Abnormal Psychology: The Science and Treatment of Psychological Disorders (2021) PDF

Abnormal Psychology Ann M. Kring Sheri L. Johnson Abnormal Psychology The Science and Treatment of Psychological Disorders Fifteenth Edition ANN M. KRING University of California, Berkeley SHERI L. JOHNSON University of California, Berkeley WILEY i Vice President: Amanda Miller Editorial Director: Justin Jeffryes Executive Editor: Glenn Wilson Senior Marketing Manager: Carolyn Wells Managing Editorial Director: Barbara Heaney Senior Managing Editor: Lauren Olesky Senior Manager, Course Development & Production Content Operations: Dorothy Sinclair Senior Course Production Operations Specialist: Valerie A. Vargas Creative Product Design Lead: Jon Boylan Senior Creative Product Designer: Thomas Nery Senior Manager, Content Enablement & Operations: Simon Eckley Cover Photo: © shulz/E+/Getty Images This book was typeset in 9.5/11.5 Source Sans Pro at Lumina Datamatics. 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Upon completion of the review period, please return the evaluation copy to Wiley. Return instructions and a free of charge return shipping label are available at www.wiley.com/go/returnlabel. If you have chosen to adopt this textbook for use in your course, please accept this book as your complimentary desk copy. Outside of the United States, please contact your local representative. EPUB ISBN: 978-1-119-705390 The inside back cover will contain printing identification and country of origin if omitted from this page. In addition, if the ISBN on the cover differs from the ISBN on this page, the one on the cover is correct. Library of Congress Cataloging-in-Publication Data Names: Kring, Ann M., author. - Johnson, Sheri L., author. Title: Abnormal psychology: the science and treatment of psychological disorders/Ann M. Kring, University of California, Berkeley, Sheri L. Johnson, University of California, Berkeley. Description: Fifteenth edition. - Hoboken: Wiley, - Revision of: Abnormal psychology/Ann M. Kring…. [et al]. 2012.12th ed. Identifiers: LCCN 2020055848 (print) - LCCN 2020055849 (ebook) - ISBN 9781119705475 (paperback) - ISBN 9781119809074 (adobe pdf) - ISBN 9781119705390(epub) Subjects: LCSH: Psychology, Pathological. Classification: LCC RC454.A243 2021 (print) - LCC RC454 (ebook) - DDC 616.89-dc23 LC record available at https://lccn.loc.gov/2020055848 LC ebook record available at https://lccn.loc.gov/2020055849 Printed in the United States of America. SKY10024255_012121 To Angela Hawk Daniel Rose About the Authors ANN M. KRING is Professor of Psychology at the University of California at Berkeley. She received her B.S. from Ball State University and her M.A. and Ph.D. from the State University of New York at Stony Brook. Her internship in clinical psychology was completed at Bellevue Hospital and Kirby Forensic Psychiatric Center, both in New York. From 1991 to 1998, she taught at Vanderbilt University. She joined the faculty at UC Berkeley in 1999, served two terms as Director of the Clinical Science Program and Psychology Clinic, and was Chair of the Psychology Department from 2015 to 2020. She received a Distinguished Teaching Award from UC Berkeley in 2008. She serves on the editorial boards of Psychological Clinical Science and Current Directions in Psychological Science, and she is a former Associate Editor for Journal of Abnormal Psychology, Cognition and Emotion, Collabora: Clinical Psychology, and Applied & Preventive Psychology. She was elected President of the Society for Research in Psychopathology and President of the Society for Affective Science. She is member of the Board of Directors of the Association for Psychological Science. She was given a Young Investigator Award by the National Alliance for Research on Schizophrenia and Depression (NARSAD) in 1997 and the Joseph Zubin Memorial Fund Award in 2006 in recognition of her research on schizophrenia. In 2005, she was named a fellow of the Association for Psychological Science. Her research has been supported by grants from the Scottish Rite Schizophrenia Research Program, NARSAD, and the National Institute of Mental Health. She is co-editor (with Denise Sloan) of Emotion Regulation and Psychopathology (Guilford Press) and co- author (with Janelle Caponigro, Erica Lee, and Sheri Johnson) of Bipolar Disorder for the Newly Diagnosed (Hew Harbinger Press). She is also the author of more than 100 articles and book chapters. Her current research focuses on emotion and psychopathology, with a specific interest in the emotional features, negative symptoms, and social factors of schizophrenia. As part of a follow-up study of children whose mothers were enrolled in a study in the early 1960s, she is also studying how early development might influence clinical, cognitive, social, and neural functioning in middle-aged adults. SHERI L. JOHNSON is Professor of Psychology at the University of California at Berkeley. She received her B.A. from Salem College and her Ph.D. from the University of Pittsburgh. She completed an internship and postdoctoral fellowship at Brown University, and she was a clinical assistant professor at Brown from 1993 to 1995. From 1995 to 2008, she taught in the Department of Psychology at the University of Miami, where she was recognized three times with the Excellence in Graduate Teaching Award. In 1993, she received a Young Investigator Award from the National Alliance for Research in Schizophrenia and Depression (NARSAD). She is an associate editor for Psychological Bulletin and a consulting editor for Clinical Psychological Science and Journal of Abnormal Psychology. She has served as President of the Society for Research in Psychopathology and is a fellow of the Academy of Behavioral Medicine Research, the Association for Behavioral and Cognitive Therapies, and the Association for Psychological Science. Her work has been funded by NARSAD, the National Cancer Institute, the National Science Foundation, and the National Institute of Mental Health. She has published over 275 articles and chapters, and her findings have been published in leading journals such as Biological Psychiatry, Journal of Abnormal Psychology, Psychological Bulletin, and American Journal of Psychiatry. She is co-editor or co-author of several books, including Psychological Treatment of Bipolar Disorder (Guilford Press), Bipolar Disorder for the Newly Diagnosed (New Harbinger Press), Bipolar Disorder: Advances in Psychotherapy Evidence-Based Practice (Hogrefe Publishing), and Emotion and Psychopathology (American Psychological Association). Her work focuses on emotion, emotion-related disorders, and impulsivity. Preface The focus of this book has always been on the balancing and blending of research and clinical application and on the effort to involve the learner in the problem solving engaged in by clinicians and scientists. We continue to emphasize an integrated approach, showing how psychopathology is best understood by considering multiple perspectives and how these varying perspectives can provide us with the clearest accounting of the causes of these disorders as well as the best possible treatments. With the fifteenth edition, we have once again emphasized the recent and comprehensive research coverage that has been the hallmark of the book. Of equal importance, however, we have worked to make the prose ever more accessible to a variety of students. The cover image is an abstract photo that shows how different nodes connect and interweave to form a network. Just as in a complex network, there are myriad influences that contribute to psychological disorders. People are shaped by the interaction of their neurobiology and environment, which is what the study of psychological disorders is all about: different influences (genetic, neuroscience, personality, cognitive, behavioral, and social) coming together to shape the development and course of different psychological disorders. This is also how science works. New discoveries help to reshape the domains of scientific inquiry, shifting the connecting points in the network of our current understanding of psychological disorders. Goals of the Book With each new edition, we update, make changes, and streamline features to enhance both the scholarly and the pedagogical characteristics of the book. We also devote considerable effort to couching complex concepts in prose that is sharp, clear, and vivid. The domains of psychopathology and intervention continue to become more multifaceted and technical. Therefore, good coverage of psychological disorders must engage students in order to foster the focused attention necessary to acquire a deep, critical understanding of the material. Some of the most exciting breakthroughs in psychopathology research and treatment that we present in the book have come in complex areas such as molecular genetics, neuroscience, and cognitive science. Rather than oversimplify these knotty issues, we have instead worked to make the explanations clear and accessible. We strive to present up-to-date theories and research in psychopathology and intervention as well as to convey some of the intellectual excitement of the search for answers to some of the most puzzling questions facing us today. We encourage students to participate with us in a process of discovery as we sift through the evidence on the origins of psychopathology and the effectiveness of specific interventions. As always, we emphasize ways in which we can help to do away with the stigma unfortunately still associated with psychological disorders. Despite the ubiquity of psychopathology, such stigma can keep some individuals from seeking treatment, keep our legislatures from providing adequate funding for treatment and research, and keep myths about psychological disorders alive and well. A major goal for this book is to combat the stigma and present a positive and hopeful view on the causes and treatments of mental illness. Another difference between our book and others is the broadening of our title to emphasize the science and treatment of psychological disorders. The term abnormal psychology is a vestige of the past in many ways, even though many courses covering the causes and treatment of psychological disorders retain this title. It is our hope that abnormal psychology will soon be replaced because it can perpetuate the stigma that people with psychological disorders are “abnormal” in many ways. Our contention is that people with psychological disorders are first and foremost people and that the term abnormal is overly broad and can be misconstrued to the detriment of people who have psychological disorders. Organization of the Fifteenth Edition In Chapters 1 through 4, we place the field in historical context, introduce the major approaches to understanding psychopathology, describe the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and critically discuss its validity and reliability, provide an overview of major approaches and techniques in clinical assessment, and then look at the major research methods of the field. These chapters provide the foundation for interpreting and understanding the later chapters. As in the fourteenth edition, specific psychological disorders and their treatment are discussed in Chapters 5 through 15. Throughout the book, we discuss several influences relevant to understanding the causes and treatments of psychological disorders, including genetic, neuroscience, cognitive behavioral, personality, and socioemotional influences. We also emphasize the importance of adopting an integrative