Abnormal Psychology Reviewer (Kring).pdf

ABNORMAL PSYCHOLOGY: THE SCIENCE AND TREATMENT OF PSYCHOLOGICAL DISORDERS Ann Kring, Sheri Johnson, Gerald C. Davison, and John M. Neale  Abnormal Psychology Ann Kring...

ABNORMAL PSYCHOLOGY: THE SCIENCE AND TREATMENT OF PSYCHOLOGICAL DISORDERS Ann Kring, Sheri Johnson, Gerald C. Davison, and John M. Neale  Abnormal Psychology Ann Kring Board Exam Reviewer Chapter 1 Introduction and Historical Overview  As you approach the study of psychopathology, the field concerned with the nature, development, and treatment of mental disorders, keep in mind that the field is continually developing and adding new findings.  Stigma refers to the destructive beliefs and attitudes held by a society that are ascribed to groups considered different in some manner, such as people with mental illness.  More specifically, stigma has four characteristics: 1. A label is applied to a group of people that distinguishes them from others (e.g., “crazy”). 2. The label is linked to deviant or undesirable attributes by society (e.g., crazy people are dangerous). 3. People with the label are seen as essentially different from those without the label, contributing to an “us” versus “them” mentality (e.g., we are not like those crazy people). 4. People with the label are discriminated against unfairly (e.g., a clinic for crazy people can’t be built in our neighborhood).  In 1999, David Satcher, then Surgeon General of the United States, wrote that stigma is the “most formidable obstacle to future progress in the arena of mental illness and mental health” in his groundbreaking report on mental illness. Sadly, this remains true more than 10 years later.  Many mental health practitioners and advocates hoped that the more people learned about the neurobiological causes of mental disorders, the less stigmatized these disorders would be. However,  results from a recent study shows that this may not be true. People’s knowledge has increased, but unfortunately stigma has not decreased. Defining Mental Disorder  The definition of mental disorder presented in the fourth edition of the American diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), as well as the proposed definition for the fifth edition of the DSM (DSM-5), which is scheduled for release in May 2013, includes a number of characteristics essential to the concept of mental disorder, including the following: 1. The disorder occurs within the individual. 2. It causes personal distress or disability. 3. It is not a culturally specific reaction to an event (e.g., death of a loved one). 4. It is not primarily a result of social deviance or conflict with society. Personal Distress  One characteristic used to define mental disorder is personal distress—that is, a person’s behavior may be classified as disordered if it causes him or her great distress.  Personal distress also characterizes many of the forms of mental disorder considered in this book— people experiencing anxiety disorders and depression suffer greatly.  But not all mental disorders cause distress. For example, an individual with the antisocial type of personality disorder may treat others coldheartedly and violate the law without experiencing any guilt, remorse, anxiety, or other type of distress.  And not all behavior that causes distress is disordered—for example, the distress of hunger due to religious fasting or the pain of childbirth. Disability  Disability—that is, impairment in some important area of life (e.g., work or personal relationships)—can also characterize mental disorder.  For example, substance use disorders are defined in part by the social or occupational disability (e.g., serious arguments with one’s spouse or poor work performance) created by substance abuse.  Being rejected by peers, as Felicia was, is also an example of this characteristic. Phobias can produce both distress and disability—for example, if a severe fear of flying prevents someone living in California from taking a job in New York.  Like distress, however, disability alone cannot be used to define mental disorder, because some, but not all, disorders involve disability. For example, the disorder bulimia nervosa involves binge eating and compensatory purging (e.g., vomiting) in an attempt to control weight gain but does not necessarily involve disability. Many people with bulimia lead lives without impairment, while bingeing and purging in private. Violation of Social Norms  This way of defining mental disorder is both too broad and too narrow. For example, it is too broad in that criminals violate social norms but are not usually studied within the domain of psychopathology; it is too narrow in that highly anxious people typically do not violate social norms.  Also, of course, social norms vary a great deal across cultures and ethnic groups, so behavior that clearly violates a social norm in one group may not do so at all in another. Dysfunction  In an influential and widely discussed paper, Wakefield proposed that mental disorders could be defined as harmful dysfunction.  A judgment that a behavior is harmful requires some standard, and this standard is likely to depend on social norms and values, the characteristic just described.  Dysfunctions are said to occur when an internal mechanism is unable to perform its natural function—that is, the function that it evolved to perform.  Clearly, like the other definitions of mental disorder, Wakefield’s concept of harmful dysfunction has its limitations. The DSM definition of dysfunction refers to the fact that behavioral, psychological, and biological dysfunctions are all interrelated. That is, the brain impacts behavior, and behavior impacts the brain; thus dysfunction in these is interrelated. This broadening does not entirely avoid the problems that Wakefield’s definition suffers from, but it is an attempt that formally recognizes the limits of our current understanding. History of Psychopathology Early Demonology  Many early philosophers, theologians, and physicians who studied the troubled mind believed that disturbed behavior reflected the displeasure of the gods or possession by demons.  The doctrine that an evil being or spirit can dwell within a person and control his or her mind and body is called demonology.  The belief that odd behavior was caused by possession led to treating it by exorcism, the ritualistic casting out of evil spirits. Exorcism typically took the form of elaborate rites of prayer, noisemaking, forcing the afflicted to drink terrible-tasting brews, and on occasion more extreme measures, such as flogging and starvation, to render the body uninhabitable to devils. Early Biological Explanations  In the fifth century b.c., Hippocrates, often called the father of modern medicine, separated medicine from religion, magic, and superstition. He rejected the prevailing Greek belief that the gods sent mental disturbances as punishment and insisted instead that such illnesses had natural causes and hence should be treated like other, more common maladies, such as colds and constipation.  Hippocrates regarded the brain as the organ of consciousness, intellectual life, and emotion; thus, he thought that disordered thinking and behavior were indications of some kind of brain pathology. Hippocrates is often considered one of the earliest proponents of the notion that something wrong with the brain disturbs thought and action.  Hippocrates regarded the brain as the organ of consciousness, intellectual life, and emotion; thus, he thought that disordered thinking and behavior were indications of some kind of brain pathology.  Hippocrates classified mental disorders into three categories: mania, melancholia, and phrenitis, or brain fever.  Further, Hippocrates believed that normal brain functioning, and therefore mental health, depended on a delicate balance among four humors, or fluids of the body, namely, blood, black bile, yellow bile, and phlegm. An imbalance of these humors produced disorders.  If a person was sluggish and dull, for example, the body supposedly contained a preponderance of phlegm. A preponderance of black bile was the explanation for melancholia; too much  yellow bile explained irritability and anxiousness; and too much blood, changeable temperament. The Dark Ages and Demonology  Historians have often pointed to the death of Galen, the second-century Greek who is regarded as the last great physician of the classical era, as the beginning of the so-called Dark Ages in western European medicine and in the treatment and investigation of mental disorders.  The Church gained in influence, and the papacy was declared independent of the state. Christian monasteries, through their missionary and educational work, replaced physicians as healers and as authorities on mental disorder.  The Persecution of Witches  In 1484, Pope Innocent VIII exhorted the clergy of Europe to leave no stone unturned in the search for witches. He sent two Dominican monks to northern Germany as inquisitors. Two years later they issued a comprehensive and explicit manual, Malleus Maleficarum (“the witches’ hammer”), to guide the witch hunts.  Those accused of witchcraft should be tortured if they did not confess, those convicted and penitent were to be imprisoned for life, and those convicted and unrepentant were to be handed over to the law for execution.  The manual specified that a person’s sudden loss of reason was a symptom of demonic possession and that burning was the usual method of driving out the supposed demon.  In the dunking test, if the woman did not drown, she was considered to be in league with the devil (and punished accordingly); this is the ultimate no-win situation.  Lunacy Trials  In all the cases that Neugebauer examined, only one referred to demonic possession. Interestingly, the term lunacy comes from a theory espoused by the Swiss physician Paracelsus, who attributed odd behavior to a misalignment of the moon and stars (the Latin word for “moon” is luna). This lunar explanation, even if unsubstantiated, was a welcome alternative to explanations involving demons or witches. Even today, many people believe that a full moon is linked to odd behavior; however, there is no scientific evidence to support this belief. Development of Asylums  Until the fifteenth century, there were very few hospitals for people with mental illness in Europe. However, there were many hospitals for people with leprosy—for example, in the twelfth century, England and Scotland had 220 leprosy hospitals serving a total population of a million and a half. Leprosy gradually disappeared from Europe, probably because with the end of wars came a break with the Eastern sources of the infection. With hospitals now underused, attention seems to have turned to people with mental illness. Leprosariums were converted to asylums, refuges for the confinement and care of people with mental illness.  Bethlehem and Other Early Asylums  The Priory of St. Mary of Bethlehem was founded in 1243. Records indicate that in 1403 it housed six men with mental illness. In 1547, Henry VIII handed it over to the city of London, thereafter to be a hospital devoted solely to the confinement of people with mental illness.  The conditions in Bethlehem were deplorable. Over the years the word bedlam, the popular name for this hospital, came to mean a place or scene of wild uproar and confusion. Bethlehem eventually became one of London’s great tourist attractions, by the eighteenth century rivaling both Westminster Abbey and the Tower of London. Even as late as the nineteenth century, viewing the patients was considered entertainment, and people bought tickets to see them.  