psychological science paper

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Chapter 12

Defining Psychological Disorders When Minor Body Imperfections Lead to Suicide

“I think we probably noticed in his early teens that he became very conscious about aspects of his appearance…he

began to brood over it quite a lot,” said Maria as she called in to the talk radio program to describe her son Robert.

Maria described how Robert had begun to worry about his weight. A friend had commented that he had a “fat”

stomach, and Robert began to cut down on eating. Then he began to worry that he wasn’t growing enough and

devised an elaborate series of stretching techniques to help him get taller.

Robert scrutinized his face and body in the mirror for hours, finding a variety of imagined defects. He believed that

his nose was crooked, and he was particularly concerned about a lump that he saw on it: “A small lump,” said his

mother. “I should say it wasn’t very significant, but it was significant to him.”

Robert insisted that all his misery stemmed from this lump on his nose, that everybody noticed it. In his sophomore

year of high school, he had cosmetic surgery to remove it.

Around this time, Robert had his first panic attack and began to worry that everybody could notice him sweating and

blushing in public. He asked his parents for a $10,000 loan, which he said was for overseas study. He used the money

for a procedure designed to reduce sweating and blushing. Then, dissatisfied with the results, he had the procedure

reversed.

Robert was diagnosed with body dysmorphic disorder. His mother told the radio host,

At the time we were really happy because we thought that finally we actually knew what we were trying to

fight and to be quite honest, I must admit I thought well it sounds pretty trivial.…

…Things seemed to go quite well and he got a new girlfriend and he was getting excellent marks in his

clinical work in hospital and he promised us that he wasn't going to have any more surgery.

However, a lighthearted comment from a friend about a noticeable vein in his forehead prompted a relapse. Robert

had surgery to tie off the vein. When that didn’t solve all his problems as he had hoped, he attempted to have the

procedure reversed but learned that it would require complicated microsurgery. He then used injections on himself to

try opening the vein again, but he could never completely reverse the first surgery.

Robert committed suicide shortly afterward, in 2001 (Mitchell, 2002). [1]

[1] Mitchell, N. (Producer). (2002, April 28). Body dysmorphic disorder and cosmetic “surgery of the psyche.” All in the mind.

ABC Radio National. Retrieved fromhttp://www.abc.net.au/rn/allinthemind/stories/2003/746058.htm

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12.1 Psychological Disorder: What Makes a Behavior “Abnormal”? L E A R N I N G O B J E C T I V E S

1. Define “psychological disorder” and summarize the general causes of disorder.

2. Explain why it is so difficult to define disorder, and how the Diagnostic and Statistical Manual of Mental

Disorders (DSM) is used to make diagnoses.

3. Describe the stigma of psychological disorders and their impact on those who suffer from them.

The focus of the next two chapters is to many people the heart of psychology. This emphasis

on abnormal psychology—the application of psychological science to understanding and

treating mental disorders—is appropriate, as more psychologists are involved in the diagnosis

and treatment of psychological disorder than in any other endeavor, and these are probably the

most important tasks psychologists face. About 1 in every 4 Americans (or over 78 million

people) are affected by a psychological disorder during any one year (Kessler, Chiu, Demler, &

Walters, 2005), [1]

and at least a half billion people are affected worldwide. The impact of mental

illness is particularly strong on people who are poorer, of lower socioeconomic class, and from

disadvantaged ethnic groups.

People with psychological disorders are also stigmatized by the people around them, resulting in

shame and embarrassment, as well as prejudice and discrimination against them. Thus the

understanding and treatment of psychological disorder has broad implications for the everyday

life of many people. Table 12.1 "One-Year Prevalence Rates for Psychological Disorders in the

United States, 2001–2003" shows the prevalence (i.e., the frequency of occurrence of a given

condition in a population at a given time) of some of the major psychological disorders in the

United States.

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Table 12.1 One-Year Prevalence Rates for Psychological Disorders in the United States, 2001–2003

Disease Percentage affected Number affected

Any mental disorder 26.2 81,744,000

Any anxiety disorder 18.1 56,472,000

Specific phobia 8.7 27,144,000

Social phobia 6.8 21,216,000

Agoraphobia 0.8 2,496,000

Generalized anxiety disorder 3.1 9,672,000

Panic disorder 2.7 8,424,000

Obsessive-compulsive disorder 1.0 3,120,000

Posttraumatic stress disorder 3.5 10,920,000

Any mood disorder 9.5 29,640,000

Major depressive disorder 6.7 20,904,000

Bipolar disorder 2.6 8,112,000

Schizophrenia 1.0 3,120,000

Personality disorders

Antisocial personality disorder 1.5 4,680,000

Borderline personality disorder 1.5 4,680,000

Anorexia nervosa 0.1 312,000

Any substance abuse disorder 3.8 11,856,000

Alcohol use disorder 4.4 13,728,000

Drug use disorder 1.8 5,616,000

All cancers* 5.4 16,848,000

Diabetes* 10.7 33,348,000

* These nonpsychological conditions are included for comparison.

Sources: Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-

month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6),

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617–627; Narrow, W. E., Rae, D. S., Robins, L. N., & Regier, D. A. (2002). Revised prevalence based estimates of

mental disorders in the United States: Using a clinical significance criterion to reconcile 2 surveys’ estimates.Archives

of General Psychiatry, 59(2), 115–123.

In this chapter our focus is on the disorders themselves. We will review the major psychological

disorders and consider their causes and their impact on the people who suffer from them. Then

in Chapter 13 "Treating Psychological Disorders", we will turn to consider the treatment of these

disorders through psychotherapy and drug therapy.

Defining Disorder

A psychological disorder is an ongoing dysfunctional pattern of thought, emotion, and behavior

that causes significant distress, and that is considered deviant in that person’s culture or

society (Butcher, Mineka, & Hooley, 2007). [2]

Psychological disorders have much in common

with other medical disorders. They are out of the patient’s control, they may in some cases be

treated by drugs, and their treatment is often covered by medical insurance. Like medical

problems, psychological disorders have both biological (nature) as well as environmental

(nurture) influences. These causal influences are reflected in the bio-psycho-social model of

illness (Engel, 1977). [3]

The bio-psycho-social model of illness is a way of understanding disorder that assumes that

disorder is caused by biological, psychological, and social factors (Figure 12.1 "The Bio-

Psycho-Social Model"). The biological componentof the bio-psycho-social model refers to the

influences on disorder that come from the functioning of the individual’s body. Particularly

important are genetic characteristics that make some people more vulnerable to a disorder than

others and the influence of neurotransmitters. The psychological component of the bio-psycho-

social model refers to the influences that come from the individual, such as patterns of negative

thinking and stress responses. Thesocial component of the bio-psycho-social model refers to the

influences on disorder due to social and cultural factors such as socioeconomic status,

homelessness, abuse, and discrimination.

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Figure 12.1 The Bio-Psycho-Social Model

The bio-psycho-social model of disorder proposes that disorders are caused by biological, psychological, and social-

cultural factors.

To consider one example, the psychological disorder of schizophrenia has a biological cause

because it is known that there are patterns of genes that make a person vulnerable to the disorder

(Gejman, Sanders, & Duan, 2010). [4]

But whether or not the person with a biological

vulnerability experiences the disorder depends in large part on psychological factors such as how

the individual responds to the stress he experiences, as well as social factors such as whether or

not he is exposed to stressful environments in adolescence and whether or not he has support

from people who care about him (Sawa & Snyder, 2002; Walker, Kestler, Bollini, & Hochman,

2004). [5]

Similarly, mood and anxiety disorders are caused in part by genetic factors such as

hormones and neurotransmitters, in part by the individual’s particular thought patterns, and in

part by the ways that other people in the social environment treat the person with the disorder.

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We will use the bio-psycho-social model as a framework for considering the causes and

treatments of disorder.

Although they share many characteristics with them, psychological disorders are nevertheless

different from medical conditions in important ways. For one, diagnosis of psychological

disorders can be more difficult. Although a medical doctor can see cancer in the lungs using an

MRI scan or see blocked arteries in the heart using cardiac catheterization, there is no

corresponding test for psychological disorder. Current research is beginning to provide more

evidence about the role of brain structures in psychological disorder, but for now the brains of

people with severe mental disturbances often look identical to those of people without such

disturbances.

Because there are no clear biological diagnoses, psychological disorders are instead diagnosed

on the basis of clinical observations of the behaviors that the individual engages in. These

observations find that emotional states and behaviors operate on a continuum, ranging from more

―normal‖ and ―accepted‖ to more ―deviant,‖ ―abnormal,‖ and ―unaccepted.‖ The behaviors that

are associated with disorder are in many cases the same behaviors we that engage in our

―normal‖ everyday life. Washing one’s hands is a normal healthy activity, but it can be overdone

by those with an obsessive-compulsive disorder (OCD). It is not unusual to worry about and try

to improve one’s body image, but Robert’s struggle with his personal appearance, as discussed at

the beginning of this chapter, was clearly unusual, unhealthy, and distressing to him.

Whether a given behavior is considered a psychological disorder is determined not only by

whether a behavior is unusual (e.g., whether it is ―mild‖ anxiety versus ―extreme‖ anxiety) but

also by whether a behavior is maladaptive—that is, the extent to which it causes distress (e.g.,

pain and suffering) and dysfunction (impairment in one or more important areas of functioning)

to the individual (American Psychiatric Association, 2000). [6]

An intense fear of spiders, for

example, would not be considered a psychological disorder unless it has a significant negative

impact on the sufferer’s life, for instance by causing him or her to be unable to step outside the

house. The focus on distress and dysfunction means that behaviors that are simply unusual (such

as some political, religious, or sexual practices) are not classified as disorders.

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Put your psychology hat on for a moment and consider the behaviors of the people listed

in Table 12.2 "Diagnosing Disorder". For each, indicate whether you think the behavior is or is

not a psychological disorder. If you’re not sure, what other information would you need to know

to be more certain of your diagnosis?

Table 12.2 Diagnosing Disorder

Yes No

Need more

information Description

Jackie frequently talks to herself while she is working out her math homework. Her

roommate sometimes hears her and wonders if she is OK.

Charlie believes that the noises made by cars and planes going by outside his house

have secret meanings. He is convinced that he was involved in the start of a nuclear

war and that the only way for him to survive is to find the answer to a difficult riddle.

Harriet gets very depressed during the winter months when the light is low. She

sometimes stays in her pajamas for the whole weekend, eating chocolate and

watching TV.

Frank seems to be afraid of a lot of things. He worries about driving on the highway

and about severe weather that may come through his neighborhood. But mostly he

fears mice, checking under his bed frequently to see if any are present.

A worshipper speaking in ―tongues‖ at an Evangelical church views himself as

―filled‖ with the Holy Spirit and is considered blessed with the gift to speak the

―language of angels.‖

A trained clinical psychologist would have checked off ―need more information‖ for each of the

examples in Table 12.2 "Diagnosing Disorder" because although the behaviors may seem

unusual, there is no clear evidence that they are distressing or dysfunctional for the person.

Talking to ourselves out loud is unusual and can be a symptom of schizophrenia, but just because

we do it once in a while does not mean that there is anything wrong with us. It is natural to be

depressed, particularly in the long winter nights, but how severe should this depression be, and

how long should it last? If the negative feelings last for an extended time and begin to lead the

person to miss work or classes, then they may become symptoms of a mood disorder. It is

normal to worry about things, but when does worry turn into a debilitating anxiety disorder? And

what about thoughts that seem to be irrational, such as being able to ―speak the language of

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angels‖? Are they indicators of a severe psychological disorder, or part of a normal religious

experience? Again, the answer lies in the extent to which they are (or are not) interfering with the

individual’s functioning in society.

Another difficulty in diagnosing psychological disorders is that they frequently occur together.

For instance, people diagnosed with anxiety disorders also often have mood disorders (Hunt,

Slade, & Andrews, 2004), [7]

and people diagnosed with one personality disorder frequently

suffer from other personality disorders as well. Comorbidity occurs when people who suffer from

one disorder also suffer at the same time from other disorders. Because many psychological

disorders are comorbid, most severe mental disorders are concentrated in a small group of people

(about 6% of the population) who have more than three of them (Kessler, Chiu, Demler, &

Walters, 2005). [8]

Psychology in Everyday Life: Combating the Stigma of Abnormal Behavior

Every culture and society has its own views on what constitutes abnormal behavior and what causes it (Brothwell,

1981). [9]

The Old Testament Book of Samuel tells us that as a consequence of his sins, God sent King Saul an evil spirit

to torment him (1 Samuel 16:14). Ancient Hindu tradition attributed psychological disorder to sorcery and witchcraft.

During the Middle Ages it was believed that mental illness occurred when the body was infected by evil spirits,

particularly the devil. Remedies included whipping, bloodletting, purges, and trepanation (cutting a hole in the skull)

to release the demons.

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Figure 12.3

Trepanation (drilling holes in the skull) has been used since prehistoric times in attempts to cure epilepsy,

schizophrenia, and other psychological disorders.

Source: Courtesy of Peter Treveris,http://commons.wikimedia.org/wiki/File:Peter_Treveris_-_

engraving_of_Trepanation_for_Handywarke_of_surgeri_1525.png.

Until the 18th century, the most common treatment for the mentally ill was to incarcerate them in

asylums or ―madhouses.‖ During the 18th century, however, some reformers began to oppose

this brutal treatment of the mentally ill, arguing that mental illness was a medical problem that

had nothing to do with evil spirits or demons. In France, one of the key reformers was Philippe

Pinel (1745–1826), who believed that mental illness was caused by a combination of physical

and psychological stressors, exacerbated by inhumane conditions. Pinel advocated the

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introduction of exercise, fresh air, and daylight for the inmates, as well as treating them gently

and talking with them. In America, the reformers Benjamin Rush (1745–1813) and Dorothea Dix

(1802–1887) were instrumental in creating mental hospitals that treated patients humanely and

attempted to cure them if possible. These reformers saw mental illness as an underlying

psychological disorder, which was diagnosed according to its symptoms and which could be

cured through treatment.

Despite the progress made since the 1800s in public attitudes about those who suffer from psychological disorders,

people, including police, coworkers, and even friends and family members, still stigmatize people with psychological

disorders. A stigma refers to a disgrace or defect that indicates that person belongs to a culturally devalued social

group. In some cases the stigma of mental illness is accompanied by the use of disrespectful and dehumanizing labels,

including names such as “crazy,” “nuts,” “mental,” “schizo,” and “retard.”

The stigma of mental disorder affects people while they are ill, while they are healing, and even after they have healed

(Schefer, 2003). [10]

On a community level, stigma can affect the kinds of services social service agencies give to people

with mental illness, and the treatment provided to them and their families by schools, workplaces, places of worship,

and health-care providers. Stigma about mental illness also leads to employment discrimination, despite the fact that

with appropriate support, even people with severe psychological disorders are able to hold a job (Boardman, Grove,

Perkins, & Shepherd, 2003; Leff & Warner, 2006; Ozawa & Yaeda, 2007; Pulido, Diaz, & Ramirez, 2004). [11]

The mass media has a significant influence on society’s attitude toward mental illness (Francis, Pirkis, Dunt, & Blood,

2001). [12]

While media portrayal of mental illness is often sympathetic, negative stereotypes still remain in

newspapers, magazines, film, and television. (See the following video for an example.)

Television advertisements may perpetuate negative stereotypes about the mentally ill. Burger King recently ran an ad

called “The King’s Gone Crazy,” in which the company’s mascot runs around an office complex carrying out acts of

violence and wreaking havoc.

The most significant problem of the stigmatization of those with psychological disorder is that it slows their recovery.

People with mental problems internalize societal attitudes about mental illness, often becoming so embarrassed or

ashamed that they conceal their difficulties and fail to seek treatment. Stigma leads to lowered self-esteem, increased

isolation, and hopelessness, and it may negatively influence the individual’s family and professional life (Hayward &

Bright, 1997). [13]

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Despite all of these challenges, however, many people overcome psychological disorders and go on to lead productive

lives. It is up to all of us who are informed about the causes of psychological disorder and the impact of these

conditions on people to understand, first, that mental illness is not a “fault” any more than is cancer. People do not

choose to have a mental illness. Second, we must all work to help overcome the stigma associated with disorder.

Organizations such as the National Alliance on Mental Illness (NAMI; n.d.), [14]

for example, work to reduce the

negative impact of stigma through education, community action, individual support, and other techniques.

Diagnosing Disorder: The DSM

Psychologists have developed criteria that help them determine whether behavior should be

considered a psychological disorder and which of the many disorders particular behaviors

indicate. These criteria are laid out in a 1,000-page manual known as

theDiagnostic and Statistical Manual of Mental Disorders (DSM), a document that provides a

common language and standard criteria for the classification of mental disorders (American

Psychiatric Association, 2000). [15]

The DSM is used by therapists, researchers, drug companies,

health insurance companies, and policymakers in the United States to determine what services

are appropriately provided for treating patients with given symptoms.

The first edition of the DSM was published in 1952 on the basis of census data and psychiatric

hospital statistics. Since then, the DSM has been revised five times. The last major revision was

the fourth edition (DSM-IV), published in 1994, and an update of that document was produced in

2000 (DSM-IV-TR). The fifth edition (DSM-V) is currently undergoing review, planning, and

preparation and is scheduled to be published in 2013. The DSM-IV-TR was designed in

conjunction with the World Health Organization’s 10th version of the International

Classification of Diseases (ICD-10), which is used as a guide for mental disorders in Europe and

other parts of the world.

As you can see in Figure 12.7, the DSM organizes the diagnosis of disorder according to five

dimensions (or axes) relating to different aspects of disorder or disability. The axes are important

to remember when we think about psychological disorder, because they make it clear not only

that there are different types of disorder, but that those disorders have a variety of different

causes. Axis I includes the most usual clinical disorders, including mood disorders and anxiety

disorders; Axis II includes the less severe but long-lasting personality disorders as well as mental

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retardation; Axis III and Axis IV relate to physical symptoms and social-cultural factors,

respectively. The axes remind us that when making a diagnosis we must look at the complete

picture, including biological, personal, and social-cultural factors.

