Abnormal Psychology 9780133852059, 1292157763, 9781292157764, 0133852059

Table of contents :
Cover......Page 1
Title Page......Page 2
Copyright Page......Page 3
Brief Contents......Page 4
Contents......Page 5
Features......Page 14
What's New in DSM-5? A Quick Guide......Page 16
Preface......Page 18
Acknowledgments......Page 21
About the Authors......Page 24
1 Abnormal Psychology: Overview and Research Approaches......Page 26
Indicators of Abnormality......Page 28
The World Around Us Extreme Generosity or Pathological Behavior?......Page 31
The DSM-5 and the Definition of Mental Disorder......Page 32
What Are the Disadvantages of Classification?......Page 33
How Can We Reduce Prejudicial Attitudes Toward People Who Are Mentally Ill?......Page 34
Culture and Abnormality......Page 35
Prevalence and Incidence......Page 37
Prevalence Estimates for Mental Disorders......Page 38
Treatment......Page 40
Research Approaches in Abnormal Psychology......Page 41
Case Studies......Page 42
Observational Approaches......Page 43
Forming and Testing Hypotheses......Page 44
Sampling and Generalization......Page 45
Criterion and Comparison Groups......Page 46
Measuring Correlation......Page 47
Statistical Significance......Page 48
Retrospective versus Prospective Strategies......Page 49
The Experimental Method in Abnormal Psychology......Page 50
Studying the Efficacy of Therapy......Page 51
Developments in Research Do Magnets Help with Repetitive-Stress Injury?......Page 52
Unresolved Issues Are We All Becoming Mentally Ill? The Expanding Horizons of Mental Disorder......Page 54
Summary......Page 55
Key Terms......Page 56
2 Historical and Contemporary Views of Abnormal Behavior......Page 57
Historical Views of Abnormal Behavior......Page 58
Hippocrates' Early Medical Concepts......Page 59
Developments in Thinking Melancholia Through the Ages......Page 60
Later Greek and Roman Thought......Page 61
Views of Abnormality During the Middle Ages......Page 62
The Resurgence of Scientific Questioning in Europe......Page 64
The Establishment of Early Asylums......Page 65
Humanitarian Reform......Page 66
Changing Attitudes Toward Mental Health in the Early Twentieth Century......Page 70
Mental Hospital Care in the Twentieth Century......Page 71
Biological Discoveries: Establishing the Link Between the Brain and Mental Disorder......Page 73
The Development of a Classification System......Page 74
Developments in Research The Search for Medications to Cure Mental Disorders......Page 75
The Evolution of the Psychological Research Tradition: Experimental Psychology......Page 78
Unresolved Issues Interpreting Historical Events......Page 81
Summary......Page 83
Key Terms......Page 84
3 Causal Factors and Viewpoints......Page 85
Necessary, Sufficient, and Contributory Causes......Page 86
Diathesis-Stress Models......Page 88
The Biological Perspective......Page 91
Genetic Vulnerabilities......Page 92
Developments in Thinking Nature, Nurture, and Psychopathology: A New Look at an Old Topic......Page 96
Brain Dysfunction and Neural Plasticity......Page 97
Imbalances of Neurotransmitters and Hormones......Page 98
Temperament......Page 100
The Psychological Perspective......Page 101
The Psychodynamic Perspective......Page 102
Developments in Thinking The Humanistic and Existential Perspectives......Page 107
The Behavioral Perspective......Page 108
The Cognitive-Behavioral Perspective......Page 111
What the Adoption of a Perspective Does and Does Not Do......Page 114
Early Deprivation or Trauma......Page 115
Problems in Parenting Style......Page 118
Marital Discord and Divorce......Page 120
Low Socioeconomic Status and Unemployment......Page 121
Maladaptive Peer Relationships......Page 122
Prejudice and Discrimination in Race, Gender, and Ethnicity......Page 123
Universal and Culture-Specific Symptoms of Disorders......Page 124
Culture and Over- and Undercontrolled Behavior......Page 125
The World Around Us Culture and Attachment Relationships......Page 126
Unresolved Issues Theoretical Perspectives and the Causes of Abnormal Behavior......Page 127
Summary......Page 128
Key Terms......Page 129
4 Clinical Assessment and Diagnosis......Page 131
The Relationship Between Assessment and Diagnosis......Page 132
Taking a Social or Behavioral History......Page 133
The Influence of Professional Orientation......Page 134
Trust and Rapport Between the Clinician and the Client......Page 135
The Neurological Examination......Page 136
The Neuropsychological Examination......Page 139
Assessment Interviews......Page 140
The Clinical Observation of Behavior......Page 141
Psychological Tests......Page 142
Developments in Practice The Automated Practice: Use of the Computer in Psychological Testing......Page 143
The Case of Andrea C.: Experiencing Violence in the Workplace......Page 150
Developments in Practice Computer-Based MMPI-2 Report for Andrea C.......Page 151
Ethical Issues in Assessment......Page 153
Differing Models of Classification......Page 154
Formal Diagnostic Classification of Mental Disorders......Page 155
Unresolved Issues The DSM-5: Issues in Acceptance of Changed Diagnostic Criteria......Page 158
Summary......Page 159
Key Terms......Page 160
5 Stress and Physical and Mental Health......Page 161
What Is Stress?......Page 162
Factors Predisposing a Person to Stress......Page 163
Characteristics of Stressors......Page 164
Resilience......Page 165
Stress and Physical Health......Page 166
The Stress Response......Page 167
Understanding the Immune System......Page 168
Stress and Cytokines......Page 170
Chronic Stress and Inflammation......Page 171
The World Around Us Racial Discrimination and Cardiovascular Health in African Americans......Page 172
Personality......Page 174
Depression......Page 175
Positive Emotions......Page 176
Psychological Interventions......Page 178
Adjustment Disorder......Page 180
Posttraumatic Stress Disorder......Page 181
Thinking Critically about DSM-5 Changes to the Diagnostic Criteria for PTSD......Page 182
Posttraumatic Stress Disorder: Causes and Risk Factors......Page 183
DSM-5 Criteria for… Posttraumatic Stress Disorder......Page 184
Rates of PTSD after Traumatic Experiences......Page 185
Individual Risk Factors......Page 187
Biological Factors......Page 188
Sociocultural Factors......Page 189
Prevention......Page 190
The World Around Us Does Playing Tetris After a Traumatic Event Reduce Flashbacks?......Page 191
Treatment for Stress Disorders......Page 192
Trauma and Physical Health......Page 193
The World Around Us Virtual Reality Exposure Treatment for PTSD in Military Personnel......Page 194
Summary......Page 195
Key Terms......Page 197
6 Panic, Anxiety, Obsessions, and Their Disorders......Page 198
Fear......Page 199
Anxiety......Page 200
Overview of the Anxiety Disorders and Their Commonalities......Page 201
DSM-5 Criteria for. . . Specific Phobia......Page 202
Psychological Causal Factors......Page 204
Treatments......Page 206
Prevalence, Age of Onset, and Gender Differences......Page 208
DSM-5 Criteria for. . . Social Anxiety Disorder (Social Phobia)......Page 209
Biological Causal Factors......Page 210
Treatments......Page 211
Panic Disorder......Page 212
Agoraphobia......Page 213
DSM-5 Criteria for. . . Agoraphobia......Page 214
The Timing of a First Panic Attack......Page 215
Biological Causal Factors......Page 216
Psychological Causal Factors......Page 217
Developments in Research Nocturnal Panic Attacks......Page 219
Treatments......Page 220
Generalized Anxiety Disorder......Page 222
DSM-5 Criteria for. . . Generalized Anxiety Disorder......Page 223
Psychological Causal Factors......Page 224
Biological Causal Factors......Page 226
Treatments......Page 227
Thinking Critically about DSM-5 Why Is OCD No Longer Considered to Be an Anxiety Disorder?......Page 228
DSM-5 Criteria for. . . Obsessive-Compulsive Disorder......Page 230
Psychological Causal Factors......Page 231
Biological Causal Factors......Page 233
Treatments......Page 235
Body Dysmorphic Disorder......Page 237
DSM-5 Criteria for. . . Body Dysmorphic Disorder......Page 238
Trichotillomania......Page 240
The World Around Us Taijin Kyofusho......Page 241
Unresolved Issues The Choice of Treatments: Medications or Cognitive-Behavior Therapy?......Page 242
Summary......Page 243
Key Terms......Page 244
7 Mood Disorders and Suicide......Page 245
Types of Mood Disorders......Page 246
The Prevalence of Mood Disorders......Page 247
DSM-5 Criteria for. . . Manic Episode......Page 248
Major Depressive Disorder......Page 249
Persistent Depressive Disorder......Page 252
Other Forms of Depression......Page 253
Developments in Thinking A New DSM-5 Diagnosis: Premenstrual Dysphoric Disorder......Page 254
Biological Causal Factors......Page 255
Psychological Causal Factors......Page 260
Developments in Research Why Do Sex Differences in Unipolar Depression Emerge During Adolescence?......Page 268
Bipolar Disorders (I and II)......Page 271
Biological Causal Factors......Page 274
Sociocultural Factors Affecting Unipolar and Bipolar Disorders......Page 276
Treatments and Outcomes......Page 277
Pharmacotherapy......Page 278
Alternative Biological Treatments......Page 280
Psychotherapy......Page 281
Suicide: The Clinical Picture and the Causal Pattern......Page 284
Who Attempts and Dies by Suicide?......Page 285
Psychological Disorders......Page 286
Other Psychosocial Factors Associated with Suicide......Page 287
Theoretical Models of Suicidal Behavior......Page 288
Crisis Intervention......Page 289
Unresolved Issues Is There a Right to Die?......Page 290
Summary......Page 291
Key Terms......Page 293
8 Somatic Symptom and Dissociative Disorders......Page 294
Somatic Symptom and Related Disorders: An Overview......Page 295
DSM-5 Criteria for. . . Somatic Symptom Disorder......Page 296
Causes of Somatic Symptom Disorder......Page 297
Treatment of Somatic Symptom Disorder......Page 300
Conversion Disorder (Functional Neurological Symptom Disorder)......Page 301
Range of Conversion Disorder Symptoms......Page 302
Prevalence and Demographic Characteristics......Page 303
Causes of Conversion Disorders......Page 304
Treatment of Conversion Disorder......Page 305
Factitious Disorder......Page 306
DSM-5 Criteria for. . . Factitious Disorder......Page 307
Dissociative Disorders: An Overview......Page 308
Depersonalization/Derealization Disorder......Page 309
Dissociative Amnesia......Page 311
DSM-5 Criteria for. . . Dissociative Amnesia......Page 313
Thinking Critically about DSM-5 Where Does Conversion Disorder Belong?......Page 314
Dissociative Identity Disorder......Page 315
DSM-5 Criteria for. . . Dissociative Identity Disorder......Page 316
Causal Factors and Controversies about DID......Page 317
Current Perspectives......Page 321
Treatment and Outcomes in Dissociative Disorders......Page 322
Unresolved Issues DID and the Reality of "Recovered Memories"......Page 324
Summary......Page 325
Key Terms......Page 327
9 Eating Disorders and Obesity......Page 328
Anorexia Nervosa......Page 329
DSM-5 Criteria for. . . Anorexia Nervosa......Page 330
DSM-5 Criteria for. . . Bulimia Nervosa......Page 332
Binge-Eating Disorder......Page 333
DSM-5 Criteria for. . . Binge-Eating Disorder......Page 334
Age of Onset and Gender Differences......Page 335
Prevalence of Eating Disorders......Page 336
Medical Complications of Eating Disorders......Page 337
Diagnostic Crossover......Page 338
Association of Eating Disorders with Other Forms of Psychopathology......Page 339
Eating Disorders Across Cultures......Page 340
The World Around Us Ethnic Identity and Disordered Eating......Page 341
Biological Factors......Page 342
Sociocultural Factors......Page 343
Individual Risk Factors......Page 345
Treatment of Anorexia Nervosa......Page 349
Treatment of Bulimia Nervosa......Page 350
Developments in Practice New Options for Adults with Anorexia Nervosa......Page 351
Treatment of Binge-Eating Disorder......Page 352
The Problem of Obesity......Page 353
Weight Stigma......Page 354
The Role of Genes......Page 355
Hormones Involved in Appetite and Weight Regulation......Page 356
Sociocultural Influences......Page 357
Family Influences......Page 358
Pathways to Obesity......Page 359
Lifestyle Modifications......Page 360
Bariatric Surgery......Page 361
The Importance of Prevention......Page 362
Unresolved Issues The Role of Public Policy in the Prevention of Obesity......Page 363
Summary......Page 364
Key Terms......Page 365
10 Personality Disorders......Page 366
Clinical Features of Personality Disorders......Page 367
Challenges in Personality Disorders Research......Page 369
Difficulties in Diagnosing Personality Disorders......Page 370
Difficulties in Studying the Causes of Personality Disorders......Page 371
Thinking Critically about DSM-5 Why Were No Changes Made to the Way Personality Disorders Are Diagnosed?......Page 372
Paranoid Personality Disorder......Page 373
Schizoid Personality Disorder......Page 374
DSM-5 Criteria for. . . Schizoid Personality Disorder......Page 375
Schizotypal Personality Disorder......Page 376
Histrionic Personality Disorder......Page 377
DSM-5 Criteria for. . . Histrionic Personality Disorder......Page 378
DSM-5 Criteria for. . . Narcissistic Personality Disorder......Page 379
Antisocial Personality Disorder......Page 380
DSM-5 Criteria for. . . Antisocial Personality Disorder......Page 381
Borderline Personality Disorder......Page 384
Thinking Critically about DSM-5 Nonsuicidal Self-Injury: Distinct Disorder or Symptom of Borderline Personality Disorder?......Page 385
DSM-5 Criteria for. . . Borderline Personality Disorder......Page 386
Avoidant Personality Disorder......Page 389
Dependent Personality Disorder......Page 390
DSM-5 Criteria for. . . Dependent Personality Disorder......Page 391
Obsessive-Compulsive Personality Disorder......Page 392
General Sociocultural Causal Factors for Personality Disorders......Page 393
Adapting Therapeutic Techniques to Specific Personality Disorders......Page 394
Treating Borderline Personality Disorder......Page 395
Treating Other Personality Disorders......Page 396
Dimensions of Psychopathy......Page 397
Developments in Research Are You Working for a Psychopath?......Page 400
The Clinical Picture in Psychopathy......Page 401
Causal Factors in Psychopathy......Page 402
A Developmental Perspective on Psychopathy......Page 404
Treatments and Outcomes in Psychopathic Personality......Page 405
Summary......Page 406
Key Terms......Page 408
11 Substance-Related Disorders......Page 409
Alcohol-Related Disorders......Page 410
The Prevalence, Comorbidity, and Demographics of Alcohol Abuse and Dependence......Page 411
The Clinical Picture of Alcohol-Related Disorders......Page 413
Developments in Research Fetal Alcohol Syndrome: How Much Drinking Is Too Much?......Page 415
Biological Causal Factors in Alcohol Abuse and Dependence......Page 417
Psychosocial Causal Factors in Alcohol Abuse and Dependence......Page 419
The World Around Us Binge Drinking in College......Page 421
Use of Medications in Treating Alcohol Abuse and Dependency......Page 422
Psychological Treatment Approaches......Page 423
Alcoholics Anonymous......Page 424
Outcome Studies and Issues in Treatment......Page 425
Relapse Prevention......Page 426
Drug Abuse and Dependence......Page 427
Biological Effects of Morphine and Heroin......Page 428
Social Effects of Morphine and Heroin......Page 429
Neural Bases for Physiological Addiction......Page 430
Cocaine......Page 431
Amphetamines......Page 433
Thinking Critically about DSM-5 Can Changes to the Diagnostic Criteria Result in Increased Drug Use?......Page 434
Effects of Barbiturates......Page 436
LSD......Page 437
Ecstasy......Page 438
Marijuana......Page 439
The World Around Us Should Marijuana Be Marketed and Sold Openly as a Medication?......Page 440
Gambling Disorder......Page 441
DSM-5 Criteria for. . . Gambling Disorder......Page 442
Summary......Page 443
Key Terms......Page 445
12 Sexual Variants, Abuse, and Dysfunctions......Page 446
Sociocultural Influences on Sexual Practices and Standards......Page 447
Case 1: Degeneracy and Abstinence Theory......Page 448
Case 3: Homosexuality and American Psychiatry......Page 449
Fetishistic Disorder......Page 451
DSM-5 Criteria for. . . Several Different Paraphilic Disorders......Page 452
Transvestic Disorder......Page 453
Exhibitionistic Disorder......Page 454
Sexual Sadism Disorder......Page 455
Sexual Masochism Disorder......Page 456
Causal Factors and Treatments for Paraphilias......Page 457
DSM-5 Criteria for. . . Gender Dysphoria in Children......Page 458
DSM-5 Criteria for. . . Gender Dysphoria in Adolescents and Adults......Page 459
Transsexualism......Page 460
Treatment for Transsexualism......Page 461
Childhood Sexual Abuse......Page 462
Pedophilic Disorder......Page 464
Incest......Page 465
Rape......Page 466
The World Around Us Megan's Law......Page 469
Sexual Dysfunctions......Page 471
Sexual Dysfunctions in Men......Page 472
DSM-5 Criteria for. . . Different Sexual Dysfunctions......Page 473
Sexual Dysfunctions in Women......Page 477
Unresolved Issues How Harmful Is Childhood Sexual Abuse?......Page 480
Summary......Page 481
Key Terms......Page 483
13 Schizophrenia and Other Psychotic Disorders......Page 484
Origins of the Schizophrenia Construct......Page 485
Epidemiology......Page 486
Delusions......Page 487
DSM-5 Criteria for. . . Schizophrenia......Page 488
Hallucinations......Page 489
Disorganized Speech......Page 490
Negative Symptoms......Page 491
Schizophreniform Disorder......Page 492
DSM-5 Criteria for. . . Delusional Disorder......Page 493
Genetic Factors......Page 494
The World Around Us The Genain Quadruplets......Page 496
Prenatal Exposures......Page 501
Genes and Environment in Schizophrenia: A Synthesis......Page 502
A Neurodevelopmental Perspective......Page 503
Thinking Critically about DSM-5 Attenuated Psychosis Syndrome......Page 505
Neurocognition......Page 506
Social Cognition......Page 507
Affected Brain Areas......Page 508
White Matter Problems......Page 509
Brain Functioning......Page 510
Cytoarchitecture......Page 511
Synthesis......Page 512
Neurochemistry......Page 513
Do Bad Families Cause Schizophrenia?......Page 515
Families and Relapse......Page 516
Immigration......Page 517
Cannabis Use and Abuse......Page 518
A Diathesis-Stress Model of Schizophrenia......Page 519
Clinical Outcome......Page 520
Pharmacological Approaches......Page 521
Psychosocial Approaches......Page 523
Unresolved Issues Why Are Recovery Rates in Schizophrenia Not Improving?......Page 525
Summary......Page 526
Key Terms......Page 527
14 Neurocognitive Disorders......Page 528
Brain Impairment in Adults......Page 529
Clinical Signs of Brain Damage......Page 530
Diffuse Versus Focal Damage......Page 531
The Neurocognitive/Psychopathology Interaction......Page 533
Clinical Picture......Page 534
Major Neurocognitive Disorder......Page 535
DSM-5 Criteria for. . . Major Neurocognitive Disorder......Page 536
Alzheimer's Disease......Page 537
Clinical Picture......Page 538
Prevalence......Page 539
Causal Factors......Page 540
Neuropathology......Page 542
Early Detection......Page 544
Developments in Research New Approaches to the Treatment of Alzheimer's Disease......Page 545
Supporting Caregivers......Page 546
Neurocognitive Disorder Associated with HIV-1 Infection......Page 547
Neurocognitive Disorder Characterized by Profound Memory Impairment (Amnestic Disorder)......Page 548
Disorders Involving Head Injury......Page 549
Clinical Picture......Page 550
Treatments and Outcomes......Page 552
The World Around Us Brain Damage in Professional Athletes......Page 553
Unresolved Issues Should Healthy People Use Cognitive Enhancers?......Page 554
Summary......Page 555
Key Terms......Page 556
15 Disorders of Childhood and Adolescence (Neurodevelopmental Disorders)......Page 557
The Classification of Childhood and Adolescent Disorders......Page 559
Anxiety Disorders of Childhood and Adolescence......Page 560
Childhood Depression and Bipolar Disorder......Page 562
Developments in Research Bipolar Disorder in Children and Adolescents: Is There an Epidemic?......Page 564
Disruptive, Impulse-Control, and Conduct Disorder......Page 565
DSM-5 Criteria for. . . Conduct Disorder......Page 566
Causal Factors in ODD and CD......Page 567
Treatments and Outcomes......Page 568
Enuresis......Page 569
Attention-Deficit/Hyperactivity Disorder......Page 570
DSM-5 Criteria for. . . Attention-Deficit/Hyperactivity Disorder......Page 571
Autism Spectrum Disorder......Page 574
DSM-5 Criteria for. . . Autism Spectrum Disorder......Page 576
Tic Disorders......Page 577
Developments in Practice Can Video Games Help Children with Neurodevelopmental Disorders?......Page 578
Specific Learning Disorders......Page 579
Treatments and Outcomes......Page 580
Intellectual Disability......Page 581
Levels of Intellectual Disability......Page 582
Causal Factors in Intellectual Disability......Page 583
Organic Intellectual Disability Syndromes......Page 584
Treatments, Outcomes, and Prevention......Page 587
Special Factors Associated with Treatment of Children and Adolescents......Page 588
Family Therapy as a Means of Helping Children......Page 590
Unresolved Issues How Should Society Deal with Delinquent Behavior?......Page 591
Summary......Page 592
Key Terms......Page 594
16 Psychological Treatment......Page 595
Why Do People Seek Therapy?......Page 596
The Therapeutic Relationship......Page 598
Objectifying and Quantifying Change......Page 599
The World Around Us When Therapy Harms......Page 601
Evidence-Based Treatment......Page 602
Combined Treatments......Page 603
Behavior Therapy......Page 604
Cognitive and Cognitive-Behavioral Therapy......Page 607
Humanistic-Experiential Therapies......Page 609
Psychodynamic Therapies......Page 612
Couples and Family Therapy......Page 615
Rebooting Psychotherapy......Page 616
Psychotherapy and Cultural Diversity......Page 617
Antipsychotic Drugs......Page 618
Antidepressant Drugs......Page 619
Antianxiety Drugs......Page 622
Lithium and Other Mood-Stabilizing Drugs......Page 623
Thinking Critically about DSM-5 What Are Some of the Clinical Implications of the Recent Changes?......Page 624
Nonmedicinal Biological Treatments......Page 625
The World Around Us Deep Brain Stimulation for Treatment-Resistant Depression......Page 628
Unresolved Issues Do Psychiatric Medications Help or Harm?......Page 629
Summary......Page 630
Key Terms......Page 631
17 Contemporary and Legal Issues in Abnormal Psychology......Page 632
Perspectives on Prevention......Page 633
Universal Interventions......Page 634
Selective Interventions......Page 635
The Mental Hospital as a Therapeutic Community......Page 638
Deinstitutionalization......Page 640
The World Around Us Important Court Decisions for Patient Rights......Page 642
Assessment of "Dangerousness"......Page 643
The World Around Us Controversial Not Guilty Pleas: Can Altered Mind States or Personality Disorder Limit Responsibility for a Criminal Act?......Page 644
The Insanity Defense......Page 647
Competence to Stand Trial......Page 650
Does Having Mental Health Problems Result in Convicted Felons Being Returned to Prison After Being Released?......Page 651
U.S. Efforts for Mental Health......Page 652
Challenges for the Future......Page 654
The Individual's Contribution......Page 655
Unresolved Issues The HMOs and Mental Health Care......Page 656
Summary......Page 658
Key Terms......Page 659
A......Page 660
C......Page 662
D......Page 664
E......Page 666
F......Page 667
G......Page 668
H......Page 669
J......Page 670
M......Page 671
N......Page 672
O......Page 673
P......Page 674
R......Page 676
S......Page 677
T......Page 680
V......Page 681
Z......Page 682
References......Page 683
Credits......Page 755
B......Page 762
C......Page 764
E......Page 765
G......Page 766
H......Page 767
K......Page 768
L......Page 769
M......Page 770
N......Page 771
P......Page 772
S......Page 773
U......Page 775
W......Page 776
Z......Page 777
A......Page 778
B......Page 779
C......Page 780
D......Page 782
E......Page 783
G......Page 784
I......Page 785
M......Page 786
O......Page 787
P......Page 788
Q......Page 789
S......Page 790
U......Page 792
Z......Page 793