Medical treatments were often crude and painful. Benjamin Rush, for example, began practicing medicine in Philadelphia in 1769 and is considered the father of American psychiatry. Yet he believed that mental disorder was caused by an excess of blood in the brain, for which his favored treatment was to draw great quantities of blood from disordered individuals. Rush also believed that many people with mental illness could be cured by being frightened. Thus, one of his recommended procedures was for the physician to convince the patient that death was near!  Pinel’s Reforms  Philippe Pinel has often been considered a primary figure in the movement for humanitarian treatment of people with mental illness in asylums.  In 1793, while the French Revolution raged, he was put in charge of a large asylum in Paris known as La Bicêtre. Many texts assert that Pinel removed the chains of the people imprisoned in La Bicêtre, an event that was memorialized in well-known paintings.   Historical research, however, indicates that it was not Pinel who released the patients from their chains. Rather, it was a former patient, Jean-Baptiste Pussin, who had become an orderly at the hospital. In fact, Pinel was not even present when the patients were released. Several years later, though, Pinel did praise Pussin’s efforts and began to follow the same practices.  Moral Treatment  In the United States, the Friends’ Asylum, founded in 1817 in Pennsylvania, and the Hartford Retreat, established in 1824 in Connecticut, were established to provide humane treatment. In accordance with this approach, which became known as moral treatment, patients had close contact with attendants, who talked and read to them and encouraged them to engage in purposeful activity; residents led lives as close to normal as possible and in general took responsibility for themselves within the constraints of their disorders. Further, there were to be no more than 250 patients in a given hospital.  Moral treatment was largely abandoned in the latter part of the nineteenth century. Ironically, the efforts of Dorothea Dix, a crusader for improved conditions for people with mental illness who fought to have hospitals created for their care, helped effect this change. She campaigned vigorously to improve the lives of people with mental illness and personally helped see that 32 state hospitals were built. These large public hospitals took in many of the patients whom the private hospitals could not accommodate. Unfortunately, the small staffs of these new hospitals were unable to provide the individual attention that was a hallmark of moral treatment. The Evolution of Contemporary Thought Biological Approaches  Discovering Biological Origins in General Paresis and Syphilis  Perhaps the most striking medical success was the elucidation of the nature and origin of syphilis, a venereal disease that had been recognized for several centuries.  Since the late 1700s it had been known that a number of people with mental illness manifested a syndrome characterized by a steady deterioration of both mental and physical abilities, including symptoms such as delusions of grandeur (i.e., the belief that you hold special and great power or  can accomplish more than any other person on the planet) and progressive paralysis; the presumed disease associated with this syndrome was given the name general paresis.  In the 1860s and 1870s, Louis Pasteur established the germ theory of disease, which posited that disease is caused by infection of the body by minute organisms. This theory laid the groundwork for demonstrating the relation between syphilis and general paresis.  Genetics  Francis Galton, often considered the originator of genetic research with twins, because of his study of twins in the late 1800s in England, attributed many behavioral characteristics to heredity. He is credited with coining the terms nature and nurture to talk about differences in genetics (nature) and environment (nurture).  Unfortunately, Galton is also credited with creating the eugenics movement in 1883. Advocates of this movement sought to eliminate undesirable characteristics from the population by restricting the ability of certain people to have children (e.g., by enforced sterilization). Indeed, in a sad page from U.S. history, state laws in the late 1800s and early 1900s prohibited people with mental illness from marrying and forced them to be sterilized in order to prevent them from “passing on” their illness.  Biological Treatments  In the early 1930s, the practice of inducing a coma with large dosages of insulin was introduced by Sakel, who claimed that up to three-quarters of the people with schizophrenia whom he treated showed significant improvement. Later findings by others were less encouraging, and insulin-coma therapy—which presented serious risks to health, including irreversible coma and death—was gradually abandoned.  In the early twentieth century, electroconvulsive therapy (ECT) was originated by two Italian physicians, Ugo Cerletti and Lucino Bini. Cerletti was interested in epilepsy and was seeking a way to induce seizures experimentally. Shortly thereafter he found that by applying electric shocks to the sides of the human head, he could produce full epileptic seizures. Then, in Rome in 1938, he used the technique on a patient with schizophrenia. In the decades that followed, ECT was administered to people with schizophrenia and severe depression, usually in hospital settings. As we will discuss in Chapter 5, it is still used today for people with severe depression. Fortunately,  important refinements in the ECT procedures have made it less problematic, and it remains an effective treatment.  In 1935, Egas Moniz, a Portuguese psychiatrist, introduced the prefrontal lobotomy, a surgical procedure that destroys the tracts connecting the frontal lobes to other areas of the brain. His initial reports claimed high rates of success, and for 20 years thereafter thousands of people with mental illness underwent variations of this psychosurgery. The procedure was used especially for those whose behavior was violent. Many people did indeed quiet down and could even be discharged from hospitals, largely because their brains were damaged. During the 1950s, this intervention fell into disrepute for several reasons. After surgery, many people became dull and listless and suffered serious losses in their cognitive capacities—for example, becoming unable to carry on a coherent conversation with another person—which is not surprising given the destruction of parts of their brains that support thought and language. Psychological Approaches  Mesmer and Charcot  During the eighteenth century in western Europe, many people were observed to be subject to hysteria, which referred to physical incapacities, such as blindness or paralysis, for which no physical cause could be found.  Franz Anton Mesmer, an Austrian physician practicing in Vienna and Paris in the late eighteenth century, believed that hysteria was caused by a particular distribution of a universal magnetic fluid in the body. Moreover, he felt that one person could influence the fluid of another to bring about a change in the other’s behavior.  Although Mesmer regarded hysteria as having strictly biological causes, we discuss his work here because he is generally considered one of the earlier practitioners of modern-day hypnosis (the word mesmerism is a synonym for hypnotism; the phenomenon itself was known to the ancients of many cultures, where it was part of the sorcery and magic of conjurers and faith healers).  The great Parisian neurologist Jean Martin Charcot also studied hysterical states. Although Charcot believed that hysteria was a problem with the nervous system and had a biological cause, he was also persuaded by psychological explanations. One day, some of his enterprising students hypnotized a healthy woman and, by suggestion, induced her to display certain hysterical symptoms. Charcot was deceived into believing that she was an actual patient with hysteria. When  the students showed him how readily they could remove the symptoms by waking the woman, Charcot became interested in psychological interpretations of these very puzzling phenomena.  Breuer and the Cathartic Method  In the nineteenth century, a Viennese physician, Josef Breuer , treated a young woman, whose identity was disguised under the pseudonym Anna O., with a number of hysterical symptoms, including partial paralysis, impairment of sight and hearing, and, often, difficulty speaking. She also sometimes went into a dreamlike state, or “absence,” during which she mumbled to herself, seemingly preoccupied with troubling thoughts. Breuer hypnotized her, and while hypnotized, she began talking more freely and, ultimately, with considerable emotion about upsetting events from her past.  Reliving an earlier emotional trauma and releasing emotional tension by expressing previously forgotten thoughts about the event was called catharsis, and Breuer’s method became known as the cathartic method.  Ironically, later investigation revealed that Breuer and Freud reported the case incorrectly. Historical study by Henri Ellenberger indicates that the young woman was helped only temporarily by Breuer’s talking cure. This is supported by Carl Jung, a renowned colleague of Freud’s, who is quoted as saying that during a conference in 1925, Freud told him that Anna O. had never been cured. Hospital records discovered by Ellenberger confirmed that Anna O. continued to rely on morphine to ease the “hysterical” problems that Breuer is reputed to have cured by catharsis.  Freud and Psychoanalysis  The central assumption of Freud’s theorizing, often referred to as psychoanalytic theory, is that psychopathology results from unconscious conflicts in the individual.  Structure of the Mind  According to Freud, the id is present at birth and is the repository of all of the energy needed to run the psyche, including the basic urges for food, water, elimination, warmth, affection, and sex. Trained as a neurologist, Freud saw the source of the id’s energy as biological, and he called this energy libido. The individual cannot consciously perceive this energy—it is unconscious, below the level of awareness. The id seeks immediate gratification of its urges, operating on  what Freud called the pleasure principle. When the id is not satisfied, tension is produced, and the id impels a person to eliminate this tension as quickly as possible.  According to Freud, the ego begins to develop from the id during the second 6 months of life. Unlike the contents of the id, those of the ego are primarily conscious. The ego thus operates on what Freud termed the reality principle as it mediates between the demands of reality and the id’s demands for immediate gratification.  The superego—the third part of the psyche in Freud’s theory—can be roughly conceived of as a person’s conscience. Freud believed that the superego develops throughout childhood, arising from the ego much as the ego arises from the id.  Defense Mechanisms  A defense mechanism is a strategy used by the ego to protect itself from anxiety.  