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Abnormal Psychology
Abnormal Psychology
Sixth Edition
Susan Nolen-Hoeksema
Yale University

ABNORMAL PSYCHOLOGY, SIXTH EDITION
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Library of Congress Cataloging-in-Publication Data
Nolen-Hoeksema, Susan, 1959-2013.

Abnormal psychology I Susan Nolen-Hoeksema, Yale. - Sixth edition.
pages em
Includes index.
ISBN 978-D-07-803538-8-ISBN 0-07-803538-4 (hard copy : alk. paper) 1. Psychology,
Pathological-Textbooks. 2. Mental illness-Textbooks. I. Title.
RC454.N64 2014
616.89
2013031494
The Internet addresses listed in the text were accurate at the time of publication. The inclusion of a website does not indicate
an endorsement by the authors or McGraw-Hill Education, and McGraw-Hill Education does not guarantee the accuracy of
the information presented at these sites.
www.mhhe.com
o In Memoriam
Susan Nolen-Hoeksema (1959-2013)

In January 2013, we lost our esteemed author and friend, Susan
Nolen-Hoeksema. Susan was a renowned scholar, teacher, mentor,
and academic leader. She was recognized internationally for her
work on how people regulate their feelings and emotions and
how particular patterns of thinking can make people vulnerable
to and recover slowly from emotional problems, especially depres-
sion. Her research shaped the field's perspective on depression in
women and girls, and countless empirical studies and theoretical
contributions followed as she developed her groundbreaking the-
ory of rumination and depression.
In her words, "My career has focused on two parallel goals.
The first is to use empirical methods to address important social
and mental health problems (depression, rumination, women's
mental health). The second goal is to disseminate psychological
science. I also believe in taking science to the public, through my textbook on (Ab )normal Psychology
and books for the general public on women's mental health."
Susan taught at Stanford University, the University of Michigan, and Yale University. Susan's work
focused on depression, mood-regulation, and gender, for which she was recognized and received the
David Shakow Early Career Award from Division 12, the Distinguished Leadership Award from the
Committee on Women of American Psychological Association, the James McKeen Cattell Fellow Award
from the Association for Psychological Science, and a Research Career Award, and multiple grants from
the National Institute of Mental Health. In addition, she was the founding editor of the Annual Review
of Clinical Psychology, now the most highly cited journal in the field of clinical psychology.
In addition to being an accomplished professor, scholar, teacher, and writer, Susan was a loving and
devoted mother, wife, daughter, sister, friend, and mentor. Susan touched and inspired the lives of many
people both professionally and personally, and she will be dearly missed.
BRIEF CONTENTS
Preface xv
1 Looking at Abnormality 2
2 Theories and Treatment of Abnormality 22
3 Assessing and Diagnosing Abnormality 58
4 The Research Endeavor 82
5 Trauma, Anxiety, Obsessive-Compulsive,
and Related Disorders 106
6 Somatic Symptom and Dissociative Disorders 150
7 Mood Disorders and Suicide 174
8 Schizophrenia Spectrum and Other Psychotic Disorders 216
9 Personality Disorders 250
10 Neurodevelopmentol and Neurocognitive Disorders 282
11 Disruptive, Impulse Control, and Conduct Disorders 318
12 Eating Disorders 336
13 Sexual Disorders 362
14 Substance Use and Gambling Disorders 394
15 Health Psychology 432
16 Mental Health and the Low 462
Discussions for Think Critically 48 7

Glossary G-7
References R-7
Credits C-7
Name Index N/-7
Subject Index Sl-7
vii
. '
Preface xv
2 Theories and Treatment
of Abnormality 22
1 Looking at Abnormality 2 Approaches Along the Continuum 23
Abnormality Along the Continuum 3
Extraord inary People-Steven Hayes 24
Extraordinary People 4
Biological Approaches 26
Defining Abnormality 4
Brain Dysfunction 27
Mental Illness 5
Biochemical Imbalances 29
Cultural Norms 5
Genetic Abnormalities 31
The Four Ds of Abnormality 6
Drug Therapies 33
Shades of Gray 7
Electroconvulsive Therapy and Newer Brain
Historical Perspectives on Abnormality 7 Stimulation Techniques 34
Ancient Theories 7 Psychosurgery 35
Medieval Views 9 Assessing Biological Approaches 35
The Spread of Asylums 11 Psychological Approaches 36
Moral Treatment in the Eighteenth Behavioral Approaches 36
and Nineteenth Centuries 12
Cognitive Approaches 39
The Emergence of Modern Perspectives 14
Psychodynamic Approaches 41
The Beginnings of Modern Biological
Humanistic Approaches 45
Perspectives 14
Family Systems Approaches 46
The Psychoanalytic Perspective 14
Shades of Gray 47
The Roots of Behaviorism 15
Third-Wave Approaches 48
The Cognitive Revolution 16
Using New Technology
Modern Mental Health Care 16 to Deliver Treatment 48
Deinstitutionalization 16
Sociocultural Approaches 49
Managed Care 17
Cross-Cultural Issues
Professions Within Abnormal in Treatment 50
Psychology 19
Culturally Specific Therapies 52
Chapter Integration 19 Assessing Sociocultural Approaches 53
Shades of Gray Discussion 20
Prevention Programs 53
Think Critically 20
Common Elements in Effective
Chapter Summary 20 Treatments 53
Key Terms 21 Chapter Integration 54
viii
CONTENTS
Shades of Gray Discussion 55 Shades of Gray 74

Think Critically 55 The Social-Psychological Dangers
of Diagnosis 77
Chapter Summary 55
Chapter Integration 79
Key Terms 57
Think Critically 79
3 Assessing and Diagnosing Chapter Summary 80
Abnormality 58 Key Terms 81
Assessment and Diagnosis Along

the Continuum 59
Extraordinary People-Morya Hornbacher 60 4 The Research Endeavor 82
Assessment Tools 60 Research Along the Continuum 83
Validity 60 Extraordinary People-The Old Order Amish
Reliability 61 of Pennsylvania 84
Standardization 62 The Scientific Method 84
Clinical Interview 62 Defining the Problem and Stating

a Hypothesis 85
Symptom Questionnaires 63
Choosing and Implementing
Personality Inventories 64 a Method 85
Behavioral Observation Shades of Gray 86
and Self-Monitoring 64
Ethical Issues in Research 86
Intelligence Tests 66
Case Studies 87
Neuropsychological Tests 66
Evaluating Case Studies 88
Brain-Imaging Techniques 67
Psychophysiological Tests 67 Correlational Studies 88
Projective Tests 68 Measuring the Relationship

Between Variables 89
Challenges in Assessment 68
Selecting a Sample 90
Resistance to Providing Information 68
Evaluating Correlational Studies 91
Evaluating Children 69
Epidemiological Studies 92
Evaluating Individuals
Across Cultures 70 Evaluating Epidemiological Studies 92
Diagnosis 71 Experimental Studies 93
Diagnostic and Statistical Manual Human Laboratory Studies 93

of Mental Disorders (DSM) 72 Therapy Outcome Studies 94
ix
X Contents
Single-Case Experimental Designs 95 Panic Disorder 127

Animal Studies 97 Theories of Panic Disorder 128
Genetic Studies 98 Treatments for Panic Disorder 130
Family History Studies 98 Generalized Anxiety Disorder 132
Twin Studies 98 Theories of Generalized Anxiety
Disorder 133
Adoption Studies 99
Treatments for Generalized Anxiety
Molecular Genetic Studies
Disorder 134
and Linkage Analyses 99
Separation Anxiety Disorder 135
Cross-Cultural Research 99
Theories of Separation Anxiety Disorder 136
Meta-Analysis 100
Treatments for Separation Anxiety
Evaluating Meta-Analysis 101 Disorder 138
Chapter Integration 1Ol Obsessive-Compulsive Disorder 139
Shades of Gray Discussion 102 Theories of OCD and Related Disorders 143
Think Critically 102 Treatment of OCD and
Related Disorders 144
Chapter Summary 102
Anxiety Disorders in Older Adults 145
Key Terms 104
5 Trauma, Anxiety, Obsessive- Shades of Gray Discussion

Think Critically 147
147
Compulsive, and Related

Disorders 106 Chapter Summary 148
Fear and Anxiety Along KeyTerms 149

the Continuum 107
Extraordinary People-David Beckham,
Perfection On and Off the Field 108 6 Somatic Symptom and
Posttraumatic Stress Disorder Dissociative Disorders 150
and Acute Stress Disorder 11 0 Somatic Symptom and Dissociative
Traumas Leading to PTSD 113 Disorders Along the Continuum 151
Theories of PTSD 115 Extraordinary People-Anna 0.,
The Talking Cure 152
Treatments for PTSD 11 7
Somatic Symptom Disorders 152
Specific Phobias and Agoraphobia 118
Somatic Symptom Disorder and Illness
Specific Phobias 11 8
Anxiety Disorder 153
Shades of Gray 119
Shades of Gray 155
Agoraphobia 120
Conversion Disorder (Functional
Theories of Phobias 120 Neurological Symptom Disorder) 157
Treatments for Phobias 122 Factitious Disorder 159
Social Anxiety Disorder 123 Dissociative Disorders 160
Theories of Social Anxiety Disorder 125 Dissociative Identity Disorder 160
Treatments for Social Anxiety Disorder 126 Dissociative Amnesia 166
Contents xi
Depersonalization I Derealization Interpersonal and Social Rhythm Therapy

Disorder 168 and Family-Focused Therapy 202
Controversies Around the Dissociative Comparison of Treatments 203
Disorders 169
Suicide 204
Defining and Measuring Suicide 204
Understanding Suicide 207
Thin k Critically 172
Treatment and Prevention 210
Chapter Summary 172 Chapter Integration 212
Key Terms 173 Shades of Gray Discussion 213
7 Mood Disorders and Chapter Summary 213
Suicide 174 Key Terms 215
Mood Disorders Along

the Continuum 175
Extraordinary People-Kay Redfield Jamison,
8 Schizophrenia Spectrum and
An Unquiet Mind 176 Other Psychotic Disorders 216
Schizophrenia Spectrum and Other
Characteristics of Depressive Disorders 176
Psychotic Disorde rs Along
Symptoms of Depression 176 the Continuum 21 7
Diagnosing Depressive Disorders 177 Extraordinary People-John Nash,
Prevalence and Course A Beautiful Mind 218
of Depressive Disorders 180 Symptoms, Diagnosis, and Course 219
Shades of Gray 181 Positive Symptoms 219
Characteristics of Bipolar Disorder 181 Hallucinations 222
Symptoms of Mania 182 Negative Symptoms 224
Prevalence and Course Cognitive Deficits 225
of Bipolar Disorder 184
Diagnosis 225
Creativity and the Mood Disorders 184
Prognosis 227
Theories of Depression 185
Other Psychotic Disorders 229
Biological Theories of Depression 185
Biological Theories 232
Psychological Theories of Depression 188
Shades of Gray 233
Theories of Bipolar Disorder 192
Genetic Contributors to Schizophrenia 233
Biological Theories of Bipolar Disorder 192
Structural and Functional Brain
Psychosocial Contributors Abnormalities 235
to Bipolar Disorder 193
Neurotransmitters 237
Treatment of Mood Disorders 193
Psychosocial Perspectives 238
Biological Treatments
Social Drift and Urban Birth 238
for Mood Disorders 193
Stress and Relapse 238
Psychological Treatments
for Mood Disorders 199 Schizophrenia and the Family 239
xii Contents
Cognitive Perspectives 240 Chapter Integration 278

Cross-Cultural Perspectives 240 Shades of Gray Discussion 279
Treatment 241 Think Critically 279
Biological Treatments 241 Chapter Summary 280

Psychological and Key Terms 281
Social Treatments 243
Shades of Gray Discussion 24 7 10 Neurodevelopmental and
Think Critically 248 Neurocognitive Disorders 282
Neurodevelopmental and
Chapter Summary 248
Neurocognitive Disorders Along
Key Terms 249 the Continuum 283
Extraordinary People-Temple Grandin
Thinking in Pictures 284
9 Personality Disorders 250

Attention-Deficit/Hyperactivity Disorder
Biological Factors 287
284
Personality Disorders Along

the Continuum 251 Psychological and Social Factors 288
Extraordinary People-Susanna Kaysen Treatments for ADHD 288

Girl, Interrupted 252 Shades of Gray 289
General Definition of Autism Spectrum Disorder 290
Personality Disorder 254
Contributors to Autism Spectrum
Cluster A: Odd-Eccentric Personality Disorder 293
Disorders 255
Treatments for Autism Spectrum Disorder 294
Paranoid Personality Disorder 256
Intellectual Developmental Disorder 294
Schizoid Personality Disorder 258
Biological Causes of Intellectual
Schizotypal Personality Disorder 259 Disability 295
Cluster B: Dramatic-Emotional Sociocultural Factors 298
Personality Disorders 262
Treatments for Intellectual Disability 298
Borderline Personality Disorder 262
Learning, Communication,
Histrionic Personality Disorder 267 and Motor Disorders 299
Narcissistic Personality Disorder 268 Specific Learning Disorder 299
Cluster C: Anxious-Fearful Personality Communication Disorders 301
Disorders 270
Causes and Treatment of Learning
Avoidant Personality Disorder 270 and Communication Disorders 302
Dependent Personality Disorder 272 Motor Disorders 303
Obsessive-Compulsive Personality Major and Minor Neurocognitive Disorders 304
Disorder 273
Symptoms of Major Neurocognitive
Shades of Gray 27 4 Disorder 305
Alternative OSM-5 Model for Personality Types of Major and Minor Neurocognitive
Disorders 27 6 Disorder 306
Contents xiii
The Impact of Gender, Culture,

and Education on Neurocognitive 12 Eating Disorders 336
Disorder 311 Eating Disorders Along the Continuum 337
Treatments for and Prevention
Extraordinary People-Fashion Models,
of Neurocognitive Disorder 312
Dying to Be Thin 338
Delirium 312
Characteristics of Eating Disorders 339
Causes of Delirium 313
Anorexia Nervosa 339
Treatments for Delirium 314
Bulimia Nervosa 343
Chapter Integration 314 Binge-Eating Disorder 345
Shades of Gray Discussion 315 Other Specified Feeding or
Think Critically 316 Eating Disorder 346
Obesity 347
Chapter Summary 316
Shades of Gray 350
Key Terms 317
Understanding Eating Disorders 350
Biological Factors 350
1 1 Disruptive, Impulse Control, Sociocultural and Psychological

Factors 351
and Conduct Disorders 318
Treatments for Eating Disorders 357
Disorders of Conduct
and Impulse Control Across Psychotherapy for Anorexia Nervosa 357
the Continuum 319
Psychotherapy for Bulimia Nervosa
Extraordinary People-Ted Bundy, Portrait and Binge-Eating Disorder 357
of a Serial Killer 320 Biological Therapies 359
Conduct Disorder and Oppositional Defiant Chapter Integration 359
Disorder 321
Contributors to Conduct Disorder
and Oppositional Defiant Disorder 324 Think Critically 360
Shades of Gray 325 Chapter Summary 361
Treatments for Conduct Disorder and Key Terms 361
Oppositional Defiant Disorder 328
Antisocial Personality Disorder 329
Contributors to Antisocial Personality
13 Sexual Disorders
- - - -Sexuality Along the Continuum
362
Disorder 331 363
Treatments for Antisocial Personality Extraordinary People-David Reimer,

Disorder 332 The Boy Who Was Raised as a Girl 364
Intermittent Explosive Disorder 332 Sexual Dysfunctions 366

Disorders of Sexual Interest/Desire
and Arousal 366
Disorders of Orgasm or Sexual Pain 368
Causes of Sexual Dysfunctions 370
Chapter Summary 335 Treatments for Sexual Dysfunctions 375
Key Terms 335 Gay, Lesbian, and Bisexual People 379
xiv Contents
Paraphilic Disorders 380 Cannabis 414

Fetishistic Disorder and Transvestic Inhalants 415
Disorder 380
Other Drugs of Abuse 41 6
Sexual Sadism and Sexual Masochism
Disorders 382 Theories of Substance Use Disorders 417
Shades of Gray 383 Biological Factors 417
Voyeuristic, Exhibitionistic, and Frotteuristic Psychological Factors 418

Disorders 383 Sociocultural Factors 419
Pedophilic Disorder 384 Gender Differences 419
Causes of Paraphilias 385
Treatments for Substance Use Disorders 420
Treatments for the Paraphilias 386
Biological Treatments 420
Gender Dysphoria 388 Psychosocial Treatments 421
Contributors to Gender Dysphoria 390 Substance Use Treatment
Treatments for Gender Dysphoria 390 for Older Adults 425
Chapter Integration 391 Comparing Treatments 426
Shades of Gray Discussion 391 Prevention Programs 426
Think Critically 392 Gambling Disorder 427

Chapter Summary 392
Key Terms 393
Chapter Summary 429

14 Substance Use and Gambling Key Terms 431
Disorders 394
Substance Use Along the Continuum 395
Extraordinary People-
15 Health Psychology 432
Celebrity Drug Abusers 396 Stress Along the Continuum 433
Defining Substance Use Disorders 398 Extraordinary People-Norman Cousins,

Healing with Laughter 434
Depressants 400
Psychological Factors
Alcohol 400 and General Health 436
Shades of Gray 405 Appraisals and Pessimism 436
Benzodiazepines and Barbiturates 405 Coping Strategies 436
Stimulants 406 Shades of Gray 438
Cocaine 406 Psychological Disorders
Amphetamines 409 and Physical Health 438
Nicotine 41 0 Psychosocial Factors

in Specific Diseases 439
Caffeine 411
The Immune System 439
Opioids 411
Coronary Heart Disease
Hallucinogens and PCP 413 and Hypertension 442
Conte nts XV
Interventions to Improve Health-Related Prevalence of Involuntary

Behaviors 446 Commitment 469
Guided Mastery Techniques 446 Patients' Rights 470
Internet-Based Health Interventions 447 Right to Treatment 470
Sleep and Health 448 Right to Refuse Treatment 470
Assessing Sleep 449 Competence to Stand Trial 471
Sleep Disorders 450 The Insanity Defense 472
Chapter Integration 459 Insanity Defense Rules 473
Shades of Gray Discussion 460 Shades of Gray 476
Think Critically 460 Problems with the Insanity Defense 476
Chapter Summary 460 Guilty but Mentally Ill 476
Key Terms 461 Mental Health Care in the Justice System 477
16 Mental Health and

Shades of Gray Discussion
479
the Law 462

Mental Health Law Along Chapter Summary 479
the Continuum 463 Key Terms 480
Extraordinary People-Greg Bottoms,
Angelhead 464 Discussions for Think Critically 481
Glossary G- l
Civil Commitment 464
References R- l
Criteria for Civil Commitment 465 Credits C- l
Violence by People Name Index NI- l
with Mental Disorders 467 Subject Index Sl- l
ABNORMAL PSYCHOLOGY-PROVEN SCHOLARSHIP,
ADAPTIVE LEARNING
Abnormal Psychology, Sixth Edition, was thoroughly E- connect'
updated to reflect the changes in the DSM-5, and chap- ~-11
ters were reorganized in light of DSM-5 recategoriza-
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detailed disorder-by-disorder guides to changes in diag- 0.. EdpBtJn 11o studying tN etfects ot ak'.ohol on
r'MCIIOO tkntl To do tt.. she needla place
nostic criteria to help them adjust their lectures and course where .t~ c:en ,.... l\el ~rUdpantll spodflc
dose ot alcohol. altow tJmiJ for the l!lkoOOI to be
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materials. And, through McGraw-Hill Connect, your stu- Mihaprocrnmtol~fort.herreactlofltlme
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dents will experience a new and adaptive way to learn
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xvi
PREFACE
a deeper understanding of psychological disorders. Twelve Category Analysis Reports: The Category Analysis
different disorders are presented, including ADHD, report is the place to go to find out how your students
Borderline Personality Disorder, Schizophrenia, and Post- are performing relative to specific learning objectives
traumatic Stress Disorder. Faces: Interactive is available and goals.
exclusively through Connect and ConnectPlus. Item Analysis Reports: The Item Analysis report is
the best way to get a bird's-eye view of a single
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Integrated eBook improving or if a particular concept is something
A fully loaded eBook allows students to review Abnormal you want to spend additional time on in class.
Psychology anytime and anywhere. They can highlight, take Student Performance Reports: The Student
notes, and quickly search for key terms and phrases. Performance report helps you search for a specific
student in your class and focus on that student's
progress across your assignments.
Assignable and Assessable Activities
Assignment Results & Statistics Reports: The
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Whether a class is face-to-face, hybrid, or entirely online,
Abnormal Psychology provides the tools needed to reduce the REORGANIZATION
amount of time and energy instructors must expend to
administer their course. Easy-to-use course management The DSM-5 recategorized and reorganized some disorders,
tools allow: particularly those identified in the DSM-IV-TR as the child-
hood disorders, some of the anxiety disorders, and the per-
At-Risk Student Reports: The At-Risk report provides sonality disorders. Abnormal Psychology, Sixth Edition,
instructors with one-click access to a dashboard that retains much of the organization of the fifth edition but reor-
identifies students who are at risk of dropping out of ganizes certain chapters to reflect the major changes in the
a course due to a low engagement level. DSM-5. Specific changes:
Childhood Disorders: The DSM-5 separated diagnoses
formerly in this category into several categories,
Psychology 101 ;.. CDr1!1eCt including neurodevelopmental disorders (intellectual
development disorder [formerly mental retardation]
home library and specific learning disorders, autism, attention-
reports deficit/ hyperactivity disorder) and disruptive, impulse
section perfonnance control, and conduct disorders (conduct disorder,
72.78%~ OVIfaiiMCIOI'Iavtntoe br6 at:~~gnman!lsl oppositional defiant disorder, pyromania, kleptomania,
A 6 student(s) have an overall average between 0-59'1.
intermittent explosive disorder, antisocial personality
disorder); separation anxiety disorder has been placed
in the anxiety disorders.
Anxiety Disorders: The DSM-5 separated post-
As of 12129rf2012 6:30PM EST traumatic stress disorder (PTSD) and obsessive-
compulsive disorder (OCD) from the other anxiety
xvii
xviii Preface
disorders. The new DSM-5 OCD chapter includes Explanation to the adoption of the nonaxial diagnostic
hoarding, hair-pulling disorder, and body dysmorphic system in the DSM-5.
disorder; as noted above, the DSM-5 moves separation Revised coverage of past and present controversies
anxiety from the childhood disorders to the anxiety associated with the DSM.
disorders.
Abnormal Psychology, Sixth Edition, renames the
"Anxiety Disorders" chapter in the fifth edition Chapter 4: The Research Endeavor
"Trauma, Anxiety, Obsessive-Compulsive, and Related
Disorders" and continues to cover OCD and PTSD in Expanded Research Along the Continuum feature to
this chapter; separation anxiety is now covered in this include cautions about drawing definitive conclusions
chapter, as are hoarding, hair-pulling disorder, and from single research studies.
body dysmorphic disorder. Streamlined discussion of comparison groups in the
Abnormal Psychology, Sixth Edition, includes a complete discussion of samples.
revision of the "Personality Disorders" chapter to
reflect the changes in the DSM-5.
Chapter 5: Trauma, Anxiety,
Obsessive-Compulsive,
CHAPTER-BY-CHAPTER CHANGES
and Related Disorders
IN THE SIXTH EDITION
Complete revision of trauma, fear, and anxiety in
Abnormal Psychology, Sixth Edition, has been thoroughly accordance with the DSM-5.
updated with nearly 300 new references, approximately
80 percent of which date from 2010 and later. The revi- Expanded Fear and Anxiety Along the Continuum
sion is based on the May 2013 publication of the DSM-5 feature.
and reflects all the theoretical and diagnostic changes in Revised diagnostic criteria for PTSD and its subtype:
that reference. Both text and art have been updated as with prominent dissociative (depersonalization/
appropriate. derealization) symptoms.
Revised coverage of specific phobias and their
Chapter 1: looking at Abnormality diagnostic criteria.
Revised and expanded Abnormality Along the Revised coverage of social anxiety disorder and its
Continuum feature . diagnostic criteria.
A new Extraordinary People feature . Revised coverage of panic disorder and its diagnostic
Reorganized "Defining Abnormality" section to enhance criteria.
clarity on cultural norms and cultural relativity. Revised coverage of generalized anxiety disorder
(GAD) and its diagnostic criteria.
Chapter 2: Theories and Treatment Addition of emotional factors in theories of GAD.
of Abnormality
Addition of separation anxiety disorder and its
Revised Approaches Along the Continuum feature. diagnostic criteria.
A new Extraordinary People feature. Revised coverage of obsessive-compulsive disorder
Added coverage of third-wave approaches to theory and its diagnostic criteria; added coverage of subtypes
and treatment, including dialectical behavioral therapy (hoarding, hair-pulling disorder, skin-picking
and acceptance and commitment therapy. disorder, body d ysmorphic disorder and related
symptoms).
Added coverage of new technology and the delivery
of treatment. Added coverage of anxiety disorders in older adults.
Chapter 3: Assessing and

Diagnosing Abnormality Chapter 6: Somatic Symptom
Updated examples in text, tables, and art to agree with and Dissociative Disorders
changed nosology of the DSM-5. Revised coverage of somatic (formerly somatoform)
Updated "Diagnostic and Statistical Manual of Mental symptoms and dissociative disorders and their
Disorders" section to account for the changes in the diagnostic criteria. The five new disorders under the
DSM-5. rubric of somatic symptoms are presented: somatic
Preface xix
symptom disorder, illness anxiety disorder (formerly Revised coverage of autism spectrum disorder and its
hypochondriasis), conversion disorder, factitious diagnostic criteria.
disorder, and psychological factors affecting a medical Revised coverage of intellectual development disorder
condition. and its diagnostic criteria.
Revision of dissociative disorders and their diagnostic Revised coverage of learning, communication,
criteria. and motor disorders and their diagnostic
Revision of depersonalization/ derealization disorder criteria.
(formerly depersonalization disorder) and its Revised coverage of major and minor neurocognitive
diagnostic criteria. disorders (including Alzheimer's disease and
disorders caused by vascular disease, head injury,
progressive diseases such as Parkinson's disease
Chapter 7: Mood Disorders and HIV disease, or chronic drug abuse) and their
and Suicide diagnostic criteria.
Expanded Mood Disorders Along the Continuum
feature to cover the difficulty involved in distinguishing Chapter 11: Disruptive, Impulse
a disordered condition from normal mood responses Control, and Conduct Disorders
to life events.
Entirely revised chapter to reflect reconceptualizations
Revised coverage of depressive disorders and subtypes
of the disorders in these areas by the DSM-5.
and their diagnostic criteria.
Revised coverage of conduct disorder and
Revision of bipolar disorder and its diagnostic
oppositional defiant disorder and their diagnostic
criteria.
criteria. Childhood-onset conduct disorder and
Addition of disruptive mood dysregulation disorder adolescent-onset conduct disorder are defined and
(with comparison to temper tantrums). compared. Life-course-persistent conduct disorder
Revised section on stressful life events and suicide. is also included.
Revised coverage of antisocial personality disorder and
its diagnostic criteria.
Chapter 8: Schizophrenia Spectrum Revised coverage of intermittent explosive disorder
and Other Psychotic Disorders and its diagnostic criteria.
Revised Schizophrenia Spectrum and Other Psychotic
Disorders Along the Continuum feature. Chapter 12: Eating Disorders
Revised coverage of schizophrenia spectrum (formerly
schizophrenia) and its diagnostic criteria. New Eating Disorders Along the Continuum feature
reflecting DSM-5 developments.
Revised coverage of other psychotic disorders,
including schizoaffective disorder, schizophreniform New Extraordinary People feature.
disorder, brief psychotic disorder, delusional disorder, Revised coverage of anorexia nervosa and its
and schizotypal personality disorder and their diagnostic criteria.
diagnostic criteria. Revised coverage of bulimia nervosa and its diagnostic
criteria.
Revised coverage of binge-eating disorder and its
Chapter 10: Neurodevelopmental diagnostic criteria.
and Neurocognitive Disorders New coverage of eating disorder not otherwise
A new Neurodevelopmental and Neurocognitive specified and its diagnostic criteria.
Disorders Along the Continuum feature.
Complete revision of the former "Childhood Chapter 13: Sexual Disorders
Disorders" chapter to reflect the DSM-5
reconceptualization of these disorders (now called New Sexuality Along the Continuum feature.
neurodevelopmental disorders) and those neurological Revised sexual dysfunctions and their diagnostic
disorders that typically arise in older age (called criteria, including disorders of sexual interest/ desire
neurocognitive disorders). and arousal and disorders of orgasm or sexual pain.
Revised coverage of attention-deficit/hyperactivity Revised coverage of paraphilic disorders and their
disorder and its diagnostic criteria. diagnostic criteria.
XX Preface
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Revised coverage of gender dysphoria (formerly called
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Preface xxi
and corresponding coverage in the text. The Test Bank is Dara G. Friedman-Wheeler, Jubemi 0. Ogisi,
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ACKNOWLEDGMENTS Barbara Kennedy, University of Houston-
Brevard Community Houston
We are grateful to Anthony Giuliano, Harvard Medical College
Judith Rauenzahn,
School, for his invaluable contributions to this edition. A
number of instructors were instrumental in the develop-
Marvin Lee, Kutztown University
Tennessee State University
ment of this text. Their input and ideas as reviewers were Elizabeth E. Seebach,
invaluable in the process. Thank you: Howard Markowitz, Saint Mary's University of
Hawaii Pacific University- Minnesota
Sandra K. Arntz, Kimberly Dasch-Yee,
Honolulu
Waubonsee Community Holy Family University Wayne Stein,
College Sarah Nolan, Brevard Community College
Donald Evans,
University of Florida
Holly Chalk, Simpson College
McDaniel College
xxii Preface
CHAPTER 5 DSM-IV-TR Anxiety Disorders CHAPTER 6 DSM-IV-TR Somatoform Disorders
DSM-IV- TR Anxiety Disorders Categorized DSM-IV- TR Somatoform Disorders Categorized in the

in the DSM-5 as Anxiety Disorders DSM-5 as Somatic Symptom and Related Disorders
DSM-IV-TR DSM-5 DSM-IV-TR DSM-5
Specific Phobia Specific Phobia Somatization Disorder, Pain Somatic Symptom

Social Phobia Social Anxiety Disorder Disorder, Hypochondriasis Disorder
Panic Disorder Panic Disorder (with physical symptoms)
Agoraphobia (as specifier Agoraphobia Hypochondriasis (without Illness Anxiety Disorder

of Panic Disorder) physical symptoms)
Generalized Anxiety Generalized Anxiety Conversion Disorder Conversion Disorder

Disorder Disorder (Functiona l Neurological
Symptom Disorder)
DSM-IV- TR Anxiety Disorders Categorized in the DSM-5 as Psychological Factors Psychological Factors
Trauma- and Stressor-Related Disorders Affecting Medical Affecting Other
Conditions (in DSM-IV Medical Conditions
DSM-IV-TR DSM-5 Appendix)
Posttraumatic Stress Posttraumatic Stress DSM-IV-TR Factitious Disorders

Disorder Disorder
DSM-IV-TR Factitious Disorders Categorized in the DSM-5
Acute Stress Disorder Acute Stress Disorder
as Somatic Symptom Disorders
DSM-IV-TR Anxiety Disorders Categorized in the DSM-5 as DSM-IV-TR DSM-5

Obsessive-Compulsive and Related Disorders
Factitious Disorder Factitious Disorder
DSM-IV-TR DSM-5
Factitious Disorder
Obsessive-Compulsive Obsessive-Compulsive Imposed on Self
Disorder Disorder Factitious Disorder by Proxy Factitious Disorder
Imposed by Another
DSM-IV-TR Adjustment Disorders
DSM-IV- TR Dissociative Disorders
DSM-IV- TR Adjustment Disorders Categorized in the
DSM-5 as Trauma- and Stressor-Related Disorders DSM-IV-TR DSM-5
DSM-IV-TR DSM-5 Dissociative Identity Dissociative Identity
Disorder Disorder
Adjustment Disorder Adjustment Disorder
Dissociative Amnesia Dissociative Amnesia
with depressed mood with depressed mood
Dissociative Fugue Specifier: Dissociative
with anxiety with anxiety
Fugue
with mixed anxiety and with mixed anxiety and Depersonalization Disorder Depersonalization/
depressed mood depressed mood
Derealization Disorder
with disturbance of with disturbance of
conduct conduct
with mixed disturbance with mixed disturbance
of emotions and of emotions and
conduct conduct
Preface xxiii
CHAPTER 7 DSM-IV-TR Mood Disorders CHAPTER 9 DSM-IV-TR Personality Disorders
DSM-IV- TR Mood Disorders Categorized in the DSM-5 as DSM-/V-TR Personality Disorders Categorized in the DSM-5
Depressive Disorders as Personality Disorders
DSM-IV-TR DSM-5 DSM-/V-TR DSM-5
Major Depression Major Depressive Disorder Cluster A Personality Cluster A Personality

Single Episode Single Episode Disorders Disorders
Recurrent Recurrent Episode Paranoid Personality Paranoid Personality
Disorder Disorder
Dysthymic Disorder Persistent Depressive
Disorder Schizoid Personality Schizotypal Personality
Disorder Disorder
DSM-IV- TR Mood Disorders Categorized in the DSM-5 as Schizotypal Personality Schizotypal Personality
Bipolar and Related Disorders Disorder Disorder
Cluster B Personality Cluster B Personality
DSM-IV-TR DSM-5 Disorders Disorders
Antisocial Personality Antisocial Personality
Bipolar I Diso rder Bipolar I Disorder
Disorder Disorder
Bipolar II Disorder Bipolar II Disorder
Borderline Personality Borderline Personality
Cyclothymic Disorder Cyclothymic Disorder Disorder Disorder
Histrionic Personality Histrionic Personality
Disorder Disorder
Narcissistic Personality Narcissistic Personality
Disorder Disorder
CHAPTER 8 DSM-IV-TR Schizophrenia and Cluster C Personality Cluster C Personality
Related Psychotic Disorders Disorders Disorders
Avoidant Personality Avoidant Personality
DSM-IV- TR Schizophrenia and Related Psychotic Disorders Disorder Disorder
Categorized in the DSM-5 as Schizophrenia Spectrum and
Dependent Personality Dependent Personality
Other Psychotic Disorders
Disorder Disorder
DSM-IV-TR DSM-5 Obsessive-Compulsive Obsessive-Compulsive
Personality Disorder Personality Disorder
Delusional Disorder Delusional Disorder Alternative DSM-5 Model Alternative DSM-5 Mode l
Shared Psychotic Disorder Delusional Disorder for Personality Disorders for Personality Disorders
Brief Psychotic Disorder Brief Psychotic Disorder
Schizophreniform Disorder Schizophreniform Disorder
Schizophrenia Schizophrenia
Schizoaffective Disorder Schizoaffective Disorder
xxiv Preface
CHAPTER 10 DSM-IV-TR Delirium, Dementia, CHAPTER 10 DSM-IV-TR Delirium, Dementia,

and Amnesic and Other Cognitive Disorders and Amnesic and Other Cognitive Disorders
(continued)
DSM-/V-TR Delirium, Dementia, and Amnesic and Other
Cognitive Disorders Categorized in the DSM-5 as DSM-IV- TR Disorders First Diagnosed in Infancy, Childhood,
Neurocognitive Disorders or Adolescence
DSM-IV-TR DSM-5 DSM-IV- TR Disorders First Diagnosed in Infancy,

Childhood, and Adolescence Categorized in the DSM-5
Delirium Delirium as Neurodevelopmental Disorders
Due to a Medical Due to Another Med ical
Condition
DSM-/V-TR DSM-5
Cond ition
Substance Intoxication Substance Intoxication Pervasive Developmental Autism Spectrum Disorder
Delirium Delirium Disorde rs (Autism,
Substance Withdrawal Substance Withdrawal Asperger's Disorder,
Delirium Delirium Rett's Disorder,
Dementia of the Neurocognitive Disorder Chi ldhood Disi ntegrative
Alzheimer's Type Due to Alzheimer's Disorder, PDD-NOS )
Disease Attention-Deficit/ Attention-Deficit/
Vascular Dementia Vascular Neurocogn itive Hyperactivity Disorder Hyperactivity Disorder
Disorder Mental Retardation Intellectual Disabil ity
Dementia Due to HIV Neurocognitive Disorder Reading Disorder Specific Learning Disorder
Disease Due to HIV Infection Mathematics Disorder With Impairment in:
Dementia Due to Head Neurocognitive Disorder Disorder of Written Reading
Trauma Due to Traumatic Expression Written Expression
Brain Injury
Mathematics
Dementia Due to Neurocognitive Disorder
Communication Disorders Communication Disorders
Parkinson's Disease Due to Parkinson's
Disease Expressive Language Language Disorder
Disorder Speech Sound Disorder
Dementia Due to Neurocognitive Disorder
Huntington's Disease Due to Huntington's Mixed Receptive- Social (Pragmatic)
Disease Expressive Language Communication
Dementia Due to Pick's Frontotemporal Disorder Disorder
Disease Neurocognitive Disorder Phonological Disorder Chi ldhood-Onset
Dementia Due to Neurocognitive Diso rd er Fluency Disorder
Creutzfeldt-Jakob Disease Due to Prion Disease (Stuttering)
Substance-Induced Substance/Medication- Developmental Coordination Developmental
Persisting Dementia Induced Neurocognitive Disorder Coordination Disorder
Disorder Tourette's Disorder Tourette's Disorder
Amnesic Disorders Neurocognitive Disorder Chronic Motor or Vocal Tic Persistent Motor or Vocal
Substance-Induced Due to Another Medical Disorder Tic Disorder
Persisting Amnesic Condition Stereotypic Movement Stereotypic Movement
Disorder Disorder Disorder
Preface XXV
CHAPTER 10 DSM-IV-TR Delir ium, Dementia, CHAPTER 12 DSM-IV-TR Eating Disorders

and Amnesic and Other Cognitive Disorders
(continued) DSM-IV-TR Eating Disorders Categorized in the DSM-5 as
Feeding and Eating Disorders
DSM-IV-TR Disorders First Diagnosed in Infancy,
DSM-IV-TR DSM-5
as Anxiety Disorders Anorexia Nervosa
Anorexia Nervosa
DSM-IV-TR DSM-5 Bulimia Nervosa Bulimia Nervosa
Binge-Eating Disorder Binge-Eating Disorder
Separation Anxiety Disorder Separation Anxiety Disorder
DSM-IV-TR Disorders First Diagnosed in Infancy,

as Elimination Disorders
CHAPTER 13 DSM-IV-TR Sexual and Gender
DSM-IV-TR DSM-5 Identity Disorders
Enuresis Enuresis DSM-IV-TR Sexual and Gender Identity Disorders

Encopresis Encopresis Categorized in the DSM-5 as Sexual Dysfunctions
DSM-IV-TR Disorders First Diagnosed in Infancy, DSM-IV-TR DSM-5

Sexual Desire Disorders
as Feeding and Eating Disorders
Hypoactive Sexual Desire Male Hypoactive Sexua l
DSM-IV-TR DSM-5 Disorder Desire Disorder
Sexual Aversion Disorder Female Sexual Interest/
Pica Pica Arousal Disorder
Rumination Rumination Disorder Sexual Arousal Disorders
Female Sexual Arousal Female Sexual Interest/
Disorder Arousal Disorder
Male Erectile Disorder Erectile Disorder
CHAPTER 11 DSM-IV-TR Impulse-Control Orgasm ic Disorders
Disorders Not Elsewhere Classified Female Orgasmic Disorder Female Orgasmic Disorder
Male Orgasmic Disorder Delayed Ejaculation
DSM-IV-TR Impulse-Control Disorders Not Elsewhere
Classified Categorized in the DSM-5 as Disruptive, Impulse Premature Ejaculation Premature (Early)
Control. and Conduct Disorders Ejaculation
Sexual Pain Disorders
DSM-IV-TR DSM-5 Dyspareunia Genito-Pelvic Pain/
Vaginismus Penetration Disorder
Intermittent Explosive Intermittent Explosive
Disorder Disorder
DSM-IV- TR Sexual and Gender Identity Disorders
Categorized in the DSM-5 as Paraphilic Disorders
DSM-IV- TR Impulse-Control Disorders Not Elsewhere
Classified Categorized in the DSM-5 as Substance-Related DSM-IV-TR DSM-5
and Addictive Disorders
Exhibitionism Exhibitionistic Disorder
DSM-IV-TR DSM-5
Fetishism Fetishistic Disorder
Pathological Gambling Gambling Disorder Frotteu rism Frotteuristic Disorder
Pedophilia Pedophilic Disorder
DSM-IV-TR Impulse-Control Disorders Not Elsewhere Sexual Masochism Sexual Masochism Disorder
Classified Categorized in the DSM-5 as Obsessive- Sexual Sadism Sexua l Sadism Disorder
Compulsive and Related Disorders
Transvestic Fetishism Transvestic Disorder
DSM-IV-TR DSM-5 Voyeurism Voyeuristic Disorder
Trichotillomania Trichotillomania
(Hair-Pulling Disorder)
xxvi Prefa ce
CHAPTER 13 DSM-IV-TR Sexual and Gender CHAPTER 14 DSM-IV-TR Substance-Related

Identity Disorders (continued) Disorders (continued)
DSM-IV- TR Sexual and Gender Identity Disorders DSM-IV-TR DSM-5

Categorized in the DSM-5 as Gender Dysphoria
Halluci nogen-Related Hallucinogen-Related
DSM-IV-TR DSM-5 Disorders Disorders
Hallucinogen Abuse Other Hallucinogen Use
Gender Identity Disorder Gender Dysphoria Disorder
in Children Hallucinogen Dependence Other Hallucinogen
in Adolescents or Adults in Children Use Disorder
in Adolescents and Hallucinogen Intoxication Other Hallucinogen
Adults Intoxication
Hallucinogen Persisting Hallucinogen Persisting
Perception Disorder Perception Disorder
Inhalant-Related Disorders Inhalant-Related Disorders
Inhalant Abuse Inhalant Use Disorder
CHAPTER 14 DSM-IV-TR Substance-Related Inhalant Use Disorder
Disorders Inhalant Dependence
Inhalant Intoxication Inhalant Intoxication
DSM-IV-TR Substance-Related Disorders Categorized in Nicotine-Related Disorders Tobacco-Related Disorders
the DSM-5 as Substance-Related and Addictive Disorders
Nicotine Dependence Tobacco Use Disorder
DSM-IV-TR DSM-5 Nicotine Withdrawal Tobacco Withdrawal
Opioid-Related Disorders Opioid-Related Disorders
Substance Abuse Substance Use Disorders Opioid Abuse Opio id Use Disorder
Substance Dependence Substance Use Disorders Opioid Dependence Opioid Use Disorder
Alcohol-Induced Disorders Alcohol -Related Disorders Opioid Intoxication Opio id Intoxication
Alcohol Abuse Alcohol Use Disorder Opioid Withdrawal Opioid Withdrawal
Alcohol Dependence Alcohol Use Disorder Phencyclidine-Related Hallucinogen-Related
Alcohol Intoxication Alcohol Intoxication Disorders Disorders
Alcohol Withdrawal Alcohol Withdrawal Phencyclidine Abuse Phencyclidine Use
Amphetamine-Related Stimulant-Related Disorder
Disorders Disorders Phencycl idine Dependence Phencyclidine Use
Amphetam ine Abuse Stimulant Use Disorder Disorder
Amphetamine Dependence Stimulant Use Disorder Phencyclidine Intoxication Phencyclidine Intoxication
Amphetamine Intoxication Stimu lant Intoxication Sedative, Hypnotic, or Sedative, Hypnotic, or
Amphetamine Withdrawal Sti m u Iant Withdraw a I Anxiolytic-Related Anxiolytic-Related
Cocaine-Related Disorders Disorders Disorders
Stimulant-Related Disorders
Cocaine Abuse Stimulant Use Disorder Sedative, Hypnotic, or Sedative, Hypnotic, or
Anxiolytic-Related Abuse Anxiolytic Use Disorder
Cocaine Dependence Stimulant Use Disorder
Sedative, Hypnotic, or Sedative, Hypnotic, or
Cocaine Intoxication Stimulant Intoxication
Anxiolytic-Related Anxiolytic Use Disorder
Cocaine Withdrawal Stimulant Withdrawal Dependence
Caffeine-Related Disorders Caffeine-Related Disorders Sedative, Hypnotic, or Sedative, Hypnotic, or
Caffeine Intoxication Caffeine Intoxication Anxiolytic-Related Anxiolytic Intoxication
Caffeine Withdrawal Intoxication
Cannabis-Related Disorders Cannabis-Related Disorders Sedative, Hypnotic or Sedative, Hypnotic, or
Cannabis Abuse Cannabis Use Disorder Anxiolytic-Related Anxiolytic Withdrawal
Withdrawal
Cannabis Dependence Cannabis Use Disorder
Cannabis Intoxication Cannabis Intoxication
Cannabis W ithdrawal
Preface xxvii
CHAPTER 15 DSM-IV-TR Sleep Disorders
DSM-IV-TR Sleep Disorders Categorized in the DSM-5 as Sleep-Wake Disorders
DSM-IV-TR DSM-5 DSM-IV-TR DSM-5
Primary Insomnia Insomnia Disorder Circadian Rhythm Sleep Circadian Rhythm Sleep-
Primary Hypersomnia Hypersomnolence Disorders Disorders Wake Disorders
Narcolepsy Narcolepsy Delayed phase type Delayed Sleep Phase Type
Narcolepsy without Jet lag type Advanced Sleep phase
Cataplexy but with Type
Hypercreti n Deficiency Irregular Sleep-Wake Type
Breathing-Related Sleep Breathing-Related Sleep Non-24-Hour Sleep-Wake
Disorders Disorders Type
Central Sleep Apnea Central Sleep Apnea Shift work type Shift Work Type
Obstructive Sleep Apnea Obstructive Sleep Apnea/ Parasomnias
Hypopnea Sleep Terror Disorder Non-Rapid Eye Movement
Sleep-Related Sleepwalking Disorder Sleep Arousal Disorder
Hypoventilation Nightmare Disorder Nightmare Disorder
Rapid Eye Movement
(REM) Sleep Behavior
Disorder
Restless legs syndrome
Substance-Induced Sleep Substance/Medication-
Disorder Induced Sleep Disorder
Sleep Disorders Related to
Another Mental Disorder
Sleep Disorders Related to a
General Medical Condition
Abnormal Psychology
Looking at Abnormality
CHAPTER OUTLINE
Abnormality Along the Continuum Shades of Gray Discussion

Extraordinary People Think Critically
Defining Abnorma lity Chapter Summary
Shades of Gray Key Terms
Historical Perspectives on Abnormal ity
The Emergence of Modern Perspectives
Modern Mental Health Care
Chapter Integration
Behaviors, thoughts, and feelings are one
Behaviors, thoughts, and feelings are or more of the following:
the following: Highly unusual for the social context
Typical for the social context The source of significant individ ual distress
Not distressing to the individual Significantly interfering with social or
Not interfering wi th social life or work/sc hool occupational functioning
Not dangerous Highly dangerous to the individual or othe rs
(Example: College students who are self-confident Sodally established (Example: College students who are hopeless about
and happy, petform to their capacity in school, division between the future, are self-loathing, chronically abuse drugs,
and have good friends) normal and abnormal fail courses, and have alienated all their friends)
Normal Abnormal
Behaviors, thoughts, and feelings are one

or more of the following:
Somewhat unusual for t he social context
Distressi ng to the individual
Interfering with social or occupational functioning
Dangero us
(Example: College students who are often unsure and
self-critical, occasionally abuse prescription drugs, fail
some courses, and avoid friends who disapprove of
their drug use)
As humans, we think, we feel, we behave. Most of the time, our like to think there is a clear dividing line between normal varia-
thoughts, feelings, and behaviors help us function in everyday tions i n thoughts, emotions, and behaviors and what we would
life and are in the service of important goals or values we hold. label "abnormal." Once an individual's behaviors or feelings
Sometimes, however, we all have thoughts that upset us, experi- crossed that line, we would be just if ied in saying that there is
ence feelings we'd rather not have, and act in ways that are self- something wrong with that person or that he or she has a dis-
defeating or detrimental to others. We may find ourselves in order. As we discuss in this chapter and throughout this book,
situations in which we can't think, feel or behave as others however, there is increasing evidence that no such dividing
would-for example, we can 't let go of a failed relat ionship. We line exists, perhaps for any of the mental health problems that
may become upset over a situation that others don't find distress- are currently recognized . We make decisions about whe re to
ing, such as getting an average grade on an exam. Our thoughts, draw the line that indicates a sufficient amount of abnormality
feelings, or behaviors may be interfering with our functioning in to warrant a diagnosis or treatment. You will see that this
everyday life, for example, if we become afraid to walk alone after continuum model of abnormality applies to all the disorders
being mugged. Or we may be acting in ways that are dangerous we discuss in this book. In this chapter, we discuss some of the
to- ourselves or others, such as driving a car when intoxicated. factors that influence how thoughts, emotions, and behaviors
Problems in thoughts, feelings, and behavior vary from are labeled abnormal.
normal to abnormal, as illustrated in the diagram above. We'd
Abnormality Along the Continuum 3

4 Chapter 1 Looking at Abnormality
Extraordinary People
My illness began slowly, gradually, when I was be- cliffs along the side of the road took on a human
tween the ages of 15 and 17. During that time reality appearance, and I perceived them as women, be-
became distant and I began to wander around in a draggled and weeping. At the time I didn't know
sort of haze, foreshadowing the delusional world what to make of these changes in my perceptions.
that was to come later. I also began to have visual On the one hand, I thought they came as a gift from
hallucinations in which people changed into different God, but on the other hand, I feared that something
characters, the change indicating to me their moral was dreadfully wrong. However, I didn't tell anyone
value. For example, the mother of a good friend al- what was happening; I was afraid of being called
ways changed into a witch, and I believed this to be insane. I also feared, perhaps incredibly, that some-
indicative of her evil nature. Another type of visual one would take it lightly and tell me nothing was
hallucination I had at this time is exemplified by an wrong, that I was just having a rough adolescence,
occurrence during a family trip through Utah: The which was what I was telling myself.
Sou rce: (Anonymous, 1992, "First person account: Portrait of a schizophrenic." Schizophrenia Bulletin, 18, pp. 333-334)
The study of abnormal psychology is the study of In this book, we explore the lives of people
people, like the young woman in the Extraordinary with troubling psychological symptoms to un-
People feature, who suffer mental, emotional, and derstand how they think, what they feel, and
often physical pain, often referred to as psychopa- how they behave. We investigate what is known
thology. Sometimes the experiences of people with about the causes of these symptoms and the
psychopathology are as unusual as those this appropriate treatments for them. The purpose
young woman describes. Sometimes, however, of this book is not only to provide you with in-
people with psychopathology have experiences formation, facts and figures, theories, and re-
that are familiar to many of us but more extreme, search but also to help you understand the
as Kay Redfield Jamison (1995, p. 110) describes in experience of people with psychological symp-
An Unquiet Mind. toms. The good news is that, thanks to an explo-
sion of research in the past few decades, effective
biological and psychological treatments are
available for many of the mental health prob-
PROFILES lems we discuss.
From the time I woke up in the morning until the

time I went to bed at night, I was unbearably mis-
erable and seemingly incapable of any kind of joy
or enthusiasm. Everything -every thought, word, DEFINING ABNORMALITY
movement-was an effort. Everything that once
was sparkling now was flat. I seemed to myself to In popular culture, there are a lot of words for
be dull, boring, inadequate, thick brained, unlit, people and behaviors that seem abnormal:
unresponsive, chill skinned, bloodless, and spar- around the bend, bananas, barmy, batty, berserk,
row drab. I doubted, completely, my ability to do bonkers, cracked, crazy, cuckoo, daft, delirious,
anything well. It seemed as though my mind had demented, deranged, dingy, erratic, flaky,
slowed down and burned out to the point of being flipped out, freaked out, fruity, insane, kooky,
virtually useless. The wretched, convoluted, and lunatic, mad, mad as a March hare, mad as a hat-
pathetically confused mass of gray worked only ter, maniacal, mental, moonstruck, nuts, nutty,
well enough to torment me with a dreary litany of nutty as a fruitcake, of unsound mind, out of
my inadequacies and shortcomings in character one's mind, out of one's tree, out to lunch, potty,
and to taunt me with the total, the desperate psycho, screw loose, screwball, screwy, silly,
hopelessness of it all. touched, unbalanced, unglued, unhinged, un-
zipped, wacky. People talk as if they have an in-
(www.randomhouse.com. For on-line information about other
Random House, Inc. books and authors, see the internet web tuitive sense of what abnormal behavior is. Let's
site at http://www.randomhouse.com) explore some of the ways abnormality has been
defined.
Defining Abnormality 5
Mental Illness
A common belief is that behaviors, thoughts, or
feelings can be viewed as pathological or abnor-
mal if they are symptoms of a mental illness. This
implies that a disease process, much like hyper-
tension or diabetes, is present. For example, when
many people say that an individual "has schizo-
phrenia" (which is characterized by unreal per-
ceptions and severely irrational thinking), they
imply that he or she has a disease that should
show up on some sort of biological test, just as
hypertension shows up when a person's blood
pressure is taken.
To date, however, no biological test is avail-
able to diagnose any of the types of abnormality
we discuss in this book (Hyman, 2010). This is not
just because we do not yet have the right biologi- In Mexico. some Christians have themselves nailed to a cross to commemorate
cal tests. Modern conceptualizations of mental the crucifixion of Jesus.
disorders view them not as singular diseases with
a common pathology that can be identified in all
people with the disorder. Rather, mental health
experts view mental disorders as collections of expect that some of the other behaviors listed,
problems in thinking or cognition, in emotional such as driving a nail through one's hand or
responding or regulation, and in social behavior barking like a dog, are abnormal in all circum-
(Hyman, 2010; Insel et al., 2010; Sanislow et al., stances, yet even these behaviors are accepted in
2011). Thus, for example, a person diagnosed certain situations. In Mexico, some Christians
with schizophrenia has a collection of problems have themselves nailed to crosses on Good Fri-
in rational thinking and in responding emotion- day to commemorate the crucifixion of Jesus.
ally and behaviorally in everyday life, and it is Among the Yoruba of Africa, traditional healers
this collection of problems that we label schizo- act like dogs during healing rituals (Murphy,
phrenia. It is still possible, and in the case of 1976). Thus, the context, or circumstances sur-
schizophrenia likely, that biological factors are as- rounding a behavior, influences whether the be-
sociated with these problems in thinking, feeling, havior is viewed as abnormal.
and behaving. But it is unlikely that a singular Cultural norms play a large role in defining
disease process underlies the symptoms we call abnormality. A good example is the behaviors peo-
schizophrenia. ple are expected to display when someone they
love dies. In cultures dominated by Shinto and
Cultural Norms Buddhist religions, it is customary to build altars
to honor dead loved ones, to offer them food and
Consider these behaviors: gifts, and to speak with them as if they were in the
1. A man driving a nail through his hand room (Stroebe, Gergen, Gergen, & Stroebe, 1992).
In cultures dominated by Christian and Jewish
2. A woman refusing to eat for several days
religions, such practices would potentially be con-
3. A man barking like a dog and crawling on the sidered quite abnormal.
floor on his hands and knees Cultures have strong norms for what is con-
4. A woman building a shrine to her dead sidered acceptable behavior for men versus
husband in her living room and leaving women, and these gender-role expectations also
food and gifts for him at the altar influence the labeling of behaviors as normal or
abnormal (Addis, 2008). In many cultures, men
Do you think these behaviors are abnormal? You who display sadness or anxiety or who choose to
may reply, "It depends." Several of these behav- stay home to raise their children while their
iors are accepted in certain circumstances. In wives work are at risk of being labeled abnormal,
many religious traditions, for example, refusing while women who are aggressive or who don't
to eat for a period of time, or fasting, is a com- want to have children are at risk of being labeled
mon ritual of cleansing and penitence. You might abnormal.
Cultural relativism is the view that there are position recognize that culture and gender have a
no universal standards or rules for labeling a number of influences on the expression of abnor-
behavior abnormal; instead, behaviors can be mal behaviors and on the way those behaviors are
labeled abnormal only relative to cultural norms treated. First, culture and gender can influence the
(Snowden & Yamada, 2005). The advantage of ways people express symptoms. People who lose
this perspective is that it honors the norms and touch with reality often believe that they have di-
traditions of different cultures, rather than im- vine powers, but whether they believe they are
posing the standards of one culture on judgments Jesus or Mohammed depends on their religious
of abnormality. Yet opponents of cultural relativ- background.
ism argue that dangers arise when cultural norms Second, culture and gender can influence peo-
are allowed to dictate what is normal or abnor- ple's willingness to admit to certain types of be-
mal. In particular, psychiatrist Thomas Szasz haviors or feelings (Snowden & Yamada, 2005).
(1971) noted that, throughout history, societies People in Eskimo and Tahitian cultures may be re-
have labeled individuals and groups abnormal luctant to admit to feeling anger because of strong
in order to justify controlling or silencing them. cultural norms against the expression of anger.
Hitler branded Jews abnormal and used this label The Kaluli of New Guinea and the Yanomamo of
as one justification for the Holocaust. The former Brazil, however, value the expression of anger and
Soviet Union sometimes branded political dissi- have elaborate and complex rituals for expressing
dents mentally ill and confined them in mental it (Jenkins, Kleinman, & Good, 1991).
hospitals. When the slave trade was active in the Third, culture and gender can influence the
United States, slaves who tried to escape their types of treatments deemed acceptable or helpful
masters could be diagnosed with a mental dis- for people exhibiting abnormal behaviors. Some
ease that was said to cause them to desire free- cultures may view drug therapies for psychopa-
dom; the prescribed treatment for this disease thology as most appropriate, while others may be
was whipping and hard labor (Cartwright, 1851, more willing to accept psychotherapy (Snowden &
quoted in Szasz, 1971). Yamada, 2005). Throughout this book, we will ex-
Most mental health professionals these days plore these influences of culture and gender on be-
do not hold an extreme relativist view on abnor- haviors labeled abnormal.
mality, recognizing the dangers of basing defini-
tions of abnormality solely on cultural norms. Yet
even those who reject an extreme cultural-relativist
The Four Ds of Abnormality
If we do not want to define abnormality only on
the basis of cultural norms, and if we cannot de-
fine abnormality as the presence of a mental ill-
ness because no singular, identifiable disease
process underlies most psychological problems,
how do we define abnormality? Modern judg-
ments of abnormality are influenced by the inter-
play of four dimensions, often called "the four
Ds": dysfunction, distress, deviance, and danger-
ousness. Behaviors, thoughts, and feelings are
dysfunctional when they interfere with the per-
son's ability to function in daily life, to hold a job,
or to form close relationships. The more dysfunc-
tional behaviors and feelings are, the more likely
they are to be considered abnormal by mental
health professionals. For example, thinking that is
out of touch with reality (for example, believing
you are Satan and should be punished) makes it
difficult to function in everyday life and so is con-
sidered dysfunctional.
Behaviors and feelings that cause distress to
When the slave trade was active, slaves who tried to escape were sometimes the individual or to others around him or her are
labeled as having mental illness and were beaten to cure them . also likely to be considered abnormal. Many of the
problems we discuss in this book cause individuals
Historical Perspectives on Abnormality 7
SHADES OF GRAY
Consider the following descriptions of two Mark is what you might call a "heavy drinker:'
students. Although he is only 18, he has ready access to al-
cohol, and most nights he typically drinks at least
In the year between her eighteenth and nineteenth five or six beers. He rarely feels drunk after that
birthdays, Jennifer, who is 5'6", dropped from a much alcohol, though, so he might also throw back
weight of 125 pounds to 105 pounds. The weight a few shots, especially when he is out partying on
loss began when Jennifer had an extended case of Saturday nights. He's gotten caught a few times
the flu and lost 10 pounds. Friends complimented and received tickets for underage drinking, but he
her on being thinner, and Jennifer decided to lose proudly displays them on his dorm wall as badges
more weight. She cut her intake of food to about of honor. Mark's grades are not what they could be,
1,200 calories, avoiding carbs as much as possible, but he finds his classes boring and has a hard time
and began running a few miles every day. Sometimes doing the work.
she is so hungry she has trouble concentrating on
her schoolwork. Jennifer values her new lean look Do you find Jennifer's or Mark's behaviors abnor-
so much, however, that she is terrified of gaining the mal? How would you rate their level of dysfunc-
weight back. Indeed, she'd like to lose a few more tion, distress, deviance, and danger? (Discussion
pounds so she could fit into a size 2. appears at the end of this chapter.)
tremendous emotional and even physical pain; HISTORICAL PERSPECTIVES

in other cases, the person diagnosed with a dis-
order is not in distress but causes others distress, ON ABNORMALITY
for example, through chronic lying, stealing, or Across history, three types of theories have been
violence. used to explain abnormal behavior. The biological
Highly deviant behaviors, such as hearing theories have viewed abnormal behavior as simi-
voices when no one else is around, lead to judg- lar to physical diseases, caused by the breakdown
ments of abnormality. What is deviant is influ- of systems in the body. The appropriate cure is
enced by cultural norms, of course. Finally, some the restoration of bodily health. The supernatural
behaviors and feelings are of potential harm to the theories have viewed abnormal behavior as a result
individual, such as suicidal gestures, or to others, of divine intervention, curses, demonic possession,
such as excessive aggression. Such dangerous be- and personal sin. To rid the person of the perceived
haviors and feelings are often seen as abnormal. affliction, religious rituals, exorcisms, confessions,
The four Ds together make up mental health and atonement have been prescribed. The psycho-
professionals' definition of behaviors or feelings as logical theories have viewed abnormal behavior
abnormal or maladaptive. The experiences of the as a result of traumas, such as bereavement, or of
woman described in Extraordinary People and the chronic stress. According to these theories, rest, re-
feelings related by Jamison, presented at the begin- laxation, a change of environment, and certain
ning of this chapter, would be labeled abnormal herbal medicines are sometimes helpful. These
based on these criteria because the symptoms in- three types of theories have influenced how people
terfere with these people's daily functioning, cause acting abnormally have been regarded in the soci-
them suffering, are highly unusual, and are poten- ety. A person thought to be abnormal because he or
tially dangerous to them. she was a sinner, for example, would be regarded
We are still left making subjective judgments, differently from a person thought to be abnormal
however. How much emotional pain or harm must because of a disease.
a person be suffering? How much should the be-
haviors be interfering with daily functioning? We
return to the continuum model to acknowledge
Ancient Theories
that each of the four Ds lies along its own contin- Our understanding of prehistoric people's con-
uum. A person's behaviors and feelings can be ceptions of abnormality is based on inferences
more or less dysfunctional, distressing, deviant, or from archaeological artifacts-fragments of bones,
dangerous. Thus, there is no sharp line between tools, artwork, and so on-as well as from ancient
what is normal and what is abnormal. writings about abnormal behavior. It seems that
humans have always viewed abnormality as some-

thing needing special explanation.
Driving Away Evil Spirits

Historians speculate that even prehistoric people
had a concept of insanity, probably one rooted in
supernatural beliefs (Selling, 1940). A person who
acted oddly was suspected of being possessed by
evil spirits. The typical treatment for abnormality,
according to supernatural theories, was exorcism-
driving the evil spirits from the body of the suf-
fering person. Shamans, or healers, would recite
prayers or incantations, try to talk the spirits out
of the body, or make the body an uncomfortable
place for the spirits to reside-often through ex-
treme measures such as starving or beating the
person. At other times, the person thought to
be possessed by evil spirits would simply
Some of the earliest writings on mental d isorders are
be killed. from ancient Chinese texts. This illustration shows a
One treatment for abnormality during the healer at work.
Stone Age and well into the Middle Ages may have
been to drill holes in the skull of a person display-
ing abnormal behavior to allow the spirits to depart
(Feldman & Goodrich, 2001) . Archaeologists have
each other. If the two forces were in balance, the
found skulls dating back to a half-million years ago individual was healthy. If not, illness, including
in which sections of the skull have been drilled or
insanity, could result. For example, excited insan-
cut away. The tool used for this drilling is called a
ity was considered the result of an excessive posi-
trephine, and the operation is called trephination.
tive force:
Some historians believe that people who were
seeing or hearing things that were not real The person suffering from excited insan-
and people who were chronically sad were sub- ity initially feels sad, eating and sleeping
Some scholars
jected to this form of brain surgery (Feldman & less; he then becomes grandiose, feeling
believe that holes Goodrich, 2001). Presumably, if the person that he is very smart and noble, talking
found in ancient survived this surgery, the evil spirits would have and scolding day and night, singing, be-
skulls are from been released and the person's abnormal behav- having strangely, seeing strange things,
trephination. a ior would decline. However, we cannot know hearing strange voices, believing that he
crude form of
surgery possibly with certainty that trephination was used to can see the devil or gods, etc. As treat-
performed on drive away evil spirits. Other historians suggest ment for such an excited condition with-
people acting that it was used primarily for the removal of holding food was suggested, since food
abnormally. blood clots caused by stone weapons during was considered to be the source of posi-
warfare and for other medical purposes (Maher tive force and the patient was thought to
& Maher, 1985). be in need of a decrease in such force.
(Tseng, 1973, p. 570)
Ancient Chino: Balancing Yin Chinese medical philosophy also held that
and Yang human emotions were controlled by internal or-
Some of the earliest written sources on abnormal- gans. When the "vital air" was flowing on one of
ity are ancient Chinese medical texts (Tseng, 1973). these organs, an individual experienced a particu-
Nei Ching (Classic of Internal Medicine) was prob- lar emotion. For example, when air flowed on the
ably written around 2674 BCE by Huang Ti, the leg- heart, a person felt joy; when on the lungs, sorrow;
endary third emperor of China. when on the liver, anger; when on the spleen,
Ancient Chinese medicine was based on the worry; and when on the kidney, fear. This theory ~
concept of yin and yang. The human body was said encouraged people to live in an orderly and har-
to contain a positive force (yang) and a negative monious way so as to maintain the proper move-
force (yin), which confronted and complemented ment of vital air.
Although the perspective on psychological For the most part, however, Greek physicians
symptoms represented by ancient texts was largely rejected supernatural explanations of abnormal
a biological one, the rise of Taoism and Buddhism behavior (Wallace & Gach, 2008). Hippocrates, of-
during the Chin and T'ang dynasties (420-618 CE) ten regarded as the father of medicine, argued that
led to some religious interpretations of abnormal abnormal behavior was like other diseases of the
behavior. Evil winds and ghosts were blamed for body. According to Hippocrates, the body was
bewitching people and for inciting people's erratic composed of four basic humors: blood, phlegm,
emotional displays and uncontrolled behavior. yellow bile, and black bile. All diseases, including
Religious theories of abnormality declined in abnormal behavior, were caused by imbalances
China after this period (Tseng, 1973). in the body's essential humors. Based on careful
observation of his many patients, which included
Ancient Egypt, Greece, and Rome: listening to their dreams, Hippocrates classified
Biological Theories Dominate abnormal behavior into four categories: epilepsy,
Other ancient writings on abnormal behavior are mania, melancholia, and brain fever.
found in the papyri of Egypt and Mesopotamia The treatments prescribed by the Greek physi-
(Veith, 1965). The oldest of these, a document known cians were intended to restore the balance of the
as the Kahun Papyrus after the ancient Egyptian city four humors. Sometimes these treatments were
in which it was found, dates from about 1900 BCE. physiological and intrusive, for example, bleeding
This document lists a number of disorders, each fol- a patient to treat disorders thought to result from
lowed by a physician's judgment of the cause of the an excess of blood. Other treatments consisted of
disorder and the appropriate treatment. rest, relaxation, a change of climate or scenery, a
Several of the disorders apparently left people change of diet, or living a temperate life. Some
with unexplainable aches and pains, sadness or nonmedical treatments prescribed by these physi-
distress, and apathy about life, such as "a woman cians sound remarkably like those prescribed by
who loves bed; she does not rise and she does not modern psychotherapists. Hippocrates, for exam-
shake it" (Veith, 1965, p . 3). These disorders were ple, believed that removing a patient from a diffi-
said to occur only in women and were attributed cult family could help restore mental health. Plato
to a "wandering uterus." The Egyptians believed argued that insanity arose when the rational mind
that the uterus could become dislodged and wan- was overcome by impulse, passion, or appetite.
der throughout a woman's body, interfering with Sanity could be regained through a discussion
her other organs. Later, the Greeks, holding to the with the individual designed to restore rational
same theory of anatomy, named this disorder hys- control over emotions (Maher & Maher, 1985).
teria (from the Greek word hystera, which means Among the Greeks of Hippocrates' and Plato's
"uterus"). These days, the term hysteria is used to time, the relatives of people considered insane were
refer to physiological symptoms that probably are encouraged to confine their afflicted family mem-
the result of psychological processes. In the Egyp- bers to the home. The state claimed no responsibility
tian papyri, the prescribed treatment for this disor- for insane people; it provided no asylums or institu-
der involved the use of strong-smelling substances tions, other than the religious temples, to house and
to drive the uterus back to its proper place. care for them. The state could, however, take rights
Beginning with Homer, the Greeks wrote away from people declared insane. Relatives could
frequently of people acting abnormally (Wallace bring suit against those they considered insane, and
& Gach, 2008). The physician Hippocrates the state could award the property of insane people
(460-377 BCE) described a case of a common pho- to their relatives. People declared insane could not
bia: A man could not walk alongside a cliff, pass marry or acquire or dispose of their own property.
over a bridge, or jump over even a shallow ditch Poor people who were considered insane were sim-
without feeling unable to control his limbs and ply left to roam the streets if they were not violent. If
having his vision impaired. they were violent, they were locked away. The gen-
Most Greeks and Romans saw abnormal eral public greatly feared insanity of any form, and
behavior as an affliction from the gods. Those people thought to be insane often were shunned or
afflicted retreated to temples honoring the god even stoned (Maher & Maher, 1985).
Aesculapius, where priests held healing ceremo-
nies. Plato (423-347 BCE) and Socrates (469-399 BCE)
argued that some forms of abnormal behavior were
Medieval Vi ews
divine and could be the source of great literary and The Middle Ages (around 400-1400 CE) are often de-
prophetic gifts. scribed as a time of backward thinking dominated
by an obsession with supernatural forces, yet even centuries-the period known as the Renaissance
within Europe supernatural theories of abnormal (Mora, 2008).
behavior did not dominate until the late Middle Some psychiatric historians have argued that
Ages, between the eleventh and fifteenth centu- persons accused of witchcraft must have been
ries (Neugebauer, 1979). Prior to the eleventh cen- mentally ill (Veith, 1965; Zilboorg & Henry, 1941).
tury, witches and witchcraft were accepted as real Accused witches sometimes confessed to speaking
but were considered mere nuisances, overrated by with the devil, flying on the backs of animals, or
superstitious people. Severe emotional shock and engaging in other unusual behaviors. Such people
physical illness or injury most often were seen as may have been experiencing delusions (false be-
the causes of bizarre behaviors. For example, Eng- liefs) or hallucinations (unreal perceptual experi-
lish court records attributed mental health prob- ences), which are signs of some psychological
lems to factors such as a "blow received on the disorders. However, confessions of such experi-
head," explained that symptoms were "induced ences may have been extracted through torture or
by fear of his father," and noted that "he has lost in exchange for a stay of execution (Spanos, 1978).
his reason owing to a long and incurable infir- In 1563, Johann Weyer published The Decep-
mity" (Neugebauer, 1979, p. 481). While laypeople tion of Dreams, in which he argued that those ac-
probably did believe in demons and curses as cused of being witches were suffering from
causes of abnormal behavior, there is strong evi- melancholy (depression) and senility. The Church
dence that physicians and government officials banned Weyer's writings. Twenty years later, Reg-
attributed abnormal behavior to physical causes inald Scot, in his Discovery of Witchcraft (1584),
or traumas. supported Weyer's beliefs: "These women are but
diseased wretches suffering from melancholy, and
their words, actions, reasoning, and gestures show
Witchcraft
that sickness has affected their brains and im-
Beginning in the eleventh century, the power of the
paired their powers of judgment" (Castiglioni,
Catholic Church in Europe was threatened by the
1946, p. 253). Again, the Church-joined this time
breakdown of feudalism and by rebellions. The
by the state-refuted the arguments and banned
Church interpreted these threats in terms of heresy
Scot's writings.
and Satanism. The Inquisition was established orig-
As is often the case, change came from within.
inally to rid the Earth of religious heretics, but even-
In the sixteenth century, Teresa of Avila, a Spanish
tually those practicing witchcraft or Satanism also
nun who was later canonized, explained that the
became the focus of hunts. The witch hunts contin-
mass hysteria that had broken out among a group
ued long after the Reformation, perhaps reaching
of nuns was not the work of the devil but was the
their height during the fifteenth to seventeenth
result of infirmities or sickness. She argued that
these nuns were comas enfermas, or "as if sick." She
sought out natural causes for the nuns' strange be-
haviors and concluded that they were due to mel-
ancholy, a weak imagination, or drowsiness and
sleepiness (Sarbin & Juhasz, 1967).
The culture so completely accepted the exis-
tence of witches and witchcraft that some per-
fectly sane people may have self-identified as
witches. In addition, most writings of medieval
and Renaissance times, as well as writings from
the witch hunt period in Salem, Massachusetts,
clearly distinguish between people who were mad
and people who were witches. The distinction be-
tween madness and witchcraft continues to this
day in cultures that believe in witchcraft.
Psychic Epidemics
Psychic epidemics are defined as a phenomenon in
which large numbers of people engage in unusual
Some people burned at the stake as witches may have had mental disorders behaviors that appear to have a psychological origin.
that caused them to act abnormally. During the Middle Ages, reports of dance frenzies or
manias were frequent. A monk, Peter of Herental,
described a rash of dance frenzies that broke out over headache, and nausea. Although some initially
a 4-month period in 1374 in Germany: showed symptoms of mild carbon monoxide in-
toxication in blood tests, no evidence of toxic gas
Both men and women were abused by the in the school could be found. The physicians treat-
devil to such a degree that they danced in ing the children and teachers concluded that the
their homes, in the churches and in the outbreak was a case of mass hysteria prompted by
streets, holding each other's hands and the fear of chemical warfare during the Persian
leaping in the air. While they danced they Gulf War (Rockney & Lemke, 1992).
called out the names of demons, such as Psychic epidemics are no longer viewed as the
Friskes and others, but they were unaware result of spirit possession or the bite of a tarantula.
of this nor did they pay attention to mod- Rather, psychologists attempt to understand th~m
esty even though people watched them. At through research from social psychology on them-
the end of the dance, they felt such pains in fluence of others on individuals' self-perceptions.
the chest, that if their friends did not tie The social context can affect even our perceptions
linen clothes tightly around their waists, of our own bodies, as we will see when we discuss
they cried out like madmen that they were people's differing reactions to psychoactive sub-
dying. (cited in Rosen, 1968, pp. 196-197) stances such as marijuana (see Chapter 14) and
Other instances of dance frenzy were reported in people's interpretations of their physical sensa-
1428 during the feast of Saint Vitus, at Schaffhausen, tions (see Chapter 6).
at which a monk danced himself to death. In 1518,
a large epidemic of uncontrolled dance frenzy ~c The Spread of Asylums
curred at the chapel of Saint Vitus at Hohlenstem,
As early as the twelfth century, many t~wns in
near Zabem. According to one account, more than
Europe took some responsibility for housmg and
400 people danced during the 4 weeks the frenzy caring for people considered mentally ill (Kroll,
lasted. Some writers of the time began to call the
1973). Remarkable among these towns was Gheel,
frenzied dancing Saint Vitus' dance.
Belgium, where townspeople regularly too~ into
A similar phenomenon, tarantism, was noted
their homes the mentally ill visiting the shrme of
in Italy as early as the fourteenth century and be-
Saint Dymphna for cures.
came prominent in the seventeenth century. Peo-
In about the eleventh or twelfth century, general
ple suddenly developed an acute pain, w~ch they
hospitals began to include special rooms or facilities
attributed to the bite of a tarantula. They JUmped
for people exhibiting abnormal behavior. The men-
around and danced wildly in the streets, tearing at
tally ill were little more than inmates in these early
their clothes and beating each other with whips.
hospitals, housed against their will, often in ex-
Some people dug holes in the earth and rolled on
tremely harsh conditions. One of the most famous of
the ground; others howled and made obscene ges-
these hospitals was the Hospital of Saint Mary of
tures. At the time, many people interpreted dance
Bethlehem, in London, which officially became a
frenzies and tarantism as the results of possession
mental hospital in 1547. This hospital, nicknamed
by the devil. The behaviors may have been the
Bedlam, was famous for its deplorable conditions.
remnants of ancient rituals performed by people
At Bedlam and other mental hospitals established
worshipping the Greek god Dionysus.
in Europe in the sixteenth, seventeenth, and eigh-
We see episodes of psychic epidemics in mod-
teenth centuries, patients were exhibited to the pub-
em times. On February 8, 1991, a number of stu-
lic for a fee. They lived in filth and confinement, often
dents and teachers in a high school in Rhode Island
chained to the wall or locked inside small boxes. The
thought they smelled noxious fumes coming from
following description of the treatment of patients in
the ventilation system. The first person to detect
La Bid~tre Hospital, an asylum for male patients in
these fumes, a 14-year-old girl, fell to the floor, cry-
Paris, provides an example of typical care:
ing and saying that her stomach hurt and her eyes
stung. Other students and the teacher in that room The patients were ordinarily shackled to
then began to experience symptoms. They were the walls of their dark, unlighted cells by
moved into the hallway with a great deal of com- iron collars which held them flat against
motion. Soon students and teachers from adjacent the wall and permitted little movement.
rooms, who could see clearly into the hallway, be- Ofttimes there were also iron hoops around
gan to experience symptoms. Eventually, 21 peo- the waists of the patients and both their
ple (17 students and 4 teachers) were admitted to hands and feet were chained. Although
the local hospital emergency room. All were hy- these chains usually permitted enough
perventilating, and most complained of dizziness, movement that the patients could feed
12 Chapter 1 Looking at Abnorma lity
themselves out of bowls, they often kept

them from being able to lie down at night.
Since little was known about dietetics, and
the patients were presumed to be animals
anyway, little attention was paid to whether
they were adequately fed or whether the
food was good or bad. The cells were fur-
nished only with straw and were never
swept or cleaned; the patient remained in
the midst of all the accumulated ordure. No
one visited the cells except at feeding time,
no provision was made for warmth, and
even the most elementary gestures of hu-
manity were lacking. (Adapted from
Selling,1940,pp.54-55)
The laws regarding the confinement of the
mentally ill in Europe and the United States were
concerned with the protection of the public and the
ill person's relatives (Busfield, 1986; Scull, 1993).
For example, Dalton's 1618 edition of Common Law
states that "it is lawful for the parents, kinsmen or
other friends of a man that is mad, or frantic ... to
take him and put him into a house, to bind or chain
him, and to beat him with rods, and to do any other
forcible act to reclaim him, or to keep him so he
shall do no hurt" (Allderidge, 1979).
The first Act for Regulating Madhouses in In the medieval and early modern periods. doctors used
England was passed in 1774, with the intention of bleeding to treat people with mental d isorders and
cleaning up the deplorable conditions in hospitals many other ailments .
and madhouses and protecting people from being
unjustly jailed for insanity. This act provided for
the licensing and inspection of madhouses and re-
admitted. The act's provisions applied only to pay-
quired that a physician, a surgeon, or an apothe-
ing patients in private madhouses, however, and
cary sign a certificate before a patient could be
not to the poor people confined to workhouses.
These asylums typically were established and
run by people who thought that abnormal behav-
iors were medical illnesses. For example, Benjamin
Rush (1745- 1813), one of the founders of American
psychiatry, believed that abnormal behavior was
caused by excessive blood in the brain and pre-
scribed bleeding the patient, or drawing huge
amounts of blood from the body. Thus, although
the supernatural theories of the Middle Ages have
often been decried as leading to brutal treatment of
people with mental illnesses, the medical theories
of those times and of the next couple of centuries
did not always lead to better treatment.
Moral Treatment
in the Eighteenth
and Nineteenth Centuries
Bedlam- the Hospital of Saint Mary of Bethlehem in London- was famous for
The eighteenth and nineteenth centuries saw the
the chaotic and deplorable conditions in which people with mental d isorders
were kept. growth of a more humane treatment of people with
mental health problems, a period known as the
mental hygiene movement. This new treatment

was based on the psychological view that people
developed problems because they had become sep-
arated from nature and had succumbed to the
stresses imposed by the rapid social changes of the
period (Rosen, 1968). The prescribed treatment, in-
cluding prayers and incantations, was rest and re-
laxation in a serene and physically appealing place.
A leader of the movement for moral treatment
of people with abnormality was Philippe Pinel
(1745-1826), a French physician who took charge of
La Bicetre in Paris in 1793. Pinel argued, "To detain
maniacs in constant seclusion and to load them
with chains; to leave them defenceless, to the bru-
tality of underlings ... in a word, to rule them with
a rod of iron . . . is a system of superintendence,
more distinguished for its convenience than for its
humanity or success" (Grob, 1994, p. 27). Pinel be- Philippe Pinel. a leader in the moral movement in France, helped free mental
patients from the horrible conditions of the hospitals.
lieved that many forms of abnormality could be
cured by restoring patients' dignity and tranquility.
Pinel ordered that patients be allowed to walk
freely around the asylum. They were provided of laws and appropriations to fund the cleanup of
with clean and sunny rooms, comfortable sleeping mental hospitals and the training of mental health
quarters, and good food. Nurses and professional professionals dedicated to the moral treatment of
therapists were trained to work with the patients patients. Between 1841 and 1881, Dix personally
to help them regain their sense of tranquility and helped establish more than 30 mental institutions in
engage in planned social activities. Although many the United States, Canada, Newfoundland, and
physicians thought Pinel himself was mad for re- Scotland. Hundreds of more public hospitals for the
leasing the patients from confinement, his ap- insane established during this period by others were
proach was remarkably successful. Many people run according to humanitarian perspectives.
who had been locked away in darkness for de- Unfortunately, the moral treatment movement
cades became able to control their behavior and grew too fast. As more asylums were built and
reengage in life. Some improved so much that they more people went into them, the
could be released from the asylum. Pinel later suc- capacity of the asylums to recruit
cessfully reformed La Salpetriere, a mental hospi- mental health professionals and
tal for female patients in Paris (Grob, 1994). to maintain a humane, individual
In 1796, the Quaker William Tuke (1732-1822) approach to each patient declined
opened an asylum in England, called The Retreat, (Grob, 1994; Scull, 1993). The phy-
in direct response to the brutal treatment he saw sicians, nurses, and other caretak-
being delivered at other facilities to people with ers simply did not have enough
abnormal behavior. Tuke' s treatment was designed time to give each patient the calm
to restore patients' self-restraint by treating them and dedicated attention needed.
with respect and dignity and encouraging them to The fantastic successes of the early
exercise self-control (Grob, 1994). moral treatment movement gave
One of the most militant crusaders for moral way to more modest successes,
treatment of the insane was Dorothea Dix (1802- and to many outright failures, as
1887). A retired schoolteacher living in Boston, Dix patients remained impaired or
visited a jail on a cold Sunday morning in 1841 to their condition worsened. Even
teach a Sunday school class to women inmates. some patients who received the
There she discovered the negligence and brutality best moral treatment could not
that characterized the treatment of poor people ex- benefit from it because their prob-
hibiting abnormal behavior, many of whom were lems were not due to a loss of dignity or tranquility. Dorothea Dix
simply warehoused in jails. With so many patients receiving moral treatment, fought for the
That encounter began Dix's tireless quest to im- the number of patients who failed to benefit from moral treatment of
mental patients in
prove the treatment of people with mental health it increased, and questions about its effectiveness the United States.
problems. Dix's lobbying efforts led to the passage grew louder (Grob, 1994).
At the same time, the rapid pace of immigra- systems, as we will discuss in Chapter 3. Having a
tion into the United States in the late nineteenth good classification system gives investigators a com-
century meant that an increasing percentage of its mon set of labels for disorders as well as a set of cri-
asylum patients were from different cultures and teria for distinguishing between them, contributing
often from the lower socioeconomic classes. Preju- immensely to the advancement of the scientific
dice against these "foreigners," combined with in- study of the disorders.
creasing attention to the failures of moral treatment, One of the most important discoveries under-
led to declines in public support for funding such pinning modern biological theories of abnormality
institutions. Reduced funding led to even greater was the discovery of the cause of general paresis, a
declines in the quality of care. At the turn of the disease that leads to paralysis, insanity, and eventu-
twentieth century, many public hospitals were no ally death (Duffy, 1995). In the mid-1800s, reports
better than warehouses (Grob, 1994; McGovern, that patients with paresis also had a history of syph-
1985; Scull, 1993). ilis led to the suspicion that syphilis might be a cause
Effective treatments for most major mental of paresis. In 1897, Viennese psychiatrist Richard
health problems were not developed until well into Krafft-Ebing injected paretic patients with matter
the twentieth century. Until then, patients who from syphilitic sores. None of the patients devel-
could not afford private care were warehoused in oped syphilis, and Krafft-Ebing concluded that they
large, overcrowded, physically isolated state insti- must already have been infected with it. The discov-
tutions that did not offer treatment (Deutsch, 1937). ery that syphilis is the cause of one form of insanity
lent great weight to the idea that biological factors
can cause abnormal behaviors (Duffy, 1995).
THE EMERGENCE OF As we will discuss in more detail in Chapter 2,
MODERN PERSPECTIVES modern biological theories of the psychological
disorders have focused on the role of genetics,
Although the treatment of people who exhibited ab- structural and functional abnormalities in the
normal behavior deteriorated somewhat at the turn brain, and biochemical imbalances. The advances
of the twentieth century, the early twentieth century in our understanding of the biological aspects of
saw tremendous advances in the scientific study of psychological disorders have contributed to the
disorders. These advances laid the groundwork for development of therapeutic medications.
the biological, psychological, and social theories of
abnormality that now dominate psychology and
psychiatry. The Psychoanalytic Perspective
The development of psychoanalytic theory be-
The Beginnings of gins with the odd story of Franz Anton Mesmer
Modern Biological (1734-1815), an Austrian physician who believed
Perspectives that people have a magnetic fluid in the body that
must be distributed in a particular pattern in or-
Basic knowledge of the anatomy, der to maintain health. The distribution of mag-
physiology, neurology, and chemistry netic fluid in one person could be influenced by
of the body increased rapidly in the the magnetic forces of other people, as well as by
late nineteenth century. With the ad- the alignments of the planets. In 1778, Mesmer
vancement of this basic knowledge opened a clinic in Paris to treat all sorts of dis-
came an increasing focus on biol- eases by applying animal magnetism.
ogical causes of abnormality. In The psychological disorders that were the focus
1845, German psychiatrist Wilhelm of much of Mesmer's treatment were the hysterical
Griesinger (1817-1868) published The disorders, in which people lose functioning or feel-
Pathology and Therapy of Psychic Disor- ing in some part of the body for no apparent physi-
ders, presenting a systematic argu- ological reason. His patients sat in darkness around
Emil Kraepelin ment that all psychological disorders a tub containing various chemicals, and the affected
(1856-1926) can be explained in terms of brain pathology. In areas of their bodies were prodded by iron rods
developed a 1883, one of Griesinger's followers, Emil Kraepelin emerging from the tub. With music playing, Mesmer
classification (1856-1926), also published a text emphasizing the emerged wearing an elaborate robe, touching each ~
system for mental importance of brain pathology in psychological dis- patient as he passed by, supposedly realigning peo-
disorders that
remains influential orders. More important, Kraepelin developed a ple's magnetic fluids through his own powerful
today. scheme for classifying symptoms into discrete disor- magnetic force. This process, Mesmer said, cured ill-
ders that is the basis for our modern classification ness, including psychological disorders.
The Emergence of Modern Perspectives 15
Mesmer eventually was labeled a charlatan than conscious discussion, allowing the therapist to
by a scientific review committee that included elicit important psychological material more easily.
Benjamin Franklin. Yet his methods, known as Breuer and Freud collaborated on a paper
mesmerism, continued to fuel debate long after he published in 1893 as On the Psychical Mechanisms of
had faded into obscurity. The "cures" Mesmer ef- Hysterical Phenomena, which laid out their discov-
fected in his psychiatric patients were attributed to eries about hypnosis, the unconscious, and the
the trancelike state that Mesmer seemed to induce therapeutic value of catharsis. This paper proved
in his patients. Later, this state was labeled hypno- to be a foundation stone in the development of
sis. Under hypnosis, Mesmer's patients appeared psychoanalysis, the study of the unconscious.
very suggestible, and the mere suggestion that Freud introduced his ideas to America in 1909 in a
their ailments would disappear seemed enough to series of lectures at Clark University in Worcester,
make them actually disappear. Massachusetts, at the invitation of G. Stanley Hall,
The connection between hypnosis and hyste- one of the founders of American psychology.
ria fascinated several leading scientists of the time, Freud wrote dozens of papers and books on
although not all scientists accepted this connec- his theory of psychoanalysis (discussed in detail in
tion. In particular, Jean Charcot (1825-1893), head Chapter 2), and he became the best-known figure
of La Salpetriere Hospital in Paris and the leading in psychiatry and psychology. The impact of
neurologist of his time, argued that hysteria was Freud's theories on the development of psychol-
caused by degeneration in the brain. The work of ogy over the next century cannot be overstated.
two physicians practicing in the French town of Freudian ideas not only influenced the profes-
Nancy, Hippolyte-Marie Bernheim (1840-1919) sional literature on psychopathology but also are
and Ambroise-Auguste Liebault (1823-1904), used heavily in literary theory, anthropology, and
eventually won over Charcot, however. Bernheim other humanities. They pervade popular notions
and Liebault showed that they could induce the of psychological processes to this day.
symptoms of hysteria, such as paralysis in an arm
or the loss of feeling in a leg, by suggesting these The Roots of Behaviorism
symptoms to patients who were hypnotized. For-
In what now seems like a parallel universe, while
tunately, they could also remove these symptoms
psychoanalytic theory was being born, the roots of
under hypnosis. Charcot was so impressed by the
behaviorism were being planted first in Europe and
evidence that hysteria has psychological roots that
then in the United States. Ivan Pavlov (1849- 1936),
he became a leading researcher of the psychologi-
a Russian physiologist, developed methods and
cal causes of abnormal behavior. The experiments
theories for understanding behavior in terms of
of Bernheim and Liebault, along with the leader-
stimuli and responses rather than in terms of the
ship of Charcot, did a great deal to advance psy-
internal workings of the unconscious mind. He
chological perspectives on abnormality.
One of Charcot's students was Sigmund Freud discovered that dogs could be conditioned to sali-
(1856-1939), a Viennese neurologist who went to
vate when presented with stimuli other than
study with Charcot in 1885. In the course of this food if the food was paired with these other
work, Freud became convinced that much of the stimuli-a process later called classical condition-
mental life of an individual remains hidden from ing. Pavlov's discoveries inspired American John
consciousness. This view was further supported by Watson (1878-1958) to study important human
Freud's interactions with Pierre Janet (1859-1947) behaviors, such as phobias, in terms of classical
in Paris. Janet was investigating multiple personal- conditioning (see Chapter 5). Watson rejected psy-
ity disorder, in which people appear to have mul- choanalytic and biological theories of abnormal
tiple, distinct personalities, each of which operates behaviors such as phobias and explained them
independently of the others, often not knowing the entirely on the basis of the individual's history of
others exist (Matarazzo, 1985). conditioning. Watson (1930) went so far as to boast
When he returned to Vienna, Freud worked that he could train any healthy child to become
any kind of adult he wished:
with Josef Breuer (1842-1925), another physician in-
terested in hypnosis and in the unconscious pro- Give me a dozen healthy infants, well-
cesses behind psychological problems. Breuer had formed, and my own specified world to
discovered that encouraging patients to talk about bring them up in, and I'll guarantee
their problems while under hypnosis led to a great to take any one at random and train him to
upwelling and release of emotion, which eventually be any type of specialist I might select-
was called catharsis. The patient's discussion of his doctor, lawyer, artist, merchant-chief,
or her problems under hypnosis was less censored and yes, even beggar-man and thief,
regardless of his talents, penchants, ten- their patients' irrational belief systems. It became
dencies, abilities, vocations, and the race very popular, however, and moved psychology into
of his ancestors . (p. 104) the study of the thought processes behind serious
emotional problems. Another therapy, developed
At the same time, two other psychologists, by Aaron Beck, focused on the irrational thoughts of
E. L. Thorndike (1874-1949) and B. F. Skinner people with psychological problems. Beck's cogni-
(1904-1990), were studying how the conse- tive therapy has become one of the most widely
quences of behaviors shape their likelihood of re- used therapies for many disorders (see Chapter 2).
currence. They argued that behaviors followed by Since the 1970s, theorists have continued to empha-
positive consequences are more likely to be re-
size cognitive factors in psychopathology, although
peated than are behaviors followed by negative
behavioral theories have remained strong as inter-
consequences. This process came to be known as personal theories, which we will examine in Chap-
operant, or instrumental, conditioning. This idea
ter 2, have become more prominent.
may seem simple to us now (one sign of how
much it has influenced thinking over the past
century), but at the time it was considered radical MODERN MENTAL
to argue that even complex behaviors, such as
violence against others, can be explained by the
HEALTH CARE
reinforcement or punishment these behaviors Halfway through the twentieth century, major
have received in the past. breakthroughs were made in drug treatments for
Behaviorism-the study of the impact of rein- some of the major forms of abnormality. In particu-
forcements and punishments on behavior-has lar, the discovery of a class of drugs that can re-
had as profound an impact on psychology and on duce hallucinations and delusions, known as the
our common knowledge of psychology as has psy- phenothiazines (see Chapter 2), made it possible
choanalytic theory. Behavioral theories have led to for many people who had been institutionalized
many of the effective psychological treatments for for years to be released from asylums and hospi-
disorders that we will discuss in this book. tals. Since then, there has been an explosion of new
drug therapies for psychopathology. In addition,
The Cognitive Revolution as we will discuss in Chapter 2, several types of
psychotherapy have been developed that have
In the 1950s, some psychologists argued that be-
proven effective in treating a wide range of psy-
haviorism was limited in its explanatory power by
chological problems. However, there are still sig-
its refusal to look at internal thought processes that
nificant problems in the delivery of mental health
mediate the relationship between stimulus and re-
care, some of which began with the deinstitution-
sponse. It wasn't until the 1970s that psychology
alization movement of the mid-twentieth century.
shifted its focus substantially to the study of cogni-
tions, thought processes that influence behavior
and emotion. An important player in this cognitive
Deinstitutionalization
revolution was Albert Bandura, a clinical psychol- By 1960, a large and vocal movement known as the
ogist trained in behaviorism who had contributed patients' rights movement had emerged. Patients'
a great deal to the application of behaviorism to rights advocates argued that mental patients can
psychopathology (see Chapters 2 and 5). Bandura recover more fully or live more satisfying lives if
argued that people's beliefs about their ability to they are integrated into the community, with the
execute the behaviors necessary to control impor- support of community-based treatment facilities-
tant events-which he called self-efficacy beliefs- a process known as deinstitutionalization. While
are crucial in determining people's well-being. many of these patients would continue to need
Again, this idea seems obvious to us now, but only around-the-clock care, it could be given in treat-
because it took hold in both professional psychol- ment centers based in neighborhoods rather than
ogy and lay notions of psychology. in large, impersonal institutions. In the United
Another key figure in cognitive perspectives States, the community mental health movement
was Albert Ellis, who argued that people prone to was officially launched in 1963 by President John
psychological disorders are plagued by irrational Kennedy as a "bold new approach" to mental
negative assumptions about themselves and the health care. This movement attempted to provide
world. Ellis developed a therapy for emotional prob- coordinated mental health services to people in
lems based on his theory called rational-emotive community mental health centers.
therapy. This therapy was controversial because it The deinstitutionalization movement had a
required therapists to challenge, sometimes harshly, massive effect on the lives of people with serious
Modern Mental Health Care 17
psychological problems. Between 1955 and 1998, Trends in the Numbers of Psychiatric Beds
the number of patients in state psychiatric hospi- FIGURE 1.1 in Western Europe, 1978-2002
tals in the United States declined from a high of
559,000 to about 57,000, almost a 90 percent reduc- 450 -,-- - - - - - - - - - - - - - - - - -Austria
tion (Lamb & Weinberger, 2001). Parallel trends -Belgium
8 400 -+=~_.....,,..------------------ - Denmark
were seen in Europe (Figure 1.1). Many former o - Finland
0
mental patients who had lived for years in cold, ~ 350 -France
~ -Germany
sterile facilities, receiving little useful care, experi- ~V> 300 ---"~----------- Greece
enced dramatic increases in their quality of life on "' - I cela nd
their release. Moreover, they suddenly had the ~
u
2SO
-+-.......----- -
"'""--.3l"'- __________ -Italy
- rreland
c:
freedom to live where they wanted, as they saw fit. ....., Luxembourg
Several types of community-based treatment
:E 200 Netherlands
~ 1~~~~~~~~~~~~~!~~~
facilities that were created at this time continue to ~ 150 Portugal
b - spain
serve people with mental health problems. Com- OJ 100 -Sweden
munity mental health centers often include teams of E - Norway
Switzerland
~ 50 United Kingdom
social workers, therapists, and physicians who co-
ordinate care. Halfway houses offer people with
long-term mental health problems the opportunity 1980 1985 1990 1995 2000
to live in a structured, supportive environment as
they try to reestablish working relationships and
Source: European health for all database, WHO Regional Office for Europe, 2004. In
ties to family and friends. Day treatment centers McDaid & Thornicroft, 2005.
allow people to obtain treatment during the day,
along with occupational and rehabilitative thera-
pies, but live at home at night.
People with acute problems that require hos- some researchers estimate that up to four-fifths of
pitalization may go to inpatient wards of general all long-term homeless adults in the United States
hospitals or specialized psychiatric hospitals. Some- and Europe have a major mental disorder, a severe
times, their first contact with a mental health pro- substance use disorder (such as alcohol dependence),
fessional is in the emergency room of a hospital. or both (WHO World Mental
Once their acute problems have subsided, how- Health Survey Consortium, 2004).
ever, they often are released back to their commu- In emergencies, these people end
nity treatment center rather than remaining for the up in general or private hospitals
long term in a psychiatric hospital. that are not equipped to treat them
Unfortunately, the resources to care for all the appropriately. Many end up in
mental patients released from institutions have never jail. One study of prison inmates
been adequate. There were not enough halfway found that two-thirds had experi-
houses built or community mental health centers enced some form of diagnosable
funded to serve the thousands of men and women mental disorder in their life-
who formerly were institutionalized or would have time (Trestman, Ford, Zhang, &
been institutionalized if the movement had not taken Wiesbrock,2007).
place. Meanwhile, the state psychiatric hospitals to Thus, although deinstitution-
which former patients would have retreated were alization began with laudatory
closed down by the hundreds. The community men- goals, many of these goals were
tal health movement spread to Europe, with similar never fully reached, leaving many
consequences. Twenty-eight percent of European people who formerly would have
countries have few or no community-based services been institutionalized in mental
for people with serious mental health problems hospitals no better off. In recent Deinstitutionalization
(Semrau, Barley, Law, & Thornicroft, 2011; WHO years, the financial strains on local, state, and led to a rise in
World Mental Health Survey Consortium, 2004). federal governments have led to the closing of homelessness
Men and women released from mental institu- many community mental health centers. among people with
tions began living in nursing homes and other types mental illnesses.
which often go
of group homes, where they received little mental
health treatment, or with their families, many of
Managed Care untreated.
whom were ill-equipped to handle serious mental The entire system of private insurance for health
illness (Lamb, 2001 ). Some began living on the streets. care in the United States underwent a revolution in
Certainly not all homeless people are mentally ill, but the second half of the twentieth century, when
managed care emerged as the dominant means made daily life more difficult for poor people in
for organizing health care. Managed care is a col- general, and in particular for people with serious
lection of methods for coordinating care that mental disorders, who often have exhausted their
ranges from simple monitoring to total control financial resources.
over what care can be provided and paid for. The Only 50 to 60 percent of people in the United
goals are to coordinate services for an existing States with serious psychological problems receive
medical problem and to prevent future medical stable mental health treatment, with much lower
problems. Often, health care providers are given percentages receiving care in less-developed and
a set amount of money per member (patient) per poorer countries (Kessler et al., 2001; Wang et al.,
month and then must determine how best to 2007). For example, while in Europe wealthier
serve each patient. countries such as Finland and Belgium have over
Managed care can solve some of the problems 20 mental health experts per 100,000 people, poorer
created by deinstitutionalization. For example, countries such as Turkey and Tajikistan have fewer
instead of leaving it up to people with a serious than 2 mental health experts per 100,000 people
psychological problem, or their families, to find (Semrau et al., 2008). Sometimes, people refuse
appropriate care, the primary provider might find care that might help them. Other times, they fall
this care and ensure that patients have access to it. through holes in the medical safety net because of
Suppose an individual patient reported to his phy-
sician that he was hearing voices when no one was
around. The physician might refer the patient to a
psychiatrist for an evaluation to determine if the CASE STUDY
Because of severe schizo-
patient might be suffering from schizophrenia. In
affective disorder, Rebecca J., age 56, had spent
some cases, the primary care physician might co-
25 years in a NewYork State psychiatric hospital.
ordinate care offered by other providers, such as
She lived in a group home in the community but
drug treatments, psychotherapy, and rehabilita-
required rehospitalization for several weeks ap-
tion services. The primary provider also might en-
proximately once a year when she relapsed de-
sure continuity of care so that patients do not "fall
spite taking medications. As a result of the
through the cracks." Thus, theoretically, managed
reduction in state hospital beds (for people with
care can have tremendous benefits for people with
mental disorders) and attempts by the state to
long-term, serious mental health problems. For
shift readmissions for fiscal reasons, these re-
people with less severe psychological problems,
hospitalizations increasingly took place on the
the availability of mental health care through man-
psychiatric wards of general hospitals that varied
aged care systems and other private insurance sys-
widely in quality. In 1994, she was admitted to a
tems has led to a large increase in the number of
new hospital because the general hospital where
people seeking psychotherapy and other types of
she usually went was full. The new hospital was
mental health care.
inadequately staffed to provide care for patients
Unfortunately, however, mental health care of-
as sick as Rebecca J. In addition, the psychiatrist
ten is not covered fully by health insurance. Also,
was poorly trained and had access to only a
many people do not have any health insurance. Laws
small fraction of Rebecca J.'s complex and volu-
have been passed in recent years that are intended to
minous past history. During her 6-week hospital-
increase the availability of coverage for mental health
ization, Rebecca J. lost 10 pounds because the
services, but these laws are being hotly contested.
nursing staff did not help her eat, had virtually all
Mental health services are expensive. Because mental
her clothing and personal effects lost or stolen,
health problems are sometimes chronic, mental
became toxic from her lithium medication, which
health treatment can take a long time.
was not noticed until she was semicomatose,
The Medicaid program, which covers one-
and was prematurely discharged while she was
quarter of all mental health care spending in the
still so psychotic that she had to be rehospital-
United States, has been a target for reductions in
ized in another hospital less than 24 hours later.
recent years, even as the number of people seeking
Meanwhile, less than a mile away in the state
mental health care has risen. Many states have re-
psychiatric hospital where she had spent many
duced or restricted eligibility and benefits for men-
years, a bed sat empty on a ward with nursing
tal health care, increased co-payments, controlled
staff and a psychiatrist who knew her case well
drug costs, and reduced or frozen payments to
and with her case records readily available in a
providers (Shirk, 2008). At the same time, reduc-
file cabinet (Torrey, 1997, pp. 105-106).
tions in state and city welfare programs and other
community services targeted at the poor have
~ bureaucratic rules designed to shift the burden of tremendous gratification working with people
mental health care costs from one agency to an- with psychological problems, whereas others
other, as in the case of Rebecca J. find it more gratifying to conduct research that
As we discuss the research showing the might answer important questions about these
effectiveness of various treatments for specific dis- problems. Many mental health professionals of
orders throughout the remainder of the book, it is all types combine clinical practice and research
important to keep in mind that those treatments in their careers.
can work only if people have access to them.
Professions Within Abnormal CHAPTER INTEGRATION

Psychology Although the biological, psychological, and so-
In our times, a number of professions are con- cial theories of abnormality have traditionally
cerned w ith abnormal or maladaptive behavior. been viewed as competing with one another to
Psychiatrists have an MD degree and have received explain psychological disorders, many clinicians
specialized training in the treatment of psycholog- and researchers now believe that theories that in-
ical problems. Psychiatrists can prescribe medica- tegrate biological, psychological, and social per-
tions for the treatment of these problems and have spectives on abnormality will prove most useful
been trained to conduct psychotherapies as well. (Figure 1.2). For example, in Chapter 5 we will
Clinical psychologists typically have a PhD in discuss theories of anxiety disorders that take
psychology, with a specialization in treating and into account individuals' genetic and biochemi-
researching psychological problems. Some have a cal vulnerabilities, the impact of stressful events,
PsyD degree from a graduate program that empha- and the role of cognition in explaining why some
sizes clinical training more than research training. people suffer debilitating anxiety. Throughout
Clinical psychologists can conduct psychotherapy, this book, we will emphasize how biological,
but in most states they do not currently prescribe psychological, and social factors interact with
medications. (They do have limited prescrip- and influence one another to produce and main-
tion privileges in some states, and psychologists tain mental health problems. In other words, we
are lobbying for prescription privileges in many will present an integrationist approach to psy-
others.) chological problems.
Marriage and family therapists specialize in help-
ing families, couples, and children overcome prob-
lems that are interfering with their well-being.
Clinical social workers have a master's degree in so- The Integrationist
cial work and often focus on helping people with FIGURE 1.2
Approach to
psychological problems overcome social condi- Understanding Mental
tions that are contributing to their problems, such Health. Many mental health theories today
as joblessness or homelessness. Some states have strive to integrate biological, psychological,
licensed mental health counselors, individuals who and social factors in understanding mental
have graduate training in counseling beyond the health issues. This integrationist approach
bachelor's degree in counseling but have not ob- will be emphasized in this book.
tained a PhD. Psychiatric nurses have a degree in
nursing, with a specialization in the treatment of
Biological factors
people with severe psychological problems. They
often work on inpatient psychiatric wards in hos-
pitals, delivering medical care and certain forms of
psychotherapy, such as group therapy to increase
patients' contacts with one another. In some states,
they have privileges to write prescriptions for psy-
chotherapeutic drugs.
Each of these professions has its rewards and
~ limitations. Students who are interested in one Social factors
or more of these professions often find it helpful
to volunteer as a research assistant in studies
of psychological problems or for work in a psy-
chiatric clinic or hospital. Some students find
SHADES OF GRAY DISCUSSION (review p. 7l
Our society highly values extreme thinness in young men (see Chapter 14). so his level of drinking
women, and Jennifer has received substantial rein- is deviant. He also has experienced some dysfunc-
forcement for her weight loss. Thus, we see her tion as a result of his drinking: He has gotten in le-
behaviors as not very deviant. Her dieting causes gal trouble and his grades are low. Mark certainly
her some dysfunction and distress: She is having doesn't seem distressed about his drinking. Mark's
trouble concentrating in school and is terrified of behaviors are dangerous: He is more likely to be
gaining weight. But her weight loss is also bringing involved in accidents while drunk and risks alcohol
her social benefits. Are her behaviors dangerous? poisoning from the volume he consumes. So Mark's
Extremely thin women risk medical complications behaviors might be considered more abnormal
such as reduced bone density and heart arrhyth- than Jennifer's behaviors, but people will differ on
mias (see Chapter 12). So Jennifer's behaviors are the degree of abnormality.
somewhat dysfunctional, distressing, and danger- Would your judgments of the abnormality of
ous, but they are so typical of women her age that these behaviors change if it were Jennifer who
people will differ in whether they believe her be- was drinking heavily and Mark who was dieting
haviors qualify as abnormal. excessively to lose weight? Cultural norms for
Mark's behaviors also seem familiar, because thinness and for drinking alcohol differ signifi-
drinking is considered a "rite of passage" by some cantly for women and men. Gender strongly influ-
students. Mark drinks considerably more than most ences our views of normality and abnormality.
THINK CRITICALLY
Chances are you have known a family member, contributed to your concerns about this person?
friend, or acquaintance whom you suspected might Where would you say his or her behaviors or feel-
have a psychological problem. Now that you have ings fall along the four Ds of dysfunction, distress,
read about the factors that influence judgments of deviance, and dangerousness? (Discussion appears
abnormality, think back to that person . What factors on p. 481 at the back of this book.)
CHAPTER SUMMARY
Cultural relativists argue that the norms of a Historically, theories of abnormality have fallen
society must be used to determine the normality into on e of three categories . Biological theories
of a behavior. Others have suggested that unusual saw psychological disorders as similar to physical
behaviors, or behaviors that cause subjective diseases, caused by the breakdown of a system
distress in a person, should be labeled abnormal. of the body. Supernatura l theories saw abnormal
Still others have suggested that only behaviors behavior as a result of divine intervention,
resulting from mental illness or disease are curses, demonic possession, and personal sin.
abnormal. All these criteria have serious Psychological theories saw abnormal behavior
limitations, however. as being a result of stress.
The current consensus among professionals In prehistoric times, people probably had
is that behaviors that cause a person to suffer largely supernatural theories of abnormal
distress, prevent him or her from functioning behavior, attributing it to demons or ghosts.
in daily life, are unusual or deviant, and pose a A treatment for abnormality in the Stone Age
threat to the person or others are abnormal. may have been to drill holes in the skull to
These criteria can be remembered as the allow demons to depart, a procedure known
four Ds: dysfunction, distress, deviance, and as trephination .
dangerousness. Abnormal behaviors fall Ancient Chinese, Egyptian, and Greek texts
along a continuum from adaptive to maladap- suggest that these cultures took a biologica l
tive, and the location of the line designating view of abnormal behavior, although references
behaviors as disordered is based on a subjective to supernatural and psychological theories also
decision. can be found .
Key Te rm s 21
During the Middle Ages, abnormal behavior and eventually Sigmund Freud, became inter-
may have been interpreted as being due to ested in the role of the unconscious in producing
witchcraft. abnormality.
In psychic epidemics and mass hysterias, Behaviorist views on abnormal behavior began
groups of people show similar psychological with John Watson and B. F. Skinner, who used
and behavioral symptoms. Usually, these principles of classical and operant conditioning
have been attributed to common stresses to explain normal and abnormal behavior.
or beliefs. Cognitive theorists such as A lbert Ellis, Albert
Even well into the nineteenth and twentieth Bandura, and Aaron Beck focused on the role
centuries, many people who acted abnormally of thinking processes in abnormality.
were shut away in prisonlike conditions, The deinstitutionalization movement attempted
tortured, starved, or ignored. to move mental patients from mental health
As part of the mental hygiene movement, facilities to community-based mental health
the moral management of mental hospitals centers. Unfortunately, community-based mental
became more widespread. Patients in these health centers have never been fully funded
hospitals were treated with kindness and or supported, leaving many former mental
given the best biological treatments available. patients with few resources in the community.
However, effective biological treatments for Managed care systems are meant to provide
most psychological problems were not coordinated, comprehensive medical care to
available until the mid-twentieth century. patients. They can be a great asset to people
Modern biological perspectives on psychological with long-term, serious psychological
disorders were advanced by Kraepelin's devel- disorders.
opment of a classification system and the dis- The professions within abnormal psychology
covery that general paresis is caused by a include psychiatrists, psychologists, marriage
syphilis infection. and fami ly therapists, clinical social workers,
The psychoanalytic perspective began with the licensed mental health counselors, and
work of Anton Mesmer. It grew as Jean Charcot, psychiatric nurses.
KEY TERMS
continuum model of abnormality 3 psychoanalysis 15
psychopathology 4 classical conditioning 15
cultura l relativism 6 behaviorism 16
biological theories 7 cognitions 16
supernatural theories 7 self-efficacy beliefs 16
psychological theories 7 patients' rights movement 16
trephination 8 deinstitutionalization 16
psychic epidemics 10 community mental health movement 16
mental hygiene movement 13 community mental health centers 16
moral treatment 13 halfway houses 17
general paresis 14 day treatment centers 17
mesmerism 15 managed care 18
Theories and Treatment
of Abnormality
CHAPTER OUTLINE
Approaches Along the Continuum Common Elements in Effective

Treatments
Extraordinary People: Steven Hayes
Chapter Integration
Biological Approaches
Psychological Approaches
Think Critically
Shades of Gray
Chapter Summary
Sociocultural Approaches
Key Terms
Prevention Programs
Normal Abnormal
Sociocultural
Psychological
Biological
No Mild anxiety Moderate Isolated panic Four panic Chronic

anxiety before an exam anxiety attack before attacks in the last panic attacks
before an one exa m month unprovoked that impair
exam by stressors fu nctioni ng
In this chapter, we discuss three general approaches to under- processing that are due to deficits in specific areas of the brain.
standing psychological disorders. The sociocultural approach These problems in cognition and emotional processing can
views these disorders as the result of environmental conditions range from very mild to very severe, causing symptoms that also
and cultural norms. The biological approach views disorders as vary along a continuum from mild to severe. In other words, a
the result of abnormal genes or neurobiological dysfunction. The person can have "a little bit of schizophrenia" or can exhibit sig-
psychological approach views disorders as the result of thinking nificantly more symptoms, to the point of qualifying for a diag-
processes, personality styles, and conditioning. nosis of schizophrenia.
People who favor a sociocultural approach generally view Psychological approaches to disorders have also been moving
psychological disorders as falling along a continuum because toward a continuum model of psychopathology in recent years
they do not view these disorders as vastly different from normal (Widiger & Mullins-Sweatt, 2009). According to these approaches,
functioning . Instead, they think of psychological disorders as psychological processes such as cognition, learning, and emotional
labels that society puts on people whose behaviors and feelings control also fall along a continuum that ranges from very typical to
differfrom social and cultural norms (Castro, Barrera, & Holleran highly dysfunctional. Minor learning difficulties, for example, would
Steiker, 201 0). While they agree that these behaviors may be be placed on the more "typical" end of the continuum, and severe
dysfunctional, distressing, deviant, and dangerous, they see mental retardation on the "dysfunctional" end (Sherman, 2008) .
them as understandable consequences of social stress in the Likewise, problems in emotional control might range from feeling
individuals' lives. blue (typical) to feeling severely depressed with suicidal intentions
A decade ago, proponents of the biological approach gener- (dysfunctional). A continuum perspective would suggest that peo-
ally did not accept a continuum model of abnormality. Instead, ple on the less severe end of the spectrum (who do not meet the
they viewed psychological disorders as either present or absent- criteria for the disorder) give us insight into the behavior of those
much the way they viewed medical or physical disorders (such on the more severe end (those who do meet the criteria).
as cancer) . In recent years, however, proponents of biological As we discuss in this chapter, the sociocultura l, biological,
approaches have embraced a continuum perspective on abnor- and psychological approaches are increasingly being integrated
mality, seeing disorders as collections of deficits in fundamental into a biopsychosocial approach to mental disorders. This inte-
neurobiological processes (Cannon & Keller, 2006; Hyman, 2010; grative approach suggests that factors along the continua of bio-
lnsel et al., 2010). For example, the symptoms of schizophrenia logical dysfunction, psychological dysfunction, and sociocultural
are increasingly viewed as problems in cognition and emotional risks interweave to create the problems we call mental disorders.
Approaches Along the Continuum 23

24 Chapter 2 Theories and Treatment of Abnormality
Steven Hayes
Sitting in a faculty meet- movie theater or an elevator, without being en-

ing in the Psychology gulfed with anxiety. He thought his career and his
Department at the Uni- life were over.
versity of North Carolina Now, nearly 30 years later, Hayes is a full profes-
at Greensboro, assistant sor at the University of Nevada and one of the most
professor Steven Hayes accomplished psychologists in the field, with over
opened his mouth to 300 published articles. Hayes says that he didn't
make a point and found overcome his debilitating anxiety with medications
himself unable to utter a or with any of the psychotherapies prominent in the
sound. His heart began 1980s, when he was suffering the most. Instead, he
racing, and he thought learned to accept that he would have anxiety attacks
he might be having a and to stop fighting them. Out of his experiences, he
heart attack. He was only developed a new form of psychological therapy,
29. The episode passed, called acceptance and commitment therapy or ACT.
but a week later he had a This therapy teaches individuals with psychological
similar experience in an - problems to be more accepting and compassionate
other meeting. Over the toward themselves, to commit to their values, and to
next 2 years, his attacks use meditation practices that help them live more in
of absolute panic became more frequent and began the present moment. ACT is one of the hottest of the
dominating his life. He had great difficulty lecturing third-wave approaches to psychotherapy, which we
and couldn't be in an enclosed place, such as a discuss later in this chapter.
Steven Hayes was able to integrate his personal ex- psychological or environmental?" This question
periences with his training in psychology to develop is often called the nature-nurture question: Is the
a new theory and therapy of his own. A theory is a cause of psychological problems something in the
set of ideas that provides a framework for asking n ature or biology of the person, or is it in the per-
questions about a phenomenon and for gathering son's nurturing or history of events to which the
and interpreting information about that phenome- person was exposed? This question implies that
non. A therapy is a treatment, usually based on a such problems must have a single cause, rather
theory of a phenomenon, that addresses those than multiple causes. Indeed, most theories of
factors the theory says cause the phenomenon. psychological problems over history have
Hayes believed that his anxiety attacks were searched for the one factor-the one gene, the one
due to the inability to accept his symptoms, but traumatic experience, the one personality trait-
other theories suggest alternative causes. If you that causes people to develop a particular set of
took a biological approach to abnormality, you symptoms.
would suspect that Hayes's symptoms were Many contemporary theorists, however, take a
caused by a biological factor, such as a genetic biopsychosocial approach, recognizing that it is
vulnerability to anxiety, inherited from his par- often a combination of biological, p sychological,
ents. The psychological approach, like Hayes's and sociocultural factors that results in the devel-
approach, looks for the causes of abnormality in opment of psychological symptoms. These factors
people's beliefs, life experiences, and relation- are often referred to as risk factors, because they
ships. Finally, if you took a sociocultural ap- increase the risk of psychological problems. Risk
proach, you would consider the ways H ayes's factors can be biological, such as a genetic predis-
cultural values or social environment might affect position. They may also be psychological, such as ~
his anxiety. difficulty remaining calm in stressful situations.
Traditionally, these different approaches have Or they may be sociocultural, such as growing up
been seen as incompatible. People frequently with the stress of discrimination based on ethnicity
ask, "Is the cause of these symptoms biological or or race.
The Diathesis-Stress Model of the Development of Disorders. The

FIGURE 2.1 diathesis-stress model says that it takes both an existing diathesis to a disorder
and a trigger, or stress, to create the disorder.
Diathesis Stress
Biological factor (genes, Biological trigger (onset of a

disordered biochemistry, brain disease, exposure to toxins, etc.)
anomalies)
Social trigger (traumatic event,
Social factor (maladaptive
upbringing, chronic stress, etc.)
+ major loss, etc.)
Psychological trigger (perceived

Psychological factor (unconscious loss of control, violation of a
conflicts, poor skills, maladaptive trust, etc.)
cognitions, etc.)
Some risk factors may lead specifically to cer- theories of mental disorders most often prescribe
tain types of symptoms; for example, a specific medication, although several other types of bio-
gene, known as DISCl, appears to substantially logical treatments are discussed in this book. Pro-
increase the risk of developing schizophrenia ponents of psychological and some sociocultural
(Cannon et al., 2005). More commonly, however, approaches to abnormality most often prescribe
risk factors create increased risk for a number of psychotherapy. There are many forms of psycho-
different problems. For instance, severe stress, therapy, but most involve a therapist (psychia-
such as being the victim of sexual abuse, is asso- trist, psychologist, clinical social worker) talking
ciated with increased risk of developing a wide with the person suffering from psychological
range of psychopathologies (Maniglio, 2009). problems (typically called a patient or client)
Factors that increase risk for multiple types of about his or her symptoms and what is contribut-
psychological problems are referred to as transdi- ing to these symptoms. The specific topic of these
agnostic risk factors (Nolen-Hoeksema & Watkins, conversations depends on the therapist's theo-
2011). We will discuss several biological, psycho- retical approach. Both medications and psycho-
logical, and sociocultural transdiagnostic risk therapy have proven effective in the treatment of
factors in this book. many types of psychological symptoms. Medica-
In many cases, a risk factor may not be enough tions and psychotherapy are often used together
to lead a person to develop severe psychological in an integrated approach (Benjamin, 2005). Pro-
symptoms. It may take some other experience or ponents of sociocultural approaches also may
trigger for psychopathology to develop. Again, work to change social policies or the social condi-
this trigger can be biological, such as an illness that tions of vulnerable individuals so as to improve
changes a person's hormone levels. Or the trigger their mental health.
can be psychological or social, such as a traumatic In this chapter, we introduce the major theo-
event. Only when the risk factor and the trigger or ries of abnormality that have dominated the field
stress come together in the same individual does in its modern history, along with the treatments
the full-blown disorder emerge. This situation is that derive from these theories. We present the
often referred to as a diathesis-stress model (dia- theories and treatments one at a time to make them
thesis is another term for risk factor) (Figure 2.1). easier to understand. Keep in mind, however, that
Although Hayes may indeed have had a genetic most mental health professionals now take an inte-
or personality vulnerability to anxiety (his diathe- grated biopsychosocial approach to understand-
sis), it may have been only when he experienced ing mental health problems, viewing them as the
particular stressors that he developed significant result of a combination of biological, psychologi-
anxiety. cal, and social risk factors and stresses that come
Each of the different approaches to abnormal- together and feed off one another. We will discuss
ity has led to treatments meant to relieve the these integrated biopsychosocial approaches
symptoms people suffer. Proponents of biological throughout this book.
FIGURE 2.2
BIOLOGICAL APPROACHES
Consider the story of Phineas Gage, one of the
most dramatic examples of the effect of biological
factors on psychological functioning.
. " .
CASE STUDY
On September 13, 1848,
Phineas P. Gage, a 25-year-old construction fore-
man for the Rutland and Burlington Railroad in
New England, became the victim of a bizarre acci-
dent. On the fateful day, an accident led to a pow-
erful explosion that sent a fine-pointed, 3-cm-thick,
109-cm-long tamping iron hurling, rocketlike,
through Gage's face, skull, and brain and then into
the sky. Gage was momentarily stunned but re-
gained full consciousness immediately after. He
was able to talk and even walk with the help of his
Source: Damasio H, Grabowski, T, Frank R, Galaburda AM ,
men. The iron landed several yards away. Damasio AR. (1994) The return of Phineas Gage: Clues about
Phineas Gage not only survived the momen- the brain from the skull of a famous patient. Science,
tous injury, in itself enough to earn him a place in 264(5162):1102-1105. 1994 American Association for the
Advanceme nt of Science . Readers may view, browse, and/or
the annals of medicine, but he survived as a differ- download material for temporary copying purposes only,
ent man. Gage had been a responsible, intelligent, provided these uses are for noncommercial personal
and socially well -adapted ind ividual, a favorite purposes. Except as provided by law, this material may not be
further reproduced, distributed, transmitted, modified,
with peers and elders. He had made progress and adapted, performed, displayed, published or sold in whole or
showed promise. The signs of a profound change in part, without prior written permission from the publisher."
in personality were already evident during his con-
valescence under the care of his physician, John
Harlow. But as the months passed, it became ap- socially appropriate man into an impulsive, emo-
parent that the transformation was not only radi- tional, and socially inappropriate man. Almost
cal but difficult to comprehend. In some respects, 150 years later, researchers u sing modern neuro-
Gage was fully recovered . He remained as able- imaging techniques on Gage's preserved skull
bodied and appeared to be as intelligent as before and a computer simulation of the tamping-iron
the accident, he had no impairment of movement accident determined the precise location of the
or speech, new learning was intact, and neither damage to Gage's brain (Figure 2.2).
memory nor intelligence in the conventional sense Studies of people today who suffer damage to
had been affected. However, he had become irrev- this area of the brain reveal that they have trouble
erent and capricious. His respect for the social con- with making rational decisions in personal and so-
ventions by which he once abided had vanished . cial matters and with processing information
His abundant use of profanity offended those about emotions. They do not have trouble, how-
around him. Perhaps most troubling, he had taken ever, with following the logic of an abstract prob-
leave of his sense of responsibility. He could not lem, with arithmetic calculations, or with memory.
be trusted to honor his commitments. His employ- Like Gage, their basic intellectual functioning re-
ers had deemed him "the most efficient and ca- mains intact, but their emotional control and social
pable" man in their "employ" but now they had to judgment are impaired (Damasio et al., 1994).
dismiss him. In the words of his physician, "the The damage Gage suffered caused areas of his
equilibrium or balance, so to speak, between his brain to not function properly. Brain dysfunction is
intellectual faculty and animal propensities" had one of three causes of abnormality on which bio-
been destroyed. In the words of his friends and logical approaches often focus. The other two are
acquaintances, "Gage was no longer Gage:' biochemical imbalances and genetic abnormali-
(Adapted from Damasio et al., 1994, p. 1102) ties. Brain dysfunction, biochemical imbalances, r---.,
and genetic abnormalities can all influence one an-

other. For example, brain dysfunction may be the
As a result of damage to his brain from the ac- result of genetic factors and may cause biochemi-
cident, Gage's basic personality seemed to have cal imbalances. We explore these three biological
changed. He was transformed from a responsible, causes of abnormality in this section.
~ Brain Dysfunction FIGURE 2.3 Organization of the Brain.

Like Phineas Gage, people whose brains do not
function properly often show problems in psy- Thalamus
chological functioning. The brain can be divided
into three main regions (Kalat, 2007): the hind- Hypothalamus
brain, which includes all the structures located in
Pituitary gland
the hind (posterior) part of the brain, closest to
the spinal cord; the midbrain, located in the mid- Limbic system
dle of the brain; and the forebrain, which includes
the structures located in the front (anterior) part Cerebrum
of the brain (Figures 2.3 and 2.4). The hindbrain
sits on top of the spinal cord and is crucial for Midbrain
basic life functions. It contains the medulla, which Superior and
helps control breathing and reflexes; the pons, inferior colliculus
which is important for attentiveness and the
Substantia nigra
timing of sleep; the reticular formation, a network
of neurons that control arousal and attention to
stimuli; and the cerebellum, which is concerned
Medulla
primarily with the coordination of movement.
The midbrain contains the superior colliculus and Pons
inferior colliculus, which relay sensory informa-
tion and control movement, and the substantia Reticular formation
nigra, a crucial part of the pathway that regulates
responses to reward. Cerebellum
The human forebrain is relatively large and
~ developed compared to that of other organisms
(Kalat, 2007). The outer layer of the cerebrum is
called the cerebral cortex (or simply cortex; Fig-
ure 2.5a and b); it is this area of the brain that was hemispheres on the left and right sides of the
damaged in Phineas Gage's accident. The cere- brain that are connected by the corpus collosum.
bral cortex is involved in many of our most ad- Each hemisphere is divided into four lobes (see
vanced thinking processes. It is composed of two Figure 2.5a and b): the frontal, parietal, occipital,
FIGURE 2.4 Some of the Major Structures of the Brain.
Corpus callosum ------.... FOREBRAIN

Bridge of fibers passing
information between the two ~-L~~"'l;;:-------- Cerebral cortex
cerebral hemispheres Involved in many of our most
advanced thinking processes
Pons - - - - - - - - -
Involved in sleep and arousal
Reticular formation - - - -
A network of neurons related to
sleep, arousal, and attention
Medulla _ _ _ _ _ ____.-- r-- - - - - - - - - - - - - - - S p i n a l cord
Responsible for regulating Responsible for communication
largely unconscious functions between brain and rest of body;
such as breathing and circulation involved with simple reflexes
FIGURE 2.5 Major Sections of the Cerebra l Cortex.
Central fissure
Left
hemisphere ""-
Motor cortex
Central fissure
Sensory cortex
Visual Parietal lobe

cortex
Lateral fissure
Occipital lobe Auditory Occipital lobe

cortex
Temporal lobe ':hlo...;<- - - Visual cortex
Corpus callosum
(a) Lateral view (b) Superiorview
and temporal lobes, large regions that perform information from sense receptors (such as vision
diverse functions . and hearing) to the cerebrum. The hypothala-
The other structures of the forebrain are mus, a small structure just below the thalamus,
found just under the cerebrum and are called sub- regulates eating, drinking, and sexual behavior.
cortical structures. The thalamus directs incoming The hypothalamus is also involved in processing
basic emotions. For example, stimulation of cer-
Structures of the limbic System. The limbic
tain areas of the h ypothalamus produces sensa-
FIGURE 2.6 tions of pleasure, whereas stimulation of other
system is a collection of struct ures that are
closely interconnected wit h t he hypothalamus. areas produces sensations of pain or unpleasant-
They appear to exert additional control over some of t he ness (Kalat, 2007). The pituitary gland is the most
instinctive behaviors regulated by the hypothalamus, such as important part of the endocrine system, discussed
eating, sexual behavior, and reaction to stressful situations. in the next section.
Around the central core of the brain and
closely interconnected with the hypothalamus
Cingulate cortex
is the limbic system, a set of structures that
regulate many instinctive behaviors, such as
reactions to stressful events and eating and sex-
Septum
ual behavior (Figure 2.6). The amygdala is a
structure of the limbic system that is critical
in emotions such as fear (Debiec, et al., 2010).
Monkeys with damage to the limbic system
sometimes become chronically aggressive, react-
ing with rage to the slightest provocation. At
other times, they become exceptionally passive,
not reacting at all to real threats. The hippocam-
pus is a part of the limbic system that plays a
role in memory.
Brain dysfunction can result from injury,
Hippocampus
such as from an automobile accident, and from
diseases that cause brain deterioration (Kalat,
2007). You will see that certain areas of the brain
~ are associated with a wide range of psychologi- Neurotransmitters and the Synapse. The
cal symptoms. Thus, dysfunctions in these areas neurotransmitter is released into the synaptic
are transdiagnostic risk factors. For example, FIGURE 2.7 gap. There it may bind with the receptors on the
alterations in the size or activity of the frontal postsynaptic membrane.
cortex are associated with schizophrenia, a se-
vere disorder in which people have hallucina-
tions (unreal perceptual experiences) and
delusions (unreal beliefs); with depression; and
with attention-deficit/hyperactivity disorder
(ADHD), among other disorders. We will also
consider examples of how environmental and Axon
psychological factors can change brain function-
ing. For example, a number of studies have
shown that psychotherapy alone, without drug Receiving
therapy, can change brain activity (Frewen, neuron
Dozois, & Lanius, 2008).
Biochemical Imbalances
The brain requires a number of chemicals in order
to work efficiently and effectively. These chemicals
include neurotransmitters and hormones, the lat-
ter produced by the endocrine system.
Neurotransmitters
Neurotransmitters are biochemicals that act as
messengers carrying impulses from one neuron, or
nerve cell, to another in the brain and in other
parts of the nervous system (Figure 2.7). Each neu-
ronhas a cell body and a number of short branches,
called dendrites. The dendrites and cell body re- Postsynaptic Neurotransmitter
ceive impulses from adjacent neurons. The im- membrane molecule
pulse then travels down the length of a slender,
tubelike extension, called an axon, to small swell-
ings at the end of the axon, called synaptic termi-
nals. Here the impulse stimulates the release of
neurotransmitters (Kalat, 2007).
The synaptic terminals do not actually touch The process of reuptake occurs when the initial
the adjacent neurons. There is a slight gap be- neuron releasing the neurotransmitter into the
tween the synaptic terminals and the adjacent synapse reabsorbs the neurotransmitter, decreas-
neurons, called the synaptic gap or synapse. The ing the amount left in the synapse. Another pro-
neurotransmitter is released into the synapse. It cess, degradation, occurs when the receiving
then binds to special receptors-molecules on the neuron releases an enzyme into the synapse that
membrane of adjacent neurons. This binding breaks down the neurotransmitter into other bio-
works somewhat the way a key fits into a lock. chemicals. The reuptake and degradation of neu-
The binding stimulates the adjacent neuron to rotransmitters happen naturally. When one or
initiate the impulse, which then runs through its both of these processes malfunction, abnormally
dendrites and cell body and down its axon to high or low levels of neurotransmitter in the syn-
cause the release of more neurotransmitters be- apse result.
tween it and other neurons. Psychological symptoms may also be associ-
Many biochemical theories of psychopathol- ated with the number and functioning of the
~
ogy suggest that the amount of certain neu- receptors for neurotransmitters on the dendrites
I rotransmitters in the synapses is associated with (Kalat, 2007). If there are too few receptors or if the
specific types of psychopathology (Kalat, 2007). receptors are not sensitive enough, the neuron will
The amount of a neurotransmitter available in not be able to make adequate use of the neurotrans-
the synapse can be affected by two processes. mitter available in the synapse. If there are too
many receptors or if they are too sensitive, the neu- different types of psychopathology. It plays an
ron may be overexposed to the neurotransmitter important role in emotional well-being, particu-
that is in the synapse. Within the neuron, a com- larly in depression and anxiety, and in dysfunc-
plex system of biochemical changes takes place as tional behaviors, such as aggressive impulses
the result of the presence or absence of neurotrans- (Belmaker & Agam, 2008).
mitters. Psychological symptoms may be the con- Dopamine is a prominent neurotransmitter in
sequence of malfunctioning in neurotransmitter those areas of the brain associated with our experi-
systems; also, psychological experiences may ence of reinforcements or rewards, and it is af-
cause changes in neurotransmitter system func- fected by substances, such as alcohol, that we find
tioning (Kalat, 2007). rewarding (Ruiz, Strain, & Langrod, 2007). Dopa-
Scientists have identified more than 100 differ- mine also is important to the functioning of muscle
ent neurotransmitters. Serotonin is a neurotrans- systems and plays a role in disorders involving
mitter that travels through many key areas of control over muscles, such as Parkinson's disease.
the brain, affecting the function of those areas. Thus, dopamine dysfunction is also a transdiag-
You will see throughout this book that dysfunc- nostic risk factor.
tion in the system regulating serotonin is a trans- Norepinephrine (also known as noradrenaline)
diagnostic risk factor, associated with several is a neurotransmitter produced mainly by neu-
rons in the brain stem. Two well-known drugs,
cocaine and amphetamine, prolong the action of
norepinephrine by slowing its reuptake process.
The Endocrine System. The hypothalamus Because of the delay in reuptake, the receiving
FIGURE 2.8 regulates the endocrine system, which produces
neurons are activated for a longer period of time,
most of the major hormones of the body.
which causes the stimulating psychological
effects of these drugs (Ruiz et al., 2007). Con-
versely, when there is too little norepinephrine
in the brain, the person's mood is depressed.
Hypothalamus Another prominent neurotransmitter is gamma-
aminobutyric acid, or GABA, which inhibits the
action of other neurotransmitters. Certain drugs
have a tranquilizing effect because they increase
Thyroid gland
the inhibitory activity of GAB A. GABA is thought
to play an important role in anxiety symptoms, so
v,~.....;.;:o......__ _ Parathyroid gland one contributor to Steven Hayes's anxiety could
be a dysfunction in his GABA system (Kalivas &
Volkow, 2005).
The Endocrine System

Other biochemical theories of psychopathology
focus on the body's endocrine system (Fig-
ure 2.8). This system of glands produces chemi-
cals called hormones, which are released directly
into the blood. A hormone carries messages
throughout the body, potentially affecting a per-
son's mood, level of energy, and reaction to
-iii+- - - ' ' - - - - - : - - - - Ovary
(in females)
stress (Kalat, 2007) . One of the major endocrine
glands, the pituitary, has been called the master
~a-----Testis gland because it produces the largest number of
(in males) different hormones and controls the secretion
of other endocrine glands. It lies just below the
hypothalamus.
The relationship between the pituitary gland
and the hypothalamus illustrates the complex
interactions between the endocrine and central
nervous systems. For example, in response to
stress (fear, anxiety, pain, and so forth), neurons
in the hypothalamus secrete a substance called Chromosomes contain individual genes, which
corticotropin-release factor (CRF). CRF is carried are segments of long molecules of deoxyribonu-
from the hypothalamus to the pituitary through cleic acid (DNA; Figure 2.9). Genes give coded in-
a channel-like structure. The CRF stimulates the structions to cells to perform certain functions,
pituitary to release the body's major stress hor- usually to manufacture certain proteins. Genes,
mone, adrenocorticotrophic hormone (ACTH). like chromosomes, come in pairs. One half of the
ACTH, in turn, is carried by the bloodstream to pair comes from the mother, and the other half
the adrenal glands and to various other organs from the father. Abnormalities in genes are much
of the body, causing the release of about 30 hor- more common than major abnormalities in the
mones, each of which plays a role in the body's structure or number of chromosomes.
adjustment to emergency situations (Sapolsky, For example, as noted earlier, the neurotrans-
2007). mitter serotonin appears to play a role in depres-
As we will discuss in Chapters 5 and 7, some sion. One gene that influences the functioning of
theories of anxiety and depression suggest that serotonin systems in the brain is the serotonin
these disorders result from dysregulation, or mal- transporter gene. Every gene has two alleles, or
functioning, of a system called the hypothalamic- coding sequences. Alleles for the serotonin trans-
pituitary-adrenal axis (or HPA axis). People who porter gene can be either short (s) or long (1). Thus,
have a dysregulated HPA axis may have abnormal any given individual could have two short alleles
physiological reactions to stress that make it more
difficult for them to cope with the stress, resulting
in symptoms of anxiety and depression.
The proper working of the neurotransmitter Chromosome. Chromosomes consist of
and endocrine systems requires a delicate balance, individual genes, long molecules of
and many forces can upset this balance. For ex- deoxyribonucleic acid (DNA).
ample, chronic stress can cause dysregulation in
neurotransmitter and endocrine systems that per-
sists even after the stress has subsided.
Gene 1
Genetic Abnormalities
Behavior genetics, the study of the genetics of
personality and abnormality, is concerned with
two questions: (1) To what extent are behaviors or
behavioral tendencies inherited? and (2) What are
the processes by which genes affect behavior
(Loehlin, 2009)?
Let us begin by reviewing the basics of genet- Gene 2
ics. At conception, the fertilized embryo has
46 chromosomes, 23 from the female egg and 23
from the male sperm, making up 23 pairs of chro-
mosomes. One of these pairs is referred to as the
sex chromosomes because it determines the sex of
the embryo: The XX combination results in a fe-
male embryo, and the XY combination results in a
male embryo. The mother of an embryo always
contributes an X chromosome, and the father can
contribute either an X or a Y.
Alterations in the structure or number of chro-
mosomes can cause major defects. Down syn-
drome, which is characterized by mental
retardation, heart malformations, and facial fea-
~
tures such as a flat face, a small nose, protruding
I
lips and tongue, and slanted eyes, results when
chromosome 21 is present in triplicate instead of Source: www.accessexcellence.org/AB/GG/genes.html.
as the usual pair.
(s / s genotype), two long alleles (1 / 1 genotype), or

one short and one long allele (s/1 genotype). Some
studies have suggested that the presence of at least
one s allele on the serotonin transporter gene may
increase an individual's chance of developing de-
pression (Levinson, 2006) .
Although you may often hear of scientists
having discovered "the gene" for a major disor-
der, most disorders are associated not with a sin-
gle abnormal gene but with multiple abnormal
genes. Each of these altered genes may make only
a partial contribution to vulnerability for the dis-
order, some greater than others. But when a criti-
Studies of identical twins reared apart have revealed
cal number of these altered genes come together, amazing similarities. Jim Lewis and Jim Springer were
the individual may develop the disorder. This is reared apart but, when reunited, fou nd that they were
known as a multi-gene, or polygenic, process- it identical in more than appearance.
takes multiple genetic abnormalities coming to-
gether in one individual to create a specific disor-
der. A number of physiological disorders, such as
diabetes, coronary heart disease, epilepsy, and each other? Genetic researchers think not. In-
cleft lip and palate, result from such polygenic stead, people with identical genes may have simi-
processes. Most genetic models of the major types lar temperaments and talents that cause them to
of mental disorder are also polygenic. In the case choose similar environments (Bouchard & Loehlin,
of depression, the presence of at least one s allele 2001; Johnson, McGue, Krueger, & Bouchard, 2004).
increases the likelihood that an individual will For example, both of the Jim twins may have wood-
have depression but probably is not sufficient to working talent that causes them to build work-
cause it. Rather, a combination of genetic abnor- shops in their basements and circular benches in
malities is thought to contribute to depression their yards.
(Kaufman et al., 2004). Most examples of genes influencing our
choices of environment are not as startling as in
Interactions Between Genes the case of the Jim twins, but such influences may
and Environment be important in producing psychological symp-
Genetic factors and the environment interact in toms. For example, children with tendencies to-
a number of ways to influence our behaviors ward aggression and impulsive behavior, both of
(Ulbricht & Neiderhiser, 2009). First, genetic fac- which appear to be influenced by genetic factors,
tors can influence the kinds of environments we tend to choose friends who encourage their aggres-
choose, which then reinforce our genetically in- sive and impulsive behaviors and provide oppor-
fluenced personalities and interests. Consider a tunities to engage in antisocial acts (Dishion &
startling example that involves identical twins, Patterson, 1997).
who have 100 percent of their genes in common. Second, the environment may act as a catalyst
Jim Lewis and Jim Springer were identical twins for a genetic tendency. For example, as noted ear-
reunited at the age of 39 after being separated lier, the presence of at least one s allele on the sero-
since infancy (Holden, 1980). To their shock, tonin transporter gene may increase an individual's
both had married and later divorced women chance of developing depression, but it does not
named Linda. Their second wives were both determine whether the individu al will develop
named Betty. Both had sons named James Allan depression. Researchers Avshalom Caspi, Terri
and dogs named Toy. Both chain-smoked Salem Moffitt, and colleagues (2003) found that individu-
cigarettes, worked as sheriffs' deputies, drove als who carried at least one s allele for the sero-
Chevrolets, chewed their fingernails, enjoyed tonin transporter gene were at increased risk for
stock car racing, had basement workshops, and depression as adults only if they had a history of
had built circular white benches around trees in being maltreated as young children (Figure 2.10).
their yards. Among individuals with no history of maltreat-
Could there possibly be genes for marrying ment, their genotype for the serotonin transporter
women named Betty or for having basement gene had no relationship to depression. Those with
workshops that account for the similarities be- the s/1 genotype showed a greater probability of
tween these twins, who had never before met depression if they had been maltreated, and those
they are less fearful and physiologically reactive

Gene by Environment
FIGURE 2.10 Interaction. In this
to stress than when they are raised by their own
study, the interaction of mothers; and when the biological offspring of
certain genes and a history of maltreatment mothers who lick and groom more are raised
predicted the probability of depression. by mothers who lick and groom less, they are
more fearful and physiologically reactive to
0.7 stress than when they are raised b y their own
Genotype mothers. This pattern of results suggests that the
0.6 - sfs
c:: mother's behavior influences the development of
0
v; - s/l the pups' reactions to stress (Meaney, 2010). The
0.5
"'0.
~
- lfl amount that mother rats lick and groom pups in
"'
'0
..... 0.4
the first week of life affects the release of certain
0
~ 0.3 hormones in the pup. These hormones in turn af-
""
:.c fect the expression of a gene that influences the
"'e
.0 0.2
development of the hippocampus (refer to Fig-
a.
0.1 ure 2.6), an area of the brain that influences the
stress response. So the mother's behavior toward
0
None Probable Severe the pup during the first week of life affects the
Extent of maltreatment expression of key genes, changing the develop-
ment of an area of the brain and, in turn, influ-
encing the pups' behavioral and physiological
Source: Caspi et al., 2003.
responses to stress.
The role of epigenetics in psychopathology in
humans is only beginning to be studied, but it
likely is very important. For example, epigenetic
processes could help explain how identical twins
with the sIs genotype showed an even greater prob- who share the same DNA sequence could differ in
ability of depression if they had been maltreated. their expression of a disorder. Both twins may
Some subsequent studies have failed to replicate carry genes that increase their risk for a disorder,
the findings of Caspi and colleagues (see Risch et but if the environments of the twins differ during
al., 2009), but this intriguing study inspired many fetal development or in critical stages of develop-
other researchers to search for gene-environment ment after birth, the expression of these genes may
interactions. differ, leading one twin but not the other to de-
Third, the fascinating line of research called velop the disorder (see Chapter 8).
epigenetics indicates that environmental condi-
tions can affect the expression of genes. DNA
can be chemically modified by different environ-
Drug Therapies
mental conditions, resulting in genes being Most of the biological treatments for abnormality
turned on or off. As a result, cells, tissues, and are drug treatments (Table 2.1). These drugs are
organs are altered in their development. Bpi- thought to relieve psychological symptoms by
genetics is the study of heritable changes in the improving the functioning of neurotransmitter
expression of genes without change in the gene systems.
sequence. Antipsychotic drugs help reduce the symp-
Researcher Michael Meany studied the ef- toms of psychosis, which include hallucinations
fects of epigenetic processes on stress responses (unreal perceptual experiences) and delusions
in rats (Hellstrom & Meaney, 2010; Meaney, (fantastic, unrealistic beliefs). The first group of
2010). Mother rats typically lick and groom their antipsychotic drugs was the phenothiazines
infants (called pups), but the amount of licking (Valenstein, 1998). These drugs have been ex-
and grooming varies from one mother to another. tremely helpful in reducing psychotic symp-
Pups who are licked and groomed more tend to toms, but they carry a number of dangerous side
grow into adult rats that are less fearful and effects. These side effects include severe seda-
~ show more modest physiological responses to tion, visual disturbances, and tardive dyskinesia, a
I stress, compared to pups who are licked and neurological disorder characterized by involun-
groomed less. In addition, when the biological tary movements of the tongue, face, mouth, or
offspring of mothers who lick and groom less are jaw (see Chapter 8). Fortunately, newer medica-
raised by mothers who lick and groom more, tions, referred to as the atypical antipsychotics,
TABLE 2.1 Drug Therapies for Mental Disorders
These are the major types of drugs used to treat several kinds of mental disorders.
Type of Drug Purpose Examples
Antipsychotic drugs Reduce symptoms of psychosis {loss of Thorazine {a phenoth iazi ne)
reality testing, hallucinations, delusions) Haldol {a butyrophenone)
Clozaril {an atypical antipsychotic)
Antidepressant drugs Reduce symptoms of depression {sadness, Parnate {an MAO inhibitor)
loss of appetite, sleep disturbances) Elavi l {a tricyclic)
Prozac {a selective serotonin
reuptake inhibitor)
Lithium Reduces symptoms of mania {agitation, Litho bid
excitement, grandiosity) Cibalith-S
Antianxiety drugs Reduce symptoms of anxiety {fearfulness, Nembutal {a barbiturate)
worry, tension) Valium {a benzodiazepine)
seem to be effective in treating psychosis with- gerous activities). Lithium's significant side effects
out inducing some of the same side effects (see include extreme nausea, blurred vision, diarrhea,
Chapter 8). tremors, and twitches (see Chapter 7). Other drugs,
Antidepressant drugs reduce symptoms of known as the anticonvulsants, are also used in the
depression (sadness, low motivation, and sleep treatment of mania (see details in Chapter 7) and
and appetite disturbance). The most frequently have fewer side effects than lithium.
used antidepressants, the selective serotonin reup- The first group of antianxiety drugs was the
take inhibitors (SSRis; see Chapter 7), affect these- barbiturates, introduced at the beginning of the
rotonin neurotransmitter system. Some of the twentieth century. Although these drugs are effec-
newest antidepressant drugs, se- tive in inducing relaxation and sleep, they are
lective serotonin-norepinephrine highly addictive, and withdrawal from them can
reuptake inhibitors (SNRis; see cause life-threatening symptoms such as increased
Chapter 7), are designed to target heart rate, delirium, and convulsions.
both serotonin and norepineph- The other major class of anxiety-reducing
rine. Common side effects of drugs, the benzodiazepines, appears to reduce the
SSRis and SNRis include nausea, symptoms of anxiety without interfering substan-
diarrhea, headache, tremor, day- tially with an individual's ability to function in
time sedation, sexual dysfunc- daily life. The most frequent use of these drugs is
tion, and agitation. Older classes as sleeping pills. As many as 70 million prescrip-
of antidepressants include the tions for benzodiazepines are written each year in
tricyclic antidepressants and the the United States. Unfortunately, these drugs are
monoamine oxidase inhibitors also highly addictive, and up to 80 percent of peo-
(see Chapter 7). ple who take them for 6 weeks or longer show
Lithium is a metallic element withdrawal symptoms, including heart rate accel-
present in the sea, in natural eration, irritability, and profuse sweating.
springs, and in animal and plant
tissue. It is widely used as a mood Electroconvulsive Therapy
stabilizer, particularly in the treat- and Newer Brain Stimulation
Media stories about so-called wonder ment of bipolar disorder, which
drugs. including Prozac. often tout involves swings back and forth
Techniques
their ability to alleviate a wide range
of problems beyond the treatment of
from depression to mania (highly An alternative to drug therapies in the treatment
serious psychological disorders. elevated mood, irritability, gran- of some disorders is electroconvulsive therapy,
diosity, and involvement in dan- or ECT. ECT was introduced in the early twenti-
eth centu ry as a treatment for schizophrenia. Psychosurgery

Eventually, clinicians found that ECT is effective
for treating depression but not for treating In Chapter 1, we described theories suggesting
schizophrenia. that prehistoric peoples performed crude brain
ECT consists of a series of treatments in surgery, called trephination, on people with men-
which a brain seizure is induced by passing elec- tal disorders in order to release the evil spirits
trical current through the patient's brain. Pa- causing the disorders. In modern times, brain
tients are first anesthetized and given muscle surgery did not become a mode of treatment for
relaxants so that they are not conscious when mental disorders until the early twentieth cen-
they have the seizure and their muscles do not tury. A Portuguese neurologist, Antonio de Egas
jerk violently during it. Metal electrodes are Moniz, introduced a procedure in 1935 in which
taped to the head, and a current of 70 to 150 volts the frontal lobes of the brain are severed from the
is passed through one side of the brain for about lower centers of the brain in people with psycho-
1h second. Patients typically have a convulsion sis. This procedure eventually developed into the
that lasts about 1 minute. The full series of treat- procedure known as prefrontal lobotomy. Al-
ments consists of 6 to 12 sessions. The side effects though Moniz won the Nobel Prize for his work,
of ECT include confusion and memory loss prefrontal lobotomies eventually were criticized
(Sackeim et al., 2007). as a cruel and ineffective means of treating psy-
More recently, researchers have been devel- chosis (Valenstein, 1986). Patients often would
oping alternative techniques for stimulating experience severe and permanent side effects, in-
the brain that can be more targeted and that have cluding either an inability to control impulses or
fewer side effects (Slotema, Blom, Hoek, & an inability to initiate activity, extreme listless-
Sommer, 2010). One procedure, known as repeti- ness and loss of emotions, seizures, and some-
tive transcranial magnetic stimulation (rTMS) , times even death.
exposes patients to repeated, high-intensity By the 1950s, the use of psychosurgery had
magnetic pulses focused on particular brain declined dramatically, especially in countries out-
structures. In the procedure known as deep brain side the United States. Today, psychosurgery is
stimulation, electrodes are surgically implanted used rarely, and only with people who have se-
in specific areas of the brain. These electrodes vere disorders that do not respond to other forms
are then connected to a pulse generator placed of treatment. Modern neurological assessment
under the skin that delivers stimulation to the and surgical techniques make psychosurgery
specific brain areas. Similarly, in vagus nerve more precise and safer than it was formerly, al-
stimulation, electrodes are attached to the vagus though it remains highly controversial, even
nerve, a part of the nervous system that carries among professionals. Neurosurgeons attempt to
information to several areas of the brain, in- lesion, or destroy, minute areas of the brain
cluding the hypothalamus and amygdala. These thought to be involved in a patient's symptoms.
electrodes are connected to a pulse generator One of the greatest remaining problems in psy-
that delivers stimulation to the vagus nerve, chosurgery, however, is that we do not yet know
which in turn travels to targeted areas of the what areas of the brain are involved in producing
brain. most psychiatric symptoms, and it is likely that
Some studies have suggested that these many areas of the brain are involved in any given
newer brain stimulation techniques can be help- disorder.
ful in relieving the symptoms of depression and
auditory hallucinations (hearing voices that Assessing Biological
aren't there) in patients (Slotema et al., 2010).
Electrical stimulation of neurons can result in
Approaches
long-term changes in neurotransmission across The biological therapies have revolutionized the
synapses. Patients who receive these newer brain treatment of people with psychological disorders.
stimulation treatments report few side effects- We entered the twentieth century able only to
usually only minor headaches treatable by aspi- house and comfort people with severe psychologi-
rin. Thus, there is a great deal of hope that these cal disturbances. In the twenty-first century, we
techniques will be effective and safe alternative are able to treat many of these people so success-
therapies, particularly for people who do not re- fully that they can lead normal lives, thanks in part
spond to drug therapies and may not be able to to the biological therapies that have been devel-
tolerate ECT. oped in recent decades.
Many people find biological theories appeal- Behavioral Approaches

ing because they seem to erase any blame or re-
sponsibility that might be placed o~ th~ sufferer Behavioral approaches focus on the influence of
of a disorder. Indeed, many orgamzatwns that reinforcements and punishments in producing be-
advocate for people with mental disorders argue hav ior. The two core principles or processes of
that mental disorders should be seen as medical learning according to behaviorism are classical
diseases, just like diabetes or high blood pres- conditioning and operant conditioning. Learning
sure. They argue that people who suffer from can also occur through modeling and observa-
these disorders simply must accept that they tional learning.
have a disease and obtain the appropriate medi-
cal treatment. Classical Conditioning
Despite their current popularity, however, Around the turn of the twentieth century, Ivan
the biological therapies are not a panacea. They Pavlov, a Russian physiologist, was conducting
do not work for everyone. Indeed, some people experiments on the salivary glands of dogs when
with psychological disorders do not respond to he made discoveries that would revolutionize psy-
any of the drugs or other biological treatm.ents chological theory. Not surprisingly, his dogs would
currently available. In addition, for some disor- salivate when Pavlov or an assistant put food in
ders, such as phobias (see Chapter 5), psycho- their mouths. Pavlov noticed that, after a while,
therapy works better than drug therapies in the dogs would salivate when he or his assistant
alleviating symptoms. simply walked into the room.
Most of the biological therapies have signifi- Pavlov had paired a previously neutral stim-
cant side effects, as later chapters of this book ulus (himself) with a stimulus that naturally
will describe. Often, these side effects are tol- leads to a certain response (the dish of food,
erable, and people endure them because the which leads to salivating), and eventually the
drugs offer relief from their psychological dis- neutral stimulus (Pavlov) was able to elicit that
order. For some people, however, the side ef- response (salivation). This process gained the
fects are worse than the disorder itself. For yet name classical conditioning. The stimulus that
others, the side effects can be dangerous or even naturally produces a response is the uncondi-
deadly. tioned stimulus (US), and the response created
Some critics of biological theories and drug by the unconditioned stimulus is the uncondi-
therapies worry that people will turn to the drugs tioned response (UR). Thus, in Pavlov's experi-
rather than deal with the issues in their lives that ments, the dish of food was the US, and salivation
are causing or contributing to their psychological in response to this food was the UR. The previ-
problems. Critics also argue that biological theo- ously neutral stimulus is the conditioned stimu-
ries often ignore the role of environmental and lus (CS), and the response that it elicits is the
psychological processes in biological function- conditioned response (CR). Thus, Pavlov was
ing. Finally, recent research suggests that indi- the CS, and when the dogs salivated in response
viduals who attribute their mental health to seeing him, this salivation became the CR (Fig-
problems to biological causes are more pessimis- ure 2.11) .
tic about their prognosis for recovery than are
Classical conditioning has been used to ex-
individuals who attribute their mental health
plain people's seemingly irrational responses to
problems to nonbiological causes (Lebowitz & a host of neutral stimuli. For example, a college
Ahn, 2012).
student who previously failed a test in a particu-
lar classroom may break out in a cold sweat when
she enters that room again. This response is the
PSYCHOLOGICAL result of classical conditioning. The room has be-
APPROACHES come a conditioned stimulus, eliciting a response
of anxiety, because it was paired with an uncon-
We turn now to a discussion of different psycho- ditioned stimulus (failing an exam) that elicited
logical approaches to understanding and treat- anxiety.
ing abnormality. We begin with behavioral and
cognitive approaches, which are the focus .of
much research in psychopathology. We then dis- Operant Conditioning
cuss psychodynamic and humanistic approaches, E. L. Thorndike observed that behaviors that are
family systems approaches, and third-wave followed by a reward are strengthened, whereas
approaches. behaviors that are followed by a punishment are
Psychological Approaches 37
Stimulus and Response in Classical Conditioning. Classical conditioning is

FIGURE 2.11 a major way abnormal behaviors are learned, according to behavioral theories .
Unconditioned stimulus (US): Conditioned stimulus (CS):

stimulus that naturally produces previously neutral stimulus paired
a desired response with the unconditioned stimulus
!
Unconditioned response (UR):
response naturally occurring in the
!
Conditioned response (CR):
response occurring in the presence
presence of the unconditioned stimulus of the conditioned stimulus
weakened. This simple but important observation, frequently gamble are seldom rewarded, but they
which Thorndike labeled the law of effect, led to continue to gamble in anticipation of that occa-
the development of the principles of operant sional, unpredictable win.
conditioning-the shaping of behaviors by pro- Hobart Mowrer's (1939) two-factor model
viding rewards for desired behaviors and provid- suggests that combinations of classical and oper-
ing punishments for undesired behaviors. ant conditioning can explain the persistence of
In the 1930s, B. F. Skinner showed that a pi- fears. Initially, people develop fear responses to
geon will learn to press on a bar if pressing it is previously neutral stimuli through classical con-
associated with the delivery of food and will learn ditioning. Then, through operant conditioning,
to avoid pressing another bar if pressing it is asso- they develop behaviors designed to avoid trig-
ciated with an electric shock. Similarly, a child will gers for that fear. For example, a woman may
learn to make his bed if he receives a hug and a have a fear of bridges developed through classi-
kiss from his mother each time he makes the bed, cal conditioning: She fell off a bridge into icy wa-
and he will learn to stop hitting his brother if he ters as a child, and now any time she nears a
doesn't get to watch his favorite television show bridge she feels very anxious. This woman then
every time he hits his brother. develops elaborate means of getting around her
In operant conditioning, behaviors will be hometown without having to cross
learned most quickly if they are paired with the any bridges. Avoiding the bridges re-
reward or punishment every time the behavior is duces her anxiety, and thus her
emitted. This consistent response is called a con- avoidant behavior is reinforced. This
tinuous reinforcement schedule. Behaviors can be woman has developed a conditioned
learned and maintained, however, on a partial avoidance response through operant
reinforcement schedule, in which the reward or conditioning. As a result, however,
punishment occurs only sometimes in response to she never exposes herself to a bridge
the behavior. Extinction-eliminating a learned and never has the opportunity to ex-
behavior-is more difficult when the behavior tinguish her initial fear of bridges. As
was learned through a partial reinforcement we shall see, many of the therapeutic
schedule than when the behavior was learned techniques developed by behavioral
through a continuous reinforcement schedule. theorists are designed to extinguish
I~ This is because the behavior was learned under conditioned avoidance responses, Gambling is reinforced by wins
conditions of occasional reward, so a constant re- which can interfere greatly with a only occasionally, but this makes
it more difficult to extinguish the
ward is not needed to maintain the behavior. A person's ability to function in every- behavior.
good example is gambling behavior. People who day life.
Modeling and Observational Learning

Skinner and other "pure" behaviorists argued that
humans and animals learn behaviors only by di-
rectly experiencing rewards or punishments for
the behaviors. In the 1950s, however, psychologist
Albert Bandura argued that people also learn be-
haviors by watching other people, a view that
came to be known as social learning theory. First, in
modeling, people learn new behaviors from imi-
tating the behaviors modeled by important people
in their lives, such as their parents. Learning
through modeling is more likely to occur when the
person modeling the behavior is seen as an authority
figure or is perceived to be like oneself. For exam- Behavioral therapy is very effective for treating phobias .
ple, Bandura (1969) argued that children are most
likely to imitate the behaviors modeled by their
same-sex parent, because this parent is an authority
figure and because their same-sex parent seems gradual method for extinguishing anxiety re-
more similar to them than does their opposite- sponses to stimuli and the maladaptive behavior
sex parent. that often accompanies this anxiety. In systematic
Second, observational learning takes place desensitization, the client first learns relaxation
when a person observes the rewards and punish- exercises and then develops a hierarchy of feared
ments that another person receives for his or her stimuli, ranging from stimuli that would cause
behavior and then behaves in accordance with him or her only mild anxiety to stimuli that would
those rewards and punishments. For example, a cause severe anxiety or panic. A person with a
child who views her sibling being punished for snake phobia might put at the bottom of his hier-
dropping food on the floor will learn, through ob- archy "imagining a snake in a closed container
servation, the consequences of dropping food on across the room." A little further up on the hierar-
the floor and will be less likely to engage in this chy might be "watching someone else handle a
behavior herself. Some theorists argue that even snake." At the top of his hierarchy might be
extremely negative behaviors, such as teenagers "touching a snake myself." Then the therapist
going on a shooting rampage, are also due to ob- would help him proceed through this hierarchy,
servational learning. Teenagers see figures in the starting with the least-feared stimulus. He would
media being rewarded for violent behavior with be instructed to vividly imagine the feared stimu-
fame and thus learn that behavior. They also are lus, or even be exposed to the feared stimulus for
directly rewarded for violent behavior in certain a short period, while implementing relaxation ex-
video games. ercises to control the anxiety. When he gets to the
point where he can imagine or experience the
Behavioral Therapies least-feared stimulus without feeling anxious, he
Behavioral therapies focus on identifying those moves on to the next-most-feared stimulus, imag-
reinforcements and punishments that contribute ining or experiencing it while implementing re-
to a person's maladaptive behaviors and on chang- laxation exercises. This process continues until he
ing specific behaviors. The foundation for behav- reaches the most-feared stimulus on the list and is
ioral therapy is the behavioral assessment of the able to experience this stimulus without anxiety.
client's problem. The therapist works with the cli- Thus, by the end of systematic desensitization
ent to identify the specific circumstances that seem therapy, a person with a snake phobia should be
to elicit the client's unwanted behavior or emo- able to pick up and handle a large snake without
tional responses: What situations seem to trigger becoming anxious.
anxiety symptoms? When is the client most likely Often, systematic desensitization therapy is
to begin heavy drinking? What types of interac- combined with modeling- the client might watch
tions with other people make the client feel most as the therapist picks up a snake, pets it, and plays
distressed? with it, observing that the therapist is not afraid, is
There are many specific techniques for behav- not bitten or choked, and seems to enjoy playing
ior change (Table 2.2). A mainstay of behavior with the snake. Eventually, the client is encour-
therapy is systematic desensitization therapy, a aged to imitate the therapist's behaviors with and
TABLE 2.2 Behavior Change Techniques
These are some of the methods used in behavior therapy.
Label Description
Removal of reinforcements Removes the individual from the reinforcing situation or environment
Aversion therapy Makes the situation or stimulus that was once reinforcing no longer
reinforcing
Relaxation exercises Help the individual volunt arily control physiological manifestations
of anxiety
Distraction techniques He lp the individual temporarily distract from anxiety-producing
situations; divert attention from physiological manifestations
of anxiety
Flooding, or implosive, therapy Exposes the ind ividual to the dreaded or feared stimulus while
preventing avoidant behavior
Systematic desensitization Pairs the implementation of relaxation techniques w ith hierarch ical
exposure to the aversive stimulus
Response shaping through operant Pairs rewards with desired behaviors
conditioning
Behavioral contracting Provides rewards for reaching proximal goals
Modeling and observationa l learning Models desired behaviors, so that the client can learn through
observation
reactions to the snake. In some cases, people un- The behavioral theories do have limitations.
dergoing systematic desensitization are asked only How behavioral principles could account for some
to imagine experiencing the feared stimuli. In disorders, such as schizophrenia, is unclear. Also,
other cases, they are asked to experience these most evidence for behavioral theories is from labo-
stimuli directly, actually touching and holding the ratory studies, but, as we discuss in Chapter 4, lab
snake, for example. This latter method, known as results do not always apply to the complexity of
in vivo exposure, generally has stronger results the real world. Further, the behavioral theories
than exposure only in the client's imagination have been criticized for not recognizing free will in
(Follette & Hayes, 2000). people's behaviors-the active choices people
make to defy the external forces acting on them.
Assessing Behavioral Approaches

Behavioral theorists set the standard for scien-
C og nitive Approaches
tifically testing hypotheses about how normal Cognitive theories argue that it is not simply re-
and abnormal behaviors develop. The hypothe- wards and punishments that motivate human be-
ses developed from these theories are precise, havior. Instead, our cognitions-thoughts or
and the studies that have been done to test these beliefs-shape our behavior and the emotions we
hypotheses are rigorously controlled and exact. experience.
As we will see in subsequent chapters, these When something happens to us, we ask our-
studies have provided strong support for behav- selves why that event happened (Abramson,
ioral explanations of many types of abnormal Metalsky, & Alloy, 1989; Abramson, Seligman, &
behavior, particularly anxiety disorders such as Teasdale, 1978). The answer to this "why" ques-
phobias and panic disorder (Newmann et al., tion is our causal attribution for the event. The
2011). Similarly, the effectiveness of behavior attributions we make for events can influence our
therapies has been extensively and systemati- behavior because they impact the meaning we
cally supported in controlled studies (Follette & give to events and our expectations for similar
Hayes, 2000). events in the future.
The attributions we make for our People who hold such beliefs often will react ~
own behavior can affect our emotions to situations with irrational thoughts and behav-
and self-concept. For example, if we iors and negative emotions. For example, someone
act rudely toward another person and w ho believes that she must be completely compe-
attribute this behavior to situational tent, intelligent, and achieving in all areas of her
factors (the other person acted rudely life will be extremely upset by even minor failures
first), we may feel slightly guilty but or unpleasant events. If she were to score poorly
we may also feel justified. However, if on an exam, she may have thoughts such as "I am
we attribute our rude behavior to per- a total failure. I will never amount to anything. I
sonality factors (I am a rude person), should have gotten a perfect score on that exam."
then we may feel guilty and diminish
our self-esteem.
Cognitive Therapies
In addition to making attributions
Cognitive therapies help clients identify and
for specific events, we have broad be-
Aaron Beck is one of the challenge their negative thoughts and dysfunc-
liefs about ourselves, our relationships,
founders of cognitive theories tional belief systems. Cognitive therapists also
and the world. These can be either pos-
of psychopathology. help clients learn more effective problem-solving
itive and helpful to us or negative and
techniques for dealing with the concrete problems
destructive. These broad beliefs are
in their lives. Cognitive therapy is designed to be
called global assumptions. Two prom-
short-term, on the order of 12 to 20 weeks in dura-
inent proponents of this view are Albert Ellis and
tion, with one or two sessions per week (Beck,
Aaron Beck. They argued that most negative emo-
Rush, Shaw, & Emery, 1979). There are three main
tions or maladaptive behaviors are the result of one
goals in cognitive therapy (Beck, 1976):
or more of the dysfunctional global assumptions
that guide a person's life. Some of the most com- 1. Assist clients in identifying their irrational
mon dysfunctional assumptions are these: and maladaptive thoughts. A client might
be asked to keep a diary of thoughts she has
1. I should be loved by everyone for everything
whenever she feels anxious. ~
I do.
2. Teach clients to challenge their irrational
2. It is better to avoid problems than to face
or maladaptive thoughts and to consider
them.
alternative ways of thinking. A client might
3. I should be completely competent, intelligent, be asked to evaluate the evidence for a belief
and achieving in all I do. or to consider how other people might think
4. I must have perfect self-control. about a difficult situation.
3. Encourage clients to face their worst fears
about a situation and recognize ways they
could cope.
Cognitive techniques are often combined
with behavioral techniques in what is known as
cognitive-behavioral therapy, or CBT. The thera-
pist may use behavioral assignments to help the
client gather evidence concerning his or her be-
liefs, to test alternative viewpoints about a situa-
tion, and to try new methods of coping with
different situations. These assignments are pre-
sented to the client as ways of testing hypotheses
and gathering information that will be useful in
therapy regardless of the outcome. The assign-
ments can also involve trying out new skills, such
as skill in communicating more effectively, be-
tween therapy sessions.
The following case study illustrates how a
therapist might use behavioral assignments to pro-
A socially anxious client may be given the behavioral assignment to talk with
vide a depressed student with opportunities to
a stranger at a party. practice new skills and to gather information about
thoughts that contribute to negative emotions.
-r~""Q;' ,~.-. "">:;r
CASE_STUDY (2) a method of investigating

A student was unable to the mind, and (3) a form of
complete her degree because she feared meeting treatment for psychopathology
with a professor to discuss an incomplete grade (McWilliams & Weinberger,
she had received in a course. She was quite con- 2003). As we noted in Chap-
vinced that the professor would "scream at her" ter 1, Freud was a Viennese
and had been unable to comp lete a homework neurologist who became in-
assignment to call the professor's secretary to ar- terested in unconscious pro-
range a meeting. An in vivo task was agreed on in cesses while working with
which she called the professor from her thera- Jean Charcot in Paris in the
pist's office. Her thoughts and feelings before, late nineteenth century. He
during, and after the call were carefully exam- then returned to Vienna and
ined. As might be expected, the professor was worked with physician Josef
quite glad to hear from his former student and Breuer, most notably on the
was pleased to accept her final paper. She was case of" Anna 0."
able to see that her beliefs were both maladap- Anna 0. had extensive
tive and erroneous. (Adapted from Freeman & symptoms of hysteria-
Reinecke, 1995, pp. 203-204) physical ailments with no
apparent physical cause-
including paralysis of the legs
Sigmund Freud believed that normal and
and right arm, deafness, and abnormal behaviors are motivated by
disorganized speech. Breuer needs and drives. most of which are
Assessing Cognitive Approaches attempted to hypnotize Anna unconscious.
Particularly in studies of mood disorders and anxi- 0., hoping he could cure her
ety disorders, and increasingly in studies of sexual symptoms by suggestion.
disorders and substance use disorders, evidence Anna 0. began to talk about painful memories
demonstrates the effect of maladaptive cognitions from her past, which apparently were tied to the
Goormann, 2008). Further, as we will see in subse- development of her hysterical symptoms. She ex-
quent chapters, cognitive therapies have proven pressed a great deal of distress about these memo-
useful in the treatment of these disorders (Hollon & ries, but following the recounting of the memories
Dirnidjian, 2008). under hypnosis, many of her symptoms went
The greatest limitation of the cognitive theo- away. Breuer labeled the release of emotions con-
ries has been the difficulty of proving that mal- nected to these memories catharsis, and Anna 0.
adaptive cognitions precede and cause disorders, labeled the entire process her "talking cure."
rather than being the symptoms or consequences Breuer and Freud suggested that hysteria is
of the disorders. For example, it is clear that de- the result of traumatic memories that have been
pressed people think depressing thoughts. But is repressed from consciousness because they are
this a cause of their depression or a symptom of it? too painful. They defined repression as the moti-
It turns out to be harder than you might think to vated forgetting of a difficult experience, such as
answer this question definitively. being abused as a child, or of an unacceptable
wish, such as the desire to hurt someone. Repres-
sion does not dissolve the emotion associated
Psychodynamic Approaches
with the memory or wish. Instead, argued Breuer
The psychodynamic theories of abnormality sug- and Freud, this emotion is "dammed up" and
gest that all behaviors, thoughts, and emotions, emerges as symptoms.
whether normal or abnormal, are influenced to a
large extent by unconscious processes (McWilliams The ld, Ego, and Superego
& Weinberger, 2003). The psychodynamic theories Freud believed that the two basic drives that moti-
began with Sigmund Freud in the late nineteenth vate human behavior are the sexual drive, which
century and have expanded to include several he referred to as libido, and the aggressive drive
newer theories. These theories accept many of (McWilliams & Weinberger, 2003) . The energy
Freud's basic assumptions about the workings of from these drives continually seeks to be released
the human mind but emphasize different processes but can be channeled or harnessed by different
from those that Freud emphasized. psychological systems. Most of Freud's writings
Freud developed psychoanalysis, which refers focused primarily on libido (or libidinal drive), so
to (1) a theory of personality and psychopathology, our discussion will do so as well.
prompting the ego to push them back into the

unconscious. This pushing of material back into
the unconscious is repression (McWilliams &
Weinberger, 2003) .
Freud-and later his daughter, Anna Freud-
described certain strategies, or defense mecha-
nisms, that the ego uses to disguise or transform
unconscious wishes. The particular defense mech-
anisms that a person regularly uses shape his or
her behavior and personality. Table 2.3 provides a
list and examples of the basic defense mecha-
nisms. Everyone uses defense mechanisms to a
degree, because everyone must protect against
awareness of unacceptable wishes and conform to
societal norms. When a person's behavior be-
ScienceCartoonsP/us.com comes ruled by defense mechanisms or when the
mechanisms themselves are maladaptive, how-
ever, these mechanisms can result in abnormal,
pathological behavior.
According to Freud, three systems of the hu-
man psyche that help regulate the libido are the id, Psychosexual Stages
the ego, and the superego (McWilliams & Wein- Psychoanalytic theory argues that the nurturance a
berger, 2003). The id is the system from which the child receives from his or her early caregivers
libido emerges, and its drives and impulses seek strongly influences personality development.
immediate release. The id operates by the pleasure Freud proposed that as children develop they pass
principle-the drive to maximize pleasure and through a series of universal psychosexual stages.
minimize pain as quickly as possible. In each stage, sexual drives are focused on the
Freud argued that as children grow older, they stimulation of certain body areas, and particular
become aware that they cannot always quickly sat- psychological issues can arouse anxiety in the
isfy their impulses. A part of the id splits off and child. The responses of caregivers, usually parents,
becomes the ego, the force that seeks to gratify our to the child's attempts to satisfy basic needs and
wishes and needs in ways that remain within the wishes can greatly influence whether a given stage
rules of society for their appropriate expression. is negotiated successfully. If the parents are not ap-
A preschooler who may wish to suckle at the propriately responsive, helping the child learn ac-
mother's breast but is aware that this is no longer ceptable ways of satisfying and controlling his or
allowed may satisfy himself with cuddling in his her drives and impulses, the child can become fix-
mother's lap. ated at a stage, trapped in the concerns and issues
Freud further argued that the superego devel- of that stage and never successfully moving be-
ops from the ego a little later in childhood. It is the yond that stage and through the subsequent stages.
storehouse of rules and regulations for the conduct According to Freud, the earliest stage of life,
of behavior that are learned from one's parents the oral stage, lasts for the first 18 months following
and from society. These rules and regulations are birth. In the oral stage, libidinal impulses are best
in the form of absolute moral standards. We inter- satisfied through stimulation of the mouth area,
nalize these moral standards because living ac- usually through feeding or sucking. At this stage,
cording to them reduces anxiety (McWilliams & the child is entirely dependent on caregivers for
Weinberger, 2003). gratification, and the central issues of this stage are
Freud believed that most interactions among issues of one's dependence and the reliability of
the id, ego, and superego occur in the unconscious, others. If the child's caregiver, typically the mother,
completely out of our awareness. The precon- is not adequately available to the child, he or she
scious is intermediate between the unconscious can develop deep mistrust and fear of abandon-
and the conscious. Some material (wishes, needs, ment. Children fixated at the oral stage develop an
or memories) from the unconscious can make its "oral personality," characterized by excessive de-
way into the preconscious but rarely reaches the pendence on others but mistrust of others' love.
conscious level. Because these unconscious desires A number of habits focused on the mouth area-
are often unacceptable to the individual or society, for example, smoking or excessive drinking and
they cause anxiety if they seep into the conscious, eating-are said to reflect an oral character.
TABLE 2.3 Defense Mechanisms
These defense mechanisms were described by Sigmund and Anna Freud .
Defense Mechanism Definition Example
Regression Retreating to a behavior of an earlier A woman abandoned by he r lover curls up

developmental period to prevent in a cha i r, rocking and sucking her fingers.
anxiety and satisfy current needs
Denial Refusing to perceive or accept reality A husband whose wife recently died den ies
she is gone and actively searches for her.
Displacement Discharging unacceptable feelings A woman who is angry at her ch ildren
against someone or something other kicks a dog.
than the true ta rget of these feelings
Rationalization Inventing an acceptable motive to A soldier who killed innocent civilians
explain unacceptably motivated rationalizes that he was only following
behavior orders.
Intellectualization Adopting a cold, distanced perspective An emergency room physician who is
on a matter t hat actually creates strong, troubled by seeing young people with
unp leasant feelings severe gunshot wounds every night has
discussions with colleagues that focus only
on the technical aspects of treatment.
Projection Attributing one's own unacceptable A husband who is sexua lly attracted to a
motives or desires to someone else colleague accuses his wife of cheating on him.
Reaction formation Adopting a set of attitudes and A man who cannot accept his own
behaviors that are the opposite of homosexuality becomes extremely
one's true dispositions homophobic.
Identification Adopting the ideas, values, and Prisoners adopt the attitudes of thei r
tendencies of someone in a superior captors toward other prisoners .
position in order to elevate self-worth
Sublimation Translating wishes and needs into An adolescent with strong aggressive
socially acceptable behavior impulses tra in to be a boxer.
The anal stage lasts from about 18 months to against them by castrating them. This fear leads
3 years of age. During this phase, the focus of grat- them to put aside their desire for their mother and
ification is the anus. The child becomes very inter- aspire to become like their father. The successful
ested in toilet activities, particularly the passing resolution of the Oedipus complex helps instill a
and retaining of feces. Parents can cause a child to strong superego in boys, because it results in boys
become fixated at this stage by being too harsh or identifying with their father and their father's
critical during toilet training. People with an "anal value system.
personality" are said to be stubborn, over control- Freud believed that, during the phallic stage,
ling, stingy, and too focused on orderliness and girls recognize that they do not have a penis and
tidiness. are horrified at this discovery. They also recognize
During the phallic stage, lasting from about age that their mother does not have a penis and disdain
3 to age 6, the focus of pleasure is the genitals. Dur- their mother and all females for this deficit. Girls
ing this stage, one of the most important conflicts develop an attraction for their father, in hopes that
of sexual development occurs, and it occurs differ- he will provide the penis they lack. Freud labeled
ently for boys and girls. Freud believed that boys this the Electra complex, after the character in Greek
~ become sexually attracted to their mother and hate mythology who conspires to murder her mother to
their father as a rival. Freud labeled this the Oedi- avenge her father's death. Girls cannot have castra-
pus complex, after the character in Greek mythol- tion anxiety, because, according to Freud, they feel
ogy who unknowingly kills his father and marries they have already been castrated. As a result, girls
his mother. Boys fear that their father will retaliate do not have as strong a motivation as boys to
develop a superego. Freud argued that females throughout adulthood, and they affect all our sub-
never develop superegos as strong as those of sequent relationships. More contemporary types
males and that this leads to a greater reliance on of psychoanalysis include self psychology and
emotion than on reason in the lives of women. relational psychoanalysis, which emphasize the
Freud also thought that much of women's behavior unconscious dimensions of our relationships with
is driven by penis envy-the wish to have the male one another from pregnancy and infancy through-
sex organ. out all of life.
The unsuccessful resolution of the phallic stage Carl Jung, who was a student of Freud, re-
can lead to a number of psychological problems in jected many of Freud's ideas about the importance
children. If children do not fully identify with their of sexuality in development. He argued that spiri-
same-sex parent, they may not develop "appropri- tual and religious drives were as important as sex-
ate" gender roles or a heterosexual orientation. ual drives, and he suggested that the wisdom
They also may not develop a healthy superego and accumulated by a society over hundreds of years
may become either too self-aggrandizing or too of human existence is stored in the memories of
self-deprecating. If children's sexual attraction to individuals. He referred to this wisdom as the
their parents is not met with gentle but firm dis- collective unconscious.
couragement, they may become overly seductive
or sexualized and have a number of problems in Psychodynamic Therapies
future romantic relationships. Therapies based on Freud's classical psychoana-
After the turmoil of the phallic stage, children lytic theory and on later psychodynamic theories
enter the latency stage, during which libidinal focus on uncovering and resolving the uncon-
drives are quelled somewhat. Their attention turns scious processes that are thought to drive psycho-
to developing skills and interests and becoming logical symptoms. The goal of psychodynamic
fully socialized into the world in which they live. therapies is to help clients recognize their mal-
They play with friends of the same sex and avoid adaptive coping strategies and the sources of their
children of the opposite sex. unconscious conflicts. The resulting insights are
At about age 12, children's sexual desires thought to free clients from the grip of the past and
emerge again as they enter puberty, and they enter give them a sense of agency in making changes in
the genital stage. If they have successfully resolved the present (Vakoch & Strupp, 2000).
the phallic stage, their sexual interests turn to het- Freud and others developed the method of
erosexual relationships. They begin to pursue ro- free association, in which a client is taught to talk
mantic alliances and learn to negotiate the world about whatever comes to mind, trying not to cen-
of dating and early sexual encounters with mem- sor any thoughts. The therapist notices what
bers of the opposite sex. themes seem to recur in a client's free associations,
exactly how one thought seems to lead to another,
Later Psychodynamic Theories and the specific memories that a client recalls.
Many of Freud's followers modified his original The material the client is reluctant to talk
psychoanalytic theory, leading to a group of about during psychotherapy- that is, the client's
theories collectively referred to as psychodynamic resistance to certain material-is an important
theories. Anna Freud extended her work on de- clue to the client's central unconscious conflicts,
fense mechanisms to develop the field of ego because the most threatening conflicts are those
psychology, emphasizing the importance of the the ego tries hardest to repress (Vakoch & Strupp,
individual's ability to regulate defenses in ways 2000). The therapist eventually puts together these
that allow healthy functioning within the reali- pieces of the puzzle to form a suggestion or an
ties of society. interpretation of a conflict the client might be fac-
Other theorists also focused on the role of the ing and then voices this interpretation to the cli-
ego as an independent force striving for mastery ent. Sometimes, the client accepts the interpretation
and competence (e.g., Jacobson, 1964; Mahler, as a revelation. Other times, the client is resistant
1968). The object relations perspective integrated to the interpretation. The therapist might interpret
significant aspects of Sigmund Freud's drive the- resistance as a good indication that the interpre-
ory with the role of early relationships in the devel- tation has identified an important issue in the
opment of self-concept and personality. According client's unconscious.
to proponents of this perspective-such as Melanie The client's transference to the therapist is
Klein, Margaret Mahler, and Otto Kernberg- our also a clue to unconscious conflicts and needs.
early relationships create images, or representa- Transference occurs when the client reacts to the
tions, of ourselves and others. We carry these images therapist as if the therapist were an important
person in the client's early development, such as satisfying theories. They explain both normal and
his or her father or mother. For example, a client abnormal behavior with similar processes. Also,
may find himself reacting with rage or extreme they have an "Aha!" quality about them that
fear when a therapist is just a few minutes late for leads us to believe they offer important insights.
an appointment, a reaction that might stem from Psychodynamic theories have played a major role
his feelings of having been emotionally aban- in shaping psychology and psychiatry over the
doned by a parent during childhood. The thera- past century.
pist might point out the ways the client behaves Psychodynamic theories also have many lim-
that represent transference and might then help itations and weaknesses. Chief among these is
the client explore the roots of this behavior in the that it is difficult or impossible to test their fun-
client's relationships with significant others. damental assumptions scientifically (Erdelyi,
By working through, or going over and over, 1992; but see Lubarsky & Barrett, 2006; Westen,
painful memories and difficult issues, clients are 1998). The processes described by these theories
able to understand them and weave them into are abstract and difficult to measure. Because the
their self-definition in acceptable ways. This al- key factors thought to be influencing behavior
lows them to move forward in their lives. Psycho- are unconscious and unobservable, it is easy to
dynamic therapists believe that catharsis, or the provid e explanations for why a particular pre-
expression of emotions connected to memories diction might not be borne out in a particular
and conflicts, is also central to the healing pro- circumstance.
cesses in therapy. Catharsis unleashes the energy As for psychodynamic therapy, its long-term,
bound in unconscious memories and conflicts, al- intensive nature makes it unaffordable for many
lowing this material to be incorporated into a more people. In addition, people suffering from acute
adaptive self-view. problems, such as severe depression or anxiety, of-
What is the difference between classical psy- ten cannot tolerate the lack of structure in tradi-
choanalysis and modern psychodynamic therapy? tional psychodynamic therapy and need more
Psychoanalysis typically involves three or four immediate relief from their symptoms (Bachrach,
sessions per week over a period of many years. Galatzer-Levy, Skolnikoff, & Waldron, 1991).
The focus of psychoanalysis is primarily on the in- For these reasons, modern psychodynamic
terpretation of transferences and resistances, as therapists have developed some shorter-term,
well as on experiences in the client's past (Lubor- more structured versions of psychodynamic ther-
sky & Barrett, 2006). Psychodynamic therapy also apy (Luborsky, 1984). Studies conducted on the ef-
may go on for years, but it can be as short as fectiveness of these short-term therapies suggest
12 weeks (Crits-Christoph & Barber, 2000). Trans- that they can result in significant improvement in
ferences, resistances, and the client's relationships symptoms for people with psychological problems
with early caregivers are also the focus of psycho- (Gibbons, Crits-Christoph, & Hearon, 2008).
dynamic therapy, but the psychodynamic thera- This book focuses on those theories of specific
pist, compared with the psychoanalyst, may focus disorders, and the therapies for these disorders,
more on current situations in the client's life. that have received substantial scientific support.
Interpersonal therapy, or IPT, emerged out of Because psychodynamic theories and therapies
modern psychodynamic theories of psychopathol- have had much less empirical support than many
ogy, which shifted the focus from the unconscious newer psychological theories and therapies, we
conflicts of the individual to the client's pattern of will not discuss them in detail in reviewing the re-
relationships with important people in his or her search on most disorders.
life (Klerman, Weissman, Rounsaville, & Chevron,
1984; Weissman & Markowitz, 2002). IPT differs
from psychodynamic therapies in that the thera-
Humanistic Approaches
pist is much more structuring and directive in the Humanistic theories are based on the assumption
therapy, offering interpretations much earlier and that humans have an innate capacity for goodness
focusing on how to change current relationships. and for living a full life (Rogers, 1951). Pressure
IPT is designed to be a short-term therapy, often from society to conform to certain norms rather
lasting only about 12 weeks. than to seek one's most-developed self interferes
with the fulfillment of this capacity. The humanis-
Assessing Psychodynamic Approaches tic theorists recognized that we often are not
Psychodynamic theories are among the most com- aware of the forces shaping our behavior and that
prehensive theories of human behavior established the environment can play a large role in our hap-
to date. For some people, they are also the most piness or unhappiness. But they were optimistic
that once people recognized these aspects of the client's experience but rather tries to
forces and became freer to direct communicate an understanding of the client and
their own lives, they would natu- explicitly asks for feedback from the client about
rally make good choices and be this understanding.
happier.
Carl Rogers (1951) developed Assessing Humanistic Approaches
the most widely known version of The humanistic theories struck a positive chord in
humanistic theory. Rogers be- the 1960s and still have many proponents, espe-
lieved that, without undue pres- cially among self-help groups and peer-counseling
sure from others, individuals programs. The optimism and attribution of free
naturally move toward personal will of these theories are a refreshing change from
growth, self-acceptance, and self- the emphasis on pathology and external forces of
actualization-the fulfillment of other theories. Humanistic theories shift the focus
their potential for love, creativity, from what is wrong with people to questions about
and meaning. Under pressure how people can be helped to achieve their greatest
from society and family, however, potential. These theories have been criticized,
Carl Rogers (January 8. 1902- people can develop rigid and dis- however, for being vague and not subject to scien-
February 4. 1987) was among the torted perspectives of the self. tific testing (Bohart, 1990).
founders of the humanistic approach People often experience conflict Client-centered therapy has been used to treat
(or client-centered approach) to due to differences between their people with a wide range of problems, including
psychology.
true self, the ideal self they wish depression, alcoholism, schizophrenia, anxiety dis-
to be, and the self they feel they orders, and personality disorders (Bohart, 1990).
ought to be to please others. This conflict can lead Although some studies have shown that CCT
to emotional distress, unhealthy behaviors, and results in better outcomes than comparison thera-
even the loss of touch with reality. pies, other studies have not (Greenberg, Elliot, &
Lietaer, 1994). Some therapists believe that CCT
Humanistic Therapy may be appropriate for people who are moder-
The stated goal of humanistic therapy is to help ately distressed but insufficient for people who are
clients discover their greatest potential through seriously distressed (Bohart, 1995).
self-exploration (Bohart, 1995). The job of the ther-
apist in humanistic therapy is not to act as an au-
thority who provides healing to the client but
Family Systems Approaches
rather to provide the optimal conditions for the Family systems theories see the family as a com-
client to heal him- or herself. Humanistic thera- plex interpersonal system, with its own hierar-
pists do not push clients to uncover repressed chy and rules that govern family members'
painful memories or unconscious conflicts. In- behavior. The family system can function well
stead, they believe that when clients are supported and promote the well-being of its members, sup-
and empowered to grow, the clients eventually porting their growth and accepting their change.
will face the past when doing so becomes neces- Or the family system can be dysfunctional, creat-
sary for their further development (Bohart, 1995). ing and maintaining psychopathology in one or
The best known of these therapies is Carl more members (Mirsalimi, Perleberg, Stovall, &
Rogers's client-centered therapy (CCT; Rogers, Kaslow, 2003).
1951). In CCT, the therapist communicates a genu- When a member of the family has a psycho-
ineness in his or her role as helper to the client, logical disorder, family systems theorists see it not
acting as an authentic person rather than an au- as a problem within the individual but as an indi-
thority figure . The therapist also shows uncondi- cation of a dysfunctional family system. The par-
tional positive regard for the client and ticular form that any individual's psychopathology
communicates an empathic understanding of the takes depends on the complex interactions among
client's underlying feelings and search for self. the family's cohesiveness, adaptability to change,
The main strategy for accomplishing these and communication style (Mirsalimi et al., 2003).
goals is the use of reflection. Reflection is a method For example, an inflexible family is resistant to
of response in which the therapist expresses an at- and isolated from all forces outside the family and
tempt to understand what the client is experiencing does not adapt well to changes within the family,
and trying to communicate (Bohart, 1995). The ther- such as a child moving into adolescence. In an en-
apist does not attempt to interpret the unconscious meshed family, each member is overly involved in
SHADES OF GRAY
I
A student comes into a therapist's office to discuss How might a humanistic therapist versus a
her feelings about her schoolwork and career. She psychodynamic therapist respond to this
says "I'm feeling so lost in my career. Every time I student's concerns? (Discussion appears at
seem to be getting close to doing something really the end of this chapter.)
good, like acing a class, I somehow manage to screw
it up. I never feel like I am really using my potential.
There is a block there:' (Bohart, 1995, p. 101 ).
the lives of the others, to the point that individuals the dysfunction of the family system (Minuchin,
do not have personal autonomy and can feel con- 1981; Satir, 1967).
trolled. A disengaged family, in contrast, is one in Behavioral family systems therapy (BFST) targets
which the members pay no attention to each other family communication and problem solving, those
and operate as independent units isolated from beliefs of parents and adolescents that impede com-
other family members. And in pathological trian- munication, and systemic barriers to problem solv-
gular relationships, parents avoid dealing with ing (Robin, 2003). Behavioral and cognitive methods
conflicts with each other by always keeping their are used to teach problem-solving and communica-
children involved in their conversations and action skills and to challenge the unhelpful beliefs of
tivities (Mirsalimi et al., 2003). So a family theorist parents and teens. Therapists also address dysfunc-
trying to understand Steven Hayes's anxiety tional family system characteristics, such as weak
would examine how his family functioned as he coalitions between parents. Therapists actively pro-
was growing up and how that continues to influ- vide instructions, feedback, and opportunities for
ence him as an adult. the rehearsal of skills and role playing.
Some of the research on family systems theo-
ries of psychopathology has focused on disorders Assessing Family Systems Approaches
presented by the children in the family, particu- Family systems theories have led to therapeutic ap-
larly eating disorders (e.g., Minuchin, Rosman, & proaches that have proven useful for treating some
Baker, 1978; Robin, 2003). This research suggests types of disorders (Mirsalimi et al., 2003). Family
that many young girls who develop eating disor- systems therapies may be particularly appropriate
ders are members of enmeshed families . The par-
ents of these girls are overcontrolling and
overinvested in their children's success, and in
turn the children feel smothered and dependent
on their parents. Anorexia nervosa, a disorder in
which an individual refuses to eat and becomes
emaciated, may be a girl's way of claiming some
control over her life. The family system of these
girls supports the anorexia rather than helping
them overcome it. The anorexia becomes a focal
point and excuse for the family's enmeshment.
(See also Chapter 12.)
Family systems therapy is based on the belief
that an individual's problems are always rooted in
interpersonal systems, particularly family sys-
tems. According to this viewpoint, you cannot
help an individual without treating the entire fam-
ily system that created and is maintaining the indi-
vidual's problems. In fact, these theorists argue
that the individual may not even have a problem
Family therapists work with the entire family rather than with only the "identified
but rather has become the "identified patient" in patient:
the family, carrying the responsibility or blame for
in the treatment of children, because children are so experiential avoidance-that is, avoidance of painful
much more entwined in their families than are thoughts, memories, and feelings-is at the heart
adults. Although the details of many family sys- of many mental health problems. Accepting one's
tems theories have not been thoroughly tested in feelings, thoughts, and past history and learning to
research, it is clear that families can contribute to or be present in the moment are key to achieving pos-
help diminish the psychological symptoms of their itive change. ACT uses a variety of techniques to
members (e.g., Mirsalimi et al., 2003). However, help individuals accept their emotions, be present
much more research on family systems theories in the moment, relate to their thoughts differently
and therapies is needed. Such research is difficult (e.g., watching them as external objects), and com-
to carry out, because it usually involves observing mit to changing their behaviors in accord with
people in the context of their relationships, which their goals and values. ACT has been used in pre-
are difficult to capture in a laboratory setting. liminary trials in the treatment of a wide variety of
problems, especially in the area of substance abuse
and dependence (Hayes et al., 2006).
Third-Wave Approaches
In recent years, a group of psychotherapeutic ap- Assessing Third-Wave Approaches
proaches known as third-wave approaches (the first The third-wave approaches have their roots in
wave was behavioral approaches, and the second well-established behavioral and cognitive theories
wave was cognitive approaches) has become promi- and techniques, but they draw innovative ideas
nent in the theory and treatment of psychological and techniques from spiritual and philosophical
disorders. Several of these approaches view poor traditions, such as Buddhism, and theories of adap-
regulation of emotions as a transdiagnostic risk fac- tive emotion-regulation. Existing studies of the ef-
tor at the core of many forms of psychopathology, fectiveness of therapies based on emotion-focused
including depression, anxiety, substance abuse, and approaches suggest that these therapies may be
most personality disorders (Campbell-Sills & Barlow, helpful in the treatment of a wide range of mental
2007; Kring & Sloan, 2009). They combine techniques health problems (Hayes et al., 2006; Holzel et al.,
from behavioral and cognitive therapy with mind- 2011; Lynch et al., 2007). Much more research is
fulness meditation practices derived from Zen Bud- needed, however, particularly into claims of how
dhism to help individuals accept, understand, and and why these therapies may help individuals
better regulate their emotions. change their behaviors and emotional reactions.
The most-established third-wave approach is di-
alectical behavior therapy (DBT; Linehan, 1999). The Using New Technology
term dialectical in dialectical behavior therapy refers
to the constant tension between conflicting images or
to Deliver Treatment
emotions in people prone to certain forms of psycho- The burden of mental health problems in the world
pathology. Dialectical behavior therapy focuses on is much greater than the availability of mental
difficulties in managing negative emotions and in health professionals trained to deliver the inter-
controlling impulsive behaviors. The therapy inven tions described (Kazdin & Blase, 2011). For ex-
volves a number of behavioral and cognitive tech- ample, recent estimates by the World Health
niques and mindfulness exercises aimed at increasing Organization derived from studies done in 17 na-
problem-solving skills, interpersonal skills, and skill tions suggest that between 12 and 47 percent of
at managing negative emotions. DBT originally was individuals will have symptoms that meet the cri-
developed to treat people with borderline personal- teria for diagnosis of a mental disorder in their life-
ity disorder who were suicidal, and studies com- time (Kessler et al., 2009). In the United States,
paring this therapy to control conditions suggest lifetime rates of mental disorders are estimated at
that it can reduce suicidal thoughts and behaviors as 50 percent, with 25 percent of the population meet-
well as improve interpersonal skills (Lynch, Trost, ing the criteria for a diagnosis in any given year
Salsman, & Linehan, 2007). Most recently, DBT has (Kessler & Wang, 2008). That amounts to about
been adapted for the treatment of eating disorders 75 million people-when there are only about
(Safer, Telch, & Chen, 2009) and is being used to 700,000 mental health professionals in the United
treat other individuals with difficulties in emotional States (Kazdin & Blase, 2011). The rate of mental
regulation and impulse control (Lynch et al., 2007). health problems is especially high within disad-
Steven Hayes (Hayes et al., 2006), whom we vantaged ethnic minority groups (Alegria et al.,
met in the Extraordinary People feature at the be- 2008), but individuals in these groups tend to have
ginning of this chapter, is the founder of acceptance less access to mental health services than individuals
and commitment therapy (ACT), which assumes that in majority groups. For example, it is estimated that
only 12.5 percent of African Americans and 10.7 per- grocery stores) and little cohesion among neigh-
cent of Hispanic Americans needing mental health bors (Gustafsson et al., 2009). In turn, people living
care have access to appropriate care, compared to in poverty-stricken urban neighborhoods experi-
over 22 percent of European Americans (Wells, ence more substance abuse, juvenile delinquency,
Klap, Koike, & Sherbourne, 2001). In addition, be- depression, and anxiety (Belle & Doucet, 2003).
cause mental health care providers tend to be con- Second, the upheaval and disintegration of so-
centrated in urban areas of developed countries, cieties due to war, famine, and natural disaster are
people living in rural areas of the United States potent transdiagnostic risk factors for mental
and in developing areas of the world often have health problems. As we will discuss in Chapter 5,
very little access to mental health care. individuals who live in countries ravaged by war
Increasingly, new technology, including the or who must flee their homelands and live as refu-
Internet and smart phone applications, is being gees show high rates of posttraumatic stress disor-
used to deliver mental health care, with promising der and other mental health problems. For
effectiveness (Kazdin & Blase, 2011). For example, example, a study of citizens of Afghanistan found
a smart phone application known as Mobile Therapy that 42 percent could be diagnosed with posttrau-
prompts users to report their levels of happiness, matic stress disorder and 72 percent had some sort
sadness, anxiety, and anger on a touchscreen "mood of anxiety symptoms (Cardozo et al., 2004).
map." Based on users' reports, exercises based on Third, social norms and policies that stigmatize
cognitive-behavioral therapy techniques-such as and marginalize certain groups put individuals in
exercises to challenge negative thoughts-are pro- these groups at increased risk for mental health
vided to help individuals repair their mood. A problems even if they do not suffer socioeconomic
1-month study of the application showed that us- stress. For example, gay, lesbian, bisexual, and
ers became more self-aware of their moods and transgender individuals suffer higher rates of de-
of the triggers of negativity and that their skill pression, anxiety, and substance use compared to
in coping with their negative moods increased heterosexuals (Hatzenbuehler, 2009; Meyer, 2003).
(Morris et al., 2010). These higher rates have been linked to the experi-
Although the delivery of interventions through ence of discrimination based on sexual orientation
new technologies is only beginning in the mental and to social policies that disadvantage sexual
health field, it has been thriving in the field of health minorities (Hatzenbuehler, Nolen-Hoeksema, &
psychology, as we discuss in Chapter 15. Several Erickson, 2008; Meyer, 2003). For example, data from
studies have shown that interventions delivered a nationally representative study of over 34,000 par-
through the Internet, smart phones, regular phones, ticipants found higher rates of mental health
and even fictional television and radio shows have problems among lesbian, gay, and bisexual (LGB)
improved people's diets, leading to lower levels of respondents living in states with social policies that
obesity and diabetes; decreased levels of smoking; do not confer protection for LGB individuals (e.g.,
and increased the use of condoms to prevent sexu- states that do not treat anti-LGB violence as a hate
ally transmitted diseases (see Chapter 15; Kazdin & crime) compared to LGB respondents who reside
Blase, 2011). These interventions can be made avail- in states with protective policies (Hatzenbuehler,
able to people living in rural areas and developing Keyes, & Hasin, 2009). Another long-term study
countries and to people with modest incomes, and found increases in mental health problems among
they have been shown to be effective in these popu- LGB individuals living in states that instituted
lations (e.g., Munoz et al., 2006). bans on gay marriage in the 2004--2005 elections
(Hatzenbuehler, McLaughlin, Keyes, & Hasin, 2010).
SOCIOCULTURAL Thus, sociocultural discrimination at the level of
APPROACHES state policies can affect citizens' mental health.
Fourth, societies may influence the types of
Sociocultural approaches suggest that we need to psychopathology their members show by having
look beyond the individual or even the family to implicit or explicit rules about what types of abnor-
the larger society in order to understand people's mal behavior are acceptable (Castro et al., 2010).
problems. First, socioeconomic disadvantage is a Throughout this book, we will see that the rates of
transdiagnostic risk factor for a wide range of men- disorders vary from one culture or ethnic group to
tal health problems (Gustafsson, Larsson, Nelson, another and between males and females. For ex-
& Gustafsson, 2009). Individuals who are poor tend ample, people from "traditional" cultures, such as
to live in neighborhoods in which they are exposed the Old Order Amish in the United States, appear
to violence and inadequate schools and where to suffer less depression than people in modern
there are few resources for everyday living (such as cultures (Egeland & Hostetter, 1983). In addition,
the particular manifestations of disorders seem to generating ideas about what is causing their symp-
vary from one culture to another. For example, the toms and what changes they might want to make.
symptoms of anorexia nervosa, the disorder in These expectations can clash with cultural norms
which people refuse to eat, appear to be different in that require deference to people in authority (Sue &
Asian cultures than in American culture. Sue, 2003). A client from a culture in which one
Indeed, some disorders appear to be specific to speaks only when spoken to and never challenges
certain cultures (Alarcon et al., 2009). In Japan, there an elder or an authority figure may be extremely
is a disorder called taijinkyofusho, in which individu- uncomfortable with a therapist who does not di-
als have intense fears that their body displeases, em- rectly tell the client what is wrong and how to fix it.
barrasses, or is offensive to other people. Throughout Fourth, many clients who are in ethnic minority
Latin American and Mediterranean cultures, ataque groups may also be in lower socioeconomic groups,
de nervios is a common reaction to stress. People may while their therapists are likely to be in middle- or
feel out of control, displaying uncontrollable shout- upper-class socioeconomic groups. This situation
ing, crying, and trembling and verbal or physical can create tensions due to class differences as well
aggression. We will discuss the influence of culture as cultural differences (Miranda et al., 2005).
on the manifestation of distress further in Chapter 3. Some studies suggest that people from Latino,
Asian, and Native American cultures are more com-
fortable with structured and action-oriented thera-
Cross-Cultural Issues in Treatment pies, such as behavioral and cognitive-behavioral
For the most part, people from diverse cultures who therapies, than with the less structured therapies
seek psychotherapy are treated with the types of psy- (Miranda et al., 2005). The specific form of therapy
chotherapy described in this chapter, with little ad- may not matter as much as the cultural sensitivity
aptation of these approaches to specific cultures the therapist shows toward the client, whatever
(Castro et al., 2010). A number of the assumptions therapy is being used. Stanley Sue and Nolan Zane
inherent in mainstream psychological therapies, (1987, pp. 42-43) give the following example of the
however, can clash with the values and norms of importance of cultural sensitivity in the interaction
people in certain cultures. Therefore, therapists must between client and therapist. First, they describe
take a culturally sensitive approach to their clients the problems the client faced; then they describe
(Snowden & Yamada, 2005; Sue & Lam, 2002). how the therapist (one of the authors of the study)
First, most psychotherapies are focused on the responded to these problems.
individual-the individual's unconscious conflicts,
dysfunctional ways of thinking, maladaptive be-
havior patterns, and so on. In contrast, many cul-
tures focus on the group, or collective, rather than
CASE STUDY
At the advice of a close
on the individual (Sue & Sue, 2003). In these cul- friend, Mae C. decided to seek services at a mental
tures, the identity of the individual is not seen apart health center. She was extremely distraught and
from the groups to which that individual belongs- tearful as she related her dilemma. An immigrant
his or her family, community, ethnic group, and from Hong Kong several years ago, Mae met and
religion. If therapists fail to recognize this when married her husband (also a recent immigrant
working with clients from collectivist cultures, they from Hong Kong). Their marriage was apparently
may make useless or perhaps even harmful recom- going fairly well until six months ago when her
mendations, leading to conflicts between their husband succeeded in bringing over his parents
clients and important groups in the clients' lives from Hong Kong. While not enthusiastic about
that the clients cannot handle. having her parents-in-law live with her, Mae real-
Second, most psychotherapies value the expres- ized that her husband wanted them and that both
sion of emotions and the disclosure of personal con- she and her husband were obligated to help their
cerns, whereas many cultures, for example, Japanese parents (her own parents were still in Hong Kong).
culture, value restraint with regard to emotions and After the parents arrived, Mae found that she
personal concerns (Sue & Sue, 2003). Some counsel- was expected to serve them. For example, the
ors may view this restraint as a problem and try to mother-i n-law would expect Mae to cook and
encourage their clients to become more expressive. serve dinner, to wash all the clothes, and to do
Again, this effort can clash with the self-concepts of other chores. At the same time, she would con-
clients and with the norms of their culture. stantly complain that Mae did not cook the din-
Third, in many psychotherapies, clients are ner right, that the house was always messy, and
expected to take the initiative in communicating that Mae should wash certain clothes separately.
their concerns and desires to the therapist and in
The parents-in-law also displaced Mae and her so that we could discuss the suitability of having
husband from the master bedroom. The guest someone else intervene. Almost immediately, Mae
room was located in the basement, and the par- mentioned her uncle (the older brother of the
ents refused to sleep in the basement because it mother-in-law) whom she described as being quite
reminded them of a tomb. understanding and sensitive. We discussed what
Mae would occasionally complain to her she should say to the uncle. After calling her uncle,
husband about his parents. The husband would who lived about 50 miles from Mae, she reported
excuse his parents' demands by indicating "They that he wanted to visit them. The uncle apparently
are my parents and they're getting old:' In gen- realized the gravity of the situation and offered to
eral, he avoided any potential conflict; if he took help. He came for dinner, and Mae told me that she
sides, he supported his parents. Although Mae overheard a discussion between the uncle and
realized that she had an obligation to his parents, Mae's mother-in-law. Essentially, he told her that
the situation was becoming intolerable to her. Mae looked unhappy, that possibly she was work-
I (the therapist) indicated (to Mae) that con- ing too hard, and that she needed a little more
flicts with in-laws were very common, especially praise for the work that she was doing in taking
for Chinese, who are obligated to take care of care of everyone. The mother-in-law expressed
their parents . I attempted to normalize the prob- surprise over Mae's unhappiness and agreed that
lems because she was suffering from a great Mae was doing a fine job. Without directly con-
deal of guilt over her perceived failure to be the fronting each other, the uncle and his younger sis-
perfect daughter-in-law. I also conveyed my be- ter understood the subtle messages each conveyed.
lief that in therapy we could try to generate new Older brother was saying that something was
ideas to resolve the problem-ideas that did not wrong and younger sister acknowledged it. After
simply involve extreme courses of action such as this interaction, Mae reported that her mother-in-
divorce or total submission to the in-laws (which law's criticisms did noticeably diminish and that
she believed were the only options). she had even begun to help Mae with the chores.
I discussed Mae during a case conference with
other mental health personnel. It is interesting that
many suggestions were generated: Teach Mae how If Mae's therapist had not been sensitive to
to confront her parents-in-law; have her invite the Mae's cultural beliefs about her role as a daughter-
husband for marital counseling so that husband in-law and had suggested some of the solutions
and wife could form a team in negotiation with his put forward by his colleagues in the case confer-
parents; conduct extended family therapy so that ence, Mae might even have dropped out of ther-
Mae, her husband, and her in-laws could agree on apy. People from ethnic minority groups in the
contractual give-and-take relationships. The staff United States are much more likely than European
agreed that working solely with Mae would not Americans to drop out of psychosocial therapy
change the situation .... Confronting her in-laws (Snowden & Yamada, 2005). Because Mae's thera-
was discrepant with her role of daughter-in-law, pist was willing to work within the constraints of
and she felt very uncomfortable in asserting her- her cultural beliefs, he and Mae found a solution to
self in the situation. Trying to involve her husband her situation that was acceptable to her.
or in-laws in treatment was ill advised. Her hus- In treating children, cultural norms about child-
band did not want to confront his parents. More rearing practices and the proper role of doctors can
important, Mae was extremely fearful that her fam- make it difficult to include the family in a child's
ily might find out that she had sought psychother- treatment. For example, in a study of behavior ther-
apy. Her husband as well as her in-laws would be apy for children, Hong Kong Chinese parents were
appalled at her disclosure of family problems to a very reluctant to be trained to engage in behavioral
therapist who was an outsider. ... How could Mae's techniques, such as responding with praise or ignor-
case be handled? During the case conference, we ing certain behaviors. Such techniques violated the
discussed the ways that Chinese handle interper- parents' views of appropriate childrearing practices
sonal family conflicts which are not unusual to see. and their expectations that the therapist should be
Chinese often use third-party intermediaries to re- the person "curing" the child. However, several clini-
solve conflicts. The intermediaries obviously have cians argue that family-based therapies are more ap-
to be credible and influential with the conflicting propriate than individual therapy in cultures that are
parties. At the next session with Mae, I asked her to highly family-oriented, including Native American,
list the persons who might act as intermediaries, Hispanic, African American, and Asian American
cultures (Miranda et al., 2005).
Jeannette Rossell6 and Guillermo Bernal (2005) and a client's beliefs about the likely effectiveness
adapted both cognitive-behavioral therapy and in- of a therapy contribute strongly to the client's full
terpersonal therapy to be more culturally sensitive engagement in the therapy and its effectiveness.
in the treatment of depressed Puerto Rican adoles- However, studies testing treatments essentially
cents. The Puerto Rican value of familism, a strong have ignored the question of whether the effective-
attachment to family, was incorporated into the ness of treatments varies by cultural group or eth-
therapy. Issues of the balance between dependence nicity (Miranda et al., 2005). An analysis conducted
and independence were explicitly discussed in for the report of the Surgeon General (U.S. Depart-
family groups. The adapted therapies proved effec- ment of Health and Human Services, 2001) found
tive in treating the adolescents' depression. that of 9,266 participants involved in the efficacy
Must a therapist come from the same culture as studies forming the major treatment guidelines
the client to fully understand the client? A review for bipolar disorder, schizophrenia, depression,
of several studies suggests that ethnic matching is and attention-deficit/hyperactivity disorder, only
not an important predictor of how long clients re- 561 African Americans, 99 Americans of Latin de-
main in therapy or of the outcomes of therapy scent, 11 Asian Americans / Pacific Islanders, and
(Maramba & Nagayama Hall, 2002). Cultural sensi- no Native Americans were included. Few of these
tivity probably can be acquired through training studies could examine the impact of treatment on
and experience (Castro et al., 2010). In fact, a thera- specific minorities. There is obvious need for more
pist's being from the same ethnic or racial group as studies that specifically examine cultural variation
the client does not mean that therapist and client in the efficacy of psychotherapy.
share the same value system (Teyber & McClure, As for gender, there is little evidence that
2000). For example, a fourth-generation Japanese women or men do better in therapy with a thera-
American who has fully adopted the competitive pist of the same gender (Cottone, Drucker, & Javier,
and individualistic values of Americans may clash 2002; Huppert et al., 2001; Teyber & McClure,
with a recent immigrant from Japan who subscribes 2000). Women and men do tend to report that they
to the self-sacrificing, community-oriented values prefer a therapist of the same gender, however
of Japanese culture. Value differences among peo- (Garfield, 1994; Wintersteen, Mensinger, & Diamond,
ple of the same ethnic/ racial group may explain 2005). Because the client's comfort with a therapist
why studies show that matching the ethnicity, race, is an important contributor to a client's seeking
or gender of the therapist and the client does not therapy and continuing it for an entire course,
necessarily lead to a better outcome for the client gender matching may be important in therapy
(Maramba & Nagayama Hall, 2002). On the other (Winterstein et al., 2005).
hand, the relationship between client and therapist
Culturally Specific Therapies
Our review of the relationships between culture
or gender and therapy has focused on those forms
of therapy most often practiced in modern, indus-
trialized cultures, such as behavioral, cognitive,
and psychodynamic therapies. Even within mod-
ern, industrialized countries, however, cultural
groups often have their own forms of therapy for
distressed people (Hall, 2001; Koss-Chioino, 2000).
Let us examine two of these cultural therapies.
Native American healing processes focus si-
multaneously on the physiology, psychology, and
religious practices of the individual (Gone, 2010).
"Clients" are encouraged to transcend the self, to
experience the self as embedded in the community
and as an expression of the community. Family and
friends are brought together with the individual in
traditional ceremonies involving prayers, songs,
and dances that emphasize Native American cul-
tural heritage and the reintegration of the individ-
ual into the cultural network. These ceremonies
herapy adapted for Puerto Rican families incorporated the values of familism. may be supplemented by a variety of herbal medi-
cines that have been used for hundreds of years to
Common Elements in Effective Treatments 53
treat people exhibiting physical and psychological prevention strategies for reducing drug abuse and
symptoms. delinquency might include changing neighbor-
Hispanics in the southwestern United States hood characteristics that seem to contribute to
and Mexico suffering from psychological prob- drug use or delinquency.
lems may consult folk healers, known as curanderos Secondary prevention is focused on detecting
or curanderas (Chevez, 2005; Koss-Chioino, 2000). a disorder at its earliest stages and thereby prevent-
Curanderos use religion-based rituals, including ing the development of the full-blown disorder
prayers and incantations, to overcome the folk ill- (Munoz et al., 2010). Secondary prevention often
nesses believed to cause psychological and physi- involves screening for early signs of a disorder, for
cal problems. Curanderos also may apply healing example, administering a questionnaire to detect
ointments or oils and prescribe herbal medicines mild symptoms of depression. An intervention
(Chevez, 2005; Koss-Chioino, 2000). might be administered to individuals with mild
Native Americans and Hispanics often seek symptoms to prevent them from developing de-
help from both folk healers and mental health pro- pressive disorders. Several studies have shown that
fessionals who practice the therapies described in administering a cognitive-behavioral intervention
this chapter. Mental health professionals need to to an individual with mild depressive symptoms
be aware of the practices and beliefs of folk healing can significantly reduce the individual's chances
when they treat clients from these cultural groups, of developing a depressive disorder (Cuijpers, van
keeping in mind the possibility that clients will Straten, van Oppen, & Andersson, 2008).
combine the different forms of therapy and follow Tertiary prevention focuses on people who al-
some recommendations of both types of healers. ready have a disorder. It seeks to prevent relapse
and reduce the impact of the disorder on the per-
Assessing Sociocultural son's quality of life. As we will see in Chapter 8,
Approaches programs that provide job-skills training and so-
cial support to people with schizophrenia can
The sociocultural approaches to abnormality argue help prevent the recurrence of psychotic episodes
_.. . . . _ that we should analyze the larger social and cultural (Liberman et al., 2002).
forces that may influence people's behavior. It is not
enough to look only at what is going on within indi- COMMON ELEMENTS IN
viduals or their immediate surroundings. Sociocul-
tural approaches are often given credit for not EFFECTIVE TREATMENTS
"blaming the victim," as other theories seem to do On the surface, the different types of therapy de-
by placing the responsibility for psychopathology scribed in this chapter may seem radically different.
within the individual. The sociocultural approaches There is evidence, however, that successful thera-
also raise our consciousness about our responsibility pies share some common components, even when
as a society to change the social conditions that put the specific techniques of the therapies differ greatly.
some individuals at risk for psychopathology. Com- The first common component is a positive rela-
munity psychology and social work are two profes- tionship with the therapist (Norcross, 2002). Clients
sions focused on empowering individuals to change who trust their therapist and believe that the thera-
their social conditions in order to help them improve pist understands them are more willing to reveal
their psychological well-being and quality of life. important information, engage in homework as-
The sociocultural theories can be criticized, signments, and try new skills or coping techniques
however, for being vague about exactly how social suggested by the therapist. In addition, simply
and cultural forces lead to psychological distur- having a positive relationship with a caring and
bance in individuals. In what ways does social understanding human being helps people over-
change or stress lead to depression, schizophrenia, come distress and change their behaviors (Teyber
and so on? Why do most people who are exposed & McClure, 2000).
to social stress and change develop no psychologi- Second, all therapies provide clients with an
cal disturbance at all? explanation or interpretation of why they are suffering
(Ingram, Hayes, & Scott, 2000). Simply having a
PREVENTION PROGRAMS label for painful symptoms and an explanation for
those symptoms seems to help many people feel
Preventing people from developing psychopa- better. In addition, the explanations that therapies
thology in the first place is better than waiting to provide for symptoms usually are accompanied by a
treat it once it develops. Stopping the development set of recommendations for how to overcome those
of disorders before they start is called primary symptoms, and following the recommendations
prevention (Munoz et al., 2010). Some primary may provide the main relief from the symptoms.
CHAPTER INTEGRATION
As we noted at the beginning of this chapter, many
scientists believe that only models that integrate
biological, psychological, and social risk factors can
provide comprehensive explanations of psycho-
logical disorders. Only integrated models can ex-
plain why many people with disordered genes or
deficiencies in neurotransmitters do not develop
painful emotional symptoms or bizarre thoughts.
Similarly, only integrated models can suggest how
traumatic experiences and toxic interpersonal rela-
tionships can cause changes in the basic biochemis-
try of the brain, which then cause changes in a
person's emotions, thoughts, and behaviors.
Figure 2.12 illustrates how some of the biologi-
cal, psychological, and social risk factors discussed
in this chapter might combine to contribute to symp-
toms of depression, for example. Initially, some peo-
ple's genetic characteristics lead to poor functioning
A positive relationship between client and therapist is important to successful of the hypothalamic-pituitary-adrenal axis. Chronic
treatment. arousal of this axis may lead individuals to be overly
How Some Biological,

Psychological, and Social
In any case, it seems clear that a client must be- Factors Might Interact
lieve the explanation given for the symptoms for to Cause Depression.
the therapy to help (Frank, 1978). For example,
studies of cognitive-behavioral therapy for depres-
sion have found that the extent to which clients be- Genetic abnormalities
lieve and accept the rationale behind this therapy is
a significant predictor of the effectiveness of the
therapy (Fennell & Teasdale, 1987). Clients to whom
!
Poor functioning of the
the rationale behind cognitive therapy makes sense hypothalamic-pituitary-
engage more actively in therapy and are less de- adrenal axis
pressed after a course of therapy than clients who
don't accept the rationale for the therapy from the !
outset. A major problem in drug therapies is the Excessive and
high dropout rate. Often, people drop out either be- r+ unregulated responses
to stress Symptoms of
cause they do not experience quick enough relief depression (social
from the drugs and therefore believe the drugs will
not work or because they feel they need to talk
i !
Interpretation of one's
r--
withdrawal,
inability to cope
with stress,
about their problems in order to overcome them. responses to stress as negative thinking,
Third, most therapies encourage clients to con- "I can't cope!" etc.)
front painful emotions and use techniques designed
to help them become less sensitive to these emo- !
tions (Frank, 1978; Prochaska, 1995; Snyder, Ilardi, Social withdrawal,
leading to a reduction
Michael, & Cheavens, 2000). In behavior therapy, in positive
systematic desensitization or flooding might be reinforcements
used. In psychodynamic therapy, clients are encour-
aged to express painful emotions and thoughts.
Whatever technique is used, the goal is to help the
i !
More negative
client stop denying, avoiding, or repressing the '-- evaluations of the self
and the world
painful emotions and become able to accept, expe-
rience, and express the emotions without being
debilitated by them.
Chapter Summary 55
responsive to stress. If they tend to interpret their depression. Then, when they are confronted with
reactions to stress in terms of "I can't cope!" they new stressors, they might not have good strategies
may develop a negative thinking style. This nega- for coping with them and might overreact psycho-
tive thinking style can then cause them to withdraw logically as well as physiologically. All these p ro-
socially, leading to fewer positive reinforcements. cesses come together to produce the key symptoms
This in turn could feed negative evaluations of of depression-social withdrawal, an inability to
themselves and of the world, further contributing to cope with stress, negative thinking, and so on.
A humanistic therapist would provide a reflection A psychodynamic interpretation: " It sounds

that attempts to accu rately restate what the student like every time you get close to success you
said and the emot ions she exp ressed, without unconsciously sabotage yourself. Perhaps
suggesting any interpretation of her feelings: success means something to you that is
troubling or uncomfortable, and you are not
Reflection: " It's really frustrating to screw aware of what that is. "
up and kill your chances; and it fee ls like it's
something in you that's making that happen The psychodynamic interpretation may be
again and again." true, but t he client-centered therapist would view
it as inappropriate because it brings to the client's
A psychodynamic therapist might infer that attention something not currently in the client's
the student's expressed concerns reflect uncon- awareness (adapted from Bohart, 1995, p. 101 ).
scious conflicts about success. When he or she
feels there is enough evidence, an int erpretation
such as the following might be offered:
THINK CRITICALLY
Read the following case study. Then explain the their best to calm Anika during her frequent temper
causes of Anika's symptoms according to three dif- tantrums, while other families became abusive when
ferent approaches: the biological approach, at least she acted out.
one of the psychological approaches, and the socio- Anika did very poorly in school. She was always
cultural approach. (Discussion appears on p. 481 at daydreaming and seldom did any of her homework,
the back of this book.) finding it impossible to concentrate long enough to
Anika was born to a 16-year-old mother who was read and retain material. On top of that, Anika was
addicted to alcohol and multiple illegal drugs. While constantly in trouble for being aggressive toward
Anika's mother tried to stop using alcohol and drugs othe r students or skipping classes to smoke ciga-
after Anika was born, the addiction proved too pow- rettes with some of the other students.
erful. She lost custody of Anika because of her con- When Anika reached puberty, she became self-
tinued substance abuse and her neglect and abuse destructive, sometimes cutting herself with razors
of her daughter. While her mother returned to the and twice attempting t o kill herself. She was forced
streets, Anika went from foster home to foster home. to see therapists, and she told them that she was "no
Some of the families were loving people who did good" and "defective " and that she wanted to die.
CHAPTER SUMMARY
Biological theories of psychopathology typically Structural abnormalities in the brain can be
attribute sympt oms to st ructural abnorma lities in caused by faulty genes, by disease, or by injury.
th e brain, diso rdered biochemist ry, or faulty Which particular area of the brain is damaged
genes. influences the symptoms individuals show.
Many biological theories attribute psycho- in the individual and resu lt in maladaptive
pathology to imbalances in neurotransmitters behavior. Freud argued that these conflicts
or t o the functioning of receptors for neurotrans- arise when the impulses of the id clash with the
mitters. constraints on behavior imposed by the ego and
superego.
Genetic theories of abnormality usually suggest
that it takes an accumulation of faulty genes to People use various types of defense mechanisms
cause a psychopathology. to handle their internal conflicts. How caregivers
handle a child's transitions through the psycho-
Genes can influence the environments people
sexual stages determines the concerns or issues
choose, which then influence the expression
the child may become fixated on.
of genetic tendencies. Epigenetics is the study
of how environmental conditions can influence More recent psychodynamic theorists focus
the expression of genes. less on the role of unconscious impulses and
more on the development of the individual's
Biological therapies most often involve the use
self-concept in the context of interpersonal
of drugs intended to regulate the functioning of
relationships. They see a greater role for the
the brain neurotransmitters associated with a
environment in shaping personality and have
psychologica l disorder or to compensate for
more hope for change during adulthood than
structura l brain abnormalities or the effects
Freud had.
of genetics.
Psychodynamic therapy focuses on unconscious
Antipsychotic medications help reduce unreal
conflicts that lead to maladaptive behaviors and
perceptual experiences, unreal beliefs, and other
emotions. Interpersonal therapies are based on
symptom s of psychosis. Antidepressant drugs
psychodynamic theories but focus more on
help reduce symptoms of depression. Lithium
current relationships and concerns.
and anticonvulsants help reduce mania.
Barbit u rates and benzodiazepines help Humanistic theories suggest that all humans
reduce anxiety. strive to fulfill their potential for good and to
self-actualize. The inabi lity to fulfill one's potential
Electroconvulsive therapy is used to treat arises from the pressures of society to conform
severe depression. Various new methods are
to others' expectations and values. ~
being developed to stimulate the brain without
using electricity. Psychosurgery is used in rare Humanistic therapies seek to help a client realize
circumstances. his or her potential for self-actualization.
The behavioral theories of abnormality reject Family systems theories and therapies see the
notions of unconscious conflicts and focus family as a complex interpersonal system, with
only on the rewards and punishments in the its own hierarchy and rules that govern family
environment that shape and maintain behavior. members' behavior. When a member of the family
has a psycho logical disorder, family systems
Classical conditioning takes place when a theorists see it not as a problem within the
previously neutral stimulus is paired with a individual but as an indication of a dysfunctional
stimulus that naturally creates a certain response; family system .
eventually, the neutral stimulus also elicits
the response. Third-wave approaches generally combine
methods and theories from the cognitive and
Operant conditioning involves rewarding desired behavioral approaches with practices derived
behaviors and punishing undesired behaviors. from Buddhist mindfulness meditation to help
People also learn by imitating the behaviors people accept painful thoughts and emotions
modeled by others and by observing the and regulate them more healthfully.
rewards and punishments others receive for Sociocultural theories suggest that socioeco-
their behaviors. nomic stress, discrimination, and social upheaval
Behavior therapies focus on changing specific can lead to mental health problems in individuals.
maladaptive behaviors and emotions by Cultures also have implicit and explicit rules
changing the reinforcements for them. regarding the types of abnormal behavior they
permit.
Cognitive theories suggest that people's cognitions
(e.g., attributions for events, global assumptions) Some clients may wish to work with therapists
influence the behaviors and emotions with which of the same culture or gender, but it is unclear
they react to situations. whether matching therapist and client in terms
of culture and gender is necessary for therapy ~
Cognitive therap ies focus on changing the way a
to be effective. It is important that therapists be
client thinks about important situations.
sensitive to the influences of culture and gender
Psychodynamic theories of psychopathology on a client's attitudes toward therapy and toward
focus on unconscious conflicts that cause anxiety various solutions to problems.
Key Terms 57
Prevention programs focus on preventing Common components of effective therapy seem

disorders before they develop, retarding the to be a good therapist-cl ient relationship, an
development of disorders in their early stages, explanation for symptoms, and the confrontation
and reducing the impact of disorders on people's and expression of negative emotions.
functioning.
KEY TERMS
sociocultural approach 23 f looding 39
biological approach 23 cognitive theories 39
psychological approach 23 cognitions 39
theory 24 causal attribution 39
biopsychosocial approach 24 global assumptions 40
diathesis-stress model 25 cognitive therapies 40
cerebral cortex 27 cognitive-behavioral therapy (CBT) 40
thalamus 28 psychodynamic theories 41
hypothalamus 28 psychoanalysis 41
limbic system 28 catharsis 41
amygdala 28 repression 41
hippocampus 28 libido 41
neurotransmitters 29 id 42
synapse 29 ego 42
receptors 29 superego 42
reuptake 29 unconscious 42
degradation 29 preconscious 42
endocrine system 30 conscious 42
hormone 30 defense mechanisms 42
pituitary 30 psychosexual stages 42
behavior genetics 31 ego psychology 44
polygenic 32 object relations 44
epigenetics 33 self psychology 44
antipsychotic drugs 33 relational psychoanalysis 44
antidepressant drugs 34 collective unconscious 44
lithium 34 psychodynamic therapies 44
anticonvulsants 34 free association 44
antianxiety drugs 34 resistance 44
electroconvulsive therapy (ECT) 34 transference 44
psychosurgery 35 working through 45
behavioral approaches 36 interpersonal therapy (IPT) 45
classical conditioning 36 humanistic theories 45
unconditioned stimulus (US) 36 self-actua Iization 46
unconditioned response (UR) 36 humanistic therapy 46
conditioned stimulus (CS) 36 client-centered therapy (CCT) 46
conditioned response (CR) 36 reflection 46
operant conditioning 37 family systems theories 46
modeling 38 family systems therapy 47
observational learning 38 third-wave approaches 48
behavioral therapies 38 primary prevention 53
systematic desensitization therapy 38 secondary prevention 53
desensitization 38 tertiary prevention 53
Assessing and Diagnosing
Abnormality
CHAPTER OUTLINE
Assessment and Diagnosis Along the Shades of Gray

Continuum
Chapter Integration
Extraordinary People: Marya
Hornbacher Shades of Gray Discussion
Assessment Tools Think Critically
Challenges in Assessment Chapter Summary
Diagnosis Key Terms

When you drink alcohol, how many drinks do you normally have in one 2-hour period?
Less than More than

1 drink 2 drin ks 3 dri nks 4 drinks 5 drinks 6 dri nks
'===
1 drin k 6 drinks
Diagnostic
L-----+- - - - Not bi nge dri nki ng - - - - - - - - - ' syste ms defi ne Bfog driokf og (fO< womeo) - - - - - - - - '
. - - - - - - - - th reshold
Symptoms meet criteria for alcoh ol abuse

Occasional drinking with
Normal No disorder Disorder Multiple social and legal problems Abnormal
no significant problems
due to alcohol abuse
Assessment tools Assessment tools can also Diagnostic systems assume

can be based on a be based on a threshold that we can define a threshold
continuum model. point that divides the above which a disorder is present.
continuum into acceptable
behavior and problematic
behavior.
As a student, you have taken a variety of tests intended to assess point-to make t his dete rmination and therefore seem to oppose
your learning in different subjects. Similarly, mental hea lth profes- a continuum model. Increasingly, however, researchers and cli -
sionals use different tests or tools to assess mental health. Some nicia ns are building a co ntinuum perspective into the diagnostic
assessment tools described in t his ch apter are based on the as- process. For example, the most rece nt ve rsion of the manua l
sumption that behaviors or feelings lie along a contin uu m-the used to diagnose disorders in the Un ited States, the DSM-5, de-
task is to determine where an individual's experiences fa ll alo ng f ines personality disorders at least somewhat in line with a con -
that co ntinu um . For example, a questionnaire that asked you about tinu um model. Fo r most disorders, however, the DSM-5 and
you r drinking behavior might have severa l options indicating dif- other diagn ostic syst ems set criteria for when a person 's behav-
ferent levels of d rinking. The researcher doing a study on predic- iors and feelings cross t he line into a disorder, even in the ab-
tors of drinking behavior might be interested in what factors predict sence of a purely sci entific way to draw t hat line.
where people fall along the contin uu m f rom little or no d rinking to T here are adva ntages and disadvantages both to a con-
a great deal of drinking. A clinician may be interested in charting tinuum approach to assessment and diagnosis and to a cate-
how a person's dri nki ng behavior changes over the course of ther- gorical approa ch that f ocuses o n t hre sholds and cutoffs for
apy. Other tools, however, are more like true/false tests: They are identifying disorders. The continu um approach captures the
based on the assumption that there is a threshold for the behaviors nua nces in people' s behaviors better than does a categorical
they are assessing, and either people have these behaviors or they app roach . The continuum app roach also does not assume that
do not. For example, some researchers set the threshold for an we know wh ere the cutoff is for problematic behavior. But the
alcohol " binge " for women at four drinks (Chapter 14). Thus, a cont i nuum app roac h can make it mo re difficu lt to commun i-
woman who regularly drinks th is amount or more at one setting cate informat ion about peop le, in part because we often think
would be considered a binge drinker, whereas a woman having more i n categorical te rm s. For example, saying that a perso n is
three drinks wou ld not be considered a binge drinker. a binge dri nker may convey more information t o a therapist
Currently, the guidelines used to determ ine whether a per- or researc her than saying that the perso n drinks moderately
son has a mental disorder use a thres ho ld-a specific cutoff to heavily.
Assessment and Diag nosis Al ong the Continuum 59

60 Chapter 3 Assessing and Diagnosing Abnormality
Marya Hornbacher
By her late 20s, Marya a young woman's ability to recover from these
Hornbacher appeared disorders.
to be an amazing suc- But those who knew her had doubts that she
cess story. She had was well, as she recounts in her book Madness
published her first (2008). She was drinking, which was nothing new
book, Wasted, which for her. But the volume and ferocity of her drinking
was heralded as an surprised everyone around her. Even though she is
eloquent account of her a petite woman, it took a dozen glasses of wine or
many years with severe hard liquor to even give her a buzz. Marya seemed
eating disorders, and to have boundless energy and was bouncing off
Hornbacher was sought the walls much of the time-that is, except when
after for speaking en- she went crashing down into depression and re-
gagements and readings across the United States treated into her bed for days on end. Hoping to
and Europe. Apparently cured of her disorder, gain some control over her life, she resorted to
she served as a living testament both to the controlling her eating again and began to lose
horrors of bulimia and anorexia nervosa and to weight rapidly.
Marya Hornbacher presents a puzzling picture. of these tools are new, while others have been
She shows signs of alcohol abuse, mood swings, around for many years. These tools provide infor-
and a lingering eating disorder. Why did these mation about the individual's personality charac-
symptoms emerge after she apparently had recov- teristics, cognitive deficits (such as learning
ered from her eating disorder and had achieved disabilities or problems in maintaining attention),
success as a writer? Which of these problems is a emotional well-being, and biological functioning.
cause of the other symptoms, and which is a conse- We also consider modern systems of diagnos-
quence? How would we go about diagnosing her ing psychological problems. A standardized sys-
problems? The assessment and diagnosis of symp- tem of diagnosis is crucial to communication
toms is the focus of this chapter. among mental health professionals as well as to
Assessment is the process of gathering infor- research into psychological problems. We must
mation about people's symptoms and the possible agree on what we mean when we use a diagnostic
causes of these symptoms. Many types of infor- label. A standardized diagnostic system provides
mation are gathered during an assessment, in- agreed-on definitions of disorders.
cluding information about current symptoms and
ways of coping with stress, recent events and
physical condition, drug and alcohol use, personal ASSESSMENT TOOLS
and family history of psychological disorders, A number of assessment tools have been devel-
cognitive functioning, and sociocultural back- oped to help clinicians gather information. All as-
ground. The information gathered in an assess- sessment tools must be valid, reliable, and
ment is used to determine the appropriate standardized. We first discuss these important
diagnosis for a person's problems. A diagnosis is concepts and then look at specific types of assess-
a label for a set of symptoms that often occur to- ment tools.
gether. Marya Hornbacher's symptoms qualify
for several diagnoses we will discuss in later
chapters, including eating disorders, substance
Validity
use disorders, and bipolar disorder. If you administer a test to determine a person's
In this chapter, we discuss the modern tools of behaviors and feelings, you want to be sure that
assessment and how they are used both to diag- the test is an accurate measure. The accuracy of a
nose psychological symptoms and to help us un- test in assessing what it is supposed to measure is
derstand and treat psychological problems. Some called its validity. The best way to determine the
Assessment Tool s 61
validity of a test is to see if the results of the test Types of Validity for a Questionnaire or
yield the same information as an objective and FIGURE 3.1 Test. There are a number of types of validity.
accurate indicator of what the test is supposed to
measure. For example, if there were a blood test
that definitively proved whether a person had a Content validity:
Test assesses all important
particular psychological disorder, you would want aspects of a phenomenon.
any other test for that disorder (such as a question-
naire) to yield the same results when administered
Face validity: Predictive validity:
to the person. Test appears to measure Test predicts the behavior it
As we've already discussed in Chapter 1, there what it is supposed to is supposed to measure.
are currently no definitive blood tests, brain scans, measure.
or other objective tests for any of the psychological
disorders we discuss in this book. Fortunately, the
validity of a test can be estimated in a number of
other ways (Figure 3.1). A test is said to have face
t Types of
validity
t
validity when, on face value, the items seem to
measure what the test is intended to measure. For
example, a questionnaire for anxiety that asks "Do Concurrent validity: Construct validity:
Test yields the same results Test measures what it is
you feel jittery much of the time?" and "Do you as other measures of the supposed to measure, not
worry about many things?" has face validity be- same behavior, thoughts, something else.
cause it seems to assess symptoms of anxiety. If it or feelings.
also meets other standards of validity, researchers
are more likely to trust its results.
Content validity is the extent to which a test
assesses all the important aspects of a phenome-
non that it purports to measure. For example, if a and to recognize any tricks and obviously incor-
measure of anxiety asked only about physical rect answer choices.
symptoms (nervousness, restlessness, stomach
distress, rapid heartbeat) and not cognitive symp- Reliability
toms (apprehensions about the future, anticipation It is important that a test provides consistent in-
of negative events), then we might question whether formation about a person. The reliability of a test
it is a good measure of anxiety. indicates its consistency in measuring what it is
Concurrent (or convergent) validity is the extent supposed to measure. As with validity, there are
to which a test yields the same results as other, es- several types of reliability (Figure 3.2). Test-retest
tablished measures of the same behavior, thoughts,
or feelings. A person's score on a new anxiety
questionnaire should bear some relation to infor-
mation gathered from the person's answers to an
Types of Reliability for a Questionnaire
established anxiety questionnaire. FIGURE 3.2 orTest. Reliability can be determined
A test has predictive validity if it is good at in several ways.
predicting how a person will think, act, or feel in
the future. An anxiety measure has good predic-
tive validity if it correctly predicts which people Test-retest reliability: Alternate form reliability:
Test produces similar results Two versions of the same
will behave in anxious ways when confronted when given at two points test produce similar results.
with stressors in the future and which people in time.
will not.
Construct validity is the extent to which a test
measures what it is supposed to measure and
l Types of
reliability
t
not something else altogether (Cronbach &
Meehl, 1955). Consider the construct validity of
multiple-choice exams in school. They are sup- Internal reliability: Interrater, or interjudge,
posed to measure a student's knowledge and Different parts of the same reliability: Two or more raters
understanding of content. However, they may test produce similar results. or judges who administer and
also measure the student's ability to take multiple- score a test come to similar
conclusions.
choice tests, that is, their ability to determine
the instructor's intent in asking each question
reliability describes how consistent the results of a cutoff are considered severe) makes the interpreta-
test are over time. If a test supposedly measures tion of the test more valid and reliable. Thus, stan-
an enduring characteristic of a person, then the dardization of both the administration and the
person's scores on that test should be similar interpretation of tests is important to their validity
when he or she takes the test at two different and reliability.
points in time. For example, if an anxiety ques- With these concepts in mind, let's explore
tionnaire is supposed to measure people's gen- some commonly used assessment tools.
eral tendencies to be anxious, then their scores
should be similar if they complete the question-
naire this week and then again next week. On the
Clinical Interview
other hand, if an anxiety questionnaire is a mea- Much of the information for an assessment is
sure of people's current symptoms of anxiety gathered in an initial interview. This interview
(asking questions such as "Do you feel jittery may include a mental status exam, which assesses
right now?"), then we might expect low test- the person's general functioning. In the mental
retest reliability on this measure. Typically, mea- status exam, the clinician probes for five types of
sures of general and enduring characteristics information. First, the clinician assesses the indi-
should have higher test-retest reliability than vidual's appearance and behavior. Is he or she
measures of transient characteristics. dressed neatly and well groomed, or does he or
When people take the same test a second she appear disheveled? The ability to care for
time, they may try to give the same answers so as one's basic grooming indicates how well one is
to seem consistent. For this reason, researchers of- functioning generally. Also, the clinician will note
ten will develop two or more forms of a test. if the individual seems to be moving particularly
When people's answers to different forms of a slowly, which may indicate depression, or seems
test are similar, the tests are said to have alternate agitated.
form reliability. Similarly, a researcher may split a Second, in a mental status exam a clinician will
test into two or more parts to determine whether take note of the individual's thought processes, in-
people's answers to one part of a test are similar cluding how coherently and quickly he or she
to their answers to another part. When there is speaks. Third, the clinician will be concerned with
similarity in people's answers among different the individual's mood and affect. Does he or she
parts of the same test, the test is said to have high appear down and depressed, or perhaps elated? Is
internal reliability. the affect appropriate to the situation or inappro-
Finally, many of the tests we examine in this priate? For example, the individual may seem to
chapter are interviews or observational measures laugh excessively at his own jokes, which may in-
that require a clinician or researcher to make judg- dicate nervousness or an inability to relate well to
ments about the people being assessed. These others. Fourth, the clinician will observe the indi-
tests should have high interrater, or interjudge, reli- vidual's intellectual functioning, that is, how well
ability. That is, different raters or judges who ad- the person speaks and any indications of memory
minister and score the interview or test should or attention difficulties. Fifth, the clinician will
come to similar conclusions when they are evalu- note whether the individual seems appropriately
ating the same people. oriented to place, time, and person: Does the indi-
vidual understand where he or she is, what day
Standardization and time it is, and who he or she is, as well as who
the clinician is?
One important way to improve both validity and Increasingly, clinicians and researchers use a
reliability is to standardize the administration structured interview to gather information about
and interpretation of tests. A standard method of individuals. In a structured interview, the clini-
administering a test prevents extraneous factors cian asks the respondent a series of questions
from affecting a person's response. For example, if about symptoms he or she is experiencing or has
the test administrator were to deviate from the experienced in the past. The format of the ques-
written questions, suggesting the "right" answer tions and the entire interview is standardized,
to the respondents, this would reduce the validity and the clinician uses concrete criteria to score
and reliability of the test. In contrast, if the adminis- the person's answers (Table 3.1). At the end of
trator of the test only read aloud the specific ques- the interview, the clinician should be able to
tions on the test, this would increase the validity determine whether the respondent's symptoms
and reliability of the test. Similarly, a standard way qualify for a diagnosis of any major psychologi-
of interpreting results (e.g., scores above a certain cal problems.
Assessm ent Tools 63
1972). The most recent form of the BDI has

