ag

50443_ch02_ptg01_hr_032-073.indd 59 28/09/16 5:30 PM

60 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

to others that there is some- thing they could do. People make an attribution that they have no control, and they become depressed (Abramson, Seligman, & Teasdale, 1978; Miller & Norman, 1979). We revisit this important psycho- logical theory of depression in Chapter 7. It illustrates, again, the necessity of recognizing that different people process information about events in the environment in different ways. These cognitive differ- ences are an important com- ponent of psychopathology.

Lately, Seligman has turned his attention to a different set of attributions, which he terms learned optimism (Seligman, 1998, 2002). In other words, if people faced with considerable stress and difficulty in their lives nevertheless display an optimistic, upbeat attitude, they are likely to function better psychologically and physically. We return to this theme repeatedly throughout this book but particularly in Chapter 9, when we talk about the effects of psychological factors on health. But consider this one example: In a classic study by Levy, Slade, Kunkel, & Kasl (2002), individuals between ages 50 and 94 who had positive views about themselves and positive attitudes toward aging lived 7.5 years longer than those without such positive, optimistic attitudes. This connection was still true after the investigators controlled for age, sex, income, loneliness, and physical capability to engage in household and social activities. This effect is extremely powerful, and it exceeds the 1–4 years of added life associated with other factors, such as low blood pressure, low cholesterol levels, and no history of obe- sity or cigarette smoking. These results have been strongly sup- ported in more recent studies (Steptoe & Wardle, 2012). Studies such as this have created interest in a new field of study called posi- tive psychology, in which investigators explore factors that account for positive attitudes and happiness (Diener, 2000; Lyubomirsky, 2001). We return to these themes in the chapters describing spe- cific disorders.

Social Learning Another influential psychologist, Albert Bandura (1973, 1986), observed that organisms do not have to experience certain events in their environment to learn effectively. Rather, they can learn just as much by observing what happens to someone else in a given situation. This fairly obvious discovery came to be known as modeling or observational learning. What is important is that, even in animals, this type of learning requires a symbolic integration of the experiences of others with judgments of what might happen to oneself; in other words, even an animal that is not intelligent by human standards, such as a monkey, must make a decision about the conditions under which its own expe- riences would be similar to those of the animal it is observing. Bandura expanded his observations into a network of ideas in

which behavior, cognitive factors, and environmental influences converged to produce the complexity of behavior that confronts us. He also specified in some detail the importance of the social context of our learning; that is, much of what we learn depends on our interactions with other people around us. More recently, these ideas have been integrated with new findings on the genetic and biological bases of social behavior in a new field of study called social neuroscience (Cacioppo et al., 2007).

The basic idea in all Bandura’s work is that a careful analy- sis of cognitive processes may well produce the most accurate scientific predictions of behavior. Concepts of probability learn- ing, information processing, and attention have become increas- ingly important in psychopathology (Bar-Haim, Lamy, Pergamin, Bakermans-Kranenburg, & Van Ijzendoorn, 2007; Barlow, 2002; Davey, 2006; Lovibond, 2006; Yiend, 2010).

Prepared Learning It is clear that biology and, probably, our genetic endowment influ- ence what we learn. This conclusion is based on our learning to fear some objects more easily than others. In other words, we learn fears and phobias selectively (Mineka & Sutton, 2006; Morris, Öhman, & Dolan, 1998; Öhman, Flykt, & Lundqvist, 2000; Öhman & Mineka, 2001; Rakison, 2009). Why might this be? According to the concept of prepared learning, we have become highly pre- pared for learning about certain types of objects or situations over the course of evolution because this knowledge contributes to the survival of the species (Mineka, 1985; Seligman, 1971). Even without any contact, we are more likely to learn to fear snakes or spiders than rocks or flowers, even if we know rationally that the snake or spider is harmless (for example, Fredrikson, Annas, & Wik, 1997; Pury & Mineka, 1997). In the absence of experience, however, we are less likely to fear guns, cars, or electrical outlets, even though they are potentially deadlier.

Why do we so readily learn to fear snakes or spiders? One possibility is that our ancestors who avoided snakes and spiders eluded deadly varieties and therefore survived in greater numbers to pass down their genes to us, thus contributing to the survival of the species. In fact, recent research has found that a sex difference may exist for this type of learning: females are particularly sensi- tive to this learning and, unlike males, demonstrate it as early as 11 months of age (Rakison, 2009). Thus, “prepared learning” may account for the greater incidence of snake and spider phobias in adult women (see Chapter 5). This is just a theory, but at pres- ent it seems a likely explanation. According to the theory it would have been more important for women, in their roles as foragers and gatherers, to develop a tendency to avoid snakes and spiders than males, in their primary roles as risk-taking hunters (Rakison, 2009).

In any case, something within us recognizes the connection between a certain signal and a threatening event. If you’ve ever gotten sick on an exotic alcoholic drink, chances are you won’t make the same mistake again. This quick, or “one-trial,” learning also occurs in animals that eat something that tastes bad, causes nausea, or may contain poison. It is easy to see that survival is associated with quickly learning to avoid poisonous food. If ani- mals are shocked instead of poisoned when eating certain foods,

Martin Seligman first described the concept of learned helplessness.

M ar

tin S

el ig

m an

/U ni

ve rs

ity o

f lll

in oi

50443_ch02_ptg01_hr_032-073.indd 60 28/09/16 5:30 PM

behaviOral anD cOgnit ive sc ience 61

however, they do not learn this association nearly as quickly, prob- ably because in nature shock is not a consequence of eating, where- as food is more closely associated with getting poisoned. Perhaps these selective associations are also facilitated by our genes and depend on the context and the nature of the associated stimuli (Barlow, 2002; Cook, Hodes, & Lang, 1986; Garcia, McGowan, & Green, 1972; Mallan, Lipp & Cochrane, 2013).

Cognitive Science and the Unconscious Advances in cognitive science have revolutionized our concep- tions of the unconscious. We are not aware of much of what goes on inside our heads, but our unconscious is not necessarily the seething caldron of primitive emotional conflicts envisioned by Freud. Rather, we simply seem able to process and store informa- tion, and act on it, without having the slightest awareness of what the information is or why we are acting on it (Bargh & Chartrand, 1999; Uleman, Saribay, & Gonzalez, 2008). Is this surprising? Consider briefly these two examples.

Lawrence Weiskrantz in a classic study (1992) describes a phenomenon called blind sight or unconscious vision. He relates the case of a young man who, for medical reasons, had a small section of his visual cortex (the center for the control of vision in the brain) surgically removed. Although the operation was considered a success, the young man became blind in both eyes. Later, during routine tests, a physician raised his hand to the left of the patient who, much to the shock of his doctors, reached out and touched it. Subsequently, scientists determined that he could not only reach accurately for objects but could also distinguish among objects and perform most of the functions usually associ- ated with sight. Yet, when asked about his abilities, he would say, “I couldn’t see anything, not a darn thing,” and that all he was doing was guessing.

The phenomenon in this case is associated with real brain dam- age. More interesting, from the point of view of psychopathology, is that the same thing seems to occur in healthy individuals who have been hypnotized (Hilgard, 1992; Kihlstrom, 1992); that is, normal individuals, provided with hypnotic suggestions that they are blind, are able to function visually but have no awareness or memory of their visual abilities. This condition, which illustrates a process of dissociation between behavior and consciousness, is the basis of the dissociative disorders discussed in Chapter 6.

