Psychological Disorders

PSYCHOLOGICAL DISORDERS
I felt the need to clean my room at home in Indianapolis every Sunday and would spend
four to five hours at it. I would take every book out of the bookcase, dust and put it back.
At the time I loved doing it. Then I didnt want to do it anymore, but I couldnt stop. The
clothes in my closet hung exactly two fingers apart.
I made a ritual of touching the wall
in my bedroom before I went out because something bad would happen if I didnt do it the
right way. I had a constant anxiety about it as a kid, and it made me think for the first time
that I might be nuts.
.
Marc, diagnosed with obsessive-corn putsive disorder (from Summers, 1996)

Whenever I get depressed its because Ive lost a sense of self. I cant find reasons to like
myself. I think Im ugly. I think no one likes me
I become grumpy and short-tempered.
Nobody wants to be around me. Im left alone. Being alone confirms that I am ugly and
not worth being with. I think Im responsible for everything that goes wrong.
Greta, diagnosed with depression (from Thorne, 1993, p. 21)

Voices, like the roar of a crowd, came. I felt like Jesus; I was being crucified. It was dark.
I just continued to huddle under the blanket, feeling weak, laid bare and defenseless in a
cruel world I could no longer understand.
Stuart, diagnosed with schizophrenia (from Emmons et at., 1997)
ow and then, all of us feel, think, or act in ways that may resemble
a psychological disorder. We feel anxious, depressed, withdrawn, or sus
picious, just less intensely and more briefly. So its no wonder that we
are drawn to try to understand disturbed mental stateswe sometimes
see ourselves in the psychological disorders we study. To study the abnormal is the
best way of understanding the normal, said William James (18421910).
Another reason for our curiosity is that most of us will, at some point, encounter
someone with a psychological disorder. Personally or through friends or family, we
may experience the bewilderment and pain of unexplained physical symptoms,
irrational fears, or a feeling that life is not worth living. In one study of 26 Amen
can college campuses, 32 percent of students reported an apparent mental health
problem (Eisenberg et al., 2011).
Worldwide, some 450 million people live with mental or behavior disorders
(WHO, 2010). Although their rates and symptoms vary by culture, no known soci
ety is free of two terrible disordersmajor depression and schizophrenia (Baumeis
ter & Hrter, 2007; Draguns, 1990a,b, 1997). This chapter examines these disorders
and others. Chapter 16 considers their treatment.
IL
610
CHAPTER 15:
Introduction to
Psychological Disorders
in the rainbow can draw the
line tvhere the violet tint ends and the
orange tint begins? Distinctly we see
the difference of the colors, but where
exactly does the one first blendingly
enter into the other? So with sanity
and insanity.
\\lho
Herman
Melville, Billy Budd, Sailor, 1924
Most people would agree that someone who is too depressed to get out of bed for weeks
at a time has a psychological disorder. But what about those who, having experienced a
loss, are unable to resume their usual social activities? Where should we draw the line
between sadness and depression? Between zany creativity and bizarre irrationality?
Between normality and abnormality? Lets start with these questions:
How should we define psychological disorders?
How should we understand disorders? How do underlying biological factors contrib
ute to disorder? How do troubling environments influence our well-being? And how
do these effects of nature and nurture interact?
How should we classify psychological disorders? And can we do so in a way that
allows us to help people without stigmatizing them with labels?
What do we know about rates of psychological disorders? How many people have
them? \Vho is vulnerable, and when?
psychological disorder a syndrome

marked by a clinically significant
disturbance in an individuals cognition,
emotion regulation, or behavior.
Culture and normality Young men

of the West African Wodaabe tribe put
on elaborate makeup and costumes to
attract women. Young American men
may buy flashy cars with loud stereos
to do the same. Each culture may view
the others behavior as abnormal.
Defining Psychological Disorders

ti How should we draw the line between normality and disorder?
A psychological disorder is a syndrome (collection of symptoms) marked by a clini

cally significant disturbance in an individuals cognition, emotion regulation, or behav
ior (American Psychiatric Association, 2013). Disturbed, or d)sfuflctioflat thoughts,
emotions, or behaviors are maladajtivethey interfere with normal day-to-day life.
Believing your home must be thoroughly cleaned every weekend is not a disorder. But
if cleaning rituals interfere with work and leisure, as lVIarcs did in this chapters open
ing, they may be signs of a disorder. And occasional sad moods that persist and become
disabling may likewise signal a psychological disorder.
Distress often accompanies dysfunctional behaviors. 1vlarc, Greta, and Stuart were
all distressed by their behaviors or emotions.
Over time, definitions of what makes for a significant disturbance have varied.
From 1952 through December 9, 1973, homosexuality was classified as a psychologi
cal disorder. By days end on December 10,
it was not. The American Psychiatric Asso
ciation made this change because more
and more of its members no longer viewed
same-sex attraction as a psychological prob
lem. Such is the power of shifting societal
beliefs. (Later research revealed, however,
that the stigma and stresses that gay, lesbian,
and transsexual people often experience
can increase the risk of mental health prob
lems [Hatzenbuehler et al., 2009; Meyer,
2003].) In the twenty-first century, other
controversies swirl over new or altered diag
noses (such as attention-deficit/hyperactivity
disorder) in the most recent classification

tool for describing disorders. (Youll hear
more about this later.)
CHAPTER 15:
611
RETRIEVAL PRACTICE
A lawyer is distressed by feeling the need to wash his hands 100 times a day. He has
no time left to meet with clients, and his colleagues are wondering about his compe
tence. His behavior would probably be labeled disordered, because it is
that is, it interferes with his day-to-day life.
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Understanding Psychological Disorders

tDl How do the medical model and the biopsychosocial approach influence our
understanding of psychoLogical disorders?
The way we view a problem influences how we try to solve it. In earlier times,
people often viewed strange behaviors as evidence that strange forcesthe move
ments of the stars, godlike powers, or evil spiritswere at work. Had you lived
during the IVIiddle Ages, you might have said The devil made him do it. Believ
ing that, you might have approved of a cure that would drive out the evil demon.
Thus, people considered mad were sometimes caged or given therapies such as
genital mutilation, beatings, removal of teeth or lengths of intestines, or transfu
sions of animal blood (farina, 1982). Barbaric treatments for mental illness linger
even today. In some places, people are chained to a bed, locked in their rooms, or
even locked in a room with wild hyenas, in the belief that the animals will see and
attack evil spirits (Hooper, 2013). Noting the physical and emotional damage of
such restraint, the World Health Organization launched a chain-free initiative
that aims to reform hospitals into patient-friendly and humane places with mini
mum restraints (WHO, 2014).
Yesterdays therapy Through
the ages, psychologically disordered

people have received brutal treatments,
including the ttephination evident in
this Stone Age skull. Drilling skull holes
like these may have been an attempt
to telease evil spirits and cute those
with mental disorders. Did this patient
survive the cute?
The Medical Model

Brutal treatments may worsen, rather than improve, mental health. Reformers, such as
Philippe Pinel (17451826) in France, opposed such brutal treatments. Madness is not
demon possession, he insisted, but a sickness of the mind caused by severe stress and
inhumane conditions. Curing the illness, he said, requires moral treatment, including
boosting patients morale by unchaining them and talking with them. He and others
worked to replace brutality with gentleness, isolation with activity, and filth with clean
air and sunshine.
Moral treatment Under Philippe
Pinels influence, hospitals sometimes

sponsored patient dances, often called
lunatic balls, depicted in this paint
ing by George Bellows (Dance in a
Madhouse).
612
CHAPTER 15:
medical model the concept that

diseases, in this case psychological
disorders, have physical causes that
can be diognosed, treated, and, in most
cases, cured, often through treatment in
a hospitot
epigenetics the study of environmental

influences on gene expression that occur
without a DNA change.
By the 1800s, the discovery that syphilis infects the brain and distorts the mind
drove further gradual reform. Hospitals replaced asylums, and the medical model of
mental disorders was born. This model is reflected in the terms we still use today. We
speak of the mental health movement: A mental illness (also called a psychopathology)
needs to be diagnosed on the basis of its symptoms. It needs to be treated through
therapy, which may include time in a psychiatric hospital.
The medical perspective has gained credibility from recent discoveries that geneti
cally influenced abnormalities in brain structure and biochemistry contribute to many
disorders. But as we will see, psychological factors, such as chronic or traumatic stress,
also play an important role.
The Biopsychosocial Approach
Increasingly, North Americas dis

orders, along with McDonalds and
MTV, have spread across the globe
(Watters, 2010).
To call psychological disorders sicknesses tilts research heavily toward the influence
of biology and away from the influence of our personal histories and social and cultural
surroundings. But in the study of disorders, as in so many other areas, ive must remem
ber that our behaviors, our thoughts, and our feelings are formed by the interaction of
biological, psychological, and social-cultural influences. As individuals, we differ in the
amount of stress we experience and in the ways we cope with stressors. Cultures also
differ in their sources of stress and in traditional ways of coping.
Some disorders, such as depression and schizophrenia, occur worldwide. From
Asia to Africa and across the Americas, schizophrenias symptoms often include irra
tionality and incoherent speech. Other disorders tend to be associated with specific
cultures. In Malaysia, amok describes a sudden outburst of violent behavior (thus the
English phrase run amok). Latin America lays claim to susto, a condition marked by
severe anxiety, restlessness, and a fear of black magic. In Japanese culture, people may
experience taijin kyofushosocial anxiety about their appearance, combined with a
readiness to blush and a fear of eye contact. The eating disorders anorexia nervosa and
bulimia nervosa occur mostly in food-abundant Western cultures. Such disorders may
share an underlying dynamic (such as anxiety) while differing in the symptoms (an eat
ing problem or a type of fear) manifested in a particular culture.
Disorders reflect genetic predispositions and physiological states, inner psychologi
cal dynamics, and social and cultural circumstances. The biopsychosocial approach
emphasizes that mind and body are inseparable (FIGURE 15.1). Negative emotions con
tribute to physical illness, and physical abnormalities contribute to negative emotions.
Epigenetics, the study of how nurture shapes nature, also informs our understand
ing of disorders (Powledge, 2011). Genes and environment are not the whole story, as
weve seen in other chapters. It turns out our environment can affect whether a gene
is expressed or not, and thus affect the development of various psychological disorders.
BiologicaL influences:
evolution
individual genes
brain structure and chemistry
V FIGURE 15.1
The biopsychosocial approach
to psychological disorders
Todays psychology studies how

biological, psychological, and
social-cultural factors interact to
produce specific psychological
disorders.
PsychoLogicaL influences:
stress
trauma
learned helplessness
mood-related perceptions and
memories
Psychological
t
Social-cultural influences:
roles
expectations
definitions of normality and disorder
Getty images
CHAPTER 75:
For example, even identical twins (with identical genes) do not share the same risks of
developing psychological disorders. They are more likely, but not always destined, to
develop the same disorders. Their varying environmental factors influence whether
certain culprit genes are expressed.
613
DSM-5 the American Psychiatric Asso

ci ations Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition; a widely
used system for c[assifying psychological
disorders.
RETRIEVAL PRACTICE
Are psychological disorders universal, or are they culture-specific? Explain with

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psychological disorders?
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Classifying Disordersand Labeling People

ii How and why do clinicians classify psychological disorders, and why do some
psychologists criticize the use of diagnostic labels?
In biology, classification creates order. To classify an animal as a mammal says a great
dealthat it is warm-blooded, has hair or fur, and produces milk to nourish its young.
In psychiatry and psychology, too, classification orders and describes symptoms. To
classify a persons disorder as schizophrenia suggests that the person talks incoher
ently, has bizarre beliefs, shows either little emotion or inappropriate emotion, or is
socially withdrawn. Schizophrenia is a quick way to describe a complex disorder.
But diagnostic classification gives more than a thumbnail sketch of a persons disor
dered behavior, thoughts, or feelings. In psychiatry and psychology, classification also
(J
aims to
predict the disorders future course.
suggest appropriate treatment.
prompt research into its causes.
To study a disorder, we must first name and describe it.
The most common tool for describing disorders and estimating how often they
occur is the American Psychiatric Associations 2013 Diagnostic and Statistical Manual
of IVIental Disorders, now in its fifth edition (DSM-5). Physicians and mental health
workers use the detailed diagnostic criteria and codes in the DSM-5 to guide medical
diagnoses and treatment. For example, a person may be diagnosed with and treated for
insomnia disorder if he or she meets all of the criteria in TABLE 15.1.
V TABLE 15.1
Insomnia Disorder
Feeling unsatisfied with amount or quality of sleep (trouble falling asleep, staying
asleep, or returning to sleep)
Sleep disruption causes distress or diminished everyday functioning
Happens three or more nights each week
Occurs during at least three consecutive months
Happens even with sufficient sleep opportunities
Independent from other sleep disorders (such as narcolepsy)
Independent from substance use or abuse
Independent from other mental disorders or medical conditions
Im always like this, and my family was

wondering if you could prescribe a mild
depressant.
A book of case illustrations accom

panying the previous DSM edition
provided several examples for this
chapter.
614
CHAPTER 15:
Struggles and recovery Boston

Mayor Martin Walsh spoke openly about
his struggles with alcohol. His story of
recovery helped him win the closest
Boston mayoral election in decades.
In the DSM-5, some diagnostic labels have changed. The conditions formerly called
autism and Aspergers syndrome have now been combined under the label autism
spectrum disorder. Mental retardation has become intellectual thsabiltt) New catego
ries, such as hoarding disorder and binge-eating disorder, have been added.
Some of the new or altered diagnoses are controversial. Disruptive mood dysregula
tion disorder is a new DSM-5 diagnosis for children who exhibit persistent irritability
and frequent episodes of behavior outbursts three or more times a week for more than
a year. Will this diagnosis assist parents who struggle with unstable children, or will it
turn temper tantrums into a mental disorder and lead to overmedication, as the chair
of the previous DSM edition has warned (Frances, 2012)?
Real-world tests (field trials) have assessed clinician agreement when using the new
DSIVI-5 categories (Freedman et al., 2013). Some diagnoses, such as adult posttraumatic
stress disorder and childhood autism spectrum disorder fared wellwith agreement near
70 percent. (If one psychiatrist or psychologist diagnosed someone with one of these
disorders, there was a 70 percent chance that another mental health worker would
independently give the same diagnosis.) Others, such as antisocial personality disorder
and generalized anxiety disorder, fared poorly.
Critics have long faulted the DS1\I for casting too wide a net and bringing almost
any kind of behavior within the compass of psychiatry (Eysenck et al., 1983). Some
now worry that the DSM-5s even wider net will extend the pathologizing of everyday
lifefor example, by turning childish rambunctiousness into ADHD, and bereave
ment grief into a depressive disorder (Frances, 2013). (See Thinking Critically About:
ADHD.) Others respond that hyperactivity and depression, though needing careful
definition, are genuine disorderseven when the depression was triggered by a major
life stress such as a death when the grief does not go away (Kendler, 2011; Kupfer, 2012).
Other critics register a more basic complaintthat these labels are at best subjec
tive and at worst value judgments masquerading as science. Once we label a person,
we view that person differently (Bathje & Pryor, 2011; Farina, 1982; Sadler et al., 2012).
Labels can change reality by putting us on alert for evidence that confirms our view.
When teachers were told certain students were gifted, they acted in ways that elicited
the behaviors they expected (Snyder, 1984). Someone who was led to think you are
nasty may treat you coldly, leading you to respond as a mean-spirited person would.
Labels can be self-fulfilling. They create expectations that guide how we perceive and
interpret people.
The biasing power of labels was clear in a now-classic study. David Rosenhan (1973)
and seven others went to hospital admissions offices, complaining (falsely) of hearing
voices saying empty, hollow, and thud. Apart from this com
plaint and giving false names and occupations, they answered
questions truthfully. All eight healthy people were misdiag
nosed with disorders.
Should we be surprised? As one psychiatrist noted, if some
one swallows blood, goes to an emergency room, and spits it
up, should we fault the doctor for diagnosing a bleeding ulcer?
Surely not. But what followed the Rosenhan study diagnoses
was startling. Until being released an average of 19 days later,
those eight patients showed no other symptoms. Yet after
analyzing their (quite normal) life histories, clinicians were
able to discover the causes of their disorders, such as has
ing mixed emotions about a parent. Even routine note-taking
behavior was misinterpreted as a symptom.
Labels matter. In another study, people watched videotaped
interviews. If told the interviewees were job applicants, the
viewers perceived them as normal (Langer et al., 1974, 1960).
CHAPTER 75:
615
THINKING CRITiCALLY AT
ADHDNormal High Energy or Disordered Behavior?