Figure 12.7

The DSM organizes psychological disorders into five dimensions (known as axes) that concern the different aspects

of disorder.

Source: Adapted from American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

disorders (4th ed., text rev.). Washington, DC: Author.

The DSM does not attempt to specify the exact symptoms that are required for a diagnosis.

Rather, the DSM uses categories, and patients whose symptoms are similar to the description of

the category are said to have that disorder. TheDSM frequently uses qualifiers to indicate

different levels of severity within a category. For instance, the disorder of mental retardation can

be classified as mild, moderate, or severe.

Each revision of the DSM takes into consideration new knowledge as well as changes in cultural

norms about disorder. Homosexuality, for example, was listed as a mental disorder in

the DSM until 1973, when it was removed in response to advocacy by politically active gay

rights groups and changing social norms. The current version of the DSM lists about 400

disorders. Some of the major categories are shown in Table 12.3 "Categories of Psychological

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Disorders Based on the ", and you may go to http://en.wikipedia.org/wiki/DSM-

IV_Codes_(alphabetical) and browse the complete list.

Table 12.3 Categories of Psychological Disorders Based on the DSM

Category and description Examples

Disorders diagnosed in infancy and childhood

Mental retardation

Communication, conduct, elimination, feeding, learning, and

motor skills disorders

Autism spectrum disorders

Attention-deficit and disruptive behavior disorders including

attention-deficit/hyperactivity disorder (ADHD)

Separation anxiety disorder

Delirium, dementia, and amnesia (forgetting or memory

distortions caused by physical factors)

Delirium

Dementia and Alzheimer disease

Dissociative disorders (forgetting or memory distortions

that do not involve physical factors)

Dissociative amnesia

Dissociative fugue

Dissociative identity disorder (―multiple personality‖)

Substance abuse disorders

Alcohol abuse

Drug abuse

Caffeine abuse

Schizophrenia and other psychotic disorders

Mood disorders

Mood disorder

Major depressive disorder

Bipolar disorder

Anxiety disorders

Generalized anxiety disorder

Panic disorder

Specific phobia including agoraphobia

Obsessive-compulsive disorder (OCD)

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Category and description Examples

Posttraumatic stress disorder (PTSD)

Somatoform disorders (physical symptoms that do not

have a clear physical cause and thus must be

psychological in origin)

Conversion disorder

Pain disorder

Hypochondriasis

Body dysmorphic disorder (BDD)

Factitious disorders (conditions in which a person acts as

if he or she has an illness by deliberately producing,

feigning, or exaggerating symptoms)

Sexual disorders

Sexual dysfunctions including erectile and orgasmic disorders

Paraphilias

Gender identity disorders

Sexual abuse

Eating disorders

Anorexia nervosa

Bulimia nervosa

Sleep disorders

Narcolepsy

Sleep apnea

Impulse-control disorders

Kleptomania (stealing)

Pyromania (fire lighting)

Pathological gambling (addiction)

Personality disorders

Cluster A (odd or eccentric behaviors)

Paranoid personality disorder

Schizoid personality disorder

Schizotypal personality disorder

Cluster B (dramatic, emotional, or erratic behaviors)

Antisocial personality disorder

Borderline personality disorder

Histrionic personality disorder

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Category and description Examples

Narcissistic personality disorder

Cluster C (anxious or fearful behaviors)

Avoidant personality disorder

Dependent personality disorder

Obsessive-compulsive personality disorder

Other disorders

Includes academic problems, antisocial behavior, bereavement,

child neglect, occupational problems, relational problems,

physical abuse, and malingering

Although the DSM has been criticized regarding the nature of its categorization system (and it is

frequently revised to attempt to address these criticisms), for the fact that it tends to classify

more behaviors as disorders with every revision (even ―academic problems‖ are now listed as a

potential psychological disorder), and for the fact that it is primarily focused on Western illness,

it is nevertheless a comprehensive, practical, and necessary tool that provides a common

language to describe disorder. Most U.S. insurance companies will not pay for therapy unless the

patient has a DSM diagnosis. The DSM approach allows a systematic assessment of the patient,

taking into account the mental disorder in question, the patient’s medical condition,

psychological and cultural factors, and the way the patient functions in everyday life.

Diagnosis or Overdiagnosis? ADHD, Autistic Disorder, and Asperger’s Disorder

Two common critiques of the DSM are that the categorization system leaves quite a bit of

ambiguity in diagnosis and that it covers such a wide variety of behaviors. Let’s take a closer

look at three common disorders—attention-deficit/hyperactivity disorder (ADHD), autistic

disorder, and Asperger’s disorder—that have recently raised controversy because they are being

diagnosed significantly more frequently than they were in the past.

Attention-Deficit/Hyperactivity Disorder (ADHD)

Zack, aged 7 years, has always had trouble settling down. He is easily bored and distracted. In

school, he cannot stay in his seat for very long and he frequently does not follow instructions. He

is constantly fidgeting or staring into space. Zack has poor social skills and may overreact when

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someone accidentally bumps into him or uses one of his toys. At home, he chatters constantly

and rarely settles down to do a quiet activity, such as reading a book.

Symptoms such as Zack’s are common among 7-year-olds, and particularly among boys. But

what do the symptoms mean? Does Zack simply have a lot of energy and a short attention span?

Boys mature more slowly than girls at this age, and perhaps Zack will catch up in the next few

years. One possibility is for the parents and teachers to work with Zack to help him be more

attentive, to put up with the behavior, and to wait it out.

But many parents, often on the advice of the child’s teacher, take their children to a psychologist

for diagnosis. If Zack were taken for testing today, it is very likely that he would be diagnosed

with a psychological disorder known asattention-deficit/hyperactivity disorder (ADHD). ADHD

is a developmental behavior disorder characterized by problems with focus, difficulty

maintaining attention, and inability to concentrate, in which symptoms start before 7 years of

age (American Psychiatric Association, 2000; National Institute of Mental Health,

2010). [16]

Although it is usually first diagnosed in childhood, ADHD can remain problematic in

adults, and up to 7% of college students are diagnosed with it (Weyandt & DuPaul, 2006). [17]

In

adults the symptoms of ADHD include forgetfulness, difficulty paying attention to details,

procrastination, disorganized work habits, and not listening to others. ADHD is about 70% more

likely to occur in males than in females (Kessler, Chiu, Demler, & Walters, 2005), [18]

and is

often comorbid with other behavioral and conduct disorders.

The diagnosis of ADHD has quadrupled over the past 20 years such that it is now diagnosed in

about 1 out of every 20 American children and is the most common psychological disorder

among children in the world (Olfson, Gameroff, Marcus, & Jensen, 2003). [19]

ADHD is also

being diagnosed much more frequently in adolescents and adults (Barkley, 1998). [20]

You might

wonder what this all means. Are the increases in the diagnosis of ADHD due to the fact that

today’s children and adolescents are actually more distracted and hyperactive than their parents

were, due to a greater awareness of ADHD among teachers and parents, or due to psychologists

and psychiatrists’ tendency to overdiagnose the problem? Perhaps drug companies are also

involved, because ADHD is often treated with prescription medications, including stimulants

such as Ritalin.

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Although skeptics argue that ADHD is overdiagnosed and is a handy excuse for behavioral

problems, most psychologists believe that ADHD is a real disorder that is caused by a

combination of genetic and environmental factors. Twin studies have found that ADHD is

heritable (National Institute of Mental Health, 2008), [21]

and neuroimaging studies have found

that people with ADHD may have structural differences in areas of the brain that influence self-

control and attention (Seidman, Valera, & Makris, 2005). [22]

Other studies have also pointed to

environmental factors, such as mothers’ smoking and drinking alcohol during pregnancy and the

consumption of lead and food additives by those who are affected (Braun, Kahn, Froehlich,

Auinger, & Lanphear, 2006; Linnet et al., 2003; McCann et al., 2007). [23]

Social factors, such as

family stress and poverty, also contribute to ADHD (Burt, Krueger, McGue, & Iacono, 2001). [24]

Autistic Disorder and Asperger’s Disorder

Jared’s kindergarten teacher has voiced her concern to Jared’s parents about his difficulties with

interacting with other children and his delay in developing normal language. Jared is able to

maintain eye contact and enjoys mixing with other children, but he cannot communicate with

them very well. He often responds to questions or comments with long-winded speeches about

trucks or some other topic that interests him, and he seems to lack awareness of other children’s

wishes and needs.

Jared’s concerned parents took him to a multidisciplinary child development center for

consultation. Here he was tested by a pediatric neurologist, a psychologist, and a child

psychiatrist.

The pediatric neurologist found that Jared’s hearing was normal, and there were no signs of any

neurological disorder. He diagnosed Jared with a pervasive developmental disorder, because

while his comprehension and expressive language was poor, he was still able to carry out

nonverbal tasks, such as drawing a picture or doing a puzzle.

Based on her observation of Jared’s difficulty interacting with his peers, and the fact that he did

not respond warmly to his parents, the psychologist diagnosed Jared

with autistic disorder (autism), a disorder of neural development characterized by impaired

social interaction and communication and by restricted and repetitive behavior, and in which

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symptoms begin before 7 years of age. The psychologist believed that the autism diagnosis was

correct because, like other children with autism, Jared, has a poorly developed ability to see the

world from the perspective of others; engages in unusual behaviors such as talking about trucks

for hours; and responds to stimuli, such as the sound of a car or an airplane, in unusual ways.

The child psychiatrist believed that Jared’s language problems and social skills were not severe

enough to warrant a diagnosis of autistic disorder and instead proposed a diagnosis

of Asperger’s disorder, a developmental disorder that affects a child’s ability to socialize and

communicate effectively with others and in which symptoms begin before 7 years of age. The

symptoms of Asperger’s are almost identical to that of autism (with the exception of a delay in

language development), and the child psychiatrist simply saw these problems as less extreme.

Imagine how Jared’s parents must have felt at this point. Clearly there is something wrong with

their child, but even the experts cannot agree on exactly what the problem is. Diagnosing

problems such as Jared’s is difficult, yet the number of children like him is increasing

dramatically. Disorders related to autism and Asperger’s disorder now affect almost 1% of

American children (Kogan et al., 2007). [25]

The milder forms of autism, and particularly

Asperger’s, have accounted for most of this increase in diagnosis.

Although for many years autism was thought to be primarily a socially determined disorder, in

which parents who were cold, distant, and rejecting created the problem, current research

suggests that biological factors are most important. The heritability of autism has been estimated

to be as high as 90% (Freitag, 2007). [26]

Scientists speculate that autism is caused by an

unknown genetically determined brain abnormality that occurs early in development. It is likely

that several different brain sites are affected (Moldin, 2003), [27]

and the search for these areas is

being conducted in many scientific laboratories.

But does Jared have autism or Asperger’s? The problem is that diagnosis is not exact (remember

the idea of ―categories‖), and the experts themselves are often unsure how to classify behavior.

Furthermore, the appropriate classifications change with time and new knowledge. The

American Psychiatric Association has recently posted on its website a proposal to eliminate the

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term Asperger’s syndrome from the upcoming DSM-V. Whether or not Asperger’s will remain a

separate disorder will be made known when the next DSM-V is published in 2013.

K E Y T A K E A W A Y S

 More psychologists are involved in the diagnosis and treatment of psychological disorder than in any other endeavor,

and those tasks are probably the most important psychologists face.

 The impact on people with a psychological disorder comes both from the disease itself and from the stigma associated

with disorder.

 A psychological disorder is an ongoing dysfunctional pattern of thought, emotion, and behavior that causes significant

distress and that is considered deviant in that person’s culture or society.

 According to the bio-psycho-social model, psychological disorders have biological, psychological, and social causes.

 It is difficult to diagnose psychological disorders, although the DSMprovides guidelines that are based on a category

system. The DSM is frequently revised, taking into consideration new knowledge as well as changes in cultural norms

about disorder.

 There is controversy about the diagnosis of disorders such as ADHD, autistic disorder, and Asperger’s disorder.

E X E R C I S E S A N D C R I T I C A L T H I N K I N G

1. Do you or your friends hold stereotypes about the mentally ill? Can you think of or find clips from any films or other

popular media that portray mental illness positively or negatively? Is it more or less acceptable to stereotype the

mentally ill than to stereotype other social groups?

2. Consider the psychological disorders listed in Table 12.3 "Categories of Psychological Disorders Based on the ". Do you

know people who may suffer from any of them? Can you or have you talked to them about their experiences? If so,

how do they experience the illness?

3. Consider the diagnosis of ADHD, autism, and Asperger’s disorder from the biological, personal, and social-cultural

perspectives. Do you think that these disorders are overdiagnosed? How might clinicians determine if ADHD is

dysfunctional or distressing to the individual?

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[1] Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-

IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–627.

[2] Butcher, J., Mineka, S., & Hooley, J. (2007). Abnormal psychology and modern life (13th ed.). Boston, MA: Allyn & Bacon.

[3] Engel, G. (1977). The need for a new medical model: A challenge for biomedicine.Science, 196(4286), 129.

doi:10.1126/science.847460

[4] Gejman, P., Sanders, A., & Duan, J. (2010). The role of genetics in the etiology of schizophrenia. Psychiatric Clinics of North

America, 33(1), 35–66. doi:10.1016/j.psc.2009.12.003

[5] Sawa, A., & Snyder, S. (2002). Schizophrenia: Diverse approaches to a complex disease.Science, 296(5568), 692–695.

doi:10.1126/science.1070532; Walker, E., Kestler, L., Bollini, A., & Hochman, K. (2004). Schizophrenia: Etiology and

course. Annual Review of Psychology, 55, 401–430. doi:10.1146/annurev.psych.55.090902.141950

[6] American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.).

Washington, DC: Author.

[7] Hunt, C., Slade, T., & Andrews, G. (2004). Generalized anxiety disorder and major depressive disorder comorbidity in the

National Survey of Mental Health and Well Being.Depression and Anxiety, 20, 23–31.

[8] Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-

IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–627.

[9] Brothwell, D. (1981). Digging up bones: The excavation, treatment, and study of human skeletal remains. Ithaca, NY: Cornell

University Press.

[10] Schefer, R. (2003, May 28). Addressing stigma: Increasing public understanding of mental illness. Presented to the Standing

Senate Committee on Social Affairs, Science and Technology. Retrieved

fromhttp://www.camh.net/education/Resources_communities_organizations/addressing_stigma_senatepres03.pdf

[11] Boardman, J., Grove, B., Perkins, R., & Shepherd, G. (2003). Work and employment for people with psychiatric

disabilities. British Journal of Psychiatry, 182(6), 467–468. doi:10.1192/bjp.182.6.467; Leff, J., & Warner, R. (2006). Social

inclusion of people with mental illness. New York, NY: Cambridge University Press; Ozawa, A., & Yaeda, J. (2007). Employer

attitudes toward employing persons with psychiatric disability in Japan.Journal of Vocational Rehabilitation, 26(2), 105–113;

Pulido, F., Diaz, M., & Ramírez, M. (2004). Work integration of people with severe mental disorder: A pending question.Revista

Psiquis, 25(6), 26–43.

[12] Francis, C., Pirkis, J., Dunt, D., & Blood, R. (2001). Mental health and illness in the media: A review of the literature.

Canberra, Australia: Commonwealth Department of Health & Aged Care.

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[13] Hayward, P., & Bright, J. (1997). Stigma and mental illness: A review and critique.Journal of Mental Health, 6(4), 345–354.

[14] National Alliance on Mental Illness. (n.d.). Fight stigma. Retrieved

fromhttp://www.nami.org/template.cfm?section=fight_stigma

[15] American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.).

Washington, DC: Author.

[16] American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.).

Washington, DC: Author; National Institute of Mental Health. (2010). Attention-deficit hyperactivity disorder (ADHD). Retrieved

fromhttp://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml

[17] Weyandt, L. L., & DuPaul, G. (2006). ADHD in college students. Journal of Attention Disorders, 10(1), 9–19.

[18] Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-

IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–627.

[19] Olfson, M., Gameroff, M., Marcus, S., & Jensen, P. (2003). National trends in the treatment of attention deficit

hyperactivity disorder. American Journal of Psychiatry, 160, 1071–1077.

[20] Barkley, R. A. (1998). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (2nd ed.). New York,

NY: Guilford Press.

[21] National Institute of Mental Health. (2010). Attention-deficit hyperactivity disorder (ADHD). Retrieved

from http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml

[22] Seidman, L., Valera, E., & Makris, N. (2005). Structural brain imaging of attention deficit/hyperactivity disorder. Biological

Psychiatry, 57, 1263–1272.

[23] Braun, J., Kahn, R., Froehlich, T., Auinger, P., & Lanphear, B. (2006). Exposures to environmental toxicants and attention-

deficit/hyperactivity disorder in U.S. children.Environmental Health Perspectives, 114(12), 1904–1909; Linnet K., Dalsgaard, S.,

Obel, C., Wisborg, K., Henriksen T., Rodriguez, A.,…Jarvelin, M. (2003). Maternal lifestyle factors in pregnancy risk of attention-

deficit/hyperactivity disorder and associated behaviors: Review of the current evidence. American Journal of Psychiatry, 160(6),

1028–1040; McCann, D., Barrett, A., Cooper, A., Crumpler, D., Dalen, L., Grimshaw, K.,…Stevenson, J. (2007). Food additives and

hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: A randomised, double-blinded, placebo-

controlled trial. Lancet, 370(9598), 1560–1567.

[24] Burt, S. A., Krueger, R. F., McGue, M., & Iacono, W. G. (2001). Sources of covariation among attention-deficit/hyperactivity

disorder, oppositional defiant disorder, and conduct disorder: The importance of shared environment. Journal of Abnormal

Psychology, 110(4), 516–525.