Citation preview

Global edition

Abnormal Psychology SEVENTEENTH edition

Jill M. Hooley • James N. Butcher • Matthew K. Nock • Susan Mineka

Abnormal Psychology Seventeenth Edition Global Edition

Jill M. Hooley Harvard University

James N. Butcher University of Minnesota

Matthew K. Nock Harvard University

Susan Mineka Northwestern University

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Acknowledgements of third-party content appear on page 754, which constitutes an extension of this c­ opyright page. Pearson Education Limited Edinburgh Gate Harlow Essex CM20 2JE England and Associated Companies throughout the world Visit us on the World Wide Web at: www.pearsonglobaleditions.com © Pearson Education Limited 2017 The rights of Jill M. Hooley, James N. Butcher, Matthew K. Nock, and Susan Mineka to be identified as the authors of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act 1988. Authorized adaptation from the United States edition, entitled Abnormal Psychology, 17th edition, ISBN 978-0-13385205-9, by Jill M. Hooley, James N. Butcher, Matthew K. Nock, and Susan Mineka, published by Pearson Education © 2016. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior written permission of the publisher or a license permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency Ltd, Saffron House, 6–10 Kirby Street, London EC1N 8TS. All trademarks used herein are the property of their respective owners.The use of any trademark in this text does not vest in the author or publisher any trademark ownership rights in such trademarks, nor does the use of such trademarks imply any affiliation with or endorsement of this book by such owners. ISBN 10: 1-292-15776-3 ISBN 13: 978-1-292-15776-4 British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. 10 9 8 7 6 5 4 3 2 1 14 13 12 11 10 Typeset in Palatino LT Pro Roman by Integra Software Services Pvt. Ltd. Printed and bound by Vivar in Malaysia.