A second example, more relevant to psychopathology, is called implicit memory (Bowers & Marsolek, 2003; Kandel et al., 2014; McNally, 1999; Schacter, Chiu, & Ochsner, 1993). Implicit memory is apparent when someone clearly acts on the basis of things that have happened in the past but can’t remember the events. (A conscious memory for events is called explicit memory.) But implicit memory can be selective for only certain events or circumstances. Clinically, we have already seen in Chapter 1 an example of implicit memory at work in the story of Anna O., the classic case first described by Breuer and Freud (1895/1957) to demonstrate the existence of the unconscious. It was only after therapy that Anna O. remembered events surrounding her father’s death and the connection of these events to her paralysis. Thus, Anna O.’s behavior (occasional paralysis) was evidently connected to implicit memories of her father’s death. Many scientists have

concluded that Freud’s speculations on the nature and structure of the unconscious went beyond the evidence, but the existence of unconscious processes has since been demonstrated, and we must take them into account as we study psychopathology.

What methods do we have for studying the unconscious? The black box refers to unobservable feelings and cognitions inferred from an individual’s self-report or behaviors. In recent decades, psychologists and neuroscientists, confident in an established sci- ence of behavior, have returned to the black box with new meth- ods, attempting to reveal the unobservable. Several methods for studying the unobservable unconscious have been made possible by advances in technology. One of them is the Stroop color- naming paradigm.

In the Stroop paradigm, participants are shown a variety of words, each printed in a different color. They are shown these words quickly and asked to name the colors in which they are printed while ignoring their meaning (e.g., the person is asked to say “blue” if she sees the word red printed in a blue color). Color naming is delayed when the meaning of the word attracts the par- ticipant’s attention, despite efforts to concentrate on the color; that is, the meaning of the word interferes with the participant’s abil- ity to process color information. For example, experimenters have determined that people with certain psychological disorders, like Judy, are much slower at naming the colors of words associated with their problem (for example, blood, injury, and dissect) than the colors of words that have no relation to the disorder. Thus, psychologists can now uncover particular patterns of emotional significance, even if the participant cannot verbalize them or is not even aware of them.

Recently, cognitive neuroscientists using brain imaging methods (functional magnetic resonance imaging [fMRI]) have noticed differences in the processing of neural activity in the brain depending on whether the person is aware of the information or not (Uehara et al., 2013; see Chapter 4). Generally the greater the duration, intensity, and coherence of the neural representation of a piece of information in the brain, the more likely that the person will be aware or conscious of the information (Schurger, Pereira, Treisman, & Cohen, 2010; Schwarzkopf & Rees, 2010; Kandel et al., 2014; Wimmer & Shohamy, 2012). But, so far, this work has been carried out only in experiments with normal individuals. It remains to be seen if the unconscious experience of people with psychological disorders will look similar during brain imaging.

The Stroop paradigm. Have someone keep time as you name the colors of the words but not the words themselves and again while you name the words and colors together.

C en

ga ge

L ea

rn in

50443_ch02_ptg01_hr_032-073.indd 61 28/09/16 5:30 PM

62 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

These developments in our understanding of the nature of psychopathology will come up repeatedly as we discuss specific disorders. Again, note that these findings support Freud’s theo- ries about the unconscious, up to a point. But no assumptions are made about an elaborate structure existing within the mind that is continually in conflict (Freud’s id, ego, and superego); and at present, there is no evidence to support the existence of an uncon- scious with such a complex structure and array of functions.

emotions Emotions play an enormous role in our day-to-day lives and can contribute in major ways to the development of psychopathology (Barrett, 2012; Gross, 2015; Kring & Sloan, 2010; Rottenberg & Johnson, 2007). Consider the emotion of fear. Have you ever found yourself in a really dangerous situation? Have you ever almost crashed your car and known for several seconds beforehand what was going to happen? Have you ever been swimming in the ocean and realized you were out too far or caught in a current? Have you ever almost fallen from a height, such as a ladder or a roof? In any of these instances, you would have felt an incredible surge of arousal. As the first great emotion theorist, Charles Darwin (1872), pointed out more than 100 years ago, this kind of reaction seems to be programmed in all animals, including humans, which sug- gests that it serves a useful evolutionary function. The alarm reac- tion that activates during potentially life-threatening emergencies is called the flight or fight response. If you are caught in ocean currents, your almost instinctual tendency is to struggle toward shore. You might realize rationally that you’re best off just floating until the current runs its course and then, more calmly, swimming in later. Yet somewhere, deep within, ancient instincts for survival won’t let you relax, even though struggling against the ocean will only wear you out and increase your chance of drowning. Still, this kind of reaction might momentarily give you the strength to lift a car off your trapped brother or fight off an attacker. The whole

purpose of the physical rush of adrenaline that we feel in extreme danger is to mobilize us to escape the danger (flight) or to fend it off (fight).

The Physiology and Purpose of Fear How do physical reactions prepare us to respond this way? The great physiologist Walter Cannon (1929) speculated on the rea- sons. Fear activates your cardiovascular system. Your blood ves- sels constrict, thereby raising arterial pressure and decreasing the blood flow to your extremities (fingers and toes). Excess blood is redirected to the skeletal muscles, where it is available to the vital organs that may be needed in an emergency. Often people seem “white with fear”; that is, they turn pale as a result of decreased blood flow to the skin. “Trembling with fear,” with your hair stand- ing on end, may be the result of shivering and piloerection (in which body hairs stand erect), reactions that conserve heat when your blood vessels are constricted.

These defensive adjustments can also produce the hot-and- cold spells that often occur during extreme fear. Breathing becomes faster and, usually, deeper to provide necessary oxygen to rapidly circulating blood. Increased blood circulation carries oxygen to the brain, stimulating cognitive processes and sensory functions, which make you more alert and able to think more quickly during emergencies. An increased amount of glucose (sugar) is released from the liver into the bloodstream, further energizing various crucial muscles and organs, including the brain. Pupils dilate, pre- sumably to allow a better view of the situation. Hearing becomes more acute, and digestive activity is suspended, resulting in a reduced flow of saliva (the “dry mouth” of fear). In the short term, voiding the body of all waste material and eliminating digestive processes further prepare the organism for concentrated action and activity, so there is often pressure to urinate and defecate and, occasionally, to vomit.

It is easy to see why the flight or fight reaction is fundamentally important. Millennia ago, when our ancestors lived in unstable circumstances, those with strong emergency reactions were more likely to live through attacks and other dangers than those with weak emergency responses, and the survivors passed their genes down to us.

emotional Phenomena The emotion of fear is a subjective feeling of terror, a strong moti- vation for behavior (escaping or fighting), and a complex physi- ological or arousal response. To define “emotion” is difficult, but most theorists agree that it is linked to an action tendency (Barlow et al. 2014; Barlow, 2002; Lang, 1985, 1995; Lang, Bradley, & Cuthbert, 1998); that is, a tendency to behave in a certain way (for example, escape), elicited by an external event (a threat) and a feeling state (terror) and accompanied by a (possibly) char- acteristic physiological response (Fairholme, Boisseau, Ellard, Ehrenreich, & Barlow, 2010; Barrett, 2012; Gross, 2015; Izard, 1992; Lazarus, 1991, 1995). Any emotional experience is associ- ated with approach and avoidance tendencies. One purpose of a feeling state is to motivate us to carry out a behavior: if we escape, our terror, which is unpleasant, will be decreased, so decreasing

Charles Darwin (1809–1882) drew this cat frightened by a dog to show the flight or fight reaction.

