Abnormal Behavior PDF - Unit XII

Unit XII Abnormal Behavior Modules 65 Introduction to Psychological Disorders 66 Anxiety Disorders, Obsessive-Compulsive Disorder, and Posttraumatic Stress Disorder 67 Mood Disorders 68 Schizophrenia 69 Other Disorders I felt the need to clean my room at home in Indian...

Unit XII Abnormal Behavior Modules 65 Introduction to Psychological Disorders 66 Anxiety Disorders, Obsessive-Compulsive Disorder, and Posttraumatic Stress Disorder 67 Mood Disorders 68 Schizophrenia 69 Other Disorders I felt the need to clean my room at home in Indianapolis every Sunday and would spend four to five hours at it. I would take every book out of the bookcase, dust and put it back.... I couldn’t stop. Marc, diagnosed with obsessive­-­compulsive disorder (from Summers, 1996) Whenever I get depressed it’s because I’ve lost a sense of self. I can’t find reasons to like myself. I think I’m ugly. I think no one likes me. Greta, diagnosed with depression (from Thorne, 1993, p. 21) Voices, like the roar of a crowd, came. I felt like Jesus; I was being crucified. Stuart, diagnosed with schizophrenia (from Emmons et al., 1997) People are fascinated by the exceptional, the unusual, the abnormal. “The sun shines and warms and lights us and we have no curiosity to know why this is so,” observed Ralph Waldo Emerson, “but we ask the reason of all evil, of pain, and hunger, and [unusual] people.” Why such fascination with disturbed people? Even when we are well, do we see in them something of ourselves? At various moments, all of us feel, think, or act the way disturbed people do much of the time. We, too, get anxious, depressed, withdrawn, suspicious, or deluded, just less intensely and more briefly. No won- der studying psychological disorders sometimes evokes an eerie sense of self­-­ recognition, one that illuminates our own personality. “To study the abnormal is the best way of understanding the normal,” proposed William James (1842–1910). 649 650   Unit XII Abnormal Behavior Another reason for our curiosity is that so many of us have felt, either personally or through friends or family, the bewilderment and pain of a psychological disorder that may bring unexplained physical symptoms, irrational fears, or a feeling that life is not worth living. Indeed, as members of the human family, most of us will at some point encounter a person with a psychological disorder. The World Health Organization (WHO, 2010) reports that, worldwide, some 450 million people suffer from mental or behavioral disorders. These disorders account for 15.4 percent of the years of life lost due to death or disability—scoring slightly below cardiovascular conditions and slightly above cancer (Murray & Lopez, 1996). Rates and symptoms of psychological disorders vary by culture, but two terrible maladies appear more consistently worldwide: depression and schizophrenia. Module 65 Introduction to Psychological Disorders Module Learning Objectives 65-1 Discuss how we draw the line between normality and disorder. Discuss the controversy over the diagnosis of attention- 65-2 deficit/hyperactivity disorder. china face/G Contrast the medical model with the biopsychosocial approach to etty Im 65-3 ages psychological disorders. 65-4 Describe how and why clinicians classify psychological disorders. 65-5 Explain why some psychologists criticize the use of diagnostic labels. Discuss the prevalence of psychological disorders, and summarize 65-6 the findings on the link between poverty and serious psychological disorders. M ost people would agree that someone who is too depressed to get out of bed for weeks at a time has a psychological disorder. But what about those who, having experienced a loss, are unable to resume their usual social activities? Where should we draw the line between sadness and depression? Between zany creativity and bizarre irrationality? Between normality and abnormality? Let’s start with these questions:  Introduction to Psychological Disorders Module 65    651 How should we define psychological disorders? “Who in the rainbow can draw How should we understand disorders? How do underlying biological factors contribute the line where the violet tint ends to disorder? How do troubling environments influence our well-being? And how do and the orange tint begins? these effects of nature and nurture interact? Distinctly we see the difference of the colors, but where exactly How should we classify psychological disorders? And can we do so in a way that does the one first blendingly enter allows us to help people without stigmatizing them with labels? into the other? So with sanity and insanity.” -Herman Melville, Billy Budd, Sailor, 1924 Defining Psychological Disorders 65-1 How should we draw the line between normality and disorder? A psychological disorder is a syndrome marked by a “clinically significant disturbance psychological disorder in an individual’s cognition, emotion regulation, or behavior” (American Psychiatric As- a syndrome marked by a clinically sociation, 2013). Disturbed, or dysfunctional, behaviors are maladaptive—they interfere with significant disturbance in an normal day-to-day life. An intense fear of spiders may be abnormal, but if it doesn’t interfere individual’s cognition, emotion with your life, it is not a disorder. Marc’s cleaning rituals (from this unit’s opening) did inter- regulation, or behavior. (Adapted fere with his work and leisure. If occasional sad moods persist and become disabling, they from American Psychiatric Association, 2013.) may signal a psychological disorder. Distress often accompanies dysfunctional behaviors. Marc, Greta, and Stuart were all distressed by their behaviors or emotions. Over time, definitions of what makes for a “significant disturbance” have varied. From 1952 through December 9, 1973, homosexuality was classified as a mental illness. By day’s end on December 10, it was not. The American Psychiatric Association had dropped homosexual- ity as a disorder because more and more of its members no longer viewed it as a psychological problem. (Later research revealed that the stigma and stresses that often accompany homo- sexuality, however, increase the risk of mental health problems [Hatzenbuehler et al., 2009; Meyer, 2003].) In this new century, controversy swirls over the frequent diagnosing of children with attention-­­deficit/hyperactivity disorder (see Thinking Critically About: ADHD—Normal High Energy or Disordered Behavior? on the next page). Culture and normality Carol Beckwith iStock/Thinkstock Young men of the West African Wodaabe tribe put on elaborate makeup and costumes to attract women. Young American men may buy flashy cars with loud stereos to do the same. Each culture may view the other’s behavior as abnormal. Yesterday’s “therapy” In other Understanding Psychological Disorders times and places, psychologically disordered people sometimes 65-3 How do the medical model and the received brutal treatments, biopsychosocial approach understand including the trephination evident in this Stone Age skull. psychological disorders? Drilling skull holes like these may have been an attempt to release To explain puzzling behavior, people in earlier times often presumed evil spirits and cure those with the work of strange forces—the movements of the stars, godlike mental disorders. Did this powers, or evil spirits. Had you lived during the Middle Ages, you patient survive the “cure”? might have said, “The devil made him do it,” and you might have John W. Verano 652   Unit XII Abnormal Behavior approved of a cure to rid the evil force by exorcising the demon. Until the last two cen- turies, “mad” people were sometimes caged in zoo-like conditions or given “therapies” appropriate to a demon: beatings, burning, or castration. In other times, therapy included pulling teeth, removing lengths of intestines, cauterizing the clitoris, or giving transfu- sions of animal blood (Farina, 1982). Thinking Critically About ADHD—Normal High Energy or Disordered Behavior? Why