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[25] Kogan, M., Blumberg, S., Schieve, L., Boyle, C., Perrin, J., Ghandour, R.,…van Dyck, P. (2009). Prevalence of parent-reported

diagnosis of autism spectrum disorder among children in the US, 2007. Pediatrics, 124(5), 1395–1403. doi:10.1542/peds.2009-

1522

[26] Freitag C. M. (2007). The genetics of autistic disorders and its clinical relevance: A review of the literature. Molecular

Psychiatry, 12(1), 2–22.

[27] Moldin, S. O. (2003). Editorial: Neurobiology of autism: The new frontier. Genes, Brain & Behavior, 2(5), 253–254.

12.2 Anxiety and Dissociative Disorders: Fearing the World Around Us L E A R N I N G O B J E C T I V E S

1. Outline and describe the different types of anxiety disorders.

2. Outline and describe the different types of dissociative disorders.

3. Explain the biological and environmental causes of anxiety and dissociative disorders.

Anxiety, the nervousness or agitation that we sometimes experience, often about something that

is going to happen, is a natural part of life. We all feel anxious at times, maybe when we think

about our upcoming visit to the dentist or the presentation we have to give to our class next

week. Anxiety is an important and useful human emotion; it is associated with the activation of

the sympathetic nervous system and the physiological and behavioral responses that help protect

us from danger. But too much anxiety can be debilitating, and every year millions of people

suffer from anxiety disorders, which arepsychological disturbances marked by irrational fears,

often of everyday objects and situations (Kessler, Chiu, Demler, & Walters, 2005). [1]

Generalized Anxiety Disorder

Consider the following, in which ―Chase‖ describes her feelings of a persistent and exaggerated

sense of anxiety, even when there is little or nothing in her life to provoke it:

For a few months now I’ve had a really bad feeling inside of me. The best way to describe it is

like a really bad feeling of negative inevitability, like something really bad is impending, but I

don’t know what. It’s like I’m on trial for murder or I’m just waiting to be sent down for

something. I have it all of the time but it gets worse in waves that come from nowhere with no

apparent triggers. I used to get it before going out for nights out with friends, and it kinda

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stopped me from doing it as I’d rather not go out and stress about the feeling, but now I have it

all the time so it doesn’t really make a difference anymore. (Chase, 2010) [2]

Chase is probably suffering from a generalized anxiety disorder (GAD), a psychological

disorder diagnosed in situations in which a person has been excessively worrying about money,

health, work, family life, or relationships for at least 6 months, even though he or she knows that

the concerns are exaggerated, and when the anxiety causes significant distress and dysfunction.

In addition to their feelings of anxiety, people who suffer from GAD may also experience a

variety of physical symptoms, including irritability, sleep troubles, difficulty concentrating,

muscle aches, trembling, perspiration, and hot flashes. The sufferer cannot deal with what is

causing the anxiety, nor avoid it, because there is no clear cause for anxiety. In fact, the sufferer

frequently knows, at least cognitively, that there is really nothing to worry about.

About 10 million Americans suffer from GAD, and about two thirds are women (Kessler, Chiu,

Demler, & Walters, 2005; Robins & Regier, 1991). [3]

Generalized anxiety disorder is most likely

to develop between the ages of 7 and 40 years, but its influence may in some cases lessen with

age (Rubio & Lopez-Ibor, 2007). [4]

Panic Disorder

When I was about 30 I had my first panic attack. I was driving home, my three little girls were in

their car seats in the back, and all of a sudden I couldn’t breathe, I broke out into a sweat, and my

heart began racing and literally beating against my ribs! I thought I was going to die. I pulled off

the road and put my head on the wheel. I remember songs playing on the CD for about 15

minutes and my kids’ voices singing along. I was sure I’d never see them again. And then, it

passed. I slowly got back on the road and drove home. I had no idea what it was. (Ceejay,

2006) [5]

Ceejay is experiencing panic disorder, a psychological disorder characterized by sudden attacks

of anxiety and terror that have led to significant behavioral changes in the person’s life.

Symptoms of a panic attack include shortness of breath, heart palpitations, trembling, dizziness,

choking sensations, nausea, and an intense feeling of dread or impending doom. Panic attacks

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can often be mistaken for heart attacks or other serious physical illnesses, and they may lead the

person experiencing them to go to a hospital emergency room. Panic attacks may last as little as

one or as much as 20 minutes, but they often peak and subside within about 10 minutes.

Sufferers are often anxious because they fear that they will have another attack. They focus their

attention on the thoughts and images of their fears, becoming excessively sensitive to cues that

signal the possibility of threat (MacLeod, Rutherford, Campbell, Ebsworthy, & Holker,

2002). [6]

They may also become unsure of the source of their arousal, misattributing it to

situations that are not actually the cause. As a result, they may begin to avoid places where

attacks have occurred in the past, such as driving, using an elevator, or being in public places.

Panic disorder affects about 3% of the American population in a given year.

Phobias

A phobia (from the Greek word phobos, which means ―fear‖) is a specific fear of a certain

object, situation, or activity. The fear experience can range from a sense of unease to a full-

blown panic attack. Most people learn to live with their phobias, but for others the fear can be so

debilitating that they go to extremes to avoid the fearful situation. A sufferer of arachnophobia

(fear of spiders), for example, may refuse to enter a room until it has been checked thoroughly

for spiders, or may refuse to vacation in the countryside because spiders may be there. Phobias

are characterized by their specificity and their irrationality. A person with acrophobia (a fear of

height) could fearlessly sail around the world on a sailboat with no concerns yet refuse to go out

onto the balcony on the fifth floor of a building.

A common phobia is social phobia, extreme shyness around people or discomfort in social

situations. Social phobia may be specific to a certain event, such as speaking in public or using a

public restroom, or it can be a more generalized anxiety toward almost all people outside of close

family and friends. People with social phobia will often experience physical symptoms in public,

such as sweating profusely, blushing, stuttering, nausea, and dizziness. They are convinced that

everybody around them notices these symptoms as they are occurring. Women are somewhat

more likely than men to suffer from social phobia.

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The most incapacitating phobia is agoraphobia, defined as anxiety about being in places or

situations from which escape might be difficult or embarrassing, or in which help may not be

available (American Psychiatric Association, 2000). [7]

Typical places that provoke the panic

attacks are parking lots; crowded streets or shops; and bridges, tunnels, or expressways. People

(mostly women) who suffer from agoraphobia may have great difficulty leaving their homes and

interacting with other people.

Phobias affect about 9% of American adults, and they are about twice as prevalent in women as

in men (Fredrikson, Annas, Fischer, & Wik, 1996; Kessler, Meron-Ruscio, Shear, & Wittchen,

2009). [8]

In most cases phobias first appear in childhood and adolescence, and usually persist

into adulthood. Table 12.4 "The Most Common Phobias" presents a list of the common phobias

that are diagnosed by psychologists.

Table 12.4 The Most Common Phobias

Name Description

Acrophobia Fear of heights

Agoraphobia Fear of situations in which escape is difficult

Arachnophobia Fear of spiders

Astraphobia Fear of thunder and lightning

Claustrophobia Fear of closed-in spaces

Cynophobia Fear of dogs

Mysophobia Fear of germs or dirt

Ophidiophobia Fear of snakes

Pteromerhanophobia Fear of flying

Social phobia Fear of social situations

Trypanophobia Fear of injections

Zoophobia Fear of small animals

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Obsessive-Compulsive Disorders

Although he is best known his perfect shots on the field, the soccer star David Beckham also

suffers from Obsessive-Compulsive Disorder (OCD). As he describes it,

I have got this obsessive-compulsive disorder where I have to have everything in a straight line

or everything has to be in pairs. I’ll put my Pepsi cans in the fridge and if there’s one too many

then I’ll put it in another cupboard somewhere. I’ve got that problem. I’ll go into a hotel room.

Before I can relax, I have to move all the leaflets and all the books and put them in a drawer.

Everything has to be perfect. (Dolan, 2006) [9]

David Beckham’s experience with obsessive behavior is not unusual. We all get a little obsessive

at times. We may continuously replay a favorite song in our heads, worry about getting the right

outfit for an upcoming party, or find ourselves analyzing a series of numbers that seem to have a

certain pattern. And our everyday compulsions can be useful. Going back inside the house once

more to be sure that we really did turn off the sink faucet or checking the mirror a couple of

times to be sure that our hair is combed are not necessarily bad ideas.

Obsessive-compulsive disorder (OCD) is a psychological disorder that is diagnosed when an

individual continuously experiences distressing or frightening thoughts, and engages

in obsessions (repetitive thoughts) orcompulsions (repetitive behaviors) in an attempt to calm

these thoughts. OCD is diagnosed when the obsessive thoughts are so disturbing and the

compulsive behaviors are so time consuming that they cause distress and significant dysfunction

in a person’s everyday life. Washing your hands once or even twice to make sure that they are

clean is normal; washing them 20 times is not. Keeping your fridge neat is a good idea; spending

hours a day on it is not. The sufferers know that these rituals are senseless, but they cannot bring

themselves to stop them, in part because the relief that they feel after they perform them acts as a

reinforcer, making the behavior more likely to occur again.

Sufferers of OCD may avoid certain places that trigger the obsessive thoughts, or use alcohol or

drugs to try to calm themselves down. OCD has a low prevalence rate (about 1% of the

population in a given year) in relation to other anxiety disorders, and usually develops in

adolescence or early adulthood (Horwath & Weissman, 2000; Samuels & Nestadt, 1997). [10]

The

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course of OCD varies from person to person. Symptoms can come and go, decrease, or worsen

over time.

Posttraumatic Stress Disorder (PTSD)

―If you imagine burnt pork and plastic; I can still taste it,‖ says Chris Duggan, on his experiences

as a soldier in the Falklands War in 1982. ―These helicopters were coming in and we were asked

to help get the boys off…when they opened the doors the stench was horrendous.‖

When he left the army in 1986, he suffered from PTSD. ―I was a bit psycho,‖ he says. ―I was

verbally aggressive, very uncooperative. I was arguing with my wife, and eventually we

divorced. I decided to change the kitchen around one day, get all new stuff, so I threw everything

out of the window. I was 10 stories up in a flat. I poured brandy all over the video and it melted.

I flooded the bathroom.‖ (Gould, 2007) [11]

People who have survived a terrible ordeal, such as combat, torture, sexual assault,

imprisonment, abuse, natural disasters, or the death of someone close to them may

develop posttraumatic stress disorder (PTSD). The anxiety may begin months or even years after

the event. People with PTSD experience high levels of anxiety along with reexperiencing the

trauma (flashbacks), and a strong desire to avoid any reminders of the event. They may lose

interest in things they used to enjoy; startle easily; have difficulty feeling affection; and may

experience terror, rage, depression, or insomnia. The symptoms may be felt especially when

approaching the area where the event took place or when the anniversary of that event is near.

PTSD affects about 5 million Americans, including victims of the 9/11 terrorist attacks, the wars

in Afghanistan and Iraq, and Hurricane Katrina. Sixteen percent of Iraq war veterans, for

example, reported experiencing symptoms of PTSD (Hoge & Castro, 2006). [12]

PTSD is a

frequent outcome of childhood or adult sexual abuse, a disorder that has its own Diagnostic and

Statistical Manual of Mental Disorders (DSM) diagnosis. Women are more likely to develop

PTSD than men (Davidson, 2000). [13]

Risk factors for PTSD include the degree of the trauma’s severity, the lack of family and

community support, and additional life stressors (Brewin, Andrews, & Valentine,

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2000). [14]

Many people with PTSD also suffer from another mental disorder, particularly

depression, other anxiety disorders, and substance abuse (Brady, Back, & Coffey, 2004). [15]

Dissociative Disorders: Losing the Self to Avoid Anxiety

On October 23, 2006, a man appeared on the television show Weekend Today and asked America

to help him rediscover his identity. The man, who was later identified as Jeffrey Alan Ingram,

had left his home in Seattle on September 9, 2006, and found himself in Denver a few days later,

without being able to recall who he was or where he lived. He was reunited with family after

being recognized on the show. According to a coworker of Ingram’s fiancée, even after Ingram

was reunited with his fiancée, his memory did not fully return. ―He said that while her face

wasn’t familiar to him, her heart was familiar to him…He can’t remember his home, but he said

their home felt like home to him.‖

People who experience anxiety are haunted by their memories and experiences, and although

they desperately wish to get past them, they normally cannot. In some cases, however, such as

with Jeffrey Ingram, people who become overwhelmed by stress experience an altered state of

consciousness in which they become detached from the reality of what is happening to them.

A dissociative disorder is a condition that involves disruptions or breakdowns of memory,

awareness, and identity. The dissociation is used as a defense against the trauma.

Dissociative Amnesia and Fugue

Dissociative amnesia is a psychological disorder that involves extensive, but selective, memory

loss, but in which there is no physiological explanation for the forgetting (van der Hart &

Nijenhuis, 2009). [16]

The amnesia is normally brought on by a trauma—a situation that causes

such painful anxiety that the individual ―forgets‖ in order to escape. These kinds of trauma

include disasters, accidents, physical abuse, rape, and other forms of severe stress (Cloninger &

Dokucu, 2008). [17]

Although the personality of people who are experiencing dissociative

amnesia remains fundamentally unchanged—and they recall how to carry out daily tasks such as

reading, writing, and problem solving—they tend to forget things about their personal lives—for

instance, their name, age, and occupation—and may fail to recognize family and friends (van der

Hart & Nijenhuis, 2009). [18]

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A related disorder, dissociative fugue, is a psychological disorder in which an individual loses

complete memory of his or her identity and may even assume a new one, often far from home.

The individual with dissociative fugue experiences all the symptoms of dissociative amnesia but

also leaves the situation entirely. The fugue state may last for just a matter of hours or may

continue for months, as it did with Jeffrey Ingram. Recovery from the fugue state tends to be

rapid, but when people recover they commonly have no memory of the stressful event that

triggered the fugue or of events that occurred during their fugue state (Cardeña & Gleaves,

2007). [19]

Dissociative Identity Disorder

You may remember the story of Sybil (a pseudonym for Shirley Ardell Mason, who was born in

1923), a person who, over a period of 40 years, claimed to possess 16 distinct personalities.

Mason was in therapy for many years trying to integrate these personalities into one complete

self. A TV movie about Mason’s life, starring Sally Field as Sybil, appeared in 1976.

Sybil suffered from the most severe of the dissociative disorders, dissociative identity

disorder. Dissociative identity disorder is a psychological disorder in which two or more distinct

and individual personalities exist in the same person, and there is an extreme memory disruption

regarding personal information about the other personalities (van der Hart & Nijenhuis,

2009). [20]

Dissociative identity disorder was once known as ―multiple personality disorder,‖ and

this label is still sometimes used. This disorder is sometimes mistakenly referred to as

schizophrenia.

In some cases of dissociative identity disorder, there can be more than 10 different personalities

in one individual. Switches from one personality to another tend to occur suddenly, often

triggered by a stressful situation (Gillig, 2009). [21]

The host personality is the personality in

control of the body most of the time, and thealter personalities tend to differ from each other in

terms of age, race, gender, language, manners, and even sexual orientation (Kluft, 1996). [22]

A

shy, introverted individual may develop a boisterous, extroverted alter personality. Each

personality has unique memories and social relationships (Dawson, 1990). [23]

Women are more

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frequently diagnosed with dissociative identity disorder than are men, and when they are

diagnosed also tend to have more ―personalities‖ (American Psychiatric Association, 2000). [24]

The dissociative disorders are relatively rare conditions and are most frequently observed in

adolescents and young adults. In part because they are so unusual and difficult to diagnose,

clinicians and researchers disagree about the legitimacy of the disorders, and particularly about

dissociative identity disorder. Some clinicians argue that the descriptions in the DSM accurately

reflect the symptoms of these patients, whereas others believe that patients are faking, role-

playing, or using the disorder as a way to justify behavior (Barry-Walsh, 2005; Kihlstrom, 2004;

Lilienfeld & Lynn, 2003; Lipsanen et al., 2004). [25]

Even the diagnosis of Shirley Ardell Mason

(Sybil) is disputed. Some experts claim that Mason was highly hypnotizable and that her

therapist unintentionally ―suggested‖ the existence of her multiple personalities (Miller &

Kantrowitz, 1999). [26]

Explaining Anxiety and Dissociation Disorders

Both nature and nurture contribute to the development of anxiety disorders. In terms of our

evolutionary experiences, humans have evolved to fear dangerous situations. Those of us who

had a healthy fear of the dark, of storms, of high places, of closed spaces, and of spiders and

snakes were more likely to survive and have descendants. Our evolutionary experience can

account for some modern fears as well. A fear of elevators may be a modern version of our fear

of closed spaces, while a fear of flying may be related to a fear of heights.

Also supporting the role of biology, anxiety disorders, including PTSD, are heritable (Hettema,

Neale, & Kendler, 2001), [27]

and molecular genetics studies have found a variety of genes that

are important in the expression of such disorders (Smoller et al., 2008; Thoeringer et al.,

2009). [28]

Neuroimaging studies have found that anxiety disorders are linked to areas of the brain

that are associated with emotion, blood pressure and heart rate, decision making, and action

monitoring (Brown & McNiff, 2009; Damsa, Kosel, & Moussally, 2009). [29]

People who

experience PTSD also have a somewhat smaller hippocampus in comparison with those who do

not, and this difference leads them to have a very strong sensitivity to traumatic events

(Gilbertson et al., 2002). [30]

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Whether the genetic predisposition to anxiety becomes expressed as a disorder depends on

environmental factors. People who were abused in childhood are more likely to be anxious than

those who had normal childhoods, even with the same genetic disposition to anxiety sensitivity

(Stein, Schork, & Gelernter, 2008). [31]

And the most severe anxiety and dissociative disorders,

such as PTSD, are usually triggered by the experience of a major stressful event. One problem is

that modern life creates a lot of anxiety. Although our life expectancy and quality of life have

improved over the past 50 years, the same period has also created a sharp increase in anxiety

levels (Twenge, 2006). [32]

These changes suggest that most anxiety disorders stem from

perceived, rather than actual, threats to our well-being.