C ha

rle s

D ar

w in

. E vo

lu tio

n of

t he

S pe

ci es

, 1 89

50443_ch02_ptg01_hr_032-073.indd 62 28/09/16 5:30 PM

emOtiOns 63

unpleasant feelings motivates us to escape (Campbell-Sills, Ellard, & Barlow, 2015; Gross, 2015; Hofmann, in press; Öhman, 1996). As Öhman (1996; Öhman, Flykt, & Lundquist, 2000) points out, the principal function of emotions can be understood as a clever means, guided by evolution, to get us to do what we have to do to pass on our genes successfully to coming generations. How do you think this works with anger or with love? What is the feeling state? What is the behavior?

Emotions are usually short-lived, temporary states lasting from several minutes to several hours, occurring in response to an external event. Mood is a more persistent period of affect or emotionality. Thus, in Chapter 7 we describe enduring or recur- ring states of depression or excitement (mania) as mood disorders. But anxiety disorders, described in Chapter 5, are characterized by enduring or chronic anxiety and, therefore, could also be called mood disorders. Alternatively, both anxiety disorders and mood disorders could be called emotional disorders, a term not formally used in psychopathology. This is only one example of the occa- sional inconsistencies in the terminology of abnormal psychology. A related term you will see occasionally, particularly in Chapters 3 and 13, is affect, which often refers to the valence dimension (i.e., pleasant or positive vs. unpleasant or negative) of an emotion. For example, positive affect is experienced during joy, whereas nega- tive affect is experienced during anger and fear. Together with arousal dimension (i.e., activated or high arousal vs. deactivated or low arousal), any emotional experience can be assigned as a point on this two-dimensional system. This two dimensional system is known as the circumplex model of emotions (e.g., Colibazzi et al., 2010). A third dimension (time) could be added to specify whether the emotional experience is short or long-lasting (e.g., surprise vs. joy). Affect can also refer to the momentary emotional tone that accompanies what we say or do. For example, if you just got an A+ on your test, but you look sad, your friends might think your reaction strange because your affect is not appropriate to the event. Finally, the term affective style is sometimes used to sum- marize commonalities among emotional states characteristic of an individual. Thus, someone who tends to be fearful, anxious, and depressed has a negative affective style, whereas sometimes with a positive affective style would subsume, or include, tendencies to be generally pleasant, joyful, excited, and so on.

The Components of emotion Emotion scientists now agree that emotion is composed of three related components—behavior, physiology, and cognition—but most emotion scientists tend to concentrate on one component or another (see E Figure 2.16). Emotion scientists who concentrate on behavior think that basic patterns of emotion differ from one another in fundamental ways; for example, anger may differ from sadness not only in how it feels but also behaviorally and physi- ologically. These scientists also emphasize that emotion is a way of communicating between one member of the species and another. One function of fear is to motivate immediate and decisive action, such as running away. But if you look scared, your facial expres- sion will quickly communicate the possibility of danger to your friends, who may not have been aware that a threat is imminent. Your facial communication increases their chance for survival

because they can now respond more quickly to the threat when it occurs. This may be one reason emotions are contagious, as we observed in Chapter 1 when discussing mass hysteria (Hatfield, Cacioppo, & Rapson, 1994; Wang, 2006).

Other scientists have concentrated on the physiology of emo- tions, most notably Cannon (1929). In some pioneering work, he viewed emotion as primarily a brain function. Research in this tradition suggests that areas of the brain associated with emotional expression are generally more ancient and primitive than areas associated with higher cognitive processes, such as reasoning.

Other research demonstrates direct neurobiological connec- tions between emotional centers of the brain and parts of the eye (the retina) or the ear that allow emotional activation without the influence of higher cognitive processes (LeDoux, 1996, 2002; Öhman, Flykt, & Lundqvist, 2000; Zajonc, 1984, 1998). In other words, you may experience various emotions quickly and directly without necessarily thinking about them or being aware of why you feel the way you do.

Finally, a number of prominent emotion scientists concentrate on studying the cognitive aspects of emotion. Notable among these theorists was the late Richard S. Lazarus (for example, 1968, 1991, 1995), who proposed that changes in a person’s environment are appraised in terms of their potential impact on that person. The type of appraisal you make determines the emotion you expe- rience. For example, if you see somebody holding a gun in a dark alley, you will probably appraise the situation as dangerous and experience fear. You would make a different appraisal if you saw a tour guide displaying an antique gun in a museum. Lazarus would suggest that thinking and feeling cannot be separated, but other cognitive scientists are concluding otherwise by suggesting that, although cognitive and emotional systems interact and overlap, they are fundamentally separate (Teasdale, 1993). All components

Basic patterns of emotional behavior (freeze, escape, approach, attack) that differ in fundamental ways. Emotional behavior is a means of communication.

•

Emotion and Behavior

Emotion is a brain function involving (generally) the more primitive brain areas. Direct connection between these areas and the eyes may allow emotional processing to bypass the influence of higher cognitive processes.

•

Physiology of Emotion

Appraisals, attributions, and other ways of processing the world around you that are fundamental to emotional experience.

•

Cognitive Aspects of Emotion

E FigUre 2.16 Emotion has three important and overlapping components: behavior, cognition, and physiology.

50443_ch02_ptg01_hr_032-073.indd 63 28/09/16 5:30 PM

64 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

putting them at risk for dangerous disturbances in heart rhythm (arrhythmias).

This study was the first to prove that anger affects the heart through decreased pumping efficiency, at least in people who already have heart disease. This was confirmed in a large high- risk study examining 13,171 participants (Kucharska-Newton et al., 2014). The incidence of heart failure was greater among those with high, as compared to those with low or moderate trait anger, and men had a higher risk for heart failure than women.

Suarez and colleagues (2002) demonstrated how anger may cause this effect. Inflammation produced by an overactive immune system in particularly hostile individuals may contribute to clogged arteries (and decreased heart-pumping efficiency).

Interestingly, it seems that adopting a forgiving attitude can neutralize the toxic effects of anger on cardiovascular activity. In the words of the Buddhist leader, the Dalai Lama: Harboring anger is like swallowing poison and expecting the other person to die. The antidote to anger is forgiveness, compassion, and kindness. These insights are supported by scientific data. For example, Larsen et al. (2012) had participants think about a previous offense from either an angry perspective or a forgiving perspective or while they were distracted by focusing on a neutral topic. All of them were then dis- tracted by focusing on the neutral topic for five minutes, after which they could freely ruminate on the offense. As expected, thinking about the offense from an angry perspective had negative effects on cardiovascular measures (increased blood pressure and heart rate, etc.) compared with the distraction condition, but taking a forgiv- ing attitude not only greatly reduced this cardiovascular reactiv- ity to a level present in the distraction condition, but these effects were still present during the follow-up free rumination period, even compared to the distraction condition as that group began ruminating on the offense causing increases in their reactivity.

Taken together, these results provide strong support for the effects of anger on the heart, but shall we conclude that too much anger causes heart attacks? This would be another example of one-dimensional causal modeling. Increasing evidence, includ- ing the studies just mentioned, suggests that anger and hostility contribute to heart disease, but so do many other factors, includ- ing a genetically determined biological vulnerability. We discuss cardiovascular disease in Chapter 9.

of emotion—behavior, physiology, and cognition—are important, and theorists are adopting more integrative approaches by study- ing their interaction (Barrett, 2009, 2012; Gendron & Barrett, 2009; Gross, 2015; Hofmann, in press).