Why is there controversy over attention-deficit!
hyperactivity disorder?
Eight-year-old Todd has always been energetic. At home, he chat

ters away and darts from one activity to the next, rarely settling
down to read a book or focus on a game. At play, he is reckless and
overreacts when playmates bump into him or take one of his toys.
At school, Todd fidgets, and his exasperated teacher complains
that lie doesnt listen, follow instructions, or stay in his seat and
do his lessons. As Todd matures to adulthood, his hyperactivity
likely will subside, but his inattentiveness may persist (Kessler et
aL, 2010).
If taken for a psychological evaluation, Todd may be diagnosed
with attention-deficit/hyperactivity disorder (ADHD). Some
11 percent of American 4- to 17-year-olds receive the diagno
sis after displaying its key symptoms (extreme inattention,
hyperactivity, and impulsivity) (Schwarz & Cohen, 2013). Stud
ies also find 2.5 percent of adultsthough the number dimin
ishes with ageexhibit ADHD symptoms (Simon et al., 2009).
The looser criteria for adult ADHD in the DSM-5 has led critics
to fear increased diagnosis and overuse of prescription drugs
(Frances, 2012).
To skeptics, being distractible, fidgety, and impulsive sounds
like a disorder caused by a single genetic variation: a Y chro
mosome (the male sex chromosome). And sure enough, ADHD
is diagnosed three times more often in boys than in girls.
Children who are a persistent pain in the neck in school are
often diagnosed with ADHD and given powerful prescription
drugs (Gray, 2010). Minority youth less often receive an ADHD
diagnosis than do Caucasian youth, but this difference has
shrunk as minority ADHD diagnoses have increased (Getaliun
et al., 2013).
The problem may reside less in the child than in todays abnor
mal environment that forces children to do what evolution has not
prepared them to doto sit for long hours in chairs. In more natu
ral outdoor environments, these children might seem perfectly
healthy.
Rates of medication for presumed ADHD vary by age, sex, and
location. Prescription drugs are more often given to teens than
to younger children. Boys are nearly three times more likely to
receive them than are girls. And location matters. Among 4to 17-year-olds, prescription rates have varied from 1 percent
in Nevada to 9 percent in North Carolina (CDC, 2013). Some
students seek out the stimulant drugscalling them the good-
grade pills. They hope to increase their focus and achievement,

but the risks include the development of addiction, depressive
disorders, or bipolar disorder (Schwarz, 2012).
Not everyone agrees that ADHD is being overdiagnosed.
Some argue that todays more frequent diagnoses reflect
increased awareness of the disorder, especially in those areas
where rates are highest. They also note that diagnoses can
be inconsistentADHD is not as clearly defined as a broken
arm. Nevertheless, declared the World Federation for Mental
Health (2005), there is strong agreement among the interna
tional scientific community that ADHD is a real neurobiologi
cal disorder whose existence should no longer be debated.
A consensus statement by 75 neuroimaging researchers
noted that abnormal brain activity often accompanies ADHD
(Barkley et al., 2002).
What, then, is known about ADHDs causes? It is not caused
by too much sugar or poor schools. There is mixed evidence
suggesting that extensive TV watching and video gaming are
associated with reduced cognitive self-regulation and ADHD
(Bailey et al., 2011; Courage & Setliff, 2010; Ferguson et al., 2011).
ADHD often coexists with a learning disorder or with defiant and
temper-prone behavior. ADHD is hertfab]e, and research teams
are sleuthing the culprit genes and abnormal neural pathways
(Lionel et al., 2014; Poelmans et al., 2011; Volkow et al., 2009;
Williams et al., 2010). It is treatable with medications such as
Ritalin and Adderall, which are considered stimulants but help
calm hyperactivity and increase ones ability to Sit and focus on a
taskand to progress normally in school (Barbaresi et al., 2007).
Psychological therapies, such as those focused on shaping class
room and at-home behaviors, also help address the distress of
ADHD (Fabiano et al., 2008).
The bottom line: Extreme inattention, hyperactivity, and impul
sivity can derail social, academic, and vocational achievements,
and these symptoms can be treated with medication and other
therapies. But the debate continues over whether normal high
energy is too often diagnosed as a psychiatric disorder, and
whether there is a cost to the long-term use of stimulant drugs in
treating ADHD.
attention-deficit/hyperactivity disorder (ADHD) a

psychological disorder marked by extreme inattention and/or
hyperactivity and impulsivity.
Other viewers who were told they were watching psychiatric or cancer patients per
ceived the same interviewees as different from most people. Therapists who thought
they were watching an interview of a psychiatric patient perceived him as frightened
of his own aggressive impulses, a passive, dependent type, and so forth. A label can,
as Rosenhan discovered, have a life and an influence of its own.
Labels also have power outside the laboratory. Getting a job or finding a place
to rent can be a challenge for people recently released from a mental hospital.
616
CHAPTER 15:
Mv sister suffers from a bipolar

disorder and my nephew from schizoaf
fective disorder. There has, in fact, been
a lot of depression and alcoholism in my
family and, traditionally, no one ever
spoke about it. It just wasnt done. The
7
stigma is toxic.
Actress Glenn Close, Mental Illness:
The Stigma of Silence, 2009
Label someone as mentally ill and people may fear them as potentially violent (see
Thinking Critically About: Are People With Psychological Disorders Dangerous?)
Such negative reactions may fade as people better understand that many psychologi
cal disorders involve diseases of the brain, not failures of character (Solomon, 1996).
Public figures have helped foster this new understanding by speaking openly about
their own struggles with disorders such as depression and substance abuse. The
more contact we have with people with disorders, the more accepting our attitudes
are (Kolodziej & Johnson, 1996).
1!1KING CRITICALLY ABOUT
..
Are People With Psychological Disorders Dangerous?

t1 Do psychological disorders predict violent behavior?
September 16, 2013, started like any other Monday at Washing

ton, DCs, Navy Yard, with people arriving early to begin work.
Then government contractor Aaron Alexis parked his car, entered
the building, and began shooting people. An hour later, 13 people
were dead, including Alexis. Reports later confirmed that Alexis
had a history of mental illness. Before the shooting, he had stated
that an ultra low frequency attack is what Ive been subject
to for the last three months. And to be perfectly honest, that is
what has driven me to this. This devastating mass shooting, like
the one in a Connecticut elementary school in 2012 and many
others since then, reinforced public perceptions that people with
psychological disorders pose a threat (Jorm et al., 2012). After the
2012 slaughter, New Yorks governor declared, People who have
mental issues should not have guns (Kaplan & Hakim, 2013).
Does scientific evidence support the governors statement?
If disorders actually increase the risk of violence, then denying
people with psychological disorders the right to bear arms might
reduce violent crimes. But real life tells a different story. The vast
majority of violent crimes are committed by people with no diag
nosed disorder (Fazel & Grann, 2006; Walkup & Rubin, 2013).
People with disorders are more likely to be victims than perpe
trators of violence (Marley & Bulia, 2001). According to the U.S.
Surgeon Generals Office (1999, p. 7), There is very little risk of
violence or harm to a stranger from casual contact with an indi
vidual who has a mental disorder. People with mental illness
commit proportionately little gun violence. The bottom line:
Focusing gun restrictions only on mentally ill people will likely
not reduce gun violence (Friedman, 2012).
If mental illness is not a good predictor of violence, what is?
Better predictors are a history of violence, use of alcohol or drugs,
and access to a gun. The mass-killing shooters have one more
thing in common: They tend to be young males. We could avoid
two-thirds of all crime simply by putting all able-bodied young
men in cryogenic sleep from the age of 12 through 28, said one
psychologist (Lykken, 1995).
Mental disorders seldom lead to violence, and clinical predic
tion of violence is unreliable. What, then, are the triggers for the
few people with psychological disorders who do commit violent
acts? For some, the trigger is substance abuse. Foi others, like
the Navy Yard shooter, its threatening delusions and halluci
nated voices that command them to act (Douglas et al., 2009;
JJaNIItCI.
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How to prevent mass shootings? Following the Newtown, Connecticut, slaughter of 20 young children and 6
adults, people wondered: Could those at risk for violence be
identified in advance by mental health workers and reported
to police? Would laws that require such reporting discour
age disturbed gun owners from seeking mental health
treatment?
Elbogen & Johnson, 2009; Fazel et al., 2009, 2010). Whether

people with mental disorders who turn violent should be held
responsible for their behavior remains controversial. U.S. Presi
dent Ronald Reagans near-assassin, John Hinckley, was sent to a
hospital rather than to prison. The public was outraged. Hinkley
insane. Public mad, declared one headline. They were outraged
again in 2011, when Jared Lee Loughner killed six people and
injured several others, including U.S. Representative Gabrielle
Giffords. Loughner was diagnosed with schizophrenia and twice
found incompetent to stand trial. He was later judged competent
to stand trial, pled guilty to 19 charges of murder and attempted
murder, and was sentenced to life in prison without parole.
Which decision was correct? The first two, which blamed
Loughners madness for clouding his judgment? Or the final
one, which decided that he should be held responsible for the acts
he committed? As we come to better understand the biological
and environmental bases for all human behavior, from generosity
to vandalism, when should weand should we nothold people
accountable for their actions?
CHAPTER 15:
617
Better portrayals Old stereotypes

are slowly being replaced in media
portrayals of psychological disorders.
Recent films offer fairly realistic depic
tions. Iron Man 3 (2013) portrayed a
main character, shown here, with posttraumatic stress disorder. Black Swan
(2010) dramatized a lead character
suffering a delusional disorder. A Single
Man (2009) depicted depression.
Despite their risks, diagnostic labels have benefits. Mental health professionals use
labels to communicate about their cases, to comprehend the underlying causes, and
to discern effective treatment programs. Researchers use labels when discussing work
that explores the causes and treatments of disorders. Clients are often relieved to learn
that the nature of their suffering has a name, and that they are not alone in experienc
ing this collection of symptoms.
0 LounchPod To test your ability to form diagnoses, visit LaunchPads PsychSim

6: Classifying Disorders.
Whats the use of their having

names, the Gnat said, if they wont
answer to them?
No use to them, said Alice; but its
useful to the people that name them,
7
I suppose.
Lewis Carroll. Through the Looking-Glass, 1871
RETRIEVAL PRACTICE
What is the value, and what are the dangers, of labeling individuals with disorders?
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V TABLE 15.2
Rates of Psychological Disorders

ti How many people have, or have had, a psychological disorder? Is poverty a
risk factor?
Who is most vulnerable to psychological disorders? At what times of life? To answer

such questions, various countries have conducted lengthy structured interviews with
representative samples of thousands of their citizens. After asking hundreds of ques
tions that probed for symptomsHas there ever been a period of two weeks or more
when you felt like you wanted to die?the researchers have estimated the current,
prior-year, and lifetime prevalence of various disorders.
How many eote have, or have had, a jjsychological disorder? More than most of us
suppose:
The U.S. National Institute of Mental Health (2008, based on Kessler et al., 2005)
has estimated that just over 1 in 4 adult Americans suffer from a diagnosable men
tal disorder in a given year (TABLE 15.2).
A large-scale World Health Organization (2004a) studybased on 90-minute inter
views of 60,463 peopleestimated the number of prior-year mental disorders in 20
countries. As FIGURE 15.2 on the next page displays, the lowest rate of reported
mental disorders was in Shanghai, the highest rate in the United States. Moreover,
immigrants to the United States from Mexico, Africa, and Asia averaged better
mental health than their U.S. counterparts with the same ethnic heritage (Breslau
Percentage of Americans
Reporting Selected Psychological
Disorders in the Past Year
Psychotogical
Disorder
Percentage
Generalized anxiety
disorder
3.1
Social anxiety disorder
6.8
Phobia of specific
object or situation
8.7
Depressive disorders
or bipolar disorder
9.5
Obsessive-compulsive
disorder (OCD)
1.0
Schizophrenia
1.1
Posttraumatic stress
disorder (PTSD)
3.5
Attention -deficit!
hyperactivity disorder
(ADHD)
4.1
Data from; National Institute of Mental Health, 2008.
618
CHAPTER 75:
FIGURE 15.2
Prior-year prevalence of disorders
in selected areas From World Health
Organization (WHO, 2004a) interviews
in 20 countries.
et al., 2007; Maldonado-Molina et al., 2011). For example, compared with people
who have recently immigrated from Mexico, Mexican-Americans born in the
United States are at greater risk of mental disordera phenomenon known as the
immigrant paradox (Schwartz et al., 2010).
United States
Ukraine
France
Colombia
What increases vulnerability to mental disorders? As TABLE 15.3 indicates, there is

a wide range of risk and protective factors for mental disorders. But one predictor of
mental disorder, poverty, crosses ethnic and gender lines. The incidence of serious psy
chological disorders has been doubly high among those below the poverty line (CDC,
1992). Like so many other correlations, the poverty-disorder association raises further
questions: Does poverty cause disorders? Or do disorders cause poverty? It is both,
though the answer varies with the disorder. Schizophrenia understandably leads to
poverty. Yet the stresses and demoralization of poverty can also precipitate disorders,
especially depression in women and substance abuse in men (Dohrenwend et al., 1992).
Lebanon
TABLE 15.3
Risk and Protective Factors for Mental Disorders
Netherlands
Mexico
Belgium
Spain
Germany
Beijing
Japan
Italy
Nigeria
Shanghai
o%
io%
20%
Any mental disorder

Serious mental disorder
30/o
Risk Factors
Protective Factors
Academic failure
Birth complications
Caring for those who are chronically ill or
who have a neurocognitive disorder
Child abuse and neglect
Chronic insomnia
Chronic pain
Family disorganization or conflict
Low birth weight
Low socioeconomic status
Medical illness
Neurochemical imbalance
Parental mental illness
Parental substance abuse
Personal loss and bereavement
Poor work skills and habits
Reading disabitities
Sensory disabilities
Social incompetence
Stressful life events
Substance abuse
Trauma experiences
Aerobic exercise
Community offering empowerment,
opportunity, and security
Economic independence
Effective patenting
Feelings of mastery and control
Feelings of security
Literacy
Positive attachment and early bonding
Positive parent-child relationships
Problem-solving skills
Resilient coping with stress and adversity
Self-esteem
Social and work skills
Social support from family and friends
Research from: World Health Organization (WHO, 2004b,c).
In one natural experiment on the poverty-pathology link, researchers tracked rates of

behavior problems in North Carolina Native American children as economic develop
ment enabled a dramatic reduction in their communitys poverty rate. As the study
began, children of poverty exhibited more deviant and aggressive behaviors. After four
years, children whose families had moved above the poverty line exhibited a 40 percent
decrease in the behavior problems. Those who continued in their previous positions
below or above the poverty line exhibited no change (Costello et al., 2003).
At what times of life do disorders strike? Usually by early adulthood. Over 75 percent
of our sample with any disorder had experienced [their] first symptoms by age 24,
CHAPTER 75:
619
reported Lee Robins and Darrel Regier (1991, P. 331). Among the earliest to appear are
the symptoms of antisocial personality disorder (median age 8) and of phobias (median
age 10). Alcohol use disorder, obsessive-compulsive disorder, bipolar disorder, and
schizophrenia symptoms appear at a median age near 20. Major depressive disorder
often hits somewhat later, at a median age of 25.
RETRIEVAL PRACTICE
What is the relationship between poverty and psychological disorders?

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REVIEW
Introduction to Psychological Disorders
LEARNING OBJECTIVES
TERMS AND CONCEPTS TO REMEMBER
RETRIEVAL PRACTICE Take a moment to answer each of

these Learning Objective Questions (repeated here from within
this section). Then turn to Appendix C, Complete Chapter Re
views, to check your answers. Research suggests that trying
to answer these questions on your own will improve your longterm retention (McDaniel et al., 2009).
RETRIEVAL PRACTICE Test yourself on these terms by trying

to write down the definition before flipping back to check your
answers.
I How should we draw the line between normality and

disorder?
I.lHow do the medical model and the biopsychosocial
approach influence our understanding of psychological
disorders?
How and why do clinicians classify psychological
disorders, and why do some psychologists criticize the use of
diagnostic labels?
II Why is there controversy over attention-deficit!
hyperactivity disorder?
Do psychological disorders predict violent behavior?
How many people have, or have had a psychological
disorder? Is poverty a risk factor?
psychological disorder, p. 610

medical model, p. 612
epigenetics, p. 612
DSM-5, p. 613
attention-deficit/hyperactivity disorder (ADHD), p. 615
LeornlngCur/e to create your personalized study plan, which will

Use
LunchPod.
direct you to the resources that will help you most in
Anxiety Disorders, OCD,

and PTSD
Anxiety is part of life. Speaking in front of a class, peering down from a ladder, or waiting
to play in a big game, any one of us might feel anxious. Anxiety may even cause us to avoid
talking or making eye contactshyness, we call it. Fortunately for most of us, our uneasi
ness is not intense and persistent. Some of us, however, are more prone to notice and
remember threats (Mitte, 2008). When the brains danger-detection system becomes hyper
active, we are at greater risk for an anxiety disorder, or for two other disorders that involve
anxiety: obsessive-compulsive disorder (OCD) or posttraumatic stress disorder (PTSD).
1. OCD and PTSD were formerly classified as anxiety disorders, but the DSM-S now classifies them separately.
620
CHAPTER 15:
Anxiety Disorders
How do generaLized anxiety disorder, panic disorder, and phobias differ?
The anxiety disorders are marked by distressing, persistent anxiety or dysfunctional

anxiety-reducing behaviors. Lets take a closer look at three of them:
Generalized anxiety disorder, in which a person is unexplainably and continually
tense and uneasy
Panic disorder, in which a person experiences panic attackssudden episodes of
intense dreadand fears the unpredictable onset of the next episode
Phobias, in which a person is intensely and irrationally afraid of a specific object,
activity, or situation
Generalized Anxiety Disorder
anxiety disorders psychological

disorders characterized by distressing,
persistent anxiety or maladaptive behav
iors that reduce anxiety.
generalized anxiety disorder an
anxiety disorder in which a person is
continually tense, apprehensive, and in
a state of autonomic nervous system
arousal.
panic disorder an anxiety disorder
marked by unpredictable, minutes-[ong
episodes of intense dread in which a
person experiences terror and accom
panying chest pain, choking, or other
frightening sensations. Often followed by
worry over a possible next attack.
phobia an anxiety disorder marked by a
persistent, irrational fear and avoidance
of a specific object, activity, or situation.
for the past two years, Tom, a 27-year-old electrician, has been bothered by dizziness,
sweating palms, heart palpitations, and ringing in his ears. He feels on edge and some
times finds himself shaking. With reasonable success, he hides his symptoms from his
family and co-workers. But he allows himself few other social contacts, and occasionally
he has to leave work. His family doctor and a neurologist can find no physical problem.
Toms unfocused, out-of-control, agitated feelings suggest a generalized anxiety dis
order, which is marked by excessive and uncontrollable worry. The symptoms of this
disorder are commonplace; their persistence, for six months or more, is not. People
with this condition worry continually, and they are often jittery, agitated, and sleepdeprived. Concentration is diffictilt as attention switches from worry to worry. Their
tension and apprehension may leak out through furrowed brows, twitching eyelids,
trembling, perspiration, or fidgeting from autonomic nervous system arousal.
The person may not be able to identify, and therefore relieve or avoid, the tensions
cause. To use Sigmund Freuds term, the anxiety is free-floating (not linked to a specific
stressor or threat). Generalized anxiety disorder is often accompanied by depressed
mood, but even without depression it tends to be disabling (Hunt et al., 2004; Moffitt
et al., 2007b). Moreover, it may lead to physical problems, such as high blood pressure.
Women are twice as likely as men to experience generalized anxiety disorder
(McLean & Anderson, 2009). This anxiety gender difference was reflected in a Gallup
poli taken eight months after 9/11, when more U.S. women (34 percent) than men (19
percent) said they were still less willing than before 9/11 to go into skyscrapers or fly
on planes. And in early 2003, more women (57 percent) than men (36 percent) said they
were somewhat worried about becoming a terrorist victim (Jones, 2003).
Some people with generalized anxiety disorder were maltreated and inhibited as
children (Moffitt et al., 2007a). As time passes, however, emotions tend to mellow, and
by age 50, generalized anxiety disorder becomes fairly rare (Rubio & LOpez-Ibor, 2007).
Panic Disorder
For the 1 person in 75 with panic disorder, anxiety suddenly escalates into a terrify
ing panic attacka minutes-long episode of intense fear that something horrible is
about to happen. Physical symptoms, such as irregular heartbeat, chest pains, short
ness of breath, choking, trembling, or dizziness may accompany the panic. One woman
recalled suddenly feeling
hot and as though I couldnt breathe. My heart was racing and I started to sweat and trem
ble and I was sure I was going to faint. Then my fingers started to feel numb and tingly and
things seemed unreal. It was so bad I wondered ff1 was dying and asked my husband to
take me to the emergency room. By the time we got there (about 10 minutes) the worst of
the attack was over and I just felt washed out (Greist et al., 1986).
CHAPTER 75:
These anxiety tornados strike suddenly, wreak havoc, and disappear, but they are
not forgotten. Ironically, worries about anxietyperhaps fearing another panic attack,
or fearing anxiety-caused sweating in publiccan amplify anxiety symptoms (Ola
tunji & Wolitzky-Taylor, 2009). After several panic attacks, people may avoid situations
where the previous panic attacks have struck. If their fear is intense enough, people
may develop agoraphobia, fear or avoidance of situations in which escape might be dif
ficult when panic strikes. Given such fear, people may avoid being outside the home, in
a crowd, on a bus, or in an elevator.
Charles Darwin began suffering panic disorder at age 28, after spending five
years sailing the world. Because of the attacks, he moved to the country, avoided
social gatherings, and traveled only in his wifes company. But the relative seclu
sion did free him to focus on developing his evolutionary theory. Even ill health,
he reflected, has saved me from the distraction of society and its amusements
(quoted in Ma, 1997).
Smokers have at least a doubled risk of panic disorder (Zvolensky & Bernstein, 2005).
They also show greater panic symptoms in situations that often produce panic attacks,
such as when they hyperventilate (Knuts et al., 2010). Because nicotine is a stimulant,
lighting up doesnt lighten up.
Phobias
We all live with some fears. But people with phobias are consumed by a persistent,
irrational fear and avoidance of some object, activity, or situation. Specific phobias may
focus on animals, insects, heights, blood, or close spaces (FIGURE 15.3 on the next
page). Many people avoid the triggers, such as high places, that arouse their fear, and
they manage to live with their phobia. Others are incapacitated by their efforts to avoid
the feared situation. Marilyn, an otherwise healthy and happy 2$-year-old, fears thun
derstorms so intensely that she feels anxious as soon as a weather forecaster mentions
possible storms later in the week. If her husband is away and a storm is forecast, she
may stay with a close relative. During a storm, she hides from windows and buries her
head to avoid seeing the lightning.
Not all phobias have specific triggers. Sociat anxiety disorder (formerly called social
phobia) is shyness taken to an extreme. People with this disorder have an intense fear
of other peoples negative judgments. They may avoid potentially embarrassing social
situationssuch as speaking up, eating out, or going to partiesor they may sweat or
tremble when doing so.
621
Panicked playing Golfer Charlie