approach, which recognizes that these domains interweave to contribute to psychological disorders. For instance, genetic influences are important in attention-deficit/hyperactivity disorder, but genes do their work via the environment. In the anxiety disorders, conditioning models are prominent, and the neurobiological studies help enrich our understanding of how conditioning works. In disorders such as depression, social influences such as trauma can drive neurobiological shifts. For still other disorders—for example, dissociative disorders— cognitive factors involving consciousness are believed to be central, and researchers are considering how neural profiles might contribute to gaps in consciousness. We continue to include considerable material on the role of culture, race, and ethnicity in the study of causes and treatment of psychological disorders, as well as the role of trauma, childhood maltreatment, and interpersonal issues. Throughout all the chapters, we point to specific examples of the important role of these influences. For example, in Chapter 3, “Diagnosis and Assessment,” we discuss cultural bias in assessment and ways to guard against this selectivity in perception. We also include new information on the role of race and culture in anxiety, depression, schizophrenia, and substance use disorders. New to This Edition The fifteenth edition has many new and exciting additions and changes. First, we have removed paradigms as an organizing principle, in order to highlight the concept that the science of psychopathology involves identifying influences within each domain and then considering how those might interweave. Second, as the research on each disorder has burgeoned, we continue to focus on only the most exciting, replicable, and accepted theories, research, and treatments. This edition, like past ones, contains hundreds (n = 538) of updated references. Third, we have simplified the writing throughout the book to increase the clarity of presentation and to highlight the key issues in the field. In so doing, we have been able to decrease the overall length of the book while increasing the amount of up-to-date content. We have added new figures and tables to carefully illustrate various concepts. We have continued to add pedagogy based on feedback from students and professors. For example, we have included a new feature called Read More About It, in which we highlight recent important books about different disorders. We have also added new Focus on Discovery boxes to showcase cutting- edge research on selected topics or important historical highlights. In addition, we have modified and added Check Your Knowledge questions so that students can do a quick check to see if they are learning and integrating the material. Drawing on evidence supporting the importance of generative thinking for learning, we include open-ended questions. There are many new photos providing illustrations of real-world applications of psychopathology, including photos of some of the highly successful and well-known people who have come forward in the past several years to discuss their own psychological disorders. The end-of-chapter summaries continue to be consistent across the chapters, using a bulleted format to summarize the descriptions, causes, and treatments of the disorders covered. New and Expanded Coverage We are excited about the new features of this edition. The major new material in this edition is outlined by chapter here. Chapter 1: Introduction and Historical Overview - New material on reducing stigma - New Read More About It feature, covering two books on stigma by Stephen Hinshaw - New information on mental hospitals today - Added description of intermittent reinforcement - New information in the section on mental health professionals Chapter 2: Current Approaches in Psychopathology - Removal of terminology in previous edition relating to paradigms - Expanded discussion of multiple influences on psychological disorders and how they are important individually and collectively - Removal of diathesis-stress as a unifying theme because the entire book now integrates influences - Added cautionary notes about the promises and pitfalls of GWAS - Added information about shared genetic vulnerability across disorders - Added information on the HPA axis and stress - Added information on brain connectivity and networks - Added information noting that the influences of brain regions and networks on psychopathology are not necessarily specific to particular disorders - New information on cognitive behavioral approaches to psychopathology - Expanded discussion of behavioral influences - New section on socioemotional influences - New information on race, ethnicity, and gender -. New information on couples therapy - New information on trauma and childhood maltreatment - New information on violence against women Chapter 3: Diagnosis and Assessment - Added description of the poor reliability of the diagnosis of major depressive disorder in the DSM-5 field trials - New Read More About It feature, covering an example of misdiagnosis - New information on HiTOP, a major initiative focused on rethinking the diagnostic system based on the co-occurrence of symptoms and syndromes - Reorganized discussion of assessment to focus on key methods (reduced coverage of content that is not focused on later in the book, including Rorschach, MMPI-2 details, and CT scans) - Restructured section on common self-report questionnaires in psychopathology research - New information on brain stimulation methods - New coverage of the personality inventory NEO-PI - Updated material on cultural biases Chapter 4: Research Methods in Psychopathology - Consolidation of details on GWAS and association studies with the section on genetic influences in Chapter 2 Chapters: Mood Disorders - New information on the heterogeneity of depressive symptom profiles - New note on the lack of support for a categorical diagnosis of depression rather than a continuum of severity - New coverage of the current debate about the prevalence of seasonal affective disorder - Removal of the discussion of cultural influences on somatic symptom reporting in depression, as those have not been replicated in studies that control for the treatment context - New Read More About It feature, describing Kay Redfield Jamison’s work on creativity and the research that followed release of her book - New findings regarding structural deficits and functional connectivity in key brain regions in unipolar and bipolar disorders - Simplification of material regarding cytokines, which was moved from a Focus on Discovery box to the main text - New findings indicating that information-processing biases may be predictive of psychological, but not physical, symptoms of depression - A new section on etiology called “Putting It All Together,” which covers the links between biological, social, and psychological risk factors for depression - Simplified and updated section on ECT - Updated material on the epidemiology of suicide - Updated and simplified section on the neurobiology of suicide, focusing only on the replicated findings, which are for serotonergic disruptions - New information on social influences in suicide, including suicide clusters and protective factors - New section on differentiating suicidal ideation from action - New information on DBT, CAMS, brief CBT, and means restriction approaches to reducing suicidality Chapter 6: Anxiety Disorders - New Read More About It feature, focused on a book by Scott Stossel, editor of The Atlantic, which skillfully weaves together personal experience with a synopsis of the history and science of anxiety disorders - New information on the correlations between national levels of income inequality and the prevalence rates for anxiety disorders - Added evidence that genetic vulnerability to anxiety disorders (and depression) may be partially explained by higher neuroticism levels - New explanation of criticism of the term fear circuit, given that these same brain regions are involved in processing a broad range of salient stimuli, and elimination of use of that label to define key brain regions involved in anxiety disorders - New “Putting It All Together” section focused on the integration of biological, social, and psychological factors - New information on how social anxiety disorder may relate to an oversensitivity to social hierarchies and, relatedly, to subordinate behavior - Added information about basic research on interoceptive conditioning - New findings in support of the contrast avoidance model of generalized anxiety disorder - New findings regarding the behavioral model of exposure treatment and the Unified Protocol - Simplification of the discussion of pharmacological treatment of anxiety disorders - Removed material on cultural differences in tendencies to report somatic vs. psychological symptoms, dot probe task, attentional bias modification, and psychodynamic treatment for panic disorder, given mixed findings Chapter 7: Obsessive-Compulsive-Related and Trauma- Related Disorders - New Read More About It feature on work by David Adam, an award-winning journalist who wrote a compelling autobiography about his experience of OCD - Updated prevalence estimates for BDD (3%) and additional information about the prevalence of comorbid anxiety disorder (75%) among those with OCD - New meta-analytic findings suggesting that thought suppression failures are specifically observed when working memory capacity is limited - Summarized findings that teasing appears to be common before onset of BDD - New research in which eye tracking was used to understand gaze patterns of those with BDD when viewing photos of their own and others’ faces - Updates on pharmacological and brain stimulation treatment for OCD - More detail about the diagnostic criteria for acute stress disorder - Noted links of PTSD with cardiovascular disease - Added information on the severity of assaults to the section on trauma severity - New prospective findings on hippocampal blunting and functional connectivity in PTSD - Updated findings on medications and psychotherapies for PTSD Chapter 8: Dissociative Disorders and Somatic Symptom and Related Disorders - Evidence that those with dissociative disorders tend to endorse a range of highly unusual, improbable symptoms on measures designed to detect exaggeration of symptoms - Removal of laboratory studies on directed forgetting, given some failures to replicate - New data on recovered memory during therapy - Added clarification that DID can involve alternate personality states rather than personalities - Updated information on the prevalence of DID, as assessed using the best validated structured interview, the SCID-D - New theory and research on the causes of depersonalization/derealization, focused on difficulties in integrating information across sensory channels - Removal of statements that the sociocultural model of DID acknowledges the role of abuse, given that several recent articles on the sociocultural model note mixed evidence on whether abuse can prospectively predict dissociation during adulthood - Added information that 80% of people report an unexplained somatic symptom in the past week - Evidence from a large study that health anxiety is moderately heritable - New evidence that recent life events and early adversity are common precipitants of conversion disorder - New evidence that internet-based CBT can be helpful in addressing health anxiety Chapter 9: Schizophrenia - Trimmed-down version of material from the previous edition on behavior genetics - Removal of nonreplicated and outdated material on candidate gene approach - Addition of latest GWAS and discussion of nonspecificity of findings - Move of familial high risk studies to section on behavior genetics and trimming of older studies - New information on rTMS in schizophrenia - New table on delusions - New and updated neuroscience information - Three new Read More About It features, focusing on The Center Cannot Hold by Elyn Saks, The Collective Schizophrenias by Esme Weijun Wang, and Hidden Valley Road: Inside the Mind of an American Family by Robert Kolker - New information on trauma - Removal of older information from retrospective studies on the development of schizophrenia - New information on medication and psychosocial treatments for schizophrenia Chapter 10: Substance Use Disorders - Reorganization of opening of chapter for greater clarity - New information on opioids, including treatment - New information on fetal alcohol spectrum disorders - Updated information on prevalence rates of substance use and disorders in all tables and figures - New Read More About It feature on Beth Macy’s Dopesick: Dealers, Doctors, and the Drug Company That Addicted America - Updated Focus on Discovery box on gambling disorder, including discussion of internet gaming - New information on expectancy effects - New information on e-cigarettes and vaping - New information on treatments for smoking addiction - New information on marijuana and the impact of legalization - New information on psilocybin - New section on risky decision making - New information on dopamine’s role in substance use disorders - New material on computer-based CBT Chapter 11: Eating Disorders - New information on obesity in Focus on Discovery 11.1 - New information on medication and psychological treatments for eating disorders - New information on stigma and eating disorders - New information on culture, race, and ethnicity and eating disorders - Removal of outdated material - Updated information on prognosis for eating disorders - New information on the brain’s reward system, dopamine, and eating disorders - New information on emotion and eating disorders - New information on prevention programs Chapter 12: Sexual Disorders - New community-based data on the prevalence of sexual dysfunction disorders - New “Putting It All Together” section highlighting that biological and psychosocial factors interact in the genesis of sexual dysfunction - Mention of the #metoo movement in the section on sexual coercion - Updated descriptions of FDA-approved medication for female sexual interest/arousal disorder and fast-acting medication for erectile disorder - Note on the WHO decision to remove several paraphilic disorders as diagnostic categories in the ICD-11, reflecting the debate over whether paraphilic interests that do not involve nonconsenting adults should be diagnosed - In keeping with the WHO decisions, removal of coverage of fetishistic disorder - New description of a study showing that higher empathy for children may relate to less likelihood of acting on pedophilic urges - Note that some paraphilic disorders show little relationship with personality traits - More information about the evidence gaps regarding biological treatments for paraphilic disorders - Note on the huge variability in prevalence estimates for sexual coercion - New data on empathy in men who are attracted to children, indicating that those with more empathy were less likely to have acted on their impulses - New information about prevention efforts targeted toward men who are attracted to children - Removal of outdated material on Masters and Johnson’s theory, Kaplan’s sexual response cycle, and castration Chapter 13: Disorders of Childhood - Considerable streamlining of the chapter to focus on the most recent and well-replicated research - New information on girls and attention-deficit/hyperactivity disorder (ADHD) and longitudinal outcomes - New information on ADHD in adulthood - New information on parenting and ADHD and conduct disorder - New information on stimulant medications for ADHD - New information on callous and unemotional traits in conduct disorder - Removal of older and poorly replicated molecular genetics research - New information on depression in youth, including discussion of the influence of screen time - New information on the prevalence of anxiety and depression in youth - New information on anxiety in children and adolescents, including the role of childhood maltreatment - New information on treatment for anxiety, including general and specific treatments - New information on the etiology and treatment of depression in children and adolescents - New information on treatment for intellectual disability, including functional communication training and augmentative and alternative communication training - Removal of section on causes and treatment for dyslexia - Streamlining of the section on specific learning disorders - Updated information on the genetics of autism spectrum disorder - Updated information on the brain and autism Chapter 14: Late Life and Neurocognitive Disorders - Updated information on mental health and selective mortality - New graphs showing prevalence rates of specific psychological disorders and dementia overtime - New information that training pharmacists to monitor polypharmacy can be helpful - Added information that low rates of mental health problems are observed in major national surveys outside the United States, such as data from Australia - New content that mental health problems in the elderly are often undiagnosed and untreated - Replacement of the DSM-5 criteria for mild cognitive impairment and dementia with the criteria developed by experts with support from the National Institute of Aging and the Alzheimer’s Association - New table summarizing the major forms of dementia - New section on traumatic brain injury and its relationship to sports and the risk of late life dementia - Updated information on the predictive power of lifestyle factors in dementia, the efficacy of lifestyle interventions, and the use of medications to treat dementia - New clinical case illustrating frontotemporal dementia. New information on lifestyle factors as predictors of the course of frontotemporal dementia - New section on Huntington’s disease - Updated material on interventions for caregivers of those with dementia - Simplification of material on the search for new treatment approaches for dementia - Removal of findings that have failed to be replicated, such as caregiver interventions influencing outcomes for the person with dementia and historical decreases in the extent of cognitive decline with aging Chapter 15: Personality Disorders - New Read More About It feature, focusing on the process of therapy and change in borderline personality disorder, as captured in the autobiography of Kiera Van Gelder - Inclusion of a third issue concerning diagnoses of personality disorders: the arbitrary thresholds for diagnosis - Addition explaining that ICD-11 has largely adopted the trait-based diagnostic system for personality disorders - New coverage of a study on social cognition deficits in schizotypal personality disorder - Reduction of clinical coverage of schizoid, histrionic, and dependent personality disorders because they rarely occur and of paranoid personality disorder because it usually co-occurs with other personality disorders - New information on how genetic vulnerability for antisocial personality disorder overlaps with the vulnerability for substance use disorders - New evidence linking psychopathy to disruptions of functional connectivity of the amygdala and ventromedial prefrontal cortex in response to social cues of others’ distress - New findings suggesting that clinicians did not rate fragile self-esteem as a core component of narcissistic personality disorder - Removal of discussion of comorbidity and overlap of genetic vulnerability for OCD and OCPD, as these have diminished with the new DSM-5 criteria - Due to nonreplication, removal of statements that comorbid conditions like anxiety and depression predict longer duration of personality disorders and that pharmacological treatment addresses impulsivity in personality disorders Chapter 16: Legal and Ethical Issues - New Focus on Discovery box on gun violence and mental illness - New information on the “Goldwater Rule” - Two new Read More About It features, focusing on Nobody’s Child: A Tragedy, a Trial, and a History of the Insanity Defense by Susan Vinocour and Insane: America’s Criminal Treatment of Mental Illness by Alisa Roth - New information on violence and mental illness - New information on jail diversion programs and the crisis intervention team approach Special Features for Students Several features of this book are designed to help students to master and enjoy the material. Clinical Cases We include Clinical Cases throughout the book. These cases provide a clinical context for the theories and research that occupy most of our attention in the chapters, and they help make vivid the real-life implications of the empirical work of psychopathologists and clinicians. FOCUS On Discovery In-depth discussions of selected topics appear throughout the book as stand-alone Focus on Discovery boxes, allowing us to involve readers in specialized topics without detracting from the flow of the main chapter text. Sometimes a Focus on Discovery expands on a point discussed in the chapter; sometimes it deals with an entirely separate but relevant issue—often a controversial one. Read More About It Read More About It features discuss selected books on the topics covered in the chapters. Included are first-person accounts of experiencing a psychological disorder and works detailing the origins of disorders and their consequences or discussing psychological disorders in a broader community context. Quick Summaries We include short summaries of sections throughout the chapters to give students an opportunity to pause and assimilate the material. These can help students keep track of the multifaceted and complex issues that surround the study of psychopathology. End-of-Chapter Summaries At the end of each chapter we review the chapter material in a bulleted summary. In Chapters 5-15, we organize these summaries into sections on clinical descriptions, etiology, and treatment—the major sections of every chapter covering the disorders. We believe that this format makes it easier for readers to review and remember the material. In fact, we suggest that students read the summary before beginning the chapter itself to get a good sense of what lies ahead. Reading the summary again after completing the chapter will enhance students’ understanding and provide an immediate sense of the knowledge acquired in just one reading of the chapter. Check Your Knowledge Questions Throughout each chapter, we provide three to seven sets of review questions covering the material discussed. These questions are intended to help students assess their understanding and retention of the material, as well as to provide them with samples of the types of questions that often are found in course exams. We believe that these review questions will be useful aids for students as they make their way through the chapters. Glossary When an important term is introduced, it is boldfaced and defined or discussed immediately. Most such terms appear again later in the book, where they are not highlighted in this way. All these terms are listed again at the end of each chapter in an alphabetical list of key terms, and definitions appear at the end of the book in a glossary. Defining Symptoms Boxes we include a box with the defining symptoms of each of the disorders we cover in the book. The symptoms in these lists represent the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, known as DSM-5, as well as the eleventh edition of the International Classification of Disease, known as ICD-11. We discuss both of these works in Chapter 3. We make considerable use of DSM-5, though in a selective and occasionally critical manner. Sometimes we find it more effective to discuss theory and research on a problem in a way that is different from DSM-5’s conceptualization. To Learn More This 15th edition of Abnormal Psychology: The Science and Treatment of Psychological Disorders is available in two formats: as a print text and as an enhanced e-Text. The enhanced e-Text and practical printed text options offer the flexibility to suit multiple course formats, whether they be face-to-face, a hybrid/blended learning environment, or an online class. Students who opt for the enhanced e-Text have Case Study Videos and other interactive study tools integrated with the text. The collection of 7- to 10-minute Case Study Videos presents an encompassing view of 16 psychological disorders. Produced by documentary filmmaker Nathan Friedkin in collaboration with Ann Kring and Sheri Johnson, each case study features people with psychological disorders and their families, describing symptoms from their own perspective. In addition, each video also provides concise information about the available treatment options and commentary from a mental health professional. Along with the Case Study Videos, the enhanced e-Text includes a variety of Interactivities that promote engagement and Flashcards that give students the opportunity to easily test their knowledge of key terms and vocabulary. All instructors have access to a Book Companion Website that provides access to the Case Study Videos and a variety of Instructor Resources including a complete Test Bank, Lecture Presentation Slides, and an Instructor’s Manual with Lecture Launchers, Discussion Stimulators, Handouts, suggestions for a variety of demonstrations and activities, and an annotated list of Web Resources for each chapter that puts useful online resources into the context of your Abnormal Psychology course. Acknowledgments We are grateful for the contributions of our colleagues and staff, for it was with their assistance that this edition was able to become the book that it is. Sheri is deeply thankful to Matthew Jewik for assistance with library research and Morgan Robison for the helpful editing suggestions. We have also benefited from the skills and dedication of the folks at Wiley and Lumina. For this edition, we have many people to thank. Specifically, we thank Executive Editor Glenn Wilson and Managing Editorial Director Barbara Heaney; working with you on this edition has been a pleasure. In addition, we would like to thank Sally Lifland and Beverly Peavler for the magnificent copy editing. And finally, we would like to thank Neha Bhargava for guiding us through the production process. From time to time, students and faculty colleagues have sent us their comments; these communications are always welcome. Readers can e-mail us at [email protected], [email protected]. Finally, and most important, our heartfelt thanks go to the most important people in our lives for their continued support and encouragement along the way. A great big thanks to Angela Hawk (AMK) and Daniel Rose (SLJ), to whom this book is dedicated with love and gratitude. December 2020 ANN M. KRING SHERI L. JOHNSON Brief Contents preface… v part I Introduction and Fundamental Issues… 1 1 Introduction and Historical Overview… 1 2 Current Approaches in Psychopathology… 27 3 Diagnosis and Assessment… 54 4 Research Methods in Psychopathology… 86 part iiPsychological Disorders… 114 5 Mood Disorders… 114 6 Anxiety Disorders… 153 7 Obsessive-Compulsive-Related and Trauma-Related Disorders… 184 8 Dissociative Disorders and Somatic Symptom and Related Disorders… 211 9 Schizophrenia… 238 10 Substance Use Disorders… 270 11 Eating Disorders… 313 12 Sexual Disorders… 339 13 Disorders of Childhood… 369 14 Late Life and Neurocognitive Disorders… 409 15 Personality Disorders… 433 16 Legal and Ethical Issues… 462 appendix: DSM-5 Diagnoses… A-1 glossary / references / name index / subject index Contents 1 Introduction and Historical Overview… 1 Psychological Disorders and Stigmas… 2 Defining Psychological Disorder… 6 Personal Distress… 7 Disability and Dysfunction… 7 Violation of Social Norms… 8 Early History of Psychopathology… 9 Supernatural Explanations… 9 Early Biological Explanations… 10 The Dark Ages: Back to the Supernatural… 10 Development of Asylums… 11 Historical Antecedents of Contemporary Views… 14 Biological Approaches… 14 Psychological Approaches… 16 Have We Learned From History?… 22 The Mental Health Professions… 24 Summary… 25 2 Current Approaches in Psychopathology… 27 Genetic Influences… 27 Behavior Genetics… 29 Molecular Genetics… 30 Gene-Environment Interactions… 31 Evaluating the Role of Genetic Influences in Psychopathology… 32 Neuroscience Influences… 34 Neurons and Neurotransmitters… 34 Structure and Function of the Human Brain… 35 The Neuroendocrine System… 36 The Immune System… 38 Neuroscience Approaches to Treatment… 39 Evaluating the Role of Neuroscience Influences in Psychopathology… 39 Cognitive Behavioral Influences… 40 Influences from Behaviorism… 40 Cognitive Science… 41 The Role of the Unconscious… 42 Cognitive Behavior Therapy… 43 Evaluating the Role of Cognitive Behavioral Influences in Psychopathology… 43 Socioemotional Influences… 45 The Importance of Emotion… 45 Sociocultural Influences… 46 Interpersonal Influences and the Role of Stress… 47 Evaluating the Role of Socioemotional Influences in Psychopathology… 50 Summary… 52 3 Diagnosis and Assessment… 54 Cornerstones of Diagnosis and Assessment: Reliability and Validity… 55 Reliability… 55 Validity… 56 Diagnosis… 58 The Diagnostic System of the American Psychiatric Association: DSM-5… 58 Specific Criticisms of the DSM… 63 General Criticisms of Diagnosing Psychological Disorders… 68 Psychological Assessment… 70 Clinical Interviews… 70 Personality Tests… 73 Cognitive and Neuropsychological Tests… 75 Direct Observation of Behavior… 76 Experience Sampling… 77 Self-Report Questionnaires… 77 Neurobiological Assessment… 79 Brain Imaging: “Seeing” the Brain… 79 Brain Stimulation… 80 Psychophysiological Assessment… 81 Diversity and Assessment… 82 Cultural and Racial Bias in Assessment… 82 Strategies for Avoiding Cultural and Racial Bias in Assessment… 83 Summary… 84 4 Research Methods in Psychopathology… 86 Science, Theory, and Hypotheses… 87 Research Designs in Psychopathology… 87 The Case Study… 87 The Correlational Method… 88 The Experiment… 95 One Example of Experimental Research: Treatment Outcome Research… 100 Defining the Treatment Condition… 102 Defining Control Groups… 102 Defining a Sample… 103 Assessing and Implementing Treatments in the Real World… 105 Analogues in Psychopathology Research… 106 Integrating the Findings of Multiple Studies… 108 Replication… 108 Meta-Analysis… 110 Summary… 112 5 Mood Disorders… 114 Clinical Descriptions and Epidemiology of Depressive Disorders… 115 Major Depressive Disorder… 116 Persistent Depressive Disorder… 117 Epidemiology and Consequences of Depressive Disorders… 117 Clinical Descriptions and Epidemiology of Bipolar Disorders… 121 Bipolar I Disorder… 121 Bipolar II Disorder… 122 Cyclothymic Disorder… 122 Epidemiology and Consequences of Bipolar Disorders… 123 Etiology of Mood Disorders… 124 Genetic Influences… 125 Neurotransmitters… 125 Neural Regions Involved in Emotion and Reward Processing… 126 Cortisol Dysregulation… 128 Cytokines… 129 Social Influences on Depression: Childhood Adversity, Life Events, and Interpersonal Difficulties… 129 Psychological Influences on Depression… 130 Putting It All Together: Integrating Biological and Social Influences on Depression… 133 Social and Psychological Influences on the Course of Bipolar Disorder… 134 Treatment of Mood Disorders… 136 Psychological Treatment of Depression… 137 Psychological Treatment of Bipolar Disorder… 140 Biological Treatment of Mood Disorders… 141 Suicide… 144 Epidemiology of Suicide and Suicide Attempts… 145 Risk Factors for Suicide… 147 Preventing Suicide… 148 Summary… 151 6 Anxiety Disorders… 153 Emotions of Anxiety and Fear… 154 Clinical Descriptions of the Anxiety Disorders… 155 Specific Phobias… 156 Social Anxiety Disorder… 158 Panic Disorder… 159 Agoraphobia… 159 Generalized Anxiety Disorder… 160 Comorbidity in Anxiety Disorders… 161 Gender and Cultural Influences on the Anxiety Disorders… 162 Gender… 162 Culture… 162 Common Influences Across the Anxiety Disorders… 163 Fear Conditioning… 164 Genetic Influences… 166 Neurobiological Correlates: Brain Regions and Activity of Neurotransmitters… 166 Personality: Neuroticism and Behavioral Inhibition… 167 Cognitive Influences… 167 Putting It All Together: Integrating Biological, Behavioral, and Social Influences… 169 Etiology of Specific Anxiety Disorders… 170 Etiology of Specific Phobias… 170 Etiology of Social Anxiety Disorder… 171 Etiology of Panic Disorder… 173 Etiology of Agoraphobia… 175 Etiology of Generalized Anxiety Disorder… 175 Treatments of the Anxiety Disorders… 177 Commonalities Across Psychological Treatments… 177 Psychological Treatments of Specific Anxiety Disorders… 178 Medications That Reduce Anxiety… 180 Summary… 181 7 Obsessive-Compulsive-Related and Trauma-Related Disorders… 184 Clinical Descriptions and Epidemiology of Obsessive- Compulsive and Related Disorders… 185 Obsessive-Compulsive Disorder… 186 Body Dysmorphic Disorder… 188 Hoarding Disorder… 189 Prevalence and Comorbidity of Obsessive-Compulsive and Related Disorders… 191 Etiology of the Obsessive- Compulsive and Related Disorders… 192 Etiology of Obsessive-Compulsive Disorder… 192 Etiology of Body Dysmorphic Disorder… 194 Etiology of Hoarding Disorder… 194 Treatment of the Obsessive-Compulsive and Related Disorders… 195 Medications… 196 Psychological Treatment… 196 Brain Stimulation for Treatment-Resistant OCD… 199 Clinical Description and Epidemiology of Posttraumatic Stress Disorder and Acute Stress Disorder… 199 Etiology of Posttraumatic Stress Disorder… 203 Nature of the Trauma: The Severity and Type of Trauma Matter… 203 Neurobiology: The Hippocampus… 204 Coping… 205 Treatment of Posttraumatic Stress Disorder and Acute Stress Disorder… 206 Medication Treatment of PTSD… 206 Psychological Treatment of PTSD… 206 Psychological Treatment of Acute Stress Disorder… 208 Summary… 209 8 Dissociative Disorders and Somatic Symptom and Related Disorders… 211 Clinical Descriptions and Epidemiology of the Dissociative Disorders… 212 Depersonalization/Derealization Disorder… 213 Dissociative Amnesia… 214 Dissociative Identity Disorder… 217 The Epidemiology of Dissociative Disorders: Increases Over Time… 218 Etiology of Dissociative Disorders… 219 Etiology of Depersonalization/Derealization Disorder… 219 Etiology of Dissociative Identity Disorder… 219 Treatment of Dissociative Disorders… 222 Clinical Description of Somatic Symptom and Related Disorders… 222 Clinical Description of Somatic Symptom Disorder… 224 Clinical Description of Illness Anxiety Disorder… 225 Clinical Description of Conversion Disorder… 225 Etiology of Somatic Symptom and Related Disorders… 228 Neurobiological Factors That Increase Awareness of and Distress Over Somatic Symptoms… 229 Cognitive