maladaptive, disruptive, or uncomfortable
for those who are a?ected or for those
with whom they come in contact.Guy who washes his hands and cleans himself all the time so he doesn’t get AIDS
they are diagnosed as having two or even three disorders
has value but also some flaws
considered deviant By this criterion, the few people who believe that space aliens are
stealing their thoughts would be judged abnormal, and the many people who worry
about crime or terrorism would not. But statistical infrequency alone is a poor criterion
for abnormality because it would define as abnormal any rare quality, including creative
genius or world-class athletic ability. Further, the infrequency criterion implies that to
be normal, one must conform to all aspects of the majority’s standards. Equating non-
conformity with abnormality can result in the oppression of those who express unusual
or unpopular views or ideas. Finally, just how rare must a behavior be to warrant the
designation “abnormal”? The dividing line is not easy to locate.
in relation to others (see the chapter on social influence). people can be described as abnormal if they behave in ways that are unusual or disturbing enough to violate social norms. Like infrequency, though, norm violation alone is an inadequate measure of abnormality. For one thing, some norm violations are better characterized as eccentric or illegal than as abnormal. People who
seldom bathe or who stand too close during conversation violate social norms, but are they abnormal or merely annoying? Further, whose norms are we talking about?
Social norms vary across cultures, subcultures, and historical eras, so actions that qualify as abnormal in one part of the world might be perfectly acceptable elsewhere.
people are sometimes distressed about characteristics (such as being gay or lesbian) that are not mental disorders.
long-lasting that it interferes with their ability to hold a job or care for their children, it is likely to be considered abnormal. But it isn’t quite fair to call someone abnormal just because the person is dysfunctional. The dysfunction might be caused by physical illness, by an overwhelming but temporary family problem, or by a variety of things other than a psychological disorder. Further, some people who display significant psychological disorders are still able to function reasonably well at school, at work, or at home.
disorders are seen as re?ecting disturbances in the anatomy and chemistry of the brain and in other
biological processes. For example, the ancient Greek physician Hippocrates said that psychological disor-
ders resulted from imbalances among four humors, or bodily fluids (blood, phlegm, black bile, and yellow bile). In ancient Chinese cultures, psychological disorders were
thought to result from an imbalance of yin and yang, the dual forces of the universe flowing in the physical body. gave rise to the idea that abnormality is mental illness, and in fact, most people in Western cultures today still tend to seek medical doctors and hospitals for the diagnosis and treatment of psychological disordersJosé may have organic disorders (e.g., genetic tendency toward anxiety; brain tumor, endocrine dysfunction; neurotransmitter imbalance).
psychological processes. The roots of this ______of mental disorders can be seen in ancient Greek literature and drama dealing with the psyche, or mind—especially with
the mind’s struggles to resolve inner conflicts or to overcome the effects of stressful events. These ideas took center stage in the late 1800s when Sigmund Freud challenged the assumption that psychological disorders had only physical causes. As described in the personality chapter, Freud’s explanations of mental disorders were part of his psychodynamic approach. He believed that those disorders are the result of unresolved, mostly unconscious conflicts that begin in childhood. These conflicts pit people’s inborn impulses against the limits placed on those impulses by society.José has unconscious conflicts and desires. Instinctual impulses are breaking through ego defenses into consciousness, causing panic.
as social learning theorists
interaction of past learning and current situations. Just as people learn to avoid hot grills after being burned, say these theorists, bad experiences in school or a dental office can “teach” people to fear such places. Social-cognitive theorists also emphasize that learned expectations, schemas, and other mental processes discussed in the chapter on cognition and language can influence the development of disordersJosé interprets physical stress symptoms as signs of serious illness or impending death. Panic is rewarded by reduction in work stress when he stays home.
when a person’s natural tendency toward healthy growth is blocked, usually by a failure to be aware of and to express true feelings. When this happens, the person’s perceptions of reality become distorted. The greater the distortion, the more serious the psychological disorder.José fails to recognize his genuine feelings about work and his place in life, and he fears expressing himself.
gender, age, ethnicity, and other social and cultural factors. Suggests that we cannot fully explain all forms of psychopathology without also looking outside the individual—especially at the social and cultural factors that form the background of abnormal behavior.A culturally based belief that “a man should not show weakness” amplifies the intensity of stress reactions.
appearance and form of maladaptive
behavior.To find causes of disorders in this sociocultural context, we must pay attention to _______factors such as gender, age, and marital status; the physical, social, and economic situations in which people live; and the cultural values, traditions, and expectations in which they are immersed (Appignanesi, 2009; Lim, 2006; Sue ; Sue, 2008). Sociocultural context influences not only what is and is
not labeled “abnormal” but also who displays what kind of disorder and how likely people are to receive treatment for it.create differing stressors, social roles, opportu-
nities, experiences, and avenues of expression for different groups of people. They also help shape the disorders and symptoms to which certain categories of people are prone, and they even affect responses to treatment. For example, among people diagnosed with schizophrenia, those living in a developing country such as India are much more likely to improve than those living in a more developed country, such as the United States (Hopper ; Wanderling, 2000). We don’t yet know for certain what is responsible for this difference, but it may have something to do with the ways in
which schizophrenia is understood in different cultures.
heart palpitations, shaking, shouting, nervousness, depression, and, on occasion,
fainting or seizurelike episodes
a predisposition for a disorder combines with su?cient amounts of stress to trigger symptoms. It assumes that biological, psychological, and sociocultural factors can predispose us toward a disorder but that it takes a certain amount of stress to actually trigger that disorder. People with a strong _____ are more vulnerable, so even
relatively mild stress may be enough to create a problem. People whose diathesis is weaker may not show signs of a disorder until stress becomes extreme or prolonged.
Another way to think about the notion of _____ is in terms of risk: The more risk factors for a disorder a person has—whether in the form of genetic tendencies, personality traits, cultural traditions, or stressful life events—the more likely it is that the person will display a form of psychological disorder associated with those risk factors.José has a biological (possibly genetic) predisposition to be overly responsive to stressors. The stress of work and extra activity exceeds his capacity to cope and triggers panic as a stress response.
teria outlining the conditions that must be present before a person can be given that diagnostic label. Diagnosticians using ______ can evaluate troubled people on as many as five dimensions, or axes (plural of axis). In keeping with the biopsychosocial approach, evaluations on all relevant dimensions are combined to create a broad outline of the person’s biological and psychological problems, as well as of any socio-cultural factors that might contribute to them.
symptoms of every illness they read about, some psychology students worry that their behavior (or that of a relative or friend) signals a mental disorder. These days, this worry is called because it often stems from people’s unguided use of the Internet to learn about psy-
panic disorder, and obsessive-compulsive disorder. Another type, called posttraumatic stress disorder, is described in the chapter on health, stress, and coping. Together, these are the most common psychological disorders in North America; about 29 per-
cent of the U.S. population will have an ______ at some point in their lives.Most anxiety disorders, including panic disorder, obsessive-compulsive disorder, and generalized social phobia, appear to run in familiesGenetic influences on these disorders are suggested by research showing that if one identical twin has an anxiety disorder, the other twin (who shares the same genes) is more likely also to have an anxiety disorder than is the case in nonidentical twin pairs
Although biological predispositions
may set the stage for ________, most researchers agree that environmental stressors and psychological factors, including cognitive processes and learning, are cru-
cial to the development of most _____
As suggested by the diathesis-stress
approach and as discussed in the chapter on health, stress, and coping, the impact of people’s experiences is heightened or dampened by other factors, such as their genetic and biological vulnerability or resilience to stress, their previous experiences with frightening events, their expectations and other cognitive habits, and the social support and other conditions that follow the trauma (Armfield, 2006; Leyro, Zvolensky, & Bernstein, 2010; Mineka & Zinbarg, 2006; Xie et al., 2009). In short, learning—including the learning that supports the development of anxiety disorders—occurs more quickly among those who are biologically and psychologically prepared for it.