Anxieties are also learned through classical and operant conditioning. Just as rats that are

shocked in their cages develop a chronic anxiety toward their laboratory environment (which has

become a conditioned stimulus for fear), rape victims may feel anxiety when passing by the

scene of the crime, and victims of PTSD may react to memories or reminders of the stressful

event. Classical conditioning may also be accompanied by stimulus generalization. A single dog

bite can lead to generalized fear of all dogs; a panic attack that follows an embarrassing moment

in one place may be generalized to a fear of all public places. People’s responses to their

anxieties are often reinforced. Behaviors become compulsive because they provide relief from

the torment of anxious thoughts. Similarly, leaving or avoiding fear-inducing stimuli leads to

feelings of calmness or relief, which reinforces phobic behavior.

In contrast to the anxiety disorders, the causes of the dissociative orders are less clear, which is

part of the reason that there is disagreement about their existence. Unlike most psychological

orders, there is little evidence of a genetic predisposition; they seem to be almost entirely

environmentally determined. Severe emotional trauma during childhood, such as physical or

sexual abuse, coupled with a strong stressor, is typically cited as the underlying cause (Alpher,

1992; Cardeña & Gleaves, 2007). [33]

Kihlstrom, Glisky, and Angiulo (1994) [34]

suggest that

people with personalities that lead them to fantasize and become intensely absorbed in their own

personal experiences are more susceptible to developing dissociative disorders under stress.

Dissociative disorders can in many cases be successfully treated, usually by psychotherapy

(Lilienfeld & Lynn, 2003). [35]

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K E Y T A K E A W A Y S

 Anxiety is a natural part of life, but too much anxiety can be debilitating. Every year millions of people suffer from

anxiety disorders.

 People who suffer from generalized anxiety disorder experience anxiety, as well as a variety of physical symptoms.

 Panic disorder involves the experience of panic attacks, including shortness of breath, heart palpitations, trembling,

and dizziness.

 Phobias are specific fears of a certain object, situation, or activity. Phobias are characterized by their specificity and

their irrationality.

 A common phobia is social phobia, extreme shyness around people or discomfort in social situations.

 Obsessive-compulsive disorder is diagnosed when a person’s repetitive thoughts are so disturbing and their

compulsive behaviors so time consuming that they cause distress and significant disruption in a person’s everyday life.

 People who have survived a terrible ordeal, such as combat, torture, rape, imprisonment, abuse, natural disasters, or

the death of someone close to them, may develop PTSD.

 Dissociative disorders, including dissociative amnesia and dissociative fugue, are conditions that involve disruptions or

breakdowns of memory, awareness, and identity. The dissociation is used as a defense against the trauma.

 Dissociative identity disorder, in which two or more distinct and individual personalities exist in the same person, is

relatively rare and difficult to diagnose.

 Both nature and nurture contribute to the development of anxiety disorders.

E X E R C I S E S A N D C R I T I C A L T H I N K I N G

1. Under what situations do you experience anxiety? Are these experiences rational or irrational? Does the anxiety keep

you from doing some things that you would like to be able to do?

2. Do you or people you know suffer from phobias? If so, what are the phobias and how do you think the phobias

began? Do they seem more genetic or more environmental in origin?

[1] Kessler, R., Chiu, W., Demler, O., & Walters, E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders

in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–627.

[2] Chase. (2010, February 28). Re: “anxiety?” *Online forum comment+. Mental Health Forum. Retrieved

from http://www.mentalhealthforum.net/forum/showthread.php?t=9359

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[3] Kessler, R., Chiu, W., Demler, O., & Walters, E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders

in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–27; Robins, L., & Regier, D. A.

(1991).Psychiatric disorders in America: The Epidemiologic Catchment Area Study. New York, NY: Free Press.

[4] Rubio, G., & Lopez-Ibor, J. (2007). Generalized anxiety disorder: A 40-year follow up study. Acta Psychiatric Scandinavica,

115, 372–379.

[5] Ceejay. (2006, September). My dance with panic [Web log post]. Panic Survivor. Retrieved

from http://www.panicsurvivor.com/index.php/2007102366/Survivor-Stories/My-Dance-With-Panic.html

[6] MacLeod, C., Rutherford, E., Campbell, L., Ebsworthy, G., & Holker, L. (2002). Selective attention and emotional

vulnerability: Assessing the causal basis of their association through the experimental manipulation of attentional bias. Journal

of Abnormal Psychology, 111(1), 107–123.

[7] American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.).

Washington, DC: Author.

[8] Fredrikson, M., Annas, P., Fischer, H., & Wik, G. (1996). Gender and age differences in the prevalence of specific fears and

phobias. Behaviour Research and Therapy, 34(1), 33–39. doi:10.1016/0005-7967(95)00048-3; Kessler, R., Meron-Ruscio, A.,

Shear, K., & Wittchen, H. (2009). Epidemiology of anxiety disorders. In M. Anthony, & M. Stein (Eds).Oxford handbook of anxiety

and related disorders. New York, NY: Oxford University Press.

[9] Dolan, A. (2006, April 3). The obsessive disorder that haunts my life. Daily Mail. Retrieved

from http://www.dailymail.co.uk/tvshowbiz/article-381802/The-obsessive-disorder-haunts-life.html

[10] Horwath, E., & Weissman, M. (2000). The epidemiology and cross-national presentation of obsessive-compulsive

disorder. Psychiatric Clinics of North America, 23(3), 493–507. doi:10.1016/S0193-953X(05)70176-3; Samuels, J., & Nestadt, G.

(1997). Epidemiology and genetics of obsessive-compulsive disorder. International Review of Psychiatry, 9, 61–71.

[11] Gould, M. (2007, October 10). You can teach a man to kill but not to see dying. The Guardian. Retrieved

fromhttp://www.guardian.co.uk/society/2007/oct/10/guardiansocietysupplement.socialcare2

[12] Hoge, C., & Castro, C. (2006). Post traumatic stress disorder in UK and U.S. forces deployed to Iraq. Lancet, 368, 867.

[13] Davidson, J. (2000). Trauma: The impact of post-traumatic stress disorder. Journal of Psychopharmacology, 14(2 Suppl 1),

S5–S12.

[14] Brewin, C., Andrews, B., & Valentine, J. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-

exposed adults. Journal of Consulting and Clinical Psychology, 68(5), 748–766. doi:10.1037//0022-006X.68.5.748

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[15] Brady, K. T., Back, S. E., & Coffey, S. F. (2004). Substance abuse and posttraumatic stress disorder. Current Directions in

Psychological Science, 13(5), 206–209.

[16] van der Hart, O., & Nijenhuis, E. R. S. (2009). Dissociative disorders. In P. H. Blaney & T. M. Millon (Eds.), Oxford textbook of

psychological disorder (2nd ed., pp. 452–481). New York, NY: Oxford University Press.

[17] Cloninger, C., & Dokucu, M. (2008). Somatoform and dissociative disorders. In S. H. Fatemi & P. J. Clayton (Eds.), The

medical basis of psychiatry (3rd ed., pp. 181–194). Totowa, NJ: Humana Press. doi:10.1007/978-1-59745-252-6_11

[18] van der Hart, O., & Nijenhuis, E. R. S. (2009). Dissociative disorders. In P. H. Blaney & T. M. Millon (Eds.), Oxford textbook of

psychological disorder (2nd ed., pp. 452–481). New York, NY: Oxford University Press.

[19] Cardeña, E., & Gleaves, D. (2007). Dissociative disorders. In M. M. Hersen, S. M. Turner, & D. C. Beidel (Eds.), Adult

psychological disorder and diagnosis (5th ed., pp. 473–503). Hoboken, NJ: John Wiley & Sons.

[20] van der Hart, O., & Nijenhuis, E. R. S. (2009). Dissociative disorders. In P. H. Blaney, & T. M. Millon (Eds.), Oxford textbook

of psychological disorder (2nd ed., pp. 452–481). New York, NY: Oxford University Press.

[21] Gillig, P. M. (2009). Dissociative identity disorder: A controversial diagnosis.Psychiatry, 6(3), 24–29.

[22] Kluft, R. P. (1996). The diagnosis and treatment of dissociative identity disorder. InThe Hatherleigh guide to psychiatric

disorders (1st ed., Vol. 1, pp. 49–96). New York, NY: Hatherleigh Press.

[23] Dawson, P. L. (1990). Understanding and cooperation among alter and host personalities. American Journal of

Occupational Therapy, 44(11), 994–997.

[24] American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.).

Washington, DC: Author.

[25] Barry-Walsh, J. (2005). Dissociative identity disorder. Australian and New Zealand Journal of Psychiatry, 39, 109–110;

Kihlstrom, J. F. (2004). An unbalanced balancing act: Blocked, recovered, and false memories in the laboratory and

clinic. Clinical Psychology: Science and Practice, 11(1), 34–41; Lilienfeld, S. O., & Lynn, S. J. (2003). Dissociative identity disorder:

Multiple personalities, multiple controversies. In S. O. Lilienfeld, S. J. Lynn, & J. M. Lohr (Eds.), Science and pseudoscience in

clinical psychology (pp. 109–142). New York, NY: Guilford Press; Lipsanen, T., Korkeila, J., Peltola, P., Jarvinen, J., Langen, K., &

Lauerma, H. (2004). Dissociative disorders among psychiatric patients: Comparison with a nonclinical sample. European

Psychiatry, 19(1), 53–55.

[26] Miller, M., & Kantrowitz, B. (1999, January 25). Unmasking Sybil: A reexamination of the most famous psychiatric patient in

history. Newsweek, pp. 11–16.

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[27] Hettema, J. M., Neale, M. C., & Kendler, K. S. (2001). A review and meta-analysis of the genetic epidemiology of anxiety

disorders. The American Journal of Psychiatry, 158(10), 1568–1578.

[28] Smoller, J., Paulus, M., Fagerness, J., Purcell, S., Yamaki, L., Hirshfeld-Becker, D.,…Stein, M. (2008). Influence of RGS2 on

anxiety-related temperament, personality, and brain function. Archives of General Psychiatry, 65(3), 298–308.

doi:10.1001/archgenpsychiatry.2007.48; Thoeringer, C., Ripke, S., Unschuld, P., Lucae, S., Ising, M., Bettecken, T.,…Erhardt, A.

(2009). The GABA transporter 1 (SLC6A1): A novel candidate gene for anxiety disorders. Journal of Neural Transmission, 116(6),

649–657. doi:10.1007/s00702-008-0075-y

[29] Brown, T., & McNiff, J. (2009). Specificity of autonomic arousal to DSM-IV panic disorder and posttraumatic stress

disorder. Behaviour Research and Therapy, 47(6), 487–493. doi:10.1016/j.brat.2009.02.016; Damsa, C., Kosel, M., & Moussally,

J. (2009). Current status of brain imaging in anxiety disorders. Current Opinion in Psychiatry, 22(1), 96–110.

doi:10.1097/YCO.0b013e328319bd10

[30] Gilbertson, M. W., Shenton, M. E., Ciszewski, A., Kasai, K., Lasko, N. B., Orr, S. P.,…Pitman, R. K. (2002). Smaller

hippocampal volume predicts pathologic vulnerability to psychological trauma. Nature Neuroscience, 5(11), 1242.

[31] Stein, M., Schork, N., & Gelernter, J. (2008). Gene-by-environment (serotonin transporter and childhood maltreatment)

interaction for anxiety sensitivity, an intermediate phenotype for anxiety disorders. Neuropsychopharmacology, 33(2), 312–

319. doi:10.1038/sj.npp.1301422

[32] Twenge, J. (2006). Generation me. New York, NY: Free Press.

[33] Alpher, V. S. (1992). Introject and identity: Structural-interpersonal analysis and psychological assessment of multiple

personality disorder. Journal of Personality Assessment. 58(2), 347–367. doi:10.1207/s15327752jpa5802_12; Cardeña, E., &

Gleaves, D. (2007). Dissociative disorders. In M. M. Hersen, S. M. Turner, & D. C. Beidel (Eds.), Adult psychological disorder and

diagnosis (5th ed., pp. 473–503). Hoboken, NJ: John Wiley & Sons.

[34] Kihlstrom, J. F., Glisky, M. L., & Angiulo, M. J. (1994). Dissociative tendencies and dissociative disorders. Journal of

Abnormal Psychology, 103, 117–124.

[35] Lilienfeld, S. O., & Lynn, S. J. (2003). Dissociative identity disorder: Multiple personalities, multiple controversies. In S. O.

Lilienfeld, S. J. Lynn, & J. M. Lohr (Eds.),Science and pseudoscience in clinical psychology (pp. 109–142). New York, NY: Guilford

Press.

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12.3 Mood Disorders: Emotions as Illness L E A R N I N G O B J E C T I V E S

1. Summarize and differentiate the various forms of mood disorders, in particular dysthymia, major depressive disorder,

and bipolar disorder.

2. Explain the genetic and environmental factors that increase the likelihood that a person will develop a mood disorder.

The everyday variations in our feelings of happiness and sadness reflect ourmood, which can be

defined as the positive or negative feelings that are in the background of our everyday

experiences. In most cases we are in a relatively good mood, and this positive mood has some

positive consequences—it encourages us to do what needs to be done and to make the most of

the situations we are in (Isen, 2003). [1]

When we are in a good mood our thought processes open

up, and we are more likely to approach others. We are more friendly and helpful to others when

we are in a good mood than we are when we are in a bad mood, and we may think more

creatively (De Dreu, Baas, & Nijstad, 2008). [2]

On the other hand, when we are in a bad mood

we are more likely to prefer to be alone rather than interact with others, we focus on the negative

things around us, and our creativity suffers.

It is not unusual to feel ―down‖ or ―low‖ at times, particularly after a painful event such as the

death of someone close to us, a disappointment at work, or an argument with a partner. We often

get depressed when we are tired, and many people report being particularly sad during the winter

when the days are shorter. Mood (or affective) disorders are psychological disorders in which the

person’s mood negatively influences his or her physical, perceptual, social, and cognitive

processes. People who suffer from mood disorders tend to experience more intense—and

particularly more intense negative—moods. About 10% of the U.S. population suffers from a

mood disorder in a given year.

The most common symptom of mood disorders is negative mood, also known as sadness

or depression. Consider the feelings of this person, who was struggling with depression and was

diagnosed with major depressive disorder:

I didn’t want to face anyone; I didn’t want to talk to anyone. I didn’t really want to do anything

for myself…I couldn’t sit down for a minute really to do anything that took deep

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concentration…It was like I had big huge weights on my legs and I was trying to swim and just

kept sinking. And I’d get a little bit of air, just enough to survive and then I’d go back down

again. It was just constantly, constantly just fighting, fighting, fighting, fighting, fighting.

(National Institute of Mental Health, 2010) [3]

Mood disorders can occur at any age, and the median age of onset is 32 years (Kessler, Berglund,

Demler, Jin, & Walters, 2005). [4]

Recurrence of depressive episodes is fairly common and is

greatest for those who first experience depression before the age of 15 years. About twice as

many women suffer from depression than do men (Culbertson, 1997). [5]

This gender difference is

consistent across many countries and cannot be explained entirely by the fact that women are

more likely to seek treatment for their depression. Rates of depression have been increasing over

the past years, although the reasons for this increase are not known (Kessler et al., 2003). [6]

As you can see below, the experience of depression has a variety of negative effects on our

behaviors. In addition to the loss of interest, productivity, and social contact that accompanies

depression, the person’s sense of hopelessness and sadness may become so severe that he or she

considers or even succeeds in committing suicide. Suicide is the 11th leading cause of death in

the United States, and a suicide occurs approximately every 16 minutes. Almost all the people

who commit suicide have a diagnosable psychiatric disorder at the time of their death (American

Association of Suicidology, 2010; American Foundation for Suicide Prevention, 2007; Sudak,

2005). [7]

Behaviors Associated with Depression

 Changes in appetite; weight loss or gain

 Difficulty concentrating, remembering details, and making decisions

 Fatigue and decreased energy

 Feelings of hopelessness, helplessness, and pessimism

 Increased use of alcohol or drugs

 Irritability, restlessness

 Loss of interest in activities or hobbies once pleasurable, including sex

 Loss of interest in personal appearance

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 Persistent aches or pains, headaches, cramps, or digestive problems that do not improve with treatment

 Sleep disorders, either trouble sleeping or excessive sleeping

 Thoughts of suicide or attempts at suicide

Dysthymia and Major Depressive Disorder

The level of depression observed in people with mood disorders varies widely. People who

experience depression for many years, such that it becomes to seem normal and part of their

everyday life, and who feel that they are rarely or never happy, will likely be diagnosed with a

mood disorder. If the depression is mild but long-lasting, they will be diagnosed

with dysthymia, a condition characterized by mild, but chronic, depressive symptoms that last

for at least 2 years.

If the depression continues and becomes even more severe, the diagnosis may become that

of major depressive disorder.Major depressive disorder (clinical depression) is a mental disorder

characterized by an all-encompassing low mood accompanied by low self-esteem and by loss of

interest or pleasure in normally enjoyable activities. Those who suffer from major depressive

disorder feel an intense sadness, despair, and loss of interest in pursuits that once gave them

pleasure. These negative feelings profoundly limit the individual’s day-to-day functioning and

ability to maintain and develop interests in life (Fairchild & Scogin, 2008). [8]

About 21 million American adults suffer from a major depressive disorder in any given year; this

is approximately 7% of the American population. Major depressive disorder occurs about twice

as often in women as it does in men (Kessler, Chiu, Demler, & Walters, 2005; Kessler et al.,

2003). [9]

In some cases clinically depressed people lose contact with reality and may receive a

diagnosis of major depressive episode with psychotic features. In these cases the depression

includes delusions and hallucinations.

Bipolar Disorder

Juliana is a 21-year-old single woman. Over the past several years she had been treated by a

psychologist for depression, but for the past few months she had been feeling a lot better. Juliana

had landed a good job in a law office and found a steady boyfriend. She told her friends and

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parents that she had been feeling particularly good—her energy level was high and she was

confident in herself and her life.

