Chapter 1 PDF - Understanding Psychopathology

wrong with her, nor could several other physicians. By Learning Objectives...

wrong with her, nor could several other physicians. By Learning Objectives the time she was referred to our clinic, she was fainting 5 to 10 times a week, often in class. Clearly, this was prob- LO1.1 Define psychological disorders according to the three lematic for her and disruptive in school; each time Janelle basic criteria of psychopathology. fainted, the other students flocked around her, trying to LO1.2 Describe each of the three basic categories of research in help, and class was interrupted. Because no one could psychopathology. find anything wrong with her, the principal finally con- LO1.3 Compare the three prominent historical approaches cluded that she was being manipulative and suspended to psychopathology in terms of how they explain and treat her from school, even though she was an honor student. psychological disorders. Janelle was suffering from what we now call LO1.4 Differentiate Freudian psychoanalysis from the blood–injection–injury phobia. Her reaction was quite humanistic and behavioral approaches according to their severe, thereby meeting the criteria for phobia, a research and therapeutic emphases. psychological disorder characterized by marked and persistent fear of an object or situation. But many LO1.5 List the main influences on the development of people have similar reactions that are not as severe psychopathology according to the integrative approach. when they receive an injection or see someone who is injured, whether blood is visible or not. For people who react as severely as Janelle, this phobia can be disabling. They may avoid certain careers, such as Understanding Psychopathology medicine or nursing, and, if they are so afraid of Today you may have gotten out of bed, had breakfast, gone to needles and injections that they avoid them even class, studied, and, at the end of the day, enjoyed the company when they need them, they put their health at risk. of your friends before dropping off to sleep. For some people going through this routine, it might not occur to them that many physically capable people are not able to do some or any of these activities. What they have in common is a psychological disorder, What Is a Psychological Disorder? a psychological dysfunction within an individual associated with Keeping in mind the real-life problems faced by Janelle, let’s distress or impairment in functioning and a response that is not look more closely at the definition of psychological disorder typical or culturally expected. Before examining exactly what this or problematic abnormal behavior: It is a psychological dys- means, let’s look at one individual’s situation. function within an individual that is associated with distress or impairment in functioning and a response that is not typical or culturally expected (see Figure 1.1). On the surface, these The Girl Who Fainted at three criteria may seem obvious, but they were not easily arrived Janelle... at and it is worth a moment to explore what they mean. You will the Sight of Blood learn importantly that no one criterion has yet been developed J anelle, a 16-year-old, was referred to our anxiety disorders clinic after increasing episodes of fainting. About 2 years earlier, in Janelle’s first biology class, that fully defines a psychological disorder. Psychological Dysfunction Psychological dysfunction refers to the teacher had shown a movie of a frog dissection to a breakdown in cognitive, emotional, or behavioral functioning. illustrate various points about anatomy. For example, if you are out on a date, it should be fun. But if you This was a particularly graphic film, with vivid images of blood, tissue, and muscle. About halfway through, Janelle felt a bit lightheaded and left the room. But the images did not leave her. She continued to be bothered by them and occasionally felt slightly queasy. She began to avoid situations in which she might see Psychological blood or injury. She stopped looking at magazines that disorder might have gory pictures. She found it difficult to look at raw meat or even Band-Aids because they brought the feared images to mind. Eventually, anything her friends Psychological dysfunction or parents said that evoked an image of blood or injury caused Janelle to feel lightheaded. It got so bad that if Distress or impairment one of her friends exclaimed, “Cut it out!” she felt faint. Beginning about 6 months before her visit to the clinic, Atypical response Janelle actually fainted when she unavoidably encountered something bloody. Her family physician could find nothing Figure 1.1 The criteria defining a psychological disorder. U n d e r s t a n d i n g P s y c h o p a t h o l o g y   3 Copyright 2023 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  experience severe fear all evening and just want to go home, even often quite normal to be distressed—for example, when someone though there is nothing to be afraid of, and the severe fear happens close to you dies. The human condition is such that suffering and on every date, your emotions are not functioning properly. distress are very much part of life. This is not likely to change. However, if all your friends agree that the person who asked you Furthermore, for some disorders, by definition, suffering and dis- out is unpredictable and dangerous in some way, then it would not tress are absent. Consider the person who feels extremely elated be dysfunctional for you to be fearful and avoid the date. and may act impulsively as part of a manic episode. As you will A dysfunction was present for Janelle: She fainted at the sight see in Chapter 7, one of the major difficulties with this problem is of blood. But many people experience a mild version of this that some people enjoy the manic state so much they are reluctant reaction (feeling queasy at the sight of