Beljan experienced what he later
learned were panic attacks during an
important tournament. His thumping
heartbeat and shortness of breath led
him to think he was having a heart
attack. But hospital tests revealed that
his symptoms, though serious, were
not related to a physical illness. He re
covered, went on to win $846,000, and
has become an inspiration to others.
622
CHAPTER 15:
FIGURE 15.3
Some common and uncommon
specific fears Researchers sur
veyed Dutch people to identify the
most common events or objects they
feared. A strong fear becomes a
phobia if it provokes a compelling
but irrational desire to avoid the
dreaded object or situa
tion. (Data from Depla ,,
et at., 2008.)
25%
Percentage
of people
surveyed
20
15
:iiiiii1_F
10
Being
alone
Feat
Flying
Storms
Water
Blood
Enclosed
spaces
Animals
Heights
Phobia
Martin Haraey/D,gtal Vnan/Getty Irng
RETRIEVAL PRACTICE
Unfocused tension, apprehension, and arousal are symptoms of

disorder.
Aaixue peZ!pJauaB dMSNV
Those who experience unpredictable periods of terror and intense dread, accompa
disor
nied by frightening physical sensations, may be diagnosed with a
de r.
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If a person is focusing anxiety on specific feared objects or situations, that person

may
have
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Obsessive-Compulsive Disorder (OCD)

SlVC
I.:J What is OCD?
COrIIULSIVE uRE PRN]
Spin your partner round and round,

then spin your partner round again, spin
her round six more times, now touch the
light switch near the door.
obsessive-compulsive disorder
(OCD) a disorder characterized by un
wanted repetitive thoughts (obsessions),
actions (compulsions), or both.
posttraumatic stress disorder
(PTSD) a disorder characterized by
haunting memories, nightmares, social
withdrawal, jumpy anxiety, numbness
of feeling, and/or insomnia that lingers
for four weeks or more after a traumatic
experience.
As with the anxiety disorders, we can see aspects of obsessive-compulsive disorder

(OCD) in our everyday behavior. We all may at times be obsessed with sense
less or offensive thoughts that wilt not go away. Or we may engage in compul
sive behaviors, perhaps lining up books and pencils just so before studying.
Obsessive thoughts and compulsive behaviors cross the fine line between
normality and disorder when they persistently interfere with everyday living
and cause distress. Checking to see you locked the door is normal; checking
10 times is not. \Vashing your hands is normal; washing so often that your skin
becomes raw is not. (TABLE 15.4 offers more examples.) At some time during
their lives, often during their late teens or twenties, 1 to nearly 3 percent of
TABLE 15.4
Common Obsessions and Compulsions Among Children and
Adolescents With Obsessive-Compulsive Disorder
Thought or Behavior
Obsessions (repetitive thoughts)

Concern with dirt, germs, or toxins
Something terrible happening (fire, death, illness)
Symmetry, order, or exactness
Compulsions (repetitive behaviors)
Excessive hand washing, bathing, toothbrushing, or grooming
Repeating rituals (in/out of a door, up/down from a chair)
Checking doors, locks, appliances, car brakes, homework
Source: Data from Rapoport, 1989.
Percentage
Reporting Symptom
40
24
17
85
51
46
CHAPTER 75:
623
people cross that line from normal preoccupations and fussiness to debilitating dis
order (Kessler et al., 2012). An analysis of 14 twin studies showed that OCD has a
strong genetic basis (Taylor, 2011). Although the person knows them to be irrational,
the anxiety-fueled obsessive thoughts become so haunting, the compulsive rituals so
senselessly time-consuming, that effective functioning becomes impossible.
LunchPod For a 7-minute video illustrating struggles associated with compul
Q
sive rituals, visit LaunchPads Obsessive-Compulsive Disorder: A Young Mothers
Struggle.
Former professional basketball player Royce White, who is open about his obsessivecompulsive disorder, said that his wealth allowed him to purchase a large house. What
was the most difficult part of his transition to mansion living? The toughest thing is
going around and seeing that dust has collected in a room [I] dont use often. And then
Ive got to spend 30 minutes dusting that thing (Wrenn, 2012).
OCD is more common among teens and young adults than among older people
(Samuels & Nestadt, 1997). A 40-year follow-up study of 144 Swedish people diagnosed
with the disorder found that, for most, the obsessions and compulsions had gradually
lessened, though only 1 in 5 had completely recovered (Skoog & Skoog, 1999).
Posttraumatic Stress Disorder (PTSD)
Making everything perfect
Soccer star David Beckham has openly

discussed his obsessive-compulsive
tendencies, which have driven him to
line up objects in pairs or to spend
hours straightening furniture (Adams,
2011).
i] What is PTSD?
As an Iraq war soldier, Jesse saw the murder of children and women. It was just horri
ble for anyone to experience. After calling in a helicopter strike on one house where he
had seen ammunition crates carried in, he heard the screams of children from within.
I didnt know there were kids there, he recalled. Back home in Texas, he suffered real
bad flashbacks (Welch, 2005).
Jesse is not alone. In one study of 103,788 veterans returning from Iraq and Afghani
stan, 25 percent were diagnosed with a psychological disorder (Seal et al., 2007). Some
had traumatic brain injuries (TBI), but the most frequent diagnosis was posttraumatic
stress disorder (PTSD). Typical symptoms include recurring haunting memories and
nightmares, a numb feeling of social withdrawal, jumpy anxiety, and trouble sleeping
(Germain, 2013; Hoge et al., 2004, 2006, 2007; Kessler, 2000). Although many battlescarred veterans have been diagnosed with PTSD, others also suffer from this dis
order. Survivors of accidents, disasters, and violent and sexual assaults (including an
estimated two-thirds of prostitutes) have experienced PTSD symptoms (Brewin et al.,
1999; Farley et al., 1998; Taylor et al., 1998).
The greater ones emotional distress during a trauma, the higher the risk for posttraumatic symptoms (Ozer et al., 2003). Among American military personnel in
Afghanistan, 7.6 percent of combatants and 1.4 percent of noncombatants developed
PTSD (McNally, 2012). Among New Yorkers who witnessed or responded to the 9/11
terrorist attacks, most did not experience PTSD (Neria et al., 2011). After experiencing
a traumatic life event, about 5 to 10 percent of people develop PTSD (Bonanno et al.,
2011). PTSD diagnoses among survivors who had been inside the World Trade Center
during the attack were, however, double the rates found among those who were outside
(Bonanno et al., 2006).
About half of us will experience at least one traumatic event in our lifetime. Why
do some people develop PTSD after a traumatic event, but others dont? Some people
may have more sensitive emotion-processing limbic systems that flood their bodies
with stress hormones (Kosslyn, 2005; Ozer & Weiss, 2004). PTSD patients have smaller
amygdalathat acorn-shaped brain region that governs fear (Morey et al., 2012). Genes
and gender also matter. Twins, compared with nontwins, more commonly share PTSD
Bringing the war home Neatly a
quarter-million Iraq and Afghanistan

war veterans have been diagnosed with
PTSD or traumatic brain injury (TBI).
Many vets participate in an intensive
recovery program using deep breath
ing, massage, and group and individual
discussion techniques to treat their
PTSD or TBI.
624
CHAPTER 75:
cognitive risk factors (Gilbertson et al., 2006). And the odds of getting this disorder
after a traumatic event are about two times higher for women than for men (01ff et al.,
2007; Ozer & Weiss, 2004).
Some psychologists believe that PTSD has been overdiagnosed, due partly to a
broadening definition of trauma (Dobbs, 2009; McNally, 2003). Too often, say some crit
ics, PTSD gets stretched to include normal bad memories and dreams after a bad expe
rience. In such cases, well-intentioned attempts to have people relive the trauma may
amplify their emotions and pathologize normal stress reactions (Wakefield & Spitzer,
2002). For example, survivors may be debriefed right after a trauma and asked to
revisit the experience and vent emotions. This tactic has been generally ineffective and
sometimes harmful (Bonanno et al., 2010).
Most people, male and female, display an impressive survivor resiliency, or ability to
recover after severe stress (Bonanno et al., 2010). For more on human resilience and on
the posttraumatic growth that some experience, see Chapter 16.
RETRIEVAL PRACTICE
Those who express anxiety through unwanted repetitive thoughts or actions may have
disorder.
a(n)
AisjndwoD-Aissesqo :dM9NV
Those with symptoms of recurring memories and nightmares, social withdrawal,
jumpy anxiety, numbness of feeling, and/or insomnia for weeks after a traumatic event
may be diagnosed with
disorder.
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V.
:.
Understanding Anxiety Disorders, OCD,

and PTSD
hI.-[.] How do conditioning, cognition, and biology contribute to the feelings and
thoughts that mark anxiety disorders, OCD, and PTSD?

Anxiety is both a feeling and a cognitiona doubt-laden appraisal of ones safety or
social skill. How do these anxious feelings and cognitions arise? Sigmund Freuds psy
choanalytic theory proposed that, beginning in childhood, people repress intolerable
impulses, ideas, and feelings. This submerged mental energy sometimes, he thought,
leaks out in odd symptoms, such as anxious handwashing. Few of todays psychologists
share Freuds interpretation of anxiety. Most believe that three modern perspectives
conditioning, cognition, and biologyare more helpful.
Conditioning
Some bad events come with a warning. Your underdog team might lose the big game.
You arent prepared and you may fail your quiz. Youre running late and might miss the
bus. But when bad events happen unpredictably and uncontrollably, anxiety and other
disorders often develop (Field, 2006; Mineka & Oehlberg, 2008). In a classic experi
ment, an infant called Little Albert learned to fear furry objects that were paired
with loud noises. In other experiments, researchers have created anxious animals by
giving rats unpredictable electric shocks (Schwartz, 1984). The rats, like assault victims
who report feeling anxious when returning to the scene of the crime, became uneasy
in their lab environment. The lab had become a cue for fear.
Such research helps explain why anxious people are hyperattentive to possible
threats, and how panic-prone people come to associate anxiety with certain cues (Bar
Haim et al., 2007; Bouton et al., 2001). In one survey, 58 percent of those with social
anxiety disorder experienced their disorder after a traumatic event (Ost & Hugdahl,
1981).
CHAPTER 15:
625
Through conditioning, the short list of naturally painful and frightening events can
multiply into a long list of human fears. Can you recall a frightening event that left
you fearful for a while? We can. I [DM] was headed home when my car was struck by
another when its driver missed a stop sign. For months afterward, I felt a twinge of
unease as a car approached from a side street. Likewise, I [ND] remember watching
a terrifying movie about spiders, Arachnophobia, when a severe thunderstorm struck
and the theater lost power. For months, I experienced anxiety at the sight of spiders or
harmless cobwebs.
How might conditioning magnify a single painful and frightening event into a fullblown phobia? The answer lies in part in two conditioning processes: stimulus general
ization and reinforcement.
Stimulus generalization occurs when a person experiences a fearful event and later
develops a fear of similar events. Each of us [DM and ND] generalized our fears: One
of us feared cars approaching from side streets and the other feared spiders. Those
fears eventually disappeared, but sometimes fears can linger and grow. Marilyns thun
derstorm phobia may have similarly generalized after a terrifying or painful experience
during a thunderstorm.
Once fears and anxieties arise, reinforcement helps maintain them. Anything that
helps us avoid or escape the feared situation can be reinforcing because it reduces
anxiety and gives us a feeling of relief. Fearing a panic attack, we may decide not to
leave the house. Reinforced by feeling calmer, we are likely to repeat that maladap
tive behavior in the future (Antony et al., 1992). So, too, with compulsive behaviors. If
washing our hands relieves our feelings of anxiety, we may wash our hands again when
those feelings return.
Cognition
Conditioning influences our feelings of anxiety, but so does cognition
our thoughts, memories, interpretations, and expectations. By observing
others, we can learn to fear what they fear. Nearly all monkeys raised in
the wild fear snakes, yet lab-raised monkeys do not. Surely, most wild
monkeys do not actually suffer snake bites. Do they learn their fear
through observation? To find out, Susan Mineka (1985, 2002) experi
mented with six monkeys raised in the wild (all strongly fearful of snakes)
and their lab-raised offspring (virtually none of which feared snakes). After repeat
edly observing their parents or peers refusing to reach for food in the presence of a
snake, the younger monkeys developed a similar strong fear of snakes. When the mon
keys were retested three months later, their learned fear persisted. We humans learn
many of our own fears by observing others (Helsen et al., 2011; Olsson et al., 2007).
Our past experiences shape our expectations and influence our interpretations and
reactions. Whether we interpret the creaky sound in the old house simply as the wind
or as a possible knife-wielding intruder determines whether we panic. People with anxi
ety disorders tend to be hypervigilant. A pounding heart signals a heart attack. A lone
spider near the bed becomes a likely infestation. An everyday disagreement with a
friend or boss spells possible doom for the relationship. Anxiety is especially common
when people cannot switch off such intrusive thoughts and perceive a loss of control
and a sense of helplessness (Franklin & Foa, 2011).
Biology
There is, however, more to anxiety disorders, OCD, and PTSD than conditioning and
cognitive processes alone. Why will some of us develop lasting phobias or PTSD after
suffering traumas? Why do we all learn some fears so readily? Why are some of us more
vulnerable? The biological perspective offers insight.
Hemera Technologios/PhotoObjects net/3b0/Getty Images
626
CHAPTER 15:
Genes Genes matter. Pair a traumatic event with a sensitive, high-strung tempera
ment and the result may be a new phobia (Belsky & Pluess, 2009). Some of us have
genes that make us like orchidsfragile, yet capable of beauty under favorable circum
stances. Others of us are like dandelionshardy, and able to thrive in varied circum
stances (Ellis & Boyce, 2008; Pluess & Belskv, 2013).
Among monkeys, fearfulness runs in families. A monkey reacts more strongly
to stress if its close biological relatives are anxiously reactive (Suomi, 1986). So, too,
with people. If one identical twin has an anxiety disorder, the other is likewise at risk
(Hettema et aL, 2001; Kendler et al., 2002a,b; Van Houtem et al., 2013). Even when
raised separately, identical twins may develop similar phobias (Garey, 1990; Eckert
et al., 1981). One pair of 35-year-old female identical twins independently became so
afraid of water that each would wade in the ocean backward and only up to the knees.
Given the genetic contribution to anxiety disorders, researchers are now sleuth
ing the culprit genes. One research team identified 17 gene variations associated with
typical anxiety disorder symptoms (Hovatta et al., 2005). Other teams have found genes
associated specifically with OCD (Taylor, 2013).
Genes can influence disorders by regulating neurotransmitters. Some studies point
to an anxiety gene that affects brain levels of serotonin, a neurotransmitter that influ
ences sleep, mood, and attention to negative images (Canli, 2008; Pergamin-Hight et
al., 2012). Other studies implicate genes that regulate the neurotransmitter glutamate
(Lafleur et al., 2006; Welch et al., 2007). With too much glutamate, the brains alarm
centers become overactive.
Among PTSD patients, a history of child abuse leaves long-term epigenetic marks,
increasing the likelihood that a genetic vulnerability to the disorder will be expressed
(v1ehta et al., 2013). Suicide victims show a similar epigenetic effect (McGowan et al., 2009).
V FIGURE 15.4
An obsessive-compulsive
brain Neuroscientists Nicholas Maltby,
David Tolin, and their colleagues (2005)
used functional MRI scans to compare
the brains of those with and without
OCD as they engaged in a challenging
cognitive task. The scans of those with
OCD showed elevated activity in the
anterior cingulate cortex in the brains
frontat area (indicated by the yellow
area on the far right).
The Brain Our experiences change our brain, paving new pathways. Traumatic fearlearning experiences can leave tracks in the brain, creating fear circuits within the
amygdala (Etkin & Wager, 2007; Kolassa & Elbert, 2007; Herringa et al., 2013). These
fear pathways create easy inroads for more fear experiences (Armony et al., 1998).
Anxiety-related disorders differ from one another, but they all involve biological
events. In OCD, for example, when the disordered brain detects that something is
amiss, it generates a mental hiccup of repeating thoughts (obsessions) or actions (com
pulsions) (Gehring et al., 2000). Brain scans of people with PTSD show higher-thannormal activity in the amygdala when they view traumatic images (Nutt & Malizia,
2004). Brain scans of people with OCD reveal elevated activity in specific brain areas
during behaviors such as compulsive hand washing, checking, ordering, or hoarding
(Insel, 2010; lVlataix-Cols et al., 2004, 2005). These brain areas are not only more active
among people with OCD, they are also enlarged (Rotge et al., 2010). As FIGURE 15.4
shows, the anterior cingulate cortex, a brain region that monitors our actions and
checks for errors, seems especially likely to be hyperactive (Maltbv et al., 2005).
When deciding to get rid of ones personal possessions, those with hoarding disorder
also show elevated activity in the anterior cingulate cortex (Tolin et al., 2012).
Some antidepressant drugs dampen this fear-circuit activity and its associated
obsessive-compulsive behavior. Fears can also be blunted by giving people drugs as
they recall and then rerecord (reconsolidate) a traumatic experience (Kindt et al.,
2009; Norberg, et al., 2008). Although they dont forget the experience, the associ
ated emotion is largely erased.
Natural Selection We seem biologically prepared to fear threats faced by our
Reprinted roe, Neornlrnage, 24, Maltby, N 1 .Jin, D.F Worhoesky,

