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Chapter 14 Psychological Disorders

Gateway Theme

Judgments about abnormality are relative, but psychological disorders clearly exist and need to be classified, explained, and treated.

From the beginning of recorded history, there have been people who suffer from unusual or abnormal psychological functioning. We now refer to those situations as psychological or mental disorders, but throughout history they have been called many other things.

The modern study of psychopathology focuses on the study of mental, emotional, and behavioral disorders. The term also refers to maladaptive behaviors.

Gateway Questions (1 of 2)

How is abnormality defined?

What are the major mental disorders?

How are mental disorders diagnosed?

What causes mental disorders?

What are the general characteristics of psychotic disorders?

What is schizophrenia, and what causes it?

What are mood disorders, and what causes them?

Gateway Questions (2 of 2)

Why do people commit suicide, and can they be stopped?

What problems result when a person suffers high levels of anxiety?

What are anxiety-related disorders?

What is a personality disorder?

How can “grit” and perseverance help me in my personal and professional life?

Criteria of the Norm

The normal curve and abnormality

In order to understand what is abnormal, we must first ask “what is normal?” This becomes a very complex question, as there are many criteria we may use to formulate an answer.

- Statistical abnormality involves extremes, showing very high or low levels of a given quality.

- Social nonconformity involves an unwillingness or inability to adhere to public standards for appropriate conduct.

- Situational contexts are related to social nonconformity and remind us that what is considered normal at one place or time may be considered abnormal at another.

- Subjective discomfort, or distress, refers to unpleasant feelings related to a given set of symptoms.

None of these criteria are alone adequate to determine a mental illness. Think of examples of how each may exist independent of psychopathology.

Mental Disorders Are Maladaptive

A major criterion of psychopathology, perhaps the most important one, is that it is maladaptive. Symptoms of a mental disorder typically interfere with a person’s ability to adapt to their surroundings and to accomplish day-to-day responsibilities. Once again, however, we need to consider a larger picture. A person grieving the death of a parent may be temporarily maladaptive inasmuch as they need time away from work or social responsibilities, but this would not be considered abnormal or pathological unless it was extreme and chronic.

Consider normality as a continuum rather than an either/or situation, and then ask how close to the ends of that continuum one must be to be considered pathological.

Abnormal Behavior and the Law

When the mental health industry intersects with the criminal justice system, many complex questions can emerge. The concept of insanity is a legal term that indicates a person’s inability to manage their affairs or anticipate the outcomes of their decisions. What factors go into the determination that an individual is legally insane and, as such, may not be responsible for criminal behavior?

Comorbidity and Cultural Influences (1 of 2)

Table 14.1 Major DSM-5 Categories of Psychopathology

Problem	Primary Symptom	Typical Signs of Trouble	Examples
Neurodevelopmental Disorders	Impairment of nervous system development before adulthood	You have intellectual, communication, attentional, or motor problems that emerge early in your life.	Intellectual developmental disorder, Autism spectrum disorder, Attention deficit/hyperactivity disorder
Schizophrenia spectrum and other psychotic disorders	Loss of contact with reality	You hear or see things that others don’t; your mind has been playing tricks on you.	Delusional disorder, Schizophrenia, Brief psychotic disorder
Bipolar and related disorders	Alternating mania and depression	You feel depressed, or you talk too loud and too fast and have a rush of ideas and feelings that others think are unreasonable.	Cyclothymic disorder, Bipolar I disorder, Bipolar II disorder
Depressive disorders	Depression	You feel sad and hopeless.	Persistent depressive disorder (dysthymia), Major depressive disorder, Postpartum depression, Seasonal affective disorder

Released in its latest edition in 2013, the Diagnostic and Statistical Manual of Mental Disorder (DSM-5) is a book that catalogues every diagnosable mental disorder with lists of symptoms needed for a given diagnosis.

Comorbidity refers to a situation where a person suffers from more than one diagnosable psychological disorder at a time, and one might significantly enhance the problems of the other.

Culture-bound syndromes are those that appear to be limited to a given group of people. Some examples include amok and hikikomori. Are these truly distinct conditions or are they cultural variations on some diagnoses seen in the DSM-5? How do you think cultural norms affect the diagnosis, experience, and treatment of a given condition?