blood) without meeting to begin treatment or stay long in treatment. Thus, defining psy- the criteria for the disorder, so knowing where to draw the line chological disorder by distress alone doesn’t work, although the between normal and abnormal dysfunction is often difficult. For concept of distress contributes to a good definition. this reason, some of these problems are often considered to be on The concept of impairment is useful, although not entirely satis- a continuum or a dimension rather than to be categories that are factory. For example, many people consider themselves shy or lazy. either present or absent (McNally, 2011; Stein, Phillips, Bolton, This doesn’t mean that they’re abnormal. But if you are so shy that Fulford, Sadler, & Kendler, 2010; Widiger & Crego, 2013). This, you find it impossible to date or even interact with people and you too, is a reason that just having a dysfunction is not enough to make every attempt to avoid interactions even though you would meet the criteria for a psychological disorder. like to have friends, then your social functioning is impaired. Janelle was clearly impaired by her phobia, but many people Distress or Impairment That the behavior must be associated with similar, less severe reactions are not impaired. This differ- with distress to be classified as a disorder adds an important com- ence again illustrates the important point that most psychological ponent and seems clear: The criterion is satisfied if the individual disorders are simply extreme expressions of otherwise normal is extremely upset. We can certainly say that Janelle was distressed emotions, behaviors, and cognitive processes. and even suffered with her phobia. But remember, by itself this criterion does not define problematic abnormal behavior. It is Atypical or Not Culturally Expected Finally, the criterion that the response be atypical or not culturally expected is import- ant but also insufficient to determine if a disorder is present by itself. At times, something is considered abnormal because it occurs infrequently; it deviates from the average. The greater the deviation, the more abnormal it is. You might say that someone is abnormally short or abnormally tall, meaning that the person’s height deviates substantially from average, but this obviously isn’t a definition of disorder. Many people are far from the average in their behavior, but few would be considered disordered. We might call them talented or eccentric. Many artists, movie stars, and athletes fall in this category. For example, it’s not normal to wear a dress made entirely out of meat, but when Lady Gaga wore this to an awards show, it only enhanced her celebrity. The late novelist J. D. Salinger, who wrote The Catcher in the Rye, retreated to a small town in New Hampshire and refused to see any outsiders for years, but he continued to write. In most cases, the more produc- tive you are in the eyes of society, the more eccentricities society will tolerate. Therefore, “deviating from the average” doesn’t work well as a definition for problematic abnormal behavior. MediaNews Group/Boston Herald via Getty Images/Getty Images Another view is that your behavior is disordered if you are violating social norms, even if a number of people are sym- pathetic to your point of view. This definition is useful in considering important cultural differences in psychological disorders. For example, to enter a trance state and believe you are possessed reflects a psychological disorder in most Western cultures but not in many other societies, where the behavior is accepted and expected (see Chapter 6). (A cultural perspective is an important point of reference throughout this book.) A social standard of normal has been misused, however. Con- sider, for example, the practice of committing political dissidents to mental institutions because they protest the policies of their Distress and suffering are a natural part of life and do not in them- government. Although such dissident behavior clearly violated selves constitute a psychological disorder. social norms, it should not alone be cause for commitment. 4  C h a p t e r 1 Psychopathology in Historical Context Copyright 2023 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  distress and impairment in functioning, or increased risk of suffering, death, pain, or impairment. This definition can be useful across cul- tures and subcultures if we pay careful attention to what is functional or dysfunctional (or out of control) in a given society. But, again, it is never easy to decide what represents a dysfunction, and some schol- ars have argued persuasively that the health professions will never be able to satisfactorily define disease or disorder (see, for example, Lil- ienfeld & Marino, 1995, 1999; McNally, 2011; Stein et al., 2010; Zachar & Kendler, 2014). The best we may be able to do is to consider how the apparent disease or disorder matches a “typical” profile of a dis- order—for example, major depression or schizophrenia—when most or all symptoms that experts would agree are part of the disorder are present. We call this typical profile a prototype, and as described in Chapter 3, the diagnostic criteria from DSM-5 found throughout this book are all prototypes. This means that patients may have only some features or symptoms of the disorder (a minimum number) and still meet criteria for the disorder because their set of symptoms is close to the prototype. But one of the differences between DSM-5 and its predecessor, DSM-IV, is the addition of dimensional estimates of the severity of specific disorders in DSM-5 (American Psychiatric Asso- ciation, 2013; Helzer, Wittchen, Krueger, & Kraemer, 2008; Regier, Narrow, Kuhl, & Kupfer, 2009). Thus, for the anxiety disorders, for example, the intensity and frequency of anxiety within a given dis- order such as panic disorder is rated on a 0 to 4 scale, where a rating Steve Granitz/Getty