Anger and Your Heart When we discussed Judy’s blood phobia, we observed that behav- ior and emotion may strongly influence biology. Scientists have made important discoveries about the familiar emotion of anger. We have known for years that negatively valenced emotions such as hostility and anger increase a person’s risk of developing heart disease (Chesney, 1986; MacDougall, Dembroski, Dimsdale, & Hackett, 1985). Sustained hostility with angry outbursts and repeatedly and continually suppressing anger contributes more strongly to death from heart disease than other well-known risk factors, including smoking, high blood pressure, and high cholesterol levels (Harburg, Kaciroti, Gleiberman, Julius, & Schork, 2008; Williams, Haney, Lee, Kong, & Blumenthal, 1980).

Why is this, exactly? In a classic study, Ironson and colleagues (1992) asked a number of people with heart disease to recall some- thing that made them angry in the past. Sometimes these events had occurred many years earlier. In one case, an individual who had spent time in a Japanese prisoner-of-war camp during World War II became angry every time he thought about it, especially when he thought about reparations paid by the U.S. government to Japanese Americans who had been held in internment camps during the war. Ironson and associates compared the experience of anger with stressful events that increased heart rate but were not associated with anger. For example, some participants imag- ined making a speech to defend themselves against a charge of shoplifting. Others tried to figure out difficult problems in arith- metic within a time limit. Heart rates during these angry situa- tions and stressful ones were then compared with heart rates that increased as a result of exercise (riding a stationary bicycle). The investigators found that the ability of the heart to pump blood efficiently through the body dropped significantly during anger but not during stress or exercise. In fact, remembering being angry was sufficient to cause the anger effect. If participants were really angry, their heart-pumping efficiency dropped even more,

Our emotional reaction depends on context. Fire, for example, can be threatening or comforting.

el vi

nW /S

hu tt

er st

oc k.

co m

A rie

l S ke

lle y/

B le

nd Im

ag es

/J up

ite r

Im ag

50443_ch02_ptg01_hr_032-073.indd 64 28/09/16 5:30 PM

cultural, sOcial , anD interpersOnal FactOrs 65

emotions and Psychopathology We now know that suppressing almost any kind of emotional response, such as anger or fear, increases sympathetic nervous sys- tem activity, which may contribute to psychopathology (Barlow, Sauer-Zavala, Carl, Bullis, & Ellard, 2014, Campbell-Sills et al., 2015; Fairholme, Boisseau, Ellard, Ehrenreich, & Barlow, 2010). Other emotions seem to have a more direct effect. In Chapter 5, we study the phenomenon of panic and its relationship to anxiety disorders. One interesting possibility is that a panic attack is sim- ply the normal emotion of fear occurring at the wrong time, when there is nothing to be afraid of (Barlow, 2002). Some patients with mood disorders become overly excited and joyful. They think they have the world on a string and they can do anything they want and spend as much money as they want because everything will turn out all right. Every little event is the most wonderful and excit- ing experience they have ever had. These individuals are suffering from mania, which is part of a serious mood disorder called bipo- lar disorder, discussed in Chapter 7. People who suffer from mania usually alternate periods of excitement with periods of extreme sadness and distress, when they feel that all is lost and the world is a gloomy and hopeless place. During extreme sadness or distress, people are unable to experience any pleasure in life and often find it difficult even to get out of bed and move around. If hopelessness becomes acute, they are at risk for suicide. This emotional state is depression, a defining feature of many mood disorders.

Thus, basic emotions of fear, anger, sadness or distress, and excitement may contribute to many psychological disorders and may even define them. Emotions and mood also affect our cogni- tive processes: if your mood is positive, then your associations, interpretations, and impressions also tend to be positive (Diener, Oishi, & Lucas, 2003). Your impression of people you first meet and even your memories of past events are colored to a great extent by your current mood. If you are consistently negative or depressed, then your memories of past events are likely to be unpleasant. The pessimist or depressed person sees the bottle as half empty. In con- trast, the cheerful optimist is said to see the world through rose- colored glasses and to see the bottle as half full. This is a rich area of investigation for cognitive and emotion scientists (Eysenck, 1992; Rottenberg & Johnson, 2007; Teasdale, 1993), particularly those interested in the close interconnection of cognitive and emotional processes. Leading psychopathologists are beginning to outline the nature of emotion disruption (or dysregulation) and to under- stand how these disruptions interfere with thinking and behavior in various psychological disorders (Barlow, Allen, & Choate, 2004; Campbell-Sills et al., 2015; Gross, 2015; Hofmann, Sawyer, Fang, & Asnaani, 2012; Kring & Sloan, 2010).

Cultural, Social, and interpersonal Factors Given the jumble of neurobiological and psychological variables impinging on our lives, is there any room for the influence of social, interpersonal, and cultural factors? Studies are beginning to demonstrate the substantial power and depth of such influ- ences. Researchers have now established that cultural and social influences can kill you. Consider the following example.

Voodoo, the evil eye, and Other Fears In many cultures around the world, individuals may suffer from fright disorders, which are characterized by exaggerated startle responses, and other observable fear and anxiety reactions. One example is the Latin American susto, which describes various anxiety-based symptoms, including insomnia, irritability, pho- bias, and the marked somatic symptoms of sweating and increased heart rate (tachycardia). But susto has only one cause: The individ- ual believes that he or she has become the object of black magic, or witchcraft, and is suddenly badly frightened. In some cultures, the sinister influence is called the evil eye (Good & Kleinman, 1985; Tan, 1980), and the resulting fright disorder can be fatal. Cannon (1942), examining the Haitian phenomenon of voodoo death, suggested that the sentence of death by a medicine man may create an intolerable autonomic arousal in the participant, who has little ability to cope because there is no social support. That is, friends and family ignore the individual after a brief period of grieving because they assume death has already occurred. Ultimately, the condition leads to damage to internal organs and death. Thus, from all accounts, an individual who is from a physical and psy- chological point of view functioning in a perfectly healthy and adaptive way suddenly dies because of marked changes in the social environment.

Fear and phobias are universal, occurring across all cultures. But what we fear is strongly influenced by our social environment. Israeli and Bedouin researchers studied the fears of hundreds of Jewish and Bedouin children living in the same region of Israel (Elbedour,

Check your understanding of behavioral and cognitive influ- ences by identifying the descriptions. Choose your answers from (a) learned helplessness, (b) modeling, (c) prepared learning, and (d) implicit memory.

Concept Check 2.4

1. Karen noticed that every time Tyrone behaved well at lunch, the teacher praised him. Karen decided to behave better to receive praise herself. ______________

2. Josh stopped trying to please his father because he never knows whether his father will be proud or outraged. ______________

3. Greg fell into a lake as a baby and almost drowned. Even though Greg has no recollection of the event, he hates to be around large bodies of water. ______________

4. Juanita was scared to death of the tarantula, even though she knew it wasn’t likely to hurt her. ______________

50443_ch02_ptg01_hr_032-073.indd 65 28/09/16 5:30 PM

66 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

Caspi, & Moffitt, 2006). Everyone experiences anxiety and fear, and phobias are found all over the world. But phobias have a peculiar characteristic: The likelihood of your having a particular phobia is powerfully influenced by your gender. For example, someone who complains of an insect or small-animal phobia severe enough to prohibit field trips or visits to friends in the country is almost cer- tain to be female, as are 90% of the people with this phobia (pos- sible reasons for this were mentioned on pp. 62–63). But a social phobia strong enough to keep someone from attending parties or meetings affects men and women more or less equally but perhaps for different reasons.