TABLE 3.1 Sample Structured Interview 21 items, each of w hich describes four lev els of a
giv en symptom of d epression (Table 3.2). The re-
ANXIETY DISORDERS
spondent is asked to indicate which d escrip tion
Panic Disorder Questions best fits how he or she has been feeling in the
past week. The items are scored to indicate the
Have you ever had a panic attack, when you lev el of depressive symptoms the person is expe-
suddenly felt frightened, anxious, or extremely riencing. Cutoff scores hav e been established to
uncomfortable?
indicate moderate and severe levels of depres-
lfYes:Tell me about it. When does that happen?
sive symptoms.
(Have you ever had one that just seemed to
Critics of the BDI hav e argued that it does
come out of the blue?)
not clearly differentiate between th e clinical syn-
If pan ic attacks took place in expected
situations: Di d you ever have one of these
drome of d epression and the general distress
attacks w he n you weren't in (EXPECTED that may be related to an anxiety disorder or to
SITUATION )? sev eral other disorders (see Kend all et al. , 1987).
Have yo u ever had four attacks like that in a 4-week The BDI also cannot indica te wheth er the re-
pe riod? spondent w ould qualify for a diagnosis of de-
If No: Did you worry a lot about having another pression. But because the BDI is extremely quick
one? (How long did you worry?) and easy to administer and has good test-retest
When wa s the last bad one (EXPECTED OR reliability, it is w idely used, especially in research
UNEXPECTE D)? on depression.
Now I am going to ask you about that attack. Clinicians treating depressed people also use
W hat was the f irst thing you noticed?Then the BDI to monitor those indiv idu als' symptom
w hat? levels from w eek to w eek. An individual may be
During the attack . . . asked to complete the BDI at the beginning of each
. .. we re you short of breath? (have trouble therapy session, and both th e individual and the
catch ing your breat h?)
.. . did you feel dizzy, unsteady, or as if you
m ig ht faint? TABLE 3.2 Sample Items from
... d id you r heart race, pound, or skip? the Beck Depression Inventory,
... d id you tremble or shake? Second Edition (BDI-11)
. . . did you sweat?
UNHAPPINESS
.. . did y ou fee l as if you were choking?
.. . d id you have nausea , upset stomach, 0 I do not feel unhappy.
or the fee l ing that you were going to have 1 I feel unhappy.
d iarrhea? 2 I am unhappy.
. . . d id th ings around you see m unreal or did 3 I am so unhappy that I can't stand it.
you feel detached from things around you or
detached from part of your body? CHANGES IN ACTIVITY LEVEL
0 I have not experienced any change in activity

Source: Data from First, Spitzer, Gibbon, & Williams, 1997. level.
1a I am somewhat more active than usual.
1b I am somewhat less active t han usual.
2a I am a lot more active than usual.
Symptom Questionna ires 2b I am a lot less active than usual.
3a I am not active most of the day.
Often, when clinicians or researchers want a
3b I am active all of the day.
quick way to determine a person's symptoms,
they will ask the person to complete a symptom
Source: Simulated Items similar to those in the Beck
q uestionnaire. These questionnaires can cover a Depression lnventory-11 (BDI-11) . Copyright 1996 by
wide v ariety of symptoms representing sev eral Aaron T Beck. Reproduced with perm ission of the
different disorders. Other questionnaires focus on publisher, NCS Pea rson, Inc. All rights reserved.
" Beck Dep ression Inventory " and " BDI" are trademarks, in
the symptoms of specific disorders.
the US and/or other countries, of Pearson Education, Inc. or
One of the most common questionnaires its affiliates(s).
used to assess symptoms of depression is the
Beck Depression Inv entory, or BDI (Beck & Beck,
clinician then have a concrete indicator of any the person responds honestly to the items on the
changes in symptoms. scale or distorts his or her answers in a way that
might invalidate the test (Table 3.3). For example,
Personality Inventories the Lie Scale measures the respondent's tendency
to respond to items in a socially desirable way in
Personality inventories usually are questionnaires order to appear unusually positive or good.
meant to assess people's typical ways of thinking, Because the items on the MMPI were chosen
feeling, and behaving. These inventories are used
for their ability to differentiate people with specific
as part of an assessment procedure to obtain infor-
types of psychological problems from people with-
mation on people's well-being, self-concept, atti-
out psychological problems, the concurrent valid-
tudes and beliefs, ways of coping, perceptions of ity of the MMPI scales was "built in" during their
their environment, and social resources, and vul-
development. The MMPI may be especially useful
nerabilities. as a general screening device for detecting people
The most widely used personality inventory who are functioning very poorly psychologically.
in professional clinical assessments is the Minne-
The test-retest reliability of the MMPI has also
sota Multiphasic Personality Inventory (MMPI) , proven to be high (Dorfman & Leonard, 2001).
which has been translated into more than 150 lan-
However, many criticisms have been raised
guages and is used in more than 50 countries
about the use of the MMPI in culturally diverse
(Groth-Marnat, 2003). The original MMPI was de-
samples (Groth-Marnat, 2003). The norms for the
veloped in the 1930s by Starke Hathaway and original MMPI-the scores considered "healthy"-
Charnley McKinley. In 1989, an updated version
were based on samples of people in the United
was published under the name MMPI-2. Both ver- States not drawn from a wide range of ethnic and
sions of the MMPI present respondents with sen-
racial backgrounds, age groups, and social classes.
tences describing moral and social attitudes,
In response to this problem, the publishers of the
behaviors, psychological states, and physical con-
MMPI established new norms based on more rep-
ditions and ask them to respond "true," "false," or
resentative samples of eight communities across
"can't say" to each sentence. Here are some exam-
the United States. Still, concerns that the MMPI
ples of items from the MMPI:
norms do not reflect variations across cultures in
I would rather win than lose in a game. what is considered normal or abnormal persist. In
I am never happier than when alone. addition, some question the linguistic accuracy of
the translated versions of the MMPI and the com-
My hardest battles are with myself.
parability of these versions to the English version
I wish I were not bothered by thoughts (Dana, 1998).
about sex.
I am afraid of losing my mind. Behavioral Observation
When I get bored, I like to stir up some and Self-Monitoring
excitement.
Clinicians often will use behavioral observation
People often disappoint me.
of individuals to assess deficits in their skills or
The MMPI was developed empirically, mean- their ways of handling situations. The clinician
ing that a large group of possible inventory items looks for specific behaviors and what precedes and
was given to psychologically "healthy" people follows these behaviors. For example, a clinician
and to people with various psychological prob- might watch a child interact with other children to
lems. The items that reliably differentiated among determine what situations provoke aggression in
groups of people were included in the inventory. the child. The clinician can then use information
The items on the original MMPI are clustered from the behavioral observation to help the indi-
into 10 scales that measure different types of psy- vidual learn new skills, stop negative habits, and
chological characteristics or problems, such as understand and change how he or she reacts to
paranoia, anxiety, and social introversion. Another certain situations. A couple seeking marital ther-
4 scales have been added to the MMPI-2 to assess apy might be asked to discuss with each other a
vulnerability to eating disorders, substance abuse, topic on which they disagree. The clinician would
and poor functioning at work. A respondent's observe this interaction, noting the specific ways
scores on each scale are compared with scores from the couple handles conflict. For example, one
the normal population, and a profile of the respon- member of the couple may lapse into statements
dent's personality and psychological problems is that blame the other member for problems in their
derived. Also, 4 validity scales determine whether marriage, escalating conflict to the boiling point.
Assessment Tools 65
TABLE 3.3 Clinical and Validity Scales of the Original MMPI
The MMPI is one of the most widely used questionnaires for assessing people's symptoms and personalities. It also includes sca les
to assess whether respondents are lying or trying to obfuscate their answers.
CLINICAL SCALES
Scale Number Scale Name What It Measures
Scale 1 Hypochondriasis Excessive somatic concern and physical compla ints

Scale 2 Depression Symptomatic depression
Scale 3 Hysteria Hysterical personality features and tendency to develop physical symptoms
under stress
Scale 4 Psychopathic deviate Antisocial tendencies
Scale 5 Masculinity-femininity Sex-role conflict
Scale 6 Paranoia Suspicious, paranoid thinking
Scale 7 Psychasthenia Anxiety and obsessive behavior
Scale 8 Schizophrenia Bizarre thoughts and disordered affect
Scale 9 Hypomania Behavior found in mania
Scale 0 Social introversion Social anxiety, withdrawal, overcontrol
VALIDITY SCALES
Scale Name What It Measures
Cannot say scale Total number of unanswered items

Lie scale Tendency to present favorab le image
Infrequency scale Tendency to falsely claim psychologica l problems
Defensiveness scale Tendency to see oneself in unrealistically positive manner
Source: Minnesota Multiphasic Personality Inventory (MMPI). Copyright 1942, 1943, 1951 , 1967 (renewed 1970), 1983. Reprinted by perm issi on of the
University of Minnesota. "MMPI" and "Minnesota Multiphasic Personality Inventory" are tradema rks owned by the University of Minnesota.
Direct behavioral observation has the advan- possible in some situations. In that case, a clinician
tage of not relying on individuals' reporting and may have a client role-play a situation, such as the
interpretation of their own behaviors. Instead, the client's interactions with an employer.
clinician sees firsthand how the individuals han- If direct observation or role playing is not
dle important situations. One disadvantage is that possible, clinicians may require self-monitoring
individuals may alter their behavior when they are by individuals-that is, keeping track of the num-
being watched. Another disadvantage is that dif- ber of times per day they engage in a specific be-
ferent observers may draw different conclusions havior (e. g., smoking a cigarette) and the conditions
about individuals' skills; that is, direct behavioral under which this behavior occurs. Following
observations may have low interrater reliability, is an example (adapted from Thorpe & Olson,
especially in the absence of a standard means of 1997, p. 149):
making the observations. In addition, any individ-
ual rater may miss the details of an interpersonal Steve, a binge drinker, was asked to self-
interaction. For example, two raters watching a monitor his drinking behavior for 2 weeks,
child play with others on a playground may focus noting the situational context of urges to
on different aspects of the child's behaviors or be drink and his associated thoughts and
distracted by the chaos of the playground. For feelings. These data revealed that Steve's
these reasons, when behavioral observation is drinking was completely confined to bar
used in research settings, the situations are highly situations, where he drank in the company
standardized and observers watch for a set list of of friends. Gaining relief from stress was a
behaviors. Finally, direct observation may not be recurring theme.
Self-monitoring is open to biases in what individu- widely used intelligence tests assess verbal and
als notice about their behavior and are willing to analytical abilities but do not assess other talents
report. However, individuals can discover the or skills, such as artistic and musical ability.
triggers of unwanted behaviors through self- Some psychologists argue that success in life is
monitoring, which in turn can lead them to change as strongly influenced by social skills and other
these behaviors. talents not measured by intelligence tests as it is
by verbal and analytical skills (Gardner, 2003;
Sternberg, 2004) .
Intelligence Tests Another important criticism of intelligence
In clinical practice, intelligence tests are used to tests is that they are biased in favor of middle- and
get a sense of an individual's intellectual strengths upper-class, educated individuals because such
and weaknesses, particularly when mental retar- people are more familiar with the kinds of reason-
dation or brain damage is suspected (Ryan & ing assessed on the tests (Sternberg, 2004). In addi-
Lopez, 2001). Intelligence tests are also used in tion, educated European Americans may be more
schools to identify "gifted" children and children comfortable taking intelligence tests because tes-
with intellectual difficulties. They are used in oc- ters often are also European Americans and the
cupational settings and the military to evaluate testing situation resembles testing situations in
adults' capabilities for certain jobs or types of ser- their educational experience. In contrast, different
vice. Some examples of these tests are the Wechsler cultures within the United States and in other
Adult Intelligence Scale, the Stanford-Binet Intelli- countries may emphasize forms of reasoning other
gence Test, and the Wechsler Intelligence Scale for than those assessed on intelligence tests, and mem-
Children. bers of these cultures may not be comfortable with
These tests were designed to measure basic in- the testing situation.
tellectual abilities, such as the ability for abstract A "culture-fair" test would have to include
reasoning, verbal fluency, and spatial memory. The items that are equally applicable to all groups or
term IQ is used to describe a method of comparing that are different for each culture but psychologi-
an individual's score on an intelligence test with cally equivalent for the groups being tested. At-
the performance of individuals in the same age tempts have been made to develop culture-fair
group. An IQ score of 100 means that the person tests, but the results have been disappointing.
performed similarly to the average performance of Even if a universal test were created, making state-
other people the same age. ments about intelligence in different cultures
Intelligence tests are controversial in part would be difficult because different nations and
because there is little consensus as to what is cultures vary in the emphasis they place on "intel-
meant by intelligence (Sternberg, 2004). The most lectual achievement."
The Bender-Gestalt Test. On the left are

Neuropsychological Tests
the figures as presented to the clients . On the If the clinician suspects neurological impairment
FIGURE 3.3 right are the figures as copied by a child with in a person, paper-and-pencil neuropsychological
a brain tumor that is creating perceptual-motor tests may be useful in detecting specific cognitive
difficulties .
deficits such as a memory problem, as occurs in
dementia (Golden & Freshwater, 2001). One fre-
~ quently used neuropsychological test is the

Bender-Gestalt Test (Bender, 1938). This test as-
sesses individuals' sensorimotor skills by having
0 0 000000000000000000000000000000000
them reproduce a set of nine drawings (Figure 3.3).
People with brain damage may rotate or change
parts of the drawings or be unable to reproduce
the drawings. When asked to remember the draw-
ings after a delay, they may show significant mem-
ory deficits. The Bender-Gestalt Test appears to be
good at differentiating people with brain damage
from those without brain damage, but it does not
reliably identify the specific type of brain damage
a person has (Groth-Marnat, 2003).
Assessment Tools 67
More extensive batteries of tests have been de- psychological disorder and people
veloped to pinpoint types of brain damage. Two of without a disorder.
the most popular batteries are the Halstead-Reitan Another procedure to assess
Test (Reitan & Davidson, 1974) and the Luria- brain activity is single photon emis-
Nebraska Test (Luria, 1973). These batteries con- sion computed tomography, or
tain several tests that provide specific information SPECT. The procedures of SPECT
about an individual's functioning in several skill are much like those of PET except
areas, such as concentration, dexterity, and speed that a different tracer substance is
of comprehension. injected. It is less accurate than PET
but also less expensive.
Magnetic resonance imaging
Brain-Imaging Techniques (MRI) has several advantages over
Increasingly, neuropsychological tests are being CT, PET, and SPECT technology. It
used with brain-imaging techniques to identify does not require exposing the pa-
specific deficits and possible brain abnormalities. tient to any radiation or injecting ra-
Clinicians use brain imaging to determine if a pa- dioisotopes, so it can be used
tient has a brain injury or tumor. Researchers use repeatedly for the same individual.
brain imaging to search for differences in brain ac- It provides much more finely de-
tivity or structure between people with a psycho- tailed pictures of the anatomy of the
logical disorder and people with no disorder. Let brain than do other technologies, CT scans can detect structural
us review existing brain-imaging technologies and and it can image the brain at any abnormalities such as brain tumors.
what they can tell us now. angle. Structural MRI provides static
Computerized tomography (CT) is an en- images of brain structure. Functional MRI (fMRI)
hancement of X-ray procedures. In CT, narrow provides images of brain activity.
X-ray beams are passed through the person's head MRI involves creating a magnetic field around
in a single plane from a variety of angles. The the brain that causes a realignment of hydrogen at-
amount of radiation absorbed by each beam is oms in the brain. When the magnetic field is turned
measured, and from these measurements a com- off and on, the hydrogen atoms change position,
puter program constructs an image of a slice of the causing them to emit magnetic signals. These sig-
brain. By taking many such images, the computer nals are read by a computer, which reconstructs a
can construct a three-dimensional image showing three-dimensional image of the brain. To assess ac-
the brain's major structures. A CT scan can reveal tivity in the brain, many images are taken only mil-
brain injury, tumors, and structural abnormalities. liseconds apart, showing how the brain changes
The two major limitations of CT technology are from one moment to the next or in response to
that it exposes patients to X-rays, which can be some stimulus. Researchers are using MRI to study
harmful, and that it provides an image of brain structural and functional brain abnormalities in
structure rather than brain activity. almost every psychological disorder.
Positron-emission tomography (PET) can
provide a picture of activity in the brain. PET re-
quires injecting the patient with a harmless radio-
Psychophysiological Tests
active isotope, such as fluorodeoxyglucose (FDG) . Psychophysiological tests are alternative methods
This substance travels through the blood to the to CT, PET, SPECT, and MRI used to detect changes
brain. The parts of the brain that are active need in the brain and nervous system that reflect emo-
the glucose in FDG for nutrition, so FDG accumu- tional and psychological changes. An electroen-
lates in active parts of the brain. Subatomic parti- cephalogram (EEG) measures electrical activity
cles in FDG called positrons are emitted as the along the scalp produced by the firing of specific
isotope decays. These positrons collide with elec- neurons in the brain. EEG is used most often to
trons, and both are annihilated and converted to detect seizure activity in the brain and can also be
two photons traveling away from each other in op- used to detect tumors and stroke. EEG patterns re-
posite directions. The PET scanner detects these corded over brief periods (such as 1h second) in
photons and the point at which they are annihi- response to specific stimuli, such as the individu-
' lated and constructs an image of the brain, show- al's viewing of an emotional picture, are referred
ing those areas that are most active. PET scans can to as evoked potentials or event-related potentials. Cli-
be used to show differences in the activity level of nicians can compare an individual's response to
specific areas of the brain between people with a the standard response of healthy individuals.
Heart rate and respiration are highly respon- like "People may see many different things in these ~
sive to stress and can be easily monitored. Sweat inkblot pictures; now tell me what you see, what
gland activity, known as electrodermal response (for- it makes you think of, what it means to you"
merly called galvanic skin response), can be assessed (Exner, 1993). Clinicians are interested in both the
with a device that detects electrical conductivity content and the style of the individual's responses
between two points on the skin. Such activity can to the inkblot. In the content of responses, they
reflect emotional arousal. Psychophysiological look for particular themes or concerns, such as
measures are used to assess people's emotional frequent mention of aggression or fear of aban-
response to specific types of stimuli, such as the donment. Important stylistic features may include
response to war scenes of a veteran with post- the person's tendency to focus on small details of
traumatic stress disorder. the inkblot rather than the inkblot as a whole or
hesitation in responding to certain inkblots
Projective Tests (Exner, 1993).
The Thematic Apperception Test (TAT) con-
A projective test is based on the assumption that
sists of a series of pictures. The individual is asked
when people are presented with an ambiguous
to make up a story about what is happening in the
stimulus, such as an oddly shaped inkblot or a
pictures (Murray, 1943). Proponents of the TATar-
captionless picture, they will interpret the stimu-
gue that people's stories reflect their concerns and
lus in line with their current concerns and feelings,
wishes as well as their personality traits and mo-
relationships with others, and conflicts or desires.
tives. As with the Rorschach, clinicians are inter-
People are thought to project these issues onto
ested in both the content and the style of people's
their description of the "content" of the stimulus-
responses to the TAT cards. Some cards may stim-
hence the name projective tests. Proponents of
ulate more emotional responses than others or no
these tests argue that they are useful in uncovering
response at all. These cards are considered to tap
the unconscious issues or motives of a person or in
the individuals' most important concerns.
cases when the person is resistant or is heavily bi-
Clinicians operating from psychodynamic
asing the information he or she presents to the as-
perspectives value projective tests as tools for as- ~
sessor. Two of the most frequently used projective
sessing the underlying conflicts and concerns
tests are the Rorschach Inkblot Test and the Thematic
that individuals cannot or will not report directly.
Apperception Test (TAT).
Clinicians operating from other perspectives
The Rorschach Inkblot Test, commonly re-
question the usefulness of these tests. The valid-
ferred to simply as the Rorschach, was developed
ity and reliability of all the projective tests have
in 1921 by Swiss psychiatrist Hermann Rorschach.
not proven strong in research (Groth-Marnat,
The test consists of 10 cards, each containing a
2003). In addition, because these tests rely so
symmetrical inkblot in black, gray, and white or in
greatly on subjective interpretations by clini-
color. The examiner tells the respondent something
cians, they are open to a number of biases. Fi-
nally, the criteria for interpreting the tests do not
take into account an individual's cultural back-
ground (Dana, 2001).
CHALLENGES IN
ASSESSMENT
Some challenges that arise in assessing people's
problems include people's inability or unwilling-
ness to provide information. In addition, special
challenges arise when evaluating children and
people from cultures different from that of the
assessor.
Resistance to Providing
Information
One of the greatest challenges to obtaining valid
* Rorschach! What's to become of you? *
ScienceCartoonsPius.com information from an individual can be his or her
resistance to providing information. Sometimes,
Challenges in Assessment 69
the person does not want to be assessed or treated. her understanding of the causes of his or her
For example, when a teenager is forced to see a behaviors or emotions may not be very well de-
psychologist because of parental concern about his veloped. Children, particularly preschool-age chil-
behavior, he may be resistant to providing any in- dren, cannot describe their feelings or associated
formation. Because much of the information a cli- events as easily as adults can. Young children may
nician needs must come directly from the person not differentiate among different types of emo-
being assessed, resistance can present a formidable tions, often just saying that they feel "bad," for ex-
problem. ample (Harter, 1983). When distressed, children
Even when a person is not completely resis- may talk about physical aches and pains rather
tant to being assessed, he or she may have a than the emotional pain they are feeling. Or a child
strong interest in the outcome of the assessment might show distress only in nonverbal behavior,
and therefore may be highly selective in the infor- such as making a sad face, withdrawing, or behav-
mation he or she provides, may bias his or her ing aggressively.
presentation of the information, or may even lie These problems with children's self-reporting
to the assessor. Such problems often arise when of emotional and behavioral concerns have led cli-
assessments are part of a legal case, for example, nicians and researchers to rely on other people,
when parents are fighting for custody of their usually adults in the children's lives, to provide
children in a divorce. When speaking to psychol- information about children's functioning. Parents
ogists who have been appointed to assess fitness are often the first source of information about a
for custody of the children, each parent will want child's functioning . A clinician may interview a
to present him- or herself in the best light and child's parents when the child is taken for treat-
also may negatively bias his or her reports on the ment, asking the parents about changes in the
other parent. child's behavior and corresponding events in the
child's life. A researcher studying children's func-
tioning may ask parents to complete question-
Evaluating Children naires assessing the children's behavior in a variety
Consider the following conversation between a of settings.
mother and her 5-year-old son, Jonathon, who was Because parents typically spend more time
sent home from preschool for fighting with an- with their child than any other person does, they
other child. potentially have the most complete information
about the child's functioning and the best sense of
Mom: Jonathon, why did you hit that boy?
how the child's behavior has or has not changed
Jonathon: I dunno. I just did. over time. Unfortunately, however, parents are not
Mom: But I want to understand what hap- always accurate in their assessments of their chil-
pened. Did he do something that made you dren's functioning. One study found that parents
mad? and children disagreed on what problems had
Jonathon: Yeah, I guess. brought the child to a psychiatric clinic in 63 per-
cent of cases (Yeh & Weisz, 2001). Parents' percep-
Mom: What did he do? Did he hit you?
tions of their children's well-being can be
Jonathon: Yeah. influenced by their own symptoms of psychopa-
Mom: Why did he hit you? thology and by their expectations for their chil-
Jonathon: I dunno. He just did. Can I go now? dren's behavior (Nock & Kazdin, 2001). Indeed,
parents sometimes take children for assessment
Mom: I need to know more about what
and treatment of psychological problems as a way
happened. of seeking treatment for themselves.
(Silence) Parents also may be the source of a child's psy-
Mom: Can you tell me more about what chological problems, and, as a result, they may be
happened? unwilling to acknowledge or seek help for the
Jonathon: No. He just hit me and I just hit
child's difficulties. The most extreme example is
him. Can I go now? parents who are physically or sexually abusive.
Such parents are unlikely to acknowledge the psy-
Anyone who has tried to have a conversation chological or physical harm they are causing the
with a distressed child about why he or she misbe- child or to seek treatment for the child.
haved has some sense of how difficult it can be to Cultural norms for children's behaviors differ,
engage a child in a discussion about emotions or and parents' expectations for their children and
behaviors. Even when a child talks readily, his or their tolerance of deviant behavior in children are
affected by these norms. For example, Jamaican

parents appear to be more tolerant than American
parents of unusual behaviors in children, includ-
ing both aggressive behavior and behavior indicat-
ing shyness and inhibition. In turn, Jamaican
parents have a higher threshold than American
parents in terms of the appropriate time to take a
child to a clinician (Lambert et al., 1992).
Teachers also provide information about chil-
dren's functioning. Teachers and other school per-
sonnel (such as guidance counselors and coaches)
are often the first to recognize that a child has a
problem and to initiate an intervention to address
the problem. Teachers' assessments of children, Cultural differences between clients and clinicians can
however, are often different from the assessments lead to misinterpretations of clients ' problems.
made by other adults, including parents and
trained clinicians (Weisz, Donenberg, Han, &
Kauneckis, 1995). Such discrepancies may arise those who are not trained assessors themselves
because these other adults are providing invalid can misunderstand and mistranslate a clinician's
assessments of the children whereas the teachers questions and the person's answers, as in the fol-
are providing valid assessments. The discrepan- lowing example (Marcos, 1979, p. 173):
cies may also arise because children function dif- Clinician to Spanish-speaking patient: Do
ferently in different settings. At home, a child may you feel sad or blue? Do you feel that life is not
be well behaved, quiet, and withdrawn, while at worthwhile sometimes?
school the same child may be impulsive, easily an-
Interpreter to patient: The doctor wants to
gered, and distractible.
know if you feel sad and if you like your life.
Evaluating Individuals Patient's response: No, yes, I know that my
Across Cultures children need me, I cannot give up, I prefer not
to think about it.
A number of challenges to assessment arise when
Interpreter to clinician: She says no, she says
there are significant cultural differences between
that she loves her children and that her children
the assessor and the person being assessed (Dana,
need her.
2000; Tsai, Butcher, Munoz, & Vitousek, 2001;
Tseng, 2001). Imagine having to obtain all the in- In this case, the interpreter did not accurately
formation needed to evaluate someone from a cul- reflect the person's answer to the clinician's ques-
ture very different from your own. The first tion, giving the clinician a sense that the person
problem you may run into is that the person may was doing better than the person reported she was.
not speak your language or may speak it only par- In addition, different people from the same coun-
tially (and you may not speak his or hers at all). try can speak different dialects of a language or
Symptoms can be both underdiagnosed and over- may have different means of expressing feelings
diagnosed when the individual and the assessor and attitudes. Mistranslation can occur when the
do not share a language (Okazaki & Sue, 2003). interpreter does not speak the particular dialect
Overdiagnosis may occur when an individual tries spoken by the individual or comes from a different
to describe symptoms in the assessor's language subculture.
but the assessor interprets the individual's slow Cultural biases can arise when everyone sup-
and confused description of symptoms as indicat- posedly is speaking the same language but has a
ing more pathology than is really present. Under- unique cultural background. There is evidence
diagnosis may occur when the individual cannot that African Americans in the United States are
articulate complex emotions or strange perceptual overdiagnosed as having symptoms of schizo-
experiences in the assessor's language and thus phrenia (Neighbors, Trierweiler, Ford, & Muroff,
does not even try to do so. 2003) . Some investigators believe that cultural dif-
One solution is to find an interpreter to transferences in the presentation of symptoms play a
late between the clinician and the person. While in- role (Neighbors, 1984). African Americans may
terpreters can be invaluable to good communication, present more intense symptoms than European
Diagnosis 71
Americans, and these symptoms then are misun- Syndr omes as Clust ers of Symptoms.
derstood by European American assessors as rep- FIGURE 3.4 Syndromes are clusters of symptoms that
resenting more severe psychopathology. Some frequently co-occur. The symptoms of one
European American assessors may be too quick to syndrome, such as symptoms of depression, can overlap
diagnose psychopathology in African Americans the symptoms of another syndrome, such as symptoms of
because of negative stereotypes. anxiety.
Even when clinicians avoid all these biases,
they are still left with the fact that people from
other cultures often think and talk about their
psychological symptoms differently than do
members of the clinician's culture. We discuss ex-
amples of cultural differences in the presentation Depressed mood Excessive worry
of symptoms throughout this book. One of the Loss of interest Restlessness
most pervasive differences is in whether cultures Weight loss Irritability
experience and report psychological distress Muscle tension
in emotional or somatic (physical) symptoms.
European Americans tend to view the body and
mind separately, whereas many other cultures do
not make sharp distinctions between the experi-
ences of the body and those of the mind (Okazaki &
Sue, 2003). Following a psychologically distress-
ing event, European Americans tend to report that
they feel anxious or sad, but members of many
other cultures tend to report having physical aches
and maladies. To conduct an accurate assessment,
clinicians must be aware of cultural differences in symptoms at all. Rather, they are lists of symptoms
the manifestation of disorders and in the presenta- that tend to co-occur within individuals. The
tion of symptoms, and they must use this infor- symptoms of one syndrome may overlap those of
mation correctly in interpreting the symptoms another. Figure 3.4 shows the overlap in the symp-
individuals report. Cultural differences are fur- toms that make up depression (see Chapter 7) and
ther complicated by the fact that not every mem- anxiety (see Chapter 5). Both syndromes include
ber of a culture conforms to what is known about the symptoms fatigue, sleep disturbances, and
that culture's norms. Within every culture, people concentration problems. However, each syndrome
differ in their acceptance of cultural norms for has symptoms more specific to it.
behavior. For centuries, people have tried to organize
the confusing array of psychological symptoms
into a limited set of syndromes. A set of syndromes
DIAGNOSIS and the rules for determining whether an individ-
Recall that a diagnosis is a label we attach to a set ual's symptoms are part of one of these syndromes
of symptoms that tend to occur together. This set constitute a classification system.
of symptoms is called a syndrome. Typically, sev- One of the first classification systems for psy-
eral symptoms make up a syndrome, but people chological symptoms was proposed by Hippocrates
differ in which of these symptoms they experi- in the fourth century BCE. Hippocrates divided all
ence most strongly. Some of the symptoms that mental disorders into mania (states of abnormal
make up the syndrome we call depression include excitement), melancholia (states of abnormal de-
sad mood, loss of interest in one's usual activities, pression), paranoia, and epilepsy. In 1883, Emil
sleeplessness, difficulty concentrating, and thoughts Kraepelin published the first modern classification
of death. But not everyone who becomes de- system, which is the basis of our current systems.
pressed experiences all these symptoms- for Current systems divide the world of psychological
example, some people lose interest in their usual symptoms into a much larger number of syn-
activities but never really feel sad or blue, and dromes than did Hippocrates. We will focus on the
only a subset of depressed people have promi- classification system most widely used in the
nent thoughts of death. United States, the Diagnostic and Statistical
Syndromes are not lists of symptoms that all Manual of Mental Disorders, or DSM. The classifi-
people have all the time if they have any of the cation system used in Europe and much of the rest
of the world, the International Classification of Dis- given a diagnosis. The developers tried to be as a
ease (ICD), has many similarities to the most recent theoretical and descriptive as possible in listing
editions of the DSM. the criteria for each disorder. A good example is
the diagnostic criteria for panic disorder, which
are given in Table 3.4. A person must have 4 of 13
Diagnostic and Statistical possible symptoms as well as meet other criteria
Manual of Mental in order to be diagnosed with panic disorder.
Disorders (DSM) These criteria reflect the fact that not all the
symptoms of panic disorder are present in every
For more than 60 years, the official manual for individual.
diagnosing psychological disorders in the In 2013, the newest edition of the DSM, DSM-5
United States has been the Diagnostic and Statis- (American Psychiatric Association, 2013), was
tical Manual of Mental Disorders of the American released. (The roman numeral was replaced be-
Psychiatric Association. The first edition of the cause it is limiting in our electronic age.) This
DSM, published in 1952, outlined the diagnostic new edition removed some diagnoses that were
criteria for all the mental disorders recognized in the DSM-IV-TR, added some new diagnoses,
by the psychiatric community at the time. These and modified the criteria for others. In addition,
criteria were somewhat vague descriptions the authors of the DSM-5 (a committee of the
heavily influenced by psychoanalytic theory. For American Psychiatric Association) attempted to
example, the diagnosis of anxiety neurosis could incorporate a continuum or dimensional per-
be manifested in a great variety of behaviors and
spective on mental disorders, much like that de-
emotions. The key to the diagnosis was whether scribed in Chapter 1, into the diagnosis of several
the clinician believed that unconscious conflicts
disorders, particularly autism and the personal-
were causing the individual to experience anxi- ity disorders. Substantial controversy has sur-
ety. The second edition of the DSM (DSM-II), rounded the development of the DSM-5 (Frances
published in 1968, included some disorders that
& Widiger, 2012), focused on the empirical justi-
had been newly recognized since the publication
fication for the inclusion and exclusion of disor-
of the first edition but otherwise was not much
ders, claims that the process of developing the
different. DSM-5 was clouded by secrecy and a disregard
Because the descriptions of disorders in the
of alternative points of view, and concerns about
first and second editions of the DSM were so ab-
the social impact of some of the new diagnoses
stract and theoretically based, the reliability of
(e.g., lowering the threshold for some diagnoses
the diagnoses was low. For example, one study
formally pathologizes normal variation in be-
found that four experienced clinicians using the
haviors). Throughout this book, the criteria for
first edition of the DSM to diagnose 153 patients
disorders specified by the DSM-5 will be given.
agreed on their diagnoses only 54 percent of the
Because the DSM-5 is quite new, however, much
time (Becket al., 1962). This low reliability even-
of the existing research is based on disorders as
tually led psychiatrists and psychologists to call
defined by the DSM-IV-TR or earlier editions.
for a radically new system of diagnosing mental
Thus, when appropriate, the differences between
disorders.
DSM-5 criteria and DSM-IV-TR criteria will be
noted, and implications for our understanding of
DSM-111, DSM-1/IR, DSM-IV, DSM-IV-TR, the relevant disorders will be discussed.
and DSM-5 Two other elements distinguish the later edi-
In response to the reliability problems of the first tions of the DSM from their predecessors. First, the
and second editions of the DSM, in 1980 the later editions specify how long a person must
American Psychiatric Association published the show symptoms of the disorder in order to be given
third edition of the DSM, known as DSM-III. This the diagnosis (see Table 3.4, item B). Second, the
third edition was followed in 1987 by a revised criteria for most disorders require that symptoms
third edition, known as DSM-IIIR, and in 1994 by interfere with occupational or social functioning.
a fourth edition, known as DSM-IV, revised as This emphasis on symptoms that are long-lasting
DSM-IV-TR in 2000. In these newer editions of and severe reflects the consensus among psychia-
the DSM, the developers replaced the vague de- trists and psychologists that abnormality should
scriptions of disorders with specific and concrete be defined in terms of the impact of behaviors on
criteria for each disorder. These criteria are in the the individual's ability to function and on his or
form of behaviors people must show or experi- her sense of well-being (see Chapter 1). While the
ence or feelings they must report in order to be DSM attempts to precisely define the threshold
Diagnosis 73
TABLE 3.4 DSM-5 Criteria for Panic Disorder
A. Recurrent unexpected panic attacks, defined as an abrupt surge of intense fear or intense discomfort that reaches a peak within
m i nutes, and during which time four or more of the following symptoms occur. (Note: The abrupt surge can occur from a calm
state or an anxious state .)
1. Palpitations, pounding heart, or accelerated heart rate

2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feel ing dizzy, unsteady, lightheaded, or faint
9. Chills or heat sensations
10. Paresthesias (numbness or tingling sensations)
11 . Derealization (feelings of unreality) or depersonalization (being detached from oneself)
12. Fear of losing control or going crazy
13. Fear of dying
B. At least one of the attacks has been followed by 1 month (or more) of one or both of t he following:
1. Persistent concern or worry about add itional Pan ic Attacks or their consequences (e.g., losing contro l, having a heart attack,
"going crazy")
2. Sig nificant maladaptive change in behavior related to the attacks (e.g ., behaviors designed to avoid having Pan ic Attacks,
such as avo idance of exercise or unfamilia r situations)
C. The disturbance is not attributable to the direct phys iologica l effects of a substance (e.g., a drug of abuse, a medication) or
another medical condition (e.g., hyperthyroid ism, ca rdiopulmonary disorders).
D. The distu rbance is not better accounted for by another mental disorder (e.g., the Panic Attacks do not occur only in response to
feared socia l situations in Social Anxiety Disorder, circumscribed phobic objects or situations in Specific Phobia, obsessions in
Obsessive-Compulsive Disorder, reminders of traumatic events in Posttraumatic Stress Disorder, or separation from attachment
f igures in Separation Anxiety Disorder).
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright 2013 American Psych iatric
Association .
between normality and abnormality, remember Low reliability of diagnoses can be due to
that the setting of the threshold along the contin- many factors. Although the developers of the
uum is a subjective judgment. DSM-III and DSM-IIIR attempted to make the
criteria for each disorder explicit, many criteria
Reliability of the DSM still were vague and required the clinician to
Despite the use of explicit criteria for disorders, the make inferences about the indiv idual's symp-
reliability of many of the diagnoses listed in the toms or to rely on the individual's willingness to
DSM-III and DSM-IIIR was disa ppointing. On av- report symptoms. For example, most of the
erage, experienced clinicians agreed on their diag- symptoms of the mood disorders and the anxiety
noses using these manuals only about 70 percent disorders are subjective experiences (e.g., sadness,
of the time (Kirk & Kutchins, 1992). The reliability apprehensiveness, hopelessness), and only the
of some of the diagnoses, particularly the person- indiv idual can report whether he or she has these
ality disorder diagnoses, was much lower. symptoms and how severe they are. To diagnose
SHADES OF GRAY
As you read the following case study, compare over, and he trembled uncontrollably. He was
Brett's symptoms to the criteria in Table 3.4. sure, when these feelings were happening, that
Do Brett's symptoms meet the criteria for panic he was dying of a heart attack. The symptoms
disorder? (Discussion appears at the end of lasted about 10 minutes and then subsided. His
this chapter.} doctor asked Brett where he was when these
symptoms began. Brett said the first time he felt
When Brett went to an appointment with his phy- this way was when he was about to give a pre-
sician, he looked pale and visibly nervous. He sentation in an important class. The second time
told his doctor that twice in the last month he had was when he was on his way to meet his parents
had an episode in which his heart suddenly for dinner.
started racing, he felt short of breath and cold all
any of the personality disorders, the clinician The criteria for most of the diagnoses to be included
must establish that the person has a lifelong his- in the DSM-IV were tested in clinical and research
tory of specific dysfunctional behaviors or ways settings. In a field trial, testing determines whether
of relating to the world. Unless the clinician has diagnostic criteria can be applied reliably and
known the person his or her entire life, the clini- whether they fit individuals' experiences. As a result,
cian must rely on the person and his or her fam- the reliability of the DSM-IV and DSM-IV-TR diag-
ily to provide information about the person's noses was higher than the reliability of their prede-
history. Different sources of information can cessors, although clearly they were not completely
provide very different pictures of the person's reliable (Widiger, 2002). Field trials were conducted
functioning . during the development of the DSM-5, although
To increase the reliability of diagnoses in the questions have been raised about their adequacy
DSM-IV, the task force that developed it conducted (First, 2011). The reliability of the DSM-5 diagnoses
numerous field trials (see Frances & Widiger, 2012). remains to be determined.
Nonaxial Approach in the DSM-5

.. _...,...,, ,~,H-neaded
Since the DSM-III, clinicians have been asked to
Numbness '
evaluate patients on multiple axes in order to cap-
ture important information about them. The first
__ Memory loss axes included clinical disorders, the second ad-
dressed personality disorders and intellectual
__ Loss of co d . disabilities. The remaining axes covered medical,
Psychiatric on /nation psychosocial, environmental and childhood fac-
tors that added to the clinical picture. These axes
~Anxiety/stress were often used by insurance companies and gov-

ernmental agencies in making their professional
assessments. Clinicians were never obligated to
__ Problems With use the axes in making a mental disorder diagno-
Bh Depression sleep sis; they were intended to provide as varied a
clinical assessment as possible.
OOd/Lymphati The DSM-5 has moved away from the axial
system to bring it more in line with the manual
-Unexplained used internationally, the International Classification
of Diseases (!CD), published by the World Health
---Easy brUiSJn
CJth
.. Organization (WHO) . The changes reflect the glo-
balization of research on mental health problems
er (pleasR e-n"'_ and the desire of researchers around the world for
similar diagnostic systems.
For over sixty years the Diagnostic and Statistical Manual With the publication of the DSM-5 the former
of the Mental Disorders, or DSM has been the official
reference for diagnosing psychological disorders in the Axes I, II, and III are integrated into the overall
United States.The fifth edition was published in 2013. diagnostic scheme. Separate notations for impor-
tant psychosocial and contextual factors (former
Diagnosis 75
Axis IV) and disability (former Axis V) are made can impede progress in research and treatment as
by the clinician. The approach of making separate researchers focus on understanding the causes of
notions about psychosocial and contextual factors and treatments for the diagnosis rather than on
is consistent with the approach established by the biological, psychological, and social problems
the WHO and the ICD. The goal is to consider the that underlie the disorder and related disorders
individual's functional status separately from his (Hyman, 2010). Indeed, it can be difficult for
or her diagnosis or symptom status. researchers to obtain funding to study problems
DSM-IV Axis IV addressed psychosocial and that are not official diagnoses in the DSM and for
environmental problems that might affect the di- clinicians to be reimbursed by insurance compa-
agnosis, treatment and prognosis of mental disor- nies to treat them.
ders. The editors of DSM-5 felt that this resource
should no longer provide diagnostic criteria sepa- Category or Continuum The DSM-IV-TR and
rate from those used in the ICD.
its predecessors were categorical diagnostic sys-
DSM-IV Axis V consisted of the Global Assess-
tems, meaning that their diagnostic criteria defined
ment of Functioning (GAF) scale, which allowed
where normality ends and psychopathology be-
clinicians to register their judgment of an individu-
gins. The DSM-5 retains the categorical system for
al's overall level of functioning. The scale ran from most diagnoses, but it introduces a continuum or
0 to 100 with 100 representing maximum function-
dimensional perspective on a number of disorders,
ing. One person might be diagnosed with depres-
such as the autism spectrum disorders and person-
sion and receive a GAF score of 40 whereas another
ality disorders. Further, a number of dimensional
person with the same diagnosis might receive a
assessment scales for rating a person's symptoms
score of 70. Although each person has the same di-
and functioning have been added to the DSM-5.
agnosis, the clinical portrait of each would be seen
These moves toward a more dimensional model of
differently. Perhaps one person is too depressed to
diagnosis reflect the growing consensus that all be-
go to work whereas another is capable of handling
haviors fall along a continuum and that most disor-
most of life's responsibilities. This scale was
ders represent extremes along this continuum.
dropped in the DSM-V because contributors noted
Yet questions have been raised about whether
its lack of conceptual clarity: for example, different
a continuum perspective is practical for real-world
clinicians might assess the same person with dif-
use (First, 2010). Busy clinicians have to make hun-
ferent scores. To provide some global measure
dreds of decisions per day, and it may be easier to
of disability, the DSM-5 recommends the WHO
think in terms of categories than continuums. Prior
Disability Assessment Schedule (WHODAS).
versions of the DSM had some dimensions along
which clinicians could rate patients' functioning,
Continuing Debates About the DSM but there is evidence that most clinicians did not
Although the recently introduced DSM-5 was use them (First, 2010). So although in reality men-
meant to reflect the developments in our under- tal health and mental disorder may exist along
standing of mental disorders over the last decade continuums or dimensions, the human mind may
or so, debates continue over fundamental ques- be constructed to think more in terms of categories
tions about the classification and diagnosis of dis- and the presence or absence of disorders.
orders. We next consider some of these debates.
Differentiating Mental Disorders from
Reifying Diagnoses Once a diagnosis is de- One Another A frequent complaint with the
fined in any classification system, people tend to DSM-IV and DSM-IV-TR was the difficulty in
reify it, seeing it as real and true rather than as the differentiating the mental disorders from one an-
product of a set of judgments about how symp- other (Watson, 2009). Most people who were di-
toms tend to occur together (Hyman, 2010). These agnosed with one disorder also met the criteria
judgments may be made by experts and be based for at least one other disorder, a situation referred
on the best empirical science of the time, but they to as comorbidity. This overlap occurs, in part,
are highly fallible and, to some extent, always so- because certain symptoms show up in the crite-
cial constructions based on our society's current ria for several different disorders. For example,
views of mental disorders. Moreover, as noted in irritability or agitation can be part of depression,
Chapter 1, it's increasingly clear that certain prob- mania, anxiety, schizophrenia, some of the per-
lems in biological, psychological, and social func- sonality disorders, and some of the childhood
tioning cut across many disorders (Insel, 2010; disorders. Some changes in the DSM-5 were made
Sanislow et al., 2011). The reification of diagnoses to try to correct the problem of comorbidity. For
TABLE 3.5 Culture-Bound Syndromes
Certain synd romes appear to occur only in some cultures.
Syndrome Cultures Where Found Symptoms
Amok Malaysia, Laos, Philipp ines, Brooding followed by an outburst of vio lent,
Polynesia, Papua New Guinea, aggressive, or homicidal behavior
Puerto Rico
Ataque de nervios Latin America and Latin Uncontrollable shouting, attacks of crying, trembling,
Med iterranean cultures heat in the chest rising into the head, verbal or physical
aggression, a sense of being out of control
Dhat India, Sri Lanka, China Severe anxiety about the discharge of semen, whitish
discoloration of the urine, feelings of weakness and
exhaustion
Ghost sickness Native American cultures Preoccupation with death and the deceased,
manifested in dreams and in severe anxiety
Koro Malaysia, China, Thailand Episode of sudden and intense anxiety that the penis
(or, in women , the vulva and nipples) will recede into
the body and possibly cause death
Mal de ojo Mediterranean cultures Fitful sleep, crying without apparent cause, diarrhea,
vomiti ng, fever
Shinjingshuairuo China Physical and mental fatigue, dizziness, headaches,
other pains, concentration difficulties, sleep
disturbance, memory loss
Susto U.S. Latinos, Mexico, Appetite disturbances, sleep problems, sadness, lack of
Central America, South America motivation, low self-worth, aches and pa ins; follows a
frightening experience
Taijinkyofusho Japan Intense fear that one's body displeases, embarrasses,
or is offensive to other people
example, many of the diagnoses of the personal- specific disorder with which an individual might
ity disorders (Chapter 9) were revised to reduce be diagnosed (see Helzer et al., 2008).
the amount of overlap in the criteria for different In the meantime, however, most people who
disorders. are given one diagnosis of a mental disorder will
Although we might want to make the diagnos- also meet the criteria for at least one other diagno-
tic criteria for disorders more distinct, recent resis (Kessler et al., 2005). This leads to many ques-
search suggests that much of the comorbidity tions, such as which diagnosis should be considered
among disorders exists because it reflects problems the primary diagnosis and which the secondary
in fundamental cognitive, emotional, and behav- diagnosis, which diagnosis should be treated first,
ioral processes that cut across many disorders, such whether people with diagnoses A and B are funda-
as sleep problems, depressed or anxious mood, and mentally different from or similar to people with
substance use (Sanislow et al., 2011). Some experts diagnoses A and C, and so on.
believe that diagnostic systems of the future will
specify how these dimensions come together to cre- Addressing Cultural Issues Different cul-
ate different types of psychopathology, as well as tures have distinct ways of conceptualizing men-
how and why these psychopathologies are related tal disorders. Some disorders that are defined in
(Insel, 2010). The authors of the DSM-5 developed one culture do not seem to occur in others.
a set of instruments to assess variations in cogni- Table 3.5 d escribes som e of these culture-bound
tive, emotional, and behavioral processes. These syndromes. In addition, there is cultural variation
instruments are not part of the DSM-5 but are avail- in the presentation of symptoms. For example,
able for use by researchers and clinicians to obtain there are differences among cultures in the content
ratings for important dimensions regardless of the of delusions (beliefs out of touch with reality) in
Diagnosis 77
schizophrenia. The DSM-5 and its predecessors Even psychiatrists and psychologists who do
provide guidelines for considering cultural issues not fully agree with Szasz's perspective recognize
such as the kinds of symptoms acceptable in the that giving a person a diagnosis leads to certain
individual's culture. Some critics do not believe judgments and expectations of them that can have
these guidelines have gone far enough in recog- unintended consequences. This point was made in
nizing cultural variation in what behaviors, a classic study of the effects of diagnoses by psy-
thoughts, and feelings are considered healthy or chologist David Rosenhan (1973). He and seven
unhealthy (Kirmayer, 2001; Tsai et al., 2001). colleagues had themselves admitted to 12 different
Throughout the remainder of this book, we will mental hospitals by reporting to hospital staff that
comment on cultural variations in the experience they had been hearing voices saying the words
and prevalence of each disorder recognized by empty, hollow, and thud. When they were ques-
the DSM. tioned by hospital personnel, they told the truth
about every other aspect of their lives, including
the fact that they had never experienced mental
The Social-Psychological health problems before. All eight were admitted to
the hospitals, all but one with a diagnosis of schizo-
Da ngers of Diagnosis phrenia (see Chapter 8).
We noted earlier that once a diagnosis is given, Once they were admitted to the hospitals, the
people tend to see it as real rather than as a judg- pseudopatients stopped reporting that they were
ment. This can make people oblivious to the biases hearing voices and behaved as normally as they
that may influence diagnoses. One influential critic usually did. When asked how they were doing
of psychiatry, Thomas Szasz (1920-2012), argued by hospital staff, the pseudopatients said they
that so many biases are inherent in determining felt fine and no longer heard voices. They coop-
who is labeled as having a mental disorder that the erated in activities. The only thing they did dif-
entire system of diagnosis is corrupt and should be ferently from other patients was to write down
abandoned. Szasz (1961) believed that people in their observations on notepads occasionally dur-
power use psychiatric diagnoses to label and iso- ing the day.
late people who do not "fit in." He suggested that Not one of the pseudopatients was ever de-
mental disorders do not really exist and that peo- tected as normal by hospital staff, although they
ple who seem to be suffering from mental disor- remained in the hospitals for an average of 19 days.
ders are oppressed by a society that does not accept Several of the other patients in the mental hospi-
their alternative ways of behaving and looking at tals detected the pseudopatients' normality, how-
the world. ever, making comments such as "You're not crazy,
Children who are labeled as different

can be ostracized by other children .
you're a journalist, or a professor [referring to the interaction, the boys were asked several ques-
continual note taking] . You're checking up on the tions about each other and about their enjoyment
hospital" (Rosenhan, 1973). When the pseudopa- of the interaction.
tients were discharged, they were given the diag- The boys who had been told that their part-
nosis of schizophrenia in remission, meaning that ners had a behavior disorder were less friendly
the physicians still believed the pseudopatients toward their partners during the task, talked
had schizophrenia but the symptoms had sub- with them less often, and were less involved in
sided for the time being. the interaction with their partners than were the
Rosenhan (1973) concluded, "It is clear that boys who had been told nothing about their part-
we cannot distinguish the sane from the insane ners. In tum, the boys who had been labeled as
in psychiatric hospitals. The hospital itself im- having a behavior disorder enjoyed the interac-
poses a special environment in which the mean- tion less, took less credit for their performance
ings of behavior can be easily misunderstood." on the task, and said that their partners were less
He also noted that, if even mental health profes- friendly toward them than did the boys who had
sionals cannot distinguish sanity from insanity, not been so labeled. Most important, labeling a
the dangers of diagnostic labels are even greater boy as having a behavior disorder influenced his
in the hands of nonprofessionals: "Such labels, partner's behaviors toward him and his enjoy-
conferred by mental health professionals, are as ment of the task regardless of whether he actu-
influential on the patient as they are on his rela- ally had a behavior disorder. These results show
tives and friends, and it should not surprise any- that labeling a child as having a disorder strongly
one that the diagnosis acts on all of them as a affects other children's behaviors toward him or
self-fulfilling prophecy. Eventually, the patient her, even when there is no reason for the child to
himself accepts the diagnosis, with all of its sur- be so labeled.
plus meanings and expectations, and behaves Should we avoid psychiatric diagnoses alto-
according! y." gether? Probably not. Despite the potential dangers
Not surprisingly, Rosenhan's study created a of diagnostic systems, they serve vital functions.
furor in the mental health community. How could The primary role of diagnostic systems is to orga-
seasoned professionals have made such mistakes- nize the confusing array of psychological symp-
admitting mentally healthy people to psychiatric toms in an agreed-on manner. This organization
hospitals on the basis of one symptom (hearing facilitates communication from one clinician to
voices), not recognizing the pseudopatients' be- another and across time.
havior as normal, allowing them to be discharged For example, if Dr. Jones reads in a patient's
carrying a diagnosis that suggested they still had history that he was diagnosed with schizophrenia
schizophrenia? Even today, Rosenhan's study is according to the DSM-5, she knows what criteria
held up as an example of the abuses of the power to were used to make that diagnosis and can compare
label people as sane or insane, normal or abnormal, the patient's diagnosis then with his symptoms
good or bad. Not only do clinicians and the public now. Such information can assist Dr. Jones in
begin to view the person as his or her disorder (e.g., making an accurate assessment of the patient's
he is a schizophrenic, she is a depressive), but peo- current symptoms and in determining the proper
ple with disorders also take on the role of a disor- treatment for his symptoms. For example, if the
dered person, a role they may carry for the rest of patient's current symptoms also suggest schizo-
their lives. phrenia and the patient responded to Drug X
Another study of boys in grades 3 to 6 illus- when he had schizophrenia a few years ago, this
trates how labeling children can influence how history indicates that he might respond well to
others treat them (Harris, Milich, Corbitt, & Drug X now.
Hoover, 1992). Researchers paired boys who Having a standard diagnostic system also
were the same age. In half the pairs, one of the greatly facilitates research on psychological dis-
boys was told that his partner had a behavior orders. For example, if a researcher at Univer-
disorder that made him disruptive. In reality, sity A is using the DSM-5 criteria to identify
only some of the boys labeled as having a behav- people with obsessive-compulsive disorder and a
ior disorder actually had a behavior disorder. In researcher at University B is using the same crite-
the other half of the pairs, the boys were not told ria for the same purpose, the two researchers will
anything about each other, although some of the be better able to compare the results of their re-
boys actually did have a behavior disorder. All search than if they were using different criteria to
the pairs worked together on a task while re- diagnose obsessive-compulsive disorder. Stan-
searchers videotaped their interaction. After the dardization can lead to faster advances in our
Think Critically 79
~ understanding of the causes of and effective treat- Integration of Biological, Psychological,

ments for disorders. FIGURE 3.5 and Social Factors in Assessment and
Diagnosis
CHAPTER INTEGRATION
Assessment is inherently a process of biopsycho-
social integration of pieces of information about
an individual. After clinicians administer a bat-
tery of assessment tests to a person, they must
r
Social factors:
then integrate the information gathered from support networks, work
these tests to form a coherent picture of the relationships, social skills
person' s strengths and weaknesses. This picture
weaves together information on biological
functioning (major illnesses, possible genetic Psychological factors:
Biological factors:
vulnerability to psychopathology), psychologi- major illnesses, possible - . - - - - - personality, coping skills,
cal functioning (personality, coping skills, in- genetic vulnerabilities, intellectual strengths,
tellectual strengths), and social functioning brain functioning symptoms
(support networks, work relationships, social
skills) (Figure 3.5).
If you determined that Brett has experienced panic and may often (or expectedly) occur in these situa-
attacks, you are correct. The DSM-5 requires four tions. In addition, criterion B requires him to have
symptoms for diagnosis of a panic attack (see cri- been persistently fearful of another panic attack or
terion A), and Brett reports five: rapid heartbeat; to have made significant maladaptive changes in
shortness of breath, chills, trembling, and feeling his behavior related to panic attacks for at least a
as though he was going to die. Further, these month. We cannot tell whether either of these con-
symptoms seem to have developed suddenly and ditions has been met. We also cannot rule out the
to have increased in intensity within minutes, possibility of an organic factor, such as too much
meeting criterion A in Table 3.4. coffee, or another mental disorder having caused
It is less clear whether Brett's symptoms meet his panic attacks, so we do not know if he meets
the criterion that they are "unexpected," because criteria C and D. Thus, although it appears that
his panic attacks occurred before giving an impor- Brett has experienced some panic attacks, we can-
tant presentation and before meeting his parents not currently diagnose him with panic disorder.
THINK CRITICALLY
Reread the Shades of Gray case study of Brett and with panic disorder? How would these assessments
the criteria for panic disorder listed in Table 3.4. help you decide? (Discussion appears on p. 481 at the
What assessment tools from this chapter would you back of this book.)
use to determine whether Brett can be diagnosed
80 Chapter 3 Assessi ng a nd Diagnosing Abnormality
CHAPTER SUMMARY ~
Assessment is the process of gathering individuals' reactions to the stimuli. Both

information about people's symptoms and the the validity and the reliability of these tests
causes of these symptoms. Diagnosis is a label are low.
we attach to symptoms that tend to co-occur. During the assessment procedure, many problems
The validity and reliabi lity of assessment tools and biases can be introduced. Individuals may
indicate their quality. Validity is the accuracy be resistant to being assessed and thus distort
of a test in assessing what it is supposed to the information they provide. They may be too
assess. Five types of validity are face validity, impaired by cognitive deficits, distress, or lack
content validity, concurrent validity, predictive of development of verbal skills to provide infor-
validity, and construct validity. Reliability is the mation. Further, many biases can arise when
consistency of a test. Types of reliability include the clinician and the individual are from different
test-retest reliability, alternate form reliability, cultures.
internal reliability, and interrater reliability. A classification system is a set of definitions of
Standardization of the implementation and syndromes and rules for determining when a
interpretation of an assessment tool can person's symptoms are part of each syndrome.
increase both validity and reliability. In the United States, the predominant classifica-
In a mental status exam, the clinician assesses tion system for psychological problems is the
the individual's (a) appearance and behavior, Diagnostic and Statistical Manual of Mental
(b) thought processes, (c) mood and affect, Disorders (DSM) of the American Psychiatric
(d) intellectual functioning, and (e) orientation. Association. Its most recent editions provide
To assess emotional and behavioral functioning, specific criteria for diagnosing each of the
clinicians use structured clinical interviews, recognized psychological disorders, as well as
symptom questionnaires, personality inventories, information on the course and prevalence of
behavioral observation, and self-monitoring. disorders.
Paper-and-pencil neuropsychological tests can The explicit criteria in the DSM have increased
assess specific cognitive deficits that may be the reliability of diagnoses, but there is still room
related to brain damage in patients. Intelligence for improvement.
tests provide a more general measure of verbal The DSM-5 provides three axes on which clinicians
and analytical skills. can assess individuals. On Axis I, major clinical
Brain-imaging techniques such as CT, PET, syndromes and any medical conditions individuals
SPECT, and MRI scans currently are being used have are noted. On Axis II, psychosocial and
primarily for research purposes, but in the environmental stressors are noted. On Axis Ill,
future they may contribute to the diagnosis individuals' general levels of functioning are
and assessment of psychological disorders. assessed .
Psychophysiological tests, including the Critics point to many dangers in labeling people
electroencephalogram (EEG) and electrodermal as having psychiatric disorders, including the
responses, assess brain and nervous system danger of stigmatization. Diagnosis is important,
activity detectable on the periphery of the body however, to communication among clinicians and
(such as on the scalp and skin). researchers. Only when a system of definitions
of disorders is agreed on can communication
Projective tests present individuals with
about disorders be improved .
ambiguous stimuli. Clinicians interpret
Key Terms 81
KEY TERMS
assessment 60 single photon emission computed tomography
diagnosis 60 (SPECT) 67
validity 60 magnetic resonance imaging (MRI) 67
reliability 61 psychophysiological tests 67
structured interview 62 electroencephalogram (EEG) 67
symptom questionnaire 63 projective test 68
personality inventories 64 syndrome 71
behavioral observation 64 classification system 71
self-monitoring 65 Diagnostic and Statistical Manual of Mental
Disorders (DSM) 71
intelligence tests 66
multiaxial system 74
neuropsychological tests 66
comorbidity 75
computerized tomography (CT) 67
positron-emission tomography (PET) 67
The Research Endeavor
CHAPTER OUTLINE
Research Along the Continuum Genetic Studies

Extraordinary People: The Old Order Cross-Cultural Research
Amish of Pennsylvania
Meta-Analysis
The Scientific Method
Chapter Integration
Shades of Gray
Case Studies
Think Critically
Correlational Studies
Chapter Summary
Epidemiological Studies
Key Terms
Experimental Studies
Research with Continuum Approach Research with Threshold Approach
Studies focus on people with symptoms Studies focus on people with diagnosed
that range in severity from the everyday disorders of various severities
(occasional sad mood) to the highly (adjustment disorder with depressed
impairing and Likely to meet criteria for mood, major depressive disorder) or on
a disorder (paralyzing depression) . comparisons of people with diagnosed
disorders and people without disorders.
Depressive symptoms:
Severe symptoms
No symptoms Low symptoms Moderate symptoms
meeting diagnostic criteria
This text helps you understand psychopathology using a contin- as a study of the relationship between how many stressors indi-
uum model. This model actually is a hot topic for debate in the viduals have experienced and how many depressive symptoms
field of abnormal psychology. Researchers disagree on whether they report. In contrast, investigators who are interested only in
studies should reflect a continuum model of psychopathology or differences between people with diagnosed disorders and pea-
instead focus only on disorders as diagnosed in the DSM-5 and pie who do not meet diagnostic criteria would be more likely to
related diagnostic schemes. The difference lies mainly in how compare these two groups on the number of stressors they
researchers view people who have some symptoms of a disorder have experienced. We explore several research methods in this
but do not meet the criteria for diagnosis. Researchers who favor chapter.
continuum models believe that such individuals provide valu- It is important to remember that research is a cumulative
able insights into people who have diagnosable disorders. For process. No one study can defin itively answer complex ques-
~
example, they argue that the results of studies of people with tions about the causes of and best treatments for mental disor-
moderate depression can be generalized to individuals with di- ders. Too often, individual studies generate a great deal of media
agnosed depressive disorders (Angst et al., 2007). Researchers attention, with headlines such as "Scientists find the gene for
who do not support continuum models argue that people who schizophrenia " or "Study shows antidepressant medications do
fall short of a diagnosable disorder are inherently different from not work." The public can be given false hopes for breakthroughs
those who have a disorder and therefore studies of these people that are dashed by future studies, leading to cynicism and re-
cannot be applied to those who have a disorder. To continue our duced funding of mental health science . People with mental
example, these researchers believe that the results of studies of health problems can also come to believe that they should dis-
people with moderate depression cannot be generalized to peo- continue some treatment because one study raised doubts about
pie with diagnosed depressive disorders (Gotlib, Lewinsohn, & its effectiveness. Only by the accumulation of evidence from
Seeley, 1995). multiple studies using multiple methods can we beg in to have
The debate continues, with evidence supporting both points faith in the answer to a question about the causes of or appropri-
of view. Some research methods use a continuum model, such ate treatments for a disorder.
Research Along the Continuum 83

84 Chapter 4 The Research Endeavor
The Old Order Amish of Pennsylvania
The Old Order Amish Despite their self-enforced isolation from main-
are a religious sect stream American society, the Amish of southeastern
whose members avoid Pennsylvania welcomed researcher Janice Egeland
contact with the mod- and several of her colleagues to conduct some ofthe
ern world and live a most intensive studies of depression and mania
simple, agrarian life, ever done (Egeland, 1986, 1994; Egeland & Hostetter,
much as people lived 1983; Pauls, Morton, & Egeland, 1992). These re-
in the eighteenth cen- searchers examined the records of local hospitals
tury. The Amish use looking for Amish people who had been hospital-
a horse and buggy as ized for psychological problems. They also inter-
transportation, most of viewed thousands of members of this community to
their homes do not have electricity or telephone discover people with mood disorders who had not
se rvice, and there is little movement of people into been hospitalized. The closed society of the Amish
or out of their culture. The rules of social behavior and their meticulous recordkeeping of family histo-
among the Amish are very strict, and roles within ries proved a perfect setting in which to study the
the community are clearly set. Members who do transmission of psychological disorders within fam-
not comply with community norms are isolated or ilies. The result was groundbreaking research on
shunned. genetic factors that contribute to mood disorders.
While research in abnormal psychology in many piece together the partial answers from several
ways resembles research in other fields, the study studies to get a complete picture.
of psychopathology presents some special chal- Despite these challenges, researchers have
lenges. One challenge is accurately measuring ab- made tremendous strides in understanding many
normal behaviors and feelings . We cannot see, forms of abnormality in the past 50 years or so.
hear, or feel other people's emotions and thoughts. They have overcome many of the challenges of re-
Researchers often must rely on people's own ac- searching psychopathology by using a multi-
counts, or self-reports, of their internal states and method approach, that is, using different methods
experiences. Self-reports can be distorted in a to study the same issue. Each different research
number of ways, intentionally or unintentionally. method may have some limitations, but taken to-
Similarly, relying on an observer's assessments of gether the methods can provide convincing evi-
a person has its own pitfalls. The observer's as- dence concerning an abnormality.
sessments can be biased by stereotypes involving In this chapter, we discuss the most common
gender and culture, idiosyncratic biases, and lack methods of mental health research. In our discus-
of information. A second challenge is the difficulty sion, we will use various research methods to test
of obtaining the participation of populations of the idea that stress contributes to depression. Of
interest, such as people who are paranoid and course, these research methods also can be used to
hearing voices. test many other ideas.
A third challenge, mentioned in the Research
Along the Continuum feature, is that most forms
of abnormality probably have multiple causes. Un-
THE SCIENTIFIC METHOD
less a single study can capture all the biological, Any research project involves a basic series of
psychological, and social causes of the psychopa- steps designed to obtain and evaluate information
thology of interest, it cannot fully explain the relevant to a problem in a systematic way. This
causes of that abnormality. Rarely can a single process is often called the scientific method.
study accomplish so much. Instead, we usually are First, researchers must select and define a
left with partial answers to the question of what problem. In our case, the problem is to determine
causes a certain disorder or symptom, and we must the relationship between stress and depression.
Th e Scientific Method 85
Then a hypothesis, or testable statement of what A variable is a factor or characteristic that can
we predict will happen in our study, must be vary within an individual or between individuals.
formulated. Next, the method for testing the hy- Weight, mood, and attitudes toward one's mother
pothesis must be chosen and implemented. Once are all factors that can vary over time, so they are
the data have been collected and analyzed, the re- considered variables. Characteristics such as sex
searcher draws the appropriate conclusions and and ethnicity do not vary for an individual over
documents the results in a research report. time, but because they vary from one individual to
another, they too can be considered variables. A
dependent variable is the factor we are trying to
Defining the Problem predict in our study. In our studies of stress and
and Stating a Hypothesis depression, we will be trying to predict depres-
sion, so depression is our dependent variable. An
Throughout this chapter, we will examine the idea
independent variable is the factor we believe will
that stress causes depression. This simple idea is
affect the dependent variable. In our studies, the
too broad and abstract to test directly. Thus, we
independent variable is the amount of stress an in-
must state a hypothesis, or a testable prediction of
dividual has experienced.
what relationship between stress and depression
In order to research depression and stress, we
we expect to find in our study. must first define what we mean by these terms. As
To generate a hypothesis, we might ask,
we will discuss in Chapter 7, depression is a syn-
"What kind of evidence would support the idea
drome or a collection of the following symptoms:
that stress causes depression?" If we find that peo-
sadness, loss of interest in one's usual activities,
ple who have recently experienced stress are more
weight loss or gain, changes in sleep, physical agi-
likely to be depressed than people who have not
tation or slowing down, fatigue and loss of energy,
recently experienced stress, this evidence would
feelings of worthlessness or excessive guilt, prob-
support our idea. One hypothesis, then, is that
lems in concentration or indecisiveness, and sui-
people who have recently been under stress are
cidal thoughts (American Psychiatric Association,
more likely to be depressed than people who have
2013). Researchers who adopt a continuum model
not. We can test this hypothesis by a number of
of depression focus on the full range of depressive
research methods.
symptoms, from no symptoms to moderate symp-
The alternative to our hypothesis is that peo-
toms to the most severe symptoms. Researchers
ple who experience stress are not more likely to
who do not accept a continuum model would con-
develop depression than people who do not
sider anyone who has some of these symptoms of
experience stress. This prediction that there is no
depression but does not meet the criteria for one of
relationship between the phenomena we are
the depressive disorders to be not depressed.
studying-in this case, stress and depression-is
Stress is more difficult to define, because the
called the null hypothesis. Results often support
term has been used in so many ways in research
the null hypothesis instead of the researcher 's
and in the popular press. Many researchers con-
primary hypothesis.
sider stressful events to be events that are uncon-
Does support for the null hypothesis mean
trollable, unpredictable, and challenging to the
that the underlying idea has been disproved? No.
limits of people's abilities to cope (see Chapter 15).
The null hypothesis can be supported for many
reasons, including flaws in the study design. Re-
Operationalization refers to the way we mea-
sure or manipulate the variables in a study. Our
searchers often will continue to test their primary
definitions of depression and stress will influence
hypothesis, using a variety of methodologies. If
how we measure these variables. For example, if
the null hypothesis continues to get much more
we define depression as a diagnosable depressive
support than the primary hypothesis, the research-
disorder, then we will measure depression in terms
ers eventually either modify or drop the primary
of whether people's symptoms meet the criteria
hypothesis.
for a depressive disorder. If we define depression
as symptoms along the entire range of severity,
Choosing and Implementing then we might measure depression as scores on a
a Method depression questionnaire.
In measuring stress, we might assess how of-
Once we have stated a hypothesis, the next step in ten a person has encountered events that most
testing our idea that stress leads to depression is to people would consider stressful. Or we might de-
choose how we are going to define the phenomena vise a way of manipulating or creating stress so
we are studying. that we can then examine people's depression in
SHADES OF GRAY
Imagine that you are the student member of the would be randomly assigned to receive feedback
human participants committee that is considering that they had done well on the test. The researcher
the ethics of research at your school. A researcher would measure participants' moods before and
proposes a study in which participants would be- after taking the test and receiving the feedback.
lieve they were taking a test that indicated their
intellectual ability. In truth, half the participants At a minimum, what would you require of the
would be randomly assigned to receive feedback researcher in order to consider this study ethical?
that they had done poorly on the test, and half (Discussion appears at the end of this chapter.)
response to this stress. In the remaining sections of data gathered from individuals should obtain
this chapter, we will discuss different methods for their explicit permission.
testing hypotheses, as well as the conclusions that 3. Right to refuse or withdraw participation.
can and cannot be drawn from these methods. Participants should be allowed to refuse
to participate in the study or to withdraw
Ethical Issues in Research from participation once the study has begun
without suffering adverse consequences.
Any research, whether experimental or some other If students are participating in a study as a
type, must be evaluated for whether it is ethical. course requirement or as an opportunity
All colleges and universities have human partici- for extra credit for a class, they should be
pants committees (sometimes referred to as human given the choice of equitable alternative
subjects committees, institutional review boards, activities if they wish not to participate.
or ethics committees). These committees review Payment or other inducements for being
the procedures of studies done with humans to en- in a study should not be so great that indi-
sure that the benefits of the study substantially viduals essentially cannot afford to refuse
outweigh any risks to the participants and that the to participate.
risks to the participants have been minimized. The
committees ensure that each research study in- 4. Informed consent. Usually, participants'
cludes certain basic rights for all participants: consent to participate in the study should
be documented in writing. In some cases, a
1. Understanding the study. Participants have the written informed consent document is not
right to understand the nature of the research used, as when participants are filling out
they are participating in, particularly any an anonymous survey (in this case, their
factors that might influence their willingness willingness to complete the survey is taken
to participate. For example, if they are likely to as their consent to participate). Also, if
experience discomfort (psychological or phys- obtaining written documentation of partici-
ical) as a result of participating in the study or pants' consent could put them at risk, the
if the study entails any risk to their well-being, researcher sometimes is allowed to obtain
the researcher should explain this in plain lan- only verbal consent. Examples of when this
guage to the participants. Individuals not ca- would be permitted include research being
pable of understanding the risks of a study, done in countries where a civil war is ongo-
such as young children or adults with mental ing or an oppressive regime is in power,
impairments, must have a parent, guardian, or in which case participants might be at risk
other responsible adult make the judgment if it is discovered they have talked with
about their participation in the study. researchers.
2. Confidentiality. Participants should expect 5. Deception. Researchers should use deception
their identity and any information gathered in studies only when doing so is absolutely
from them in the course of the study to be essential and justified by the study's potential
held in strict confidence. Researchers usually contributions. Participants should not be
report data aggregated across participants deceived about those aspects of the research
rather than data gathered from individual that might affect their willingness to partici-
participants. Researchers who intend to report pate, such as physical risks, discomfort, or
Case Studies 87
unpleasant emotional experiences. If deception

"To them, I was wasting my life;' he told the Los
is necessary, researchers should explain the
Angeles Times. "To me, I was fighting for it:'
deception to the participants after the research
Cobain didn't speak to his father for 8 years.
is completed.
When Nirvana went to the top of the charts, Don
6. Debriefing. At the end of the study, researchers Cobain began keeping a scrapbook. "Everything
should explain the purpose of the research I know about Kurt;' he told Azerrad, "I've read in
and answer participants' questions. newspapers and magazines:'
Although these rights may seem straightforward, The more famous Nirvana became, the more
human participants committees must make judg- Cobain wanted none of it. ... Nirvana-with their
ment calls as to whether a given study adequately stringy hair, plaid work shirts, and torn jeans-
protects participants' rights and whether the po- appealed to a mass of young fans who were tired
tential benefits of the study outweigh any risks to of false idols like Madonna and Michael Jackson
the participants. and who'd never had a dangerous rock-and-roll
hero to call their own. Unfortunately, the band
also appealed to the sort of people Cobain had
CASE STUDIES always hated: poseurs and band wagoneers, not
Throughout this book, you will see case studies- to mention record company execs and fashion
detailed histories of individuals who have some designers who fell over themselves cashing in
form of psychological disorder. Case studies on the new sights and sounds. Cobain, who'd
have been used for centuries as a way to under- grown up as an angry outsider, tried to shake his
stand the experiences of individuals and to make celebrity....
more general inferences about the sources of By 1992, it became clear that Cobain's per-
psychopathology. sonal life was as tangled and troubling as his
If we wanted to use a case study to test our idea music. The singer married [Courtney] Love in
that stress causes depression, we would focus on Waikiki-the bride wore a moth-eaten dress once
an individual, interviewing him or her at length to owned by actress Frances Farmer-and the couple
discover the links between periods of depression embarked on a self-destructive pas de deux widely
and stressful events in his or her life. We might also referred to as a 90s version of Sid and Nancy. As
interview close friends and family to obtain addi- Cobain put it, "I was going off with Courtney and
tional information. Based on the information we we were scoring drugs and we were f-king up
gathered, we would create a detailed description of against a wall and stuff ... and causing scenes just
the causes of his or her depressive episodes, with to do it. It was fun to be with someone who would
emphasis on the role of stressful events in these epi- stand up all of a sudden and smash a glass on the
sodes. As an example, this brief case study describes table:' In September 1992, Vanity Fair reported that
singer Kurt Cobain of the hit 1990s rock band Love had used heroin while she was pregnant with
Nirvana, who committed suicide. [their daughter] Frances Bean. She and Cobain de-
nied the story (the baby is healthy). But authorities
were reportedly concerned enough to force them
CASE STUDY to surrender custody of Frances to Love's sister,
[Kurt] Cobain always had a Jamie, for a month, during which time the couple
fragile constitution (he was subject to bronchitis, was, in Cobain's words, "totally suicidal:' . . .
as well as the recurrent stomach pains he claimed [T]hose who knew the singer say there was a
drove him to a heroin addiction). The image one real fragility buried beneath the noise of his mu-
gets is that of a frail kid batted between warring sic and his life .... If only someone had heard the
parents. "[The divorce] just destroyed his life;' alarms ringing at that rambling , gray-shingled
Wendy O'Connor tells Michael Azerrad in the home near the lake. Long before there was a void
Nirvana biography Come As You Are. "He in our hearts, there was a void in Kurt Cobain's.
changed completely. I think he was ashamed. (From J. Giles, "The Poet of Alienation:' From
And he became very inward-he just held every- Newsweek, April 18, 1994 1994 Newsweek, Inc.
thing [in] . ... I think he's still suffering:' As a teen, All rights reserved. Used by permission and pro-
Cobain dabbled in drugs and punk rock and tected by the Copyright Laws of the United
dropped out of school. His father persuaded him States. The printing, copyin g, redistribution, or
to pawn his guitar and take an entrance exam for retransmission of the material without express
the navy. But Cobain soon returned for the guitar. written permission is prohibited.)
Case studies also suffer from a lack of objectiv- ~

Evaluating Case
ity on the part of both the individuals telling their
Studies stories and the therapists or researchers listening
Case studies are a time- to the stories. People might have biased recollec-
honored method of research, tions of their pasts and may selectively report
for several reasons. No other events that happen in the present. The therapists
method captures the unique- or researchers might selectively remember parts of
ness of the individual as the stories that support their beliefs and assump-
much as a case study. The nu- tions about the causes of human behavior and for-
ances of an individual's life get parts that do not. Thus, two case studies of the
and experiences can be de- same person conducted by two different research-
tailed, and the individual's ers may lead to different conclusions about the
own words can be used to motivations and key events in that person's life.
describe these experiences.
Exploring the unique experi-
ences of individuals and hon-
CORRELATIONAL STUDIES
oring their perspectives on Correlational studies examine the relationship be-
these experiences are impor- tween an independent variable and a dependent
tant goals for many research- variable without manipulating either variable.
ers, and in-depth case studies Correlational studies are the most common type of
of individual lives have be- study in psychology and medicine. For example,
come even more popular in you will often read about studies of the link be-
recent years. tween television watching and violence, smoking
Case studies can be the and heart disease, and Internet use and depression
only way to study rare prob- in which researchers have examined the naturally
lems, because there simply occurring relationships between variables.
are not enough people with There are many kinds of correlational studies.
such problems to study The most common type of correlational study in
In-depth histories of troubled people. such through another method. For abnormal psychology is a study of two or more
as Kurt Cobain. may be rich in detail but example, much of the re- continuous variables. A continuous variable is mea-
not generalizable. search on people with multi- sured along a continuum. For example, on a scale
ple personalities has come measuring severity of depression, scores might fall
from case studies, because this form of psychopa- along a continuum from 0 (no depression) to 100 (ex-
thology historically has been quite rare. treme depression). On a scale measuring number of
Case studies can be invaluable in helping gen- recent stressors, scores might fall along a continuum
erate new ideas and providing tentative support from 0 (no stressors) to 20 (20 or more recent stress-
for those ideas. Today one of the most common ors). If we measured severity of depression and
uses of case studies is in drug treatment research to number of recent stressors in the same group of peo-
report unusual reactions patients have had to cer- ple and then looked at the relationship between
tain drugs. These reports can alert other clinicians these two continuous variables, we would be doing
to watch for similar reactions in their patients. If a continuous variable correlational study.
enough case reports of these unusual reactions Another type of correlational study is a group
emerge in the literature, larger-scale research comparison study. In this type of study, researchers
to study the sources of the reactions may be are interested in the relationship between people's
warranted. membership in a particular group and their scores
Case studies have drawbacks, however. The on some other variable. For example, we might be
first involves generalizability-the ability to ap- interested in the relationship between depression
ply what we have learned to other individuals or and whether people have experienced a specific
groups. The conclusions drawn from the study of type of stress, such as failing a test. In this case, the
an individual may not apply to many other indi- groups of interest are students who failed a test and
viduals. This limitation is especially obvious when students who did not. We would find people who
case studies focus on people whose experiences represented these two groups, then measure depres-
may have been dramatic but unusual. For exam- sion in both groups. This is still a correlational study
ple, the circumstances leading to Kurt Cobain's because we are only observing the relationship be-
death may be interesting, but they may not tell us tween two variables-test failure and depression-
anything about why other people commit suicide. and are not manipulating any variable. In this type
Correlational Studies 89
~ of study, however, at least one of the variables- coefficient. Let us review what this statistic is and
group membership-is not a continuous variable. how to interpret it.
Both continuous variable studies and group
comparison studies can be either cross-sectional-
observing people at only one point in time- or Correlation Coefficient
longitudin al-observing people on two or more A correlation coefficient is a statistic used to repre-
occasions over time. Longitudinal studies have a sent the relationship between variables, usually
major advantage over cross-sectional studies, be- denoted by the symbol r. A correlation coefficient
cause they can show that the independent variable can fall between - 1.00 and + 1.00. A positive cor-
precedes and predicts changes in the dependent relation coefficient indicates that as values of the
variable over time. For example, a longitudinal independent variable increase, values of the
study of stress and depression can show that peo- dependent variable also increase (Figure 4.1a). For
ple who are not depressed at the beginning of the example, a positive correlation between stress and
study are much more likely to be depressed later in depression would mean that people who report
the study if they have experienced a stressful event more stressors have higher levels of depression.
in the interim than if they have not. A negative correlation coefficient indicates that
as values of the independent variable increase, val-
Measuring the Relationship ues of the dependent variable decrease (Figure 4.1b).
If we were measuring stressors and depression, a
Betwee n Variables negative correlation would mean that people who
In most correlational studies, the relationship be- report more stressors actually have lower levels of
tween the variables is indicated by a correlation depression. This is an unlikely scenario, but there
Correlations. Correlations can be positive (a) or negative (b). A zero correlation

(c) indicates that there is no relationship between the independent and dependent
FIGURE 4.1
variables. Most correlations are moderate (d), indicating that the value of the
dependent variable is not perfectly predicted by that of the independent variable.
,......
High High
. ...
...
+-'
-o" "'
"'~
.c
...... . +-'
" "'
w~
-o .c
. ..,
"C.ro
wc
0"'
"'
>
..... .. .. "c.ro
w c"'
0"' > ,
~,
Low
,. Low
..-~
Low High Low High

(a) Independent variable (b) Independent variable
High High

+-'
" "'

+-'
" "'

w~ w~
-o .c -o .c
"c.ro
wc"' wc"'
"c.ro

0"' >
0"' >

Low Low

Low High Low High
(c) Independent variable (d) Independent variable
are many instances of negative correlations between so small as to suggest that stress is not a very good
variables. For example, people who receive more predictor of depression. Similarly, two groups may
positive social support from others typically have differ in their mean levels of depression to a statis-
lower levels of depression. tically significant degree because the sample sizes
The magnitude (size) of a correlation is the de- of both groups are very large. But if the two groups
gree to which the variables move in tandem with actually differ only by 1 or 2 points on a depression
each other. It is indicated by how close the correla- questionnaire in which scores can range from 0 to
tion coefficient is to either + 1.00 or -1.00. A corre- 60, the clinical significance of the difference in the
lation (r) of 0 indicates no relationship between the two groups would be questionable. Increasingly,
variables (Figure 4.1c). A value of r of + 1.00 or -1.00 research is being examined for whether an effect is
indicates a perfect relationship between the two not only statistically significant but also clinically
variables (as illustrated in Figure 4.1a and b)-the significant.
value of one variable is perfectly predicted by the
value of the other variable; for example, every time Correlation Versus Causation
people experience stress they become depressed. A high correlation between an independent and a
Seldom do we see perfect correlations in psy- dependent variable does not tell us that the inde-
chological research. Instead, correlations often are pendent variable caused the dependent variable. If
in the low to moderate range (for example, .2 to .5), we found a strong positive correlation between
indicating some relationship between the two stress and depression, we still could not conclude
variables but a far from perfect relationship (Fig- that stress causes depression. All a positive corre-
ure 4.1d). Many relationships between variables lation tells us is that there is a relationship between
happen by chance and are not meaningful. Scien- stress and depression. It could be that depression
tists evaluate the importance of a correlation coef- causes stress, or some other variable may cause
ficient by examining its statistical significance. both stress and depression. The latter situation is
called the third variable problem-the possibility
Statistical Significance that variables not measured in a study are the real
The statistical significance of a result, such as a cause of the relationship between the variables
correlation coefficient, is an index of how likely it that are measured. For example, perhaps some
is that the result occurred simply by chance. You people with difficult temperaments both are prone
will often see statements in research studies such as to depression and generate stressful experiences in
"The result was statistically significant at p < .05." their lives by being difficult to live with. If we mea-
This means that the probability (p) is less than 5 in sured only stress and depression, we might ob-
100 that the result occurred only by chance. Re- serve a relationship between them because they
searchers typically accept results at this level of co-occur within the same individuals. But this rela-
significance as support of their hypotheses, al- tionship actually would be due to the common re-
though the choice of an acceptable significance lationship of stress and depression to temperament.
level is somewhat arbitrary.
Whether a correlation coefficient will be statis-
tically significant at the p < .05 level is determined
Selecting a Sample
by its magnitude and the size of the sample on A critical choice in a correlational study is the
which it is based. Both larger correlations and choice of the sample. A sample is a group of peo-
larger sample sizes increase the likelihood of ple taken from the population we want to study.
achieving statistical significance. A correlation of
.30 will be significant if it is based on a large sam- Representativeness
ple, say 200 or more, but will not be significant if it A representative sample is a sample that is highly
is based on a small sample, say 10 or fewer partici- similar to the population of interest in terms of sex,
pants. On the other hand, a correlation of .90 will ethnicity, age, and other important variables. If a
be statistically significant even if the sample is as sample is not representative-for example, if there
small as 30 people. are more women or more people of color in our
A result can be statistically significant but not sample than in the general population of interest-
clinically significant. For example, a study of then the sample is said to have bias. If our sample
10,000 people might find a correlation of .15 be- represents only a small or unusual group of people,
tween the number of stressors people experienced then we cannot generalize the results of our study
and their scores on a depression questionnaire. to the larger population. For example, if all the peo-
This correlation would likely be statistically sig- ple in our study are white, middle-class females,
nificant because of the very large sample, but it is we cannot know whether our results generalize to
Correlational Studies 91
males, people of color, or people in other socio-

economic classes.
An effective way to obtain a representative
sample of a population is to generate a random
sample of that population. For example, some
studies have obtained random samples of the en-
tire U.S. population by randomly dialing phone
numbers throughout the country and then recruit-
ing into the study the people who answer the
phone. Often, researchers can settle for random
samples of smaller populations, such as particular
cities. When a sample is truly random, the chances
are high that it will be similar to the population of
interest in terms of ethnicity, sex, age, and all the
other important variables in the study.
Selection of a Comparison Group

A group comparison study compares the experi-
ences of one group with those of another group. A study of depression in student athletes might need
to include a comparison group of students who are
For example, we may be interested in the depres-
not athletes.
sion levels of students who are athletes and stu-
dents who are not athletes. We might begin by
recruiting our sample of student athletes, attempt-
ing to make this sample as representative as pos- Longitudinal correlational studies have sev-
sible of student athletes at our university. eral advantages over cross-sectional correlational
Our comparison group of nonathletes should studies. In longitudinal correlational studies, re-
match our group of athletes on any variable (other searchers can determine whether there are differ-
than stress) that might influence levels of depres- ences between the groups before the event of
sion. If the two groups are not as similar as pos- interest occurs. If there are no differences before
sible, then any differences in their levels of the event but significant differences after the event,
depression could be attributable to other vari- then researchers can have more confidence that it
ables. For example, women generally are more was the event that actually led to the differences
likely to be depressed than men. If we had more between the groups. Longitudinal designs also al-
women in our athlete group than in our nonath- low researchers to follow groups long enough to
lete group, then higher levels of depression in assess both short-term and long-term reactions to
the athlete group might be attributable to a third the event.
variable--the fact that there are more women in Longitudinal studies can be time-consuming
that group- rather than to the effects of participa- and expensive to run. Chapter 8 reports studies in
tion in athletics. For this reason, our athlete and which children at high risk for schizophrenia were
nonathlete groups should be alike on all third studied from their preschool years to their early
variables that might influence our dependent adult years to determine what characteristics could
variable, depression. predict who would develop schizophrenia and
who would not (Erlenmyer-Kimling, Rock,
Evaluating Squires-Wheeler, & Roberts, 1991). Some of these
studies have been going on for more than 25 years
Correlational Studies and have cost millions of dollars. They are produc-
Correlational studies have provided much impor- ing extremely valuable data, but at a high cost in
tant information for abnormal psychology. One both researchers' time and research dollars.
major advantage of correlational studies is that The greatest disadvantage of all correlational
they focus on situations occurring in the real studies is that they cannot indicate what is a cause
world, rather than those manipulated in a labora- and what is a consequence. For example, many
tory. This gives them relatively good external va- stressful events that depressed people report may
lidity, the extent to which a study's results can be be the consequences of their depression rather
generalized to real-life phenomena. The results of than the causes (Hammen, 2005). The symptoms of
these studies may be generalizable to wider popu- depression can cause stress by impairing interper-
lations and to people's actual life experiences. sonal skills, interfering with concentration on the
job, and causing insomnia. The same problem ex- will be diagnosed with the disorder in any
ists for studies of many types of psychopathology. 12-month period. Table 4.1 illustrates the fact,
For example, the symptoms of schizophrenia can mentioned earlier, that the prevalence of major de-
disrupt social relationships, alcoholism can lead to pression is greater for women than for men. As we
unemployment, and so on. will discuss in Chapter 7, this fact, revealed by
Finally, all correlational studies suffer from many epidemiological studies, has been an impor-
the third variable problem. Researchers seldom tant focus of research into depression.
can measure all possible influences on partici- Second, epidemiological research seeks to de-
pants' levels of depression or other psychopathol- termine the incidence of a disorder, or the number
ogies. Third variable problems are one of the of new cases of the disorder that develop during a
major reasons why researchers turn to experimen- specified period of time. The 1-year incidence of a
tal studies. disorder is the number of people who develop the
disorder during a 1-year period.
Third, epidemiological research is concerned
EPIDEMIOLOGICAL STUDIES with the risk factors for a disorder-those condi-
Epidemiology is the study of the frequency and tions or variables that are associated with a higher
distribution of a disorder, or a group of disorders, risk of having the disorder. If women are more
in a population. An epidemiological study asks likely than men to have a disorder, then being a
how many people in a population have the disor- woman is a risk factor for the disorder. In terms of
der and how this number varies across important our interest in the relationship between stress and
groups within the population, such as men and depression, an epidemiological study might show
women or people with high and low incomes. that people who live in high-stress areas of a city
Epidemiological research focuses on three are more likely to have depression than people
types of data. First, research may focus on the who live in low-stress areas of the city.
prevalence of a disorder, or the proportion of the How do researchers determine the prevalence,
population that has the disorder at a given point or incidence, and risk factors for a disorder? Epide-
period in time. For example, a study might report miological researchers first identify the population
the lifetime prevalence of a disorder, or the num- of interest and next identify a random sample of
ber of people who will have the disorder at some that population, for example, by randomly phon-
time in their life. The 12-month prevalence of a dis- ing residential telephone numbers. They then use
order would be the proportion of the population structured clinical interviews that ask specific
who will be diagnosed with the disorder in any questions of participants to assess whether they
12-month period. have the symptoms that make up the disorder and
Table 4.1 shows the lifetime and 12-month the risk factors, such as gender or socioeconomic
prevalence of one of the more severe forms of status, being studied. (Recall our discussion of
depression- major depressive disorder-from a structured clinical interviews in Chapter 3.) From
nationwide epidemiological study conducted in these data, epidemiologists estimate how many
the United States (Kessler et al., 1994). Not surpris- people in different categories of risk factors have
ingly, the proportion of the population who will be the disorder.
diagnosed with major depressive disorder at some
time in their life is larger than the proportion who Evaluating Epidemiological
Studies
Epidemiological studies have provided valuable
TABLE 4.1 Lif etime and 12-Month
information on the prevalence, incidence, and risk
Prevalence of Major Depressive Disorder
factors for disorders, and we discuss evidence
Lifetime 12-Month gathered from some major nationwide and inter-
Prevalence (%) Prevalence (%) national epidemiological studies throughout this
book. This research can give us important clues as
Males 12.7 7.7 to who is at highest risk for a disorder. In turn, we
Females 21.3 12.9 can use this information to test hypotheses about
Total 17.1 10.3 why those people are at higher risk.
Epidemiological studies are affected by many
Sou rce: Kessler et al. , 1994. of the same limitations as correlational studies.
First and foremost, they cannot establish that any
risk factor causes a disorder. While a study may
Experimental Studies 93
show that people living in higher-stress neighbor- To control third variables,

hoods are more likely to have a disorder, this does researchers create a control
not mean that the high-stress environment caused group or control condition, in
the disorder. Also, as in correlational studies, third which participants have all the
variables may explain the relationship between same experiences as the group
any risk factor and the rates of a disorder. of main interest in the study
except that they do not receive
the key manipulation-in our
EXPERIMENTAL STUDIES example, the stressor of the
The hallmark of experimental studies is control. unsolvable puzzles. The con-
Researchers attempt to control the independent trol group for our study could
variable and any potentially problematic third be given similar but solvable
variables rather than simply observing them as anagrams. Thus, the control
they occur naturally. There are various types of ex- group's experience would
perimental studies we could do to investigate be identical to that of the
whether stress leads to depression. We will exam- other group-the experimen-
ine four types in particular. tal group or experimental
condition-except for receiv-
ing the unsolvable puzzles.
Human Laboratory Studies Another threat to inter-
To test our hypothesis that stress leads to depres- nal validity can arise if the
sion, we could expose participants to a stressor in participants in the experi-
Researchers may give participants an
the laboratory and then determine whether it mental group (the group unsolvable puzzle in order to observe the
causes an increase in depressed mood. This given the unsolvable ana- effects of stress on mental health.
method is known as a human laboratory study. grams) and in the control
Several studies of this type have been done (see group (the group given the
Peterson & Seligman, 1984). The stressor that is of- solvable anagrams) differ in important ways be-
ten used in this type of study is an unsolvable task fore beginning the experiment. If such differences
or puzzle, such as an unsolvable anagram. In this exist, we cannot be sure that our manipulation is
case, our index of stress is participants' exposure to the cause of any changes in the dependent vari-
unsolvable anagrams. Because we are manipulat- able. Internal validity requires random assign-
ing stress, not simply measuring it, we have the ment, which means that each participant must
advantage of knowing precisely what type of stress have an equal chance of being in the experimental
participants are exposed to and when. We cannot group or the control group. Often, a researcher
create in the laboratory many of the types of stress will use a table of random numbers to assign par-
that may cause depression in the real world, such ticipants to groups.
as the destruction of a person's home in a hurricane Yet another threat to internal validity is the
or continual physical abuse. Instead, we create presence of demand characteristics-situations
analogues-situations that capture some key char- that cause participants to guess the purpose of the
acteristics of these real-world events, such as their study and thus change their behavior. For exam-
uncontrollability and unpredictability. ple, if our measure of depression is too obvious,
participants might guess what hypothesis we are
Internal Validity testing. To avoid the presence of demand charac-
We want to ensure that our experiment has inter- teristics, we could use subtler measures of depres-
nal validity, meaning that changes in the depen- sion embedded in other tests-often called filler
dent variable can confidently be attributed to our measures-to obscure the real purpose of our study.
manipulation of the independent variable and not Researchers also often use cover stories, telling par-
to other factors. For example, people who partici- ticipants a false story to prevent them from guess-
pate in our experiment using anagrams might being the true purpose of the experiment. After the
come more depressed over the course of the study, participants should be debriefed about the
experiment simply because participating in an ex- deception they were exposed to in the study1 as
periment is a difficult experience, not because the well as its true purpose.
anagrams are unsolvable. This threat to internal Participants' behavior in the study can be af-
validity is basically the same type of third variable fected if they know what group they are in ahead of
problem encountered in correlational and epide- time. Similarly, if experimenters know what condi-
miological studies. tion a participant is in, they might inadvertently
behave in ways that affect how the participant re- induce distress, even mild distress, in people? Dif-
sponds to the manipulations. In order to reduce ferent people will give different answers to this
these demand characteristics, both the participants question.
and the experimenters who interact with them
should be unaware of whether participants are in
Therapy Outcome Studies
the experimental condition or the control condi-
tion. This situation is referred to as a double-blind Therapy outcome studies are experimental stud-
experiment. ies designed to test whether a specific therapy-a
We have instituted a number of safeguards to psychological therapy or a biological therapy-
ensure internal validity in our study: Participants reduces psychopathology in individuals who re-
have been randomly selected and assigned, and ceive it. Because therapies target supposed causes
our participants and experimenters are unaware of of psychopathology, therapy outcome studies can
which condition participants are in. Now we can produce evidence that reducing these causes re-
conduct the study. When our data are collected duces psychopathology, which in turn supports
and analyzed, we find that, as we predicted, par- the hypothesis that these factors played a role in
ticipants given the unsolvable anagrams showed creating the psychopathology in the first place.
greater increases in depressed mood than did par-
ticipants given the solvable anagrams. Control Groups
What can we conclude about our idea of de- Sometimes, people simply get better with time.
pression, based on this study? Our experimental Thus, we need to compare the experiences of peo-
controls have helped us rule out third variable ex- ple who receive our experimental therapy with
planations, so we can be relatively confident that it those of a control group made up of people who
was the experience of the uncontrollable stressor do not receive the therapy to see whether our par-
that led to the increases in depression in the ex- ticipants' improvement actually has anything to
perimental group. Thus, we can say that our study do with our therapy. Sometimes, researchers use a
supports our hypothesis that people exposed to simple control group consisting of participants
uncontrollable stress will show more depressed who do not receive the experimental therapy but
mood than will people not exposed to such stress. are tracked for the same period of time as the par-
ticipants who do receive the therapy.
Evaluating Human laboratory Studies A variation on this simple control group is the
The primary advantage of human laboratory wait list control group. The participants in this
studies is control. Researchers have more control type of group do not receive the therapy when the
over third variables, the independent variable, experimental group does but instead are put on a
and the dependent variable in these studies than wait list to receive the intervention at a later date,
they do in any other type of study they can do when the study is completed. Both groups of par-
with humans. ticipants are assessed at the beginning and end of
Yet human laboratory studies also have their the study, but only the experimental group re-
limitations. Because we cannot know if our results ceives the therapy as part of the study.
generalize to what happens outside the laboratory, Another type of control group, the placebo
their external validity can be low. Is being exposed control group, is used most often in studies of
to unsolvable anagrams anything like being ex- the effectiveness of drugs. The participants in
posed to major, real-world uncontrollable stress- this group have the same interactions with ex-
ors, such as the death of a loved one? Clearly, the perimenters as the participants in the experi-
severity of the two types of experiences differs, but mental group, but they take pills that are
is this the only important difference? Similarly, do placebos (inactive substances) rather than the
the increases in depressed mood in the partici- drug being studied. Usually, to prevent demand
pants in our study, which probably were small, tell effects, both the participants and the experiment-
us anything about why some people develop ex- ers in these studies are unaware of which group
tremely severe, debilitating episodes of depres- the participants are in; thus, this type of experi-
sion? Experimental studies such as this have been ment is double-blind.
criticized for their lack of generalizability to major
psychopathologies that occurs in real life. Evaluating Therapy Outcome Research
Apart from posing problems of generalizabil- Although therapy outcome studies might seem the
ity, human laboratory studies sometimes pose seri- most ethical way of conducting research on people
ous ethical concerns. Is it ethical to deliberately in distress, they have their own methodological
challenges and ethical issues. Most psychological

therapies involve a package of techniques for re-
sponding to people's problems. For example, de-
pressed people in an experimental therapy group
might be taught assertiveness skills, social
problem-solving skills, and skills in changing
self-defeating thinking. Which of these skills was
most responsible for alleviating their depression?
Even when a therapy works, researchers often
cannot know exactly what it is about the therapy
that works.
Ethical problems arise in using all three
types of control groups-simple control groups,
wait list control groups, and placebo control
groups- in therapy outcome research. Some re-
searchers believe it is unethical to withhold
treatment or to provide a treatment believed to
be ineffective for people in distress. For exam-
ple, many depressed participants assigned to a Therapy outcome studies focus on the experiences of people receiving therapy.
control group may be in severe distress or in
danger of harming themselves and therefore
may need immediate treatment.
In response to this concern, many therapy out- competent therapists. Patients usually are screened
come studies now compare the effectiveness of so that they fit a narrow set of criteria for being
two or more therapies expected to have positive included in the study, and often only patients who
effects. These studies basically are a competition stick with the therapy to its end are included in the
between rival therapies and the theories behind final analyses.
them. The idea is that all the participants in such In the real world, mental health services are
studies benefit, while at the same time researchers not always delivered in controlled, high-quality
gain useful information about the most effective atmospheres by the most competent therapists. Pa-
type of therapy for the pathology. Regardless of tients are who they are, and their complicated
which type of control or comparison group experi- symptom presentations and lives may not fit
menters use in a therapy outcome study, partici- neatly into the criteria for an "optimal patient."
pants must be informed of the types of groups the Also, patients often leave and return to therapy
study involves and of the fact that they will be ran- and may not receive a full trial of the therapy be-
domly assigned to one group or another (and thus fore dropping out for financial or personal reasons.
run the risk of not receiving useful treatment as Therapy outcome research that tests how well
part of the study). a therapy works in highly controlled settings with
Another ethical issue concerns the obligation a narrowly defined group of people is said to test
of the therapist to respond to the needs of the pa- the efficacy of a therapy. In contrast, therapy out-
tient. How much can a therapy be modified to re- come research that tests how well a therapy works
spond to a specific participant's needs without in real-world settings, with all the complications
compromising the scientific integrity of the study? mentioned, is said to test the effectiveness of a
Therapists may feel the need to vary the dosage of therapy.
a drug or to deviate from a study's procedure for
psychological intervention. Departing too much Single-Case Experimental
from the standard therapy, however, will lead to
significant variation in the therapy received by
Designs
participants in the intervention, which could com- Another type of experimental study is the single-
promise the results of the study. case experimental design, in which a single indi-
A related methodological issue has to do with vidual or a small number of individuals are
generalizing results from therapy outcome studies studied intensively. Unlike the case studies dis-
to the real world. In these studies, the therapeutic cussed earlier, a single-case experimental design
intervention usually is delivered to patients in a exposes the individual to some manipulation or
controlled, high-quality atmosphere by the most intervention, and his or her behavior is examined
before and after the intervention to determine the lower when she was taking the drug (B) than when
effects. In addition, in a single-case experimental she was not taking the drug (A).
design, the participant's behaviors are measured
repeatedly over time through some standard Multiple Baseline Designs
method, whereas a case study often is based on In a multiple baseline design, an intervention
the researcher's impressions of the participant might be given to the same individual but in differ-
and the factors affecting his or her behaviors, ent settings, or to different individuals at different
thoughts, and emotions. points in time. To test whether a meditation exer-
cise reduces depression, a researcher might teach a
ABAB Design depressed person how to use the exercise while at
A specific type of single-case experimental design work when she feels depressed. If the participant's
is the ABAB, or reversal, design, in which an in- depression decreased at work but not at home,
tervention is introduced, withdrawn, and then re- where she did not use the meditation exercise, the
instated and the behavior of the participant is researcher has some evidence that the exercise was
examined both on and off the treatment. For ex- responsible for the reduction in depression. If the
ample, in the study of the effects of a drug for participant were then told to use the meditation ex-
depression, an individual depressed participant ercise at home and her depression decreased in this
might be assessed for her level of depression each setting also, this would be further evidence of the
day for 4 weeks. This is the baseline assessment exercise's utility.
(A; Figure 4.2). Then the participant would be Similarly, the researcher might teach the medi-
given the drug for 4 weeks (B), and her level of tation exercise to multiple individuals, but at differ-
depression would be assessed each day during ent points in time when their experiences are likely
that period. The drug then would be withdrawn to be different. For example, the researcher might
for 4 weeks (A), and, again, her level of depression teach the meditation exercise to one depressed col-
would be assessed each day. Finally, the drug lege student during the first week of classes, to an-
would be reinstated for 4 weeks (B) and her level other student during spring break, and to still
of depression assessed each day during that pe- another during exam week. If all the students expe-
riod. If the participant's levels of depression fol- rienced relief of their depression symptoms after
lowed the pattern seen in Figure 4.2, this result learning the meditation exercise, despite their dif-
would suggest that her depression level was much ferent levels of stress, this would be evidence that
the effects of the meditation exercise were general-
izable across individuals and settings.
Evaluating Single-Case
Effects Over Time of Drug Treatment for Experimental Designs
FIGURE 4.2 A major advantage of single-case experimental de-
Depression in an Individual. This graph
shows an individual's level of depression during signs is that they allow much more intensive as-
a 4-week baseline assessment (A). during 4 weeks of drug sessment of participants than might be possible if
treatment (B), when the drug treatment is withdrawn for 4 weeks there were more participants. For example, an in-
(A). and when the drug treatment is reinstated for 4 weeks (B). dividual child could be observed for hours each
day as he was put on and then taken off a treat-
ment. This intensity of assessment can allow re-
30 searchers to pinpoint the types of behaviors that
25 are and are not affected by the treatment.
Q)
The major disadvantage of single-case experi-
>
~
20 mental designs is that their results may not be
c: generalizable to the wider population. One indi-
-~ 15
"'~ vidual's experience on or off a treatment may not
~ 10 be the same as other individuals' experiences. In
Cl
addition, not all hypotheses can be tested with
5
single-case experimental designs. Some treat-
0 ments have lingering effects after they end. For ~
0 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 example, if a person is taught new skills for cop-
Baseline (A) Treatment (B) Withdrawal (A) Reinstatement (B) ing with stress during the treatment, these skills
will continue to be present even after the treat-
ment is withdrawn.
~ Animal Studies Shuttle Box for Learned Helplessness

FIGURE 4.3 Experiments. Researchers used an apparatus
Researchers sometimes try to avoid the ethical like this to deliver controllable or uncontrollable
issues involved in experimental studies with hu-
shocks to dogs in order to investigate the phenomenon of learned
mans by conducting the studies with animals.
helplessness.
Animal research has its own set of ethical issues,
but many researchers feel it is acceptable to ex-
pose animals to situations in the laboratory that
it would not be ethical to impose on humans.
Animal studies thus provide researchers with
even more control over laboratory conditions
and third variables than is possible in human
laboratory studies.
In a well-known series of animal studies de-
signed to investigate depression (discussed in
Chapter 7), Martin Seligman, Bruce Overmier,
Steven Maier, and their colleagues subjected dogs
to an uncontrollable stressor in the laboratory
(Overmier & Seligman, 1967; Seligman & Maier,
1967). The experimental group of dogs received a
series of uncontrollable electric shocks. Let us call
this Group E, for experimental.
In addition, there were two control groups.
One control group of dogs received shocks but
could control them by jumping over a barrier
(Figure 4.3). Let us call this Group J, for jump.
The dogs in Groups E and J received the same
number and duration of shocks. The only differ-
ence between the groups was that the dogs in
Group E could not control the shocks, whereas
the dogs in Group J could. The second control initiation of behavior, and the inability to see op-
group of dogs received no shock. Let us call this portunities to improve one's environment (see
Group N, for none. Seligman, 1975). They argued that many human
Dogs in Group E initially responded to the depressions result from people learning that they
shocks by jumping around their cages. Soon, how- have no control over important outcomes in their
ever, the majority became passive. Later, when the lives. This learned helplessness theory of depres-
researchers provided the dogs with an opportu- sion seems helpful in explaining the depression
nity to escape the shock by jumping over a barrier, and passivity seen in chronically oppressed
these dogs did not learn to do so. It seemed that groups, such as battered spouses and some people
they had learned they could not control the shock, who grow up in poverty.
so they did not recognize opportunities for control Another type of animal study is similar to
when offered. The researchers labeled this set of therapy outcome studies. In studies of the effec-
behaviors learned helplessness deficits. tiveness of drugs, animals often are given the
The dogs in the controllable shock group, drugs to determine their effects on different bodily
Group J, learned to control the shock and did not systems and behaviors. Sometimes the animals are
develop learned helplessness deficits. The fact killed after receiving the drugs, to enable detailed
that the two groups of dogs experienced the physiological analyses of their effects. Obviously,
same number and duration of shocks suggests such studies could not be done with humans. Ani-
that lack of control, not the shocks alone, led to mal studies of drugs are particularly useful in the
the learned helplessness deficits in the experi- early stages of research, when the possible side ef-
mental group. The dogs in Group N, which re- fects of the drugs are unknown.
ceived no shocks, also did not develop learned
helplessness deficits. Evaluating Animal Studies
Seligman and colleagues likened the learned There clearly are problems with animal studies.
helplessness deficits shown by their dogs to the First, some people believe it is no more ethical to
symptoms of depression in humans: apathy, low conduct painful, dangerous, or fatal experiments
with animals than it is to do so with humans. Sec- families of people who do not have the disorder.
ond, from a scientific vantage point, we must ask This is true whether the disorder is associated
whether we can generalize the results of experi- with one or with many genes. To conduct a family
ments with animals to humans. Are learned help- history study, scientists first identify people who
lessness deficits in dogs really analogous to human clearly have the disorder in question. This group
depression? The debate over the ethical and scien- is called the probands. The researchers also identify
tific issues of animal research continues. Particu- a control group of people who clearly do not have
larly with regard to research on drug effectiveness, the disorder. They then trace the family pedigrees,
however, animal research may be crucial to the ad- or family trees, of individuals in these two groups
vancement of our knowledge of how to help peo- and determine how many of their relatives have
ple overcome psychopathology. the disorder. Researchers are most interested in
first-degree relatives, such as full siblings, parents,
or children, because these relatives are most ge-
GENETIC STUDIES netically similar to the subjects (unless they have
Identifying genetic factors associated with psycho- an identical twin, who will be genetically identical
pathology involves a variety of research methods. to them).
Researchers investigate the degree to which genes Figure 4.4 illustrates the degree of genetic rela-
play a role in a particular disorder, or its heritabil- tionship between an individual and various cate-
ity, through family history studies, twin studies, gories of relatives. This figure gives you an idea of
and adoption studies. To investigate specific genes why the risk of inheriting the genes for a disorder
that may be involved in a disorder, they may use quickly decreases as the relationship between an
molecular genetic studies (also called association individual and the relative with the disorder be-
studies) or linkage analyses. comes more distant: The percentage of genes the
individual and the relative with the disorder have
in common decreases greatly with distance.
Family History Studies Although family history studies provide very
Disorders that are genetically transmitted should, useful information about the possible genetic ~
on average, show up more often in families of transmission of a disorder, they have their prob-
people who have the disorder than they do in lems. The most obvious is that families share not
only genes but also environment. Several mem-
bers of a family might have a disorder because
Degrees of Genetic they share the same environmental stresses. Fam-
FIGURE 4.4
Relationship. People with ily history studies cannot tease apart the genetic
whom you share 50 percent and environmental contributions to a disorder. Re-
of your genes are your first-degree relatives. searchers often turn to twin studies to do this.
People with whom you share 25 percent
of your genes are your second-degree
relatives. People with whom you share Twin Studies
12.5 percent of your genes are your third- Notice in Figure 4.4 that identical twins, or mono-
degree relatives. zygotic (MZ) twins, share 100 percent of their
genes. This is because they come from a single
Percent of genes in common fertilized egg, which splits into two identical
parts. In contrast, nonidentical twins, or dizy-
Identical (monozygotic) twins - - - - - - - - 1 0 0 % gotic (DZ) twins, share, on average, 50 percent of
their genes because they come from two separate
Parent-child---------.... eggs fertilized by separate sperm, just as non-
Full siblings (both parents in common) twin siblings do.
Nonidentical (dizygotic) twins
Researchers have capitalized on this difference
between MZ and DZ twins to conduct twin stud-
Grandparent-grandchild~
Unclej aunt- nephew/ niece ies on the contribution of genetics to many disor-
Half-siblings (one parent in common) ders. If a disorder is determined entirely by
2
genetics, then when one member of a monozygotic
Great-grandparent-great-grandchild - - 12 (MZ) twin pair has a disorder, the other member of
Great-uncle/ aunt-grandnephew/ niece
First cousins the pair should always have the disorder. This
probability that both twins will have the disorder
if one twin has it is called the concordance rate for
Cross-Cultural Research 99
the disorder. Thus, if a disorder is entirely deter- Molecular Genetic Studies

mined by genes, the concordance rate among MZ and Linkage Analyses
twins should be close to 100 percent. The concor-
dance rate for the disorder among dizygotic (DZ) The technology for examining human genes has
twins will be much lower than 100 percent. Even advanced rapidly in recent decades, allowing re-
when a disorder is transmitted only partially by searchers to search for associations between spe-
genes, the concordance rate for MZ twins should cific genetic abnormalities (also referred to as
be considerably higher than the concordance rate genetic markers) and psychopathology in what are
for DZ twins, because MZ twins are genetically called m-olecular genetic studies or association
identical while DZ twins share only about half studies. A typical study might compare a group of
their genes. people who have been diagnosed with a particular
For example, suppose the concordance rate for disorder, such as depression, with people who
Disorder X for MZ twins is 48 percent, whereas the have no form of psychopathology. DNA from indi-
concordance rate for DZ twins is 17 percent. These viduals in both groups is obtained either through
concordance rates tell us two things. First, because blood samples or by swabbing the inside of the
the concordance rate for MZ twins is considerably individuals' cheeks to obtain a small amount of
higher than that for DZ twins, we have evidence tissue. This DNA is then analyzed (genotyped) to
that Disorder X is genetically transmitted. Second, determine whether each individual has a genetic
because the concordance rate for MZ twins is well characteristic or marker of interest.
under 100 percent, we have evidence that a combi- Because the human genome is so vast, re-
nation of a genetic predisposition and other factors searchers may try to narrow down the location of
(biological or environmental) causes an individual the gene marker associated with a psychological
to develop Disorder X. disorder by looking for other characteristics that
Twin studies do not fully separate genetic co-occur with the disorder and have known ge-
and environmental factors, because MZ twins netic markers, a process called linkage analysis.
may have more similar environments and experi- For example, in the study of mood disorders
ences than do DZ twins. For example, MZ twins among the Amish described in the Extraordinary
typically look alike, whereas DZ twins often do People segment at the beginning of this chapter,
not, and physical appearance can affect other researchers found that two markers on chromo-
people's reactions to an individual. MZ twins some 11, one for insulin and one for a known can-
also may be more likely than DZ twins to share cer gene, were linked to the presence of mood
talents that influence their opportunities. For in- disorder in one large family (Biron et al., 1987).
stance, MZ twins may both be athletic or talented This suggests that a gene that plays a role in vul-
academically or musically, which can affect their nerability to mood disorders may be on chromo-
treatment by others and their opportunities in some 11. Unfortunately, this linkage has not been
life. Finally, parents may simply treat MZ twins replicated in other studies. In Chapter 8, we will
more similarly than they do DZ twins. To ad- discuss genetic linkage studies that have identified
dress these problems, researchers have turned to possible genetic markers for schizophrenia.
a third method for studying heritability, the
adoption study.
CROSS-CULTURAL
Adoption Studies RESEARCH
An adoption study can be carried out in a number Not long ago, most psychological research was
of ways. Most commonly, researchers first identify conducted with college students, most of whom
people who have the disorder of interest who were were white and middle- or upper-class. Research-
adopted shortly after birth. They then determine ers believed that any results they obtained from
the rates of the disorder in the biological relatives of these samples could be generalized to any other
these adoptees and in the adoptive relatives of the relevant sample. Only anthropologists and a hand-
adoptees. If a disorder is strongly influenced by ge- ful of psychologists and psychiatrists argued that
netics, researchers should see higher rates of the dis- what is true of one ethnic group, culture, or gender
~ order among the biological relatives of the adoptee is not necessarily true of others.
than among the adoptive relatives. If the disorder is In the past few decades, however, there has
strongly influenced by environment, they should been an explosion of cross-cultural research in ab-
see higher rates of the disorder among the adoptive normal psychology. Researchers are investigating
relatives than among the biological relatives. the similarities and differences across culture in
the nature, causes, and treatment of psychopathol- precisely translated into another language. Many
ogy. These cross-cultural researchers face several languages contain variations of pronouns and
special challenges. verbs whose usage is determined by the social
First, researchers must be careful in applying relationship between the speaker and the person
theories or concepts that were developed in stud- being addressed. For example, in Spanish, the
ies of one culture to another culture (Rogier, second-person pronoun usted ("you") connotes re-
1999). Because the manifestations of disorders spect, establishes an appropriate distance in a
can differ across cultures, researchers who insist social relationship, and is the correct way for a
on narrow definitions of disorders may fail to young interviewer to address an older respondent
identify people manifesting disorders in cultur- (Rogier, 1989). In contrast, when a young inter-
ally defined ways. Similarly, theoretical variables viewer addresses a young respondent, the relation-
can have different meanings or manifestations in ship is more informal, and the appropriate form of
different cultures. address is tu (also "you"). An interviewer who vio-
A good example is the variable known as ex- lates the social norms implicit in a language can
pressed emotion. Families high in expressed emo- alienate a respondent and impair the research.
tion are highly critical of and hostile toward other Third, there may be cultural or gender differ-
family members and emotionally overinvolved ences in people's responses to the social demands
with one another. Several studies of the majority of interacting with researchers. For example, peo-
cultures in America and Europe have shown that ple of Mexican origin, older people, and people in
people with schizophrenia whose families are high a lower socioeconomic class are more likely to an-
in expressed emotion have higher rates of relapse swer yes to researchers' questions, regardless of
than those whose families are low in expressed the content, and also to attempt to answer ques-
emotion (Hooley, 2007). The meaning and mani- tions in socially desirable ways than are Anglo-
festation of expressed emotion can differ greatly Americans, younger people, and people in a higher
across cultures, however: socioeconomic class. These differences appear to
result from differences among groups in their def-
Criticism within Anglo-American family
erence to authority figures and concern over pre-
settings, for example, may focus on allega-
senting a proper appearance (Ross & Mirowsky,
tions of faulty personality traits (e.g., lazi-
1984). Similarly, it is often believed that men are
ness) or psychotic symptom behaviors
less likely than women to admit to "weaknesses,"
(e.g., strange ideas). However, in other so-
such as symptoms of distress or problems coping.
cieties, such as those of Latin America, the
If researchers do not take biases into account when
same behaviors may not be met with criti-
they design assessment tools and analyze data,
cism. Among Mexican-descent families,
erroneous conclusions can result.
for example, criticism tends to focus on
disrespectful or disruptive behaviors that
affect the family but not on psychotic META-ANALYSIS
symptom behavior and individual per-
Often the research literature contains many studies
sonality characteristics. Thus, culture
that have investigated a particular idea (e.g., that
plays a role in creating the content or tar-
gets of criticism. Perhaps most impor- stress leads to depression). An investigator may
tantly, culture is influential in determining want to know what the overall trend across all
studies is and what factors might account for some
whether criticism is a prominent part of the
studies supporting their hypothesis and others
familial emotional atmosphere. Genkins &
Karno, 1992, p. 10) not. A researcher could read over all the studies
and draw conclusions about whether most of them
Today's researchers are more careful to search for support or do not support the hypothesis. These
culturally specific manifestations of the character- conclusions can be biased, however, by the reader's
istics of interest in their studies and for the possi- interpretations of the studies.
bility that the characteristics or variables that A more objective way to draw conclusions
predict psychopathology in one culture may be about a body of research is to conduct a meta-
irrelevant in other cultures. analysis, a statistical technique for summarizing
Second, even if researchers believe they can results across several studies. The first step in a
apply their theories across cultures, they may have meta-analysis is to do a thorough literature search,
difficulty translating their questionnaires or other usually with the help of computer search engines
assessment tools into different languages. A key that will identify all studies containing certain
concept in English, for example, may not be keywords. Often, studies use different methods
and measures for testing a hypothesis, so the sec- and therefore do not end up in meta-analyses.
ond step of a meta-analysis is to transform the re- This file drawer effect biases the results of meta-
sults of each study into a statistic common across analyses toward finding an overall positive effect
all the studies. This statistic, called the effect size, of a treatment or of some other difference between
indicates how big the differences are between two groups.
groups (such as a group that received a specific
form of therapy and one that did not) or how
strong the relationship is between two continuous
variables (such as the correlation between levels
CHAPTER INTEGRATION
of stress and levels of depression). Researchers We noted in Chapter 2 that theories or models of
can then examine the average effect size across psychopathology are increasingly based on the
studies and relate the effect size to characteristics integration of concepts from biological, psycho-
of the study, such as the year it was published, the logical, and social approaches. These concepts
type of measure used, or the age or gender of the often are viewed from a vulnerability-stress per-
participants. For example, a meta-analysis of stud- spective. The characteristics that make a person
ies of children's depression levels found that stud- more vulnerable to abnormality might include
ies done in more recent years tend to find lower biological characteristics, such as a genetic predis-
levels of depression than studies done previously position, or psychological characteristics, such as
(Twenge & Nolen-Hoeksema, 2002). This finding a maladaptive style of thinking about the world.
suggests that levels of depression among children These personal characteristics must interact with
may be decreasing. characteristics of the situation or environment
to create the abnormality. For example, a woman
with a genetic predisposition to depression may
Evaluating Meta-Analysis never develop the disorder in its full form if she
Meta-analysis can overcome some of the prob- has a supportive family and never faces major
lems resulting from small numbers of partici- stressors.
pants in an individual study by pooling the data Conducting research that reflects this integra-
from thousands of study participants, thereby tionist perspective on abnormality is not easy. Re-
providing more power to find significant effects. searchers must gather information about people's
The studies examined by Twenge and Nolen- biological, psychological, and social vulnerabili-
Hoeksema (2002) generally had small numbers of ties and strengths. This work may require special-
ethnic minority children, making it difficult to ized equipment or expertise. It also may require
compare their depression scores with those of following participants longitudinally to observe
nonminority children. By pooling studies, how- what happens when people with vulnerabilities
ever, the overall sample sizes of Hispanic and face stressors that may trigger episodes of their
African American children were large enough to disorder.
allow comparisons by race / ethnicity. The meta- Increasingly, researchers work together in
analysis found that Hispanic children generally teams to share both their expertise in specialized
had higher depression scores than African Ameri- research methods and their available resources,
can or white children. making multidisciplinary longitudinal research
Meta-analyses have their problems, however. possible. Researchers also train in multiple disci-
First, some published studies have methodologi- plines and methods. For example, psychologists
cal flaws . These flawed studies may be included are learning to use magnetic resonance imaging
in a meta-analysis along with methodologically (MRI), positron-emission tomography (PET) scans,
stronger studies, influencing the overall results. and other advanced biological methods in their in-
Second, there is a file drawer effect-studies that do vestigations of abnormality.
not support the hypothesis they are designed to If you pursue a career in researching abnor-
test are less likely to get published than studies mality, you might integrate methods from psy-
that do. For example, a study that finds that a psychology (which have been the focus of this
chotherapy is not any more effective than a wait chapter), sociology, and biology to create the
list control is less likely to get published than a most comprehensive picture of the disorder you
study that finds that the same psychotherapy is are investigating. This task may seem daunting,
more effective than the wait list control. The bias but an interactionist approach holds out the pos-
toward publishing studies with positive results sibility of producing breakthroughs that can
means that many perfectly good studies that fail greatly improve the lives of people vulnerable to
to find the expected effects do not get published psychopathology.
SHADES OF GRAY DISCUSSION {review p. 86)
Your greatest challenge in deciding the ethics ofthis bogus, this clearly would affect participants' re-
particular study is that the study involves deception. sponses to the feedback. The researcher would
Some ethics committees would never accept a argue that participants cannot be told in the in-
study in which students were deceived about their formed consent document that the study involves
results on an intelligence test. Other committees deception. Your ethics committee then must de-
might approve this study if it ensured all or most cide whether the potential benefits of the informa-
of the basic rights discussed on pages 86-87. tion obtained in this study warrant the deception.
Participants must be made aware that they may ex- Following the study, the researcher should re-
perience psychological distress as a result of par- veal the nature of the deception and the justifica-
ticipating. They must know that they may decline tion for using it. Many participants, especially
participation or withdraw at any point. Usually, college students, continue to believe negative feed-
these statements must appear in an informed con- back they receive in an experiment even after being
sent document that individuals should read before told that they were deceived. The researchers who
deciding to participate. This document should also discovered this phenomenon recommended con-
tell participants how confidential their responses in ducting a process debriefing (Ross, Lepper, &
the study will be. In this case, there is no reason why Hubbard, 1975). In such a debriefing, experiment-
participants' responses should not be confidential. ers discuss at length the purposes and procedures
If the researcher told participants before the of the experiment, explaining that the feedback
study began that the feedback they will receive is was not a reflection of participants' abilities.
THINK CRITICALLY
Imagine that you want to test the hypothesis that 5. Outline a correlational study that you could do to
pressure to be thin leads women to develop eating test your hypothesis.
disorders. 6. Outline an experimental study that you could do
1. What are your dependent variable and indepen- to test your hypothesis.
dent variable? 7. Outline a therapy outcome study that you could
2. What type of sample would you recruit for your do to test your hypothesis.
study? 8. How could a meta-analysis be useful in testing
3. How are you going to define "pressure to be your hypothesis?
thin" and "eating disorders"? (Discussion appears on pp. 481-482 at the back of
4. What would be the advantages and disadvantages this book.)
of using a case study to test your hypothesis?
CHAPTER SUMMARY
A hypothesis is a testable statement of what we A sample is a group taken from the population
predict will happen in a study. of interest to participate in the study. The sample
The dependent variable is the factor the study for the study must be representative of the popu-
aims to predict. The independent variable is the lation of interest, and the research must be gen-
factor used or manipulated to predict the depen- eralizable to the population of interest.
dent variable.
Chapter Summary 103
A control group consists of peop le who are sim i- sample at multiple points in time. A longitudinal
lar in most ways to the primary group of interest study often assesses a samp le that is expected to
but who do not experience the variable the experience some key event in t he future both be-
theory hypothesizes causes changes in the fore and after the event, then examines changes
dependent variable. Matching the control group that occurred in the sample. Group comparison
to the group of primary interest can help control studies evaluate differences between key groups,
third variables, which are variables unrelated to such as a group that experienced a certain
the theory that still may have some effect on the stressor and a matched comparison group that
dependent variable. did not.
The basic rights of participants in studies include Ep idemiological studies look at the frequency
being told the risks of participation, having their and distribution of a disorder in a population.
information kept confidential, having the right to The prevalence of a disorder is the proportion
refuse participation or withdraw from the study, of the population that has the disorder at a given
giving informed consent, not being exposed to point or period in time. The incidence of a disor-
deception unless it is well justified, and being der is the number of new cases of the disorder
debriefed following the study. that develop during a specific period of time.
Risk factors for a disorder are conditions or vari-
Case studies of individuals provide detailed in-
ables associated with a higher risk of having the
formation about their subjects. They are helpful
disorder.
in generating new ideas and in studying rare
problems. They suffer from problems in general - Experimental stud ies can prov ide evidence that a
izability and in the subjectivity of both the person given variable causes psychopathology. A hu-
being studied and the person conducting the man laboratory study has the goal of inducing
study. the conditions that we hypothesize wi ll lead to
our outcome of interest (e.g., increasing stress to
Correlational studies examine the relationship
cause depression) in people in a controlled set-
between two variables without manipulati ng the
ting. Participants are randomly assigned to either
variables. A correlation coefficient is an index of
the experimental group, which receives a manip-
the relationship between two variables. It can
ulation, or a control group, which does not.
range from - 1.00 to + 1.00. The magnitude ofthe
correlation indicates how strong the relationship Generalizing experimental studies to real-world
between the variables is. phenomena sometimes is not possible. In addi-
tion , manipulating people who are in distress
A positive correlation indicates that as values of
in an experimental study can create ethical
one variable increase, values of the other vari-
problems.
able increase. A negative correlation indicates
that as values of one variable increase, values of A therapy outcome study allows researchers
the other variable decrease. to test a hypothesis about the causes of a
psychopathology while providing a service to
A result is said to be statistically significant if it is
participants.
unlikely to have happened by chance . The con-
vention in psychological research is to accept re- In therapy outcome studies, researchers some-
sults for which there is a probability of less than times use wait list control groups, in which
5 in 100 that they happened by chance. control participants wait to receive the interven-
A correlationa l study can show that two variables tions until after the studies are completed.
are related, but it cannot show that one variable Alternatively, researchers may try to construct
causes the other. All correlational studies have placebo control groups, in which participants re-
the third variable problem-the possibility that ceive the general support of therapists but none
variables not measured in the study actually ac- of the elements of the therapy thought to be ac-
count for the relationship between the variables tive . Both types of control groups have practical
and ethical limitations.
measured in the study.
Continuous variable studies evaluate the rela- Difficult issues associated with therapy outcome
tionship between two variables that vary along studies include problems in knowing what ele-
a continuum. ments of therapy were effective, questions about
the appropriate control groups to use, questions
A representative sample resembles the popula- about whether to allow modifications of the ther-
tion of interest on all important variables . One apy to fit individual participants' needs, and the
way to generate a representative sample is to lack of generalizability of the results of these
obtain a random sample. studies to the real world .
Whereas cross-sectional studies assess a sample Single-case experimental designs involve the
at one point in time, longitudina l stud ies assess a intensive investigation of single individuals or
104 Chapter 4 The Researc h Endeavor
small groups of individuals before and after a dizygotic twins. Molecular genetic (or associ a- ~
manipulation or intervention. In an ABAB, or tion) studies look for specific genes associated
reversal, design, an intervention is introduced, with a disorder. Linkage analyses investigate the
withdrawn, and then reinstated, and the re lationship between a biological characteristic
behavior of a participant on and off the for which the genes are known and a psychologi-
treatment is examined. cal disorder for which they are not.
In multiple baseline designs, an individual is Cross-cultu ral research poses challenges.
given a treatment in different settings or multiple Theories and concepts that make sense in one
individuals are given a treatment at different culture may not be applicable to other cultures.
times across different settings, and the effects Questionnaires and other assessment tools must
of the treatment are systematically observed. be translated accurately. Also, culture can affect
Animal studies allow researchers to manipulate how people respond to the social demands of
their subjects in ways that are not ethically per- research. Finally, researchers must be careful not
missible with human participants, although to build into their research any assumptions that
many people feel that such animal studies are one culture is normal and another is deviant.
equally unethical. Animal studies raise questions Meta-analysis is a statistical technique for sum-
about their generalizability to humans. marizing results across several studies. In a
Genetic studies include a variety of research meta-analysis, the results of individual studies
methods. Family history studies determine are standardized by use of a statistic called the
whether biological relatives of someone with a effect size. Then the magnitude of the effect size
disorder are more likely to have it than are peo- and its relationship to characteristics of the study
ple not related to someone with the disorder. are examined.
Adoption studies determine whether the biologi- Meta-analyses reduce bias that can occur when
cal family members of adoptees with a disorder investigators draw conclusions across studies in
are more likely to have the disorder than are the a more subjective manner, but they can include
adoptive family members. Twin studies deter- studies that have poor methods or exclude good
mine whether monozygotic twins are more alike studies that did not get published because they
in the presence or absence of a disorder than are did not find significant effects. ~
KEY TERMS
scientific method 84 longitudinal 89
hypothesis 85 correlation coefficient 89
null hypothesis 85 statistical significance 90
variable 85 third variable problem 90
dependent variable 85 sample 90
independent variable 85 external validity 91
operationalization 85 epidemiology 92
case studies 87 prevalence 92
general izability 88 incidence 92
correlational studies 88 risk factors 92
continuous variable 88 experimental studies 93
g roup comparison study 88 human laboratory study 93
cross-sectional 89 internal validity 93
Key Terms 105
control group 93 multiple baseline design 96

experimental group 93 animal studies 97
random assignment 93 family history study 98
demand characteristics 93 monozygotic (MZ) twins 98
double-blind experiment 94 dizygotic (DZ) twins 98
therapy outcome studies 94 twin studies 98
wait list control group 94 concordance rate 98
placebo control group 94 adoption study 99
efficacy 95 molecular genetic studies 99
effectiveness 95 association studies 99
single-case experimental design 95 linkage analysis 99
ABAB (reversal) design 96 meta-analysis 100
Trauma, Anxiety,
Obsessive-Compulsive,
and Related Disorders
CHAPTER OUTLINE
Fear and Anxiety Along the Continuum Generalized Anxiety Disorder

Extraordinary People: David Beckham, Separation Anxiety Disorder
Perfection On and Off the Field
Obsessive-Compulsive Disorder
Posttraumatic Stress Disorder Anxiety Disorders in Older Adults
and Acute Stress Disorder
Chapter Integration
Specific Phobias and
Agoraphobia Shades of Gray Discussion
Shades of Gray Think Critically
Social Anxiety Disorder Chapter Summary
Panic Disorder Key Terms
Fear is in response to objectively Potentially meets diagnostic criteria for an
threatening events (fearing you will fail a anxiety disorder:
class after failing the midterm) Fear is moderately unrealistic (fearing a car
Fear is of appropriate severity given the accident if you drive on Friday the 13th)
threat (being concerned because you need Fear is definitely more than is warranted
this class to graduate) given the severity of the threat (being vel}'
Fear subsides when threat has passed nervous when forced to drive on Friday the 13th)
(relaxing when you learn there was a grading Fear persists for quite a while after the
error and you actually did well) threat has passed (worl}'ing about the next
Fear leads to adaptive behaviors to confront Friday the 13th)
or avoid threat (asking your instructor 1j you Fear leads to behaviors that are potentially
can improve your grade with extra work) dangerous or impairing (skipping class to
avoid driving on Friday the 13th)
Functional Dysfunctional
1- ,_
Fear may be somewhat unrealistic Likely meets diagnostic criteria for an

(fear of appearing foolish when giving a anxiety disorder:
presentation in class) Fears are completely unrealistic
Fear may be somewhat more than is (fearing that evel}' ache or pain is a sign
warranted given the severity of the threat of terminal illness)
(being unable to sleep the night before Fears are excessive given the objective
a presentation) threat (thinking one is dying when one
Fear persists after the threat has passed feels pain)
(after you give the presentation, analyzing Fears persist long after the threat has
it and worl}'ing about what people thought) passed, and chronic anticipatory anxiety
Fear leads to behaviors that may be exists (believing one has a terminal
somewhat inappropriate (taking a illness despite physician reassurance)
tranquilizer before the presentation to relax Fear leads to dangerous behavior or
impairment (seeking out surgery to cure
the terminal illness your physician says
you do not have)
Think of a time you felt fearful or anxious, perhaps on the first threat, and in how they behave i n response to their fears . Fear
day of college. Chances are you felt a bit tense or jittery, you can become maladaptive when it arises in situations that most
worried about what you might encounter, and there were times people would not find threatening. For example, some people
you wished you could just retreat back to familiar surroundings become incapacitated with fear if they have to leave their home.
and people. This is a typical response to a new and potentially Fear is maladaptive if it is greatly out of proportion to the threat,
threatening situation-here the threat is that you might not like for example, when people become panicked at the possibility of
the people at your college, you might not feel you fit in, or you encountering a snake on a nature walk. Fear becomes anxiety
might not do well in your classes. Fear is adaptive when it is when it persists long after the threat has subsided. For exam-
realistic (i.e., when there is a real threat in the environment), ple, some people who have experienced traumatic events con-
when it is in proportion to the threat, if it subsides when the tinue to be extremely fearful long after the trauma has ended.
threat has passed, and if it leads to appropriate behaviors to And fear can become an anxiety disorder when a person en-
overcome the threat (e.g., making an effort to meet new people gages in maladaptive behaviors in response to a threat; for ex-
and become familiar with your new surroundings). ample, a person with agoraphobia may become housebound
People vary greatly, however, in the situations they find due to fear of venturing out.
threatening, in how fearful they become when they encounter a
Fear and Anxiety Along the Continuum 107

108 Chapter 5 Trauma. Anxiety. Obsessive-Compulsive. and Related Disorders
David Beckham, Perfection On and Off the Field
Soccer star David coordinated down either side . We've got three
Beckham's extraordi- fridges-food in one, salad in another and drinks
nary ability to curve in the third . In the drinks one, everything is sym-
shots on corner kicks metrical. If there's three cans he'll throw away
was immortalized in one because it has to be an even number" (quoted
the movie Bend It Like in Frith, 2006). Beckham has traveled around the
Beckham. Beckham's world, playing for top teams including Real
perfectionism on the Madrid, Manchester United, Los Angeles Galaxy,
field is paralleled by and AC Milan. Each time he enters a new hotel
his perfectionism about room, he has to arrange everything in order: "I'll
order and symmetry: go into a hotel room . Before I can relax I have to
"I've got this obsessive compulsive disorder where move all the leaflets and all the books and put
I have to have everything in a straight line or every- them in a drawer. Everything has to be perfect"
thing has to be in pairs" (quoted in Dolan, 2006). (quoted in Frith, 2006) . His teammates on
Beckham spends hours ordering the furniture in his Manchester United knew of his obsessions and
house in a particular way or lining up the clothes in compulsions and would deliberately rearrange
his closet by color. His wife, Victoria (the fo rme r his clothes or move the furniture around in his
Posh Spice), says, "If you open our fridge, it's all hotel room to infuriate him.
When we face any type of threat or stressor, our The hypothalamus activates the adrenal-cortical
body mobilizes to handle it. Over evolutionary system by releasing corticotropin-release factor
history, humans have developed a characteristic (CRF), which signals the pituitary gland to secrete
fight-or-flight response, a set of physical and psy- adrenocorticotropic hormone (ACTH), the body's
chological responses that help us fight a threat or major stress hormone. ACTH stimulates the outer
flee from it. The physiological changes of the layer of the adrenal glands (the adrenal cortex), re-
fight-or-flight response result from the activation leasing a group of hormones, the major one being
of two systems controlled by the hypothalamus, cortisol. The amount of cortisol in blood or urine
as seen in Figure 5.1 : the autonomic nervous samples is often used as a measure of stress. ACTH
system (in particular, the sympathetic division also signals the adrenal glands to release about 30
of this system) and the adrenal-cortical system other hormones, each of which plays a role in the
(a hormone-releasing system; see Chapter 2). The body's adjustment to emergency situations. Even-
hypothalamus first activates the sympathetic divi- tually, when the threatening stimulus has passed,
sion of the autonomic nervous system. This sys- the hippocampus, a part of the brain that helps
tem acts directly on the smooth muscles and regulate emotions, turns off this physiological cas-
internal organs to produce key bodily changes: cade. The fight-or-flight system thus has its own
The liver releases extra sugar (glucose) to fuel the feedback loop that normally regulates the level of
muscles, and the body's metabolism increases in physiological arousal we experience in response to
preparation for expending energy on physical ac- a stressor. In many of the disorders we discuss in
tion. Heart rate, blood pressure, and breathing this chapter, the normal response becomes abnor-
rate increase, and the muscles tense. Less essential mal, and the fight-or-flight system becomes dys-
activities, such as digestion, are curtailed. Saliva regulated.
and mucus dry up, increasing the size of the air In addition to these physiological responses to
passages to the lungs. The body secretes endor- a threat, characteristic emotional, cognitive, and
phins, which are natural painkillers, and the sur- behavioral responses occur (Table 5.1). Emotionally, ~
face blood vessels constrict to reduce bleeding in we experience terror and dread, and we often are
case of injury. The spleen releases more red blood irritable or restless. Cognitively, we are on the look-
cells to help carry oxygen. out for danger. Behaviorally, we seek to confront the
The Fight-or-Flight Response. The body's fight-or-flight response is initiated by

FIGURE 5.1
the part of the brain known as the hypothalamus. The hypothalamus stimulates
------..J the sympathetic division of the autonomic nervous system, which acts on smooth
muscles and internal organs to produce the bodily changes shown in the figure. The hypothalamus
also releases corticotrophin-release factor (CRF), which triggers the pituitary gland to release
adrenocorticotropic hormone (ACTH). In turn, ACTH stimulates the adrenal glands to release about
30 other hormones. The hormones act on organs and muscles to prepare the body to fight or flee.
Stressor
+
Amygdala
!
Hypothalamus
~
Adrenal-cortical
Sympathetic nervous system system
I
Releases CRF
~
Pituitary gland
Weakly stimulates - - - - - -- - -- 1:-

salivary glands
I
Releases ACTH
Relaxes bronchi-------~~
in lungs
Accelerates and ----------;~----r--=:;~

strengthens heartbeat
j
Adrenal glands
Stimulates release of - - - - -- 7
glucose by the liver
Stimulates secretions - - - - - - - - - '

by the adrenal glands
I \
Adrenal cortex Adrenal medulla
\
Releases
I
Releases
epinephrine and
'-"'~
corticosteroids norepinephrine
Inhibits stomach activity _ _ _ ___/
Relaxes bladder - - - -------"

\ Changes in internal
organs and muscles
I
threat or escape from it. In a realistic fear response, bouts of anxiety (Watson, 2009). People with
these emotional, cognitive, and behavioral responses schizophrenia often feel anxious when they be-
subside when the threat subsides. In anxiety and lieve they are slipping into a new episode of psy-
~ related disorders, these responses may persist in the chosis. Many people who abuse alcohol and other
absence of any objective threat. drugs do so to dampen anxious symptoms. In ad-
Anxiety is a part of many psychological disor- dition, people with one anxiety disorder are likely
ders. Most people with serious depression report to have another (Craske & Waters, 2005).
110 Chapter 5 Trauma. Anxiety. Obsessive-Compulsive, and Related Disorders
TABLE 5.1 Responses to Threat
These characteristic responses to threat can also be symptoms of an anxiety disorder.
Somatic Emotional Cognitive Behavioral
Tense muscles Sense of dread Anticipation of harm Escape

Increased heart rate Terror Exaggeration of danger Avoidance
Changes in respiration Restlessness Problems in concentrating Aggression
Dilated pupils Irritability Hypervigilance Freezing
Increased perspiration Worried, ruminative thinking
Adrenaline secretion Fear of losing control
Inhibited stomach acid Fear of dying
Decreased salivation Sense of unreality
Bladder relaxation
PROFILES
This chapter focuses on disorders in which I just can't let go of it. I was working at my desk
anxiety is a key feature. We begin with two disor- on the 1Oth floor of the World Trade Center when
ders in which an initial, potentially adaptive fear the first plane hit. We heard it but couldn't imag-
response develops into a maladaptive anxiety ine what it was. Pretty soon someone started
disorder. yelling, "Get out-it's a bomb!" and we all ran
for the stairs.
The dust and smoke were pouring down the
POSTTRAUMATIC staircase as we made our way down. It seemed to
STRESS DISORDER take an eternity to get to the ground. When I got
outside, I looked up and saw that the top of the
AND ACUTE STRESS tower was on fire. I just froze; I couldn't move.
DISORDER Then the second plane hit. Someone grabbed my
arm and we started running . Concrete and glass
Two psychological disorders, posttraumatic stress
began to fly everywhere. People were falling
disorder (PTSD) and acute stress disorder, are by
down, stumbling. Everyone was covered in dust.
definition the consequences of experiencing ex-
When I got far enough away, I just stood and
treme stressors, referred to as traumas. In every-
stared as the towers fell. I couldn't believe what I
day conversations, people refer to a wide range of
was seeing. Other people were crying and
events as traumas, from a romantic breakup ("He
screaming, but I just stared. I couldn't believe it.
was traumatized by her leaving him.") to horrific
Now, I don't sleep very well. I try, but just as
tragedies (e.g., being the victim of a mass shooting,
I'm falling asleep, the images come flooding into
losing one's family in a tornado). The DSM-5 con-
my mind. I see the towers falling. I see people
strains traumas to events in which individuals are
with cuts on their faces. I see the ones who didn't
exposed to actual or threatened death, serious in-
make it out, crushed and dead. I smell the dust
jury, or sexual violation (Table 5.2). In addition, in
and smoke. Sometimes, I cry to the point that my
the diagnostic criteria for PTSD and acute stress
pillow is soaked. Sometimes, I just stare at the
disorder, the DSM-5 requires that individuals ei-
ceiling, as I stared at the towers as they fell. During
ther directly experience or witness the traumatic
the day, I go to work, but often it's as if my head is
event, learn that the event happened to someone
in another place. Someone will say something to
they are close to, or experience repeated or extreme
me, and I won't hear them. I often feel as if I'm
exposure to the details of a traumatic event (as do
floating around, not touching or really seeing any-
first responders at a tragedy). Blair, a survivor of
thing around me. But if I do hear a siren, which
the terrorist attack on the World Trade Center on
you do a lot in the city, I jump out of my skin.
September 11, 2001, describes many core symp-
toms of both disorders.
Posttraumatic Stress Disorder a nd Acute Stress Disorder 111
TABLE 5.2 DSM-5 Criteria for Posttraumatic Stress Disorder
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).

2. Witnessing , in person, t he event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close fam ily member or close friend. In cases of actual or threatened death
of a f amily member or friend, the event(s) must have been violent or accidental.
4. Ex perie ncing repeat ed o r extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting
human rema ins; pol ice officers repeatedly exposed to details of child abuse) .
Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure
is work related .
B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the
traumatic event(s) occurred :
1. Recurrent, involunt ary, and intrusive distressing memories of the traumatic event(s).
2. Recurrent d ist ressing dreams i n which the content and/or affect of the dream are related to the traumatic event(s) .
3. Dissociative react ions (e.g ., f lashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such
reactions may occur on a co ntinuum , with the most extreme expression being a complete loss of awareness of present
su rroundings.)
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of
the traumatic event(s).
5. Marked physiological reactions to i nternal or external cues that symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimu li associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as
evidenced by one or both of the following:
1. Avoida nce of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic
event(s) .
2. Avoidance of or efforts to avo id external reminders (people, places, conversations, activities, objects, situations) that arouse
distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginn ing or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typ ically due to dissociative amnesia and not to other
factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can
be trusted," "The world is completely dangerous," "My whole nervous system is permanently ruined").
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame
himself/herself or others.
4. Persistent negative emotional state (e.g ., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the following:
1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression
toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervig ilance.
4. Exaggerated startle response.
5. Problems with concentration .
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). (continued)
112 Chapter 5 Trauma, Anxiety. Obsessive-Compulsive. and Related Disorders
TABLE 5.2 DSM-5 Criteria for Posttraumatic Stress Disorder (continued)
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in socia l, occupational, or other importa nt areas of
functioning.
H. The disturbance is not attributable to the physiological effects of a substance (e.g ., medication, alcohol) or another medica l
condition.
Specify whether:
With dissociative symptoms: The individual's symptoms meet the criteria for posttra umatic stress disorder, and in addition, in
response to the stressor, the individual experiences persistent or recurrent symptoms of either of the fo llowing:
1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of,
one's mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or
of t i me moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g ., the world around the ind ivi dual is
experi enced as unreal, dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be attribut able to the physiological effects of a substa nce
(e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g. , complex partia l seizures).
Specify if:
With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (a lthough the onset and
expression of some symptoms may be immediate) .
Source: Reprinted with permiss ion from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition . Copyright 2013 American Psyc hiatric
Association.
Immediately after the World Trade Center at-

tacks, about 20 percent of people living nearby had
symptoms meeting the diagnosis of PTSD, includ-
ing reexperiencing the event (e.g., flashbacks or
nightmares), feeling numb and detached, or being
hypervigilant and chronically aroused (Galea et
al., 2002). Even people not physically present were
traumatized by the event. Nationwide studies
showed that just after September 11, 2001, 44 per-
cent of adults reported symptoms of PTSD
(Schuster et al., 2001). Two months later, 21 per-
cent of adults nationwide reported still being
"quite a bit" or "extremely" bothered by distress
symptoms (Stein et al., 2004). Those in this study
experiencing persistent distress reported accom-
plishing less at work (65 percent), avoiding public
gathering places (24 percent), and using alcohol or
other drugs to quell worries about terrorism
(38 percent).
A wide range of specific events can induce
posttraumatic stress disorder or acute stress dis-
order, ranging from extraordinary events such as a
terrorist attack to common events such as a traffic
accident. The experiences qualify as traumas un-
Traumatic events such a s the attack on the World Trade
der the DSM-5 as long as they expose the individ-
Center can lead to posttraumatic stress. ual to actual or threatened death, serious injury, or
sexual violation. About 7 percent of adults will be
Posttraumatic Stress Disorder and Acute Stress Disorder 113
exposed to a traumatic event and develop posttra- Another disorder associated with traumas,
umatic stress disorder at some time in their lives, acute stress disorder, occurs in response to trau-
with women at greater risk than men (Kessler et al., mas similar to those involved in PTSD but is diag-
2005). For some, the symptoms can be mild to nosed when symptoms arise within 1 month of
moderate, permitting normal functioning. For oth- exposure to the stressor and last no longer than
ers, however, the symptoms can be immobilizing, 4 weeks. As in PTSD, the individual with acute
causing deterioration in their work, family, and stress disorder persistently reexperiences the
social lives. trauma through flashbacks, nightmares, and intru-
A diagnosis of PTSD requires the presence of sive thoughts; avoids reminders of the trauma;
four types of symptoms (Table 5.2). The first in- and is constantly aroused. In acute stress disorder,
volves repeated reexperiencing of the traumatic dissociative symptoms are common, including
event. PTSD sufferers may experience intrusive numbing or detachment, reduced awareness of sur-
images or thoughts, recurring nightmares, or flash- roundings, derealization (experiencing the world
backs in which they relive the event. Memories of as unreal or dreamlike), depersonalization (feeling
the World Trade Center attack intrude into Blair's detached from one's body or mental processes),
consciousness against her will, particularly when and an inability to recall important aspects of the
she encounters something that reminds her of the trauma. Although acute stress disorder is defined
event. She also relives her emotional reaction to as a short-term response to trauma, people who
the event, and she chronically experiences nega- experience acute stress disorder are at high risk
tive emotions that have not diminished with time. of continuing to experience posttraumatic stress
The second type of symptoms in PTSD in- symptoms for many months (Bryant et al., 2011).
volves persistent avoidance of situations, thoughts, Another trauma- and stress-related diagnosis
or memories associated with the trauma. People is adjustment disorder, which consists of emo-
will shun activities, places, or other people that re- tional and behavioral symptoms (depressive
mind them of the event. The third group of symp- symptoms, anxiety symptoms, and/ or antisocial
toms involves negative changes in thought and behaviors) that arise within 3 months of the experi-
mood associated with the event. People may not ence of a stressor. The stressors that lead to adjust-
be able to remember aspects of the trauma. They ment disorder can be of any severity, while those
may unrealistically blame themselves or others for that lead to PTSD and acute stress disorder are, by
the event and feel permanently damaged. They definition, extreme. Adjustment disorder is a diag-
may report "survivor guilt" about having lived nosis for people experiencing emotional and be-
through the traumatic event or about things they havioral symptoms following a stressor who do
had to do to survive. They may be chronically dis- not meet the criteria for a diagnosis of PTSD, acute
tressed or, like Blair, become emotionally numb stress disorder, or an anxiety or mood disorder re-
and withdrawn, feeling detached from themselves sulting from stressful experience.
and their ongoing experiences.
The fourth type of symptoms includes hyper-
vigilance and chronic arousal. People with PTSD
Traumas Leading to PTSD
are always on guard for the traumatic event tore- The traumas that can lead to PTSD unfortunately
cur. Sounds or images that remind them of their are common. Among them are natural disasters
trauma can instantly create panic and flight. A war such as floods, tsunamis, earthquakes, fires, hurri-
veteran, hearing a car backfire, may jump into a canes, and tornadoes. One of the largest natural di-
ditch and begin to have flashbacks of the war, re- sasters in recent history was the tsunami that struck
experiencing the terror he or she felt on the front south and southeast Asia on December 26, 2004.
lines. Irritability and agitation are common, as is Over 280,000 people were killed, and 1.2 million
insomnia. were displaced. In the state of Tamil Nadu, India,
Many people with PTSD experience some 7,983 people were killed, and 44,207 had to be relo-
symptoms of dissociation, a process in which dif- cated to camps due to damage to their homes. Two
ferent facets of their sense of self, memories, or months after the tsunami, researchers found that
consciousness become disconnected from one an- 13 percent of adults in this area were experiencing
other. For some people with PTSD, dissociative PTSD (Kumar et al., 2007). Five months after Hur-
symptoms are especially prominent and persis- ricane Katrina devastated the northern coast of the
tent (see Friedman et al., 2011). These people can Gulf of Mexico in 2005, 30 percent of people from
be diagnosed with the subtype PTSD with promi- the New Orleans metropolitan area and 12 percent
nent dissociative (depersonalization/derealization) from the rest of the hurricane area were diagnosed
symptoms. with PTSD (Galea et al., 2007).
114 Chapter 5 Trauma, Anxiety, Obsessive-Compulsive, and Related Disorders
found that approximately 15 to 19 percent of those ~

deployed in Iraq and about 11 percent of those de-
ployed in Afghanistan can be diagnosed with
PTSD (Erbes, Westermeyer, Engdahl, & Johnsen,
2007; Hoge et al., 2004; Hoge, Auchterlonie, &
Milliken, 2006; Sundin et al., 2010). Follow-up
studies of soldiers returning from Iraq have found
that as many as 42 percent report some mental
health problems, most often PTSD symptoms
(Milliken, Auchterlonie, & Hoge, 2007) . Army
sergeant Kristofer Goldsmith, who served 4 years
in active duty in Iraq, is one of those soldiers.
CASE STUDY
Kristopher Goldsmith was
a 19-year-old, fresh out of high school, when he
joined the Army. He was soon deployed to Sadr
City, one of the most violent places in Iraq .
Goldsmith's duty was to photograph and docu-
Survivors of natural disa sters such a s the tsunami in Asia in 2004, Hurric ane ment the incidents his platoon encountered, in-
Katrina in 2005, the 2010 earthquake in Haiti, or Super Storm Sandy in 2012 cluding mutilated men, women, and children.
(shown here) often experience posttraumatic stress disorder.
When his unit was back home for a while,
family and friends noticed that Goldsmith was a
different man. His drinking escalated to binges
Search and rescue personnel who respond in every day. He also seemed to get into fights or be
the hours and days just after a disaster are at sig- violent in some way every day. He was con-
nificant risk for PTSD. A meta-analysis of 28 stud- stantly hypervigilant for any threats . Simply
ies of ambulance personnel, firefighters, police, walking through a crowded shopping mall was
and other first responders across the world found enough to spark paranoia as he scanned every
that 10 percent currently experienced PTSD, re- person and scene for enemies who might spring
gardless of whether they had recently responded out and hurt him . Innocent remarks by clerks or
to a large-scale traumatic event (Berger et al., 2012). being touched by someone as he was walking by
Ambulance w orkers had the highest rates of PTSD, could spark violent outbursts. There were times
presumably because their job involves daily expo- when he seemed not to know what he was doing
sure to people who are seriously injured and dy- and was totally out of control. At one party, he
ing, in a chronically pressured work environment. suddenly grabbed another guy and choked him
Human-made disasters such as wars, terrorist until he stopped breathing .
attacks, and torture may be even more likely to Soon Goldsmith's unit was ordered to rede-
lead to PTSD than are natural disasters. PTSD ploy to Iraq. Believing he couldn't face the scenes
symptoms went by different names in the two of devastation and death that now haunted him,
w orld w ars and the Korean War: "combat fatigue he attempted suicide, swallowing massive num-
syndrome," "war zone stress," and "shell shock." bers of painkillers and gulping a liter and a half
In follow-up studies of soldiers experiencing of vodka. Goldsmith survived and was eventu-
these syndromes, the soldiers showed chronic ally diagnosed with PTSD. (Gajilan, 2008)
posttraumatic stress symptoms for decades after
the war (Elder & Clipp, 1989; Sutker, Allain, &
Winstead, 1993). PTSD became widely recognized
after the Vietnam War. Almost 19 percent of The citizens of countries besieged by war are
Vietnam veterans had the disorder at some point, also at high risk for PTSD. The Afghan people have
and 9 percent still had it 10 to 12 years after their endured decades of war and occupation, the re- ~
service ended (Dohrenwend et al., 2006) . pressive regime of the Taliban, the U.S. bombing of
Recent and ongoing wars and conflicts have their country after the September 11 attacks, and,
left thousands of PTSD sufferers in their wake. since 2001, protracted violence. Thousands of Af-
Studies of U.S. Army soldiers and Marines have ghanis have been killed, injured, or displaced from
their homes. Many of the displaced now live in Posttraumatic Symptoms in Rape
makeshift tents without adequate food or water. FIGURE 5.2
survivors. Almost all women shown symptoms
Posttraumatic stress disorder was found in 42 per- of posttraumatic stress disorder severe enough
cent of Afghan citizens, and other anxiety symp- to be diagnosed with it in the first or second week following a
toms were found in 72 percent (Cardozo et al., rape. Over the 3 months following a rape, the percentage of
2004). Afghan women may be especially likely to women continuing to show symptoms of PTSD declines.
experience PTSD, because the Taliban deprived However, almost 50 percent of women continue to be diagnosed
them of their basic human rights, killed their hus- with PTSD 3 months after a rape.
bands and male relatives, and then made it impos-
sible for them to survive without those men. Over 100 . --------------------------------------------
90 percent of these women reported some anxiety
symptoms, and 42 percent were diagnosed with 90
PTSD (see also Scholte et al., 2004).
Sexual assault is the trauma most commonly 80
associated with PTSD, and nearly half (46 percent) E
~ 70
of sexual assault survivors develop PTSD at some E
~
time in their lives (Zinzow et al., 2012) . Most Cl 60
~
women report some PTSD symptoms shortly after 0..
g' 50
a sexual assault (see Figure 5.2), and almost 50 per-
-e
cent still qualify for the diagnosis 3 months after 0
~ 40
the rape, while as many as 25 percent still experi- .....c
ence PTSD 4 to 5 years later (Faravelli, Giugni, ~ 30
Salvatori, & Ricca, 2004; Foa & Riggs, 1995; Resnick, :f.
20
Kilpatrick, Dansky, & Saunders, 1993; Rothbaum,
Foa, Riggs, & Murdock, 1992). 10
0
2 6
Theories of PTSD 3 4 5 7
Weeks since the rape
What kind of trauma is most likely to cause long-
term, severe psychological impairment? Why do
Source: Adapted from Faa & Riggs, 1995.
some people develop PTSD in the wake of trauma,
whereas others do not? Researchers have identi-
fied a number of factors that seem to increase the
likelihood of developing PTSD. to experience PTSD than are those whose lives
are less severely affected (Galea, Tracy, Norris, &
Coffey, 2008).
Environmental and Social Factors Another predictor of vulnerability to PTSD is
Strong predictors of people's reactions to trauma the available social support. People who have the
include its severity and duration and the individu- emotional support of others after a trauma recover
al's proximity to it (Cardozo, Vergara, Agani, & more quickly than do people who do not (Kendall-
Gotway, 2000; Ehlers et al., 1998; Hoge et al., 2004; Tackett, Williams, & Finkelhor, 1993; LaGreca,
Kessler et al., 1995). People who experience more Silverman, Vernberg, & Prinstein, 1996; Sutker,
severe and longer-lasting traumas and are directly Davis, Uddo, & Ditta, 1995). Survivors of Hurricane
affected by a traumatic event are more prone to Katrina who could talk with others about their ex-
developing PTSD. For example, veterans are more periences and who received emotional and practical
likely to experience PTSD if they were on the front support were less likely to develop PTSD than were
lines for an extended period (Iverson et al., 2008). those who did not receive such support (Galea et al.,
People at Ground Zero during the World Trade 2008). Search and rescue personnel responding to
Center attacks were more likely to develop PTSD the 2010 earthquake in Haiti were unlikely to de-
than were those who were not at the site (Galea et velop PTSD if they had strong social support among
al., 2002). Rape survivors who were violently and their colleagues and in their community (van der
repeatedly raped over an extended period are Velden, van Loon, Benight, & Eckardt, 2012).
particularly likely to experience PTSD (Epstein,
Saunders, & Kilpatrick, 1997; Zinzow et al., 2012) . Psychological Factors
Victims of natural disasters who are injured or People who already are experiencing increased
who lose their homes or loved ones are more likely symptoms of anxiety or depression before a trauma
116 Chapter 5 Trauma. Anxiety, Obsessive-Compulsive. and Related Disorders
occurs are more likely to develop PTSD following Culture also appears to strongly influence the
the trauma (Cardozo, Kaiser, Gotway, & Agani, manifestation of anxiety. People in Latino cultures
2003; Hoge et aL, 2004; Mayou, Bryant, & Ehlers, report a syndrome known as ataque de nervios (attack
2001). Children who were anxious prior to Hurri- of the nerves) (see Lewis-Fernandez et aL, 2010). A
cane Katrina were more likely to develop symp- typical ataque de nervios might include trembling,
toms of PTSD than were those who were not heart palpitations, a sense of heat in the chest rising
(Weems et aL, 2007). War veterans who have psy- into the head, difficulty moving limbs, loss of con-
chological distress or poor interpersonal relation- sciousness or the mind going blank, memory loss, a
ships before they enter combat are more likely to sensation of needles in parts of the body (paresthe-
develop symptoms of PTSD (Koenen et aL, 2002). sia), chest tightness, difficulty breathing (dyspnea),
Once trauma occurs, people's styles of coping dizziness, faintness, and spells. Behaviorally, the
may also influence their vulnerability. Several stud- person begins to shout, swear, and strike out at oth-
ies have shown that people who use self-destructive ers. The person then falls to the ground and either
or avoidant coping strategies, such as drinking and experiences convulsive body movements or lies as
self-isolation, are more likely to experience PTSD if dead. Ataque de nervios is more common among
(Merrill et aL, 2001; Sutker et aL, 1995). Another form recent trauma victims (Guarnaccia et al., 1996).
of coping that may increase the likelihood of PTSD is More chronic anxiety-like symptoms, known as
dissociation, or psychological detachment from the nervios, are common in Latino communities, particu-
trauma and ongoing traumatic events. People who larly among the poor and uneducated (Guarnaccia
dissociate may feel that they are in another place, or et al., 1996). The term nervios encompasses a broad
in someone else's body watching the trauma and its array of symptoms, including physical ailments
aftermath unfold. Those who dissociate shortly after (headaches, stomach problems, dizziness) and
a trauma are at increased risk of developing PTSD emotional symptoms (sadness, irritability, anger,
(Cardefia & Carlson, 2011; Friedman et aL, 2011). absentmindedness), as well as the presence of in-
trusive worries or negative thoughts. One study of
Gender and Cross-Cultural Differences 942 adults in rural Mexico found that 21 percent of
Women are more likely than men to be diagnosed the women and 10 percent of the men had chronic
with PTSD, as well as most other anxiety disorders nervios (de Snyder, Diaz-Perez, & Ojeda, 2000). The
including panic disorder, social anxiety disorders, authors suggest that among the underprivileged,
and generalized anxiety disorder (Hanson et aL, particularly women, nervios expresses the anger and
2008; Roberts, Gilman, Brelau, & Koenen, 2011). frustration of "being at the bottom" and provides
Women may experience some of the triggers for temporary release from the grinding everyday bur-
anxiety disorders more often than men, particu- dens of life (see also Lopez & Guarnaccia, 2000).
larly sexual abuse (Burnam, Stein, Golding, &
Siegel, 1988). Women also may be more likely to Biological Factors
develop PTSD because the types of traumas they The biological responses to threat appear to be dif-
frequently experience, such as sexual abuse, are ferent in people with PTSD than in people without
stigmatized, decreasing the amount of social sup- the disorder. Genetic factors may predispose vic-
port they receive. Men are more likely to suffer tims of threat to these different biological responses.
traumas that carry less stigma, such as exposure to
war (Resick & Calhoun, 2001). Neuroimaging Findings Neuroimaging stud-
Nationwide studies in the United States find ies using positron-emission tomography (PET) and
that African Americans have higher rates of PTSD magnetic resonance imaging (MRl; see Chapter 3)
compared to whites, Hispanics, and Asian Ameri- have shown differences in brain activity between
cans (Roberts et aL, 2011). Whites reported being people with PTSD and those without it in response
exposed to the greatest number of potentially trau- to threatening or emotional stimuli. These differ-
matizing events, but African Americans reported ences occur in brain areas that regulate emotion,
more traumas of certain types than did other the fight-or-flight response, and memory, including
groups, namely, witnessing domestic violence and the amygdala, hippocampus, and prefrontal cortex
being the victim of a violent assault. Asians had the (Britton & Rauch, 2009). The amygdala appears to
most reports of being a refugee or a civilian in a war respond more actively to emotional stimuli in those
zone. All the racial/ ethnic minority groups were with PTSD. Further, the medial prefrontal cortex,
less likely than whites to seek treatment for trauma- which modulates the reactivity of the amygdala to
related symptoms, perhaps due to lower socioeco- emotional stimuli, is less active in people with
nomic status and less access to health care or to more severe symptoms of PTSD than in people
greater stigmatization against seeking mental health with less severe symptoms. Thus, the brains of peo-
treatment (Roberts et aL, 2011). ple with severe PTSD may be both more reactive to
emotional stimuli and less able to dampen that re- Nemeroff, 2004). Studies of maltreated (severely
activity when it occurs (Shin et al., 2011). neglected or physically, emotionally, or sexually
Some studies also show shrinkage in the hip- abused) children show abnormal cortisol re-
pocampus among PTSD patients, possibly due to sponses to stressors (Cicchetti & Rogosch, 2001)
overexposure to neurotransmitters and hormones and a diminished startle response (Klarman,
released in the stress response (Britton & Rauch, Cicchetti, Thatcher, & Ison, 2003). Adults abused
2009). The hippocampus functions in memory, and as children continue to have abnormal cortisol re-
damage to it may result in some of the memory sponses and elevated startle and anxiety responses
problems reported by PTSD patients. It also helps to laboratory stressors, even when they no longer
regulate the body's fear response, as discussed ear- show symptoms of PTSD or depression (Heim,
lier. Thus, damage to the hippocampus may inter- Meinlschmidt, & Nemeroff, 2003; Pole et al., 2007).
fere with returning the fear response to a normal Depressed women who were abused as children
level after the threat has passed. show lower volume of the hippocampus than de-
pressed women who were not abused as children
Biochemical Findings Recall that one of the (Vythilingam et al., 2002). Thus, early childhood
major hormones released as part of the fight-or-flight trauma may leave permanent physical and emo-
response is cortisol and that high levels usually tional scars that predispose individuals to later
indicate an elevated stress response. Interestingly, psychological problems, including PTSD.
resting levels of cortisol among people with PTSD
(when not exposed to trauma reminders) tend to be Genetics Vulnerability to PTSD may be inher-
lower than among people without PTSD (Yehuda, ited (Uddin, Amstadter, Nugent, & Koenen, 2012).
Pratchett, & Pelcovitz, 2012). For example, studies One study of about 4,000 twins who served in the
that have assessed cortisol levels in people injured Vietnam War found that if one developed PTSD,
in a traffic accident one to two days previously the other was much more likely to develop it if
have found that those with lower cortisol levels are the twins were identical rather than fraternal
at significantly increased risk for PTSD over the (True et al., 1993; Stein et al., 2002). The adult
next weeks and months (Ehring, Ehlers, Cleare, & children of Holocaust survivors with PTSD are
Glucksman, 2008; McFarlane, Barton, Yehuda, & over three times more likely to develop it than
Wittert, 2011). Cortisol acts to reduce sympathetic are matched comparison groups. They also have
nervous system activity after stress, so lower levels abnormally low levels of cortisol, whether or not
may result in prolonged activity of the sympathetic they have ever been exposed to traumatic events
nervous system following stress. As a result, some or developed PTSD (Yehuda, Blair, Labinsky &
people may more easily develop a conditioned fear Bierer, 2007). These findings suggest that abnor-
of stimuli associated with the trauma and subse- mally low cortisol levels may be one heritable risk
quently develop PTSD (Ballenger et al., 2004). factor for PTSD. Other studies have found that the
Some other physiological responses to stress are abnormalities in brain responses to emotional
exaggerated in PTSD sufferers, including elevated stimuli also appear to have a genetic basis (Shin
heart rate and increased secretion of the neurotrans- et al., 2011).
mitters epinephrine and norepinephrine (Ballenger
et al., 2004; Pole et al., 2007). In people vulnerable to Treatments for PTSD
PTSD, different components of the stress response Psychotherapies for PTSD generally have three
may not be working in sync with one another. The goals: exposing clients to what they fear in order to
hypothalamic-pituitary-adrenal (HPA) axis may be extinguish that fear, challenging distorted cogni-
unable to shut down the response of the sympa- tions that contribute to symptoms, and helping cli-
thetic nervous system by secreting necessary levels ents reduce stress in their lives. These goals are
of cortisol, resulting in overexposure of the brain addressed in cognitive-behavioral therapy for
to epinephrine, norepinephrine, and other neuro- PTSD and in stress-management therapies. Some
chemicals. This overexposure may cause memories clients also benefit from antianxiety and antide-
of the traumatic event to be "overconsolidated," or pressant medications.
planted more firmly in memory (Ballenger et al.,
2004; Walderhaug, Krystal, & Neumeister, 2011). Cognitive-Behavioral Therapy
Increasing evidence suggests that exposure to and Stress Management
extreme or chronic stress during childhood may Cognitive-behavioral therapy has proven effective
permanently alter children's biological stress rein the treatment of PTSD (Chard, Shuster, & Resick,
sponse, making them more vulnerable to PTSD-as 2012). A major element is systematic desensitization
well as to other anxiety disorders and depression- (see Chapter 2). The client identifies thoughts and
throughout their lives (Cicchetti & Toth, 2005; situations that create anxiety, ranking them from
118 Chapter 5 Trauma. Anxiety, Obsessive-Compulsive, and Related Disorders
most anxiety-provoking to least. The therapist takes used to treat symptoms of PTSD, particularly sleep
the client through this hierarchy, using relaxation problems, nightmares, and irritability (Ballenger et
techniques to quell the anxiety. It usually is impos- al., 2004). Although some people with PTSD bene-
sible to return to the actual traumatic event, so fit from these medications, the evidence for their
imagining it vividly must replace actual exposure. effectiveness in treating PTSD is mixed (Institute
A combat veteran being treated for PTSD imagines of Medicine, 2008).
the bloody battles and scenes of killing and death
that haunt him; a rape survivor imagines the min-
ute details of the assault. The therapist also watches SPECIFIC PHOBIAS AND
for unhelpful thinking patterns, such as survivor AGORAPHOBIA
guilt, and helps the client challenge these thoughts.
Repeatedly and vividly imagining and de- People can develop irrational fears of many objects
scribing the feared events in the safety of the thera- and situations. The DSM-5 divides phobias into
pist's office allows the client to habituate to his or specific phobias, which focus on particular objects
her anxiety and distinguish memory from present or animals (e.g., snakes) or places (e.g., heights),
reality (Resick & Calhoun, 2001). It may also allow and agoraphobia, which is a generalized fear of
the client to integrate the events into his or her con- situations in which the person might not be able to
cepts of self and of the world (Chard et al., 2012). escape or get help if needed.
Studies of rape survivors, combat veterans, survi-
vors of traffic collisions, and refugees have found
that this kind of repeated exposure therapy signifi-
Specific Phobias
cantly decreases PTSD symptoms and helps pre- Specific phobias are unreasonable or irrational
vent relapse (Ehlers et al., 2010; Institute of fears of specific objects or situations (LeBeau et al.,
Medicine, 2008; Powers et al., 2010). 2010). The DSM-5 groups specific phobias into five
Some clients with PTSD cannot tolerate expo- categories: animal type, natural environment type,
sure to their traumatic memories. For these clients, situational type, blood-injection-injury type, and
stress-inoculation therapy may be warranted. other (Table 5.3). When people with these phobias
Therapists teach clients skills for overcoming prob- encounter their feared object or situation, their
lems in their lives that increase their stress and anxiety is immediate and intense, sometimes pro-
problems that may result from PTSD, such as mar- ducing a panic attack. They also become anxious
ital problems or social isolation (Keane, Gerardi, over the possibility of encountering the object or
Quinn, & Litz, 1992). Meta-analyses find stress- situation and will go to great lengths to avoid it.
inoculation therapy to be an efficacious form of Most phobias develop during childhood. Adults
treatment for PTSD (Powers et al., 2010). with phobias recognize that their anxieties are un-
reasonable, although children may not. As many as
Biological Therapies 13 percent of people will have a specific phobia at
The selective serotonin reuptake inhibitors (SSRis) some time in their lives, making phobias one of the
and, to a lesser extent, the benzodiazepines are most common mental disorders (Kessler et al., 2005).
Almost 90 percent of those with a specific phobia
never seek treatment (Regier et al., 1993).
Animal-type phobias focus on specific ani-
mals or insects, such as dogs, cats, snakes, or spi-
ders. Snakes and spiders are the most common
objects of animal phobias, probably because it has
been adaptive over evolutionary history to fear
these objects Gacobi et al., 2004). While most peo-
ple who come across a feared animal or insect will
startle and move away quickly, they would not be
diagnosed with a phobia because they do not live
in terror of encountering a snake or spider or orga-
nize their lives around avoiding them.
Natural environment type phobias, which are
also extremely common (LeBeau et al., 2010), focus
Technology can provide a controlled repetitive exposure
to "virtual " trauma to help people. such as this soldier,
on events or situations in the natural environment,
process their actual trauma . such as storms, heights, or water. Mild to moderate
fears of these natural events or situations are
SHADES OF GRAY
Read the following case study. sweating and sometimes screaming . He has to go
into his daughter's bedroom and touch her to con-
Last week, Ramon was turning left at a light when vince himself she is okay. His concentration at
another driver sped through the intersection and work is dim inished because he is ti red from loss of
ran into his car, smash ing the entire passenger sleep and because he keeps going over the acci-
side . Fortunately, Ramon was physically unin- dent, thinking about how he could have p revented
jured, thanks in part to his air bag. He got out of it. Today he was at his desk, replaying the accident
his car screaming at the driver who hit him but again in h is mind, when his boss came by to ask
then saw that he was unconscious and bleeding. him a question. Ramon jumped so badly at the
Ramon immediately called 911, and the ambu - sound of his name that he spilled his coffee all
lance came within a few minutes. over his desk.
Since the accident, Ramon has been having
nightmares in which he is in the accident aga in, Does Ramon meet the criteria for posttraumatic
only this time his 3-year-old daughter is in the stress disorder or acute stress disorder?
backseat and is seriously injured. He wakes up (Discussion appears at the end of this chapter.)
extremely common and are adaptive in that they Situational type phobias usually involve fear
help us avoid dan ger. A diagnosis of p hobia is of public tran sp ortation, tunnels, bridges, eleva-
warranted only when p eople reorganize their lives tors, flying, or d riving. Clau strophobia, or fear of
to avoid the feared situations or have severe enclosed spaces, is a common situational phobia.
anxiety attacks when confronted with them. One p rominent person with a situational ph obia is
TABLE 5.3 DSM-5 Criteria for Specific Phobia
A. Marked fear or anxiety about a specific object or situation (e.g ., flying, heights, animals, receiving an injection, seeing blood).
B. The phobic object or situation almost always provokes immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural
context.
E. The fear, anxiety, or avoidance is persistent, typical ly lasting six months or more.
F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important
areas of functioning.
G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of
situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations
related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder);
separation from home or attachment figures (as in separation anxiety disorder); or socia l situations (as in social anxiety disorder).
Specify if:
Code based on the phobic stimu lus:
300.29 (F40.218) Animal (e.g., spiders, insects, dogs).
300.29 (F40.228) Natural environment (e.g. , heights, storms, water) .
300.29 (F40.23x) Blood-injection-injury (e .g., needles, invasive medical procedures) .
Coding note: Select specific ICD-10-CM code as follows: F40.230 fear of blood; F40.231 fear of injections and transfusions;
F40.232 fear of other medical care; or F40.233 fear of injury.
300.29 (F40.248) Situational (e .g., airplanes, elevators, enclosed places).
300.29 (F40.298) Other (e.g., situations that may lead to choking or vomiting; in children, e.g., loud sounds or costumed characters).
Coding note: When more than one phobic stimulus is present, code all ICD-10-CM codes that app ly (e.g., for fear of snakes and
flying, F40 .218 specific phobia, animal, and F40.248 specific phobia, situational) .
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition . Copyright 2013 American Psychiatric
Associ ation .
are in their early 20s and is more common in ~

women than in men.
People with agoraphobia often reach the point
where they will not leave their homes alone. Some-
times, they are able to venture out with a close fam-
ily member who makes them feel safe. However,
family and friends may not be willing to chaperone
them everywhere they go. When people with agora-
phobia force themselves to enter situations that
frighten them, they experience persistent and in-
tense anxiety, causing many to retreat to their homes.
Some tum to alcohol or another substance to dampen
their anxiety symptoms (Wittchen et al., 2010).
John Madden 's fear of flying leads him to travel to sports events by bus.
Theories of Phobias
The phobias have been a battleground among var-
ious psychological approaches to abnormality.
John Madden, the former coach and sports an- Freud (1909) argued that phobias result when un-
nouncer. Madden is so afraid of flying that he trav- conscious anxiety is displaced onto a neutral or
els over 60,000 miles a year on his personal bus to symbolic object. That is, people become phobic of
get to sports events around the United States. objects or situations not because they have any real
Blood-injection-injury type phobias are diag-
fear of them but because they have displaced their
nosed in people who fear seeing blood or an injury. anxiety over other issues onto them.
Whereas people with another type of specific pho- This theory is detailed in a 150-page case history
bia typically experience increases in heart rate, of a little boy named Hans, who had a phobia of
blood pressure, and other fight-or-flight responses horses after seeing a horse fall on the ground and
when confronted with their feared object or situa-
writhe violently. How did Hans's phobia develop?
tion, people with blood-injection-injury type pho-
According to Freud, young boys have a sexual de-
bia experience significant drops in heart rate and
sire for their mothers and jealously hate their fathers,
blood pressure and are likely to faint. This type of
but they fear that their fathers will castrate them in
phobia runs more strongly in families than do the
retaliation for this desire. As noted in Chapter 2, this
other types (LeBeau et al., 2010).
phenomenon is known as the Oedipus complex. In
Freud's interpretation, little Hans unconsciously
Agoraphobia displaced this anxiety onto horses, which symbol-
The term agoraphobia comes from the Greek for ized his father for him. Freud's evidence came from
"fear of the marketplace." People with agorapho- Hans's answers to a series of leading questions.
bia fear places where they might have trouble es- After long conversations about what Hans was
caping or getting help if they become anxious. "really" afraid of, Hans reportedly became less
This often includes public transportation (being fearful of horses because, according to Freud, he had
on a bus, train, plane, or boat), open spaces (such gained insight into the true source of his anxiety.
as a parking lot), being in shops or theaters, being There is little reason to accept Freud's theory
in crowded places, or being alone anywhere out- of phobias. Hans never provided any spontaneous
side their home. People with agoraphobia also of- or direct evidence that his real problem was Oedipal
ten fear that they will embarrass themselves if concerns rather than fear of horses. In addition,
others notice their symptoms or their efforts to Hans's phobia of horses decreased slowly over
escape during an attack. Actually, other people time, rather than suddenly in response to an in-
can rarely tell when a person is anxious (Craske & sight. Many children have specific fears that sim-
Barlow, 2001). ply fade over time. In general, psychodynamic
About 50 percent of people with agoraphobia therapy is not highly effective for treating phobias,
have a history of panic attacks (described below) suggesting that insight into unconscious anxieties
that preceded the development of the agoraphobia is not what is needed in their treatment.
(Wittchen et al., 2010) . The remaining people with
agoraphobia typically have a history of another Behavioral Theories
anxiety disorder, a somatic symptoms disorder In contrast to the psychodynamic theories, the be-
(see Chapter 6), or depression (Wittchen et al., havioral theories have been very successful in ex-
2010). Agoraphobia most often begins when people plaining phobias. According to Mowrer's (1939)
metal bar loudly just above his head. Naturally,

Little Albert was startled and began to cry. After
several more pairings of the white rat with the loud
noise from the metal bar, Little Albert would have
nothing to do with the rat. When presented with it,
he retreated and showed distress. Little Albert's
fear also generalized to other white furry animals-
he would not approach white rabbits either.
Although by today's standards this experiment
would raise serious ethical questions, it showed the
creation of a phobia through classical conditioning.
__"'_.___
.. ------ - . ~ --- --
Little Albert. shown in this photo. developed a fear of
white rats through classical conditioning.
The unconditioned stimulus (US) was the loud noise
from the banged bar, and the unconditioned re-
sponse (UR) was Little Albert's startle response to
the noise. The conditioned stimulus (CS) was the
white rat, and the conditioned response (CR) was
the startle-and-fear response to the white rat (Fig-
ure 5.3). If Little Albert had later been presented
two-factor theory, classical conditioning leads to the with the white rat several times without the noise,
fear of the phobic object, and operant conditioning his fear of white rats should have been extinguished.
helps maintain it. As discussed in Chapter 2, in clas- Most people who develop a phobia, however,
sical conditioning a previously neutral object (the try to avoid being exposed to their feared object,
conditioned stimulus) is paired with an object that thus avoiding what could extinguish the phobia. If
naturally elicits a reaction (an unconditioned stimu- they are suddenly confronted with their feared ob-
lus that elicits an unconditioned response) until the ject, they experience extreme anxiety and run away
previously neutral object elicits the same reaction as quickly as possible. Running away reduces their
(now called the conditioned response). When a tone anxiety; thus, their avoidance of the feared object
is paired with an electric shock, the conditioned is reinforced by the reduction of their anxiety- an
stimulus is the tone, the unconditioned stimulus is operant conditioning process known as negative
the electric shock, the unconditioned response is reinforcement (Mowrer, 1939). Thereafter, they
anxiety in response to the shock, and the condi- avoid the feared object.
tioned response is anxiety in response to the tone. Some theorists argue that phobias can develop
The first application of these theories to pho- through observational learning as well as through
bias came in a series of studies done 90 years ago by direct classical conditioning (see Mineka & Zinbarg,
John Watson and Rosalie Raynor (1920). Watson 2006). For example, small children may learn to
and Raynor placed a white rat in front of an fear snakes if their parents show severe fright
11-month-old boy named Little Albert. As Little when they see a snake (Bandura, 1969; Mineka,
Albert reached for the white rat, they banged a Davidson, Cook, & Keir, 1984).
FIGURE 5.3
~
1. Unconditioned stimulus (US) Unconditioned response (UR)
Banged bar naturally leads to
Startle
2. Unconditioned stimulus (US) Conditioned stimulus (CS)

paired with
Banged bar White rat
3. Conditioned stimulus (CS)

White rat
then leads to
Conditioned response (CR)
Startle
[m
An extension of the behavioral theory of pho- makes them more susceptible to the development
bias may answer the question of why humans de- of phobias given even mildly aversive experiences
velop phobias of some objects or situations and not (Craske & Waters, 2005).
others (deSilva, Rachman, & Seligman, 1977;
Mineka, 1985; Seligman, 1970). Phobias of spiders, Biological Theories
snakes, and heights are common, but phobias of The first-degree relatives (that is, parents, children,
flowers are not. Many phobic objects appear to be and siblings) of people with phobias are three to
things whose avoidance, over evolutionary history, four times more likely to have a phobia than the
has been advantageous for humans. Our distant first-degree relatives of people without phobias.
ancestors had many nasty encounters with insects, Twin studies suggest that this is due, at least in
snakes, heights, loud noises, and strangers. Those part, to genetics (Hettema, Neale, & Kendler, 2001;
who quickly learned to fear and avoid these objects Merikangas, Lieb, Wittchen, & Avenevoli, 2003).
or events were more likely to survive and bear off- Some studies suggest that situational and animal
spring. Thus, evolution may have selected for the phobias are associated with similar genes, while
rapid conditioning of fear to certain objects or situ- other studies suggest a general tendency toward
ations. Although these are less likely to cause us phobias that is not isolated to one type of phobia
harm today, we carry the vestiges of our evolution- (LeBeau et al., 2010).
ary history and are biologically prepared to learn
certain associations quickly. This theory is known Treatments for Phobias
as prepared classical conditioning (Seligman,
1970). Many objects more likely to cause us harm in A number of behavioral techniques can treat pho-
today's world (such as guns and knives) have not bias. Some therapists include cognitive techniques
been around long enough, evolutionarily speaking, and medications.
to be selected for rapid conditioning, so phobias of
them should be relatively difficult to create. Behavioral Treatments
To test this idea, researchers presented subjects Behavioral therapies for phobias use exposure to
with pictures of objects that theoretically should be extinguish the person's fear of the object or situa-
evolutionarily selected for conditioning (snakes tion. These therapies cure the majority of phobias
and spiders) and objects that should not be so se- (Hopko, Robertson, Widman, & Lejuez, 2008).
lected (houses, faces, and flowers). They paired the Some studies suggest that just one session of be-
presentation of these pictures with short but pain- havior therapy can lead to major reductions in
ful electric shocks. The subjects developed anxiety phobic behaviors and anxiety (Davis, Ollendick, &
reactions to the pictures of snakes and spiders Ost, 2009). Three basic components of behavior
within one or two pairings with shock, but it took therapy for phobias are systematic desensitization,
four or five pairings of the pictures of houses, modeling, and flooding.
faces, or flowers with shock to create a fear reac- As we have already discussed, in systematic
tion. Extinguishing the subjects' anxiety reactions desensitization clients formulate lists of situations
to houses or faces was relatively easy once the pic- or objects they fear, ranked from most to least
tures were no longer paired with shock, but the feared. They learn relaxation techniques and begin
anxiety reactions to spiders and snakes were diffi- to expose themselves to the items on their "hierar-
cult to extinguish (Hugdahl & Ohman, 1977; chy of fears," beginning with the least feared. A
Ohman, Fredrikson, Hugdahl, & Rimmo, 1976; person with a severe dog phobia who has "seeing
Ohman & Mineka, 2001). a picture of a dog in a magazine" first on her list
The behavioral theory seems to provide a com- might look at a picture of a dog. The therapist will
pelling explanation for phobias, particularly when coach her to use relaxation techniques to replace
we add the principles of observational learning her anxiety with a calm reaction. When she can
and prepared classical conditioning. It has also led look at a picture of a dog without experiencing
to effective therapies. Its most significant problem anxiety, she might move on to looking at a dog in a
is that many people with phobias can identify no pet store window, again using relaxation tech-
traumatic event in their own lives or the lives of niques to lower her anxiety reaction and replace it
people they are close to that triggered their pho- with calm. Gradually, the client and therapist will
bias. Without conditioned stimuli, it is hard to ar- move through the entire list, until the client is able
gue that they developed their phobias through to pet a big dog without feeling overwhelming
classical conditioning or observational learning. anxiety.
Some individuals who develop phobias may have Blood-injection-injury phobia requires a dif-
a chronic low-level anxiety or reactivity, which ferent approach, because people with this phobia
The therapist first models handling a

snake for this woman with a snake
phobia .Then gradually the woma n is
able to handle it herself.
experience severe decreases in heart rate and night in a dog kennel. The therapist typically will
blood pressure (Ost & Sterner, 1987). Thus, thera- prepare clients with relaxation techniques they can
pists teach them to tense the muscles in their use to reduce their fear. Flooding is as effective as
arms, legs, and chest until they feel the warmth of systematic desensitization or modeling and often
their blood rising in their faces . This applied ten- works more quickly. However, it is more difficult
sion technique increases blood pressure and to get clients to agree to this type of therapy, be-
heart rate and can keep people with this type of cause it is frightening to contemplate (Thorpe &
phobia from fainting when confronted with the Olson, 1997).
feared object. Then systematic desensitization can
help extinguish fear of blood, injury, or injections. Biological Treatments
Modeling techniques are often adopted in Some people use the benzodiazepines to reduce
conjunction with systematic desensitization. A their anxiety when forced to confront their phobic
therapist treating a person with a snake phobia objects; for example, they use Valium before flying
may perform (model) each behavior on the client's or giving a presentation. These drugs produce
hierarchy of fears before asking the client to per- temporary relief, but the phobia remains Gefferson,
form it. The therapist will stand in the room with 2001). In contrast, behavioral techniques can cure
the snake before asking the client to do so, touch most phobias in a few hours (Davis et al., 2009).
the snake before asking the client to do so, and For now, it appears that the age-old advice to
hold the snake before the client does. Through "confront your fears" through behavior therapy is
observational learning, the client associates these the best strategy.
behaviors with a calm response in the therapist,
which reduces anxiety about engaging in the be-
haviors. Modeling is as effective as systematic de-
SOCIAL ANXIETY DISORDER
sensitization in reducing phobias (Bandura, 1969; Most of us don't like to be embarrassed in front of
Thorpe & Olson, 1997). others or rejected by other people. One of the most
Flooding intensively exposes a client to his or common social fears is public speaking (see
her feared object until anxiety is extinguished. In a Table 5.4). Nearly half of college students identify
flooding treatment, a person with claustrophobia themselves as "shy" and say they get nervous
might lock himself in a closet for several hours, meeting new people or encountering unfamiliar
and a person with a dog phobia might spend the social situations (Heiser, Turner, & Beidel, 2003).
TABLE 5.4 Lifetime Prevalence of Social grocery store for fear that he would run his cart
Fears in a National Survey into someone or say something stupid to a clerk.
He found a grocery store and several restaurants
Social Fear Percent of People that took orders online for food to be delivered to
Saying They customers' homes. He liked this service because
Experienced
he could avoid even ta lking to someone over the
the Fear in
phone to place an order.
Their Lifetime
In the past, Malcolm's job had allowed him
Public speaking 30.2% to remain quietly in his office all day, without in-
Talking in front of a small group 15.2 teracting with other people. Recently, however,
Talking with others 13.7 his company was reorganized and took on a
number of new projects. Malcolm's supervisor
Using a toilet away from home 6.6
said that everyone in Malcolm's group needed to
Writing while someone watches 6.4
begin working together more closely to develop
Eating or drinking in public 2.7
new products. Malcolm was supposed to make a
Any social fear 38.6 presentation to his group about some software
he was developing, but he called in sick the day
Source: Kessler, Stei n, & Berglund , 1998, p. 614.
of the presentation because he could not face the
situation. Malcolm was thinking that he had to
change jobs and perhaps go into private consult-
ing, so he could work from his home and avoid
having to work with anyone else.
People with social anxiety disorder become so
anxious in social situations and are so afraid of
being rejected, judged, or humiliated in public that
they are preoccupied with worries about such
events to the point that their lives may become
focused on avoiding social encounters (see the In social situations, people with social anxi-
DSM-5 criteria in Table 5.5). Social anxiety disor- ety disorder may tremble and perspire, feel con-
der is more likely than a specific phobia to create fused and dizzy, have heart palpitations, and
severe disruption in a person's daily life (Bagels et eventually have a full panic attack. Like Malcolm
al., 2010). In most cultures, it is easier to avoid in the Case Study, they think others see their ner-
snakes or spiders than it is to avoid social situa- vousness and judge them as inarticulate, weak,
tions. Consider the inner pain Malcolm, in the case stupid, or crazy. Malcolm avoided speaking in
study, experiences and the way he has organized public and having conversations with others for
his life to avoid social situations. f~ar of being judged. People with social anxiety
d1sorder may avoid eating or drinking in public,
for fear that they will make noises when they eat,
drop food, or otherwise embarrass themselves.
They may avoid writing in public, afraid that
CASE STUDY others will see their hands tremble. Men with so-
Malcolm was a computer
expert who worked for a large software firm . One
cial anxiety disorder often avoid urinating in
public bathrooms.
of the things he hated most was to ride the eleva-
tor at his office when there were other people
Social anxiety disorder is relatively common,
riding it. He felt that everyone was watching him,
with a lifetime prevalence of about 12 percent in
commenting silently on his rumpled clothes, and
the United States (Kessler et al., 2005) and 3 to 7 per-
noticing every time he moved. He held his breath
cent internationally (Alonso et al., 2004; Wittchen
& Fehm, 2003). Women are somewhat more likely
for almost the entire elevator ride, afraid that he
than men to develop this disorder (Lang & Stein,
might say something or make an embarrassing
2001). One study found that women with social
sound. Often, he walked up the eight flights of
anxiety disorder have more severe social fears
sta irs to his office rather than risk that someone
might get on the elevator with him.
than men, particularly with regard to performance
situations (such as giving a presentation) (Turk,
Malcolm rarely went anywhere except to
Heimberg, & Hope, 2001).
work and home. He hated even to go to the
Social anxiety disorder tends to develop in
either the early preschool years or adolescence,
Spec ific Phobias and Ago raphobia 125
TABLE 5.5 DSM-5 Criteria for Social Anxiety Disorder
A. Marked fear or anx iety about one or more socia l situati o ns in wh ich the individ ual is ex posed to poss ib le
scrutiny by others . Examples include social interactions (e .g., havi ng a co nversation , m eet ing u nfam i liar
people). being observed (e.g., eating or drinking). and performing in f ro nt of othe rs (e. g., giv in g a
speech).
B. The individual fears that he or she w ill act in a way or show anxiety sym ptom s th at will be negatively
evaluated (i .e., will be hum iliating or embarrassing; w ill lead to rejection o r offend oth ers).
C. The social situations almost always provoke fear or anxiety.
D. The social situations are avoided or endured w ith intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the socia l sit uation and to t he
sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 m onths or mo re.
G. The fea r, anxiety, or avoidance causes cl inically significant distress or impairm ent in social , occupationa l, o r
othe r important areas of functioning .
H. The fear, anx iety, or avoidance is not attributa ble to the physiol ogi cal effects of a substance (e.g., a drug of
abuse, a medication) or another medica l condition .
I. The fear, anx iety, or avoidance is not better explained by t he sympto m s of anot her m ental disorde r, such as
pa nic d isorder, body dysmorphic diso rder, o r autism spectrum disorder.
J. If another medica l co ndition (e.g., Parkinson' s disease, o besity, disfigu rem ent f rom burns or injury) is
present, the fear, anxiety, or avoidance is clearly unrelated or is excessiv e.
Specify if:
~ Perform ance only: If the fear is restricted to speaking or pe rform ing in publ ic.
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright 201 3
American Psychiatric Association.
when many people become self-conscious and this disorder may fear blushing, emitting body
concerned about others' opinions of them odor, displaying unsightly body parts, speaking
(Bogels et al., 2010; Deardorff et al., 2007) . Over their thoughts aloud, or irritating others (see
90 percent of adults w ith social anxiety disorder Lewis-Fernandez et al., 2010) . This concern is in
report humiliating experiences that contributed line w ith the emphasis in Japan on deference to
to their symptoms, such as extreme teasing as a others (Kirmayer, 2001).
child (McCabe et al., 2003). Others report feeling
uncomfortable in social situations all their lives.
Social anxiety disorder often co-occurs w ith Theories of Social
mood disorders and other anxiety disorders
(Neal & Edelmann, 2003; Wittchen & Fehm,
Anxiety Disorder
2003). Once it develops, social anxiety disorder Social anxiety, or more generally
tends to be chronic if left untreated (Bogels et shyness, runs in families, and
al., 2010). Most people do not seek treatment tw in studies suggest it has a
(Kessler, 2003) . genetic basis (Bogels et al., 2010) .
In Japan, the term taijinkyofu-sho describes an Genetic factors do not appear to
intense fear of interpersonal relations. Taijinkyofu- lead specifically to anxiety about
sho is characterized by shame about and persistent social situations, how ever, but Prime Minister Naoto Kan apologized
fear of causing others offense, embarrassment, or rather to a more general tendency to the Japanese people for his
government's poor handling of the
even harm through one's personal inadequacies. tow ard the anxiety disorders
nuclear disaster in 2011 at the
It is most frequently encountered, at least in treat- (e.g., Hettema, Prescott, Myers, & Fukashima I Nuclear Power Plant.
ment settings, among young men . People w ith Neal, 2005).
Cognitive perspectives on social anxiety working up to the more anxiety-producing situa-

disorder have dominated psychological theories tions. Therapists may role-play situations with cli-
(Heimberg, Brozovich, & Rapee, 2010; Morrison ents (e.g., having a conversation with a store clerk),
& Heimberg, 2013). According to these per- accompany clients in social situations to coach
spectives, people with social anxiety disorder them as they engage in social encounters, and as-
have excessively high standards for their social sign clients homework to carry out "experiments"
performance-for example, they believe they in which they attempt a social interaction they be-
should be liked by everyone. They also focus on lieve they can't tolerate. They may teach them re-
negative aspects of social interactions and evalu- laxation techniques to quell their anxiety in these
ate their own behavior harshly. They tend to no- situations or skills that can help them interact more
tice potentially threatening social cues (such as a effectively with others, for example, in starting
grimace on the face of the person they are speak- conversations. They also help them recognize and
ing to) and to misinterpret them in self-defeating eliminate their safety behaviors (e.g., avoiding eye
ways (Heinrichs & Hofman, 2001). They are ex- contact). The cognitive component of therapy in-
quisitely attuned to their self-presentation and volves identifying negative cognitions clients have
their internal feelings and tend to assume that, if about themselves and about social situations and
they feel anxious, it is because the social interac- teaching them how to dispute these cognitions.
tion is not going well (Clark & Wells, 1995). They CBT for social anxiety can be administered in a
engage in a number of "safety behaviors" to re- group setting in which group members form an
duce their anxiety. They may avoid eye contact, audience for one another, providing exposure to
or social interactions altogether; excessively re- the very situation each member fears. Individuals
hearse what they will say in an interaction; and can practice their feared behaviors in front of the
fail to self-disclose, thereby reducing the quality others while the therapist coaches them in the use
of the social interaction and the impression they of relaxation techniques to calm their anxiety. The
actually leave with others (Morrison & Heimberg, group can also help the individual challenge any
2013). After a social interaction, they ruminate ex- negative, catastrophizing thoughts about his or
cessively about their performance and the other her behavior, as in the following excerpt from a
person's reactions. group cognitive therapy session with Gina.
What creates these behavioral habits and cog-
nitive biases? Adults with social anxiety disorder
often describe their parents as having been over-
protective and controlling but also critical and
negative (Bogels et al., 2010; Craske & Waters, PROFILES
2005). Such retrospective accounts could be incor-
rect. To date, prospective studies of the family en-
Therapist: So your automatic thought is, "I
vironments of people who develop social anxiety
don't know how to have a conversation," is
disorder are lacking.
that right?
Gina: Yeah, I always screw it up.
Treatments for Social Anxiety Therapist: All right, let's ask the rest of the
Disorder group what they think about that Who has
had a conversation with Gina or noticed her
The selective serotonin reuptake inhibitors (SSRls) talking with someone else?
and serotonin-norepinephrine reuptake inhibitors
Ed: We walked out to our cars together last
(SNRls) have been shown to be efficacious in
week and talked in the parking lot for a while.
reducing symptoms of social anxiety (see meta-
[Several other group members mention simi-
analysis by de Menezes et al., 2011). Symptoms
lar conversations.]
tend to return when individuals stop taking these
medications, however. Therapist: So it sounds like you have had a
Cognitive-behavioral therapy (CBT) seems number of conversations with the rest of the
particularly useful for treating social anxiety group.
(Morrison & Heimberg, 2013; Rodebaugh, Gina: I guess so.
Holaway, & Heimberg, 2004). The behavioral com-
Therapist: Group, how did she do? How did
ponent of this therapy involves exposing clients to
the conversations go?
social situations that make them anxious, starting
with the least anxiety-producing situations and
Panic Disorder 127
Celia is suffering from panic attacks, short but in-

Sally:It was fine. She was asking me about my tense periods during which she experiences many
car, because she has been looking for a new symp~oms of anxiety: heart palpitations, trembling,
one, so we talked mostly about that. [Other a feelmg of choking, dizziness, intense dread, and
group members provide similar answers.] so on (Table 5.6). Celia's panic attacks appear to
Therapist: Well, Gina, the rest of the group come "out of the blue," in the absence of any envi-
doesn't seem to agree that you don't know ronmental trigger. Simply handing a customer a
how to have conversations. hamburger should not cause such terror. This is one
of the baffling characteristics of some panic attacks.
Gina: I guess I've always been so nervous that
Other people have panic attacks triggered by
I never stopped to think that sometimes the
specific situations or events. Someone with a so-
conversations go OK.
cial anxiety disorder, for instance, may have a
(Adapted from Turk et al., 2001, pp. 124-125) panic attack when forced into a social situation
(Craske et al., 2010). Most commonly, panic at-
tacks arise in certain situations but not every time.
In all cases, however, they are terrifying experi-
ences, causing a person intense fear or discomfort,
A number of meta-analyses have found that CBT
the physiological symptoms of anxiety, and the
is an effective treatment for social anxiety disorder, is
feeling of losing control, going crazy, or dying.
just as effective as antidepressants in reducing symp-
As many as 28 percent of adults have occa-
toms over the course of therapy, and is much more
sional panic attacks, especially during times of
effective in preventing relapse following therapy (see
stress (Kessler, Chiu, et al., 2006). For most, the at-
Rodebaugh et al., 2004; Heimberg & Morrison, 2013).
tacks are annoying but isolated events that do not
CBT is equally effective whether administered indi-
change how they live their lives. However, when
vidually or in a group (Rodebaugh et al., 2004).
they become a common occurrence, when they are
Mindfulness-based interventions also can
not usually provoked by any particular situation
prove helpful for people with social anxiety disor-
but are unexpected, and when a person begins to
der (Goldin & Gross, 2010). These interventions
worry about having them and changes behaviors
teach individuals to be less judgmental about their
as a result of this worry, a diagnosis of panic disor-
own thoughts and reactions and more focused on,
der may be made.
and relaxed in, the present moment.
. Some. people with panic disorder have many
episodes m a short period of time, such as every
PANIC DISORDER day for a week, and then go weeks or months
without any episodes, followed by another period
of frequent attacks. Other people have attacks less
CASE STUDY frequently but more regularly, such as once every
The first time Celia had a
w~ek for mo~ths. Between full-blown attacks, they
panic attack, two days before her twentieth birth-
might expenence minor bouts of panic.
day, she was working at McDonald's. As she was
Peo~le with panic disorder often fear that they
handing a customer a Big Mac, the earth seemed
~ave a life-threatening illness, and they are more
to open up beneath her. Her heart began to
likely .to ~ave a personal or family history of serious
pound, she felt she was suffocating, she broke
chrome illness. Even after such an illness is ruled
into a sweat, and she was sure she was going to
o~t, they may continue to believe they are about to
have a heart attack and die. After about 20 min-
die of a heart attack, seizure, or other physical crisis.
utes of terror, the panic subsided. Trembling, she
Another common but erroneous belief is that they
got in her car, raced home, and barely left the
are "going crazy" or "losing control." Many people
house for the next 3 months.
with panic disorder feel ashamed and try to hide it
Since that time, Celia has had about three
from others. If left untreated, people with panic dis-
attacks a month . She does not know when they
order may become demoralized and depressed
are coming. During them she feels dread, sear-
(Craske & Waters, 2005).
ing chest pain, suffocating and choking, dizzi-
~bo.ut 3 to 5 percent of people will develop
ness, and shakiness. She sometimes thinks this
paruc disorder at some time (Craske & Waters,
is all not real and she is going crazy. She also
2005; Kessler et al., 2005), usually between late ad-
thinks she is going to die. (Adapted from
olescence and the mid-thirties. It is more common
Seligman, 1993, p. 61) in women and tends to be chronic (Craske &
Waters, 2005).
128 Chapter 5 Trauma. Anxiety. Obsessive-Compulsive, and Related Disorders
TABLE 5.6 DSM-5 Diagnostic Criteria for Panic Disorder
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak
within mi nutes, and during which time four (or more} of the following symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.

2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering .
5. Feelings of choking .
6. Chest pain or discomfort.
7. Nausea o r abdomina l distress.
8. Feel ing dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations}.
11 . De real izat ion (feelings of unrea lity} or depersonalization (being detached from oneself} .
12. Fear of losing control or "going crazy."
13. Fear of dying .
Note: Culture-specific symptoms (e.g., tinn itus, neck soreness, headache, uncontrollable screaming or crying} may be see n. Such
symptoms should not count as one of the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more} of one or both of the fo llowing:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack,
" going crazy"}.
2. A significa nt maladaptive change in behavior related to the attacks (e.g. , behaviors desig ned to avoid having panic attacks,
such as avoidance of exercise or unfam il iar situations}.
C. The distu rbance is not attributable to the physiological effects of a substance (e .g., a drug of abuse, a medication} or another
medical condition (e.g., hyperthyroid ism , cardiopulmonary disorders}.
D. The d isturbance is not better explained by anothe r menta l disorder (e .g., the panic attacks do not occur only in response to feared
social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in
response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic
stress disorder; or in resp onse to separation from attachme nt figures, as in separation anxiety disorder}.
Source : Rep rinted with permission from the Diagnostic and Statistical Manual of Menta l Disorders, Fifth Edition. Copyright 2013 American Psychiatric Association .
Panic disorder can be debilitating. Many suf- disorder is about 43 to 48 percent (Wittchen et al.,
ferers also show chronic generalized anxiety, de- 2010). No specific genes have been consistently
pression, and alcohol abuse (Wilson & Hayward, identified as causing panic disorder.
2005). Those with panic disorder who are depressed The fight-or-flight response appears to be
or who abuse alcohol may be at an increased risk poorly regulated in people who develop panic
for suicide attempts (Craske et al., 2010). disorder, perhaps due to poor regulation of sev-
eral neurotransmitters, including norepinephrine,
serotonin, gamma-aminobutyric acid (GABA),
Theories of Panic Disorder and cholecystokinin (CCK; Charney et al., 2000).
Biological and psychological factors interact to cre- Panic attacks can easily be triggered in sufferers of
ate vulnerability to panic disorder (see Figure 5.4) . panic disorder if they hyperventilate, inhale a ~
small amount of carbon dioxide, ingest caffeine,
Biological Factors breathe into a paper bag, or take infusions of so-
Panic disorder clearly runs in families (Hettema, dium lactate, a substance that resembles the lac-
Neale, & Kendler, 2001), and family history and tate produced during exercise (Craske & Barlow,
twin studies suggest that the heritability of panic 2001; Wittchen et al., 2010) . These activities initiate
Panic Disorder 129
Areas of the Brain An Integrated Model of Panic Disorder.

FIGURE 5.4 Biological and psychological factors come
Involved in Panic Disorder.
Several areas of the limbic together to create panic disorder and
system shown here, along with the locus agoraphobia.
ceruleus, may be involved in panic attacks.
Genetic vulnerability Vulnerability to dysregulation of the
to panic or to chronic, neurotransmitters norepinephrine,
diffuse anxiety - - - - - serotonin, GABA, and CCK in the locus
ceruleus and limbic systems creates
panic or chronic diffuse anxiety.
L Cognitive vulnerability:
Person is hyperattentive to
bodily sensations, misinterprets
and catastrophizes these
_j
sensations.
Hypothalamus
Hippocampus
Person associates
Periaqueductal Person has anticipatory anxiety certain situations with
over the possibility of future panic attacks and
gray
panic attacks, and anxiety --+ begins to avoid those
about anxiety. and similar situations.
Locus ceruleus
Panic disorder
the physiological changes of the fight-or-flight re-

sponse. People without a history of panic attacks
may experience some physical discomfort during
these activities, but rarely a full-blown attack.
Neuroimaging studies show differences be- susceptibility. Increases in progesterone also can
tween people with panic disorder and those with- induce mild chronic hyperventilation. In women
out panic disorder in several areas of the limbic prone to panic attacks, this may be enough to
system involved in the stress response, including induce a full-blown attack.
the amygdala, hypothalamus, and hippocampus
(Roy-Byrne, Craske, & Stein, 2006). People with Cognitive Factors
the disorder also show dysregulation of norepi- Although many people with panic disorder may
nephrine systems in an area of the brain stem have a biological vulnerability to it, psychological
called the locus ceruleus (see Figure 5.5). The locus factors also appear to help determine who develops
ceruleus has well-defined pathways to the limbic the disorder. Cognitive theorists argue that people
system. Poor regulation in the locus ceruleus may prone to panic attacks tend to (1) pay very close at-
cause panic attacks, which then stimulate the lim- tention to their bodily sensations, (2) misinterpret
bic system, lowering the threshold for the activa- these sensations in a negative way, and (3) engage
tion of diffuse and chronic anxiety (Gorman, in snowballing catastrophic thinking, exaggerating
Papp, & Coplan, 1995). This anticipatory anxiety symptoms and their consequences (Barlow, 2011;
may, in turn, increase the likelihood of dysregula- Clark & Beck, 2010). A person prone to panic disor-
tion of the locus ceruleus and thus of another der who feels a bit dizzy after standing up too
panic attack. quickly might think, "I'm really dizzy. I think I'm
Some women with panic disorder report in- going to faint. Maybe I'm having a seizure. Oh God,
creased anxiety symptoms during premenstrual what's happening?" This kind of thinking increases
periods and postpartum (Brawman-Mintzer & the subjective sense of anxiety as well as physiolog-
Yonkers, 2001). The hormone progesterone can af- ical changes such as increased heart rate. The per-
fect the activity of both the serotonin and GABA son interprets these feelings catastrophically and is
neurotransmitter systems. Fluctuations in proges- on the way to a full panic attack. Between attacks,
terone levels with the menstrual cycle or postpar- the person is hypervigilant for any bodily sensa-
tum might lead to an imbalance or dysfunction of tions, worrying about his or her health generally
the serotonin or GABA systems, thereby influencing and about having more panic attacks specifically.
130 Chapter 5 Trauma. Anxiety. Obsessive-Compulsive. and Related Disorders
This constant arousal makes further attacks more about their physiological symptoms. Such cog-
likely (Barlow, 2011; Clark & Beck, 2010). nitions increase the intensity of initially mild
The unfounded belief that bodily symptoms physiological symptoms to the point of a panic
have harmful consequences is labeled anxiety attack. They also make the individuals hyper-
sensitivity (McNally, 1999). People high in anxi- vigilant for signs of another panic attack, put-
ety sensitivity are more likely than people low in ting them at a constant mild to moderate level of
it to already have panic disorder, to have more anxiety. This anxiety increases the probability
frequent panic attacks, or to develop panic at- that they will become panicked again, and the
tacks over time (Hayward, Killen, Kraemer, & cycle continues.
Taylor, 2000). Some people then begin to associate certain
Those prone to panic attacks also appear to situations with symptoms of panic and may begin
have increased interoceptive awareness-a height- to feel them again if they return to the situations.
ened awareness of bodily cues (such as slight sen- By avoiding these places, they reduce their symp-
sations of arousal or anxiety) that may signal a toms, thereby reinforcing their avoidance behav-
coming panic attack (Razran, 1961). These bodily ior. This process is known as a conditioned
cues have occurred at the beginning of previous avoidance response (Mowrer, 1939). Thus, a man
panic attacks and have become conditioned stim- who has a panic attack while sitting in a theater
uli signaling new attacks, a process called intero- may later associate the theater with his symptoms
ceptive conditioning (Bouton, Mineka, & Barlow, and begin to feel anxious whenever he is near it.
2001). Thus, slight increases in anxiety, even if not By avoiding it, he can reduce his anxiety. He may
consciously recognized, can elicit conditioned fear associate other places, such as his home or a spe-
that grows into a full panic attack. If the individual cific room, with lowered anxiety levels, so being
doesn't recognize this process, the attack seems to in these places is reinforcing. Eventually, he con-
come from nowhere. fines himself to his safe places and avoids a wide
Beliefs about the controllability of symptoms range of places he feels are unsafe. Thus develops
appear to be important to the development of agoraphobia.
panic attacks. In one study, two groups of people
with panic disorder were asked to wear breath- Treatments for Panic Disorder
ing masks, which delivered air slightly enriched
with carbon dioxide. Participants were warned Both biological and psychological treatments for
that inhaling carbon dioxide could induce an panic disorder have been developed. Certain anti-
attack. One group was told they could not control depressant drugs effectively treat panic attacks
the amount of carbon dioxide that came through and agoraphobia, and the benzodiazepines can
their masks. The other group was told they could help some people. Cognitive-behavioral therapies
control it by turning a knob. Actually, neither appear to be as successful as medications in reduc-
group had any control over the amount of carbon ing symptoms and better than medications at pre-
dioxide, and both groups inhaled the same venting relapse.
amount. However, 80 percent of the people who
believed they had no control experienced a panic Biological Treatments
attack, compared to 20 percent of those who be- The most common biological treatment for panic
lieved they had control (Sanderson, Rapee, & disorder is medication affecting serotonin and
Barlow, 1989). norepinephrine systems, including selective sero-
tonin reuptake inhibitors (SSRis, such as Paxil,
An Integrated Model Prozac, Zoloft), serotonin-norepinephrine reup-
The biological and cognitive theories of panic dis- take inhibitors (SNRis, such as Effexor), and tri-
order have been integrated into the model illus- cyclic antidepressants (Batelaan, Van Balkom &
trated in Figure 5.5 (Bouton et al., 2001; Craske & Stein, 2012; see Chapter 2 for common side effects
Waters, 2005). Many people who develop panic of these drugs). The benzodiazepines, which sup-
disorder seem to have a biological vulnerability to press the central nervous system and influence
a hypersensitive fight-or-flight response. Pre- functioning in the GABA, norepinephrine, and
sented with only a mild stimulus, their heart be- serotonin neurotransmitter systems, work quickly
gins to race, their breathing becomes rapid, and to reduce panic attacks and general symptoms of
their palms begin to sweat. anxiety in most patients (Culpepper, 2004). Un-
These people typically will not develop fre- fortunately, they are physically (and psychologi-
quent panic attacks or a panic disorder, however, cally) addictive and have significant withdrawal
unless they engage in catastrophizing thinking symptoms (see Chapter 2). Most people with
Panic Disorder 131
panic disorder will experience a relapse of symp- A Panic Thoughts Diary. This man recorded
toms when drug therapies are discontinued if the thoughts he had had during panic attacks
they have not also received cognitive-behavioral FIGURE 5.6
and then worked on these thoughts in cognitive
therapy (Batelaan et al., 2012). therapy.
Cognitive-Behavioral Therapy
As in treatment for PTSD and phobias, cognitive-
behavioral therapy for panic disorder has clients
confront the situations or thoughts that arouse Dia.i.Nss (11-\iU) here. Peuple vvill see /rl.e
anxiety. Confrontation seems to help in two ways:
It allows clients to challenge and change irrational
thoughts about these situations, and it helps them
extinguish anxious behaviors.
Cognitive-behavioral interventions have mul-
tiple components (Barlow, 2011; Clark & Beck,
2010). First, clients are taught relaxation and
breathing exercises, which impart some control (severe )
over symptoms and permit clients to engage in the
other components of the therapy. Second, the clini-
(severe )
cian guides clients in identifying the catastrophiz- H~rt rr;rc0rf (severe )
ing cognitions they have about changes in bodily Dia.i.Nss (severe )
sensations. Clients may keep diaries of their
thoughts about their bodies on days between ses-
sions, particularly at times when they begin to feel
they are going to panic. Figure 5.6 shows one
man's panic thoughts diary. He noted mild symp-
toms of panic at work but more severe symptoms
while riding the subway home. In both situations,
he had thoughts about feeling trapped, suffocat-
ing, and fainting.
Many clients, too overwhelmed while having
symptoms to pay attention to their thoughts, need
to experience panic symptoms in the presence of themselves, using the cognitive techniques de-
their therapist in order to identify their catastroph- scribed in Chapter 2. The therapist might help
izing cognitions (Barlow, 2011). The therapist may clients reinterpret the sensations accurately. For
try to induce symptoms during sessions by having example, the client whose thoughts are listed in
clients exercise to elevate their heart rate, spin to Figure 5.6 frequently felt as if he were choking. His
get dizzy, or put their head between their knees therapist might explore whether his choking sen-
and then stand up quickly to get light-headed (due sation might be due to the stuffiness of a small
to sudden changes in blood pressure). None of office or a subway on a warm summer day. If he
these activities is dangerous, but all are likely to interprets the increase in his heart rate as a heart
produce the kind of symptoms clients catastroph- attack, the therapist might have him collect evi-
ize. As clients experience these symptoms and dence from his physician that he is in perfect
their catastrophizing cognitions, the therapist cardiac health. The therapist might also explore
helps them collect their thoughts. the client's expectations that he will die of a heart
Third, clients practice relaxation and breathing attack because a relative did. If relaxation tech-
exercises while experiencing panic symptoms dur- niques allow a client to reduce panic symptoms
ing the session. If attacks occur during sessions, during a therapy session, the therapist will chal-
the therapist talks clients through them, coaching lenge the client's belief that the symptoms are un-
them in the use of relaxation and breathing tech- controllable (Barlow, 2011).
niques, suggesting ways to improve their skills, Fifth, the therapist uses systematic desensiti-
and noting clients' success in using the skills to zation therapy to expose clients gradually to the
stop the attacks. situations they fear most while helping them
Fourth, the therapist challenges clients' cata- maintain control over their symptoms (Barlow,
strophizing thoughts about their bodily sensations 2011). The client and therapist begin by listing
and teaches them to challenge these thoughts panic-inducing situations, from most to least
132 Chapter 5 Trauma , Anxiety, Obsessive-Compulsive, and Related Disorders
threatening. Then, after learning relaxation and receiving CBT, nearly 90 percent were panic-free ~
breathing skills and perhaps gaining some 2 years after treatment. Cognitive-behavioral ther-
control over panic symptoms induced during apy appears to be considerably better than antide-
therapy sessions, clients begin to expose them- pressants at preventing relapse after treatment
selves to their panic-inducing situations, starting ends (Barlow, 2011), probably because this therapy
with the least threatening. The therapist might teaches people strategies to prevent the recurrence
accompany clients in this exercise, coaching of panic symptoms.
them in their relaxation and breathing skills
and in how to challenge catastrophic cognitions
that arise. GENERALIZED ANXIETY
A large-scale, multisite study compared tricyclic
antidepressants to cognitive-behavioral therapy
DISORDER
(CBT) in the treatment of 312 people with panic PTSD, the phobias, social anxiety disorder, and
disorder and found them equally effective in elim- panic disorder involve periods of anxiety that are
inating symptoms (Barlow, Gorman, Shear, & acute and more or less specific to certain objects,
Woods, 2000). Several other studies have found thoughts, or situations. Some people are anxious
that 85 to 90 percent of panic disorder patients all the time, however, in almost all situations.
treated with CBT experienced complete relief from These people may be diagnosed with generalized
their panic attacks within 12 weeks (Barlow, 2011; anxiety disorder (GAD; Table 5.7). People with
Clark & Beck, 2010; Roy-Byrne et al., 2010; Schmidt GAD worry about many things in their lives, as
& Keough, 2010). In follow-up studies of patients Claire describes in the following profile.
TABLE 5. 7 DSM-5 Criteria for Generalized Anxiety Disorder
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months,
about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptom s (with at least some
symptoms having been present for more days than not for the past 6 months) :
1. Restlessness or feeling keyed up or on edge.