Images of 1 would indicate mild or occasional symptoms and a rating of 4 would indicate continual and severe symptoms (Beesdo-Baum, et al., 2012; LeBeau, Bogels, Moller, & Craske, 2015; LeBeau et al., 2012). These concepts are described more fully in Chapter 3, where the diagnosis of psychological disorders is discussed. For a final challenge, take the problem of defining a psycho- We accept extreme behaviors by entertainers, such as Lady Gaga, that would not be tolerated in other members of our society. logical disorder a step further and consider this: What if Janelle passed out so often that after a while neither her classmates nor her teachers even noticed because she regained consciousness quickly? Furthermore, what if Janelle continued to get good Jerome Wakefield (1999, 2009), in a thoughtful analysis of grades? Would frequent fainting at the mere thought of blood be the matter, uses the shorthand definition of harmful dysfunction. a disorder? Would it be impairing? Dysfunctional? Distressing? However, this definition assumes that we know what the evo- What do you think? lutionary function of a behavior is, which is often not the case (McNally, 2001). Another possibility is to determine whether the behavior is out of the individual’s control (something the person doesn’t want to do) (Widiger & Crego, 2013; Widiger & Sankis, 2000). Variants of these approaches are most often used in current diagnostic practice, as outlined in the fifth edition of the Diagnostic and Statistical Manual (American Psychiatric Association, 2013), which contains the current listing of criteria for psychological disorders (Stein et al., 2010). These approaches guide our thinking in this book. An Accepted Definition In conclusion, it is difficult to define Giulio Ercolani/Alamy Stock Photo what constitutes a psychological disorder (Lilienfeld & Marino, 1995, 1999)—and the debate continues (Blashfield, Keeley, ­Flanagan, & Miles, 2014; McNally, 2011; Spitzer, 1999; Stein et al., 2010; ­Wakefield, 2003, 2009; Zachar & Kendler, 2014). The most widely accepted defi- nition used in the Diagnostic and Statistical Manual of Mental Disor- ders, fifth edition (DSM-5) (American Psychiatric Association, 2013) describes behavioral, psychological, or biological dysfunctions that Some religious behaviors may seem unusual to us but are culturally are unexpected in their cultural context and associated with present or individually appropriate. U n d e r s t a n d i n g P s y c h o p a t h o l o g y   5 Copyright 2023 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. The Science of Psychopathology to see whether they work. They are accountable not only to their Psychopathology is the scientific study of psychological disorders. patients but also to the government agencies and insurance com- Within this field are specially trained professionals, including panies that pay for the treatments, so they must demonstrate clinical and counseling psychologists, psychiatrists, psychiatric clearly whether their treatments are effective or not. Third, sci- social workers, and psychiatric nurses, as well as marriage and fam- entist-practitioners might conduct research, often in clinics or ily therapists and mental health counselors. Clinical psychologists hospitals, that produces new information about disorders or and counseling psychologists receive the Ph.D., doctor of philoso- their treatment, thus becoming immune to the fads that plague phy, degree (or sometimes an Ed.D., doctor of education, or Psy.D., our field, often at the expense of patients and their families. For doctor of psychology) and follow a course of graduate-level study example, new “miracle cures” for psychological disorders that lasting approximately 5 years, which prepares them to conduct are reported several times a year in popular media would not be research into the causes and treatment of psychological disorders used by a scientist-practitioner if there were no sound scientific and to diagnose, assess, and treat these disorders. Although there is data showing that they work. Such data flow from research that a great deal of overlap, counseling psychologists tend to study and attempts three basic things: to describe psychological disorders, treat adjustment and vocational issues encountered by relatively to determine their causes, and to treat them (see Figure 1.3). healthy individuals, and clinical psychologists usually concentrate These three categories compose an organizational structure that on more severe psychological disorders. Also, programs in pro- recurs throughout this book and that is formally evident in the fessional schools of psychology, where the degree is often a Psy.D., discussions of specific disorders beginning in Chapter 5. A gen- focus on clinical training and deemphasize or eliminate research eral overview of them now will give you a clearer perspective on training. In contrast, Ph.D. programs in universities integrate clini- our efforts to understand abnormality. cal and research training. Psychologists with other specialty training, such as experimental and social psychologists, concentrate on inves- Clinical Description In hospitals and clinics, we often say tigating the basic determinants of behavior but do not assess or treat that a patient “presents” with a specific problem or set of prob- psychological disorders. lems or we discuss the presenting problem. Presents is a tradi- Psychiatrists first earn an M.D. degree in medical school and tional shorthand way of indicating why the person came to the then specialize in psychiatry during residency training that lasts clinic. Describing Janelle’s presenting problem is the first step 3 to 4 years. Psychiatrists also investigate the nature and causes of psychological disorders, often from a biological point of view; make diagnoses; and offer treatments. Many psychiatrists emphasize drugs or other biological treatments, although most use psychosocial