Comorbidity and Cultural Influences (2 of 2)

Problem	Primary Symptom	Typical Signs of Trouble	Examples
Anxiety disorders	High anxiety or anxiety-related distortions of behavior	You have anxiety attacks and feel like you are going to die; or you are afraid to do things that most people can do.	Generalized anxiety disorder, Panic disorder, Agoraphobia, Specific phobia, Social phobia
Obsessive-compulsive and related disorders	Unnecessarily repetitious Behavior	You spend unusual amounts of time doing things such as washing your hands or counting your heartbeats.	Obsessive compulsive disorder, Hoarding disorder
Trauma- and stressor-related disorders	Difficulty dealing with a traumatic or stressful event	You persistently re-experience a traumatic event; you have an exceptionally strong negative reaction to a traumatic event such as becoming highly anxious, depressed, or, being unable to sleep.	Adjustment disorder, Acute stress disorder, Post-traumatic stress disorder
Dissociative disorders	Amnesia, feelings of unreality, multiple identities	There are major gaps in your memory of events; you feel like you are a robot or a stranger to yourself; others tell you that you have done things that you don’t remember doing.	Dissociative amnesia, Dissociative identity Disorder
Somatic symptom disorders	Body complaints without an organic (physical) basis	You feel physically sick, but your doctor says nothing is wrong with you; you suffer from pain that has no physical basis; or you are preoccupied with thoughts about being sick.	Somatic symptom disorder, Factitious disorder, Conversion disorder

Comorbidity refers to a situation where a person suffers from more than one diagnosable psychological disorder at a time, and one might significantly enhance the problems of the other.

The Impact of Psychiatric Labels (1 of 3)

Table 14.1 Major DSM-5 Categories of Psychopathology

Problem	Primary Symptom	Typical Signs of Trouble	Examples
Somatic symptom disorders	Body complaints without an organic (physical) basis	You feel physically sick, but your doctor says nothing is wrong with you; you suffer from pain that has no physical basis; or you are preoccupied with thoughts about being sick.	Somatic symptom disorder, Factitious disorder, Conversion disorder
Feeding and eating disorders	Disturbance of food intake into the body	You eat nonfood items (pica) or have difficulty eating enough food to remain healthy	Anorexia nervosa, Bulimia nervosa, Binge eating disorder
Elimination disorders	Disturbance of waste elimination from the body	You have trouble controlling the elimination of urine (enuresis) or feces (encopresis).	Enuresis, Encopresis
Sleep–wake disorders	Troubles falling asleep, staying asleep, or waking up.	You have difficulty getting a healthy night’s sleep; you snore, have nightmares, or fall asleep inappropriately (narcolepsy).	Insomnia disorder, Hypersomnolence disorder, Narcolepsy, Nightmare Disorder

What is the consequence of diagnosing a person with a psychological disorder? On the plus side, perhaps it provides avenues for treatment and, in time, improvement. But are there also drawbacks to such labels. How are people treated when others become aware of a diagnostic label? What do you think are the social stigmas attached to a psychological diagnosis?

Review the text’s discussion of the landmark study by Rosenhan, as well as some of the stigmatizing results of psychiatric labels being applied to people throughout history.

The Impact of Psychiatric Labels (2 of 3)

Problem	Primary Symptom	Typical Signs of Trouble	Examples
Sexual dysfunctions	Problems in sexual adjustment	You have problems with sexual desire, arousal, orgasm, or pain.	Erectile disorder, Female sexual interest/arousal disorder, Genito-pelvic pain/penetration disorder, Male hypoactive sexual desire disorder
Gender dysphoria	Disturbed gender identity	You feel that you are a man trapped in a woman’s body (or the reverse).	Gender dysphoria
Disruptive, impulse control and conduct disorders	Difficulties of self-control	You are defiant and aggressive; you set fires (pyromania) or are a chronic thief (kleptomania).	Oppositional defiant disorder, Intermittent explosive disorder, Pyromania, Kleptomania.
Substance use and addictive disorders	Disturbances related to drug abuse or dependence as well as other addictive behaviors	You have been drinking too much, using illegal drugs, taking prescription drugs more often than you should, or gambling too much.	Opioid use disorder, Stimulant use disorder, Alcohol use disorder, Tobacco use disorder, Gambling disorder
Neurocognitive disorders	Impairment of nervous system development while in adulthood	Your ability to think and remember has suffered a dramatic decline in adulthood.	Delirium, Neurocognitive disorder due to Alzheimer’s disease, Neurocognitive disorder due to Parkinson’s disease, Neurocognitive disorder due to HIV Infection

Review the text’s discussion of the landmark study by Rosenhan, as well as some of the stigmatizing results of psychiatric labels being applied to people throughout history.