2. Being easily fatigued .
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impa irment in social,
occupational, or other important areas of functioning.
E. The disturbance is not attributable to the direct physiological effects of a substance (e.g ., a drug of abuse, a
medication) or another medical condition (e .g., hyperthyroidism).
F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having
panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination
or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation
anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gain ing weight in anorexia
nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic
disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in
schizophrenia or delusional disorder).
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright 2013
Generalized Anxiety Disorder 133
PROFILES time in their lives (Moffitt et al., 2010) and more

women than men developing the disorder (Vesga-
Lopez et al., 2008). It tends to be chronic (Kessler et
I just feel anxious and tense all the time. It started
al., 2002). Many people with this disorder report
in high school. I was a straight-A student, and I
that they have been anxious all their lives; the dis-
worried constantly about my grades, whether
order most commonly begins in childhood or ado-
the other kids and the teachers liked me, being
lescence. Almost 90 percent of people with GAD
prompt for classes-things like that. ... Now I
have another mental disorder, most often another
vacuum four times a week and clean the bath-
anxiety disorder, but there are also high rates of
rooms every day. There have even been times
comorbid mood disorders and substance abuse
when I've backed out of going out to dinner with
(Grant et al., 2005; Newman et al., 2013). GAD-
my husband because the house needed to be
more specifically, worry-increases the risk for
cleaned .
physical ailments as well, particularly cardiovas-
I get so upset and irritated over minor
cular disease (see Newman et al., 2013).
things .... I still worry about being on time to
church and to appointments. Now I find I worry a
lot about my husband. He's been doing a tremen- Theories of Generalized
dous amount of traveling for his job, some of it Anxiety Disorder
by car, but most of it by plane. Because he works
Emotional and Cognitive Factors
on the northeastern seaboard, and because he
People with GAD report experiencing more intense
frequently has to travel in the winter, I worry that
negative emotions, even compared to people with
he'll be stuck in bad weather and get into an ac-
major depression (Aldao, Mennin, Linardatos, &
cident or, God forbid, a plane crash.
Fresco, 2010), and are highly reactive to negative
Oh, and I worry about my son. He just started
events (Tan et al., 2012). They report feeling that
playing on the varsity footba ll team, so he's
their emotions are not controllable or manageable
bound to get an injury some time. It's so nerve-
(Newman et al., 2013). In neuroimaging studies,
wracking to watch him play that I've stopped go-
people with GAD showed heightened reactivity to
ing to his games. I'm sure my son must be
emotional stimuli in the amygdala, an area of the
disappointed ... , but it's simply too much for
brain involved in processing emotion (Schienle,
me to take. (Adapted from Brown, O'Leary, &
Hettema, Caceda, & Nemeroff, 2011). Physiologi-
Barlow, 2001 , p. 187)
cally, they show chronically elevated activity of
their sympathetic nervous systems and hyperreac-
tivity to threatening stimuli (Brosschot et al., 2007;
Pieper, Brosschot, van der Leeden, & Thayer, 2010).
Cognitively, people with GAD make a number
People with GAD may worry about their per- of maladaptive assumptions, such as "It's always
formance on the job, their relationships, and their best to expect the worst" and "I must anticipate and
health. Like Claire, they also may worry about mi- prepare myself at all times for any possible danger"
nor issues such as being late. The focus of their (Beck & Emery, 1985; Ellis, 1997). Many of these as-
worries may shift frequently, and they tend to sumptions reflect concerns about losing control.
worry about many things instead of focusing on Their maladaptive assumptions lead people with
only one issue of concern (Andrews et al., 2010). GAD to respond to situations with automatic
Because of anxiety and worry about situations, thoughts that stir up anxiety, cause them to be hy-
these individuals frequently spend inordinate pervigilant, and lead them to overreact (Beck &
amounts of time and energy preparing for feared Emery, 1985). When facing an exam, a person with
situations or avoiding those situations, are immo- GAD might reactively think, "I don't think I can do
bilized by procrastination and indecision, and seek this," "I'll fall apart if I fail this test," and "My par-
reassurance from others. Their worry is accompa- ents will be furious if I don't get good grades."
nied by physiological symptoms, including mus- Even the unconscious cognitions of people with
cle tension, sleep disturbances, and chronic GAD appear to focus on detecting possible threats in
restlessness. People with GAD feel tired much of the environment (Mathews & MacLeod, 2005). In the
~ the time, probably due to chronic muscle tension Stroop color-naming task, participants are presented
and sleep loss (Craske & Waters, 2005). with words printed in color on a computer screen
GAD is relatively common, with longitudinal (Figure 5.7). Their role is to say what color the word
studies showing as many as 14 percent of individ- is printed in. In general, people are slower in naming
uals meeting the criteria for the disorder at some the color of words that have special significance to
negative emotion. That is, they prefer a chronic but ~

The Stroop Color-Naming Task. In this task,
FIGURE 5.7 familiar state of distress to sudden shifts in emotion
words are flashed on a computer screen for a
in response to specific negative events.
brief period of time, and the person is asked to
name the color the word is printed in. People with generalized
anxiety disorder are slower to name the color of words with Biological Factors
threatening content than that of neutral words, presumably We've already noted that people with GAD show
because they are attending to the content of the threatening words. heightened activity of their sympathetic nervous
system and greater reactivity to emotional stimuli
in the amygdala, a part of the brain's limbic sys-
tem. This greater activity may be associated with
abnormalities in the GABA neurotransmitter sys-
tem, which plays an important role in many areas
DISEASE CHAIR of the brain, including the limbic system (Charney,
2004; LeDoux, 1996). When GABA binds to a neu-
ronal receptor, it prevents the neuron from firing.
One theory is that people with generalized anxiety
disorder have a deficiency of GABA or of GABA
receptors, which results in excessive firing of neu-
rons through many areas of the brain, particularly
them (such as disease or failure for people with the limbic system. As a result of excessive and
chronic anxiety) than in naming the color of nonsig- chronic neuronal activity, the person experiences
nificant words. Presumably, they are paying more chronic, diffuse symptoms of anxiety.
attention to the content of those words than to the Genetic studies suggest that GAD, as a specific
colors (Mathews & MacLeod, 2005). disorder, has a modest heritability (Andrews et al.,
Why do some people become hypervigilant 2010). The more general trait of anxiety is much
for signs of threat? One theory is that they have more clearly heritable and puts individuals at risk
experienced stressors or traumas that were uncon- for GAD (Craske & Waters, 2005) .
trollable and came without warning, particularly
an interpersonal trauma such as a rejection or a
loss (see Newman et al., 2013). Animals given un- Treatments for Generalized
predictable and uncontrollable shocks often ex- Anxiety Disorder
hibit symptoms of chronic fear or anxiety. Studies The effective treatments for GAD are cognitive-
have shown that the level of control and predict- behavioral or biological.
ability in an infant monkey's life is related to the
symptoms of anxiety it exhibits as an adolescent or
adult (Mineka, Gunnar, & Champoux, 1986; Suomi,
Cognitive-Behavioral Treatments
Cognitive-behavioral treatments focus on helping
1999). People who have had unpredictable and
people with GAD confront the issues they worry
uncontrollable life experiences-such as an abu-
about most; challenge their negative, catastroph-
sive parent-also may develop chronic anxiety
(Newman et al., 2013). izing thoughts; and develop coping strategies. In
What function does the characteristic worry of the following profile, a cognitive-behavioral thera-
GAD serve? People with GAD say that worrying pist helps Claire challenge her tendency to over-
helps them avoid bad events by motivating them to estimate the probability that her son will be injured
engage in problem solving (Borkovec & Roemer, while playing football.
1995). Yet they seldom get to the problem solving.
Thomas Borkovec (Borkovec, Alcaine, & Behar,
2004), in his cognitive avoidance model of GAD, PROFILES
argued that worrying actually helps people with
GAD avoid awareness of internal -and external Therapist: Claire, you wrote that you were afraid
threats and thus helps reduce their reactivity to un- about your son playing in his football game.
avoidable negative events. Michelle Newman and What specifically were you worried about?
Sandra Llera (2011) extended the cognitive avoid-
Claire: That he'd get seriously hurt. His team
ance model to suggest that by worrying about pos-
was playing last year's state champions, so
sible threats, people with GAD maintain a constant
you know that those boys are big and strong.
level of anxiety that is more tolerable than leaving
themselves open to sudden sharp increases in
Cognitive-behavioral therapy is more effective

Therapist: How specifically do you imagine than benzodiazepine therapy, placebos, or nondi-
your son getting hurt? rective supportive therapy in the treatment of
Claire: Getting a broken back or neck. GAD (Borkovec, Newman, & Castonguay, 2003;
Someth ing that will result in paralysis or Borkovec & Ruscio,2001; Siev & Chambless, 2007).
death. It happened to two NFL players this In one follow-up study, its positive effects re-
past year, remember? mained after 2 years (Borkovec, Newman, Pincus,
& Lytle, 2002).
Therapist: What happened to your son when
he played in the game?
Claire: Nothing, really. He came home that The benzodiazepine drugs (such as Xanax, Librium,
afternoon with a sore thumb, but that went Valium, and Serax) provide short-term relief from
away after a while. He said he scored a touch- anxiety symptoms (Gorman, 2003). However, their
down and had an interception . I guess he side effects and addictiveness preclude long-
played really we ll. term use. Once people discontinue the drugs, their
Therapist: So you had predicted that he would anxiety symptoms return (Davidson, 2001).
be injured during the game, but that didn't Both the tricyclic antidepressant imipramine
happen. When we're anxious, we tend to com- (trade name Tofranil) and the selective serotonin
mit a common cognitive error, called "proba- reuptake inhibitor paroxetine (trade name Paxil)
bility overestimation." In other words, we have been shown to be better than a placebo in re-
overestimate the likel ihood of an unlikely ducing anxiety symptoms in GAD, and paroxetine
event. While you were feeling anxious and improves anxiety more than a benzodiazepine.
worried, what was the probability in your Venlafaxine (trade name Effexor), a serotonin-
mind that your son would be hurt, from 0 norepinephrine reuptake inhibitor, also reduces
to 100 percent? symptoms of anxiety in GAD better than a placebo
(Davidson et al., 2008).
Claire: About 75 percent.
Therapist: And now what would you rate the
probability of your son getting hurt in a future SEPARATION ANXIETY
game?
DISORDER
Claire: Well, if you put it that way, I suppose
around a 50 percent chance of him getting Children, like adults, can suffer from posttra-
inju red . umatic stress disorder, panic attacks, phobias,
social anxiety disorder, and generalized anxiety
Therapist: So that means for every two times
disorder. One anxiety disorder whose onset occurs
that your son plays football, he gets hurt once.
most often in childhood is separation anxiety dis-
Is that correct?
order (see the DSM-5 criteria in Table 5.8). Many
Claire: Umm, no. I don't think it's that high . infants become anxious and upset if they are sepa-
Maybe about 30 percent. rated from their primary caregivers. With develop-
Therapist: That would be one out of every ment, however, most come to understand that their
three times that your son gets hurt. What caregivers will return, and they find ways to com-
evidence can you provide from your son's fort themselves while their caregivers are away.
play in g history to account for your belief Some children continue to be extremely anx-
that he'll get hurt one out of every three ious when they are separated from their caregiv-
games? ers, even into childhood and adolescence. They
may be very shy, sensitive, and demanding of
Claire: We ll, none. He had a sprained ankle
adults. They may refuse to go to school because
during summer training, but th at's it.
they fear separation, and they may experience
Therapist: So what you're sayin g is that you stomachaches, headaches, nausea, and vomiting if
don't have very much evidence at all to prove forced to leave their caregivers. They may follow
that your son has a 30 percent chance of get- their caregivers around the house, have night-
ting hurt in a game. mares with themes of separation, and be unable to
Claire: Gee, I never thought of it that way. sleep at night unless they are with their caregivers.
When separated from their caregivers, they worry
(Adapted from Brown et al., 2001, pp. 193-194) that something bad will happen to the caregivers
and harbor exaggerated fears of natural disasters,
136 Chapter 5 Trauma, Anxiety. Obsessive-Compulsive. and Related Disorders
TABLE 5.8 DSM-5 Criteria for Separation Anxiety Disorder
A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom
the individual is attached, as evidenced by at least three of the following:
1. Recurrent excessive distress when anticipating or experiencing separation from home or major
attachment figures.
2. Persistent and excessive worry about losing major attachment figures or possible harm to them, such as
illness, injury, d isasters, or death.
3. Persistent and excessive worry about experiencing an untoward event (e .g., getting lost, being
kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of
fear of separation.
5. Persistent and excessive fear or reluctance about being alone or without major attachment figures at
home or in other settings.
6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major
attachment figure.
7. Rep eated nightmares involving the theme of separation.
8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when
separation from major attachment figures occurs or is anticipated .
B. Th e fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and
typically 6 months or more in adults.
C. The disturbance causes clinically significant distress or impairment in socia l, academic, occupational, or
other important areas of functioning.
D. The disturbance is not better explained by another mental disorder, such as refusing to leave home
because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations
concerning separation in psychotic disorders; refusal to go outside without a trusted companion in
agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety
disorder; or concerns about having an illness in illness anxiety disorder.
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition . Copyright 2013
kidnappings, and accidents. Younger children may and peer relationships. One study examined the
cry inconsolably. Older children may avoid activi- adult outcomes of children with separation anxi-
ties, such as being on a baseball team, that might ety who had refused to go to school. They had
take them away from their caregivers. more psychiatric problems as adults than did the
Many children go through a few days of these comparison group, were more likely to continue to
symptoms after a traumatic event, such as getting live with their parents, and were less likely to have
lost in a shopping mall or seeing a parent hospital- married and had children (Flakierska-Praquin,
ized for a sudden illness. Separation anxiety disor- Lindstrom, & Gilberg, 1997).
der is not diagnosed unless symptoms persist for
at least 4 weeks and significantly impair the child's
functioning. Theories of Separation
About 3 percent of children under age 11 years,
more commonly girls, experience separation anxi-
Anxiety Disorder
ety disorder (Angold et al., 2002; Rapee, Schnier- Biological Factors
ing, & Hudson, 2009). Left untreated, the disorder Children with separation anxiety disorder tend
can recur throughout childhood and adolescence, to have family histories of anxiety and depres-
significantly interfering with academic progress sive disorders (Biederman, Faraone, et al., 2001;
Manicavasagar et al., 2001). Twin studies suggest could not control their access to them became
that the tendency toward anxiety is heritable, fearful and inhibited. Other monkeys given the
more so in girls than in boys, although it is not same amount of food and water but under condi-
clear that a specific tendency toward separation tions that allowed them to exert some control did
anxiety is heritable (Rapee et al., 2009). What may not become fearful. This result suggests that some
be inherited is a tendency toward a trait known as human children raised in conditions over which
behavioral inhibition. Children high on behav- they have little control may develop anxiety
ioral inhibition are shy, fearful, and irritable as symptoms.
toddlers and cautious, quiet, and introverted as Moreover, Stephen Suomi (1999) found that
school-age children (Kagan, Reznick, and Snidman, although some rhesus monkeys seem to be born
1987). These children tend to avoid or withdraw behaviorally inhibited, the extent to which they
from novel situations, are clingy with their par- develop serious signs of fearfulness and anxiety
ents, and become excessively aroused in unfamil- later in life depends on the parenting they re-
iar situations. Behavioral inhibition appears to be ceive. Those raised by anxious mothers, who are
a risk factor for developing anxiety disorders in inhibited and inappropriately responsive to the
childhood (Biederman et al., 1990, 1993; Caspi, infants, are prone to develop monkey versions of
Harrington, et al., 2003). anxiety disorders. Those raised by calm, respon-
sive mothers who model appropriate reactions
Psychological and Sociocultural to stressful situations typically are no more
Factors likely to develop anxiety problems as adoles-
Observational studies of interactions between cents or adults than those not born behaviorally
anxious children and their parents show that the inhibited.
parents tend to be more controlling and intrusive Children may learn to be anxious from their
both behaviorally and emotionally, and also more parents or as an understandable response to
critical and negative in their communications their environment (Rapee et al., 2009). In some
with their children (Hughes, Hedtke, & Kendall, cases, such as in the following case study, sepa-
2008). Some of this behavior may be in response ration anxiety disorder develops after a trau-
to the children's anxious behaviors, but many matic event.
parents of anxious children are themselves anx-
ious or depressed.
Some of the best evidence that environmental
and parenting factors can influence the develop- In the early morning hours,
ment of anxiety disorders in youngsters comes 7-year-old Maria was abruptly awakened by a
from studies of primates (Mineka et al., 1986; loud rumbling and violent shaking. She sat up-
Suomi, 1999). Susan Mineka and colleagues found right in bed and called out to her 10-year-old sis-
that rhesus monkeys who, from ages 2 to 6 ter, Rosemary, who was leaping out of her own bed
months, were given adequate food and water but 3 feet away. The two girls ran for their mother's
bedroom as their toys and books plummeted
from shelves and dresser tops. The china hutch in
the hallway teetered in front of them and then
fell forward with a crash, blocking their path to
their mother's room. Mrs. Marshall called out to
them to go back and stay in their doorway. They
huddled there together until the shaking finally
stopped. Mrs. Marshall climbed over the hutch
and broken china to her daughters. Although
they were all very scared, they were unhurt.
Two weeks later, Maria began to complain
every morning of stomachaches, headaches, and
dizziness, asking to stay home with her mother.
After 4 days, when a medical examination re-
vealed no physical problems, Maria was told she
must return to school. She protested tearfully, but
Children with separation anxiety disorder often c ling (continued)
desperately to their parents.
individualized CBT to anxious children, family- r---

her mother insisted, and Rosemary promised based CBT to anxious children and their parents,
to hold her hand all the way to school. In the and simple education and support. At the end of
classroom, Maria could not concentrate on her therapy, the children in both the individualized
schoolwork and was often out of her seat, look- and the family-based CBT showed substantial de-
ing out the window in the direction of home. clines in anxiety symptoms, while the children
She told her teacher she needed to go home to who received only education and support showed
see whether her mother was okay. When told less improvement. With all three treatments, the
she couldn't go home, she began to cry and declines in anxiety symptoms were sustained over
tremble so violently that the school nurse called a 1-year follow-up period.
Mrs. Marshall, who picked Maria up and took Consider how Maria was treated for her sepa-
her home. ration anxiety.
The next morning, Maria's protests grew
stronger and she refused to go to school until her
mother promised to go with her and sit in her
classroom for the first hour. When Mrs. Marshall . CASE STUDY
began to leave, Maria clung to her, crying, plead- Mrs. Marshall was in-
ing for her not to leave, and following her into structed to take Maria to school and leave four
the hallway. The next day, Maria refused to leave times during the period she was there. Initially,
the house for her Brownie meeting and her danc- Mrs. Marshall left for 30 seconds each time. Over
ing lessons or even to play in the front yard. She time, she gradually increased the amount of
followed her mother around the house and in- time and distance she was away while Maria
sisted on sleeping with her at night. "I need to be remained in the classroom. Maria was given a
with you, Mommy, in case something happens;' sticker at the end of the school day for each time
she declared. she remained in her seat while her mother was
out of the room. In addition, she was praised by
her teacher and her mother, and positive self-
statements ("My mommy will be okay; I'm a big
girl and I can stay at school") were encouraged.
No response was made when Maria failed to stay
Treatments for Separation in her chair. Maria could exchange her stickers
Anxiety Disorder for prizes at the end of each week.
Cognitive-behavioral therapies (CBT) most often At home, Mrs. Marshall was instructed
are used to treat separation anxiety disorder to give minimal attention to Maria's inquiries
(Kendall, Aschenbrand, & Hudson, 2003). Chil- about her well-being and to ignore excessive,
dren are taught new skills for coping and for chal- inappropriate crying. Eventually, Maria was
lenging cognitions that feed their anxiety. They given a sticker and praise each morning for
might learn relaxation exercises to practice when sleeping in her own bed.
they are separated from their parents. Their fears The first few times Mrs. Marshall left the
about separation are challenged, and they are classroom, Maria followed her out. Soon, how-
taught to use self-talk to calm themselves when ever, she began to stay in her chair and receive
they become anxious. stickers. At home, she remained in her own bed
As therapy progresses, the number and dura- the first night, even though she was told she had
tion of periods of separation from their parents are to stay only 2 hours to earn her sticker. At her
increased. Parents must be willing to participate in own request, she returned to Brownie meetings
therapy and to cope with their children's (and and attended summer camp.
their own) reactions to increased periods of sepa-
ration. Parents may need to be taught to model
nonanxious reactions to separations from their
children and to reinforce nonanxious behavior in Drugs used to treat childhood anxiety disor-
their children. ders include antidepressants; antianxiety drugs,
Controlled clinical trials of this type of ther- such as the benzodiazepines; stimulants; and ~
apy show that it can be effective in the short antihistamines. The selective serotonin reuptake
term and maintain its effects over the long term inhibitors, such as fluoxetine, are used most fre-
(Rapee et al., 2009; Shortt, Barrett, & Fox, 2001; quently and have been shown to be most consis-
Velting, Setzer, & Albano, 2004). Philip Kendall tent in effectively reducing anxiety symptoms in
and his colleagues (2008) tested three treatments: children (Birmaher et al., 2003; Thienemann, 2004).
Obsessive-Compulsive Disorder 139
OBSESSIVE-COMPULSIVE OCD often begins at a young age. The peak

age of onset for males is between 6 and 15, and for
DISORDER females between 20 and 29 (Angst et al., 2004; Foa
Obsessions are thoughts, images, ideas, or urges & Franklin, 2001). Children often hide their symp-
(e.g., to harm oneself) that are persistent, that un- toms, even from their parents; as a result, the
controllably intrude on consciousness, and that symptoms can go undetected for years (Rapoport
usually cause significant anxiety or distress. Com- et al., 2000).
pulsions are repetitive behaviors or mental acts OCD tends to be chronic if left untreated
that an individual feels he or she must perform. (Leckman et al., 2010) . Obsessional thoughts are
Obsessive-compulsive disorder (OCD; see usually distressing to people with OCD, and
Table 5.9) was classified as an anxiety disorder engaging in compulsive behaviors can be time-
prior to the DSM-5 because people experience consuming or harmful (e.g., hand-washing to the
anxiety as a result of their obsessional thoughts point of bleeding). As many as 66 percent of people
and their inability to carry out their compulsive with OCD are also significantly depressed (Foa &
behaviors (Leckman et al., 2010). OCD differs Franklin,2001). Panic attacks, phobias, and substance
enough from the anxiety disorders, however, that abuse are common among OCD sufferers.
the DSM-5 authors moved OCD into its own Between 1 and 3 percent of people will develop
category, along with several related disorders: OCD at some time in their lives, and many more peo-
hoarding, hair-pulling disorder (also known as tricho- ple will have symptoms that don't quite meet the
tillomania), skin-picking disorder, and body dysmor- diagnostic criteria (Kessler et al., 2005; Leckman et
phic disorder. al., 2010). In the United States, European Americans
The obsessions and compulsions of some peo- show higher rates of OCD than African Americans
ple with OCD, like David Beckham's obsession or Hispanic Americans (Hewlett, 2000). The preva-
with orderliness described in the Extraordinary lence of OCD does not seem to differ greatly across
People feature at the beginning of this chapter, can countries that have been studied, including the
seem simply quirky. Other patterns of obsessions United States, Canada, Mexico, England, Norway,
and compulsions can appear much stranger, or Hong Kong, India, Egypt, Japan, and Korea (Escobar,
even bizarre, as illustrated by the profile of a young 1993; Insel, 1984; Kim, 1993). Although some studies
boy named Zach who has OCD. have found slightly higher rates in women (Angst
et al., 2004), other studies have not (Edelmann, 1992;
Karno & Golding, 1991).
Across cultures, the most common type of ob-
PROFILES session in OCD is thoughts and images associated
with aggression (such as thoughts of hurting one's
When I was 6 I started doing all these strange child), sexuality (such as recurrent pornographic
things when I swallowed saliva . When I swal- images), and/ or religion (such as a compulsion to
lowed saliva I had to crouch down and touch the shout obscenities in a house of worship) (Bloch et
ground. I didn't want to lose any saliva-for a bit I al., 2008). Although thoughts of this kind occur to
had to sweep the ground with my hand-and later most people occasionally, most of us can dismiss
I had to blink my eyes if I swallowed. I was frus- or ignore them. People with OCD cannot. The
trated because I couldn't stop the compulsions.
Each time I swallowed I had to do something. For
a while I had to touch my shoulders to my chin. I
don't know why. I had no reason. I was afraid. It
was just so unpleasant if I didn't. If I tried not to do
these things, all I got was failure. I had to do it,
and no matter how hard I tried, I just still had to.
It wrecked my life. It took away all the time.
I couldn't do anything. If you put it all together
I did it maybe an hour and a half or sometimes
three hours a day. (Rapoport, 1990, pp. 43-44)
Zach's thoughts and behaviors might seem

Howie Mandel. host of Deal or No Deal. has a severe germ
out of touch with reality. However, people with phobia and cannot shake hands with other people. but
OCD usually know that their thoughts and behav- he can tolerate fist bumps.
iors are irrational. They simply cannot control them.
TABLE 5.9 DSM-5 Criteria for Obsessive-Compulsive Disorder
A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intru sive
and unwanted, and that in most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought
or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2) :
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeati ng words silently)
that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or
situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to
neutralize or prevent, or are clearly excessive.
B. The obsessions or compulsions are time-consuming (e.g ., take more than 1 hour per day) or cause clinically significant distress
or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized
anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions,
as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin -picking]
disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with
substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety
disorder; sexual urges or fantasies, as in paraphi lic disorders; impulses, as in disruptive, impulse-control, and conduct disorders;
guilty ruminations, as in major depressive d isorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum
and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Copyright 2013 American Psychiatric Association .
second most common type involves symmetry

and ordering, such as David Beckham's arrange- PROFILES
ment of soda cans in the refrigerator. The third
most common type of obsession concerns contami- I'm driving down the highway doing 55 MPH. Out
nation and is often accompanied by a cleaning of nowhere an obsessive-compulsive disorder
compulsion (Leckman et al., 2010). Howie Mandel, (OCD) attack strikes. While in reality no one is on
comedian and host of Deal or No Deal, has obses- the road, I'm intruded by the heinous thought
sions about germs and contamination that keep that I might have hit someone ... a human being!
him from shaking hands with anyone (Mandel, I think about this for a second and then say
2005). When contestants win big money on the to myself, "That's ridiculous. I didn't hit any-
show, he will do a fist bump with them but will not body." Nonetheless, a gnawing anxiety is born.
shake their hand. He keeps his head shaved be- I reason, "Well, if I hit someone while driv-
cause it helps him feel cleaner. ing, I would have felt it." This brief trip into real-
Sometimes, an individual's compulsion is tied ity helps the pain dissipate . .. but only for a
logically to his or her obsession. If Howie Mandel second. Why? Because the gnawing anxiety that
does touch someone' s hand or an object he feels is I really did commit the illusionary accident is
dirty, he will wash his hands over and over until growing larger-so is the pain.
he feels clean (Mandel, 2005). The compulsive be- The pain is a terrible guilt that I have commit-
havior becomes so extreme and repetitive that it is ted an unthinkable, negligent act. At one level, I
irrational. "Checking" compulsions, which are ex- know this is ridiculous, but there's a terrible pain in
tremely common, are tied to obsessional doubts, as my stomach telling me something quite different.
illustrated in the following profile.
Obsessive-Compulsive Disorder 141
I start ruminating, "Maybe I did hit someone

and didn't realize it. ... Oh, my God! I might have
killed somebody! I have to go back and check."
Checking is the only way to calm the anxiety. It
brings me closer to truth somehow. I can't live
with the thought that I actually may have killed
someone-1 have to check it out. (Rapoport,
1990, pp. 21-22)
The man's compulsive checking makes some

sense, given what he is thinking. However, what
he is thinking-that he hit someone on the road Only a small subset of people who hoard also meet the
without knowing it-is highly improbable. The criteria for OCD. but hoarders tend to have high rates of
compulsive checking briefly quells his obsessional major depression. social anxiety, and generalized anxiety
disorder.
thoughts, but they recur with even more force.
Often, the link between the obsession and the
compulsion is the result of "magical thinking" 25 times perfectly, fearing that something bad will
(Rapoport, 1991). Many people with OCD believe happen to his family if he does not.
that repeating a behavior a certain number of times Hoarding is a compulsive behavior that is
will ward off danger to themselves or others. Their closely related to OCD but is classified as a separate
rituals often become stereotyped and rigid, and diagnosis in the DSM-5 (see Table 5.10), due to evi-
they develop obsessions and compulsions about dence that hoarding has distinct features and may
not performing them correctly. An individual have different biological correlates (Frost, Steketee &
might feel compelled to read a passage in a book Tolin, 2012; Mataix-Cols et al., 2010). As featured in
TABLE 5.10 DSM-5 Criteria for Hoarding Disorder
A. Persistent difficulty discard ing or parting with possessions, regardless of their actual value.
B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them.
C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and
substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third
parties (e.g., family members, cleaners, authorities).
D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
(including maintaining a safe environment for self and others).
E. The hoard ing is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).
F. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive
disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive
deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder).
Specify if:
With excessive acquisition : If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed
or for which there is no available space.
Specify if:
With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors {pertaining to difficulty discarding
items, clutter, or excessive acquisition) are problematic.
With poor insight: The individual is mostly convinced that hoarding -related beliefs and behaviors (pertaining to difficulty discarding
items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.
With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining
to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.
Source: Reprinted w ith permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright 2013 American Psychiatric Association .
the reality TV show Hoarding: 2010). For diagnosis as a disorder, the behavior
Buried Alive, people who must cause significant distress or impairment and
hoard cannot throw away their must not be due to another mental or medical con-
possessions-even things that dition (American Psychiatric Association, 2013).
most of us consider trash, such The estimated prevalence of hair-pulling dis-
as newspapers or take-out order is 1 to 3 percent (Christenson, Pyle, & Mitchell,
food containers. They stock- 1991). It is seen most often in females, and the av-
pile these items in their homes erage age of onset is 13 (Christenson & Mansueto,
and cars to the point of creat- 1999). The estimated prevalence of skin-picking
ing a hazard, making these disorder is 2 to 5 percent, and it most often begins
spaces unusable. Compulsive in adolescence, often with a focus on acne lesions
hoarders often show emo- (Stein et al., 2010).
tional attachments to their People with body dysmorphic disorder are ex-
possessions, equating them cessively preoccupied with a part of their body that
with their identity or imbuing they believe is defective but that others see as nor-
them with human characteris- mal or only slightly unusual. These preoccupations
tics (Frost et al., 2012). For ex- most often focus on the face or head (e.g., nose, ears,
ample, one woman bought a skin), but they can focus on any body part (Phillips
half dozen puppets from a TV et al., 2010). As a result of their preoccupations,
shopping station because no these people may spend a great deal of time check-
one else was bidding on them ing themselves in the mirror, attempting to hide or
Trichotillomania is the compulsion to pull
and she didn't want the pup- change the body part (e.g., combing their hair over
out one's own hair. pets' feelings to be hurt (Frost ears they believe are defective), or seeking reassur-
& Steketee, 2010). The woman ance from others about the body part. People with
fully realized her behavior body dysmorphic disorder spend an average of 3 to
wasn't rational, but she still felt bad for the puppets. 8 hours on their preoccupations and their checking
Epidemiological studies suggest that 2 to 5 or grooming behavior, and they may even seek sur-
percent of the population engage in hoarding gery to correct their perceived flaws (Phillips et al.,
(Iervolino et al., 2009). Only a small subset of peo- 2010). If preoccupations with weight and shape are
ple who hoard also meet the criteria for OCD, but part of an eating disorder (see Chapter 12), then
these people also tend to have high rates of major body dysmorphic disorder is not diagnosed.
depression, social anxiety, and generalized anxiety Although it is not clear whether there are gen-
disorder (Frost et al., 2011; Samuels et al., 2008). der differences in the prevalence of this disorder,
People's hoarding behavior often increases as they men and women with body dysmorphic disorder
age (Ayers et al., 2009). tend to obsess about different parts of their bodies
Hoarding differs from OCD in that people (Phillips et al., 2010). Women seem to be more con-
with the disorder do not experience thoughts cerned with their breasts, legs, hips, and weight,
about their possessions as intrusive, unwanted, or whereas men tend to be preoccupied with their
distressing, but rather as part of their natural body build, their genitals, excessive body hair, and
stream of thought (Mataix-Cols et al., 2010). People thinning hair. These gender differences likely rep-
who hoard do not experience anxiety about their resent extreme versions of societal norms concern-
hoarding behavior, but they may become ex- ing attractiveness in women and men.
tremely anxious, angry, or sad when pressured to Case studies of people with body dysmorphic
get rid of their hoarded possessions. disorder indicate that their perceptions of defor-
People diagnosed with hair-pulling disorder mation can be so severe and bizarre as to be con-
(trichotillomania) have a history of the recurrent sidered out of touch with reality (Phillips, Didie,
pulling out of their hair, resulting in noticeable hair Feusner, & Wilhelm, 2008). Even if they do not lose
loss. People with skin-picking disorder recurrently touch with reality, some people with the disorder
pick at scabs or places on their skin, creating sig- have severe impairment in their functioning. Most
nificant lesions that often become infected and people with this disorder avoid social activities be-
cause scars. People with both these disorders some- cause of their "deformity," and many become
times report tension immediately before or while housebound (Phillips & Diaz, 1997). About 30 per-
attempting to resist the impulse, and pleasure or cent attempt suicide (Phillips et al., 2008).
relief whe:1 giving in to it. Much of the time, how- Body dysmorphic disorder tends to begin in the
ever, the hair pulling or skin picking is automatic, teenage years and to become chronic if left untreated.
occurring without much awareness (Stein et al., The average age of onset of this disorder is 16, and
ObsessivEK:ompulsive Disorder 143
,.--..._ the average number of bodily preoccupations is OCD in the Brain. A three-dimensional view of
about four. Those who seek treatment wait an av- FIGURE 5.8
the human brain (with parts shown as they
erage of 6 years from the onset of their concerns
would look if the overlying cerebral cortex were
before seeking help (Cororve & Gleaves, 2001).
transparent) clarifies the locations of the orbital frontal cortex
Body dysmorphic disorder is highly comorbid
and the basal ganglia-areas implicated in obsessive-compulsive
with several disorders, including anxiety and de-
disorder. Among the basa l ganglia's structures are the caudate
pressive disorders, personality disorders, and sub-
nucleus, which filters powerful impulses that arise in the orbita l
stance use disorders (Cororve & Gleaves, 2001).
frontal cortex so that only the most powerful ones reach the
Obsessive-compulsive disorder is relatively com-
thalamus. Perhaps the orbital frontal cortex, the caudate nucleus,
mon in people with body dysmorphic disorder
or both are so active in people with obsessive-compulsive
(Stewart, Stack, & Wilhelm, 2008).
disorder that numerous impulses reach the thalamus, generating
obsessive thoughts or compulsive actions.
Theories of OCD and Related
Disorders Basal ganglia
The biological theories of OCD have dominated (~----~

A ------~\
research in recent years. Cognitive-behavioral Putamen and Caudate
theories have also been proposed. globus pallidus nucleus
Cerebral cortex
Biological Theories
Biological theories of obsessive-compulsive disor-
der have focused on a circuit in the brain involved
in motor behavior, cognition, and emotion (Milad &
Rauch, 2012). This circuit projects from specific ar-
eas of the frontal cortex to areas of the basal ganglia
called the striatum, then through the basal ganglia to
the thalamus, and then loops back to the frontal
cortex (Figure 5.8). People with OCD, hair-pulling
disorder, and skin-picking disorder show altera- Cerebellum
tions in the structure and activity level of these areas Thalamus
and in the connections between these areas (Milad
& Rauch, 2012). People with hoarding disorder
show alterations in other areas of the frontal cortex
Source: Adapted from Rapoport, 1989, p. 85.
and the limbic system (Saxena, 2008).
For people with OCD and related disorders,
dysfunction in this circuit may result in the sys-
tem's inability to turn off the primitive urges (e.g., Saxena et al., 2003). Those patients who respond to
aggressive urges) or the execution of the stereo- serotonin-enhancing drugs tend to show a greater
typed behaviors. When most of us think our hands reduction in the rate of activity in these brain areas
are dirty, we engage in a fairly stereotyped form of than patients who do not respond well to the drugs
cleansing: We wash them. People with OCD, how- (Baxter, Schwartz, Bergman, & Szuba, 1992; Saxena
ever, continue to have the urge to wash their hands et al., 1999, 2003). Interestingly, people with OCD
because their brains do not shut off their thoughts who respond to behavior therapy also tend to show
about dirt or their hand-washing behavior when decreases in the rate of activity in the caudate nu-
the behavior is no longer necessary. Proponents of cleus and the thalamus (Schwartz et al., 1996).
this biological theory point out that many of the In rare cases, a sudden onset of OCD in chil-
obsessions and compulsions of people with OCD dren is associated with a strep infection (Swedo et
have to do with contamination, sex, aggression, al., 1998). It is thought that autoimmune processes
and repeated patterns of behavior-all issues with triggered by the infection affect the areas of the
which this brain circuit deals (Milad & Rauch, basal ganglia implicated in OCD in some vulner-
2012; Rauch et al., 2003). able children, creating the symptoms of OCD
People with OCD and related disorders often (Leckman et al., 2010).
get some relief from their symptoms when they Finally, genes may help determine who is vul-
take drugs that regulate the neurotransmitter nerable to OCD (Mundo, Zanoni, & Altamura,
serotonin, which plays an important role in the cir- 2006). Family history studies clearly show that
cuit's proper functioning (Micallef & Blin, 2001; OCD, hair pulling, and skin picking run in families,
and twin studies support a substantial genetic as guilty as if I actually did"). Of course, this just
component in obsessive and compulsive behaviors makes them more anxious when they have the
(Eley et al., 2003; Hudziak et al., 2004). Different thoughts, making it harder to dismiss the thoughts.
genes may be involved in vulnerability to OCD According to these theories, compulsions de-
and to hoarding or body dysmorphic disorder velop largely through operant conditioning. Peo-
(Mataix-Cols et al., 2010; Phillips et al., 2010). ple with anxiety-provoking obsessions discover
that if they engage in certain behaviors, their anxi-
Cognitive-Behavioral Theories ety is reduced. Each time the obsessions return and
Most people, including those without OCD, occa- the person uses the behaviors to reduce them, the
sionally have negative, intrusive thoughts, includ- behaviors are negatively reinforced. Thus, com-
ing thoughts about harming others or doing pulsions are born.
something against their moral code (Angst et al., Research has supported the argument put forth
2004; Leckman et al., 2010; Rachman & deSilva, by this theory that people with OCD have these
1978). People are more prone to having such rigid and unrealistic beliefs (Julien, O'Connor, &
thoughts and to engaging in rigid, ritualistic be- Aardema, 2007). Also, as we will see, cognitive-
haviors when they are distressed (Clark & Purdon, behavioral therapies based on this model have
1993; Rachman, 1997). Many new mothers, ex- proven quite useful in treating OCD (Franklin &
hausted from sleep deprivation and the stress of Foa, 2011).
caring for a newborn, think of harming their baby People with hoarding disorder also often have
even though they are horrified by such thoughts an exaggerated sense of responsibility, feeling
and would never carry them out. guilty about wasting things, having an excessive
Most people can ignore or dismiss such need to "be ready just in case," and feeling respon-
thoughts, attributing them to their distress. With sible for not "hurting" the item (Frost et al., 2012).
the passage of time, the thoughts subside. Accord- People who hoard also tend to believe they have a
ing to cognitive-behavioral theories of OCD, what poor memory and therefore need to keep items in
differentiates people with OCD from people with- sight in order to remember them or to keep control
out the disorder is their inability to turn off these over them.
negative, intrusive thoughts (Clark, 1988; Rachman
& Hodgson, 1980; Salkovskis, 1998). Treatment of OCD and
Why do people who develop OCD have trou-
ble turning off their thoughts, according to cognitive-
Related Disorders
behavioral theories? First, they may be depressed Both biological and cognitive-behavioral treat-
or generally anxious much of the time so that even ments are helpful for people with OCD.
minor negative events are likely to invoke intru-
sive, negative thoughts (Clark & Purdon, 1993). Biological Treatments
Second, people with OCD may have a tendency In the 1980s, it was fortuitously discovered that
toward rigid, moralistic thinking (Rachman, 1993; antidepressant drugs affecting levels of serotonin
Salkovskis, 1998). They judge their negative, intru- helped relieve symptoms of OCD in many patients
sive thoughts as more unacceptable than most (Marazziti, Catena, & Pallanti, 2006). Clomip-
people would and become more anxious and guilty ramine (trade name Anafranil) was the first such
about having them. Their anxiety then makes it drug (Rapoport, 1989). Then the SSRis, including
harder for them to dismiss the thoughts (Salkovs- fluoxetine (trade name Prozac), paroxetine (trade
kis, 1998). People who feel more responsible for name Paxil), sertraline (trade name Zoloft), and
events that happen in their lives and the lives of fluvoxamine (trade name Luvox), proved effec-
others will also have more trouble dismissing tive. Controlled studies suggest that 50 to 80 per-
thoughts such as "Did I hit someone on the road?" cent of OCD patients experience decreases in their
and thus might be more likely to develop OCD. obsessions and compulsions while on these d rugs,
Third, people with OCD appear to believe that compared to only 5 percent of patients on placebos
they should be able to control all their thoughts and (Marazziti et al., 2006; Hurley et al., 2008). These
have trouble accepting that everyone has horrific drugs can also be effective with people with hoard-
notions from time to time (Clark & Purdon, 1993; ing disorder (Mataix-Cols et al., 2010) and body
Freeston, Ladouceur, Thibodeau, & Gagnon, 1992). dysmorphic disorder (Phillips et al., 2010).
They tend to believe that having these thoughts These drugs are not the complete answer for
means they are going crazy, or they equate having people with OCD and related disorders, however. A
the thoughts with actually engaging in the behav- substantial number of OCD sufferers do not respond
iors ("If I'm thinking about hurting my child, I'm to the SSRis. Among those who do, obsessions and
Anxiety Disorders in Older Adults 145
compulsions are reduced only 30 to 40 percent, and maladaptive cognitions about their body, exposing
patients tend to relapse if they discontinue the drugs them to feared situations concerning their body, ex-
(Franklin & Foa, 2011). Significant side effects, which tinguishing anxiety about their body parts, and pre-
include drowsiness, constipation, and loss of sexual venting compulsive responses to that anxiety
interest, prevent many people from taking them. (Cororve & Gleaves, 2001). For example, a client
Studies suggest that adding an atypical antipsy- may identify her ears as her deformed body part.
chotic (see Chapter 8) can help people who do not The client could develop her hierarchy of things she
respond fully to the SSRis (Bystritsky et al., 2004). would fear doing related to her ears, ranging from
looking at herself in the mirror with her hair fully
Cognitive-Behavioral Treatments covering her ears to going out in public with her
Many clinicians believe that drugs must be com- hair pulled back and her ears fully exposed. After
bined with cognitive-behavioral therapies that use learning relaxation techniques, the client would be-
exposure and response prevention to help people gin to work through the hierarchy and engage in
recover completely from OCD and related disor- the feared behaviors, beginning with the least feared
ders. Exposure and response prevention therapy and using the relaxation techniques to quell her
repeatedly exposes the client to the focus of the anxiety. Eventually, the client would work up to the
obsession and prevents compulsive responses to most feared situation, exposing her ears in public.
the resulting anxiety (Franklin & Foa, 2011). Re- At first, the therapist might contract with the client
peated exposure to the content of the obsession that she could not engage in behaviors intended to
while preventing the person from engaging in the hide the body part (such as putting her hair over her
compulsive behavior extinguishes the client's anx- ears) for at least 5 minutes after going out in public.
iety about the obsession. The client learns that not The eventual goal in therapy would be for the cli-
engaging in the compulsive behavior does not lead ent's concerns about her ears to diminish totally
to a terrible result. and no longer affect her behavior or functioning.
Clients may be given homework that helps Empirical studies have supported the efficacy of
them confront their obsessions and compulsions. cognitive-behavioral therapies in treating body dys-
Early in therapy, a client might be assigned simply morphic disorder (Cororve & Gleaves, 2001).
to refrain from cleaning the house every day and
instead to clean it only every three days. Later he
might be asked to drop a cookie on a dirty kitchen ANXIETY DISORDERS
floor and then pick it up and eat it, or to drop the
kitchen knives on the floor and then use them to
IN OLDER ADULTS
prepare food. Anxiety is one of the most common problems
The cognitive component of cognitive- among older adults, with up to 15 percent of peo-
behavioral therapy for OCD involves challenging ple over age 65 experiencing an anxiety disorder
the individual's moralistic thoughts and excessive (Bryant, Jackson, & Ames, 2008). Some older people
sense of responsibility. For example, a woman with a have had anxiety disorders all their lives. For other
germ obsession who believes she would be a bad people, anxiety first arises in old age. It often takes
mother if she touched her baby when she wasn't the form of worry about loved ones or about the
completely sure her hands were clean would be older person's own health or safety, and it fre-
guided through exposure exercises (such as touch- quently exists together with medical illness and
ing her baby with slightly dirty hands) with re- with depression, as with Mrs. Johnson in the fol-
sponse prevention (not washing her hands), while lowing case study.
being helped to challenge her thoughts that her
baby was being harmed (by noticing that the baby
was fine after being touched by slightly dirty hands).
These cognitive-behavior therapies lead to sig- CASE STUDY
Mrs. Johnson is a 71-year-
nificant improvement in obsessions and compul-
old female who was referred by a family practice
sive behavior in 60 to 90 percent of OCD clients
physician working in a nearby town. Mrs. Johnson
(see review by Franklin & Foa, 2011). In most cli-
had become extremely anxious and moderately
ents, the improvement remains for up to 6 years.
depressed following a major orthopedic surgery,
CBT can also be effective in the treatment of hoard-
a total hip replacement. She was a retired office
ing (Frost et al., 2012), although less research has
worker.
been conducted on this disorder.
(continued)
Cognitive-behavioral therapies for body dys-
morphic disorder focus on challenging clients'
health are dismissed as understandable when in

I was immediately struck by her general fact these worries indicate that they are suffering
level of anxiety. For example, she expressed from GAD.
fears about her ability to get her husband to take Panic disorder is relatively rare in later life
her to an appointment and was concerned that (Bryant et al., 2008). One epidemiological study es-
she might not be the right type of person for timated that only 0.1 percent of people over age
psychological treatment. Her anxiety seemed to 65 can be diagnosed with this disorder (Regier et
interfere with her ability to adequately attend to al., 1988). Obsessive-compulsive disorder also is
and process information. For example, she quite rare, diagnosed in only 0.8 percent of the
seemed to have difficulty getting down the di- older people in this study. The symptoms of
rections to my office. She stated that she was posttraumatic stress disorder (PTSD) and acute
concerned about being able to find the building stress disorder, however, are relatively common
and that she would leave her house early in case among older people, often occurring in response
she got lost. Mrs. Johnson was early to her ap- to the loss of a loved one (Bryant et al., 2008).
pointment. She looked distraught throughout Very few older adults seek treatment for anxiety
the session. She wrung her hands, cried on a disorders, and those who do tend to consult their
couple of occasions, and repeatedly stated, "I family physician rather than a mental health profes-
don't want to be a burden:' sional (Scogin et al., 2000). For those older people
Her main concern was that due to her recent who do seek help, cognitive-behavioral therapy has
surgery, she might not be able to continue living been shown to be effective in treating their anxiety
in the home she and her husband had lived in symptoms (Wetherell, Lenze, & Stanley, 2005).
most of her adult life. She was extremely afraid Physicians frequently prescribe an antianxiety
of having a fall and not being found for hours. drug, such as a benzodiazepine, when an older pa-
Mrs. Johnson stated that when she was tient complains of anxiety. With age come changes
raising her children, she worried about their in drug absorption and distribution, metabolism,
education and about money. Her children were and sensitivity to side effects. Side effects such as
living various distances away from her, so that unsteadiness can lead to falls and bone fractures
their invo lvement, at least physically, was not (Scogin et al., 2000). Also, tolerance can develop
an option. Mrs. Johnson indicated that she with prolonged use of the benzodiazepines, leading
loved all her children but that she worried to severe withdrawal effects and the rebound of
about two of them. Both had been divorced anxiety symptoms when the person discontinues
and she was concerned about their well-being their use. Antidepressant drugs, including buspi-
and that of her three grandchildren. She re- rone and the selective serotonin reuptake inhibitors,
ported not having the desire to eat because her are increasingly used to treat anxiety symptoms
stomach was "fluttery." I asked, "Do you find and have fewer side effects and withdrawal effects
yourself worrying about things?" to which she than the benzodiazepines. Older adults often are
responded, "Yes, a lot. I worry that I've begun taking several prescription and over-the-counter
to be a burden for my husband. I worry about medications that can interact with psychotropic
my hip and I worry about not being able to drugs. All these factors make the management of
get around. I guess I'm crazy because I worry drug therapy in older adults more complex than in
about being worried so much:' I assured her younger adults (Scogin et al., 2000).
that she was not crazy, just anxious, which can
oftentimes make you feel like you are crazy.
(Adapted from Scogin, Floyd, & Forde, 2000,
pp. 117-118) CHAPTER INTEGRATION
Biology clearly influences the experience of anxi-
ety. Evolution has prepared our bodies to respond
to threatening situations with physiological
Mrs. Johnson was diagnosed with generalized changes that make it easier for us to flee from or
anxiety disorder. One study estimated that 7.3 per- confront a threat. For some people, this natural
cent of older adults suffer from GAD (Beekman physiological response may be impaired, leading
et al., 1998). This rate is lower than the rate among to overreactivity, chronic arousal, or poorly regu-
young adults, but, as in young adults, women are lated arousal. These people may be more prone to
about twice as likely as men to suffer from the dis- severe anxiety reactions to threatening stimuli and
order. Older adults may worry more about health to anxiety disorders.
and about family issues than do younger adults Psychological and social factors also clearly
(Scogin et al., 2000). Too often, their worries about play a role in anxiety and the anxiety disorders.
Traumatic experiences lead to the development of Vulnerability-Stress Models. Vulnerability-

some anxiety disorders, particularly PTSD. People stress models of anxiety disorders describe how
differ in what they perceive as threatening, leading biological, psycho logical, and social factors
to differences in the level of anxiety they feel in po- work together to create these disorders.
tentially threatening situations. These differences
may be due to specific traumas that some people
have experienced or to people's upbringing. A Vulnerabilities
child may develop a phobia of dogs because her Biological: genetics, poorly
mother modeled a fearful response to dogs. An- regulated autonomic nervous
other child may be chronically anxious and may system, chronic anxiety or
depression
believe he must be perfect because his parents pun-
ish him severely if he makes any type of mistake.
Vulnerability (diathesis)-stress models (Fig-
ure 5.9) stipulate that people who develop an anxi-
1
Psychological: catastrophizing,
New stressors
ety disorder have pre-existing biological or
psychological vulnerabilities due in part to trauma
absolutist thinking,
hypervigilance for threat + or traumas
or severe stress and that these vulnerabilities inter-

act with new stressors to create anxiety disorders.
Such models help explain why some people, but
1
Social: past experience of
not others, experience anxiety so severe and traumas, upbringing that
chronic that it develops into a disorder. enhanced anxiety
Neither posttraumatic stress disorder nor acute startle response he had in the interchange with his
stress disorder applies to Ramon. Although his re- boss seems to be an isolated incident, and his sleep
current nightmares meet the reexperiencing crite- difficulties are caused primarily by his nightmares.
rion for PTSD and acute stress disorder, he actively For now, Ramon appears to be having an un-
thinks about the accident rather than avoiding derstandable, but not diagnosable, reaction to a
thoughts of it. We have no evidence that he displays very frightening event. If you were his psycholo-
a lack of interest in activities, feels detached or es- gist, you would want to check up in a week or two.
tranged from others, has restricted affect, or has a If his nightmares and thoughts about the accident
sense of a foreshortened future or other negative be- persist, and if they begin to more significantly im-
liefs or thoughts. We also lack evidence that Ramon pair his functioning, you might then diagnose him
has significant arousal symptoms; the exaggerated with an adjustment disorder.
THINK CRITICALLY
The diagnosis of PTSD has been questioned recently Vlahov, 2006). This was a randomly selected sample
on two fronts. First, some researchers suggest that of people with a range of exposure to the attack, but
the criteria for PTSD are too broad and that too many even those most directly affected showed resilience-
stressful events are accepted as possible triggers over half who saw the attack in person or lost a
(Spitzer, First, & Wakefield, 2007). The criteria for friend or relative did not develop PTSD symptoms.
PTSD in the DSM-5 have been narrowed somewhat, Among the 22 participants who had been in the
which may reduce the number of people meeting World Trade Center at the time, 7 developed PTSD,
the criteria for the diagnosis. Second, the PTSD field while 5 had two or fewer symptoms and 10 had only
has been criticized for ignoring evidence that most one symptom or none at all (Bonanno et al., 2006).
people who experience severe trauma do not de- Have mental health professionals exaggerated
velop significant symptoms of PTSD or other mental the effects of trauma on mental health? Or should
disorders. A study of New Yorkers 6 months after the PTSD have a broad definition so that individuals
attacks on the World Trade Center in 2001 found that who suffer after experiencing a trauma are not over-
65 percent of the 2,752 adults studied had at most looked? (Discussion appears on p. 482 at the back of
one PTSD symptom (Bonanno, Galea, Bucciarelli, & this book.)
148 Chapter 5 Trauma, Anxiety, Obsessive-Compu lsive, and Related Disorders
CHAPTER SUMMARY ~
Posttraumatic stress disorder (PTSD) occurs after develop phobias to objects our distant ancestors
exposure to actual or threatened death, serious had reason to fear, such as snakes.
injury, or sexual violation. It manifests four types Behavioral treatments focus on extinguishing
of symptoms: (1) repeatedly reexperiencing the fear responses to phobic objects and have proven
traumatic event through intrusive images or effective. People with blood-injection-injury
thoughts, recurring nightmares, flashbacks, and phobias must learn to tense their muscles when
psychological and physiological reactivity to they confront their phobic objects to prevent
stimuli that remind the person of the traumatic decreases in blood pressure and heart rate. Drug
event; (2) avoidance of anything that might therapies have not proven useful for phobias.
arouse memories of the event; (3) negative cog-
nitive and emotional symptoms; and (4) hyper- Social anxiety disorder is fear of being judged or
vigilance and chronic arousal. embarrassed.
A subtype of PTSD is characterized by prominent Cognitive theories suggest that social anxiety
dissociative (depersonalization/derealization) disorder develops in people who have overly
symptoms. high standards for their social performance, as-
sume others will judge them harshly, and give
Acute stress disorder has symptoms similar to biased attention to signs of social rejection.
those of PTSD but occurs within 1 month of a
stressor and usually lasts less than 1 month. Antidepressant drugs show some effectiveness
in the treatment of social anxiety symptoms, and
Social factors appear to influence the risk for cognitive-behavioral therapy has also been
PTSD. The more severe and longer-lasting a proven effective.
trauma and the more deeply involved a person
is in it, the more likely he or she is to develop A panic attack is a short, intense experience of
PTSD. People with less social support are at several physiological symptoms of anxiety, plus
increased risk. thoughts that one is going crazy, losing control,
or dying. Panic disorder is diagnosed when a
Psychological factors also play a role in PTSD. person has spontaneous panic attacks frequently,
People who are already depressed or anxious worries about having them, and changes his or
before a trauma or who cope through avoidance her lifestyle as a result.
or -dissociation may be at increased risk.
One biological theory of panic disorder holds
The biological factors that increase vulnerability that sufferers have overreactive autonomic ner-
to PTSD may include abnormally low cortisol vous systems, putting them into a full fight-or-
levels and a genetic risk. People with PTSD flight response with little provocation. This
show hyperarousal of the amygdala, atrophy reaction may be the result of imbalances in nor-
in the hippocampus, and exaggerated heart rate
epinephrine or serotonin in areas of the brain
responses to stressors. stem and the limbic system . Evidence of genetic
Effective treatment for PTSD exposes a person to contributions to panic disorder also exists.
memories of a trauma through systematic desen-
Psychological theories of panic disorder suggest
sitization to extinguish the anxiety these memories
that afflicted people pay close attention to bodily
elicit. Cognitive techniques that help clients de-
sensations, misinterpret these sensations in neg-
velop more adaptive viewpoints on the trauma are
ative ways, and engage in snowballing or cata-
also useful. Some people cannot tolerate such ex-
strophic thinking, which increases physiological
posure, however, and may do better with stress-
activation and promotes a full panic attack.
inoculation therapy to reduce and prevent stress.
Antidepressants and benzodiazepines are effec-
The benzodiazepines and antidepressant drugs
tive in reducing panic attacks and agoraphobic
can quell some of the symptoms of PTSD.
behavior, but people tend to relapse when they
The specific phobias are fears of certain objects discontinue the drugs.
or situations. Common categories are animal
An effective cognitive-behavioral therapy for
type, natural environment type, situational type,
panic attacks and agoraphobia teaches clients to
and blood-injection-injury type.
use relaxation exercises and to identify and chal-
Behavioral theories suggest that phobias de- lenge their catastrophic styles of thinking, often
velop through classical and operant condition- during panic attacks induced in therapy sessions.
ing. The person has learned that avoiding the Systematic desensitization techniques reduce
phobic object reduces fear, so avoidance is rein- agoraphobic behavior.
forced. Phobias also develop through observa- People with generalized anxiety disorder (GAD)
tional learning. It appears that, through prepared are chronically anxious in most situations.
classical conditioning, humans more readily Cognitive theories argue that people with GAD
Key Term s 149
appear more vigilant toward threatening infor- People with body dysmorphic disorder are ex-
mation, even on an unconscious level. cessively preoccupied with a part of their body
that they believe is defective but that others see
Benzodiazepines can produce short-term relief
as normal or only slightly unusual.
for some peop le with GAD but are not suitable in
long-term treatment. Antidepressants appear One biological theory of obsessive-compulsive
helpful in treating GAD. disorder (OCD} and related disorders speculates
that they result from abnormalities in a brain cir-
Cognitive-behavioral therapies focus on chang-
cuit that projects from specific areas of the frontal
ing the catastrophic thinking styles of people
cortex to areas of the basal ganglia called the stri-
with GAD and have been shown to reduce acute
atum, then through the basal ganglia to the thala-
symptoms and prevent relapse in most patients.
mus, and then loops back to the frontal cortex.
People (mostly children} w ith separation anxiety Dysfunction in these areas may result in the sys-
disorder become excessively anxious when apart tem's inability to turn off the primitive urges (e.g .,
from their attachment figures. aggressive urges} or the execution of the stereo-
Separation anxiety disorder may stem from a typed behaviors. These brain areas are rich in the
general biological vulnerability to shyness and neurotransmitter serotonin. Drugs that regulate
behavioral inhibition. The parents of children serotonin have proven helpful in treatment.
with separation anxiety have also been shown to Cogn itive-behavioral theories suggest that people
be overprotective and controlling. with OCD judge the occasional intrusive thoughts
Obsessions are thoughts, images, ideas, or im- that most peop le have as unacceptable and be-
pulses that are persistent, intrusive, and distress- lieve they should be able to control all their
ing. They commonly focus on contamination, sex, thoughts. Studies further suggest that people
violence, and repeated doubts. Compulsions are with OCD are overly moralistic and prone to feel-
repetitive behaviors or mental acts the individual ing excessively responsible for their own and oth-
feels he or she must perform to dispel obsessions. ers' well-being. Compulsive behaviors develop
through operant conditioning when people are
People with hoarding disorder collect objects and
reinforced for behaviors that reduce their anxiety.
have great difficulty giving up their possessions.
The most effective drug therapies for OCD and
People diagnosed with hair-pul ling disorder
related disorders are the SSRis.
(trichotillomania} have a history of pulling out
their hair, resulting in noticeable hair loss. People Exposure and response prevention has also
with skin-picking disorder recurrently pick at scabs proven to be an effective therapy for OCD and
or places on their skin, creating significant lesions related disorders.
that often become infected and cause scars.
KEY TERMS
anxiety 107 panic attacks 127
fight-or-flight response 108 panic disorder 127
cortisol 108 locus ceruleus 129
posttraumatic stress disorder (PTSD} 110 anxiety sensitivity 130
acute stress disorder 110 interoceptive awareness 130
PTSD with prominent dissociative interoceptive conditioning 130
(depersonalization/derealization} symptoms 113 conditioned avoidance response 130
adjustment d isorder 113 generalized anxiety disorder (GAD} 132
stress-inoculation therapy 118 separation anxiety disorder 135
specific phobias 118 behavioral inhibition 137
animal-type phobias 118 obsessions 139
natural environment type phobias 118 compulsions 139
situational type phobias 119 obsessive-compulsive disorder (OCD} 139
blood-injection-injury type phobias 120 hoarding 141
_.--"' agoraphobia 120 hair-pulling disorder (trichotillomania} 142
negative reinforcement 121 skin-picking disorder 142
prepared classical conditioning 122 body dysmorphic disorder 142
applied tension technique 123 exposure and response prevention 145
social anxiety disorder 124
Somatic Symptom and
Dissociative Disorders
CHAPTER OUTLINE
Somatic Symptom and Dissociative Shades of Gray Discussion

Disorders Along the Continuum
Think Critically
Extraordinary People: Anna 0.,
The Talking Cure Chapter Summary
Somatic Symptom Disorders Key Terms
Shades of Gray
Dissociative Disorders
Chapter Integration
Somatic Symptom and Dissociative Disorders Along
the Continuum
Potentially meets diagnostic
criteria for a dissodative or
somatic symptom disorder: likely meets diagnostic
Dissodative experiences that criteria for a dissodative or
Transient dissodative More frequent dissodative
experiences not due to stress, interfere with daily functioning somatic symptom disorder:
experiences, sometimes
(not being able to recall Dissociative experiences that
resulting from stress, sleep sleep deprivation , or substance
substantial parts of the day, are chronic and significantly
deprivation, substance use use (frequently forgetting
conversations you have had or finding yourself someplace and int erfere with functioni ng
(zoning out during a
conversation or while driving) where you were earlier in the day) not knowing how you got there)
Transient physical Occasionally worrying Frequently worrying Ch ronically worrying

symptoms or fears about about your health about your health and about health, seeking
health experienced durin g with little reason scanning your body for medical attention, and
times of st ress any medical problems fearing the medical
seriousness of you r
symptoms
The disorders we discuss in this chapter are considered by some But even these more bizarre experiences happen, at least occa-
theorists to be associated with a psycho logical process known as sionally, to a substantial percentage of the general population.
dissociation, in which different parts of an individual's identity, Fatigue and stress are probably the most common causes of dis-
memory, or consciousness split off from one another. You may sociation . A study of mentally healthy soldiers undergoing sur-
not realize it, but you likely have had dissociative experiences vival training in the U.S. Army found that over 90 percent
(Aderibigbe, Bloch, & Walker, 2001; Seedat, Stein, & Forde, reported dissociative symptoms in response to the stress of the
2003) : You are driving down a familiar road, thinking about a re- training; the symptoms included feeling separated from what
cent conversation with a friend, and suddenly you real ize that was happening, as if they were watching themselves in a movie
you've d riven several miles and don't remember traveling that (Morgan et al., 2001 ). A small subset of people, however, have
section of the road. That's a dissociative experience, as is day- frequent dissociative experiences and as a result have difficulty
dreaming. When we daydream, we can lose consciousness of functioning in dai ly life.
where we are and of what is going on around us. Becoming ab- Just as we all experience mild dissociative symptoms,
sorbed in a movie or a book is also a d issociative experience. many of us "carry o ur stress in our body," experiencing tension
Researcher Colin Ross (1997) asked more than a thousand and distressing or preoccupying aches, pains, and health con-
adults from the general community about a number of different cerns when we feel stress. This may be the result of dissociation
dissociative experiences. Missing part of a conversation appears in which our consciousness of our psychological pain is dimin-
to be the most common dissociative experience (reported by ished and instead we are aware only of physical pain . Usually,
83 percent of people), followed by being unsure of whether you these aches and pains subside when our stress subsides. For a
have actually carried through with something (such as brushing small number of people, however, their attention to their per-
your teeth) or have only thought about doing it (reported by ceived aches and pains is chronic and they have very high levels
73 percent). These experiences are not harmful. Farther down of worry about illness, resulting in significant functional impair-
the list are somewhat more bizarre experiences, such as hearing ment. Their lives focus excessively on fears about their physical
voices in your head (reported by 26 percent), feeling as though health, and they may be diagnosed with a somatic symptom
your body is not your own (reported by 23 percent), and not disorder. Whether or not a person's symptoms are medically
recognizing objects or other people as real (reported by 26 percent) . explained, their suffering is real.
Somatic Symptom a nd Dissociative Disorders Along the Continuum 151

152 Chapter 6 Somatic Symptom and Dissociative Disorders
Anna 0., The Talking Cure
One of the most fa- (quoted in Edinger, 1963). These new disturbances
mous cases in the were a variety of physical ailments that didn't ap-
annals of psychology pear to have any physical causes. She experienced
and psychiatry was that head pain, dizziness and profound visual distur-
of Anna 0 ., a young bances, an inability to move her head and neck,
woman whose real and numbness and contractions in her lower-right
name was Bertha limbs. Breuer treated Pappenheim by asking her to
Pappenheim. She was talk about her symptoms under hypnosis, and after
born in Vienna in 18 months her symptoms seemed to subside.
1859 into a we a Ithy Pappenheim dubbed this the "talking cure:' After
Orthodox Jewish fam- Breuer told her that he thought she was well and
ily. Highly intelligent, she craved intellectual stimu- he would not be seeing her again, he was called to
lation but rarely received it after leaving school. She her house later that evening, where she was
was strong-willed and slightly temperamental. In thrashing around in her bed, going through imagi-
1880, at age 21, Pappenheim became ill while caring nary childbirth . She claimed that the baby was
for her father during his serious illness and eventual Breuer's. He calmed her down by hypnotizing her,
death. Josef Breuer, a colleague of Freud who but he soon fled the house and never saw her
treated Pappenheim, noted, "Up to the onset of again. Breuer collaborated with Sigmund Freud in
the disease, the patient showed no sign of nervous- writing about Anna 0., and their descriptions of
ness, not even during pubescence .... Upon her the talking cure launched psychoanalysis as a form
father's illness, in rapid succession there seemingly of psychotherapy.
developed a series of new and severe disturbances"
Bertha Pappenheim, or Anna 0., appeared to suf- SOMATIC SYMPTOM

fer from what the DSM-5 calls a somatic symptom
disorder-she experienced physiological symp-
DISORDERS
toms that Breuer argued were the result of painful As noted in previous chapters, drawing sharp
emotions or memories. In this chapter, we discuss distinctions between the body and the mind is
the somatic symptom disorders as well as the dis- becoming increasingly unfounded as we come to
sociative disorders, in which people develop multi- understand how intertwined biological and psy-
ple separate personalities or completely lose their chological factors are. The somatic symptom dis-
memory of significant portions of their lives. The orders are a prime example of the fluid boundary
somatic symptom disorders and dissociative dis- between mind and body. People with these disor-
orders have historically been thought to result ders may experience significant physical symp-
from similar processes-patients cannot confront toms for which there is no apparent organic cause,
difficult emotions and stressful experiences, so but this seems to be the result of psychological fac-
they unconsciously convert their emotions into tors. They are often excessively concerned about
physical and psychological symptoms. As seen in their symptoms and spend a great deal of time
the story of Bertha Pappenheim, these phenomena worrying and seeking medical treatment.
provided the material for much of the early theo- One difficulty in diagnosing somatic symptom
rizing by Breuer, Freud, and other psychoanalysts. disorders is the possibility that an individual has a
In recent years, these disorders and the idea that real physical disorder that is difficult to detect or ~
people can completely lose conscious access to diagnose. Many of us have friends or relatives who
painful memories and emotions have become con- have complained for years about symptoms that
troversial. We discuss this controversy at the end physicians attributed to "nervousness" or "atten-
of the chapter. tion seeking" but that later were determined to be
early symptoms of serious disease. The diagnosis of asthma (Everson-Rose & Lewis, 2005; Katon, 2003).
somatic symptom disorder is easier when psycho- We will discuss the effects of psychological factors
logical factors leading to the development of the on medical conditions in detail in Chapter 15. In
symptoms can be identified clearly or when physi- this chapter, we focus on disorders in which there
cal examination proves that the symptoms are not are distressing somatic symptoms along with
physiologically possible. For example, when a child abnormal thoughts, feelings, and behaviors in
is perfectly healthy on weekends but has stomach- response to these bodily symptoms. Medically un-
aches in the morning just before going to school, it is explained symptoms are present to varying
possible that the stomachaches are due to distress degrees, particularly in conversion disorder where
over going to school. A more extreme example of a psychological factors are assumed to underlie the
clear somatic symptom disorder is pseudocyesis, or symptoms.
false pregnancy, in which a woman believes she is
pregnant but physical examination and laboratory Somatic Symptom Disorder
tests confirm that she is not. Bertha Pappenheim and Illness Anxiety Disorder
apparently displayed pseudocyesis.
The category of somatic symptom disorders A person with somatic symptom disorder has one
includes five specific disorders. The first is simply or more distressing physical symptoms and spends
called somatic symptom disorder. This disorder is a great deal of time and energy thinking about
new to the DSM-5 and combines a number of diag- these symptoms and seeking medical care for
noses from the DSM-IV-TR that were difficult to them. They can be gastrointestinal symptoms (e.g.,
distinguish. Other disorders in the somatic symp- nausea, diarrhea), pain symptoms, neurological
tom disorders category are illness anxiety disorder symptoms (e.g., dizziness, tremors), or symptoms
(formerly hypochondriasis), conversion disorder, affecting any part of the body. Although anyone
and factitious disorder. One final diagnosis in this with painful or life-threatening symptoms might
category of disorders is psychological factors affect- be preoccupied with them and seek alternative
ing other medical conditions (sometimes referred to opinions about their causes and treatments, people
as psychosomatic disorders), in which people have with somatic symptom disorder have health con-
an actual, documented physical illness or defect, cerns that are excessive given their actual physical
such as high blood pressure, that is worsened by health, that persist even when they have evidence
psychological factors. For example, depression can that they are well, and that interfere with their
exacerbate a number of medical diseases, includ- daily functioning (see Table 6.1). When they experi-
ing cancer, heart disease, diabetes, arthritis, and ence a symptom, they may assume the worst-that
TABLE 6.1 DSM-5 Diagnostic Criteria for Somatic Symptom Disorder
A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns
as manifested by at least one of the following :
1. Disproportionate and persistent thoughts about the seriousness of one's symptoms.
2. Persistently high level of anxiety about health or symptoms.
3. Excessive t ime and energy devoted to these symptoms or health concerns.
C. Although any one symptom may not be continuously present, the state of being symptomatic is persistent
(typically more than 6 months).
Specify if:
With predominant pain, for individuals whose somatic symptoms predominantly involve pain.
Persistent: characterized by severe symptoms, marked impairment, and long duration (> 6 months).
Mild (only one Criterion B symptom); Moderate (two or more Criterion B symptoms); Severe (two or more
Criterion B symptoms, and multiple or one very severe somatic complaint).
Source: Reprinted with perm ission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition . Copyright 2013
American Psychiatric Association .
it is cancer, a heart attack, a stroke, and so on. They worry that they will develop or have a serious ~
may insist on medical procedures-even surgeries- illness but do not always experience severe physical
that clearly are unnecessary. They may avoid a symptoms (Table 6.2). However, when they do have
wide range of activities, fearing exacerbation of physical complaints, people with illness anxiety
their symptoms, to the point that they become iso- disorder become very alarmed and are more likely
lated and inactive (Martin & Rief, 2011). For others, to seek immediate medical care. People with illness
their health concerns become a core feature of their anxiety disorder may go through many medical
identity and dominate their interpersonal relation- procedures and float from physician to physician,
ships. Often, the fears and complaints focus on a sure that they have a dreadful disease. They may
particular organ system. Carlos, in the following insist that toxins or other environmental condi-
case study, was convinced something was wrong tions are affecting their health, despite evidence to
with his bowels. the contrary. One extensive community study in
Germany found that the majority of individuals
had multiple concerns about the health effects of
environmental toxins, most often pesticides, hor-
. CASE STUDY mones or antibiotics in food, or genetically modi-
Carlos, a married man of fied food (Rief et al., 2012).
39, came to the clinic complaining, "I have trou-
ble in my bowels and then it gets me in my head.
My bowels just spasm on me, I get constipated:'
The patient's complaints dated back 12 years to TABLE 6.2 DSM-5 Diagnostic Criteria
an attack of "acute indigestion" in which he for Illness Anxiety Disorder
seemed to bloat up and pains developed in his
A. Preoccupation with having or acqu iring a serious
abdomen and spread in several directions. He
illness.
traced some of these pathways with his finger as
he spoke. Carlos spent a month in bed at this B. Somatic symptoms are not present or, if present,
are only mild in intensity. If another med ical
time and then, based on an interpretation of
condition is present or there is a high risk of
something the doctor said, rested for another
developing a medical condition (e.g ., strong
2 months before working again. Words of reas- family histo ry is present), the preoccupation is
surance from his doctor failed to take effect. He clearly excessive or disproportionate.
felt "sick, worried, and scared;' feeling that he
C. There is a high level of anxiety about health,
would never really get well again.
and the individual is easily alarmed about
Carlos became very dependent on the personal health status.
woman he married when he was 22 years old. He
D. The ind ividua l performs excessive health-
left most of the decisions to her and showed little
related behaviors (e .g., repeatedly checking his
interest in sexual relations. His wife was several
or her body for signs of illness) or exhibits
years older than he and did not seem to mind his
maladaptive avoidance (e.g ., avoiding doctor
totally passive approach to life. His attack of appointments and hospitals).
"acute indigestion" followed her death, 5 years
E. Illness preoccupation has been present for at
after marriage, By 3 months during which he felt
least 6 months, but the specific illness that is
lost and hopeless. In time, he moved to a rural
feared may change over that period of time.
area and remarried. His second wife proved less
F. The illness-related preoccupation is not better
willing to assume major responsibility for him
explained by another mental disorder, such as
than the first, and she made sexual demands on
somatic symptom disorder, panic disorder,
him that he felt unable to meet. He became more
generalized anxiety disorder, body dysmorphic
and more preoccupied with his gastrointestinal disorder, obsessive-compulsive disorder or
welfare. (Adapted from Cameron & Rychlak, 1985) delusional disorder, somatic type.
Specify whether:
Care-seeking type: Medical care is frequently used.
Illness anxiety disorder is very similar to so- Care-avoidant type: Medical care is rare ly used.
matic symptom disorder. The primary distinction
in the DSM-5 between the two disorders is that Source: Reprinted with perm issio n from t he Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition.
people with somatic symptom disorder actually Copyright 201 3 American Psychiat ri c Association .
experience physical symptoms and seek help for
them, whereas people with illness anxiety disorder
SHADES OF GRAY
Consider this description of a young boy with Ben's health worries seem to have started
health worries. about 8 months ago, after he had a serious case of
the flu that kept him home in bed for over a week.
Ben is a 9-year-old whose teachers refer to him as Shortly after that, his parents separated because of
"the worrier:' At least once a week, he ends up in marital conflict that had been escalating for years.
the school nurse's office with complaints of a When his mother has tried to talk with Ben about
headache or a stomachache, insisting he needs to the possibility that his aches and pains are con-
rest or go home. The school nurse always dutifully nected to his parents' separation, he has acknowl-
takes Ben's temperature, which is always normal. edged that this could be true. But within a few days,
Still, Ben will not go back to class. His frequent he has experienced another headache or stomach-
absences are causing his grades to decline. Ben's ache, saying "This time it's real, and it really hurts!"
mother has taken him to his pediatrician a number
of times, and multiple tests have revealed no med- Does Ben appear to have a somatic symptom dis-
ical problems that could be causing his frequent order? If so, which one? (Discussion appears at
headaches and stomachaches. the end of this chapter.}
People with somatic symptom disorder or ill- feel "bad" or that they have a stomachache or a
ness anxiety disorder may be prone to periods of headache.
anxiety and depression. They may express their The experience of multiple somatic symptoms
distress as physical symptoms or mask the distress and health concerns tends to be long-term and dis-
with alcohol abuse or antisocial behavior (Feder abling (Rief et al., 2011). One longitudinal study
et al., 2001; Katon, Sullivan, & Walker, 2001; Noyes found that people with many health complaints
et al., 2001). Their symptoms and health concerns but no diagnosed medical illness were more likely
become their identity. Moreover, changes in their to suffer disability, low income, impaired sleep,
symptoms mirror their emotional well-being: and psychological distress (Ladwig et al., 2010).
When they are anxious or depressed, they report They also were more likely to develop high blood
more physical complaints and worries than when pressure, obesity, and high cholesterol, were hos-
they are not anxious or depressed (Craig, Boardman, pitalized more often, and were more likely to die
Mills, & Daly-Jones, 1993). in the 12-year follow-up than people with few
Studies find that a large percentage of the pop- health complaints.
ulation complain of multiple somatic symptoms
and health concerns that are not well-explained by Theories of Somatic Symptom Disorder
a medical condition (Ladwig et al., 2010; Rief et al., and Illness Anxiety Disorder
2011). For example, one large study of patients Cognitive factors are thought to play a strong role
seeking care in cardiology, neurology, respiratory, in somatic symptom disorder and illness anxiety
and gastrointestinal clinics found that nearly disorder (Rief et al., 2010; Voigt et al., 2010). People
20 percent had excessive illness anxiety (Tyrer et al., with these disorders often have dysfunctional be-
2011). Multiple symptom complaints and concerns liefs about illness, assuming that serious illnesses
about health are more common in older adults are common, and tend to misinterpret any physi-
than in middle-aged adults, even after taking into cal change in themselves as a sign for concern
account the increased incidence of medical illness (Marcus & Church, 2003). They believe they are
with age (Feder et al., 2001; Ladwig et al, 2010) . vulnerable to a wide range of physical illnesses and
The cultural norms with which older adults were unable to tolerate pain (Rief et al., 2010). People
raised often prohibited admitting to depression or with somatic symptom disorder tend to experi-
anxiety. For this reason, older adults who are de- ence bodily sensations more intensely than other
pressed or anxious may be more likely to express people, to pay more attention than others to physi-
their negative emotions in somatic complaints, cal symptoms, and to catastrophize these symp-
which are acceptable and expected in old age. toms (Figure 6.1) (Kirmayer & Taillefer, 1997; Martin
Young children also often express their distress in & Rief, 2011). For example, a person with somatic
somatic complaints (Garber, Walker, & Zeman, symptom disorder might have a slight case of indi-
1991). While they may not have the language to gestion but experience it as severe chest pain and
express difficult emotions, they can say that they interpret the pain as a sure sign of a heart attack.
reinforced, increasing the likelihood that he will

A Model of Somatic Symptom Disorder.
1
interpret future symptoms similarly.
!' FIGURE 6.1 Biological and psychosocial factors may
Multiple health complaints and excessive
r combine to lead to somatization disorder.
health concerns run in families, primarily among
I
" female relatives (Phillips, 2001). Anxiety and de-
Medical illness, Interpersonal pression are also common in the female relatives of
everyday conflict, emotional people with these symptoms (Garber et al., 1991).
physiological distress, psychiatric
perturbations disorder, stress, The male relatives of people with multiple, exces-
or trauma sive health complaints also have higher than usual
rates of alcoholism and antisocial personality dis-
!
Physiological
order. It is not clear that the transmission of multi-
ple somatic symptoms and health concerns in
disturbance families is related to genetics (Gillespie et al., 2000).
The children of parents who catastophize their so-
Attention to body j matic symptoms may model their parents' think-

ing styles and health behaviors (Marshall et al.,
2007). Parents who somatize also are more likely to
neglect their children, and the children may learn
that the only way to receive care and attention is to
be ill. This finding is in accord with a behavioral
account of somatic complaints and health con-
cerns, which views them as the result of reinforce-
Previous illness Illness worry,
experience catastrophizing, ments for "sickness behavior" that individuals
demoralization have received over much of their lives (Ullman &
Krasner, 1975).
Somatic symptom disorder and illness anxiety
Help seeking disorder may be part of post-traumatic stress dis-
order experienced by a person who has survived a
severe stressor (Katon et al., 2001; Pribor, Yutzy,
Dean, & Wetzel, 1993). For example, refugees and
Family, health care
providers, work recent immigrants w ho have post-traumatic stress
conditions, disability disorder also have been shown to have an increased
insurance, and risk of somatic symptoms and health concerns
compensation system Social response (Cervantes, Salgado de Snyder, & Padilla, 1989).
One study of Hmong immigrants to the United
States, who had fled Cambodia during the Khmer
Source: Reprinted from p. 353 of "'Somatoform Disorders, "' by L. J . Kirm aye r and Rouge regime, found that 17 percent had post-
S. Taillefer. InS. M . Turner and M . Hersen (Eds.), Adult Psychopatholog y and
Diagnosis, 3rd ed. , 1997, pp. 333-383. Copyright 1997 John Wiley & Sons, Inc.
traumatic stress disorder characterized by moder-
Reprinted with permission of John Wiley & Sons, Inc. ate to severe somatic symptoms (Westermeyer,
Bouafuely, Neider, & Callies, 1989).
Treatment of Somatic Symptom Disorder

and Illness Anxiety Disorder
The person's interpretation of his experience may Convincing people with these disorders that they
have a direct influence on his physiological pro- need psychological treatment is not easy. They
cesses by increasing his heart rate or blood pres- may continue to insist that they are physically ill
sure, thereby maintaining and exacerbating the despite dozens of physicians telling them they are
pain. Further, his cognitions will influence the way not and hundreds of medical tests establishing no
he presents his symptoms to his physician and his physical illness. Psychodynamic therapies focus
family. As a result, the physician may prescribe on providing insight into the connections between
more potent medication or order more diagnostic emotions and physical symptoms by helping peo-
tests, and family members may express more sym- ple recall events and memories that may have
pathy, excuse the person from responsibilities, and triggered their symptoms. Behavioral therapies
otherwise encourage passive behavior (Turk & attempt to determine the reinforcements individu-
Ruby, 1992). In this way, the person's misinterpre- als receive for their symptoms and health com-
tation and catastrophizing of his symptoms are plaints and to eliminate these reinforcements while
increasing positive rewards for healthy behavior. therapy or another type of psychotherapy used by
Cognitive therapies for these disorders help peo- the dominant, non-Hispanic culture but rather the
ple learn to interpret their physical symptoms ap- cultural belief system concerning the role of spirits
propriately and to avoid catastrophizing them, in producing physical symptoms.
similar to the cognitive treatment of panic symp-
toms (see Chapter 5; Abramowitz & Braddock,
2011). Cognitive-behavioral treatments that focus Conversion Disorder
on identifying and challenging illness beliefs and (Functional Neurological
misinterpretations of physical sensations have
shown some positive effects (Kroenke, 2009). Anti-
Symptom Disorder)
depressants can also reduce somatic symptoms. A dramatic type of somatic symptom disorder is
Some clinicians use the belief systems and cul- conversion disorder (Table 6.3). People with this
tural traditions of individuals they are treating to disorder lose neurologic functioning in a part of
motivate them to engage in therapy and help them their bodies, apparently not due to medical causes.
overcome their physical complaints. Following is a Some of the most common conversion symptoms
case study that shows the use of cultural beliefs in are paralysis, blindness, mutism, seizures, loss of
treating a Hispanic woman with somatic symptom hearing, severe loss of coordination, and anesthe-
disorder. sia in a limb. One particularly dramatic conversion
symptom is glove anesthesia, in which people
lose all feeling in one hand, as if they were wearing
a glove that wiped out physical sensation. As
CASE STUDY Figure 6.2 shows, however, the nerves in the hand
Ellen was a 45-year-old
woman who consulted many doctors for "high are distributed in a way that makes this pattern of
fever, vomiting, diarrhea, inabi lity to eat, and anesthesia highly unlikely. Conversion disorder
rapid weight loss:' After numerous negative la b typically involves one specific symptom, such as
tests, her doctor told her, "I can't go on with you; blindness or paralysis, but a person can have re-
go to one of the espiritistas or a curandera [tradi- peated episodes of conversion involving different
tional healers]:' A cousin then took her to a parts of the body. The name "conversion disorder"
Spiritist center "for medicine:' She was given presumes that psychological distress, often over a
herbal remedies-some baths and a tea of traumatic event, is "converted" into a physical
molinillo to take in the morning before eating. symptom. Patients and physicians alike often
But the treatment focused mainly on the appear- object to this presumption (Stone et al., 2011), so
ance of the spirit of a close friend who had died a
month earlier from cancer. The spirit was looking
for help from Ellen, who had not gone to help
during her friend's illness because of her own
TABLE 6.3 DSM-5 Diagnostic Criteria
family problems. The main thrust of the healer's
for Conversion Disorder (Functional
treatment plan was to help Ellen understand
Neurological Symptom Disorder)
how she had to deal with the feelings of distress
related to the stress of a paralyzed husband and A. One or more symptoms of altered voluntary
caring for two small daughters alone. The spirit's moto r or sensory function .
influence on Ellen's body was an object lesson B. Clin ical findings provide evidence of
that was aimed at increasing her awareness of incompatibility between the symptom and
how her lifestyle was causing her to neglect the recognized neurolog ical or medical conditions.
care of her own body and feelings much as she
C. The symptom or deficit is not better explained
had neglected her dying friend . (Adapted from by another medical or mental disorder.
Koss, 1990, p. 22)
D. The symptom or deficit causes clinically
sign ifica nt distress or impairment in social,
occupational, or oth er important areas of
The spiritual healer in Ellen's case recognized functioning or warrants medical evaluation.
the cause of her somatic complaints as stress, an-
ger, and guilt; helped her link her physical symp- Source: Reprinted w ith permission from t he Diagnostic and
Statistical Manua l of Mental Disorders, Fifth Edition.
toms to these emotions; and helped her find ways Copyright 2013 American Psych iatric Association .
to cope more adaptively with the emotions. The
context for this intervention was not cognitive
conversion symptoms play in alleviating distress ~

by removing the individual from difficult envi-
ronments and allowing him or her to avoid un-
wanted responsibilities or situations (Deary,
Chalder, & Sharpe, 2007). Conversion symptoms
apparently were quite common during the two
world wars, when soldiers inexplicably would be-
come paralyzed or blind and therefore unable to
return to the front (Ironside & Batchelor, 1945).
Many of the soldiers seemed unconcerned about
their paralysis or blindness, a phenomenon called
la belle indifference. Sometimes, the physical symp-
toms represented traumas the soldiers had wit-
nessed. For example, a soldier who had shot a
civilian in the chest might have chest pains.
Children can also have conversion symptoms.
Most often, their symptoms mimic those of someone
close to them who has a real illness (Grattan-Srnith,
Fairly, & Procopis, 1988; Spierings et al., 1990). For
example, a child whose cherished grandfather has
had a stroke and has lost functioning on his right
side may become unable to use his right arm.
Conversion symptoms may occur among
some victims of sexual abuse (Anderson, Yasenik,
& Ross, 1993; Sar et al., 2004). Consider the follow-
ing case study of a woman who was raped and
later developed both post-traumatic stress disor-
der (see Chapter 5) and conversion mutism.
the DSM-5 parenthetically labels this disorder

functional neurological symptom disorder, a
more neutral name that doesn't presume a psycho- CASE STUDY
logical cause. Unexplained neurological symp- At the time she sought
toms are relatively common. It has been estimated treatment, Jane was a 32-year-old woman living
that 20 percent of patients in neurological clinics with her 15-year-old son and employed as a
have symptoms with no apparent medical cause lower-level executive. When she was 24, two
(Feinstein, 2011). The number of individuals men entered her home after midnight, held a
meeting full criteria for persistent conversion dis- knife to her throat, and threatened to kill her if
order is very low, perhaps around 20 in 100,000 she made a sound or struggled. They raped her
(Feinstein, 2011). orally and vaginally in front of her son, who was
7 at the time, and then locked them in the base-
Theories of Conversion Disorder ment before leaving. Several weeks after the
Freud and his contemporaries viewed conversion rape, Jane's mother, to whom she was very
symptoms as the result of the transfer of the psy- close, died of cancer. Jane felt she had to be "the
chic energy attached to repressed emotions or strong one" in the family and prided herself be-
memories to physical symptoms. The symptoms cause she "never broke down:'
often symbolized the specific concerns or memo- At age 31, during an abusive relationship
ries being repressed. The reduction in anxiety was with a live-in boyfriend, Jane developed conver-
referred to as the primary gain. In addition, patients sion mutism. In the midst of attempting to ask her
receive attention and concern from others and may boyfriend to leave her house, she was unable to
be relieved of obligations and expectations, rein- produce any sound. After several months of treat-
forcing the conversion symptoms. Freud called ment with a speech therapist, Jane became able
this the secondary gain. to whisper quietly but did not regain her normal
Behavioral theories don't infer that conver- speech. The speech therapist referred Jane to a
sion symptoms represent transferred uncon- clinic for the treatment of rape-related PTSD.
scious anxiety, but they do emphasize the role
on insight into the relationship between these and

The pretreatment interview confirmed that the conversion symptoms (Feinstein, 2011). Be-
Jane suffered from chronic PTSD as a result havioral treatments focus on relieving the per-
of the rape. She presented with fears, panicky son's anxiety centered on the initial trauma that
reactions, nightmares, flashbacks, and intrusive caused the conversion symptoms and on reducing
thoughts about the assault. She reported at- any benefits the person is receiving from the con-
tempts to avoid thinking about the assault and version symptoms (Looper & Kirmayer, 2002). For
situations that reminded her of it and feelings of example, the treatment of Jane, the woman in the
detachment from others. She also complained of case study, involved both systematic desensitiza-
sleep problems, exaggerated startle, and hyper- tion therapy and exposure therapy (see Chapters 2
alertness. Jane was moderately depressed and and 5). A hierarchy of situations that Jane avoided-
quite anxious. During the intake interview, Jane mostly situations that reminded her of her rape-
ind icated that she had never verbally expressed was constructed. For the exposure therapy, Jane
her feelings about the assault and believed that was aided in approaching those situations that
this constriction underlay her inability to speak. made her feel anxious and in progressing through
(Adapted from Rothbaum & Foa, 1991) her hierarchy to increasingly more feared situations
while practicing relaxation techniques. During the
imagery sessions, Jane recounted the details of the
Research suggests that people with conversion assault first in general terms and later in great detail,
symptoms are highly hypnotizable (Roelofs et al., including both the details of the situation and the
2002; Stone et al., 2011). This supports the idea that details of her physiological and cognitive reactions
conversion symptoms result from spontaneous to the assault. At first, Jane was able to describe the
self-hypnosis, in which sensory or motor functions assault only in a whisper, but she cried at full
are dissociated, or split off, from consciousness in volume. After crying, Jane's speech became increas-
reaction to extreme stress. ingly louder, with occasional words uttered at full
Neurological models suggest that conversion volume. Eventually, she regained a full-volume
symptoms arise when sensory or motor areas of voice. Following treatment, Jane's PTSD symptoms
the brain are impaired by anxiety (Aybek, Kanaan, also decreased, and they diminished further over
& David, 2008). For example, in a case study of a the next year (Rothbaum & Foa, 1991).
woman with conversion mutism, researchers used
functional neuroimaging to show that there was
normal activity in speech areas of the brain (the
Factitious Disorder
inferior frontal gyrus) when the woman did avo- The final diagnosis in the DSM-5 somatic symptom
calization task, but impaired connectivity between disorder category we will consider is factitious dis-
these speech areas and areas of the brain that regu- order, in which a person deliberately fakes an illness
late anxiety (specifically the anterior cingulate) specifically to gain medical attention and play the
(Bryant & Das, 2012). After this woman received sick role. Factitious disorder is also referred to as
cognitive-behavioral therapy that overcame her Munchhausen's syndrome. Factitious disorder differs
mutism, connectivity between the speech areas from somatic symptom disorder in that factitious
and the areas regulating anxiety was restored, disorder involves evidence that the individual is
whereas the connectivity between speech areas providing false information or behaving decep-
and areas involved in the experience of anxiety tively. Factitious disorder differs from malingering,
(the amygdala) was reduced. Such studies suggest in which people fake a symptom or a disorder in
that conversion disorder does not involve im- order to avoid an unwanted situation, such as mili-
paired activity in areas of the brain associated spe- tary service, or in order to gain something, such as
cifically with the loss of functioning (such as an insurance payment. The major difference be-
speech areas in mutism) but rather changes in con- tween malingering and factitious disorder is the mo-
nectivity between these areas and areas associated tivation for faking symptoms. In malingering the
with the generation and regulation of anxiety. symptoms help an individual avoid an unwanted
situation, while in factitious disorder the symptoms
Treatment of Conversion Disorder are intentionally created to gain medical attention.
~ People with conversion disorder can be difficult to Factitious disorder imposed on another (for-
treat because they do not believe there is anything merly referred to as factitious disorder by proxy) is
wrong with them psychologically. Psychoanalytic diagnosed when an individual falsifies illness in
treatment for conversion disorder focuses on the another (e.g., child, pet, older adult). For example,
expression of painful emotions and memories and parents fake or even create illnesses in their children
in order to gain attention for themselves. They act as no pain during a painful procedure but would re-
devoted and long-suffering protectors of their chil- member the pain when the hypnotist gave them a
dren, drawing praise for their dedicated nursing. specific cue. These subjects indeed showed no
Their children are subjected to unnecessary and of- awareness of pain during the procedure. When
ten dangerous medical procedures and may actually cued, they reported memories of the pain in a
die from their parents' attempts to make them ill. matter-of-fact fashion, as if a lucid, rational ob-
Seven-year-old Jennifer Bush appeared to be server of the event had registered the event for the
one victim of factitious disorder imposed on another. subject. Other research showed that some anesthe-
Jennifer underwent almost 200 hospitalizations and tized surgical patients could later recall, under
40 operations in efforts to cure the puzzling array of hypnosis, specific pieces of music played during
ailments she seemed to have. Her mother, Kathleen the surgery. Again, it was as if a hidden observer
Bush, was with her through it all, dealing with med- was registering the events of the operations even
ical professionals and standing by as the family's while the patients were completely unconscious
finances were ruined by Jennifer's medical bills. All under anesthesia (see Kihlstrom, 2001; Kihlstrom
the while, however, it seems Kathleen Bush was ac- & Couture, 1992; Kirsch & Lynn, 1998).
tually causing her daughter 's illnesses by giving her For most people, the active and receptive
unprescribed drugs, altering her medications, and modes of consciousness weave our experiences
even putting fecal bacteria in her feeding tube. Bush together so seamlessly that we do not notice any
eventually was arrested and convicted of child abuse division between them. People who develop dis-
and fraud and served 3 years in prison (Toufexis, sociative disorders, however, may have chronic
Blackman, & Drummond, 1996). problems integrating their active and their recep-
tive consciousness (Hilgard, 1992; Kihlstrom,
2001). That is, the different aspects of conscious-
DISSOCIATIVE DISORDERS ness in these people do not integrate with each
Scientific interest in dissociative disorders has waxed other in normal ways but instead remain split and
and waned over the past century (Kihlstrom, 2005). operate independently of each other.
There was a great deal of interest in dissociation in We begin our discussion of specific dissocia-
nineteenth-century France and in the United States tive disorders with dissociative identity disorder
among neurologists and psychologists such as (DID), formerly known as multiple personality
Charcot, Freud, CarlJung, and William James. French disorder. We then move to dissociative amnesia
neurologist Pierre Janet viewed dissociation as a and depersonalization/ derealization disorder. All
process in which components of mental experience these disorders involve frequent experiences in
are split off from consciousness but remain accessible which various aspects of a person's "self" are split
through dreams and hypnosis. One case he investi- off from each other and felt as separate.
gated was that of a woman named Irene, who had no
memory of the fact that her mother had died. How- Dissociative Identity Disorder
ever, during her sleep, Irene physically dramatized
~
the events surrounding her mother's death. "' ? ""
After about 1910, interest in dissociative phe- .>CASE'STUDV

;-: r ~
nomena waned, partly because of the rise within Eve White was a quiet,
psychology of behaviorism and biological ap- proper, and unassuming woman, a full-time
proaches, which rejected the concept of repression homemaker and devoted mother to a young
and the use of techniques such as hypnosis in ther- daughter. She sought help from a psychiatrist for
apy. Ernest Hilgard (1977 / 1986) revitalized interest painful headaches that were occurring with in-
in dissociation in his experiments on the hidden ob- creasing frequency. The psychiatrist decided that
server phenomenon. He argued that there is an active her headaches were related to arguments she
mode to consciousness, which includes our con- was having with her husband over whether to
scious plans and desires and our voluntary actions. raise their young daughter in the husband's
In its passive receptive mode, the conscious registers church (which was Catholic) or in her church
and stores information in memory without being (wh ich was Baptist). After undergoing some
aware that the information has been processed, as if marital therapy, Mrs. White's marriage improved
hidden observers were watching and recording and her headaches subsided for a year or so.
events in people's lives without their awareness. Then, her husband recontacted her thera-
Hilgard and his associates conducted experi- pist, alarmed over changes in his wife's behavior.
mental studies in which participants were hypno- She had gone to visit a favorite cousin in a town
tized and given a suggestion that they would feel
Dissociative Disorders 161
50 miles away and during the visit had behaved "Why just fine-never better! How you
in a much more carefree and reckless manner doing yourself, Doc? ... She's been having a
than she usually did. Mrs. White told her hus- real rough time. There's no doubt about that;'
band over the phone that she was not going to the girl said carelessly. "I feel right sorry for
return home, and the two had a terrible fight that her sometimes. She's such a damn dope
ended in an agreement to divorce. When Mrs. though .... What she puts up with from that
White did return home a few days later, however, sorry Ralph White-and all her mooning over
she said she had no memory of the fight with her that little brat ... !To hell with it, I say!" ...
husband or, for that matter, of the visit with her The doctor asked, "Who is 'she'?"
cousin . "Why, Eve White, of course. Your long-
Shortly thereafter, Mrs. White apparently suffering, saintly, little patient:'
went shopping and bought hundreds of dollars "But aren't you Eve White?" he asked.
worth of elaborate clothing, which the couple "That's for laughs;' she exclaimed, a rip-
could not afford. When confronted by her hus- ple of mirth in her tone . . . . "Why, I'm Eve
band about her expenditures, Mrs. White claimed Black;' she said .... "I'm me and she's her-
to have no memory of buying the clothing . self;' the girl added. "I like to live and she
At the urging of her husband, Mrs. White don't. ... Those dresses-well, I can tell you
made an appointment with the therapist whom about them. I got out the other day, and I
she had originally consulted about her head- needed some dresses. I like good clothes. So
aches. In the session, she admitted that her head- I just went into town and bought what I
aches had returned and were much more severe wanted. I charged 'em to her husband, too!"
now than before. Eventually, she also tearfully She began to laugh softly. "You ought've
admitted that she had begun to hear a voice seen the look on her silly face when he
other than her own speaking inside her head and showed her what was in the cupboard!"
that she feared she was going insane. The thera- (Reprinted with permission from C. H.
pist asked her more questions about the clothes- Thigpen and H. M. Cleckley, The Three Faces
buying spree, and Mrs. White became more of Eve. Copyright 1957 McGraw-Hill)
tense and had difficulty getting words out to dis-
cuss the incident. Then, as her therapist reported,
The brooding look in her eyes became

almost a stare. Eve seemed momentarily
dazed. Suddenly her posture began to
change. Her body slowly stiffened until she
sat rigidly erect. An al ien, inexplicable ex-
pression then came over her face. This was
suddenly erased into utter blankness. The
lines of her countenance seemed to shift in a
barely visible, slow, rippling transformation.
For a moment there was the impression of
something arcane. Closing her eyes, she
winced as she put her hands to her temples,
pressed hard, and twisted them as if to com-
bat sudden pain. A slight shudder passed
over her entire body.
Then the hands lightly dropped. She re-
laxed easily into an attitude of comfort the
physician had never before seen in this
patient. A pair of blue eyes popped open.
There was a quick reckless smile. In a bright,
unfamiliar vo ice that sparked, the woman
said, "Hi, there, Doc!"
The movie The Three Faces of Eve depicts the story of a
Still busy with his own unassimilated
woman with dissociative identity disorder. Here. she has
surprise, the doctor heard himself say, "How discovered extravagant articles of clothing in her closet
do you feel now? " that she doesn't remember buying.
The story of Eve White, depicted in the movie The The cardinal symptom in dissociative identity
Three Faces of Eve, is one of the most detailed and disorder is the apparent presence of multiple per-
gripping accounts of a person diagnosed with dis- sonalities with distinct qualities, referred to as al-
sociative identity disorder (DID) . In later sessions, ters or alternate identities. These alters can take
Eve Black told the psychiatrist of escapades in many forms and perform many functions. Child
which she had stayed out all night drinking and alters- alters that are young children, who do not
then had gone "back in" in the morning to let Eve age as the individual ages-appear to be the most
White deal with the hangover. At the beginning of common type of alter (Ross, 1997). Childhood
therapy, Eve White had no consciousness of Eve trauma is often associated with the development of
Black or of more than 20 personalities eventually dissociative identity disorder. A child alter may be
identified during therapy. Eve White eventually created during a traumatic experience to take on the
recovered from her disorder, integrating the as- role of victim in the trauma, while the host person-
pects of her personality represented by Eve Black ality escapes into the protection of psychological
and her other personalities into one entity and oblivion. Or an alter may be created as a type of
living a healthy, normal life. big brother or sister to protect the host personality
Dissociative identity disorder is one of the from trauma. When a child alter is "out," or in con-
most controversial and fascinating disorders recog- trol of the individual's behavior, the adult may
nized in clinical psychology and psychiatry. People speak and act in a childlike way.
with this disorder appear to have more than one Another type of alter is the persecutor person-
distinct identity or personality state, and many ality. These alters inflict pain or punishment on the
have more than a dozen (Table 6.4). Each personal- other personalities by engaging in self-mutilative
ity has different ways of perceiving and relating to behaviors, such as self-cutting or -burning and sui-
the world, and each takes control over the individ- cide attempts (Coons & Milstein, 1990; Ross, 1997).
ual's behavior on a regular basis. As was true of A persecutor alter may engage in a dangerous be-
Eve White/Black, the alternate personalities can be havior, such as taking an overdose of pills or jump-
extremely different from one another, with distinct ing in front of a truck, and then "go back inside,"
facial expressions, speech characteristics, physio- leaving the host personality to experience the pain.
logical responses, gestures, interpersonal styles, Persecutors may believe that they can harm other
and attitudes (International Society for the Study of personalities without harming themselves.
Trauma and Dissociation [ISSTD], 2011; Vermetten Yet another type of alter is the protector, or
et al., 2006). Often they are different ages and differ- helper, personality. The function of this personality
ent genders and perform specific functions. is to offer advice to other personalities or perform
TABLE 6.4 DSM-5 Diagnostic Criteria for Dissociative Ident ity Disorder
A. Disruption of identity characterized by two or more distinct personality states, which may be described in
some cultures as an experience of possession. The disruption in identity involves marked discontinuity in
sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness,
memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be
observed by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events
that are inconsistent with ord in ary forgetting.
C. The symptoms cause clinically significant distress or impairment in social, occupational , or other important
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.
Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.
E. The symptoms are not attributable to the direct physiological effects of a substance (e.g., blackouts
or chaotic behavior during intoxication) or another medical condition (e.g., complex partial
seizures).
of amnesia is difficult, but some studies suggest

that information and memories tend to transfer be-
tween identities, even in individuals who believe
that certain personalities experience amnesia (Allen
& Iacono, 2001; Kong, Allen, & Glisky, 2008).
Posttraumatic stress disorder is frequently co-
morbid with DID (Rodewald et al., 2011). Self-
injurious behavior is common among people with
dissociative identity disorder and often is the reason
they seek or are taken for treatment. Their behavior
includes self-inflicted burns or other injuries, wrist
slashing, and drug overdoses. About three-quarters
of patients with dissociative identity disorder have a
history of suicide attempts, and over 90 percent re-
port recurrent suicidal thoughts (Ross, 1997).
Like adults, children diagnosed with dissocia-
tive identity disorder exhibit a host of behavioral
and emotional problems (Putnam, 1991). Their per-
formance in school may be erratic, sometimes very
good and sometimes very poor. They are prone to
antisocial behavior, such as stealing, fire setting,
and aggression. They may engage in sexual rela-
tions and abuse alcohol or illicit drugs at an early
age. They tend to show many symptoms of post-
traumatic stress disorder (PTSD; see Chapter 5),
including hypervigilance, flashbacks to traumas
they have endured, traumatic nightmares, and an
exaggerated startle response. Their emotions are
unstable, alternating among explosive outbursts of
People with dissociative identity disorder may engage in
self-mutilative behavior. anger, deep depression, and severe anxiety.
Most children and many adults with dissocia-
tive identity disorder report hearing voices inside
their head. Some report awareness that their ac-
functions the host personality is unable to per- tions or words are being controlled by other per-
form, such as engaging in sexual relations or sonalities. For example, Joe, an 8-year-old boy with
hiding from abusive parents. Helpers sometimes dissociative identity disorder, described how "a
control the switching from one personality to guy inside of me," called B. J. (for Bad Joey), would
another or act as passive observers who can report make him do "bad things."
on the thoughts and intentions of all the other
personalities (Ross, 1997).
People with dissociative identity disorder PROFILES
typically report significant periods of amnesia, or
blank spells. They describe being completely
Well, say B. J. hears someone call me names,
amnesic for the periods when other personalities
then he would strike me to do something, like I'd
are in control or having one-way amnesia between
be running at the other kid, but it wouldn't be my
certain personalities. In these instances, one per-
legs, I'd be saying to my legs, "no .. . , stop ... , "
sonality is aware of what the other is doing, but the
but they'd keep going on their own because
second personality is completely amnesic for peri-
that's B. J. doing that. Then my arm would be
ods when the first personality is in control. As with
going at the other kid, hitting him, and I could
Eve White, people with dissociative identity disor-
see my arm doing that, but I couldn't stop it, and
der may suddenly discover unknown objects in
it wouldn't hurt when my hand hit him. not until
their home or may lose objects. People they do not
later when B. J. goes back in and then my arm is
recognize might approach them on the street,
my own arm. Then it starts hurting. (Hornstein &
claiming to know them. They may consistently re-
Putnam, 1992, p. 1081)
ceive mail or phone calls addressed to someone
with a different first or last name. Verifying reports
Reliable estimates of the prevalence of disso- (see Table 6.4) to make the criteria more applicable
ciative identity disorder are hard to come by. Stud- to diverse cultural groups by identifying a common
ies of patients in psychiatric care find that between presentation of DID in non-Western cultures as
1 and 6 percent of patients can be diagnosed with well as subgroups in Western cultures (e.g., immi-
DID (Foote et al., 2006; ISSTD, 2011). The vast ma- grant and some conservative or fundamentalist
jority of people diagnosed with this disorder are religious groups) (Spiegel et al., 2011). Many fea-
adult women. tures of DID can be influenced by an individual's
cultural background and the fragmented identities
Issues in Diagnosis may take the form of possessing spirits, deities,
Dissociative identity disorder was rarely diag- demons, animals, or mythical figures considered
nosed before about 1980, after which there was a to be real. In contrast to culturally normative
great increase in the number of reported cases possession states that may be part of a spiritual
(Braun, 1986; Coons, 1986). This is due in part to practice, abnormal possession DID is experienced
the fact that dissociative identity disorder was first as involuntary, distressing, and uncontrollable, and
included as a diagnostic category in the DSM in its often involves conflict between the individual and
third edition, published in 1980. The availability of social, cultural, or religious norms (Criterion D).
specific diagnostic criteria for this disorder made it Research has shown that cases of pathological pos-
more likely to be diagnosed. At the same time, the session with dissociative symptoms occur in many
diagnostic criteria for schizophrenia were made countries (Cardena, van Duijl, Weiner, & Terhune,
more specific in the 1980 version of the DSM, pos- 2009), and one study showed that nearly 60 percent
sibly leading to some cases that earlier would have of patients with DID in Western settings felt as if
been diagnosed as schizophrenia being diagnosed they were possessed (Ross, 2011). Other DSM-5
as dissociative identity disorder. One final, and im- changes include that transitions in identity do not
portant, influence on diagnostic trends was the have to be directly observed by others but instead
publication of a series of influential papers by psy- could be self-reported (Criterion A), and problems
chiatrists describing persons with dissociative with recall (amnesia) include everyday events and
identity disorder whom they had treated (Bliss, not just traumatic experiences (Criterion B).
1980; Coons, 1980; Greaves, 1980; Rosenbaum, Dissociative identity disorder is diagnosed
1980). These cases aroused interest in the disorder more frequently in the United States than in
within the psychiatric community. Great Britain, Europe, India, or Japan (Boysen,
Still, most mental health professionals are re- 2011; Ross, 1989; Saxena & Prasad, 1989; Takahashi,
luctant to give this diagnosis. Most people diag- 1990). Some studies suggest that Latinos, both
nosed with dissociative identity disorder have within and outside the United States, may be more
previously been diagnosed with at least three likely than other ethnic groups to experience dis-
other disorders (Kluft, 1987; Rodewald et al., 2011). sociative symptoms in response to traumas. For
Some of the other disorders diagnosed may be sec- example, a study of Vietnam veterans found that
ondary to or the result of the dissociative identity Latino veterans were more likely than non-Latina
disorder. For example, one study of patients with veterans to show dissociative symptoms (Koopman
dissociative identity disorder found that 97 per- et al., 2001). Another study conducted with Latino
cent could also be diagnosed with major depres- survivors of community violence in the United
sion; 90 percent had an anxiety disorder, most States found that those who were less acculturated
often post-traumatic stress disorder; 65 percent to mainstream U.S. culture were more likely to
were abusing substances; and 38 percent had an show dissociative symptoms than were those who
eating disorder (Eliason, Ross, & Fuchs, 1996). In were more acculturated (Marshall & Orlando,
addition, most people with dissociative identity 2002). Dissociative symptoms may be part of the
disorder also are diagnosed with a personality dis- syndrome ataque de nervios, a culturally accepted
order (Dell, 1998). Some of the earlier diagnoses reaction to stress among Latinos that involves
may be misdiagnoses of the dissociative symp- transient periods of loss of consciousness, convul-
toms. For example, when people with dissociative sive movements, hyperactivity, assaultive behav-
identity disorder report hearing voices talking in- iors, and impulsive acts (see Chapter 5). Some
side their heads, they may be misdiagnosed as researchers have argued that psychiatrists in the
having schizophrenia (ISSTD, 2011). United States are too quick to diagnose dissocia-
While the diagnostic criteria for DID had not tive identity disorder; others argue that psychia-
changed very much since DSM-III, DSM-5 includes trists in other countries misdiagnose it as another
some important changes. DSM-5 added the words disorder (Boysen, 2011; Coons, Cole, Pellow, &
"or an experience of possession" to Criterion A Milstein, 1990; Fahy, 1988).
..------- Substantial controversy has revolved around and abuse by cults, human trafficking, multigen-
claims by some people with dissociative disorders erational abusive family systems, pedophile net-
that during adulthood they have recovered memo- works, or even aliens or government "mind
ries of severe abuse after years of not remembering experiments" (ISSTD, 2011).
the abuse. We discuss this controversy in detail at People who develop dissociative identity dis-
the end of this chapter. order tend to be highly suggestible and hypnotiz-
able and may use self-hypnosis to dissociate
Theories of Dissociative Identity Disorder and escape their traumas (Kihlstrom, Glisky, &
Many theorists who study dissociative identity dis- Angiulo, 1994). They may create the alternate per-
order view it as the result of coping strategies used sonalities to help them cope w ith their traumas,
by persons faced with intolerable trauma-most much as a child might create imaginary playmates
often childhood sexual and / or physical abuse- to ease pangs of loneliness. These alternate person-
that they are powerless to escape (Bliss, 1986; alities can provide the safety, security, and nurtur-
ISSTD, 2011; Kluft, 1987; Putnam, Zahn, & Post, ing that they are not receiving from their caregivers.
1990). As Ross (1997, p. 64) describes: Retreating into their alternate personalities or us-
ing these personalities to perform frightening func-
The little girl being sexually abused by her
tions becomes a chronic way of coping with life.
father at night imagines that the abuse is A contrasting view is the sociocognitive model
happening to someone else, as a way to dis- (Piper & Mersky,2004; Spanos, 1994), which argues
tance herself from the overwhelming emo- that the alternate identities are created by patients
tions she is experiencing. She may float up
who adopt the idea or narrative of dissociative
to the ceiling and watch the abuse in a de-
identity disorder as an explanation that fits their
tached fashion. Now not only is the abuse
lives. The identities are not true personalities with
not happening to her, but she blocks it out
clear-cut demarcations but rather a metaphor used
of her mind-that other little girl remem-
by the patients to understand their subjective expe-
bers it, not the original self. In this model,
riences. Patients are not faking their multiple per-
r- DID is an internal divide-and-conquer
sonalities but rather are playing out a role that
strategy in which intolerable knowledge
helps them deal with stresses in their lives and is
and feeling is split up into manageable
reinforced by attention and concern from others.
compartments. These compartments are
A few family history studies suggest that disso-
personified and take on a life of their own.
ciative identity disorder may run in some families
Most studies find that the majority of people (Coons, 1984; Dell & Eisenhower, 1990). In addition,
diagnosed with dissociative identity disorder studies of twins and of adopted children have found
self-report having been a victim of sexual or evidence that the tendency to dissociate is substan-
physical abuse during childhood (e.g., Ross & tially affected by genetics (Becker-Blease et al., 2004;
Ness, 2010) and, in turn, that dissociative experi- Jang, Paris, Zweig-Frank, & Livesley, 1998). The abil-
ences are commonly reported by survivors of ity and tendency to dissociate as a coping response
child sexual abuse (Butzel et al., 2000; Kisiel & may to some extent be biologically determined.
Lyons, 2001) . For example, in a study of 135 per-
sons with dissociative identity disorder, 92 per- Treatment of Dissociative
cent reported having been sexually abused, and Identity Disorder
90 percent reported having been repeatedly phys- Treating dissociative identity disorder can be ex-
ically abused (Eliason et al., 1996; see also Putnam, tremely challenging. The goal of treatment is inte-
Guroff, Silberman, & Barban, 1986). Researchers grating all the alter personalities into one coherent
have found similar results in studies in which pa- personality and helping the patient rebuild the ca-
tients' reports of abuse were corroborated by at pacity for trusting healthy relationships (Chu, 2011;
least one family member or by emergency room ISSTD, 2011). This integration is achieved by "giving
reports (Coons, 1994; Coons & Milstein, 1986). voice" to each identity and helping the identities be-
The abuse most often was carried out by parents come aware of one another, determining the function
or other family members and was chronic over an or role of each personality, helping each personality
extended period of childhood. Other types of confront and work through the traumas that led to
------ trauma that have been associated with the devel- the disorder and the concerns each one has or repre-
opment of dissociative identity disorder include sents, and negotiating with the personalities for uni-
kidnapping, natural disasters, war, famine, and fication into one personality who has learned
religious persecution (Ross, 1999). Some people adaptive styles of coping with stress. Building trust
with DID report having been the victim of torture and therapeutic alliance is critical, as patients with
TABLE 6.5 DSM-5 Diagnostic Criteria for Dissociative Amnesia

A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature,
that is inconsistent with ordinary forgett ing.
Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or
events; or generalized amnesia for identity and life history.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important
C. The disturbance is not attributable to the direct physiological effects of a substance (e .g ., alcohol or other
drug of abuse, a medication) or a neurological or other medical cond ition (e.g., partial complex seizures,
sequelae of a traumatic brain injury, other neurologica l condition) .
D. The disturbance is not better explained by dissociative identity disorder, posttraumatic-stress disorder,
acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.
Specify if:
With Dissociative Fugue: Apparently purposeful travel or bewildered wandering that is associated with
amnesia for identity or for other important autobiographical information.
DID often have experienced traumas that have com- some people have significant periods of amnesia
pletely shattered their trust in others. The therapist without assuming new personalities or identities.
interacts with each of the alters to engage them in the They cannot remember important facts about
process of reviewing and understanding the trauma their lives and their personal identities and typi-
history and integrating their memories and strengths cally are aware of large gaps in their memory or
into one coherent personality. Hypnosis is sometimes knowledge of themselves. These people are said
used in the treatment of dissociative identity disorder to have dissociative amnesia (see Table 6.5).
(Putnam & Lowenstein, 1993). Possession-form DID Amnesia is considered to be either organic or
would likely require culturally adapted treatments, psychogenic (Table 6.6). Organic amnesia is caused
perhaps involving indigenous healers (Martinez- by brain injury resulting from disease, drugs, acci-
Taboas, 2005; Spiegel et al., 2011). dents (such as blows to the head), or surgery.
One of the few studies to empirically evaluate Organic amnesia that involves the inability to
the treatment of DID found that patients who were remember new information is known as antero-
able to integrate their personalities through treat- grade amnesia. Psychogenic amnesia arises in the
ment remained relatively free of symptoms over absence of any brain injury or disease and is thought
the subsequent 2 years (Eliason & Ross, 1997). to have psychological causes. Psychogenic amnesia
These patients also reported few symptoms of sub- rarely involves anterograde amnesia.
stance abuse or depression and were able to re- Retrograde amnesia, the inability to remember
duce their use of antidepressants and antipsychotic information from the past, can have both organic
medications. In contrast, patients who had not and psychogenic causes. For example, people who
achieved integration during treatment continued have been in a serious car accident can have retro-
to show symptoms of DID and a number of other grade amnesia for the few minutes just before the
disorders. This study did not compare the out- accident. This retrograde amnesia can be due to
come of the patients who received therapy with brain injury resulting from blows to the head dur-
that of patients who did not, nor did it compare ing the accident, or it can be a motivated forgetting
different types of therapy. of the events leading up to the trauma. Retrograde
amnesia can also occur for longer periods of time.
When retrograde amnesias are due to organic
Dissociative Amnesia causes, people usually forget everything about the
In dissociative identity disorder, individuals claim past, including both personal information, such
to have amnesia for those periods of time when as where they lived and people they knew, and
their alternate personalities are in control. Yet general information, such as the identity of the
TABLE 6.6 Differences Between Psychogenic and Organic Amnesia
There are several important differences between psychogenic amnesia and organic amnesia .
Psychogenic Amnesia Organic Amnesia
Caused by psychological factors Caused by biological factors (such as disease, drugs,

and blows to the head)
Seldom involves anterograde amnesia (inability Often involves anterograde amnesia
to learn new information acquired since onset
of amnesia)
Can involve retrograde amnesia (inability to Can involve retrograde amnesia
remember events from the past)
Retrograde amnesia often only for personal Retrograde amnesia usually for both personal and
information, not for general information general information
president and major historical events of the period. Loss of memory due to alcohol intoxication is
They typically retain memory of their personal common, but usually the person forgets only the
identity, however; while they may not remember events occurring during the period of intoxication.
their children, they know their own name. When People who have severely abused alcohol much of
long-term retrograde amnesias are due to psycho- their lives can develop a more global retrograde
logical causes, people typically lose their identity amnesia, known as Korsakoff's syndrome, in
and forget personal information but retain their which they cannot remember much personal or
memory for general information. The following general information for a period of several years or
case study describes a man with a psychogenic decades. However, the type of retrograde amnesia
retrograde amnesia. in the previous case study, which apparently in-
volved only one episode of heavy drinking and the
loss of only personal information, typically has
psychological causes.
CASE STUDY A subtype of dissociative amnesia is a disso-
' Some years ago a man was ciative fugue, in which the individual travels to a
found wandering the streets of Eugene, Oregon, new place and may assume a new identity with no
not knowing his name or where he had come memory of his or her previous identity. People in a
from. The police, who were baffled by his inabil- dissociative fugue may behave quite normally in
ity to identify himself, called in Lester Beck ... , a their new environment and not find it odd that
psychologist they knew to be familiar with hyp- they cannot remember anything from their past.
nosis, to see if he could be of assistance. He Just as suddenly, they may return to their previous
found the man eager to cooperate and by means identity and home, resuming their life as if nothing
of hypnosis and other methods was able to re- had happened, with no memory of what they did
construct the man's history.... during the fugue. The autobiographical memory
Following domestic difficulties, the man had loss in a dissociative fugue may be especially long-
gone on a drunken spree completely out of keep- lasting and resistant to "re-learning." A fugue may
ing with his earlier social behavior, and he had last for days or years, and a person may experience
subsequently suffered deep remorse. His amne- repeated fugue states or a single episode.
sia was motivated in the first place by the desire As in DID, some theorists argue that psycho-
to exclude from memory the mortifying experi- genic amnesias may be the result of using dissocia-
ences that had gone on during the guilt-producing tion as a defense against intolerable memories or
episode. He succeeded in forgetting all the stressors (Freyd, 1996; Gleaves, Smith, Butler, &
events before and after this behavior that re- Spiegel, 2004). Psychogenic amnesias most fre-
minded him of it. Hence the amnesia spread quently occur following traumatic events, such as
from the critical incident to events before and wars or sexual and/ or physical abuse of increased
after it, and he completely lost his sense of per- severity, frequency, and violence. Alternatively,
sonal identity. (Hilgard 1977/1986, p. 68) amnesia for a specific event may occur because in-
dividuals are in such a high state of arousal during
the event that they do not encode and store infor- (Kopelman, 1987). In most of these cases, the vic-
mation during it and thus are unable to retrieve tims are closely related to the killers (lovers,
information about it later. spouses, close friends, or family members), the
Arnnesias for specific periods of time around killings appear to be unpremeditated, and the
traumas appear to be fairly common, but general- killers are in a state of extreme emotional arousal
ized retrograde amnesias for an individual's entire at the time of the killings. More rarely, the killers
past and identity appear to be very rare. Studies of appear to have been in a psychotic state at the
people in countries that have been the site of at- time of the killings.
tempted genocides, ethnic cleansings, and wars There is no clear-cut way to differentiate true
have suggested that the rate of dissociative amne- amnesias from feigned ones. Moderate or severe
sias in these countries may be elevated. For exam- head injuries leading to amnesia may be detectable
ple, a study of 810 Bhutanese refugees in Nepal through neuroimaging of the brain. Feigned amne-
found that almost 20 percent of those who had sia is more common in individuals with financial,
been tortured during conflicts in their countries sexual, or legal problems, or a wish to escape stress-
could be diagnosed with dissociative amnesia (van ful circumstances. Some clinicians advocate the use
Ommeren et al., 2001). of hypnosis to help people remember events around
One complication that arises in diagnosing crimes if it is suspected that the amnesia is due to
amnesias is the possibility that the amnesias are psychological causes. However, the possibility that
being faked by people trying to escape punish- hypnosis will "create" memories through the power
ment for crimes they committed during the peri- of suggestion has led many courts to deny the use of
ods for which they claim to be amnesic. True hypnosis in such cases. In most cases, it is impossible
amnesias also can occur in conjunction with the to determine whether the amnesia is real.
commission of crimes. Many crimes are commit- People suffering from dissociative amnesia or
ted by persons under the influence of alcohol or dissociative fugue may recover on their own. Psy-
other drugs, and the drugs can cause blackouts for chotherapy involves helping patients recall and
the periods of intoxication (Kopelman, 1987). Simi- understand the trauma that contributed to their
larly, people who incur a head injury while com- dissociation (Maldonado & Spiegel, 2008).
mitting a crime-for example, by falling while
trying to escape the scene of a crime-can have Depersonalization/
amnesia for the commission of the crime.
Amnesia is seen most often in homicide cases,
Derealization Disorder
with 25 to 45 percent of persons arrested for ho- People with depersonalization/derealization dis-
micide claiming to have amnesia for the killings order have frequent episodes during which they
feel detached from their own mental processes or
body, as if they are outside observers of themselves
(Table 6.7). Occasional experiences of deperson-
alization or derealization are common, particu-
larly when people are sleep-deprived or under
the influence of drugs (Baker et al., 2003). Ap-
proximately half of all adults report having had at
least one brief episode of depersonalization or de-
realization, usually following a significant stressor
(American Psychiatric Association, 2013). The
worldwide lifetime prevalence of depersonaliza-
tion/ derealization disorder is between 0.8 percent
and 2.8 percent, and is equally common among
men and women.
Depersonalization/ derealization disorder is di-
agnosed when episodes are so frequent and distress-
ing that they interfere with the individual's ability to
function. One study of people diagnosed with the
disorder found that the average age of onset was
about 23 years and that two-thirds reported having
Lorena Bobbit cut off her husband"s penis after years of
experiencing his abuse. She claimed to have amnesia
had chronic experiences of depersonalization/
for the act of cutting it off. derealization since the onset (Baker et al., 2003).
Seventy-nine percent reported impaired social or
TABLE 6. 7 DSM-5 Diagnostic Criteria for Depersonalization/Derealization Disorder
A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both :
1. Depersonal ization: Experie nces of unreality, detachment, or being an outside observer with respect to
one's thoug hts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of
time, unreal or absent self, emotional and/or physical numbing) .
2. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g ., ind ividuals or
objects are experienced as unreal, dreamlike, foggy, life less, or visually distorted).
B. During the depersonalization or derealization experiences, reality testing remains intact.
C. The symptoms cause cli nically significant distress o r impairment in social, occupational, or other important
D. The disturbance is not attributable to the direct physiological effects of a substance (e.g. , a drug of abuse,
medication ) or another medical condition (e.g., seizures).
E. The d isturbance is not better explained by another mental disorder, such as schizophren ia, panic disorder,
major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative
disorder.
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyrig ht 2013
work functioning, and the majority also had another (Freyd, DePrince, & Gleaves,2007). Nonbelievers
psychiatric diagnosis, most often depression. People argue that the empirical evidence against the va-
diagnosed with this disorder often report a history lidity of dissociative amnesia is ample and that the
of childhood emotional, physical, or sexual abuse supportive evidence is biased (Kihlstrom, 2005;
(Simeon et al., 2001). Loftus, 2011) .
Most of the evidence for the phenomenon of
Controversies Around the repressed memories comes from studies of people
who either are known to have been abused or
Dissociative Disorders self-report abuse and who claim to have forgotten or
Surveys of psychiatrists in the United States and repressed their abuse at some time in the past. For
Canada find that less than one-quarter of them be- example, Linda Williams (1995) surveyed 129 women
lieve there is strong empirical evidence that the who had documented histories of having been
dissociative disorders are valid diagnoses (Lalonde, sexually abused sometime between 1973 and 1975.
Hudson, Gigante, & Pope, 2001; Pope et al., 1999). These women, who were between 10 months and
Skeptics argue that the disorders are artificially 12 years old at the time of their abuse, were inter-
created in suggestible clients by clinicians who reviewed about 17 years after their abuse. Williams
inforce clients for creating symptoms of a dissocia- found that 49 of these 129 women either had no
tive disorder and who may even induce symptoms memory of the specific abuse events that were docu-
of the disorder through hypnotic suggestion (see mented or had forgotten about the abuse completely.
Kihlstrom, 2005; Lilienfeld et al., 1999; Loftus, 2011; John Briere and Jon Conte (1993) located 450
Spanos, 1994). therapy patients w ho self-identified as abuse
Controversy over the diagnosis of dissocia- victims. Briere and Conte asked these people if there
tive amnesia increased in response to claims that had ever been a time before their eighteenth birthday
some survivors of childhood sexual abuse re- w hen they "could not remember" their abuse.
pressed their memories of the abuse for years Fifty-nine percent answered yes to this question. As
and then eventually recalled these memories, another example, Judith Herman and Mary Harvey
often in the context of psychotherapy. These (1997) examined interviews of 77 women who had
repressed memories represent a form of disso- reported memories of childhood trauma. They
ciative amnesia. Those who believe in repressed found that 17 percent spontaneously reported
memories argue that the clinical evidence for having had some delayed recall of the trauma and
dissociative or psychogenic amnesia is ample that 16 percent reported a period of complete
and that the empirical evidence is growing amnesia following the trauma.
Nonbelievers in repressed memories have flannel shirt." On the fifth day, he started
raised questions about the methods and conclusions remembering the mall itself: "I sort of re-
of these studies (Kihlstrom, 2005; Loftus, 2003; member the stores." In his last recollec-
McNally, 2003). For example, regarding the Williams tion, he could even remember a
study, it turns out that 33 of the 49 women who said conversation with the man who found
they could not remember the specific abuse incidents him: "I remember the man asking me if I
they were asked about could remember other child- was lost." . .. A couple of weeks later,
hood abuse incidents. Thus, they had not completely Chris described his false memory and he
forgotten or repressed all memories of abuse. greatly expanded on it. "I was with you
Instead, they simply could not remember the spe- guys for a second and I think I went over
cific incident about which they were being asked. to look at the toy store, the Kay-Bee Toy
Williams did not give any additional information and uh, we got lost and I was looking
about the 16 women who could remember no inci- around and I thought, 'Uh-oh, I'm in
dents of childhood molestation. They may simply trouble now.' You know. And then I ... I
have been too young to remember the incidents, be- thought I was never going to see my
cause memory for anything that happens before family again. I was really scared you
about age 3 tends to be sketchy. know. And then this old man, I think he
Nonbelievers in repressed memories also cite was wearing a blue flannel, came up to
numerous studies from the literature on eyewit- me . ... He was kind of old. He was kind of
ness identification and testimony indicating that bald on top . . .. He had like a ring of gray
people can be made to believe certain events oc- hair ... and he had glasses."
curred that in fact never happened (Ceci & Bruck,
1995; Frenda, Nichols, & Loftus, 2011; Read & Other studies have found that repeatedly ask-
Lindsay, 1997) and that these beliefs can persist for ing adults about childhood events that never actu-
months or years (Zhu et al., 2012). For example, ally happened leads perhaps 20 to 40 percent
Elizabeth Loftus and her colleagues developed a eventually to "remember" these events and even
method for instilling a childhood memory of being explain them in detail (Frenda et al., 2011; H yman
lost on a specific occasion at age 5 (Loftus, 2003). & Billings, 1998). For example, in one study, 40 per-
This method involved a trusted family member cent of a British sample said they had seen footage
engaging the subject in a conversation about the of a bus exploding in the 2005 London terrorist
time he or she was lost (Loftus, 1993, p. 532): attacks, when such footage did not exist (Ost,
Granhag, Udell, & Hjelmsater, 2008). Thirty-five
Chris (14 years old) was convinced by his percent of these described memories of details that
older brother Jim that he had been lost in they could not have seen.
a shopping mall when he was 5 years The percentage of participants developing
old. Jim told Chris this story as if it were false memories of events that never happened can
the truth: "It was 1981 or 1982. I remem- be increased by procedures that mimic some of the
ber that Chris was 5. We had gone shop- psychotherapeutic methods used with people who
ping in the University City shopping "recover" repressed memories. For example, fam-
mall in Spokane. After some panic, we ily photo albums are sometimes reviewed in psy-
found Chris being led down the mall by chotherapy to help people remember traumatic
a tall, oldish man (I think he was wearing events. In false memory experiments, showing
a flannel shirt). Chris was crying and participants photographs of themselves or other
holding the man's hand. The man ex- family members in the context of telling a story of
plained that he had found Chris walking a false memory makes participants more likely to
around crying his eyes out just a few mo- believe the false memory with strong confidence
ments before and was trying to help him (Lindsay et al., 2004). Simply having a psycholo-
find his parents." Just two days later, gist suggest that an individual's dreams reflect re-
Chris recalled his feelings about being pressed memories of childhood events leads a
lost: "That day I was so scared that I majority of subjects subsequently to report that the
would never see my family again. I knew events depicted in their dreams actually happened
that I was in trouble." On the third day, (Mazzoni & Loftus, 1998).
he recalled a conversation with his Critics of this line of work question the appli-
mother: "I remember Mom telling me cation of these studies to claims of repressed
never to do that again." On the fourth memories of sexual abuse (Barlow & Freyd, 2009;
day: "I also remember that old man's Gleaves, Hernandez, & Warner, 2003). They argue
that while people might be willing to go along sociation recall fewer trauma-related words but
with experimenters who try to convince them that more neutral words they previously had been in-
they were lost in a shopping mall as a child, they structed to remember, while low-dissociation par-
are unlikely to be willing to go along with a thera- ticipants show the opposite pattern. This suggests
pist who tries to convince them that they were that people high in dissociation are better able to
sexually abused if such abuse did not in fact hap- keep threatening information from their explicit
pen. Abuse is such a terrible thing to remember, awareness, particularly if they can instead turn
and the social consequences of admitting the abuse their attention to other tasks or other events in
and confronting the abuser are so negative, that their environment.
people simply would not claim the memory was The repressed memory debate is likely to
true if it was not. continue for some time. Researchers are striving
Researchers have used paradigms from to apply scientific techniques to support their
cognitive psychology to test hypotheses about views. Psychologists are being called on to testify
the reality of repressed memories. In a series in court cases involving claims of recovered or
of studies, Richard McNally and colleagues false memories. Through all the controversy, people
(McNally, 2003; McNally, Clancy, & Schacter, trying to understand their distressing symptoms
2001; McNally, Clancy, Schacter, & Pitman, 2000a, find themselves at the center of this scientific
2000b) have found that individuals reporting maelstrom.
recovered memories of either childhood sexual
abuse or abduction by space aliens have a
greater tendency to form false memories during
CHAPTER INTEGRATION
certain laboratory tasks. For example, one task Philosophers and scientists have long debated the
required participants to say whether they rec- mind-body problem: Does the mind influence
ognized words similar to, but not exactly the bodily processes? Do changes in the body affect a
same as, other words they previously had person's sense of "self"? Exactly how do the body
learned. People who claimed to have recovered and the mind influence each other?
memories of alien abductions were more prone As noted earlier, the dissociative and somatic
than comparison groups to falsely recognize symptom disorders provide compelling evidence
words they had not seen previously (Clancy, that the mind and the body are complexly interwo-
Schacter, McNally, & Pitman, 2000; Clancy et ven (Figure 6.3). In conversion disorder, psychologi-
al., 2002). The researchers argue that these cal stress causes the person to lose eyesight, hearing,
people are characterized by an information- or functioning in another important physiological
processing style that may render them more system. In somatic symptom disorder, a person un-
likely to believe they have experienced specific der psychological stress experiences physiological
events, such as childhood sexual abuse, when symptoms, such as severe headaches. An underly-
in fact they have experienced other, broadly ing theme of these disorders is that some people find
similar events, such as physical abuse or emo- it easier or more acceptable to experience psycho-
tional neglect. logical distress through changes in their body than
Jennifer Freyd and colleagues (2007) have ar- to express it more directly as sadness, fear, or anger,
gued that the kinds of cognitive tasks McNally perhaps because of cultural or social norms.
and colleagues used do not tap into the specific We all somatize our distress to some degree-
cognitive phenomena associated with repressed we feel more aches and pains when we are upset
memories. Specifically, they suggest that individ-
uals who dissociate from, and forget, their abu-
sive experiences are most likely to differ from Mind and Body in the Somatic Symptom
FIGURE 6.3
other individuals in the performance of cognitive and Dissociative Disorders
tasks that require divided attention-that is, pay-
ing attention to more than one thing at a time-
Sodal factors: trauma, role Psychological factors:
because a division of attention is critical to
dissociation (DePrince & Freyd, 1999, 2001; Freyd
et al., 1998). One divided-attention task requires
models who express distress
through physical symptoms,
reinforcement for physical
-----+t. inability to cope with or
express distress, exaggerated
physical symptoms
symptoms
participants to press a key on a keyboard in re-
t---oooottl~
sponse to a secondary task while attending to
words on a computer screen and committing them
to memory. Under these divided-attention condi-
Physical symptoms ,...,.,_
_ _ _..t
tions, people who score high on measures of dis-
about something than when we are happy. People differentiate between what is going on in their
who develop somatic symptom disorders, and mind and what is going on in their body may be
perhaps dissociative disorders, may somatize their minimal, and they may favor an extreme bodily
distress to an extreme degree. Their tendency to expression of what is going on in their mind.
Ben's health concerns do seem to be linked to his physical and emotional distress over his perceived
parents' separation and not to a medical condition . headaches and stomachaches. Therefore, his symp-
His insistence of real pain and his refusal to return toms are more in line with a somatic symptom dis-
to class signal that he experiences significant order than with illness anxiety disorder.
THINK CRITICALLY
Imagine yourself as a juror in the following murder fragments would return, until Eileen had a rich and de-
case (from Loftus, 1993). The defendant is George tailed memory. She remembered her father sexually
Franklin, Sr., 51 years old, standing trial for a murder assaulting Susie in the back of a van. She remem-
that occurred more than 20 years earlier. The victim bered that Susie was struggling as she said "No,
was 8-year-old Susan Kay Nason. Franklin's daugh- don't!" and "Stop!" She remembered her father say-
ter, Eileen, only 8 years old herself at the time of the ing "Now Susie;' and she even mimicked his precise
murder, provided the major evidence against her intonation. Next, her memory took the three of them
father. Eileen's memory of the murder, however, outside the van, where she saw her father raise a
had re-emerged only recently, after 20 years of being rock above his head. She remembered screaming
repressed. and walking back to where Susie lay, covered with
Eileen's memory first began to come back when blood, the silver ring on her finger smashed. When
she was playing with her 2-year-old son and her questioned by prosecutors, Eileen was highly confi-
5-year-old daughter. At one moment, her daughter dent in her memory.
looked up and asked a question like "Isn't that right, Would you convict George Franklin of the mur-
Mommy?" A memory of Susan Nason suddenly der of Susan Nason? Why or why not? (Discussion
came to Eileen. She recalled the look of betrayal appears on p. 482 at the back of this book.)
in Susie's eyes just before the murder. Later, more
CHAPTER SUMMARY
The somatic symptom disorders are a group of The cognitive theory of the somatic symptom dis-
disorders in which the individual experiences orders is that affected people believe they are vul-
distress ing physical symptoms and abnormal nerable to illness, focus excessively on physical
thoughts, feelings, and behaviors in response to symptoms, and catastrophize these symptoms.
these symptoms. They are reinforced by the attention and concern
they receive from others. Treatment involves help-
Somatic symptom disorder involves a long his-
ing people have more realistic perspectives on
tory of physical complaints for which an individ -
their health, removing reinforcements for illness
ua l has sought treatment. Medically unexplained
behavior, and teaching people to cope better
symptoms are present to various degrees and
with stress.
are a key feature in conversion disorder. People
with these disorders show high rates of anxiety In conversion disorder, individuals lose all
and depression . sensory and/or motor functioning in a part
of their body, such as the eyes or the legs.
Peop le with illness anxiety disorder fear becom-
Conversion symptoms often occur after trauma
ing ill, although they may not experience actual
or stress. People with conversion disorder tend
symptoms of illness.
Key Term s 173
to have high rates of depression, anxiety, alcohol by brain injury and in which a person may have
abuse, and antisocial personality disorder. difficulty remembering new information (antero-
Treatment for the disorder focuses on the ex- grade amnesia), a rare condition in psychogenic
pression of associated emotions or memories. amnesia. In addition, with organic amnesia loss
of memory for the past (retrograde amnesia)
In the dissociative disorders, the individual's usually is generalized, whereas with psychogenic
identity, memories, and consciousness become amnesia memory loss is limited to personal
separated, or dissociated, from one another. In
information.
dissociative identity disorder (DID), the individual
develops two or more distinct personalities, Psychogenic amnesia typically occurs following
which alternate their control over the individual's traumatic events. It may be due to motivated for-
behavior. Persons with dissociative identity getting of events, to poor storage of informati on
disorder often engage in self-injurious and during events due to hyperarousal, or to avoid-
self-mutilative behaviors. ance of the emotions experienced during trau-
matic events and of the memories associated
The vast majority of diagnosed cases of dissocia-
with these events.
tive identity disorder are women, and they tend
to have a history of severe childhood sexual and/ Dissociative fugue is a subtype of dissociative
or physical abuse. The alternate personalities amnesia in which the person suddenly moves
may have been formed during the traumatic ex- away from home and assumes an entirely new
periences as a way of psychologically managing identity, with complete amnesia for the previous
these experiences, particularly among people identity.
who are highly hypnotizable. The treatment of
Depersonalization/derealization disorder in-
dissociative identity disorder typically involves
volves frequent episodes in which individuals
helping the various personalities become
feel detached from their mental processes or
integrated into one functional personality.
their body. Transient depersonalization/dereal-
Dissociative, or psychogenic, amnesia involves ization experiences are common, especially in
the loss of memory due to psychological causes. people who are sleep-deprived or under the
It differs from organic amnesia, which is caused influence of drugs.
KEY TERMS
somatic symptom disorders 152 dissociative amnesia 166
illness anxiety disorder 154 organic amnesia 166
conversion disorder (functional neurological anterograde amnesia 166
symptom disorder) 157 psychogenic amnesia 166
factitious disorder 159 retrograde amnesia 166
malingering 159 dissociative fugue 167
factitious disorder imposed on another 159 depersonalization/derealization disorder 168
dissociation 160
dissociative identity disorder (DID) 162
Mood Disorders
and Suicide
CHAPTER OUTLINE
Mood Disorders Along the Continuum Treatment of Mood Disorders

Extraordinary People: Kay Redfield Suicide
Jamison. An Unquiet Mind
Chapter Integration
Characteristics of Depressive Disorders
Shades of Gray
Think Critically
Characteristics of Bipolar Disorder
Chapter Summary
Theories of Depression
Key Terms
Theories of Bipolar Disorder
Typical mood symptoms Li kely meets criteria
in response to events for manic episode
Feeling blue or down but Potentially meets criteria Expansive mood including
able to function normally; for hypomania irritability, grandiosity, racing thoughts,
feeling happy and exuberant Moderate and frequent elation, and decreased need far sleep
because something good inflated self-esteem, some that significantly interferes with
happened impulsiveness, high energy functioning
Pot entially meets criteria Likely meets criteria for major

fo r depression depressive episode
Moderate and frequent Severe symptoms of
symptoms of sadness, apathy, sadness, apathy, hopelessness,
fatigue, etc. , that somewhat low energy, etc., that significantly
interfere with functioning interfere with functioning
"I'm depressed" is a phrase you may have uttered, perhaps after impatient with others. Their extreme self-confidence may lead
you didn't do as well as you expected on an exam or when a them to carry out grandiose schemes to ea rn money or infl uence
friend became angry and wouldn't speak to you. Such events others, or to engage in extremely risky or impulsi v e beha viors.
often sap our energy and motivation, shake our self-esteem, and Drawing the line between normal mood responses to com-
make us feel down and blue-all symptoms of depression. mon or uncommon eve nts and the mood disorders has been
More significant events, such as the death of a loved one, very challeng ing for resea rchers and clinician s. When you are
the breakup of a marriage, or the loss of a job, can lead to more saddened by a loss, how long is too long for t hese feelings to last
serious symptoms of depression. In some people, the symptoms before they should be diagnosed as a disorder? One of the
may be mild or moderate and not interfere with daily function- biggest controve rsies in the development of the DSM-5 has been
ing. Sometimes, however, symptoms of depression following the question of how to define bereavement-related de press ive
negative events become debilitating and can last for a long pe- disorders (Frances & Widiger, 2012) . Some arg ue that depressive
riod of time. In some cases, severe symptoms of depression symptoms following a loss should not be diagnosed as a disor-
emerge without any obvious cause. A diagnosis of depression der the vast majority of the time, while others argue that exclud-
depends on both the severity and the duration of symptoms. ing bereaveme nt-related depressions from diagnoses fa il s to
Like symptoms of depression, symptoms of mania also vary recognize the negative impact of these depressions on people's
in severity and duration. Perhaps you've experienced a "fizzing lives and the need for treatment.
over" feeling of exuberance when something in your life is going On the other hand, being extremely self-confident, possess-
particularly well-such as getting an acceptance to college or being grand and risky ideas, and having boundless energy are a
ginning a relationship with somebody special. As in depression, recipe for success in our go-go, high-tech world . Indeed, t hese
moderate symptoms of mania usually are tied to specific situations are traits that many leaders and innovators in business, politics
and lessen as those situations pass. Symptoms of a manic episode, and government, and the arts have had over history (Jamison,
however, go beyond feeling happy when something good has 1993). Where do we draw the line between creative genius or
happened. People diagnosed with mania are often irritable and entrepreneurialism and mania?
Mood Disorders Along the Continuum 175

176 Chapter 7 Mood Disorders and Suicide
Kay Redfield Jamison, An Unquiet Mind
I was a senior in high wearing me out, Kay. Slow down, Kay. And those
school when I had my times when they didn't actually come out and say
first attack. At first, it, I still could see it in their eyes: For God's sake,
everything seemed so Kay, slow down.
easy. I raced about I did, finally, slow down. In fact, I came to a
like a crazed weasel, grinding halt. The bottom began to fall out of my
bubbling with plans life and my mind. My thinking, far from being
and enthusiasms, im- clearer than a crystal, was tortuous. I would read
mersed in sports, and the same passage over and over again only to
staying up all night, realize that I had no memory at all for what I had
night after night, out just read. My mind had turned on me: It mocked
with friends, reading everything that wasn't nailed me for my vapid enthusiasms; it laughed at all my
down, filling manuscript books with poems and foolish plans; it no longer found anything interest-
fragments of plays, and making expansive, coming or enjoyable or worthwhile. It was incapable of
pletely unrealistic plans for my future. The world concentrated thought and turned time and again
was filled with pleasure and promise; I felt great. to the subject of death: I was going to die, what
Not just great, I felt really great. I felt I could do difference did anything make? Life's run was only
anything, that no task was too difficult. My mind a short and meaningless one; why live? I was
seemed clear, fabulously focused, and able to make totally exhausted and could scarcely pull myself
intuitive mathematical leaps that had up to that out of bed in the mornings. It took me twice as
point entirely eluded me. Indeed, they elude me long to walk anywhere as it ordinarily did, and I
still. At the time, however, not only did everything wore the same clothes over and over again, as it
make perfect sense, but it all began to fit into a was otherwise too much of an effort to make a
marvelous kind of cosmic relatedness. My sense of decision about what to put on. I dreaded having to
enchantment with the laws of the natural world talk with people, avoided my friends whenever
caused me to fizz over, and I found myself button- possible, and sat in the school library in the early
holing my friends to tell them how beautiful it all mornings and late afternoons, virtually inert, with
was . They were less than transfixed by my insights a dead heart and a brain as cold as clay:' (Jamison,
into the webbings and beauties of the universe 1995, pp. 35-38; www.randomhouse.com . For on-
although considerably impressed at how exhaust- line information about other Random House, Inc.
ing it was t o be around my enthusiastic ramblings: books and authors, see the internet web site at
You're talking too fast, Kay. Slow down, Kay. You're http://www.randomhouse .com)
The emotional roller-coaster ride Kay Jamison CHARACTERISTICS OF

describes is known as bipolar disorder, or manic-
depression. First, Jamison had mania, with great DEPRESSIVE DISORDERS
energy and enthusiasm for everything, talking and We will consider depressive disorders first. In de-
thinking so fast that her friends could not keep up pressive disorders, the symptoms of depression
with her. Eventually, though, she crashed into a take over the whole person-emotions, bodily
depression. Her energy and enthusiasm were functions, behaviors, and thoughts.
gone, and she was slow to think, to talk, and to
move. The joy had been drained from her life.
Bipolar disorder is one of the two major types of
Symptoms of Depression
mood disorders. The other type is depressive dis- A cardinal symptom of depression is depressed
orders. People with depressive disorders experi- mood out of proportion to any cause. Many people
ence only depression, and not mania. diagnosed with depression report that they have
lost interest in everything in life, a symptom least 2 weeks (Table 7.1). In addition, these symp-
referred to as anhedonia. Even when they try to do toms must be severe enough to interfere with the
something enjoyable, they may feel no emotion. person's ability to function in everyday life. People
As Kay Jamison (1995, p. 110) writes, she was who experience only one depressive episode re-
"unbearably miserable and seemingly incapable of ceive a diagnosis of major depressive disorder, single
any kind of joy or enthusiasm." episode. Two or more episodes separated by at least
In depression, changes in appetite, sleep, and 2 consecutive months without symptoms merit the
activity levels can take many forms. Some people diagnosis of major depressive disorder, recurrent episode.
with depression lose their appetite, while others The DSM-5 criteria in Table 7.1 include a note
find themselves eating more, perhaps even binge to clinicians that a "normal and expected" depres-
eating. Some people with depression want to sleep sive response to a negative event such as a loss
all day, while others find it difficult to sleep and should not be diagnosed as a major depressive dis-
may experience early morning wakening, in which order unless other, more atypical symptoms are
they awaken at 3 or 4 A.M. every morning and can- present, including worthlessness, suicidal ideas,
not go back to sleep. psychomotor retardation, and severe impairment.
Behaviorally, many people with depression are In addition, research has shown that a syndrome
slowed down, a condition known as psychomotor re- labeled complicated grief is shown by 10 to 15 per-
tardation. They walk more slowly, gesture more cent of bereaved people, characterized by strong
slowly, and talk more slowly and quietly. They have yearning for the deceased person and preoccupa-
more accidents because they cannot react quickly tion with the loss, persistent regrets about one's
enough to avoid them. Many people with depres- own or others' behavior toward the deceased, dif-
sion lack energy and report feeling chronically fa- ficulty accepting the finality of the loss, and a sense
tigued. A subset of people with depression exhibit that life is empty and meaningless (Horowitz et al.,
psychomotor agitation instead of retardation-these 1997). People who show complicated grief after a
people feel physically agitated, cannot sit still, and loss are more likely to be functioning poorly 2 to
may move around or fidget aimlessly. 3 years after the loss than are those who show
The thoughts of people with depression may milder grief reactions or those who show only
be filled with themes of worthlessness, guilt, symptoms of major depressive disorder (Bonanno
hopelessness, and even suicide. They often have et al., 2007; Bonanno, Westphal, & Mancini, 2011).
trouble concentrating and making decisions. As More chronic forms of depression have been re-
Jamison (1995, p. 100) describes, "It seemed as formulated in DSM-5. Persistent depressive disor-
though my mind had slowed down and burned der (formerly dysthymic disorder and chronic major
out to the point of being virtually useless." depressive disorder in DSM-IV) has as its essential fea-
In some severe cases, people with depression ture depressed mood for most of the day, for more
lose touch with reality, experiencing delusions (be- days than not, for at least 2 years. In children and
liefs with no basis in reality) and hallucinations adolescents, persistent depressive disorder requires
(seeing, hearing, or feeling things that are not real). depressed or irritable mood for at least 1 year
These delusions and hallucinations usually are duration. In addition, its diagnosis requires the pres-
negative. People with depression may have delu- ence of two or more of the following symptoms:
sions that they have committed a terrible sin, that (a) poor appetite, (b) insomnia or hypersomnia,
they are being punished, or that they have killed or (c) low energy or fatigue, (d) low self-esteem, (e) poor
hurt someone. They may hear voices accusing concentration, and/ or (f) hopelessness. During these
them of having committed an atrocity or instruct- 2 years (1 year in youth), the person must never have
ing them to kill themselves. been without symptoms of depression for longer
than a 2-month period. When an individual meets
Diagnosing Depressive diagnostic criteria for major depressive disorder
for 2 years, he or she is also given the diagnosis of
Disorders persistent depressive disorder. DSM-5 combined
Depression takes several forms. A severe bout of the DSM-IV categories of dysthymic and chronic
depressive symptoms lasting two weeks or more major depressive disorder because research failed
can be diagnosed as a major depressive disorder. to find a meaningful difference between these
The diagnosis of major depressive disorder requires two conditions, despite the DSM-IV notion that
that a person experience either depressed mood or dysthymic disorder was a less severe form of
loss of interest in usual activities, plus at least four depression. In fact, individuals with persistent de-
other symptoms of depression, chronically for at pressive disorder show a higher risk for comorbid
TABLE 7.1 DSM-5 Criteria for Major Depressive Disorder

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from
previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (Note: Do not
incl ude symptoms that are clearly attributable to another medical condition.)
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad , empty, hopeless)
or observation made by others (e.g., appears tearful) . (Note: In children and adolescents, can be irritable mood .)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either
subjective account or observation).
3. Sign ificant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or
decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or
being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-
reproach or guilt about being sick) .
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by
others) .
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a
specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to t he physiological effects of a substance or to another medical condition .
Note: Criteria A-C represent a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or
disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in
Criterion A, which may rese mble a depressive episode. Although such symptoms may be understandable and considered
appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should
be carefully consid ered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the
cultural norms for the expression of distress in the context of loss.
D. The occurrence of the major depressive episode is not better explained by sch izoaffective disorder, schizophrenia, schizophreniform
disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode.
Note: This exclusion does not apply if all the manic-like or hypomanic-like episodes are substance-induced or are attributable to
the physiological effects of another medical condition .
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Ed ition. Copyright 2013 American Psychiatric Associatio n.
disorders than those with major depressive disor- disorder. In other cases, the depression follows
der alone, particularly anxiety and substance use and may be the consequence of the other disorder.
disorders, and tend to experience worse func- The DSM-5 recognizes several subtypes of de-
tional consequences. pression, that is, different forms the disorder can
Over 70 percent of people diagnosed with ma- take (Table 7.2). The first subtype is depression with
jor depressive or persistent depressive disorder anxious distress. Anxiety is extremely common in
also have another psychological disorder at some depression (Watson, 2009), and people with this
time in their lives. The most common disorders subtype have prominent anxiety symptoms as well
that are comorbid with (occur with) depression as depressive symptoms. The second subtype of
are substance abuse, such as alcohol abuse; anxiety depression is with mixed features. People with this
disorders, such as panic disorder; and eating subtype meet the criteria for a major depressive
disorders (Kessler et al., 2003). Sometimes, the disorder and have at least 3 symptoms of mania,
depression precedes and may cause the other but they do not meet the full criteria for a manic
TABLE 7.2 Subtypes of Major Depressive Episodes
Subtype Characteristic Symptoms
Anxious distress Prominent anxiety symptoms

Mixed features Presence of at least three manic/hypomanic symptoms, but does not meet criteria for a manic episode
Melancholic features Inability to experience pleasu re, distinct depressed mood, depression regularly worse in morning, early
morning awakening, marked psychomotor retardation or agitation, significant anorexia or weight loss,
excessive guilt
Psychotic features Presence of mood-congruent or mood-incongruent delusions or hallucinations
Catatonic features Catatonic behaviors: not actively relating to environment, mutism, posturing, agitation, mimicking
another's speech or movements
Atypical features Positive mood reactions to some events, significant weight ga in or increase in appetite, hypersomnia,
heavy or leaden feelings in arms o r legs, long-standing pattern of sensitivity to interpersonal rejection
Seasonal pattern History of at least two years in which major depressive episodes occur during one season of the year
(usually the winter) and remit when the season is over
Peripartum onset Onset of major depressive episode during pregnancy or in the 4 weeks following delivery
episode (discussed on p. 182). The third subtype is winter. Rather, the mood changes must seem to
depression with melancholic features, in which the come on without reason or cause.
physiological symptoms of depression are particu- Although many of us may experience mood
larly prominent. The fourth subtype is depression changes with the seasons, only about 5 percent of the
with psychotic features, in which people experience U.S. population have a diagnosable seasonal affec-
~ delusions and hallucinations. The content of delu- tive disorder, and only 1 to 5 percent internationally
sions and hallucinations may be consistent with (Rohan, Roecklein, & Haaga, 2009; Westrin & Lam,
typical depressive themes of personal inadequacy, 2007). SAD is more common among people in lati-
guilt, death, or punishment (mood-congruent), or tudes with fewer hours of daylight in the winter
their content is unrelated to depressive themes or months. For example, a study in Greenland found a
mixed (mood-incongruent). In the fifth subtype, de- relatively high rate of SAD (9 percent) and found
pression with catatonic features, people show the that individuals living in northern latitudes were
strange behaviors collectively known as catatonia, more likely to meet the criteria for SAD than indi-
which can range from a complete lack of movement viduals living in southern latitudes (Kegel, Dam,
to excited agitation. The sixth subtype is depression Ali, & Bjerregaard, 2009). Similarly, in the United
with atypical features-the criteria for this subtype States the rate is only 1.4 percent in Florida but
are an odd assortment of symptoms (see Table 7.2). 9.9 percent in Alaska (Rohan et al., 2009).
The seventh subtype of major depressive dis- Eighth is depression with peripartum onset.
order is depression with seasonal pattern, also This diagnosis is given to women when the onset
referred to as seasonal affective disorder, or SAD. of a major depressive episode occurs during preg-
People with SAD have a history of at least 2 years nancy or in the 4 weeks following childbirth.
of experiencing and fully recovering from major Because 50 percent of "postpartum" major depres-
depressive episodes. They become depressed when sive episodes actually begin prior to delivery,
the daylight hours are short and recover when the DSM-5 refers to these episodes collectively as
daylight hours are long. In the Northern Hemi- peripartum episodes. More rarely, some women
sphere, this means that people are depressed from develop mania postpartum and are given the diag-
November through February and not depressed nosis of bipolar disorder with peripartum onset. In
from June through August. Some people with this the first few weeks after giving birth, as many as
disorder actually develop mild forms of mania or 30 percent of women experience the postpartum
have full manic episodes during the summer blues-emotional lability (unstable and quickly
~ months and are diagnosed with bipolar disorder shifting moods), frequent crying, irritability, and
with seasonal pattern. In order to be diagnosed fatigue. For most women, these symptoms cease
with seasonal affective disorder, a person's mood completely within 2 weeks of the birth. About 1 in
changes cannot be the result of psychosocial events, 10 women experiences postpartum depression
such as regularly being unemployed during the serious enough to warrant a diagnosis of a major
depressive disorder with peripartum onset

(O'Hara et al., 2013).
The last depressive disorder to be discussed is
premenstrual dysphoric disorder. Some women
regularly experience significant increases in dis-
tress during the premenstrual phase of their men-
strual cycle. Their symptoms are often a mixture of
depression, anxiety and tension, and irritability
and anger, which may occur in mood swings dur-
ing the week before the onset of menses, improve
once menses has begun, and become minimal or
absent in the week postmenses. These women also
often report physical symptoms such as breast ten-
derness or swelling, bloating and weight gain, and
joint and muscle pain. These women can be
diagnosed with premenstrual dysphoric disorder.
Although many women experience mild premen-
strual symptoms, only about 2 percent of women
meet the diagnostic criteria for premenstrual dys-
phoric disorder (Epperson et al., 2012).
Prevalence and Course

of Depressive Disorders
Sixteen percent of Americans experience an
episode of major depression at some time in their
life (Kessler, Merikangas, & Wang, 2007).
International studies in North America, Latin
America, Europe, and Japan show that the lifetime Depression is less common among children than among
prevalence of major depression ranges from 3 per- adults. Still, at any point in time. as many as 2.5 percent
cent in Japan to the 16 percent rate in the United of children and 8.3 percent of adolescents can be
States (Andrade et al., 2003). diagnosed with major depression.
In the United States, 18- to 29-year-olds are
most likely to have had a major depressive episode
in the past year (Kessler et al., 2003). Rates of de- Although these factors are important, other
pression in the past year go down steadily and are researchers suggest that the low rate is valid,
lowest in people over age 65 (Kessler et al., 2010). and they have offered several explanations for it
However, the rates of depression rise among peo- (Lyness, 2004). The first is quite grim: Depression
ple over age 85. When they do occur, depressions appears to interfere with physical health, and as a
in older people tend to be severe, chronic, and result people with a history of depression may be
debilitating (Fiske, Wetherell, & Gatz, 2009). more likely to die before they reach old age. The
It may be surprising that the rate of depression second explanation is more hopeful: As people age,
is so low among adults over age 65. Diagnosing de- they may develop more adaptive coping skills and
pression in older adults is complicated (Fiske et al., a psychologically healthier outlook on life (Fiske
2009). First, older adults may be less willing than et al., 2009). We consider a third explanation, that
younger adults to report the symptoms of depres- there have been historical changes in people's vul-
sion because they grew up in a society less accept- nerability to depression, later in this chapter.
ing of depression. Second, depressive symptoms in Depression is less common among children
older adults often occur in the context of a serious than among adults. Still, at any point in time, as
medical illness, which can interfere with making an many as 2.5 percent of children and 8.3 percent of
appropriate diagnosis (Kessler et al., 2010). Third, adolescents can be diagnosed with major depres-
older people are more likely than younger people to sion, and as many as 1.7 percent of children and
have mild to severe cognitive impairment, and it is 8.0 percent of adolescents can be diagnosed with
often difficult to distinguish between a depressive persistent depressive disorder (see Garber &
disorder and the early stages of a cognitive disorder Horowitz, 2002; Kessler et al., 2012; Merikangas &
(see Chapter 10). Knight, 2009). As many as 24 percent of youth will
Characteristics of Bipolar Disorder 181
SHADES OF GRAY
Consider the following case study of a college term, however, Carmen's depressed mood had
student, who may resemble someone you know. deepened, and she had spent days on end locked
in her bedroom, apparently sleeping. She had said
Carmen's friends were shocked to find her passed it was no use going to class because she couldn't
out in her dorm room with an empty bottle of concentrate. She had been skipping meals and
sleeping pills on the floor next to her. Carmen had had lost 12 pounds.
experienced years of unhappiness, a sense of low
self-worth, pessimism, and chronic fatigue. She Based on the time frame and symptoms described,
often told her friends she couldn't remember a what diagnosis would Carmen most likely receive?
time when she was happy for more than a few (Discussion appears at the end of the chapter.)
days at a time. Since the beginning of the winter
experience an episode of major depression at some 2003). We might ask why people experiencing the
time before age 20. Children will often show irrita- terrible symptoms of depression don't seek treat-
bility instead of sadness; also, rather than lose ment. One reason is that they may lack insurance
weight, they may simply fail to gain the weight or the money to pay for care. Often, however, they
expected for their developmental period. expect to get over their symptoms on their own.
Women are about twice as likely as men to They believe that their symptoms are simply a
experience both mild depressive symptoms and phase that will pass with time and that won't affect
severe depressive disorders (Nolen-Hoeksema & their lives over the long term.
Hilt, 2013). This gender difference in depression has
been found in many countries, in most ethnic groups, CHARACTERISTICS OF
and in all adult age groups. We discuss possible rea-
sons for these differences later in the chapter. BIPOLAR DISORDER
Depression appears to be a long-lasting, recur-
rent problem for some people. One nationwide PROFILES
study found that people with major depression had
spent an average of 16 weeks during the previous
year with significant symptoms of depression There is a particular kind of pain, elation, loneli-
(Kessler et al., 2003). The picture that emerges is of ness, and terror involved in this kind of madness.
depressed people spending much of their time at When you're high it's tremendous. The ideas and
least moderately depressed. After recovery from feelings are fast and frequent like shooting stars
one episode of depression, people with depression and you follow them until you find better and
remain at high risk for a relapse. As many as brighter ones. Shyness goes, the right words and
75 percent of people who experience a first episode gestures are suddenly there, the power to se-
of depression will experience subsequent episodes duce and captivate others a felt certainty. There
(Kessing, Hansen, & Andersen, 2004). People with a are inte rests found in uninteresting people.
history of multiple episodes of depression are more Sensuality is pervasive and the desire to seduce
likely to remain depressed for long periods of time. and be seduced irresistible. Feelings of ease, in-
Depression is a costly disorder, both to the indi- tensity, power, well-being, financial omnipo-
vidual and to society. People who have a diagnosis tence, and euphoria now pervade one's marrow.
of major depression lose an average of 27 days But, somewhere, this changes. The fast ideas
of work per year because of their symptoms. are far too fast and there are far too many; over-
Depression in workers costs employers an estimated whelming confusion replaces clarity. Memory
$37 billion per year in lost productivity alone (not goes. Humor and absorption on friends' faces are
including the cost of treatment) (Kessler et al., 2007). replaced by fear and concern. Everything previ-
The good news is that when people undergo ously moving with the grain is now against-
treatment for their depression, they tend to recover you are irritable, angry, frightened , uncontrollable,
much more quickly than they would without treat- and enmeshed totally in the blackest caves of
ment and to reduce their risk of relapse. The bad the mind. You never knew those caves were there.
news is that many people with depression either It will never end . (Goodwin & Jamison, 1990,
never seek care or wait years after the onset of pp . 17- 18)
symptoms before they seek care (Kessler et al.,
TABLE 7.3 DSM-5 Criteria for a Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and
persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day,
nearly every day (or any duration if hospitalization is necessary}.
B. During the period of mood disturbance and increased energy or activity, three (or more} of the following
symptoms (four if the mood is only irritable} are present to a significant degree, and represent a noticeable
change from usual behavior:
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep}
3. More talkative t han usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli}, as reported
or observed
6. Increase in goal-directed activity (either socially, at work or school, or sexually} or psychomotor agitation
(i.e., purposeless non-goa l-d irected activity}
7. Excessive involvement in activities that have a high potential for painful consequences (e.g. , engaging in
unrestrained buying sprees, sexual indiscretions, or foolish business investments}
C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning
or to necessitate hospita lization to prevent harm to self or others, or there are psychotic features.
D. The episode is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication, or other treatment}, or to another medical condition.
Note: At least one lifetime manic episode is required for the dignosis of bipolar I disorder.
The person in the profile is describing an episode of agitated and irritable, particularly with people
bipolar disorder. When she is manic, she has tremen- they perceive as "getting in the way." They may
dous energy and vibrancy, her self-esteem is soaring, engage in a variety of impulsive behaviors, such as
and she is filled with ideas and confidence. Then, sexual indiscretions or spending sprees. Often,
when she becomes depressed, she is despairing and they will frenetically pursue grand plans and goals.
fearful, she doubts herself and everyone around her, In order to be diagnosed with a manic episode,
and she wishes to die. This alternation between peri- an individual must show an elevated, expansive, or
ods of mania and periods of depression is the classic irritable mood for at least 1 week, as well as at least
manifestation of bipolar disorder. three of the other symptoms listed in Table 7.3. These
symptoms must impair the individual's functioning.
People who experience manic episodes meet-
Symptoms of Mania ing these criteria are said to have bipolar I disorder.
We have already discussed the symptoms of de- Almost all these people eventually will fall into a
pression in detail, so here we focus on the symp- depressive episode; mania without any depression
toms of mania (Table 7.3). The mood of people is rare (Goodwin & Jamison, 2007). For some people
who are manic can be elated, but that elation is with bipolar I disorder, the depressions are as
often mixed with irritation and agitation. severe as major depressive episodes, whereas for
People with mania have unrealistically positive others the episodes of depression are relatively mild
and grandiose (inflated) self-esteem. They experi- and infrequent. Some people diagnosed with bipo-
ence racing thoughts and impulses. At times, these lar I disorder have mixed episodes in which they
grandiose thoughts are delusional and may be experience the full criteria for manic episodes and at
accompanied by grandiose hallucinations. People least three key symptoms of major depressive epi-
experiencing a manic episode may speak rapidly sodes in the same day, every day for at least 1 week.
and forcefully, trying to convey a rapid stream of People with bipolar II disorder experience se-
fantas tic thoughts. Some people may become vere episodes of depression that meet the criteria
Characteristics of Bipolar Disorder 183
TABLE 7.4 Criteria for Bipolar I and Bipolar II Disorders
Bipolar I and II disorders differ in the presence of major depressive episodes, episodes meeting the full criteria
for mania, and hypomanic episodes.
Criteria Bipolar I Bipolar II
Major depressive episodes Can occur but are not necessary Are necessary for diagnosis
for diagnosis
Episodes meeting full criteria Are necessary for diagnosis Cannot be present for
for mania diagnosis
Hypomanic episodes Can occur between episodes of severe Are necessary for diagnosis
mania or major depression but are
not necessary for diagnosis
for major depression, but their episodes of mania One area of great interest and controversy is
are milder and are known as hypomania (Table 7.4). bipolar disorder in youth. Until the past decade, it
Hypomania involves the same symptoms as mania. was assumed that bipolar disorder could not be
The major difference is that in hypomania these diagnosed reliably until individuals were in their
symptoms are not severe enough to interfere with late teens or early adulthood. Increasingly, re-
daily functioning, do not involve hallucinations or searchers and clinicians have become interested in
delusions, and last at least 4 consecutive days. identifying early signs of bipolar disorder in chil-
There is also a less severe but more chronic form dren and young teenagers so interventions can be
of bipolar disorder, known as cyclothymic disorder. initiated and researchers can investigate the causes
A person with distinct cyclothymic disorder alter- and course of the disorder in youth (Leibenluft &
nates between periods of hypomanic symptoms and Rich, 2008; Taylor & Miklowitz, 2009).
periods of depressive symptoms, chronically over at Although some children show the alternating
least a 2-year period. The hypomanic and depressive episodes of mania and depression interspersed
symptoms are of insufficient number, severity, or du- with periods of normal mood characteristic of
ration to meet full criteria for hypomania or major bipolar disorder (Birmaher et al., 2006), others
depressive episode, respectively. During the periods show chronic symptoms and rapid mood switches.
of hypomanic symptoms, the person may be able to Individuals in the latter group tend toward severe
function reasonably well. Often, however, the peri- irritability characterized by frequent temper tan-
ods of depressive symptoms significantly interfere trums or rages (Leibenluft & Rich, 2008). These
with daily functioning, although the episodes are less children are at increased risk of developing anxiety
severe than major depressive episodes. People with and depressive disorders later in life but do not
cyclothymic disorder are at increased risk of devel- tend to develop classic bipolar disorder (Stringaris,
oping bipolar disorder (Goodwin & Jamison, 2007). Cohen, Pine, & Leibenluft, 2009). In addition, it is
About 90 percent of people with bipolar disor- difficult to distinguish the agitation and risky
der have multiple episodes or cycles during their behavior that accompany mania in youth from
lifetimes (Merikangas et al., 2007). The length of an the symptoms of attention-deficit/hyperactivity
individual episode of bipolar disorder varies greatly disorder (ADHD; see Chapter 10), which include
from one person to the next. Some people are in a hyperactivity, poor judgment, and impulsivity, or
manic state for several weeks or months before mov- from the symptoms of oppositional defiant disor-
ing into a depressed state. More rarely, people switch der (see Chapter 11), which include chronic irrita-
from mania to depression and back within a matter bility and refusal to follow rules. There has been
of days or, as noted above, even in the same day. The considerable debate as to whether these agitated,
number of lifetime episodes also varies tremen- irritable children have bipolar disorder, ADHD, or
dously from one person to the next, but a relatively oppositional defiant disorder, none of which seems
common pattern is for episodes to become more fre- to fit their symptoms perfectly.
quent and closer together over time. Four or more The authors of the DSM-5 decided to distin-
mood episodes that meet criteria for manic, hypo- guish children with these temper tantrums from
manic, or major depressive episode within 1 year children with more classic bipolar disorder by
lead to a diagnosis of rapid cycling bipolar I or adding a new diagnosis for youth age 6 and older
bipolar II disorder. called disruptive mood dysregulation disorder.
prevalence of the disorder among ethnic groups or ~

across cultures. These facts suggest that biological
factors may be more responsible for bipolar disor-
der than for depressive disorders, which show
more variability across cultures. Most people who
develop bipolar disorder do so in late adolescence
or early adulthood (Merikangas et al., 2011).
Like people with depressive disorders, people
with bipolar disorder often face chronic problems
on the job and in their relationships (Marangell,
2004). The majority of people with bipolar disorders
also meet the criteria for other psychiatric disorders,
most often an anxiety disorder (Merikangas et al.,
2011). In addition, people with bipolar disorder
often abuse substances such as alcohol and hard
drugs, which impairs their control over their
disorder, their willingness to take medications, and
their functioning. Despite the impairment resulting
from their symptoms, most people with bipolar dis-
order, especially those in developing countries, do
not receive any treatment (Merikangas et al., 2011).
Creativity and the

Mood Disorders
As noted in Mood Disorders Along the Contin-
uum, some theorists have argued that the symp- ,.....--....
toms of mania-increased self-esteem, a rush of
ideas and the courage to pursue those ideas, high
Some c hildren who regularly throw temper tantrums energy, little need for sleep, excessive optimism, and
may have bipolar disorder or another condition. such decisiveness-can actually have benefits in certain
as the new DSM-5 category called disruptive mood settings. In turn, the melancholy of depression is
dysregulation disorder. often seen as inspirational for artists . Indeed,
some of the most influential people in history have
To qualify for this diagnosis, a young person must
show severe temper outbursts that are grossly out
of proportion in intensity and duration to a situation
and inconsistent with developmental level. During
an outburst, these children may rage at others
verbally and become physically violent toward
others. Between outbursts, their mood is persistently
and obviously irritable and angry. To receive the
diagnosis, a child must have at least three temper
outbursts per week for at least 12 months and in at
least two settings (e.g., home and school).
Prevalence and Course

of Bipolar Disorder
Bipolar disorder is less common than depressive
disorders. Internationally, only 0.6 percent of peo-
ple will experience bipolar I disorder and only
0.4 percent of people bipolar II disorder in their
Winston Churchill had periods of
lifetimes (Merikangas et al., 2011). Men and manic symptoms that may have
women seem equally likely to develop the disor- been both an asset and a liability.
der, and there are no consistent differences in the
Although many creative people with bipolar

disorder may have been able to learn from their
periods of depression and to exploit their periods
of mania, many also have found the highs and lows
of the disorder unbearable and have attempted or
completed suicide. In general, the mood disorders
substantially impair thinking and productivity. As
Elizabeth Wurtzel (1995, p. 295) notes:
While it may be true that a great deal of art
finds its inspirational wellspring in sor-
row, let's not kid ourselves in how much
time each of those people wasted and lost
by being mired in misery. So many pro-
ductive hours slipped by as paralyzing de-
spair took over. This is not to say that we
should deny sadness its rightful place
among the muses of poetry and of all art
forms, but let's stop calling it madness,
let's stop pretending that the feeling itself
is interesting. Let's call it depression and
admit that it is very bleak.
Game show host Drew Carey has struggled with
depression.
THEORIES OF DEPRESSION
Depression is one of the most researched of all the
suffered, and perhaps benefited, from bipolar dis- psychological disorders. We will discuss biological,
order or depression Gamison, 1993). behavioral, cognitive, interpersonal, and sociocul-
Political leaders including Abraham Lincoln, tural theories.
Alexander Hamilton, Winston Churchill, Napoleon
Bonaparte, and Benito Mussolini and religious Biological Theories
leaders including Martin Luther and George Fox
(founder of the Society of Friends, or Quakers) of Depression
have been posthumously diagnosed by psychiatric A number of different biological processes appear
biographers as having had periods of mania, hypo- to be involved in depression, including genetics,
mania, or depression (Jamison, 1993). Although neurotransmitter systems, structural and func-
during periods of depression these leaders often tional abnormalities of the brain, and neuroendo-
were incapacitated, during periods of mania and crine systems.
hypomania they accomplished extraordinary feats.
While manic, they devised brilliant and daring Genetic Factors
strategies for winning wars and solving national Family history studies find that the first-degree
problems and had the energy, self-esteem, and relatives of people with major depressive disorder
persistence to carry out these strategies. are two to three times more likely to also have de-
Writers, artists, and composers have a higher- pression than are the first-degree relatives of peo-
than-normal prevalence of mania and depression. ple without the disorder (Levinson, 2010). Twin
For example, a study of 1,005 famous twentieth- studies of major depression find higher concor-
century artists, writers, and other professionals dance rates for monozygotic twins than for dizy-
found that the artists and writers experienced two gotic twins, implicating genetic processes in the
to three times the rate of mood disorders, psycho- disorder (Kendler, Myers, Prescott, & Neale, 2001).
sis, and suicide attempts than comparably success- Depression that begins early in life appears to have
ful people in business, science, and public life. The a stronger genetic base than depression that begins
poets in this group were most likely to have been in adulthood (Levinson, 2010) .
manic (Ludwig, 1992). More recently, actor Zach It is probable that multiple genetic abnormali-
Braff, actress Kirsten Dunst, game-show host Drew ties contribute to depression. Several studies sug-
Carey, rapper DMX, and singer Janet Jackson are gest that the serotonin transporter gene may play a
among the celebrities who have publicized their role (Saveanu & Nemeroff, 2012). As we will discuss
mood disorder. below, serotonin is one of the neurotransmitters
or serotonin in the synapses between neurons

Neurotransmitter Abnormalities Implicated
(Glassman, 1969; Schildkraut, 1965).
in Depression. Several problems in the
FIGURE 7.1 As our understanding of the functioning of
production and regulation of serotonin and
neurotransmitters in the brain has increased, theo-
norepinephrine may contribute to depression.
ries of their role in depression have become much
more complex (Saveanu & Nemeroff, 2012). A
number of processes within brain cells that affect
Presynaptic the functioning of neurotransmitters may go awry
neuron
Synthesis of in depression (Figure 7.1) . For example, serotonin
serotonin and . and norepinephrine are synthesized in neurons
hnne
norepmep T ptophan Tyrosme
may be abnormal. ~ from tryptophan and tyrosine, respectively, and
some studies suggest that abnormalities in this
synthesis process may contribute to depression
(Zhang et al., 2004). Both serotonin and norepi-
nephrine are released by one neuron (referred to as
There may be the presynaptic neuron) into the synapse and then
abnormalities in bind to receptors on other neurons (referred to as
genes regulating the postsynaptic neurons; see Figure 7.1). The re-
serotonin and--------..: t . Norepmephrine
norepinephrine t 5era 0~1 lease process, which is regulated by the serotonin
transport. ranspo er transporter
transporter gene, may be abnormal in depression.
In addition, the receptors for serotonin and norepi-
r ,..a.-.:....-11!~:..::
---- Recept._:o.:_
Receptors for---- nephrine on the postsynaptic neurons may be less
serotonin and sensitive than normal in people with depression,
norepinephrine or they may sometimes malfunction (Saveanu &
may malfunction. Postsynaptic neuron
Nemeroff, 2012).
Structural and Functional Brain

Abnormalities
Neuroimaging studies have found consistent
abnormalities in at least four areas of the brain
implicated in depression. Abnormalities on the se- in people with depression: the prefrontal cortex,
rotonin transporter gene could lead to dysfunction anterior cingulate, hippocampus, and amygdala
in the regulation of serotonin, which in turn could (Figure 7.2).
affect the stability of individuals' moods. In a lon- Critical functions of the prefrontal cortex in-
gitudinal study, Avshalom Caspi and colleagues clude attention, working memory, planning, and
(Caspi, Sugden, et al., 2003) found that people with novel problem solving. Many studies have shown
abnormalities on the serotonin transporter gene reduced metabolic activity and a reduction in the
were at increased risk for depression when they volume of gray matter in the prefrontal cortex, par-
faced negative life events (see also Kaufman et al., ticularly on the left side, in people with serious
2004, 2006) . Not all studies have replicated these depression (Saveanu & Nemeroff, 2012). In addition,
findings (see Risch et al., 2009), but a recent meta- electroencephalographic (EEG) studies show lower
analysis supported the interaction between the se- brain-wave activity on the left side of the prefrontal
rotonin transporter gene and early stress in the cortex in depressed people compared to nonde-
prediction of later depression (Karg, Burmeiester, pressed people (Davidson, Pizzagalli, Nitschke, &
Shedden, & Sen, 2011). Putnam, 2002). The left prefrontal cortex is particu-
larly involved in motivation and goal-orientation,
Neurotransmitter Theories and inactivity in this region may be associated
The neurotransmitters that have been implicated with motivational difficulties like those seen in de-
most often in depression are the monoamines, pression. The successful treatment of depression
specifically, norepinephrine, serotonin, and, to a with antidepressant medications is associated with
lesser extent, dopamine. These neurotransmitters increases in metabolic and brain-wave activity in
are found in large concentrations in the limbic sys- the left prefrontal cortex (Kennedy et al., 2001). r---._
tem, a part of the brain associated with the regula- The anterior cingulate, a subregion of the pre-
tion of sleep, appetite, and emotional processes. The frontal cortex, plays an important role in the body's
early theory of the role of these neurotransmitters response to stress, in emotional expression, and in
in mood disorders was that depression is caused social behavior (Davidson et al., 2010). People with
by a reduction in the amount of norepinephrine depression show different levels of activity in the
anterior cingulate relative to controls (Thase, 2010). Areas of the Brain Implicated in Major
This altered activity may be associated with prob- Depression. Neuroimaging studies have found
lems in attention, in the planning of appropriate FIGURE 7.2
abnormalities in the prefrontal cortex, anterior
responses, and in coping, as well as with anhedonia cingulate, amygdala, and hippocampus.
found in depression. Again, activity normalizes in
this region of the brain when people are success-
fully treated for their depression (Dougherty &
Rauch, 2007).
The hippocampus is critical in memory and in
fear-related learning. Neuroimaging studies show
smaller volume and lower metabolic activity in the
hippocampus of people with major depression --"t--->r-- Prefrontal
(Konarski et al., 2008). Damage to the hippocampus cortex
could be the result of chronic arousal of the body's
stress response. As we will discuss, people with
depression show chronically high levels of the hor-
mone cortisol, particularly in response to stress, Amygdala
indicating that their bodies overreact to stress and
their levels of cortisol do not return to normal as
Hippocampus
quickly as those of nondepressed people. The
hippocampus contains many receptors for cortisol,
and chronically elevated levels of this hormone
may kill or inhibit the development of new neurons
in the hippocampus (Pittenger & Duman, 2008).
Treatment with antidepressants or electroconvul- system richly interconnected with the amygdala,
sive therapy results in the growth of new cells in hippocampus, and cerebral cortex. This system,
the hippocampus in rats (Pittenger & Duman, 2008). often referred to as the hypothalamic-pituitary-
Abnormalities in the structure and functioning adrenal axis, or HPA axis, is involved in the fight-
of the amygdala also are found in depression or-flight response (see Chapter 5).
(Thase, 2010) . The amygdala helps direct attention Normally, when we are confronted with a
to stimuli that are emotionally salient and have stressor, the hypothalamus releases corticotropin-
major significance for the individual. Studies of releasing hormone (CRH) onto receptors on the
people with mood disorders show an enlargement anterior pituitary (Figure 7.3). This results in secre-
and increased activity in this part of the brain, and tion of corticotropin into the plasma in the blood-
activity in the amygdala has been observed to de- stream, stimulating the adrenal cortex to release
crease to normal levels in people successfully cortisol into the blood. This process helps the body
treated for depression (Thase, 2010). The effects of fight the stressor or flee from it. The hypothalamus
overactivity in the amygdala are not yet entirely has cortisol receptors that detect when cortisol lev-
clear, but the overactivity may bias people toward els have increased and normally responds by de-
aversive or emotionally arousing information and creasing CRH to regulate the stress response. Thus,
lead to rumination over negative memories and this biological feedback loop both helps activate
negative aspects of the environment (Davidson, the HPA system during stress and calms the sys-
Pizzagalli, & Nitschke, 2009). tem when the stress is over.
People with depression tend to show elevated
Neuroendocrine Factors levels of cortisol and CRH, indicating chronic hy-
Hormones have long been thought to play a role peractivity in the HPA axis and difficulty in the
in mood disorders, especially depression. The HPA axis's returning to normal functioning follow-
neuroendocrine system regulates a number of ing a stressor (Saveanu & Nemeroff, 2012). In tum,
important hormones, which in tum affect basic the excess hormones produced by heightened HPA
functions such as sleep, appetite, sexual drive, activity seem to have an inhibiting effect on recep-
and the ability to experience pleasure (to review tors for the monoamine neurotransmitters. One
the neuroendocrine system, see Chapter 2). These model for the development of depression proposes
hormones also help the body respond to environ- that people exposed to chronic stress may develop
mental stressors. poorly regulated neuroendocrine systems. Then,
Three key components of the neuroendocrine when they are exposed to even minor stressors
system-the hypothalamus, pituitary, and adrenal later in life, the HPA axis overreacts and does not
cortex-work together in a biological feedback easily return to baseline. This overreaction changes
blunted (Cicchetti & Toth, 2005). Christine Heim and

The Hypothalamic-
FIGURE 7.3 colleagues (Heim & Nemeroff, 2001; Heim, Plotsky,
Pituitary-Adrenal Axis.
& Nemeroff, 2004) have found that women who
The hypothalamus
were sexually abused as children show altered HPA
synthesizes corticotropin-releasing
responses to stress as adults, even when they are
hormone (CRH). CRH is transported to the
not depressed. Similarly, animal studies show that
pituitary gland, where it stimulates the
early stress (such as separation from the mother)
synthesis and release of adrenocorticotropic
promotes exaggerated neurobiological stress reac-
hormone (ACTH). which then circulates to
tivity and a vulnerability to depression-like re-
the adrenal glands, producing cortisol.
sponses to future stressors (Saveanu & Nemeroff,
Cortisol then inhibits the production of
2012). Notably, these neurobiological vulnerabili-
further ACTH and CRH. Normally, this
ties can be reduced in animals by providing them
process prevents too much or too prolonged
with subsequent supportive maternal care and/ or
physiological arousal following a stressor.
pharmacological interventions.
In major depression, however, people
Hormonal factors have often been implicated
often show abnormal cortisol functioning,
in women's greater vulnerability to depression
suggesting that there is dysregulation in the
(Nolen-Hoeksema & Hilt, 2013). Changes in the
hypothalamic-pituitary-adrenal (HPA) axis.
ovarian hormones, estrogen and progesterone, af-
fect the serotonin and norepinephrine neurotrans-
mitter systems and thus theoretically could affect
mood. Some women show increases in depressed
mood when their levels of estrogen and progester-
CRH ~------------------, one are in flux, such as during pregnancy and the
postpartum period and premenstrually (Epperson
et al., 2012; O'Hara & McCabe, 2013). Further, girls
show increases in their rate of depression around
ages 13 to 15 (Twenge & Nolen-Hoeksema, 2002),
possibly because of the hormonal changes of pu-
berty (Angold, Castello, & Worthman, 1998). Find-
ings of a direct link between changes in estrogen and
ACTH ~----------------, progesterone levels and vulnerability to depression
have not been consistent, however. The hormonal
changes of puberty, the menstrual cycle, the peripar-
tum period, and menopause may trigger depression
1
Adrenal - - - - - - - - - - - - - - - - + - Cortisol
only in women with a genetic or other biological
vulnerability to the disorder (Steiner, Dunn, & Born,
2003; Young & Korzun, 1999).
Psychological Theories
the functioning of the monoamine neurotransmit-
ters in the brain, and an episode of depression
of Depression
is likely to follow (Southwick, Vythilingam, & Behavioral theorists have focused on the role of
Charney, 2005). In addition, chronic excessive uncontrollable stressors in producing depression.
exposure to cortisol may account for the volume Cognitive theorists have argued that the ways peo-
reductions in several brain areas seen in depressed ple think can contribute to, and maintain, depres-
people, including the hippocampus, the prefrontal sion. Interpersonal theorists have considered the
cortex, and the amygdala. role of relationships in causing and maintaining
Early traumatic stress, such as being the victim depression. Sociocultural theorists have focused
of sexual and/ or physical abuse, suffering severe on explanations for the differences in rates of de-
neglect, or being exposed to other serious chronic pression among sociodemographic groups.
stress, may lead to some of the neuroendocrine ab-
normalities that predispose people to depression Behavioral Theories
(Southwick et al., 2005). Studies of children who Depression often arises as a reaction to stressful
have been abused or neglected show that their bio- negative events, such as the breakup of a relation-
logical responses to stress- particularly the response ship, the death of a loved one, a job loss, or a seri-
of their HPA axis-often are either exaggerated or ous medical illness (Hammen, 2005; Monroe, 2010).
Up to 80 percent of people with depression report

a negative life event prior to the onset of their de-
pression (Mazure, 1998). People with depression
are more likely than people without depression to
have chronic life stressors, such as financial strain
or a bad marriage. They also tend to have a history
of traumatic life events, particularly events involv-
ing loss (Hammen, 2005).
Behavioral theories of depression suggest that
life stress leads to depression because it reduces
the positive reinforcers in a person's life (Lewinsohn
& Gotlib, 1995). The person begins to withdraw,
which results in a further reduction in reinforcers,
which leads to more withdrawal, creating a self-
perpetuating chain.
For example, a man having difficulty in his
marriage may initiate interactions with his wife
less often because these interactions are no longer
as positively reinforcing as they once were. This
only worsens the communication between him
The loss of a loved one can increase the risk of depression.
and his wife, so the relationship deteriorates. He
then withdraws further and becomes depressed
about this area of his life. Behavioral theorists sug-
gest that such a pattern is especially likely in peo-
ple with poor social skills, because they are more world, and the future. They then commit errors in
likely to experience rejection by others and also thinking that support their negative cognitive triad,
more likely to withdraw in response to rejection such as ignoring good events and exaggerating neg-
than to find ways to overcome it (Lewinsohn, ative events. Their negative thinking both causes
1974). In addition, once a person begins engaging and perpetuates their depression. Many studies
in depressive behaviors, these behaviors are rein- have demonstrated that people with depression
forced by the sympathy and attention they engen- show these negative ways of thinking, and some
der in others. longitudinal studies have shown that these think-
Another behavioral theory-the learned helping styles predict depression over time (Abramson
lessness theory-suggests that the type of stress- et al., 2002; Joormann, 2010). Beck's theory led to
ful event most likely to lead to depression is an one of the most widely used and successful thera-
uncontrollable negative event (Seligman, 1975). Such pies for depression----cognitive-behavioral therapy.
events, especially if they are frequent or chronic, can Another cognitive theory of depression, the
lead people to believe they are helpless to control im- reformulated learned helplessness theory, explains
portant outcomes in their environment. In turn, this how cognitive factors might influence whether a
belief in helplessness leads people to lose their moti- person becomes helpless and depressed following
vation and to reduce actions on their part that might a negative event (Abramson et al., 1978; Peterson &
control the environment as well as leaving them Seligman, 1984). This theory focuses on people's
unable to learn how to control situations that are causal attributions for events. A causal attribution
controllable. These learned helplessness deficits are is an explanation of why an event happened.
similar to the symptoms of depression: low motiva- According to this theory, people who habitually
tion, passivity, and indecisiveness (Seligman, 1975). explain negative events by causes that are internal,
For example, battered women may develop the be- stable, and global tend to blame themselves for
lief that they cannot control their beatings or other these negative events, expect negative events to
parts of their lives. This belief may explain their high recur in the future, and expect to experience nega-
rates of depression and their tendency to remain in tive events in many areas of their lives. In turn,
abusive relationships (Koss & Kilpatrick, 2001). these expectations lead them to experience long-
term learned helplessness deficits as well as loss of
Cognitive Theories self-esteem in many areas of their lives.
Aaron Beck (1967) argued that people with depres- For example, consider a student who becomes
sion look at the world through a negative cognitive depressed after failing a psychology exam. The
triad: They have negative views of themselves, the reformulated learned helplessness theory would
then tracked these students for the next 2 years, in-

terviewing them every 6 weeks. Among the stu-
dents with no history of depression, those with a
hopeless attributional style were much more likely
to develop a first onset of major depression than
were those with an optimistic attributional style
(17 percent versus 1 percent). In addition, among
students with a history of depression, those with a
hopeless style were more likely to have a relapse of
depression than were those with an optimistic style
(27 percent versus 6 percent). Thus, a pessimistic
attributional style predicted both first onset and
relapse of depression.
Another cognitive theory, the ruminative re-
sponse styles theory, focuses more on the process of
thinking than on the content of thinking as a con-
tributor to depression (Nolen-Hoeksema, Wisco, &
Lyubomirsky, 2008). Some people, when they are
sad, blue, and upset, focus intently on how they
feel-their symptoms of fatigue and poor concen-
tration and their sadness and hopelessness-and
can identify many possible causes. They do not
attempt to do anything about these causes, how-
ever, and instead continue to engage in rumination
about their depression. Several studies have shown
People who attribute negative events, such as failing an
exam, to internal CI failed "), stable CI always fail ") , and that people with this more ruminative coping style
global causes ("I always fail at everything) may be at are more likely to develop major depression (Nolen-
greater risk for d epression. Hoeksema et al., 2008).
People who are depressed show a bias toward
negative thinking in basic attention and memory
processes (Harvey, Watkins, Mansell, & Shafran,
suggest that she has blamed her failure on internal 2004; Joormann, 2010). Depressed people are more
causes-she didn't study hard enough-rather likely than nondepressed people to dwell on nega-
than external causes-the exam was too hard. Fur- tive stimuli, such as sad faces (Gotlib, Krasnoperova,
ther, she has assumed that the failure was due to Yue, & Joormann, 2004) and to have trouble dis-
stable causes, such as a lack of aptitude in psychol- engaging their attention from negative stimuli
ogy, rather than to unstable causes, such as the in- Goormann, 2004). After learning a list of words and
structor not allowing enough time. Therefore, she then being surprised with the task of recalling those
expects to fail again. Finally, she has attributed her words, depressed people tend to recall more nega-
failure to a global cause, such as her difficulty tive words than positive words, while nondepressed
learning the material. This global attribution then people show the opposite memory bias (Blaney,
leads her to expect failure in other academic areas. 1986; Matt, Vasquez, & Campbell, 1992). These
Hopelessness depression develops when people biases in attention to and memory for negative infor-
make pessimistic attributions for the most impor- mation could form the basis of depressed people's
tant events in their lives and perceive that they have tendency to see the world in a negative light and
no way to cope with the consequences of these may help maintain this tendency.
events (Abramson et al., 1989). Both the reformu- In addition, depressed people tend to show
lated learned helplessness theory and the hopeless- overgeneral memory (Williams et al., 2007). When
ness theory have led to much additional research given a simple word cue such as "angry" and
(Abramson et al., 2002). One of the most definitive asked to describe a memory prompted by that cue,
studies of the hopelessness theory of depression depressed people are more likely than nonde-
was a long-term study of college students (Alloy, pressed people to offer memories that are highly
Abramson, & Francis, 1999). The researchers inter- general (e.g., "People who are mean") instead of
viewed first-year students at two universities and concrete (e.g., "Jane being rude to me last Friday").
identified those with hopeless attributional styles Mark Williams and colleagues (2007) suggest that
and those with optimistic attributional styles. They depressed people develop the tendency to store
and recall memories in a general fashion as a way Klerman & Weissman, 1989). For example, fewer
of coping with a traumatic past. Vague, general than 20 percent of people born before 1915 appear
memories are less emotionally charged and pain- to have experienced major depression, w hereas
ful than memories that are rich in concrete detail, over 40 percent of people born after 1955 appear to
and thus they help reduce the emotional pain de- be at risk for major depression at some time in
pressed people feel over their past. Interestingly, their lives. Some theorists suggest that more recent
the one other disorder characterized by overgen- generations are at higher risk for depression be-
eral memory is posttraumatic stress disorder (see cause of the rapid changes in social values begin-
Chapter 5), which develops specifically in response ning in the 1960s and the disintegration of the
to traumatic events (Williams et al., 2007). family unit (Klerman & Weissman, 1989). Another
possible explanation is that younger generations
Interpersonal Theories have unrealistically high expectations for them-
The interpersonal relationships of people with de- selves that older generations did not have.
pression often are fraught with difficulty. The
interpersonal theories of depression focus on Gender Differences We noted earlier that
these relationships (Coyne, 1976; Hames, Hagan, & women are about twice as likely as men to suffer
Joiner, 2013). Interpersonal difficulties and losses from depression. Several explanations have been
frequently precede depression and are the stress- offered for this gender difference (Nolen-
ors most commonly reported as triggering depres- Hoeksema & Hilt, 2013).
sion (Hammen, 2005; Rudolph, 2008). Depressed When faced with distress, men are more likely
people are more likely than nondepressed people than women to turn to alcohol to cope and to deny
to have chronic conflict in their relationships with that they are distressed, while women are more
family, friends, and co-workers (Hammen, 2005). likely than men to ruminate about their feelings
Depressed people may act in ways that engen- and problems (Nolen-Hoeksema & Hilt, 2013).
der interpersonal conflict (Hammen, 2005). Some Men therefore may be more likely to develop dis-
depressed people have a heightened need for ap- orders such as alcohol abuse, while women's ten-
proval and expressions of support from others dency to rumin ate appears to make them more
(Leadbeater, Kuperminc, Blatt, & Herzog, 1999; likely to develop depression. These different re-
Rudolph & Conley, 2005) but at the same time eas- sponses to stress may be due to social norms-
ily perceive rejection by others, a characteristic it is more acceptable for men to turn to alcohol
called rejection sensitivity (Downey & Feldman, and for women to ruminate (Addis, 2008; Nolen-
1996). They engage in excessive reassurance seek- Hoeksema & Hilt, 2013).
ing, constantly looking for assurances from others Perhaps also due to gender socialization,
that they are accepted and loved Goiner & Timmons, women tend to be more interpersonally oriented
2009). They never quite believe the affirmations than men (Feingold, 1994). On one hand, women's
other people give, however, and anxiously keep strong interpersonal networks may give them sup-
going back for more. After a while, their family port in times of need. However, when bad things
and friends can become weary of this behavior and happen to others or when there is conflict in their
may become frustrated or hostile. The insecure relationships, women are more likely than men to
person picks up on these cues of annoyance and report depressive symptoms (Hammen, 2003;
panics over them. The person then feels even more Rudolph, 2009). Women also appear more likely
insecure and engages in excessive reassurance than men to base their self-worth on the health of
seeking. Eventually, the person's social support their relationships (Jack, 1991). In addition, women
may be withdrawn altogether, leading to increased in most societies have less status and power than
and longer depression. do men, and as a result they experience more
prejudice, discrimination, and violence (Nolen-
Sociocultural Theories Hoeksema & Hilt, 2013). Sexual abuse, particularly
Sociocultural theorists have focused on how differ- in childhood, contributes to depression in women
ences in the social conditions of demographic throughout their lifetime (Widom, DuMont, &
groups lead to differences in vulnerability to Czaja, 2007).
depression. Earlier in this chapter, we noted biological ex-
planations for women's greater vulnerability to
Cohort Effects Historical changes may have depression compared to men. Biological and socio-
put more recent generations at higher risk for de- cultural factors likely interact to lead to the large
pression than previous generations, a phenome- gender difference in the incidence of depression
non called a cohort effect (Kessler et al., 2003; (Nolen-Hoeksema & Hilt, 2013).
Ethnicity/Race Differences In the United Biological Theories of Bipolar

States, individuals from Hispanic cultures tend Disorder
to show a higher prevalence of depression in the
previous year than non-Hispanic white individu- Genetic Factors
als (Anderson & Mayes, 2010; Blazer, Kessler, Bipolar disorder is strongly and consistently linked
McGonagle, & Swartz, 1994). This may reflect rela- to genetic factors, although the specific genetic ab-
tively high rates of poverty, unemployment, and normalities that contribute to bipolar disorder are
discrimination among Hispanics. not yet known. First-degree relatives (parents, chil-
Adult studies indicate that African Americans dren, and siblings) of people with bipolar disorder
have lower rates of depression than Caucasian have 5 to 10 times higher rates of both bipolar dis-
Americans (Anderson & Mayes, 2010; Blazer et al., order and depressive disorders than relatives of
1994). This may seem puzzling given the disad- people without bipolar disorder (Farmer, Elkin, &
vantaged status of African Americans in U.S. soci- McGuffin, 2007). Also, the identical twins of indi-
ety. However, African Americans have high rates viduals with bipolar disorder are 45 to 75 times
of anxiety disorders, suggesting that the stress of more likely to develop the disorder than are people
their social status may make them especially prone in the general population (McGuffin et al., 2003).
to anxiety disorders rather than to depression.
Other studies have found extremely high rates of Structural and Functional Brain
depression among Native Americans, especially Abnormalities
the young (Saluja et al., 2004). Depression among Like the depressive disorders, bipolar disorder is
Native American youth is tied to poverty, hope- associated with abnormalities in the structure and
lessness, and alcoholism. functioning of the amygdala, which is involved in
the processing of emotions (Figure 7.4; Rich et al.,
2007), and the prefrontal cortex, which is involved
THEORIES OF BIPOLAR in cognitive control of emotion, planning, and
judgment (Konarski et al., 2008). In contrast to de-
DISORDER pression, bipolar disorder has not consistently
Most existing theories of bipolar disorder focus on been associated with alterations in the size or func-
biological causes. In recent years, however, there tioning of the hippocampus.
has been increasing interest in psychological and An area of the brain called the striatum, part of
social contributors to new episodes in people with a structure called the basal ganglia, is involved in
bipolar disorder. the processing of environmental cues of reward.
For example, this brain structure becomes active
when rewarding stimuli, such as tasty food or op-
portunities to earn money, are perceived by the in-
dividual. This area of the brain is activated
abnormally in people with bipolar disorder but
not consistently so in people with major depres-
sion, suggesting that people with bipolar disorder
may be hypersensitive to rewarding cues in the en-
vironment (Caligiuri et al., 2003; Saxena et al.,
2002) . A circuit from the prefrontal cortex through
the striatum to the amygdala is involved in adap-
tation to changing contingencies of reward (i.e.,
knowing when you should drop one strategy in
favor of another in order to get a reward). Some
researchers suggest that individuals with bipolar
disorder have abnormalities in the functioning of
this circuit that lead them to have inflexible re-
sponses to reward (Leibenluft & Rich, 2008). When
they are in a manic phase, they inflexibly and ex-
cessively seek reward; when they are in a depres-
sive phase, they are highly insensitive to reward
(Depue & Iacono, 1989).
Source: Leibenluft & Rich, 2008. Some studies suggest that youth with bipolar
disorder have abnormalities in the white matter
of the brain, particularly in the prefrontal cortex Another psychological factor that has been
(Frazier et al., 2007; Pillai et al., 2002). White matter studied in people with bipolar disorder is stress.
is tissue that connects various structures in the Experiencing stressful events and living in an un-
brain and transmits messages between them. supportive family may trigger new episodes of bi-
White-matter abnormalities are found in children at polar disorder (Altman et al., 2006; Frank, Swartz,
their first episodes of bipolar disorder, before they & Kupfer, 2000; Hlastala et al., 2000). Even positive
have been medicated (Adler et al., 2006), and in chil- events can trigger new episodes of mania or hypo-
dren at risk for bipolar disorder because of family mania, particularly if they involve striving for
history (Frazier et al., 2007). White-matter abnor- goals seen as highly rewarding. A study of college
malities could result in the brain's prefrontal area students found that among those with bipolar dis-
having difficulty communicating with and exerting order, preparing for and completing exams tended
control over other areas, such as the amygdala, to trigger hypomanic symptoms, particularly
leading to the disorganized emotions and extreme among students who were highly sensitive to re-
behavior characteristic of bipolar disorder. wards (Nusslock et al., 2007). Thus, goal-striving
situations may trigger high reward sensitivity,
Neurotransmitter Factors which in turn triggers manic or hypomanic symp-
The monoamine neurotransmitters have been toms in people with bipolar disorder.
implicated in bipolar disorder as well as in major Changes in bodily rhythms or usual routines
depressive disorder. In particular, several studies also can trigger episodes in people with bipolar
have suggested that dysregulation in the dopa- disorder (Frank et al., 2000). For example, changes
mine system contributes to bipolar disorder in sleep and eating patterns can lead to relapse.
(Leibenluft & Rich, 2008). High levels of dopamine Significant changes in daily routine can do the
are thought to be associated with high reward same, particularly if they are due to changes in the
seeking, while low levels are associated with in- social climate, such as starting a new job. A psy-
sensitivity to reward. Thus, dysregulation in the chosocial therapy we discuss later in this chapter,
dopamine system may lead to excessive reward interpersonal and social rhythm therapy, helps
seeking during the manic phase and a lack of re- people with bipolar disorder keep their bodily and
ward seeking in the depressed phase (Berk et al., social rhythms regular.
2007; Depue & Iacono, 1989).
Psychosocia l Contributors TREATMENT OF MOOD

to Bipolar Disorder DISORDERS
In line with biological evidence that dysregulation Many forms of treatment are now available for suf-
of reward systems plays a role in bipolar disorder, ferers of mood disorders. In any given year, how-
psychologists have been examining relationships ever, only about half the people who have bipolar
between bipolar disorder and behavioral indica- disorder and about 60 percent of the people having
tors of sensitivity to reward. In some of these stud- an episode of major depression seek treatment in the
ies, individuals play games on the computer, such United States, and many fewer seek treatment in
as gambling games, that assess their willingness developing nations (Kessler et al., 2003; Merikangas
to take risks in order to pursue possible rewards et al., 2011). Most often, those who eventually do
and their ability to detect what kinds of behaviors seek treatment do so a number of years after the
will be rewarded. These studies confirm that onset of their symptoms.
people with bipolar disorder, even when they are
asymptomatic, show greater sensitivity to reward Biological Treatments
than do people without the disorder (Alloy et al.,
2008; Johnson, Fulford, & Carver, 2012) . In addi- for Mood Disorders
tion, a study that followed people with bipolar Most of the biological treatments for depression
disorder for nearly 3 years found that those with and bipolar disorder are drug treatments. In addi-
greater sensitivity to reward relapsed into manic tion to being treated with drugs, some people with
or hypomanic symptoms sooner than did those mood disorders are treated with electroconvulsive
~ with lower sensitivity to reward (Alloy et al., therapy (ECT). Three new treatments for mood
2008). In contrast, individuals with high sensitiv- disorders-repetitive transcranial magnetic stimu-
ity to punishment relapsed into depressive epi- lation (rTMS), vagus nerve stimulation, and deep
sodes sooner than did those with lower sensitivity brain stimulation-hold out hope for many peo-
to punishment. ple. People with seasonal affective disorder (SAD)
TABLE 7.5 Antidepressant Medications
A number of different types of medication are available for the treatment of depression.
Class Generic Name Brand Name Prominent Side Effects
Selective serotonin Citalopram Celexa Nausea, diarrhea, insomnia , tremor, sexual

reuptake inhibitors Escitalopram Lexapro dysfunction, daytime sedation, agitation/
Fluoxetine Prozac restlessness, possible increases in suicidal
Flovoxamine Luvox thought and behavior.
Paroxetine Paxil
Sertraline Zoloft
Selective serotonin- Venlafaxine Effexor Nausea, diarrhea, insomnia, tremor, sexual
norepinephrine reuptake Duloxetine Cymba Ita dysfunction, daytime sedation, agitation/
inhibitors restlessness, possible increases in suicidal
thought and behavior, increased sweating, dry
mouth, rapid heartbeat, headaches.
Norepinephrine-dopamine Bupropion Wellbutrin Nausea, vomiting, insomnia, headaches,
reuptake inhibitor Zyban seizures.
Tricyclic antidepressants Am itri ptyl i ne Elavil Anticholinergic effects (dry mouth, constipation,
Clomipramine Anafranil difficulty urinating, blurred vision, memory
Doxepin Sinequan impairment, confusion) .
Less commonly: difficulty sleeping, headaches,
Imipramine Tofranil tremor, appetite change.
Trimipramine Surmontil Especially problematic: drop in blood pressure,
Desipramine Norpramin cardiac arrhythmias for people with heart
Nortriptyline Aventyl problems, can be lethal in overdose.
Protriptyline Vivactil
Amoxapine Ascend in
Maprotiline Ludiomil
Monoamine oxidase inhibitors lsoca rboxazid Marplan Dry mouth, constipation, difficulty urinating,
Phenelzine Nardi I blurred vision, memory impairment, confusion.
Tranylcypromine Par nate Less commonly: difficulty sleeping, headaches,
tremor, appetite change.
Especially problematic: drop in blood pressure,
cardiac arrhythmias for people with heart
problems, potentially life-threatening increase in
blood pressure following ingestion of certain
foods or medications.
Source: Thase, M.E., & Denko, T. " Pharmacotherapy of mood disorders. " Adapted and reprinted, with permission from the Annual Review of Clinical
Psychology, Volume 4, copyright Annual Reviews, Inc., 2008, www.a nnualreviews.org, in the format Textbook via Copyright Clearance Center.
can benefit from a simple therapy: exposure to of bipolar disorder. Initially, they were thought to
bright lights. work by altering levels of the neurotransmitters se-
rotonin, norepinephrine, or dopamine in synapses
Drug Treatments for Depression or by affecting the receptors for these neurotrans-
The late twentieth century saw rapid growth in the mitters. However, these changes occur within hours
number of drugs available for depression and in the or days of taking the drugs, whereas reductions in ,-----...,
number of people using them. Table 7.5 summa- depressive symptoms typically don't appear for
rizes the classes of drugs commonly used in treating weeks. More recent theories suggest that these
depressive disorders and the depressive symptoms drugs have slow-emerging effects on intracellular
processes in the neurotransmitter systems discussed

earlier (see Figure 7.1) and on the action of genes
that regulate neurotransmission, the limbic system,
and the stress response (Rim & Gitlin, 2010; Thase &
Denko, 2008).
All the different antidepressant drugs cur-
rently available reduce depression in about 50 to
60 percent of people who take them (Thase &
Denko, 2008). These medications appear to work
better for treating severe and persistent depression
than for treating mild-to-moderate depression. A
meta-analysis of 718 patients from six studies
found that antidepressants were substantially bet-
ter than a placebo in reducing symptoms only in
very severely depressed patients; in patients with
mild-to-moderate depression, the effects of the an-
tidepressants were small to nonexistent (Fournier
et al., 2010; see also Khan, Leventhal, Khan, &
Brown, 2002; Kirsch et al., 2008). The Federal Drug Administration (FDA) requires warnings for SSRis saying that
The choice of which drug to begin treatment they may increase the risk of suicide.
with tends to be based on the experience of the
physician and concerns about the patient's abil-
ity to tolerate side effects . It typically takes a few 2008). The most common side effects are gastroin-
weeks to know whether a person will respond to testinal symptoms (e.g., nausea and diarrhea),
a drug. Most people try more than one medica- tremor, nervousness, insomnia, daytime sleepi-
tion before they find the one that works for them. ness, diminished sex drive, and difficulty achiev-
These days, antidepressant drugs are used to re- ing orgasm. When people first begin taking an
lieve the acute symptoms of depression. Then SSRI, they sometimes report feeling "jittery" or
individuals usually are maintained on antide- having a feeling of "crawling out of one's skin."
pressant drugs for at least 6 months after their Some people who have bipolar disorder may de-
symptoms have subsided, to prevent relapse. velop manic symptoms when they take an SSRI.
Discontinuing antidepressant use during the The agitation some people experience while taking
first 6 to 9 months after symptoms subside seems an SSRI may contribute to an increase in suicidal
to double the risk of relapse in severe depression thought and behavior. This risk may be greatest for
(Geddes et al., 2004). People with bipolar disorder children and adolescents; reviews of controlled
often take antidepressants continually to prevent studies show that approximately 4 percent of
a relapse of depression. youth treated with an SSRI show suicidal thought
and behavior, about double the percentage of
Selective Serotonin Reuptake Inhibitors youth taking a placebo (Thase & Denko, 2008).
The selective serotonin reuptake inhibitors, or SSRis are associated with a smaller increase in sui-
SSRis, are widely used to treat depressive symp- cidal thought and behavior among adults than
toms. SSRis are not more effective in the treatment among children, and among the elderly SSRis are
of depression than the other available antidepres- associated with a reduction in suicidal thought
sants, but they have fewer difficult-to-tolerate side and behavior.
effects (Thase & Denko, 2008). In addition, they are
much safer if taken in overdose than many of the Selective Serotonin-Norepinephrine Reup-
older antidepressants, such as the tricyclic antide- take Inhibitors The selective serotonin-
pressants and the monoamine oxidase inhibitors, norepinephrine reuptake inhibitors (SNRis) were
described below. Finally, they have positive effects designed to affect levels of norepinephrine as well
on a wide range of symptoms that co-occur with as serotonin. Perhaps because these drugs influ-
depression, including anxiety, eating disorders, ence both neurotransmitters, they show a slight
and impulsiveness. advantage over the selective serotonin reuptake
The SSRis do have side effects, however, and inhibitors in preventing a relapse of depression
5 to 10 percent of people have to discontinue their (Nemeroff et al., 2007). The dual action of these
use because of these side effects (Thase & Denko, drugs also may account for their slightly broader
array of side effects compared to the SSRis (see Mood Stabilizers

Table 7.5). People with bipolar disorder may take antidepres-
sants to relieve their depressive symptoms, but
Bupropion: A Norepinephrine-Dopamine they also usually take a mood stabilizer (lithium or
Reuptake Inhibitor Bupropion affects the nor- an anticonvulsant medication) to relieve or pre-
epinephrine and dopamine systems and thus is vent symptoms of mania. Lithium can also have
known as a norepinephrine-dopamine reuptake positive effects on depressive symptoms in people
inhibitor. It may be especially useful in treating with depression. In addition, many people are
people suffering from psychomotor retardation, prescribed atypical antipsychotic medications to
anhedonia, hypersomnia, cognitive slowing, inat- control mood swings.
tention, and craving-for example, bupropion can
help people stop craving cigarettes. In addition, Lithium Lithium may work by improving the
bupropion appears to overcome the sexual dys- functioning of the intracellular processes that appear
function side effects of the SSRis and thus some- to be abnormal in the mood disorders (Belmaker,
times is used in conjunction with them (Thase & 2004). Most people with bipolar disorder take
Denko, 2008). lithium even when they have no symptoms of mania
or depression in order to prevent relapses. People
Tricyclic Antidepressants Although the tri- maintained on adequate doses of lithium have
cyclic antidepressants were some of the first drugs significantly fewer relapses of mania and depression
shown to consistently relieve depression, they are than people with bipolar disorder not maintained on
used less frequently these days than the other lithium (Geddes et al., 2004; Ghaemi, Pardo, & Hsu,
drugs reviewed in this section (Thase & Denko, 2004). Lithium is also quite effective in reducing
2008). This is due in large part to their numerous suicide risk, as we discuss later in this chapter.
side effects, many of which are anticholinergic ef- Although lithium has literally been a lifesaver
fects, so-called because they are related to levels of for many people with mood disorders, it poses
the neurotransmitter acetylcholine. The tricyclic some problems. The difference between an effec-
antidepressants also can cause a drop in blood tive dose of lithium and a toxic dose is small, leav-
pressure and cardiac arrhythmia in people with ing a narrow window of therapeutic effectiveness.
heart problems. Further, the tricyclics can be fatal People who take lithium must be monitored care-
in overdose, which is only three to four times the fully by a physician, who can determine whether
average daily prescription for the drug; for this the dosage of lithium is adequate to relieve their
reason, physicians are wary of prescribing these symptoms but not so large as to induce toxic side
drugs, particularly for people with depression effects. The side effects of lithium range from an-
who might be suicidal. noying to life threatening. Many patients experi-
ence abdominal pain, nausea, vomiting, diarrhea,
Monoamine Oxidase Inhibitors Another tremors, and twitches. People on lithium complain
older class of drugs that is no longer used frequently of blurred vision and problems in concentration
to treat depression is the monoamine oxidase in- and attention that interfere with their ability to
hibitors (MAOis). MAO is an enzyme that causes work. Lithium can cause diabetes, hypothyroid-
the breakdown of the monoamine neurotransmit- ism, and kidney dysfunction and can contribute to
ters in the synapse. MAOis decrease the action of birth defects if taken during the first trimester of
MAO and thereby increase the levels of these neu- pregnancy. Up to 55 percent of patients develop
rotransmitters in the synapses. resistance to lithium within 3 years, and only about
The MAOis are as effective as the tricyclic 33 percent of patients remain symptom-free on
antidepressants, but their side effects are poten- lithium (Nemeroff, 2000).
tially quite dangerous (Thase & Denko, 2008).
When people taking MAOis ingest aged cheese, Anticonvulsant and Atypical Antipsychotic
red wine, or beer, they can experience a poten- Medications In the mid-1990s, it was discov-
tially fatal rise in blood pressure. The MAOis ered that a medication that helps reduce seizures,
also can interact with several drugs, including valproate (trade name Depakote), also helped
antihypertension medications and over-the- stabilize mood in people with bipolar disorder.
counter drugs such as antihistamines. The Another anti-epileptic medication, carbamazepine
MAOis also can cause liver damage, weight gain, (trade names Tegretol, Equetro), has been approved
severe lowering of blood pressure, and several for use in treating bipolar disorder. The side effects
of the same side effects caused by the tricyclic of carbamazepine include blurred vision, fatigue,
antidepressants. vertigo, dizziness, rash, nausea, drowsiness, and
liver disease. Valproate seems to induce fewer side

effects and is used more often than carbamazepine
(Thase & Denko, 2008). But the anti-epileptics can
cause birth defects if women take them while preg-
nant, and they do not prevent suicide as effectively
as lithium does. The anti-epileptics may work by
restoring the balance between the neurotransmitter
systems in the amygdala (Thase & Denko, 2008).
The atypical antipsychotic medications, which
are described in more detail in Chapter 8, are also
used to quell the symptoms of severe mania (Thase
& Denko, 2008). These drugs, w hich include olan-
zapine (Zyprexa), ariprizole (Abilify), quetiapine
(Seroquel), and risperidone (Risperdal), reduce Electroconvulsive therapy is a controversial but effective
functional levels of dopamine and seem to be espe- treatment for depression.
cially useful in the treatment of psychotic manic
symptoms. The side effects of these drugs can
include weight gain and problematic metabolic ECT can lead to memory loss and difficulty
changes (e.g., increased risk of diabetes and in- learning new information, particularly in the days
creased insulin, glucose, and low-density lipopro- following treatment (Sackeim et al., 2007). When
tein cholesterol levels). ECT was first developed, it was administered to
With the increased recognition of bipolar disor- both sides of the brain, and the effects on memory
der and related syndromes in children, such as and learning sometimes were severe and perma-
disruptive mood regulation disorder, there has been nent. These days, ECT usually is delivered to only
an increase in the use of medications to treat children. one side of the brain-usually the right side, because
These medications include mood stabilizers, atypical this side is less involved in learning and memory.
antipsychotics, and antidepressants. Existing studies As a result, patients undergoing modem ECT are
show that these drugs can help stabilize children's less likely to experience significant or long-term
moods, but the number of well-controlled, large memory loss or learning difficulties, but people
group studies is small, and there are significant who have undergone ECT still experience a signifi-
concerns about both the short-term and the long- cant increase in memory problems (Sackeim et al.,
term toxic effects of these drugs on children's devel- 2007). In addition, because this unilateral adminis-
oping brains and bodies (Liu et al., 2011). tration sometimes is not as effective as bilateral ad-
ministration, some people are still given bilateral
Electroconvulsive Therapy ECT. Although ECT can be extremely effective in
Perhaps the most controversial of the biological eliminating the symptoms of depression, the relapse
treatments for mood disorders is electroconvulsive rate among people who have undergone ECT can
therapy (ECT). ECT was introduced in the early be as high as 85 percent (Fink, 2001).
twentieth century, originally as a treatment for
schizophrenia (see Chapter 2). It consists of a series Newer Methods of Brain Stimulation
of treatments in which a brain seizure is induced by In recent years, researchers have been investigat-
passing electrical current through the patient's head. ing new methods of stimulating the brain without
Patients are first anesthetized and given muscle applying electric current. Each of these methods
relaxants so they are not conscious when they have has been shown in randomized clinical trials to re-
the seizure and so their muscles do not jerk violently sult in more improvement in depressive symp-
during the seizure. Metal electrodes are taped to the toms than a placebo in patients with depressive
head, and a current of 70 to 130 volts is passed disorders or bipolar disorder whose depressive
through one side of the brain for about 1 second. symptoms have not responded to other forms of
Patients typically have a convulsion that lasts about treatment (Slotema, Blom, Hoek, & Sommer, 2010).
1 minute. The full ECT treatment consists of 6 to In the procedure known as repetitive transcra-
12 sessions. Neuroimaging studies show that ECT nial magnetic stimulation (rTMS), scientists expose
results in decreases in metabolic activity in several patients to repeated, high-intensity magnetic pulses
regions of the brain, including the frontal cortex and focused on particular brain structures (Figure 7.5a).
the anterior cingulate, although the mechanisms by In treating people with depression, researchers have
which ECT relieves depressive symptoms are not targeted the left prefrontal cortex, which tends to
clear (Henry et al., 2001; Oquendo et al., 2001). show abnormally low metabolic activity in some
Left vagus
nerve
Right vagus - ---'-:-f/ Electrodes

nerve
Pulse
generator
(b)
Thalamus
Pulse
generator
(a) (c)
people with depression. Patients who receive rTMS electronic device, much like a cardiac pacemaker,
report few side effects-usually only minor head- that is surgically implanted under the patient's
aches treatable by over-the-counter pain relievers. skin in the left chest wall. How VNS relieves de-
Patients can remain awake, rather than having to pression is not entirely clear, but positron-emission
be anesthetized as in electroconvulsive therapy studies show that VNS results in increased activ-
(ECT), thereby avoiding possible complications of ity in the hypothalamus and amygdala, which
anesthesia. may have antidepressant effects (Slotema et al.,
Another newer method that holds consider- 2010).
able promise in the treatment of serious depression The newest and least studied procedure to
is vagus nerve stimulation (VNS; Figure 7.5b). date is deep brain stimulation, in which electrodes
The vagus nerve, part of the autonomic nervous are surgically implanted in specific areas of the
system, carries information from the head, neck, brain (Figure 7.5c). The electrodes are connected to
thorax, and abdomen to several areas of the brain, a pulse generator that is placed under the skin and
including the hypothalamus and amygdala, which stimulates these brain areas. Very small trials of deep
are involved in depression. In vagus nerve stimu- brain stimulation have shown promise in relieving
lation, the vagus nerve is stimulated by a small intractable depression (Mayberg et al., 2005).
Light Therapy
Recall that seasonal affective disorder (SAD) is a
form of mood disorder in which people become de-
pressed during the winter months, when there are
the fewest hours of daylight. Their moods improve
in the summer months, when there are more hours
of daylight each day. People with SAD may have
deficient retinal sensitivity to light, meaning that
their bodies react more strongly than most people's
to changes in the amount of light each day (Rohan,
Roecklein, Lacy, & Vacek, 2009). It turns out that ex-
posing people with SAD to bright light for a few
hours each day during the winter months, known as
light therapy, can significantly reduce some peo-
ple's symptoms. One study found that 57 percent
of people with SAD who completed a trial of light
therapy showed remission of their symptoms and
79 percent of those who had both light therapy and
cognitive therapy (described below) showed remis- Inactivity may contribute to depression. Behavioral therapy encourages people
sion, compared to 23 percent of a control group who to become more active.
did not receive intervention (Rohan et al., 2007).
One theory is that light therapy helps reduce
seasonal affective disorder by resetting circadian 2002). Behavioral therapy is designed to be short-
rhythms, natural cycles of biological activity that term, lasting about 12 weeks.
occur every 24 hours. The production of several The first phase of behavioral therapy involves
hormones and neurotransmitters varies over the a functional analysis of the connections between
course of the day according to these rhythms, specific circumstances and the depressed person's
which are regulated by internal clocks but can be symptoms. When does the depressed person feel
affected by environmental stimuli, including light. worst? Are there any situations in which he or she
People with depression sometimes show dysregu- feels better? This analysis helps the therapist pin-
lation of their circadian rhythms. Light therapy point the behaviors and interaction patterns that
may work by resetting circadian rhythms, thereby need to be the focus of therapy. It also helps the
normalizing the production of hormones and neu- client understand the intimate connections be-
rotransmitters (Rohan et al., 2009). tween his or her symptoms and his or her daily
Another theory is that light therapy works by activities or interactions.
decreasing levels of the hormone melatonin, which Once the circumstances that precipitate the cli-
is secreted by the pineal gland (Rohan et al., 2009). ent's depressive symptoms are identified, therapists
Decreasing melatonin levels can increase the levels help the client change aspects of the environment
of norepinephrine and serotonin, reducing the that are contributing to the depression, such as iso-
symptoms of depression. Also, studies suggest lation. They teach depressed clients skills for chang-
that exposure to bright lights may directly increase ing their negative circumstances, particularly
serotonin levels, also decreasing depression. negative social interactions. They also help clients
learn new skills, such as relaxation techniques, for
Psychological Treatments managing their moods in unpleasant situations.
for Mood Disorders Several of these techniques are illustrated in the fol-
lowing case study.
Each of the psychological theories has led to a
treatment designed to overcome those factors the
theory asserts cause and maintain mood disorders. CASE STUDY
Mark worked constantly.
Behavioral Therapy When he was not actually at work, he was work-
~ Behavioral therapy focuses on increasing positive ing at home. He had a position of considerable
reinforcers and decreasing aversive experiences in responsibility and was convinced that if he didn't
an individual's life by helping the depressed stay focused on his job, he'd miss something that
person change his or her patterns of interaction wou ld result in his being fired or kicked off the
with the environment and with other people career ladder. Mark had not taken a vacation in
(Dimidjian et al., 2011; Hollon, Haman, & Brown,
link between those thoughts and their depression.

several years. Although he wanted to continue to Often, the therapist will assign clients the home-
get pay raises and promotions, as he has each work of keeping track of times when they feel sad
year, he was also painfully aware that life was or depressed and writing down on record sheets,
passing him by. He felt stressed, depressed, and such as the one in Figure 7.6, what is going through
hopeless about ever having a "normal" life. their mind at such times.
Mark clearly felt rewarded for his one- The second step in cognitive-behavioral ther-
dimensional life with praise, pay raises, promo- apy is to help clients challenge their negative
tions, and the absence of mistakes for which he thoughts. People with depression often believe that
might be punished. Mark's behavior was gov- there is only one way to interpret a situation-their
erned by his work focus. He engaged in no social negative way. Therapists use a series of questions
activities, lived alone, and did not organize his to help clients consider alternative ways of think-
time to include anything but his work. The behaving about a situation and the pros and cons of these
ior therapist suggested that if he wanted to im- alternatives, such as "What is the evidence that you
prove his quality of life, and his outlook on life, are right in the way you are interpreting this situa-
he must learn some very specific new behaviors. tion?"" Are there other ways of looking at this situ-
Mark was encouraged to schedule time for social ation?" and "What can you do if the worst-case
and recreational opportunities. He learned that scenario comes true?"
he needed to actively and deliberately do things The third step in cognitive-behavioral therapy
that are fun and pleasurable. He and the thera- is to help clients recognize the deeper, basic beliefs
pist practiced new ways to meet people and form or assumptions they might hold that are fueling
social relationships (friendships, dating). The their depression. These might be beliefs such as "If
therapist also taught him relaxation skills to re- I'm not loved by everyone, I'm a failure" or "If I'm
duce his stress. Eventually, Mark felt a new sense not a complete success at everything, my life is
of control over his life, and his depression lifted. worthless." The therapist will help clients question
(Adapted from Yapko, 1997) such beliefs and decide if they truly want to base
their lives on them. The case of Susan illustrates
some of the cognitive components of cognitive-
behavioral therapy.
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) represents a
blending of cognitive and behavioral theories of . .
depression (Beck, Weissman, Lester, & Trexler, CASE STUDY

1974; Ellis & Harper, 1961; Lewinsohn, Munoz, Susan was a young, single,
Youngren, & Zeiss, 1986; Rehm, 1977). This ther- 24-year-old woman. Her goals for therapy were to
apy has two general goals. First, it aims to change learn how to overcome chronic feelings of
the negative, hopeless patterns of thinking de- depression and temptations to overeat. Susan was
scribed by the cognitive models of depression. Sec- unemployed and living with her aunt and uncle in
ond, it aims to help people with depression solve a rural area. She had no means of personal trans-
concrete problems in their lives and develop skills portation. Hypersensitivity to the reactions of sig-
for being more effective in their world so they no nificant others and the belief that they could
longer have the deficits in reinforcers described by control her feelings seemed to be central to her
behavioral theories of depression. negative self-concept and feelings of helplessness.
Like behavioral therapy, cognitive-behavioral Susan described her mother as knowing which
therapy is designed to be brief and time-limited. "buttons to push:' This metaphor was examined
The therapist and client usually will agree on a set and challenged. She was questioned as to how her
of goals they wish to accomplish in 6 to 12 weeks. mother controlled her emotions: Where were
These goals focus on specific problems that clients these buttons? Once aga in, the principle was as-
believe are connected to their depression, such as serted that it is not the actions of others that cause
problems in their marriage or dissatisfaction with emotions, but one's cognitions about them.
their job. From the beginning of therapy, the thera- Then the cognitions she had concerning cer-
pist urges clients to set their own goals and make tain looks or critical statements were examined.
their own decisions. When her aunt was looking "sickly and silent;'
The first step in cognitive-behavioral therapy Susan believed that it was because she was
is to help clients discover the negative automatic displeased with her for not helping enough. The
thoughts they habitually have and understand the
FIGURE 7.6
Da;te, Evutt 1M,()tia~ AutoUUtti& t/wuq/ttr

AMi?4 Borr r~ aJUW)!.ed. sad MI/XiatM 0~ wfutt /w.,v-e, I Mftb IWw?
~
worried Jj_ I ~~ kiuv mad,
!'141/~ to fired.
-
Af!:!:-i?S HtMbcuut ~'t f,IJ7),)ff sad !'141/ ro_fgt fUUi 1:1f}k
to~wv-e,.
Af!:!:-i? 7 Borr J-eited a;t A~XWIM !'141/ n,e,xt.

MWtker ~v~.
--
AMi?9 HtMbcuut raid he-! sad defeated He,'r r-obaNy._g.ot a, miftrw
t~ btMi.nMr romewlwre,. MJ- 14'UU"riat{e, u
trW. n,e,x t IM,()I1J:~. ~P.f!M,t.
Af!:!:-i? 10 N~/Wor brol:1f}./tt A tittu ~ she-r-obab(j!. tki.trla I CMI/'t

over ro~ wokieo. IM,()rtWrad wo/0. I wo/0 ~ ru.ck a, 14Wfr
aJj, the- t~. Arui ~ MIMe,
WtU a, dirtUter ~rite-
~in,!
evidence for this belief was examined, and there became better at ignoring her mother's critical
was none. Alternative explanations were ex- remarks and not taking them to heart, her mother
plored, such as that the aunt might be truly ill, began to be more relaxed and open around her
having a bad day, or upset with her spouse. Susan and criticized her less. (Adapted from Thorpe &
admitted that all explanations were equally plau - Olson, 1997, pp. 225- 227)
sible. Furthermore, it was noted that in ambigu-
ous social situations, she tended to draw the most
negative and personalized conclusions. Cognitive-behavioral therapists also use behav-
During the last stage of therapy, Susan's ioral techniques to train clients in new skills they
mother visited . This provided a real test of the might need to cope better. Often people with de-
gains Susan had made, as it was her mother's pression are unassertive in making requests of other
criticism that she feared the most. At first, she people or in standing up for their rights and needs.
reported feeling easily wounded by her mother's This lack of assertiveness can be the result of their
criticism. These examples were used as opportu- negative automatic thoughts. For example, a person
nities to identify and challenge self-defeating who often thinks "I can't ask for what I need be-
thoughts. Soon, Susan was able to see her moth- cause the other person might get mad and that
er's critical statements as her mother's problem , would be horrible" is not likely to make even rea-
not her own . She also discovered that, as she sonable requests of other people. The therapist first
will help clients recognize the thoughts behind their
TABLE 7.6 Interpersonal Therapy
Interpersonal therapists focus on four types of interpersona l problems as sources of depression.
Type of Problem Therapeutic Approach
Grief, loss Help th e client accept feelings and evaluate a relationship w ith a lost person;
help the client invest in new relationships
Interpersonal role disputes Help the client make decisions about concessions willing to be made and
learn better ways of communicating
Role trans iti ons Help the client develop more realistic perspectives toward roles that are lost
and re gard new roles in a more positive manner
Interpersonal skills deficits Review the client's past relati onships, helping the client understand these
relationships and how they might be affecting current re latio nships; directly
teach the client social skills, such as assertiveness
Source: Hollon et al., 2005.
actions (or lack of action). The therapist then may depressed over the role they must leave behind.
work with the clients to devise exercises or home- Therapists help clients develop more realistic per-
work assignments in which they practice new skills, spectives toward roles that are lost and learn to
such as assertiveness, between therapy sessions. regard new roles in a more positive manner. If a
client feels unsure about his or her ability to per-
Interpersonal Therapy form a new role, the therapist helps the client de-
In interpersonal therapy (IPT), therapists look for velop a sense of mastery in the new role. Sometimes,
four types of problems in depressed individuals clients need help developing new networks of so-
(Table 7.6; Weissman & Verdeli, 2013). First, many cial support to replace the support systems they
depressed people are grieving the loss of a loved have left behind in their old roles.
one, perhaps not from death but instead from the Fourth, people with depression also turn to in-
breakup of an important relationship. Interper- terpersonal therapy for help with problems caused
sonal therapists help clients face such losses and by deficits in interpersonal skills. Such skill deficits
explore their feelings about them. Therapists also can be the reason people with depression have in-
help clients begin to invest in new relationships. adequate social support networks. The therapist
A second type of problem on which interper- reviews with clients their past relationships, espe-
sonal therapy focuses is interpersonal role disputes, cially important childhood relationships, and helps
which arise when people do not agree on their roles them understand these relationships and how they
in a relationship. For example, a college student and might be affecting their current relationships. The
a parent may disagree on the extent to which the therapist also might directly teach clients social
student should follow the parent's wishes in choos- skills, such as assertiveness.
ing a career. Interpersonal therapists first help the
client recognize the dispute and then guide him or Interpersonal and Social
her in making choices about what concessions might Rhythm Therapy and
be made to the other person in the relationship.
Therapists also may need to help clients modify and
Family-Focused Therapy
improve their patterns of communicating with oth- Interpersonal and social rhythm therapy (ISRT) is
ers in relationships. For example, a student who re- an enhancement of interpersonal therapy designed
sents his parents' intrusions into his private life may specifically for people with bipolar disorder (Frank
tend to withdraw and sulk rather than directly con- et al., 2005). When people with bipolar disorder ex-
front his parents about their intrusions. He would be perience disruptions in either their daily routines
helped to develop more effective ways of communi- or their social environment, they sometimes experi-
cating his distress over his parents' intrusions. ence an upsurge in symptoms. ISRT combines in-
The third type of problem addressed in inter- terpersonal therapy techniques with behavioral
personal therapy is role transitions, such as the techniques to help patients maintain regular rou-
transition from college to work or from work to tines of eating, sleeping, and activity, as well as sta-
full-time motherhood. People sometimes become bility in their personal relationships. By having
patients self-monitor their patterns over time, ther- We might expect the combination of psycho-
apists help patients understand how changes in therapy and drug therapy to be more effective in
sleep patterns, circadian rhythms, and eating hab- treating people with persistent depressive disor-
its can provoke symptoms. Then therapists and pa- der than either type of therapy alone, and some
tients work together to develop a plan to stabilize studies support this expectation (Cuijpers, Dekker,
the patients' routines and activities. Similarly, pa- Hollon, & Andersson, 2009; Cuijpers, van Straten,
tients learn how stressors in their family and work Warmerdam, & Andersson, 2009). For example, in
relationships affect their moods, and they develop one study, 681 patients with persistent depressive
better strategies for coping with these stressors. disorder were randomly assigned to receive a sero-
Studies show that patients who receive ISRT in tonin modulator (nefazadone, a drug no longer sold
conjunction with medication show fewer symp- because of adverse side effects), cognitive-behavioral
toms and relapses over time than patients who do therapy, or both for 12 weeks (Keller et al., 2000).
not receive ISRT (Frank et al., 2005). About 50 percent of the people receiving medica-
Family-focused therapy (FFT) is also de- tion or cognitive-behavioral therapy alone experi-
signed to reduce interpersonal stress in people enced relief from their depression, while 85 percent
with bipolar disorder, particularly within the con- of the patients receiving both medication and
text of families. Patients and their families are edu- cognitive-behavioral therapy experienced relief.
cated about bipolar disorder and trained in Relapse rates in depression are quite high, even
communication and problem-solving skills. Stud- among people whose depressions completely dis-
i~s comparing family-focused therapy with stan- appear with treatment. For this reason, many psy-
/ dard therapy (medication with periodic individual chiatrists and psychologists argue that people with
checkups with a psychiatrist) have found that a history of recurrent depression should be kept on
adults receiving family-focused therapy show a maintenance level of therapy even after their de-
lower relapse rates over time (Miklowitz et al., pression is relieved (Thase & Denko, 2008). Usu-
2003). In addition, applications of FFT to adoles- ally, the maintenance therapy is a drug therapy,
cents with bipolar disorder show promise in help- and many people remain on antidepressant drugs
ing these youths and their families manage for years after their initial episodes of depression
symptoms and reduce the impact of the disorder have passed. Studies of behavioral therapy, inter-
on the adolescents' functioning and development personal therapy, and cognitive-behavioral therapy
(Taylor & Miklowitz, 2009). show that maintenance levels of these therapies-
usually consisting of once-a-month meetings with
therapists-also can substantially reduce relapse
Comparison of Treatments rates (Hollon et al., 2002; Verdeli et al., 2013).
Which of the many treatments for mood disorders Even when maintenance doses of psychother-
is best? In the past few decades, several studies apy are not available, people who have had any of
have compared behavioral, cognitive-behavioral, the empirically supported psychotherapies appear
interpersonal, and drug therapies in the treatment to be less likely to relapse than those who have had
of depressive disorders. Perhaps surprisingly, only drug therapy. For example, researchers fol-
these therapies, despite their vast differences, lowed the 240 patients in one of the studies de-
appear to be about equally effective in treating scribed earlier for a year after they had recovered
most people with depression (Cuijpers et al., 2008; from acute depression. They found that those who
DeRubeis, Gelfand, Tang, & Simons, 1999; had had cognitive-behavioral therapy showed a
Dimidjian et al., 2006; Hollon et al., 2002; Weissman lower rate of relapse than those who continued
& Verdeli, 2013). For example, in one study, with the drug therapy (paroxetine) only and that
240 people with major depression were randomly both groups had much lower rates of relapse than
assigned to receive either the SSRI paroxetine those who were taking a placebo pill over those
(Paxil) or cognitive-behavioral therapy for 16 weeks 12 months (Figure 7.7; Hollon et al., 2005).
(DeRubeis et al., 2005). At the end of treatment, In the case of bipolar disorder, combining drug
about 60 percent in each group no longer experi- treatment with the psychological therapies may re-
enced major depression. Another study compared duce the rate at which patients stop taking their
the results of behavioral therapy, cognitive therapy medication and may lead more patients to achieve
(without behavioral interventions), and drug ther- full remission of their symptoms, compared to lith-
apy (paroxetine) in 240 patients with major de- ium treatment alone (Miklowitz, 2010; Swartz &
pressive disorder (Dirnidjian et al., 2006) . In this Frank, 2001). Psychotherapy can help people with
study, behavioral therapy led to improvement in bipolar disorder understand and accept their need
the greatest number of patients, followed by cogni- for lithium treatment as well as help them cope
tive therapy and then drug therapy. with the impact of the disorder on their lives.
man who goes on a drinking binge and crashes his

Relapse Rates After Drug
FIGURE 7.7 car into a tree has committed suicide. Is an elderly
Versus Cognitive-
person who refuses life support when dying from a
Behavioral Therapy for
painful disease committing suicide? Is a middle-
Major Depression. Patients with major
aged person with severe heart disease who contin-
depression who had received CBT showed
ues to smoke cigarettes, eat fatty foods, and drink
lower relapse rates in the next year than
excessive amounts of alcohol committing suicide?
those who continued to take only an SSRI.
Clearly, suicide-like behaviors fall along the type of
Both groups showed lower rates of relapse
continuum we discuss throughout this book.
than patients who received a placebo pill.
We can distinguish among completed suicides,
80 which end in death; suicide attempts, which may
or may not end in death; and suicidal ideation or
70 thought. Many people with mental disorders think
~
"'
Q)
60 about committing suicide but never attempt to kill
.... themselves. Also, actual suicide attempts are much
Q;
> 50 more common than completed suicides, with some
0
"'c: 40
v;
studies estimating that suicide attempts are 20 times
c. as common as completed suicides (WHO, 2012).
"'
~ 30
+-'
Given the difficulty of defining suicide, it is not
c:
Q)
~ 20 surprising that accurate suicide rates are difficult to
Q)
0... obtain. Many deaths are ambiguous, particularly
10 when no notes are left behind and no clues exist as
0 to the victim's mental state before death. Recorded
Paxil CBT Placebo rates probably are low, because the stigma against
suicide is a great incentive for labeling a death
Source: Hollon et al., 2005.
anything but a suicide. Accurate data on nonlethal
suicide attempts are even harder to obtain.
Even so, the statistics indicate that suicide is
more common than we would like to believe. More
than 33,000 people kill themselves each year in the
SUICIDE United States, an average of 90 people per day. In ad-
Suicide is among the three leading causes of death dition, as many as 3 percent of the population make
worldwide among people ages 15 to 44 (World a suicide attempt (with intent to die) sometime in
Health Organization [WHO], 2012). Around the their lives (Nock & Kessler, 2006), and more than
world, more people die from suicide than from ho- 13 percent report having had suicidal thoughts at
micide. Suicide is associated with mood disorders, some time (Borges et al., 2008). Suicide is not just an
and thus we address it in the final section of this American phenomenon, however. Internationally, an
chapter. Note, however, that the risk of suicide is estimated 1 million people die by suicide each year,
increased in people with any mental disorder. or 1 person about every 40 seconds (WHO, 2012).
In the context of the tragic statistics just re-
Defining and Measuring viewed, DSM-5 approaches suicide risk and behav-
ior more deliberately than did DSM-IV. Throughout
Suicide DSM-5, particular characteristics that make people
The Centers for Disease Control and Prevention more vulnerable to suicide are highlighted, and
(CDC), one of the federal agencies in the United those mental disorders that are associated with an
States that tracks suicide rates, defines suicide as elevated risk for suicide are identified specifically
"death from injury, poisoning, or suffocation where (e.g., not just mood or personality disorders, but
there is evidence (either explicit or implicit) that the schizophrenia, anorexia, and posttraumatic stress
injury was self-inflicted and that the decedent in- disorder). By describing the suicidal patterns associ-
tended to kill himself/herself." As clear as this defi- ated with a range of diagnoses, DSM-5 encourages
nition seems, there is great variability in the form clinicians to attend to suicide risk early and often
that suicide takes, and whether to call particular in treatment. In addition, DSM-5 includes two new
types of death suicide is open to debate. We may eas- conditions for further research study in a special
ily agree that a young man who is despondent and section toward the end of the manual. These in-
shoots himself in the head has committed suicide. It clude proposed criteria sets for suicidal behavior
is harder to agree on whether an unhappy young disorder and nonsuicidal self-injury, for which
Suicide 205
future research is encouraged, both of which repre- Gender, Age, and Suicide. In many nations
sent major problems on college campuses. While the of the world, males are more likely to commit
proposed criteria sets are not intended for clinical suicide than females across almost all age
use (and are not yet officially recognized as disor- groups.
ders), their inclusion provides increased emphasis
on suicide as an important focus of future clinical
research.
Gender Differences
While two to three times more women than men
attempt suicide (Nock & Kessler, 2006), men are
40
four times more likely than women to complete 0
0
0
suicide (CDC, 2007). This gender difference is true 00
,....
across all age groups, as seen in Figure 7.8. (i; 30
The gender difference in rates of completed Cl.
...,
Q)
suicide may be due in part to gender differences in "'

c::
the means of attempting suicide. Men tend to 20
choose more lethal methods of suicide than do
women, with more than half of men who kill them-
selves using a firearm (CDC, 2007). For women the
most common method of suicide is poisoning. In
addition, men who attempt suicide tend to be
more sure in their intent to die than are women 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75+
(Jack, 1992; Linehan, 1973). Age groups
Ethnic and Cross-Cultural Differences Source: World Health Organization, 2004.