P. OKeete. T. M., & Kiehi, IC A, Dystunctionat action monitoring
hyperactivates frontalstrrata circuits in obsessive-compuLsive disorder
An event-related IMRI stody, 495-503, 2005, with pe,mission roe,
Elsevier
ancestors. Our phobias focus on such specific fears: spiders, snakes, and other ani
mals; enclosed spaces and heights; storms and darkness. (Those fearless about these
occasional threats were less likely to survive and leave descendants.) Thus, even in
Britain, with only one poisonous snake species, people often fear snakes. It is easy to
CHAPTER 75:
627
Fearless The biological perspective

helps us understand why most of
us have more fear of heights than
does Felix Baumgartner, shown here
skydiving from 24 miles above the
Earth in 2012.
condition and hard to extinguish fears of such evolutionarily relevant stimuli (Coelbo
& Purkis, 2009; Davey, 1995; Ohman, 2009). Some of our modern fears can also have
an evolutionary explanation. A fear of flying may be rooted in our biological predisposi
tion to fear confinement and heights.
Compare our easily conditional fears to what we do not easily learn to fear. World
War II air raids, for example, produced remarkably few lasting phobias. As the air blitzes
continued, the British, Japanese, and German populations did not become more and
more panicked. Rather, they grew more indifferent to planes outside their immediate
neighborhoods (Iviineka & Zinbarg, 1996). Evolution has not prepared us to fear bombs
dropping from the sky.
Just as our phobias focus on dangers faced by our ancestors, our compulsive acts
typically exaggerate behaviors that contributed to our species survival. Grooming gone
wild becomes hair pulling. Washing up becomes ritual hand washing. Checking territo
rial boundaries becomes rechecking an already locked door (Rapoport, 1989).
RETRIEVAL PRACTICE
Researchers believe that conditioning and cognitive processes contribute to anxiety

disorders, OCD, and PTSD. What biological factors also contribute to these disorders?
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REVIEW
Anxiety Disorders, OCD, and PTSD
LEARNING OBJECTIVES
RETRIEVAL_PRACTICE Take a moment to answer each of

How do generalized anxiety disorder, panic disorder, and
phobias differ?
:jWhat is OCD?
iJ What is PTSD?

answers.
anxiety disorders, p. 620

generalized anxiety disorder, p. 620
panic disorder, p. 620
phobia, p. 621
obsessive-compulsive disorder (OCD), p. 622
posttraumatic stress disorder (PTSD), p. 623
II[.J How do conditioning, cognition, and biology contribute to the
feelings and thoughts that mark anxiety disorders, OCD, and PTSD?
Use
LeornlngCurv to create your personalized study plan, which will
LounchPod.
62$
CHAPTER 75:
Depressive Disorders and

Bipolar Disorder
i.-ii How do major depressive disorder, persistent depressive disorder, and bipolar
disorder differ?
Most of us will have some direct or indirect experience with 4
depression. If you are like many college students, at some time
during this yearmore likely the dark months of winter than the
bright days of summeryou may experience some of depressions
symptoms. You might feel deeply discouraged about the future,
dissatisfied with your life, or socially isolated. You may lack the
energy to get things done or even to force yourself out of bed;
be unable to concentrate, eat, or sleep normally; or even won
der if you would be better off dead. Perhaps academic success
came easily to you before, but now you find that disappointing
grades leopardize your goals. Maybe social stress, such as lone
liness, feeling you are the target of prejudice, or experiencing
a romantic breakup, have plunged you into despair. And perdwennr/MonetsI/c-ettyIrr
haps low self-esteem increases your brooding, worsening your
self-torment (Sowislo & Orth, 2012). Likely you think you are more alone in having
such negative feelings than you really are (Jordan et al., 2011). In one national survey
of American collegians, 31 percent said they had at some time in the past year, felt so
depressed that it was difficult to function (ACHA, 2009). I\Iisery has more company
than most suppose.
Joy, contentment, sadness, and despair exist at different points on a continuum,
points at which any of us may find ourselves at any given moment. To feel bad in
reaction to profoundly sad events is to be in touch with reality. In such times, there
is an up side to being down. Sadness is like a cars low-fuel lighta signal that warns
us to stop and take appropriate measures. Biologically speaking, lifes purpose is not
happiness but survival and reproduction. Coughing, vomiting, swelling, and pain pro
tect the body from dangerous toxins. Similarly, depression resembles a sort of psychic
hibernation: It slows us down, defuses aggression, helps us let go of unattainable
goals, and restrains risk taking (Andrews & Thomson, 2009a,b; Wrosch & Miller,
2009). When we grind temporarily to a halt and reassess our life, as depressed people
do, we can redirect our energy in more promising ways (Watkins, 2008). We may also
make better decisions. Even mild sadness can improve peoples recall, make them
more discerning, and help them make complex decisions (Forgas, 2009). It can also
help them process and recall faces more accurately (Hills et al., 2011). There is sense
to suffering.
But sometimes this response, taken to an extreme, can become seriously maladap
tive and signal a disorder. The difference between a blue mood after bad news and a
depression-related disorder is like the difference between gasping for breath after a
hard run and being chronically short of breath.
In this section, we consider three disorders in which depression impairs daily
living:
My life had come to a sudden stop. I

was able to breathe, to eat, to drink, to
sleep. I could not, indeed, help doing
so; but there was no real life in me.
Leo Tolstoy, My Confession, 1887
If someone offered you a pill that

would make you permanently happy,
you would be well advised to run fast
and run far. Emotion is a compass that
tells us what to do, and a compass that
is perpetually stuck on NORTH is
worthless.
Daniel Gilbert,
The Science of Happiness, 2006
Mojor depressive disorder, a persistent state of hopelessness and lethargy

Persistent depressive disorder, in which a person experiences milder depressive
feelings
Bipolar disorder (formerly called manic-depressive disorder), in which a person alter
nates between depression and overexcited hyperactivity
CHAPTER 15:
629
Major Depressive Disorder

Major depressive disorder occurs when at least five signs of depression last two or
more weeks (TABLE 15.5). The symptoms must cause near-daily distress or impairment
and not be attributable to substance use or another medical or mental illness.
To sense what major depression feels like, suggest some clinicians, imagine combin
ing the anguish of grief with the sluggishness of bad jet lag. If stress-related anxiety is a
crackling, menacing brushfire, noted biologist Robert Sapolskv (2003), depression is a
suffocating heavy blanket thrown on top of it.
V TABLE 15.5
Diagnosing Major Depressive Disorder

The DSM-5 classifies major depressive disorder as the presence of at least five of the
following symptoms over a two-week period of time (minimally including depressed
mood or reduced interest (American Psychiatric Association, 2013).
Depressed mood most of the time
Dramaticalty reduced interest or enjoyment in most activities most of the time
Significant challenges regulating appetite and weight
Significant challenges regulating sleep
Physical agitation or lethargy
Feeling listless or with much less energy
Feeling worthless; or feeling unwarranted guilt
.
Problems in thinking, concentrating, or making decisions
Thinking repetitively of death and suicide
Adults diagnosed with persistent depressive disorder (also called dysthymia) experi
ence a mildly depressed mood more often than not for two years or more (American
Psychiatric Association, 2013). They also display at least two of the following symptoms:
Difficulty with decision-making and concentration
Feeling hopeless
Poor self-esteem
Reduced energy levels
Problems regulating sleep
Problems regulating appetite
Bipolar Disorder
With or without therapy, episodes of major depression usually end, and people tempo
rarily or permanently return to their previous behavior patterns. However, some people
rebound to, or sometimes start with, the opposite emotional extremethe hyperactive,
overly talkative, wildly optimistic state of mania. If depression is living in slow motion,
mania is fast forward. Alternating between depression and mania signals bipolar disorder.
Adolescent mood swings, from rage to bubbly, can, when prolonged, lead to a bipolar
diagnosis. Between 1994 and 2003, diagnoses of bipolar disorder swelled. U.S. National
Center for Health Statistics annual physician surveys revealed an astonishing 10-fold
increase in bipolar disorder diagnoses in those 19 and underfrom an estimated 20,000
to 800,000 (Carey, 2007; flora & Bobby, 2008; Moreno et al., 2007). Americans are twice
as likely as people of other countries to have ever had a diagnosis of bipolar disorder
major depressive disorder a disorder

in which a person experiences, in the
absence of drugs or another medical
condition, two or more weeks with five
or more symptoms, at least one of which
must be either (1) depressed mood or (2)
loss of interest or pleasure.
mania a hyperactive, wildly optimistic
state in which dangerously poor judg
ment is common.
bipolar disorder a disorder in which a
person alternates between the hopeless
ness and lethargy of depression and the
overexcited state of mania. (Formerly
called manic-depressive disorder.)
630
CHAPTER 15:
Bipolar disorder Artist Abigail

Southworth illustrated her experience
of bipolar disorder.
V TABLE 15.6
Percentage Answering Yes

When Asked Have You Cried
Today?
Percentage who criedJ
Men
Women
August
4%
7%
December
8%
21%
Source: lime/CNN Survey, 1994
Creativity and bipolar disorder

There have been many creative art
ists, composers, writers, and musical
performers with bipolar disorder.
(Merikangas et aL, 2011). The new popularity of

the diagnosis, given in two-thirds of the cases to
boys, has profited companies whose drugs are
prescribed to lessen mood swings. Under the
new DSM-5 classifications, the number of child
and adolescent bipolar diagnoses will likely
decline, because some individuals with emo
tional volatility will be diagnosed with disrup
tive mood dysregutation disorder (Miller, 2010).
During the manic phase, people with bipo
lar disorder typically have little need for sleep.
They show fewer sexual inhibitions. Their posi
tive emotions persist abnormally (Gruber, 2011;
Gruber et al., 2013). Their speech is loud, flighty, and hard to interrupt. They find
advice irritating. Yet they need protection from their own poor judgment, which may
lead to reckless spending or unsafe sex. Thinking fast feels good, but it also increases
risk taking (Chandler & Pronin, 2012; Pronin, 2013).
For some people suffering depressive disorders or bipolar disorder, symptoms may
have a seasonal pattern. Depression may regularly return each fall or winter, and mania
(or a reprieve from depression) may dependably arrive with spring. for many others,
winter darkness simply means more blue moods. When asked Have you cried today?
Americans have agreed more often in the winter (TABLE 15.6).
In milder forms, manias energy and flood of ideas fuel creativity. George Frideric
Handel, who may have suffered from a mild form of bipolar disorder, composed his
nearly four-hour-long Messiah (1742) during three weeks of intense, creative energy
(Keynes, 1980). Robert Schumann composed 51 musical works during two years of
mania (1840 and 1849) but none during 1844, when he was severely depressed (Slater
& Meyer, 1959). Those who rely on precision and logic, such as architects, designers,
and journalists, suffer bipolar disorder less often than do those who rely on emotional
expression and vivid imagery (Ludwig, 1995). Composers, artists, poets, novelists, and
entertainers seem especially prone (Jamison, 1993, 1995; Kaufman & Baer, 2002; Lud
wig, 1995). Indeed, one analysis of over a million individuals showed that the only psy
chiatric condition linked to working in a creative profession was bipolar disorder (Kyaga
et al., 2013). As one staff member said of the great leader Winston Churchill, Hes
either on the crest of the wave, or in the trough (Ghaemi, 2011).
It is as true of emotions as of everything else: What goes up comes down. Before
long, the elated mood either returns to normal or plunges into a depression. Though
bipolar disorder is much less common than major depressive disorder, it is often more
dysfunctional, claiming twice as many lost workdays yearly (Kessler et al., 2006). It
afflicts adult men and women about equally.
Actor Russell Brand
Writer Virginia Woolf
Humorist Samuel Clemens

(Mark Twain)
CHAPTER 15:
PSYCHOLOGIcAL DISORDERS
631
Understanding Depressive Disorders and

Bipolar Disorder
it.fri How can the biological and social-cognitive perspectives help us understand
depressive disorders and bipolar disorder?

In thousands of studies, psychologists continue to accumulate evidence to help explain
why people have depressive disorders and bipolar disorder and to design more effec
tive ways to treat and prevent them. Here, we focus primarily on depressive disorders.
One research group summarized the facts that any theory of depression must explain,
including the following (Lewinsohn et al., 1985, 1998, 2003):
Many behavioral and cognitive changes accompany depression. People trapped in
a depressed mood become inactive and feel unmotivated. They are sensitive to neg
ative events (Peckham et al., 2010). They more often recall negative information.
They expect negative outcomes (my team will lose, my grades will fall, my love will
fail). When the depression lifts, these behavioral and cognitive accompaniments
disappear. Nearly half the time, people also exhibit symptoms of another disorder,
such as anxiety or substance abuse.
Depression is widespread. Worldwide, more than 350 million people suffer depres
sion (WHO, 2012). Although phobias are more common, depression is the numberone reason people seek mental health services. At some point during their lifetime,
depression plagues 12 percent of Canadian adults and 17 percent of U.S. adults
(Holden, 2010; Patten et al., 2006). Moreover, depression is the leading cause of dis
ability worldwide (Ferrari et al., 2013). Depressions commonality suggests that its
causes, too, must be common.
Womens risk of major depression is nearly double mens. In 2009, when Gallup
pollsters asked more than a quarter-million Americans if they had ever been diag
nosed with depression, 13 percent of men and 22 percent of women said they had
(Pelham, 2009). When Gallup asked Americans if they had experienced sadness
during a lot of the day yesterday, 17 percent of men and 28 percent of women
answered Yes (Mendes & IvlcGeeney, 2012). The depression gender gap has been
found worldwide (FIGURE 15.5). The trend begins in adolescence; preadolescent
girls are not more depression-prone than are boys (Hyde et al., 2008). With adoles
cence, girls often think and fret more about their bodies.
The factors that put women at risk for depression (genetic predispositions,
child abuse, low self-esteem, marital problems, and so forth) similarly put men at
risk (Kendler et al., 2006). Yet women are more vulnerable to disorders involving
internalized states, such as depression, anxiety, and inhibited sexual desire. Women
experience more situations that may increase their risk for depression, such as
receiving less pay for equal work, juggling multiple roles, and caring for children
Life after depression ]. K. Rowling,

author of the Harry Potter books, reported
suffering acute depressiona dark time,
with suicidal thoughtsbetween ages 25
and 28. It was a terrible place, she said,
but it formed a foundation that allowed
her to come back stronger (McLaughlin,
2010).
15%
Percentage
of adults
experiencing
major depression
in previous
12 months
V FIGURE 15.5
Around the world, women

tend to be more susceptible
todepression
10
1J dli
Belgium France Germany

Males
Females
Israel
} ii J I
.
Italy
Japan Netherlands
New
Zealand
Spain
USA
Gender and major

depression Interviews
with 89,037 adults in 18
countries (10 of which
are shown here) confirm
mens. (Data from Bromet

et a[., 2011.)
632
CHAPTER 75:
and elderly family members (Freeman & Freeman, 2013). Mens disorders tend to
be more externalalcohol use disorder, antisocial conduct, lack of impulse control.
When women get sad, they often get sadder than men do. When men get mad, they
often get madder than women do.
Most major depressive episodes self-terminate. Therapy often helps and tends
to speed recovery. But even without professional help, most people recover from
major depression and return to normal. The plague of depression comes and, a few
weeks or months later, it goes, though for some (about half), it eventually returns
(Burcusa & lacono, 2007; Curry et al., 2011; Hardeveld et al., 2010). Only about 20
percent experience chronic depression (Klein, 2010). On average, a person with
major depressive disorder today will spend about three-fourths of the next decade
in a normal, nondepressed state (Furukawa et al., 2009). Recovery is more likely to
be permanent the later the first episode strikes, the longer the person stays well, the
fewer the previous episodes, the less stress experienced, and the more social sup
port received (Belsher & Costello, 1988; Fergusson & Woodwarcl, 2002; Kendler et
al., 2001).
Stressful events related to work, marriage, and close relationships often precede
depression. As anxiety is a response to the threat of future loss, depression is often
a response to past and ctirrent loss. About 1 person in 4 diagnosed with depression
has been brought down by a significant loss or trauma, such as a loved ones death,
a ruptured marriage, a physical assault, or a lost job (Kendler et al., 2008; Monroe &
Reid, 2009; Orth et al., 2009; Wakefield et al., 2007). Minor daily stressors can also
leave emotional scars. People who overreacted to minor stressors, such as a broken
appliance, were more often depressed 10 years later (Charles et al., 2013). Moving to
a new culture can also increase depression, especially among younger people who
have not yet formed their identities (Zhang et al., 2013). One long-term study (Kend
ler, 1998) tracked rates of depression in 2000 people. The risk of depression ranged
from less than 1 percent among those who had experienced no stressful life event
in the preceding month to 24 percent among those who had experienced three
such events in that month.
I see depression as the plague of the

modern era.
Lewis Judd, former chief, National Institute of
Mental Health. 2000
With each ne;v generation, depression strikes earlier (now often in the late teens)
and affects more people, with the highest rates in developed countries among
young adults. This trend has been reported in Canada, the United States, England,
France, Germany, Italy, Lebanon, New Zealand, Puerto Rico, and Taiwan (Col
lishaw et al., 2007; Cross-National Collaborative Group, 1992; Kessler et al., 2010;
Twenge et al., 2008). In one study, 12 percent of Australian adolescents reported
symptoms of depression (Sawyer et al., 2000). Most hid it from their parents;
almost 90 percent of those parents perceived their depressed teen as not suffering
depression. In North America, young adults are three times more likely than their
grandparents to report having recentlyor eversuffered depression (despite
the grandparents many more years of being at risk). The increase appears partly
authentic, but it may also reflect todays young adults greater willingness to dis
close depression.
Armed with these points of understanding, todays researchers propose biological and
cognitive explanations of depression, often combined in a biopsychosocial perspective.
.
The Biological Perspective

Genetic Influences Depressive disorders and bipolar disorder run in families. As
one researcher noted, emotions are postcards from our genes (Plotkin, 1994). The
risk of major depression and bipolar disorder increases if you have a parent or sibling
with the disorder (Sullivan et al., 2000). If one identical twin is diagnosed with major
CHAPTER 15:
depressive disorder, the chances are about 1 in 2 that at some

90%
time the other twin will be, too. This effect is even stronger
80
for bipolar disorder: If one identical twin has it, the chances
are 7 in 10 that the other twin will at some point be diagnosed
60
similarlyeven if the twins were raised apart (DiLalla et al.,
1996). Among fraternal twins, the corresponding odds are just
50
under 2 in 10 (Tsuang & Faraone, 1990). Summarizing the
40
major twin studies (see FIGURE 15.6), one research team estimated the heritability of major depressive disorder (the extent
20
to which individual differences are attributable to genes) at
37 percent (Bienvenu et al., 2011).
10
To tease out the genes that put people at risk for depression,
0
Psychological
some researchers have turned to linkage analysis. First, geneti
cists find families in which the disorder appears across several
generations. Next, the researchers examine DNA from affected and unaffected fam
ily members, looking for differences. Linkage analysis points them to a chromosome
neighborhood; A house-to-house search is then needed to find the culprit gene (Plomm & McGuffin, 2003). Such studies reinforce the view that depression is a complex
condition. lvlany genes work together, producing a mosaic of small effects that interact
with other factors to put some people at greater risk. If culprit gene variations can be
identifiedso far, chromosome 3 genes have been implicated in separate British and
American studies (Breen et al., 2011; Pergadia et al., 2011)they may open the door to
more effective drug therapy.
Bipolar disorder
Schizophrenia
Anorexia nervosa
Major depressive disorder