is there controversy over that forces children to do what evolution has not prepared them 65-2 attention-deficit/hyperactivity disorder? to do—to sit for long hours in chairs. On the other side of the debate are those who argue that Eight­-­year­-­old Todd has always been energetic. At home, he the more frequent diagnoses of ADHD today reflect increased chatters away and darts from one activity to the next, rarely awareness of the disorder, especially in those areas where rates settling down to read a book or focus on a game. At play, he is are highest. They acknowledge that diagnoses can be subjec- reckless and overreacts when playmates bump into him or take tive and sometimes inconsistent—ADHD is not as objectively one of his toys. At school, his exasperated teacher complains defined as is a broken arm. Nevertheless, declared the World that fidgety Todd doesn’t listen, follow instructions, or stay in his Federation for Mental Health (2005), “there is strong agreement seat and do his ­lessons. As he matures to adulthood, Todd’s among the international scientific community that ADHD is a hyperactivity likely will subside, but his inattentiveness may per- real neurobiological disorder whose existence should no longer sist (Kessler et al., 2010). be debated.” A consensus statement by 75 researchers noted If taken for a psychological evaluation, Todd may be diag- that in neuroimaging studies, ADHD has associations with ab- nosed with attention­-­deficit/hyperactivity disorder (ADHD), normal brain activity patterns (Barkley et al., 2002). as are some 11 percent of American 4- to 17-year-olds who dis- What, then, is known about ADHD’s causes? It is not play its key symptoms (extreme inattention, hyperactivity, and im- caused by too much sugar or poor schools. There is mixed evi- pulsivity) (Schwarz & Cohen, 2013). Studies also find 2.5 percent dence suggesting that extensive TV watching and video gaming of adults­ —though a diminishing number with age—exhibiting are associated with reduced cognitive self-regulation and ADHD ADHD symptoms (Simon et al., 2009). Psychiatry’s new diag- (Bailey et al., 2011; Courage & Setliff, 2010; Ferguson, 2011). nostic manual loosens the criteria for adult ADHD, leading crit- ADHD often coexists with a learning disorder or with defiant ics to fear increased diagnosis and overuse of prescription drugs and temper­-­prone behavior. ADHD is heritable, and research (Frances, 2012). teams are sleuthing the culprit genes and abnormal neural path- To skeptics, being distractible, fidgety, and impulsive ways (Nikolas & Burt, 2010; Poelmans et al., 2011; Volkow et sounds like a “disorder” caused by a single genetic variation: al., 2009; Williams et al., 2010). It is treatable with medications a Y chromosome. And sure enough, ADHD is diagnosed three such as Ritalin and Adderall, which are considered stimulants times more often in boys than in girls. Does energetic child + but help calm hyperactivity and increase the ability to sit and boring school = ADHD overdiagnosis? Is the label being applied focus on a task—and to progress normally in school (Barbaresi to healthy schoolchildren who, in more natural outdoor environ- et al., 2007). Psychological therapies, such as those focused ments, would seem perfectly normal? on shaping behaviors in the classroom and at home, have also Skeptics think so. In the decade after 1987, they note, the helped address the distress of ADHD (Fabiano et al., 2008). proportion of American children being treated for ADHD nearly The bottom line: Extreme inattention, hyperactivity, and im- quadrupled (Olfson et al., 2003). How commonplace the diag- pulsivity can derail social, academic, and vocational achieve- nosis is depends in part on teacher referrals. Some teachers re- ments, and these symptoms can be treated with medication fer lots of kids for ADHD assessment, others none. ADHD rates and other therapies. But the debate continues over whether have varied by a factor of 10 in different counties of New York normal rambunctiousness is too often diagnosed as a psychiat- State (Carlson, 2000). Although African-American youth display ric disorder, and whether there is a cost to the long­-­term use of more ADHD symptoms than do Caucasian youth, they less often stimulant drugs in treating ADHD. receive an ADHD diagnosis (Miller et al., 2009). Depending on where they live, children who are “a persistent pain in the neck in attention­-­deficit/hyperactivity disorder (ADHD) school” are often diagnosed with ADHD and given powerful pre- a psychological disorder marked by the appearance by age 7 scription drugs, notes Peter Gray (2010). But the problem resides of one or more of three key symptoms: extreme inattention, less in the child, he argues, than in today’s abnormal environment hyperactivity, and impulsivity.  Introduction to Psychological Disorders Module 65    653 The Medical Model In opposition to brutal treatments, reformers, including Philippe Pinel (1745–1826) in France, insisted that madness is not demon possession but a sickness of the mind caused by severe stresses and inhumane conditions. For Pinel and others, “moral treatment” included boosting patients’ morale by unchaining them and talking with them, and by replacing bru- tality with gentleness, isolation with activity, and filth with clean air and s­ unshine. While such measures did not often cure patients, they were certainly more humane. By the 1800s, the discovery that syphilis infects the brain and distorts the mind drove further gradual reform. Hospitals replaced asylums, and the medical world began search- ing for physical causes and treatments of mental disorders. Today, this medical model is medical model the concept that recognizable in the terminology of the mental health movement: A mental illness (also called diseases, in this case psychological disorders, have physical causes a psychopathology) needs to be diagnosed on the basis of its symptoms and treated through that can be diagnosed, treated, and, therapy, which may include time in a psychiatric hospital. in most cases, cured, often through The medical perspective has gained credibility from recent discoveries that genetically in- treatment in a ­hospital. fluenced abnormalities in brain structure and biochemistry contribute to many disorders. But as we will see, psychological factors, such as chronic or traumatic stress, also play an important role. “Moral treatment” Under Philippe San Diego Museum of Art, USA/Museum Purchase/The Bridgeman Art Library Dance in a Madhouse, 1917 (litho), Bellows, George Wesley (1882–1925)/ Pinel’s influence, hospitals sometimes sponsored patient dances, often called “lunatic balls,” depicted in this painting by George Bellows (Dance in a Madhouse). The Biopsychosocial Approach Today’s psychologists contend that all behavior, whether called normal or disordered, arises from the interaction of nature (genetic and physiological factors) and nurture (past and present experiences). To presume that a person is “mentally ill,” they say, attributes the condition to a “sickness” that must be identified and cured. But difficulty in the person’s environment, the person’s current interpretations of events, or the person’s bad habits and poor social ­skills may also be factors. Evidence of such effects comes from links between specific disorders and cultures (Beardsley, 1994; Castillo, 1997). Cultures differ in their sources of stress, and they produce different ways of coping. The eating disorders anorexia nervosa and bulimia nervosa, for example, have occurred mostly in Western cultures. In Malaysia, amok describes a sudden outburst of violent behavior (thus the phrase “run amok”). Latin America lays claim to susto, FYI a condition marked by severe anxiety, restlessness, and a fear of black magic. Taijin­-­kyofusho, Increasingly, North American social anxiety about one’s appearance combined with a readiness to blush and a fear of eye disorders, such as eating contact, appears in Japan, as does the extreme withdrawal of hikikomori. Such disorders may disorders, are, along with McDonald’s and MTV, spreading share an underlying dynamic (such as anxiety) while differing in the symptoms (an eating across the globe (Watters, 2010). problem or a type of fear) manifested in a particular ­culture. But not all disorders are culture-bound. Depression and schizophrenia occur world- wide. From Asia to Africa and across the Americas, schizophrenia’s symptoms often include irrationality and incoherent speech. 