treatments as well. Mental health Psychiatric social workers typically earn a master’s degree in professional social work as they develop expertise in collecting information relevant to the social and family situation of the individual with a Consumer of science Enhancing the practice psychological disorder. Social workers also treat disorders, often concentrating on family problems associated with them. Psychiatric Evaluator of science Kevin Peterson/Photodisc/Getty Images nurses have advanced degrees, such as a master’s or even a Ph.D., Determining the effectiveness of the and specialize in the care and treatment of patients with psycholog- practice ical disorders, usually in hospitals as part of a treatment team. Finally, marriage and family therapists and mental health coun- Creator of science Conducting research selors typically spend 1 to 2 years earning a master’s degree and that leads to new are employed to provide clinical services by hospitals or clinics, procedures useful usually under the supervision of a doctoral-level clinician. in practice The Scientist-Practitioner The most important development Figure 1.2 in the recent history of psychopathology is the adoption of sci- Functioning as a scientist-practitioner. entific methods to learn more about the nature of psychological disorders, their causes, and their treatment. Many mental health Focus professionals take a scientific approach to their clinical work Clinical description and therefore are called scientist-practitioners (Barlow, Hayes, Studying & Nelson, 1984; Hayes, Barlow, & Nelson-Gray, 1999). Mental psychological Causation (etiology) health practitioners may function as scientist-practitioners in one disorders or more of three ways (see Figure 1.2). First, they may keep up Treatment and outcome with the latest scientific developments in their field and there- fore use the most current diagnostic and treatment procedures. In this sense, they are consumers of the science of psychopathol- Figure 1.3 ogy to the advantage of their patients. Second, scientist-practi- Three major categories make up the study and discussion of tioners evaluate their own assessments or treatment procedures psychological disorders. 6  C h a p t e r 1 Psychopathology in Historical Context Copyright 2023 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. in determining her clinical description, which represents the We call the study of changes in behavior over time developmental unique combination of behaviors, thoughts, and feelings that psychology, and we refer to the study of changes in abnormal behavior make up a specific disorder. The word clinical refers both to the as developmental psychopathology. When you think of developmental types of problems or disorders that you would find in a clinic psychology, you probably picture researchers studying the behavior or hospital and to the activities connected with assessment and of children. We change throughout our lives, however, and so treatment. Throughout this text are excerpts from many more researchers also study development in adolescents, adults, and older individual cases, most of them from our personal files. adults. Study of abnormal behavior across the entire age span is One important function of the clinical description is to specify referred to as life-span developmental psychopathology. The field is what makes the disorder different from normal behavior or from relatively new but expanding rapidly. other disorders. Statistical data may also be relevant. For example, how many people in the population as a Causation, Treatment, and Etiology Outcomes Etiology, whole have the disorder? This figure is called the prevalence or the study of origins, has to do with why a disorder begins of the disorder. Statistics on how many new cases occur during (what causes it) and includes biological, psychological, and social a given period, such as a year, represent the incidence of the dimensions. The question of causality is deeply philosophical. Just disorder. You may have become familiar with these terms because two events co-occur does not mean that they are in any during the COVID-19 pandemic. Other statistics include the way causally related: Correlation does not imply causality. Stat- sex ratio—that is, what percentage of women and men have isticians often use the term Granger causality to describe when a the disorder (unfortunately, this traditional term does not series of events temporally predict another series of events. But consider nonbinary gender identity)—and the typical age of even if events are related, it is often difficult if not impossible to onset, which often differs from one disorder to another. pinpoint a single cause of something, especially if many factors In addition to having different symptoms, age of onset, and contribute to it. For example, could we really say that a flap of the possibly a different sex ratio and prevalence, most disorders fol- wings of a butterfly in the Amazon jungle caused a tornado in low a somewhat individual pattern, or course. For example, some Nebraska, even if these events were, in fact, somehow related? As disorders, such as schizophrenia (see Chapter 13), follow a chronic is true for the weather, many factors also “cause” a psychological course, meaning that they tend to last a long time, sometimes a lifetime. Other disorders, like mood disorders (see Chapter 7), follow an episodic course, in that the individual is likely to recover within a few months, only to suffer a recurrence of the disorder at a later time. This pattern may repeat throughout a person’s life. Still other disorders may have a time-limited course, meaning the disorder will improve without treatment in a relatively short period with little or no risk of recurrence. Closely related to differences in course of disorders are differ- ences in onset. Some disorders have an acute onset, meaning that they begin suddenly; others