Generalized anxiety disorder
disorder
V FIGURE 15.6
The heritability of various

psychological disorders
Researchers Joseph Bienvenu, Dimitry
Davydow, and Kenneth Kend[er (2011)
aggregated data from studies of identi
cal and fraternal twins to estimate
the heritability of bipolar disorder,
schizophrenia, anorexia nervosa, major
depressive disorder, and generalized
anxiety disorder.
The Depressed Brain Scanning devices open a window on the brains activity
during depressed and manic states. One study gave 13 elite Canadian swimmers the
wrenching experience of watching a video of the swim in which they failed to make
the Olympic team or failed at the Olympic games (Davis et al., 2008). Functional MRI
scans showed the disappointed swimmers experiencing brain activity patterns similar
to those of patients with depressed moods.
Many studies have found diminished brain activity during slowed-down depressive
states, and more activity during periods of mania (FIGURE 15.7). The left frontal lobe
and an adjacent brain reward center become more active during positive emotions,
(Davidson et al., 2002; Heller et al., 2009; Robinson et al., 2012). In studies of depressed
people, MRI scans also found their frontal lobes were smaller than normal (Coffey et
al., 1993; Ribeiz et al., 2013; Steingard et al., 2002). Other studies show that the hip
ocampus, the memory-processing center linked with the brains emotional circuitry, is
vulnerable to stress-related damage.
Neuroscientists have also discovered altered brain structures in people with bipolar
disorder. One analysis discovered decreased white matter and enlarged fluid-filled ven
tricles (Arnone et al., 2009).
V FIGURE 15.7
Depressed state
(May 17)
Manic state
(May18)
Depressed state
(May27)
633
The ups and downs of bipolar

disorder These top-facing PET scans
show that brain energy consumption
rises and falls with the patients emo
tional switches. Red areas are where
the brain rapidly consumes glucose.
634
CHAPTER 15:
Neurotransmitter systems also influence depressive disorders and bipolar disorder. Nor
epinephrine, which increases arousal and boosts mood, is scarce during depression and
overabundant during mania. (Drugs that decrease mania reduce norepinephrine.) IVIanv
people with a history of depression also have a history of habitual smoking (Pasco et al.,
2008). Once the urge to smoke is ignited, depression also makes it more difficult to quit
(Hitsman et al., 2012). This may indicate an attempt to self-medicate with inhaled nico
tine, which can temporarily increase norepinephrine and boost mood (HMHL, 2002).
Researchers are also exploring a second neurotransmitter, serotonin (Carver et al.,
2008). One well-publicized study of New Zealand young adults found that the recipe
for depression combined two necessary ingredientssignificant life stress plus a varia
tion of a serotonin-controlling gene (Caspi et al., 2003; Moffitt et al., 2006). Depression
arose from the combination of an adverse environment plus a genetic susceptibility,
but not from either alone. But stay tuned: The story of gene-environment interactions
is still being written, as other researchers debate the reliability of this result (Caspi
et al., 2010; Culverhouse et a!., 2013; Karg et al., 2011; MunafO et al., 2009; Uher &
McGuffin, 2010).
Drugs that relieve depression tend to increase norepinephrine or serotonin sup
plies by blocking either their reuptake (as Prozac, Zoloft, and Paxil do with serotonin)
or their chemical breakdown. Repetitive physical exercise, such as jogging, reduces
depression because it increases serotonin, which affects mood and arousal (Airan et al,
2007; Ilardi, 2009; Jacobs, 1994). In one study, running for two hours increased brain
activation in regions associated with euphoria (Boecker et al., 2008). To run away from
a bad mood, you can use your own two feet.
Nutritional Effects Whats good for the heart is also good for the brain and mind.
People who eat a heart-healthy Mediterranean diet (heavy on vegetables, fish, and
olive oil) have a comparatively low risk of developing heart disease, stroke, late-life cog
nitive decline, and depressionall of which are associated with inflammation (Dowlati
et al., 2010; Psaltopoulou et al., 2013; Snchez-Villegas et al., 2009; Tangney et al., 2011).
Excessive alcohol use also correlates with depressionmostly because alcohol misuse
leads to depression (Fergusson et al., 2009).
The Social-Cognitive Perspective

Biological influences contribute to depression, but in the naturenurture dance, our
actions also play a part. Diet, drugs, stress, and other life experiences lay down ejJi
genetic merks, which are often organic molecules. These molecular tags attach to our
chromosomes and turn certain genes on or off. Animal studies suggest that epigenetic
influences may play a long-lasting role in depression (Nestler, 2011).
Thinking matters, too. The societ-cognitive jersective explores how peoples
assumptions and expectations influence what they perceive. Depressed people view
life through the dark glasses of low self-esteem (Kuster et al., 2012; Sowislo & Orth,
2012). Their intensely negative assumptions about themselves, their situation, and their
future lead them to magnify bad experiences and minimize good ones (Wenze et al.,
2012). Listen to Norman, a Canadian college professor, recalling his depression:
I [despaired] of ever being human again. I honestly felt subhuman, lower than the lowest
vermin. Furthermore, I was self-deprecatory and could not understand why anyone would
I was positive that I was a fraud and a
want to associate with me, let alone love me.
phony and that I didnt deserve my Ph.D. I didnt deserve to have tenure; I didnt deserve to
I didnt deserve the research grants I had been awarded; I couldnt
be a Full Professor.
I must have conned a lot of
understand how I had written books and journal articles
people. (Endler, 1982, pp. 4549)
.
Expecting the worst, depressed peoples self-defeating betiefs and their negative explan
atory style feed depressions vicious cycle.
CHAPTER 15:
Negative Thoughts and Negative Moods Interact Self-defeating beliefs

may arise from learned hetjtessness, the hopelessness and passive resignation animals and
humans learn when they experience uncontrollable painful events. Learned helpless
ness has been found more often in women than in men, and women may respond more
strongly to stress (Hankin & Abramson, 2001; Mazure et al., 2002; Nolen-Hoeksema,
2001, 2003). For example, 38 percent of women and 17 percent of men entering Ameri
can colleges and universities have reported feeling at least occasionally overwhelmed
by all I have to do (Pryor et al., 2006). (vIen reported spending more time in light
anxiety activities such as sports, TV watching, and partying, possibly avoiding activities
that might make them feel overwhelmed.) This gender difference may help explain why,
beginning in their early teens, women have been nearly twice as vulnerable to depres
sion. Susan Nolen-Hoeksema (2003) related womens higher risk of depression to what
she described as their tendency to ruminate or overthink. Ruminationstaying foctised
on a problem (thanks to the continuous firing of a frontal lobe area that sustains atten
tion)can be adaptive (Altamirano et al., 2010; Andrews & Thomson, 2009a,b). But
relentless, self-focused rumination can divert us from thinking about other life tasks, and
can increase negative moods (Kuppens et al., 2010; Kuster et al., 2012).
Even so, why do lifes unavoidable failures lead only some people to become
depressed? The answer lies partly in their exlanatory stylewho or what they blame
for their failures. Think of how you might feel if you failed a test. If you can external
ize the blame (\Vhat an unfair test!), you are more likely to feel angry. If you blame
yourself, you probably will feel stupid and depressed.
So it is with depressed people, who often explain bad events in terms that are stable
(Its going to last forever), global (Its going to affect everything I do), and internal
(Its all my fault) (FIGURE 15.8). Depression-prone people respond to bad events in
an especially self-focused, self-blaming way (Mor & Winquist, 2002; Pyszczynski et al.,
1991; Wood et al., 1990a,b). When they describe themselves, their brains activate in a
region that processes self-relevant information (Sarsam et al., 2013). Their self-esteem is
also more plasticit climbs with praise and plummets with threats (Butler et al,, 1994).
Pessimistic, overgeneralized, self-blaming attributions may create a depressing sense
of hopelessness (Abramson et al., 1989; Panzarella et al., 2006). As Martin Seligman has
Susan Nolen-Hoeksema
(19592013) This epidemic of morbid

meditation is a disease that women
suffer much more than men. Women
can ruminate about anything and every
thingour appearance, our families, our
career, our health. (Women Who Think
Too Much: How to Break Free of Overthinking and Reclaim Your Life, 2003)
rumination compulsive fretting

overthinking about our problems and their
causes.
Breakup with a romantic partner
Stable
Ill never get over this.
Temporary
This is hard to take, but I
will get through this.
Global
Without my partner, I cant
seem to do anything right.
Specific
I miss my partner, but thankfully
I have family and other friends.
Internal
Our breakup was all my fault.
,,
External
It takes two to make a relationship
work and it wasntmeant to be.
I
Depression
Successful coping
635
V FIGURE 15.8
Explanatory style and depression

After a negative experience, a depressionprone person may respond with a nega
tive explanatory style.
636
CHAPTER 15:
You should never engage in

unsupervised introspection.
Man never reasons so much and

becomes so introspective as when he
suffers, since he is anxious to get at
,
the cause of his sufferings.
Luigi Pirandello,
Six Characters in Search of an Author, 1922
Some cause happiness wherever they

go; others, whenever they go.
Irish writer Oscar Wilde (18541900)
noted, A recipe for severe depression is preexisting pessimism encountering failure

(1991, p. 78). What then might we expect of new college students who are not depressed
but do exbibit a pessimistic explanatory style? In one study, Lauren Alloy and her col
leagues (1999) monitored students every 6 weeks for 2.5 years. Among those identified
as having a pessimistic thinking style, 17 percent had a first episode of major depres
sion, as did only 1 percent of those who began college with an optimistic thinking style.
Why is depression so common among young Westerners? Seligman (1991, 1995) has
pointed to the rise of individualism and the decline of commitment to religion and
family, which forces young people to take responsibility for failure or rejection. In nonWestern cultures, where close-knit relationships and cooperation are the norm, major
depression is less common and less tied to self-blame over personal failure (Ferrari et
al., 2013; WHO, 2004a). In Japan, for example, depressed people instead tend to report
feeling shame over letting others down (Draguns, 1990a).
Critics note a chicken-and-egg problem nesting in the social-cognitive explanation
of depression. Which comes first? The pessimistic explanatory style, or the depressed
mood? Certainly, the negative explanations coincide with a depressed mood, and they
are indicators of depression. But do they cause depression, any more than a speedom
eters reading 70 mph causes a cars speed? Before or after being depressed, peoples
thoughts are less negative. Perhaps a depressed mood triggers negative thoughts. If
you temporarily put people in a bad or sad mood, their memories, judgments, and
expectations suddenly become more pessimistic. Memory researchers understand this
tendency to recall experiences that are consistent with ones current good or bad mood.
They call it state-dependent memory.
Depressions Vicious Cycle Depression is both a cause and an effect of stressful

experiences that disrupt our sense of who we are and why we are worthy human beings.
Such disruptions can lead to brooding, which amplifies negative feelings. Being with
drawn, self-focused, and complaining can in turn elicit rejection (Furr & Funder, 1998;
Cotlib & Hammen, 1992). One study set up brief phone conversations between partici
pants and people who did or did not have depression. After the conversation, participants
could accept or reject the other person. The result? They rejected depression-prone peo
ple more often. The participants also noted that they felt more depressed, anxious, and
hostile after speaking with depressed people (Coyne, 1976). Indeed, people in the throes
of depression are at high risk for divorce, job loss, and other stressful life events. Weary
of the persons fatigue, hopeless attitude, and lethargy, a spouse may threaten to leave or
a boss may begin to question the persons competence. (This provides another example
of genetic-environmental interaction: People genetically predisposed to depression more
often experience depressing events.) Rejection and depression feed each other. Misery
may love anothers company, but company does not love anothers misery.
We can now assemble some of the pieces of the depression puzzle (FICURE 15.9):
(1) Negative, stressful events interpreted through (2) a ruminating, pessimistic explana
tory style create (3) a hopeless, depressed state that (4) hampers the way the person
thinks and acts. This, in turn, fuels (1) negative, stressful experiences such as rejection.
Depression is a snake that bites its own tail.
None of us are immune to the dejection, diminished self-esteem, and negative think
ing brought on by rejection or defeat. Even small losses can temporarily sour our think
ing. In one study, researchers studied some avid Indiana University basketball fans who
seemed to regard the team as an extension of themselves (Hirt et al., 1992). After the
fans watched their team lose or win, the researchers asked them to predict the teams
future performance and their own. After a loss, the morose fans offered bleaker assess
ments not only of the teams future but also of their own likely performance at throw
ing darts, solving anagrams, and getting a date. When things arent going our way, it
may seem as though they never will.
CHAPTER 15:
Stressful
experiences
4
Cognitive and
behavioral changes
Negative
explanatory style
637
V FIGURE 15.9
The vicious cycle of depressed
thinking Therapists recognize this
cycle, and they work to help depressed
people break out of it. Each of the
bottom three points offers an exit to
work toward: 2. Reverse self-blame
and a negative outlook. 3. Turn atten
tion outward. 4. Engage in more
pleasant activities and more competent
behavior.
Depressed
mood
It is a cycle we can all recognize. Bad moods feed on themselves: When we feel
down, we think negatively and remember bad experiences. Abraham Lincoln was so
withdrawn and brooding as a young man that his friends feared he might take his own
life (Kline, 1974). Poet Emily Dickinson was so afraid of bursting into tears in public
that she spent much of her adult life in seclusion (Patterson, 1951). As their lives remind
us, people can and do struggle through depression. Most regain their capacity to love,
to work, and even to succeed at the highest levels.
Suicide and Self-Injury

iisi What factors increase the risk of suicide, and what do we know about
nonsuicidal self-injury?
Each year over 800,000 despairing people worldwide will elect a permanent solution
to what might have been a temporary problem (WHO, 2014). For those who have been
depressed, the risk of suicide is at least five times greater than for the general population (Bostwick & Pankratz, 2000). People seldom commit suicide while in the depths of
depression, when energy and initiative are lacking. The risk increases when they begin
to rebound and become capable of following through.
Comparing the suicide rates of different groups, researchers have found
national differences: Britains, Italys, and Spains suicide rates are little more than
half those of Canada, Australia, and the United States. Austrias and Finlands are
about double (WHO, 2011). Within Europe, people in the most suicide-prone coun
try (Belarus) have been 16 times more likely to kill themselves than those in the
least (Georgia).
racial differences: Within the United States, Whites and Native Americans kill
themselves twice as often as Blacks, Hispanics, and Asians (CDC, 2012).
gender differences: Women are much more likely than men to attempt suicide
(WHO, 2011). But men are two to four times more likely (depending on the country)
to actually end their lives. Men use more lethal methods, such as firing a bullet into
the head, the method of choice in 6 of 10 U.S. suicides.
age differences and trends: In late adulthood, rates increase, peaking in middle
age and beyond. In the last half of the twentieth century, the global rate of annual
suicide deaths nearly doubled (WHO, 2008).
other group differences: Suicide rates have been much higher among the rich, the
nonreligious, and those who were single, widowed, or divorced (Hoyer & Lund,
1993; Okada & Samreth, 2013; Stack, 1992; Stengel, 1981). Witnessing physical pain
and trauma can increase the risk of suicide, which may help explain physicians
elevated suicide rates (Bender et al., 2012; Cornette et al., 2009). Gay and lesbian
But life, being weary of these worldly

bars, Never lacks power to dismiss
itself.
William
Shakespeare, Julius Caesar,
1599
638
CHAPTER 15:
youth facing an unsupportive environment, including family or peer rejection, are

also at increased risk of attempting suicide (Goldfried, 2001; Haas et al., 2011; Hat
zenhuehler, 2011). Among people with alcohol use disorder, 3 percent die by suicide.
This rate is roughly 100 times greater than the rate for people without alcohol use
disorder (Murphy & Wetzel, 1990; Sher, 2006).
day of the week differences: Negative emotion tends to go up midweek, which can
have tragic consequences (Watson, 2000). A surprising 25 percent of U.S. suicides

occur on Wednesdays (Kposowa & DAuria, 2009).
Social suggestion may trigger suicide. Following highly publicized suicides and TV
programs featuring suicide, known suicides increase. So do fatal auto and private air
plane accidents. One six-year study tracked suicide eases among all 1.2 million people
who lived in metropolitan Stockholm at any time during the 1990s (Hedstrom et al.,
2008). Men exposed to a family suicide were 8 times more likely to commit suicide than
were nonexposed men. That phenomenon may be partly attributable to family genes.
But shared genetic predispositions cannot explain why men exposed to a co-workers
suicide were 3.5 times more likely to commit suicide, compared with nonexposed men.
Because suicide is so often an impulsive act, environmental barriers (such as jump
barriers on high bridges and the unavailability of loaded guns) can save lives (Anderson,
2008). Common sense may suggest that a determined person will simply find another
way to complete the act, but such restrictions give time for self-destructive impulses to
subside.
Suicide is not necessarily an act of hostility or revenge. Peopleespecially older
adultsmay choose death as an alternative to current or future suffering, a way to
switch off unendurable pain and relieve a perceived burden on family members. Sui
cidal urges typically arise when people feel disconnected from others and a burden to
them, or when they feel defeated and trapped by an inescapable situation (Joiner, 2010;
Taylor et al., 2011). Thus, suicide rates increase a bit during economic recessions (Luo
et al., 2011). Suicidal thoughts also may increase when people are driven to reach a goal
or standardto become thin or straight or richand find it unattainable (Chatard &
Selimbegovie, 2011).
In hindsight, families and friends may recall signs they believe should have fore
warned themverbal hints, giving possessions away, or withdrawal and preoccupation
with death. To judge from surveys of 84,850 people across 17 nations, about 9 percent
of people at some point in their lives have thought seriously of suicide. About 3 in 10 of
those who think about it will actually attempt suicide (Nock et al., 2008). Only about 1
in 25 Americans die in that attempt (AAS, 2009). Of those who die, one-third had tried
to kill themselves previously. Most discussed it beforehand. So, if a friend talks suicide
to you, its important to listen and to direct the person to professional help. Anyone
who threatens suicide is at least sending a signal of feeling desperate or despondent.
Nonsuicidal Self-Injury Suicide is not the only way to send a message or deal
with distress. Some people, especially adolescents and young adults, may engage in
nonsuzczdal self-injury (NSSI) (FIGURE 15.10). These people hurt themselves in various
ways. They may cut or burn their skin, hit themselves, insert objects under their nails
or skin, or tattoo themselves (Fikke et al., 2011). Though painful, these self-injuries are
not fatal. People who engage in NSSI tend to be less able to tolerate emotional distress.
They are extremely self-critical and often have poor communication and problem-solv
ing skills (Noek, 2010). Why do they hurt themselves? Through NSSI they may
find relief from intense negative thoughts through the distraction of pain.
attract attention and possibly get help.
relieve guilt by inflicting self-punishment.
CHAPTER i5)kPSYCHOLOGlCAL DISORDERS
639
450
Injury rate
per ioo,ooo
people
400
350
300
250
200
150
100
50
0
04
59
1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 7579 8084
85+
Age group (years)
FIGURE 15.10
Rates of nonfatal self-injury in the
U.S. Self-injury rates peak higher for
females than for males. (Data from
get others to change their negative behavior (bullying, criticism).

fit in with a peer group.
Does NSSI lead to suicide? Usually not. Those who engage in NSSI are typically sui
cide gesturers, not suicide attempters (Nock & Kessler, 2006). Suicide gesturers engage
in NSSI as a desperate but non-life-threatening form of communication or when they
are feeling overwhelmed. Nevertheless, NSSI is considered a risk factor for future sui
cide attempts (Wilkinson & Goodyer, 2011). If people do not find help, their nonsui
cidal behavior may escalate to suicidal thoughts and, finally, to suicide attempts.
RETRIEVAL PRACTICE
What does it mean to say that depression is a whole-body disorder?

