Chapter Outline

1. Abnormal behavior: Myths, realities, and controversies
   1. The medical model applied to abnormal behavior
      1. Medical model: proposes that it is useful to think of abnormal behavior as a disease
      2. Basis for many of the terms used to refer to abnormal behavior (e.g., mental illness, psychological disorder)
      3. Rise of medical model (in 18th, 19th centuries) brought improvements in treatment
      4. Problems with model
         1. Thomas Szasz suggests that abnormal behavior usually involves a deviation from social norms rather than an illness
         2. Results in derogatory labels being applied to people with disorders
      5. Putting the model in perspective
         1. Model is useful as an analogy
         2. Diagnosis involves distinguishing one illness from another
         3. Etiology refers to the apparent causation and developmental history of an illness
         4. Prognosis is a forecast about the probable course of an illness
   2. Criteria of abnormal behavior
      1. Three criteria most frequently used
         1. Deviance (e.g., transvestic fetishism: a sexual disorder in which a man achieves sexual arousal by dressing in women's clothing)
         2. Maladaptive behavior
         3. Personal distress
      2. The cultural bounds of normality
         1. Considerable continuity across cultures in regard to what is considered abnormal
         2. But judgments of abnormality influenced to some extent by cultural norms, values vCultural norms within a society can change over time (e.g., homosexuality once considered a sexual disorder)
         3. Key point is that diagnoses of psychological disorders involve value judgments
      3. Normality and abnormality as a continuum
         1. Normality/abnormality matter of degree, not an either-or proposition
         2. David Rosenhan's classic study of "pseudopatients" in mental hospitals
   3. Psychodiagnosis: The classification of disorders
      1. First version of Diagnostic and Statistical Manual of Mental Disorders (DSM) published in 1952 by American Psychiatric Association
      2. Current version, DSM-IV introduced in 1994
      3. The multiaxial system
         1. Axis I -- clinical syndromes
         2. Axis II -- personality disorders
         3. Axis III -- general medical conditions
         4. Axis IV -- psychological and environmental problems
         5. Axis V -- global assessment of functioning
      4. Controversies surrounding the DSM
         1. Validity of diagnostic categories
         2. Inclusion of everyday problems not traditionally thought of as mental illnesses (e.g., extreme clumsiness in children)
   4. The prevalence of psychological disorders
      1. Epidemiology: study of the distribution of mental or physical disorders in a population
      2. Prevalence: the percentage of a population that exhibits a disorder during a specified time period
      3. Estimates suggest that psychological disorders are more common than most people realize
         1. Recent studies suggest that one-third of population may be affected
         2. Increase in numbers mostly due to more effective tabulation of drug-related disorders
         3. Most common disorders include anxiety disorders, substance use disorders, and mood disorders
2. Anxiety disorders
   1. Anxiety disorders: a class of disorders marked by feelings of excessive apprehension and anxiety
      1. Four principal types, not mutually exclusive
      2. Quite common, occurring in about 17% of population
   2. Generalized anxiety disorder (marked by a chronic, high level of anxiety that is not tied to any specific threat)
      1. Sometimes called "free-floating anxiety"
      2. Frequently accompanied by physical symptoms (e.g., trembling, muscle tension, etc.)
   3. Phobic disorder (marked by a persistent and irrational fear of an object or situation that presents no realistic danger)
      1. Fears seriously interfere with everyday behavior
      2. Common phobias include acrophobia (fear of heights), claustrophobia (fear of enclosed places), hydrophobia (fear of water)
   4. Panic disorder and agoraphobia
      1. Panic disorder: characterized by recurrent attacks of overwhelming anxiety that usually occur suddenly and unexpectedly
      2. Agoraphobia: a fear of going out to public places
         1. A common complication of panic disorders
         2. More similar to panic disorder than phobic disorder
      3. Vast majority of people with these disorders are women
   5. Obsessive-compulsive disorder (OCD) is marked by persistent, uncontrollable intrusions of unwanted thoughts (obsessions) and urges to engage in senseless rituals (compulsions)
      1. Typical age of onset is early adulthood
      2. Prevalence seems to be increasing, but may be due to changes in clinicians' and researchers' diagnostic tendencies
   6. Etiology of anxiety disorders
      1. Biological factors
         1. May be weak genetic predisposition
         2. Associated with inhibited temperament in infants
         3. Anxiety sensitivity may make people vulnerable to anxiety disorders
         4. Has been linked to neurochemical activity in brain
            1. Neurotransmitters: chemicals that carry signals from one neuron to another
            2. Disturbances in neural circuits using GABA may play role
      2. Conditioning and learning
         1. Many anxiety responses may be acquired through classical conditioning, maintained through operant conditioning
         2. Martin Seligman's concept of preparedness helps explain the tendency to develop phobias of certain objects
            1. Suggests that people may be biologically prepared to acquire some fears (e.g., snakes, spiders)
            2. Only modest research support
         3. Conditioning models have number of problems
      3. Cognitive factors
         1. Certain styles of thinking may make some people vulnerable to anxiety disorders
         2. Theorists suggest these people tend to:
            1. Misinterpret harmless situations as threatening
            2. Focus excessive attention on perceived threats
            3. Selectively recall information that seems threatening
      4. Personality
         1. Neuroticism correlated with an elevated prevalence of anxiety disorders
         2. Mechanisms underlying association are subject of debate