Psychoanalytic Therapy  In psychoanalytic and newer psychodynamic treatments, the goal of the therapist is to understand the person’s early-childhood experiences, the nature of key relationships, and the patterns in current relationships.  With free association , a patient reclines on a couch, facing away from the analyst, and is encouraged to give free rein to his or her thoughts, verbalizing whatever comes to mind, without censoring anything.   Transference refers to the patient’s responses to his or her analyst that seem to reflect attitudes and ways of behaving toward important people in the patient’s past, rather than reflecting actual aspects of the analyst–patient relationship.  In the technique of interpretation, the analyst points out to the patient the meanings of certain of the patient’s behaviors. Defense mechanisms are a principal focus of interpretation.  Neo-Freudian Psychodynamic Perspectives  Jung and Analytical Psychology  Carl Gustav Jung, a Swiss psychiatrist originally considered Freud’s heir apparent, broke with Freud in 1914 on many issues, after a 7-year period of intense correspondence about their disagreements. Jung proposed ideas radically different from Freud’s, ultimately establishing analytical psychology.  Jung hypothesized that in addition to the personal unconscious postulated by Freud, there is a collective unconscious, the part of the unconscious that is common to all human beings and that consists primarily of what Jung called archetypes, or basic categories that all human beings use in conceptualizing about the world.  Jung also catalogued various personality characteristics; perhaps most important among them are extraversion (an orientation toward the external world) versus introversion (an orientation toward the inner, subjective world).  Adler and Individual Psychology  Adler’s theory, which came to be known as individual psychology, regarded people as inextricably tied to their society because he believed that fulfillment was found in doing things for the social good. Like Jung, he stressed the importance of working toward goals.  Continuing Influences of Freud and His Followers 1. Childhood experiences help shape adult personality. Contemporary clinicians and researchers still view childhood experiences and other environmental events as crucial. They seldom focus on the psychosexual stages about which Freud wrote, but some emphasize problematic parent–child relationships in general and how they can influence later adult relationships in negative ways.  2. There are unconscious influences on behavior. This research shows that people can be unaware of the causes of their behavior. However, most current researchers and clinicians do not think of the unconscious as a repository of id instincts. 3. The causes and purposes of human behavior are not always obvious. Contemporary psychodynamic theorists continue to caution us against taking everything at face value. A person expressing disdain for another, for example, may actually like the other person very much yet be fearful of admitting positive feelings.  Freud’s Ideas on Depression  He theorized that the potential for depression is created early in childhood, during the oral period. If the child’s needs are insufficiently or excessively gratified, the person becomes fixated in the oral stage. This arrest in development may cause the person to become excessively dependent on other people for the maintenance of self-esteem.  According to the theory, the mourner’s anger toward the lost one becomes directed inward, developing into ongoing self-blame and depression. In this view, depression can be described as anger turned against oneself. The Rise of Behaviorism  John Watson looked to the experimental procedures of the psychologists who were investigating learning in animals, and because of his efforts, the dominant focus of psychology switched from thinking to learning. Behaviorism focuses on observable behavior rather than on consciousness or mental functioning.  Classical Conditioning  Around the turn of the twentieth century, the Russian physiologist and Nobel laureate Ivan Pavlov discovered classical conditioning, quite by accident.  Experiment conducted on Little Albert cited a possible relationship between classical conditioning and the development of certain disorders, in this instance a phobia. It is important to note that this type of study could never be done today because it breaches ethical standards.  Operant Conditioning  Thorndike formulated what was to become an extremely important principle, the law of effect: behavior that is followed by consequences satisfying to the organism will be repeated, and behavior that is followed by noxious or unpleasant consequences will be discouraged.  B. F. Skinner introduced the concept of operant conditioning, so called because it applies to behavior that operates on the environment. Renaming Thorndike’s “law of effect” the “principle of reinforcement”, Skinner distinguished two types of reinforcement. 1. Positive reinforcement refers to the strengthening of a tendency to respond by virtue of the presentation of a pleasant event, called a positive reinforcer. For example, a water-deprived pigeon will tend to repeat behaviors (operants) that are followed by the availability of water. 2. Negative reinforcement also strengthens a response, but it does so via the removal of an aversive event, such as the cessation of electric shock.  Operant conditioning principles may contribute to the persistence of aggressive behavior, a key feature of conduct disorder.  Modeling  Learning often goes on even in the absence of reinforcers. We all learn by watching and imitating others, a process called modeling. In the 1960s, experimental work demonstrated that witnessing someone perform certain activities can increase or decrease diverse kinds of behavior, such as sharing, aggression, and fear. For example, Bandura and Menlove used a modeling treatment to reduce fear of dogs in children.  Behavior Therapy  Behavior therapy emerged in the 1950s. In its initial form, this therapy applied procedures based on classical and operant conditioning to alter clinical problems. Sometimes the term behavior modification is used as well, and therapists who use operant conditioning as a treatment often prefer that term.  One important behavior therapy technique that is still used to treat phobias and anxiety today is called systematic desensitization. Developed by Joseph Wolpe in 1958, it includes two components: (1) deep muscle relaxation and (2) gradual exposure to a list of feared situations,  starting with those that arouse minimal anxiety and progressing to those that are the most frightening. The Importance of Cognition  Cognitive Therapy  In cognitive therapy, the therapist typically begins by helping clients become more aware of their maladaptive thoughts. By changing cognition, therapists hope that people can change their feelings, behaviors, and symptoms.  The roots of cognitive therapy included Aaron Beck’s cognitive therapy and Albert Ellis’s rational- emotive behavior therapy (REBT). Ellis’s principal thesis was that sustained emotional reactions are caused by internal sentences that people repeat to themselves; these self-statements reflect sometimes unspoken assumptions––irrational beliefs––about what is necessary to lead a meaningful life.  In Ellis’s REBT, the aim is to eliminate self-defeating beliefs. A person with depression, for example, may say several times a day, “What a worthless jerk I am.” Ellis proposed that people interpret what is happening around them, that sometimes these interpretations can cause emotional turmoil, and that a therapist’s attention should be focused on these beliefs rather than on historical causes or, indeed, on overt behavior. The Mental Health Professions  Clinical psychologists must have a Ph.D. or Psy.D. degree, which entails 4 to 8 years of graduate study.  As in other fields of psychology, the Ph.D. is basically a research degree, and candidates are required to write a dissertation on a specialized topic. But candidates in clinical psychology learn skills in two additional areas, which distinguish them from other Ph.D. candidates in psychology. First, they learn techniques of assessment and diagnosis of psychopathology; that is, they learn the skills necessary to determine whether a person’s symptoms or problems indicate a particular disorder. Second, they learn how to practice psychotherapy, a primarily verbal means of helping people change their thoughts, feelings, and behavior to reduce distress and to achieve greater life satisfaction.   Another degree option for clinical psychologists is the Psy.D. (doctor of psychology), for which the curriculum is similar to that required of Ph.D. students, but with less emphasis on research and more on clinical training.  Psychiatrists hold an M.D. degree and have had postgraduate training, called a residency, in which they have received supervision in the practice of diagnosis and pharmacotherapy (administering medications). Most often, however, the only aspect of medical practice in which psychiatrists engage is prescribing psychoactive medications, chemical compounds that can influence how people feel and think. Psychiatrists may receive some training in psychotherapy as well, though this is not a strong focus of training.  A psychiatric nurse typically receives training at the bachelor’s or master’s level. Nurses can also receive more specialized training as a nurse practitioner that will allow them to prescribe psychoactive medications.  Counseling psychologists originally dealt mostly with vocational issues; their focus today may be quite similar to that in clinical psychology, though still with less of an emphasis on mental disorders and more of an emphasis on prevention, education, and general life problems. Counseling psychologists work in a variety of settings, including schools, mental health agencies, industry, and community health centers.  Social workers have an M.S.W. (master of social work) degree. Training programs are shorter than Ph.D. programs, typically requiring 2 years of graduate study. The focus of training is on psychotherapy. Those in social work graduate programs do not receive training in psychological assessment.  Marriage and family therapists treat families or couples, focusing on the ways in which these relationships impact a variety of mental health issues.  Chapter 2 Current Paradigms in Psychopathology  Our view is that every effort should be made to study psychopathology according to scientific principles. But science is not a completely objective and certain enterprise.  Rather, as suggested by philosopher of science Thomas Kuhn, subjective factors as well as our human limitations enter into the conduct of scientific inquiry.  Central to scientific activity, in Kuhn’s view, is the notion of a paradigm, a conceptual framework or approach within which a scientist works—that is, a set of basic assumptions, a general perspective, that defines how to conceptualize and study a subject, how to gather and interpret relevant data, even how to think about a particular subject.  We note at the outset that no one paradigm offers the “complete” conceptualization of psychopathology. Rather, for most disorders, each paradigm offers some important information with respect to etiology and treatment, but only part of the picture. The Genetic Paradigm  Each chromosome is made up of many genes, the carriers of the genetic information (DNA) passed from parents to child.  