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People desire death when two fun

damental needs are frustrated to
the point of extinction: The need to
belong with or connect to others, and
the need to feel effective with or to
influence others.
elOqM
REVIEW
Thomas Joiner (2006, p. 47)
Depressive Disorders and Bipolar Disorder
LEARNING OBJECTIVES

ii How do major depressive disorder, persistent depressive
disorder, and bipolar disorder differ?
jjJ How can the biological and social-cognitive perspectives
help us understand depressive disorders and bipolar disorder?

answers.
major depressive disorder, p. 629

mania, p. 629
bipolar disorder, p. 629
rumination, p. 635
IIH What
factors increase the risk of suicide and what do we

know about nonsuicidal self-injury?
Use
LeornlngCurve to create your personalized study plan, which will
direct you to the resources that will hetp you most in
L.ounchFd.
640
CHAPTER 15:
schizophrenia a psychological
disorder characterized by delusions,
hallucinations, disorganized speech, and!
or diminished, inappropriate emotional
expression.
delusion a false belief, often of perse
cution or grandeur, that may accompany
psychotic disorders.
Schizophrenia
During their most severe periods, people with schizophrenia live in a private inner
world, preoccupied with the strange ideas and images that haunt them. The word itself
means split (schizo) mind (phrenia). In this disorder, however, the mind is not split
into multiple personalities. Rather, the mind has suffered a split from reality that shows
itself in disturbed perceptions, disorganized thinking and speech, and diminished,
inappropriate emotions. Schizophrenia is the chief example of a psychosis, a broad
term for a break or split from reality.
Symptoms of Schizophrenia
CC
When someone asks me to explain

schizophrenia I tell them, you know
how sometimes in your dreams you
are in them yourself and some of them
feel like real nightmares? My schizo
phrenia was like I was walking through
a dream. But everything around me
was real. At times, todays world seems
so boring and I wonder if I would like
to step back into the schizophrenic
dream, but then I remember all the
scary and horrifying experiences.
Stuart Emmons, with Craig Geiser,
Ka[man J. Kaplan, and Martin Harrow,
Living With Schizophrenia, 1997
ii-ri What patterns of perceiving, thinking, and feeling characterize schizophrenia?
Schizophrenia comes in varied forms. Schizophrenia patients with positive symptoms

may experience hallucinations, talk in disorganized and deluded ways, and exhibit
inappropriate laughter, tears, or rage. Those with negative symptoms may have toneless
voices, expressionless faces, or mute and rigid bodies.
Disturbed Perceptions
People with schizophrenia sometimes have hallucinationsthey see, feel, taste, or
smell things that exist only in their minds. Most often, the hallucinations are sounds,
frequently voices making insulting remarks or giving orders. The voices may tell the
person that she is bad or that she must burn herself with a cigarette lighter. Imagine
your own reaction if a dream broke into your waking consciousness, making it hard
to separate your experience from your imagination. When the unreal seems real, the
resulting perceptions are at best bizarre, at worst terrifying.
Disorganized Thinking and Speech

Art by someone diagnosed with
schizophrenia Commenting on the
kind of artwork shown here (from Craig
Geisers 2010 art exhibit in Michigan),
poet and art critic John Ashbery wrote:
The lure of the work is strong, but
so is the terror of the unanswerable
riddles it proposes.
Hallucinations are false perceptions. People with schizophrenia also have disorga
nized, fragmented thinking, which is often distorted by false beliefs called delusions.
If they have paranoid tendencies, they may believe they are being threatened or
pursued.
Maxine, a young woman with schizophrenia, believed she was Mary Poppins. Com
municating with Maxine was difficult because her thoughts spilled out in no logical
order. Her biographer, Susan Sheehan (1982, p. 25), observed her saying aloud to no one
in particular, This morning, when I was at Hillside [HospitalJ, I was making a movie.
I was surrounded by movie stars.
Is this room painted blue to get me upset? My
grandmother died four weeks after my eighteenth birthday.
Jumbled ideas may make no sense even within sentences, forming what is known as
word salad. One young man begged for a little more allegro in the treatment, and sug
gested that liberationary movement with a view to the widening of the horizon will
ergo extort some wit in lectures.
One cause of disorganized thinking may be a breakdown in selective attention. Nor
mally, we have a remarkable capacity for giving our undivided attention to one set of
sensory stimuli while filtering out others. People with schizophrenia cannot do this.
Thus, tiny, irrelevant stimuli, such as the grooves on a brick or the inflections of a
voice, may distract their attention from a bigger event or a speakers meaning. As one
former patient recalled, What had happened to me
was a breakdown in the filter,
and a hodge-podge of unrelated stimuli were distracting me from things which should
have had my undivided attention (MacDonald, 1960, p. 218). This selective attention
difficulty is but one of dozens of cognitive differences associated with schizophrenia
(Reichenberg & Harvey, 2007).
.
200E
CHAPTER 15:
641
Diminished and Inappropriate Emotions

The expressed emotions of schizophrenia are often utterly inappropriate, split off from
reality (Kring & Caponigro, 2010). Maxine laughed after recalling her grandmothers
death. On other occasions, she cried when others laughed, or became angry for no
apparent reason. Others with schizophrenia lapse into an emotionless flat affect state
of no apparent feeling. Most also have an impaired theory of mindthey have difficulty
perceiving facial emotions and reading others states of mind (Green & Horan, 2010;
Kohier et al., 2010). These deficiencies occur early in the illness and have a genetic
basis (Bora & Fantelis, 2013).
Motor behavior may also be inappropriate. Some perform senseless, compulsive
acts, such as continually rocking or rubbing an arm. Others may remain motionless for
hours (a condition called catatonia) and then become agitated.
As you can imagine, such disturbed perceptions, disorganized thinking, and inap
propriate emotions profoundly disrupt social and work relationships. During their most
severe periods, people with schizophrenia live in a private inner world, preoccupied
with illogical ideas and unreal images. Many have sleep problems, which can increase
night eating and obesity (Palmese et al., 2011). Given a supportive environment and
medication, over 40 percent of people with schizophrenia will have periods of a year
or more of normal life experience (Jobe & Harrow, 2010). Many others remain socially
withdrawn and isolated or rejected for much of their lives (Hooley, 2010).
Onset and Development of Schizophrenia

iii-i How do chronic and acute schizophrenia differ?
Nearly 1 in 100 people will experience schizophrenia this year, joining the estimated
24 million worldwide who have this disorder (Abel et al., 2010; WHO, 2011). It typically
strikes as young people are maturing into adulthood. It knows no national boundaries,
and it affects both males and females. Men tend to be struck earlier, more severely,
and slightly more often (Aleman et al., 2003; Eranti et al., 2013; Picchioni & Murray,
2007). The risk of schizophrenia is higher for those who experience childhood abuse:
They are three times more likely than their unabused counterparts to develop this dis
order (Matheson et al., 2013). Other types of childhood adversity, such as bullying, also
increase the risk (Varese et al., 2012).
When schizophrenia is a slow-developing process, called chronic schizophrenia,
recovery is doubtful (WHO, 1979). This was the case with Maxines schizophrenia, which
took a slow course, emerging from a long history of social inadequacy and poor school
performance (MacCabe et al., 200$). Those with chronic schizophrenia often exhibit the
persistent and incapacitating negative symptom of social withdrawal (Kirkpatrick et al.,
2006). Men, whose schizophrenia develops on average four years earlier than womens,
more often exhibit negative symptoms and chronic schizophrenia (Rsnen et al., 2000).
In one study that followed people with chronic schizophrenia over 34 years, the majority
showed worsened symptoms and functioning (Newman et al., 2012).
When previously well-adjusted people develop schizophrenia rapidly following
particular life stresses, this is called acute schizophrenia, and recovery is much more
likely. They more often have the positive symptoms that are more likely to respond to
drug therapy (Fenton & McGlashan, 1991, 1994; Fowles, 1992).
Understanding Schizophrenia
Schizophrenia is a dreaded psychological disorder. It is also one of the most heavily
researched. 1vlost studies now link it with abnormal brain tissue and genetic predisposi
tions. Schizophrenia is a disease of the brain manifested in symptoms of the mind.
chronic schizophrenia (also called

process schizophrenia) a form of schizo
phrenia in which symptoms usually
appear by [ate adolescence or early
adulthood. As people age, psychotic epi
sodes last longer and recovery periods
shorten.
acute schizophrenia (also called
reactive schizophrenia) a form of
schizophrenia that can begin at any
age, frequently occurs in response to
an emotionally traumatic event, and has
extended recovery periods.
642
CHAPTER 15:
Brain Abnormalities
II[i What brain abnormalities are associated with schizophrenia?
Might chemical imbalances in the brain underlie schizophrenia? Scientists have long
known that strange behavior can have strange chemical causes. The saying mad as a
hatter refers to the psychological deterioration of British hatmakers whose brains, it
was later discovered, were slowly poisoned as they moistened the brims of mercuryladen felt hats with their tongue and lips (Smith, 1983). Could schizophrenia symptoms
have a similar biochemical key? Scientists continue to track the mechanisms by which
chemicals produce hallucinations and other symptoms.
Most people with schizophrenia smoke,

often heavily. Nicotine apparently stim
ulates certain brain receptors, which
helps focus attention (Diaz et al., 2008;
Javitt & Coyle, 2004).
Dopamine Overactivity One possible answer emerged when researchers exam

ined schizophrenia patients brains after death. They found an excess of receptors for
dojaminea sixfold excess for the dopamine receptor D4 (Seeman et al., 1993; Wong
et al., 1986). Such a hyper-responsive dopamine system may intensify brain signals in
schizophrenia, creating positive symptoms such as hallucinations and paranoia (Grace,
2010). Drugs that block dopamine receptors often lessen these symptoms. Drugs that
increase dopamine levels, such as amphetamines and cocaine, sometimes intensify
them (Seeman, 2007; Swerdlow & Koob, 1987).
Abnormal Brain Activity and Anatomy Brain scans show that abnormal
activity accompanies schizophrenia. Some people diagnosed with schizophrenia have
abnormally low brain activity in the frontal lobes, areas that help us reason, plan, and
solve problems (Ivlorey et al., 2005; Pettegrew et al., 1993; Resnick, 1992). Brain scans
also show a noticeable decline in the brain waves that reflect synchronized neural fir
ing in the frontal lobes (Spencer et al., 2004; Symond et al., 2005). Out-of-sync neurons
may disrupt the integrated functioning of neural networks, possibly contributing to
schizophrenia symptoms.
One study took PET scans of brain activity while people were hallucinating (Sil
bersweig et al., 1995). When participants heard a voice or saw something, their brain
became vigorously active in several core regions. One was the thalamus, the structure
that filters incoming sensory signals and transmits them to the brains cortex. Another
PET scan sttidy of people with paranoia found increased activity in the amygdala, a
fear-processing center (Epstein et al., 1998).
Many studies have found enlarged, fluid-filled areas and a corresponding shrinkage
and thinning of cerebral tissue in people with schizophrenia (Goldman et al., 2009;
Wright et al., 2000). People often inherit these brain differences. If one affected identical
twin shows brain abnormalities, the odds are at least 1 in 2 that the other twin will have
them (van Haren et al., 2012). Even people who will toter develop the disorder may show
these symptoms (Karlsgodt et al., 2010). The greater the brain shrinkage, the more severe
the thought disorder (Collinson et al., 2003; Nelson et al., 1998; Shenton, 1992).
Two smaller-than-normal areas are the cortex and the corpus callosum connect
ing the brains two hemispheres (Arnone et al., 2008). Another is the thalamus, which
may explain why people with schizophrenia have difficulty filtering sensory input and
focusing attention (Andreasen et al., 1994; Ellison-Wright et al., 2008). The bottom line
is that schizophrenia involves not one isolated brain abnormality but problems with
several brain regions and their interconnections (Andreasen, 1997, 2001).
Prenatal Environment and Risk

What prenatal events are associated with increased risk of developing
schizophrenia?
What causes brain abnormalities in people with schizophrenia? Some scientists point
to mishaps during prenatal development or delivery (Fatemi & Folsom, 2009; Walker et
al., 2010). Risk factors for schizophrenia include low birth weight, maternal diabetes,
CHAPTER 15:
older paternal age, and oxygen deprivation during delivery (King et al., 2010). famine
may also increase risks. People conceived during the peak of World War IIs Dutch war
time famine later developed schizophrenia at twice the normal rate. Those conceived
during the famine of 1959 to 1961 in eastern China also displayed this doubled rate
(St. Clair et al., 2005; Susser et al., 1996).
Lets consider another possible culprit. Might a midpregnancy viral infection impair
fetal brain development (Brown & Patterson, 2011)? Can you imagine some ways to test
this fetal-virus idea? Scientists have asked the following:
Are people at increased risk of schizophrenia if, during the middle of their fetal devel
opment, their country experienced a flu epidemic? The repeated answer has been Yes
(Mednick et al., 1994; Murray et al., 1992; Wright et al., 1995).
Are people born in densely populated areas, where viral diseases spread more readily,
at greater risk for schizophrenia? The answer, confirmed in a study of 1.75 million
Danes, has again been Yes (Jablensky, 1999; Mortensen, 1999).
Are those born during the winter and spring monthsafter the fall-winter flu
seasonalso at increased risk? Although the increase is small, just 5 to 8 percent,
the answer has been Yes (Fox, 2010; Schwartz, 2011; Torrey et al., 1997, 2002).
In the Southern Hemisphere, where the seasons are the reverse of the Northern
Hemisphere, are the months of above-average schizophrenia births similarly reversed?
Again, the answer has been Yes, though somewhat less so. In Australia, people
born between August and October are at greater risk. But there is an exception: For
people born in the Northern Hemisphere, who later moved to Australia, the risk is
greater if they were born between January and Ivlarch (McGrath et al., 1995, 1999).
Are mothers who report being sick with influenza during pregnancy more likely to bear
children who develop schizophrenia? In one study of nearly 8000 women, the answer
was Yes. The schizophrenia risk increased from the customary 1 percent to about
2 percentbut only when infections occurred during the second trimester (Brown
et al., 2000). Maternal influenza infection during pregnancy affects brain develop
ment in monkeys also (Short et al., 2010).
Does blood drawn from pregnant women whose offspring develop schizophrenia
show higher-than-normal levels of antibodies that suggest a viral infection? In one
study of 27 women whose children later developed schizophrenia, the answer was
Yes (Buka et al., 2001). And the answer was again Yes in a huge California study,
which collected blood samples from some 20,000 pregnant women during the 1950s
and 1960s (Brown et al., 2004). Another study found traces of a specific retrovirus
(HERV) in nearly half of people with schizophrenia and virtually none in healthy
people (Perron et al., 2008).
These converging lines of evidence suggest that fetal-virus infections contribute to
the development of schizophrenia. They also strengthen the U.S. government recom
mendation that pregnant women need a flu shot (CDC, 2014).
Why might a second-trimester maternal flu bout put a fetus at risk? Is the virus itself
the culprit? The mothers immune response to it? Medications taken (Wyatt et al.,
2001)? Does the infection weaken the brains supportive glial cells, leading to reduced
synaptic connections (Moises et al., 2002)? In time, answers may become available.
Genetic Factors
hI1:I Do genes influence schizophrenia? What factors may be early warning signs of
schizophrenia in children?
fetal-virus infections may increase the odds that a child will develop schizophrenia. But
many women get the flu during their second trimester of pregnancy, and only 2 percent
of them bear children who develop schizophrenia. Why are only some children at risk?
643
644
CHAPTER 15:
FIGURE 1511
Risk of developing schizophrenia The lifetime risk of developing
schizophrenia varies with ones
genetic relatedness to someone
having this disorder. Across
countries, barely more than 1 in
10 fraternal twins, but some 5 in
10 identical twins, share a schizo
phrenia diagnosis. (Data from
Gottesman, 2001.)
V
Schizophrenia risk
for twins of those
with schizophrenia
70
Fraternal twins
.
ldentical twins
60
50
40
30
20
--
---
10
0
---
------
lapan
Denmark
Finland
Germany
U.K.
(1996)
(1996)
(1998)
(1998)
(1999)
Might some people be more vulnerable because they inherit a predisposition to this dis
order? Some people with no family history of schizophrenia develop the disorder (Xu et
al., 2011). But the evidence strongly suggests that, Yes, some may inherit a predisposi
tion to schizophrenia. The nearly 1-in-100 odds of any persons being diagnosed with
schizophrenia become about 1 in 10 among those who have a sibling or parent with
the disorder. If the affected sibling is an identical twin, the odds increase to nearly 5 in
10 (FIGURE 15.11). Those odds remain the same even when the twins are raised apart
(Plomin et al., 1997). (Only about a dozen such cases are on record.)
Remember, though, that identical twins share more than their genes. They also
share a prenatal environment. About two-thirds share a placenta and the blood it sup
plies; the other one-third have separate placentas. Shared placentas matter. If the
co-twin of an identical twin with schizophrenia shared the placenta, the chances of
developing the disorder are 6 in 10. If the identical twins had separate placentas (as
do fraternal twins), the co-twins chances of developing schizophrenia drop to 1 in 10
(Davis et al., 1995a,b; Phelps et al., 1997). Twins who share a placenta are more likely
to share the same prenatal viruses. So perhaps shared germs as well as shared genes
produce identical twin similarities.
Adoption studies help untangle genetic and environmental influences. Children
adopted by someone who develops schizophrenia seldom catch the disorder. Rather,
adopted children have an elevated risk if a biological parent is diagnosed with schizo
phrenia (Gottesman, 1991).
Schizophrenia in identical twins
The search is on for specific genes that, in some combination, predispose
When twins differ, only the one af
schizophrenia-inducing brain abnormalities (Levinson et al., 2011; Mitchell & Porte
flicted with schizophrenia typically has
enlarged, fluid-filled cranial cavities
ous, 2011; Ripke et al., 2011; Vacic et al., 2011). (It is not our genes but our brains that
(right) (Suddath et al., 1990). The differ
directly control our behavior.) Some of these genes influence the effects of dopamine
ence between the twins implies some
and other neurotransmitters in the brain. Others affect the production of myetin, a
nongenetic factor, such as a virus, is
fatty substance that coats the axons of nerve cells and lets impulses travel at high speed
also at work.
through neural networks.
Although genes matter, the genetic formula is not as straightforward
as the inheritance of eye color. Genome studies of thousands of indi
viduals with and without schizophrenia indicate that schizophrenia is
influenced by many genes, each with very small effects (International
Schizophrenia Consortium, 2009; Xu et al., 2012). And, as we have so
often seen, nature and nurture interact. Epigenetic (literally in addition
to genetic) factors influence whether or not genes will be expressed.
Like hot water activating a tea bag, environmental factors such as viral
infections, nutritional deprivation, and maternal stress can turn on
the genes that put some of us at higher risk for schizophrenia. Identi
cal twins differing histories in the womb and beyond explain why only
No schizophrenia
Schizophrenia
CHAPTER 75:
one of them may show differing gene expressions (Dempster et a!., 2013; Walker et al.,
2010). Our heredity and our life experiences work together. Neither hand claps alone.
Thanks to our expanding understanding of genetic and brain influences on mala
dies such as schizophrenia, the general public more and more attributes psychiatric dis
orders to biological factors (Pescosolido et a!., 2010). In 2007, one privately funded new
research center announced its ambitious aim: To unambiguously diagnose patients
with psychiatric disorders based on their DNA sequence in 10 years time (Holden,
2007). In 2010, S120 million in start-up funding launched a bold new effort to study
the neuroscience and genetics of schizophrenia and other psychiatric disorders (Kaiser,
2010). So, can scientists develop genetic tests that reveal who is at risk? If so, will people
in the future subject their embryos to genetic testing (and gene repair or abortion) if
they are at risk for this or some other psychological or physical malady? Might they take
their egg and sperm to a genetics lab for screening before combining them to produce
an embryo? Or will children be tested for genetic risks and given appropriate preventive
treatments? In this brave new twenty-first-century world, such questions await answers.
Environmental Triggers for Schizophrenia