develop gradually over an extended period, which is sometimes called an insidious onset. It is important to know the typical course of a disorder so that we can know what to expect in the future and how best to deal with the problem. This is an important part of the clinical description. For example, if someone is suffering from a mild disorder with acute onset that we know is time limited, we might advise the individual not to bother with expen- sive treatment because the problem will be over soon enough, like a common cold. If the disorder is likely to last a long time (become chronic), however, the individual might want to seek treatment and take other appropriate steps. The anticipated course of a disorder is called the prognosis. So we might say, “the prognosis is good,” meaning the individual will probably recover, or “the prognosis is guarded,” meaning the probable outcome doesn’t look good. The patient’s age may be an important part of the clinical Hung Chung Chih /Shutterstock.com description. A specific psychological disorder occurring in child- hood may present differently from the same disorder in adulthood or old age. Children experiencing severe anxiety and panic often assume that they are physically ill because they have difficulty understanding that there is nothing physically wrong. Because their thoughts and feelings are different from those experienced by adults with anxiety and panic, children are often misdiagnosed Children experience panic and anxiety differently from adults, so their and treated for a medical disorder. reactions may be mistaken for symptoms of physical illness. U n d e r s t a n d i n g P s y c h o p a t h o l o g y   7 Copyright 2023 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. disorder, and some are more important than others. Because the theories or models of behavior popular at the time. The purpose etiology of psychological disorders is so important to this field, of these models is to explain why someone is “acting like that.” we devote an entire chapter (Chapter 2) to it. Three major models that have guided us date back to the begin- Treatment, also, is often important to the study of psychological nings of civilization. disorders. If a new drug or psychosocial treatment is successful in Humans have always supposed that agents outside our treating a disorder, it may give us some hints about the nature of the bodies and environment influence our behavior, thinking, and disorder and its causes. For example, if a drug with a specific known emotions. These agents—which might be divinities, demons, effect within the nervous system alleviates a certain psychological spirits, or other phenomena such as magnetic fields or the moon disorder, we know that something in that part of the nervous system or the stars—are the driving forces behind the supernatural might either be causing the disorder or helping maintain it. Simi- model. In addition, since the era of ancient Greece, the mind has larly, if a psychological treatment designed to help clients regain a often been called the soul or the psyche and considered separate sense of control over their lives is effective with a certain disorder, from the body. Although many have thought that the mind can a diminished sense of control may be an important psychological influence the body and, in turn, the body can influence the component of the disorder itself. mind, most philosophers looked for causes of abnormal behav- As you will see in the next chapter, psychopathology is rarely ior in one or the other. This split gave rise to two traditions of simple. This is because the effect does not necessarily imply the thought about abnormal behavior, summarized as the biological cause. To use a common example, you might take an aspirin to model and the psychological model. These three models—the relieve a tension headache you developed during a grueling day supernatural, the biological, and the psychological—are very old of taking exams. If you then feel better, that does not mean that but continue to be used today. the headache was caused by a lack of aspirin. Nevertheless, many people seek treatment for psychological disorders, and treatment The Supernatural Tradition can provide interesting hints about the nature of the disorder. In the past, textbooks emphasized treatment approaches in a For much of our recorded history, deviant behavior has been general sense, with little attention to the disorder being treated. considered a reflection of the battle between good and evil. For example, a mental health professional might be thoroughly When confronted with unexplainable, irrational behavior and trained in a single theoretical approach, such as psychoanalysis or by suffering and upheaval, people have perceived evil. In fact, behavior therapy (both described later in the chapter), and then in the great Persian empire from 900 to 600 B.C., all physical use that approach on every disorder. More recently, as our science and mental disorders were considered the work of the devil has advanced, we have developed specific effective treatments (Millon, 2004). Barbara Tuchman, a noted historian, chronicled that do not always adhere neatly to one theoretical approach or the second half of the 14th century, a particularly difficult time another but that have grown out of a deeper understanding of for humanity, in A Distant Mirror (1978). She ably captures the the disorder in question. For this reason, there are no separate conflicting tides of opinion on the origins and treatment of insanity during that bleak and tumultuous period. chapters in this book on such types of treatment approaches as psychodynamic, cognitive behavioral, or humanistic. Rather, the latest and most effective drug and psychosocial treatments (non- Demons and Witches medical treatments that focus on psychological, social, and cul- One strong current of opinion put the causes and treatment of tural factors) are