Brief Contents 1 Abnormal Psychology: Overview and Research Approaches 

2 Historical and Contemporary Views of Abnormal Behavior 

3 Causal Factors and Viewpoints  4 Clinical Assessment and Diagnosis  5 Stress and Physical

and Mental Health 

6 Panic, Anxiety, Obsessions, and Their Disorders 

7 Mood Disorders and Suicide  8 Somatic Symptom

and Dissociative Disorders 

9 Eating Disorders and Obesity 

25 56 84 130 160 197 244 293

10 Personality Disorders 

365

11 Substance-Related Disorders 

408

12 Sexual Variants, Abuse, and Dysfunctions 

13 Schizophrenia and Other

445

Psychotic Disorders 

483

14 Neurocognitive Disorders 

527

15 Disorders of Childhood

and Adolescence (Neurodevelopmental Disorders) 

16 Psychological Treatment  17 Contemporary and Legal Issues in Abnormal Psychology 

556 594 631

327

3

Contents Features What’s New in DSM-5? A Quick Guide Preface About the Authors

1 Abnormal Psychology: Overview and Research Approaches

What Do We Mean by Abnormality? Indicators of Abnormality

13 15 17 23

Summary

54

Key Terms

55

2 Historical and Contemporary 25 27 27

Views of Abnormal Behavior

Historical Views of Abnormal Behavior Demonology, Gods, and Magic Hippocrates’ Early Medical Concepts

56 57 58 58

The World Around Us  Extreme Generosity or Pathological Behavior?

30

Thinking Critically about DSM-5  What Is the DSM and Why Was It Revised?

Developments in Thinking  Melancholia Through the Ages

59

31

Early Philosophical Conceptions of Consciousness Later Greek and Roman Thought Early Views of Mental Disorders in China Views of Abnormality During the Middle Ages

60 60 61 61

The DSM-5 and the Definition of Mental Disorder

31

Classification and Diagnosis What Are the Disadvantages of Classification? How Can We Reduce Prejudicial Attitudes Toward People Who Are Mentally Ill?

32 32

Culture and Abnormality

34

How Common Are Mental Disorders? Prevalence and Incidence Prevalence Estimates for Mental Disorders The Global Burden of Disease Treatment Mental Health Professionals

36 36 37 39 39 40

Research Approaches in Abnormal Psychology

40

Sources of Information Case Studies Self-Report Data Observational Approaches

41 41 42 42

Forming and Testing Hypotheses Sampling and Generalization Internal and External Validity Criterion and Comparison Groups

43 44 45 45

Correlational Research Designs Measuring Correlation Statistical Significance Effect Size Meta-Analysis Correlations and Causality Retrospective versus Prospective Strategies

46 46 47 48 48 48 48

The Experimental Method in Abnormal Psychology Studying the Efficacy of Therapy Single-Case Experimental Designs

49 50 51

Developments in Research  Do Magnets Help with Repetitive-Stress Injury?

51

Animal Research

4

Unresolved Issues  Are We All Becoming Mentally Ill? The Expanding Horizons of Mental Disorder 53

33

53

Toward Humanitarian Approaches The Resurgence of Scientific Questioning in Europe The Establishment of Early Asylums Humanitarian Reform Nineteenth-Century Views of the Causes and Treatment of Mental Disorders Changing Attitudes Toward Mental Health in the Early Twentieth Century

63 63 64 65 69 69

The World Around Us  Chaining Mental Health Patients

70

Mental Hospital Care in the Twentieth Century

70

The Emergence of Contemporary Views of Abnormal Behavior Biological Discoveries: Establishing the Link Between the Brain and Mental Disorder The Development of a Classification System Development of the Psychological Basis of Mental Disorder Developments in Research  The Search for Medications to Cure Mental Disorders

72 72 73 74 74

The Evolution of the Psychological Research Tradition: Experimental Psychology 77 Unresolved Issues  Interpreting Historical Events

80

Summary

82

Key Terms

83

3 Causal Factors and Viewpoints Risk Factors and Causes of Abnormal Behavior Necessary, Sufficient, and Contributory Causes Feedback and Bidirectionality in Abnormal Behavior Diathesis–Stress Models

84 85 85 87 87

Contents 5

Perspectives to Understanding the Causes of Abnormal Behavior

90

The Biological Perspective Genetic Vulnerabilities

90 91

Developments in Thinking  Nature, Nurture, and Psychopathology: A New Look at an Old Topic Brain Dysfunction and Neural Plasticity Imbalances of Neurotransmitters and Hormones Temperament The Impact of the Biological Viewpoint The Psychological Perspective The Psychodynamic Perspective Developments in Thinking  The Humanistic and Existential Perspectives The Behavioral Perspective The Cognitive-Behavioral Perspective What the Adoption of a Perspective Does and Does Not Do The Social Perspective Early Deprivation or Trauma Problems in Parenting Style Marital Discord and Divorce Low Socioeconomic Status and Unemployment Maladaptive Peer Relationships Prejudice and Discrimination in Race, Gender, and Ethnicity The Impact of the Social Perspective

95 96 97 99 100 100 101 106 107 110 113 114 114 117 119 120 121 122 123

123 The Cultural Perspective Universal and Culture-Specific Symptoms of Disorders 123 Culture and Over- and Undercontrolled Behavior 124 The World Around Us  Culture and Attachment Relationships

125

Unresolved Issues  Theoretical Perspectives and the Causes of Abnormal Behavior

126

Summary

127

Key Terms

128

4 Clinical Assessment and Diagnosis

130

The Basic Elements in Assessment The Relationship Between Assessment and Diagnosis Taking a Social or Behavioral History Ensuring Culturally Sensitive Assessment Procedures The Influence of Professional Orientation Reliability, Validity, and Standardization Trust and Rapport Between the Clinician and the Client

131

Assessment of the Physical Organism The General Physical Examination The Neurological Examination The Neuropsychological Examination

135 135 135 138

Psychosocial Assessment

139

131 132 133 133 134 134

Assessment Interviews The Clinical Observation of Behavior Psychological Tests

139 140 141

Developments in Practice  The Automated Practice: Use of the Computer in Psychological Testing 142 The Case of Andrea C.: Experiencing Violence in the Workplace Developments in Practice  Computer-Based MMPI-2 Report for Andrea C.

149 150

The Integration of Assessment Data Ethical Issues in Assessment

152 152

Classifying Abnormal Behavior Differing Models of Classification Formal Diagnostic Classification of Mental Disorders

153 153

Unresolved Issues  The DSM-5: Issues in Acceptance of Changed Diagnostic Criteria

154 157

Summary

158

Key Terms

159

5 Stress and Physical

and Mental Health

160

What Is Stress? Stress and the DSM Factors Predisposing a Person to Stress Characteristics of Stressors Measuring Life Stress Resilience

161 162 162 163 164 164

Stress and Physical Health The Stress Response The Mind–Body Connection Understanding the Immune System

165 166 167 167

Stress and Immune System Functioning Stress and Cytokines Chronic Stress and Inflammation Stress and Premature Aging

169 169 170 171

The World Around Us  Racial Discrimination and Cardiovascular Health in African Americans

171

Emotions and Health Personality Depression Anxiety Social Isolation and Lack of Social Support Positive Emotions The Importance of Emotion Regulation

173 173 174 175 175 175 177

Treatment of Stress-Related Physical Disorders Biological Interventions Psychological Interventions

177 177 177

Stress and Mental Health Adjustment Disorder Adjustment Disorder Caused by Unemployment Posttraumatic Stress Disorder

179 179 180 180

6 Contents Thinking Critically about DSM-5  Changes to the Diagnostic Criteria for PTSD Acute Stress Disorder Posttraumatic Stress Disorder: Causes and Risk Factors DSM-5 Criteria for…  Posttraumatic Stress Disorder Prevalence of PTSD in the General Population Rates of PTSD after Traumatic Experiences Causal Factors in Posttraumatic Stress Disorder Individual Risk Factors Biological Factors Sociocultural Factors Long-Term Effects of Posttraumatic Stress Prevention and Treatment of Stress Disorders Prevention The World Around Us  Does Playing Tetris After a Traumatic Event Reduce Flashbacks? Treatment for Stress Disorders Trauma and Physical Health

181 182 182 183

189 189

Obsessive-Compulsive and Related Disorders Obsessive-Compulsive Disorder

194 196

222

Prevalence, Age of Onset, and Gender Differences Comorbidity with Other Disorders Psychological Causal Factors Biological Causal Factors Treatments

223 223 223 225 226 227 227

Prevalence, Age of Onset, and Gender Differences Comorbidity with Other Disorders Psychological Causal Factors Biological Causal Factors Treatments Body Dysmorphic Disorder

227

230 230 230 232 234 236

DSM-5 Criteria for. . .  Body Dysmorphic Disorder 237

and Their Disorders

197

The Fear and Anxiety Response Patterns Fear Anxiety

198 198 199

Overview of the Anxiety Disorders and Their Commonalities

200

Specific Phobias

201 201

Prevalence, Age of Onset, and Gender Differences Psychological Causal Factors Biological Causal Factors Treatments

203 203 205 205

Social Phobia Prevalence, Age of Onset, and Gender Differences Psychological Causal Factors

207 207 208

DSM-5 Criteria for. . .  Social Anxiety Disorder (Social Phobia)

208

Hoarding Disorder Trichotillomania

239 239

Cultural Perspectives

240

The World Around Us  Taijin Kyofusho

240

Unresolved Issues  The Choice of Treatments: Medications or Cognitive-Behavior Therapy?

241

Summary

242

Key Terms

243

7 Mood Disorders and Suicide Mood Disorders: An Overview Types of Mood Disorders DSM-5 Criteria for. . .  Major Depressive Disorder The Prevalence of Mood Disorders DSM-5 Criteria for. . .  Manic Episode

209 210 211 212 212 213

DSM-5 Criteria for. . .  Agoraphobia 213 Comorbidity with Other Disorders The Timing of a First Panic Attack

221

DSM-5 Criteria for. . .  Generalized Anxiety Disorder

DSM-5 Criteria for. . .  Obsessive-Compulsive Disorder 229

Key Terms

Agoraphobia Prevalence, Age of Onset, and Gender Differences

219

191 192

194

DSM-5 Criteria for. . .  Panic Disorder

218

Thinking Critically about DSM-5  Why Is OCD No Longer Considered to Be an Anxiety Disorder?

Summary

Panic Disorder

215 216

190

Unresolved Issues  Why Is the Study of Trauma So Contentious?

Biological Causal Factors Treatments

Treatments Generalized Anxiety Disorder

193

DSM-5 Criteria for. . .  Specific Phobia

Developments in Research  Nocturnal Panic Attacks

184 184 186 186 187 188 189

The World Around Us  Virtual Reality Exposure Treatment for PTSD in Military Personnel

6 Panic, Anxiety, Obsessions,

Biological Causal Factors Psychological Causal Factors

214 214

Unipolar Depressive Disorders Major Depressive Disorder Persistent Depressive Disorder

244 245 245 246 246 247 248 248 251

DSM-5 Criteria for. . .  Persistent Depressive Disorder 252 Other Forms of Depression

252

Thinking Critically about DSM-5  Was It Wise to Drop the Bereavement Exclusion for Major Depression?