The Impact of Psychiatric Labels (3 of 3)

Problem	Primary Symptom	Typical Signs of Trouble	Examples
Personality disorders	Unhealthy personality patterns	Your behavior patterns repeatedly cause problems at work, at school, and in your relationships with others.	Antisocial personality disorder, Borderline personality disorder
Paraphilic disorders	Deviant sexual behavior	You can gain sexual satisfaction only by engaging in highly atypical sexual behavior.	Pedophilic disorder, Exhibitionistic disorder, Voyeuristic disorder, Fetishistic disorder

Source: American Psychiatric Association, 2013; Sue et al., 2017.

Review the text’s discussion of the landmark study by Rosenhan, as well as some of the stigmatizing results of psychiatric labels being applied to people throughout history.

Types of Symptoms

It can be difficult to distinguish temporary distress or problems from more serious, ongoing conditions. In many cases (though not all), symptoms must be present for a significant time period before a diagnosis would be made. Diagnosis also typically requires the presence of certain conditions, but in some cases it also requires the absence of certain behaviors or events.

Some symptoms are categorized as positive, which indicates a pathological excess of a given behavior or attribute. Others are called negative symptoms. As you may guess, this indicates an unusual or problematic absence of given behaviors. Read about delusions and hallucinations, which we’ll cover more when we discuss schizophrenia.

Biological Factors

There are several families of mental disorders that are due mainly to a variety of biological factors. Neurodevelopmental disorders are those that affect the nervous system and are typically seen first in childhood or adolescence. When problems do not emerge until adulthood (typically middle or later adulthood), they are neurocognitive disorders. The one that is likely most familiar to you, Alzheimer’s disease, involves serious memory loss as well as other cognitive losses.

Many psychological disorders show a significant genetic component, with stronger genetic relationships being associated with higher concordance rates between relatives.

Psychosocial Factors

Stress-vulnerability model

The stress-vulnerability model (also called the stress-diathesis model) notes that some people have a genetic proclivity toward a given illness, but that environment factors must occur in order for that condition to emerge.

Delusional Disorders

Those with delusional disorder have deeply entrenched false beliefs that are not supported by any evidence from reality. There are several types that they may experience:

Erotomanic

Grandiose

Jealous

Persecutory

Somatic

An important consideration is that the delusions cannot be considered “bizarre,” or else a different psychotic diagnosis may be more appropriate (typically schizophrenia or a schizophrenia-related condition).

Paranoid Psychosis

Table 14.2 DSM-5 Classification of Schizophrenia Spectrum and Other Psychotic Disorders

Problem	Typical Signs of Trouble
Delusional disorder	You have some deeply held and bizarre but false beliefs.
Schizophrenia	Your personality has disintegrated; you have hallucinations, delusions, or both.
Brief Psychotic Disorder	You suffer a sudden, but short-lived loss of contact with reality.

Source: American Psychiatric Association, 2013; Sue et al., 2017.

Those who suffer from paranoid psychosis believe that others are wronging them in some meaningful way. Suspiciousness is their default cognitive setting, but there is little to no evidence to support their belief of being harassed.

Can you see how treatment might be difficult? If you try to help a person with such unusual beliefs, what might they come to believe about you?

Symptoms of Schizophrenia

Schizophrenia, with its variety of symptoms and presentations, is one of the most debilitating of the psychological disorders. It is sometimes thought of as a spectrum condition rather than a singular illness, because there is such variety among those with the condition.

Refer to your text to understand the various symptom types:

Disturbed thinking

Disturbed perception

Disturbed emotions

Disturbed behaviors

Disorganized symptoms

Causes of Schizophrenia

Lifetime risk of developing schizophrenia

The majority of current attempts to understand schizophrenia focus on biological causes, but psychosocial factors are also considered. Many with this condition live in troubled family situations with conflicted communication and emotional patterns.

Heredity is certainly a factor, as indicated by various types of studies (twin, family pedigree, adoption studies). The closer the genetic similarity, the greater the likelihood that one relative having the condition predicts the other having it as well. But as there is no “perfect” concordance, heredity is not a complete explanation.

Neurotransmitters have also been examined, with primary attention being paid to overactivity in the dopamine system. Glutamate has also recently garnered some focus, and the answer may lie in both (and perhaps other) neurotransmitter abnormalities.

Remember also the stress-vulnerability model, which noted that a genetic proclivity when combined with certain psychosocial factors may cause schizophrenia to emerge. In this model, the genetic vulnerability in the absence of eliciting environmental attributes would cause the illness to stay dormant.

Depressive Disorders

Depressive disorders, including major depressive disorder, involve extended periods of intense sadness, hopelessness, and a lack of ability to take pleasure in previously enjoyed activities. They can emerge in response to external events or show up for no discernable reason whatsoever.

When the disorder is less severe but much longer lasting, it is called persistent depressive disorder (or dysthymia).