We think these substantial differences have to do with, at least in part, cultural expectations of men and women, or our gender roles. For example, an equal number of men and women may have an experience that could lead to an insect or small-animal phobia, such as being bitten by one, but in our society it isn’t always accept- able for a man to show or even admit fear. So a man is more likely to hide or endure the fear until he gets over it. It is more acceptable for women to acknowledge fearfulness, so a phobia develops. It is also more acceptable for a man to be shy than to show fear, so he is more likely to admit social discomfort.

To avoid or lessen a panic attack, an extreme experience of fear, some males drink alcohol instead of admitting they’re afraid (see Chapter 5). In many cases, this attempt to cope may lead to alcoholism, a disorder that affects many more males than females (see Chapter 11). One reason for this gender imbalance is that males are more likely than females to self-medicate their fear and panic with alcohol and in so doing start down the slippery slope to addiction.

It even seems that men and women may respond differently to the same standardized psychological treatment (Felmingham & Bryant, 2012). After exposure therapy for posttraumatic stress disorder (see Chapter 5), both groups benefited, but women main- tained their gains significantly better during a follow-up period. The authors suggest that the well-established ability of women to recall emotional memories somewhat better than men may facili- tate emotional processing and long term treatment gains.

Bulimia nervosa, the severe eating disorder, occurs almost entirely in young females. Why? As you will see in Chapter 8, a

Shulman, & Kedem, 1997). Although they all feared potentially life- threatening events, Jewish children, whose society emphasizes indi- viduality and autonomy, have fewer fears than Bedouin children, who grow up in a strongly paternalistic society in which the group and family are central and who are taught to be cautious about the rest of the world. Bedouin and Jewish children have different fears, and the Bedouin children have more of them, many centering on the possible disintegration of the family. Thus, cultural factors influ- ence the form and content of psychopathology and may differ even among cultures side by side in the same country.

gender Gender roles have a strong and sometimes puzzling effect on psy- chopathology (Kistner, 2009; Maeng & Milad, in press; Rutter,

A “possessed” person receives treatment in a voodoo ritual.

TH O

N Y

B E

LI ZA

IR E

/A FP

/G et

ty Im

ag es

Jewish children, whose culture emphasizes individuality and autonomy, have been found to be less fearful of outsiders than Bedouin children in the same community, whose culture emphasizes the group and the family.

O rit

A llu

sh /P

ho to

S to

ck -Is

ra el

/A la

m y

S to

ck P

ho to

A nd

rz ej

K ub

ik /S

hu tt

er st

oc k.

co m

50443_ch02_ptg01_hr_032-073.indd 66 28/09/16 5:30 PM

cultural, sOcial , anD interpersOnal FactOrs 67

network. Cohen, Doyle, Skoner, Rabin, and Gwaltney (1997) used nasal drops to expose 276 healthy volunteers to one of two different rhinoviruses (cold viruses); then they quarantined the participants for a week. The researchers measured the extent of participation in 12 types of social relationships (for example, spouse, parent, friend, and colleague), as well as other factors, such as smoking and poor sleep quality, that are likely to increase susceptibility to colds. The surprising results were that the greater the extent of social ties, the smaller the chance of catching a cold, even after all other factors were taken into consideration (controlled for). Those with the fewest social ties were more than 4 times more likely to catch a cold than those with the greatest number of ties. This effect also extends to pets! Compared with people who do not have pets, people with pets evidenced lower resting heart rate and blood pressure and responded with smaller increases in these variables during laboratory stressors (Allen, Bloscovitch, & Mendes, 2002). What could account for this? Again, social and interpersonal fac- tors seem to influence psychological and neurobiological variables such as the immune system—sometimes to a substantial degree (Cacioppo & William, 2008). Thus, we cannot study psychologi- cal and biological aspects of psychological disorders (or physical disorders, for that matter) without taking into account the social and cultural context of the disorder.

That a multidimensional point of view is necessary is shown time and again. Consider a classic experiment with primates that illustrates the dangers of ignoring social context. Monkeys were injected with amphetamine, a central nervous system stimulant (Haber & Barchas, 1983). Surprisingly, the drug had no reliable effect on the average behavior of the monkeys as a group. When the investigators divided the monkeys according to whether they were socially dominant or submissive in their group, however, dramatic effects appeared. Amphetamine increased dominant behaviors in primates that were high in the social hierarchy and submissive behaviors in those that were low in the hierarchy. Thus, the effects of a biological factor (the drug) on psychological char- acteristics (the behavior) were uninterpretable unless the social context of the experiment was considered.

cultural emphasis on female thinness plagues our society and, increasingly, societies around the world. The pressures for males to be thin are less apparent, and of the few males who develop bulimia, a substantial percentage are gay; for these individu- als, cultural imperatives to be thin are present in many specific instances (Rothblum, 2002).

Finally, in an exciting finding, Taylor (2002, 2006; Taylor et al., 2000) described a unique way in which females in many spe- cies respond to stress in their lives. This unique response to stress is called “tend and befriend” and refers to protecting themselves and their young through nurturing behavior (tend) and form- ing alliances with larger social groups, particularly other females (befriend). Taylor et al. (2000) supposed that this response fits bet- ter with the way females respond to stress because it builds on the brain’s attachment–caregiving system and leads to nurturing and affiliative behavior. Furthermore, the response is characterized by identifiable neurobiological processes in the brain that are gender specific.

Our gender doesn’t cause psychopathology. But because gen- der role is a social and cultural factor that influences the form and content of a disorder, we attend closely to it in the chapters that follow.

Social effects on Health and Behavior Many studies have demonstrated that the greater the number and frequency of social relationships and contacts, the longer you are likely to live (Miller, 2011). Conversely, the lower you score on a social index that measures the richness of your social life, the shorter your life expectancy. Studies documenting this finding have been reported in the United States (Berkman & Syme, 1979; House, Robbins, & Metzner, 1982; Schoenbach, Kaplan, Fredman, & Kleinbaum, 1986), as well as in Sweden and Finland. They take into account existing physical health and other risk factors for dying young, such as high blood pressure, high cholesterol levels, and smoking habits, and they still produce the same result. Studies also show that social relationships seem to protect individuals against many physical and psychological disorders, such as high blood pressure, depression, alcoholism, arthritis, the progression to AIDS, and bearing low birth weight babies (Cobb, 1976; House, Landis, & Umberson, 1988; Leserman et al., 2000; Thurston & Kubzanksy, 2009). Conversely, the risk of depression for people who live alone is approxi- mately 80% higher than for people who live with others, based on a count of new prescriptions for anti-depressant medication (Pulkki-Raback et al., 2012). Also, social iso- lation increases the risk of death about as much as smok- ing cigarettes and more than physical inactivity or obesity (Holt-Lunstad, Smith, & Layton, 2010). Interestingly, it is not just the absolute number of social contacts that is important. It is the actual perception of loneliness. Thus, some people can live alone with few ill effects. Others might feel lonely despite frequent social contacts (Cacioppo, Grippo, London, Goossensm & Cacioppo, 2015; Cacioppo & William, 2008).