described in the context of specific disorders in psychological disorders squarely in the realm of the supernatu- keeping with our integrative multidimensional perspective. ral. During the last quarter of the 14th century, religious and lay We now survey many early attempts to describe and treat authorities supported these popular superstitions, and society as a abnormal behavior and to comprehend its causes, which will give whole began to believe more strongly in the existence and power you a better perspective on current approaches. In Chapter 2, we of demons and witches. The Catholic Church had split, and a sec- examine exciting contemporary views of causation and treatment. ond center, complete with a pope, emerged in the south of France In Chapter 3, we discuss efforts to describe, or classify, abnormal to compete with Rome. In reaction to this schism, the Roman behavior. In Chapter 4, we review research methods—our system- Church fought back against the evil in the world that it believed atic efforts to discover the truths underlying description, cause, must have been behind this heresy. and treatment that allow us to function as scientist-practitioners. People increasingly turned to magic and sorcery to solve their In Chapters 5 through 15, we examine specific disorders; our problems. During these turbulent times, the bizarre behavior of discussion is organized in each case in the now familiar triad of people afflicted with psychological disorders was seen as the work description, cause, and treatment. Finally, in Chapter 16 we exam- of the devil and witches. It followed that individuals possessed by ine legal, professional, and ethical issues relevant to psychological evil spirits were probably responsible for any misfortune experi- disorders and their treatment today. With that overview in mind, enced by people in the local community, which inspired drastic let us turn to the past. action against the possessed. Treatments included exorcism, in which various religious rituals were performed in an effort to rid the victim of evil spirits. Other approaches included shaving the Historical Conceptions of Abnormal Behavior pattern of a cross in the hair of the victim’s head and securing For thousands of years, humans have tried to explain and con- sufferers to a wall near the front of a church so that they might trol problematic behavior. But our efforts always derive from the benefit from hearing Mass. 8  C h a p t e r 1 Psychopathology in Historical Context Copyright 2023 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  caused by mental or emotional stress, and that it was curable Concept Check 1.1 (Alexander & Selesnick, 1966; Maher & Maher, 1985a). Mental depression and anxiety were recognized as illnesses (Kemp, 1990; Part A Schoeneman, 1977), although symptoms such as despair and Write the letter for any or all of the following definitions lethargy were often identified by the church with the sin of acedia, of abnormality in the blanks: (a) societal norm violation, (b) or sloth (Tuchman, 1978). Common treatments were rest, sleep, impairment in functioning, (c) dysfunction, and (d) distress. and a healthy and happy environment. Other treatments included 1. Miguel recently began feeling sad and lonely. baths, ointments, and various potions. Indeed, during the 14th Although still able to function at work and fulfill and 15th centuries, people with insanity, along with those with other responsibilities, he finds himself feeling physical deformities or disabilities, were often moved from house down much of the time, and he worries about to house in medieval villages as neighbors took turns caring for what is happening to him. Which of the defini- them. We now know that this medieval practice of keeping people tions of abnormality apply to Miguel’s situation? who have psychological disturbances in their own community is _____________ beneficial (see Chapter 13). We return to this subject when we 2. Three weeks ago, Makayla, a 35-year-old business discuss biological and psychological models later in this chapter. executive, stopped showering, refused to leave In the 14th century, one of the chief advisers to the king of her apartment, and started watching television talk France, a bishop and philosopher named Nicholas Oresme, also shows. Threats of being fired have failed to bring suggested that the disease of melancholy (depression) was the Jane back to reality, and she continues to spend her days staring blankly at the television screen. Which of the definitions seems to describe Jane’s behavior? ______________ Part B Match the following words that are used in c­ linical descriptions with their corresponding examples: (a) presenting problem, (b) prevalence, (c) incidence, (d) prognosis, (e) course, and (f) etiology. 3. Maria should recover quickly with no intervention necessary. Without treatment, Kofi will deteriorate rapidly. ________________ 4. Three new cases of bulimia have been reported in this county during the past month and only one in the next county. ______________ 5. Kaliah visited the campus mental health center because of her increasing feelings of guilt and anxiety. _________________ 6. Biological, psychological, and social influences all contribute to a variety of disorders. ______________ 7. The pattern a disorder follows can be chronic, time-limited, or episodic. _________ 8. How many people in the population as a whole suffer from obsessive-compulsive disorder? ____________ The conviction that sorcery and witches are causes of mad- DEA PICTURE LIBRARY/Getty Images ness and other evils continued into the 15th century, and evil continued to be blamed for unexplainable behavior, even after the founding of the United States, as evidenced by the Salem, Mas- sachusetts, witch trials in the late 17th century, which resulted in the hanging deaths of 20 innocent people. Stress and Melancholy During the Middle Ages, individuals