Psychopathology is polygenic, meaning several genes, perhaps operating at different times during the course of development, turning themselves on and off as they interact with a person’s environment is the essence of genetic vulnerability.  Thus, we do not inherit mental illness from our genes; we develop mental illness through the interaction of our genes with our environments.  Heritability refers to the extent to which variability in a particular behavior (or disorder) in a population can be accounted for by genetic factors. 1. Heritability estimates range from 0.0 to 1.0: the higher the number, the greater the heritability.  2. Heritability is relevant only for a large population of people, not a particular individual. Thus, it is incorrect to talk about any one person’s heritability for a particular behavior or disorder.  Knowing that the heritability of attention-deficit/hyperactivity disorder (ADHD) is around 0.70 does not mean that 70 percent of Jane’s ADHD is because of her genes and 30 percent is due to other factors. It means that in a population (e.g., a large sample in a study), the variation in ADHD is understood as being attributed to 70 percent genes and 30 percent environment. There is no heritability in ADHD (or any disorder) for a particular individual.  Shared environment factors include those things that members of a family have in common, such as family income level, child-rearing practices, and parents’ marital status and quality.  Nonshared environment factors (sometimes referred to as unique environment) are those things believed to be distinct among members of a family, such as relationships with friends or specific events unique to a person (e.g., being in a car accident or on the swim team), and these are believed to be important in understanding why two siblings from the same family can be so different. Behavior Genetics  Behavior genetics is the study of the degree to which genes and environmental factors influence behavior. To be clear, behavior genetics is not the study of how genes or the environment determine behavior.  The total genetic makeup of an individual, consisting of inherited genes, is referred to as the genotype (physical sequence of DNA); the genotype cannot be observed outwardly.  We defined gene expression earlier: the genotype should not be viewed as a static entity. Genes switch off and on at specific times, for example, to control various aspects of development. Indeed, genetic programs are quite flexible—they respond in remarkable ways to things that happen to us.  In contrast, the totality of observable behavioral characteristics, such as level of anxiety, is referred to as the phenotype.  The phenotype changes over time and is the product of an interaction between the genotype and the environment. For example, a person may be born with the capacity for high intellectual achievement, but whether he or she develops this genetically given potential depends on environmental factors such as upbringing and education. Hence, intelligence is an index of the phenotype. Molecular Genetics  Molecular genetics studies seek to identify particular genes and their functions. Gene–Environment Interactions  Life experience shapes how our genes are expressed, and our genes guide us in behaviors that lead to the selection of different experiences. A gene–environment interaction means that a given person’s sensitivity to an environmental event is influenced by genes.  They also measured a particular gene called the serotonin transporter gene (5-HTT). This gene has a polymorphism such that some people have two short alleles (short–short), some have two long alleles (long–long), and some have one short and one long allele (short–long). They found that those individuals who had either the short–short allele or the short–long allele combinations of the 5-HTT gene and were maltreated as children were more likely to have major depressive disorder as adults than either those people who had the same gene combination but no childhood maltreatment or those people who were maltreated as children but had the long–long allele combination of the gene.  The study of how the environment can alter gene expression or function is called epigenetics. The term epigenetic means “above or outside the gene” and refers to the chemical “marks” that are attached to and protect the DNA in each gene. Reciprocal Gene–Environment Interactions  Another important way in which genes are important in psychopathology is in how they may promote certain types of environments. This is called a reciprocal gene–environment interaction. The basic idea is that genes may predispose us to seek out certain environments that then increase our risk for developing a particular disorder.  For example, a genetic risk for alcohol use disorder may predispose persons to life events that put them in high-risk situations for alcohol use such as being in trouble with the law.  One study found that genetic vulnerability to depression may promote certain life events, such as breaking up with a boyfriend or difficulties with parents, that can trigger depression among adolescent girls.  People seem to select environments that increase the likelihood of certain kinds of stressful life events at least in part based on their genes. The Neuroscience Paradigm  The neuroscience paradigm holds that mental disorders are linked to aberrant processes in the brain. Neurons and Neurotransmitters  Serotonin and dopamine may be involved in depression, mania, and schizophrenia.  Norepinephrine is a neurotransmitter that communicates with the sympathetic nervous system, where it is involved in producing states of high arousal and thus may be involved in the anxiety disorders and other stress-related conditions.  GABA inhibits nerve impulses throughout most areas of the brain and may be involved in the anxiety disorders.  Early theories linking neurotransmitters to psychopathology sometimes proposed that a given disorder was caused by either too much or too little of a particular transmitter (e.g., mania is associated with too much norepinephrine, anxiety disorders with too little GABA).  Other research has focused on the possibility that the neurotransmitter receptors are at fault in some disorders. If the receptors on the postsynaptic neuron were too numerous or too easily excited, the result would be akin to having too much transmitter released.  The delusions and hallucinations of schizophrenia, for example, may result from an overabundance of dopamine receptors.  When a cell has been firing more frequently, this receptor releases second messengers. Once second messengers are released, they play a role in adjusting the sensitivity of postsynaptic receptors to dopamine, norepinephrine, or serotonin. One can think of second messengers as helping a neuron adjust receptor sensitivity when it has been overly active.  One method that investigators use to study how neurotransmitters are working in the brain is to have people take a drug that stimulates a particular neurotransmitter’s receptors. This kind of drug is referred to as an agonist.  A serotonin agonist, for example, is a drug that stimulates serotonin receptors to produce the same effects as serotonin does naturally.  By contrast, an antagonist is a drug that works on a neurotransmitter’s receptors to dampen the activity of that neurotransmitter.   For example, many drugs used to treat schizophrenia are dopamine antagonists that work by blocking dopamine receptors. Structure and Function of the Human Brain  The major connection between the two hemispheres is a band of nerve fibers, called the corpus callosum, that allows the two hemispheres to communicate.  The cortex is comprised of the neurons that form the thin outer covering of the brain, the so-called gray matter of the brain.  The gray matter of the cerebral cortex does not extend throughout the interior of the brain. Much of the interior is white matter, made up of large tracts of myelinated (sheathed) fibers that connect cell bodies in the cortex with those in the spinal cord and in other centers lower in the brain.  One important set of areas, collectively referred to as the basal ganglia, is located deep within each hemisphere. The basal ganglia help regulate starting and stopping both motor and cognitive activity.  Also deep within the brain are cavities called ventricles. These ventricles are filled with cerebrospinal fluid.  The thalamus is a relay station for all sensory pathways except the olfactory.  The amygdala is also an important area for attention to emotionally salient stimuli and memory of emotionally relevant events. For example, people with depression show more activity in the amygdala when watching pictures of emotional faces than do people without depression.  Then, somewhat surprisingly, a number of synaptic connections begin to be eliminated—a process called pruning. The Neuroendocrine System  The HPA axis is central to the body’s response to stress, and stress figures prominently in many of the disorders we discuss in this book.  When people are faced with threat, the hypothalamus releases corticotropin-releasing factor (CRF), which then communicates with the pituitary gland. The pituitary then releases adrenocorticotropic hormone, which travels via the blood to the adrenal glands. The outer layers of the adrenal glands are referred to as the adrenal cortex; this area promotes the release of the hormone cortisol. Cortisol is often referred to as the stress hormone.  A simple way to think about these two components of the ANS is that the sympathetic nervous system prepares the body for “fight or flight” and the parasympathetic nervous system helps “calm down” the body.  The sympathetic portion of the ANS, when energized, accelerates the heartbeat, dilates the pupils, inhibits intestinal activity, increases electrodermal activity (i.e., sweat on the skin), and initiates other smooth muscle and glandular responses that prepare the organism for sudden activity and stress.  Division of activities is not quite so clear-cut, however, for it is the parasympathetic system that increases blood flow to the genitals during sexual excitement. Neuroscience Approaches to Treatment  Antidepressants, such as Prozac, increase neural transmission in neurons that use serotonin as a neurotransmitter by inhibiting the reuptake of serotonin.  Benzodiazepines, such as Xanax, can be effective in reducing the tension associated with some anxiety disorders, perhaps by stimulating GABA neurons to inhibit other neural systems that create the physical symptoms of anxiety.  Antipsychotic drugs, such as Olanzapine, used in the treatment of schizophrenia, reduce the activity of neurons that use dopamine as a neurotransmitter by blocking their receptors and also impact serotonin.  