One day Juliana was feeling so good that she impulsively quit her new job and left town with her

boyfriend on a road trip. But the trip didn’t turn out well because Juliana became impulsive,

impatient, and easily angered. Her euphoria continued, and in one of the towns that they visited

she left her boyfriend and went to a party with some strangers that she had met. She danced into

the early morning and ended up having sex with several of the men.

Eventually Juliana returned home to ask for money, but when her parents found out about her

recent behavior, and when she acted aggressively and abusively to them when they confronted

her about it, they referred her to a social worker. Juliana was hospitalized, where she was

diagnosed with bipolar disorder.

While dysthymia and major depressive disorder are characterized by overwhelming negative

moods, bipolar disorder is a psychological disorder characterized by swings in mood from overly

“high” to sad and hopeless, and back again, with periods of near-normal mood in between.

Bipolar disorder is diagnosed in cases such as Juliana’s, where experiences with depression are

followed by a more normal period and then a period of mania or euphoria in which the person

feels particularly awake, alive, excited, and involved in everyday activities but is also impulsive,

agitated, and distracted. Without treatment, it is likely that Juliana would cycle back into

depression and then eventually into mania again, with the likelihood that she would harm herself

or others in the process.

Bipolar disorder is an often chronic and lifelong condition that may begin in childhood.

Although the normal pattern involves swings from high to low, in some cases the person may

experience both highs and lows at the same time. Determining whether a person has bipolar

disorder is difficult due to the frequent presence of comorbidity with both depression and anxiety

disorders. Bipolar disorder is more likely to be diagnosed when it is initially observed at an early

age, when the frequency of depressive episodes is high, and when there is a sudden onset of the

symptoms (Bowden, 2001). [11]

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Explaining Mood Disorders

Mood disorders are known to be at least in part genetic, because they are heritable. (Berrettini,

2006; Merikangas et al., 2002). [12]

Neurotransmitters also play an important role in mood

disorders. Serotonin, dopamine, and norepinephrine are all known to influence mood (Sher &

Mann, 2003), [13]

and drugs that influence the actions of these chemicals are often used to treat

mood disorders.

The brains of those with mood disorders may in some cases show structural differences from

those without them. Videbech and Ravnkilde (2004) [14]

found that the hippocampus was smaller

in depressed subjects than in normal subjects, and this may be the result of

reduced neurogenesis (the process of generating new neurons) in depressed people (Warner-

Schmidt & Duman, 2006). [15]

Antidepressant drugs may alleviate depression in part by

increasing neurogenesis (Duman & Monteggia, 2006). [16]

Research Focus: Using Molecular Genetics to Unravel the Causes of Depression

Avshalom Caspi and his colleagues (Caspi et al., 2003) [17]

used a longitudinal study to test whether genetic

predispositions might lead some people, but not others, to suffer from depression as a result of environmental stress.

Their research focused on a particular gene, the 5-HTT gene, which is known to be important in the production and

use of the neurotransmitter serotonin. The researchers focused on this gene because serotonin is known to be

important in depression, and because selective serotonin reuptake inhibitors (SSRIs) have been shown to be effective

in treating depression.

People who experience stressful life events, for instance involving threat, loss, humiliation, or defeat, are likely to

experience depression. But biological-situational models suggest that a person’s sensitivity to stressful events depends

on his or her genetic makeup. The researchers therefore expected that people with one type of genetic pattern would

show depression following stress to a greater extent than people with a different type of genetic pattern.

The research included a sample of 1,037 adults from Dunedin, New Zealand. Genetic analysis on the basis of DNA

samples allowed the researchers to divide the sample into two groups on the basis of the characteristics of their 5-

HTT gene. One group had a short version (orallele) of the gene, whereas the other group did not have the short allele

of the gene.

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The participants also completed a measure where they indicated the number and severity of stressful life events that

they had experienced over the past 5 years. The events included employment, financial, housing, health, and

relationship stressors. The dependent measure in the study was the level of depression reported by the participant, as

assessed using a structured interview test (Robins, Cottler, Bucholtz, & Compton, 1995). [18]

As you can see in Figure 12.12 "Results From Caspi et al., 2003", as the number of stressful experiences the

participants reported increased from 0 to 4, depression also significantly increased for the participants with the short

version of the gene (top panel). But for the participants who did not have a short allele, increasing stress did not

increase depression (bottom panel). Furthermore, for the participants who experienced 4 stressors over the past 5

years, 33% of the participants who carried the short version of the gene became depressed, whereas only 17% of

participants who did not have the short version did.

Figure 12.12Results From Caspi et al., 2003

Caspi et al. (2003) found that the number of stressful life experiences was associated with increased depression for

people with the short allele of the 5-HTT gene (top panel) but not for people who did not have the short allele

(bottom panel).

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Source: Adapted from Caspi, A., Sugden, K., Moffitt, T. E., Taylor, A., Craig, I. W., Harrington, H.,…Poulton, R.

(2003). Influence of life stress on depression: Moderation by a polymorphism in the 5-HTT gene. Science, 301(5631),

386–389.

This important study provides an excellent example of how genes and environment work together: An individual’s

response to environmental stress was influenced by his or her genetic makeup.

But psychological and social determinants are also important in creating mood disorders and

depression. In terms of psychological characteristics, mood states are influenced in large part by

our cognitions. Negative thoughts about ourselves and our relationships to others create negative

moods, and a goal of cognitive therapy for mood disorders is to attempt to change people’s

cognitions to be more positive. Negative moods also create negative behaviors toward others,

such as acting sad, slouching, and avoiding others, which may lead those others to respond

negatively to the person, for instance by isolating that person, which then creates even more

depression (Figure 12.13 "Cycle of Depression"). You can see how it might become difficult for

people to break out of this ―cycle of depression.‖

Figure 12.13 Cycle of Depression

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Negative emotions create negative behaviors, which lead people to respond negatively to the individual, creating

even more depression.

Weissman et al. (1996) [19]

found that rates of depression varied greatly among countries, with

the highest rates in European and American countries and the lowest rates in Asian countries.

These differences seem to be due to discrepancies between individual feelings and cultural

expectations about what one should feel. People from European and American cultures report

that it is important to experience emotions such as happiness and excitement, whereas the

Chinese report that it is more important to be stable and calm. Because Americans may feel that

they are not happy or excited but that they are supposed to be, this may increase their depression

(Tsai, Knutson, & Fung, 2006). [20]

K E Y T A K E A W A Y S

 Mood is the positive or negative feelings that are in the background of our everyday experiences.

 We all may get depressed in our daily lives, but people who suffer from mood disorders tend to experience more

intense—and particularly more intense negative—moods.

 The most common symptom of mood disorders is negative mood.

 If a person experiences mild but long-lasting depression, she will be diagnosed with dysthymia. If the depression

continues and becomes even more severe, the diagnosis may become that of major depressive disorder.

 Bipolar disorder is characterized by swings in mood from overly “high” to sad and hopeless, and back again, with

periods of near-normal mood in between.

 Mood disorders are caused by the interplay among biological, psychological, and social variables.

E X E R C I S E S A N D C R I T I C A L T H I N K I N G

1. Give a specific example of the negative cognitions, behaviors, and responses of others that might contribute to a cycle

of depression like that shown inFigure 12.13 "Cycle of Depression".

2. Given the discussion about the causes of negative moods and depression, what might people do to try to feel better

on days that they are experiencing negative moods?

[1] Isen, A. M. (2003). Positive affect as a source of human strength. In J. Aspinall, Apsychology of human strengths:

Fundamental questions and future directions for a positive psychology (pp. 179–195). Washington, DC: American Psychological

Association.

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[2] De Dreu, C. K. W., Baas, M., & Nijstad, B. A. (2008). Hedonic tone and activation level in the mood-creativity link: Toward a

dual pathway to creativity model. Journal of Personality and Social Psychology, 94(5), 739–756.

[3] National Institute of Mental Health. (2010, April 8). People with depression discuss their illness. Retrieved

fromhttp://www.nimh.nih.gov/media/video/health/depression.shtml

[4] Kessler, R. C., Berglund, P. A., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions

of DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 62(6), 593–602.

[5] Culbertson, F. M. (1997). Depression and gender: An international review. American Psychologist, 52, 25–31.

[6] Kessler, R. C., Berglund, P., Demler, O, Jin, R., Koretz, D., Merikangas, K. R.,…Wang, P. S. (2003). The epidemiology of major

depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R). Journal of the American Medical

Association, 289(23), 3095–3105.

[7] American Association of Suicidology. (2010, June 29). Some facts about suicide and depression. Retrieved

from http://www.suicidology.org/c/document_library/get_file?folderId=232&name=DLFE-246.pdf; American Foundation for

Suicide Prevention. (2007).About suicide: Facts and figures. National statistics. Retrieved

fromhttp://www.afsp.org/index.cfm?fuseaction=home.viewpage&page_id= 050FEA9F-B064-4092-B1135C3A70DE1FDA;

Sudak, H. S. (2005). Suicide. In B. J. Sadock & V. A. Sadock (Eds.), Kaplan & Sadock’s comprehensive textbook of psychiatry.

Philadelphia, PA: Lippincott Williams & Wilkins.

[8] Fairchild, K., & Scogin, F. (2008). Assessment and treatment of depression. In K. Laidlow & B. Knight (Eds.), Handbook of

emotional disorders in later life: Assessment and treatment. New York, NY: Oxford University Press.

[9] Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-

IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–27; Kessler, R. C.,

Berglund, P., Demler, O, Jin, R., Koretz, D., Merikangas, K. R.,…Wang, P. S. (2003). The epidemiology of major depressive

disorder: Results from the National Comorbidity Survey Replication (NCS-R). Journal of the American Medical Association,

289(23), 3095–3105.

[10] Thomas, P., & Bracken, P. (2001). Vincent’s bandage: The art of selling a drug for bipolar disorder. British Medical Journal,

323, 1434.

[11] Bowden, C. L. (2001). Strategies to reduce misdiagnosis of bipolar depression.Psychiatric Services, 52(1), 51–55.

[12] Berrettini, W. (2006). Genetics of bipolar and unipolar disorders. In D. J. Stein, D. J. Kupfer, & A. F. Schatzberg

(Eds.), Textbook of mood disorders. Washington, DC: American Psychiatric Publishing; Merikangas, K., Chakravarti, A., Moldin,

Saylor URL: http://www.saylor.org/books Saylor.org 46

S., Araj, H., Blangero, J., Burmeister, M,…Takahashi, A. S. (2002). Future of genetics of mood disorders research.Biological

Psychiatry, 52(6), 457–477.

[13] Sher, L., & Mann, J. J. (2003). Psychiatric pathophysiology: Mood disorders. In A. Tasman, J. Kay, & J. A. Lieberman

(Eds.), Psychiatry. New York, NY: John Wiley & Sons.

[14] Videbech, P., & Ravnkilde, B. (2004). Hippocampal volume and depression: A meta-analysis of MRI studies. American

Journal of Psychiatry, 161, 1957–1966.

[15] Warner-Schmidt, J. L., & Duman, R. S. (2006). Hippocampal neurogenesis: Opposing effects of stress and antidepressant

treatment. Hippocampus, 16, 239–249.

[16] Duman, R. S., & Monteggia, L. M. (2006). A neurotrophic model for stress-related mood disorders. Biological Psychiatry, 59,

1116–1127.

[17] Caspi, A., Sugden, K., Moffitt, T. E., Taylor, A., Craig, I. W., Harrington, H.,…Poulton, R. (2003). Influence of life stress on

depression: Moderation by a polymorphism in the 5-HTT gene. Science, 301(5631), 386–389.

[18] Robins, L. N., Cottler, L., Bucholtz, K., & Compton, W. (1995). Diagnostic interview schedule for DSM-1V. St. Louis, MO:

Washington University.

[19] Weissman, M. M., Bland, R. C., Canino, G. J., Greenwald, S., Hwu, H-G., Joyce, P. R.,…Yeh, E-K. (1996). Cross-national

epidemiology of major depression and bipolar disorder.Journal of the American Medical Association, 276, 293–299.

[20] Tsai, J. L., Knutson, B., & Fung, H. H. (2006). Cultural variation in affect valuation.Journal of Personality and Social

Psychology, 90, 288–307.

12.4 Schizophrenia: The Edge of Reality and Consciousness L E A R N I N G O B J E C T I V E S

1. Categorize and describe the three major symptoms of schizophrenia.

2. Differentiate the five types of schizophrenia and their characteristics.

3. Identify the biological and social factors that increase the likelihood that a person will develop schizophrenia.

The term schizophrenia, which in Greek means ―split mind,‖ was first used to describe a

psychological disorder by Eugen Bleuler (1857–1939), a Swiss psychiatrist who was studying

patients who had very severe thought disorders.Schizophrenia is a serious psychological disorder

marked by delusions, hallucinations, loss of contact with reality, inappropriate affect,

disorganized speech, social withdrawal, and deterioration of adaptive behavior.

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Schizophrenia is the most chronic and debilitating of all psychological disorders. It affects men

and women equally, occurs in similar rates across ethnicities and across cultures, and affects at

any one time approximately 3 million people in the United States (National Institute of Mental

Health, 2010). [1]

Onset of schizophrenia is usually between the ages of 16 and 30 and rarely

after the age of 45 or in children (Mueser & McGurk, 2004; Nicholson, Lenane, Hamburger,

Fernandez, Bedwell, & Rapoport, 2000). [2]

Symptoms of Schizophrenia

Schizophrenia is accompanied by a variety of symptoms, but not all patients have all of them

(Lindenmayer & Khan, 2006). [3] As you can see inTable 12.5 "Positive, Negative, and

Cognitive Symptoms of Schizophrenia", the symptoms are divided into positive

symptoms, negative symptoms, and cognitive symptoms (American Psychiatric Association,

2008; National Institute of Mental Health, 2010). [4]Positive symptoms refer to the presence of

abnormal behaviors or experiences (such as hallucinations) that are not observed in normal

people, whereas negative symptoms (such as lack of affect and an inability to socialize with

others) refer to the loss or deterioration of thoughts and behaviors that are typical of normal

functioning. Finally, cognitive symptoms are the changes in cognitive processes that accompany

schizophrenia (Skrabalo, 2000). [5]Because the patient has lost contact with reality, we say that

he or she is experiencing psychosis, which is a psychological condition characterized by a loss of

contact with reality.

Table 12.5 Positive, Negative, and Cognitive Symptoms of Schizophrenia

Positive symptoms Negative symptoms Cognitive symptoms

Hallucinations Social withdrawal Poor executive control

Delusions (of grandeur or persecution) Flat affect and lack of pleasure in everyday life Trouble focusing

Derailment Apathy and loss of motivation Working memory problems

Grossly disorganized behavior Distorted sense of time Poor problem-solving abilities

Inappropriate affect Lack of goal-oriented activity

Movement disorders Limited speech

Poor hygiene and grooming

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People with schizophrenia almost always suffer fromhallucinations—imaginary sensations that

occur in the absence of a real stimulus or which are gross distortions of a real stimulus.

Auditory hallucinations are the most common and are reported by approximately three quarters

of patients (Nicolson, Mayberg, Pennell, & Nemeroff, 2006). [6]

Schizophrenic patients frequently

report hearing imaginary voices that curse them, comment on their behavior, order them to do

things, or warn them of danger (National Institute of Mental Health, 2009). [7]

Visual

hallucinations are less common and frequently involve seeing God or the devil (De Sousa,

2007). [8]

Schizophrenic people also commonly experience delusions, which are false beliefs not commonly

shared by others within one’s culture, and maintained even though they are obviously out of

touch with reality. People withdelusions of grandeur believe that they are important, famous, or

powerful. They often become convinced that they are someone else, such as the president or

God, or that they have some special talent or ability. Some claim to have been assigned to a

special covert mission (Buchanan & Carpenter, 2005). [9]

People with delusions of

persecution believe that a person or group seeks to harm them. They may think that people are

able to read their minds and control their thoughts (Maher, 2001). [10]

If a person suffers from

delusions of persecution, there is a good chance that he or she will become violent, and this

violence is typically directed at family members (Buchanan & Carpenter, 2005). [11]

People suffering from schizophrenia also often suffer from the positive symptom

of derailment—the shifting from one subject to another, without following any one line of

thought to conclusion—and may exhibit grossly disorganized behavior including inappropriate

sexual behavior, peculiar appearance and dress, unusual agitation (e.g., shouting and swearing),

strange body movements, and awkward facial expressions. It is also common for schizophrenia

sufferers to experience inappropriate affect. For example, a patient may laugh uncontrollably

when hearing sad news. Movement disorders typically appear as agitated movements, such as

repeating a certain motion again and again, but can in some cases include catatonia, a state in

which a person does not move and is unresponsive to others (Janno, Holi, Tuisku, & Wahlbeck,

2004; Rosebush & Mazurek, 2010). [12]

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Negative symptoms of schizophrenia include social withdrawal, poor hygiene and grooming,

poor problem-solving abilities, and a distorted sense of time (Skrabalo, 2000). [13]

Patients often

suffer from flat affect, which means that they express almost no emotional response (e.g., they

speak in a monotone and have a blank facial expression) even though they may report feeling

emotions (Kring, 1999). [14]

Another negative symptom is the tendency toward incoherent

language, for instance, to repeat the speech of others (―echo speech‖). Some schizophrenics

experience motor disturbances, ranging from complete catatonia and apparent obliviousness to

their environment to random and frenzied motor activity during which they become hyperactive

and incoherent (Kirkpatrick & Tek, 2005). [15]

Not all schizophrenic patients exhibit negative symptoms, but those who do also tend to have the

poorest outcomes (Fenton & McGlashan, 1994). [16]

Negative symptoms are predictors of

deteriorated functioning in everyday life and often make it impossible for sufferers to work or to

care for themselves.