Depressive disorders are among the most commonly diagnosed of all psychological conditions, and are typically severe enough to warrant significant therapeutic intervention. They also are often comorbid with a variety of other diagnoses.

Bipolar and Related Disorders

Table 14.3 DSM-5 Classification of Mood Disorders

Problem	Typical Signs of Trouble
Depressive Disorders
Persistent depressive disorder (dysthymia)	You feel down and depressed more days than not; your self-esteem and energy levels have been low for many months.
Major depressive disorder	You feel extremely sad, worthless, fatigued, and empty; you are unable to feel pleasure; you are having thoughts of suicide.
Bipolar and Related Disorders
Cyclothymic disorder	You have been experiencing upsetting emotional ups and downs for many months.
Bipolar I disorder	At times, you have little need for sleep, you can’t stop talking, your mind races, and everything you do is of immense importance; at other times, you feel extremely sad, worthless, and empty.
Bipolar II disorder	Most of the time, you feel extremely sad, worthless, fatigued, and empty; however, at times, you feel unusually good, cheerful, energetic, or “high.”

Source: American Psychiatric Association, 2013; Sue et al., 2017.

Those with bipolar disorder experience both periods of depression as well as mania. Mania, sometimes thought of as the opposite of depression, is an elevated, active emotional state. Read how your author distinguishes DSM’s different diagnoses of Bipolar I disorder, Bipolar II disorder, and cyclothymic disorder based on the severity and chronicity of the associated mood states.

Causes of Mood Disorders

Mood disorders have a number of possible causes, and more than one factor may be at play at the same time:

Gender: Women are diagnosed with depression about twice as often as men. This may be related to biological factors, different sex-based psychosocial stressors, or a combination of both.

Postpartum depression: When severe symptoms of depression follow childbirth, this may be the correct diagnosis.

Biological factors: Genetic factors contribute to depression, as the concordance rate for identical twins approaches 70%.

Sometimes depression emerges during times of the year when exposure to the sun is reduced. This is called seasonal affective disorder. It is sometimes treated, in part, with therapeutic exposure to certain types of light, a practice called phototherapy.

Factors Influencing Suicidality

The slippery slope of suicide

The conscious decision to end one’s life, suicide, is a serious issue that affects not only the person who dies but everyone around them. It is often associated with mental disorders, and certain factors help us understand suicide risk. Review how these factors—sex, ethnicity, age, and marital status—are related to one’s risk of developing suicidal feelings.

It is important that people know how to respond to the threat of suicide in another person. What is the best way to help? Being supportive is important, but recognizing your own limits and knowing how to get someone help is just as crucial. What is most important, however, is not doing nothing.

Anxiety Disorders

Table 14.4 DSM-5 Classification of Anxiety Disorders

Type of Disorder	Typical Signs of Trouble
Anxiety Disorders
Generalized anxiety Disorder	You have been extremely anxious or worried for six months.
Panic disorder	You are anxious much of the time and have sudden panic attacks. You are afraid that your attacks might occur in public places, so you rarely leave home.
Agoraphobia	You fear that something extremely embarrassing will happen if you leave home (but you don’t have panic attacks).
Specific phobia	You have an intense fear of particular objects, activities, or locations.
Social phobia	You fear social situations in which people can watch, criticize, embarrass, or humiliate you.

Source: American Psychiatric Association, 2013; Sue et al., 2017.

Anxiety disorders include conditions that involve chronic disruptive worry, fear, or apprehension that would be considered culturally unexpected.

Generalized anxiety disorder includes an extended period of free-floating anxiety that is not tied to any one particular trigger. They seem to worry about everything, but cannot place their finger on what it is that has them upset or concerned.

Panic disorder is marked by sudden and overwhelming attacks (panic attacks) of dread and worry that are accompanied by physical symptoms that mirror a heart attack. They can lead to a vicious cycle of worrying about the next attack which, in turn, actually can trigger an attack.

Phobias (or phobic disorders) are intense and irrational fears that center around a specific trigger (an object or situation). This is called a specific phobia. The dysfunctional nature of phobias often lies in the fact that they lead to pathological avoidance of the trigger, which in many cases can be very disruptive. Phobias can also involve social phobia and agoraphobia.

Causes of Anxiety Disorders

The major paradigms used to explain anxiety disorders are briefly summarized here:

Psychodynamic approach—anxiety causes unconscious conflicts that intrude upon our conscious life.

Humanistic-existential approach—Faulty self-images lead to anxious symptoms, or the anxiety of existential realities overwhelm us.

Behavioral approach—Learning and conditioning teach us that anxiety is a normal response to different life situations.