Behavioral Factors That Increase Awareness of and Distress Over Somatic Symptoms… 230 Etiology of Conversion Disorder… 231 Treatment of Somatic Symptom and Related Disorders… 233 Somatic Symptom Disorder and Illness Anxiety Disorder… 233 Conversion Disorder… 235 Summary… 236 9 Schizophrenia… 238 Clinical Descriptions of Schizophrenia… 239 Positive Symptoms… 240 Negative Symptoms… 241 Disorganized Symptoms….242 Other Schizophrenia Spectrum Disorders… 244 Etiology of Schizophrenia… 246 Genetic Influences… 247 The Role of Neurotransmitters… 251 Connectivity in the Brain… 253 Environmental Factors Influencing the Developing Brain… 254 Psychological Influences… 255 Developmental Factors… 258 Treatment of Schizophrenia… 260 Medications… 260 Psychological Treatments… 264 Summary… 268 10 Substance Use Disorders… 270 Overview: Substance Use by the Numbers… 270 Clinical Descriptions: Alcohol, Tobacco, and Marijuana Use Disorders… 273 Alcohol Use Disorder… 273 Tobacco Use Disorder… 277 Marijuana… 280 Clinical Descriptions: Opioid, Stimulant, and Other Drug Use Disorders… 284 Opioids… 284 Stimulants… 287 Hallucinogens, Ecstasy, and PCP… 289 Etiology of Substance Use Disorders… 292 Genetic Influences… 292 Neurobiological Influences… 293 Psychological Influences… 296 Sociocultural Influences… 299 Treatment of Substance Use Disorders… 301 Treatment of Alcohol Use Disorder… 302 Treatments for Smoking… 304 Treatment of Drug Use Disorders… 306 Prevention of Substance Use Disorders… 310 Summary… 311 11 Eating Disorders… 313 Clinical Descriptions of Eating Disorders… 314 Anorexia Nervosa… 314 Bulimia Nervosa… 318 Binge Eating Disorder… 319 Etiology of Eating Disorders… 324 Genetic Influences… 324 Neurobiological Influences… 324 Cognitive Behavioral and Emotion Influences… 326 Sociocultural Influences… 328 Other Influences Contributing to the Etiology of Eating Disorders… 332 Treatment of Eating Disorders… 334 Medications… 334 Psychological Treatment of Anorexia Nervosa… 334 Psychological Treatment of Bulimia Nervosa… 335 Psychological Treatment of Binge Eating Disorder… 336 Preventive Interventions for Eating Disorders… 337 Summary… 338 12 Sexual Disorders… 339 Sexual Norms and Behavior… 340 Research Methods in the Study of Sexuality… 342 Gender and Sexuality… 342 Clinical Descriptions of Sexual Dysfunctions… 344 Disorders Involving Sexual Interest, Desire, and Arousal… 346 Orgasmic Disorders… 347 Sexual Pain Disorder… 349 Etiology of Sexual Dysfunctions… 350 Biological Influences… 350 Psychosocial Influences… 351 Putting It All Together: Integrating Biological and Psychosocial Influences on Sexual Dysfunction… 352 Treatments of Sexual Dysfunctions… 353 Psychoeducation… 354 Couples Therapy… 354 Cognitive Interventions… 354 Sensate Focus… 354 Treatments for Specific Sexual Dysfunctions… 355 Clinical Descriptions of the Paraphilic Disorders… 356 Pedophilic Disorder and Incest… 358 Voyeuristic Disorder… 359 Exhibitionistic Disorder… 359 Frotteuristic Disorder… 360 Sexual Sadism and Masochism Disorders… 360 Etiology of the Paraphilic Disorders… 361 Neurobiological Influences… 362 Childhood Sexual Abuse… 362 Psychological Influences… 362 Treatments and Community Prevention for the Paraphilic Disorders… 364 Strategies to Enhance Motivation… 365 Cognitive Behavioral Treatment… 365 Biological Treatments… 365 Prevention… 366 Balancing Efforts to Protect the Public Against the Civil Liberties of Those with Paraphilias… 366 Summary… 367 13 Disorders of Childhood… 369 Classification and Diagnosis of Childhood Disorders… 370 Externalizing Disorders: ADHD and Conduct Disorder… 371 Attention-Deficit/Hyperactivity Disorder… 371 Conduct Disorder… 377 Internalizing Disorders: Depression and Anxiety Disorders… 385 Depression… 386 Anxiety… 390 Specific Learning Disorder and Intellectual Disability… 394 Dyslexia: A Type of Specific Learning Disorder… 394 Intellectual Disability… 396 Autism Spectrum Disorder… 400 Clinical Descriptions, Prevalence, and Prognosis of Autism Spectrum Disorder… 400 Etiology of Autism Spectrum Disorder… 404 Treatment of Autism Spectrum Disorder… 406 Summary… 407 14 Late Life and Neurocognitive Disorders… 409 Aging: Myths, Problems, and Methods… 410 Myths About Late Life… 411 The Problems Experienced in Late Life… 412 Research Methods in the Study of Aging… 412 Psychological Disorders in Late Life… 414 Prevalence Estimates of Psychological Disorders in Late Life… 415 Methodological Issues in Estimating the Prevalence of Psychopathology… 416 Treatment… 416 Dementia… 417 Alzheimer’s Disease… 419 Behavioral Variant Frontotemporal Dementia… 423 Vascular Dementia… 424 Dementia with Lewy Bodies… 424 Huntington’s Disease… 425 Treatments for Dementia… 425 Delirium… 428 Etiology of Delirium… 430 Treatment of Delirium… 430 Summary… 431 15 Personality Disorders… 433 The DSM-5 Approach to Classification… 435 Problems with the DSM-5 Approach to Personality Disorders… 436 Alternative DSM-5 Model for Personality Disorders… 438 Common Risk Factors Across the Personality Disorders… 440 Clinical Description and Etiology of the Odd/Eccentric Cluster… 442 Schizotypal Personality Disorder… 442 Clinical Description and Etiology of the Dramatic/Erratic Cluster… 444 Antisocial Personality Disorder and Psychopathy… 445 Borderline Personality Disorder… 448 Narcissistic Personality Disorder… 451 Clinical Description and Etiology of the Anxious/Fearful Cluster… 454 Avoidant Personality Disorder… 454 Obsessive-Compulsive Personality Disorder… 455 Treatment of Personality Disorders… 457 Treatment of Schizotypal Personality Disorder and Avoidant Personality Disorder… 458 Treatment of Borderline Personality Disorder… 458 Summary… 460 16 Legal and Ethical Issues… 462 Criminal Commitment… 463 The Insanity Defense… 464 Current Insanity Pleas… 467 Competency to Stand Trial… 469 Insanity, Intellectual Disability, and Capital Punishment… 474 Civil Commitment… 475 Preventive Detention and Problems in the Prediction of Dangerousness… 476 Protection of the Rights of People with Psychological Disorders… 479 Ethical Dilemmas in Therapy and Research… 484 Ethical Restraints on Research… 484 Informed Consent… 486 Confidentiality and Privileged Communication… 487 Summary… 487 APPENDIX: DSM-5 Diagnoses… A-l GLOSSARY / REFERENCES / NAME INDEX / SUBJECT INDEX [Blank Page] CHAPTER 1 Introduction and Historical Overview 1. Explain the meaning of stigma as it applies to people with psychological disorders. 2. Understand the characteristics that define psychological disorder. 3. Understand how the causes and treatments of psychological disorders have changed over the course of history. 4. Describe the historical forces that have helped to shape our current view of psychological disorders, including biological and psychological views. 5. Understand what we have (and have not) learned from history. 6. Describe the different mental health professions, including the training involved and the expertise developed. [Clinical Case Jack Jack dreaded family gatherings. His parents’ house would be filled with his brothers and their families, and all the little kids would run around making a lot of noise. His parents would urge him to “be social” and spend time with the family, even though Jack preferred to be alone. He knew that the kids called him “crazy Uncle Jack.” In fact, he had even heard his younger brother Kevin call him “crazy Jack” when Kevin stopped by to see their mother the other day. Jack’s mother admonished Kevin, reminding him that Jack had been doing very well on his new medication. “Schizophrenia is an illness,” his mother had said. Jack had not been hospitalized with an acute episode of schizophrenia for over 2 years. Even though Jack still heard voices, he had learned not to talk about them in front of his mother because she would then start hassling him about taking his medication or ask him all sorts of questions about whether he needed to go back to the hospital. He hoped he would soon be able to move out of his parents’ house and into his own apartment. The landlord at the last apartment he had tried to rent rejected his application once he learned that Jack had schizophrenia. His mother and father needed to cosign the lease, and they had inadvertently said that Jack was doing very well with his illness. The landlord asked about the illness, and once his parents mentioned schizophrenia, the landlord became visibly uncomfortable. The landlord called later that night and said the apartment had already been rented. When Jack’s father pressed him, the landlord admitted he “didn’t want any trouble” and that he was worried that people like Jack were violent.] Felicia Felicia didn’t like to think back to her early school years. Elementary school was not a very fun time. She couldn’t sit still or follow directions very well. She often blurted out answers when it wasn’t her turn to talk, and she never seemed to be able to finish her class papers without many mistakes. As if that wasn’t bad enough, the other girls often laughed at her and called her names. She still remembers the time she tried to join in with a group of girls during recess. They kept running away, whispering to each other, and giggling. When Felicia asked what was so funny, one of the girls laughed and said, “You are hyper, girl! You fidget so much in class, you must have ants in your pants!” When Felicia started fourth grade, her parents took her to a psychologist. She took several tests and answered all sorts of questions. At the end of these testing sessions, the psychologist diagnosed Felicia with attention- deficit/hyperactivity disorder (ADHD). Felicia began seeing a different psychologist, and her pediatrician prescribed the medication Ritalin. She enjoyed seeing the psychologist because she helped her learn how to deal with the other kids’ teasing and how to do a better job of paying attention. The medication helped, too—she could concentrate better and didn’t seem to blurt out things as much anymore. Now in high school, Felicia is much happier. She has a good group of close friends, and her grades are better than they have ever been. Though it is still hard to focus sometimes, she has [earned several ways to deal with her distractibility. She is looking forward to college, hoping she can get into the top state school. Her guidance counselor has encouraged her, thinking her grades and extracurricular activities will make for a strong application.] We all try to understand other people. Determining why another person does or feels something is not easy to do. In fact, we do not always understand our own feelings and behavior. Figuring out why people behave in normal, expected ways is difficult enough; understanding seemingly abnormal behavior, such as the behavior of Jack and Felicia, can be even more difficult. Psychological Disorders and Stigmas In this book, we will consider the description, causes, and treatments of several different psychological disorders. We will also demonstrate the numerous challenges professionals in this field face. As you approach the study of psychopathology, the field concerned with the nature, development, and treatment of psychological disorders, keep in mind that the field is continually developing and adding new findings. As we proceed, you will see that the field’s interest and importance are ever growing. Our subject matter, human behavior, is personal and powerfully affecting. Who has not experienced irrational thoughts or feelings? Most of us have known someone, a friend or a relative, whose behavior was upsetting or difficult to understand, and we realize how frustrating it can be to try to understand and help a person with psychological difficulties. Our closeness to the subject matter also adds to its intrinsic fascination; undergraduate courses in clinical or abnormal psychology are among the most popular in the entire college curriculum, not just in psychology departments. Our feeling of familiarity with the subject matter draws us to the study of psychopathology, but it also has a distinct disadvantage: We bring to the study our preconceived notions of what the subject matter is. Each of us has developed certain ways of thinking and talking about psychological disorders, certain words and concepts that somehow seem to fit. As you read this book and try to understand the psychological disorders it discusses, we may be asking you to adopt different ways of thinking about psychological disorders from those to which you are accustomed. Perhaps most challenging of all, we must not only recognize our own preconceived notions of psychological disorders, but also confront and work to change the stigma we often associate with these conditions. 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 psychological disorders. More specifically, stigma has four characteristics (see Figure 1.1): 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). [FIGURE 1.1 The four characteristics of stigma.] The case of Jack illustrates how stigma can lead to discrimination. Jack was denied an apartment because of his schizophrenia. The landlord believed Jack’s schizophrenia meant he would be violent. However, a person with a psychological disorder is more likely to be a victim of violence than a perpetrator of it (Desmarais, Van Dorn, et al., 2014), even though people with psychological disorders can be violent if they do not receive treatment (Torrey, 2014). As we will see, the treatment of people with psychological disorders throughout recorded history has not generally been good, and this has contributed to their stigmatization, to the extent that they have often been brutalized and shunned by society. In the past, torturous treatments were held up to the public as miracle cures, and even today, terms such as crazy, insane, retard, and schizo are tossed about without thought of the people who have psychological disorders and for whom these insults and the intensely distressing feelings and behaviors they refer to are a reality of daily life. The cases of Jack and Felicia illustrate how hurtful using such careless and mean-spirited names can be. Psychological disorders remain the most stigmatized of conditions in the 21st century, despite advances in the public’s knowledge about the origins of psychological disorders (Hinshaw, 2018). In 1999, then Surgeon General of the United States David Satcher, in his groundbreaking report on mental illness, wrote that stigma is the “most formidable obstacle to future progress in the arena of mental illness and mental health” (U.S. Department of Health and Human Services, 1999). Sadly, this is still true today. In 2010, a staff person working with then Wisconsin gubernatorial candidate Scott Walker wrote dismissively about an election opponent’s plan to make mental health care a focus of the campaign, “No one cares about crazy people.” This awful phrase was turned into something hopeful when author Ron Powers opted to use it as the title of his book, an unflinchingly honest memoir about his two sons with schizophrenia and the current state of mental health care in the United States (Powers, 2017). Throughout this book, we hope to fight this stigma by showing you the latest evidence about the nature and causes of these disorders, together with treatments, dispelling myths and other misconceptions as we proceed. As part of this effort, we will try to put a human face on psychological disorders by including descriptions of actual people with these disorders. Additional ways to fight stigma are presented in Read More About It 1.1. But you will have to help in this fight, for the mere acquisition of knowledge does not ensure the end of stigma (Corrigan, 2015). Many mental health practitioners and advocates had hoped that the more people learned about the neurobiological causes of psychological disorders, the less stigmatized these disorders would be. However, results from an important study show that this may not be true (Pescosolido, Martin, et al., 2010). People’s knowledge has increased, but unfortunately stigma has not decreased. In the study, researchers surveyed people’s attitudes and knowledge about psychological disorders at two points in time: 1996 and 2006. The Mark of Shame and Another Kind of Madness The psychologist Stephen Hinshaw published two important books about stigma and mental illness. In 2007, he published The Mark of Shame: The Stigma of Mental Illness and an Agenda for Change. In this important book, Hinshaw discusses several steps that can be taken to end stigma surrounding psychological disorders. In 2017, he published a second book, entitled Another Kind of Madness: A Journey Through the Stigma and Hope of Mental Illness, which is a deeply personal story about the toll that stigma can take on families. In this book, Hinshaw works to humanize mental illness by telling his own personal story about his father, who had bipolar disorder. In both of these books, Hinshaw makes a strong case for why stigma is a “final frontier for human rights” (see also Hinshaw, 2018). Here we briefly discuss some of the key suggestions for fighting stigma in many arenas, including community, mental health professions, and individual/family behaviors and attitudes. Community Strategies Housing Options Rates of homelessness in people with psychological disorders are too high, and more programs to provide community residences and group homes are needed. However, many neighborhoods are reluctant to embrace the idea of people with a psychological disorder living among them. Lobbying legislatures and community leaders about the importance of adequate housing is a critically important step toward providing housing for people with psychological disorders and reducing stigma. Education Educating people about psychological disorders (one of the goals of this book!) is an important step toward reducing stigma. Education alone won’t completely eradicate stigma. By learning about psychological disorders, though, people may become less hesitant to interact with people who have different disorders. Many of you already know someone with a psychological disorder. Sadly, however, stigma often prevents people from disclosing their history with a psychological disorder. Education may help lessen people’s hesitancy to talk about their illnesses. Personal Contact Providing greater housing opportunities for people with psychological disorders will likely mean that people with these disorders will shop and eat in local establishments alongside people without these disorders. Research suggests that this type of contact—where status is relatively equal—can reduce stigma. In fact, personal contact is more effective than education in reducing stigma (Corrigan, Morris, et al., 2012). Informal settings, such as local parks and churches, can also help bridge the personal contact gap between people with and without psychological disorders. Mental Health and Health Profession Strategies Mental Health Evaluations Many children see their pediatricians for well-baby or well-child exams. The goal of these visits is to prevent illness before it occurs. Hinshaw (2007) makes a strong case for including similar efforts to prevent psychological disorders among children and adolescents by, for example, using rating scale assessments from parents and teachers to help identify problems before they become more serious. Education, Training, and Support Mental health professionals should receive training in stigma issues (Hinshaw, 2018). This type of training would undoubtedly help professionals recognize the pernicious signs of stigma, even within the very profession that is charged with helping people with psychological disorders. In addition, mental health professionals need to keep current on the descriptions, causes, and empirically supported treatments for psychological disorders. This would certainly lead to better interactions with people and might also help educate the public about the important work being done by mental health professionals. Indeed, some evidence suggests that mental health professionals I can exhibit stigma even though they have devoted their professional lives to helping others with psychological disorders (Corrigan & Nieweglowski, 2019). Mental health professionals should also seek support as they do this important work to help others, to guard against burnout and the development of stigma. Individual and Family Strategies Education for Individuals and Families It can be frightening and disorienting for families to learn that a loved one has been diagnosed with an illness, and this may be particularly true for psychological disorders. Receiving current information about the causes and treatments of psychological disorders is crucial because it helps to alleviate blame and remove stereotypes families might hold about psychological disorders. Educating people with a psychological disorder is also extremely important. Sometimes termed psychoeducation, this type of information is built into many types of treatments, whether pharmacological or psychosocial. For people to understand why they should adhere to certain treatment regimens, it is important for them to know the nature of their illness and the treatment alternatives available. Support and Advocacy Groups Participating in support or advocacy groups can be a helpful adjunct to treatment for people with psychological disorders and their families. Websites such as Mind Freedom International (http://www.mindfreedom.org) and the Icarus Project (http://www.theicarusproject.net) are designed to provide a forum for people with psychological disorders to find support. These sites, developed and run by people with psychological disorders, contain useful links, blogs, and other helpful resources. In-person support groups are also helpful, and many communities have groups supported by the National Alliance on Mental Illness (http://www.nami. org). Finding peers in the context of support groups can be beneficial, especially for emotional support and empowerment.] Compared with people in 1996, people in 2006 were more likely to believe that psychological disorders such as schizophrenia, depression, and alcohol addiction had a neurobiological cause, but stigma toward these disorders did not decrease. In fact, in some cases it increased. For example, people in 2006 were less likely than people in 1996 to want to have a person with schizophrenia as their neighbor. Sadly, evidence from other studies backs up the findings from this study: Knowing more about the causes or available treatments of psychological disorders like schizophrenia or depression does not decrease stigma, according to studies in 13 different countries around the world (Pescosolido, Medina, et al., 2013). Knowing more is linked to a greater desire for more social distance from people with psychological disorders (Kvaale, Haslam, & Gottdiener, 2013; Schnittker,2008). Two factors that can reduce stigma are contact and familiarity. A recent meta-analysis (see Chapter 4) of studies around the world found that coming into contact with someone with a psychological disorder can reduce stigma, and this reduction persists a year later (Maunder & White, 2019). Familiarity refers to whether a