654   Unit XII Abnormal Behavior To assess the whole set of in- Biological influences: Psychological influences: evolution stress fluences—genetic predispositions individual genes trauma and physiological states, inner brain structure and chemistry learned helplessness psychological dynamics, and so- mood-related perceptions and memories cial and cultural circumstances— the biopsychosocial model helps Psychological (FIGURE 65.1). This approach disorder recognizes that mind and body Figure 65.1 are inseparable. Negative emo- The bio­psycho­­social approach to tions contribute to physical illness, psychological disorders Today’s Social-cultural influences: and physical abnormalities con- psychology studies how biological, roles tribute to negative emotions. We © cultura/Corbis psychological, and social-cultural expectations definitions of normality and are mind ­embodied and socially factors interact to produce specific disorder embedded. psychological disorders. Classifying Psychological Disorders 65-4 How and why do clinicians classify psychological disorders? In biology and the other sciences, classification creates order. To classify an animal as a “mammal” says a great deal—that it is warm­-­blooded, has hair or fur, and nourishes its young with milk. In psychiatry and psychology, too, classification orders and describes symptoms. To classify a person’s disorder as “schizophrenia” suggests that the person talks incoherently; hallucinates or has delusions (bizarre beliefs); shows either little emotion or inappropriate emotion; or is socially withdrawn. “Schizophrenia” provides a handy short- hand for describing a complex ­disorder. In psychiatry and psychology, diagnostic classification aims not only to describe a FYI disorder but also to predict its future course, imply appropriate treatment, and stimulate A book of case illustrations research into its causes. Indeed, to study a disorder we must first name and describe it. accompanying the previous DSM edition provides several examples The most common system for describing disorders and estimating how often they occur for this unit. is the American Psychiatric Association’s 2013 Diagnostic and Statistical Manual of Men- tal Disorders, now in its fifth edition (DSM-5). Physicians and mental health workers use the detailed “diagnostic criteria and codes” in the DSM-5 to guide medical diagnoses and define who is eligible for treatments, including medication. For example, a person may be diagnosed with and treated for “insomnia disorder” if he or she meets all of the DSM-5 the American Psychiatric following criteria: Association’s Diagnostic and Statistical Manual of Mental Is dissatisfied with sleep quantity or quality (difficulty initiating, maintaining, or Disorders, Fifth Edition; a widely returning to sleep). used system for classifying psychological disorders. Sleep disturbance causes distress or impairment in everyday functioning. Occurs at least three nights per week. Present for at least three months. Occurs despite adequate opportunity for sleep. Is not explained by another sleep disorder (such as narcolepsy). Is not caused by substance use or abuse. Is not caused by other mental disorders or medical conditions. In this new DSM edition, some diagnostic labels have changed. For example, “autism” and “Asperger’s syndrome” are no longer included; they have been combined into “autism spectrum disorder.” “Mental retardation” has become “intellectual disability.” New catego- ries include “hoarding disorder” and “binge-eating disorder.”  Introduction to Psychological Disorders Module 65    655 Some new or altered diagnoses are controversial. “Disruptive mood dysregulation dis- order” is a new DSM-5 diagnosis for children “who exhibit persistent irritability and fre- quent episodes of behavior outbursts three or more times a week for more than a year.” Will this diagnosis assist parents who struggle with unstable children, or will it “turn temper tantrums into a mental disorder” and lead to overmedication, as the chair of the previous DSM edition has warned (Frances, 2012)? Critics have long faulted the DSM for casting too wide a net and bringing “al- most any kind of behavior within the compass of psychiatry” (Eysenck et al., 1983). ScienceCartoonsPlus.com They worry that the DSM-5 will extend the pathologizing of everyday life—for example, by turning bereavement grief into depression and boyish rambunctious- ness into ADHD (Frances, 2013). Others respond that depression and hyperactivity, though needing careful definition, are genuine disorders even, for example, those trig- gered by a major life stress such as a death when the grief does not go away (Kendler, “I’m always like this, and my family was wondering if you could prescribe 2011; Kupfer, 2012). a mild depressant.” Labeling Psychological Disorders 65-5 Why do some psychologists criticize the use of diagnostic labels? The DSM has other critics who register a more fundamental complaint—that these labels are at best arbitrary and at worst value judgments masquerading as science. Once we label a person, we view that person differently (Farina, 1982). Labels create preconceptions that guide our perceptions and our interpretations. In a now-classic study of the biasing power of labels, David Rosenhan (1973) and seven “One of the unpardonable sins, in the eyes of most people, is for a others went to hospital admissions offices, complaining of “hearing voices” saying empty, man to go about unlabeled. The hollow, and thud. Apart from this complaint and giving false names and occupations, they world regards such a person as answered questions truthfully. All eight normal people were misdiagnosed with disorders. the police do an unmuzzled dog, not under proper control.” -T. H. Should we be surprised? As one psychiatrist noted, if someone swallows blood, goes Huxley, Evolution and Ethics, 1893 to an emergency room, and spits it up, should we fault the doctor for diagnosing a bleeding ulcer? Surely not. But what followed the diagnosis in the Rosenhan study was startling. Un- til being released an average of 19 days later, the “patients” exhibited no further symptoms such as hearing voices. Yet after analyzing their (quite normal) life histories, clinicians were able to “discover” the causes of their disorders, such as reacting with mixed emotions about a parent. Even the routine behavior of taking notes was misinterpreted as a s­ ymptom. Labels matter. When people in another experiment watched videotaped interviews, those told the interviewees were job applicants perceived them as normal (Langer et al., 1974, 1980). Those who thought they were watching psychiatric or cancer patients perceived them as “different from most people.” Therapists who thought an interviewee was a psy- chiatric patient perceived him as “frightened of his own aggressive impulses,” a “passive, dependent type,” and so forth. A label can, as Rosenhan discovered, have “a life and an influence of its own.” Surveys in Europe and North America have demonstrated the stigmatizing power of labels (Page, 1977). Getting a job or finding a place to rent can be a challenge for those known to be just released from prison—or a mental hospital. But as we are coming to “My sister suffers from a bipolar understand that many psychological disorders are diseases of the brain, not failures of disorder and my nephew from schizoaffective disorder. There has, character, the stigma seems to be lifting (Solomon, 1996). Public figures are feeling freer in fact, been a lot of depression to “come out” and speak with candor about their struggles with disorders such as depres- and alcoholism in my family and, sion. And the more contact people have with individuals with disorders, the more ac- traditionally, no one ever spoke cepting their attitudes are (Kolodziej & Johnson, 1996). People express greatest sympathy about it. It just wasn’t done. The stigma is toxic.” -Actress Glenn for people whose disorders are gender atypical—for men suffering depression (which is Close, “Mental Illness: The Stigma more common among women), or for women plagued by alcohol use disorder (Wirth & of Silence,” 2009 Bodenhausen, 2009). 