with psychological disorders were An equally strong opinion, even during this period, reflected sometimes thought to be possessed by evil spirits and exorcisms the enlightened view that insanity was a natural phenomenon, were attempted through rituals. T h e S u p e r n a t u r a l Tr a d i t i o n   9 Copyright 2023 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. source of some bizarre behavior, rather than demons. Oresme the responsibilities of running the kingdom, claiming pointed out that much of the evidence for the existence of sorcery that if he had few worries or irritations, his mind would and witchcraft, particularly among those considered insane, was gradually strengthen and further improve. obtained from people who were tortured and who, quite under- Unfortunately, the physician died, and the insanity standably, confessed to anything. of King Charles VI returned more seriously than before. These conflicting crosscurrents of natural and supernat- This time, however, he came under the influence of the ural explanations for mental disorders are represented more conflicting crosscurrent of supernatural causation. “An or less strongly in various historical works, depending on the unkempt evil-eyed charlatan and pseudo-mystic named sources consulted by historians. Some assumed that demonic Arnaut Guilhem was allowed to treat Charles on his influences were the predominant explanations of abnormal claim of possessing a book given by God to Adam by behavior during the Middle Ages (for example, Zilboorg & means of which man could overcome all affliction result- Henry, 1941); others believed that the supernatural had little ing from original sin” (Tuchman, 1978, p. 514). Guilhem or no influence. As in the handling of the severe psychological insisted that the king’s malady was caused by sorcery, disorder experienced by late-14th-century King Charles VI of but his treatments failed to bring about a cure. France, both influences were strong, sometimes alternating in A variety of remedies and rituals of all kinds were tried, the treatment of the same case. but none worked. High-ranking officials and doctors of the university called for the “sorcerers” to be discovered and punished. “On one occasion, two Augustinian friars, after getting no results from magic incantations and a Charles VI... The Mad King liquid made from powdered pearls, proposed to cut inci- sions in the King’s head. When this was not allowed by I n the summer of 1392, King Charles VI of France was under a great deal of stress, partly because of the division of the Catholic Church. As he rode with his army the King’s council, the friars accused those who opposed their recommendation of sorcery” (Tuchman, 1978, p. 514). Even the king himself, during his lucid moments, to the province of Brittany, a nearby aide dropped his came to believe that the source of madness was evil and lance with a loud clatter, and the king, thinking he was sorcery. “In the name of Jesus Christ,” he cried, weeping under attack, turned on his own army, killing several in his agony, “if there is any one of you who is an accom- prominent knights before being subdued from behind. plice to this evil I suffer, I beg him to torture me no longer The army immediately marched back to Paris. The king’s but let me die!” (Tuchman, 1978, p. 515). lieutenants and advisers concluded that he was mad. During the following years, at his worst the king hid in a corner of his castle believing he was made of glass or roamed the corridors howling like a wolf. At other times, he couldn’t remember who or what he was. He Treatments for Possession became fearful and enraged whenever he saw his own With a perceived connection between evil deeds and sin on the one royal coat of arms and would try to destroy it if it was hand and psychological disorders on the other, it is logical to con- brought near him. clude that the sufferer is largely responsible for the disorder, which The people of Paris were devastated by their might well be a punishment for evil deeds. Does this sound familiar? leader’s apparent madness. Some thought it reflected The acquired immune deficiency syndrome (AIDS) epidemic was God’s anger because the king failed to take up arms to associated with a similar belief among some people, particularly end the schism in the Catholic Church; others thought in the late 1980s and early 1990s. Because the human immunode- it was God’s warning against taking up arms; and still ficiency virus (HIV) is, in Western societies, still quite prevalent others thought it was divine punishment for heavy among the gay community, many people believed it was a divine taxes (a conclusion some people might make today). punishment for what they considered immoral behavior. This view But most thought the king’s madness was caused by became less common as the AIDS virus spread to other segments of sorcery, a belief strengthened by a great drought that the population, yet some people still hold on to this belief. dried up the ponds and rivers, causing cattle to die of Possession, however, is not always connected with sin but may thirst. Merchants claimed their worst losses in 20 years. be seen as involuntary and the possessed individual as blameless. Naturally, the king was given the best care available Furthermore, exorcisms at least have the virtue of being relatively at the time. The most famous healer in the land was a painless. They sometimes work, as do other forms of faith healing, 92-year-old physician whose treatment program included for reasons we explore in subsequent chapters. But what if they moving the king to one of his residences in the country did not? In the Middle Ages, if exorcism failed, some authorities where the air was thought to be the cleanest in the land. thought that steps were necessary to make the body uninhabitable The physician prescribed rest, relaxation, and recreation. by evil spirits, and many people were