Download chapter 14

CHAPTER 14
14.1 Psychopathology (sickness or pathology of the mind) refers to problematic patterns of
thought, feeling, or behavior that disrupt an individual’s sense of well-being or social or
occupational functioning. Many forms of psychopathology are found across cultures; however,
cultures differ in the disorders to which their members are vulnerable and the ways they
categorize mental illness. Szasz sees mental illness as a myth used to make people conform to
society’s standards of normality; labeling theory similarly argues that diagnosis is a way of
stigmatizing deviants. Both approaches have some validity but, considering that many disorders
are recognized cross-culturally, treatment would be impossible without classification, and
accumulating evidence that disorders like schizophrenia are illnesses of the brain suggest that
these views understate the realities of mental illness.
14.2 Psychodynamic theorists distinguish among three broad classes of psychopathology that
reflect different degrees of functioning: neuroses (enduring problems in living that cause distress
or dysfunction), personality disorders (chronic, severe disturbances that substantially inhibit the
capacity to love and to work), and psychoses (gross disturbances involving a loss of touch with
reality). While nature and nurture are both implicated, neuroses are most closely linked to
environmental factors, while psychoses are most closely linked biological abnormalities. A
psychodynamic formulation is a set of hypotheses about the patient’s motives and conflicts,
ego functioning (adaptive skills), and object relations (ability to form meaningful relationships
and maintain self-esteem).
14.3 Cognitive-behavioral clinicians integrate an understanding of thought processes and
conditioning. Many psychological problems involve conditioned emotional responses, in which a
previously neutral stimulus has become associated with unpleasant emotions. Irrational fears in
turn elicit avoidance, which perpetuates them and may lead to secondary problems, such as poor
social skills. Likewise, many psychological problems reflect dysfunctional attitudes, beliefs, and
other cognitive processes, such as a tendency to interpret events negatively.
14.4 The biological approach looks for the roots of mental disorders in the brain’s circuitry, such
as neurotransmitter dysfunction, abnormalities of specific brain structures, or dysfunction
anywhere along a pathway that regulates behavior or mental processes. Theorists of various
persuasions often adopt a diathesis-stress model, which proposes that people with an underlying
biological vulnerability (called a diathesis) may exhibit symptoms under stressful circumstances.
14.5 A systems approach explains an individual’s behavior in the context of a social group,
such as a couple, family, or larger group. Most systems clinicians adopt a family systems model,
which views an individual’s symptoms as symptoms of family dysfunction. Family systems
theorists focus on how families are organized including family roles (parts individuals play in
repetitive family dramas), boundaries (physical and psychological limits of the family and its
subsystems), and alliances (patterns in which family members side with one another), the ways
members preserve equilibrium in the family (family homeostatic mechanisms), the marital
subsystem (the relationship between the parents), and problematic communication patterns.
14.6 Evolutionary psychologists could explain psychopathology in at least three ways. First,
random variation is necessary and psychopathology is likely to be weeded out by natural
selection. Second, psychopathology may be the result of broader evolutionary pressures that
regulate the percentage of genes in the population that are functional at certain levels but
dysfunctional at others. Third, psychopathology can reflect normal processes gone awry because
of abnormal circumstances.
14.7 In descriptive diagnosis, mental disorders are classified into clinical syndromes,
constellations of symptoms that tend to occur together. The descriptive approach embodied in
DSM-IV tends to be most compatible with a disease model that presumes psychological disorders
fall into discrete categories. DSM-IV uses a multiaxial system, placing symptoms in their
biological and social context by evaluating patients along five axes: clinical syndromes such as
schizophrenia or depression, personality disorders (and mental retardation), medical conditions,
environmental stressors, and global level of functioning.
14.8 The two most common disorders that are usually diagnosed in childhood are attentiondeficit hyperactivity disorder (ADHD) and conduct disorder. Attention-deficit
hyperactivity disorder is characterized by inattention, impulsiveness, and hyperactivity
inappropriate for the child’s age, and is more prevalent in boys. ADHD has both biological
(genetic) and environmental links such as severe marital discord, low social class, etc.). Both
biological and environmental relationships are also true of conduct disorder (in which a child
persistently violates societal norms and the rights of others). Ineffectively lax or excessively
punative parenting are associated with such delinquent behaviors in children.
14.9 Substance-related disorders are characterized by continued use of a substance (such as
alcohol or cocaine) that negatively affects psychological and social functioning. The most
common substance-related disorder is alcoholism. Research has clearly demonstrated both
environmental and genetic contributions to alcoholism and other substance-related disorders,
although researchers are still trying to track down precisely how genetic transmission occurs in
different individuals. The best data provide evidence that people who abuse one drug are at risk
for abusing several—a suggestion that genes and experience conspire to create a vulnerability to
substance abuse in general.
14.10 Schizophrenia is an umbrella term for a number of psychotic disorders that involve
disturbances in thought, perception, behavior, language, communication, and emotion. Positive
symptoms reflect the presence of something not usually found in the psyche, and include
disorganized symptoms (disordered thoughts, speech, and behavior) and psychotic symptoms
(delusions and hallucinations). Negative symptoms reflect the absence of something usually
found in the psyche and include flat affect, lack of motivation, peculiar or withdrawn
interpersonal behavior, and intellectual impairments. Positive and negative symptoms appear to
involve different neural circuits and to respond to different kinds of medications. Onset of
schizophrenia is usually in the late teens or early twenties.
