22 Assessment & Anxiety Disorders

A. Factors in Mental Disorders
B. Assessing Mental Disorders
C. Diagnosing Mental Disorders
D. Anxiety Disorders
E. Somatoform Disorders
Concept Review
F. Cultural Diversity: An Asian Disorder
G. Research Focus: School Shootings
H. Application: Treating Phobias
Summary Test
Critical Thinking
Why Women Marry Killers behind Bars
Links to Learning
PowerStudy 4.5™
Complete Module
Photo Credit: © Pierre Perrin/Corbis Sygma
& Anxiety
Photo Credits: left, © Jeff Tuttle/AFP/Getty Images; right, © Elizabeth Roll
Mental Disorder
He was a loving husband, devoted father,
How did a
respected church elder, and straitlaced county
official. He also worked for a home security
serial killer go
company, where he would help individuals
protect themselves from dangerous people.
Until the day he was caught, he blended into the Wichita community
as an average next-door neighbor. But over a period of 17 years, Dennis Rader planned and carried out the cruel murders of 10 people. He
became known as the “BTK killer,” which stands for Bind, Torture,
and Kill, describing the methods he used with his victims.
In a very real sense, Rader led two different lives. In public, Rader
seemed like a quiet, law-abiding guy who helped to protect the safety
of others. However, in private, Rader would break into people’s homes,
hide, and then sneak up on his victims. He would proceed to tie them
up, callously strangle them, and eventually murder them.
Although no two serial killers are alike, Rader fits the typical pattern. Serial killers usually look like ordinary people, often with families
and good jobs. Many serial killers have experienced
a traumatic childhood event and have serious
personality defects, such as low self-esteem and
a lifelong sense of loneliness. They are obsessed
with control, manipulation, and dominance and
often con their victims into agreeing to their
requests. Most serial killers enjoy not the
actual killing, but the ruthless torturing of
their victims. This explains why serial killers feel special when their victims suffer
and plead for help, and why Rader became
sexually aroused as he strangled each of
Dennis Rader, who
his victims (Hickey, 2006; Mann, 2005).
murdered 10 people, fits
When Rader’s trial began, his defense
the pattern of serial killers.
attorneys had to decide whether they
wanted to claim he was legally insane when he committed the murders. You are probably thinking that a person who coldheartedly plans
and carries out 10 violent murders must certainly be insane, but let’s
consider what it means to be insane.
Insanity, according to its legal definition, means not knowing the difference
between right and wrong.
As inhumane as Rader’s behaviors may seem, his defense did not
claim he was insane. Based on Rader’s testimony, it was clear he
knew all along that his actions were wrong and conducted for his
own selfish interests. In 2005, thirty-one years after the first BTK
attacks, Rader was charged with 10 counts of first-degree murder for
which he must serve 10 life sentences (Davey, 2005; O’Driscoll, 2005;
Wilgoren, 2005).
When mental health professionals examine Rader’s behaviors, they
are trying to identify his particular mental disorder.
A mental disorder is generally defined as a prolonged or recurring problem
that seriously interferes with an individual’s ability to live a satisfying personal
life and function adequately in society.
Deciding whether a person has a mental disorder can be difficult
because so many factors are involved in defining what is abnormal.
As you’ll learn in this module, someone’s behavior may be described
as abnormal but the person may or may not have a mental disorder.
There is no doubt that Dennis Rader’s
murder and mutilation of 10 individuals
indicate extremely abnormal behavior
and a severe mental disorder (Hickey,
2006). In other cases, mental disorders
may involve a relatively common behavior or event that,
through some learning, observation, or other process, has the
power to elicit tremendous anxiety and becomes a phobia
(Rowa et al., 2006).
so scary
about flying?
A phobia (FOE-bee-ah) is an anxiety disorder characterized by an
intense, excessive, and irrational fear that is out of all proportion to
the danger elicited by the object or situation.
Kate Premo’s phobia of
f lying began in her childhood, when she experienced
a turbulent flight that left her
scared and anxious. Later,
as a young adult, her fear
of f lying was worsened by
memories of the 1988 terrorist bombing of Pan Am flight
103, which killed several of
her fellow students from Syracuse University. After that
incident, her phobia of flying
kept her from visiting friends
and family. She would try to
f ly and even make reservaKate Premo is trying to
overcome her phobia of flying.
tions but always cancel them
at the last minute.
An estimated 9% of American adults have a similar irrational and intense fear of flying, which is called aviophobia;
they refuse to get on a plane. Another 27% of American adults
report being at least somewhat afraid to fly (USA Today/CNN/
Gallup, 2006). To treat her phobia, Kate Premo (photo above)
took part in a weekend seminar that included actually flying in
a plane. We’ll tell you about Kate’s phobia and treatment later
in this module.
These two examples of Dennis Rader and Kate Premo raise
a number of questions about mental disorders: How do they
develop? How are they diagnosed? How are they treated? We’ll
answer these three questions as we discuss mental disorders.
What’s Coming
In this module, we’ll discuss three approaches to understanding mental disorders. We’ll explain how mental disorders are
assessed and diagnosed and go into some specific examples of
mental disorders, such as generalized anxiety, phobias,
obsessive-compulsive behaviors, and somatoform disorders.
Finally, we’ll discuss how common phobias, such as fear of
flying, are treated.
We’ll begin with the different factors that are involved in
defining, explaining, and treating mental disorders, such as
that of Dennis Rader.
A. Factors in Mental Disorders
Causes of Abnormal Behavior
girls and God-fearing adults (L. Shapiro, 1992). In the 1960s,
one major cause of mental disorders was thought to be environmental factors, such as stressful events. In the 1990s came
advances in studying genetic factors as well as new methods
to study the structures and functions of living brains (p. 70).
As a result, current researchers and clinicians believe that
mental disorders, such as that of Dennis Rader, result from a
number of factors, which include biological, cognitive-emotionalbehavioral, and environmental influences (Hersen & Thomas, 2006).
Biological Factors
Cognitive-Emotional-Behavioral & Environmental Factors
Biological influences include genetic or inherited factors and various neurological factors that influence how the brain functions.
Genetic factors. As an infant, Joan would cry, show great
fear, and try to avoid new or novel objects or situations. Because
Joan showed great fear as an infant, researchers concluded that her
fearfulness was primarily due to genetic factors (Kagan, 2003a).
Because biological factors themselves do not always explain why
people develop mental disorders, psychologists point to various
cognitive-emotional-behavioral factors that interact with and contribute to developing mental disorders.
Genetic factors that contribute to the development of mental disorders are unlearned or inherited tendencies that influence how a person
thinks, behaves, and feels.
Genetic factors operate by affecting the developing brain and/
or the neurotransmitters that the brain uses for communication.
Researchers estimate that genetic factors contribute from 30% to
60% to the development of mental disorders, such as depression,
schizophrenia, and anxiety disorders (Rutter & Silberg, 2002).
Neurological factors. Joan, who had started life as a fearful
infant, had developed a serious mental disorder called a social
phobia (p. 518) by the time she was 20. Researchers believed that
one reason she developed a social phobia was that her brain’s emotional detector, called the amygdala (p. 362), was overactive and
too often identified stimuli as threatening
when they were only new or novel. In
fact, when researchers measured the
activity (fMRI) of Joan’s amygdala,
they found that her amygdala overreacted when she looked at new or novel
faces, something that did not happen
the amygdalas of individuals who did
not have social phobias (C. E. Schwartz et
al., 2003). In a related study, individuals
Very fearful adults
who had developed social phobias, like
had more activity in
Joan, showed far more amygdala activity
the amygdala.
when looking at angry, fearful, or disgusted
faces than did individuals without social phobias (Luan et al.,
2006). The studies illustrate neurological factors, such as having
an overactive brain structure that contributes to the development
of a mental disorder by causing a person to see the world in a
biased or distorted way and to see threats when none really exist.
Although these studies show that biological factors—genetic
and neurological—can contribute to the development of mental
disorders, not everyone with an overactive amygdala develops a
mental disorder. This means that other factors are also involved
in the development of mental disorders.
Cognitive-emotional-behavioral and
environmental factors that contribute to the
development of mental disorders include
deficits in cognitive processes, such as having unusual thoughts and beliefs; deficits in
processing emotional stimuli, such as underor overreacting to emotional situations;
behavioral problems, such as lacking social
skills; and environmental challenges, such
Unusual thoughts, emotions,
as dealing with stressful situations.
behaviors, or events contribute
For example, Dennis Rader was to
developing mental disorders.
a shy and polite child who preferred
to spend time alone. As a boy, he recalls watching his grandparents
strangle chickens at their farm, and by the time he reached high
school, he was strangling cats and dogs. Rader’s hobby during childhood was looking at pictures of women in bondage. By his teens, he
fantasized about tying up, controlling, and torturing women. He was
becoming increasingly bothered by murderous impulses but did not
know how to tell anyone about it (Ortiz, 2005; Singular, 2006). Rader’s
many maladaptive thoughts, emotions, and behaviors interacted with
his biological factors and resulted in his serious mental disorder.
Environmental factors. In some cases, traumatic events, such as
being in a war, having a serious car accident, watching some horrible event (a dog attacking and killing a child), or being brutally
mugged, assaulted, or raped, can result in a long-lasting emotional
disorder called posttraumatic stress disorder, or PTSD. As we discussed earlier (p. 491), a person with PTSD may relive the terrible
event through memories and nightmares and have serious emotional
problems that often require professional help (Resick et al., 2008).
Experiencing PTSD is an example of how traumatic environmental
factors can contribute to developing a serious mental disorder.
Many factors. The answer to why Joan developed a social phobia, or Dennis Rader became a serial killer, or a family member,
friend, or relative developed a mental disorder involves a number
of factors—genetic, neurological, cognitive-emotional-behavioral,
and environmental. As several or more of these factors interact, the
result in some cases can be the development of one of the mental
disorders that we’ll discuss in this and the next module.
Photo Credit: right, © Colin Anderson/Brand X/Corbis
Explanations for the causes of mental disorders have
changed dramatically through the centuries. In the Middle Ages, mental disorders were thought to be the result
of demons or devils who inhabited individuals and made
them do strange and horrible things. In the 1600s, mental disorders were thought to involve witches, who were
believed to speak to the devil. This was the case in Salem,
Massachusetts, in 1692, where, in a short span of four months, 14
women and 5 men were hanged as witches on the testimony of young
Definitions of Abnormal Behavior
In some cases, such as Dennis Rader’s murder and mutilation of 10 individuals, we
have no doubt that he demonstrated an extremely abnormal behavior pattern. In
other cases, such as Kate Premo’s phobia of flying, we would probably say that most
of her life appears to be normal except for a small piece—fear of flying in airplanes—that is abnormal. In still other cases, such as that of 54-year-old Richard
Thompson (right photo), it is less clear what is abnormal behavior.
The City of San Diego evicted Thompson and all his belongings from his home. His belongings
included shirts, pants, dozens of shoes, several Bibles, a cooler, a tool chest, lawn chairs, a barbecue grill,
tin plates, bird cages, two pet rats, and his self-fashioned bed. For the previous nine months, Thompson
had lived happily and without any problems in a downtown storm drain (sewer). Because the city does
not allow people to live in storm drains, however, Thompson was evicted from his underground stormdrain home and forbidden to return. Although Thompson later lived in several care centers and mental
hospitals, he much preferred the privacy and comfort of the sewer (Grimaldi, 1986).
There are three different ways to decide whether Richard Thompson’s behavior—living in the
sewer—was abnormal.
Photo Credits: top and bottom center, © San Diego Union Tribune/ZUMA Press; bottom left, © PhotoDisc, Inc.; bottom right, © Kelly Redinger/Design Pics/Corbis
Is Mr.
Is it abnormal to live in a storm
drain if you don’t bother anyone?
Statistical Frequency
Deviation from Social Norms
Maladaptive Behavior
Although Thompson caused no problems
to others except to violate a city law against
living in a storm drain, his preferred living style could be considered abnormal
according to statistical frequency.
Thompson’s behavior—preferring to
live in a sewer—could also be considered abnormal based on social norms.
The major problem with the first two definitions
of abnormal behavior—statistical frequency and
deviation from social norms—is that they don’t
say whether a particular behavior is psychologically damaging or maladaptive.
The statistical frequency approach says
that a behavior may be considered
abnormal if it occurs rarely or
infrequently in relation to the
behaviors of the general
By this definition,
Thompson’s living in a
storm drain would be
According to
considered very abnorstatistical
mal since, out of over
living in a
300 million people in
monastery is
the United States, only
a very few prefer his
kind of home. This illustrates that even
though statistical frequency is a relatively precise measure, it is not a very useful
measure of abnormality. By this criterion,
getting a Ph.D., being president, living in
a monastery, and selling a million records
are abnormal, although some of these behaviors would be considered very desirable by most people. In fact, Guinness
World Records (2009) lists thousands of
people who have performed some statistically abnormal behaviors and are very
proud of them. We would not consider
any of these individuals to necessarily
have mental disorders.
As all these examples demonstrate, the
statistical frequency definition of abnormality has very limited usefulness.
The social norms approach says that
a behavior is considered abnormal if it
deviates greatly from accepted social
standards, values, or norms.
Thompson’s decision to live by
himself in a storm drain greatly deviates from society’s norms about
where people should live. However, a
definition of abnormality based solely
on deviations from social norms runs
into problems when social norms
change with time. For
exa mple, 25 years
ago, very few males
wore earrings, while
today many males
consider earrings
ver y f a s h ionable. Similarly,
40 years ago, a
woman who preAccording to
ferred to be very
social norms,
thin was considliving in a storm
ered to be ill and
drain is abnormal.
in need of medical help. Today, our society pressures
women to be thin like the fashion
models in the media.
Thus, defining abnormality on the
basis of social norms can be risky, as
social norms may, and do, change
over time. The definition of abnormality most used by mental health
professionals is the next one.
The maladaptive behavior approach defines a
behavior as psychologically damaging or abnormal if it
interferes with the individual’s ability to function in his
or her personal life or in society.
For example, being terrified of flying, hearing voices that dictate dangerous acts, feeling
compelled to wash one’s hands for hours on end,
starving oneself to the point of death (anorexia
nervosa), and Dennis Rader’s committing serial
murders would all be considered maladaptive
and, in that sense, abnormal.
However, Thompson’s seemingly successful
adaptation to living in a sewer may not be maladaptive for him and certainly has no adverse
consequences to society.
Most useful. Of the three definitions discussed here, menta l
hea lt h professiona ls
find that the most useful definition of abnormal behaviors is the one
based on the maladaptive definition—that is,
whether a behavior or
behavior pattern interferes with a person’s
According to the
ability to function normaladaptive definition,
behavior is abnormal
mally in society (Sue et
if it interferes with a
al., 2010).
person’s functioning.
However, you’ll see
that deciding whether behavior is truly maladaptive is not always so easy.
B. Assessing Mental Disorders
Definition of Assessment
In some cases, it’s relatively easy to identify
her car by the edge of the lake, strapped her two children into their
what’s wrong with a person. For example,
car seats, shut the windows and doors, got out of the car, walked to
it’s clear that Dennis Rader was a serial
the rear, and pushed the car into the lake. She covered her ears so
killer and that Kate Premo has an intense she couldn’t hear the splash. The car disappeared under the water.
and irrational fear of flying. But in other The two little boys, strapped into their seats, drowned.
cases, it’s more difficult to identify exactly what the
Susan’s confession stunned the nation as everyone asked,
person’s motivation and mental problem are. Take
“How could she have killed her own children?” “What’s
the tragic case of Susan Smith.
wrong with Susan?” To answer these questions, mental health
Susan Smith appeared on the “Today” show,
professionals evaluated Susan’s mental health with a procecrying for the return of her two little boys (right
dure called the clinical assessment (J. M. Wood et al., 2002).
photo), Michael, 3 years old, and Alex, 14 months
A clinical assessment involves a systematic evaluation of an
Susan first said her
individual’s various psychological, biological, and social factors, as
old, who, she said, had been kidnapped. She begged
sons were kidnapped
well as identifying past and present problems, stressors, and other
the kidnapper to feed them, care for them, and
but later confessed that
please, please, return them. And then, nine days she had drowned them. cognitive or behavioral symptoms.
later, after a rigorous investigation turned up doubts
A clinical assessment is the first step in figuring out
about the kidnapping story, the police questioned Susan again. Not
which past or current problems may have contributed to Susan
only did she change her story, but she made the teary confession
killing her own children (Begley, 1998b). We’ll discuss how a
that she had killed her two children. She said that she had parked
clinical assessment is done.
How do
you find out
what’s wrong?
Three Methods of Assessment
After Susan’s arrest, mental health professionals did clinical assessments to try to discover what terrible forces
pushed her over the edge. Depending on their training, mental health professionals use one or more of three
major techniques—neurological exams, clinical interviews, and psychological tests—to do clinical
Neurological Tests
Clinical Interviews
Psychological Tests
We can assume that Susan was
given a number of neurological
tests to check for possible brain
damage or malfunction. These
tests might include evaluating
reflexes, brain structures (MRI
scans), and brain functions
(fMRI scans—p. 70).
Neurological exams are part
of a clinical assessment because
a variety of abnormal psychological symptoms may
be caused
by tumors,
diseases, or
infections of the
Susan have
tests are used to
distinguish physical or organic
causes (tumors) from psychological ones (strange beliefs)
(Zillmer et al., 2008). Susan was
reported to have no neurological
As part of her clinical assessment, several psychiatrists
spent many hours interviewing Susan. This method is
called a clinical interview (Hersen & Thomas, 2007).
As part of her assessment, psychologists may have given Susan a number
of personality tests (pp. 450, 474).
During the clinical interview,
Susan would have been asked about
the history of her current problems,
such as when they started and what
What are
other events accompanied them. The
Susan’s past
focus of the interview would have
and current
been on Susan’s current problem,
killing her children, especially on the
details of the symptoms that led up to
the killing. The clinical interview is perhaps the primary
technique used to assess abnormal behavior (Durand &
Barlow, 2006).
Based on 15 hours of interviews, Dr. Seymour Halleck
testified that Susan was scarred by her father’s suicide
and her stepfather sexually abusing her, which led to
periods of depression, her current problem (Towle, 1995).
As we also discussed in Modules
19 and 20, personality tests help
clinicians evaluate a person’s traits,
attitudes, emotions, and beliefs.
Purpose. A major goal of doing
a clinical assessment is to decide
which mental health disorder best
accounts for a client’s symptoms.
For example, based on her symptoms,
Susan was described as having a
mood disorder, which you’ll see
next is one of many possible mental
health problems.
The clinical interview is one method of gathering information about a person’s past and current behaviors, beliefs, attitudes, emotions, and problems. Some clinical interviews are
unstructured, which means they have no set
questions; others are structured, which
means they follow a standard format of
asking a similar set of questions.
Personality tests include two different
kinds of tests: objective tests (self-report
questionnaires), such as the MMPI, which
consist of specific statements or questions to which the person responds with
specific answers, and projective tests,
such as the Rorschach inkblot test, which
have no set answers but consist of ambiguous stimuli that a person interprets or
makes up a story about.
Photo Credits: top, © Time & Life Pictures/Getty Images; bottom center, © AP Images/Tim Kimzey
How was
Susan evaluated?
C. Diagnosing Mental Disorders
Real-Life Assessment
What can a
clinical assessment
tell us?
In criminal trials that involve questions of mental health, the defense and prosecution usually hire their own
psychiatrists or psychologists because they are looking for different problems or symptoms. In Susan’s case,
at least two psychiatrists did clinical assessments to answer a number of questions: What are her current
symptoms? What past events and situations caused these symptoms? What role did her symptoms play in the
killing of her children?
Her Past
Her Present
During clinical interviews, the psychiatrist
The psychiatrist found that Susan’s present problems included
found that when Susan was 8 years old, her
becoming depressed after being rejected by her current boyfriend.
father shot himself. When she was 13, psyShe confessed to being so lonely in the months before the killings
chologists wanted to admit her to a hospital
that she had multiple sexual encounters: with her stepfather, who
to treat her depression, but her mother and
had molested her as a teenager; with her estranged husband,
stepfather refused to cooperate. Later, when
whom she was divorcing; with her current boyfriend, who later
Susan was 15, her stepfather sexually molestwrote a good-bye letter; and with her boyfriend’s father. In addied her, but her mother refused to press chargtion, Susan was drinking heavily during this period.
es. When she was in high school, she had
Dr. Halleck testified that Susan suffered from severe depresSusan’s clinical
periods of depression and attempted suicide.
drinking, and an adjustment disorder that caused her to have
assessment revealed a
disturbed person. She is
However, she did well academically, was an
a heightened emotional reaction to stress (D. Morgan, 1995).
led away to serve a
honor student and a member of the math being life
In just 2½ hours, the jury decided that Susan Smith was guilty
club, and was voted the “friendliest female”
of murder. She was led from the courthouse (upper left photo) to
in the class of 1989. She married David in 1991, but one
serve a life sentence.
year after the birth of their second son, their marriage fell
As a result of her clinical assessment, Susan was diagnosed as having a
apart and they filed for divorce (Bragg, 1995).
mood disorder and was treated in prison with antidepressants.
Dr. Seymour Halleck testified that Susan was scarred
A clinical assessment is a method of identifying a client’s symptoms,
by her father’s suicide, her stepfather’s sexual abuse,
which are used to make a diagnosis. Making a diagnosis requires matchand her periods of depression, which contributed to her
ing the symptoms to a particular disorder, which involves using the DSMcurrent difficulties (Towle, 1995).
Those who knew Susan tried to diagnose
the problem that led to her tragic crime.
“Maybe Susan was just plain crazy.”
“Maybe she was too depressed to know
what she was doing.” “Maybe she had
bad genes.” “Maybe something bad happened to her as a child.”
Using a more rigorous method, mental health professionals conduct clinical assessments to identify symptoms, which
are then used to make a clinical diagnosis.
many mental
Photo Credit: © AP Images/Ruth Fremson
A clinical diagnosis is a process of matching an individual’s specific symptoms to those that define a particular mental disorder.
Making a clinical diagnosis was very difficult prior to the
1950s because there was no uniform code or diagnostic system.
However, since 1952, the American Psychiatric Association
(APA) has been developing a uniform diagnostic system, whose
most recent version is known as the Diagnostic and Statistical
Manual of Mental Disorders-IV-Text Revision, abbreviated as
DSM-IV-TR (American Psychiatric Association, 2000).
The Diagnostic and Statistical Manual of Mental Disorders-IVText Revision, or DSM-IV-TR, describes a uniform system for assessing specific symptoms and matching them to almost 300 different
mental disorders.
With each revision of the DSM, there have been improvements
in diagnosing mental disorders. For example, the DSM-II (1968)
gave only general descriptions of mental problems because it was based on
Sigmund Freud’s general concepts of psychoses (severe mental disorders,
such as schizophrenia) and neuroses (less severe forms of psychological
conflict, such as anxiety). Using only general descriptions caused disagreements in diagnosing problems. The DSM-III (1980) dropped Freudian
terminology and instead listed specific symptoms and criteria for mental
disorders. However, these criteria were based primarily on clinical opinions, not research, so disagreements continued. A major improvement in
the current DSM-IV-TR is that it establishes criteria and symptoms for
mental disorders based more on research findings than on clinical opinions (L. A. Clark et al., 1995). When the next DSM comes out, likely in
2012, mental health experts predict that
Number of Disorders
it will use new findings from genetics
and neuroscience to better identify the
DSM-I 106
underlying causes of mental disorders
(First, 2007; M. C. Miller, 2007).
Interestingly, the first Diagnostic and
Statistical Manual of Mental Disorders DSM-III
(1952) described about 100 mental dis297
orders, as compared to almost 300 in the DSM-IV-TR
most recent DSM-IV-TR (right figure).
We’ll use the cases of Dennis Rader (serial killer), Susan Smith (murderer), and Kate Premo (phobia of flying) to show how mental health
professionals use the DSM-IV-TR to make a diagnosis.
C. Diagnosing Mental Disorders
In making a clinical diagnosis, a mental health
professional first assesses the client’s specific
symptoms and then matches these symptoms
to those described in the DSM-IV-TR. The
DSM-IV-TR has five major dimensions, called
axes, which serve as guidelines for making decisions about symptoms. We’ll first describe Axis I and show how it can be used to
diagnose the very different problems of Susan Smith and Kate
Premo. (The numbered items below and on the opposite page are
based on the Diagnostic and Statistical Manual of Mental DisordersIV-Text Revision [2000], American Psychiatric Association.)
How do
we make a
Axis I: Nine Major Clinical Syndromes
Axis I contains lists of symptoms and criteria about the onset, severity, and duration of these symptoms. In turn these lists of symptoms
are used to make a clinical diagnosis of the following nine major
clinical syndromes.
1. Disorders usually first diagnosed in infancy, childhood,
or adolescence.