~
Within the United States, there are substantial dif-
ferences in suicide rates among ethnic I racial
groups (CDC, 2005; Oquendo et al., 2001). European
Americans have higher suicide rates than all
other groups-approximately 12 people per seriously consider suicide, 15 percent devise a spe-
100,000 population-and Native Americans are cific plan to attempt suicide, more than 8 percent
close behind, at approximately 11 per 100,000. attempt suicide, and about 2 percent make a seri-
Suicide among Native Americans is tied to pov- ous suicide attempt that requires medical attention
erty, lack of education and hope, discrimination, (Jacobson & Gould, 2009). Suicide may become
substance abuse, and the easy availability of more common in adolescence than in childhood
firearms (Berman & Jobes, 1995). Suicide rates because the rates of several types of psychopathol-
among African American males have increased ogy tied to suicide, including depression, anxiety
greatly in recent decades (Joe & Kaplan, 2001). disorders, and substance abuse, increase in adoles-
There are cross-national differences in suicide cence. Suicide rates also may rise during the teen
rates, with higher rates in much of Europe, the for- years because adolescents are more sophisticated
mer Soviet Union and China and lower rates in than children in their thinking and can contemplate
Latin America and South America (Figure 7.9; suicide more clearly. Finally, adolescents simply
WHO, 2012). The suicide rates in Australia, the may have readier access to the means to commit
United States, Canada, and England fall between suicide (e.g., drugs and guns) than do children.
these two extremes. The differences may be due in As is the case for adults, girls are much more
part to cultural and religious norms. Followers of likely to attempt suicide than boys, but boys are
religions that expressly forbid suicide are less more likely to succeed (Jacobson & Gould, 2009).
likely to attempt it (O'Donnell, O'Donnell, Wardlaw, Males are six times more likely than females in this
& Stueve, 2004; Statham et al., 1998). age range to commit suicide (CDC, 2004). Homo-
sexual and bisexual adolescents have rates of sui-
Suicide in Children and Adolescents cide attempts 2 to 6 times higher than those of
Although suicide is relatively rare in young heterosexual adolescents (Jacobson & Gould, 2009).
children, it is not unheard of. The rate of suicide Hispanic females have especially high rates of
increases substantially in early adolescence. Each suicidal thoughts and plans and attempted suicides
year, 17 percent of teenagers in the United States compared to Hispanic males and adolescents from
Map of Suicide Rates. There are significant differences across countries in suicide
FIGURE 7.9 rates. This map shows the rate per 100,000 people in different regions.
6.5-13
. 6.5
no data
Source: World Health Organization, 2012.
other racial/ ethnic groups (Jacobson & Gould, College Students

2009). Luis Zayas and colleagues (2005) suggest The college years are full of academic and social
that these high rates are linked to clashes between pressures and challenges. In a survey of college stu-
Hispanic girls, who are highly acculturated to dents, 9 percent said they had thought about com-
American values, and their parents, who may hold mitting suicide since entering college, and
traditional cultural values of familism (centrality of 1 percent said they had attempted suicide while at
family to one's life) and may reject their daughters' college (Furr, Westefeld, McConnell, & Jenkins,
bids for independence. 2001). Students who had contemplated or attempted
Rates of suicide among children and teenagers suicide were more likely than those who had not to
more than doubled between the 1950s and the early have experienced depression and hopelessness,
1990s, but they have steadily declined since 1994 loneliness, and problems with their parents. Regret-
(Jacobson & Gould, 2009). The initial increase may tably, only 20 percent of the students who had con-
have been linked to the increase in substance use templated suicide had sought any type of counseling.
by teenagers during that same period, coupled
with an increased availability of firearms. The de- Suicide in Older Adults
crease in suicide rates since the mid -1990s is Although there has been a 50 percent decline in sui-
thought to be related to an increase in the use of cide rates among adults over age 65 in the past few
antidepressants, particularly SSRis, to treat depres- decades, older people, particularly older men, still
sion in adolescents (Zalsman, Shoval, & Rotstein, remain at relatively high risk for suicide. The highest
2009). Unfortunately, there has been a spike in ado- risk is among European American men over age 85
lescent suicide rates since 2004-the same year the (CDC, 2004). When they attempt suicide, older
FDA mandated a warning regarding the use of people are much more likely than younger people to
SSRis by youth. Since that warning was required, be successful. It seems that most older people who
prescriptions for SSRis for teenagers have declined attempt suicide fully intend to die (Mcintosh, 1995). ~
(Nemeroff et al., 2007). Some experts are concerned Some older people commit suicide because they
that the FDA warning has had the unintended cannot tolerate the loss of their spouse or other loved
consequence of leaving many depressed teenagers ones. Suicide rates are highest in the first year after a
untreated and vulnerable to suicidal thoughts and loss but remain relatively high for several years
behaviors (Zalsman et al., 2009). (Mcintosh, 1995). Other older people who commit
Suicide 207
---- suicide wish to escape the pain and suffering of de-

bilitating illness. Escape from illness and disabilities
may be a particularly strong motive for suicide
among men, who are reluctant to become a burden
to others (Conwell & Thompson, 2008). In one study
of older people who committed suicide, 44 percent
said they could not bear being placed in a nursing
home and would rather be dead (Loebel et al., 1991).
Most older people who lose a spouse or be-
come ill do not commit suicide. Those with a his-
tory of depression or other psychological problems
are at greatest risk for responding to the challenges
of old age with suicide (Harwood, Hawton, Hope,
& Jacoby, 2000).
Nonsuicidal Self-Injury
Some people-often adolescents-repeatedly cut,
burn, puncture, or otherwise significantly injure
their skin with no intent to die, a behavior known
as nonsuicidal self-injury, or NSSI (Nock, 2010).
NSSI seems to be relatively common, with esti- Illness is often a precursor to su icide among older adults.
mates of adolescents having engaged in NSSI at
some time in their lives ranging from 13 to 45 per-
cent (Lloyd-Richardson, Perrine, Dierker, & Kelley, Historical Perspectives on Suicide
2007; Plener et al., 2009; Ross & Heath, 2002). Clini- Freud argued that depressed people express anger
cians, teachers, and other health professionals re- at themselves instead of at the people they feel
port a dramatic increase in NSSI in recent years, have betrayed or abandoned them. When that an-
but longitudinal data are lacking (Nock, 2010). ger becomes so great in depressed people that they
Individuals who engage in NSSI are at in- wish to annihilate the image of the lost person,
creased risk for suicide attempts (Nock, 2010). The- they destroy themselves. For example, teenagers
ories of NSSI suggest that it functions as a way of who cannot express anger at their parents may at-
regulating emotion and/ or influencing the social tempt suicide to punish them. Like many of
environment (Nock & Prinstein, 2004). People who Freud's theories, this idea is difficult to test be-
engage in NSSI often report that the experience of cause it involves emotions that people are unable
feeling the pain and seeing the blood actually calms or unwilling to express or acknowledge.
them and releases tension (Lloyd-Richardson et al., In his classic work on suicide, sociologist Emile
2007). Self-injury also draws support and sympa- Durkheim (1897) focused on the mind-sets certain so-
thy from others or may punish others (Nock & cietal conditions can create that increase the risk for
Prinstein, 2004). Much more research on what trig- suicide. He proposed that there are three types of
gers self-injury is needed, however. suicide. Egoistic suicide is committed by people who
feel alienated from others, empty of social contacts,
Understanding Suicide
and alone in an unsupportive world. The patient with
Our ability to understand the causes of suicide is schizophrenia who kills herself because she is com-
hampered by many factors. First, although suicide pletely isolated from society may be committing ego-
is more common than we would hope, it is still istic suicide. Anomie suicide is committed by people
rare enough to make studying it difficult. Second, who experience severe disorientation because of a
in the wake of a suicide, family members and major change in their relationship to society. A man
friends may selectively remember certain informa- who loses his job after 20 years of service may feel
tion about the victim (e.g., evidence that he or she anomie, a complete confusion of his role and his worth
was depressed) and forget other information. in society, and may commit anomie suicide. Finally,
Third, most people who kill themselves do not albuistic suicide is committed by people who believe
leave a note. The notes that are left often do not that taking their life will benefit society. For instance,
provide much understanding of what led the peo- during the Vietnam War, Buddhist monks publicly
ple to take their lives Gamison, 1993). In this sec- immolated themselves to protest the war.
tion, we briefly discuss historical perspectives on Durkheim's theory suggests that social ties
suicide and then discuss research findings on the and integration into a society will help prevent
factors contributing to suicide. suicide if the society discourages suicide and
supports individuals in overcoming negative by a partner is a potent predictor of suicide at-

situations in ways other than suicide. However, if tempts (Kaslow et al., 2000; Ragin et al., 2002) .
a society supports suicide as a beneficial act in Another stressful event consistently linked to
some situations, then ties with such a society may increased vulnerability to suicide is economic
promote suicide. For example, some terrorist hardship (Borges et al., 2010; Fanous, Prescott, &
groups promote suicide as an honorable, even glo- Kendler, 2004). Loss of a job, for example, can pre-
rious, act in the service of striking at enemies. cipitate suicidal thoughts and attempts (Crosby,
Modern empirical research has identified a Cheltenham, & Sacks, 1999; Platt & Hawton, 2000).
number of psychological, biological, and environ- The high suicide rate among African American
mental factors that increase the risk for suicide. We males may be tied to perceptions that their eco-
turn now to this research. nomic futures are uncertain as well as to compari-
sons of their economic status to that of the majority
Psychological Disorders and Suicide culture. Rates of suicide among African American
More than 90 percent of people who commit sui- males in the United States are highest in communi-
cide probably have been suffering from a diagnos- ties where the occupational and income inequali-
able mental disorder (Borges et al., 2010; Jacobson ties are greatest (Joe & Kaplan, 2001) .
& Gould, 2009; Joiner, Brown, & Wingate, 2005). Finally, a large international study found that
Depression increases the odds of a suicide attempt physical illness, especially if it occurred early in
by approximately 6 times, and bipolar disorder in- life, was a risk factor for suicidal ideation, plans,
creases the odds of a suicide attempt by 7 times and attempts even in people who did not have a
(Nock et al., 2008). Internationally, one in every mental disorder (Scott et al., 2010). The illness most
four people with bipolar I disorder, and one in ev- strongly related to suicidal thoughts and behavior
ery five people with bipolar II disorder, has a his- was epilepsy.
tory of suicide attempts (Merikangas et al., 2011).
By far the best predictor of future suicidal Suicide Contagion
thoughts and behavior is past suicidal thoughts Can suicide be contagious? When a well-known
and behavior (Borges et al., 2008, 2010). Among member of society commits suicide, people who
adolescents, a history of a previous suicide attempt closely identify with that person may see suicide
increases the odds of suicide by 30 times among as more acceptable (Jacobson & Gould, 2009) .
boys and by 3 times among girls (Shaffer et al., When two or more suicides or attempted suicides
1996). Thus, it is critically important that suicidal are nonrandomly bunched together in space or
thoughts and behaviors be assessed and that inter- time, such as a series of suicide attempts in the
vention be made, regardless of what other psycho- same high school or a series of completed suicides
logical problems they may be related to. in response to the suicide of a celebrity, scientists
refer to them as a suicide cluster (Joiner, 1999).
Stressful Life Events and Suicide Suicide clusters seem to occur primarily among
Studies across cultures have shown that a variety of adolescents (Jacobson & Gould, 2009).
stressful life events increase the risk of suicide Suicide clusters appear likeliest among people
(Borges et al., 2010). A large cross-national study who knew the person who committed suicide.
found that interpersonal violence, especially sexual One well-documented example is that of a high
abuse, is the traumatic event most strongly linked school with about 1,500 students in which 2 stu-
to suicidal thoughts and attempts (Stein et al., 2010). dents committed suicide within 4 days. Over an
Such experiences not only are immediate triggers of 18-day span, 7 other students attempted suicide,
suicidal thoughts and behavior but also are associ- and an additional23 students reported having sui-
ated with increased risk over the victim's lifespan. cidal thoughts (Brent et al., 1989). Many of those
For example, a nationwide study in the United who attempted suicide or had active suicidal
States found that a history of child sexual abuse in- thoughts were friends of one another and of the
creased the odds of a suicide attempt by 2 to 4 times students who had completed suicide.
for women and by 4 to 11 times for men (Molnar, Other suicide clusters occur not among close
Berkman, & Buka, 2001; see also Brent et al., 2002). friends but among people who are linked by media
Loss of a loved one through death, divorce, or exposure to the suicide of a stranger, often a celeb-
separation is also consistently related to suicide at- rity. Some studies have suggested that suicide rates,
tempts or completions (Jacobson & Gould, 2009) . at least among adolescents, increase after a publi-
People feel they cannot go on without the lost rela- cized suicide (Gould, Jamieson, & Romer, 2003). For
tionship and wish to end their pain. Studies focus- example, researchers in Taiwan interviewed 438 in-
ing on women have also found that physical abuse dividuals suffering from depression shortly after
Suicide 209
massive media coverage of the suicide of popular Biological Factors

television star M. J. Nee. They found that 38.8 percent in Suicide
of the depressed individuals reported that the media Suicide runs in families. For
coverage had increased their own thoughts about example, one study found
suicide, and 5.5 percent said it had led them to make that the children of parents
a suicide attempt (Cheng, Hawton, Lee, & Chen, who had attempted suicide
2007). Individuals who had themselves attempted were 6 times more likely to
suicide in the month prior to the media coverage of also attempt suicide than
the celebrity suicide were nearly 12 times more likely were the children of parents
to report having made another suicide attempt in who had a mood disorder
response to the media coverage than were individu- but had not attempted
als who had not recently attempted suicide. suicide (Brent et al., 2002,
What is the reason for suicide clustering? Some 2003).
theorists have labeled it suicide contagion (Stack, Although some of this
1991). Survivors who become suicidal may be clustering of suicide within
modeling the behavior of the friend or admired families may be due to envi-
celebrity who committed suicide. That suicide also ronmental factors, such as
may make the idea of suicide more acceptable and family members modeling
thus lower inhibitions for suicidal behavior in survi- each other or sharing com-
vors. For example, among the depressed individuals mon stressors, twin and
in the Taiwanese study described above, several said adoption studies suggest
"His case showed that suicide is not shameful" and that genetics is involved as
"He was a courageous martyr for me to follow well (Joiner et al., 2005).
elegantly" (Cheng et al., 2007, pp. 72-73). In addi- Twin studies estimate that
Could media coverage of school shootings
tion, the local and media attention given to a suicide the risk of suicide attempts and suicides, such as the one in Newtown,
can be attractive to some people who are feeling increases by 5.6 times if a Connecticut, in 2012, inspire other students to
alienated and abandoned. After the murder-suicide person's monozygotic twin commit similar acts?
rampage of two teenagers at Columbine High has attempted suicide, and
School in Littleton, Colorado, some teenagers said by 4.0 times if a person's di-
that receiving the media attention that was given to zygotic twin has attempted suicide (Glowinski
the shooters would be an attractive way to "go out." et al., 2001; Joiner et al., 2005). Strong evidence of a
genetic component to suicide remained when re-
Personality and Cognitive Factors searchers controlled for histories of psychiatric
in Suicide problems in the twins and their families, for recent
The personality characteristic that seems to predict and past negative life events, for how close the
suicide best is impulsivity, the general tendency to twins were to each other socially, and for personal-
act on one's impulses rather than to inhibit them ity factors.
when it is appropriate to do so Gainer et al., 2005). Many studies have found a link between suicide
When impulsivity is overlaid on another psycho- and low levels of the neurotransmitter serotonin
logical problem-such as depression, substance (Asberg & Forslund, 2000; Mann, Brent, & Arango,
abuse, or living in a chronically stressful environ- 2001). For example, postmortem studies of the brains
ment-it can be a potent contributor to suicide. One of people who committed suicide find low levels of
family history study showed that the children of serotonin (Gross-Isseroff, Biegon, Voet, & Weizman,
parents with a mood disorder who also scored high 1998). Also, people with a family history of suicide
on measures of impulsivity were at much greater or who have attempted suicide are more likely to
risk of attempting suicide (Brent et al., 2002). have abnormalities on genes that regulate serotonin
The cognitive variable that has most consis- (Courtet et al., 2004; Joiner et al., 2005; Joiner,
tently predicted suicide is hopelessness-the feel- Johnson, & Soderstrom, 2002). People with low se-
ing that the future is bleak and there is no way rotonin levels who attempt suicide are 10 times
to make it more positive (Beck, Steer, Kovacs, & more likely to make another suicide attempt than
Garrison, 1985). Thomas Joiner and colleagues are people with higher serotonin levels (Roy, 1992).
(2005) suggest that hopeless feelings about being a Low serotonin levels are linked to suicidal tenden-
burden on others and about never belonging with cies even in people who are not depressed, sug-
others are especially linked to suicide. Hopelessness gesting that the connection between serotonin and
also may be one reason why people who are sui- suicide is not due entirely to a common connection
cidal often do not seek treatment. to depression.
Treatment and Prevention they regulate levels of serotonin, which may have
an independent effect on suicidal intentions (Thase
Some intervention and prevention programs ap- & Denko, 2008). As we discussed earlier, however,
pear to reduce the risk of suicide. Intervention pro- there is some evidence that the serotonin reuptake
grams include crisis intervention services (e.g., inhibitors increase the risk of suicide in children
suicide hotlines) and dialectical behavior therapy. and adolescents. Clinicians must weigh the poten-
Prevention programs generally have focused on tial benefits and risks and carefully monitor indi-
educating people broadly about suicide risk and viduals for signs of increased suicidal thoughts
the steps to take if they are suicidal or know of when they begin taking an SSRI (Zalsman, Levy, &
someone who is suicidal. Because access to guns is Shoval, 2008).
associated with higher suicide rates, some preven- Psychological therapies designed to treat de-
tion efforts focus on removing access to guns, pression can be effective in treating suicidal
which might reduce the chances of a person taking individuals. Dialectical behavior therapy (DBT) was
his or her own life impulsively. developed to treat people with borderline person-
ality disorder, who frequently attempt suicide (see
Treatment of Suicidal Persons Chapter 9; Linehan, 1999). This therapy focuses on
A person who is gravely suicidal needs immediate managing negative emotions and controlling im-
care. Sometimes people require hospitalization to pulsive behaviors. It aims to increase problem-
prevent an imminent suicide attempt. They may solving skills, interpersonal skills, and skill at
voluntarily agree to be hospitalized. If they do not managing negative emotions. Studies suggest that
agree, they can be hospitalized involuntarily for a dialectical behavior therapy can reduce suicidal
short period of time (usually about 3 days). We thoughts and behaviors, as well as improve inter-
will discuss the pros and cons of involuntary hos- personal skills (Lynch et al., 2007).
pitalization in Chapter 16. What is clearest from the literature on the
Community-based crisis intervention programs treatment of suicidal people is that they are woe-
are available to help suicidal people deal in the fully undertreated. Most people who are suicidal
short term with their feelings and then refer them to never seek treatment (Crosby et al., 1999). Even
mental health specialists for longer-term care. Some when their families know they are suicidal, they
crisis intervention is done over the phone, on sui- may not be taken for treatment because of denial
cide hotlines. Some communities have walk-in clin- and a fear of being stigmatized.
ics or suicide prevention centers, which may be part
of a more comprehensive mental health system. Suicide Prevention
Crisis intervention aims to reduce the risk of an Suicide hotlines and crisis intervention centers
imminent suicide attempt by providing suicidal per- provide help to suicidal people in times of their
sons someone to talk with who understands their greatest need, hoping to prevent a suicidal act un-
feelings and problems. The counselor can help them til the suicidal feelings have passed. In addition,
mobilize support from family members and friends many prevention programs aim to educate entire
and can make a plan to deal with specific problem communities about suicide. These programs often
situations in the short term. The crisis intervention are based in schools or colleges. Students are given
counselor may contract with the suicidal person that information about the rate of suicide in their age
he or she will not attempt suicide, or at least will group, the risk factors for suicide, and actions to
contact the counselor as soon as suicidal feelings take if they or a friend is suicidal.
return. The counselor will help the person identify Unfortunately, broad-based prevention or edu-
other people he or she can tum to when feeling pan- cation programs do not tend to be very helpful and
icked or overwhelmed and make follow-up ap- might even do harm (Gould, Greenberg, Velting, &
pointments with the suicidal person or refer him or Shaffer, 2003). One major problem with these
her to another counselor for long-term treatment. programs is that they often simultaneously target
The medication most consistently shown tore- both the general population of students and those
duce the risk of suicide is lithium. A review of 33 students at high risk for suicide. The programs may
published treatment studies of people with major attempt to destigmatize suicide by making it appear
depression or bipolar disorder found that those not quite common and by not mentioning that most
treated with lithium were 13 times more likely to suicidal people are suffering from a psychological
commit or attempt suicide than those treated with disorder, in hopes that suicidal students will feel
lithium (Baldessarini, Tondo, & Hennen, 2001). freer to seek help. But such messages can backfire
The selective serotonin reuptake inhibitors with students who are not suicidal, making suicide
also may reduce the risk of suicide, because they seem like an understandable response to stress. In
reduce depressive symptoms and possibly because addition, studies of school-based suicide prevention
Suicide 211
programs have found that adolescents who had usually in the midst of a quarrel.
made prior suicide attempts generally reacted nega- The final 3 percent of deaths
tively to the programs, saying that they were less were due to accidental shootings
inclined to seek help after attending the program of a family member (Kellermann,
than before (Gould, Greenberg, et al., 2003). Rivara, Somes, & Reay, 1992).
Researchers have tailored suicide prevention The mere presence of a fire-
messages to specific populations-particularly arm in the home appears to be a
high-risk populations-in hopes of getting the risk factor for suicide when
right kind of help to the neediest people. David other risk factors are taken into
Shaffer and his colleagues have designed a pro- account, especially when hand-
gram that involves screening adolescents for risk guns are improperly secured or
of suicide, doing a diagnostic interview with high- are kept loaded (Brent et al.,
risk adolescents, and then interviewing them to 1991; Miller & Hemenway, 2008).
determine the most appropriate referral to a men- These suicides do not occur only
tal health specialist (Shaffer & Gould, 2000). This among people with mental dis-
program has had some success in identifying high- orders. One study found that
risk youth and getting them into effective treat- while the presence of a gun in
ment. Similar programs have been developed for the home increased the risk of
college students (Haas, Hendin, & Mann, 2003). suicide by 3 times for people
Parents and school officials often worry that with a mental disorder, it in-
asking teenagers about thoughts of suicide might creased the risk of suicide by 33
"put the idea in their head." One study addressed times for people without a men-
this concern directly (Gould et al., 2005). The re- tal disorder (Kellerman et al.,
searchers randomly assigned more than 2,000 teen- 1992; see also Brent et al., 1993).
agers to complete questionnaires that either This apparently counterintuitive
included or did not include questions about sui- finding is the result of the dra-
cidal thoughts and behaviors. Two days later the matic increase in impulsive sui- Restricting access to guns appears to
researchers had all the teenagers fill out a measure cides seen among residents of lower suicide rates.
of suicidal thought. Teenagers who had completed homes containing a loaded gun,
the suicide questionnaire did not report any more even among people without a known risk factor
(or less) suicidal thought or distress than the teen- such as psychopathology (Brent & Bridge, 2003).
agers who had not been asked about suicide. Thus, Can the number of such suicides be reduced
there was no evidence that answering questions by laws that restrict access to guns? Several studies
about suicide induced teenagers to consider sui- have found that suicide rates are lower in cities,
cide or made them highly distressed. states, or countries with strict antigun legislation
that limits people's access to guns (Brent & Bridge,
Guns and Suicide 2003; Leenaars, 2007). For example, one interna-
In the United States, 53 percent of suicides involve tional study showed that the proportion of sui-
guns (Miller & Hemenway, 2008). Purchase of a gun cides by gun decreased proportionately with the
can indicate suicidal intent: A longitudinal study of number of households owning guns; in addition,
people who had purchased handguns in California after countries enacted stricter gun control laws,
found that their risk of suicide increased 57 times in the proportion of suicides involving guns de-
the first week after the purchase (Wintemute et al., creased (Ajdacic-Gross et al., 2006; see also Bridges,
1999). The majority of people who commit suicide 2004). Similarly, in the United States, in states with
by gun, however, use a gun that has been in their unrestrictive firearm laws (e.g., Alaska, Kentucky,
household for some time; the presence of a gun in Montana) rates of suicide by firearm were 3.7 times
the home increases the risk of suicide by 4 to 5 times higher among men and 7.9 times higher among
(Brent & Bridge, 2003; Miller & Hemenway, 2008). women than in states with restrictive firearm laws
Indeed, the most frequent use of a gun in the (e.g., New York, Connecticut, Rhode Island) (Miller
home is for suicide. Researchers examined 398 con- & Hemenway, 2008). Such patterns related to gun
secutive deaths by gun in the homes of families laws and suicide are found even after controlling for
who owned guns (usually handguns). Of these differences in socioeconomic status, race/ ethnicity,
deaths, only 0.5 percent involved intruders shot by and urbanization (Conner & Zhong, 2003).
families protecting themselves. In contrast, 83 per- Although people who are intent on committing
cent were suicides of adolescent or adult family suicide can find other means to do so when guns are
members. Another 12 percent were homicides of not available, restricting ready access to them
one adult in the home by another family member, appears to reduce impulsive suicides with guns.
Suicides by means other than guns (e.g., by jumping 11. Take care of yourself. Interacting with a per-
off a building or inhaling carbon monoxide) show son who is suicidal can be extremely stressful
no increase when access to guns is restricted, and disturbing. Talk with someone you trust
suggesting that people do not consistently substi- about it-perhaps a friend, family member, or
tute different means of committing suicide when counselor-particularly if you worry about
guns are not available (Connor & Zhong, 2003; how you handled the situation or that you
Miller & Hemenway, 2008). Instead, the unavail- will find yourself in that situation again.
ability of guns seems to give people a cooling off
period during which their suicidal impulses can
wane (Brent & Bridge, 2003; Lambert & Silva, 1998).
CHAPTER INTEGRATION
The mood disorders affect the whole person. De-
What to Do If a Friend Is Suicidal pression and mania involve changes in every as-
What should you do if you suspect that a friend or pect of functioning, including biology, cognitions,
family member is suicidal? The Depression and Bi- personality, social skills, and relationships. Some
polar Support Alliance (2008), a patient-run advo- of these changes may be causes of the depression
cacy group, makes the following suggestions in or mania, while others may be consequences.
Suicide and Depressive Illness: The fact that the mood disorders are phe-
nomena affecting the whole person illustrates the
1. Take the person seriously. Although most intricate connections among biology, cognitions,
people who express suicidal thoughts do not personality, and social interactions. These areas
go on to attempt suicide, most people who of functioning are so intertwined that major
do commit suicide have communicated their changes in any one area almost necessarily will
suicidal intentions to friends or family mem- provoke changes in other areas . Many recent
bers beforehand. models of the mood disorders suggest that most
2. Get help. Call the person's therapist, a suicide people who become depressed carry a vulnera-
hotline, 911, or any other source of profes- bility to depression for much of their lives. This
sional mental health care. may be a biological vulnerability, such as dys-
3. Express concern. Tell the person concretely function in the neurotransmitter systems, or a
why you think he or she is suicidal. psychological vulnerability, such as overdepen-
dence on others. Not until these vulnerabilities
4. Pay attention. Listen closely, maintain eye con-
interact with certain stressors is a full-blown de-
tact, and use body language to indicate that you
pression triggered, however (Figure 7.10).
are attending to everything the person says.
5. Ask direct questions about whether the per-
son has a plan for suicide and, if so, what that An Integrative Model
FIGURE 7.10
plan is. of Depression
6. Acknowledge the person's feelings in a non-
judgmental way. For example, you might say
something like "I know you are feeling really
horrible right now, but I want to help you get
r Genetic factors '
through this" or "I can't begin to completely un- Dysfunction in Personality

neurotransmitter and characteristics that
derstand how you feel, but I want to help you." neuroendocrine systems increase stress response
7. Reassure the person that things can be better. and exposure to stressors
(e.g., neuroticism)
Emphasize that suicide is a permanent solu-
8.
9.
tion to a temporary problem.
Don't promise confidentiality. You need the
freedom to contact mental health profession-
als and tell them precisely what is going on.
Make sure guns, old medications, and other
L J Heightened
vulnerability
to stress
means of self-harm are not available.

Encounters with
10. If possible, don't leave the person alone until new stressors
he or she is in the hands of professionals. Go
with him or her to the emergency room if
need be. Then, once he or she has been hospi-
talized or has received other treatment, follow
up to show you care.
Chapter Summary 213
Fortunately, the interconnections among these people's cognitive and social functioning can
areas of functioning may mean that improving improve their biological functioning, and so on.
functioning in one area can improve functioning in Thus, although there may be many pathways into
other areas: Improving people's biological func- mood disorders (biologicat psychologicat and
tioning can improve their cognitive and social social), there also may be many pathways out.
functioning and their personalities, improving
SHADES OF GRAY DISCUSSION (review p. 1s1 l
Carmen's symptoms-currently severe depressed major depressive episode are currently met, but
mood in the context of longstanding unhappiness, she has experienced periods of at least 2 months in
excessive sleep every day (hypersomnia), difficulty the past 2 years with symptoms that fall below the
concentrating to a degree that interfered with her threshold for a full major depressive episode.
ability to engage her college classes, feelings of Because Carmen's more severe symptoms
worthlessness, and significant weight loss (likely began in the winter term, you may wonder if she is
greater than 5 percent of her body weight) because experiencing a major depressive disorder with
she's skipping meals-are characteristic of a major seasonal pattern, or what used to be known as
depressive episode. While we know she "spent days seasonal affective disorder (SAD). "With seasonal
on end in her bedroom," we are not entirely clear if pattern" is a specifier that applies to recurrent major
her current symptoms meet the criterion of 2 con- depressive disorder and highlights a temporal
secutive weeks to receive a diagnosis of major de- relationship between the onset of major depressive
pressive disorder. What we know more certainly is episodes and a particular time of year (e.g., in the
that she has experienced many years (> 2) strug- fall or winter) . The addition of this specifier is not
gling with moderately low mood, low self-esteem, currently warranted because (a) it requires evidence
pessimism, and chronic fatigue. Thus, she would that Carmen has experienced seasonal changes in
clearly meet criteria for persistent depressive disor- mood in the last 2 years, and we only have evidence
der, likely early onset (before age 21 ), severe, but we that Carmen's depression has worsened in this year,
would need to get more information to add the and (b) the specifier requires that Carmen's depres-
specifier of "with intermittent major depressive sive symptoms lift during the spring or summer-
episodes, with current episode." The addition of time. Instead, Carmen's depressive symptoms seem
the specifier would indicate that full criteria for a to persist throughout the year.
THINK CRITICALLY
Depression can have devastating effects on people's techniques from cognitive-behavioral and interper-
lives, from marring their quality of life to leading to sonal therapies for depression? (Discussion appears
a tragic end. How might you design a program to on p. 482 at the back of this book.)
prevent depression in vulnerable people based on
CHAPTER SUMMARY
People with depressive disorders experience or mania (elated or agitated mood, grandiosity,
only the symptoms of depression (sad mood, little need for sleep, racing thoughts and speech,
loss of interest, disruption in sleep and appetite, increase in goals, and dangerous behavior). The
motor retardation or agitation, loss of energy, presence of one or more hypomanic or manic
feelings of worthlessness and guilt, suicidal episodes is the core feature of the bipolar
thoughts and behavior). disorders (see Table 7.4).
Peopl e with bipolar disorder experience Major depressive disorder is the classic condition
symptoms of both depression and hypomania among the depressive disorders. It is characterized
by discrete episodes of depressed mood and/or Sociocultural theorists have tried to explain the dif-
loss of interest or pleasure and other symptoms ferences in rates of depression among different
that lasts at least 2 weeks. In addition, there are demographic groups. The decreased risk of de-
several subtypes of major depressive disorder: pression in older adults may be due to historical
with mixed features, with anxiety features, with cohort effects. Women's greater risk for depression
melancholic features, with psychotic features, with may be due to differences in the ways women and
catatonic features, with atypical features, with sea- men respond to distress and to women's greater
sonal pattern, and with peripartum onset. interpersonal orientation, lesser power and status,
Persistent depressive disorder (dysthymia) is a and higher rates of victimization. High rates of
chronic form of depression that continues for at depression in Hispanic Americans may be due to
least 2 years in adults or 1 year in youth. It can low socioeconomic status.
be less severe than major depressive disorder Bipolar disorder has an even greater connection to
(full criteria are not met in last 2 years) or it genetic factors than does depression. The areas of
may represent intermittent or persistent major the brain most implicated in bipolar disorder are
depressive episodes, and includes many of the the amygdala, prefrontal cortex, and striatum.
same subtypes as major depressive disorder. Adolescents with bipolar disorder show abnormal-
Premenstrual dysphoric disorder is diagnosed in ities in white-matter tissue. Dopamine is the neu-
women who show increases in symptoms of dis- rotransmitter most implicated in bipolar disorder.
tress in the week before the onset of menses, People with bipolar disorder may have dysfunc-
with relief of symptoms after menses begins. tional reward systems: They are hypersensitive
Cyclothymic disorder is a less severe but more to reward when in a manic state and insensitive to
chronic form of bipolar II disorder that does not reward when in a depressed state.
include major depressive episodes. Most of the biological therapies for mood disorders
Depression is one of the most common disor- are drug therapies, including antidepressants and
ders, but there are substantial age, gender, and mood stabilizers. Electroconvulsive therapy is used
cross-cultural differences in depression. Bipolar to treat severe depression that does not respond to
disorder is much less common than the depres- drugs. Newer methods of stimulating the brain,
sive disorders and tends to be a lifelong problem. including repetitive transcranial magnetic stimula-
The length of individual episodes of bipolar disor- tion, vagus nerve stimulation, and deep brain stim-
der, as in depression, varies dramatically from ulation, hold promise for the treatment of mood
one person to the next and over the life course. disorders. Light therapy is helpful in treating major
depressive disorder with seasonal pattern.
The neurotransmitters norepinephrine, serotonin,
and dopamine have been implicated in the mood Behavior therapies focus on increasing positive
disorders. Disordered genes may lead to dysfunc- reinforcers and decreasing negative events by
tion in these neurotransmitter systems. In addi- building social skills and teaching clients how to
tion, neuroimaging studies show abnormal engage in pleasant activities and cope with their
structure or activity in several areas of the brain, moods. Cognitive-behavioral therapies help peo-
including the prefrontal cortex, hippocampus, an- ple with depression develop more adaptive ways
terior cingulate, and amygdala. There is evidence of thinking. Interpersonal therapy helps people
that people with depression have chronic hyperac- with depression identify and change the patterns
tivity in the hypothalamic-pituitary-adrenal axis, in their relationships.
which may make them more susceptible to stress. Interpersonal social rhythm therapy helps people
Behavioral theories of depression suggest that with bipolar disorder manage their social relation-
people with much stress in their lives may have ships and daily rhythms to try to prevent relapse.
too low a rate of reinforcement and too high a rate Family-focused therapy may help people with
of punishment, leading to depression. Stressful bipolar disorder manage their disorder.
events also can lead to learned helplessness- Direct comparisons of various psychotherapies
the belief that nothing you do can control your and drug therapies show that they tend to be
environment-which also is linked to depression. equally effective in treating depression.
The cognitive theories argue that depressed people Psychotherapies may be more effective than
have negative views of themselves, the world, and drug therapies in reducing relapse.
the future and engage in biased thinking that pro- Suicide is defined as death from injury, poison-
motes this negativity. People who ruminate in re- ing, or suffocation when there is evidence
sponse to distress are more prone to depression. (either explicit or implicit) that the injury was
Interpersonal theories suggest that people prone self-inflicted and that the decedent intended to
to depression are highly sensitive to rejection kill him- or herself.
and engage in excessive reassurance seeking. Women are more likely than men to attempt sui-
Levels or interpersonal stress and conflict are cide, but men are more likely than women to com-
high in the lives of depressed people. plete suicide. Cross-cultural differences in suicide
Key Terms 215
rates may have to do with religious proscriptions, Family history, twin, and adoption studies all
stressors, or cultural norms about suicide.Young suggest a genetic vulnerability to suicide. Many
people are less likely than adults to commit suicide, studies have found a link between low serotonin
but suicide rates among youth have been fluctuat- levels and suicide.
ing dramatically in recent decades.The elderly, par- Drug treatments for suicidal patients most often
ticularly elderly men, are at high risk for suicide. involve lithium or antidepressant medications .
Several mental disorders, including depression, Psychotherapies for suicide are similar to those
bipolar disorder, substance abuse, schizophrenia, for depression . Dialectical behavior therapy ad-
and anxiety disorders, increase the risk for suicide. dresses skill deficits and thinking patterns in
people who are recurrently suicidal.
Several negative life events or circumstances,
including economic hardship, serious illness, Suicide hotlines and crisis intervention programs
loss, and abuse, increase the risk for suicide. provide immediate help to people who are highly
suicidal. Community prevention programs aim to
Suicide clusters (also called suicide contagion)
educate the pub lic about suicide and t o encour-
occur when two or more suicides or attempted
age suicidal people to enter treatment.
suicides are nonrandomly bunched together in a
place or time. Guns are involved in the majority of suicides, and
some research suggests that restricting access to
Impulsivity and hopelessness predict suicidal
guns can reduce the number of su icide attempts.
behavior.
KEY TERMS
bipolar disorder 176 cohort effect 191
mania 176 selective serotonin reuptake inhibitors (SSRis) 195
depression 176 selective serotonin-norepinephrine reuptake
depressive d isorders 176 inhibitors (SNRis) 195
major depressive disorder 177 norepinephrine-dopamine reuptake inhibitor 196
persistent depressive disorder 177 tricyclic antidepressants 196
seasonal affective disorder (SAD) 179 monoamine oxidase inhibitors (MAOis) 196
premenstru al dysphoric disorder 180 repetitive transcranial magnetic stimulation
(rTMS) 197
bipolar I disorder 182
vagus nerve stimulation (VNS) 198
bipolar II disorder 182
deep brain stimulation 198
hypomania 183
light therapy 199
cyclothymic disorder 183
rapid cycling bipolar I disorder 183 behavioral therapy 199
rapid cycling bipolar II disorder 183 interpersonal and social rhythm therapy
(ISRT) 202
disruptive mood dysregulation disorder 183
family-focused therapy (FFT) 203
monoamines 186
suicide 204
norepinephrine 186
suicide attempts 204
serotonin 186
suicidal ideation 204
dopamine 186
nonsu icidal self-injury (NSSI) 207
hypothalamic-pituitary-adrenal axis (HPA axis) 187
egoistic suicide 207
behavioral theories of depression 189
anomie suicide 207
learned helplessness theory 189
altruistic suicide 207
negative cognitive triad 189
suicide cluster 208
reformulated learned helplessness theory 189
suicide contagion 209
rumination 190
impulsivity 209
interpersonal theories of depression 191
hopelessness 209
rejection sensitivity 191
Schizophrenia Spectrum
and Other Psychotic
Disorders
CHAPTER OUTLINE
Schizophrenia Spectrum and Other Treatment

Psychotic Disorders Along the
Continuum Chapter Integration
Extraordinary People: John Nash, Shades of Gray Discussion

A Beautiful Mind Think Critically
Symptoms, Diagnosis, and Course Chapter Summary
Shades of Gray Key Terms
Biological Theories
Psychosocial Perspectives
Schizophrenia Spectrum and Other Psychotic Disorders
Along the Continuum
Deficits in attention
and working memory
(may or may not Delusional Schizophreniform
lead to difficulties disorder disorder
in communication, (persistent beliefs (symptoms of Schizoaffective
Normal thought, or that are unrealistic, schizophrenia disorder
thinking, social interaction) but no other for more than (mixed symptoms of
communication, symptoms of 1 month but less schizophrenia and
and social schizophrenia) than 6 months) a mood disorder)
interactions
I
Schizotypal No longer Bri ef psychotic Schizophrenia

personality disorder distinguished disorder (delusions,
(paranoia, beliefs that in DSM-5 (symptoms of hallucinations,
random events are schizophrenia for disorganized speech
related to the individual, less than 1 month) or behavior, andjor
magical thinking, negative symptoms,
perceptual illusions, and functional
social isolation, decline for 6 months)
restricted emotions)
Schizophrenia is one of those disorders you've probably seen order of severity. The first disorder along the continuum is
depicted in the media. People with this disorder see, hear, and schizotypal personality disorder, which involves moderate symp-
feel things that aren't real (hallucinations) and may have fixed toms resembling those of schizophrenia but with a retained grasp
beliefs, for example, that they are going to be harmed by some on reality. People with this personality disorder often speak in odd
organization or that their thoughts have been "removed" by and eccentric ways, have unusual beliefs or perceptions, and have
some outside force (delusions). Such experiences and beliefs difficulty relating to other people. Farther along the continuum are
that are out of touch with reality are called psychotic. People with disorders in which people lose touch with reality. In delusional
psychosis may speak incoherently and act in an unpredictable disorder, individuals have persistent beliefs that are contrary to
manner. Although you might think schizophrenia is so different reality, but they lack other symptoms of schizophrenia and often
from normal experience that it couldn't possibly be on a contin- are not impaired in their functioning. Their delusions tend to be
uum, the symptoms that make up schizophrenia can appear in about things that are possible but untrue. In brief psychotic disor-
mild to moderate form in many people who do not meet the full der, individuals have symptoms of schizophrenia for 1 month or
criteria for any disorder (Ahmed, Buckley, & Mabe, 2012; Linscott less. In schizophreniform disorder, individuals have symptoms of
& van Os, 2010). For example, in a study of 8,580 people from an schizophrenia for 1 to 6 months but usually resume their normal
unselected community sample, 28 percent reported having had lives. Schizoaffective disorder presents a mixed picture of schizo-
at least one symptom characteristic of schizophrenia, such as phrenia and major depression or mania. Other psychotic disorders
hearing voices that no one else heard or believing that thei r include substance-induced psychotic disorder and psychotic (or
thoughts were being controlled by someone else (Johns et al., catatonic) disorder associated with another medical condition are
2004). In addition, biological family members of people with psychoses specifically brought on by a substance or an illness,
schizophrenia often show problems in attention and memory, as respectively. They may be short-term or longer lasting.
well as neurological abnormalities similar to those seen in The continuum of disorders illustrated here represents what
schizophrenia, but less severe. the DSM-5 calls the schizophrenia spectrum-a set of psychotic
The DSM-5 recognizes the continuum of psychotic experi- disorders that share similarities with schizophrenia but are not as
ences by listing schizophrenia and other psychotic disorders in severe or persistent.
Sch izophrenia Spectrum a nd Other Psychotic Disorders Along the Continuum 217
218 Chapter 8 Schizophrenia Spectrum and Other Psychotic Disorders
John Nash, A Beautiful Mind
In 1959, at age 30, John Nash was a widely behave rationally, although his inner world remained
recognized mathematician and professor at the unchanged. On his release, Nash resigned from
Massachusetts Institute ofTechnology. While still a MIT, furious that the institution had "conspired" in
graduate student at Princeton, he had introduced his commitment to Mclean Hospital.
the notion of equilibrium to game theory, which After traveling around Europe for 2 years, Nash
eventually would revolutionize the field of econom- walked the streets of Princeton with a fixed expres-
ics and win him the Nobel Prize. sion and a dead gaze, wearing Russian peasant gar-
As writer Sylvia Nasar details in her biography ments and going into restaurants in his bare feet.
of John Nash, A Beautiful Mind-the basis for the He wrote endless letters and made many phone
Academy Award-winning film-Nash had always calls to friends and eminences around the world,
been eccentric and had few social skills. But in 1959 talking of numerology and world affairs. Alicia was
Nash began writing letters to the United Nations, forced to have him committed again, this time in
the FBI, and other government agencies complain- Trenton State Hospital. After 6 weeks, Nash was
ing of conspiracies to take over the world. He also considered much improved and was moved to an-
began talking openly about his belief that powers other ward of the hospital, where he began to work
from outer space, or perhaps from foreign govern- on a paper on fluid dynamics. After 6 months of
ments, were communicating with him through the hospitalization, a month after his thirty-third birth-
front page of the New York Times. Nash later de- day, he was discharged. Nash appeared to be well
scribed one of his delusions: for some time, but then his thinking, speech, and
behavior began to slip again. Eventually, he ended
I got the impression that other people at MIT
up living with his mother in Roanoke, Virginia.
were wearing red neckties so I would notice
them. As I became more and more delusional, His daily rounds extended no farther than the
not only persons at MIT but people in Boston library or the shops at the end of Grandin Road, but
wearing red neckties [would seem significant to in his mind he traveled to the remotest reaches of the
me] . . . [there was some relation to] a crypto- globe and lived in refugee camps, foreign embas-
communist plot:' (Nasar, 1998, p. 242) sies, prisons, and bomb shelters. At other times, he
felt that he was inhabiting an inferno, a purgatory, or
Nash's wife, Alicia, saw him become increasingly
a polluted heaven. His many identities included a
distant and cold toward her. His behavior grew
Palestinian refugee, a Japanese shogun, and even, at
more and more bizarre:
times, a mouse (Nasar, 1998).
Several times, Nash had cornered her with odd After his mother died, Nash returned to
questions when they were alone, either at home Princeton and lived with Alicia. During the 1970s
or driving in the car. "Why don't you tell me and 1980s, his illness gradually subsided without
about it?" he asked in an angry, agitated tone,
treatment. Nash was awarded the Nobel Prize in
apropos of nothing. "Tell me what you know;'
economics for his contributions to game theory.
he demanded. (Nasar, 1998, p. 248)
He and Alicia live in Princeton, where Nash works
Alicia had him committed to Mclean Hospital on his mathematical theories. He helps care for
in April 1959 after his threats to harm her became their son, Johnny, who obtained his Ph.D. in math-
more severe and his behavior became increasingly ematics several years ago and who also has de-
unpredictable. There Nash was diagnosed with veloped paranoid schizophrenia. Although Johnny
paranoid schizophrenia and was given medication is receiving the newest treatments for schizophre-
and daily psychoanalytic therapy. Nash learned nia, they help only a little, and he is hospitalized
to hide his delusions and hallucinations and to frequently.
What must it be like to walk around w ith percep- your head. You might believe that the ideas you are ~
tions that do not map onto reality, as John Nash did having are being broadcast over television, so that
during the acute phases of his illness? You might see others already know what you are thinking. If you
things that do not really exist. You might hear voices are unable to tell the difference between what is real
that are not coming from other people but are only in and what i s unreal, you are experiencing psychosis.
Symptoms. Diagnosis. and Course 219
Psychosis can take many forms. One of the Distribution of People

most severe and puzzling psychotic disorders is FIGURE 8.1
with Schizophrenia. Most
schizophrenia. At times, people with schizophre- people with schizophrenia live
nia think and communicate clearly, have an accu- with family members or independently, but a
rate view of reality, and function well in daily life. number are in hospitals, in nursing homes, in
At other times during the active phase of their ill- group homes, in jail, or on the street.
ness, their thinking and speech are disorganized,
they lose touch with reality, and they have diffi-
culty caring for themselves.
Schizophrenia and other psychotic disorders ex-
act a heavy toll, including high medical costs. More
Jails and
than 90 percent of people with psychotic disorders prisons
seek treatment in a mental health or general medi- 6%
cine facility in any given year (Narrow et al., 1993). Living with
International studies show that nations spend up to family member
25%
3 percent of their health care budget treating people
with psychotic disorders, and tens of billions of 5%
dollars more are lost in declines in productivity
(Gustavsson et al., 2011; Knapp, Mangalore, &
Simon, 2004). Most people who develop psychotic Living
independently
disorders do so in the late teenage or early adult 34%
years, when they are ready to begin contributing to
society. Then the disorder strikes. Instead of pursu-
ing their education, a career, or a family, they may
need continual services, including residential care,
rehabilitative therapy, subsidized income, and the Source: Torrey, 2006.
help of social workers to obtain needed resources-
and they may need these services for the rest of their
lives, because schizophrenia tends to be chronic.
are five domains of symptoms that define psychotic
Within the United States, 1 to 2 percent of the
disorders, and their number, severity, and duration
population will develop schizophrenia at some
distinguish psychotic disorders from each other.
time in their lives (Lieberman, Stroup, & Perkins,
People with schizophrenia may show all or just
2012; Walker, Kestler, Bollini, & Hochman, 2004).
some psychotic symptoms, and the disorder can
Similarly, studies around the globe find that
look different across individuals. The five domains
between 0.5 and 2 percent of the general popula-
of psychotic symptoms include four kinds of positive
tion will develop schizophrenia (Gottesman, 1991;
symptoms, namely, delusions, hallucinations, disor-
Linscott & van Os, 2010).
ganized thought (speech), disorganized or abnormal
E. Fuller Torrey (2006) compiled data from sev-
motor behavior (including catatonia), and negative
eral sources to estimate where people with schizo-
symptoms (e.g., restricted emotional expression or af-
phrenia are living; his estimates are shown in
fect). People with schizophrenia also often show nu-
Figure 8.1. Note that the majority of people with
merous cognitive deficits that research has shown are
schizophrenia live independently or with their
linked to declines in functioning, though cognitive
family. Note also that there are almost as many peo-
symptoms are not part of the diagnostic criteria.
ple with schizophrenia in jails, prisons, homeless
shelters, and on the street as there are in hospitals
and nursing homes. The criminal justice system
Positive Symptoms
and shelters often are repositories for people with The positive symptoms of schizophrenia include
schizophrenia who do not have a family to support delusions, hallucinations, disorganized thought
them or the resources to receive psychiatric help. and speech, and disorganized or catatonic behav-
ior. These are described as positive because they
SYMPTOMS, DIAGNOSIS, represent overt expressions of unusual percep-
tions, thoughts, and behaviors.
AND COURSE
Schizophrenia is a complex disorder with psychosis Delusions
as its core diagnostic symptom. DSM-5 refers to the Delusions are ideas that an individual believes
schizophrenia spectrum to reflect the fact that there are true but that are highly unlikely and often
TABLE 8.1 Types of Delusions
These are some types of delusions that are often woven together in a complex and frightening system of beliefs.
Type of Delusion Definition Example
Persecutory delusion False belief that oneself or one's loved ones are Belief that the CIA, FBI, and local police are
being persecuted, watched, or conspired against conspiring to catch you in a sting operation
by others
Delusion of reference Belief that everyday events, objects, or other people Belief that a newscaster is reporting on your
have an unusual personal significance movements, or that a random manhole cover
was put there so you could see it
Grandiose delusion False belief that one has great power, knowledge, Belief that you are Martin Luther King, Jr.,
or talent or that one is a famous and powerful reincarnated
person
Delusion of being Belief that one's thoughts, feelings, or behaviors Belief that an alien has taken over your body
controlled are being imposed or controlled by an external force and is controlling your behavior
Thought broadcasting Belief that one's thoughts are being broadcast from Belief that your thoughts are being transmitted
one's mind for others to hear via the Internet against your will
Thought insertion Belief that another person or object is inserting Be lief that your spouse is inserting
thoughts into one's mind blasphemous thoughts into your mind
Thought withdrawal Belief that thoughts are being removed from one's Belief that your roommate is stealing all your
mind by another person or by an object thoughts while you sleep
Delusion of guilt or sin False belief that one has committed a terrible act Belief that you have killed someone or that
or is responsible for a terrible event you are responsible for a disaster (e.g., flood)
Somatic delusion False belief that one's appearance or part of Belief that your intestines have been replaced
one's body is diseased or altered by snakes
simply impossible. Of course, most people occa- Table 8.1 lists some of the more common
sionally hold beliefs that are likely to be wrong, types of delusions. Most common are persecutory
such as the belief that they will win the lottery. delusions (Bentall et al., 2008). People with perse-
These kinds of self-deceptions differ from delu- cutory delusions may believe they are being
sions in at least three ways (Strauss, 1969). First, watched or tormented by people they know, such
self-deceptions are at least possible, whereas delu- as their professors, or by agencies or persons in
sions often are not. It is possible, if highly unlikely, authority with whom they have never had direct
that you are going to win the lottery, but it is not contact, such as the FBI or a particular member of
possible that your body is dissolving and floating Congress. Pamela Spiro Wagner, a person with
into space. Second, people harboring self-deceptions schizophrenia, writes about delusions she had after
may think about these beliefs occasionally, but peo- having a tooth filled at the dentist's office.
ple harboring delusions tend to be preoccupied with
them. Delusional people look for evidence in sup-
port of their beliefs, attempt to convince others of
these beliefs, and take actions based on them, such PROFILES
as filing lawsuits against the people they believe are
trying to control their mind. Third, people holding
A few days later, I came to understand that amal-
self-deceptions typically acknowledge that their be-
gam is not all the dentist filled the tooth with. I
liefs may be wrong, but people holding delusions
realize from various signs and evidence around
often are highly resistant to arguments or compel-
me that he implanted a computer microchip for
ling facts that contradict their delusions. They may
reasons I can't yet determine. The computers at
view the arguments others make against their beliefs
the drugstore across the street, programmed by
as a conspiracy to silence them and as evidence of
the truth of their beliefs.
Symptoms. Diagnosis, and Course 221
the Five People, have tapped into myTV set and concept of telepathy, universally present at birth
monitor my activities with radar. If I go out, spe- and measurable, might have as much influence
cial agents keep every one of my movements un- as the basic ideas of Darwin and Freud. Each
der surveillance. (Wagner & Spiro, 2005, p. 205) speaker focused on David. By using allusions and
nonverbal communications that included pointing
and glancing, each illuminated different aspects
of David's contribution. Although his name was
Another common type of delusion is the delu-
never mentioned, the speakers enticed David into
sion of reference, in which people believe that ran-
feeling that he had accomplished something
dom events or comments by others are directed at
supernatural in writing the paper. . .. David was
~em. People with delusions of reference may be-
described as having a halo around his head, and
lieve .that the comments of a local politician at a rally
the Second Coming was announced as forthcom-
~e drrected at them. John Nash believed that people
ing. Messianic feelings took hold of him . His mis-
m Boston were wearing red neckties so he would
sion would be to aid the poor and needy,
notice them as part of some cryptocommunist plot.
especially in underdeveloped countries .. ..
Grandiose delusions are beliefs that one is a
David's sensitivity to nonverbal communica-
special being or possesses special powers (Mueser &
tion was extreme; he was adept at reading peo-
~cGurk, 2004). A person may believe herself a deity
ple's minds. His perceptual powers were so
mcarnated, or she may believe that she is the most
developed that he could not discriminate be-
intelligent person on earth or has discovered the cure
tween telepathic reception and spoken language
for a disease. Another common type of delusion is
by others. He was distracted by others in a way
delusions of thought insertion, or beliefs that one's
that he had never been before. It was as if the
thoughts are being controlled by outside forces .
nonverbal behavior of people interacting with
Delusional beliefs can be simple and transient,
him was a kind of code. Facial expressions, ges-
such as when a person with schizophrenia believes
tures, and postures of others often determined
~ the pain he has just experienced in his stomach is
what he felt and thought.
the result of someone across the room shooting a
Several hundred people at the conference
laser beam at him. However, delusional beliefs of-
were talking about David. He was the subject of
ten are complex and elaborate, with the person
enormous mystery, profound in his silence.
clinging to these beliefs for long periods. The
Criticism, though, was often expressed by skep-
following profile illustrates how several types of
tics of the anticipated Second Coming. David felt
delusions- grandiose delusions, persecutory delu-
the intense communication about him as tortur-
sions, delusions of reference, and delusions of
ous. He wished the talking, nonverbal behavior,
thought insertion-may work together in one per-
and pervasive train of thoughts about him would
son's belief system. Although the passage is written
stop. (Zeit, 1981, pp. 527-531)
by a person with schizophrenia about his own ex-
perience, he speaks of himself in the third person.
PROFILES David's grandiose delusions were that he had

discovered the source of telepathy, that all the scien-
tists ~ought highly of him, and that he might be the
A drama that profoundly transformed David Zeit
~ess1ah. These grandiose delusions were accompa-
began at a conference on human psychology.
rued by persecutory delusions-that the scientists
David respected the speakers as scholars and
were criticizing him because they were jealous.
wanted their approval of a paper he had written
David's delusions of reference were that all the scien-
about telepathy. A week before the conference
tists were talking about him, both directly and indi-
David had sent his paper "On the Origins of
rectly. David believed that he could read others'
Telepathy" to one speaker, and the other speak-
minds. Finally, he had delusions of thought control-
ers had all read it. He proposed the novel scien-
that the scientists were determining his feelings with
tific idea that telepathy could only be optimally
their facial expressions, gestures, and postures.
studied during the process of birth ....
. Del~si~n~ also occur in other disorders. In par-
David's paper was viewed as a monumental
ticular, md1v1duals with severe forms of depres-
contribution to the conference and potentially to
sion or bipolar disorder (Chapter 7) often have
psychology in general. If scientifically verified, his
delusions that are consistent with their moods:
When they are depressed they may believe they
have committed some unforgivable sin, and when example, a person in the culture described who be-
they are manic they may believe they are a deity lieved that her dead relatives were causing her heart
(Bentall et al., 2008). to rot would be considered delusional. DSM-5 also
Although the types of delusions we have dis- changed the definition of delusions to "fixed be-
cussed likely occur in all cultures, the specific con- liefs that are not amenable to change in light of
tent of delusions can differ across cultures (Suhail & conflicting evidence" from "erroneous beliefs" (as
Cochrane, 2002; Tateyama et al., 1998). For example, in DSM-IV) because it is often highly difficult to
one study found that many of the delusions of establish the fully false nature of a belief (Coltheart
British people with schizophrenia focused on being et al., 2011).
controlled by televisions, radios, and computers, but
this focus was rare among Pakistani people with Hallucinations
schizophrenia, whose delusions were more likely to
Have you ever had a strange perceptual experi-
involve being controlled by black magic (Suhail &
ence, such as thinking you saw someone when no
Cochrane, 2002). These differences in the content of
one was near, thinking you heard a voice talking to
delusions probably reflect differences in the cultures'
you, or feeling as though your body was floating
belief systems as well as differences in the people's
through the air? In one study, 15 percent of men-
environments. Studies comparing Japanese people
tally healthy college students reported sometimes
and Western Europeans with schizophrenia have
hearing voices, such as their "conscience" giving
found that, among the Japanese, delusions of being
them advice or two voices (usually both their own)
slandered by others and delusions that others know
debating a topic (Chapman, Edell, & Chapman,
something terrible about them are relatively com-
1980). Most of these students probably would not
mon, perhaps due to the emphasis in Japanese
be diagnosed with schizophrenia because their au-
culture on being thought well of by others. In con-
ditory "hallucinations" are occasional and brief-
trast, among Germans and Austrians with schizo-
often occurring when they are tired, stressed, or
phrenia, religious delusions of having committed a
under the influence of alcohol or other drugs-and
sin (e.g., "Satan orders me to pray to him; I will be
do not impair their daily functioning in any way.
punished") are relatively common, perhaps due to
In addition, the hallucinations that occur due to
the influence of Christianity in Western Europe
alcohol or drug use usually are arbitrary percep-
(Tateyama et al., 1993).
tual experiences, such as flashes of light or blasts of
Some theorists argue that odd or impossible be-
noise (Aleman & Laroi, 2008).
liefs that are part of a culture's shared belief system
T~e hallucinations-unreal perceptual
cannot be considered delusions (Fabrega, 1993). If
expenences-of people with schizophrenia tend to
the people of a particular culture believe that the
spirits of dead relatives watch over the living, then be more frequent, persistent, complex, sometimes
individuals in that culture who hold that belief are more bizarre, and often entwined with delusions
not considered delusional. However, people who than these college students' hallucinations. They
hold extreme manifestations of their culture's a_lso are not precipitated simply by sleep depriva-
shared belief systems are considered delusional. For tion, stress, or drugs, as the person in the following
profile describes.
PROFILES
At one point, I would look at my co-workers and

their faces would become distorted. Their teeth
looked like fangs ready to devour me. Most of
the time I couldn't trust myself to look at anyone
for fear of being swallowed. I had no respite from
the illness. Even when I tried to sleep, the de-
mons would keep me awake, and at times 1
would roam the house search ing for them. 1was
being consumed on all sides whether I was
awake or asleep. I felt I was being consumed by
The specific content of hallucinations and delusions may demons. (Long, 1996)
be influenced by culture.
Symptoms, Diagnosis, and Course 223
Hallucinations can involve any of the senses I also see the image of Jesus Christ, with the crown
(Aleman & Laroi, 2008). Auditory hallucinations of thorns and bleeding." Interviewers who know
(hearing voices, music, and so on) are the most Puerto Rican culture, however, might recognize
common hallucinations. They may consist of a this woman's beliefs and experiences as consistent
voice speaking the individual's thoughts aloud or with a spiritual group common in Latin America
carrying on a running commentary on the person's that believes in clairvoyance and religious visions
behavior, a collection of voices speaking about the (Guarnaccia et al., 1992).
individual in the third person, or voices issuing
commands and instructions (Aleman & Laroi, Disorganized Thought and Speech
2008). The voices may seem to come either from The disorganized thinking of people with schizo-
inside the person's head or from somewhere out- phrenia is often referred to as a formal thought
side. They often have a negative quality, criticizing disorder. One of the most common forms of disorga-
or threatening the individuals or telling them to nization in schizophrenia is a tendency to slip from
hurt themselves or others (Aleman & Laroi, 2008). one topic to a seemingly unrelated topic with little
People with schizophrenia may talk back to the coherent transition, often referred to as loose associa-
voices even as they are trying to talk to people who tions or derailment. For example, one person with
are actually in the room with them. The second schizophrenia posted this "announcement":
most common type of hallucination is visual hal-
Things that relate, the town of Antelope,
lucinations, often accompanied by auditory hallu-
Oregon, Jonestown, Charlie Manson, the
cinations. For example, a woman may see a figure
Hillside Strangler, the Zodiac Killer,
of a man standing at her bedside, telling her she is
Watergate, King's trial in L.A., and many
damned and must die. An individual's hallucina-
more. In the last 7 years alone, over
tions may be consistent with her delusions-the
23 Starwars scientists committed suicide
person who sees Satan telling her she must die may
for no apparent reason. The AIDS coverup,
think that she is related to Satan.
the conference in South America in 87 had
Tactile hallucinations involve the perception
over 1,000 doctors claim that insects can
that something is happening to the outside of the
transmit it. To be able to read one's
person's body-for example, that bugs are crawl-
thoughts and place thoughts in one's mind
ing up her back. Somatic hallucinations involve
without the person knowing it's being
the perception that something is happening inside
done. Realization is a reality of bioelectro-
the person's body-for example, that worms are
magnetic control, which is thought trans-
eating his intestines. These hallucinations often
fer and emotional control, recording
are very frightening (NIMH, 2008; Torrey, 2006).
individual brain-wave frequencies of
Hallucinations do not occur only in schizophre-
thought, sensation, and emotions.
nia and other psychotic disorders (Aleman & Laroi,
2008). One study of individuals with visual halluci- The person who wrote this announcement saw
nations (Gauntlett-Gilbert & Kuipers, 2003) found clear connections among the events he listed in the
that 60 percent were diagnosed with schizophrenia first half of the paragraph and between these
or schizoaffective disorders (described below) but events and his concerns about mind reading and
that 25 percent were diagnosed with depression and bioelectromagnetic control. However, it is difficult
15 percent with bipolar disorder (see Chapter 7), for us to see these connections.
As with delusions, the types of hallucinations A person with schizophrenia may answer
people experience in different cultures appear sim- questions with unrelated or barely related com-
ilar, but the content of the hallucinations can be ments. For example, when asked why he is in the
culturally specific. For example, a person from hospital, a man with schizophrenia might answer,
Asia may see the ghosts of ancestors haunting him "Spaghetti looks like worms. I really think it's
or her, but this hallucination is not common among worms. Gophers dig tunnels but rats build nests."
Europeans (Browne, 2001; Westermeyer, 1993). As At times, the person's speech is so disorganized as
with delusions, clinicians must understand hallu- to be totally incoherent to the listener, a form of
cinations in their cultural context (Aleman & Laroi, speech known as "word salad." For example, "Much
2008). For example, a Puerto Rican woman might of abstraction has been left unsaid and undone in
be diagnosed with schizophrenia by a European these products milk syrup, and others, due to eco-
American interviewer because she believes she has nomics, differentials, subsidies, bankruptcy, tools,
special powers to anticipate events and because buildings, bonds, national stocks, foundation craps,
she describes what sound like hallucinations, such weather, trades, government in levels of breakages
as "I see images of saints and virgins in the house. and fuses in electronics too all formerly states not
necessarily factuated" (Maher, 1966, p. 395). The agitatedly because no one will believe him and of-
person may make up words that mean something fer him the help he thinks he needs.
only to him or her, known as neologisms. Or the per- People with schizophrenia often have trouble
son may make associations between words based organizing their daily routines of bathing, dressing
on the sounds of the words rather than on the con- properly, and eating regularly. Because their atten-
tent, known as clangs, or may repeat the same word tion and memory are impaired, it takes all their con-
or statement over and over again. centration to accomplish even one simple task, such
Men with schizophrenia tend to show more as brushing their teeth (NIMH, 2008; Torrey, 2006).
severe deficits in language than do women with They may engage in socially unacceptable behavior,
schizophrenia, possibly because language is con- such as public masturbation. Many are disheveled
trolled more bilaterally-that is, by both sides of and dirty, sometimes wearing few clothes on a cold
the brain-in women than in men (Goldstein et al., day or heavy clothes on a very hot day.
2002). Thus, the brain abnormalities associated Catatonia is disorganized behavior that re-
with schizophrenia may not affect women's lan- flects unresponsiveness to the environment. This
guage and thought as much as they do men's be- ranges from a lack of response to instructions (neg-
cause women can use both sides of their brain to ativism), to showing a rigid, inappropriate, or bi-
compensate for deficits. In contrast, language is zarre posture, to a complete lack of verbal or motor
more localized in men, so when these areas of the responses (e.g., mutism). In catatonic excitement, the
brain are affected by schizophrenia, men may not person shows purposeless and excessive motor ac-
be as able to compensate for the deficits. tivity for no apparent reason. The individual may
articulate a number of delusions or hallucinations
Disorganized or Catatonic Behavior or may be incoherent (Mueser & Jeste, 2008).
The disorganized behavior of people with schizo-
phrenia often frightens others. People with schizo- Negative Symptoms
phrenia may display unpredictable and apparently
untriggered agitation-suddenly shouting, swear- You might say to yourself that all the symptoms of
ing, or pacing rapidly. These behaviors may occur schizophrenia seem negative. However, specific
in response to hallucinations or delusions. For psychotic symptoms are explicitly labeled nega-
example, a man who believes he is being perse- tive symptoms because they involve the loss of
cuted may hallucinate a frightening figure chasing certain qualities of the person, rather than behav-
him; in response, he screams and runs. Another iors or thoughts that the person expresses overtly
man who believes a computer chip has been im- (Messinger et al., 2011). The core negative symp-
planted under his skin to control him may pace toms in schizophrenia are restricted affect and
a volition/ asociality. Although the positive symp-
toms of schizophrenia may strike you as more se-
vere and debilitating than the negative symptoms,
the presence of strong negative symptoms is more
associated with poor outcome than is the presence
of strong positive symptoms, in part because the
negative symptoms tend to be persistent and
more difficult to treat (Galderisi et al., 2012;
Strauss, Harrow, Grossman, & Rosen, 2010). Neg-
ative symptoms are less prominent in other psy-
chotic disorders.
Restricted Affect
Restricted affect refers to a severe reduction in or
absence of emotional expression in people with
schizophrenia. People with schizophrenia show
fewer facial expressions of emotion, may avoid eye
contact, and are less likely to use gestures to com-
municate emotional information than people w ith-
out the disorder. Their tone of voice may be flat,
with little change in emphasis, intonation (speech
A significant percentage of people with schizophrenia end up homeless and melody), rhythm, tempo, or loudness to indicate
on the streets. emotion or social engagement (Kirkpatrick, Fenton,
Carpenter, & Marder, 2006).
Symptoms. Diagnosis. and Course 225
Do people with schizophrenia actually experi- in attention and working memory make it difficult
ence less affect than people without the disorder? for people with schizophrenia to pay attention to
Self-report questionnaires often find that people relevant information and to suppress unwanted or
with schizophrenia report significant anhedonia, or a irrelevant information. As a result, they find it dif-
loss of the ability to experience pleasure (e.g., Horan, ficult to distinguish the thoughts in their mind that
Kring, & Blanchard, 2006). Yet in laboratory stud- are relevant to the situation at hand and to ignore
ies in which individuals' responses to standard- stimuli in their environment that are not relevant to
ized positive stimuli (e.g., pleasant outdoor scenes what they are doing. These deficits taken together
or photos of food) are assessed, people with schizo- may contribute to the hallucinations, delusions,
phrenia often report as much positive affect as disorganized thought and behavior, and avolition
people without the disorder (Minor & Cohen, 2010; of people with schizophrenia (Barch, 2005). Infor-
Kring & Moran, 2008). Similarly, some studies have mation and stimulation constantly flood their con-
shown emotionally charged films to people with sciousness, and they are unable to filter out what is
and without schizophrenia while recording their fa- irrelevant or to determine the source of the infor-
cial expressions and physiological arousal (Kring & mation. This makes it difficult for them to concen-
Neale, 1996). The people with schizophrenia showed trate, maintain a coherent stream of thought or
less facial responsiveness to the films than did the conversation, perform a basic task, or distinguish
normal group, but they reported experiencing just real from unreal. Social relationships and work per-
as much emotion and showed even more physiolog- formance are severely affected, and daily function-
ical arousal. Thus, people with schizophrenia who ing is impaired (Bowie et al., 2008). Delusions and
show no emotion may be experiencing intense emo- hallucinations may develop as individuals try to
tion that they cannot express. The self-reports of an- make sense of the thoughts and perceptions bom-
hedonia by people with schizophrenia may reflect barding their consciousness (Beck & Rector, 2005).
limitations in self-report questionnaires or second- The immediate relatives of people with schizo-
ary problems with depression, which is common in phrenia also show many of these cognitive deficits
schizophrenia (Messinger et al., 2011). to a less severe degree, even if they do not show the
symptoms of schizophrenia (Snitz, MacDonald, &
Avolition/ Asociality Carter, 2006). In addition, longitudinal studies of
Avolition is an inability to initiate or persist at com- people who develop schizophrenia suggest that
mon, goal-directed activities, including those at many show these cognitive deficits before they de-
work, at school, and at home. The person is physi- velop acute symptoms of the disorder (Cannon
cally slowed down in his or her movements and et al., 2003) and cognitive deficits often do not
seems unmotivated. He or she may sit around all improve over the course of the disorder or with
day doing almost nothing. Personal hygiene and treatment. Cognitive deficits may be an early
grooming are lacking. Avolition may be expressed marker of risk for schizophrenia and may contrib-
as asociality, the lack of desire to interact with other ute to the development of other symptoms (Gur
people. Individuals with schizophrenia are often et al., 2007) and strongly contribute to the disabil-
withdrawn and socially isolated. Some of this so- ity of the illness (Green et al., 2000).
cial isolation may be the result of the stigma of
schizophrenia- families sometimes dissociate
themselves from their members with schizophrenia, Diagnosis
and people often shun them. Asociality should be Schizophrenia has been recognized as a psycho-
diagnosed only when the individual has access to logical disorder since the early 1800s (Gottesman,
welcoming family and friends but shows no interest 1991). In 1883, German psychiatrist Emil Kraepelin
in socializing with them (Messinger et al., 2011). labeled the disorder dementia praecox (precocious
dementia), because he believed that the disorder
Cognitive Deficits results from premature deterioration of the brain.
People with schizophrenia show deficits in basic He viewed the disorder as progressive, irrevers-
cognitive processes, including attention, memory, ible, and chronic (Lavretsky, 2008).
and processing speed (Savla, Moore, & Palmer, Eugen Bleuler disagreed with Kraepelin's view
2008). Compared to people without schizophrenia, that this disorder develops at an early age and always
------ they have greater difficulty focusing and maintain- leads to severe deterioration of the brain (Lavretsky,
ing their attention at will, for example, in tracking a 2008). Bleuler introduced the label schizophrenia for
moving object with their eyes. In addition, people this disorder, from the Greek words schizein, mean-
with schizophrenia show deficits in working ing "to split," and phren, meaning "mind." Bleuler
memory, the ability to hold information in mem- believed that this disorder involves the splitting of
ory and manipulate it (Barch, 2005). These deficits usually integrated psychic functions of mental
associations, thoughts, and emotions. (Bleuler did consistently and acutely present for at least 1 month, ~
not view schizophrenia as the splitting of distinct referred to as the acute phase of the disorder. In addi-
personalities, as in dissociative identity disorder, nor tion, the individual must have some symptoms of
do modem psychiatrists and psychologists.) the disorder for at least 6 months to a degree that
Bleuler argued that the primary problem un- impairs social or occupational functioning. These
derlying the symptoms of schizophrenia is the symptoms cannot be due to ingestion of a sub-
"breaking of associative threads," that is, a break- stance, a medical disease, or a mood disorder (see
ing of associations among thought, language, Chapter 7). When symptoms of catatonia are pres-
memory, and problem solving. He argued that the ent, these symptoms are specified in the diagnosis.
attentional problems seen in schizophrenia are due During the 6 months before and after the active
to a lack of the necessary links between aspects of phase (meeting Criterion A in Table 8.2), the indi-
the mind and that the disorganized behavior is vidual may show predominantly negative symp-
similarly due to an inability to maintain a train of toms, with milder forms of the positive symptoms.
thought (Lavretsky, 2008). These are often referred to as prodromal symptoms
The DSM-5 states that, in order to be diagnosed (before the acute phase) and residual symptoms
with schizophrenia, an individual must show two or (after the acute phase). When experiencing prodro-
more symptoms of psychosis, at least one of which mal and residual symptoms, people with schizo-
should be delusions, hallucinations, or disorganized phrenia may be withdrawn and uninterested in
speech (see Table 8.2). These symptoms must be others. They may express beliefs that are unusual
TABLE 8.2 DSM-5 Diagnostic Criteria for Schizophrenia
A. Two (or more) of the following, each present for a sign ificant portion of time during a 1-month period (or
less if successfully treated). At least one of these must be 1, 2, or 3:
1. Delusions
2. Hallucinations
3. Disorganized speech (i .e., frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (i.e., diminished emotional expression or avol ition)
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more
major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior
to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of
interpersonal, academic, or occupational functioning).
C. Continuo us signs of the disturbance persist for at least 6 months. This 6-month period must include at least
1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms)
and may include periods of prodromal or residual symptoms. During these prodromal or residual periods,
the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms
listed in Criterion A present in an attenuated form (e.g ., odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out
because either (1) no major depressive or manic episodes have occurred concurrently with the active-p hase
symptoms, or (2) if mood episodes have occurred during active-phase symptoms, they have been present
for a minority of the active and residual periods of the illess.
E. The disturbance is not attributable to the physiological effects of a substance (e .g., a drug of abuse, a
medication) or another medical condition.
F. If there is a history of autism spectrum disorder or communication disorder of childhood onset, the
additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations in addition to
the other required symptoms of schizophrenia are also present for at least 1 month (or less if successfully
treated).
Specify if:
With catatonia
Symptoms, Diagnosis. and Course 227
but not delusional (Nelson & Yung, 2008). They may and hallucinations that involve themes of persecu-
have strange perceptual experiences, such as sens- tion and grandiosity. Their delusions often focus
ing another person in the room, without reporting on being hunted, spied on, persecuted and con-
full-blown hallucinations. They may speak in a spired against by others, including government
somewhat disorganized and tangential way but re- agencies, the media, family and friends, and com-
main coherent. Their behavior may be peculiar-for plete strangers, perhaps because they have special
example, collecting scraps of paper- but not grossly knowledge or powers. They may believe that any-
disorganized. During the prodromal phase, family one who disagrees with their delusions is part of
members and friends may perceive the person with the conspiracy. They can become angry, suspicious,
schizophrenia as "gradually slipping away" (Torrey, and even violent, as John Nash did. They often do
2006). Left untreated, schizophrenia is both chronic not show grossly disorganized speech or behavior.
and episodic; after the first onset of an acute episode, They may be lucid and articulate, relating elabo-
individuals may have chronic residual symptoms rate stories of plots against them.
punctuated by relapses into acute episodes. Although paranoia is still recognized as a com-
The odd behaviors and asociality seen in schi- mon symptom in schizophrenia, the DSM-5
zophrenia can resemble the symptoms of autism dropped the DSM-IV subtypes of schizophrenia
spectrum disorders (see Chapter 10). To distinguish because evidence supporting their diagnostic
the two disorders, the diagnostic criteria for schizo- stability, validity, and usefulness is not strong
phrenia specify that schizophrenia can be diag- (Linscott, Allardyce, & van Os, 2009).
nosed only if delusions and/ or hallucinations are
clearly present. In addition, the severe deficits in Prognosis
social interaction control to autism spectrum disor- Schizophrenia is one of the most severe and debili-
der begin very early in the developmental period. tating mental disorders, and many people with the
The impact of schizophrenia symptoms on disorder suffer symptoms and impairment for many
people's lives is enormous. One review of 37longi- years, even with treatment (Harrow, Grossman,
tudinal studies that had followed individuals for Jobe, & Herbener, 2005). Between 50 and 80 percent
an average of 3 years after their first episode of of people hospitalized for one episode of active-
acute schizophrenia symptoms found that only phase schizophrenia will be rehospitalized some-
about 40 percent were employed or in school and time in their lives (Eaton, Moortensenk, Herrman, &
only about 37 percent had recovered a good level of Freeman, 1992; Harrow et al., 2005). The life expec-
functioning (Menezes, Arenovich, & Zipursky, tancy of people with schizophrenia is as much as
2006). Difficulties in functioning are tied to the neg- 10 years shorter than that of people without schizo-
ative symptoms of schizophrenia- the lack of mo- phrenia (McGlashan, 1988; Mortensen, 2003). People
tivation and appropriate emotional responding- as with schizophrenia suffer from infectious and circu-
well as to the positive symptoms. People with latory diseases at a higher rate than do people with-
schizophrenia who show many negative symp- out the disorder, for reasons that are unclear. As
toms have lower levels of educational attainment many as 10 to 15 percent of people with schizophre-
and less success holding jobs, poorer performance nia commit suicide (Joiner, 2005). The following ac-
on cognitive tasks, and a poorer prognosis than do count of a woman's suicidal thoughts gives a sense
those with predominantly positive symptoms of the psychological pain that many people with
(Andreasen et al., 1990; Messinger et al., 2011). In schizophrenia live with and wish to end through
addition, the negative symptoms are less respon- suicide.
sive to medication than are the positive symptoms:
With medication, a person with schizophrenia may
be able to overcome the hallucinations, delusions,
and thought disturbances but may not be able to
PROFILES
overcome the restricted affect and avolition. Thus,
the person may remain chronically unresponsive, I had major fantasies of suicide by decapitation
unmotivated, and socially isolated even when not and was reading up on the construction of guillo-
acutely psychotic (Messinger et al., 2011). tines. I had written several essays on the problem
You may have heard the media refer to people of the complete destruction of myself; I thought
with schizophrenia as "paranoid schizophrenics." my inner being to be a deeply poisonous sub-
Prior versions of the DSM listed subtypes of stance. The problem, as I saw it, was to kill myself,
schizophrenia, the best known of which was para- but then to get rid of my essence in such a way that
noid schizophrenia. People with this type of it did not harm creation . (Anonymous, 1992, p. 334)
schizophrenia, such as John Nash, have delusions
Despite the dire statistics, many people with In both men and women with schizophrenia,
schizophrenia do not show a progressive deteriora- functioning seems to improve with age (Jablensky,
tion in functioning across the life span and, instead, 2000; Harrow et al., 2005). Why? Perhaps they find
stabilize within 5 to 10 years of their first episode, treatments that help them stabilize, or maybe they
showing few or no relapses and regaining a moder- and their families learn to recognize the early
ately good level of functioning (Eaton et al., 1992; symptoms of a relapse and seek earlier treatment be-
Eaton, Thara, Federman, & Tien, 1998; Menezes fore the symptoms become acute (Torrey, 2006). Al-
et al., 2006). For example, one 15-year study found ternatively, the aging of the brain might somehow
that 41 percent of people with schizophrenia had at reduce the likelihood of new episodes of schizo-
least one or more periods of complete recovery last- phrenia. Some think this might be related to are-
ing at least 1 year (Harrow et al., 2005). duction in dopamine levels in the brain with age; as
we will discuss, high dopamine levels have been im-
Gender and Age Factors plicated in schizophrenia (Downar & Kapur, 2008).
Women with schizophrenia tend to have a better
prognosis than men with the disorder (Seeman, Sociocultural Factors
2008). For example, in a 20-year study of people Culture appears to play a strong role in the
with schizophrenia, 61 percent of the women course of schizophrenia. Schizophrenia tends to
had periods of recovery, compared to 41 percent have a more benign course in developing coun-
of the men (Grossman et al., 2008). Women are tries than in developed countries (Anders, 2003;
hospitalized less often than men and for briefer Jablensky, 2000). Cross-national studies find that
periods of time, show milder negative symptoms persons who develop schizophrenia in countries
between periods of active-phase symptoms, and such as India, Nigeria, and Colombia are less dis-
have better social adjustment when they are not abled by the disorder in the long term than are
psychotic (Grossman et al., 2008). The reasons persons who develop schizophrenia in countries
for these gender differences are not entirely such as Great Britain, Denmark, and the United
clear. Women diagnosed with schizophrenia tend States (Figure 8.2; Jablensky, 2000).
to have better prior histories than men: They are
more likely to have graduated from high school or
college, to have married and had children, and to Cultural Differences
FIGURE 8.2
have developed good social skills (Seeman, 2008). in the Course of
This may be, in part, because the onset of schizo- Schizophrenia. People
phrenia in women tends to be in the late twenties with schizophrenia in developing countries
or early thirties, whereas men more often develop show a more positive course of the disorder
schizophrenia in their late teens or early twenties than do people in developed countries.
(Goldstein & Lewine, 2000). Women with schizo-
phrenia also show fewer cognitive deficits than 70
Developing countries
men with the disorder (Goldstein et al., 2002). All
Developed countries
these factors lead to expectations of a better prog- 60 c----..--
nosis for women but do not entirely explain it
(Grossman et al., 2010). 50 -
Estrogen may affect the regulation of dopa-
mine, a neurotransmitter implicated in schizophre-
nia, in ways that are protective for women (Seeman, ....c 40 I -
2008). Some of the sex differences, particularly in
cognitive deficits, may also be due to normal sex
(1)
t:
"'
a..
30 r----
- f---
.--
r--
r----
differences in the brain (Goldstein et al., 2002). The
pace of prenatal brain development, which is hor-
monally regulated, is slower in males than in fe-
20 - 1------ -
r--
males and may place males at higher risk than
10 - :----- 1------ -
females for abnormal brain development. Exposure
to toxins and illnesses in utero increases the risk for
abnormal brain development and the development 0
In remission Continuous Impaired
of schizophrenia. Several studies suggest that males or episodic social
with schizophrenia show greater abnormalities in symptoms functioning
brain structure and functioning than do females Source: Jablensky, 2000.
with schizophrenia (Goldstein & Lewine, 2000).
TABLE 8.3 DSM-5 Diagnostic Criteria for Schizoaffective Disorder
A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic)
current w ith Criterion A of schizophrenia.
Note: The major depressive episode must include Criterion A 1: Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or
manic) during the lifetime duration of the illness.
C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of
the active and residual portions of the illness.
D. The disturbance is not attributable to the effects of a substance (e.g ., a drug of abuse, a medication) or
anoth er medical condition .
Specify type:
Bipola r type: A manic episode is part of the presentation. Major depressive episodes may also occur.
Depressive type: If only major depressive episodes are part of the presentation .
Specify if: With catatonia
Source: Reprinted with perm ission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright 2013
Ame ri can Psychiatric Association.
The social environment of people with schizo- Disorders Along the Continuum on p . 217). Schizo-
phrenia in developing countries may facilitate phrenia has the worst long-term outcome of these
adaptation and recovery better than the social envi- disorders, followed by schizoaffective disorder,
ronment of people with schizophrenia in devel- schizophreniform disorder, and the other psy-
oped countries (Anders, 2003). In developing chotic disorders in the order shown on page 217
countries, broader and closer family networks (Harrow et al., 2005). Schizoaffective disorder
surround people with schizophrenia (Karno & is a mix of schizophrenia and a mood disorder
Jenkins, 1993). This ensures that no one person is (Table 8.3). People with schizoaffective disorder si-
solely responsible for the care of a person with multaneously experience psychotic symptoms
schizophrenia, a situation that is risky for both the (delusions, hallucinations, disorganized speech
person with schizophrenia and the caregiver. Fami- and behavior, and/or negative symptoms) and
lies in some developing countries also score lower prominent mood symptoms meeting the criteria
on measures of hostility, criticism, and overinvolve- for a major depressive or manic episode (see Chap-
ment than do families in some developed countries ter 7) . Mood symptoms must be present for the
(Hooley, 2007). This may help lower relapse rates majority of the period of illness. Unlike mood
for their family members with schizophrenia. disorders with psychotic features, schizoaffective
Whatever the reasons for variations in the disorder requires at least 2 weeks of hallucina-
course of schizophrenia across cultures and be- tions or delusions without mood symptoms.
tween men and women, the conventional wisdom The diagnosis of schizophreniform disorder
that schizophrenia is inevitably a progressive dis- requires that individuals meet Criteria A, D, and
order, marked by more deterioration with time, E for schizophrenia but show symptoms that last
has been replaced by new evidence that many only 1 to 6 months (Table 8.4). The 1- to 6-month
people with schizophrenia achieve a good level of duration requirement is intermediate between
functioning over time. that for brief psychotic disorder (discussed next)
and schizophrenia. While functional impairments
may be present, they are not necessary for a diag-
Other Psychotic Disorders nosis of schizophreniform disorder. Individuals
The DSM-5 recognizes other psychotic disorders with this disorder who have a good prognosis
that share features with schizophrenia. These have a quick onset of symptoms, functioned well
disorders fall along a continuum of severity (see previously, and experience confusion but not
Schizophrenia Spectrum and Other Psychotic blunted or flat affect. Individuals who do not
TABLE 8.4 DSM-5 Diagnostic Criteria for Schizophreniform Disorder
A. Criteria A, D, and E of Schizophrenia are met (see Table 8.2, p. 226).

B. An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made
without waiting for recovery, it should be qualified as "provisional."
Specify if:
With good prognostic features: as evidenced by two or more of the following:
1. Onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior
or functioning
2. Confusion or perplexity
3. Good premorbid social and occupational functioning
4. Absence of blunted or flat affect
Without good prognostic features
With catatonia
show two or more of these features are said to be Individuals with brief psychotic disorder show
without good prognostic fea tures. The majority a sudden onset of delusions, hallucinations, disor-
(about two thirds) of individuals with schizo- ganized speech, and/ or disorganized behavior.
phreniform disorder w ill eventually receive a However, the episode lasts only between 1 day and
diagnosis of schizophrenia or schizoaffective dis- 1 month, after which the symptoms completely re-
order (American Psychiatric Association, 2013). mit (Table 8.5). Symptoms sometimes emerge after a
TABLE 8.5 DSM-5 Diagnostic Criteria for Brief Psychotic Disorder
A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3) :
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., frequent derailment or incohere nce)
4. Grossly disorganized or catatonic behavior
Note: Do not include a symptom if it is a culturally sanctioned response.
B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to
premorbid level of functioning.
C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or
another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the physiological
effects of a substance (e.g., substance of abuse, a medication) or another medical condition.
Specify if:
With marked stressor(s)(brief reactive psychosis): if symptoms occur in response to events that, singly or
together, would be markedly stressful to almost anyone in similar circumstances in the individual's cu lture .
Without marked stressor(s): if symptoms do not occur in response to events that, singly or together, would be
markedly stressful to almost anyone in similar circumstances in the individual's culture.
With postpartum onset: if onset is during pregnancy or within 4 weeks postpartum
With catatonia
Source: Reprinted w ith permiss ion from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition . Copyright 2013
American Psychiatric Associa tion.
TABLE 8.6 DSM-5 Diagnostic Criteria for Delusional Disorder
A. The presence of one (or more) delusions with a duration of 1 month or longer.
B. Criterion A of schizophrenia has never been met.
Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the
sensation of being infested with insects associated with delusions of infestation).
C. Apart from the impact of the delusion(s) or its ramifications, funct ion ing is not markedly impaired, and
behavior is not obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the
delusional periods.
E. The disturbance is not attributable to the physiological effects of a substance or another medical condition
and is not better explained by another menta l disorder, such as body dysmorphic disorder or obsess ive-
compulsive disorder.
Specify whether:
Erotomanic type: The central theme of the delusion is that another person is in love with the individual.
Grandiose type: The central theme of the delusion is the conviction of having some great (but
unrecognized) talent or insight or having made some important discovery.
Jealous type: The central theme of the delusion is that one's spouse or lover is unfaithful.
Persecutory type: The central them of the delusion is the belief that one is being conspired against, cheated,
spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of
long-term goals.
Somatic type: The central theme of the delusion involves bodily functions or sensations .
Mixed type: No one delusional theme predominates.
Unspecified type: The dominant delusional belief cannot be clearly determined or is not described in the
specific types (e.g., refere ntial delusions without a prominent persecutory or grandiose theme).
Specify if:
With bizarre content: If delusions are clearly implausible, not understandable, and not derived from
ordinary life experiences (e.g., delusional belief that one' s internal organs have been removed by a stranger
and replaced with someone else's organs without leaving any wounds or scars) .
major stressor, such as being in an accident. At other age of first admission to a psychiatric facility of
times, no stressor is apparent. Approximately 1 in 40 to 49 (Munro, 1999).
10,000 women experience brief psychotic episodes Finally, people with schizotypal personality
shortly after giving birth (Steiner et al., 2003). Al- disorder (Table 9.5) have a lifelong pattern of sig-
though risk of relapse is high, most people show an nificant oddities in their self-concept, their ways of
excellent outcome. relating to others, and their thinking and behavior.
Individuals with delusional disorder (Table 8.6) They do not have a strong and independent sense
have delusions lasting at least 1 month regarding of self and may have trouble setting realistic or
situations that occur in real life, such as being clear goals. Their emotional expression may be
followed, being poisoned, being deceived by a restricted, as in schizophrenia, or odd for the cir-
spouse, or having a disease. Unlike schizophrenia, cumstances. They may have few close relation-
they do not show any other psychotic symptoms. ships and trouble understanding the behaviors of
Other than the behaviors that may follow from others. They tend to perceive other people as de-
their delusions, they do not act oddly or have dif- ceitful and hostile and may be socially anxious and
~ ficulty functioning. In the general population, de- isolated because of their suspiciousness. People
lusional disorder may be rare, with an estimated with schizotypal personality disorder think and
lifetime prevalence of 0.2 percent. It appears to af- behave in ways that are very odd, although they
fect females more than males. Onset tends to be maintain their grasp on reality. They may believe
later in life than most disorders, with an average that random events or circumstances are related to
TABLE 8.7 Diagnostic Criteria for Schizotypal Personality Disorder
A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced
capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of
behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five or more of
the following:
1. Ideas of reference (excluding delusions of reference).
2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g.,
superstitiousness, belief in clairvoyance, telepathy, or "sixth sense" ; in children and adolescents, bizarre
fantasies or preoccupations).
3. Unusual perceptual experiences, including bodily illusions.
4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
5. Suspiciousness or paranoid ideation.
6. Inappropriate or constricted affect.
7. Behavior or appearance that is odd, eccentric, or peculiar.
8. Lack of close friends or confidants other than first-degree relatives.
9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid
fears rather than negative judgments about self.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with
psychotic features, another psychotic disorder, or autism spectrum disorder.
Note: If criteria are met prior to the onset of schizophrenia, add "premorbid," e.g., "schizotypal personality
disorder (premorbid)."
them. For example, they may think it highly sig- personality disorder. More information about
nificant that a fire occurred in a store in which they schizotypal personality disorder is presented in
had shopped only yesterday. Their perceptions are Chapter 9 on personality disorders.
also odd, for example, thinking they see people in
the patterns of wallpaper. They may be easily dis-
tracted or fixate on an object for long periods of
BIOLOGICAL THEORIES
time, lost in thought or fantasy. On neuropsycho- Given the similarity in the symptoms and preva-
logical tests (see Chapter 3), people with schizo- lence of schizophrenia across cultures and time,
typal personality disorder show deficits in working biological factors have long been thought key to its
memory, learning, and recall similar to, but less development. There are several biological theories
severe than, those shown by people with schizo- of schizophrenia. First, evidence indicates genetic
phrenia (Barch, 2005). They also share some of the transmission, although genetics does not fully ex-
same genetic traits and neurological abnormalities plain w ho develops this disorder. Second, some
of people with schizophrenia (Cannon, van Erp, & people with schizophrenia show structural and
Glahn, 2002). Some people diagnosed with schizo- functional abnormalities in specific areas of the
typal personality disorder have episodes symp- brain, which may contribute to the disorder. Third,
tomatic of brief psychotic disorder, and some many people with schizophrenia have a history of
eventually develop the full syndrome of schizo- birth complications or prenatal exposure to viruses,
phrenia. While schizotypal personality disorder which may affect brain development. Fourth, neu- ~
falls below the threshold required for a diagnosis of rotransmitter theories hold that excess levels of do-
a psychotic disorder, DSM-5 recognizes it as part of pamine contribute to schizophrenia; new research
the schizophrenia spectrum of disorders (Beckers also focuses on the neurotransmitters serotonin,
et al., 2013). The DSM-5 also considers it to be a GABA, and glutam ate.
SHADES OF GRAY
Read the following case study (adapted from around the town he had grown up in to deliver the
Andreasen, 1998). pizzas to the right addresses. His parents reported
that he seemed suspicious much of the time and
Jeff, age 19, had been a normal but somewhat shy that he had no desire to be around f riends or
kid until about 2 years ago. On a high school trip to peers. Jeff didn't seem to care about anything. His
France, he had become acutely anxious and re- grooming and hygiene had deteriorated. The
turned home early. After that, Jeff began to with- apartment he rented was filthy and full of decay-
draw. He no longer wanted to be with friends and ing food and dirty laundry. There was no history of
dropped off the football team. His grades plum- drug abuse of any type.
meted from his usual As and Bs, but he was able When interviewed by a psychiatrist, Jeff said
to graduate. His parents commented that a grad- he did not feel sad or blue, just "empty:' Jeff re-
ual but dramatic personality change had taken ported no experiences of hearing voices when no
place over the past 2 years, and he just seemed one was around, seeing th ings that other people
"empty:' All their efforts to encourage him, to help can't see, or feeling like he'd lost control of his
him find new directions, or to reassess his goals m ind or body.
seemed to have led nowhere.
Jeff had begun coursework in college but was Does Jeff have schizophrenia or one of the disor-
unable to study and dropped out. He got a job de- ders along the schizophrenia spectrum?
livering pizzas but couldn't even find his way (Discussion appears at the end of this chapter.)
Genetic C ontributors (e.g., a nontwin sibling), who shares ab out

50 percent of genes with the person with schizo-
to Sch izophre nia phrenia, has about a 10 percent chance of develop-
Family, twin, and adoption studies all indicate ing the disorder. In contrast, a niece or nephew of
the presence of a genetic component to the trans- a person with schizophrenia, who shares about
mission of schizophrenia (Allen et al., 2008). 25 percent of genes with the person with schizo-
Many scientists believe that no sin gle genetic phrenia, has only a 3 percent chance of developing
abnormality accounts for this complex disorder. the disorder. The general population has a risk of
Indeed, it may be that different genes are respon- developing the disorder of about 1 to 2 percent.
sible for different symptoms of the disorder; for The relationship between an individual's degree of
example, one set of genes may contribute to the genetic similarity to a schizophrenic relative and
positive symptoms, and a different set of genes the individual's own risk of developing schizo-
may contribute to the negative symptoms (Gur phrenia strongly suggests that genes p lay a role in
et al., 2007). its development.
Having a biological relative with schizophre-
Family Studies nia increases an individual's risk for the disorder
Psychologist Irving Gottesman compiled more but does not mean that the individual will develop
than 40 studies to determine the lifetime risk of it. For example, of all children who have one par-
developing schizophrenia for people with various ent with schizophrenia, 87 percent will not de-
familial relationships to a person with schizophre- velop the disorder. Also, 63 percent of people with
nia (Gottesman & Shields, 1976). His conclusions schizophrenia have no first- or second-degree rela-
are summarized in Figure 8.3. The children of two tive with the disorder (Gottesman & Erlenrneyer-
parents with schizophrenia and monozygotic Kimling, 2001).
(identical) twins of people with schizophrenia
share the greatest number of genes with people Adoption Studies
with schizophrenia. As the top bars of the graph in Even when the child of a person with schizophrenia
Figure 8.3 show, these individuals also have the develops the disorder, it may not be due to genetics.
greatest risk of developing schizophrenia at some A home with a parent with schizophrenia is likely to
time in their lives. be a stressful environment. When a parent is psy-
As the genetic similarity to a person with chotic, the child may be exposed to illogical thought,
schizophrenia decreases, an individual's risk of mood swings, and chaotic behavior. Even when the
developing schizophrenia also decreases. Thus, a parent is not actively psychotic, the residual nega-
first-degree relative of a person with schizophrenia tive symptoms of schizophrenia-restriction of
schizophrenia and 185 children of mothers without

Risk for Schizophrenia and Genetic
FIGURE 8.3 schizophrenia; all the children had been given up
Relatedness. One's risk of developing
for adoption early in life. Approximately 10 percent
sch izophrenia decreases substantially as one's
of the children whose biological mother had schizo-
genetic relationship to a person with schizophrenia becomes
phrenia developed schizophrenia or another psy-
more distant.
chotic disorder, compared to about 1 percent of the
children whose biological mother did not have
Genetic schizophrenia.
Relationship Relatedness Risk
Identical twin 100% Twin Studies

Figure 8.3 also shows the compiled results of sev-
eral twin studies of schizophrenia. The results
Offspring of two show a concordance rate for monozygotic (identi-
schizophrenic 50%
parents cal) twins of 46 percent, and a concordance rate for
dizygotic (fraternal) twins of 14 percent. A study
that assessed all twins born in Finland between
Fraternal twin 50%
1940 and 1957 using statistical modeling estimated
that 83 percent of the variation in schizophrenia is
Offspring of one due to genetic factors (Cannon et al., 1998).
schizophrenic 50% Even when a person carries a genetic risk for
parent
schizophrenia, however, many other biological and
environmental factors may influence whether and
Sibling 50% how he or she manifests the disorder. The classic
illustration of this point is the story of the Genain
quadruplets, who shared the same genes and fam-
Nephew or niece 25% ily environment. While all developed schizophre-
nia, their specific symptoms, onset, course, and
outcomes varied substantially (Mirsky et al., 2000).
Spouse 0% Recently, researchers have been investigating
epigenetic factors that influence the expression of
genes. Recall from Chapter 2 that DNA can be
Unrelated person 0% chemically modified by different environmental
conditions, resulting in genes being turned on or off,
0% 20% 40% 60% thereby altering the development of cells, tissues,
Source: Gottesman, 1991 .
affect, lack of motivation, and disorganization-may

impair the parent's child-care skills.
Several adoption studies addressing the ques-
tion of genes versus environment indicate that ge-
netics plays an important role in schizophrenia.
For example, Seymour Kety and colleagues (1994)
found that the biological relatives of adoptees with
schizophrenia were 10 times more likely to have a
diagnosis of schizophrenia than were the biologi-
cal relatives of adoptees who did not have schizo-
phrenia. In contrast, the adoptive relatives of
adoptees with schizophrenia showed no increased
risk for the disorder.
The Gena in quadruplets all later developed
In one of the largest adoption studies, Pekka schizophrenia, but the specific forms of the disorder
Tienari (Tienari et al., 2003, Tienari, Wahlberg, & differed among the sisters.
Wynne, 2006) tracked 155 offspring of mothers with
and organs. When monozygotic (MZ) twins who The prefrontal cortex undergoes major devel-
were discordant for schizophrenia (i.e., one twin opment in the years from adolescence to young
had schizophrenia, but the other twin did not) adulthood (Steinberg et al., 2006). Aberrations in
were compared with MZ twins who both had the normal development of the prefrontal cortex
schizophrenia, researchers found that the MZ during mid- to late adolescence may help explain
twins discordant for schizophrenia showed numer- the emergence of the disorder during this period
ous differences in the molecular structure of their (Cannon et al., 2003). Neuroimaging studies of in-
DNA, particularly on genes regulating dopamine dividuals who developed schizophrenia in adoles-
systems. In contrast, the MZ twins concordant for cence show significant structural changes across
schizophrenia showed many fewer molecular dif- the cortex, particularly in the prefrontal cortex,
ferences in their DNA (Petronis et al., 2003). The from before to after development of symptoms
reasons for these epigenetic differences are unclear. (Figure 8.4; Sun et al., 2009).
However, a number of environmental events that The hippocampus is another brain area that
could affect development in utero appear to increase consistently differs from the norm in people with
the risk for schizophrenia. Some of these events schizophrenia (Karlsgodt et al., 2010). The hippo-
might alter genes that guide brain development. campus plays a critical role in the formation of
long-term memories. In some studies, people with
Structural and Functional schizophrenia show abnormal hippocampal acti-
vation when doing tasks that require them to
Brain Abnormalities encode information for storage in their memory or
Clinicians and researchers have long believed that to retrieve information from memory (Barch,
the brains of people with schizophrenia differ fun- Csernansky, Conturo, & Snyder, 2002; Schacter,
damentally from those of people without schizo- Chiao, & Mitchell, 2003) . Other studies show that
phrenia. With the development of technologies people with schizophrenia have abnormalities in
such as positron-emission tomography (PET scans), the volume and shape of their hippocampus and at
computerized axial tomography (CAT scans), and the cellular level (Knable et al., 2004; Shenton et al.,
magnetic resonance imaging (MRI), scientists have 2001). Similar abnormalities in the hippocampus
been able to examine in detail the structure and
functioning of the brain. These new technologies
have shown major structural and functional defi-
cits in the brains of some people with schizo-
phrenia (Barch, 2005; Karlsgodt, Sun, & Cannon,
2010). Most theorists think of schizophrenia as a
neurodevelopmental disorder, in which a variety
of factors lead to abnormal development of the
brain in the uterus and early in life.
The most consistent finding is a gross reduction
in gray matter in the cortex of people with schizo-
phrenia, particularly in the medial, temporal, supe-
rior temporal, and prefrontal areas (Figure 8.4;
Karlsgodt et al., 2010). In addition, people who are
at risk for schizophrenia because of a family history
but have not yet developed the disorder show abnor-
mal activity in the prefrontal cortex (Lawrie et al.,
2008). The prefrontal cortex is important in language,
emotional expression, planning, and carrying out
plans (Barch, 2005). The prefrontal cortex connects to
all other cortical regions, as well as to the limbic sys-
tem, which is involved in emotion and cognition,
and to the basal ganglia, which is involved in motor
movement. Thus, it seems logical that a person with
an unusually small or inactive prefrontal cortex
would show the deficits in cognition, emotion, and
social interactions seen with schizophrenia, such as
difficulty holding a conversation, responding appro-
priately to social situations, and carrying out tasks.
are found in the first-degree relatives of people in the few weeks before or after birth) (Goldstein
with schizophrenia (Seidman et al., 2002). et al., 2000). As many as 30 percent of people with
In addition to reductions in gray matter, the schizophrenia have a history of perinatal hypoxia.
brains of people with schizophrenia show reduc- A prospective study of 9,236 people born in
tions and abnormalities in white matter (material Philadelphia between 1959 and 1966 found that the
that forms the connections between areas of the odds of an adult diagnosis of schizophrenia in-
brain), particularly in areas associated with working creased in direct proportion to the degree of perina-
memory (Karlsgodt et al., 2008). These white-matter tal hypoxia (Cannon et al., 1999). The authors of
abnormalities are present in individuals before they this study suggest that the effects of oxygen depri-
develop overt symptoms of schizophrenia, suggest- vation interact w ith a genetic vulnerability to
ing that they are early signs of the disorder rather schizophrenia, resulting in a person's developing
than consequences of the disease process (Karlsgodt, the disorder. Most people experiencing oxygen de-
Niendam, Bearden, & Cannon, 2009). White-matter privation prenatally or at birth do not develop
abnormalities create difficulties in the working schizophrenia, however.
together of various areas of the brain, which could
lead to the severe deficits seen in schizophrenia. Prenatal Viral Exposure Epidemiological
Along with these changes in the structure and studies have shown high rates of schizophrenia
activity of cortical and other brain areas, people among persons w hose mothers were exposed to
with schizophrenia show enlargement of ventricles, viral infections while pregnant (Cannon et al.,
fluid-filled spaces in the brain (Lawrie et al., 2008). 2003). For example, people whose mothers were
Enlarged ventricles suggest atrophy, or deteriora- exposed to the influenza epidemic that swept
tion, in other brain tissue. People with schizophre- Helsinki, Finland, in 1957 were significantly more
nia with enlarged ventricles tend to show social, likely to develop schizophrenia than were people
emotional, and behavioral deficits long before they whose mothers were not exposed. The link was
develop the core symptoms of schizophrenia. They particularly strong among people whose mothers
also tend to have more severe symptoms than other were exposed during the second trimester of preg-
people with schizophrenia and are less responsive nancy (Mednick, Machon, Huttunen, & Bonett,
to medication. These characteristics suggest gross 1988; Mednick et al., 1998). The second trimester is
alterations in the functioning of the brain, which are a crucial period for the development of the central
difficult to alleviate with treatment. nervous system of the fetus. Disruption in this
phase of brain development could cause the major
structural deficits found in the brains of some peo-
Damage to the Developing Brain ple with schizophrenia. Interestingly, people with
What causes the neuroanatomical abnormalities schizophrenia are somewhat more likely to be
in schizophrenia? Genetic factors and epigenetic born in the spring months than at other times
factors seem to play a major role (van Heren et al., of the year (Ellman & Cannon, 2008). Pregnant
2012) . In addition, these abnormalities may be tied women may be more likely to contract influenza
to birth complications, traumatic brain injury, and other viruses at critical phases of fetal devel-
viral infections, nutritional deficiencies, and defi- opment if they are pregnant during the fall and
ciencies in cognitive stimulation (Barch, 2005; winter.
Conklin & Iacono, 2002).
Other types of prenatal insults also seem to
increase risk for schizophrenia. For example, in-
Birth Complications Serious prenatal and dividuals whose mothers were pregnant during
birth difficulties are more frequ ent in the histories the famine in China from 1959 to 1961 had a two-
of people with schizophrenia than in those of peo- fold risk of developing schizophrenia compared
ple without schizophrenia and may play a role in to individuals whose mothers were not pregnant
the development of neurological difficulties during times of famine (Xu et al., 2009). Another
(Cannon et al., 2003). Moreover, a longitudinal study found that individuals whose mothers had
study of individuals at high risk for schizophrenia been exposed to the herpes simplex virus while
found that those with a history of obstetric difficul- pregnant were more likely to have a psychotic
ties were more likely to develop the full syndrome disorder, most often schizophrenia (Buka et al.,
of schizophrenia than were those without such a 2008). The authors of this study suggest that viral
history (Mittal et al., 2009). infections prompt a mother's immune system to
One type of birth complication that may be es- be more active, which can negatively impact the
pecially important in neurological development is development of brain cells and dopamine sys-
perinatal hypoxia (oxygen deprivation at birth or tems in the fetus.
Neurotransmitters Second, there may be unusually low dopamine

activity in the prefrontal area of the brain, which is
The neurotransmitter dopamine has long been involved in attention, motivation, and the organi-
thought to play a role iil schizophrenia (Howes & zation of behavior (Barch, 2005). Low dopamine
Kapur, 2009). The original dopamine theory was activity here may lead to the negative symptoms of
that the symptoms of schizophrenia are caused by schizophrenia: lack of motivation, inability to care
excess levels of dopamine in the brain, particularly for oneself in daily functions, and the restriction of
in the prefrontal cortex and the limbic system. affect. This idea is consistent with the evidence as-
This theory was supported by several lines of sociating structural and functional abnormalities in
evidence. First, drugs that tend to reduce the symp- this part of the brain with the negative symptoms
toms of schizophrenia, the phenothiazines or neu- of schizophrenia. It also helps explain why the phe-
roleptics, block the reuptake of dopamine, reducing nothiazines, which reduce dopamine activity, do
the functional level in the brain (Dolder, 2008). Sec- not effectively alleviate the negative symptoms.
ond, drugs that increase the functional level of do- Although the revised version of the dopamine
pamine in the brain, such as amphetamines, tend to hypothesis was proposed over two decades ago,
increase the incidence of the positive symptoms of many of its components continue to be supported
schizophrenia (Davis, Kahn, Ko, & Davidson, 1991). (see Howes & Kapur, 2009). Dysregulation of do-
Third, neuroimaging studies suggest the presence pamine systems seem to be involved in multiple
of more receptors for dopamine and higher levels of forms of psychosis (and mood disorders), not just
dopamine in some areas of the brain in people with in schizophrenia.
schizophrenia than in people without the disorder Other neurotransmitters also play an impor-
(Conklin & Iacono, 2002). tant role in schizophrenia. Serotonin neurons reg-
The original dopamine theory of schizophrenia ulate dopamine neurons in the mesolimbic system,
proved too simple (Conklin & Iacono, 2002; Davis and some of the newest drugs for treating schizo-
et al., 1991; Howes & Kapur, 2009). Many people phrenia bind to serotonin receptors (Howes &
with schizophrenia do not respond to the phenothi- Kapur, 2009). The interaction between serotonin
azines. In addition, even people with schizophrenia and dopamine may be critical in schizophrenia.
who do respond to the phenothiazines tend to Still other research has found abnormal levels of
experience more relief from positive symptoms the neurotransmitters glutamate and gamma-
(hallucinations and delusions) than from negative aminobutyric acid (GABA) in people with schizo-
symptoms (Kutscher, 2008). This suggests that sim- phrenia (Tiihonen & Wahlbeck, 2006). Glutamate
ple dopamine depletion does not fully explain the
negative symptoms. Further, levels of dopamine
change relatively soon after drug therapy begins, Areas of Abnormal
while changes in symptoms often take longer. This FIGURE 8.5
Dopamine Activity in the
suggests that the level of dopamine in the brain is Brain in Schizophrenia.
not the only determinant of symptoms. There may be excess dopamine activity in
Kenneth Davis and colleagues (1991) proposed the mesolimbic pathway, which begins in the
a revised theory that suggests that different types ventral tegmental area and projects to the
of dopamine receptors and different levels of do- hypothalamus, amygdala, and hippocampus.
pamine in various areas of the brain can account But there may be unusually /ow dopamine
for the symptoms of schizophrenia. First, there activity in the prefrontal cortex.
may be excess dopamine activity in the mesolim-
bic pathway, a subcortical part of the brain in-
volved in the processing of salience and reward Ventral
(Figure 8.5). Abnormal functioning in this area of tegmental cortex
area
the brain may lead individuals to attribute salience
to otherwise innocuous stimuli, contributing to
hallucinations and delusions and to deficits in mo-
tivation (Howes & Kapur, 2009). Newer drugs in
the treatment of schizophrenia, the atypical antipsy-
chotics, may work to reduce the symptoms of Mesolimbic
pathway
schizophrenia by binding to a specific type of do- Hypothalamus
pamine receptor common in the mesolimbic sys-
tem, blocking the action of dopamine (Sajatovic,
Madhusoodanan, & Fuller, 2008) .
238 Chapter 8 Schizophrenia Spectrum and Other fYsychotic Disorders
and GABA are widespread in the brain, and defi- E. Fuller Torrey and Robert Yolken (1998) argue
ciencies could contribute to cognitive and emotional that the link between urban living and psychosis is
symptoms. Glutamate neurons are the major ex- due not to stress but to overcrowding, which in-
citatory pathways linking the cortex, limbic sys- creases the risk that a pregnant woman or a new-
tem, and thalamus, regions of the brain shown to born will be exposed to infectious agents. Many
behave abnormally in people with schizophrenia. studies have shown that the rates of many infec-
Drugs, such as PCP and ketamine, that block glu- tious diseases-including influenza, tuberculosis,
tamate receptors cause hallucinations and delu- respiratory infections, herpes, and measles-are
sions in otherwise healthy individuals (Tiihonen higher in crowded urban areas than in less crowded
& Wahlbeck, 2006). areas. As noted earlier, there is a link between pre-
natal or perinatal exposure to infectious disease
and schizophrenia.
PSYCHOSOCIAL
PERSPECTIVES Stress and Relapse
Although schizophrenia is strongly linked to bio-
While stressful circumstances may not cause some-
logical factors, social factors can influence its on-
one to develop schizophrenia, they may trigger
set, course, and outcome.
new episodes in people with the disorder. Re-
searchers found higher levels of stress occurring
Social Drift and Urban Birth shortly before the onset of a new episode com-
People with schizophrenia are more likely than pared to other times in the lives of people with
people without schizophrenia to experience chron- schizophrenia (Norman & Malla, 1993). For exam-
ically stressful circumstances, such as living in ple, in one study, researchers followed a group of
impoverished inner-city neighborhoods and hav- people with schizophrenia for 1 year, interviewing
ing low-status occupations or being unemployed them every 2 weeks to determine whether they
(Dohrenwend, 2000). Most research supports a had experienced any stressful events and/ or any
social drift explanation for this link: Because increase in their symptoms. Those who experi-
schizophrenia symptoms interfere with a person's enced relapses of psychosis were more likely than
ability to complete an education and hold a job, those who did not to have experienced negative life
people with schizophrenia tend to drift down- events in the month before their relapse (Ventura,
ward in social class compared to the class of their Neuchterlein, Lukoff, & Hardesty, 1989).
family of origin. One major stressor linked to an increased risk
A classic study showing social drift tracked for episodes in schizophrenia is immigration. Re-
the socioeconomic status of men with schizophre- cent immigrants often have left behind extended
nia and compared it to the status of their brothers networks of family and friends to move to a new
and fathers (Goldberg & Morrison, 1963). The men country where they may know few people. They
with schizophrenia tended to end up in socioeco- may face financial stress, particularly if the educa-
nomic classes well below those of their fathers . In tion they received in their native country isn't rec-
contrast, the healthy brothers of the men with ognized in their new country. They may not know
schizophrenia tended to end up in socioeconomic the language of their new country and may not be
classes equal to or higher than those of their comfortable in the new culture. Studies in the
fathers. More recent data also support the social United States and Britain have found that first-
drift theory (Dohrenwend, 2000). and second-generation immigrants have a higher
Several studies also have shown that people incidence of acute schizophrenia symptoms than
with schizophrenia and other forms of psychosis individuals from their ethnic group who have
are more likely to have been born in a large city been in the country longer or individuals native to
than in a small town (Kendler, Gallagher, Abelson, the country (Cantor-Graae & Selten, 2005; Coid
& Kessler, 1996; Lewis, David, Andreasson, & et al., 2008; Kirkbride et al., 2006).
Allebeck, 1992; Takei, Sham, O'Callaghan, & Mur- It is important not to overstate the link between
ray, 1992; Takei et al., 1995; Torrey, Bowler, & Clark, stressful life events and new episodes of schizo-
1997; van Os, Hanssen, Bijl, & Vollebergh, 2001). phrenia. In the study that followed people with
For example, studies in the United States find that schizophrenia for a year, more than half the partici-
people with psychotic disorders are as much as pants who had a relapse of active psychotic symp-
five times more likely to have been born and raised toms in the year they were followed had not
in a large metropolitan area than in a rural area. experienced a negative life event just before their
Does the stress of the city lead to psychosis? relapse (Ventura et al., 1989). In addition, other
Psychosocial Perspectives 239
studies suggest that many of the life events that A number of studies have shown that people with
people with schizophrenia experience prior to re- schizophrenia whose families are high in ex-
lapse actually may be caused by prodromal symp- pressed emotion are more likely to suffer relapses
toms that occur just before their relapse into of psychosis than are those whose families are
psychosis (Dohrenwend et al., 1987). For example, low in expressed emotion (e.g., Hooley, 2007).
one prodromal symptom of psychosis relapse is so- More recently, a longitudinal study of individuals
cial withdrawal. Those negative life events that at high risk for schizophrenia found that those liv-
most often precede a relapse, such as the breakup ing in a family characterized by low warmth and
of a relationship or the loss of a job, might be caused high criticism (components of high expressed
partially by the person's social withdrawal. emotion) were more likely to develop the full syn-
drome of schizophrenia than were those living in a
family with greater warmth and less criticism
Schizophrenia and the Family (Schlosser et al., 2010). Being in a family with high
Historically, theorists blamed schizophrenia on expressed emotion may create stresses for persons
mothers. Early psychodynamic theorists suggested with schizophrenia that overwhelm their ability to
that schizophrenia results when mothers are at the cope and thus trigger first or new episodes of psy-
same time overprotective and rejecting of their chosis.
children (Fromm-Reichmann, 1948). These schizo- The link between high levels of family ex-
phrenogenic (schizophrenia-causing) mothers dom- pressed emotion and higher relapse rates has been
inated their children, not letting them develop an replicated in studies of several cultures, including
autonomous sense of self and simultaneously those of Europe, the United States, Mexico, and
making the children feel worthless and unlovable. India. In Mexico and India, however, families of
Similarly, Gregory Bateson and his colleagues people with schizophrenia tend to score lower on
(1956) argued that parents (particularly mothers) of measures of expressed emotion than do their coun-
children who develop schizophrenia put their chil- terparts in Europe or the United States (Figure 8.6;
dren in a double bind by constantly communicat- Karno & Jenkins, 1993; Karno et al., 1987). The
ing conflicting messages to their children. Such a lower levels of expressed emotion in families in
mother might physically comfort her child when developing countries may help explain the lower
he falls down and is hurt but, at the same time, be relapse rates of people with schizophrenia in these
verbally hostile to and critical of the child. Children countries.
chronically exposed to such mixed messages sup- Critics of the literature on expressed emotion ar-
posedly cannot trust their feelings or their percep- gue that the hostility and intrusiveness observed in
tions of the world and thus develop distorted views some families of people with schizophrenia might be
of themselves, of others, and of their environment the result of the symptoms exhibited by the person
that contribute to schizophrenia. These theories with schizophrenia rather than contributors to re-
did not hold up to scientific scrutiny, but they lapse (Parker, Johnston, & Hayward, 1988). Although
heaped guilt on the family members of people with families often are forgiving of the positive symptoms
schizophrenia. of schizophrenia (e.g., hallucinations, delusions) be-
One factor in family interaction that research cause they view them as uncontrollable, they can be
shows is associated with multiple episodes of unforgiving of the negative symptoms (e.g., lack of
schizophrenia is expressed emotion. Families high motivation, blunted affect), viewing them as control-
in expressed emotion are overinvolved with one lable by the person with schizophrenia (Hooley &
another, are overprotective of the family member Campbell, 2002). People with more of the negative
with schizophrenia, and voice self-sacrificing atti- symptoms may elicit more expressed emotion from
tudes toward the family member while at the same their families. They also may be especially prone to
time being critical, hostile, and resentful toward relapse, but for reasons other than exposure to ex-
him or her (Hooley, 2007). Although these family pressed emotion.
members do not doubt their loved one's illness, Family members who rate particularly high on
they talk as if the ill family member can control his expressed emotion are themselves more likely to
or her symptoms (Hooley & Campbell, 2002). They have some form of psychopathology (Goldstein,
often have ideas about how the family member Talovic, Nuechterlein, & Fogelson, 1992). Thus,
can improve his or her symptoms or functioning. people with schizophrenia in these families may
Expressed emotion has been assessed through have high rates of relapse because they have a
lengthy interviews with people with schizophre- greater genetic loading for psychopathology, rather
nia and their families, through projective tests, and than because their family members show high lev-
through direct observation of family interactions. els of expressed emotion. Perhaps the best evidence
to explain strange perceptual experiences. Halluci-

Cultural Differences in
FIGURE 8.6
the Prevalence of
nations result from a hypersensitivity to percep-
Expressed Emotion in
tual input, coupled with a tendency to attribute
Families of People with Schizophrenia.
experiences to external sources. Rather than think-
Fam ilies of people with schizophrenia from
ing ''I'm hearing things/' the person with schizo-
phrenia will think "Someone is trying to talk to
developing countries tend to show lower
levels of expressed emotion than do families
me." The negative symptoms of schizophrenia
of people with schizophrenia from developed
arise from expectations that social interactions will
countries. This may be one reason why
be aversive and from the need to withdraw and
people with schizophrenia from developing
conserve scarce cognitive resources.
countries have fewer relapses than do those
This cognitive conceptualization has led to cog-
from developed countries.
nitive treatments for people with schizophrenia.
Cognitive therapies help patients identify and cope
with stressful circumstances associated with the
80
development and worsening of symptoms. They
also teach patients to dispute their delusional be-
70 67 - liefs or hallucinatory experiences. Negative symp-
c:
.....--
0 toms are treated by helping patients develop the
:;:;
0 60 - expectation that being more active and interacting
E
Q)
-a more with other people will have positive benefits.

:;:
Vl
50 48 - - This cognitive intervention has shown greater suc-
~
c. r--- cess in reducing symptoms than does simply pro-
X
Q)
..c:
41 viding patients with support (Beck & Rector, 2005) .
0>
:E
40 f--- f-
..c:
.....
"';: Cross-Cultural Perspectives
Vl
Q)
30 ,------ f--- f-
:::;
" 23 Different cultures vary greatly in how they explain
~ r--- schizophrenia (Anders, 2003; Karno & Jenkins, 1993).
....
0
20 t- t--- t--- 1---- ~
.....c: Most have a biological explanation for the disorder,
Q)
:= including the general idea that it runs in families.
Q)
0.. 10 t- t--- t--- 1--- f- Intermingled with biological explanations are theo-
ries that attribute the disorder to stress, lack of spir-
0 itual piety, and family dynamics. Kevin Browne
Indian Mexican British European
American (2001) offers a case study of a woman from Java,
whose understanding of her schizophrenia symp-
toms included all these factors .
Source: Karno & Jenki ns, 1993.
that family expressed emotion does in fact influ-

Anik is a 29-year-old
ence relapse in people with schizophrenia is that Javanese woman who was born in a rural area
interventions to reduce family expressed emotion but has lived in the city of Yogyakarta for the past
tend to reduce the relapse rate in family members 4 years . She has been married 1% years but is
with schizophrenia (Hooley, 2007). very unhappy in her marriage, feeling her hus-
band is lacking in openness and compassion .
Cognitive Perspectives Anik has been unable to care for her 8-month-old
Aaron Beck and Neil Rector (Beck & Rector, 2005) daughter for the past several months, so the
suggest that fundamental difficulties in attention, daughter was living with Anik's aunt in Jakarta.
inhibition, and adherence to the rules of communi- When her illness began, Anik first became with-
cation lead people with schizophrenia to try to drawn and didn't sleep or eat. She developed
conserve their limited cognitive resources. One hallucinations of accusatory voices criticizing her
way they do this is by using certain biases or think- husband, his family, and their landlady. Anik also
suffered from jealous delusions that her hus-
ing styles for understanding the overwhelming
band was having an affair. She was taken to the
information streaming through their brain. Delu-
sions arise as the person with schizophrenia tries
Treatment 241
hospital by her brother, where her symptoms in-
cluded mondar-mandir ("wandering without pur- Over the centuries, many treatments for schizophre-
pose"), ngamuk ("being irritable"), being easily nia have been developed, based on the scientific
offended and suspicious, talking to herself, cry- theories of the time (Valenstein, 1998). Physicians
ing, insomnia, malmun ("daydreaming"), and have performed brain surgery on people with
quickly changing emotions. Her sister-in-law re- schizophrenia in an attempt to "fix" or eliminate the
ported that she had been chronically fearful and part of the brain causing hallucinations or delusions.
irritable for some time and would frequently These patients sometimes were calmer after their
slam doors and yell. In Javanese culture, the surgeries, but they often also experienced signifi-
control of emotions in social situations is of great cant cognitive and emotional deficits as a result of
importance, so Anik's outbursts were seen as the surgery. Insulin coma therapy was used in the
clear signs of some sort of pathology. 1930s to treat schizophrenia. People with schizo-
Anik had several explanations for her behav- phrenia would be given massive doses of insulin-
ior. First and foremost, she believed that she was the drug used to treat diabetes-until they went
in a bad marriage, and this stress was a contrib- into a coma. When they emerged from the coma,
uting factor. Shortly before her symptoms be- however, patients rarely were much better, and the
gan, her landlady said something harsh to her, procedure was very dangerous (Valenstein, 1998).
and Anik believed that her startle reaction to this Electroconvulsive therapy, or ECT, was also used to
(goncangan) led to sajithati, literally "liver sick- treat schizophrenia until it became clear that it had
ness:' In addition, Anik's mother had a brief pe- little effect (although it is effective in treating seri-
riod during Anik's childhood when she "went ous depression alone, or in schizophrenia as dis-
crazy;' becoming loud and violent, and Anik be- cussed in Chapter 7).
lieves she may have inherited this tendency from Mostly, however, people with schizophrenia
her mother. Anik initially sought to overcome her were simply warehoused. In 1955, one out of every
symptoms by increasing the frequency with two people housed in psychiatric hospitals had been
which she repeated Muslim prayers and asking diagnosed with schizophrenia, although by today's
to be taken to a Muslim boarding house. Once standards of diagnosis some may actually have had
she was taken to the hospital, she agreed to take different disorders (Rosenstein, Milazzo-Sayre, &
antipsychotic medications, which helped her Manderscheid, 1989). These patients received custo-
symptoms somewhat. She was discharged from dial care-they were bathed, fed, and prevented
the hospital after a short time but was rehospital - from hurting themselves, often with the use of
ized multiple times over the next year. physical restraints- but few received any treat-
ment that actually reduced their symptoms and im-
proved their functioning. Not until the 1950s was
an effective drug treatment for schizophrenia-
chlorpromazine-introduced. Since then, several
Anik's experience illustrates the interweav-
other antipsychotic drugs (also called neuroleptics)
ing in people with schizophrenia symptoms of
have been added to the arsenal of treatments for
traditional beliefs and practices and modern
schizophrenia. More recently, the atypical antipsy-
biological treatments. Although she agreed to
chotics hold out the promise of relieving positive
take antipsychotic medications, the understand-
ing she and her family had of her symptoms was symptoms while inducing fewer intolerable side ef-
fects than the traditional or typical antipsychotics.
not primarily a biological one but rather one
rooted in concerns about stress and, to some
extent, religion. Typical Antipsychotic Drugs
In the early 1950s, French researchers Jean Delay
and Pierre Deniker found that chlorpromazine
TREATMENT (Thorazine), one of a class of drugs called the
phenothiazines, calms agitation and reduces hal-
Comprehensive treatment for people with schizo- lucinations and delusions in patients with schizo-
phrenia includes medications to help reduce psy- phrenia (Valenstein, 1998). Other phenothiazines
chotic symptoms, therapy to help people cope that became widely used include trifluoperazine
with the consequences of the disorder, and social (Stelazine), thioridazine (Mellaril), fluphenazine
services to support community integration and to (Prolixin), and perphenazine (Trilafon). These drugs
ensure their access to the resources they need to appear to block receptors for dopamine, thereby re-
participate in daily life. ducing its action in the brain. For the first time,
many people with schizophrenia could control the movements over and over again. Tardive dyskine- ~
positive symptoms of the disorder (hallucinations, sia often is irreversible and may occur in over
delusions, thought disturbances) by taking these 20 percent of persons with long-term use of the
drugs even when they were asymptomatic. phenothiazines (Kutscher, 2008).
Thanks to these drugs, by 1971 the number of The side effects of the neuroleptics can be re-
people with schizophrenia who required hospital- duced by lowering dosages. For this reason, many
ization had decreased to half of what would have clinicians prescribe for people with schizophrenia
been expected without the use of the drugs the lowest dosage possible that still keeps active
(Lavretsky, 2008). Other classes of antipsychotic symptoms at bay, known as a maintenance dose.
drugs introduced after the phenothiazines include Unfortunately, maintenance doses often do not re-
the butyrophenones (such as Haldol) and the thio- store an individual to full functioning (Kutscher,
xanthenes (such as Navane). 2008). The negative symptoms of schizophrenia
Although the typical antipsychotic drugs rev- may still be strongly present, along with mild ver-
olutionized the treatment of schizophrenia, about sions of the positive symptoms, making it hard for
25 percent of people with schizophrenia do notre- the individual to function in daily life. Some peo-
spond to them (Adams, Awad, Rathbone, & Thornley, ple with schizophrenia have frequent hospitaliza-
2007) . Among people who do respond, the typical tions and ongoing difficulties outside the hospital.
antipsychotics are more effective in treating the
positive symptoms of schizophrenia than in treat- Atypical Antipsychotics
ing the negative symptoms (lack of motivation and Fortunately, newer drugs, the atypical antipsy-
interpersonal deficits). Many people with schizo- chotics, seem to be more effective in treating
phrenia who take these drugs are not actively psy- schizophrenia than the neuroleptics, without the
chotic but still are unable to hold a job or build neurological side effects of the latter (Sharif, Raza,
positive social relationships. People with schizo- & Ratakonda, 2000; Walker et al., 2009). One of the
phrenia typically must take an antipsychotic drug most common of these drugs, clozapine (sold in the
all the time in order to prevent new episodes of United States as Clozaril), binds to the D4 dopa-
active symptoms. If the drug is discontinued, about mine receptor, but it also influences several other
78 percent of people with schizophrenia relapse neurotransmitters, including serotonin (Sajotovic
within 1 year and 98 percent relapse within 2 years, et al., 2008). Clozapine has helped many people
compared to about 30 percent of people who con- with schizophrenia who never responded to the
tinue on their medications (Gitlin et al., 2001). phenothiazines, and it appears to reduce the nega-
Unfortunately, however, these drugs have sig- tive symptoms as well as the positive symptoms in
nificant side effects that cause many people to want many patients (Sharif et al., 2007).
to discontinue their use (Adams et al., 2007). The While clozapine does not induce tardive dys-
side effects include grogginess, dry mouth, blurred kinesia, it does have some side effects, including
vision, drooling, sexual dysfunction, visual distur- dizziness, nausea, sedation, seizures, hypersaliva-
bances, weight gain or loss, constipation, menstrual tion, weight gain, and tachycardia. In addition, in
irregularities in women, and depression. Another 1 to 2 percent of the people who take clozapine, a
common side effect is akinesia, which includes condition called agranulocytosis develops (Sharif
slowed motor activity, monotonous speech, and an et al., 2007). This is a deficiency of granulocytes,
expressionless face. Patients taking the phenothi- substances produced by bone marrow that fight
azines often show symptoms similar to those seen infection. The condition can be fatal, so patients
in Parkinson's disease, including muscle stiffness, taking clozapine must be carefully monitored. Due
freezing of the facial muscles, tremors and spasms to these side effects, clozapine often is used only
in the extremities, and akathesis, an agitation that after other atypical antipsychotics have been tried.
causes people to pace and be unable to sit still A number of other atypical antipsychotics
(Adams et al., 2007). The fact that Parkinson's dis- have been introduced over the past two decades,
ease is caused by a lack of dopamine in the brain including risperidone (trade name Risperdal),
suggests that these side effects occur because the olanzapine (Zyprexa), and ziprasidone (Geodone,
drugs reduce the functional levels of dopamine. Zeldox). These drugs do not tend to induce agran-
One serious side effect is tardive dyskinesia, a ulocytosis, but they can cause a number of side ef-
neurological disorder that involves involuntary fects, including significant weight gain and ~
movements of the tongue, face, mouth, or jaw. Peo- increased risk for diabetes, as well as sexual dys-
ple with this disorder may involuntarily smack function, sedation, low blood pressure, seizures,
their lips, make sucking sounds, stick out their gastrointestinal problems, vision problems, and
tongue, puff their cheeks, or make other bizarre problems with concentration.
Treatment 243
A randomized clinical trial conducted by the help people with schizophrenia and their families
National Institute of Mental Health in several sites reduce the stress and conflict in their lives,
across the United States compared the effective- thereby reducing the risk of relapse into psycho-
ness of five of these drugs (quetiapine, perphen- sis (Pharoah, Mari, Rathbone, & Wong, 2006) . In
azine, risperidone, olanzapine, and ziprasidone) in addition, the lack of effectiveness of the antipsy-
over 1,000 patients with schizophrenia (Levine chotic drugs suggested by the studies reviewed in
et al., 2011). The focus of the trial was how many the preceding section is due in part to people dis-
patients would show remission of symptoms over continuing the drugs either because they do not
an 18-month follow-up period. Unfortunately, only think they need them or because they find the side
44.5 percent of the patients experienced remission effects intolerable (Barkhof et al., 2012). Psychologi-
of any duration during this period, 21.0 per- cal interventions can help people with schizophre-
cent showed remission for at least 3 months, and nia understand their disorder, appreciate the need
only 11.7 percent showed remission for at least to remain on their medications, and cope more
6 months. Among the five medications, 6-month effectively with the side effects of the medications.
remission rates were highest (12.4 percent) for the Because of the severity of their disorder, many peo-
olanzapine treatment group, followed by quetiap- ple with schizophrenia have trouble finding or
ine (8.2 percent), perphenazine (6.8 percent), zipra- holding a job, feeding and sheltering themselves,
sidone (6.5 percent), and risperidone (6.3 percent). and obtaining necessary medical or psychiatric
Clearly, much more work is needed to find safe care. Psychologists, social workers, and other men-
and effective drug treatments for schizophrenia. tal health professionals can assist people with
schizophrenia in meeting these basic needs.
Psychological and Social Behavioral, Cognitive, and Social
Treatments Treatments
Even when antipsychotic medications do help re- Most experts in the treatment of schizophrenia ar-
duce the psychotic symptoms of schizophrenia, gue for a comprehensive approach that addresses
they often do not completely restore the life of a the wide array of behavioral, cognitive, and social
person with schizophrenia, as the following profile deficits in schizophrenia and is tailored to the spe-
illustrates. cific deficits of each individual with the disorder
(Liberman, 2008; Mueser et al., 2013). These treat-
ments are given in addition to medication and can
increase patients' level of everyday functioning and
significantly reduce the risk of relapse (see review by
PROFILES Barkhof et al., 2012).
Cognitive treatments include helping people
Medicine did not cause sanity; it only made it with schizophrenia recognize and change demoral-
possible . Sanity came through a minute-by- izing attitudes they may have toward their illness
minute choice of outer reality, which was often so that they will seek help when needed and par-
without meaning, over inside reality, which was ticipate in society to the extent that they can (Beck
full of meaning . Sanity meant choosing reality & Rector, 2005) . Behavioral treatments, based on
that was not real and having faith that someday social learning theory (see Chapter 2), include the
the choice would be worth the fear involved and use of operant conditioning and modeling to teach
that it would someday hold meaning. (Anonymous, persons with schizophrenia skills such as initiating
1992, p. 335) and maintaining conversations with others, asking
for help or information from physicians, and per-
sisting in an activity, such as cooking or cleaning
(Liberman, 2008). These interventions may be ad-
ministered by the family. In that case, a therapist
Many individuals who are able to control the would teach a client's family members to ignore
positive symptoms of schizophrenia with drugs schizophrenia symptoms, such as bizarre com-
still experience many of the negative symptoms, ments, and instead reinforce socially appropriate
particularly problems in motivation and in social behavior by giving it attention and positive emo-
interactions. Psychological interventions can help tional responses. In psychiatric hospitals and resi-
these individuals increase their social skills andre- dential treatment centers, token economies
duce their isolation and apathy (Bustillo, Lauriello, sometimes are established, based on the principles
Horan, & Keith, 2001). Such interventions also can of operant conditioning. Patients earn tokens that
they can exchange for special privileges (such as therapy alone. On average, approximately 24 per-
additional outings beyond what is ordinarily pro- cent of people who receive family-oriented ther-
vided) by completing daily self-care tasks (such as apy in addition to drug therapy relapse into
showering or changing clothing) or even by simply schizophrenia, compared to 64 percent of people
engaging in appropriate conversations with others. who receive routine drug therapy alone (Bustillo
Social interventions include increasing contact et al., 2001; Pitschel-Walz et al., 2001). Family-
between people with schizophrenia and support- based therapies also can increase patients' adher-
ive others, often through self-help support groups ence to taking antipsychotic medications. For
(Liberman, 2008) . These groups discuss the impact example, Guo and colleagues (2010) randomly as-
of the disorder on their lives, the frustration of try- signed 1,268 patients with early-stage schizophre-
ing to make people understand their disorder, nia to receive antipsychotic medication alone or
their fear of relapse, their experiences with various medication plus family therapy, which included
medications, and other day-to-day concerns. Group skills training and cognitive-behavioral interven-
members also can help one another learn social tions. Over the year the patients were followed,
and problem-solving skills by giving feedback and 33 percent of the patients receiving family-based
providing a forum in which individual members intervention discontinued their medications, com-
can role-play new skills. People with schizophre- pared to 47 percent of the patients receiving medi-
nia also are often directly taught problem-solving cation alone. The patients receiving family-based
skills applicable to common social situations. For intervention also experienced less relapse of symp-
example, they may practice generating and role- toms and greater improvement in social function-
playing solutions for when a receptionist tells ing and quality of life than those who received
them no one is available at a company to interview medication alone.
them for a potential job. People with schizophrenia are more likely to
be cared for by their family and to be deeply em-
Family Therapy bedded in it in some cultures than in others. Family-
Recall that high levels of expressed emotion within oriented interventions may be even more critical
the family of a person with schizophrenia can sub- for people in these cultures (Lopez, Kopelowicz, &
stantially increase the risk and frequency of relapse. Canive, 2002). The interventions must be culturally
Many researchers have examined the effectiveness sensitive. One study found that behavior therapies
of family-oriented therapies for people with schizo- to increase communication actually backfired in
phrenia. Successful therapies combine basic educa- some Hispanic families, perhaps because these
tion on schizophrenia with the training of family families already had low levels of expressed emo-
members in coping with their loved one's inappro- tion and found the techniques suggested by the
priate behaviors and the disorder's impact on their therapists to violate their cultural norms for how
lives (Hogarty et al., 1991; see review by Barkhof family members should interact (Telles et al., 1995).
et al., 2012). For example, some of the most traditional family
In the educational portion of these therapies, members in this study expressed great discomfort
families are taught about the disorder's biological during exercises that encouraged them to establish
causes, its symptoms, and the medications and eye contact or express negative feelings to author-
their side effects. The hope is that this information ity figures, because these actions were considered
will reduce self-blame in family members, increase disrespectful. As with other disorders, therapists
their tolerance for the uncontrollable symptoms of must take into account the culture of their clients in
the disorder, and allow them to monitor their fam- designing interventions.
ily member 's use of medication and possible side
effects. Family members also learn communication Assertive Community Treatment
skills to reduce harsh, conflictual interactions, as Programs
well as problem-solving skills to help manage is- Some people with schizophrenia lack families to
sues in the family such as lack of money, in order care for them. Even those with families have such a
to reduce the overall level of stress in the family. wide array of needs-for the monitoring and adjust-
They also learn specific behavioral techniques for ment of their medications, occupational training,
encouraging appropriate behavior and discourag- assistance in receiving financial resources (such as
ing inappropriate behavior on the part of their Social Security and Medicaid), social skills training,
family member with schizophrenia. emotional support, and sometimes basic housing-
These family-oriented interventions, when that comprehensive community-based treatment
combined with drug therapy, appear to be more programs are necessary. Assertive community treat-
effective at reducing relapse rates than drug ment programs provide comprehensive services
Treatment 245
for people with schizophrenia, relying on the exper- followed for another 28 months. Their progress
tise of medical professionals, social workers, and was compared with that of another group of pa-
psychologists to meet the variety of patients' needs tients, who received standard hospital treatment
24 hours a day (Bustillo, Lauriello, Horan, & Keith, for their positive symptoms. Both groups were
2012). treated with antipsychotic medications. The pa-
In Chapter 1, we discussed the community tients who received the home-based intensive skills
mental health movement, which was initiated by interventions were less likely than the control-
President Kennedy in the 1960s to transfer the care group patients to be hospitalized and more likely
of people with serious mental disorders from pri- to be employed both during the treatment and in
marily psychiatric hospitals to comprehensive the 28 months of follow-up (Figure 8.7). The home-
community-based programs. The idea was that based intervention group also showed lower levels
people with schizophrenia and other serious disor- of emotional distress and of positive symptoms
ders would spend time in the hospital when severe during the intervention than did the control group.
symptoms required it but when discharged from The difference in levels of symptoms between the
the hospital would go to community-based pro- two groups diminished after the intervention pe-
grams, which would help them reintegrate into riod ended. In general, the gains that people in
society, maintain their medications, gain needed skills-based interventions make tend to decline
skills, and function at their highest possible level. once the interventions end, suggesting that these
Hundreds of halfway houses, group homes, and interventions need to be ongoing. However, their
therapeutic communities were established for peo- benefits can be great. Since the original tests of
ple with serious mental disorders who needed a assertive community treatment, dozens of addi-
supportive place to live. tional randomized clinical trials have supported
One classic example of such programs was The
Lodge, a residential treatment center for people with
schizophrenia established by George Fairweather Effects of Home-Based Treatment on Need
and his colleagues (1969). At The Lodge, mental FIGURE 8.7
for Institutional Care. In one study, patients
health professionals were available for support and with schizophrenia who received intensive
assistance, but residents ran the household and home-based skills training and care were much less likely to be
worked with other residents to establish healthy be- hospitalized for psychotic symptoms or to need other types of
haviors and discourage inappropriate behaviors. institutional care .
The residents also established their own employ-
ment agency to assist with finding jobs. Follow-up 30 ,-------------------------------------------------
studies showed that Lodge residents fared much - Intervention group
better than people with schizophrenia who were - Control group
simply discharged from the hospital into the care of 25
their families or into less intensive treatment pro-
~
grams (Fairweather et al., 1969). For example, Lodge "'u
residents were less likely to be rehospitalized and ~ 20
0
much more likely to hold a job than were those in a .p
....,::l
comparison group, even after The Lodge closed. -~
Other comprehensive treatment programs pro- .;: 15

vide skills training, vocational rehabilitation, and "'
c
'6
Q)
social support to people with schizophrenia who Q)

c
live at home. Studies of these programs find that ~

Q)
10
i:'
they reduce the amount of time spent in the hospi- 8:.
tal and, as a result, can be cost-effective (Bustillo
et al., 2001). 5
A program known as assertive community ther-
apy has become the gold standard for community-
based interventions (Test & Stein, 1980). The model 0
4 8 12 16 20 24 28
program of this type of therapy was first established Months
in a study done in Madison, Wisconsin. Mental
During treatment After treatment
health professionals worked with chronically dis-
abled people with schizophrenia. Interventions
were provided in the homes or communities of the Source: Test & Stein, 1980.
patients for 14 months, and then the patients were
Cross-Cultural Treatments: Traditional
Healers
In developing countries and in parts of industrial-
ized countries, the symptoms of schizophrenia
sometimes are treated by folk or religious healers,
according to cultural beliefs about the meaning and
causes of the symptoms. Anthropologists and cul-
tural psychiatrists have described four models that
traditional healers tend to follow in treating schizo-
phrenic symptoms (Karno & Jenkins, 1993). Accord-
ing to the structural model, there are interrelated
levels of experience-such as the body, emotion, and
cognition or the person, society, and culture-and
Some modern treatment facilities provide people with schizophrenia with symptoms arise when the integration of these levels
comprehensive services in a positive. pleasant setting. is lost. Healing thus involves reintegrating these lev-
els through a change of diet or environment, the pre-
scription of herbal medicines, or rituals.
The social support model holds that symptoms
the effectiveness of this type of treatment over most arise from conflictual social relationships, and
types of controls (Catty et aL, 2002; Williams et aL, healing involves mobilizing a patient's kin to sup-
2011). port him or her through the crisis and reintegrat-
Although 38 states in the United States have ad- ing the patient into a positive social support
opted assertive community treatment as the gold network. The persuasive model suggests that rituals
standard for care for people with schizophrenia and can transform the meaning of symptoms for pa-
other serious mental disorders, only 2 percent of in- tients, diminishing their pain. Finally, in the clinical
dividuals with these disorders are currently being model, the faith the patient has in the traditional
served by such programs (Padgett & Henwood, healer to provide a cure for the symptoms is suffi-
2011). Unfortunately, the community mental health cient. In developing countries, care for people with
movement was never funded at a level that could schizophrenia is more likely to be carried out by
support its lofty goals. With the changes in medical the extended family than by a mental health insti-
insurance in recent years, funding for mental health tution (Karno & Jenkins, 1993). Thus, it may bees-
care for the seriously mentally ill has been even pecially important in these countries that
tighter. Although billions of dollars are spent on interventions for a person with schizophrenia also
mental health care each year in the United States, include his or her family.
much of that money goes not to direct services to
people with schizophrenia but rather to subsistence
programs such as Social Security disability pay- CHAPTER INTEGRATION
ments and to community services for people with There is probably more consensus among mental
less serious mental disorders (Torrey, 2006). Much health professionals about the biological roots of
of the financial burden of caring for people with schizophrenia than of any other psychopathology
schizophrenia falls to state and local governments, discussed in this book. The evidence that the fun-
which lack the necessary resources, or to families, damental vulnerability to schizophrenia is biologi-
who too often are bankrupted by the cost of care. cal is compelling, yet there is growing consensus
As a result, 40 to 60 percent of people with that psychosocial factors also contribute to the risk
schizophrenia receive little or no care in a given for schizophrenia among people who have a bio-
year (Torrey, 2006). Those who do receive care of- logical vulnerability. Theorists are increasingly de-
ten are hospitalized only when their symptoms are veloping models that integrate the biological and
acute, and they remain in the hospital for an inad- psychosocial contributors to schizophrenia in or-
equate period of time to allow their symptoms to der to provide comprehensive explanations of the
stabilize. They may be discharged with little or no development of this disorder (Figure 8.8; Cannon,
follow-up. Some return to their families, but many 2009; Fatemi & Folsom, 2009).
end up in nursing homes, where they receive only Genetic factors clearly play a role in vulnera-
custodial care, or in single-room-occupancy hotels bility to schizophrenia. Environmental factors early
or rooming houses, often in run-down inner-city in a person's life, such as exposure to toxins or to
neighborhoods. Many end up homeless or in viruses in utero or hypoxia during childbirth, can
prison (Torrey, 2006). interact with a genetic liability stemming from
246
FIGURE 8.8 The Interaction of Biological and Psychosocial Factors in Schizophrenia
Genetic and neurological

vulnerability to
schizophrenia Supportive family,
Family and
1
environmental stress low exposure to stress
Little evidence
Qf disorder
More stress, in part New episodes triggered

due to symptoms
Comprehensive biological Inadequate treatment

and psychosocial treatment
Reduction in symptoms, .__ _...,..__ _ _ _,.., Continuation of symptoms

more positive prognosis
epigenetic processes to increase the person's vul- vulnerability and grows up in a stressful atmo-
nerability to developing schizophrenia. If a person sphere is more likely to develop the full syndrome
with this biological vulnerability to schizophrenia of schizophrenia. Psychosocial stress also clearly
is raised in a supportive, low-expressed-emotion contributes to new episodes of psychosis in people
family and escapes exposure to major stressors, he with this disorder.
or she may never develop the full syndrome of There is widespread consensus among mental
schizophrenia. The person still may have mild health professionals that the most effective thera-
symptoms, however, because the biological under- pies for schizophrenia are those that address both
pinnings of this disorder play such an important the biological and the psychosocial contributors to
role. Alternatively, a person who has a biological the disorder.
As you may have noticed, Jeff's symptoms do not isolated and apathetic, he stopped taking the med-
fit neatly into any of the categories in the DSM-5. ications. Two months later, he said he was experi-
You might wonder if he is depressed, because he encing severe electrical sensations in his head that
reports feelings of emptiness. But because he he believed were being transmitted through his
does not show most of the other symptoms of de- father's mind. He also began to have "horrible
pression (see Chapter 7), this is not an appropriate thoughts" that were put there by his father. He be-
diagnosis. His emptiness, social isolation, lack of came agitated and one night grabbed a knife, went
motivation, and general deterioration in function- into his parents' bedroom, and threatened to kill
ing all look like negative symptoms of schizophre- his father if he would not stop tormenting him.
nia. However, he does not appear to have the Fortunately, his father was able to talk him into
positive symptoms-delusions, hallucinations, or dropping the knife and going to the emergency
incoherence in speech or thought. room.
The psychiatrist treating Jeff believed that he Jeff was admitted to the hospital, given a di-
was showing prodromal or early symptoms of agnosis of schizophrenia, and placed on a higher
schizophrenia, which often are predominantly neg- dose of antipsychotic medications. His positive
ative. He was given antipsychotic medications and symptoms diminished, but his negative symp-
allowed to go home with his parents. Remaining toms remained. (Adapted from Andreasen, 1998)
THINK CRITICALLY ~
In their book Divided Minds, identical twins Carolyn schizophrenia. Carolyn went on to graduate from
Spiro and Pamela Spiro Wagner describe a close Brown and then from Harvard Medical School. She
childhood relationship, apart from typical sibling ri- is now a practicing psychiatrist. Pamela lives nearby,
valries. Carolyn often felt she had to prove that she doing her artwork when she can but constantly bat-
was as intelligent and creative as Pamela. As they tling to keep her schizophrenia under control with
entered their teenage years, however, the twins medications and therapy. The twins once again are
grew apart. Pamela's increasingly bizarre behaviors very close emotionally.
became an embarrassment to Carolyn. By the time Given what you have learned about the causes
the twins were college students at Brown University, of schizophrenia, how might you explain why
Pamela was becoming more and more reclusive. Pamela developed schizophrenia but Carolyn did
Eventually, Pamela had a psychotic episode, although not? (Discussion appears on p. 483 at the back of
it was years before she was diagnosed with paranoid this book.)
CHAPTER SUMMARY
There are five domains of symptoms that define Individuals with schizophreniform disorder meet
psychotic disorders. They include positive and the criteria for schizophrenia but for a period of
negative symptoms. only 1 to 6 months. Those with brief psychotic
The positive symptoms of schizophrenia include disorder meet the criteria for schizophrenia but
delusions {fixed beliefs that are held strongly defor a period of less than 1 month and sometimes
spite conflicting evidence), hallucinations {unreal in response to a major stressor. Delusional disor-
perceptual experiences), thought disturbances der is characterized by just one kind of psychotic
{incoherent thought and speech), and grossly symptoms, delusions. Schizotypal personality
disorganized or catatonic behavior. disorder is characterized by a life-long pattern of
severe oddities in thought, behavior, and self-
The negative symptoms of schizophrenia include concept that fall short of psychosis.
restricted affect and avolition {the inabil ity to
initiate and persist in goal-directed activities) or Biological theories of schizophrenia focus on
asociality. Separate prodromal and residual genetics, structural and functional abnormalities
symptoms are mild versions of the positive and in the brain, and neurotransmitters. There is clear
negative symptoms that occur before and after evidence of a genetic transmission of schizophre-
episodes of acute symptoms. nia. People with schizophrenia show abnormal
functioning in the cortical areas of the brain, par-
Cognitive deficits in schizophrenia include ticularly prefrontal areas and the hippocampus,
problems in attention, working memory, proces- as well as enlarged ventricles. Many people with
sing speed, learning and memory, abstraction, schizophrenia have a history of prenatal difficul-
and problem solving. ties, such as exposure to the influenza virus dur-
Estimates of the prevalence of schizophrenia in ing the second trimester of gestation, or birth
various countries range from about 0.1 to 2.0 per- complications, including perinatal hypoxia. Brain
cent, but most estimates are between 0.5 and abnormalities and dysfunction in dopamine sys-
1.0 percent. There are some slight ethnic differ- tems play a role in schizophrenia.
ences in rates of schizophrenia, but these may Stressful events probably cannot cause schizo-
be due to differences in socioeconomic status. phrenia in people who lack a vulnerability to the
The content of delusions and hallucinations disorder, but they may trigger new episodes of
varies somewhat across cultures, but the form of psychosis in people with the disorder.
these symptoms remains similar, and many clini- Expressed emotion theorists argue that some
cians and researchers believe that schizophrenia families of people with schizophrenia are simul-
can be diagnosed reliably across cultures. taneously overprotective and hostile and that
A number of other psychotic disorders are recog- this increases the risk of relapse.
nized by the DSM-5. Schizoaffective disorder is Cognitive theories suggest that some psychotic
diagnosed when symptoms of schizophrenia oc- symptoms are attempts by the individual to un-
cur with periods of major depression or mania. derstand and manage cognitive deficits.
Key Terms 249
Drugs known as the phenothiazines, introduced symptoms and the negative symptoms of schizo-
in the 1950s, brought relief to many people with phrenia for many people. Still, many people
schizophrenia . The phenothiazines reduce the with schizophrenia do not respond or respond
positive symptoms of schizophrenia but often only partially to these drugs.
are not effective in reducing the negative symp- Psychological and social treatments focus on
toms. Major side effects include tardive dyskine- helping people with schizophrenia reduce stress,
sia, an irreversible neurological disorder improve family interactions, learn social skills,
characterized by involuntary movements of the manage their illness, and cope with the impact
tongue, face, mouth, or jaw. of the disorder on their lives. Comprehensive
Atypical anti psychotics, most of which were in- treatment programs combining drug therapy
troduced in the past two decades, seem to in- with an array of psychological and social treat-
duce fewer side effects than the phenothiazines ments have been shown to reduce relapse
and are effective in treating both the positive significantly.
KEY TERMS
psychosis 218 residual symptoms 226
schizophrenia 219 schizoaffective disorder 229
schizophren ia spectrum 219 schizophreniform disorder 229
positive symptoms 219 brief psychotic disorder 230
delusions 219 delusional disorder 231
persecutory delusions 220 schizotypal personality disorder 231
delusion of reference 221 phenothiazines 237
grandiose delusions 221 neuroleptics 237
delusions of thought insertion 221 mesolimbic pathway 237
hallucinations 222 social drift 238
formal thought disorder 223 expressed emotion 239
catatonia 224 chlorpromazine 241
negative symptoms 224 tardive dyskinesia 242
restricted affect 224 atypical antipsychotics 242
avolition 225 assertive community treatment programs 244
prodromal symptoms 226
Personality Disorders
CHAPTER OUTLINE
Personality Disorders Along Shades of Gray

the Continuum
Alternative OSM-5 Model for Personality
Extraordinary People: Susanna Kaysen, Disorders
Girl, Interrupted
Chapter Integration
General Definition of Personality Disorder
Cluster A: Odd-Eccentric Personality
Disorders Think Critically
Cluster B: Dramatic-Emotional Personality Chapter Summary

Disorders Key Terms
Cluster C: Anxious-Fearful Personality
Disorders
250
Long-standing patterns of behavior, Potentially meets diagnostic criteria for
thought, and feeling that lead to a personality disorder:
positive soda! and occupational Long-standing patterns of behavior,
functioning thought. and feeling that somewhat interfere
A student who is interested in classes, with soda! and/or occupa-tional functioning
has good relationships with friends, A student who is often inappropriate with others
can regulate his or her emotions, and or sodally withdrawn, is having significant difficulties
reflects on him- or herself accurately understanding him- or herself or others, andjor
frequently overreacts emotionally or behaviorally
-------
Long-standing patterns of behavior, Likely meets diagnostic criteria for

thought, and feeling that are unusual a personality disorder:
but do not interfere with soda! or Long-standing patterns of behavior,
occupational functioning thought, and feeling that substan-
A student who is awkward ar sometimes tially interfere with soda! andfor
inappropriate with others; struggles with occupational functioning
his or her sense of self self-esteem, or life A student who is chronically
goals; and/or sometimes overreacts inappropriate with others or sadally
emotionally withdrawn; has severe difficulties with
identity, self-esteem, or self-direction;
and/or becomes aut of control
emotionally in distressing situations
Your personality affects your daily life constantly. It determines and maintain good interpersonal relationsh ips. Some people
how you perceive the events of your day, how you feel, and how find it difficult to care about others appropriately, being either
you interact with others. A core aspect of your personality is your too self-sacrificing or too self-absorbed to empathize with others.
sense of self, or identity (Bender et al., 2011 ; Morey et al., 2011 ). Some people have difficulty tolerating differing perspectives and
On the functional end of the personality continuum are people differentiating their own needs and desires from those of others.
who have a sense of self that is relatively stable and is distinct Some may find interpersonal relationships too distressi ng or un-
from others. They have a sense of meaning and purpose in their rewarding and withdraw from other people altogether. When
life and the ability to pursue personally important goa ls that are ind ividuals have significant deficits in their identity and their ca -
socially acceptable. Another core aspect of personality is the way pacity for interpersona l relationships, they may be diagnosed
we relate to others (Bender et al., 2011 ; Morey et al., 2011 ). with a personality disorder.
People with adaptive personalities can empathize and cooperate We've noted throughout this book that drawing a line be-
with others, can be intimate with others appropriately, and ap- tween normal and abnormal , between functional and dysfunc-
preciate the uniqueness of the different people in their life. tional, is problematic for all the mental disorders. Personality
Some people have difficulty in their sense of self and i n their disorders have presented especially great challenges in defining
relationships to others. Their identity may be diffuse and their where unhealthy functioning that constitutes a disorder begins.
self-esteem unstable, prone to deflation by mild slights or infla- The DSM-5 includes two models of personality disorders. Its cur-
tion by simple compliments. They may wander through life with- rent categorical model is nearly the same as DSM-/V. Its alterna-
out meaningful goals or constructive internal standards of tive dimensional model is based on ample evidence that
behavior. Or their identity may be too rigid, unable to adapt to personality disorders, for the most part, represent extreme ver-
changes in their circumstances, as when they lose a job or de- sions of typical personality traits (Krueger et al., 2008; Trull &
velop an illness. People also vary greatly in their ability to form Durrett, 2005; Widiger & Mullins-Sweatt, 2009) .
Personality Disorders Along the Continuum 251

252 Chapter 9 Personality Disorders
Susanna Kaysen, Girl, Interrupted
Susanna Kaysen was emptiness and boredom came from the fact
18, depressed, drifting that I was living a life based on my incapacities,
through life and end- which were numerous. A partial list follows.
I could not and did not want to: ski, play tennis,
lessly oppositional to-
or go to gym class; attend to any subject in
ward her parents and
school other than English and biology; write pa-
teachers. She tried to
pers on any assigned topics (I wrote poems in-
commit suicide and stead of papers for English; I got Fs); plan to go
eventually was hospi- or apply to college; give any reasonable expla-
talized, remaining in nation for these refusals.
the hospital for nearly My self-image was not unstable. I saw my-
2 years. Later, Kaysen self, quite correctly, as unfit for the educational
discovered that her di- and social systems. But my parents and teach-
agnosis had been borderline personality disorder. ers did not share my self-image. Their image of
In her autobiography, Girl, Interrupted, she raises me was unstable, since it was out of kilter with
reality and based on their needs and wishes.
many questions about this diagnosis.
They did not put much value on my capacities,
... I had to locate a copy of the Diagnostic which were admittedly few, but genuine. I read
and Statistical Manual of Mental Disorders and everything, I wrote constantly, and I had boy-
look up Borderline Personality to see what they friends by the barrelful. . ..
really thought about me. I often ask myself if I'm crazy. I ask other
It's a fairly accurate picture of me at eigh- people too. "Is this a crazy thing to say?" I'll ask
teen, minus a few quirks like reckless driving before saying something that probably isn't
and eating binges . .. . I'm tempted to try refut- crazy.
ing it, but then I would be open to the further I start a lot of sentences with "Maybe I'm to-
charges of "defensiveness" and "resistance:' tally nuts;' or "Maybe I've gone 'round the bend:'
All I can do is give the particulars: an anno- If I do something out of the ordinary-take two
tated diagnosis. baths in one day, for example-! say to myself:
... "Instability of self-image, interpersonal Are you crazy? (Kaysen, 1993, pp. 150-159)
relationships, and mood .. . uncertainty about . . .
long-term goals or career choice . .. : Isn't this a Was Susanna Kaysen just a mixed-up teenager
good description of adolescence? Moody, fickle, whose parents expected too much of her and locked
faddish, insecure: in short, impossible. her away when she didn't comply? Or was she a
"Self-mutilating behavior (e.g ., wrist deeply troubled young woman whose stay in the
scratching) . .. : I've skipped forward a bit. This
hospital prevented her complete psychological dete-
is the one that caught me by surprise as I sat on
rioration? Is the diagnosis of borderline personality
the floor of the bookstore reading my diagnosis.
Wrist scratching! I thought I'd invented it. Wrist disorder valid, or is it a label we attach to people who
banging, to be precise .. .. don't conform? Kaysen's Girl, Interrupted (which was
"The person often experiences this insta- made into a film starring Winona Ryder) brings life to
bility of self-image as chronic feelings of empti- the enduring debate about the validity and ethics of
ness or boredom:' My chronic feelings of the diagnosis of borderline personality disorder.
In your daily conversations, you likely refer to peo- One of the leading theories of personality is the
ple's personalities all the time. Personality is en- five-factor model, a dimensional perspective that
during patterns of perceiving, feeling, thinking posits that everyone's personality is organized along
about, and relating to oneself and the environment. five broad personality traits, or factors. These factors
You might say that a person you just met is outgo- are often referred to as the Big 5: negative emotional-
ing, or that you tend to be disorganized, or that a ity, extraversion, openness to experience, agreeable-
friend of yours is highly emotional. A personality ness, and conscientiousness (McCrae & Costa, 1999,
trait is a prominent aspect of personality that is 2013). Each factor has a number of facets, or dimen-
relatively consistent across time and across situa- sions, as shown in Table 9.1. Considerable research
tions, such as being outgoing, caring and compas- supports the five-factor model of personality. These
sionate, exploitive or hostile, impulsive or unstable. traits seem to capture a great deal of the variation in
TABLE 9.1 The Big 5 Personality Factors
Each of the Big 5 personality factors is composed of different facets, or components .
FACTOR 1: NEGATIVE EMOTIONALITY VERSUS EMOTIONAL STABILITY
Facet Individuals high on this facet are Individuals low on this facet are
Anxiousness fearful, apprehensive relaxed, unconcerned, cool

Angry hostility angry, bitter even-tempered
Depressiveness pessimistic, glum optimistic
Self-consciousness timid, embarrassed self-assured, glib, shameless
Impulsivity tempted, urgent controlled, restrained
Vulnerability helpless, fragile clear-thinking, fearless, unflappable
FACTOR 2: EXTRAVERSION VERSUS INTROVERSION
Warmth cordial, affectionate, attached cold, aloof, indifferent

Gregariousness sociable, outgoing withdrawn, isolated
Assertiveness dominant, forceful unassuming, quiet, resigned
Activity unassuming, quiet, resigned passive, lethargic
Excitement seeking reckless, daring cautious, monotonous, dull
Positive emotions high-spirited placid, anhedonic
FACTOR 3: OPENNESS VERSUS CLOSEDNESSTO ONE'S OWN EXPERIENCE
Fantasy dreamers, unrealistic, imaginative practical, concrete

Aesthetics aberrant interests, aesthetic uninvolved, no aesthetic interests
Feelings self-aware constricted, unaware
Actions unconventional, eccentric routine, predictable, habitual, stubborn
Ideas unusual, creative pragmatic, rigid
Values permissive, broad-minded traditional, inflexible, dogmatic
FACTOR 4: AGREEABLENESS VERSUS ANTAGONISM
Trust gullible, na'ive, trusting skeptical, cynical, suspicious, paranoid
Straightforwardness confiding, honest cunning, manipulative, deceptive
Altruism sacrificial, giving stingy, selfish, greedy, exploitative
Compliance docile, cooperative oppositional, combative, aggressive
Modesty meek, self-effacing, humble confident, boastful, arrogant
Tender-minded ness soft, empathetic tough, callous, ruthless
FACTOR 5: CONSCIENTIOUSNESS VERSUS UNDEPENDABILITY
Competence perfectionistic, efficient lax, negligent
Order ordered, methodical, organized haphazard, disorganized, sloppy
Dutifulness rigid, reliable, dependable casual, undependable, unethical
Achievement workaholic, ambitious aimless, desultory
Self-discipline dogged, devoted hedonistic, negligent
Deliberation cautious, ruminative, reflective hasty, careless, rash
Source: T. A. Widiger, personal communication, 2009.

people's personalities, and they have been repli- (Table 9.2). The general criteria for a personality
cated in cultures very different from that of the disorder specify that an individual's personality
United States (Benet-Martinez & John, 1998; Yang et pattern must deviate markedly from the expecta-
al., 2002). The personality traits, especially the facet tions of his or her culture as shown in styles of
dimensions, in the five-factor model appear to be thinking about oneself, others, or events; emo-
strongly influenced by genetics (Briley & Tucker- tional experience and expression; interpersonal
Drab, 2012; Jang et al., 1998, 2006). You can probably functioning; and / or impulse control. An individu-
find yourself among the traits and facets of the Big 5. al's personality pattern must be pervasive and in-
As mentioned earlier, the DSM-5 includes two flexible across situations, be stable over time, have
models of personality disorders. Similar to the an onset in adolescence or early adulthood, and
DSM-IV-TR, the first model is categorical and de- lead to significant distress or functional impair-
fines 10 different personality disorders in terms of ment. An individual's long-term pattern of func-
distinct criteria sets. The categorical model is in- tioning also cannot be better explained as a
tended for current clinical use. An alternative trait- manifestation or consequence of another mental,
specific, or dimensional, model was developed for substance use, or medical disorder.
DSM-5 and is included in a different section of the By definition, a personality disorder is an en-
manual designated for further study. It makes use during pattern of thinking, feeling, and behaving
of a continuum model of personality disorders that is relatively stable over time, and the particu-
such as that represented in the Big 5 model. The lar personality features must be evident by early
alternative model essentially assumes that normal adulthood. For a personality disorder to be diag-
and abnormal personality fall on an integrated con- nosed in an individual younger than 18 years, the
tinuum of personality, with personality disorders personality patterns must have been present for at
representing more extreme and maladaptive vari- least 1 year (with the exception of antisocial per-
ants of personality traits, as described in this chap- sonality disorder, which cannot be diagnosed be-
ter's Along the Continuum feature. We will first fore age 18). Most clinicians will thus assess the
describe the DSM-5's current model before turning stability of personality traits over time and across
to a review of its limitations and the DSM-5's alter- different situations, taking into account ethnic, cul-
native model of personality disorders. tural, and social background influences and taking
care to distinguish the personality traits that define
the personality disorders from characteristics that
emerge in response to situational stressors or more
GENERAL DEFINITION OF transient mental states like mood, anxiety, or sub-
stance use disorders.
PERSONALITY DISORDER The DSM-5 also moved away from a multiaxial
The DSM-5 carries forward the categorical per- system of diagnosis, first introduced in DSM-IIJ,
spective first established in DSM-III in 1980. It and collapsed Axes I and II into a common section
treats personality disorders as if they were entirely (see Chapter 3). Until the DSM-5, the personality
different from "normal" personality traits. Unlike disorders were treated differently and placed on
prior manuals, however, the DSM-5 provides a gen- Axis II, because it was believed that personality
eral definition of personality disorder that applies disorders were especially pervasive and chronic,
to each of the 10 specific personality disorders rather than occurring in more discrete or acute
TABLE 9.2 Personality Disorder
The general criteria for a personality disorder specify that an individual's personality pattern must deviate
signi ficantly from t he expectations of his or her culture as shown in the styles of thinking about oneself, others,
or events; emotional experience and expression; interpersonal functioning; and/or impulse control.
By definition, a personality disorder is an enduring pattern of thinking, feeling, and behaving that is relatively
stable over time, and the particular personality features must be evident by early adulthood.
Cluster A: Odd-Eccentric Personality Disorders 255
TABLE 9.3 Personality Disorder Clusters
The DSM-5 groups personality disorders into three clusters based on descriptive similarities .
CLUSTER A: ODD-ECCENTRIC PERSONALITY DISORDERS
People with these disorders have symptoms similar to those of people with schizophrenia, including
inappropriate or flat affect, odd thought and speech patterns, and paranoia. People with these disorders
maintain their grasp on reality, however.
CLUSTER 8: DRAMATIC-EMOTIONAL PERSONALITY DISORDERS
People with these disorders tend to be manipulative, volatile, and uncaring in social relationships. They are
prone to impulsive, sometimes violent behaviors that show little regard for their own safety or the safety or
needs of others.
CLUSTER C: ANXIOUS-FEARFUL PERSONALITY DISORDERS
People with these disorders are extremely concerned about being criticized or abandoned by others and thus
have dysfunctional relationships with others .
episodes, which characterize the clinical disorders histrionic personality disorder, borderline person-
coded on Axis I. While most people diagnosed with ality disorder, and narcissistic personality disor-
a personality disorder also experience another der. People diagnosed with these disorders tend to
clinical disorder at some time in their life (Grant, be manipulative, volatile, and uncaring in social
Stinson, et al., 2004), the DSM-5 had as one of its relationships and prone to impulsive behaviors.
goals to reduce comorbidity and no longer regarded They may behave in exaggerated ways or even at-
the Axis I and Axis II distinction as clinically useful tempt suicide to try to gain attention.
(Links & Eynan, 2013; Skodal et al., 2011). Cluster C includes three disorders character-
The DSM-5 groups 10 distinct personality dis- ized by anxious and fearful emotions and chronic self-
orders into three clusters based on their descrip- doubt: dependent personality disorder, avoidant
tive similarities (Table 9.3). Importantly, DSM-5 personality disorder, and obsessive-compulsive
explicitly recognizes that this clustering system is personality disorder. People diagnosed with these
limited, has not been consistently validated, and disorders have little self-confidence and difficulty
fails to account for the fact that individuals often in relationships.
show co-occurring personality disorders from dif-
ferent clusters. Cluster A includes three disorders
characterized by odd or eccentric behaviors and think-
ing: paranoid personality disorder, schizoid per-
sonality disorder, and schizotypal personality CLUSTER A:
disorder. Each of these has some of the features of ODD-ECCENTRIC
schizophrenia, but people diagnosed with these
personality disorders are not out of touch with re-
PERSONALITY DISORDERS
ality. Their behaviors often appear odd, eccentric, The behavior of people diagnosed with the odd-
and inappropriate. For example, they may be eccentric personality disorders (Table 9.4) is simi-
chronically suspicious of others or speak in odd lar to that of people with schizophrenia, but these
ways that are difficult to understand. people retain their grasp on reality to a greater de-
Cluster B includes four disorders characterized gree than do people who are psychotic. They may
by dramatic, erratic, or emotional behavior and interper- be paranoid, speak in odd and eccentric ways that
sonal relationships: antisocial personality disorder, make them difficult to understand, have difficulty
TABLE 9.4 Cluster A: Odd-Eccentric Personality Disorders
People with an odd-eccentric persona lity disorder may ex hibit mild signs of schizophrenia .
Label Key Features Relationship to Schizophrenia
Paranoid personality disorder A pattern of distrust and suspiciousness Weak relationship

such that others' motives are interpreted
as ma levolent
Schizoid personality disorder A pattern of detachment from social relationsh ips Unclear relationship
and a restricted range of emotional expression
Schizotypal personality disorder A pattern of acute discomfort in close relationships, Strong relationship-considered a mild
cognitive or perceptua l distortions, and eccentricities version of schizophrenia
of behavior
relating to other people, and have unusual beliefs great deal of time trying to decipher such clues to
or perceptual experiences that fall short of delu- other people's true intentions. They are also very
sions and hallucinations. Some researchers con- sensitive and angrily reactive to real or perceived
sider this group of personality disorders to be part criticism and tend to bear grudges.
of the schizophrenia spectrum (Nigg & Goldsmith, People with paranoid personality disorder
1994), particularly schizotypal personality disor- tend to misinterpret situations in line with their
der (Siever & Davis, 2004), though they are below suspicions. For example, a husband might inter-
the threshold for the diagnosis of a psychotic dis- pret his wife's cheerfulness one evening as evi-
order (see Chapter 8) . That is, these disorders show dence that she is having an affair with someone at
some attenuated schizophrenia-like symptoms work. These people are resistant to rational argu-
and may be precursors to schizophrenia in a small ments against their suspicions and may consider
proportion of people who go on to develop schizo- the fact that another person is arguing with them
phrenia or another psychotic disorder, especially as evidence that the person is part of the conspir-
schizotypal personality disorder (Woods et al., acy against them. Some are secretive and with-
2009). These disorders also more often occur in draw from other people in an attempt to protect
people with first-degree relatives who have schizo- themselves, but others become hostile and argu-
phrenia or persecutory type delusional disorder. mentative, sure that their way of looking at the
world is right and superior and that the best de-
fense against the conspiring of others is a good of-
Paranoid Personality Disorder
fense. Felix, in the following case study, was
The defining feature of paranoid personality disor- diagnosed with paranoid personality disorder.
der is a pattern of pervasive distrust and suspicious-
ness of others such that their motives are interpreted
as malevolent. People diagnosed with this disorder ~:~l~!r':~"~~ :,.~ : y
believe that other people are chronically trying to t~~~ ~-?~JTU,DY

deceive or exploit them, and they are preoccupied "' ~ _. " Felix is a 59-year-old con-
with concerns about being victimized or mistreated struction worker who worries that his co-workers
by others. They are hypervigilant for evidence con- might hurt him. Last week, while he was using a
firming their suspicions. Often they are penetrating table saw, Fe lix's hand slipped and his fingers
observers of situations, noting details most other came very close to being cut badly. Felix won-
people miss. For example, they notice a slight gri- ders if someone sabotaged the saw, so that
mace on the face of their boss or an apparently triv- somehow the piece of wood he was working
ial slip of the tongue by their spouse that would go with slipped and drew his hand into the saw
unnoticed by everyone else. Moreover, people diag- blade. Since this incident, Felix has observed his
nosed with paranoid personality disorder consider co-workers looking at him and whispering to
these events to be highly meaningful and spend a
diagnosed with paranoid personality disorder

each other. He mentioned his suspicion that the found that they endorsed beliefs as predicted by this
saw had been tampered with to his boss, but the cognitive theory more than did patients diagnosed
boss told him that was a crazy idea and that Felix with other personality disorders (Becket al., 2001).
obviously had just been careless.
Felix does not have any close friends. Even Treatment of Paranoid
his brothers and sisters avoid him, because he Personality Disorder
frequently misinterprets things they say to be People diagnosed with paranoid personality dis-
criticisms of him. Felix was married for a few order usually come into contact with clinicians
years, but his wife left him when he began to only when they are in crisis. They may seek treat-
demand that she not see any of her friends or go ment for severe symptoms of depression or anxi-
out without him, because he suspected she was ety, but they often do not feel a need for treatment
having affairs with other men. Felix lives in a of their paranoia. Their guarded and suspicious
middle-class neighborhood in a small town that style will often undercut the development of a
has very little crime. Still, he owns three hand- trusting, therapeutic relationship. In addition, ther-
guns and a shotgun, which are always loaded, in apists' attempts to challenge their paranoid think-
expectation of someone breaking into his house. ing are likely to be misinterpreted in line with their
paranoid belief system. For these reasons, treating
paranoid personality disorder can be quite difficult
Epidemiological studies suggest that between (Millon et al., 2000).
0.7 and 5.1 percent of people in the general popula- In order to gain the trust of a person diagnosed
tion can be diagnosed with paranoid personality with a paranoid personality disorder, the therapist
disorder (Lenzenweger, 2008). People diagnosed must be calm, respectful, and extremely straight-
with this disorder appear to be at increased risk for forward (Siever & Kendler, 1985). The therapist
a number of clinical disorders, including major de- cannot directly confront the client's paranoid
pression, anxiety disorders, substance abuse, and thinking but instead must rely on indirect means
psychotic episodes (Bernstein, Useda, & Siever, of raising questions in the client's mind about his
1995; Grant, Stinson, et al., 2004), as well as im- or her typical way of interpreting situations. Al-
paired vocational functioning (McGurk et al., 2013). though many therapists do not expect paranoid
Not surprisingly, they are difficult to get along clients to achieve full insight into their problems,
with, and their interpersonal relationships, includ- they hope that, by developing at least some degree
ing intimate relationships, tend to be unstable. Ret- of trust in the therapist, the client can learn to trust
rospective studies suggest that their prognosis others a bit more and thus develop somewhat im-
generally is poor, with their symptoms intensify- proved interpersonal relationships.
ing under stress, sometimes experiencing very Cognitive therapy for people diagnosed with
brief psychotic episodes. this disorder focuses on increasing their sense of
self-efficacy in dealing with difficult situations,
Theories of Paranoid thus decreasing their fear and hostility toward oth-
Personality Disorder ers. As an example, consider the following inter-
Some family history studies have shown that para- change between a cognitive therapist and a woman,
noid personality disorder is more common in the Ann, who believed that her co-workers were inten-
families of people with schizophrenia than in the tionally trying to annoy her and to turn her super-
families of healthy control subjects. This finding sug- visor against her.
gests that paranoid personality disorder may be part
of the schizophrenia spectrum of disorders (Chang
et al., 2002; Nigg & Goldsmith, 1994). One twin
study found the heritability of paranoid personality
disorder to be .50 (Coolidge, Thede, & Jang, 2004).
PROFILES
Cognitive theorists view paranoid personality
disorder as the result of an underlying belief that Therapist: You're reacting as though this is a
other people are malevolent and deceptive, com- very dangerous situation. What are the risks
bined with a lack of self-confidence about being able you see?
to defend oneself against others (Beck & Freeman, Ann: They'll keep dropping things and making
1990). Thus, the person must always be vigilant for noise to annoy me.
signs of others' deceit or criticism and must be (continued)
quick to act against others. A study of 17 patients
In this interchange, the therapist did not directly ~

Therapist: Are you sure nothing worse is at challenge Ann's beliefs about her co-workers' in-
risk? tentions but did try to reduce the sense of danger
Ann: Yeah. Ann felt about her workplace by helping her rede-
Therapist: So you don't think there's much fine the situation as aggravating rather than threat-
chance of them attacking you or anything? ening. The therapist also enlisted Ann in an effort
to develop new coping skills that might further
Ann: Nah, they wouldn't do that.
reduce her aggravation.
Therapist: If they do keep dropping things and
making noises, how bad will that be? Schizoid Personality Disorder
Ann: Like I told you, it's real aggravating. It
You may have heard the term "schizoid" used to
really bugs me.
describe people who strongly prefer to turn their
Therapist: So it would continue pretty much attention inward and away from the outside world,
as it's been going for years now. often engaging in solitary activities. People diag-
Ann: Yeah. It bugs me, but I can take it. nosed with schizoid personality disorder show a
Therapist: And you know that if it keeps hap- pervasive pattern of detachment from social rela-
pening, at the very least you can keep han- tionships and a restricted range of emotional ex-
dling it the way you have been-holding the pression in their interactions with others. They
aggravation in, then taking it out on your hus- seem indifferent to opportunities to develop close
band when you get home. Suppose we could relationships and derive little, if any, pleasure from
come up with some ways to handle the ag- family or social interactions. Their experience and
gravation even better or to have them get to expression of positive emotions are very low, and
you less. Is that something you'd be inter- their interest in having sexual experiences with an-
ested in? other person is typically very limited. Other peo-
ple describe them as emotionally aloof or cold,
Ann: Yeah, that sounds good.
"loners," or "bland," uninteresting, and humor- ~
Therapist: Another risk you mentioned earlier less. People diagnosed with this disorder are often
is that they might talk to your supervisor and indifferent to others' praise or criticism, and they
turn her against you. As you see it, how long take pleasure in few activities. While they tend to
have they been trying to do this? view relationships with others as unrewarding,
Ann: Ever since I've been there. messy, and intrusive, in those few situations in
Therapist: How much luck have they had so which they may temporarily feel comfortable talk-
far in doing that? ing about themselves, they may acknowledge hav-
ing painful feelings, particularly related to social
Ann: Not much.
interactions. The man described next shows sev-
Therapist: Do you see any indications that eral of these symptoms.
they're going to have any more success now
than they have so far?
Ann: No, I don't guess so.
Therapist: So your gut reaction is as though
CASE STUDY
Roy was a successful sani-
the situation at work is really dangerous. But tation engineer involved in the planning and
when you stop and think it through, you con- maintenance of water resou rces for a large city;
clude that the worst they're going to do is to his job called for considerable foresight and in-
be really aggravating, and that even if we dependent judgment but little supervisory re-
don't come up with anything new, you can sponsibility. In general, he was appraised as an
handle it well enough to get by. Does that undistinguished but competent and reliable em-
sound right? ployee. There were few demands of an interper-
Ann: [Smiling] Yeah, I guess so. sonal nature made of him, and he was viewed by
Therapist: And if we can come up with some most of his colleagues as reticent and shy and by
ways to handle the stress better or handle others as cold and aloof.
them better, there will be even less they can Difficulties centered around his relationship
do to you . with his wife. At her urging they sought marital
counseling, for, as she put it, "he is unwilling to
(Beck & Freeman, 1990, pp. 111-112) join in family activities, he fails to take interest in
homework assignments in which the client tries

the children, he lacks affection, and he is disinter- out new social skills with other people, is an im-
ested in sex:' portant component of cognitive therapies. Some
The pattern of social indifference, flatness of therapists recommend group therapy for people
affect, and personal isolation that characterized with schizoid personality disorder. In the context
much of Roy's behavior was of little consequence of group sessions, the group members can model
to those with whom a deeper or more intimate interpersonal relationships, and each person with
relationship was not called for; with his immedi- schizoid personality disorder can practice new so-
ate family, however, these traits took their toll. cial skills directly with other group members.
(Millon, 1969, p. 224)
Schizotypal Personality
Roy would be diagnosed with schizoid personality
Disorder
disorder because of his long-standing avoidance of People diagnosed with schizotypal personality
relationships with other people and his lack of disorder show symptoms similar to those of
close relationships with family members. schizophrenia but in milder form (Kwapil &
Schizoid personality disorder is uncommon, Barrantes-Vidal, 2012). Like schizoid and para-
with about 0.8 to 1.7 percent of adults manifesting noid personality disorders, people with schizo-
the disorder at some time in their life (Lenzenweger, typal personality disorder tend to be socially
2008). Among people seeking treatment for this isolated, to have a restricted range of emotions,
disorder, males outnumber females (Zimmerman, and to be uncomfortable in interpersonal interac-
Rothschild, & Chelminski, 2005). People with schiz- tions (Table 9.5). As children, they are passive, so-
oid personality disorder can function in society, par- cially unengaged, and hypersensitive to criticism
ticularly in occupations that do not require frequent (Olin et al., 1999), and they may attract teasing
interpersonal interactions. because they appear "odd" or "eccentric." The
distinguishing characteristics of schizotypal per-
Theories of Schizoid Personality Disorder sonality disorder are the cognitive and perceptual
There is a slightly increased rate of schizoid per- distortions and odd and eccentric behaviors.
sonality disorder in the relatives of persons with These characteristics generally fall into four cate-
schizophrenia, but the link between the two disor- gories (Beck & Freeman, 1990).
ders is not clear (Kendler, Neale, Kessler, Heath, & The first category is paranoia or suspicious-
Eaves, 1993; Nigg & Goldsmith, 1994). Twin stud- ness. As in paranoid personality disorder, people
ies of the personality traits associated with schiz- diagnosed with schizotypal personality disorder
oid personality disorder, such as low sociability perceive other people as deceitful and hostile, and
and low warmth, strongly suggest that these per- much of their social anxiety emerges from this
sonality traits may be partially inherited (Costa paranoia. The second category is ideas of refer-
& Widiger, 2002). The evidence for the heritability ence. People diagnosed with schizotypal personal-
of schizoid personality disorder is only indirect, ity disorder tend to believe that random events or
however. circumstances have a particular meaning just for
them. For example, they may think it highly sig-
Treatment of Schizoid nificant that a fire occurred in a store in which they
Personality Disorder had shopped only yesterday. The third category is
As you might expect, people with schizoid person- odd beliefs and magical thinking. For example,
ality disorder may not be very motivated for treat- they may believe that others know what they are
ment, and the interpersonal closeness of therapy thinking. The fourth category is illusions that are
may be experienced as stressful instead of sup- just short of hallucinations. For example, they may
portive. Despite these treatment challenges, psy- think they see people in the patterns of wallpaper.
chosocial treatments for schizoid personality In addition to demonstrating cognitive and per-
disorder focus on increasing the person's aware- ceptual distortions, people diagnosed with schizo-
ness of his or her own feelings, as well as increas- typal personality disorder tend to have speech that
ing his or her social skills and social contacts (Beck is tangential, circumstantial, vague, or overelabo-
& Freeman, 1990; Quality Assurance Project, 1990). rate. In interactions with others, they may have in-
The therapist may model the expression of feelings appropriate emotional responses or no emotional
for the client and help the client identify and ex- response to what other people say or do. Their be-
press his or her own feelings. Social skills training, haviors also are odd, sometimes reflecting their odd
done through role-playing with the therapist and thoughts. They may be easily distracted or may
TABLE 9.5 Schizotypal Personality Disorder
A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced
capacity for, close relationships as well as by cognitive of perceptual distortions and eccentricities of
behavior, beginning by early adulthood .
-Symptoms include:
Restricted range of emotion
Uncomfortable interpersonal interactions
Odd and eccentric behavior
Paranoia
-Preva lence rate is 3.9 percent of general population
-More commonly diagnosed in males than in females
fixate on an object for a long period of time, lost in

thought or fantasy. each time before they were worn? He did not
Although the quality of these oddities of regard concerns such as these as senseless,
thought, speech, and behavior is similar to that though he acknowledged that the amount of
seen in schizophrenia, their severity is not as great time spent thinking about them might be exces-
as in schizophrenia, and people diagnosed with sive. He could recite from memory his most re-
schizotypal personality disorder retain basic con- cent monthly bank statement, including the
tact with reality. The man in the following case amount of every check and the running balance
study shows many of the oddities of schizotypal as each check was written. He knew his balance
on any particular day, but he sometimes got
personality disorder.
anxious if he considered whether a certain check
or deposit had actually cleared. Reprinted
with permi ssion from the DSM-V Casebook: A
Learning Companion to the Diagnostic and
Statistical Manual of Mental Disorders, Fifth
A 41-year-old man was re-
Edition, (Copyright 2013). American Psychiatric
ferred to a community mental health center's ac-
Publishing, Inc.
tivities program for help in improving his social
skills. He had a lifelong pattern of social isola-
tion, with no real friends, and spent long hours
worrying that his angry thoughts about his older
brother would cause his brother harm. He had
The prevalence of schizotypal personality dis-
previously worked as a clerk in civil service but
order in the general population is 3.9 percent
had lost his job because of poor attendance and
(Pulay et al., 2009). Among people seeking treat-
low productivity.
ment, it is more commonly diagnosed in males
On interview t he patient was distant and
than in females (Zimmerman et al., 2005). People
somewhat distrustful. He described in elaborate
diagnosed with schizotypal personality disorder
and often irrelevant detail his rather uneventful
are at increased risk for depression and for schizo-
and routine daily life. For two days he had studied
phrenia or isolated psychotic episodes (Siever,
the washing instructions on a new pair of jeans:
Bernstein, & Silverman, 1995).
Did "Wash befo re weari ng" mean that the jeans
For a person to be given a diagnosis of schizo-
were to be washed before wearing the first time,
typal personality disorder, his or her odd or ec-
or d id they need, for some reason, to be washed
centric thoughts cannot be part of cultural beliefs,
such as a cultural belief in magic or specific
superstitions. Still, some psychologists have ar- dopamine in the brain (Abi-Dargham et al., 2004).
gued that people of color are diagnosed more of- Thus, like people with schizophrenia, people
ten with schizophrenia-like disorders, such as with schizotypal personality disorder may have
schizotypal personality disorder, than are whites abnormally high levels of dopamine in some ar-
because white clinicians often misinterpret cul- eas of the brain.
turally bound beliefs as evidence of schizotypal Although people with schizotypal personality
thinking (Snowden & Cheung, 1990). One large disorder show abnormalities in the same areas of
study of people in treatment found that African the brain as people with schizophrenia, these ab-
American patients were more likely than white normalities tend to be less severe in schizotypal
or Hispanic patients to be diagnosed with schizo- personality disorder than in schizophrenia,
typal personality disorder on both self-report perhaps reflecting the less severe symptoms
and standardized diagnostic interviews (Chavira (Barch, 2005). For example, one study showed that
et al., 2003). This finding suggests that African people with both disorders show gray matter re-
Americans may be diagnosed with this disorder ductions in areas of the temporal lobe of the brain
relatively frequently even when steps are taken compared to controls, but the reductions were less
to avoid clinician bias. It is possible that African in people with schizotypal personality disorder
Americans are more likely to be exposed to con- than in people with schizophrenia (Takahashi
ditions that enhance a biological vulnerability to et al., 2011). Further, people w ith schizoptypal
schizophrenia-like disorders. These conditions in- personality disorder do not tend to show the ab-
clude urban living and low socioeconomic status normalities in the prefrontal areas of the brain
(see Chapter 8 for a discussion of these condi- shown by people with schizophrenia (Hazlett
tions in schizophrenia). et al., 2008; Suzuki et al., 2005), perhaps reflecting
the less severe symptoms in schizotypal personal-
ity disorder.
Theories of Schizotypal People with schizotypal personality disorder
Personality Disorder also tend to have more frequent histories of a
Schizotypal personality disorder is the most well wide range of childhood adversities compared to
researched of the cluster A personality disorders. the general population, including physical, emo-
Family history, adoption, and twin studies all sug- tional, and sexual abuse and having a parent who
gest that schizotypal personality disorder is was battered, abused substances, or spent time
transmitted genetically (Siever & Davis, 2004). In- in jail.
deed, a twin study found the heritability of schizo-
typal personality disorder to be .81 (Coolidge,
Thede, & Jang, 2004). In addition, schizotypal per- Treatment of Schizotypal
sonality disorder is much more common in the Personality Disorder
first-degree relatives of people with schizophrenia Schizotypal personality disorder is most often
than in the relatives of either psychiatric patients or treated with the same drugs used to treat schizo-
healthy control groups (Gilvarry, Russell, Hemsley, phrenia, including traditional neuroleptics such as
& Murray, 2001; Kendler et al., 1993). This sup- haloperidol and thiothixene and atypical antipsy-
ports the view that schizotypal personality chotics such as olanzapine, and typically at lower
disorder is a mild form of schizophrenia that is doses (Ripoll et al., 2011). As in schizophrenia,
transmitted through genes in ways similar to those these drugs appear to relieve psychotic-like symp-
in schizophrenia. A gene that regulates the NMDA toms, which include distorted ideas of reference,
receptor system has been associated with both magical thinking, and illusions. Antidepressants
schizophrenia and schizotypal personality disor- sometimes are used to help people with schizo-
der (Ohi et al., 2012). typal personality disorder who are experiencing
People with schizotypal personality disorder significant distress.
show many of the same cognitive deficits as peo- Although there are few psychological theo-
ple with schizophrenia, including difficulties in ries of schizotypal personality disorder, psycho-
verbal fluency, in inhibiting information when a logical therapies have been developed to help
task calls for it, and in memory (Barch, 2005; people with this disorder overcome some of their
Cochrane, Petch, & Pickering, 2012; Mitropoulou symptoms. In psychotherapy for schizotypal
et al., 2003). People with schizotypal personality personality disorder, it is especially important
disorder, like people with schizophrenia, tend to for the therapist to first establish a good relation-
show dysregulation of the neurotransmitter ship with the client, because these clients
typically have few close relationships and tend regard for their own safety or the safety of others
to struggle with paranoid thoughts and excessive (Table 9.6). For example, they may engage in
social anxiety (Beck & Freeman, 1990). The next suicidal behaviors or self-damaging acts such as
step in therapy is to help the client increase social self-cutting. They also may act in hostile, even vio-
contacts and learn socially appropriate behaviors lent, ways against others. One core feature of this
through social skills training. Group therapy group of disorders is a lack of concern for others.
may be especially helpful in increasing clients' Two of the disorders in this cluster, borderline per-
social skills. sonality disorder and antisocial personality disor-
The crucial component of cognitive therapy der, have been the focus of a great deal of research,
with clients diagnosed with schizotypal personality whereas the other two, histrionic personality disor-
disorder is teaching them to look for objective der and narcissistic personality disorder, have not.
evidence in the environment to support their Because antisocial personality disorder shares im-
thoughts and to disregard bizarre thoughts. For portant symptom patterns that have a develop-
example, a client who frequently thinks she is mental continuity with conduct disorder, it is
not real can be taught to identify that thought discussed in Chapter 11.
as bizarre and to discount the thought when it
occurs, rather than taking it seriously and acting
on it.
Borderline Personality Disorder
Recall that Susanna Kaysen, whom we met in the
CLUSTER B: Extraordinary People feature, suffered a variety
DRAMATIC-EMOTIONAL of symptoms and received a diagnosis of border-
line personality disorder, which she later ques-
PERSONALITY DISORDERS tioned. In the following case study, a clinician
People diagnosed with the dramatic-emotional describes her introduction to another woman
personality disorders engage in behaviors that are who later was diagnosed with borderline person-
dramatic and impulsive, and they often show little ality disorder.
TABLE 9.6 Cluster C Personality Disorders: Dramatic-Emotional
People with dramatic-emotional personality disorders tend to have unstable emotions and to engage in
dramatic and impulsive behavio r.
Label Key Features Similar Disorders
Antisoci al personality disorder A pattern of disregard for, and violation of, Conduct disorder
the rights of others; crim inal, impulsive, (evidenced by age 15)
deceitful, or callous behavior; lack of remorse
Borderline personality disorder A pattern of instability in self-image, mood, Mood disorders
and interpersonal relationships and marked
impu lsivity; transient dissociative states; highly
reactive to real or imagined abandonment
Histrionic personality disorder A pattern of excessive emotionality and Somatoform disorders,

attention seeking; dramatic, seductive, or mood disorders
provocative behavior; suggestible; shallow
emotional express io n and relationsh ips
Narcissistic perso nality disorder A pattern of grandiosity, need for adm iration, Manic symptoms
and lack of empathy; entitled, arrogant, and
exploitative attitudes and behavior
/
Cluster B: Dramatic-Emotional Personality Disorders 263
point cut or burn herself, usually while in a state

CASE STUDY of "automatic pilot:' Consequently, Cindy often
At the initial meeting, Cindy
was a 30-year-old, white, married woman with had difficulty remembering specifics of the ac-
no children who was living in a middle-class sub- tual acts. At one point, Cindy burned her leg so
urban area with her husband. She had a college badly (and then injected it with dirt to convince
education and had successfully completed al- the doctor that he should give her more atten-
most 2 years of medical school. Cindy was re- tion) that reconstructive surgery was required .
ferred by her psychiatrist of 11 years, who was no (Adapted from Linehan, Cochran, & Kehrer, 2001,
longer willing to provide more than pharmaco- pp. 502- 504)
therapy following a recent hospitalization for a
near-lethal suicide attempt. In the 2 years prior to
referral, Cindy had been hospitalized at least Cindy's symptoms represent some of the
10 times (one lasting 6 months) for psychiatric benchmarks of borderline personality disorder:
treatment of suicidal ideation; had engaged in out-of-control emotions that cannot be smoothed, a
numerous instances of parasuicidal behavior, in- hypersensitivity to abandonment, a tendency to
cluding at least 10 instances of drinking Clorox cling too tightly to other people, and a history of
bleach, multiple deep cuts, and burns; and had hurting oneself (see the DSM-5 criteria in Table 9.7).
had three medically severe or nearly lethal suicide This disorder is characterized by fundamental
attempts, including cutting an artery in her neck. deficits in identity and in interpersonal relation-
Until age 27 Cindy was able to function well ships. The self-concept of people with borderline
in work and school settings, and her marriage personality disorder is unstable, with periods of
was reasonably satisfactory to both partners, al- extreme self-doubt alternating with periods of
though the husband complained of Cindy's ex- grandiose self-importance and accompanied by a
cessive anger. When Cindy was in the second need for others to support their self-esteem. Fur-
year of medical school, a classmate she knew ther, like Cindy, people with this disorder are
only slightly committed suicide. Cindy stated prone to transient dissociative states, in which
that when she heard about the suicide, she im- they feel unreal, lose track of time, and may even
mediately decided to kill herself also but had forget who they are.
very little insight into what about the situation Their interpersonal relationships are extremely
actually elicited the inclination to kill herself. unstable-they can switch from idealizing others
Within weeks she left medical school and be- to despising them without provocation. People
came severely depressed and actively suicidal. with borderline personality disorder often de-
Although Cindy presented herself as a person scribe an emptiness that leads them to cling to new
with few psychological problems before the acquaintances or therapists in an attempt to fill
classmate's suicide, further questioning revealed their internal void . They worry about abandon-
a history of severe anorex ia nervosa, bulimia ment and misinterpret other people's everyday ac-
nervosa, and alcohol and prescription medications as desertion or rejection. For example, if a
tion abuse, originating at age 14. therapist has to cancel an appointment because of
Over the course of therapy, a consistent pat- illness, a client with borderline personality disor-
tern associated with self-harm became apparent. der might interpret this as rejection by the thera-
The chain of events would often begin with an pist and become very depressed or angry.
interpersonal encounter (almost always with her Along with instability of self-concept and in-
husband), which culminated in her feeling threat- terpersonal relationships, the mood of people with
ened, criticized, or unloved. These feelings would borderline personality disorder is unstable, with
often be followed by urges either to self-mutilate bouts of severe depression, anxiety, or anger seem-
or to kill herself, depending somewhat on her ing to arise frequently, often without cause. People
levels of hopelessness, anger, and sadness. with this disorder also show a strong tendency
Decisions to self-mutilate and/or to attempt sui- to engage in impulsive, self-damaging behaviors,
cide were often accompanied by the thought "I'll including self-mutilating or suicidal behavior.
show you:' At other times, hopelessness and a Cindy's self-mutilating behavior was to cut and
desire to end the pain permanently seemed pre- burn herself.
dominant. Following the conscious decision to The variety of symptoms in borderline person-
self-mutilate or attempt suicide, Cindy would ality disorder and their shifting nature make it a
then immediately dissociate and at some later complex disorder to diagnose and treat. This
complexity is heightened by the fact that people
TABLE 9.7 Borderline Personality Disorder
A pervasive pattern of instability of interpersonal re lationships, self-image, and affect and marked impulsivity
beginning by early adulthood.
-Symptoms include:
Out-of-control emotions
Unstable interpersonal relationships
Concerns about abandonment
Self-damaging behavior
Impulsivity
Frequently accompanied by depression, anxiety, or anger
-Prevalence rate is 5.9 percent of general population
-More commonly diagnosed in females than in males
with borderline personality disorder frequently study of people in treatment for personality disor-
are also diagnosed with another mental disorder, ders found that Hispanics were more likely than
such as substance abuse, depression, generalized whites or African Americans to be diagnosed with
anxiety disorder, a simple phobia, agoraphobia, borderline personality disorder (Chavira et al.,
posttraumatic stress disorder, panic disorder, or 2003). This could be because factors that contribute
somatization disorder (Eaton et al., 2011; Hasin to the disorder, such as extreme stress, are more
et al., 2011). About 75 percent of people with bor- common among Hispanics. Or clinicians may over-
derline personality disorder attempt suicide, and diagnose the disorder in Hispanic people because
about 10 percent die by suicide (Soloff & Chiapetta, they do not take into account Hispanic cultural
2012). The greatest risk for suicide appears to be in norms that permit greater expression of strong emo-
the first year or two after diagnosis with the disor- tions such as anger, aggressiveness, and sexual at-
der, possibly because people often are not diag- traction (Chavira et al., 2003).
nosed until a crisis brings them to the attention of Although borderline personality disorder has
the mental health system. been viewed as a chronic, intractable disorder
A large nationwide study of adults in the United by clinicians, recent studies have shown that over
States found that 5.9 percent could be diagnosed 85 percent of people diagnosed with this disorder
with borderline personality disorder (Zanarini, show remission of symptoms within 10 to 15 years
Frankenburg, et al., 2012). In clinical settings, bor- and that only a minority of those in remission have
derline personality disorder is diagnosed much a relapse of the disorder (Gunderson, Stout, et al.,
more often in women than in men, but the gender 2011; Zanarini et al., 2012). The ability of these indi-
difference in a large nationwide study of adults in viduals to hold a job significantly improved over
the community was small. It is somewhat more the time period studied, but they continued to show
commonly diagnosed in people of color than in difficulty in having stable, positive social relation-
whites, and in people in the lower socioeconomic ships. Stressful life events and lack of social support
classes than in people in other classes (Chavira et al., are triggers for relapse in individuals whose symp-
2003; Grilo, Sanislow, & McGlashan, 2002). A large toms have remitted (Gunderson et al., 2011).
Theories of Borderline Psychoanalytic theorists, particularly those in

Personality Disorder the object relations school (Kernberg, 1979; Klein,
Given the emotional instability characteristic of bor- 1952), suggest that people with borderline person-
derline personality disorder, it is not surprising that ality disorder never learned to fully differentiate
several theorists have argued that people with this their view of themselves from their view of others,
disorder have fundamental deficits in regulating making them extremely reactive to others' opin-
emotion (Baer et al., 2012; Gunderson, 2001; Selby, ions of them and to the possibility of abandon-
Anestis, Bender, & Joiner, 2009). People with border- ment. When they perceive others as rejecting them,
line personality disorder score higher than healthy they reject themselves and may engage in self-
subjects on measures of difficulty in regulating punishment or self-mutilation. They also have
emotion and in laboratory tasks assessing unwill- never been able to integrate the positive and nega-
ingness to tolerate emotional distress in order to tive qualities of either their self-concept or their
reach a goal (Gratz et al., 2010; Rosenthal et al., concept of others, because their early caregivers
2008). In one study, participants carried beepers were rewarding when they remained dependent
that randomly cued them to provide ratings of and compliant but hostile when they tried to sepa-
their moods. People with borderline personality rate from the caregivers. They tend to see them-
disorder showed greater variability in their moods, selves and other people as either all good or all bad
particularly with regard to hostility, fear, and sad- and to vacillate between these two views, a pro-
ness, than people with no personality disorder cess known as splitting. The instability in their
(Trull et al., 2008). emotions and interpersonal relationships is due to
Cognitively, people with borderline personality such splitting, reflecting their vacillation between
disorder are hyperattentive to negative emotional the aU-good and the all-bad self and the aU-good
stimuli in the environment, their memories tend to and the all-bad other.
be more negative, and they tend to make negatively Neuroimaging studies show that the amyg-
biased interpretations of situations (Baer et al., dala and hippocampus of people with borderline
2012). While they frequently try to suppress their personality disorder are smaller in volume than
negative thoughts, their attempts usually are un- those of people without the disorder (Ruocco,
successful, and they end up ruminating about the Amirthavasagam, & Zakzanis, 2012). Recall that
negative thoughts or acting out impulsively or the amygdala is a part of the brain that is impor-
aggressively in response to them (Selby et al., 2009). tant in the processing of emotion and that the
What do these difficulties in processing and hippocampus is involved in the regulation of
regulating emotion stem from? Empirical studies stress and in memory. In addition, people with
have found that people with borderline personal- borderline personality disorder have greater acti-
ity disorder are more likely than people without vation of the amygdala in response to pictures of
the disorder to report a childhood marked by in- emotional faces, which may partly explain the
stability, neglect, and parental psychopathology difficulty they have in regulating their moods
(Gunderson, Zanarini, et al., 2011; Helgeland & (Donegan et al., 2003). Neuroimaging studies also
Torgersen, 2004). They often have a history of phys- have found structural and metabolic abnormali-
ical and sexual abuse during childhood (Afifi et al., ties in the prefrontal cortex of patients with bor-
2011; Martins et al., 2011). This abuse, neglect, and derline personality disorder (Soloff et al., 2012).
instability could contribute to difficulties in regu- This area of the brain is important in the regula-
lating emotions and in attaining a positive, stable tion of emotional reactions and control of impul-
identity through several mechanisms. sive behavior.
Marsha Linehan (Linehan et al., 2001) suggests The neurobiological differences between peo-
that a history of exposure to abuse, neglect, and ple with borderline personality disorder and
criticism by significant others makes it difficult for healthy individuals could be due to genetic fac-
people with borderline personality disorder to learn tors. The disorder runs in families (Gunderson,
appropriate emotion-regulation skills and to under- Zanarini, et al., 2011), and twin studies provide
stand and accept their emotional reactions to events. evidence that the symptoms of borderline person-
People with this disorder come to rely on others to ality disorder are heritable (Distel et al., 2009).
help them cope with difficult situations but do not Early abuse and maltreatment also are associated
have enough self-confidence to ask for this help in with changes in the structure and organization of
mature ways. They become manipulative and indi- the brain, particularly the amygdala and hippo-
rect in their attempt to gain support from others, campus, which may explain in part why child
and their extreme emotional reactions to situations abuse could contribute to the deficits seen in peo-
lead to impulsive actions. ple with the disorder (Ruocco et al., 2012).
Treatment of Borderline for people with borderline personality disorder

Personality Disorder that combines cognitive techniques challenging
One of the first psychotherapies irrational and maladaptive cognitions and be-
shown to have positive effects in havioral techniques addressing self-management
Prefrontal
cortex patients with borderline person- and problem solving. A clinical trial of STEPPS
ality disorder was dialectical be- compared to usual therapy (support plus medi-
havior therapy (Linehan et al., cation) showed that clients receiving STEPPS
Amygdala 2001). This therapy focuses on showed greater improvement in negative affect,
helping clients gain a more realis- impulsivity, and functioning than clients receiv-
tic and positive sense of self, learn ing the usual therapy (Blum et al., 2008). Simi-
The amygdala and the prefrontal
cortex have been implicated in
adaptive skills for solving prob- larly, trials of cognitive-behavioral therapy
borderline personality disorder. lems and regulating emotions, focusing on challenging patients' maladaptive
and correct dichotomous thinking. core beliefs and teaching them more adaptive
Therapists teach clients to monitor self-disparaging ways to function in daily life resulted in signifi-
thoughts and black-or-white evaluations of people cant reductions in hospitalizations and suicide at-
and situations and to challenge these thoughts and tempts, as well as greater improvements in mood,
evaluations. Therapists also help clients learn ap- compared to patients receiving general support
propriate assertiveness skills to use in close rela- (Davidson et al., 2006; Giesen-Bloo et al., 2006).
tionships so that they can express their needs and Psychodynamically oriented therapies also
feelings in a mature manner. Clients may learn how show promise in the treatment of borderline per-
to control their impulsive behaviors by monitoring sonality disorder. Transference-focused therapy
situations most likely to lead to such behaviors and uses the relationship between patient and ther-
learning alternative ways to handle those situa- apist to help patients develop a more realistic
tions. Controlled clinical trials comparing dialecti- and healthier understanding of themselves and
cal behavior therapy to wait list controls have found their interpersonal relationships. Patients with
that the therapy reduces depression, anxiety, and borderline personality disorder receiving this
self-mutilating behavior while increasing interper- therapy showed reductions in suicidality, impul-
sonal functioning (Bohus et al., 2004; Linehan, sivity, aggression, and anger (Clarkin, Levy,
Heard, & Armstrong, 1993). Lenzenweger, & Kernberg, 2007). Mentalization-
Cognitive therapy treatments for borderline based treatment is based on the theory that people
personality disorder have also proven helpful. with borderline personality disorder have funda-
Systems training for emotional predictability and mental difficulty understanding the mental states
problem solving (STEPPS) is a group intervention of themselves and others because of traumatic ex-
periences in childhood and poor attachment to their
caregivers (Fonagy & Bateman, 2008). This psycho-
dynamically oriented therapy provides patients
with validation and support. Further, it attempts to
help patients appreciate alternatives to their own
subjective sense of self and others by using the rela-
tionship between the patient and the therapist, and
the patient and others, to illustrate those alterna-
tives. One long-term study found significant im-
provement in mood and functioning in patients
receiving mentalization-based therapy compared
to patients receiving typical community care.
Also, over a 5-year follow-up, patients receiving
mentalization-based therapy needed less medica-
tion, had fewer suicide attempts, and continued to
function better on several dimensions than patients
receiving the usual care (Bateman & Fonagy, 2008).
The medications that have proven most useful
in the treatment of borderline personality disorder
are the mood stabilizers aripriprazole and la-
Suicidal behavior is common among people with borderline personality motrigine and the atypical antipsychotics, such as
disorder. olanzapine (Lieb et al., 2010; Zanarini, Schulz,
et al., 2012). You might expect serotonin reuptake
~ inhibitors to improve mood and reduce aggres-

points in the interview, going through large
siveness and impulsivity in people with borderline
numbers of tissue. She continually asked for re-
personality disorder, but so far evidence of their
assurance. ("Willi be OK?" "Can I get over this?")
effectiveness is lacking (Lieb et al., 2010). Overall,
She talked nonstop throughout the evaluation.
the results of drug treatment studies have been
When gently interrupted by the evaluator, she
mixed, and adding a drug treatment to an effective
was very apologetic, laughing and saying, " I
psychotherapy such as dialectical behavior ther-
know I talk too much;' yet she continued to do so
apy does not appear to improve recovery rates
(Lieb et al., 2010; Linehan et al., 2001; Paris, 2008; throughout the session. (Beck & Freeman, 1990,
pp. 211-212)
Simpson et al., 2004).
Histrionic Personality Disorder

Histrionic personality disorder shares features National epidemiological survey data from
with borderline personality disorder, including
2001-2002 suggest a prevalence of histrionic per-
rapidly shifting emotions and intense, unstable re- sonality disorder of 1.84 percent (Grant et al.,
lationships. However, people with borderline per-
2004), with women more likely to be diagnosed
sonality disorder also show self-destructiveness,
with the disorder than men in clinical settings.
angry disruptions in close relationships, and
People with this disorder are more likely to be
chronic feelings of inner emptiness, while people
separated or divorced than married (Disney,
with histrionic personality disorder behave in
Weinstein, & Oltmanns, 2012). Like people with
ways to draw attention to themselves across situ-
the somatoform disorders, they tend to exaggerate
ations. A person with borderline personality disor-
medical problems and make more medical visits
der may desperately cling to others as an expression
than the average person, and this group has an in-
of self-doubt and unstable identity, but a person
creased rate of suicidal threats and behavior to co-
with histrionic personality disorder simply wants
erce attentive caregiving (Kraus & Reynolds, 2001;
~ flattering nurturance and preferential attention
Nestadt, Romanowski, Chahal, & Merchant, 1990).
and may be overly trusting of and influenced by
People with this disorder most often seek treat-
others, particularly strong authority figures. Indi-
ment for depression or anxiety (Fabrega, Ulrich,
viduals with histrionic personality disorder pur-
Pilkonis, & Mezzich, 1991).
sue others' attention by being highly dramatic
(e.g., gregarious, exaggerated emotional expres-
Theories of Histrionic
sion) and overtly seductive and by flamboyantly
Personality Disorder
emphasizing the positive qualities of their physical
Although discussions of histrionic personalities
appearance. Others see them as self-centered and
date back to the ancient Greek philosophers, little
shallow, unable to delay gratification, demanding,
is known about causes or effective treatments.
and overly dependent, and they often end up alien-
Family history studies indicate that histrionic per-
ating friends with the demands for constant atten-
sonality disorder clusters in families, along with
tion. Debbie, in the following case study, was
borderline and antisocial personality and somatic
diagnosed with histrionic personality disorder.
symptom disorders (Dahl, 1993). Whether this
disorder is genetically caused or results from pro-
cesses within the family or the environment is
, CASE STUDY unclear.
Debbie was a 26-year-old
woman who worked as a salesclerk in a trendy Treatment of Histrionic
clothing store and who sought therapy for panic Personality Disorder
disorder with agoraphobia. She dressed flam- Psychodynamic treatments focus on uncovering
boyantly, with an elaborate and dramatic hairdo. repressed emotions and needs and helping people
Her appearance was especially striking, since with histrionic personality disorder express these
she was quite short (under 5 feet tall) and at least emotions and needs in more socially appropriate
75 pounds overweight. She wore sunglasses in- ways. Cognitive therapy focuses on identifying cli-
doors throughout the evaluation and constantly ents' assumptions that they cannot function on
fiddled with them, taking them on and off ner- their own and helping them formulate goals and
vously and waving them to emphasize a point. plans for their life that do not rely on the approval
She cried loudly and dramatically at various of others (Beck & Freeman, 1990). Therapists at-
tempt to help clients tone down their dramatic
evaluations of situations by challenging these disorder rely on their inflated self-evaluations and
evaluations and suggesting more adaptive ones. see dependency on others as weak and threatening.
Several case-related studies of treatments that aim As the name implies, grandiosity is a distinguish-
to promote appropriate behavior in daily life con- ing feature, as they are preoccupied with thoughts
texts have shown reductions in self-reported de- of their self-importance and with fantasies of power
pression and interpersonal difficulties (Callaghan, and success, and they view themselves as superior
Summers, & Weidman, 2003; Kellett, 2007). None to most other people. In interpersonal relation-
of the therapies for this disorder have been tested ships, they make entitled demands on others to
empirically. follow their wishes, ignore or devalue the needs
and wants of others, exploit others to gain power,
Narcissistic Personality and are arrogant and condescending. In contrast to
Disorder borderline personality disorder, they do not expe-
rience the same abandonment concerns, despite
Most of us have encountered narcissists before- needing the admiration of others. David, in the fol-
people who think they are better than everyone lowing case study, has been diagnosed with narcis-
else and should get their way in all circumstances sistic personality disorder.
and who will walk all over others to accomplish
their goals. The word narcissist comes from the
Greek myth of Narcissus, who fell in love with
the reflection of himself in a pool, was unable to David was an attorney in
leave it, and died as a result. his early 40s when he sought treatment for de-
The characteristics of narcissistic personality pressed mood. He cited business and marital
disorder are similar to those of histrionic personal- problems as the source of his distress and won-
ity disorder. In both disorders, individuals act in a dered if he was having a midlife crisis. David had
dramatic manner, seek admiration from others, grown up in a comfortable suburb of a large city,
and are shallow in their emotional expressions and the oldest of three children and the only son of a
relationships with others. Whereas people with successful businessman and a former secretary.
histrionic personality disorder look to others for David spoke of being an "ace" student and a
approval, people with narcissistic personality "super" athlete but could not provide any details
that would validate a superior performance in
these areas. He also recollected that he had his
pick of girlfriends, as most women were "thrilled"
to have a date with him.
David went to college, fantasizing about be-
ing famous in a high-profile career. He majored
in communications, planning to go on to law
school and eventually into politics. He met his
first wife during college, the year she was the
university homecoming queen. They married
shortly after their joint graduation . He then went
on to law school, and she went to work to sup-
port the couple.
During law school, David became a worka-
holic, fueled by fantasies of brilliant work and
international recognition. He spent minimal time
with his wife and, after their son was born, even
less time with either of them. At the same time,
he continued a string of extramarital affairs,
mostly brief sexual encounters. He spoke of his
wife in an annoyed, devaluing way, complaining
about how she just did not live up to his expecta-
tions. He waited until he felt reasonably secure in
his first job so that he could let go of her financial
support and then he sought a divorce. He contin-
The word narcissist comes from the Greek myth of ued to see his son occasionally, but he rarely
Narcissus, who fell in love with the reflection of himself
paid his child support.
in a pool. was unable to leave it. and died as a result.
positive view of themselves or adaptive strategies

After his divorce, David decided that he was for handling stress and distress as children, so they
totally free to just please himself. He loved rely on the praise and domination of others for
spending all his money on himself, and he lav- their self-esteem (Kernberg, 1993; Kohut, 1977).
ishly decorated his condominium and bought an Cognitive theorists have argued that some people
attention-getting wardrobe. He constantly sought with narcissistic personality disorder develop un-
the companionship of attractive women. He was realistically positive assumptions about their self-
very successful at making initial contacts and worth as the result of indulgence and overvaluation
getting dates, but he rarely found anyone good by significant others during childhood (Beck &
enough to date more than once or twice. Freeman, 1990). Other people with this disorder
At work, David believed that because he was develop the belief that they are unique or excep-
" different" from other people, they had no right tional as a defense against rejection or unmet ba-
to criticize him. But he had every right to criticize sic emotional needs by important people in their
others. He also believed that other people were lives. One study found that people diagnosed with
weak and needed contact with someone like him narcissistic personality disorder were significantly
in order to bring direction or pleasure into their more likely to endorse beliefs such as "I don't have
lives. He saw no problem in taking advantage of to be bound by rules that apply to other people"
other people if they were "stupid" enough to al- than were people diagnosed with other disorders
low him to do so. (Adapted from Beck & Freeman, (Becket al., 2001).
1990, pp. 245-247) Aaron Pincus and Mark Lukowitzky (2010)
emphasize that narcissists can be both grandiose
and vulnerable. The grandiose narcissist copes
People with narcissistic personality disorder can with difficulties in self-esteem by viewing himself
be successful in societies that reward self-confidence as superior and unique and by engaging in grandi-
and assertiveness, such as the United States (Millon ose fantasies. Such people are entitled, exploit-
et al., 2000). When they grossly overestimate their ative, envious, and aggressive, particularly when
abilities, however, they can make poor choices in distressed. They may engage in criminal or violent
their careers and may experience many failures, and acts toward others. The vulnerable narcissist copes
they annoy and often alienate the important people with difficulties in self-esteem by engaging in
in their lives (Miller, Campbell, & Pilkonis, 2007). grandiose fantasies to quell intense shame. Such
People with this disorder seek treatment most often people are hypersensitive to rejection and criticism
for depression and for trouble adjusting to life stres- and thus avoid others. There is evidence of these
sors (Fabrega, Ulrich, Pilkonis, & Mezzich, 1991). two subtypes of narcissism in the behaviors and
A nationwide study in the United States found thoughts endorsed by people who have narcissis-
that 7.7 percent of men and 4.8 percent of women tic personality disorder or who score high on mea-
could be diagnosed with narcissistic personality sures of narcissism (Pincus & Lukowitzky, 2010;
disorder (Stinson et al., 2008). These data also sug- Ronningstam, 2011).
gest that narcissistic personality disorder is more Like borderline personality disorder, narcissis-
prevalent among younger adults, possibly sup- tic personality disorder is associated with a history
porting the impression that narcissistic personality of childhood adversity, including physical abuse
disorder is on the rise as a result of social and eco- and neglect, and with having a parent who was
nomic conditions that support more extreme ver- abused or who had a mental health problem (Afifi
sions of self-focused individualism (Bender, 2012). et al., 2011).
People diagnosed with the disorder have high
rates of substance abuse and of mood and anxiety Treatment of Narcissistic
disorders. In addition, they have increased rates of Personality Disorder
physical and sexual aggression, impulsivity, homi- People with narcissistic personality disorder tend
cidal thoughts, and suicidal behaviors (Pincus et al., not to seek treatment except when they develop
2009; Ronningstam, 2011). depression or are confronted with severe interper-
sonal problems (Ronningstam, 2011). In general,
Theories of Narcissistic they see any problems they encounter as due to the
Personality Disorder weakness and problems of others. Not surpris-
Psychodynamically oriented theorists suggest that ingly, narcissistic personality traits pose significant
the symptoms of narcissistic personality disorder challenges to the development of a stable working
are maladaptive strategies for managing emotions alliance between a client and therapist. By empha-
and self-views (Ronningstam, 2011). People with sizing a collaborative therapeutic approach, ather-
this disorder did not develop a realistically apist using cognitive techniques can help these
TABLE 9.8 Cluster C: Anxious-Fearful Personality Disorders
People with the anxious-fearful personality disorders are often anxious or fearful.
Label Key Features Similar Disorders
Avoidant personality A pattern of social inhibition, feelings of inadequacy, Social phobia

disorder and a fear of being criticized, which lead to the
avoidance of social interactions and nervousness
Dependent personality A pattern of submissive and clinging behavior Separation anxiety disorder,
disorder related to an excessive need to be taken care of, persistent depressive disorder
and leading to high levels of dependence on others {dysthymia)
Obsessive-compulsive A pattern of preoccupation with orderliness, Obsessive-compulsive
persona lity disorder extreme perfectionism, and control, leading to disorder
emotional constriction, rigidity in one's activities
and relationships, and anxi ety about even minor
disruptions in one's routines
clients develop more realistic expectations of their thus avoid interactions in which there is any possi-
abilities and more sensitivity to the needs of others bility of being criticized (see Table 9.9). They might
by teaching them to challenge their initially self- choose occupations that are socially isolated, such as
aggrandizing ways of interpreting situations (Beck wilderness park rangers. The two pathological per-
& Freeman, 1990). Such self-understanding and sonality traits that characterize them are negative a- ,.-...
changes in self-serving biases don't come easily for fectivity and detachment. When they must interact
people with narcissistic personality disorder, and with others, people with avoidant personality disor-
often they do not remain in therapy once their der are restrained, nervous, and hypersensitive to
acute symptoms or interpersonal problems lessen. signs of being evaluated or criticized. They are terri-
Like histrionic personality disorder, however, no fied of saying something silly or doing something
systematic psychotherapy or medication treatment to embarrass themselves. They tend to be depressed
studies have been published (Dhawan et al., 2010; and lonely. While they may crave relationships
Stoffers et al., 2011). with others, they feel unworthy of these relation-
ships and isolate themselves, as the following case
study illustrates.
CLUSTER C:
ANXIOUS-FEARFUL
PERSONALITY DISORDERS
CASE STUDY
The cluster C anxious-fearful personality disorders- Ruthann is a 32-year-old
avoidant personality disorder, dependent per- postal employee who petitioned her supervisors
sonality disorder, and obsessive-compulsive to assign her to a rural route where she wouldn't
personality disorder-are characterized by a chronic have to talk with anyone most of the day. Ruthann
sense of anxiety or fearfulness and behaviors in- has always been terrified of interacting with oth-
tended to ward off feared situations (Table 9.8). Peo- ers, believing that they would judge her. When
ple with each of the three disorders fear something she was forced to interact, she was sure other
different, but they are all nervous and unhappy. people found her stupid and ugly and caught the
many "social mistakes" she felt she committed in
Avoidant Personality Disorder these interactions. Ruthann lived alone and did
not date because she was sure men would find
People with avoidant personality disorder have
her unattractive and silly and would reject her.
low self-esteem, are prone to shame, and are ex-
tremely anxious about being criticized by others and
Cluster C : Anxious-Fearful Personality Disorders 271
TABLE 9.9 Avoidant Personality Disorder
People with avoidant personality disorder may choose professions that allow them to avoid other people.
-Symptoms include:
Prone to shame
Hypersensitive to criticism
Restrained and detached
Isolated from others
Severe anxiety about social situations
-Prevalence rate is 2.4 percent of general population
-More commonly diagnosed in females than in males
-Frequently accompanied by depress ion and anxiety
Nationwide studies in the United States find have a strong relationship to sexual or physical
that 2.4 percent of people can be diagnosed with abuse in childhood, although people with this dis-
avoidant personality disorder, with more women order do report higher rates of emotional neglect
than men diagnosed (Grant, Hasin, et al., 2004). (Afifi et al., 2011).
People with this disorder are prone to persistent Cognitive theorists suggest that people with
depressive disorder, including bouts of major de- avoidant personality disorder develop dysfunc-
pression and severe anxiety (Grant, Stinson, et al., tional beliefs about being worthless as a result of
2004). rejection by important others early in life (Beck &
There is overlap between the characteristics Freeman, 1990). They contend that children whose
of avoidant personality disorder and those of parents reject them conclude, "If my parents don't
social anxiety disorder (see Chapter 5), so much like me, how could anyone?" Thus, they avoid
so that they may be alternate forms of the same interactions with others. Their thoughts are of this
disorder. In particular, people with either disor- sort: "Once people get to know me, they see I'm
der are highly self-critical about their social inter- really inferior." When they must interact with oth-
actions (Cox et al., 2011). People with avoidant ers, they are unassertive and nervous, thinking,
personality disorder tend to have more severe "I must please this person in every way or she will
and generalized anxiety about social situations criticize me." They also tend to discount any posi-
than people with social anxiety disorder and are tive feedback they receive from others, believing
more impaired by their anxiety (Huppert et al., that other people are simply being nice or do not
2008) . Nonetheless, they also may desire accep- see how incompetent they really are. A study of
tance and affection and sometimes fantasize about 130 patients with avoidant personality disorder
idealized relationships with others. found that they endorsed such beliefs more often
than patients with other personality disorders
(Becket al., 2001).
Theories of Avoidant
Twin studies show that genetics plays a role in Treatment of Avoidant
avoidant personality disorder and that the same Personality Disorder
genes likely are involved in avoidant personality Cognitive and behavioral therapies have proven
disorder and social anxiety disorder (Reichborn- helpful for people with avoidant personality dis-
Kuennerud et al., 2007). Unlike other personality order. These therapies have included graduated
disorders, avoidant personality disorders does not exposure to social settings, social skills training,
care and support. They deeply fear the loss of re-

lationship supports and the prospect of having to
assume independent responsibility, and they may
allow themselves to be exploited and abused to
maintain relationships, as in the following case of
Francesca.
CASE STUDY
Francesca was in a panic
because her husband seemed to be getting in-
creasingly annoyed with her. Last night, he be-
came very angry when Francesca asked him to
People with avoidant personality disorder may choose professions that allow cancel an upcoming business trip because she
them to avoid other people. was terrified of being left at home alone. In a rage,
her husband shouted, "You can't ever be alone!
You can't do anything by yourself! You can't even
and challenges to negative automatic thoughts decide what to have for dinner by yourself! I'm
about themselves and social situations. People resick of it. Grow up and act like an adult!"
ceiving these therapies show increases in the fre- It was true that Francesca had a very difficult
quency and range of social contacts, decreases in time making decisions for herself. While she was
avoidance behaviors, and increases in comfort and in high school, she couldn't decide which courses
satisfaction when engaging in social activities to take and talked with her parents and friends
(Emmelkamp et al., 2006; Pretzer, 2004). for hours about what she should do, finally do-
The serotonin reuptake inhibitors are some- ing whatever her best friend or her mother told
times used to reduce the social anxiety of people her to do. When she graduated from high school,
with avoidant personality disorder, but little re- she didn't feel smart enough to go to college,
search on their effectiveness in treating avoidant even though she had gotten good grades in
personality disorder has been done (Ripoll, high school. She drifted into a job because her
Triebwasser, & Siever, 2011). best friend had a job with the same company
and she wanted to remain close to that friend.
The friend eventually dumped Francesca, how-
Dependent Personality ever, because she was tired of Francesca's in-
Disorder cessant demands for reassurance. Francesca
frequently bought gifts for the friend and offered
People with dependent personality disorder are
to do the friend's laundry or cooking, in obvious
anxious about interpersonal interactions, but their
attempts to win the friend's favor. But Francesca
anxiety stems from a deep need to be cared for by
also kept the friend for hours in the evening,
others, rather than from a concern that they will
asking her whether she thought Francesca had
be criticized. Their desire to be loved and taken
made the right decision about some trivial issue,
care of by others leads people with dependent
such as what to buy her mother for Christmas
personality disorder to deny any of their own
and how she thought Francesca was performing
thoughts and feelings that might displease others
on the job.
and result in disagreements, to submit to even the
Soon after her friend dumped her, Francesca
most unreasonable or unpleasant demands, and
met her future husband, and when he showed
to cling frantically to others. People with this per-
some interest in her, she quickly tried to form a
son~l~ty di~order have difficulty making everyday
close relationship with him. She liked the fact
deCisiOns, mstead heavily relying on others for
that he seemed strong and confident, and when
advice and reassurance, and they do not initiate
he asked her to marry him, Francesca thought
new activities except in an effort to please others.
that perhaps finally she would feel safe and se-
Ir: contrast to people with avoidant personality
cure. But especially since he has begun to get
disorder, who avoid relationships unless certain
angry with her frequently, Francesca has been
of being liked, people with dependent personality
worrying constantly that he is going to leave her.
disorder can function only within a relationship
and will overly accommodate others to obtain
Cluster C: Anxious-Fearful Personality Disorders 273
National epidemiologic survey data suggest a dependent behaviors, often by examining their re-
relatively low estimated lifetime prevalence of lationship style with the therapist and interpreting
dependent personality disorder of 0.49 percent the transference process. Nondirective and hu-
(Grant et al., 2004). Higher rates of the disorder manistic therapies may be helpful in fostering au-
are found with self-report methods than with tonomy and self-confidence in persons with
structured clinical interviews, suggesting that dependent personality disorder (Millon et al.,
many people feel they have this disorder when 2000).
clinicians would not diagnose it in them. More Cognitive-behavioral therapy for dependent
women than men are diagnosed with this disor- personality disorder includes behavioral tech-
der in clinical settings (Fabrega et al., 1991). De- niques designed to increase assertive behaviors
pressive and anxiety disorders commonly co-occur and decrease anxiety, as well as cognitive tech-
in people with dependent personality disorder, niques designed to challenge clients' assumptions
often triggered by interpersonal conflict or rela- about the need to rely on others (Beck & Freeman,
tionship disruption (Bornstein, 2012; Grant, 1990). Clients might be given graded exposure to
Stinson, et al., 2004). Dependent personality disor- anxiety-provoking situations, such as making ev-
der increases the risk for physical illness, partner eryday and then more important decisions inde-
and child abuse, suicidal behavior, and high levels pendently and in a graded fashion . For example,
of functional impairment and health care costs they and their therapists might develop a hierar-
(Bornstein, 2012; Loas, Cormier, & Perez-Diaz, chy of increasingly difficult independent actions
2011). that the clients gradually attempt on their own,
beginning with deciding what to have for lunch
and ending with deciding what job to take. After
Theories of Dependent making each decision, clients are encouraged to
Personality Disorder recognize their competence and to challenge any
Dependent personality disorder runs in families, negative thoughts they had about making the deci-
and one twin study estimated the heritability of sion. They also may be taught relaxation skills to
this disorder to be .81 (Coolidge et al., 2004). Chil- enable them to overcome their anxiety enough to
dren and adolescents with a history of separation engage in homework assignments. Regardless of
anxiety disorder or chronic physical illness appear the therapeutic approach, it is important for the
to be more prone to developing dependent person-
therapist to consider the dependent person's social
ality disorder. network, and sometimes marital or family therapy
Cognitive theories argue that people with de-
can help elucidate relationship patterns that foster
pendent personality disorder have exaggerated
dependency, reinforce feelings of helplessness and
and inflexible beliefs related to their depending
anxiety, and interfere with independent decision-
needs, such as "I am needy and weak/' which in
making (Bornstein, 2012).
turn drive their dependent behaviors. A study of
38 patients with dependent personality disorder
found that they endorsed such beliefs more often Obsessive-Compulsive
than patients with other personality disorders Personality Disorder
(Becket al., 2001).
Self-controt attention to detait perseverance, and
reliability are highly valued in many societies, in-
Treatment of Dependent cluding U.S. society. Some people, however, de-
Personality Disorder velop these traits to an extreme and become rigid,
Unlike people with many of the other personality perfectionistic, dogmatic, ruminative, and emo-
disorders, persons with dependent personality tionally blocked. These people are said to have
disorder frequently seek treatment (Millon et al., obsessive-compulsive personality disorder. Peo-
2000) and are likely to show greater insight and ple with this disorder base their self-esteem on
self-awareness. Their desire to strengthen ties to their productivity and on meeting unreasonably
caring authority figures likely facilitates early de- high goals. They are compulsive; preoccupied
velopment of a positive working alliance with the with rules, details, and order; and perfectionistic.
therapist (Paris, 1998). Although many psychoso- They tend to persist in a task even when their ap-
cial therapies are used in the treatment of this dis- proach is failing, leading them to experience nega-
order, none have been systematically tested for tive affect. Interpersonally, they have difficulty
their effectiveness. Psychodynamic treatment fo- appreciating others or tolerating their quirks and
cuses on helping clients gain insight into the early may be rigidly bound to rules. They are often stub-
experiences with caregivers that led to their born and may force others to follow strict standards
SHADES OF GRAY
Ellen Farber, a single 35-year-old insurance com- employers and another $100,000 to various local
pany executive, came to a psychiatric emergency banks due to spending sprees.
room of a university hospital with complaints In addition to lifelong feelings of emptiness,
of depression and the thought of driving her car Ms. Farber described chronic uncertainty about what
off a cliff. . . . She reported a 6-month period she wanted to do in life and with whom she wanted
of increasingly persistent dysphoria and lack of to be friends. She had many brief, intense relation-
energy and pleasure. Feeling as if she were ships with both men and women, but her quick tem-
"made of lead;' Ms. Farber had recently been per led to frequent arguments and even physical
spending 15 to 20 hours a day in her bed. She fights. Although she had always thought of her child-
also reported daily episodes of binge-eating, hood as happy and carefree, when she became de-
when she would consume "anything I can find;' pressed she began to recall episodes of abuse by her
including entire chocolate cakes or boxes of mother. Initially, she said she had dreamt that her
cookies. She reported problems with intermit- mother had pushed her down the stairs when she
tent binge-eating since adolescence, but these was only 6, but then she began to report previously
episodes had recently increased in frequency, unrecognized memories of beatings or verbal as-
resulting in a 20-pound weight gain over the past saults by her mother. Reprinted with permission
few months . ... from the DSM-V Casebook: A Learning Companion
She attributed her increasing symptoms to fi- to the Diagnostic and Statistical Manual of Mental
nancial difficulties. Ms. Farber had been fired from Disorders, Fifth Edition, (Copyright 2013). American
her job 2 weeks before com ing to the emergency Psychiatric Publishing, Inc.
room. She claimed it was because she "owed a
small amount of money:' When asked to be more What diagnosis would you give Ms. Farber?
specific, she reported owing $150,000 to her former (Discussion appears at the end of this chapter.)
of performance. Many of the disorder's features "inferiors." Although they are extremely con-
overlap with "type A" personality characteristics. cerned with efficiency, their perfectionism and ob-
This disorder shares features with obsessive- session about following rules often interfere with
compulsive disorder (OCD; see Chapter 5) and completing tasks and getting along with others, as
has a moderately high comorbidity with OCD in the following case study.
(Lochner et al., 2011). But obsessive-compulsive
personality disorder involves a more general
way of interacting with the world than does
obsessive-compulsive disorder, w hich often in- CASE STUDY
Ronald Lewis is a 32-year-
volves only specific obsessional thoughts and
old accountant who is "having trouble holding
compulsive behaviors. While people with obsessive-
on to a woman:' He does not understand why,
compulsive disorder will be focused on very spe-
but the reasons become very clear as he tells his
cific thoughts, images, ideas, or behavior and
story. Mr. Lewis is a remarkably neat and well-
may feel very anxious if they do not engage in
organized man who tends to regard others as an
these (e.g., becoming anxious if they cannot check
interference to the otherwise mechanically per-
whether they have turned off the stove), people
fect progress ion of his life. For many years he
with obsessive-compulsive personality disorder
has maintained an almost inviolate schedule. On
will be more generally prone to being perfectionis-
weekdays he arises at 6:47, has two eggs soft-
tic, rigid, and concerned with order.
boiled for 2 minutes, 45 seconds, and is at his
People with obsessive-compulsive personality
desk at 8:15. Lunch is at 12:00, dinner at 6:00,
disorder often seem grim and austere, tensely in
bedtime at 11:00. He has separate Saturday and
control of their emotions, and lacking in spontane-
Sunday schedules, the latter characterized by a
ity (Millon et al., 2000). They are workaholics who
methodical and thorough trip through the New
see little need for leisure activities or friendships.
York Times. Any change in schedule causes him
Other people experience them as stubborn, stingy,
to feel varying degrees of anxiety, annoyance,
possessive, moralistic, and officious. They tend to
and a sense that he is doing something wrong
relate to others in terms of rank or status and are
and wasting time.
ingratiating and deferential to "superiors" but dis-
missive, demeaning, or authoritarian toward
Cluster C: Anxious-Fearful Personality Disorders 275
Orderliness pervades Mr. Lewis's life. His

apartment is immaculately clean and meticu-
lously arranged. His extensive collections of
books, records, and stamps are all carefully cata-
logued, and each item is reassuringly always in
the right and familiar place. Mr. Lewis is highly
valued at his work because his attention to detail
has, at times, saved the company considerable
embarrassment. . . . His perfectionism also pres-
ents something of a prob lem, however. He is the
slowest worker in the office and probably the
least productive. He gets the detai ls right but
may fail to put them in perspective. His relation-
sh ips to co-workers are cordial but formal. He is
on a "Mr. and Ms:' basis with people he has
known for years in an office that generally favors People with obsessive-compulsive personality disorder are very concerned
with orderliness.
first names. Mr. Lewis's major problems are with
women and follow the same repetitive pattern.
At first, things go well. Soon, however, he be-
gins to resent the intrusion upon his schedule a
woman inevitably causes. This is most strongly il-
lustrated in the bedtime arrangements. Mr. Lewis Theories of Obsessive-Compulsive
is a light and nervous sleeper with a rather elabo- Personality Disorder
rate routine preced ing his going to bed. He must Cognitive theories suggest that people with this
spray his sinuses, take two aspirin, straighten up disorder harbor beliefs such as "Flaws, defects, or
the apartment, do 35 sit-ups, and read two pages mistakes are intolerable." One study found that
of the dictionary. The sheets must be of just the people diagnosed with obsessive-compulsive per-
right crispness and temperature and the room sonality disorder endorsed such beliefs signifi-
must be noiseless. Obviously, a woman sleeping cantly more often than people diagnosed with
over interferes with his inner sanctum and, after other personality disorders (Becket al., 2001), but a
sex, Mr. Lewis tries either to have the woman go more recent study found that they did not (Arntz,
home or sleep in the living room. No woman has Weertman, & Salet, 2011).
put up with this for very long. (From Spitzer, R. L., Obsessive-compulsive personality disorder ap-
Skodol, A. E., Gibbon, M ., & Williams, J. B. W., pears to be related to genetic factors similar to those
1983, Psychopathology: A Case Book, pp. 63-64. found in obsessive-compulsive disorder (Lochner
Copyright 1983 The McGraw-Hill Compan ies, et al., 2011; Taylor, Asmundson, & Jang, 2011). Peo-
Inc. Reprinted w ith Permission. ple with obsessive-compulsive personality disorder
have a slightly greater history of physical neglect
than people with no disorder (Afifi et al., 2011).
Treatment of Obsessive-Compulsive
Obsessive-compulsive personality disorder is Personality Disorder
the most prevalent personality disorder, with up There are no controlled psychological treatment
to 7.9 percent of the U.S. population meeting the studies focusing primarily on obsessive-compulsive
criteria for a diagnosis and no gender differences personality disorder, and only one medication
in its prevalence (Grant, Hasin, et al., 2004). Peo- trial. Supportive therapies may assist people with
ple with this disorder are prone to depressive, this disorder in overcoming the crises that bring
anxiety, and eating disorders, but not to the same them in for treatment, and behavioral therapies
extent as people with the other personality dis- can decrease their compulsive behaviors (Beck &
orders already discussed (Grant, Stinson, et al., Freeman, 1990; Millon et al., 2000). For example, a
2004). Interestingly, the majority of individuals client may be given the assignment to alter his
with OCD do not also have obsessive-compulsive usual rigid schedule for the day, first by simply get-
personality disorder, but when they co-occur ting up 15 minutes later than usual and then by
OCD and depression symptoms are more severe gradually changing additional elements of his
(Gordon, Salkovskis, et al., 2013) . schedule. The client may be taught to use relaxation
techniques to overcome the anxiety created by al- studies found that people diagnosed with these
terations in the schedule. He might also write down disorders varied over time in how many symp-
the automatic negative thoughts he has about toms they exhibited and in the severity of these
changes in the schedule ("Getting up 15 minutes symptoms, going into and out of the diagnosis
later is going to put my entire day off"). In the next (Shea et al., 2002). In particular, people often
therapy session, he and the therapist might discuss seemed as if they had a personality disorder when
the evidence for and against these automatic they were suffering from an acute disorder, such as
thoughts, gradually replacing maladaptive thoughts major depressive disorder, but then their personal-
and rigid expectations with more flexible beliefs and ity disorder symptoms seemed to diminish when
attitudes that include valuing close relationships, their depressive symptoms subsided. Finally, de-
leisure and recreation, and feelings. Sometimes the spite having 10 different personality disorder diag-
selective serotonin reuptake inhibitor medications noses, the DSM criteria did not fit many people
(e.g., Prozac) may be used to reduce obsessionality. who seemingly had pathological personalities, nor
did the criteria reflect the extensive literature on
fundamental personality traits that are consistent
across cultures (Verheul & Widiger, 2004).
ALTERNATIVE DSM-5 The alternative DSM-5 model characterizes
MODEL FOR PERSONALITY personality disorders in terms of impairments in
personality functioning and pathological person-
DISORDERS ality traits. The first step in diagnosing a personal-
The DSM-5's definition of personality disorder ity disorder is determining an individual's level
and the criteria used for diagnosing the personal- of functioning in terms of their sense of self (or
ity disorders reviewed in this chapter have not identity) or their relationships with others on a
changed from those in the DSM-IV-TR. In fact, its scale. Disturbances in self and interpersonal func-
categorical scheme for understanding personality tioning are at the core of personality psychopa-
disorders has remained in place for over 30 years thology and are evaluated on a continuum based
since the publication of the DSM-III in 1980. How- on the Level of Personality Functioning Scale.
ever, the DSM-5 includes an alternative model for Note that there are five levels of impairment,
diagnosing personality disorders that incorporates ranging from little or no impairment (Level 0,
a dimensional, or continuum, perspective. It is pre- healthy adaptive functioning) to extreme impair-
sented in a separate section of the DSM-5 desig- ment (Level 4). By definition, a moderate level of
nated for further study (Section III) and is not impairment (Level 2) is required for the diagnosis
meant for current clinical use. It is reviewed here of a personality disorder.
to provide a perspective on the evolution of the The second step in diagnosing a personality
diagnosis of personality disorders, as well as one disorder is determining whether the individual has
approach to responding to the problems with a any pathological personality traits. Although there
categorical diagnostic system. is tremendous variability across people in the spe-
Over the years, many limitations of the DSM's cific nature of their personalities, as noted at the be-
categorical approach to the diagnosis of personal- ginning of this chapter (e.g., the Big 5), there appears
ity disorders have been recognized by clinicians to be a relatively small set of personality traits or
and researchers (Kupfer, First, & Regier, 2002; dimensions along which people's personalities
Bernstein et al., 2007). Some of the most significant vary (Krueger et al., 2011; McCrae & Terracciano,
limitations include that the 10 separate personality 2005). One fundamental trait is the extent to which
disorders have a good deal of overlap in their di- people tend to be even-tempered and calm, secure,
agnostic criteria (Grant et al., 2005; Zimmerman, and able to handle stress or emotionally labile,
Rothschild, & Chelminski, 2005). There was poor insecure, and overreactive to stress, a dimension
agreement among clinicians as to whether individ- referred to in personality theories as neuroticism
uals met the criteria for these disorders (Trull & (McCrae & Costa, 1999) or in DSM-5 alternative
Durrett, 2005; Zanarini et al., 2000) . Although model terms as negative affectivity. A second
the personality disorders are conceptualized as core personality trait domain involves the ex-
stable characteristics of an individual, longitudinal tent to which people are appropriately outgoing
Alternative OSM-5 Model for Personality Disorders 277
A core personality trait involves the extent to which people are appropriately outgoing and trusting of others (left) or
tend to be withdrawn, avoidant. and untrusting.
and trusting of others or tend to be withdrawn, certain types of dysfunction (Krueger et al., 2011;
avoidant, and untrusting, a dimension the alter- Watson, Clark, & Chmielewski, 2008). People high
native DSM-5 model labels detachment. The on this dimension have highly unusual beliefs and
third dimension, which the DSM-5 calls antago- perceptions and tend to be quite eccentric.
nism, is anchored at the positive end by charac- Taken together, the alternative DSM-5 model
teristics such as honesty, appropriate modesty, specifies that, in order to diagnose an individual
and concern for others and at the negative end with a personality disorder, he or she must show
by characteristics such as deceitfulness, grandi- significant difficulties in identity and interper-
osity, and callousness. A fourth core personality sonal functioning and significant pathological
trait domain, called disinhibition, ranges from a personality traits. In addition, these difficulties
tendency to be responsible, organized and cau- and traits must be unusual for the individual's de-
tious to a tendency to be impulsive, risk-taking, velopmental stage and sociocultural environment.
and irresponsible. For example, if an individual believed he could
The alternative DSM-5 model includes a fifth speak to dead relatives but this was a common
dimension, psychoticism, that captures personal- belief in his culture, then he might not be rated
ity characteristics that are relatively rare in the high on the psychoticism trait domain. Finally, these
general population but are important aspects of difficulties and pathological traits cannot be due to
Antisocial personality disorder is associated with a history of adversity in childhood

including abuse. neglect. and parental instability.
ingesting a substance, such as hallucinatory percep- which pathological personality traits the person
tions while on a narcotic, or to a medical condition, has. Thus, the DSM-5 approach to personality dis-
such as a blow to the head, or better explained by orders is a hybrid model; that is, it combines a dimen-
another mental disorder. sional or continuum approach with the categorical
Although the DSM-5 explicitly incorporates a approach more typical of other types of disorders.
continuum approach into its general criteria in the This hybrid dimensional-categorical model
alternative model for a personality disorder, it also and its components aim to address the significant
includes six specific personality disorders with limitations of a purely categorical approach to per-
which individuals may be diagnosed: antisocial, sonality disorders. The authors of the DSM-5 in-
avoidant, borderline, narcissistic, obsessive-compulsive, cluded the model in a separate section of the
and schizo typal. Note that four personality disorders manual to encourage research that might support
discussed in this chapter are not specifically recog- the model in the diagnosis and care of people with
nized in the alternative model. personality disorders, as well as contribute to im-
The third step in the diagnosis of personality disproved understanding of the causes and treat-
orders is determining whether individuals meet the ments of personality pathology. Future research
criteria for any of these six disorders. If an individual relating the alternative DSM-5 model to general
doesn't meet the criteria for any of these disorders personality traits (e.g., the Big 5) might also facili-
but still has significant difficulties in his or her sense tate integration of normal and pathological per-
of self and relationships together with pathological sonality (Gore & Widiger, 2013).
personality traits, the diagnosis personality disorder-
trait specified is given. For example, a person who
does not meet the definition for antisocial, avoidant,
borderline, narcissistic, obsessive-compulsive, or
schizotypal personality disorder but is highly prone
CHAPTER INTEGRATION
to being anxious about whether other people like Several of the personality disorders discussed in
him and also behaves irresponsibly in an attempt to this chapter, as well as antisocial personality dis-
get attention from others might be diagnosed as hav- order (see Chapter 11), are associated with a his-
ing personality disorder- trait specified. tory of adversity in childhood, including abuse
When clinicians diagnose someone with per- and neglect, and parental instability and psycho-
sonality disorder-trait specified, they then specify pathology (Afifi et al., 2011). There are a number
of possible explanations for this relationship (see

