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CHAPTER 15
Psychological Disorders
OUTLINE
I.
DEFINING PSYCHOLOGICAL DISORDERS
A. What Is Abnormal?
There are several approaches to defining normality, but none is perfect. No behavior is
universally abnormal.
1.
B.
II.
Infrequency. Those behaviors displayed by the greatest number of people are
considered normal. Statistical infrequency considers behavior that is atypical or rare to
be abnormal. However, some behavior that is rare, such as creative genius,
extraordinary language skills, or world-class athletic ability, is valued; therefore,
statistical infrequency alone is not an adequate criterion.
2. Norm Violation. People who behave in ways that are bizarre, unusual, or disturbing
enough to violate social norms or cultural rules are termed abnormal.
3. Personal Suffering. Psychological problems causing distress require treatment.
Because some people with disorders may not experience distress, personal suffering
cannot be the only criterion for abnormality.
Behavior in Context: A Practical Approach
The content of behavior (whether behavior is bizarre, dysfunctional, or harmful), the
sociocultural context in which the behavior occurs (where and when behavior occurs), and
the consequences of behavior are all taken into consideration when judging whether
behavior is abnormal. A practical approach also considers whether behavior causes
impaired functioning. Cultures and subcultures determine which behaviors are appropriate
for a given situation.
EXPLAINING PSYCHOLOGICAL DISORDERS
A. The Biopsychosocial Model
The biopsychosocial model looks at abnormal behavior as caused by a combination and
interaction of biological, psychological, and sociocultural factors.
1.
B.
Biological Factors. The ancient Greek physician Hippocrates introduced the medical
model, in which he explained that psychological disorders resulted from imbalances
among four humors. The medical model eventually evolved into the concept of mental
illness. The medical model is now termed the neurobiological model because it looks
at problems in anatomy and physiology of the brain and other areas.
2. Psychological Processes. In this view, mental disorders are caused by inner turmoil or
other psychological events. Psychological models include the psychodynamic, socialcognitive, and humanistic approaches.
3. Sociocultural Context. The sociocultural model relies on factors such as gender and
age, physical and social situations, cultural values and expectations, and historical eras.
Culture-general disorders appear in most societies, while culture-specific forms appear
only in certain ones.
Diathesis-Stress as an Integrative Explanation
According to the diathesis-stress approach, genetics, early learning, biological processes,
and stress levels may all contribute to psychological disorders.
III. CLASSIFYING PSYCHOLOGICAL DISORDERS
A. A Classification System: DSM-IV
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) describes each form
of disorder and provides criteria for diagnosis. DSM-IV consists of a series of evaluations on
five dimensions called axes. Every person is rated on each axis. Axis I comprises descriptive
criteria of sixteen major mental disorders. Axis II contains personality disorders and mental
retardation. Axis III comprises physical conditions or disorders. Axis IV has types and levels
of stress. Axis V has a rating of the highest level of functioning. (Neurosis, characterized by
anxiety, and psychosis, whose symptoms include a break with reality, are no longer major
diagnostic categories in DSM.)
B.
Evaluating the Diagnostic System
The major goals of diagnosis are to help identify appropriate treatment for clients and to
accurately and consistently group patients with similar disorders so that research efforts can
more easily identify underlying causes of mental illness. Two limitations of diagnosis are
validity and interrater reliability. Interrater reliability is the degree to which different
diagnosticians give the same label to one patient.
C.
Thinking Critically: Is Psychological Diagnosis Biased?
What am I being asked to believe or accept?
Clinicians’s diagnoses are biased by, for example, racial stereotypes.
What evidence is available to support the assertion?
African American people are more frequently diagnosed with schizophrenia than are
European Americans. In addition, African Americans are overrepresented in facilities noted
for higher incidences of more serious disorders (public mental health hospitals).
Are there alternative ways of interpreting the evidence?
Diagnostic differences by race may not reflect bias. There could very well be physiological
or cultural differences that cause mental illness.
What additional evidence would help to evaluate the alternatives?
Studies that ask physicians to diagnose pairs of people with identical symptoms but different
races could detect bias in diagnoses of mental illnesses. Other studies that have examined
diagnostic practices (examining notes and interviews) and controlled the research for the
type and severity of symptoms have shown that African Americans are more frequently
diagnosed with schizophrenia. Therefore, ethnic bias is a factor in some diagnoses.