Even whether or not we come down with a cold is strongly influenced by the quality and extent of our social

A long and productive life usually includes strong social relationships and interpersonal relations.

Ye llo

w D

og P

ro du

ct io

ns /D

ig ita

l V is

io n/

G et

ty Im

ag es

50443_ch02_ptg01_hr_032-073.indd 67 28/09/16 5:30 PM

68 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

Returning to human studies, how do social relationships have such a profound impact on our physical and psychological char- acteristics? We don’t know for sure, but there are some intriguing hints (Cacioppo & William, 2008; Cacioppo et al., 2007). Some people think interpersonal relationships give meaning to life and that people who have something to live for can overcome physi- cal deficiencies and even delay death. You may have known an elderly person who far outlived his or her expected time to wit- ness a significant family event, such as a grandchild’s graduation from college. Once the event has passed, the person dies. Another common observation is that if one spouse in a long-standing mar- ital relationship dies, particularly an elderly wife, the other often dies soon after, regardless of health status. It is also possible that social relationships facilitate health-promoting behaviors, such as restraint in the use of alcohol and drugs, getting proper sleep, and seeking appropriate health care (House, Landis, & Umberson, 1988; Leserman et al., 2000).

Sometimes social upheaval is an opportunity for studying the impact of social networks on individual functioning. Several decades ago when Israeli settlements in the Sinai Peninsula were dismantled and the Israeli residents were evacuated as part of peace negotiations with Egypt, Steinglass, Weisstub, and Kaplan De-Nour (1988) studied residents of an Israeli community threat- ened with dissolution. They found that believing oneself embed- ded firmly in a social context was just as important as having a social network. Poor long-term adjustment was best predicted in those who perceived that their social network was disintegrating, regardless of whether it actually was or not.

In another example, whether you live in a city or the country may be associated with your chances of developing schizophre- nia, a severe disorder. Lewis, David, Andreasson, and Allsbeck (1992) found that the incidence of schizophrenia was 38% greater in men who had been raised in cities than in those raised in rural areas. We have known for a long time that more schizophrenia exists in the city than in the country, but researchers thought people with schizophrenia who drifted to cities after developing

schizophrenia or other endemic urban factors, such as drug use or unstable family relationships, might account for the disparity. But Lewis and associates carefully controlled for such factors, and it now seems something about cities beyond those influences may contribute to the development of schizophrenia (Boydell & Allardyce, 2011. Pedersen & Mortensen, 2006; Vassos, Pederson, Murray, Collier, & Lewis, 2012). A meta-analysis by Vassos et al. (2012) estimated that the risk for schizophrenia in the most urban environment is 2.37 times higher than in the most rural environment.

We do not yet know what it is. This finding, if it is replicated and shown to be true, may be important in view of the mass migration of individuals to overcrowded urban areas, particularly in less developed countries.

In summary, we cannot study psychopathology independently of social and interpersonal influences, and we still have much to learn. Many major psychological disorders, such as schizophre- nia and major depressive disorder, seem to occur in all cultures, but they may look different from one culture to another because individual symptoms are strongly influenced by social and inter- personal context (Cheung, 2012; Cheung, van de Vijver, & Leong, 2011). For example, as you will see in Chapter 7, depression in Western culture is reflected in feelings of guilt and inadequacy and in developing countries with physical distress such as fatigue or illness.

Social and Interpersonal Influences on the elderly Finally, the effect of social and interpersonal factors on the expres- sion of physical and psychological disorders may differ with age (Charles & Carstensen, 2010; Holland & Gallagher-Thompson, 2011). Grant, Patterson, and Yager (1988) studied 118 men and women 65 years or older who lived independently. Those with fewer meaningful contacts and less social support from relatives had consistently higher levels of depression and more reports of unsatisfactory quality of life. If these individuals became physi-

cally ill, however, they had more substantial support from their families than those who were not physi- cally ill. This finding raises the unfortunate possibil- ity that it may be advantageous for elderly people to become physically ill, because illness allows them to reestablish the social support that makes life worth living. If further research confirms this finding, we will know for fact what seems to make intuitive sense: involvement with their families before they become ill might help elderly people maintain their physical health (and significantly reduce health-care costs).

The study of older adults is growing at a rapid pace. In 2010, an estimated 40 million people in the United States (13% of the population) were 65 and older, and by 2030 this number is expected to reach 71.5 million (20% of the population) (Federal Inter- agency Forum on Aging-Related Statistics, 2012). With this growth will come a corresponding increase in the number of older adults with mental health problems, many of whom will not receive appropriate care (Holland & Gallagher-Thompson, 2011). As you

In developing countries, personal upheaval because of political strife affects mental health.

N ei

l C oo

pe r/

A la

m y

S to

ck P

ho to

50443_ch02_ptg01_hr_032-073.indd 68 28/09/16 5:30 PM

l i Fe -span DevelOpment 69

because most societies have not yet developed the social context for alleviating and ultimately preventing them. Changing soci- etal attitudes is just one of the challenges facing us as the century unfolds.

Life-Span Development Life-span developmental psychopathologists point out that we tend to look at psychological disorders from a snapshot perspec- tive: we focus on a particular point in a person’s life and assume it represents the whole person. The inadequacy of this way of look- ing at people should be clear. Think back on your own life over the past few years. The person you were, say, 3 years ago, is different from the person you are now, and the person you will be 3 years from now will have changed in important ways, even though we tend to have a cognitive bias called “the end of history” illusion that makes us think that we will change very little in the years to come (Quoidbach, Gilbert, & Wilson, 2013). To understand psychopathology, we must appreciate how experiences during different periods of development may influence our vulnerabil- ity to other types of stress or to differing psychological disorders (Charles & Carstensen, 2010; Rutter, 2002).

Important developmental changes occur at all points in life. For example, adulthood, far from being a relatively stable period, is highly dynamic, with important changes occurring into old age. Erik Erikson (1982) suggested that we go through eight major cri- ses during our lives, each determined by our biological maturation and the social demands made at particular times. Unlike Freud, who envisioned no developmental stages beyond adolescence, Erikson believed that we grow and change beyond the age of 65. During older adulthood, for example, we look back and view our lives either as rewarding or as disappointing.

Although aspects of Erikson’s theory of psychosocial develop- ment have been criticized as being too vague and not supported by research (Shaffer, 1993), it illustrates the comprehensive approach to human development advocated by life-span devel- opmentalists. Basic research is beginning to confirm the impor- tance of this approach. In one experiment, Kolb, Gibb, and Gorny (2003) placed animals in complex environments as juveniles, as adults, or in old age when cognitive abilities were beginning to decline (senescence). They found that the environment had dif- ferent effects on the brains of these animals depending on their developmental stage. Basically, the complex and challenging envi- ronments increased the size and complexity of neurons in the motor and sensory cortical regions in the adult and aged animals; however, unlike the older groups, in young animals the complex and challenging environments decreased the size and complexity of neurons in the spine. Nevertheless, this decrease was associ- ated with enhanced motor and cognitive skills when the animals became adults, indicating that stimulating environments can affect brain function in a positive way at any age. For example, it has been shown that the disease progression of disorders that typically begin in adulthood or old age, such as Huntington’s dis- ease, Alzheimer’s disease, and Parkinson’s, and even genetic dis- orders, such as fragile X and Down syndrome, can be delayed or slowed down through enriched environments (Nithianantharajah & Hannan, 2006). Even prenatal experience seems to affect brain

can see, understanding and treating the disorders experienced by older adults is necessary and important.