such a reaction. People who experience phobias usually realize that their fears are groundless, but that’s not enough to make the anxiety go away. The continuing
discomfort and avoidance of the object or event may greatly interfere with daily life.Once phobias are learned, avoiding the feared object or situation prevents the person from finding out that there is nothing to fear. This cycle of avoidance helps explain why many phobias do not simply extinguish, or disappear, on their own
An anxiety disorder involving strong, irrational fears relating to social situations. involve anxiety about being criticized by others or acting in a way that is embarrassing or humiliating. The anxiety is so intense and persistent that it impairs the person’s normal functioning. Common social phobias are fear of public speaking or performance (“stage fright”), fear of eating in front of others, and fear of using public restrooms
Some evidence suggests that genetic factors appear to influence social phobia more strongly in males than in females
ally all social situations (Jacobs et al., 2009; Mineka & Zinbarg, 2006). One person described the problem this way
become housebound, unwilling to even try going out alone. Most individuals who display agoraphobia have a history of panic attacks, which we describe later (Fava
et al., 2008). Their intense fear of public places occurs partly because they don’t want to risk triggering an attack by going to places in which they had a previous attack or
where they feel an attack would be dangerous or embarrassing (Kessler, Chiu, et al.,
6 percent of the population at some point in their lives (Hollander ; Simeon, 2008; Kessler ; Wang, 2008). This disorder tends to appear somewhat later in life than most
of the other anxiety disorders (the median age of onset is 31 for GAD, whereas it is the teens or early twenties for phobias). Generalized anxiety disorder is more common in
women, often accompanying other problems such as depression or substance abuse
like Mark, whose story opened this chapter, people displaying OCD are plagued by persistent, upsetting, and unwanted thoughts—called obsessions—that often center on the possibility of infection, contamination, or doing harm to themselves or others. They do not actually carry out harmful acts, but the obsessive thoughts motivate ritualistic, repetitive behaviors—called compulsions—that are performed in an effort to avoid some dreaded outcome or to reduce feelings of anxiety associated with the obsessions
(Noyes ; Hoehn-Saric, 2006).To social-cognitive theorists, then, obsessive-compulsive disorder is a pat-tern that is sparked by distressing thoughts and maintained by operant conditioning
(Noyes ; Hoehn-Saric, 2006). For example, Mark engaged in incessant, ritualized cleaning to protect himself from infection. Other common _______ include rituals such
as checking locks; repeating words, images, or numbers; counting things; or arranging objects “just so.”
disorder are present without a physical cause. The classic example is conversion disorder, a condition in which a person appears to be, but is not, blind, deaf, paralyzed, or insensitive to pain in various parts of the bodySome cases of somatoform disorder may be related to childhood experiences in which a person learns that symptoms of physical illness bring special attention,
care, and privilegesOthers, including conversion disorder, may be triggered by severe stressors
Cognitive factors also come into play. When given information about their health, people with hypochondria-
sis are strongly biased to focus on threat-confirming information but to ignore reassuring information
Abnormal serotonin functioning has also been associated with hypochondriasis, and various combinations of neurochemical and social skill deficits appear to accompany conversion disorder and body dysmorphic disorder
Based on such findings, many researchers have adopted a diathesis-stress approach to explaining somatoform disorders. The results of their work suggest that
certain people may have biological and psychological traits that make them especially vulnerable to somatoform disorders, particularly when combined with a history
of physical illness.
Sociocultural factors may shape the nature of some somatoform disorders. In many Asian, Latin American, and African cultures, it is not unusual for people to experience severe physical symptoms in association with psychological or interpersonal conflict
blindness, deafness, or other symptoms of sensory or motor failure without a physical cause. Conversion disorders differ from true physical disabilities in several ways. First, they tend to appear when a person is under severe stress. Second, they often help reduce that stress by allowing the person to avoid unpleasant or threatening situations. Third, the person may show remarkably little concern about what is apparently a rather serious problem. Finally, the symptoms may be neurologically impossible or
improbable, as Figure 15.2 illustrates. conversion disorder is diagnosed only when the symptoms are not being faked. Rather than destroying sensory or motor ability, the conversion process may prevent the person from being aware of information that the brain is processing
of having physical illness. a strong, unjustified fear that one has cancer, heart disease, AIDS, or some other serious physical problem. In some ways, hypochondriasis is like an anxiety disorder in that it involves health concerns and includes elements of phobia, panic, and obsessive-compulsive disorder. People with hypochondriasis
make frequent doctor visits to report numerous symptoms and request unnecessary treatment. They may even become “experts” on their most feared diseases, sometimes by endlessly searching health-related Internet Web sites
physical complaints without veri?able physical illness. is characterized by dramatic but vague reports of a multitude of physical problems rather than any specific illness.
(typically in the neck, chest, or back) with no physical cause.
temporary disruptions in a person’s memory, consciousness, or identity. Have you ever driven for hours on a boring highway and suddenly realized that you
couldn’t remember anything about the previous half-hour? This is a common experience, but when disruptions in a person’s memory, consciousness, or identity are more
intense and long-lasting, they are known as _____________. These disruptions can come on gradually, but they usually occur suddenly and last from a few hours to
many yearsResearch on dissociative disorders so far supports four conclusions. First, memory loss and other forms of dissociations are genuine phenomena, and as seen
in dissociative fugue, they can sometimes become extreme. Second, many people displaying DID have experienced events they would like to forget or avoid. The
majority (some clinicians believe all) have suffered severe, unavoidable, persistent abuse in childhood (Foote et al., 2006; Kihlstrom, 2005). Third, like Mary, most of
these people appear to be skilled at self-hypnosis, through which they can induce a trancelike state. Fourth, most found that they could escape the trauma of abuse, at
least temporarily, by creating “new personalities” to deal with stress (Spiegel, 1994; van der Hart, Bolt, & van der Kolk, 2005). However, not all abused children display
DID, and there is evidence that DID can indeed be triggered by media stories or by therapists who expect to see alternative personalities and use hypnosis and other
methods that encourage clients to display them (Lindsay et al., 2004; McHugh, 2009; Rieber, 2006).
loss of memory and possible assumption
of a new identity in a new location. In some cases, the
person adopts an entirely new identity
reports having more than one identity. formerly known as—and still commonly called—multiple personality disorder (MPD). A person diagnosed with DID appears to have more than one identity, each of which speaks, acts, and writes in a different way. Each personality seems to have its own
memories, wishes, and (often conflicting) impulses. Here is a case example (Spitzer
et al., 1994):
Phobias-Intense, unreasonable, disruptive fear of objects or situations
Generalized anxiety disorder- Excessive anxiety not focused on a specific object or situation; free-floating
Panic disorder- Repeated attacks of intense fear involving physical symptoms such as faintness, dizziness, and nausea
Obsessive-compulsive disorder= Persistent ideas or worries accompanied
Conversion disorder=A loss of physical ability (e.g., sight, hearing) that is related to psychological factors
Hypochondriasis=Preoccupation with or belief that one has a serious illness in the absence of any physical evidence
Somatization disorder=Large number of somatic complaints that occur over several years and are
not the result of a known physical disorder
Somatoform pain disorder=Preoccupation with pain in the absence of physical reasons for the pain
Dissociative amnesia – Sudden loss of memory
Fugue reaction (dissociative fugue)- Sudden loss of memory, which may result in relocation and the assumption of a new identity
Dissociative identity disorder (multiple personality disorder)- Appearance within the same person of two or more distinct identities, each with a unique way of thinking and behaving
are not consistent with the events around them, they are said to show an _____ (also known as a mood disorder). We will describe two main types: depressive disorders and bipolar disorders.
An a?ective disorder in which a person feels sad and hopeless for weeks or months. Despite the person’s best efforts, everything from conversation to bathing is an unbearable, exhausting effort. Changes in eating habits resulting in weight loss or weight gain often accompany major depression, as does sleep disturbance or, less often, excessive sleeping. Problems in working, concentrating, making decisions, and thinking clearly are also common. More often than not, there are also symptoms of an accompanying anxiety disorder
Major depression may come on suddenly or gradually. It may consist of a single episode or, more commonly, repeated depressive periods. These episodes can last
weeks or months; the average length of the first one is four to nine month. Exaggerated feelings of inadequacy, worthlessness, hopelessness, or guilt are common in major depression
The prevalence and severity of major depression is similar across many ethnic groups
In the United States and other Western
countries, females are two to three times more likely than males to experience major depression but this difference is smaller in the less economically developed countries of the Middle East, Africa, and Asia
In the United States, suicide is most common among people over 65, especially men (Warner, 2010). The suicide rate for men who are 85 or older is 55 per 100,000; for women in this age group, it is only 4 per 100,000 (CDC, 2004). However, since 1950, suicide in the 15-to-24 age group has tripled. . And although the rate has begun to level off in the past decade, suicide is still the third leading cause of death, after accidents and homicides, among people in this age group
Suicide rates also differ considerably, depending on sociocultural factors such as age, gender, and ethnicity
Suicide is the second leading cause of death among college students. About ten thousand try to kill themselves each year, and about 10 percent of them succeed. These
figures are much higher than for 18- to 24-year-olds in general but much lower than for older adults (NIMH, 2009). Women attempt suicide three times as often as men, but men are four times as likely to actually kill themselves (CDC, 2006). The gender difference is even greater among people who have been diagnosed with depression. In this group, the male suicide rate of 65 per 100,000 is ten times higher than the rate for women (Blair-West et al., 1999; CDC, 1999b).
Suicide rates also differ across ethnic groups (CDC, 2002c; Oquendo et al., 2001). Among males in the United States, for example, the overall rate for American Indians is 15.1 per 100,000, compared with 13.9 for European Americans, 5.7 for Asian Americans, 4.9 for Hispanic Americans, and 5.0 for African Americans. The same pattern of ethnic differences appears among women, though the actual rates are much lower (NIMH, 2009).
The risk of suicide is heightened among people diagnosed with an affective disorder, anxiety disorder, or schizophrenia and people who have suffered extended unemployment. Among older adults, suicide is most common in males who suffer depression over health problems (e.g., Brown, Bongar, ; Cleary, 2004). The risk is higher, too, in depressed people who have certain genetic characteristics, have made a specific plan, have given away possessions, and are impulsive (CDC, 2004; Kohli et al., 2010). A previous suicide attempt may not always be a good predictor of eventual suicide because such attempts may have been help-seeking gestures rather than failed efforts to die (Nock ; Kessler, 2006). In fact, although about 10 percent of unsuccessful attempters try again and succeed, most people who commit suicide had made no prior attempts (Clark ; Fawcett, 1992).