An Integrated Model
FIGURE 9.1 Figure 9.1). It may be the result of genetic factors
of the Personality
that create both parental psychopathology (which
Disorders. A difficult
leads to neglectful and abusive parenting and an
temperament may combine with ineffective
unstable household) and vulnerability to a per-
parenting to lead to personality disorders.
sonality disorder in children. Abuse and neglect,
along with a genetic predisposition, may produce
Biological predisposition to permanent changes in the developing brain of
a difficult temperament some children that result in symptoms of certain
personality disorders (Ruocco et al., 2012). Abuse,
neglect, and poor parenting resulting from paren-
Parenting that is harsh, critical, tal psychopathology could also lead children to
or unsupportive or is alternately develop maladaptive ways of thinking about
overprotective and indulgent themselves and the world and poor regulation of
their emotions (Beck & Freeman, 1990; Millon et
al., 2000). Genetic factors may also contribute to
Behavioral and emotional the children developing maladaptive cognitions
dysregulation; maladaptive beliefs and emotion regulation strategies. Children who
about the self show early symptoms of personality disorders
likely are more difficult to parent, which may lead
to more hostile or neglectful behavior on the
Negative reactions from peers part of their parents. On the other hand, children
and adults born with a vulnerability to personality disorder
symptoms but have parents who validate their
children's emotional experiences, are responsive
to their needs, and help them develop an appro-
Worsening of temperamental
difficulties in controlling emotions priate view of themselves and adaptive ways to
and behaviors cope with stress and relate to the world may never
develop a full-blown personality disorder.
SHADES OF GRAY DISCUSSION !review p. 274l
Ms. Farber shows signs of a mood disorder, with sense of herself and her relationships suggest
dysphoria, lack of energy or pleasure, and suicidal borderline personality disorder. This case illus-
thoughts. Her sleeping and eating patterns have trates a common problem clinicians face in mak-
changed dramatically as well. This could suggest ing the diagnosis of a personality disorder: People
that she has a major depressive disorder, but with a personality disorder often come to the at-
other details of her story point to the possibility of tention of mental health professionals when they
a personality disorder. Ms. Farber's spending are in a crisis, making it difficult to diagnose
sprees, intense and even violent relationships whether they have an acute disorder, such as de-
with others, feelings of emptiness, and unstable pression, and/or a personality disorder.
THINK CRITICALLY
Borderline personality disorder is diagnosed much applications of the diagnosis of borderline personal-
more often in women than in men in clinical ity disorder might account for more women than
settings, but epidemiological studies of the general men being diagnosed in clinical settings? Why or
public show it to be only slightly more prevalent in why not? (Discussion appears on p. 475 at the back
women than men (Zanarini, Frankenburg, et al., of this book.)
2012). Do you think gender biases in clinicians'
280 Chapter 9 Persona lity Disorders
CHAPTER SUMMARY ~
Perso nal ity is enduring patterns of perceiving , instabil ity in self-concept, emotional regulation,
feeling, thinking about , and rel ating to oneself and interpersonal relationships, along with
and the environment. A personality trait is a impulsive behavior. People with histrionic per-
prominent aspect of personality that is relatively sonality disorder show rapidly shifting moods,
consistent across time and situations. unstable relationships, a need for attention and
approval, and dramatic, seductive behavior.
The DSM-5 defi nes personality disorder as an
People with narcissistic personality disorder
enduring patt ern of inner experience and behav-
show grandiosity, arrogance, and exploitation
ior (e .g., ways of perceiving and interpreting se lf,
of others.
others, events; emotional responses; impu lse
control; interperso nal functioning) that deviates Theories of borderline personality disorder argue
markedly from the expectations of an individual's that it is due to difficulties in self-concept and
culture. The personality pattern is pervasive and regulating emotions. These difficulties may be
inflexible ac ross time and situations, with onset related to childhood adversity (especially abuse),
in adolescence or early adulthood, and leads to which is commonly (though not always) reported
clinical ly significant distress and/or functional by people with this disorder. The disorder is also
impairment. associated with smaller volume in the hippocam-
Like DSM-IV- TR, the DSM-5 takes a categorical pus and amygdala, greater reactivity of the
approach toward classifying personality disor- amygda la to emotional stimuli, and less activity
ders and assumes that there is a dividing line in the prefrontal cortex, possibly leading to
between normal perso nal ity and pathological impulsive behavior and emotion regulation
personality. However, the DSM-5 no longer difficulties.
classifies personal ity disorders on a separate Dialectical behavior therapy has been shown to
axis, as in DSM-IV-TR. be effective in treating people with borderline
It divides the personality disorders into three personality disorder. This therapy focuses on
clusters based on their descriptive similarities: helping clients gain a more realistic and positive
Cluster A includes the odd-eccentric disorders, sense of self; learn adaptive skills for managing
cluster B includes the dramatic-emotional disor- distress, regulating emotions, and solving prob-
ders, and cluster C consists of the anxious-fearful lems; and correct dichotomous thinking.
disorders. Cognitive and psychodynamic therapies (i.e .,
transference focused and mentalization focused
The cluster A odd-eccentric persona lity disorders treatments) are also helpful. Mood stabilizers
include paranoid personality disorder (extreme and atypical antipsychotics may be the most
mistrust of others), schizoid personality disorder helpful medications.
(extreme social withdrawal and detachment),
and schizotypal persona lity disorder (discomfort Treatments for histrionic and narcissistic person -
in close relationships, odd behavior, inappropri- ality disorders are less well developed, and peo-
ate social interactions, and cognitive-perceptual ple with these disorders tend not to seek therapy
distortions). These disorders, particularly schizo- unless they develop significant distress (e.g.,
typal personality disorder, may be genetically depression) or problems. Cognitive therapy may
linked to schizophren ia and may represent mild be helpful to them.
versions of schizophrenia. People with these The cluster C anxious-fearful personality disor-
disorders tend to have poor social relationships
ders include three disorders characterized by anx-
and to be at increased risk for depression and ious and fearful emotions and chronic self-doubt,
sch izophrenia.
leading to maladaptive behaviors: dependent
Psychotherapies for the odd-eccentric disorders personality disorder (extreme need to be cared
have not been empirically tested for their effi- for and fear of rejection), avoidant personality
cacy. They may be treated with traditional and disorder (social anxiety and sense of inadequacy
atypical antipsychotics. leading to social avoidance), and obsessive-
compulsive personality disorder (rigidity in
The cluster B dramatic-emotional personality
activities and interpersonal relationships) .
disorders include four disorders characterized by
dramatic, erratic, and emotional behavior and in- Genetic factors and childhood experiences of re-
terpersonal relationships: antisocial personality jection by significant others are implicated in the
disorder (see Chapter 11 ), borderline personality development of avoidant personality disorder.
disorder, histrionic personality diso rder, and Treatment involves cognitive-behavioral inter-
narcissistic personality disorder. People with ventions to expose people to the interpersonal
borderline perso nality d isorder show profound situations that make them anxious and to help
Key Terms 281
them change the way they interpret criticism includes an alternative dimensional trait model
from others. in a separate section of the manual designated
for further study. The alternative model re-
People with obsessive-compulsive personality
quires clinicians to diagnose a personality dis-
disorder often also have obsessive-compulsive
order based on particular difficulties in
disorder, and the disorders share some of the
personality functioning and on specific patterns
same genetic risk factors. Treatment with behav-
of pathological personality traits. The alterna-
ioral interventions to reduce compulsions and
tive model may represent how the diagnosis
cognitive techniques to challenge rigid, perfec-
of personality disorders will evolve in the future
tionistic beliefs can be helpful.
and may facilitate integration of normal and
In addition to the current categorical model for pathological personality theories and research .
diagnosing personality disorders, the DSM-5
KEY TERMS
personality 252 histrionic personality disorder 267
personality trait 252 narcissistic personality disorder 268
five-factor model 252 avoidant personality disorder 270
personality disorder 254 dependent personality disorder 272
paranoid personality disorder 256 obsessive-compulsive personality disorder 273
schizoid personality disorder 258 negative affectivity 276
schizotypal personality disorder 259 detachment 277
borderline personality disorder 262 antagonism 277
dialectical behavior therapy 266 disinhibition 277
transference-focused therapy 266 psychoticism 277
mentalization-based treatment 266
Neurodevelopmental and
Neurocognitive Disorders
CHAPTER OUTLINE
Neurodevelopmental and Learning, Communication, and Motor

Neurocognitive Disorders Along Disorders
the Continuum
Major and Mild Neurocognitive
Extraordinary People: Temple Grandin, Disorders
Thinking in Pictures
Delirium
Attention-Deficit I Hyperactivity
Disorder Chapter Integration
Shades of Gray Shades of Gray Discussion
Autism Spectrum Disorder Think Critically
Intellectual Disability Chapter Summary

Key Terms
One of the most fascinating discoveries in the last few decades is
how much the human brain changes across the life span . The
pace of brain development is extraordinary i n early life, with dra-
matic growth in its size and complexity in infancy and childhood ,
followed by further shaping and maturation into early adulthood
(Casey, Totten ham, Liston, & Durston, 2005). The brain continues
1.5.---------------------------------
to change throughout adulthood in response to people's life- Speed of processing, working ,
styles, ex periences, and health. Then, as people grow older, 1.0 -+----- and long-term memory --------------
come gradual declines in the structural and functional integrity
of the brain but adaptations in the ways the bra in processes in-
formation that allow most people to retain a high level of func- ~
:;::;
tioning well into old age (Park & Reuter-Lorenz, 2009; Sowell ~ -0.5-1-----
0
et al., 2003). L)
Yet there is tremendous variability across people in the de-

velopment and aging of the brain and in related cognitive, emo- -1.5 ..J..._--.---.---.---.---.---.---.--
20s 30s 40s 50s 60s 70s 80s
tional, and behavioral functioning. Parents of young children
Age
often anxiously chart their child's progress on major milestones
of development, such as talking, walking, and reading. Although
some children reach these milestones later than others, most Source: Park & Reuter-Lorenz, 2009.
eventually gain the critical skills that allow them to function in

everyday life. Some children, however, continue to have major
problems with basic academ ic skills, such as reading, writing,
and mathematics. Others have more global cognitive deficits compensate for these declines in cognitive-processing ability.
that interfere with their ability to function in many domains of However, for some people, deterioration in the brain is more se-
life. For others, the deficits are in their ability to regulate their vere and widespread than usual, leading to moderate or severe
emotions and behaviors and to understand social interactions. deficits in the processing of information and thus in their ability
Although such difficulties may stem in part from adverse envi- to function in daily life.
ronmental experiences, such as trauma or poverty, they often Brain dysfunction in either childhood or older age can be
have their roots in atypical brain development. understood only in the context of what is typical or functional for
Similarly, as our brains age in middle- and older adulthood individuals in those periods of life. Psycho logists who focus
they decrease in size and efficiency, leading most of us to experi- on functional and dysfunctional development in children are
ence gradual declines in how quickly we perceive and process referred to as developmental psychopathologists. Those con -
information, in our ability to hold and manipulate information in cerned with functional and dysfunctional changes in older age
working memory, and in long-term memory (see Figure 10.1). are referred to as geropsychologists.
Most of us can use our accumulated knowledge and expertise to
Neurodevelopmental and Neurocognitive Disorders Along the Continuum 283

284 Chapter 10 Neurodevelopmental and Neurocognitive Disorders
Temple Grandin, Thinking in Pictures
Dr. Temple Grandin, she entered elementary school, although most of

professor of animal her social interaction deficits remained. When she
sciences at Colorado was 12, Grandin scored 137 on an 10 test (which
State University, has falls in the very superior range) but still was thrown
designed one-third of out of a regular school because she didn't fit in. She
the livestock-handling persisted, however, and eventually went to college,
facilities in the United where she earned a degree in psychology, and then
States. She has pub- to graduate school, where she earned a PhD in ani-
lished dozens of scien- mal sciences.
tific papers and gives Grandin has been able to thrive in her career
lectures throughout and personal life. Still, she finds it very difficult to
the world. Some of her understand emotions and social relationships. She
lectures describe her does not "read" other people well and often finds
new equipment and procedures for safer and more herself offending others or being stared at because
humane animal handling. Others describe her life of her social awkwardness:
with autism.
I have always felt like someone who watches
Grandin showed the classic symptoms of au-
from the outside. I could not participate in the
tism during childhood (now called autism spectrum social interactions of high school life ... . My
disorder). As a baby, she had no desire to be held peers spent hours standing around talking
by her mother, though she was calm if left alone. As about jewelry or some other topic with no real
a young child, she seldom made eye contact with substance. What did they get out of this? I just
others and seemed to lack interest in people. She did not fit in. I never fit in with the crowd, but I
frequently threw wild tantrums. If left alone, she had a few friends who were interested in the
rocked back and forth or spun around repeatedly. same things, such as skiing and riding horses.
She could sit for hours on the beach, watching sand Friendship always revolved around what I did
dribble through her fingers, in a trancelike state. At rather than who I was. (Grandin, 1995, p. 132)
age 2, she still had not begun talking and was la- Still, Grandin does not regret that she has autism.
beled "brain-damaged" because doctors at that She says,
time did not know about autism spectrum disorder.
Fortunately, Grandin's mother was determined If I could snap my fingers and be a nonautistic
person, I would not. Autism is part of what I am.
to find good teachers, learn ways to calm her
(p. 60)
daughter, and encourage her to speak and engage
with others. Grandin did learn to speak by the time
All the disorders in this book are related to dys- ATTENTION-DEFICIT I

function in the brain to one degree or another.
The disorders we discuss in this chapter are clas-
HYPERACTIVITY DISORDER
sified in the DSM-5 specifically as neurological "Pay attention! Slow down! You're so hyper today!"
disorders. We consider a group of disorders that Most parents say this at least occasionally. A major
typically arise first in childhood, known as the focus of socialization is helping children learn to
neurodevelopmental disorders: attention-deficit/ pay attention, control their impulses, and organize
hyperactivity disorder; autism spectrum disor- their behaviors so that they can accomplish long-
der; intellectual disability; and learning, commu- term goals. Some children have tremendous trouble
nication, and motor disorders. Then we consider learning these skills, however, and may be diag- ~
disorders that typically arise in older age. These nosed with attention-deficit/hyperactivity disor-
are known as the neurocognitive disorders: vari- der, or ADHD (see the DSM-5 criteria in Table 10.1).
ous major and mild neurocognitive disorders, Eddie in the following case study is a young boy
and delirium. withADHD.
Attentio n-Deficit / Hyperactivity Disorder 285
TABLE 10.1 DSM-5 Criteria for Attention-Deficit/Hyperactivity Disorder
A. A persistent pattern of inattention and/or hyperactivity that interferes with functioning or development, as characterized by (1)
and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with
developmental level and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks
or instructions. For older adolescents and adults (age 17 and older). at least five symptoms are required.
a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities
(e.g. , overlooks or misses details, work is inaccurate)
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures,
conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction)
d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts
tasks but quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials
and belongings in order; messy, disorganized work; poor time management; tends to fa il to meet dead lines)
f . Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g ., schoolwork or homework;
for older adolescents and adults, preparing reports, completing forms, or reviewing lengthy papers)
g. Often loses things necessary for tasks or activities (e.g., school materia ls, pencils, books, tools, wallets, keys, paperwork,
eyeglasses, mobile telephones)
h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts)
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls,
paying bills, keeping appointments)
2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is
inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities.
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hosti lity, or a failure to understand
tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
a. Often fidgets with or taps hands or feet or squirms in seat
b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, office or
other workplace, or other situations that require remaining in place)
c. Often runs about or climbs in situations where it is inappropriate (Note: in adolescents or adults, may be limited to feeling
restless)
d. Often unable to play or engage in leisure activities quietly
e. Is often "on the go," acting as if "driven by a motor" (e.g., is unable to be o r uncomfortab le being still for an extended
time, as in restaurants, meetings; may be experienced by others as being restless and difficu lt to keep up with)
f . Often talks excessively
g. Often blurts out an answer before a question has been completed (e.g., completes people's sentences; cannot wait for turn
in conversation)
h. Often has difficulty waiting his or her turn (e.g., while waiting in line)
i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's
things without asking or receiving permission; for adolescents or adults, may intrude into or take over what others are doing)
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with
friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the qua lity of, social, academic, or occupationa l functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorde r and are not better
explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance
intoxication or withdrawal).
Specify Based on Current Presentation
Combined Presentation: If both Criterion A 1 (Inattention) and Criterion A2 (Hyperactivity-Impulsiv ity) are met for the past 6 months.
Predominantly Inattentive Presentation: If Criterion A 1 (Inattention) is met but Criterion A2 (Hyperactivity-Impulsivity) is not met for
the past 6 months.
Predominantly Hyperactive/Impulsive Presentation: If Criterion A2 (Hyperactivity-Impulsivity) is met and Criterion A1 (Inattention) is
not met for the past 6 months.
Source: Reprinted with permission from th e Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright 2013 American Psychiatric Association,
pp. 59-60.
r . -.- .. - . :~ -.~
, CASE'STUDY . diagnosed if six or more symptoms of hyperactivity-

Eddie, age 9, was referred impulsivity but less than six symptoms of inatten-
to a child psychiatrist at the request of his school tion are present. Eddie appears to have this last
because of the difficulties he creates in class. His presentation of ADHD.
teacher complains that he is so restless that By definition, ADHD begins in childhood. One
his classmates are unable to concentrate. He is of the major changes in the diagnostic criteria for
hardly ever in his seat and mostly roams around ADHD in the DSM-5 is that the age limit for the
ta lking to other children while they are working. onset of symptoms was raised from 7 years to
In his seat, he fidgets with his hands and feet and 12 years, in response to research suggesting that the
drops things on the floor. His most recent sus- cutoff of 7 years failed to capture many children
pension from school was for swinging from the who eventually show ADHD but a cutoff of 12 years
fluorescent light fixture over the blackboard. captured 95 percent of individuals who develop
Because he was unable to climb down again, the ADHD (Barkley & Brown, 2011; Frick & Nigg, 2012;
class was in an uproar. Kieling et al., 2010). Epidemiological studies based
His mother says that Eddie's behavior has on the earlier cutoff of 7 years of age indicate that
been difficult since he was a toddler and that, as 5 percent of children develop ADHD (Polanczyk &
a 3-year-old, he was extremely hyperactive and Jensen, 2008). This likely is an underestimate of the
demanding. He has always required little sleep prevalence according to the new DSM-5 criterion of
and awoken before anyone else. When he was onset by 12 years of age. Boys are a little more than
small, "he got into everything;' particularly in the two times more likely than girls to develop ADHD in
early morning, when he would get up at 4:30 or childhood and early adolescence (Ramtekker et al.,
5:00 and go downstairs by himself. His parents 2010). Girls with ADHD tend to present primar-
would awaken to find the living room or kitchen ily with inattentive features and have less disrup-
" demolished:' When he was 4, he unlocked the tive behavior than boys with ADHD, which may
door of the apartment and wandered off into a lead to an underidentification of ADHD in girls
busy street; fortunately, he was rescued by a (Biederman et al., 2002). ADHD is found across
passerby. most cultures and ethnic groups. Contrary to some
Eddie has no interest in TV and dislikes media accounts, the percentage of children diag-
games or toys that require any concentration or nosed with ADHD is not much greater in the United
patience. He is not popular with other children States than it is in other countries (Polanczyk &
and at home prefers to be outdoors, playing with Jensen, 2008). Like Eddie, most children with
his dog or riding his bike. If he plays with toys, ADHD are diagnosed in elementary school.
his games are messy and often broken. His Children with ADHD often do poorly in school
mother cannot get him to keep his things in any (Langberg et al., 2012). Because they cannot pay
order. (Reprinted from the DSM Casebook: A attention or calm their hyperactivity, they do not
Learning Companion to the Diagnostic and learn the material and often perform below their
Statistical Manual of Mental Disorders, Fifth intellectual capabilities. In addition, 20 to 25 per-
Edition. Copyright 2013 American Psychiatric cent of children with ADHD may have a specific
Association .) learning disorder that makes it doubly hard for
them to concentrate in school and to learn (Wilens,
Biederman, & Spencer, 2002).
Children with ADHD may have poor relation-
Most elementary-school-age children can sit still ships with other children and, like Eddie, often are
for some period of time and engage in games that rejected outright (Hoza et al., 2005). When interact-
require patience and concentration. They can inhibit ing with their peers, children with ADHD may be
their impulses to jump up in class or walk into traf- intrusive, irritable, and demanding. They want to
fic. Eddie cannot. His behavior is driven and disor- play by their own rules and sometimes show mood
ganized, as is common in children with ADHD. and temper problems. When things do not go their
There are three subtypes or presentations of way, they may become aggressive.
ADHD in the DSM-5. The combined presentation re- The behavior problems of some children with
quires six or more symptoms of inattention and six ADHD worsen over the course of development, and
or more symptoms of hyperactivity-impulsivity. The become severe enough to be diagnosed as a conduct
predominantly inattentive presentation is diagnosed if disorder. This is particularly true for ADHD chil-
six or more symptoms of inattention but less than six dren with the combined presentation. Children with
symptoms of hyperactivity-impulsivity are present. conduct disorders grossly violate the social and cul-
The predominantly hyperactive/impulsive presentation is tural norms for appropriate behavior toward others
Attention-Deficit /Hyperactivity Disorder 287
which is involved in working

memory and planning; and the
cerebellum, which is involved in
motor behaviors (Cubillo et al.,
Prefrontal
2012). The cerebral cortex is cortex
smaller in volume in children, and
there is less connectivity between
frontal areas of the cortex and
areas of the brain that influence
motor behavior, memory and at-
tention, and emotional reactions. The prefrontal cortex is smaller and
shows abnormal activity in children
Because the cortex continues to de- withADHD.
velop well into adolescence, one
Children normally have high energy levels, but only a hypothesis is that children with
minority of children can be labeled hyperactive. ADHD are neurologically immature-that is, their
brains are slower to develop than the brains of unaf-
fected children-leaving them unable to maintain
attentior: and control their behavior at an age-
by acting in uncaring and even antisocial ways (see
appr~pnate le~el. This immaturity hypothesis helps
Chapter 11). Between 45 and 60 percent of children
explaill why ill some children the symptoms of
with ADHD develop a conduct disorder, abuse
ADHD, especially hyperactivity symptoms, decline
drugs or alcohol, or violate the law (Frick & Nigg,
with age (Cubillo et al., 2012).
2012; Lee et al., 2011). For some individuals, conduct
The catecholamine neurotransmitters, particu-
problems persist into adulthood.
larly .dopamine and norepinephrine, appear to
The long-term outcomes for children with
functiOn abnormally in individuals with ADHD
ADHD vary considerably. Symptoms persist into
(del Campo, Chamberlain, Sahakian, & Robbins,
young adulthood in about 50 percent of cases
2011). We have previously discussed the role of
(Klassen, Katzman, & Chokka, 2010). Adults diag-
these. neurotransmitters in mood, but they also
nosed with ADHD as children are at increased risk
play rmportant roles in sustained attention, inhibi-
for antisocial personality disorder, substance abuse,
tion of impulses, and processing of errors (Barnes
mood and anxiety disorders, marital problems,
et al., 2011). Drugs that affect levels of these neu-
traffic accidents, legal infractions, and frequent job
rotransmitters are useful in treating ADHD.
changes (Fischer & Barkley, 2006; Wilens et al.,
ADHD is strongly tied to genetic factors
2002). Some adults who have had lifelong problems
(Albayrak et al., 2008; Poelmans et al., 2011). Sib-
achieving success in school and at work and diffi-
lings of children with ADHD are three to four times
culties in social relationships might have had undi-
more likely to develop it than siblings of children
agnosed and untreated ADHD as children. An
without the disorder (Todd, Lobos, Sun, & Neuman,
epidemiological study of the United States found
2003). Several other disorders also tend to run in
that 4.4 percent of adults could be diagnosed with
~DHD (Kessler, Adler, et al., 2006). They were more
the. fa~ilies of children with ADHD, including
anhs~Cial personality disorder, alcoholism, and de-
~e~y to. be male, and they showed a wide range of
difficulties at work and in their social lives. Most pression (Barkley, 1991; Faraone, Biederman,
~eenan, ~ Tsuang, 1991). Twin studies and adop-
had not received treatment for ADHD specifically,
~on studies. s.uggest that genetic factors play a role
although many had been treated for other disorders.
ill vulnerability to ADHD (Mick & Faraone, 2008).
Ad~ts withADHD are at higher risk for depression,
Both the attentional and hyperactivity symptoms
aruaety disorders, substance abuse, and antisocial
of ADHD seem to have a genetic basis (Nikolas &
personality disorder (Klassen et al., 2010).
Burt, 2010): Molecular genetics studies suggest that
genes that influence dopamine, noradrenaline, and
Biological Factors serotonin may be abnormal in individuals with
U:
The diffic~lties ~t.tention, planning and carrying ADHD (Barnes et al., 2011).
through with activities, and impulse control seen in Children with ADHD often have a history of
ADHD appear to be tied to fundamental abnormal- prenatal and birth complications. ADHD is associ-
ities in the brain (Cubillo et al., 2012). Abnormal a~e~ with low birth weight, premature delivery, and
activity has been seen in several areas, including dif~cult delivery leading to oxygen deprivation
the prefrontal cortex, which is key to the control of (Nigg, 2006). Some investigators suspect that mod-
cognition, motivation and behavior; the striatum, erate to severe drinking or heavy use of nicotine or
288 Chapter 10 Neurodevelopmental a nd Neurocognitive Disorders
barbiturates by mothers during pregnancy can lead concern that stimulants may stunt growth, and
to the kinds of behavioral inhibition deficits seen in some evidence exists that children with ADHD who
children with ADHD. Others regard these associa- begin taking stimulants show a decrease in their
tions as a result of shared genetic risk among ADHD growth rate (Swanson et al., 2007). Stimulants also
and drinking and smoking habits. Some children carry a risk of abuse by people looking for a high,
with ADHD were exposed to high concentrations of to make money by resale, or hoping to gain an
lead as preschoolers when they ingested lead-based edge in high school, college, or the workplace (see
paint (Fergusson, Horwood, & Lynskey, 1993). Chapter 14).
The links between diet and symptoms of Nationwide, the number of children pre-
ADHD are inconsistent. An unhealthy "Western" scribed stimulant medications in the United States
diet full of fat, sodium, sugar, and food additives is increased by 200 to 300 percent in the 1980s and
associated with greater symptoms of hyperactivity 1990s, and then increased more slowly after 2000
both in healthy children and in children with (Zuvekas & Vitiello, 2012). Non-Hispanic whites
ADHD, but it is not clear that this diet causes and children in the northeastern states show the
ADHD or other forms of psychopathology (How- highest rates of use. Some researchers argue that
ard et al., 2011). A small number of children with this increase reflects greater recognition of children
ADHD show improvement in their symptoms with ADHD and of their need for treatment. Oth-
when synthetic food colorings are removed from ers say that it represents an inappropriate overuse
their diet (Nigg, Lewis, Edinger, & Falk, 2012). of the drugs, particularly for children who are dif-
ficult to control (Angold, Erkanli, Egger, & Costello,
2000). There is scant empirical evidence on which
Psychological and Social to judge these competing claims.
Factors In a longitudinal study of children in the south-
Children with ADHD are more likely than children eastern United States, 72 percent of those with
without a psychological disorder to belong to fami- ADHD received stimulants at some point during
lies that experience frequent disruptions and in the 4 years they were followed, suggesting that most
which the parents are prone to aggressive and hos- children with ADHD are being treated (Angold
tile behavior and substance abuse (Barkley, Fischer, et al., 2000). In this study, however, the majority of
Smallish, & Fletcher, 1990). However, these associa- the children taking stimulants did not have symp-
tions are likely due to genetic effects on impulsivity toms meeting the diagnostic criteria for ADHD,
and cognitive problems, which lead to both the pa- suggesting that stimulants were misprescribed,
rental behaviors and ADHD in children (Handley especially for the boys and the younger children in
et al., 2011). Family interaction patterns, especially the study. More research is needed to determine
in early childhood, influence the course and sever- w hether stimulants are being used appropriately in
ity of ADHD, including the development of con- treating children.
duct problems. Other drugs that treat ADHD include atomox-
etine, clonidine, and guanfacine, which are not
stimulants but affect norepinephrine levels. These
Treatments for ADHD drugs can help reduce tics, common in children
Most children with ADHD are treated with stimu- with ADHD, and increase cognitive performance
lant drugs, such as Ritalin, Dexedrine, and Adder- (del Campo et al., 2011; Kratochvil et al., 2007).
all (McBurnett & Starr, 2011). It may seem odd to Side effects of these drugs include dry mouth, fa-
give a stimulant to a hyperactive child, but be- tigue, dizziness, constipation, and sedation.
tween 70 and 85 percent of ADHD children re- Antidepressant medications sometimes are
spond to these drugs with decreases in demanding, prescribed to children and adolescents withADHD,
disruptive, and noncompliant behavior (Swanson particularly if they also have depression. These
et al., 2008). The children also show increases in drugs have some positive effects on cognitive per-
positive mood, in the ability to be goal-directed, formance but are not as effective for ADHD as the
and in the quality of their interactions with others. stimulants (Wilens et al., 2002). Bupropion, an anti-
The stimulants may work by increasing levels of depressant with particularly strong effects on dopa-
dopamine in the synapses of the brain, enhancing mine levels, appears to be more effective for ADHD
release and inhibiting reuptake of this neurotrans- than some other antidepressants. Unfortunately, the
mitter (Swanson, Baler, & Volkow, 2011). gains made by ADHD children treated with medi-
The side effects of stimulants include reduced cations alone are short-term Goshi, 2004). As soon as
appetite, insomnia, edginess, and gastrointestinal medication is stopped, symptoms often return.
upset. Stimulants also can increase the frequency Behavioral therapies for ADHD focus on rein-
of tics in children with ADHD. There has been forcing attentive, goal-directed, and prosocial
Attention-Deficit /Hyperactivity Disorder 289
SHADES OF GRAY
Read the following description of Jake, a college discouraged and confused about school. He
student. agreed that he didn't get the good grades his
brothers did and knew his parents expected more
Jake had just earned a 2.4 GPA in his freshman of him. When he was younger he did well in
year at the University of Washington when his par- school, and in elementary school he thought of
ents took him to see a psychologist about his aca- himself as smart. But his grades had slipped when
demic performance. At the meeting with the he transitioned into middle school, then again
psychologist, his parents described their middle when he entered high school, and now again in
son as lazy, unmotivated, stubborn, and disorga- college. He thought he understood what was go-
nized. His brothers were successful at school, as ing on in class but was always forgetting or losing
his parents had been . Growing up, Jake had things, and his mind would often wander. Outside
seemed smart, but he often sabotaged his grades of the classroom, he had a small but supportive
by forgetting to do his homework, quitting in the group of friends, and he was involved in a wide
middle of assignments, and not finishing tests. variety of sports and activities. He denied any in-
When he completed a project, he would often volvement with drugs or illegal activity. (Adapted
leave it behind or lose it. He could be engrossed in from Vitkus, 2004, pp. 193-199)
TV or a video game, but when it came to his home-
work, he lacked focus. His parents also noted that
he was constantly late and didn't seem to care What might be causing Jake's problems? What
about making everyone else wait for him. additional information would you want before
When the psychologist spoke with Jake alone, making a diagnosis? (Discussion appears at the
Jake seemed like a nice, polite teenager. Jake felt end of this chapter.)
behaviors and extinguishing impulsive and combined-treatment group had reduced or discon-
hyperactive behaviors (Miller & Hinshaw, 2012). tinued their ADHD behaviors, such as aggression
These therapies typically engage parents and teach- and lack of concentration. In the medication-alone
ers in changing rewards and punishments in many group, 56 percent showed reduced or discontinued
aspects of the child's life. A child and his parents symptoms. Behavior therapy alone reduced symp-
might agree that he will earn a chip every time he toms in only 34 percent of group members, and only
obeys a request to wash his hands or put away his 25 percent of those given routine community care
toys. At the end of each week, he can exchange his showed reductions in their symptoms. In follow-ups
chips for fun activities. Each time the child refuses 3, 6, and 8 years later, all three treatment groups con-
to comply, he loses a chip. Such techniques can help tinued to have fewer ADHD symptoms than they
parents break the cycle of engaging in arguments had had before treatment, but there were no differ-
with their children that escalate problem behaviors, ences between treatment groups in outcome Gensen,
which in turn lead to more arguments and perhaps
physical violence. The children learn to anticipate
the consequences of their behaviors and to make
less impulsive choices. They are taught to interact
more appropriately with others, including waiting
their turn in games, finding nonaggressive ways to
express frustration, and listening when others
speak. A meta-analysis of 174 studies evaluating
the effectiveness of behavioral therapy found
strong and consistent evidence that behavioral
therapy is highly effective in reducing symptoms
of ADHD in children (Fabiano et al., 2009).
Some studies suggest that the combination of
stimulant therapy and psychosocial therapy is more
likely to produce short-term improvements than ei-
ther therapy alone. In one multi-site study, 579 chil- In behavioral therapies for ADHD. a child and her parents
dren with ADHD were randomly assigned to receive might agree that she will earn a chip every time she
obeys a request to wash her hands. At the end of each
the combination of Ritalin and behavior therapy,
week, she can exchange her chips for fun activities such
one therapy alone, or routine community care as eating an ice cream cone or extra television time.
Gensen et al., 2001 ). After 14 months, 68 percent of the
- -
Arnold, et al., 2007; Molina et al., 2009). In addition, 6 CASE STUDY
and 8 months after treatment ended, all three groups Richard, age 3%, appeared
still had more symptoms than classmates who had to be self-contained and aloof from others. He did
not been diagnosed with ADHD (Molina et al., 2009). not greet his mother in the mornings or his father
when he returned from work, though if left with a
baby-sitter, he tended to scream much of the time.
AUTISM SPECTRUM He had no interest in other children and ignored
DISORDER his younger brother. His babbling had no conver-
sational intonation. It was not until age 3 that he
Autism spectrum disorder involves impairment
could understand simple practical instructions. His
in two fundamental behavior domains-deficits in
speech consisted of echoing some words and
social interactions and communications and re-
phrases he had heard in the past, with the original
stricted, repetitive patterns of behaviors, interests,
speaker's accent and intonation; he could use one
and activities (see Table 10.2). Richard, a child with
or two such phrases to indicate his simple needs.
autism spectrum disorder, shows a range of defi-
For example, if he said, "Do you want a drink?"
cits characteristic of this disorder.
TABLE 10.2 DSM-5 Diagnostic Criteria for Autism Spectrum Disorder
A. Persistent deficits in social communication and social interaction across multip le contexts, as manifested by
the following, currently or by history (examples are il lustrative, not exhaustive; see text [of the OSM-5]:
1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal
back-and-forth conversation, to reduced sharing of interests, emotions, or affect or fail ure to initiate or
respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social interaction, ra ng ing , for example, from
poorly integrated verbal and nonverbal communication, to abnormalities in eye contact and body
language, to deficits in understanding and use of gestures, or to a total lack of facial expression or
nonverba l communication.
3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from
difficulties adjusting behavior to suit various socia l contexts, to difficulties in sharing imaginative play
or in making friend s, or to an absence of interest in peers.
B. Restricted, repetitive patterns of behavior, interests, o r activities as manifested by at least two of the
following, currently or by history (examples are illustrative, not exhaustive; see text [of the OSM-5]):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies,
lining up toys or flipping objects, echolalia, idi osyncratic phrases).
2. Insistence on sameness, inflex ible adherence to routines, or ritualized patterns of verbal or nonverbal
behavior (such as extreme distress at small changes, difficulties with transitions, rigid thinking patterns,
greeting rituals, need to take same route or eat same food each day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (such as strong attachment to
or preoccupation with unusual objects, excessively circumscribed or perseverative interests)
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of environment
(such as apparent ind ifference to pain/temperature, adverse response to specific sounds or textures,
excessive smelling or touching of objects, fascination with lights or movement).
C. Symptoms must be present in the early developmental period (but may not become fully manifest until
social demands exceed limited capacities, or may be masked by learned strategies in later life).
D. Symptoms cause clinically sign ificant impairment in social, occupational, or other important areas of
current functioning.
E. These disturbances are not better explained by intellectual disability or global developmental delay.
Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of
autism spectrum disorder and intellectual disability, social communication (Criteria A) must be below that
expected for general developmental level.
Autism Spectrum Disorder 291
delayed language development. When they are a

he meant he was thirsty. He did not communi- bit older, children with autism spectrum disorder
cate by facial expression or use gesture or mime, may not be interested in playing with other chil-
except for pulling someone along with him and dren, preferring solitary play. They also do not
placing his or her hand on an object he wanted. seem to react to other people's emotions. In the
He was fascinated by bright lights and spinning chapter opener, Temple Grandin describes how
objects and would stare at them while laughing, she had to work hard to overcome her lack of un-
flapping his hands, and dancing on tiptoe. He derstanding of social interactions.
was intensely attached to a miniature car, which Approximately 50 percent of children with au-
he held in his hand, day and night, but he never tism spectrum disorder do not develop useful speech.
played imaginatively with this or any other toy. Those who do develop language may not use it as
From age 2 he had collected kitchen utensils and other children do. In the case study about Richard, he
arranged them in repetitive patterns all over the showed several of the communication problems
floors of the house. These pursuits, together characteristic of children with autism spectrum dis-
with occasional periods of aimless running order. Rather than generating his own words, he sim-
around, constituted his whole repertoire of ply echoed what he had just heard, a behavior called
spontaneous activities. echolalia. He reversed pronouns, using you when he
The major management problem was meant I. When he did try to generate his own words
Richard's intense resistance to any attempt to or sentences, his language was one-sided and lacked
change or extend his interests. Removing his toy social reciprocity and he did not modulate his voice
car, even retrieving, for example, an egg whisk or for expressiveness, instead sounding almost like a
a spoon for its legitimate use in cooking, or trying monotone voice-generating machine.
to make him look at a picture book precipitated The second group of deficits concerns the activi-
temper tantrums that could last an hour or more, ties and interests of children with autism spectrum
with screaming, kicking, and the biting of himself disorder. Rather than engaging in symbolic play
or others. These tantrums could be cut short by with toys, they are preoccupied with one feature of a
restoring the status quo. toy or an object. Richard was preoccupied with his
His parents had wondered if Richard might miniature car, carrying it everywhere without play-
be deaf, but his love of music, his accurate echoing with it, and Temple Grandin was interested only
ing, and his sensitivity to some very soft sounds, in watching sand dribble through her fingers. They
such as those made by unwrapping chocolate in may engage in bizarre, repetitive behaviors with
the next room, convinced them that this was not toys. Rather than using two dolls to play "house," a
the cause of his abnormal behavior. Psychological child with autism spectrum disorder might take the
testing gave Richard a mental age of 3 years arm off one doll and simply pass it back and forth
in non-language-dependent skills (such as as- between her two hands. Routines and rituals often
sembling objects) but only 18 months in lan- are extremely important to children with autism
guage comprehension. (Reprinted from the DSM spectrum disorder. When any aspect of their daily
Casebook: A Learning Companion to the Diagnostic routine is changed-for example, if their mother
and Statistical Manual of Mental Disorders, Fifth stops at the bank on the way to school- they may
Edition. Copyright 2013 American Psychiatric become excessively frightened and highly dis-
Association.) tressed. Some children perform stereotyped and re-
petitive behaviors using some part of their body,
such as incessantly flapping their hands or banging
their head against a wall. These behaviors some-
The deficits in social interactions and commu- times are referred to as self-stimulatory behaviors, un-
nications of autism may first show up in infants' der the assumption that these children engage in
and toddlers' interactions with their parents, such behaviors for self-stimulation. It is not clear,
which are usually characterized by reciprocal ado- however, that this is their true purpose.
ration. Compared to normally developing chil- Children with autism spectrum disorder often
dren, infants with autism spectrum disorder may do poorly on measures of intellectual ability, such
not smile and coo in response to their caregivers or as IQ tests, with approximately 50 percent of autis-
initiate play with their caregivers. They may not tic children showing at least moderate intellectual
want to cuddle with their parents, even when they disability (Mattila et al., 2011; Sigman, Spence, &
are frightened. They may hardly ever make eye Wang, 2006). The deficits of some children with
contact relative to cultural norms or show joint at- autism spectrum disorder are confined to skills
tention (i.e., failure to follow a caregiver's pointing that require language and understanding others'
or eye gaze). Other early symptoms often include points of view, and they may score in the average
range on tests that do not In the DSM-IV-TR (published in 1994), autism

require language skills. was one of multiple diagnoses in the category per-
Temple Grandin is clearly vasive developmental disorders (PDDs), and it re-
of above-average intelli- quired the presence of two symptoms of social
gence despite her autism impairment (from a list of four possible symptoms)
spectrum disorder. Much and one symptom each of communication problems
has been made in the popu- and repetitive /stereotyped behaviors (from lists of
lar press about the special four possible symptoms each); in addition, the onset
talents of some children had to be before age 3. Asperger's disorder was
with autism spectrum dis- another PDD and was often considered a high-
order, such as the ability to functioning form of autism involving deficits in
play music without having social interactions and restricted, repetitive behavior
been taught or to draw ex- but no significant communication deficits. Two other
tremely well, or exceptional relatively rare variants (Rett's disorder and child-
memory and mathematical hood disintegrative disorder) were also in the PDD
calculation abilities as de- category, along with pervasive developmental
picted in the movie Rain disorder not otherwise specified (PDD-NOS). The
Man. These persons some- lifetime prevalence of all PDDs combined was
times are referred to as sa- estimated to be about 1 to 2 percent (~aird et al.,
vants. Such cases are quite 2006; Kim et al., 2011; Fombonne, 2009).
rare, however (Bolte & In the DSM-5, the PDD category has been
Poustka, 2004). dropped, and there is only one autism spectrum dis-
For the diagnosis of au- order, as defined in Table 10.2. These changes were
tism spectrum disorder, made due to evidence that the distinctions between
symptoms must have their the different PDDs, especially autism and Asperg-
onset in early childhood. It er 's disorder, were difficult to make reliably and that
is important to note that the PDDs seemed to share common etiologies
there is wide variation in (Swedo et al., 2012). Moreover, because the disorder
the severity and outcome presents differently depending on symptom sever-
of this disorder. One study ity, developmental level (e.g., IQ), and age, DSM-5
In the movie Rain man, Dustin Hoffman followed 68 individuals uses the term "spectrum" to capture the range of
plays a man with autism who had some
who had been diagnosed related but varied presentations. The impact of the
extraordinary abilities.
with autism as children and changes in the treatment of autism spectrum disor-
who had a performance ders in the DSM-5 is a matter of some debate and
(nonverbal) IQ of at least 50 (Howlin, Goode, concern. Several initial studies that reanalyzed data
Hutton & Rutter, 2004). As adults, 13 of them had on children diagnosed under the DSM-IV-TR crite-
been able to obtain some sort of academic degree, ria found that the DSM-5 criteria for autism spec-
5 had gone on to college, and 2 had obtained a trum disorder captured only about 50 to 60 percent
postgraduate degree. Of the 68 people in the study, of children who previously would have been diag-
23 were employed, and 18 had close friendships. nosed with autism, Asperger's disorder, or PDD-
The majority, however, required ongoing support NOS (Mattila et al., 2011; McPartland, Reichow, &
from their parents or required some form of resi- Volkmar, 2012). These studies indicated that the chil-
dential care. Fifty-eight percent, or 39 individuals, dren most likely not to fit the DSM-5 criteria for au-
had overall outcomes that were rated "poor" or tism spectrum disorder are those who have higher
"very poor." They were unable to live alone or hold IQs and who lack deficits in verbal communications.
a job, and they had persistent problems in communi- Only about one-quarter of individuals previously
cation and social interactions. diagnosed with Asperger's syndrome or PDD-NOS
By far the best predictor of the outcome of au- meet the criteria for autism spectrum disorder based
tism spectrum disorder is a child's IQ and the on the DSM-5 criteria (McPartland et al., 2012).
amount of language development before age 6 These findings raised concerns about the effects of
(Howlin et al., 2004; Nordin & Gillberg, 1998). these changes on access to services for individuals
Children who have an IQ above 50 and communi- who have previously been diagnosed with autistic
cative speech before age 6 have a much better disorders other than classic, low-functioning autism
prognosis than do others. People diagnosed with (McPartland et al., 2012). The most recent and larg-
autism spectrum disorder who had an IQ of 70 or est study of this kind, however, found that DSM-5
above were especially likely to achieve a "good" or criteria identified 91 percent of children with estab-
"very good" outcome (How lin et al., 2004). lished DSM-IV PDD diagnoses (Huerta et al., 2012),
Autism Spectrum Disorder 293
suggesting that most children would remain eligible A consistent finding is greater
for the diagnosis and related services. Future stud- head and brain size in children
ies will likely further clarify the impact of these with the disorder than in children
changes to the diagnostic criteria. without it (Lotspeich et al., 2004;
Via et al., 2011).
Contributors to Autism Neuroimaging studies have
suggested a variety of structural
Spectrum Disorder abnormalities in the brains of in-
Cerebellum
Over the years, a wide variety of theories of autism dividuals with autism spectrum
have been proposed. The psychiatrist who first de- disorder, including in the cerebel-
scribed autism, Leo Kanner (1943), thought that lum, the cerebrum, the amygdala, These areas of the brain have been
implicated in autism.
autism was caused by a combination of biological and possibly the hippocampus
factors and poor parenting. He and later psycho- (Sigman et al., 2006; Via et al.,
analytic theorists (Bettelheim, 1967) described the 2011). When children with autism spectrum disor-
parents of children with autism as cold, distant, der are doing tasks that require perception of facial
and uncaring. The child's symptoms were seen as expressiops, joint attention with another person,
a retreat inward to a secret world of fantasies in empathy, or thinking about social situations, they
response to unavailable parents. However, re- ~ -s now abnormal functioning in areas of the brain
search over the decades has shown clearly that un- that are recruited for such tasks. For example,
responsive parenting plays little or no role in the when shown photos of faces, children with autism
development of autism. spectrum disorder show less activation than do
Several biological factors have been impli- typically developing children in an area of the
cated in the development of autism spectrum dis- brain involved in facial perception called the fusi-
order. Family and twin studies strongly suggest form gyrus (Figure 10.2; Schultz, 2005). Difficulty
that genetics plays a role in the development of the in perceiving and understanding facial expres-
disorder. The siblings of children with autism sions could contribute to these children's deficits
spectrum disorder are 50 times more likely to have in social interactions.
the disorder than are the siblings of children with- Neurological dysfunctions could be the result
out autism spectrum disorder (Sigman et al., 2006). of genetic factors. Alternatively, children with autism
Twin studies show concordance rates for autism have a higher-than-average rate of prenatal and birth
spectrum disorder to be about 60 percent for complications, and these complications might create
monozygotic (MZ) twins and 0 to 10 percent for the neurological abnormality (Sigman et al., 2006).
dizygotic (DZ) twins (Folstein & Rosen-Sheidley, Further, studies have found differences between chil-
2001). In addition, about 90 percent of the MZ dren with and without autism spectrum disorder in
twins of children with autism spectrum disorder levels of the neurotransmitters serotonin and
have a significant cognitive impairment, compared dopamine, although what these differences mean is
to 10 percent of DZ twins. Also, children with autism not entirely clear (Anderson & Hoshino, 1997).
spectrum disorder have a higher-than-average rate
of other genetic disorders associated with cognitive
impairment, including fragile X syndrome and PKU FIGURE 10.2
(Volkmar, State, & Klin, 2009). These data suggest
that a general vulnerability to several types of cogni-
tive impairment, only one of which is manifested as
autism spectrum disorder, runs in families. No single
gene seems to cause autism spectrum disorder;
rather, abnormalities in several genes have been
associated with autism spectrum disorder (Liu,
Paterson, Szatmari, and the Autism Genome Project
Consortium, 2008; Sigman et al., 2006).
Neurological factors probably play a role in au-
tism spectrum disorder. The array of deficits seen in
autism spectrum disorder suggests disruption in the
normal development and organization of the brain
(Sigman et al., 2006). In addition, approximately
30 percent of children with autism spectrum disorder
develop seizure disorders by adolescence, suggesting
a severe neurological dysfunction (Fombonne, 1999).
Treatments for Autism INTELLECTUAL DISABILITY

Spectrum Disorder Intellectual disability (or intellectual developmen-
A number of drugs have been shown to improve tal disorder), formerly referred to as mental retar-
some of the symptoms of autism spectrum disor- dation, involves significant deficits in the ability to
der, including overactivity, stereotyped behaviors function in three broad domains of daily living (see
(e.g., head banging and hand flapping) , sleep dis- Table 10.3). First, in the conceptual domain, indi-
turbances, and tension (McPheeters et al., 2011). viduals show deficits in skills such as language,
The selective serotonin reuptake inhibitors appear reading, writing, m ath, reasoning, know ledge,
to reduce repetitive behaviors and aggression, and memory, and problem solving. Second, in the social
they improve social interactions in some people domain, individuals have difficulty in being aw are
with autism spectrum disorder. The atypical anti- of and understanding others' experiences, in inter-
psychotic medications are used to reduce obses- personal communication skills, in the ability to
sive and repetitive behaviors and to improve make and keep friends, in social judgment, and in
self-control. Naltrexone, a drug that blocks recep- regulating their own reactions in social interac-
tors for opiates, has been shown to be useful in re- tions. Third, in the practical domain, individuals
ducing hyperactivity in some children with autism show deficits in managing personal care (such as
spectrum disorder. Finally, stimulants are used to maintaining hygiene, grocery shopping, cooking),
improve attention (Handen, Taylor, & Tumuluru,
2011). While these drugs do not alter the core fea-
tures of autism spectrum disorder, they sometimes
make it easier for people w ith autism spectrum
TABLE 10.3 DSM-5 Criteria for
disorder to participate in school and in behavioral
Intellectual Disability (IDD)
treatments.
Psychosocial therapies for autism spectrum dis-
Intellectual disability (intellectual developmental
order combine behavioral techniques and structured
d isorder) is a disorder with an onset during the
educational services (Lovaas & Smith,2003; Reichow, developmental period that includes both
Barton, Boyd, & Hume, 2012; Vismara & Rogers, intellectua l and adaptive functioning deficits in
2010). Operant conditioning strategies are used to co nceptual, social, and practical doma ins. The
reduce excessive behaviors, such as repetitive or following three criteria must be met:
ritualistic behaviors, tantrums, and aggression, and
to alleviate deficits or delays, such as deficits in com- A. Deficits in intellectua l functions, such as
munication and in interactions with others. These reason ing, problem solving, planning, abstract
thinking, j udgment, academic learning, and
techniques may be implemented in highly struc-
learning from experience, confirmed by both
tured schools designed especially for children with
clinica l assessment and individualized,
autism spectrum disorder or in regular classrooms if standard ized intelligence testing.
children are mainstreamed. The specific deficits a
B. Deficits in adaptive functioning that result in
child has in cognitive, motor, or communication
fai lure to meet developmental and sociocultura l
skills are targeted, and materials that reduce possi-
standa rds for personal independence and social
ble distractions (such as books that do not have respo nsibility . Without ongoing support,
words printed in bright colors) are used. Parents the adaptive deficits limit funct ioning in o ne
may be taught to implement the techniques consis- or mo re act ivities of daily life, such as
tently when the children are at home. com mu nication, social participation, and
One pioneering study showed that 47 percent independent living, across mu ltiple
of children with autism spectrum disorder given enviro nments, such as home, school, work,
this intensive behavioral treatment for at least 40 and com m unity.
hours a week for at least 2 years achieved normal C. Onset of intellectual and adaptive deficits
intellectual and educational functioning by age 7, during t he developmental pe riod.
compared to only 2 percent of children with au- The severity of intellectual disabi lity can be
tism who received institutional care alone (Lovaas, cl ass ified as mild, moderate, severe, o r profound,
1987). Several other studies have shown strong o n t he basis of adaptive function (and not 10 alone)
improvements in cognitive skills and behavioral and the leve l of supports required .
control in children with autism spectrum disorder
who were treated with a comprehensive behavior So urce : Reprinted with permiss ion from the Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition.
therapy administered both by their parents and in Copyright 2013 American Psychiatric Association.
their school setting from an early age (see meta-
analysis by Eldevik et al., 2009).
Intellectual Disability 295
managing their own finances, recreation, transpor- features of objects. Co-occurring sensory and mo-
tation, and organizing themselves to hold a job or tor impairments may prevent functional use of ob-
attend school. People with intellectual disability jects and limit participation in everyday activities
also often have problems with motor skills, such as to watching. In the social domain, the individual
eye-hand coordination and balance. These deficits may only be able to understand simple concrete
have to be significant compared to other people instructions and gestures. Even in adulthood, the
who are the same age and have a similar sociode- individual is fully dependent on others for all
mographic background and culture. aspects of daily living, including physical care,
The DSM-5 classifies intellectual disability health, and safety. Maladaptive behavior is present
into four levels of severity: mild, moderate, severe, in a significant minority of individuals with pro-
and profound. Children and adults with a mild found intellectual disability.
level of intellectual disability generally have some Individually administered intelligence tests
limitations in their ability to acquire typical aca- are used to assess the level of intellectual function-
demic or job-related skills, may seem immature in ing of a person suspected of having intellectual
social interactions and overly concrete in their disability. Intelligence tests measure verbal com-
communications with others, show limited social prehension, working memory, perceptual reason-
judgment and understanding of risk, and may be ing, quantitative reasoning, abstract thought, and
able to care for themselves reasonably well except processing speed. Individuals with intellectual
in complex situations such as making legal or disability generally have scores of two standard
health decisions. Adults with mild intellectual dis- deviations below the mean IQ score of the general
ability often hold competitive jobs that don't em- population of 100; in other words, an IQ score of
phasize conceptual skills. 70 ( 5 or 65-75) or lower. However, DSM-5 de-
Children with a moderate level of intellectual emphasizes intelligence test scores in the diagnostic
disability typically have significant delays in lan- criteria to determine level of severity, and rather
guage development, such as using only 4 to 10 focuses clinicians' attention on the individual's
words by age 3. They may be physically clumsy level of adaptive functioning across the concep-
and have some trouble dressing and feeding them- tual, social, and practical domains, in part because
selves. They typically do not achieve beyond the IQ scores can be misleading or misused. It is esti-
second-grade level in academic skills but, with mated that 1 to 3 percent of the population has in-
special education, can acquire simple vocational tellectual development disorder (Humeau,
skills. As adults, they may be able to -hold a job re- Gambino, Chelly, & Vitale, 2009).
quiring only an elementary-schoollevel of concep-
tual skills, but they likely will require considerable
assistance. With extensive training, they can learn Biological Causes of
to care for their personal needs (eating, personal Intellectual Disability
hygiene). Their social interactions may be im-
paired by communication difficulties, and they Many biological factors can cause intellectual dis-
may show poor social judgment. ability, including chromosomal and gestational
Individuals with severe intellectual disability disorders, exposure to toxins prenatally or in early
have a very limited vocabulary and may speak in childhood, infections, brain injury or malforma-
two- or three-word sentences. As children they tions, metabolism and nutrition problems, and
may have significant deficits in motor develop- some kinds of seizure disorders (e.g., infantile
ment and may play with toys inappropriately (e.g., spasms). We examine these factors first and then
banging two dolls together). As adults, they can turn to sociocultural factors.
feed themselves with a spoon and dress them-
selves if the clothing is not complicated (with Genetic Factors
many buttons or zippers). They cannot travel alone Nearly 300 genes affecting brain development and
for any distance and cannot shop or cook for them- functioning have been implicated in the develop-
selves. Some individuals may be able to learn some ment of intellectual disability (Vaillend, Poirier, &
unskilled manual labor, but many are unable to do Laroche, 2008). These genes do not lead to the disor-
so. In the social domain, they generally lack aware- der as such but rather to one or more of the types of
ness of risk, and may easily be led by others due to deficits people with ID show. It is not surprising,
naivete in social situations. They require support then, that families of children with intellectual dis-
for all aspects of daily living. ability tend to have high incidences of a variety of
At the profound level of intellectual disability, intellectual problems, including the different levels
individuals often don't develop conceptual skills of intellectual disability and autism spectrum disor-
beyond simple matching of concrete physical der (Humeau et al., 2009).
Two metabolic disorders they seem to age more rapidly than normal, and ~
that are genetically transmitted their life expectancy is shorter than average. People
and that cause intellectual dis- with Down syndrome have abnormalities in the
ability are phenylketonuria neurons in their brains that resemble those found
(PKU) and Tay-Sachs disease. in Alzheimer's disease. Nearly all individuals with
PKU is carried by a recessive Down syndrome past age 40 develop the thinking
gene and occurs in about 1 and memory deficits characteristic of a neurocogni-
in 20,000 births. Children with tive disorder due to Alzheimer's disease (see Chap-
PKU are unable to metabolize ter 10) and lose the ability to care for themselves
phenylalanine, an amino acid. (Visser et al., 1997).
As a result, phenylalanine and Fragile X syndrome, another common cause of
its derivative, phenylpyruvic intellectual disability, is caused when a tip of the X
acid, build up in the body and chromosome breaks off (Turk, 2011). This syn-
cause brain damage. Fortunately, drome affects primarily males because they do not
children who receive a special have a second, normal X chromosome to balance the
diet free of phenylalanine from mutation. The syndrome is characterized by se-
an early age can attain an aver- vere to profound intellectual disability, speech de-
age level of intelligence. Most fects, and severe deficits in interpersonal
states mandate testing for PKU interaction. Males with fragile X syndrome have
in newborns. If left untreated, large ears, a long face, and enlarged testes. Females
children with PKU typically with the syndrome tend to have a less severe level
have an IQ below 50 and severe of intellectual disability (Koukoui & Chaudhuri,
or profound ID. 2007). Two other chromosomal abnormalities that
Tay-Sachs disease also is cause severe intellectual disability and shortened
carried by a recessive gene and life expectancy are trisomy 13 (chromosome 13 is
occurs primarily in Jewish pop- present in triplicate) and trisomy 18 (chromosome
ulations. When an affected child 18 is present in triplicate).
Advocates of mainstreaming argue that
individuals with intellectual disabilities is between 3 and 6 months old, a The risk of having a child with Down syn-
should be integrated into everyday life. progressive degeneration of the drome or any other chromosomal abnormality in-
nervous system begins, leading creases with the age of the parents. This may be
to mental and physical deterio- because the older a parent is, the more likely chro-
ration. These children usually die before age 6, and mosomes are to have degenerated or to have been
there is no effective treatment. damaged by toxins.
Several types of chromosomal disorders
can lead to intellectual disability (Williams, 2010). Brain Damage During Gestation
Children are born with 23 pairs of chromosomes. and Early Life
Twenty-two of these pairs are known as auto- Intellectual development can be profoundly af-
somes, and the twenty-third pair contains the sex fected by the fetus's prenatal environment (King,
chromosomes. One of the best-known causes of Hodapp, & Dykens, 2005). When a pregnant woman
intellectual disability is Down syndrome, which contracts the rubella (German measles) virus, the
occurs when chromosome 21 is present in tripli- herpes virus, or syphilis, there is a risk of damage to
cate rather than in duplicate. (For this reason, the fetus that can cause intellectual disability.
Down syndrome is also referred to as trisomy 21.) Chronic maternal disorders, such as high blood
Down syndrome occurs in about 1 in every 800 pressure and diabetes, can interfere with fetal nutri-
children born in the United States. tion and brain development and thereby affect the
From childhood, almost all people with Down intellectual capacities of the fetus. If these maternal
syndrome have intellectual disability, although the disorders are treated effectively throughout the
severity level varies from mild to profound. Their pregnancy, the risk of damage to the fetus is low.
ability to care for themselves, live somewhat inde- Children whose mothers abuse alcohol during
pendently, and hold a job depends on their level of pregnancy are at increased risk for fetal alcohol
intellectual deficit and the training and support syndrome (FAS; see Mukherjee, Hollins, & Turk,
they receive. Children with Down syndrome have 2006). Children with fetal alcohol syndrome have a ~
a round, flat face and almond-shaped eyes; a small below average IQ of 68 and have poor judgment,
nose; slightly protruding lip and tongue; and short, distractibility, and difficulty understanding social
square hands. They tend to be short in stature and cues. As adolescents, their academic functioning is
somewhat obese. Many have congenital heart at only the second- to fourth-grade level, and they
defects and gastrointestinal difficulties. As adults, have trouble following directions. It is estimated
Intellectual Disability 297
CASE STUDY,
Abel Dorris was adopted
when he was 3 years old by Michael Dorris. Abel's
mother had been a heavy drinker throughout the
pregnancy and after Abel was born. She had sub-
sequently died at age 35 of alcohol poisoning.
Abel had been born almost 7 weeks premature,
with low birth weight. He had been abused and
malnourished before being removed to a foster
home. At age 3, Abel was small for his age, was
not yet toilet-trained , and could only speak about
20 words. He was diagnosed with a mild intellec-
tual disability. His adoptive father hoped that, in a
positive environment, Abel could catch up.
Yet, at age 4, Abel was still in diapers and
weighed only 27 pounds. He had trouble remem -
bering the names of other children, and his activ-
ity level was unusually high. When alone , he
would rock back and forth rhythmically. At age 4,
he suffered the first of several severe seizures,
which caused him to lose consciousness for
days. No drug treatments seemed to help.
When he entered school, Abel had trouble
learning to count, to identify colors, and to tie his Children whose mothers abuse alcohol during
shoes. He had a short attention span and difficulty pregnancy are at increased risk for fetal alcohol
following simple instructions. Despite devoted syndrome.
teachers, when he finished elementary school,
Abel still could not add, subtract, or identify his
place of residence. His 10 was in the mid-60s. Day, & Larkby, 2002). One study found that a
Eventually, at age 20, Abel entered a voca- mother 's consumption of even one to three drinks
tional train ing program and moved into a super- per week during pregnancy was associated
vised home. His main preoccupations were his with significant deficits in young children's social
collections of stuffed animals, paper dolls, news- engagement and interaction skills (Brown, Olson,
paper cartoons, family photographs, and old birth- & Croninger, 2010).
day cards. At age 23, he was hit by a car and killed. Severe head traumas that damage children's
(Adapted from Dorris, 1989; Lyman, 1997) brains also can lead to intellectual disability. Shaken
baby syndrome results when a baby is shaken, lead-
ing to intracranial injury and retinal hemorrhage
(Caffey, 1972). Babies' heads are relatively large and
that from 2 to 15 children per 10,000 in the United heavy compared to the rest of their body, and their
States have fetal alcohol syndrome, and three times neck muscles are too weak to control their head
that number are born with lesser alcohol-related when they are shaken. The rapid movement of their
neurological and birth defects (CDC, 2008b). Abel head when shaken can lead to their brain's being
Dorris, in the following case study, was born with banged against the inside of the skull and bruised.
fetal alcohol syndrome. Bleeding in and around the brain or behind the eyes
Even low to moderate levels of drinking dur- can lead to seizures, partial or total blindness, pa-
ing pregnancy can lead to negative outcomes, ralysis, intellectual disability, or death. Although the
such as higher rates of miscarriage, delivery be- shaking of a baby may be part of a pattern of chronic
fore full gestation, lower birth weight, congenital abuse, shaken baby syndrome can occur when an
abnormalities, and impaired social and cognitive otherwise nonabusive parent becomes frustrated
development (Jacobson & Jacobson, 2000; Kelly, and shakes the baby only once.
Day, & Streissguth, 2000; Olson et al., 1998). For Young children face a number of other hazards
example, longitudinal studies of children exposed that can cause brain damage. Exposure to toxic
prenatally to alcohol show negative effects on substances-such as lead, arsenic, and mercury-
growth at age 6 and on learning and memory skills during early childhood can lead to intellectual dis-
at age 10, even if the children do not evidence the ability by damaging areas of the brain. Children
full syndrome of PAS (Cornelius, Goldschmidt, also can incur traumatic brain injury leading to
intellectual disability through accidents, including Behavioral Strategies

motor vehicle accidents in which they are not A child's parents or caregivers and teachers can
properly restrained. work together using behavioral strategies to en-
hance the child's positive behaviors and reduce
negative behaviors. These strategies help children
Sociocultural Factors and adults learn new skills, from identifying colors
Children with intellectual disability are more correctly to applying vocational skills. Social and
likely to come from low socioeconomic back- communication skills also may be taught. Individ-
grounds (Emerson, Shahtahmasebi, Lancaster, & uals may learn to initiate conversations by asking
Berridge, 2010) . It may be that their parents also questions and to articulate what they want to say
have intellectual disability and have not been able more clearly. The desired behavior may be mod-
to acquire well-paying jobs. The social disadvan- eled in incremental steps and rewards given to the
tages of being poor also may contribute to lower- individual as he or she comes closer to mastering
than-average intellectual development. Poor the skill. Behavioral strategies also can help reduce
mothers are less likely to receive good prenatal self-injurious and other maladaptive behaviors.
care, increasing the risk of premature birth. Chil- Typically, behavioral methods do not simply focus
dren living in lower socioeconomic areas are at in- on isolated skills but rather are integrated into a
creased risk for exposure to lead, because many comprehensive program designed to maximize
older buildings have lead paint, which chips off the individual's ability to function in the commu-
and can be ingested. Poor children are concen- nity (Feldman, 2004).
trated in poorly funded schools, where those with
lower IQs receive less favorable attention from Social Programs
teachers and fewer learning opportunities, espe- Social programs have focused on integration of the
cially if they are also members of a minority group child into the mainstream where possible, on place-
(Alexander, Entwisle, & Thompson, 1987). Poor ment in group homes that provide comprehensive
children also are less likely to have parents who care, and on institutionalization when necessary.
read to them and are involved in their schooling. The earlier these interventions begin, the greater
These factors may directly affect a child's intellec- the chance that the child will develop to his or her
tual development and exacerbate the biological full potential.
conditions that impede a child's cognitive devel-
opment (Zigler, Gilliam, & Jones, 2006) . Early Intervention Programs Many experts
recommend beginning comprehensive interven-
Treatments for Intellectual tions with children at risk for intellectual develop-
ment disorder from the first days of life. These
Disability measures include intensive one-on-one interven-
Interventions for children and adults with intel- tions to enhance their development of basic skills;
lectual disability must be comprehensive, inten- efforts to reduce the social conditions that might
sive, and long-term to show benefits (Zigler et al., interfere with the children's development, such as
2006; Zigler & Styfco, 2004, 2008) . child abuse, malnutrition, or exposure to toxins;
and adequate medical care (Zigler & Styfco, 2004).
Drug Therapy One such program was the Infant Health and
Medications are used to reduce seizures, which are Development Program (Gross, Brooks-Gunn, &
common in people with intellectual disability; to Spiker, 1992), which focused on children with a birth
control aggressive or self-injurious behavior; and weight of 2,500 grams (Slh pounds) or less and ages-
to improve mood (Matson & Neal, 2009) . Neuro- tational age of 37 completed weeks or less. This pro-
leptic medications (see Chapter 8) can reduce ag- gram had three components. First, specially trained
gressive, destructive, and antisocial behavior; counselors visited each child's home during the first
however, the potential for neurological side effects 3 years of the child's life, providing support to the
has made these medications controversial. The mother and fostering parent-child activities that
atypical antipsychotics, such as risperidone, have would enhance the child's development. The moth-
been shown to reduce aggression and self-injurious ers were given training in good parenting practices
behavior in adults with intellectual disability with- and in ways to facilitate their children's cognitive
out having serious neurological side effects (Unwin development. For example, they were taught ways
& Deb,2011). Antidepressant medications can reduce to calm their babies (who tended to be irritable), pro-
depressive symptoms, improve sleep patterns, and vide appropriate levels of stimulation as well as
help control self-injurious behavior in individuals opportunities for exploration, and reduce stress in
with intellectual disability. the family's environment. Second, the children went
Learning. Communication. and Motor Disorders 299
daily to a child development center with specially in special education, where they receive intensive
trained teachers, who worked to overcome the chil- training to overcome skills deficits, and some time in
dren's intellectual and physical deficits. Third, par- regular classrooms over the course of the week.
ent support groups were started to help the parents
cope with the stresses of parenting. Group Homes Many adults with intellectual
At 36 months of age, the children in the inter- disability live in group homes, where they receive
vention group were significantly less likely to have assistance in performing daily tasks (e.g., cooking,
IQ scores in the low range than were those in the cleaning) and training in vocational and social skills.
control group, who received only medical care They may work in sheltered workshops during the
(Infant Health and Development Program, 1990). day, performing unskilled or semiskilled labor.
The children who received the program interven- Increasingly, they are being mainstreamed into the
tion also showed fewer behavioral and emotional general workforce, often in service-related jobs (e.g.,
problems at age 36 months than did the children in in fast-food restaurants or as baggers in grocery
the control group. stores). Some community-based programs for adults
What accounted for the positive effects of the with intellectual disability have been shown to be
intervention? Several factors were noted. The home effective in enhancing their social and vocational
environments of the children in the intervention skills (Chilvers, Macdonald, & Hayes, 2006).
group improved significantly (Berlin, Brooks-
Gunn, McCartoon, & McCormick, 1998; McCormick Institutionalization In the past, most children
et al., 1998). More learning materials were avail- with intellectual disability were institutionalized for
able, and their mothers more actively stimulated life. Institutionalization is much less common these
the children's learning. The mothers of the children days, even for children with severe intellectual dis-
in the intervention program were better able to as- ability. African American and Latino families are less
sist their children in problem solving, remaining likely than European American families to institu-
more responsive and persistent with their children. tionalize their children with intellectual disability
In turn, these children showed more enthusiasm (Blacher, Hanneman, & Rousey, 1992). This may be
for and involvement in learning tasks. In addition, because African American and Latino families are
the mothers in the intervention program reported less likely than European American families to have
better mental health than the mothers in the control the financial resources to place their children in
group and also were less likely to use harsh disci- high-quality institutions, or it may be because
pline with their children. All these factors were as- African American and Latino cultures place a stron-
sociated with better outcomes for the children in ger emphasis on caring for ill or disabled family
the intervention group. members within the family.
Mainstreaming Controversy exists over whether

children with intellectual disability should be LEARNING,
placed in special education classes or instead be COMMUNICATION, AND
mainstreamed-that is, put into regular class-
rooms. On one hand, special education classes can MOTOR DISORDERS
provide children with extra training in skills they Rather than having deficits in a broad array of
lack. On the other hand, some critics argue that skills, as in intellectual disability, children with
these classes stigmatize children and provide them learning, communication, or motor disorders have
with an education that asks less of them than they deficits or abnormalities in specific skills or behav-
are capable of achieving. iors. These disorders are not due to intellectual dis-
Placing children with intellectual disability in a ability, global developmental delay, neurological
classroom with children of average intelligence can disorders, or general external factors like economic
put them at certain disadvantages. One study found disadvantage. The severity of these disorders can
that children with intellectual disability were viewed range from mild to severe.
negatively by the other children in their classrooms
(Zigler & Hodapp, 1991). Also, children with intel-
lectual disability who are mainstreamed may not
Specific Learning Disorder
receive the special training they need. Studies com- Individuals with specific learning disorder have
paring the academic progress of children with intel- deficits in one or more academic skills: reading, writ-
lectual disability in special education programs and ten expression, and/ or mathematics (see Table 10.4).
in regular classrooms have reported mixed results The DSM-5 diagnosis is given only when the in-
(Dessemontet, Bless, & Morin, 2012; Freeman & dividual's performance in one or more of these
Alkin, 2000). Many children today spend some time domains is significantly below that expected for
300 Chapter 10 Neurodeve lopmenta l a nd Neurocognitive Disorders
TABLE 10.4 DSM-5 Criteria for Specific Learning Disorder
A. Difficulties learning and using academic skills, as indicated by the presence of at least one of the following
symptoms that have persisted for at least 6 months, despite the provision of interventions that target those
difficulties:
1. Inaccurate or slow and effortful word reading (e.g., reads single words aloud incorrectly or slowly and
hesitantly, frequently guesses words, has difficulty sounding out words) .
2. Difficulty understanding the meaning of what is read (e.g., may read text accurately but not understand
the sequence, re lationships, inferences, or deeper meanings of what is read).
3. Difficulties with spelling (e .g., may add, omit, or substitute vowels or consonants).
4. Difficulties with written expression (e.g., makes multiple grammatical or punctuation errors within
sentences; employs poor paragraph organization; written expression of ideas lacks clarity).
5. Difficulties mastering number sense, number facts, or calculation (e.g., has poor understanding of
numbe rs, their magnitude, and re lationships; counts on fingers to add single-digit numbers instead of
recalling the math fact that peers do; gets lost in the midst of arithmetic computation and may switch
procedures).
6. Difficu lties with mathematical reasoning (e.g., has severe difficulty applying mathematica l concepts,
facts, or procedures to solve quantitative problems).
B. The affected academic skills are substantially and quantifiably below those expected for the individual's
chronological age, and cause significant interference with academic and occupational performance, or with
activities of daily living. Skill impairments are confirmed by individually administered standardized
achievement measures and comprehensive clinical assessment. For individuals 2: 17 years, a documented
history of impairing learning difficulties may be substituted for the standardized assessment.
C. The learning difficulties begin during school-age years and may not become fully manifest until the
demands for those affected academic skills exceed the individual's limited capacities (e.g., as in timed tests,
reading, or writing lengthy complex reports for a tight deadline, excessively heavy academic loads).
D. The learning difficulties are not better accounted for by intellectual disabilities, uncorrected visual or
auditory acuity, other mental or neurological disorders, psychosocial adversity, lack of proficiency in the
language of academic instruction, or inadequate educational instruction.
Specify all academic domains and subskills that are impaired. When more than one domain is impaired, each
one should be coded according to the following specifiers:
With im pairment in reading:
Word read ing accuracy
Reading rate or fluency
Reading comprehension
With impairment in written expression :
Spelling accuracy
Grammar and punctuation accuracy
Clarity or organization of written expression
With impairment in mathematics:
Number sense
Memorization of arithmetic facts
Accurate or fluent calculation
Accurate math reasoning
Source: Reprinted with permissio n from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright 2013
Learning, Communication, and Motor Disorders 301
his or her age, schooling, and overall level of intel- ing disorder may also affect their social relation-
ligence. Although the threshold for diagnos~s of a ships (Fletcher, Lyon, Fuchs, & Barnes, 2007).
specific learning disorder is som~w~a.t arbitrary,
unexpected low performan~e or: ~dividually a~ Communication Disorders
ministered, culturally and lmgmshcally appro~n The communication disorders involve persis-
ate standardized academic achievement tests IS a tent difficulties in the acquisition and use of lan-
ge~erally used criterion for school-age individuals guage and other means of communicati?n (see
(e.g.,:::; 1 or 1.5 standard deviations below the age- Table 10.5). Children with language disorder
based population mean). have difficulties with spoken language, written
Difficulties in reading, often referred to as dys- language, and other language modaliti~s (e.g.,
lexia, are usually apparent by the fourth grade .and sign language). Their symptoms may mcl~de
represent the most common specific learning disor- problems with vocabulary,. grammar,. narrative
der. Reading impairments include poor word re~d (i.e., knowing how to descnbe somethmg or put
ing accuracy, slow reading rate, and .readmg together a story), and other pragmatic la~guage
comprehension weaknesses. They are seen m abo':t abilities. Children with speech sound disorder
4 percent of children, more commonly boys (Katusic have persistent difficulties in producing speech.
et al., 2001, 2005; Rutter et al., 2004). Difficulties in They may not use speech sounds appro~riate for
mathematics may include problems in understand- their age or dialect, or they may substitute one
ing mathematical terms, recognizing numer.ical sound for another (e.g., use a t for a k sound) or
symbols, clustering objects into groups: counting, omit certain sounds (such as final consonants on
mastering math facts, and understandmg mathe- words). Their words come out sounding like baby
matical principles. Although many people fe~l that talk. They may say wabbit for rabbit, or bu for blue
they are not great at math, deficits in math skills se- (Kartheiser, Ursano, & Barnhill, 2007).
vere enough to warrant this diagnosis occur ~ ?nly A third DSM-5 communication disorder is
about 1 percent of children (Tannock, 2005). Difficul- childhood-onset fluency disorder or stuttering.
ties in written expression involve significant weak- Children who stutter have significant problems
nesses in spelling, constructing a sentence or with speaking evenly and fluently, often voicing
paragraph, or grammar and punctuation. frequent repetitions of sounds or syllables (such as
Children with learning disorders often strug-
"1-1-1-1 see him"). Some children also repeat whole
gle with low academic performance or have to.put words or short phrases, for example, "Kids tease
forth extraordinarily high levels of effort to achieve
me about my, about my s-s-s-stutter." The severity
average grades. They can become demoralized or
of their speech problems varies by the situation
disruptive in class. If left untreated, they are at
but usually is worse when they are under pressure
high risk for dropping out of school, with as many
to speak well, as when giving an oral report. Stut-
as 40 percent never finishing high school. As
tering often begins gradually and almost always
adults, they may have problems getting and keep-
starts before age 10. Estimates of the prevalence of
ing a good job, and often avoid leisure or work ac-
stuttering range from 0.3 percent to 5 percent, with
tivities that require reading, arithmetic, and/ or
roughly twice as many boys as girls diagnosed
writing. The emotional side effects of their learn-
(Howell, 2007; McKinnon, McLeod, & Reilly, 2008;
Proctor, Yairi, Duff, & Zhang, 2008). As many as
80 percent of children who stutter recover on their
own by age 16 (Drayna & Kang, 2011). Others,
however, continue to stutter as adults. Stuttering
can lower children's self-esteem and cause them to
limit their goals and activities.
Finally, children with social communication
disorder have deficits in using verbal and nonverbal
communication for social purposes, such as greeting
and sharing information, in a manner that is appro-
priate for the social context. Because children with
social communication disorder have difficulty
changing their communication to match the needs
of the listener or following rules for conversation
Learning disorders can lead to frustration and low and storytelling, their social participation and social
self-esteem . relationships are often impaired. Note that children
TABLE 10.5 Diagnostic Features of Communication Disorders
Disorder Description
Language Disorder Persistent difficulties in the acquisition and use of language

in speech, written or sign language due to deficits in the
comprehension or production of vocabulary, sentence structure,
or discourse.
Speech Sound Disorder Persistent difficulty with speech sound production that interferes
with speech intellig ibility or prevents verbal communication of
messages. Includes deficits in the phonologica l knowledge of
speech sounds and/or difficu lty coordinating movements of the
jaw, tongue, or lips for clear speech with breathing and vocalizing
for speech.
Childhood-Onset Flue ncy A disturbance in the normal fluency and time patterning of speech
Disorder (Stuttering) (e.g., sound syllable repetitions, sound prolongations of consonants
and vowels, pauses within words).
Social (Pragmatic) Communication Persistent difficulties with pragmatics or the social use of language
Disorde r and nonverbal communication in naturalistic contexts, which affects
the development of social relationships and social participation.
Symptoms are not better explained by autism spectrum disorder,
intellectual disability, or low abilities in the domains of word structure
and grammar or general cognitive ability.
with autism spectrum disorder have difficulties in articulate and analyze words. An area in the parieto-
social communication. The DSM-5 specifies that the temporal region is involved in the ability to map the
diagnosis of social communication disorder can be visual perception of the printed word onto the basic
given only if the child's communication difficulties structures of language. Another area, in the occipita-
are not better explained by autism spectrum disor- temporal region, is involved in the rapid, automatic,
der, and thus the child cannot currently or by history fluent identification of words (Shaywitz & Shaywitz,
also show evidence of restricted/ repetitive patterns 2008). In individuals with dyslexia, a condition in
of behavior, interests, or activities. which the individual has difficulty with accurate
and fluent word recognition, neuroimaging studies
show unusually low activity in the parietotemporal
Causes and Treatment of and occipitotemporal regions (Shaywitz, 2003).
Learning and Communication Environmental factors linked to the learning
disorders include lead poisoning, birth defects,
Disorders sensory deprivation, and low socioeconomic sta-
Genetic factors are implicated in all the learning tus (Fletcher et al., 2007). These conditions may
and communication disorders (Davis, Haworth, & create the risk of damage to critical brain areas.
Plomin, 2009; Drayna & Kang, 2011; Wittke- Children whose environments offer fewer oppor-
Thompson et al., 2007). While there may not be tunities to develop language skills are less likely to
specific genes responsible for specific disorders in overcome biological contributors to learning prob-
most cases, certain genetic abnormalities may ac- lems (Shaywitz & Shaywitz, 2008).
count for a number of different learning disorders The treatment of these disorders usually in-
(Davis et al., 2009). volves therapies designed to build the missing skills
Abnormalities in brain structure and function- (Fletcher et al., 2007). Under the provisions of the
ing have long been thought to cause learning disor- Individuals with Disabilities Education Act, these
ders. Studies of people with difficulties in reading interventions are bundled in a child's comprehen- ~
have identified three areas of the brain involved in sive Individualized Education Plan (IEP). The IEP
three separate but interrelated skills (Shaywitz & describes the child's specific skills deficits as deter-
Shaywitz, 2008). An area of the inferior frontal gyrus mined by formal tests and observations by parents
called Broca's area is involved in the ability to and teachers. The plan also involves parents and
Learning. Communication, and Motor Disorders 303
teachers in strategies to help the child overcome tics include jerking of the head, arm, or leg; eye
these deficits. A child with dyslexia might receive blinking; facial grimacing; and neck stretching.
systematic instruction in word recognition while in Vocal tics can be almost any sound or noise, but
school, supplemented with practice at home, possi- common ones include throat clearing, sniffing,
bly using computerized exercises. Such programs and grunting (Singer, 2005) . People with To-
appear to significantly improve skills in children urette's disorder have multiple motor tics and at
with learning disorders (Gajria, Jitendra, Sood, & least one or more vocal tics that have persisted
Sacks, 2007). for more than a year since the first tic onset.
Studies suggest that specialized instruction to About 10 percent of people with Tourette's have
overcome skills deficits actually can change brain a complex form of vocal tic that involves uttering
functioning. In one study, children with dyslexia or shouting obscenities or other socially objec-
received daily individual tutoring. Before, imme- tionable words or phrases (Singer, 2005). People
diately after, and 1 year after the intervention, the with PMVTD have only motor or vocal tics, not
children underwent neuroimaging. Children who both. People with these disorders often feel a
received this intervention not only improved their premonition that a tic is imminent and an urge
reading but also demonstrated increased activa- just before the tic occurs; the urge to tic is tempo-
tion in the parietotemporal and occipitotemporal rarily reduced by the tic behavior (Flessner,
regions (Shaywitz et al., 2004). Other researchers 2011). The frequency of tics in both disorders in-
also have seen neural effects of specialized train- creases when people are under stress or do not
ing to overcome learning problems (Richards et al., have alternative activities to occupy them.
2000; Temple et al., 2003). The distinctions between Tourette' s disorder
and PMVTD may seem minor, and studies show
that similar genetic and other biological factors may
Motor Disorders underlie both tic disorders (e.g., Harris & Singer,
The DSM-5 specifies four motor disorders (see 2006). Tourette's disorder, especially with the pres-
Table 10.6) . Two of these are tic disorders, ence of complex vocal tics, is more debilitating and
Tourette's disorder and persistent motor or vocal more often comorbid with other disorders than is
tic disorder (PMVTD). They are relatively PMVTD such as ADHD or OCD, so the authors of
common, with prevalences of 1 percent and 3 to the DSM-5 chose to keep them as separate diagno-
4 percent, respectively (Roessner, Hoekstra, & ses (Walkup et al., 2010).
Rothenberger, 2011). Tics are sudden, rapid, re- People with stereotypic movement disorder
current, nonrhythmic motor movements or vocal- engage in repetitive, seemingly driven, and appar-
izations (Walkup et al., 2010). Examples of motor ently purposeless motor behavior, such as hand
TABLE 10.6 Criteria for Motor Disorders
Tourette's Disorder Both multiple motor and one or more vocal tics that have been present
at some time during the illness, although not necessarily concurrently
Persistent Motor or Vocal Single motor or vocal tics, persistent for at least 1 year, and with onset
Tic Disorder before age 18
Stereotypic Movement Disorder Repetitive, seemingly driven, and apparently purposeless motor
behavior (e.g., hand shakin g or waving, body rocking, head banging,
self-biting) causing clinically significant distress or functional
impairment
Developmental Coordination Motor performance that is substantially below expected leve ls, given
Disorder the person's chronologie age and previous opportunities for skill
acquisition (e.g., poor balance, clumsiness, dropping or bumping into
things; marked delays in acquiring basic motor skills such as walking,
crawling, sitting, catching, throwing, cutting , coloring, or printing)
Note: For tic disorders that do not meet the criteria forTourette's Disorder or Persistent Motor orVoca i Tic
Disorder, the DSM-5 provides diagnoses of Other Specified or Unspecified Tic Disorder.
304 Chapter 1o Neurodevelopmental and Neurocognitive Disorders
shaking or waving, hair twirling, body ~ockin.g, MAJOR AND MILD

head banging, and self-biting. These behav1~rs dif-
fer from tics in that the individual may continue to NEUROCOGNITIVE
engage in them for an extended period of time (St~in DISORDERS
et al., 2010). They are often seen in individuals :"1th
In the remainder of the chapter, we discuss disorders
other disorders, particularly autism spectrum disor-
that most often arise later in life, namely the neuro-
der, intellectual disability, and attention-deficit/
cognitive disorders (NCDs), which include major
hyperactivity disorder (Stein et al., 2010).
and mild NCO and delirium. These disorders result
All three of these motor disorders typically be-
from medical conditions that cause impairment
gin in childhood and increase in adolescence and
in cognition or from substance intoxication or
then decline in adulthood (Roessner et al., 2011;
withdrawal. Cognitive problems include memory
Walkup et al., 2010). All three are highly com~rbid
deficits, language disturbances, perceptual distur-
with obsessive-compulsive disorder and hkely
bances, impairment in the capacity to plan and
share common causes with OCD (Walkup et al.,
organize, and failure to recognize or identify objects.
2010). Specifically, these three motor disorders .an~
OCD co-occur in families and may be due to sum-
lar genetic factors. Further, these disorders are as-
sociated with dysfunctions in dopamine systems CASE STUDY
A 61-year-old high school
in areas of the brain involved in control of motor
science department head who was an experienced
behavior, such as the cerebrum, basal ganglia, and
and enthusiastic camper and hiker became ex-
frontal cortex, as is the case in OCD (see reviews
tremely fearful while on a trek in the mountains.
in Roessner et al., 2011; Stein et al., 2010; Walkup
Gradually, over the next few months, he lost inter-
et al., 2010). Tourette's syndrome and PMVTD
est in his usual hobbies. Formerly a voracious
both respond to drugs that alter dopamine sys-
reader, he stopped reading. He had difficulty doing
tems, such as atypical antipsychotic medications
computations and made gross errors in home fi-
(Walkup et al., 2010). All three motor disorders
nancial management. On several occasions he be-
also can be treated with a behavioral therapy called
came lost while driving in areas that were formerly
habit reversal therapy (Azrin & Nunn, 1973), in
familiar to him. He began to write notes to himself
which the triggers for and signs of impendin~ tics
so that he would not forget to do errands. Very
or stereotypic behaviors are identified and clients
abruptly, and in uncharacteristic fashion, he de-
are taught to engage in competing behaviors (e.~.,
cided to retire from work, without discussing his
squeezing their hands when they feel a vocal he
plans with his w ife. Intellectual deterioration grad-
coming on, crossing their arms when they feel they
ually progressed. He spent most of the day piling
are about to engage in hand flapping), with posi-
miscellaneous objects in one place and then trans-
tive results (Flessner, 2011; Miller, Singer, Bridges,
porting them to another spot in the house. He be-
& Waranch, 2006).
came stubborn and querulous. Eventually he
Developmental coordination disorder is an-
required assistance in shaving and dressing.
other motor disorder involving fundamental defi-
When examined 6 years after the first symp-
cits or significant delays in the development of basic
toms had developed, the patient was alert and
motor skills, such as sitting, crawling, walking, run-
cooperative. He was disoriented with respect to
ning, simple athletic skills (throwing or catching a
place and time. He could not recall the names
ball), and motor skills involved in writing, cutting,
of four or five objects after a 5-minute interval of
or coloring. These deficits cannot be due to a medi-
distraction. He could not remember the names of
cal condition such as muscular dystrophy. Signifi-
his college and graduate school or the subject in
cant deficits such as these are fairly common, with a
which he had majored. He could describe his job
prevalence of 5-6 percent in children (affecting
by title only. In 1978 he thought that Kennedy was
more boys than girls), and can cause moderate to
president of the United States. He did not know
severe distress and d ysfunction in a child's life
Stalin's nationality. His speech was fluent and well
(Blank, Smits-Engelsman, Polatajko, & Wilson,
articulated, but he had considerable difficulty find-
2012). These deficits are frequently comorbid with
ing words and used many long, essentially mean-
other disorders, especially ADHD at 50 percent
ingless phrases. He called a cup a vase and
(Sigurdsson, van Os, & Fombonne, 2002). The causes
identified the rims of glasses as "the holders:' He
of developmental coordination disorder are not
did simple calculations poorly. He could not copy a
known, and may be highly heterogeneous (Blank
cube or draw a house. (Spitzer et al., 2002, p. 302)
et al., 2012). The disorder is most often treated with
physical or occupational therapy.
Major and Mild Neurocognitive Disorders 305
TABLE 10.7 DSM-5 Criteria for Major

Symptoms of Major
Neurocognitive Disorder (NCO) Neurocognitive Disorder
Major neurocognitive disorder is characterized by a
A. Evidence of significant cognitive decline from a
previous level of performance in one or more
decline in cognitive functioning severe enough to
cognitive domains (complex attention, executive interfere with daily living (see Table 10.7). Memory
function, learning and memory, language, deficits are prominent. In the early stages of major
perceptual-motor, or social cognition) based on: NCO, the memory lapses may be similar to those
1. Concern of the individual, a knowledgeable we all experience from time to time-forgetting the
informant, or the clinician that there has been a name of someone we know casually, our phone
sig nificant decline in cogn itive function; and number, or what we went into the next room to get.
2. A substantial impairment in cognitive perfor- Most of us eventually remember what we tempo-
mance, preferably documented by standardized rarily forgot, either spontaneously or by using tricks
neuropsychologica l testing or, in its absence, that jog our memory. The difference in major NCO
another quantified cl inical assessment. is that memory does not return spontaneously and
B. The cognitive deficits interfere with independence may not respond to reminders or other cues.
in everyday activities (i.e., at a minimum, People in the early stages of major NCO, or
requ iring assistance with complex instrumental who have mild neurocognitive disorder, may re-
activities of daily living such as paying bi lls or peat questions because they do not remember ask-
managing medications) .
ing them moments ago or do not remember getting
C. The cognitive deficits do not occur exclusively in an answer. They frequently misplace items, such
the context of delirium.
as keys or wallets. They may try to compensate for
D. The cognitive deficits are not better explained by their memory loss. For example, they may care-
another mental disorder (e.g., major depressive
fully write down their appointments or things
disorder, schizophrenia) .
they need to do. Eventually, however, they forget
Note: NCDs are specified by their etiological subtypes, such as to look at their calendars or lists. As memory prob-
whether, for example, they are due to Alzheimer's disease,
lems become more significant, they may become
frontotemporal lobar degeneration, Lewy body disease,
traumatic bra in injury, or substance/medication use. angry when asked questions or may make up an-
Source: Reprinted with perm ission from the Diagnostic swers in an attempt to hide their memory loss. As
and Statistical Manual of Mental Disorders, Fifth Edition. the disorder progresses, they may become lost in
Copyright 2013 American Psychiatric Association.
familiar surroundings and be unable to find their
way when not accompanied by someone.
Eventually, long-term memory also becomes im-
We begin our discussion with major and mild paired. People with major NCO will forget the order
neurocognitive disorder. of major events in their life, such as graduation from
The man in the case study was slowly losing college, marriage, and the birth of their children.
his ability to remember the most fundamental facts After a time, they will be unable to recall the events at
of his life, to express himself through language, all and may not even know their own name.
and to carry out basic everyday tasks. This is a Another cognitive deficit of major NCO is
picture of a major neurocognitive disorder, aphasia, a deterioration of language. People with
commonly known as dementia when referring to major NCO will have tremendous difficulty pro-
older adults with degenerative disorders like ducing the names of objects or people and often
Alzheimer's disease (see the DSM-5 criteria in may use terms such as thing or vague references to
Table 10.7). Milder versions of this disorder that the objects or people to hide their inability to pro-
involve modest cognitive decline from a previous duce concrete names. If asked to identify a cup, for
level of performance, but do not yet result in example, they may say that it is a thing for drink-
significant impairment in functioning, can be diag- ing but be unable to name it as a cup. They also
nosed as mild neurocognitive disorder. may be unable to understand what another person
Major neurocognitive disorder (NCO) typically is saying or to follow simple requests such as "Turn
occurs in late life. The estimated prevalence of the on the lights and shut the door." In advanced
most common type of major NCO-that due to stages of major NCO, people may exhibit echola-
Alzheimer's disease-is 5 to 10 percent of people lia, simply repeating what they hear, or palilalia,
over age 65 (Epple, 2002). The prevalence of most repeating sounds or words over and over.
types of major NCO increases with age, and experts Another common cognitive deficit is apraxia,
estimate that 30 percent of individuals age 85 and impairment of the ability to execute common ac-
older are living with major NCO (Ferri et al., 2005). tions such as waving good-bye or putting on a
shirt. This deficit is not caused by problems in mo-

tor functioning (e.g., moving the arm), in sensory
functioning, or in comprehending what action is
required. People with major NCD simply are un-
able to carry out actions that are requested of them
or that they wish to carry out.
Agnosia is the failure to recognize objects or
people. People with major NCD may not be able to
identify common objects, such as chairs or tables.
At first, they fail to recognize casual friends or dis-
tant family members. With time, they may not rec-
ognize their spouse or children or even their own
reflection in a mirror.
Most people with major NCD eventually lose
executive functions, those brain functions that in-
volve the ability to plan, initiate, monitor, and stop
complex behaviors. Cooking Thanksgiving dinner,
Former President Ronald Reagan.
for example, requires executive functioning. Each who d ied in 2004 at age 93. was
menu item (the turkey, the stuffing, the pumpkin diagnosed with Alzheimer's disease.
pie) requires different ingredients and preparation.
The cooking of various menu items must be coordi-
nated so that all the items are ready at the same people with major NCD). Violent outbursts and
time. People with mild NCD may attempt to cook combative behavior sometimes occur, particularly
Thanksgiving dinner but forget important compo- in moderate to severe stages of major NCDs.
nents (such as the turkey) or fail to coordinate the
dinner, burning certain items and undercooking Types of Major and Minor
others. People with major NCD are unable even to
Neurocognitive Disorder
initiate such a complex task.
Deficits in executive functioning also involve There are several types of neurocognitive disorder
difficulty in the kind of abstract thinking required to based on their causes. DSM-5 recommends that the
evaluate new situations and respond appropriately type of major or mild NCD be specified based on its
to these situations. For example, if a man with major medical or substance/medication-induced cause(s).
NCD is presented with the proverb "People who The most common is Alzheimer's disease, which ac-
live in glass houses shouldn't throw stones," he counts for up to two-thirds of all cases of neurocog-
might be unable to interpret the abstract meaning of nitive disorders (Gatz, 2007). These disorders also
the proverb and instead interpret it concretely to can be caused by vascular disease (blockage or leak-
mean "People don't want their windows broken." age of blood to the brain, commonly referred to as a
In addition to these cognitive deficits, people stroke); by traumatic brain injury; by progressive
with major NCD often show changes in emotional diseases, such as Parkinson's disease and HN dis-
functioning and personality. Shoplifting and exhi- ease; and by chronic substance abuse.
bitionism are common manifestations of a decline
in judgment and an inability to control impulses. Neurocognitive Disorder
People with NCDs may become depressed when Due to Alzheimer's Disease
they recognize their cognitive deterioration. Often, People with neurocognitive disorder due to
however, they do not recognize or admit to their Alzheimer's disease meet the criteria for major or
cognitive deficits. This can lead them to engage in mild NCD, and show clear evidence of decline
unrealistic or dangerous actions, such as driving a in learning and memory. The disease typically
car when they are too impaired to do so safely. begins with mild memory loss, but as the disease
They may become paranoid and angry with family progresses the memory loss and disorientation
members and friends, whom they see as thwarting quickly become profound. About two-thirds of
their desires and freedom. They may accuse others Alzheimer's patients show psychiatric symptoms,
of stealing belongings they have misplaced. They including agitation, irritability, apathy, and dys-
may believe that others are conspiring against phoria. Often these emotional and behavioral
them- the only conclusion left to them when they symptoms are as difficult for caregivers of people
simply do not remember conversations in which with Alzheimer 's disease to deal with as the
they agreed to some action (e.g., starting a new cognitive symptoms. As the disease worsens, suf-
medication or moving into a treatment facility for ferers may become violent and may experience
FIGURE 10.3 FIGURE 10.4
hallucinations and delusions. The disease usually memory and cognition (Atiya, H yman, Albert, &
begins after age 65, but there is an early-onset type Killiany, 2003; Duet al., 2001).
of Alzheimer's disease that tends to progress more There is extensive cell death in the cortex of Al-
quickly than the late-onset type (Gatz, 2007). On zheimer's patients, resulting in shrinking of the cor-
average, people with this disease die within 8 to tex and enlargement of the ventricles of the brain
10 years of its diagnosis, usually as a result of (Figure 10.4). The remaining cells lose many of their
physical decline or independent diseases common dendrites-the branches that link one cell to other
in old age, such as heart disease. cells (Figure 10.5). The result of all these brain abnor-
malities is profound memory loss and an inability to
Brain Abnonnalities in Alzheimer's Disease coordinate self-care and other daily activities.
What we now call Alzheimer's disease was first
described in 1906 by Alois Alzheimer. He observed Causes of Alzheimer's Disease Genetic fac-
severe memory loss and disorientation in a 51-year- tors appear to predispose some people to the brain
old female patient. Following her death at age 55, changes seen in Alzheimer's disease. Family history
an autopsy revealed that filaments within nerve studies suggest that 24 to 49 per-
cells in her brain were twisted and tangled. These cent of first-degree relatives of
neurofibrillary tangles are common in the brains patients with Alzheimer's disease
of Alzheimer's patients but rare in people without eventually develop the disease
cortex
a NCD (Figure 10.3). The tangles, which are made (Gatz, 2007). The lifetime risk of
up of a protein called tau, impede nutrients and developing Alzheimer's disease is
other essential supplies from moving through cells 1.8 to 4.0 times higher for people Amygdala
to the extent that cells eventually die. Another with a family history of the disor-
brain abnormality seen in Alzheimer 's disease is der than for those without such a Hippocampus
plaques (see Figure 10.3). Plaques are deposits of a history. Twin studies confirm an
class of protein, called beta-amyloid, that are important role of genetics in the
neurotoxic and accumulate in the spaces between risk for Alzheimer's disease, as Plaques accumulate between cells in
these and other areas of the brain in
the cells of the cerebral cortex, hippocampus, well as for other types of NCD. Alzheimer's disease.
amygdala, and other brain structures critical to Concordance rates for all types of
a defective gene on chromosome 21 might be

linked with Alzheimer's disease came from the
fact that people with Down syndrome are more
likely than people in the general population to de-
velop Alzheimer's disease in late life. Researchers
hypothesized that the gene responsible for some
forms of Alzheimer's disease may be on chromo-
some 21 and that people with Down syndrome are
more prone to Alzheimer's disease because they
have an extra chromosome 21.
This hypothesis has been supported by studies
of families with high rates of Alzheimer's disease.
These studies have found links between the pres-
ence of the disease and the presence of an abnor-
mal gene on chromosome 21 (Webb & Murphy,
2012). Also, this abnormal gene on chromosome 21
is near the gene responsible for producing a pre-
cursor of the amyloid protein known as the amy-
loid precursor protein gene, or APP gene. It may
Healthy cells Alzheimer's cells be that defects along this section of chromosome
21 cause an abnormal production and buildup
of amyloid proteins in the brain, resulting in
Alzheimer's disease. A number of other genes
NCD in monozygotic twins are 44 percent for men have been implicated in Alzheimer's disease,
and 58 percent for women; concordance rates for though somewhat inconsistently (Gatz, 2007).
dizygotic twins are 25 percent for men and Even taken altogether, however, the genes shown
45 percent for women (Gatz et al., 2006). to be associated with Alzheimer's disease account
Several genes have been linked to Alzheimer's for only about 50 percent of cases.
disease. The gene most consistently associated with People with Alzheimer's disease also show def-
the disease is the apolipoprotein E gene (ApoE), icits in a number of neurotransmitters, including
which is on chromosome 19. This gene regulates the acetylcholine, norepinephrine, serotonin, soma-
ApoE protein, which is involved in the transport of tostatin (a corticotropin-releasing factor), and pep-
cholesterol through the blood. ApoE also binds to tide Y (Micheau & Marighetto,2011). The deficits in
beta-amyloid protein and may play a role in its regu- acetylcholine are particularly noteworthy because
lation. The ApoE gene has three alleles, or versions: this neurotransmitter is thought to be critical in
e2, e3, and e4. People who inherit an e4 allele from memory function. The degree of cognitive decline
one parent have a 2 to 4 times greater risk of devel- seen in patients with Alzheimer's is significantly
oping Alzheimer's disease than people who do not correlated with the degree of deficit in acetylcholine
inherit an e4 allele, and people who inherit e4 alleles (Micheau & Marighetto, 2011). Drugs that enhance
from both parents have an 8 to 12 times greater risk levels of acetylcholine can slow the rate of cognitive
of developing the disorder (Coon et al., 2007). decline in some Alzheimer's sufferers.
Neuroimaging studies show that people with We will likely know much more about the
the e4 version of the ApoE gene have reduced cor- causes of Alzheimer's disease in the next few years.
tex and hippocampus volume compared to people The technologies for studying the genetic and neu-
without the e4 version of the ApoE gene, even as rological processes of the disease are advancing
children or adolescents (Jack et al., 2007; Shaw rapidly, and many researchers are investigating this
et al., 2007; Thompson et al., 2004). As adults, people disorder. Four and a half million people in the
with the e4 version of the A poE gene show greater United States and 18 million people worldwide
cognitive deficits and earlier onset of Alzheimer's have been diagnosed with Alzheimer's disease, and
disorder (Perneczky, Alexopoulos, Wagenpfeil, & this number is expected to increase by at least 300
Kurz, 2012). percent by 2050 (Hebert et al., 2003; Tariot, 2003).
Other genes are implicated in the develop- The annual cost of caring for people with neurocog-
ment of less common forms of Alzheimer's dis- nitive disorder in the United States is expected to be
ease, which begin in middle age and are more $400 billion by 2050 (Lyketsos & Miller, 2012). We
strongly familial. One of these genes is on chromo- can hope that by then we will understand the disor-
some 21 (Webb & Murphy, 2012). The first clue that der well enough to treat it effectively.
Vascular Neurocognitive Disorder

Another common type of neurocognitive disorder is
vascular NCO. People with this disorder meet the
criteria for major or mild NCD, depending on the
severity of cognitive symptoms and functional de-
cline. The most prominent cognitive symptoms are
significant declines in processing speed, in the abil-
ity to pay attention, and in the executive functions
described earlier. In addition, there must be evidence
of a recent vascular event or cerebrovascular dis-
ease. Cerebrovascular disease occurs when the
blood supply to areas of the brain is blocked, caus-
ing tissue damage in the brain. Neuroimaging tech-
niques, such as PET and MRI, can detect areas of
tissue damage and reduced blood flow in the brain,
confirming cerebrovascular disease.
Sudden damage to an area of the brain due to
the blockage of blood flow or to hemorrhaging
(bleeding) is called a stroke. Vascular NCD can
occur after one large stroke or after an accumulation
of small strokes. Cerebrovascular disease can be
caused by high blood pressure and the accumula-
tion of fatty deposits in the arteries, which block
blood flow to the brain. It also can be a complication
of diseases that inflame the brain and of traumatic
brain injuries.
About 25 percent of stroke patients develop
Michael J. Fox is a well-known person suffering from
cognitive deficits severe enough to qualify for a Parkinson's disease.
diagnosis of neurocognitive disorder (Stephens et
al., 2004). A greater risk of developing vascular
NCD is seen in stroke patients who are older (over
age 80), who have less education, who have a his- age 60 (Sarnii, Nutt, & Ransom, 2004). Muhammed
tory of strokes, or who have diabetes. Ali and Michael J. Fox are two well-known people
Even stroke patients who do not immediately with Parkinson's disease. Its primary symptoms are
develop NCD are at increased risk of cognitive de- tremors, muscle rigidity, and the inability to initiate
cline compared to people the same age who do not movement. The symptoms result from the death of
suffer a stroke (Hachinski, 2008). The patients most brain cells that produce the neurotransmitter do-
likely to eventually develop NCD tend to have ad- pamine. Approximately 75 percent of people with
ditional strokes over time, some of which were ob- Parkinson's disease develop neurocognitive disor-
vious and others that were "silent" (or without der (Aarsland & Kurz, 2009).
obvious symptoms) and detected only later. In ad- Neurocognitive disorder due to Lewy body disease
dition, patients who have medical events or condi- is the second most common type of progressive
tions that cause widespread oxygen or blood neurocognitive disorder after Alzheimer's disease.
deficiency-such as seizures, cardiac arrhythmias, It is caused by abnormal round structures that de-
congestive heart failure, and pneumonia-are more velop in the brain. It's characteristic symptoms in-
likely to develop vascular NCDs (Hachinski, 2008). clude changes in attention and alertness, visual
hallucinations, and the symptoms of Parkinson's
Neurocognitive Disorders Associated disease. There is some evidence that it is related to
with Other Medical Condition both Alzheimer's disease and Parkinson's disease.
A variety of other serious medical conditions can The human immunodeficiency virus (HIV), the
produce neurocognitive disorders, including Lewy virus that causes AIDS, can cause a mild or major
body disease, Parkinson's disease, the human im- NCD. People's memory and concentration become
munodeficiency virus (HIV), and Huntington's dis- impaired. Their mental processes slow-they may
ease. Parkinson's disease is a degenerative brain have difficulty following conversations or may take
disorder that affects about 0.3 percent of people in much longer to organize their thoughts and to com-
the general population and 1 percent of people over plete simple, familiar tasks. They may withdraw
socially and lose their spontaneity. Weakness in the caused by motor vehicle accident, explosion, or
legs or hands, clumsiness, loss of balance, and lack sports injury. In the United States, falls account for
of coordination are also common. If the neurocogni- 28 percent of traumatic brain injuries, motor vehi-
tive disorder progresses, the deficits worsen. Speech cle accidents for 20 percent, being struck by an ob-
becomes increasingly impaired, as does the under- ject for 19 percent, violence for 11 percent, and
standing of language. People become confined to bicycle accidents for 3 percent (Langlois, Rutland-
bed, often indifferent to their surroundings. Brown, & Wald, 2006). Leland, in the following
HIV-associated major NCD is diagnosed when case study, developed a major NCD after a motor
the deficits and symptoms become severe and vehicle accident.
global, with significant disruption of daily activi-
ties and functioning. As antiretroviral therapies
have become widely used in treating people with
HIV, new onsets of HIV-related neurocognitive CASE STUDY
A 41-year-old factory worker
disorder have decreased, as has its severity. On the
named Leland was returning home along a rural
other hand, as more patients with HIV survive into
road one night after work. A drunk driver ran a
older age due to these drugs, the number of people
stop sign and collided at a high rate of speed
with HIV-related NCD is increasing, particularly
with the driver's side of Leland's car. Leland was
among people who abused drugs or also had a
not wearing a seat belt. The collision sent Leland
hepatitis C infection (Nath et al., 2008).
through the windshield and onto the pavement.
Huntington's disease is a rare genetic disor-
He lived but sustained a substantial brain injury,
der that afflicts people early in life, usually be-
as we ll as many broken bones and cuts. Leland
tween ages 25 and 55. People with this disorder
was unconscious for more than 2 weeks and
eventually develop a major NCD and chorea-
then spent another 2 months in the hospital, re-
irregular jerks, grimaces, and twitches. Hunting-
covering from his injuries.
ton's disease is transmitted by a single dominant
When he returned home to his family, Leland
gene on chromosome 4 (Gusella, MacDonald,
was not himself. Before the accident, he was a
Ambrose, & Duyao, 1993). If one parent has the
quiet man who doted on his family and fre-
gene, his or her children have a 50 percent chance
quently displayed a wry sense of humor. After
of inheriting the gene and developing the disor-
the accident, Leland was sullen and chronically
der. Huntington's disease affects many neu-
irritable. He screamed at his wife or children for
rotransmitters in the brain, but which of these
the slightest annoyance. He even slapped his
changes causes chorea and neurocognitive disor-
wife once when she confronted him about his
der remains unclear.
verbal abuse of the children.
Mild and major neurocognitive disorder can
Leland did not fare much better at work. He
also be caused by a rare disorder called prion disease
found he now had great trouble concentrating
(also known as Creutzfeld-Jacob's disease); by brain
on his job, and he could not follow his boss's in-
tumors; by endocrine conditions, such as hypothy-
structions. When his boss approached Leland
roidism; by nutritional conditions, such as deficien-
about his inability to perform his job, Leland
~ies ?f thiamine, niacin, and vitamin B12; by
could not express much about the trouble he was
infec~ons, such as syphilis; and by other neurologi-
cal diseases, such as multiple sclerosis. In addition, having. He became angry at his boss and ac-
the chronic heavy use of alcohol, inhalants, and sed- cused him of wanting to fire him. Leland had al-
atives, especially in combination with nutritional ways been much liked by his co-workers, and
they welcomed him back after the accident with
d~~icien.cies, can cause brain damage and neurocog-
rutive disorder. As many as 10 percent of chronic al- sincere joy, but soon he began to lash out at
cohol abusers may develop neurocognitive disorder them , as he was lashing out at his wife and chil-
(Winger, Hofmann, & Woods, 1992). Alcohol-related dren. He accused a close friend of stealing from
neurocognitive disorder usually has a slow, insidi- him. These symptoms continued acutely for
ous onset. While it can be slowed with nutritional about 3 months. Gradually, they declined. Finally,
supplements, it often is persistent, particularly when about 18 months after the accident, Leland's
use was prolonged and as age increases. emotional and personality functioning appeared
to be back to normal. His cognitive functioning
Traumatic brain injury, another potential cause
also improved greatly, but he still found it more
of neurocognitive disorder, can result from pene-
trating injuries, such as those caused by gunshots, difficult to pay attention and to complete tasks
than he did before the accident.
or closed head injuries, typically caused by impact
to the head and/ or concussive forces such as
Leland's symptoms are characteristic of people

with a severe traumatic brain injury. He showed
changes both in his cognitive abilities and in his
usual emotional and personality functioning . For-
tunately, Leland's symptoms subsided after several
months. Many victims of moderate to severe brain
injury never fully recover (Beatty, 1995).
Neurocognitive disorders that follow single
closed head injuries are typically mild and more
likely to dissipate with time than are NCDs that
follow repeated closed head injuries, such as those
experienced by boxers, some soldiers, or people in
multiple motor vehicle accidents. Between 1.6 and
3.8 million traumatic brain injuries in the United
States each year are the result of sports and recre-
ation activities; young men are most likely to suf-
fer neurocognitive disorder due to brain injury
because they take more risks associated with brain
injuries than do other groups (CDC, 2007). Soldiers who have served in Iraq and Afghanistan have had high rates of
traumatic brain injury.
Soldiers who have served in Iraq and Afghani-
stan have had high rates of traumatic brain injury
due to blasts from roadside bombs and other ex-
plosive devices. It is estimated that 22 percent of neurocognitive disorder. Studies in the United
all injuries in these wars are traumatic brain inju- States, Europe, Israel, and China show that people
ries (Committee on Gulf War and Health, 2008). with lower levels of education are more likely to be
Soldiers with traumatic brain injuries show de- diagnosed with neurocognitive disorder than are
clines in neurocognitive function similar to those people with higher levels of education (Chen et al.,
seen in neurocognitive disorder, as well as depres- 2012; Katzman, 1993; Stem, Gurland, Tatemichi, &
sion, aggressive behavior, long-term unemploy- Tang, 1994). Neuroimaging studies of people with
ment, and problems in their social relationships. neurocognitive disorder find that those with less
education show more of the brain deterioration
The Impact of Gender, associated with neurocognitive disorder than do
Culture, and Education those with more education. It may be that people
with more education have a higher socioeconomic
on Neurocognitive Disorder status, which in tum provides them with better
There are more elderly women than elderly men with nutrition and health care that protect them against
neurocognitive disorder, particularly Alzheimer's the conditions contributing to Alzheimer's dis-
disease (Gatz, 2007). This may be simply because ease. Education and, more generally, cognitive ac-
women tend to live longer than men and thus live tivity throughout one's life actually may increase
long enough to develop an age-related neurocogni- brain resources in ways that forestall the develop-
tive disorder. Among people with the same degree ment of neurocognitive disorder in people prone
of the brain changes due to Alzheimer's, women to the disorder (Gatz, Prescott, & Pedersen, 2006).
tend to show greater cognitive impairment than The likelihood that a person with neurocogni-
men (Barnes et al., 2005; Pemeczky et al., 2007). The tive disorder will be institutionalized rather than
reasons for these gender differences are not known. cared for in the family is greater among European
In general, African Americans are diagnosed Americans than among Asians or Hispanics and
with neurocognitive disorder more frequently than Latinos (Chin et al., 2011; Mausbach et al., 2004;
European Americans (Chin, Negash, & Hamilton, Torti et al., 2004). One reason may be that European
2011; Chui & Gatz, 2005). African Americans have Americans are more likely to have the substantial
higher rates of hypertension and cardiovascular dis- financial resources it takes to treat family members
ease, both of which contribute to vascular neurocog- with neurocognitive disorder (Chin et al., 2011). In
nitive disorder. However, the genetic factors leading addition, Asian and Latino cultures may have a
to neurocognitive disorder may be more prevalent more positive view of caring for sick and elderly
in European Americans than in African Americans. family members than European American culture.
Differences in people's level of education Asian and Latino cultures also exert greater societal
also may contribute to differences in rates of pressure to care for ill family members in the home.
Treatments for and Prevention drugs may be used to help control emotional symp-
toms. Antipsychotic drugs may help control hallu-
of Neurocognitive Disorder cinations, delusions, and agitation (Sultzer et al.,
Two classes of drugs are approved for treatment of 2008).
the cognitive symptoms of neurocognitive disor- Behavior therapies can be helpful in control-
der (Martorana, Esposito, & Koch, 2010). The first ling patients' angry outbursts and emotional insta-
class is cholinesterase inhibitors, such as donepezil bility (Fitzsimmons & Buettner, 2002; Teri et al.,
(Aricept), rivastigmine (Exelon), and galantamine 2003). Often, family members are given training in
(Reminyl). These drugs help prevent the breakdown behavioral techniques to help them manage pa-
of the neurotransmitter acetylcholine, and ran- tients at home. These techniques not only reduce
domized trials show that they have a modest posi- stress and emotional distress in family caregivers
tive effect on neurocognitive disorder symptoms but also may result in fewer behavior problems in
(Martorana et al., 2010). The side effects of these the family member with neurocognitive disorder
drugs include nausea, diarrhea, and anorexia. The (Teri et al., 2003).
second class is drugs that regulate the activity of Many people are interested in behavioral
the neurotransmitter glutamate, which plays an means of reducing their risk for neurocognitive
essential role in learning and memory; memantine disorder. Aerobic exercise and mental activity may
(Namenda) is one such drug. have some protective value (Deeny et al., 2008;
Many other drugs used to treat people with Valenzuela, 2008). Reducing the risk factors for
neurocognitive disorder affect the secondary symp- stroke-for example, avoiding smoking, obesity,
toms of the disorder rather than the primary cogni- and hypertension-may reduce the risk for vascu-
tive symptoms. Antidepressants and antianxiety lar neurocognitive disorder (Gatz, 2007).
One of the most fascinating studies to show a
link between intellectual activity beginning early in
life and a reduced risk of Alzheimer's disease is the
Nun Study, a longitudinal study of several hundred
elderly nuns in the School Sisters of Notre Dame.
Nuns who entered old age with greater intellectual
strengths were less likely to develop severe neuro-
cognitive disorder, even when their brain showed
evidence of significant neurofibrillary tangles and
senile plaques (Snowdon, 1997). For example, the
level of linguistic skill the nuns showed in journal
writings when they were in their twenties signifi-
cantly predicted their risk of developing neurocog-
nitive disorder in later life (Snowdon et al., 1996).
The best example was Sister Mary, who had high
cognitive test scores right up until her death at age
101. An evaluation of Sister Mary's brain revealed
that Alzheimer's disease had spread widely through
her brain, even though her cognitive test scores
slipped only from the "superior" range to the "very
good" range as she aged. Other results from this
study showed that tiny strokes may lead a mildly
deteriorating brain to develop a major neurocogni-
tive disorder (Snowdon et al., 1997).
DELIRIUM
Delirium is characterized by disorientation, re-
cent memory loss, and a clouding of attention
(Table 10.8). A delirious person has difficulty
focusing, sustaining, or shifting attention. These
The School Sisters of Notre Dame have participated in a
fascinating study of the effects of early intellectual
signs arise suddenly, within several hours or days.
activity on mental and physical health in old age. They fluctuate over the course of a day and often
become worse at night, a condition known as
Delirium 313
symptoms alternate with intervals of lucid func-

TABLE 10.8 DSM-5 Criteria for Delirium tioning and the symptoms become worse at night,
a diagnosis of delirium is likely. If the person is
A. A disturbance in attention (i.e., reduced ability not disoriented (to time, place, or person) or if
to direct, focus, sustain, and shift attention) and
recent memory loss is absent, then a diagnosis of
orientation to the environment and awareness
delirium is unlikely.
(reduced orientation to the environment).
The onset of delirium may be dramatic, as
B. The disturbance develops over a short period of when a normally quiet person suddenly becomes
time (usually hours to a few days). and represents
loud, verbally abusive, and combative or when a
a change from baseline attention and awareness,
compliant hospital patient tries to pull out his in-
and tends to fluctuate in severity during the
course of a day.
travenous tube. Sometimes, though, the onset of
delirium manifests as an exaggerated form of an
C. An additional disturbance in cognition (e.g., individual's normal personality traits. For exam-
memory deficit, disorientation, language,
ple, a generally cranky person recovering from
visuospatial ability, or perception).
surgery may complain loudly and harshly about
D. The disturbances in Criteria A and Care not the "inadequate" care she is receiving from the at-
better explained by another preexisting,
tending nurses. It would be easy for attending staff
established, or evolving neurocognitive
to regard her irritability as consistent with her per-
disorder and do not occur in the context of a
severely reduced level of arousal, such as coma.
sonality style: "She must be feeling better; she's
beginning to complain." In this type of case, the
E. There is evidence from the history, physical
delirium may go unrecognized until more severe
examination, or laboratory findings that
symptoms emerge.
the disturbance is a direct physiological
consequence of another medical condition,
Sometimes, delirious individuals simply appear
substance intoxication or withdrawal, or confused. People who know the person well might
exposure to a toxin, or due to multiple say, "He just doesn't seem like himself." These de-
etiologies. lirious individuals may call an acquaintance by the
wrong name or forget how to get to a familiar loca-
Source: Reprinted with permission from the Diagnostic tion, such as their room. In such cases, the first indi-
and Statistical Manual of Mental Disorders, Fifth Edition. cation of delirium often comes from the observations
Copyright 2013 American Psychiatric Association.
of family or medical staff. They notice that the per-
son seems calm during the day but becomes agitated
at night. It is important to monitor such a person
around the clock. Detecting delirium also may re-
sundowning. The duration of these signs is short- quire the frequent testing of the person's orientation
rarely longer than a month. Delirious patients often (by asking his or her name, the date and time, and
are agitated or frightened. They also may experience the location). Close monitoring is also important
disrupted sleep-wake cycles, incoherent speech, because, with delirium, accidents such as falling out
delusions, and hallucinations. of bed or stepping into traffic are common.
The symptoms of delirium usually follow a Delirium typically signals a serious medical
common progression (Cole, 2004). In the early condition. When it is detected and the underlying
phase, patients report mild symptoms such as fa- medical condition is treated, delirium is tempo-
tigue, decreased concentration, irritability, rest- rary and reversible (Cole, Ciampi, Belzile, &
lessness, or depression. They may experience Zhong, 2009). The longer delirium continues, how-
mild cognitive impairments or perceptual distur- ever, the more likely the person is to suffer perma-
bances, or even visual hallucinations. As the de- nent brain damage, because the causes of delirium,
lirium worsens, the person's orientation becomes if left untreated, can induce permanent changes in
disrupted. A patient may think she is in her child- the functioning of the brain.
hood home instead of in the hospital. If unde-
tected, the delirium progresses, and the person's
orientation to familiar people becomes distorted.
Causes of Delirium
For example, a delirious person may misidentify Neurocognitive disorder is the strongest predictor
~ his wife or fail to recognize his child. Immediate of delirium, increasing the risk fivefold (Cole, 2004).
memory is the first to be affected, followed by in- A wide range of medical disorders, including stroke,
termediate memory (memories of events occur- congestive heart failure, infectious diseases, a high
ring in the past 10 minutes) and finally by remote, fever, and HIV infection, is associated with a risk
or distant, memory. When intervals of these for delirium. Intoxication with illicit drugs and
Some people are at increased risk for delir- ~

ium. Risk factors include age (the older the per-
son, the higher the risk), gender (males are at
greater risk than females), and pre-existing brain
damage or neurocognitive disorder (Brown &
Boyle, 2002). African Americans have higher rates
of delirium than European Americans, possibly
because African Americans are less likely to have
health insurance and thus do not receive early in-
tervention for a serious illness. As a result, their
illness may be more likely to become severe enough
to cause delirium.
Treatments for Delirium

It is extremely important that delirium be recog-
nized and treated quickly. If a delirious person is
not already hospitalized, immediate referral to a
Delirium is a common problem in older adult hospital patients. physician should be made. If another medical con-
dition is associated with the delirium (e.g., stroke
or congestive heart failure), the first priority is to
treat that condition (Cole, 2004). Drugs that may
withdrawal from these drugs or from prescription contribute to the delirium must be discontinued.
medications also can lead to delirium. Other possi- Antipsychotic medications sometimes are used to
ble causes include fluid and electrolyte imbalances, treat the person's confusion. It also may be neces-
medication side effects, and toxic substances. sary to prevent people with delirium from harm-
Delirium may be caused when a medical con- ing themselves accidently (Maxmen & Ward,
dition, a drug, or a toxic substance affects the level 1995). Often, nursing care is required to monitor
of acetylcholine in the brain (White, 2002). Abnor- people's state and prevent them from wandering
malities in a number of other neurotransmitters, off, tripping, or ripping out intravenous tubes and
including dopamine, serotonin, and GABA, are to manage their behavior if they should become
seen in people who are delirious. noncompliant or agitated and combative. In some
Delirium is probably the most common psychi- instances, restraints are necessary. Providing a re-
atric syndrome found in general hospitals, particu- assuring atmosphere filled with familiar personal
larly in older people. About 15 to 20 percent of belongings, such as family photographs and the
older people are delirious on admission to the hos- person's own clothing, can help patients prone to
pital for a serious illness, and another 10 to 15 per- delirium be less agitated and feel more secure and
cent develop delirium while in the hospital. Older in control.
people often experience delirium following sur-
gery (Brown & Boyle, 2002; Cole, 2004). The delir-
ium may be the result of the person's medical
disorder or the effect of medications. It also may
CHAPTER INTEGRATION
result from sensory isolation. A syndrome known As noted in the Along the Continuum feature at
as ICU/CCU psychosis occurs in intensive care the beginning of this chapter, both developmental
and cardiac care units (Maxmen & Ward, 1995). Pa- psychopathologists and geropsychologists em-
tients who are kept in unfamiliar surroundings that phasize the importance of understanding the neu-
are monotonous may hear noises from machines as rodevelopmental and neurocognitive disorders in
human voices, see the walls quiver, or hallucinate the context of normal development and aging. De-
that someone is tapping them on the shoulder. velopment and aging are not simply biological
Among the elderly, a high mortality rate is as- processes but rather involve the interaction of bio-
sociated with delirium (Cole, 2004). The typical logical, environmental, and psychosocial processes,
reason is that the underlying condition or the as depicted in Figure 10.6.
cause of the delirium is very serious. Between 15 All the disorders in this chapter are related to
and 40 percent of delirious hospital patients die genetic abnormalities, but the environment can
within 1 month, compared to half that rate for affect the expression of genes through epigenetic
nondelirious patients. processes (see Chapter 2). For example, there is
lifespan causes DNA damage that results in a

Integrating Biological,
FIGURE 10.6 higher risk for autism spectrum disorder in their
Environmental, and
children.
Psychosocial Factors in
In addition, the impact of biological vulner-
Neurodevelopmental and Neurocognitive
abilities to neurodevelopmental or neurocogni-
Disorders
tive disorders on functioning can be significantly
influenced by the environment and people's be-
Biological havior. Children with autism spectrum disorder
vulnerability who receive early, intense behavioral interven-
tion may eventually function very similarly to a
child without the disorder, whereas children
with autism spectrum disorder who receive no
intervention are much less likely to develop typi-
Environmental and cal functioning. As another example, the likeli-
psychosocial modifers hood of developing many diseases in old age is
substantially influenced by a person's behavior
as a younger adult-people who keep mentally
active into middle and old age may be less likely
Environmental to develop Alzheimer's disease or develop less
Epigenetic
processes and severe versions of NCDs.
social interventions Similarly, the social and emotional environ-
ment can affect the severity of deficits among peo-
ple with neurodevelopmental and neurocognitive
disorders. A child with ADHD whose parents are
Neurodevelopmental or overwhelmed by his behavior and withdraw or be-
neurocognitive disorder
symptoms come aggressive in response is less likely to develop
the ability to regulate his behavior than is a child
whose parents respond more effectively. If an older
adult who is easily confused or forgetful is further
stressed by family members who frequently be-
evidence that the risk of autism spectrum disor- come annoyed with her or expect too much of her,
der is higher among children whose biological then her cognitive deficits can become even more
fathers are older (e.g., over 40) at the time of con- severe. Thus, even though the neurodevelopmental
ception (see Hultman et al., 2011). This may be or neurocognitive disorders are rooted in brain mal-
because sperm deteriorate due to aging, or it may function, psychosocial factors can influence the
be that accumulated exposure to toxins over the severity and manifestation of these disorders.
Before giving Jake a diagnosis, there are several their expectations, and difficulty with concentra-
possibilities worth considering. First, you might tion, memory, and work completion are common
consider whether Jake has a learning disability features of depression. Also, the fact that Jake's
that is hurting his academic performance. You grades tended to drop at times of transition could
might administer testing to see if this is the case. suggest trouble coping with change. You would
Second, you may note that people with the inat- need to thoroughly investigate these possibilities
tentive type of ADHD are not hyperactive and of- before making a diagnosis. More than just the
ten may seem absent-minded. Jake's tendencies presence of symptoms, an accurate diagnosis of
to forget things, to leave projects incomplete, to ADHD requires that symptoms have a childhood
have his mind wander, and to be late all fit the onset, be developmentally inappropriate and per-
symptoms of a predominantly inattentive presen- sistent, be present in multiple settings, cause sig-
tation of ADHD. However, they also could be nificant functional problems, and not be due to
caused by depression. Jake's parents often were any other psychiatric disorder.
critical of him and felt that he wasn't living up to
THINK CRITICALLY ~
In recent years, increasing concerns have been The atypical antipsychotics, however, do raise
raised about prescribing psychotropic medications concerns about safety. The meta-analysis by Peter
to children when the medications have been tested Jensen and colleagues (2007) showed that the most
primarily on adults. For example, the atypical anti- common side effects of these medications in youth
psychotic medications, which were developed and are sleepiness and we ight gain. Significant weight
tested for adult schizophrenia (see Chapter 8), are gain may increase risk for the development of diabe-
now being widely used to treat disruptive and self- tes. Some children who take atypical antipsychotics
injurious behaviors in children and adolescents with show increases in levels of the hormone prolactin,
conduct disorder, autism spectrum disorder, and a and the long-term effects ofthese elevated levels are
variety of other diagnoses (Jensen et al., 2007). The not known. Some rare adverse events have been
few studies that have compared these medications reported, including heart arrhythmias.
with a placebo in double-blind, controlled trials gen- If your child had significant problems with ag-
erally have found that they are effective in reducing gressive and disruptive behavior or self-injury, would
aggressive and disruptive behavior and self-injury in you agree to have him or her take atypical antipsy-
youth (see Jensen et al., 2007, for a meta-analysis). chotics if they were prescribed by a child psychiatrist?
Thus, it seems that the atypical antipsychotics are a What do you think should be the policy on the pre-
valuable tool in the treatment of symptoms that can scription of drugs for children when the drugs have
be dangerous for children and severely impair their been tested prima rily on adults? (Discussion appears
functioning. on p. 483 at the back of this book.)
CHAPTER SUMMARY
Attention-deficit/hyperactivity disorder (ADHD) is the disorder. Behavior therapy is used to reduce
characterized by inattentiveness and hyperactiv- inappropriate and self-inj urious behaviors and
ity. Children with ADHD often do poorly in school encourage prosocial behaviors.
and in peer relationships and are at increased Intellectual disability is defined as significant def-
risk for developing behavior problems. ADHD is icits in conceptual, social, and practical skills that
more common in boys than in girls. affect everyday functioning with onset during the
Biological factors that have been implicated in the developmental period. It is not diagnosed by low
development of ADHD include genetics, exposure IQ alone, and its level of severity is determined
to toxins prenatally and early in childhood, and by adaptive functioning deficits.
abnormalities in neurological functioning. A number of biological factors are implicated in
Treatments for ADHD usually involve stimulant intellectual disability, including metabolic disor-
drugs and behavior therapy designed to de- ders (PKU, Tay-Sachs disease); chromosomal
crease children's impulsivity and hyperactivity disorders (Down syndrome, fragile X, trisomy 13,
and help them increase attention. trisomy 18}; prenatal exposure to rubella, herpes,
Autism spectrum disorder is characterized by sig- syphilis, or drugs (especially alcohol, as in fetal
nificant impairment in social interaction, commu- alcohol syndrome}; premature delivery; and
nication with others, and everyday behaviors, traumatic brain injury (such as that arising from
interests, and activities. Many children with autism being shaken as an infant }.
spectrum disorder score in the intellectual disabil- There is some evidence that intensive and com-
ity range on IQ tests. Outcomes of autism spec- pre hensive educational interventions, adminis-
trum disorder vary widely, although the majority tered very early in a child's life, can help
of people must receive continual care, even as decrease the level of intellectual disability.
adults. The best predictors of a good outcome in Specific learning disorder affects skills in read-
autism spectrum disorder are an IQ above 50 and ing, mathematics, or written expression.
language development before age 6.
The commun ication disorders involve persistent
Possible biological causes of autism spectrum difficulties in the acquisition and use of language
disorder include a genetic predisposition to and other means of communication . ,-----..._
cognitive impairment, central nervous system Children with language disorder have difficulties
damage, prenatal comp lications, and neu- with spoken language, written language, and
rotransmitter imbalances. other language modalities (e .g., sign language}.
Drugs reduce some symptoms in autism spec- Their symptoms may include problems with vo-
trum disorder but do not elim inate the core of cabulary, grammar, narrative (i.e., knowing how
Key Terms 317
to describe something or put together a story), impairments in neurocognitive disorder include

and other pragmatic language abilities. memory impairment, aphasia, apraxia, agnosia,
Children with speech disorder have persistent and loss of executive functioning.
difficulties in producing speech. The most common type of neurocognitive disorder
Childre n with social communication disorder is that due to Alzheimer's disease. The brain of an
have difficulties in the acquisition and use of Alzheimer's patient shows neurofibrillary tangles,
spoken or written language or other, nonverbal plaques made up of beta-amyloid protein, and cor-
forms of communication for social communica- tical atrophy. Recent theories of Alzheimer's dis-
tion in naturalistic settings that interfere with ease focus on genes that might contribute to the
their social relationships. buildup of beta-amyloid protein in the brain of
Some of the learning and communication disor- Alzheimer's patients, particularly the ApoE gene.
ders may have genetic roots. Abnormalities in Neurocognitive disorder also can be caused by
brain structure and functioning have been impli- cerebrovascular disease, traumatic brain injury,
cated in these disorders. Environmental factors, and progressive disorders such as Parkinson's
including lead poisoning, birth defects, sensory disease, Lewy body disease, HIV infection,
deprivation, and low socioeconomic status, may Huntington's disease, and prion disease
contribute to brain dysfunction . (Creutzfeldt-Jakob disease). Chronic substance
Treatment of the learning and communication abuse and the nutritional deficiencies that often
disorders usually focuses on building skills in accompany it also can lead to neurocognitive
problem areas through specialized training, as disorder.
well as computerized exercises. Drugs may help reduce the cognitive symptoms
Tourette's disorder and chronic motor or vocal tic of neurocognitive disorder and the accompanying
disorder are motor disorders involving the pres- depression, anxiety, and psychotic symptoms in
ence of persistent tics. Stereotypic movement some patients.
disorder is a motor disorder characterized by Delirium is characterized by disorientation, re-
repetitive, seemingly driven, and apparently pur- cent memory loss, and a global attention distur-
poseless motor behavior. These disorders are bance. Delirium typically is a signal of a serious
highly comorbid with obsessive-compulsive medical condition, such as a stroke, congestive
disorder and may be related to similar biological heart fai lure, an infectious disease, a high fever,
factors. or drug or medication intoxication or withdrawal.
Developmental coordination disorder involves It is a common syndrome in hospitals, particu-
deficits in fundamental motor skills. larly among elderly surgical patients.
Neurocognitive disorders involve deterioration in Treating delirium involves treating the underly-
cognitive functioning, often accompanied by ing condition leading to the delirium and keeping
emotional and behavioral changes. Cognitive the patient safe until the symptoms subside.
KEY TERMS
neurodevelopmental disorders 284 developmental coordination disorder 304
neurocognitive disorders 284 major neurocognitive disorder 305
attention-deficit/hyperactivity disorder (ADHD) 284 dementia 305
autism spectrum disorder (ASD) 290 mild neurocognitive disorder 305
autism 291 aphasia 305
echolalia 291 palilalia 305
pervasive developmental disorders (PODs) 292 apraxia 305
intellectual disability (ID) 294 agnosia 306
fetal alcohol syndrome (FAS) 296 executive functions 306
specific learning disorder 299 Alzheimer's disease 306
communication disorders 301 neurofibrillary tangles 307
language disorder 301 plaques 307
speech sound disorder 301 beta-amyloid 307
childhood-onset fluency disorder 301 vascular neurocognitive disorder 309
social communication disorder 301 cerebrovascular disease 309
motor disorders 303 stroke 309
Tourette's disorder 303 traumatic brain injury 311
persistent motor or vocal tic disorder (CMVTD) 303 delirium 312
stereotypic movement disorder 303
Disruptive Impulse-ControL I
and Conduct Disorders

CHAPTER OUTLINE
Disorders of Conduct and Impulse Chapter Integration

Control Across the Continuum
Extraordinary People: Ted Bundy,
Portrait of a Serial Killer Think Critically
Conduct Disorder and Oppositional Chapter Summary

Defiant Disorder Key Terms
Shades of Gray
Antisocial Personality Disorder

Intermittent Explosive Disorder
Healthy levels of conduct and Potentially meets criteria for
impulse control conduct/impulse control disorder
Empathic toward others, capadty for constraint, Frequently disobedient andjor disrespectful
and cooperative with societal rules and values of others' feelings andjor property
Occasional issues with conduct Likely meets criteria for

and/or impulse control conduct/impulse control disorder
Generally compassionate and Callous andjor unemotional contact with
law-abiding, but occasionally others, cruel and/or unlawful behavior
breaks rules or defies authority
The disorders discussed in this chapter all involve disruptive, mistakes and bad behavior. Children diagnosed with conduct
impulsive, and antisocial behavior that violates major social disorder act in even more antisocial ways, repeatedly being ag-
norms. You've no doubt observed that people vary in how coop- gressive and cruel toward animals and people, vandalizing and
erative they are with social norms and in how empathetic and destroying others' property, stealing and lying, and violating
caring they are toward other people. On one end of the contin- basic family and school rules. The other two disorders are d iag-
uum are people who exemplify a strong social and moral code nosed only in individuals age 18 and older. Intermittent explo-
and who deeply care for others, even sacrificing their own well- sive disorder is characterized by repeated outbursts of verbal or
being on behalf of others (think Mother Teresa). Most of us are a physical aggression toward others that is far out of proportion
little farther along the continuum: Although we generally are to any provocation. Antisocial personality disorder is character-
law-abiding and try to be compassionate toward others, we ized by a chronic pattern of disregard for the basic rights of oth -
break a few rules now and then (e.g ., driving too fast) and are ers. People with th is d isorder are selfish, manipulative, deceitfu l,
sometimes unkind to others, especially when we are stressed or cruel, and often aggressive toward others in o rder to get what
in a bad mood. Yet farther along the continuum are people who they want.
think some social norms don't apply to them and who can be Throughout this chapter, we discuss biological and psycho-
downrig ht cruel toward others, particularly when it helps them social factors that appear to contribute to the development of
accomplish their goals, such as Meryl Streep's character Miranda these disorders. These factors may also help account for bad
Priestly in The Devil Wears Prada. behavior that falls short of meeting any of the diagnoses-the
The individuals who receive the diagnoses discussed in everyday bad behavior we see in people with whom we interact
th is chapter persistently break basic social rules regulating be- or people in the media. Fundamentally, all behavior, good and
havior and often treat others very badly, even being aggressive bad, moral and immoral, is tied to biological and psychosocia l
or violent toward others. Two of the disorders we discuss apply factors. This raises the following question: What are the impl ica -
only to children . Children d iagnosed with oppositional defiant tions of identifying causes of bad behavior for how society
disorder are chronically angry and irritable; are argumentative should deal w ith people who violate major social norms and hurt
and defiant, refusing to comply with adult requests; and are others? We return to this question in Th ink Critically at the end of
vindictive toward others, often blaming others for their own the chapter.
Disorders of Conduc t a nd Imp ulse-Contro l Ac ross the Continu um 319

320 Chapter 11 Disruptive. Impulse-Control. a nd Cond uct Disorders
Ted Bundy, Portrait of a Serial Killer
Ted Bundy was born in first murder. After his arrest, he was linked to several
Burlington, Vermont. murders and was scheduled to stand trial.
He did well in school While in custody, his charm, good looks, and
and typically earned Ns cooperation soon won over his captors. They gave
in most of his classes, him special treatment, including the least restric-
although he was some- tive restraints. He insisted on defending himself in
t imes in trouble for court and was allowed access to the local library,
fighting with other chil- where he diligently studied legal documents. He
dren. He later attributed proved to be a quick study in the field of law and
much of his scholastic was able to delay his hearings and trial for quite
success t o the diligent some time. During this delay he lost enough weight
efforts of his mother to encourage him. Despite his to fit his body through a 12-inch aperture and es-
fondness for his mother, they never discussed per- cape by crawling through openings above the jail
sonal matters, and he stated that their relationship cells and offices.
was not an open one. Bundy reported that he found After escaping custody he settled near Florida
it difficult to socialize and often chose to be alone or State University. Not long after, he was once again
engage in solitary hobbies when in high school. raping , beating, and killing women. During this
Although he was described as charming, intelligent, time, he lived under a false name and supported
and attractive, he had limited social contacts because himself by using stolen credit cards. He was even-
he did not enjoy drinking and preferred the role of a tually arrested after bludgeon ing to death many
scholar. He also had relatively few experiences with members of a sorority house as they slept. He was
girls in high school and only went on one date. subsequently found guilty and twice sentenced to ~
After graduation, Bundy became involved with death . However, his legal acumen was so high dur-
politics and worked on several successful cam- ing the trial that, after sentencing him, the judge
paigns, where he was described as being respon- stated that Bundy "should have been a lawyer:'
sible, dedicated, and hard-working . Through this These legal skills continued to serve him while in
experience he was able to establish a wide social prison as he delayed his execution for 10 years.
network. Bundy used his charm and qu ick wit to Others, however, suggested that his arrogant self-
establish himself as an up-and-coming politician confidence contributed to a failure to obtain com-
and even was referred to as a " young JFK" for his petent legal counsel and that his effort to serve
political savvy. as his own lawyer ultimately was harmfu l to his
At age 27, Bundy began abducting, raping, and defense.
murdering young women. He often lured these While in prison, Bundy granted numerous in-
women into his car by deception, such as by imper- terview requests and revealed that he committed
sonating a police detective. The brutal murders in- the murders as a means of gaining full possession
cluded bludgeoning, mutilation, and rape. Bundy's of the women . He claimed that the rapes were not
murders attracted media and police attention, yet he brutal and that he had attempted to make the mur-
continued to abduct women and evade detection. ders as painless as possible for the victims. Bundy
He planned and executed the kidnappings with great never expressed any explicit or compelling feelings
care, in order to avoid discovery. His colleagues of remorse for the murders. He in fact withheld the
found him charming and endearing, and they could identities of many of his victims as a means of de-
not imagine him capable of such acts. Bundy was laying his execution. (Adapted from T. A. Widiger,
finally arrested approximately 15 months after his personal communication, 2009)
Ted Bundy was one of the most extreme examp les responsibility for his actions, blaming his unlawful ~
of what man y people call a psychopath or sociopath. beh avior on the bad influence of the violent por-
He could be charming, charism atic, cunning, and nography he was attracted to as a youth.
hideously sadistic, deriving great pleasure from The disorders we consider in this chapter all re-
inflicting pain on others. He never accepted flect the tendency to engage in behavior that violates
Conduct Disorder and Oppositional Defiant Disorder 321
the basic rights of others or major social norms. In

"The truth is not in Phillip. When caught
most cases, these antisocial behaviors are nowhere
in actual misdeeds, he denies everything and
near as extreme as those of Ted Bundy's, but they
can still exact a heavy toll on the targets of the be- takes upon himself an air of injured inno-
havior. We start with conduct disorder and opposi- cence. He believes we are picking on him. His
tional defiant disorder, which by definition begin attitude is sullen when he is refused any-
during childhood. Then we discuss intermittent thing. He pouts, and when asked why he
explosive disorder, which, as the name implies, is does these things, he points to his head and
characterized by intermittent but recurrent aggres- says, Because I'm not right up here. This boy
sive outbursts. Finally, we cover antisocial person- needs help badly. He does not seem to have
ality disorder, which is diagnosed only in adults any friends. His aggressive behavior pre-
and could be applied to Ted Bundy. vents the children from liking him. Our school
psychologist tested Phillip, and the results
indicated average intelligence, but his school
CONDUCT DISORDER achievement is only at the third- and low
AND OPPOSITIONAL fourth-grade level:' (Jenkins, 1973, pp. 60-64)
DEFIANT DISORDER
Have you ever lied, stolen something, or hit some-
one? Most of us would have to answer yes to at The behaviors of children with conduct dis-
least one of these. However, relatively few would order fall into four categories: (1) aggression to
answer yes to the following questions: people and animals, (2) destruction of property,
Have you ever pulled a knife or a gun on an- (3) deceitfulness or theft, and (4) serious viola-
other person? tions of rules. Approximately 3 to 7 percent of chil-
Have you ever forced someone into sexual dren and adolescents exhibit behaviors serious
activity at knifepoint? enough to warrant a diagnosis of conduct disorder
(Costello et al., 2003; Maughan et al., 2004). These
Have you ever deliberately set a fire with the children are highly likely to engage in violent and
hope of damaging someone's property? criminal behavior (Frick & Nigg, 2012) . The annual
Have you ever broken into someone else's car cost to schools of vandalism by juveniles in the
or house with the intention of stealing? United States is estimated to be over $600 million.
Many young people who have conduct disorder An important distinction is made between
answer yes to these questions and engage in other conduct disorder that begins in childhood and
serious transgressions of societal norms for behav- conduct disorder that begins in adolescence (Frick
ior (see the DSM-5 criteria in Table 11.1). These & Nigg, 2012; Moffitt, 2006), and DSM-5 requires
children have a chronic pattern of unconcern for that conduct disorder be specified based on its age
the basic rights of others. Consider Phillip, in the at onset. Children with childhood-onset conduct
following case study. disorder (beginning before age 10) often show be-
havioral problems in preschool or early elemen-
tary school, and their problems tend to worsen as
they grow older. They are more likely than indi-
viduals with adolescent-onset conduct disorder
Phillip, age 12, was sus- ~eg~in? at age 10 or later) to continue to engage
pended from a small-town Iowa school and re- m antisocial behavior into adolescence and adult-
ferred for psychiatric treatment by his principal, hood, a pattern called life-course-persistent
who sent the following note: an.tisocial behavior (Moffitt, Caspi, Harrington, &
"This child has been a continual problem
Milne, 2002; Odgers et al., 2008). For example, as
since coming to our school. He does not get a~olesc~nts, about 50 percent of those diagnosed
along on the playground because he is mean w~th.childhood-onset conduct disorder engage in
to other children. He disobeys school rules,
cnmmal behavior and drug abuse. As adults,
teases the patrol children, steals from the about 75 ~o 85 percent are chronically unemployed,
other children, and defies all authority. Phillip
have a history of unstable personal relationships,
f~equently engage in impulsive physical aggres-
keeps getting into fights with other children
on the bus.
SIOn, or abuse their spouse (Moffitt et al., 2008).
Between 35 and 40 percent are diagnosed with an-
tisocial personality disorder as adults.
322 Chapter 11 Disruptive. Impulse-Control, and Conduct Disorders
TABLE 11.1 DSM-5 Criteria for Conduct Disorder
A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate
societal norms or rules are violated, as manifested by the presence of at least three of the following
15 criteria in the past 12 months from any of the categories below, with at least one criterion present
in the past 6 months:
Aggression to People and Animals
1. Often bullies, threatens, or intimidates others

2. Often initiates physical fights
3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
4. Has been physically cruel to people
5. Has been physically cruel to animals
6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
7. Has forced someone into sexual activity
Destruction of Property
8. Has deliberately engaged in fire setting with the intention of causing serious damage
9. Has deliberately destroyed others' property (other than by fire setting)
Deceitfulness or Theft
10. Has broken into someone else's house, building, or car

11. Often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)
12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking
and entering; forgery)
Serious Violations of Rules
13. Often stays out at night despite parental prohibitions, beginning before age 13 years.
14. Has run away from home overnight at least twice while living in the parental or parental surrogate
home, or once without returning for a lengthy period.
15. Is often truant from school, beginning before age 13 years.
B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational
functioning .
C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.
The DSM-5 allows another specifier for the di- presentation are less reactive to signs of fear and
agnosis, with limited prosocial emotions, which can distress in others and less sensitive to punish-
be applied to children who meet the full criteria ment (Frick & White, 2008). They tend to be fear-
for conduct disorder and show at least two of less and thrill-seeking. These traits characterize
the following characteristics in multiple relation- psychopathy, a more severe, aggressive, and
ships and settings: (a) lack of remorse or guilt for difficult-to-treat pattern predictive of more long-
their actions, (b) lack of empathy for others (cal- term problems into adulthood (Cleckley, 1941 /
lousness), (c) lack of concern about performance 1982; Hare & Neumann, 2008; McMahon et al., ~
at school, at work, or in other important activities, 2010; Rowe et al., 2009). Because psychopathy has
and (d) shallow or deficient emotions (e.g., insin- been studied more in adults than in children, we
cerity in emotions, using emotions to manipulate will discuss it below in relation to antisocial per-
others). Children with this callous-unemotional sonality disorder.
TABLE 11 .2 DSM-5 Criteria for Oppositional Defiant Disorder
A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least

6 months as evidenced by at least four symptoms from any of the following categories, and exhibited
during interaction with at least one individual who is not a sibling.
Angry/Irritable Mood
1. Often loses temper

2. Is often touchy or easily annoyed
3. Is often angry and rese ntful
Argumentative/Defiant Behavior
4. Ofte n argues w ith authority figures, or for chi ldren and adolescents, with adults
5. Often actively defies or refuses to comply with requests from authority figures or with rules
6. Often del iberate ly annoys others
7. Often blames others for his or her mistakes or misbehavior
Vindictiveness
S. Has been spiteful or vind ictive at least twice w ithin the past 6 months
Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is
within normal limits from a behavior that is symptomatic. For children under 5 years of age, the behavior
should occur on most days for a period of at least 6 months unless otherwise noted (Criterion AS) . For
individua ls 5 years or older, the behavior should occur at least once per week for at least 6 months, unless
otherwise noted (Criterion AS). Wh ile these frequency criteria provide guidance on a minimal level of
frequency to define symptoms, other factors should also be considered, such as whether the frequency and
intensity of the behaviors are outside a range that is normative for the individua l's developmental level,
gende r, and culture.
B. The disturbance in behavior is associated with d istress in the individual or others in his or her immediate
socia l context (e.g., fami ly, pee r group, work co ll eagues), or it impacts negatively on socia l, educational,
occupational, or other important areas of functioning.
C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or
bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.
So urce: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright 2013
The DSM-5 also recognizes a less severe pattern Jeremy has been i ncreas-
of chronic misbehavior, oppositional defiant disor- ingly diffi cult to manage since nursery school. At
der (see Table 11.2). Note that the symptoms schoo l, he teases and kicks other chi ldren, trips
are grouped into three types, reflecting both emo- them, and calls them names. He is descr ibed as
tional and behavioral symptom categories. Unlike b ad tempered and irritable, though at t imes he
children with conduct disorder, children with op- see m s to enjoy schoo l. Often he appears to be
positional defiant disorder are not aggressive to- de li be rate ly trying to an noy ot her children ,
ward people or animals, do not destroy property, t hough he always claims that others have started
and do not show a pattern of theft and deceit. They t he argument s. He does not get in se rious fights
are, however, chronically negativistic, defiant, dis- b ut does occas iona ll y exchange a few blows
obedient, and hostile (Frick & Nigg, 2012). We see with another ch i ld .
several symptoms of oppositional defiant disorder (continued)
in 9-year-old Jeremy in the follow ing case study.
324 Chapter 11 Disruptive, Impulse-Control. and Conduct Disorders
Jeremy sometimes refuses to do what his

two teachers tell him to do, and this year he has
been particularly difficult during arithmetic, art,
and science lessons. He gives many reasons why
he should not have to do his work and argues
when told to do it. At home, Jeremy's behavior
varies. Some days he is defiant and rude to his
mother, needing to be told to do everything sev-
eral times, though he usually complies eventu-
ally. Other days he is charming and volunteers to
help, but his unhelpful days predominate. His
mother says, "The least little thing upsets him,
and then he shouts and screams:' Jeremy is de-
scribed as spiteful and mean with his younger
brother, Rickie. His mother also says that he tells
many minor lies, though when pressed he is
truthful about important things. (Reprinted from
the DSM Casebook: A Learning Companion Girls may be aggressive toward others
to the Diagnostic and Statistical Manual of in different ways than boys.
Mental Disorders, Fifth Edition. Copyright
2013 American Psychiatric Association.)
Some researchers have suggested that antiso-

cial behavior is not rarer in girls than in boys
but just looks different (Crick & Grotpeter, 1995;
Zoccolillo, 1993). Girls' aggression is more likely to
Symptoms of oppositional defiant disorder of- be indirect and verbal rather than physical. Girls
ten begin during the toddler and preschool years. appear to engage in relational aggression, such as
Being defiant and obstinate are common character- excluding their peers, gossiping about them, and
istics of "the terrible twos," and concerns have colluding with others to damage the social status
been raised that the diagnosis of oppositional defi- of their targets (Crick & Grotpeter, 1995).
ant disorder pathologizes typical behavior in However, girls and boys with conduct disor-
young children. Indeed, some children who meet der are equally likely to engage in stealing, lying,
the criteria for oppositional defiant disorder seem and substance abuse (Tiet et al., 2001). Long-term
to outgrow these behaviors by late childhood or studies of girls diagnosed with conduct disorder
early adolescence. Children diagnosed with oppo- find that, as adolescents and adults, they also show
sitional defiant disorder, however, are significantly high rates of depression and anxiety disorders, se-
more likely than children who do not meet the cri- vere marital problems, criminal activity, and early,
teria for the diagnosis to go on to develop conduct unplanned pregnancies (Loeber & Burke, 2011;
disorder, substance use disorders, and mood and Moffitt et al., 2001).
anxiety disorders (Loeber, Burke, & Pardini, 2009b;
Rowe et al., 2010) . Contributors to Conduct
Across cultures, boys are about three times Disorder and Oppositional
more likely than girls to be diagnosed with con-
duct disorder or oppositional defiant disorder
Defiant Disorder
(Frick & Nigg, 2012; Moffitt, Caspi, Rutter, & Silva, The risk factors for conduct disorder and opposi-
2001). Males are 10 to 15 times more likely than tional defiant disorder are largely the same, so we
females to have life-course-persistent antisocial discuss them together, referring primarily to con-
behavior (Moffitt, 2006). The biological and psy- duct disorder because the majority of the research
chosocial causes of these disorders may be present has focused on this disorder.
more often in boys than in girls. Also, boys with
conduct disorder tend to be more physically ag- Biological Factors
gressive than girls with conduct disorder and thus Children with conduct disorder are more likely than
more likely to draw attention (Maughan et al., children without the disorder to have parents with a
2000; Tiet et al., 2001). history of antisocial behavior (Odgers et al., 2007).
SHADES OF GRAY
Consider t he description below of Jake. other child. In the last 6 months, Jake has been
ambushing children who have been mean to him
Jake has been larger than most kids from the day in the past on their way home from school and
he was born. Now, at age 10, he towers over all the beating them up fairly severely. This has accom-
other boys and is 15 pounds heavier than most, plished Jake's goals-the retribution against the
with most of the extra weight in muscle. Over the other children feels good, and he doesn't get
last couple of years, Jake's parents encouraged teased much anymore. Lately, he's taken to am-
him to channel his size and energies into sports, bushing children who have never teased him, just
but he wasn't very coordinated and was teased by to send a message to others to stay clear of him
other kids, who called him "the gorilla:' When this and treat him with re spect.
happened, Jake would sometimes lash out at the
child who teased him, punching or kicking him. Could Jake be diagnosed with a conduct disorder
Given Jake's size advantage, this behavior usually based on the information in the description?
resulted in a moderate-to-severe injury for the (Discussion appears at the end of this chapter.)
Twin and adoption studies indicate that this aggre- in responding to emotional stimuli, including the
gation of antisocial behaviors in families is due to anterior cingulate (Stadler et al., 2006; Sterzer et
both genetic and environmental factors (Arsenault al., 2005). They also show less amygdala activity
et al., 2003; Silberg, Maes, & Eaves, 2012). Genetics in response to emotional stimuli (Sterzer et al.,
appears to play a particularly strong role in 2005), possibly suggesting that children with con-
childhood-onset conduct disorder. Several specific duct disorder do not process emotional cues the
genes have been associated with an increased risk way healthy children do. Indeed, children with
~ of conduct disorder and oppositional defiant dis- conduct disorder show deficits on tasks that mea-
order, primarily genes involved in the regulation sure planning and organizing ability and the pro-
of the neurotransmitters dopamine, serotonin, and cessing of emotional cues (Blair et al., 2006; Nigg
norepinephrine (Moffitt et al., 2008). One of these & Huang-Pollock, 2003).
genes is the monoamine oxidase A (MAOA) gene, In addition to genetics, another source of the
which encodes an enzyme that metabolizes sero- neurological deficits these children have may be
tonin, dopamine, and norepinephrine (see meta- exposure to neurotoxins and drugs prenatally or
analyses by Dodge & Sherrill, 2007; Taylor & during the preschool years. Boys whose mothers
Kim-Cohen, 2007). Several studies have found that smoke during pregnancy are 2.6 times more likely
children who have both an abnormal variant of the to demonstrate oppositional behavior in early
MAOA gene and a history of childhood maltreat- childhood, followed by increasingly more aggres-
ment (including physical and sexual abuse as well sive and severe antisocial behavior as they grow
as neglect) are especially likely to develop aggres- older (Wakschlag, Pickett, Kasza, & Loeber, 2006).
sive traits in general, and conduct disorder in par- The role of serotonin in violent behavior has
ticular (e.g., Caspi et al., 2002). This is another been the focus of many studies. One study of a
example of interactions between genes and envi- large community-based sample found that young
ronment contributing to psychopathology. men with high blood serotonin levels relative to
The exact mechanisms by which genetic and the levels of other men their age were much more
environmental vulnerabilities create conduct dis- likely to have committed a violent crime (Moffitt et
order are still being mapped (Dodge, 2009). Chil- al., 1998). Several other studies, but not all, have
dren with conduct disorder may have neurological found an association between measures of sero-
deficits in those brain systems responsible for tonin activity and antisocial behavior in children
planning and controlling behavior. They have (van Goozen, Fairchild, Snoek, & Harold, 2007).
high rates of comorbid attention-deficit/hyperac- Children with conduct disorder have a slower
tivity disorder (ADHD; see Chapter 10; Beau- heart rate than children without the disorder, both
chaine, Hinshaw, & Pang, 2010), a fundamentally while resting and especially when confronted with
neurological disorder characterized by difficul- a stressor (Ortiz & Raine, 2004). They also show
ties in attention, impulsivity, and hyperactivity. abnormal cortisol levels both at rest and in re-
Neuroimaging studies show abnormalities in the sponse to a stressor (van Goozen et al., 2007). Be-
functional areas of the prefrontal cortex involved cause they become less physiologically aroused
326 Chapter 11 Disruptive, Impulse-Control, and Conduct Disorders
than other children when confronted by stressors,

children with conduct disorder may be more will-
ing to take risks and may have more difficulty
learning from being punished for their behavior.
People often link aggressive behavior to the
hormone testosterone. A meta-analysis of studies
of testosterone and aggression in humans found a
small but statistically significant correlation of .14
(Book, Starzyk, & Quinsey, 2001). The association
between testosterone and aggression depends on
the social context of the participants. In a study of
9- to 15-year-old boys, higher testosterone levels
were associated with more conduct disorder
symptoms in boys whose peers engaged in socially
deviant behaviors (Rowe et al., 2004). In boys
whose peers did not engage in such behaviors, tes-
tosterone was associated with leadership rather
than with conduct disorder symptoms.
Social Factors
Conduct disorder and oppositional defiant disor-
der are found more frequently in children in lower
socioeconomic classes and in urban areas than in
children in higher socioeconomic classes and in
rural areas (Costello, Keeler, & Angold, 2001). An
"experiment of nature" provided evidence that
poverty may play a causal role in antisocial behav-
ior. For several years, researchers had been follow-
Children are more likely to exhibit disruptive and
ing 1,420 children in rural North Carolina, about delinquent behavior if they have been physically
one-quarter of whom were Native American abused.
(Costello, Compton, Keeler, & Angold, 2003). Dur-
ing the study, a casino operated by Native Ameri-
cans opened, providing a sudden and substantial
increase in income for the families of some of these Children who are physically abused or se-
children. The rates of conduct and oppositional de- verely neglected by their parents are more likely to
fiant disorder decreased in those Native American develop disruptive and delinquent behavior
children whose families benefited from the casino (Stouthamer-Loeber, Loeber, Hamish, & Wei,2001).
money. Children whose parents are not involved in their
The quality of parenting that children receive, everyday life-for example, whose parents do not
particularly children with vulnerability to conduct know who their friends are or what they are doing
disturbances, is strongly related to whether they in school-are more likely to develop conduct dis-
develop the full syndrome of conduct disorder turbances. When parents do interact with their chil-
(Kim-Cohen et al., 2006; Loeber, Burke, & Pardini, dren with conduct disturbances, the interactions
2009a). Children who develop conduct disorder often are characterized by hostility, physical vio-
tend to have been difficult babies and toddlers, at lence, and ridicule (Dishion & Patterson, 1997).
least as reported by their parents (Shaw, Keenan, & Such parents frequently ignore their children or
Vondra, 1994; Shaw & Winslow, 1997). They are are absent from home, but when the children trans-
described as having been irritable, demanding, gress the parents lash out violently (Kim-Cohen et
disobedient, and impulsive. They seemed to lack al., 2006; Smith & Farrington, 2004). These parents
self-control and responded to frustration with ag- are more likely to physically punish boys more se-
gression. Some theorists argue that such children verely than girls, which may account partially for
are born with a biologically based difficult tem- the higher rate of conduct disturbances in boys
perament that interacts with parenting and envi- than in girls (Lytton & Romney, 1991).
ronmental factors to produce behavioral problems Young people living in such families may turn
(Caspi, Harrington, et al., 2003). to their peers to receive validation and escape their
parents. Unfortunately, their peer group may consist will look to these and other interventions as they
of others with similar conduct disturbances who are used with children with conduct disorder.
tend to encourage delinquent acts and even provide
opportunities for them (Dishion & Patterson, 1997). An Integrative Model
For example, they may dare a new group member to Biological, social, and cognitive factors contributing
commit a robbery to "show he is a man" and even to conduct disorder often may coincide and interact,
provide him with a weapon and a getaway car. Chil- sending a child on a trajectory toward antisocial be-
dren who become part of a deviant peer group are haviors that is difficult to stop (Figure 11.1) (Dodge,
especially likely to begin abusing alcohol and illicit 2009; Dodge & Pettit, 2003; Loeber et al., 2009a). An-
drugs, which in turn leads to further deviant acts tisocial parents appear both to confer a genetic vul-
(Loeber et al., 2009a). nerability to conduct disturbances on their children
Individuals with antisocial tendencies also tend and to parent them in ways that engender antisocial
to choose mates with similar tendencies (Smith &
Farrington, 2004). Conversely, those who form close
relationships with others who do not have a con-
duct disturbance are much more likely to outgrow An Integrative Model
FIGURE 11.1
their behaviors. Delinquent young men who marry of the Development of
young women with no history of conduct problems Antisociality. Biological,
tend to cease their delinquent acts permanently social, and psychological factors interact
(Sampson & Laub, 1992). across a child's development to lead to a
lifetime of antisociality in some children.
Cognitive Factors
Biological dispositions toward aggression, impulsivity,
Children with conduct disorder tend to process in- poor executive functions, Low arousability
formation about social interactions in ways that
promote aggressive reactions (Crick & Dodge,
1994). They assume that others will be aggressive
Aggressive, impulsive, Harsh, inconsistent
toward them, and they use these assumptions- oppositional behavior in ...,.. parenting, neglect
rather than cues from specific situations-to inter- the child
pret the actions of their peers (Dodge & Schwartz,
1997). For example, when accidentally bumped
into by another child, a child with conduct disor-
High Levels of Expectations of hostility
der will assume that the bump was intentional and interpersonal conflict from others and belief
meant to provoke a fight. Children with conduct that aggression is an
disorder tend to consider a narrow range of re- appropriate reaction
sponses to perceived provocation by a peer, usu-
ally including aggression (Pettit, Dodge, & Brown,
1988). When pressed to consider other responses,
they generate ineffective or vague ideas and often Academic and social Rejection by teachers
judge anything besides aggression as a useless or problems in school and mainstream peers
unattractive response (Crick & Ladd, 1990).
Children who think about social interactions
this way are likely to act aggressively toward oth-
ers. Others then may retaliate-other children will
Turn to deviant peers
j
hit back, parents and teachers will punish them,
and people will perceive them negatively. These
reactions feed the children's assumption that the
l
Violent and antisocial
world is against them, causing them to misinter- behavior encouraged
pret future actions by others. A cycle of interac-
tions can be built that maintains and encourages
aggressive, antisocial behaviors.
Again, the best evidence that thinking patterns
are causes, rather than simply correlates, of antiso-
cial behavior in children comes from studies show-
ing that changing children's aggressive thinking Source: Dodge & Pettit, 2003.
patterns can reduce their aggressive behavior. We
328 Chapter 11 Disruptive. Impulse-Control. and Conduct Disorders
behaviors, for example, exhibiting violence and hos- Psychological and Social Therapies
tility, neglect, and a lack of warmth (Loeber et al., Most psychotherapies for conduct disorder are
2009a; Silberg et al., 2012). These children also may cognitive-behavioral in focus and aim to change
be exposed to maternal drug use, poor prenatal nu- children's ways of interpreting interpersonal in-
trition, pre- and postnatal exposure to toxic agents, teractions by teaching them to take and respect
child abuse, poverty, and the stress of growing up in the perspectives of others, to use self-talk to control
a violent neighborhood (Loeber et al., 2009a; Silberg impulsive behaviors, and to use more adaptive
et al., 2003). Infants and toddlers with the neuropsy- ways of solving conflicts than aggression (Kazdin,
chological problems seen in children with conduct 2003b; Lechman, Barry, & Pardini, 2003). Many
disorder are more irritable, impulsive, awkward, therapies try to involve parents in order to change
overreactive, inattentive, and slow to learn than family interaction patterns that are helping main-
their peers. This makes them difficult to care for and tain the children's antisocial behaviors (Webster-
puts them at increased risk for maltreatment and Stratton & Reid, 2003).
neglect. Early symptoms of aggression and opposi- The first step in cognitive-behavioral therapy
tional behavior in a child lead to and interact with is to teach children to recognize situations that
harsh discipline and a lack of warmth from parents trigger anger or aggressive and impulsive behav-
and conflicts with aggressive peers. These children iors. Therapists observe children in their natural
are at risk for academic and social problems in settings and then point out situations in which
school, which can motivate them to turn to deviant they misbehave or seem angry. They then discuss
peer groups that encourage antisocial behavior. hypothetical situations and how the children
Along the way, such children learn that the world is would react to them, asking older children to keep
hostile and that they must defend themselves rap- a diary of their feelings and behaviors. The chil-
idly and aggressively. They are prone to impulsive dren also learn to analyze their thoughts in these
behaviors or rash reactions to others. These children situations and to consider alternative ways to in-
enter adulthood with a long history of negative interpret them. The children's assumptions that oth-
teractions with others, violent and impulsive out- ers intentionally act meanly toward them are
bursts, and alienation from mainstream society. All challenged, and they learn to adopt other people's
these factors feed on one another, perpetuating the perspectives on situations. Children may be taught
cycle of antisocial behavior into adulthood. to use self-talk, repeating phrases to help them
In a longitudinal study following children avoid reacting negatively to situations.
from age 3 into adulthood, Terri Moffitt, Avshalom Therapists teach adaptive problem-solving
Caspi, and colleagues (Moffitt & Caspi, 2001; Mof- skills by discussing real and hypothetical problem
fitt et al., 2001) found that the combination of a bio- situations with children and helping them gener-
logical disposition toward cognitive deficits and a ate positive solutions. For example, if a therapist
difficult temperament plus growing up in a risky and a child are discussing how to respond to an-
environment characterized by inadequate parent- other child who has cut in line in the lunchroom,
ing and disrupted family bonds tended to lead to the therapist initially might model an assertive
conduct disorder that developed in childhood and (rather than aggressive) response, such as saying
persisted into adulthood. In contrast, youth who "I would like you to move to the back of the line"
were antisocial only in adolescence were much less to the child cutting in. Then the child in therapy
likely to have this combination of biological and might practice the assertive response, perhaps
environmental risk factors. Another study found also pretending to be the child cutting in line in
impulsivity in boys to be linked to a greater risk order to gain some perspective on the other child's
for late-adolescent delinquency only among those behavior.
who grew up in poor and violent neighborhoods Some psychosocial therapies for children with
(Lynam et al., 2000). conduct disorder include parents, particularly if the
family dynamics support the children's behavior
Treatments for Conduct (Kazdin, 2003a; Kazdin & Wassell, 2000). Parents
Disorder and Oppositional learn to reinforce positive behaviors in their chil-
dren and to discourage aggressive or antisocial be-
Defiant Disorder haviors. They also are given nonviolent discipline
Psychological and social treatments can reduce vi- techniques and strategies for controlling their own
olent and disruptive behavior in children with angry outbursts. These behavioral techniques are
these disorders. Some children are also given med- especially important in treating younger children,
ications to decrease their emotional dysregulation who may not be able to analyze and challenge their
and difficult behaviors. thinking and problem-solving processes.
Anti social Personality Disorder 329
Unfortunately, it can be difficult to get those effective in reducing aggression in these children
parents who need the most improvement in par- (Pappadopulos et al., 2006). Antidepressants, par-
enting skills to participate in therapy (Kazdin, ticularly the selective serotonin reuptake inhibitors
2003a). Therapists also need to be sensitive to cul- and the serotonin-norepinephrine reuptake inhibi-
tural differences in behavioral norms for children tors, may help reduce episodes of irritable and agi-
and parents. For example, in families of color it tated behavior in children (Emslie, Portteus, Kumar,
often is useful to engage the extended family & Hume, 2004). Children with conduct disorder
(grandparents, aunts, uncles) in family therapy as sometimes are prescribed atypical antipsychotics
well as the parents (Dudley-Grant, 2001) . (see Chapter 8), which seem to suppress aggressive
All these cognitive-behavioral therapies- behavior (Pappadopulos et al., 2006). Whether they
particularly interventions made in the home, in the affect other symptoms of conduct disorder, such as
classroom, and in peer groups-reduce aggressive lying and stealing, is unclear. Traditional antipsy-
and impulsive behaviors in children (August, Real- chotic medications, such as Haldol and Mellaril (see
mutto, Hektner, & Bloomquist, 2001; Kazdin, 2003b; Chapter 8), also have been used to treat children
Webster-Stratton & Reid, 2003). Unfortunately, many with conduct disorder, with some success (Pappa-
children relapse, particularly if their parents have dopulos et al., 2006). The neurological side effects
poor parenting skills, a history of alcoholism or drug of these drugs (see Chapter 8) have discouraged
abuse, or some other psychopathology. Interven- many physicians from prescribing them, however.
tions are most likely to have long-term positive ef- Some controlled studies suggest that mood stabi-
fects if they begin early in a disturbed child's life lizers, including lithium and anticonvulsants (see
(Estrada & Pinsof, 1995). Booster sessions after a Chapter 7), may effectively treat children with ag-
course of initial therapy can help a child avoid re- gressive conduct disorder (Chang & Simeonova,
lapse (Lachman, White, & Wayland, 1991). 2004).
One ambitious program attempted to delay or
prevent the onset of conduct disorder in children
who showed a number of risk factors, such as a ANTISOCIAL PERSONALITY
parental history of antisocial behavior. This pro-
gram, called Fast Track, provided intensive cognitive-
DISORDER
behavioral therapy to children and behavioral In the Extraordinary People feature at the begin-
training to parents as described above, as well as ning of this chapter, you read the chilling account
academic tutoring from kindergarten through of Ted Bundy, the serial rapist and killer. People
grade 10 (Conduct Problems Prevention Research like Bundy who exhibit chronic antisocial behav-
Group, 1992). After the first 3 years, the children in iors are diagnosed as having antisocial personal-
the intervention group showed better social inter- ity disorder (ASPD; Table 11.3). While ASPD
action skills and peer relations and less aggressive diagnostic criteria are presented in the "Personal-
behavior in the classroom than children in the con- ity Disorders" chapter in the DSM-5, it is also dual
trol group, who received no intervention (Conduct coded as a conduct disorder in DSM-5. ASPD is
Problems Prevention Research Group, 2002). After reviewed in this chapter because it is very closely
5 years, 22 percent of the intervention group had connected to the spectrum of disruptive, impulse-
conduct disorder compared to 29 percent of the control, and conduct disorders, including its de-
control group (Conduct Problems Prevention Re- velopmental origins, while still sharing the key
search Group, 2007). As adolescents, those in the features of a personality disorder (see Chapter 9).
intervention group reported less antisocial behav- The key features of antisocial personality disor-
ior and were less likely to seek outpatient care for der, as defined by the DSM-5, are an impairment in
mental health problems Gones et al., 2010). the ability to form positive relationships with others,
a tendency to engage in behaviors that violate basic
Drug Therapies rights of others and major social norms and values,
Children who exhibit severely aggressive behavior and a focus on doing whatever it takes to gratify
have been prescribed a variety of drugs. Stimulants one's personal desires. People with this disorder are
are the most widely prescribed drugs for conduct deceitful, repeatedly lying or conning others for per-
disorder in the United States, Canada, and many sonal profit or pleasure. Like Ted Bundy, they may
other countries, in part because conduct disorder commit violent criminal offenses against others-
often is comorbid with ADHD (Michelson, 2004). A including assault, murder, and rape-in order to
meta-analysis of clinical trials found that stimulants gain pleasure or get what they want. When caught,
are highly effective in relieving ADHD symptoms they tend to have little remorse and seem indifferent
in children with conduct disorder, and moderately to the pain and suffering they have caused others.
TABLE 11.3 DSM-5 Diagnostic Criteria for Antisocial Personality Disorder
A. A pervasive pattern of disrega rd f or and v iolation of the rights of others, occurring since age 15 years, as
indicated by three (or mo re) of the foll ow in g:
1. Fail ure to confo rm to social norms with res pect to lawfu l behaviors, as indicated by repeatedly
performing acts that are grounds for arrest .
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conn in g others for personal profit or
pleasure.
3. Im pulsivit y o r fail ure to plan ah ead.
4. Irritability and agg ressiveness, as ind icated by repeated physica l f ights or assaults .
5. Reckless disrega rd for safety of se lf o r others.
6. Consistent irresponsibility, as indicated by repeat ed f ail ure t o sustain co nsi stent wo rk behavior or
honor financ ial o bligati ons.
7. Lack of remorse, as indicated by being i nd iffere nt to or ration al izing havi ng hurt, mi streat ed, or stolen
f ro m anoth er.
B. The individ ual is at least age 18 y ea rs .
C. Th ere is evi dence of conduct d isorde r w ith o nset bef ore age 15 ye ars.
D. The occurre nce of anti socia l behavior is not excl usiv ely durin g t he course of sch izophrenia or bipol ar
d isorder.
Source: Reprinted w ith pe rmiss ion from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright 2013
A prominent characteristic of antisocial person- toward boredom and a need for stimulation, a his-
ality disorder is poor impulse control. People with tory of pathological lying, cunning and manipula-
this disorder have low frustration tolerance and of- tiveness, and a lack of remorse. People with
ten act impetuously, with no apparent concern for psychopathy are cold and callous, gaining plea-
the consequences of their behavior. They often take sure by competing with and humiliating everyone
chances and seek thrills, with no concern for danger. and anyone. They can be cruel and malicious. They
They are easily bored and restless, unable to endure often insist on being seen as faultless and are dog-
the tedium of routine or to persist at the day-to-day matic in their opinions. However, when they need
responsibilities of marriage or a job (Millon et al., to, people with psychopathy can be gracious and
2000). As a result, they tend to drift from one rela- cheerful-until they get what they want. Then
tionship to another and often have lower-status they may revert to being brash and arrogant.
jobs. They may impulsively engage in criminal Cleckley (1941 / 1982) noted that, although psycho-
activity-50 to 80 percent of men and about 20 per- paths often end up in prison or dead, many be-
cent of women in prison may be diagnosable with come successful businesspeople and professionals.
antisocial personality disorder (Cale & Lilienfeld, He suggested that the difference between
2002; Fazel & Danesh, 2002; Warren et al., 2002). successful psychopaths and those who end up in
We noted earlier that Ted Bundy would be prison is that the successful ones are better able to
called a psychopath by some theorists. The definition maintain an outward appearance of normality.
of psychopathy by pioneers in the field such as They may be able to do this because they have
Hervey Cleckley (1941 / 1982) and Robert Hare superior intelligence and can put on a "mask of
(Hare & Neumann, 2008) extends the DSM-5 crite- sanity" and superficial social charm in order to
ria for antisocial personality disorder, emphasizing achieve their goals.
certain broad personality traits. The DSM-5 criteria Epidemiological studies assessing antisocial r---
for antisocial personality disorder and definitions of personality disorder as defined by the DSM-IV
psychopathy overlap, but are not entirely the same. suggest that it is one of the most common personal-
Psychopaths are characterized by a superficial ity disorders, with as many as 4.1 percent of the
charm, a grandiose sense of self-worth, a tendency general population being diagnosed w ith the
Antisocial Personality Disorder 331
disorder at some time in their life (Lenzenweger, twins, compared to 20 percent or lower in dizygotic
2008). Men are substantially more likely than women twins (Larsson et al., 2007; Rutter et al., 1990).
to be diagnosed with this disorder (Lenzenweger, Adoption studies find that the criminal records of
Lane, Loranger, & Kessler, 2007). Epidemiological adopted sons are more similar to the criminal re-
studies have not found ethnic or racial differences in cord of their biological father than to that of their
rates of diagnosis (Lenzenweger et al., 2007). adoptive father (Cloninger & Gottesman, 1987;
As many as 80 percent of people with antiso- Mednick, Reznick, Hocevar, & Baker, 1987).
cial personality disorder abuse substances such as Those genes most frequently implicated in
alcohol and illicit drugs (Kraus & Reynolds, 2001; adult antisociality are genes associated with func-
Trull, Waudby, & Sher, 2004). Substance use, such tioning in the serotonin system, which is involved
as binge drinking, may be just one form of impul- in impulsivity, and genes associated with function-
sive behavior that is part of antisocial personality ing in the dopamine system, which is involved in
disorder. Substance use probably feeds impulsive reward seeking and processing. There appear to
and antisocial behavior in people with this person- be complex interactions between these genes and
ality disorder. Alcohol and other substances may others in the production of antisocial personality
reduce any inhibitions they do have, making them disorder (e.g., Arias et al., 2011). As in studies of
more likely to lash out violently at others. People children, studies of adults find that those who
with this disorder also are at somewhat increased have a genotype that influences serotonin func-
risk for suicide attempts (particularly females) and tioning and who grow up in socioeconomically de-
violent death (Cale & Lilienfeld, 2002). prived circumstances are at particularly increased
Adults with antisocial personality disorder typi- risk for developing symptoms of antisocial per-
cally have shown a disregard for societal norms and sonality disorder (Lyons-Ruth et al., 2007).
a tendency toward antisocial behavior since child- People with antisocial personalities tend to
hood, and most would have been diagnosed with show deficits in verbal skills and in the executive
conduct disorder by mid-adolescence (see Table 11.3, functions of the brain: the ability to sustain concen-
Criterion C). For some people with this disorder, tration, abstract reasoning, concept and goal forma-
however, there is a tendency for their antisocial be- tion, the ability to anticipate and plan, the capacity
havior to diminish as they age. This is particularly to program and initiate purposive sequences of be-
true of people who were not antisocial as children havior, self-monitoring and self-awareness, and the
but became antisocial as adolescents or young adults ability to shift from maladaptive patterns of behav-
(Moffitt, 1993). This tendency may be due to psycho- ior to more adaptive ones (Henry & Moffitt, 1997). In
logical or biological maturation or to the possibility turn, studies have found differences between antiso-
that many people with this disorder have been jailed cial adults and the general population in the struc-
or otherwise constrained by society from acting out ture or functioning of specific areas of the prefrontal
their antisocial tendencies. cortex of the brain. These areas are involved in a
wide range of advanced cognitive processes, such as
Contributors to Antisocial decision making, planning, impulse control, regula-
tion of emotions, learning from punishments and
Personality Disorder rewards, and feeling empathy for others (Morgan &
Because most adults diagnosed with antisocial Lilienfeld, 2000; Siever, 2008). For example, Adrian
personality disorder have exhibited antisocial ten- Raine and colleagues (2000) observed an 11 percent
dencies since childhood, the biological and psy- reduction in the volume of gray matter in the pre-
chosocial factors associated with this disorder are frontal cortex of males with antisocial personality
similar to those associated with conduct disorder. disorder compared to males without the disorder. In
Here we summarize those factors, focusing on another study, Raine and colleagues (2011) observed
studies that have been done with adults with anti- reductions in the volume of the prefrontal cortex of
social tendencies. Many of these studies have used both males and females with symptoms of antisocial
samples of individuals (mostly men) exhibiting personality disorder compared to individuals with
criminal behaviors, rather than those specifically no symptoms. In addition, across the sample as a
with antisocial personality disorder. whole, males had less volume in the prefrontal cor-
There is substantial evidence of a genetic influ- tex than females, and the differences between males
ence on antisocial behaviors, particularly criminal and females in prefrontal cortex volume accounted
behaviors (Baker et al., 2007; Eley, Lichenstein, & for the differences in the number of antisocial symp-
Stevenson, 1999; Taylor, Iacono, & McGue, 2000). toms they had. Thus, Raine and colleagues suggest
Twin studies find that the concordance rate for that a tendency toward less gray matter in specific
such behaviors is nearly 50 percent in monozygotic areas of the prefrontal cortex in males compared to
females helps explain the gender differences in rates had elevated rates of having been battered by a
of antisocial personality disorder. caregivier and of having a parent who had a sub-
These deficits in structure and brain function- stance use problem, who went to jail, and/ or who
ing could be tied to the genetic abnormalities that attempted suicide (Afifi et al., 2011). They also had
have been seen in people with antisocial personal- over twice the rates of physical, emotional, and
ity disorder. They may also be caused by medical sexual abuse as individuals without the disorder.
illnesses or exposure to toxins during infancy and As in children with conduct disorder, the ge-
childhood, both of which are more common among netic, neurobiological, and social factors associ-
people who develop antisocial and criminal behav- ated with antisocial personality disorder probably
ior than among those who do not. Whatever their interact (see Figure 11.1, p. 319) to create a cycle of
causes, the deficits in executive functions, empathy violence in the lives of people with the disorder.
for others, and learning from punishment might They then perpetuate that violence in their own
contribute to poor impulse control and difficulty in relationships and families.
anticipating the consequences of one's actions.
The risk taking, fearlessness, and difficulty in Treatments for Antisocial
learning from punishment seen in people with an-
tisocial personality disorder have also been tied to
low levels of arousability as measured by a rela- People with antisocial personality disorder tend to
tively low resting heart rate, low skin conductance believe they do not need treatment. They may sub-
activity, or excessive slow-wave electroencephalo- mit to therapy when forced to because of marital
gram readings (Sylvers et al., 2008). One interpre- discord, work conflicts, or incarceration, but they
tation of these data is that low levels of arousal are prone to blaming others for their current situa-
indicate low levels of fear in response to threaten- tion rather than accepting responsibility for their
ing situations (Raine, 1997). Fearlessness can be actions. As a result, many clinicians do not hold
put to good use-bomb disposal experts and much hope for effectively treating persons with
British paratroopers also show low levels of this disorder through psychotherapy (Kraus &
arousal (McMillan & Rachman, 1987; O'Connor, Reynolds, 2001; Millon et al., 2000).
Hallam, & Rachman, 1985). However, fearlessness When clinicians do attempt psychotherapy,
also may predispose some people to antisocial and they tend to focus on helping the person with anti-
violent behaviors that require fearlessness to exe- social personality disorder gain control over his or
cute, such as fighting and robbery. In addition, her anger and impulsive behaviors by recognizing
low-arousal individuals may not fear punishment triggers and developing alternative coping strate-
and thus may not be deterred from antisocial be- gies (Kraus & Reynolds, 2001). Some clinicians
havior by the threat of punishment. also try to increase the individual's understanding
Chronically low arousal also may be an un- of the effects of his or her behaviors on others
comfortable state and may lead to stimulation (Hare & Hart, 1993).
seeking (Eysenck, 1994). If an individual seeks Lithium and the atypical antipsychotics have
stimulation through prosocial or neutral acts, such been used successfully to control impulsive and ag-
as skydiving, this trait may not lead to antisocial gressive behaviors in people with antisocial person-
behavior. Some individuals, however, may seek ality disorder (Markovitz, 2004; Ripoll et al., 2011).
stimulation through antisocial acts that are dan- Antiseizure drugs also have been used to reduce im-
gerous or impulsive, such as fighting. The direc- pulsiveness and aggressiveness (Ripoll et al., 2011).
tion stimulation seeking takes-toward antisocial
activities or toward more neutral activities-may
depend on the reinforcement individuals receive INTERMITTENT EXPLOSIVE
for their behaviors. Those who are rewarded for
antisocial behaviors by family and peers may de- DISORDER
velop antisocial personalities, whereas those who Children with conduct disorder and adults with an-
are consistently punished for such behaviors and tisocial personality disorder often engage in aggres-
are given alternative, more neutral options for be- sive acts, which may be impulsive outbursts or
havior may not (Dishion & Patterson, 1997). premeditated behavior that unfolds over a longer
Like the other personality disorders, antisocial period of time. The diagnosis of intermittent explo-
personality disorder is linked to a history of child- sive disorder is given to individuals age 6 and older
hood adversity and maltreatment. A study of ana- who engage in relatively frequent impulsive acts of
tionally representative sample found that adults aggression (see Table 11.4). The aggression may be
diagnosed with antisocial personality disorder verbal or physical (though noninjurious), and must
TABLE 11 .4 DSM-5 Criteria for Intermittent Explosive Disorder
A. Recurrent behavioral outbursts representing a failure to cont rol aggressive imp ul ses as manifested by eit her of t he follow ing :
1. Verbal aggression (e .g., temper tantrums, tirades, verbal arguments o r fights) or physical agg ression towa rd prope rty,
animals, or other individuals, occurring twice weekly, o n average, fo r a pe riod of 3 m ont hs. The physical aggress io n does not
result in damage or destruction of property and does not result in physical injury to an i mals or oth er individu als.
2. Three behavioral outbursts involving damage or destructi o n of property and/or physical assa ult involving phy sica l injury
against animals or other individuals occurring within a 13-month period .
B. The magnitude of aggressiveness expressed during t he recurrent outbursts is grossly out of proportion to the provocation or to
any precipitating psychosocial stressors.
C. The recurrent aggressive outbursts are not premeditated (i.e., are impulsive and/or anger-based) and are not com m itte d to
ach ieve some tangible objective (e.g., money, power, intimidatio n).
D. The recurrent aggressive outbursts cause either marked dist ress in the individual or impairment in occupatio nal o r interpersonal
functi o ning, or are associated with financial or legal co nsequences.
E. Chronological age is at least 6 years (or equivalent deve lopmenta l leve l).
F. The recu rring aggressive outbursts are not better exp lained by another mental disorder (e .g., maj o r depressive disorder, bipo lar
disorder, disruptive mood dysregulation disorder, a psychotic disorder, antisocia l pe rso nality disorder, borde rline personal ity
disorder) and are not attributable to another med ica l condit ion (e .g., head trauma, Alzheimer's disease) or t o t he physiological
effects of a substance (e.g., a drug of abuse, a medicatio n). For children 6-18 years, aggressive behavior that occurs as part of an
adjustment disorder should not be considered for t his diagnosis.
Note: This diagnosis can be made in addition to attention-def icit/hyperactivity disorder, cond uct disorder, oppositio nal def iant
diso rde r, or autism spectrum disorder when recurrent impul si ve aggressive ou t bursts are in excess of t hose usua lly seen in t hese
d isorders and warrant independent clinical attentio n.
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright 2013 America n Psych iatric
Association.
be grossly out of proportion to the situation (e.g., runs in families, but it is not known whether this is
angrily throwing a water bottle at a salesperson due to genetic factors or to environmental and par-
who won't give you a discount). The outbursts can't enting factors (Coccaro, 2010).
be the kind that are calculated to gain some advan- Cognitive-behavioral treatments for intermit-
tage, such as a baseball player yelling at an umpire tent explosive disorder help individuals identify
who has called a strike on him. Instead, they must and avoid triggers for explosive outbursts and ap-
be "out of control" as the result of anger, and repre- praise situations in ways that do not provoke ag-
sent an inability to inhibit the impulse to be aggres- gression on their part. One study found that both
sive in the immediate context of frustration or individual and group cognitive-behavioral therapy
a perceived stress that would not typically result were more effective than a wait-list control in reduc-
in an aggressive outburst. Epidemiological studies ing anger, aggression, hostile thinking, and depres-
suggest that as many as 7 percent of the population sive symptoms while improving anger control in
could be diagnosed w ith intermittent explosive individuals with intermittent explosive disorder
disorder (Kessler, Coccaro, et al., 2006), but more (McCloskey et al., 2008). Serotonin and norepi-
narrow definitions suggest a lower one-year preva- nephrine reuptake inhibitors and mood stabilizers
lence of 2.7 percent (APA, 2013). It typically begins (e.g., lithium) have been shown to reduce aggres-
in late childhood or adolescence and rarely onsets sion in individuals with this disorder in small, un-
after age 40. This chronic disorder can lead to legal controlled studies (Myrseth & Pallesen, 2010).
difficulties and to failed relationships and loss of
employment (McCloskey et al., 2008).
One theory of intermittent explosive disorder
CHAPTER INTEGRATION
is that the impulsive aggressive behavior is caused We noted earlier that integrative models of the dis-
by an imbalance in serotonin levels, although only ruptive, impulse control, and conduct disorders
a small amount of research has been conducted view them as the result of interactions between bio-
(Coccaro, Lee, & Kavoussi, 2010). The disorder logical and psychosocial factors. The reciprocal
334 Chapter 11 Disruptive. Impulse-ControL and Conduct Disorders
effects of these factors on each other in these disor-

Reciprocal Effects
FIGURE 11.2 ders are striking. Parents who are antisocial pass on
Between Biological and
their genes to their children, and parent them in
,, Psychosocial Factors in
ways that promote uncontrolled, aggressive, rule-
~ ~ ~:.~~:;~:~:;d::;:.lse Contol, and breaking behavior. In addition, families whose
members engage in antisocial behavior may expe-
rience downward social drift: The adults in these fam-
ilies cannot keep good jobs, and the families'
Biological factors:
Genetics
socioeconomic status tends to decline, leading to
Neurobiological the children growing up in poor surroundings,
abnormalities where they are exposed to toxins that can damage
their developing brains.
I
Sodal factors:
Poverty
\
Psychological factors:
Hostile,
These children tend to be irritable and difficult
and thus draw hostility from their parents, teachers,
and peers. The negative reactions of others feeds
these children's own hostile tendencies, convincing
.,.1--ot)l~' aggressive parenting them that the world is against them. They join devi-
Toxins
Violent 4 Abuse ant peer groups, whose members reinforce their bad
neighborhoods Hostile views of others behavior. Their lack of achievement in school, inabil-
Deviant peer groups and the world
ity to get along with others, and criminal behavior
cause them to live in poverty. Then, when they have
children of their own, the cycle begins again.
The criteria for conduct disorder require three bullies, and 6 percent have been both (Tanner,
symptoms over a 12-month period, one of which 2001 ). Adults can be bullies, too, as in Michael
is present in the past 6 months. Jake's current be- Douglas's portrayal of Gordon Gekko in the movie
havior of ambushing other children would likely Wall Street. Bullying is associated with a broad ar-
meet the criteria if it continues-he's initiating ray of antisocial behaviors in children and adults,
fights, being physically cruel, and intimidating including physical fights, school and work atten-
others intentionally. Prior to his beginning to am- dance problems, cruelty to animals, stealing, and
bush other kids, the fights he got into were pro- harassment (Vaughn et al., 2010). Bullies are sig-
voked by teasing, so it's not clear that they would nificantly more likely than nonbullies to be diag-
count toward a diagnosis of conduct disorder. nosed with conduct disorders as children and to
Jake seems to have turned into a bully, re- have a history of parental antisocial behavior. As
peatedly harassing and victimizing innocent and adults, they are more likely to commit crimes and
often helpless others (Oiweus, 2011 ). A study of to be diagnosed with antisocial personality disor-
American students found that 11 percent have der and substance use disorders (Ttofi, Farrington,
been victims of bullying, 13 percent have been & Losel, 2012; Vaughn et al., 2010).
THINK CRITICALLY
In this chapter, we have reviewed evidence that im- disorder who have committed violent crimes con-
pulsive, aggressive, and antisocial tendencies are as- sider this evidence that the defendants' antisocial
sociated with certain genetic abnormalities, structural behavior is biologically based? If so, how should
and functional abnormalities in the brain, and abnor- such evidence influence their judgments of guilt and
malities in neurotransmitter and neuroendocrine sys- their sentencing of people found guilty of violent
tems. Should judges and juries in legal cases against crimes? (Discussion appears on p. 483 at the back of
individuals with, for example, antisocial personality this book.)
Key Terms 335
CHAPTER SUMMARY
Conduct disorder is characterized by a persistent drugs, antidepressants, and stimulant drugs also
pattern of (a) aggression toward people and ani- are sometimes used to treat conduct disorder.
mals, (b) destruction of property, (c) deceitful- Antisocial personality disorder is characterized by
ness or theft, and (d) serious violations of rules an impairment in the ability to form positive rela-
and social norms. tionships with others, a tendency to engage in be-
Conduct disorder is more common in boys than in haviors that violate basic rights of others and
girls and is highly stable across childhood and ado- social norms and values, deceit and manipulative-
lescence. Childhood-onset conduct disorder is more ness, and a focus on doing whatever it takes to
persistent than adolescent-onset conduct disorder. gratify one's personal desires.
A diagnosis of conduct disorder with limited Psychopathy is not recognized in DSM-5 but
prosocial emotions is given to children who meet overlaps with antisocial personality disorder.
the full criteria for conduct disorder and have at Psychopathy extends the criteria for antisocial
least two of the following characteristics: (a) lack personality disorder beyond persistent violations
of remorse or guilt for their actions, (b) lack of of others' rights and social norms to include traits
empathy for others, (c) lack of concern about like egocentricity, shallow emotions, manipula-
performance in important life domains, and tiveness, and lack of empathy, guilt, and remorse.
(d) shallow or deficient emotions (e.g., insincerity Genetic factors, particu larly those that affect se-
in emotions, using emotions to manipulate others). rotonin and dopamine systems, may play a role
Children with oppositional defiant disorder are in antisocial personality disorder. As in conduct
chronically negativistic, defiant, disobedient, and disorder, the interaction between certain genes
hostile. Unlike children with conduct disorder, and growing up in deprived circumstances is as-
they do not tend to be aggressive toward other sociated with antisocial behavior.
people or animals, to steal, or to destroy property. People with antisocial personalities tend to show
Conduct and oppositional defiant disorders have deficits in areas of the brain associated with ver-
been linked to genes involved in the regulation bal skills, planning, and control of behavior.
of the neurotransmitters dopamine, serotonin, Low levels of arousability may contribute to the
and norepinephrine. The combination of certain risk taking, fearlessness, and difficulty in learning
genes and a history of maltreatment is especially from experience in people with antisocial per-
strongly linked to conduct disorder. sonality disorder.
Children with conduct disorder show a range of Psychotherapy is not considered to be very effec-
neurological deficits in brain systems responsi- tive for people with antisocial personality disor-
ble for controlling behavior and impulses. These der. Lithium, antipsychotic drugs, and antiseizure
deficits may be caused by genetic factors and/or drugs may help control their impulsive behaviors.
exposure to toxins. Intermittent explosive disorder is characterized by
Abnormal serotonin levels, low physiological persistent intermittent anger-based outbursts of
arousal, and high testosterone levels may also noninjurious and nondestructive physical or ver-
be linked to conduct disorder. bal aggress ion greatly out of proportion to the cir-
Poverty, maltreatment, parenting characterized cumstances (e.g., in response to a minor stress).
by harsh discipline with a lack of warmth, and Intermittent explosive disorder may be related to
deviant peer groups are social factors associated imbalances in serotonin systems or to genetic
with conduct disorder. factors, but little research into its causes has
Children with conduct disorder tend to process in- been done.
formation about social interactions in hostile ways Cognitive-behavioral treatments for intermittent
and to see aggression as the only way to respond. explosive disorder he lp individua ls identify and
The treatment for conduct disorder is most avoid triggers for explosive outbursts and ap-
often cogn itive-behavioral therapy, focusing on praise situations in ways that do not provoke
changing children's ways of interpreting interper- aggression on their part. Se rotonin and norepi -
sonal situations and helping them control their nephrine reuptake inhibitors and mood stab iliz-
angry impulses. Parents are taught methods to ers (e.g., lithium) have been shown to reduce
control their children's behavior with appropriate aggression in individuals with this disorder.
punishments and reinforcements. Antipsychotic
KEY TERMS
conduct disorder 321 psychopathy 322
childhood -onset conduct disorder 321 oppositiona l defiant disorde r 323
adolescent-onset conduct disorder 321 antisocial personality di sorder (ASPD) 329
life-course-persistent antisocial behavior 321 intermittent explos ive disorder 332
Eating Disorders
CHAPTER OUTLINE
Eating Disorders Along the Continuum Shades of Gray Discussion

Extraordinary People: Fashion Models, Think Critically
Dying to Be Thin
Chapter Summary
Characteristics of Eating Disorders
Key Terms
Shades of Gray
Understanding Eating Disorders

Treatments for Eating Disorders
Chapter Integration
336
Potentially meets criteria
for eating disorder:
Frequent dieting, skipping meals
to control weight, compensatory
behaviors (e.g., extreme exercise)
Healthy eating habits or binge eating
No concerns about weight Frequent concern about weight
and shape and shape
Occasional dieting, Likely meets criteri a

skipping meals to control for eating disorder:
weight, or binge eating Chronic dieting, skipping meals
Some concern about weight to control weight, compensatory
and shape behaviors (e.g., extreme exercise,
purging) or binge eating; weight
loss of more than 15 percent of
normal weight; loss of menses
in women
Chronic dissatisfa ction about
weight and shape
A "normative discontent" -that's how researchers 30 years ago women surveyed admitted to having engaged in some purging
labeled the dissatisfaction with weight and shape that is rampant behavior (e.g., self-induced vomiting} and that 28 percent classi-
among women, particularly young women, in developed coun- fied themselves as obsessed with their weight (Rozin et al., 2003).
tries (Rodin, Silberstein, & Striegei-Moore, 1984}. Sadly, this dis- Rates for men responding to these questions were 4 percent and
content has only gotten worse in the last 30 years, and it has 11 percent, respectively.
spread worldwide through mass media (Becker et al., 2011 }. In the At the far end of the continuum are people whose concerns
United States, 84 percent of young women want to be thinner than about weight become so preoccupying and whose behaviors
they are (Neighbors & Sobal, 2007) . A study in Iceland found that surrounding eating get so out of control that they have an eating
64 percent of women who were of normal weight felt they needed disorder. There are three specific types of eating disorders: an-
to lose weight (Matthiasdottir, Jonsson, & Kristjansson, 2010) . orexia nervosa, bulimia nervosa, and binge-eating disorder.
Although men are less likely to be concerned with their weight, in Anorexia nervosa is a pursuit of thinness that leads people to
recent years men have become increasingly concerned with at- starve themselves. Bulimia nervosa is a cycle of bingeing fol-
taining the lean lower body and strong, toned upper body cele- lowed by extreme behaviors to prevent weight gain, such as self-
brated in pop culture and the media . Nearly half of men want to be induced vomiting. Binge-eating disorder is applied to people
leaner and more muscular than they are (Neighbors & Sobal, who regularly binge but do not purge what they eat. As you will
2007; Pope et al., 2000;Tiggemann, Martins, & Kirkbride, 2007}. see in this chapter, while relatively few people meet the full crite-
Dieting is the most common way people try to overcome ria for these eating disorders, many more people have some
their body dissatisfaction. Most people diet at least occasionally: symptoms, what researchers call partial-syndrome eating disor-
A study of college students found that only 33 percent of the ders (Lewinsohn, Striegel-Moore, & Seeley, 2000} .
women said they "never" diet, compared to 58 percent of college In this chapter, we discuss the diagnosis and epidemiology
men (Rozin, Bauer, & Catanese, 2003). Other behaviors you of eating disorders; the causes of eating disorders, including
might associate with eating disorders are also common, espe- the psychological and biological factors that may lead some
cially among young adults. A study of 2,200 students in six co l- people to develop the disorders; and effective treatments for
leges around the United States found that 15 percent of the eating disorders.
Eating Disorders Along the Continuum 337

338 Chapter 12 Eating Disorders
Fashion Models, Dying to Be Thin
any models working in that country. The fashion

industry in the United States says it is instituting
measures to reduce self-starvation in models.
But we all know that the shape and weight these
models represent is unattainable by most people, so
no one really believes they should look like them,
right? Studies show that adolescent and adult fe-
males' attitudes toward themselves are affected by
the thin ideal promoted by models and in articles
about weight and shape in fashion magazines (see
Grabe, Ward, & Hyde, 2008; Groesz, Levine, &
Murnen, 2002). For example, Eric Stice and Heather
Shaw (1994) showed college-age women either im-
ages of models from fashion magazines or images
that didn't portray thin models for just 3 minutes.
Those women who saw the fashion magazine im-
ages experienced increases in depression, shame,
They glide down runways, extraordinary examples guilt, stress, insecurity, and body dissatisfaction
of beauty, sophistication, and superiority. They repre- compared to those women who were exposed to the
sent the ultimate look, not just in the clothes they other images. Other studies show that teenage girls
display but in the shape of their bodies. Lean to the given subscriptions to fashion magazines become
point of being emaciated, perfect. But fashion mod- more depressed, more dissatisfied with their body,
els are literally dying in their attempt to attain and diet more, and show more bulimic symptoms over
maintain the extreme thinness demanded by the time compared to teenage girls given subscriptions
industry. When French model and actress lsabele to nonfashion magazines, especially if the girls al-
Caro was photographed in an Italian advertising ready expressed dissatisfaction with their body and
campaign about the fashion industry's insistence that had little social support (Stice, Spangler, & Agras,
models be ultrathin, she weighed 60 pounds (she 2001 ). Similar results have
was 5 feet 4 inches tall). She survived on just one been found in studies that
chocolate square and a cup of tea per day. She had expose adolescent or adult
lost her hair and several teeth. More than once she males to media depictions of
had lapsed into a coma. But the notoriety that her idealized male bodies (Blond,
anorexic photos gained her landed her a spot as a 2008).
judge on the French version of "America's Next Top Obviously, not everyone
Model:' A couple of years later she was dead at who reads fashion magazines
the age of 28. Before Caro's death, Brazilian model or sees fashion models on
Ana Carolina Reston died at the age of 21, weighing television becomes obsessed
only 88 pounds. Model Luisel Ramos of Uruguay with his or her weight and
died from heart failure resulting from self-starvation shape or develops symptoms
just after stepping off a fashion show runway. In of an eating disorder. Later in
2010, male model Jeremy Gillitzer died from com- this chapter, we discuss fac-
plications of anorexia nervosa at age 38. When he tors that enhance vulnerabil-
had spoken to reporters a couple of years earlier, ity to these pressures. But
he had weighed only 88 pounds. there is good reason to think
The deaths of models from complications of that the extraordinary stan-
self-starvation have prompted European cities such dards set by fashion models
as Madrid to set minimum weight standards for and media stars do affect how
fashion models. In March 2012, the Israeli govern- women and men view and
ment passed a law requiring a minimum weight for treat their own bodies. Jeremy Gillitzer
Does the following profile, excerpted from a college threaten their lives. As discussed in Eating Disor-
student's diary, sound like someone you know? ders Along the Continuum, however, people's at-
titudes and behaviors toward food and their
bodies cover a wide range of problems.
PROFILES
CHARACTERISTICS OF
This morning I had a half of a grapefruit for break- EATING DISORDERS
fast, and some coffee-no sugar or cream . For
lunch, I had an apple and a diet soda. For dinner, I Although we discuss anorexia nervosa, bulimia
had some plain white rice and a salad with just nervosa, and binge-eating disorder separately,
some lemon squeezed over it. So I was feeling re- most individuals who initially meet the criteria for
ally good about myself, really virtuous. That is, un- one of these disorders "migrate" between them,
til Jackie came over, and completely messed up meeting the criteria for two or more of the disor-
my day. She brought over a movie to watch, which ders at different times (Fairburn & Cooper, 2011;
was fine. But then she insisted on ordering a pizza. Keel, Brown, Holland, & Bodell, 2012). Moreover,
I told her I didn't want any, that I wasn't hungry many individuals show behaviors and concerns
(which was a lie, because I was starving). But she characteristic of one or more of the eating disor-
ordered it anyway.The pizza arrived, and I thought I ders without meeting the full criteria for one of
cou ld be good and not have any. But it was just these diagnoses. Such individuals may be given
sitting there on the table, and I couldn't think of the diagnosis other specified feeding or eating disorder.
anything except having some. I couldn't concen-
trate on the movie. I kept smelling the pizza and Anorexia Nervosa
feeling the emptiness in my stomach . Like a weak-
People with anorexia nervosa starve themselves,
ling, I reached out and got one piece, a small piece.
subsisting on little or no food for very long periods
It was ice cold by then, and kind of greasy, but I
of time, yet they remain convinced that they need
didn't care. I ate that piece in about 5 seconds flat.
to lose more weight. As a result, their body weight
Then I had another piece. And another. I stopped
is significantly below what is minimally normal
after four pieces. But I still couldn't pay attention to
for their age and height (see the DSM-5 criteria in
the movie. All I could think about was what a pig I
Table 12.1). For example, Isabele Caro, described
was for eating that pizza, and how I'll never lose
in the Extraordinary People feature, was 5 feet
10 pounds so I can fit into size 2 jeans. Jackie's
4 inches tall and weighed only 60 pounds. The ex-
gone now, and I still keep thinking about how ugly
treme weight loss often causes women and girls
and fat I am, and how I have no willpower. I didn't
who have begun menstruating to stop having
deserve to have that pizza tonight, because I
menstrual periods, a condition known as amenor-
haven't lost enough weight this month. I'm going
rhea, although some women who meet the other
to have to skip breakfast and lunch tomorrow, and
DSM-5 criteria for anorexia nervosa still report
exercise for a couple of hours, to make up for be-
some menstrual activity (Attia & Roberto,2009). In
ing a complete pig tonight.
fact, DSM-5 eliminated the DSM-IV requirement
for amenorrhea from its diagnostic criteria.
Despite being emaciated, people with anorexia
Being overweight can have many negative nervosa have a distorted image of their body, often
consequences, such as high blood pressure, heart believing that they are disgustingly fat and need to
disease, and diabetes, as we discuss later in this lose more weight. They struggle with an intense
chapter. But most people care about their weight fear of gaining weight or of becoming fat, yet de-
because what you weigh is equated with your self- spite low weight they routinely engage in behavior
worth in our society. Eating has become more than that interferes with any weight gain. They feel
a source of nourishment, and exercise more than a good and worthwhile only when they have com-
means of improving health. What people eat and plete control over their eating and when they are
how much they exercise have become linked to losing weight. Their weight loss causes people
feelings of worth, merit, guilt, sin, rebelliousness, with anorexia to be chronically fatigued, yet they
and defiance, in turn affecting people's self-esteem. drive themselves to exercise excessively and to
In this chapter, we focus on people whose con- keep up a grueling schedule at work or school.
cern with weight and shape and whose eating People with anorexia nervosa often develop
behaviors are severe enough not only to interfere elaborate rituals around food, as writer Marya
with their functioning in daily life, but also to Hornbacher describes in her autobiography, Wasted.
TABLE 12.1 DSM-5 Criteria for Anorexia Nervosa
A. Restriction of energy intake relative to requirements, leading to a significant ly low body wei ght in t he context of age, sex,
developmental trajectory, and physical health . Significantly low weight is defined as a weight that is less t han m in imally
normal or, for children and adolescents, less than that minima lly expected.
B. Intense fear of gaining weight or of becoming fat, or of persistent behavi or that interferes w ith w eight gain, even t hough at a
significantly low weight.
C. Distu rbance in the way in which one's body weight or shape is experienced, undu e inf lu ence of body w eig ht or sha pe on
self-eval uation, or persistent lack of recognition of the seriousness of the current low body w ei ght.
Specify current subtype:
Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging
behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas}. Wei ght loss is accomplished primarily
through dieting, fasting, and/or excessive exercise.
Binge-Eating/Purging type: During the last 3 months, the individual has engaged in recurre nt episodes of binge eating or purging
behavio r (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas}.
Source: Reprinted with permission from th e Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Copyright 2013 A merican Psych iat ri c
Association .
PROFILES people attempt to go for days without eating any-

thing; most eat very small amounts of food each
I would spread my paper out in front of me, set the day, in part simply to stay alive and in part in re-
yogurt aside, check my watch. I'd read the same sponse to pressure from others to eat. Hombacher
sent ence over and over, to prove that I could sit in survived for months on one cup of yogurt and one
front of food without snarfing it up, to prove it was fat-free muffin per day. Daphne, in the following
no b ig d eal. When f ive minutes had passed , I case study, also has the restricting type of anorexia
would start to skim my yogurt .. .. You take the nervosa, one that includes excessive exercise as part
edge of your spoon and run it over the top of the of her weight-loss behavior pattern.
yogurt, bei ng careful to get only the melted part.
Then let the yogurt drip off until there's only a
sheen of it on the spoon. Lick it-wait, be careful,
yo u have to only lick a teeny bit at a time, the
.\;:CASE STUDY
Daphne is 5 feet 11 inches
sheen should last at least four or f ive licks, and you
tall and weighs 102 pounds. She has felt "large"
have to lick the back of t he spoon fi rst, then turn
since her height soared above her schoolmates
the spoon ove r and lick the front, with the tip of
in the fifth grade. She has been on a diet ever
your t ongue.Then set the yogurt as ide again . Read
since. During her junior year in high school,
a full page, but don't look at t he yogurt to check the
Daphne decided that she had to take drastic
me lt prog ression. Repeat. Repeat. Do not take a
measures to lose more weight. She began by
mout hful, do not eat any of the yogurt unless it's
cutting her calorie intake to about 1,000 calories
m elted. Do not f ant asize about toppings, crumbled
per day. She lost several pounds, but not fast
Oreos, or chocolate sauce. Do not fantasize about
enough for her liking, so she cut her intake to
a sandwich . A sandwich would be so complicated.
500 calories per day. She also began a vigorous
(Hornbacher, 1998, pp. 254-255)
exercise program of cross-country running. Each
day, Daphne would not let herself eat until she had
run at least 10 miles. Then she would have just a
few vegetables and a handful of cereal. Later in
Hornbacher describes one of the two types of
the day, she might have some more vegetables
anorexia nervosa- the restricting type (Table 12.2).
and some fruit, but she would wait until she was
People with the restricting type of anorexia nervosa
so hungry that she was faint. Daphne dropped to
simply refuse to eat and/ or engage in excessive ex-
ercise as a way of preventing weight gain. Some
TABLE 12.2 Comparison of Eating Disorders
Th e eati ng disorders vary on several cha racte ristics.
Anorexia Nervosa Anorexia Nervosa Bulimia Binge-eating

Characteristic Restrict ing Type Binge/Purge Type Nervosa Disorder
Body weight Significantly Significantly Often normal Often signifi cantly

un derwe ight underweight weight or overweight overweight
Body image Seve rely disturbed Severely disturbed Overconcerned with Often very
weight and shape distressed with
overweight
Si ngein g No Yes Yes Yes
Pu rging or other No Yes Yes No
compensato ry behaviors
Sense of lack of control No During binges Yes Yes
ove r eating
people with bulimia nervosa typically are at nor-

110 pounds, and she stopped menstruating. Her mal weight or somewhat overweight. Often, a per-
mother expressed some concern about how little son with the binge / purge type of anorexia nervosa
Daphne was eating , but as her mother tended to does not engage in binges in which large amounts
be overweight, she did not discourage Daphne of food are eaten. If even a small amount of food is
from dieting. eaten, the person feels as if she has hinged and will
When it came time to go to college, Daphne purge this food (Stoving et al., 2012) .
was excited but also frightened, because she had Similar to DSM-I~ individuals with anorexia
always been a star student in high school and nervosa are required by Criterion A (see Table 12.1) to
wasn't sure she could maintain her straight A 's be at a significantly low body weight. DSM-5, how-
in college . In the first examination pe riod in col- ever, provides guidance regarding how to determine
lege, Daphne got mostly A's but one B. She felt whether an individual is at a significantly low weight
very vulnerable, like a failure, and as if she were and severity specifiers. For example, DSM-5 sug-
losing control. She also was unhappy with her gests using a body mass index (BMI) of 18.5 kg/ m 2 as
social life, which, by the middle of the first se- the lower limit of normal body weight, a benchmark
mester, was going nowhere. Daphne decided employed by the Centers for Disease Control and
that things might be better if she lost more Prevention (CDC) and the World Health Organiza-
weight, so she cut her food intake to two apples tion (WHO). The level of severity of anorexia ner-
and a handful of cereal each day. She also ran at vosa would be mild if BMI 2: 17 kg/ m 2, moderate if
least 15 miles each day. By the end of fall semes- BMI 16-16.99 kg/ m 2, severe ifBMI 15-15.99 kg/ m 2,
ter, she was down to 102 pounds. She was also and extreme if BMI < 15 kg/ m 2. However, the level
chronica lly tired, had trouble concentrating, and of severity is not only based on BMI, but can be
occasionally fainted. Still, when Daphne looked adjusted based on clinical symptoms, the degree of
in the mirror, she saw a fat homely young woman functional disability, or the need for supervision.
who needed to lose more weight. Community-based studies in the United States
and Europe find that the lifetime prevalence of
anorexia nervosa is 0.9 percent in adult women
(Hudson, Hiripi, Pope, & Kessler, 2007; Preti et al.,
The other type of anorexia is the binge/purge 2009) and 0.3 percent in adolescent girls (Swanson,
type of anorexia nervosa, in which people peri- Crow, et al., 2011). The rate among males is 0.3 per-
odically engage in binge eating or purging behav- cent in the U.S. studies (Hudson et al., 2007;
iors (e.g., self-induced vomiting or the misuse of Swanson, Crow, et al., 2011), and no men with an-
laxatives or diuretics). This disorder is different orexia nervosa were found in the community
from bulimia nervosa in that people with the binge/ samples in the European study (Preti et al., 2009).
purge type of anorexia nervosa continue to be These rates are based on the DSM-IV criteria, which
substantially below a healthy body weight, whereas are stricter than the DSM-5 criteria. In the DSM-IV,
an individual was required to be at least 15 percent

condition was perfunctory. When asked whether
below normal weight and women were required to
she consciously tried to restrict the amount she
show amenorrhea to obtain a diagnosis of anorexia
ate, she said, "No:' When questioned why she
nervosa. In future studies using the DSM-5 criteria,
had gone for periods of 8 or more waking hours
the prevalence rates may be found to be higher.
without eating anything, she said it was because
In the United States, Caucasians are more likely
she had no hunger and felt distended, pointing
than African Americans and Hispanic Americans
to the lower left side of her abdomen . All physi-
to develop the disorder (Striegel-Moore & Franko,
2008; Swanson, Crow, et al., 2011). This may be be- cal examinations revealed no biological source
cause Caucasians are more likely to accept the thin for her feelings of distension, however. MissY
ideal promoted in the media (Smolak & Striegel- was often in a low mood and became transiently
Moore, 2001). Similarly, there is some evidence that tearful when her grief over the broken relation-
cultures that do not value thinness in females have ship was acknowledged. However, she resisted
lower rates of anorexia nervosa than those in the all attempts to discuss this loss in detail and all
United States and Europe (Hoek et al., 2005). other psychological and medical treatments.
The incidence of anorexia nervosa has in- MissY later died of cardiac arrest. Postmortem
creased substantially since the early part of the examination revealed no specific pathology
twentieth century (Hoek & van Hoeken, 2003) . other than multiple organ atrophy due to starva-
For example, a study of over 30,000 Swedish tion. (Adapted from Sing, 1995, pp. 27-29)
twins found significantly higher rates of anorexia
nervosa among those born after 1945 than among
those born before 1945 (Bulik et al., 2006) . The
motivations for self-starvation also seem to vary One question that can be raised is whether
across culture and time. In centuries past, and out- self-starvation in the absence of expressed weight
side the United States and Europe, the stated moti- concerns can be called anorexia nervosa, given
vations for excessive fasting have had less to do that weight concerns are a defining feature of the
with weight concerns than with stomach discom- disorder in the DSM-5 (see Table 12.1, Criterion B).
fort or religious considerations (Keel & Klump, Alternatively, it is possible that the more culturally
2003). Patients with anorexia nervosa in Asian sanctioned rationale for dietary restriction involv-
countries do not have the distorted body image ing gastrointestinal discomfort was put forth by
characteristic of anorexia in the United States and Miss Y, substituting for the expression of weight
Europe and readily admit to being very thin. None- concerns. DSM-5 Criterion B was expanded to in-
theless, they stubbornly refuse to eat, as illustrated clude not only overtly expressed fear of weight
by the following case study of one Chinese woman. gain but also persistent behavior that interferes
with weight gain; Miss Y clearly shows the latter.
;; - ~ ... --";~ '* -- ~~
While the DSM-5 itself is a culture-bound docu-
ment, representing views of mental disorders in
CASE STUQY
. : ..
MissY, age 31, was 5 foot
"Western" cultures, its text often addresses culture-
3 inches. She had formerly weighed 110 pounds
related diagnostic issues in understanding and
but now weighed 48 pounds. Her anorexia be-
describing illness experiences.
gan 4 years previously, when she was suddenly Anorexia nervosa usually begins in adoles-
deserted by her boyfriend , who came from a cence or young adulthood (Hudson et al., 2007;
neighboring village. Greatly saddened by his de-
Preti et al., 2009; Swanson, Crow, et al., 2011). The
parture for England, MissY started to complain
course of the disorder varies greatly from person to
of abdominal discomfort and reduced her food
person. Long-term studies suggest that the median
intake. She became socially withdrawn and
number of years from onset to remission of the dis-
unemployed. At her psychiatric examination, she
order is 7 years for women and 3 years for men,
wore long hair and was shockingly emaciated-
even among patients in treatment (Staving et al.,
v irtually a skeleton. She had sunken eyes, hol-
2011). Ten to 15 years after onset of the diagnosis,
low cheeks, and pale, cold skin. She recognized
about 70 percent of patients no longer qualify for
her striking wasting readily but claimed a com-
a diagnosis, but many continue to have eating-
plete lack of hunger and blamed the weight loss
related problems or other psychopathology, partic-
on an unidentifiable abdominal problem. Her
ularly depression (Staving et al., 2011; Wade et al.,
concern over the seriousness of her physical
2006). Individuals with the binge / purge type of
anorexia nervosa tend to have more comorbid psy-
chopathology than people with the restricting type,
particularly impulsive, suicidal, and self-harming

behaviors (Peat, Mitchell, Hoek, & Wonderlich, TABLE 12.3 DSM-5 Criteria for Bulimia Nervosa
2009), and a more chronic course of the disorder A. Recurrent episodes of binge eating. A n episode of binge eating is
(Staving et al., 2012). characte rized by both of the follow ing:
Anorexia nervosa is a dangerous disorder,
1. Eating , in a discrete period of time (e.g., within any 2-h o ur period ),
with a death rate of 5 to 9 percent (Arcelus, Mitchell, an amount of foo d th at is definitely la rger than most people would
Wales, & Nielson, 2011; Erdur et al., 2012). Some of eat during a sim ilar period of t ime under sim il ar circumstance s.
the most serious consequences of anorexia are car-
2. A sense of lack of control over eating du ring the epi sode (e .g., a
diovascular complications, including bradycardia
feel ing t hat one cannot stop eati ng o r co ntro l what or how m uch
(extreme slowing of heart rate), arrhythmia (ir- one is eat ing).
regular heart beat), and heart failure. Another po-
B. Recu rrent inappropriate co m pensato ry behav iors in order to prevent
tentially serious complication of anorexia is acute
we ight gain, su ch as se lf- ind uced vomiting; m isuse of laxatives,
expansion of the stomach, to the point of ruptur-
d iuretics, or othe r medicati ons; fast in g; or excessive exe rci se.
ing. Bone strength is an issue for women who
have amenorrhea, presumably because low estro- C. The binge eating and inappropriate com pensatory behaviors both
occur, on average, at least once per week for 3 mo nths.
gen levels reduce bone strength. Kidney damage
has been seen in some people with anorexia, and D. Self-evaluation is unduly influenced by body shape and w eig ht.
impaired immune system functioning may make E. The disturbance does not occur excl us ively d uring episod es of
people with anorexia more vulnerable to medical anore xi a nervosa.
illnesses. In addition, the suicide rate among peo-
ple with anorexia nervosa is 31 times the rate in Sou rce: Reprinted w ith perm ission f rom t he Diagnostic and Statistical Manual of Mental
the general population (Preti et al., 2011). Disorders, Fifth Editio n. Co py ri g ht 2013 American Psych iatric Assoc iation.
Bulimia Nervosa
The core characteristic of bulimia nervosa is uncon-
trolled eating, or bingeing, followed by behaviors people with anorexia nervosa, the self-evaluations
designed to prevent weight gain from the binges of people with bulimia nervosa are heavily influ-
(see the DSM-5 criteria in Table 12.3). Mild presen- enced by their body shape and weight. When they
tations of bulimia include an average of 1-3 epi- are thin, they feel like a good person. However,
II II
sodes of inappropriate compensatory behavior per people with bulimia nervosa, unlike people with
week, while more extreme forms involve an aver- anorexia nervosa, do not tend to show gross dis-
age of 14 or more episodes per week. The DSM-5 tortions in their body images. Whereas a woman
defines a binge as occurring over a discrete period with anorexia nervosa who is absolutely emaci-
of time, such as 1 or 2 hours, and involving an ated looks in the mirror and sees herself as obese, a
amount of food definitely larger than most people woman with bulimia nervosa has a more realistic
would eat during a similar period of time and in perception of her actual body shape and weight.
similar circumstances. People with eating disorders Still, people with bulimia nervosa are constantly
show tremendous variation in the size of their dissatisfied with their shape and weight and con-
binges, however. Some people consume 3,000 to cerned about losing weight.
4,000 calories in one seating, focusing on food high Self-induced vomiting is the behavior people
in fat and carbohydrates; in other cases, the binge is most often associate with bulimia. Bulimia is often
between 1,200 and 2,000 calories (Hilbert et al., 2011; discovered by family members, roommates, and
Wolfe, Baker, Smith, & Kelly-Weeder, 2009). What friends when people with the disorder are caught
makes these lesser amounts binges is people's sense vomiting or leave messes after they vomit. Den-
that they are violating some dietary rule they have tists also recognize people with bulimia because
set for themselves and that they have no control frequent vomiting can rot teeth due to exposure to
over their eating but feel compelled to eat even stomach acid. The cycle ofbingeing and then purg-
though they are not hungry (Fairburn & Cooper, ing or using other compensatory behaviors to con-
2007; Wolfe et al., 2009). Recognizing this aspect of trol weight becomes a way of life.
binges, the DSM-5 criteria for a binge include a Other people use excessive exercise or fasting
sense of lack of control over eating (Criterion A2). to control their weight. The man in the following
The behaviors people with bulimia use to con- profile fasted for a day or longer after a binge to
trol their weight include self-induced vomiting; control his weight. As the pressures of his job and
the abuse of laxatives, diuretics, or other purging a failed marriage increased, his bulimic pattern of
medications; fasting; and excessive exercise. As with bingeing and then fasting grew more serious.
PROFILES
1 would sigh with relief when Sunday evening
came, since I had no work responsibilities until
the next morning, and I would have just returned
my son to his mother's custody. I would then care-
fully shop at convenience stores for "just right"
combinations of cheese, lunch meats, snack chips,
and sweets such as chocolate bars. I would also
make a stop at a neighborhood newsstand to buy
escapist paperback novels (an essential part of
the binge) and then settle down for a three-hour
session of reading and slow eating until I could
barely keep my eyes open. My binges took the
place of Sunday dinner, averaging approximately Men with bulimia nervosa are more likely than women
6,000 calories in size. Following the binge, my with bulimia nervosa to use excessive exercising to
stomach aching with distension, I would carefully control their weight.
clean my teeth, wash all the dishes, and fall into a
drugged slumber. I would typically schedule the
following day as a heavy working day with eve- The lifetime prevalence of bulimia nervosa is
ning meetings in order to distract myself from in- estimated to be 0.5 percent in adults (Hudson et al.,
creasing hunger as I fasted . I began running .. . . I 2007) and 0.9 percent in adolescents (Swanson,
would typically run for one hour, four to five days Crow, et al., 2011). It is much more common in
per week, and walked to work as a further weight females than in males (Swanson, Crow, et al., 2011).
control measure .... As time went on, I increased These prevalence rates are based on DSM-IV crite-
the frequency of these binges, probably because ria, and, as with anorexia nervosa, the criteria for
of the decreasing structured demands for my the diagnosis of bulimia nervosa were loosened
time. They went from weekly to twice per week, somewhat in the DSM-5 (by reducing the mini-
then I was either bingeing or fasting with no nor- mum average number of times per week binge/
mal days in my week at all. My sleep patterns purge behaviors must occur from two to one).
were either near-comatose or restless, with either Thus, future studies using the DSM-5 criteria will
sweating after a binge or shivering after a fast. I likely show higher prevalence rates. Men with bu-
became increasingly irritable and withdrawn ... limia nervosa are more likely than women with the
prompting increased guilt on my part that I re- disorder to exercise excessively to control their
sented the intrusion of my friends, my patients, weight and to be focused on developing a lean,
and even my son into my cycle . .. . The nadir of muscular look rather than on being excessively
my life as a bulimic occurred when I found myself thin (Morgan, 2012).
calling patients whom I had scheduled for eve- There is clear evidence of cultural, racial/
ning appointments, explaining to them that I was
ethnic, and historical differences in the prevalence
ill, then using the freed evening for bingeing .... I of bulimia nervosa. In the United States, it is more
was physically exhausted most of the time, and common in Caucasians than in African Americans
my hands, feet, and abdomen were frequently (Striegel-Moore & Franko, 2008; Swanson, Crow,
puffy and edematous, which I, of course, inter- et al., 2011), and a meta-analysis found that bulimia
preted as gain in body fat and which contributed nervosa is considerably more common in Western-
to my obsession with weight and food. I weighed ized cultures than in non-Westernized cultures
myself several times per day in various locations, (Keel and Klump, 2003). In addition, the preva-
attending to half pound variations as though my lence of bulimia nervosa increased significantly in
life depended on them. ("Male Bulimia Nervosa: the second half of the twentieth century. Since
An Autobiographical Case Study;' by Wilps, R. F., 1990, the prevalence of bulimia nervosa has
Jr. From MALES WITH EATING DISORDERS by remained stable in the United States, Europe, and
A. E. Andersen (ed .), copyright 1990 TAYLOR & Australia despite the increased availability of
FRANCIS GROUP LLC-BOOKS. Reproduced effective treatments for the disorder (Crowther
with permission ofTAYLOR & FRANCIS GROUP et al., 2008; Keel et al., 2006).
LLC-BOOKS in the format Textbook via Copy- The onset of bulimia nervosa most often oc-
right Clearance Center.) curs in adolescence (Hudson et al., 2007; Swanson,
Crow, et al., 2011). Although the death rate among
people with bulimia is not as high as among peo-

ple with anorexia, bulimia also has serious medical TABLE 12.4 DSM-5 Criteria for Binge-Eating Disorder
complications and a death rate nearly double that A. Recurrent episodes of binge eating. An episode of binge eating is
in the general population (Arcelus et al., 2011) . characterized by both of the following:
One of the most serious complications is an elec-
1. Eating, in a discrete period of time (e.g., w ithin any 2-hour period),
trolyte imbalance, which results from fluid loss an amount of food that is definitely large r than most people would
following excessive and chronic vomiting, laxative eat in a similar period of time under similar circumstances.
abuse, and diuretic abuse. Imbalances in electrolytes
2. A sense of lack of control over eating during the episode (e .g., a
can lead to heart failure . The suicide rate among
feeling that one cannot stop eating or control what or how much
people with bulimia nervosa is 7.5 times higher
one is eating) .
than in the general population (Preti et al., 2011).
Bulimia nervosa tends to be a chronic condi- B. The binge-eating episodes are associated with three (or more) of the
following :
tion. A long-term study of people seeking treat-
ment found that 15 years after the disorder about 1. Eating much more rapidly than normal.
50 percent showed remission of their symptoms 2. Eating until fee ling uncomfortably full.
but the other 50 percent still had symptoms quali- 3. Eating large amounts of food when not feeling physically hungry.
fying for a diagnosis (Staving et al., 2011). The
4. Eating alone because of feeling embarrassed by how much one is
frequent use of purging is a predictor of a poorer
eating.
outcome (Staving et al., 2012).
5. Feeling disgusted with oneself, depressed, or very guilty
Binge-Eating Disorder afterward.
C. Marked distress regarding binge eati ng is present.
Binge eating disorder was included in DSM-IV as
a proposed condition in need of further study. As a D. The binge eating occurs, on average, at least once a week for
3 months.
result of extensive research supporting its clinical
usefulness and validity over the past 20 years, it is E. The binge eating is not associated with the recurrent use of
included in DSM-5 as a mental disorder. Binge- inappropriate compensato ry behavior and does not occur exclusively
eating disorder resembles bulimia nervosa, except during the course of bulimia nervosa or anorexia nervosa.
that a person with binge-eating disorder does not
regularly engage in purging, fasting, or excessive Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition. Copyright 2013 American Psychiatric Association.
exercise to compensate for binges (Table 12.4).
People with binge-eating disorder may eat contin-
uously throughout the day, with no planned meal-
times (Masheb, Grilo, & White, 2011). Others
engage in discrete binges of large amounts of food,
often in response to stress and to feelings of anxi-
ety or depression (Munsch, Meyer, Quartier, & said, 'What the hell,' and started eating, and what
Wilhelm, 2012; Wonderlich et al., 2009). They may I did then was an absolute sin:'
eat very rapidly and appear almost in a daze as He described starting in a grocery store
they eat, as the man in the following case study where he bought a cake, several pieces of pie,
describes. and boxes of cookies. Then he drove through
heavy midtown traffic with one hand, pulling
food out of the bag with the other hand and eat-
ing as fast as he could. After consuming all of his
CASE STUDY . groceries, he set out on a furtive round of restau-
"The day after New Year's rants, staying only a short time in each and eating
Day I got my check cashed. I usually eat to cele- only small amounts. Although in constant dread
brate the occasion, so I knew it might happen. On of discovery, he had no idea what "sin" he felt he
the way to the bank I steeled myself against it. I was committing. He knew only that it was not
kept reminding myself ofthe treatment and about pleasurable. " I didn't enjoy it at all. It just hap-
my NewYear's resolution about dieting .... pened . It's like a part of me just blacked out. And
"Then I got the check cashed. And I kept out when that happened there was nothing there
a hundred . And everything just seemed to go except the food and me, all alone:' Finally he
blank. I don't know what it was. All of my good went into a delicatessen, bought another $20
intentions just seemed to fade away. They just worth of food and drove home, eating all the way,
didn't seem to mean anyth ing anymore. I just "until my gut ached:' (Stunkard, 1993, pp. 20-21)
People with binge-eating disorder often are sig- adult women. Researchers in Oregon followed a
nificantly overweight and say they are disgusted large group of adolescents for several years, examin-
with their body and ashamed of their bingeing ing the ebb and flow of what they called partial-
(Stunkard, 2011; Wonderlich et al., 2009). They typi- syndrome eating disorders- syndromes that don't
cally have a history of frequent dieting, member- meet the full criteria for anorexia nervosa or buli-
ship in weight-control programs, and family obesity mia nervosa (Lewinsohn et al., 2000; Striegel-Moore,
(Fairburn et al., 1997). As many as 30 percent of Seeley, & Lewinsohn, 2003). Adolescents with
people currently in weight-loss programs may have partial-syndrome eating disorders may binge a cou-
binge-eating disorder (Stunkard, 2011). In contrast, ple of times a month but not every week. They may
approximately 2 to 3.5 percent of the general popu- be underweight but not severely so. They tend to be
lation have the disorder (Hudson et al., 2007). highly concerned with their weight and judge them-
Binge-eating disorder is somewhat more com- selves on the basis of their weight, but their symp-
mon in women than in men, both in the general toms don't add up to a full-blown eating disorder.
community and among people in weight-loss pro- The researchers found that adolescents with
grams, although the gender difference is not signifi- partial-syndrome eating disorders, the vast major-
cant in some studies (Hudson et al., 2007; Stunkard, ity of whom were girls, were just as likely as those
2011). In the United States, there do not appear to be with full-blown eating disorders to have several
racial or ethnic differences in rates of binge-eating psychological problems, both in adolescence and in
disorder (Striegel-Moore & Franko, 2008). People their 20s. These problems included anxiety disor-
with this disorder also have high rates of depression ders, substance abuse, depression, and attempted
and anxiety and possibly a higher incidence of alco- suicide. Almost 90 percent had a diagnosable psy-
hol abuse and personality disorders (Striegel-Moore chiatric disorder when they were in their early 20s.
& Franko, 2008). Binge-eating disorder tends to be Those diagnosed with partial-syndrome eating dis-
chronic; one retrospective study found the mean orders also had lower self-esteem, poorer social
duration of the disorder to be 8 years (Hudson et al., relationships, poorer physical health, and lower
2007), and another study found a mean duration of levels of life satisfaction than those with no signs of
14.4 years (Pope et al., 2006). an eating disorder. They were less likely to have
earned a bachelor's degree and more likely to be
Other Specified Feeding or unemployed.
Eating Disorder The DSM-5 created a new diagnostic category
called other specified feeding or eating disorder to
As noted in Eating Disorders Along the Continuum, capture presentations of an eating disorder that cause
subclinical symptoms of eating disorders are quite clinically significant distress or impairment but do
common, particularly among adolescent and young not meet the full diagnostic criteria for any of the
eating disorders previously discussed. The partial-
syndrome eating disorders would fit into this new
category. DSM-IV included a similar category
called eating disorders not otherwise specified
(EDNOS). In fact, about 5 percent of the general
population experiences EDNOS (Fairburn et al.,
2007; Wade et al., 2006). EDNOS tends to be as se-
vere and persistent as bulimia nervosa or anorexia
nervosa (Fairburn et al., 2007).
The DSM-5 other specified feeding or eating
disorder category includes disorders like atypical
anorexia nervosa wherein all the criteria for an-
orexia nervosa are met, except that despite signifi-
cant weight loss, the individual's weight is within
or above the normal range. Another example is
b ulimia nervosa of low frequency and/or limited
duration, which involves meeting all of the criteria
for bulimia nervosa, except that the binge eating
and inappropriate compensatory behaviors oc-
People with night eating disorder often are overweight and suffer from cur, an average, less than once a week and/ or for
depression. less than 3 months. One last example is night
eating syndrome, a new disorder introduced in
DSM-5. People with this disorder regularly eat ex- Obesity in the United States. The percent
cessive amounts of food after dinner and into the of adults in the United States meeting the
night (VanderWal, 2012). The eating behavior is not FIGURE 12.1 criteria for obesity (BMI 2 30) is shown based
part of cultural or social norms-this is not the typi- on age, gender, and ethnic/racial group.
cal ordering of pizza with friends after a party or the
occasional bout of the late-night munchies. People 60
with night eating disorder feel an overwhelming de- - Non-Hispanic - Non-Hispanic - Hispanic
white black
sire to eat at night most nights of the week and are
highly distressed that they cannot control their eat- 50
~
ing behavior. They experience frequent insomnia
and may believe they need to eat in order to fall
asleep. They typically are not hungry in the morning 40
l f---- I-- r-- c-
..l- l
and skip breakfast (Allison et al., 2010). Night eating '-
disorder most often begins in early adulthood and
,_, R'
It
~.-
tends to be long-lasting (Vander Wal, 2012). People r-- r- !
- ;.
r- -
[~
- r
with this disorder often are overweight and suffer
,')
from depression. Night eating disorder differs from
sleep-eating, which can occur in some sleep disorders 20 r- r- f
ii'
'----- ik r- r--- - :t r
t;f
t~
i-.
..
~~
(see Chapter 15), in that people with night eating -~
f~ I
disorder are awake and aware when they are eating !~I
r: r- I 'j
i'~l
while people who sleep-eat are not. 10 [} - r- - r- ~
-
:.'
I'' I
Obesity I
i"'
L,. I
0
>20 20-39 40-59 60+ >20 20-39 40-59 60+
Although obesity is not included in DSM-5 as a
mental disorder, it is common among people with Men Age Women
binge-eating disorder and is one of the greatest
public health concerns internationally (Gearhardt Source: Flegel, Carroll, Ogden, & Curtin (2010). Journal of the American Medical
et al., 2012). It is included here because obesity is Association, 303, 235-241 .
highly associated with numerous mental disor-
ders, is a risk factor for the development of some
mental disorders (e.g., depressive disorders), and
is the result of psychotropic medication side ef- & Brownell, 2011). In the United States, 5 to 7 per-
fects (e.g., atypical antipsychotics, Chapter 8). cent of all health care costs are due to the effects of
Obesity (excess body fat) is defined as a body obesity. People with obesity suffer not only more
mass index (BMI) of 30 or over, with BMI calcu- physical illnesses but also a lower quality of life
lated as your weight in pounds multiplied by 703, and more emotional problems, due in part to the
then divided by the square of your height in stigmatization of obese people (Gearhdardt et al.,
inches (CDC, 2010). Between 1980 and 2002, the 2012). For example, experimental studies have
prevalence of obesity in the United States doubled shown that employers are less likely to hire or pro-
in adults and tripled in children and adolescents mote individuals described in vignettes as over-
(Flegal, Carroll, Ogden, & Johnson, 2002; Hedley weight than they are to hire or promote individuals
et al., 2004; Ogden, Flegal, Carroll, & Johnson, with identical credentials not described as over-
2002). Rates have continued to climb, and cur- weight (Roehling, Pichler, Oswald, & Bruce, 2008).
rently it is estimated that over one-third of Ameri- High school students who are obese report fre-
can adults and 17 percent of American children quent teasing and bullying and report that they
are obese (Ogden, Carroll, Kit, & Flegel, 2012). skip school as a result (Puhl & Luedicke, 2012).
African Americans have the highest obesity rate, Although many people think such stigmatization
followed by Hispanic and non-Hispanic whites could serve as motivation for obese people to lose
(Figure 12.1). Rates of obesity also are climbing weight, experimental studies show that exposure
around the world, particularly in countries where to stigmatizing media portrayals leads obese peo-
the standard of living and access to American fast ple to eat more rather than less (Pearl, Puhl, &
foods are increasing (Novak & Brownell, 2011). Brownell, 2012).
Obesity is associated with an increased risk of ' The dramatic historical increases in obesity
coronary heart disease, hypertension and stroke, point to environmental causes. Researcher Kelly
type 2 diabetes, and some kinds of cancer (Novak Brownell argues that we live in a toxic environment
of high-fat, high-calorie, in- Obese people show less activity in certain reward
expensive food and adver- areas of the brain than do lean people when they
tisers who promote the actually consume such food, however, suggesting
consumption of large quan- that changes in the brain similar to those seen in
tities of this food (Brownell drug addicts occur after chronic exposure to ultra-
& Horgen, 2004; Gearhardt processed foods (Stice et al., 2008; Stice, Spoor, Ng,
et al., 2012) . Added to this & Zald, 2009). Finally, people w ho show behav-
"Super-Size Me" culture is a ioral signs of food addiction, such as craving, toler-
significant reduction over ance, and withdrawal from high-fat, high-sugar
the past several decades in ultraprocessed foods, have brain activity in re-
the amount of physical sponse to viewing food photos and consuming
activity people engage in. processed foods similar to that of obese people
More than 60 percent of (and drug addicts) (Gearhardt, Yokum, et al., 2011).
Americans do not get 30 min- Thus, the ultraprocessed foods that are the staple
utes of physical exercise per of American and, increasingly, international diets
day, and 25 percent get no may be causing addictions to these foods that
exercise at all (Godfrey & make them hard to resist.
Brownell, 2008). In the Other evidence that a toxic food environment
United States, only 2 percent contributes to obesity comes from studies of im-
of high schools, 8 percent of migrants. One study compared Pima Indian
middle schools, and 4 per- women who migrated to Arizona to their female
cent of elementary schools relatives who remained in Mexico. The women
The toxic environment includes large require daily physical edu- in Arizona had an average dietary fat intake of
portions of high-fat foods and low prices.
cation (Story, Nanney, & 41 percent of all calories, an average body weight
Schwartz, 2009). A typical of 198 kilograms, and an average BMI of 37. In
day for many Americans involves driving to comparison, the women in Mexico had an average
work or school, passing through the drive- dietary fat intake of only 23 percent of all calories,
through at a fast-food restaurant to get a fat- and an average body weight of 154 kilograms, and an
cholesterol-laden breakfast sandwich, sitting at average BMI of 25 (Ravussin et al., 1994).
work or school all day, getting up only to go to Not everyone living in a toxic food environ-
another fast-food restaurant for a lunch that may ment becomes overweight or obese. Genes ap-
have thousands of calories, and then driving pear to account for a substantial percentage of the
home to spend the evening sitting in front of the variability in obesity (Stice, Yokum, et al., 2011).
television. Eating like this is a prescription for Genes affect the number of fat cells and the likeli-
obesity. hood of fat storage, the tendency to overeat, and
In addition, there is increasing evidence that the activity level in the brain in response to food.
the ultraprocessed foods sold by fast-food restau- These genetic factors interact with the toxic envi-
rants can create addictions similar to those created ronment to contribute to obesity. For example,
by drugs of abuse (Gearhardt et al., 2012) . Food Eric Stice and colleagues (2008, 2010) found that
companies have manipulated the fat, sugar, salt, individuals who showed atypical activity in re-
food additives, flavor enhancers, and caffeine in ward areas of the brain in response to tasty food
processed food in ways that increase flavor and were at risk for future weight gain only if they
result in quicker absorption of ingredients such as had a certain variant of a gene associated with
sugar into the bloodstream, increasing the foods' reward processing.
addictive properties (Gearhardt, Davis, et al., Millions of people try to lose weight on their
2011). Rats fed this type of food are more likely own, with the aid of self-help books; millions of
than rats fed regular rat food to endure repeated others participate in commercial weight-loss pro-
electric shocks in order to get more high-fat, high- grams such as Weight Watchers. Evaluations of
sugar foods, and they show changes in the brain popular weight-loss programs suggest that they
similar to those seen in people addicted to sub- can result in modest weight loss (Gearhardt et al.,
stances like cocaine (Johnson & Kenny, 2010). In 2012) . For example, Christopher Gardner and col-
humans, obese people, who eat more ultrapro- leagues (2007) randomly assigned women with a
cessed foods, show more activity in reward areas BMI of 27 to 40 to follow the Atkins (carbohydrate-
of the brain associated with drug abuse when ex- restricted), the Ornish (fat-restricted), the Zone
posed to photos of such foods than do lean people (macronutrients balance), or the LEARN (exercise
(Rothemund et al., 2007; Stoeckel et al., 2008). and changes in eating patterns) program. At the
end of 1 year, the women on the