253

Developments in Thinking  A New DSM-5 Diagnosis: Premenstrual Dysphoric Disorder

253

Contents 7

Causal Factors in Unipolar Mood Disorders Biological Causal Factors Psychological Causal Factors Developments in Research  Why Do Sex Differences in Unipolar Depression Emerge During Adolescence?

254 254 259

267 270 270 270

Causal Factors in Bipolar Disorders Biological Causal Factors Psychological Causal Factors

273 273 275

Sociocultural Factors Affecting Unipolar and Bipolar Disorders Cross-Cultural Differences in Depressive Symptoms Cross-Cultural Differences in Prevalence

275 276 276

Treatments and Outcomes Pharmacotherapy Alternative Biological Treatments Psychotherapy

276 277 279 280

Suicide: The Clinical Picture and the Causal Pattern Who Attempts and Dies by Suicide? Psychological Disorders

283 284 285

The World Around Us  Warning Signs for Suicide

286

Other Psychosocial Factors Associated with Suicide Biological Factors Theoretical Models of Suicidal Behavior

286 287 287

Unresolved Issues  Is There a Right to Die?

Treatment of Conversion Disorder Developments in Practice  Treatment of a Patient Who Was Mute

Bipolar and Related Disorders Cyclothymic Disorder Bipolar Disorders (I and II)

Suicide Prevention and Intervention Treatment of Mental Disorders Crisis Intervention Focus on High-Risk Groups and Other Measures

Developments in Research  What Can Neuroimaging Tell Us about Conversion Disorder?

288 288 288 289

Factitious Disorder DSM-5 Criteria for. . .  Factitious Disorder Distinguishing Between Different Types of Somatic Symptom and Related Disorders

304 304 305 305 306 307

Dissociative Disorders: An Overview

307

Depersonalization/Derealization Disorder

308

DSM-5 Criteria for. . .  Depersonalization/ Derealization Disorder Dissociative Amnesia

310 310

DSM-5 Criteria for. . .  Dissociative Amnesia

312

Thinking Critically about DSM-5  Where Does Conversion Disorder Belong?

313

Dissociative Identity Disorder

314

DSM-5 Criteria for. . .  Dissociative Identity Disorder 315 The World Around Us  DID, Schizophrenia, and Split Personality: Clearing Up the Confusion Causal Factors and Controversies about DID Current Perspectives Cultural Factors, Treatments, and Outcomes in Dissociative Disorders Cultural Factors in Dissociative Disorders Treatment and Outcomes in Dissociative Disorders Unresolved Issues  DID and the Reality of “Recovered Memories”

316 316 320 321 321 321 323

289

Summary

324

Summary

290

Key Terms

326

Key Terms

292

8 Somatic Symptom and Dissociative Disorders

9 Eating Disorders and Obesity 293

Somatic Symptom and Related Disorders: An Overview 294 Somatic Symptom Disorder DSM-5 Criteria for. . .  Somatic Symptom Disorder Causes of Somatic Symptom Disorder Treatment of Somatic Symptom Disorder Illness Anxiety Disorder DSM-5 Criteria for. . .  Illness Anxiety Disorder

295 295 296 299 300 300

Conversion Disorder (Functional Neurological Symptom Disorder) 300 DSM-5 Criteria for. . .  Conversion Disorder Range of Conversion Disorder Symptoms Important Issues in Diagnosing Conversion Disorder Prevalence and Demographic Characteristics Causes of Conversion Disorders

301 301 302 302 303

Clinical Aspects of Eating Disorders Anorexia Nervosa DSM-5 Criteria for. . .  Anorexia Nervosa Bulimia Nervosa DSM-5 Criteria for. . .  Bulimia Nervosa Binge-Eating Disorder DSM-5 Criteria for. . .  Binge-Eating Disorder Age of Onset and Gender Differences Thinking Critically about DSM-5  Other Forms of Eating Disorders Prevalence of Eating Disorders Medical Complications of Eating Disorders Course and Outcome Diagnostic Crossover Association of Eating Disorders with Other Forms of Psychopathology Eating Disorders Across Cultures

327 328 328 329 331 331 332 333 334 335 335 336 337 337 338 339

8 Contents The World Around Us  Ethnic Identity and Disordered Eating

340

Risk and Causal Factors in Eating Disorders Biological Factors Sociocultural Factors Family Influences Individual Risk Factors

341 341 342 344 344

Treatment of Eating Disorders Treatment of Anorexia Nervosa Treatment of Bulimia Nervosa

348 348 349

Developments in Practice  New Options for Adults with Anorexia Nervosa Treatment of Binge-Eating Disorder The Problem of Obesity Medical Issues Definition and Prevalence Weight Stigma The World Around Us  Do Negative Messages about Being Overweight Encourage Overweight People to Eat More or Less? Obesity and the DSM

350 351

DSM-5 Criteria for. . .  Narcissistic Personality Disorder Antisocial Personality Disorder

377 378 378 379

384

DSM-5 Criteria for. . .  Borderline Personality Disorder

385

354

355 356 357 358 358

362

Summary

363

Key Terms

364

365

Clinical Features of Personality Disorders

366

Challenges in Personality Disorders Research Difficulties in Diagnosing Personality Disorders Difficulties in Studying the Causes of Personality Disorders

368 369 370

371 372 372

DSM-5 Criteria for. . .  Paranoid Personality Disorder 373 Schizoid Personality Disorder

Narcissistic Personality Disorder

376 376

354

359 359 360 360 361

Cluster A Personality Disorders Paranoid Personality Disorder

DSM-5 Criteria for. . .  Histrionic Personality Disorder

376

Thinking Critically about DSM-5  Nonsuicidal SelfInjury: Distinct Disorder or Symptom of Borderline Personality Disorder?

Treatment of Obesity Lifestyle Modifications Medications Bariatric Surgery The Importance of Prevention

Thinking Critically about DSM-5  Why Were No Changes Made to the Way Personality Disorders Are Diagnosed?

Cluster B Personality Disorders Histrionic Personality Disorder

375

DSM-5 Criteria for. . .  Antisocial Personality Disorder

354 354

10 Personality Disorders

Schizotypal Personality Disorder DSM-5 Criteria for. . .  Schizotypal Personality Disorder

374

352 353 353 353

Risk and Causal Factors in Obesity The Role of Genes Hormones Involved in Appetite and Weight Regulation Sociocultural Influences Family Influences Stress and “Comfort Food” Pathways to Obesity

Unresolved Issues  The Role of Public Policy in the Prevention of Obesity

DSM-5 Criteria for. . .  Schizoid Personality Disorder

373

Borderline Personality Disorder

Cluster C Personality Disorders Avoidant Personality Disorder DSM-5 Criteria for. . .  Avoidant Personality Disorder Dependent Personality Disorder

380 383

388 388 389 389

DSM-5 Criteria for. . .  Dependent Personality Disorder

390

Obsessive-Compulsive Personality Disorder

391

DSM-5 Criteria for. . .  Obsessive-Compulsive Personality Disorder

392

General Sociocultural Causal Factors for Personality Disorders

392

Treatments and Outcomes for Personality Disorders Adapting Therapeutic Techniques to Specific Personality Disorders Treating Borderline Personality Disorder The World Around Us  Marsha Linehan Reveals Her Own Struggle with Borderline Personality Disorder Treating Other Personality Disorders Psychopathy Dimensions of Psychopathy Developments in Research  Are You Working for a Psychopath? The Clinical Picture in Psychopathy Causal Factors in Psychopathy A Developmental Perspective on Psychopathy Treatments and Outcomes in Psychopathic Personality Unresolved Issues  DSM-5: How Can We Improve the Classification of Personality Disorders?

393 393 394

395 395 396 396 399 400 401 403 404 405

Summary

405

Key Terms

407

Contents 9

11 Substance-Related Disorders

408

Alcohol-Related Disorders The Prevalence, Comorbidity, and Demographics of Alcohol Abuse and Dependence

409

DSM-5 Criteria for. . .  Alcohol Use Disorder The Clinical Picture of Alcohol-Related Disorders

412

Developments in Research  Fetal Alcohol Syndrome: How Much Drinking Is Too Much? Causal Factors in the Abuse of and Dependence on Alcohol Biological Causal Factors in Alcohol Abuse and Dependence Psychosocial Causal Factors in Alcohol Abuse and Dependence The World Around Us  Binge Drinking in College Sociocultural Causal Factors

410

412 414 416 416 418 420 421

Treatment of Alcohol-Related Disorders Use of Medications in Treating Alcohol Abuse and Dependency Psychological Treatment Approaches Controlled Drinking versus Abstinence Alcoholics Anonymous Outcome Studies and Issues in Treatment Relapse Prevention

421

Drug Abuse and Dependence

426

Opium and Its Derivatives Biological Effects of Morphine and Heroin Social Effects of Morphine and Heroin Causal Factors in Opiate Abuse and Dependence Neural Bases for Physiological Addiction Addiction Associated with Psychopathology Treatments and Outcomes

427 427 428

Stimulants Cocaine Amphetamines Methamphetamine Caffeine and Nicotine

430 430 432 433 433

Thinking Critically about DSM-5  Can Changes to the Diagnostic Criteria Result in Increased Drug Use?

421 422 423 423 424 425

429 429 430 430

433

Sedatives Effects of Barbiturates Causal Factors in Barbiturate Abuse and Dependence Treatments and Outcomes

435 435

Hallucinogens LSD Mescaline and Psilocybin Ecstasy Marijuana

436 436 437 437 438

436 436

The World Around Us  Should Marijuana Be Marketed and Sold Openly as a Medication? Gambling Disorder

439 440

DSM-5 Criteria for. . .  Gambling Disorder

441

Unresolved Issues  Exchanging Addictions: Is This an Effective Treatment Approach?

442

Summary

442

Key Terms

444

12 Sexual Variants, Abuse, and Dysfunctions

445

Sociocultural Influences on Sexual Practices and Standards Case 1: Degeneracy and Abstinence Theory Case 2: Ritualized Homosexuality in Melanesia Case 3: Homosexuality and American Psychiatry

446 447 448 448

Paraphilic Disorders Fetishistic Disorder

450 450

DSM-5 Criteria for. . .  Several Different Paraphilic Disorders Transvestic Disorder Voyeuristic Disorder Exhibitionistic Disorder Frotteuristic Disorder Sexual Sadism Disorder Sexual Masochism Disorder Causal Factors and Treatments for Paraphilias Gender Dysphoria

451 452 453 453 454 454 455 456 457

DSM-5 Criteria for. . .  Gender Dysphoria in Children

457

DSM-5 Criteria for. . .  Gender Dysphoria in Adolescents and Adults Treatment for Gender Dysphoria Transsexualism Treatment for Transsexualism

458 459 459 460

Sexual Abuse Childhood Sexual Abuse Pedophilic Disorder

461 461 463

Thinking Critically about DSM-5  Pedophilia and Hebephilia Incest Rape Treatment and Recidivism of Sex Offenders

464 464 465 468

The World Around Us  Megan’s Law

468

Sexual Dysfunctions Sexual Dysfunctions in Men

470 471

DSM-5 Criteria for. . .  Different Sexual Dysfunctions 472 Sexual Dysfunctions in Women 476 Unresolved Issues  How Harmful Is Childhood Sexual Abuse?

479

Summary

480

Key Terms

482

10 Contents

13 Schizophrenia and Other Psychotic Disorders

483

Schizophrenia Origins of the Schizophrenia Construct Epidemiology

484 484 485

Clinical Picture Delusions

486 486

DSM-5 Criteria for. . .  Schizophrenia Hallucinations The World Around Us  Stress, Caffeine, and Hallucinations Disorganized Speech Disorganized Behavior Negative Symptoms Subtypes of Schizophrenia Other Psychotic Disorders Schizoaffective Disorder

487 488 489 489 490 490 491 491 491

DSM-5 Criteria for. . .  Schizoaffective Disorder Schizophreniform Disorder

491 491

DSM-5 Criteria for. . .  Schizophreniform Disorder Delusional Disorder Brief Psychotic Disorder

492 492 492

DSM-5 Criteria for. . .  Delusional Disorder

492

DSM-5 Criteria for. . .  Brief Psychotic Disorder

493

Genetic and Biological Factors Genetic Factors The World Around Us  The Genain Quadruplets Prenatal Exposures Developments in Thinking  Could Schizophrenia Be an Immune Disorder? Genes and Environment in Schizophrenia: A Synthesis A Neurodevelopmental Perspective Thinking Critically about DSM-5  Attenuated Psychosis Syndrome

493 493 495 500 501 501 502 504

Structural and Functional Brain Abnormalities Neurocognition Social Cognition Loss of Brain Volume Affected Brain Areas White Matter Problems Brain Functioning Cytoarchitecture Brain Development in Adolescence Synthesis Neurochemistry

505 505 506 507 507 508 509 510 511 511 512

Psychosocial and Cultural Factors Do Bad Families Cause Schizophrenia? Families and Relapse

514 514 515

Urban Living Immigration Cannabis Use and Abuse A Diathesis–Stress Model of Schizophrenia Treatments and Outcomes Clinical Outcome Pharmacological Approaches Psychosocial Approaches Unresolved Issues  Why Are Recovery Rates in Schizophrenia Not Improving?