Social Stigma Other factors make the consideration of social and cultural issues imperative to the study of psychopathology. Psychological disorders continue to carry a substantial stigma in our society (Hinshaw & Stier, 2008). To be anxious or depressed is to be weak and cowardly. To be schizophrenic is to be unpredictable and crazy. For physical injuries in times of war, we award medals. For psychological injuries, the unfortunate soldiers earn scorn and derision, as anyone knows who has seen the classic movie Born on the Fourth of July depicting the Vietnam War era; the 2010 Academy Award–winning The Hurt Locker or the 2014 Academy Award-winning American Sniper portraying events in post- invasion Iraq and Afghanistan. Often a patient with psychological disorders does not seek health insurance reimbursement for fear a coworker might learn about the problem. With far less social sup- port than for physical illness, there is less chance of full recovery and a greater risk of suicide, as we are seeing in the United States in veterans returning from Iraq and Afghanistan. We discuss some consequences of social attitudes toward psychological disorders in Chapters 3 and 16.

global incidence of Psychological Disorders Important surveys from the World Health Organization (WHO) reveal that mental disorders account for 13% of the global burden of disease (WHO, 2015). Behavioral and mental health problems in developing countries are exacerbated by political strife, tech- nological change, and massive movements from rural to urban areas. Ten to twenty percent of all primary medical services in poor countries are sought by patients with psychological disor- ders, principally anxiety and mood disorders (including suicide attempts), as well as alcoholism, drug abuse, and childhood developmental disorders (WHO, 2015). Treatments for disor- ders such as depression and addictive behaviors that are success- ful in the United States can’t be administered in countries where mental health care is limited. In Cambodia, during and after the bloody reign of the Khmer Rouge, all mental health profession- als either died or disappeared. As of 2006, only 26 psychiatrists were available to see 12 million people. In sub-Saharan Africa it’s even worse, with only one psychiatrist per 2 million people (WHO, 2011). In the United States, approximately 200,000 mental health professionals serve almost 300 million people, yet only 1 in 3 persons with a psychological disorder in the United States has ever received treatment of any kind (Institute of Medicine, 2001). And despite the wonderful efforts of the Bill and Melinda Gates Foundation, there’s no mention of mental health among the goals of the foundation’s “Grand Challenges in Global Health” initiative. Mental disorders — and especially the most common ones, such as anxiety disorders and depression— not only impose great suffer- ing to the affected individuals, but they also lead to high economic cost to society by being undertreated (Laird & Clark, 2014). These shocking statistics suggest that in addition to their role in causa- tion, social and cultural factors substantially maintain disorders

50443_ch02_ptg01_hr_032-073.indd 69 28/09/16 5:30 PM

70 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

structure, because the offspring of an animal housed in a rich and complex environment during the term of her pregnancy have the advantage of more complex cortical brain circuits after birth (Kolb, Gibb, & Robinson, 2003). You may remember the study by Cameron et al. (2005) discussed earlier in the chapter, in which mother rats’ behavior in the first week of their pups’ lives, but not thereafter, strongly influenced the ability of the pups to handle stress throughout their lives.

Thus, we can infer that the influence of developmental stage and prior experience has a substantial impact on the development and presentation of psychological disorders, an inference that is receiving confirmation from sophisticated life-span developmen- tal psychologists such as Laura Carstensen (Carstensen, Charles, Isaacowitz, & Kennedy, 2003; Carstensen et al., 2011; Charles & Carstensen, 2010; Isaacowitz, Smith, & Carstensen, 2003). For example, in depressive (mood) disorders, children and adoles- cents do not receive the same benefit from antidepressant drugs as do adults (Hazell, O’Connell, Heathcote, Robertson, & Henry, 1995; Santosh, 2009), and for many of them these drugs pose risks that are not present in adults (Santosh, 2009). Also, the gender dis- tribution in depression is approximately equal until puberty, when it becomes more common in girls (Compas et al., 1997; Hankin, Wetter, & Cheely, 2007).

the Principle of equifinality Like a fever, a particular behavior or disorder may have a number of causes. The principle of equifinality is used in developmental psychopathology to indicate that we must consider a number of paths to a given outcome (Cicchetti, 1991). There are many exam- ples of this principle. A delusional syndrome may be an aspect of schizophrenia, but it can also arise from amphetamine abuse. Delirium, which involves difficulty focusing attention, often occurs in older adults after surgery, but it can also result from thia- mine deficiency or renal (kidney) disease. Autism can sometimes occur in children whose mothers are exposed to rubella during pregnancy, but it can also occur in children whose mothers expe- rience difficulties during labor.

Different paths can also result from the interaction of psy- chological and biological factors during various stages of devel- opment. How someone copes with impairment resulting from physical causes may have a profound effect on that person’s overall functioning. For example, people with documented brain dam- age of approximately equal severity may have different levels of disorder. Those with healthy systems of social support, consist- ing of family and friends, as well as highly adaptive personality characteristics, such as confidence in their abilities to overcome challenges, may experience only mild behavioral and cognitive disturbance despite physical (organic) pathology. Those without comparable support and personality may be incapacitated. This may be clearer if you think of people you know with physical dis- abilities. Some, paralyzed from the waist down by accident or dis- ease (paraplegics), have nevertheless become superb athletes or accomplished in business or the arts. Others with the same condi- tion are depressed and hopeless; they have withdrawn from life or, even worse, ended their lives. Even the content of delusions and hallucinations that may accompany a disorder, and the degree to

which they are frightening or difficult to cope with, is partly deter- mined by psychological and social factors.

Researchers are exploring not only what makes people experi- ence particular disorders but also what protects others from hav- ing the same difficulties. If you were interested in why someone would be depressed, for example, you would first look at people who display depression. But you could also study people in similar situations and from similar backgrounds who are not depressed. An excellent example of this approach is research on “resilient” children, which suggests that social factors may protect some chil- dren from being hurt by stressful experiences, such as one or both parents suffering a psychiatric disturbance (Cooper, Feder, South- wick & Charney, 2007; Garmezy & Rutter, 1983; Becvar, 2013; Goldstein, & Brooks, 2013). The presence of a caring adult friend or relative can offset the negative stresses of this environment, as can the child’s own ability to understand and cope with unpleasant situations. More recently, scientists are discovering strong biologi- cal differences in responsiveness to trauma and stress as a result of protective factors such as social support, or having a strong pur- pose or meaning of life (Alim et al., 2008; Charney, 2004; Ozbay et al., 2007). Perhaps if we better understand why some people do not encounter the same problems as others in similar circumstances, we can better understand particular disorders, assist those who suf- fer from them, and even prevent some cases from occurring.

Conclusions We have examined modern approaches to psychopathology, and we have found the field to be complex indeed. In this brief overview (even though it may not seem brief), we have seen that contributions from (1) psychoanalytic theory, (2) behav- ioral and cognitive science, (3) emotional influences, (4) social and cultural influences, (5) genetics, (6) neuroscience, and (7) life-span developmental factors all must be considered when we think about psychopathology. Even though our knowledge is incomplete, you can see why we could never resume the one- dimensional thinking typical of the various historical traditions described in Chapter 1.