On the contrary, those who say they are thinking of suicide are much more likely than other people to attempt suicide. In fact, most suicides are preceded by some kind of warning, whether direct (“I think I’m going to kill myself”) or vague (“Sometimes I wonder if life is worth living”).
mania, which is an extremely agitated and usually elated emotional state. While in this state, people are utterly optimistic, boundlessly energetic, certain of having extraordinary powers and abilities, and bursting with all sorts of ideas. They become irritated with anyone who tries to reason with them or “slow them down” and may become aggressive or careless enough to pose a danger to themselves or others. During manic episodes, individuals may make impulsive and unwise decisions, such as spending their life savings on foolish schemesThere are two versions of bipolar disorder, known as bipolar I and bipolar II.
In bipolar I disorder, manic episodes may alternate with periods of deep depression (Ghaemi, 2008). One bipolar patient described the disorder, which has also been called manic depression, this way: “You’re really up or you’re drop-dead bottom” (Fairbanks, 2009). In many cases, though, these extremes are separated by periods of relatively normal mood (Tohen et al., 2003). Compared to major depression, bipolar I disorder is rare. It occurs in only about 1 percent of adults, and it affects men and women about equally.Another 1 percent of adults display bipolar II disorder, in which episodes of major depression alternate with episodes known as hypomania, which are less severe than the manic phases seen in bipolar I disorder (Merikangas et al., 2007). Both versions can severely disrupt a person’s ability to work or maintain social relationships (Kessler, Berglund, Demler, et al., 2005; NIMH, 2006).
state. While in this state, people are utterly optimistic, boundlessly energetic, certain of having extraordinary powers and abilities, and bursting with all sorts of ideas. They become irritated with anyone who tries to reason with them or “slow them down” and may become aggressive or careless enough to pose a danger to themselves or others. During manic episodes, individuals may make impulsive and unwise decisions, such as spending their life savings on foolish schemes (
pattern of mood swings that is less extreme than that of bipolar disorders.
1. Deep sadness, feelings of worthlessness, changes in eating and sleeping habits, loss of interest and pleasure
2. Lasts weeks or months; may occur in repeating episodes; severe cases may include delusions; danger of
1. Similar to major depressive disorder, but less severe and longer lasting
2. Hospitalization is usually not necessaryBipolar disorder
1.Alternating extremes of mood, from deep depression to mania, and back
2. Manic episodes include impulsivity,
unrealistic optimism, high energy, severe agitation
Cyclothymic personality (cyclothymic disorder)
1. Similar to bipolar disorder, but less severe
2. Hospitalization is usually not necessary
Research on the causes of affective disorders has focused on biological, psychological, and sociocultural risk factors. The more of these risk factors people have, the more
likely they are to experience an affective disorder.
For example, bipolar disorder is much more likely to appear in both members of genetically identical twin pairs than in nonidentical twins
Family studies also show that close relatives of people with a bipolar disorder are more likely than others to develop that disorder themselves
Findings such as these suggest that genetic influences tend to be stronger for affective disorders, especially for bipolar disorders and severe, early-onset depression, than for most other disorders.
Other biological factors that may contribute to affective disorders include malfunctions in regions of the brain devoted to mood, imbalances in the brain’s neurotransmitter systems, malfunctioning of the endocrine system, disruption of biological rhythms, and underdevelopment in the frontal lobes, hippocampus,
or other brain areas
As for the role of neurotransmitters, norepinephrine, serotonin, and dopamine were implicated in affective disorders decades ago when scientists discovered that
drugs capable of altering these brain chemicals also relieved affective disorders. Early research suggested that depression was triggered by too little of these neurotransmitters, whereas unusually high levels caused mania. However, the neurochemical causes now appear far more complex. For example, affective disorders may result in part from changes in the sensitivity of the neuronal receptors at which these chemicals have their effects in the brain. The precise nature of these neurotransmitter-receptor mechanisms and just how they affect mood are not yet fully understood.
Affective disorders have also been related to malfunctions in the endocrine system, especially the hypothalamic-pituitary-adrenocortical (HPA) system. As described in the chapter on health, stress, and coping, this system is involved in the body’s responses to stress. Research shows, for example, that as many as 70 percent of depressed people secrete abnormally high levels of the stress hormone cortisol. Studies of identical twins also suggest that higher levels of cortisol are associated with depression
Researchers have come to recognize that
whatever biological causes are involved in affective disorders, their effects are always combined with those of psychological and social causes.
For example, the higher incidence of depression among females—and especially among poor, ethnic minority, single mothers—has been attributed to several factors. Women have greater exposure than men to certain adverse experiences during childhood (e.g., sexual abuse) and adulthood (e.g., domestic violence, poverty). When these risk factors combine with depressive ways of thinking and loss of social support, depression becomes more likely
(Miranda & Green, 1999; Nolen-Hoeksema, 2006; Whiffen, 2006). Environmental stressors affect men, too, which may be one reason why gender differences in depression
are smaller in countries in which men and women face equally stressful lives (Bierut et al.,
1999; Maier et al., 1999).
aron Beck’s cognitive theory of depression suggests
that depressed people develop mental habits of (1) blaming themselves when things go wrong, (2) focusing on and exaggerating the negative side of events, and (3) jumping to overly generalized, pessimistic conclusions (
Severe, long-lasting depression is especially common among people who see their lack of control or other problems as caused by a permanent, generalized lack
of personal competence rather than by a temporary condition or an external cause (Seligman et al., 1988). This negative attributional style is regarded by some researchers as a partly inherited trait that leaves people prone to depression because they attribute negative events to their own characteristics and believe that they will never be capable of doing better
Given the number and complexity of biological, psychological, social, and situational factors potentially involved in causing affective disorders, the biopsychosocial
approach and the diathesis-stress model appear to be especially appropriate guides to
sciousness (Monteleone ; Maj, 2008). This second possibility seems especially likely in the 15 percent of depressed people who consistently experience a calendar-linked pattern of depressive episodes known asDuring months of shorter daylight, these people slip into severe depression, accompanied by irritability and excessive sleeping (
in the world, occurring in 1 to 2 percent of the population (American Psychiatric Association, 2000; NIMH, 2006). In the United States, it appears about equally in various ethnic groups, but like most disorders, it tends to be diagnosed more frequently in economically disadvantaged populations. Schizophrenia occurs about equally in
men and women, although in women it generally appears later in life, tends to be less severe, and responds better to treatment (Aleman, Kahn, ; Selten, 2003; American
Psychiatric Association, 2000; Häfner, 2003Schizophrenia tends to develop in adolescence or early adulthood. About 75 percent of the time, its onset is gradual, with the earliest signs appearing as much as five years before the first major schizophrenic episode.About 40 percent of people with schizophrenia improve with treatment and are able to function reasonably well. One of the best predictors of the course of schizophrenia is premorbid adjustment,which is the level of functioning a person had achieved before schizophrenic symptoms first appeared. Improvement is more likely in those who had reached higher levels of education and occupation and who had established supportive relationships with family and friends
It refers instead to a splitting of normally integrated mental processes, such as thoughts and feelings. For
instance, some schizophrenics may giggle while claiming to feel sad. Schizophrenic thought and language are often disorganized, as illustrated in the following letter that arrived in the mail several years ago:
schizophrenia runs in families
Even if they are adopted by families in which there is no schizophrenia, the children of schizophrenic parents are ten times more likely to develop schizophrenia
than adopted children whose biological parents are not schizophrenic
Still, it is unlikely that a single gene transmits schizophrenia
schizophrenia patients have less tissue in thalamic regions, prefrontal cortex, and some subcortical areas
shrinkage of tissue in these regions leads to correspond-
ing enlargement of the brain’s fluid-filled spaces, called ventricles. The brain areas in which anatomical abnormalities have been found are active in emotional expression, thinking, and information processing—functions that are disordered in schizophrenia. Enlarged ventricles and reduced prefrontal cortex are more often found in patients whose schizophrenic symptoms are
predominantly negative (Sigmundsson et al., 2001). Continued tissue loss has been associated with worsening of negative symptoms
impairments in information processing and other cognitive abilities are related to structural abnormalities
some investigators speculate that schizophrenia results from excess dopamine.