      5. Stress
         1. Anxiety disorders may be stress related
         2. High stress may help precipitate onset of anxiety disorders
3. Somatoform disorders
   1. Psychosomatic diseases versus somatoform disorders
      1. Psychosomatic diseases: genuine physical ailments caused in part by psychological factors, especially emotional stress
         1. Include maladies such as ulcers, asthma, high blood pressure
         2. Recorded on DSM axis for physical problems (Axis III)
      2. Somatoform disorders: physical ailments with no authentic organic basis that are due to psychological factors
         1. Recorded on AXIS I (clinical syndromes) of DSM
         2. Symptoms are more imaginary than real, although people are not simply faking
   2. Somatization disorder is marked by a history of diverse physical complaints that appear to be psychological in origin
      1. Occur mostly in women, and often in conjunction with depression or generalized anxiety disorder
      2. Diversity of victims' complaints is distinguishing feature
   3. Conversion disorder is characterized by a significant loss of physical function, with no apparent organic basis, usually in a single organ system
      1. Common symptoms include loss of vision, hearing; paralysis
      2. People with conversion disorders usually troubled by more severe ailments than people with somatization disorders
   4. Hypochondriasis: (more widely known as hypochondria) is characterized by excessive preoccupation with health concerns and incessant worry about developing physical illnesses
      1. People tend to over-interpret every conceivable sign of illness
      2. Frequently coexists with other psychological disorders, especially anxiety disorders, depression
   5. Etiology of somatoform disorders
      1. Inherited aspects of physiological functioning may predispose some people to somatoform disorders
      2. Personality factors
         1. Often associated with histrionic personality characteristics
         2. Neuroticism may also play a role
      3. The sick role
         1. Some people grow fond of role associated with being sick
         2. Benefits or role include being able to avoid life's challenges, getting attention from others
4. Dissociative disorders (a class of disorders in which people lose contact with portions of their consciousness or memory, resulting in disruptions in their sense of identity)
   1. Dissociative amnesia and fugue
      1. Dissociative amnesia: a sudden loss of memory for important personal information that is too extensive to be due to normal forgetting
         1. Memory loss may occur for single traumatic event, or for extended period of time surrounding the event
         2. Cases have been observed as a result of disasters, accidents, combat stress, physical abuse, etc.
      2. Dissociative fugue: people experience extensive amnesia and confusion about their identity, coupled with unexpected travel away from their customary home
   2. Dissociative identity disorder(the disorder formerly known as multiple-personality disorder or MPD) involves the coexistence in one person of two or more largely complete, and usually very different, personalities
      1. Formal name changed in recent version of DSM, but more widely known by its traditional name of MPD
      2. A rare disorder
      3. Various personalities often unaware of each other
      4. Appears that a handful of clinicians have begun over-diagnosing the disorder
   3. Etiology of dissociative disorders
      1. Dissociative amnesia, fugue usually attributed to excessive stress
         1. Relatively little is known about why such an extreme reaction occurs in tiny minority of people vSpeculation that certain personality traits may make some people more susceptible (e.g., fantasy proneness)
      2. Causes of MPD are obscure
         1. Some skeptics suggest that people fake the disorder
         2. Although some faking occurs, most theorists believe at least some cases are authentic
         3. May be associated with severe emotional trauma in childhood
5. Mood disorders: a class of disorders marked by emotional disturbances that may spill over to disrupt physical, perceptual, social, and thought processes
   1. Introduction
      1. Tend to be episodic in nature
      2. Episodes of disturbance vary greatly in length; typically last several months
   2. Major depressive disorder is marked by persistent feelings of sadness and despair and a loss of interest in previous sources of pleasure
      1. Negative emotions main symptom
      2. Other symptoms include reduced appetite, insomnia, lack of energy
      3. A relatively common disorder
         1. Recent studies indicate that as many as 17% of Americans endure a depressive disorder at some time
         2. Prevalence is increasing, particularly for people born since World War II
         3. About twice as common in women as in men
            1. Gender gap opens up during middle to late adolescence
            2. Many possible explanations have been offered
   3. Bipolar disorders (formerly known as manic-depressive disorders) marked by the experience of both depressed and manic periods
      1. Manic episodes characterized by elevated mood, high self-esteem, optimism, energy
      2. Much less common than unipolar depression
      3. Seen equally often in men and women
   4. Etiology of mood disorders
      1. Genetic vulnerability
         1. Evidence indicates genetic factors influence likelihood of developing disorder
         2. Concordance rate: the percentage of twin pairs or other pairs of relatives that exhibit the same disorder
            1. Twin studies, which compare identical and fraternal twins, suggest that genetic factors are involved
            2. Concordance rates average around 67% for identical twins, 15% for fraternal twins
      2. Neurochemical factors
         1. Correlations found between mood disorders and levels of two neurotransmitters in brain (norepinephrine, serotonin)
         2. Drug therapies are fairly effective in treatment
      3. Cognitive factors
         1. Explanatory styles may play a role; pessimistic explanatory style, learned helplessness or a sense of hopelessness may be cognitive styles that contribute to elevated vulnerability to depression.