What conclusions are most reasonable?
Clinicians, because they are human, are prone to bias when diagnosing people who
potentially have mental illness. However, bias can be minimized by becoming educated
about a prospective patient’s cultural background and its effect on behavior and mental
processes.
IV. ANXIETY DISORDERS
A. Types of Anxiety Disorders
1. Phobia. A phobia is an anxiety disorder involving a strong, irrational fear of an object
or situation that should not cause such a reaction. Specific phobias involve fear of
specific physical objects, places, or activities. Social phobias involve fear of being
negatively evaluated by others or publicly embarrassed by doing something impulsive,
outrageous, or humiliating. Agoraphobia is a strong fear of being separated from a safe
place like home or of being trapped in a place from which escape might be difficult.
2.
B.
C.
V.
Generalized Anxiety Disorder. The condition called generalized anxiety disorder
involves milder but long-lasting feelings of anxiety, worry, dread, or apprehension that
are not focused on any particular object or situation. Free-floating anxiety is a term
sometimes used to describe the nonspecific nature of this anxiety.
3. Panic Disorder. Periodic episodes of extreme terror (panic attacks) without warning or
obvious cause are characteristic of people with panic disorder.
4. Obsessive-Compulsive Disorder. The persistent intrusion of thoughts or images
(obsessions) and a compulsive need to perform certain behavior patterns are symptoms
of obsessive-compulsive disorder (OCD). When the obsessive thinking or compulsive
behaviors are interrupted, severe anxiety results.
Causes of Anxiety Disorders
1. Biological Factors. Biological explanations of anxiety disorders include abnormal
levels of particular neurotransmitters and oversensitive brainstem mechanisms.
2. Psychological Factors. A person suffering from an anxiety disorder may exaggerate
the danger associated with certain stimuli and underestimate his or her coping skills,
causing anxiety and depression.
Linkages: Anxiety Disorders and Learning
Phobias start with distressing thoughts followed by operantly rewarded behaviors. Phobias
can also be explained by classical conditioning. People may be biologically prepared to learn
certain fears and avoid stimuli that had potential for harm to our evolutionary ancestors.
Rare phobias may be a product of classical conditioning, but common ones such as snakes,
fire, height, and insects may be due to a biological preparedness to react negatively to certain
potentially hazardous things.
SOMATOFORM DISORDERS
Somatoform disorders are characterized by physical symptoms with no physical cause. In
conversion disorder, a person appears to be, but is actually not, functionally impaired (for
example, blind, deaf, or paralyzed). The physical symptoms often help reduce stress, and the
person may seem unconcerned about them. Hypochondriasis involves strong fears of a specific
severe illness that are usually accompanied by complaints of many vague symptoms. In
somatization disorder, a person makes dramatic but vague reports about a multitude of physical
problems rather than any specific illness. Pain disorder is characterized by severe, often constant,
pain with no apparent physical cause.
VI. DISSOCIATIVE DISORDERS
A. Dissociative disorders are characterized by a sudden, usually temporary, disruption in
memory, consciousness, or identity. Dissociative fugue is characterized by sudden memory
loss and the assumption of a new identity in a new locale. In dissociative amnesia, a person
has sudden memory loss without leaving home and creating a new identity. The most
dramatic and least common dissociative disorder is dissociative identity disorder (DID),
formerly known as multiple personality disorder (MPD), which involves having more than
one identity, each of which speaks, acts, and writes differently. Psychodynamic theorists
believe that dissociative disorders are methods of repressing (forgetting) unwanted impulses
or memories. Behavioral theorists believe that dissociative disorders are examples of learned
behavior patterns that have become so discrepant that a person may feel like and be
perceived as a different person from time to time.
B. Dissociative identity disorders are currently appearing more frequently in society. Recent
studies have drawn several conclusions about people displaying multiple personalities:
Many have experiences they would like to forget or avoid (such as child abuse), many are
skilled at self-hypnosis, and most can escape trauma by creating “new personalities” to deal
with the stress.
VII. MOOD DISORDERS
Mood disorders, or affective disorders, are characterized by persistent extreme mood swings that
are inconsistent with environmental events.
A.