Cognitive approach—Distorted thinking processes lead us to misinterpret or misevaluate situations.

Is the best answer located in one of these models or a combination of them all?

Obsessive-Compulsive and Related Disorders

Obsessive-compulsive disorder (OCD) includes repeating intrusive thoughts that increase anxiety (obsessions), which are often followed by repetitive ritualistic behaviors (compulsions) that feel like they are venting that anxiety.

A related condition is hoarding disorder, which is when a person focuses “obsessively” on obtaining and keeping various items. Older models suggest that obsessions give rise to compulsions, but a more recent “COD” model suggests exactly the opposite direction of cause.

Trauma- and Stressor-Related Disorders

Pathological responses to upsetting or traumatic events can lead to ongoing psychological symptoms. Before we discuss the different diagnoses, make sure to avoid the belief that those who fight these symptoms are in some way weaker than those who don’t. There is no way to predict who will or will not respond to traumatic events with ongoing symptoms.

Adjustment disorders are when typical or usual experiences push people beyond normal reaction ranges.

Acute stress disorder or (the longer lasting) post-traumatic stress disorder (PTSD) involve problematic symptoms—nightmares, flashbacks, unwanted memories, etc.—in response to an upsetting or traumatic event.

Dissociative Disorders

Disruptions in memory, consciousness, or identity typify dissociative disorders, which take their name from the separation (or “dissociation”) that they involve.

Dissociative amnesia includes a loss of memory of personally relevant information that exceeds the boundaries of normal forgetting processes. They can, but do not always, involve a person leaving home and/or adopting a new identity (a dissociative fugue).

Dissociative identity disorder (formerly called multiple personality disorder) includes the development of two or more identities in the same individual. It is a highly controversial diagnosis, both in terms of how it develops as well as whether it even truly exists. Abusive histories have been offered as an explanation for dissociative disorders, but it many who have been abused do not develop such a disorder, and some with the disorders have no abuse history.

Somatic Symptom and Related Disorders

Glove anesthesia

Somatic symptom disorders (and their related diagnoses) occur when physical symptoms appear that have no identifiable physical cause.

Somatic symptom disorder involves symptoms of several older diagnoses, including hypochondriasis somatization disorder, and pain disorder.

Those who intentionally cause symptoms in themselves or others might be diagnosed with factitious disorder.

In conversion disorder, a person experiences a loss of function in a major body part or system (e.g., blindness or physical insensitivity) that has no physical cause or explanation.

Clearly diagnosing these problems is complicated, as it is important that we do not assess true physical problems as psychological in nature. They also do not reflect a person “faking” symptoms but rather truly believing that their physical complaints are real, even if they are not.

Maladaptive Personality Patterns (1 of 2)

Table 14.6 DSM-5 Classification of Personality Disorders

Type of Personality Disorder	Typical Signs of Trouble
Paranoid	You deeply distrust others and are suspiciousness of their motives, which you perceive as insulting or threatening.
Schizoid	You feel very little emotion and can’t form close personal relationships with others.
Schizotypal	You are a loner, you engage in extremely odd behavior, and your thought patterns are bizarre, but you are not actively psychotic.
Antisocial	You are irresponsible, lack guilt or remorse, and engage in antisocial behavior, such as aggression, deceit, or recklessness.
Borderline	Your self-image, moods, and impulses are erratic, and you are extremely sensitive to any hint of criticism, rejection, or abandonment by others.
Histrionic	You are dramatic and flamboyant; you exaggerate your emotions to get attention from others.

Personality disorders are longstanding, inflexible ways of interacting with others that create a variety of problems.

Maladaptive Personality Patterns (2 of 2)

Type of Personality Disorder	Typical Signs of Trouble
Narcissistic	You think that you are wonderful, brilliant, important, and worthy of constant admiration.
Avoidant	You are timid and uncomfortable in social situations and fear evaluation.
Dependent	You lack confidence, and you are extremely submissive and rely on others excessively (clinging).
Obsessive-compulsive	You demand order, perfection, control, and rigid routine at all times.

Source: American Psychiatric Association, 2013; Sue et al., 2017.

Personality disorders are longstanding, inflexible ways of interacting with others that create a variety of problems.

Antisocial Personality Disorder

Antisocial personality disorder is marked by impulsive behaviors that violate the basic rights of others and the norms and rules of society. Many believe that “antisocial” equates to wanting to be separated from others, but that is inaccurate.

People with this disorder manipulate and use others for their own benefit, lack empathy for the harm that they cause others, and focus almost entirely on their own needs and desires. There is typically a history of harmful or aggressive behaviors going back to childhood.