656   Unit XII Abnormal Behavior Accurate portrayal Nevertheless, stereotypes linger in media Protozoa Pictures/Phoenix Pictures/The Kobal Collection Recent films have offered portrayals of psychological disorders. Some are some realistic depictions of psychological reasonably accurate and sympathetic. But too of- disorders. Black Swan ten people with disorders are portrayed as objects (2010), shown here, of humor or ridicule (As Good as It Gets), as homi- portrayed a main character suffering a cidal maniacs (Hannibal Lecter in Silence of the delusional disorder. Lambs), or as freaks (Nairn, 2007). Apart from the Temple Grandin few who experience threatening delusions and (2010) dramatized a hallucinated voices that command a violent act, lead character who successfully copes with and from those whose dysfunctionality includes autism spectrum disorder. substance abuse, mental disorders seldom lead to A Single Man (2009) violence (Douglas et al., 2009; Elbogen & Johnson, depicted depression. 2009; Fazel et al., 2009, 2010). In real life, people with disorders are more likely to be the victims of violence than the perpetrators (Marley & Bulia, 2001). Indeed, reported the U.S. Surgeon A P ® E x a m Ti p General’s Office (1999, p. 7), “There is very little risk of violence or harm to a stranger from Notice that the term insanity comes casual contact with an individual who has a mental disorder.” (Although most people with out of the legal system. It is not a psychological or medical diagnosis psychological disorders are not violent, those who are create a moral dilemma for society. and does not appear in the DSM-5. For more on this topic, see Thinking Critically About: Insanity and Responsibility.) Thinking Critically About Insanity and Responsibility “My brain... my genes... my bad upbringing made me do it.” Jail or hospital? Jared Lee Loughner HANDOUT/Reuters/Corbis was charged with the 2011 Tucson, Such defenses were anticipated by Shakespeare’s Hamlet. If I Arizona, shooting that killed six people and wrong someone when not myself, he explained, “then Hamlet left over a dozen others injured, including does it not, Hamlet denies it. Who does it then? His madness.” U.S. Representative Gabrielle Giffords. Loughner had a history of mental health Such is the essence of a legal insanity defense. “Insanity” is a issues, including paranoid beliefs, and was legal rather than a psychological concept, and was created in diagnosed with schizophrenia. Usually, 1843 after a deluded Scotsman tried to shoot the prime min- however, schizophrenia is only associated with violence when accompanied by ister (who he thought was persecuting him) but killed an as- substance abuse (Fazel et al., 2009). sistant by mistake. Like U.S. President Ronald Reagan’s near­-­ assassin, John Hinckley, Scotsman Daniel M’Naghten was sent Most people with psychological disorders are not violent. to a mental hospital rather than to ­prison. But what should society do with those who are? What do we In both cases, the public was outraged. “Hinckley Insane, do with disturbed individuals who mow down innocents at Public Mad,” declared one headline. They were mad again when movie theaters and schools? Sometimes there is nothing to a deranged Jeffrey Dahmer in 1991 admitted murdering 15 young be done, as in the case of the 2012 Sandy Hook Elementary men and eating parts of their bodies. They were mad in 1998 when School tragedy in Connecticut, where the shooter’s final fatal 15-year­-­old Kip Kinkel, driven by “those voices in my head,” killed his shot was self-inflicted. Many people who have been executed parents and two fellow Springfield, Oregon, students and wounded or are now on death row have been limited by intellectual dis- 25 others. They were mad in 2002 when Andrea Yates, after be- ability or motivated by delusional voices. The State of Arkansas ing taken off her antipsychotic medication, was tried in Texas for forced one murderer with schizophrenia, Charles Singleton, to drowning her five children. And they were mad in 2011, when an take two anti-psychotic drugs—in order to make him mentally irrational Jared Loughner gunned down a crowd of people, includ- competent, so that he could then be put ­to death. ing survivor Congresswoman Gabrielle Giffords, in an Arizona su- Which of Yates’ two juries made the right decision? The first, permarket parking lot. Following their arrest, most of these people which decided that people who commit such rare but terrible were sent to jails, not hospitals. (Hinckley was sent to a psychiatric crimes should be held responsible? Or the second, which decided hospital and later, after another trial, Yates was instead hospitalized.) to blame the “madness” that clouds their vision? As we come to As Yates’ fate illustrates, 99 percent of those whose insanity de- better understand the biological and environmental basis for all hu- fense is accepted are nonetheless institutionalized, often for as long man behavior, from generosity to vandalism, when should we— as those convicted of crimes (Lilienfeld & Arkowitz, 2011). and should we not—hold people accountable for their actions?  Introduction to Psychological Disorders Module 65    657 Not only can labels bias perceptions, they can also change reality. When teachers are told certain students are “gifted,” when students expect someone to be “hostile,” or when interviewers check to see whether someone is “extraverted,” they may act in ways that elicit the very behavior expected (Snyder, 1984). Someone who was led to think you are nasty may treat you coldly, leading you to respond as a mean­-­spirited person would. Labels can serve as self­-­fulfilling prophecies. But let us remember the benefits of diagnostic labels. Mental health professionals use la- bels to communicate about their cases, to comprehend the underlying causes, and to discern effective treatment programs. Diagnostic definitions also inform patient self-understandings. And they are useful in research that explores the causes and treatments of disordered behavior. Rates of Psychological Disorders 65-6 How many people suffer, or have suffered, from a psychological disorder? Is poverty a risk factor? Who is most vulnerable to psychological disorders? At what times of life? To answer such questions, various countries have conducted lengthy, structured interviews with representative samples of thousands of their citizens. After asking hundreds of ques- tions that probed for symptoms—“Has there ever been a period of two weeks or more when you felt like you wanted to die?”