Stimulants, such as Adderall, are often used to treat children with attention-deficit/hyperactivity disorder; they operate on several neurotransmitters that help children pay attention. Evaluating the Neuroscience Paradigm  Reductionism refers to the view that whatever is being studied can and should be reduced to its most basic elements or constituents. In the case of mental disorders, reductionism happens when scientists try to reduce complex mental and emotional responses to biology. In its extreme form, reductionism asserts that psychology and psychopathology are ultimately nothing more than biology. The Cognitive Behavioral Paradigm  The cognitive behavioral paradigm traces its roots to learning principles and to cognitive science. As we willl see, the basic principles from classical and operant conditioning as well as cognitive science have shaped the development of many cognitive behavioral therapies. Influences from Behavior Therapy  Generally, problem behavior is thought to be reinforced by four possible consequences: getting attention, escaping from tasks, generating sensory feedback (such as results from the hand flapping often seen in children with autism spectrum disorder), and gaining access to desirable things or situations.  Once the source of reinforcement has been identified, treatment is then tailored to alter the consequences of the problem behavior.   For example, if it was established that getting attention reinforced the problem behavior, the treatment might be to ignore the behavior.  Alternatively, the problem behavior could be followed by time-out—the person is sent for a period of time to a location where positive reinforcers are not available. Today, time-out is a commonly used parenting technique for children who exhibit a problematic behavior of some sort.  Another successful example of operant conditioning is behavioral activation (BA) therapy of depression, which involves helping a person engage in tasks that provide an opportunity for positive reinforcement.  We introduced the technique called systematic desensitization in Chapter 1. Recall that this involves two components: (1) deep muscle relaxation and (2) gradual exposure to a list of feared situations, starting with those that arouse minimal anxiety and progressing to those that are the most frightening.  The still-influential contribution from this behavioral approach is the exposure component of this treatment. The basic idea is that the anxiety will extinguish if the person can face the object or situation for long enough with no actual harm occurring.  Sometimes this exposure can be conducted in vivo—that is, in real-life situations. For example, if someone has a fear of flying, you might have him or her take an actual flight.  At times, exposure cannot be conducted in real life, so imaginal exposure will be used to address fears, such as rape, trauma, or contamination. In other situations, both types of exposure are used. Cognitive Science  A person fits new information into an organized network of already-accumulated knowledge, often referred to as a schema, or cognitive set.  The Stroop task has been modified to focus on emotion rather than colors. In this emotion Stroop task, participants are still instructed to name the color of the ink rather than saying the word. However, the list of words now contains emotion words instead of color words. So, for example, words such as threat, danger, happy, or anxious are written in different ink colors. In such an emotion Stroop task, individuals with anxiety disorders find that some of the emotion words are so attention grabbing that the impulse to say the word is especially strong. The Role of the Unconscious  The concept of implicit memory refers to the idea that a person can, without being aware of it, be influenced by prior learning. A person may be shown a list of words so quickly that he or she cannot identify the words. Later, the person will be able to recall those words even though the words were not consciously perceived during the rapid initial presentation. Thus, a memory is formed implicitly (i.e., without conscious awareness). Cognitive Behavior Therapy  Cognitive behavior therapy (CBT) incorporates theory and research on cognitive processes. Cognitive behavior therapists pay attention to private events—thoughts, perceptions, judgments, self- statements, and even tacit (unconscious) assumptions—and have studied and manipulated these processes in their attempts to understand and modify overt and covert disturbed behavior.  Cognitive restructuring is a general term for changing a pattern of thought.  People with depression may not realize how often they think self-critically, and those with anxiety disorders may not realize that they tend to be overly sensitive to possible threats in the world.  Beck’s Cognitive Therapy  Psychiatrist Aaron Beck, one of the leading cognitive behavior therapists, developed a cognitive therapy for depression based on the idea that depressed mood is caused by distortions in the way people perceive life experiences.  Beck’s therapy, which has now been adapted for other disorders in addition to depression, addresses these biases by trying to persuade patients to change their opinions of themselves and the way in which they interpret life events. Factors That Cut across the Paradigms Emotion and Psychopathology  Emotions are believed to be fairly short-lived states, lasting for a few seconds, minutes, or at most hours. Sometimes the word affect is used to describe short-lasting emotional feelings.  Moods, on the other hand, are emotional experiences that endure for a longer period of time.  Another important consideration in the study of emotion and psychopathology is the concept of ideal affect, which simply refers to the kinds of emotional states that a person ideally wants to feel.  People from Western cultures, such as the United States, do indeed value happiness as their ideal state.  However, people from East Asian cultures , like China, value less arousing positive emotions, such as calmness, more than happiness.  Tsai and colleagues have also shown a linkage between people’s ideal affect and drug usage; if the ideal affect is a state of low arousal, like calmness, a person is less likely, for example, to use cocaine.  Cross-nationally, more people in the United States seek treatment for cocaine and amphetamines, drugs that are stimulating and associated with feelings of excitement and happiness; more people in China seek treatment for heroin, a drug that has calming effects. Sociocultural Factors and Psychopathology  Depression is nearly twice as common among women as among men.  On the other hand, antisocial personality disorder and alcohol use disorder are more common among men than women.  Childhood disorders, such as attention-deficit/hyperactivity disorder , affect boys more than girls, but some researchers question whether this reflects a true difference between boys and girls or a bias in the diagnostic criteria.  The Japanese term hikikomori refers to a condition where a person completely withdraws from his social world (although women are affected, it is observed predominantly among men). People with hikikomori may completely shut themselves into their room or house—in some cases, for many years— refusing to interact with other people and leaving only occasionally to buy food. Interpersonal Factors and Psychopathology  In couples therapy, the therapist works with both partners together to reduce relationship distress. Most couples treatments focus on improving communication, problem solving, satisfaction, trust, and positive feelings. To enhance communication, each partner is trained to listen empathically to the other and to state clearly to the partner what he or she understands is being said and what feelings underlie those remarks.  Family therapy is based on the idea that the problems of the family influence each member and that the problems of each member influence the family. As such, family therapy is used to address specific symptoms of a given family member, particularly for the treatment of childhood problems.  Interpersonal Therapy  Interpersonal therapy (IPT) emphasizes the importance of current relationships in a person’s life and how problems in these relationships can contribute to psychological symptoms.  The therapist first encourages the patient to identify feelings about his or her relationships and to express these feelings, and then helps the patient generate solutions to interpersonal problems.  IPT has been shown to be an effective treatment for depression.  IPT has also been used to treat eating disorders, anxiety disorders, and personality disorders.  In IPT, four interpersonal issues are assessed to examine whether one or more might be impacting symptoms: 1. Unresolved grief—for example, experiencing delayed or incomplete grieving following a loss 2. Role transitions—for example, transitioning from child to parent or from worker to retired person 3. Role disputes—for example, resolving different relationship expectations between romantic partners 4. Interpersonal or social deficits—for example, not being able to begin a conversation with an unfamiliar person or finding it difficult to negotiate with a boss at work Diathesis–Stress: An Integrative Paradigm  The diathesis–stress paradigm is an integrative paradigm that links genetic, neurobiological, psychological, and environmental factors. It is not limited to one particular school of thought, such as cognitive behavioral, genetic, or neurobiological.  Its appeal continues today for many disorders, however, because, like the gene–environment interaction models reviewed above, it is a model that focuses on the interaction between a predisposition toward disease—the diathesis—and environmental, or life, disturbances—the stress.  Diathesis refers most precisely to a constitutional predisposition toward illness, but the term may be extended to any characteristic or set of characteristics of a person that increases his or her chance of developing a disorder.  Neurobiological diatheses include oxygen deprivation at birth, poor nutrition, and a maternal viral infection or smoking during pregnancy. Each of these conditions may lead to changes in the brain that predispose the individual toward psychopathology.  In the psychological diathesis, a diathesis for depression may be a particular cognitive schema or the chronic feeling of hopelessness sometimes found in people with depression.  Other psychological diatheses include the ability to be easily hypnotized, which may be a diathesis for dissociative identity disorder (formerly called multiple personality disorder), and an intense fear of becoming fat, which is a vulnerability factor for some eating disorders.  The stress part of diathesis–stress is meant to account for how a diathesis may be translated into an actual disorder. In this context stress generally refers to some noxious or unpleasant environmental stimulus that triggers psychopathology.  The key point of the diathesis–stress model is that both diathesis and stress are necessary in the development of disorders.  Chapter 3 Diagnosis and Assessment  DIAGNOSIS AND ASSESSMENT are the critically important “first steps” in the study and treatment of psychopathology.  Diagnosis can be the first major step in good clinical care. Having a correct diagnosis will allow the clinician to describe base rates, causes, and treatment for Aaron and his family, all of which are important aspects of good clinical care.  Hearing a diagnosis can provide relief in several different ways.  Often, a diagnosis can help a person begin to understand why certain symptoms are occurring, which can be a huge relief.  Many disorders are extremely common, such as depression, anxiety, and substance abuse— knowing that his or her diagnosis is common can also help a person feel less unusual.  Diagnosis enables clinicians and scientists to communicate accurately with one another about cases or research.  Diagnosis is important for research on causes and treatments.  