If prenatal viruses and genetic predispositions do not, by themselves, cause schizophre
nia, neither do family or social factors alone. It remains true, as Susan Nicol and Irving
Gottesman (1983) noted over three decades ago, that no environmental causes have
been discovered that will invariably, or even with moderate probability, produce schizo
phrenia in persons who are not related to a person with schizophrenia.
Hoping to identify environmental triggers of schizophrenia, researchers have com
pared the experiences of high-risk children (for example, those with relatives with
schizophrenia) and low-risk children. In one 2.5-year study that followed 163 teens and
early-twenties adults who had two relatives with schizophrenia, the 20 percent of par
ticipants who developed schizophrenia showed social withdrawal or other abnormal
behavior before the onset of the disorder (Johnstone et al., 2005). Researchers (Abel
et al., 2010; Freedman et al., 1998; Schiffman et al., 2001; Susser, 1999; Welham et al.,
2009) identified these other possible early warning signs:
A mother whose schizophrenia was severe and long-lasting
Birth complications, often involving oxygen deprivation and low birth weight
Separation from parents
Short attention span and poor muscle coordination
Disruptive or withdrawn behavior
Emotional unpredictability
Poor peer relations and solo play
Childhood physical, sexual, or emotional abuse
** *
Few of us can relate to the strange thoughts, perceptions, and behaviors of schizophre
nia. Sometimes our thoughts jump around, but we rarely talk nonsensically. Occasion
ally we feel unjustly suspicious of someone, but we do not fear that the world is plotting
against us. Often our perceptions err, but rarely do we see or hear things that are not
there. We feel regret after laughing at someones misfortune, but we rarely giggle in
response to bad news. At times we just want to be alone, but we do not live in social iso
lation. However, millions of people around the world do talk strangely, suffer delusions,
hear nonexistent voices, see things that are not there, laugh or cry at inappropriate
times, or withdraw into private imaginary worlds. The quest to solve the cruel puzzle of
schizophrenia continues, more vigorously than ever.
645
_LounchPd
HOW WOULD YOU KNOW?
Consider how researchers have stud
ied these issues with LaunchPads
How Would You Know If Schizophre
nia is Inherited?
646
CHAPTER 15:
0 LounchPod For
an 8-minute description of how clinicians define and treat schizo

ph renia, visit Launch Pads VideoSchizophrenia: New Definitions, New Therapies.
RETRIEVAL PRACTICE
A person with schizophrenia who has

(positive/negative) symptoms may
have an expressionless face and toneless voice. These symptoms are most common
with
(chronic/acute) schizophrenia and are not likely to respond to drug
therapy. Those with
(positive/negative) symptoms are likely to experi
ence delusions and to be diagnosed with
(chronic/acute) schizophrenia,
which is much more likely to respond to drug therapy.
aflDe aAEisod DIUO]cp aAiWU
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LEARNING OBJECTIVES
Take a moment to answer each of

RETRIEVAL PRACTICE
yourself on these terms by trying
answers.
RETRIEVAL PRACTICE
jfj What
patterns of perceiving, thinking, and feeling

characterize schizophrenia?
How do chronic and acute schizophrenia differ?
What brain abnormalities are associated with
schizophrenia?
What prenatal events are associated with increased risk of
developing schizophrenia?
R1.I:iDo genes infLuence schizophrenia? What factors may be
early warning signs of schizophrenia in children?
schizophrenia, p. 640
delusion, p. 640
chronic schizophrenia, p. 647
acute schizophrenia, p. 64]
Use
LeorningCurv6 to create your personalized study plan, which will
LuncIPod.
Dissociative, Personality,
and Eating Disorders
Dissociative Disorders
II.-]
dissociative disorders controversial,

rare
disorders in which
conscious
awareness becomes separated (dissoci

ated) from previous memories, thoughts,
and feelings.
What are dissociative disorders, and why are they controversial?
Among the most bewildering disorders are the rare dissociative disorders, in which a
persons conscious awareness dissociates (separates) from painful memories, thoughts,
and feelings. The result may be a fugue state, a sudden loss of memory or change in
identity, often in response to an overwhelmingly stressful situation. Such was the case
for one Vietnam veteran who was haunted by his comrades deaths, and who had left
his World Trade Center office shortly before the 9/11 attack. Later, he disappeared on
CHAPTER 15:
the way to work. Six months later, when he was discovered in a Chicago homeless
shelter, he reported no memory of his identity or family (Stone, 2006).
Dissociation itself is not so rare. Any one of us may have a sense of being unreal,
of being separated from our body, of watching ourselves as if in a movie. Sometimes
we may say, I was not myself at the time. Perhaps you can recall getting up to go
somewhere and ending up at some unintended location while your mind was preoc
cupied. Or perhaps you can play a well-practiced tune on a guitar or piano while
talking to someone. When we face trauma, dissociative detachment may protect us
from being overwhelmed by emotion.
Dissociative Identity Disorder

A massive dissociation of self from ordinary consciousness occurs in dissociative
identity disorder (DID), in which two or more distinct identitieseach with its own
voice and mannerismsseem to control a persons behavior at different times. Thus,
the person may be prim and proper one moment, loud and flirtatious the next. Typi
cally, the original personality denies any awareness of the other(s).
People diagnosed with DID (formerly called multite jersonality disorder) are rarely
violent. But cases have been reported of dissociations into a good and a bad (or
aggressive) personalitya modest version of the Dr. JekyllMr. Hyde split immortal
ized in Robert Louis Stevensons story. One unusual case involved Kenneth Bianchi,
accused in the Hillside Strangler rapes and murders of 10 California women. During a
hypnosis session, Bianchis psychologist called forth a hidden personality: Ive talked
a bit to Ken, btit I think that perhaps there might be another part of Ken that.. maybe
feels somewhat differently from the part that Ive talked to.
Would you talk with
me, Part, by saying, Im here? Bianchi answered Yes and then claimed to be Steve
(Watkins, 1984).
Speaking as Steve, Bianchi stated that he hated Ken because Ken was nice and that
he (Steve), aided by a cousin, had murdered women. He also claimed Ken knew noth
ing about Steves existence and was innocent of the murders. Was Bianchis second
personality a trick, simply a way of disavowing responsibility for his actions? Indeed,
Bianchia practiced liar who had read about multiple personality in psychology
bookswas later convicted.
.
647
.1/
jfEveU
The fhreetIMA I
JOANNE OOOARO OAYID WAYNE LEE]. GOON NUNNALLY JflHNSON

Multiple personalities Chris
Sizemores story, told in the book and
movie, The Three Faces of Eve, gave
early visibility to what is now called
dissociative identity disorder.
Understanding Dissociative Identity Disorder

Skeptics have raised serious concerns about DID. First, instead of being a true disor
der, could DID be an extension of our normal capacity for personality shifts? Nicholas
Spanos (1986, 1994, 1996) asked college students to pretend they were accused murderers
being examined by a psychiatrist. Given the same hypnotic treatment Bianchi received,
most spontaneously expressed a second personality. This discovery made Spanos won
der: Are dissociative identities simply a more extreme version of our capacity to vary the
selves we presentas when we display a goofy, loud self while hanging out with friends,
and a subdued, respectful self around grandparents? Are clinicians who discover multiple
personalities merely triggering role playing by fantasy-prone people? Do these patients,
like actors who commonly report losing themselves in their roles, then convince them
selves of the authenticity of their own role enactments? Spanos was no stranger to this
line of thinking. In a related research area, he had also raised these questions about the
hypnotic state. Because most DID patients are highly hypnotizable, whatever explains
one conditiondissociation or role playingmay help explain the other.
Skeptics also find it suspicious that the disorder has such a short and localized his
tory. Between 1930 and 1960, the number of North American DID diagnoses averaged
2 per decade. By the 1980s, when the American Psychiatric Associations Diagnostic
and Statistical Manual of Mental Disorders (DSM) contained the first formal code for
The Hillside Strangler Kenneth

Bianchi is shown here at his trial.
Pretense may become reality.

Chinese proverb
dissociative identity disorder (DID)

a rare dissociative disorder in which a
person exhibits two or more distinct and
alternating personalities. Formerly called
multiple personality disorder.
648
CHAPTER 75:
-2.
jr
Widespread dissociation Shirley

Mason was a psychiatric patient
diagnosed with dissociative identity dis
order. Her life formed the basis of the
bestselling book, Sybil (Schreiber, 1973),
and of two movies. Some argue that the
book and movies popularity fueled the
dramatic rise in diagnoses of dissocia
tive identity disorder. Skeptics wonder
whether she actually had dissociative
identity disorder (Nathan, 2011).
Though this be macmess, yet there is

method in t.
WIIiam Shakespeare, Hamlet, 1600
Would it be possible to speak with the

personality that pays the bills?
this disorder, the number exploded to more than 20,000 (McHugh, 1995a). The average
number of displayed personalities also mushroomedfrom 3 to 12 per patient (Cuff &
Simms, 1993). This disorder is much less prevalent outside North America, although in
other cultures people may be said to be possessed by an alien spirit (Aldridge-Morris,
1989; Kluft, 1991). In Britain, DIDwhich some have considered a wacky American
fad (Cohen, 1995)is rare. In India and Japan, it is essentially nonexistent (or at least
unreported).
Such findings, skeptics note, point to a cultural phenomenona disorder created by
therapists in a particular social context (ivlerskey, 1992). Rather than being provoked
by trauma, dissociative symptoms tend to be exhibited by suggestible, fantasy-prone
people (Giesbrecht et al., 2008, 2010). Patients do not enter therapy saying Allow me to
introduce myselves. Instead, charge the critics, some therapists go fishing for multiple
personalities: Have you ever felt like another part of you does things you cant control?
Does this part of you have a name? Can I talk to the angry part of you? Once patients
permit a therapist to talk, by name, to the part of you that says those angry things,
they begin acting out the fantasy. The result may be the experience of another self.
Other researchers and clinicians believe DID is a real disorder. They find support
for this view in the distinct body and brain states associated with differing personalities
(Putnam, 1991). Handedness sometimes switches with personality (Henninger, 1992).
Shifts in visual acuity and eye-muscle balance have been recorded as patients switched
personalities, but not as control group members tried to simulate DID behavior (1viiller
et al., 1991). Abnormal brain anatomy and activity can also accompany DID. Brain
scans show shrinkage in areas that aid memory and detection of threat (Vermetten et
al., 2006). Heightened activity appears in brain areas associated with the control and
inhibition of traumatic memories (Elzinga et al., 2007).
Both the psychodynamic and learning perspectives have interpreted DID symptoms
as ways of coping with anxiety. Some psychodynamic theorists see them as defenses
against the anxiety caused by the eruption of unacceptable impulses. In this view, a
second personality enables the discharge of forbidden impulses. Learning theorists see
dissociative disorders as behaviors reinforced by anxiety reduction.
Some c]inicians include dissociative disorders under the umbrella of posttraumatic
stress disordera natural, protective response to traumatic experiences during child
hood (Putnam, 1995; Spiegel, 2008). Many DID patients recall being physically, sexu
ally, or emotionally abused as children (Gleaves, 1996; Lilienfeld et al., 1999). In one
study of 12 murderers diagnosed with DID, 11 had suffered severe, torturous child
abuse (Lewis et al., 1997). One had been set afire by his parents. Another had been
used in child pornography and was scarred from being made to sit on a stove burner.
Some critics wonder, however, whether vivid imagination or therapist suggestion con
tributed to such recollections (Kihlstrom, 2005).
So the debate continues. On one side are those who believe multiple personalities
are the desperate efforts of people trying to detach from a horrific existence. On the
other are the skeptics who think DID is a condition constructed out of the therapistpatient interaction and acted out by fantasy-prone, emotionally vulnerable people. If
the skeptics view wins, predicted psychiatrist Paul McHugh (1995b), this epidemic
will end in the way that the witch craze ended in Salem. The [multiple personality
phenomenon] will be seen as manufactured.
RETRIEVAL PRACTICE
The psychodynamic and learning perspectives agree that dissociative identity disorder
symptoms are ways of dealing with anxiety. How do their explanations differ?
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CHAPTER 75:
649
Personality Disorders
iiz.] What are the three clusters of personality disorders? What behaviors and brain
activity characterize the antisocial personality?
The disruptive, inflexible, and enduring behavior patterns of personality disorders

interfere with social functioning. These disorders tend to form three clusters, charac
terized by
anxiety, such as a fearful sensitivity to rejection that predisposes the withdrawn
avoidant personaht) disorder.
eccentric or odd behaviors, such as the emotionless disengagement of schizotypal
personality disorder.
dramatic or impulsive behaviors, such as the attention-getting borderline personality
disorder, the self-focused and self-inflating narcissistic personality disorder, and the
callous, and sometimes dangerous, antisocial personality disorder.
Antisocial Personality Disorder

A person with antisocial personality disorder is typically a male whose lack of con
science becomes plain before age 15, as he begins to lie, steal, fight, or display unre
strained sexual behavior (Gale & Lilienfeld, 2002). About half of such children become
antisocial adultsunable to keep a job, irresponsible as a spouse and parent, and
assaultive or otherwise criminal (farrington, 1991). (These people are sometimes called
socio paths or psychopaths.) They may show lower emotional intelligencethe ability to
understand, manage, and perceive emotions (Ermer et al., 2012). When the antisocial
personality combines a keen intelligence with amorality, the result may be a
charming and clever con artistor even a fearless, focused, ruthless soldier,
CEO, or politician (Dutton, 2012).
Despite their remorseless and sometimes criminal behavior, criminality
is not an essential component of antisocial behavior (Skeem & Cooke, 2010).
Moreover, many criminals do not fit the description of antisocial personal
ity disorder. Why? Because they actually show responsible concern for their
friends and family members.
Antisocial personalities behave impulsively, and then feel and fear little
(fowles & Dindo, 2009). Their impulsivity can have violent, horrifying conse
quences (Camp et al., 2013). Consider the case of Henry Lee Lucas. He killed
his first victim when he was 13. He felt little regret then or later. He con
fessed that, during his 32 years of crime, he had brutally beaten, suffocated, stabbed,
shot, or mutilated some 360 women, men, and children, for the last six years of his
reign of terror, Lucas teamed with Ottis Elwood Toole, who reportedly slaughtered
about 50 people he didnt think was worth living anyhow (Darrach & Norris, 1984).
.
No remorse Dennis Rader, known as

the BTK killer in Kansas, was con
victed in 2005 of killing 10 people over
a 30-year span. Rader exhibited the
extreme lack of conscience that marks
antisocial personality disorder.
-.
Thu rsday is out. I have jury duty.

Many criminals, like this one, exhibit a
sense of conscience and responsibility in
other areas of their life, and thus do not
exhibit antisocial personality disorder.
Understanding Antisocial Personality Disorder

Antisocial personality disorder is woven of both biological and psychological strands.
Twin and adoption studies reveal that biological relatives of people with antisocial and
unemotional tendencies are at increased risk for antisocial behavior (frisell et al., 2012;
Tuvblad et al., 2011). No single gene codes for a complex behavior such as crime. Molec
ular geneticists have, however, identified some specific genes that are more common in
those with antisocial personality disorder (Gunter et al., 2010). The genetic vulnerabil
ity of people with antisocial and unemotional tendencies appears as a fearless approach
to life. Awaiting aversive events, such as electric shocks or loud noises, they show little
autonomic nervous system arousal (Hare, 1975; van Goozen et al., 2007). Long-term
studies have shown that their levels of stress hormones were lower than average when
personality disorders inflexible and

enduring behavior patterns that impair
socia[ functioning.
antisocial personality disorder a
personality disorder in which a person
(usually a man) exhibits a lack of con
science for wrongdoing, even toward
friends and family members; may be ag
gressive and ruthless or a clever con artist.
650
CHAPTER 75:
they were youngsters, before committing any crime (FIGURE 15.12).

Three-year-olds who are slow to develop conditioned fears are later more
likely to commit a crime (Gao et al., 2010). Other studies have found that
15
preschool boys who later became aggressive or antisocial adolescents tended
to be impulsive, uninhibited, unconcerned with social rewards, and low in
anxiety (Caspi et al., 1996; Tremblay et al., 1994).
10
Traits such as fearlessness and dominance can be adaptive. In fact, some
argue that psychopaths and heroes are twigs off the same branch tSmith
et al., 2013). If channeled in more productive directions, fearlessness may
5
lead to star-level athleticism, adventurism, or courageous heroism (Poulton
& Milne, 2002). One analysis of 42 American presidents showed that they
scored higher than the general population on such traits as fearlessness and
0
dominance (Lilienfeld et al., 2012). Consistent with evidence that such traits
Nonstressful
Stressful
situation
situation
can run in families, two of the most fearless and dominant presidents were
distant
cousins with the same last name: Roosevelt. (Two of the least fear
No criminal conviction
less and dominant presidents were a father and son, John Adams and John Quincy
Criminal conviction
Adams.) Lacking a sense of social responsibility, the same disposition may produce a
V FIGURE 1512
cool con artist or killer (Lykken, 1995).
Cold-blooded arousability and
Genetic influences, often in combination with child abuse, help wire the brain
risk of crime Levels of the stress
(Dodge,
2009). In people with antisocial criminal tendencies, the emotion-controlling
hormone adrenaline were measured
amygdala is smaller (Pardini et al., 2013; Yang et al., 2010). The frontal lobes are also
in two groups of 13-year-old Swedish
less active, as Adrian Raine (1999, 2005) found when he compared PET scans of 41
boys. In both stressful and nonstressful
situations, those who would later be
murderers brains with those from people of similar age and sex (FIGURE 15.13). This
convicted of a crime as 18- to 26-yeararea of the cortex helps control impulses. The reduced activation was especially appar
olds showed relatively low arousal.
ent in those who murdered impulsively. In a follow-up study, Raine and his team (2000)
(Data from Magnusson, 1990.)
found that violent repeat offenders had 11 percent less frontal lobe tissue than normal.
This helps explain why people with antisocial personality disorder exhibit marked defi
cits in frontal lobe cognitive functions, such as planning, organization, and inhibition
(Morgan & Lilienfeld, 2000). Compared with people who feel and display empathy,
Does a full Moon trigger madness in
their brains also respond less to facial displays of others distress, which may contribute
some people? James Rotton and I. W.
to their lower emotional intelligence (Deeley et al., 2006).
Kelly (1985) examined data from 37 stud
A biologically based fearlessness, as well as early environment, helps explain the
ies that related lunar phase to crime,
reunion of long-separated sisters Joyce Lott, 27, and Mary Jones, 29in a South Caro
homicides, crisis calls, and mental hospi
lina prison where both were sent on drug charges. After a newspaper story about their
tal admissions. Their conclusion: There
reunion, their long-lost half-brother frank Strickland called. He explained it would be
is virtually no evidence of Moon mad
a while before he could come see thembecause he, too, was in jail, on drug, bur
ness. Nor does lunar phase correlate
glary, and larceny charges (Shepherd et al., 1990). The genes that put people at risk for
with suicides, assaults, emergency room
antisocial behavior also put people at risk for substance use disorders, which may help
visits, or traffic disasters (Martin et al.,
explain why these disorders often appear in combination (Dick, 2007).
1992; Raison et al., 1999).
Genetics alone do not tell the whole story of antisocial crime, however. In another
Raine-led study (1996), researchers checked criminal records on nearly
400 Danish men at ages 20 to 22. All these men either had experi
enced biological risk factors at birth (such as premature birth)
V FIGURE 15.13
or came from family backgrounds marked by poverty and
Murderous minds
family instability. The researchers then compared each
Researchers have found
of these two groups with a third biosociat group (people
reduced activation in a
whose lives were marked by both those biological and
murderers frontal lobes.
social risk factors). The biosocial group had double
This brain area (shown in
Frontal
a left-facing brain) helps
the
risk of committing crime (FIGURE 15.14). Similar
lobes
brake impulsive, aggres
findings emerged from a famous study that followed
sive behavior (Raine,
1037 children for a quarter-century: Two combined
1999).
factorschildhood maltreatment and a gene that altered
Adrenaline
excretion (ng/min.)
Males with criminal convictions
as adults had lower levels of

arousal as 13-year-olds
CHAPTER 75:
651
neurotransmitter balancepredicted antisocial problems (Caspi et

aL, 2002). Neither bad genes alone nor a bad environment alone
Percentage 35%
of criminal 3O
predisposed later antisocial behavior. Rather, genes predisposed
offenders
some children to be more sensitive to maltreatment. Within geneti
25cally vulnerable segments of the population, environmental influ
2O-ences matterfor better or for worse (Beisky et al., 2007; Moffitt,
15
2005; Pluess & Belsky, 2013).
With antisocial behavior, as with so much else, nature and nurture
interact and the biopsychosocial perspective helps us understand the
1
whole story. To explore the neural basis of antisocial personality disor
Total crime
Thievery
Violence
der, neuroscientists are trying to identify brain activity differences in
criminals who display symptoms of this disorder. Shown emotionally
W Childhood
Obstetrical
Both poverty and
poverty
evocative photographs, such as a man holding a knife to a womans
corn p1 ications
obstetrical complications
throat, criminals with antisocial personality disorder display blunted
V FIGURE 15.14
heart rate and perspiration responses, and less activity in brain areas that typically respond
Biopsychosocial roots of crime
to emotional stimuli (Harenski et al., 2010; Kiehl & Buckholtz, 2010). They also have a
Danish male babies whose back
larger and hyper-reactive dopamine reward system, which predisposes their impulsive drive
grounds were marked both by obstetri
to do something rewarding despite the consequences (Buckholtz et al., 2010; Glenn et al.,
cal complications and social stresses
2010). Such data provide another reminder: Everything psychological is also biological.
associated with poverty were twice as
likely to be criminal offenders by ages
20 to 22 as those in either the biologi
RETRIEVAL PRACTICE
cal or social risk groups. (Data from
How do biological and psychological factors contribute to antisocial personality disorder?
Raine et at., 1996.)
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Eating Disorders
ii-i What are the three main eating disorders, and how do biological, psychological,
and social-cultural influences make people mote vulnerable to them?

Our bodies are naturally disposed to maintain a steady weight, including stored energy
reserves for times when food becomes unavailable. But sometimes psychological influences
overwhelm biological wisdom. This becomes painfully clear in three eating disorders.
Anorexia nervosa typically begins as a weight-loss diet. People with anorexia
usually adolescents and 9 out of 10 times
femalesdrop significantly below normal
weight. Yet they feel fat, fear being fat, remain
obsessed with losing weight, and sometimes
exercise excessively. About half of those with
anorexia display a binge-purge-depression
cycle.
Bulimia nervosa may also be triggered by a
weight-loss diet, broken by gorging on forbid
den foods. Binge-purge eatersmostly women
in their late teens or early twentieseat in
spurts, sometimes influenced by negative
emotion or by friends who are bingeing
(Crandall, 1988; Haedt-Matt & Keel, 2011).
In a cycle of repeating episodes, overeating is
followed by compensatory purging (through
vomiting or laxative use), fasting, or excessive
anorexia nervosa an eating disorder

in which a person (usually an adolescent
female) maintains a starvation diet
despite being significantly underweight;
sometimes accompanied by excessive
exercise.
bulimia nervosa an eating disorder
in which a person alternates binge eat
ing (usually of high-calorie foods) with
purging (by vomiting or laxative use) or
fasting.
Sibling rivalry gone awry Twins

Maria and Katy Campbell have anorexia
nervosa. As children they competed to
see who could be thinner. Now, says
Maria, her anorexia nervosa is like a
ball and chain around my ankle that I
cant throw off (Foster, 2011).
652
CHAPTER 75:
binge-eating disorder significant

binge-eating episodes, followed by
distress, disgust, or guilt, but without the
compensatory purging or fasting that
marks bulimia nervosa.
exercise (Wonderlich et al., 2007). Preoccupied with food (craving sweet and highfat foods), and fearful of becoming overweight, binge-purge eaters experience bouts
of depression, guilt, and anxiety during and following binges (Hinz & Williamson,
1987; Johnson et al., 2002). Unlike anorexia, bulimia is marked by weight fluctua
tions within or above normal ranges, making the condition easy to hide.
Those with binge-eating disorder engage in significant bouts of overeating, fol
lowed by remorse. But they do not purge, fast, or exercise excessively and thus may
be overweight.
A U.S. National Institute of Mental Health-funded study reported that, at some
point during their lifetime, 0.6 percent of the Americans studied had met the criteria
for anorexia, 1 percent for bulimia, and 2.8 percent for binge-eating disorder (Hudson
et al., 2007). So, how can we explain these disorders?
Understanding Eating Disorders

Eating disorders do not provide (as some have speculated) a telltale sign of childhood
sexual abuse (Smolak & Murnen, 2002; Stice, 2002). The family environment may pro
vide a fertile ground for the growth of eating disorders in other ways, however.
Mothers of girls with eating disorders tend to focus on their own weight and on
their daughters weight and appearance (Pike & Rodin, 1991).
Families of those with bulimia tend to have a higher-than-usual incidence of child
hood obesity and negative self-evaluation (Jacobi et al., 2004).
Families of those with anorexia tend to be competitive, high-achieving, and protec
tive (Berg et al., 2014; Pate et al., 1992; Yates, 1989, 1990).
A too-fat body image underlies

anorexia.
Why do women have such low selfesteem? There are many complex
psychological and societal reasons, by
which I mean Barbie.
Dave Barry, 1999
Those with eating disorders often have low self-evaluations, set perfectionist stan
dards, fret about falling short of expectations, and are intensely concerned with how
others perceive them (Brauhardt et al., 2014; Pieters et al., 2007; Polivy & Herman,
2002; Sherry & Hall, 2009). Some of these factors also predict teen boys pursuit of
unrealistic muscularity (Ricciardelli & McCabe, 2004).
Heredity also matters. Identical twins share these disorders more often than frater
nal twins do (Culbert et al., 2009; Kiump et a!., 2009; Root et al., 2010). Scientists are
now searching for culprit genes, which may influence the bodys available serotonin
and estrogen (Klump & Culbert, 2007). In one analysis of 15 studies, having a gene that
reduced available serotonin added 30 percent to a persons risk of anorexia or bulimia
(Calati et al., 2011).
But these disorders also have cultural and gender components. Ideal shapes vary
across culture and time. In impoverished areas of the world, including much of Africa
where plumpness means prosperity and thinness can signal poverty or illnessbigger
seems better (Knickmeyer, 2001; Swami et al., 2010). Bigger does not seem better in
Western cultures, where, according to 222 studies of 141,000 people, the rise in eating
disorders in the last half of the twentieth century coincided with a dramatic increase in
women having a poor body image (Feingold & Mazzella, 1998).
Those most vulnerable to eating disorders are also those (usually women or gay
men) who most idealize thinness and have the greatest body dissatisfaction (Feldman
& Meyer, 2010; Kane, 2010; Stice et al., 2010). Should it surprise us, then, that when
women view real and doctored images of unnaturally thin models and celebrities, they
often feel ashamed, depressed, and dissatisfied with their own bodiesthe very atti
tudes that predispose eating disorders (Grabe et al., 2008; Myers & Crowther, 2009;
Tiggeman & Kliller, 2010)? Eric Stice and his colleagues (2001) tested this modeling
idea by giving some adolescent girls (but not others) a 15-month subscription to an
American teen-fashion magazine. Compared with those who had not received the
CHAPTER 15:
magazine, vulnerable girlsdefined as those who were already dissatisfied, idealizing

thinness, and lacking social supportexhibited increased body dissatisfaction and eat
ing disorder tendencies. Even ultra-thin models do not reflect the impossible standard
of the classic Barbie doll, who had, when adjusted to a height of 5 feet 7 inches, a
321629 figure (in centimeters, 824173) (Norton et al., 1996).
There is, however, more to body dissatisfaction and anorexia than media effects
(Ferguson et al., 2011). Peer influences, such as teasing, also matter. So does affluence,
increased marriage age, and especially, competition for available mates.
Nevertheless, the sickness of todays eating disorders stems in part from todays
weight-obsessed culturea culture that says, in countless ways, fat is bad, that moti
vates millions of women to be always dieting, and that encourages eating binges by
pressuring women to live in a constant state of
semistarvation. One former model told the story of
how her anorexia caused her organs to fail (Caroll,
2013). Starving from not having eaten for days, she
walked into a meeting with her modeling agent,
who greeted her by saying, Whatever you are
doing, keep doing it.
If cultural learning contributes to eating behav
ior, then might prevention programs increase
acceptance of ones body? Reviews of prevention
studies answer Yes. They seem especially effective
if the programs are interactive and focused on girls
over age 15 (Beintner et al., 2012; Stice et al., 2007;
Vocks et al., 2010).
A growing number of people, especially teenagers
and young adults are being diagnosed with psycho
logical disorders. Although mindful of their pain,
we can also be encouraged by their successes.
ivlany live satisfying lives. Some pursue brilliant careers, as did 18 U.S. presidents,
including the periodically depressed Abraham Lincoln, according to one psychiatric
analysis of their biographies (Davidson et al., 2006). The bewilderment, fear, and sor
row caused by psychological disorders are real. But, as this texts discussion of therapy
shows, hope, too, is real.
RETRIEVAL PRACTICE
People with
(anorexia nervosa/bulimia nervosa) continue to want to lose
weight even when they are underweight. Those with
(anorexia nervosa/
bulimia nervosa) tend to have weight that fluctuates within or above normal ranges.
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653
Thanks, but we dont eat.
Too thin? Many worry that such super-
thin modets make self-starvation seem

fashionable.
654
CHAPTER 75:
Dissociative, Personality, and Eating Disorders

LEARNING OBJECTIVES

IIiJ What are dissociative disorders, and why are they
controversial?
hIZ.J What are the three clusters of personality disorders?
What behaviors and brain activity characterize the antisocial
personality?
ii.ii What are the three main eating disorders, and how do
biological, psychological, and social-cultural influences make
people more vulnerable to them?

answers.
dissociative disorders, p. 646

dissociative identity disorder (DID), p. 647
personality disorders, p. 649
antisocial personality disorder, p. 649
anorexia nervosa, p. 651
bulimia nervosa, p. 651
binge-eating disorder, p. 652
LeorningCurle to create your personalized study plan, which will

Use
LounchPod.
Test yourself repeatedly throughout your studies. This will not
only help you figure out what you know and dont know; the
testing itself will help you learn and remember the information
more effectively thanks to the testing effect.
6. Why is the DSM, and the DSM-5 in particular, considered
controversial?
7. One predictor of psychiatric disorders that crosses ethnic
and gender lines is

appear around age 10;
tend[s] to appear later, around age 25.
schizophrenia; bipolar disorder
bipolar disorder; schizophrenia
major depressive disorder; phobias
phobias; major depressive disorder
8. The symptoms of
Introduction to Psychological Disorders

7. Two disorders are found worldwide. One is schizophrenia,
2.
3.
4.
5.
and the other is

Anna is embarrassed that it takes her several minutes to
parallel park her car. She usually gets out of the car once
or twice to inspect her distance both from the curb and
from the nearby cars. Should she worry about having a
psychological disorder?
What is susto, and is this a culture-specific or universal
psychological disorder?
A therapist says that psychological disorders are sicknesses
and people with these disorders should be treated as
patients in a hospital. This therapist believes in the
model.
Many psychologists reject the disorders-as-illness
view and instead contend that other factors may also be
involvedfor example, the persons bad habits and poor
approach.
social skills. This view represents the
a. medical
b. evil spirits
c. biopsychosocial
d. diagnostic labels
a.
b.
c.
d.
Anxiety Disorders, OCD, and PTSD

9. Anxiety that takes the form of an irrational and maladaptive
fear of a specific object, activity, or situation is called a

JO. An episode of intense dread, accompanied by trembling,
dizziness, chest pains, or choking sensations and by feelings

of terror, is called
a. a specific phobia.
b. compulsion.
c. a panic attack.
U. an obsessive fear.
11. Marina became consumed with the need to clean the entire
house and refused to participate in any other activities. Her
family consulted a therapist, who diagnosed her as having
disorder.
-
CHAPTER 15:
655
12. The learning perspective proposes that phobias are
20. Chances for recovery from schizophrenia are best when
a. the result of individual genetic makeup.

b. a way of repressing unacceptable impulses.
c. conditioned fears.
a. onset is sudden, in response to stress.

b. deterioration occurs gradually, during childhood.
c. no environmental causes can be identified.
d. there is a detectable brain abnormality.
U. a symptom of having been abused as a child.

Depressive Disorders and Bipolar Disorder
Dissociative, Personality, and Eating

Disorders
73. The gender gap in depression refers to the finding that
risk of depression is nearly double that of
21. Dissociative identity disorder is controversial because

a. dissociation is actually quite rare.
14. Rates of bipotar disorder have risen dramatcally in the
twenty-first century, especially among

a. middle-aged women.
b. middle-aged men.
c. females 19 and under.
d. males 19 and under.
15. Treatment for depression often includes drugs that
increase supplies of the neurotransmitters
and
16. Psychologists who emphasize the importance of negative
perceptions, beliefs, and thoughts in depression are working

within the
perspective.
-
Schizophrenia
17. Victor exclaimed, The weather has been so schizophrenic
lately: Its hot one day and freezing the next! Is this an
accurate comparison? Why or why not?
18. A person with positive symptoms of schizophrenia is most
likely to experience
a. catatonia.
b. delusions.
c. withdrawal.
d. flat emotion.
19. People with schizophrenia may hear voices urging selfdestruction, an example of afn)
b. it was reported frequently in the 1920s but rarely today.

c. it is almost never reported outside North America.
d. its symptoms are nearly identical to those of obsessivecompulsive disorder.
22. A personality disorder, such as antisocial personality, is
characterized by
a. depression.
b. hallucinations.
c. inflexible and enduring behavior patterns that impair
social functioning.
d. an elevated level of autonomic nervous system arousal.
23. PET scans of murderers brains have revealed
a. higher-than-normal activation in the frontal lobes.
b. lower-than-normal activation in the frontal lobes.
c. more frontal lobe tissue than normal.
d. no differences in brain structures or activity.
24. Which of the following statements is true of bulimia nervosa?
a. People with bulimia continue to want to lose weight even
when they are underweight.
b. Bulimia is marked by weight fluctuations within or above
normal ranges.
c. Bulimia patients often come from middle-class families
that are competitive, high-achieving, and protective.
U. If one twin is diagnosed with bulimia, the chances of the
other twins sharing the disorder are greater if they are
fraternal rather than identical twins.
Find answers to these questions in Appendix D, in the back of the book.
lntroduction to Therapy and the Psychological Therapies

Evaluating Psychotherapies
Biomedical Therapies and Preventing Psychological Disorders

Psychological Disorders

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Psychological Disorders

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PSYCHOLOGICAL DISORDERS

Marc, diagnosed with obsessive-corn putsive disorder (from Summers, 1996)

Greta, diagnosed with depression (from Thorne, 1993, p. 21)

Stuart, diagnosed with schizophrenia (from Emmons et at., 1997)

Melville, Billy Budd, Sailor, 1924

psychological disorder a syndrome

Culture and normality Young men

Defining Psychological Disorders

A psychological disorder is a syndrome (collection of symptoms) marked by a clini

disorder) in the most recent classification

Understanding Psychological Disorders

understanding of psychoLogical disorders?

Yesterdays therapy Through

the ages, psychologically disordered

The Medical Model

Moral treatment Under Philippe

Pinels influence, hospitals sometimes

medical model the concept that

epigenetics the study of environmental

The Biopsychosocial Approach

Increasingly, North Americas dis

Todays psychology studies how

DSM-5 the American Psychiatric Asso

Are psychological disorders universal, or are they culture-specific? Explain with

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Classifying Disordersand Labeling People

Im always like this, and my family was

A book of case illustrations accom

Struggles and recovery Boston

ADHDNormal High Energy or Disordered Behavior?

Eight-year-old Todd has always been energetic. At home, he chat

grade pills. They hope to increase their focus and achievement,

attention-deficit/hyperactivity disorder (ADHD) a

Mv sister suffers from a bipolar

1!1KING CRITICALLY ABOUT

Are People With Psychological Disorders Dangerous?

September 16, 2013, started like any other Monday at Washing

Elbogen & Johnson, 2009; Fazel et al., 2009, 2010). Whether

Better portrayals Old stereotypes

0 LounchPod To test your ability to form diagnoses, visit LaunchPads PsychSim

Whats the use of their having

Rates of Psychological Disorders

Who is most vulnerable to psychological disorders? At what times of life? To answer

Social anxiety disorder

Data from; National Institute of Mental Health, 2008.

What increases vulnerability to mental disorders? As TABLE 15.3 indicates, there is

Any mental disorder

Research from: World Health Organization (WHO, 2004b,c).

In one natural experiment on the poverty-pathology link, researchers tracked rates of

What is the relationship between poverty and psychological disorders?

Introduction to Psychological Disorders

TERMS AND CONCEPTS TO REMEMBER

RETRIEVAL PRACTICE Take a moment to answer each of

RETRIEVAL PRACTICE Test yourself on these terms by trying

I How should we draw the line between normality and

psychological disorder, p. 610

LeornlngCur/e to create your personalized study plan, which will

Anxiety Disorders, OCD,

The anxiety disorders are marked by distressing, persistent anxiety or dysfunctional

Generalized Anxiety Disorder

anxiety disorders psychological

Panicked playing Golfer Charlie

Martin Haraey/D,gtal Vnan/Getty Irng

Unfocused tension, apprehension, and arousal are symptoms of