—the researchers have estimated the current, prior-year, and lifetime prevalence of various disorders. United States How many people have, or have had, a psychological disorder? More than most of Ukraine us suppose: Table 65.1 Percentage France The U.S. National Institute of Mental of Americans Reporting Health (2008, based on Kessler et Colombia Selected Psychological al., 2005) estimates that 26 percent Disorders in the Past Year Lebanon of adult Americans “suffer from a diagnosable mental disorder in a Psychological Netherlands given year” (TABLE 65.1). Disorder Percentage Mexico A large-scale World Health Generalized anxiety 3.1 Organization (2004a) study—based Belgium Social anxiety 6.8 on 90-minute interviews of 60,463 disorder Spain people—estimated the number of prior­-­year mental disorders in 20 Phobia of specific 8.7 Germany countries. As FIGURE 65.2 displays, object or situation Beijing the lowest rate of reported mental Mood disorder 9.5 disorders was in Shanghai, the highest Japan Obsessive­-­ 1.0 rate in the United States. Moreover, compulsive disorder Italy immigrants to the United States from (OCD) Mexico, Africa, and Asia average Nigeria better mental health than their native Schizophrenia 1.1 Shanghai U.S. counterparts (Breslau et al., 2007; Posttraumatic stress 3.5 Maldonado-Molina et al., 2011). disorder (PTSD) 0% 10% 20% 30% For example, compared with people Any mental disorder who have recently immigrated from Attention-deficit/ 4.1 Serious mental disorder Mexico, Mexican-Americans born in hyperactivity disorder the United States are at greater risk (ADHD) Figure 65.2 of mental disorder—a phenomenon Prior-year prevalence of disorders Any mental disorder 26.2 in selected areas From World Health known as the immigrant paradox Organization (WHO, 2004a) interviews in (Schwartz et al., 2010). Source: National Institute of Mental Health, 2008. 20 countries. 658   Unit XII Abnormal Behavior Who is most vulnerable to mental disorders? As we have seen, the answer varies with the disorder. One predictor of mental disorder, poverty, crosses ethnic and gender lines. The incidence of serious psychological disorders has been doubly high among those below the poverty line (CDC, 1992). Like so many other correlations, the poverty­-­disorder association raises a chicken­-­and­-­egg question: Does poverty cause disorders? Or do disorders cause poverty? It is both, though the answer varies with the disorder. Schizophrenia understand- ably leads to poverty. Yet the stresses and demoralization of poverty can also precipitate dis- orders, especially depression in women and substance use disorder in men (Dohrenwend et al., 1992). In one natural experiment on the poverty­-­pathology link, researchers tracked rates of behavior problems in North Carolina Native American children as economic devel- opment enabled a dramatic reduction in their community’s poverty rate. As the study be- gan, children of poverty exhibited more deviant and aggressive behaviors. After four years, children whose families had moved above the poverty line exhibited a 40 percent decrease in the behavior problems, while those who continued in their previous positions below or above the poverty line exhibited no change (Costello et al., 2003). As TABLE 65.2 indicates, there is a wide range of risk and protective factors for mental disorders. At what times of life do disorders strike? Usually by early adulthood. “Over 75 percent of our sample with any disorder had experienced its first symptoms by age 24,” reported Lee Robins and Darrel Regier (1991, p. 331). The symptoms of antisocial person- ality disorder and of phobias are among the earliest to appear, at a median age of 8 and 10, respectively. Symptoms of alcohol use disorder, obsessive­-­compulsive disorder, bipolar disorder, and schizophrenia appear at a median age near 20. Major depression often hits somewhat later, at a median age of 25. Such findings make clear the need for research and treatment to help the growing number of people, especially teenagers and young adults, who suffer the bewilderment and pain of a psychological ­disorder. Table 65.2 Risk and Protective Factors for Mental Disorders Risk Factors Protective Factors Academic failure Aerobic exercise Birth complications Community offering empowerment, Caring for chronically ill or patients with    opportunity, and security   neurocognitive disorder Economic independence Child abuse and neglect Effective parenting Chronic insomnia Feelings of mastery and control Chronic pain Feelings of security Family disorganization or conflict Literacy Low birth weight Positive attachment and early bonding Low socioeconomic status Positive parent­-­child relationships Medical illness Problem­-­solving skills Neurochemical imbalance Resilient coping with stress and adversity Parental mental illness Self-esteem Parental substance abuse Social and work skills Personal loss and bereavement Social support from family and friends Poor work skills and habits Reading disabilities Sensory disabilities Social incompetence Stressful life events Substance abuse Trauma experiences Source: World Health Organization (WHO, 2004b,c).  Introduction to Psychological Disorders Module 65    659 Although mindful of the pain, we can also be encouraged by the many successful peo- ple—including Leonardo da Vinci, Isaac Newton, and Leo Tolstoy—who pursued brilliant careers while enduring psychological difficulties. So have 18 U.S. presidents, including the periodically depressed Abraham Lincoln, according to one psychiatric analysis of their biog- raphies (Davidson et al., 2006). The bewilderment, fear, and sorrow caused by psychological disorders are real. But, as Unit XIII shows, hope, too, ­is real. Before You Move On c ASK YOURSELF How would you draw the line between sending disturbed criminals to prisons or to mental hospitals? Would the person’s history (for example, having suffered child abuse) influence your decisions? c TEST YOURSELF What is the biopsychosocial approach, and why is it important in our understanding of psychological disorders? Answers to the Test Yourself questions can be found in Appendix E at the end of the book. Module 65 Review How should we draw the line between 65-1 normality and disorder? According to psychologists and psychiatrists, a psychological The biopsychosocial approach assumes that three sets of disorder is a syndrome marked by a clinically significant influences—biological (evolution, genetics, brain structure disturbance in an individual’s cognition, emotion regula- and chemistry), psychological (stress, trauma, learned tion, or behavior. helplessness, mood-related perceptions and memories), and social-cultural (roles, expectations, definitions of Why is there some controversy over “normality” and “disorder”)—interact to produce specific 65-2 attention-deficit/hyperactivity disorder? psychological disorders. A child who by age 7 displays extreme inattention, 65-4 How and why do clinicians classify hyperactivity, and impulsivity may be diagnosed with psychological disorders? attention-deficit/hyperactivity disorder (ADHD) and treated with medication and other therapy. The American Psychiatric Association’s DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) The controversy centers on whether the growing number contains diagnostic labels and descriptions that of ADHD cases reflects overdiagnosis or increased provide a common language and shared concepts for awareness of the disorder. Long-term effects of stimulant- communication and research. drug treatment for ADHD are not yet known. Some critics believe the DSM editions have become too How do the medical model and the detailed and extensive. 65-3 biopsychosocial approach understand psychological disorders? The medical model assumes that psychological disorders are mental illnesses with physical causes that can be diagnosed, treated, and, in most cases, cured through therapy, sometimes in a hospital. 660   Unit XII Abnormal Behavior Why do some psychologists criticize the How many people suffer, or have suffered, 65-5 65-6 use of diagnostic labels? from a psychological disorder? Is poverty a risk factor? Other critics view DSM diagnoses as arbitrary labels that create preconceptions which bias perceptions of Psychological disorder rates vary, depending on the time the labeled person’s past and present behavior. The and place of the survey. In one multinational survey, legal label, “insanity,” raises moral and ethical questions rates for any disorder ranged from less than 5 percent about whether society should hold people with disorders (Shanghai) to more than 25 percent (the United States). responsible for their violent actions. Poverty is a risk factor: Conditions and experiences Most people with disorders are nonviolent and are more associated with poverty contribute to the development likely to be victims than attackers. of psychological disorders. But some disorders, such as schizophrenia, can drive people into poverty. Multiple-Choice Questions 1. Which of the following describes the idea that 3. Which of the following disorders do Americans report psychological disorders can be diagnosed and treated? most frequently? a. Taijin-kyofusho a. Schizophrenia b. The DSM b. Mood disorders c. The biopsychosocial approach c. Posttraumatic stress disorder (PTSD) d. Amok d. Obsessive-compulsive disorder (OCD) e. The medical model e. Attention-deficit/hyperactivity disorder (ADHD) 2. Which of the following is the primary purpose of the DSM? a. Diagnosis of mental disorders b. Selection of appropriate psychological therapies for mental disorders c. Placement of mental disorders in appropriate cultural context d. Selection of appropriate medicines to treat mental disorders e. Understanding the causes of mental disorders Practice FRQs 1. Name and describe the two major approaches to 2. Explain two criticisms of the DSM. understanding psychological disorders. (2 points) Answer 2 points: The medical model, which is an attempt to first diagnose and then treat psychological disorders. 2 points: The biopsychosocial approach, which is an attempt to understand psychological disorders as an interaction of biological, psychological, and social-cultural factors.  Anxiety Disorders, Obsessive-Compulsive Disorder, and Posttraumatic Stress Disorder Module 66    661 Module 66 Anxiety Disorders, Obsessive-Compulsive s Image Getty Disorder, and Posttraumatic Stress rns via Redfe Disorder enge/ rew B And Module Learning Objectives 66-1 Identify the different anxiety disorders. 66-2 Describe obsessive-compulsive disorder. 66-3 Describe posttraumatic stress disorder. Describe how the learning and biological perspectives explain anxiety 66-4 disorders, OCD, and PTSD. 66-1 What are the different anxiety disorders? anxiety disorders psychological disorders characterized by distressing, Anxiety is part of life. Speaking in front of a class, peering down from a ladder, or waiting to persistent anxiety or maladaptive play in a big game, any one of us might feel anxious (even seasoned performers like Green behaviors that reduce anxiety. Day’s Billie Joe Armstrong, whose anxiety and substance abuse resulted in cancelled con- certs in 2012 and 2013). At times we may feel enough anxiety to avoid making eye contact or talking with someone—“shyness,” we call it. Fortunately for most of us, our uneasiness is not intense and persistent. Some of us, however, are more prone to notice and remember threats (Mitte, 2008). This tendency may place us at risk for one of the anxiety disorders, marked by distressing, persistent anxiety or dysfunctional anxiety-reducing behaviors. We will consider these three: Generalized anxiety disorder, in which a person is unexplainably and continually tense and uneasy Panic disorder, in which a person experiences sudden episodes of intense dread Phobias, in which a person is intensely and irrationally afraid of a specific object or situation Two other disorders involve anxiety, though the DSM-5 now classifies them separately: © Jason Love Obsessive­-­compulsive disorder, in which a person is troubled by repetitive thoughts or actions Posttraumatic stress disorder, in which a person has lingering memories, nightmares, Obsessing about obsessive-compulsive and other symptoms for weeks after a severely threatening, uncontrollable event disorder 662   Unit XII Abnormal Behavior A P ® E x a m Ti p Generalized Anxiety Disorder The way disorders are classified For the past two years, Tom, a 27-year­-­old electrician, has been bothered by dizziness, can be confusing, so it’s worth taking some time to keep the sweating palms, heart palpitations, and ringing in his ears. He feels edgy and sometimes organization straight. Sometimes, finds himself shaking. With reasonable success, he hides his symptoms from his family and there is a broad classification co­-­workers. But he allows himself few other social contacts, and occasionally he has to leave that includes more specific work. His family doctor and a neurologist can find no physical ­problem. disorders—the broad category of anxiety disorders, for example, Tom’s unfocused, out­-­of­-­control, agitated feelings suggest a generalized anxiety dis- includes generalized anxiety order, which is marked by pathological worry. The symptoms of this disorder are com- disorder, panic disorder, and monplace; their persistence, for six months or more, is not. People with this condition­— phobia. Other times, there is just one level of classification. two­-­thirds are women (McLean & Anderson, 2009)—worry continually, and they are often Obsessive-compulsive disorder jittery, agitated, and sleep-deprived. Concentration is difficult as attention switches from and posttraumatic stress disorder worry to worry, and their tension and apprehension may leak out through furrowed brows, do not fit into broader categories. twitching eyelids, trembling, perspiration, or fidgeting. One of generalized anxiety disorder’s worst characteristics is that the person may not be able to identify, and therefore deal with or avoid, its cause. To use Sigmund Freud’s term, the anxiety is free­-­floating. Generalized anxiety disorder is often accompanied by depressed mood, but even without depression it tends to be disabling (Hunt et al., 2004; Moffitt et al., 2007b). Moreover, it may lead to physical problems, such as high blood ­pressure. Many people with generalized anxiety disorder were maltreated and inhibited as chil- dren (Moffitt et al., 2007a). As time passes, however, emotions tend to mellow, and by age 50, generalized anxiety disorder becomes fairly rare (Rubio & López-Ibor, 2007). Panic Disorder Panic disorder entails an anxiety tornado. Panic strikes suddenly, wreaks havoc, and dis- appears. For the 1 person in 75 with this disorder, anxiety suddenly escalates into a terrify- ing panic attack—a minutes­-­long episode of intense fear that something horrible is about to happen. Heart palpitations, shortness of breath, choking sensations, trembling, or dizziness typically accompany the panic, which may be misperceived as a heart attack or other seri- ous physical ailment. Smokers have at least a doubled risk of panic disorder (Zvolensky & Bernstein, 2005). Because nicotine is a stimulant, lighting up doesn’t lighten up. One woman recalled suddenly feeling “hot and as though I couldn’t breathe. My heart was racing and I started to sweat and tremble and I was sure I was going to faint. Then my generalized anxiety disorder fingers started to feel numb and tingly and things seemed unreal. It was so bad I wondered an anxiety disorder in which a person is continually tense, if I was dying and asked my husband to take me to the emergency room. By the time we got apprehensive, and in a state of there (about 10 minutes) the worst of the attack was over and I just felt washed out” (Greist autonomic nervous system ­arousal. et al., 1986). panic disorder an anxiety disorder marked by unpredictable, minutes­-­long episodes of intense Phobias dread in which a person experiences Phobias are anxiety disorders in which an irrational fear causes the person to avoid some terror and accompanying chest object, activity, or situation. Many people accept their phobias and live with them, but others pain, choking, or other frightening sensations. Often followed by worry are incapacitated by their efforts to avoid the feared situation. Marilyn, an otherwise healthy over a possible next attack. and happy 28-year­-­old, fears thunderstorms so intensely that she feels anxious as soon as a weather forecaster mentions possible storms later in the week. If her husband is away and a phobia an anxiety disorder marked by a persistent, irrational fear and storm is forecast, she may stay with a close relative. During a storm, she hides from windows avoidance of a specific object, and buries her head to avoid seeing the lightning. activity, or situation. Other specific phobias may focus on animals, insects, heights, blood, or enclosed spaces social anxiety disorder intense (FIGURE 66.1). People avoid the stimulus that arouses the fear, hiding during thunder- fear of social situations, leading to storms or avoiding high places. avoidance of such. (Formerly called Not all phobias have such specific triggers. Social anxiety disorder (formerly social phobia.) called social phobia) is shyness taken to an ­extreme. Those with social anxiety disorder,  Anxiety Disorders, Obsessive-Compulsive Disorder, and Posttraumatic Stress Disorder Module 66    663 25% Figure 66.1 Percentage Some common and uncommon 20 of people specific fears This Dutch national surveyed interview study identified the 15 commonality of various specific fears. A strong fear becomes a phobia if it 10 provokes a compelling but irrational 5 desire to avoid the dreaded object or situation. (From Delpa et al., 2008.) 