Cognitive symptoms of schizophrenia are typically difficult for outsiders to recognize but make it

extremely difficult for the sufferer to lead a normal life. These symptoms include difficulty

comprehending information and using it to make decisions (the lack of executive control),

difficulty maintaining focus and attention, and problems with working memory (the ability to use

information immediately after it is learned).

Explaining Schizophrenia

There is no single cause of schizophrenia. Rather, a variety of biological and environmental risk

factors interact in a complex way to increase the likelihood that someone might develop

schizophrenia (Walker, Kestler, Bollini, & Hochman, 2004). [17]

Studies in molecular genetics have not yet identified the particular genes responsible for

schizophrenia, but it is evident from research using family, twin, and adoption studies that

genetics are important (Walker & Tessner, 2008). [18]

As you can see in Figure 12.15 "Genetic

Disposition to Develop Schizophrenia", the likelihood of developing schizophrenia increases

dramatically if a close relative also has the disease.

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Figure 12.15 Genetic Disposition to Develop Schizophrenia

The risk of developing schizophrenia increases substantially if a person has a relative with the disease.

Source: Adapted from Gottesman, I. I. (1991). Schizophrenia genesis: The origins of madness. New York, NY: W. H.

Freeman.

Neuroimaging studies have found some differences in brain structure between schizophrenic and

normal patients. In some people with schizophrenia, the cerebral ventricles (fluid-filled spaces in

the brain) are enlarged (Suddath, Christison, Torrey, Casanova, & Weinberger, 1990). [19]

People

with schizophrenia also frequently show an overall loss of neurons in the cerebral cortex, and

some show less activity in the frontal and temporal lobes, which are the areas of the brain

involved in language, attention, and memory. This would explain the deterioration of functioning

in language and thought processing that is commonly experienced by schizophrenic patients

(Galderisi et al., 2008). [20]

Many researchers believe that schizophrenia is caused in part by excess dopamine, and this

theory is supported by the fact that most of the drugs useful in treating schizophrenia inhibit

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dopamine activity in the brain (Javitt & Laruelle, 2006). [21]

Levels of serotonin may also play a

part (Inayama et al., 1996). [22]

But recent evidence suggests that the role of neurotransmitters in

schizophrenia is more complicated than was once believed. It also remains unclear whether

observed differences in the neurotransmitter systems of people with schizophrenia cause the

disease, or if they are the result of the disease itself or its treatment (Csernansky & Grace,

1998). [23]

A genetic predisposition to developing schizophrenia does not always develop into the actual

disorder. Even if a person has an identical twin with schizophrenia, he still has less than a 50%

chance of getting it himself, and over 60% of all schizophrenic people have no first- or second-

degree relatives with schizophrenia (Gottesman & Erlenmeyer-Kimling, 2001; Riley & Kendler,

2005). [24]

This suggests that there are important environmental causes as well.

One hypothesis is that schizophrenia is caused in part by disruptions to normal brain

development in infancy that may be caused by poverty, malnutrition, and disease (Brown et al.,

2004; Murray & Bramon, 2005; Susser et al., 1996; Waddington, Lane, Larkin, O’Callaghan,

1999). [25]

Stress also increases the likelihood that a person will develop schizophrenic

symptoms; onset and relapse of schizophrenia typically occur during periods of increased stress

(Walker, Mittal, & Tessner, 2008). [26]

However, it may be that people who develop

schizophrenia are more vulnerable to stress than others and not necessarily that they experience

more stress than others (Walker, Mittal, & Tessner, 2008). [27]

Many homeless people are likely

to be suffering from undiagnosed schizophrenia.

Another social factor that has been found to be important in schizophrenia is the degree to which

one or more of the patient’s relatives is highly critical or highly emotional in their attitude toward

the patient. Hooley and Hiller (1998) [28]

found that schizophrenic patients who ended a stay in a

hospital and returned to a family with high expressed emotion were three times more likely to

relapse than patients who returned to a family with low expressed emotion. It may be that the

families with high expressed emotion are a source of stress to the patient.

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K E Y T A K E A W A Y S

 Schizophrenia is a serious psychological disorder marked by delusions, hallucinations, and loss of contact with reality.

 Schizophrenia is accompanied by a variety of symptoms, but not all patients have all of them.

 Because the schizophrenic patient has lost contact with reality, we say that he or she is experiencing psychosis.

 Positive symptoms of schizophrenia include hallucinations, delusions, derailment, disorganized behavior,

inappropriate affect, and catatonia.

 Negative symptoms of schizophrenia include social withdrawal, poor hygiene and grooming, poor problem-solving

abilities, and a distorted sense of time.

 Cognitive symptoms of schizophrenia include difficulty comprehending and using information and problems

maintaining focus.

 There is no single cause of schizophrenia. Rather, there are a variety of biological and environmental risk factors that

interact in a complex way to increase the likelihood that someone might develop schizophrenia.

E X E R C I S E A N D C R I T I C A L T H I N K I N G

1. How should society deal with people with schizophrenia? Is it better to keep patients in psychiatric facilities against

their will, but where they can be observed and supported, or to allow them to live in the community, where they may

commit violent crimes against themselves or others? What factors influence your opinion?

[1] National Institute of Mental Health. (2010, April 26). What is schizophrenia? Retrieved

from http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml

[2] Mueser, K. T., & McGurk, S. R. (2004). Schizophrenia. Lancet, 363(9426), 2063–2072; Nicolson, R., Lenane, M., Hamburger, S.

D., Fernandez, T., Bedwell, J., & Rapoport, J. L. (2000). Lessons from childhood-onset schizophrenia. Brain Research Review,

31(2–3), 147–156.

[3] Lindenmayer, J. P., & Khan, A. (2006). Psychological disorder. In J. A. Lieberman, T. S. Stroup, & D. O. Perkins (Eds.), Textbook

of schizophrenia (pp. 187–222). Washington, DC: American Psychiatric Publishing.

[4] American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.).

Washington, DC: Author; National Institute of Mental Health. (2010, April 26). What is schizophrenia? Retrieved

fromhttp://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml

[5] Skrabalo, A. (2000). Negative symptoms in schizophrenia(s): The conceptual basis.Harvard Brain, 7, 7–10.

[6] Nicolson, S. E., Mayberg, H. S., Pennell, P. B., & Nemeroff, C. B. (2006). Persistent auditory hallucinations that are

unresponsive to antipsychotic drugs. The American Journal of Psychiatry, 163, 1153–1159. doi:10.1176/appi.ajp.163.7.1153

Saylor URL: http://www.saylor.org/books Saylor.org 53

[7] National Institute of Mental Health. (2009, September 8). What are the symptoms of schizophrenia? Retrieved

fromhttp://www.nimh.nih.gov/health/publications/schizophrenia/what-are-the-symptoms-of-schizophrenia.shtml

[8] De Sousa, A. (2007). Types and contents of hallucinations in schizophrenia. Journal of Pakistan Psychiatric Society, 4(1), 29.

[9] Buchanan, R. W., & Carpenter, W. T. (2005). Concept of schizophrenia. In B. J. Sadock & V. A. Sadock (Eds.), Kaplan &

Sadock’s comprehensive textbook of psychiatry. Philadelphia, PA: Lippincott Williams & Wilkins.

[10] Maher, B. A. (2001). Delusions. In P. B. Sutker & H. E. Adams (Eds.), Comprehensive handbook of psychological disorder (3rd

ed., pp. 309–370). New York, NY: Kluwer Academic/Plenum.

[11] Buchanan, R. W., & Carpenter, W. T. (2005). Concept of schizophrenia. In B. J. Sadock & V. A. Sadock (Eds.), Kaplan &

Sadock’s comprehensive textbook of psychiatry. Philadelphia, PA: Lippincott Williams & Wilkins.

[12] Janno, S., Holi, M., Tuisku, K., & Wahlbeck, K. (2004). Prevalence of neuroleptic-induced movement disorders in chronic

schizophrenia patients. American Journal of Psychiatry, 161, 160–163; Rosebush, P. I., & Mazurek, M. F. (2010). Catatonia and

its treatment. Schizophrenia Bulleting, 36(2), 239–242. doi:10.1093/schbul/sbp141

[13] Skrabalo, A. (2000). Negative symptoms in schizophrenia(s): The conceptual basis.Harvard Brain, 7, 7–10.

[14] Kring, A. M. (1999). Emotion in schizophrenia: Old mystery, new understanding.Current Directions in Psychological Science,

8, 160–163.

[15] Kirkpatrick, B., & Tek, C. (2005). Schizophrenia: Clinical features and psychological disorder concepts. In B. J. Sadock & S. V.

Sadock (Eds.), Kaplan & Sadock’s comprehensive textbook of psychiatry (pp. 1416–1435). Philadelphia, PA: Lippincott Williams &

Wilkins.

[16] Fenton, W. S., & McGlashan, T. H. (1994). Antecedents, symptom progression, and long-term outcome of the deficit

syndrome in schizophrenia. American Journal of Psychiatry, 151, 351–356.

[17] Walker, E., Kesler, L., Bollini, A., & Hochman, K. (2004). Schizophrenia: Etiology and course. Annual Review of Psychology,

55, 401–430.

[18] Walker, E., & Tessner, K. (2008). Schizophrenia. Perspectives on Psychological Science, 3(1), 30–37.

[19] Suddath, R. L., Christison, G. W., Torrey, E. F., Casanova, M. F., & Weinberger, D. R. (1990). Anatomical abnormalities in the

brains of monozygotic twins discordant for schizophrenia. New England Journal of Medicine, 322(12), 789–794.

[20] Galderisi, S., Quarantelli, M., Volper, U., Mucci, A., Cassano, G. B., Invernizzi, G.,…Maj, M. (2008). Patterns of structural MRI

abnormalities in deficit and nondeficit schizophrenia. Schizophrenia Bulletin, 34, 393–401.

[21] Javitt, D. C., & Laruelle, M. (2006). Neurochemical theories. In J. A. Lieberman, T. S. Stroup, & D. O. Perkins (Eds.), Textbook

of schizophrenia (pp. 85–116). Washington, DC: American Psychiatric Publishing.

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[22] Inayama, Y., Yoneda, H., Sakai, T., Ishida, T., Nonomura, Y., Kono, Y.,…Asaba, H. (1996). Positive association between a DNA

sequence variant in the serotonin 2A receptor gene and schizophrenia. American Journal of Medical Genetics, 67(1), 103–105.

[23] Csernansky, J. G., & Grace, A. A. (1998). New models of the pathophysiology of schizophrenia: Editors’

introduction. Schizophrenia Bulletin, 24(2), 185–187.

[24] Gottesman, I. I., & Erlenmeyer-Kimling, L. (2001). Family and twin studies as a head start in defining prodomes and

endophenotypes for hypothetical early interventions in schizophrenia. Schizophrenia Research, 5(1), 93–102; Riley, B. P., &

Kendler, K. S. (2005). Schizophrenia: Genetics. In B. J. Sadock & V. A. Sadock (Eds.), Kaplan & Sadock’s comprehensive textbook

of psychiatry (pp.1354–1370). Philadelphia, PA: Lippincott Williams & Wilkins.

[25] Brown, A. S., Begg, M. D., Gravenstein, S., Schaefer, C. S., Wyatt, R. J., Bresnahan, M.,…Susser, E. S. (2004). Serologic

evidence of prenatal influenza in the etiology of schizophrenia. Archives of General Psychiatry, 61, 774–780; Murray, R. M., &

Bramon, E. (2005). Developmental model of schizophrenia. In B. J. Sadock & V. A. Sadock (Eds.),Kaplan & Sadock’s

comprehensive textbook of psychiatry (pp. 1381–1395). Philadelphia, PA: Lippincott Williams & Wilkins; Susser, E. B.,

Neugebauer, R., Hock, H.W., Brown, A. S., Lin, S., Labowitz, D., & Gorman, J. M. (1996). Schizophrenia after prenatal famine:

Further evidence. Archives of general psychiatry, 53, 25–31; Waddington J. L., Lane, A., Larkin, C., & O’Callaghan, E. (1999). The

neurodevelopmental basis of schizophrenia: Clinical clues from cerebro-craniofacial dysmorphogenesis, and the roots of a

lifetime trajectory of disease. Biological Psychiatry, 46(1), 31–9.

[26] Walker, E., Mittal, V., & Tessner, K. (2008). Stress and the hypothalamic pituitary adrenal axis in the developmental course

of schizophrenia. Annual Review of Clinical Psychology, 4, 189–216.

[27] Walker, E., Mittal, V., & Tessner, K. (2008). Stress and the hypothalamic pituitary adrenal axis in the developmental course

of schizophrenia. Annual Review of Clinical Psychology, 4, 189–216.

[28] Hooley, J. M., & Hiller, J. B. (1998). Expressed emotion and the pathogenesis of relapse in schizophrenia. In M. F.

Lenzenweger & R. H. Dworkin (Eds.), Origins and development of schizophrenia: Advances in experimental psychopathology (pp.

447–468). Washington, DC: American Psychological Association.

12.5 Personality Disorders L E A R N I N G O B J E C T I V E S

1. Categorize the different types of personality disorders and differentiate antisocial personality disorder from

borderline personality disorder.

2. Outline the biological and environmental factors that may contribute to a person developing a personality disorder.

Saylor URL: http://www.saylor.org/books Saylor.org 55

To this point in the chapter we have considered the psychological disorders that fall on Axis I of

the Diagnostic and Statistical Manual of Mental Disorders(DSM) categorization system. In

comparison to the Axis I disorders, which may frequently be severe and dysfunctional and are

often brought on by stress, the disorders that fall on Axis II are longer-term disorders that are less

likely to be severely incapacitating. Axis II consists primarily of personality disorders.

Apersonality disorder is a disorder characterized by inflexible patterns of thinking, feeling, or

relating to others that cause problems in personal, social, and work situations. Personality

disorders tend to emerge during late childhood or adolescence and usually continue throughout

adulthood (Widiger, 2006). [1]

The disorders can be problematic for the people who have them,

but they are less likely to bring people to a therapist for treatment than are Axis I disorders.

The personality disorders are summarized in Table 12.6 "Descriptions of the Personality

Disorders (Axis II)". They are categorized into three types: those characterized by odd or

eccentric behavior, those characterized by dramatic or erratic behavior, and those characterized

by anxious or inhibited behavior. As you consider the personality types described in Table 12.6

"Descriptions of the Personality Disorders (Axis II)", I’m sure you’ll think of people that you

know who have each of these traits, at least to some degree. Probably you know someone who

seems a bit suspicious and paranoid, who feels that other people are always ―ganging up on

him,‖ and who really doesn’t trust other people very much. Perhaps you know someone who fits

the bill of being overly dramatic—the ―drama queen‖ who is always raising a stir and whose

emotions seem to turn everything into a big deal. Or you might have a friend who is overly

dependent on others and can’t seem to get a life of her own.

The personality traits that make up the personality disorders are common—we see them in the

people whom we interact with every day—yet they may become problematic when they are

rigid, overused, or interfere with everyday behavior (Lynam & Widiger, 2001). [2]

What is

perhaps common to all the disorders is the person’s inability to accurately understand and be

sensitive to the motives and needs of the people around them.

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Table 12.6 Descriptions of the Personality Disorders (Axis II)

Cluster

Personality

disorder Characteristics

A. Odd/eccentric

Schizotypal

Peculiar or eccentric manners of speaking or dressing. Strange beliefs. ―Magical

thinking‖ such as belief in ESP or telepathy. Difficulty forming relationships. May

react oddly in conversation, not respond, or talk to self. Speech elaborate or difficult

to follow. (Possibly a mild form of schizophrenia.)

Paranoid

Distrust in others, suspicion that people have sinister motives. Apt to challenge the

loyalties of friends and read hostile intentions into others’ actions. Prone to anger

and aggressive outbursts but otherwise emotionally cold. Often jealous, guarded,

secretive, overly serious.

Schizoid

Extreme introversion and withdrawal from relationships. Prefers to be alone, little

interest in others. Humorless, distant, often absorbed with own thoughts and

feelings, a daydreamer. Fearful of closeness, with poor social skills, often seen as a

―loner.‖

B.

Dramatic/erratic

Antisocial

Impoverished moral sense or ―conscience.‖ History of deception, crime, legal

problems, impulsive and aggressive or violent behavior. Little emotional empathy or

remorse for hurting others. Manipulative, careless, callous. At high risk for

substance abuse and alcoholism.

Borderline

Unstable moods and intense, stormy personal relationships. Frequent mood changes

and anger, unpredictable impulses. Self-mutilation or suicidal threats or gestures to

get attention or manipulate others. Self-image fluctuation and a tendency to see

others as ―all good‖ or ―all bad.‖

Histrionic

Constant attention seeking. Grandiose language, provocative dress, exaggerated

illnesses, all to gain attention. Believes that everyone loves him. Emotional, lively,

overly dramatic, enthusiastic, and excessively flirtatious.

Narcissistic

Inflated sense of self-importance, absorbed by fantasies of self and success.

Exaggerates own achievement, assumes others will recognize they are superior.

Good first impressions but poor longer-term relationships. Exploitative of others.

C.

Anxious/inhibited

Avoidant

Socially anxious and uncomfortable unless he or she is confident of being liked. In

contrast with schizoid person, yearns for social contact. Fears criticism and worries

about being embarrassed in front of others. Avoids social situations due to fear of

rejection.

Dependent Submissive, dependent, requiring excessive approval, reassurance, and advice.

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Cluster

Personality

disorder Characteristics

Clings to people and fears losing them. Lacking self-confidence. Uncomfortable

when alone. May be devastated by end of close relationship or suicidal if breakup is

threatened.

Obsessive-

compulsive

Conscientious, orderly, perfectionist. Excessive need to do everything ―right.‖

Inflexibly high standards and caution can interfere with his or her productivity. Fear

of errors can make this person strict and controlling. Poor expression of emotions.

(Not the same as obsessive-compulsive disorder.)

Source: American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.,

text rev.). Washington, DC: Author.