And yet, books about psychological disorders and news reports in the popular press often describe the causes of these disorders in one-dimensional terms without considering other influences. For example, how many times have you heard that a psychological dis- order such as depression, or perhaps schizophrenia, is caused by a “chemical imbalance” without considering other possible causes? When you read that a disorder is caused by a chemical imbalance, it sounds like nothing else really matters and all you have to do is correct the imbalance in neurotransmitter activity to “cure” the problem.

Based on the research we review when we talk about specific psychological disorders, there is no question that psychologi- cal disorders are associated with altered neurotransmitter activ- ity and other aspects of brain function (a chemical imbalance). But you have learned in this chapter that a chemical imbalance could, in turn, be caused by psychological or social factors such as stress, strong emotional reactions, difficult family interactions, changes caused by aging, or, most likely, some interaction of all these factors. Therefore, it is inaccurate and misleading to say that

50443_ch02_ptg01_hr_032-073.indd 70 28/09/16 5:30 PM

cOnclus iOns 71

a psychological disorder is “caused” by a chemical imbalance, even though chemical imbalances almost certainly exist.

Similarly, how many times have you heard that alcoholism or other addictive behaviors were caused by “lack of willpower,” implying that if these individuals simply developed the right atti- tude they could overcome their addiction? There is no question that people with severe addictions may well have motivational problems and faulty cognitive processes as indicated by ratio- nalizing their behavior, or other faulty appraisals, or by attribut- ing their problems to stress in their lives or some other “bogus” excuse. They may also misperceive the effects that alcohol has on them, and these cognitions and attitudes all contribute to develop- ing addictions. But considering only cognitive processes without considering other factors, such as genes and brain physiology, as causes of addictions would be as incorrect as saying that depres- sion is caused by a chemical imbalance. Interpersonal, social, and cultural factors also contribute strongly to the development of addictive behaviors. To say, then, that addictive behaviors such as alcoholism are caused by lack of willpower or certain faulty ways of thinking is also highly simplistic and just plain wrong.

If you learn one thing from this book, it should be that psy- chological disorders do not have just one cause. They have many causes—these causes all interact with one another—and we must understand this interaction to appreciate fully the origins of psychological disorders. To do this requires a multidimensional integrative approach. In chapters covering specific psychological disorders, we return to cases like Judy’s and consider them from this multidimensional integrative perspective. But first we must explore the processes of assessment and diagnosis used to measure and classify psychopathology.

Fill in the blanks to complete these statements relating to the cultural, social, and developmental factors influencing psychopathology.

1. What we ______________ is strongly influenced by our social environments.

2. The likelihood of your having a particular phobia is powerfully influenced by your ______________.

3. A large number of studies have demonstrated that the greater the number and frequency of ______________ relationships and ______________, the longer you are likely to live.

4. The effect of social and interpersonal factors on the expression of physical and psychological disorders may differ with ______________.

5. The principle of ______________ is used in devel- opmental psychopathology to indicate that we must consider a number of paths to a given outcome.

Concept Check 2.5

50443_ch02_ptg01_hr_032-073.indd 71 28/09/16 5:30 PM

72 CHAPTER 2 an integrat ive apprOach tO psychOpathOlOgy

One-Dimensional versus Multidimensional Models

p The causes of abnormal behavior are complex and fascinating. Psychological disorders are caused by a complex interplay of nature (biology) and nurture (psychosocial factors).

p To identify the causes of a psychological disorder in a given per- son we must consider the interaction of all relevant dimensions: genetic contributions, the role of the nervous system, behavioral and cognitive processes, emotional influences, social and inter- personal influences, and developmental factors. Thus, we have arrived at a multidimensional integrative approach to the causes of psychological disorders.

Genetic Contributions to Psychopathology p The genetic influence on much of our development and most of our behavior, personality, and even IQ score is polygenic—that is, influenced by many genes. This is assumed to be the case in abnormal behavior as well, although research is beginning to identify specific small groups of genes that relate to some major psychological disorders.

p In studying causal relationships in psychopathology, researchers look at the interactions of genetic and environmental effects. In the diathesis–stress model, individuals are assumed to inherit cer- tain vulnerabilities that make them susceptible to a disorder when the right kind of stressor comes along. In the gene–environment correlation or reciprocal gene–environment model, the indi- vidual’s genetic vulnerability toward a certain disorder may make it more likely that the person will experience the stressor that, in turn, triggers the genetic vulnerability and thus the disorder. In epigenetics, the immediate effects of the environment (such as early stressful experiences) influence cells that turn certain genes on or off. This effect may be passed down through several generations.

Neuroscience and Its Contributions to Psychopathology

p Brain science and the field of neuroscience promise much as we try to unravel the mysteries of psychopathology. Within the nervous system, levels of neurotransmitter and neuroendocrine

activity interact in complex ways to modulate and regulate emo- tions and behavior and contribute to psychological disorders.

p Critical to our understanding of psychopathology are the neu- rotransmitter currents called brain circuits. Of the neurotrans- mitters that may play a key role, we investigated five: serotonin, gamma-aminobutyric acid (GABA), glutamate, norepinephrine, and dopamine.

Behavioral and Cognitive Science p The relatively new field of cognitive science provides a valuable perspective on how behavioral and cognitive influences affect the learning and adaptation each of us experience throughout life. Clearly, such influences not only contribute to psychologi- cal disorders but also may directly modify brain functioning, brain structure, and even genetic expression. We examined some research in this field by looking at learned helplessness, modeling, prepared learning, and implicit memory.

Emotions p Emotions have a direct and dramatic impact on our function- ing and play a central role in many mental disorders. Mood, a persistent period of emotionality, is often evident in psychological disorders.

Cultural, Social, and Interpersonal Factors p Social and interpersonal influences profoundly affect both psycho- logical disorders and biology.

Life-Span Development p In considering a multidimensional integrative approach to psychopathology, it is important to remember the principle of equifinality, which reminds us that we must consider the various paths to a particular outcome, not just the result.

Summary

50443_ch02_ptg01_hr_032-073.indd 72 28/09/16 5:30 PM

summary 73

Key Terms multidimensional integrative

approach, 33 genes, 36 diathesis–stress model, 38 vulnerability, 38 gene–environment correlation

model, 40 epigenetics, 42 neuroscience, 42 neuron, 43 action potentials, 43 terminal button, 43 synaptic cleft, 43 neurotransmitters, 43 excitatory, 43 inhibitory, 43 hormone, 47 brain circuits, 49 agonist, 50 antagonist, 50 inverse agonist, 50

reuptake, 50 glutamate, 50 gamma-aminobutyric acid

(GABA), 50 serotonin, 51 norepinephrine (also

noradrenaline), 52 dopamine, 53 cognitive science, 58 learned helplessness, 59 modeling (also observational

learning), 60 prepared learning, 60 implicit memory, 61 flight or fight response, 62 emotion, 62 mood, 63 affect, 63 circumplex model, 63 equifinality, 70

Answers to Concept Checks 2.1 1. b; 2. a (best answer) or c; 3. e; 4. a (initial), c (maintenance)

2.2 1. F (first 22 pairs); 2. T; 3. T; 4. F (reciprocal gene– environment model); 5. F (complex interaction of both nature and nurture)

2.3 1. b; 2. c; 3. f; 4. g; 5. d; 6. e; 7. h; 8. a

2.4 1. b; 2. a; 3. d; 4. c

2.5 1. fear; 2. gender; 3. social, contacts; 4. age; 5. equifinality

50443_ch02_ptg01_hr_032-073.indd 73 28/09/16 5:30 PM