14.11 Most theorists adopt a diathesis-stress model of schizophrenia. Heritability of
schizophrenia is at least 50 percent. According to the dopamine hypothesis, positive symptoms
of schizophrenia reflect too much dopamine activity in subcortical circuits involving the basal
ganglia and limbic system, whereas negative symptoms reflect too little dopamine activity in the
prefrontal cortex. Glutamate may also play a role, at least in some individuals with
schizophrenia. Other data implicate abnormalities in the structure and function of the brain, such
as enlarged ventricles and corresponding atrophy (degeneration) in the frontal and temporal
lobes. Environmental variables, notably expressed emotion (criticism, hostile interchanges, and
emotional over-involvement by family members), play an important role in both onset and
relapse. Prenatal and perinatal events that affect the developing nervous system may also be
involved in some cases of schizophrenia, such as prenatal malnutrician and exposure to viruses,
and birth complications.
14.12 Mood disorders are characterized by disturbances in emotion and mood. The most
severe form of depression is major depressive disorder, characterized by depressed mood and
anhedonia (loss of interest in pleasurable activities). Dysthymic disorder refers to a chronic
low-level depression lasting more than two years, with intervals of normal moods that never last
more than a few weeks or months. In bipolar disorder, individuals generally have alternating
manic and depressive episodes. Mania is characterized by symptoms such as abnormally
elevated mood, grandiosity, and racing thoughts.
14.13 Genetic factors increase the vulnerability to mood disorders, particularly bipolar disorder.
Serotonin and norepinephrine have been implicated in both major depression and bipolar
disorder. Both childhood and adult negative experiences also play a significant role in the
etiology and course of mood disorders. According to cognitive theories a trio of dysfunctional
thought patterns called the negative triad (pessimism, negative interpretation, and low self
regard), plays a crucial role in depression. Depressed people tend to automatically and implicitly
interpret neutral or positive information as negative, through cognitive distortions. According to
psychodynamic theory, depression can be rooted in identification with a depressed or belittling
parent, or an attachment history that predisposes a person to object relation difficulties.
Depression has equivalents in all cultures, but the way it is viewed and experienced varies across
them considerably.
14.14 In anxiety disorders, people experience frequent, intense, and irrational anxiety.
Generalized anxiety disorder is characterized by continuous, persistent anxiety and excessive
worry about life circumstances that are not triggered by any particular circumstances. A common
type of phobia (irrational fear) is social phobia, which occurs when the person is in a specific
social or performance situation. Panic disorder is characterized by attacks of intense fear and
feelings of doom or terror not justified by the situation. Agoraphobia involves a fear of being in
places or situations from which escape might be difficult. Obsessive-compulsive disorder is
marked by recurrent obsessions (persistent thoughts or ideas) and compulsions (stereotyped
rituals performed in response to an obsession). Post-traumatic stress disorder is marked by
flashbacks and recurrent thoughts of a psychologically distressing event outside the range of
usual human experience.
14.15 As in other disorders, heredity and environment both contribute to the etiology of anxiety
disorders as do adult and childhood stressors. Behaviorist theories implicate classical
conditioning and negative reinforcement of avoidance behavior in the etiology and maintenance
of anxiety disorders. Cognitive theorists emphasize negative biases in thinking, such as attention
to threatening stimuli. A comprehensive cognitive-behavioral model suggests that patients
develop classically conditioned fear of their own autonomic responses, which, combined with
fearful thoughts, perpetuates anxiety and can trigger panic episodes.
14.16 Eating disorders are characterized by dysfunctional eating-related thoughts and behaviors
and are most prevalent in women. Anorexia nervosa is characterized by a distorted body image,
along with self-starvation, excessive exercise, and/or food elimination behaviors that result in an
individual losing 15 percent or more of ideal body weight. Bulimia is characterized by binging
followed by purging. Research on etiology points to vulnerabilities caused by genetics and
cultural norms for thinness. Personality is also implicated in that people with anorexia tend to be
overly-controlled and inhibited, those with bulimia under-controlled and impulsive, and both are
often high functioning, perfectionistic, and self-critical.
14.17 Dissociative disorders are characterized by disruptions in consciousness, memory, sense
of identity, or perception. In dissociative identity disorder, at least two distinct personalities are
displayed within the person. Dissociative disorders show little or no genetic influence, but almost
always reflect a history of severe (usually sexual) childhood trauma. Personality disorders are
characterized by enduring maladaptive patterns of thought, feeling, and behavior that lead to
chronic disturbances in interpersonal and occupational functioning. Borderline personality
disorder is marked by extremely unstable interpersonal relationships, dramatic mood swings, an
unstable sense of identity, intense fears of separation and abandonment, manipulativeness,
impulsive behavior, and self-mutilating behavior, and is more prominent in women. Antisocial
personality disorder is marked by irresponsible socially-disruptive behavior, lack of empathy,
and lack of remorse, and is more prominent in men. Borderline personality disorder is related to
a genetic tendency toward negative affect and impulsivity, troubled attachment history, and
sexual abuse. Antisocial personality disorder is related to genetics, absent or criminal male role
models, and physical abuse.
14.18 Using classification systems to diagnose mental illness has been challenged by researchers
and theorists in recent years. One reason for this is that people often experience multiple
problems simultaneously making it difficult to apply a single diagnosis. Furthermore, teasing
apart the roles of nature and nurture in the etiology of psychological disturbances is more
difficult than it may first appear, because each affects the other. Inherited characteristics
typically determine which environmental events are psychologically toxic, and environmental
events can translate into changes in the brain.