The personality disorders create a bit of a problem for diagnosis. For one, it is frequently difficult

for the clinician to accurately diagnose which of the many personality disorders a person has,

although the friends and colleagues of the person can generally do a good job of it (Oltmanns &

Turkheimer, 2006). [3]

And the personality disorders are highly comorbid; if a person has one, it’s

likely that he or she has others as well. Also, the number of people with personality disorders is

estimated to be as high as 15% of the population (Grant et al., 2004), [4]

which might make us

wonder if these are really ―disorders‖ in any real sense of the word.

Although they are considered as separate disorders, the personality disorders are essentially

milder versions of more severe Axis I disorders (Huang et al., 2009). [5]

For example, obsessive-

compulsive personality disorder is a milder version of obsessive-compulsive disorder (OCD),

and schizoid and schizotypal personality disorders are characterized by symptoms similar to

those of schizophrenia. This overlap in classification causes some confusion, and some theorists

have argued that the personality disorders should be eliminated from the DSM. But clinicians

normally differentiate Axis I and Axis II disorders, and thus the distinction is useful for them

(Krueger, 2005; Phillips, Yen, & Gunderson, 2003; Verheul, 2005). [6]

Although it is not possible to consider the characteristics of each of the personality disorders in

this book, let’s focus on two that have important implications for behavior. The first, borderline

personality disorder (BPD), is important because it is so often associated with suicide, and the

second,antisocial personality disorder (APD), because it is the foundation of criminal behavior.

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Borderline and antisocial personality disorders are also good examples to consider because they

are so clearly differentiated in terms of their focus. BPD (more frequently found in women than

men) is known as aninternalizing disorder because the behaviors that it entails (e.g., suicide and

self-mutilation) are mostly directed toward the self. APD (mostly found in men), on the other

hand, is a type of externalizing disorder in which the problem behaviors (e.g., lying, fighting,

vandalism, and other criminal activity) focus primarily on harm to others.

Borderline Personality Disorder

Borderline personality disorder (BPD) is a psychological disorder characterized by a prolonged

disturbance of personality accompanied by mood swings, unstable personal relationships,

identity problems, threats of self-destructive behavior, fears of abandonment, and impulsivity.

BPD is widely diagnosed—up to 20% of psychiatric patients are given the diagnosis, and it may

occur in up to 2% of the general population (Hyman, 2002). [7]

About three quarters of diagnosed

cases of BDP are women.

People with BPD fear being abandoned by others. They often show a clinging dependency on the

other person and engage in manipulation to try to maintain the relationship. They become angry

if the other person limits the relationship, but also deny that they care about the person. As a

defense against fear of abandonment, borderline people are compulsively social. But their

behaviors, including their intense anger, demands, and suspiciousness, repel people.

People with BPD often deal with stress by engaging in self-destructive behaviors, for instance by

being sexually promiscuous, getting into fights, binge eating and purging, engaging in self-

mutilation or drug abuse, and threatening suicide. These behaviors are designed to call forth a

―saving‖ response from the other person. People with BPD are a continuing burden for police,

hospitals, and therapists. Borderline individuals also show disturbance in their concepts of

identity: They are uncertain about self-image, gender identity, values, loyalties, and goals. They

may have chronic feelings of emptiness or boredom and be unable to tolerate being alone.

BPD has both genetic as well as environmental roots. In terms of genetics, research has found

that those with BPD frequently have neurotransmitter imbalances (Zweig-Frank et al.,

2006), [8]

and the disorder is heritable (Minzenberg, Poole, & Vinogradov, 2008). [9]

In terms of

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environment, many theories about the causes of BPD focus on a disturbed early relationship

between the child and his or her parents. Some theories focus on the development of attachment

in early childhood, while others point to parents who fail to provide adequate attention to the

child’s feelings. Others focus on parental abuse (both sexual and physical) in adolescence, as

well as on divorce, alcoholism, and other stressors (Lobbestael & Arntz, 2009). [10]

The dangers

of BPD are greater when they are associated with childhood sexual abuse, early age of onset,

substance abuse, and aggressive behaviors. The problems are amplified when the diagnosis is

comorbid (as it often is) with other disorders, such as substance abuse disorder, major depressive

disorder, and posttraumatic stress disorder (PTSD; Skodol et al., 2002). [11]

Research Focus: Affective and Cognitive Deficits in BPD

Posner et al. (2003) [12]

hypothesized that the difficulty that individuals with BPD have in regulating their lives (e.g., in

developing meaningful relationships with other people) may be due to imbalances in the fast and slow emotional

pathways in the brain. Specifically, they hypothesized that the fast emotional pathway through the amygdala is too

active, and the slow cognitive-emotional pathway through the prefrontal cortex is not active enough in those with

BPD.

The participants in their research were 16 patients with BPD and 14 healthy comparison participants. All participants

were tested in a functional magnetic resonance imaging (fMRI) machine while they performed a task that required

them to read emotional and nonemotional words, and then press a button as quickly as possible whenever a word

appeared in a normal font and not press the button whenever the word appeared in an italicized font.

The researchers found that while all participants performed the task well, the patients with BPD had more errors than

the controls (both in terms of pressing the button when they should not have and not pressing it when they should

have). These errors primarily occurred on the negative emotional words.

Figure 12.16 "Results From Posner et al., 2003" shows the comparison of the level of brain activity in the emotional

centers in the amygdala (left panel) and the prefrontal cortex (right panel). In comparison to the controls, the

borderline patients showed relatively larger affective responses when they were attempting to quickly respond to the

negative emotions, and showed less cognitive activity in the prefrontal cortex in the same conditions. This research

suggests that excessive affective reactions and lessened cognitive reactions to emotional stimuli may contribute to the

emotional and behavioral volatility of borderline patients.

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Figure 12.16Results From Posner et al., 2003

Individuals with BPD showed less cognitive and greater emotional brain activity in response to negative emotional

words.

Source: Adapted from Posner, M., Rothbart, M., Vizueta, N., Thomas, K., Levy, K., Fossella, J.,…Kernberg, O.

(2003). An approach to the psychobiology of personality disorders. Development and Psychopathology, 15(4),

1093–1106. doi:10.1017/S0954579403000506.

Antisocial Personality Disorder (APD)

In contrast to borderline personality disorder, which involves primarily feelings of inadequacy

and a fear of abandonment,antisocial personality disorder (APD) is characterized by a disregard

of the rights of others, and a tendency to violate those rights without being concerned about

doing so. APD is a pervasive pattern of violation of the rights of others that begins in childhood

or early adolescence and continues into adulthood. APD is about three times more likely to be

diagnosed in men than in women. To be diagnosed with APD the person must be 18 years of age

or older and have a documented history of conduct disorder before the age of 15. People having

antisocial personality disorder are sometimes referred to as ―sociopaths‖ or ―psychopaths.‖

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People with APD feel little distress for the pain they cause others. They lie, engage in violence

against animals and people, and frequently have drug and alcohol abuse problems. They are

egocentric and frequently impulsive, for instance suddenly changing jobs or relationships. People

with APD soon end up with a criminal record and often spend time incarcerated. The intensity of

antisocial symptoms tends to peak during the 20s and then may decrease over time.

Biological and environmental factors are both implicated in the development of antisocial

personality disorder (Rhee & Waldman, 2002). [13]

Twin and adoption studies suggest a genetic

predisposition (Rhee & Waldman, 2002), [14]

and biological abnormalities include low autonomic

activity during stress, biochemical imbalances, right hemisphere abnormalities, and reduced gray

matter in the frontal lobes (Lyons-Ruth et al., 2007; Raine, Lencz, Bihrle, LaCasse, & Colletti,

2000). [15]

Environmental factors include neglectful and abusive parenting styles, such as the use

of harsh and inconsistent discipline and inappropriate modeling (Huesmann & Kirwil, 2007). [16]

K E Y T A K E A W A Y S

 A personality disorder is a disorder characterized by inflexible patterns of thinking, feeling, or relating to others that

causes problems in personal, social, and work situations.

 Personality disorders are categorized into three clusters: those characterized by odd or eccentric behavior, dramatic

or erratic behavior, and anxious or inhibited behavior.

 Although they are considered as separate disorders, the personality disorders are essentially milder versions of more

severe Axis I disorders.

 Borderline personality disorder is a prolonged disturbance of personality accompanied by mood swings, unstable

personal relationships, and identity problems, and it is often associated with suicide.

 Antisocial personality disorder is characterized by a disregard of others’ rights and a tendency to violate those rights

without being concerned about doing so.

E X E R C I S E S A N D C R I T I C A L T H I N K I N G

1. What characteristics of men and women do you think make them more likely to have APD and BDP, respectively? Do

these differences seem to you to be more genetic or more environmental?

2. Do you know people who suffer from antisocial personality disorder? What behaviors do they engage in, and why are

these behaviors so harmful to them and others?

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[1] Widiger, T.A. (2006). Understanding personality disorders. In S. K. Huprich (Ed.),Rorschach assessment to the personality

disorders. The LEA series in personality and clinical psychology (pp. 3–25). Mahwah, NJ: Lawrence Erlbaum Associates.

[2] Lynam, D., & Widiger, T. (2001). Using the five-factor model to represent the DSM-IVpersonality disorders: An expert

consensus approach. Journal of Abnormal Psychology, 110(3), 401–412.

[3] Oltmanns, T. F., & Turkheimer, E. (2006). Perceptions of self and others regarding pathological personality traits. In R. F.

Krueger & J. L. Tackett (Eds.), Personality and psychopathology (pp. 71–111). New York, NY: Guilford Press.

[4] Grant, B., Hasin, D., Stinson, F., Dawson, D., Chou, S., Ruan, W., & Pickering, R. P. (2004). Prevalence, correlates, and

disability of personality disorders in the United States: Results from the national epidemiologic survey on alcohol and related

conditions.Journal of Clinical Psychiatry, 65(7), 948–958.

[5] Huang, Y., Kotov, R., de Girolamo, G., Preti, A., Angermeyer, M., Benjet, C.,…Kessler, R. C. (2009). DSM-IV personality

disorders in the WHO World Mental Health Surveys. British Journal of Psychiatry, 195(1), 46–53.

doi:10.1192/bjp.bp.108.058552

[6] Krueger, R. F. (2005). Continuity of Axes I and II: Towards a unified model of personality, personality disorders, and clinical

disorders. Journal of Personality Disorders, 19, 233–261; Phillips, K. A., Yen, S., & Gunderson, J. G. (2003). Personality disorders.

In R. E. Hales & S. C. Yudofsky (Eds.), Textbook of clinical psychiatry. Washington, DC: American Psychiatric Publishing; Verheul,

R. (2005). Clinical utility for dimensional models of personality pathology. Journal of Personality Disorders, 19, 283–302.

[7] Hyman, S. E. (2002). A new beginning for research on borderline personality disorder.Biological Psychiatry, 51(12), 933–935.

[8] Zweig-Frank, H., Paris, J., Kin, N. M. N. Y., Schwartz, G., Steiger, H., & Nair, N. P. V. (2006). Childhood sexual abuse in relation

to neurobiological challenge tests in patients with borderline personality disorder and normal controls. Psychiatry Research,

141(3), 337–341.

[9] Minzenberg, M. J., Poole, J. H., & Vinogradov, S. (2008). A neurocognitive model of borderline personality disorder: Effects

of childhood sexual abuse and relationship to adult social attachment disturbance. Development and Psychological disorder.

20(1), 341–368. doi:10.1017/S0954579408000163

[10] Lobbestael, J., & Arntz, A. (2009). Emotional, cognitive and physiological correlates of abuse-related stress in borderline

and antisocial personality disorder. Behaviour Research and Therapy, 48(2), 116–124. doi:10.1016/j.brat.2009.09.015

[11] Skodol, A. E., Gunderson, J. G., Pfohl, B., Widiger, T. A., Livesley, W. J., & Siever, L. J. (2002). The borderline diagnosis I:

Psychopathology, comorbidity, and personality structure. Biological Psychiatry, 51(12), 936–950.

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[12] Posner, M., Rothbart, M., Vizueta, N., Thomas, K., Levy, K., Fossella, J.,…Kernberg, O. (2003). An approach to the

psychobiology of personality disorders. Development and Psychopathology, 15(4), 1093–1106.

doi:10.1017/S0954579403000506

[13] Rhee, S. H., & Waldman, I. D. (2002). Genetic and environmental influences on anti-social behavior: A meta-analysis of twin

and adoptions studies. Psychological Bulletin, 128(3), 490–529.

[14] Rhee, S. H., & Waldman, I. D. (2002). Genetic and environmental influences on anti-social behavior: A meta-analysis of twin

and adoptions studies. Psychological Bulletin, 128(3), 490–529.

[15] Lyons-Ruth, K., Holmes, B. M., Sasvari-Szekely, M., Ronai, Z., Nemoda, Z., & Pauls, D. (2007). Serotonin transporter

polymorphism and borderline or antisocial traits among low-income young adults. Psychiatric Genetics, 17, 339–343; Raine, A.,

Lencz, T., Bihrle, S., LaCasse, L., & Colletti, P. (2000). Reduced prefrontal gray matter volume and reduced autonomic activity in

antisocial personality disorder. Archive of General Psychiatry, 57, 119–127.

[16] Huesmann, L. R., & Kirwil, L. (2007). Why observing violence increases the risk of violent behavior by the observer. In D. J.

Flannery, A. T. Vazsonyi, & I. D. Waldman (Eds.),The Cambridge handbook of violent behavior and aggression (pp. 545–570).

New York, NY: Cambridge University Press.

12.6 Somatoform, Factitious, and Sexual Disorders L E A R N I N G O B J E C T I V E S

1. Differentiate the symptoms of somatoform and factitious disorders.

2. Summarize the sexual disorders and paraphilias.

Although mood, anxiety, and personality disorders represent the most prevalent psychological

disorders, as you saw in Table 12.3 "Categories of Psychological Disorders Based on the " there

are a variety of other disorders that affect people. This complexity of symptoms and

classifications helps make it clear how difficult it is to accurately and consistently diagnose and

treat psychological disorders. In this section we will review three other disorders that are of

interest to psychologists and that affect millions of people:somatoform disorder, factitious

disorder, and sexual disorder.

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Somatoform and Factitious Disorders

Somatoform and factitious disorders both occur in cases where psychological disorders are

related to the experience or expression of physical symptoms. The important difference between

them is that in somatoform disorders the physical symptoms are real, whereas in factitious

disorders they are not.

One case in which psychological problems create real physical impairments is in the somatoform

disorder known assomatization disorder (also called Briquet’s syndrome or Brissaud-

Marie syndrome). Somatization disorder is a psychological disorder in which a person

experiences numerous long-lasting but seemingly unrelated physical ailments that have no

identifiable physical cause. A person with somatization disorder might complain of joint aches,

vomiting, nausea, muscle weakness, as well as sexual dysfunction. The symptoms that result

from a somatoform disorder are real and cause distress to the individual, but they are due entirely

to psychological factors. The somatoform disorder is more likely to occur when the person is

under stress, and it may disappear naturally over time. Somatoform disorder is more common in

women than in men, and usually first appears in adolescents or those in their early 20s.

Another type of somatoform disorder is conversion disorder, a psychological disorder in which

patients experience specific neurological symptoms such as numbness, blindness, or paralysis,

but where no neurological explanation is observed or possible (Agaki & House, 2001). [1]

The

difference between conversion and somatoform disorders is in terms of the location of the

physical complaint. In somatoform disorder the malaise is general, whereas in conversion

disorder there are one or several specific neurological symptoms.

Conversion disorder gets its name from the idea that the existing psychological disorder is

―converted‖ into the physical symptoms. It was the observation of conversion disorder (then

known as ―hysteria‖) that first led Sigmund Freud to become interested in the psychological

aspects of illness in his work with Jean-Martin Charcot. Conversion disorder is not common (a

prevalence of less than 1%), but it may in many cases be undiagnosed. Conversion disorder

occurs twice or more frequently in women than in men.

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There are two somatoform disorders that involve preoccupations. We have seen an example of

one of them, body dysmorphic disorder, in the Chapter 12 "Defining Psychological

Disorders" opener. Body dysmorphic disorder (BDD) is a psychological disorder accompanied

by an imagined or exaggerated defect in body parts or body odor. There are no sex differences in

prevalence, but men are most often obsessed with their body build, their genitals, and hair loss,

whereas women are more often obsessed with their breasts and body shape. BDD usually begins

in adolescence.

Hypochondriasis (hypochondria) is another psychological disorder that is focused on

preoccupation, accompanied by excessive worry about having a serious illness. The patient often

misinterprets normal body symptoms such as coughing, perspiring, headaches, or a rapid

heartbeat as signs of serious illness, and the patient’s concerns remain even after he or she has

been medically evaluated and assured that the health concerns are unfounded. Many people with

hypochondriasis focus on a particular symptom such as stomach problems or heart palpitations.

Two other psychological disorders relate to the experience of physical problems that are not real.

Patients with factitious disorder fake physical symptoms in large part because they enjoy the

attention and treatment that they receive in the hospital. They may lie about symptoms, alter

diagnostic tests such as urine samples to mimic disease, or even injure themselves to bring on

more symptoms. In the more severe form of factitious disorder known asMünchausen syndrome,

the patient has a lifelong pattern of a series of successive hospitalizations for faked symptoms.

Factitious disorder is distinguished from another related disorder known asmalingering, which

also involves fabricating the symptoms of mental or physical disorders, but where the motivation

for doing so is to gain financial reward; to avoid school, work, or military service; to obtain

drugs; or to avoid prosecution.

The somatoform disorders are almost always comorbid with other psychological disorders,

including anxiety and depression and dissociative states (Smith et al., 2005). [2]

People with

BDD, for instance, are often unable to leave their house, are severely depressed or anxious, and

may also suffer from other personality disorders.