subjected to confinement, After some time, the king seemed to recover. The physi- beatings, and other forms of torture (Kemp, 1990). cian recommended that the king not be burdened with Somewhere along the way, a creative “therapist” decided that hanging people over a pit full of poisonous snakes might 10  C h a p t e r 1 Psychopathology in Historical Context Copyright 2023 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  scare the evil spirits right out of their bodies (to say nothing All the students and teachers had been in four classrooms, of terrifying the people themselves). This approach sometimes two on each side of the hallway. The incident began when a worked; that is, the most disturbed, oddly behaving individuals 14-year-old young woman reported a funny smell that seemed would suddenly come to their senses and experience relief from to be coming from a vent. She fell to the floor, crying and com- their symptoms, if only temporarily. Naturally, this was rein- plaining that her stomach hurt and her eyes stung. Soon, many of forcing to the therapist, so snake pits were built in many insti- the students and most of the teachers in the four adjoining class- tutions. Although these torture procedures seemed temporarily rooms, who could see and hear what was happening, experienced effective, these “treatments” are not the kinds of approaches we similar symptoms. Of 86 susceptible people (82 students and 4 want to use because there is no good theoretical (or ethical) teachers in the four classrooms), 21 patients (17 students and 4 reason for using them. teachers) experienced symptoms severe enough to be evaluated at the hospital. Inspection of the school building by public health Mass Hysteria authorities revealed no apparent cause for the reactions, and Another fascinating phenomenon is characterized by large-scale physical examinations by teams of physicians revealed no phys- outbreaks of bizarre behavior. To this day, these episodes puzzle his- ical abnormalities. All the patients were sent home and quickly torians and mental health practitioners. During the Middle Ages, recovered (Rockney & Lemke, 1992). they lent support to the notion of possession by the devil. In Europe, Mass hysteria may simply demonstrate the phenomenon of whole groups of people were simultaneously compelled to run out emotion contagion, in which the experience of an emotion seems in the streets, dance, shout, rave, and jump around in patterns as to spread to those around us (Hatfield, Cacioppo, & Rapson, 1994; if they were at a particularly wild party late at night (still called a Ntika, Sakellariou, Kefalas, & Stamatpoulou, 2014; Wang, 2006). rave today, but with music). This behavior was known by several If someone nearby becomes frightened or sad, chances are that, names, including Saint Vitus’s Dance and tarantism. It is most inter- for the moment, you also will feel fear or sadness. When this kind esting that many people behaved in this strange way at once. In an of experience escalates into full-blown panic, whole communities attempt to explain the inexplicable, several reasons were offered in are affected (Barlow, 2002). People are also suggestible when they addition to possession. One reasonable guess was reaction to insect are in states of high emotion. Therefore, if one person identifies bites. Another possibility was what we now call mass hysteria (Veith, a “cause” of the problem, others will probably assume that their 1965). Consider the following example. own reactions have the same source. In popular language, this shared response is sometimes referred to as mob psychology. Until recently, it was assumed that victims had to be in contact with Modern Mass Hysteria each other for the contagion to occur, as were the young women One Friday afternoon, an alarm sounded over the public address described above in the adjacent classrooms. But lately there are system of a community hospital, calling all physicians to the documented cases of emotion contagion occurring across social emergency room immediately. Arriving from a local school in a networks, raising the possibility that episodes of mass hysteria may fleet of ambulances were 17 students and 4 teachers who reported increase (Bartholomew, Wessely, & Rubin, 2012; Dimon, 2013) dizziness, headache, nausea, and stomach pains. Some were vom- iting; most were hyperventilating. The Moon and the Stars Paracelsus, a Swiss physician who lived from 1493 to 1541, rejected notions of possession by the devil, suggesting instead that the movements of the moon and stars had profound effects on people’s psychological functioning. Echoing similar thinking in ancient Greece, Paracelsus speculated that the gravitational effects of the moon on bodily fluids might be a possible cause of mental disorders (Rotton & Kelly, 1985). This influential theory inspired the word lunatic, which is derived from the Latin word luna, meaning “moon.” You might hear some of your friends explain something crazy they did one night by saying, “It must have been the full moon.” The belief that heavenly bodies affect Source: U.S. National Library of Medicine human behavior still exists, although there is no scientific evi- dence to support it (Raison, Klein, & Steckler, 1999; Rotton & Kelly, 1985). Despite much ridicule, millions of people around the world are convinced that their behavior is influenced by the stages of the moon or the positions of the stars. This belief is most noticeable today in followers of astrology, who hold that their behavior and the major events in their lives can be predicted by In hydrotherapy, patients were shocked back to their senses by their day-to-day relationship to the position of the planets. No applications of ice-cold water. serious evidence has ever confirmed such a connection, however. T h e S u p e r n a t u r a l Tr a d i t i o n   11 Copyright 2023 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppres