Fundamentals of Psychological Disorders PDF

Fundamentals of Psychological Disorders Fundamentals of Psychological Disorders PDF Version of the Textbook – Fundamentals of Psychological Disorders – 3rd edition 5TR – version 3.5 Order a print copy: https://www.lulu.com/shop/lee-w-daffin-jr-and-alexis-bridley/fundamentals-of-psychological-disorders/pa perback/product-y2kqn4.html?q=daffin&page=1&pageSize=4 This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Attribution-NonCommercial-ShareAlike 4.0 International Official translations of this license are available in other languages. Creative Commons Corporation (“Creative Commons”) is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer- client or other relationship. Creative Commons makes its licenses and related information available on an “as-is” basis. 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Contents Licensing Information.............................................................................................................................. II Table of Contents.................................................................................................................................... IX Record of Changes.................................................................................................................................. XI DSM-5-TR Statement............................................................................................................................. XII Tokens of Appreciation......................................................................................................................... XIII Other Books in the Discovering Psychology Series.............................................................................. XIV Part I. Setting the Stage............................................................................................................................. Module 1: What is Abnormal Psychology?....................................................................................... 16 Module 2: Models of Abnormal Psychology..................................................................................... 50 Module 3: Clinical Assessment, Diagnosis, and Treatment............................................................. 85 Part II. Mental Disorders – Block 1............................................................................................................. Module 4: Mood Disorders............................................................................................................ 102 Module 5: Trauma- and Stressor-Related Disorders..................................................................... 125 Module 6: Dissociative Disorders.................................................................................................. 142 Part III. Mental Disorders – Block 2........................................................................................................... Module 7: Anxiety Disorders......................................................................................................... 155 Module 8: Somatic Symptom and Related Disorders.................................................................... 173 Module 9: Obsessive-Compulsive and Related Disorders.............................................................. 188 Part IV. Mental Disorders – Block 3........................................................................................................... Module 10: Feeding and Eating Disorders.................................................................................... 203 Module 11: Substance-Related and Addictive Disorders............................................................... 218 Part V. Mental Disorders – Block 4............................................................................................................. Module 12: Schizophrenia Spectrum and Other Psychotic Disorders........................................... 238 Module 13: Personality Disorders................................................................................................. 254 Part VI. Mental Disorders – Block 5........................................................................................................... Module 14: Neurocognitive Disorders........................................................................................... 275 Module 15: Contemporary Issues in Psychopathology.................................................................. 288 Module 16: Disorders of Childhood Overview............................................................................... 297 Glossary................................................................................................................................................ 327 References............................................................................................................................................ 328 Index..................................................................................................................................................... 329 1 Licensing Information Alexis Bridley and Lee W. Daffin Jr. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Attribution-NonCommercial-ShareAlike 4.0 International Official translations of this license are available in other languages. Creative Commons Corporation (“Creative Commons”) is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer- client or other relationship. Creative Commons makes its licenses and related information available on an “as-is” basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible. 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VIII 2 Table of Contents Preface Record of Changes Part I. Setting the Stage Module 1: What is Abnormal Psychology? 1-1 Module 2: Models of Abnormal Psychology 2-1 Module 3: Clinical Assessment, Diagnosis, and Treatment 3-1 Part II. Mental Disorders – Block 1 Module 4: Mood Disorders 4-1 Module 5: Trauma- and Stressor-Related Disorders 5-1 Module 6: Dissociative Disorders 6-1 Part III. Mental Disorders – Block 2 Module 7: Anxiety Disorders 7-1 Module 8: Somatic Symptom and Related Disorders 8-1 Module 9: Obsessive-Compulsive and Related Disorders 9-1 Part IV. Mental Disorders – Block 3 Module 10: Feeding and Eating Disorders 10-1 Module 11: Substance-Related and Addictive Disorders 11-1 Part V. Mental Disorders – Block 4 Module 12: Schizophrenia Spectrum and Other Psychotic Disorders 12-1 Module 13: Personality Disorders 13-1 IX Part VI. Mental Disorders – Block 5 Module 14: Neurocognitive Disorders 14-1 Module 15: Contemporary Issues in Psychopathology 15-1 Module 16: Disorders of Childhood Overview 16-1 Glossary References Index Instructors – See the Instructor Resources Instructions – Read First page to request access to Instructor Resources. X 3 Record of Changes Edition As of Date Changes Made 1.0 Fall 2017 Initial writing; feedback pending 1.01 Spring 2018 Addition of Modules 2, 3, and 15 Summer 1.02 Addition of Index, Glossary, and Preface; made minor edits based on student feedback. 2018 Summer 1.03 Proofreading edits 2019 Proofreading edits and overall improvements such as end of section summaries and review questions. Added a Tokens of 2.00 August 2020 Appreciation page. Added lecture slides courtesy of Arizona State University. Section 1.1.1. changed the following: “Psychology worked with the disease model for over 60 years, from about the late November 2.05 1800s into the middle part of the 20th century.” It previously indicated 19th century when it should have said 20th which 2021 was the mid-1900s. Thank you to Dr. Irving Herman of Columbia University for pointing this out. NAME CHANGE – The name of the book has changed from Abnormal Behavior to Fundamentals of Psychological Disorders. We have continued with the numerical progression of edition numbers, making this three, despite the shift in 3.00 August 2022 name. We do not want instructors using the book to believe the book is different. Additional round of text revisions but main changes were to update the book to the newly released DSM 5-TR in March 2022. Some references have been updated as well. Addition of Module 16: Disorders of Childhood Overview; updating of the references, index, glossary, and front matter, 3.5 July 2023 accordingly. Creation of new PDF of the entire book. XI 4 DSM-5-TR Statement DSM-5-TR Conversion COMPLETE as of 8-1-2022 We are pleased to announce that the final module was updated to DSM-5-TR. Be advised that the sections in each module on Clinical Presentation, Epidemiology, and Comorbidity were updated for DSM-5-TR and new statistics provided when applicable. The sections on Etiology and Treatment were not updated unless there was an issue identified to us by a user of this book. They did receive another proofread. These sections will be updated in version 3.5 and by summer 2023. Instructor resources will be updated during the fall 2022 as time permits. The priority will be on the lectures and test banks, followed by OpenClass and other resources. Note that with this edition the name of the book changed to Fundamentals of Psychological Disorders and from Abnormal Behavior. We believe this better represents the scope of the textbook. Thank you for your patience and we hope you enjoy the book. A PDF of the book is provided at the top of the title page once you select Read. Lee Daffin for Alexis Bridley XII 5 Tokens of Appreciation August 2022 Alexis and I want to offer a special thank you to Ms. Celeste Ernst, undergraduate within the online Bachelor of Science degree in Psychology program, for her edits of the 1st edition during the spring 2020. Her changes, and our own, were integrated into the 2nd edition of the book and are a dramatic improvement over the 1st edition. Thank you, Celeste. Many of those changes will be present in the 3rd edition and improved upon as we transition to DSM 5-TR. We would also like to extend a special thank you to Madeleine Stewart and Matt Meier, PsyD., of the Department of Psychology at Arizona State University for the development of the lecture slides for this book. They did this work unsolicited and produced top quality presentations which we will include in a password protected page, along with additional ancillaries such as an Instructor’s Manual and test banks, in the very near future (i.e. hopefully by mid fall semester at the latest but the slides in August) and for Instructors (Not students. Sorry). Thank you again for your excellent work, Madeleine and Matt. It is more appreciated than you could ever imagine. And now to our reader. We hope you enjoy the book and please, if you see any issues whether typographical, factual, or just want to suggest some type of addition to the material or another way to describe a concept, general formatting suggestion, etc. please let us know. The beauty of Open Education Resources (OER) is that we can literally make a minor change immediately and without the need for expensive printings of a new edition. And it’s available for everyone right away. If you have suggestions, please email them to either Alexis or myself (Lee Daffin) using the emails on the title page. Enjoy the 3rd edition of Fundamentals of Psychological Disorders (formerly Abnormal Psychology). Lee Daffin On behalf of, Alexis Bridley XIII 6 Other Books in the Discovering Psychology Series Interested in learning more about the field of psychology? Please visit any of the books in the Discovering Psychology Series of texts. The Psychology of Gender, 2nd edition Principles of Social Psychology, 2nd edition Principles of Analysis and Behavior, 4th edition Motivation, 2nd edition Behavioral Disorders of Childhood, 2nd edition Drugs and Behavior, 1st edition Principles of Learning and Behavior, 2nd edition XIV I Part I. Setting the Stage 3rd edition as of July 2023 Part I. Setting the Stage Topics Covered: 1. What is Abnormal Psychology? 2. Models of Abnormal Psychology 3. Clinical Assessment, Diagnosis, and Treatment Module 1: What is Abnormal Psychology? 3rd edition as of July 2023 Module Overview Cassie is an 18-year-old female from suburban Seattle, WA. She was a successful student in high school, graduating valedictorian and obtaining a National Merit Scholarship for her performance on the PSAT during her junior year. She was accepted to a university on the opposite side of the state, where she received additional scholarships giving her a free ride for her entire undergraduate education. Excited to start this new chapter in her life, Cassie’s parents begin the 5-hour commute to Pullman, where they will leave their only daughter for the first time in her life. The semester begins as it always does in mid to late August. Cassie meets the challenge with enthusiasm and does well in her classes for the first few weeks of the semester, as expected. Sometime around Week 6, her friends notice she is despondent, detached, and falling behind in her work. After being asked about her condition, she replies that she is “just a bit homesick,” and her friends accept this answer as it is a typical response to leaving home and starting college for many students. A month later, her condition has not improved but worsened. She now regularly shirks her responsibilities around her apartment, in her classes, and on her job. Cassie does not hang out with friends like she did when she first arrived for college and stays in bed most of the day. Concerned, Cassie’s friends contact Health and Wellness for help. Cassie’s story, though hypothetical, is true of many Freshmen leaving home for the first time to earn a higher education, whether in rural Washington state or urban areas such as Chicago and Dallas. Most students recover from this depression and go on to be functional members of their collegiate environment and accomplished scholars. Some students learn to cope on their own while others seek assistance from their university’s health and wellness center or from friends who have already been through the same ordeal. These are normal reactions. However, in cases like Cassie’s, the path to recovery is not as clear. Instead of learning how to cope, their depression increases until it reaches clinical levels and becomes an impediment to success in multiple domains of life such as home, work, school, and social circles. In Module 1, we will explore what it means to display abnormal behavior, what mental disorders are, and the way society views mental illness today and how it has been regarded throughout history. Then we will review research methods used by psychologists in general and how they are adapted to study abnormal behavior/mental disorders. We will conclude with an overview of what mental health professionals do. Module Outline 1.1. Understanding Abnormal Behavior 1.2. Classifying Mental Disorders 1.3. The Stigma of Mental Illness 16 Fundamentals of Psychological Disorders 1.4. The History of Mental Illness 1.5. Research Methods in Psychopathology 1.6. Mental Health Professionals, Societies, and Journals Module Learning Outcomes Explain what it means to display abnormal behavior. Clarify how mental health professionals classify mental disorders. Describe the effect of stigma on those who have a mental illness. Outline the history of mental illness. Describe the research methods used to study abnormal behavior and mental illness. Identify types of mental health professionals, societies they may join, and journals they can publish their work in. 1.1. Understanding Abnormal Behavior Section Learning Objectives Describe the disease model and its impact on the field of psychology throughout history. Describe positive psychology. Define abnormal behavior. Explain the concept of dysfunction as it relates to mental illness. Explain the concept of distress as it relates to mental illness. Explain the concept of deviance as it relates to mental illness. Explain the concept of dangerousness as it relates to mental illness. Define culture and social norms. Clarify the cost of mental illness on society. Define abnormal psychology, psychopathology, and mental disorders. 1.1.1. Understanding Abnormal Behavior To understand what abnormal behavior is, we first have to understand what normal behavior is. Normal really is in the eye of the beholder, and most psychologists have found it easier to explain what is wrong with people then what is right. How so? Psychology worked with the disease model for over 60 years, from about the late 1800s into the middle part of the 20th century. The focus was simple – curing mental disorders – and included such pioneers as Freud, Adler, Klein, Jung, and Erickson. These names are synonymous with the psychoanalytical school of thought. In the 1930s, behaviorism, under B.F. Skinner, presented a new view of human 17 Fundamentals of Psychological Disorders behavior. Simply, human behavior could be modified if the correct combination of reinforcements and punishments were used. This viewpoint espoused the dominant worldview of the time – mechanism – which presented the world as a great machine explained through the principles of physics and chemistry. In it, human beings serve as smaller machines in the larger machine of the universe. Moving into the mid to late 1900s, we developed a more scientific investigation of mental illness, which allowed us to examine the roles of both nature and nurture and to develop drug and psychological treatments to “make miserable people less miserable.” Though this was an improvement, there were three consequences as pointed out by Martin Seligman in his 2008 TED Talk entitled, “The new era of positive psychology.” These are: “The first was moral; that psychologists and psychiatrists became victimologists, pathologizers; that our view of human nature was that if you were in trouble, bricks fell on you. And we forgot that people made choices and decisions. We forgot responsibility. That was the first cost.” “The second cost was that we forgot about you people. We forgot about improving normal lives. We forgot about a mission to make relatively untroubled people happier, more fulfilled, more productive. And “genius,” “high-talent,” became a dirty word. No one works on that.” “And the third problem about the disease model is, in our rush to do something about people in trouble, in our rush to do something about repairing damage, it never occurred to us to develop interventions to make people happier — positive interventions.” Starting in the 1960s, figures such as Abraham Maslow and Carl Rogers sought to overcome the limitations of psychoanalysis and behaviorism by establishing a “third force” psychology, also known as humanistic psychology. As Maslow said, “The science of psychology has been far more successful on the negative than on the positive side; it has revealed to us much about man’s shortcomings, his illnesses, his sins, but little about his potentialities, his virtues, his achievable aspirations, or his full psychological height. It is as if psychology had voluntarily restricted itself to only half its rightful jurisdiction, and that the darker, meaner half.” (Maslow, 1954, p. 354). Humanistic psychology instead addressed the full range of human functioning and focused on personal fulfillment, valuing feelings over intellect, hedonism, a belief in human perfectibility, emphasis on the present, self-disclosure, self-actualization, positive regard, client centered therapy, and the hierarchy of needs. Again, these topics were in stark contrast to much of the work being done in the field of psychology up to and at this time. In 1996, Martin Seligman became the president of the American Psychological Association (APA) and called for a positive psychology or one that had a more positive conception of human potential and nature. Building on Maslow and Roger’s work, he ushered in the scientific study of such topics as happiness, love, hope, optimism, life satisfaction, goal setting, leisure, and subjective well-being. Though positive and humanistic psychology have similarities, their methodology was much different. While humanistic psychology generally relied on qualitative methods, positive psychology utilizes a quantitative approach and aims to help people make the most out of life’s setbacks, relate well to others, find fulfillment in creativity, and find lasting meaning and satisfaction (https://www.positivepsychologyinstitute.com.au/what-is-positive-psychology). So, to understand what normal behavior is, do we look to positive psychology for an indication, or do we first define abnormal behavior and then reverse engineer a definition of what normal is? Our preceding 18 Fundamentals of Psychological Disorders discussion gave suggestions about what normal behavior is, but could the darker elements of our personality also make up what is normal to some extent? Possibly. The one truth is that no matter what behavior we display, if taken to the extreme, it can become disordered – whether trying to control others through social influence or helping people in an altruistic fashion. As such, we can consider abnormal behavior to be a combination of personal distress, psychological dysfunction, deviance from social norms, dangerousness to self and others, and costliness to society. 1.1.2. How Do We Determine What Abnormal Behavior Is? In the previous section we showed that what we might consider normal behavior is difficult to define. Equally challenging is understanding what abnormal behavior is, which may be surprising to you. A publication which you will become intimately familiar with throughout this book, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders 5th edition, Text Revision (DSM-5-TR; 2022), states that, “Although no definition can capture all aspects of the range of disorders contained in DSM-5″ (pg. 13) certain aspects are required. These include: Dysfunction – Includes “clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (pg. 14). Abnormal behavior, therefore, has the capacity to make well-being difficult to obtain and can be assessed by looking at an individual’s current performance and comparing it to what is expected in general or how the person has performed in the past. As such, a good employee who suddenly demonstrates poor performance may be experiencing an environmental demand leading to stress and ineffective coping mechanisms. Once the demand resolves itself, the person’s performance should return to normal according to this principle. Distress – When the person experiences a disabling condition “in social, occupational, or other important activities” (pg. 14). Distress can take the form of psychological or physical pain, or both concurrently. Alone though, distress is not sufficient enough to describe behavior as abnormal. Why is that? The loss of a loved one would cause even the most “normally” functioning individual pain. An athlete who experiences a career-ending injury would display distress as well. Suffering is part of life and cannot be avoided. And some people who exhibit abnormal behavior are generally positive while doing so. Deviance – Closer examination of the word abnormal indicates a move away from what is normal, or the mean (i.e., what would be considered average and in this case in relation to behavior), and so is behavior that infrequently occurs (sort of an outlier in our data). Our culture, or the totality of socially transmitted behaviors, customs, values, technology, attitudes, beliefs, art, and other products that are particular to a group, determines what is normal. Thus, a person is said to be deviant when he or she fails to follow the stated and unstated rules of society, called social norms. Social norms change over time due to shifts in accepted values and expectations. For instance, homosexuality was taboo in the U.S. just a few decades ago, but today, it is generally accepted. Likewise, PDAs, or public displays of affection, do not cause a second look by most people unlike the past when these outward expressions of love were restricted to the privacy of one’s own house or bedroom. In the U.S., crying is generally seen as a weakness for males. However, if the behavior occurs in the context of a tragedy such as the Vegas mass shooting on October 1, 2017, in which 58 people were killed and about 500 were wounded while attending the Route 91 Harvest Festival, then it is appropriate and understandable. Finally, consider that 19 Fundamentals of Psychological Disorders statistically deviant behavior is not necessarily negative. Genius is an example of behavior that is not the norm. Though not part of the DSM conceptualization of what abnormal behavior is, many clinicians add dangerousness to this list when behavior represents a threat to the safety of the person or others. It is important to note that having a mental disorder does not imply a person is automatically dangerous. The depressed or anxious individual is often no more a threat than someone who is not depressed, and as Hiday and Burns (2010) showed, dangerousness is more the exception than the rule. Still, mental health professionals have a duty to report to law enforcement when a mentally disordered individual expresses intent to harm another person or themselves. It is important to point out that people seen as dangerous are also not automatically mentally ill. 1.1.3. The Costs of Mental Illness This leads us to wonder what the cost of mental illness is to society. The National Alliance on Mental Illness (NAMI) states that mental illness affects a person’s life which then ripples out to the family, community, and world. For instance, people with serious mental illness are at increased risk for diabetes, cancer, and cardiometabolic disease while 18% of those with a mental illness also have a substance use disorder. Within the family, an estimated 8.4 million Americans provide care to an adult with an emotional or mental illness with caregivers spending about 32 hours a week providing unpaid care. At the community level 21% of the homeless also have a serious mental illness while 70% of youth in the juvenile justice system have at least one mental health condition. And finally, depression is a leading cause of disability worldwide and depression and anxiety disorders cost the global economy $1 trillion each year in lost productivity (Source: NAMI, The Ripple Effect of Mental Illness infographic; https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers). In terms of worldwide impact, data from 2010 estimates $2.5 trillion in global costs, with $1.7 trillion being indirect costs (i.e., invisible costs “associated with income losses due to mortality, disability, and care seeking, including lost production due to work absence or early retirement”) and the remainder being direct (i.e., visible costs to include “medication, physician visits, psychotherapy sessions, hospitalization,” etc.). It is now projected that mental illness costs will be around $16 trillion by 2030. The authors add, “It should be noted that these calculations did not include costs associated with mental disorders from outside the healthcare system, such as legal costs caused by illicit drug abuse” (Trautmann, Rehm, & Wittchen, 2016). The costs for mental illness have also been found to be greater than the combined costs of somatic diseases such as cancer, diabetes, and respiratory disorders (Whiteford et al., 2013). Christensen et al. (2020) did a review of 143 cost-of-illness studies that covered 48 countries and several types of mental illness. Their results showed that mental disorders are a substantial economic burden for societies and that certain groups of mental disorders are more costly than others. At the higher cost end were developmental disorders to include autism spectrum disorders followed by schizophrenia and intellectual disabilities. They write, “However, it is important to note that while disorders such as mood, neurotic and substance use disorders were less costly according to societal cost per patient, these disorders are much more prevalent and thus would contribute substantially to the total national cost in a country.” And much like Trautmann, Rehm, & Wittchen (2016) other studies show that indirect costs are higher than direct costs (Jin & Mosweu, 2017; Chong et al., 2016). 20 Fundamentals of Psychological Disorders 1.1.4. Defining Key Terms Our discussion so far has concerned what normal and abnormal behavior is. We saw that the study of normal behavior falls under the providence of positive psychology. Similarly, the scientific study of abnormal behavior, with the intent to be able to predict reliably, explain, diagnose, identify the causes of, and treat maladaptive behavior, is what we refer to as abnormal psychology. Abnormal behavior can become pathological and has led to the scientific study of psychological disorders, or psychopathology. From our previous discussion we can fashion the following definition of a psychological or mental disorder: mental disorders are characterized by psychological dysfunction, which causes physical and/or psychological distress or impaired functioning, and is not an expected behavior according to societal or cultural standards. Key Takeaways You should have learned the following in this section: Abnormal behavior is a combination of personal distress, psychological dysfunction, deviance from social norms, dangerousness to self and others, and costliness to society. Abnormal psychology is the scientific study of abnormal behavior, with the intent to be able to predict reliably, explain, diagnose, identify the causes of, and treat maladaptive behavior. The study of psychological disorders is called psychopathology. Mental disorders are characterized by psychological dysfunction, which causes physical and/or psychological distress or impaired functioning, and is not an expected behavior according to societal or cultural standards Section 1.1 Review Questions 1. What is the disease model and what problems existed with it? What was to overcome its limitations? 2. Can we adequately define normal behavior? What about abnormal behavior? 3. What aspects are part of the American Psychiatric Association’s definition of abnormal behavior? 4. How costly is mental illness? 5. What is abnormal psychology? 6. What is psychopathology? 7. How do we define mental disorders? 21 Fundamentals of Psychological Disorders 1.2. Classifying Mental Disorders Section Learning Objectives Define and exemplify classification. Define nomenclature. Define epidemiology. Define the presenting problem and clinical description. Differentiate prevalence, incidence, and any subtypes. Define comorbidity. Define etiology. Define course. Define prognosis. Define treatment. 1.2.1. Classification Classification is not a foreign concept and as a student you have likely taken at least one biology class that discussed the taxonomic classification system of Kingdom, Phylum, Class, Order, Family, Genus, and Species revolutionized by Swedish botanist, Carl Linnaeus. You probably even learned a witty mnemonic such as ‘King Phillip, Come Out For Goodness Sake’ to keep the order straight. The Library of Congress uses classification to organize and arrange their book collections and includes such categories as B – Philosophy, Psychology, and Religion; H – Social Sciences; N – Fine Arts; Q – Science; R – Medicine; and T – Technology. Simply, classification is how we organize or categorize things. The second author’s wife has been known to color-code her Blu Ray collection by genre, movie title, and release date. It is useful for us to do the same with abnormal behavior, and classification provides us with a nomenclature, or naming system, to structure our understanding of mental disorders in a meaningful way. Of course, we want to learn as much as we can about a given disorder so we can understand its cause, predict its future occurrence, and develop ways to treat it. 1.2.2. Determining Occurrence of a Disorder Epidemiology is the scientific study of the frequency and causes of diseases and other health-related states in specific populations such as a school, neighborhood, a city, country, and the world. Psychiatric or mental health epidemiology refers to the occurrence of mental disorders in a population. In mental health facilities, we say that a patient presents with a specific problem, or the presenting problem, and we give a clinical description of it, which includes information about the thoughts, feelings, and behaviors that constitute that mental disorder. We also seek to gain information about the occurrence of the disorder, its cause, course, and treatment possibilities. Occurrence can be investigated in several ways. First, prevalence is the percentage of people in a 22 Fundamentals of Psychological Disorders population that has a mental disorder or can be viewed as the number of cases divided by the total number of people in the sample. For instance, if 20 people out of 100 have bipolar disorder, then the prevalence rate is 20%. Prevalence can be measured in several ways: Point prevalence indicates the proportion of a population that has the characteristic at a specific point in time. In other words, it is the number of active cases. Period prevalence indicates the proportion of a population that has the characteristic at any point during a given period of time, typically the past year. Lifetime prevalence indicates the proportion of a population that has had the characteristic at any time during their lives. According to a 2020 infographic by the National Alliance on Mental Illness (NAMI), for U.S. adults, 1 in 5 experienced a mental illness, 1 in 20 had a serious mental illness, 1 in 15 experienced both a substance use disorder and mental disorder, and over 12 million had serious thoughts of suicide (2020 Mental Health By the Numbers: US Adults infographic). In terms of adolescents aged 12-17, in 2020 1 in 6 experienced a major depressive episode, 3 million had serious thoughts of suicide, and there was a 31% increase in mental health-related emergency department visits. Among U.S. young adults aged 18-25, 1 in 3 experienced a mental illness, 1 in 10 had a serious mental illness, and 3.8 had serious thoughts of suicide (2020 Mental Health By the Numbers: Youth and Young Adults infographic). These numbers would represent period prevalence rates during the pandemic, and for the year 2020. In the, You are Not Alone infographic, NAMI reported the following 12-month prevalence rates for U.S. Adults: 19% having an anxiety disorder, 8% having depression, 4% having PTSD, 3% having bipolar disorder, and 1% having schizophrenia. Source: https://www.nami.org/mhstats Incidence indicates the number of new cases in a population over a specific period. This measure is usually lower since it does not include existing cases as prevalence does. If you wish to know the number of new cases of social phobia during the past year (going from say Aug 21, 2015 to Aug 20, 2016), you would only count cases that began during this time and ignore cases before the start date, even if people are currently afflicted with the mental disorder. Incidence is often studied by medical and public health officials so that causes can be identified, and future cases prevented. Finally, comorbidity describes when two or more mental disorders are occurring at the same time and in the same person. The National Comorbidity Survey Replication (NCS-R) study conducted by the National Institute of Mental Health (NIMH) and published in the June 6, 2005 issue of the Archives of General Psychiatry, sought to discover trends in prevalence, impairment, and service use during the 1990s. The first study, conducted from 1980 to 1985, surveyed 20,000 people from five different geographical regions in the U.S. A second study followed from 1990-1992 and was called the National Comorbidity Survey (NCS). The third study, the NCS-R, used a new nationally representative sample of the U.S. population, and found that 45% of those with one mental disorder met the diagnostic criteria for two or more disorders. The authors also found that the severity of mental illness, in terms of disability, is strongly related to comorbidity, and that substance use disorders often result from disorders such as anxiety and bipolar disorders. The implications of this are significant as services to treat substance abuse and mental disorders are often separate, despite the disorders appearing together. 23 Fundamentals of Psychological Disorders 1.2.3. Other Key Factors Related to Mental Disorders The etiology is the cause of the disorder. There may be social, biological, or psychological explanations for the disorder which need to be understood to identify the appropriate treatment. Likewise, the effectiveness of a treatment may give some hint at the cause of the mental disorder. More on this in Module 2. The course of the disorder is its particular pattern. A disorder may be acute, meaning that it lasts a short time, or chronic, meaning it persists for a long time. It can also be classified as time-limited, meaning that recovery will occur after some time regardless of whether any treatment occurs. Prognosis is the anticipated course the mental disorder will take. A key factor in determining the course is age, with some disorders presenting differently in childhood than adulthood. Finally, we will discuss several treatment strategies in this book in relation to specific disorders, and in a general fashion in Module 3. Treatment is any procedure intended to modify abnormal behavior into normal behavior. The person suffering from the mental disorder seeks the assistance of a trained professional to provide some degree of relief over a series of therapy sessions. The trained mental health professional may prescribe medication or utilize psychotherapy to bring about this change. Treatment may be sought from the primary care provider, in an outpatient facility, or through inpatient care or hospitalization at a mental hospital or psychiatric unit of a general hospital. According to NAMI, the average delay between symptom onset and treatment is 11 years with 45% of adults with mental illness, 66% of adults with serious mental illness, and 51% of youth with a mental health condition seeking treatment in a given year. They also report that 50% of white, 49% of lesbian/gay and bisexual, 43% of mixed/multiracial, 34% of Hispanic or Latinx, 33% of black, and 23% of Asian adults with a mental health diagnosis received treatment or counseling in the past year (Source: Mental Health Care Matters infographic, https://www.nami.org/mhstats). Key Takeaways You should have learned the following in this section: Classification, or how we organize or categorize things, provides us with a nomenclature, or naming system, to structure our understanding of mental disorders in a meaningful way. Epidemiology is the scientific study of the frequency and causes of diseases and other health- related states in specific populations. Prevalence is the percentage of people in a population that has a mental disorder or can be viewed as the number of cases divided by the total number of people in the sample. Incidence indicates the number of new cases in a population over a specific period. Comorbidity describes when two or more mental disorders are occurring at the same time and in the same person. The etiology is the cause of a disorder while the course is its particular pattern and can be acute, chronic, or time-limited. Prognosis is the anticipated course the mental disorder will take. 24 Fundamentals of Psychological Disorders Section 1.2 Review Questions 1. What is the importance of classification for the study of mental disorders? 2. What information does a clinical description include? 3. In what ways is occurrence investigated? 4. What is the etiology of a mental illness? 5. What is the relationship of course and prognosis to one another? 6. What is treatment and who seeks it? 1.3. The Stigma of Mental Illness Section Learning Objectives Clarify the importance of social cognition theory in understanding why people do not seek care. Define categories and schemas. Define stereotypes and heuristics. Describe social identity theory and its consequences. Differentiate between prejudice and discrimination. Contrast implicit and explicit attitudes. Explain the concept of stigma and its three forms. Define courtesy stigma. Describe what the literature shows about stigma. In the previous section, we discussed the fact that care can be sought out in a variety of ways. The problem is that many people who need care never seek it out. Why is that? We already know that society dictates what is considered abnormal behavior through culture and social norms, and you can likely think of a few implications of that. But to fully understand society’s role in why people do not seek care, we need to determine the psychological processes underlying this phenomenon in the individual. Social cognition is the process through which we collect information from the world around us and then interpret it. The collection process occurs through what we know as sensation – or detecting physical energy emitted or reflected by physical objects. Detection occurs courtesy of our eyes, ears, nose, skin and mouth; or via vision, hearing, smell, touch, and taste, respectfully. Once collected, the information is relayed to the brain through the neural impulse where it is processed and interpreted, or meaning is added to this raw sensory data which we call perception. One way meaning is added is by taking the information we just detected and using it to assign people to categories, or groups. For each category, we have a schema, or a set of beliefs and expectations about 25 Fundamentals of Psychological Disorders a group of people, believed to apply to all members of the group, and based on experience. You might think of them as organized ways of making sense of experience. So, it is during our initial interaction with someone that we collect information about them, assign the person to a category for which we have a schema, and then use that to affect how we interact with them. First impressions, called the primacy effect, are important because even if we obtain new information that should override an incorrect initial assessment, the initial impression is unlikely to change. We call this the perseverance effect, or belief perseverance. Stereotypes are special types of schemas that are very simplistic, very strongly held, and not based on firsthand experience. They are heuristics, or mental shortcuts, that allow us to assess this collected information very quickly. One piece of information, such as skin color, can be used to assign the person to a schema for which we have a stereotype. This can affect how we think or feel about the person and behave toward them. Again, human beings tend to imply things about an individual solely due to a distinguishing feature and disregard anything inconsistent with the stereotype. Social identity theory (Tajfel, 1982; Turner, 1987) states that people categorize their social world into meaningfully simplistic representations of groups of people. These representations are then organized as prototypes, or “fuzzy sets of a relatively limited number of category-defining features that not only define one category but serve to distinguish it from other categories” (Foddy and Hogg, as cited in Foddy et al., 1999). We construct in-groups and out-groups and categorize the self as an in-group member. The self is assimilated into the salient in-group prototype, which indicates what cognitions, affect, and behavior we may exhibit. Stereotyping, out-group homogeneity, in-group/out-group bias, normative behavior, and conformity are all based on self-categorization. How so? Out-group homogeneity occurs when we see all members of an outside group as the same. This leads to a tendency to show favoritism to, and exclude or hold a negative view of, members outside of, one’s immediate group, called the in-group/out-group bias. The negative view or set of beliefs about a group of people is what we call prejudice, and this can result in acting in a way that is negative against a group of people, called discrimination. It should be noted that a person can be prejudicial without being discriminatory since most people do not act on their attitudes toward others due to social norms against such behavior. Likewise, a person or institution can be discriminatory without being prejudicial. For example, when a company requires that an applicant have a certain education level or be able to lift 80 pounds as part of typical job responsibilities. Individuals without a degree or ability to lift will be removed from consideration for the job, but this discriminatory act does not mean that the company has negative views of people without degrees or the inability to lift heavy weight. You might even hold a negative view of a specific group of people and not be aware of it. An attitude we are unaware of is called an implicit attitude, which stands in contrast to explicit attitudes, which are the views within our conscious awareness. We have spent quite a lot of space and time understanding how people gather information about the world and people around them, process this information, use it to make snap judgements about others, form groups for which stereotypes may exist, and then potentially hold negative views of this group and behave negatively toward them as a result. Just one piece of information can be used to set this series of mental events into motion. Outside of skin color, the label associated with having a mental disorder can be used. Stereotypes about people with a mental disorder can quickly and easily transform into prejudice when people in a society determine the schema to be correct and form negative emotions and evaluations of this group (Eagly & Chaiken, 1993). This, in turn, can lead to discriminatory practices such as an employer refusing to hire, a landlord refusing to rent an apartment, or avoiding a romantic 26 Fundamentals of Psychological Disorders relationship, all due to the person having a mental illness. Overlapping with prejudice and discrimination in terms of how people with mental disorders are treated is stigma, or when negative stereotyping, labeling, rejection, and loss of status occur. Stigma takes on three forms as described below: Public stigma – When members of a society endorse negative stereotypes of people with a mental disorder and discriminate against them. They might avoid them altogether, resulting in social isolation. An example is when an employer intentionally does not hire a person because their mental illness is discovered. Label avoidance –To avoid being labeled as “crazy” or “nuts” people needing care may avoid seeking it altogether or stop care once started. Due to these labels, funding for mental health services could be restricted and instead, physical health services funded. Self-stigma – When people with mental illnesses internalize the negative stereotypes and prejudice, and in turn, discriminate against themselves. They may experience shame, reduced self-esteem, hopelessness, low self-efficacy, and a reduction in coping mechanisms. An obvious consequence of these potential outcomes is the why try effect, or the person saying ‘Why should I try and get that job? I am not worthy of it’ (Corrigan, Larson, & Rusch, 2009; Corrigan, et al., 2016). Another form of stigma that is worth noting is that of courtesy stigma or when stigma affects people associated with a person who has a mental disorder. Karnieli-Miller et al. (2013) found that families of the afflicted were often blamed, rejected, or devalued when others learned that a family member had a serious mental illness (SMI). Due to this, they felt hurt and betrayed, and an important source of social support during a difficult time had disappeared, resulting in greater levels of stress. To cope, some families concealed their relative’s illness, and some parents struggled to decide whether it was their place to disclose their child’s condition. Others fought with the issue of confronting the stigma through attempts at education versus just ignoring it due to not having enough energy or desiring to maintain personal boundaries. There was also a need to understand the responses of others and to attribute it to a lack of knowledge, experience, and/or media coverage. In some cases, the reappraisal allowed family members to feel compassion for others rather than feeling put down or blamed. The authors concluded that each family “develops its own coping strategies which vary according to its personal experiences, values, and extent of other commitments” and that “coping strategies families employ change over- time.” Other effects of stigma include experiencing work-related discrimination resulting in higher levels of self-stigma and stress (Rusch et al., 2014), higher rates of suicide especially when treatment is not available (Rusch, Zlati, Black, and Thornicroft, 2014; Rihmer & Kiss, 2002), and a decreased likelihood of future help-seeking intention (Lally et al., 2013). The results of the latter study also showed that personal contact with someone with a history of mental illness led to a decreased likelihood of seeking help. This is important because 48% of the university sample stated that they needed help for an emotional or mental health issue during the past year but did not seek help. Similar results have been reported in other studies (Eisenberg, Downs, Golberstein, & Zivin, 2009). It is also important to point out that social distance, a result of stigma, has also been shown to increase throughout the life span, suggesting that anti-stigma campaigns should focus on older people primarily (Schomerus, et al., 2015). One potentially disturbing trend is that mental health professionals have been shown to hold negative attitudes toward the people they serve. Hansson et al. (2011) found that staff members at an outpatient 27 Fundamentals of Psychological Disorders clinic in the southern part of Sweden held the most negative attitudes about whether an employer would accept an applicant for work, willingness to date a person who had been hospitalized, and hiring a patient to care for children. Attitudes were stronger when staff treated patients with a psychosis or in inpatient settings. In a similar study, Martensson, Jacobsson, and Engstrom (2014) found that staff had more positive attitudes towards persons with mental illness if their knowledge of such disorders was less stigmatized; their workplaces were in the county council where they were more likely to encounter patients who recover and return to normal life in society, rather than in municipalities where patients have long-term and recurrent mental illness; and they have or had one close friend with mental health issues. To help deal with stigma in the mental health community, Papish et al. (2013) investigated the effect of a one-time contact-based educational intervention compared to a four-week mandatory psychiatry course on the stigma of mental illness among medical students at the University of Calgary. The curriculum included two methods requiring contact with people diagnosed with a mental disorder: patient presentations, or two one-hour oral presentations in which patients shared their story of having a mental illness, and “clinical correlations” in which a psychiatrist mentored students while they interacted with patients in either inpatient or outpatient settings. Results showed that medical students held a stigma towards mental illness and that comprehensive medical education reduced this stigma. As the authors stated, “These results suggest that it is possible to create an environment in which medical student attitudes towards mental illness can be shifted in a positive direction.” That said, the level of stigma was still higher for mental illness than it was for the stigmatized physical illness, type 2 diabetes mellitus. What might happen if mental illness is presented as a treatable condition? McGinty, Goldman, Pescosolido, and Barry (2015) found that portraying schizophrenia, depression, and heroin addiction as untreated and symptomatic increased negative public attitudes towards people with these conditions. Conversely, when the same people were portrayed as successfully treated, the desire for social distance was reduced, there was less willingness to discriminate against them, and belief in treatment effectiveness increased among the public. Self-stigma has also been shown to affect self-esteem, which then affects hope, which then affects the quality of life among people with severe mental illness. As such, hope should play a central role in recovery (Mashiach-Eizenberg et al., 2013). Narrative Enhancement and Cognitive Therapy (NECT) is an intervention designed to reduce internalized stigma and targets both hope and self-esteem (Yanos et al., 2011). The intervention replaces stigmatizing myths with facts about illness and recovery, which leads to hopefulness and higher levels of self-esteem in clients. This may then reduce susceptibility to internalized stigma. Stigma leads to health inequities (Hatzenbuehler, Phelan, & Link, 2013), prompting calls for stigma change. Targeting stigma involves two different agendas: The services agenda attempts to remove stigma so people can seek mental health services, and the rights agenda tries to replace discrimination that “robs people of rightful opportunities with affirming attitudes and behavior” (Corrigan, 2016). The former is successful when there is evidence that people with mental illness are seeking services more or becoming better engaged. The latter is successful when there is an increase in the number of people with mental illnesses in the workforce who are receiving reasonable accommodations. The federal government has tackled this issue with landmark legislation such as the Patient Protection and Affordable Care Act of 2010, Mental Health Parity and Addiction Equity Act of 2008, and the Americans 28 Fundamentals of Psychological Disorders with Disabilities Act of 1990. However, protections are not uniform across all subgroups due to “1) explicit language about inclusion and exclusion criteria in the statute or implementation rule, 2) vague statutory language that yields variation in the interpretation about which groups qualify for protection, and 3) incentives created by the legislation that affect specific groups differently” (Cummings, Lucas, and Druss, 2013). More on this in Module 15. Key Takeaways You should have learned the following in this section: Stigma is when negative stereotyping, labeling, rejection, and loss of status occur and take the form of public or self-stigma, and label avoidance. Section 1.3 Review Questions 1. How does social cognition help us to understand why stigmatization occurs? 2. Define stigma and describe its three forms. What is courtesy stigma? 3. What are the effects of stigma on the afflicted? 4. Is sti

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