This category includes disorders that arise before adolescence, such
as attention-deficit disorders, autism, mental retardation, enuresis,
and stuttering (discussed in Modules 1, 2, and 13).
2. Organic mental disorders.
These disorders are temporary or permanent dysfunctions of brain
tissue caused by diseases or chemicals, such as delirium, dementia
(Alzheimer’s—p. 50), and amnesia (p. 265).
3. Substance-related disorders.
This category refers to the maladaptive use of drugs and alcohol.
Mere consumption and recreational use of such substances are not
disorders. This category requires an abnormal pattern of use, as with
alcohol abuse and cocaine dependence (pp. 188–189).
4. Schizophrenia and other psychotic disorders.
The schizophrenias are characterized by psychotic symptoms (for
example, grossly disorganized behavior, delusions, and hallucinations) and by over six months of behavioral deterioration. This category, which also includes delusional disorder and schizoaffective
disorder, will be discussed in Module 23.
5. Mood disorders.
The cardinal feature is emotional disturbance. Patients may or may
not have psychotic symptoms. These disorders, including major
depression, bipolar disorder, dysthymic disorder, and cyclothymic
disorder, are discussed in Module 23. Susan Smith is an example of a
person with a mood disorder.
Susan Smith: Diagnosis—Mood Disorder
From childhood on, Susan’s symptoms include being depressed,
attempting suicide, seeking sexual alliances to escape loneliness,
drinking heavily, and having feelings of low self-esteem and hopelessness, all of which match the DSM-IV-TR’s list of symptoms for a
mood disorder. In Susan’s case, the specific mood disorder most
closely matches major depressive disorder but without serious
thought disorders and delusions.
In diagnosing major depression, the DSMIV-TR distinguishes between early (before age
21) and late onset depression—Susan would
be early, and between mild and severe
depression, as judged by how many episodes of depression she had and whether
she showed a decreased capacity to function normally, such as the inability to work
or care for children. Susan’s ability to hold
job and care for her children suggests mild
Mood disorder
depression. This example shows how the
guidelines of Axis I are used to arrive at one of nine major clinical
syndromes—in this case, major depression.
6. Anxiety disorders.
These disorders are characterized by physiological signs of anxiety (for example, palpitations) and subjective feelings of tension,
apprehension, or fear. Anxiety may be acute and focused (phobias) or continual and diffuse (generalized anxiety disorder). An
example of an anxiety disorder is that of Kate Premo.
Kate Premo: Diagnosis—Specific Phobia
Kate Premo’s symptoms include having an
intense fear of flying, knowing that her fear is
irrational and that she can’t control it, going
out of her way to avoid flying, and making reservations that she later cancels. Kate’s symptoms most closely match the DSM-IV-TR’s list
of symptoms for an anxiety disorder called a
specific phobia. The DSM-IV-TR’s symptoms
Specific phobia
for a specific phobia match those of Premo—
experiencing intense and irrational fear when
exposed to a feared situation (flying) and having to avoid that situation at all costs, which interferes with part of her normal activities
(going to meetings).
7. Somatoform disorders.
These disorders are dominated by somatic symptoms that resemble physical illnesses. These symptoms cannot be accounted for by
organic damage. There must also be strong evidence that these
symptoms are produced by psychological factors or conflicts. This
category, which includes somatization and conversion disorders
and hypochondriasis, will be discussed in this module.
8. Dissociative disorders.
These disorders all feature a sudden, temporary alteration or dysfunction of memory, consciousness, identity, and behavior, as in
dissociative amnesia and multiple personality disorder (discussed
in Module 23).
9. Sexual and gender-identity disorders.
There are three types of disorders in this category: gender-identity
disorders (discomfort with identity as male or female), paraphilias
(preference for unusual acts to achieve sexual arousal), and sexual
dysfunctions (impairments in sexual functioning) (discussed in
Module 15).
Photo Credits: top, © AP Images/Tim Kimzey; right, © Elizabeth Roll
Figure/Text Credit: Syndrome titles from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright © 1994 American Psychiatric Association.
Nine Major Problems: Axis I
Other Problems and Disorders: Axes II, III, IV, V
We have explained how Axis I is used to make clinical diagnoses of such mental disorders as major depression (mood disorder) and specific phobias (fear of flying). Now, we’ll
briefly describe how the other four axes are used in diagnosing problems.
Axis II: Personality Disorders
Photo Credit: © Jeff Tuttle/AFP/Getty Images
Figure/Text Credit: Syndrome titles from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright © 1994 American Psychiatric Association.
This axis refers to disorders that involve patterns of personality traits that are long-standing, maladaptive, and inflexible and involve impaired functioning or subjective distress.
Examples include borderline, schizoid, and antisocial personality disorders. Personality
disorders will be discussed in Module 23. An example of a personality disorder is that
of Rader.
Dennis Rader: Diagnosis—Antisocial Personality Disorder
Dennis Rader’s symptoms include torturing and killing 10 individuals,
feeling no guilt or remorse, and exhibiting this behavior over a considerable period of time. Rader’s symptoms may indicate a combination
of mental disorders, but here we’ll focus on only one from the DSMIV-TR, a personality disorder. According to the DSM-IV-TR, the
essential features of an antisocial personality disorder are strange
inner experiences that differ greatly from the expectations of one’s
culture, that lead to significant impairment in personal, occupational, or social functioning, and that form a pattern of disregard
Diagnosis: Antisocial
for, and violation of, the rights of others. This list of symptoms
personality disorder
from the DSM-IV-TR matches those of Rader.
Axis III: Personality Disorders
This axis refers to physical disorders or conditions, such as diabetes, arthritis, and hemophilia, that have an influence on someone’s mental disorder.
Axis IV: Psychosocial and Environmental Problems
This axis refers to psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders in Axes I and II. A psychosocial or environmental problem may be a negative life event (experiencing a traumatic event), an
environmental difficulty or deficiency, a familial or other interpersonal stress, an inadequacy of social support or personal resources, or another problem that describes the context in which a person’s difficulties have developed (PTSD was discussed on p. 491).
Axis V: Global Assessment of Functioning Scale
This axis is used to rate the overall psychological, social, and occupational functioning of
the individual on a scale from 1 (severe danger of hurting self) to 100 (superior functioning in all activities).
Using all five axes. Mental health professionals use all five axes to make a clinical
diagnosis. For example, in the case of Dennis Rader, his unusual sexual symptoms may
match those of a sexual disorder in Axis I. His other maladaptive symptoms match those
of an antisocial personality disorder in Axis II. Rader apparently had no related medical conditions listed in Axis III. Rader was a loner with poor self-esteem and struggled
with his schoolwork, which match some of the psychological, social, and environmental
factors listed in Axis IV. Amazingly, Rader functioned well enough to hold a job and
go unnoticed in his neighborhood, which would be used to rate his general functioning listed in Axis V. As you can see, each of the five axes in the DSM-IV-TR focuses on
a different factor that contributes to making an overall clinical diagnosis of a person’s
mental health.
Usefulness of DSM-IV-TR
The figure below shows the steps in making a clinical diagnosis. Mental health
professionals begin by using three different methods to identify a client’s symptoms, a process called clinical assessment. Next, the client’s symptoms are
matched to the five axes in the DSM-IVTR to arrive at a diagnosis of each client’s
particular mental disorder.
1. Clinical interviews
2. Psychological tests
3. Neurological tests
Clinical assessment:
identify symptoms
Use symptoms to
diagnose mental disorder
For mental health professionals, there
are three advantages of using the DSMIV-TR’s uniform system to diagnose and
classify mental disorders (Widiger &
Clark, 2000).
First, mental health professionals use
the classification system to communicate with one another and discuss their
clients’ problems.
Second, researchers use the classification system to study and explain
mental disorders.
Third, therapists use the classification
system to design their treatment program so as to best fit a particular client’s
Although using the DSM-IV-TR system to diagnose mental problems has
advantages, it also has a number of potential problems. For example, mental
health professionals do not always agree
on whether a client fits a particular diagnosis. In addition, there may be social,
political, and labeling problems, which
we’ll discuss next.
C. Diagnosing Mental Disorders
Potential Problems with Using the DSM-IV-TR
Is labeling
a problem?
It’s not uncommon to hear people use labels, such as “Jim’s really anxious,” “Mary Ann is compulsive,” or “Vicki is
schizophrenic.” Although the goal of the DSM-IV-TR is to give mental disorders particular diagnostic labels, once a
person is labeled, the label itself may generate a negative stereotype. In turn, the negative stereotype results in negative
social and political effects, such as biasing how others perceive and respond to the labeled person (Greatley, 2004).
Labeling Mental Disorders
Social and Political Implications
David Oaks, a sophomore at Harvard University, was having
such fearful emotional experiences that he was examined by a
psychiatrist. Although David believed that he was having a
mystical experience, the psychiatrist
interpreted and labeled David’s fearful
experiences as indicating a kind of
short-term schizophrenic disorder
(Japenga, 1994). This mental health
professional made a clinical diagnosis
that resulted in giving a label to
David’s problem.
Diagnostic labels can change how a person is perceived and thus
have political and social implications. For instance, in the 1970s, gays
protested that homosexuality should not be included in the DSM-I
and II as a mental disorder. When studies found that homosexuals
were no more or less mentally healthy than heterosexuals, homosexuality as a mental disorder was eliminated from the DSM-III.
In the 1980s, women protested the DSM label of selfdefeating personality disorder because the label applied
primarily to women who were said to make destructive life
choices, such as staying in abusive relationships (Japenga,
1994). This label was dropped from the DSM-IV because
it suggested that women were choosing bad relationships,
which wasn’t true (P. Caplan, 1994).
Despite these advances, labeling continues to be a serious
problem. For instance, 68% of Americans don’t want someone with a
mental illness marrying into their family and 58% don’t want people
with mental illness at their workplace (J. K. Martin et al., 2000). Also,
even though mental illness does not increase the chance of someone
being violent, many Americans still believe that people with mental
illness tend to behave in violent ways (Elbogen & Johnson, 2009).
Japan has a special problem with labels: Mental disorder labels
have very negative connotations, which discourages Japanese from
seeking professional help for mental disorders. One result is that,
compared to the United States, Japan has a very high rate of suicide.
That’s because one risk for suicide is depression, a label the Japanese
avoid and thus they do not get timely treatment. In comparison, in
the United States, the label of depression is widely accepted, so people are more likely to be treated, even by doctors in general practice
(Menchetti et al., 2009).
These examples illustrate the social and political implications of
labeling individuals with mental disorders.
Labeling refers to identifying and naming differences among individuals. The
label, which places individuals into specific categories, may have either positive
or negative associations.
Some labels
(anxious, depressed)
have negative
At first David felt relieved to know
that his problem had a diagnosis or
label. Later he realized that his new label was changing his life
for the worse. People no longer responded to him as Davidthe-college-sophomore but as David-with-schizophrenicdisorder.
As David’s case shows, the advantage of diagnostic labels
is their ability to summarize and communicate a whole lot of
information in a single word or phrase. But, the disadvantage
is that if the label has negative associations—for example,
mentally ill, retarded, schizo—the very label may elicit negative or undesirable responses. For this reason, mental health
professionals advise that we not respond to people with mental disorders by their labels and instead respond to the person
behind the label (Albee & Joffe, 2004).
Frequency of Mental Disorders
Although labels are a fact of life, researchers and clinicians try to
What was surprising was that 59% of those with a mental disorder
apply the DSM labels as fairly as possible. Researchers interviewed
had neither asked for nor received any professional treatment. This
a national sample of 9,282 noninstistudy also found that about 50% of all lifePercentage Who Will Have a
tutionalized civilians aged 18 and
time mental disorders begin by age 14 and
Mental Disorder in Their Lifetime
older and diagnosed their problems
75% begin by age 24.
using the DSM’s diagnostic system. Any disorder
Researchers concluded that about one in
As the graph at the right shows,
two people will develop a mental disorder
based on those surveyed, 51% of Anxiety disorders
sometime in their life, most individuals with
people will develop at least one disa mental disorder do not seek treatment, and
Mood disorders
order during their lifetime (Kessler
there is a need to understand how to best
et al., 2005). The most common mentreat mental disorders in youth.
15% Alcohol use disorders
tal disorder was anxiety, followed by
Next, we’ll examine the symptoms and
9% Drug use disorders
mood disorders and substance abuse,
treatment of specific disorders, beginning
especially problems with alcohol.
with anxiety.
D. Anxiety Disorders
The most common mental disorder reported by adults in
the United States is any kind of anxiety disorder (right
graph) (Kessler et al., 2005). We have already discussed
two serious anxiety problems, panic disorder (p. 481) and
posttraumatic stress disorder (PTSD) (p. 491). Here we’ll review panic disorder
and PTSD, as well as discuss other common forms of anxiety: generalized anxiety
disorder, three kinds of phobias, and obsessive-compulsive disorder.
How common
is anxiety?
Anxiety Disorders
Any anxiety disorder
Generalized Anxiety Disorder
During his initial therapy interview, Fred was sweating,
fidgeting in his chair, and repeatedly asking for water to quench
a never-ending thirst. From all indications, Fred was visibly distressed and extremely nervous. At first, Fred spoke only of his
dizziness and problems with sleeping. However, it soon became
clear that he had nearly always felt tense. He admitted to a long
history of difficulties in interacting with others, difficulties
that led to his being fired from two jobs. He constantly worried about all kinds of possible disasters that might happen to
him (Davison & Neale, 1990). Fred’s symptoms showed that
he was suffering from generalized anxiety disorder.
Generalized anxiety disorder (GAD) is characterized by
excessive or unrealistic worry about almost everything or
feeling that something bad is about to happen. These anxious
feelings occur on a majority of days for a period of at least six
months (American Psychiatric Association, 2000).
About 5% of adults are reported to have GAD,
but almost twice as many adult women (6.6%) report
GAD as do men (3.6%) (Halbreich, 2003).
Generalized anxiety disorder is commonly treated with psychotherapy (see Module 24), with or without drugs. The drugs most
frequently prescribed are tranquilizers such as alprazolam and
diazepam, which belong to a group known as the benzodiazepines (ben-zoh-die-AS-ah-peens). One of the limitations of these
drugs is that at high doses they are addicting and interfere with
the ability to remember newly learned information (Arkowitz &
Lilienfeld, 2007a; Rupprecht et al., 2009). Antidepressant drugs
are also used to treat GAD and have fewer side effects and a
lower risk of addiction (Holmes & Newman, 2006).
Researchers found that about 40–50% of clients treated
for generalized anxiety disorder with either psychotherapy
(cognitive-behavioral) or drugs (tranquilizers) were free of
symptoms six months to one year later (Arntz, 2003; Holmes
& Newman, 2006).
Social phobia
Specific phobia
Posttraumatic stress disorder
Generalized anxiety
Panic disorder
Obsessive-compulsive disorder
Panic Disorder
One afternoon, Luisa (pictured below), a 23-year-old college student, was
walking on campus and she suddenly felt her heart rate rapidly accelerate,
her throat tighten up, and her arms and legs tremble. She became so nauseous she almost vomited. Luisa felt she had no control over what was
happening. Then, weeks later, while at the movies, she had another
episode during which she experienced dizziness, chest pain,
shortness of breath, and weakness in her legs and feet. She
feared she was having a heart attack and might die, but after a
series of tests, her doctors found no medical problem. Luisa’s
symptoms indicate that she had a panic disorder.
Anxiety can be
treated with drugs
and psychotherapy.
Generalized anxiety disorder includes both psychological and
physical symptoms. Psychological symptoms include being
irritable, having difficulty concentrating, and being unable to
control one’s worry, which is out of proportion to the actual
event. Constant worrying causes significant distress or
impaired functioning in social, occupational, and other areas.
Physical symptoms include restlessness, fatigue, sweating,
flushing, pounding heart, insomnia, headaches, and muscle
tension or aches (American Psychiatric Association, 2000).
Panic disorder is characterized by recurrent and unexpected panic attacks (described below). The person becomes so
worried about having another panic attack that this intense worrying interferes with normal psychological functioning (American
Psychiatric Association, 2000).
Like Luisa, about 4% of adults in the United States suffer from panic disorder, and women are two to three times more likely
to report it than are men (Halbreich, 2003). People who suffer from
panic disorder have an increased risk of alcohol and other drug abuse,
an increased incidence of suicide, decreased social functioning, and less
marital happiness. About half suffer from depression (Smits et al., 2006).
Luisa’s symptoms on campus and at the movies indicate that she was
having a panic attack, which may occur in several different anxiety disorders but is the essential feature of panic disorder.
A panic attack is a period of intense fear or discomfort in which four or
more of the following symptoms are present: pounding heart, sweating, trembling, shortness of breath, feelings of choking, chest pain, nausea, feeling dizzy,
and fear of losing control or dying (American Psychiatric Association, 2000).
Panic disorders are usually treated with drugs—benzodiazepines, antidepressants (Prozac-like drugs, which are selective serotonin reuptake
inhibitors, or SSRIs)—and/or psychotherapy. Research indicates psychotherapy is at least as effective as drug therapy and drug therapy
alone increases the risk of clients relapsing after treatment ends (Smits
et al., 2006). Researchers found that, one year after treatment with a
combination of psychotherapy and drugs, about 30–50% of clients were
symptom-free (Page, 2002).
Another kind of anxiety disorder that is relatively common involves
different kinds of phobias.
D. Anxiety Disorders
A phobia (FOE-bee-ah) is an anxiety disorder characterized by
an intense and irrational fear that is out of all proportion to the
possible danger of the object or situation. Because of this intense
fear, which is accompanied by increased physiological arousal, a
person goes to great lengths to avoid the feared event. If the
feared event cannot be avoided, the person feels intense anxiety.
Reseachers report that because many individuals with phobias
trace their onset to specific traumatic events, phobias are learned
through conditioning or observing a person showing fear of something. Research also points to genetic and environmental causes of
phobias. Thus, different pathways may lead to people developing
phobias (Rowa et al., 2006).
Common Phobias
We discussed fear of blood and injections
Social phobia
earlier (pp. 201, 493). Here we’ll discuss three
common phobias—social phobias, specific
Specific phobia 11%
phobias, and agoraphobia (graph at left)
5% Agoraphobia
(Durand & Barlow, 2006).
Social Phobias
Specific Phobias
Why didn’t Billy speak up in class?
In junior high school,
Billy never, never
spoke up in class or
answered any questions. The school
counselor said that
Billy would be sick
to his stomach the
whole day if he
knew that he was going to be called
on. Billy began to hide out in the
restrooms to avoid going to class.
Billy’s fear of speaking up in class is
a n exa mple of a socia l phobia
(Durand & Barlow, 2010).
Why couldn’t Kate get on a plane?
In the beginning of this module, we told
you about Kate Premo
(photo at left), whose
traumatic childhood
and adult experiences
with f ly ing turned
into a phobia of f lying, which is called a
specific phobia.
Why couldn’t Rose leave her house?
Fear trapped Rose in her house for years. If she
thought about going outside to do her shopping,
pain raced through her arms and chest. She grew
hot and perspired. Her heart beat rapidly and her
legs felt like rubber. She said that thinking about
leaving her house caused stark terror, sometimes
lasting for days.
This 39-year-old
mother of two is
one of millions
of A mer ic a n s
suffering from
an intense fear
of being in public places, which
is called agoraphobia (Los Angeles Times, October 19, 1980).
Social phobias are characterized by
irrational, marked, and continuous fear
of performing in social situations. The
individuals fear that they will humiliate
or embarrass themselves (American
Psychiatric Association, 2000).
Social Phobias
Speaking in public
Speaking to strangers
Eating in public
Source: Eaton et al., 1991
As a fearful social situation approaches (graph above), anxiety
builds up and may result in considerable bodily distress, such as
nausea, sweating, and other signs
of heightened physiological arousal. Although a person with a social
phobia realizes that the fear is excessive or irrational, he or she may
not know how to deal with it, other
than by avoiding the situation.
Specific phobias, formerly called simple
phobias, are characterized by marked and
persistent fears that are unreasonable and
triggered by anticipation of, or exposure to, a
specific object or situation (flying, heights,
spiders, seeing blood) (American Psychiatric
Association, 2000).
Specific Phobias
Bugs, snakes, etc.
Closed places
Source: Eaton et al., 1991
Among the more common specific
phobias seen in clinical practice (graph
above) are fear of animals (zoophobia),
fear of heights (acrophobia), fear of confinement (claustrophobia), fear of injury
or blood, and fear of flying (Durand &
Barlow, 2006).
The content and occurrence of specific phobias vary with culture. For
example, fears of spirits or ghosts are
present in many cultures but become
specific phobias only if the fear turns
excessive and irrational (American Psychiatric Association, 2000).
Agoraphobia is characterized by anxiety about being in
places or situations from which escape might be difficult
or embarrassing (graph above) if a panic attack or paniclike symptoms (sudden
dizziness or onset of diAgoraphobia
arrhea) were to occur
Public transport
(American Psychiatric
Association, 2000).
or bridges
Agoraphobia arises
Crowds 7%
Source: Eaton et al., 1991
out of an underlying
fear of either having
a full-blown panic attack or having a sudden and
unexpected onset of paniclike symptoms.
After any of these phobias are established, they
are extremely persistent and may continue for years
if not treated (M. E. Coles & Horng, 2006). We’ll discuss drug and psychological treatments for phobias
later in this module—in the Application section.
Next, we’ll look at another form of anxiety
that can be very difficult to deal with—obsessivecompulsive disorder.
Photo Credit: center, © Elizabeth Roll
Figure/Text Credit: (bottom) Bar graphs data on phobias from “Panic and Phobia” by W. W. Eaton, A. Dryman & M. M. Weissman, 1991. In L. N. Robins & D. A. Regier
(Eds.), Psychiatric Disorders in America: The Epidemiological Catchment Area Study. Free Press.
When common fears of seeing blood, spiders, or
mice, having injections, meeting new people,
speaking in public, f lying, or being in small
places turn into very intense fears, they are called
phobias (over 500 phobias are listed on www.phobialist.com).
Can fear
go wild?
Obsessive-Compulsive Disorder
Shirley was an outgoing, popular high-school student with average
grades. Her one problem was that she was late for school almost every
day. Before she could leave the house in the morning, she had to be sure
was Shirley
always late? she was clean, so she needed to take a shower that lasted a full 2 hours.
After her shower, she spent a long time dressing because, for each thing
she did, such as putting on her stockings, underclothes, skirt, and blouse, she had to repeat
the act precisely 17 times. When asked about her washing and counting, she
said she knew it was crazy but she just had to do it and couldn’t explain why
(Rapoport, 1988). Shirley’s symptoms would be diagnosed as indicative of
an anxiety problem called obsessive-compulsive disorder.
An obsessive-compulsive disorder consists of obsessions, which are persistent,
recurring irrational thoughts, impulses, or images that a person is unable to control and
that interfere with normal functioning, and compulsions, which are irresistible impulses
to perform over and over some senseless behavior or ritual (hand washing, checking
things, counting, putting things in order) (American Psychiatric Association, 2000).
Obsessive-compulsive disorder, or OCD, was once considered relatively
rare, but now it is known to affect about 3% of adults in the United States
(Riggs & Foa, 2006). We’ll discuss OCD’s symptoms and treatments.
Repeating an
act 17 times is
a sign of OCD.
Stress Disorder
Mark was driving home from work when
a huge truck unexpectedly lost control
and rammed his car from behind. Mark
had no way to escape the traumatic accident. Though he needed hospital treatment, he was lucky to walk away alive.
However, since the accident Mark has
become so fearful of driving that he
works from home now. He still experiences troublesome, recurring memories
of the event and frequently has terrifying
nightmares about being in a car accident.
Mark’s symptoms would be diagnosed as
indicative of an anxiety problem called
posttraumatic stress disorder.
Shirley’s symptoms included both obsession—need to be very clean and careful about dressing—and compulsions—need to take 2-hour showers and to perform each act of dressing
precisely 17 times. Some individuals have obsessions (irrational, recurring thoughts) without
compulsions. Because compulsions are usually very time-consuming, they often take an
hour or more to complete each day.
Common compulsions involve cleaning, checking, and counting; the less common
include buying, hoarding, and putting things in order. For example, individuals obsessed
with being contaminated reduce their anxiety by washing their hands until their skin is raw,
while those obsessed with leaving a door unlocked may be driven to check the lock every
few minutes (American Psychiatric Association, 2000). These kinds of obsessive-compulsive
behaviors interfere with normal functioning and make holding a job or engaging in social
interactions difficult. OCD can be a chronic problem that requires treatment with drugs,
psychotherapy, or some combination (Riggs & Foa, 2006).
Photo Credit: right, © Chip Simons/Science Faction/Corbis
Shirley’s compulsive behaviors are thought to be one way that she
reduces or avoids anxiety. Currently, about half of patients with OCD
report improvement after being treated with drugs or exposure therapy (Franklin et al., 2002).