Sometimes researchers discover unique causes and treatments associated with a certain set of symptoms. For example, autism was only recognized in the Diagnostic and Statistical Manual in 1980. Since that time, research on the causes and treatments of autism has grown exponentially. Cornerstones of Diagnosis and Assessment Reliability  Reliability refers to consistency of measurement.  Interrater reliability refers to the degree to which two independent observers agree on what they have observed.  Test–retest reliability measures the extent to which people being observed twice or taking the same test twice, perhaps several weeks or months apart, receive similar scores. This kind of reliability makes sense only when we can assume that the people will not change appreciably between test sessions on the underlying variable being measured; a prime example of a situation in which this type of reliability is typically high is in evaluating intelligence tests.  Sometimes psychologists use two forms of a test rather than giving the same test twice, perhaps when there is concern that test takers will remember their answers from the first round of taking the test and aim merely to be consistent. This approach enables the tester to determine alternate-form reliability, the extent to which scores on the two forms of the test are consistent.  Finally, internal consistency reliability assesses whether the items on a test are related to one another. Validity  Validity is a complex concept, generally related to whether a measure measures what it is supposed to measure.  Content validity refers to whether a measure adequately samples the domain of interest.  Criterion validity is evaluated by determining whether a measure is associated in an expected way with some other measure (the criterion).  If both variables are measured at the same point in time, the resulting validity is referred to as concurrent validity.  Alternatively, criterion validity can be assessed by evaluating the ability of the measure to predict some other variable that is measured at some point in the future, often referred to as predictive validity.  Construct validity is a more complex concept. It is relevant when we want to interpret a test as a measure of some characteristic or construct that is not observed simply or overtly. More broadly, construct validity is related to theory. Classification and Diagnosis The Diagnostic System of the American Psychiatric Association: Toward DSM-5  In 1952, the American Psychiatric Association published its Diagnostic and Statistical Manual (DSM).  DSM-IV was published in 1994, and in June 2000, a “text revision,” DSM-IV-TR, followed. Almost no changes were made to the diagnostic categories and criteria in the 2000 revision.  Rather, DSM-IV-TR provided a summary of new research findings on prevalence rates, course, and etiology (causes).  Two major innovations were introduced in DSM-III that have been retained by each edition since. 1. Specific diagnostic criteria—the symptoms for a given diagnosis—are spelled out precisely, and clinical symptoms are defined in a glossary. Table 3.1 compares the descriptions of a manic episode given in DSM-II with the diagnostic criteria given in the likely DSM-IV-TR. Notice how DSM-IV-TR is much more detailed and concrete.  2. The characteristics of each diagnosis are described much more extensively than they were in DSM-II. For each disorder there is a description of essential features, then of associated features, such as laboratory findings (e.g., enlarged ventricles in schizophrenia) and results from physical exams (e.g., electrolyte imbalances in people who have eating disorders). Next, a summary of the research literature provides information about age of onset, course, prevalence and sex ratio, familial pattern, and differential diagnosis (i.e., how to distinguish similar diagnoses from each other).  The DSM-IV and DSM-IV-TR introduced more focus on cultural issues as well as separate dimensions, or axes, to rate people.  This multiaxial classification system, by requiring judgments on each of the five axes, forces the diagnostician to consider a broad range of information.  The DSM-IV-TR Axis I includes all diagnostic categories except the personality disorders and mental retardation, which make up Axis II. Thus Axes I and II cover the classification of mental disorders.  Axis III covers general medical conditions. For many diagnoses, the DSM includes a provision for indicating that the disorder is due to a medical condition or substance abuse.  On Axis IV, the clinician codes psychosocial problems that may contribute to the disorder, including occupational problems, housing problems, economic problems, or interpersonal difficulties.  Finally, on Axis V, the clinician indicates the person’s current level of adaptive functioning, using ratings from 0 to 100 on the Global Assessment of Functioning (GAF) scale to consider social relationships, occupational functioning, and use of leisure time. Early Efforts at Classification of Mental Illness  Emil Kraepelin authored an influential early classification system in his textbook of psychiatry first published in 1883. His classification system attempted to definitively establish the biological nature of mental illnesses.  Kraepelin noted that certain symptoms clustered together as a syndrome. He labeled a set of syndromes and hypothesized that each had its own biological cause, course, and outcome.  Kraepelin proposed two major groups of severe mental illnesses: dementia praecox (an early term for schizophrenia) and manic-depressive psychosis (an early term for bipolar disorder).  He postulated a chemical imbalance as the cause of dementia praecox and an irregularity in metabolism as the explanation of manic-depressive psychosis.  Though his theories about causes were not quite correct, Kraepelin’s classification scheme nonetheless influenced the current diagnostic categories. Development of the WHO and DSM Systems  In 1939 the World Health Organization (WHO) added mental disorders to the International List of Causes of Death (ICD). In 1948 the list was expanded to become the International Statistical Classification of Diseases, Injuries, and Causes of Death, a comprehensive listing of all diseases, including a classification of abnormal behavior. Unfortunately, the mental disorders section was not widely accepted.  Even though American psychiatrists had played a prominent role in the WHO effort, the American Psychiatric Association published its own Diagnostic and Statistical Manual (DSM) in 1952. Changes to the Multiaxial System  The five axes of DSM-IV-TR are reduced to one axis for clinical syndromes and one for psychosocial and environmental problems.  The codes for the Psychosocial and Environmental Problems Axis are changed to be more similar to those used by the international community in the World Health Organization’s (WHO) International Classification of Diseases (ICD).  The DSM-IV-TR axis V is removed in DSM-5; instead, clinicians will be asked to rate severity along a continuum using scales developed specifically for each disorder. Organizing Diagnoses by Causes  The DSM-IV-TR diagnoses are clustered into chapters based on similarity of symptoms.  For example, in DSM-IV-TR, obsessive-compulsive disorder is included as an anxiety disorder. The etiology of this disorder, though, seems to involve distinct genetic and neural influences compared to other anxiety disorders.  In the DSM-5, the chapters are reorganized to reflect patterns of comorbidity and shared etiology.  The DSM-5 includes a new chapter for obsessive-compulsive and other related disorders. This new chapter includes three disorders that often co-occur and share some risk factors: obsessive- compulsive disorder, hoarding disorder, and body dysmorphic disorder. Including a Continuous Severity Rating to Supplement Categorical Classification  In the DSM-IV-TR clinical diagnoses are based on categorical classification. Does the patient have schizophrenia or not? This type of classification does not consider continuity between normal and abnormal behavior.  We see that the diagnosis of mania requires the presence of three symptoms from a list of seven, or four if the person’s mood is irritable. But why require three symptoms rather than two or five?  A categorical system forces clinicians to define one threshold as “diagnosable”. There is often little research support for the threshold defined. Categorical diagnoses foster a false impression of discontinuity.  It may be more helpful to know the severity of symptoms as well as whether they are present. In contrast to categorical classification, dimensional systems describe the degree of an entity that is present (e.g., a 1-to-10 scale of anxiety, where 1 represents minimal and 10, extreme).  Despite some debate, DSM-5 preserves a categorical approach to diagnosis. The categories, though, are supplemented by a severity rating for each disorder. Severity ratings will not be considered unless a person is first diagnosed with a categorical diagnosis. Ethnic and Cultural Considerations in Diagnosis  Mental illness is universal. There is not a single culture in which people are free of mental illness. But there are many different cultural influences on the risk factors for mental illness (e.g., social  cohesion, poverty, access to drugs of abuse, and stress), the types of symptoms experienced, the willingness to seek help, and the treatments available.  The DSM includes 25 culture-bound syndromes in the appendix. Culture-bound syndromes are diagnoses that are likely to be seen within specific regions. The following are some examples of syndromes listed in the DSM appendix. 1. Amok.A dissociative episode in which there is a period of brooding followed by a violent and sometimes homicidal outburst. The episode tends to be triggered by an insult and is found primarily among men. Persecutory delusions are often present as well. The term is Malaysian and is defined by the dictionary as a murderous frenzy. You may have heard the phrase “run amok”. 2. Ghost sickness. An extreme preoccupation with death and those who have died, found among certain Native American tribes. 3. Drat. A term used in India to refer to severe anxiety about the discharge of semen. 4. Koru. Reported in South and East Asia, an episode of intense anxiety about the possibility that the penis or nipples will recede into the body, possibly leading to death. 5. Shenjing shuairuo (neurasthenia). A common diagnosis in China, a syndrome characterized by fatigue, dizziness, headaches, pain, poor concentration, sleep problems, and memory loss. 6. Taijin kyofusho. The fear that one could offend others through inappropriate eye contact, blushing, a perceived body deformation, or one’s own foul body odor. This disorder is most common in Japan, but cases have been reported in the United States. 7. Hikikomori (withdrawal). This refers to a syndrome observed in Japan, Taiwan, and South Korea in which an individual, most often an adolescent boy or young adult man, shuts himself into a room (e.g., bedroom) for a period of 6 months or more and does not socialize with anyone outside the room.  Kleinman interviewed 100 Chinese people who had been diagnosed with shenjing shuairuo and found that 87 percent of them met criteria for major depressive disorder. Many of those responded to antidepressant medications.  