516 516 517 518 519 519 520 522 524

Summary

525

Key Terms

526

14 Neurocognitive Disorders Brain Impairment in Adults Thinking Critically about DSM-5  Is the Inclusion of Mild Neurocognitive Disorder a Good Idea? Clinical Signs of Brain Damage Diffuse Versus Focal Damage The Neurocognitive/Psychopathology Interaction Delirium Clinical Picture DSM-5 Criteria for. . .  Delirium

527 528 529 529 530 532 533 533 534

Treatments and Outcomes

534

Major Neurocognitive Disorder

534

DSM-5 Criteria for. . .  Major Neurocognitive Disorder Parkinson’s Disease Huntington’s Disease Alzheimer’s Disease Clinical Picture Prevalence Causal Factors Developments in Research  Depression Increases the Risk of Alzheimer’s Disease Neuropathology Treatment and Outcome Early Detection

535 536 536 536 537 538 539 541 541 543 543

Developments in Research  New Approaches to the Treatment of Alzheimer’s Disease

544

The World Around Us  Exercising Your Way to a Healthier Brain?

545

Supporting Caregivers Neurocognitive Disorder Resulting from HIV Infection or Vascular Problems Neurocognitive Disorder Associated with HIV-1 Infection Neurocognitive Disorder Associated with Vascular Disease Neurocognitive Disorder Characterized by Profound Memory Impairment (Amnestic Disorder)

545 546 546 547 547

Contents 11

Disorders Involving Head Injury Clinical Picture Treatments and Outcomes The World Around Us  Brain Damage in Professional Athletes Unresolved Issues  Should Healthy People Use Cognitive Enhancers?

548 549 551 552 553

Summary

554

Key Terms

555

Special Considerations in Understanding Disorders of Childhood and Adolescence Psychological Vulnerabilities of Young Children The Classification of Childhood and Adolescent Disorders Anxiety and Depression in Children and Adolescents Anxiety Disorders of Childhood and Adolescence Childhood Depression and Bipolar Disorder Developments in Research  Bipolar Disorder in Children and Adolescents: Is There an Epidemic? Disruptive, Impulse-Control, and Conduct Disorder Oppositional Defiant Disorder Conduct Disorder DSM-5 Criteria for. . .  Conduct Disorder Causal Factors in ODD and CD Treatments and Outcomes

Family Therapy as a Means of Helping Children Child Advocacy Programs

556 558 558 558 559 559 561

563 564 565 565 565 566 567

Elimination Disorders Enuresis Encopresis

568 568 569

Neurodevelopmental Disorders Attention-Deficit/Hyperactivity Disorder

569 569

DSM-5 Criteria for. . .  Attention-Deficit/ Hyperactivity Disorder

570

Autism Spectrum Disorder DSM-5 Criteria for. . .  Autism Spectrum Disorder Tic Disorders Developments in Practice  Can Video Games Help Children with Neurodevelopmental Disorders? Specific Learning Disorders Causal Factors in Learning Disorder Treatments and Outcomes

Special Considerations in the Treatment of Children and Adolescents Special Factors Associated with Treatment of Children and Adolescents The World Around Us  The Impact of Child Abuse on Psychological Disorders

15 Disorders of Childhood and

Adolescence (Neurodevelopmental Disorders)

Intellectual Disability Levels of Intellectual Disability Causal Factors in Intellectual Disability Organic Intellectual Disability Syndromes Treatments, Outcomes, and Prevention

573 575 576

577 578 579 579

Thinking Critically about DSM-5  What Role Should Cultural Changes Have in Developing Medical Terminology? 580

Unresolved Issues  How Should Society Deal with Delinquent Behavior?

580 581 582 583 586 587 587 589 589 590 590

Summary

591

Key Terms

593

16 Psychological Treatment

594

An Overview of Treatment Why Do People Seek Therapy? Who Provides Psychotherapeutic Services? The Therapeutic Relationship

595 595 597 597

Measuring Success in Psychotherapy Objectifying and Quantifying Change Would Change Occur Anyway? Can Therapy Be Harmful?

598 598 600 600

The World Around Us  When Therapy Harms

600

What Therapeutic Approaches Should Be Used? Evidence-Based Treatment Medication or Psychotherapy? Combined Treatments

601 601 602 602

Psychosocial Approaches to Treatment Behavior Therapy Cognitive and Cognitive-Behavioral Therapy Humanistic-Experiential Therapies Psychodynamic Therapies Couples and Family Therapy Eclecticism and Integration Rebooting Psychotherapy

603 603 606 608 611 614 615 615

Sociocultural Perspectives Social Values and Psychotherapy Psychotherapy and Cultural Diversity

616 616 616

Biological Approaches to Treatment Antipsychotic Drugs Antidepressant Drugs Antianxiety Drugs Lithium and Other Mood-Stabilizing Drugs

617 617 618 621 622

Thinking Critically about DSM-5  What Are Some of the Clinical Implications of the Recent Changes?

623

Nonmedicinal Biological Treatments

624

12 Contents The World Around Us  Deep Brain Stimulation for Treatment-Resistant Depression

627

Unresolved Issues  Do Psychiatric Medications Help or Harm?

628

Summary

629

Key Terms

630

17 Contemporary and Legal Issues in Abnormal Psychology

631

Perspectives on Prevention Universal Interventions Selective Interventions Indicated Interventions

632 633 634 637

Inpatient Mental Health Treatment in Contemporary Society The Mental Hospital as a Therapeutic Community Aftercare Programs Deinstitutionalization

637 637 639 639

Controversial Legal Issues and the Mentally Ill Civil Commitment

641 641

The World Around Us  Important Court Decisions for Patient Rights Assessment of “Dangerousness”

The World Around Us  Controversial Not Guilty Pleas: Can Altered Mind States or Personality Disorder Limit Responsibility for a Criminal Act? 643 The Insanity Defense Competence to Stand Trial Does Having Mental Health Problems Result in Convicted Felons Being Returned to Prison After Being Released?

646 649

650

Organized Efforts for Mental Health U.S. Efforts for Mental Health International Efforts for Mental Health

651 651 653

Challenges for the Future The Need for Planning The Individual’s Contribution

653 654 654

Unresolved Issues  The HMOs and Mental Health Care

655

Summary

657

Key Terms

658

Glossary

659

References

682

Credits

754

641

Name Index

761

642

Subject Index

777

Features Developments in Research Do Magnets Help with Repetitive-Stress Injury?

51

The Search for Medications to Cure Mental Disorders

74

DID, Schizophrenia, and Split Personality: Clearing Up the Confusion

316

Ethnic Identity and Disordered Eating

340 354

Nocturnal Panic Attacks

218

Why Do Sex Differences in Unipolar Depression Emerge During Adolescence?

Do Negative Messages about Being Overweight Encourage Overweight People to Eat More or Less?

267

Marsha Linehan Reveals Her Own Struggle with Borderline Personality Disorder

395

Binge Drinking in College

420

Should Marijuana Be Marketed and Sold Openly as a Medication?

439

Megan’s Law

468

Stress, Caffeine, and Hallucinations

489

The Genain Quadruplets

495

What Can Neuroimaging Tell Us about Conversion Disorder?

304

Are You Working for a Psychopath?

399

Fetal Alcohol Syndrome: How Much Drinking Is Too Much?

414

Depression Increases the Risk of Alzheimer’s Disease

541

New Approaches to the Treatment of Alzheimer’s Disease

544

Exercising Your Way to a Healthier Brain?

545

Bipolar Disorder in Children and Adolescents: Is There an Epidemic?

Brain Damage in Professional Athletes

552

563

The Impact of Child Abuse on Psychological Disorders

589

When Therapy Harms

600

Developments in Thinking Melancholia Through the Ages

59

Nature, Nurture, and Psychopathology: A New Look at an Old Topic

Deep Brain Stimulation for Treatment-Resistant Depression

627

95

Important Court Decisions for Patient Rights

641

Controversial Not Guilty Pleas: Can Altered Mind States or Personality Disorder Limit Responsibility for a Criminal Act?

643

The Humanistic and Existential Perspectives

106

A New DSM-5 Diagnosis: Premenstrual Dysphoric Disorder

253

Could Schizophrenia Be an Immune Disorder?

501

Developments in Practice

Unresolved Issues Are We All Becoming Mentally Ill? The Expanding Horizons of Mental Disorder

53

142

Interpreting Historical Events

80

Computer-Based MMPI-2 Report for Andrea C.

150

Treatment of a Patient Who Was Mute

305

Theoretical Perspectives and the Causes of Abnormal Behavior

New Options for Adults with Anorexia Nervosa

350

Can Video Games Help Children with Neurodevelopmental Disorders?

The DSM-5: Issues in Acceptance of Changed Diagnostic Criteria 157

577

Why Is the Study of Trauma So Contentious?

194

The Choice of Treatments: Medications or Cognitive-Behavior Therapy?

241

The Automated Practice: Use of the Computer in Psychological Testing

The World Around Us

126

Extreme Generosity or Pathological Behavior?

30

Is There a Right to Die?

289

Chaining Mental Health Patients

70

DID and the Reality of “Recovered Memories”

323

The Role of Public Policy in the Prevention of Obesity

362

Culture and Attachment Relationships

125

Racial Discrimination and Cardiovascular Health in African Americans

171

Does Playing Tetris After a Traumatic Event Reduce Flashbacks?

DSM-5: How Can We Improve the Classification of Personality Disorders?

405

190

Virtual Reality Exposure Treatment for PTSD in Military Personnel

Exchanging Addictions: Is This an Effective Treatment Approach?

442

193

How Harmful Is Childhood Sexual Abuse?

479

Taijin Kyofusho

240

Warning Signs for Suicide

286

Why Are Recovery Rates in Schizophrenia Not Improving?

524

13

14 Features Should Healthy People Use Cognitive Enhancers?

553

DSM-5 Criteria for… Gambling Disorder

441

How Should Society Deal with Delinquent Behavior?

590

Do Psychiatric Medications Help or Harm?

628

DSM-5 Criteria for… Several Different Paraphilic Disorders

451

The HMOs and Mental Health Care

655

DSM-5 Criteria for… Gender Dysphoria in Children

457

DSM-5 Criteria for… Gender Dysphoria in Adolescents and Adults

358

DSM-5 Boxes DSM-5 Criteria for… Posttraumatic Stress Disorder

183

DSM-5 Criteria for… Different Sexual Dysfunctions

472

DSM-5 Criteria for… Specific Phobia

201

DSM-5 Criteria for… Schizophrenia

487

DSM-5 Criteria for… Social Anxiety Disorder (Social Phobia)

DSM-5 Criteria for… Schizoaffective Disorder

491

208

DSM-5 Criteria for… Schizophreniform Disorder

492

DSM-5 Criteria for… Panic Disorder

212

DSM-5 Criteria for… Delusional Disorder

492

DSM-5 Criteria for… Agoraphobia

213

DSM-5 Criteria for… Brief Psychotic Disorder

493

DSM-5 Criteria for… Generalized Anxiety Disorder

222

DSM-5 Criteria for… Delirium

534

DSM-5 Criteria for… Obsessive-Compulsive Disorder

229

DSM-5 Criteria for… Major Neurocognitive Disorder

535

DSM-5 Criteria for… Body Dysmorphic Disorder

237

DSM-5 Criteria for… Conduct Disorder

565

DSM-5 Criteria for… Major Depressive Disorder

246

DSM-5 Criteria for… Manic Episode

247

DSM-5 Criteria for… Attention-Deficit/Hyperactivity Disorder

570

DSM-5 Criteria for… Persistent Depressive Disorder

252

DSM-5 Criteria for… Autism Spectrum Disorder

575

DSM-5 Criteria for… Somatic Symptom Disorder

295

DSM-5 Criteria for… Illness Anxiety Disorder

300

DSM-5 Criteria for… Conversion Disorder

301

What Is the DSM and Why Was It Revised?