         2. Research indicates that people who consistently tend to make internal, stable, and global attributions are more prone to depression
         3. Depressed people who ruminate about their depression tend to stay depressed longer
      4. Interpersonal roots
         1. Inadequate social skills may put people on road to depression
         2. Depressed people tend not to be enjoyable companions
      5. Precipitating stress
         1. Evidence indicates moderately strong link between stress and onset of mood disorders
         2. Stress may also affect how people with mood disorders respond to treatment
         3. Stress may trigger mood disorders in people who are vulnerable
6. Schizophrenic disorders: a class of disorders marked by disturbances in thought that spill over to affect perceptual, social, and emotional processes
   1. Introduction
      1. Estimates suggests it occurs in about 1-1.5% of population
      2. A severe, debilitating disorder
   2. General symptoms
      1. Irrational thought
         1. Delusions: false beliefs that are maintained even though they clearly are out of touch with reality
         2. Thinking becomes chaotic
      2. Deterioration of adaptive behavior
      3. Distorted perception
         1. Hallucinations: sensory perceptions that occur in the absence of a real, external stimulus or that represent gross distortions of perceptual input
         2. Auditory hallucinations are most common
      4. Disturbed emotion
         1. Some victims show flattening of emotions
         2. Others show inappropriate emotional responses
         3. Some become emotionally volatile
   3. Four subtypes
      1. Paranoid schizophrenia: dominated by delusions of persecution, along with delusions of grandeur
      2. Catatonic schizophrenia: marked by striking motor disturbances, ranging from muscular rigidity to random motor activity
      3. Disorganized schizophrenia: marked by a particularly severe deterioration of adaptive behavior
      4. Undifferentiated schizophrenia: marked by idiosyncratic mixtures of schizophrenic symptoms
      5. Some researchers (e.g., Nancy Andreasen) have proposed alternative approach to sub-typing based on predominance of negative versus positive symptoms
         1. Negative symptoms involve behavior deficits (e.g., flattened emotions, social withdrawal)
         2. Positive symptoms involve behavioral excesses or peculiarities (e.g., hallucinations, delusions)
   4. Course and outcome
      1. Disorders usually emerge during adolescence, early adulthood
      2. Emergence may be sudden or gradual
      3. Factors related to favorable prognosis
         1. Onset was sudden rather than gradual
         2. Onset occurred at later age
         3. Patient was well adjusted prior to onset
         4. Patient has healthy, supportive family to return to
   5. Etiology of schizophrenia
      1. Genetic vulnerability
         1. Much evidence for role of hereditary factors
         2. People seem to inherit genetically transmitted vulnerability
      2. Neurochemical factors
         1. Associated with changes in neurotransmitter activity in brain
         2. Excess dopamine activity implicated, although evidence is riddled with inconsistencies
      3. Structural abnormalities in brain
         1. Problems with attention suggest that disorders may be caused by neurological defects
         2. Evidence suggests association between enlarged brain ventricles and chronic schizophrenia
            1. Particularly true for male patients
            2. Significance of evidence is hotly debated
         3. Researchers currently intrigued by finding that thalamus is smaller and shows less metabolic activity in schizophrenic patients
      4. The Neurodevelopmental Hypothesis
         1. This hypothesis proposes that schizophrenia is produced by a series of disruptions in the normal development of the brain
         2. The suspected causes of these disruptions are exposure to viruses during prenatal development, malnutrition, and obstetrical complications
      5. Expressed emotion
         1. Expressed emotion is degree to which relatives are highly critical, emotionally over-involved
         2. Relapse rates are much greater for patients returning to families high in expressed emotion
         3. Patients suffering from mood disorders whose families are high in expressed emotion also show elevated relapse rates
      6. Precipitating stress
         1. Stress seems to play role in triggering the disorder
         2. High stress may also trigger relapses
7. Psychological Disorders and the Law
   1. Insanity
      1. Insanity is a legal status indicating that a person cannot be held responsible for his or her actions because of metal illness.