person knows someone with a severe mental illness. In general, familiarity is associated with less stigma (Corrigan & Nieweglowski, 2019). That is, if you work or live with someone who has a psychological disorder, you are less likely to exhibit stigma. Unfortunately, though, there is some evidence that greater familiarity, as in being a caretaker or mental health professional, is associated with more stigma (Corrigan & Nieweglowski, 2019). How can this be? Researchers have suggested that family burden and job burnout can foster stigma, which points to the importance of providing support for family members and mental health professionals. Clearly, there is work to be done to reduce stigma. Other efforts to reduce stigma have been quite creative in their use of social media and other means to get the message out that psychological disorders are common and affect us all in one way or another. Indeed, close to 47 million people in the United States (i.e., about 1 in 5 people) had some type of psychological disorder in 2017, according to the National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2018). For example, the website Bring Change to Mind (http:// bringchange2mind.org) is a platform for personal stories that seeks to end stigma associated with psychological disorders; it was co-founded by the actress Glenn Close and her sister Jessie, who has bipolar disorder (see Chapter 5), and her nephew Calen, who has schizophrenia (see Chapter 9). Many blogs and podcasts feature people talking poignantly about their lives with different psychological disorders, and these accounts help to demystify and therefore destigmatize the disorders. For example, Allie Brosh wrote a blog called Hyperbole and a Half about her experiences with depression (http://hyperboleandahalf.blogspot.com) that culminated in a book (Brosh, 2013). Podcasts such as “The Mental Illness Happy Hour,” “All in the Mind,” and “Invisibilia” include discussions of psychological disorders and psychology topics more broadly. The blog that is part of Strong365 (http://strong365.org) features stories of people living with different psychological disorders. Patients Like Me (http://www.patientslikeme. com) is a social networking site for people with all sorts of illnesses. [Image: The signer Demi Lovato has talked about her struggles with bipolar disorder and substance use.] Celebrities or public figures with psychological disorders can also help reduce stigma. For example, the singer and songwriter Demi Lovato and the actor Chyler Leigh openly discuss their lives with bipolar disorder and have worked with the campaign BeVocal (http://www.bevocalspeakup.com/) to help reduce stigma. In this chapter, we first discuss what we mean by the term psychological disorder. Then we look briefly at how our views of psychological disorders have evolved through history to the more scientific perspectives of today. We conclude with a discussion of the current mental health professions. [Quick Summary This book focuses on the description, causes, and treatments of several different psychological disorders. It is important to note at the outset that the personal impact of our subject matter requires us to make a conscious, determined effort to remain objective. Stigma remains a central problem in the field of psychopathology. Stigma has four components that involve the labels for psychological disorders and their uses. Even the use of everyday terms such as crazy or schizo can contribute to the stigmatization of people with psychological disorders.] Check Your Knowledge 1.1 (Answers are at the end of the chapter.) 1. Characteristics of stigma include all the following except: a. a label reflecting desirable characteristics b. discrimination against those with the label c. focus on differences between those with and without the label d. labeling a group of people who are different 2. True or false? Psychological disorders remain the most stigmatized of conditions in the 21st century. 3. True or false? Close to 20 million people in the United States had some type of psychological disorder in 2017, according to the National Survey on Drug Use and Health conducted by SAMHSA. Defining Psychological Disorder A difficult but fundamental task facing those in the field of psychopathology is to define psychological disorder. The best current definition of psychological disorder is one that contains several characteristics. The definition of mental disorder presented in the fifth edition of the American diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), includes several characteristics essential to the concept of psychological disorder (Stein, Phillips, et al., 2010), as shown in Table 1.1. [Image: Actor Chyler Leigh has played the DC Comics superhero SuperGirl and she has also talked about her life with bipolar disorder] TABLE 1.1 The DSM-5 Definition of Mental Disorder The DSM-5 definition of mental disorder includes the following: - The disorder occurs within the individual. - It involves clinically significant difficulties in thinking, feeling, or behaving. - It usually involves personal distress of some sort, such as in social relationships or occupational functioning. - It involves dysfunction in psychological, developmental, and/or neurobiological processes that support mental functioning. - It is not a culturally specific reaction to an event (e.g., death of a loved one). - It is not primarily a result of social deviance or conflict with society. In the following sections, we consider three key characteristics that should be part of any comprehensive psychological disorder definition: personal distress, disability and dysfunction, and violation of social norms (see Figure 1.2). We will see that no single characteristic can fully define the concept, although each has merit and each captures some part of what might be a full definition. Consequently, psychological disorder is usually determined based on the presence of several characteristics at one time. Personal Distress One characteristic used to define psychological disorder is personal distress—that is, a person’s behavior may be classified as disordered if it causes him or her great distress. Felicia felt distress about her difficulty in paying attention and the social consequences of this difficulty—that is, being called names by other schoolgirls. Personal distress also characterizes many of the forms of psychological disorder considered in this book—people experiencing anxiety disorders and depression suffer greatly. But not all psychological disorders cause distress. For example, an individual with antisocial 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 grief after the loss of a loved one. Disability and Dysfunction Disability—that is, impairment in some important area of life (e.g., work or personal relationships)—can also characterize psychological 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 psychological disorder because some, but not all, disorders involve disability. For example, the disorder bulimia nervosa involves binge eating and compensatory purging (e.g., vomiting) to control weight, but it does not necessarily involve disability. Many people with bulimia lead lives without impairment, while bingeing and purging in private. Other characteristics that might, in some circumstances, be considered disabilities-such as being blind and wanting to become a professional race car driver—do not fall within the domain of psychopathology. We do not have a rule that tells us which disabilities belong in our domain of study and which do not. [FIGURE 1.2 Three characteristics of a comprehensive definition of psychological disorder.] [Image: Personal distress can be part of the definition of psychological disorder.] Jose Jose didn’t know what to think about his nightmares. Ever since he returned from the war, he couldn’t get the bloody images out of his head. He woke up nearly every night with nightmares about the carnage he had witnessed as a soldier stationed in Fallujah. Even during the day, he would have flashbacks to the moment his Hum-vee was nearly sliced in half by a rocket-propelled grenade. Watching his friend die sitting next to him was the worst part; even the occasional pain from shrapnel still embedded in his shoulder was not as bad as the recurring dreams and flashbacks. He seemed to be sweating all the time now, and whenever he heard a loud noise, he jumped out of his chair. Just the other day, his grandmother stepped on a balloon left over from his “welcome home” party. To Jose, it sounded like a gunshot, and he immediately dropped to the ground. His grandmother was worried about him. She thought he must have ataque de nervios, just as her father had back home in Puerto Rico. She said her father had been afraid all the time and felt like he was going crazy. She kept going to Mass and praying for Jose, which he appreciated. The army doctor said he had posttraumatic stress disorder (PTSD). Jose was supposed to go to the Veterans Administration (VA) hospital for an evaluation, but he didn’t really think there was anything wrong with him. Yet his buddy Jorge had been to a group session at the VA, and he said it made him feel better. Maybe he would check it out. He wanted these images to get out of his head.] [Image: To some people, extreme tattoos are a violation of the social norm However, social norm violations are not necessarily signs of a psychological disorder.] Dysfunction refers to something that has gone wrong and is not working as it should. The DSM-5 definition, shown in Table 1.1, provides a broad concept of dysfunction, which is supported by the current body of evidence. Specifically, the DSM definition of dysfunction refers to the fact that developmental, psychological, and biological dysfunctions are all interrelated. That is, the brain impacts behavior, and behavior impacts the brain; thus, dysfunction in these areas is interrelated. Violation of Social Norms In the realm of behavior, social norms are widely held standards (beliefs and attitudes) that people use consciously or intuitively to make judgments about where behaviors are situated on such scales as good-bad, right-wrong, justified- unjustified, and acceptable-unacceptable. Behavior that violates social norms might be classified as disordered. For example, the repetitive rituals performed by people with obsessive-compulsive disorder (see Chapter 7) and the conversations with imaginary voices that some people with schizophrenia engage in (see Chapter 9) are behaviors that violate social norms. Jose’s dropping to the floor at the sound of a popping balloon does not fit within most social norms. Yet this way of defining psychological 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. For example, in some cultures but not in others, it violates a social norm to directly disagree with someone. In Puerto Rico, Jose’s behavior would not likely have been interpreted in the same way as it would be in Iowa. Throughout this book, we will address this important issue of cultural and ethnic diversity as it applies to the descriptions, causes, and treatments of psychological disorders. Defining psychological disorder remains difficult. Several different definitions have been offered, but none can entirely account for the full range of disorders. A behavior causing personal distress can be a characteristic of psychological disorder. But not all behaviors that we consider to be part of psychological disorders cause distress. Behaviors that cause a disability or are unexpected can be considered part of a psychological disorder. But again, some behaviors that are part of a disorder do not cause disability, nor are they unexpected. Behavior that violates social norms can also be considered part of a psychological disorder. However, not all such behavior is considered part of a psychological disorder, and some behaviors that are characteristic of psychological disorders do not necessarily violate social norms. Taken together, each definition of psychological disorder has something helpful to offer in the study of psychopathology. Check Your Knowledge 1.2 1. True or false? Phobias can produce both distress and disability. 