Exposure therapy involves gradually exposing the person to the actual
anxiety-producing situations or objects that he or she is attempting to avoid
and continuing the exposure treatments until the anxiety decreases.
For example, a client like Shirley with OCD could be exposed over
and over to her fearful objects (dirt or dirty things) until such exposures elicit little or no anxiety. Exposure therapy may involve 15 twohour sessions over the course of a month. However, Shirley refused to
try exposure therapy and instead was given antidepressant drugs.
Clients like Shirley, who cannot tolerate or are not motivated to
undergo exposure therapy, may be given antidepressant drugs. After
taking an antidepressant for about three weeks, Shirley’s urges to
wash and count faded sufficiently that she could try exposure therapy
Treatment for
OCD is psycho(Rapoport, 1988). However, about one-third of clients with OCD are
therapy and/or antinot helped by antidepressants (Riggs & Foa, 2006).
depressant drugs.
A new, last resort treatment for OCD is deep brain stimulation
(p. 61) (DeNoon, 2009b; Talan, 2009).
Next, we’ll describe how a threatening event can lead to posttraumatic stress disorder.
Posttraumatic stress disorder, or PTSD,
is a disabling condition that results from personally experiencing an event that involves
actual or threatened death or serious injury
or from witnessing or hearing of such an
event happening to a family member or close
friend. People suffering from PTSD experience a number of psychological symptoms,
including recurring and disturbing memories,
terrible nightmares, and intense fear and
anxiety (APA, 2000).
These horrible memories and feelings
of fear keep stress levels high and result
in a range of psychosomatic symptoms,
including sleep problems, pounding
heart, and stomach problems (Marshall
et al., 2006; Schnurr et al., 2002).
Treatment. Treatment may involve
drugs, but some form of cognitivebehavioral therapy (p. 568) is more
effective in the long term (Bolton et al.,
2004). Cognitive-behavioral therapy
provides emotional support so victims
can begin the healing process, helps to
slowly eliminate the horrible memories
by bringing out the details of the experience, and gradually replaces the feeling
of fear with a sense of courage (Harvey
et al., 2003; Resick et al., 2008).
Next, we’ll discuss how people can
create real physical symptoms that
interfere with normal functioning.
E. Somatoform Disorders
Definition and Examples
Imagine someone whose whole life centers around physical symptoms, some that
are imagined and others that appear real, such as developing paralysis in one’s
legs. This intense focus on imagined, painful, or uncomfortable physical symptoms is characteristic of individuals with somatoform disorders.
Somatoform (so-MA-tuh-form) disorders are marked by a pattern of recurring, multiple, and significant bodily (somatic) symptoms that extend over several years. The bodily
symptoms (pain, vomiting, paralysis, blindness) are not under voluntary control, have no
known physical causes, and are believed to be caused by psychological factors (American
Psychiatric Association, 2000).
Although not easily diagnosed, somatoform disorders are among the most
common health problems seen in general medical practice (Wise & Birket-Smith,
2002). The DSM-IV-TR lists seven kinds of somatoform disorders. We’ll discuss
two of the more common forms—somatization and conversion disorders.
Somatization Disorder
One kind of somatoform disorder, which was
historically called hysteria, is now called somatization disorder and is relatively rare (2.7% of the population).
Somatization disorder begins before age 30, lasts several
years, and is characterized by multiple symptoms—including pain,
gastrointestinal, sexual, and neurological symptoms—that have
no physical causes but are triggered by psychological problems
or distress (American Psychiatric Association, 2000).
This disorder is especially common among
women (P. Fink et al., 2004). Those who have somatization disorder use health services frequently and
have twice the annual medical care costs of people
without somatization disorder (Barsky et al., 2005). Many people with somatization disorder are raised in emotionally cold and unsupportive family environments and are often victims of emotional or physical abuse (R. J. Brown et al.,
2005). Somatization disorders may be a means of coping with a stressful situation
or obtaining attention (Durand & Barlow, 2010).
A psychologically distressed
individual may have painful
physical symptoms that have
no physical causes.
Mass Hysteria
As more than 500 students from various schools
began to give a choir and orchestra concert, they
suddenly began to complain of headaches, dizziness, weakness, abdominal pain, and nausea. These
symptoms spread rapidly until about half the students developed one or more of the symptoms. Students who became ill were most often those who
saw someone near them become ill. Students from
one school, particularly girls in the soprano section, experienced the highest rate of symptoms.
Younger members reported more symptoms than
older ones, and girls (51%) reported more symptoms than boys (41%). At first, someone thought
that a gas line had broken, but no one in the audience developed any symptoms. There was no ruptured gas line. The students’ symptoms resulted
from mass hysteria (Small et al., 1991).
Mass hysteria is a condition experienced by a group
of people who, through suggestion, observation, or other
psychological processes, develop similar fears, delusions, abnormal behaviors, or physical symptoms.
In this case, several of the most popular and visible girls complained of feeling dizzy and nauseous
(they had been standing for hours). Soon, other students were complaining about having similar physical symptoms until over 200 students eventually
developed these same symptoms. A similar case of
mass hysteria was reported in a group of teenage girls
in Vietnam, 50 of whom were hospitalized due to
sudden fainting after watching one girl collapse and
be carried away by medical personnel (IANS, 2006).
Conversion Disorder
Some people report serious physical problems, such as blindness, that have no physical causes and are examples of conversion disorder, a type of somatoform disorder.
Usually the symptoms of a conversion disorder are associated with psychological factors, such as depression, concerns about health, or the occurrence of
a stressful situation. Recent research examining the brains of people with medically unexplainable paralysis has shown that when patients try to move their
paralyzed limbs, the emotional areas of the brain are activated inappropriately
and may inhibit the functioning of the motor cortex, leaving the patients unable
to move their paralyzed limbs (Kinetz, 2006). The development of such physical
symptoms gets the person attention, removes the person from threatening or anxiety-producing situations, and thus reinforces the occurrence and maintenance
of the symptoms involved in the conversion disorder (Durand & Barlow, 2010).
Researchers found that in some cultures, bodily complaints (somatoform disorders) are used instead of emotional complaints to express psychological problems
(Lewis-Fernandez et al., 2005).
The same kind of painful or uncomfortable physical symptoms observed in
somatoform disorders are observed in individuals suffering from mass hysteria.
Individuals who are emotionally aroused in a group
may experience similar physical symptoms.
In the Middle Ages, hysteria was attributed to
possession by evil spirits or the devil. Today, mass
hysteria is known to involve members of a group
who experience and share emotional arousal or
excitement, which spreads through the group and
results in its members developing real physical
symptoms with no known physical causes (Barlow
& Durand, 2009). Mass hysteria is another example
of somatoform disorders.
After the Concept Review, we’ll discuss how
symptoms of mental disorders can vary among
cultures, as we examine a disorder that seems to be
unique to Asian cultures, especially Japan.
Photo Credit: left, © Marvin Mattelson
A conversion disorder refers to changing anxiety or emotional distress into real physical, motor, sensory, or neurological symptoms (headaches, nausea, dizziness, loss of sensation, paralysis) for which no physical or organic cause can be identified (American
Psychiatric Association, 2000).
Concept Review
1. A prolonged or recurring problem that seriously interferes with
the ability of an individual to live a satisfying personal life and
function in society is called a
Photo Credits: (#2) © Colin Anderson/Brand X/Corbis; (#3) © San Diego Union Tribune/ZUMA Press; (#4) © AP Images/Tim Kimzey
2. Mental disorders arise from the interaction of a number of
factors. Biological factors include inherited behavioral tendencies,
which are called (a)
These factors contribute from 30% to 60% to
the development of mental disorders. Biological
factors also include the overreaction of brain
structures to certain stimuli, which are called
factors. Other factors
that contribute to the development of mental
disorders, such as deficits or problems in thinking, processing
emotional stimuli, and social skills, are called (c)
factors. Being in or seeing a traumatic event, which is called an
factor, can contribute to developing a mental
disorder such as PTSD.
3. There are three definitions of abnormality. A behavior that
occurs infrequently in the general population is abnormal according to the (a)
A behavior that deviates greatly from accepted
social norms is abnormal according to the
definition. Behavior that
interferes with the individual’s ability to function
as a person or in society is abnormal according
to the (c)
definition, which is
used by most mental health professionals.
4. When performed by a mental health professional, a systematic
evaluation of an individual’s various psychological, biological,
and social factors that may be contributing to his or her problem
is called a clinical (a)
. A mental
health professional who determines whether an
individual’s specific problem meets or matches the
standard symptoms that define a particular mental
disorder is doing a clinical (b)
One of the primary techniques used to gather an
enormous amount of information about a person’s
past behavior, attitudes, and emotions and details of current problems is the clinical (c)
5. The manual that describes the symptoms for almost 300 different
mental disorders is called the (a)
. The manual’s
primary goal is to provide mental health professionals with a
means of (b)
mental disorNumber of Disorders
ders and (c)
that informaDSM-I 106
tion in a systematic and uniform way. The
DSM-IV-TR has five major dimensions, called DSM-III
, that serve as guidelines DSM-IV-TR
for making decisions about symptoms.
6. There are several kinds of anxiety disorders.
An anxiety disorder that is characterized by
excessive and/or unrealistic worry or feelings of
general apprehension about events or activities,
when those feelings occur on a majority of days
for a period of at least six months, is called
disorder. An anxiety dis(a)
order marked by the presence of recurrent and unexpected panic
attacks, plus continued worry about having another panic attack,
when such worry interferes with psychological functioning, is
called a (b)
disorder. Suppose a person has a
period of intense fear or discomfort during which four or more
of the following symptoms are present: pounding heart, sweating,
trembling, shortness of breath, feelings of choking, chest pain,
nausea, feeling dizzy, and fear of losing control or dying. That
person is experiencing a (c)
7. An anxiety disorder characterized by an intense
and irrational fear and heightened physiological
arousal that is out of all proportion to the danger
elicited by the object or situation is called a
, of which there are several
kinds. Unreasonable, marked, and persistent fears
that are triggered by anticipation of, or exposure
to, a specific object or situation are called a
. An anxiety that comes from being in places
or situations from which escape might be difficult or embarrassing if a panic attack or paniclike symptoms were to occur is called
. Irrational, marked, and continuous fear of
performing in social situations and feeling humiliated or embarrassed is called a (d)
8. A disorder that consists of persistent, recurring irrational thoughts, impulses, or images that a person is
unable to control and irresistible impulses to perform
over and over some senseless behavior or ritual is called
disorder. A nondrug treatment for
this disorder, which consists of gradually exposing the
person to the real anxiety-producing situations or
objects that he or she is attempting to avoid, is called
9. When something happens to a group of
people so that all share the same fears or
delusions or develop similar physical
symptoms, it is called (a)
There is a disorder that involves a pattern
of recurring, multiple, and significant bodily
complaints that have no known physical causes. This is called
disorder, and one of its more common forms
is somatization disorder.
Answers: 1. mental disorder; 2. (a) genetic, (b) neurological, (c) cognitive-emotional-behavioral, (d) environmental; 3. (a) statistical frequency,
(b) social norms, (c) maladaptive behavior; 4. (a) assessment, (b) diagnosis, (c) interview; 5. (a) Diagnostic and Statistical Manual of Mental
Disorders-IV-TR, (b) diagnosing, (c) communicating, (d) axes; 6. (a) generalized anxiety, (b) panic, (c) panic attack; 7. (a) phobia, (b) specific
phobia, (c) agoraphobia, (d) social phobia; 8. (a) obsessive-compulsive, (b) exposure; 9. (a) mass hysteria, (b) somatoform
F. Cultural Diversity: An Asian Disorder
Anxiety is a worldwide concern and is the second most comCan a
mon mental disorder in the United States and several Asian
culture create
nations, notably Japan. The symptoms of one kind of anxiety
disorder, somatoform disorder, occur in very similar form in
a disorder?
many cultures around the world (Lewis-Fernandez et al., 2005).
However, it’s also true that the unique cultural values of some countries, such as Japan,
can result in the development of a unique anxiety order not found in Western cultures,
such as the United States.
If you had a social phobia in the United States, it would usually mean that you
had a great fear or were greatly embarrassed about behaving or performing in social
situations, such as making a public speech. But if you had a social phobia in several
Asian cultures, especially Japan and somewhat in Korea, it might mean that you
had a very different kind of fear or embarrassment, called taijin kyofusho, or TKS
(Tarumi et al., 2004).
In Japan, the fear
of offending others (by
staring) is considered a
kind of social phobia.
Taijin kyofusho (tai-jin kyo-foo-show), or TKS, is a kind of social phobia characterized by a
terrible fear of offending others through awkward social or physical behavior, such as staring,
blushing, giving off an offensive odor, having an unpleasant facial expression, or having trembling
hands (Dinnel et al., 2002).
Although many Westerners are also concerned or embarrassed about offending others through staring, having offensive body odors, or blushing, TKS is different in that
it is an intense, irrational, morbid fear—in other words, a true phobia. In desperately
trying to avoid TKS symptoms, Asians may try to avoid social interactions altogether.
The Japanese word taijin-kyofu literally means “fear of interpersonal relations.”
Occurrence. The graph below shows that TKS is the third most common psychiatric disorder treated in Japanese college students (Kirmayer, 1991). TKS is more common in males than in females, with a ratio of about 5:4. Most patients have a primary
symptom, which has changed during the past 40 years. Initially, fear of blushing was
the primary symptom, but it has been replaced by
Percentage of Students
fear of making eye contact or staring (Yamashita,
1993). In comparison, making eye contact is very
common in Western cultures; if you do not make
eye contact in social interactions, you may be
judged as shy or lacking in social skills.
TKS begins around adolescence, when interpersonal interactions play a big role in one’s life.
TKS is rarely seen after the late twenties because, by then, individuals have learned the
proper social behaviors. TKS seems to develop from certain cultural influences that
are unique to Japan.
Cultural values. The Japanese culture places great emphasis on the appropriate
way to conduct oneself in public, which means a person should avoid making direct
eye contact, staring, blushing, having trembling hands, or giving off offensive odors.
To emphasize the importance of avoiding these improper behaviors, mothers often
use threats of abandonment, ridicule, and embarrassment as punishment. Through
this process of socialization, the child is made aware of the importance of avoiding improper public behaviors, which result in a loss of face and reflect badly on the
person’s family and social group. Thus, from early on, Japanese children are strongly
encouraged to live up to certain cultural expectations about avoiding improper
public behaviors, especially staring and blushing, which are considered to be rude
and disgraceful.
Social Customs
In Japan, individuals are expected to know
the needs and thoughts of others by reading
the emotional expressions of faces rather
than asking direct questions, which is considered rude social behavior. In contrast,
Westerners may ask direct questions to clarify some point and often use direct eye contact to show interest. Individuals in Japan
who make too much eye contact or ask too
direct questions are likely to be viewed as
insensitive to others, unpleasantly bold, or
aggressive. In fact, Japanese children are
taught to fix their gaze at the level of the neck
of people they are talking to. This Japanese
social custom that emphasizes not making
eye contact, blushing, or having trembling
hands or offensive body odors during social
interactions results in about 20% of Japanese
teenagers and young adults developing the
intense, irrational fear called TKS. This social
phobia is so common in Japan that there are
special clinics devoted only to treating TKS.
The Japanese TKS clinics are comparable in
popularity to the numerous weight-loss clinics found in the United States. Interestingly,
TKS is a kind of social phobia that doesn’t
occur in Western cultures (Dinnel et al., 2002;
Tarumi et al., 2004).
Cultural differences. Although people in
many cultures report anxiety about behaving
or performing in public, the particular fears
that they report may depend on their own culture’s values. For example, TKS is unique to
Asian cultures and unknown in Western cultures. Japanese who are especially at risk for
developing TKS are those who score low on
independence and high on interdependence,
two traits found in traditional Japanese cultural values (Dinnel et al., 2002). Clinicians
emphasize the importance of taking cultural values, influences, and differences into
account when diagnosing behaviors across
cultures (Fernando, 2002).
In Japan,
it is very
to know
and show
the proper
Next, we’ll discuss a very serious problem
in the U.S. culture: school shootings.
Photo Credits: left, © David Young Wolff/PhotoEdit; right, © PhotoDisc, Inc.
Taijin Kyofusho, or TKS
G. Research Focus: School Shootings
What Drove Teens to Kill Fellow Students and Teachers?
Sometimes researchers are
faced w it h a nswer i ng
tragic questions, such as
why teenagers took guns
to schools and shot and killed at least 500 and
wounded another 1,000. Everyone wonders what
turns these teens into killers. In some cases, but
not all, these adolescents might be diagnosed
with conduct disorder.
What is
their problem?
The diagnosis of conduct disorder seems to apply to Kipland
Kinkel, age 15, who was charged with firing 50 rounds from a
semiautomatic rifle into the school cafeteria, killing 2 students
and injuring 22. Those who knew him said that Kinkel had a
violent temper and a history of behavioral problems, which
included killing his cat by putting a firecracker in its mouth,
blowing up a dead cow, stoning cars from a highway overpass, and making bombs (Witkin et al., 1998). In trying
to answer the question “Why did these adolescents shoot
their fellow students and teachers?” mental health profesAdolescent school
sionals have primarily used the case study approach.
Photo Credit: © AP Images/Virginia State Police
Conduct disorder refers to a repetitive and persistent pattern of behaving that has been going on for at
shooters may have
least a year and that violates the established social rules
A case study is an in-depth analysis of the thoughts, feelings,
conduct disorder.
or the rights of others. Problems may include aggressive
beliefs, experiences, behaviors, and problems of a single individual.
behaviors such as threatening to harm people, abusing or killing animals,
We’ll give brief case studies of two school shooters and then examdestroying property, being deceitful, or stealing.
ine some factors that put a student at risk for becoming a shooter.
Case Studies
Risks Shared by Adolescent School Shooters
The first school shooting that received national attention
occurred in Moses Lake, Washington, on February 2,
1996. On that date, Barry Loukaitis, 14, fired on his algebra class, killing three and wounding one. He said that he
wanted to get back at a popular boy who had teased him.
Loukaitis shot that boy dead. Since then, school shootings have continued at an alarming rate. Across the
world, there have been at least 50 adolescents, mostly
boys, who took guns to their schools, fired hundreds of
shots, killed at least 500 teachers and students, and
wounded about 1,000 more (IANSA, 2007).
One such shooter is 23-year-old college student SeungHui Cho (below photo), who in 2007 killed 32 people and
wounded 25 others on the Virginia Tech campus, making
it the deadliest school shooting in history. Cho was born
in South Korea and immigrated to the United States when
he was 8 years old. As a child, he was relentlessly teased
and bullied for being shy and speaking with a strong
accent. Consequently, he was isolated and developed
anger toward his more “privileged”
peers. He came to view himself as an
avenger against those who humiliated him (White and affluent). He
wanted to get even with the “rich
brats” who had trust funds and
drove Mercedes. In a disturbing
message on the day of his shooting,
he stated to the privileged, “You
have never felt a single ounce of
pain in your whole lives.” At the
Seung-Hui Cho
committed the
end of his killing spree, Cho took
deadliest school
his own life (Gibbs, 2007; Schute,
shooting in history.
2007; E. Thomas, 2007).
However, very, very few students who are picked on
and bullied commit violent acts, such as shooting teachers and students. We’ll examine some of the factors that
put students as risk for committing violent acts.
Although there are differences among school shooters, researchers have identified a number of risk factors that these boys shared (FBI, 2001; Langman,
2009; R. Lee, 2005; Pollack, 2007; Robertz, 2007; Verlinden et al., 2000).
O Most of the boys (shooters) showed uncontrolled anger and depression, blaming others for problems and threatening violence. Most had poor
coping skills, discipline problems at school or home, access to weapons, and
a history of drug use.
O Half of the boys had been given little parental supervision, had
troubled family relationships, and perceived themselves as receiving little
support from their families. Most of the boys had recently experienced the
breakup of a relationship, a stressful event, or loss of status.
O Most of the boys were generally isolated and rejected by their peers
in school. Most had poor social skills and felt picked on, bullied, and persecuted and made friends who were also antisocial. The most commonly
stated motives for shootings were to mete out justice to peers or adults who
the teenage shooters believed had wronged them and to obtain status or
importance among their peers. Most teenage shooters gave warning signs of
their violent intentions that were not taken seriously.
Neurological factors. Although coming from a broken home, being
bullied, and dealing with various life stressors are risk factors for adolescents committing violent acts, another important risk factor is inside an
adolescent’s brain. Everyone gets angry and has felt
rage and the desire to get revenge, but most of us are
able to control these violent impulses. This control
involves the prefrontal cortex (p. 411), which has
executive functions, such as planning, making
decisions, and controlling strong emotional and
violent impulses that arise from a very primitive
part of the brain called the limbic system (p. 411)
(right figure). The prefrontal cortex in the adolescent brain is still immature and may not reach
complete maturity until the early twenties. For this reason, adolescents are
especially at risk for committing all kinds of impulsive and violent behaviors and, in extreme cases, even school shootings (Luna, 2006).
Gathering data about what motivates school shooters is an example of using
the case study method. Next, we turn to explaining several ways of treating
two relatively common anxiety disorders—social and specific phobias.
H. Application: Treating Phobias
Specific Phobia: Flying
Kate is undergoing exposure
therapy for fear of flying.
Cognitive-Behavioral Therapy
Kate’s phobia of f lying involves fearful and irrational
thoughts, which in turn cause increased physiological
arousal. She can learn to reduce her irrational and fearful thoughts and reduce her arousal through cognitivebehavioral therapy (Singer & Dobson, 2006).
Cognitive-behavioral therapy involves using a combination
of two methods: changing negative, unhealthy, or distorted
thoughts and beliefs by substituting positive, healthy, and realistic ones; and changing limiting or disruptive behaviors by
learning and practicing new skills to improve functioning.
Thoughts. Cognitive-behavioral therapy is useful
in helping Kate control her fearful thoughts and eliminate dangerous beliefs about flying. For example, Kate
had learned to fear various noises during flight, which
she believed indicated trouble. To change these fearful thoughts, an airplane pilot explained the various
noises, such as the thumps meant the landing gear was
retracting after takeoff or being put down for landing.
Thus, when Kate has a fearful thought, for example,
“That noise must mean trouble,” she immediately stops
herself and substitutes a realistic thought, “That’s just
the landing gear.”
Behaviors. Because Kate automatically gets nervous and fearful when just thinking about flying, she
is instructed to do breathing, relaxation, and imagery
exercises that will help her calm down. Deep and rhythmic breathing is an effective calming exercise because it
distracts Kate from her fears and focuses her attention
on a pleasant activity. Relaxing and tensing groups of
muscles are also calming and help to decrease physiological arousal. Finally, imagery exercises are calming
because focusing on pleasant images is a very powerful
way of using her mind to control (relax) her body’s fightflight response.
Cognitive-behavioral methods have proved effective
in treating a variety of phobias (Singer & Dobson, 2006).
Sometimes cognitive-behavioral therapy is combined
with another kind of therapy, called exposure therapy.
f lying, crashing, heights, being in small enclosed
spaces, or not having control of the situation (Van
Gerwen et al., 1997).
Most phobias do not disappear without some
treatment, and on the few occasions that Premo was
forced to fly, she dosed herself with so much alcohol and tranquilizers that she was groggy for days.
Finally, she joined a weekend seminar that helps people overcome their fears of flying (M. Miller, 2003).
Treatment for phobias can involve psychotherapy or
drugs, or some combination of them. We’ll discuss
psychotherapy and drug treatment, beginning with
cognitive-behavioral and exposure therapy.
Exposure Therapy
For treating phobias, cognitive-behavioral therapy is often combined with
exposure therapy. The most difficult part of Kate’s phobia treatment is exposure therapy, when she must actually confront her most feared situation.
Exposure therapy consists of gradually exposing the person to the real anxietyproducing situations or objects that he or she is attempting to avoid and continuing
exposure treatments until the anxiety decreases.
The first part of Kate’s treatment involved cognitive-behavioral therapy,
in which she learned how to control her irrational thoughts and acquire
some basic relaxation techniques. The second part of her treatment involves
exposure therapy, in which she is required to fly on a regularly scheduled
airline, meaning that she will be exposed to her most feared situation. To
help Kate deal with her fear of flying, Captain Michael Freebairn (photo
below) sat next to Kate. Each time Kate tensed or looked fearful, the captain reassured Kate that all was normal and then reminded her to begin
relaxation exercises (breathing and relaxing muscles), to use pleasant images, and
to substitute positive, healthy thoughts
for negative, fearful ones. When the plane
landed, Kate was all smiles (left photo) after
realizing that exposure therapy had significantly reduced her fear or phobia of flying.