31

DSM-5 Criteria for… Factitious Disorder

306

Changes to the Diagnostic Criteria for PTSD

181

DSM-5 Criteria for… Depersonalization/Derealization Disorder

310

Why Is OCD No Longer Considered to Be an Anxiety Disorder?

227

Was It Wise to Drop the Bereavement Exclusion for Major Depression?

253

Where Does Conversion Disorder Belong?

313

Other Forms of Eating Disorders

335

Why Were No Changes Made to the Way Personality Disorders Are Diagnosed?

371

Nonsuicidal Self-Injury: Distinct Disorder or Symptom of Borderline Personality Disorder?

384

Can Changes to the Diagnostic Criteria Result in Increased Drug Use?

433

Pedophilia and Hebephilia

464

Attenuated Psychosis Syndrome

504

Is the Inclusion of Mild Neurocognitive Disorder a Good Idea?

529

Thinking Critically About DSM-5

DSM-5 Criteria for… Dissociative Amnesia

312

DSM-5 Criteria for… Dissociative Identity Disorder

315

DSM-5 Criteria for… Anorexia Nervosa

329

DSM-5 Criteria for… Bulimia Nervosa

331

DSM-5 Criteria for… Binge-Eating Disorder

333

DSM-5 Criteria for… Paranoid Personality Disorder

373

DSM-5 Criteria for… Schizoid Personality Disorder

374

DSM-5 Criteria for… Schizotypal Personality Disorder

376

DSM-5 Criteria for… Histrionic Personality Disorder

377

DSM-5 Criteria for… Narcissistic Personality Disorder

378

DSM-5 Criteria for… Antisocial Personality Disorder

380

DSM-5 Criteria for… Borderline Personality Disorder

385

DSM-5 Criteria for… Avoidant Personality Disorder

389

DSM-5 Criteria for… Dependent Personality Disorder

390

DSM-5 Criteria for… Obsessive-Compulsive Personality Disorder

What Role Should Cultural Changes Have in Developing Medical Terminology?

580

392

DSM-5 Criteria for… Alcohol Use Disorder

412

What Are Some of the Clinical Implications of the Recent Changes?

623

What’s New in DSM-5? A Quick Guide

M

any changes occurred from DSM-IV-TR to DSM-5. Here is a summary of some of the most important revisions. Many of these changes are highlighted in the “Thinking Critically about DSM-5” boxes throughout this edition. • The chapters of the DSM have been reorganized to reflect a consideration of developmental and lifespan issues. Disorders that are thought to reflect developmental perturbations or that manifest early in life (e.g., neurodevelopmental disorders and disorders such as schizophrenia) are listed before disorders that occur later in life. • The multiaxial system has been abandoned. No distinction is now made between Axis I and Axis II disorders. • DSM-5 allows for more gender-related differences to be taken into consideration for mental health problems. • It is extremely important for the clinician to understand the client’s cultural background in appraising mental health problems. DSM-5 contains a structured interview that focuses on the patient’s cultural background and characteristic approach to problems. • The term intellectual disability is now used instead of the term mental retardation. • A new diagnosis of autism spectrum disorder now encompasses autism, Asperger’s disorder, and other forms of pervasive developmental disorder. The diagnosis of Asperger’s disorder has been eliminated from the DSM. • Changes to the diagnostic criteria for attention deficit disorder now mean that symptoms that occur before age 12 (rather than age 7) have diagnostic significance. • A new diagnosis, called disruptive mood dysregulation disorder, has been added. This will be used to diagnose children up to age 18 who show persistent irritability and frequent episodes of extreme and uncontrolled behavior. • The subtypes of schizophrenia have been eliminated.

• Premenstrual dysphoric disorder has been promoted from the appendix of DSM-IV-TR and is now listed as a new diagnosis. • A new diagnosis of persistent depressive disorder now subsumes dysthymia and chronic major depressive disorder. • The bereavement exclusion has been removed in the diagnosis of major depressive episode. • The diagnosis of phobia no longer requires that the person recognize that his or her anxiety is unreasonable. • Panic disorder and agoraphobia have been unlinked and are now separate diagnoses in DSM-5. • Obsessive-compulsive disorder is no longer classified as an anxiety disorder. DSM-5 contains a new chapter that covers obsessive-compulsive and related disorders. • New disorders in the obsessive-compulsive and related disorders category include hoarding disorder and excoriation (skin-picking) disorder. • Posttraumatic stress disorder is no longer considered to be an anxiety disorder. Instead, it is listed in a new chapter that covers trauma- and stressor-related ­disorders. • The diagnostic criteria for posttraumatic stress disorder have been significantly revised. The definition of what counts as a traumatic event has been clarified and made more explicit. DSM-5 now also recognizes four-symptom clusters rather than the three noted in DSM-IV-TR. • Dissociative fugue is no longer listed as a separate diagnosis. Instead, it is listed as a form of dissociative amnesia. • The DSM-IV-TR diagnoses of hypochondriasis, somatoform disorder, and pain disorder have been removed and are now subsumed into the new diagnosis of somatic symptom disorder.

• The special significance afforded to bizarre delusions with regard to the diagnosis of schizophrenia has been removed.

• Binge-eating disorder has been moved from the appendix of DSM-IV-TR and is now listed as an official diagnosis.

• Bipolar and related disorders are now described in a separate chapter of the DSM and are no longer listed with depressive disorders.

• The frequency of binge-eating and purging episodes has been reduced for the diagnosis of bulimia ­nervosa.

15

16  What’s New in DSM-5? A Quick Guide • Amenorrhea is no longer required for the diagnosis of anorexia nervosa. • The DSM-IV-TR diagnoses of dementia and amnestic disorder have been eliminated and are now subsumed into a new category called major neurocognitive disorder. • Mild neurocognitive disorder has been added as a new diagnosis. • No changes have been made to the diagnostic c­ riteria for personality disorders, although an alternative model is now offered as a guide for future research.

• Substance-related disorders are divided into two separate groups: substance use disorders and substanceinduced disorders. • A new disorder, gambling disorder, has been included in substance-related and addictive disorders. • Included for the first time in Section III of DSM-5 are several new disorders regarded as being in need of further study. These include attenuated psychosis syndrome, nonsuicidal self-injury disorder, Internet gaming disorder, and caffeine use disorder.

Preface

W

e are so excited about this course and hope that you are too! We (the authors) all took this course when we were undergraduate students because we were curious about abnormal aspects of human behavior. Why do some people become so depressed they can’t get out of bed? Why do others have trouble controlling their use of alcohol and drugs? Why do some people become violent toward others, and in other cases toward themselves? We continue to be intensely curious about, and fascinated by, the answers to these and many other questions about abnormal human behavior. The purpose of this book is to provide a comprehensive (and hopefully engaging) introduction to the primary psychological disorders studied within abnormal psychology. As you will learn, there are many different types of psychological disorders, and each is caused by the interaction of many different factors and can be considered from many different perspectives. We thought a lot about how best to present this information in a way that will be clear and engaging and will allow you to gain a solid, fundamental understanding of psychological disorders. As such, we use a biopsychosocial approach to provide a sophisticated appreciation of the total context in which abnormalities of behavior occur. This means that we present and describe the wide range of biological, psychological, and social factors that work together to lead to the development of psychological disorders. In addition, we discuss treatment approaches that target each of these different factors. For ease of understanding we also present material on each disorder in a logical and consistent way. More specifically, we focus on three significant aspects: (1) the clinical picture, where we describe the symptoms of the disorder and its associated features; (2) factors involved in the development of the disorder; and (3) treatment approaches. In each case, we examine the evidence for biological, psychosocial (i.e., psychological and interpersonal), and sociocultural (the broader social environment of culture and subculture) influences. Because we wish never to lose sight of the person, we try to integrate as much case material as we can into each chapter. An additional feature of this book is a heavy focus on treatment. Although treatment is discussed in every chapter in the context of specific disorders, we also include a separate chapter that addresses issues in treatment more broadly. This provides students with increased understanding of a

wide range of treatment approaches and permits more indepth coverage than is possible in specific disorder–based chapters. Abnormal Psychology has a long and distinguished tradition as an undergraduate text. Ever since James Coleman wrote the first edition many years ago, this textbook has been considered the most comprehensive in the field. Along the way there have been many changes. This is very much the case with this new edition. Perhaps the most exciting change, however, is the addition of Harvard Professor Matthew Nock to the author team. Matt, a recent MacArthur Award (aka, “Genius Grant”) recipient, brings his brilliance, scholarship, and wry sense of humor to the book, providing fresh approaches and new perspectives. We are delighted that he has joined the author team and welcome him with great enthusiasm! The Hooley-Butcher-Nock-Mineka author team is in a unique position to provide students with an integrated and comprehensive understanding of abnormal psychology. Each author is a noted researcher, an experienced teacher, and a licensed clinician. Each brings different areas of expertise and diverse research interests to the text. We are committed to excellence. We are also committed to making our text accessible to a broad audience. Our approach emphasizes the importance of research as well as the need to translate research findings into informed and effective clinical care for all who suffer from mental disorders. In this new edition, we seek to open up the fascinating world of abnormal psychology, providing students with comprehensive and up-to-date knowledge in a clear and engaging way. We hope that this newest edition conveys some of the passion and enthusiasm for the topic that we still experience every day.

Why Do You Need This New Edition? The book you are reading is the seventeenth edition of Abnormal Psychology. Why so many revisions? And why not just use an old copy of the fifteenth or sixteenth edition? The reason is that our field is constantly making advances in our understanding of abnormal psychology. New research is being published all the time. As authors, it is important to us that these changes and new ways of thinking about the etiology, assessment, and treatment of

17

18 Preface psychological disorders are accurately presented in this text. Although many of the ideas and diagnostic concepts in the field of abnormal psychology have persisted for hundreds of years, changes in thinking often occur. And, at some point, events occur that force a rethinking of familiar topics. A major example here is the revision of the manual that is used to classify mental disorders (called the DSM-5). This new edition of Abnormal Psychology includes the most up-to-date information about DSM-5 diagnostic categories, classifications, and criteria. Every time we work on a revision of Abnormal Psychology we are reminded of how dynamic and vibrant our field is. Developments in areas such as genetics, brain imaging, behavioral observation, and classification, as well changes in social and government policy and in legal decisions, add to our knowledge base and stimulate new treatments for those whose lives are touched by mental disorders. If you’re wondering what exactly is so new in this edition of Abnormal Psychology, here are seven big revisions that we have made. 1. We have a new author! Matt Nock brings a fresh and new perspective to this authoritative and established text. 2. The seventeenth edition of Abnormal Psychology includes the most up-to-date and in-depth information about biological influences on the entire spectrum of behavioral abnormalities, while still maintaining a comprehensive and balanced biopsychosocial approach to understanding abnormal behavior. 3. As a result of the publication of DSM-5, the diagnostic criteria for many disorders have changed. This edition includes detailed boxes listing the current DSM-5 diagnostic criteria for all the disorders covered in the book. Specific highlight boxes and discussions in the text also alert you to some of the most important changes in DSM-5. 4. Other feature boxes provide opportunities for critical thinking by illustrating some of the controversies associated with the changes that were (or were not) made. Throughout the text we also provide readers with different perspectives on the likely implications that these changes will have (or are having) for clinical diagnosis and research in psychopathology. 5. Reflecting the ever-changing field of abnormal psychology, hundreds of new references have been added, highlighting the newest and most important research findings. 6. Changes have been made in many chapters to improve the flow of the writing and enhance learning. The presentation of material in many chapters has also been

reorganized to provide a more logical and coherent narrative. 7. Finally, at the beginning of each chapter, clearly defined learning objectives provide the reader with an overview of topics and issues that will be included in the chapter. These learning objectives also appear again in the specific sections to which they apply. This makes it easier for readers to identify what they should be learning in each section. At the end of each chapter a summary of the learning objectives is also provided. In Review questions at the end of major sections within chapters also provide additional opportunities for self-assessment and increased ­learning.