Atkins program had lost an av-
erage of about 10 pounds, sig-
nificantly more weight loss than
that of women on the Zone pro-
gram (3.5 pounds) but not sig-
nificantly different from that of
women on the Ornish program
(4.8 pounds) or the LEARN pro-
gram (5.7 pounds). Another
study that included both men
and women found that the
Atkins, Ornish, Zone, and Weight
Watchers programs all resulted in
similar weight loss (Dansinger et
al., 2005). Weight Watchers led to
an average loss of 4 to 7 pounds,
but only 50 to 65 percent of peo-
ple stuck to the diet for 1 year.
Even for those who do stick to
these programs, the modest
weight loss is discouraging, espe-
cially given the advertisements TV weatherman AI Roker underwent bariatric surgery to lose weight.
suggesting that these programs
can result in much greater weight
loss for obese people. Yet even a modest weight (Wadden, Faulconbridge, et al., 2011). One person
loss of 5 to 10 percent of body weight can result in who underwent bariatric surgery is TV weather-
significant health improvements for obese people. man Al Raker.
Weight-loss drugs, such as sibutramine It is difficult for overweight and obese people
(Meridia), orlistat (Xenical), and rimonabant to lose weight, and even more difficult to keep it
(Acomplia), suppress appetite and can help peo- off. To combat the discouragement many people
ple lose weight. A meta-analysis of controlled feel about losing weight, researchers are encourag-
trials of these drugs showed that they led to an ing obese people to adopt reasonably modest goals
average weight loss of 11 pounds or less, depend- for weight loss and to focus on increasing their
ing on the drug, over 1 to 4 years (Rucker et al., physical activity, both of which can lead to sub-
2007). All these medications have side effects, stantial improvements in cardiac functioning
including gastrointestinal upset (orlistat), in- and diabetes risk (Wadden, Wilson, Stunkard, &
creased blood pressure and heart rate (sibutra- Berkowitz, 2011). In general, the proven methods
mine), and negative mood changes (rimonabant). for preventing weight gain and reducing weight
For obese people with a BMI between 30 and are these:
39, low-calorie diets (900 to 1,200 calories per
day), often using prepackaged, portion-controlled Eat more nutrient-dense foods and fewer
servings (such as SlimFast shakes), are recom- foods with empty calories.
mended (Wadden, Neiberg, et al., 2011). Individ- Aim for a minimum of 30 minutes of physical
uals also are encouraged to increase their level of activity daily.
physical activity. Such a program results in
Structure your environment so that healthy
significantly more weight loss than when indi-
viduals consume a self-selected diet of conven- choices are easier to make; for example, keep
low-fat foods readily available in your house
tional food (Berkowitz et al., 2011). For extremely
and purge your cabinets of junk food.
obese people with a BMI of 40 or over who have
at least one severe health problem (e.g., diabetes), Be more active throughout the day: Use the
bariatric surgery is an option. A small pouch stairs rather than the elevator, park in the
is created at the base of the esophagus, severely farthest spot from the building rather than
limiting food intake, and the stomach may be sta- the closest, and seek other opportunities that
pled, banded, or bypassed. Such surgery can re- encourage movement over standing or sitting
sult in a substantial weight loss of 25 to 30 percent (Godfrey & Brownell, 2008).
SHADES OF GRAY
Read the following case study. When Rachel returned home for Christmas va-
cation, her family noticed that she looked thin and
At the insistence of her parents, Rachel, a 19-year- tired. Despite encouragement to catch up on rest,
old freshman at a competitive liberal arts college, she awoke early each morning to run. She re-
received a psychiatric evaluation during spring turned to school in January and thought she might
break. According to her parents, Rachel had lost be developing depression. Courses seemed less
16 pounds since her precollege physical the previ- interesting, and she wondered whether the col-
ous August. She now weighed 104 pounds at a lege she attended was right for her after all. She
height of 5 feet 5 inches, when a healthy weight was sleeping less well and felt cold much of the
for a small-framed woman her height is about day. The night Rachel returned home for spring
120 pounds. Rachel explained that she had been break, her parents asked her to step on the bath-
a successful student and field hockey player in room scale. Rachel was surprised to learn that her
high school. After deciding not to play field hockey weight had fallen to 104 pounds, and she agreed
in college, she began running several mornings to a visit to her pediatrician, who found no evi-
each week during the summer and "cut out junk dence of a medical illness and recommended a
food" to protect herself from gaining "that fresh- psychiatric consultation. (Adapted from Evelyn
man 15:' Rachel lost a few pounds that summer Attia and B. Timothy Walsh (2007). "Anorexia
and received compliments from friends and fam- Nervosa," American Journal of Psychiatry, 164.
ily for looking so "fit:' She reported feeling more Reprinted with permission from the American
confident and ready for college than she had ex- Journal of Psychiatry. Copyright 2007 American
pected. Once she began school, Rachel increased Psychiatric Association.)
her running to daily, often skipped breakfast in
order to get to class on time, and selected from Does Rachel have an eating disorder? What crite-
the salad bar for her lunch and dinner. She worked ria does she meet? Are there any criteria that she
hard in school and made the dean's list the first doesn't meet? (Discussion appears at the end of
semester. this chapter.}
UNDERSTANDING EATING for one type of eating disorder (Bulik et al., 2010). A
genetic risk for developing eating disorders appears
DISORDERS to interact with the biological changes of puberty to
A number of biological, sociocultural, and psycho- contribute to the onset of eating disorders in girls,
logical factors have been implicated in the devel- but not in boys (Klump et al., 2012). That is, in girls
opment of the eating disorders. As we discuss at changes in hormones at puberty may activate a ge-
the end of this chapter, it is likely that it takes an netic risk for the eating disorders. The biological
accumulation of several of these factors for any in- changes of puberty are accompanied by changes in
dividual to develop an eating disorder. In this sec- girls' social worlds that likely contribute to their risk
tion, however, we consider each factor separately. for eating disorders, as we discuss below.
Much of the current research on the biological
causes of the eating disorders focuses on those
Biolog ical Factors bodily systems that regulate appetite, hunger, sati-
Like most psychological disorders, ety, initiation of eating, and cessation of eating (Trace
anorexia nervosa, bulimia ner- et al., 2013; Keel et al., 2012). The hypothalamus plays
vosa, and binge-eating disorder a central role in regulating eating (Berthoud &
tend to run in families (Trace, Morrison, 2008). It receives messages about the
Baker, Penas-Lled6, & Bulik, 2013). body's recent food consumption and nutrient level
A study of more than 30,000 twins and sends messages to cease eating when the body's
found a heritability of 56 percent nutritional needs are met. These messages are car-
for anorexia nervosa (Bulik et al., ried by a variety of neurotransmitters, including
2006). A twin study of binge-eating norepinephrine, serotonin, and dopamine, and by a ~
The hypothalamus plays a central role disorder found a heritability of number of hormones, including cortisol and insulin.
in regulating eating and is implicated 41 percent (Bulik, Sullivan, & Disordered eating behavior might be caused by
in the disordered eating behaviors
Kendler, 2003). Genes appear to imbalances in or dysregulation of any of the neu-
c haracteristic of bulimia nervosa and
anorexia nervosa . carry a general risk for eating dis- rochemicals involved in this system or by struc-
orders rather than a specific risk tural or functional problems in the hypothalamus.
For example, disruptions of tills system could cause The Thin Ideal and Body Dissatisfaction
the individual to have trouble detecting hunger The ideal shape for women in many developed
accurately or to stop eating when full, both of which nations has become thlnner and thinner since the
are characteristics of people with eating disorders. mid-twentieth century (Keel & Klump, 2003). Models
People with anorexia nervosa show lowered in fashion magazines, winners of the Miss America
functioning of the hypothalamus and abnormali- and Miss Universe pageants, and Barbie dolls-icons
ties in the levels of several hormones important to of beauty for women- all have been getting thlnner
its functioning, including serotonin and dopamine (Figure 12.2; Gamer & Garfinkel, 1980; Wiseman,
(Attia & Walsh, 2007; Lock et al., 2011). Whether Gray, Mosimann, &Ahrens, 1992). Also, as discussed
these disruptions are causes or consequences of in the Extraordinary People feature, the average
the self-starvation of anorexia is unclear. Some model in a fashion magazine these days is pencil-
studies have found that people with anorexia con- thin, with a figure that is physically unattainable by
tinue to show abnormalities in hypothalamic and most adult women. Several studies show that women
hormonal functioning and neurotransmitter levels who intemalize the thin ideal promoted in the media
after they gain some weight, whereas other studies are at risk for eating disorders (see meta-analysis by
have found that these abnormalities disappear Stice, 2002).
with weight gain (Polivy & Herman, 2002). Both anorexia nervosa and bulimia nervosa
Many people with bulimia show abnormalities are much more common in females than in males,
in the systems regulating the neurotransmitter sero- perhaps because thinness is more valued and more
tonin (Keel et al., 2012). Deficiencies in serotonin strongly encouraged in females than in males. For
might lead the body to crave carbohydrates, example, studies of popular women's and men's
and people with bulimia often binge on high- magazines find 10 times more diet articles in wom-
carbohydrate foods. These people may then engage en's magazines than in men's magazines (Andersen
in self-induced vomiting or some other type of & DiDomenico, 1992; Nemeroff, Stein, Diehl, &
purge in order to avoid gaining weight from Smilack, 1994). As discussed in the Extraordinary
carbohydrates. People feature, the more exposure young females
Thus, a number of biological abnormalities have to media pressure to be thin, the more dissat-
have been found to be associated with anorexia isfied they become with their bodies (Grabe et al.,
nervosa and bulimia nervosa. These abnormalities 2008; Groesz et al., 2002). Body dissatisfaction fed
could contribute to disordered eating behavior by by pressures to be thin is one of the strongest pre-
causing the body to crave certain foods or by mak- dictors of risk for the development of eating disor-
ing it difficult for a person to read the body's signals ders in young women. In one longitudinal study of
regarding hunger and fullness . Exactly why people high school girls, 24 percent of those with the
with eating disorders also develop a distorted body greatest body dissatisfaction developed a diagnos-
image and the other cognitive and emotional probable eating disorder, compared to 6 percent of
lems seen in the eating disorders is not clear. those with less body dissatisfaction (Stice, Marti, &
Durant, 2011).
Sociocultural and Social pressure to be thin has been taken to
Psychological Factors new extremes with reality TV shows in which indi-
viduals undergo cosmetic surgery "makeovers."
Societal pressures to be thin and attractive proba- These shows have been very popular with adults
bly play a role in the eating disorders, although, as under age 50. One study found that college-age
noted earlier, many people who are exposed to women who viewed episodes of one of these
these pressures do not develop an eating disorder. shows, The Swan, reported greater perceptions of
Certain psychological factors may also need to pressures to be thin and greater beliefs that they
come into play for an eating disorder to develop. could control their body's appearance than women
who viewed a reality TV show about home im-
Social Pressures and Cultural Norms provement (Mazzeo, Trace, Mitchell, & Cow, 2007).
Psychologists have linked the historical and cross- The NBC show The Biggest Loser has been criticized
cultural differences in the prevalence of the eating for encouraging contestants and viewers to use
disorders to differences in the standards of beauty extreme measures, including starvation and exces-
for women at different historical times and in dif- sive exercise, to lose weight at an unhealthy pace
ferent cultures (Gamer & Garfinkel, 1980; McCarthy, (Wyatt, 2009).
1990; Sohal & Stunkard, 1989). In addition, certain People can avoid some pressures to conform to
groups within a culture, such as athletes, may have the ideal of thinness by avoiding fashion magazines
standards for appearance that put them at greater and other media depictions. People can't completely
risk for developing an eating disorder. avoid their friends, however, and sometimes peers
Our Changing Beauty Standards. In the period from 1959 to 1978, the average
weight of women who were Playboy centerfolds or who won the Miss America
FIGURE 12.2
pageant became lower and lower, relative to what would be expected for women
of their height.
92 .-----------------------------------------------------------------
- Playboy centerfolds
91 4-- \------------------------------------------------------------- ------
- Miss America winners
...,
_.<::
"'
-~ 87~~L_------~~~------~r-~----f-~~-~--~---~~~------~.-----------------
-o
Q)
t
~ 86 ~------------------------~~--~r-~~~---t-,t---i-------ir.t----------------
....~
0
81 ~---------------------------------------------------------L--------------
80
1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987
Source: Wiseman et al. , 1992.
are the most effective carriers of appearance-related

messages. Stice and colleagues had women college
students talk to another college woman they
thought was simply another student but actually
was an accomplice in the study (Stice, Maxfield, &
Wells, 2003). This accomplice was a thin, attractive
19-year-old woman. In the pressure condition, the
accomplice complained about how dissatisfied she
was with her weight and discussed her extreme
exercise routine and restrictive diet. In the neutral
condition, the accomplice talked about classes she
was currently taking and her plans for the week-
end. The target women in the pressure condition
became significantly more dissatisfied with their
bodies after talking with the thin accomplice about ~
her weight concerns. In contrast, the women in the
The TV show The Biggest Loser may encourage people to use extreme.
neutral condition did not become more dissatisfied
dangerous measures to lose weight. with their bodies after talking with the same woman
about matters unrelated to weight or dieting.
A study of adolescent girls in Fiji demon- see also Krentz & Warschburger, 2011). Many of the
strated the dual influences of peers and the media women athletes with eating disorders reported
on eating behavior (Becker et al., 2011). In Fiji's in- feeling that the physical changes of puberty had
digenous population, access to popular media decreased their competitive edge. They had started
(television and the Internet) varies greatly from dieting severely to try to maintain their prepubes-
one region to another. Girls who had more direct cent figure . The case of Heidi, described by her ther-
media exposure had more eating disorder symp- apist, illustrates several of these triggers.
toms, but the strongest predictor of symptoms was .... .' - . .
the amount of media exposure the girls' friends
had. Those girls whose friends watched the most CASE STUDY
Heidi arrived in my office
television and had the most Internet access had the
after gymnastics practice. Blond and pretty, she
highest scores on a measure of eating pathology.
was dressed in a shiny red -and-white warm-up
When a girl is barraged by messages promoting
suit. We talked about gymnastics, which Heidi
the thin ideal in the media and these messages are
had been involved in since she was 6. At that
reinforced in her peer network, her risk of devel-
time, she was selected to train with the univer-
oping an eating disorder increases significantly.
sity coaches. Now she trained 4 hours a day,
Athletes and Eating Disorders One group 6 days a week. She didn't expect to make an
with additional pressure to maintain a specific Olympic team, but she anticipated a scholarship
weight and body shape is athletes, especially those to a Big Ten Conference school.
participating in sports in which weight is consid- Heidi glowed when she talked about gym-
ered an important factor in competitiveness, such as nastics, but I noticed her eyes were red and she
gymnastics, ice skating, dancing, horse racing, had a small scar on the index finger of her right
wrestling, and bodybuilding (Smolak, Murnen, & hand . (When a finger is repeatedly stuck down
Ruble, 2000). Researchers in Norway assessed all the throat, it can be scarred by the acids in the
522 elite female athletes between ages 12 and 35 for mouth .) I wasn 't surprised when she said she
the presence of eating disorders. They found that was coming in for help with bulimia.
those participating in sports classified as "aesthetic" Heidi said, "I've had this problem for two
or "weight-dependent," including diving, figure years, but lately it's affecting my gymnastics.
skating, gymnastics, dance, judo, karate, and wres- I am too weak, particularly on the vault, which
tling, were most likely to have anorexia nervosa or requires strength . It's hard to concentrate.
bulimia nervosa (Table 12.5; Sundgot-Borgen, 1994; " I blame my training for my eating disorder;'
Heidi continued. "Our coach has weekly weigh-
ins where we count each other's ribs. If they are
TABLE 12.5 Rates of Eating Disorders
hard to count we're in trouble:'
in Elite Women Athletes
I clucked in disapproval. Heidi explained that
since puberty she had had trouble keeping her
Sports that emphasize weight are especially likely
weight down. After meals, she was nervous that
to encourage eating disorders.
she'd eaten too much. She counted calories; she
Percentage w ith was hungry but afraid to eat. In class she pinched
Sport an Eating Disorder the fat on her side and freaked out. The first time
she vomited was after a gymnastics meet. Coach
Aesthetic sports (e.g.,
took her and the other gymnasts to a steak
figure skating, gymnastics) 35%
house. Heidi ordered a double cheeseburger and
Weight-depende nt sports onion rings. After she ate, she obsessed about
(e.g., judo, wrestling) 29
the weigh-in the next day, so she decided, just
Endurance sports
this once, to get rid of her meal. She slipped into
(e.g., cycling, runn ing,
the restaurant bathroom and threw up.
swimming) 20
She blushed. "It was harder than you would
Technical sports (e.g ., golf,
think. My body resisted, but I was able to do it. It
high jumping) 14
was so gross that I thought, 'I'll never do that again;
Ball game sports (e .g.,
but a week later I did. At first it was weekly, then
volleyball, soccer) 12
twice a week. Now it's almost every day. My dentist
said that acid is eating away the enamel of my
So urce : Data from Sundgot-Borgen, 1994.
teeth:' (Adapted from Pipher, 1994, pp. 165-168)
Among men, body- independent exercisers still had higher rates of

building is an increasingly some eating-disorder behaviors than did women
popular sport, but body- who did not exercise (Holm-Denoma et al., 2009).
builders routinely have However, a meta-analysis of studies concluded
substantial weight fluctua- that, although elite athletes do show increased rates
tions as they shape their of eating disorders, nonelite athletes-particularly
bodies for competition and those participating in sports in which thinness is not
then binge in the off-season. emphasized-showed lower rates of eating prob-
Male body builders tend to lems than nonathletes (Smolak et al., 2000).
have a pattern of eating and
exercising as obsessive as Cognitive Factors
that of men with eating When the body dissatisfaction that comes from so-
disorders, but with a focus cial pressures to achieve a certain shape or weight
on gaining muscle rather is combined with low self-esteem and perfection-
than on losing fat (Morgan, ism, the result is a toxic mix of cognitive factors that
2012). In one study of male strongly predict the development of an eating dis-
bodybuilders, 46 percent re- order (Fairburn et al., 2008; Vohs, Bardone, Joiner,
ported bingeing after most & Abramson, 1999; Vohs et al., 2001). Women who
competitions, and 85 per- feel they need a perfect body, are dissatisfied with
cent reported gaining sig- their body, and have low self-esteem will engage
nificant weight (an average in maladaptive strategies to control their weight,
of 15 pounds) in the off- including excessive dieting and purging.
season. Then they dieted In addition, people with eating disorders tend
to prepare for competi- to be more concerned with the opinions of others
tion, losing an average of and are more conforming to others' wishes, per-
Some people with eating disorders may 14 pounds. In a parallel haps making them more susceptible to social pres-
control their weight through excessive exercise. study of female body- sures to be thin (Fairburn et al., 2008; Wade et al.,
builders and weight lifters, 2008). People with eating disorders tend to have a
42 percent reported having been anorexic at some dichotomous thinking style, judging things as ei-
time in their life, 67 percent were terrified of being ther all good or all bad. For example, if they eat one
fat, and 58 percent were obsessed with food cookie, they may think that they have blown their
(Anderson, Bartlett, Morgan, & Brownell, 1995). A diet and might as well eat the whole box of cookies.
study of female weight lifters found that they often They will say that they cannot break their rigid eat-
abused ephedrine, a stimulant that helps reduce ing routines or they will completely lose control
body fat, particularly if they had symptoms of an over their eating. They obsess over their eating rou-
eating disorder (Gruber & Pope, 1998). tines and plan their days around these routines,
There is mixed evidence as to whether amateur down to the smallest detail (Abramson et al., 2006).
athletics contributes to eating-disorder behaviors. Women with eating disorders may be con-
One study of women college students found cerned with body size at an unconscious level
that varsity athletes showed the highest rates of (see Keel et al., 2012). Women with and without
eating-disorder behaviors, but club athletes and symptoms of bulimia were shown photos of women
THAT'S WHAT I ~1\ICH 15 IOOR&E, TilE WEIGHT MA'{ NOT

MTI~ TilE PIE se KEReotrArN .. BUT
OR WIISTIP.K7 lliE THE LOGIC ICZ,.
WttOLE 0A'{ THINK-
100 ABOUT IT?!!
CATHY 1983 Cathy Guisewite. Reprinted with permission of Universal Uclick. All rights reserved.
who varied in terms of both their body size and the or an anxiety disorder over time and also are more
emotions shown on their faces. The participants likely to continue to engage in severe binge eating,
were not told that these were the critical dimensions compared to women with the dieting subtype
along which the photos varied. Women with bu- (Stice & Fairburn, 2003; Stice, Bohon, et al., 2008).
limic symptoms were more likely than the other Over an 8-year follow-up, 80 percent of the women
women in the study to attend to information about with the depressive subtype developed major de-
body size rather than to information about facial pression. Among those women who suffered both
emotion and to classify the photos on the basis of elevated depressive symptoms and body dissatis-
body size rather than facial emotion (Viken et al., faction, 43 percent developed a diagnosable eating
2002). Thus, women who show bulimic symptoms disorder (Stice, Marti, & Durant, 2011).
unconsciously organize their perceptions of the
world around body size more so than do women Family Dynamics
who do not show significant bulimic symptoms. Hilde Bruch (1973, 1982), a pioneer in the study of
eating disorders, argued that anorexia nervosa of-
Emotion Regulation Difficulties ten occurs in girls who have been unusually "good
Eating-disorder behaviors may sometimes serve girls" - high achievers, dutiful and compliant
as maladaptive strategies for dealing with painful daughters who are always trying to please their
emotions (Fairburn et al., 2009; Stice, Agras, et al., parents and others by being "perfect." These girls
2001; Svaldi, Griepenstroh, Tuschen-Caffier, & tend to have parents who are overinvested in their
Ehring, 2012) . Individuals suffering depressive daughters' compliance and achievements, are
symptoms or, more generally, negative affect are at overcontrolling, and will not allow the expression
risk for the development of anorexic and bulimic of feelings, especially negative feelings (see also
symptoms (Bulik, 2005; Stice, Burton, & Shaw, Minuchin et al., 1978). As a result, the daughters
2004; Stice, Presnell, & Spangler, 2002). Stice and do not learn to identify and accept their own feel-
colleagues (2002) followed a group of adolescent ings and desires. Instead, they learn to monitor
girls over a period of 2 years and found that girls closely the needs and desires of others and to com-
~ who engaged in emotional eating-eating when ply with others' demands, as can be seen in the
they felt distressed in an attempt to feel better- case of Renee and her family.
were significantly more likely to develop chronic
binge eating over those 2 years.
Stice and colleagues have identified two sub- CASE STUDY
types of disordered eating patterns involving binge Renee is a 16-year-old with
eating (Stice et al., 2002; Stice, Bohon, Marti, & anorexia nervosa. Her parents are highly edu-
Fischer, 2008). One subtype is connected to exces- cated and very successful, having spent most of
sive attempts to lose weight. Women with this diet- their careers in the diplomatic corps. Renee, her
ing subtype are greatly concerned about their body two brothers, and her parents are "very close, as
shape and size and try their best to maintain a strict are many families in the diplomatic corps, be-
low-calorie diet, but they frequently abandon their cause we move so much;' although the daily care
regimen and engage in binge eating. They then of- of the children has always been left to nannies.
ten use vomiting or exercise to try to purge them- The children had to follow strict rules for appro-
selves of the food or of the weight it puts on their priate conduct, both in and outside the home.
bodies. The other subtype is the depressive subtype. These rules were driven partly by the require-
Women with this subtype also are concerned about ments of the families of diplomats to "be on their
their weight and body size, but they are plagued by best behavior" in their host country and partly by
feelings of depression and low self-esteem and of- Renee's parents' very conservative religious be-
ten eat to quell these feelings. liefs. Renee, as the only daughter in the family,
Women with the depressive subtype of disor- always had to behave as "a proper lady" to coun-
dered eating patterns suffer greater social and psy- teract the stereotype of American girls as brash
chological consequences over time than do women and sex ually promiscuous. All the children were
with the dieting subtype (Stice et al., 2002; Stice, required to act mature beyond their years, con-
Bohon, et al., 2008). They face more difficulties in trolling any emotional outbursts, accepting de-
their relationships with family and friends; are feats and disappointments without complaint,
more likely to suffer significant psychiatric disor- and happily picking up and moving every couple
ders, such as anxiety disorders; and are less likely of years when their parents were reassigned to
to respond well to treatment. Longitudinal studies another country.
find that women with the depressive subtype are (continued)
more likely to be diagnosed with major depression
rage against their parents for their overcontrol and

Renee's anorex ic behaviors began when her become angry, defiant, and distrustful. They also
parents announced they were leaving the diplo- discover that controlling their food intake both
matic corps to return to the United States. Renee gives them a sense of control over their life and
had grown very fond of their last post in Europe, elicits concern from their parents. Their rigid con-
because she had finally found a group of friends trol of their body provides a sense of power over
that she liked and of whom her parents approved the self and the family that they have never had
and she liked her school. She had always done before. It also provides a way of avoiding peer
well in school but often had hated the harshly relationships-the girl dons the persona of an
strict teachers. In her present school, she felt ac- anorexic, presenting herself as sickly, distant,
cepted by her teachers as well as challenged by untouchable, and superior in her self-control.
the work. When Renee told her parents she Research has confirmed that the families of girls
would like to finish her last year of high school in with eating disorders have high levels of conflict,
this school rather than go to the United States discourage the expression of negative emotions,
with them, they flatly refused to even consider it. and emphasize control and perfectionism (Polivy &
Renee tried to talk with her parents, suggesting Herman, 2002; Wade, Gillespie, & Martin, 2007).
she stay with the family of one of her friends, Several of these negative characteristics are also
who was willing to have her, but her parents cut prevalent in the families of children with depression,
her off and told her they would not discuss the anxiety disorders, and several other forms of psy-
idea further. Renee became sullen and with- chopathology. What may distinguish families in
drawn and stopped eating shortly after the fam- which anorexia nervosa or bulimia nervosa devel-
ily arrived in the United States. ops is that the mothers in these families believe their
daughters should lose more weight, criticize their
daughters' weight, and are themselves more likely
to show disordered eating patterns (Hill & Franklin,
One important task of adolescence is separa- 1998). One longitudinal study showed that eating
tion and individuation from one's family. Bruch and weight-related concerns in 10-year-old children
argues that girls from overcontrolling families were predicted by the amount of conflict over eat-
deeply fear separation because they have not de- ing habits and issues of control during mealtimes
veloped the ability to act and think independently when the children were 5 years old (Stein et al.,
of their family. They also fear involvement with 2006). In addition, a lack of awareness of their bodily
peers, especially sexual involvement, because they sensations may allow some girls in these families to
neither understand their feelings nor trust their ignore even the most severe hunger pangs (Leon,
judgment. Yet at some level they recognize their Fulkerson, Perry, & Early-Zald, 1995). Girls from
need to separate from their family. They harbor these troubled families who cannot completely
ignore their hunger may fall into the binge/purge
type of anorexia nervosa or into bulimia nervosa.
Studies of adult women with binge-eating dis-
order suggest that the combination of low parental
warmth and high parental demands or control
seems to distinguish girls and women who develop
binge-eating disorder from those who develop
other forms of psychopathology (Striegel-Moore
et al., 2005; Wilfley, Pike, & Striegel-Moore, 1997). An-
other family characteristic that distinguishes people
with binge-eating disorder from individuals with
other mental disorders is a history of binge eating
among other family members (Striegel-Moore et al.,
2005). Thus, individuals who develop the tendency
to binge may come from families that modeled and
reinforced bingeing behavior.
Unfortunately, the majority of studies of the
families and personality characteristics associated
with eating disorders have compared people who
One theory of eating disorders emphasizes the role of overcontrolling families. already have an eating disorder with those who do
not (Polivy & Herman, 2002). As a result, we do not
Treatments for Eating Disorders 357
know to what extent these family and personality continue to have self-esteem issues, family prob-
characteristics actually are causes of eating disor- lems, and periods of depression and anxiety.
ders. The controlling nature of parents' behaviors Cognitive-behavioral therapies are the most re-
toward their child may be a consequence as well as searched treatment for anorexia nervosa (Yu et al.,
a cause of the disorder, with parents exerting con- 2011). The client's overvaluation of thinness is con-
trol in order to try to save their child's life. fronted, and rewards are made contingent on the
person's gaining weight. If the client is hospitalized,
certain privileges in the hospital are used as rewards,
TREATMENTS FOR EATING such as going outside the hospital for a shopping
DISORDERS trip or receiving family visits (assuming all parties
In this section, we discuss psychotherapies and agree to this plan). The client also may be taught
drug treatments for people with eating disorders. relaxation techniques to use as she becomes ex-
There are many more studies of treatments for tremely anxious about ingesting food . Random-
bulimia nervosa and binge-eating disorder than for ized clinical trials find that cognitive-behavioral
anorexia nervosa, in part because the prevalence of therapy can lead to weight gains and reductions
anorexia nervosa is low. in symptoms, although a substantial percentage of
patients drop out of therapy or return to anorexic
Psychotherapy for Anorexia behaviors over time (Wade & Watson, 2012).
In family therapy, the person with anorexia and
Nervosa her family are treated as a unit. The best-studied
It can be difficult to engage people with anorexia family therapy is the Maudsley model (Lock, le
nervosa in psychotherapy. Because they so highly Grange, Agras, & Dare, 2001). The intervention in-
value the thinness they have achieved and be- volves 10 to 20 sessions over 6 to 12 months. Parents
lieve they must maintain absolute control over are coached to take control of their child's eating and
their behaviors, people with anorexia nervosa can weight. As the therapy progresses, the child's au-
be resistant to therapy in general, and to thera- tonomy is linked explicitly to the resolution of the
pists' attempts to change their behaviors or atti- eating disorder. There is evidence that family ther-
tudes in particular. Regardless of the type of apy can be successful in treating girls with anorexia
psychotherapy a therapist uses with a client with nervosa (Lock, Agras, Bryson, & Kraemer, 2005;
anorexia, he or she must do much work to win the RieneckeHoste, Celio Doyle, & le Grange, 2012).
client's trust and encourage participation in the
therapy and to maintain this trust and participa- Psychotherapy for Bu lim ia
tion as the client begins to regain the dreaded Nervosa and Binge-Eating
weight (Wade & Watson, 2012).
Disorder
Winning the trust of someone with anorexia
can be especially difficult if the therapist is forced Cognitive-behavioral therapy (CBT) has received
to hospitalize the client because she has lost so the most empirical support for treating bulimia
much weight that her life is in danger. However, nervosa (Fairburn, 2005; Wade & Watson, 2012).
hospitalization and forced refeeding sometimes CBT is based on the view that the extreme con-
are necessary (Olmsted et al., 2010). Because peo- cerns about shape and weight are the central fea-
ple with anorexia nervosa typically do not seek tures of the disorder (Fairburn et al., 2008). The
treatment themselves, often they do not come to therapist teaches the client to monitor the cogni-
the attention of a therapist until they are so mal- tions that accompany her eating, particularly the
nourished that they have a medical crisis, such as a binge episodes and purging episodes. Then the
cardiac problem, or until their families fear for therapist helps the client confront these cognitions
their life. During hospitalization, the therapist will and develop more adaptive attitudes toward
try to engage the client in facing and solving the weight and body shape. An interchange between a
psychological issues causing her to starve herself. therapist and a client might go like this:
Psychotherapy can help many people with an-
Therapist: What were you thinking just before
orexia, particularly adolescents, but it typically is a
you began to binge?
long process, often marked by many setbacks
(Wade & Watson, 2012). Along the way, many peo- Client: I was thinking that I felt really upset
ple with anorexia who have an initial period of and sad about having no social life. I wanted
recovery- with restoration of normal weight and to eat just to feel better.
healthy eating patterns-relapse into bulimic or Therapist: And as you were eating, what were
anorexic behaviors (Carteret al., 2012). They often you thinking?
Client: I was thinking that the ice cream tasted thoughts she has about these meals and about the
really good, that it was making me feel good. possibility of gaining weight. Cognitive-behavioral
But I was also thinking that I shouldn't be eat- therapy for bulimia usually lasts about 3 to 6 months
ing this, that I'm bingeing again. But then I and involves 10 to 20 sessions.
thought that my life is such a wreck that I de- Controlled studies of the efficacy of cognitive-
serve to eat what I want to make me feel better. behavioral therapy for bulimia find that about half
Therapist: And what were you thinking after the clients completely stop the binge / purge cycle
you finished the binge? (Fairburn, 2005; Shapiro et al., 2007). Clients under-
going this therapy also show a decrease in depres-
Client : That I was a failure, a blimp, that I have
sion and anxiety, an increase in social functioning,
no control, that this therapy isn't working. and a lessening of concern about dieting and weight.
Therapist: Okay, let's go back to the beginning. Cognitive-behavioral therapy is more effective than
You said you wanted to eat because you drug therapies in producing complete cessation of
thought it would make you feel better. Did it? binge eating and purging and in preventing relapse
Client: Well, as I said, the ice cream tasted good over the long term (Fairburn, 2005). Expanded
and it felt good to indulge myself. cognitive-behavioral therapies that also address
emotion-regulation difficulties are especially effec-
Therapist: But in the long run, did bingeing
tive in people with a combination of eating disor-
make you feel better?
ders and depression (Fairburn et al., 2009).
Client: Of course not. I felt terrible afterward. Other studies of the treatment of bulimia have
Therapist: Can you think of anything you compared cognitive-behavioral therapy (CBT) with
might say to yourself the next time you get three other types of psychotherapy: interpersonal
into such a state, when you want to eat in or- therapy (IPT), supportive-expressive psychody-
der to make yourself feel better? namic therapy, and behavioral therapy without a
Client: I could remind myself that I'll feel better focus on cognitions (Agras et al., 2000; Fairburn,
only for a little while, but then I'll feel terrible. Jones, Peveler, & Carr, 1991; Fairburn et al., 1995;
Gamer, Rockert, Davis, & Gamer, 1993; Wilson
Therapist: How likely do you think it is that
et al., 1999, 2002). In interpersonal therapy, the client
you'll remember to say this to yourself?
and the therapist discuss interpersonal problems re-
Client: Not very likely. lated to the client's eating disorder, and the thera-
Therapist: Is there any way to increase the like- pist works actively with the client to develop
lihood? strategies to solve these problems. In supportive-
Client: Well, I guess I could write it on a card expressive psychodynamic therapy, the therapist
or something and put the card near my also encourages the client to talk about problems
refrigerator. related to the eating disorder-especially interper-
sonal problems-but in a highly nondirective man-
Therapist: That's a pretty good idea. What else
ner. In behavioral therapy, the client is taught how
could you do to prevent yourself from eating to monitor her food intake, is reinforced for intro-
when you feel upset? What other things could ducing avoided foods into her diet, and is taught
you do to relieve your upset, other than eat? coping techniques for avoiding bingeing. In the
Client: I could call my friend Keisha and talk studies, all the therapies resulted in significant im-
about how I feel. Or I could go for a walk- provement in the clients' eating behaviors and emo-
someplace away from food- like up in the tional well-being, but the cognitive-behavioral and
hills, where it's so pretty. Walking up there al- interpersonal therapy clients showed the greatest
ways makes me feel better. and most enduring improvements. Comparisons of
Therapist: Those are really good ideas. It's im- CBT and IPT suggest that CBT is significantly more
portant to have a variety of things you can do, effective than IPT in treating bulimia and works
other than eat, to relieve bad moods. more quickly, with substantial improvement being
shown by 3 to 6 weeks into treatment with CBT
The behavioral components of this therapy in- (Agras et al., 2000; Fairburn, 2005; Wilson et al.,
volve introducing forbidden foods (such as bread) 1999, 2002). CBT and IPT appear to be equally effec-
back into the client's diet and helping the client tive in preventing relapse in 1- and 6-year follow-
confront her irrational thoughts about these foods, ups (Agras et al., 2000).
such as "If I have just one doughnut, I'm inevitably For binge-eating disorder, cognitive-
going to binge." Similarly, the client is taught to eat behavioral therapy has been shown to be
three healthy meals a day and to challenge the more effective than other psychotherapies or
antidepressant medications (Vocks et al., 2010). binge eating but do not tend to reduce concerns
CBT reduces binges as well as overconcern with about body shape or weight (Flament et al., 2012;
weight, shape, and eating in people with binge- Reas & Grilo, 2008; Vocks et al., 2010).
eating disorder.
CHAPTER INTEGRATION
Biological Therapies Experts generally have suggested that biological,
The selective serotonin reuptake inhibitors (SSRis), psychological, and social factors interact to cause
such as fluoxetine (trade name Prozac), have been the eating disorders (Agras & Kirkley, 1986; Gamer
the focus of much research on biological treat- & Garfinkel, 1985; Polivy & Herman,2002; Striegel-
ments for bulimia nervosa. These drugs appear to Moore, 1993). Any one factor alone may not be
reduce binge-eating and purging behaviors, but enough to lead someone to develop anorexia ner-
often they fail to restore the individual to normal vosa or bulimia nervosa, but combined they may
eating habits (see meta-analyses by Flament, do so (Figure 12.3).
Bissada, & Spettigue, 2012; Reas & Grilo, 2008). First, societal pressures for thinness clearly
Adding cognitive-behavioral therapy to antide- provide a potent influence on the development of
pressant treatment increases rates of recovery unhealthy attitudes toward eating, especially for
(Fairburn, 2005). Antidepressants are often used to women. If these pressures were simply toward
treat anorexia nervosa, and they result in reduc- achieving a healthy weight and maintaining fitness,
tion of symptoms in half the studies conducted they would not be so dangerous. However, the ideal
(see Flament et al., 2012). Olanzapine, an atypical weight for women promoted by beauty symbols in
antipsychotic (see Chapter 8), leads to increases in developed countries is much lower than that con-
weight in people with anorexia nervosa (see Fla- sidered healthy and normal for the average woman,
ment et al., 2012). Meta-analyses of medications and thus women may develop a negative body im-
for binge eating found that a number of drugs, in- age. This leads them to engage in excessive dieting.
cluding the SSRis, antiepileptic medications (such Unfortunately, excessive dieting sets up conditions
as topiramate), and obesity medications (such as for impulsive binge eating, which leads to negative
orlistat), all are better than a placebo in reducing emotions and even lower self-esteem.
FIGURE 12.3 Multiple Pathways into the Eating Disorders
Social pressures toward Overvaluation of appearance,

Genetic predisposition ~~ perfectionism, Low
extreme thin ness
self-esteem, etc.
---- ~
L Negative body image Anxiety and depression
l Excessive dieting
If successful in Losing
weight, reinforced by Compensatory behaviors
society and sense of control (purging, excessive exercise)
Second, biological factors may interact with characteristics are more likely to develop in chil-
these societal pressures to make some people more dren whose parents are lacking in affection and
likely than others to develop an eating disorder. nurturance and who at the same time are control-
People who develop eating disorders may have a ling and demanding of perfection.
genetic predisposition to these disorders or to dys- Whatever pathway an individual takes into
regulation of the hormone or neurotransmitter sys- the eating disorders, these behaviors tend to be
tem. Exactly how the genetic vulnerabilities lead to maintained once they begin. The excessive concem
the symptoms of eating disorders is unclear, but over weight among people with anorexia or buli-
they may contribute to an ability to diet excessively. mia nervosa is constantly reinforced by societal
Another biological factor that may predispose some images, and any weight loss they do achieve is re-
people to acquiesce to the pressures to diet and to be inforced by peers and family. People with anorexia
thin is a tendency toward anxiety or mild depres- also may be reinforced by the sense of control they
sion. Many people with eating disorders, especially gain over their lives by highly restrictive dieting.
people with bulimia nervosa, are often depressed People with bulimia nervosa and binge-eating dis-
and eat impulsively in response to their moods. Al- order may greatly desire control but are unable to
though problems in mood in people with an eating maintain it, so they fall into binge eating to escape
disorder may be the result of environmental cir- negative emotions. The compensatory behaviors
cumstances or of the stresses of the disorder, they of bulimia nervosa help the individual regain some
also may have a biological origin in some people. sense of control, however fragile, and thereby are
Third, personality factors may interact with reinforced.
societal pressures to be thin and/ or with the bio- Thus, it may take a mixture of these factors,
logical predispositions described to lead some rather than any single factor, to lead someone to
people to develop an eating disorder. Perfection- develop a diagnosable eating disorder. Once the
ism, aU-or-nothing thinking, and low self-esteem disorder sets in, however, it tends to be rein-
may make people more likely to engage in ex- forced and perpetuated. Note also that many of
treme measures to control their weight in pursuit the same factors contribute to each different eat-
of an ideal of attractiveness. These personality ing disorder. ~
SHADES OF GRAY DISCUSSION (review p. 350)
Rachel's eating and exercise behaviors are com- DSM-IV diagnosis of eating disorder not other-
mon for college women and, to some extent, are wise specified because she has significant symp-
in line with recommendations to cut out junk food, toms that nonetheless do not meet the criteria
eat more fruits and vegetables, and get more exer- for anorexia nervosa, bulimia nervosa, or binge-
cise. Yet Rachel's weight has dropped to a level eating disorder. The DSM-5 does not require ces-
that is well below what is considered healthy for sation of menses for the diagnosis of anorexia
her height. She also has become obsessive about nervosa, so Rachel's symptoms now would prob-
her exercise routine, her mood is chronically low, ably qualify for the diagnosis. Rachel's case illus-
and she is losing interest in school. trates questions that have been debated over the
Prior to the DSM-5, Rachel would not have last few decades about whether the diagnostic cri-
been diagnosed with anorexia nervosa because teria for the eating disorders are too strict or
there is no evidence that her menstrual periods whether it would be better to avoid applying a
have stopped . Rachel might have received a psychiatric diagnosis to such common behavior.
THINK CRITICALLY
Given what you know about the contributors to eat- prevalence of these disorders among students?
ing disorders, what kind of prevention program (Discussion appears on p. 484 at the back of this
might you design for your school to try to reduce the book.)
Key Terms 361
CHAPTER SUMMARY
The eati ng disorders include an orexi a nerv osa, Obesity is defined as a body mass index of 30 or
bulimia nervosa, and binge-eat ing disorder. more . Obesity rates have skyrocketed in recent
Anorexia nervosa is characte rized by self - years, largely due to increases in the intake of
starvation, a distorted body image, intense f ears hig h-fat, low-n utrient food and decreases in
of becoming fat, and often amenorrhea. People physi ca l activity. Treatments for obesity include
with the restricting type of anorexia ne rvosa re- comme rcial weight-loss programs, medications,
fuse to eat and/or engage in excessive exe rcise low-cal o rie diets, and bariatric surgery.
in order to prevent weight gain. People w ith the The biologica l factors implicated in the develop-
binge/purge type period ically en gage in bi ng ein g ment of the eat ing disorders include genetics,
and then purge to prevent weight ga in. the dysregulation of hormone and neurotrans-
The lifetime prevalence of anorexia is und er mitter systems, and generally lower functioning
1 percent, with 90 to 95 percent of cases seen in t he hypothalamus.
in females. Anorexia nervosa usually beg ins Sociocultural theorists have attributed the eating
in adolescence, and the cou rse is variable f rom disorders to pressures to be thin, especially in
one person to another. It is a very dan ge rou s developed nations.
disorder with a relatively high deat h rate f rom Eating d isorders may develop in some people as
complications of self-starvation an d su icide. ma ladaptive strategies for coping with negative
Bulimia nervosa is characte ri zed by unco nt rol led em oti o ns. Also, certain cognitive factors, includ-
bingeing followed by inappropriate co m pensa- ing overvaluation of appearance, perfectionism,
tory behaviors designed t o prevent w eig ht ga in low se lf-esteem, excessive concern about others'
from the binges (e.g. , self-induced vo m it ing, mi s- opinions, and a rigid, dichotomous thinking
use of laxatives or diuretics, excessive exercise). style, may contribute to the development of the
Bul imia nervosa is more commo n in females eating disorders.
than in ma les. The onset of bul imi a nervosa The families of girls w ith eating disorders may
most often is in adol escence . Altho ugh people be overcontrolling, overprotective, and hostile
with bulimia do not tend t o be un derweigh t, and may not allow the expression of feelings,
bulimia nervosa has severa l dan gerous medical especially negative feelings. In adolescence,
complications. these girls may develop eating disorders as a
People with binge-eating di sorder engage in way of exerting control.
bingeing , but not in purgi ng o r in be haviors Cognitive-behavioral therapy and family therapy
designed to compensate fo r th e bi nges. People have been shown to be effective in the treatment
with the disorder tend to be sign ificantly of anorexia nervosa.
overweight. Cognitive-behavioral therapy has proven to be
The DSM-5 diagnosis oth er specified f eed ing o r the most effective therapy for reducing the
eating d isorder replace d the DSM-IV eatin g dis- symptoms of bulimia and binge-eating disorder
order not otherwise spec ified . It may be g iven and preventing relapse. Interpersonal therapy,
to individuals who show severe sympto m s of supportive-expressive psychodynamic therapy,
an eating disorder but do not meet th e ful l cri- and behavioral therapy also appear to be effec-
teria for one of the eating disorders (e. g., atyp i- tive in t reating bulimia nervosa.
cal anorexia nervosa, bul im ia nervosa of low Antidepressants can reduce symptoms in
frequency and/or limited duration). Peopl e wit h anorexia nervosa, bulimia nervosa, and binge-
night eating disorder, who ingest much of eating disorder. The atypical antipsychotic
their caloric intake at night, may be given th is olanzapine can help restore weight in people
diagnosis. with anorexia nervosa.
KEY TERMS
anorexia nervosa 339 other specified feed ing or eating disorder 346
amenorrhea 339 atypical anorexia nervosa 346
restricting type of anorexia nervosa 340 bulimia nervosa of low frequency and/or limited
binge/purge type of anorex ia nervosa 341 du ration 346
bulimia nervosa 343 ni ght eating syndrome 346
bingeing 343 o besity 347
binge-eating disorder 345
Sexual Disorders
CHAPTER OUTLINE
Sexuality Along the Continuum Gender Dysphoria
Extraordinary People: David Reimer, Chapter Integration

The Boy Who Was Raised as a Girl
Sexual Dysfunctions
Think Critically
Paraphilic Disorders
Chapter Summary
Shades of Gray
Key Terms
Potentially meets diagnostic criteria
for a sexual disorder:
Difficulties in sexual functioning that cause
moderate di stress or difficulties in relationships
Sexual f unctioning,
(frequent difficulty reaching orgasm)
sexual practices, and
Atypical sexual practices t hat cause distress or
gender identity that
bring the individual difficulties in social functioning (one's partner
positive well-being disapproves of the objects used in sexual practice)
and relation ships Uncertainty about gender identity
Occasi onal difficulties i n sexual Likely meets diagnostic criteria

functioning that do not cause distress for a sexual disorder:
or relationships difficulties Chronic difficulties in sexual functioning that
(occasional difficulty reaching orgasm) cause significant distress or difficulties in
Atypical sexual practices that do not relationshi ps (complete lack of sexual desire)
cause distress or difficulties in social Atypical sexual practices that cause significant
distress or difficulties in social functioning
functioning (use of objects as part of
(inappropriate objects become the sole focus of
sex play with a consenting partner)
sexual activities, arrests for illegal sexual behavior)
Questions about gender i dentity that
Si gni ficant distress regarding gender
eventually are resolved
identity, desire to change genders
Before the work of researchers William Masters and Virginia disorder often feel compelled to engage in their paraphilias, even
Johnson in the 1950s and 1960s, we knew little about typical or though their behaviors cause them distress or create social,
atypical sexual functioning, that is, what happens in the body occupational, or legal problems.
during sexual activity. They argued that the sexual response cycle Finally, individuals also vary in their gender identity - their
can be divided into five phases: desire, arousal or excitement, perception of themselves as male or female. Gender identity dif-
plateau, orgasm, and resolution, as reviewed later in this chapter. fers from gender roles, wh ich are society's expectations for how
Occasional problems with sexual functioning, such as difficulty males and females should act. Many females engage in behaviors
reaching orgasm or lack of sexual desire, are extremely common. considered part ofthe masculine gender role, such as playing ag-
When people have difficulties in sexual functioning that are persis- gressive sports or pursuing competitive careers, but still have a
tent and that cause significant distress or interpersonal difficulty, fundamental sense of themselves as female . Similarly, many
they may be diagnosed with a sexual dysfunction (Balon, males engage in behaviors considered part of the feminine gen-
Segraves, & Clayton, 2007). Studies around the world suggest that der role, such as caring for children, cooking, or sewing, but still
40 to 45 percent of women and 20 to 30 percent of men frequently have a fundamental sense of themselves as male. When an indi-
experience sexual dysfunctions (Lewis et al., 2010) . v idual believes he or she was born with the body of the wrong
The activities and objects that people f ind arousing vary gender, the DSM-5 defines this as gender dysphoria (formerly
tremendously. When people focus their sexual activity on some- called gender identity disorder). People with gender dysphoria
thing considered inappropriate by society-for example, nonliv- feel trapped in the wrong body, wish to be rid of their genitals,
ing objects, prepubescent children, nonconsenting adults, or and want to live as a member of the other gender.
suffering or humiliation-they may be diagnosed with a paraphilic The DSM-5 definitions of sexual disorders are controversial
disorder. Many people have occasional paraphilic fantasies. One because they single out some sexual behaviors as abnormal and
study found that 62 percent of men fantasized about having sex disordered but not others. For example, adults whose sexual fanta-
with a young girl, 33 percent fantasized about raping a woman, sies, urges, and behaviors focus on women's breasts can be diag-
and 12 percent fantasized about being humiliated during sex nosed with a sexual disorder, but adults who prefer sexual activity
(Crepault & Couture, 1980). People diagnosed with a paraphilic with prostitutes may not be diagnosed under the DSM-5 criteria.
Sexuality Alo ng the Continuu m 363

364 Chapter 13 Sexual Disorders
Extra ordinary People

David Reimer, The Boy Who Was Raised as a Girl
In April 1966, 8-month- As Brenda grew up, she refused surgery to cre-
old Bruce Reimer ate a vagina for her and insisted on urinating stand-
underwent a routine ing up. Beginning at age 12, Brenda was given
circumcision to allevi- estrogen, and as a result she began to develop
ate a painful medical breasts. However, her voice began to crack, just like
condition on his penis. her brother's. Finally, when Brenda was 14, her father
The operation went ter- told her the truth about the botched circumcision and
ribly wrong, however, her parents' decision to raise her as a girl. Brenda
and Bruce's penis was said, "I was relieved .... Suddenly it all made sense
accidentally severed. why I felt the way I did. I wasn't some sort of weirdo.
None of the doctors I wasn't crazy" (Colapinto, 2000, p. 180).
whom Bruce's anguished parents consulted could Brenda immediately decided to revert to her
offer any hope of restoring the penis and sug- biological sex. She renamed herself David, after
gested that he would never be able to function as a the biblical king and giant-slayer. David began to
normal male. But Dr. John Money offered them a take injections of testosterone and in 1980 under-
solution: Raise Bruce as a girl and have him un- went a double mastectomy to remove the breasts
dergo sex reassignment therapy. Dr. Money firmly he had grown. Then, a month before his sixteenth
believed that male or female identity depends on birthday, he had surgery to create a rudimentary
the environment in which a child is raised, not on penis. Still, David's reentry into life as a boy was
genes or the genitals with which he or she is born. difficult. He still looked and talked differently from
Bruce's condition presented Dr. Money with the other boys and, as a result, was teased and shunned.
perfect opportunity to prove his theory. Not only The artificial genitals that had been fashioned for
had Bruce been born male, but he had an identical him frequently became blocked, and he went
twin brother as well. If surgically reassigning through several additional surgeries and treat-
Bruce's sex and raising him as a girl resulted in ments. Over the next few years, David attempted
Bruce fully accepting himself as a girl, when his suicide and secluded himself in a mountain cabin
twin brother identified himself as a boy, Money's for months at a time.
theories of gender identity would be soundly Finally, after his twenty-second birthday, David
supported. had a new kind of surgery to create a more accept-
Bruce's parents renamed him Brenda Lee and able and functional penis. In 1990, David married a
began dressing him in feminine clothes. The child young woman named Jane, and things went well
underwent a bilateral orchidectomy-removal of for a while. But after losing his job, experiencing
both testicles-at the age of 22 months. Brenda's financial difficulties, and separating from his wife,
parents then furnished her with dolls and tried to David committed suicide in 2004. According to his
reinforce her identity as a girl. Brenda, however, re- mother, he had also been grieving the death of his
sisted. As brother Brian recalled, "When I say there brother, which had occurred 2 years before the sui-
was nothing feminine about Brenda ... I mean there cide. In a newspaper story after David's death, John
was nothing feminine. She walked like a guy. Sat Colapinto, his biographer, noted, "David's blighted
with her legs apart. We both wanted to play with childhood was never far from his mind. Just before
guys, build forts and have snowball fights and play he died, he talked to his wife about his sexual'inad-
army. She'd get a skipping rope for a gift, and the equacy,' his inability to be a true husband. Jane
only thing we'd use that for was to tie people up, tried to reassure him . But David was already head-
whip people with it" (Colapinto, 2000, p. 57). ing for the door" (Slate, 3 June 2004).
David Reimer's story raises many questions we consider how biology interacts with social ~
about the biological and social contributors to norms and psychological factors to produce both
our self-concept as male or female, our sexual sexual health and sexual disorders.
preferences, and the role of sexuality and gender As noted in Sexuality Along the Continuum,
in our psychological well-being. In this chapter, much of what we know about what happens in the
human body during sexual activity is rooted in The Sexual Response Cycle. Masters and
Masters and Johnson's (1970) ground-breaking Johnson divided the sexual response cycle
work. They observed people engaging in a variety FIGURE 13.1 into five phases (see discussion in Sexuality
of sexual practices in a laboratory setting and Along the Continuum).
recorded the physiological changes that occurred,
concluding that the human sexual response cycle
Desire Phase
consists of five phases: desire, arousal or excite- Sexual urges in response to sexual
ment, plateau, orgasm, and resolution (Figure 13.1). fantasies or environmental cues
Sexual desire is the urge to engage in any type of
sexual activity. The arousal phase, or excitement
phase, combines a psychological experience of
\
Arousal Phase
pleasure and the physiological changes known as Psychological experience of sexual
arousal; vasocongestion (increased
vasocongestion and myotonia. Vasocongestion, or blood flow to penis in males and
engorgement, occurs when blood vessels and tissues pelvic area in fer.1ales) and
myotonia (muscular tension)
fill with blood. In males, erection of the penis is
caused by an increase in the flow of blood into the
arteries of the penis, accompanied by a decrease in
Plateau Phase
the outflow of blood from the penis through the High but stable level of exdtement
veins. In females, vasocongestion causes the clitoris before orgasm
to enlarge, the labia to swell, and the vagina to be-
come moist. Myotonia is muscular tension. During
the arousal phase, many muscles in the body be- Orgasm Phase
come tenser, culminating in the muscular contrac- In males, sense of inevitability of
ejaculation followed by ejaculation;
tions known as orgasm. in females, rhythmic contractions
After arousal is the plateau phase, when ex- of the vagina and more irregular
contractions of the uterus
citement remains at a high but stable level. This
period is pleasurable in itself, and some people try
to extend the plateau phase as long as possible be-
Resolution Phase
fore reaching orgasm, the discharge of the neuro- Decreased arousal; deep relaxation
muscular tension built up during the excitement possible
and plateau phases. In males, orgasm involves
rhythmic contractions of the prostate and the entire
length of the penis and urethra, accompanied by Source: Masters & Johnson, 1970.
the ejaculation of semen. After ejaculation, a refrac-
tory period, lasting from a few minutes to a few
hours, occurs in which the male cannot achieve full
erection and another orgasm, regardless of the type of these phases anytime they engage in sexual ac-
or intensity of sexual stimulation. In females, or- tivity. For example, Masters and Johnson's depic-
gasm generally involves rhythmic contractions of tion of the sexual response cycle may be more
the vagina and more irregular contractions of the characteristic of men than of women, as women's
uterus, which are not always felt. Because females responses tend to be more variable than men's
do not have a refractory period, they are capable of (Basson et al., 2001). Sometimes, the excitement
experiencing additional orgasms immediately fol- phase is short for a female, and she reaches a dis-
lowing one. However, not all women find multiple cernible orgasm quickly. At other times, the excite-
orgasms easy to achieve or desirable. Following ment phase is longer, and she may or may not
orgasm, the entire musculature of the body relaxes, experience a full orgasm.
and men and women tend to experience a state of Occasional difficulties at one or more of the
deep relaxation, the stage known as resolution. phases of the sexual response cycle are common
If you are sexually active, you may or may not (see Figure 13.2; Michael, Gagnon, Laumann, &
have recognized all these phases in your sexual Kolata, 1994). As we discuss later, these difficulties
response cycle. People vary greatly in the length may be tied to stresses in individuals' lives, medi-
and distinctiveness of each phase. Although the cations they are taking, illness, or problems in their
work of Masters and Johnson was critical to our relationships. Individuals who have persistent dif-
understanding of sexual functioning, it soon be- ficulties that cause them distress or interfere with
came clear that people vary tremendously in the their social or occupational functioning may be
extent to which they consciously experience each diagnosed with a sexual dysfunction.
seek treatment for a sexual problem have more

Percentage of People Who Have Had
FIGURE 13.2 than one nonsexual dysfunction.
a Sexual Difficulty in the Past Year.
A national survey found that many people
report having had one or more sexual difficulties in the past year. Disorders of Sexual Interest I
Desire and Arousal
l I Sexual desire can be manifested in a person's
Lacked interest in sex Men sexual thoughts and fantasies, a person's interest
- Women in initiating or participating in sexual activities,
Unable to reach orgasm r--. and a person's awareness of sexual cues from
---, others (Sand & Fisher, 2007). People vary tremen-
Sex not pleasurable dously in their levels of sexual desire or interest,
Experienced pain during sex --. and an individual's level of sexual desire or
interest can vary greatly across time (Michael
et al., 1994). Low sexual desire or arousal is
Anxiety about performance among the most common problems for which
people seek treatment (Bach, Wincze, & Barlow,
Climax too early 2001; Hackett, 2008).
Unable to keep an erection Male Hypoactive Sexual Desire Disorder

Men with male hypoactive sexual desire disorder
Had trouble lubricating have little desire for sex-they do not fantasize
about sex or initiate sexual activity and may be un-
0 10 20 30 40 50 60 70
responsive when a partner initiates sex (American
Percent
Psychiatric Association, 2013). This lack of sexual
desire causes them marked distress or interpersonal
Source: Michael et al., 1994, p. 126. difficulty. In some rare cases, men report never hav-
ing had much interest in sex, either with other peo-
ple or privately (e.g., viewing of erotic films,
masturbation, or fantasy). These men are diagnosed
with lifelong male hypoactive sexual desire disorder, as
the disturbance has always been present. In most
SEXUAL DYSFUNCTIONS cases, the man used to enjoy sex but has lost interest
The sexual dysfunctions are a set of disorders in in it, a condition diagnosed as acquired male hypoac-
which people have difficulty responding sexually tive sexual desire disorder. Inhibited desire can be ei-
or experiencing sexual pleasure (Table 13.1). To ther generalized to all partners and situations or
qualify for a diagnosis of a sexual dysfunction, specific to certain partners or types of stimulation.
the difficulty must be more than occasional or Obviously, the judgment about when a man's sex-
transient, and must cause significant distress or ual desire has been too low for too long is subjec-
interpersonal difficulty. The DSM-5 recognizes tive. The DSM-5 specifies that the clinician should
seven distinct sexual dysfunction disorders, make this determination with consideration of
which can roughly be divided into disorders of other aspects of the person's life, including age. Be-
desire and arousal and disorders of orgasm and tween 5 and 13 percent of men report frequent prob-
sexual pain (see Table 13.1). To be diagnosed with lems involving hypoactive sexual desire, with
any of these disorders, the dysfunction must oc- higher rates among older men than among younger
cur most of the time for at least 6 months, must men (Laumann, Paik, & Rosen, 1999; Laumann,
cause significant distress or impairment, and Das, & Waite, 2008).
must not be due to another, nonsexual psychiatric
problem (e.g., depression); a substance or medi- Female Sexual Interest I Arousal Disorder
cation; a general medical condition; or stressors. The nature of sexual desire or interest may be dif-
If individuals do have a sexual dysfunction ferent for men and women. For men, the DSM-5
caused by a substance (such as chronic alcohol defines desire as the presence of sexual fantasies
abuse) or a medication (such as an antidepressant), and yearning to have sex, but many women say
they may be diagnosed with substance/medication- they seldom engage in sexual fantasies or yearn-
induced sexual dysfunction. In reality, these dysfunc- ing for sex yet do desire and enjoy sex (Sand &
tions overlap significantly, and many people who Fisher, 2007). In addition, sexual interest or desire
Sexual Dysfu nctions 367
TABLE 13.1 DSM-5 Sexual Dysfunctions
The sexual dysfunction disorders can be roughly divided into disorders of sexual desire and arousal and disorders of orgasm and
sexual pain. If a sexual dysfunction is caused by a substance (e.g., alcohol) or medication, it is given the diagnosis substance/
medication-induced sexual dysfunction. All sexual dysfunctions (except substance/medication-induced sexual dysfunction) require a
minimum duration of approximately 6 months.
Disorders of Sexual Interest/Desire or Arousal

Female sexual interest/arousal disorder Persistent lack of, or significantly reduced, interest in sexual activity and/or lack
of arousal in response to sexual activity.
Male hypoactive desire disorder Persistently absent or deficient sexual/erotic thoughts or fantasies, or desire for
sexual activity.
Erectile disorder Recurrent inability to attain or maintain an erection or a marked decrease in
erectile rigidity.
Disorders of Orgasm or Sexual Pain

Female orgasmic disorder Reduced intensity, or recurrent delay or absence of orgasm during sexua l activity
Early ejaculation Recurrent ejaculation within 1 minute of initiation of partnered sexual activity
when not desired
Delayed ejaculation Marked delay, infrequency, or absence of ejaculation during sexual encounters
Genito-pelvic pain/penetration disorder Marked difficulties having vaginal penetration; pain or tightening of pelvic floor
muscles during penetration
and sexual arousal seem to be more intimately sexual desire increase to 26 percent in postmeno-
connected with each other in women than in men pausal women (Leiblum et al., 2006). Women with
(Brotto, 2009; Maserejian et al., 2012). In some low sexual desire are more likely than men to report
women, sexual interest precedes arousal, while anxiety, depression, and life stress. About 20 per-
in others it follows it (Graham et al., 2004). As a cent of women report difficulties with lubrication
result of these differences between women and or arousal during sexual activity (Laumann et al.,
men, for women the DSM-5 combines difficulties 1999; Lewis et al., 2004; Lewis et al., 2010). The
in sexual interest or arousal into one diagnosis, study of over 31,000 women found that 5.4 percent
female sexual interest/ arousal disorder. In order could be diagnosed with a DSM-IV sexual arousal
to receive this diagnosis, a woman must, for at disorder (Clayton, 2007).
least 6 months, report at least three of the follow-
ing symptoms: absent or significantly reduced in- Erectile Disorder
terest in sexual activity, in sexual or erotic thoughts Erectile disorder in men (sometimes referred to as
or fantasies, in initiation of sex or receptiveness to impotence) involves the recurrent inability to attain
sex, in excitement or pleasure in most sexual en- or maintain an erection until the completion of
counters, in sexual responsiveness to erotic cues, sexual activity. Men with the lifelong form of erec-
or in genital or nongenital responses to sexual tile disorder h ave never been able to sustain an
activity. As in male hypoactive sexual disorder, erection for a desired period of time. Men w ith the
female sexu al interest / arousal disorder can be acquired form of the disorder were able to sustain
either lifelong or acquired. an erection in the past but no longer can. Occa-
The data we have on these problems in women sional problems in achieving or sustaining an erec-
come mostly from the DSM-IV diagnostic scheme, tion are common, with as many as 30 million men
which separated sexual desire problems and sexual in the United States having erectile problems at
arousal problems in women. As seen in Figure 13.2, some time in their life. Such problems do not con-
over 30 percent of women report an occasional lack stitute a disorder until they become persistent and
of desire for sex. In a study of over 31,000 women, significantly interfere with a man's interpersonal
unusually low sexual desire was diagnosed in relationship s or cause him distress. The criteria for
9.5 percent of them (Clayton, 2007). Rates of low erectile disorder specify that a man must fail to
achieve or maintain an erection until completion

of sexual activity on all or almost all (75 to 100 per-
cent) occasions over a period of approximately
6months.
One nationwide study (Saigal et al., 2006) found
that one in five men over age 20 could be diagnosed
with erectile dysfunction. The prevalence of erectile
dysfunction increased dramatically with age, with
over 77 percent of men over age 75 affected by it
(Lewis et al., 2010; Saigal et al., 2006). Problems
with erectile functioning can be both the result
and the cause of other difficulties in a couple's rela-
tionship, as in the following case study.
Paul and Geraldine had

been living together for the past 6 months and
were contemplating marriage. Geraldine de-
scribed the problem that brought them to the sex
therapy clinic: "For the past 2 months he hasn't
been able to keep his erection after he enters me:'
The psychiatrist learned that Paul, age 26, Thanks in part to endorsements by celebrities such as
was a recently graduated lawyer and that Rafael Palmeiro. sales of medications to treat erectile
Geraldine, age 24, was a successful buyer for a disorder have skyrocketed.
large department store. They had both grown up
in educated, middle-class, suburban families.
They had met through mutual friends and had Disorders of Orgasm
started to have sexual intercourse a few months
or Sexual Pa in
after they met, with no problems at that time.
Two months later, Paul had moved from his Individuals can desire to have sex, become aroused
family home into Geraldine's apartment. This was during sexual activity, but not experience an or-
her idea, and Paul was unsure that he was ready gasm. In addition, women can experience signifi-
for such an important step. Within a few weeks, cant pain or tightening of the pelvic muscles upon
Paul noticed that although he continued to be penetration.
sexually aroused and wanted intercourse, as
soon as he entered his partner, he began to lose Female Orgasmic Disorder
his erection and could not stay inside.They would Women with female orgasmic disorder, or anor-
try again, but by then his desire had waned and gasmia, experience markedly reduced intensity of
he was unable to achieve another erection. orgasms, or delay or absence of orgasm, after hav-
The psychiatrist learned that sex was not ing reached the excitement phase of the sexual
the only area of contention in the relationship. response cycle in at least 75 percent of sexual en-
Geraldine complained that Paul did not spend counters. Female orgasmic disorder can be either
enough time with her and preferred to go to base- lifelong or acquired.
ball games with his male friends. Even when he About one in four women reports occasional
was home, he would watch all the sports events difficulty reaching orgasm (Laumann et al., 1999),
that were available on TV and was not interested in and 4.7 percent can be diagnosed with orgasmic
going to foreign movies, museums, or the theater disorder (Clayton, 2007). The problem is greater
with her. Despite these differences, the couple was among postmenopausal women, with about one in
planning to marry and had set a date. (Reprinted three reporting some problem reaching orgasm
from the DSM-IV- TR Casebook: A Learning during sexual stimulation (Clayton, 2007) .
Companion to the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Early Ejaculation and Delayed
Revision. Copyright 2000 American Psychiatric Ejaculation
Association .) The most common form of orgasmic disorder in
males is early or premature ejaculation. Men with
Sexual Dysfunctions 369
this disorder persistently ejaculate with minimal

and marital crisis was precipitated by Margaret's
sexual stimulation before they wish to ejaculate.
belief that Bill was acting more isolated and dis-
Again, it is a judgment call as to when early ejacu-
tant when they did have intercourse. When they
lation becomes a sexual dysfunction. The DSM-5
talked about their sexual relationship, it was usu-
specifies that, in order to receive this diagnosis, a
ally in bed after intercourse, and the communica-
man must ejaculate within 1 minute of penetration
in partnered sexual activity and before the man tion quickly broke down into tears, anger, and
wishes it on 75 percent of occasions over a period accusations. Bill was on the defensive and han-
of at least 6 months. It can be either lifelong or ac- dled the sexual issue by avoiding talking to
quired. The DSM-5 also notes that early ejaculation Margaret, which frustrated her even more.
may be applied to nonvaginal sexual activities, but Unbeknownst to Margaret, Bill had attempted
specific duration criteria are not known. a do-it-yourself technique to gain better control.
Edward Laumann and colleagues (1999) found He had bought a desensitizing cream he'd read
that 21 percent of men reported problems with early about in a men's magazine and applied it to the
ejaculation. Some men seeking treatment for this glans of his penis (the caplike structure at the end
problem simply cannot prevent ejaculation before of the penis) 20 minutes before initiating sex.
their partner reaches orgasm. Others ejaculate after During intercourse he tried to keep his leg muscles
very little stimulation, long before their partner is tense and think about sports as a way of keeping
fully aroused. A community-based study found his arousal in check. Bill was unaware that Margaret
that 13 percent of men could be diagnosed with pre- felt emotionally shut out during sex. Bill was be-
mature ejaculation by the DSM-IV-TR criteria, coming more sensitized to his arousal cycle and
which were less specific than the DSM-5 criteria in was worrying about erection. He was not achiev-
defining early ejaculation or requiring that it occur ing better ejaculatory control, and he was enjoying
at least 75 percent of the time (Patrick et al., 2005). sex less. The sexual relationship was heading
Men try to manage problems with early ejacula- downhill, and miscommunication and frustration
tion by applying desensitizing cream to the penis were growing. (McCarthy, 1989, pp. 151-152)
before sex, wearing multiple condoms, distracting
themselves with other thoughts while having sex,
not allowing their partner to touch them, and mas-
turbating multiple times shortly before having sex Men with delayed ejaculation experience a
(Althof, 1995). These tactics generally are unsuccess- marked delay in or the absence of orgasm follow-
ful and can make the man's partner feel shut out of ing the excitement phase of the sexual response
the sexual encounter, as in the following case study. cycle in at least 75 percent of sexual encounters.
~nlike ear~y ejaculation, the definition of "delay"
IS not precisely defined and research does not yet
suggest a clear definition. In most cases of this dis-
order, a man cannot ejaculate during intercourse
CASE STUDY but can ejaculate with manual or oral stimulation.
Bill and Margaret were a
couple in their late 20s who had been married for
Eight percent of men report problems reaching or-
2 years. They had had a tumultuous dating rela-
gasm (Laumann et al., 1999); it is estimated that
tionship before marriage. A therapist helped Bill
less than 3 percent of men could be diagnosed with
and Margaret deal with issues in their relation-
delayed ejaculation (Perelman & Rowland, 2008).
ship. However, the therapist made an incorrect
assumption that with increased intimacy and the
Genito-Pelvic Pain/Penetration Disorder
commitment of marriage, Bill's ejaculatory con-
In community surveys, 12 to 39 percent of women
trol problem would disappear.. ..
report frequent pain during intercourse (Farmer,
Margaret saw the early ejaculation as a sym-
Kukkonen, & Binik, 2008). The pain may be shal-
~ow during _intromission (insertion of the penis
bol of lack of love and caring on Bill's part. As the
problem continued over the next 2 years,
mto the vagma) or deep during penile thrusting.
Margaret became increasingly frustrated and
Some women ~lso experience pain when inserting
t~mpons, havmg a gynecological exam, riding a
withdrawn. She demonstrated her displeasure
by resisting his sexual advances, and their inter-
bike, or even walking (Farmer, Kao, & Binik, 2009).
course frequency decreased from three or four
The pain can be the result of dryness of the vagina
times per week to once every 10 days. A sexual
caused by antihistamines or other drugs, infection
of the clitoris or vulval area, injury or irritation to
the vagina, or tumors of the internal reproductive
organs. Pain during intercourse is rare in men, but levels of both androgens and estrogens may play a
when it does occur, it involves painful erections or role in sexual dysfunction, although less consis-
pain during thrusting (Farmer et al., 2009). tently so than in men (Meston & Bradford, 2007).
In addition, some women experience involun- Estrogen problems in women may result in low
tary contraction of the muscles surrounding the arousal due to reduced vaginal lubrication. Levels
outer third of the vagina when penetration with a of estrogen drop greatly at menopause; thus, post-
penis, finger, tampon, or speculum is attempted. menopausal women often complain of lowered
These women may experience sexual arousal and sexual desire and arousal. Similarly, women who
have an orgasm when their clitoris is stimulated. In have had a radical hysterectomy-which removes
other women, even the anticipation of vaginal inser- the main source of estrogen, the ovaries-can ex-
tion may result in this muscle spasm. It is estimated perience reductions in both sexual desire and
that 5 to 17 percent of women experience such mus- arousal. Androgens seem to play a role in the
cle tightening (Reissing, Binik, & Khalife, 1999). maintenance of sexual desire and mood and also
Women who recurrently experience either may enhance the function of vaginal tissue.
pain or muscle tightening during sex for approx- Vaginal dryness or irritation, which causes
imately 6 months can be diagnosed with genito- pain during sex and therefore lowers sexual desire
pelvic pain/penetration disorder. and arousal, can be caused by antihistamines,
douches, tampons, vaginal contraceptives, radia-
tion therapy, endometriosis, and infections such as
Causes of Sexual Dysfunctions vaginitis or pelvic inflammatory disease (Meston &
Most sexual dysfunctions probably have multiple Bradford, 2007). Injuries during childbirth that
causes, including both biological and psychosocial have healed poorly, such as a poorly repaired episi-
causes. otomy, can cause sexual pain in women (Masters,
Johnson, & Kolodny, 1993). Women who have had
Biological Causes gynecological cancers sometimes report pain,
The DSM-5 specifies that to receive a diagnosis of changes in the vaginal anatomy, and problems with
any sexual dysfunction, the dysfunction cannot be their body image or sexual self-concept (Lagana,
caused exclusively by a medical condition. Still, McGarvey, Classen, & Koopman,2001).
many medical illnesses can cause problems in sex- Several prescription drugs can diminish sex-
ual functioning in both men and women. One of ual drive and arousal and interfere with orgasm
the most common contributors to sexual dysfunc- (Clayton, 2007). These include antihypertensive
tion is diabetes, which can lower sexual drive, drugs taken by people with high blood pressure,
arousal, enjoyment, and satisfaction, especially in antipsychotic drugs, antidepressants, lithium, and
men (lncrocci & Gianotten, 2008). Diabetes often
goes undiagnosed, leading people to believe that
psychological factors are causing their sexual dys-
function when the cause actually is undiagnosed
diabetes. Other diseases that are common causes
of sexual dysfunction, particularly in men, are car-
diovascular disease, multiple sclerosis, kidney fail-
ure, vascular disease, spinal cord injury, and injury
to the autonomic nervous system due to surgery or
radiation (Lewis et al., 2010).
As many as 40 percent of cases of erectile disor-
der are caused by one of these medical conditions
(Lewis, Yuan, & Wangt, 2008). In men with cardio-
vascular disease, sexual dysfunction can be caused
directly by the disease, which can reduce blood
flow to the penis, or it may be a psychological re-
sponse to the presence of the disease. For example,
a man who recently has had a heart attack may fear
he will have another one if he engages in sex.
In men, abnormally low levels of the androgen
hormones, especially testosterone, or high levels of Although many people drink alcohol to decrease their
sexual inhibitions. alcohol also can impair sexual
the hormones estrogen and prolactin can cause performance.
sexual dysfunction (Hackett, 2008) . In women,
tranquilizers. Indeed, sexual dysfunction is one of or is a "necessary evil" understandably may lack
the most common side effects of the widely used the desire to have sex (van Lankveld, 2008). They
selective serotonin reuptake inhibitors (Meston & also may know so little about their own body
Bradford, 2007). and sexual responses that they do not know how
Many recreational drugs, including marijuana, to make sex pleasurable. Such is the case with
cocaine, amphetamines, and nicotine, can impair Mrs. Booth in the following case study.
sexual functioning (Lewis et al., 2010; Schiavi &
Segraves, 1995). Although people often drink alco-
hol to make them feel sexier and less inhibited, CASE STUDY
even small amounts of alcohol can significantly Mr. and Mrs. Booth have
impair sexual functioning. Chronic alcohol abus- been married for 14 years and have three chil-
ers and alcohol dependents often have diagnos- dren, ages 8 through 12.They are both bright and
able sexual dysfunctions (Lewis et al., 2008). As well educated. Both are from Scotland, from
noted previously, when a sexual dysfunction is which they moved 10 years ago because of
caused by substance use, it is given the diagnosis Mr. Booth's work as an industrial consultant.
substance-induced sexual dysfunction. They present with the complaint that Mrs. Booth
To determine whether a man is capable of at- has been able to participate passively in sex "as
taining an erection, clinicians can do a psychophys- a duty" but has never enjoyed it since they have
iological assessment with devices that directly been married.
measure men's erections. In a laboratory, strain Before their marriage, although they had
gauges can be attached to the base and glans of a had intercourse only twice, Mrs. Booth had been
man's penis to record the magnitude, duration, and highly aroused by kissing and petting and felt
pattern of arousal while he watches erotic films or she used her attractiveness to "seduce" her hus-
listens to erotic audio recordings (Lewis et al., band into marriage. She did, however, feel in-
2008). For women, the physical ability to become tense guilt about their two episodes of premarital
aroused can be measured with a vaginal photople- intercourse; during their honeymoon, she began
thysmograph, a tampon-shaped device inserted to think of sex as a chore that could not be pleas-
into a woman's vagina that records the changes ing. Although she periodically passively com-
accompanying vasocongestion, the rush of blood plied with intercourse, she had almost no
to the vagina during arousal (Geer, Morokoff, & spontaneous desire for sex. She never mastur-
Greenwood, 1974). bated, had never reached orgasm, thought of all
variations such as oral sex as completely repul-
Psychological Causes sive, and was preoccupied with a fantasy of how
People's emotional well-being and beliefs and at- disapproving her family would be if she ever en-
titudes about sex greatly influence their sexuality. gaged in any of these activities.
Mrs. Booth is almost totally certain that no
Mental Disorders Again, the DSM-5 criteria woman she respects in any older generation has
for the diagnosis of sexual dysfunction exclude that enjoyed sex and that despite the "new vogue" of
caused by other (nonsexual) mental disorders, but sexuality only sleazy, crude women let them -
a number of mental disorders can cause sexual dys- selves act like "animals:' These beliefs have led
function (Meston & Bradford, 2007; van Lankveld, to a pattern of regular but infrequent sex that at
2008). A person with depression may have no de- best is accommodating and gives little or no
sire for sex or may experience any of the problems pleasure to her or her husband. Whenever
in sexual arousal and functioning discussed in this Mrs. Booth comes close to having a feeling of
chapter. Unfortunately, the medications used to sexual arousal, numerous negative thoughts come
treat depression often lead to problems in sexual into her mind such as, "What am I, a tramp?"; "If
functioning. Similarly, people with an anxiety dis- I like this, he'll just want it more often"; and "How
order, such as generalized anxiety disorder, panic could I look at myself in the mirror after some-
disorder, or obsessive-compulsive disorder, may thing like this?" These thoughts almost inevitably
find their sexual desire and functioning waning. are accompanied by a cold feeling and an insen-
Loss of sexual desire and functioning also is com- sitivity to sensual pleasure. As a result, sex is
mon in people with schizophrenia (van Lankveld, invariably an unhappy experience. Almost any
2008). excuse, such as fatigue or being busy, is suffi-
cient for her to rationalize avoiding intercourse.
Attitudes and Cognitions People who have (Adapted from Spitzer et al., 2002, pp. 251-252)
been taught that sex is dirty, disgusting, or sinful
Although the attitudes Mrs. Booth has toward These worry thoughts are so distracting that peo- ~
sex may be uncommon among younger people ple experiencing them cannot focus on the plea-
these days, many younger and older women still sure that sexual stimulation is giving them and
report a fear of "letting go," which interferes with thus do not become as aroused as they want to
orgasm (Nobre & Pinto-Gouveia, 2006; Tugrul & or need to in order to reach orgasm (Figure 13.3;
Kabakci, 1997). They say they fear losing control or Barlow, Sakheim, & Beck, 1983; Cranston-Cuebas &
acting in some way that will embarrass them. This Barlow, 1990).
fear of loss of control may result from a distrust of In addition, many people engage in spectator-
one's partner, a sense of shame about sex, a poor ing: They anxiously attend to reactions and perfor-
body image, or a host of other factors. mance during sex as if they were spectators rather
Another set of attitudes that interfere with sex- than participants (Masters & Johnson, 1970). Spec-
ual functioning is often referred to as performance tatoring distracts from sexual pleasure and inter-
concerns or performance anxiety (LoPiccolo, 1992; feres with sexual functioning. Unfortunately, people
Masters & Johnson, 1970). People worry so much who have had some problems in sexual functioning
about whether they are going to be aroused and only develop more performance concerns, which
have an orgasm that this worry interferes with then further interfere with their functioning. By the
their sexual functioning: "What if I can't get an time they seek treatment for sexual dysfunction,
erection? I'll die of embarrassment!" "''ve got to they may be so anxious about "performing" sexu-
have an orgasm, or he'll think I don't love him!" ally that they avoid all sexual activity.
I
A Model Showing How Anxiety and Cognitive Interference Can Produce
FIGURE 13.3
Erectile Dysfunction and Other Sexual Disorders.
Sexually functional people Sexually dysfunctional people

(positive feedback loop) sexual performance (negative feedback loop)
Positive emotions
Accurate perception of
I '-----~ Negative emotions (anxiety)
Inaccurate perception of
erection and arousal erection and arousal
DESIRE
SEX
Attention focused on Cognitive interference
erotic thoughts Attention on failure and
other nonerotic thoughts
!
Increased autonomic
arousal (sexual arousa l)
Increased autonomic
arousal (anxiety)
Attention increasingly focused Increased cognitive

on erotic thoughts interference
Successful functioning
Source: Barlow, 1986.

Trauma Reductions in sexual desire and func- partner's arousal, focusing only on themselves.
tioning often follow personal trauma, such as the Couples often do not communicate with each other
loss of a loved one, the loss of a job, or the diagno- about what is arousing, so even if each partner in-
sis of severe illness in one's child. Unemployment tends to please the other, neither knows what the
may contribute to declines in sexual desire and other desires.
functioning in men. Traumas such as unemploy- Anorgasmia (lack of orgasm) characteristic of
ment can challenge a person's self-esteem, inter- female orgasmic disorder, may be tied to lack of
fering with his or her sexual self-concept. Trauma communication between a woman and her partner
can also cause a person to experience a depression about what the woman needs to reach orgasm
that includes a loss of interest in most pleasurable (Meston & Bradford, 2007). In sexual encounters be-
activities, including sex. In such cases, clinicians tween men and women, men still are more likely to
typically focus on treating the depression, with the decide when to initiate sex, how long to engage in
expectation that sexual desire will resume once the foreplay, when to penetrate, and what position to
depression has lifted. use during intercourse. A man's pattern of arousal
One type of personal trauma often associated often is not the same as a woman's pattern of arousal,
with sexual desire disorders in women is sexual and he may be making these decisions on the basis
assault (van Lankveld, 2008). A woman who has of his level of arousal and needs for stimulation,
been sexually assaulted may lose all interest in sex not understanding that hers may be different.
and become disgusted or extremely anxious when Most women have difficulty reaching orgasm
anyone, particularly a man, touches her. Her sex- by coitus alone and need oral or manual stimula-
ual aversion may become tied to a sense of vulner- tion of the clitoris to become aroused enough to
ability and loss of control or to a conditioned reach orgasm (Hite, 1976; Kaplan, 1974). Because
aversion to all forms of sexual contact. In addition, many men and women believe that men should be
male partners of women who have been sexually able to bring women to orgasm by penile insertion
assaulted sometimes cannot cope with the trauma and thrusting alone, women may never receive the
and withdraw from sexual encounters with the stimulation they need to be sufficiently aroused to
sexual assault survivor. Survivors then may feel orgasm. They may feel inhibited from telling their
victimized yet again, and their interest in sex may partner that they would like him to stimulate their
decline even further. clitoris more, because they are afraid of hurting
their partner 's feelings or angering him or because
Interpersonal and Sociocultural Factors they believe they do not have the right to ask for
Although our internal psychological states and be- the kind of stimulation they want. Some women
liefs play important roles in our sexuality, sex is fake an orgasm to protect their partner's ego. Of-
largely an interpersonal activity-one that societ- ten, their partner knows that they are not fully sat-
ies attempt to control. For this reason, interper- isfied, however. Communication between partners
sonal and sociocultural factors also play important may break down further, and sex may become a
roles in people's sexual interests and activities. forum for hostility rather than mutual pleasure
(McCarthy & Thestrup, 2008).
Interpersonal Factors Problems in intimate Conflicts between partners that are not directly
relationships are extremely common in people related to their sexual activity can affect their sex-
with sexual dysfunctions. Sometimes these prob- ual relationship as well, as we saw in the case of
lems are the consequences of sexual dysfunctions, Paul and Geraldine (McCarthy & Thestrup, 2008;
as when a couple cannot communicate about the Rosen & Leiblum, 1995). Anger, distrust, and lack
sexual d ysfunction of one partner and the two of respect for one's partner can greatly interfere
grow distant from each other. Relationship prob- with sexual desire and functioning. When one part-
lems also can be the direct cause of sexual dysfunc- ner suspects that the other partner has been un-
tions (McCarthy & Thestrup, 2008). faithful or is losing interest in the relationship, all
Conflicts between partners may be about the sexual interest may disappear. Often, there is an
couple's sexual activities (Meston & Bradford, imbalance of power in a relationship, and one part-
2007). One partner may want to engage in a type of ner feels exploited, subjugated, and underappreci-
sexual activity that the other partner is uncomfort- ated by the other partner, leading to problems in
able with, or one partner may want to engage in their sexual relationship (Rosen & Leiblum, 1995).
sexual activity much more often than the other part- Among people seeking treatment for sexual
ner. People with inhibited desire, arousal, or orgasm problems, women are more likely than men to re-
often have sexual partners who do not know how to port problems in their marital relationship, other
arouse their partner or are not concerned with their stressful events in their life, and higher levels of
psychological distress (Meston & Bradford, 2007). man does not have an erection, it is assumed that
Men seeking treatment are more likely than he does not want sex. In some African cultures, the
women to be experiencing other types of sexual preference is for a woman's vagina to be dry and
d ysfunction in addition to low sexual desire, such tight for sexual intercourse (Brown, Ayowa, &
as erectile d ysfunction. Brown, 1993). Several herbal treatments are used
to achieve this dryness.
Cultural Factors Other cultures recognize In surveys in the United States, less educated
types of sexual dysfunction not described in the and poorer men and women tend to experience
DSM-5. For example, both the traditional Chinese more sexual dysfunctions. Problems include hav-
medical system and the Ayurvedic medical sys- ing pain during sex, not finding sex pleasurable,
tem, which is native to India, teach that loss of se- being unable to reach orgasm, lacking interest in
men is detrimental to a man's health (Dewaraja & sex, climaxing too early, and, for men, having trou-
Sasaki, 1991). Masturbation is strongly discour- ble maintaining an erection (Laumann, Gagnon,
aged because it results in semen loss without the Michael, & Michaels, 1994; Lewis et al., 2010). Peo-
possibility of conception. A study of 1,000 consecu- ple in lower educational and income groups may
tive patients seeking treatment in a sexual clinic in have more sexual dysfunctions because they are
India found that 77 percent of the male patients under more psychological stress, because their
reported difficulties with premature ejaculation physical health is worse, or because they have not
and 71 percent were concerned about nocturnal had the benefit of educational programs that teach
emissions associated with erotic dreams (Verma, people about their bodies and about healthy social
Khaitan, & Singh, 1998). relationships. In addition, people from cultural
A depersonalization syndrome known as Koro, backgrounds that teach negative attitudes toward
thought to result from semen loss, has been re- sex are more likely to develop sexual dysfunctions
ported among Malaysians, Southeast Asians, and resulting from these attitudes (Gagnon, 1990).
southern Chinese. This syndrome involves an
acute anxiety state, characterized by a feeling of Trends Across the Life Span
panic and impending death, and a delusion that Our culture conveys the message that young
the penis is shrinking into the body and disappear- adults, particularly men, can't get enough sex but
ing (American Psychiatric Association, 2013). To that sexual activity declines steadily w ith age.
stop the penis from disappearing into the body, Supposedly, older adults (i.e., over about age 65)
the patient or his relatives may grab and hold the hardly ever have sex. While sexual activity is
penis until the attack of Koro is ended. greater among younger adults than among older
In Polynesian culture, there is no word for adults, many adults remain sexually active well
erection problems in men (Mannino, 1999). If a into old age (Bartlik & Goldstein, 200la, 2001b;
Laumann et al., 2008).
Age-related biological changes can affect sexual
functioning (Brotto & Luria, 2008; Lewis et al., 2010).
Both men and women need adequate levels of tes-
tosterone to maintain sexual desire. Testosterone
levels begin to decline in a person's 50s and con-
tinue to decrease steadily throughout the rest of the
person's life. Lower testosterone levels are associ-
ated with increased difficulty in achieving and
maintaining an erection (Agronin, 2009). Dimin-
ished estrogen levels in postmenopausal women
can lead to vaginal dryness and lack of lubrication
and thus to a reduction in sexual responsivity
(Brotto & Luria, 2008). In many cases of sexual dys-
function in older adults, the cause is not age itself
but rather medical conditions, which are more com-
mon in older age.
For both older men and older women, the loss
of a lifelong spouse, losses of other family members
Many older adults remain sexua lly active and experience little decline in sexual and friends, health concerns, and discomfort with
functioning. one's own aging can contribute to sexual problems
(Brotto & Luria, 2008). Conflicts and dissatisfactions
in a couple's relationship can worsen as the couple also may help men whose erectile dysfunction is
spends more time together following retirement caused by taking antidepressants, allowing them
and/or their children's moving out of the house. to continue taking the antidepressants without los-
Older couples may need to learn to be more flexible ing sexual functioning (Balon & Segraves, 2008).
and patient with each other as their bodies change In men with erectile disorder, certain drugs
and to try new techniques for stimulating each can be injected directly into the penis to induce an
other. A number of biological and psychosocial erection. Although this method is effective, it has
treatments are available for sexual dysfunctions in the obvious drawback of requiring injections
both older and younger people. (Lewis et al., 2008).
Mechanical interventions are available for
Treatments for Sexual men with erectile dysfunction (Lewis et al., 2008).
One device includes a cylinder that fits over the
Dysfunctions penis and connects to a manual or battery-powered
Because most sexual dysfunctions have multiple vacuum pump, which induces engorgement of the
causes, treatment may involve a combination of ap- penis with blood. Alternatively, prosthetic devices
proaches, often including biological interventions, can be surgically implanted into the penis to make
psychosocial therapy focusing on problems in a re- it erect. One prosthesis consists of a pair of rods
lationship or on the concerns of an individual client, inserted into the penis. The rods create a perma-
and sex therapies to help clients learn new skills for nent erection, which can be bent either up or down
increasing their sexual arousal and pleasure. against the body. Another type is a hydraulic in-
flatable device, which allows a man to create an
Biological Therapies erection by pumping saline into rods inserted in
If a sexual dysfunction is the direct result of an- the penis and then to relieve the erection by pump-
other medical condition, such as diabetes, treating ing out the saline. Erections achieved with these
the medical condition often will reduce the sexual devices technically are full erections but frequently
dysfunction (Incrocci & Gianotten, 2008). Simi- do not evoke bodily or mental feelings of sexual
larly, if medications are contributing to a sexual arousal (Delizonna et al., 2001).
dysfunction, adjusting the dosage or switching to For men suffering from premature ejaculation,
a different type of medication can relieve sexual some antidepressants can be helpful, including
difficulties. Also, getting a person to stop using fluoxetine (Prozac), clomipramine (Anafranil), and
recreational drugs such as marijuana can often sertraline (Zoloft). Several studies suggest that these
cure sexual dysfunction. drugs significantly reduce the frequency of prema-
A number of biological treatments are avail- ture ejaculation (Rowland & McMahon, 2008).
able for men with erectile disorder (Lewis et al., Several studies have examined the effects of
2008). The drug that has received the most media hormone therapy, specifically the use of testoster-
attention in recent years is sildenafil (trade name one, to increase sexual desire in men and women
Viagra). This drug has proven effective both in with hypoactive sexual desire disorder. Hormone
men whose erectile dysfunction has no known or- replacement therapy can be very effective for men
ganic cause and in men whose erectile dysfunction whose low levels of sexual desire or arousal are
is caused by a medical condition, such as hyper- linked to low levels of testosterone; they are not
tension, diabetes, or spinal cord injury (Lewis effective for men whose low sexual desire or
et al., 2008). Two other drugs, Cialis and Levitra, arousal is not linked to low levels of testosterone
have similar positive effects. These drugs do have (Segraves, 2003). For women, the effects of testos-
side effects, though, including headaches, flush- terone therapy are mixed (see review by Meston &
ing, and stomach irritation, and they do not work Bradford, 2007). Some studies find that high levels
in up to 44 percent of men (Bach et al., 2001). of testosterone increase sexual desire and arousal
Some antidepressants, particularly the selec- in women but also run the risk of significant side
tive serotonin reuptake inhibitors (SSRis), can effects, including masculinization (e.g., chest hair,
cause sexual dysfunctions. Other drugs can be voice changes) (Shifren et al., 2000). More moder-
used in conjunction with these antidepressants to ate levels of testosterone do not have consistent
reduce their sexual side effects (Balon & Segraves, effects on libido for women. Bupropion has proven
2008). One drug that has proven helpful in this re- helpful in treating some women with hypoactive
gard is bupropion, which goes by the trade names sexual desire (Segraves et al., 2004).
Wellbutrin and Zyban. Bupropion appears to re- Large controlled studies investigating the ef-
duce the sexual side effects of the SSRis and can fects of sildenafil for women with sexual dysfunc-
itself be effective as an antidepressant. Sildenafil tions also report mixed results (Basson et al., 2002;
Meston & Bradford, 2007; Nurnberg et al., 2008). experiences and to improve communication and
The drug does increase vasocongestion and lubri- interactions with their sexual partners.
cation in women, but these physiological changes
do not consistently lead to greater subjective Individual and Couples Therapy A therapist
arousal. It seems that, particularly for women, begins treatment by assessing the attitudes, beliefs,
achieving sexual arousal and pleasure takes more and personal history of an individual client or of
than physiological arousal. both members of a couple in order to discover expe-
riences, thoughts, and feelings that might be con-
Psychotherapy and Sex Therapy tributing to sexual problems. Cognitive-behavioral
The introduction of drugs, such as sildenafil, that interventions often are used to address attitudes
can overcome sexual dysfunctions, at least in men, and beliefs that interfere with sexual functioning
has dramatically changed the nature of treatments (McCarthy & Thestrup, 2008; Pridal & LoPiccolo,
for these disorders. Given the financial and time 2000; Rosen & Leiblum, 1995). For example, a man
constraints imposed by managed care, many peo- who fears that he will embarrass himself by not sus-
ple seeking treatment for a sexual dysfunction are taining an erection in a sexual encounter may be
offered only a medication and not psychotherapy challenged to examine the evidence of this having
(McCarthy & Thestrup, 2008). Also, many people happened to him in the past. If this has been a com-
want only a medication and do not want to engage mon occurrence for the man, his therapist would
in psychotherapy to address possible psychologi- explore the thought patterns surrounding the expe-
cal and interpersonal contributors to their sexual rience and then help the man challenge these cogni-
problems. tions and practice more positive ones. Similarly, a
A variety of psychotherapeutic techniques woman who has low sexual desire because she was
have been developed, however, and have been taught by her parents that sex is dirty would learn
shown to help people with sexual dysfunctions to challenge this belief and to adopt a more accept-
(Leiblum & Rosen, 2000). One technique is individ- ing attitude toward sex.
ual psychotherapy, in which individuals explore When one member of a couple has a sexual
the thoughts and previous experiences that impede dysfunction, it may be the result of problems in
them from enjoying a positive sexual life. Couples the couple's relationship, or, conversely, it may
therapy often helps couples develop more satisfy- be contributing to problems in the relationship.
ing sexual relationships. As part of both individual For this reason, many therapists prefer to treat
and couples therapy, behavioral techniques are sexual dysfunctions in the context of the couple's
used to teach people skills to enhance their sexual relationship, if possible, rather than focusing
only on the individual with the sexual dysfunc-
tion. The therapist may use role playing during
therapy sessions to observe how the couple dis-
cusses sex and how the partners perceive each
other's role in their sexual encounters (Pridal &
LoPiccolo, 2000) .
Some couples in long-term relationships have
abandoned the seduction rituals- those activities
that arouse sexual interest in both partners- they
followed when they were first together (McCarthy,
2001; Verhulst & Heiman, 1988). Couples in which
both partners work may be particularly prone to
try squeezing in sexual encounters late at night,
when both partners are tired and not really inter-
ested in sex. These encounters may be rushed or
not fully satisfying and can lead to a gradual de-
cline in interest in any sexual intimacy. A therapist
may encourage a couple to set aside enough time
to engage in seduction rituals and satisfying sex-
ual encounters (McCarthy, 1997). For example,
partners may decide to hire a babysitter for their
~any busy couples do not take time for activities that can maintain their sexual children, have a romantic dinner out, and then go
1terest in each other. to a hotel, where they can have sex without rush-
ing or being interrupted by their children.
Partners often differ in their scripts for sexual they need in order to become aroused (Meston &
encounters-their expectations about what will Bradford, 2007). Studies show that more than 80 per-
take place during a sexual encounter and about cent of anorgasmic women are able to have an or-
what each partner's responsibilities are (Pridal & gasm when they learn to masturbate and that 20 to
LoPiccolo, 2000). Resolving these differences in 60 percent are able to have an orgasm with their
scripts may be a useful goal in therapy. For exam- partner after learning to masturbate (Heiman,
ple, if a woman lacks desire for sex because she 2000). These women also report increased enjoy-
feels her partner is too rough during sex, a thera- ment and satisfaction from sex, a more relaxed at-
pist may encourage the partner to slow down and titude toward sex and life, and increased acceptance
show the woman the kind of gentle intimacy she of their body.
needs to enjoy sex. In general, therapists help part- The client's cognitions while engaging in new
ners understand what each wants and needs from sexual skills can be evaluated and used as a focus
sexual interactions and helps them negotiate mu- of therapy sessions (McCarthy & Thestrup, 2008).
tually acceptable and satisfying repertoires of sex- For example, a woman who is learning how to
ual exchange. masturbate for the first time may realize that she
When the conflicts between partners involve has thoughts such as ''I'm going to get caught, and
matters other than their sexual practices, the thera- I'll be so embarrassed"; "I shouldn't be doing
pist will focus primarily on these conflicts and only this-this is sinful"; and "Only pathetic people do
secondarily on the sexual dysfunction. Such con- this" while masturbating. A cognitive-behavioral
flicts may involve an imbalance of power in the rela- therapist can then help the woman address the ac-
tionship, distrust or hostility, or disagreement over curacy of these thoughts and decide whether she
important values or decisions. Cognitive-behavioral wants to maintain this attitude toward masturba-
therapies are used most commonly, although some tion. If the woman is in psychodynamic therapy,
therapists use psychodynamic interventions and the therapist might explore the origins of the wom-
some use interventions based on family systems an's attitudes about masturbation in her early rela-
therapy. Cognitive-behavioral therapies have been tionships. Thus, the behavioral techniques of sex
researched more than other types of therapy and therapy not only directly teach the client new sex-
have been shown to be effective for several types of ual skills but also provide material for discussion
sexual dysfunction (see Leiblum & Rosen, 2000; in therapy sessions.
Meston, Seal, & Hamilton, 2008).
Sensate Focus Therapy One of the mainstays
Sex Therapy Whether a therapist uses a cognitive- of sex therapy is sensate focus therapy (Altho,
behavioral or some other therapeutic approach 2000; Masters & Johnson, 1970). In the early phases
to address the psychological issues involved in a of this therapy, partners are instructed not to be
sexual dysfunction, direct sex therapy using be- concerned about or even to attempt intercourse.
havioral techniques may be a part of the therapy. Rather, they are told to focus intently on the plea-
When a sexual dysfunction seems to be due, at sure created by the exercises. These instructions
least in part, to inadequate sexual skill on the part are meant to reduce performance anxiety and any
of the client and his or her partner, sex therapy that concern about achieving orgasm.
focuses on practicing skills can be useful. Some In the first phase of sensate focus therapy,
people have never learned what gives them or partners spend time gently touching each other,
their partner pleasure or have fallen out of the but not around the genitals. They are instructed to
habit of engaging in some practices. Sex therapy focus on the sensations and to communicate with
both teaches skills and helps partners develop a each other about what does and does not feel good.
regular pattern of engaging in satisfying sexual The goal is to have the partners spend intimate
encounters. time together communicating, without pressure
Sex therapy often includes teaching or encour- for intercourse. This first phase may continue for
aging clients to masturbate (Heiman, 2000; Meston several weeks, until the partners feel comfortable
et al., 2008). The goals of masturbation are for peo- with the exercises and have learned what gives
ple to explore their bodies to discover what is each of them pleasure.
arousing and to become less inhibited about their In the second phase of sensate focus therapy, the
sexuality. Then individuals are taught to commu- partners spend time directly stimulating each oth-
nicate their newly discovered desires to their part- er's breasts and genitals, but still without attempt-
ners. This technique can be especially helpful for ing intercourse. If the problem is a female sexual
anorgasmic women, many of whom have never interest/ arousal disorder, the woman guides her
masturbated and have little knowledge of what partner to stimulate her in arousing ways. It is
help couples recognize and confront the complex ~

personal and interpersonal issues that may be
interfering with their enjoyment of sex.
Murray, a 53-year-old suc-

cessful insurance agent, and his wife, a 50-year-
old nutritional counselor, had been married for
28 years. With the exception of time spent on
vacation, Murray had a 7-year history of erectile
dysfunction. The frequency of their lovemaking
had gradually declined to its current level of once
every 4 months. Murray reported considerable
performance anxiety, enhanced by his competi-
tive personality style. He summed up his di-
lemma: "When you have a life full of successes,
you don't get much practice at how to deal with
inadequacy:'
During the first hour of therapy, sensate fo-
cus exercises were suggested and instructions
given to engage in sensual nongenital touching.
They returned in a week, noting how difficult it
had been to find time to pleasure one another.
Their mutual avoidance was discussed and un-
derstood as a means of warding off feelings of
inadequacy. Working through the resistance al-
In sensate focus therapy, couples are encouraged to lowed the couple to engage in the exercises
spend time exploring what sexually arouses each of three times over the course of the next week.
them without feeling pressured to reach orgasm.
With the pleasuring, Murray began to achieve
good, long-lasting erections.
Therapy then progressed to include genital
acceptable for a woman to be aroused to orgasm
touching. After the first week, they talked about
during these exercises, but the partners are instructed
their problem of "silliness:' They realized that hu-
not to attempt intercourse until she regularly be-
mor had been used to cope with the dysfunction.
comes fully aroused by her partner during the sen-
Now, however, joking in bed seemed to inhibit
sate focus exercises. If the problem is a male erectile
sexual closeness. Murray's good erections were
~isorder, the man guides his partner in touching him
maintained, although he was having trouble con-
rn ways that feel arousing. If he has an erection, he is
centrating on his sensations. Further exploration
to let it come and go naturally. Intercourse is forbid-
revealed that he was focusing his attention in a
den until he is able to have erections easily and fre-
driven, intense manner. To counter this, the ther-
quently during the sensate focus exercises.
apist redirected him to maintain a relaxed aware-
Throughout these exercises, the partner with
ness akin to meditation. Murray found this
the problem is instructed to be selfish and to focus
analogy helpful, and the couple felt ready to pro-
only on the arousing sensations and on communi-
ceed with vaginal containment. During the fol-
cating with his or her partner about what feels
lowing week, they "disobeyed" and moved on to
good. The touching should proceed in a relaxed
have mutually satisfying intercourse. They feared
and nondemanding atmosphere. Once the partner
the recurrence of the old problem, but it did not
with the problem regularly experiences arousal
return, and the remaining two sessions were
wit~ ge~tal stimulation, the partners may begin
spent talking about their sexual life. Despite oth-
havrng rntercourse, but the focus remains on en-
erwise good communication, they had never
hancing and sustaining pleasure rather than on
been able before to broach this topic with one
orgasm or performance.
another. (Aithof, 2000, p. 270)
The following case study indicates how the be-
havioral techniques of sensate focus therapy can
Techniques for Treating Early Ejaculation (McCarthy,2001). The man's partner stimulates him
Two techniques are useful in helping a man with to an erection, and then, when he signals that ejacu-
early ejaculation gain control over his ejaculations: lation is imminent, his partner applies a firm but
the stop-start technique (Semans, 1956) and the gentle squeeze to his penis, either at the head or at
squeeze technique (Masters & Johnson, 1970). The the base, for 3 or 4 seconds. This results in a partial
stop-start technique can be carried out either loss of erection. The partner then can stimulate him
through masturbation or with a partner. In the first again to the point of ejaculation and use the squeeze
phase, the man is told to stop stimulating himself technique to stop the ejaculation. The goal of this
or to tell his partner to stop stimulating him just technique, as with the stop-start technique, is for the
before he is about to ejaculate. He then relaxes and man with a premature ejaculation disorder to learn
concentrates on the sensations in his body until his to identify the point of ejaculatory inevitability and
level of arousal declines. At that point, he or his control his arousal level at that point.
partner can resume stimulation, again stopping
before the point of ejaculatory inevitability. If stim- Techniques for Treating Pelvic Muscle
ulation stops too late and the man ejaculates, he is Tightening Pelvic muscle tightening is often
encouraged not to feel angry or disappointed but treated by deconditioning the woman's automatic
to enjoy the ejaculation and reflect on what he has tightening of her vaginal muscles (Leiblum, 2000).
learned about his body and then resume the exer- She is taught about the muscular tension at the
cise. If a man is engaging in this exercise with a opening of her vagina and the need to learn to re-
female partner, they are instructed not to engage in lax those muscles. In a safe setting, she is instructed
intercourse until he has sufficient control over his to insert her fingers into her vagina. She examines
ejaculations during her manual stimulation of him. her vagina in a mirror and practices relaxation ex-
In the second phase of this process, when a fe- ercises. She may also use silicon or metal vaginal
male partner is involved, the man lies on his back dilators made for this exercise. Gradually, she in-
with his female partner on top of him, and she in- serts larger and larger dilators as she practices re-
serts his penis into her vagina but then remains laxation exercises and becomes accustomed to the
quiet. Most men with premature ejaculation have feel of the dilator in her vagina. If she has a partner,
intercourse only in the man-on-top position, with his or her fingers may be used instead of the dila-
quick and short thrusting during intercourse, tor. If the woman has a male partner, eventually
which makes it very difficult for them to exert con- she guides his penis into her vagina while remain-
trol over their ejaculations. The goal is for the man ing in control.
to enjoy the sensation of being in the woman's va-
gina without ejaculating. During the exercise, he is Gay, Lesbian, and
encouraged to touch or massage his partner and to
Bisexual People
communicate with her about what each is experi-
encing. If he feels he is reaching ejaculatory inevi- Gay, lesbian, and bisexual people experience sexual
tability, he can request that she dismount and lie dysfunctions for the same reasons as heterosexual
next to him until his arousal subsides. Partners are people, such as medical disorders, medications, ag-
encouraged to engage in this exercise for at least 10 ing, or conflicts with partners. Gay, lesbian, and
to 15 minutes, even if they must interrupt it several bisexual people face additional stressors related to
times to prevent the man from ejaculating. their sexuality due to continuing stigma and dis-
In the third phase of the stop-start technique, crimination against them (Gilman et al., 2001).
the woman creates some thrusting motion while still Therapists treating gay, lesbian, or bisexual cli-
on top of her partner but uses slow, long strokes. The ents must be sensitive to the psychological stresses
partners typically reach orgasm and experience the these clients face as a result of society's rejection of
entire encounter as highly intimate and pleasurable. their sexual orientation, as well as to the contribu-
Female partners of men with premature ejaculation tions of these stresses to their sexual functioning.
often have trouble reaching orgasm themselves, be- Most of the sex therapy treatments can readily be
cause the men lose their erection after ejaculating, adapted for gay, lesbian, or bisexual couples.
long before the women are highly aroused, and ten- The attitude of clinical psychology as a profes-
sion is high between the partners during sex. The sion toward homosexuality changed several de-
stop-start technique can create encounters in which cades ago. Early versions of the DSM listed
the female partner receives the stimulation she homosexuality, particularly ego-dystonic homosexual-
needs to reach orgasm as well. ity (which meant that the person did not want to be
The squeeze technique is used somewhat homosexual), as a mental disorder. Gay men, lesbi-
less often because it is harder to teach to partners ans, and bisexual people argue that their sexual
orientation is a natural part of themselves. Apart The definitions of the paraphilias and paraphilic
from society's homophobia, their orientation disorders are highly controversial. The DSM-5 at-
causes them no discomfort. In addition, there is tempted to tighten the definition of a paraphilic dis-
little evidence that psychotherapy can lead a ho- order by specifying that the presence of a paraphilia
mosexual person to become heterosexual. In 1973, does not constitute a disorder and that a diagnosis
the American Psychiatric Association removed can be given only when the behaviors cause the per-
homosexuality from its list of recognized psycho- son distress or impairment or cause others harm.
logical disorders (Spitzer, 1981). However, questions remain as to why some varia-
tions in sexual behavior are considered mental dis-
orders while others are not (Gijs, 2008). On the other
PARAPHILIC DISORDERS hand, labeling sexual behaviors that involve victims,
People vary greatly in the sexual activities they find such as pedophilia, as mental disorders runs the risk
arousing (see Table 13.2). Atypical sexual prefer- of providing an "excuse" for behaviors that society
ences have been called paraphilias (Greek for besides wishes to forbid and punish (Gijs, 2008).
and love) . Paraphilias are sometimes divided into Some researchers wanted to include a disorder
those that involve the consent of others (e.g., some called paraphilic coercive disorder in the DSM-5;
sadomasochistic practices) and those that involve this diagnosis would apply to individu als who de-
nonconsenting others (e.g., voyeurism). They also rive sexual pleasure from coercing others into non-
can be divided into those that involve contact with consensual sex (i.e., rape). Not surprisingly, this
others (e.g., pedophilia) and those that do not nec- proposal raised a firestorm of concern (Frances &
essarily involve contact with others (e.g., some fe- First, 2011; Knight, 2010; Wollert & Cramer, 2011),
tishes). The DSM-5 specifies that paraphilias are and the authors of the DSM-5 decided to reject the
not in and of themselves mental disorders, and proposal, once again confirming that rape is not a
cannot be diagnosed as a paraphilic disorder. A mental disorder but a criminal act. Another pro-
paraphilic disorder is a paraphilia that is currently posed but rejected for inclusion in DSM-5 diagnosis
causing the individual significant distress or im- is hypersexual disorder, which is characterized by
pairment, or entails personal harm or risk of harm excessive preoccupation with sexual fantasies,
to others. Table 13.3 lists the paraphilic disorders urges, and activities (sometimes referred to as sexual
recognized by the DSM-5. addiction) and lasts at least 6 months. Again, initial
proposals to include this diagnosis in the DSM-5
(Kafka, 2010) met with sharp criticism that there was
TABLE 13.2 The Kinds of Sexual Practices People insufficient evidence for its validity as a psychiatric
Find Appealing disorder (Halpern, 2011; Moser, 2011), though a later
study suggested high reliability on validity when
A nati onal survey of 18- to 44-year-olds found th at many different sexual applied in a clinical setting (Reid et al., 2012). The
practices appeal to people, with men find in g more activities appealing problem of sexual addiction awaits further study,
than do women.
while those individuals with sexual addictions (such
Percent Saying as excessive pornography use) and associated dis-
"Very Appealing" tress or impairment will seek treatment for a prob-
Practice
lem that is not yet defined as a mental disorder.
Men Women
These controversies are difficult to resolve be-
Vaginal interco urse 83% 78% cause they involve moral judgments and powerful
Watching partner undress 50 30
social norms. In addition, the research literature on
Receiving oral sex 50
most paraphilic disorders is limited and inconsis-
33
Giving oral sex
tent, providing little information on which to base
37 19
judgments about how pathological these behav-
Group sex 14 1
iors are (Laws & O'Donohue, 2008).
Anus stimulated by partne r's finge rs 6 4
Using dildos/vibrators 5 3
Fetishistic Disorder and
Watch ing others do sexual things 6 2
Having a same-gender sex partner 4 3
Transvestic Disorder
Having sex with a stranger 5 Fetishistic disorder involves the use of nonliv-
ing objects or nongenital body parts for sexual
Source: M ichael et al., 1994. arousal or gratification. Commonly eroticized
body parts include feet, toes, and hair. Soft fe-
tishes are objects that are soft, furry, or lacy, su ch
Paraphilic Disorders 381
TABLE 13.3 Paraphilic Disorders
The paraphilic disorders involve atypical, recurrent, intense sexually arousing fantasies, sexual urges, or
behaviors that cause the individual significant distress or impairment, or entail harm to others or the risk of harm.
Diagnosis Object of Fantasies, Urges, or Behaviors
Fetishistic disorder Nonliving objects (e.g ., female undergarments} or nongenital body part(s}
Transvestic disorder Cross-dressing
Sexual sadism disorder Acts (real, not simulated) involving the physical or psychological
suffering (including humiliation) of another person
Sexual masochism disorder Acts (real, not simulated) of being humiliated, beaten, bound, or otherwise
made to suffer
Voyeuristic disorder Act of observing an unsuspecting person who is naked, in the process of
undressing, or engaged in sexual activity
Exhibitionistic disorder Exposure of one's genitals to an unsuspecting stranger
Frotteuristic disorder Touching and rubbing against a nonconsenting person
Pedophilic disorder Sexual activity with a prepubescent child or children
as frilly lingerie, stockings, and garters. Hard fe-

tishes are objects that are smooth, harsh, or black, He found pretexts to "wander" into the bedrooms
such as spike-heeled shoes, black gloves, and of women during social occasions and would
garments made of leather or rubber (Darcangelo, quickly rummage through their possessions until
Hollings, & Paladino, 2008). These soft and hard he found a pa ir of panties to his satisfaction. He
objects are somew hat arousing to m any people later used these to masturbate into and then
and, indeed, are promoted as such by their man- "saved them" in a "private cache:' The pattern of
ufacturers. For most people, however, the objects masturbating into women's underwear had been
simply add to the sexiness of the people wearing his preferred method of achieving sexual excite-
them, and their d esire is for sex with those peo- ment and orgasm from adolescence until the
ple. For the person with a fetish, the desire is for present co nsultation.
the object itself (Darcangelo et al., 2008), as in the The patient first had sexual intercourse at 18.
following case study. Since then he had had intercourse on many occa-
sions, and his preferred partner was a prostitute
paid to wear panties, with the crotch area cut
- away, during the act. On less common occasions
CASE STUDY:. when sexual activity was attempted with a part-
A 32-year-old, single, male ner who did not wear panties, his sexual excite-
freelance photographer presented with the chief ment was sometimes weak.
complaint of "ab normal sex drive:' The patient The patient felt uncomfortable dating " nice
related that although he was somewhat sexually women" as he felt that friendliness might lead to
attracted by women, he was far more attracted sexual intimacy and that they would not under-
by "their panties: stand his sexual needs. He avoided socializing
To the best of the patient's memory, sexual with friends who might introduce him to such
excitement began at about age 7, when he came women. He recognized that his appearance, social
upon a pornographic magazine and felt stimu- style, and profession all resulted in his being per-
lated by pictures of partially nude women wear- ceived as a highly desirable bachelor. He felt anx-
in g panties. His first ejaculation occurred at 13 via ious and depressed because his social life was
masturbation to fantasies of women wearing limited by his sexual preference. (Reprinted from
panties. He masturbated into his older sister's the DSM-IV- TR Casebook: A Learning Companion
panties, which he had stolen without her knowl- to the Diagnostic and Statistical Manual of Mental
edge. Subseq uently, he stole panties from her Disorders, Fourth Edition, Text Revision. Copyright
friends and from other women he met socially. 2000 American Psychiatric Association.}
Fetishistic disorder is almost ex- Sexual Sadism and Sexual

clusively reported in males in clini- Masochism Disorders
cal samples. Although many men
may engage in fetishistic behavior, Sexual sadism and sexual masochism are two
perhaps less than 1 percent would separate diagnoses, although sadistic and mas-
be diagnosed with a disorder, be- ochistic sexual practices often are considered to-
cause their behavior does not cause gether as a pattern referred to as sadomasochism.
significant distress or impairment In sexual sadism disorder, a person's sexual fan-
(Darcangelo, 2008). tasies, urges, or behaviors involve inflicting pain
One variation on fetishism is and humiliation on his or her sex partner. Further,
transvestic disorder, or dressing in for the diagnosis to be given, the urges must
the clothes of the opposite sex as cause the person significant distress or impair-
a means of becoming sexually ment in functioning or the person must have
aroused. The diagnosis requires that acted on these urges with a nonconsenting per-
the cross-dressing behavior cause son. In sexual masochism disorder, a person's
the individual significant distress or sexual fantasies, urges, or behaviors involve suf-
impairment. Transvestic disorder fering pain or humiliation during sex, and they
can be distinguished from transves- must cause the person significant distress or im-
tism, which is cross-dressing behav- pairment in functioning.
ior that may or may not be for the Similarly, some people occasionally engage in
purposes of sexual arousal or gratifi- mild or moderately sadistic or masochistic behav-
cation (Wheeler, Newring, & Draper, iors during sex or simulate such behaviors with-
2008). One community-based study out actually carrying through with the infliction
Transvestic disorder involves found that 2.8 percent of men and of pain or suffering (Hucker, 2008). These people
wearing the clothes of the opposite 0.4 percent of women reported en- probably would not be given a diagnosis, espe-
sex. sometimes including a wig and gaging in cross-dressing for sexual cially if their behaviors occur in the context of a
makeup for men, a s a way to
arousal (Langstrom & Zucker, 2005). trusting relationship in which boundaries have
achieve sexual arousal.
For many men who engage in been set and safety measures are in place (e.g.,
cross-dressing, it is not the women's having a "safe word" that, when uttered by either
clothes themselves that are sexually partner, stops the behavior). People diagnosed
arousing but dressing in women's clothes. They may with sexual sadism disorder or sexual masochism
surreptitiously wear only one women's garment, disorder typically engage in sadistic and masoch-
such as a pair of women's panties. Or they may dress istic behaviors as their preferred or exclusive form
fully in women's garments, complete with makeup of sexual gratification.
and a wig. Some men engage in cross-dressing The sexual rituals in sadism and masochism
alone. Others participate in transvestite subcultures, disorders are of four types: physical restriction,
in which groups of men gather for drinks, meals, which involves the use of bondage, chains, or
and dancing while dressed as women (Wheeler et handcuffs as part of sex; the administration of pain,
al., 2008). About half of men who engage in cross-
dressing for sexual gratification find the behavior
acceptable and thus might not meet the DSM-5 crite-
ria for the disorder (Langstrom & Zucker, 2005).
Most adults who engage in cross-dressing re-
port that the behavior began secretly prior to
or during puberty (Wheeler et al., 2008). The func-
tion of the cross-dressing at young ages may not be
explicitly sexual but instead may be more generally
pleasurable or exciting or may alleviate negative
psychological states associated with male gender
roles. With puberty, cross-dressing activities increas-
ingly are paired with sexual behavior. Most men
who engage in cross-dressing are married and have
children (Langstrom & Zucker, 2005). With age, the Sexual sadism and sexual masochism exist along a
sexual function of cross-dressing may diminish even continuum . More moderate forms that occur between
consenting adults, such as those portrayed in the
as men continue to cross-dress as a self-soothing
blockbuster romance Fifty Shades of Grey, by E. L.
behavior to achieve feelings of comfort or well-being James, would likely not qualify for a DSM-5 diagnosis.
(Newring, Wheeler, & Draper, 2008).
SHADES OF GRAY
Read the following case study. Transvestia, he began to increase his cross-dressing
activity. He learned there were other men like him-
Mr. A., a 65-year-old security guard, is distressed self, and he became more and more preoccupied
about his wife's objections to his wearing a night- with female clothing in fantasy and progressed to
gown at home in the evening, now that his young- sometimes dressing completely as a woman.
est child has left home. His appearance and More recently he has become involved in a trans-
demeanor, except when he is dressing in women's vestite network, writing to other transvestites
clothes, are always masculine, and he is exclu- contacted through the magazine and occasionally
sively heterosexual. Occasionally, over the past attending transvestite parties. These parties have
5 years, he has worn an inconspicuous item of been the only times that he has cross-dressed out-
female clothing even when dressed as a man- side his home.
sometimes a pair of panties, sometimes an Although still committed to his marriage, sex
ambiguous pinkie ring. He always carries a photo- with his wife has dwindled over the past 20 years
graph of himself dressed as a woman. as his waking thoughts and activities have be-
His first recollection of an interest in female come increasingly centered on cross-dressing.
clothing was putting on his sister's underwear at Over time this activity has become less eroticized
age 12, an act accompanied by sexual excitement. and more an end in itself, but it still is a source of
He continued periodically to put on women's some sexual excitement. He always has an in-
underpants-an activity that invariably resulted in creased urge to dress as a woman when under
an erection, sometimes a spontaneous emission, stress; it has a tranquilizing effect. If particular
and sometimes masturbation but never accom- circumstances prevent him from cross-dressing,
panied by fantasy. Although he occasionally wished he feels extremely frustrated. (Reprinted from the
to be a girl, this desire never figured into his sex- DSM-IV-TR Casebook: A Learning Companion to
ual fantasies. During his single years he was always the Diagnostic and Statistical Manual of Mental
attracted to women but was shy about sex. Disorders, Fourth Edition, Text Revision. Copyright
Following his marriage at age 22, he had his first 2000 American Psychiatric Association.)
heterosexual intercourse.
His involvement with female clothes was of Should Mr. A. be diagnosed with transvestic
the same intensity even after his marriage. At age disorder? (Discussion appears at the end of
45, after a chance exposure to a magazine called this chapter.)
in which one partner inflicts pain or harm on the far. A particularly dangerous activity is hypoxy-
other with beatings, whippings, electrical shock, philia, which involves sexual arousal by means of
burning, cutting, stabbing, strangulation, torture, oxygen deprivation, obtained by placing a rope
mutilation, or even death; hypermasculinity prac- around the neck, putting a plastic bag or mask
tices, including the aggressive use of enemas, fists, over the head, or exerting severe chest compres-
and dildos in the sexual act; and humiliation, in sion (Hucker, 2008). Accidents involving hypoxy-
which one partner verbally and physically humili- philia can result in permanent injury or death.
ates the other during sex (Sandnabba, Santtila,
Alison, & Nordling, 2002). The partner who is the
victim in such encounters may be either a masoch- Voyeuristic, Exhibitionistic,
ist and a willing victim or a nonconsenting victim.
A variety of props may be used in these encounters,
and Frotteuristic Disorders
including black leather garments, chains, shackles, Voyeurism, as a form of sexual arousal, involves
whips, harnesses, and ropes. Men are much more watching another person undress, do things in the
likely than women to enjoy sadomasochistic sex, in nude, or have sex. Voyeurism is probably the most
the roles of both sadist and masochist (Sandnabba common illegal paraphilia (Langstrom, 2009). A
et al., 2002). Some women find such activities excit- survey of 2,450 randomly selected adults from the
ing, but many consent to them only to please their general population of Sweden found that 12 per-
partners or because they are paid to do so, and cent of the men and 4 percent of the women re-
some are nonconsenting victims of sadistic men. ported at least one incident of being sexually aroused
Although sadomasochistic sex between con- by spying on others having sex (Langstrom &
senting adults typically does not result in physical Seto, 2006) . A study of 60 male college students
injury, the activities can get out of control or go too in the United States suggested that 42 percent
had secretly watched others in sexual situations

him, and usually he would then ejaculate. He
(Templeman & Stinnet, 1991).
also fantasized about past encounters while
For a diagnosis of voyeuristic disorder to be
made, the voyeuristic behavior must be repeated masturbating. He feels guilty and ashamed after
over 6 months and must be compulsive. Further, exhibiting himself and vows never to repeat it.
for a diagnosis to be given, the urges must cause Nevertheless, the desire often overwhelms him,
the person significant distress or impairment in and the behavior recurs frequently, usually at
functioning or the voyeur must have acted on periods of tension. (Reprinted from the DSM-
these urges with a nonconsenting person. Most IV- TR Casebook: A Learning Companion to the
people who engage in voyeurism are men who Diagnostic and Statistical Manual of Mental
watch women (Lavin, 2008). They may masturbate Disorders, Fourth Edition,Text Revision. Copyright
during or immediately after the act of watching. 2000 American Psychiatric Association.)
The person who engages in exhibitionism ob-
tains sexual gratification by exposing his or her
genitals to involuntary observers, who usually are
strangers. The survey in Sweden cited above found
People who engage in exhibitionism are more
that 4.1 percent of men and 2.1 percent of women
likely than most sex offenders to get caught, in
reported having experienced sexual arousal from
part because of the public nature of their behavior.
exposing their genitals to a stranger at least once in
In addition, some of them repeatedly return to
their life (Langstrom & Seto, 2006). In order to ob-
places where they have already exhibited them-
tain the diagnosis of exhibitionistic disorder, indi-
selves. The danger of being caught heightens their
viduals must have acted on their urges to engage in
arousal. People who engage in exhibitionism are
the behavior, or the behavior must cause significant
also likely to continue their behavior after having
distress or impairment. Most exhibitionists are men,
been caught (Murphy & Page, 2008).
and their targets tend to be women, children, or
Frotteurism is a paraphilia that often co-occurs
adolescents (Murphy & Page, 2008). The exhibition-
with voyeurism and exhibitionism. The person who r--..
ist typically confronts his victim in a public place,
engages in frotteurism gains sexual gratification
such as at a park or on a bus. His arousal comes
from rubbing against and fondling parts of the body
from observing the victim's surprise, fear, or dis-
of a nonconsenting person. Often, this happens in
gust or from a fantasy that his victim is becoming
crowded places, such as an elevator, and the target
sexually aroused. His behavior often is compulsive
may not recognize the contact as sexual (Krueger &
and impulsive-he feels a sense of excitement, fear,
Kaplan, 2008). In order to receive the diagnosis of
restlessness, and sexual arousal and then feels com-
frotteuristic disorder, individuals must have acted
pelled to find relief by exhibiting himself (Murphy &
on their urge~ to e~ga?~ in the behavior, or the urges
~ag~, 2008). Some people who engage in exhibi-
must be causmg Significant distress or impairment.
horusm masturbate while exhibiting themselves.
Most people who engage in frotteurism are males,
Others draw on memories or fantasies of exposing
and the onset of the disorder most often is in early
themselves to arouse themselves while masturbat-
adulthood (Lussier & Piche, 2008).
ing, as in the following case study.
Pedophilic Disorder
People with pedophilic disorder have sexual fanta-
si~s, urges, and behaviors focused on prepubescent
A 27-year-old engineer re-
quested consultation at a psychiatric clinic be-
children. To be diagnosed with pedophilic disorder
cause of irresistible urges to exhibit his penis to
the individual must have acted on the urges, or th~
female strangers. At age 18, for reasons un-
urges must have caused significant distress or im-
known to himself, he first experienced an over-
pairment. Most people with pedophilic disorder are
whelming desire to engage in exhibitionism. He
heterosexual men attracted to young girls (Seto,
sought situations in which he was alone with a
2008). Homosexual men with pedophilia typically
woman he did not know. As he approached her, are. ~ttracted ~o ~oung boys. Women can have pedo-
he would become sexually excited. He would then
philia, but this Situation is rarer.
DSM-5 recognizes that pedophilic disorder can
walk up to her and display his erect penis. He
found that her shock and fear further stimulated
be exclusive (i.e., attracted only to children) or non-
exclusive. Additional specifiers indicate whether
an individual is sexually attracted to males,
females, or both, and whether the pedophilic be-

Intellectually, Dr. Crone knew that others would
havior is limited to incest.
Not all individuals with pedophilic fantasies disapprove of his many sexual involvements with
engage in sexual contact with children; instead, young girls. He never believed, however, that he
many use child pornography to become sexually had caused any of these youngsters harm, feeling
aroused (Seto, 2009). Still, most of what we know instead that they were simply sharing pleasurable
about pedophilia is based on studies conducted feelings together. He frequently prayed for help
with individuals who have committed sexual of- and that his actions would go undetected. He
fenses with children. Sexual encounters between kept promising himself that he would stop, but
people with pedophilic disorder and their child the temptations were such that he could not.
victims often are brief, although they may recur (Reprinted from the DSM-IV-TR Casebook: A
frequently. People with pedophilic disorder may Learning Companion to the Diagnostic and
threaten children with harm, physically restrain Statistical Manual of Mental Disorders, Fourth
them, or tell them that they will punish them or Edition, Text Revision. Copyright 2000 American
their loved ones if the children do not comply. Psychiatric Association .)
Other people with pedophilic disorder are loving,
caring, and gentle to the child, using emotional
closeness to gain sexual access to the child. This is
The impact on the child victims of people with
especially true in incestuous relationships, in
pedophilic disorder can be great. The most fre-
which people with pedophilic disorder may see
quent symptoms shown by sexually abused chil-
themselves as simply being good, loving parents.
dren are fearfulness, posttraumatic stress disorder,
They believe that what they do to the child is not
conduct disorder and hyperactivity, sexualized be-
sexual but loving (Seto, 2009). Some predatory in-
haviors (promiscuity and sexual behavior inap-
dividuals with pedophilic disorder develop elabo-
propriate for their age), and poor self-esteem
rate plans for gaining access to children, such as
(Kendall-Tackett et al., 1993; McConaghy, 1998).
winning the trust of the mother or marrying the
More severe symptoms are experienced by chil-
mother, trading children with other people with
dren who endure frequent abuse over a long pe-
pe~ophilic disorder, or, in rare cases, abducting
riod, who are penetrated by the perpetrator, who
ch1ldren or adopting children from foreign coun-
are abused by a family member (typically, a father
tries (McConaghy, 1998).
or stepfather), and whose mother does not provide
support on learning of the abuse. About two-thirds
of victimized children show significant recovery
from their symptoms within 12 to 18 months fol-
lowing cessation of the abuse, but significant
Dr. Crone, a 35-year-old, numbers of abused children continue to experi-
single child psychiatrist, had been arrested and ence psychological problems even into adulthood
convicted of fondling several neighborhood (Burnam et al., 1988; Kendall-Tackett et al., 1993).
girls, ages 6 to 12. Friends and colleagues were
shocked and d ismayed, as he had been consid- Causes of Paraphilias
ered by all to be particularly caring and support-
ive of children.
Beha:ioral theories of the paraphilias explain them
Dr. Crone's first sexual experience was at age
as bemg due to an initial classical pairing of intense
early sexual arousal with a particular stimulus
6, when a 15-year-old female camp counselor
(Figure 13.4; Gijs, 2008). For example, a child may
performed fellatio on him several times over the
course of the summer-an experience that he
become aroused when spying on the babysitter's
lovemaking with her boyfriend or while being held
had always kept to himself. As he grew older, he
down and tickled erotically. This may be followed
was surprised to notice that the age range of girls
b~ inten~ive operant conditioning in which the
who attracted him sexually did not change, and
stimulus 1s present during masturbation. For exam-
he continued to have recurrent erotic urges and
ple, the individual may repeatedly fantasize about a
fantasies about girls between ages 6 and 12.
particular scenario, such as watching the babysitter
Whenever he masturbated, he would fantasize
have sex, while masturbating. This reinforces the
about a girl in that age range, and on a couple of
occasions over the years, he had felt himself to
association between the stimulus and sexual
arous~l. The individual may try to suppress the
be in love with such a youngster.
un~es~r~~ ar~usal or behaviors, but these attempts
at inh1b1t1on mcrease the frequency and intensity
property crimes and did not have a paraphilia

A Behavioral Account
(Lee, Jackson, Pattison, & Ward, 2002). Childhood
FIGURE 13.4 of the Development
sexual abuse was a particularly strong predictor
of Paraphilias
of pedophilia. Similarly, studies of juvenile sex
offenders, most of whom assaulted a younger
Initial pairing of child, find that many likely suffered sexual abuse
stimulus and arousal (Gerardin & Thibaut, 2004).
-4
(may be accidental or
vicarious) Cognitive theorists have also identified anum-
ber of distortions and assumptions that people
Lack of alternative with a paraphilia have about their behaviors and
sexual reinforcement
opportunities and skills the behaviors of their victims, as listed in Table 13.4
for relating appropriately (Gerardin & Thibaut, 2004; Maletzky, 1998). These
to others Inappropriate sexual distortions may have been learned from parents'
fantasies repeatedly deviant messages about sexual behavior. They are
paired with masturbation
used to justify the person's victimization of others.
Several lines of evidence suggest that altera-
tions in the development of the brain and hormonal
Attempts to inhibit systems may contribute to pedophilia (Seto, 2008).
fantasies and behavior, Men with pedophilia are more likely to have had a
increasing their frequency
and intensity
head injury before age 13, to have cognitive and
memory deficits, to have lower intelligence, and to
have differences in brain structure volume (Cantor
et al., 2008). In addition, some small studies suggest
that men with pedophilia have dysfunctions in the
frontal areas of the brain involved in regulating im-
pulsive and aggressive behavior and in testoster-
one levels (Jordan, Fromberger, Stolpmann, &
of the fantasies. Eventually, the sexual arousal may Muller, 2011). How these factors specifically con-
generalize to other stimuli similar to the initial tribute to pedophilia is not yet clear.
fantasy, such as actually watching other people's
lovemaking, leading to paraphilic behavior (e.g.,
Treatments for the Paraphilias
voyeurism). Some people with paraphilia appear
to have a strong sex drive and masturbate often, Most people with a paraphilia do not seek treat-
providing many opportunities for the pairing of ment for their behaviors (Darcangelo et al., 2008).
their fantasies with sexual gratification (Kafka & Treatment is often forced on those who are arrested
Hennen, 2003). Often, the person with a paraphilia after engaging in illegal acts including voyeurism,
also has few opportunities for other types of sex- exhibitionism, frotteurism, or pedophilia. Simple
ual reinforcement and has difficulty relating ap- incarceration does little to change these behaviors,
propriately to other adults. and convicted sex offenders are likely to become
These classic behavioral theories have been repeat offenders (Seto, 2008).
supplemented with principles of social learning Biological interventions generally are aimed at
theory (see Chapter 2), which suggest that the reducing the sex drive in order to reduce para-
larger environment of a child's home and culture philic behavior. Surgical castration, which almost
influences his or her tendency to develop deviant completely eliminates the production of andro-
sexual behavior. Children whose parents fre- gens, lowers repeat offense rates among sex of-
quently use corporal punishment and engage in fenders (Maletzky & Field, 2003; Seto, 2009).
aggressive contact with each other are more likely Castration has been performed on hundreds of con-
to engage in impulsive, aggressive, and perhaps victed sex offenders in the Netherlands, Germany,
sexualized acts toward others as they grow older. and the United States, although it is rarely used
Many people with pedophilia have poor interper- today (Seto, 2009).
sonal skills and feel intimidated when interacting Sex offenders can be offered antiandrogen
sexually with adults (Seto, 2008). drugs that suppress the production of testosterone
A study of 64 convicted sex offenders with and thereby reduce the sex drive. These drugs typ-
various types of paraphilia found that they had ically are used in conjunction with psychotherapy
higher rates of childhood abuse and family dys- and can be useful for hypersexual men who are
function than did offenders who had committed motivated to change their behavior (Guay, 2009).
TABLE 13.4 Distortions, Assumptions, and Justifications Associated with Paraphilias
People with a paraphilia or who engage in rape may have cognitions that provide a rationale for their behaviors.
Category Pedophilia Exhibitionism Rape
Misattributing blame "She started it by bei ng "She kept looking at me li ke "She was saying 'no; but her
too cudd ly:' she was expecting it:' body said 'yes." '
"She would always run "The way she was d ressed,
around half dressed :' she wa s asking fo r it:'
Mi nimizing o r denying " I was teaching her about " I was just looking for a "I was trying to teach her a
sexual intent sex ... better from her place to pee:' lesson . . .. She deserved it:'
father than so m eone else:' " My pa nts j ust slipped down:'
Debasing t he victim " She'd had sex before with " She was just a slut anyway:' "The w ay she came o n
he r boyfriend:' to me at t he pa rty, she
" She always lies:' deserved it:'
"S he never f ought back.
She must have liked it:'
Mini mizin g "S he's always bee n real "I never to uched her, so I "She'd had sex w ith
consequ ences f rie nd ly to me, eve n cou ldn't hav e hurt her:' hu nd reds of guys before.
afte rward:' " She smiled, so she must have It was no big dea l:'
" Sh e w as messed up even liked it:'
befo re it hap pened:'
Defl ectin g censure "This happened yea rs ag o. "It's not li ke I raped anyone:' "I o nly did it once:'
... W hy can' t everyone
forget about it?"
Ju stifying t he cause "If I wa sn't m o lested as a "If I knew how to get dates, I " If my girlfrie nd gave me
kid , I'd neve r have do ne wouldn't have to expose:' what I wa nt, I wouldn't be
t his:' forced to rape :'
Source: From A Guide to Treatments That Work, edited by Peter Nathan and Jack Gorman (1998): Tab le 24.5 (p. 4481 from " The Paraphilias: Research and
Treatment" by Barry M . Maletzky. By pe rmiss ion of Oxford University Press, Inc.
Follow-up studies have shown that people with a people with a paraphilia are willing to change their
paraphilia treated with antiandrogen drugs show behavior (Seto, 2009). Aversion therapy is used to
reductions in their paraphilic behavior, although extinguish sexual responses to objects or situations a
the results are mixed (Gerardin & Thibaut, 2004; person with a paraphilia finds arousing. During such
Jordan et al., 2011; Maletzky & Field, 2003). These therapy, a person with a paraphilia might be ex-
drugs have a number of side effects, however, in- posed to painful but harmless electric shocks or loud
cluding fatigue, sleepiness, depression, weight bursts of noise while viewing photographs of what
gain, leg cramps, breast formation, hair loss, and arouses them, such as children, or while actually
osteoporosis (Gijs, 2008) . Nine states have laws touching objects that arouse them, such as women's
that require some sex offenders who want to be panties. Desensitization procedures may be used
paroled to take antiandrogen drugs or undergo to reduce the person's anxiety about engaging in
surgical castration (Seto, 2009). normal sexual encounters with other adults. For
The selective serotonin reuptake inhibitors example, people with a paraphilia might be taught
(SSRis) have been used to reduce sexual drive and relaxation exercises, which they then use to control
paraphilic behavior. Some studies find that these their anxiety as they gradually build up fantasies
drugs have positive effects on sexual drive and of interacting sexually w ith other adults in ways
impulse control (e.g., Greenberg, Bradford, Curry, & that are fulfilling to them and to their partners
O'Rourke, 1996), although the effects are not totally (Maletzky, 1998). These behavioral treatments gen-
consistent across studies (Gijs, 2008; Seto, 2009). erally are effective in the treatment of nonpreda-
Behavior modification therapies commonly are tory paraphilias such as fetishism (Darcangelo
used to treat paraphilia and can be successful if et al., 2008).
388 Chapter 13 Sexua l Disorde rs
Cognitive interventions may be combined with cross-gender identification, DSM-5's gender dys-
behavioral interventions designed to help people phoria is diagnosed when there is a discrepancy
learn more socially acceptable ways to approach between individuals' gender identity (i.e., sense
and interact with people they find attractive (Cole, of themselves as male or female) and their bio-
1992). Role playing might be used to give the per- logical sex (Table 13.5). Stephanie, in the follow-
son with a paraphilia practice in approaching an- ing case study, would be diagnosed with gender
other person and eventually negotiating a positive dysphoria.
sexual encounter with him or her. Also, group ther-
apy in which people with p araphilias support one "t:~ ~..-
another through changes in their behavior can be

helpful. Multiple studies find that these combined
,;. CASE STUDY
'
Stephanie was 30 when
cognitive-behavioral treatments can effectively she first attended our clinic. She gave a history of
treat nonpredatory p araphilias in individuals moti- conviction that she was, in fact, male and wished
vated to change (Darcangelo et al., 2008). to rid herself of identifiably female attributes and
Cognitive-behavioral therap y also has been acquire male traits and features. She said she
used to help people with a predatory paraphilia had been cross- living and employed as a male
(e.g., pedophilia, exhibitionism, voyeurism) iden- for about 1 year, following the breakdown of a
tify and challenge thoughts and situations that trig- 10-year marriage. She was taking testosterone
ger their behaviors and serve as justifications for prescribed by her family physician. She pre-
the behaviors, such as those listed in Table 13.4 sented at our clinic with a request for removal of
(Maletzky, 1998; McConaghy, 1998). Unfortunately, her uterus and ovaries.
randomized clinical trials of cognitive-behavioral She did not give a chi ldhood history of tom-
therapy for sex offenders have found no significant
boy attitudes, thoughts, or behavior. She said so-
differences in the recidivism rate between men
cial interaction with other children, boys or girls,
who received the therapy and those w ho did not
was minimal. Desperate for a friend, she fanta-
(Camilleri & Quinsey, 2008; Marques et al., 2005).
sized " an articulate and strong" boy, exactly her
age, named Ronan. They were always together
GENDER DYSPHORIA and they talked over everything: thoughts and
feelings and the events of her life. Cross-dressing
Gender dysphoria is a new DSM-5 diagnostic cat-
in her father's clothing also began during
egory that replaces DSM-IV's gender identity disor-
der. While gender identity disorder emphasized
TABLE 13.5 DSM-5 Criteria for Gender Dysphoria in Adolescents or Adults
A. A marked incongruence between one's ex perienced/expressed gender and assigned gender, of at least
6 months duration, as manifested by at least two of the following:
1. A marked incongruence between one's experienced/expressed gender and primary and/or secon dary sex ch aracteristics (o r, in
young adolescents, the anticipated secondary sex characteristics)
2. A strong desire to be rid of on e's primary and/or secondary sex characte ristics because of a m arked incong ruence with one's
experie nced/expressed gender (or, in young adolescents, a desire to prevent t he devel op ment of t he anticipated secondary sex
characte ristics)
3. A strong desire for the prima ry and/or secondary sex characteri st ics of the other gen der
4. A strong desire to be of the other gender (or some alternative gende r differe nt f rom one's assigned gender)
5. A strong desire to be treated as the other gender (or some alternative gender different f ro m one's assigned gender)
6. A strong conviction that one has the typical feelings and reactions of t he other gende r (or so me alternative gender different
f rom one's assigned gender)
B. The condition is associated with clinically significant distress or impai rme nt in social, occupatio nal, or ot her impo rtant areas of
f unctioning.
Source: Reprinted with permi ssion from th e Diagnostic and Sta tistical Manual of Mental Disorders, Fifth Ed ition. Copyright 2013 Ame rica n Psych iatric
Association .
Gender Dysphoria 389
typically is in the preschool years. Boys are referred

childhood. There was no history of sexual arousal more often than girls for concerns regarding gen-
associated with or erotic fantasy involving cross- der dysphoria. This may reflect a greater preva-
dressing. lence of gender dysphoria in males than in females,
Puberty at age 12 and the accompanying or it may reflect a greater concern on the part of
bodily changes apparently did not overly distress parents with violations of gender roles in boys
Stephanie. Sexual and romantic feelings focused than in girls (Zucker & Cohen-Kettenis, 2008).
on "slender, feminine-appearing men:' At 16, Adults who might be diagnosed with gender
Stephanie met such a man and they were to- dysphoria sometimes are called transsexuals
gether for 2 years. Her next romantic involve- (Sohn & Basinski, 2007). The term transgender more
ment was with a "male bisexual transvestite:' broadly refers to individuals with varying degrees
Sexual interaction, according to Stephanie, in- of cross-gender identity, including transsexuals
cluded experimentation with drugs and "role re- but also individuals who cross-dress and people
versals:' She and her partner cross-dressed, and with transvestic fetishes (see Lawrence, 2008).
Stephanie took the dominant and active role. People with gender dysphoria who cross-dress are
During vaginal sex, she imagined herself as a not sexually aroused by this practice but simply
male with another male. believe they are putting on the clothes of the gen-
At 19, she met a slender, good-looking man. der to which they really belong. The sexual prefer-
They were compatible and married soon after. ences of individuals with gender dysphoria vary.
The marriage was a success. Stephanie's pre- Some individuals are asexual, having little interest
ferred position for intercourse was with both in either sex; some are heterosexual; and some are
kneeling, she behind her husband, rubbing her homosexual (Lawrence, 2008). People with gender
pubic area against him while masturbating him . dysphoria who can afford it may seek a sex-change
She would imagine she had a penis and was pen- operation. Gender dysphoria is rare, with an esti-
etrating him . Stephanie's marriage broke down mated prevalence of 1 in 12,900 for male to female
after the couple's business failed . She decided to gender dysphoria and 1 in 33,800 for female to
~ live full-time in the male role as Jacob. Whi le on male gender dysphoria (De Cuypere et al., 2007).
the West Coast, she started treatment with male
hormones. She moved back east and presented
at ou r clinic for assessment. She saw herself as a
male, primarily attracted to gay or gay-appearing
males. She was uninterested in relationships
with women , except perhaps as purely sexua l en-
counters of short duration. (Adapted from Dickey
& Stephens, 1995, pp. 442-443)
DSM-5 acknowledges the wide variation of

gender incongruent conditions and provides sep-
arate criteria sets for gender d ysphoria in children
and in adolescents and adults, the latter of which
are more detailed (see Table 13.5). Gender dysphoria
in children is a rare condition in which a child per-
sistently rejects his or her anatomic sex and
strongly desires to be or insists he or she is a mem-
ber of the opposite sex. Girls with this disorder
seek masculine-type activities and male peer
groups to a degree far beyond that of a tomboy.
Sometimes, these girls express the belief that they
will eventually grow a penis. Boys with the disor-
~ der seek feminine-type activities and female peer
groups and tend to begin cross-dressing in girls'
clothes at a very early age (Zucker & Wood, 2011). Some transsexuals argue that they do not have a disorder
They express disgust with their penis and wish it and should have the right to live their life as they wish.
would disappear. The onset of these behaviors
Some people with gender dysphoria are so children's gender identity. Parents encourage chil- ~
disturbed by their misassignment of gender that dren to identify with one sex or the other by reinforc-
they develop alcohol and other substance abuse ing "gender-appropriate" behavior and punishing
problems and/ or other psychological disorders "gender-inappropriate" behavior. From early in-
(Lawrence, 2008). Low self-esteem and psycho- fancy, they buy male or female clothes for their chil-
logical distress also result from their rejection by dren and sex-stereotyped toys (dolls or trucks).
others. High rates of HIV infection among people They encourage or discourage playing rough-and-
with gender dysphoria have been reported in some tumble games or playing with dolls. A long-term
studies (Lawrence, 2008). HIV may be contracted study of a large sample of boys with gender dys-
through risky sexual behaviors or through the phoria found that their parents were less likely than
sharing of needles during drug use or hormone in- the parents of boys without gender dysphoria to
jections. Many people with gender dysphoria avoid discourage cross-gender behaviors (Green, 1986).
seeking medical attention because of negative in- That is, these boys were not punished, either subtly
teractions with physicians. Indeed, some physicians or overtly, for engaging in feminine behavior such
refuse to treat people with gender dysphoria. as playing with dolls or wearing dresses as much as
were boys who did not have gender dysphoria. Fur-
Contributors to Gender ther, boys who were highly feminine (although not
necessarily with gender dysphoria) tended to have
Dysphoria mothers who had wanted a girl rather than a boy,
Biological theories of gender dysphoria have fo- saw their baby sons as girls, and dressed their baby
cused on the effects of prenatal hormones on brain sons as girls. When the boys were older, their moth-
development (Bradley, 1995; Zucker & Wood, 2011). ers tended to prohibit rough-and-tumble play, and
Although several specific mechanisms have been the boys had few opportunities to have male play-
implicated, most theories suggest that people who mates. About one-third of these boys had no father
develop gender dysphoria have been exposed to in the home, and those who did have a father in the
unusual levels of hormones, which influence later home tended to be very close to their mother. In
gender identity and sexual orientation by influenc- general, however, the evidence in support of psy-
ing the development of brain structures involved in chological contributors to gender dysphoria has
sexuality. In genetic females, female-to-male gender been weak (Zucker & Wood, 2011).
dysphoria has been associated with hormonal dis-
orders resulting in prenatal exposure to high levels Treatments for Gender
of androgens (Baba et al., 2007), whereas in genetic
males, male-to-female gender dysphoria has been
Dysphoria
associated with prenatal exposure to very low lev- Therapists who work with people with gender
els of androgens (Hines, Ahmed, & Hughes, 2003; dysphoria help these individuals clarify their gen-
Wisniewski & Migeon, 2002). der identity or experienced gender and their de-
A cluster of cells in the hypothalamus called sire for treatment. In addition to psychotherapy,
the bed nucleus of the stria terminalis, which plays there are three principal treatments for gender
a role in sexual behavior, has been implicated in dysphoria: (1) cross-sex hormone therapy, (2) full-
gender dysphoria in multiple studies (Chung, De time real-life experience in the desired gender
Vries, & Swaab, 2002; Kruijver et al., 2000; Zhou, role, and (3) sex reassignment surgery, which pro-
Hofman, & Swaab, 1995). Typically, this cluster of vides the genitalia and secondary sex characteris-
cells is smaller in women's brains than in men's. tics (e.g., breasts) of the gender with which the
Studies have found that this cluster of cells is half individual identifies (Byne et al., 2012).
as large in men with gender dysphoria as in men Cross-sex hormone therapy stimulates the de-
without the disorder and close to the size usually velopment of secondary sex characteristics of the
found in women's brains. preferred sex and suppresses secondary sex char-
Hormonal disorders contributing to gender acteristics of the birth sex. Estrogens are used in
dysphoria may be tied to genetic abnormalities. feminizing hormone therapy for male-to-female
Family and twin studies suggest that gender dys- individuals with gender dysphoria. These hor-
phoria may have genetic causes (Coolidge, Thede, mones cause fatty deposits to develop in the
& Young, 2002; Heylens et al., 2012), although the breasts and hips, soften the skin, and inhibit the ~
specific genetic factors involved are not yet known growth of a beard. Testosterone is used to induce
(Ujike et al., 2009). masculinization in female-to-male individuals
Most psychosocial theories of gender dysphoria with gender dysphoria. This hormone causes the
focus on the role parents play in shaping their voice to deepen, hair to become distributed in a
male pattern, fatty tissue in the breast to recede, created by that identity. Most clinicians consider
and muscles to enlarge; the clitoris also may grow hormone therapies and surgeries unacceptable for
larger (Byne et al., 2012). Hormone therapy may be children and adolescents because they cannot give
given to individuals regardless of whether they fully informed consent for such procedures (Byne
wish to undergo sex reassignment surgery. et al., 2012).
Before undergoing sex reassignment surgery,
individuals spend up to a year or more living full-
time in the gender role they seek. Some choose to CHAPTER INTEGRATION
live full-time in their desired gender role even if Nowhere is the interplay of biological, psychologi-
they do not undertake sex reassignment surgery or cal, and social forces more apparent than in mat-
hormone therapy (Byne et al., 2012). ters of sexuality (Figure 13.5). Biological factors
Sex reassignment requires a series of surgeries influence gender identity, sexual orientation, and
and hormone treatments, often over a period of sexual functioning. These biological factors can be
2 years or longer. In male-to-female surgery, the greatly moderated, however, by psychological and
penis and testicles are removed, and tissue from social factors. The meaning people assign to a sex-
the penis is used to create an artificial vagina. The ual dysfunction, an unusual sexual practice, or an
construction of male genitals for a female-to-male atypical gender identity is heavily influenced by
reassignment is technically more difficult (Byne their attitude toward their sexuality and by the re-
et al., 2012). First, the internal sex organs (ovaries, actions of people around them. In addition, as we
fallopian tubes, uterus) and any fatty tissue remain- saw with sexual dysfunctions, purely psychologi-
ing in the breasts are removed. Then the urethra is cal and social conditions can cause a person's body
rerouted through the enlarged clitoris, or an artifi- to stop functioning as it normally would.
cial penis and scrotum are constructed from tissue
taken from other parts of the body. This penis al-
lows urination while standing but cannot achieve a Interplay of Biological, Psychological,
FIGURE 13.5
natural erection. Other procedures, such as artifi- and Social Factors in Sexuality
cial implants, may be used to create an erection.
Sex reassignment surgery is controversial.
Biological factors: Psychological factors:
Follow-up studies suggest that the outcome tends genetic sex, hormonal attitudes and expectations
to be positive when patients are carefully selected functioning, diseases toward sex and one's body,
for gender reassignment procedures based on their affecting sexual arousal and
functioning, effects of drugs
----+-1 classical and operant
conditioning of arousal
motivation for change and their overall psycho- patterns, anxiety, depression,
logical health and are given psychological counsel- other mental health problems
ing to help them through the change (Byne et al.,
J
2012). Reviews of outcome studies have found ad-
equate levels of sexual functioning and high sexual Sodal factors: relationships
satisfaction following sex reassignment surgery with sexual partners, reinforce-
ments and punishments for
(Klein & Gorzalka, 2009; Murad et al., 2010). sexual behaviors, cultural norms ..,.~I-_.
Treatment of children and adolescents with for sexual behaviors, gender
gender dysphoria focuses primarily on psychother- roles, traumas and more
chronic stressors
apy to help them clarify their gender identity and
deal with interpersonal and psychological issues
SHADES OF GRAY DISCUSSION !review p. 383)
Although you may have thought the evidence of Currently, there is no evidence that he is distressed
transvestic disorder increased as Mr. t>:s case pro- over his behavior or over the consequences of his
gressed from his wife's objection over a nightgown behavior, even though his wife objects to it. While
to his enjoyment of transvestite parties, he proba- Mr. /l:s case does not warrant a diagnosis now, he
bly would not receive a diagnosis. In order to be may receive one in the future if the decline in his
diagnosed with transvestic disorder, he would marriage or difficulty at work due to cross-dressing
have to show that cross-dressing causes signifi- causes him significant distress.
cant distress or impairment in his functioning.
392 Chapter 13 Sexua l Disorders
THINK CRITICALLY ~
One man goes to a public beach to watch women in movies, television shows, and commercials. The
skimpy bikinis. A second man pays to see a female behavior of the second man is a form of legal sexual
topless dancer in a nightclub. A third man stands commerce . Only the behavior of the third man is
outside a woman's bedroom window at night, se- labeled a sexual disorder and is not allowed by cul-
cretly watching her undress. tural norms o r by laws. Although we may like to
Our society-like all societies across cultures think that, in ou r modern culture, we prohibit only
and throughout history-makes judgments about those sexual behaviors that are truly "sick;' ou r judg-
the types of sexual activities we allow and the types ments are still subj ective and culturally specific.
we do not. The actions of the three men described In your judgment, are there any sexual disorders
above are all motivated by the desire to be sexually in this chapt er that you think should not be consid-
aroused by the sight of women's naked, or almost ered a disorder and instead should be considered
naked, bodies. But consider how differently our soci- simply a personal preference? (Discussion appears
ety judges each behavior. The behavior of the first on p. 484 at the back of this book.)
man is not only allowed but also promoted in many
CHAPTER SUMMARY
The sexual response cycle can be divided into Fortunately, most sexual dysfunctions can be
the desire, arousal, plateau, orgasm, and resolu- treated successfully. Biological treatments include
tion phases . drugs that increase sexual functioning, such as
Viagra, and the alleviation of medical conditions ~
Disorders of sexual desire/interest and arousal
(male hypoactive sexual desire disorder, female that might be contributing to sexual dysfunction.
sexual interest/arousal disorder, and erectile Psychological treatments combine (1) psycho-
disorder) are among the most common sexual therapy focused on the personal concerns of the
dysfunctions. People with these disorders experi- individual with the dysfunction and on the con-
ence a chronically lowered or absent desire for flicts between the individual and his or her part-
sex or deficiencies in sexual arousal. ner and (2) sex therapy designed to decrease
Women with female orgasmic disorder experi- inhibitions about sex and teach new techniques
ence a persistent or recurrent delay in or the com- for achieving optimal sexual enjoyment.
plete absence of orgasm, after having reached the One set of techniques in sex therapy is sensate fo-
excitement phase of the sexual response cycle. cus exercises. The exercises lead partners through
Men with early ejaculation persistently experi- three stages, from gentle nongenital touching to
ence ejaculation (after minimal sexual stimula- direct genital stimulation and finally to intercourse
tion) before, on, or shortly after penetration and focused on enhancing and sustaining pleasure,
before they wish it. Men with delayed ejaculation rather than on orgasm and performance.
experience a persistent or recurrent delay in or
Men experiencing premature ejaculation can
the absence of ejaculation following the excite-
be helped with the stop-start technique or the
ment phase of the sexual response cycle.
squeeze technique.
Genito-pelvic pain/penetration disorder involves
The paraphilic disorders involve recurrent atypi-
genital pain associated with intercourse or, in
cal sexual fantasies, urges, and behaviors that
women, involuntary contraction of the muscles
cause the individual distress or impairment, or
surrounding the outer third of the vagina when
cause harm or risk of harm to others.
the vagina is penetrated.
Fetishistic disorder is a paraphilic disorder that
A variety of biological factors, including medical
involves sexual fantasies, urges, or behaviors
illnesses, the side effects of drugs, nervous sys-
tem injury, and hormonal deficiencies, can cause focused on nonliving objects or nongenital body
parts. A particular form of fetish is transvestism,
sexual dysfunction. The psychological and socio-
in which individuals cross-dress in order to
cultural factors leading to sexual dysfunction
become sexual ly aroused.
most commonly involve negative attitudes to-
ward sex, traumatic or stressful experiences, or Sexual sadism disorder involves sexual fantasies,
conflicts with sexual partners. urges, or behaviors focused on inflicting pain
Key Terms 393
and humiliation on a sex partner. Sexual mas- behavioral interventions to decondition arousal
ochism disorder involves sexual fantasies, urges, due to paraphilic objects, and cognitive-
or behaviors focused on experiencing pain or behavioral interventions to combat cognitions
humiliation during sex. supporting paraphilic behavior and increase
coping skills.
Voyeuristic disorder involves sexual fantasies,
urges, or behaviors focused on secretly watching Gender dysphoria is diagnosed when an indi-
another person undressing, doing things in the vidual believes that he or she was born with the
nude, or engaging in sex. Almost all people who wrong genitals and is fundamentally a person of
engage in voyeurism are men who watch women. the opposite sex. People with this disorder expe-
Exhibitionistic disorder involves sexual fantasies, rience a chronic discomfort and sense of inappro-
urges, or behaviors focused on exposing the gen- priateness with their gender and genitals, wish
itals to involuntary observers, usually strangers. to be rid of them, and want to live as members of
the opposite sex. Gender dysphoria of childhood
Frotteuristic disorder often co-occurs with voyeur- is a rare condition in which a child persistently
ism and exhibitionism. The person who engages rejects his or her anatomic sex, desires to be or
in frotteurism has sexual fantasies, urges, or be- insists he or she is a member of the opposite
haviors focused on rubbing against and fondling sex, and shows a strong preference for cross-
parts of the body of a nonconsenting person. gender roles and activities.
Usually this occurs in a crowded public space.
Biological theories suggest that gender dyspho-
People with pedophilic disorder have sexual fan-
ria is due to prenatal exposure to hormones that
tasies, urges, or behaviors focused on prepubes-
affect development of the hypothalamus and
cent children. other brain structures involved in sexuality.
Some neurodevelopmental differences are found Socialization theories suggest that the parents of
between people with pedophilic disorder and children (primarily boys) with gender dysphoria
people without the disorder. do not strictly encourage gender-appropriate
Behavioral theories suggest that the sexual be- behaviors.
haviors of people with paraphilic disorder result Treatment for gender dysphoria includes cross-
from classical and operant conditioning. sex hormone therapy, real -life experience as a
Treatments for the paraphilic disorders include member of the desired sex, and sex reassign-
biological interventions to reduce sexual drive, ment surgery.
KEY TERMS
sexual functioning 363 sensate focus therapy 377
gender identity 363 stop-start technique 379
sexual desire 365 squeeze technique 379
arousal phase 365 paraphilic disorder 380
plateau phase 365 fetishistic disorder 380
orgasm 365 transvestic disorder 382
resolution 365 sexual sadism disorder 382
sexual dysfunction 366 sexual masochism disorder 382
male hypoactive sexual desire disorder 366 sadomasochism 382
female sexual interest/arousal disorder 367 voyeuristic disorder 384
erectile disorder 367 exhibitionistic disorder 384
female orgasmic disorder 368 frotteuristic disorder 384
early or premature ejaculation 368 pedophilic disorder 384
delayed ejaculation 369 aversion therapy 387
genito-pelvic pain/penetration disorder 370 genderdysphoria 388
substance-induced sexual dysfunction 371 transsexuals 389
performance anxiety 372
Substance Use and
Gambling Disorders
CHAPTER OUTLINE
Substance Use Along the Continuum Inhalants
Extraordinary People: Celebrity Other Drugs of Abuse

Drug Abusers
Theories of Substance Use Disorders
Defining Substance Use Disorders Treatments for Substance Use Disorders
Depressants Gambling Disorder
Shades of Gray Chapter Integration
Stimulants Shades of Gray Discussion
Opioids Think Critically
Hallucinogens and PCP Chapter Summary
Cannabis Key Terms

Potentially meets criteria for a mild Likely meets diagnostic criteria for a
alcohol use disorder: severe alcohol use disorder:
Heavy drinking with some social, Clear evidence of significant social,
occupational, legal, or physical occupational, legal, and/ or physical
consequences consequences
(DUI, misbehavior while intoxicated May have tolerance and withdrawal
that affects job, frequent under- Unsuccessful attempts to control or
Abstinence Light social drinking cut down on consumption
performance at work or school.
No significant social, increased blaod pressure, damage to Life becomes taken over by
occupational. or physical liver, etc.) obtaining, using, and recovering
consequences from the substance
Moderate drinking, mostly in Likely meets diagnostic criteria for

social situations a moderate alcohol use disorder:
Usually no social, occupational, or Clear evidence of significant
physical consequences, but accidents social, occupational. legal. and/ or
may occur (driving while "buzzed"), physical consequences
performance may be impaired the Continued use despite these
next day, and physical consequences consequences
may occur in vulnerable people
(increases in blood pressure in people
with cardiac problems)
As a student, you likely know more people along the continuum Further along the continuum are peop le who use drugs and
of substance use than along any continuum in previous chapters . alcoho l " recreationally:' Nearly half the U.S. population admits
TV shows and movies often show substance use as a rite of pas- to having tried an illegal substance at some time in their life, and
sage into ad ulthood-think of the college drinking scenes in approximately 14 percent hav e used one in the past yea r
movies like Animal House-and statistics suggest there is some (SAMHSA, 2008b) .
truth in this portrayal. Illegal drug use is highest among young Alt hough movies and TV often make substance use seem
adults (Figure 14.1; Substance Abuse and Mental Health Services cool, the consequen ces are staggeringly serious. There are more
Administration [SAMHSAL 2008b), with about 20 percent of deaths from traffic accidents involving substance-impaired driv-
college students reporting current use. ers than from all other types of accidents. In 2008, 15 percent of
At one end of the continuum are people who abstain com- drivers in t he United States reported driving under the inf luence
pletely. Some of these do not enjoy the effects of substances; of alcohol, and another 5 percent reported driving under the influ-
others live in cultures or follow rel ig ions that proh ibit the use of ence of an illicit drug (SAMHSA, 2008c). Over 10 percent of emer-
alcohol or drugs. Globally, 46 percent of men and 73 percent of gency room visits in the United States are related to the misuse of
women abstain f rom alcohol, w ith most of these people con- alcohol or of illegal or prescription drugs (SAMHSA, 2008a ).
centrated in a belt stretching from North Africa across the east- At the other end of the continuum are individuals who build
ern Mediterranean, south central Asia, and Southeast Asia to their lives around substances. Thei r immoderate substance use
the islands of Indonesia (WHO, 2011 ). In other areas of the impairs their everyday functioning - they may avoid job and fa m ily
world, such as Europe, less than 20 percent of the population responsibilities, act impulsively or bizarrely, or endanger their own
abstain from alcohol. and others' lives. These people have a substance use disorder.
Substance Use Along the Continuum 395

396 Chapter 14 Substance Use and Gambling Disorders
Celebrity Drug Abusers
Whitney Houston was the Joker in The Dark Knight won him an Oscar in
one of the most suc- 2009. However, the actor was not present to accept
cessful music artists of his award because on January 22, 2008, he had
all time, selling over died of an overdose of prescription drugs, includ-
170 million albums, ing oxycodone, hydrocodone, Valium, Restoril,
singles, and music vid- Xanax, and doxylamine (a sleep aid). Ledger was 28
eos and winning more and on the brink of a promising career. Many other
awards for her music celebrities have had public problems with drugs
than any other female and alcohol, including Kate Moss, Britney Spears,
artist. Her single "I Will Lindsey Lohan, Robert Downey Jr., Drew Barrymore,
Always Love You" and Courtney Love. Drug-related celebrity deaths in-
Whitney Houston died of a from the movie The clude Michael Jackson, D.J. AM, Chris Farley, Anna
drug overdose in 2012.
Bodyguard, which she Nicole Smith, John Belushi, Russell Jones (01' Dirty
also starred in, be- Bastard), Amy Winehouse, and Rick James. As gui-
came the best-selling single in history by a female tarist Keith Richards of the Rolling Stones said,
artist. She rode the top of the pop charts through "I used to know a few guys that did drugs all the
the 1980s and 1990s, but then the hits stopped time, but they're not alive anymore .... And you get
coming and her album sales plummeted as stories the message after you've been to a few funerals:'
emerged about drug use leading to bizarre behav- Are celebrities more vu lnerable to drug addic-
ior and the loss of her once extraordinary voice. In tion than regular folks? Probably not. As we discuss
a 2002 interview on ABC News, she admitted to in this chapter, alcohol and drug use disorders are
abusing cocaine, marijuana, and pills. She at- among the most common mental health problems
tempted comebacks, but her voice was often frayed in the United States and around the world.
and shaky in public appearances. Then, in February Celebrities have more money to buy illicit drugs,
2012, Whitney Houston, age 48, was found drowned and drugs and alcohol are a big part of the social
in the bathtub of a Beverly Hills hotel room. A coro- scene in the entertainment industry. Some celebri-
ner's report ruled the death an accident due to the ties can't handle the pressure to stay on top of their
effects of cocaine, marijuana, and multiple other field and may turn to drugs to cope. Also, when ce-
drugs in her system and to heart damage associ- lebrities do abuse drugs or alcohol, the media
ated with her long-term drug abuse. broadcast their missteps widely. But much celebrity
Whitney Houston is only one in a long line of drug abuse probably is due to the same biological
celebrity drug abusers who have died early as a and psychosocial factors that contribute to drug
result of their drug use. Heath Ledger's portrayal of and alcohol use disorders in noncelebrities.
Everyone has temptations, and some people have popularly referred to as drugs (e.g., cocaine and
more trouble resisting them than others. In this heroin). People who abuse these drugs are often
chapter, we consider disorders that involve chronic referred to as drug addicts. Yet a person need not
difficulties in resisting the desire to drink alcohol or be physically dependent on a substance, as the
take drugs, known in the DSM-5 as substance use term addict implies, in order to have a problem
disorders. We also consider gambling disorder, with it. For example, some club-goers who are
which involves the inability to resist the impulse to not physically addicted to Ecstasy or Molly still
gamble, because the behavioral patterns and causes may think they need the drug to have a good
of this disorder appear to be similar to the behav- time.
ioral patterns and causes of the substance use dis- Societies differ in their attitudes toward sub-
orders (Denis, Fatseas, & Auriacombe, 2012). stances with psychoactive effects, with some seeing
We begin with the substance use disorders. A their use as a matter of individual choice and others ~
substance is any natural or synthesized product seeing it as a grave public health and security con-
that has psychoactive effects-it changes percep- cern. Within the United States, attitudes have varied
tions, thoughts, emotions, and behaviors. Some greatly over time and across subgroups (Keyes et al.,
of the substances we discuss in this chapter are 2011). U.S. ambivalence toward alcohol use is nicely
illustrated in a letter from former Congressman Billy Illicit Drug Use in the Past Year. In the
Mathews to one of his then-constituents, who wrote: FIGURE 14.1 United States, ethnic and age groups have
"Dear Congressman, how do you stand on whis- different rates of drug use.
key?" Because the congressman did not know how
the constituent stood on alcohol, he fashioned the
following safe response:
My dear friend, I had not intended to dis-
cuss this controversial subject at this par-
ticular time. However, I want you to know
that I do not shun a controversy. On the
contrary, I will take a stand on any issue at
any time, regardless of how fraught with
controversy it may be. You have asked me
how I feel about whiskey. Here is how I
stand on the issue.
If when you say whiskey, you mean
the Devil's brew; the poison scourge; the
bloody monster that defiles innocence, de-
thrones reason, destroys the home, creates
misery, poverty, fear; literally takes the
bread from the mouths of little children; if
you mean the evil drink that topples the
Christian man and woman from the pin-
nacles of righteous, gracious living into 12-17 18-25 26+
the bottomless pit of degradation and de- Age
spair, shame and helplessness and hope-
lessness; then certainly, I am against it Source: SAMHSA, 2008c.
with all of my power. Note: Illicit drugs include marijuana, cocaine, heroin, hallucinogens, inhalants, or
prescription drugs used nonmedically. No estimate is given for Native Americans
But, if when you say whiskey, you 12-17 years old because of a low response rate.
mean the oil of conversation, the philo-
sophic wine, the ale that is assumed when
great fellows get together, that puts a song
in their hearts and laughter on their lips,
and the warm glow of contentment in
their eyes; if you mean Christmas cheer; if
you mean that stimulating drink that puts
the spring in the old gentleman's step on
a frosty morning; if you mean the drink
that enables the man to magnify his joy All Classes, Ages
and his happiness and to forget, if only for and Sexes
a little while, life's great tragedies and DRINK
Ofll'M
heartbreaks and sorrows; if you mean that
drink, the sale of which pours into our
Treasury untold millions of dollars which
are used to provide tender care for little The Satisfactory Beverage
crippled children, our blind, our deaf, our It satisfies the thirst and pleases the palate. Re-
pitiful aged and infirm; to build high- lieves the fati~e that comes from over-work,
over-shoppin~t or over-play. Puts vim and
ways, hospitals, and schools; then cer- 110 into tired brains and bodies.
tainly, I am in favor of it. This is my stand, Cooling-Refreshing-DeJic:ious,
'fbirst-Quencbing
and I will not compromise. Your congress-
man. (Quoted in Marlatt, Larimer, Baer, &
Quigley, 1993, p. 462)
Many substances have been used for medicinal
purposes for centuries. As long ago as 1500 BCE, Coca-Cola originally contained cocaine.
people in the Andes highlands chewed coca leaves
to increase their endurance (Cocores, Pottash, & they ingest, the more intoxicated they become. In-
Gold, 1991). Coca leaves can be manufactured into toxication declines as the amount of the substance
cocaine, which was used legally throughout in blood or tissue declines, but symptoms may last
Europe and the United States into the twentieth for hours or days after the substance no longer is
century to relieve fatigue. It was an ingredient in detectable in the body (Virani, Bezchlybnik-Butler,
the original Coca-Cola drink and in more than 50 & Jeffries, 2009).
other widely available beverages and elixirs. The specific symptoms of intoxication de-
Psychoactive substances also have traditionally pend on what substance is taken, how much of it
appeared in religious ceremonies. When chewed, is taken and when, the user's tolerance, and the
peyote causes visual hallucinations of colored lights context. For example, you may have observed
or of geometric forms, animals, or people. Native that alcohol makes some people aggressive and
groups in North America have used it in religious others withdrawn. Short-term, or acute, intoxica-
rituals for hundreds of years. tion can produce symptoms different from those
of chronic intoxication. The first time people take
a moderate dose of cocaine, they may be outgo-
DEFINING SUBSTANCE ing and upbeat. With chronic use over days or
USE DISORDERS weeks, they may begin to withdraw socially
(Virani et al., 2009). People's expectations about a
There are four conditions that have historically substance's effects also can influence the types of
been seen as important in defining individuals' symptoms they show. People who expect mari-
use of substances: intoxication, withdrawal, abuse, juana to make them relaxed may experience
and dependence. We first define these conditions. relaxation, whereas people who are frightened of
Substance intoxication is a set of behavioral disinhibition may experience anxiety (Ruiz,
and psychological changes that occur as a result of Strain, & Langrod, 2007).
the physiological effects of a substance on the cen- The setting also can influence the types of in-
tral nervous system. People become intoxicated toxication symptoms people develop. People who
soon after they ingest a substance, and the more consume a few alcoholic drinks at a party may
become uninhibited and loud, but when they con-
sume the same amount at home alone they may
become tired and depressed (Brick, 2008). The
environment can also influence how maladaptive
the intoxication is. People who drink alcohol only
at home may be less likely to cause harm to them-
selves or others than are people who drink at bars
and drive home under the influence of alcohol.
The diagnosis of intoxication with a substance is
given only when the behavioral and psychological
changes the person experiences are significantly
maladaptive, that is, when they substantially
disrupt the person's social and family relation-
ships, cause occupational or financial problems, or
place the individual at significant risk for adverse
effects, such as a traffic accident, severe medical
complications, or legal problems. For example,
getting into a fist fight while clearly under the
influence of a substance would merit a diagnosis
of intoxication. Substance intoxication is common
among individuals with a substance use disorder,
but also occurs among those without a substance
use disorder.
Substance withdrawal is a set of physiologi-
The setting in which a person becomes intoxicated can influence the type of
cal and behavioral symptoms that result when
symptoms people develop. People who consume a few alcoholic drinks at a
party may become uninhibited and loud, but when they consume the same people who have been using substances heavily
amount at home alone they may become tired and depressed. for prolonged periods of time stop or greatly re-
duce their use. Symptoms typically are the
Defining Substance Use Disorders 399
opposite of those of intoxication. The diagnosis compulsively despite experiencing significant

of withdrawal from a substance requires signifi- social, occupational, psychological, or medical
cant distress or impairment in a person's every- problems as a result. The diagnosis of substance
day functioning. dependence preempted the diagnosis of sub-
The DSM-IV distinguished between substance abuse. Some individuals abused sub-
stance abuse and substance dependence. The diag- stances for years, severely disrupting their lives,
nosis of substance abuse was given when a without qualifying for a diagnosis of substance
person's recurrent use of a substance resulted in dependence.
significant harmful consequences comprising The DSM-5 combined substance abuse and de-
four categories. First, the individual fails to fulfill pendence into one diagnosis, substance use disor-
important obligations at work, school, or home. der, because of difficulties in distinguishing between
He or she may fail to show up at work or for abuse and dependence in clinical and research set-
classes, may be unable to concentrate and there- tings and because of the low reliability of the diag-
fore performs poorly, or may even consume the nosis of substance abuse (Hasin et al., 2012). The
substance at work or at school. Second, the indi- DSM-5 diagnostic criteria for substance use disor-
vidual repeatedly uses the substance in situa- der include impaired control, the continued use of
tions in which it is physically hazardous to do so, substances despite negative social, occupational,
such as while driving. Third, the individual and health consequences, risky use, as well as evi-
repeatedly has legal problems as a result of sub- dence of tolerance or withdrawal (see Table 14.1).
stance use, such as arrests for drunk driving or Users must show two or more of the symptoms as-
for the possession of illegal substances. Fourth, sociated with substance use disorder over the
the individual continues to use the substance de- course of a year to receive the diagnosis. The crite-
spite repeated social or legal problems as a result rion in the DSM-IV regarding legal problems was
of use. The DSM-IV diagnosis of substance abuse dropped because such problems were relatively
required that the person show repeated problems rare among adults and thus were not very informa-
in at least one of these categories within a tive, but a criterion of craving was added because it
12-month period. is a common and diagnostically important symp-
The diagnosis of substance dependence in the tom among people with substance use issues
DSM-IV was closest to what people often refer to (Hasin et al., 2012). Clinicians also rate the severity
as drug addiction. People who are dependent on, or of the substance use disorder as mild (two or three of
addicted to, a substance often show tolerance- the criteria are met), moderate (four or five criteria
they experience diminished effects from the same are met), or severe (six or more criteria are met).
dose of a substance and need more and more of it One study reanalyzed data from a large,
to achieve intoxication. People who have smoked nationally representative sample of the United States
cigarettes for years often smoke more than 20 ciga- to determine the effects of changes from the DSM-IV
rettes a day, an amount that would have made to the DSM-5 criteria for the diagnosis of alcohol-
them violently ill when they first began smoking. related disorders and found that the 12-month prev-
A person highly tolerant of a substance may have alence of alcohol use disorder based on the DSM-5
a very high blood level of it without being aware of criteria (10.8 percent) was quite similar to the com-
its effects. The risk for tolerance varies greatly bined 12-month prevalence of DSM-IV diagnoses
among substances. Alcohol, opioids, stimulants, of alcohol abuse or alcohol dependence (9.7 per-
and nicotine have high risks for tolerance, whereas cent) (Agrawal, Heath, & Lynskey, 2011). This sug-
cannabis and PCP appear to have lower risks gests that the combined prevalences of abuse and
(Brick, 2008). People who are physiologically de- dependence diagnoses for each substance based on
pendent on a substance often show severe with- the DSM-IV criteria can be used to estimate the
drawal symptoms when they stop using it. prevalence of substance use disorders for each sub-
Sometimes the substance must be withdrawn stance discussed in this chapter.
gradually to prevent the symptoms from becom- DSM-5 recognizes 10 substance classes around
ing overwhelming or dangerous (Brick, 2008). which substance use disorders emerge. This chap-
Users may continue to take the substance to relieve ter organizes these substance use disorders into
or avoid withdrawal symptoms. five categories: (1) central nervous system depres-
Physiological dependence (evidence of toler- sants, including alcohol, barbiturates, benzodiaze-
ance or withdrawal) was not required for a diag- pines, and inhalants; (2) central nervous system
nosis of substance dependence in the DSM-IV, stimulants, including cocaine, amphetamines, nic-
however. A person needed only to use a substance otine, and caffeine; (3) opioids, including heroin
TABLE 14.1 Criteria for Substance Use Disorder
Impaired centre control

1. The substance is taken in increas ingly larger amounts or over a longer period of time than originally intended.
2. The substance user craves the use of the substance.
3. The substance user feels an ongoing desire to cut down or control substance abuse.
4. Much t ime is spent in obtaining, using, or recovering from the substance.
Social impairment
5. The ongoing use of the substance often results in an inability to meet responsibil ities at home, work, or school.
6. Important social, work-related, or recreational activities are abandoned or cut back because of substance use.
7. Ongoing substance use despite recurr ing social or relationship difficulties caused or made worse by the effects of the substa nce.
Risky use
8. Ongoing substance use in physically dangerous situations such as driving a car or operating machinery.
9. Substance use continues despite the awareness of ongoing physical or psychological problem s that have likely arisen or been
made worse by the substance.
Pharmacological criteria
10. Changes in the substances user's tolerance of the substance is indicated by the need for increased amounts of the substance to
achieve the desired effect or by a diminished experience of intoxication over time with the same amount of the substance.
11 . Withdrawal is demonstrated by the characteristic withdrawal syndrome of the substance and/or taking the same or similar
substance to relieve withdrawal symptoms.
Sou rce: Generally two or more of th e above criteria are required to make a diagnosis of substance abuse disorder.
and morphine; (4) hallucinogens and phencycli- reducing their sexual inhibitions), even low doses
dine (PCP); and (5) cannabis. We consider the can impair sexual functioning.
characteristics of the problems people experience People intoxicated by alcohol slur their words,
from using substances in each category and then walk unsteadily, have trouble paying attention or
discuss certain other drugs commonly misused. remembering things, and are slow and awkward
in their physical reactions. They may act inappro-
priately, becoming aggressive or belligerent, or say-
DEPRESSANTS ing rude things. Their moods may swing from
Depressants slow the central nervous system. In exuberance to despair. With extreme intoxication,
moderate doses, they make people relaxed and people may fall into a stupor or a coma. Often,
somewhat sleepy, reduce concentration, and im- they do not recognize that they are intoxicated or
pair thinking, judgment, and motor skills. In heavy may flatly deny it. Once sober, they may have am-
doses, they can induce stupor or even death (see nesia, known as a blackout, for the events that oc-
Table 14.2). curred while they were intoxicated (Ruiz, Strain,
& Langrod, 2007).
One critical determinant of how quickly peo-
Alcohol ple become intoxicated with alcohol is whether
Alcohol's effects on the brain occur in two distinct their stomach is full or empty. An empty stomach
phases (Brick, 2008). In low doses, alcohol causes speedily delivers alcohol to the small intestine,
many people to feel more self-confident, more re- where it is rapidly absorbed into the body. A person
laxed, and perhaps slightly euphoric. They may be with a full stomach may ingest significantly more
less inhibited, and this disinhibitory effect may be drinks before reaching a dangerous blood-alcohol
what many people find attractive. At increasing level or showing clear signs of intoxication (Brick,
doses, however, alcohol induces many of the 2008). People in countries where alcohol is usually
symptoms of depression, including fatigue and consumed with meals, such as France, show lower
lethargy, decreased motivation, sleep disturbances, rates of alcohol use disorders than do people in
depressed mood, and confusion. Also, although countries where alcohol often is consumed on an
many people take alcohol to feel sexier (mainly by empty stomach.
Depressants 401
TABLE 14.2 Intoxication with and Withdrawal from Depressants
The depressant drugs depress activity in the central nervous system.
Drug Intoxication Symptoms Withdrawal Symptoms
Alcohol Behaviora l symptoms (e.g ., inappropriate Autonomic hyperactivity

sexual or aggressive behavior, mood (e.g., sweating,
lability, impaired judgment) fast pulse)
Benzodiazepi nes Sleepiness Hand tremor
Barbiturates Slurred speech Insomnia
Incoordination Nausea or vomiting
Unsteady gait Transient hallucinations
or ill usions
Involuntary eye movement Psychomotor agitat ion
Impairment in attention or memory Anxiety
Stupor or coma Seizu res
The legal definition of alcohol intoxication is have a lower body water content than men, leading
much narrower than the criteria for a diagnosis of to higher concentrations of alcohol in the blood for
alcohol intoxication. Most U.S. states consider a per- a given dose. Deficits in attention, reaction time,
son to be under the influence of alcohol if his or her and coordination arise even with the first drink and
blood-alcohol level is 0.08 or above. As Table 14.3 can interfere with the ability to operate a car or ma-
indicates, it does not take many drinks for most chinery safely and to perform other tasks requiring
people to reach this level. It takes less alcohol to a steady hand, coordination, clear thinking, and
reach a high blood-alcohol level in women than in clear vision. These deficits are not always readily
men because women generally are smaller and observable, even to trained eyes. People often leave
parties or bars without appearing drunk but having
a blood-alcohol level well above the legal limit
(Brick, 2008).
Heavy drinking can be part of the culture of a
peer group, but it still can lead to alcohol use dis-
order in some members. Drinking large quantities
of alcohol can be fatal, even in people who are not
chronic alcohol abusers. About one-third of such
deaths result from respiratory paralysis, usually
due to a final large dose of alcohol in people who
are already intoxicated. Alcohol can also interact
fatally with a number of substances, including
some antidepressant drugs (Brick, 2008).
Unintentional alcohol-related injuries due to
automobile accidents, drowning, bums, poisoning,
and falls account for approximately 600,000 deaths
per year internationally (WHO, 2005). Nearly half
of all fatal automobile accidents and deaths due to
falls or fires and over one-third of all drownings
are alcohol-related (Fleming & Manw ell, 2000;
Hunt, 1998). Even being a little "buzzed" (i.e.,
Drinking alcohol with food leads to a slower absorption
having a blood alcohol level of 0.02 percent) is as-
rate of the alcohol. sociated with a significantly increased risk of hav-
ing an automobile accident compared to being
TABLE 14.3 Relationships Among Sex. Weight. Oral Alcohol Consumption. and Blood-Alcohol Level
It doesn't take ve ry ma ny drinks for most people to reach a blood-alcohol level of 0.08, which is the lega l definition of intoxication in
most states.
Blood-Alcohol Level (Percent)
Total Alcohol
Content Beverage Female Male Female Male Female Male
(Ounces) Intake* (100 lb) (100 lb) (150 lb) (150 lb) (200 lb) (200 lb)
1/2 1 ozsp irits' 0.045 0.037 0.03 0.025 0.022 0.019

1 glass wine
1 can beer
2 oz spi rits 0.090 0.075 0.06 0.050 0.045 0.037
2 glasses win e
2 cans beer
2 4 oz spirits 0.180 0.150 0.12 0.100 0.090 0.070
4 glasses w ine
4 cans beer
3 6 oz spirits 0.270 0.220 0.18 0.150 0.130 0.110
6 glasses wine
6 cans beer
4 8 oz spirits 0.360 0.300 0.24 0.200 0.180 0.150
8 glasses w ine
8 cans beer
5 10 oz spirits 0.450 0.370 0.30 0.250 0.220 0.180
10 glasses wine
10 cans beer
* In 1 hour
' 100-proof spi ri ts (50 perce nt alcoho l)
Source: Data fro m Ray & Ks ir, 1993, p. 194.
completely sober (Phillips & Brewer, 2011). More open. Those whose alcohol use disorder is mod-
than half of all murderers and their victims are be- erate may experience only this first stage of with-
lieved to be intoxicated with alcohol at the time of drawal, and the symptoms may disappear within
the murders, and people who attempt or commit a few days.
suicide often do so under the influence of alcohol. The second stage includes convulsive sei-
The symptoms of alcohol withdrawal mani- zures, which may begin as soon as 12 hours after
fest in three stages (Brick, 2008). The first, which drinking stops but more often appear during the
usually begins within a few hours after drinking second or third day. The third stage of withdrawal
has been stopped or sharply curtailed, includes is characterized by delirium tremens, or DTs. Au-
tremulousness (the "shakes"), weakness, and ditory, visual, and tactile hallucinations occur. The
profuse perspiration. The person may complain person also may develop bizarre, terrifying delu-
of anxiety (the "jitters"), headache, nausea, and sions, such as the belief that monsters are attack-
abdominal cramps and may retch and vomit. He ing. He or she may sleep little and may become ~
or she is flushed, restless, and easily startled but agitated and disoriented. Fever, profuse perspira-
alert. The EEG pattern may be mildly abnormal. tion, and an irregular heartbeat may develop. De-
The person may begin to see or hear things, at lirium tremens is fatal in approximately 10 percent
first only with eyes shut but later also with eyes of cases. Death may occur from hyperthermia
Depressants 403
(extremely high body temperature) or the collapse among European Americans, due largely to high
of the peripheral vascular system. Fortunately, percentages of minority women who completely
only about 11 percent of individuals with severe abstain from alcohol. We discuss other contribu-
alcohol use disorder ever experience seizures or tors to the gender differences in substance use
DTs (Schuckit, Tip, Reich, & Hesselbrock, 1995). later in this chapter.
These symptoms are more common in people who Strong age differences in alcohol use disor-
drink large amounts in a single sitting and have ders decline with age. There are many reasons for
an existing medical illness. this decline. First, with age the liver metabolizes
alcohol at a slower rate, and the lower percentage
of body water increases the absorption of alcohol.
Alcohol Misuse
As a result, older people become intoxicated
As noted in Substance Use Along the Continuum,
faster and experience the negative effects of alco-
alcohol use and misuse span a broad range from
hol more severely and more quickly. Second, as
people who completely abstain from drinking al-
people grow older, they may become more ma-
cohol to those who drink alcohol occasionally in
ture in their choices, including choices about
social situations, to those who drink more fre-
drinking alcohol to excess. Third, older people
quently and heavily, and finally to those for whom
have grown up under stronger prohibitions
alcohol use creates significant social, occupational,
against alcohol use and abuse than have younger
and health problems. Near the maladaptive end of
people. Fourth, people who have used alcohol
the continuum are people who engage in heavy
drinking (two or more drinks per day for men, one
or more drinks per day for women) or binge drink-
ing (five or more drinks within a couple of hours
Gender Differences in
for men, four or more drinks w ithin a couple of FIGURE 14.2
Alcohol Use in the Past
hours for women). Heavy drinking and binge
Month. Men engage in
drinking are associated with significant health
more alcohol use than women do.
problems (Paul et al., 2011). Large nationwide
studies in the United States find that about 7 per-
70
cent of adults are heavy drinkers, and 17 to 23 per-
cent of adults report binge drinking at least once in Men
the last month (Paul et al., 2011; SAMHSA, 2008c). - Women
60
Binge drinking on college campuses is common.
Nationwide, 35 percent of college students report
binge drinking in the past month, compared to
50
32 percent of 18- to 22-year-olds not in college
(Johnston, O'Malley, Bachman, & Schulenberg,
2012) . Binge drinking is especially common
40
among members of fraternities and sororities, +-'
c
with 75 percent of members saying they binge Q)
~
Q)
drink (Wechsler et al., 2002). a..
30
Gender and Age Differences In most na-

tions of the world, men are more likely to drink 20
alcohol than are women, and also are more likely
to drink heavily or binge drink (Wilsnack et al.,
2009) . Similarly, across all age groups, males are 10
much more likely to develop alcohol use disorders
than are females, as can be seen in Figure 14.2. The
gender gap in alcohol use is much greater among 0
Any alcohol use Bingeing Heavy use
men and women who subscribe to traditional
gender roles, which condone drinking for men
but not for women (Huselid & Cooper, 1992; Source: SAMHSA, 2008c.
Wilsnack et al., 2009) . Similarly, the gender gap is Note: Singeing is defined as five or more drinks on the same
occasion at least once in the past 30 days. Heavy use is
greater among U.S. ethnic minority groups that defined as five or more drinks on the same occasion on at
more widely accept traditional gender roles, such least 5 different days in the past 30 days.
as Hispanics and recent Asian immigrants, than
excessively for many years may die from alcohol-

related diseases before they reach old age (Sher,
Grekin, & Williams, 2005).
Although alcohol use is illegal for persons un-
der 21 years of age in the United States, one-third
of 8th graders and 70 percent of 12th graders have
tried alcohol (Johnston et al., 2012). Of particular
concern, 22 percent of 12th graders report having
engaged in binge drinking in the last year. Several
studies suggest that the use of alcohol and the
prevalence of alcohol-related problems have been
increasing among young people in recent decades
and that the age at which alcohol is first consumed
is decreasing (e.g., Grucza, Bucholz, Rice, & Bierut, As people grow older. they may become more mature in
2008; Keyes et al., 2008, 2010). The earlier the age of their choices. inc luding choices about drinking alcohol
to excess.
onset of drinking and drinking-related problems,
the more likely individuals are to develop alcohol
use disorders (Alvanzo et al., 2011).
Cultural and Ethnic/Racial Differences

Cultures differ markedly in their use of alcohol
Consumption of Pure Alcohol in Various and rates of alcohol-related problems (Figure 14.3).
FIGURE 14.3
Regions of the World. Cultures vary greatly in Consumption in the Russian Federation is high
their consumption of alcohol. (Southeast Asia among both men and women, and the rates of neg-
includes India and neighboring countries . Western Pacific ative health consequences due to alcohol are high-
includes Australia, China, Japan, and the Pacific Rim Countries.) est in this and surrounding countries (Rehm et al.,
2009). Low rates of consumption in some African ~
and middle eastern countries are tied to Islam's
prohibitions against alcohol.
Ethnic groups within the United States differ
substantially in their alcohol use. One group at
high risk for alcohol-related problems is Native
Americans, 43 percent of whom meet the criteria
for alcohol abuse or alcohol dependence at some
~ 71----------===;----------- time in their life (Hasin, Stinson, Ogburn, & Grant,
.....
:.::;
.s 2007). Deaths related to alcohol are as much as five
5 6 1---------1
.;::;
times more common among Native Americans
a.. than in the general U.S. population (Manson et al.,
E
5"' 1992). This higher rate of alcohol-related problems

Vl
5 -1----------1
u has been tied to excessive rates of poverty and un-
-ro
"'
c: employment, lower levels of education, and a
~ 4 -1----------1
greater sense of helplessness and hopelessness
"'0>
~ (Manson et al., 1992).
"'
~ 3 -+----------1
Long-Term Effects of Alcohol Misuse
Heavy and prolonged use of alcohol can have
toxic effects on several systems of the body, in-
cluding the stomach, esophagus, pancreas, and
liver (Paul et al., 2011). One of the most common
medical conditions associated with alcohol mis-
0 use is low-grade hypertension. This condition,
Africa Americas Eastern Europe Southeast Western
Mediterranean Asia Pacific combined with increases in the levels of triglycer-
ides and low-density lipoprotein (or "bad") cho-
lesterol, puts alcohol abusers at increased risk for
Source: World Health Organization, 2005b. heart disease. Heavy alcohol use increases the risk
of cancer, particularly breast cancer in women
Depressants 405
SHADES OF GRAY
As you may have observed, binge drinking on the was able to keep decent grades through his first
weekends is fairly common on college campuses. year, despite missing many classes. In sophomore
Read about Nick and his friends, who may year, classes in his major were harder, and he
resemble people you know. would abstain from drinking from Sunday after-
noon until noon on Thursday. But Thursday after-
Nick began drinking in high school, but his drink- noon he would get the keg of beer for his friends,
ing escalated when he moved away from home and the old pattern would kick in.
for college. After just a couple of weeks there, Nick One night during a drinking game, Nick acciden-
became friends with a group that liked to party on tally punched a hole in the wall of his dorm room
the weekends. On Thursday nights, they would and was kicked off campus as a result. Between this
drink and get so loud and obnoxious that their incident and his declining grades, his parents threat-
neighbors in the dorm would sometimes com- ened to stop paying his college tuition.
plain. They would sleep off their hangovers on
Friday, miss classes, and then begin drinking again Would you diagnose Nick with an alcohol use
from Friday afternoon through Saturday, finally disorder? (Discussion appears at the end of this
stopping on Sunday to sleep and recover. Nick chapter.)
(Chen et al., 2011). People with alcohol use disor- tests. The few longitudinal studies that have been
ders often are malnourished, in part because done suggest that these deleterious effects of alco-
chronic alcohol ingestion decreases the absorption hol consumption may persist even after people
of critical nutrients from the gastrointestinal sys- stop drinking.
tem and in part because they tend to "drink their Some studies indicate that moderate alcohol
...-" meals." Some show a chronic thiamine (vitamin B1) consumption, particularly of red wine, carries
deficiency, which can lead to several disorders of health benefits. Red wine contains antioxidants
the central nervous system, including numbness that can increase good cholesterol, along with
and pain in the extremities, deterioration in the other chemicals that can help prevent damage to
muscles, and the loss of visual acuity for both near blood vessels and reduce bad cholesterol, produc-
and far objects (Martin & Bates, 1998). Heavy pro- ing positive cardiac effects (Fillmore et al., 2006;
longed use of alcohol is a risk factor for dementia, Le Strat & Gorwood, 2011). Several studies sug-
a permanent substance-induced major neuro- gest that individuals who consume one or two
cognitive disorder involving loss of intellectual drinks a day have better physical health and lower
abilities, including memory, abstract thinking, mortality rates than individuals who abstain from
judgment, and problem solving, and often accom- alcohol (Corrao, Bagnardi, Zambon, & LaVecchia,
panied by personality changes such as increased 2004; Rehm, Greenfield, & Rogers, 2001). How-
paranoia (see Chapter 10). Subtler deficits due to ever, abstainers and moderate drinkers differ on
central nervous system damage (e.g., substance- many other variables that can affect health. Ab-
induced mild neurocognitive disorder) are ob- stainers are more likely than moderate drinkers to
served in many chronic abusers of alcohol, even be older, less well educated, physically inactive,
after they quit drinking (Martin & Bates, 1998). and overweight and to have diabetes, hyperten-
As noted earlier, binge drinking is relatively sion, and high cholesterol (Naimi et al., 2005).
common among adolescents and young adults. Some people classified as abstainers drank heav-
There is increasing evidence that heavy and pro- ily earlier in life and have quit due to negative
longed use of alcohol during adolescence and health effects (Fillmore et al., 2006). These factors
early adulthood may have permanent negative ef- make the potential health benefits of moderate
fects on the brain, which is undergoing massive drinking less clear.
developmental changes during these periods of
life (Jacobus & Tapert, 2013). Neuroimaging stud- Benzodiazepines
ies show changes in the structure and functioning
of several areas of the brain in adolescents and
and Barbiturates
young adults who binge-drink frequently or are Like alcohol, benzodiazepines and barbiturates
chronic heavy drinkers, changes associated w ith depress the central nervous system. Intoxication
deficits in performance on a variety of cognitive with and withdrawal from these substances are
similar to alcohol intoxication and withdrawal. amphetamines account for more than a third of ~
Users may initially feel euphoric and become drug-related emergency room visits (SAMHSA,
disinhibited but then experience depressed moods, 2008a). Prescription stimulants, including Dexe-
lethargy, perceptual distortions, loss of coordina- drine and Ritalin, are used to treat asthma and other
tion, and other signs of central nervous system respiratory problems, obesity, neurological disor-
depression. ders, attention-deficit/hyperactivity disorder
Benzodiazepines (such as Xanax, Valium, (ADHD; see Chapter 10), and a variety of other con-
Halcion, Librium, and Klonopin) and barbitu- ditions. Use of these prescription stimulants for
rates (such as Seconal) are legally manufactured nonmedical purposes has increased sharply in re-
and sold by prescription, usually as sedatives for cent decades (McCabe et al., 2008). Caffeine and
the treatment of anxiety and insomnia. Benzodi- nicotine also are stimulants, and although their psy-
azepines are also used as muscle relaxants and chological effects are not as severe as those of co-
antiseizure medicines. In the United States, ap- caine and amphetamines, these drugs-particularly
proximately 90 percent of people hospitalized for nicotine-can have long-term negative effects.
medical care or surgery are prescribed sedatives
(Virani et al., 2009). Large quantities of these sub- Cocaine
stances end up on the black market, however.
Cocaine, a white powder extracted from the coca
They are especially likely to be abused in combi-
plant, is one of the most addictive substances
nation with other psychoactive substances to pro-
known. People snort the powder or inject it intra-
duce greater feelings of euphoria or to relieve the
venously. In the 1970s, even more powerful free-
agitation created by other substances. Abuse of
base cocaine appeared when users developed a
prescription sedatives and tranquilizers has in-
method for separating the most potent chemicals
creased in recent years. Nationwide studies find
that about 9 percent of adults, 9.6 percent of col-
lege students, and close to 5 percent of teenagers
report using prescription sedatives or tranquiliz-
ers in the last year for nonmedical purposes
(Johnston et al., 2012; McCabe, Cranford, & West,
2008; SAMHSA, 2008). DSM-5 classifies problem-
atic misuse of these drugs as sedative, hypnotic,
or anxiolytic use disorders.
Barbiturates and benzodiazepines cause de-
creases in blood pressure, respiratory rate, and heart
rate. In overdose, they can be extremely dangerous
and even cause death from respiratory arrest or car-
diovascular collapse. Overdose is especially likely
when people take these substances (particularly
benzodiazepines) with alcohol. These were among
the drugs that Heath Ledger overdosed on (see this
chapter's Extraordinary People).
STIMULANTS
Stimulants activate the central nervous system,
causing feelings of energy, happiness, and power;
a decreased desire for sleep; and a diminished ap-
petite (see Table 14.4). Cocaine and the amphet-
amines (including the related methamphetamines)
are the two types of stimulants associated with
severe substance use disorders. Both impart a psy-
chological lift or rush. They cause dangerous in-
creases in blood pressure and heart rate, alter the Cocaine use causes dangerous increases in blood
rhythm and electrical activity of the heart, and pressure and heart rate. alterations in the rhythm
constrict the blood vessels, which can lead to heart and electrical activity of the heart. and constricted
blood vessels. which can lead to heart attacks,
attacks, respiratory arrest, and seizures. In the respiratory arrest. and seizures.
United States, toxic reactions to cocaine and the
Stimulants 407
TABLE 14.4 Intoxication with and Withdrawal from Stimulants
The stimulants activate the central nervous system .
Cocaine and Behavioral changes (e.g., euphoria or affective Dysphoric mood

amphetamines blunting; changes in sociability; hypervigilance; Fatigue
interpersonal sensitivity; anxiety, tension, or Vivid, unpleasant dreams
anger; impaired judgment) Insomnia or hypersomnia
Rapid heartbeat Increased appetite
Dilation of pupils Psychomotor retardation or agitation
Elevated or lowered blood pressure
Perspiration or chills
Nausea or vom iting
Weight loss
Psychomotor agitation or retardation
Muscular weakness
Slowed breathing
Chest pain
Confusion, seizures, coma
Nicotine Not a diagnosis in the DSM-5 Dysphoria or depressed mood
Insomnia
Irritability, frustration, or anger
Anxiety
Difficulty concentrating
Restlessness
Decreased heart rate
Increased appetite or weight gain
Caffeine Restlessness Marked fatigue or drowsiness
Nervousness Dysphoric mood or irritability
Excitement Flulike symptoms
Insomn ia (e.g ., nausea or vomiting)
Flushed face
Frequent urination
Stomach upset
Muscle twitching
Rambling flow of thought or speech
Rapid or irreg ular heartbeat
Periods of inexhau stibility
Psychomotor agitation
in cocaine by heating it with ether. Freebase co- impulsiveness, hypersexuality, compulsive behav-
caine is usually smoked in a water pipe or mixed ior, agitation, and anxiety reaching the point of panic
in a tobacco or marijuana cigarette. Crack is a form and paranoia. Stopping cocaine use can induce
of freebase cocaine boiled down into tiny chunks, exhaustion and depression.
or rocks, and usually smoked. Cocaine activates those areas of the brain
Initially, cocaine produces an instant rush of in- that register reward and pleasure. Normally, a
tense euphoria, followed by heightened self-esteem, pleasurable event releases dopamine into the syn-
alertness, energy, and feelings of competence and apses in these areas. Dopamine then binds to re-
creativity. Users crave increasing amounts of the ceptors on neighboring synapses (Figure 14.4).
substance, for both its physiological and its psycho- Cocaine blocks the reuptake of dopamine into the
logical effects (Ruiz et al., 2007). When taken repeat- transmitting neuron, causing it to accumulate in
edly or at high doses, however, it leads to grandiosity, the synapse and maintaining the pleasurable
feeling (Ruiz et al., 2007). The rapid, strong effects

When he graduated from dental school his wife
of cocaine on the brain's reward centers make this
substance more likely than most to lead to a stimu- was pregnant, and he was "scared to death" at
lant use disorder. The following case study illus- the prospect of being a father. His deepening
depression was characterized by social isola-
trates this process.
tion, increased loss of interests, and frequent
temper outbursts. He needed intoxication with
marijuana, or occasionally sedatives, for sex,
CASE STUDY relaxation, and social ization. Following the
Dr. Arnie Rosenthal is a birth of the child he "never felt so crazy;' and
31-year-old white male dentist, married for 10years his marijuana and sedative use escalated. Two
with two children. His wife insisted he see a psy- years later, a second child was born. Dr. Rosenthal
chiatrist because of uncontrolled use of cocaine, was financially successful, had moved to an ex-
which over the past year had made it increasingly pensive suburban home with a swimming pool,
difficult for him to function as a dentist. During the and had two cars and "everything my parents
previous 5 years he used cocaine virtually every wanted for me:' He was 27 years old, felt he
day, with only occasional 1- or 2-week periods of had nothing to look forward to, and felt pain-
abstinence. For the past 4 years Rosenthal wanted fully isolated; drugs were no longer providing
to stop, but his desire was overridden by a "com- relief.
pulsion" to take the drug. Rosenthal tried cocaine for the first time and
He began using marijuana after being mar- immediately felt good. "I was no longer de-
ried a year, smoking a joint each day after pressed. I used cocaine as often as possible be-
school and spending the evening staring atTV. cause all my problems seemed to vanish, but I
had to keep doing it. The effects were brief and it
was very expensive, but I didn't care. When the
immediate effects wore off, I'd feel even more
miserable and depressed so that I did as much
Effects of Cocaine on Dopamine Systems. cocaine as I was able to obtain:' He is now con-
Cocaine blocks transporters for the reuptake tinuously nervous and irritable. (From Spitzer,
of dopamine, resulting in excess dopamine in R. L., Skodol, A. E., Gibbon, M ., & Williams, J. B. W.,
the synapses. 1983, Psychopathology: A Case Book, pp. 81-83.
Copyright 1983 The McGraw-Hill Companies,
Normal dopamine reuptake Inc. Reprinted with permission.)
--==1\:;0~ Receiving
0
0 Cocaine's effects wear off quickly, and the

0
0 0
dependent person must take frequent doses to
maintain a high. Tolerance also can develop, and
the individual must obtain larger and larger
0
amounts to experience a high (Ruiz et al., 2007).
People with cocaine-related stimulant use disor-
der spend huge amounts of money on the sub-
stance and may engage in theft, prostitution, or
drug dealing to obtain enough money to pur-
chase it. Desperation can lead frequent users to
participate in extremely dangerous behaviors.
Many contract HIV, the virus that causes AIDS,
by sharing needles with infected users or by hav-
ing unprotected sex in exchange for money or
cocaine (Ruiz et al., 2007).
Other frequent medical complications of co-
caine use are heart rhythm disturbances and
heart attacks; respiratory failure; neurological ef-
r . - cocaine fects, including strokes, seizures, and headaches;
and gastrointestinal complications, including
Stimulants 409
abdominal pain and nausea. Physical symptoms

include chest pain, blurred vision, fever, muscle
spasms, convulsions, and coma (Ruiz et al., 2007).
A large percentage of people who grew up in
the 1960s and 1970s have tried cocaine, but these
percentages are much lower in more recent
generations: A nationwide study in the United States
found that 48 percent of individuals who gradu-
ated from high school in 1979 had tried cocaine at
some time in their life, compared to about 20 per-
cent of individuals who had graduated from high
school between 1980 and 1995 (Johnston et al.,
2012). Among U.S. college students, 5.5 percent re-
port ever having used cocaine, whereas 12 percent
of 18- to 22-year-olds not in college report ever
having used cocaine; among high school students,
about 3.5 percent report ever having used cocaine
(Johnston et al., 2012). On the street, amphetamines are known as "speed." "meth." and "chalk." They
are most often swallowed as pills but can be injected intravenously, and
methamphetamine can be snorted ("crank") or smoked ("crystal meth " or
Amphetamines "ice"). Serious health problems can result from their use.
Amphetamines and the related methamphetamines
are stimulants prescribed for the treatment of at-
tention problems (e.g., Ritalin, Adderall), narco- behavior while intoxicated or as a result of buy-
lepsy, and chronic fatigue. They also are found in ing the drug illegally. Tolerance develops quickly,
antihistamines (e.g., Sudafed) and diet drugs. as does physical dependence. Users may switch
Many stimulants are used appropriately under from swallowing pills to injecting amphetamines
the supervision of a physician, but a great many intravenously. Some go on a speed run, in which
doses are diverted to illegal use and abuse (Ruiz they inject amphetamines frequently over sev-
et al., 2007). Because of the potential for abuse, eral days without eating or sleeping. Then they
most states regulate over-the-counter sales of diet crash into a devastating depression. Acute with-
drugs and antihistamines. On the street, amphet- drawal symptoms typically subside within a
amines are known as "speed," "meth," and few days, but chronic users may experience
"chalk." They are most often swallowed as pills mood instability, memory loss, confusion, para-
but can be injected intravenously, and metham- noid thinking, and perceptual abnormalities for
phetamine can be snorted ("crank") or smoked weeks, months, or even years. They often battle
("crystal meth" or "ice"). the withdrawal symptoms with another speed
Amphetamines release the neurotransmitters run (Ruiz et al., 2007).
dopamine and norepinephrine and block their Abuse of amphetamines and methamphet-
reuptake. The symptoms of intoxication are simi- amines can lead to a number of medical issues,
lar to those of cocaine intoxication: euphoria, self- particularly cardiovascular problems-including
confidence, alertness, agitation, and paranoia rapid or irregular heartbeat, increased blood pres-
(Ruiz et al., 2007). Like cocaine, amphetamines sure, and irreversible, stroke-producing damage to
can produce perceptual illusions. The movement the small blood vessels in the brain. Elevated body
of other people and objects may seem distorted or temperature and convulsions can occur during
exaggerated. Users may hear frightening voices overdoses, leading to death. People who share
making derogatory statements about them, see needles to inject amphetamines risk contracting
sores all over their body, or feel snakes crawling HIV or hepatitis (Brick, 2008). With extended use,
on their arms. They may have delusions of being people become irritable and hostile and need more
stalked that lead them to act out violently. Some stimulants to avoid withdrawal symptoms. Their
users know that these experiences are not real, personal relationships and health decline. Between
but others lose their grip on reality and develop 1995 and 2002, emergency room visits involving
amphetamine-induced psychotic disorders (Ruiz amphetamines increased 54 percent in the United
et al., 2007). States (SAMHSA, 2005).
Legal problems typically arise for amphet- Abuse of these drugs has risen in recent years.
amine abusers due to aggressive or inappropriate In 2011, 8.2 percent of 12th-graders reported using
amphetamines or methamphetamines (Johnston in part to significantly increased taxes on tobacco

et al., 2012). College students trying to stay up late products, laws restricting their use in public
to study may take them; nationwide studies find places, and lawsuits limiting tobacco companies'
that 13.4 percent of college students report ever ability to advertise. In contrast, tobacco use is in-
having used amphetamines or methamphet- creasing in developing countries.
amines, with 9.3 percent reporting their use in the Nicotine operates on both the central and the
last year (Johnston et al., 2012). Employers may peripheral nervous systems. It helps release
even provide amphetamines to their employees to several biochemicals in the brain, including
increase productivity. dopamine, norepinephrine, serotonin, and the
endogenous opioids. Although people often say
they smoke to reduce stress, nicotine's physio-
Nicotine logical effects actually resemble the fight-or-
All the substances discussed thus far, except al- flight response (see Chapter 5)-several systems
cohol, are illegal for nonprescription use, and in the body are aroused, including the cardiovas-
many laws regulate the use of alcohol. One of the cular and respiratory systems. The subjective
most addictive substances known, however, is sense that smoking reduces stress actually may
fully legal for use by adults and readily available reflect the reversal of the tension and irritability
to adolescents-nicotine. that signal nicotine withdrawal. In other words,
Nicotine is an alkaloid found in tobacco. Ciga- nicotine addicts need nicotine to feel normal to
rettes, the most popular nicotine delivery device, counteract its effects on the body and the brain
get this substance to the brain within seconds. In (Ruiz et al., 2007). DSM-5 recognizes nicotine de-
the United States, 70 percent of people over age 12 pendence as a tobacco use disorder.
have smoked cigarettes at some time in their life, In 1964, based on a review of 6,000 empirical
and about 28 percent currently are smokers studies, the surgeon general of the United States
(Johnston et al., 2012; SAMHSA, 2008c). Smoking concluded that smoking, particularly cigarette
usually begins in the early teens. A 2011 survey of smoking, causes lung cancer, bronchitis, and
12th-graders found that 40 percent had smoked a probably coronary heart disease. Mortality rates
cigarette at some time in their life and that 10 perfor smokers are 70 percent greater than for non-
cent were smoking daily (Johnston et al., 2012). smokers, meaning that a person between ages 30
Rates of cigarette use are much higher in Europe and 35 who smokes two packs a day will die 8 to
and many developing nations (Danielsson, 9 years earlier than a nonsmoker. Each year, an
Wennberg, Hibell, & Romelsj6 2012). Over two- estimated 443,000 people in the United States die
thirds of people who begin smoking become de- prematurely from smoking-related coronary
pendent on nicotine, a rate much higher than is heart disease, lung cancer, emphysema, or chronic
found with most other psychoactive substances bronchitis or from exposure to secondhand
(Lopez-Quintero et al., 2011). Tobacco use has de- smoke. An additional 8.6 million people have a
clined in the United States and other industrial- serious illness related to smoking (CDC, 2009).
ized countries over the past few decades, thanks Women who smoke while pregnant give birth to
smaller babies. The longer a person smokes and
the more he or she smokes each day, the greater
the health risks.
When chronic heavy smokers try to quit or are
prohibited from smoking for an extended period,
such as while at work or on an airplane, they show
severe withdrawal symptoms. They become de-
pressed, irritable, angry, anxious, frustrated, rest-
less, and hungry; they have trouble concentrating;
and they desperately crave another cigarette.
These symptoms are immediately relieved by
smoking, another sign of physiological depen-
dence (Ruiz et al., 2007).
Because nicotine is relatively cheap and avail-
able, dependents tend not to spend much time
While the rate of cigarette smoking has decreased in
the United States. it is on the rise in many developing trying to obtain it. They may panic, however, if
countries around the world. they run out of cigarettes and replacements are
not available. They also may spend a large part of
Opioids 411
their day smoking or chewing tobacco, and they example, might be so agitated that she cannot sit
continue to use nicotine even though it is damag- through her exams and so shaky that she cannot
ing their health (e.g., after they have been diagnosed drive a car; such a person could be given a diagno-
with emphysema). They may skip social activi- sis of caffeine intoxication.
ties where smoking is not allowed or recreational Some heavy coffee drinkers who joke that
activities such as sports because they have trouble they are "caffeine addicts" actually cannot be di-
breathing. agnosed with caffeine use disorder, according to
Over 70 percent of people who smoke say they the DSM-5, because dependence on the drug
want to quit (Goldstein, 1998). Quitting is difficult, seems not to cause significant social and occupa-
however, in part because the withdrawal syndrome tional problems. Still, caffeine users can develop
is difficult to withstand. Only about 7 percent of tolerance and undergo withdrawal if they stop
smokers who try to stop smoking are still abstinent ingesting caffeine. They may require several
after 1 year, and most relapse within a few days of cups of coffee in the morning to feel "normal"
quitting (National Institute on Drug Abuse [NIDA], and may experience significant headaches, fa-
2002b). The craving can remain after a smoker tigue, and anxiety if they do not get their coffee.
quits, with 50 percent of people who quit smoking
reporting they have desired cigarettes in the past OPIOIDS
24 hours (Goldstein, 1994). Nicotine patches and
gum can help fight this urge. Morphine, heroin, codeine, and methadone are all
opioids. They are derived from the sap of the
opium poppy, which has been used for thousands
Caffeine of years to relieve pain. Our bodies produce natural
Caffeine is by far the most heavily used stimu- opioids, including endorphins and enkephalins, to
lant, with 75 percent of it ingested in coffee cope with pain. For example, a sports injury in-
(Chou, 1992). A cup of brewed coffee has about duces the body to produce endorphins to reduce
100 milligrams of caffeine, and the average U.S. pain and avoid shock. Doctors also may prescribe
adult drinks about two cups per day. Other
sources include tea (about 40 milligrams of caf-
feine per 6 ounces), caffeinated soda (45 milli-
grams per 12 ounces), over-the-counter analgesics
and cold remedies (25 to 50 milligrams per tab-
let), weight-loss drugs (75 to 200 milligrams per
tablet), and chocolate and cocoa (5 milligrams
per bar).
Caffeine stimulates the central nervous sys-
tem, increasing the levels of dopamine, norepi-
nephrine, and serotonin. It also increases
metabolism, body temperature, and blood pres-
sure. People's appetite wanes, and they feel more
alert. But in doses equivalent to just two to three
cups of coffee, caffeine can cause unpleasant
symptoms, including restlessness, nervousness,
and hand tremors. People may experience an up-
set stomach and feel their heart beating rapidly or
irregularly. They may have trouble going to sleep
later on and may need to urinate frequently.
These are symptoms of caffeine intoxication. Ex-
tremely large doses of caffeine can cause extreme
agitation, seizures, respiratory failure, and car-
diac problems.
The DSM-5 specifies that a diagnosis of
caffeine intoxication should be given only if an
individual experiences significant distress or im-
pairment in functioning as a result of the symp-
Severe intoxication from heroin use can lead to
toms. Someone who drinks too much coffee for unconsciousness, coma, and seizures.
several days in a row during exam week, for
TABLE 14.5 Intoxication with and Withdrawal from Opioids
The opioids include morphine, heroin, codeine, and methadone.
Opioids Behavioral changes (e.g., initial euphoria followed Dysphoric mood

by apathy, dysphoria, psychomotor ag itation or Nausea or vomiting
retardation; impaired judgment} Muscle aches
Constriction of pupils Tearing or nasal mucus discharge
Drowsiness or coma Dilation of pupils
Slurred speech Goose bumps
Attention and memory problems Sweating
Diarrhea
Yawning
Fever
Insomnia
synthetic opioids, such as hydrocodone (Lorcet, to pain, and a craving for more opioids. The per-
Lortab, Vicodin) or oxycodone (Percodan, Percocet, son may experience nausea, vomiting, profuse
OxyContin) for pain. sweating and goose bumps, diarrhea, and fever
Morphine was widely used as a pain reliever (Ruiz et al., 2007). These symptoms usually appear
in the nineteenth century, until it was found to be within 8 to 16 hours of last use and peak within 36
highly addictive. Heroin was developed from to 72 hours. In chronic or heavy users, they may
morphine in the late nineteenth century and was continue in strong form for 5 to 8 days and in a
used for a time for medicinal purposes. By 1917, milder form for weeks to months.
however, it was clear that heroin and all the opi- Most street heroin is cut with other sub-
oids have dangerous addictive properties, and stances, so users do not know the actual strength
Congress passed a law making heroin illegal and of the drug or its true contents, leaving them at
banning the other opioids except for specific medi- risk for overdose or death. Users also risk con-
cal needs. Heroin remained widely available on tracting HIV through contaminated needles or
the street, however (Winger et al., 1992). through unprotected sex, which many opioid
When used illegally, opioids often are injected abusers exchange for more heroin. In some areas
into the veins (mainlining), snorted, or smoked. of the United States, up to 60 percent of chronic
The initial symptom of opioid intoxication often heroin users are infected with HIV. Intravenous
is euphoria (see Table 14.5). People describe a users also can contract hepatitis, tuberculosis,
sensation in the abdomen like a sexual orgasm, serious skin abscesses, and deep infections.
referring to it as a thrill, kick, or flash. They may Women who use heroin during pregnancy risk
have a tingling sensation and a pervasive sense of miscarriage and premature delivery, and chil-
warmth. They pass into a state of drowsiness, dren born to mothers with opioid use disorders
during which they are lethargic, their speech is are at increased risk for sudden infant death
slurred, and their mind may be clouded. They syndrome (Brady, Back, & Greenfield, 2009).
may experience periods of light sleep with vivid The use and misuse of prescription opioid pain
dreams. Pain is reduced (Ruiz et al., 2007). A per- relievers such as oxycodone or Vicodin have in-
son in this state is referred to as being on the nod. creased significantly in the past decade and were
Severe intoxication can lead to unconsciousness, among the prescription drugs involved in Heath
coma, and seizures. Ledger's overdose. One-third of middle-aged adults
Opioids can suppress the respiratory and car- in the United States report having used these drugs
diovascular systems to the point of death. The for nonmedical purposes sometime in their life.
drugs are especially dangerous when combined Thirteen percent of 12th-graders, 12 percent of col-
with depressants, such as alcohol or sedatives. lege students, and 18 percent of 18- to 22-year-olds
Withdrawal symptoms include dysphoria, an achy not in college report having ever used these drugs
feeling in the back and legs, increased sensitivity for nonmedical purposes Oohnston et al., 2012).
Hallucinogens and PCP 413
HALLUCINOGENS AND PCP TABLE 14.6 Intoxication with Hallucinogens and PCP
Most of the substances discussed so far can pro-
duce perceptual illusions and distortions when The hallucinogens and PCP cause a variety of perceptual and behavioral
used in large doses. The hallucinogens and phen- changes.
cyclidine (PCP) produce perceptual changes even Drug Intoxication Symptoms
in small doses (see Table 14.6). The hallucinogens
are a mixed group of substances, including lyser- Hallucinogens Behavioral changes (e.g. , marked anxiety or
gic acid diethylamide (LSD) and peyote. The depression, the feeling that others are talking
psychoactive effects of LSD were first discovered about you, fear of losing your mind, paranoia,
in 1943 when Dr. Albert Hoffman accidentally impaired judgment)
swallowed a minute amount and experienced Perceptual changes while awake (e.g .,
visual hallucinations. He later purposefully intensification of senses, depersonalization,
swallowed a small amount of LSD and reported illusions, hallucinations)
its effects. Dilation of pupils
Rapid heartbeat
Sweating
Palpitations
PROFILES Blurring of vision
Tremors
Incoordination
As far as I remember, the following were the
most outstand ing symptoms: vertigo, visual dis- PCP Behavioral changes (e.g., belligerence,
assaultiveness, impulsiveness,
turbances; the faces of those around me ap-
unpredictability, psychomotor agitation,
peared as grotesque, colored masks; marked
impaired judgment)
motor unrest, alternating with paresis; an inter-
Involuntary rapid eyeball movement
mittent heavy feeling in the head, limbs, and the
Hypertension
entire body, as if they were filled with metal;
cramps in the legs, coldness, and loss of feeling Numbness
in the hands; a metallic taste on the tongue; dry Loss of muscle coord ination
constricted sensation in the throat; feeling of Problems speaking due to poor muscle control
choking; confusion alternating between clear rec- Muscle rigidity
ognition of my condition, in which state I some- Seizures or coma
times observed, in the manner of an independent, Exceptionally acute hearing
neutral observer, that I shouted half insanely or Perceptual disturbances
babbled incoherent words. Occasionally, I felt as
if I were out of my body. The doctor found a rather
weak pulse but an otherwise normal circulation.
Six hours after ingestion of the LSD my condition
had already improved considerably. Only the
visual disturbances were still pronounced.
As Hoffman describes, one symptom of intoxi-
Everything seemed to sway and the proportions
cation from LSD and other hallucinogens is synes-
were distorted like the reflections in the surface
thesia, the overflow from one sensory modality to
of moving water. Moreover, all objects appeared
another. People say they hear colors and see
in unpleasant, constantly changing colors, the
sounds. They feel at one with their surroundings,
predominant shades being sickly green and blue.
and time seems to pass very slowly. Moods also
When I closed my eyes, an unending series of
may shift from depression to elation to fear. Some
colorful, very realistic and fantastic images
people become anxious. Others feel a sense of de-
surged in upon me. A remarkable feature was the
tachment and a great sensitivity for art, music, and
manner in which all acoustic perceptions (e.g.,
feelings. These experiences lent the drugs the label
the noise of a passing car) we re transformed into
psychedelic, from the Greek words for "soul" and
optical effects, every sound causing a corre-
"to make manifest." LSD was used in the 1960s as
sponding colored hallucination constantly chang-
part of the consciousness-expanding movement
ing in shape and color like pictures in a
(Winger et al., 1992).
kaleidoscope. (Hoffman, 1968, pp. 185-186)
The hallucinogens are dangerous drugs, how-
ever. Although LSD was legal for use in the early
1960s, by 1967 reports of "bad acid trips," or "bum- adults, however, with 5.8 percent of 12th-graders,
mers," had become common, particularly in the 4.1 percent of college students, and 6.4 percent of
Haight-Ashbury district of San Francisco, where 18- to 22-year-olds not in college reporting use of a
many LSD enthusiasts from around the United hallucinogen in the past year (Johnston et al.,
States congregated (Smith & Seymour, 1994). 2012).
Symptoms included severe anxiety, paranoia, and
loss of control. Some people on bad trips would
walk off a roof or jump out a window, believing
CANNABIS
they could fly, or walk into the sea, believing they The leaves of the cannabis (or hemp) plant can be
were "one with the universe." For some, the anxi- cut, dried, and rolled into cigarettes or inserted
ety and hallucinations were severe enough to pro- into food and beverages. In North America, the
duce psychosis requiring hospitalization and result is known as marijuana, weed, pot, grass,
long-term treatment. Some people reexperience reefer, and Mary Jane. Cannabis is the most com-
their psychedelic experiences, especially visual monly used illegal drug, with 42 percent of adults
disturbances, long after the drug has worn off and in the United States and 23 percent of Europeans
may develop a distressing or impairing hallucino- having used the drug (Degenhardt et al., 2008;
gen persisting perception disorder. European Monitoring Centre for Drugs and Drug
Phencyclidine (PCP)-also known as angel Action, 2011; Johnston et al., 2012). About half of
dust, PeaCePill, Hog, and Tranq-is manufactured older adolescents and young adults say they have
as a powder to be snorted or smoked. Although used cannabis at some time in their life, and about
PCP is not classified as a hallucinogen, it has many 20 percent have used it in the last year (Johnston
of the same effects. At lower doses, it produces a et al., 2012).
sense of intoxication, euphoria or affective dulling, Intoxication usually begins with a "high" feel-
talkativeness, lack of concern, slowed reaction ing of well-being, relaxation, and tranquility (see
time, vertigo, eye twitching, mild hypertension, Table 14.7). Users may feel dizzy, sleepy, or dreamy.
abnormal involuntary movements, and weakness. They may become more aware of their environ-
At intermediate doses, it leads to disorganized ment, and everything may seem funny. They may
thinking, distortions of body image (e.g., feeling become grandiose or lethargic. People who al-
that one's arms are not part of one's body), deper- ready are very anxious, depressed, or angry may
sonalization, and feelings of unreality. A user may become more so (Ruiz et al., 2007). The symptoms
become hostile, belligerent, and even violent of cannabis intoxication may develop within min-
(Morrison, 1998). At higher doses, PCP produces utes if the drug is smoked but may take a few
amnesia and coma, analgesia sufficient to allow hours to develop if it is taken orally. The acute
surgery, seizures, severe respiratory problems, hy- symptoms last 3 to 4 hours, but some symptoms
pothermia, and hyperthermia. The effects begin may linger or recur for 12 to 24 hours.
immediately after injecting, snorting, or smoking Although people often view cannabis as a
and peak within minutes. Symptoms of severe in- benign or safe drug, it can significantly affect cog-
toxication can persist for several days; people with nitive and motor functioning. People taking can-
PCP intoxication may be misdiagnosed as having nabis may believe they are thinking profound
a psychotic disorder unrelated to substance use thoughts, but their short-term memory is im-
(Morrison, 1998). paired to the point that they cannot remember
Phencyclidine or other hallucinogen use disor- thoughts long enough to express them in sen-
der is diagnosed when individuals repeatedly fail tences. Motor performance also is impaired.
to fulfill major role obligations at school, work, or People's reaction times are slower and their con-
home due to intoxication with these drugs. They centration and judgment are deficient, putting
may use the drugs in dangerous situations, such as them at risk for accidents. The cognitive impair-
while driving a car, and they may have legal trou- ments caused by cannabis can last up to a week
bles due to their possession of the drugs. Because after heavy use stops (Pope et al., 2001). These
the drugs can cause paranoia or aggressive behav- effects appear to be greater in women than in men
ior, frequent users may find their work and social (Pope et al., 1997).
relationships affected. About 11 percent of the U.S. The physiological symptoms of cannabis in-
population reports having tried a hallucinogen or toxication include increased or irregular heartbeat,
PCP, but only 0.4 percent report having used it in increased appetite, and dry mouth. Cannabis
the past month (Johnston et al., 2012; SAMHSA, smoke is irritating and increases the risk of chronic
2002). Use is higher among teenagers and young cough, sinusitis, bronchitis, and emphysema. It
Inhalants 415
TABLE 14.7 Intoxication and Withdrawal Symptoms with Cannabis
Cannabis is the most commonly used illegal drug i n the United States.
Cannabis Behavioral changes (e.g ., impaired Irritability, anger, or aggression

motor coordination, euphoria, Nervousness or anxiety
anxiety, sensation of slowed time, Sleep difficulty
impaired judgment) Decreased appetite or weight loss
Red eyes Restlessness
Increased appetite Depressed mood
Dry mouth Stomach pain, shakiness, sweating,
Rapid heartbeat fever, chills, headache
contains even larger amounts of known carcino- cannabis use disorder (Kendler & Prescott, 1998;
gens than does tobacco and thus creates a high risk SAMHSA, 2008c).
of cancer. The chronic use of cannabis lowers sperm
count in men and may cause irregular ovulation in
women (Ruiz et al., 2007).
INHALANTS
At moderate to large doses, cannabis users ex- Inhalants are volatile substances that produce
perience perceptual distortions, feelings of deper- chemical vapors, which can be inhaled and which
sonalization, and paranoid thinking. Some find depress the central nervous system (see Table 14.8;
these hallucinogenic effects pleasant, but others Virani et al., 2009). One group of inhalants is sol-
become frightened . Some users may have severe vents, including gasoline, glue, paint thinners, and
anxiety episodes resembling panic attacks. Sev- spray paints. Users may inhale vapors directly
eral studies have found that cannabis use signifi- from the can or bottle containing the substance,
cantly increases the risk of developing a psychotic soak a rag with the substance and hold the rag to
disorder (e.g., Kuepper et al., 2011). Physical toler- their mouth and nose, or place the substance in a
ance to cannabis can develop, with users needing paper or plastic bag and inhale the gases from the
greater amounts to avoid the symptoms of with- bag. The chemicals rapidly reach the lungs, blood-
drawal, which include loss of appetite, hot flashes, stream, and brain. Another group of inhalants is
runny nose, sweating, diarrhea, and hiccups medical anesthetic gases, such as nitrous oxide
(Kouri & Pope, 2000). Seven to 10 percent of the ("laughing gas"), which also can be found in
U.S. population would qualify for a diagnosis of whipped cream dispensers and products that
boost octane levels. Nitrites, another class of inhal-
ants, dilate blood vessels and relax muscles and
are used as sex enhancers. Illegally packaged ni-
trites are called "poppers" or "snappers" on the
street (NIDA, 2002a). In diagnosing an inhalant
use disorder, DSM-5 recommends specifying the
particular substance involved w hen possible (e.g.,
solvent use disorder).
A nationwide study of adults found that less
than 2 percent reported ever having used inhal-
ants, with about 75 percent of users being male
(Howard et al., 2010) . Adolescents report higher
levels of use, with about 10 percent of teenagers
reporting ever having used inhalants (Johnston
Seven to 10 percent of the U.S. population would qualify et al., 2012). Some studies find that nearly all the
for a diagnosis of cannabis use disorder. children on some Native American reservations
have experimented with inhaling gasoline.
In this section, w e discuss ecstasy (3,4-methyl-