Programs that treat specific phobias,
such as fear of flying, often use some combination of cognitive-behavioral and expoKate smiles after successfully
sure therapy, which significantly reduces
flying without feeling
fear in the majority of clients (R. A. Friedintense fear.
man, 2006; M. Miller, 2003).
Clients not helped by cognitive-behavioral or exposure therapy may be
given drug therapy (see next page) or they may try virtual reality therapy.
Virtual reality therapy. Although clients never leave the ground, they
sit in real airplane seats that vibrate to the sound of airplane engines. Clients wear head-mounted displays that surround them with 3-D experiences
of “taking off ” and “flying.” Everything appears so real that clients who
have a fear of flying begin to sweat and their hearts pound just as on real
flights. Virtual reality therapy is a kind of exposure therapy, and it can be
combined with relaxation exercises and thought substitution and be used
to treat a variety of specific phobias, including fear of flying (Rothbaum et
al., 2006).
Photo Credits: top and bottom, © Elizabeth Roll
At the beginning of this module, we told you about
Kate Premo (right photo), who developed a phobia of
flying. In some cases, people don’t remember what
caused their phobias, but Premo remembers exactly
when her phobia began. Her fear began as a child
when she was on a very turbulent and stressful flight.
Her fear was further intensified by her memories of
the terrorist bombing of Pan Am flight 103, which
killed several of her fellow students. After that incident, her fear of flying turned into a real phobia that
kept her from flying to visit friends and family. An
estimated 9% of American adults have a phobia of flying called aviophobia, which may include fear of
Social Phobia: Public Speaking
Just as specific phobias can be successWhen does a
fully treated with psychotherapy, so
fear become
too can social phobias, such as public
speaking. Almost everyone is somea phobia?
what anxious about getting up and
speaking in public. For a fear to become a full-blown phobia,
however, the fear must be intense, irrational, and out of all
proportion to the object or situation. For example, individuals
with social phobias have such intense, excessive, and irrational
fears of doing something humiliating or embarrassing that
they will go to almost any lengths to avoid speaking in public.
There are a number of very effective nondrug programs for
treating social phobias (fear of speaking, performing, or acting in public). These programs combine cognitive-behavioral
and exposure therapies and usually include the following four
components (M. E. Coles & Horng, 2006).
1 Explain. Clinicians explain to the person that, since the
fears involved in social phobias are usually learned, there are
also methods to unlearn or extinguish such fears. The person
is told how both thoughts and physiological arousal can
exaggerate the phobic feelings and make the person go to any
lengths to avoid the feared situation.
Learn and substitute. Clinicians
found that some individuals needed to
learn new social skills (initiating a
conversation, writing a speech) so that
they would function better in social
situations. In addition, individuals were
told to record their thoughts immediately after thinking about being in a
feared situation. Then they were
shown how to substitute positive
healthy thoughts for negative
Treating social
and fearful ones.
phobias involves four
Expose. Clinicians first used
imaginary exposure, during which a person imagines being
in the situation that elicits the fears. For example, some individuals imagined presenting material to their co-workers,
making a classroom presentation, or initiating a conversation
with the opposite sex. After imaginary exposure, clinicians
used real (in vivo) exposure, in which the person gives his or
her speech in front of a group of people or initiates conversations with strangers.
Practice. Clinicians asked subjects to practice homework assignments. For instance, individuals were asked to
imagine themselves in feared situations and then to eliminate negative thoughts by substituting positive ones. In addition, individuals were instructed to gradually expose
themselves to making longer and longer public presentations
or having conversations with the opposite sex.
Researchers report that programs similar to the one above
resulted in reduced social fears in about 56% of those who
completed the program (Lincoln et al., 2003).
Drug Treatment of Phobias
Imagine being told to walk
into a room and meet a
group of strangers while
you are stark naked. For
most of us, this idea would
cause such embarrassment, fear, and anxiety
that we would absolutely refuse. This imagined
situation is similar to the terrible negative emotions that individuals with social phobia feel
when they must initiate a conversation, meet
strangers, or give a public presentation. As we
have discussed, social phobias can be treated
with cognitive-behavioral and exposure therapy. However, some individuals with social
Drug therapy for
phobias involves
phobia do not choose to or are too fearful to
tranquilizers or
complete a therapy program that includes expoantidepressants.
sure to the feared situation. Instead, these individuals may choose drug therapy, which may involve tranquilizers
(benzodiazepines) or the increasingly prescribed antidepressants
(Blanco et al., 2003; M. E. Coles & Horng, 2006).
The graphs below show the results of a double-blind study in which
individuals with social phobia were given either a placebo or an antidepressant, in this case sertraline
Average Score on Fear Scale:
(Zoloft). After 20 weeks of treatDrug reduced fear more
ment, individuals given antidepresthan placebo
sants showed a significant clinical
reduction in scores on both anxiety
and fear tests, which means they
were able to function relatively well
Average Score on Fear Scale:
in social situations (Van AmerinDrug reduced avoidance more
gen et al., 2001). Although 34% of
than placebo
those on antidepressants showed
a significant decrease in social
anxiety, a remarkable 18% of those
given placebos (sugar pills) showed
a similar decrease. This means that the significant decrease in the
social fears of almost one out of five individuals resulted from purely
psychological factors, such as a client’s expectations and beliefs (“The
pill is powerful medicine and will reduce my fear”).
Although drug treatments are effective in reducing social phobias,
there are two potential problems. First, about 50–75% of individuals
relapse when drugs are discontinued, which means that their original
intense social phobic symptoms return. Second, long-term maintenance
on drugs can result in tolerance and increases in dosage, which, in turn,
can result in serious side effects, such as loss of memory (S. M. Stahl,
2000, 2002). Compared to drug treatment of phobias, psychotherapy
programs have the advantages of no problems with tolerance and no
unwanted physical side effects.
Which treatment to choose? Whether a client chooses psychotherapy or drug treatment for phobias depends to a large extent on
each individual client’s preference. That’s because drug treatment
(tranquilizers or antidepressants) and cognitive-behavioral or exposure therapy are about equally effective in the treatment of different
phobias, including specific phobias, social phobias, and agoraphobia
(Liebowitz et al., 1999).
are drugs?
Summary Test
A. Factors in Mental Disorders
C. Diagnosing Mental Disorders
1. A prolonged or recurring problem that seriously interferes with an individual’s ability to
live a satisfying personal life and function in
society is a
. This definition
takes into account genetic, behavioral, cognitive, and environmental factors, all of which
may contribute to a mental disorder.
6. When mental health professionals
determine whether an individual’s specific problem meets or matches the standard symptoms that define a particular
mental disorder, they are making a
. In trying to reach
an agreement on the clinical diagnosis,
mental health professionals use a set of
guidelines, developed by the American Psychiatric Association,
called the (b)
, which is abbreviated as
3. If a behavior is considered abnormal because it occurs infrequently in the general population, we are using a definition based
on (a)
frequency. If a behavior is considered
abnormal because it deviates greatly from what’s acceptable, we
are using a definition based on (b)
. If a behavior
is considered abnormal because it interferes with an individual’s
ability to function as a person or in society, we are using a
definition based on (c)
B. Assessing Mental Disorders
4. A systematic evaluation of an individual’s
various psychological, biological, and social
factors that may be contributing to his or her
problem is called a (a)
. The
primary method used in clinical assessments is
to get information about a person’s background,
current behavior, attitudes, and emotions and
also details of present problems through a
. A complete clinical assessment usually includes three major methods:
, and
5. Assessing mental disorders may be difficult because
vary in intensity and complexity. The
assessment must take into account past and present problems
and current stressors. The accurate assessment of symptoms is
important because it has significant implications for the kind of
that the client will be given.
7. The DSM-IV-TR is a set of guidelines that uses five different
dimensions or (a)
to diagnose mental disorders.
The advantage of the DSM-IV-TR is that it helps mental health
professionals communicate their findings, conduct research, and
plan for treatment. One disadvantage of using the DSM-IV-TR to
make a diagnosis is that it places people into specific categories
that may have bad associations; this problem is called
D. Anxiety Disorders
8. A mental disorder that is marked by excessive
and/or unrealistic worry or feelings of general
apprehension about events or activities, when those
feelings occur on a majority of days for a period
of at least six months, is called
This anxiety disorder is treated with some form of
psychotherapy and/or drugs known as benzodiazepines.
9. One mental disorder is characterized by recurring and unexpected panic attacks and continued worry about having another
panic attack; such worry interferes with psychological functioning. This problem is called a
10. Suppose you experience a period of intense fear or discomfort
in which four or more of the following symptoms are present:
pounding heart, sweating, trembling, shortness of breath, feelings
of choking, chest pain, nausea, feeling dizzy, and fear of losing
control or dying. You are having a (a)
. Panic
disorders are treated with a combination of benzodiazepines or
antidepressants and (b)
11. Another anxiety disorder characterized by increased physiological arousal and an intense, excessive, and irrational fear that is
out of all proportion to the danger elicited by the object or situation is called a
12. The DSM-IV-TR divides phobias into three categories. Those
that are triggered by common objects, situations, or animals (such
as snakes or heights) are called (a)
Photo Credits: (#1) © San Diego Union Tribune/ZUMA Press; (#4) © AP Images/Ruth Fremson
2. Mental disorders arise from the interaction of a number of
factors. Biological factors include inherited behavioral tendencies,
which are called (a)
factors. These factors contribute from 30% to 60% to the development of mental disorders.
Biological factors also include the overreaction of brain structures
to certain stimuli, which are called (b)
Other factors that contribute to the development of mental disorders, such as deficits or problems in thinking, processing emotional stimuli, and social skills, are called (c)
factors. Being in or seeing a traumatic event, which is called an
factor, can contribute to developing a mental
disorder such as PTSD.
Those that are brought on by having to perform in social situations and expecting to be humiliated and embarrassed are called
phobias. Those that are characterized by
fear of being in public places from which it may be difficult or
embarrassing to escape if panic symptoms occur are called
. Once established, phobias are extremely
persistent and may require treatment.
13. Persistent, recurring irrational thoughts that a person is
unable to control and that interfere with normal functioning are
called (a)
. Irresistible impulses to perform some
ritual over and over, even though the ritual serves no rational purpose, are called (b)
. A disorder that consists of
both of these behaviors and that interferes with normal functioning
is called (c)
. The most effective nondrug treatment for obsessive-compulsive disorder is (d)
E. Somatoform Disorders
14. The appearance of real physical symptoms and bodily complaints that are not
under voluntary control, have no known
physical causes, extend over several years,
and are believed to be caused by psychological
factors is characteristic of (a)
disorders. The DSM-IV-TR lists seven kinds
of somatoform disorders. The occurrence of
multiple symptoms—including pain, gastrointestinal, sexual, and neurological symptoms—that have no physical causes but are triggered by psychological problems or distress
is referred to as (b)
disorder; a disorder characterized by unexplained and significant physical symptoms or
deficits that affect voluntary motor or sensory functions and
that suggest a real neurological or medical problem is called a
disorder. A recent survey reported that
somatoform disorders occur worldwide, although their symptoms
may differ across cultures.
Photo Credit: (#14) © Marvin Mattelson
F. Cultural Diversity: An Asian Disorder
15. A social phobia found in
Percentage of Students
Asia, especially Japan, that is
characterized by morbid fear
of making eye-to-eye contact,
blushing, giving off an offensive
odor, having an unpleasant or
tense facial expression, or having trembling hands is called
. This phobia appears to result from Asian cultural and social influences that stress the importance of showing
proper behavior in public.
G. Research Focus: School Shootings
16. A method of investigation that involves an indepth analysis of the thoughts, feelings, beliefs,
experiences, behaviors, or problems of a single
individual is called a (a)
This method was used to decide if teenage
school shooters had repetitive and persistent
patterns of behavior that had been going on
for at least a year and involved threats or
physical harm to people or animals, destruction of property, being deceitful, or stealing. These symptoms
define a mental disorder that is called (b)
H. Application: Treating Phobias
17. There are several different treatments for
phobias. A nondrug treatment combines changing
negative, unhealthy, or distorted thoughts and
beliefs by substituting positive, healthy, and realistic
ones and learning new skills to improve functioning; this treatment is called (a)
therapy. Another therapy that gradually exposes
the person to the real anxiety-producing situations or objects that he or she has been avoiding
is called (b)
therapy. Individuals who are
unwilling or too fearful to be exposed to fearful situations or
objects may choose drug therapy.
18. Social and specific phobias have been successfully treated
with tranquilizers called (a)
. Although these
drugs are effective, they have two problems: When individuals stop
taking these drugs, the original fearful symptoms may return,
which is called (b)
; and, if individuals are maintained on drugs for some length of time, they may develop tolerance, which means they will have to take larger doses, which in
turn may cause side effects such as loss of (c)
Researchers found that drug therapy was about equally effective
as cognitive-behavioral or exposure therapy in reducing both
social and specific phobias, including agoraphobia.
Answers: 1. mental disorder; 2. (a) genetic, (b) neurological, (c) cognitiveemotional-behavioral, (d) environmental; 3. (a) statistical frequency,
(b) social norms, (c) maladaptive behavior; 4. (a) clinical assessment,
(b) clinical interview, (c) clinical interview, psychological tests, neurological
tests; 5. (a) symptoms, (b) treatment; 6. (a) clinical diagnosis, (b) Diagnostic and Statistical Manual of Mental Disorders-IV-TR; 7. (a) axes,
(b) labeling; 8. generalized anxiety; 9. panic; 10. (a) panic attack,
(b) psychotherapy; 11. phobia; 12. (a) specific, (b) social, (c) agoraphobia;
13. (a) obsessions, (b) compulsions, (c) obsessive-compulsive disorder,
(d) exposure; 14. (a) somatoform, (b) somatization, (c) conversion;
15. taijin kyofusho, or TKS; 16. (a) case study, (b) conduct disorder;
17. (a) cognitive-behavioral, (b) exposure; 18. (a) benzodiazepines,
(b) relapse, (c) memory
Critical Thinking
Why Women Marry
Killers behind Bars
How would clinicians decide if
women who fall in
love with killers have
a mental disorder?
Do women who
almost instantly
fall in love with prisoners they have never
met have obsessivecompulsive disorder?
According to
the three definitions of abnormal
behavior, is Doreen
Lioy abnormal?
According to
Freud’s psychodynamic theory of
personality, why is
it difficult to explain
why women fall in
love with and marry
Which of the five
axes in the DSMIV-TR best describes
the problems these
women share?
What are the
advantages and
disadvantages of
labeling these women’s problems?
Photo Credit: © GN/RCS Reuters
n 2004, Scott Peterson was
convicted of murdering his
wife and unborn child. Within an hour of being on Death
Row, he received a marriage
proposal from a woman he
didn’t even know. As if this
prop o s a l wa s n’t bi z a r r e
enough, on Scott’s first day
at San Quentin State Prison,
the warden’s office received
calls from over 30 women
A woman fell in love with a convicted and jailed killer.
desperate to make contact
with the convicted killer, many of kept by inmate after the marriage
them believing they were in love ceremony. The marriage ceremony
with Peterson.
will be conducted in the visiting
About a decade earlier, Doreen area with the glass separating the
Lioy, a 41-year-old woman, fell in couple being married” (“Inmate
love with satanic serial killer Rich- marriages,” 2007).
ard Ramirez, who was convicted of
According to Sheila Isenberg, autorturing, sexually abusing, and thor of Women Who Marry Men
murdering 13 people. Lioy described Who Kill, women who pursue intiher attraction to Ramirez beginning mate relationships with killers are
immediately upon seeing his mug usually attractive, intelligent, and
shot on TV: “I saw something in his very well accomplished. Isenberg
eyes. Something that captivated me” also says most of these women have
(Warrick, 1996, E-1). Lioy began come from loveless homes and have
sending Ramirez letters and visiting been abused by men earlier in their
him behind bars, and soon after lives. Gilda Carle, a relationship adthey married at the prison, even viser, explains that these women are
though Ramirez would eventually attracted to the “bad boy syndrome”
be executed. Lioy speaks about her and they feel special when the man
complete devotion to her new hus- who has hurt and killed others treats
band: “Because of my love for Rich- them with love, kindness, and reard, I have given up my family, spect. In fact, the most repugnant
home, employment, and friends” murderers receive the most attention
(Warrick, 1996, E-1).
from women.
There is such a demand for prisonWomen in love with convicted killer romance that matchmaking web- ers find the danger, excitement, and
sites, such as prisonpenpals.com, drama of prison romance more
offer thousands of ads from inmates arousing than the routine and prewho want to find love outside of their dictability of romance outside prison.
cellblocks. Marriages in prisons are Having an intimate relationship with
common enough for each prison to a man behind bars also makes the rehave its own set of regulations for in- lationship exceptionally safe. (Adaptmate marriages. Some of the rules ed from Fimrite & Taylor, 2005; “Infor one California prison include: mate marriages,” 2007; Warrick,
“No property will be exchanged and 1996, 1997; Wiltenburg, 2003)
Links to Learning
Key Terms/Key People
agoraphobia, 518
antidepressant drugs, 519
assessment, 512
aviophobia, 509
Axis I: Nine major clinical
syndromes, 514
Axis II: Personality
disorders, 515
Axis III: General medical
conditions, 515
Axis IV: Psychosocial
and environmental
problems, 515
Axis V: Global assessment
of functioning scale, 515
case study, 523
clinical assessment, 512
clinical diagnosis, 513
clinical interviews, 512
therapy, 524
cognitive-emotionalbehavioral and environmental factors, 510
conduct disorder, 523
conversion disorder, 520
definitions of abnormal
behavior, 511
deviation from social
norms, 511
Diagnostic and Statistical
Manual of Mental
Disorders, 513
drug treatment of
phobias, 525
exposure therapy, 519, 524
frequency of mental
disorders, 516
generalized anxiety
disorder, 517
genetic factors, 510
insanity, 509
labeling, 516
maladaptive behavior, 511
maladaptive behavior
approach, 511
mass hysteria, 520
mental disorder, 509
neurological tests, 512
disorder, or OCD, 519
panic attack, 517
panic disorder, 517
personality tests, 512
phobia, 509, 518
posttraumatic stress
disorder, 519
psychological tests, 512
school shootings, 523
social and political
implications of
labeling, 516
social customs, 522
social norms approach, 511
social phobia, 518
social phobia: public
speaking, 525
somatization disorder, 520
somatoform disorders, 520
specific phobia, 518
statistical frequency
approach, 511
taijin kyofusho, or TKS, 522
virtual reality therapy, 524
Learning Activities
PowerStudy for Introduction
PowerStudy 4.5™
to Psychology 4.5
Try out PowerStudy’s SuperModule for Assessment & Anxiety Disorders! In
addition to the quizzes, learning activities, interactive Summary Test, key
terms, module outline and abstract, and extended list of correlated websites
provided for all modules, the DVD’s SuperModule for Assessment & Anxiety
Disorders features:
disorder, and virtual reality therapy.
pages 526–527 and the critical thinking questions for the article on page 528.
Want to maximize your online study time? Take this easyto-use study system’s diagnostic pre-test and it will create a personalized study
plan for you. The plan will help you identify the topics you need to understand
better and direct you to relevant companion online resources that are specific
to this book, speeding up your review of the module.
Introduction to Psychology Book Companion Website
Visit this book’s companion website for more resources to help you
study, including learning objectives, additional quizzes, flash cards, updated
links to useful websites, and a pronunciation glossary.
Study Guide and WebTutor
Work through the corresponding module in your Study
Guide for tips on how to study effectively and for help learning the material
covered in the book. WebTutor (an online Study Tool accessed through your
eResources account) provides an interactive version of the Study Guide.
Suggested Answers to Critical Thinking
1. Clinicians would use a clinical assessment (neurological and psychological/personality tests and interviews) to identify symptoms and then
match symptoms to the mental disorders listed in the DSM-IV-TR.
2. These women may have obsessions, which are persistent, irrational
thoughts, but there is no indication that the obsessions cause marked
anxiety or that the women engage in compulsions, which are irresistible, senseless behaviors or rituals.
3. A woman who falls in love with a convicted killer after seeing his mug
shot and pursues him even though he will never be able to leave prison is certainly abnormal in terms of statistical frequency, in terms of
deviation from social norms, and in terms of engaging in maladaptive
behavior (giving up family, home, work, friends).
4. According to Freud’s psychodynamic theory of personality,
women who fall in love with and marry killers are influenced by
unconscious forces, wishes, and repressed desires, which are
difficult to examine and understand because they are unconscious and not easily revealed or brought to the surface.
5. To identify potential problems of women who fall in love with killers, clinicians might use Axis II, which focuses on long-standing
personality traits that are maladaptive or impair functioning.
6. One advantage of labeling these women’s problem is that it
may help decide which therapy is best. One disadvantage is that
giving women a label may bias how others perceive and respond
to her.
A. Mood Disorders
B. Electroconvulsive Therapy
C. Personality Disorders
D. Schizophrenia
Concept Review
E. Dissociative Disorders
F. Cultural Diversity: Interpreting Symptoms
G. Research Focus: Exercise Versus Drugs
H. Application: Dealing with Mild Depression
Summary Test
Critical Thinking
What Is a Psychopath?
Links to Learning
PowerStudy 4.5™
Complete Module
Photo Credit: © AP Images/Vincent Yu
Mood Disorders
& Schizophrenia
Photo Credits: both, © Robert Gauthier
Mood Disorder
Chuck Elliot (photo below) was checkWhy do
ing out the exhibits at an electronics
his thoughts
convention in Las Vegas when suddenly
his mind seemed to go wild and spin at
speed up?
twice its regular speed. His words could
not keep up with his thoughts,
and he was talking in what
sounded like some strange
code, almost like rapid fire
“dot, dot, dot.” Then he
stripped off all his clothes
a nd r a n s t a rk n a k e d
through the gambling
casi no of t he Hi lton
Hotel. The police were
called, and Chuck was taken
to a mental hospital. After his
symptoms were reviewed,
Chuck was diagnosed with
what was then called manic
Chuck Elliot’s mind spins
and whirls out of control. He
was diagnosed with having
At one time, Chuck had a
bipolar I disorder.
very successful career. After
taking postgraduate courses, he obtained a doctor of education degree (Ed.D.). He started and ran his own video production business while also designing computer software.
But since that first strange episode at the computer electronics convention, Chuck has been hospitalized about twice a
year when his mind races and spins wildly out of control in
what are called manic episodes. He usually takes medication,
but because the drug slows him down more than he likes, he
stops taking his medication every so often. Without medication, his energy may come back with such force that it blasts
him into superactive days and sleepless nights, and he often
ends up in a psychiatric hospital.
His last regular job ended when he was in the middle of
another manic attack. He was going on 100 hours without
sleep when he went out to his car, grabbed a bunch of magazines, books, fruits, and vegetables, and piled them all on the
desk in his office. When his boss came by and found a desk
piled high with junk and Chuck sitting there with his mind
spinning, the boss fired him on the spot (C. Brooks, 1994).
Since that time, despite his very good academic, computer,
and business qualifications, he has not been able to hold a
steady job.
More recently, Chuck married a woman he had been
dating for only ten days. She understands Chuck very well
because she too is manic-depressive and has similar mental
health problems. She hopes that they can care for each other.
She says, “Chuck is the most brilliant man I have ever met. I
am so lucky” (C. Brooks, 1994, p. 4).
In this module, we’ll explain Chuck’s illness, his treatment,
and how he is dealing with his problem.
When Michael McCabe was 18 years old, Marsha,
his mother, thought that he was just about over his
rebellious phase. She was looking forward to
relaxing and enjoying herself. But then Michael
said that he was hearing voices. At first Marsha
thought that Michael’s voices came from his smoking marijuana. But
the voices persisted for two weeks, and Marsha checked Michael into a
private drug treatment center. He left the center after 30 days and
seemed no better off than he had been before. Several days later, Marsha found Michael in her parents’ home, a couple of miles down the
road from her own house. Michael was sitting on the floor, his head
back, holding his throat and making grunting sounds like an animal.
Marsha got really scared and called the police, but before they arrived,
Michael ran off.
Michael spent time with his grandparents, who finally called Marsha
and said that they couldn’t take his strange behavior anymore. Once
again Marsha called the police. Just as Michael (photo below) tried
to run away, the police caught him and took him to the community
psychiatric hospital.
Marsha received a call from
a psychiatrist at the hospital,
who explained that Michael
had been diagnosed as having schizophrenia, a serious
mental disorder that includes
hea ring voices a nd hav ing
disoriented thinking. A few
days later, Michael escaped
from the hospital. He was later
returned by police, put into
leather restraints, and given
antipsychotic drugs that would
also calm him down. Michael
Michael McCabe, 18 years old, began
remained in the hospital and
hearing voices and was diagnosed with
was treated with drugs for about
having schizophrenia.
a month, with little success.