What’s New This new edition of Abnormal Psychology has been redesigned to reflect the newest and most relevant research findings, presented in a way that is engaging to the newest generation of students. We’ve done a lot of updating! Our focus has been on streamlining material throughout the book to decrease the length of each chapter while retaining all of the important information that students should be learning. We have also done our best to include the most exciting changes and advances occurring in our field. For example, throughout the text, we have significantly increased the focus on the manifestation and treatment of psychological disorders around the globe, using data from a recently completed cross-national series of studies in more than 20 different countries. In Chapter 3, we have added a new and more accessible description of why correlation does not equal causation—and what does! In Chapter 5, we now adopt a more broad and integrative approach to the health consequences of stress, including a focus on the mechanisms through which stress is thought to cause physical health problems. Chapter 7 has been updated substantially and now includes more information about some of the problems most relevant to college students, such as suicide and self-injury. New case studies have also been added throughout the book. Chapter 8, for example, has four new case studies, as well as two new highlight boxes. These illustrate recent neuroimaging research on patients with conversion disorder, as well as a very creative new approach to the treatment of this fascinating disorder. Chapter 11 has significant new material on how alcohol and drugs affect the brain, what causes hangovers, and information on new synthetic drugs that have recently hit the streets. In Chapter 13, the most current genetic findings concerning schizophrenia are described, and new developments in

Preface 19

our understanding of the nature of dopamine abnormality in schizophrenia are discussed. A new Developments in Thinking highlight box also presents new ideas about the possibility that schizophrenia might be an immune function disorder. Chapter 15 has been reorganized and updated throughout; for instance, it now includes cutting-edge findings on the potential causes and most effective treatments for autism spectrum disorders. And throughout the book we have included information about some of the newest ways in which researchers and clinicians are treating psychological disorders, such as via the use of new smartphone apps, brain stimulation treatments, and assistive therapeutic robots! These are just a handful of the many changes we have made to give readers the most current perspectives possible. We want students to stay ahead of the curve and to provide them with the most up-to-date information we can. We also want to give students a sense of how and in what ways various fields are likely moving. This edition also retains features that were very well received in the last edition. To assist both instructors and students, we continue to feature specialized boxes, highlighting many of the key changes that were made in DSM-5. In this edition, however, we also provide a detailed but accessible description of the RDoC approach. As before, chapters begin with learning objectives. These orient the reader to the material that will be presented in each specific chapter. Learning objectives are also repeated by the section they apply to and summarized at the end of each chapter. Most chapters also begin with a case study (many of which are new) that illustrates the mental health problems to be addressed in the chapter. This serves to capture students’ interest and attention right from the outset. Numerous new references, photographs, and illustrations have also been added. In short, outdated material has been replaced, current findings have been included, and new developments have been identified. Importantly, all of this has been accomplished without adding length to the book! We hope you enjoy this new edition.

Features and Pedagogy The extensive research base and accessible organization of this book are supported by high-interest features and helpful pedagogy to further engage students and support learning. We also hope to encourage students to think in depth about the topics they are learning about through specific highlight features that emphasize critical thinking.

Features FEATURE BOXES  Special sections, called Developments in Research, Developments in Thinking, Developments

in Practice, and The World Around Us, highlight topics of particular interest, focusing on applications of research to everyday life, current events, and the latest research methodologies, technologies, and findings. CRITICAL THINKING  Many of the revisions to DSM-5 were highly contentious and controversial. A feature box called “Thinking Critically about DSM-5” introduces students to the revised DSM and encourages them to think critically about the implications of these changes. UNRESOLVED ISSUES  All chapters include end-of-

chapter sections that demonstrate how far we have come and how far we have yet to go in our understanding of psychological disorders. The topics covered here provide insight into the future of the field and expose students to some controversial topics.

Pedagogy LEARNING OBJECTIVES  Each chapter begins with learning objectives. These orient the reader to the material that will be presented in each specific chapter. Learning objectives are also repeated by the section they apply to and summarized at the end of each chapter. This provides students with an excellent tool for study and review. In this edition, sections of many chapters have also been reorganized and material has been streamlined whenever possible. All the changes that have been made are designed to improve the flow of the writing and enhance pedagogy. CASE STUDIES  Extensive case studies of individuals with various disorders are integrated in the text throughout the book. Some are brief excerpts; others are detailed analyses. These cases bring important aspects of the disorders to life. They also remind readers that the problems of abnormal psychology affect the lives of people—people from all kinds of diverse backgrounds who have much in common with all of us. IN REVIEW QUESTIONS   Review questions appear at the end of each major section within the chapter, providing regular opportunities for self-assessment as students read and further reinforce their learning. DSM-5 BOXES  Throughout the book these boxes contain

the most up-to-date (DSM-5) diagnostic criteria for all of the disorders discussed. In a convenient and visually accessible form, they provide a helpful study tool that reflects current diagnostic practice. They also help students understand disorders in a real-world context. RESEARCH CLOSE-UP TERMS  Appearing through-

out each chapter, these terms illuminate research

20 Preface methodologies. They are designed to give students a clearer understanding of some of the most important research concepts in the field of abnormal psychology. CHAPTER SUMMARIES  Each chapter ends with a

summary of the essential points of the chapter organized around the learning objectives presented at the start of the chapter. These summaries use bulleted lists rather than formal paragraphs. This makes the information more accessible for students and easier to scan. KEY TERMS  Key terms are identified in each chapter. Key terms are also listed at the end of every chapter with page numbers referencing where they can be found in the body of the text. Key terms are also defined in the Glossary at the end of the text.

MyPsychLab Available at www.MyPsychLab.com, MyPsychLab is an online homework, tutorial, and assessment program that truly engages students in learning. It helps students better prepare for class, quizzes, and exams—resulting in better performance in the course. It provides educators a dynamic set of tools for gauging individual and class performance: Customizable—MyPsychLab is customizable. Instructors choose what students’ course looks like. Homework, applications, and more can easily be turned on and off. Blackboard Single Sign-on—MyPsychLab can be used by itself or linked to any course management system. Blackboard single sign-on provides deep linking to all New MyPsychLab resources. Pearson eText and Chapter Audio—Like the printed text, students can highlight relevant passages and add notes. The Pearson eText can be accessed through laptops, iPads, and tablets. Download the free Pearson eText app to use on tablets. Students can also listen to their text with the Audio eText. Assignment Calendar & Gradebook—A drag and drop assignment calendar makes assigning and completing work easy. The automatically graded assessment provides instant feedback and flows into the gradebook, which can be used in the MyPsychLab or exported. Personalized Study Plan—Students’ personalized plans promote better critical thinking skills. The study plan organizes students’ study needs into sections, such as Remembering, Understanding, Applying, and Analyzing.

Instructor’s Manual A comprehensive tool for class preparation and management, each chapter includes teaching objectives; a chapter overview; a detailed lecture outline; a list of key terms; teaching resources, including lecture launchers, class activities, demonstrations, assignments, teaching tips, and handouts; a list of video, media, and Web resources; and a sample syllabus. Available for download on the Instructor ’s Resource Center at www.pearsonglobaleditions. com/Butcher.

Test Bank The Test Bank is composed of approximately 2,000 fully referenced multiple-choice, completion, short-answer, and concise essay questions. Each question is accompanied by a page reference, difficulty level, skill type (factual, conceptual, or applied), topic, and a correct answer. Available for download on the Instructor’s Resource Center at www. pearsonglobaleditions.com/Butcher.

Lecture PowerPoint Slides The PowerPoint slides provide an active format for presenting concepts from each chapter and feature relevant figures and tables from the text. Available for download on the Instructor’s Resource Center at www.pearsonglobaleditions. com/Butcher. Enhanced Lecture PowerPoint Slides with Embedded Videos have been embedded with select Speaking Out video pertaining to each disorder chapter, enabling instructors to show videos within the context of their lecture. PowerPoint Slides for Photos, Figures, and Tables contain only the photos, figures, and line art from the text. Available for download on the Instructor’s Resource Center at www.pearsonglobaleditions.com/Butcher.

Acknowledgments It takes each member of the author team more than a year of focused work to produce a new edition of this textbook. During this time, family and friends receive much less attention than they deserve. We are aware that a few lines of acknowledgment in a preface do little to compensate those close to us for all the inconveniences and absences they have endured. Nonetheless, Jill Hooley is ever grateful to Kip Schur for his patience, love, support, and ability to retain a sense of humor throughout the revision process. She also wishes to thank Tina Chou for

Preface 21

her help with producing an image for Chapter 10. James Butcher would like to thank his wife, Carolyn L. ­Williams, and his children, Holly Butcher, Sherry Butcher, and Jay Butcher, for their patience and support during this time. Matthew Nock would like to thank his wife, Keesha, and their children Matt Jr., Maya, and Georgina, for their patience (and tolerance). He is also grateful to Franchesca Ramirez and Nicole Murman for their assistance in the preparation of this edition. Finally, Susan Mineka thanks her graduate students, friends, and family for their patience and support. The authors would like to express our most extreme gratitude, respect, and appreciation to our amazing ­development editor, Stephanie Ventura. Her insightful recommendations, editorial excellence, and all-around ­awesomeness made her a delight to work with. (Note: If they had let her edit this section, she would have caught that we just ended a sentence with a preposition. She’s that good.) A big thank you also goes to Amber Chow, our acquisitions editor, for her leadership, guidance, advice, and support of this book. Without Amber’s ability to manage every challenge that arose, this book might still be in the production stages. In addition, we are grateful to Carrie Brandon for all of her hard work, support, and especially for her instrumental role in creating new video for this edition. Another special thank you goes to Cecilia Turner, our program manager, for her expert coordination of all aspects of this project as well as to Donna Simons and Sherry Lewis for their skillful management of the production of this book. We also thank Laura Chadwick for her efforts to secure all the permissions necessary for the figures and photographs. Many experts, researchers, and users of this book provided us with comments on individual chapters. We are extremely grateful for their input and feedback. Their knowledge and expertise help us keep this text current and accurate. We are also especially grateful to the many reviewers who have given us invaluable feedback on this and previous editions of Abnormal Psychology: Joe Davis, CSU/ SWC; Dan Fox, University of Houston; Marvin Lee, Tennessee State University; Stevie McKenna, Rutgers University; Loreto Prieto, Iowa State University; Hugh Riley, Baylor University; Edward Selby, Rutgers University; Tasia Smith, University of Florida; Stephanie Stein, Central Washington University; David Topor, Harvard University; Anthony Zoccolillo, Texas A&M; Angela Bragg, Mount Hood Community College; Greg Carey, University of Colorado; Louis Castonguay, Pennsylvania State University; Richard Cavasina, California University of Pennsylvania; Dianne Chambless,

University of Pennsylvania; Lee Anna Clark, The University of Iowa; Barbara Cornblatt; William Paul Deal, University of Mississippi; Raymond L. Eastman, Stephen F. Austin State University; John F. Edens, Sam Houston State University; Colleen Ehrnstrom, University of Colorado at Boulder; William Fals-Stewart, The State University of New York at Buffalo; John P. Forsyth, The State University of New York at Albany; Louis R. Franzini, San Diego State University; David H. Gleaves, Texas A&M University; Michael Green, University of California at Los Angeles; Steven Haynes, University of Hawaii at Manoa; Kathi Heffner, Ohio University; Daniel Holland, University of Arkansas at Little Rock; Steven Hollon, Vanderbilt University; Joanne Hoven Stohs, California State University Fullerton; Robert Howland, University of Pittsburgh, School of Medicine; Jean W. Hunt, Cumberland College; Alexandrea Hye-Young Park, Virginia Tech; William G. Iacono, University of Minnesota; Jessica Jablonski, University of Delaware; Erick Janssen, Indiana University; Sheri Johnson, University of Miami; Ann Kane, Barnstable High; Alan Kazdin, Yale University; Lynne Kemen, Hunter College; Carolin Keutzer, University of Oregon; John F. Kihlstrom, University of California at Berkeley; Gerald Koocher, Simmons College; David Kosson, Chicago Medical School; Marvin Lee, Tennessee State University; Brett Litz, Boston University; Brendan Maher, Harvard University; Richard McNally, Harvard University; Edwin Megargee, Florida State University; William Miller, University of New Mexico; Robin Morgan, Indiana University Southeast; Michael Neboschick, College of Charleston; Matthew Nock, Harvard University; Chris Patrick, Florida State University; Marcus Patterson, University of Massachusetts; John Daniel Paxton, Lorain County Community College; Walter Penk, Memorial Veterans Hospital, Bedford, MA; Diego Pizzagalli, Harvard University; Lauren Polvere, Concordia University; Andy Pomerantz, Southern Illinois University, Edwardsville; Harvey Richman, Columbus State University; Barry J. Ries, Minnesota State University; Lizabeth Roemer, University of Massachusetts at Boston; Rick Seime, Mayo Clinic; Frances Sessa, Pennsylvania State University, Abington; Brad Schmidt, Ohio State University; Kandy Stahl, Stephen F. Austin State University; Stephanie Stein, Central Washington University; Xuan Stevens, Florida International University; Eric Stice, University of Texas at Austin; Marcus Tye, Dowling College; Beverly Vchulek, Columbia College; Michael E. Walker, Stephen F. Austin State University; Clifton Watkins, University of North Texas; Nathan Weed, Central Michigan University; and Kenneth J. Zucker, Centre for Addiction and Mental Health, Ontario, Canada.