Suzuki and colleagues have pointed out that the symptoms of taijin kyofusho overlap with those of social phobia (excessive fear of social interaction and evaluation) and body dysmorphic disorders (the mistaken belief that one is deformed or ugly), which are more commonly diagnosed in the United States. Specific Criticisms of the DSM  Too Many Diagnoses?  Others argue that the system includes too many minute distinctions based on small differences in symptoms. One side effect of the huge number of diagnostic categories is a phenomenon called comorbidity, which refers to the presence of a second diagnosis. Comorbidity is the norm rather than the exception.  A more subtle issue about the large number of diagnoses is that many risk factors seem to trigger more than one disorder. Anxiety and mood disorder seem to share overlap in genes , diminished function of a brain region called the prefrontal cortex, and low serotonin function.  Reliability of the DSM in Everyday Practice  Diagnostic systems must have high interrater reliability to be useful. Before DSM-III, reliability for DSM diagnoses was poor, mainly because the criteria for making a diagnosis were not clear.  How Valid Are Diagnostic Categories?  The central question, then, is whether diagnoses made with the DSM criteria reveal anything useful about patients. We have organized this book around the major DSM diagnostic categories because we believe that they do indeed possess some construct validity. General Criticisms of Diagnosing Mental Illness  Research shows that many view people with mental illness negatively, and patients and their families often encounter stigma against mental illness, which, as we discussed in Chapter 1, remains a huge problem.  Another concern is that when a diagnostic category is applied, we may lose sight of the uniqueness of that person. Because of this concern, the American Psychological Association recommends that people avoid using words like schizophrenic or depressive to describe people. Rather, psychologists are encouraged to use phrases such as a person with schizophrenia. Psychological Assessment Clinical Interviews  Characteristics of Clinical Interviews  Great skill is necessary to carry out good clinical interviews. Clinicians, regardless of the paradigm adopted, recognize the importance of establishing rapport with the client.  Most clinicians empathize with their clients in an effort to draw them out and to encourage them to elaborate on their concerns.  Structured Interviews  At times, mental health professionals need to collect standardized information, particularly for making diagnostic judgments based on the DSM.  One example of a commonly used structured interview is the Structured Clinical Interview (SCID) for Axis I of DSM-IV. The SCID is a branching interview; that is, the client’s response to one question determines the next question that is asked. It also contains detailed instructions to the interviewer concerning when and how to probe in detail and when to go on to questions about another diagnosis. Assessment of Stress  Broadly, stress can be conceptualized as the subjective experience of distress in response to perceived environmental problems.  Life stressors can be defined as the environmental problems that trigger the subjective sense of stress.  A Brief History of Stress  The pioneering work by the physician Hans Selye set the stage for our current conceptualizations of stress. He introduced the term general adaptation syndrome (GAS) to describe the biological response to sustained and high levels of stress. 1. During the first phase, the alarm reaction, the autonomic nervous system is activated by the stress. 2. During the second phase, resistance, the organism tries to adapt to the stress through available coping mechanisms. 3. If the stressor persists or the organism is unable to adapt effectively, the third phase, exhaustion, follows, and the organism dies or suffers irreversible damage.  The Bedford College Life Events and Difficulties Schedule  Because the interview is only semistructured, the interviewer can tailor questions to cover stressors that might only occur to a small number of people.  The interviewer and the interviewee work collaboratively to produce a calendar of each of the major events within a given time period.  Self-Report Stress Checklists  Often clinicians and researchers want a quicker way to assess stress and thus may turn to self-report checklists, such as the List of Threatening Experiences (LTE) or the Psychiatric Epidemiological Research Interview Life Events Scale (PERL).  These checklists typically list different life events (e.g., death of a spouse, serious physical illness, major financial crisis), and participants are asked to indicate whether or not these events happened to them in a specified period of time.  One difficulty associated with these types of measures is that there is a great deal of variability in how people view these events. For example, the death of a spouse could be the most horrible event ever for someone in a loving relationship. However, for someone in an abusive relationship, it might be the source of relief rather than stress.  Other problems with such self-report checklists include difficulties with recall. For example, people may forget about some events.  There is also evidence that people who are feeling depressed or anxious when they complete the measure may be biased in their responses. Personality Tests  Self-Report Personality Inventories  Perhaps the best known of these tests is the Minnesota Multiphasic Personality Inventory (MMPI), developed in the early 1940s by Hathaway and McKinley and revised in 1989. The MMPI is called multiphasic because it was designed to detect a number of psychological problems. Over the years, the MMPI has been widely used to screen large groups of people for whom clinical interviews are not feasible.  The MMPI-2 includes several “validity scales” designed to detect deliberately faked responses.  In one of these, the lie scale, a series of statements sets a trap for the person who is trying to look too good.  High scores on the F scale also discriminate between people trying to fake psychopathology and real patients.  Projective Personality Tests  A projective test is a psychological assessment tool in which a set of standard stimuli—inkblots or drawings—ambiguous enough to allow variation in responses is presented to the person.  The assumption is that because the stimulus materials are unstructured and ambiguous, the person’s responses will be determined primarily by unconscious processes and will reveal his or her true attitudes, motivations, and modes of behavior. This notion is referred to as the projective hypothesis.  The Thematic Apperception Test (TAT) is a projective test. In this test a person is shown a series of black-and-white pictures one-by-one and asked to tell a story related to each. There are few reliable scoring methods for this test, and the norms are based on a small and limited sample (i.e., few norms for people of different ethnic or cultural backgrounds). The construct validity of the TAT is also limited.  The Rorschach Inkblot Test is perhaps the best-known projective technique. In the Rorschach test, a person is shown 10 inkblots, one at a time, and asked to tell what the blots look like. Half the  inkblots are in black, white, and shades of gray; two also have red splotches; and three are in pastel colors. Intelligence Tests  An intelligence test, often referred to as an IQ test, is a way of assessing a person’s current mental ability. IQ tests are based on the assumption that a detailed sample of a person’s current intellectual functioning can predict how well he or she will perform in school, and most are individually administered.  Regarding construct validity, it is important to keep in mind that IQ tests measure only what psychologists consider intelligence. Behavioral and Cognitive Assessment  Direct Observation of Behavior  It is difficult to observe most behavior as it actually takes place, and little control can be exercised over where and when it may occur. For this reason, many therapists contrive artificial situations in their consulting rooms or in a laboratory so they can observe how a client or a family acts under certain conditions. Observers behind a one-way mirror watched the proceedings and reliably coded the child’s reactions to the mother’s efforts to control as well as the mother’s reactions to the child ’s compliant or noncompliant responses.  Self-Observation  Cognitive behavior therapists and researchers have also asked people to observe and track their own behavior and responses, an approach called self-monitoring.  Another method of self-observation is called ecological momentary assessment (EMA). EMA involves the collection of data in real time as opposed to the more usual methods of having people reflect back over some time period and report on recently experienced thoughts, moods, or stressors. The methods for implementing EMA range from having people complete diaries at specified times during the day (perhaps signaled by a wristwatch that beeps at those times) to supplying them with smartphones that not only signal when reports are to be made but also allow them to enter their responses directly into the device.  Cognitive-Style Questionnaires  Cognitive questionnaires tend to be used to help plan targets for treatment as well as to determine whether clinical interventions are helping to change overly negative thought patterns. Neurobiological Assessment Brain Imaging: “Seeing” the Brain  Computerized axial tomography, the CT or CAT scan, helps to assess structural brain abnormalities (and is able to image other parts of the body for medical purposes).  Other devices for seeing the living brain include magnetic resonance imaging, also known as MRI, which is superior to the CT scan because it produces pictures of higher quality and does not rely on even the small amount of radiation required by a CT scan.  An even greater advance has been a technique called functional MRI (fMRI), which allows researchers to measure both brain structure and brain function. This technique takes MRI pictures so quickly that metabolic changes can be measured, providing a picture of the brain at work rather than of its structure alone.  Positron emission tomography, the PET scan, a more expensive and invasive procedure, also allows measurement of both brain structure and brain function, although the measurement of brain structure is not as precise as with MRI or fMRI. Neurotransmitter Assessment  In postmortem studies, the brains of deceased patients are removed and the amount of specific neurotransmitters in particular brain areas can then be directly measured. Different brain areas can be infused with substances that bind to receptors, and the amount of binding can then be quantified; more binding indicates more receptors.  In studies of participants who are alive, one common method of neurotransmitter assessment involves analyzing the metabolites of neurotransmitters that have been broken down by enzymes. A metabolite, typically an acid, is produced when a neurotransmitter is deactivated.  