         1. This is an issue because criminal acts must be intentional.
         2. There is no simple way to establish insanity
         3. Most people with psychological diagnoses would not qualify as insane
         4. The most widely used rule for establishing insanity is the M'naghten rule, which states that insanity exists when a mental disorder makes a person unable to distinguish between right and wrong
         5. People tend to vastly overestimate the use of the insanity defense, it is rarely used, and when used, rarely succeeds
   2. Involuntary Commitment
      1. In involuntary commitment people are hospitalized in psychiatric facilities against their will. In order for this to occur, a mental health professional and legal authority must certify that the person is:
         1. A danger to his or her self
         2. A danger to others
         3. In need of treatment due to severe disorientation vIn emergencies, mental health professionals can order a temporary commitment, but extensive involuntary hospitalization requires court proceedings
8. Application: Understanding eating disorders (severe disturbances in eating behavior characterized by preoccupation with weight and unhealthy efforts to control weight)
   1. Anorexia nervosa (involves intense fear of gaining weight, disturbed body image, refusal to maintain normal weight, and dangerous measures to lose weight)
      1. Two subtypes
         1. Restricting type characterized by tendency to drastically reduce intake of food, sometimes to point of starvation
         2. Binge-eating purging type involves attempts to lose weight by deliberately vomiting after meals, misusing laxatives and diuretics, and engaging in excessive exercise
      2. Both types entail a disturbed body image, which results in relentless decline in body weight
      3. Leads to variety of medical problems, including amenorrhea (loss of menstrual cycles in women), gastrointestinal problems, low blood pressure, etc.
      4. Leads to death in 2-10% of patients
      5. Often coexists with other psychological disorders (e.g., depression, anxiety disorders)
   2. Bulimia nervosa (involves habitually engaging in out-of-control overeating followed by unhealthy compensatory efforts, such as self-induced vomiting, fasting, abuse of laxatives and diuretics, and excessive exercise)
      1. Eating binges usually carried out in secret, followed by intense guilt
         1. Feelings motivate ill-advised strategies to undo the effects of overeating
         2. People suffering from bulimia nervosa typically maintain reasonably normal body weight
      2. Medical problems include amenorrhea, dental problems, metabolic deficiencies, etc.
      3. Shares many features with anorexia nervosa (e.g., morbid fear of becoming obese)
      4. Different than anorexia nervosa in crucial ways
         1. Bulimia is less life-threatening
         2. Bulimics are more likely to recognize that eating behavior is pathological, cooperate with treatment
   3. History and prevalence
      1. Although disorder is not new, it did not become a common affliction until middle part of 20th century
      2. Anorexia, bulimia are product of modern, affluent Western culture
      3. About 90-95% of sufferers are female
         1. Appears to be result of cultural pressures
         2. Prevalence of disorders also elevated in groups that place undue emphasis on thinness (e.g., fashion models, dancers)
      4. Prevalence has increased dramatically in recent decades, although it might be leveling off
   4. Etiology of eating disorders
      1. Genetic vulnerability
         1. Evidence not as strong as it is for other types of psychopathology
         2. But genetic predisposition may exist
      2. Personality factors
         1. Most victims of anorexia tend to be obsessive, rigid, neurotic, emotionally restrained; victims of bulimia tend to be impulsive, overly sensitive, low in self-esteem
         2. Most of these personality traits are influenced by genetics
      3. Cultural values
         1. Contribution can hardly be overestimated
         2. Western society's emphasis on thinness, attractiveness in women plays a role
      4. The role of the family
         1. Some theorists suggest overly involved parents may have an influence
         2. Other theorists argue that parents of adolescents with eating disorders tend to define their children's needs for them
      5. Cognitive factors
         1. Cognitive theorists emphasize role of disturbed thinking
         2. Additional research is needed to determine whether disturbed thinking is a cause or merely a symptom of eating disorders
      6. The role of dieting
         1. History of dieting is viewed as risk factor
         2. Dieting is only important in conjunction with other factors (e.g., vulnerability, stress)
   5. Course and outcome
      1. Variety of therapies have been applied, with mixed results
         1. About 40-50% experience full recovery
         2. Treatment largely a failure for about 20-25% of patients
         3. Remaining patients fall somewhere in between
      2. Prognosis is somewhat better for bulimia than for anorexia