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Somatoform and factitious disorders are problematic not only for the patient, but they also have

societal costs. People with these disorders frequently follow through with potentially dangerous

medical tests and are at risk for drug addiction from the drugs they are given and for injury from

the complications of the operations they submit to (Bass, Peveler, & House, 2001; Looper &

Kirmayer, 2002). [3]

In addition, people with these disorders may take up hospital space that is

needed for people who are really ill. To help combat these costs, emergency room and hospital

workers use a variety of tests for detecting these disorders.

Sexual Disorders

Sexual disorders refer to a variety of problems revolving around performing or enjoying sex.

These include disorders related to sexual function, gender identity, and sexual preference.

Disorders of Sexual Function

Sexual dysfunction is a psychological disorder that occurs when the physical sexual response

cycle is inadequate for reproduction or for sexual enjoyment. There are a variety of potential

problems (Table 12.7 "Sexual Dysfunctions as Described in the "), and their nature varies for

men and women (Figure 12.17 "Prevalence of Sexual Dysfunction in Men and Women"). Sexual

disorders affect up to 43% of women and 31% of men (Laumann, Paik, & Rosen,

1999). [4]

Sexual disorders are often difficult to diagnose because in many cases the dysfunction

occurs at the partner level (one or both of the partners are disappointed with the sexual

experience) rather than at the individual level.

Table 12.7 Sexual Dysfunctions as Described in the DSM

Disorder Description

Hypoactive sexual

desire disorder Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity

Sexual aversion disorder

Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual

contact with a sexual partner

Female sexual arousal

disorder

Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity,

an adequate lubrication-swelling response of sexual excitement

Male erectile disorder Persistent or recurrent inability to attain or maintain an adequate erection until completion of

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Disorder Description

the sexual activity

Female orgasmic

disorder

Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement

phase

Male orgasmic disorder

Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement

phase during sexual activity

Premature ejaculation

Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after

penetration and before the person wishes it

Dyspareunia

Recurrent or persistent genital pain associated with sexual intercourse in either a male or a

female

Vaginismus

Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina

that interferes with sexual intercourse

Source: American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.,

text rev.). Washington, DC: Author.

Figure 12.17 Prevalence of Sexual Dysfunction in Men and Women

This chart shows the percentage of respondents who reported each type of sexual difficulty over the previous 12

months.

Source: Adapted from Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual dysfunction in the United States:

Prevalence and predictors. Journal of the American Medical Association, 281(6), 537–544.

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Hypoactive sexual desire disorder, one of the most common sexual dysfunctions, refers to a

persistently low or nonexistent sexual desire. How ―low sexual desire‖ is defined, however, is

problematic because it depends on the person’s sex and age, on cultural norms, as well as on the

relative desires of the individual and the partner. Again, the importance of dysfunction and

distress is critical. If neither partner is much interested in sex, for instance, the lack of interest

may not cause a problem. Hypoactive sexual desire disorder is often comorbid with other

psychological disorders, including mood disorders and problems with sexual arousal or sexual

pain (Donahey & Carroll, 1993). [5]

Sexual aversion disorder refers to an avoidance of sexual behavior caused by disgust or aversion

to genital contact. The aversion may be a phobic reaction to an early sexual experience or sexual

abuse, a misattribution of negative emotions to sex that are actually caused by something else, or

a reaction to a sexual problem such as erectile dysfunction (Kingsberg & Janata, 2003). [6]

Female sexual arousal disorder refers to persistent difficulties becoming sexually aroused or

sufficiently lubricated in response to sexual stimulation in women. The disorder may be

comorbid with hypoactive sexual desire or orgasmic disorder, or mood or anxiety disorders.

Male erectile disorder (sometimes referred to as ―impotence‖) refers to persistent and

dysfunctional difficulty in achieving or maintaining an erection sufficient to complete sexual

activity. Prevalence rates vary by age, from about 6% of college-aged males to 35% of men in

their 70s. About half the men aged 40 to 70 report having problems getting or maintaining an

erection ―now and then.‖

Most erectile dysfunction occurs as a result of physiological factors, including illness, and the

use of medications, alcohol, or other recreational drugs. Erectile dysfunction is also related to

anxiety, low self-esteem, and general problems in the particular relationship. Assessment for

physiological causes of erectile dysfunction is made using a test in which a device is attached to

the man’s penis before he goes to sleep. During the night the man may have an erection, and if

he does the device records its occurrence. If the man has erections while sleeping, this provides

assurance that the problem is not physiological.

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One of the most common sexual dysfunctions in men is premature ejaculation. It is not possible

to exactly specify what defines ―premature,‖ but if the man ejaculates before or immediately

upon insertion of the penis into the vagina, most clinicians will identify the response as

premature. Most men diagnosed with premature ejaculation ejaculate within one minute after

insertion (Waldinger, 2003). [7]

Premature ejaculation is one of the most prevalent sexual

disorders and causes much anxiety in many men.

Female orgasmic disorder refers to the inability to obtain orgasm in women. The woman enjoys

sex and foreplay and shows normal signs of sexual arousal but cannot reach the peak experience

of orgasm. Male orgasmic disorderincludes a delayed or retarded ejaculation (very rare) or

(more commonly) premature ejaculation.

Finally, dyspareunia and vaginismus refer to sexual pain disorders that create pain and

involuntary spasms, respectively, in women, and thus make it painful to have sex. In most cases

these problems are biological and can be treated with hormones, creams, or surgery.

Sexual dysfunctions have a variety of causes. In some cases the primary problem is biological,

and the disorder may be treated with medication. Other causes include a repressive upbringing in

which the parents have taught the person that sex is dirty or sinful, or the experience of sexual

abuse (Beitchman, Zucker, Hood, & DaCosta, 1992). [8]

In some cases the sex problem may be

due to the fact that the person has a different sexual orientation than he or she is engaging in.

Other problems include poor communication between the partners, a lack of sexual skills, and

(particularly for men) performance anxiety.

It is important to remember that most sexual disorders are temporary—they are experienced for a

period of time, in certain situations or with certain partners, and then (without, or if necessary

with, the help of therapy) go away. It is also important to remember that there are a wide variety

of sex acts that are enjoyable. Couples with happy sex lives work together to find ways that work

best for their own styles. Sexual problems often develop when the partners do not communicate

well with each other, and are reduced when they do.

Gender Identity Disorder

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Gender identity refers to the identification with a sex. Most children develop an appropriate

attachment to their own sex. In some cases, however, children or adolescents—sometimes even

those as young as 3 or 4 years old—believe that they have been trapped in a body of the wrong

sex.Gender identity disorder (GID, or transsexualism) is diagnosed when the individual displays

a repeated and strong desire to be the other sex, a persistent discomfort with one’s sex, and a

belief that one was born the wrong sex, accompanied by significant dysfunction and distress.

GID usually appears in adolescence or adulthood and may intensify over time (Bower,

2001). [9]

Since many cultures strongly disapprove of cross-gender behavior, it often results in

significant problems for affected persons and those in close relationships with them.

Gender identity disorder is rare, occurring only in about 1 in every 12,000 males and 1 in every

30,000 females (Olsson & Möller, 2003). [10]

The causes of GID are as of yet unknown, although

they seem to be related in part to the amount of testosterone and other hormones in the uterus

(Kraemer, Noll, Delsignore, Milos, Schnyder, & Hepp, 2009). [11]

The classification of GID as a mental disorder has been challenged because people who suffer

from GID do not regard their own cross-gender feelings and behaviors as a disorder and do not

feel that they are distressed or dysfunctional. People suffering from GID often argue that a

―normal‖ gender identity may not necessarily involve an identification with one’s own biological

sex. GID represents another example, then, of how culture defines disorder, and the next edition

of the DSMmay change the categorizations used in this domain accordingly.

Paraphilias

A third class of sexual disorders relates to sexual practices and interest. In some cases sexual

interest is so unusual that it is known as a paraphilia—a sexual deviation where sexual arousal is

obtained from a consistent pattern of inappropriate responses to objects or people, and in which

the behaviors associated with the feelings are distressing and dysfunctional. Paraphilias may

sometimes be only fantasies, and in other cases may result in actual sexual behavior (Table 12.8

"Some Paraphilias").

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Table 12.8 Some Paraphilias

Paraphilia Behavior or fantasy that creates arousal

Bestiality Sex with animals

Exhibitionism Exposing genitals to an unsuspecting person

Fetishism Nonliving or unusual objects or clothing of the opposite sex

Frotteurism Rubbing up against unsuspecting persons

Masochism Being beaten, humiliated, bound, or otherwise made to suffer

Pedophilia Sexual activity with a prepubescent child

Sadism Witnessing suffering of another person

Voyeurism Observing an unsuspecting person who is naked, disrobing, or engaged in intimate behavior

People with paraphilias are usually rejected by society but for two different reasons. In some

cases, such as voyeurism and pedophilia, the behavior is unacceptable (and illegal) because it

involves a lack of consent on the part of the recipient of the sexual advance. But other paraphilias

are rejected simply because they are unusual, even though they are consensual and do not cause

distress or dysfunction to the partners. Sexual sadism and sexual masochism, for instance, are

usually practiced consensually, and thus may not be harmful to the partners or to society. A

recent survey found that individuals who engage in sadism and masochism are as

psychologically healthy as those who do not (Connolly, 2006). [12]

Again, as cultural norms

about the appropriateness of behaviors change, the new revision of the DSM, due in 2013, will

likely change its classification system of these behaviors.

K E Y T A K E A W A Y S

 Somatoform disorders, including body dysmorphic disorder and hypochondriasis, occur when people become

excessively and inaccurately preoccupied with the potential that they have an illness or stigma.

 Patients with factitious disorder fake physical symptoms in large part because they enjoy the attention and treatment

that they receive in the hospital. In the more severe form of factitious disorder known as Münchhausen syndrome,

the patient has a lifelong pattern with a series of successive hospitalizations for faked symptoms.

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 Sexual dysfunction is a psychological disorder that occurs when the physical sexual response cycle is inadequate for

reproduction or for sexual enjoyment. The types of problems experienced are different for men and women. Many

sexual dysfunctions are only temporary or can be treated with therapy or medication.

 Gender identity disorder (GID, also called transsexualism) is a rare disorder that is diagnosed when the individual

displays a repeated and strong desire to be the other sex, a persistent discomfort with one’s sex, and a belief that one

was born the wrong sex, accompanied by significant dysfunction and distress.

 The classification of GID as a mental disorder has been challenged because people who suffer from it do not regard

their own cross-gender feelings and behaviors as a disorder and do not feel that they are distressed or dysfunctional.

 A paraphilia is a sexual deviation where sexual arousal is obtained from a consistent pattern of inappropriate

responses to objects or people, and in which the behaviors associated with the feelings are distressing and

dysfunctional. Some paraphilias are illegal because they involve a lack of consent on the part of the recipient of the

sexual advance, but other paraphilias are simply unusual, even though they may not cause distress or dysfunction.

E X E R C I S E S A N D C R I T I C A L T H I N K I N G

1. Consider the biological, personal, and social-cultural aspects of gender identity disorder. Do you think that this

disorder is really a “disorder,” or is it simply defined by social-cultural norms and beliefs?

2. Consider the paraphilias in Table 12.8 "Some Paraphilias". Do they seem like disorders to you, and how would one

determine if they were or were not?

3. View one of the following films and consider the diagnosis that might be given to the characters in it: Antwone

Fisher, Ordinary People, Girl Interrupted,Grosse Pointe Blank, A Beautiful Mind, What About Bob?, Sybil, One Flew

Over the Cuckoo’s Nest.

[1] Akagi, H., & House, A. O. (2001). The epidemiology of hysterical conversion. In P. Halligan, C. Bass, & J. Marshall

(Eds.), Hysterical conversion: Clinical and theoretical perspectives (pp. 73–87). Oxford, England: Oxford University Press.

[2] Smith, R. C., Gardiner, J. C., Lyles, J. S., Sirbu, C., Dwamena, F. C., Hodges, A.,…Goddeeris, J. (2005). Exploration of DSM-

IV criteria in primary care patients with medically unexplained symptoms. Psychosomatic Medicine, 67(1), 123–129.

[3] Bass, C., Peveler, R., & House, A. (2001). Somatoform disorders: Severe psychiatric illnesses neglected by

psychiatrists. British Journal of Psychiatry, 179, 11–14; Looper, K. J., & Kirmayer, L. J. (2002). Behavioral medicine approaches to

somatoform disorders.Journal of Consulting and Clinical Psychology, 70(3), 810–827.

[4] Laumann, E. O., Paik, A., Rosen, R. (1999). Sexual dysfunction in the United States.Journal of the American Medical

Association, 281(6), 537–544.

Saylor URL: http://www.saylor.org/books Saylor.org 73

[5] Donahey, K. M., & Carroll, R. A. (1993). Gender differences in factors associated with hypoactive sexual desire. Journal of Sex

& Marital Therapy, 19(1), 25–40.

[6] Kingsberg, S. A., & Janata, J. W. (2003). The sexual aversions. In S. B. Levine, C. B. Risen, & S. E. Althof (Eds.), Handbook of

clinical sexuality for mental health professionals (pp. 153–165). New York, NY: Brunner-Routledge.

[7] Waldinger, M. D. (2003). Rapid ejaculation. In S. B. Levine, C. B. Risen, & S. E. Althof (Eds.), Handbook of clinical sexuality for

mental health professionals (pp. 257–274). New York, NY: Brunner-Routledge.

[8] Beitchman, J. H., Zucker, K. J., Hood, J. E., & DaCosta, G. A. (1992). A review of the long-term effects of child sexual

abuse. Child Abuse & Neglect, 16(1), 101–118.

[9] Bower, H. (2001). The gender identity disorder in the DSM-IV classification: A critical evaluation. Australian and New Zealand

Journal of Psychiatry, 35(1), 1–8.

[10] Olsson, S.-E., & Möller, A. R. (2003). On the incidence and sex ratio of transsexualism in Sweden, 1972–2002. Archives of

Sexual Behavior, 32(4), 381–386.

[11] Kraemer, B., Noll, T., Delsignore, A., Milos, G., Schnyder, U., & Hepp, U. (2009). Finger length ratio (2D:4D) in adults with

gender identity disorder. Archives of Sexual Behavior, 38(3), 359–363.

[12] Connolly, P. (2006). Psychological functioning of bondage/domination/sado-masochism (BDSM) practitioners. Journal of

Psychology & Human Sexuality, 18(1), 79–120. doi:10.1300/j056v18n01_05

12.7 Chapter Summary

More psychologists are involved in the diagnosis and treatment of psychological disorder than in

any other aspect of psychology.

About 1 in every 4 Americans (over 78 million people) are estimated to be affected by a

psychological disorder during any one year. The impact of mental illness is particularly strong on

people who are poorer, of lower socioeconomic class, and from disadvantaged ethnic groups.

A psychological disorder is an unusual, distressing, and dysfunctional pattern of thought,

emotion, or behavior. Psychological disorders are often comorbid, meaning that a given person

suffers from more than one disorder.

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The stigma of mental disorder affects people while they are ill, while they are healing, and even

after they have healed. But mental illness is not a ―fault,‖ and it is important to work to help

overcome the stigma associated with disorder.

All psychological disorders are multiply determined by biological, psychological, and social

factors.

Psychologists diagnose disorder using the Diagnostic and Statistical Manual of Mental

Disorders (DSM). The DSM organizes the diagnosis of disorder according to five dimensions (or

axes) relating to different aspects of disorder or disability. The DSM uses categories, and patients

with close approximations to the prototype are said to have that disorder.

One critique of the DSM is that many disorders—for instance, attention-deficit/hyperactivity

disorder (ADHD), autistic disorder, and Asperger’s disorder—are being diagnosed significantly

more frequently than they were in the past.

Anxiety disorders are psychological disturbances marked by irrational fears, often of everyday

objects and situations. They include generalized anxiety disorder (GAD), panic disorder, phobia,

obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). Anxiety

disorders affect about 57 million Americans every year.

Dissociative disorders are conditions that involve disruptions or breakdowns of memory,

awareness, and identity. They include dissociative amnesia, dissociative fugue, and dissociative

identity disorder.

Mood disorders are psychological disorders in which the person’s mood negatively influences

his or her physical, perceptual, social, and cognitive processes. They include dysthymia, major

depressive disorder, and bipolar disorder. Mood disorders affect about 30 million Americans

every year.

Schizophrenia is a serious psychological disorder marked by delusions, hallucinations, loss of

contact with reality, inappropriate affect, disorganized speech, social withdrawal, and

deterioration of adaptive behavior. About 3 million Americans have schizophrenia.

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A personality disorder is a long-lasting but frequently less severe disorder characterized by

inflexible patterns of thinking, feeling, or relating to others that causes problems in personal,

social, and work situations. They are characterized by odd or eccentric behavior, by dramatic or

erratic behavior, or by anxious or inhibited behavior. Two of the most important personality

disorders are borderline personality disorder (BPD) and antisocial personality disorder (APD).

Somatization disorder is a psychological disorder in which a person experiences numerous long-

lasting but seemingly unrelated physical ailments that have no identifiable physical cause.

Somatization disorders include conversion disorder, body dysmorphic disorder (BDD), and

hypochondriasis.

Patients with factitious disorder fake physical symptoms in large part because they enjoy the

attention and treatment that they receive in the hospital.

Sexual disorders refer to a variety of problems revolving around performing or enjoying sex.

Sexual dysfunctions include problems relating to loss of sexual desire, sexual response or

orgasm, and pain during sex.

Gender identity disorder (GID, also called transsexualism) is diagnosed when the individual

displays a repeated and strong desire to be the other sex, a persistent discomfort with one’s sex,

and a belief that one was born the wrong sex, accompanied by significant dysfunction and

distress. The classification of GID as a mental disorder has been challenged because people who

suffer from GID do not regard their own cross-gender feelings and behaviors as a disorder and

do not feel that they are distressed or dysfunctional.

A paraphilia is a sexual deviation where sexual arousal is obtained from a consistent pattern of

inappropriate responses to objects or people, and in which the behaviors associated with the

feelings are distressing and dysfunctional.