2. Which of the following definitions of psychological disorder is currently thought best? a. personal distress b. disability and dysfunction c. norm violation d. none of the above 3. What is an advantage of the DSM-5 definition of psychological disorder? a. It includes information about both violation of social norms and dysfunction. b. It includes many components, none of which alone can account for psychological disorder. c. It is part of the current diagnostic system. d. It recognizes the limits of our current understanding. Early History of Psychopathology Many textbooks begin with a chapter on the history of the field. Why? It is important to consider how concepts and approaches have changed (or not) over time, because we can learn from mistakes made in the past and because we can see that our current concepts and approaches are likely to change in the future. As we consider the history of psychopathology, we will see that many new approaches to the treatment of psychological disorders throughout time have appeared to go well at first and been heralded with much excitement and fanfare, only to eventually fall into disrepute. These are lessons that should not be forgotten as we consider more contemporary approaches to treatment and their attendant excitement and fanfare. Supernatural Explanations Before the age of scientific inquiry, all good and bad manifestations of power beyond human control—eclipses, earthquakes, storms, fire, diseases, the changing seasons— were regarded as supernatural. Behavior seemingly out of individual control was also ascribed to supernatural causes. 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. Examples of supernatural explanations are found in the records of the early Chinese, Egyptians, Babylonians, and Greeks. Among the Hebrews, odd behavior was attributed to possession of the person by bad spirits, after God in his wrath had withdrawn protection. The New Testament includes the story of Christ curing a man with an unclean spirit by casting out the devils from within him and hurling them onto a herd of swine (Mark 5:8-13). 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 BCE, Hippocrates (460?-377? BCE), 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 contributes to psychological disorders. Hippocrates classified psychological disorders into three categories: mania, melancholia, and phrenitis, or brain fever. He believed that healthy 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. For example, if a person had a preponderance of black bile, the explanation was melancholia; too much yellow bile explained irritability and anxiousness; and too much blood, changeable temperament. Through Hippocrates’ teachings, the phenomena associated with psychological disorders became more clearly the province of physicians rather than religious figures. The treatments he suggested were quite different from exorcism. For melancholia, for example, he prescribed tranquility, sobriety, care in choosing food and drink, and abstinence from sexual activity. Hippocrates left behind remarkably detailed records clearly describing many of the symptoms now recognized in seizure disorders, alcohol use disorder, stroke, and paranoia. Hippocrates’ ideas, of course, did not withstand later scientific scrutiny. However, his basic premise—that human behavior is markedly affected by bodily structures or substances and that odd behavior is produced by physical imbalance or even damage—did foreshadow aspects of contemporary thought. In the next seven centuries, Hippocrates’ naturalistic approach to disease and disorder was generally accepted by other Greeks as well as by the Romans, who adopted the medicine of the Greeks after the Roman Empire became the major power in the ancient European world. [Image: The Greek physician Hippocrates held a biological view of psychological disorders, considering psychological disorders to be diseases of the brain.] [Image: Galen was a Greek physician who followed Hippocrates’ ideas and is regarded as the last great physician of the classical era.] The Dark Ages: Back to the Supernatural Historians have often pointed to the death of Galen (ce 130- 200), 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 psychological disorders (see photo). Following several centuries of decay, Greek and Roman civilization ceased to be. The Church now 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 psychological disorder.1 The monks in the monasteries cared for and nursed the sick, and a few of the monasteries were repositories for the classic Greek medical manuscripts, even though the monks may not have made use of the knowledge in these works. Monks cared for people with psychological disorders by praying over them and touching them with relics; they also concocted fantastic potions for them to drink in the waning phase of the moon. Many people with psychological disorders roamed the countryside, destitute and progressively becoming worse. During this period, there was a return to a belief in supernatural causes of psychological disorders. [Footnote: 1The teachings of Galen continued to be influential in the Islamic world. For example, the Persian physician al- Razi (865-925) established a facility for the treatment of people with psychological disorders in Baghdad and was an early practitioner of psychotherapy.] Lunacy Trials From the 13th century on, as the cities of Europe grew larger, hospitals began to come under secular jurisdiction. Municipal authorities, gaining in power, tended to supplement or take over some of the activities of the Church, one of these being the care of people with psychological disorders. The foundation deed for the Holy Trinity Hospital in Salisbury, England, dating from the mid-14th century, specified the purposes of the hospital, one of which was that the “mad are kept safe until they are restored of reason.” English laws during this period allowed people with psychological disorders to be hospitalized. Notably, the people who were hospitalized were not described as being possessed (Allderidge, 1979). Beginning in the 13th century, lunacy trials to determine a person’s mental health were held in England. As explained by Neugebauer (1979), the trials were conducted under the Crown’s right to protect people with psychological disorders, and a judgment of insanity allowed the Crown to become guardian of the person’s estate. The defendant’s orientation, memory, intellect, daily life, and habits were at issue in the trial. Usually, strange behavior was attributed to physical illness or injury or to some emotional shock. 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 (1493-1541), who attributed odd behavior to a misalignment of the moon and stars (the Latin word for “moon” is luna). 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 15th century, there were very few hospitals in Europe for people with psychological disorders. However, there were many hospitals for people with leprosy. As leprosy gradually disappeared from Europe (probably because with the end of wars came a break with the sources of the infection), these buildings were now underused. Attention seems to have turned to people with psychological disorders, and the old leprosy hospitals were converted to asylums, refuges for the housing and care of people with psychological disorders. 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 psychological disorders. In 1547, Henry VIII handed it over to the city of London, thereafter to be a hospital devoted solely to the housing of people with psychological disorders. 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 (Jay, 2016). Bethlehem eventually became one of London’s great tourist attractions, by the 18th century rivaling both Westminster Abbey and the [Image: 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.] [Image: In this 18th-century painting by Hogarth, two upper- class women find amusement in touring St. Mary’s of Bethlehem (Bedlam).] Tower of London. Even as late as the 19th century, viewing the people housed in Bethlehem was considered entertainment, and people bought tickets to see them. Similarly, in the Lunatics Tower, which was constructed in Vienna in 1784, people were confined in the spaces between inner square rooms and the outer walls, where they could be viewed by passersby. Unfortunately, housing people with psychological disorders in hospitals and placing their care in the domain of medicine did not necessarily lead to more humane and effective treatment. In fact, the medical treatments were often crude and painful. Benjamin Rush (1745-1813), for example, began practicing medicine in Philadelphia in 1769 and is considered the father of American psychiatry. Yet he believed that psychological disorder was caused by an excess of blood in the brain, for which his favored treatment was to draw great quantities of blood from people with psychological disorders (Farina, 1976). Rush also believed that many people with psychological disorders 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 (1745-1826) has often been considered a primary figure in the movement for more humane treatment of people with psychological disorders in asylums. In 1793, while the French Revolution raged, he was put in charge of a large asylum in Paris known as La Bicetre. A historian described the conditions at this particular hospital: [The patients were] shackled to the walls of their cells, by iron collars which held them flat against the wall and permitted little movement They could not lie down at night, as a rule. Oftentimes there was a hoop of iron around the waist of the patient and in addition chains on both the hands and the feet. These chains [were] sufficiently long so that the patient could feed himself out of a bowl, the food usually being a mushy gruel—bread soaked in a weak soup. Since little was known about dietetics, [no attention] was paid to the type of diet given the patients. They were presumed to be animals and not to care whether the food was good or bad. (Selling, 1940, p. 54] Many texts assert that Pinel removed the chains of the people imprisoned in La Bicetre. Historical research, however, indicates that it was not Pinel who released the people 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 people were released (Weiner, 1994). Several years later, though, Pinel praised Pussin’s efforts and began to follow the same practices. Pinel came to believe that people in his care were first and foremost human beings, and thus these people should be approached with compassion and understanding and treated with dignity. He surmised that if their reason had left them because of severe personal and social problems, it might be restored to them through comforting counsel and purposeful activity. Thus, light and airy rooms replaced dungeons. People formerly considered dangerous now strolled through the hospital and grounds without creating disturbances or harming

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