Studies have shown, for instance, that prenatal exposure to physical traumas, influenza, or other viral infections is associated with increased risk for developing schizophrenia
The expression of a genetically transmitted predisposition for brain abnormality may be enhanced by environmental factors such as maternal drug use during pregnancy, oxygen deprivation or other complications during birth, or childhood malnutrition (
When only one member of an identical-twin pair
has schizophrenia, both tend to have unusually small brains, but the schizophrenic twin’s brain in each pair is the smaller of the two (Baare et al., 2001). This finding
suggests that some environmental influence caused degeneration in an already underdeveloped brain, making it even more prone to function abnormally.
tendency for one thought to be logically unconnected or only slightly related to the next.
gathering, to the forest stream, reinstatement to be placed, poling the paddleboat, of the swamp morass, to the forest compensation of the dunce”
Fall into three categories
1. Delusions of influence focus on the belief that one’s body, thinking, or behavior are being affected
or controlled by external forces. Patients with these delusions might claim that the CIA has implanted a control device in their brains. They might believe that other
people’s thoughts are appearing in their mind (thought insertion) or that they can broadcast their thoughts to others (thought broadcasting)
2. Self-significant delusions involve exaggerated beliefs about oneself. People with these delusions may believe, for
example, that certain TV commercials contain coded messages about their innermost secrets; that they are truly an emperor, the pope, or even God (delusions of grandeur); or that they are guilty of some terrible sin. P
3. People displaying delusions of persecution
believe that others are out to harass or harm them. They may claim, for example, that they are always being followed, that space aliens are trying to steal their internal
organs, or that they are the targets of an assassin. These delusions tend to be deeply entrenched and resistant to change, no matter how strong the evidence against them
(Minzenberg et al., 2008;Woodward et al., 2006).
example, that certain TV commercials contain coded messages about their innermost secrets; that they are truly an emperor, the pope, or even God (delusions of grandeur); or that they are guilty of some terrible sin. P
(Minzenberg et al., 2008;Woodward et al., 2006).
Hallucinations can also create sights, smells, tastes, and touch sensations even when no external stimuli are present.
1. 40% of schizophrenics; usually appears after age 25-30 2. Delusions of grandeur or persecution; anger; anxiety; argumentativeness; extreme jealousy; onset often sudden;
signs of impairment may be subtleDisorganized schizophrenia
1. 5% of all schizophrenics; high prevalence in homeless
2. Delusions; hallucinations; incoherent speech; facial grimaces; inappropriate laughter or giggling; neglected
personal hygiene; loss of bladder or bowel controlCatatonic schizophrenia
1. 18% of all schizophrenics
2. Disordered movement, alternating between immobility (stupor) and wild excitement. In stupor, the person does
not speak or attend to communication
1. 40% of all schizophrenics
2. Patterns of disordered behavior, thought, and emotion that do not fall easily into any other subtype
2. Applies to people who have had prior episodes of schizophrenia but are not currently displaying symptoms
hallucinations, and delusions.because they appear as undesirable additions to a person’s mental life. Describing patients in terms of positive and negative symptoms does not require that they be placed in one category or the other. In fact, many patients exhibit both positive
and negative symptoms.
less responsive to treatment
also includes other diagnoses that share features with schizophrenia. For example, people diagnosed with schizoaffective disorder show symptoms of both schizophrenia and depression. Schizophreniform disorder is characterized by schizophrenia-like symptoms that do not last as long as those typically seen in schizophrenia.
The diathesis-stress approach is embodied in the ______ of schizophrenia
This theory suggests that (1) vulnerability to schizophrenia is mainly biological, (2) different people have differing degrees of vulnerability, (3) vulnerability is influenced partly by genetic influences on development and partly by neurodevelopmental abnormalities associated with environmental risk, and (4) psychological components—such as exposure to poor parenting or high-stress families or having inadequate coping skills—may help determine whether schizophrenia actually appears and may also influence the course of the disorder (Walker & Diforio, 1998; Wearden et al., 2000).
1. Disorders of thought=Disturbed content, including delusions; disorganization, including loose associations, neologisms, and word salad
2. Disorders of perception=Hallucinations; poorly focused attention
3. Disorders of emotion= Flat affect; inappropriate tears, laughter, or anger
1. Biological=Genetics; abnormalities in brain structure; abnormalities in dopamine systems; neurodevelopmental problems
2. Psychological= Learned maladaptive behavior; disturbed patterns of family communication
_____Long-standing, in?exible ways of behaving that create a variety of problems.
These disorders affect all areas of functioning and, beginning in childhood or adolescence,
create problems for those who display them and for others (Cohen, 2008; Millon & Davis, 1996). Some psychologists view personality disorders as interpersonal strate-
gies (Kiesler, 1996) or as the extreme, rigid, and maladaptive expressions of personality traits (Widiger, 2008). The ten personality disorders listed on Axis II of DSM-IV-TR are grouped into three clusters that share certain features (see Table 15.5)
Some critics have suggested that there is gender bias in the application of diagnoses—pointing to the fact that women are labeled as borderline much more often than men, while men are labeled as antisocial more often than women (Bjorklund, 2006; Boggs et al., 2009). Even the stability of personality disorders over the lifetime has been questioned (Durbin & Klein, 2006). Some aspects of personality disorder diagnoses may be revised in DSM-V, but as yet there is no strong consensus about what changes should be made.
ality disorder, for example, display some of the peculiarities seen in schizophrenia but are not disturbed enough to be labeled as schizophrenic. Rather than hallucinating, these people may report “illusions” of sights or sounds. They may also exhibit “magicalthinking,” including odd superstitions or beliefs (such as that they have extrasensory perception or that salt under the mattress will prevent insomnia).2. The dramatic-erratic cluster=called cluster B—includes the histrionic, narcissistic, borderline, and antisocial personality disorders. The main characteristics of narcissistic personality disorder, for example, are an exaggerated sense of self- importance, extreme sensitivity to criticism, a constant need for attention, and a tendency to arrogantly overestimate personal abilities and achievements. People displaying this disorder feel
entitled to special treatment by others but are markedly lacking in empathy for others.3. The anxious-fearful cluster=cluster C—includes dependent, obsessive-compulsive, and avoidant personality disorders. Avoidant personality disorder, for example, is similar to social phobia in the sense that people labeled with this disorder tend to be “loners”
with a long-standing pattern of avoiding social situations and of being particularly sensitive to criticism or rejection. They want to be with others but are too inhibited.
Cluster A (odd-eccentric)
1.Paranoid = Suspiciousness and distrust of others, all of whom are assumed to be hostile
2. Schizoid= Detachment from social relationships; restricted range of emotion
3. Schizotypal= Detachment from, and great discomfort in, social relationships; odd perceptions, thoughts, beliefs, and behaviors
Cluster B (dramatic-erratic)
1.Histrionic= Excessive emotionality and preoccupation with being the center of attention; emotional shallowness; overly dramatic
2. Narcissistic=Exaggerated ideas of self-importance and achievements; preoccupation with fantasies of success; arrogance
3. Borderline=Lack of stability in interpersonal relationships, self-image, and emotion; impulsivity; angry
outbursts; intense fear of abandonment; recurring suicidal
4. Antisocial= Chronic, remorseless pattern of impulsive, irresponsible, dishonest behavior
Cluster C (anxious-fearful)
1. Dependent= Helplessness; excessive need to be taken care of; submissive and clinging behavior; difficulty in
2. Obsessive-compulsive= Preoccupation with orderliness,
perfection, and control
3.Avoidant= Inhibition in social situations; feelings of inadequacy; oversensitivity to criticism
and even criminal behavior beginning in childhood or early adolescence (Washburn et al., 2007). In the 1800s, this pattern was called moral insanity because the people
displaying it appear to have no morals or common decency. Later the term sociopath or psychopath was applied to individuals who display shallow emotions, lack of empathy, and superficial charm and who callously violate social norms (Coid & Ullrich, 2010; Hare & Newmann, 2009). The current “antisocial personality” label used in DSM-IV-TR more accurately portrays people displaying the disorder as troublesome and sometimes dangerous but not “insane” by the legal standards we will discuss shortly. About 3 percent of men and about 1 percent of women in the United States faThey can be charming, intelligent “fast talkers” who borrow money and fail to return it. They can be arrogant and self-centered manipulators who con people into
doing things for them, usually by lying and taking advantage of the decency and trust of others. At their most troublesome, people with this disorder are criminals, sometimes violent ones. Persistent violent offenders, most of whom have APD, make up less than 5 percent of the male population, but they commit over 50 percent of violent crimesA hallmark of people with APD is a lack of anxiety, remorse, or guilt, whether they have wrecked a borrowed car or killed an innocent person
Fortunately, these individuals tend to become less active and dangerous after the age of 40 or so (
Genes may influence brain development; reduced brain size and reductions in the amygdala and hippocampal regions are associated with antisocial personality (C
Other evidence suggests more specific information- processing defects. For example, people diagnosed with antisocial personality disorder perform less well than others do on neuropsychological tests of the ability to make plans
The APD males reported lower levels of guilt and fear and higher levels of excitement and happiness while watching
Broken homes, rejection by parents, poor discipline, lack of good parental models, lack of attachment to early caregivers, impulsivity, conflict-filled childhoods, and
poverty have all been suggested as psychological and social factors contributing to the development of antisocial personality disorder
The apparent role of abuse in antisocial personality disorder was particularly pronounced in men, and it remained strong even when other factors—such as age, ethnicity, and socioeconomic status—were accounted for in the statistical analyses. It is interesting to note that one other factor—failure to graduate from high school—was also strongly associated with the appearance of antisocial personality disorder, whether or not childhood abuse had occurred.