0 Being Flying Storms Water Blood Enclosed Animals Height alone spaces Fear Phobia an intense fear of being scrutinized by others, avoid poten- tially embarrassing social situations, such as speaking up, eating out, or going to parties—or will sweat or tremble when doing so. Much as fretting over insomnia may, ironically, cause in- Martin Harvey/ somnia, so worries about anxiety—perhaps fearing another Jupiterimages panic attack, or fearing anxiety-caused sweating in public­— agoraphobia fear or avoidance of can amplify anxiety symptoms (Olatunji & Wolitzky-Taylor, 2009). People who have experi- situations, such as crowds or wide enced several panic attacks may come to avoid situations where the panic has struck ­before. open places, where one has felt loss If the fear is intense enough, it may become agoraphobia, fear or avoidance of situations of control and panic. in which escape might be difficult or help unavailable when panic strikes. Given such fear, obsessive­-­compulsive disorder people may avoid being outside the home, in a crowd, on a bus, or on an elevator. (OCD) a disorder characterized After spending five years sailing the world, Charles Darwin began suffering panic dis- by unwanted repetitive thoughts (obsessions) and/or actions order at age 28. Because of the attacks, he moved to the country, avoided social gatherings, (compulsions). and traveled only in his wife’s company. But the relative seclusion did free him to focus on developing his evolutionary theory. “Even ill health,” he reflected, “has saved me from the distraction of society and its amusements” (quoted in Ma, 1997). Obsessive­-­Compulsive Disorder Making everything perfect Soccer star David Beckham has 66-2 What is obsessive-compulsive disorder? openly discussed his obsessive- compulsive tendencies, which have As with generalized anxiety and phobias, we can see aspects of obsessive­-­compulsive driven him to line up objects in pairs or disorder (OCD) in our everyday behavior. We all may at times be obsessed with senseless to spend hours straightening furniture (Adams, 2011). or offensive thoughts that will not go away. Or we may engage in compulsive behaviors, perhaps lining up books and pencils Stephen Dunn/Getty Images “just so” before ­studying. Obsessive thoughts and compulsive behaviors cross the fine line between normality and disorder when they persistently in- terfere with everyday living and cause distress. Checking to see you locked the door is normal; checking 10 times is not. Washing your hands is normal; washing so often that your skin becomes raw is not. (TABLE 66.1 on the next page offers more examples.) At some time during their lives, often during their late teens or twenties, 2 to 3 percent of people cross that line from normal preoccupations and fussiness to debilitating disorder (Karno et al., 1988). Although the person knows them to be irrational, the anxiety-fueled obsessive thoughts become so haunting, the compulsive rituals so senselessly time­-­consuming, that effective functioning becomes impossible.  664   Unit XII Abnormal Behavior Table 66.1 Common Obsessions and Compulsions Among Children and Adolescents With Obsessive-Compulsive Disorder Percentage Thought or Behavior Reporting Symptom Obsessions (repetitive thoughts)    Concern with dirt, germs, or toxins 40    Something terrible happening (fire, death, illness) 24    Symmetry, order, or exactness 17 Compulsions (repetitive behaviors)    Excessive hand washing, bathing, toothbrushing, or grooming 85    Repeating rituals (in/out of a door, up/down from a chair) 51    Checking doors, locks, appliances, car brakes, homework 46 Source: Adapted from Rapoport, 1989. OCD is more common among teens and young adults than among older people (Sam- post­­traumatic stress disorder uels & Nestadt, 1997). A 40-year follow­-­up study of 144 Swedish people diagnosed with (PTSD) a disorder characterized by haunting memories, nightmares, the disorder found that, for most, the obsessions and compulsions had gradually lessened, social withdrawal, jumpy anxiety, though only 1 in 5 had completely recovered (Skoog & Skoog, 1999). numbness of feeling, and/or insomnia that lingers for four weeks or more after a traumatic experience. Post­traumatic Stress Disorder 66-3 What is posttraumatic stress disorder? As an Iraq war soldier, Jesse “saw the murder of children, women. It was just horrible for anyone to experience.” After calling in a helicopter strike on one house where he had seen Bringing the war home Nearly ammunition crates carried in, he heard the screams of children from within. “I didn’t know a quarter of a million Iraq and there were kids there,” he recalls. Back home in Texas, he suffered “real bad flashbacks” Afghanistan war veterans have been (Welch, 2005). diagnosed with PTSD or traumatic brain injury (TBI). Many vets participate Our memories exist in part to protect us in the future. So there is biological wis- in an intensive recovery program using dom in not being able to forget our most emotional or traumatic experiences—our great- deep breathing, massage, and group est embarrassments, our worst accidents, our most horrid experiences. But sometimes, and individual discussion techniques to treat their PTSD or TBI. for some of us, the unforgettable takes over our lives. The complaints of battle-scarred veterans such as Jesse—recurring haunting memories and Lynn Johnson/National Geographic Society/Corbis nightmares, a numbed social withdrawal, jumpy anxiety, in- somnia—are typical of what once was called “shellshock” or “battle fatigue” and now is called post­­traumatic stress disorder (PTSD) (Babson & Feldner, 2010; Yufik & Simms, 2010). What defines and explains PTSD is less the event it- self than the severity and persistence of the trauma memory (Rubin et al., 2008). PTSD symptoms have also been reported by survivors of accidents, disasters, and violent and sexual assaults (includ- ing an estimated two­-­thirds of prostitutes) (Brewin et al., 1999; Farley et al., 1998; Taylor et al., 1998). A month after the 9/11 terrorist attacks, a survey of Manhattan residents indicated that 8.5 percent were suffering PTSD, most as a result of the attack (Galea et al., 2002). Among those living near the World Trade Center, 20 percent reported such telltale signs as nightmares, severe anxiety, and fear of public places (Susser et al., 2002).  Anxiety Disorders, Obsessive-Compulsive Disorder, and Posttraumatic Stress Disorder Module 66    665 To pin down the frequency of this disorder, the U.S. Centers for Disease Control (1988) compared 7000 Vietnam combat veterans with 7000 noncombat veterans who served during the same years. On average, according to a reanalysis, 19 percent of all Vietnam veterans re- ported PTSD symptoms. The rate varied from 10 percent among those who had never seen combat to 32 percent among those who had experienced heavy combat (Dohrenwend et al., 2006). Similar variations in rates have been found among more recent combat veterans and among people who have experienced a natural disaster or have been kidnapped, held captive, tortured, or raped (Brewin et al., 2000; Brody, 2000; Kessler, 2000; Stone, 2005; Yaffe et al., 2010). The toll seems at least as high for veterans of the Iraq war, where 1 in 6 U.S. combat infantry personnel has reported symptoms of PTSD, depression, or severe anxiety in the months after returning home (Hoge et al., 2006, 2007). In one study of 103,788 veterans returning from Iraq and Afghanistan, 1 in 4 was diagnosed with a psychological disorder, most frequently PTSD (Seal et al., 2007). So what determines whether a person suffers PTSD after a traumatic event? Research indicates that the greater one’s emotional distress during a trauma, the higher the risk for post­­traumatic symptoms (Ozer et al., 2003). Among New Yorkers who witnessed the 9/11 attacks, PTSD was doubled for survivors who were inside rather than outside the World Trade Center (Bonanno et al., 2006). And the more frequent an assault experience, the more adverse the long­-­term outcomes tend to be (Golding, 1999). In the 30 years after the Viet- nam war, veterans who came home with a PTSD diagnosis had twice the normal likelihood of dying (Crawford et al., 2009). A sensitive limbic system seems to increase vulnerability, by flooding the body with stress hormones again and again as images of the traumatic experience erupt into conscious- ness (Kosslyn, 2005; Ozer & Weiss, 2004). Brain scans of PTSD patients suffering memory flashbacks reveal an aberrant and persistent right temporal lobe activation (Engdahl et al., 2010). Genes may also play a role. In one study, combat-exposed men had identical twins who did not experience combat. But these nonexposed co-twins still tended to share their brother’s risk for cognitive difficulties, such as unfocused attention. Such findings suggest that some PTSD symptoms may actually be genetically predisposed (Gilbertson et al., 2006). Some psychologists believe that PTSD has been overdiagnosed, due partly to a broaden- ing definition of trauma (Dobbs, 2009; McNally, 2003). PTSD is actually infrequent, say those critics, and well-intentioned attempts to have people relive the trauma may exacerbate their emotions and pathologize normal stress reactions (Wakefield & Spitzer, 2002). “Debriefing” survivors right after a trauma by getting them to revisit the experience and vent emotions has actually proven generally ineffective and sometimes harmful (Bonanno et al., 2010). Researchers have noted the impressive survivor resiliency of those who do not develop PTSD (Bonanno et al., 2010). About half of adults experience at least one traumatic event in their lifetime, but only about 1 in 10 women and 1 in 20 men develop PTSD (Olff et al., 2007; Ozer & Weiss, 2004; Tolin & Foa, 2006). More than 9 in 10 New Yorkers, although stunned and grief­-­stricken by 9/11, did not respond pathologically. By the following January, the stress FYI symptoms of the rest had mostly subsided (Galea et al., 2002). Similarly, most combat-­stressed A $125 million, five-year U.S. Army veterans and most political dissidents who survive dozens of episodes of torture do not lat- program is currently assessing the well-being of 800,000 soldiers er exhibit PTSD (Mineka & Zinbarg, 1996). Likewise, the Holocaust survivors in 71 studies and training them in emotional “showed remarkable resilience.” Despite some lingering stress symptoms, most experienced resilience (Stix, 2011). essentially normal physical health and cognitive functioning (Barel et al., 2010). Psychologist Peter Suedfeld (1998, 2000; Cassel & Suedfeld, 2006), who as a boy sur- vived the Holocaust under deprived conditions while his mother died in Auschwitz, has documented the resilience of Holocaust survivors, most of whom have lived productive lives. “It is not always true that ‘What doesn’t kill you makes you stronger,’ but it is often true,” he reports. And “what doesn’t kill you may reveal to you just how strong you really are.” posttraumatic growth positive psychological changes as a result of Indeed, suffering can lead to “benefit finding” (Aspinwall & Tedeschi, 2010a,b; Helgeson struggling with extremely challenging et al., 2006), and to what Richard Tedeschi and Lawrence Calhoun (2004) call post­traumatic circumstances and life crises. growth. Tedeschi and Calhoun have found that the struggle with challenging crises, such as 666   Unit XII Abnormal Behavior facing cancer, often leads people later to report an increased appreciation for life, more meaning- ful relationships, increased personal strength, changed priorities, and a richer spiritual life. This idea—that suffering has transformative power—is also found in Judaism, Christianity, Hindu- ism, Buddhism, and Islam. The idea is confirmed by research with ordinary people. Compared with those with traumatic life histories and with those unchallenged by any significant adversity, people whose life history includes some adversity tend to enjoy better mental health and well- being (Seery et al., 2010). Out of even our worst experiences some good can come. Like the body, the mind has great recuperative powers and may grow stronger with exertion. Understanding Anxiety Disorders, OCD, and PTSD 66-4 How do the learning and biological perspectives explain anxiety disorders, OCD, and PTSD? Anxiety is both a feeling and a cognition, a doubt­-­laden appraisal of one’s safety or social skill. How do these anxious feelings and cognitions arise? Freud’s psychoanalytic theory pro- posed that, beginning in childhood, people repress intolerable impulses, ideas, and feelings and that this submerged mental energy sometimes produces mystifying symptoms, such as anxiety. Today’s psychologists have instead turned to two contemporary perspectives— learning and biological. The Learning Perspective CLASSICAL AND OPERANT CONDITIONING When bad events happen unpredictably and uncontrollably, anxiety or other disorders often develop (Field, 2006b; Mineka & Oehlberg, 2008). Recall from Unit VI that dogs learn to fear neutral stimuli associated with shock and that infants come to fear furry objects associated with frightening noises. Using classical conditioning, researchers have A P ® E x a m Ti p also created chronically anxious, ulcer­-­prone rats by giving them unpredictable electric This is a good time to return to shocks (Schwartz, 1984). Like assault victims who report feeling anxious when returning Unit VI and review the principles to the scene of the crime, the rats become apprehensive in their lab environment. This of classical and operant link between conditioned fear and general anxiety helps explain why anxious or trauma- conditioning. tized people are hyperattentive to possible threats, and how panic-­prone people come to associate anxiety with certain cues (Bar-Haim et al., 2007; Bouton et al., 2001). In one survey, 58 percent of those with social anxiety disorder experienced their disorder after a traumatic event (Ost & Hugdahl, 1981). Through conditioning, the short list of naturally painful and frightening events can multiply into a long list of human fears. My car was once struck by another whose driver missed a stop sign. For months afterward, I felt a twinge of unease when any car approached from a side street. Marilyn’s phobia of thunderstorms may have been similarly conditioned during a terrifying or painful experience associated with a thunderstorm. Two specific learning processes can contribute to these disorders. The first, stimulus gen- eralization, occurs, for example, when a person attacked by a fierce dog later develops a fear of all dogs. The second learning process, reinforcement, helps maintain our phobias and compulsions after they arise. Avoiding or escaping the feared situation reduces anxiety, thus reinforcing the phobic behavior. Feeling anxious or fearing a panic attack, a person may go inside and be reinforced by feeling calmer (Antony et al., 1992). Compulsive behaviors op- erate similarly. If