Depressive Disorders
Major depressive disorder involves feelings of sadness, hopelessness, inadequacy,
worthlessness, and guilt that persist for long periods. Also common are changes or
disturbances in eating habits, sleep, decision making, and concentration. In extreme cases,
depressed people exhibit delusions. A more common pattern of depression is dysthymic
disorder, which involves symptoms similar to those of major depressive disorder but to a
lesser degree and spread out over a longer time period.
1.
B.
Suicide and Depression. Repeated bouts of depression and suicide are closely linked.
Interpersonal crises; intense feelings of frustration, anger or self-hatred; the absence of
meaningful life goals; and constant exposure to stress are associated with suicide and
depression. Student populations, the elderly, and females have a higher incidence of
suicide than the general population. Those who say they are thinking about suicide are
much more likely to attempt it than the general population.
Bipolar Disorders
Bipolar I disorder is characterized by alternating feelings of extreme depression and mania
over a period of days, weeks, or years. Bipolar I disorder is relatively rare in comparison to
major depressive disorder. Even less common is bipolar II disorder, which features major
depressive episodes alternative with less severe manic episodes known as hypomania.
Cyclothymic disorder is a slightly more common pattern of less extreme mood swings.
C.
Causes of Mood Disorders
1. Biological Factors. Altered levels and possibly dysregulation of norepinephrine and
serotonin (neurotransmitters), changes in the control of the stress-related hormone
cortisol, abnormal biological rhythms, and genetic influences are causative factors in
affective disorders. There is strong evidence that bipolar disorders may be inherited.
2. Psychological and Social Factors. Traditional psychodynamic theorists believe that
people with strong dependency needs turn inward the feelings of worthlessness, guilt,
and blame that are really meant for others. Behavioral theorists believe that people
become depressed when they lose important reinforcements. Learned helplessness can
also be a causative factor in depression. Social cognitive theorists believe that negative
mental habits (such as focusing on and exaggerating the dark side of events and being
generally pessimistic) and attributional style can lead to depression.
VIII. SCHIZOPHRENIA
Schizophrenic symptoms include severely disturbed thinking, emotion, perception, and behavior,
which impair a person’s ability to communicate and function on a daily basis. Schizophrenia is
rare, occurring in only about 1 percent of the population. Improvement is more likely if a person
had achieved a higher level of functioning before the symptoms appeared.
A.
Symptoms of Schizophrenia
1. People with schizophrenia often display incoherent forms of thought; for example,
neologisms, word salads, clang associations, and loose associations are common
symptoms. Schizophrenic thought content is equally disturbed; common symptoms
include ideas of reference and thought broadcasting, blocking, and insertion.
2. Symptoms of schizophrenia include an inability to focus attention or concentrate.
Changes in perception of body parts or of other people may also occur. Many people
with schizophrenia report hallucinations or false perceptions. Emotions are often
absent (“flat affect”) or inappropriate for a given situation. Movements may range from
constant agitation to almost total immobility. Lack of motivation and social skills,
B.
deterioration in personal hygiene, and an inability to function from day to day are other
common characteristics of schizophrenia.
Categorizing Schizophrenia
The DSM-IV lists five subtypes of schizophrenia: paranoid, disorganized, catatonic,
undifferentiated, and residual. Many symptoms overlap, and no links are made to biological
conditions thought to underlie schizophrenia. Instead, the focus is more on describing
patients in terms of positive symptoms (additions of undesirable elements, such as
hallucinations) and negative symptoms (subtractions of normal elements of mental
functioning, such as lack of emotion). There is also evidence for three separate dimensions
of schizophrenia: psychotic (displaying hallucinations or delusions), disorganized
(incoherence, inappropriate affect, and chaotic behavior), and negative (displaying negative
symptoms).
C.
Causes of Schizophrenia
1. Biological Factors. Possible biological causes of schizophrenia include inherited
predispositions; oversensitivity to dopamine; loss, deterioration, or disorganization of
certain brain cells; enlarged brain ventricles; reduced blood flow in certain parts of the
brain; and abnormal brain lateralization. Not all persons with schizophrenia have all
the biological problems listed here. Evidence suggests that specific symptoms are
correlated with specific biological problems: positive symptoms are associated with
increased dopamine activity; negative symptoms are associated with decreased
dopamine activity and abnormal brain structures.