from the perspective of social and political psychology—terrorists are spurred to take extreme destructive measures by political and religious ideologies during intense group conflict (Saucier et al., 2009). In short, the psychology of group conflict and war might better explain the terrorism of today, just as it might have explained the terrifying behavior of Japanese kamikaze pilots during World War II
disorder, for example, constantly worry that they will be lost, kidnapped, or injured or that some harm may come to a parent (usually the mother). The child clings desperately to the parent and becomes upset or sick at the prospect of any separation. Refusal to go to school
(sometimes called “school phobia”) is often the result. Children who are shy or withdrawn are at a higher risk than others for internalizing disorders, but these problems are also associated with environmental factors, including being rejected by peers and (especially for girls) being raised by a single parent (Phares, 2008; Prinstein ; La Greca, 2002).
into either the externalizing or internalizing category. Children diagnosed with these disorders show severe problems in communication and impaired social relationships. They also often display repetitive, stereotyped behaviors and unusual preoccupations
and interests (American Psychiatric Association, 2000). The disorders in this group, also known as autistic spectrum disorders (ASD), share many of these core symptoms,
children have autistic disorder, which can be the most severe of the group. The earliest signs of autistic disorder usually appear within the first thirty months after birth, as these babies show little or no evidence of forming an attachment to their caregivers. Language development is seriously disrupted in most of these children; half of them never learn to speak at all. They have great diffi culty engaging in tasks that require shared attention, and they often focus on nonsocial aspects of human interaction, such as clothing, rather than on social aspects such as eye contact, facial expression, and tone of voice (Klin
et al., 2002). Those who display high-functioning autism or a less severe autistic spectrum disorder called Asperger’s syndrome (also known as Aspberger’s disorder) have impaired relationships, engage in repetitive behaviors, and may memorize arcane facts or activities
(such as sports scores or ZIP codes), but they show few severe cognitive deficits and are able to function adaptively and, in some cases, independently as adults (e.g., Grandin, 1996; Shore, 2003).Possible biological roots of autistic disorder include genetic factors and neurodevelopmental abnormalities affecting language and communicationResearchers studying these biological factors have recently become interested in the activity of mirror neurons in the brain. As described in the chapter on biological aspects of psychology, these neurons are activated when we see other people’s actions, such as smiling, frowning, or showing disgust. Because they are in the areas of our own brain that control these same actions, activity in mirror neurons help us understand how the other person might be feeling and empathize with those feelings. The functioning of such neurons appears disturbed in people with autism, partly explaining why these individuals seem to operate with little appreciation for what others might be thinking or feeling
Other problems have been found in the brains of children with autism, mainly in the prefrontal cortex and in the corpus callosum (which connects the two cerebral hemispheres). These problems may impair the communication among brain areas that is necessary for normal social interaction and language (
Hypotheses that autistic disorder is caused by having cold and unresponsive parents or by injections of measles, mumps, rubella (MMR) vaccine have been rejected by the
results of scientific research (e.g. Doja & Roberts, 2006).
take one example, children whose separation anxiety causes spotty school attendance may not only fall behind academically but also fail to form the relationships with
other children that promote normal social development (Wood, 2006). Some children never make up for this deficit. They may drop out of school and risk a life of poverty, crime, and violence. Moreover, children are dependent on others to obtain help for their psychological problems, but all too often those problems may go unrecognized or untreated. For some, the long-term result may be adult forms of mental disorder.
months or years in ways that harm the user
or others. These disorders create major political, economic, social, and health problems worldwide. The substances involved most often are alcohol and other CNS depressant drugs (such as barbiturates), opiates (such as heroin), CNS stimulating drugs (such as cocaine or amphetamines), and hallucinogenic drugs (such as LSD).
About half the world’s population uses at least one psychoactive substance, and about two-thirds of U.S. citizens report that problems related to alcohol or drug use have affected them, their families, or their close friends
getting and using it. People who are psychologically dependent on a drug often display problems that are at least as serious as those of people who are physiologically
addicted, and the problems are sometimes more diffi cult to treat. Even when use of a drug does not lead to psychological or physiological dependence, some people may use it in a way that is harmful to themselves or others. For example, they may rely on the drug to bolster self-confidence or to avoid depression, anger, fear, or other unpleasant feelings. However, the drug effects these people seek may also impair their ability to hold a job, care for their children, or drive safely. This pattern of behavior, defined in DSM-IV-TR as substance abuse, causes significant social, legal, and interpersonal problems
problems.The biopsychosocial model suggests that alcohol use disorders stem from a com-
bination of genetic characteristics (including inherited aspects of temperament such
as impulsivity and emotionality) and what people learn in their social and cultural
environmentOne possibility involves inherited abnormali-
ties in the brain’s neurotransmitter systems or in the body’s metabolism of alcohol
However, the genetics of addiction is complex, and there are likely multiple pathways to alcoholism
Something in these boys’ nonalcoholic family environment had apparently moderated whatever genetic tendency toward alcoholism they might have inherited. Youngsters typically learn to drink by watching their parents and their peers. These observations help shape their expectations, such as that alcohol will make them feel good and help them cope with stressors (Schell et al., 2005). But if drinking becomes a person’s main coping strategy, alcohol use can become abuse and ultimately addiction (NIAAA, 2001). The importance of social and cultural learning is supported by evidence that alcoholism is more common among ethnic and cultural groups (such as the Irish and English) in which frequent drinking tends to be socially reinforced than among groups (such as Jews, Italians, and Chinese) in which anything beyond moderate drinking tends to be discouraged (Gray ; Nye, 2001; Wilson et al., 1996). Moreover, variations in social support for drinking can result in differing consumption patterns within a cultural group. For example, one study found significantly more drinking among Japanese men living in Japan (where social norms for males’ drinking are quite permissive) than among those living in Hawaii or California, where excessive drinking is less strongly supported (Kitano et al., 1992). Learning would also help explain why rates of alcoholism are higher than average among bartenders,
cocktail servers, and others who work where alcohol is available and drinking is socially reinforced or even expected (Fillmore & Caetano, 1980). (Of course, it is also possible that attraction to alcohol led some of these people into such jobs in the first place.)
are unable to understand the proceedings and charges against them or to assist in their own defense, they are declared to be_____to stand trial. In such cases, defendants are sent to a mental institution until they are judged to have become _____. If still not competent after a court-specified period—two years, in most cases—a defendant may be ruled permanently ineligible for trial and either committed
in civil court to a mental institution or released. Release is rare, however, because competency to stand trial requires only minimal mental abilities. If drugs can produce even
temporary mental competence, the defendant will usually go to trial
mental illness prevented them from understanding what they were doing, knowing that what they were doing was wrong, or resisting the impulse to do wrong. The first two
of these criteria—understanding the nature or wrongfulness of an act—are “cognitive” riteria known as the M’Naghton rule. This rule stems from an 1843 case in England in which a man named Daniel M’Naghton, upon hearing “instructions from God,” tried to kill British prime minister Robert Peel. He was found not guilty by reason of insanity and put into a mental institution for life. The third criterion, which is based on a defendant’s emotional state during a crime, is known as the irresistible-impulse test. All three criteria were combined in a rule proposed by the American Law Institute (ALI) in 1962 and now followed by about one-third of the U.S. states: “A person is not responsible for criminal conduct if at the time of such conduct as a result of mental disease or defect he lacks substantial capacity either to appreciate the criminality (wrongfulness) of his conduct or to conform his conduct to the requirements of law” (p. 66).
their actions and punished for their crimes. Others point out significant problems in the implementation of insanity rules. For one thing, different experts often give conflicting, highly technical testimony about a defendant’s sanity at the time of a crime. (In the case mentioned at the beginning of this section, one expert said Cheryl was
sane; another concluded she was insane.) Jurors are then left in the diffi cult position of deciding which expert to believe and what to make of the experts’ diagnostic judg-
ments. Their task is complicated by the fact that people with mental disorders—even those as severe as schizophrenia—are still capable of some rational decision making and of controlling some aspects of their behavior (Grisso & Appelbaum, 1995; Matthews, 2004). Concern over such problems has led four U.S. states—Montana,
Idaho, Utah, and Kansas—to abolish the insanity defense. Other states have tried less extreme reforms. In thirteen states, it is possible for juries to find defendants guilty
but mentally ill. These defendants still serve a sentence, and although they are supposed to receive treatment while confined, they seldom do (Cassel & Bernstein, 2007).
A second reform already noted is that federal courts no longer use the irresistible impulse criterion in defining insanity. Third, federal courts and some state courts now
require defendants to prove that they were insane at the time of their crime, rather than requiring the prosecution to prove that the defendants were sane.
psychological disorders through talking
and other psychological methods.
Such as talking about problems and exploring new ways of thinking and acting. These methods are based on psychodynamic, humanistic, or social-cognitive (behavioral) theories of disorder and treatment. We then consider biological approaches to treatment, which
consist of prescription drugs and other physical therapies. (Many clients receive medication in addition to psychotherapy during the course of psychological treatment.
both) while living in the community. Compared with inpatients, outpatients tend to have fewer and less severe symptoms of disorder and to function better in social and
for the relief of psychological problems
or (usually) doctoral degree in clinical or counseling psychology and who may have received additional specialty training. Except in New Mexico and Louisiana, psychologists are not authorized to prescribe drugs, though this privilege may eventually be granted to spe-
cially trained psychologists elsewhere.
with particular clients or particular problems, they incorporate other methods as well
clients gain insight by recognizing and understanding unconscious thoughts and emotions. was aimed at understanding these unconscious conflicts and how they affect clients. Almost all forms of psychotherapy incorporate some of his ideas, including a one-to-one treatment approach; a search for relationships between current problems and events in a client’s past; an emphasis on the role of thoughts, emotions, and motivations; and a focus on the client-therapist
relationship. We will describe Freud’s original methods first and then consider treatments that are rooted in his psychodynamic approach. Freud’s psychoanalysis came to focus on an exploration of the unconscious and the conflicts raging within it.
to help troubled people gain insight into their problems by recognizing unconscious thoughts and emotions. Then they are encouraged to discover, or work through, the
many ways in which those unconscious elements continue to motivate maladaptive thinking and behavior in everyday life. The treatment may require as many as three to
five sessions per week, usually over several years. Generally, the psychoanalyst is compassionate but emotionally neutral as the patient slowly develops an understanding of how past conflicts influence current problems (Gabbard, 2004).
Freud believed that focusing on the transference allows patients to see how old conflicts haunt their lives and helps them resolve these conflicts.
conflicts, rather than waiting for free association or other more subtle methods to reveal these conflicts.Object relations therapists work to develop a nurturing relation-
ship with their clients, providing a “second chance” for them to receive the support that may have been lacking in infancy and to counteract some of the consequences of
maladaptive early attachment patterns
clients explore and overcome the problematic effects of interpersonal events that occur after early childhood—events such as the loss of a loved one, conflicts with a parent or a spouse, job loss, or social isolation
ceive their world. Disordered behavior, they say, reflects a blockage of natural growth]
brought on by distorted perceptions or lack of awareness of feelings. Accordingly,
humanistic therapy operates on the following assumptions:1. Treatment is an encounter between equals, not a “cure” given by an expert. It is
a way to help clients restart their natural growth and to feel and behave more in
line with that growth.
2. Clients will improve on their own, given the right conditions. These ideal
conditions promote clients’ awareness, acceptance, and emotional expression.
So, like psychodynamic therapy, humanistic therapy promotes insight, but it is
insight into current feelings and perceptions, not into unconscious childhood
3. Ideal conditions in therapy can best be established through a relationship in
which clients feel fully accepted and supported as human beings, no matter how
problematic or undesirable their behavior may be. It is the clients’ experience of
this relationship that brings beneficial changes. (Notice that this assumption is
shared with object relations therapy and some other forms of brief psychodynamic
4. Clients must remain responsible for choosing how they will think and behave.
Of the many humanistically oriented treatments in use today, the most influential are client-centered therapy, developed by Carl Rogers (1951), and Gestalt therapy,
developed by Frederick and Laura Perls.
talk about, without direction, judgment, or interpretation from the therapist. relies on the creation of a relationship that reflects three intertwined attitudes of the therapist:
unconditional positive regard, empathy, and congruence.
acceptance helps clients overcome the sense that their value as a person depends on being successful, intelligent, attractive, or meeting the other conditions of worth
described in the personality chapter. Acceptance is communicated through the therapist’s willingness to listen to the client without interrupting and without making judgments or expressing opinions. The therapist doesn’t have to approve of everything the client says but must accept each statement as reflecting the client’s view of the world.
to empathic reflection by elaborating on their feelings. In this example, the client went on to say, “It is scary, because I don’t like to feel in the dark about myself. I have
always prided myself on being in control.” Clients do this, said Rogers, simply because the therapist expresses the desire to listen and understand without asking disruptive
questions. Active listening tends to be so effective in promoting self-understanding and awareness that it is used across a wide range of therapies
For example, if they are confused by what a client has said, they would say so rather than trying to pretend that they always understand everything. When the therapist’s
acceptance and empathy are genuine, the client is able to see that relationships can be built on openness and honesty. Ideally, this experience will help the client become more congruent in other relationships.
with genuine feelings and disown foreign ones. Gestalt psychologists emphasized the idea that people actively organize their perceptions of the world.) As a result, he believed that people create their own versions of reality and that their natural psychological growth continues only as long as they accurately perceive, remain aware of, and act on their true feelings. Growth stops and symptoms appear, said Perls, when people are not aware of all aspects of themselves. seeks to create conditions in which clients can become more unified, self-aware, and self-
accepting—and thus ready to grow again. However, Gestalt therapists use more direct and dramatic methods than Rogerians do. Often working in group settings, Gestalt therapists prod clients to become aware of feelings and impulses that they have disowned and to discard feelings, ideas, and values that are not really their own. For example, the therapist or other group members might point out inconsistencies between what clients say and
how they behave. Gestalt therapists pay particular attention to clients’ gestures and other kinds of “body language” that appear to conflict with what the clients are saying (Kepner, 2001). They may also ask clients to engage in imaginary dialogues, or “conversations,”
with other people, with parts of their own personalities, and even with objects (Elliott, Watson, & Goldman, 2004a, 2004b). Like a shy person who can be socially outgoing only while masked at a costume party, clients often find that these dialogues help them get in touch with and express their feelings (Woldt & Toman, 2005).
kind of knowledge: namely, that most psychological problems are learned behaviors
and that they can be changed by taking action to learn new ones without first searching for hidden meanings or unconscious causes. _____ would offer just such an alternative by first identifying the signals, rewards and punishments, and other learning-based factors that maintain José’s anxiety and then helping him develop new responses in feared situations.these approaches emphasize the role of learning in the development of personality, as well as in most psychological disorders. Accordingly, behaviorists tend to see those disorders as examples of the maladaptive thoughts and actions that a client has learned. For instance, behavior therapists believe that fear of leaving home (agoraphobia) develops through classically conditioned associations between being away from home and having panic attacks. The problem is maintained in part through operant conditioning: Staying home and making excuses for doing so are rewarded by reduced anxiety. Therapists adopting a behavioral approach argue that if past learning experiences can create problems, then new learning experiences can help eliminate those problems. So even if the experiences that led to today’s problems began in the client’s childhood, behavior therapy seeks to solve those problems by creating beneficial new experiences using the principles discussed in the chapter on learning.Because ineffective procedures are soon altered or abandoned, behavioral treatment tends to be one of the briefest forms of therapy
1. Development of a productive therapist-client relationship. As in other therapies, this relationship enhances clients’ confidence that change is possible and makes it easier for them to speak openly and to cooperate in treatment (Creed & Kendall, 2005; Lejuez et al., 2005).
2. A careful listing of the behaviors and thoughts to be changed (Umbreit et al., 2006). This assessment—and the establishment of specific treatment goals—often replaces
the formal diagnosis used in some other therapy approaches. So instead of treating “depression” or “obsessive-compulsive disorder,” behavior therapists work to change the specific thoughts, behaviors, and emotional reactions that are associated with these diagnostic labels.
3. A therapist who acts as a teacher or mentor by providing learning-based treatments, giving “homework” assignments, and helping the client make specific plans for dealing with problems rather than just talking about them (Kazantzis et al, 2005).
4. Continuous monitoring and evaluation of treatment, along with constant adjustments to any procedures that are not working as expected (Farmer & Nelson-Gray, 2005).Because ineffective procedures that are not working as expected
This in vivo, or “real life,” form of desensitization therapy was once difficult to arrange or control, especially in cases involving fear of flying, heights, or highway driving, for example. However, virtual reality graded exposure now makes it possible for clients to “experience” extremely vivid and precisely graduated versions of feared situ-
ations without actually being exposed to them. In one early study, clients who feared heights wore a head-mounted virtual reality helmet that gave them the impression of standing on bridges of gradually increasing heights, on outdoor balconies at higher and higher floors, and in a glass elevator as it slowly rose forty-nine stories (Rothbaum et al., 1995). The same technology has been used successfully in the treatment of many other anxiety disorders, ranging from fear of spiders or air travel to social phobia and posttraumatic stress disorder (Traditionally, clinicians believed that change occurs because of basic learning processes—either through classical conditioning of a new, calmer response to the fear-provoking stimulus or through extinction, as the object or situation that had been a conditioned fear stimulus repeatedly occurs without being paired with pain or any other aversive unconditioned stimulusMore recent explanations emphasize that desensitization also modifies clients’ cognitive processes, including their expectation that they can deal calmly and successfully with
previously feared situations
in order to interact with others more comfortably and effectively. as been used to help children get along better with peers, to help social-phobic singles make conversation on dates, and to help rebuild mental
patients’ ability to interact normally in social situations
role playing of specific situations (Spence, 2003). For example, group assertiveness training has helped wheelchair-bound adults more comfortably handle the socially awkward situations in which they sometimes find themselves
behavior by saying the appropriate words. The children almost immediately began to utter the phrases themselves and were reinforced for doing so. The effects of positive
reinforcement generalized to other situations, and as indicated in Figure 16.2, the new skills were still evident at a follow-up session six months later
clients in which desirable behaviors are rewarded with tokens that can be exchanged for desired items or activities. systems in which desirable behaviors are positively reinforced with coin- like tokens or points that can be exchanged later for snacks, access to television, or other rewards (Kazdin, 2008; LePage et al., 2003; Matson & Boisjoli, 2009; Seegert, 2003). The goal is to shape behavior patterns that will persist outside the institution
Just as reinforcing desirable behaviors can make them more likely to occur, failing to reinforce undesirable behaviors can make them less likely to occur, a process known as extinction. Treatment methods that use extinction change behavior slowly but offer a valuable way of reducing inappropriate behavior in children and
adolescents and in intellectually disabled or seriously disturbed adults. For example, a client who gets attention by disrupting a classroom, damaging property, or violating
hospital rules might be placed in a quiet, boring “time-out” room for a few minutes to eliminate reinforcement for misbehavior
Extinction is also the basis of ?ooding, an anxiety reduction treatment in which clients are kept in a feared but harmless situation and are not permitted to use their
normally rewarding escape strategies (O’Donohue, Hayes, ; Fisher, 2003). The clients are flooded with fear at first, but after an extended period of exposure to the feared
stimulus (a frog, say) without experiencing pain, injury, or any other dreaded result, the association between the feared stimulus and the fear response gradually weakens, and the conditioned fear response is extinguished
presence of strong anxiety-provoking stimuli until the intensity of their emotional reactions decrease.
Because they continuously expose clients to feared stimuli, flooding and other similar methods are also known as exposure therapy. Although often highly effective, these methods do cause considerable distress, much like immediately exposing a fearful client to the most diffi cult item on a desensitization hierarchy. Therefore, some
therapists prefer more gradual exposure therapy methods, especially when treating fear that is not focused on a specific stimulus (Berry, Rosenfield, ; Smits, 2009). In
dealing with agoraphobia, for instance, the therapist might provide gradual exposure by escorting the client away from home for increasingly lengthy periods and eventually
venturing into shopping malls and other previously avoided places (Barlow, Raffa, ; Cohen, 2002; Craske et al., 2003). Clients can also practice gradual exposure methods on their own. They might be instructed, for example, to spend a little more time each day looking at photos of some feared animal or to spend some time alone in a dental chair or a dentist’s waiting room. In one study, clients suffering from various phobias made as much progress after six hours of instruction in gradual self-exposure methods and daily “homework” exercises as those who received an additional nine hours of therapist-aided gradual exposure (Al-Kubaisy et al., 1992). Effective self-treatment using gradual exposure has also been reported in cases of panic disorder (Lamplugh et al., 2008), social phobia
negative response to a particular stimulus.
Some unwanted behaviors—such as excessive gambling,
addictive drug use, or sexual exhibitionism—become so habitual and immediately rewarding that they must be made less attractive if a client is to have any hope of
giving them up. Methods for reducing the appeal of certain stimuli are known as aversion therapy. The name reflects the fact that these methods rely on a classical con-
ditioning principle called aversion conditioning to associate nausea, painful electrical shock, or some other unpleasant stimulus with undesirable actions, thoughts, or
situations (Because aversion therapy is unpleasant and uncomfortable, because it may not work with all clients (Flor et al., 2002), and because its effects are often temporary, behavior therapists use this method relatively rarely, only when it is the best treatment choice, and only long enough to allow the client to learn more appropriate alternative behaviors.
undesirable behavior by following it with an unpleasant stimulus.Sometimes the only way to eliminate a dangerous or disruptive behavior is to punish it with an unpleasant but harmless stimulus, such as a shouted “No!” or a mild electrical shock. Unlike aversion conditioning, in which the unpleasant stimulus occurs along with the behavior that is to be eliminated (a classical conditioning approach), punishment is an operant conditioning technique; it presents the unpleasant stimulus after the undesirable response occurs. The use of punishment can be appropriate and beneficial in working with certain
institutionalized clients, impaired outpatients, and some children, but before using it, behavior therapists must consider several ethical and legal questions: Would the cli-
ent’s life be in danger without treatment? Have all other methods failed? Has an ethics ommittee reviewed and approved the procedures? And has the client or a close relative formally agreed to the treatment? (Kazdin, 2008). When the answer to these questions is yes, punishment can be an effective and sometimes lifesaving treatment, as in the case illustrated in Figure 6.11 in the chapter on learning. But as with extinction and aversion conditioning, punishment works best when it is used only long enough to eliminate undesirable behavior and is combined with other behavioral methods designed to reinforce more appropriate behavior
becomes easier and more rewarding for clients to let these new thoughts guide their behavior (Beck, 2005
and change self-defeating thoughts that
lead to anxiety and other symptoms of
disorder.One prominent form of cognitive behavior
therapy is rational-emotive behavior therapy (REBT). Developed by Albert Ellis (1962, 1993, 2004a, 2004b; Ellis ; MacLaren, 2005), REBT is based on the notion that
anxiety, guilt, depression, and other psychological problems are caused by how people think about events, not by the events themselves. Ellis’s therapy aims first at identifying self-defeating beliefs, usually in the form of shoulds or musts, such as “I should be loved or approved by everyone” or “I must be perfect in order to be worthwhile.” After the client learns to recognize thoughts like these and to see how they can cause problems, the therapist uses modeling, encouragement, and logic to help the client replace maladaptive thoughts with more realistic ones. The client is then given “homework” assignments to try out these new ways of thinking in everyday situations. Here is part of an REBT session with a woman who suffered from panic attacks (Masters et al., 1987). She has just said that it would be “terrible” if she had an attack in a restaurant and that people “should be able to handle themselves!”
upsetting thoughts with alternative thinking patterns are called
______, in which clients imagine being in a stressful situation and then practice newly learned cognitive skills to remain calm (Meichenbaum, 2003). In one study of stress inoculation training, first-year law students tried out their calming new thoughts during role-playing exercises that simulated stressful classroom ques-
tioning, hostile feedback, and a competitive learning atmosphere. Following training, these students showed reductions in troublesome responses to stressors as well as improved academic performance
and change negative thoughts associated with anxiety and depression. Beck’s treatment approach is based on the idea that certain psychological problems—especially those involving depression and anxiety, as well as some personality disorders—can be traced to errors in logic, or what he calls cognitive distortions (Beck, Freeman, ; Davis, 2007; Beck et al., 2008). Common cognitive distortions include catastrophizing (e.g., “If I fail my driver’s test the first time, I’ll never pass it, and that’ll be the end of my social life”), all-or-none thinking (e.g., “Everyone
ignores me”), and personalization (e.g., “I know those people are laughing at me”). Beck points out that these learned cognitive distortions occur so quickly and automatically that the client never stops to consider that they might not be trueCognitive therapy is an active, structured, problem-solving approach in which the therapist first helps clients identify the errors in logic, false beliefs, and other cognitive distortions that precede anxiety, depression, conduct problems, eating disorders, and other psychological diffi culties (Beck ; Rector, 2005; Drinkwater ; Stewart, 2002; Fairburn, 2008; Hendricks ; Thompson, 2005; Pardini ; Lochman, 2003). Then, much as in the five-step critical thinking system illustrated throughout this book, those thoughts and beliefs are treated as hypotheses to be scientifically tested rather than as assertions to be accepted uncriticallyAccordingly, therapist and client take the role of “investigators” who develop ways to test beliefs such as “I’m no good around the house.” They might decide on tasks that the client will attempt as “homework”—such as cleaning out the basement, cooking a meal, paying bills, or cutting the grass. Success at accomplishing even one of these tasks provides concrete evidence to challenge a false belief that has supported depression, thus helping reduce it. As therapy progresses, clients become more skilled at recognizing and then correcting the cognitive distortions related to their problems.
So cognitive behavior therapists also work with clients to develop more optimistic ways of thinking and to reduce their tendency to blame themselves for negative out-
comes (Persons, Davidson, ; Tompkins, 2001). In some cases, cognitive restructuring is combined with social skills training, practice at using logical thinking, and anxiety
management techniques, all of which are designed to help clients experience success and develop confidence in situations in which they had previously expected to fail
(Bryant et al., 2008). Some cognitive therapists have also encouraged clients to use traditional Eastern
practices such as meditation (see the chapter on consciousness) to help monitor problematic thoughts. This combined approach is called mindfulness-based cognitive
therapy (Hofmann et al., 2010; Ma ; Teasdale, 2004). Research in the field of positive psychology suggests, too, that the effects of cognitive behavior therapy may be
enhanced through exercises deigned to promote positive emotions—such as identifying and using personal strengths and making a list of things that have gone well each day
ance of a therapist who encourages helpful interactions among group members. Many groups are organized around a particular problem (such as alcoholism) or a particular type of client (such as adolescents). In most cases, six to twelve clients meet with their therapist at least once a week for about two hours. All group members agree to hold confidential everything that occurs during these sessions. Group therapy offers several features not found in individual treatment1. group therapy allows the therapist to see clients interacting with one another, which can be helpful in iden-
tifying problems in clients’ interpersonal styles.2. clients discover that they are not alone as they listen to others and realize that many people struggle with difficulties similar to theirs. This realization tends to raise each client’s expectations for improvement, a factor important in all forms of treatment.