Just about the time Marsha was at her wits’ end about what to do
next, Michael was put on a new antipsychotic drug, clozapine. After
about a month on the new drug, Michael improved enough to be discharged back into Marsha’s care (C. Brooks, 1994, 1995a).
In this module, we’ll explain what schizophrenia is, describe the
drugs Michael was given, and report how his treatment is working.
Why was
he hearing
What’s Coming
We’ll discuss several different mental disorders and their treatments.
We’ll explain mood disorders and their treatments, including the treatment of last resort for depression, electroconvulsive shock therapy.
We’ll also examine several personality disorders and different kinds of
schizophrenia, along with old and new antipsychotic drugs. We’ll end
with a group of strange and unusual disorders, one of which is multiple
personality disorder.
We’ll begin with Chuck Elliot’s problem, which is an example of one
kind of mood disorder.
A. Mood Disorders
Kinds of Mood Disorders
Depression is not choosy; it happens to about 6 million
Americans a year. Major depression is one example of
a mood disorder.
blues that most of us feel as having a paper cut on our finger.
Then major depression is more like having to undergo openheart surgery. It’s some of the worst news that you can get.
The DSM-IV-TR lists ten different mood disorders, but
we’ll focus on the symptoms of three of the more common
forms: major depressive disorder, bipolar I disorder, and
dysthymic disorder.
A mood disorder is a prolonged and disturbed emotional
state that affects almost all of a person’s thoughts, feelings, and behaviors.
Most of us have experienced a continuum of moods, with depression
on one end and elation on the other. However, think of the depression or
Major Depression
Bipolar I Disorder
Dysthymic Disorder
Popular singer-songwriter Sheryl Crow (photo below)
says that she has battled major depression most of her life.
Unlike Sheryl Crow,
who has a major
depressive disorder, Chuck Elliot
(right photo) fluctuates between two
extreme moods of
depression and
mania; he has
what is called bipolar I disorder.
Another mood disorder that is less
serious than major depression is
called dysthymic (dis-THY-mick)
Major depressive disorder is marked by at least two
weeks of continually being in a bad mood, having no interest
in anything, and getting no pleasure from activities. In addition,
a person must have at least four of the following symptoms:
problems with eating, sleeping, thinking,
concentrating, or making decisions,
lacking energy, thinking about suicide, and feeling worthless or
guilty (American Psychiatric
Association, 2000).
Sheryl Crow says that she
had been on a world tour with
Michael Jackson, singing in
front of 70,000 screaming
fans. When the tour ended, she was back in her lonely
apartment with the anxiety of having to get a record
contract. All this stress triggered her first bout of depression, which resulted in her lying in bed, hardly able to
move, going unshowered, stringy-haired, and ordering
take-out for seven straight months (Hirshey, 2003). Like
Crow, about 16%
Major Depressive Disorder
of U.S. adults
reported at least
one lifetime
episode of major
with women
men by a ratio
Time (years)
of 2 to 1 (Thase,
To help understand mood disorders, look at the
graph above, which shows three general mood states.
The top bar shows a manic episode or period of incredible energy and euphoria that we’ll discuss later. The
middle bar shows a normal period when a person’s
moods and emotions do not interfere with normal psychological functioning. However, like what happened
to Crow, some event may cause a person to go from a
normal period to a period of depression (bottom bar).
Individuals may fluctuate between a normal period and
a bout of severe depression.
Bipolar I disorder is marked by fluctuations between episodes of depression
and mania. A manic episode goes on for
at least a week, during which a person is
unusually euphoric, cheerful, and high
and has at least three of the following
symptoms: has great self-esteem, has
little need for sleep, speaks rapidly and
frequently, has racing thoughts, is easily
distracted, and pursues pleasurable
activities (American Psychiatric
Association, 2000).
About 1.3% of the population
suffer from bipolar I disorder, and
1.6% suffer from only manic episodes
(Rush, 2003).
Chuck Elliot has the typical pattern of bipolar I disorder. As shown
in the graph below, Elliot may have
periods of being normal, which may
turn into extreme manic episodes
followed by periods of extreme
Bipolar I Disorder
Time (years)
Dysthymic disorder is characterized by being chronically but not continuously depressed for a period of two
years. While depressed, a person experiences at least two of the following
symptoms: poor appetite, insomnia,
fatigue, low self-esteem, poor concentration, and feelings of hopelessness
(American Psychiatric Association,
Individuals with dysthymic
disorder, which affects about
6% of the population, are often
described as “down in the dumps.”
Some of these individuals become
accustomed to such feelings and
describe themselves as “always
being this way.”
Besides these three mood
disorders, we have also discussed
another mood disorder, seasonal affective disorder, or SAD
(p. 159). People with SAD become
depressed as a result of a decrease
in the number of sunny days,
such as occurs in fall and winter
months, and they recover with the
arrival of summer.
Next, we’ll examine some of the
common causes of mood disorders.
Photo Credits: left, © Evan Agostini/Getty Images; center, © Robert Gauthier
How bad
is it?
Causes of Mood Disorders
Sheryl Crow says that she has had a lifetime battle with
mood disorders and, contrary to popular myths, when
depressed she cannot make great music or work much at
anything. Crow thought her depression was due to some
Biological Factors
Psychosocial Factors
Using recently developed techniques for studying the living brain and
information from mapping the genetic code (Human Genome Project—
p. 68), researchers have been actively studying biological factors involved in
mood disorders.
In addition to biological factors, an individual may be at
risk for depression because of psychosocial factors.
Biological factors underlying depression are genetic, neurological, chemical, and
physiological components that may predispose or put someone at risk for developing
a mood disorder.
Photo Credits: top, © Evan Agostini/Getty Images; right, © Imagesource/Photolibrary
chemical imbalance in her brain and that depression ran in families (partly inherited or genetic)
because her father suffered from similar mood
problems (Hirshey, 2003). Let’s see if she’s right.
Genetic factors. Sheryl Crow was right about depression having a
genetic component. Research studies comparing depression rates of identical twins with those of fraternal twins, who share only 50% of their
genes, find that 40–60% of each individual’s susceptibility to depression is
explained by genetics (Canli, 2008). Researchers believe there is no single
gene but rather a combination of genes that produces a risk, or predisposition, for developing a mood disorder (B. Bower, 2009b; Levinson, 2009). One
theory states that defects in specific genes affect our sensitivity to stress,
which can result in depression (D. R. Weinberger, 2005). Genes play a role
in developing a mood disorder because genes are involved in regulating
the brain’s neurotransmitter or chemical system used for communication
(Canli, 2008).
Neurological factors. Sheryl Crow was also right about depression
involving a chemical imbalance in her brain. A group of neurotransmitters, called the monoamines (serotonin, norepinephrine, and dopamine),
are known to be involved in mood problems. Abnormal levels of certain
neurotransmitters can interfere with the functioning of the brain’s communication networks and, in turn, put individuals at risk for developing
mood disorders. More recently, researchers discovered that continued stress
causes the brain and the body’s stress management machinery (p. 485) to go
into overdrive, which in turn alters hormonal and neurotransmitter levels
and can trigger depression (Thase, 2009).
Brain scans. Researchers took computerized photos of the structure
and function of living brains and compared brains of depressed patients
with those of individuals with normal moods. Researchers reported that a
brain area called the anterior cingulate cortex (figure below) was overactive
in very depressed patients. When the anterior cingulate cortex is overactive, it allows negative emotions to overwhelm thinking and mood. These
same researchers cured two-thirds of a group
of very depressed patients who had not
benefitted from years of psychotherapy,
drugs, or electroconvulsive therapy
(p. 535) by electrically stimulating
the brain, which led to reduced
activity in the anterior cingulate
cortex (Mayberg, 2006; Mayberg et al., 2005). This and other
research examining the brains of
depressed patients suggest that faulty
The anterior cingulate cortex is
overactive in very depressed patients,
brain structure or function contribwhich allows negative emotions to
utes to the onset and/or maintenance
overwhelm thoughts and mood.
of mood disorders (Thase, 2009).
Psychosocial factors, such as personality traits, cognitive
styles, social supports, and the ability to deal with stressors,
interact with predisposing biological factors to put one at risk
for developing a mood disorder.
Stressful life events. Sheryl Crow says that her
period of depression was triggered by the overwhelming
stress of seeing a fantastic world tour end with her living in a lonely apartment, having to wait on tables while
struggling to get a record contact. Researchers found that
stressful life events are strongly related to the onset of
mood disorders such as depression (Kendler et al., 2004).
Negative cognitive style. There is considerable
research to support Aaron Beck’s (1991) idea that depression may result from one’s perceiving the world in a negative way, which in turn leads to feeling depressed. We’ll
discuss Beck’s theory later in the Application, but just
note here that having a negative cognitive style or negative way of thinking and perceiving can put one at risk
for developing a mood disorder
such as depression.
Personality factors. IndiCertain
viduals who are especially
sensitive to and overreact to
factors increase
negative events (rejections, critirisk for mood
cisms) with feelings of fear, anxidisorders.
ety, guilt, sadness, and anger are at
risk for developing a mood disorder
(D. N. Klein et al., 2002). Researchers also found that
individuals who make their self-worth primarily dependent on what others say or think have a kind of socially
dependent personality, which puts them at risk for
becoming seriously depressed when facing the end of a
close personal relationship or friendship. Some individuals have a need for control, which puts them at risk for
depression when they encounter uncontrollable stress
(Mazure et al., 2000).
Depressed mothers. Research shows that a depressed
mother significantly increases her child’s susceptibility
to depression, even if the child is adopted and shares no
genes with the mother. Also, when depressed mothers
receive successful treatment, their depressed children
experience mood improvement without receiving therapy
themselves (B. Bower, 2008c; Tully et al., 2008).
The above psychosocial factors interact with underlying biological factors to increase one’s risk of developing
a mood disorder (Thase, 2006).
Next, we discuss the treatment for depression.
A. Mood Disorders
Treatment of Mood Disorders
Because the causes of depression include both biological and psychosocial factors, the treatment for depression,
depending upon the diagnosis and severity, may include psychotherapy, antidepressant drugs, or both. We’ll discuss the effectiveness of drugs and psychotherapy.
Major Depression and Dysthymic Disorder
Bipolar I Disorder
After months of depression, Sheryl Crow’s mother finally persuaded her (with
threats of coming to haul her baby out of bed) to get professional treatment,
which involved both psychotherapy and antidepressant drugs.
Unlike Sheryl Crow’s problem, which is major depressive disorder, Chuck Elliot has bipolar I disorder,
which means he cycles between episodes of depression
and mania. For example, one of Elliot’s manic episodes lasted four days, during which he was in almost
constant motion and did not sleep. Several times,
when he lost control, he screamed at
his wife and ripped the blinds from
the windows. His wife called the
police, who handcuffed Elliot (right
photo) and drove him to a psychiatric hospital for drug treatment.
Treatment. In the past, the drug
of choice to treat bipolar I disorder
was a mood stabilizer called lithium
(LITH-ee-um). Although still used
Bipolar I
is treated with
today as the drug of choice, lithium
and other
is often combined with other drugs, lithium
including antipsychotics and antidepressants, which offer a more effective long-term
treatment program (C. F. Newman, 2006).
Lithium is thought to prevent manic episodes
by preventing neurons from being overstimulated
(Lenox & Hahn, 2000). When Elliot takes medication,
he functions well enough that he has enrolled in law
school and is working toward his degree. The problem
arises when Elliot doesn’t take lithium. When patients
with bipolar I disorder stop taking lithium (and combined drugs), about 50% experience a manic episode
(P. E. Keck & McElroy, 2003). In terms of effectiveness, 50% of bipolar patients are greatly helped with
a combined drug program (lithium plus other drugs),
30% are partially helped, and 20% get little or no help
(F. K. Goodwin, 2003).
Mania. Lithium has been found to be effective in
treating individuals with mania—that is, the manic
episodes without the depression (F. K. Goodwin,
2003). Because lithium prevents mania, patients may
stop taking it to experience the euphoria they miss, as
Elliot did several times.
Relapse. For both major depression and bipolar
I disorder, 10–30% of patients receive no help from
current drugs and 30–70% initially improve but later
relapse. Researchers are constantly searching for new
ways to treat mood disorders and prevent relapse.
For individuals with major depression who are not
helped by drugs, there is something called the treatment
of last resort.
Antidepressant drugs act by increasing the levels of a specific
group of neurotransmitters (monoamines—serotonin, norepinephrine,
and dopamine) that are involved in the regulation of emotions and
Selective serotonin reuptake inhibitors—SSRIs. About
80% of prescribed antidepressant drugs, such as Prozac and
Zoloft, belong to a group of drugs called SSRIs (selective
often requires
serotonin reuptake inhibitors) (Noonan & Cowley, 2002). The
SSRIs work primarily by raising the level of the neurotransmithelp.
ter serotonin. Common side effects include nausea, insomnia,
sedation, and sexual problems (decreased libido, erectile dysfunction) (Gitlin,
2009; Khawam et al., 2006). Antidepressants have recently become the most
commonly prescribed medication in the United States, used by 10% of the population (Olfson & Marcus, 2009).
Effectiveness of antidepressants. When depressed patients use an antidepressant, which may take up to 8 weeks to work, symptoms for only onethird of the patients will go away (comparable to the recovery rate for a placebo)
(Berenson, 2006). The challenge for physicians prescribing antidepressants is
that for any given individual, some antidepressants work better than others,
but no one antidepressant has been found to be more effective for everyone.
Often, patients must try a second or third antidepressant until they find one
that works well and has minimal side effects (Arkowitz & Lilienfeld, 2007b).
Psychotherapy. Researchers compared patients who had received antidepressant drugs, psychotherapy, or a combination of drugs and psychotherapy
to treat major depression. For patients with less severe
depression, psychotherapy was as effective as antidepressant drugs. For patients with more severe
depression, a combination of antidepressant drugs
(SSRIs) and psychotherapy was more effective than
either treatment alone (Hollon et al., 2002).
Relapse. When patients who had recovered were
followed for 18 months, the results were discouraging because, within that time, 70% of the patients had
relapsed, which means they became depressed again
and required additional treatment. Of those who main- and
are about equally
tained their recovery and were doing well, 30% had
been treated with psychotherapy, 20% with antidepressant drugs, and 20% with placebos. Thus, patients treated with psychotherapy
were somewhat less likely to relapse than those treated with drugs or placebos
(Shea et al., 1992). Psychotherapy may take longer to begin working, but its
strength is in reducing the likelihood of relapse (Charney, 2009).
Because 70% of patients treated for depression relapse within 18 months and
82% relapse during the first five years, clinicians concluded that major depression
is a long-term or chronic disorder that may require further treatments during
the patient’s lifetime (Moran, 2004; Vos et al., 2004).
Photo Credits: left, © Evan Agostini/Getty Images; right, © Robert Gauthier
What’s the
B. Electroconvulsive Therapy
Photo Credits: top, © Photo Researchers, Inc.; bottom, © Canadian Press/Phototake
Because the use of shock as therapy has
What’s it
often been portrayed incorrectly in the
like to get
media, it helps to see the treatment from
the eyes of an actual patient.
“. . . As far as manic-depressive tales
go, my stories are typical. My illness went undiagnosed for a
decade, a period of euphoric highs and desperate lows highlighted by $25,000
shoppi ng sprees,
impetuous trips to
Tokyo, Paris, and
M i la n, d r ug a nd
alcohol binges. . . .
After seeing eight
psychiatrists, I fin a l l y re c e i ve d a
Electrodes on this patient’s forehead will
diagnosis of bipocarry electricity through the brain and
lar disorder on my
cause a major seizure.
32nd birthday. Over
the next year and a half, I was treated unsuccessfully with
more than 30 medications. My suburban New Jersey upbringing, my achievements as a film major at Wesleyan, and
a thriving career in public relations couldn’t help me. . . . As a
last resort, I’m admitted to the hospital for ECT, electroconvulsive therapy, more commonly known as electroshock. . . .
The doctor presses a button. Electric current shoots through
my brain for an instant, causing a grand-mal seizure for 20
seconds. . . . I wake up 30 minutes later and think I’m in a
hotel room in Acapulco. My head feels as if I’ve just downed
a frozen margarita too quickly. . . . After four treatments,
there is marked improvement. No more egregious highs or
lows. But there are huge gaps in my memory. I avoid friends
and neighbors because I don’t know their names anymore. I
can’t remember the books I’ve read or the movies I’ve seen.
I have trouble recalling simple vocabulary. I forget phone
numbers. . . . But I continue treatment because I’m getting
better. . . . On the one-year anniversary of my first electroshock treatment, I’m clearheaded and even-keeled. I call my
doctor to announce my ‘new and improved’ status. . . . Two
and a half years later, I still miss ECT. But medication keeps
my illness in check, and I’m more sane than I’ve ever been”
(Behrman, 1999, p. 67).
This patient received electroconvulsive therapy (ECT).
Electroconvulsive therapy, or ECT, involves placing electrodes on the skull and administering a mild electric current that
passes through the brain and causes a seizure. Usual treatment
consists of a series of 10 to 12 ECT sessions, at the rate of about
three per week.
Usage. Because antidepressants fail to decrease depression in up to 40% of patients, many of these patients choose
to undergo ECT, a last resort option to treat their severe
depression. In the United States, ECT is currently used for
100,000 patients per year (Gitlin, 2009; Newsweek, 2006;
Westly, 2008).
Effectiveness of ECT
Because antidepressants had not worked, the
patient we just described agreed to ECT. The reason ECT is the last resort for treating depression
is that ECT produces major brain seizures and
may cause varying degrees of memory loss. However, even as a treatment of last resort, ECT is effective in reducing
depressive symptoms in about 70–90% of patients (Husain et al., 2004).
For example, the graph below shows the results for eight out of nine seriously depressed patients who had received no help from antidepressants.
After a series of ECT treatments, they showed a dramatic reduction in
depressive symptoms and remained symptom-free after one year (Paul et
al., 1981). However, the average
relapse rate after ECT treatment
exceeds 50%, which means patients
may need antidepressant therapy
following ECT treatment or addi8
tional ECT treatments for depresPost-ECT
sion (Nemeroff, 2007). Researchers
are not sure how ECT works but
suggest it changes brain chemistry
1 0 1 2 3 4 5
and restores a normal balance to
neurotransmitters (Salzman, 2008).
Modern ECT. Unlike patients who received ECT in the movie One
Flew Over the Cuckoo’s Nest, there is no evidence that modern ECT procedures cause brain damage or turn people into “vegetables” (Ende et al.,
2000). Modifications to modern ECT, including the proper placement of
electrodes on the scalp and reduced levels of electric current, have lessened the risk for complications (Nemeroff, 2007; Sackeim et al., 2000).
Memory loss. A side effect of ECT is memory loss, which ranges from
a loss of memory for events experienced during the weeks of treatment to
events both before and after treatment. Following ECT treatment, there
is a gradual improvement in memory functions, and for most patients,
memory returns to normal levels. However, some patients complain of
long-term memory problems (Gitlin, 2009; Sackeim & Stern, 1997).
Mental health experts cautiously endorse ECT as a treatment of last
resort for severe depression (Glass, 2001; K. G. Rasmussen, 2003). Now
we’ll briefly discuss another last resort treatment.
New treatment. For patients with treatment-resistant depression, a new
treatment option is transcranial magnetic stimulation (shown below).
Why is ECT
considered the
last resort?
Daily depression rating
Definition and Usage
Transcranial magnetic stimulation (TMS) is a noninvasive technique that
activates neurons by sending pulses of magnetic energy into the brain.
Research shows that depressed patients who did not
benefit from various medications experienced significant improvement in symptoms after 40 minutes
of TMS daily for four weeks (O’Reardon
et al., 2007). Although side effects, such
as headache, light-headedness, and
scalp discomfort, may occur, advantages of TMS over ECT are that it is
unlikely to cause seizures and does
not require anesthesia (Baldauf, 2009;
George, 2009).
Next, we’ll discuss a disorder
shared by many serial killers.
C. Personality Disorders
We have all heard the expression “Don’t judge a book by its
What are serial
cover.” That advice proved absolutely true when we heard
what their friends and neighbors said about the following
killers like?
His boss said David Berkowitz was “quiet and reserved and kept pretty much to
himself. That’s the way he was here, nice—a quiet, shy fellow.” Berkowitz, known
as “Son of Sam,” was convicted of killing six people.
A neighbor of Westley Allan Dodd said that he “seemed so harmless, such an
all-around, basic good citizen.” Dodd was executed for kidnapping, raping, and
murdering three small boys.
A neighbor said John Esposito “was such a quiet, caring person. He was a very
nice person.” Esposito was charged with kidnapping a young girl and keeping her
in an underground bunker for 16 days.
A friend said Jeffrey Dahmer “didn’t have much to say,
was quiet, like the average Joe.” Dahmer confessed to killing and dismembering 15 people (Time, July 12, 1993,
p. 18).
Notice how friends and neighbors judged all these
cold-blooded killers to be “quiet” and “nice” and even
“caring” individuals. However, while these individuals
appeared very ordinary in public appearance and behavior, each was hiding a deep-seated, serious, and dangerous
personality disorder (Hickey, 2006).
Why do friends describe
serial killers, such as
Dahmer, as quiet,
nice, and caring?
A personality disorder consists of inflexible, long-standing,
maladaptive traits that cause significantly impaired functioning
or great distress in one’s personal and social life (American
Psychiatric Association, 2000).
Personality disorders are found in about 9% of the adult population in the
United States, affecting men and women equally, although gender may influence
which personality disorder a person develops (Kluger, 2003). Of the ten different personality disorders described in DSM-IV-TR, here are seven of the more
common types.
O Paranoid personality disorder is a pattern of distrust and suspiciousness and perceiving
others as having evil motives (0.5–2.5% of population).
O Schizotypal personality disorder is characterized by an acute discomfort in close relationships, distortions in thinking, and eccentric behavior (3–5% of population).
O Histrionic personality disorder is characterized by excessive emotionality and attention
seeking (2% of population).
O Obsessive-compulsive personality disorder is an intense interest in being orderly,
achieving perfection, and having control (4% of population).
O Dependent personality disorder refers to a pattern of being submissive and clingy
because of an excessive need to be taken care of (2% of population).
O Borderline personality disorder is a pattern of instability in personal relationships, selfimage, and emotions, as well as impulsive behavior (2% of population).
O Antisocial personality disorder refers to a pattern of disregarding or violating the rights
of others without feeling guilt or remorse (3% of population, predominantly males)
(American Psychiatric Association, 2000).
Individuals with personality disorders often have the following characteristics:
troubled childhoods, childhood problems that continue into adulthood, maladaptive or poor personal relationships, and abnormal behaviors that are at the extreme
end of the behavioral continuum. Their difficulties arise from a combination of
genetic, psychological, social, and environmental factors (Vargha-Khadem, 2000).
We’ll focus on two particular personality disorders, the borderline personality
and antisocial personality, because they are mentioned most often by the media.
Borderline Personality Disorder
People who have borderline
personality disorder have
i nten s e , u npre d ic t able
emotional outbursts and
lack impulse control, which
causes them to express inappropriate anger and
engage in very dangerous behaviors.
About 75% of patients with borderline personality disorder hurt themselves through cutting,
burning, or other forms of self-mutilation, and
another 10% eventually commit suicide. Patients
with borderline personality are so emotionally
erratic that they are capable of expressing profound love and intense rage almost simultaneously.
Such emotional volatility makes it difficult
for them to maintain
stable interpersonal
relationships. They are
terrified of losing the
people most close to
them, yet they ragefully attack these same
people, only to later
show sweetness and
affection toward them
(APA, 2000; Cloud,
75% of people with
borderline personality
We’ll discuss the
disorder hurt themselves.
causes and treatment
of borderline personality disorder.
Causes. Borderline personality disorder
appears to have both environmental and genetic
causes. Experiencing trauma during childhood,
such as being abused or prohibited from expressing negative emotions, places individuals at risk
for this condition. Brain scan studies have shown
that the amygdala (emotional center of the brain)
in these patients is overactive, while the brain areas
responsible for controlling emotional responses are
underactive. This helps explain why these patients
lack emotional regulation. Though no specific
genes have been identified, we know that the major
symptoms of this condition, such as impulsivity
and aggression, are highly heritable (J. E. Brody,
2009; Cloud, 2009; Meyer-Lindenberg, 2009).
Treatment. The most effective treatment
for this condition is dialectical behavior therapy,
What does
it mean to be
a type of cognitive-behavioral therapy, which helps
patients identify thoughts, beliefs, and assumptions that
make their life challenging and teaches them different
ways to think and react (Linehan, 1993). Typically,
intense, long-term therapy is required, as well as
Photo Credits: left, © Alan Fredrickson/Reuters/Corbis; right, © Angela Hampton Picture Library/Alamy
Definition and Types
Antisocial Personality Disorder
The “nice,” “quiet” killers we described would probably be diagnosed as having antisocial
personality disorder or some combination of personality disorders. Between 50% and 80%
of prisoners meet the criteria for a diagnosis of antisocial personality disorder (Ogloff,
2006). But, not all people diagnosed with antisocial personality disorder are alike, and
the diagnostic symptoms vary along a continuum. At one end of the continuum are the
chronic delinquents, bullies, and lawbreakers; at the other end are the serial killers.