2. Psychological and Sociocultural Factors. Psychodynamic theory suggests that
schizophrenic symptoms represent a regression to early childhood. Behaviorists
believe that schizophrenic symptoms are learned methods of trying to cope with
anxiety. They may also be the product of patterns of reinforcement and punishment in
early life.
3. Vulnerability Theory. The vulnerability model takes a diathesis-stress approach. The
vulnerability can be biological or psychological in nature.
IX. PERSONALITY DISORDERS
Personality disorders, which are less severe than psychological disorders, are lifestyles or ways of
behaving that begin in childhood or adolescence and create problems, usually for others. Ten
personality disorders are described in the DSM-IV on Axis II. They are grouped into three clusters
that share certain features. The odd-eccentric cluster features symptoms similar to but milder than
schizophrenia and includes schizoid, schizotypal, and paranoid personality disorder. The anxiousfearful clusters is self-explanatory and includes dependent, obsessive-compulsive, and avoidant
personality disorders. The dramatic-erratic cluster includes histrionic, narcissistic, borderline, and
antisocial personality disorders. The main features of the dramatic-erratic disorders are extreme
self-absorption and lack of empathy for others. Antisocial personality disorder is the most serious.
It is characterized by a long-term pattern of irresponsible, impulsive, unscrupulous, and
sometimes even criminal behavior.
A.
Focus on Research Methods: Exploring Links Between Child Abuse and Antisocial
Personality Disorder
Using a prospective design, researchers compared 416 adults whose backgrounds included
official records of abuse by age 11 to 283 adults without records of abuse. Although a
minority of both groups showed criminal tendencies and incidence of antisocial personality,
the rate of both was greater for the abused group. The two groups were matched on
important variables such as socioeconomic status, but it is possible that abuse may indirectly
cause criminality and antisocial personality disorder, as abused children are likely exposed
to other risk factors such as poor role models. Future research should investigate this
possibility more directly.
X.
A SAMPLING OF OTHER PSYCHOLOGICAL DISORDERS
A. Psychological Disorders of Childhood
Childhood disorders are unique because of the incomplete nature of children’s development
and their limited coping skills. Most childhood behavior problems can be categorized as
either externalizing (lack of control) or internalizing (overcontrol) disorders. Common
externalizing disorders include conduct disorders and attention-deficit hyperactivity disorder
(ADHD). Internalizing disorders include separation anxiety disorder. Autistic spectrum
disorders fall into neither category, involving communication difficulties and social
impairments.
B.
Substance-Related Disorders
Substance-related disorder is the result of the prolonged use of, or addiction to, psychoactive
drugs, which can cause physical or psychological harm to the user and consequently to
others around her or him.
1.
Alcohol Use Disorders. Alcoholism afflicts 7 percent of American adults. It is a pattern
of continual or intermittent drinking that may lead to addiction and almost always
causes severe social, physical, and other problems. Behavioral theory suggests that
people learn to use alcohol because it helps them cope with stressors and reduce stress
reactions. Biological evidence suggests that alcoholism may be due to an inherited
predisposition, especially in males.
2. Heroin and Cocaine Dependence. One million Americans are addicted to cocaine
(estimate), and millions more use it. Continued cocaine use or overdose can produce a
range of symptoms: nausea, hyperactivity, paranoid thinking, sudden depressive
“crashes,” and even death. Addiction to heroin is largely a biological process.
However, psychological factors may be involved in the initial involvement with drugs.
XI. MENTAL ILLNESS AND THE LAW
People with mental illnesses are protected in two ways when accused of committing crimes. First,
if a person can’t understand the charges at the time of trial or assist in the defense, she or he is
said to be mentally incompetent. Second, the person can be found not guilty by reason of insanity
if, at the time of the crime, mental illness prevented the defendant from understanding what she or
he was doing or that the act was wrong, or if it prevented the defendant from resisting the impulse
to do wrong. These laws were designed to protect people with mental illnesses, but critics
question the idea of protection. Others point to problems deciding who is insane and who is not
when there is conflicting testimony.
Some states have abolished the insanity defense. Other states now permit a verdict of guilty but
mentally ill. The irresistible-impulse criterion has been eliminated from the definition of insanity
in federal courts, and the defense is now required to prove the defendant was insane at the time of
the crime (the latter is also the case in some states).