TABLE 14.8 Intoxication with Inhalants enedioxymethamphetamine, or MDMA), GHB
(gamma-hydroxybutyrate), ketamine, and rohypnol
Inha lants have a va riety of effects depending on (flunitrazepam).
t he specific drug. Ecstasy has the stimulant effects of an am-
Drug Intoxication Symptoms phetamine along with occasional hallucinogenic
properties (NIDA, 2009) . It is fairly popular w ith
Inhalants Behaviora l changes (e.g ., young adults; 6.8 percent of college students and
be ll igerence, assa ult iveness, 13.0 percent of 18- to 22-year-olds not in college
apathy, impa ired judgment) report having used ecstasy at some time (John-
Dizziness ston et al., 2012). Users experience heightened
Nystagmus energy and restlessness and claim that their so-
Incoordinati o n cial inhibitions decrease and their affection for
Slurred speech others increases. Even short-term use can have
Unsteady gait long-term negativ e effects on cognition and
Lethargy health, how ever. People who use ecstasy score
Depressed reflexes
lower on tests related to attention, memory,
Psychomoto r reta rdation
learning, and general intelligence than do people
who do not use the drug. The euphoric effects of
Tremor
ecstasy, and some of the brain damage, may be
Generalized muscle w eakness
due to alterations in the functioning of serotonin
Blurred vision o r d iplo pia in the brain-serotonin levels in ecstasy users are
Stupor or coma half those in people who are not users (Gold, Ta-
Eup horia brah, & Frost-Pineda, 2001). Long-term users risk
several cardiac problems and liver failure and
show increased rates of anxiety, depression, psy-
chotic symptoms, and paranoia (Gold, et al.,
2001) . Another effect of ecstasy is teeth-grinding;
some users suck a baby pacifier at parties to re-
Chronic users of inhalants may have a vari- lieve this effect.
ety of respiratory irritations and rashes. Inhal- GHB is a central nervous system depressant
ants can cause permanent damage to the central approved for the treatment of the sleep disorder
nervous sys tem, including degener ation and narcolepsy (NIDA, 2008a). At low doses, it can
lesions of the brain; this d am age can lead to relieve anxiety and promote relaxation. At higher
cognitive deficits, including severe dementia. doses, it can result in sleep, coma, or death. In the
Recurrent use can also cause hepatitis and other 1980s, GHB was widely used by bodybuilders
liver and kidney disease. Death can occur from and athletes to lose fat and build muscle and was
depression of the respiratory or cardiovascular available over the counter in health food stores.
system. Sudden sniffing d eath is due to acute In 1990, it was banned except under the supervi-
heartbeat irregularities or loss of oxygen. Users sion of a physician due to reports of severe side
sometimes suffocate w hen they fall unconscious effects, including high blood pressure, wide
w ith an inhalant-filled plastic b ag over their mood swings, liver tumors, and violent behavior.
nose and mouth. Users also can die or be seri- Other side effects include sweating, headache,
ously injured w hen the inhalants induce the decreased heart rate, nausea, vomiting, impaired
delusion that they can do fantastic things, such breathing, loss of reflexes, and tremors (NIDA,
as fly, and they then jump off a cliff or a tall 2008a). GHB is also considered a date-rape drug
building to test their perceived ability (Virani because it has been associated w ith sexual as-
et al., 2009). saults (NIDA, 2008a). It goes by the street names
Griev ous Bodily Harm, G., Liquid Ecstasy, and
Georgia Home Boy.
Ketamine is a rapid-acting anesthetic that pro-
OTHER DRUGS OF ABUSE duces hallucinogenic effects ranging from rapture
Drug sellers are creative in coming up with new to paranoia to boredom (NIDA, 2008a). Ketamine
psychoactive substances. Often these substances can elicit an out-of-body or near-death experience.
initially have legitimate medicinal purposes and It also can render the user comatose. It has effects
then are hijacked or transformed into street drugs. similar to those of PCP, including numbness, loss
Theories of Substance Use Disorders 417
of coordination, a sense of invulnerability, muscle explains why users on a binge

rigidity, aggressive or violent behavior, slurred or need to use cocaine much
blocked speech, an exaggerated sense of strength, more frequently to maintain a
and a blank stare. Because ketamine is an anes- high than do those using am- Frontal cortex
thetic, users feel no pain, which can lead them to phetamines (Koob & Volkow,
injure themselves (NIDA, 2008a). 2010). Snorting, smoking, or
Nucleus
A ketamine high usually lasts 1 hour but can last injecting drugs delivers them accumbens
as long as 4 to 6 hours, and it takes 24 to 48 hours for to the brain much faster than
users to feel normal again. Large doses can produce taking them orally and thus
vomiting and convulsions and may lead to oxygen produces a quicker, more in-
starvation in the brain and muscles. One gram can tense reaction. Other drugs
The brain's "pleasure pathway begins in
cause death. Ketamine is another date-rape drug increase the availability of do- the ventral tegmental area, then goes
used to anesthetize victims (NIDA, 2008a). pamine more indirectly. For through the nucleus accumbens and on
A widely known date-rape drug is rohypnol, example, the neurons in the to the frontal cortex. It is rich in neurons
which goes by the slang names Roofies, Rophies, ventral tegmental area are insensitive to dopamine.
Roche, and the Forget-Me-Not Pill. It is a benzo- hibited from continuously fir-
diazepine and has sedative and hypnotic effects ing by GABA neurons, so the
(NIDA, 2008a). Users may experience a high, as firing of GABA neurons reduces the high caused
well as muscle relaxation, drowsiness, impaired by activity in the dopamine neurons. The opiate
judgment, blackouts, hallucinations, dizziness, drugs inhibit GABA, which stops the GABA neu-
and confusion. Rohypnol tablets can easily be rons from inhibiting dopamine, making dopamine
crushed and slipped into someone's drink. Ro- available in the reward center (Koob & Volkow,
hypnol is odorless, colorless, and tasteless, so vic- 2010).
tims often don't notice that their drink has been Other areas of the frontal cortex, including the
altered. Side effects can include headaches, mus- orbitofrontal cortex, the dorsolateral frontal cor-
cle pain, and seizures. In combination with alco- tex, and the inferior frontal gyrus, play important
hol or other depressants, rohypnol can be fatal roles in controlling the urge to drink alcohol or
(NIDA, 2008a) . use drugs (Bechara, 2005; Goldstein & Volkow,
2002). Individuals whose reward network over-
powers their control network may be more likely
THEORIES OF SUBSTANCE to use substances (Goldstein & Volkow, 2002;
Hutchison, 2010).
USE DISORDERS The chronic use of psychoactive substances al-
All the substances we have discussed have power- ters the reward centers, creating a craving for these
ful effects on the brain that determine their re- substances (Robinson & Berridge, 1993). The re-
warding effects. Whether individuals ever use peated use of substances such as cocaine, heroin,
substances and whether their use progresses into a and amphetamines causes the brain to reduce its
substance use disorder depend on a complex inter- production of dopamine, with the result that dopa-
play of biological, psychological, and social vul- mine receptors in the brain become less sensitive.
nerabilities (Koob & Volkow, 2010). As the brain produces less dopamine, more of the
drug is needed to produce the desired effects. If the
Biological Factors individual stops taking the drug, the brain does not
immediately compensate for the loss of dopamine,
The brain appears to have its own "pleasure path- and withdrawal symptoms occur. Also, because the
way" that affects our experience of reward. This brain is not producing its typical amount of dopa-
pathway begins in the ventral tegmental area in mine, the person may feel sad and unmotivated
the midbrain, then progresses through an area of and may have difficulty experiencing pleasure
the limbic system called the nucleus accumbens from other sources, such as food or happy events.
and on to the frontal cortex. It is particularly rich in Craving for the drug sets in because only the drug
neurons sensitive to the neurotransmitter dopa- can produce pleasure (Robinson & Berridge, 1993).
mine (Koob & Volkow, 2010). Psychoactive drugs also affect a number of
~ Some drugs, such as amphetamines and co- other biochemical (including glutamate) and
caine, directly increase the availability of dopa- brain systems. Alcohol produces sedative and an-
mine in this pathway, producing a strong sense tianxiety effects largely by enhancing the activity
of reward or a "high." Cocaine clears out of the of the neurotransmitter GABA in the septal/hip-
brain more rapidly than do amphetamines, which pocampal system. Alcohol also affects serotonin
systems, which are associated with changes in

mood (Brick, 2008) .
Although individuals who have used a sub-
stance for an extended period experience de-
creased sensitivity to the rewarding aspects of the
substance, they become more sensitive to cues as-
sociated with their substance use, such as the loca-
tions where they typically use the substance or the
paraphernalia associated with it. These condi-
tioned responses to drug cues can induce power-
ful cravings that can lead to relapse (Koob &
Volkow, 2010). Stress also activates reward sys-
tems, creating cravings. In addition, chronic use of
drugs seems to lead to disrupted activity in fron- Children may learn substance-related behaviors from
tal regions of the brain involved in impulse con- their parents.
trol, making it even more difficult for individuals
to resist cravings.
Genetic factors regulate the functioning of the parents abuse alcohol by frequently getting
neurotransmitter systems involved in the reward- drunk or by driving while intoxicated learn that
ing effects of substance use. Family history, adop- these are acceptable behaviors and thus are more
tion, and twin studies all suggest that genetics likely to engage in them (Chassin, Pitts, DeLucia,
plays a substantial role in determining who is at & Todd, 1999).
risk for substance use disorders, with about 50 per- Because alcohol-related problems are more
cent of the variation in risk for substance use disor- common among males than females, most of the
ders attributable to genetic factors (see reviews by adults modeling inappropriate use of alcohol are
Urbanoski & Kelly, 2012; Young-Wolff, Kendler, male. In turn, because children are more likely to
Ericson, & Prescott, 2011). There seems to be a learn from adults who are similar to themselves,
common underlying genetic vulnerability to sub- male children and adolescents may be more
stance use disorders in general, rather than to use likely to learn these behaviors than female chil-
of specific substances, perhaps accounting for the dren and adolescents. Thus, maladaptive pat-
fact that individuals who use one substance are terns of alcohol use may be passed down through
likely to use several. the males in a family through modeling (Chassin
Much research has focused on the genes that et al., 1999).
control the dopamine system, given its importance The cognitive theories of alcohol use disor-
in the reinforcing properties of substances. Genetic ders have focused on people's expectations of
variation in the dopamine receptor gene (labeled alcohol's effects and their beliefs about the ap-
DRD2) and the dopamine transporter gene (la- propriateness of using it to cope with stress
beled SLC6A3) influences how the brain processes (Marlatt, Baer, Donovan, & Kivlahan, 1988). Peo-
dopamine, thereby affecting how reinforcing a ple who expect alcohol to reduce their distress
person finds substances such as nicotine (Nemoda, and who do not have more adaptive means of
Szekely, & Sasvari-Szekely, 2011). In addition, the coping (e.g., problem-solving skills or support-
genes that control GABA have also been impli- ive friends or family) are more likely than others
cated in substance use disorders, particularly alco- to drink alcohol when they are upset and to have
hol use disorders. social problems related to drinking (Cooper
et al., 1992). In long-term studies of the sons of
Psychological Factors parents with alcohol use disorders, men who
used alcohol to cope and relax were more likely
Social learning theories (see Chapter 2) suggest to develop alcohol use disorders themselves
that children and adolescents may learn sub- (Schuckit, 1998).
stance use behaviors from the modeling of their One personality characteristic consistently re-
parents and important others in their culture. lated to an increased risk of substance use disor-
Even as preschoolers, the children of heavy ders is behavioral undercontrol, or the tendency to
drinkers are more likely than other children to be be impulsive, sensation-seeking, and prone to anti-
able to identify alcoholic drinks and view alcohol social behaviors such as violating laws. People
use as a part of daily life (Zucker, Kincaid, with high levels of behavioral undercontrol take
Fitzgerald, & Bingham, 1995). Children whose psychoactive drugs at an earlier age, ingest more
Theories of Substance Use Disorders 419
psychoactive drugs, and are more likely to be diag- expect drug consumption to have a positive out-
nosed with substance use disorders (McGue et al., come (Nolen-Hoeksema & Harrell, 2002).
2001; White, Xie, & Thompson, 2001). Behavioral Women suffer alcohol-related physical ill-
undercontrol runs strongly in families, and twin nesses at lower levels of exposure to alcohol than
studies suggest that this may be due in part to men do (Fillmore et al., 1997). In addition, heavy
genes (Rutter, Silberg, O'Connor, & Simona, alcohol use is associated with reproductive prob-
1999). Thus, genetics may influence behavioral un- lems in women. Women may be more likely to ex-
dercontrol, which in turn influences the risk that perience greater cognitive and motor impairment
individuals will develop substance use disorders. due to alcohol than do men and to suffer physical
harm and sexual assault following alcohol use
(Abbey, Ross, McDuffie, & McAuslan, 1996).
Sociocultural Factors When they do use alcohol, women may notice
The reinforcing effects of substances-the highs that they feel intoxicated much sooner than do men,
produced by stimulants, the calming and "zoning and they may be more likely to find these effects
out" effects of the depressants and the opioids- aversive or frightening, leading them to limit their
can be more attractive to people under chronic consumption (Nolen-Hoeksema, 2004). This lower
stress. Thus, rates of substance use disorders are consumption, in turn, protects women against de-
higher among people living in poverty, women in veloping tolerance to high doses of alcohol and low-
abusive relationships, and adolescents whose par- ers their risk of developing alcohol-related social
ents fight frequently and violently (Hughes et al., and occupational problems.
2010; Zucker, Chermack, & Curran, 1999). For When women become substance abusers, their
these people, the effects of substances may be es- patterns and reasons for use tend to differ from
pecially reinforcing. They also may think that they those of men. Men tend to begin using substances
have little to lose. in the context of socializing with male friends,
Subtler environmental reinforcements and while women most often are initiated by family
punishments clearly influence people's substance members, partners, or lovers (McCrady et al., 2009).
use habits. Some societies discourage any use of One study found that 70 percent of female crack
alcohol, often due to religious beliefs, and alcohol users were living with men who also were sub-
abuse and dependence are rare in these societies. stance users, and many were living with multiple
Other societies, including many European cul- people who were abusers (Inciardi, Lockwood, &
tures, allow the drinking of alcohol but strongly Pottieger, 1993). Perhaps because women's drug
discourage excessive drinking and irresponsible
behavior while intoxicated. Alcohol-related disor-
ders are less common in these societies than in so-
cieties with few restrictions, either legal or cultural,
on alcohol use (Sher et al., 2005).
Gender Differences
Substance use, particularly alcohol use, is more ac-
ceptable for men than for women in many societies
(Hughes et al., 2010). Heavy drinking is part of
what "masculine" men do and is modeled by he-
roes and cultural icons. In contrast, until recently
heavy drinking signified that a woman was "not a
lady." Societal acceptance of heavy drinking by
women has increased in recent generations, as
has the rate of alcohol use among young women
(Nolen-Hoeksema, 2004).
Women tend to be less likely than men to
carry risk factors for substance use disorders
~ (Nolen-Hoeksema, 2004). They appear less likely
to have personality traits associated with sub-
stance use disorder (behavioral undercontrol, sen-
Women suffer the effects of excessive alcohol use at lower doses
sation seeking). They also appear less motivated than men do.
to use alcohol to reduce distress and less likely to
use is more closely tied to their intimate relation- reactions in people addicted to opioids (O'Malley
ships, studies have found that treatments that in- & Kosten, 2006).
clude their partners tend to be more effective in Naltrexone has also proven useful in treating
reducing substance use disorders in women alcohol dependents and abusers, possibly because
(McCrady et al., 2009). it blocks the effects of endorphins during drinking.
People dependent on alcohol who take naltrexone
report a diminished craving for alcohol and thus
TREATMENTS FOR drink less (O'Malley & Kosten, 2006).
SUBSTANCE USE DISORDERS The drug acamprosate affects glutamate and
GABA receptors in the brain, which are involved
The treatment of substance-related disorders is in the craving for alcohol. Meta-analyses of clinical
challenging, and media accounts of celebrity trials show that acamprosate can help people
drug abusers who are in rehab one month, out the maintain abstinence from alcohol better than a pla-
next, and back a short time later suggest that it cebo (O'Malley & Kosten, 2006).
seldom is effective. Meta-analyses and reviews of A drug that can make alcohol actually punishing
existing treatments suggest that, as a whole, they is disulfiram, commonly called Antabuse (Carroll,
help only about 17 to 35 percent of people with 2001). Just one alcoholic drink can make people tak-
substance use disorders abstain for up to 1 year ing disulfiram feel sick and dizzy and can make them
(Hutchison, 2010) . Here we review the most com- vomit, blush, and even faint. People must be very
mon and best-supported biological and psycho- motivated to remain on disulfiram, and it works to
social treatments. reduce their alcohol consumption only as long as
they continue to take it.
Biological Treatments The pharmacological treatment of nicotine de-
Medications can help wean individuals off a sub- pendence uses two general approaches (Mooney &
stance, reduce their desire for it, and maintain their Hatsukami, 2001). Most common is nicotine re-
use at a controlled level (O'Malley & Kosten,2006). placement therapy- the use of nicotine gum or a
nicotine patch, nasal spray, or inhaler to prevent
Antianxiety Drugs, Antidepressants, withdrawal effects. It is hoped that the individual
and Drug Antagonists will gradually reduce use of the nicotine replace-
Although many people with substance use disor- ment while slowly being weaned off nicotine's
ders can w ithstand withdrawal symptoms if physiological effects.
given emotional support, others may require The other approach is the use of prescription
medication. For people dependent on alcohol, a medication that reduces the craving for nicotine.
benzodiazepine, which has depressant effects One drug approved for this use is the antidepres-
similar to those of alcohol, can reduce tremors sant bupropion (marketed for smoking cessation
and anxiety, decrease pulse and respiration rate, as Zyban). A drug called varenicline (Chantix),
and stabilize blood pressure (Ntais, Pakos, Kyzas, which binds to and partially stimulates nicotine
& Joannidis, 2005). The dosage is decreased each receptors, also has been shown to reduce cravings
day so that a patient withdraws from the alcohol for nicotine products and decrease their pleasur-
slowly but does not become dependent on the able effects (Jorenby et al., 2006).
benzodiazepine.
Antidepressant drugs sometimes are used to Methadone Maintenance Programs
treat individuals with substance dependence who Gradual withdrawal from heroin can be achieved
are depressed, but their efficacy in treating either with methadone. This drug is itself an opioid, but
alcohol or other drug problems or depression with- it has less potent and less long-lasting effects than
out psychotherapy has not been consistently sup- heroin when taken orally. The person dependent
ported (Nunes & Levine, 2004). People have widely on heroin takes methadone to reduce extreme
different responses to the SSRis. negative withdrawal symptoms. Those who take
Antagonist drugs block or change the effects heroin while on methadone do not experience
of the addictive drug, reducing the desire for it. heroin's intense psychological effects, because
Naltrexone and naloxone are opioid antagonists- methadone blocks receptors for heroin (O'Malley
they block the effects of opioids such as heroin. & Kosten, 2006).
Theoretically, this can reduce the desire for and Although the goal of treatment is for indi-
therefore the use of the addictive drug. The opioid viduals eventually to withdraw from methadone,
antagonists must be administered very carefully, some patients use it for years under a physician's
however, because they can cause severe withdrawal care. Such methadone maintenance programs are
controversial. Some people believe they allow

the heroin dependent to simply transfer depen-
dency to another substance that is legal and pro-
vided by a physician. Others believe methadone
maintenance is the only way to keep some heroin
dependents from going back on the street and
relapsing. Studies find that patients in such pro-
grams are much more likely to remain in psycho-
logical treatment than are patients who try to
withdraw from heroin without methadone and
also are less likely to relapse into heroin use
(Mattick et al., 2003).
Psychosocial Treatments
Several behavioral and cognitive techniques
have proven helpful in the treatment of sub-
stance use disorders (Carroll & Rounsaville,
2006) . The techniques have certain goals in com-
mon. The first is to motivate the individual to
stop using the addictive drug. People who enter
treatment often are ambivalent about stopping
use and may have been forced into treatment Dr. Drew Pinsky treats patients with various substance-related disorders on
against their will. The second goal is to teach pa- the VHl TV show Celebrity Rehab.
tients new coping skills to replace the use of sub-
stances to cope with stress and negative feelings.
The third goal is to change the reinforcements for
using substances-for example, an individual use and thoughts of highly unpleasant conse-
may need to disengage from social circles that quences. An example of a sensitization scene that a
encourage drug use. The fourth is to enhance the therapist might take a client through begins as de-
individual's support from nonusing friend s and scribed in the following profile.
family members. The final goal often is to foster
adherence to pharmacotherapies in conjunction
with psychotherapy.
PROFILES
Behavioral Treatments You finish the first sip of beer, and you ... notice
Behavioral treatments based on aversive classical a funny feeling in your stomach .... Maybe an-
conditioning are sometimes used alone or in other drink will help .... As you tip back ... that
combination with biological or other psychoso- funny feeling in your stomach is stronger, and
cial therapies (Finney & Moos, 1998; Schuckit, you feel like you have to burp .... You swallow
1995). Drugs such as disulfiram (Antabuse) that again , trying to force it down, but it doesn't work.
make the ingestion of alcohol unpleasant or toxic You can feel the gas coming up .... You swallow
are given to people who are alcohol dependent. more, but suddenly your mouth is filled with a
Eventually, through classical conditioning, peo- sour liquid that burns the back of your throat and
ple develop conditioned responses to alcohol- goes up your nose .. . . [You] spew the liquid all
namely, nausea and vomiting. Then, through over the counter and sink . ... (Rimmele, Miller, &
operant conditioning, they learn to avoid alcohol Dougher, 1989, p. 135)
in order to avoid the aversive response. Aversive
conditioning is effective in reducing alcohol con-
sumption, at least in the short term (Schuckit,
1995). "Booster" sessions often are needed tore- The imagery gets even more graphic. Covert sen-
inforce this conditioning, because its effects tend sitization techniques seem to be effective in cre-
to weaken with time. ating conditioned aversive responses to the sight
Covert sensitization therapy uses imagery to and smell of alcohol and in reducing alcohol
create associations between thoughts of alcohol consumption.
Contingency management programs provide don't have to carry out an alternative just be-
reinforcements for individuals to curtail their use cause you consider it.
of substances-for example, employment, hous- Client: You know, I could do what I usually do
ing, or vouchers for purchases at local stores. Stud- in these kinds of situations. In fact, being as
ies show that individuals dependent on heroin, nervous as I've been these past couple of
cocaine, marijuana, or alcohol will remain in treat- months, I've done that quite often.
ment longer and be much more likely to become Therapist: You mean drinking?
abstinent when they are provided with incentives
Client: Yeah, I've been drinking quite heavily
contingent on submitting drug-free urine speci-
mens (Carroll & Rounsaville, 2006). some nights when I get home, and my wife is
really complaining.
Cognitive Treatments Therapist: Well, OK, drinking is one option.
Interventions based on the cognitive models of al- What other ways could you deal with this
cohol abuse and dependency help clients identify problem?
situations in which they are most likely to drink Client: Well, I could take the job, and on the
and lose control over their drinking, as well as side I could take some night courses in busi-
their expectations that alcohol will help them cope ness at a local college. That way I could learn
in those situations (Daley & Marlatt, 2006). Thera- how to be a supervisor. But, gee, that would be
pists work with clients to challenge these expecta- a lot of work. I don't even know if I have the
tions by reviewing alcohol's negative effects on time. Besides, I don't know if they offer the
the clients' behavior. Perhaps a client was feeling kind of training I need.
anxious at a recent party and began to drink heav- Therapist: At this point, it's really not neces-
ily. The therapist might have the client recount his sary to worry about how to carry out the op-
embarrassing behavior while intoxicated, chal- tions but simply to identify them. You're doing
lenging the notion that the alcohol helped him fine. What are some other ways you might
cope effectively. Therapists also help clients learn handle the situation?
to handle stressful situations in adaptive ways,
Client: Well, another thing I could do is to sim-
such as seeking the help of others or engaging in
active problem solving. Finally, therapists help cli- ply tell the boss that I'm not sure I'm qualified
ents learn to say "No, thanks" when they are of- and either tell him that I don't want the job or
fered a drink and to deal with social pressure by ask him if he could give me some time to learn
using assertiveness skills. my new role.
Following is an excerpt from a discussion be- Therapist: OK. Go on, you're doing fine.
tween a therapist and a client with alcohol-related Client: But what if the boss tells me that I have
problems (adapted from Sobell & Sobell, 1978, to take the job, I don't have any choice?
pp. 97-98) in which the therapist is helping the cli-
Therapist: Well, what general kinds of things
ent generate strategies for coping with the stress of
might happen in that case?
a possible job promotion. The therapist encourages
the client to brainstorm coping strategies and re- Client: Oh, I could take the job and fail. That's
frains from evaluating them for the moment so the one option. I could take the job and learn
client will feel free to generate as many strategies how to be a supervisor. I could refuse the job,
as possible. risk being fired, and maybe end up having to
look for another job. You know, I could just
Client: I really want this job, and it'll mean a go and talk to my supervisor right now and
lot more money for me, not only now but explain the problem to him and see what
also at retirement. Besides, if I refused the comes of that.
promotion, what would I tell my wife or my Therapist: Well, you've delineated a lot of op-
boss? tions. Let's take some time to evaluate them
Therapist: Rather than worrying about that for before you reach any decision.
the moment, why don't we explore what kinds
of possible behavioral options you have re- The therapist helps the client evaluate the effec-
garding this job promotion? Remember, don't tiveness of each option and anticipate any nega-
evaluate the options now. Alternatives, at this tive consequences. In this case, the client decides
point, can include anything even remotely to accept the promotion but to take some courses
possible; what we want you to do is come up at the local college to increase his business back-
with a range of possible alternatives. You ground. The two discuss the stresses of managing
a new job and classes, and they generate ways the Relapse prevention programs teach people
client can manage these stresses other than by who abuse alcohol to view slips as temporary and
drinking. situationally caused (Donovan & Witkiewitz,
In most cases, therapists using cognitive- 2012). Therapists help clients identify high-risk
behavioral approaches encourage their clients to situations, such as parties, and either avoid them
abstain from alcohol, especially when they have a or develop effective coping strategies for them. A
history of frequent relapses into abuse. When a cli- client who decides to go to a party may first prac-
ent's goal is to learn to drink socially and the thera- tice with the therapist some assertiveness skills
pist believes the client can achieve this goal, for resisting friends' pressure to drink and write
therapy may focus on teaching the client to engage down other coping strategies to use if she feels
in social, or controlled, drinking. tempted, such as starting a conversation with a
Studies have shown that cognitive-behavioral supportive friend or practicing deep-breathing
approaches are effective in treating abuse and de- exercises. She also may decide that, if the tempta-
pendence on alcohol, cannabis, nicotine, heroin, tion becomes too great, she will ask a supportive
amphetamines, and cocaine (Dennis et al., 2000; friend to leave the party with her and go some-
McCrady, 2001; Mooney & Hatsukami, 2001; where for coffee until the urge to drink passes.
Waldron et al., 2001). Relapse prevention programs have been shown in
many studies to reduce the rate of relapse in peo-
ple with several types of substance use disorders
Motivational Interviewing
(Donovan & Witkiewitz, 2012).
If individuals are not motivated to curtail their
These cognitive and behavioral interventions
substance use, no treatment will be effective.
have been combined with training in mindfulness
William Miller (1983; Miller & Rose, 2009) devel-
meditation, the nonjudgmental acceptance of
oped motivational interviewing to elicit and so-
one's current emotional and physical state, in the
lidify clients' motivation and commitment to
treatment of people with substance use disorders
changing their substance use. Rather than con-
(Bowen, Chawla, & Marlatt, 2010). People are
fronting the user, the motivational interviewer
taught to be aware of their internal states and
adopts an empathic interaction style, drawing
the external triggers for these states and to accept
out the user's statements of desire, ability, rea-
and "ride out" their negative states rather than
sons, need, and, ultimately, commitment to
reacting to them in a habitual manner (i.e., by us-
change. The interviewer focuses on the client's
ing a substance) . A study of people with alcohol
ambivalence, helping the client voice his or her
and other substance use disorders showed that
own arguments for change. Many controlled
adding mindfulness meditation training to the
studies find that just four sessions of motiva-
usual treatment led to significant reductions in
tional interviewing lead to sustained reductions
craving and relapse during the follow-up period
in substance use, particularly alcohol use (e.g.,
(Bowen et al., 2009).
Ballet al., 2007; Carroll et al., 2006; see review by
Miller & Rose, 2009).
Alcoholics Anonymous
Alcoholics Anonymous (AA) is an organization
Relapse Prevention created by and for people with alcohol-related
Unfortunately, the relapse rate for people under- problems. Its philosophy is based on the disease
going any kind of treatment for an alcohol use model of alcoholism, which asserts that, because
disorder is high. The abstinence violation effect of biological, psychological, and spiritual deficits,
contributes to relapse. It has two components. some people will lose all control over their drink-
The first is a sense of conflict and guilt when an ing once they have one drink. Therefore, the only
abstinent alcohol abuser or dependent violates way to control alcohol intake is to abstain com-
abstinence and has a drink. He or she may con- pletely. AA prescribes 12 steps that people depen-
tinue to drink to try to suppress the conflict and dent on alcohol must take toward recovery. The
guilt. The second component is a tendency to at- first step is to admit their dependence on alcohol
tribute a violation of abstinence to a lack of will- and their inability to control its effects. AA en-
power and self-control rather than to situational courages its members to seek help from a higher
factors. Thus, the person may think, 'Tm an alco- power, to admit their weaknesses, and to ask for-
holic and there's no way I can control my drink- giveness. The goal for all members is complete
ing. The fact that I had a drink proves this." This abstinence.
type of thinking may pave the way to continued, Group members provide moral and social
uncontrolled drinking. support and make themselves available to one
many of you, my friends in the Fellowship, alco-

hol became the royal road to love, respect, and
self-esteem ....
Though it's obvious to me now that my
drinking even then, in high school, and after I got
to college, was a problem, I didn't think so at the
time. A couple of minor auto accidents, one con-
viction for drunken driving, a few fights-nothing
out of the ordinary, it seemed to me at the time.
True, I was drinking quite a lot, even then, but
my friends seemed to be able to down as much
beer as I did. I guess the fact that I hadn't really
had any blackouts and that I could go for days
without having to drink reassured me that things
hadn't gotten out of control.
[Later] on, the drinking began to affect both
my marriage and my career. With enough booze
in me and under the pressures of guilt over my
failure to carry out my responsibilities to my wife
and children, I sometimes got kind of rough
physically with them. I would break furniture,
throw things around, then rush out and drive off
Alcoholics Anonymous meetings seek to help individuals
in the car. I had a couple of wrecks, lost my li-
overcome alcohol dependence.
cense for two years because of one of them.
Worst of all was when I tried to stop. By then I
was totally hooked, so every time I tried to stop
drinking, I'd experience withdrawal in all its hor-
another in times of crisis. Once they are able, rors. I never had DTs, but I came awfully close
they are expected to devote themselves to help- many times, with the vomiting and the "shakes"
ing others who are recovering from alcohol de- and being unable to sit still or to lie down. And
pendence. AA members believe that people are that would go on for days at a time .... Then,
never completely cured of alcohol dependence- about four years ago, with my life in ruins, my
they are always "recovering alcoholics," with wife given up on me and the kids with her, out of
the potential for falling back into uncontrolled a job, and way down on my luck, the Fellowship
drinking after taking only one drink. To motivate and I found each other. Jim, over there, bless his
others to abstain from alcohol, AA meetings heart, decided to sponsor me-we'd been friends
include testimonials from members, as in the for a long time, and I knew he'd found sobriety
following profile. through this group. I've been dry now for a little
over two years, and with luck and support, I may
stay sober. (From Spitzer, R. L., Skodol, A. E.,
Gibbon, M., & Williams, J. B. W., 1983,
Psychopathology: A Case Book, pp. 81-83.
PROFILES Copyright 1983 The McGraw-Hill Companies,
' Inc. Reprinted with permission.)
I am Duncan. I am an alcoholic .... I know that I
will always be an alcoholic, that I can never again
touch alcohol in any form. It'll kill me if I don't
keep away from it. In fact, it almost did .. . . I must
have been just past my 15th birthday when I had
The practices and philosophies of AA do not
that first drink everybody talks about. And like so
appeal to everyone. The emphases on one's pow-
many of them-and you-it was like a miracle.
erlessness, need for a higher power, and complete ~
With a little beer in my gut, the world was trans-
abstinence turn away many. In addition, many
formed. I wasn't a weakling anymore, I could lick
people who subscribe to AA's philosophy still
almost anybody on the block. So, like for so
find it difficult to maintain complete abstinence,
and they "fall off the wagon" throughout their
lives. However, many believe that AA has been drugs, and sedatives. Older people also are more
critical to their recovery from an alcohol use dis- likely than younger people to purchase over-the-
order, and it remains the most common source of counter drugs, including analgesics, vitamins,
treatment for people with alcohol-related prob- and laxatives .
lems. There are over 100,000 registered AA The abuse of drugs such as the benzodiaze-
groups, and meetings take place all over the pines may begin innocently. Physicians frequently
United States day and night, providing a sup- prescribe them for older patients, and as many as
portive community as an alternative to drinking one-third of older people take these drugs at least
(Tonigan & Connors, 2008). Self-help groups occasionally-for insomnia or after experiencing a
modeled on AA-including Narcotics Anony- loss, for example. As tolerance develops and the
mous, Cocaine Anonymous, and Marijuana withdrawal effects of discontinuing the drug be-
Anonymous-assist people with dependence on come evident, an individual may try to get more of
other drugs. the drug by copying prescriptions or seeing mul-
Evaluations of AA's effectiveness are compli- tiple physicians. Slurred speech and memory
cated by differences between people who might problems caused by drug use may be overlooked
attend and those who would not, the self-help na- in the elderly as normal symptoms of old age.
ture of the intervention, and the fact that out- Older adults often can hide their drug abuse for a
comes often are self-reported (Kelly, 2003). long period of time. Eventually, the side effects of
Perhaps as a result, meta-analyses and reviews of the drugs, the withdrawal symptoms people expe-
studies of AA's effectiveness have produced rience when they try to go off the drugs cold tur-
mixed results, with some analyses suggesting key, or the effects of interaction with other
that AA is effective and others suggesting that it medications may land them in a hospital emer-
is worse than no treatment (Emrick, Tonigan, gency room.
Montgomery, & Little, 1993; Kaskutas, 2009; Kelly, Treatment for older substance abusers is simi-
2003; Kownacki & Shadish, 1999; Tonigan, lar to that for younger abusers, although with-
Toscova, & Miller, 1996). drawal symptoms may be more dangerous for
older abusers and therefore must be monitored
more carefully (Lisansky-Gomberg, 2000). Psycho-
Substance Use Treatment for therapies that have been shown to be useful tend
to have the following characteristics (Schonfeld &
Older Adults Dupree, 2002):
We tend to think of substance use disorders as
problems of the young. Indeed, the use of hard Elders are treated along with people their
drugs, such as cocaine or heroin, is quite rare same age in a supportive, nonconfrontational
among the elderly. Many chronic users of illicit approach.
substances die before they reach old age, and oth- Negative emotional states (such as depres-
ers outgrow their use. Certain types of substance sion and loneliness) and their relationship
abuse and dependence are a frequent problem to the substance abuse are a focus of the
among older people, however, including alcohol- intervention.
related problems and the misuse of prescription
drugs (Lisansky-Gomberg, 2000). Social skills and social networks are
rebuilt.
Approximately 2 percent of people over age
65 can be diagnosed with an alcohol use disor- Staff members are respectful and are inter-
der, and about 10 percent can be considered ested in working with older adults.
heavy drinkers (Helzer, Burnam, & McEvoy, Linkages are made with medical facilities
1991; Merrick et al., 2008). One-third to one-half and community resources (such as housing
of abusers of alcohol first develop problems services).
after age 65 (Liberto, Oslin, & Ruskin, 1996).
Moreover, the abuse of and dependence on pre- Due to increasing longevity and the size of the
scription drugs (e.g., sedative, hypnotic, or anx- baby-boomer generation, the proportion of the
iolytic use disorders) is a substantial problem population that is above age 65 will increase dra-
among the elderly. Although only 13 percent of matically over the next few decades (King &
the U.S. population is over age 65, this group ac- Markus, 2000). In addition, older Americans will
counts for one-third of all prescription drug ex- become much more ethnically diverse in the future.
penditures (NIDA, 2008b) . The most commonly Although 85 percent of Americans over age 65 in
prescribed drugs are diuretics, cardiovascular 1995 were non-Hispanic whites, this proportion
is expected to decrease to 66 percent by 2030 problems throughout their lives. Some become
(Whitbourne, 2000) . In turn, the proportion of physically ill or unable to hold a job or maintain a
older people who are of Hispanic and Asian de- relationship. Others hide or control their alcohol use
scent will increase. Much more research is needed disorder and may be in relationships with people
on the psychological health needs of older people, who facilitate it. Often they have periods of absti-
particularly older people in ethnic and racial mi- nence, sometimes long, but then- perhaps when
nority groups with substance use disorders. facing stressful events- they begin drinking again.
Therefore, preventing the development of a sub-
Comparing Treatments stance use disorder is very important.
In the United States, young adults between 18
A large, multi-site clinical trial called Project
and 24 have the highest rates of alcohol consump-
MATCH compared three interventions designed to
tion and make up the largest proportion of prob-
help people with alcohol use disorder: cognitive-
lem drinkers of any age group. Many colleges have
behavioral intervention, motivational interview-
programs to reduce drinking and drinking-related
ing and enhancement, and a 12-step program
problems. Programs that emphasize alcohol's
based on the AA model but led by professional
health-related consequences tend not to impress
counselors (Project MATCH Research Group,
young people, who are more likely to focus on the
1998). Surprisingly, the study showed that the
short-term gains of alcohol use. Some college
three interventions were equally effective in reduc-
counselors refer students with drinking problems
ing drinking behavior and preventing relapse
to abstinence programs, such as Alcoholics Anony-
over the following year (Project MATCH Research
mous, but students often dislike admitting power-
Group, 1998; Witkiewitz, Van der Maas, Hufford,
lessness and adopting lifelong abstinence. Finally,
& Marlatt, 2007).
many colleges provide alternative activities that
Another multi-site study of over 1,300 individ-
do not focus on alcohol. In general, however, pre-
uals with alcohol use disorder, Project COMBINE,
vention programs designed to stop drinking have
indicated that combining psychosocial interven-
had limited success.
tion with medications did not yield better out-
Psychologist Alan Marlatt and his colleagues
comes than individual therapies (Anton et al.,
at the University of Washington (Marlatt, Blume, &
2006). The psychosocial treatment was a combi-
Parks, 2001; Marlatt & Witkiewitz, 2010; Parks,
nation of cognitive-behavioral therapy, motiva-
Anderson, & Marlatt, 2001) argued that a more
tional interviewing, a 12-step program facilitated
credible approach to college drinking is to recog-
by a professional, and community support. The
medications were either naltrexone, acampro- nize it as normative behavior and focus education
sate, or a combination of the two. Both psychoso- on the immediate risks of excess (alcohol-related
cial treatment and naltrexone led to significant accidents) and the payoffs of moderation (avoid-
reductions in drinking, and the combination of ance of hangovers). They view young drinkers as
the two was not superior to the individual thera- relatively inexperienced in regulating their use of
pies. Acamprosate did not perform better than a alcohol and in need of skills training to prevent
placebo either alone or combined with psychoso- abuse. Learning to drink safely is compared to
cial treatment (Anton et al., 2006). A similar pat- learning to drive safely in that people must learn
tern was found in a 1-year follow-up of the same to anticipate hazards and avoid "unnecessary ac-
individuals, with indications that those who re- cidents."
ceived psychosocial treatment were especially Based on this harm reduction model, the Alco-
likely to have good outcomes whether or not hol Skills Training Program (ASTP) targets heavy-
they also received naltrexone (Donovan et al., drinking college students for intervention. In eight
2008) . weekly sessions of 90 minutes each, participants
learn to be aware of their drinking habits-
Prevention Programs including when, where, and with whom they are
most likely to overdrink- by keeping daily re-
Only about 25 percent of people with alcohol use cords of their alcohol consumption and the situa-
disorder seek treatment (Dawson et al., 2005). About tions in which they drink. They also are taught to
25 percent may recover on their own, often due to calculate their blood-alcohol level. It often comes
maturation or positive changes in their environ- as a surprise to them how few drinks it takes to
ment (e.g., getting a good job or marrying a sup- become legally intoxicated.
portive person) that motivate them to control their Next, beliefs about the "magical" effects of
drinking (Dawson et al., 2005) . The remainder of drinking on social skills and sexual prowess are
people with significant alcohol problems carry these challenged. Participants discuss hangovers and
Gambling Disorder 427
alcohol's negative effects on social behaviors, written form as a self-help manual, also have shown
ability to drive, and weight gain. They are en- positive results (Baer et al., 2001; Baer, Marlatt,
couraged to set personal goals for limiting con- Kivlahan, & Fromme, 1992).
sumption based on their blood-alcohol level and
their desire to avoid drinking's negative effects.
They learn skills for limiting consumption, such
GAMBLING DISORDER
as alternating alcoholic and nonalcoholic bever- More than three-quarters of U.S. adults report
ages and selecting drinks for quality rather than having gambled in the past year, but most gamble
quantity (e.g., buying two good beers rather than only occasionally and recreationally (Kessler et al.,
a six-pack of generic). Later, members are taught 2008). As noted earlier, DSM-5 expanded its chap-
alternative ways to reduce negative emotional ter on substance-related and addictive disorders
states, such as using relaxation exercises or reduc- to include gambling disorder, which some refer to
ing sources of stress. Finally, via role playing, par- as a behavioral addiction. The DSM-5 criteria for
ticipants learn skills for resisting peer pressure gambling disorder are given in Table 14.9. Less
and avoiding high-risk situations in which they than 1 percent of the U.S. population meet these
are likely to overdrink. criteria (Kessler et al., 2008), but for those who do,
Evaluations of ASTP have shown that partici- their gambling frequently leads to serious finan-
pants decrease their consumption and alcohol- cial, relationship, and employment problems. The
related problems and increase their social skill at most common criteria are related to preoccupation
resisting alcohol abuse (Fromme, Marlatt, Baer, & with gambling and "chasing" losses.
Kivlahan, 1994; Marlatt, Baer, & Larimer, 1995). Pathological gamblers also tend to have prob-
ASTP was designed for a group format, and the lems with substance use, depression, and anxiety
use of group pressure to encourage change and al- and a family history of substance abuse and gam-
low role playing has many advantages. Adapta- bling problems (Grant et al., 2008). Gambling dis-
tions of this program, delivered in person or in order is more common among men than women,
TABLE 14.9 DSM-5 Criteria for Gambling Disorder
A. Persistent and recurrent problematic gambling behavior lead ing to clinically significant impairment or distress, as indicated by
the individual exhibiting four (or more) of the following in a 12-month period:
1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement.
2. Is restless or irritable when attempting to cut down or stop gambling.
3. Has made repeated unsuccessfu l efforts to control, cut back, or stop gambling.
4. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or
planning the next venture, thinking of ways to get money with which to gamble).
5. Often gambles when feeling distressed (e.g ., helpless, guilty, anxious, depressed).
6. After losing money gambling, often returns another day to get even ("chasing" one's losses).
7. Li es to conceal the extent of invo lvement with gambling.
8. Has jeopardized or lost a significant relationship, job, or educational o r career opportunity because of gambling.
9. Relies on others to provide money to relieve desperate financial situations caused by gambling.
B. The gambling behavior is not better explained by a manic episode.
Specify if:
Episodic: Meeting diagnostic criteria at more than one time point, with symptoms subsiding between periods of gambling for at
least several months.
Persistent: Continuous symptoms for multiple years.
Current Severity: Mild (4-5 criteria met); Moderate (6- 7 criteria met); Severe (8- 9 criteria met).
Source: Reprinted with perm issi o n from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition . Copyright 2013 American Psychiatric
Association .
among non-Hispanic blacks than other racial/ ~

ethnic groups, and among people with less than a
college education (Kessler et al., 2008). Men tend
to develop the disorder earlier in life, while
women are more likely to show mid- or later life
onset gambling disorder.
Gambling disorder appears to be related to the
same brain areas (i.e., activation of the brain's re-
ward system) as the substance use disorders and to
disruption in systems regulating the neurotransmit-
ter dopamine (Leeman & Potenza, 2012). People
with gambling disorder also show high levels of im-
pulsivity, as do people with substance use disorders,
as well as poor performance on cognitive tasks as-
sessing control over impulses (Potenza et al., 2003).
Cognitive-behavioral therapy (CBT) concen-
trates on changing the individual's distorted be-
liefs that he or she has more control than the
Gambling disorder appears to be related to the same brain areas as the average person over gambling (chance) outcomes,
substance use disorders and to disruption in systems regulating the overconfidence, and superstitions and on devel-
neurotransmitter dopamine.
oping new activities and coping strategies to re-
place gambling. Controlled studies of CBT have
shown that it can help reduce compulsive gambling
(Ladouceur et al., 2001, 2003; Pallesen et al., 2005).
Serotonin reuptake inhibitors have shown only
mixed success in treating pathological gambling
Integration of Biological and Psychosocial (Grant & Potenza, 2006; van Holst, van den Brink,
FIGURE 14.5 Factors in the Development of Substance- Veltman, & Goudriaan, 2010); naltrexone, which
Related Disorders affects reward sensitivity, appears to be more ef-
fective than the SSRis in reducing symptoms
(Grant & Kim, 2002). Very few people with gam-
Genetic and biochemical Environmental factors, bling disorder ever seek treatment, however
characteristics of the such as stress, and rewards (Kessler et al., 2008), and those that do typically
individual and punishments for have moderate to severe forms of the disorder.
substance use
CHAPTER INTEGRATION
Expectations for how
rewarding the substance The substances discussed in this chapter are pow-
will be erful biological agents. They affect the brain di-
rectly, producing changes in mood, thoughts, and
perceptions. Some people may be genetically or
biochemically predisposed to find these changes
How reinforcing or
.__ _..,.~ rewarding a substance more positive or rewarding than other people do
is for the individual (Figure 14.5). Rewards and punishments in the en-
vironment clearly can affect an individual's choice
to pursue the effects of substances, however. Even
many long-term chronic substance abusers can ab-
Choosing environments, stain given strong environmental and social sup-
peers, and mates who
support substance use port for abstention.
People who find substances more rewarding,
for biological and/ or environmental reasons, de-
velop expectations that the substances will be re- ~
Creating environments warding, which in turn enhance how rewarding
..__ _ _ _ _ _ for children that
encourage substance use they actually are. Likewise, heavy substance users
choose friends and situations that support their
substance use. They tend to find partners who are
Chapter Summary 429
also heavy substance users, creating a biological Similar processes may play out in gambling dis-
and psychosocial environment for their children order. For example, biological factors may influence
that increases vulnerability to substance use disor- how rewarding an individual finds gambling. The
ders. Thus, the cycle of familial transmission of person will then associate with other gamblers, who
substance misuse has intersecting biological and reinforce the gambling behavior, and eventually the
psychosocial components. impulse to gamble may become pathological.
Nick's behaviors definitely meet the criteria for an cutting back on his drinking, so the criteria for at-
alcohol use disorder. He is failing to fulfill his obli- tempting to control his substance use have not
gations at school and is continuing to use alcohol been met.
despite social problems (ejection from the cam- It may seem odd to think of a college student
pus and his parents' threat to withdraw their sup- who drinks with his friends as having a psychiatric
port). His hangovers are a sign of withdrawal, he diagnosis. Some critics argue that the criteria for
spends much time drinking and recovering, and alcohol use disorders are too broad and that too
his drinking is hurting his grades. We don't know many individuals meet them . Others argue that
whether Nick has developed tolerance to alcohol, simply because a large percentage of the popula-
although the escalation of his drinking suggests tion meet the criteria for abuse or dependence
that he needs more alcohol to achieve the desired doesn't mean we should ignore their behavior.
effect. Nick doesn't seem to have any intention of What do you think?
THINK CRITICALLY
U.S. citizens can join the military, serve on a jury, and How do you think reducing the drinking age to
vote at age 18, but they can't drink alcohol legally 18 would change things? Would it increase drinking
until they are 21. In 1984, Congress passed the among 18- to 21-year-olds substantially? Would it in-
National Minimum Drinking Age Act in response to crease alcohol-related negative consequences, such
evidence that states with higher drinking ages had as drunk driving? lfthe drinking age were lowered to
fewer traffic fatalities associated with alcohol. Some 18, are there programs that might counteract possi-
college administrators, however, believe that raising ble negative consequences? (Discussion appears on
the drinking age has not reduced drinking among p. 484 at the back of this book.)
18- to 21-year-olds but instead has driven it under-
ground, where it is more difficult to regulate.
CHAPTER SUMMARY
A substance is any natural or synthesized prod- Substance intoxication is indicated by a set of
uct that has psychoactive effects. The five groups behavioral and psychological changes that occur
of substances most often leading to substance as a direct result of the physiological effects of a
disorders are ( 1) centra l nervous system depres- substance on the central nervous system.
sants, including alcohol , barbiturates, benzodiaz- Substance withdrawal is a set of physiological
epines, and inhalants; (2) central nervous system and behavioral symptoms that result from the
stimulants, including cocaine, amphetamines, cessation of or reduction in heavy and prolonged
nicotine, and caffeine; (3) opioids; (4) hallucino- use of a substance. The specific symptoms of
gens and phencycl idine; and (5) cannabis . intoxication and withdrawal depend on the
430 Chapter 14 Substance Use a nd Gambling Disorders
substance being used, the amount ingested, and anxiety, agitation, sensitivity to pain, and a crav-
the method of ingestion. ing for more of the substance.
Substance use disorders are characterized by a The hallucinogens, phencyclidine (PCP), and
maladaptive pattern of substance use leading to cannabis produce perceptual changes, including
significant problems in a person's life, tolerance sensory d istortions and hallucinations. These
to the substance, w ithdrawal symptoms if it is experiences are pleasant for some, frightening
discontinued, and compulsive substance-taking for othe rs. Some people experience a sense
behavior. of euphoria or relaxation from using these
At low doses, alcohol produces relaxation and substances, and others become anxious and
mild euphoria. At higher doses, it produces clas- agitated.
sic signs of depression and cogn itive and motor The inhalants are volatile agents that people sniff
impairment. A large proportion of deaths due to to produce a sense of euphoria, disinhibition,
accidents, murders, and su icides are alcohol - and increased aggressiveness or sexual perfor-
related. Withdrawal symptoms can be mild or so mance. They are extremely dangerous; even
severe as to be life-threatening. People with alco- casua l use may cause permanent brain damage
hol use disorders experi ence a wide range of so- or serious disease.
cial and interpersonal problems and are at risk
Some add itional drugs of abuse are ecstasy
for many serious health problems.
(3,4-methylenedioxymethamphetamine, or
Benzodiazepines and barbiturates can cause an MDMA), GHB (gamma-hydroxybutyrate), ket-
initial rush and a loss of inh ibitions, followed by amine, and rohypnol (flunitrazepam). These
depressed mood, lethargy, and physical signs of drugs have several euphoric and sedative effects
central nervous system depression. These sub- and are used at dance clubs and sometimes by
stances are dangerous in overdose and when perpetrators of date rape .
mixed with other substances.
All substances of abuse have powerful effects on
Cocaine activates those parts of the brain that areas of the bra in involved in the processing of
register reward and pleasure and produces an reward. Repeated use of substances can cause
instant rush of euphoria, followed by increased alterations in these bra in areas that increase the
self-esteem, alertness, and energy and a greater need for more of the substance in order to expe-
sense of competence, creativity, and social accept- rience rewarding effects.
ability. The user also may experience frightening
Evidence indicates that genes play a role in vul-
perceptual changes. The symptoms of withdrawal
nerability to substance use disorders through
from cocaine include exhaustion, a need for sleep,
their effects on the synthes is and metabolism
and depression. Cocaine's extraordinarily rapid
of substances.
and strong effects on the bra in's reward centers
seem to make it more likely than most illicit sub- Behavioral theories of alcoholism note that peo-
stances to lead to abuse and dependence. ple are re inforced or punished for their alcohol-
Amphetam ines are readily available by prescrip- related behaviors and also engage in behaviors
t ion to treat certain disorders but often end up modeled by important others. Cognitive theories
available on the black market. They can make argue that people who develop alcohol-re lated
people fee l euphoric, invigorated, self-confident, problems have expectations that alcoho l w ill
and g regarious, but they also can lead to rest- help them feel better and cope better with
lessness, hypervigilance, anxiety, aggressive- stressful events. One personality characteristic
ness, and several dangerous physiological associated with substance use disorders is
symptoms and changes . behavioral undercontrol.
Nicotine is widely available. Smoking tobacco is Men may have more risk factors for substance
legal, but it causes cancer, bronchitis, and coro- use than women, and women may be more sen-
nary heart disease in users and low birth weights sitive to the negative consequences of substance
in the chi ldren of women who smoke when preg- use than men.
nant. People become physiologically dependent Medications can ease withdrawal symptoms and
on nicotine and undergo withdrawal when they reduce cravings for many substances. The symp-
stop smoking. toms of opio id withdrawal can be so severe that
The op ioids are developed from the juice of the dependents are given methadone as they try to
poppy plant. The most commonly used illegal discontinue heroin use. Methadone also blocks
op ioid is heroin. The initial symptom of opioid the effects of subsequent doses of heroin, reduc-
intoxication is euphoria, followed by drowsi- ing the desire to obtain heroin . Methadone main-
ness, lethargy, and periods of light sleep . Severe tenance programs are controversial.
intox ication can lead to respiratory difficu lties, Peop le with alcohol use d isorder sometimes re-
unconsciousness, coma, and seizures. spond to behavior therapies based on aversive
Withdrawal symptoms include dysphoria, classical conditioning . They use a drug that
Key Terms 431
makes them ill if they ingest alcohol or imagery prevention programs help identify triggers for
that makes them develop a conditioned aversive relapse .
response to the sight and smell of alcohol. The most common treatment for alcohol use dis-
Contingency management programs provide order is Alcoholics Anonymous (AAL a self-help
incentives for reducing substance use. group that encourages alcoholics to admit their
Cognitive therapies focus on training people with weaknesses and call on a higher power and on
alcohol use disorder in developing coping skills other group members to help them abstain from
and in challenging positive expectations about alcohol.
alcohol's effects. Prevention programs based on a harm reduction
Motivational interviewing attempts to em pa- model seek to teach the responsible use of alcohol.
thetically draw out individuals' motivations and Gambling disorder is new to DSM-5 and repre-
their commitment to change their substance use sents a behavioral addiction. It is characterized by
behavior. compulsive gambling even in the face of signifi-
The abstinence violation effect comprises an in- cant social, financial, and psychological conse-
dividual's feeling of guilt over relapse and attri- quences. It seems to share many risk factors and
bution of relapse to lack of self-control. Relapse clinical patterns with the substance use disorders.
KEY TERMS
substance use disorders 396 nicotine 410
gambling disorder 396 caffeine 411
substance 396 opioids 411
substance intoxication 398 hallucinogens 413
substance withdrawal 398 phencyclidine (PCP) 414
substance abuse 399 cannabis 414
substance dependence 399 inhalants 415
tolerance 399 antagonist drugs 420
depressants 400 methadone 420
delirium tremens (DTs) 402 motivational interviewing 423
benzodiazepines 406 abstinence violation effect 423
barbiturates 406 relapse prevention programs 423
stimulants 406 Alcoholics Anonymous (AA) 423
cocaine 406 harm reduction model 426
amphetamines 409
Health Psychology
CHAPTER OUTLINE
Stress Along the Continuum Sleep and Health

Extraordinary People: Norman Cousins, Chapter Integration
Healing with Laughter
Psychological Factors
and General Health Think Critically
Shades of Gray Chapter Summary
Psychosocial Factors in Specific Diseases Key Terms
Interventions to Improve
Health-Related Behaviors
432
Moderate-to-severe stress Severe stress for
Moderate stress for for constrained period constrained period
constrained period of time: of time: of time:
No stress: Moderate fight-or-flight Moderate-to-severe fight- Severe fight-or-flight
No increase in response aroused for short or-flight response aro used, respo nse aroused,
physiological period of time, declining possibly persisting for some possibly persisting for
arousal shortly after stress ends time after stress ends some time after stress ends
-- 1-
'~
Brief mild stress: Moderate stress for Moderate-to-severe stress Severe stress for
Mild fight-or-flight extended period of time: for extended period of time: extended period
response aroused for Moderate fight-or-flight Moderate-to-severe fight-or- of time:
short period of time, response chronically flight response chronically Severe fight-or-flight
declining shortly after aroused, potentially aroused, potentially creating respo nse chro nically
stress ends creating harm to bodily harm to bodily systems aroused, potentially
systems creating harm to
bodily systems
Anytime we face a stressor, a number of physiological responses status, socioeconomic status, and culture, may affect an indi-
kick in, as discussed in Chapter 5. Known collectively as the fight- vidual's exposure to uncontrollable and unpredictable events,
or-flight response (refer to Figure 5.1, p. 109), bodily changes such perceptions of these events, and reactions to them (Chen &
as increased heart rate and elevated blood pressure prepare the Miller, 2012) . For example, many African Americans are exposed
body to either face the threat or flee from it. The sympathetic to excessive stress due to racism, discrimination, and lower so-
system also stimulates the release of a number of hormones- cioeconomic status compared to many European Americans
including epinephrine (adrenaline) and norepinephrine-that (Mays, Cochran, & Barnes, 2007). In turn, African Americans
keep the body ready to react. One of the primary stress hormones score higher on a number of indicators of allostatic load, such
is cortisol, which is released by the adrenal cortex. Eventually, as persistent high blood pressure (Geronimus, Hicken, Keene,
when the threatening stimulus has passed, the increase in cortisol & Bound, 2006).
signals the body to stop releasing these hormones. This process Culture can alter the very meaning of a stressor, even one as
allows the body to adapt along a continuum of stress. severe as homelessness. A study in Nepal found that homeless
Even mild stressors trigger the fight-or-flight response. When street children actually showed lower allostatic load than chil-
the stressor is immediate, the response is activated and then sub- dren living with their families in rural villages (Worthman &
sides. This adaptation is called allostasis-the body learns how to Panter-Brick, 2008). The homeless children had formed family
react more efficiently to stress when it comes and goes, is not se- groups with other street children, protecting one another and
vere, and does not persist for long periods oftime (McEwen, 2000). collectively finding food and shelter. The rural village children
But when a stressor is chronic-that is, when it lasts over a long had stable homes, but these homes had poor sanitation , and the
period of time-and a person or animal cannot fight it or flee from children received only subsistence nutrition and faced heavy
it, then the chronic physiological arousal that results can be se- physical workloads. In more developed countries such as the
verely damaging to the body, a condition known as allostatic load. United States, in contrast, being a homeless street child is associ-
Persistent uncontrollable and unpredictable stress can created with more stress and poorer health than is living with family
ate allostatic load. Many factors, including gender, minority in a rural small town (Worthman & Panter-Brick, 2008).
Stress Along the Continuum 433

434 Chapter 15 Health Psychology
Norman Cousins, Healing with Laughter
In 1964, Norman How scientific was it to believe that

Cousins, a successful laughter-as well as the positive emotions in
general-was affecting my body chemistry for
writer at the Saturday
the better? If laughter did in fact have a salutary
Review, was diag-
effect on the body's chemistry, it seemed at least
nosed with ankylosing
theoretically likely that it would enhance the
spondylitis, a painful system's ability to fight the inflammation. So we
collagen disease. After took sedimentation-rate readings just before as
many medical tests well as several hours after the laughter epi-
and days in the hospi- sodes. Each time, there was a drop of at least
tal, doctors gave him a five points. The drop by itself was not substan-
1 in 500 chance of liv- tial, but it held and was cumulative.
ing. Cousins refused to believe that he would suc- I was greatly elated by the discovery that
cumb to the disease and set out to find a course of there is a physiological basis for the ancient the-
ory that laughter is good medicine ... . (1985,
action that might reverse its progression. His book
pp. 55-66)*
Anatomy of an Illness describes his use of com-
edy and movies to raise his levels of positive emo- Cousins eventually recovered from his illness. After
tions and thereby affect the functioning of his returning to his career as a writer for several years,
adrenal and endocrine systems: Cousins spent the last 12 years of his life at the
A good place to begin, I thought, was with UCLA Medical School, working with researchers to
amusing movies. Allen Funt, producer of the find scientific proof for his belief that positive emo-
spoofing television program "Candid Camera;' tions have healing properties. One of the leading
sent films of some of his "CC" classics, along institutes for the study of the impact of psychologi-
with a motion-picture projector. The nurse was cal factors on physical health is now named for him:
instructed in its use. The Cousins Center for psychoneuroimmunology
It worked. I made the joyous discovery that at UCLA.
ten minutes of genuine belly laughter had an
anesthetic effect and would give me at least two
hours of pain-free sleep. When the painkilling * From ANATOMY OF AN ILLNESS AS PERCEIVED BY THE PATIENT:
effect of the laughter wore off, we would switch Reflections on Healing and Regeneration by Norman Cousins.
Copyright 1979 byW. W. Norton & Company, Inc. Used by
on the motion-picture projector again, and not
permission ofW. W. Norton & Company, Inc. This selection may not
infrequently, it would lead to another pain-free be reproduced, stored in a retrieval system, or transmitted in any
sleep interval. Sometimes the nurse read to me form or by any means without the prior written permission of the
out of a trove of humor books. publisher.
In the years since Cousins's discovery that laugh- First, biological factors, such as genetic makeup,
ter was good medicine for him, a considerable age, and gender, clearly have a major influence on
number of studies have shown that positive our susceptibility to disease. For example, genet-
emotions influence physiological functioning ics plays a strong role in susceptibility to cancer,
(Fredrickson & Joiner, 2002; Fredrickson, Tugade, the risk of developing most cancers increases with
Waugh, & Larkin, 2003). These findings evoke the age, and some forms of cancer, such as breast can-
ancient mind-body question: Does the mind affect cer, are much more common in women than in
the body, or does the body affect the mind? The men. Second, social or environmental factors can
answer now is clearly that the mind and the body directly impact health. The factor most often stud-
affect each other reciprocally. ied by health psychologists is stress, as we discuss
In this chapter, we review the research in in detail below. Another important social factor is
health psychology (also referred to as behavioral med- culture, which influences our exposure to diseases
icine), a field that explores how biological, psycho- and the treatments prescribed for these diseases. ~
logical, and social/ environmental factors interact For example, the human immunodeficiency virus
to influence physical health. Figure 15.1 illustrates (HIV) is more widespread in sub-Saharan Africa
the components of a biopsychosocial approach to than anywhere else in the world (UNAIDS, 2009),
physical health (Baum, Perry, & Tarbell, 2004). and cultural stigmas against condom use have
played a role in the spread of HIV in this region Components in a Biopsychosocial

(UNAIDS, 2004). Third, a number of psychologi- FIGURE 15.1
Approach to Physical Health
cal factors can impact health. We can engage in I
behaviors that enhance our health, such as exer-
r
cising regularly and brushing our teeth, or in be- Biological factors (e.g.,
haviors that promote disease, such as smoking genetics, age, gender)
and eating fatty foods. When we are ill, we can
seek treatment and follow our doctor's orders, or
we can avoid treatment or not comply with the
Sodal and environmental Psychological factors (e.g.,
doctor's orders. factors (e.g., stressful events, behaviors affecting health,
In addition to their individual direct effects cultural norms) treatment seeking, compliance
on health, biological, psychological and social/ with doctors' orders)
I
environmental factors all interact to influence
health. Consider a few examples: Genetics not
only influences our vulnerability to a particular
disease but also influences how much stress we
are exposed to in our life and our perceptions of
stress (Kendler, Karkowski, & Prescott, 1999;
Kendler & Karkowski-Shuman, 1997). In turn, Source: Baum et al., 2004.
stress can make it more difficult to engage in

healthy behaviors such as getting enough exer-
cise. Our personalities influence how much stress
we perceive in our lives, which in turn affects our diseases, including influenza, pneumonia, and
health. Throughout this chapter, we discuss how tuberculosis (Table 15.1). Over the past century,
interactions among biological, psychological, advances in medicine have greatly reduced the
and social/ environmental factors promote or number of deaths due to these diseases. In the
damage health. twenty-first century, the five leading causes of death
As a field, health psychology has grown rap- are diseases significantly influenced by psychologi-
idly in recent decades as psychological and social/ cal and social factors such as smoking, diet, and
environmental factors have become increasingly stress. Thus, understanding how psychological and
important determinants of both the length and the social/ environmental factors interact with each
quality of our lives. At the beginning of the twenti- other and with biological vulnerabilities to create
eth century, the leading causes of death, in addition disease is a critical part of maintaining people's
to cardiovascular disease, were primarily infectious physical health.
TABLE 15.1 Leading Causes of Death in the United States, 1900 and 2009
1900 2009
Cause Rate (per 100,000) Cause Rate (per 100,000)
1. Cardiovascular diseases 345 1. Heart disease 246

(heart disease, stroke)
2. Cancer 233
2. Influenza and pneumonia 202
3. Chronic lower respiratory 56
3. Tuberculosis 194 diseases (stroke)
4. Gastritis, duodenitis, 143 4. Cerebrovascular diseases 53
enteritis, and colitis
5. Accidents 48
5. Accidents 72
Source: Data for 1900: U.S. Bureau of the Census, 1975, Historical Statistics of the United States: Colonia/Times to 1970, I. Washington,
DC: U.S. Government Printing Office. Data for 2009: Heron, M. (2012). Deaths: Leading Causes for 2009, National Vital Statistics Report,
Vol. 61, No.7.
In short, a pessimistic outlook may affect health

PSYCHOLOGICAL FACTORS directly by causing hyperarousal of the body's
AND GENERAL HEALTH physiological response to stress or indirectly by re-
We all know people who seem to be able to handle ducing positive coping strategies and healthy be-
even severe stress extremely well-they bounce haviors. In contrast, an optimistic outlook, such as
back from difficult times with renewed vigor, feel- the outlook Norman Cousins attempted to create in
ing as though they have grown psychologically himself through laughter, may promote physical
from their stressful experiences. We call these peo- health by reducing physiological stress responses
ple resilient (Masten & Powell, 2003). Other people, and promoting positive coping strategies (Chen &
however, are more fragile-even mild stresses Miller, 2012).
overwhelm them and seem to lead to psychologi-
cal and physical decline. Coping Strategies
The ways people cope with illness and other stress-
Appraisals and Pessimism ful life circumstances can affect their health (Taylor
One difference between resilient and fragile peo- & Stanton, 2007). One method of coping that can be
ple is the way they appraise or interpret events. bad for health is avoidance coping, that is, denying
People who tend to have a pessimistic style of in- that you are ill or are facing other obvious stresses.
terpreting events- seeing negative events as their Avoidance coping has been linked to several health-
fault, likely to continue in the future, and having related problems, such as greater pain after surgery
wide consequences-go through life seeing stress (Rosenberger et al., 2004), compromised recovery of
around every corner (Peterson et al., 1998). function following surgical procedures (Stephens,
Pessimism may contribute to poor health by caus- Druley, & Zautra, 2002), lower adherence to medical
ing chronic arousal of the body's fight-or-flight regimens and subsequently poorer health in HIV-
response, resulting in physiological damage. Sev- positive individuals (Weaver et al., 2005), more
eral studies have found evidence for this risky behaviors in HIV-positive intravenous drug
explanation. In one study, the blood pressure of users (Avants, Warburton, & Margolin, 2001), and
pessimists and optimists was monitored daily for increased physical symptoms among AIDS caregiv-
3 days. The pessimists had chronically higher ers (Billings, Folkman, Acree, & Moscowitz, 2000).
blood pressure levels than the optimists across the Avoidance coping also predicts the chronic disease
3 days (Raikkonen et al., 1999). Another study progression and/ or mortality of people with cancer
found that older adults who were pessimistic (Epping-Jordan, Compas, & Howell, 1994), HIV in-
showed poorer immune system functioning than fection (Leserman et al., 2000), congestive heart fail-
those who were optimistic, even after the research- ure (Murberg, Furze, & Bru, 2004), and rheumatoid
ers statistically controlled for differences between arthritis (Evers et al., 2003).
the pessimists and optimists on measures of cur- In contrast, talking about negative emotions
rent health, depression, medication use, sleep, and important issues in one's life appears to have
and alcohol use (Kamen-Siegel, Rodin, Seligman, positive effects on health (e.g., Panagopoulou,
& Dwyer, 1991). Maes, Rime, & Montgomery, 2006). In a large series
A pessimistic outlook also may lead people to of studies, James Pennebaker (2007) found that en-
engage in unhealthy behaviors. In one study of peo- couraging people to reveal personal traumas in
ple who were HIV-positive, researchers found that diaries or essays improves their health. In one
those who were more pessimistic were less likely to study, 50 healthy college students were randomly
practice healthy behaviors, such as maintaining a assigned to write either about the most traumatic
proper diet, getting enough sleep, and exercising and upsetting events in their lives or about trivial
(Milam et al., 2004; Taylor, Kemeny, Aspinwall, & topics for 20 minutes on 4 consecutive days. Blood
Schneider, 1992). These behaviors are particularly samples were taken from the students on the day
important for HIV-positive people because they can before they began writing, on the last day of writ-
reduce the risk of developing AIDS. ing, and 6 weeks after their writing. The students'
The effects of pessimism may be lifelong. In a blood was tested for several markers of immune
long-term study of men in the Harvard classes of system functioning. The number of times the stu-
1939 and 1940, those who were pessimistic in col- dents visited the college health center over the
lege were more likely to develop physical illness 6 weeks following the writing task was also recorded
over the subsequent 35 years than were those who and was compared with the number of health cen-
were more optimistic in college (Peterson, Selig- ter visits the students had made before the study.
man, & Vaillant, 1988; see also Peterson et al., 1998). As Figure 15.2 shows, students who revealed their
Psychological Factors and General Health 437
about trivial events experienced a slight increase

Student's Health After
FIGURE 15.2 in health center visits and a decrease in immune
Writing About Traumas
system functioning, for unknown reasons.
or Trivialities. Students
Pennebaker (2007) believes that writing helps peo-
who revealed personal traumas i n a series
ple understand and find meaning in the events of
of essays had stronger immune system
their lives. Understanding and finding meaning in
functioning and fewer health care visits than
turn reduce people's negative emotions regarding
students who wrote about trivial events in
events and therefore may reduce the physiological
their essays.
strain associated with chronic negative emotions.
5.1,------------------------------- A related positive coping strategy is seeking
social support. A wide variety of studies have
found that people who seek and receive positive
emotional support from others show more posi-
tive health outcomes, both on microlevel measures
~ 5.0
such as immune system activity and on macro level
t::
0
Trauma outcomes such as the progression of major dis-
~
~ eases (Hallaraker, Arefjord, Havik, & Maeland,
...,
Q)
2001; Pakenham, Chiu, Bursnall, & Cannon, 2007) .

u
0
.c Shelley Taylor and colleagues (2006) found that
c.
E
4.9
young adults who had grown up in supportive
...-J
families showed less reactivity in certain areas of
the brain to emotionally provocative photos. This
reduced emotional reactivity could reduce physi-
Control ological reactivity to stress in these individuals.
4.8 --'---------------------------------
Before writing After writing Gender Differences in Coping
Time period Women and men appear to have different re-
sponses to stress. Taylor and colleagues (2000)
0.3 -,-------------------------------
have suggested that women faced with threats en-
Control gage in a pattern termed tend and befriend. Through-
out evolutionary history, women have not been as
physically capable as men of fighting off aggres-
...,t::
.c
0
sors; also, because they have had primary respon-
E 0.2 sibility for their offspring, they have not always
Q:;
c. been able to run from an aggressor. Instead of at-
.~
S: tempting to fight a threat or flee from it, women
"' join social groups for protection and resources.
"'
Q)
~ Underlying this behavioral response to stress by

t:: 0.1 women is a different neurobiological response to
"'
Q)
::;: stress: The physiological changes associated with
Trauma
the fight-or-flight response are less prominent in
women than in men, but stressed women experi-
ence the release of the hormone oxytocin, which is
0--'--------------------------------- associated with increased affiliative behavior such
15 weeks 6 weeks
prior to study during study as seeking out and caring for others.
Time period Women are indeed more likely than men to
seek support from others in times of stress and to
have larger social networks, including friends and
Source: Pennebaker et al., 1988.
extended family (Kiecolt-Glaser & Newton, 2001).
Men, in contrast, typically have a much smaller
network of people they turn to for support and
personal traumas in their essays showed more also are less likely than women to share personal
positive immune system functioning and visited issues and concerns with friends and family mem-
the health center less frequently than did students bers. Thus, women may have more opportunity
in the control group (Pennebaker, Kiecolt-Glaser, than men to benefit from the positive health effects
& Glaser, 1988). In contrast, the group who wrote of social support.
SHADES OF GRAY
As you read the following case study, ask in other cities. John also did not tell any of his co-
yourself whether it presents a healthful way of workers about the cancer. He took vacation time to
coping with a stressful event. receive treatment and recover from its aftereffects.
John and his wife seldom spoke about the cancer.
John Park is a 62-year-old engineer, originally He preferred to go on with his life, living as nor-
from South Korea and now living in Columbus, mally as possible. He did enjoy talking with his
Ohio. John recently received news from his physi- wife about their children's lives, their grandchil-
cian that he has prostate cancer. The urologist dren's escapades, and upcoming visits with friends
John consulted recommended that he undergo and family.
radiation therapy to treat it. John told his wife
about the diagnosis and treatment, but he did not Is John coping in a healthful way with his cancer?
tell his children, all of whom are grown and living (Discussion appears at the end of this chapter.)
A major source of support is a partner or more concerned about potential harm to their rela-
spouse. Married people have less physical illness tionships if they do so (Kim, Sherman, & Taylor,
and are less likely to die from a variety of condi- 2008). People from Asian cultures instead may find
tions, including cancer, heart disease, and surgery, ways to benefit from their social networks that
than nonmarried people (see Kiecolt-Glaser & don't involve revealing personal concerns or
Newton, 2001). A conflictual marriage, however, weaknesses or potentially burdening others. For
can be a major detriment to health. Experimental example, they may remind themselves of their
studies of married couples found that those who close relationships or simply enjoy the company of
became hostile and negative toward each other people they love. Studies of Asians and Asian
while discussing marital problems showed greater Americans find that they derive more emotional
decreases in four indicators of immune system and physiological benefit (in terms of lower corti-
functioning than couples who remained calm and sol levels) from this subtler, more implicit form of
nonhostile while discussing marital problems. seeking social support than from explicitly asking
Those who became hostile also showed elevated others for support or revealing their needs (Kim et
blood pressure for longer periods of time (Kiecolt- al., 2008). In contrast, European Americans benefit
Glaser, Malarkey, Chee, & Newton, 1993). more from explicit forms of seeking social support
Women are more physiologically reactive than than from implicit forms. Thus, while coping is im-
men to marital conflict (Kiecolt-Glaser & Newton, portant to health in all cultures, the specific forms
2001). This may be because women's self-concepts, of coping that are helpful may be influenced by
as well as their financial well-being, tend to be more cultural norms.
closely tied to those of their spouse than are men's
self-concepts (Cross & Madson, 1997). Also, women Psychological Disorders
are more emotionally attuned to their partners and
more conscious of conflict in their relationships. For and Physical Health
these reasons, women may be more emotionally, People with psychological disorders have more
cognitively, and physiologically sensitive to marital physical health problems than people without psy-
conflict, and this sensitivity may counteract any chological disorders. For example, a 20-year-long
positive health effects they might derive from sup- study of people who had been diagnosed with a
port from their partner (Kiecolt-Glaser & Newton, psychological disorder found that they had more
2001). In general, women can benefit physiologi- physical health problems throughout this period
cally from being in a close relationship, but only if than people without a psychological disorder
that relationship is a positive one. (Chen et al., 2009). Serious health problems in-
cluded severe allergies, chronic respiratory disease,
Cultural Differences in Coping chronic gastrointestinal disease, cardiovascu Jar
Different cultures have different norms for coping disease, cancer, and diabetes. In particular, several
with stressful events. People from Asian cultures studies have found links between depression and a
tend to be more reluctant than European Ameri- variety of diseases, including cancer, heart disease,
cans to reach out to others for social support or to diabetes, arthritis, and asthma (Everson-Rose &
express their personal concerns, because they are Lewis, 2005; Katon, 2003).
Psychosocial Factors in Specific Diseases 439
There may be many mechanisms linking psy- These health-related behaviors put the individual
chological disorders with physical health prob- at risk for the development or worsening of a med-
lems. In some cases, psychopathology and medical ical illness.
illness may share a common genetic cause. For
example, depression and cardiovascular disease
are both related to genetic factors leading to dys- PSYCHOSOCIAL FACTORS
function in serotonin systems (McCaffery et al., IN SPECIFIC DISEASES
2006). In other cases, medical disorders may cre-
Health psychologists have intensively studied cer-
ate psychological disorders. Alzheimer's disease,
tain disease processes in which stress and psycho-
a neurological disorder leading to dementia, also
logical factors are expected to play a role. We
leads to depression, anxiety, personality changes,
consider two groups of diseases here: immune sys-
and psychotic symptoms such as hallucinations
tem diseases and cardiovascular diseases.
and delusions (see Chapter 10). Thyroid diseases
can cause depressive symptoms. Further, the so-
cial and psychological stress of having a serious
The Immune System
medical illness can cause depression or anxiety The immune system protects us from disease by
(Hammen, 2005). identifying and killing pathogens and tumor cells.
In still other cases, psychological disorders The immune system is divided into two branches,
may contribute to medical disorders. Self-starvation the innate immune system and the specific immune
in anorexia nervosa can lead to osteoporosis and system, both of which have a number of cellular
loss of bone density as well as to cardiovascular mechanisms for attacking invaders. The innate sys-
problems (Polivy & Herman, 2002). Substance tem reacts quickly and nonspecifically to any mi-
abuse or dependence can cause many medical dis- croorganism or toxin that enters the body, releasing
eases, including hypertension and liver and kid- cells that kill and ingest the invaders. The specific
ney disease (see Chapter 14). immune system is slower to respond, but its re-
Living with a psychological disorder is stress- sponse is tailored to the particular type of pathogen
ful in many ways. An individual may have diffi- present. The specific immune system remembers
culty holding down a job, face discrimination and the pathogen so that if it attacks again the system is
social rejection, and have trouble obtaining medi- able to kill it more quickly and efficiently.
cal care (Everson-Rose & Lewis, 2005). People with Stress may affect the immune system in sev-
many psychological disorders show signs of eral ways. Although short-term stress appears to
chronic arousal of the fight-or-flight response, in- increase the potency of immune responses, more
cluding chronically elevated cortisollevels (McEwen, chronic stress decreases immune functioning, in
2000). This excess allostatic load could in turn con- part because some of the biochemicals released as
tribute to physical illness. part of the fight-or-flight response, such as cortisol,
Having a psychological disorder also may lead suppress the immune system if a stressor persists
a person to be more pessimistic and to have poorer for long periods (Segerstrom & Miller, 2004). The
skills for coping with stress, which could then in- most controlled research linking stress and im-
crease the person's allostatic load. For example, one mune system functioning has been conducted
study found that the greater rate of physical illness with animals. The animals are experimentally ex-
in people with depressive disorders than in people posed to stressors, and then the functioning of
with no psychological disorder was explained in their immune system is measured directly. Studies
part by higher levels of neuroticism in the depressed have shown that immune system cells are sup-
people (Rhebergen et al., 2010). Neuroticism is a pressed in animals exposed to loud noise, electric
personality trait characterized by hyperreactivity to shock, separation from their mothers as infants,
stress and poor coping skills. separation from their peers, and a variety of other
People with psychological disorders also ap- stressors (Segerstrom & Miller, 2004).
pear to be less likely to engage in positive health- Animals are most likely to show impairment
related behaviors (Zvolensky & Smits, 2008). The of their immune system if they are exposed to
rate of smoking is two to three times higher in stressors that are uncontrollable. In one experi-
people with psychological disorders than in peo- ment, one group of rats was subjected to an elec-
ple without a psychological disorder (Grant, tric shock that the rats could turn off by pressing
Hasin, et al., 2004; Lasser et al., 2000). People with a lever (Laudenslager et al., 1983). Another group
psychological disorders also appear to be less received an identical sequence of shocks but
likely to exercise (Whooley et al., 2008) or to com- could not control the shock. A third group re-
ply with medical regimens (Chen et al., 2009). ceived no shock. The investigators examined how
demands, and their frequency of negative emo-

The Effects of
FIGURE 15.3 tions such as anger or depression. The participants
Controllable and
were examined daily for cold symptoms and for
Uncontrollable Shocks
the presence of cold viruses in their upper respira-
on Rats' Immune Systems. In one study,
tory secretions. About 35 percent of the volunteers
rats given uncontrollable shocks showed less
who reported the highest stress in their lives de-
increase in T-cells, which kill harmful cells, than
veloped colds, compared to about 18 percent of
did rats given controllable shocks or no shock.
those with the lowest stress scores.
Many other studies of humans have compared
the functioning of the immune system in persons
undergoing particular stressors with that of per-
sons not undergoing these stressors. This research
c: confirms that people show higher rates of infec-
tious diseases, such as colds, herpes, and mono-
nucleosis, during times of stress. For example,
following the 1994 Northridge earthquake in the
Uncontrollable shock
Los Angeles area, people whose lives had been
Time
more severely disrupted showed greater declines
in immune system functioning than did those who
had not experienced as much stress as a result of
Source: Laudenslager et al., 1983. the earthquake (Solomon et al., 1997). People who
worried more about the impact of the earthquake
on their lives were especially likely to show detri-
ments in immune system functioning (Segerstrom,
well the rats' killer T-cells, components of the Solomon, Kemeny, & Fahey, 1998).
specific immune system that secrete chemicals Negative interpersonal events seem particu-
that kill harmful cells, multiplied when chal- larly likely to affect immune system functioning.
lenged by invaders. They found that the T-cells in Married couples who argue more show poorer im-
the rats that could control the shock multiplied, munological functioning than married couples
as did those in the rats that were not shocked at who have fewer arguments (Kiecolt-Glaser &
all (Figure 15.3). The T-cells in the rats exposed to Newton, 2001). Men and women who have re-
uncontrollable shock increased less, however. In cently been separated or divorced show poorer im-
another study following the same experimental mune system functioning than married control
design, investigators implanted tumor cells into subjects (Robles & Kiecolt-Glaser, 2003). However,
rats, gave them controllable or uncontrollable the partner who has more control over the divorce
shocks, and examined whether the rats' natural or separation-that is, the partner who initiated
defenses rejected the tumors. Only 27 percent of it- shows better immune system functioning and
the rats given uncontrollable shocks rejected the better health than the other partner. This is another
tumors, whereas 63 percent of the rats given con- example of how perceptions of the controllability
trollable shocks rejected the tumors (Visintainer, of a stressor can influence the impact of that
Volpicelli, & Seligman, 1982). stressor on health.
Uncontrollable stress also impairs immune
system functioning in humans (Schneiderman, Cancer
Ironson, & Siegel, 2005). The most common dis- Can psychosocial factors affect severe immune-
ease in which the immune system plays a role is related diseases such as cancer? One study of
the cold. You may have observed that you and women with breast cancer found that those who
your friends are more likely to get colds during felt they had little control over their cancer and
times of stress. To test this common observation, other aspects of their lives were more likely to
investigators exposed about 400 healthy volun- develop new tumors over a 5-year period than
teers to a nasal wash containing either one of five were women who felt more in control, even
cold viruses or an innocuous salt solution (Cohen, though the two groups of women did not differ in
Tyrrell, & Smith, 1991). Participants received a the type or initial seriousness of their cancers
stress score ranging from 3 (lowest stress) to 12 (Levy & Heiden, 1991; Watson et al., 1999). An-
(highest stress) based on the number of stressful other study found that pessimistic cancer patients
events they had experienced in the past year, the are more likely to die during the first few years
degree to which they felt able to cope with daily after their diagnosis than are optimistic cancer
Psychosocial Factors in Specific Diseases 44 1
patients (Schulz et al., 1996). Coping behaviors At a 10-year follow-up, there were no differences
also may affect cancer: Studies of women with between the intervention group and the control
breast cancer found that those who actively group in recurrences of the cancer, but the interven-
sought social support from others had greater im- tion group had a higher survival rate than the con-
mune system activity (Levy, Herberman, White- trol group when other risk factors were taken into
side, & Sanzo, 1990; Turner-Cobb et al., 2000). account (Fawzy, Canada, & Fawzy, 2003).
If psychosocial factors such as social support Other studies have failed to find any effects of
and pessimism do influence the progression of psychosocial interventions on the progression of
cancer, this raises the possibility that the course of cancer, however. For example, a large clinical trial
the disease can be affected by psychosocial inter- attempting to replicate the effects in the breast
ventions. Early studies gave hope. In a landmark cancer study described above failed to find any
study of women with advanced breast cancer who effects of support groups on health in women
were expected to die within 2 years, one group of with breast cancer (Goodwin et al., 2001; see also
women participated in a series of weekly support Kissane et al., 2007). Meta-analyses and reviews of
groups and the other group did not (Spiegel, the effects of psychosocial interventions on sur-
Bollm, Kraemer, & Gottheil, 1989). All the women vival in cancer patients have not found overall
received standard medical care for their cancer. positive effects (Chow, Tsao, & Harth, 2004;
The support groups focused on facing death and Coyne, Stefanek, & Palmer, 2007; Edwards,
living their remaining days to the fullest. The re- Hulbert-Williams, & Neal, 2008; Smedslund &
searchers did not expect to alter the course of the Ringdal, 2004). Psychosocial interventions have
cancer; they wanted only to improve the women's been found to improve cancer patients' quality of
quality of life. To their surprise, 4 years later one- life, however (e.g., Antoni et al., 2001) .
third of the women participating in the support
groups had survived, whereas all the women who HIV/AIDS
had not participated in the support groups had The Centers for Disease Control estimates that
died. The average survival time for the women in well over a million people in the United States
the support groups was about 40 months, com- have been infected with the human immunodefi-
pared to about 19 months for the other women. ciency virus (HIV), which causes AIDS (CDC,
Because no other differences between the two pop- 2008a). Worldwide, over 30 million people are in-
ulations could explain the disparity in average fected with HIV (WHO, 2008). The progression of
survival times, it seems that the support groups illness in people infected with HIV varies greatly.
helped prolong the participants' lives. The authors Individuals may live for years with no symptoms,
argued that the support groups reduced stress and then begin to develop relatively minor health
distress for the women and thus reduced the re- problems such as weight loss, fever, and night
lease of corticosteroids, which can promote tumor sweats. Eventually, they may develop a number of
growth (Spiegel, 2001). Having greater support serious and potentially fatal diseases, including
also might help cancer patients engage in better pneumocystis pneumonia, cancer, dementia, and a
health habits and adhere to difficult medical treat- wasting syndrome in which the body withers
ments such as chemotherapy. away. When these diseases emerge, a diagnosis of
Some subsequent studies also found that re- AIDS may be given. Fortunately, antiretroviral
ducing stress can improve health in cancer patients drugs appear to suppress the virus in those in-
(Fawzy, Kemeny, et al., 1990; Richardson, Shelton, fected and to slow the development of AIDS. Un-
Krailo, & Levine, 1990). In a study of p atients with fortunately, these drugs do not eliminate the virus,
malignant melanoma (skin cancer), some patients and their side effects lead many people to discon-
were given six weekly treatment sessions in which tinue their use. Moreover, millions of people
they were taught stress-management procedures, around the world who are infected do not have
relaxation, and methods for coping with their ill- access to these drugs.
ness. Six months after treatment, the group that re- Some studies suggest that psychological fac-
ceived the stress-reduction intervention showed tors can affect the progression of illness in people
better immune system functioning than the control infected with HIV (Leserman, 2008). Much of this
group, whose members received only customary research has been conducted with gay men, many
medical care (Fawzy, Cousins, et al., 1990; Fawzy, of whom have lost their partners and close friends
Kemeny, et al., 1990). At aS-year follow-up, patients to AIDS, particularly before antiretroviral drugs
who had received the intervention were less likely became available. One study that followed 85 HIV-
to have had recurrences of the cancer and were sig- infected gay men for 3 to 4 years found that those
nificantly less likely to have died (Fawzy et al., 1993). whose partner or close friend had died of AIDS
showed a more rapid decline in immune system 18 months later than did those who initially were ~
functioning (Kemeny & Dean, 1995). Another less pessimistic (Milam et al., 2004). Similarly, a
group of investigators followed 96 gay men for study of gay men who were HIV-positive found
over 9 years and found that those who experienced that those who blamed themselves for negative
more severe stressors, including the deaths of close events and those who had more negative expecta-
friends and partners, showed a faster progression tions showed a greater decline in immune system
to AIDS (Leserman et al., 1999,2000, 2002). For ev- functioning and a greater development of HIV
ery increase of 1 on an index of stress experienced, symptoms over time than did those who had more
their risk of developing an AIDS-related clinical positive expectations (Reed, Kemeny, Taylor, &
condition (e.g., pneumocystis pneumonia) tripled. Visscher, 1999; Segerstrom et al., 1996).
At the end of the study, 74 percent of the men
above the median on the stress index progressed to Coronary Heart Disease
AIDS, compared to 40 percent below the median. and Hypertension
Experiencing more chronic stressors also ap-
pears to affect the progression of HIV in gay men. ~-'&"~~.._~,~~ :-.,., ~ '4:"
A study of HIV-positive gay men found that those

who felt compelled to conceal their sexual orienta-
":;cJistsl:uov ~
!\.r ~" -: t " ~ ~ ~
Orrin was so mad he could
-~ - -
tion showed a faster progression of disease than scream. He had been told at 3:00 that afternoon
those who did not (Cole et al., 1995). The differ- to prepare a report on the financial status of his
ences in health between the men who were "out" division of the company in time for a meeting of
and those who were "closeted" did not reflect dif- the board of directors the next morning. On the
ferences in health-related behaviors (e.g., smoking, way home from work, someone rear-ended him
exercise). It may be that the stress of chronically at a stoplight and caused several hundred dol-
hiding one's identity can have direct effects on lars in damage to his new car. When he got home
health. More generally, researchers found that from work, there was a message from his wife,
HIV-positive men who experienced declines in so- saying she had been delayed at work and would
cial support and increases in loneliness showed not be home in time to cook dinner for the chil-
poorer immune system control over the virus dren, so Orrin would have to do it. Then, at din-
(Dixon et al., 2001). ner, Orrin's 12-year-old son revea led that he had
Stress also affects the progression of the dis- flunked his math test that afternoon.
ease in children and adolescents who have been After finishing the dishes, Orrin went to his
infected with HIV. In a year-long study of 618 HIV- study to work on the report. The kids had the TV
positive young people, those who experienced two on so loud he couldn't concentrate. Orrin yelled
or more stressful life events, such as a parent be- to the kids to turn off the TV but they couldn't hear
coming seriously ill, a death in the family, or the him. Furious, he stalked into the family room and
loss of their home, were three times more likely began yelling at the children about the television
than other participants to show immune system and anything else that came to his mind.
declines (Howland et al., 2000). Then, suddenly, Orrin began to feel a tre-
Even stressors experienced long before an in- mendous pressure on his chest, as if a truck were
dividual is infected with HIV seem to increase the driving across it. Pain shot through his chest and
risk for disease progression. The Coping with down his left arm . Orrin felt dizzy and terrified .
HIV I AIDS in the Southeast (CHASE) Study fol- He collapsed onto the floor. His 7-year-old began
lowed 490 HIV-positive adult men and women screaming. Luckily, his 12-year-old called 911 for
from five rural southern U.S. states for up to an ambulance.
41 months (Leserman et al., 2007). Those with a
history of trauma, including childhood physical or
sexual abuse or neglect or the murder of a family
member, showed faster development of opportu-
nistic infections and were more likely to die of Orrin was having a myocardial infarction- a heart
AIDS-related causes than those without a history attack. A myocardial infarction is one end point of
of trauma (Mugavero et al., 2007). coronary h eart d isease, or CHD. CHD occurs
Interpretations of stressors appear to be im- when the blood vessels that supply the heart mus- ~
portant moderators of their effects. In one study of des are narrowed or closed by the gradual buildup
412 patients with HIV, those who scored high on of a hard, fatty substance called plaque and inflam-
questionnaires measuring pessimism at the begin- mation of the vessel walls, blocking the flow of
ning of the study had a greater load of the virus oxygen and nutrients to the heart. This process is
30,000 people in 52 countries found that about

one-third of the risk for heart disease is connected
to the stressfulness of people's environments
(Rosengren et al., 2004; Yusuf et al., 2004). People
in high-stress jobs are at increased risk for CHD,
particularly if their jobs are highly demanding but
provide them little control (Hintsanen et al., 2005;
Schneiderman et al., 2005). For example, one study
followed about 900 middle-aged men and women
over 10 years and tracked the emergence of coro-
nary heart disease (Karasek, Russell, & Theorell,
1982). The people in the study worked in a variety
of jobs, and the researchers categorized these jobs
in terms of how demanding they were and how
much control they allowed a worker. Over the
10 years of this study, workers in jobs that were
highly demanding but low in control, such as
working on a factory production line, had a risk of
coronary heart disease 1.5 times greater than that
of workers in other occupations.
Experimental studies with animals have
shown that disruption of the social environment
Coronary heart disease occurs when blood vessels can induce pathology that resembles coronary ar-
supplying the heart are blocked by plaque; complete tery disease (Sapolsky, 2007). Some of these experi-
blockage causes a myocardial infarction-a heart attack. ments have been conducted with a type of macaque
monkey w hose social organization involves the
establishment of stable hierarchies of dominance-
known as atherosclerosis. The blockage of vessels dominant and submissive animals can be identi-
can lead to pain, called angina pectoris, that radiates fied within a given group on the basis of the
across the chest and arm. When oxygen to the animals' social behavior. Introduction of unfamil-
heart is completely blocked a myocardial infarc- iar monkeys into an established social group is a
tion can result. stressor that leads to increased aggressive behav-
Coronary heart disease is a leading cause of ior as group members attempt to reestablish a so-
death and chronic illness around the world. Since cial dominance hierarchy (Sapolsky, 2007). In these
1990, more people have died from coronary heart studies, some monkey groups remained stable,
disease than from any other cause (WHO, 2007). In with fixed memberships, and other groups were
the United States, CHD accounts for 35 percent of stressed by the repeated introduction of new mem-
all deaths, or 1 in every 2.9 (American Heart As- bers. After about 2 years under these conditions,
sociation, 2010). CHD is also a chronic disease, and the high-ranking or dominant males in the unsta-
more than 12 million Americans live daily with its ble social condition showed more extensive coro-
symptoms. Men are more prone to CHD than are nary heart disease than did the subordinate males
women, but CHD still is the leading cause of death (Sapolsky, 2007).
among women. African Americans and Hispanic Hypertension, or high blood pressure, is a
Americans have higher rates of CHD than do condition in which blood flows through vessels
European Americans. There seems to be a genetic with excessive force, putting pressure on vessel
contribution to coronary heart disease-people walls. Hypertension can be caused by blood being
with family histories of CHD are at increased risk pushed with too much force by the heart through
for the disease. However, 80 to 90 percent of peo- vessels or by constriction of the vessel walls.
ple dying from coronary heart disease have one or Chronic high blood pressure can cause hardening
more major risk factors that are affected by life- of the arterial walls and deterioration of the cell
style choices, such as high blood pressure, high tissue, leading eventually to coronary heart dis-
serum cholesterol, diabetes, smoking, and obesity ease, kidney failure, and stroke. Almost one-third
(WHO, 2007). of the population of the United States has hyper-
People who live in a chronically stressful tension (Hajjar, Kotchen, & Kotchen, 2006). Genet-
environment over which they have little control ics appears to play a role in the predisposition to
appear to be at increased risk for CHD. A study of hypertension, but only about 10 percent of all cases
hypertension to return to normal following expo- ~

sure to stressors than it does the blood pressure of
those without hypertension.
Thus, people with hypertension and people
with family or genetic histories of hypertension
may have a heightened physiological reactivity to
stress. If they are exposed to chronic stress, their
chronically elevated blood pressure can lead to
hardening and narrowing of the arteries, creating a
physiologically based hypertension. Low-income
African Americans may have both this physiologi-
cal predisposition to heightened reactivity to stress
and chronic exposure to stressful environments,
making them doubly vulnerable to hypertension
(Lehman et al., 2009).
Personality and CHD

The personality factor traditionally linked to coro-
The chronic stress of poverty can contribute to diseases such as hypertension . nary heart disease is the Type A behavior pattern.
The three components of the Type A pattern,
according to the physicians who identified it
(Friedman & Rosenman, 1974), are a sense of time
of hypertension can be traced to genetics or to spe- urgency, easily aroused hostility, and competitive
cific organic causes, such as kidney dysfunction. striving for achievement. People who are Type A
The other 90 percent of cases are known as essential are always in a hurry, setting unnecessary dead-
hypertension, meaning that the causes are unknown lines for themselves and trying to do multiple
(Klabunde, 2005) . things at once. They are competitive, even in situa-
Because part of the body's response to stress- tions in which being competitive is ridiculous.
the fight-or-flight response-is to increase blood They also are chronically hostile and will fly into a
pressure, it is not surprising that people who live rage with little provocation.
in chronically stressful circumstances are more One of the most compelling studies to demon-
likely to develop hypertension (Schneiderman strate the relationship between the Type A pattern
et al., 2005). As an example, people who move from and coronary heart disease followed more than
quiet rural settings to crowded, noisy urban set- 3,000 healthy middle-aged men for 81h years (Rosen-
tings show increases in their rates of hypertension. man et al., 1976). Over the years of the study, Type A
One group that lives in chronically stressful men had twice as many heart attacks or other forms
settings and has particularly high rates of hyper- of coronary heart disease as non-Type A men. These
tension is low-income African Americans (American results held up even after diet, age, smoking, and
Heart Association, 2002). They often lack adequate other variables associated with coronary heart dis-
financial resources for daily living, may be poorly ease were taken into account. Other studies have
educated and have trouble finding good jobs, live confirmed this twofold risk and have linked Type A
in neighborhoods racked with violence, and fre- behavior to heart disease in both men and women
quently experience racism. All these conditions (Myrtek, 2007; Schneiderman et al., 2005). In addi-
have been linked to higher blood pressure tion, Type A behavior is correlated with the severity
(Chen & Miller, 2012; Lehman, Taylor, Kiefe, & of coronary artery blockage as determined at
Seeman, 2009). autopsy or in X-ray studies (Friedman et al., 1968;
People with hypertension and the children of Williams, Barefoot, Haney, & Harrell, 1988). Based
parents with hypertension tend to show a stronger on such evidence, in 1981 the American Heart As-
blood pressure response to a wide variety of stress- sociation classified Type A behavior as a risk factor
ors. In experimental situations that have people for coronary heart disease.
solve arithmetic problems or immerse their hands Subsequent research suggests that the defini-
in ice water, those with no personal or family his- tion of Type A behavior as originally formulated is
tory of hypertension show much less blood pres- too diffuse. The crucial variable in predicting coro-
sure response than do those with a history of nary heart disease may be hostility, particularly a
hypertension (Harrell, 1980). In addition, it takes cynical form of hostility characterized by suspi-
longer for the blood pressure of persons with ciousness, resentment, frequent anger, antagonism,
and distrust of others (Barefoot et al., 1989; Miller,

Smith, Turner, & Guijarro, 1996). Time urgency and
competitiveness appear to be less predictive of
heart disease.
For example, a 25-year study of 118 male law-
yers found that those who scored high on hostility
traits on a personality inventory taken in law
school were five times more likely to die before age
50 than classmates who scored low on the inven-
tory (Barefoot et al., 1989). Similarly, in a study of
physicians, hostility scores obtained in medical
school predicted the incidence of coronary heart
disease as well as mortality from all causes
(Barefoot, Dahlstrom, & Williams, 1983). In both
studies, the relationship between hostility and ill-
ness was independent of the effects of smoking,
age, and high blood pressure.
How does hostility lead to coronary heart dis-
ease? Again, overarousal of the sympathetic ner-
vous system may play a role. Hostile people show
greater physiological arousal in the anticipation of
stressors and in the early stages of dealing with Individuals with Type A personalities often put heightened stress on themselves,
which may put them at risk for coronary heart disease.
stressors (Benotsch, Christensen, & McKelvey,
1997; Lepore, 1995). Their heart rates and blood
pressures are higher, and they have greater secre-
tion of the stress-related biochemicals known as express it as readily (Kring, 2000; Lavoie, Miller,
catecholamines. They also return more slowly to Conway, & Fleet, 2001; Nolen-Hoeksema & Rusting,
baseline levels of sympathetic nervous system ac- 1999). Excessive hostility and anger, whether ex-
tivity following stressors than do nonhostile peo- pressed or suppressed, are associated with risk fac-
ple. This hyperreactivity may cause wear and tear tors for coronary heart disease in both women and
on the coronary arteries, leading to coronary heart men (Espnes & Byrne, 2008; Matthews et al., 1998).
disease. Alternately, the excessive secretion of cat-
echolamines in response to stress in hostile people Modifying Hostility to Improve
may exert a direct chemical effect on blood vessels. Cardiovascular Functioning
The frequent rise and fall of catecholamine levels A combination of cognitive and behavioral tech-
may cause frequent changes in blood pressure, re- niques has been shown to improve cardiovascular
ducing the resilience of the blood vessels. Hostile health by reducing Type A behavior, particularly
people also tend to engage in behaviors that in- hostility (Williams, 2008). One hallmark study
crease their propensity for heart disease, including included more than 1,000 individuals who had ex-
smoking, heavy drinking, and high-cholesterol di- perienced at least one heart attack (Friedman et al.,
ets (Schneiderman et al., 2005). 1994). Treatment helped hostile participants learn
Some research has suggested that men are to express themselves without exploding and to
more likely than women to have the Type A per- alter certain behaviors, such as interrupting others
sonality pattern (Barefoot, Siegler, Nowlin, & or talking or eating hurriedly. This treatment also
Peterson, 1987; Haynes, Feinleib, & Kannel, 1980). targeted other aspects of Type A behavior, because
Men also are more likely than women to carry the study was done before hostility was identified
three other risk factors for CHD: smoking, hyper- as the key factor. Participants were taught to over-
tension, and elevated cholesterol. Historically, far come their sense of time urgency by practicing
more men than women die of cardiovascular dis- standing in line (which Type A individuals find ir-
ease. In recent years, however, the number of ritating) and using the opportunity to reflect, to
women dying of cardiovascular disease has in- watch people, or to strike up a conversation with a
creased worldwide, while the number of men dy- stranger. Cognitive techniques helped participants
ing of cardiovascular disease has decreased reevaluate certain beliefs (such as the notion that
(Espnes & Byrne, 2008). success depends on the quantity of work pro-
Contrary to popular belief, women carry as duced) that might lead to urgent and hostile be-
much anger and hostility as men-they just don't havior. Also, participants found ways to make
their home and work environments less stressful, depressed patients experienced 50 percent more ~
such as by reducing unnecessary social engage- cardiac events (e.g., heart attacks) over the 4-year
ments. By the end of the study 4lh years later, the follow-up than did the nondepressed patients.
intervention group had experienced half as many The depressed patients' poor health behaviors ac-
new heart attacks as the group whose participants counted for their increased risk of cardiac events
were not taught to alter their lifestyles. even after controlling for a number of physiologi-
cal risk factors and possible third variables. In
Depression and Coronary Heart Disease particular, the depressed patients' lower level of
Major depression occurs in 15 to 20 percent of hos- physical exercise accounted for 31 percent of the
pitalized patients with coronary heart disease, and difference in cardiac events between the de-
up to 50 percent have some depressive symptoms pressed and the nondepressed patients.
(Frasure-Smith & Lesperance, 2005). There are sev- These results suggest that increasing physical
eral other variables that could account for the link exercise is an important target of intervention for
between depression and CHD. The blocked arteries depressed patients with coronary heart disease.
that lead to CHD also lead to reduced oxygen in the Exercise is effective in reducing both CHD and de-
brain and the marshaling of the immune system, pression (Blumenthal et al., 2005, 2007). In contrast,
both of which can contribute to mood changes, in- attempts to reduce depression in CHD patients
cluding depression (Alexopoulos et al., 1997; through the use of antidepressants or cognitive-
Dantzer, Wollman, & Yirmiya, 2002). Both CHD and behavioral therapy have had limited effects on
depression may be caused by a relative deficiency both the depression and the CHD (Berkman et al.,
in the polyunsaturated omega-3 fatty acids, found 2003; Glassman et al., 2002; Rees et al., 2004; van
primarily in fatty fish (Ali et al., 2009). And, as noted Melle et al., 2007).
earlier, both depression and CHD are linked to
genes that alter the functioning of the serotonin sys-
tem (Frasure-Smith & Lesperance, 2005). INTERVENTIONS TO
Several studies suggest that depression dou- IMPROVE HEALTH-RELATED
bles the risk of recurrent heart attacks and mortal-
ity in individuals with CHD (Frasure-Smith & BEHAVIORS
Lesperance, 2005). For example, one study of pa- We know that our behaviors have a large influence
tients with coronary heart disease found that those on our health, yet most of us do not follow the rec-
diagnosed with major depression were more than ommendations of experts. Why? According to
twice as likely to have a heart attack or some other health psychologists, it takes more than informa-
major cardiac event (e.g., emergency heart sur- tion to change people's actions. People must have
gery) over a 2-year follow-up period, even after the motivation to change their behavior, believe
taking into account a number of other risk factors they can change it, and have the skills to do so
for heart disease, such as age and high blood pres- (Ajzen, 1991; Bandura, 2006; Leventhal, Weinman,
sure (Frasure-Smith & Lesperance, 2008). Leventhal, & Phillips, 2008). Here we consider
Depression could contribute to CHD through some attempts to give people the tools they need
several pathways. Depression is associated with re- to change their health-related behaviors.
duced heart rate variability (i.e., less variation from
heart beat to heart beat), which is an indication of
poorer functioning of the autonomic nervous sys- Guided Mastery Techniques
tem. In turn, low heart rate variability is a risk factor Guided mastery techniques provide people with
for CHD (Frasure-Smith & Lesperance, 2005). explicit information about how to engage in positive
Depressed people with CHD are less likely health-related behaviors and with opportunities to
than nondepressed people with CHD to engage do so in increasingly challenging situations. The
in behaviors that could reduce their risk of future goals are to increase people's skills as well as their
cardiac events, such as eating a low-fat diet and beliefs that they can engage in the behaviors,
increasing their exercise (Gehi, Haas, Pipkin, & known as self-efficacy beliefs (Bandura, 2006). The
Whooley, 2005; Ziegelstein et al., 2000). In one kinds of actions that might be targeted include us-
longitudinal study of 1,017 adults with coronary ing condoms during sex in order to prevent the
heart disease, those who were depressed were spread of HIV and other sexually transmitted dis- ~
more likely than those who were not depressed to eases, refusing alcohol when being pressured to
smoke, to be less physically active, to not take drink, and starting an exercise program.
prescribed medications, and to have a higher A guided mastery program for teaching women
mean body mass index (Whooley et al., 2008) . The how to negotiate safe sexual practices might begin
Interventions to Improve Health-Related Behaviors 447
with information on condom use. A counselor then Internet-Based Health

might model how a woman can ask a man to use a Interventions
condom. The women would watch the counselor
and then practice insisting on condom use in role- Millions of people around the world get health in-
plays with the counselor or other group partici- formation from the Internet every day. The Web
pants. In this role playing, the women would face can deliver high-quality health information and
increasingly difficult challenges to their insistence interventions to promote behaviors that improve
on condom use, learn strategies for meeting these health. Moreover, online interventions can be de-
challenges, and practice using those strategies. livered to individuals who might not have access
The women might also be taught to determine when to in-person programs either because none are
it is useless to argue any longer and skills for remov- available in their area or because they cannot af-
ing themselves from unsafe sexual encounters. ford them. Over half the population of most indus-
Guided mastery techniques were used success- trialized countries has access to the Internet, and
fully in a program with African American women the majority of Internet users say they get health
called Sister-to-Sister: The Black Women's Health information off the Web (Vandelanotte, Spathonis,
Project Intervention (Jemmott, Jemmott III, & Eakin, & Owen, 2007). Controlled studies of the
O'Leary, 2007). In five short interventions, nurses effectiveness of these interventions offer hope that
gave women information about the cause, trans- they can be effective in helping people change
mission, and prevention of sexually transmitted their behaviors and improve their health.
diseases (STDs). The women then participated in Many Internet-based behavioral interventions
guided mastery exercises to increase their skills aim to increase people's exercise and improve their
and self-confidence for negotiating condom use by diet. Regular physical exercise significantly de-
their male partners. The women also learned to creases the risk of cardiovascular disease, diabetes,
eroticize condom use by incorporating putting on and several forms of cancer (Ehrman, Gordon,
condoms into foreplay and intercourse in ways that Visich, & Keteyian, 2009). Yet most people do not
increase positive attitudes toward their use. Com- exercise regularly. Similarly, while eating fresh
pared to women who received only information, fruits and vegetables every day reduces the risk of
without guided mastery exercises, these women developing several major illnesses, the diets of
showed greater confidence in negotiating condom people around the world increasingly are filled
use and a stronger intention to use condoms with high-fat, high-sugar, low-nutrition foods
(O'Leary, Jemmott, & Jemmott III, 2008). Most im- (Brownell & Horgen, 2004). As a result, obesity
portant, the program resulted in lower sexual risk rates are skyrocketing, especially in developed
behavior and lower incidence of STDs over the countries. Intensive, in-person programs can spur
12 months following it. people to increase their exercise and improve their
Cultural norms regarding health behaviors diet. However, these programs are expensive,
can affect people's willingness to engage in them time-consuming, and unavailable to many people.
(Ajzen, 1991). Programs like the guided mastery The Internet provides the opportunity to deliver
program described above have been adapted to exercise and nutrition programs to large segments
address cultural norms that might encourage or of the population for a relatively low cost.
interfere with targeted health behaviors (Bandura, One such program was designed by General
2006). For example, a strong cultural value in many Electric to improve the health of its workforce
Hispanic groups is familism, or prioritizing the re- (Pratt et al., 2006). Employees were invited by e-mail
spect and care of one's family over one's individ- to participate in the program, which involved
ual needs. One study of Hispanic adolescents increasing their daily exercise to 10,000 steps or
adapted a guided mastery program to include dis- 30 minutes of moderate-intensity physical exer-
cussions of the impact of risky sexual behaviors on cise, eating five servings of fruits and vegetables a
the loved ones of the adolescents (Koniak-Griffin day, and losing weight if significantly overweight.
et al., 2008). The adolescents in this program were Participating employees completed an online as-
all teen parents, so the program materials focused sessment of their current behaviors and physical
on cultural values of parental protectiveness, us- needs. Based on their profile, they received regular
ing traditional teachings of Chicano, Latino, and e-mails about their progress in the program, as
Native American ancestors. The adolescents who well as e-newsletters with health tips and case
received this culturally adapted intervention studies of employees who had made major life-
showed greater increases in condom use than a style changes. They were given phone and e-mail
comparison group of adolescents who received access to nutrition and fitness coaches who could
only general information about HIV prevention. answer their questions and provide personalized
advice. Participants discussed exercise and diet in disease, than other people (Ohayon, Smolensky, &
chat rooms. The Weight Watchers program was Roth, 2010).
made available online. The company even created Sleep deprivation also has many psychological
a "video reality series" that followed two employ- effects: It impairs memory, learning, logical reason-
ees who were participating in the program. ing, arithmetic skills, complex verbal processing,
An evaluation of 2,498 employees across 53 and decision making. For example, reducing your
nations who participated in the program for about amount of sleep to 5 hours each night for only
8 months showed that these employees signifi- 2 nights significantly reduces performance on math
cantly increased their physical activity and their problems and creative-thinking tasks. This means
consumption of fruits and vegetables (Pratt et al., that staying up to study for exams for only a couple
2006). They also lost an average of 4 to 5 pounds of nights can significantly impair the ability to do
over the duration of the program. well on those exams (Wolfson, 2010). Sleep depri-
A review of 15 Internet-based programs de- vation also causes irritability, emotional ups and
signed to improve both physical activity and diet downs, and perceptual distortions, such as mild
found that the majority resulted in positive out- hallucinations (Harvey, 2008).
comes for participants compared to control groups Sleep deprivation can literally kill. Each year
(Vandelanotte et al., 2007). Gains tend to be rela- in the United States, almost 20 percent of all seri-
tively modest, and they are short-lived if the pro- ous car-crash injuries are due to driver sleepiness.
grams are not continued. Across thousands or Over half of automobile drivers admit to having
even millions of people, however, the potential driven when drowsy at least once in the past year,
public health impact of these programs is great. and 28 percent say they have fallen asleep at the
wheel (National Sleep Foundation, 2009). Medical
professionals work longer hours than members of
SLEEP AND HEALTH almost any other profession, and as many as
Getting enough sleep is critically important to 98,000 deaths occur annually in the United States
health. People who sleep fewer than 6 hours each due to medical errors-many associated with sleep
night have a 70 percent higher mortality rate than deprivation. Some of the most serious disasters in
those who sleep at least 7 or 8 hours each night modern history have been the result of mistakes
(Ikehara et al., 2009; Kryger, Roth, & Dement, made by sleepy people (Mitler & Miller, 1995). In
1994). This is true for both men and women, for 1979, the worst nuclear plant accident in the United
people of many ethnicities, and for people with States occurred when fatigued workers at Three
many different health backgrounds. Lack of sleep Mile Island failed to respond to a mechanical prob-
weakens the immune system (Cruess et al., 2003; lem at the plant. In 1986, the world's worst nuclear
Irwin et al., 2008). Among middle-aged adults, disaster happened in Chernobyl in Ukraine (then
those who sleep less show greater development of part of the Soviet Union) during a test conducted
heart disease over time (King et al., 2008). People by an exhausted team of engineers. In 2008, a Boston
who work rotating shifts have higher rates of illness, trolley car crashed into a stopped trolley after the
including cardiov ascular and gastrointestinal driver of the first vehicle ran a red light; the
National Transportation Safety Board concluded
that the driver went into a "microsleep"-falling
asleep for only a few seconds-resulting in the
crash and her death (Ahlers, 2009).
It is frightening to realize that sleep depriva-
tion is so widespread. Over half of Americans say
they chronically feel sleep deprived (National
Sleep Foundation, 2009); about 9 percent of men
and 13 percent of women say they are chronically
severely sleepy (Ohayon, 2012). Young adults
need, on average, 9.2 hours of sleep each day. Yet
most young adults sleep 7.5 or fewer hours each
day (National Sleep Foundation, 2009). Similarly,
most middle-aged adults need at least 7 or 8 hours
of sleep each day, but most get fewer than 7 hours.
People who work rotating shifts or in jobs de-
Busy students are often sleep deprived. manding long periods of activity, such as nurses,
doctors, firefighters, police, and rescue personnel,
Sleep and Health 449
Assessing Sleep
What is sleep? Analysis of brain-wave activity sug-
gests that there are five stages of sleep: four differ-
ing depths of sleep and a fifth stage known as
rapid eye movement (or REM) sleep (Figure 15.4).
When a person closes his or her eyes and relaxes,
the brain waves characteristically show a regular
pattern of 8 to 12 hertz (cycles per second); these
are known as alpha waves. As the individual drifts
into Stage 1 sleep, the brain waves become less
regular and have lower amplitude. Stage 2 in-
cludes spindles-short runs of rhythmical re-
sponses of 12 to 16 hertz-and an occasional sharp
rise and fall in the amplitude of the entire EEG (re-
ferred to as a K-complex). The still deeper Stage 3
and Stage 4 are characterized by slow waves of 1 to
2 hertz, known as delta waves.
After an adult has been asleep for an hour or
so, the EEG becomes very active. Electrodes near
EEG Recordings During Various Stages

FIGURE 15.4
of Sleep. The awake stage (relaxed with
eyes closed) is characterized by alpha waves
(8 to12 hertz). Stage 1 is basically a transition from wakefulness to
the deeper stages of sleep. Stage 2 is defined by the presence of
sleep spindles (brief bursts of 12- to 16-hertz waves) and
K-complexes (a sharp rise and fall in the brainwave pattern). Stages
3 and 4 are marked by the presence of delta waves (1 to 12 hertz),
This train crash in Boston occurred when the driver fell and the only difference between these two stages is the amount of
asleep for only a few seconds .
delta waves found . Stage 3 is scored when 20 to 50 percent of the
record contains delta waves, and Stage 4 when the percentage of
delta waves is 50 percent or more.
often are chronically sleep deprived (Chatzitheochari
& Arber, 2009). Even when they have time to sleep,
they have trouble falling asleep because their body's Awake
natural rhythms have been disrupted by their ir-
regular schedule. The effects of sleep deprivation
are cumulative. A person builds up an increasing
"sleep debt" for every 24-hour period in which he Stage 1
or she does not get adequate sleep (Wolfson, 2001).
Stress is a frequent contributor to sleep prob-
lems. A 2009 poll taken during a period of eco- Stage 2
nomic crisis found that one-third of Americans
were losing sleep over the state of the U.S. econ-
omy and personal financial matters (National
Stage 3
Sleep Foundation, 2009). In general, Americans are
sleeping less while trying to cram more and more
into the day, including multiple jobs, exercise, so-
cializing, and school. Similar patterns are found in Stage 4
other developed countries, including Great Britain
(Chatzitheochari & Arber, 2009). Over the past cen-
tury, the average night's sleep time in these societ-
REM sleep
ies has declined more than 20 percent (National
Sleep Foundation, 2009).
the person's eyes detect pronounced rapid eye other disorders, perhaps in part because people
movements. This stage is known as REM sleep; the who are sleep deprived are more emotionally reac-
other four stages are known as non-REM (or NREM) tive and have more difficulty regulating their emo-
sleep. The stages alternate throughout the night, be- tions. They also have more difficulty functioning in
ginning with the NREM stages. Several sleep cycles their daily life due to decreased concentration and
occur, each containing some REM and some NREM performance, leading to the further accumulation
sleep. There usually are four or five distinct REM of stressors (Harvey, 2008).
periods over the course of an 8-hour night's sleep, Sleep disorders also often result from the
with an occasional brief awakening as morning ar- physiological effects of a medical condition. Many
rives. Dreaming occurs during REM sleep. medical conditions can disturb sleep, including
The pattern of the sleep cycles varies with a degenerative neurological illnesses, such as
person's age. Newborn infants, for instance, spend Parkinson's disease; cerebrovascular disease, in-
about half their sleeping time in REM sleep. This cluding strokes; endocrine conditions, such as
drops to 20 to 25 percent of total sleep time by age hypo- or hyperthyroidism; viral and bacterial in-
5 and remains fairly constant until old age, when it fections, such as viral encephalitis; pulmonary dis-
drops to 18 percent of total sleep time or less. Older eases, such as chronic bronchitis; and pain from
people tend to experience less Stage 3 and Stage 4 musculoskeletal diseases, such as rheumatoid
sleep (sometimes these stages disappear) and more arthritis or fibromyalgia (Wolfson, 2001). In addi-
frequent and longer nighttime awakenings (Liu & tion, substances such as illicit drugs, alcohol, or
Ancoli-Israel, 2006). prescription drugs can lead to many sleep distur-
A comprehensive assessment of how people bances; in such cases, the diagnosis is substance-
sleep can be obtained by a polysomnographic (PSG) induced sleep disorder.
evaluation. This requires individuals to spend one
or more nights in a sleep lab, connected to instru- Insomnia
ments that measure respiration and oxygen desat- Probably the most familiar sleep-wake disorder is
uration (a measure of airflow), leg movements, eye insomnia disorder-chronic difficulty initiating or
movements, brain-wave activity, and heart activity maintaining sleep or sleep that does not restore en-
(Buysse et al., 2006). An alternative is for individu- ergy and alertness. People with insomnia usually
als to wear a wristwatchlike device called an acti- report a combination of difficulty falling asleep and
graph, which records movement (Morgenthaler et intermittent wakefulness during the night.
al., 2007). The data it gathers can be compared to Occasional problems with insomnia are ex-
known patterns of movement during sleep to de- tremely common, with up to 50 percent of adults
termine when individuals are awake or asleep. reporting they have had insomnia at some time in
These methods of assessing sleep are objective their life and one in three adults complaining they
and detailed, but they also are expensive and re- have had insomnia in the past year (National Sleep
quire special equipment. More frequently, people Foundation, 2009). Episodic insomnia is defined as
are asked to keep a detailed diary of their sleep difficulty falling asleep or staying asleep that lasts
patterns (what time they go to bed, when they only a few days and is an isolated occurrence
awaken during the night, and when they get up in (Wolfson, 2001) . This difficulty is often tied to a
the morning). Questionnaires may be used to as- specific stressor, such as facing a major exam or
sess people's sleep patterns even more quickly. being in an unfamiliar place, and it stops once the
stressor has passed.
To receive the diagnosis of insomnia disorder,
Sleep Disorders the symptoms of insomnia must occur at least
Some people experience so much difficulty sleep- three nights per week for at least 3 months, and the
ing that they may be diagnosed with a sleep-wake sleep disturbance must cause significant distress
disorder. Disturbances in sleeping or staying awake or impairment in functioning (Table 15.2). Chronic
can occur for many reasons. They may be the result insomnia affects 10 to 15 percent of adults and is
of another psychological disorder. In particular, in- more frequent in women than in men and more
somnia is a symptom of unipolar depression and common in older adults than in younger adults
co-occurs at high rates in bipolar disorder, schizo- (Wolfson, 2001; Zhang & Wing, 2006).
phrenia, attention-deficit/hyperactivity disorder, When we fall asleep and when we awaken are
the anxiety disorders, and substance use disorder strongly influenced by our biological rhythms, par-
(Harvey, 2008). The symptoms of these disorders, ticularly body temperature rhythms (Lack et al.,
such as anxiety, can make it difficult to sleep. In 2008). When we are on a schedule of sleeping at
tum, insomnia can worsen the symptoms of these night and being awake and active during the day,
TABLE 15.2 DSM-5 Criteria for Insomnia Disorder
A. A predominant complaint of dissatisfaction with sleep quantity or quality associated with one (or more) of
the following symptoms:
1. Difficulty initiati ng sleep. (I n children, this may be manifested as d ifficulty in itiating sleep w ithout
caregiver intervention .)
2. Difficulty maintaini ng sleep, characterized by f requent awakenings or problems returning to sleep after
awakenings. (In children t his may be manifested as difficulty returni ng to sleep without caregiver
intervention.)
3. Early-morning awakening with inabil ity to retu rn to sleep .
B. The sleep disturba nce causes clinically sig nificant distress or impairment in socia l, occupationa l,
educationa l, academic, behavioral, or other important areas of fu nctioning.
C. The sleep difficulty occurs at least 3 nights per week.
D. The sleep d ifficulty is prese nt fo r at least 3 m o nths.
E. The sleep d ifficul ty occurs despite adequate opportun ity to sl eep.
F. The insom nia is not better explained by and does not occur exclusively during the cou rse of another sleep-
wake disorder, a parasomnia).
G. The insom nia is not attributable to t he physio logica l effects of a substance (e. g., a drug of abu se, a
medication}.
H. Coexisting mental disorders and medical condi ti ons do not adequate ly explain the predomina nt co m plaint
of insomnia.
Specify if:
W ith no n-sleep disorder mental comorbidit y, incl ud in g substance use disorders
W ith other medical comorbidity
Wit h other sleep disorder
American Psychiatric Associat ion .
our core body temperature typically reaches its min- about whether they will sleep. They may moni-
imum between 4 and 6 A .M .; falling asleep is easiest tor the clock while trying to fall asleep, worrying
5 to 6 hours before that minimum is reached (be- more as time passes (Tang, Schmidt, & Harvey,
tween about 11 P.M. and 1 A.M.) . Awakening usually 2007). This worry creates a cognitive and physi-
occurs 1 to 3 hours after the minimum core body ological arousal that keeps them awake. Second,
temperature is reached. Some people have disrup- they are hypervigilant for things that might keep
tions in this body temperature rhythm that interfere them aw ake, such as noises in the environment
with their ability to fall asleep in the late evening or or bodily aches and pains (Semler & Harvey,
to stay asleep in the early morning (Lack et al., 2008). 2007). Third, they believe they get less sleep than
Any major stressor can trigger an episode of in- they do and attribute daytime problems to their
somnia, including relationship difficulties, job loss, insomnia. This cognition feeds their anxiety about
the death of a loved one, and financial problems their insomnia. Fourth, they engage in counterpro-
(Wolfson, 2001). In a vicious cycle, this episodic in- ductive behaviors to try to help themselves sleep.
somnia can become chronic insomnia. The longer They may drink alcohol, which can exacerbate
the person lies in bed unable to go to sleep, the more insomnia, or avoid social engagements at night,
distressed and restless he or she becomes. The per- which leaves them with more time alone to worry.
son's wakefulness then becomes conditioned to the Cognitive-behavioral interventions for insomnia
environment-to the bed and bedroom-leading to can be highly effective (e.g., Bastien et al., 2004;
even more difficulty sleeping the next night. Harvey, McGlinchey, & Gruber, 2010) . These
Cognitiv e factors help maintain insomnia interventions aim to reduce worries about sleep
(Harvey, 2005) . First, during the day and when ("I wonder if I'm going to have a bad night again
trying to sleep, individuals with insomnia worry tonight!"), unhelpful beliefs about sleep ("Waking
up during the night means I haven't slept well at Various medications are used in the treatment
all"), and rnisperceptions about the effects of sleep of insomnia, including antidepressants, antihista-
loss ("If I don't get 8 hours, I'll be a wreck tomor- mines, tryptophan, delta-sleep-inducing peptide
row!"). The behavioral component of these inter- (DSIP), melatonin, and benzodiazepines (Di.indar
ventions includes stimulus control, that is, et al., 2004). All these have proven effective in at
controlling conditions that might interfere with least some studies, although the number of studies
sleep (Morin et al., 2006). A person experiencing done on most of these agents is small. Those that
insomnia would be told to do the following: have the least clear benefit are antihistamines and
tryptophan (Lee, 2004; Nowell et al., 1998). Those
1. Go to bed only when sleepy.
that have proven most reliably effective are benzo-
2. Use the bed and bedroom only for sleep and diazepines and zolpidem (trade name Ambien).
sex, not for reading, television watching, Individuals can become dependent on these sleep
eating, or working. aids, however, and may experience withdrawal
3. Get out of bed and go to another room if you when they try to stop using them (Di.indar et al.,
are unable to sleep for 15 to 20 minutes, and 2004). Rare cases of sleep-eating have been re-
do not return to bed until you are sleepy. ported among users of Ambien-they get up dur-
4. Get out of bed at the same time each morning. ing the night and consume large quantities of food,
then don' t remember doing so in the morning
5. Don't nap during the day.
(Mahowald & Bornemann, 2006). Insomnia often
Sleep restriction therapy involves initially re- returns after individuals stop taking the medica-
stricting the amount of time insomniacs can try to tions. In contrast, the behavioral and cognitive in-
sleep in the night (Morin et al., 2006). Once they terventions tend to have long-lasting positive
are able to sleep when they are in bed, they are effects (Nowell et al., 1998).
gradually allowed to spend more time in bed. In
addition, people often are taught relaxation exer- Hypersomnolence Disorders
cises and are given information about the effects of and Narcolepsy
diet, exercise, and substance use on sleep. Hypersomnolence disorders are characterized by
excessive sleepiness, which can be expressed as an
excessive quantity of sleep (also referred to as
TABLE 15.3 DSM-5 Criteria for Hypersomnolence Disorder hypersomnia) or a low quality of wakefulness (see
Table 15.3). People with a hypersomnolence disor-
A. Self-reported excessive sleepiness (hypersomnolence) despite a main
sleep period lasting at least 7 hours, with at least one of the following der are chronically sleepy and sleep for long peri-
symptoms: ods. They may sleep 12 hours at a stretch and still
wake up sleepy. A nap during the day may last an
1. Recurrent periods of sleep or lapses into sleep w ithin the same day
hour or more, and they may wake up unrefreshed.
2. A prolonged main sleep episode of more than 9 hours per day that If their environment is not stimulating (e.g., dur-
is nonrestorative (i.e., unrefreshing)
ing a boring lecture), they are sure to fall asleep.
3. Difficulty being fully awake after abrupt awakening . They may even fall asleep while driving. To qual-
B. The hypersomnolence occurs at least three times per week, for at ify for a diagnosis, the hypersomnolence must be
least 3 months. present at least three times per week for at least
C. The hypersomnolence is accompanied by significant distress or 3 months and must cause significant distress or
impa irm ent in cognitive, social, occupational, or other important impairment in functioning. Hypersomnolence is a
areas of funct ioning. chronic condition that most often begins in early
D. The hypersomnolence is not better explained by and does not adulthood (Ali et al., 2009; Anderson et al., 2007;
occur exclusively during the course of another sleep disorder Vernet & Arnulf, 2009; Vernet, Leu-Semenescu,
(e .g., narcolepsy, breathing-related sleep disorder, circadian rhythm Buzare, & Arnulf, 2010). It is estimated that only
sleep-wake d isorder, or a parasomnia) . 1 percent of the population meet the full criteria for
E. The hypersomnolence is not attributable to the physiological effects a hypersomnolence disorder (Ohayon, Dauvilliers, &
of a substance (e.g ., a drug of abuse, a medication) . Reynolds, 2012).
Narcolepsy involves recurrent attacks of an ir-
F. Coexisting mental and medical disorders do not adequately explain
the predominant complaint of hypersomno lence.
repressible need to sleep, lapses into sleep, or naps
occurring within the same day. Sleep episodes gen-
erally last 10 to 20 minutes but can last up to 1 hour,
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition. Copyright 2013 American Psychi atric Association . and people with narcolepsy move into REM sleep
within a few minutes. Most people with narco-
lepsy experience cataplexy, usually characterized
Sleep and Hea lth 453
by episodes of sudden loss of muscle tone lasting

TABLE 15.4 DSM-5 Criteria for Narcolepsy
under 2 minutes, triggered by laughter or joking in
people who have had narcolepsy for a long time. A. Recurrent periods of irrepressible need to sleep, lapsing into sleep,
People with cataplexy may suddenly drop objects, or napping occurring within the same day. These must have been
buckle at the knees, or even fall to the ground, but occurring at least three times per week over the last 3 months.
they are not asleep-their hearing and awareness B. The presence of at least one of the following :
may be normal. More rarely, cataplexy may be
1. Episodes of cataplexy, defined as either (a} or (b), occurring at
characterized by spontaneous grimacing or jaw-
least a few times per month :
opening episodes with tongue thrusting and by
a. In individuals w ith long-standing disease, brief (seconds to minutes}
low muscle tone. These symptoms tend to occur in
episodes of sudden bilateral loss of muscle tone with ma inta ined
children who then go on to develop the more com-
consciousness that are precipitated by laughter or joking .
mon characteristics of cataplexy (Plazzi et al., 2011).
b. In children or in individuals within si x months of onset,
When people with narcolepsy awaken, they may
spo ntaneous grimaces or jaw-open ing episodes w ith tongue
experience brief periods when they can't move or thrusting or a global hypotonia, without any obvious emotional
speak, referred to as sleep paralysis. triggers.
There are tw o types of narcolepsy. The vast
2. Hypocretin deficiency, as measured using cerebrosp ina l fluid (CSF}
majority of people with symptoms of narcolepsy
hypocret in-1 immunoreactivity values (less than or equal to one-
with cataplexy lack cells in the hypothalamus that third of val ues obtained in hea lthy subjects tested using the same
secrete the neurotransmitter hypocretin, w hich assay, or less than or equal to 110 pgml} . Low CSF of hypocreti n- 1
promotes wakefulness (Mignot et al., 2002). In con- must not be observed in the context of acute brain injury,
trast, only a minority of people with symptoms of inf lammation, or infection .
narcolepsy w ithout cataplexy show low levels of 3. Nocturnal sleep polysomnography showing rap id eye movement
hypocretin (Dauvilliers et al., 2003). The DSM-5 (R EM} sleep latency less than or eq ual to 15 minutes, or a multiple
defines narcolepsy as a disorder (see criteria in sleep latency test showing a mean sleep latency less than or equa l
Table 15.4) and allow s for the specification of t o 8 minutes and two or more sleep-onset REM periods .
whether h ypocretin deficiency is involved as a
subtype diagnosis. Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental
Other biological factors have been implicated Disorders, Fifth Edition. Copyright 2013 American Psychiatric Association .
in hypersomnia and narcolepsy without cataplexy.
Low levels of histamine, another neurotransmitter
that promotes w akefulness, have been found in
people with these disorders (Kanbayashi et al., cessation of respiratory activity for brief periods of
2009; Nishino et al., 2009). Also, hypersomnia and time (20 seconds or more) yet do not have frequent
narcolepsy run in families, and specific genes have awakenings and do not tend to feel tired during the
been implicated in narcolepsy (Longstreth et al., day. Central sleep apnea occurs when the brain
2007). Hypersomnia often is related to other mental does not send the signal to breathe to the respira-
disorders, particularly depression (Harvey, 2008). tory system. It can be caused by central nervous
The stimulant modafinil is consistently effective system disorders, including cerebral vascular dis-
in the treatment of daytime sleepiness in individuals ease and head trauma; heart disease; and chronic
with narcolepsy or hypersomnia (Morgenthaler et opioid use (Ramar & Guilleminault, 2008). It also
al., 2007). Other stimulants, including amphet- occurs in premature infants. The first line of treat-
amines, methamphetamine, and methylphenidate, ment is to treat the underlying disorder leading to
are also used as treatments for daytime sleepiness central sleep apnea. Sleep-related hypoventila-
due to narcolepsy or hypersomnia. Sodium oxybate tion, a new disorder in the DSM-5, is characterized
and selegiline can reduce cataplexy, hallucinations, by episodes of decreased breathing associated with
and sleep paralysis in narcolepsy. In addition, some high carbon dioxide levels. It is frequently associ-
physicians prescribe antidepressants, but their effec- ated with lung disease or diseases of the chest wall
tiveness in treating narcolepsy or hypersomnia has (Casey, Cantillo, & Brown, 2007).
not been shown in controlled studies (Morgenthaler The most common breathing-related sleep dis-
et al., 2007). order is obstructive sleep apnea hypopnea syn-
drome. As noted above, apneas are brief episodes of
Sleep-Related Breathing Disorders complete cessation of breathing. Hypopneas are
It's difficult to sleep well if you can't breathe well. episodes of abnormally shallow breathing or a low
The DSM-5 recognizes three sleep disorders related respiratory rate. To meet the criteria for this diagno-
to problems in breathing (see Table 15.5). People sis, an individual has to have evidence from poly-
w ith central sleep apnea experience complete somnograph tests show ing frequent apneas or
454 Chapter 15 Health Psycho logy
TABLE 15.5 DSM-5 Criteria for Sleep-Related Breathing Disorders
Disorder DSM-5 Criteria
Central Sleep Apnea A. Evidence by polysomnography of five or more central apneas per
hour of sleep.
B. The disorder is not better explained by another current sleep disorder.
Sleep-Related Hypoventilation A. Polysomnography demonstrates episodes of decreased respiration
associated with either C0 2 levels (Note: In the absence of objective
measurement of C0 2 , persistent low levels of hemoglobin oxygen
saturation unassociated with apneic/hypopneic events may indicate
hypoventilation.)
B. The disturbance is not better explained by another current sleep disorder.
Obstructive Sleep Apnea/ Either ( 1) or (2):

Hypopnea 1. Evidence by polysomnography of at least five obstructive apneas or
hypopneas per hour of sleep and either of the following sleep symptoms:
a. Nocturnal breathing disturbances: snoring, snoring/gasping, or
breathing pauses during sleep.
b. Daytime sleepiness, fatigue or unrefreshing sleep despite sufficient
opportunities to sleep that is not better explained by another
mental disorder (including a sleep disorder) and is not attributable
to another medical condition.
2. Evidence by polysomnography of 15 or more obstructive apnea and/or
hypopneas per hour of sleep regardless of accompanying symptoms.
Specify current severity:

Mild: Apnea hypopnea index is less than 15.
Moderate: Apnea hypopnea index is 15-30.
Severe: Apnea hypopnea index is greater than 30.
hypopneas (see Table 15.5 for frequencies). People structive sleep apnea and hypopnea, but 25 to
with this disorder may snore loudly, go silent 50 percent of people reject it because it makes
and stop breathing for several seconds at a time, them uncomfortable or does not offer sufficient
and then gasp for air. Obstructive sleep apnea/ relief from their breathing problems (Veasey et al.,
hypopnea occurs when airflow is stopped due to a 2006). CPAP also is sometimes used to treat central
narrow airway or an obstruction (an abnormality sleep apnea.
or damage) in the airway. While associated with Drugs that affect the serotonin system, in-
obesity, hypertension, and diabetes, it also can occur cluding the serotonin reuptake inhibitors, have
in tonsillitis and other disorders that cause shown mixed effects in the treatment of obstruc-
inflammation in the airway (Ramar & Guilleminault, tive sleep apnea/hypopnea; stimulants such as
2008). It occurs in up to 10 percent of the population modafinil can reduce the daytime sleepiness
and can begin at any point in the life span. associated w ith the disorder (Veasey et al., 2006).
Obstructive sleep apnea/hypopnea syndrome Surgery to remove obstructive tissue blocking
can be treated with a device called a continuous the airway or to increase the upper airway area
positive air pressure (CPAP) machine. The CPAP can be done in extreme cases, but meta-analyses
machine delivers a stream of compressed air via a of the small number of studies on the effective-
hose to a nasal mask, keeping the airway open un- ness of such surgeries do not show them to be
der air pressure so that unobstructed breathing is consistently effective in treating the disorder
possible. CPAP is an effective treatment for ob- (Franklin et al., 2009).
TABLE 15.6 DSM-5 Criteria for Circadian Rhythm

Sleep-Wake Disorders
A. A persistent or recurrent pattern of sleep disruption that is primarily due

to an alteration of the circadian system or to a misalignment between
the endogenous circadian rhythm and the sleep-wake schedule
required by an individual's physical environment social or professional.
B. The sleep disruption leads to excessive sleepiness or insomnia, or both .
C. The sleep disturbance causes cl inically significant distress or impairment
in social, occupational, or other important areas of functioning .
Specify whether:
Delayed Sleep Phase Type: A pattern of delayed sleep onset and
awakening times, w ith an inability to fall asleep and awaken at a desired
or conventionally acceptable earl ier time
Specify if:
Familial: A family history of delayed sleep phase is present.
Specify if:
Overlapping with non-24-hour sleep-wake type: De layed sleep phase
type may overlap with another circadian rhythm sleep-wake disorder,
non 24-hour sleep-wake type.
Advanced Sleep Phase Type: A pattern of advanced sleep onset and
The CPAP mac hine helps peop le with breathing- awaken ing times, with an inabi lity to remain awake or asleep until the
related sleep patterns. desired o r conventionally acceptable later sleep or wake times
Specify if:
Familial: A family history of advanced sleep phase is present.
Irregular Sleep-Wake Type: A tempora lly disorganized sleep and wake
Circadian Rhythm Sleep-Wake Disorders pattern, such that the timing of sleep and wake periods is variable
As noted, insomnia can be ca used b y disrup- throughout the 24-hou r period
tions in biological rh ythms, especially core bod y Non-24-Hour Sleep-Wake Type: A pattern of sleep and wake cycles that is
temperature. These biological rhythms, als o not synchronized to the 24-hour environment, w ith a consistent da ily
know n as circadian rhythms, are driven b y mech- d rift (usua lly to late r and late r times) of sleep onset and t imes
anisms in the brain that keep p eople in sync Sh ift Work Type: Insomnia during the major sleep period and/or
w ith the regular patterns of light and dark over excessive sleepiness (includ ing inadvertent sleep) during the maj or
the course of the d ay. These mechanisms are lo- awake period associated with shift wo rk schedule (i.e., requiring
cated in a part of the hypothalamus called the unconventional wo rk hours)
superchiasmatic nucleus and modulate d aily Unspecified type
rhythms in many systems of the body, including Specify if:
sleep and alertness (Sack et al., 2007) . Circadian Episodic: Symptoms last at least 1 month but less than 3 months.
rhythms are on a roughly 24-hour clock but can Persistent: Symptoms last 3 months or longer.
be affected by environmental time signals, espe- Recurrent:Two or more episodes occur within the space of 1 year.
cially the solar light / dark signal. Some people
h ave more difficulty than others in adjusting Source: Reprinted w ith permission from the Diagnostic and Statistical Manual of Mental
their circadian rhythms after a disruption . Indi- Disorders, Fifth Edition. Copyright 2013 American Psychiatric Association.
vidual differene'e s appear to have genetic roots
(Sack et al., 2007). If sustained and distressing,
su ch d ifficulty can be diagnosed as a circadian
rhythm sleep-wake disorder (Table 15.6). (Wolfson, 2001). Delayed sleep phase type circa-
The DSM-5 recognizes five circadian rhythm dian rhythm disorder is diagnosed only when it
sleep-wake disorders. Delayed sleep phase type seriously interferes with the person's functioning
involves a persis\:en\: pa\:\:ern o~ d.elayed. sleep on- anc\ causes c\is'n:ess. l\ \.s \"he most common c.'l:rc.a-
set and awakenings and an inability to go to sleep dian rhythm disorder diagnosed in clinical set-
or w ake up earlier if desired. Adolescents typically tings (Dagan & Eisenstein, 1999).
experience a phase in their biological clock that In contrast, advanced sleep phase type involves a
makes them want to stay up late and sleep late persistent pattern of sleep onset and awakenings that
are 2 or more hours earlier than desired. This pattern Finally, shift work type circadian rhythm sleep-
results in symptoms of early-morning insomnia and wake disorder is caused by working rotating shifts
excessive sleepiness during the day. Individuals or irregular hours. In one study, 31 percent of
with this disorder show evidence of earlier timing of night workers and 26 percent of rotating shift
circadian biomarkers, including melatonin and core workers met the criteria for this disorder (Drake
body temperature changes (Sack et al., 2007). et al., 2004).
People with irregular sleep-wake type do not have Behavioral interventions can help treat circa-
a discernable sleep-wake rhythm. Their sleep tends dian rhythm sleep-wake disorders. It is easier to
to be fragmented into at least three periods per stay up late than to go to sleep early, so rotating
24 hours; they may have insomnia during the night shift workers can more easily move their shifts
but be very sleepy during periods of the day. This clockwise than counterclockwise (Sack et al.,
disorder can be associated with neurological disor- 2007). Planned napping during night shifts also
ders (Sack et al., 2007). People with non-24-hour type can help reduce worker sleepiness and associ-
circadian rhythm sleep-wake disorder appear to ated accidents (Sallinen et al., 1998). Exposing
have a free-running sleep-wake cycle that is not en- shift workers to bright light during night shifts
trained by the light-dark cycle. It may begin with a can help shift their circadian rhythms (Sack et al.,
gradual movement of the onset of sleep to later and 2007). Similarly, exposing individuals with the
later at night until the individual sleeps during the delayed sleep phase type disorder to bright lights
day and is awake at night. Individuals with this dis- early in the morning can help shift their circa-
order complain of sleepiness during daylight and dian rhythms.
show deficits in cognition and functioning. The dis- Administering melatonin at prescribed times
order has been most frequently documented in peo- during the day has been shown to enhance the
ple who cannot see, but it also has been documented shifting of circadian rhythms in individuals with
in sighted individuals (Hayakawa et al., 2005). the delayed sleep phase type and the shift work
type circadian rhythm sleep-wake disorders
(Sack et al., 2007). The dosage and timing of mel-
atonin administration are tricky, however, and
TABLE 15.7 DSM-5 Criteria for Non-Rapid Eye Movement can vary from one individual to another (Arendt,
Sleep Arousal Disorders 2009) . Stimulants, such as modafinil, can im-
prove alertness during night shifts and after
A. Recurrent episodes of incomplete awakening from sleep, usually
occurring during the first third of the major sleep episode
crossing time zones, as can caffeine (Arendt,
accompanied by either one of the following:
2009; Sack et al., 2007).
1. Sleepwalking: Repeated episodes of rising from bed during sleep and
Disorders of Arousal
walking about. Wh ile sleepwalking, the person has a blank, staring
face, is relatively unresponsive to the efforts of others to communicate
Disorders of arousal involve recurrent episodes
with him or her, and can be awakened only with great difficulty. of incomplete awakening from sleep that seem to
mix elements of wakefulness and NREM sleep
2. Sleep terrors: Recurre nt episodes of abrupt terror arousals from
sleep, usually beginning with a panicky scream. There is intense
(see Table 15.7). There are three types: sleep ter-
fear and signs of autonomic arousal, such as mydriasis, rors, sleepwalking, and confusional arousals.
tachycardia, rapid breathing, and sweating, during each episode . Sleep terror disorder occur most often in children
There is relative unresponsiveness to efforts of others to comfort (Neylan, Reynolds, & Kupfer, 2007). The sleeping
the person during the episode. child screams, sweating and w ith heart racing.
B. No or little (e .g., on ly a single visual scene) dream imagery is recalled. Unlike nightmares, which occur during REM
sleep, sleep terrors occur during NREM sleep.
C. Amnesia for the episode is present.
Children experiencing a sleep terror cannot be
D. The episodes cause clinically significant distress or impairment in easily awakened and usually do not remember
social, occupational, or other important areas of functioning . their sleep terrors on awakening. Adults can expe-
E. Coexisting mental and medical disorders do not explain the episodes rience sleep terrors as well. One large epidemio-
of sleepwalking or sleep terrors. logical study in Norway found that 2.7 percent of
F. Coexisting mental and medical disorders do not explain the episodes adults had experienced sleep terrors at least once
of sleepwalking or sleep terrors . in the last 3 months and that 1.0 percent experienced
sleep terrors at least once per week (Bjorvatn,
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Gronli, & Pallesen, 2010).
Disorders, Fifth Edition . Copyrig ht 2013 American Psychiatric Association. Like sleep terrors, sleepwalking disorder is
relatively common in children, with 15 to 30 percent
having experienced at least one episode (Neylan et
Slee p and Health 457
al., 2007). In the study in Norway, about 22 percent

TABLE 15.8 DSM-5 Diagnostic Criteria
of adults reported having sleepwalked at some time
for Rapid Eye Movement Sleep Behavior
in their lives, but only 1.7 percent reported sleep-
walking in the previous 3 months (Bjorvatn et al., Disorder
2010). Sleepwalking occurs during NREM sleep, so A. Repeated episodes of arousal during sleep
the person sleepwalking is not acting out a dream. associ ated with vocalization and/or complex
Sleepwalkers may respond to others' questions or moto r behaviors.
commands but cannot hold a conversation. They B. These be haviors arise during rapid eye
may engage in nocturnal eating, going to the kitchen moveme nt REM sleep and therefore usually
and eating food while asleep. They can injure occur m ore than 90 minutes after sleep onset,
themselves by running into furniture or thrashing are m o re f requent during the later portions of
about, especially if they are also experiencing a the sleep period, and uncommonly occur during
sleep terror (American Psychiatric Association, dayti me naps.
2000). Sleepwalkers are difficult to wake (although C. Upo n awakening from these episodes, the
doing so is not dangerous, as popularly believed). indivi dual is completely awake, alert, and not
People typically do not remember their sleepwalk- conf used or disoriented.
ing activity (Neylan et al., 2007). D. Either of the fo llowing:
Confusional arousals are episodes of incom-
1. REM sleep without atonia on
plete awakening during NREM sleep that do not
polysomnograp hic recording.
involve sleep terrors or sleepw alking. These epi-
sodes are relatively common in adults. The study 2. A history suggestive of REM sleep behavior
di sorder and an estab li shed synucleinopathy
in Norway found that nearly 7 percent reported
diagnosis (e .g., Parkinson's disease, multiple
episodes of confusional arousal occurring in the
system atrophy}
previous 3 months, with nearly 2 percent having
had an episode at least once per week (Bjorvatn E. The be haviors cause clinically sign ifica nt
et al., 2010). distress or impairment in social, occupational,
or other importa nt areas of (which may include
Sleepw alking and sleep terrors tend to run in
injury to self o r the bed partner}.
families (Szelenberger, Niemcew icz, & Dabrowska,
2005). Twin studies of sleep terrors show higher F. The distu rbance is not attributable to the
concordance rates among monozygotic twins than physiological effects of a substance (e.g ., a drug
of abuse, a medication} or another medical
among dizygotic twins, suggesting a genetic influ-
co ndition.
ence on sleep terrors (Hublin et al., 1997). Stress,
previous sleep deprivation, extreme fatigue, and G. Coexist ing mental and medical disorders do not
the use of sedative or hypnotic drugs have been exp lain the episodes .
associated with both sleep terrors and sleepw alk-
ing (Neylan et al., 2007) . Source: Reprinted with permission from the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition. Copyright
Antidepressants are sometimes used to treat 2013 American Psychiatric Association .
sleep terrors, w ith mixed results (Neylan et al.,
2007). A behavioral treatment involves waking a
child 30 minutes before the time of night he or she
typically would have a sleep terror or sleepwalk-
ing episode; after the child can go at least a week complex and often dangerous or violent behav-
without a night terror, the scheduled wakenings iors. They may appear to be acting out dreams and
are gradually ended . One study showed that such engaging in conversations w ith people in their
scheduled wakenings quickly reduced the fre- dreams. Most p eople engaging in violent behav-
quency of children's night terrors; in a 1-year iors report having vivid dreams at the time, often
follow-up after the scheduled w akenings ended, involving being attacked by a person or an animal
the reductions in sleep terror episodes were main- or protecting a loved one from harm (Ohayon et
tained (Durand & Mindell, 1999). al., 2010) . They may actually injure themselves or
their bed partner with their behaviors. About
4 percent of adults report ever having injured
Rapid Eye Movement Sleep themselves or another during sleep (Bjorvatn et al.,
Behavior Disorder 2010) . When behaviors during REM sleep are fre-
While sleepwalking, sleep terrors, and confusional quent and impairing, the individual may be diag-
arousals occur during NREM sleep, some people nosed with rapid eye movement (REM) sleep
become active during REM sleep, engaging in behavior disorder (Table 15.8).
A substantial percentage of people with REM disorder, alone or in combination with clonaze- ~
sleep behavior disorder develop neurodegenera- pam. In contrast, some antidepressants that influ-
tive diseases such as Parkinson's disease (Iranzo et ence levels of norepinephrine and serotonin,
al., 2006; Postuma, Gagnon, & Vendette, 2009). For including venlaxafine and mirtazapine, have been
example, one study found that the risk of develop- shown to worsen REM sleep behavior disorder, as
ing Parkinson's disease or a related neurodegen- can caffeine and chocolate when consumed in ex-
erative disease among people with REM sleep cess (Boeve et al., 2007).
behavior disorder was 65 percent over a 10-year
period (Schenck & Mahowald, 2003). Individuals
Nightmare Disorder
with REM sleep behavior disorder show abnor-
Over two-thirds of adults have had nightmares,
malities in dopamine functioning in the brain sim-
or terrifying dreams (Bjorv atn et al., 2010) . Peo-
ilar to those shown by people w ith Parkinson's
ple often awaken from nightmares frightened,
disease (see Chapter 8), even when they have not
sweating and with their heart racing. They may
yet developed any neurological symptoms (Boeve,
have vivid memories of the dream, which often
2010; Iranzo et al., 2010). In addition, the violent
involves physical danger. Nightmares are com-
behaviors characteristic of REM sleep behavior
mon among people who have recently experi-
disorder are comorbid with other sleep-wake dis-
enced a traumatic event (Krakow et al., 2007).
orders, including sleepwalking, sleep terrors, con-
Nightmares are more common in children than
fusional arousals, and obstructive sleep apnea
in adults, with 10 to 50 percent of children hav-
(Ohayon, Guilleminault, & Chokroverty, 2010),
ing a sufficient number of nightmares to disturb
suggesting that these disorders share some com-
mon causes. their parents (Neylan et al., 2007). For a diagnosis
of nightmare disorder, the nightmares must be
The drug most often used to treat REM sleep
frequent enough to cause significant distress or
behavior disorder is clonazepam, an atypical anti-
psychotic medication (Boeve et al., 2007). Melato- impairment in functioning (Table 15.9) . The epi-
nin also shows some efficacy in treating the demiologic study in Norway found that 2.8 per-
cent of adults have nightmares at least once per ~
week (Bjorvatn et al., 2010) . Cognitive-behavioral
interventions for nightmare disorder include de-
sensitizing individuals to their nightmares. The
TABLE 15.9 DSM-5 Criteria for
person records the content of the nightmare in
Nightmare Disorder detail and then reads it repeatedly while doing
relaxation exercises (Burgess, Gill, & Marks,
A. Repeated occurrences of exte nded, extreme ly 1998). Such interventions have been shown in
dysphoric, and we ll-remembered dreams that small controlled trials to reduce the frequency of
usually invo lve efforts to avoid threats to nightmares as w ell as the anxiety, depression,
survival, security, or physical integrity and t hat and sleeplessness associated w ith them. These
genera lly occur during t he second ha lf of the gains persisted in a 4-year follow-up (Grandi et
major sleep episode.
al., 2006).
B. On awakening from the dysphoric d reams, the
individua l rapidly becomes orie nted and alert.
Restless Legs Syndrome
C. The sleep disturbance causes clinically significant
distress or impairment in social, occupational, or
Imagine that you are lying in bed and having
other importa nt areas of fu nctioning . creeping, crawling, tingling, itching sensations in
your legs that are prominent enough to keep you
D. The nig htmare symptoms are not attri butable
awake. You feel as though you just have to move
to the physiolog ical effects of a substance (e.g ., a
drug of abuse, a medication).
your legs. You get up and walk around and shake
out your legs, and the sensations go away. But
E. Coexisting menta l and medical d isorders do not
then, when you go back to bed, if you don't soon
adequately explain t he predom inant complaint
go to sleep the creeping, crawling sensations are
of dyspho ric dreams.
back, and you just have to move again. This is the
nature of restless legs syndrome (RLS).
Source: Reprinted with permiss ion from the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition. Copyright Many people experience restless legs syn- ~
2013 American Psychiatric Association. drome occasionally, usually or only at night. In
order to be d iagnosed with RLS, the DSM-5
stipulates that the symptoms must be frequent
TABLE 15.10 DSM-5 Diagnostic Criteria for Restless Legs Syndrome
A. An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant
sensations in the legs, characterized by all of the following :
1. The urge to move the legs begins or worsens during periods of rest or inactivity.
2. The urge to move the legs is partially or totally relieved by movement.
3. The urge to move the legs is worse in the evening or at night than during the day, or occurs only in the
evening or at night.
B. The symptoms in Criterion A occur at least three times per week and have persisted for at least 3 months.
C. The symptoms in Criterion A are accompanied by significant distress or impairment in social, occupational,
educational, academic, behavioral, or other important areas of functioning.
D. The symptoms in Criterion A are not attributable to another mental disorder of medical cond ition
(e.g., arthritis, leg edema, peripheral ischemia, leg cramps) and are not better explained by a behavioral
condition (e.g., positional discomfort, habitual foot tapping).
E. The symptoms are not attributable to the physiological effects of a drug of abuse or medication
(e.g ., akathisia).
and severe enough to significantly interfere with a life-threatening or debilitating physical ill-
with sleep and cause fatigue, mental health ness are at a greatly increased risk for depression
problems, and difficulty functioning (Table 15.10). and other emotional problems. For these reasons,
Abou t 2 to 3 percent of the population have health psychologists begin with the assumption
RLS to this degree (Cho et al., 2009; Hening et that biology, psychology, and the social environ-
al., 2004; Winkelmann et al., 2005). People with ment have reciprocal influences on one another.
this syndrome have significantly higher ra tes of They then attempt to characterize these influences
depression and anxiety disorders than do peo- and determine their relative importance.
ple in the general population (Cho et al., 2009;
Winkelmann et al., 2005).
Specific genetic loci have been associated with
RLS (Winkelmann et al., 2007). Abnormalities in
the dopamine system also are associated with the Reciprocal Effects of Psychological,
disorder, and treatment with drugs that alter dopa- FIGURE 15.5 Social. and Biological Factors in
mine levels can be effective in treating it (Zintzaras Stress-Related Disorders
et al., 2010). Iron deficiencies also are associated
with the disorder, and reversal of iron deficiencies Soda! factors: Psychological factors:
reduces symptoms (Trotti & Rye, 2011). traumas, chronic stress, personality, health
cu lture behaviors, emotions
CHAPTER INTEGRATION
This chapter amply illustrates the effects of the
body, the mind, and the environment on one an-
other (Figure 15.5). Psychological and social factors
can have direct effects on the physiology of the Biological factors:
body and indirect effects on health by leading peo-
ple to engage in behaviors that either promote or
physiological stress response,
- - - - genetic predisposition to
disease, weakened organ
+----
systems
impair health. In turn, physical health affects peo-
ple's emotional health and self-concept. People
SHADES OF GRAY DISCUSSION (review p. 438)
At first g lance you might think that John's avoid- characteristic of Asian cultures. He enjoys talking
ance of thin king or talking about his cancer is an with his wife about their children and grandchil-
unhealthy way of coping. He is not drawing on dren and about v isiting friends and family. For
social suppo rt f rom his children or his co-workers. John, this may be a more acceptable means of
You might even wonder if he is living in denial of coping than overtly asking for support from peo-
his serious illness. But look closer. John appears ple other than his wife.
to be engaging in a subt ler form of social support
THINK CRITICALLY
We would like to believe that we can improve our o r heart disease. Although some studies have shown
health by changing our attitudes and reducing stress promise, many others show no effects of such inter-
in our lives. The self-help industry makes billions of ventions on the progression of disease. Given this
dollars each year selling th is hope to the public (see mixed evidence, do you think psycholog ists should or
www.pbs.o rg/thisemotionallife/perspect ive/self-help- should not offer psychosocial interventions to pa-
or-self-harm).Yet in this chapter you read about mixed t ients with cancer or cardiovascular disease? What
evidence in studies of whether psychosocial interven- should be the goals of such interventions? (Discussion
tions can affect the progression of diseases like cancer appears on p. 484 at the back of this book.)
CHAPTER SUMMARY
Three dimensions that affect the level of stress in Chronic stress is also associated with coronary
situations are uncontrollability, unpredictability, heart disease. The Type A behavior pattern, char-
and duration. acterized by a sense of time urgency, easily
The fight-or-flight response is a set of physiologi- aroused hostility, and competitive striving for
cal changes the body undergoes when it faces a achievement, predicts coronary heart disease.
threat. In the short term it is adaptive, but if it The component of Type A that is most predictive
pers ists for a long time it can cause damage to is hostility. Depression also is predictive of CHD.
the body, a condition called allostatic load. Guided mastery techniques help people increase
Psychological factors associated with poorer their positive health-related behaviors. The
health include pessimism and avoidance coping, Internet is being used to deliver guided mastery
while expressive writing and seeking social sup- interventions worldwide.
port are associated with better health . People Substance-induced sleep disorders are due to
with psychological disorders, especially depres- the use of substances, including both prescrip-
sion, are at increased risk for a number of physi- tion medications (e.g., medications that control
ca l health problems. hypertension or cardiac arrhythmias) and
The immune system protects us from disease by nonprescription substances (e.g ., alcohol
identifying and killing pathogens and tumor and caffeine) .
cells. Chronic, uncontrollable stress; pessimism; Insomnia is difficulty initiating or maintaining
and avoidance coping are associated with im- sleep or sleep that chronically does not restore
paired immune system functioning, and with energy and alertness. It can be caused by disrup-
worse health in individuals with cancer or HIV/ tions in body temperature rhythms, stress, and
A IDS. Whether interventions to reduce stress or faulty cognitions and habits concerning sleep.
improve cognitions about stress affect the pro- Cognitive-behavioral therapy is effective in treat-
gression of cancer is not clear, however. ing insomnia. A variety of medications also are
Key Terms 461
---.... prescribed for insomnia, but cognitive-behavioral type, irregular sleep-wake type, non-24-hour
therapy is the most effective treatment. sleep-wake type, and shift work type. Melatonin,
stimulants, light therapy, and behavioral tech-
Hypersomnolence is chronic excessive sleepi-
niques to change sleep habits are used to treat
ness as evidenced by either prolonged sleep epi-
circadian rhythm sleep-wake disorders.
sodes or daytime sleep episodes that occur
almost daily. Narcolepsy involves irresistible at- Disorders of arousal include sleep terrors, sleep-
tacks of sleep; people with narcolepsy also have walking, and confusional arousal. These syn-
(1) cataplexy or (2) recurrent intrusions of ele- dromes occur during NREM sleep .
ments of rapid eye movement (REM) sleep into
Rapid eye movement (REM) sleep behavior dis-
the transition between sleep and wakefulness.
order is characterized by activity, sometimes vio-
Stimulants are prescribed for people with hyper-
lent or injurious, during REM sleep. It is
somnia or narcolepsy.
associated with neurodegenerative diseases and
Sleep-related breathing disorders (central sleep can be treated with the atypical antipsychotic
apnea, obstructive sleep apnea/hypopnea syn- clonazepam .
drome, sleep-related hypoventilation) involve
Nightmare disorder involves frequent experi-
numerous brief sleep disturbances due to breath-
ences of nightmares during REM sleep .
ing problems. Continuous positive airway pres-
sure (CPAP) machines are used to treat Restless legs syndrome is characterized by eve-
obstructive sleep apnea. Obstructive sleep apnea ning or nighttime feelings of creeping, crawling,
also is sometimes treated with weight loss and/ and itching in the legs accompanied by a desire
or surgery. Serotonin reuptake inhibitors and to move the legs. It can be caused by abnorma li-
stimulants are sometimes prescribed . ties in the dopamine system and by iron deficien-
cies, and treatment with drugs designed to
Circadian rhythm sleep-wake disorder includes
reverse these factors can be effective.
delayed sleep phase type, advanced sleep phase
KEY TERMS
allostatic load 433 central sleep apnea 453
immune system 439 sleep-related hypoventilation 453
coronary heart disease (CHD) 442 breathing-related sleep disorder 453
hypertension 443 obstructive sleep apnea hypopnea syndrome 453
Type A behavior pattern 444 circadian rhythm sleep-wake disorder 455
guided mastery techniques 446 disorders of arousal 456
sleep disorders 450 sleep terror disorder 456
substance-induced sleep diso rder 450 sleepwalking 456
insomnia disorder 450 rapid eye movement (REM) sleep behavior
hypersomnolence disorders 452 disorder 457
narcolepsy 452 nightmare disorder 458
cataplexy 452 restless legs syndrome (RLS) 458
Mental Health
and the Law
CHAPTER OUTLINE
Mental Health Law Along the Shades of Gray

Continuum
Mental Health Care in the Justice System
Extraordinary People: Greg Bottoms,
Angelhead Chapter Integration
Civil Commitment Shades of Gray Discussion
Patients' Rights Think Critically
Competence to Stand Trial Chapter Summary
The Insanity Defense Key Terms
462
A person with mental health
problems is suspected of having
committed a crime
Lega l decision must be informed
A person with no mental health by menta l health experts
problems is suspected of having (mental health worker advises if DSM-5
committed a crime the individual is fit to stand trial diagnosis
Legal decision does not need to or should be considered not guilty of mental
take mental hea lth into account by reason of insanity) disorder
Mental health problems bring a A person with a diagnosed mental

person to the attention of the law, health disorder commits a crime
although the individual does not Legal decision must take the
have a diagnosis and has not diagnosis into account, but the
committed a crime diagn osis does not guarantee th at
Legal decision may place the the perso n will receive specific
individual in a mental healt h treatment under the law
facility involunta ri ly if he is a (The individual may or may not
danger to himself or others be found not guilty by reason of
insanity)
Think back to before you took this course, before you had a sense be associated with an increased risk of aggression or violence,
of how fuzzy our definitions and understanding of mental disor- we cannot know for certain whether this particular individual will
ders can be. Imagine yourself hearing a report on the news about be violent in the future.
a college student who posted videos of himself on You Tube rant- Whe n someone who appears to have mental health pro b-
ing about injustices done to him and then went on a shooting lems interacts w ith the judicia l system, these judgment calls be-
rampage on his col lege campus and was subsequently caught and come even mo re complex . The fuzziness in our d iagnostic criteria
jailed. Back then, you might have thought that it should have been and in our underst anding of mental disorders combines with the
obvious to campus authorities that there was something seriously difficu lt ethical and social issues these cases involve. A DSM-5
wrong with this person. Once the person was incarcerated, you diagnos is of a mental disorder does not ensure that an individual
might have thought the authorities shou ld simp ly determine w ill be treated in a particular way by t he law. For example, a di-
whether he had a mental disorder that caused him to be violent agnosed mental disorder is not enough to ensure that an indi-
and then take appropriate action. If his violence was the resu lt of a vidua l rece ives needed treatment and m ay not exonerate an
mental disorder, he should be given treatment to ove rcome the individua l w ho has committed a crime. Menta l hea lth law is fur-
mental disorder; if his violence was not due to a mental disorder ther compl icated by the fact that the laws co ncerning people with
but was voluntary and intentional, he should be incarcerated. menta l health prob lems vary from region to region and have
Now you understand that the situation is not that clear-cut. cha nged d ramatically over the past 50 years.
The DSM provides criteria for diagnosing mental disorders, but Th us, the fuzziness in our diagnostic systems that is inherent
whether a particular individual ' s behaviors meet those crite ria is in t he fact th at psycho log ical problems fall along a continuum,
often a judgment call. Furthermore, we are limited in our abi lity combined wi t h the fuzziness in laws and their applicat ion to peo-
to generalize from the research literature to individual cases. For ple with mental hea lth problems, means that a great deal of sub-
example, just because a person has a mental disorder that may jective judgme nt is involved in mental health law.
Mental Health Law Al ong the Continuum 463

464 Chapter 16 Mental Health and the Law
Greg Bottoms, Angelhead
Michael Bottoms was After he was exonerated for this murder,

driven to violent out- Michael was back home again, on high doses of
bursts by psychotic antipsychotic medications but delusional, believ-
beliefs that were ing that God spoke directly to him and that his
symptoms of schizo- family was evil. Indeed, he decided that his father
phrenia. He came to was the Antichrist and that, to save his family's
believe that any medi- souls, he had to kill them. One night, as his father
cations for his schizo- lay dying of cancer and his family slept behind
phrenia were part of a locked doors, Michael set the house on fire. He
conspiracy to control rode his bicycle to the end of the street, then sat
his mind and usually watching, expecting his family's souls to float past
refused them. His violence was often directed him on the way to heaven. The family escaped. As
toward his family, to the point that his brother they stood watching the firefighters try to extin-
Greg and his parents would lock their bedroom guish the fire, Mr. Bottoms told the other family
doors at night to prevent Michael from attacking members this was the best thing that could hap-
them in their sleep. As Greg Bottoms describes in pen, because now Michael could really be put
his book Angelhead (2000), the family tried to have away. In the next instant, however, he feared that
Michael institutionalized but was told they could Michael had been in the house and was dying in
not unless they proved he was an imminent dan- the fire. He tried to run into the house to look for
ger to himself or others. Michael, but the firefighters held him back.
Eventually, the family found an institution that Meanwhile, Michael rode up on his bicycle, non-
would take their insurance and placed Michael chalant. A police officer asked Michael if he could
there. He hated the place, though, refused his medi- ask him some questions, and Michael held out his
cations, and attempted suicide. This landed him in a hands for the handcuffs. Then he turned to his
state psychiatric hospital for a while. Later he "con- mother and asked her casually what she was going
fessed" to a murder he had not committed, having to make for breakfast. Michael confessed to setting
been convinced by the vo ices in his head that he the fire with the purpose of killing his family. He
was guilty. He was jailed, but DNA evidence proved was convicted for attempted murder and arson
Michael couldn't have committed the murder. and was sent to prison for 30 years.
Mental health professionals are asked regularly to mental disorder. Finally, we discuss how society
help families such as the Bottoms family deal with treats a person who has a mental disorder and is
the laws and social systems that guide the treat- convicted of a crime.
ment of people with psychological disorders. Fun-
damental questions about society's values confront
the personal wishes of people with mental disor-
CIVIL COMMITMENT
ders and their families: Does society have a right to In the best circumstances, people who need treat-
impose treatment on an individual who doesn't ment for a psychological disorder seek it them-
want it? Under what conditions should people be selves. They work with mental health professionals
absolved of responsibility for behaviors that harm to find medication and/ or psychotherapy to reduce
others? Should the diagnosis of a psychological their symptoms and keep their disorder under con-
disorder entitle a person to special services and trol. Many people who have serious psychological
protection against discrimination? problems, however, do not recognize their need for
This chapter explores how the law becomes treatment or may refuse treatment for a variety of
involved in the lives of people with mental health reasons. For example, Michael Bottoms believed the ~
problems, focusing first on when a person can be doctors treating him were part of a conspiracy and
committed to a mental health facility against his or refused to follow their prescriptions. A man experi-
her w ill. Then we examine how the law regards a encing a manic episode may enjoy many of the
person charged with a crime who might have a symptoms-the high energy, inflated self-esteem,
and grandiose thoughts- and not want to take about a person's mental health and whether the
medication that would reduce those symptoms. A criteria for commitment are met (Meyer & Weaver,
teenager who is abusing illegal drugs may believe 2006). Even attorneys who are supposed to be up-
that it is her right to do so and that there is nothing holding an individual's rights tend to acquiesce to
wrong with her abuse. Can these people be forced the judgment of mental health professionals, par-
to enter mental institutions and to undergo treat- ticularly if the attorney is court-appointed, as is
ment against their will? These are the questions we often the case.
address in this section. In the United States and many other coun-
tries, individuals must be judged to meet one of
the following criteria in order to be committed to
Criteria for Civil Commitment a psychiatric facility against their will: (1) grave
Prior to the mid-twentieth century, in the United disability, (2) dangerousness to self, or (3) danger-
States the n eed for treatment was sufficient cause ousness to others. In addition, most states require
to hospitalize people against their will and force that the danger people pose to themselves or to
them to undergo treatment. Such involuntary hos- others be imminent-in other words, if they are
pitalization is called civil commitment. All that not immediately incarcerated, they or someone
was needed for civil commitment was a certificate else will likely be harmed in the very near future.
signed by two physicians stating that a person Finally, all persons committed to psychiatric fa-
needed treatment and was not agreeing to it vol- cilities must be diagnosed with a mental disorder,
untarily. The person could then be confined, often although the definition of mental disorders or
indefinitely, without recourse to an attorney, a mental illnesses varies from state to state (Meyer
hearing, or an appeal (Meyer & Weaver, 2006). & Weaver, 2006). In particular, some states ex-
The need for treatment alone is no longer suf- clude substance abuse or dependence and mental
ficient legal cause for civil commitment in most retardation from their list of mental disorders or
states in the United States. This change came about mental illnesses.
as part of the patients' rights movement of the
1960s, which raised concerns about violations of Grave Disability
the personal freedoms and civil liberties of mental The grave disability criterion requires that people
patients. Opponents of the civil commitment probe so incapacitated by a mental disorder that they
cess argued that it allowed people to be incarcer- cannot provide for their basic needs of food, cloth-
ated simply for having alternative lifestyles or ing, and shelter. This criterion is, in theory, much
different political or moral values (Szasz, 1963, more severe than the need for treatment criterion
1977). Certainly, there were many cases in the for- because it requires that the person's survival be in
mer Soviet Union and other countries of political immediate danger because of a mental disorder.
dissidents being labeled mentally ill and in need of You might think that the grave disability crite-
treatment and then being incarcerated in prisons rion could be used to hospitalize homeless people
for years. There also were disturbing cases of the living on the streets who appear to be psychotic
misuse of civil commitment proceedings in the and unable to take care of their basic needs. In the
United States. In the 1860s, for example, Illinois winter of 1988, New York City Mayor Ed Koch in-
law allowed a husband to have his wife involun- voked the legal principle of parens patriae (sover-
tarily committed without evidence that she had eign as parent) to have mentally ill homeless
lost touch with reality or was dangerous. For ex- people taken to mental health facilities. Mayor
ample, Mrs. E. P. W. Packard was committed by Koch argued that it was the city's duty to protect
her husband for holding "unacceptable" and these mentally ill homeless people from the rav-
"sick" political or moral views (Weiner & Wettstein, ages of the winter weather because they were un-
1993). Mrs. Packard remained hospitalized for able to protect themselves. One of the homeless
3 years before winning her release; she then began people who was involuntarily hospitalized
crusading against civil commitment. was 40-year-old Joyce Brown, who subsequently
Procedurally, most states now mandate that was diagnosed with paranoid schizophrenia.
persons being considered for involuntary com- Brown had been living on the streets on and off for
mitment have the right to a public hearing, the years, resisting efforts by her family to get her into
right to counsel, the right to call and confront wit- psychiatric treatment. Brown and the American
nesses, the right to appeal decisions, and the right Civil Liberties Union contested her commitment
to be placed in the least restrictive treatment set- and won her release on the grounds that the city
ting. In practice, however, judges typically defer had no right to incarcerate Brown if she had no
to the judgment of mental health professionals intention of being treated (Kasindorf, 1988).
One legal precedent relevant to Joyce Brown's professionals judge that the person needs further ~
release was O'Connor v. Donaldson (1975). Kenneth treatment but the person does not voluntarily
Donaldson had been committed to a Florida state agree to treatment, they can go to court to request
hospital for 14 years. Donaldson's father origi- that the person be committed for a longer period
nally had him committed, believing that Donald- of time.
son was delusional and therefore a danger to
himself. At the time, Florida law allowed people Dangerousness to Others
to be committed if their mental disorder might im- Dangerousness to others is the third criterion
pair their ability to manage their finances or to under which people can be committed involun-
protect themselves against being cheated by oth- tarily. If a person with a mental disorder is going
ers. Throughout his hospitalization, Donaldson to hurt another person if set free, then society has
refused medication because it violated his Chris- claimed the right to protect itself. While this action
tian Science beliefs. The superintendent, Dr. J. B. may seem justified, the appropriateness of this
O'Connor, considered this refusal to be a symp- criterion rests on predictions of who will be dan-
tom of Donaldson's mental disorder. Even though gerous and who will not. It is exceedingly difficult
Donaldson had been caring for himself adequately to make such predictions accurately (Monahan &
before his hospitalization and had friends who of- Walker, 1990). We can all recall incidents in which
fered to help care for him if he was released from individuals with severe mental health problems
the hospital, O'Connor and the hospital continu- became violent and the media and public cried
ally refused Donaldson's requests for release. "How could we not have seen this coming?" In
Donaldson sued on the grounds that he had re- 2007, college student Seung-Hui Cho, who had
ceived only custodial care during his hospitaliza- been diagnosed with multiple mental disorders,
tion and was not a danger to himself. He requested shot and killed 32 people and wounded 17 others
to be released to the care of his friends and family. on the campus of Virginia Polytechnic University
The Supreme Court agreed, ruling that "a State
cannot constitutionally confine ... a nondanger-
ous individual, who is capable of surviving safely
in freedom by himself or with the help of willing
and responsible family and friends" (O 'Connor v.
Donaldson, 1975, p. 4).
In practice, however, most people involuntarily
committed because of grave disability do not have
the ACLU championing their rights or the personal
ability to file suit. Often, they are people with few
financial resources or friends . Their family mem-
bers may also have serious mental disorders. The
elderly mentally ill are especially likely to be
committed because of grave disability (Turkheirner
& Parry, 1992). Often, these people are committed
to psychiatric facilities because their families are
unable to care for them and there are not enough
less restrictive treatment facilities available in
their communities.
Dangerousness to Self
The criterion dangerousness to self is most often
invoked when it is believed that a person is im-
minently suicidal. In such cases, the person often
is held in an inpatient psychiatric facility for a few
days while undergoing further evaluation and
possibly treatment. Most states allow short-term
commitments without a court hearing in emer- Adam Lanza. who had previously exhibited behavior
gency situations such as this. All that is needed is potentially indicative of a mental d isorder, killed
a certification by the attending mental health 20 children and 6 adults before fatally shooting
himself at the Sandy Hook Elementary School in
professionals that the individual is in imminent Newtown, Connecticut.
danger to him- or herself. If the mental health
(also known as Virginia Tech). Professors and stu-

dents had raised alarms with university officials
because of Cho's disturbing writings and behav-
~ NBC NEWS
iors, and Cho had been investigated for stalking a
woman student. He was ordered by a court to un-
dergo outpatient treatment for his behaviors but
did not comply and was not forced to do so. In
2009, U.S. Army psychiatrist Major Nidal Hasan
shot and killed 13 people at Fort Hood, Texas.
Students and faculty at Walter Reed Hospital,
where Hasan trained, called Hasan's behavior
"disconnected, aloof, paranoid, belligerent, and
schizoid" (Zwerdling, 2009). Still, no one con-
nected the dots to predict that Hasan could be
a danger to others, and no action was taken to
remove him from his post.
If mental health professionals believe that an
individual may harm another person, they have a
duty to warn that person, even if this violates a cli-
ent's confidentiality. This duty to warn was estab-
lished in a decision in the case of Tarasoff v. Regents
of the University of California (1974). Tatiana Tarasoff Tragedies like the shootings by Seung-Hui Choat Virginia Tech University
was a student at the University of California at (pictured) and Adam Lanza at Sandy Hook Elementary School have led the
Berkeley in the late 1960s. A graduate student public to call for more intervention for troubled, potentially violent youth.
named Prosenjit Poddar was infatuated with
Tarasoff, who had rejected him. Poddar told his
therapist in the student counseling service that he Violence by People
planned to kill Tarasoff when she returned to cam-
with Mental Disorders
pus from vacation. The therapist informed the
campus police, who picked up Poddar for ques- Incidents such as the shootings discussed above
tioning. Poddar agreed to leave Tarasoff alone, and lead the public to believe that people with a mental
the campus police released him. Two months later, disorder are much more prone to violence than peo-
Poddar killed Tarasoff. Tarasoff's parents sued the ple without a mental disorder. They also lead to
university, arguing that the therapist should have public demands for more intervention with trou-
protected Tarasoff from Poddar. The California bled youth, regardless of whether they and their
courts agreed and established the precedent that parents want it. One group of researchers examined
therapists have a duty to warn persons who are the public's beliefs about the potential for harm to
threatened by their clients during therapy sessions self or others by youth with mental health problems
and to take actions to protect those persons (Meyer and the public's willingness to coerce these youth to
& Weaver, 2006). get treatment (Pescosolido et al., 2007). They asked
After Seung-Hui Cho's shooting rampage, of- over 1,100 adults to read vignettes depicting youth
ficials at Virginia Tech reevaluated their interpre- with attention-deficit/hyperactivity disorder
tation of federal privacy laws that had led them (ADHD), major depression, asthma, or "daily trou-
not to share information about Cho's behavior or bles." Many more youth with ADHD or major de-
diagnoses with concerned faculty and adminis- pression were perceived as somewhat likely or very
trators prior to the shooting. In 2008, the U.S. De- likely to be dangerous to themselves or others
partment of Education proposed changes in the (33 percent for ADHD, 81 percent for major depres-
regulations governing the balance between pro- sion), compared to youth with asthma (15 percent)
tecting students' privacy rights and public safety or "daily troubles" (13 percent). Over one-third of
in light of the Cho incident. Virginia Tech also the adults in the study were willing to use legal
was criticized for delays in warning the campus means to force the youth with major depression to
of danger once the shooting rampage began. get mental health treatment. Adults who labeled the
Since this incident, many universities have insti- youth with ADHD or major depression "mentally
tuted new policies and alarm systems to alert stu- ill" were twice as likely to see a potential for vio-
dents, faculty, and staff when a violent incident lence in these youth and five times more likely to
is erupting. support forced treatment, compared to adults who
didn't apply the label "mentally ill" to the youth. Likelihood of Violence.
These results suggest that the public associates di- FIGURE 16.1
The lines represent the
agnoses of mental disorders in youth with danger- percentage of patients
ousness and that a substantial portion of the public w ith or without a substance abuse problem
is ready to use the legal system to force youth with (SA), and the points represent community
mental disorders into treatment. comparisons with or without a substance
Are people with a mental disorder actually abuse problem, who committed a violent act
more prone to violence than those without a in the previous 10 weeks in this study.
mental disorder? Research suggests that the an-
swer is complex (Skeem & Monahan, 2011). In
25
one major study, researchers followed 1,136 men Patients with SA
and women with mental disorders for 1 year af-
ter they were discharged from a psychiatric hos- 20
pital, monitoring their self-reports of violent
behaviors, reports in police and hospital records,
..., 15
and reports by other informants, such as family c
Q)
u
members (Steadman et al., 1998). Serious violent Q;
Cl..
acts were defined as battery that resulted in 10

physical injury, sexual assaults, assaultive acts
that involved the use of a weapon, and threats
made with a weapon in hand. The former psychi- Comparisons---+
atric patients' records of violent activity were without SA
0
compared to those of 519 people living in the 10 20 30 40 50
same neighborhoods the patients lived in after weeks weeks weeks weeks weeks
their hospital discharge. This community group Time since discharge
was interviewed only once, at the end of the
year-long study, and was asked about violent be-
Source: Steadman et al., 1998.
havior in the past 10 weeks.
The likelihood that the former patients would
commit a violent act was strongly related to their
specific diagnosis and whether they had a sub-
stance abuse problem. About 18 percent of the for- violent act during the year of the study, compared
mer patients who had a diagnosis of a major to 3 percent of those with no substance abuse prob-
mental disorder (e.g., schizophrenia, major de- lem (Steadman et al., 1998). Although the overall
pression, some other psychotic disorder) without rate of violence in the community sample was
a history of substance abuse committed a serious lower than in the patient sample, this difference
violent act in the year following discharge, com- was statistically significant only when the research-
pared to 31 percent of those with a major mental ers considered violence committed by the former
disorder and a history of substance abuse and patients shortly after their discharge. By the end of
43 percent of those with a diagnosis of "other" that year, the former patients were no more likely
mental disorder (i.e., a personality or adjustment to commit a violent act than were the people in the
disorder) and a co-occurring substance abuse community comparison group.
problem (Steadman et al., 1998). The researchers The targets of violence by both the former pa-
were somewhat surprised to find that the former tients and the community members most often
patients were most likely to commit a violent act were family members, followed by friends and
in the first couple of months following their dis- acquaintances. The former patients actually were
charge and less likely to do so as the year wore on somewhat less likely than the comparison group to
(Figure 16.1). They suggested that patients might commit a violent act against a stranger (13.8 per-
still be in crisis shortly after their hospitalization cent of the acts committed by former patients com-
and that it may take some months for social sup- pared to 22.2 percent of the acts committed by the
port systems and treatment to begin to affect their comparison group).
behavior (Steadman et al., 1998). The rates of violence recorded in this study
The rate of violence in the community sample may seem high, for both the patient group and the
was also strongly related to whether individuals comparison group. The patient group probably
had a history of substance abuse. Eleven percent of represented people with more serious psychologi-
those with a substance abuse problem committed a cal disorders who were facing acute crises in their
lives. The comparison group consisted largely of Prevalence of Involuntary

people with low socioeconomic status living in
Commitment
impoverished neighborhoods. These contextual
factors may account for the relatively high rates of How often are people involuntarily committed to
violence in both groups. a psychiatric facility? The data necessary to an-
The researchers who conducted this study em- swer this question are sparse, but the available
phasized that their data show how inappropriate it studies suggest that about 25 percent of admis-
is to consider "former mental patients" to be a ho- sions to inpatient p sychiatric facilities in the
mogeneous group of people all prone to violence. United States are involuntary and that about 15 to
The presence of substance abuse problems was a 20 percent of inpatient admissions in European
strong predictor of violent behavior both in this countries are involuntary (Monahan et al., 2001).
group and in the group of people who had not Admissions to state and county mental hospitals
been mental patients. Moreover, the majority of are much more likely to be involuntary than are
people with serious mental disorders did not com- admissions to other types of hospitals (Table 16.1).
mit any violent acts in the year after their dis- In addition, 12 to 20 percent of patients of outpa-
charge, especially against random strangers, tient psychiatric facilities report having been or-
contrary to what media depictions of former men- dered by civil courts to participate in outpatient
tal patients often suggest. treatment (Monahan et al., 2005). Court orders for
Other research has suggested that violence by outpatient care were more common among indi-
mentally ill women tends to be underestimated by viduals who lived in residential psychiatric facili-
clinicians (Coontz, Lidz, & Mulvey, 1994; Robbins, ties and who had poor social support and poor
Monahan, & Silver, 2003). Clinicians do not expect psychosocial functioning, a recent history of vio-
mentally ill women to be violent to the same de- lent behavior, recent police encounters, substance
gree that they expect mentally ill men to be vio- abuse problems, and higher rates of lifetime hos-
lent. As a result, they do not probe mentally ill pitalizations and involuntary hospitalizations
women for evidence of a tendency toward vio- (Swartz, Swanson, Kim, & Petrila, 2006).
lence as much as they do mentally ill men. In real- The numbers in Table 16.1 probably underesti-
ity, however, mentally ill women and mentally ill mate the number of people coerced into mental
men are equally likely to commit violent acts health care treatment, because parents and legal
against others (Robbins et al., 2003). The victims of guardians often "volunteer" a protesting child or
mentally ill women's violent acts are most likely incompetent adult for admission (Monahan et al.,
to be family members; mentally ill men also are 2001). In one study, nearly 50 percent of the adults
most often violent toward family members, but admitted voluntarily to inpatient psychiatric
they commit violent acts against strangers more
often than do mentally ill women (Newhill, Mulvey,
& Lidz, 1995). Mentally ill men who commit vio-
lence are more likely to have been drinking before TABLE 16.1 Frequency of Involuntary Admissions
the violence and to be arrested following it than to Psychiatric Facilities
are mentally ill women who commit violence
(Robbins et al., 2003). These data indicate the percent of al l admissi on s to vario us types of
Racial stereotypes lead people to expect men- psychiatric facilities that involve invo luntary commitme nts. Data are
tally ill persons from ethnic minority groups to be f rom t he United St ates in 1986.
more likely to commit acts of violence than white
mentally ill people. However, there are no differ- Percent of All
Admissions That
ences between ethnic groups in the rates of violence Type of Facil ity Are Involuntary
among mentally ill people (Mulvey, 1995).
A review of 31 studies found that people with State and county hosp ita ls 61.6%
a mental disorder on average are more likely to Multiservice mental health organizatio ns
commit violent acts than are those without a m en- (e.g ., community mental hea lth centers) 46.1
tal disorder, with rates varying depending on a Private psychiatric hospitals 15.6
number of factors (Choe, Teplin, & Abram, 2008). Nonfede ral general hospitals 14.8
However, it is important to note that people w ith Vetera ns Adm inist ration hospitals 5. 6
mental disorders were more likely to be the victims
of violence than they were to be the perpetrators, Source : Mon aha n et al., 2001.
and also more likely to be victimized than people
without a mental disorder.
facilities reported that someone other than them- Marvin Swartz and colleagues (2010) evalu-
selves had initiated their going to the hospital, ated the outcomes for individuals involuntarily
and 14 percent of the patients were under the cus- committed to outpatient mental health care in
tody of someone else at the time of admission New York over an 8-year period. Compared to the
(Hoge, Poythress, et al., 1997; Segal, Laurie, & period before they were ordered to receive treat-
Franskoviak, 2004). Nearly 40 percent of the vol- ment, the involuntarily committed individuals
untary patients believed they would have been had fewer hospitalizations, were more likely to
involuntarily committed if they had not agreed to have an adequate supply of medication appropri-
be hospitalized. Some of the patients felt they had ate for their diagnosis, and were more likely to be
been coerced by their therapists, who did not in- receiving intensive management of their condi-
clude them in the admissions process. Patients tion. In addition, they had fewer hospitalizations
involuntarily committed often may need treat- than individuals with similar mental health prob-
ment that they cannot acknowledge they need. lems who were receiving treatment voluntarily.
About half of those patients who felt they were Thus, it seems that involuntary treatment can
coerced into treatment eventually acknowledge result in several positive outcomes for individuals
that they needed treatment, but about half con- with serious mental health problems.
tinue to believe treatment was unnecessary
(Gardner et al., 1999).
PATIENTS' RIGHTS
Numerous court cases over the years have estab-
lished that people committed to mental health in-
PROFILES stitutions retain most of their civil rights. They also
I
have certain additional rights, which we discuss in

I talked to him this morning . I said, "You ... this section.
didn't even listen to me. You ... call yourself a
counselor .... Why did you decide to do this in- Right to Treatment
stead of . .. try to listen to me and understand ...
what I was going through." And he said, "Well, it One basic right of people who have been commit-
doesn't matter, you know, you're going any- ted is the right to treatment. In the past, mental
way." ... He didn't listen to what I had to say .... patients, including both those involuntarily com-
He didn't listen to the situation . . . . He had de- mitted and those seeking treatment voluntarily,
cided before he ever got to the house . .. that were often only warehoused. The conditions in
I was coming up here. Either I come freely or which they lived were appalling, with little stimu-
the officers would have to subdue me and bring lation and few pleasantries, let alone treatment for
me in. (Bennett et al., 1993) their disorders. In Wyatt v. Stickney (1971), patient
Ricky Wyatt and others filed a class action suit
against a custodial facility in Alabama, charging
that they received no useful treatment and lived in
minimally acceptable living conditions. After
33 years in the courts, the case finally was settled
in 2003. From the court ruling came four standards,
known as the "Wyatt Standards," for the evalua-
tion of care of psychiatric patients: (1) They must
be provided with a humane psychological and
physical environment, (2) there must be qualified
and sufficient staff for the administration of treat-
ment, (3) there must be individualized treatment
plans, and (4) restrictions of patient freedoms must
be kept to a minimum (Sundram, 2009).
Right to Refuse Treatment

Another basic right is the right to refuse treat-
ment. One of the greatest fears of people commit-
:Jne fundamental right of people committed to a mental health facility is the ted against their will is that they will be given
ight to be treated rather than simply warehoused . drugs or other treatments that rob them of their
consciousness and their free will. Many states now
Competence to Stand Trial 471
do not allow mental institutions or prisons to ad-

minister treatments without the informed consent
of patients. Informed consent means that a patient
accepts treatment after receiving a full and under-
standable explanation of the treatment being of-
fered and making a decision based on his or her
judgment of the risks and benefits of that treat-
ment (Meyer & Weaver, 2006).
The right to refuse treatment is not recognized
in some states, however, and in most states this
right can be overruled in many circumstances
(Monahan et al., 2001). Particularly if a patient is
psychotic or manic, it may be judged that he or she
cannot make a reasonable decision about treat-
ment. In some jurisdictions, the simple fact that
patients have a psychiatric diagnosis is enough to
have them declared incompetent to make deci- Competence to stand trial is one of the most common
judgments psychologists are asked to help courts make.
sions about their treatment, especially if the diag-
nosis is schizophrenia (Appelbaum, Appelbaum,
& Grisso, 1998). Yet studies using reliable measures
of patients' ability to make rational decisions sug- Impaired competence may be a common prob-
gest that as many as 75 percent of those with lem. Defense attorneys suspect impaired compe-
schizophrenia and 90 percent of those with depres- tence in their clients in up to 10 percent of cases.
sion have adequate decision-making capacity Although only a handful of these clients are re-
(Grisso & Appelbaum, 1995). ferred for formal evaluation, about 60,000 evalua-
Patients' psychiatrists or families may seek tions of criminal defendants for competence to
court rulings allowing them to administer treat- stand trial are performed every year in the United
ment even if the patients refuse treatment. Judges States (Bonnie & Grisso, 2000). Competence judg-
most often agree with the psychiatrists' or fami- ments are one of the most frequent types of judg-
lies' requests to force treatment on patients. Most ments that mental health professionals are asked
cases in which patients refuse treatment never go to make for the courts. Judges appear to value the
to court, however. Instead, clinicians and family testimony of mental health experts concerning de-
members pressure patients to accept treatment, fendants' competence and rarely rule against these
and most patients eventually agree to treatment experts' recommendations.
after initially refusing (Griffin, Steadman, & Petrila, The consequences of competence judgments
2002; Monahan et al., 2001). for defendants are great. If defendants are judged
incompetent, trials are postponed as long as there
is reason to believe they will become competent in
COMPETENCE TO the foreseeable future, and defendants may be
STAND TRIAL forced to receive treatment. On the other hand, in-
competent defendants who are wrongly judged
One fundamental principle of law is that, in order competent may not contribute adequately to their
to stand trial, accused individuals must have a defense and may be wrongly convicted and incar-
rational understanding of both the charges cerated. Defendants who are suspected of being
against them and the proceedings of the trial and incompetent are described by their attorneys as
must be able to participate in their defense. Peo- much less helpful in establishing the facts of their
ple who do not have an understanding of what is case and much less actively involved in making de-
happening to them in a courtroom and who can- cisions about their defense (MacArthur Research
not participate in their defense are said to be in- Network on Mental Health and the Law, 1998).
competent to stand trial. Incompetence may Not surprisingly, defendants with a long his-
involve impairment in several capacities, includ- tory of psychiatric problems, particularly schizo-
ing the capacity to understand information, to phrenia or psychotic symptoms, are more likely
think rationally about alternative courses of ac- than those without such a history to be referred for
tion, to make good choices, and to appreciate competence evaluations (Pirelli, Gottdiener, &
one's situation as a criminal defendant (Hoge, Zapf, 2011). Defendants referred for competence
Bonnie, et al., 1997). evaluations also tend to have less education and to
be poor, unemployed, and unmarried, compared

to those not referred for evaluation. There is also
some evidence that ethnic/racial minority indi-
viduals are more likely than whites to be judged
incompetent to stand trial (Pirelli et al., 2011).
Psychologists have developed tests of those
cognitive attributes important to the ability to fol-
low legal proceedings, and people who perform
poorly on these tests are more likely to be judged
incompetent to stand trial. These tests have not been
widely used, however. Instead, judgments of in-
competence usually are made for people who have
existing diagnoses of psychotic disorders or who
have symptoms indicating severe psychopathology,
such as gross disorientation, delusions, hallucina- John Hinckley was judged not guilty by reason of insanity
tions, and formal thought disorder (Cochrane, in the shooting of President Ronald Reagan . Thi s
judgment inspired a reappraisal of the insanity defense.
Grisso, & Frederick, 2001; Pirelli et al., 2011).
THE INSANITY DEFENSE The lay public often thinks of the insanity defense
Insanity is a legal term rather than a psychological as a means by which guilty people "get off." When
or medical term, and it has been defined in various the insanity defense has been used successfully in
ways. The insanity defense is based on the belief celebrated cases-as when John Hinckley success-
that people cannot be held fully responsible for il- fully used this defense after shooting President
legal acts if they were so mentally incapacitated at Ronald Reagan and the president's press secretary,
the time of committing the acts that they could not Jim Brady, in 1981-there have been calls to elimi-
conform to the rules of society (Meyer & Weaver, nate it altogether (Steadman et al., 1993). Indeed,
2006). Note that people do not have to be chroni- these celebrated cases have often led to reapprais-
cally mentally incapacitated for the insanity deals of the insanity defense and redefinitions of the
fense to apply. They only have to be judged to have legal meaning of insanity.
been incapacitated at the time they committed the The insanity defense actually is used much less
illegal acts. This judgment can be difficult to make. often than the public tends to think. As shown in
The insanity defense has been one of the most Table 16.2, fewer than 1 in 100 defendants in felony
controversial applications of psychology to the law. cases files an insanity plea, and only 26 percent of
TABLE 16.2 Comparison of Public Perceptions of the Insanity Defense with Actual Use and Results
The public has the perception that many more accused persons use the insanity defense successfully than is actually the case.
Public Perception Reality
Percent of felony indictments for which an insa nity plea is made 37% 1%
Percent of insanity pleas resulting in "not guilty by reason of insanity" 44% 26%
Percent of persons "not guilty by reason of insanity" sent to mental hospitals 51 % 85%
Percent of persons "not guilty by reason of insanity" set free 26% 15%
Percent given conditional release 12%
Percent assigned to outpatient treatment 3%
Percent g iven unconditional release 1%
Length of confinement of persons "not guilty by reason of in sanity":
All crimes 21.8 months
Murder 32.5 months
Source: Silver et al., 1994.

The Insanity Defense 473
these cases result in acquittal (Silver, Cirincione, about 85 percent are sent to mental hospitals, and
& Steadman, 1994). This means that only about 1 all but 1 percent are put under some type of super-
in 400 people charged with a felony is judged not vision and care. Of those wh o are sent to mental
guilty by reason of insanity. About 265 of these hospitals, the average length of stay (or incarcera-
people have diagnoses of schizophrenia, and tion) in the hospital is almost 3 years when all
most have a history of psychiatric hospitaliza- types of crimes are considered, and over 6 years
tions and previous crimes (McGreevy, Steadman, for those who have been accused of murder (and
& Callahan, 1991). acquitted by reason of insanity) (McGreevy et al.,
Almost 90 percent of the people who are ac- 1991; Silver et al., 1994). Some states stipulate that
quitted after pleading the insanity defense are people judged not guilty by reason of insanity can-
male, and 66 percent are white (McGreevy et al., not be incarcerated in mental institutions for lon-
1991; Warren et al., 2004). The reasons why men ger than they would have served in prison had
and whites are more likely to successfully plead they been judged guilty of their crimes, but not all
the insanity defense are unclear but may have to states have this rule. In short, there is little evi-
do with their greater access to competent attorneys dence that the insanity defense is widely used to
who can effectively argue the insanity defense. In help people avoid incarceration for their crimes.
the past decade or two, as society has become more
aware of the plight of abused and battered women,
increasing numbers of women are pleading the
Insanity Defense Rules
insanity defense after injuring or killing a partner Five rules have been used in modern history to
who had been abusing them. evaluate defendants' pleas that they be judged not
One such case is that of Lorena Bobbitt. Ac- guilty by reason of insanity. These rules are listed
cording to Bobbitt, her husband, John, had sexually in Table 16.3.
and emotionally abused her for years. One night in
1994, John returned home drunk and raped Lorena. M'Naghten Rule
In what her attorneys described as a brief psychotic The first insanity defense rule was the M'Naghten
episode, Lorena cut off her husband's penis and rule (Meyer & Weaver, 2006). Daniel M'Naghten
threw it away. She was acquitted of charges of mali- lived in England in the mid-1800s and believed
cious injury by reason of temporary insanity. She that the English Tory party was persecuting him.
was referred to a mental institution for further eval- He set out to kill the Tory prime minister but mis-
uation and was released a few months later. takenly shot the prime minister's secretary. At his
Even when a defendant is judged not guilty by trial in 1843, the jury judged M'Naghten not
reason of insanity, he or she usually is not set free . guilty by reason of insanity. There was a public
Of those people acquitted because of insanity, outcry at this verdict, leading the House of Lords
TABLE 16.3 Insanity D efense Rules
Five rul es have been used in determin in g whether an individual was insane at the time he or she committed a
crime and therefore should not be held responsible for the crime.
Rule The Individual Is Not Held Responsible for a Crime If ...
M 'Naghte n rule At t he time of the crime, the individual was so affected by a disease of the mind
that he or she did not know the nature of the act he or she was committing or did
not know it was wrong .
Irresistible impulse rule At the tim e of the crime, the individual was driven by an irresistib le impulse to
perform the act or had a diminished capacity to resist performing the act.
Durham rule The crime was a product of a mental disease or defect.
ALl rule At the time of t he crime, as a resu lt of a mental disease or defect, the person
lacked substantia l capacity either to appreciate the crimin ality (wrongfulness) of
the act or to conform his or her conduct to the law.
Insanity Defense At the time of the crime, as a result of mental disease or mental retardation, the
Reform Act person was unable to appreciate the wrongfulness of his or her cond uct.
to establish a rule formalizing when a person Another major problem is that the M'Naghten
could be absolved from responsibility for his or rule requires that a person not know right from
her acts because of a mental disorder. This rule, wrong at the time of the crime in order to be judged
known as the M'Naghten rule, still is used in not guilty by reason of insanity (Meyer & Weaver,
many jurisdictions today: 2006). This is a difficult judgment to make because
it is retrospective. Even when everyone agrees that
To establish a defense on the ground of
a defendant suffers from a severe psychological
insanity, it must be clearly proved that at
disorder, it does not necessarily follow that at the
the time of committing the act, the party
time of the crime the person was incapable of
accused was labouring under such a de-
knowing "right from wrong," as the M'Naghten
fect of reason, from disease of the mind, as
rule requires. For example, serial killer Jeffrey
not to know the nature and quality of the
Dahmer, who tortured, killed, dismembered, and
act he was doing, or if he did know it, that
ate his victims, clearly seemed to have a psycho-
he did not know he was doing what was
logical disorder. Nevertheless, the jury denied his
wrong.
insanity defense in part because he took great care
The M'Naghten rule reflects the doctrine that a to hide his crimes from the local police, suggesting
person must have a "guilty mind"-in Latin, mens that he knew that what he was doing was wrong
rea-or the intention to commit the illegal act in or against the law.
order to be held responsible for the act.
Applying the M'Naghten rule might seem to be Irresistible Impulse Rule
a straightforward matter-one simply determines The second rule used to judge the acceptability of
whether a person suffers from a disease of the mind the insanity defense is the irresistible impulse
and whether during the crime rule. First applied in Ohio in 1934, the irresistible
he or she understood that his impulse rule broadened the conditions under
or her actions were wrong. which a criminal act could be considered the prod-
Unfortunately, it is not that uct of insanity to include "acts of passion." Even if
simple. A major problem in a person knew the act he or she was committing
applying the M'Naghten rule was wrong, the person could be absolved of re-
is determining what is meant sponsibility for performing the act if he or she was
by a "disease of the mind." driven by an irresistible impulse to perform the act
The law has been unclear and or had a diminished capacity to resist performing
inconsistent in what disorders it (Meyer & Weaver, 2006).
it recognizes as diseases of the One of the most celebrated applications of the
mind. The most consistently notion of diminished capacity was the "Twinkie
recognized diseases are psy- Defense" of Dan White. As depicted in the 2008
choses. It has been relatively movie Milk, in 1979 Dan White assassinated San
easy for the courts and the Francisco Board of Supervisors member Harvey
public to accept that someone Milk and mayor George Moscone. White argued
experiencing severe delusions that he had had diminished capacity to resist
and hallucinations is suffering the impulse to shoot Moscone and Milk due to the
from a disease and, at times, psychological effects of extreme stress and the
may not know right from consumption of large amounts of junk food. Using
wrong. However, defendants a particularly broad definition of diminished
have argued that several other capacity in force in California law at the time, the
disorders, including alcohol jury convicted White of manslaughter instead of
abuse, severe depression, and first-degree murder. Variations of the "Twinkie
posttraumatic stress disorder, Defense" have rarely been attempted since
are diseases of the mind that White's trial.
After Dan White (pictured) killed San impair judgments of right
Francisco supervisor and gay rights activist and wrong. It is much more Durham Rule
Harvey Milk and mayor George Moscone. difficult for courts, the lay In 1954, Judge David Bazelon further broadened
his lawyers argued that he had diminished public, and mental health
the criteria for the legal definition of insanity in his
capacity due to the psychological effects
of extreme stress and the consumption of
professionals to agree on the ruling on the case Durham v. United States, which
large quantities of junk food. validity of such claims (Meyer produced the third rule for defining insanity-the
& Weaver,2006). Durham rule. According to the Durham rule, the
The Insanity Defense 475
insanity defense could be accepted for any crimes mental disease or defect. Further, in 1977, in Barrett
that were the "product of mental disease or mental v. United States, it was ruled that "temporary insan-
defect." This rule allowed defendants to claim that ity created by voluntary use of alcohol or drugs"
the presence of any disorder recognized by mental also does not qualify a defendant for acquittal by
health professionals was the "cause" of their reason of insanity.
crimes. The Durham rule did not require that de- The ALI rule was widely adopted in the United
fendants show they were incapacitated by their States, including in the jurisdiction in which John
disorders or did not understand that their acts Hinckley was tried for shooting Ronald Reagan.
were illegal. The rule eventually was dropped by Hinckley had a long-standing diagnosis of schizo-
almost all jurisdictions by the early 1970s (Meyer phrenia and an obsession with the actress Jodi
& Weaver, 2006). Foster. Letters he wrote to Foster before shooting
Reagan indicated that he committed the act under
All Rule the delusion that it would impress Foster and
The fourth rule for deciding the acceptability of the cause her to return his love. Hinckley's defense at-
insanity defense was proposed by the American torneys successfully argued that he had a dimin-
Law Institute in 1962. Motivated by dissatisfaction ished capacity to understand the wrongfulness of
with the existing legal definitions of insanity, a shooting Reagan or to conform his behaviors to the
group of lawyers, judges, and scholars associated requirements of the law. The public outcry over the
with the American Law Institute (ALI) worked to judgment that Hinckley was "not guilty by reason
formulate a better definition, which eventually of insanity" initiated another reappraisal of the
resulted in what is known as the ALI rule: legal definition of insanity and the use of the in-
sanity defense (Meyer & Weaver, 2006; Steadman
A person is not responsible for criminal
et al., 1993).
conduct if at the time of such conduct as
the result of mental disease or defect he
Insanity Defense Reform Act
lacks substantial capacity either to appre-
The reappraisal of the insanity defense after John
ciate the criminality (wrongfulness) of his
Hinckley's shooting of President Reagan led to the
conduct or to conform his conduct to the
fifth rule for defining legal insanity, codified in the
requirements of the law.
Insanity Defense Reform Act, enacted by Con-
This rule is broader than the M'Naghten rule gress in 1984. The Insanity Defense Reform Act ad-
because it requires only that the defendant have a opted the 1983 American Psychiatric Association
lack of appreciation of the criminality of his or her definition of insanity. This definition dropped the
act, not an absence of understanding of the crimi- provision in the ALI rule that absolved people of
nality of the act. The defendant's inability to con- responsibility for criminal acts if they were unable
form his or her conduct to the requirements of the to conform their behavior to the law and retained
law can result from the emotional symptoms of a the wrongfulness criterion initially proposed in
psychological disorder as well as from the cogni- the M'Naghten rule (Meyer & Weaver, 2006). The
tive deficits caused by the disorder. This expanded definition reads as follows:
understanding incorporates some of the crimes
recognized by the irresistible impulse rule. The A person charged with a criminal offense
ALI rule clearly is more restrictive than the Dur- should be found not guilty by reason of
ham rule, however, because it requires some lack insanity if it is shown that, as a result of
of appreciation of the criminality of an act, rather mental disease or mental retardation, he
than the mere presence of a mental disorder (Meyer was unable to appreciate the wrongful-
& Weaver, 2006). The ALI rule further restricts the
ness of his conduct at the time of his
types of mental disorders that can contribute to a offense.
successful insanity defense: This definition now applies in all cases tried in
As used in this Article, the term "mental U.S. federal courts and in the courts of about half
disease or defect" does not include an ab- the states. Also following the Hinckley verdict,
normality manifested only by repeated most states now require that a defendant pleading
criminal or otherwise antisocial conduct. not guilty by reason of insanity prove that he or
she was insane at the time of the crime. Previously,
This restriction prohibits defense attorneys the burden of proof had been on the prosecution to
from arguing that a defendant's long history of prove that the defendant was sane at the time the
antisocial acts is itself evidence of the presence of a crime was committed (Steadman et al., 1993).
SHADES OF GRAY
Read the following case study. Three months after the birth of her fifth child,
Andrea's father died, and her condition worsened,
On June 20, 2001, after her husband Rusty left for leading her to be hospitalized. When she was dis-
work, Andrea Yates methodically drowned all five charged, her psychiatrist gave instructions that
of her young children in the bathtub. She then she be watched around the clock. On the day of the
called 911 and asked that a police officer come to drowning, her husband left for work expecting his
her house. She also called her husband at work mother to arrive at the house soon to supervise
and told him he needed to come home. Andrea and the children . It was then that Andrea
Andrea had a long history of psychotic de- drowned the children. She later told a psychiatrist,
pression. In the summer of 1999, she had tried to "My children weren't righteous. They stumbled
commit suicide and had been hospitalized twice . because I was evil. The way I was raising them,
She had hallucinations and delusions that led her they could never be saved. They were doomed to
to believe she was evil and that her children were perish in the fires of hell:' (Houston Chronicle,
irreparably damaged and doomed to hell. Her psy- March 5, 2002)
chiatrist diagnosed her with postpartum psychosis
and successfully treated her but urged the couple Would you judge Andrea Yates "not guilty by
not to have any more children, saying future epi- reason of insanity"? Why or why not? (Discussion
sodes of psychotic depression were inevitable. appears at the end of this chapter.)
The Yates conceived their fifth child approximately
7 weeks after her discharge from the hospital.
Problems with Mental health professionals also have raised

concerns about the rules used to determine the ~
the Insanity acceptability of the insanity defense (Meyer &
Defense Weaver, 2006). Behind these rules is the assump-
Cases in which the insan- tion that most people, including most people with
ity defense is pled often a psychological disorder, have free will and usu-
use mental health profes- ally can choose how they will act in any given situ-
sionals to provide expert ation. Many current models of both normal and
opinions. Despite their ex- abnormal behavior suggest that people do not
pertise, mental health pro- have that much control over their behaviors. Bio-
fessionals often disagree logical predispositions, early life experiences, or
about the nature and disordered patterns of thinking can make people
causes of psychological act in irrational and perhaps uncontrolled ways.
disorders, the presence or This view makes it more difficult to determine
absence of a psychological when individuals should or should not be held re-
disorder, and the evalua- sponsible for their behaviors.
tion of defendants' states
of mind at the time crimes
were committed (Warren
Guilty but Mentally Ill
et al., 2004). Usually, law- In a sixth and most recent reform of the insanity
yers on both sides of the defense, some states have adopted as an alterna-
case find a mental health tive to the verdict "not guilty by reason of insan-
professional who supports ity" the verdict guilty but mentally ill (GBMI).
their point of view, and the Defendants convicted as guilty but mentally ill are
Andrea Yates argued that severe psychosis two professionals inevita- incarcerated for the normal term designated for
and postpartum depression led her to drown
her five young children in 2001.
bly are in disagreement their crimes, with the expectation that they also
with each other. This dis- will receive treatment for their mental illness. Pro- ~
agreement leads to confu- ponents of the GBMI verdict argue that it recog-
sion on the part of judges, nizes the mental illness of defendants while still
juries, and the public. holding them responsible for their actions. Critics
Mental Health Care in the Justice System 477
argue that the GBMI verdict is essentially a guilty found that over 80 percent had a lifetime history of
verdict and a means of eliminating the insanity a psychiatric disorder and that 70 percent had been
defense (Tanay, 1992). Juries may believe they are symptomatic within the previous 6 months (Teplin
ensuring that a person gets treatment by judging et al., 1996). In these studies, the most common di-
him or her guilty but mentally ill, but there is no agnosis the women received was substance abuse
guarantee that a person convicted under GBMI or dependence, but substantial percentages of the
will receive treatment. In most states, it is left to women also had been diagnosed with major de-
legal authorities to decide whether to incarcerate pression and/ or a borderline or antisocial personal-
people judged guilty but mentally ill in mental in- ity disorder.
stitutions or in prisons and, if they are sent to pris- Numerous court decisions have mandated
ons, whether to provide them with treatment for that prison inmates receive necessary mental
their mental illness. As we discuss in the next sec- health services, just as they should receive neces-
tion, people with mental disorders usually do not sary medical services. Most inmates with mental
receive adequate-if any-treatment when they disorders do not receive these services, however. A
are incarcerated. study of male inmates found that only 37 percent
of those with schizophrenia or a major mood dis-
order received treatment while in jail (Teplin,
MENTAL HEALTH CARE 1990), and a study of female inmates found that
only 23.5 percent of these with schizophrenia or a
IN THE JUSTICE SYSTEM major mood disorder received treatment in jail
Men with a mental disorder are four times likelier to (Teplin, Abram, & McClelland, 1997). Only 15.4 per-
be incarcerated than men without a mental disorder, cent of youth in detention facilities who have a
and women with a mental disorder are eight times mental disorder receive treatment (Teplin et al.,
likelier to be incarcerated than women without a 2002). Depression in inmates is particularly likely
mental disorder (Teplin, Abram, & McClelland, to go unnoticed and untreated, even though sui-
1996). Although a subset of the crimes committed cide is one of the leading causes of death among
by people with mental disorders involve violence incarcerated people.
or theft, many of their crimes involve drug pos- The services inmates do receive often are min-
session and use (Osher & Steadman, 2007). Many imal. Substance abuse treatments may involve
of these individuals are repeat offenders, going only the provision of information about drugs
through a revolving door between prison and a and perhaps Alcoholics Anonymous or Narcotics
freedom characterized by joblessness, homeless- Anonymous meetings held in the prison. Treat-
ness, and poverty. ment for schizophrenia or depression may involve
As a result, the prison system has become the only occasional visits with a prison physician who
de facto mental health system for millions of people prescribes a standard drug treatment but has nei-
with mental disorders (Osher & Steadman, 2007). ther the time nor the expertise to follow individu-
Studies of detained youth find that 60 percent of als closely.
boys and two-thirds of girls have a diagnosable Comprehensive treatment programs focusing
mental disorder, even when conduct disorder is ex- on the special needs of prison inmates with men-
cluded (Teplin et al., 2002). Over 50 percent of incar- tal disorders can successfully reduce their symp-
cerated adult males can be diagnosed with a mental toms of mental disorder, their substance abuse,
disorder, most often a substance use disorder or and their repeat offense rates. Many of these treat-
antisocial personality disorder (Collins & Schlenger, ment programs focus on male inmates, who
1983; Hodgins & Cote, 1990; Neighbors et al., 1987). greatly outnumber female inmates. The female
A study of women prison inmates found that inmate population has grown more rapidly than
64 percent had a lifetime history of a major psychi- the male inmate population in the past decade,
atric disorder such as major depression, an anxiety however, more than tripling in that time period
disorder, a substance use disorder, or a personality (Montaldo, 2003) .
disorder and that 46 percent had had symptoms of a Female inmates may have different needs for
major psychiatric disorder in the previous 6 months services than male inmates (Teplin et al., 1997).
Gordan, Schlenger, Fairbank, & Caddell, 1996). In Female inmates may be more likely than male
addition, nearly 80 percent of these women had inmates to have a history of sexual and physical
been exposed to an extreme trauma, such as sexual abuse, which needs to be addressed in treatment.
abuse, sometime in their life. Another study of Also, female inmates are more likely than male
1,272 women jail detainees awaiting trial in Chicago inmates to be suffering from depression or
anxiety and to have children for whom they will attempt to avoid reincarceration and instead use
become caregivers after they are released from milder sanctions, such as requiring offenders to re-
prison. appear before the judge, to motivate them to coop-
Increasingly, communities are developing erate with their treatment plan (Redlich et al.,
systems to divert criminal offenders with mental 2006). The effectiveness of mental health courts
disorders into community-based treatment pro- and drug courts in reducing recidivism and reha-
grams rather than incarceration (Redlich et al., bilitating offenders into the community relies
2006). The hope is that providing these individu- heavily on the availability of high-quality commu-
als with comprehensive mental health treatment nity services, services sorely lacking in many com-
combined with occupational rehabilitation and munities (Boothroyd et al., 2005).
social services will enable them to live in the com-
munity as healthy and productive citizens. Diver-
sion from jail into community services is especially
likely to be a goal when the offender is a youth
CHAPTER INTEGRATION
(Steinberg, 2009). There has perhaps been less integration of bio-
Some states have developed mental health logical, social, and psychological viewpoints in
courts, in which the cases of offenders with mental the law's approach to issues of mental health than
disorders are reviewed by judges who specialize in in the mental health field itself. The rules govern-
working with mental health and social service pro- ing the insanity defense suggest that the law takes
fessionals to divert offenders into treatment and a biological perspective on psychological disor-
rehabilitation. Courts that focus specifically on ders, conforming to the belief that mental disor-
drug offenders often are called drug courts. Offend- ders are like medical diseases (Figure 16.2).
ers diverted by mental health courts or drug courts Similarly, civil commitment rules require certifi-
into community treatment are still under the cation that a person has a mental disorder or dis-
watchful eye of the court. If they do not cooperate ease before he or she can be committed, further
with the plan developed by the mental health legitimating psychiatric diagnostic systems based
court for their treatment and rehabilitation, they on medical models.
can be diverted back into jail. This feature of men- In each area discussed in this chapter, how-
tal health courts is controversial because it amounts ever, there are mental health professionals advo-
to coercing offenders into treatment. Most courts cating a more integrated and complex view of
mental disorders than that traditionally held by
the legal system. These professionals are trying to
Differences Between the Perspective educate judges, juries, and laypeople to help
FIGURE 16.2 of the Law and That of the Mental Health them understand that some people have biologi-
Profession cal, psychological, or social predispositions to
disorders and that other biological, psychologi-
Perspective of the law
cal, or social factors can interact with these pre-
Can be absolved from responsibility
dispositions to trigger the onset of mental
r _______v_es___..,.. for a crime and can be committed to disorders or certain manifestations of mental dis-
l a mental health facility against his
or her will
orders. What is most difficult to explain is the
probabilistic nature of the predictions that can be
Does the individual have a
mental disorder or disease? made about mental disorders and about the be-
Will be held responsible for a crime havior of people with these disorders. While a
..__ _ _ _ _ _ _....,..,.. and cannot be committed to a
No mental health facility against his
predisposition or certain recent life experiences
or her will may make a person more likely to develop a dis-
order or to engage in a specific behavior (such as
a violent behavior), they do not determine the
Perspective of the mental health profession disorder or the specific behavior.
We all prefer to have predictions about the
r---------.... Yes
More likely to commit a crime future that are definite, especially when we are
Biological. psychological, making decisions that will determine a person's
or social vulnerabilities to freedom or confinement. That kind of definitive-
mental health problems
ness is not possible, however, given our present
No Less likely to commit a crime knowledge of the ways biological, psychological,

and social forces interact to influence people's
behavior.
Chapte r Summary 479
The first point you might note in making your deci- In making your judgment, you likely found
sion is that Andrea Yates had a well-documented yourself struggling with emotions related to ac-
history of psychotic depressions-in fact, the psy- cepting the killing of children by a parent. You are
chiatrist who treated her in 1999 warned that she not alone. The public often cannot accept any ex-
could harm her children as a result of her psychosis. cuse for such a crime, and therefore the plea of
Yates testified that on the morning of the drown- "not guilty by reason of insanity," supposedly as
ings, her delusions and hallucinations led her to be- the result of psychotic postpartum depression, is
lieve that she had to kill her children to "save" them. highly controversial in such cases (Williamson,
But consider the fact that Yates called 911 and her 1993). Severe postpartum depression with psy-
husband after the drownings. Would this affect your chotic symptoms is very rare, and violence by
decision? For the jury in Yates's 2002 murder trial it these women against their newborns is even rarer
did. They rejected the insanity defense, accepting (Nolen-Hoeksema, 1990). When such violence
the assertion by the State ofTexas that the fact that does occur, some courts have accepted that the
Yates called 911 proved she knew her actions were mothers' behaviors are the result of the postpar-
wrong despite her mental defect. Yates was con- tum psychosis and have judged these women not
victed of murder and sentenced to life in prison. In guilty by reason of insanity, as the Texas courts
2005, Yates's conviction was overturned due to false finally did in Andrea Yates's case. At other times,
testimony by one of the prosecution witnesses. In however, even though the law is intended to be
2006,Yates was retried, and this time she was found objective, its appl ication can be influenced by
not guilty by reason of insanity and committed to a people's emotional reactions to the behaviors of
Texas state mental hospital. people with mental disorders.
THINK CRITICALLY
Several states have adopted special laws allowing Supreme Court upheld the Kansas sexual predator
the involuntary commitment of sex offenders (Winick, law, finding that the defendant in the case, who had
2003). Under these laws, "sexually violent predators" committed sexual crimes against ch il dren, had a suf-
can be kept in confinement even after serving their ficie nt mental condition to authorize involuntary psy-
prison terms. In Kansas, a " sexually violent predator " chiatric hospitalization.
was defined as "any person who has been convicted Do you support laws allowing the involuntary
of or charged with a sexually violent offense and who commitment of sexual offenders after they have
suffers from a mental abnormality or personality dis- served their sentence? Why or why not? (Discussion
order which makes the person likely to engage in the appears on p. 485 at the back of this book.)
predatory acts of sexual violence:' In 1997, the U.S.
CHAPTER SUMMARY
Civil commitment is the procedure through may not be competent to make. In particular,
which a person may be committed for treatment the prediction of who will pose a danger tooth-
in a mental institution against his or her will. In ers in the future is difficult to make and often is
most ju risdictions, three criteria are used to de- made incorrectly.
termine whether individuals may be committed:
if they suffer from grave disability that impairs When being considered for commitment, patients
their ability to provide for their own basic have the right to have an attorney, to have a pub-
needs, if they are an imminent danger to them - lic hearing, to call and confront witnesses, to
selves, or if they pose an imminent danger to appeal decisions, and to be placed in the least
others. Each of these criteria requires a subjec- restrictive treatment setting. (The right to a hear-
tive judgment on the part of clinicians and, of- ing is often waived for short-term commitments
ten, predictions about the future that clinicians in emergency settings.) Once committed, patients
480 Chapter 16 Mental Health a nd the Law
have the right to be treated and the right to refuse that the defendant be diagnosed with a mental
treatment. disorder, and most of them require that it be
shown that the defendant did not appreciate the
People with mental disorders, particularly those
criminality of his or her act or could not control
who also have a history of substance abuse, are
his or her behaviors at the time of the crime.
somewhat more likely to commit violent acts,
especially against family members and friends, The verdict "guilty but mentally ill" was intro-
than are people without a mental disorder. The duced following public uproar over uses of the
prevalence of violence among people with men- insanity defense in high-profile cases. Persons
tal disorders is not as great as is often perceived judged guilty but mentally ill are confined for the
by the public and the media, however. duration of a regular prison term but with the
One fundamental principle of law is that, in order assumption that they will receive psychiatric
to stand trial, an accused individual must have treatment while incarcerated.
a reasonable degree of rational understanding Mental health professionals have raised a num-
both of the charges against him or her and of the ber of concerns about the insanity defense. For
proceedings of the trial and must be able to par- one thing, it requ ires after-the-fact judgments of
ticipate in his or her defense. People who do not a defendant's state of mind at the time of the
have an understanding of what is happening to crime. In addition, the rules governing the insan-
them in a courtroom and who cannot participate ity defense presume that people have free will
in their defense are said to be incompetent to and usua lly can control their actions. These pre-
stand trial. Defendants who have a history of a sumptions contradict some models of normal
psychotic disorder, who have current symptoms and abnormal behavior that suggest that behav-
of psychosis, or who perform poorly on tests of ior is strongly influenced by biological, psycho-
important cognitive skills may be judged incom- logical, and social forces.
petent to stand trial. Communities are increasingly attempting to di-
Five rules for judging the acceptability of the in- vert persons with mental disorders who commit
sanity defense have been used in recent history: crimes away from jail and into community-ba sed
the M'Naghten rule, the irresistible impulse rule, treatment programs. Mental health courts and
the Durham rule, the All rule, and the Insanity drug courts have been established specifically
Defense Reform Act. Each of these rules requires for this purpose.
KEY TERMS
need for treatment 465 insanity defense 472
civil commitment 465 M'Naghten rule 473
grave disability 465 irresistible impulse rule 474
dangerousness to self 466 Durham rule 474
dangerousness to others 466 All rule 475
right to treatment 470 Insanity Defense Reform Act 475
right to refuse treatment 470 American Psychiatric Association definition
informed consent 471 of insanity 475
incompetent to stand trial 471 guilty but mentally ill (GBMI) 476
insanity 472
DISCUSSIONS EOR THINK CRITICALLY
CHAPTER 1 (page 20) behavior offered above could be at least partially true.
Students often take a course in abnormal psychology be- Sometimes, intervening with just one factor improves
cause they want to understand the troubling behavior of a person's overall functioning. If an interpersonal
someone in their life. Some students, while reading about therapist had Anika placed in a supportive and stable
the psychological problems covered in this book, recog- home situation, this alone might help her. Other
nize these problems in themselves. Recall that all the is- times, interventions must happen on many different
sues we discuss in this book fall along a continuum, such levels before the person's behaviors and feelings can
that only a small number of people are at the extreme and improve. A biological theorist might offer medication
qualify for a disorder but many more people have mod- for Anika's problems in addition to her receiving
erate or mild versions. If you think you or someone you intervention from a behavioral theorist to help with
care about may have a disorder, refer to the four Ds to peer pressure at school and intervention from an in-
evaluate the degree of distress, dysfunction, deviance, terpersonal theorist to help with problems at home.
and dangerousness in your behaviors and feelings or in The combination of these approaches may be what
another's behaviors and feelings. Most of the time you Anika's complex case needs.
will find relatively little. If these behaviors and feelings
are causing significant distress and difficulty in function- CHAPTER 3 (page 79)
ing, if you think they are highly deviant or possibly A questionnaire or structured interview that systemati-
dangerous, consult a mental health professional. Most cally asks Brett about each of the criteria for the diagno-
schools have counselors available and will also give sis of panic disorder, such as that in Table 3.1, would be
referrals to mental health professionals in the area. extremely helpful in making a diagnosis. This question-
naire or structured interview would go point by point
CHAPTER 2 (page 55) through the criteria in Table 3.4, determining whether a
Anika's difficult life puts her at high risk for psycho- symptom was present, the frequency and duration of
logical problems. If you were a biological theorist, you symptoms, and the circumstances that were present
might look to Anika's mother. You might suggest that when the symptoms arose. Personality questionnaires
her use of alcohol and other drugs while pregnant af- might help determine whether Brett is chronically
fected Anika's brain development in ways that led to afraid of the symptoms or sees them as evidence of im-
difficulties in controlling anger, problems in concentra- pending disaster. To establish whether his racing heart
tion, and self-destructive behaviors. You might also and shortness of breath might be due to a biological
note that Anika may have inherited genes for impul- disorder (see Criterion C in Table 3.4), Brett should
siveness and emotionality. have a thorough physical exam focusing on factors
If you approached Anika's case from the perspective such as drug use, cardiac functioning, and hormone
of a psychological theorist following a cognitive ap- functioning.
proach, you would focus on Anika's beliefs that she is
no good and is defective. You might suggest that these CHAPTER 4 (page 102)
beliefs have been shaped by her experiences of abuse Here are a few suggestions for how you could answer
and rejection by her mother and by her foster parents. the questions.
If you were a behavioral theorist, you would search for 1. The dependent variable is symptoms or diagnosis of
reinforcements Anika may be getting for her aggressive eating disorders (see Chapter 12). The independent
and self-destructive behaviors-perhaps they bring her variable is some measure of "pressures to be thin."
the attention she needs. You might note that behaviors
2. Because adolescent girls and young women have
such as skipping class and smoking are reinforced by
her peers. If you were an interpersonal theorist, you high rates of eating disorders, you might want to
recruit them for your sample.
would look for the roots of Anika's problems in her se-
ries of destructive families. You might examine whether 3. You could measure pressures to be thin with a
the dynamics inAnika's current family contribute to questionnaire that asks participants how much
her self-destructive behaviors. pressure they perceive in their lives. You could
Looking at Anika's case as a sociocultural theorist, measure eating disorders with a questionnaire that
you would view Anika's behaviors as a direct result of asks participants if they have experienced each of
the stresses she has endured throughout her life. You the symptoms listed for eating disorders in the
would suggest that Anika's social environment- DSM-5 (see Chapter 12).
community, school, and family-feeds her negative 4. A case study would allow you to explore in depth
behaviors and that she may need to be removed from how pressures to be thin were related to the develop-
this toxic environment. ment of an eating disorder in one woman. The major
Most forms of psychopathology are caused by disadvantage is that you cannot know whether what
multiple factors . All the explanations of Anika's you discover is generalizable to other women.
Discussions for Think Critically 481

482 Discussions for Think Critically
5. A correlational study might examine the correlation This case was the first in America in which a convic-
between scores on a measure of pressures to be thin tion was based on a memory that apparently had been
and scores on a measure of eating disorder symptoms. repressed and then recovered, but it was followed by
6. An experimental study might include one group in a number of other cases in which individuals were
which a confederate of the experimenter initiates a charged with violence and sexual abuse based on re-
conversation with participants about how much pressed memories. As noted in the chapter, researchers
men like women who are thin and another group have provided evidence for and against the claim that
in which the confederate initiates a conversation memories can be repressed, but this evidence can go
with participants about something unrelated to only so far in helping us judge what is true in a given
being thin. The dependent variable could be how case. Often, this evidence is presented by competing
much participants in each group say they are dis- expert witnesses in court cases. In the years since the
satisfied with their bodies (see Chapter 12 for a Franklin case, jury verdicts and public opinion about
repressed memories have shifted back and forth.
similar study).
In 1996, George Franklin was set free after his convic-
7. A therapy outcome study might examine whether tion was overturned. It turned out that many of the de-
a therapy that helps young women with eating tails in Eileen Franklin's memory of the murder, such as
disorders reject pressures to be thin is more effec- the silver ring on Susan Nason's crushed finger, could
tive in reducing eating disorder symptoms than a have been known from newspaper accounts at the time.
therapy that does not specifically address pres- Indeed, some of the details Eileen recounted had factual
sures to be thin. inaccuracies that mirrored inaccuracies in the newspaper
8. A meta-analysis could summarize all studies that accounts of the murder. Other details, such as what
have examined the relationship between pressures Nason said during the incident, were unverifiable. The
to be thin and symptoms of eating disorders to judge in the case ruled that George Franklin's rights had
determine the average strength of the relationship been violated, and the district attorney decided not to
across studies. The advantage of a meta-analysis is retry the case given the problems that had emerged
that it does not reflect the peculiarities of any one with regard to Eileen Franklin's memories.
study (e.g., what sample or measures were used) but
rather provides summary information across a range
of studies. CHAPTER 7 (page 213)
Researchers have adapted CBT and IPT techniques to
CHAPTER 5 (page 147) prevent depression in people at high risk (Munoz, Le,
There is no clear right or wrong answer to this question- Clarke, & Jaycox, 2002). Working mostly in group set-
it depends on what you believe about how narrow or tings, clinicians help individuals identify, and then dis-
broad the definition of PTSD should be. Narrowing the pute, negative patterns of thinking. The group setting
definition will result in fewer people being diagnosed allows the teaching and practicing of effective social
with the disorder. On one hand, this will focus resources skills, while the clinicians focus on individuals' con-
for treatment and research on people who are most secrete problems and help them devise solutions.
verely afflicted by the disorder. It also will prevent peo- Adolescence is a notoriously difficult stage of life-
ple from being labeled as having a psychiatric disorder, you may remember painful experiences of your own.
which can still carry a stigma in our society. On the While for many people the difficulty lessens over time,
other hand, narrowing the diagnosis may result in some evidence suggests that people with depression first
people who are suffering significantly not getting help developed it in adolescence. Based on this evidence,
because they do not meet the diagnostic criteria. several researchers have focused on preventing depres-
sion in high-risk teens.
CHAPTER 6 (page 172) One study involved adolescents whose mild to
These are some of the facts from the actual trial of moderate symptoms of depression put them at high
George Franklin, held in 1990, for the murder of Susan risk for developing major depression. They were ran-
Nason, which occurred in 1969. In post-trial interviews, domly assigned to a cognitive-behavioral intervention
jurors reported that they had concluded the only way or to a no-intervention control group. The students re-
Eileen could have known the details to which she had ceiving the cognitive-behavioral intervention met for
testified was by being an eyewitness. They also had 15 sessions in small groups, where they received ther-
been impressed by the emotional recounting of the apy to help them overcome negative ways of thinking
murder and by Eileen's confidence and firmness in and learn more effective coping strategies. Over the
asserting the truth of her memories. They deliberated course of the 15 sessions, the individuals in the inter-
for only 1 day before returning a verdict of "guilty vention group benefited immediately and showed a
of murder in the first degree." decline in their depressive symptoms. Following the
Discussions for Thin k Critically 483
therapy, both the intervention group and the no- psychodynamic clinicians were more likely to diag-
treatment control group were followed for up to nose borderline personality disorder, while cognitive-
18 months. Relatively few members of the intervention behavioral clinicians were more likely to diagnose
group developed depression. In contrast, many mem- PTSD. This suggests that theoretical orientation may
bers of the control group did develop depression. The bias clinicians' interpretation of the same symptom
intervention seemed to reduce the risk for future de- presentation but gender does not.
pression in its participants (Clarke et al., 1995).
Without therapy, these adolescents might have con- CHAPTER 10 (page 316)
tinued to struggle with low self-esteem, a negative out- The decision of whether to give a child a particular
look, and other symptoms that could adversely affect medication is a highly personal one for parents. No
their lives and even lead to suicide attempts. Programs one would want to deprive a child of a medication that
like this provide hope that vulnerable young people could dramatically improve his or her functioning and
can be spared the debilitating effects of depression. quality of life. However, medications often are widely
used to treat children when few controlled studies exist
CHAPTER 8 (page 248) to show that the benefits clearly outweigh the possible
In this chapter, you read about epigenetic processes, in risks of side effects and long-term effects on develop-
which DNA can be changed chemically by different en- ment. In their meta-analysis, Peter Jensen and
vironmental conditions, leading to genes being turned colleagues (2007) argue that psychosocial treatments
on or off. These genetic changes alter the development should be the first line of treatment for disruptive, ag-
of cells, tissues, and organs. What might have set these gressive, and self-injurious behaviors in children. When
epigenetic processes in motion for these twins? An in- these treatments are not sufficiently effective, Jensen
jury that Pamela suffered in the womb or in the birth and colleagues affirm that existing studies show the
process that Carolyn did not suffer-such as a birth potential benefits of the atypical antipsychotics to
complication that deprived her of oxygen-may be the outweigh their apparent side effects. Still, they recom-
reason. Or possibly Pamela, but not Carolyn, was ex- mend that many more studies be done, particularly of
posed to an infectious disease early in life that affected the long-term effects of the atypical antipsychotics on
her brain development. growth and development in children.
CHAPTER 9 (page 279) CHAPTER 11 (page 334)