Delinquent. An example of someone on the delinquent end of the continuum is Tom, who always seemed to
be in trouble. As a child, he would steal items (silverware) from home and sell or swap them for things he wanted.
As a teenager, he skipped classes in school, set deserted buildings on fire, forged his father’s name on checks, stole
cars, and was finally sent to a federal institution. After Tom served his time, he continued to break the law, and by
the age of 21, he had been arrested and imprisoned 50 to 60 times (Spitzer et al., 1994).
Serial killer. At the other end of the psychopathic continuum is serial killer Jeffrey Dahmer, who would pick up
young gay men, bring them home, drug them, strangle them, have sex with their corpses, and then, in some cases, eat
their flesh. As Dahmer said in an interview, “I could completely control a person—a person that I found physically attractive, and keep them with me as long as possible, even if it meant just keep a part of them” (Gleick et al., 1994, p. 129).
We’ll discuss the causes and treatment of antisocial personality disorder.
Photo Credit: top, © Alan Fredrickson/Reuters/Corbis
What are people
with antisocial
disorder like?
Jeffrey Dahmer
was diagnosed as
having an antisocial
Antisocial personality disorder involves complex psychosocial and biological factors (Moffitt, 2005).
Psychosocial factors. Researchers have found that aggressive and
antisocial children whom parents find almost impossible to control are at
risk for developing an antisocial personality (Morey, 1997). Also, research
shows that children who experience physical or sexual abuse are at an
increased risk of developing antisocial personality disorder (D. Black,
2006). However, since many abused children do not develop an antisocial personality, it is difficult to determine how much childhood abuse
contributes to the development of antisocial personality disorder.
Biological factors. Researchers suggest that the early appearance
of serious behavioral problems, such as having temper tantrums, bullying other children, torturing animals, and habitually lying, indicates
that underlying biological factors, both genetic and neurological, may
predispose or place a child at risk for developing antisocial personality
disorder (Pinker, 2008).
Evidence for genetic factors comes from twin and adoption studies that
show that genetic factors contribute 30–50% to the development of antisocial personality disorder (Thapar & McGuffin, 1993). Evidence for neurological factors comes from individuals with brain damage and from MRI
studies on the brains of individuals with antisocial personality disorder.
For example, researchers found that early brain damage to the prefrontal cortex (shown below) resulted in two children who did not learn
normal social and moral behaviors and showed no empathy, remorse, or
guilt as adults. In addition, MRI scans (p. 70) indicated
that individuals diagnosed with antisocial personality disorder had 11% fewer brain cells in their
prefrontal cortex (A. Raine et al., 2000). Since
the prefrontal cortex is known to be involved in
important executive functions, such as making
decisions and planning, researchers suggest that
damage to or maldevelopment of the prefrontal
cortex predisposes or increases the risk of an individual developing antisocial personality disorder. Researchers believe that biological factors
can predispose individuals to act in certain ways but that the interaction
between biological and psychosocial factors results in the development
and onset of personality disorders (A. B. Morgan & Lilienfeld, 2000).
Psychotherapy has not proved very effective in treating people with antisocial personality disorder because these individuals are guiltless, mistrusting, irresponsible, and
practiced liars, who fail to see that many of their behaviors
are antisocial and maladaptive. As a result, psychotherapists
have a very difficult time changing their behavior (Bateman
& Fonagy, 2000).
Because of the
Drug that Increases Serotonin
relative ineffective45
ness of psychotherapy, clinicians have
tried various drugs
that raise levels of
serotonin in the
brain. Researchers
believe that some
abnormality in the
Baseline 2
brain’s serotonin
system may underlie the impulsive
and aggressive behaviors observed in personality disorders
(D. Black, 2006). As shown in the graph above, patients who
took a serotonin-increasing drug (sertraline) reported significant decreases in their aggressive behaviors across eight
weeks of treatment. However, researchers caution that
aggressive behaviors may return once patients stop taking
these serotonin-increasing drugs (Coccaro & Kavoussi, 1997).
Other research shows that the use of antipsychotic medication (p. 541) can decrease impulsivity, hostility, aggressiveness, and rage in patients with antisocial personality disorder
(C. Walker et al., 2003).
Even though there are some treatment successes, researchers caution that for 69% of the patients, antisocial personality
disorder is an ongoing, relatively stable, long-term problem
that needs continual treatment (G. Parker, 2000).
Next, we’ll examine one of the most tragic mental
Aggression score
D. Schizophrenia
At the beginning of this module, we described 18-year-old Michael
What if
McCabe (photo below), who said that his mind began to weaken
you lose touch
during the summer of 1992. “I totally hit this point in my life where
I was so high on life, it was amazing. I had this sense of indepenwith reality?
dence. I was 18 and turning into an adult. Next thing I knew I got
this feeling that people were trying to take things from me. Not my soul, but physical things
from me. I couldn’t sleep because they [his mother and sister] were planning to do something
to me. I think there was a higher power inside the
7-Eleven that was helping me out the whole time, just
bringing me back to a strong mental state” (C. Brooks,
1994, p. 9). Michael was diagnosed as having schizophrenia (skit-suh-FREE-nee-ah).
Schizophrenia is a serious mental disorder that lasts for
at least six months and includes at least two of the following
symptoms: delusions, hallucinations, disorganized speech,
disorganized behavior, and decreased emotional expression.
These symptoms interfere with personal or social functioning
(American Psychiatric Association, 2000).
Michael has a number of these symptoms, including
delusions (higher power inside the 7-Eleven), halluciMichael McCabe had many of the
nations (hearing voices), and disorganized behavior.
symptoms described on the right.
Schizophrenia affects about 0.2–2% of the adult population, or about 4.5 million people (equal numbers of men and women) in the United States
(American Psychiatric Association, 2000).
Subcategories of Schizophrenia
Michael’s case illustrates some of the symptoms that occur in schizophrenia. In fact, no two
patients have exactly the same set of symptoms, which are described in the list on the right.
The DSM-IV-TR describes five subcategories of schizophrenia, each of which is characterized
by different symptoms. We’ll briefly describe three of the more common schizophrenia
Paranoid schizophrenia is characterized by auditory hallucinations or delusions, such as thoughts
of being persecuted by others or thoughts of grandeur.
Disorganized schizophrenia is marked by bizarre ideas, often about one’s body (bones melting),
confused speech, childish behavior (giggling for no apparent reason, making faces at people), great
emotional swings (fits of laughing or crying), and often extreme neglect of personal appearance and
Catatonic schizophrenia is characterized by periods of wild excitement or periods of rigid, prolonged immobility; sometimes the person assumes the same frozen posture for hours on end.
Differentiating between types of schizophrenia can be difficult because some symptoms,
such as disordered thought processes and delusions, are shared by all types.
Chances of Recovery
Chances of recovery are dependent upon a number of factors, which have been grouped
under two major types of schizophrenia (Crow, 1985).
Type I schizophrenia includes having positive symptoms, such as hallucinations and delusions,
which are a distortion of normal functions. In addition, this group has no intellectual impairment, good
reaction to medication, and thus a good chance of recovery.
Type II schizophrenia includes having negative symptoms, such as dulled emotions and little inclination to speak, which are a loss of normal functions. In addition, this group has intellectual impairment, poor reaction to medication, and thus a poor chance of recovery.
According to this classification system, the best predictor of recovery for a person with
schizophrenia is his or her symptoms: Those with positive symptoms have a good chance of
recovery, while those with negative symptoms have a poor chance (Dyck et al., 2000).
Next, we’ll describe the major symptoms of schizophrenia.
Schizophrenia is a serious mental disorder that lasts for at least six months
and includes at least two of the following symptoms:
1 Disorders of thought.
These are characterized by incoherent
thought patterns, formation of new
words (called neologisms), inability to
stick to one topic, and irrational beliefs
or delusions. For example, Michael
believed that his mother and sister
were plotting against him.
2 Disorders of attention.
These include difficulties in concentration and in focusing on a single chain
of events. For instance, one patient
said that he could not concentrate on
television because he couldn’t watch
and listen at the same time.
3 Disorders of perception.
These include strange bodily sensations
and hallucinations.
Hallucinations are sensory experiences without any stimulation from the
About 70% of schizophrenics report
hearing voices that sound real and talk
either to them (steal brain cells) or
about them (mostly negative things,
like “You have a cancer”) (Thraenhardt,
2006). Research using brain imaging
shows that when schizophrenics hallucinate people, their visual cortex
becomes active, and when they hallucinate voices, their auditory cortex is
activated (Begley, 2008c).
4 Motor disorders.
These include making strange facial
expressions, being extremely active, or
(the opposite) remaining immobile for
long periods of time.
5 Emotional (affective) disorders.
These may include having little or no
emotional responsiveness or having
emotional responses that are inappropriate to the situation—for example,
laughing when told of the death of a
close friend.
The cause of these schizophrenia
symptoms involves biological, neurological, and environmental factors.
Photo Credit: © Robert Gauthier
Definition and Types
Biological Causes
When Michael was in the hospital, his
mother, Marsha (photo below), began
going to a support group to get help and
find out about schizophrenia. At one meeting, Marsha said, “I haven’t been doing
very well with this, to be perfectly honest. How in the hell
were we dealt this hand?”
(C. Brooks, 1994, p. 8).
The psychiatrist who led
Marsha’s group answered
that about 1 in 100 people
get schizophrenia but the
odds increase to 1 in 10 if
Marsha tries to help her son,
it’s already in the family. If a
Michael, who has schizophrenia.
person inherits a predisposition for schizophrenia, any number of things—such as drugs,
a death in the family, growing-up problems—can trigger its
onset (C. Brooks, 1994). The psychiatrist was pointing out three
major factors—biological, neurological, and environmental—
that interact in the development of schizophrenia. We’ll begin
with biological factors, specifically genetic causes.
Photo Credits: top, © Robert Gauthier; center, Courtesy of Edna Morlok
What caused
disorder. In comparison, if one brother or sister (sibling or fraternal
twin) has schizophrenia, there is only about a 10–17% chance that the
other will develop the disorder (Gottesman, 2001). Because genetic factors are involved in developing schizophrenia, researchers are searching
for the location of specific genes involved in schizophrenia; such genes
are called genetic markers (Levinson, 2003).
A genetic marker refers to an identifiable gene or number of genes or a
specific segment of a chromosome that is directly linked to some behavioral,
physiological, or neurological trait or disease.
Researchers have reported many genetic markers for schizophrenia,
but none proved valid because none could be repeated or replicated by
other laboratories. Researchers now believe that schizophrenia depends
on a combination of genes and that no one gene by itself has a strong
genetic influence (ISC, 2009; T. Walsh et al., 2008).
Breakthroughs. There have been several reports of major breakthroughs in identifying genetic markers for schizophrenia. For instance,
researchers found evidence of a slight excess of a protein in the prefrontal
cortex of people with schizophrenia, resulting from a variation in a gene
they believe may explain common symptoms of the disorder (Law &
Weinberger, 2006). Also, researchers found that a disruption in a particular gene makes new neurons that are supposed to reach the hippocampus,
an area of the brain important for memory and emotional processing, go
elsewhere, causing a burst of abnormal brain activity, which may explain
schizophrenia symptoms (H. Song, 2007). Other researchers
found a gene linked to negative symptoms of schizophrenia
(p. 541), which suggests that researchers should seek genes
responsible for specific symptoms (Fanous et al., 2005). Taken
together, recent genetic studies plus earlier studies on identical
twins indicate that schizophrenia has a genetic factor.
Genetic Predisposition
In 1930, the birth of four
identical baby girls (quadruplets) was a rare occurrence
(1 in 16 million) and received
great publicity. By the time
the girls reached high school,
all four were labeled “differInfections
ent.’’ They sometimes broke
Another biological factor that may contribute to the develAll four of these identical quadruplets
light bulbs, tore buttons off
opment of schizophrenia is infections. For instance, pregdeveloped schizophrenia.
their clothes, complained of
nant women who get the f lu have been found to be more
bones slipping out of place, and had periods of great confusion. likely to give birth to children who will develop schizophrenia. Also,
By young adulthood, all four girls, who are called the Genain some childhood infections, such as the mumps virus, have been associquadruplets and share nearly 100% of their genes, were diag- ated with an increased risk of later developing schizophrenia sympnosed with schizophrenia (Mirsky & Quinn, 1988). The finding toms. Researchers believe that some infections directly affect the brain,
that all four Genain quadruplets (above photo) developed whereas others trigger immune reactions that interfere with normal
schizophrenia indicates that increased genetic similarity is brain development (Dalman et al., 2008; Wenner, 2008a).
associated with increased risk for developing schizophrenia and
However, biological factors alone cannot completely explain why
suggests that a person inherits a predisposition for developing individuals develop schizophrenia. As we’ll discuss, environmental
the disorder. Support for a genetic predisposition also comes factors must interact with biological factors (Mueser et al., 2006).
from twin studies.
Genetic Markers
Because researchers knew that schizophrenia might
have a genetic factor, they compared rates of schizophrenia in identical twins, who share nearly 100%
of their genes, with rates in fraternal twins and siblings (brothers and sisters), who share only 50% of
their genes. The right graph shows the risk of developing schizophrenia for individuals who share different percentages of genes and thus have different
degrees of genetic similarity. Notice that if one
identical twin has schizophrenia, there is a 48–83%
chance that the other twin will also develop the
Risk of Developing Schizophrenia
Identical twins
(100% of genes in common)
Offspring of two schizophrenic parents
(50% of genes from each parent)
Fraternal twins (50%
of genes in common)
(50% of genes in common)
1%–2% General population
(0% of genes in common)
D. Schizophrenia
Is the
New techniques for studying the structures and functions of the
living brain (MRI and f MRI—p. 70) reveal major differences
between brains of schizophrenics and brains of mentally healthy
individuals. We’ll discuss two reliable differences—larger ventricles
and decreased activity in the prefrontal cortex.
Ventricle Size
Most us of don’t realize that our brains have four fluid-filled
cavities called ventricles (left figure). The fluid in these caviLateral ventricles
ties helps to cushion the brain against blows and also serves
as a reservoir of nutrients and hormones for the brain. One
reliable finding is that in up to 80% of the brains of schizophrenics, the ventricles are larger than normal (NiznikieFluid-filled ventricles
wicz et al., 2003). Using brain scans (MRIs), researchers
in normal brains
studied 15 pairs of identical twins; one was diagnosed with
schizophrenia, while the other was mentally healthy (normal). The brains of twins with schizophrenia had larger
ventricles than the brains of the mentally healthy twins (left
Lateral ventricles
figures) (Suddath et al., 1990). However, not all brains of
people with schizophrenia have larger ventricles or an overall decrease in brain size. Also, the enlarged ventricles in
some schizophrenics may remain the same over the course
Increased size of
of their illness, while the size of ventricles may change over
fluid-filled ventricles in
time for others (DeLisi et al., 2004). Researchers conclude
brains of schizophrenics
that some people with schizophrenia have abnormally large
ventricles, which results in a reduction in brain size and in turn may contribute to the
development of schizophrenia (I. C. Wright et al., 2000).
Frontal Lobe: Prefrontal Cortex
Another brain structure involved in many executive functions, such as reasoning,
planning, remembering, paying attention, and making decisions, is the prefrontal
cortex (figure below). Researchers report that in pairs of identical twins where one
twin has schizophrenia and the other does not, the brain of the twin with schizophrenia was characterized by significantly less activation of the prefrontal cortex
(F. E. Torrey et al., 1994). This decreased prefrontal lobe activity is consistent with the
deficits in many executive functions observed in schizophrenics,
such as disorganized thinking, irrational beliefs, and lack
of concentration (Niznikiewicz et al., 2003).
Other researchers report that in the brains of people
with schizophrenia, the frontal and temporal lobes are
smaller because there are fewer brain cells (neurons—
p. 50) and fewer connections (axons—p. 50) among
neurons (K. Davis, 2003; Pantelis et al., 2003). Fewer
neurons with fewer connections cause deficits in
transmitting information, which in turn may underlie
problems in executive functions, such as disorganized
thinking and reasoning, which are major symptoms of
patients diagnosed with schizophrenia (Holden, 2003).
These studies point to neurological factors, such as abnormal brain structures and
functions, that researchers believe underlie and contribute to the development of
schizophrenia and make it so difficult to treat (Holden, 2003).
Besides genetic and neurological factors, there are also environmental factors
involved in developing schizophrenia.
Environmental Causes
If biological or neurological
factors explained why people develop schizophrenia,
then the risk for developing
schizophrenia in identical
twins would be almost 100% rather than 48–
83%. Because biological and neurological factors alone cannot explain the development of
schizophrenia, researchers look at the influence
of environmental factors, such as the incidence of stressful events
and how individuals
cope. For exa mple,
when Michael McCabe
(right photo) was 18,
he began to develop
Stressful events may
symptoms of schizohave led to his onset
phrenia. The onset of
of schizophrenia.
these symptoms occurred after the death of his father and during
the potentially stressful period of adolescence.
Stressful events, such as hostile parents,
poor social relationships, the death of a parent
or loved one, and career or personal problems,
can contribute to the development and onset
of schizophrenia. This relationship between
stress and the onset of schizophrenia is called
the diathesis stress theory (S. R. Jones & Fernyhough, 2007).
Can stress
act as a
The diathesis (die-ATH-uh-sis) stress theory of
schizophrenia says that some people have a genetic
predisposition (a diathesis) that interacts with life
stressors to result in the onset and development of
The diathesis stress theory assumes that
biological or neurological factors have initially
produced a predisposition for schizophrenia.
If a person already has a predisposition for
schizophrenia, then being faced with stressful
environmental factors can increase the risk
and vulnerability for developing schizophrenia
as well as trigger the onset of schizophrenia
symptoms (S. R. Jones & Fernyhough, 2007).
Thus, the diathesis stress theory says that biological and neurological factors first create a
predisposition, such as overreacting to stressful
situations, that then makes a person vulnerable
or at risk for developing schizophrenia.
Now we’ll examine the drugs used to treat
Photo Credits: top left, Courtesy of Drs. E. Fuller Torrey & Daniel R. Weinberger, NIMH, Neuroscience Center, Washington D.C.; top right, © Robert Gauthier
Neurological Causes
After Michael (right photo) was
taken to the psychiatric hospital,
his symptoms were assessed and
he was diagnosed with schizophrenia. Schizophrenia symptoms are commonly divided into positive and
negative symptoms.
How is
ability to express thoughts, and decreased initiative to engage in goaldirected behaviors (American Psychiatric Association, 2000).
Like most individuals diagnosed with schizophrenia,
Michael had both positive symptoms, such as delusions that
people were going to steal from him, and negative symptoms,
such as loss of emotional expression. To reduce these symptoms,
he was given haloperidol, which is an example of an antipsychotic
or neuroleptic (meaning “taking hold of the nerves”) drug.
Positive symptoms of schizophrenia reflect a disMichael was
given a neuroNeuroleptic drugs, also called antipsychotic drugs, are used to
tortion of normal functions: distorted thinking results in
leptic drug to treat
delusions; distorted perceptions result in hallucinations; his schizophrenia. treat serious mental disorders, such as schizophrenia, by changing the
levels of neurotransmitters in the brain.
and distorted language results in disorganized speech.
There are two kinds of neuroleptic drugs: typical and
Negative symptoms of schizophrenia reflect a decrease in or loss of
normal functions: decreased range and intensity of emotions, decreased
Typical Neuroleptics
Atypical Neuroleptics
Typical neuroleptics
were discovered in
the 1950s and were
the first effective
medical treatment
for schizophrenia.
Photo Credits: both, © Robert Gauthier
Typical neuroleptic drugs primarily reduce
levels of the neurotransmitter dopamine. These
drugs mainly reduce positive symptoms and have
little effect on negative symptoms. Because typi-
In Michael’s case and for about 20% of all schizophrenics, typical
neuroleptic drugs (phenothiazines, such as haloperidol or Thoraneuroleptics:
zine) have little or no effect on their symptoms. Many of these
decrease dopamine
patients are being helped by newer atypical neuroleptic drugs.
& serotonin
Atypical neuroleptic drugs (clozapine, risperidone) lower levels of
dopamine and also lower levels of other neurotransmitters, especially
serotonin. These drugs primarily reduce positive symptoms, may reduce negative symptoms, and
prevent relapse (Downar & Kapur, 2008).
The first atypical neuroleptic, clozapine, was approved for use in schizophrenia in
1990. Since then, atypical neuroleptics have proven effective in decreasing symptoms of
cal neuroleptics reduce levels of dopamine,
schizophrenia, especially in patients who were not helped by typical
their action supports the dopamine theory
neuroleptics (W. Carpenter, 2003).
of schizophrenia (Downar & Kapur, 2008).
Michael, for example, showed little improvement with typical
The dopamine theory says that in schizophreneuroleptics (haloperidol). However, the atypical neuroleptic
nia, the dopamine neurotransmitter system is
clozapine reduced his positive symptoms to the point
somehow overactive and gives rise to a wide
that he was allowed to leave the psychiatric hospirange of symptoms.
tal and return home. A year later, Michael was still
The dopamine theory focuses on neurons
taking clozapine and was making slow progress in
in a group of brain structures called the
overcoming his symptoms, such as paranoia.
basal ganglia (figure below). Typical neuOn most days, Michael comes home from group
roleptics block dopamine usage in the basal
therapy and job-training classes, puts on a Bob Marganglia, which reduces commu- basal ganglia ley record, and sits and listens, afraid to do much
Atypical neuroleptics helped Michael
nication among these neurons
else. As Michael explains, “I can’t go out and
(shown with his mother and sister)
and in turn reduces some of
skate or do anything because I’m afraid I’m
reduce his symptoms.
the symptoms of schizogoing to have a paranoia attack” (C. Brooks,
phrenia. However, because
1995b, p. D-3). His mother and sister provide Michael with financial and social
20% of people with schizosupport but wish Michael would take greater initiative to improve his own life.
phrenia are not helped by
Michael, as well as others with schizophrenia, face a daily struggle to overcome
typical neuroleptics and
their symptoms, which points to the need for continued social support and
because recent findings
psychotherapy (Bustillo et al., 2001).
point to the involvement of
Current treatment. For many years, compared to typical neuroleptics, atypiseveral nondopamine neucal neuroleptics were the preferred treatment because they were reported to be at
rotransmitters (serotonin and
least as effective in reducing positive symptoms, more effective in reducing negaglutamate), the dopamine thetive symptoms, and helpful for patients who showed no improvement with typical
ory will need revision to include
neuroleptics (S. Burton, 2006; J. M. Davis et al., 2003). More recently, a large, carefully
other neurotransmitter systems.
conducted study compared the cognitive effects of the two types of neuroleptics and
Using typical neuroleptics to treat schizofound that, contrary to previous research outcomes, typical and atypical neuroleptics
phrenia is being challenged by newer drugs,
were about equally effective in boosting cognitive skills (R. S. E. Keefe et al., 2007).
called atypical neuroleptics.
Next, we’ll discuss the serious side effects of typical and atypical neuroleptics.
D. Schizophrenia
Evaluation of Neuroleptic Drugs
What are
the side
The major advantage of neuroleptic drugs is that they effectively reduce positive
symptoms so that many patients can regain some degree of normal functioning. However, neuroleptics also have two potentially serious disadvantages:
They may produce undesirable side effects, and they may decrease but not
prevent relapse or return of the original symptoms of schizophrenia.
Typical Neuroleptics
dopamine &
Atypical Neuroleptics
Side effects. One group of typical neuroleptics,
called the phenothiazines (pheen-no-THIGH-ahzeens), is widely prescribed to treat schizophrenia.
Phenothiazines can produce unwanted motor movements, which is a side effect called tardive dyskinesia
(Dolder, 2008).
Side effects. One advantage of atypical neuroleptics is they cause tardive dyskinesia in only about 5% of patients, compared to 1–29% of patients given typical
neuroleptics (Caroff et al., 2002). However, atypical neuroleptics can cause side
effects, the most serious being increased levels of cholesterol and glucose or blood
sugar, weight gain, and onset or worsening of diabetes (S. Burton, 2006; Dolder,
2008). Thus, typical and atypical neuroleptics may produce serious side effects.