These by-products of the breakdown of neurotransmitters, such as norepinephrine, dopamine, and serotonin, are found in urine, blood serum, and cerebrospinal fluid (CSF; the fluid in the spinal column and in the brain’s ventricles). For example, a major metabolite of dopamine is homovanillic acid; of serotonin, 5-hydroxyindoleacetic acid. A high level of a particular metabolite presumably indicates a high level of a neurotransmitter, and a low level indicates a low level of the transmitter. Neuropsychological Assessment  A neurologist is a physician who specializes in diseases or problems that affect the nervous system, such as stroke, muscular dystrophy, cerebral palsy, or Alzheimer’s disease.  A neuropsychologist is a psychologist who studies how dysfunctions of the brain affect the way we think, feel, and behave.  Neuropsychological tests are often used in conjunction with the brain imaging techniques just described, both to detect brain dysfunction and to help pinpoint specific areas of behavior that are impacted by problems in the brain.  One neuropsychological test is Reitan’s modification of a battery, or group, of tests previously developed by Halstead, called the Halstead–Reitan neuropsychological test battery. The following are three of the Halstead–Reitan tests. 1. Tactile Performance Test—Time. While blindfolded, the patient tries to fit variously shaped blocks into spaces of a form board, first using the preferred hand, then the other, and finally both. 2. Tactile Performance Test—Memory. After completing the timed test, the participant is asked to draw the form board from memory, showing the blocks in their proper location. Both this and the timed test are sensitive to damage in the right parietal lobe. 3. Speech Sounds Perception Test. Participants listen to a series of nonsense words, each comprising two consonants with a long-e sound in the middle. They then select the “word” they heard from a set of alternatives. This test measures left-hemisphere function, especially temporal and parietal areas.  The Luria–Nebraska battery can be administered in 2 1/2 hours and can be scored in a highly reliable manner. Criterion validity has been established by findings that test scores can correctly distinguish 86 percent of neurological patients and controls.  A particular advantage of the Luria–Nebraska tests is that one can control for educational level so that a less educated person will not receive a lower score solely because of limited educational experience. Psychophysiological Assessment  The discipline of psychophysiology is concerned with the bodily changes that are associated with psychological events. Experimenters have used measures such as heart rate, tension in the muscles, blood flow in various parts of the body, and electrical activity in the brain (so-called brain waves) to study physiological changes when people are afraid, depressed, asleep, imagining, solving problems, and so on.  One important measure is heart rate. Each heartbeat generates electrical changes, which can be recorded by electrodes placed on the chest that convey signals to an electrocardiograph or a polygraph. The signal is graphically depicted in an electrocardiogram (EKG) , which may be seen as waves on a computer screen or on a roll of graph paper.  A second measure of autonomic nervous system activity is electrodermal responding, or skin conductance. Anxiety, fear, anger, and other emotions increase activity in the sympathetic nervous system, which then boosts sweat-gland activity. Increased sweat-gland activity increases the electrical conductance of the skin. Since the sweat glands are activated by the sympathetic nervous system, increased sweat-gland activity indicates sympathetic autonomic excitation and is often taken as a measure of emotional arousal.  Brain activity can be measured by an electroencephalogram (EEG). Electrodes placed on the scalp record electrical activity in the underlying brain area. Abnormal patterns of electrical activity can indicate seizure activity in the brain or help in locating brain lesions or tumors. EEG indices are also used to measure attention and alertness. Cultural and Ethnic Diversity and Assessment Cultural Bias in Assessment  The issue of cultural bias in assessment refers to the notion that a measure developed for one culture or ethnic group may not be equally reliable and valid with a different cultural or ethnic group.  Clinicians who encounter clients claiming to be surrounded by spirits might view this belief as a sign of schizophrenia. Yet in Puerto Rican cultures, such a belief is common; therefore, believing that one is surrounded by spirits should probably not be taken as a sign of schizophrenia in a Puerto Rican person. Strategies for Avoiding Cultural Bias in Assessment  Lopez has noted three important issues that should be taught to graduate students in clinical psychology programs. 1. First, students must learn about basic issues in assessment, such as reliability and validity. 2. Second, students must become informed about the specific ways in which culture or ethnicity may impact assessment rather than relying on more global stereotypes about a particular cultural or ethnic group. 3. Third, students must consider that culture or ethnicity may not impact assessment in every individual case.  Assessment procedures can also be modified to ensure that the person truly understands the requirements of the task.  Finally, when the examiner and client have different ethnic backgrounds, the examiner may need to make an extra effort to establish a rapport that will result in the person’s best performance.  Chapter 5 Mood Disorders Depressive Disorders  The cardinal symptoms of depression include profound sadness and/or an inability to experience pleasure.  Like Mary, described in the Clinical Case, they may become focused on their flaws and deficits.  They often view things in a very negative light, and they tend to lose hope.  Physical symptoms of depression are also common, including fatigue and low energy as well as physical aches and pains.  Although people with depression typically feel exhausted, they may find it hard to fall asleep and may wake up frequently. Other people sleep throughout the day.  They may find that food tastes bland or that their appetite is gone, or they may experience an increase in appetite. Sexual interest disappears. Some may find their limbs feel heavy.  Thoughts and movements may slow for some (psychomotor retardation), but others cannot sit still— they pace, fidget, and wring their hands (psychomotor agitation).  Social withdrawal is common; many prefer to sit alone and be silent.  Some people with depression neglect their appearance. When people become utterly dejected and hopeless, thoughts about suicide are common. Major Depressive Disorder  The proposed DSM-5 diagnosis of major depressive disorder (MDD) requires five depressive symptoms to be present for at least 2 weeks. These symptoms must include either depressed mood or loss of interest and pleasure. As shown in the proposed DSM-5 criteria, additional symptoms must be present, such as changes in sleep, appetite, concentration or decision making, feelings of worthlessness, suicidality, or psychomotor agitation or retardation.  MDD is an episodic disorder, because symptoms tend to be present for a period of time and then clear.  Major depressive episodes tend to recur—once a given episode clears, a person is likely to experience another episode. About two-thirds of people with an episode of major depression will experience at least one more episode during their lifetime.  The average number of episodes is about four. Chronic Depressive Disorder (Dysthymia)  People with dysthymia are chronically depressed—more than half of the time for at least 2 years, they feel blue or derive little pleasure from usual activities and pastimes. Epidemiology and Consequences of Depressive Disorders  MDD is one of the most prevalent psychiatric disorders.  Dysthymia is rarer than MDD: about 2.5 percent of people meet criteria for dysthymia as defined by DSM-IV-TR during their lives.  MDD is twice as common among women as among men.  Socioeconomic status also matters—that is, MDD is three times as common among people who are impoverished compared to those who are not.  Since then, the same team has found that in general, Mexican minorities who move to the United States have lower rates of depression than those who were born in the United States. Why? The resiliency of people who are able to immigrate could be protective.  Countries with more fish consumption, such as Japan and Iceland, have much lower rates of MDD and bipolar disorder.  Depression in children often results in somatic complaints, such as headaches or stomachaches. In older adults, depression is often characterized by distractibility and complaints of memory loss.  About 60 percent of people who meet the criteria for diagnosis of MDD during their lifetime also will meet the criteria for diagnosis of an anxiety disorder at some point. Other common comorbid conditions include substance-related disorders, sexual dysfunctions, and personality disorders.  MDD is also one of the world’s leading causes of disability; it is estimated that MDD is associated with $31 billion per year in lost productivity in the United States.  One study found that the average duration of dysthymic symptoms was more than 5 years. Indeed, a study following patients for 5 years found that people with dysthymia were more likely to require hospitalization, to attempt suicide, and to be impaired in their functioning than were people with MDD. Bipolar Disorders  The proposed DSM-5 recognizes three forms of bipolar disorders: bipolar I disorder, bipolar II disorder, and cyclothymic disorder.  An episode of depression is not required for a diagnosis of bipolar I, but it is required for a diagnosis of bipolar II disorder.  Mania is a state of intense elation or irritability accompanied by other symptoms shown in the diagnostic criteria. They may become louder and make an incessant stream of remarks, sometimes full of puns, jokes, rhymes, and interjections about nearby stimuli that have attracted their attention.  They may be difficult to interrupt and may shift rapidly from topic to topic, reflecting an underlying flight of ideas.  During mania, people may become sociable to the point of intrusiveness. They can also become excessively self-confident. Unfortunately, they can be oblivious to the potentially disastrous consequences of their behavior, which can include imprudent sexual activities, overspending, and reckless driving. They may stop sleeping but stay incredibly energetic. Mania usually comes on suddenly over a period of a day or two.  The proposed DSM-5 also includes criteria for hypomania. Although mania involves significant impairment, hypomania does not. Rather, hypomania involves a change in functioning that does not cause serious problems. The person with hypomania may feel more social, flirtatious, energized, and productive. Bipolar I Disorder  In the proposed DSM-5, the criteria for diagnosis of bipolar I disorder (formerly known as manic-depressive disorder) include a single episode of mania during the course of a person’s life. In fact,  even someone who experienced only 1 week of manic symptoms years ago is still diagnosed with bipolar I disorder. Bipolar II Disorder  The proposed DSM-5 also includes a milder form of bipolar disorder, called bipolar II disorder. To be diagnosed with bipolar II disorder, a person must have experienced at least one major depressive episode and at least one episode of hypomania. Cyclothymic Disorder  Also called cyclothymia, cyclothymic disorder is a s