3. group members can boost one another’s self-confidence and self-acceptance as they come to trust and
value one another.
4. clients learn from one another by sharing ideas for solving problems and giving one another honest feedback about how each member “comes across” to others.
5.perhaps through mutual modeling, the group experience
makes clients more willing to share their feelings and more sensitive to other people’s
needs and messages.
6. group therapy allows clients to try out new skills—such
as assertiveness—in a safe and supportive environment.
Some of the advantages of group therapy are also applied in self-help organizations. Self-help groups, such as Alcoholics Anonymous (AA), are made up of people
who share a problematic experience and meet to help one another. There are self-help groups for a wide range of problems, including alcohol and drug addiction, childhood
sexual abuse, cancer, overeating, overspending, bereavement, compulsive gambling, and schizophrenia (Humphreys, 2004; Kurtz, 2004). These self-help organizations operate through hundreds of thousands of local chapters, enrolling ten to fifteen million participants in the United States and about half a million in Canada (Harwood ; L’Abate, 2010; Norcross et al., 2000). Many other participants in self-help groups meet solely on the Internet
Lack of reliable data makes it diffi cult to assess the value of many self-help groups, but available information suggests that active members may experience moderate
improvement in their lives (Carlbring & Smit, 2008; Kaskutas, Bond, & Avalos, 2009; Kelly, 2003; Mains & Scogin, 2003; Masudomi et al., 2004). Some professional therapists view these groups with suspicion; others encourage clients to participate in them as part of their treatment or as a first step toward more formal treatment (Haaga, 2000; Norcross, 2006), especially in cases of eating disorders, alcoholism, and other substance-related problems
from the same family system, one of whom—often a troubled child or adolescent—is the initially identified client. The term family system highlights the idea that the problems displayed by one family member usually reflect problems in the functioning of the entire family. Whether family therapy is based on psychodynamic, humanistic, or cognitive behavioral approaches, the family itself becomes the client, and treatment involves as many members as possible (Novick & Novick, 2005). In fact, the goal of family therapy is not just to ease the identified client’s problems but also to create greater harmony and balance within the family by helping each member understand the family’s interaction patterns (Blow & Timm, 2002). As with group therapy, the family format gives the therapist a chance to see how the initially identified client interacts with others, thus providing a basis for discussing topics that are important in the operation of the family system.Behavior therapists often use family therapy sessions as meetings at which family members can discuss and agree on behavioral “contracts” (e.g., Hayes et al., 2000). Based on operant conditioning principles, these contracts establish rules and reinforcement contingencies that help parents encourage their children’s desirable behaviors (while discouraging undesirable ones) and help spouses become more supportive of each other
between partners. Discussions in couples therapy sessions are usually aimed at identifying the miscommunication or lack of communication that interferes with a couple’s
happiness and intimacy. In behavioral marital therapy, for example, couples learn to abide by certain “rules for talking,” such as those listed in Table 16.3. Another version of couples therapy focuses on strengthening the bond between partners by teaching them how to deal with their unsolvable problems and recover from their fights by expressing at least five times as many positive statements as negative ones (Gottman, Driver, & Tabares, 2002). Some therapists help couples become closer by encouraging them to express their emotions more honestly and be more accepting of one another (Shadish & Baldwin, 2005; Wood et al., 2005). Some therapists even offer programs designed to prevent marital problems in couples whose interactions suggest that they are at high risk for developing discord (Gottman, Gottman, & Declaire, 2006; Jacobson et al., 2000; Laurenceau et al., 2004). “In Review: Approaches to Psychological Treatment” summarizes key features of the main approaches to treatment that we have discussed so far.
1. Nature of the human being- Driven by sexual and
2.Therapists role-Neutral; helps client explore meaning of
free associations and other material from the unconscious
3. Focus-Emphasizes unresolved unconscious conflicts from the distant past
4. Goal-Psychosexual maturity through insight;
strengthening of ego functions
5. Typical Methods- Free association; dream
analysis; analysis of transferenceContemporary Psychodynamic
1. Nature of the human being- Driven by the need for
2.Therapists role- Active; develops relationship with client
as a model for other relationships
3. Focus-Understanding the past, but focusing on current
4. Goal-Correction of effects of failures of early attachment; development of satisfying intimate relationships
5. Typical Methods-Analysis of interpersonal relationships, including the client-therapist relationshipHumanistic
1. Nature of the human being- Has free will, choice, and
capacity for self-actualization
2.Therapists role- Facilitates client’s growth; some therapists are active, some are non directive
3. Focus-Here and now; focus on immediate experience
4. Goal-Expanded awareness; fulfillment of potential;
5. Typical Methods-Reflection-oriented interviews
designed to convey unconditional positive regard,
empathy, and congruence; exercises to promote
1. Nature of the human being- Is a product of social learning and conditioning; behaves on the basis of past experience
2.Therapists role-Teacher or mentor who helps
client replace undesirable thoughts and behaviors; active,
3. Focus-Current behavior and thoughts; may not need to know original causes to create change
4. Goal-Changes in thinking and behaving in particular classes of situations; better self-management
5. Typical Methods-Systematic desensitization, social skills training, positive reinforcement, extinction, aversion therapy, punishment, and cognitive restructuring
the support of the therapist, the hope and expectancy for improvement that therapy creates, and the trust that develops between client and therapist
method works in the same way or that every psychotherapy experience will be equally beneficial. Clients entering therapy must realize that the success of their treatment can still be affected by the severity of their problems, the quality of the relationship they form with the therapist, and the appropriateness of the therapy methods chosen for their problems
clients now feel and act more like people without an anxiety disorder (see Figure 16.4). The need to demonstrate the clinical significance of treatment effects has become clearer than ever as increasingly cost-conscious clients—and their health insurance providers—
decide whether, and how much, to pay for various psychotherapy services (Levant, 2005; Makeover, 2004; Nelson & Steele, 2006). The most scientific way to evaluate treatment effects is through experiments in which clients are randomly assigned to various treatments or control conditions and their progress is measured objectively over tim
These circumstances include those in which
(1) a client is so severely disturbed or suicidal that hospitalization is needed
(2) a client uses his or her mental condition
and history of therapy as part of his or her defense in a civil or criminal trial,
(3) the therapist must defend against a client’s charge of malpractice,
(4) a client reveals information about sexual or physical abuse of a child under 18, and
(5) the therapist believes a client may commit a violent act against a specific person.
administered mainly to patients suffering severe depression (and occasionally to manic patients) who do not respond to prescription drugsNo one knows for sure how and why EST works (Greenberg ; Kellner, 2005; Shorter ; Healy, 2007), but the fact that it helps some patients has led EST researchers to seek even
safer methods of inducing seizures. Among the techniques being investigated are magnetic seizure therapy (MST), which induces seizures with timed pulses of magnetic energy (Lisanby, 2004), and a related but less intense procedure called repetitive transcranial magnetic stimulation (rTMS) (Couturier, 2005; Schutter, 2005). Deep brain stimulation (DBS) does not cause seizures but requires the placement of electrodes in the brain to provide continuous pulses of electricity to a particular target area. Some researchers suggest that these treatments may be of value in severe cases of depression and obsessive-compulsive disorder that are unresponsive to other treatments (George et al., 2010; Goodman et al.,
2010; Hardesty ; Sackeim, 2007; Martiny, Lunde, ; Bech, 2010).
Today, the most popular medications for depression are those that affect the neurotransmitter serotonin. This delayed response seems odd because antidepressants have almost immediate effects on neurotransmitters, usually increasing the availability of serotonin or norepinephrine in the brain.
cause nausea, vomiting, tremor, fatigue, slurred speech, and, if the overdose is severe, coma or death (Johnson, 2002). Further, lithium is not useful for treating a manic episode in progress because, as in the case of antidepressant drugs, it takes a week or two of regular use before its effects are seen. So as with the antidepressants, the effects of lithium probably occur through some form of long-term adaptation as the nervous system adjusts to the presence of the drug. Combining lithium with other mood-stabilizing drugs, such as carbamazepine, has shown enhanced benefits but also more adverse side effects
disorder and posttraumatic stress disorder.
1.Typical Disorders Treated-Severe depression
2. Possible Side Effects-Temporary confusion, memory loss
3. Mechanism of Action-UncertainPsychosurgery
1. Typical Disorders Treated- Schizophrenia, severe depression, obsessive-compulsive disorder
2. Possible Side Effects-Listlessness, overemotionality, epilepsy
3. Mechanism of Action-UncertainPsychoactive drugs
1. Typical Disorders Treated- Anxiety disorders, depression, obsessive-compulsive disorder, mania, schizophrenia
2. Possible Side Effects- Variable, depending on drug used: movement disorders, physical dependence
3. Mechanism of Action- Alteration of neurotransmitter systems in the brain