Tardive dyskinesia (TAR-div dis-cah-KNEE-zee-ah)
Effectiveness and relapse. From the 1950s through the middle of the 1990s,
involves the appearance of slow, involuntary, and unconthe drugs of choice for treating schizophrenia were typical neuroleptics. Begintrollable rhythmic movements and rapid twitching of the
ning in the late 1990s and continuing to the present, there has been a general
mouth and lips, as well as unusual movements of the limbs.
switch to atypical neuroleptics. That’s because, compared to typical neurolepThis condition is associated with the
tics, atypical neuroleptics have generally proved to
Risks of Developing Tardive Dyskinesia
continued use of typical neuroleptics.
be as effective in reducing positive symptoms, more
effective in reducing negative symptoms, less likely to
As shown in the right graph, the 3 months 16%
cause tardive dyskinesia, and more effective in preventrisk for developing tardive dyskine29%
ing relapse, the recurrence of schizophrenia symptoms
sia increases with use: After three 3–12 months
months, 16% developed this side 1–10 years
(S. Burton, 2006; J. M. Davis et al., 2003). However, some
effect; after ten years, 40% developed
research found that the use of typical and atypical drugs
it (Sweet et al., 1995). About 30% of More than 10 years
led to about equal improvement in patients with schizopatients with tardive dyskinesia will
phrenia and similar rates of movement-related side
experience a reduction in symptoms if they are taken
effects, such as tardive dyskinesia (J. A. Lieberman, 2005). Due to these inconoff typical neuroleptics, but the remaining 70% may
sistencies, clinicians must carefully consider which type of drug to prescribe to
continue to have the problem when the drug therapy
their patients.
is stopped (Roy-Byrne & Fann, 1997).
Conclusions. Two strange, recurring findings in the treatment of mental disEffectiveness. Researchers have completed
orders are that the same drug may help one patient but not another, and for some
several long-term follow-up studies on patients who
patients drugs cause no improvement at all. One reason drugs don’t always work
were treated for schizophrenia with typical neurois that mental disorders, like schizophrenia, may have different causes (genetic,
leptics. They found that, 2 to 12 years after treatment,
neurological, environmental) that may require a combination of different drugs
about 20–30% of patients showed a good outcome,
and/or psychotherapy. Another reason drugs don’t always work is that each perwhich means they needed no furson’s nervous system functions differently and has a different level of neurotransther treatment and had no relapse;
mitters (Niznikiewicz et al., 2003). This explains why the same drug may
about 40–60% continued to suffer
cause various types and severities of side effects for different people.
some behavior impairment and
Researchers find that, for the majority of patients, schizophrenia
relapse, although their symptoms
is a chronic or life-long problem with a high risk for relapse. Thus, in
reached a plateau in about 5 years
addition to drug treatment, patients need psychotherapy and social
and did not worsen after that; and
support to improve their social interactions, work at an acceptable job,
about 20% were not helped by these
and maintain their quality of life (Lauriello, 2007; Mueser et al., 2006).
New direction. Because some patients with schizophrenia either do
Unwanted motor
Relapse. The basic problem with movements (lip smacking) not benefit from typical or atypical neuroleptics or experience intolerare a side effect of typical
taking patients off typical neuroable side effects, researchers have been working to create a new drug that
neuroleptics but less so
leptics is that they may relapse. For with atypical neuroleptics. targets a different neurotransmitter called glutamate. Glutamate may be
example, after an average of about
just as important as dopamine and serotonin in schizophrenia because
one year, 60% of patients taken off a typical neuroit is associated with perception, memory, emotion, and concentration. Scientists
leptic experienced a relapse, as compared to a relapse
think drugs that target glutamate will provide patients with another treatment
rate of 34% for those who were maintained on an
option that promises to be effective and have limited side effects (Berenson, 2008;
Downar & Kapur, 2008; Goff, 2008; S. F. Locke, 2008).
atypical neuroleptic (Csernansky et al., 2002).
After the Concept Review, we’ll discuss a disorder that has a very strange
Next, we’ll learn about the side effects and effecsymptom—the person does not know who he or she is.
tiveness of the newer atypical neuroleptics.
Concept Review
1. A prolonged emotional state that affects almost all of a person’s
thoughts and behaviors is called a
2. The most common form of
mood disorder is marked by at
least two weeks of daily being in a
bad mood, having no interest in
anything, and getting no pleasure
from activities and having at least
Time (years)
four of these additional symptoms:
problems with weight or appetite, insomnia, fatigue, difficulty
thinking, and feeling worthless and guilty. This problem is called
3. Another depressive disorder is characterized by being chronically depressed for many but not all days over a period of two
years and having two of the following symptoms: poor appetite,
insomnia, fatigue, low self-esteem, and feelings of hopelessness.
This problem is called
4. Another mood disorder is
characterized by a fluctuation
between a depressive episode
and a manic episode that lasts
about a week, during which a
person is unusually euphoric,
Time (years)
cheerful, or high, speaks rapidly,
feels great self-esteem, and needs little sleep. This problem is
6. Factors such as dealing with stressors and stressful life events are
believed to interact with predisposing biological factors and contribute
to the development, onset, and
maintenance of mood disorders. These
are called
7. One treatment for major depression involves placing electrodes on
the skull and administering a mild
electric current that passes through
the brain and causes a seizure. Usual
treatment consists of a series of 10 to
12 such sessions, at the rate of about
three per week. This treatment is
Daily depression rating
Photo Credits: (#9) © Alan Fredrickson/ Reuters/Corbis; (#10) © Robert Gauthier
5. Underlying genetic, neurological, chemical, or physiological
components may predispose a person to developing a mood disorder. Together, these components are called
2 3
8. Certain psychoactive drugs act by increasing levels of a specific group of neurotransmitters (monoamines, such as serotonin) that
are believed to be involved in the regulation
of emotions and moods. These are called
drugs. A mood stabilizer that is used to treat
bipolar I disorder is called (b)
, and it’s often
combined with antidepressants and antipsychotics.
9. A person who has inflexible, long-standing,
maladaptive traits that cause significantly
impaired functioning or great distress in his
or her personal and social life is said to have
a (a)
disorder. Examples
of this disorder include a pattern of distrust
and suspiciousness and perceiving others
as having evil motives, which is called a
personality disorder; a
pattern of being submissive and clingy because of an excessive
need to be taken care of, which is called a (c)
personality disorder; and a pattern of disregarding or violating the
rights of others without feeling guilt or remorse, which is called an
personality disorder.
10. A serious mental disturbance that lasts
for at least six months and that includes at
least two of the following persistent symptoms—delusions, hallucinations, disorganized speech, grossly disorganized behavior,
and decreased emotional expression—is
called (a)
. There are subcategories of this disorder: the one characterized by auditory hallucinations or delusions, such as thoughts
of being persecuted by others or thoughts of grandeur, is called
11. Drugs that are used to treat schizophrenia and act primarily
to reduce levels of dopamine are called (a)
drugs. Drugs that are used
to treat schizophrenia and
reduce levels of dopamine
dopamine &
and levels of serotonin are
called (b)
drugs, which are generally more effective than (c)
drugs. The theory that, in schizophrenia, the dopamine neurotransmitter system is somehow overactive and gives rise to
many of the symptoms observed in schizophrenics is called the
theory, which is supported by the actions
of (e)
drugs but not by the actions of
Answers: 1. mood; 2. major depressive; 3. dysthymic; 4. bipolar I; 5. biological; 6. psychosocial; 7. electroconvulsive therapy, or ECT; 8. (a) antidepressant, (b) lithium; 9. (a) personality, (b) paranoid, (c) dependent, (d) antisocial; 10. (a) schizophrenia, (b) paranoid; 11. (a) typical neuroleptic,
(b) atypical neuroleptic, (c) typical neuroleptic, (d) dopamine, (e) typical neuroleptic, (f) atypical neuroleptic
E. Dissociative Disorders
dissociative experience so extreme that your own
self splits, breaks down, or disappears.
A dissociative disorder is characterized by a person having a disruption, split, or breakdown in his or
her normal integrated self, consciousness, memory,
or sense of identity. This disorder is relatively rare
and unusual (American Psychiatric Association,
What if you had a split or
breakdown in your self?
We’ll discuss three of the five more common
dissociative disorders listed in the DSM-IVTR. These are dissociative amnesia, dissociative
fugue, and dissociative identity disorder (formerly
called multiple personality disorder).
Dissociative Amnesia
Dissociative Fugue
Mark is brought into the hospital emergency room by police. He
looks exhausted and is badly sunburned. When questioned, he
gives the wrong date, answering September 27th instead of October 1st. He has trouble answering specific questions about what
happened to him. With much probing, he gradually remembers
going sailing with friends on about September 25th and hitting
bad weather. He cannot recall anything else; he doesn’t know what
happened to his friends or the sailboat, how he got to shore, where
he has been, or where he is now. Each time
I can’t remember
he is told that it is really October 1st and he
anything about the
is in a hospital, he looks very surprised
past month.
(Spitzer et al., 1994). Mark is suffering from
dissociative amnesia.
A 40-year-old man wanders the streets of Denver with $8 in his
pocket. He asks people to help him figure out who he is and where
he lives. He feels lost, alone, anxious, and desperate to learn his
identity. He appears on news shows pleading for help: “If anybody
recognizes me, knows who I am, please let somebody know”
(Ingram, 2006). After his parents and fiancée
Who am I?
see him on television, they contact the police,
What’s my name?
informing them that the man’s name is Jeffrey
Ingram and that he lives in Seattle. Upon
reuniting with his fiancée and family, Jeffrey
fails to recognize their faces. He also cannot recall anything about his past (Woodward, 2006). Jeffrey Ingram had experienced
dissociative fugue.
Dissociative amnesia is characterized by the inability to recall important
personal information or events and is
usually associated with stressful or traumatic events. The importance or extent
of the information forgotten is too great
to be explained by normal forgetfulness
(American Psychiatric Association,
In Mark’s case, you might think
his forgetfulness was due to a blow
to the head suffered on the sailboat in rough seas. However, doctors found no evidence of head
injury or neural problems. To recall the events between September 25th and October 1st, Mark was given a drug (sodium amytal)
that helps people relax and recall events that may be blocked by
stressful experiences. While under the effect of the drug, Mark
recalled a big storm that washed his companions overboard but
spared him because he had tied himself to the boat. Thus, Mark
did suffer from dissociative amnesia, which was triggered by the
stressful event of seeing his friends washed overboard (Spitzer
et al., 1994). In dissociative amnesia, the length of memory loss
varies from days to weeks to years and is often associated with a
series of stressful events (Eich et al., 1997).
As we’ll see next, a person may even forget who he or she is.
Dissociative fugue is a disturbance marked
by suddenly and unexpectedly traveling away
from one’s home or place of work and being
unable to recall one’s past. The person may not
remember his or her identity or may be confused about his or her new
assumed identity (American Psychiatric Association, 2000).
Before clinicians diagnosed Jeffrey as suffering from dissociative
fugue, they ruled out drugs, medications, and head injuries. His
fiancée explained that Jeffrey had been on his way to Canada to visit
his friend’s wife, who was dying of cancer. She believes the stress of
seeing his friend’s wife dying led him to an amnesia state. Jeffrey’s
history is especially fascinating because he had experienced a similar dissociative fugue in 1995, when he disappeared during a trip
to the grocery store and wasn’t found until 9 months later. And,
Jeffrey recently went missing for a third time! This time, he was
quickly identified because he had gotten a tattoo on his arm that
gave his name and state ID number. Jeffrey is now considering his
options to always have GPS technology with him so his family can
quickly find him if he should go missing again (Alexander, 2007).
As Jeffrey’s case illustrates, the onset of dissociative fugue is related
to stressful life events. Usually, fugue states end quite suddenly, and
the individual recalls most or all of his or her identity and past.
In other cases, a person’s self splits into two or more “true” selves
or identities, which is called dissociative identity disorder.
Photo Credit: right, © AP Images/The Denver Post/Karl Gehring
You have probably had the
experience of being so
absorbed in a fantasy,
thought, or memory that,
for a short period of time,
you cut yourself off from the real world. However, if someone calls your name, you quickly
return and explain, “I’m sorry, I wasn’t paying
attention. I was off in my own world.” This is an
example of a normal “break from reality,” or dissociative experience, which may occur when you
are self-absorbed, hypnotized, or fantasizing (Berlin &
Koch, 2009; Kihlstrom et al., 1994). Now imagine a
What if
you became
someone else?
Dissociative Identity Disorder
Is it
really true?
Photo Credits: top, © Kabik/Retna Ltd./Corbis; bottom, © Ron Nickel/Photolibrary
The idea that one individual could possess two or more “different persons” who may or may not know one another and
who may appear at different times to say and do different things describes one of the more remarkable and controversial mental disorders (Eich et al., 1997). Previously this disorder was called multiple personality disorder, but now it’s
called dissociative identity disorder. We’ll discuss a real case of dissociative identity disorder and its possible causes.
Occurrence and Causes
Herschel Walker is recognized for being an NFL legThe worldwide occurrence of dissociative identity disorder was very
end, Heisman Trophy winner, track star, Olympic
rare before 1970, with only 36 cases reported. However, an “epicompetitor, and successful businessman. You
demic” occurred in the 1970s and 1980s, with estimates ranging
would think Herschel would feel as though he was
from 300 to 2,000 cases (Spanos, 1994). Reasons for the upsurge
on top of the world. On the contrary, Herschel felt
include incorrect diagnosis, renewed professional interest, the
that his life was out of his control. He had diffitrendiness of the disorder, and therapists’ (unknowing) encourculty managing his anger, he struggled to feel conagement of patients to play the roles. Whatever the reasons, the
nected to people, and he experienced unexplained
vast majority (70–80%) of mental health professionals are
periods of memory loss.
skeptical about the upsurge in occurrence of dissociative
Herschel’s wife of 16 years (now divorced)
identity disorder (Lilienfeld et al., 1999). The patients most
also noticed several oddities about him. For
often diagnosed with dissociative identity disorder (DID)
Football legend Herschel
Walker is diagnosed with
instance, she described him as having many
are females, who outnumber males by 8 to 1. In addition,
dissociative identity
different sides, such as the side with an interpatients with DID usually have a history of other mental
disorder, formerly called
est in the Marines, the side interested in bal- multiple personality disorder. disorders.
let, the side interested in the FBI, and the side
Explanations. There are two opposing explanations for
interested in sports. She even noticed that he would occasionally
DID. One is that DID results from the severe trauma of childhood
speak in different voices and show uniquely different physical
abuse, which causes a mental splitting or dissociation of identities
as one way to defend against or
After Herschel got the courage to seek professional help to
cope with the terrible trauma.
understand what had been happening to him, his therapist diagA second explanation is that
nosed him as suffering from a very rare and complex disorder
DID has become commonplace
called dissociative identity disorder.
because of cultural factors, such
Dissociative identity disorder (formerly called multiple personality
as DID becoming a legitimate
disorder) is the presence of two or more distinct identities or personality
way for people to express their
states, each with its own pattern of perceiving, thinking about, and
frustrations or to manipulate or
relating to the world. Different personality states may take control of the
gain personal rewards (Lilienindividual’s thoughts and behaviors at different times (American
feld et al., 1999). These opposing
Psychiatric Association, 2000).
explanations reflect the current
As a boy, Herschel was severely teased and bullied for being an
controversy about why so many
overweight child who had a severe stutter. His therapist explains
patients have been diagnosed
Dissociative identity disorder is said
that Herschel developed his alter personalities to help him overwith DID.
to have two very different causes.
come the abuse by his peers as well as other major challenges he
Researchers have found biofaced later in life.
logical evidence to support the existence of dissociative identity
Herschel identifies about a dozen alter personalities, includdisorder. For instance, they found that the brains of patients with
ing “The Hero,” who came out in public appearances, and “The
the condition generate multiple distinct patterns of seeing, thinking,
Warrior,” who was in charge of playing football and coping with
and behaving. Their physiological arousal patterns (e.g., heartbeat,
the physical pain that came with it. Herschel’s therapist describes
brain wave activity) are distinctively different depending on which
meeting the alter personalities in therapy by saying, “They will
alter is present (Reinders et al., 2006).
come out and say, I am so-and-so. I’m here to tell you Herschel is
Treatment. Patients diagnosed with DID may also have probnot doing too good. . . . When he finishes, it would just disappear
lems with depression, anxiety, interpersonal relationships, and subback in him, and Herschel comes out” (Mungadze, 2008).
stance abuse. As a result, treatment for DID involves helping patients
As in Herschel’s case, the personalities are usually quite difwith these related problems as well as helping them integrate their
ferent and complex, and the original personality is seldom aware
various personalities into one unified self, which may take years. For
of the others. After nearly ten years of psychotherapy, Herschel
example, after two years of treatment, patients diagnosed with DID
managed to obtain great insight about his condition and says
who showed the greatest improvement were those who showed the
he is doing much better now (H. Walker, 2008; Woodruff et
greatest ability to integrate and resolve the differences of their sepaal., 2008).
rate selves and see themselves as a person with a single self. CliniHow common is dissociative identity disorder, and what
cians concluded that treatment for DID is a long-term process that
causes it?
usually involves some form of psychotherapy (Chu et al., 2005).
F. Cultural Diversity: Interpreting Symptoms
Spirit Possession
Imagine being a clinician and
where spirit possession is part of their culture and
interviewing a 26-year-old female
about 45% of married women over 15 years of age
client who reports the following
report spirit possession (Boddy, 1988). Although in
sy mptoms: “Somet i mes a
the United States symptoms of spirit possession would
spirit takes complete control
probably be interpreted as delusional and abnormal, in
of my body and mind and makes me do things and say
Northern Sudan spirit possession is interpreted as a
things that I don’t always remember. The spirit is very
normal behavior and an expression of the women’s
powerful and I never know when it will take control. The
culture. To deal with possible cultural differences, the
spirit first appeared when I was 16 and has been with me
DSM-IV-TR now includes an appendix that describes
ever since.”
how to diagnose symptoms within the context of a perAs a clinician, you would of course conduct a much
son’s culture (American Psychiatric Association, 2000).
more in-depth clinical interview and administer a
Spirit possession is an example of how cultural
About 45% of the women
number of psychological tests. But on the basis of these
factors determine whether symptoms are interpreted
in Northern Sudan report
symptoms alone, would you say that she has delusions
as normal or abnormal. Researchers are also finding
spirit possession, which
and hallucinations and possibly schizophrenia or that
that cultural factors and gender influence the occuris part of their culture.
she has multiple identities and possibly dissociative
rence of certain other kinds of mental disorders.
identity disorder? In this case, both diagnoses would be incorrect.
We’ll examine how culture and gender influence the occurrence of
This female client comes from a small village in Northern Sudan,
mental disorders.
How does
the world view
mental disorders?
Culture-Specific Mental Disorders
Mental illness is present across all cultures; however, cultures
often differ in what they consider to be normal and abnormal.
There are some mental disorders that are unique to a culture and
are best understood within the context of a particular culture.
They are collectively referred to as culture-specific disorders.
A culture-specific disorder is a pattern of mental illness or abnormal behavior that is unique to an ethnic or cultural population and does
not match the Western classifications of mental disorders (APA, 2007).
Cross-cultural research has identified numerous culturespecific disorders, a few of which are described below (Gaw, 2001).
O Latah involves the inability to stop copying or imitating others’ behaviors, such as
movements and speech. Individuals with
this disorder are susceptible to doing
things they wouldn’t typically do, such as
using intense profanity. Latah is found in
Malaysian and Indonesian cultures.
O Bibloqtoq involves an intense urge to
leave one’s home, tear off one’s clothes, and
Some mental
disorders are
expose oneself to the freezing cold weather.
unique to specific
It is found in Greenland, Alaska, and the
ethnic or cultural
Canadian Arctic.
O Susto involves insomnia, depression,
and anxiety and is often brought on by fear. It is found among
the people of the Andean highlands and is believed to develop
from contact with witches and the evil eye.
O Koro involves the fear and sensation of one’s penis retracting into the body and the belief that one will die as a result. This
syndrome is found in Malaysian cultures.
These examples show the importance of cultural factors in
mental disorders. Cultural factors influence not only the occurrence of disorders but also the rates of occurrence in males
and females.
Gender Differences in Mental Disorders
Many mental disorders in the United States, such as bipolar I disorder and personality disorders, are reported about equally by women
and men (Kluger, 2003; C. F. Newman, 2006). However, as shown in
the graph below, disorders such as major depression and dysthymic
disorders are reported significantly more frequently by women than
by men in the United States as well as in many other countries
around the world (Kessler, 2003; Thase, 2006).
Major Depression and Dysthymic Disorder
Some clinicians attribute the higher percentage of women reporting depression to
cultural differences in gender roles. For
example, the stereotypical gender role for
men is to be independent and assertive
and to take control, which tends to reduce
levels of stress. In comparison, the stereotypical gender role for women is to be
dependent, passive, and emotionally sensitive, which reinforces women’s feelings of
being dependent, not having control, and
Compared with men,
twice as many women
being helpless, and increases levels of stress
report problems with
and puts women at greater risk for developdepression.
ing depression (Durand & Barlow, 2006).
Some researchers suggest that biological (hormonal changes) and
psychosocial (concerns over having and raising children) factors may
also contribute to women’s higher rate of depression (NIMH, 2005).
Next, we’ll look at a very simple yet effective treatment for
G. Research Focus: Exercise Versus Drugs
Choices of Therapy for Depression
at least four of the following symptoms: problems with eating,
sleeping, thinking, concentrating, or making decisions,
lacking energy, thinking about suicide, and feeling worthless or guilty (American Psychiatric Association, 2000).
What would you think if you were in the
middle of feeling very depressed and
someone recommended running three
times a week as a good treatment? It
seems hard to believe that something as simple as exercising
could be as effective as antidepressants. Remember that
major depression is not how you feel from having a bad day
or doing poorly on an exam. Major depression must meet
the following definition.
Can exercise
Major depressive disorder is marked by at least two weeks of
continually being in a bad mood, having no interest in anything, and
getting no pleasure from activities. In addition, a person must have
Can depressed people
get help from walking?
We have already discussed how psychotherapy,
antidepressants, and a combination of the two have
proven effective in treating major depression (Goode,
2003). Now researchers are asking if regular exercise
can also be effective in treating major depression.
This Research Focus shows how scientists used
the experimental approach to answer a question that
potentially has very practical or applied benefits.
Photo Credits: top and left, © PhotoLink/PhotoDisc, Inc.
Exercise Experiment: Seven Rules
Method and Results
You may remember that there are seven rules for doing an experiment (pp. 36–37). We’ll review these seven rules by showing how
researchers followed them in their study (Babyak et al., 2000).
Rule 1: Ask. Every experiment asks a specific question that
is changed into a hypothesis or educated guess. In this study,
the hypothesis is that exercise will be as effective a treatment for
major depression as are antidepressants.
Rule 2: Identify. Researchers identify the
treatment, which is called the independent
variable because researchers Antidepressants:
are able to control or adminvariable
ister it to the subjects. Here,
the independent variable has three levels of treatments: the first level is 30 minutes of exercise
(stationary bike or walking/jogging) three times
a week; the second level is taking
antidepressants (Zoloft); and the
third level is a combination of
exercising and taking antidepressants.
Next, researchers identify the behavior(s),
called the dependent variable, which depends
Scale to
on the treatment, and measure its effectiveness. In
this study, the dependent variable is a scale (Ham- depression:
ilton rating scale for depression) that measures
increases or decreases in subjects’ depression.
Rule 3: Choose. Researchers choose subjects, who in this study
are 156 adult volunteers (50 years or older) who have been diagnosed with major depression (according to the above definition).
Rule 4: Assign. The chosen patients are randomly assigned
to groups, which means that each of the 156 patients has an equal
chance of being assigned to one of the three treatment groups.
Rule 5: Manipulate. Researchers administer or manipulate
the three levels of the treatment by giving one level of treatment
to each of the three groups of patients.
Rule 6: Measure. After 4 months of treatments, researchers use the depression scale to measure how effective each one
of the three levels of treatment was in decreasing the patients’
Rule 7: Analyze. Researchers found that about 60% of patients in
the exercise group had greatly improved, compared with 66% of subjects taking antidepressants and 69% of those who combined exercise and antidepressants. Although these percentages look different,
statistical analysis indicated that the three treatments were equally
effective. This means that exercise alone was as effective in reducing
depression as were antidepressants or the combination, which supports
the researchers’ original hypothesis.
We discussed how, after treatRelapse Rate after Treatment
ment for a mental disorder, a
certain percentage of patients
relapse or again return to having symptoms. Of the 60–69% Combination
of patients in each of the three
8% Exercise
treatment groups who showed
significant improvement (few
if any depressive symptoms), some patients had relapsed during the
6-month period following treatment. Researchers reported (above
graph) that 38% of patients who had received antidepressants had
relapsed and 31% of patients who had received both exercise and antidepressants had relapsed. However, only 8% of patients relapsed who
were in the exercise-only treatment.