Some theorists have argued that the diagnosis of bor- Aspinwall and colleagues (2012) examined how judges
derline personality disorder, which is characterized by use information that antisocial tendencies are biologi-
extreme emotionality and dependence on others, is cally based. They presented 181 trial court judges with
simply an extreme version of negative stereotypes of a hypothetical vignette, based on a real story, of a man
women's personalities (Kaplan, 1983; Sprock, 2000; who was convicted of hitting a clerk during a store
Walker, 1994). For this reason, clinicians sometimes robbery, causing permanent brain damage. During the
may be too quick to see these characteristics in women defendant's trial, a psychiatric expert testified that the
clients and to apply the diagnosis to them. In addition, defendant was diagnosed with psychopathy, a variant
the diagnosis of borderline personality disorder carries of antisocial personality disorder (seep. 329). Then
considerable stigma, and clinicians may be more will- the judges were randomly assigned to read either a
ing to apply this stigmatized diagnosis to women "biomechanical" explanation for the defendant's psy-
than to men. chopathy (e.g., that low MAOA activity and atypical
The evidence for a gender bias in clinicians' appli- amygdala functioning led to his behavior) or no such
cation of the borderline personality disorder diagnosis explanation. On one hand, the judges responded that
is mixed, with some studies showing a bias and others evidence that the defendant was diagnosed with psy-
not (see Ford & Widiger, 1989; Morey, Alexander, & chopathy created "aggravating circumstances" that
Boggs, 2005). For example, Woodward and colleagues warranted a longer sentence. But those who received
(2009) showed a vignette that depicted a person with a the biomechanical explanation generally saw this as a
history of childhood abuse and balanced symptoms of mitigating circumstance that should reduce the defen-
borderline personality disorder and post-traumatic dant's responsibility and therefore his sentence, from
stress disorder (PTSD; see Chapter 5) to a group of an average of 13.93 years in the "no explanation" con-
psychologists and psychiatrists. Half of the time the dition to 12.83 years in the "biomechanical explana-
character in the vignette was given a female name, tion" condition. Thus, it appears that having a
and half of the time a male name. The gender of the diagnosis that suggests-a tendency toward violence
character in the vignette did not influence the clini- leads to longer sentences, but having evidence that
cians' diagnosis of borderline personality disorder or this tendency toward violence is biologically based
PTSD, nor did the gender of the clinician. However, leads to shorter sentences.
484 Discussions for Think Critically
CHAPTER 12 (page 360) history of sexual contact with a child according to self-
In designing an eating-disorder prevention program for reports, criminal records, or any other available informa-
your school, you would not be alone-a number of these tion (Seto, 2009). On the other hand, 40 to 50 percent of
programs have been developed and tested in school set- individuals arrested for a sexual offense against a child
tings (see, for example, Stice et al., 2008). Most of these would not be diagnosed as pedophiles based on their
programs target known risk factors, including elevated patterns of sexual arousal and their typical behavior
pressure to be thin, internalization of the thin ideal, body (Seto, 2009). Other crimes that by definition victimize
dissatisfaction, and negative mood. Programs can consist others, such as rape, are not considered mental disorders.
of a single session or multiple sessions over time. They In the two most recent versions of the DSM (DSM-
might involve a former sufferer of an eating disorder IV-TR and DSM-5), attempts were made to narrow the
who tells others about her experience and how she over- definition of exhibitionism, voyeurism, frotteurism, and
came it. Or, over multiple sessions, a program might pedophilia so that only individuals who acted on these
teach participants to manage a healthy weight, to reject urges or who experienced clinically significant distress or
social pressure to be thin, and to cope with stress. Finally, impairment as a result of them would receive diagnoses.
some programs target only individuals known to be at As we have discussed throughout this book, however,
risk, while others target whole communities. judgments as to what constitutes a mental disorder are
Meta-analyses of these programs find that 51 percent subjective and are influenced by societal norms and his-
resulted in reduced eating-disorder risk factors (such torical trends. Nowhere is this truer than in the category
as poor body image) and 29 percent in reduced current of sexual disorders.
or future eating pathology (Stice, Shaw, & Marti, 2007).
Although 29 percent may not sound like a high success CHAPTER 14 (page 429)
rate, prevention programs for other public health prob- Both sides of this debate can marshal evidence for their
lems, such as obesity and HIV, achieve about the same positions. In 2008, the presidents of 100 U.S. colleges,
percentage. Larger positive effects were found for pro- including Duke, Ohio State, and Dartmouth, called on
grams that (a) targeted participants who already had the U.S. government to lower the drinking age to 18,
eating-disorder symptoms or risk factors, (b) focused saying that the current law is routinely flouted and
solely on women over age 15, (c) were not lecture- encourages dangerous binge drinking (see www
based but instead encouraged participation, (d) were .amethystinitiative.org). They suggested that legalizing
delivered by trained interventionists, and (e) focused drinking by 18- to 21-year-olds would bring their
on body acceptance and reducing thin-ideal internal- drinking out of hiding and afford colleges more
ization. Promising results come from prevention pro- opportunities to intervene in problem drinking. An
grams that teach women with risk factors to argue analysis of federal records by the Associated Press found
against the thin ideal and to recognize pressures from that 157 college-age people (ages 18 to 23) drank
the media. Such programs have reduced participants' themselves to death between 1999 and 2005.
acceptance of the thin ideal and decreased their body Other college presidents argue that lowering the
dissatisfaction, dieting, and bulimic symptoms (Stice drinking age will push illegal drinking even more
et al., 2008). into high schools. Statistics from the National Institute on
Alcohol Abuse and Alcoholism show that the rate of
CHAPTER 13 (page 392) accidents associated with alcohol among 16- to 20-year-
Certain sexual disorders diagnosed in the DSM-5 olds has declined since the drinking age was raised
including transvestic disorder and fetishistic disorder, to 21. Mothers Against Drunk Driving estimates that
sexual masochism, and consensual sexual sadism- 25,000 lives have been saved (see www.madd.org). For
are controversial because it can be argued that they further coverage of this debate, see www.cbsnews.com/
represent variations in people's preferences for sexual stories/2009 / 02/ 19 I 60minutes/ main481357l.shtrnl.
activities rather than mental disorders (Moser, 2009). Prevention programs such as those described in
Many transsexual individuals argue that they do not this chapter could be used to reduce the harmful con-
have a mental disorder and have a right to live their sequences of drinking by 18- to 21-year-olds. It is not
life as they wish. known, however, how many colleges would institute
You might argue that any sexual behavior that nega- such programs or whether the programs would coun-
tively affects others-such as voyeurism, exhibitionism, teract any negative consequences of lowering the
frotteurism, and particularly pedophilia-should be drinking age.
considered a mental disorder. But many people with
these sexual preferences do not act on them out of fear CHAPTER 15 (page 460)
of being caught (Moser, 2009). Even in the case of pedo- The scientific community is debating the ethical and
philia, studies find that the majority of individuals who practical issues raised by the failure to find significant
are sexually attracted to prepubescent children have no effects of psychosocial interventions on the progression
Discussions for Think Critically 485
of cancer or cardiovascular disease. Some researchers allowing involuntary commitment of sexual offenders
argue that giving patients false hope that they can in- were constitutional only if they were enacted with the
fluence the course of their disease by changing their intent to protect the public from further harm, not if
thoughts and by reducing stress is unethical and results they were enacted with the intent to further punish
in blaming the victim when health deteriorates (Coyne offenders. The public tends to support indefinitely in-
et al., 2007; see also Ehrenreich, 2009). Others argue that carcerating sex offenders, arguing that it protects the
even if psychosocial interventions cannot influence public against further harm (Carlsmith, Monahan, &
patients' survival rates, they can improve their quality of Evans, 2007). However, predicting who is going to do
life, which is itself a worthwhile goal (Frasure-Smith & harm to others in the future is difficult, and jurors'
Lesperence, 2005). The key, they say, is to give patients motives are not always purely for the public good. A
an honest and realistic expectation about what psycho- study in which potential jurors were presented with a
social interventions can and cannot do. description based on the 1997 Kansas case found that
they overwhelmingly favored confining the offender
CHAPTER 16 (page 479) after he served his sentence, regardless of the probabil-
On one hand, you may believe that justice requires free- ity that he would offend again (Carlsmith et al., 2007).
ing a sexual offender after he has served his sentence. This suggests that people's motives for supporting
On the other, you might fear future harm from the these laws have as much to do with exacting retribution
offender and therefore favor keeping him committed. against individuals who commit abhorrent crimes as
In the 1997 case, the Supreme Court held that laws with protecting the public.
GLOSSARY
A amnesia impairment in the ability to learn new infor-
ABAB (reversal) design type of experimental design in mation or to recall previously learned information
which an intervention is introduced, withdrawn, or past events
and then reinstated, and the behavior of a partici- amphetamines stimulant drugs that can produce
pant is examined on and off the treatment symptoms of euphoria, self-confidence, alertness,
abstinence violation effect what happens when a per- agitation, paranoia, perceptual illusions, and
son attempting to abstain from alcohol use ingests depression
alcohol and then endures conflict and guilt by mak- amygdala structure of the limbic system critical in emo-
ing an internal attribution to explain why he or she tions such as fear
drank, thereby making him or her more likely to animal studies studies that attempt to test theories of
continue drinking in order to cope with the self- psychopathology using animals
blame and guilt animal-type phobias extreme fears of specific animals
acute stress disorder disorder similar to post-traumatic that may induce immediate and intense panic at-
stress disorder but occurs within 1 month of expo- tacks and cause the individual to go to great lengths
sure to the stressor and does not last more than to avoid the animals
4 weeks; often involves dissociative symptoms anomie suicide suicide committed by people who
adjustment disorder stress-related disorder that experience a severe disorientation and role confu-
involves emotional and behavioral symptoms sion because of a large change in their relationship
(depressive symptoms, anxiety symptoms, and/ or to society
antisocial behaviors) that arise within 3 months of anorexia nervosa eating disorder in which people fail
the onset of a stressor to maintain body weights that are normal for their
adolescent-onset conduct disorder a conduct disorder age and height and have fears of becoming fat,
characterized by aggression, destructiveness, deceit- distorted body images, and amenorrhea
fulness, and rules violation beginning after age 10 antagonism hostility toward others
adoption study study of the heritability of a disorder by antagonist drugs drugs that block or change the
finding adopted people with a disorder and then de- effects of an addictive drug, reducing desire for
termining the prevalence of the disorder among their the drug
biological and adoptive relatives, in order to separate anterograde amnesia deficit in the ability to learn new
out contributing genetic and environmental factors information
agnosia impaired ability to recognize objects or people antianxiety drugs drugs used to treat anxiety,
agoraphobia anxiety disorder characterized by fear of insomnia, and other psychological symptoms
places and situations in which it would be difficult anticonvulsants drugs used to treat mania and
to escape, such as enclosed places, open spaces, depression
and crowds antidepressant drugs drugs used to treat the symp-
Alcoholics Anonymous (AA) an organization created toms of depression, such as sad mood, negative
by and for people with alcoholism involving a thinking, and disturbances of sleep and appetite;
12-step treatment program common types are tricyclics, selective serotonin
ALI rule legal principle stating that a person is not re- reuptake inhibitors, and serotonin-norepinephrine
sponsible for criminal conduct if he or she lacks the reuptake inhibitors
capacity to appreciate the criminality (wrongfulness) antipsychotic drugs drugs used to treat psychotic
of the act or to conform his or her conduct to the re- symptoms, such as delusions, hallucinations, and
quirements of the law as a result of mental disease disorganized thinking
allostatic load physiological condition resulting from antisocial personality disorder (ASPD) pervasive
chronic arousal of the fight-or-flight response to stress pattern of criminal, impulsive, callous, and/ or
altruistic suicide suicide committed by people who be- ruthless behavior, predicated on disregard for
lieve that taking their own life will benefit society the rights of others and an absence of respect for
Alzheimer's disease progressive neurological disease social norms
that is the most common cause of dementia anxiety state of apprehension, tension, and worry
amenorrhea cessation of the menses anxiety sensitivity belief that bodily symptoms have
American Psychiatric Association definition of harmful consequences
insanity definition of insanity stating that people aphasia impaired ability to produce and comprehend
cannot be held responsible for their conduct if, at language
the time they commit crimes, as the result of mental applied tension technique technique used to treat
disease or mental retardation they are unable to blood-injection-injury type phobias in which the
appreciate the wrongfulness of their conduct therapist teaches the client to increase his or her
G-1 Glossary
Glossary G-2
blood pressure and heart rate, thus preventing the to the avoidance of most social interactions with
client from fainting others and to restraint and nervousness in social
apraxia impaired ability to initiate common voluntary interactions
behaviors avolition inability to persist at common goal-directed
arousal phase in the sexual response cycle, psychologi- activities
cal experience of arousal and pleasure as well as
physiological changes, such as the tensing of mus-
cles and enlargement of blood vessels and tissues B
(also called the excitement phase) barbiturates drugs used to treat anxiety and insomnia
assertive community treatment programs system of that work by suppressing the central nervous
treatment that provides comprehensive services to system and decreasing the activity level of certain
people with schizophrenia, employing the expertise neurons
of medical professionals, social workers, and psy- behavioral approaches approaches to psychopathology
chologists to meet the variety of patients' needs that focus on the influence of reinforcements and
24 hours a day punishments in producing behavior; the two core
assessment process of gathering information about a principles or processes of learning according to
person's symptoms and their possible causes behaviorism are classical conditioning and operant
association studies genetic studies in which conditioning
researchers identify physical disorders associated behavioral inhibition set of behavioral traits
with a target psychological disorder for which including shyness, fearfulness, irritability,
genetic abnormalities or markers are known; cautiousness, and introversion; behaviorally
the DNA of individuals with the psychological inhibited children tend to avoid or withdraw
disorder and their first-degree relatives is then from novel situations, are clingy with parents,
examined to determine if they also have this and become excessively aroused when exposed to
genetic marker (one form of molecular genetic unfamiliar situations
studies) behavioral observation method for assessing the
attention-deficit/hyperactivity disorder (ADHD) frequency of a client's behaviors and the specific
syndrome marked by deficits in controlling atten- situations in which they occur
tion, inhibiting impulses, and organizing behavior behavioral theories of depression theories that view
to accomplish long-term goals depression as resulting from negative life events
atypical antipsychotics drugs that seem to be even that represent a reduction in positive reinforcement;
more effective in treating schizophrenia than pheno- sympathetic responses to depressive behavior
thiazines without the same neurological side effects; then serve as positive reinforcement for the
they bind to a different type of dopamine receptor depression itself
than other neuroleptic drugs behavioral therapies psychotherapeutic approaches
auditory hallucinations auditory perceptions of a phe- that focus on identifying the reinforcements and
nomenon that is not real, such as hearing a voice punishments contributing to a person's maladaptive
when one is alone behaviors and on changing specific behaviors
autism childhood disorder marked by deficits in behavioral therapy therapy that focuses on changing a
social interaction (such as a lack of interest in person's specific behaviors by replacing unwanted
one's family or other children), communication behaviors with desired behaviors
(such as failing to modulate one's voice to behavior genetics study of the processes by which
signify emotional expression), and activities genes affect behavior and the extent to which per-
and interests (such as engaging in bizarre, sonality and abnormality are genetically inherited
repetitive behaviors) behaviorism study of the impact of reinforcements and
autism spectrum disorder a spectrum of neurodevel- punishments on behavior
opmental disorders characterized by disrupted benzodiazepines drugs that reduce anxiety and
social and language development (formerly referred insomnia
to as autism) beta-amyloid class of proteins that accumulates in the
aversion therapy treatment that involves the spaces between neurons in the brain, contributing to
pairing of unpleasant stimuli with deviant or Alzheimer's disease
maladaptive sources of pleasure in order to induce binge-eating disorder eating disorder in which people
an aversive reaction to the formerly pleasurable compulsively overeat either continuously or on dis-
stimulus crete binges but do not behave in ways to compen-
avoidant personality disorder pervasive anxiety, sense sate for the overeating
of inadequacy, and fear of being criticized that lead bingeing eating a large amount of food in one sitting
G-3 Glossary
binge/purge type of anorexia nervosa type of anorexia catatonia group of disorganized behaviors that reflect an
nervosa in which periodic bingeing or purging be- extreme lack of responsiveness to the outside world
haviors occur along with behaviors that meet the catharsis expression of emotions connected to memo-
criteria for anorexia nervosa ries and conflicts, which, according to Freud, leads
biological approach view that biological factors cause to the release of energy used to keep these memories
and should be used to treat abnormality in the unconscious
biological theories theories of abnormality that focus causal attribution explanation for why an event
on biological causes of abnormal behaviors occurred
biopsychosocial approach approach to psychopathol- central sleep apnea sleep disorder characterized by
ogy that seeks to integrate biological, psychological, complete cessation of respiratory activity for brief
and social factors in understanding and treating periods of time (20 seconds or more); sufferers do not
psychopathology have frequent awakenings and do not tend to feel
bipolar disorder disorder marked by cycles between tired during the day; occurs when the brain does not
manic episodes and depressive episodes; also called send the signal to breathe to the respiratory system
manic-depression cerebral cortex part of the brain that regulates complex
bipolar I disorder form of bipolar disorder in which activities, such as speech and analytical thinking
the full symptoms of mania are experienced; depres- cerebrovascular disease disease that occurs when the
sive aspects may be more infrequent or mild blood supply to the brain is blocked, causing tissue
bipolar II disorder form of bipolar disorder in which damage to the brain
only hypomanic episodes are experienced and the childhood-onset conduct disorder a conduct disorder
depressive component is more pronounced characterized by aggression, destructiveness, deceit-
blood-injection-injury type phobias extreme fears of fulness, and rules violation beginning before age 10
seeing blood or an injury or of receiving an injec- that tends to worsen with age
tion or another invasive medical procedure, which chlorpromazine antipsychotic drug
cause a drop in heart rate and blood pressure and chronic motor or vocal tic disorder (CMVTD) a
fainting motor disorder characterized by persistent motor
body dysmorphic disorder syndrome involving obses- or vocal tics
sive concern over a part of the body the individual circadian rhythm sleep-wake disorder sleep disorder
believes is defective characterized by insomnia, excessive sleepiness, or
borderline personality disorder syndrome character- both due to disruptions in circadian rhythms
ized by rapidly shifting and unstable mood, self- civil commitment forcing of a person into a mental
concept, and interpersonal relationships, as well as health facility against his or her will
impulsive behavior and transient dissociative states classical conditioning form of learning in which a neu-
breathing-related sleep disorder group of sleep disor- tral stimulus becomes associated with a stimulus that
ders characterized by numerous brief sleep distur- naturally elicits a response, thereby making the neu-
bances due to problems breathing tral stimulus itself sufficient to elicit the same response
brief psychotic disorder disorder characterized by the classification system set of syndromes and the rules for
sudden onset of delusions, hallucinations, disorga- determining whether an individual's symptoms are
nized speech, and/ or disorganized behavior that part of one of these syndromes
lasts only between 1 day and 1 month, after which client-centered therapy (CCT) Carl Rogers's form of
the symptoms vanish completely psychotherapy, which consists of an equal relation-
bulimia nervosa eating disorder in which people en- ship between therapist and client as the client
gage in bingeing and behave in ways to prevent searches for his or her inner self, receiving uncon-
weight gain from the binges, such as self-induced ditional positive regard and an empathic under-
vomiting, excessive exercise, and abuse of purging standing from the therapist
drugs (such as laxatives) cocaine central nervous system stimulant that causes a
rush of positive feelings initially but that can lead to
c impulsiveness, agitation, and anxiety and can cause
withdrawal symptoms of exhaustion and depression
caffeine chemical compound with stimulant effects cognitions thoughts or beliefs
cannabis substance that causes feelings of well-being, cognitive-behavioral therapy (CBT) treatment focused
perceptual distortions, and paranoid thinking on changing negative patterns of thinking and
case studies in-depth analyses of individuals solving concrete problems through brief sessions in
cataplexy episodes of sudden loss of muscle tone last- which a therapist helps a client challenge negative
ing under 2 minutes, triggered by laughter or joking thoughts, consider alternative perspectives, and take
in people who have had narcolepsy for a long time effective actions
Glossary G-4
cognitive theories theories that focus on belief sys- somewhere along a continuum from healthy,
tems and ways of thinking as the causes of abnor- functional behaviors, thoughts, and feelings to
mal behavior unhealthy, dysfunctional behaviors, thoughts, and
cognitive therapies therapeutic approaches that focus feelings
on changing people's maladaptive thought patterns control group in an experimental study, group of
cohort effect effect that occurs when people born in subjects whose experience resembles that of the
one historical period are at different risk for a disor- experimental group in all ways except that they do
der than are people born in another historical period not receive the key manipulation
collective unconscious according to Carl Jung, the conversion disorder (functional neurological symp-
wisdom accumulated by a society over hundreds of tom disorder) syndrome marked by a sudden loss of
years of human existence and stored in the memo- functioning in a part of the body, usually following
ries of individuals an extreme psychological stressor
communication disorders disorders characterized by coronary heart disease (CHD) chronic illness that is a
persistent difficulties in the acquisition and use of leading cause of death in the United States, occur-
language and other means of communicating ring when the blood vessels that supply the heart
community mental health centers institutions for the with oxygen and nutrients are narrowed or closed
treatment of people with mental health problems in by plaque, resulting in a myocardial infarction
the community; may include teams of social work- (heart attack) when closed completely
ers, therapists, and physicians who coordinate care correlational studies method in which researchers
community mental health movement movement assess only the relationship between two variables
launched in 1963 that attempted to provide and do not manipulate one variable to determine
coordinated mental health services to people in its effects on another variable
community-based treatment centers correlation coefficient statistic used to indicate the
comorbidity meeting the criteria for two or more diag- degree of relationship between two variables
nostic categories simultaneously cortisol hormone that helps the body respond to
compulsions repetitive behaviors or mental acts that stressors, inducing the fight-or-flight response
an individual feels he or she must perform cross-sectional type of research examining people at one
computerized tomography (CT) method of analyzing point in time but not following them over time
brain structure by passing narrow X-ray beams cultural relativism view that norms among cultures
through a person's head from several angles to pro- set the standard for what counts as normal behavior,
duce measurements from which a computer can which implies that abnormal behavior can only be
construct an image of the brain defined relative to these norms and that no univer-
concordance rate probability that both twins will sal definition of abnormality is therefore possible;
develop a disorder if one twin has the disorder only definitions of abnormality relative to a specific
conditioned avoidance response behavior that is culture are possible
reinforced because it allows individuals to avoid cyclothymic disorder milder but more chronic form of
situations that cause anxiety bipolar disorder that consists of alternation between
conditioned response (CR) in classical conditioning, hypomanic episodes and mild depressive episodes
response that first followed a natural stimulus but over a period of at least 2 years
that now follows a conditioned stimulus
conditioned stimulus (CS) in classical conditioning,
previously neutral stimulus that, through pairing D
with a natural stimulus, becomes sufficient to elicit dangerousness to others legal criterion for involuntary
a response commitment that is met when a person would pose
conduct disorder syndrome marked by chronic disre- a threat or danger to other people if not incarcerated
gard for the rights of others, including specific be- dangerousness to self legal criterion for involuntary
haviors such as stealing, lying, and engaging in acts commitment that is met when a person is immi-
of violence nently suicidal or a danger to him- or herself as
conscious refers to mental contents and processes of judged by a mental health professional
which we are actively aware day treatment centers mental health facilities that al-
continuous variable factor that is measured along a con- low people to obtain treatment, along with occupa-
tinuum (such as 0-100) rather than falling into a dis- tional and rehabilitative therapies, during the day
crete category (such as "diagnosed with depression") but to live at home at night
continuum model of abnormality model of abnormal- deep brain stimulation procedure to treat depression
ity that views mental disorders not as categorically in which electrodes are surgically implanted in
different from "normal" experiences but as lying specific areas of the brain and connected to a pulse
G-5 Glossary
generator that is placed under the skin and psychomotor agitation or retardation, and trouble
stimulates these brain areas concentrating
defense mechanisms strategies the ego uses to disguise depressive disorders a set of disorders characterized by
or transform unconscious wishes depressed mood and / or anhedonia (and not mania)
degradation process in which a receiving neuron re- desensitization treatment used to reduce anxiety
leases an enzyme into the synapse, breaking down by rendering a previously threatening stimulus
neurotransmitters into other biochemicals innocuous by repeated and guided exposure to the
deinstitutionalization movement in which thousands of stimulus under nonthreatening circumstances
mental patients were released from mental institu- detachment the inability to connect with others
tions; a result of the patients' rights movement, which developmental coordination disorder disorder involving
was aimed at stopping the dehumanization of mental deficits in the ability to walk, run, or hold on to objects
patients and at restoring their basic legal rights diagnosis label given to a set of symptoms that tend to
delayed ejaculation marked delay, infrequency, or occur together
absence of ejaculation during sexual encounters Diagnostic and Statistical Manual of Mental Disorders
delirium cognitive disorder including disorientation (DSM) official manual for diagnosing mental disor-
and memory loss that is acute and usually ders in the United States, containing a list of specific
transient criteria for each disorder, how long a person's symp-
delirium tremens (DTs) symptoms that result during toms must be present to qualify for a diagnosis, and
severe alcohol withdrawal, including hallucinations, requirements that the symptoms interfere with daily
delusions, agitation, and disorientation functioning in order to be called disorders
delusional disorder disorder characterized by delu- dialectical behavior therapy cognitive-behavioral in-
sions lasting at least 1 month regarding situations tervention aimed at teaching problem-solving skills,
that occur in real life, such as being followed, poi- interpersonal skills, and skill at managing negative
soned, or deceived by a spouse or having a disease; emotions
people with this disorder do not show any other diathesis-stress model model that asserts that only
symptoms of schizophrenia when a diathesis or vulnerability interacts with a
delusion of reference false belief that external events, stress or trigger will a disorder emerge
such as other people's actions or natural disasters, disinhibition lack of restraint
relate somehow to oneself disorders of arousal sleep disorders that involve recur-
delusions fixed beliefs with no basis in reality rent episodes of incomplete awakening from sleep
delusions of thought insertion beliefs that one's that seem to mix elements of wakefulness and
thoughts are being controlled by outside forces NREMsleep
demand characteristics factors in an experiment that disruptive mood dysregulation disorder a disorder
suggest to participants how the experimenter would in children characterized by immature and inappro-
like them to behave priate temper outbursts that are grossly out of pro-
dementia cognitive disorder in which a gradual and portion to a situation in intensity and duration
usually permanent decline of intellectual function- dissociation process whereby different facets of an in-
ing occurs; can be caused by a medical condition, dividual's sense of self, memories, or consciousness
substance intoxication, or withdrawal become split off from one another
dependent personality disorder people suffering from dissociative amnesia loss of memory for important
this disorder are anxious about interpersonal inter- facts about a person's own life and personal identity,
actions, but their anxiety sterns from a deep need to usually including the awareness of this memory loss
be cared for by others, rather than from a concern dissociative fugue disorder in which a person moves
that they will be criticized away and assumes a new identity, with amnesia for
dependent variable factor that an experimenter seeks the previous identity
to predict dissociative identity disorder (DID) syndrome in
depersonalization/derealization disorder syndrome which a person develops more than one distinct
marked by frequent episodes of feeling detached identity or personality, each of which can have dis-
from one's own body and mental processes, as if one tinct facial and verbal expressions, gestures, inter-
were an outside observer of oneself; symptoms must personal styles, attitudes, and even physiological
cause significant distress or interference with one's responses
ability to function dizygotic (DZ) twins twins who average only 50 percent
depressants drugs that slow the nervous system of their genes in common because they developed
depression state marked by either a sad mood or a from two separate fertilized eggs
loss of interest in one's usual activities, as well dopamine neurotransmitter in the brain, excess amounts
as feelings of hopelessness, suicidal ideation, of which have been thought to cause schizophrenia
Glossary G-6
double-blind experiment study in which both there- epigenetics study of how environmental conditions
searchers and the participants are unaware of which can change the expression of genes without chang-
experimental condition the participants are in, in ing the gene sequence
order to prevent demand effects erectile disorder in men, recurrent inability to attain
Durham rule legal principle stating that the presence of or maintain an erection until the completion of
a mental disorder is sufficient to absolve an individ- sexual activity
ual of responsibility for a crime excessive reassurance seeking constantly looking
dysthymic disorder type of depression that is less for assurances from others that one is accepted
acute than major depression but more chronic; diag- and loved
nosis requires the presence of a sad mood or anhe- executive functions functions of the brain that involve
donia, plus two other symptoms of depression, for the ability to sustain concentration; use abstract rea-
at least 2 years, during which symptoms do not soning and concept formation; anticipate, plan, and
remit for 2 months or longer program; initiate purposeful behavior; self-monitor;
and shift from maladaptive patterns of behavior to
more adaptive ones
E exhibitionist disorder obtainment of sexual gratification
early ejaculation recurrent ejaculation within 1 minute by exposing one's genitals to involuntary observers
of initiation of partnered sexual activity when not experimental group in an experimental study, group of
desired participants that receive the key manipulation
eating disorder not otherwise specified (EDNOS) experimental studies studies in which the independent
diagnosis for individuals who have some symptoms variables are directly manipulated and the effects on
of anorexia or bulimia nervosa but do not meet the the dependent variable are examined
full criteria exposure and response prevention type of therapy in
echolalia communication abnormality in which an which individuals with anxiety symptoms are ex-
individual simply repeats back what he or she hears posed repeatedly to the focus of their anxiety but
rather than generating his or her own speech prevented from avoiding it or engaging in compul-
effectiveness in therapy outcome research, how well sive responses to the anxiety
a therapy works in real-world settings expressed emotion family interaction style in which
efficacy in therapy outcome research, how well a therapy families are over-involved with each other, are over-
works in highly controlled settings with a narrowly protective of the disturbed family member, voice
defined group of people self-sacrificing attitudes to the disturbed family
ego part of the psyche that channels libido to be member, and simultaneously are critical, hostile,
acceptable to the superego and within the con- and resentful of this member
straints of reality external validity extent to which a study's results can
egoistic suicide suicide committed by people who feel be generalized to phenomena in real life
alienated from others and who lack social support
ego psychology branch of psychodynamic theory em-
phasizing the importance of the individual's ability F
to regulate defenses in ways that allow healthy factitious disorder disorder marked by deliberately
functioning within the realities of society faking physical or mental illness to gain medical
electroconvulsive therapy (ECT) treatment for depres- attention
sion that involves the induction of a brain seizure by factitious disorder imposed on another disorder in
passing electrical current through the patient's brain which the individual creates an illness in another
while he or she is anesthetized individual in order to gain attention
electroencephalogram (EEG) procedure in which mul- family-focused therapy treatment for people with bipo-
tiple electrodes are placed on the scalp to detect low- lar disorder in which patients and their families are
voltage electrical current produced by the firing of given education about bipolar disorder and training
specific neurons in the brain in communication and problem-solving skills
elimination disorders disorders in which a child shows family history study study of the heritability of a disor-
frequent, uncontrolled urination or defecation far der involving identifying people with the disorder
beyond the age at which children usually develop and people without the disorder and then determin-
control over these functions ing the disorder's frequency within each person's
endocrine system system of glands that produces family
many different hormones family systems theories theories that see the family
epidemiology study of the frequency and distribution as a complex system that works to maintain the
of a disorder, or a group of disorders, in a population status quo
G-7 Glossary
family systems therapy psychotherapy that focuses on sex's genitals and is fundamentally a person of the
the family, rather than the individual, as the source opposite sex
of problems; family therapists challenge communi- gender identity one's perception of oneself as male
cation styles, disrupt pathological family dynamics, or female
and challenge defensive conceptions in order to generalizability extent to which the results of a study
harmonize relationships among all members and generalize to, or inform us about, people other than
within each member those who were studied
female orgasmic disorder in women, recurrent delay genito-pelvic pain/penetration disorder marked diffi-
in or absence of orgasm after having reached the culty having vaginal penetration; pain or tightening
excitement phase of the sexual response cycle (also of pelvic floor muscles during penetration
called anorgasmia) generalized anxiety disorder (GAD) anxiety disorder
female sexual interest/arousal disorder in women, re- characterized by chronic anxiety in daily life
current inability to attain or maintain the swelling- general paresis disease that leads to paralysis, insanity,
lubrication response of sexual excitement and eventually death; discovery of this disease
fetal alcohol syndrome (FAS) syndrome that occurs helped establish a connection between biological
when a mother abuses alcohol during pregnancy, diseases and mental disorders
causing the baby to have lowered IQ, increased risk global assumptions fundamental beliefs that encom-
for mental retardation, distractibility, and difficulties pass all types of situations
with learning from experience grandiose delusions false, persistent beliefs that one
fetishistic disorder paraphilic disorder in which a per- has superior talents and traits
son uses inanimate objects as the preferred or exclu- grave disability legal criterion for involuntary commit-
sive source of sexual arousal ment that is met when a person is so incapacitated
fight-or-flight response physiological changes in the by a mental disorder that he or she cannot provide
human body that occur in response to a perceived his or her own basic needs, such as food, clothing,
threat, including the secretion of glucose, endor- or shelter, and his or her survival is threatened as
phins, and hormones as well as the elevation of a result
heart rate, metabolism, blood pressure, breathing, group comparison study study that compares two or
and muscle tension more distinct groups on a variable of interest
five-factor model a dimensional perspective that posits guided mastery techniques interventions designed to
that everyone's personality is organized along five increase health-promoting behaviors by providing
broad personality traits: negative emotionality, ex- explicit information about how to engage in these
traversion, openness to experience, agreeableness, behaviors, as well as opportunities to engage in the
and conscientiousness behaviors in increasingly challenging situations
flooding behavioral technique in which a client is in- guilty but mentally ill (GBMI) verdict that requires a
tensively exposed to a feared object until the anxiety convicted criminal to serve the full sentence desig-
diminishes (also called implosive therapy) nated for his or her crime, with the expectation
folk illnesses problems held by a particular culture to that he or she will also receive treatment for mental
be caused by natural forces, supernatural forces, and illness
strong emotions, etc.
formal thought disorder state of highly disorganized
thinking (also known as loosening of associations) H
free association method of uncovering unconscious con- hair-pulling disorder disorder characterized by recur-
flicts in which the client is taught to talk about what- rent pulling out of the hair resulting in noticeable
ever comes to mind, without censoring any thoughts hair loss; these individuals report tension immedi-
frotteuristic disorder disorder characterized by obtain- ately before or while attempting to resist the im-
ment of sexual gratification by rubbing one's geni- pulse, and pleasure or relief when they are pulling
tals against or fondling the body parts of a out their hair (also known as trichotillomania)
nonconsenting person halfway houses living facilities that offer people with
long-term mental health problems the opportunity
to live in a structured, supportive environment
G while they are trying to reestablish employment and
gambling disorder a disorder, similar to substance ties to family and friends
abuse, characterized by the inability to resist the hallucinations perceptual experiences that are not real
impulse to gamble hallucinogens substances, including LSD and MDMA
gender dysphoria condition in which a person (ecstasy), that produce perceptual illusions and dis-
believes that he or she was born with the wrong tortions even in small doses
Glossary G-8
harm reduction model approach to treating substance

use disorders that views alcohol use as normative
behavior and focuses education on the immediate id according to Freud, most primitive part of the un-
risks of the excessive use of alcohol (such as conscious; consists of drives and impulses seeking
alcohol-related accidents) and on the payoffs of immediate gratification
moderation (such as avoidance of hangovers) illness anxiety disorder a form of anxiety characterized
hippocampus structure of the brain involved in mem- by a preoccupation with fears of having a serious
ory and in the stress response medical illness based on misinterpretations of bodily
histrionic personality disorder sharing features with sensations (formerly called hypochondriasis)
borderline personality disorder, including rapidly immune system system that protects the body from
shifting emotions and intense, unstable relation- disease-causing microorganisms and affects suscep-
ships, people with this disorder also behave in ways tibility to diseases
to draw attention to themselves across situations impulsivity difficulty controlling behaviors; acting
hoarding a compulsive disorder characterized by the without thinking first
inability to throw away unneeded possessions (such incidence number of new cases of a specific disorder
as trash) that develop during a specific period of time
hopelessness sense that the future is bleak and there is incompetent to stand trial legal status of an individual
no way to make it more positive who lacks a rational understanding of the charges
hormone chemical that carries messages throughout against him or her, an understanding of the pro-
the body, potentially affecting a person's mood, ceedings of his or her trial, or the ability to partici-
level of energy, and reaction to stress pate in his or her defense
humanistic theories views that people strive to independent variable factor that is manipulated by
develop their innate potential for goodness and an experimenter or used to predict the dependent
self-actualization; abnormality arises as a result of variable
societal pressures to conform to unchosen dictates informed consent procedure (often legally required
that clash with a person's self-actualization needs prior to treatment administration) in which a patient
and from an inability to satisfy more basic needs, receives a full and understandable explanation of the
such as hunger treatment being offered and makes a decision about
humanistic therapy type of therapy in which the goal whether to accept or refuse the treatment
is to help the client discover his or her place in the inhalants solvents, such as gasoline, glue, or paint thin-
world and to accomplish self-actualization through ner, that one inhales to produce a high and that can
self-exploration; based on the assumption that the cause permanent central nervous system damage as
natural tendency for humans is toward growth (also well as liver and kidney disease
called person-centered therapy) insanity legal term denoting a state of mental incapaci-
human laboratory study experimental study involving tation during the time a crime was committed
human participants insanity defense defense used by people accused of a
hypersomnolence disorders disorders characterized crime in which they state that they cannot be held
by excessive sleepiness, which can be expressed as responsible for their illegal acts because they were
either an excessive quantity of sleep (also referred mentally incapacitated at the time of the act
to as hypersomnia) or a low quality of wakefulness Insanity Defense Reform Act 1984law, affecting all fed-
hypertension condition in which the blood supply eral courts and about half the state courts, that finds a
through the blood vessels is excessive and can lead person not guilty by reason of insanity if it is shown
to deterioration of the cell tissue and hardening of that, as a result of mental disease or mental retarda-
the arterial walls tion, the accused was unable to appreciate the wrong-
hypomania state in which an individual shows mild fulness of his or her conduct at the time of the offense
symptoms of mania insomnia disorder a disorder characterized by chronic
hypothalamic-pituitary-adrenal axis (HPA axis) three difficulty initiating or maintaining sleep or by sleep
key components of the neuroendocrine system that that does not restore energy and alertness
work together in a feedback system interconnected intellectual development disorder a spectrum of neu-
with the limbic system and the cerebral cortex rodevelopmental disorders characterized by im-
hypothalamus component of the brain that regulates paired general intellectual functioning (formerly
eating, drinking, sex, and basic emotions; abnormal referred to as mental retardation)
behaviors involving any of these activities may be intelligence tests tests that assess a person's intellec-
the result of dysfunction in the hypothalamus tual strengths and weaknesses
hypothesis testable statement about two or more intermittent explosive disorder disorder characterized
variables and the relationship between them by (a) several episodes of failure to resist aggressive
G-9 Glossary
impulses that result in serious assaultive acts or de- lithium drug used to treat manic and depressive
struction of property, (b) a degree of aggressiveness symptoms
grossly out of proportion to the situation, and locus ceruleus area of the brain stem that plays a part
(c) symptoms not better explained by another men- in the emergency response and may be involved in
tal disorder (such as antisocial personality disorder), panic attacks
the effects of substances, or a medical condition longitudinal type of research evaluating the same
(e.g., a head trauma) group(s) of people for an extended period of time
internal validity extent to which all factors that could
extraneously affect a study's results are controlled
within a laboratory study M
interoceptive awareness sensitivity to stimuli arising magnetic resonance imaging (MRI) method of mea-
from within the body, such as heart rate suring both brain structure and brain function
interoceptive conditioning process by which symp- through the construction of a magnetic field that af-
toms of anxiety that have preceded panic attacks fects hydrogen atoms in the brain, emitting signals
become the signals for new panic attacks that a computer then records and uses to produce a
interpersonal and social rhythm therapy (ISRT) three-dimensional image of the brain
treatment for people with bipolar disorder that major depressive disorder disorder involving a sad
helps them manage their social relationships and mood or anhedonia plus four or more of the follow-
daily rhythms to try to prevent relapse ing symptoms: weight loss or a decrease in appetite,
interpersonal theories of depression theories that view insomnia or hypersomnia, psychomotor agitation or
the causes of depression as rooted in interpersonal retardation, fatigue, feelings of worthlessness or se-
relationships vere guilt, trouble concentrating, and suicidal ide-
interpersonal therapy (IPT) more structured, short- ation; these symptoms must be present for at least
term version of psychodynamic therapies 2 weeks and must produce marked impairments
irresistible impulse rule legal principle stating that even in normal functioning
a person who knowingly performs a wrongful act can major neurocognitive disorder a brain disorder charac-
be absolved of responsibility if he or she was driven terized by a deteriorating course of deficits in neuro-
by an irresistible impulse to perform the act or had a cognitive functioning (e.g., memory, attention) that
diminished capacity to resist performing the act interferes significantly with independent living
male hypoactive sexual desire disorder condition in
which a man's desire for sex is diminished to the
l point that it causes him significant distress or inter-
language disorder a communication disorder character- personal difficulties and is not due to transient life
ized by difficulties with spoken and written language circumstances or another sexual dysfunction
and other language modalities (e.g., sign language) malingering feigning of a symptom or a disorder for
learned helplessness theory view that exposure to un- the purpose of avoiding an unwanted situation,
controllable negative events leads to a belief in one's such as military service
inability to control important outcomes and a subse- managed care health care system in which all necessary
quent loss of motivation, indecisiveness, and failure services for an individual patient are supposed to be
of action coordinated by a primary care provider; the goals
libido according to Freud, psychical energy derived are to coordinate services for an existing medical
from physiological drives problem and to prevent future medical problems
life-course-persistent antisocial behavior a form of mania state of persistently elevated mood, feelings of
conduct disorder involving aggression, destructive- grandiosity, overenthusiasm, racing thoughts, rapid
ness, deceitfulness, and rules violation that persists speech, and impulsive actions
into adulthood mental hygiene movement movement to treat mental
light therapy treatment for seasonal affective disorder patients more humanely and to view mental disor-
that involves exposure to bright lights during the ders as medical diseases
winter months mental illness phrase used to refer to a physical illness
limbic system part of the brain that relays information that causes severe abnormal thoughts, behaviors,
from the primitive brain stem about changes in and feelings
bodily functions to the cortex, where the informa- mentalization-based treatment a form of psychody-
tion is interpreted namic treatment for borderline personality disorder
linkage analysis genetic study that looks for associa- based on attachment
tions between psychological disorders and physical mesmerism treatment for hysterical patients based on
disorders for which genetic causes are known the idea that magnetic fluids in the patients' bodies
Glossary G-10
are affected by the magnetic forces of other people problems, and the third axis representing global
and objects; the patients' magnetic forces are level of functioning
thought to be realigned by the practitioner through multiple baseline design type of study in which an in-
his or her own magnetic force tervention is given to the same individual but begun
mesolimbic pathway subcortical part of the brain in different settings or is given to different individu-
involved in cognition and emotion als but at different points in time and in which the
meta-analysis statistical technique for summarizing effects of the intervention are systematically observed
results across several studies
methadone opioid that is less potent and longer-lasting
than heroin; taken by heroin users to decrease their N
cravings and help them cope with negative with- narcissistic personality disorder syndrome marked by
drawal symptoms grandiose thoughts and feelings of one's own worth
minor neurocognitive disorder a brain disorder char- as well as an obliviousness to others' needs and an
acterized by a deteriorating course of deficits in neu- exploitative, arrogant demeanor
rocognitive functioning (e.g., memory, attention) narcolepsy sleep disorder characterized by irresistible
that is not so severe that it interferes significantly attacks of sleep plus (1) cataplexy or (2) recurrent
with independent living intrusions of elements of rapid eye movement
M'Naghten rule legal principle stating that, in order to (REM) sleep into the transition between sleep and
claim a defense of insanity, accused persons must wakefulness
have been burdened by such a defect of reason, from narcolepsy/hypocretin deficiency disorder recurrent
disease of the mind, as not to know the nature and attacks of an irrepressible need to sleep, lapses into
quality of the act they were doing or, if they did know sleep, or naps occurring within the same day accom-
it, as not to know what they were doing was wrong panied by low levels of hypocretin and cataplexy or
modeling process of learning behaviors by imitating oth- abnormally short onset of REM sleep
ers, especially authority figures or people like oneself natural environment type phobias extreme fears of
molecular genetic studies studies of the structure and events or situations in the natural environment that
function of genes that help in understanding how cause impairment in one's ability to function normally
genetic mutations can lead to disease need for treatment legal criterion operationalized as a
monoamine oxidase inhibitors (MAO Is) class of anti- signed certificate by two physicians stating that a
depressant drugs person requires treatment but will not agree to it
monoamines neurotransmitters, including catechol- voluntarily; formerly a sufficient cause to hospitalize
amines (epinephrine, norepinephrine, and dopa- the person involuntarily and force him or her to
mine) and serotonin, that have been implicated in undergo treatment
the mood disorders negative affectivity a dimension of personality charac-
monozygotic (MZ) twins twins who share 100 percent terized by negative mood states
of their genes because they developed from a single negative cognitive triad perspective seen in depressed
fertilized egg people in which they have negative views of them-
moral treatment type of treatment delivered in mental selves, of the world, and of the future
hospitals in which patients were treated with negative reinforcement process in which people avoid
respect and dignity and were encouraged to exer- being exposed to feared objects and their avoidance is
cise self-control reinforced by the subsequent reduction of their anxiety
motivational interviewing intervention for sufferers of negative symptoms in schizophrenia, deficits in
substance use disorders to elicit and solidify indi- functioning that indicate the absence of a capacity
viduals' motivation and commitment to changing present in people without schizophrenia, such as
their substance use; rather than confronting the user, restricted affect
the motivational interviewer adopts an empathic neurocognitive disorders behavioral disorders known
interaction style, drawing out the user's own state- or presumed to result from disruptions of brain
ments of desire, ability, reasons, need, and, ulti- structure and functioning
mately, commitment to change neurodevelopmental disorders behavioral disorders
motor disorders a group of disorders characterized by with onset during childhood known or presumed
motor symptoms such as tics, stereotypic move- to result at least in part from disruption of brain
ments, or dyscoordination development
multiaxial system a system of diagnoses on three neurofibrillary tangles twists or tangles of filaments
axes used by the DSM-5, with the first axis repre- within nerve cells, especially prominent in the cere-
senting mental disorders, the second axis repre- bral cortex and hippocampus, common in the brains
senting psychosocial and environmental of Alzheimer's disease patients
G-11 Glossary
neuroleptics drugs used to treat psychotic symptoms obsessive-compulsive personality disorder pervasive
neuropsychological tests tests of cognitive, sensory, rigidity in one's activities and interpersonal relation-
and / or motor skills that attempt to differentiate ships; includes qualities such as emotional constric-
people with deficits in these areas from normal tion, extreme perfectionism, and anxiety resulting
subjects from even slight disruptions in one's routine
neurotransmitters biochemicals, released from a send- obstructive sleep apnea hypopnea syndrome sleep
ing neuron, that transmit messages to a receiving disorder characterized by repeated episodes of
neuron in the brain and nervous system upper-airway obstruction during sleep
nicotine alkaloid found in tobacco; operates on both operant conditioning form of learning in which behav-
the central and peripheral nervous systems, result- iors lead to consequences that either reinforce or
ing in the release of biochemicals, including dopa- punish the organism, leading to an increased or a
mine, norepinephrine, serotonin, and the decreased probability of a future response
endogenous opioids operationalization specific manner in which variables
night eating disorder an eating disorder characterized in a study are measured or manipulated
by the regular intake of excessive amounts of food opioids substances, including morphine and heroin,
after dinner and into the night that produce euphoria followed by a tranquil state;
nightmare disorder sleep disorder characterized by in severe intoxication, can lead to unconsciousness,
nightmares frequent enough to cause significant coma, and seizures; can cause withdrawal symp-
distress or impairment in functioning toms of emotional distress, severe nausea, sweating,
nonsuicidal self-injury (NSSI) act of deliberately cut- diarrhea, and fever
ting, burning, puncturing, or otherwise significantly oppositional defiant disorder syndrome of chronic
injuring one's skin with no intent to die misbehavior in childhood marked by belligerence,
norepinephrine neurotransmitter that is involved in irritability, and defiance, although not to the extent
the regulation of mood found in a diagnosis of conduct disorder
norepinephrine-dopamine reuptake inhibitors drugs organic amnesia loss of memory caused by brain injury
used to treat depression; inhibit the reuptake of both resulting from disease, drugs, accidents (blows to
norepinephrine and dopamine head), or surgery
null hypothesis alternative to a primary hypothesis, orgasm discharge of neuromuscular tension built up dur-
stating that there is no relationship between the ing sexual activity; in men, entails rhythmic contrac-
independent variable and the dependent variable tions of the prostate, seminal vesicles, vas deferens,
and penis and seminal discharge; in women, entails
contractions of the orgasmic platform and uterus
0
obesity condition of being significantly overweight, de-
fined by the Centers for Disease Control as a body
p
mass index (BMI) of 30 or over, where BMI is calcu- palilalia continuous repetition of sounds and words
lated as weight in pounds multiplied by 703, then panic attacks short, intense periods during which an
divided by the square of height in inches individual experiences physiological and cognitive
object relations view held by a group of modern psy- symptoms of anxiety, characterized by intense fear
chodynamic theorists that one develops a self- and discomfort
concept and appraisals of others in a four-stage panic disorder disorder characterized by recurrent,
process during childhood and retains them through- unexpected panic attacks
out adulthood; psychopathology consists of an in- paraphilic disorder disorder characterized by atypical
complete progression through these stages or an sexual activity that involves one of the following:
acquisition of poor self- and other concepts (1) nonhuman objects, (2) nonconsenting adults,
observational learning learning that occurs when a (3) the suffering or humiliation of oneself or one's
person observes the rewards and punishments of partner, or (4) children
another's behavior and then behaves in accordance patients' rights movement movement to ensure that
with the same rewards and punishments mental patients retain their basic rights and tore-
obsessions uncontrollable, persistent thoughts, images, move them from institutions and care for them in
ideas, or impulses that an individual feels intrude the community
on his or her consciousness and that cause signifi- pedophilic disorder disorder characterized by adult
cant anxiety or distress obtainment of sexual gratification by engaging in
obsessive-compulsive disorder (OCD) anxiety disor- sexual activities with young children
der characterized by obsessions (persistent performance anxiety anxiety over sexual performance
thoughts) and compulsions (rituals) that interferes with sexual functioning
Glossary G-12
persecutory delusions false, persistent beliefs that one preconscious according to Freud, area of the psyche
is being pursued by other people that contains material from the unconscious before
personality patterns of thinking, emotions, and behav- it reaches the conscious mind
ior that tend to be enduring premenstrual dysphoric disorder a set of symptoms
personality disorder chronic pattern of maladaptive occurring immediately prior to onset of menses
cognition, emotion, and behavior that begins by characterized by a mixture of depression, anxiety
adolescence or early adulthood and continues into and tension, and irritability and anger; may occur in
later adulthood mood swings during the week before onset of men-
personality inventories questionnaires that assess peo- ses and subside once menses has begun
ple's typical ways of thinking, feeling, and behaving; prepared classical conditioning theory that evolution
used to obtain information about people's well- has prepared people to be easily conditioned to fear
being, self-concept, attitudes, and beliefs objects or situations that were dangerous in ancient
personality trait a facet of personality on which people times
differ from one another prevalence proportion of the population who have
pervasive developmental disorders disorders charac- a specific disorder at a given point or period in
terized by severe and persisting impairment in sev- time
eral areas of development primary prevention prevention of the development of
phencyclidine (PCP) substance that produces eupho- psychological disorders before they start
ria, slowed reaction times, and involuntary move- prodromal symptoms in schizophrenia, milder symp-
ments at low doses; disorganized thinking, feelings toms prior to an acute phase of the disorder, during
of unreality, and hostility at intermediate doses; and which behaviors are unusual and peculiar but not
amnesia, analgesia, respiratory problems, and yet psychotic or completely disorganized
changes in body temperature at high doses projective test presentation of an ambiguous stimulus,
phenothiazines drugs that reduce the functional level such as an inkblot, to a client, who then projects
of dopamine in the brain and tend to reduce the unconscious motives and issues onto the stimulus
symptoms of schizophrenia in his or her interpretation of its content
pituitary major endocrine gland that lies partly on the psychic epidemics phenomena in which large numbers
outgrowth of the brain and just below the hypothal- of people begin to engage in unusual behaviors that
amus; produces the largest number of different hor- appear to have a psychological origin
mones and controls the secretions of other endocrine psychoanalysis form of treatment for psychopathology
glands involving alleviating unconscious conflicts driving
placebo control group in a therapy outcome study, psychological symptoms by helping people gain
group of people whose treatment is an inactive sub- insight into their conflicts and finding ways of
stance (to compare with the effects of a drug) or a resolving these conflicts
non theory-based therapy providing social support psychodynamic theories theories developed by
(to compare with the effects of psychotherapy) Freud's followers but usually differing somewhat
plaques deposits of amyloid protein that accumulate in from Freud's original theories
the extracellular spaces of the cerebral cortex, hippo- psychodynamic therapies therapies focused on uncov-
campus, and other forebrain structures in people ering and resolving unconscious conflicts that drive
with Alzheimer's disease psychological symptoms
plateau phase in the sexual response cycle, period be- psychogenic amnesia loss of memory in the absence of
tween arousal and orgasm, during which excitement any brain injury or disease and thought to have
remains high but stable psychological causes
polygenic combination of many genes, each of which psychological approach approach to abnormality that
makes a small contribution to an inherited trait focuses on personality, behavior, and ways of think-
positive symptoms in schizophrenia, hallucinations, de- ing as possible causes of abnormality
lusions, and disorganization in thought and behavior psychological theories theories that view mental disor-
positron-emission tomography (PET) method of ders as caused by psychological processes, such as
localizing and measuring brain activity by detecting beliefs, thinking styles, and coping styles
photons that result from the metabolization of an psychopathology symptoms that cause mental, emo-
injected isotope tional, and/ or physical pain
post-traumatic stress disorder (PTSD) anxiety disorder psychopathy set of broad personality traits including
characterized by (1) repeated mental images of expe- superficial charm, a grandiose sense of self-worth, a
riencing a traumatic event, (2) emotional numbing tendency toward boredom and need for stimulation,
and detachment, and (3) hypervigilance and chronic pathological lying, an ability to be cunning and ma-
arousal nipulative, and a lack of remorse
G-13 Glossary
psychophysiological tests tests in which instruments relational psychoanalysis a subfield of psychoanalysis

are attached to the periphery of the body to record that emphasizes internalized relationships with other
changes due to activity in the nervous system people based on the influences of early formative re-
psychosexual stages according to Freud, stages in the lationships with parents and other attachment figures
developmental process children pass through; in repetitive transcranial magnetic stimulation (rTMS)
each stage, sex drives are focused on the stimulation biological treatment that exposes patients tore-
of certain areas of the body, and particular psycho- peated, high-intensity magnetic pulses that are
logical issues can arouse anxiety focused on particular brain structures in order to
psychosis state involving a loss of contact with reality stimulate those structures
as well as an inability to differentiate between real- repression defense mechanism in which the ego pushes
ity and one's subjective state anxiety-provoking material back into the unconscious
psychosurgery rare treatment for mental disorders in residual schizophrenia diagnosis made when a person
which a neurosurgeon attempts to destroy small ar- has already experienced a single acute phase of
eas of the brain thought to be involved in a patient's schizophrenia but currently has milder and less
symptoms debilitating symptoms
psychoticism proneness to psychotic-like symptoms, residual symptoms symptoms associated with schizo-
such as illusions phrenia, such as unusual beliefs or strange perceptual
PTSD with prominent dissociative (depersonalization/ experiences, that are present for at least six months
derealization) symptoms a form of post-traumatic resistance in psychodynamic therapy, when a client
stress disorder in which the individual experiences finds it difficult or impossible to address certain ma-
feelings of being detached from his or her mental pro- terial; the client's resistance signals an unconscious
cesses or body and of the unreality of the surroundings conflict, which the therapist then tries to interpret
resolution in the sexual response cycle, state of deep re-
laxation following orgasm in which a man loses his
R erection and a woman's orgasmic platform subsides
random assignment assignment of participants in an restless legs syndrome (RLS) creeping, crawling,
experiment to groups based on a random process tingling, itching sensations in the legs that are
rapid cycling bipolar disorder diagnosis given when a prominent enough to interfere with sleep
person has four or more cycles of mania and depres- restricted affect a symptom in which emotional expres-
sion within 1 year sion is reduced or absent
rapid eye movement (REM) sleep behavior disorder restricting type of anorexia nervosa type of anorexia
frequent and impairing behaviors such as sleep- nervosa in which weight gain is prevented by
walking, sleep terrors, and confusional episodes refusal to eat
during REM sleep retrograde amnesia deficit in the ability to recall previ-
receptors molecules on the membranes of neurons to ously learned information or past events
which neurotransmitters bind reuptake process in which a sending neuron reabsorbs
reflection method of responding in which a therapist some of the neurotransmitter in the synapse, de-
expresses his or her attempt to understand what the creasing the amount left in the synapse
client is experiencing and trying to communicate right to refuse treatment right, not recognized by all
reformulated learned helplessness theory view that peo- states, of involuntarily committed people to refuse
ple who attribute negative events to internal, stable, drugs or other treatment
and global causes are more likely than other people to right to treatment fundamental right of involuntarily
experience learned helplessness deficits following such committed people to receive active treatment for
events and thus are predisposed to depression their disorders rather than shelter alone
rejection sensitivity tendency to be hypervigilant and risk factors conditions or variables associated with a
overreactive to signs of rejection from others higher risk of having a disorder
relapse prevention programs treatments that seek to rumination focusing on one's personal concerns and
offset continued alcohol use by identifying high-risk feelings of distress repetitively and passively
situations for those attempting to stop or cut down
on drinking and teaching them either to avoid those
situations or to use assertiveness skills when in s
them, while viewing setbacks as temporary sadomasochism pattern of sexual rituals between a
reliability degree of consistency in a measurement- sexually sadistic "giver" and a sexually masochistic
that is, the extent to which it yields accurate "receiver"
measurements of a phenomenon across several trials, sample group of people taken from a population of
across different populations, and in different forms interest to participate in a study
Glossary G-14
schizoaffective disorder disorder in which individuals separation anxiety disorder syndrome of childhood
simultaneously experience schizophrenic symptoms and adolescence marked by the presence of abnor-
(i.e., delusions, hallucinations, disorganized speech mal fear or worry over becoming separated from
and behavior, and/or negative symptoms) and one's caregiver(s) as well as clinging behaviors in
mood symptoms meeting the criteria for a major de- the presence of the caregiver(s)
pressive episode, a manic episode, or an episode of serotonin neurotransmitter involved in the regulation
mixed mania/ depression of mood and impulsive responses
schizophrenia disorder consisting of unreal or disorga- sexual desire in the sexual response cycle, an urge or
nized thoughts and perceptions as well as verbal, inclination to engage in sexual activity
cognitive, and behavioral deficits sexual dysfunctions problems in experiencing sexual
schizophrenia spectrum the set of psychiatric disorders arousal or carrying through with sexual acts to the
related to schizophrenia that vary along a severity point of sexual arousal
continuum sexual functioning the ability and capacity to engage
schizophreniform disorder disorder in which individ- in sexual behavior
uals meet the primary criteria for schizophrenia but sexual masochism disorder disorder characterized by
show symptoms lasting only 1 to 6 months obtaining sexual gratification through experiencing
schizotypal personality disorder chronic pattern of in- pain and humiliation at the hands of one's partner
hibited or inappropriate emotion and social behav- sexual sadism disorder disorder characterized by ob-
ior as well as aberrant cognitions and disorganized taining sexual gratification through inflicting pain
speech and humiliation on one's partner
scientific method systematic method of obtaining and shared delusional disorder disorder in which individ-
evaluating information relevant to a problem uals have a delusion that develops from a relation-
seasonal affective disorder (SAD) disorder identified ship with another person who already has delusions
by a 2-year period in which a person experiences (also referred to as folie adeux)
major depression during winter months and then re- single-case experimental design experimental design
covers fully during the summer; some people with in which an individual or a small number of indi-
this disorder also experience mild mania during viduals are studied intensively; the individual is put
summer months through some sort of manipulation or intervention,
secondary prevention detection of psychological disor- and his or her behavior is examined before and after
ders in their earliest stages and treatment designed this manipulation to determine the effects
to reduce their development single photon emission computed tomography
selective serotonin-norepinephrine reuptake inhibi- (SPECT) procedure to assess brain functioning in
tors (SNRis) drugs that affect both the serotonin which a tracer substance is injected into the blood-
system and the norepinephrine system and are used stream and then travels to the brain, where it can in-
to treat anxiety and depression dicate the activity level of specific areas of the brain
selective serotonin reuptake inhibitors (SSRis) class when viewed through a SPECT scanner
of antidepressant drugs situational type phobias extreme fears of situations
self-actualization fulfillment of one's potential for love, such as public transportation, tunnels, bridges,
creativity, and meaning elevators, flying, driving, or enclosed spaces
self-efficacy beliefs beliefs that one can engage in the skin-picking disorder a disorder characterized by re-
behaviors necessary to overcome a situation current picking at scabs or places on the skin, creat-
self-monitoring method of assessment in which a cli- ing significant lesions that often become infected
ent records the number of times per day that he or and cause scars
she engages in a specific behavior and the conditions sleep-related hypoventilation episodes of decreased
surrounding the behavior breathing associated with high carbon dioxide levels
self psychology a form of psychoanalytic theory and sleep disorders disturbances in sleeping or staying
therapy developed by Heinz Kohut in which psy- awake, such as insomnia and narcolepsy
chopathology is viewed as being the result of dis- sleep terrors disorder of arousal in which the individ-
rupted or unmet developmental needs ual screams, sweats, and has a racing heart during
sensate focus therapy treatment for sexual dysfunc- NREM sleep; the person cannot be easily wakened
tion in which partners alternate between giving and usually does not remember the episode on
and receiving stimulation in a relaxed, openly awakening
communicative atmosphere in order to reduce sleepwalking disorder of arousal characterized by
performance anxiety and concern over achieving repeated episodes of walking during NREM sleep
orgasm by learning each partner's sexual fulfillment social anxiety disorder an anxiety disorder in which
needs the individual experiences intense fear of public
G-15 Glossary
humiliation or rejection and therefore tends to stress-inoculation therapy a form of cognitive-behavior

avoid social situations therapy that focuses on developing skills that allow
social communication disorder a communication dis- the individual to cope with stress
order characterized by difficulty using language stroke sudden damage to the brain due to blockage of
and other modalities for communicating in social blood flow or hemorrhaging
situations structured interview meeting between a clinician and a
social drift explanation for the association between client or a client's associate(s) in which the clinician
schizophrenia and low social status that says that asks questions that are standardized and are
because schizophrenia symptoms interfere with a usually designed to determine whether a diagnosis
person's ability to complete an education and hold is warranted
a job, people with schizophrenia tend to drift stuttering significant problem in speech fluency, often
downward in social class compared to their family including frequent repetitions of sounds or syllables
of origin substance naturally occurring or synthetically pro-
sociocultural approach approach to psychopathology duced product that alters perceptions, thoughts,
focusing on the role of the environment, stress, and emotions, and behaviors when ingested, smoked,
culture in producing psychopathology or injected
somatic hallucinations unreal perceptions that some- substance abuse diagnosis given in the DSM-IV when
thing is happening inside one's body-for example, a person's recurrent substance use leads to signifi-
that worms are eating one's intestines cant harmful consequences, as manifested by a fail-
somatic symptom disorder syndrome marked by ure to fulfill obligations at work, school, or home;
health concerns that are excessive given actual the use of substances in physically hazardous situa-
physical health, that persist despite contrary tions; legal problems; and continued use despite
evidence, and that interfere with daily social and legal problems
functioning substance dependence diagnosis given in the DSM-IV
specific learning disorder disrupted or delayed devel- when a person's substance use leads to physiologi-
opment in a specific domain of cognition, such as cal dependence or significant impairment or dis-
reading tress, as manifested by an inability to use the
specific phobias extreme fears of specific objects or sit- substance in moderation; a decline in social, occupa-
uations that cause an individual to routinely avoid tional, or recreational activities; or the spending
those objects or situations of large amounts of time obtaining substances or
speech disorder a communication disorder character- recovering from their effects
ized by difficulties in producing speech substance-induced sexual dysfunction problems in
squeeze technique sex therapy technique used for pre- sexual functioning caused by substance use
mature ejaculation; the man's partner stimulates substance-induced sleep disorder sleep disturbance
him to an erection, and then when he signals that due to the use of substances, including prescription
ejaculation is imminent, the partner applies a firm medications (e.g., medications that control hyperten-
but gentle squeeze to his penis, either at the glans or sion or cardiac arrhythmias) and nonprescription
at the base, for 3 or 4 seconds; the goal of this tech- substances (e.g., alcohol and caffeine)
nique is for the man to learn to identify the point of substance intoxication experience of significantly mal-
ejaculatory inevitability and to control his arousal adaptive behavioral and psychological symptoms
level at that point due to the effect of a substance on the central ner-
statistical significance likelihood that a study's results vous system that develops during or shortly after
have occurred only by chance use of the substance
stereotypic movement disorder a motor disorder char- substance use disorders disorders characterized by
acterized by repetitive, seemingly driven, and ap- inability to use a substance in moderation and/ or
parently purposeless motor behavior, such as hand the intentional use of a substance to change one's
waving or head banging thoughts, feelings, and/ or behaviors, leading to
stimulants drugs that activate the nervous system impairment in work, academic, personal, or social
stop-start technique sex therapy technique used for endeavors
premature ejaculation; the man or his partner stimu- substance withdrawal experience of clinically signifi-
lates his penis until he is about to ejaculate; the man cant distress in social, occupational, or other areas
then relaxes and concentrates on the sensations in of functioning due to the cessation or reduction of
his body until his level of arousal declines; the goal substance use
of this technique is for the man to learn to identify suicide purposeful taking of one's own life
the point of ejaculatory inevitability and to control suicide attempts behaviors engaged in with some
his arousal level at that point intent to kill oneself
Glossary G-16
suicide cluster when two or more suicides or at- second-wave approaches-behavioral therapy and
tempted suicides nonrandomly occur closely cognitive therapy, respectively-with mindfulness
together in space or time meditation practices derived from Zen Buddhism to
suicide contagion phenomenon in which the suicide of help people accept, understand, and better regulate
a well-known person is linked to the acceptance of their emotions
suicide by people who closely identify with that tics sudden, rapid, recurrent, nonrhythmic motor
person movements or vocalizations
suicide ideation thoughts about killing oneself tolerance condition of experiencing less and less effect
superego part of the unconscious that consists of abso- from the same dose of a substance
lute moral standards internalized from one's parents Tourette's disorder a motor disorder characterized by
during childhood and from one's culture multiple motor tics and one or more vocal tics
supernatural theories theories that see mental disor- transference in psychodynamic therapies, the client's
ders as the result of supernatural forces, such as di- reaction to the therapist as if the therapist were an
vine intervention, curses, demonic possession, and / important person in his or her early development;
or personal sins; mental disorders then can be cured the client's feelings and beliefs about this other
through religious rituals, exorcisms, confessions, person are transferred onto the therapist
and/ or death transference-focused therapy a highly structured psy-
symptom questionnaire questionnaire that assesses chodynamic treatment for borderline personality
what symptoms a person is experiencing disorder that uses the relationship between patient
synapse space between a sending neuron and a receiv- and therapist to help patients develop a more realis-
ing neuron into which neurotransmitters are first tic and healthier understanding of their interper-
released (also known as the synaptic gap) sonal relationships
syndrome set of symptoms that tend to occur together transsexuals people who experience chronic discomfort
systematic desensitization therapy type of behavior with their gender and genitals as well as a desire to
therapy that attempts to reduce client anxiety be rid of their genitals and to live as a member of the
through relaxation techniques and progressive opposite sex
exposure to feared stimuli transvestic disorder paraphilic disorder in which a
heterosexual man dresses in women's clothing
as his primary means of becoming sexually
T aroused
tactile hallucinations unreal perceptions that some- traumatic brain injury injury to the brain resulting
thing is happening to the outside of one's body-for from traumatic force; often associated with loss of
example, that bugs are crawling up one's back consciousness
tardive dyskinesia neurological disorder marked by trephination procedure in which holes were drilled in
involuntary movements of the tongue, face, mouth, the skulls of people displaying abnormal behavior,
or jaw, resulting from taking neuroleptic drugs presumably to allow evil spirits to depart their bod-
tertiary prevention program focusing on people who ies; performed in the Stone Age
already have a disease with the aim of preventing tricyclic antidepressants class of antidepressant drugs
relapse and reducing the impact of the disease on twin studies studies of the heritability of a disorder by
the person's quality of life comparing concordance rates between monozygotic
thalamus structure of the brain that directs incoming and dizygotic twins
information from sense receptors (such as vision Type A behavior pattern personality pattern character-
and hearing) to the cerebrum ized by time urgency, hostility, and competitiveness
theory set of assumptions about the likely causes of
abnormality and appropriate treatments
therapy outcome studies experimental studies that as- u
sess the effects of an intervention designed to reduce unconditioned response (UR) in classical conditioning,
psychopathology in an experimental group, while response that naturally follows when a certain
performing no intervention or a different type of stimulus appears, such as a dog salivating when
intervention on another group it smells food
third variable problem possibility that variables not unconditioned stimulus (US) in classical conditioning,
measured in a study are the real cause of the stimulus that naturally elicits a reaction, as food elic-
relationship between the variables measured in its salivation in dogs
the study unconscious area of the psyche where memories,
third-wave approaches modern psychotherapeutic wishes, and needs are stored and where conflicts
techniques that combine elements of the first- and among the id, ego, and superego are played out
G-17 Glossary
v visual hallucination visual perception of something

that is not actually present
vagus nerve stimulation (VNS) treatment in which the voyeuristic disorder disorder characterized by obtain-
vagus nerve-the part of the autonomic nervous ment of sexual arousal by compulsively and secretly
system that carries information from the head, neck, watching another person undressing, bathing,
thorax, and abdomen to several areas of the brain, engaging in sex, or being naked
including the hypothalamus and amygdala-is
stimulated by a small electronic device much like a
cardiac pacemaker, which is surgically implanted w
under a patient's skin in the left chest wall wait list control group in a therapy outcome study,
validity degree of correspondence between a measure- group of people that functions as a control group
ment and the phenomenon under study while an experimental group receives an interven-
variable measurable factor or characteristic that can tion and then receives the intervention itself after a
vary within an individual, between individuals, waiting period
or both working through method used in psychodynamic ther-
vascular neurocognitive disorder a form of dementia apies in which the client repeatedly goes over and
resulting from multiple strokes and/ or ischemic over painful memories and difficult issues as a way
events to understand and accept them
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C-2 Credits
in Abnormal Psychology, from The Files of Experts, by Halgin, & Medicine, vo!. 41, Issue 1, L. Sing, "Self starvation in context:
Richard eta! (1998). Extract of 260 words adapted from "Case Towards a culturally sensitive understanding of anorexia
Study: Jeff" (pp. 197-210) 1998 by Oxford University Press, nervosa," pp. 27-29, Copyright (1995), with permission from
Inc. By permission of Oxford University Press; p. 234, Fig 8.3: Elsevier; p . 337: From Stunkard, A. J., 1993, "A History of
From Schizophrenia Genesis: The Origins of Madness by Binge Eating," in C. G. Fairburn and G. T. Wilson (Eds.), Binge
I. Gottesman 1991 by Irving I. Gottesman. Used with permis- Eating: Nature, Assessment, and Treatment, pp. 20-21. New
sion of W. H. Freeman and Company / Worth Publishers; York: Guilford Press. Reprinted with permission; p. 344,
pp. 240-241: From Brown, T. A., O'Leary, T. A., & Barlow, Fig 12.2: From C. V. Wiseman, eta!., "Cultural Expectations of
D. H ., 2001, in Barlow, D. H. (Ed.) "Generalized Anxiety Thinness in Women: An Update," in International Journal of
Disorder," Clinical Handbook of Psychological Disorders: A Eating Disorders, vol. 11. Copyright 1992 Wiley Periodicals,
Step-by-Step Treatment Manual, Third Edition, New York: Inc., A Wiley Company. Reprinted with permission; p. 345:
Guilford Press, p. 502. Reprinted with permission. "Worshipping the Gods of Thinness", from Reviving Ophelia
by Mary Pipher, Ph.D., copyright 1994 by Mary Pipher,
CHAPTER9 Ph.D. Used by permission of G. P. Putnam's Sons, a division
p. 252: From Girl, Interrupted by Susanna Kaysen, copyright of Penguin Group (USA) Inc., and the author.
1993 by Susanna Kaysen. Used by permission of Turtle Bay
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this publication, is prohibited. Interested parties must apply John Cola pinto. Copyright 1999 by John Cola pinto.
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267, 268-269: From Beck, A. T. & Freeman, A.M., 1990, From McCarthy, B. W., 1989, "Cognitive Behavioral Strategies
Cognitive Therapy of Personalihj Disorders, pp. 245-247. New and Techniques in the Treatment of Early Ejaculation," inS. R.
York: Guilford Press. Reprinted with permission; p . 263: Leiblum & R. C. Rosen (Eds.), Principles and Practice of Sex
From Linehan, M. M., Cochran, B. N., & Kehrer, K. C., Therapy: Update for the 1990s, pp. 151-152. New York: Guilford
"Dialectical Behavior Therapy for Borderline Personality Press. Reprinted with permission; p. 370: From Altho, S. E.
Disorder," in D. H, Barlow (Ed.), Clinical Handbook of (2000). "Erectile dysfunction: Psychotherapy with men and
Psychological Disorders: A Step-by-Step Treatment Manual, couples." InS. R. Leiblum & R. C. Rosen (Eds.), Principles and
Third Edition, pp. 502- 504. NY: Guilford Press. Reprinted Practice of Sex Therapy (3rd ed.), p. 270. New York, NY:
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Adapted from Springer and the International Academy of
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Type: Two Cases," R. Dickey and J. Stephens, copyright
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NAME INDEX
Arnulf, I., 452 Barnes, N. W., 433
A Ambrose, C. M., 310
American Heart Arsenault, L., 325 Barnhill, L. J., 301
Aardema, F., 144 Association, 443,444 Asberg, M., 209 Barrantes-Vidal, N., 259
Abbey, A., 419 American Psychiatric Aschenbrand, S. G., 138 Barrera, M., Jr., 23
Abelson, J. M., 238 Association, 12, 72, 85, Asmundson, G. J. G., 275 Barrett, M. S., 45
Abi-Dargham, A., 261 112, 119, 125, 128, 132, Aspinwall, L. G., 436 Barrett, P.M., 138
Abram, K. M., 469, 477 136, 139, 141, 153, 162, Atiya, M., 307 Barry, T. D., 328
Abramowitz, J. S., 157 166, 167, 168, 169, 178, Attia, E., 339, 350, 351 Bartlett, S. J ., 354
Abramson, L. Y., 39, 189, 182, 220, 226, 229, 230, August, G. L., 329 Bartlik, B., 374
190, 354 231,254-256,262,264, Auriacombe, M., 396 Barton, C. A., 117
Acree, M., 436 270,271,277,278,285, Autism Genome Project Barton, E. E., 294
Adams, C. E., 242 290, 294, 300, 303, 313, Consortium, 293 Basson, L., 365, 375
Addis, M. E., 5, 191 322, 323, 330, 333, 340, Avants, S. K., 436 Bastien, C. H., 451
Aderibigbe, Y. A., 151 343, 366, 367, 368, 374, Avenevoli, S., 122 Batchelor, I. R. C., 158
Adler, C. M., 193 381, 383, 385, 388, 399, A wad, G., 242 Batelaan, N. M., 130, 131
Adler, L., 287 400, 427, 4!:1, 452, 453, A ybek, S., 159 Bateman, A., 266
Afifi, T. 0., 265, 269, 271, 454, 455, 456, 457, Ayers, C. R., 142 Bates, M. E., 405
275,278,332 458,459 Ayowa, 0 . B., 374 Bateson, G., 239
Agam,G.,30 American Psychological Azrin, N. H., 304 Bauer, R., 337
Agani, F., 115, 116 Association, 177, Baum, A., 434, 435
Agarwal, A., 399
Agras, W. S., 338, 355, 357,
179,380
Ames, D., 145
B Baxter, L., 143
Bearden, C. E., 236
358,359 Amirthavasagam, S., 265 Baba, T., 390 Beatty, J., 311
Agronin, M. E., 374 Amstadter, A. B., 117 Bach, A. K., 366, 375 Beauchaine, T. P., 325
Ahlers, M. M., 448 Ancoli-Israel, S., 450 Bachman, J. G., 403, 404, Bechara, A., 417
Ahmed, H. 0., 217 Anders, S. L., 228, 406,409,410,412,413, Beck, A. T., 40, 63, 72, 129,
Ahmed, S. F., 390 229,240 414,415,416 130, 131, 132, 133, 189,
Ahn, w. K., 36 Andersen, A. E., 351 Bachrach, H. M., 45 200, 209, 225, 240, 243,
Ahrens, A. H., 351 Andersen, P. K., 181 Back, S. E., 412 257,258,259,262,267,
Ajdacic-Gross, V., 211 Anderson, B. K., 426 Baer, J. S., 418, 427 269, 270, 271, 273,
Ajzen, I., 446, 447 Anderson, E. R., 192 Baer, R. A., 265 275,279
Alarcon, R. D., 50 Anderson, G., 158 Bagnardi, V., 405 Beck, J. G., 372
Albano, A. M., 138 Anderson, G. M ., 293 Baird, G., 292 Beck, R. W., 63
Albayarak, 0., 287 Anderson, K. N., 452 Baker, C. W., 343 Becker, A. E., 337, 353
Alcaine, 0., 134 Anderson, R. E., 354 Baker, D., 47, 168, 169 Becker-Blease, K. A., 165
Aldao, A., 133 Andersson, G., 53,203 Baker, J. H., 350 Behar, E., 134
Alegria, M., 48 Andrade, L., 180 Baker, L.A., 331 Beidel, D . C., 123
Aleman, A., 222, 223 Andreasen, N. C., 227, Baker, R., 331 Belle, D., 49
Alexander, K. L., 298 233,247 Baldessarini, R. J., 210 Belmaker, R. H., 30, 196
Alexopoulos, G. S., 446 Andreassen, S., 238 Baler, R. D., 288 Belzile, E., 313
Alexopoulos, P., 308 Andrews, G., 133, 134 Ball,S.A.,423 Bender, D . S., 251, 265, 269
Ali, F., 179 Anestis, M., 265 Ballenger, J. C., 117, 118 Bender, L., 66
Ali, s., 446, 452 Angiulo, M. J., 165 Balon, R., 363,375 Bender, T., 265
Alison, L., 383 Angold, A., 136, 188, Bandura, A., 38, 123, 446, 447 Benet-Martinez, V., 254
Alkin, M. C., 299 288,326 Barban, L., 165 Benight, C. C., 115
Allain, A. N., 114 Angst, J., 83, 140, 144 Barber, J. P., 45 Benjamin, L. T., Jr., 25
Allardyce, J., 227 Anton, R. F., 426 Barch, D. M ., 225, 232, 235, Bennett, N. S., 470
Allderidge, P., 12 Appelbaum, B. C., 471 236,237,261 Benotsch, E. G., 445
Allebeck, P., 238 Appelbaum, P. S., 471 Bardone, A. M., 354 Bentall, R. P., 220, 222
Allen, J. B., 163 Arango, V., 209, 331 Barefoot, J. C., 444,445 Berger, W., 114
Allen, J. J. B., 163 Arber, S., 449 Barkhof, E., 243 Berglund, P., 124
Allen, N. C., 352 Arcelus, J., 343, 345 Barkley, R. A., 286, 287, 288 Bergman, K., 143
Allison, K. C., 347 Arefjord, K., 437 Barley, E. A., 17 Berk, M., 193
Alloy, L. B., 39, 190, 193 Arendt, J., 456 Barlow, D. H., 48, 120, 128, Berkman, L. F., 446
Alonso, J., 124 Arenovich, T., 227 129, 130, 131, 132, 133, Berkowitz, R. I., 349
Altamura, A. C., 143 Arias, J. M., 331 170,366,372 Berlin, L. J., 299
Altho, S. E., 369, 377, 378 Armstrong, H . E., 266 Barnes, J. J., 287 Berman, A. L., 205
Altman, S., 193 Arnold, E., 290 Barnes, L. L., 311 Bernal, G., 52
Alvanzo, A. A. H ., 404 Arntz, A., 275 Barnes,M.A.,301 Bernstein, D. P., 257, 260, 276
Name Index Nl-1

Nl-2 Name Index
Berridge, D., 297 Borkovec, T., 134 Bruck, M., 170 Carroll, K. M., 420, 421,
Berridge, K. C., 417 Borkovec, T. D., 134, 135 Bryant, B., 116 422,423
Berthoud, H. R., 350 Born, L., 188 Bryant, C., 145, 146 Carroll, M. D., 347
Bettelheim, B., 293 Bornemann, M. A. C., 452 Bryant, R. A., 113, 159 Carter, C. S., 225
Bezchlybnik-Butler, Bornstein, R. F., 273 Bryson, S., 357 Carter, J. C., 357
K. z., 398 Bosinski, H . A., 389 Bucciarelli, A., 147 Cartwright, S., 6
Biederman, J., 136, 137, Bottoms, G., 464 Buchholz, K. K., 404 Carver, C. S., 193
286,287 Bouafuely, M., 156 Buckley, P. F., 217 Casey, B. J., 283
Biegon, A., 209 Bouchard, T. J., 32 Buettner, L. L., 312 Casey, K. R., 453
Bierer, L. M., 117 Bound, J., 433 Buka, S. L., 236 Caspi, A., 32, 33, 137, 186,
Bierut, L. J., 404 Bouton, M. E., 130 Bulik, C. M., 342, 350, 355 321,324,325,328
Bijl, R. V., 238 Bowen, S., 423 Burgess, M., 458 Castello, E. J., 188
Billings, D. W., 436 Bowie, C. R., 225 Burke, J. D., 324, 326 Castiglioni, A., 10
Billings, F. J., 170 Bowler, A. E., 238 Burmeister, M., 186 Castonguay, L. G., 135
Bingham, C. R., 418 Boyd, B. A., 294 Burnam, A., 425 Castro, F. G., 23, 49, 50, 52
Binik, Y. M., 369 Boyle, M. F., 314 Burnam, M. A., 116, 385 Catanese, D., 337
Birmaher, B., 138, 183 Boysen, G. A., 164 Bursnall, S., 437 Catena, M., 144
Biron, M., 99 Braddock, A. E., 157 Burt, S. A., 287 Catty, J., 246
Bissada, H ., 359 Bradford, A., 370, 371, 373, Burton, E. M., 355 Ceci, S. J., 170
Bjerregaard, P ., 179 374, 375, 376 Busfield, J., 12 Celio Doyle, A., 357
Bjorvatn, B., 456, 457, 458 Bradford, J. M., 387 Bustillo, J. R., 243, 244, 245 Centers for Disease Control
Blacher, J. B., 299 Bradley, S. J., 390 Butcher, J. N., 70 (CDC), 204, 205, 206,
Blackman, A., 160 Brady, K. T., 412 Butler, L. D., 167 297,311,347,410, 441
Blair, R. J. R., 325 Braun, B. G., 164 Butzel, J. S., 165 Cervantes, R. C., 156
Blair, W., 117 Brawman-Mintzer, 0., 129 Buysse, D. J., 450 Chahal, R., 267
Blanchard, J. J., 225 Brelau, J., 116 Buzare, M . A., 452 Chalder, T., 158
Blaney, P. H ., 190 Brent, D. A., 208, 209, Byne, W., 390, 391 Chamberlain, S. R., 287
Blank, R., 304 211,212 Byrne, D., 445 Chambless, D. L., 135
Blase, S. L., 48, 49 Brewer, K. M., 402 Bystritsky, A., 145 Champoux, M., 134
Blatt, S. J., 191 Brick, J., 398, 399, 400, 401, Chang, K. D., 329
Blazer, D. G., 192
Bless, G., 299
402,409, 418
Bridge, J., 211, 212
c Chapman, J.P., 222
Chapman, L. J., 222
Blin, 0., 143 Bridges, D. D., 304 Caceda, R., 133 Chard, K. M., 118
Bliss, E. L., 164, 165 Bridges, F. S., 211 Caddell, J. M., 477 Charney, D. S., 128, 134, 188
Bloch, M . H., 140 Briere, J., 169 Caffey, J., 297 Chassin, L., 418
Bloch, R. M., 151 Briley, D. A., 254 Cale, E. M., 330, 331 Chatzitheochari, S., 449
Blom, J.D., 35, 197 Britton, J. C., 116, 117 Calhoun, K. S., 116, 118 Chaudhuri, A., 296
Blond, A., 338 Brooks-Gunn, J., 298, 299 Caligiuri, M.P., 192 Chavira, D. A., 261, 264
Bloomquist, M. L., 329 Brosschot, J. F., 133 Callaghan, G. M., 268 Chawla, N., 423
Blum, N., 266 Brotto, L.A., 367, 374 Callahan, L. A., 473 Cheavens, J., 54
Blume, A. W., 426 Brown, C. W., 297 Callies, A., 156 Chee, M., 438
Blumenthal, J. A., 446 Brown, J. E., 374 Cameron, N ., 154 Chelly, J., 295
Boardman, A. P., 155 Brown, J. S., 208 Camilleri, J. A., 388 Chelrninski, I., 259, 276
Bodell, L. P., 339 Brown, L. K., 453 Campbell, C., 239 Cheltenham, M. P., 208
Boeve, B. F., 458 Brown, L. L., 199 Campbell-Sills, L., 48 Chen, E., 433,436,444
Bogels, S. M., 124, 125 Brown, M. M., 327 Campbell, W. K., 190, 269 Chen, E. Y., 48
Bohart, A. C., 46, 47, 55 Brown, R. C., 374 Canada, A. L., 441 Chen, H., 438, 439
Bohon, C., 355 Brown, T. A., 133, 339 Canive, J. M., 244 Chen, R., 311
Bohus, M., 266 Brown, T. E., 286 Cannon, T., 437 Chen, T. H ., 209
Bollini, A., 219 Brown, T. M., 314 Cannon, T. D., 23, 25, 225, Chen, W. Y., 405
Bollm, J. R., 441 Brown, W. A., 195 232,234,235,236,246 Cheng, A. T., 209
Bolte, s., 292 Browne,K.,240 Cantillo, K. 0., 453 Cheung, F. K., 261
Bonanno, G. A., 177 Browne, K. 0., 223, 240 Cantor-Graae, E., 238 Chevez, L. G., 53
Bonett, D., 236 Brownell, K., 347, 348, 447 Cantor, J. M., 386 Chevron, E., 45
Bonnano, G. A., 147 Brownell, K. D., 347, 354 Cardefia, E., 116, 164 Chiao, J. Y., 235
Bonnie, R. J., 471 Brozovich, R. G., 126 Cardozo, B. L., 49, 115, 116 Chiapetta, L., 264
Book, A. S., 326 Bru, E.,436 Carlson, E., 116 Chilvers, R., 299
Boothroyd, R. A., 478 Bruce, T., 347 Carpenter, W. T., Jr., 224 Chin, A. L., 311
Borges, G., 204, 208 Bruch, H ., 355 Carr, S. J., 358 Chiu, J., 437
Name Index Nl-3
Chiu, W. T., 127 Conner, K. R., 211, 212 Dahl, A. A., 267 Depue, R. Q., 192,193
Chmielewski, M., 277 Connors, G. J., 425 Dahlstrom, W. G., 445 DeRubeis, R. J., 203
Cho, S. J., 459 Conte, J. R., 169 Daley, D. C., 422 deSilva, P., 122, 144
Choe, J. Y., 469 Conturo, T., 235 Daly-Jones, 0., 155 Dessemontet, R. S., 299
Chokka, P., 287 Conway, M., 445 Dam, H., 179 Deutsch, A., 14
Chokroverty, S., 458 Conwell, Y., 207 Damasio, H., 26 Dewaraja, R., 374
Chou, T., 411 Cook, M., 121 Dana, R. H., 64, 68, 70 Dhawan, N., 270
Chow, E., 441 Coolidge, F. L., 257, 390 Danesh, J., 330 Diamond, G. S., 52
Christensen, A. J., 445 Coolidge, F. M., 261, 273 Danielsson, A. K., 410 Diaz-Perez, M.D., 116
Christenson, G. A., 142 Coon, K. D., 308 Dansinger, M. L., 349 Diaz, S. F., 142
Chu,J., 165 Coons, P.M., 162, 164, 165 Dansky, B. S., 115 Dickey, R., 389
Chui, H. C., 311 Coontz, P. D., 469 Dantzer, R., 446 Didie, E. R., 142
Chung, W. C., 390 Cooper, M. L., 403, 418 Darcangelo, S., 381, 382, DiDomenico, L., 351
Church, S. E., 155 Cooper, Z., 339,343 386,387,388 Diehl, N. S., 351
Ciampi, A., 313 Coplan, J. D., 129 Dare, C., 357 Dierker, L., 207
Cicchetti, D., 117, 187 Corbitt, E. M., 78 Das,A.,366 Dimidjian, S., 41, 199, 203
Cirincione, C., 473 Cormier, J., 273 Das, P., 159 Dishion, T. J., 32, 326,
Clancy, S. A., 171 Cornelius, M. D., 297 Dauvilliers, Y., 327,332
Clark, D. A., 129, 130, 131, Cororve, M. B., 143, 145 452,453 Disney, K. L., 267
132, 144 Corrao, G., 405 David, A., 238 Distel, M. A., 265
Clark, D. M., 126, 144 Costa, P. T., 252, 259, 276 David, A. S., 159 Ditta, S. R., 115
Clark, K., 238 Costello, E. J., 288, 321, 326 Davidson, J., 135 Dixon, D., 442
Clark, L.A., 277 Cote, G., 477 Davidson, J. R. T., 135 Dodge, K., 327
Clarkin, J. F., 266 Cottone, J. G., 52 Davidson, K., 266 Dodge, K. A., 325, 327
Classen, C., 370 Courtet, P., 209 Davidson, L. A., 67 Dohrenwend, B. P., 114,
Clayton, A. H., 363, 367, Cousins, N., 434, 441 Davidson, M., 121, 237 238,239
368,370 Couture, L. J., 160 Davidson, R. J., 186, 187 Dolan, A., 108
............. Cleare, A., 117 Couture, M., 363 Davis, C., 348 Dolder, C. R., 237
Cleckley, H. M., 161, 322, 330 Cox, B. J., 271 Davis, J. M., 115 Donegan, N. H., 265
Clipp, E. C., 114 Coyne, J. C., 191, 441 Davis, K. L., 237, 256, 261 Denenberg, G., 70
Cloninger, C. R., 331 Craig, T. K., 155 Davis, 0. S. P., 123, 302 Donovan, D. M., 418,
Coccaro, E. F., 333 Cramer, E., 380 Davis, R., 358 423,426
Cochran, B. N., 263 Cranford, J. A., 406 Davis, T. E., III, 122 Dorfman, W. I., 64
Cochran, S. D., 433 Cranston-Cuebas, M. A., 372 Day,N.,297 Dorris, M., 297
Cochrane, M., 261 Craske, M. G., 109, 120, Day, N. L., 297 Doucet, J., 49
Cochrane, R., 222 122, 126, 127, 129, 130, De Cuypere, G., 389 Dougher, M. J., 421
Cochrane, R. E., 472 132, 133, 134 de Menezes, G. B., 126 Dougherty, D. D., 187
Cocores, J., 397 Crepault, C., 363 de Snyder, V. N. S., 116 Downar, J., 228
Coffey, S. F., 115 Crick, N. R., 324, 327 De Vries, G. J., 390 Downey, G., 191
Cohen, A. S., 225 Crits-Christoph, P., 45 Dean, J. T., 156 Dozois, D. J. A., 29
Cohen-Kettenis, P. T., 389 Cronbach, L. J., 61 Dean, L., 442 Drake, C. L., 456
Cohen, P., 183 Croninger, R. G., 297 Deardorff, J., 124 Draper, C., 382
Cohen, S., 440 Crosby, A. E., 208, 210 Deary, V., 158 Drayna, D., 301, 302
Coid, J. W., 238 Cross, S. E., 438 Debiec, J., 28 Drucker, P., 52
Colapinto, J., 364 Crow, S. J., 341, 342, 344 Deeny, S. P., 312 Druley, J. A., 436
Cole, C., 164 Crowther, J. H., 344 Degenhardt, L., 414 Drummond, T., 160
Cole, M.G., 313,314 Cruess, D. G., 448 Dekker, J., 203 Du, Y.,307
Cole, S. W., 442 Csernansky, J. G., 235 del Campo, N., 287, 288 Dudley-Grant, G. R., 329
Cole, W., 388 Cubillo, A., 287 Delizonna, L. L., 375 Duff, M. C., 301
Collins, J. J., 477 Cuijpers, P., 53,203 Dell, P. F., 164, 165 Duffy, J. D., 14
Coltheart, M., 222 Culpepper, L., 130 DeLucia, C., 418 Duman, R. S., 187
Committee on Gulf War Curry, S., 387 Dement, W. C., 448 Dumont, K., 191
and Health, 311 Curtin, L. R., 347 Denis, C., 396 Di.indar, Y., 452
Compas, B. E., 436 Czaja, S. J., 191 Denko, T., 194, 195, 196, Dunn, E., 188
Compton, S. N., 326 197, 203, 210 Dupree, L. W., 425
Conduct Problems
Prevention Group, 329
D Dennis, M. L., 423
Depression and Bipolar
Durand, V_ M., 457
Durant, S., 351
Conklin, H. M., 236, 237 Dabrowksa, A. J., 457 Support Alliance, 212 Durkheim, E., 207
Conley, C. S., 191 Dagan, Y., 455 DePrince, A. P., 169, 171 Durrett, C. A., 251, 276
Nl-4 Name Index
Durston, S., 283 Exner, J. E., 68 Flament, M. F., 359 Frith, M., 108
Duyao, M. P., 310 Eynan, R., 255 Fleet, R. P., 445 Fromberger, P., 386, 387
Dwyer, J., 436 Eysenck, H . J., 332 Flegal, K. M., 347 Fromm-Reichmann, F., 239
Dykens, E. M., 296 Flemming, M., 401 Fromme, K., 427
Flessner, C. A., 303, 304 Prost-Pineda, K., 416
F Fletcher, J. M., 301, 302 Frost, R., 144, 145
E Fabiano, G. A., 289 Fletcher, K., 288 Frost, R. 0., 141, 142
Eakin, E. G., 447 Fabrega, H., 222, 267, Floyd, M., 146 Fuchs, D. L., 164
Early-Zald, M. B., 356 269,273 Foa, E. B., 115, 140, 144, Fuchs, L. S., 301
Eaton, N. R., 264 Fahey, J. L., 440 145, 159 Fulford, D ., 193
Eaton, W. W., 227, 228 Fahy, T. A., 164 Fogelson, D. L., 239 Fulkerson, J. A., 356
Eaves, L. J., 259, 325 Fairbank, J. A., 477 Folkman, S., 436 Fuller, M.A., 237
Eckardt, T., 115 Fairburn, C. C., 357 Follette, W. C., 39 Furr,S.R.,206
Edell, W. S., 222 Fairburn, C. G., 339, 343, 346, Folsom, T. D., 246 Furzse, G., 436
Edelmann, R. J., 125, 140 354,355,357,358,359 Folstein, S., 293
Edinger, T., 288
Edwards, A. G. K., 441
Fairchild, G., 325
Fairly, M., 158
Fombonne, E., 292, 293, 304
Fonagy, P., 266
G
Egeland, J. A., 49,84 Fairweather, G. W., 245 Foote, B., 164 Gach,J., 9
Egger, H. L., 288 Falk, M ., 288 Ford, B. C., 70 Gagnon, F., 144
Ehlers, A., 115, 116, 117, 118 Fanous, A. H., 208 Ford, J., 17 Gagnon, J. F., 458
Ehring, T., 117,355 Faraone, S. V., 136, 287 Forde, D. R., 151 Gagnon, J. H., 365, 374
Ehrman, J. K., 447 Faravelli, C., 115 Forde, J., 146 Gajilan, A. C., 114
Eisenhower, J. W ., 165 Farmer, A., 192 Forslund, K., 209 Gajria, M., 303
Eisenstein, M., 455 Farmer, M . A., 369, 370 Fournier, J. C., 195 Galatzer-Levy, R., 45
Elder, G. H., 114 Farrington, D. P., 326, Fox, T. L., 138 Galderisi, S., 224
Eldevik, S., 294 327,334 Frances, A., 380 Galea, S., 112, 113, 115, 147
Eley, T. C., 144, 331 Fatemi, S. H ., 246 Frances, A. J., 72, 74, 175 Gallagher, T. J., 238
Elkin, A., 192 Fatseas, M., 396 Francis, E. L., 190 Gambino, F., 295
Eliason, J. W., 164, Fawzy, F. I., 441 Frank, E., 193,202,203 Garber, J., 155, 156, 180
165, 166 Fawzy, N. W., 441 Frank, J.D., 54 Gardner, C. D., 348
Elliot, R., 46 Fazel, S., 330 Frankenburg, F. R., 279 Gardner, H., 66
Ellis, A., 133,200 Feder, A., 155 Franklin, E., 140, 144, 145 Gardner, W., 470
Ellman, L. M., 236 Federman, E., 228 Franklin, J. A., 356 Garfield, S. L., 52
Emerson, E., 298 Fehm, L., 124, 125 Franklin, K. A., 454 Garfinkel, P. E., 351, 359
Emery, G., 40, 133 Feingold, A., 191 Franko, D. L., 342, 344, 346 Garner, D. M., 351, 358, 359
Emmelkamp, P. M. G., 272 Feinleib, M., 445 Franskoviak, P., 470 Garner, M. V., 358
Emrick, C. D., 425 Feinstein, A., 158, 159 Frasure-Srnith, N., 446 Garrison, B., 209
Emslie, G . J., 329 Feldman, M. A., 298 Frazier, J. A., 193 Gatz, M., 180, 306, 307, 308,
Entwisle, D. R., 298 Feldman, R. P., 8 Frederick, R. I., 472 311,312
Epperson, C. N ., 180, 188 Feldman, S. I., 191 Fredrickson, B. L., 434 Gauntlett-Gilbert, J., 223
Epping-Jordan, J. E., 436 Fennell, M. J. V., 54 Fredrikson, M., 122 Gearhardt, A. N., 347, 348
Epple, D . M., 305 Fenton, W . S., 224 Freeman, A., 41 Geddes, J. R., 195, 196
Epstein, J., 115 Fergusson, D. M ., 288 Freeman, A. M., 257, 258, Geer, J. H ., 371
Erdelyi, M. H., 45 Ferri, C. P., 305 259, 262, 267, 269, 270, Gehi, A., 446
Erdur, L., 343 Feusner, J., 142 271, 273, 275, 279 Gelfand, L. A., 203
Erickson, S. J., 49 Field, G., 386, 387 Freeman, H., 227 Gerardi, R. J., 118
Ericson, M. L., 418 Fillmore, K. M., 405,419 Freeman, S. F. N., 299 Gerardin, P., 386, 387
Erkanli,A.,288 Fink, M ., 197 Freeston, M. H., 144 Gergen, K., 5
Erlenmeyer-Kimling, L., Finkelhor, D., 115 Frenda, S. J., 170 Gergen, M ., 5
91,233 Finney, J. W., 421 Fresco, D. M., 133 Geronimus, A. T., 433
Escobar, J. I., 140 First, M. B., 63, 74, 75, 147, Freshwater, S. M., 66 Gianotten, W. L., 370, 375
Espnes, G. A., 445 276,380 Freud, S., 120 Gibbon, M., 63, 275, 408, 424
Esposito, Z., 312 Fischer, K., 355 Frewen, P. A., 29 Gibbons, M . B. C., 45
Estrada, A. U., 329 Fischer, M ., 287, 288 Freyd, J. J., 167, 169, Giesen-Bloo, J., 266
European Centre for Drugs Fisher, W. A., 365 170,171 Gigante, R. A., 169
and D rug Action, 414 Fiske, A., 180 Frick, P. J., 286, 287, 321, Gijs, L., 380, 385, 387
Evers, A. W. M., 436 Fitzgerald, H. E., 418 322,323 Gilberg, C., 136
Everson-Rose, S. A., 153, Fitzsimmons, S., 312 Friedman, M., 444, 445 Gill, M., 458
438,439 Flakierska-Praquin, N., 136 Friedman, M. J., 113, 116 Gillberg, C., 292
Name Index Nl-5
Gillespie, N., 356 Granhag, P. A., 170 Hachinski, V., 309 Hearon, B., 45
Gillespie, N. A., 156 Grant, B., 255, 257, 267, 271, Hackett, G. I., 366, 370 Heath, A. C., 259,399
Gilliam, W. S., 298 273,275 Hagan, C. R., 191 Heath, N ., 207
Gilman, S. E., 116, 379 Grant, B. E., 404 Hajjar, I., 443 Hebert, L. E., 308
Gilvarry, C. M., 261 Grant, B. F., 133, 271, 273, Hall, G. C. N., 52 Beckers, S., 232
Gitlin, M., 242 275,276,439 Hallam, R., 332 Hedley, A. A., 347
Gitlin, M. J., 195 Grant, J. E., 427, 428 Hallaraker, E., 437 Hedtke, K. A., 137
Glahn, D. C., 232 Grattan-Smith, P., 158 Halpern, A. L., 380 Heiden, L., 440
Glaser, R., 437 Gratz, K. L., 265 Haman, K. L., 199 Heim, C., 117, 188
Glassman, A., 186 Gray, J.]., 351 Hames, J. L., 191 Heiman, J. R., 376, 377
Glassman, A. H., 446 Greaves, G. B., 164 Hamilton, L. D., 377 Heimberg, R. G., 124, 126
Gleaves, D. H., 143, 145, Green, M., 225 Hamilton, R., 311 Heinrichs, N., 126
167, 169, 170 Green, R., 390 Hammen, C., 91, 188, 189, Heiser, N. A., 123
Glisky, E. L., 163, 165 Greenberg, D. M., 387 191,439 Hektner, J. M., 329
Glowinski, A. L., 209 Greenberg, L. S., 46 Han,S., 70 Helgeland, M. I., 265
Glucksman, E., 117 Greenberg, T., 210, 211 Handen, B. L., 294 Hellstrom, I. C., 33
Godfrey, J. R., 348 Greenfield, S. F., 412 Handley, E. D., 288 Helzer, J. E., 76, 425
Gold, M. S., 398, 416 Greenfield, T. K., 405 Haney, T. L., 444 Hemenway, D., 211, 212
Goldberg, E. M., 237 Greenwood, P., 371 Hanneman, R. A., 299 Hemsley, D., 261
Golden, C. J., 66 Grekin, E. R., 404 Hansen, M. G., 181 Hendin, H., 211
Goldin, P. R., 127 Griepenstroh, J., 355 Hanson, R. F., 116 Hening, W., 459
Golding, J. M ., 116, 140 Griffin, P. A., 471 Hanssen, M., 238 Hennen,]., 210, 386
Goldschmidt, L., 297 Grilo, C. M., 264,345,359 Hardesty, J. P., 238 Henry, B., 331
Goldsmith, H. H., 256, Grisso, T., 471, 472 Hare, R. D., 330, 332 Henry, G. W., 10
257,259 Grob, G. N., 13, 14 Harold, G. T., 325 Henry, M . E., 197
Goldstein, A., 411 Groesz, L. M., 338, 351 Harper, R. A., 200 Henwood, B. F., 246
Goldstein, J. M., 224, 228 Gronli, J., 456 Harrell, F. E., 444 Herbener, E. S., 227, 228
Goldstein, M. G., 411 Gross-Isseroff, R., 209 Harrell, J. P., 444 Herberman, R. B., 441
Goldstein, M. J., 239 Gross, J. J., 127 Harrell, z. A. T., 419 Herman, C. P., 351, 356,
Goldstein, M. Z., 374 Gross, R. T., 298 Harrington, H., 137, 359,439
Goldstein, R. Z., 417 Grossman, L. S., 224, 321,326 Herman, J. L., 169
Gone, J. P., 52 227,228 Harris, K., 303 Hernandez, E., 170
Good, B. J., 6 Groth-Marnat, G., 64, 66, 68 Harris, M. J., 78 Heron, M., 435
Goode, S., 292 Grotpeter, J. K., 324 Harrow, M., 224, 227, 228 Herrman, H., 227
Goodrich, J. T., 8 Gruber, A. ]., 354 Hart, S. D., 332 Herzog, C., 191
Goodwin, F. K., 181, 182, 183 Gruber, J., 451 Harter, S., 69 Hesselbrock, V. M., 403
Goodwin, P. J., 441 Grucza, R. A., 404 Harth, T., 441 Hettema, J. M., 122, 126,
Gordon, 0. M., 275 Guarnaccia, P. J., 116 Harvey, A., 190 128, 133
Gordon, P. M., 447 Guarnaccia, P. J. J., 116 Harvey, A. G., 448, 450, Hewlett, W. A., 140
Gore, W. L., 278 Guay, D. R., 386 451,453 Heylens, G., 390
Gorman, J., 387 Guijarro, M. L., 445 Harvey, M. R., 169 Hibell, B., 410
Gorman, J. M., 129, 132, 135 Guilleminault, C., 453, Harwood, D. M. J., 207 Hicken, M., 433
Gorwood, 405 454,458 Hasin, D., 264 Hilbert, A., 343
Gorzalka, B. B., 391 Gunderson, J. G., 264, 265 Hasin, D. S., 49, 271, 275, Hilgard, E. R., 160, 167
Gotlib, I. H., 83, 189, 190 Gunnar, M., 134 399,404,439 Hill, A. ]., 356
Gottdiener, W. H., 471 Guo, 244 Hatsukami, D. K., 420, 423 Hilt, L., 181, 188, 191
Gottesman, I. I., 331 Cur, R. E., 225, 233 Hatzenbuehler, M. L., 49 Hines, M., 390
Gottesman, I. L., 219, 225, Gurland, B., 311 Havik, 0. E., 437 Hinshaw, S. P., 289, 325
233,234 Guroff, J.]., 165 Haworth, C. M. A., 302 Hintsanen, M., 443
Gottheil, E., 441 Gusella, J. F., 310 Hawton, K., 207, 208, 209 Hiripi, E., 341
Gotway, C. A., 116 Gustafsson, P. A., 49 Hayakawa, T., 456 Hite, S., 373
Goudriaan, A. E., 428 Gustafsson, P. E., 49 Hayes, A., 53 Hjelmsater, E., 170
Gould, M., 205, 206, 208, 211 Gustavsson, A., 219 Hayes, A. A., 299 Hlastsala, S. A., 193
Gould, M. S., 210, 211 Hayes, S. C., 39, 48 Hocevar, D., 331
Cow, R. S., 351
Grabe, S., 338, 351
H Haynes, S. G., 445
Hayward, C., 127, 130
Hochman, K. M., 219
Hodapp, R. M.,
Graham,367 Haaga, D. A. F., 179 Hayward, L., 239 296, 299
Grandi, S., 458 Haas, A. P., 211 Hazlett, E. A., 261 Hodgins, S., 477
Grandin, T., 284 Haas, D., 446 Heard, H. L., 266 Hodgson, R.]., 144
Nl-6 Name Index
Hoek, H. W., 35, 197, Hultman, C. M., 315 Jamieson, P ., 208 Kalivas, P. W., 30
342,343 Hume, J. H., 329 Jamison, K. R., 175, 176, 177, Kamen-Siegel, L., 436
Hoekstra, P . J., 303 Hume, K., 294 181,182,183,185,207 Kanaan, R. A., 159
Hoffman, A., 413 Humeau, Y., 295 Jamison, Kay Redfield, 4 Kanbayashi, T., 453
Hofman, M. A., 390 Hunt, W. A., 401 Jang, K. L., 165, 254, 257, Kang, C., 301,302
Hofman, S. G., 126 Huppert, J. D., 52, 271 261,275 Kannel, W. B., 445
Hofmann, F. G., 310 Hurley, R. A., 144 Javier, R. A., 52 Kanner, L., 293
Hogarty, G. E., 244 Huselid, R. F., 403 Jefferson, J. W., 123 Kao, A., 369
Hoge, C. W., 115, 116 Hutchison, K. E., 417, 420 Jeffries, J. J., 398 Kaplan, H. S., 373
Hoge, S. K., 470, 471 Hutton, J., 292 Jemmott, J. B., III, 447 Kaplan, M. S., 205,
Holaway, R. M ., 126 Huttunen, M . 0., 236 Jemmott, L. S., 447 208,384
Holden, C., 32 Hyde, J. S., 338 Jenkins, J. H ., 6, 100, 229, Kapur, S., 228, 237
Holland, L. A., 339 Hyman, B. T., 307 239,240,246 Karasek, R. A., 443
Holleran Steiker, L. K., 23 Hyman, I. E., 170 Jenkins, J. M., 206 Karg, K., 186
Hollings, A., 381 Hyman, S. E., 5, 23, 75 Jenkins, R. L., 321 Karkowski, L. M., 435
Hollins, 296 Jensen, P., 276 Karkowski-Shuman, L., 435
Hollon, S. D., 41, 199, 202, Jensen, P. S., 289, 316 Karlsgodt, K. H., 235, 236
203,204 Jeste, D. V., 224 Karno, M., 100, 140,229,
Holm-Denoma, J. M., 354 Iacono, W . G., 163, 192, 193, Jitendra, A. K., 303 239, 240,246
Holzel, B. K., 48 236,237,331 Jobe, T. H., 227, 228 Kartheiser, P. H., 301
Homish, D. L., 326 Iervolino, A. C., 12 Jobes, D. A., 205 Kasindorf, J., 465
Hooley, J. M ., 100, 229, Ikehara, S., 448 Joe, S., 205, 208 Kaskutus, L.A., 425
239,240 llardi, S., 54 John, 0. P., 254 Kaslow, N., 208
Hoover, D . W., 78 Inciardi, J. A., 419 Johns, L. C., 217 Kaslow, N . J., 46
Hope, D . A., 124 Incrocci, L., 370, 375 Johnson, C. L., 347 Kasza, K. E., 325
Hope, T., 207 Infant Health and Johnson, F., 209 Katon, W ., 155, 156
Hopko, D. R., 122 Development Johnson, P.M., 348 Katon, W . J., 153, 438
Horan, W. P., 225, 243, 245 Program, 299 Johnson, S. L., 193 Katusic, S., 301
Horgen, K. B., 348, 447 Ingram, R. E., 53 Johnson, V. E., 365, 370, 372, Katzman, M.A., 287
Hornbacher, M., 60, 340 Insel, T., 5, 75, 76 377,379 Katzman, R., 311
Hornstein, N. L., 163 Insel, T. R., 23, 140 Johnson, W., 32 Kaufman, J., 32, 186
Horowitz, J. L., 180 Institute of Medicine, 118 Johnston, L. D., 403, 404, Kauneckis, D., 70
Horowitz, M. J., 177 International Society for the 406,409,410,412,413, Kavoussi, R. J., 333
Horwood, J. L., 288 Study of Trauma and 414, 415, 416 Kaysen, S., 252
Hoshino, Y., 293 Dissociation (ISSTD), Johnston, P., 239 Kazdin, A. E., 48, 49, 69,
Hostetter, A. M ., 49, 84 162, 164, 165 Joiner, T., 227, 265, 434 328,329
Howard, A. L., 288 Iranzo, A., 458 Joiner, T. E., 191, 208, 209 Keane, T. M., 118
Howard, M. D., 415 Ironside, R. N ., 158 Joiner, T. E., Jr., 191, 208, Keel, P. K., 339,342,344,
Howell, D. C., 436 Ironson, G., 440 209,354 350,351,354
Howell, P., 301 Irwin, M . R., 448 Jones, D., 329 Keeler, G. P., 326
Howes, 0. D., 237 !son, J. R., 117 Jones, R., 358 Keenan, K., 287, 326
Howland, L. C., 442 Iverson, A. C., 115 Jones, S. M., 298 Keene, D., 433
Howlin, P., 292 Jonsson, S. H ., 337 Kegel, M., 179
Hoza, B., 286
Hsu, D. J., 196 J Joormann, J., 41, 190
Jordan, B. K., 477
Kehrer, C. A., 263
Keir, R., 121
Huang-Pollock, C. L., 325 Jablensky, A., 228 Jordan, K., 386, 387 Keith, S. J., 243, 245
Hubbard, M., 102 Jack, C. R., Jr., 308 Jorenby, D . E., 420 Keller, M. B., 203
Hublin, C., 457 Jack, D . C., 191 Joshi, S. V., 288 Keller, M. C., 23
Hucker, S. J., 383 Jack, R., 205 Juhasz, J. B., 10 Kellermann, A. L., 211
Hudson, J. I., 169, 341, 342, Jackson, H ., 145 Julien, D., 144 Kellett, S., 268
343,346 Jackson, H. J., 386 Kelley, M. L., 207
Hudson, J. L., 136, 138 Jacobi, F., 118
Hudziak, J. J., 144 Jacobson, C. M ., 205,
K Kelly, J. F., 418, 425
Kelly, S. J., 297
Huerta, M., 292 206,208 Kabakci, E., 372 Kelly-Weeder, S., 343
Hufford, M. R., 426 Jacobson, E., 44 Kafka, M.P., 386 Kemeny, M . E., 436, 440,
Hugdahl, K., 122 Jacobson, J. L., 297 Kagan, J., 137 441,442
Hughes, A. A., 137 Jacobson, S. W., 297 Kahn, R. S., 237 Kendall, P. C., 63, 137, 138
Hughes, I. A., 390 Jacobus, J., 405 Kaiser, R., 116 Kendall-Tackett, K. A.,
Hulbert-Williams, S., 441 Jacoby, R., 207 Kalat, J. W ., 27, 28, 29, 30 115,385
Name Index Nl-7
Kendler, K. S., 122, 128, 185, Kleinman, A., 6 Kumar, E. C., 329 Le Strat, Y., 405
208, 212, 238, 257, 259, Klerman, G. L., 45, 191 Kumar, M. S., 113 Leadbeater, B. J., 191
261,350,415,418,435 Klin,A., 293 Kuperminc, G. P., 191 LeBeau, R. T., 118, 119,
Kennedy, S. H., 186 Klorman, R., 117 Kupfer, D. J., 193, 276,456 120, 122
Kenny, P. J., 348 Kluft, R. P., 164, 165 Kurz, A., 308 Lebowitz, M. S., 36
Keough, M. E., 132 Klump, K. L., 342, 344, Kurz, M. W., 309 Leckman, J. F., 139, 140,
Kernberg, 0. F., 265, 350,351 Kutchins, H., 73 143, 144
266,269 Knable, M. B., 235 Kutscher, E. C., 237, 242 Lee, C. T., 209
Kessing, L. V., 181 Knapp, M., 219 Kwapil, T. R., 259 Lee, J. K. P., 386
Kessler, R. C., 18, 48, 76, 92, Knight, E., 180 Lee,R.,333
113, 115, 118, 124, 125,
127, 133, 140, 178, 180,
Knight, R. A., 380
Ko,G.,237
L Lee, S. S., 287
Lee, Y.-J., 452
181,191,192, 193, 204, Koch, G., 312 LaVecchia, C., 405 Leeman, R. F., 428
205, 238,259,287,331, Koenen, K. C., 116, 117 Labinsky, E., 117 Leenaars, A. A., 211
333,341,427,428 Kohut, H., 269 Lack, L. C., 450, 451 Lehman, B. J., 444
Kestler, L., 219 Koike, A., 49 Lacy, T. J., 199 Leibenluft, E., 183, 192, 193
Keteyian, S. J., 447 Kolata, G., 365 Ladd, G. W., 327 Leiblum, S. R., 373, 376,
Kety, S. S., 234 Kolodny, R. C., 370 Ladouceur, R., 144, 428 377,379
Keyes, K. M., 49, 404 Konarski, J. Z., 187, 192 Ladwig, K. H., 155 Lejuez, C. W., 122
Khaitan, B. K., 374 Kong, L. L., 163 Lagana, L., 370 Lemke, T., 11
Khalife, S., 370 Koniak-Griffen, D., 447 LaGreca, A. M., 115 Lenze, E. J., 146
Khan, A., 195 Koob, G. F., 417 Lalonde, J. K., 169 Lenzenweger, M. F.,
Khan, S. R., 195 Koopman, C., 164, 370 Lam, A. G., 50 266,331
Kiecolt-Glaser, J. K., 437, Kopelman, M. D., 167, 168 Lam, R. W., 179 Lenzenwegger, M. F.,
438,440 Kopelowics, A., 244 Lamb, H. R., 17 257,259
Kiefe, C., 444 Korzun, A., 188 Lambert, M. C., 70 Leon, G. R., 356
Kieling, C., 286 Koss-Chioino, J. D., 52, 53 Lambert, M. T., 212 Leonard, S., 64
~
Kihlstrom, J. F., 160, 165, Koss, J. D., 157 Lancaster, G., 298 Lepore, S. J., 445
169, 170 Koss, M. P., 189 Lane, M. C., 331 Lepper, M. R., 102
Killen, J. D., 130 Kosten, T. R., 420 Lang, A. J., 124 Leserman, J., 436, 441,442
Killiany, R., 307 Kotchen, J. M ., 443 Langberg, J. M., 286 Lesperance, F., 446
Kilpatrick, D. G., 115, 189 Kotchen, T. A., 443 Langrod, J. G., 30, 398, 400 Lester, D., 200
Kim-Cohen, J., 325, 326 Koukoui, S. D., 296 Langstrom, N., 382, 383, 384 Leu-Semenescu, S., 452
Kim, H . S., 438 Kouri, E. M., 415 Lanius, R. A., 29 Leventhal, E. A., 446
Kim, L. I. C., 140 Kovacs, M ., 209 Larimer, M., 427 Leventhal, H., 446
Kim, M., 469 Kownacki, R. J., 425 Larimer, M. E., 396 Leventhal, R. M., 195
Kim, S. W., 428 Kraemer, H. C., 130, Larkby, C., 297 Levine, A. M., 441
Kim, Y. S., 292 357,441 Larkin, G. R., 434 Levine, M. P., 338
Kincaid, S. B., 418 Krailo, M., 441 Laroche, S., 295 Levine, S., 243
King, B. H., 296 Krakow, B., 458 Laroi, F., 222, 223 Levinson, D. F., 32, 185
King, c. R., 448 Krasner, L., 156 Larsson, H., 331 Levy, K. N., 266
King, D. A., 425 Krasnoperova, E., 190 Larsson, I., 49 Levy, S. M., 440, 441
Kirk,S.A.,73 Kratochvil, C. J., 288 Lasser, K., 439 Levy, T., 210
Kirkbride, A., 337 Kraus, G., 267, 331, 332 Laub, J. H ., 327 Lewine, R. R. J., 228
Kirkbride, J. B., 238 Krentz, E. M., 353 Laudenslager, M. L., 439, 440 Lewinsohn, P.M., 83, 189,
Kirkley, B. G., 359 Kring, A.M., 48,225,445 Laumann, E., 366 200,337,346
Kirkpatrick, B., 224 Krisljansson, A. L., 337 Laumann, E. 0., 365, 366, Lewis-Fernandez, R.,
Kirmayer, L. J., 77, 125, 155, Kroenke, K., 157 367,368,369,374 116,125
156, 159 Kroll, J., 10 Laurie, T. A., 470 Lewis, G., 238
Kirsch, I., 160, 195 Krueger, R. B., 384 Lauriello, J., 243, 245 Lewis, K., 288
Kisiel, C. L., 165 Krueger, R. F., 32,251, Lavin, M., 384 Lewis, R. W., 363, 367, 368,
Kissane, D. W., 441 276,277 Lavoie, K. L., 445 370,371,374,375
Kit, B. K., 347 Kruijver, F. P., 390 Lavretsky, H., 225, 226, 242 Lewis, T. T., 153, 438, 439
Kivlahan, D. R., 418, 427 Kryger, M . H ., 448 Law, A., 17 Liberman, R. P., 53, 243, 244
Klabunde, R., 444 Krystal, J. H ., 117 Lawrence, A. A., 389, 390 Liberto, J. G., 425
Klap, R., 49 Ksir, C., 402 Lawrie, S.M., 235, 236 Lichenstein, P., 331
Klassen, L. J., 287 Kuepper, R., 415 Laws, D . R., 380 Lidz, C. W., 469
Klein,C., 391 Kuipers, E., 223 LeDoux, J. E., 134 Lieb, K., 266, 267
Klein, M., 265 Kukkonen, T., 369 Le Grange, D., 357 Lieb, R. , 122
Nl-8 Name Index
Lieberman, J. A., 219 Lyons, J. S., 165 Marlatt, G. A., 396, 418, 422, McEwen, B. S., 433, 439
Lietaer, G., 46 Lyons-Ruth, K., 331 423,426,427 McFarlane, A. C., 117
Lilienfeld, S. 0., 169, 330, 331 Lytle, R., 135 Marques, J. K., 388 McGarvey, E. L., 370
Lindardatos, E., 133 Lytton, H ., 326 Marshall, G. N ., 164 McGlashan, T. H., 227, 264
Lindsay, D. S., 170 Lyubornirsky, S., 190 Marshall, T., 156 McGlinchey, E., 451
Lindstrom, M., 136 Marti, C. N., 351,355 McGonagle, K. A., 192
McGovern, C. M.,14
Linehan, M. M., 48, 205, 210,
263,265,266,267 t
M Martin, A., 154, 155
Martin, C. S., 405 McGreevy, M. A., 473
Links, P. S., 255 Mabe, P. A., 217 Martin, N. G.,356 McGue, M., 32,331,419
Linscott, R. J., 217, 219, 227 MacArthur Research Martinez-Taboas, A., 166 McGuffin, P., 192
Lisansky-Gomberg, E. S., 425 Network on Mental Martins, C. M. S., 265 McGurk, S. R., 221, 257
Liston, C., 283 Health and the Martins, Y., 337 Mcintosh, J. L., 206
Little, L., 425 Law,471 Martorana, A., 312 McKelvey, L., 445
Litz, B. T., 118 MacDonald, A. W. ill, 225 Maserejian, N. N., 367 McKinnon, D. H., 301
Liu, H. Y., 197 Macdonald, G. M., 299 Masheb, R. M., 345 McLaughlin, K. A., 49
Liu, L.,450 MacDonald, M. E., 310 Masten, A. S., 436 McLeod, S., 301
Liu, X.-Q., 293 Machon, R. A., 236 Masters, W. H., 365, 370, McMahon, C. G., 375
Livesley, W. J., 165 MacLeod, C., 133, 134 372,377,379 McMahon, R. }.,322
Llera, S., 134 Madhusoodanan, S., 237 Mataix-Cols, D., 141, 144 McMillan, T. M., 332
Lloyd-Richardson, E. E., 207 Madson, L., 438 Matarazzo, J. D., 15 McNally, R. J., 130, 170, 171
Loas, G., 273 Maeland, J. G., 437 Mathews, A., 133, 134 McPartland, J., 292
Lobos, E. A., 287 Maes, H., 325 Matson, J. L., 298 McPheeters, M. L., 294
Lochrnan, J. E., 328, 329 Maes, S., 436 Matt, G. E., 190 McWilliams, N., 41-42
Lochner, C., 274, 275 Maher, B. A., 8, 9, 224 Matthews, K. A., 445 Meaney, M. J., 33
Lock, J., 351, 357 Maher, W. B., 8, 9 Matthiasdottir, E., 337 Meany, M., 33
Lockwood, D., 419 Mahler, M., 44 Mattick, R. P., 421 Mednick, B., 331
Loebel, J. P., 207 Mahowald, M. W., Mattila, M.-L., 291, 292 Mednick,S.A.,236
Loeber, R., 324, 325, 326, 452,458 Maughan, B., 321, 324 Meehl, P. E., 61
327,328 Maier, S. F., 97 Mausbach, B. T., 311 Meinlschrnidt, G., 117
Loehlin, J. C., 31, 32 Malarkey, W. B., 438 Maxfield, J., 352 Menezes, N. M., 227, 228
Loftus, E. F., 169, 170, 172 Maldonado, J. R., 168 Maxmen, J. S., 314 Mennin, D. S., 133
Long, P. W., 222 Maletzky, B. M., 386, Mayberg, H. S., 198 Mensinger, J. L., 52
Longstreth, W. T., 453 387,388 Mayes, L. C., 192 Merchant, A., 267
Looper, K. J., 159 Malia, A. K., 238 Mayou, R., 116 Merikangas, K. R., 122, 180,
Lopez-Quintero, C., 410 Mancini, A. D., 177 Mays, V. M., 433 183, 184, 193
Lopez, S. J., 66 Mandel, H., 140 Mazure, C. M., 189 Merrick, E. L., 425
Lopez, S. R., 116, 244 Manderscheid, R. W., 241 Mazzeo, S. E., 351 Merrill, L. L., 116
LoPiccolo, J., 372, 376, 377 Mangalore, R., 219 Mazzoni, G., 170 Mersky, H., 165
Loranger, A. W., 331 Manicavasagar, V., 137 McAuslan, P., 419 Messinger, J. W., 224,
Lose!, F., 334 Maniglio, R., 25 McBurnett, K., 288 225,227
Lotspeich, L. J., 293 Mann, J. J., 209, 211 McCabe, J. E., 188 Meston, C. M., 370, 371, 373,
Lovaas, 0. I., 294 Mannino, J. D., 374 McCabe, R., 125 374, 375,376,377
Lowenstein, R. J., 165, 166 Mansell, W., 190 McCabe, S. E., 406 Metalsky, G. I., 39
Luborsky, L., 45 Manson, S. M., 404 McCaffery, J. M., 439 Meyer, A. H., 345
Ludwig, A. M., 185 Mansueto, C. S., 142 McCarthy, B. W., 369, 373, Meyer, I. H., 49
Luedicke, J., 347 Manwell, L. B., 401 376,377,379 Meyer, R. G., 465, 467,
Lukoff, D., 238 Maramba, G. G., 52 McCarthy, M., 351 471, 472, 473, 474,
Lukowitsky, M. R., 269 Marangell, L. B., 184 McCartoon, C., 299 475,476
Luria, A., 67 Marazziti, D., 144 McClelland, G. M., 477 Mezzich, J., 267, 269
Luria, M ., 374 Marcos, L. R., 70 McCloskey, M. S., 333 Micallef, J., 143
Lussier, P., 384 Marcus, D. K., 155 McClure, F., 52, 53 Michael, R. T., 365, 366,
Lyketsos, C. G., 308 Marder, S. R., 224 McConaghy, N., 385, 388 374,380
Lyman, R., 297 Margolin, A., 436 McConnell, G. N., 206 Michael, S. T., 54
Lynam, D. R., 328 Mari, J., 243 McCormick, M. C., 299 Michaels, S., 374
Lynch, T. R., 48, 210 Marighetto, J., 308 McCrady, B.S., 419, Micheau, A., 308
Lyness, J. M., 180 Markovitz, P. J., 332 420,423 Michelson, D., 329
Lynn, S. J., 160 Markowitz, J. C., 45 McCrae, R. R., 252, 276 Mick, E., 287
Lynskey, M. T., 288, 399 Marks, I. M., 458 McDuffie, D., 419 Migeon, C. J., 390
Lyon, G. R., 301 Markus, H. E., 425 McEvoy, L. T., 425 Mignot, E., 453
Name Index Nl-9
Miklowitz, D . J., 203 Morokoff, P . J., 371 Neale, M. C., 122, 128, Nurnberg, H. G., 376
Milad, M . R., 143 Morris, M. E., 49 185, 259 Nusslock, R., 193
Milam, J. E., 436, 442 Morrison, A. S., 127 Negash, S., 311 Nutt, J. G., 309
Milazzo-Sayre, L. J., 241 Morrison, C., 350 Neiberg, R. H ., 349
Milich, R., 78
Miller, D. S., 308
Morrison, N. K., 126,414
Morrison, S. L., 238
Neider, J., 156
Neiderhiser, J. M., 32
0
Miller, G. E., 433, 436, Mortensen, P . B., 227 Neighbors, H. W ., 70, 477 O'Callaghan, E., 238
439,444 Morton, L. A., 84 Neighbors, L. A., 337 O'Connor, K., 332
Miller, J. C., 448 Moser, C., 380 Nelson, B., 227 O 'Connor, K. P ., 144
Miller, J. D., 269 Mosimann, J. E., 351 Nelson, N., 49 Odgen, E., 404
Miller, J. M., 304 Moskowitz, J. T., 436 Nemeroff, C. B., 117, 133, Odgers, C. L., 321, 324
Miller, M., 211, 212, 289 Mowrer, 0 . H., 37, 120, 185,186,187,188,195, O'Donnell, C., 205
Miller, S. B., 445 121, 130 196,206 O'Donnell, L., 205
Miller, T. Q., 445 Mueser, K., 224 Nemeroff, C. J., 351 O'Donohue, W. T., 380
Miller, W. R., 421, 423, 425 Mueser, K. T., 221, 243 Nemoda, Z., 418 Ogden, C. L., 347
Millon, T., 257, 259, 269, 273, Mugavero, M. J., 442 Ness, L., 165 O'Hara, M . W., 180, 188
274,275, 279,330, 332 Mukherjee, R., 296 Nestadt, G., 267 Ohayaon, M . M ., 458
Mills, K., 155 Miiller, J. L., 386, 387 Neuchterlein, K. H., 238 Ohayon, M., 448, 452, 457
Milne, B. J., 321 Mullins-Sweatt, S. N., 23, 251 Neugebauer, R., 10 Ohi, K., 261
Milstein, V., 162, 164, 165 Mulvey, E. P., 469 Neuman, R. J., 287 Ohman, A., 122
Mindell, J. A., 457 Mundo, E., 143 Neumann, C. S., 330 Ojeda, V. D., 116
Mineka, S., 121, 122, 130, Munoz, R. F., 49, 53, 70, 200 Neumeister, A., 117 Okazaki, S., 70, 71
134, 137 Munro, A., 231 Newhill, C. E., 469 O'Leary, A., 447
Minor, K. S., 225 Munsch, S., 345 Newman, M., 134 O 'Leary, T. A., 133, 135
Minuchin, S., 47, 355 Murad , M . H., 391 Newman, M . G., 133, Olin, S. S., 259
Miranda, J., 50, 51, 52 Murberg, T. A., 436 134, 135 Ollendick, T. H ., 122
Mirowsky, J., 100 Murdock, T., 115 Newmann, J. P., 39 Olmsted, M . P., 357
Mirsalirni, H ., 46, 47, 48 Murnen, S. K. , 338, 353 Newring, K. A. B., 382 Olson, H. C., 297
Mirsky, A. E., 234 Muroff, J. R., 70 Newton, T. L., 437, 438, 440 Olson, S. L., 65,
Mitchell, A. J., 343, 345 Murphy, J. M ., 5 Neylan, T. C., 456, 457, 458 123,201
Mitchell, J. E., 142, 343 Murphy, R. L., 308 Ng, J., 348 Oltmanns, T. F., 267
Mitchell, J.P., 235 Murphy, W . D., 384 Nichols, R. M ., 170 Olweus, D., 334
Mitchell, K. S., 351 Murray, H. A., 68 Nielson, S., 343, 345 O'Malley, P. M ., 403, 404,
Mitler, M . M ., 448 Murray, R. M., 238, 261 Niemcewicz, S., 457 406,409,410,412,413,
Mitropoulou, V., 261 Myers, J., 185 Niendam, T. A., 236 414,415, 416,420
Mittal, V. A., 236 M yers, L., 126 Nigg, J. T., 256, 257, 259, O 'Malley, S. S., 420
Moffitt, 133 Myrseth, H ., 333 286, 287, 288, 321, 323, Oquendo, M. A., 197, 205
Moffitt, T. E., 32, 321, 324, M yrtek, M., 444 324, 325 Orlando, M ., 164
325,328,331 Nikolas, M. A., 287 O'Rourke, A., 387
Molina, B. S., 290
Monahan, J., 466, 467, 468,
N Nishino, S., 453
Nitschke, J. B., 186, 187
Ortiz, J., 325
Osher, F. C., 477
469, 471 Nagayama Hall, G. C., 52 Nobre, P. J., 372 Oslin, D. W ., 425
Monroe, S. M ., 188 Naimi, T. S., 405 Nock, M., 207 Ost, J., 170
Montaldo, C., 477 Nanney, M. S., 348 Nock, M . K., 69, 204,205,207 Ost, L. G., 122
Montgomery, A., 436 N arrow, W. E., 219 Nolen-Hoeksema, S., 25, 49, Ost, L. S., 123
Montgomery, H. A., 425 Nasar, S., 218 101, 181, 188, 190, 191, Oswald, F., 347
Mooney, M . E., 420, 423 Nath, A., 310 419, 445,479 Overrnier, J. B., 97
Moortonsenk, P . B., 227 N a than, P . E., 387 Norcross, J. C., 53 Owen, N ., 447
Moos, R. H., 421 National Institute on Drug Nordin, V., 292
Mora, G., 10
Moran, E. K., 225
Abuse (NIDA), 415,
416, 417, 425
Nordling, N., 383 p
Norman, R. M., 238
Morey, L. C., 251 National Institute of Mental Norris, F., 115 Padgett, D. K., 246
Morgan, A. B., 331 Health, 223, 224 Novak, N. L., 347 Padilla, A. M., 156
Morgan, C. A., 151 National Sleep Foundation, Nowell, P. D., 452 Page, I. J., 384
Morgan, G. D., 354 448,449, 450 Nowlin, J. B., 445 Paik, A., 366
Morgan, J. F., 344 N eal, D ., 126, 298 Noyes, R., 155 Pakenharn, K. I., 437
Morgenthaler, T., 450, 453 Neal, J. A., 125 Nuechterlein, K. H., 239 Paladino, G ., 381
Morin, C. M., 452 Neal, R. D ., 441 Nugent, N. R., 117 Pallanti, S., 144
Morin, D., 299 Neale, J. M., 225 Nunn, R. G., 304 Pallesen, S., 456
Nl-10 Name Index
Pallesen, S., 333, 428 Pinsof, W. M., 329 Q Reznick, C., 331
Palmer, S.C., 441 Pinto-Gouveia, J., 372 Reznick, J. S., 137
Panagopoulou, E., 436 Piper, A., 165 Qualilty Assurance Rhebergen, D., 439
Pang, K. L., 325 Pipher, M., 353 Project, 259 Ricca, V., 115
Panter-Brick, C., 433 Pipkin, S., 446 Quartier, V., 345 Rice, J. P., 404
Papp, L. A., 129 Pirelli, G., 471, 472 Quigley, L. A., 396 Rich, B.A., 183,192,193
Pappadopulos, E., 329 Pitman, R. K., 171 Quinn, s. J., 118 Richards, T., 303
Pardini, D. A., 324, 326, 328 Pitschel-Walz, G., 244 Quinsey, V. L., 326, 388 Richardson, J. L., 441
Pardo, T. B., 196 Pittenger, C., 187 Rief, W., 154, 155
Paris, J., 165, 267, 273
Park, D. C., 283
Pitts, S. C., 418
Pizzagalli, D., 186, 187
R Rienecke Hoste, R., 357
Riggs, D. S., 115
Parker, G., 239 Platt, S., 208 Rachman, S. J., 122, 144,332 Rim, C. L., 195
Parks, G. A., 426 Plazzi, G., 453 Ragin, D. F., 208 Rime, B., 436
Parry, C. D., 466 Plener, P. L., 207 Raikkonen, K., 436 Rimrnele, C. T., 421
Paterson, A. D., 293 Plomin, R., 302 Raine, A., 325, 331, 332 Rimrno, P., 122
Patrick, D. L., 369 Plotsky, P.M., 188 Ramar, K., 453,454 Ringdal, G. I., 441
Patterson, G. R., 32, 326, Poelmans, G., 287 Ramtekker, U. P ., 286 Ripoll, L. H ., 261, 272, 332
327,332 Poirer, R., 295 Ransom, B. R., 309 Risch, N ., 33, 186
Pattison, P., 386 Polanczyk, G ., 286 Rapee, R. M., 126, 130, 136, Rivara, F. P., 211
Paul, L.A., 403, 404 Polatajko, H., 304 137, 138 Robbins, P. C., 469
Pauls, D. A., 84 Pole, N., 117 Rapoport, J. L., 139, 141, Robbins, T. W., 287
Pearl, R. L., 347 Polivy, J., 351, 356, 143, 144 Roberto, C. A., 339
Peat, C., 343 359,439 Ratakonda, S. S., 242 Roberts, A. L., 116
Pedersen, N. L., 311 Pope, H . G., 169, 337, 341, Rathbone, J., 242, 243 Roberts, S., 91
Pelcovitz, M., 117 354,414,415 Rauch, S. L., 116, 117, Robertson, S. M. C., 122
Pellow, T. A., 164 Pope, H. G., Jr., 346 143, 187 Robin, A. L., 47
Peftas-Lled6, E., 349 Portteus, A. M., 329 Ravussin, E., 348 Robinson, T. E., 417
Pennebaker, J. W., 436, 437 Post, R., 165 Ray, 0.,402 Rock, D., 91
Perelman, M. A., 369 Postuma, R. B., 458 Raynor, R., 121 Rockert, W., 358
Perez-Diaz, F., 273 Potenza, M. N., 428 Raza,A., 242 Rockney, M., 11
Perkins, D. 0., 219 Pottash, A. C., 397 Razran, G., 130 Rodebaugh, T. L., 126, 127
Perleberg, S. H., 46 Pottieger, A. E., 419 Read, J.D., 170 Rodewald, F., 163, 164
Perneczky, R., 308, 311 Poustka, F., 292 Realrnutto, G. M., 329 Rodin, J., 337, 436
Perrine, N., 207 Powell, J. L., 436 Reas, D. L., 359 Roecklin, K. A., 179, 199
Perry, C. L., 356 Powers, M. B., 118 Reay, D. T., 211 Roehling, M. V., 347
Perry, N. W., 434 Poythress, N., 470 Rector, N. A., 225, 240, 243 Roelofs, K., 159
Pescosolido, B. A., 467 Prasad, K. V., 164 Redlich, A. D., 478 Roemer, L., 134
Petch, I., 261 Pratchett, L., 117 Reed, G. M ., 442 Roessner, V., 303, 304
Peterson, B. L., 445 Pratt, D. S., 447, 448 Rees, K., 446 Rogers, C., 45, 46
Peterson, C., 93, 189,436 Prescott, C. A., 126, 185, 208, Regier, D. A., 118, 146 Rogers, J. D., 405
Petrila, J., 469, 471 311,415,418,435 Regier, D . E., 276 Rogers, S. J., 294
Petronis, A., 235 Presnell, K., 355 Rehm, J., 404, 405 Rogler, L. H., 100
Pettit, G. S., 327 Preti,A.,341,342,343,345 Rehm, L. P ., 200 Rogosch, F. A., 117
Peveler, R. C., 358 Pretzer, J., 272 Reich, T., 403 Rohan, K. J., 179, 199
Pharoah, F., 243 Pribor, E. F., 156 Reichborn-Kuennerud, Romanowski, A., 267
Phillips, D.P., 402 Pridal, C. G., 376, 377 T.,271 Romelsjo, A., 410
Phillips, K. A., 142, 144, 156 Prinstein, M. J., 115, 207 Reichow, B., 292, 294 Romer, D ., 208
Phillips, L. A., 446 Prochaska, J. 0., 54 Reid,380 Romney, D. M ., 326
Piche, L., 384 Procopis, P., 158 Reid, M. J., 328, 329 Ronningstam, E., 269
Pichler, S., 347 Proctor, A., 301 Reilly, S., 301 Roos, A. F., 170
Pickering, A. D ., 261 Project MATCH Research Reinecke,M.A.,41 Rose, G. S., 423
Pickett, K. E., 325 Group, 426 Reissing, E. D., 370 Rosen, C., 224
Pieper, S., 133 Puhl, R. M., 347 Reitan, R. M., 67 Rosen, G., 11, 13
Pike, K. M ., 356 Pulay, A. J., 260 Resick, P . A., 116, 118 Rosen, R. C., 366, 373,
Pilkonis, P., 267 Purdon, C., 144 Resnick, H. S., 115 376,377
Pilkonis, P. A., 269 Putnam, F. W., 162, 163, Reuter-Lorenz, P., 283 Rosen-Sheildley, B., 293
Pillai, J. J., 193 164, 165, 166 Reynolds, C. F., 452 Rosenbaum, M., 164
Pincus, A. L., 135, 269 Putnam, K., 186 Reynolds, C. F., III, 456 Rosenberger, P. H., 436
Pine, P., 183 Pyle, R. L., 142 Reynolds, D. J., 267, 331, 332 Rosengren, A., 443
Name Index Nl-11
Rosenhan, D. L., 77,78 Saluja, G., 192 Segal, S. P., 470 Sigman, M., 291, 293
Rosenman, R. H., 444 Salvatori, S., 115 Segerstrom, S. C., 439, Silberg, J. L., 325,328
Rosenstein, M. J., 241 Samii, A., 309 440,442 Silberman, E. K., 165
Rosenthal, M. Z., 265 Sampson, R. J., 327 Segraves, R. T., 363, 371, 375 Silberstein, L. R., 337
Rosman, B. L., 47 Samuels, J. F., 142 Seidman, L. J., 236 Silva,P.A.,324
Ross, C. A., 151, 158, 162, Sand, M., 365 Selby, E. A., 265 Silva, P. S., 212
163, 164, 165 Sanderson, W . C., 130 Seligman, M., 122 Silver, E., 469, 472, 473
Ross, C. E., 100 Sandnabba, N. K., 383 Seligman, M. E., 127 Silverman, J. M., 260
Ross, L., 102 Sanislow, C., 5, 75 Seligman, M. E. P., 39, 93, Silverman, W. K., 115
Ross, L. T., 419 Sanislow, C. A., 76, 264 97,189,436,440 Simeon, D., 169
Ross, S., 207 Santtila, P., 383 Selling, H., 11-12 Simeonova, D. I., 329
Rossell6, J., 52 Sanzo,K.,441 Selling, L. H., 8 Simon, J., 219
Roth, T., 448 Sapolsky, R. M., 31, 443 Selten, J.P., 238 Simons, A. D., 203
Rothbaum, B. 0., 115, 159 Sar, V., 158 Semans, J. H., 379 Simpson, E. B., 267
Rothemund, Y., 348 Sarbin, T. R., 10 Semler, C. N., 451 Sing, L., 342
Rothenberger, A., 303 Sasaki, Y., 374 Semrau, M., 17, 18 Singer, H. S., 303,304
Rothschild, L., 259, 276 Sasvari-Szekely, M., 418 Sen, S., 186 Singh, 0. P., 374
Rotstein, L., 206 Satir, V., 47 Seto, M. C., 383, 384, 385, Skeem, J. L., 467
Rounsaville, B. J., 45, 421, 422 Saunders, B. E., 115 386,387 Skodol, A. E., 255, 275
Rousey, A. B., 299 Sauveanu, R. V., 185, 186, Setzer, N.J., 138 408,424
Rowe, R., 322, 324, 325 187, 188 Seymour, R. B., 414 Skolnikoff, A., 45
Rowland, D. L., 369, 375 Saxena, S., 143, 164, 192 Shadish, W. R., 425 Sloan, D. S., 48
Roy, A., 209 Schacter, D. L., 171, 235 Shaffer, D., 210, 211 Slotema, C. W., 35, 197
Roy-Byrne, P. P., 129 Schenck, C. H., 458 Shafran, R., 190 Smallish, L., 288
Rozin, P., 337 Schiavi, R. C., 371 Shahtahmasebi, S., 298 Smedslund, G., 441
Ruble, A. E., 353 Schienle, A., 133 Sham, P. C., 238 Smilack, K. M., 351
Ruby, T. E., 155 Schildkraut, J. J., 186 Shapiro, J. R., 358 Smith, A. P., 440
Rucker, D., 348 Schlenger, W. E., 477 Sharif, Z. A., 242 Smith, A. T., 343
Rudolph, K. D., 191 Schlosser, D. A., 239 Sharpe, M., 158 Smith, C. A., 326, 327
Ruiz, P., 30, 398, 400, 407, Schmidt, D. A., 451 Shaw, B. F., 40 Smith, D. E., 414
408,409,410,412,414 Schmidt, N. B., 132 Shaw, D . S., 326 Smith, S.M., 167
Ruocco, A. C., 265, 279 Schneider, S. G., 436 Shaw, H. E., 338, 355 Smith, T., 294
Ruscio, A. M., 135 Schneiderman, N., 440, 443, Shaw, P., 308 Smith, T. W., 445
Rush, A. J., 40 444,445 Shaywitz, B. A., 302, 303 Smits-Engelsman, B., 304
Ruskin, P. E., 425 Schnierling, C. A., 136 Shaywitz, S. E., 302 Smits, J. A. J., 439
Russell, A., 261 Scholte, W. F., 115 Shea, M. T., 276 Smolak, L., 342, 353, 354
Russell, R. S., 443 Schonfeld, L., 425 Shear, M. K., 132 Smolensky, M . H., 448
Rusting, C., 445 Schuckit, M. A., 403, Shedden, K., 186 Snidman, M., 137
Rutter, M., 292, 301, 324, 331 418,421 Shelton, D. R., 441 Snitz, B. E., 225
Ryan, J. J., 66 Schulenberg, J. E., 403,404, Shenton, M. E., 235 Snoek, H ., 325
Rychlak, F., 154 406,409,410,412,413, Sher, J., 419 Snowden, L. R., 6, 50,
Rye, D. B., 459 414,415,416 Sher, K. J., 331, 404 51,261
Schultz, R. T., 293 Sherbourne, C., 49 Snowdon, D. A., 312
s Schulz, R., 441
Schuster, J. L., 118
Sherman, D. K., 438
Sherman, J. C., 23
Snyder, C. R., 54
Snyder, R. B., 235
Sack, R. L., 455,456 Schuster, M. A., 112 Sherrill, M. R., 325 Sobal, J., 337, 351
Sackeim, H. A., 35, 197 Schwartz, D., 327 Shields, J., 233 Sobel!, L. C., 422
Sacks, G., 303 Schwartz, J., 143 Shifren, J., 375 Sobell, M. B., 422
Sacks, J. J., 208 Schwartz, M. B., 348 Shin, L. M., 117 Soderstrom, K., 209
Safer, D. L., 48 Scogin, F., 146 Shirk, C., 18 Sohn, M., 389
Sahakian, B. J., 287 Scot, R., 10 Shortt, A. L., 138 Soloff, P. H., 264, 265
Saigal, C. S., 368 Scott, K. M., 208 Shoval, G., 206, 210 Solomon, G. F., 440
Sajatovic, M., 237 Scott, W., 53 Shulz, S. C., 266 Somes, G., 211
Sakheim, D. K., 372 Scull, A., 12, 13, 14 Siegel, J. M., 116 Sommer, I. E., 35, 197
Saldago de Snyder, V. N., 156 Seal, B. N., 377 Siegel, S. D., 440 Sood, S., 303
Salet, S., 275 Seedat, S., 151 Siegler, I. C., 445 Southwick, S. M., 188
,---.......
Salkovskis, P. M., 144, 275 Seeley, J. R., 83, 337, 346 Siev, J., 135 Sowell, E. R., 283
Sallinen, M., 456 Seeman, M. V., 228 Siever, L. J., 256, 257, 260, Spangler, D., 338, 355
Salsman, N., 48 Seeman, T. E., 444 261,272,331 Spanos, N. P., 10, 165, 169
Nl-12 Name Index
Tiet, Q . Q., 324

Spathonis, K. M., 447
Spence, S. J., 291
Stouthamer-Loeber,
M.,326
T Tiggemann, M., 337
Spencer, T. J., 286 Stovall, E. L., 46 Tabrah, H., 416 Tiihonen, J., 237, 238
Spettigue, W., 359 Stoving, R. K., 341, 342, Taillefer, S., 155, 156 Timmons, K. A., 191
Spiegel, D., 164, 166, 167, 343,345 Takahashi, T., 261 Tip, J. E., 403
168,441 Strain, E. C., 30, Takahashi, Y., 164 Todd, M., 418
Spierings, C., 158 398,400 Takei, N., 238 Todd, R. D., 287
Spiker, D., 298 Strauss, G. P., 224 Talovic, S. A., 239 Tolin, D. F., 141, 142
Spiro, C., 221 Strauss, J. S., 220 Tan, P. Z., 133 Tondo, L., 210
Spitzer, R. L., 63, 147, 260, Streissguth, A. P., 297 Tanay, E., 477 Tonigan, J. S., 425
274, 275, 304, 371, 380, Striegel-Moore, R. H., 337, Tang, M. X., 311 Torgersen, S., 265
408,424 342,344,346,356,359 Tang, N. K. Y., 441 Torrey, E. F., 219, 223, 224,
Spoor, S., 348 Stringaris, A., 183 Tang, T. Z., 203 227,228,238,246
Squires-Wheeler, E., 91 Stroebe, M. S., 5 Tanner, L., 334 Torti, F. M., Jr., 311
Stack, D. E., 143 Stroebe, W., 5 Tannock, R., 301 Toscova, R., 425
Stack, S., 209 Stroup, T. S., 219 Tapert, S. F., 405 Toth, S. L., 117, 188
Stadler, C., 325 Strupp, H. H., 44 Tarbell, S., 434 Tottenham, N., 283
Stanley, M. A., 146 Stueve,A.,205 Tariot, P. N., 308 Toufexis, A., 160
Stanton, A. L., 436 Stunkard, A. J., 345, 346, Tatemichi, T. K., 311 Trace, S. E., 350, 351
Starr, H. L., 288 349,351 Tateyama, M., 222 Tracy, M., 115
Starzyk, K. B., 326 Styfco, S. J., 298 Taylor, A., 325 Trestrnan, R. L., 17
Statham, D. J., 205 Substance Abuse and Taylor, C. B., 130 Trexler, L., 200
Steadman, H . J., 468, 471, Mental Health Services Taylor, D. 0., 203 Triebwasser, J., 272
472,473,475,477 Administration Taylor, J., 294, 331 Trierweiler, S. J., 70
Steer, R. A., 209 (SAMHSA), 395, 396, Taylor, S., 275 Trost, W. T., 48
Stefanek, M., 441 403,406,409,410,414, Taylor, S. E., 436, 437, 438, Trotti, L. M., 459
Stein, A., 356 415,416 442,444 True, W. R., 117
Stein, B. D., 112 Sue, D., 50 Teasdale, J., 39 Trull, T. J., 251, 265,
Stein, D. J., 130, Sue, S., 50, 70, 71 Teasdale, J. D., 54 276,331
142,304 Sugden, K., 186 Telch, C. F., 48 Tsai, J. L., 70, 77
Stein, J. A., 116 Suhail, K., 222 Telles, C., 244 Tsao, M. N., 441
Stein, L. I., 245 Sullivan, M., 155 Temple, E., 303 Tseng, W., 8, 9
Stein, M. B., 117, 124, Sullivan, P. F., 350 Templeman, T. N., 384 Tseng, W .-S., 70
129, 151 Sultzer, D. L., 312 Teplin, L. A., 469, 477 Tsuang, M. T., 287
Stein, R. I., 351 Summers, C. J., 268 Teri, L., 312 Ttofi, M. M., 334
Steinberg, L., 235, 478 Sun, D., 235,236 Terracciano, A., 276 Tucker-Drob, E. M., 254
Steiner, M., 188, 231 Sun, L. W., 287 Test, M. A., 245 Tugade, M. M., 434
Steketee, G., 141, 142 Sundgot-Borgen, J., 353 Teyber, E., 52, 53 Tugrul, C., 372
Stephens, J., 389 Sundram, C. J., 470 Thara, R., 228 Tumuluru, R., 294
Stephens, M. A. P., 436 Suomi, S. J., 134, 137 Thase, M. E., 187, 194, 195, Turk, C. L., 124
Stephens, S., 309 Sutker, P. B., 115, 116 196, 197, 203, 210 Turk, D. C., 155
Stern, Y., 311 Suzuki, M., 261 Thatcher, J. E., 117 Turk, J., 296
Sternberg, R. J., 66 Svaldi, J., 355 Thayer, J. F., 133 Turkheimer, E., 466
Sterner, U., 123 Swaab, D. F., 390 Thede, L., 257, 261 Turner, C. W., 445
Sterzer, P., 325 Swanson, J., 288 Thede, L. L., 390 Turner-Cobb, J. M., 441
Stevenson, J., 331 Swanson, J. M., 469 Theorell, T., 443 Turner, S. M., 123
Stewart, S. E., 143 Swanson, S. A., 341, Thestrup, M., 373, 376, 377 Tuschen-Caffier, B., 355
Stice, E., 338, 348, 351, 342,344 Thibaut, F., 386, 387 Twenge, J. M., 101, 188
352,355 Swartz, H. A., 193, 203 Thibodeau, N., 144 Tyrer, P., 155
Stinnet, R. D., 384 Swartz, M., 469, 470 Thienemann, M., 138 Tyrrell, D. A., 440
Stinson, F., 271, 273, 275 Swartz, M. S., 192 Thigpen, C. H., 161
Stinson, F. S., 255, 257,
269,404
Swedo, S. E., 292
Sylvers, P., 332
Thompson, C., 207
Thompson, M. S., 298
u
Stoeckel, L. E., 348 Szasz, T., 77 Thompson, P. M., 308 Uddin, M., 117
Stoffers, J. M., 270 Szasz, T. S., 6, 465 Thornicroft, G., 17 Uddo, M ., 115
Stolpmann, G., 386, 387 Szatrnari, P., 293 Thornley, B., 242 Udell, J., 170
Stone, J., 157, 159 Szekely, A., 418 Thorpe, G. L., 65, 123, 201 Ujike, H., 390
Story, M., 348 Szelenberger, W., 457 Tien, A., 228 Ulbricht, J. A., 32
Stout, R. L., 264 Szuba, M., 143 Tienari, P., 234 Ullman, L. P., 156
Name Index Nl-13
Ulrich, R., 267, 269 Virani, A. S., 398, 406, Warschburger, P., 353 Widiger, T. A., 23, 72, 74,
UN AIDS, 434, 435 415,416 Wassell, G ., 328 175,276,278,320
Unwin, G. L., 298 Visich, P. S., 447 Waters, A.M., 109, 122, 126, Widman, L., 122
Urbanoski, R. A., 418 Visintainer, M. A., 440 127, 130, 133, 134 Widom, C. S., 191
Ursano, A. M ., 301 Vismara, L. A., 294 Watkins, E., 190 Wiesbrock, V., 17
U.S. Department of Health Visscher, B. R., 442 Watkins, E. R., 25 Wilens, T. E., 251, 253, 259,
and Human Services, 52 Visser, F. E., 296 Watson, D., 75, 109, 286, 287,288
Useda, J. D., 257 Vitale, N., 295 178,277 Wilfley, D. E., 356
Vitiello, B., 288 Watson, H. J., 357 Wilhelm, F. H., 345
v Vitkus, J., 289

Vitousek, K., 70
Watson, J., 15, 121
Watson, M., 440
Wilhelm, S., 142, 143
Williams, C., 246
Vacek, P.M., 199 Vlahov, D., 147 Waudby, C. J., 331 Williams, D. L., 296
Vaillant, G. E., 436 Vocks, S., 359 Waugh, C. E., 434 Williams, D. R., 190
Vaillend, C., 295 Voet, H., 209 Wayland, K. K., 329 Williams, J. B. W., 63, 275,
Vakoch, D. A., 44 Vohs, K. D., 354 Weaver, C. M., 465, 467, 471, 408,424
Valenstein, E. S., 35 Voigt, K., 155 472,473,474,475,476 Williams, L. M., 115, 169
Valenstein, R. S., 33, 241 Volkmar, F. R., 292, Weaver, K. E., 436 Williams, M., 190-191
Valenzuela, M. J., 312 293,294 Webb, R. L., 308 Williams, N. A., 404
Van Balkom, A. J. L. M., 130 Volkow, N.D., 30, 288,417 Webster-Stratton, C., Williams, R. B., 444, 445
Van den Brink, W., 428 Vollebergh, W., 238 328,329 Williamson, G. L., 479
van der Leeden, R., 133 Volpicelli, J. R., 440 Wechsler, H., 403 Wilps, R. F., Jr., 344
Vander Maas, H . L. J., 426 Vondra, J. I., 326 Weems, C. F., 116 Wilsnack, R. W., 403
van der Velden, P. G., 115 Vythilingam, M., 117, 188 Weertman, A., 275 Wilson, G. T., 349, 358
van Erp, T. G. M ., 232 Wei, E., 326 Wilson, K. A., 127
Van Goozen, S., 325
van Heren, 236
w Weidman, M ., 268
Weinberger, J., 41-42
Wilson, P., 304
Wincze, J. P., 366
van Hoeken, D., 342 Wade, T. D., 342, 346, 354, Weinberger, L. E., 17 Wing, Y.-K., 450
Van Holst, R. J., 428 356,357 Weiner, B. A., 465 Wingate, L. R., 208
van Lankveld, J., Wagenpfeil, S., 308 Weinman, J., 446 Winger, G., 310, 412, 413
371,373 Wagner, P. S., 221 Weinstein, Y., 267 Winick, B. J., 479
van Loon, P., 115 Wahlbeck,K.,237,238 Weissman, A., 200 Winkelmann, J., 459
Van Melle, J.P., 446 Wahlberg, K. E., 234 Weissman, M., 202, 203 Winslow, E. B., 326
van Ommeren, M., 168 Waite, L. J., 366 Weissman, M. M., 45, 191 Winstead, D. K., 114
van Oppen, P., 53 Wakefield, J. C., 147 Weisz, J. R., 69, 70 Wintersteen, M. B., 52
Van Os, J., 217, 219,227, Wakschlag, L. S., 325 Weizman, A., 209 Wisco, B. E., 190
238,304 Walderhaug, E., 117 Wells, A., 126 Wiseman, C. V., 351, 352
van Straten, A., 53, 203 Waldron, H. B., 423 Wells,K.,49 Wisniewski, A. B., 390
Vandelanotte, C., 447,448 Waldron, S., 45 Wells, T., 352 Witkiewitz, K., 423, 426
VanderWal, J. S., 347 Wales, J., 343, 345 Wennberg, P., 410 Wittchen, H .-U., 120, 122,
Vasquez, C., 190 Walker, E., 155, 219 West, B. T., 406 124, 125, 128
Vaughn, M.G., 334 Walker, E. F., 242 Westefeld, J. S., 206 Wittert, G., 117
Veasey, S.C., 454 Walker, L., 466 Westen, D., 45 Wolfe, B. E., 343
Veith, I., 9, 10 Walker, L. S., 155 Westermeyer, J., 156, 223 Wolfson, A. R., 448, 449,
Velting, D. M., 210, 211 Walker, W. R., 151 Westphal, M., 177 450,451,455
Velting, 0. N., 138 Walkup, J. T., 303,304 Westrin, A., 179 Wollert, R., 380
Veltman, D. J., 428 Wallace, E. R., IV, 9 Wetherell, J. L., 146, 180 Wollman, E. E., 446
Vendette, M., 458 Walsh, B. T., 350, 351 Wettstein, R. M., 465 Wonderlich, S., 343
Ventura, J., 238 Wang, A. T., 291 Wetzel, R. D ., 156 Wonderlich, S. A., 345,346
Verdeli, H., 202,203 Wang, P. S., 18, 48, 180 Weyer, Johann, 10 Wong, W., 243
Vergara, A., 115 Wang, R., 370 Wheeler, J., 382 Wood, H., 390
Verheul, R., 276 Waranch, H. R., 304 Whitbourne, S. K., 426 Woods, J. H ., 310
Verhulst, J., 376 Warburton, L. A., 436 White, K. J., 329 Woods, S., 256
Verma, K. K., 374 Ward, L. M., 338 White, M. A., 345 Woods, S. W., 132
Vermetten, E., 162 Ward, N. G., 314 White, S., 314 World Health Organization
Vernberg, E. M., 115 Ward, T., 386 White, S. F., 322 (WHO), 17, 204, 205,
Vemet, C., 452 Wardlaw, D. M., 205 Whiteside, T., 441 206, 395, 401, 404,
Vesga-Lopez, R., 133 Warmerdam, L., 203 WHO World Mental Health 441,443
Via, E., 293 Warner, M. S., 170 Survey Consortium, 17 Worthman, C. M.,
Viken, R. J., 355 Warren, J. I., 330, 473, 476 Whooley, M.A., 439,446 188,433
Nl-14 Name Index
Wurtzel, E., 185 Yokum, S., 348 Zalsman, G., 206, 210 Zhou, J.-N., 390
W yatt, E., 351 Yonkers, K. A., 129 Zambon, A., 405 Zhu, B., 170
Wynne, L. C., 234 Young, E., 188 Zanarini, M. C., 264, 265, Ziegelstein, R. C., 446
Young, S. E., 390 266, 276, 279 Zigler, E., 298, 299
X Young-Wolff, K. C., 418
Youngren, M.A., 200
Zane,N., 50
Zanoni, S., 143
Zilboorg, G ., 10
Zimmerman, M., 259,
Xu, M .-Q.l, 236 Yu,J.,357 Zap, P. A., 471 260,276
Yuan, J., 370 Zautra, A. J., 436 Zinbarg, R., 121
y Yue, D. L., 189, 190
Yung, A., 227
Zayas, L. H., 206 Zintzaras, E., 459
Zeiss, A. M ., 200 Zinzow, H. M ., 115
Yairi, E., 301 Yusuf, S., 443 Zelt, D ., 221 Zipursky, R. B., 227
Yamada, A.M., 6, 50, 51 Yutzy, S. H ., 156 Zeman, J., 155 Zoccolillo, M ., 324
Yang, J., 254 Zhang, B., 450 Zucker, K. J., 382, 389, 390
Yapko, M. D., 200
Yasenik, L., 158
z Zhang, J., 301
Zhang, W., 17
Zucker, R. A., 418
Zuvekas, S. H ., 288
Yeh,M., 69 Zahn, T., 165 Zhang, X., 186 Zvolensky, M. J., 439
Yehuda, R., 117 Zakzanis, K. K., 265 Zhong, L., 313 Zweig-Frank, H., 165
Yirmiya, R., 446 Zald, D. H., 348 Zhong, Y., 211, 212 Zwerdling, D., 467
SUBJECT INDEX
adoption studies, 99 prevention,426-427 anhedonia, 177,225
A schizophrenia,233-234 and sexual Animal House, 395
AA (Alcoholics adrenal-cortical system, dysfunctions, 371 animalstudies,97,97-98
Anonymous), 423-425 31, 108 treatment, 420, 421, 426 animal type phobias, 118
ABAB (reversal) adrenocorticotrophic Alcohol Skills Training Anna 0 . case, 41, 152
experimental design, 96 hormone (ACTH), Program (ASTP), 426 anomie suicide, 207
Abilify (ariprizole), 197 31, 108 alcohol use disorder anorexia nervosa, 337,
abnormality advanced sleep phase type older abuser 339-343
continuum sleep disorder, 455-456 prevalence, 425 family systems related, 47
model of, 3 African Americans. See also treatments, 426 health consequences, 343
defining,4-7 racial/ ethnic Ali, Muhammed, 309 Antabuse (disulfiram),
abstinence violation differences ALI rule, 475 420,421
effect, 423 delirium, 314 alleles, 31- 32 antagonist drugs, 420
abuse, 116. See also trauma depression, 192 allostasis, 433 anterior cingulate,
and borderline personality hypertension, 444 allostatic load, 433, 439 186-187,325
disorder, 265 neurocognitive disorder alternate form reliability, 62 anterograde amnesia, 166
and conduct disorder, and, 311 alters, 162- 163 antiandrogen drugs, 386-387
325,326 post-traumatic stress altruistic suicide, 207 antianxiety drugs, 34, 138,
and depersonalization / disorder, 116 Alzheimer, Alois, 307 146, 312. See also
derealization schizotypal personality Alzheimer's disease, benzodiazepines
disorder, 169 disorder, 261 306-308 anticholinergic effects, 196
and depression, 188, 191 stress, 433 causes,307-308 anticipatory anxiety, 129
and dissociative identity suicide, 205, 208 Ambien (zolpidem), 452 anticonvulsants, 34,
disorder, 164-165 age differences amenorrhea,339,343 196-197,329
and insanity defense, 473 depressive disorders, 180 American Law Institute antidepressant drugs, 34.
and paraphilias, 383, 386 schizophrenia, 228 (ALI), 475 See also selective
and repressed memories, sleep disorders, 450 American Psychiatric serotonin reuptake
169-171 substance use disorders, Association, 72,475 inhibitors
and suicide, 208 403-404 Amish people, 84 for attention-deficit/
acamprosate,420 aging. See older adults amnesia. See also hyperactivity
acceptance and agnosia, 306 anterograde amnesia; disorder, 288
commitment therapy agoraphobia, 120 dissociative amnesia; for depression, 187, 204
(ACT), 48 agranulocytosis, 242 organic amnesia; for neurocognitive
accidents, 448-449 akathesis, 242 psychogenic amnesia; disorder, 312
acetylcholine, 308, 312, 314 akinesia, 242 retrograde amnesia for older adults, 146
Acomplia (rimonabant), 349 alcohol, 400-403 dissociative, 165-168 for schizotypal
ACT (acceptance and blood-alcohollevels, and dissociative fugue, 167 personality
commitment 401,402 and dissociative identity disorder, 261
therapy), 48 drinking age issues, 429 disorder, 163 for separation anxiety
ACTH impact on brain, 417-418 and substance use disorder, 138
(adrenocorticotrophic legal definition of disorders, 167 and sexual
hormone), 31, 108 intoxication, 401 amok, 76 dysfunctions, 375
actigraph, 450 misuse, 403-405 amphetamines, 409-410, 453 for sleep disorders, 452,
Act for Regulating Madhouses prevalence among college amygdala, 28 453,457
(England) (1774), 12 students, 426 and bipolar disorder, 192 for substance use
acute disorders, 74 unintended injuries, and borderline personality disorders, 420
acute stress disorder, 401-402 disorder, 265 antihistamines, 138,
110,113 withdrawal, 401-403 and conduct disorder, 325 409,452
Adderall, 288 alcohol-induced and depression, 187 antipsychotic drugs, 33-34.
addiction and related dementia, 405 and post-traumatic stress See also atypical
disorders. See alcohol misuse. See also disorder, 116 antipsychotics
substance use disorders substance use disorders Anafranil (clomipramine), for borderline personality
addicts, 396 dementia and, 405 144,375 disorder, 266
ADHD. See attention- gender differences, 403 anal stage of psychosexual for conduct disorder, 329
deficit / hyperactivity long-term effects, development, 43 for neurocognitive
disorder 404-405 Anatomy of an illness disorder, 312
adjustment disorder, 113 and neurocognitive (Cousins), 434 antiseizure drugs, 332
adolescent-onset conduct disorders, 310 Angelhead (Bottoms), 464 antisocial personality
disorder, 321 older adults, 425 angina pectoris, 443 disorder, DSM on, 330
Subject Index Sl
Sl-2 Subject Index
antisocial personality brain-imaging for schizophrenia, 237, behavioral family systems

disorder (ASPD), techniques, 67 242-243 therapy (BFST), 47
329-332 challenges in, 68-71 for schizotypal personality behavioral inhibition, 137
anxiety attacks, approaches children, 69-70 disorder, 261 behavioral medicine. See
to causation, 24 clinical interviews, 62-63 auditory hallucinations, 223 health psychology
anxiety disorders. See also cultural issues, 64, 66, autism, extraordinary behavioral observation,
panic disorder; post- 70-71 people, 284 64-65
traumatic stress defined,60 autism spectrum disorder, behavioral therapies, 38,
disorder integrationist approach 290-294 38-39. See also cognitive-
generalized anxiety on, 79 contributors to, 293 behavioral therapy
disorder, 132, intelligence tests, 66 DSM-5 diagnostic criteria, for attention-deficit/
132-135, 133 neuropsychological tests, 290,292 hyperactivity disorder,
integrationist approach 66-67 schizophrenia 288-289
on,146-147 personality inventories, compared, 227 for autism spectrum
obsessive-compulsive 64-66 treatment, 294 disorder, 294
disorder, 139-145, 141 projective tests, 68 autonomic nervous for avoidant personality
older adults, 145-146 psychophysiological tests, system, 108 disorder, 271-272
and sexual 67-68 aversion therapy, 387 for borderline personality
dysfunctions, 371 reliability, 61-62 aversive classical disorder, 265
anxiety sensitivity, 130 resistance to, 68-69 conditioning, 421 for conversion
anxious distress, 178 self-monitoring, 65-66 avoidance coping, 436 disorder, 159
anxious-fearful personality sleep, 449-450 avoidant personality for depression, 199
disorders, 270-276 standardization, 62 disorder, 270-272 for intellectual
aphasia, major symptom questionnaires, avolition, 225 disabilities, 298
neurocognitive 63-64 axons, 29 for neurocognitive
disorders, 305 validity, 60-61 disorder, 312
apnea, 453-454
APOE (apolipoprotein E
association (molecular
genetic) studies, 99
B for obsessive-compulsive
disorder, 145
gene), 308 ASTP (Alcohol Skills Bandura, Albert, 16, 38 for obsessive-compulsive
applied tension Training Program), 426 barbiturates, 34, 405-406 personality disorder,
teclmique, 123 asylums, 11-12 intoxication and 275-276
appraisals, 436 ataque de nervios, 50, 76, withdrawal for paraphilias, 387
apraxia, 305-306 116, 164 symptoms, 401 for phobias, 122-123
Aricept (donepezil), 312 atherosclerosis, 443 bariatric surgery, 349 forschizophrenia,243-244
aripriprazoe, 266 athletes, 353, 353-354 Barrett v. United States, 475 for sleep disorders,
ariprizole (Abilify), 197 atomoxetine, 288 basalganglia, 192,235 456,457
arousal attention-deficit/ Bazelon, David, 474 for substance use
and antisocial personality hyperactivity disorder BDI (Beck Depression disorders, 421-422
disorder, 332 (ADHD), 284, 286-290 Inventory) (Beck& for suicide, 210
and coronary heart and bipolar disorder, 183 Beck), 63 behavioral undercontrol,
disease, 445 and conduct disorder, A Beautiful Mind (Nasar), 218 418-419
and sleep disorders, 28- 79,329 beauty standards, behavior disorders, attention-
456-457 DSM criteria for, 285, 286 351-353,352 deficit/hyperactivity
arousal phase of sexual treatment, 288-290 Beck, Aaron, 16, 40 disorder, 183
response, 365 attributions, 39-40, Beck Depression Inventory behavior genetics, 31,31- 33,
asociality, 225 189-190 (BDI) (Beck & Beck), 63 33. See also genetic
ASPD (antisocial atypical anorexia Beckham, David, 108 approaches
personality disorder), nervosa,346 Bedlam, 11, 12 Bender-Gestalt Test, 66
329-332 atypical antipsychotics, behavioral approaches, benzodiazepines, 34
Asperger's 33-34 36-39. See also abuse of, 405-406
disorder, 292 for antisocial personality behavioral therapies; for generalized anxiety
assertive community disorder, 332 cognitive-behavioral disorder, 135
therapy, 245- 246 for bipolar disorder, 197 therapy intoxication and
assertive community for borderline personality on depression, 188-189 withdrawal
treatment programs, disorder, 266 origins of, 15-16 symptoms,401
244,244-246 for conduct disorder, 329 on paraphilias, 385-386 for older adults, 146, 425
assessment, 58-68 for obsessive-compulsive on phobias, 120-122, 121 for phobias, 123
behavioral observation, disorder, 145 on sleep disorders, for post-traumatic stress
64-65 risks for children, 316 451-452 disorder, 118
Subject Index Sl-3
for separation anxiety on panic disorder, in Alzheimer's Bupropion (Wellbutrin,

disorder, 138 128- 129, 130 disease, 307 Zyban), 196, 288,
for sleep disorders, 452 on phobias, 122 and amnesia, 168 375,420
for substance use on post-traumatic stress assessment, 66-67,67 Bush, Kathleen, 160
disorders, 420 disorder, 116-117 and attention-deficit/ buspirone, 146
bereavement practices, 5 and psychosurgery, 35 hyperactivity butyrophenones, 242
Bernheim, Hippolyte- on schizophrenia, 232-238 disorder, 287
Marie, 15
BFST (behavioral family
on separation anxiety
disorder, 136-137
autism spectrum
disorder, 293
c
systems therapy), 47 on sexual dysfunctions, and bipolar disorder, caffeine, 410
bias. See also prejudice / 370-371 192-193 intoxication and
discrimination on sleep disorders, 453 and borderline personality withdrawal
and assessment, 70- 71 on substance use disorder, 265 symptoms, 407
and case studies, 88 disorders, 417-418 brain structures, 27, 28-29 caffeine intoxication, 411
and meta-analysis, 101 on suicide, 209 and conduct disorder, 325 cancer,440-441
and samples, 90 and treatment model, 25 conversion disorder, 159 cannabis, 414-415
The Biggest Loser, 351-352 biopsychosocial approach, and depression, 186-187 carbamazepine (Tegretol,
binge drinking, 403, 405 24,25,434-435 and endocrine system, 31 Equetro), 196
binge-eating disorder, 345, bipolar disorder and gambling careers in abnormal
345-346 biological theories on, disorder, 428 psychology, 19
bingeing, 343. See also 184, 192- 193 and gender dysphoria, 390 Carey, Drew, 185
bulimia nervosa characteristics, 181-185 intellectual disabilities Caro, Isabele, 338
binge/ purge type of and creativity, 184-185 resulting from, 296-298 case studies, 87-88
anorexia nervosa, 341 and delusions, 221-222 learning and anorexia nervosa, 342
biochemical imbalances, DSM criteria for, 183 communication anxiety disorders,
29- 31. See also extraordinary people, 176 disorders, 302 145-146
biological theories prevalence, 184 motor disorders, 304 attention-deficit/
neurodevelopmental or and suicide, 208 and obsessive-compulsive hyperactivity
neurocognitive treatment, 196-197, disorder, 143 disorder, 286
disorders, 314-315 202-203,203 and panic disorder, 128 autism spectrum
biological theories, 23, 26-36. bipolar I disorder, 182 pleasure pathways, 417 disorder, 290-291
See also drug therapies; bipolar II disorder, 182-183 and post-traumatic stress avoidant personality
genetic approaches birth complications and disorder, 117 disorder, 270
assessment of, 35-36 schizophrenia,236 and schizophrenia, 224, borderline personality
on attention-deficit/ bisexuals. See gay, lesbian, 235- 236,236 disorder, 263
hyperactivity disorder, and bisexual people and schizotypal brain dysfunction, 26
287- 288 blackouts, 400 personality disorder, 261 cognitive approaches, 41
behavior genetics, 31-33 Bleuler, Eugen, 225-226 and sleep disorders, 453 conduct disorder, 321
biochemical imbalances, blood-alcohollevels, and substance use, 417 conversion disorder,
29-31 401,402 brain hemispheres, 27-28 158-159
on bipolar disorder, 184, blood-injection-injury type brain-imaging techniques, 67 coronary heart
192-193 phobias, 120 brain stimulation, 34-35, disease, 442
on borderline personality BMI (body mass 197-198 cultural sensitivity, 50-51
disorder, 265-266 index), 347 brain surgery. See dependent personality
brain overview, 27-29 Bobbitt, Lorena, 168, 473 psychosurgery disorder, 272
and brain stimulation, bodybuilding, 354 breathing-related sleep depression, 87, 199-200
34-35 body dysmorphic disorder, disorder, 453,453-454 dissociative amnesia, 167
on depression, 185-188 142-143 Breuer, Josef, 15, 41 dissociative identity
and drug therapies, bodyimage,342,351-352 brief psychotic disorder, disorder, 160-161
33- 34 body mass index (BMI), 347 217,230, 230-231 eating disorders, 340-341,
on eating disorders, Bonaparte, Napoleon, 185 Brown,Joyce,465-466 345,345-346,353,
350-351 borderline personality bulimia nervosa, 337, 343, 355-356
on gender dysphoria, 390 disorder, 262-267 343-345 gender dysphoria,
on generalized anxiety Bottoms, Greg, 464 prevalence, 344 388-389
disorder, 134 Braff, Zach, 185 bulimia nervosa of low heart disease, 442
historical perspectives, 7, brain dysfunction, 26, frequency and/or histrionic personality
9, 14 27- 29. See also limited duration, 346 disorder, 267
on obsessive-compulsive biological theories; Bundy, Ted, 320, illness anxiety
disorder, 143-144 neurotransmitters 329,330 disorder, 154
Sl-4 Subject Index
case studies-Cont. Charcot, Jean, 15 classical conditioning, 15, cognitive-behavioral

intellectual disability, 298 CHD (coronary heart 36, 37,421 therapy (CBT), 40
major NCD, 310 disease), 442-446 classification systems, 71 for conduct disorder,
managed care, 18 child alters, 162 claustrophobia, 119 328-329
narcissistic personality childhood disorders, use client-centered therapy for coronary heart
disorder, 268-269 of atypical (CCT), 46 disease, 445-446
neurocognitive disorders antipsychotics, 316 clinical interviews, 62, for dependent personality
(NCDs), 304, 310 childhood-onset conduct 62-63,92 disorder, 273
obsessive-compulsive disorder, 321 clinical model of traditional for depression, 200,
personality disorder, child-onset fluency healing, 246 200-202,203
274-275 disorder, 301 clinical psychologists, 19 for eating disorders,
older adults, 145-146 children. See also clinical social workers, 19 357-359
oppositional defiant neurodevelopmental clomipramine (Anafranil), for gambling
disorder, 323-324 and neurocognitive 144,375 disorder, 428
panic disorder, 127 disorders clonidine, 288 for generalized anxiety
paranoid personality assessment challenges, clozapine (Clozaril), 242 disorder, 134-135
disorder, 256--257 69-70 Clozaril (clozapine), 242 on obsessive-compulsive
paraphilias, 381, bipolar disorder, 183-184, Cobain, Kurt, 87-88 disorder, 145
384,385 192-193 Coca Cola, cocaine in, for panic disorder, 131-132
post-traumatic stress conversion disorder, 158 397-398 for paraphilias, 388
disorder, 114 depressive disorders cocaine,406-409 for phobias, 122-123
schizoid personality among, 180-181 dopamine and, 417 for post-traumatic stress
disorder, 258-259 dissociative identity prevalence of, 409 disorder, 118
schizophrenia,240-241 disorder, 163 cognitions, 16, 39 for separation anxiety
schizotypal personality and factitious disorders cognitive approaches, 16, disorder, 138
disorder, 260-261 imposed on another, 160 39-41. See also for sexual dysfunctions,
separation anxiety gender dysphoria, 389, cognitive-behavioral 376--377
disorder, 137-138 390,391 therapy for sleep disorders,
sexual dysfunctions, 368, HIV I AIDS, 441-442 on avoidant personality 451-452,456
369,371,378 obsessive-compulsive disorder, 271 cognitive disorders. See also
social phobias, 124 disorder, 140 on conduct disorder, 327 dementia;
somatic symptom paraphilias, 384-385 on dependent personality neurocognitive
disorders, 154, 157, phobias, 121 disorder, 273 disorders (NCDs)
158-159 post-traumatic stress on depression, 189-191 delirium, 312, 312-314
substance use disorder, 116, 117 on eating disorders, cognitive therapies, 40. See
disorders, 408 separation anxiety 354-355 also cognitive-
castration, 386 disorder, 135-136 on generalized anxiety behavioral therapy
cataplexy, 452-453 sleep disorders, 456 disorder, 133-134, for avoidant personality
catastrophic thinking, 129 substance use 134-135 disorder, 271- 272
catatonia, 179, 224 disorders, 404 intermittent explosive for borderline personality
catatonic excitement, 224 suicide, 205-206 disorder, 333 disorder, 266
catecholarnines, 445 violence, 467 on narcissistic personality for histrionic personality
catharsis, 15, 41, 45 China, ancient, 8-9 disorder, 269 disorder, 267-268
caudate nucleus, 143 chlorpromazine on obsessive-compulsive for narcissistic
causal attributions, 39-40, (Thorazine), 241 personality personality disorder,
189-190 cholecystokinin (CCK), 128 disorder, 275 269-270
causes of death, 435 Cho, Seung-hui, 466--467 on panic disorder, for paraphilias, 388
CBT. See cognitive- chromosomes,31 129-130 forschizophrenia,243-244
behavioral therapy chronic arousal, 113 on paranoid personality for substance use
CCK (cholecystokinin), 128 chronic disorders, 74 disorder, 257-258 disorders, 422-423
CCT (client-centered Churchill, Winston, on paraphilias, 386 cohort effects, 191
therapy), 46 184, 185 on phobias, 122 collective unconscious, 44
cell bodies, 29 Cialis, 375 on post-traumatic stress collectivist cultures, 50
central sleep apnea, 453 circadian rhythms, disorder, 118 college students, suicide
cerebellum, 27 199,455 on schizophrenia, 240 and,206
cerebral cortex, 27, 28 circadian rhythm sleep on sleep disorders, communication disorders,
cerebrovascular disorder,455,455-456 451-452 301-302
disease, 309 civil commitment, 464-470 on substance use causes and treatment,
Chantix (varenicline), 420 clangs, 224 disorders, 418 302-303
Subject Index Sl-5
diagnostic features of, 302 continuum model, 3 Creutzfeldt-Jakob cultural norms, abnormality
treatment of, 302-303 abnormality criteria, 3 disease, 310 criteria and, 5-6
community mental health assessment and CRF (corticotropin-release cultural relativism, 6
centers, 16-17 diagnosis, 59 factor), 31, 108 cultural sensitivity, 50-51
community mental health and assessment/ CRH (corticotropin- culture-bound syndromes, 76
movement, 16-17, 210, diagnosis, 75 releasing hormone), 187 curanderos/ curanderas, 53
244-246,246,478 on dissociative crime. See also legal issues; cyclothymic disorder, 183
community psychology, 53 disorders, 151 violence
comorbidity, 75-76
competence to stand trial,
on eating disorders, 337
on fear and anxiety, 107
and amnesia, 167-168
and conduct disorder,
D
471-472 on legal issues, 463 321,325,327 Dahmer, Jeffrey, 474
compulsions, 139 mental health law, 463 conduct disorders, 334 dangerousness criterion for
compulsive gambling, 428 on mood disorders, 175 crisis intervention abnormality, 6
computerized tomography on neurodevelopmental programs, 210 dangerousness to others
(CT), 67 and neurocognitive cross-cui tural research, criteria for civil
concordance rate, disorders, 283 99-100 commitment, 466-467
98-99 on personality disorders, cross-dressing, 382 dangerousness to self
concurrent validity, 61 251, 278-279 cross-sectional studies, criteria for civil
conditioned avoidance and research, 83 89,91 commitment, 466
response, 37, 130 on schizophrenia, 217 CS (conditioned date-rape drugs, 416, 417
conditioned response on sexuality, 363 stimulus), 36 daydreaming, 151
(CR), 36 on somatic symptom CT (computerized day treatment centers, 17
conditioned stimulus disorders, 151 tomography), 67 DBT (dialectical behavior
(CS), 36 on stress, 433 cultural differences therapy), 48, 210, 266
conduct disorder, on substance use alcohol misuse, 404 debriefing, 87
319-328,321 disorders, 395 bulimia nervosa, 344 deception, 86-87, 93
and attention-deficit/ and theories of conduct disorder, 329 The Deception of Dreams
hyperactivity disorder, abnormality, 23 depression, 192 (Weyer), 10
286-287,329 threshold approach dissociative identity deep brain stimulation,
biological theories on, versus, 83 disorder, 164 35, 198
324-325 control groups, 93, 94 eating disorders, defense mechanisms, 42, 43
cognitive approaches conversion disorder, 157, 342,347 degradation, 29
on,327 157-159 and health deinstitutionalization,
DSM criteria for, 322 coping strategies, 116, 191, interventions, 447 16-17,245
and oppositional defiant 436-438,441 obsessive-compulsive delayed ejaculation, 369
disorder, 323-324 coronary heart disease disorder, 140 delayed sleep phase type
social factors, (CHD), 442-446 personality disorders, 261 circadian rhythm sleep
326-327 corpuscallosum,27 post-traumatic stress disorder, 455
treatment, 328-329 correlational studies, disorder, 116 Delay, Jean, 241
conduct disorders 88-90,89 schizophrenia, 222,223, delirium,312,312-314
crime, 334 correlation coefficient, 228-229,240-241,246 causes, 313- 314
integrationist approach, 89- 90 sexual dysfunctions, 374 delirium tremens (DTs), 402
334-335 corticotropin-release factor stress, 433,438 delta-sleep-inducing
integrative model, (CRF), 31, 108 substance use, 395 peptide (DSIP), 452
327-328 corticotropin-releasing suicide, 205 delusional disorder,
psychological and social hormone (CRH), 187 traditional healers, 217,231
therapies, 328-329 cortisol, 108, 117, 187- 188, 52-53,246 delusions, 219-220, 220
confidentiality, 86 325,433 cultural issues. See also delusions of
conscious, 42 Cousins, Norman, 434 cultural differences; reference, 221
construct validity, 61 cover stories, 93 sociocultural theories delusions of thought
content validity, 61 covert sensitization and assessment, 64, 66, insertion, 221
contingency management therapy, 421 70- 71 demand characteristics, 93
programs, 422 CPAP (continuous positive and diagnosis, 76 dementia, 305
continuous positive air air pressure), familism, 52, 206, 447 and substance use
pressure (CPAP), 454,455 older adult substance use, disorders, 405
454,455 crack cocaine, 407 425-426 dementia praecox, 225
continuous reinforcement CR (conditioned research, 99-100 dendrites, 29
schedules, 37 response), 36 stressors viewed, 433 denial, 43
continuous variable, 88 creativity, 184-185 treatment, 49- 53 Deniker, Pierre, 241
Sl-6 Subject Index
Depakote (valproate), prevalence, 180--181 on depersonalization/ on schlzotypal personality

196-197 with psychotic derealization disorder, 232, 260
dependent personality features, 179 disorder, 168 on separation anxiety
disorder, 272-273 Shades of Gray on depression, 177, disorder, 136
dependent variable, 85 feature, 181 178, 179 separation anxiety
depersonalization/ symptoms of, 176-177 dissociative amnesia, 166 disorder, 136
derealization disorder, derailment (loosening of on dissociative identity on sexual disorders, 367
168- 169 associations), 223 disorder, 162, 164 on sexual
depressants, 400-406. See detachment, 276 on dramatic-emotional d ysfunctions, 367
also alcohol developmental coordination personality on social anxiety
intoxication with and disorder, 304 disorders, 262 disorder, 125
withdrawal from, 401 developmental on eating disorders, 340, on sleep disorders, 451,
depression, 175-181, psychopathology, 283 343,345 452,453,455,456,457
185-192 deviance criterion for on gambling disorder, 427 on somatic symptom
assessment instruments, 63 abnormality, 7 on gay, lesbian, and disorders, 153
biological theories on, Dexedrine,288,406 bisexual people, on substance use
185-188 dhat, 76 379-380 disorders,399,400,412
and bipolar disorder, 175 diabetes, 370 on gender dysphoria, 388 dialectical behavior therapy
case studies, 87, 199-200, diagnosis, 71-79. See also on generalized anxiety (DBT), 48, 210, 266
200--201 Diagnostic and disorder, 132 diathesis-stress models,
and coronary heart Statistical Manual of on illness anxiety 25,147
disease, 446 Mental Disorders disorder, 154 DID (dissociative identity
and delusions, 221-222 continuing debates about and integrationist disorder), 160--165,162
DSM criteria for, 177, the DSM, 75-77 approach, 79 dieting, 337, 348-349
177-178, 178-179, 179 defined,60 on intellectual as subtype, 355
and eating disorders, 355 Diagnostic and Statistical disability, 294 Discovery of Witchcraft
environmental influences, Manual of Mental on intermittent explosive (Scot), 10
32-33 Disorders overview, disorder, 333 disease model of
and obsessive-compulsive 72-73 on major depressive alcoholism, 423
disorder, 141 integrationist approach disorders, 178 disengaged family, 47
psychological theories on, on,79 on manic episodes, 182 disinhibition, 276-277
188-192 reification of, 75 on motor disorders, 303 disorders of arousal,
researching, 85 Diagnostic and Statistical multiaxial system, 74 456-457
seasonal affective Manual of Mental on neurocognitive disorganized behavior, 224
disorder, 179, 199 Disorders (DSM), disorder, 305 disorganized thought and
and sexual 72- 73, 72-76 nonaxial approach, speech,223-224
dysfunctions, 371 on antisocial personality 74-75 displacement, 43
Shades of Gray disorder, 330 on obesity, 347 disruptive mood
feature, 213 on attention-deficit / on obsessive-compulsive dysregulation disorder,
sociocultural theories hyperactivity disorder, disorder, 139, 141 183-184
on,191 285,286 on oppositional defiant dissociation, 151, 160
somatic symptom autism spectrum disorder, 323 dissociative amnesia,
disorders related, 155 disorder, 290, 292 on panic disorder, 72, 73, 165-168
and suicide, 208 on avoidant personality 79,128 dissociative disorders,
depression, treatment for disorder, 271 on paraphilias, 380 160--171
behavioral therapies, 199 on bipolar disorder, 183 on personality disorder continuum model on, 151
brain stimulation, 198 borderline personality clusters, 255 controversies, 169- 171
cognitive-behavioral disorder, 264 on personality disorders, depersonalization/
therapy, 200, on brief psychotic 254,276-278 derealization disorder,
200--202,203 disorder, 230 on phobias, 118, 119 168-169
comparisons, 203 category or continuum, 75 on post-traumatic stress dissociative amnesia,
drug therapies, 187, on conduct disorder, 111-112 165- 168
193-196,203,204 disorder, 322 reliability, 73-74 dissociative fugue, 167
interpersonal therapy, on conversion on schlzoaffective dissociative identity
202,203 disorder, 157 disorder, 229 disorder, 160--165, 162
light therapy, 199 cultural issues, 76-77 on schizophrenia, integrationist approach
depressive disorders, 176 on delirium, 313 220, 226 on,171
diagnosis, 177-180 on delusional on schlzophreniform dissociative experiences,
medications listed, 194 disorder, 231 disorder, 230 151, 152
Subject Index Sl-7
dissociative fugue, 167 for attention-deficit/ Durham rule, 474-475 Effexor (venlafaxine), 135
dissociative identity hyperactivity Durham v. United States, efficacy, 95
disorder (DID), disorder, 288 474-475 ego,42
160-165 attention-deficit/ duty to warn, 467 egoistic suicide, 207
theories, 164-165 hyperactivity dysfunction criterion for ego psychology, 44
treatment, 165 disorder, 329 abnormality, 6 Egypt, ancient, 9
dissociative symptoms, 113 for autism spectrum dyslexia, 301, 302 Electra complex, 43
distress criterion for disorder, 294 treatment, 303 electroconvulsive therapy
abnormality, 6-7 and biological theories, DZ (dizygotic) twins, 98 (ECT), 34-35, 197, 241
disulfiram (Antabuse), 33-34 electrodermal (galvanic
skin) response, 68
420,421
Dix, Dorothea, 13
for bipolar disorder,
196-197,203
E electroencephalogram
dizygotic (DZ) twins, 98 for borderline personality early intervention (EEG), 67-68
DMX, 185 disorder, 266-267 programs, intellectual Ellis, Albert, 16, 40
DNA (deoxyribonucleic for conduct disorder, 329 disability, 298-299 emotional numbing, 113
acid), 31 for depression, 186, eating disorders, 336-361. emotion-focused
Donaldson, Kenneth, 466 194-196,203,204 See also obesity approaches, 48
donepezil (Aricept), 312 for eating disorders, 359 anorexia nervosa, 337, emotion regulation, 265, 355
dopamine, 30 for gambling disorder, 428 339-343 endocrine system, 30, 30-31.
and attention-deficit/ for intellectual binge-eating disorder, See also hormones
hyperactivity disabilities, 298 337,345-346 endorphins, 411
disorder, 287 listed, 34 biological theories on, engorgement, 365
and bipolar disorder, for neurocognitive 350-351 enkaphalins, 411
193, 197 disorder, 312 and body image, 342, enrneshedfarnily,46-47
and depression, 186 for obesity, 349 354-355 environmental factors,
and eating disorders, for obsessive-compulsive bulimia nervosa, 337, 32-33. See also family;
350,351 disorder, 144-145 343-345 social learning theory
and gambling for older adults, 146,425 cognitive approaches on, antisocial personality
disorder, 428 for panic disorder, 354-355 disorder, 332
and schizophrenia, 130-131 comparison table, 341 epigenetics,33,234-235
228,237 for paraphilias, 386-387 continuum model on, 337 learning and
and schizotypal for phobias, 123 and emotion communication
personality for post-traumatic stress regulation, 355 disorders, 302
disorder, 261 disorder, 118 and family, 355-356, obesity, 347-348
and substance use for schizophrenia, 356-357 post-traumatic stress
disorders, 407-408, 409, 237-228,241-243 integrationist approach disorder, 115
417, 418 for schizotypal on,359,359-360 separation anxiety
dorsolateral frontal personality partial-syndrome, 337 disorder, 137
cortex, 417 disorder, 261 prevalence, 341-342 substance use
double binds, 239 for separation anxiety social factors, 351- 353 disorders, 419
double-blind disorder, 138 social pressures, 351-353 ephedrine, 354
experiments, 94 and sexual dysfunctions, treatment, 357-359 epidemiological studies, 92,
Down syndrome, 31 370-371 eating disorders not 92-93
causes, 296 for sexual dysfunctions, otherwise specified epigenetics, 33, 234-235
drama tic-emotional 375-376 (EDNOS), 346-347 epinephrine, 117
personality disorders, for sleep disorders, 452, ecstasy (MDMA), 416 episodic insomnia, 450, 451
262-270 453,454,456,457 ECT (electroconvulsive Equetro
borderline personality for substance use therapy), 34-35, (carbamazepine), 196
disorder, 262-267 disorders, 420-421 197,241 erectile disorder, 367-368
histrionic personality for suicide, 210 EDNOS (eating disorders treatment, 375-376
disorder, 267-268 DSIP (delta-sleep-inducing not otherwise essential hypertension, 444
narcissistic personality peptide), 452 specified), ethical issues, 86-87, 95,
disorder, 268-270 DSM. See Diagnostic and 346-347 97-98, 102
drinking behavior, 59 Statistical Manual of EEG ethnic differences. See
drug addiction, 399 Mental Disorders (electroencephalogram), racial/ ethnic
drug courts, 478 DSM-5, continuum model 67-68 differences
drug therapies, 16 related, 59 effectiveness, 95 European Americans. See
for antisocial personality DTs (delirium tremens), 402 effect size, 101 racial/ ethnic differences
disorder, 332 Dunst, Kirsten, 185 Effexor, 130 event-related potentials, 67
Sl-8 Subject Index
evoked potentials, 67 familism, 52, 206, 447 four Ds model of delirium, 314
evolutionary theory, 122 and neurocognitive abnormality, 6-7 dependent personality
excessive reassurance disorder, 312 Fox, George, 185 disorder, 273
seeking, 191 and panic disorder, 128 Fox, Michael J., 309 depression, 181, 188, 191
executive functions, in and phobias, 122 fragile X syndrome, 296 eating disorders, 341,
major neurocognitive and schizophrenia, 219, free association, 44 342,351
disorders, 306 228,239-240,244,246 freebase cocaine, 407 eating disorders in elite
Exelon (rivastigmine), 312 and separation anxiety Freud, Anna, 44 women athletes, 353
exercise, 312, 344,349,446 disorder, 137 Freud, Sigmund, 15,41-42, gambling disorder,
exhibitionistic disorder, 384 and substance use 158. See also 427-428
exorcism, 8 disorders, 418 psychodynamic histrionic personality
experiential avoidance, 48 suicide and, 209, 210 approaches disorder, 267
experimental group, 93 family-focused therapy frotteuristic disorder, 384 insanity defense, 473
experimental studies, (FFf), 203 fugue, 167 justice system mental
93-98 family history studies, 98. functional analysis, 199 health care, 477-478
exposure and response See also genetic fusiform gyrus, 293 narcissistic personality
prevention, 145 approaches disorder, 269
exposure therapy, 159 family studies of
expressed emotion, 100, schizophrenia, 233
G neurocognitive
disorders, 311
239-240,244 family systems approaches, GABA (gamma- oppositional defiant
external validity, 91 46-48 aminobutyric acid), 30, disorder, 324
extinction, 37 family systems therapy, 47 128,134,237,417,420 paraphilias,383,384
extraordinary people family therapy, 47, 244, 357 GAD (generalized anxiety post-traumatic stress
Anna 0. case, 152 fashion models, 338 disorder), 132, 132-135, disorder, 116
David Beckham, 108 fear and anxiety, 106-147 133, 146 and psychotherapy, 52
David Reimer, 364 continuum model on, 107 Gage, Phineas, 26 schizophrenia,
fashion models, 338 phobias, 118-123 galantamine (Reminyl), 312 224,228
Greg Bottoms, 464 and threat responses, galvanic skin separation anxiety
John Nash, 218 108-110, 110 (electrodermal) disorder, 136
Kay Redfield Jamison, 4, female orgasmic disorder, response (GSR), 68 sexual dysfunctions,
6,176 368,373 gambling disorder, 396, 366-367
Marya Hornbacher, 60 female sexual arousal 427-428 sleep disorders, 450
Norman Cousins, 434 disorder, 366-367 gamma-aminobutyric acid substance use disorders,
Old Order Amish, 84 female sexual interest/ (GABA), 30, 128, 134, 403,410,418,419-420
Steven Hayes, 24 arousal disorder, 237,417, 420 suicide, 205
Susanna Kaysen, 252 366-367 gamma-hydroxybutyrate Type A Behavior Pattern,
Ted Bundy, 320 fetishistic disorder, 380-382 (GHB),416 444-445
Whitney Houston, 396 FFf (family-focused gay, lesbian, and bisexual violence, 469
therapy), 203 people gender d ysphoria, 363,
F fight-or-flight response,
108, 109, 128, 410,
HN I AIDS, 441-442
sexual dysfunctions,
388- 391
prevalence, 389
face validity, 61 433,444 379-380 gender identity, 363
factitious disorders, stressors and, 433 sociocultural theories gender identity disorder.
159-160 file drawer effect, 101 on,49 See gender dysphoria
factitious disorders filler measures, 93 suicide, 205 gender incongruence, 388
imposed on another, five-factor model of gender differences. See also gender roles, 363. See also
159-160 personality, 252, gender roles gender differences
false memories. See 253,254 alcohol misuse, 403 and abnormality criteria,
repressed memories flooding, 123 antisocial personality 5,6
familism, 52, 206, 447 flunitrazepam disorder, 331 and depression, 191
family. See also family (rohypnol), 417 attention-deficit/ and gender
systems approaches; fluoxetine (Prozac), 130, hyperactivity dysphoria, 390
genetics; social factors 138,359,375 disorder, 287 and post-traumatic stress
and bipolar disorder, 203 fluphenazine (Prolixin), 241 binge-eating disorder, 346 disorder, 116
and conduct disorder, fluvoxamine (Luvox), 144 borderline personality and schizophrenia, 228
324--325,328-329 food addiction, 348 disorder, 264 and substance use
and depression, 191 forebrain, 27 conduct disorder, disorders, 419-420
and eating disorders, formal thought 324,326 and violence, 469
355-356,356-357 disorders, 223 coping strategies, 437-438 generalizability, 88
Subject Index Sl-9
generalized anxiety genetic studies, 98, 98-99 Hamilton, Alexander, 185 behaviorism, 15-16
disorder (GAD), 132, genital stage of Hans case, 120 cognitive perspectives, 16
132-135, psychosexual harm reduction model, 426 eighteenth-nineteenth
134, 146 development, 44 Hasan, Nidal, 467 centuries, 12-13
general paresis, 14 genito-pelvic pain/ Hayes, Steven, 24 medieval Europe, 9-11
genetic approaches, 31, penetration disorder, head injuries, 168,310- 311. modern biological
31-33, 33. See also 369-370 See also brain theories, 14
biological theories Geodone (ziprasidone), 242 dysfunction psychoanalytic theory,
on attention-deficit/ geropsychology, 283 health insurance, 17-18 14-15
hyperactivity disorder, GHB (gamma- health psychology, 432-461. schizophrenia, 225-226,
287,288 hydroxybutyrate), 416 See also sleep 241-242
on autism spectrum ghost sickness, 76 appraisals, 436 suicide, 207-208
disorder, 293 Gillitzer, Jeremy, 338 biopsychosocial histrionic personality
on avoidant personality Girl, Interrupted approach, 434-435 disorder, 267-268
disorder, 271 (Kaysen), 252 cancer, 440-441 HIV I AIDS, 309-310, 390,
on bipolar disorder, 192 global assumptions, 40 and causes of death, 435 408,412,441-442
and borderline personality glove anesthesia, 157, 158 continuum model on, 433 HIV-associated
disorder, 265 glucose, 108 coping strategies, neurocognitive
on conduct disorder, glutamate,237-238,312,420 436-438,441 disorder, 309-310
324-325 GMBI (guilty but mentally coronary heart disease, hoarding, 141-142, 144
on dependent personality ill), 476-477 442-446 Hoffman, Albert, 413
disorder, 273 Goldsmith, Kristofer, 114 HIV I AIDS, 441-442 homelessness, 17, 224,
on depression, 185-186 Grandin, Temple, 284 immune system, 433,465
on eating disorders, 350 grandiose delusions, 439-440,440 homosexuality. See gay,
epigenetics,33,234-235 220,221 integrationist approach lesbian, and bisexual
on gender dysphoria, 390 grave disability criteria for on,459,459-460 people
on generalized anxiety civil commitment, interventions, 446-448 hopelessness, 209
disorder, 134 465-466 physical health, 438-439 hopelessness depression, 190
on hypertension, 443-444 Greece, ancient, 9 heritability. See genetic hormones, 30-31
learning and grief, 202, 208 approaches and conduct disorder, 326
communication complicated, 177 heroin,411-412,420-421 and depression, 187,
disorders, 302 Griesinger, Wilhelm, 14 hidden observer 187-188
on obesity, 348 group comparison studies, phenomenon, 160 and gender dysphoria, 390
on obsessive-compulsive 88,91 high blood pressure, and sexual dysfunctions,
disorder, 143-144 group homes, intellectual 443-444 370,375
on phobias, 122 disability, 299 Hinckley, John, 472,475 and stress, 108, 117,
post-traumatic stress group therapy, 126, 258-259 hindbrain, 27 188,433
disorder, 117 GSR (galvanic skin hippocampus, 28, 117, 187, hormone therapy, 375,
and research, 98, 98-99 (electrodermal) 235-236 390-391
on schizophrenia, response), 68 Hippocrates, 9, 71 Hornbacher,Marya,60
233-235 guanfacine, 288 Hispanics. See also racial/ hospitals, 17
on schizotypal personality guided mastery techniques, ethnic differences hostility, 444-445
disorder, 261 446-447 ataque de nervios, 50, 76, Houston, Whitney, 396
on separation anxiety guilty but mentally ill 116,164 HPA (hypothalamic-
disorder, 137 (GMBI), 476-477 borderline personality pituitary-adrenal) axis,
on sleep disorders, 453, guns, 211-212 disorder, 264 31, 117, 187, 187-188
457,459 depression, 192 HuangTi,8
on substance use
disorders, 418 H dissociative identity
disorder, 164
human immunodeficiency
virus (HIV), 309-310,
on suicide, 209 habit reversal therapy, 304 healing traditions, 53 390,408,412,441-442
genetic factors hair-pulling disorder post-traumatic stress humanistic approaches,
in Alzheimer's disease, (OCD), 142 disorder, 116 45-46,55
307-308 Halcion, 406 substance use reflection, 55
antisocial personality Haldol, 242, 329 disorders, 403 humanistic therapy, 273
disorder, 331, 332 halfway houses, 17 suicide, 205-206 human laboratory studies,
y---..
intellectual disability, hallucinations, 222-223, 453 histamine, 453 93-94
295-296 hallucinogens, 413, 413-414 historical perspectives, 7-13 human participants
genetics. See also behavior haloperidol, 261 ancient times, 7-9 committees, 86
genetics Halstead-Reitan Test, 67 asylums, 11-12 Huntington's disease, 310
SJ-10 Subject Index
Hurricane Katrina, 113

hydrocodone, 412
Individuals with Disabilities
Education Act
biological causes,
295-298
K
hypersexual disorder, 380 (IDEA),302 case study, 298 Kahun Papyrus, 9
hypersomnia, 452-453 infectious diseases, 236, 238 DSMon, 294 Kaysen,Susanna,252
hypersornnolence disorders, inferior colliculus, 27 sociocultural factors, 298 Kennedy, John F., 16, 245
452-453,453 inferior frontal gyrus, 417 treatments, 298-299 Kernberg, Otto, 44
hypertension, 443-444 inflexible family, 46 types of, 295 ketamine, 238, 416-417
hypervigilance, informed consent, 86, 471 intellectualization, 43 killer T-cells, 440
113, 129 inhalants, 415-416 intelligence tests, 66 Klein, Melanie, 44
hypnosis, 14, 159, 167, 168 Inquisition, 10 intellectual Klonopin, 406
hypoactive sexual desire insanity defense, 472-476, disabilities, 295 koro, 76,374
disorder, 375 473-475 interjudge reliability, 62 Korsakoff's syndrome, 167
hypocretin, 453 Insanity Defense Reform intermittent explosive Kraepelin, Emil, 14, 71, 225
hypomania, 183 Act (1984), 475 disorder, 332-333 Krafft-Ebing, Richard, 14
hypothalamic-pituitary- insomnia,450-451,450-452 DSMon,333
adrenal (HPA) axis, 31,
117, 187, 187-188
insomnia disorder, 450
institutionalization. See also
internal reliability, 62
internal validity, 93-94
L
hypothalamus, 28, 30 deinstitutionalization International Classification labeling, 77-79
and eating disorders, 350 intellectual disability, 299 of Diseases (!CD), 72 Ia belle indifference, 158
and gender instrumental conditioning. Internet, 447-448 lamotrigine, 266
dysphoria, 390 See operant interoceptive language disorder, 301
and sleep disorders, conditioning awareness, 130 Lanza, Adam, 466
453,455 insulin coma interoceptive latency stage of
and stress, 108, 109 therapy, 241 conditioning, 130 psychosexual
hypothesis, 85 integra ted biopsychosocial interpersonal role development, 44
hypoxyphilia, 383 approach, 25 disputes, 202 later life. See older adults
hysteria, 9, 15 integrationist approach, 19 interpersonal skill Latino cultures. See
on anxiety disorders, deficits, 202 Hispanic cultures
146-147 interpersonal and social law of effect, 37
on assessment/ rhythm therapy (ISRT), lead poisoning, 288, 302
!CD (International diagnosis, 79 202-203 learned helplessness
Classification of on conduct disorders, interpersonal theories of deficits, 97
Diseases), 72 334-335 depression, 191 learned helplessness
ICU / CCU psychosis, 314 on eating disorders, 359, interpersonal therapy (IPT), theory, 189
id,42 359-360 45,202 learning disorders, 299-301
ideas of reference, 259 on gambling disorder, interrater reliability, 62 causes and treatment of,
identification, 43 333-334 in vivo exposure, 39 302-303
IEP (Individualized on health psychology, involuntary commitment, legal issues, 462-480. See
Education Plan), 302 459,459-460 469, 469-470 also crime
illness anxiety disorder, on legal issues, 478 IPT (interpersonal therapy), civil commitment,
153-155 on mood disorders, 45,202 464-470
theories, 154-156 212- 213 IQ, 66 competence to stand trial,
treatment, 156-157 on panic disorder, irresistible impulse 471-472
illusions, 259 129,130 rule, 474 continuum model on, 463
imipramine (Tofranil), 135 on research, 101 ISRT (interpersonal and historical perspectives, 12
immaturity hypothesis of on schizophrenia, social rhythm therapy), insanity defense, 472-476,
attention-deficit/ 246-247 202-203 473-475
hyperactivity on sexuality, 391 integrationist approach
disorder, 287 on somatic symptom
immigration, 14, 239 and dissociative J on,478
involuntary commitment
immune system, 439-440 disorders, 171 Jackson, Janet, 185 prevalence, 469,
impotence. See erectile on substance use Jamison, Kay Redfield, 469-470
disorder disorders, 428-429 4, 6,176 justice system mental
impulsivity, 209 and theories of Janet, Pierre, 15 health care, 477-478
incest, 385 abnormality, 54-55 Japan, taijinkyofusho, 50, patients' rights, 16, 465,
incidence, 92 intellectual disability, 294, 76,125 470-471
independent variable, 85 294-299 Jung, Carl, 44 violence, 467, 467-469
Individualized Education autism spectrum justice system mental health lesbians. See gay, lesbian,
Plan (IEP), 302 disorder, 291-292 care,477-478 and bisexual people
Subject Index SI-ll
Levitra, 375 managed care, 17-19 meso limbic pathway, 237 myotonia, 365
libido, 41 Mandel, Howie, 140 meta-analysis, 100-101 MZ (monozygotic)
Librium, 135,406 mania, 175, 176. See also methadone,420-421 twins, 98
licensed mental health bipolar methadone maintenance
counselors, 19
Liebault, Ambroise-
DSM criteria for, 182
symptoms, 182
programs,420-421
methamphetamines,
N
August, 15 MAOA gene, 325 409-410,453 naloxone, 420
life-course-persistent MAOis (monoamine methylphenidate, 453 Naltrexone, 294,420,428
antisocial behavior, oxidase inhibitors), midbrain, 27 Namenda (memantine), 312
321,324 34,196 Milk, 474 narcissistic personality
life-span mental health. See marijuana, 414-415 mind-body problem, 171 disorder, 268-270
older adults marriage and family Minnesota Multiphasic narcolepsy, 452-453
lifetime prevalence, 92 therapists, 19 Personality Inventory Nasar, Sylvia, 218
light therapy, 199 masochism,382-383 (MMPI), 64, 65 Nash, John, 218
limbic system, 28, 129, 134, masturbation, 377, mixed features depressive Native Americans, 52-53,
186,235 385-386 disorder, 179-180 192,205,398,404. See
Lincoln, Abraham, 185 mathematics disorder, 301 MMPI (Minnesota also racial / ethnic
linkage analysis, 99 MDMA (ecstasy), 416 Multiphasic Personality differences
lithium, 34, 196, 210, medial prefrontal cortex, Inventory),64,65 natural disasters, 113-114
329,332 116-117 M'Naghten Rule, natural environment type
Little Albert case, 121 Medicaid, 18 473-474 phobias, 119
locus ceruleus, 129 medications. See drug Mobile Therapy app, 48 nature-nurture question, 24
The Lodge, 245 therapies modafinil, 453, 456 Navane, 242
longitudinal studies, 89, 91 medieval Europe, 9-11 modeling, 38, 123 need for treatment
loosening of associations medulla, 27 molecular genetic criteria for civil
(derailment), 223 melancholic features (association) studies, 99 commitment, 465
LSD (lysergic acid depressive episodes, 179 monoamine oxidase Nee, M. J., 208- 209
diethylamide), melatonin, 199,452,456 inhibitors (MAOis), negative affectivity, 276
413-414 Mellaril (thioridazine), 34, 196 negative cognitive
Luria-Nebraska Test, 67 241,329 monoamines, 186, 193 triad, 189
Luther, Martin, 185 memantine (Namenda), 312 monozygotic (MZ) twins, 98 negative reinforcement, 121
Luvox (fluvoxamine), 144 memory. See also amnesia mood disorders, 174-215. negative symptoms of
and depression, See also bipolar schizophrenia, 219,
190-191 disorder; depression; 224-225
M and electroconvulsive suicide Nei Ching (Classic of
Madden, John, 120 therapy, 197 and borderline Internal Medicine)
Madness (Hornbacher), 60 in major neurocognitive personality (Huang Ti), 8
magical thinking, 141,259 disorders, 305 disorder, 262 neologisms, 224
magnetic resonance overgeneral, 190-191 continuum model nervios, 116
imaging (MRI), 67 and post-traumatic stress on, 175 neurocognitive disorder
Mahler, Margaret, 44 disorder, 117 and creativity, 184-185 and delirium, 312-314
mainlining, 412 and schizophrenia, 225 integrationist approach DSM criteria for, 305
mainstreaming, intellectual men. See gender differences on,212-213 gender differences, 311
disability, 299 mens rea, 474 mood stabilizers, 196 prevention, 312
maintenance doses, 242 mental health courts, 478 treatment of, 193-204 racial/ ethnic
major depressive mental health law. See legal moral treatment, 13 differences, 311
disorder, 177 issues morphine, 412 and substance use
DSM criteria for, 178 mental hygiene motivational disorders, 310
major neurocognitive movement, 12 interviewing, 423 neurocognitive disorder
disorders (NCDs), 305 mental illness, 5 motor disorders, 303- 304 due to Lewy body
DSMon,305 mentalization-based MRI (magnetic resonance disease, 309
symptoms of, 305 treatment, 266 imaging), 67 neurocognitive disorders
vascular neurocognitive mental retardation. See multimethod approach, 84 (NCDs), 284
disorder, 309 intellectual disability multiple baseline Alzheimer's disease and,
maladaptive behavior, 7 mental status exams, 62 experimental design, 306-308
mal de ojo, 76 Meridia (sibutramine), 349 95-96 case studies, 304, 310
male hypoactive sexual Mesmer, Franz Anton, Munchhausen's gender, culture and
desire disorder, 366 14-15 syndrome, 159 education related, 311
malingering, 159 mesmerism, 15 Mussolini, Benito, 185 prevention, 312
Sl-12 Subject Index
neurocognitive disorders and post-traumatic stress obsessive-compulsive p

(NCDs)- Cont. disorder, 117 personality disorder,
symptoms of, 305-306 and schizophrenia, 273-276 Packard, E. P. W., Mrs., 465
treatment, 312 237-238 obstructive sleep panic attacks, 127
types of, 306-311 and schizotypal apnea, 453 panic disorder, sample
neurodevelopmental personality disorder, 261 obstructive sleep apnea interview, 63
disorders, 235, and sleep disorders, 453 hypopnea syndrome, paranoid personality
274-294,284 and substance use 453-454 disorder, 256-258
attention-deficit/ disorders, 407-408,409, occipitotemporal prevalence, 257
hyperactivity disorder, 416,417,418 cortex, 302 paraphilic disorder, 363,
284-290,329 and suicide, 209 OCD (obsessive-compulsive 380-388
conduct disorder, 286- 287 nicotine,410-411 disorder), 139- 145 Parkinson's disease, 309
neurodevelopmental and intoxication and treatment, 144-145 partial-syndrome eating
neurocognitive withdrawal O'Connorv. disorders, 337,346
disorders, 274-317. See symptoms, 407 Donaldson, 466 Pavlov, Ivan, 36
also autism night eating syndrome, odd beliefs, 259 Paxil, 130
antisocial personality 346-347 odd-eccentric personality PCP (phencyclidine),
disorder,329,329- 332 nightmare disorder, 458 disorders, 255-262, 256 413,414
attention-deficit/ nitrites, 415 Oedipus complex, 43, 120 pedophilic disorder,
hyperactivity disorder, nitrous oxide, 415 olanzapine (Zyprexa), 197, 384-385
183,284-290 nonaxial system of 242,243,261,266 pelvic muscle
conduct disorder, 286-287, diagnosis, 74-75 older adults. See also tightening, 379
319-328 non-REM sleep, 450 cognitive disorders; performance anxiety, 372
continuum model on, 283 nonsuicidal self-injury neurocognitive persecutory delusions, 220
integrative model, 327- 328 (NSSI), 207 disorders (NCDs) persistent depressive
learning disorders, noradrenaline. See anxiety disorders, disorder, 177
299-301 norepinephrine 145-146 persistent motor or vocal
prevalence, 286 norepinephrine-dopamine neurocognitive disorders disorder (PMVTD), 303
neuroendocrine system, reuptake inhibitors, 196 (NCDs), 304-312 personality, 252
187- 188. See also norepinephrine sexual dysfunctions, personality disorders,
hormones (noradrenaline), 30 374-375 250- 281
neuroleptic drugs, 237, and attention-deficit/ substance use treatment, alternative DSM-5 model,
241-242,261 hyperactivity 425-426 276-278
neurons, 29 disorder, 287 suicide, 206-207 continuum model, 251,
neuropsychological tests, and depression, 186 Old Order Amish, 84 278-279
66,66-67 intermittent explosive On the Psychical Mechanisms dimensional
neuroticism, 439 disorder, 333 of Hysterical Phenomena perspective, 276
as personality trait, 276 and panic disorder, 130 (Breuer & Freud), 15 hybrid model, 278
neurotransmitters, 29, 29-30 and post-traumatic stress operant conditioning, 16, steps in diagnosing,
and attention-deficit/ disorder, 117 36-37,144,385 276-277
hyperactivity and substance use operationalization, 85 trait specified, 278
disorder, 287 disorders, 409 opioids,411-412,420-421 personality inventories, 64
and bipolar disorder, NSSI (nonsuicidal self- oppositional defiant personality traits, 252
193, 197 injury), 207 disorder, 183, 323- 324 persuasive model of
and borderline personality null hypothesis, 85 treatments, 328- 329 traditional healing, 246
disorder, 265 Nun Study, 312 oral stage of psychosexual pervasive developmental
and conduct nutrition, 288, 405 development, 42 disorders (PDDs), 292
disorder, 325 orbitofrontal cortex, 417 pessimism, 436,440-441
and delirium, 314
and depression, 31, 186,
0 organic amnesia, 166, 167
orgasm,365,368-369
Peter of Herental, 10-11
PET (positron-emission
194-195, 199 obesity, 347, 347-349 interpersonal tomography), 67
and eating disorders, object relations theory, factors, 373 peyote, 398
350,351 44,265 orgasmic disorders, 368-369, phallic stage of
and generalized anxiety observational learning, 373, 377, 379 psychosexual
disorder, 134 38, 121 orlistat (Xenical), 349 development, 43-44
and neurocognitive obsessions, 139 other specified feeding or phencyclidine (PCP), 238,
disorder, 312
and panic disorder,
obsessive-compulsive
disorder (OCD), 139- 145
eating disorder,
346-347
413,414
phenothiazines, 16, 33,
~
128, 130 treatment, 144-145 oxycodone (OxyContin), 412 237,241
Subject Index Sl-13
phenylketonuria intellectual disability protector (helper) on sexual dysfunctions,

(PKU),296 related, 298 personalities, 162-163 371-372,372
phobias, 118-123 and learning Prozac (fluoxetine), 130, on substance use
behavioral approaches disorders, 302 138, 359, 375 disorders, 418-419
on, 120-122 and schizophrenia, 238 pseudocyesis, 153 on suicide, 209
biological theories and sexual PSG (polysornnographic) psychomotor
on, 122 dysfunctions, 374 evaluation, 450 retardation, 177
cognitive approaches sociocultural theories psychiatric nurses, 19 psychopath, 320
on, 122 on,49 psychiatrists, 19 psychopathology, 4
DSM criteria for, 119 and substance use psychic epidemics, 10-11 continuum model of, 23
psychodynamic disorders, 404 psychoanalysis, 15, 41. See research, 84
approaches on, 120 and suicide, 208 also psychodynamic psychopathy. See also
social anxiety disorder, preconscious, 42 approaches antisocial personality
123-127, 124 predictive validity, 61 psychod ynarnic disorder
specific phobias, 118, predominant pain, 153 approaches, 14-15, defined,330
118-120 prefrontal cortex 41-45,55 psychophysiological tests,
theories of, 120-122 and attention-deficit/ on borderline personality 67-68
treatment, 122-123 hyperactivity disorder, 265 psychosexual stages, 42-44
Pinel, Philippe, 13 disorder, 287 on phobias, 120 psychosis, 219
pituitary gland, 28, 30 and bipolar disorder, 192 and treatment, 44-45, 266, psychosocial contributors to
placebo control group, 94 and borderline 267,273 bipolar disorder, 193
plaque, 442 personality psychodynamic therapies, psychosocial perspectives,
plateau phase of sexual disorder, 265 44-45,266,267,273 on schizophrenia,
response, 365 and conduct psychogenic amnesia, 238-241
Plato, 9 disorder, 325 166, 167 psychosocial therapies,
pleasure principle, 42 and depression, 186 psychological theories, 7, conduct disorders,
polygenic processes, 32 and schizophrenia, 235 23, 36-50. See also 328-329
polysornnographic (PSG) prefrontal lobotomy, 35 behavioral approaches; psychosurgery,8,35
evaluation, 450 prejudice/ discrimination. cognitive approaches; psychotherapy, medication
pons, 27 See also bias humanistic approaches; as treatment related, 25
positive symptoms of and assessment, 70-71 psychodynamic psychoticism, 277
schizophrenia,219-222 and depression, 191 approaches psychotic (or catatonic)
positron-emission and hypertension, 444 on antisocial personality disorder associated
tomography (PET), 67 and sexual disorder, 331-332 with another medical
postpartum depression, dysfunctions, 379 on attention-deficit/ condition, 217
179-180 sociocultural theories hyperactivity PTSD. See post-traumatic
post-traumatic stress on,49 disorder, 288 stress disorder
disorder (PTSD), and stress, 433 behavioral approaches
110-118 premature ejaculation, overview, 36-39
biological theories on, 368-369,375,379 on borderline personality
Q
116-117 premenstrual dysphoric disorder, 265 quetiapine (Seroquel), 197
and dissociative identity disorder, 180 cognitive approaches
disorder, 163 prenatal/birth complications, overview, 39-41
environmental/ social 287-288,325 and continuum R
factors, 115 prenatal viral exposure, model, 23 racial I ethnic differences.
gender I cultural 236-237 on depression, 188-192 See also prejudice/
differences, 116 prepared classical emotion-focused discrimination
and memory, 117 conditioning, 122 approaches, 48 borderline personality
questioning on two prevalence, 92 family systems disorder, 264
fronts, 147 prevention programs, 53 approaches, 46-48 competence to stand
theories of, 115-117 primary prevention, 53 humanistic approaches trial, 472
traumas leading to, problem-solving skills, 47, 48, overview, 45-46 delirium, 314
113-115 203,210,243,244,328 on post-traumatic stress depression, 192
trauma types, 113 prodomal symptoms of disorder, 116 eating disorders, 342
treatment, 117-118 schizophrenia,226-227 psychodynamic insanity defense, 473
poverty professions, 19 approaches overview, neurocognitive
and conduct projection, 43 41-45 disorder, 311
disorder, 326 projective tests, 68 on separation anxiety post-traumatic stress
and hypertension, 444 Prolixin (fluphenazine), 241 disorder, 137 disorder, 116
Sl-14 Subject Index
racial/ ethnic
differences-Cont.
ethical issues, 86-87,
97-98, 102
s and sexual
dysfunctions, 371
schizotypal personality experimental studies, sadism, 382-383 subtypes of, 227
disorder, 261 93-98 sadomasochism, 382-383 schizophreniform disorder,
stress, 433 genetic studies, 98, SAD (seasonal affective 229-230, 230
substance use disorders, 98-99 disorder), 179, 199 schizophrenium
403,404 integrationist approach Saint Vitus' dance, 11 disorder, 217
suicide, 205 on, 101 samples, 90-91 schizotypal personality
and violence among meta-analysis, 100-101 schizoaffective disorder, disorder, 217, 231-232,
mentally ill, 469 psychopathology, 84 217, 229 259-262
random assignment, 93 scientific method, 84-85 schizoid personality scientific method, 84-85
rape, 115,158-159,373 residual symptoms of disorder, 258-259 scripts, 377
rejected by DSM-5, 380 schizophrenia,226-227 schizophrenia,216-249 seasonal affective disorder
table of distortions and resistance, 44 and brain dysfunction, (SAD), 179, 199
assumptions, 387 resolution phase of sexual 224, 235-236 secondary prevention, 53
rapid cycling bipolar I or II response, 365 cognitive approaches seduction rituals, 376
disorder, 183 restless legs syndrome, on,240 selective serotonin-
rapid eye movement (REM) 458-459 and cognitive deficits, 225 norepinephrine
sleep behavior restricted affect, 224-225 cognitive deficits, 225 reuptake inhibitors
disorder, 457-458 restricting type of anorexia continuum model on, (SNRis), 34, 135,
rationalization, 43 nervosa,340-341 23,217 195-196,329
Raynor, Rosalie, 121 reticular formation, 27 cultural differences, 222, for autism spectrum
reaction formation, 43 retrograde amnesia, 223,240-241, 246 disorder, 294
Reagan, Ronald, 306 166-167, 167 diagnosis, 225-227 selective serotonin reuptake
receptors, 29 reuptake, 29 DISCI gene related, 25 inhibitors (SSRis), 34
reexperiencing of traumatic reversal (ABAB) drug therapies for, for conduct disorder, 329
event, 113 experimental design, 96 237-238,241-242 for depression, 195
reflection, 46 reward centers, 417 DSM criteria for, for eating disorders, 359
reformulated learned reward sensitivity, 418 220,226 for gambling disorder, 428
helplessness theory, 189 right to refuse treatment, genetic approaches on, for generalized anxiety
regression, 43 470-471 233-235 disorder, 135
Reimer, David, 364 right to treatment, 470-471 historical perspectives, for obsessive-compulsive
rejection sensitivity, 191 rimonabant (Acomplia), 349 225-226 disorder, 144
relapse prevention risk factors, 24, 24-25 and integrationist for older adults, 146
programs, 423 in epidemiological approach on, 246-247 for panic disorder, 130
relational aggression, 324 research, 92 and legal issues, 464, 471, for paraphilias, 387
relational psychoanalysis, 44 transdiagnostic, 25 473,475 for post-traumatic stress
reliability, 61, 61-62 Risperdal (risperidone), living situations, 219 disorder, 118
religious theories of 197,242 modern views, 4 for separation anxiety
abnormality, 9 risperidone (Risperdal), 197, negative symptoms, disorder, 138
Reminyl (galantamine), 312 242,243 224-225 and sexual dysfunctions,
REM sleep, 450 Ritalin, 288, 406 and neurotransmitters, 371,375
repetitive transcranial rivastigmine (Exelon), 312 237-238 for sleep disorders, 454
magnetic stimulation Rogers, Carl, 46 and other psychotic for substance use
(rTMS), 35, 197-198 rohypnol disorders, 217 disorders, 420
representative samples, (flunitrazepam), 417 and personality and suicide, 210
90-91 Roker, AI, 349 disorders, 255-256, selegiline, 453
repressed memories, 169-171 role transitions, 202 259, 261 self-actualization, 46
repression, 41, 42 Rome, ancient, 9 positive symptoms, 219, self-deceptions, 220
research, 82-102 Rorschach Inkblot 219-222 self-destructive behavior.
case studies, 87-88 Test, 68 prognosis, 227-228 See nonsuicidal self-
and continuum model, 83 rTMS (repetitive psychological injury; suicide
correlational studies, 88-90 transcranial magnetic interventions for, 244 self-efficacy beliefs, 16, 446
cross-cultural, 99-100 stimulation), 35, psychological treatments self-help support groups,
as cumulative 197-198 for, 243-256 244,423-425
process, 83 rumination, 190 psychosocial perspectives self-induced vomiting, 343
and diagnosis, 76, 78 ruminative response styles on,238-241 self-monitoring, 65-66
epidemiological studies, theory, 190 related disorders, self-mutilation. See
92-93 Rush, Benjamin, 12 229-232 nonsuicidal self-injury
Subject Index Sl-15
interpersonal and somatic symptom rapid eye movement

self psychology, 44
sociocultural factors, disorders, 155, 171 (REM) sleep behavior
self-reports, 84
373-374 stress, 438, 460 disorder, 457-458
self-talk, 328
sensate focus therapy, mechanical substance use disorders, restless legs syndrome,
377- 378 interventions, 375 405,429 458-459
separation anxiety disorder, older adults, 374-375 theories of abnormality, sleep disorders due to a
135, 135- 138 orgasmic disorders, 47,55 general medical
September 11, 2001, terrorist 368- 369,373,377,379 shift work type circadian condition, 450
attacks, 110, 112 psychological theories on, rhythm sleep sleep disorders related to
serotonin reuptake 371-373 disorder, 456 another mental
inhibitors, 454 sexual arousal disorders, shinjing shuairuo, 76 disorder, 450
Serax, 135 366- 367 shyness, 125 sleep-eating, 347
Seroquel (quetiapine), 197 sexual desire disorders, sibutramine (Meridia), 349 sleep paralysis, 453
serotonin, 30. See also 366- 367 sildenafil (Viagra), 375-376 sleep-related
selective serotonin sexual pain disorders, single-case experimental hypoventilation, 453
reuptake inhibitors 369-370 designs, 95- 96 sleep restriction
and attention-deficit/ and substance use single photo emission therapy, 452
hyperactivity disorders, 371 computed tomography sleep terror disorder, 456
disorder, 287 treatment, 375-379 (SPECT), 67 sleepwalking disorder,
and conduct disorder, 325 sexual interest/ arousal situational type phobias, 456-457
and depression, 31, 186 disorder, 366-367 119-120 smoking,410-411
and eating disorders, sexuality Skinner, B. F., 16, 37 SNRls (selective serotonin-
350,351 continuum model on, 363 skin-picking disorder, 142 norepinephrine
intermittent explosive gender dysphoria, slavery, 5 reuptake inhibitors),
disorder, 333 388-391 sleep, 448-459 34,135,195- 196,329
and panic disorder, 130 integrationist approach assessment, 449-450 social anxiety disorder,
and schizophrenia, 237 on,391 breathing-related sleep 123-127
and sleep disorders, 454 sexual masochism disorder, disorder, 453,453-454 DSM criteria for, 125
and substance use 382-383 circadian rhythm sleep prevalence, 124
disorders, 416, 417-418 sexual orientation. See gay, disorder, 455,455-456 theories on,
and suicide, 209, 210 lesbian, and bisexual deprivation prevalence, 125-126
sertraline (Zoloft), 130, people 448-449 treatments, 126-127
144,375 sexual pain disorders, hypersomnolence social communication
sex chromosomes, 31 369- 370 disorders,452-453,453 disorder, 301- 302
sex reassignment sexual response cycle, 365 narcolepsy, 452-453 social drift, 238, 326
surgery, 391 sexual sadism disorder, sleep disorders d ue to a social factors. See also family
sex therapy, 377 382-383 general medical conduct disorder and
sexual arousal disorders, Shades of Gray feature condition, 450 oppositional defiant
therapy, 375-376 abnormality criteria, sleep disorders disorder, 326-327
sexual assault, 373. See 7, 20 overview, 450 gender dysphoria, 390
also rape ADHD,315 sleep disorders related to neurocognitive
sexual desire, 365 binge drinking, 405 another mental disorder, 311
sexual desire disorders, conduct disorder, 325, 334 disorder, 450 post-traumatic stress
366-367 depression, 213 substance-induced sleep disorder, 115
sexual disorders, 362- 393. depressive disorders, 181 disorders, 450 psychic epidemics, 11
See also paraphilias; diagnosis, 74,79 sleep disorders, 448-459, schizophrenia, 229
sexual dysfunctions eating disorders, 450-459 sexual dysfunctions,
gender dysphoria and, 350,360 breathing-related sleep 373-374
363,388- 391 ethical issues, 86, 102 disorder,453, 453-454 substance use disorders,
hypersexual disorder, 380 humanistic approach, 55 circadian rhythm sleep 396-398,419
sexual dysfunctions, 363, legal issues, 476, 479 disorder,455, 455-456 social learning theory, 38,
366-380 neurodevelopmental and disorders of arousal, 243,386,418
among gay, lesbian, and neurocognitive 456-457 social phobia /social anxiety
bisexual people, disorders, 289 hypersomnolence disorder, 124
379-380 paraphilias, 383, 391 disorders, 452, 453 social programs for
biological theories on, personality disorders, 274 insomnia, 450-451, intellectual disabilities,
370-371 post-traumatic stress 450-452 298-299
cultural differences, 374 disorder, 119, 147 narcolepsy,452-453 social skills, 202
DSM criteria for, 367 schizophrenia, 233, 247 nightmare disorder, 458 and depression, 189
Sl-16 Subject Index
social skills-Cont. Stelazine substance abuse, 399. See also suicidal ideation, 204
and schizoid personality (trifluoperazine), 241 substance use disorders suicide, 204-212
disorder, 260 STEPPS (systems training antisocial personality biological theories on, 209
and schizophrenia, 228, for emotional disorder, 331 and borderline personality
229,243,244 predictability and substance-induced sexual disorder, 264
and schizotypal problem solving), 266 dysfunction, 371 defined,204
personality disorder, 262 stereotypic motor disorder, substance-induced sleep and dissociative identity
social support, 115, 246, 303-304 disorders, 450 disorder, 163
437,441 stimulant drugs, substance intoxication, 398 and guns, 211- 212
social support model of 288,329 substances, 396 historical perspectives,
traditional healing, 246 abuse of, 406-411 substance use disorders, 207-208
social work, 53 intoxication and 394-427,396 and histrionic personality
sociocultural theories, 23, withdrawal (table), 407 and amnesia, 167 disorder, 267
49-50, 191- 192. See also for separation anxiety biological theories on, hopelessness and, 209
cultural differences; disorder, 138 417-418 older adults, 206- 207
cultural issues; for sleep disorders, 453, and brain dysfunction, 417 prevalence, 204
social factors 454,457 cannabis, 414-415 prevention, 210
cross-cultural issues, stimulus control, 452 and conduct disorder, 325 psychological theories
50-53 stop-start technique, 379 continuum model on, 395 on,209
culturally specific stress. See also post- definitions, 398-400 response to suicidal
therapies, 52-53 traumatic stress and dementia, 405 ideation, 212
sociopath, 320 disorder; trauma DSM criteria for, 399, and selective serotonin
Socrates, 9 and bipolar disorder, 193 400,412 reuptake inhibitors, 210
sodium oxybate, 453 continuum model on, 433 ecstasy, 416 suicide contagion, 208-209
soldiers, 114,311 coping strategies, gender differences, 403, treatment, 210
solvents, 415 436-438,441 410,418,419-420 suicide attempts, 204
somatic hallucinations, 223 and coronary heart and gender suicide cluster, 208
somatic symptom disorders, disease, 443 dysphoria, 390 suicide contagion, 208-209
152- 160, 153-154, 171 and depression, GHB,416 Suicide and Depressive
continuum model on, 151 187- 188, 192 hallucinogens/PCP, Illness (Depression and
conversion disorder, 157, fight-or-flight response, 413-414 Bipolar Support
157- 159 108,109,128,410, integrationist approach Alliance), 212
integrationist approach 433,444 on,428-429 suicide hotlines, 210
on,171 and HIV I AIDS, 442 ketamine, 238, 416-417 sundowning, 312- 313
Shades of Gray feature, and hypertension, and major NCD, 310 superego, 42
155, 171 443-444 non-alcohol depressants, superior colliculus, 27
theories of, 155-156 and immune system, 440 405-406 supernatural theories of
treatment, 156-157 and pessimism, 436 older adults, 425-426 abnormality, 7, 8
vs. related disorders, 153 researching,85-86 opioids, 411-412, surgical castration, 386
specific learning disorders, responses to, 108- 110,110 420-421 susto, 76
299-301 and schizophrenia, pleasure pathways of The Swan, 351
DSM criteria for, 300 238-239 brain, 417 sympathetic nervous
specific phobias, 118, and sleep disorders, prenatal exposure, system, 109, 117, 445
118-120 449,451 287- 288 symptom questionnaires,
spectatoring, 372 and suicide, 208 prevalence, 399 63-64
SPECT (single photo stress-inoculation prevention,426-427 synapses, 29
emission computed therapy, 118 psychological theories on, synaptic terminals, 29
tomography), 67 stressors, insomnia, 451 418-419 syndromes, 71
speech sound disorder, 301 striatum, 192 rohypnol, 417 syphilis, 14
speed run, 409 stroke, 309, 312 and sexual systematic desensitization
spindles, 449 Stroop color-naming dysfunctions, 371 therapy, 38- 39, 118,
squeeze technique, 379 task, 134 and sleep disorders, 450 122,131-132,159,387
SSRls. See selective structural model of social factors, 396-398,419
serotonin reuptake traditional healing, 246 stimulants, 406-411
inhibitors structured interviews, 62, treatment, 420-426
T
standardization, 62 62-63,92 and violence, 468 tactile hallucinations, 223
Stanford-Binet Intelligence stuttering, 301 substance withdrawal, taijinkyofusho, 50,
Test, 66 subcortical structures, 28 398-399,401-403 76, 125
statistical significance, 90 sublimation, 43 substantia nigra, 27 tarantism, 11
Subject Index Sl-17
,.-----._
Tarasoff v. Regents of transvestic disorder, 382 and humanistic trisomy 21. See
the UniversihJ of transvestism, 383 approaches, 46 Down syndrome
California, 467 trauma. See also post- intellectual disability, tryptophan, 452
tardive dyskinesia, 33, 242 traumatic stress 298-299 Tuke, William, 13
TAT (Thematic disorder; stress in justice system, 12-month prevalence, 92
Apperception Test), 68 and coping strategies, 477-478 Twinkie Defense, 474
Tay-Sachs disease, 296 436-437 learning disorders, twinstudies,32,98-99
Tegretol and depression, 188 302-303 autism spectrum
(carbamazepine), 196 and dissociative legal issues, 470-471 disorder, 293
tertiary prevention, 53 amnesia, 167 for mood disorders, schizophrenia,
testosterone, 326, 370, and dissociative identity 193-204 234-235
374,386 disorder, 164-165 narcissistic personality two-factor model of
test-retest reliability, 61-62 and immune system, 437 disorder, 269 conditioning,37, 121
thalamus, 28 and separation anxiety neurocognitive Type A Behavior Pattern,
Thematic Apperception disorder, 137 disorder, 312 444-445
Test (TAT), 68 and sexual obsessive-compulsive
theories of abnormality, 23.
See also biological
dysfunctions, 373
types of, 113-115
disorder, 144-145
obsessive-compulsive
u
theories; psychological traumatic brain injury, personality disorder, unconditional positive
theories; sociocultural 310-311 275-276 regard, 46
theories treatment. See also panic disorder, 130-132 unconditioned response
theory, use of term, 24 depression, paranoid personality (UR), 37
therapies. See specific theories treatment for disorder, 257- 258 unconditioned stimulus
and conditions; attention-deficit/ paraphilias, 386-388 (US), 37
treatment hyperactivity disorder, phobias, 122- 123 unconscious, 42
therapy outcome studies, 288-290 post-traumatic stress unipolar depression. See
94-95 autism spectrum disorder, 117-118 depression
thioridazine (Mellaril), disorder, 294 and psychodynamic An Unquiet Mind
241,329 avoidant personality approaches,44-45 Oamison),4
thiothixene, 261 disorder, 271-272 schizoid personality
thioxanthenes, 242
third variable problem, 90,
and behavioral
approaches, 38-39
disorder, 261- 262
schizophrenia, 241- 246
v
91,92 and biological theories, schizotypal personality vaginal dryness or
third-wave approaches, 48 33- 36,35 disorder, 261-262 irritation, 370
Thorazine bipolar disorder, separation anxiety vagus nerve stimulation
(chlorpromazine), 241 196-197,203 disorder, 138 (VNS), 35, 198
Thorndike, E. L., 16, 36-37 and cognitive sexual dysfunctions, validity, 60-61, 61, 91, 93-94
threat responses, approaches, 40 375-379 Valium, 135, 406
108- 110, 110 common elements, 53-54 sleep disorders, valproate (Depakote),
The Three Faces of Eve, 162 conduct disorder, 451-452 196-197
threshold approach 328-329 substance use disorders, varenicline (Chantix), 420
continuum model conversion disorder, 159 420-426 variables, 85
versus, 83 cultural issues, 49-53 suicide, 210 vascular neurocognitive
research with, 83 delirium, 314 technologies for, 47-48 disorder, 309
thresholds, 72-73 dependent personality treatment approaches, vasocongestion, 365
tics, 288 disorder, 273 overview, 25 venlafaxine (Effexor), 135
tobacco, 410-411 dissociative identity treatments, neurocognitive ventricles, 236
Tofranil (imipramine), 135 disorder, 165 disorders (NCDs), 312 veterans, 115, 116, 311
token economies, 243-244 eating disorders, 357-359 trephination, 8, 35 Viagra (sildenafil), 375-376
tolerance, 399 and emotion-focused trichotillomania (hair- Vicodin, 412
Tourette's disorder, 303 approaches, 48 pulling disorder), 142 violence, 467, 467-469. See
traditional healers, 52-53, 246 and family systems tricyclic antidepressants, 34 also crime
transdiagnostic risk approaches,47-48 for depression, 196 visual hallucinations, 223
factors, 25 gender dysphoria, for generalized anxiety VNS (vagus nerve
transference, 44-45 390-391 disorder, 135 stimulation), 35, 198
transference-focused generalized anxiety for panic disorder, voyeurism, 383- 384
therapy, 266 disorder, 134-135 130,132 vulnerability-stress models.
transgender people, 389 histrionic personality trifluoperazine See diathesis-stress
transsexuals, 389 disorder, 267-268 (Stelazine), 241 models
Sl-18 Subject Index
w Wellbutrin (bupropion),
196, 288, 375
worry, 133
Wyatt v. Stickney, 470
z
wait list control group, 94 White, Dan, 474 Zeldox (ziprasidone), 242
war, 115, 116. See also
trauma
White, Eve, 160- 161
witchcraft, 10
X ziprasidone (Geodone,
Zeldox), 242, 243
Wasted (Hornbacher), 60 withdrawal, 398-399, Xanax,135,406 Zoloft (sertraline), 130,
Watson, John, 15-16, 121 401-403 Xenical (orlistat), 349 144, 375
Wechsler Adult Intelligence women. See gender zolpidem (Ambien), 452
Scale, 66 differences; gender roles y Zyban (bupropion), 196,
Wechsler Intelligence Scale word salad, 223 288, 375, 420
for Children, 66 working memory, 225 Yates, Andrea, Zyprexa (olanzapine), 197,
weight loss, 341, 348- 349 working through, 45 476, 479 242, 261,266
ISBN 978-1-259-21358-8
MHID 1-259-21358-7
www.mhhe.com

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Library of Congress Cataloging-in-Publication Data

Nolen-Hoeksema, Susan, 1959-2013.

Susan Nolen-Hoeksema (1959-2013)

Discussions for Think Critically 48 7

Shades of Gray Discussion 55 Shades of Gray 74

3 Assessing and Diagnosing Chapter Summary 80

Abnormality 58 Key Terms 81

Assessment and Diagnosis Along

Standardization 62 The Scientific Method 84

Clinical Interview 62 Defining the Problem and Stating

Projective Tests 68 Measuring the Relationship

Diagnosis 71 Experimental Studies 93

Diagnostic and Statistical Manual Human Laboratory Studies 93

Single-Case Experimental Designs 95 Panic Disorder 127

5 Trauma, Anxiety, Obsessive- Shades of Gray Discussion

Compulsive, and Related

Fear and Anxiety Along KeyTerms 149

Depersonalization I Derealization Interpersonal and Social Rhythm Therapy

7 Mood Disorders and Chapter Summary 213

Suicide 174 Key Terms 215

Mood Disorders Along

Cognitive Perspectives 240 Chapter Integration 278

Treatment 241 Think Critically 279

Biological Treatments 241 Chapter Summary 280

9 Personality Disorders 250

Personality Disorders Along

Extraordinary People-Susanna Kaysen Treatments for ADHD 288

The Impact of Gender, Culture,

1 1 Disruptive, Impulse Control, Sociocultural and Psychological

Treatments for Antisocial Personality Extraordinary People-David Reimer,

Intermittent Explosive Disorder 332 Sexual Dysfunctions 366

Paraphilic Disorders 380 Cannabis 414

Shades of Gray 383 Biological Factors 417

Voyeuristic, Exhibitionistic, and Frotteuristic Psychological Factors 418

Chapter Integration 391 Comparing Treatments 426

Shades of Gray Discussion 391 Prevention Programs 426

Think Critically 392 Gambling Disorder 427

Chapter Summary 429

Defining Substance Use Disorders 398 Extraordinary People-Norman Cousins,

Nicotine 41 0 Psychosocial Factors

Interventions to Improve Health-Related Prevalence of Involuntary

Chapter Summary 460 Guilty but Mentally Ill 476

16 Mental Health and

the Law 462

Chapter 3: Assessing and

Chapter 14: Substance Use

CHAPTER 5 DSM-IV-TR Anxiety Disorders CHAPTER 6 DSM-IV-TR Somatoform Disorders

DSM-IV- TR Anxiety Disorders Categorized DSM-IV- TR Somatoform Disorders Categorized in the

DSM-IV-TR DSM-5 DSM-IV-TR DSM-5

Specific Phobia Specific Phobia Somatization Disorder, Pain Somatic Symptom

Agoraphobia (as specifier Agoraphobia Hypochondriasis (without Illness Anxiety Disorder

Generalized Anxiety Generalized Anxiety Conversion Disorder Conversion Disorder

Posttraumatic Stress Posttraumatic Stress DSM-IV-TR Factitious Disorders

DSM-IV-TR Anxiety Disorders Categorized in the DSM-5 as DSM-IV-TR DSM-5

CHAPTER 7 DSM-IV-TR Mood Disorders CHAPTER 9 DSM-IV-TR Personality Disorders

DSM-IV-TR DSM-5 DSM-/V-TR DSM-5