Researchers found that after 4 months of treatment for depression,
patients in all three treatment groups showed improvement. However,
when patients were retested 6 months later, those who had received
exercise only showed less relapse. Researchers suggest that exercise
helps patients develop a sense of personal mastery and positive selfregard, which helps patients get over being depressed and decreases
the risk of future relapse (Babyak et al., 2000). Other research found
that depressed patients who exercised 30 minutes, three to five times
a week, reported a 50% reduction in symptoms of depression after
12 weeks (Dunn et al., 2005). Also, researchers found that exercise
has an immediate positive effect on mood that lasts for as long as
12 hours (Sibold, 2009). As a treatment for depression, exercise is
effective and inexpensive and has no unwanted side effects.
Next, we’ll discuss several ways to overcome mild depression.
H. Application: Dealing with Mild Depression
Mild Versus Major Depression
There is a big difference between mild and major depression.
How does
Earlier, we discussed singer Sheryl Crow, who experienced
major depressive disorder. Symptoms of major depressive disdepression
order include being in a bad mood for at least two weeks, havdiffer?
ing no interest in anything, and getting no pleasure from
activities. Additionally, to be diagnosed with major depression, a person must have at
least two of the following problems: difficulty in sleeping, eating, thinking, and making decisions or having no energy and feeling continually fatigued. Compared with
the symptoms of major depressive disorder, the symptoms of mild depression are
milder and generally have less impact on a person’s functioning. For example, take the case of Janice, who has what is
often called the sophomore blues.
“At first I was excited about going off to college and
being on my own,” explains Janice. “But now I feel
worn out from the constant pressure to study, get good
grades, and scrape up enough bucks to pay my rent. I’ve
lost interest in classes, I have trouble concentrating,
I’m doing poorly on exams, and I’m thinking about
changing my major—again. And to make everything
even more depressing, my boyfriend just broke up
with me. I sit around wondering what went wrong
or what I did or why he broke it off. What did I do
There is a big difference
that was so bad? My friends are tired of my moping
between the symptoms of
around and complaining, and I know they are starting
major and mild depression.
to avoid me. Yeah, everyone says that I should just get
over him and get on with my life. But exactly what do I do to get out of my funk?”
Continuum. Some researchers have argued that the kind of depression reported
by college students is related to general distress and does not represent any of the particular symptoms and feelings found in major depression (J. C. Coyne, 1994). However,
other researchers find that depression is best thought of as a continuum. At one end
of the continuum is mild depression, such as that experienced by many college students, which is basically similar in quality but just a milder form of major depression,
which is at the other end of the continuum (Flett et al., 1997).
College students. Although many college students experience mild depression, a considerable number also suffer from more severe forms of depression. For
instance, a national survey found that 40% of college students have reported feeling
“so depressed it’s difficult to function,” and another 10% reported they had “seriously
considered suicide.” In fact, more than 5% of students reported they had actually
attempted suicide, which is the second leading cause of death among college students, compared to its ranking as the ninth leading cause of death in the general
population (ACHA, 2007; NAMH, 2008). These statistics are devastating but perhaps
not surprising when you consider that college students are experiencing almost all
the major stressors of adulthood, including coping with a new environment, dealing
with academic pressures, trying to establish intimate personal relationships, experiencing financial difficulties, and trying to achieve some independence from parents
and family (Pennebaker et al., 1990).
Vulnerability. There are three major factors that increase an individual’s vulnerability or risk for developing mild depression. The first factor is being a young adult
who is facing new, challenging, and threatening situations and feelings. The second
factor is having a high number of negative life events. Since college students experience both of these factors, they are at high risk for developing mild depression, which
may lead to major depression later in life. The third factor involves an individual’s
pattern of thinking, which is the basis for Beck’s theory of depression.
Beck’s Theory of Depression
Janice thinks that her
depression is caused by
outside forces, such as
academic pressures, financial concerns, personal difficulties, and family pressures. There is
no question that stressful events or negative situations can depress Janice’s mood. However,
another factor that Janice may not be aware of
and that may contribute to her depression is a
particular pattern of thinking, which is described by Aaron Beck’s (1991) cognitive theory
of depression.
How much
do thoughts
Beck’s cognitive theory of depression says that
when we are feeling down, automatic negative
thoughts that we rarely notice occur continually
throughout the day. These negative thoughts distort
how we perceive and interpret the world and thus
influence our behaviors and feelings, which in turn
contribute to our feeling depressed.
Often these automatic negative thoughts
are centered on personal inadequacies, such as
thinking one is a failure, is not liked, or never
gets anything done. Beck has identified a number of specific negative, maladaptive thoughts
that he believes contribute to developing anxiety and depression. For example, thinking “I’m
a failure” after doing poorly on one test is an example of overgeneralization—that is, making a
blanket judgment about yourself based on a single incident. Thinking “People always criticize
me” is an example of selective attention—that
is, focusing on one detail so much that you do
not notice other positive events, such as being
complimented. Beck believes that maladaptive
thought patterns cause a distorted view of oneself and one’s world, which in turn may lead
to various emotional
problems, such as
Increased risk
depression. Thus,
for depression
one of the things
t h a t Ja n i c e mu s t
work on to get out of her
depressed state is to
1. Academic
identify and change
her negative, mal2. Financial concerns
adaptive thoughts.
3. Family pressures
We’ll discuss how
negative thoughts
4. Negative thought
and two other facpatterns
tors maintain depression, as well as ways to
change them.
Overcoming Mild Depression
What can one do?
Once we get “down in the dumps,” we are likely to stay there for some time unless we work at changing certain thoughts and behaviors, such as improving social skills, increasing social support, and eliminating
negative thoughts. We’ll describe several ways to “get out of the dumps” and overcome mild depression.
Improving Social Skills
Eliminating Negative Thoughts
Problem. In some cases, a person may feel mildly depressed
because he or she has poor social skills, which lead to problems in having good social interactions.
For example, researchers found that
depressed teenagers and college students
may be overly dependent, competitive, aggressive, or mistrustful, which
in turn caused problems in developing
and maintaining close social relationships (M. K. Reed, 1994). If part of being
depressed involves poor social skills, a
person can learn new ways of interacting with friends.
Program. As with every behavioral
Poor social skills
can increase
change program, the first step is to
chances of feeling
monitor our social interactions to notice
what we are doing wrong, such as complaining too much and irritating our friends. Once we’re
aware of our bad habits, such as being negative, not asking
questions or showing interest, and not being sympathetic, we
can begin to take positive steps. That means making a real
effort to stop complaining and to show more interest in our
friends’ activities and to be more sensitive to their feelings.
By proceeding in gradual steps, we can learn to improve our
social skills and get more rewards from social interactions,
which in turn will make us feel better and help us get over
our mild depression (Hokanson & Butler, 1992).
Problem. Researchers find that individuals often become
and remain mildly depressed because
they do not give themselves credit for
any success (however small), make every
situation (however small) into a bad or
unpleasant experience, and constantly
blame themselves for every failure,
which makes them more depressed and
thus elicits more negative reactions from
friends (Nurius & Berlin, 1994).
Program. The first step in increasing
our self-esteem is to become aware of
Learning to take
self-blame by monitoring our thoughts
credit for our
actions can help
and noticing all the times we blame ourovercome
selves for things, no matter how small.
feelings of mild
Once we become aware of self-blame,
we can substitute thoughts of our past
or recent accomplishments, no matter how small. By substituting thoughts of accomplishment and focusing on recent
successes, we will gradually improve our self-esteem. As
our self-esteem improves, we will slowly get a more positive
attitude, which increases the social support of our friends
(Granvold, 1994).
Problem. According to Beck’s theory of depression, a depressed person
thinks negative, maladaptive thoughts, which in turn cause the person
to pay attention to, perceive, and remember primarily negative and
depressing situations, events, and conversations (A. T. Beck, 1991). Thus,
besides improving social skills and increasing social support, depressed
individuals also need to stop the
automatic negative thought pattern
After identifying
that maintains depression.
negative thoughts . . .
Researchers found that depressed
individuals have a tendency to select
and remember unhappy, critical,
. . . substitute
or depressing thoughts, events, or
positive thoughts
remarks, remember fewer good
things than bad things, and take
a more pessimistic view of life (Corey, 2005). Although discussed later
(pp. 574–575), here’s a brief description of a program for changing negative
thought patterns.
Program. The first step is to monitor the occurrence of negative,
depressive thoughts. The second step is to eliminate depressive thoughts
by substituting positive ones. This second step is difficult because it
requires considerable effort to stop thinking negative thoughts (“I really
am a failure”) and substitute positive ones (“I’ve got a lot going for me”).
With practice, we can break the negative thought pattern by stopping
negative thoughts and substituting positive ones. These kind of “talk”
programs can help a person overcome mild depression and enjoy life
more (Freeman et al., 2004). One reason “talk” programs can help as
much as antidepressants is that “talk” programs and antidepressants
produce strikingly similar changes in the brain.
Power of Positive Thinking
Everyone has heard about the power of positive thinking, and now
researchers have found a concrete example. It began with the interesting
and reliable finding that psychotherapy (“talk” therapy) can often reduce
depressive symptoms as much as antidepressants can (Rupke et al., 2006).
Wondering why psychotherapy was as powerful as drugs, researchers took
brain scans (pp. 70–71) of patients diagnosed with depression before and
after 12 weeks of treatment with either psychotherapy or antidepressants.
The result was that both treatments, psychotherapy and antidepressants,
decreased depression. But the surprising finding was that both psychotherapy and antidepressants produced similar changes in the brain, one of
which was to decrease the abnormally high activity
of the prefrontal cortex (right figure) (A. L. Brody
et al., 2001).
Several studies have now reported similar
results: Talk therapy can and does alter brain
functioning (Roffman et al., 2005). This
means that the next time you are down in the
dumps, try the power of positive thinking to
change your brain functioning. You may be
pleasantly surprised by the happy results.
Summary Test
B. Electroconvulsive Therapy
1. A disturbed emotional state that affects almost all of
a person’s thoughts and behaviors is
called a
7. If antidepressant drugs fail to
treat major depression, the treat12
ment of last resort involves placing
electrodes on the skull and admin8
istering a mild electric current that
passes through the brain and causes
4 PreECT
a seizure. This treatment is called
1 0 1 2 3 4 5
therapy. A
potentially serious side effect of this
treatment is impairment or deficits in (b)
which usually affects events experienced during the weeks of
treatment as well as events before and after treatment. However,
following ECT treatment, there is a gradual improvement in
memory functions.
3. A mood episode that is characterized by a distinct period,
lasting at least a week, during which a person is unusually
euphoric, cheerful, or high and has at least three of the
following symptoms—has great self-esteem, needs little sleep,
speaks rapidly and frequently, experiences racing thoughts,
is easily distracted—is called a (a)
A disorder characterized by periods of fluctuation between
episodes of depression and mania is called (b)
4. Underlying genetic, neurological, or physiological components may predispose a person to developing a mood disorder.
These components are called (a)
Factors such as dealing with stressors and stressful life events
are believed to interact with predisposing biological influences
and contribute to the development, onset, and maintenance of
mood disorders. These are called (b)
C. Personality Disorders
8. A disorder that involves inflexible, longstanding, maladaptive traits that cause significantly impaired functioning or great distress
in one’s personal and social life is called a
disorder. Ten of these
disorders are listed in the DSM-IV-TR, including: a pattern of being submissive and clingy
because of an excessive need to be taken care of,
which is called a (b)
disorder, and a pattern of
disregarding or violating the rights of others without feeling guilt
or remorse, which is called an (c)
There is evidence that personality disorders develop from an
interaction of (d)
9. Evidence that genetic factors influence personality disorders
comes from studies on
, which show that genetic
factors contribute 30–50% to the development of these personality
5. Some drugs increase levels of neurotransmitters (serotonin,
norepinephrine, dopamine) called (a)
. These
drugs, which are involved in the regulation of emotions and
moods, such as major depression, are called (b)
and may take up to 8 weeks before they begin to work. The
newer and more popular antidepressants (Prozac) are called
, or SSRIs, and are not more effective
but have fewer unwanted (d)
than older
10. Schizophrenia is a serious mental disNEUROLEPTICS
turbance that lasts for at least six months
and includes at least two of the following
dopamine &
persistent symptoms: delusions, halluciserotonin
nations, disorganized speech, grossly
disorganized behavior, and decreased emotional expression. These
symptoms interfere with personal or social
6. A mood stabilizer used to treat bipolar I disorder is called
, and it’s often combined with antidepressants and antipsychotics. This drug is also used to treat
euphoric periods without depression; this disorder is called
11. The DSM-IV-TR lists five subcategories of schizophrenia,
which include the following three. A category characterized by
bizarre ideas, confused speech, childish behavior, great emotional
swings, and often extreme neglect of personal appearance and
hygiene is called (a)
schizophrenia. Another
D. Schizophrenia
Photo Credit: (#8) © Alan Fredrickson/Reuters/Corbis
2. One mood disorder is marked by
being in a daily bad mood, having
no interest in anything, getting no
pleasure from activities, and having
at least four of the following symptoms: problems with weight, appetite,
sleep, fatigue, thinking, or making decisions and having suicidal
thoughts. This is called (a)
disorder, which is
the most common form of mood disorder. Another mood disorder
is characterized by being chronically depressed for many but
not all days over a long period of time and having two of the
following symptoms: problems with appetite and sleep, fatigue,
low self-esteem, and feelings of hopelessness. This is called
Daily depression rating
A. Mood Disorders
form marked by periods of wild excitement or periods of rigid,
prolonged immobility is called (b)
schizophrenia. A third form characterized by thoughts of being persecuted or
thoughts of grandeur is called (c)
12. Researchers have searched for an identifiable gene or a specific segment of a chromosome that is directly linked to developing
schizophrenia. This genetic link is called a
13. Two kinds of neuroleptic drugs are used to treat schizophrenia
symptoms by changing levels of neurotransmitters in the brain.
Drugs that act primarily to reduce levels of the neurotransmitter
dopamine are called (a)
neuroleptics. An example is the phenothiazines. Drugs that lower levels of dopamine but,
more important, also reduce levels of other neurotransmitters,
especially serotonin, are called (b)
These drugs are generally more effective in reducing schizophrenia
symptoms and better at preventing (c)
14. One side effect of the continued use of phenothiazines is the
appearance of slow, involuntary, and uncontrollable rhythmic movements and rapid twitching of the mouth and lips, as well as unusual
movements of the limbs. This side effect is called
15. One theory of schizophrenia says that it develops when the
neurotransmitter is overactive. Another
related theory says that some people have a genetic predisposition,
called a (b)
, that interacts with life stressors to
result in the onset and development of schizophrenia.
Photo Credits: (#19) © PhotoLink/PhotoDisc, Inc.; (#16) © Ron Nickel/Photolibrary
E. Dissociative Disorders
16. A dissociative disorder is characterized by
a (a)
in a person’s normally
integrated functions of memory, identity, or
perception of the environment. The DSM-IVTR lists five types of dissociative disorder,
which include the following three. If a person is
unable to recall important personal information or events, usually
in connection with a stressful or traumatic event, and the information forgotten is too important or lengthy to be explained by
normal forgetfulness, it is called (b)
. If a person
suddenly and unexpectedly travels away from home or place of
work and is unable to recall the past and may assume a new identity, it is called (c)
. If a person experiences the
presence of two or more distinct identities or personality states,
each with its own pattern of perceiving, thinking about, and relating to the world, it is called (d)
17. One theory says that dissociative identity disorder (DID)
develops as a way to cope with the severe trauma of childhood
. A second explanation is that DID has
become a culturally approved way for people to express their
or to control others or gain personal rewards.
F. Cultural Diversity: Interpreting Symptoms
18. Spirit possession is one example of how cultural factors determine whether symptoms are interpreted as
. An
example of how cultural factors may increase
the risk for development of mood disorders
can be traced to the differences in assigned
roles: Males are expected to
be independent and in control, and females are
expected to be dependent and not have control.
G. Research Focus: Exercise Versus Drugs
19. After three different treatments, including
exercise only, researchers found that at least 60%
of patients diagnosed with (a)
showed significant improvement. Another finding
was that when patients were retested 6 months
later, those who had received exercise only
showed significantly less (b)
Researchers suggest that (c)
helps patients
develop a sense of personal mastery and positive self-regard,
which helps prevent relapse.
H. Application: Dealing with Mild Depression
20. Beck’s cognitive theory of depression says
that when we are depressed, we have automatically
occurring (a)
, which center
around being personally inadequate. In turn, these
negative thoughts (b)
how we
perceive and interpret the world and thus influence
our behaviors and feelings. There are effective programs for
developing better social skills and eliminating negative thoughts.
Psychotherapy and antidepressant drugs both reduced depression
and both produced similar changes in how the (c)
Answers: 1. mood; 2. (a) major depressive, (b) dysthymic; 3. (a) manic,
(b) bipolar I; 4. (a) biological, (b) psychosocial; 5. (a) monoamines,
(b) antidepressants, (c) selective serotonin reuptake inhibitors, (d) side
effects; 6. (a) lithium, (b) mania; 7. (a) electroconvulsive, (b) memory;
8. (a) personality, (b) dependent, (c) antisocial, (d) biological, psychological; 9. twins; 10. functioning; 11. (a) disorganized, (b) catatonic,
(c) paranoid; 12. genetic marker; 13. (a) typical, (b) atypical, (c) relapse;
14. tardive dyskinesia; 15. (a) dopamine, (b) diathesis; 16. (a) disruption,
split, breakdown, (b) dissociative amnesia, (c) dissociative fugue, (d) dissociative identity; 17. (a) physical or sexual abuse, (b) frustrations, fears;
18. (a) normal, abnormal, (b) gender; 19. (a) major depression, (b) relapse,
(c) exercise; 20. (a) negative thoughts, (b) bias or distort, (c) brain
Critical Thinking
What Is
a Psychopath?
According to the
three definitions
of abnormal behavior
(p. 511), are Dahmer
and Rader abnormal?
What objective
test can be used
to best assess for
these psychopathic
personality traits?
Which trait theory
can explain how
an individual can display such drastically
inconsistent behaviors?
What part of the
limbic system
explains how psychopaths can be so cold
and fearless?
effrey Dahmer would
pick up young gay men,
bring them home, drug
them, strangle them, have
sex with their corpses,
and then, in some cases,
eat their flesh.
Dennis Rader would
break into people’s homes,
tie them up, strangle them, and
eventually murder them. His murder
method earned him the name “BTK
killer,” which stands for Bind, Torture, and Kill.
Dahmer and Rader share much in
common. They are superf icially
charming, unemotional, impulsive,
and self-centered. They are pathological liars who constantly manipulate others. Also, both men completely lack remorse, guilt, and
empathy. Finally, they have low selfesteem, a strong desire to be in control, and a lifelong sense of loneliness. Dahmer, for example, felt so
lonely that he admitted to killing
people for company. Together, the
above chara ct er ist ic s def i ne a
What may seem surprising is that
psychopaths can love their parents,
spouses, and children but have great
diff iculty loving the rest of the
world. Rader, for instance, was a
loving husband and father. Yet, he
seemed completely devoid of humanity as he plainly recounted the
details of how he murdered his many
Some of the fascinating characteristics and behaviors of psychopaths may be explained by biological and neurological factors. For
example, some psychopaths have
abnormalities in their limbic system,
which is responsible for motivational
behaviors, such as eating and sex, as
well as emotional behaviors, such as
fear, anger, and aggression. Also,
some psychopaths have a disruption
in the communication between the
hippocampus and the prefrontal
cortex, which is believed to contribute to their lack of control, inability
to regulate aggression, and insensitivity to cues that predict they will
get caught and punished. Interestingly, psychopaths also have lower
autonomic arousal and consequently
experience less distress when exposed
to threats.
The life histories of psychopaths
often include a chaotic upbringing,
lack of parental attention, parental
substance abuse, and child abuse.
These life experiences may interact
with biological or neurological factors linked to psychopathic behaviors. For instance, children may have
genes for psychopathic behaviors
that get activated only under stress;
if they are raised in a nurturing environment, they may very well develop
into well-behaved, moral adults. In
other words, at least for some children, the consequences of having a
stressful childhood can be deadly.
(Adapted from B. Bower, 2006b,
2008e; Crenson, 2005; C. Goldberg,
2003; Hickey, 2006; Larsson et al.,
2006; Lilienfeld & Arkowitz, 2007;
Martens, 2002; A. Raine et al., 2004;
Wilgoren, 2005; Yang et al., 2005b)
How would a
psychopath do on
a lie detector test?
What is it called
when someone
has inherited a gene
for psychopathic
behaviors but develops those behaviors
only if he or she has a
stressful childhood?
Links to Learning
Key Terms/Key People
antidepressant drugs, 534
antisocial personality, 536
atypical neuroleptics, 541
Beck’s cognitive theory of
depression, 548
biological factors and
depression, 533
biological causes of
schizophrenia, 539
bipolar I disorder, 532
bipolar I, treatment, 534
borderline personality
disorder, 536
brain scans, 533
schizophrenia, 538
disorders, 546
dependent personality, 536
depressed mothers, 533
dialectical behavior
therapy, 536
diathesis stress theory, 540
schizophrenia, 538
dissociative amnesia, 544
dissociative disorder, 544
dissociative fugue, 544
dissociative identity
disorder, 545
dopamine theory, 541
dysthymic disorder, 532
electroconvulsive therapy,
ECT, 535
electroconvulsive therapy,
effectiveness, 535
eliminating negative
thoughts, 549
environmental causes of
schizophrenia, 540
exercise versus drugs, 547
genetic factors, 533
genetic marker, 539
hallucinations, 538
histrionic personality, 536
improving social skills, 549
lithium, 534
major depressive
disorder, 532, 547
major depression,
treatment, 534
mania, 534
mood disorder, 532
negative cognitive style, 533
negative symptoms of
schizophrenia, 541
neuroleptic drugs, 541
neurological causes of
schizophrenia, 540
neurological factors, 533
personality, 536
paranoid personality, 536
schizophrenia, 538
personality disorder, 536
personality factors, 533
positive symptoms of
schizophrenia, 541
power of positive
thinking, 549
psychosocial factors, 533
schizophrenia, 538
schizotypal personality, 536
selective serotonin
reuptake inhibitors, 534
spirit possession, 546
stressful life events, 533
tardive dyskinesia, 542
transcranial magnetic
stimulation, 535
Type I schizophrenia, 538
Type II schizophrenia, 538
typical neuroleptics, 541
Learning Activities
PowerStudy for Introduction
PowerStudy 4.5™
to Psychology 4.5
Try out PowerStudy’s SuperModule for Mood Disorders & Schizophrenia! In
addition to the quizzes and learning activities, interactive Summary Test, key
terms, module outline and abstract, and extended list of correlated websites
provided for all modules, the DVD’s SuperModule for Mood Disorders &
Schizophrenia offers features including:
personality disorders, and schizophrenia
pages 550–551 and the critical thinking questions for the article on page 552
Want to maximize your online study time? Take this easyto-use study system’s diagnostic pre-test and it will create a personalized study
plan for you. The plan will help you identify the topics you need to understand
better and direct you to relevant companion online resources that are specific
to this book, speeding up your review of the module.
Introduction to Psychology Book Companion Website
Visit this book’s companion website for more resources to help you
study, including learning objectives, additional quizzes, flash cards, updated
links to useful websites, and a pronunciation glossary.
Study Guide and WebTutor
Work through the corresponding module in your Study
Guide for tips on how to study effectively and for help learning the material
covered in the book. WebTutor (an online Study Tool accessed through your
eResources account) provides an interactive version of the Study Guide.
Suggested Answers to Critical Thinking
1. Dahmer and Rader’s behaviors are abnormal in terms of statistical
frequency, deviation from social norms, and being maladaptive.
2. The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) (p. 474)
is an objective personality test that assesses a range of personality
traits, including anger, truthfulness, self-esteem, friendliness, and
seriously deviant behaviors.
3. The person-situation interaction (p. 464) explains how a person’s
behavior results from an interaction between his or her traits and
the effects of being in a particular situation. It explains how psychopaths, such as Dahmer and Rader, can be loving people with their
families but cold-blooded, heartless serial killers in the community.
4. The amygdala (pp. 80, 362) is the structure located in the limbic system that is responsible for evaluating whether stimuli have positive
(happy) or negative (fearful, threatening) emotional significance for
our survival. Damage to the amygdala explains how psychopaths
can completely lack empathy and not learn to fear and avoid dangerous situations, such as cues that predict they will get caught.
5. A lie detector test (pp. 370–371) measures involuntary physiological
responses and is based on the theory that a person who lies will
feel guilt or fear, which will result in an increase in the galvanic skin
response and other physiological responses. Because psychopaths
do not feel guilt or fear and do not sweat easily due to lower autonomic arousal, they should pass a lie detector test with flying colors.
6. Having biological or neurological factors for psychopathic behaviors
produces a predisposition (p. 540) for psychopathic behaviors, which
increases the risk or vulnerability of developing such behaviors.