22 Preface

Acknowledgments for the Global Edition For their contribution to the Global Edition content, Pearson would like to thank Ashum Gupta, University of Delhi, and Malavika Kapur, National Institute of Mental Health and Neurosciences, Bangalore, and for their review of the content, Pearson would like to thank Jayanti

Banerjee, University of Calcutta; Paromita Mitra Bhaumik, Anubhav Positive Psychology Clinic, Kolkata; Bobby K. Cheon, Nanyang Technological University; Azizuddin Khan, Indian Institute of Technology Bombay; Gregor Lange, National University of Singapore; Iliana Magiati, National University of Singapore; Alizeh Batra Merchant, New York University Abu Dhabi; and Manchong Limlunthang Zou, University of Delhi.

About the Authors

Jill M. Hooley Harvard University

James N. Butcher Professor Emeritus, University of Minnesota

Jill M. Hooley is a professor of psychology at Harvard University. She is also the head of the experimental psychopathology and clinical psychology program at Harvard. Dr. Hooley was born in England and received a BSc in psychology from the University of Liverpool. This was followed by research work at Cambridge University. She then attended Magdalen College, Oxford, where she completed her DPhil. After a move to the United States and additional training in clinical psychology at SUNY Stony Brook, Dr. Hooley took a position at Harvard, where she has been a faculty member since 1985. Dr. Hooley has a long-standing interest in psychosocial predictors of psychiatric relapse in patients with severe psychopathology such as schizophrenia and depression. Her research has been supported by grants from the National Institute of Mental Health and by the Borderline Personality Disorder Research Foundation. She uses fMRI to study emotion regulation in people who are vulnerable to depression and in people who are suffering from borderline personality disorder. Another area of research interest is nonsuicidal self-harming behaviors such as skin cutting or burning. In 2000, Dr. Hooley received the Aaron T. Beck Award for Excellence in Psychopathology Research. She is also a past president of the Society for Research in Psychopathology. The author of many scholarly publications, Dr. Hooley was appointed Associate Editor for Clinical Psychological Science in 2012. She is also an associate editor for Applied and Preventive Psychology and serves on the editorial boards of several journals including the Journal of Consulting and Clinical Psychology, the Journal of Family Psychology, Family Process, and Personality Disorders: Theory, Research and Treatment. In 2015 Dr. Hooley received the Zubin Award for Lifetime Achievement in Psychopathology Research from the Society for Research in Psychopathology. At Harvard, Dr. Hooley has taught graduate and undergraduate classes in introductory psychology, abnormal psychology, schizophrenia, mood disorders, clinical psychology, psychiatric diagnosis, and psychological treatment. Reflecting her commitment to the scientist-practitioner model, she also does clinical work specializing in the treatment of people with depression, anxiety disorders, and personality disorders.

James N. Butcher was born in West Virginia. He enlisted in the army when he was 17 years old and served in the airborne infantry for 3 years, including a 1-year tour in Korea during the Korean War. After military service, he attended Guilford College, graduating in 1960 with a BA in psychology. He received an MA in experimental psychology in 1962 and a PhD in clinical psychology from the University of North Carolina at Chapel Hill. He was awarded Doctor Honoris Causa from the Free University of Brussels, Belgium, in 1990 and an honorary doctorate from the University of Florence, Florence, Italy, in 2005. He is currently professor emeritus in the Department of Psychology at the University of Minnesota. He was associate director and director of the clinical psychology program at the university for 19 years. He was a member of the University of Minnesota Press’s MMPI Consultative Committee, which undertook the revision of the MMPI in 1989. He was formerly the editor of Psychological Assessment, a journal of the American Psychological Association, and serves as consulting editor or reviewer for numerous other journals in psychology and psychiatry. Dr. Butcher was actively involved in developing and organizing disaster response programs for dealing with human problems following airline disasters during his career. He organized a model crisis intervention disaster response for the Minneapolis-St. Paul Airport and organized and supervised the psychological services offered following two major airline disasters: Northwest Flight 255 in Detroit, Michigan, and Aloha Airlines on Maui. He is a fellow of the Society for Personality Assessment. He has published 60 books and more than 250 articles in the fields of abnormal psychology, cross-cultural psychology, and personality assessment.

23

24  About the Authors

Matthew K. Nock Harvard University

Susan Mineka Northwestern University

Matthew Nock was born and raised in New Jersey. Matt received his BA from Boston University (1995), followed by two masters (2000, 2001) and a PhD from Yale University (2003). He also completed a clinical internship at Bellevue Hospital and the New York University Child Study Center (2003). Matt joined the faculty of Harvard University in 2003 and has been there ever since, currently serving as a Professor in the Department of Psychology. While an undergraduate, Matt became very interested in the question of why people do things to intentionally harm themselves and he has been conducting research aimed at answering this question ever since. His research is multidisciplinary in nature and uses a range of methodological approaches (e.g., epidemiologic surveys, laboratory-based experiments, and clinic-based studies) to better understand how these behaviors develop, how to predict them, and how to prevent their occurrence. His work is funded by research grants from the National Institutes of Health, Department of Defense, and several private foundations. Matt’s research has been published in over 100 scientific papers and book chapters and has been recognized through the receipt of awards from the American Psychological Association, the Association for Behavioral and Cognitive Therapies, and the American Association of Suicidology. In 2011 he received a MacArthur Fellowship (aka, “Genius Grant”) in recognition of his research on suicide and self-harm. At Harvard, Matt teaches courses on various topics including psychopathology, statistics, research methods, and cultural diversity. He has received numerous teaching and mentoring awards including the Roslyn Abramson Teaching Award and the Petra Shattuck Prize.

Susan Mineka, born and raised in Ithaca, New York, received her undergraduate degree magna cum laude in psychology at Cornell University. She received a PhD in experimental psychology from the University of Pennsylvania and later completed a formal clinical retraining program from 1981 to 1984. She taught at the University of Wisconsin–Madison and at the University of Texas at Austin before moving to Northwestern University in 1987. Since 1987 she has been a professor of psychology at Northwestern, and from 1998 to 2006 she served as director of clinical training there. She has taught a wide range of undergraduate and graduate courses, including introductory psychology, learning, motivation, abnormal psychology, and cognitive-behavior therapy. Her current research interests include cognitive and behavioral approaches to understanding the etiology, maintenance, and treatment of anxiety and mood disorders. She is currently a Fellow of the American Psychological Association, the American Psychological Society, and the Academy of Cognitive Therapy. She has served as editor of the Journal of Abnormal Psychology (1990–1994). She also served as associate editor for Emotion from 2002 to 2006 and is on the editorial boards of several of the leading journals in the field. She was also president of the Society for the Science of Clinical Psychology (1994–1995) and was president of the Midwestern Psychological Association (1997). She also served on the American Psychological Association’s Board of Scientific Affairs (1992–1994, chair 1994), on the Executive Board of the Society for Research in Psychopathology (1992–1994, 2000–2003), and on the Board of Directors of the American Psychological Society (2001–2004). During 1997 and 1998 she was a fellow at the Center for Advanced Study in the Behavioral Sciences at Stanford.

Chapter 1

Abnormal Psychology: Overview and Research Approaches

Learning Objectives 1.1 Explain how we define abnormality and

classify mental disorders. 1.2 Describe the advantages and disadvantages

of classification. 1.3 Explain how culture affects what is

considered abnormal and describe two different culture-specific disorders. 1.4 Distinguish between incidence and

prevalence and identify the most common and prevalent mental disorders. 1.5 Discuss why abnormal psychology research

1.6 Describe three different approaches used

to gather information about mental disorders. 1.7 Explain why a control (or comparison

group) is necessary to adequately test a hypothesis. 1.8 Discuss why correlational research designs

are valuable, even though they cannot be used to make causal inferences. 1.9 Explain the key features of an experimental

design.

can be conducted in almost any setting. 25

26  Chapter 1 Abnormal psychology is concerned with understanding the nature, causes, and treatment of mental disorders. The topics and problems within the field of abnormal psychology surround us every day. You have only to read a newspaper, flip through a magazine, surf the web, or sit through a movie to be exposed to some of the issues that clinicians and researchers deal with on a day-to-day basis. All too often, some celebrity is in the news because of a drug or alcohol problem, a suicide attempt, an eating disorder, or some other psychological difficulty. Countless books provide personal accounts of struggles with schizophrenia, depression, phobias, and panic attacks. Films and TV shows portray aspects of abnormal behavior with varying degrees of accuracy. And then there are the tragic news stories of mothers who kill their children, in which problems with depression, schizophrenia, or postpartum difficulties seem to be implicated. Abnormal psychology can also be found much closer to home. Walk around any college campus, and you will see flyers about peer support groups for people with eating disorders, depression, and a variety of other disturbances. You may even know someone who has experienced a clinical problem. It may be a cousin with a cocaine habit, a roommate with bulimia, or a grandparent who is developing Alzheimer’s disease. It may be a coworker of your mother’s who is hospitalized for depression, a neighbor who is afraid to leave the house, or someone at your gym who works out intensely despite being worrisomely thin. It may even be the disheveled street person in the aluminum foil hat who shouts, “Leave me alone!” to voices only he can hear. The issues of abnormal psychology capture our interest, demand our attention, and trigger our concern. They also compel us to ask questions. To illustrate further, let’s consider two clinical cases.

Scott Scott was born into an affluent family. There were no problems when he was born and he seemed to develop normally when he was a child. He went to a prestigious college and completed his degree in mathematics. Shortly afterwards, however, he began to isolate himself from his family and he abandoned his plans for graduate studies. He traveled to San Francisco, took an apartment in a run-down part of the city, became increasingly suspicious of people around him, and developed strange ideas about brain transfer technology. Shortly before Christmas, he received a package from a friend. As he opened the package, he reported that his “head exploded” and he began to hear voices, even though no one was around. The voices began to tell him what to do and what not to do. His concerned parents came out to visit him, but he refused to seek any help or return home to live with them. Shortly after, he left the city and, living as a homeless person, moved around the country, eventually making his way back to the East Coast. Throughout that time he was hearing voices every day—sometimes as many as five or six different ones. Eventually Scott’s worried family located him and persuaded him to seek treatment. Although he has been hospitalized several times and been on many different medications in the intervening years, Scott still has symptoms of psychosis. His voices have never entirely gone away and they still dictate his behavior to a considerable extent. Now age 49, he lives in a halfway house, and works part-time shelving books in a university library.

Perhaps you found yourself asking questions as you read about Monique and Scott. For example, because Monique doesn’t drink in the mornings, you might have

Monique Monique is a 24-year-old law student. She is attractive, neatly dressed, and clearly very bright. If you were to meet her, you would think that she had few problems in her life; but Monique has been drinking alcohol since she was 14, and she smokes marijuana every day. Although she describes herself as “just a social drinker,” she drinks four or five glasses of wine when she goes out with friends and also drinks several glasses of wine a night when she is alone in her apartment in the evening. She frequently misses early morning classes because she feels too hung over to get out of bed. On several occasions her drinking has caused her to black out. Although she denies having any problems with alcohol, Monique admits that her friends and family have become very concerned about her and have suggested that she seek help. Monique, however, says, “I don’t think I am an alcoholic because I never drink in the mornings.” The previous week she decided to stop smoking marijuana entirely because she was concerned that she might have a drug problem. However, she found it impossible to stop and is now smoking regularly again.

Fergie has spoken about her past struggles with substance abuse, specifically crystal meth.

Abnormal Psychology: Overview and Research Approaches  27

wondered whether she could really have a serious alcohol problem. She does. This is a question that concerns the criteria that must be met before someone receives a particular diagnosis. Or perhaps you wondered whether other people in Monique’s family likewise have drinking problems. They do. This is a question about what we call family aggregation—that is, whether a disorder runs in families. You may also have been curious about what is wrong with Scott and why he is hearing voices. Questions about the age of onset of his symptoms as well as predisposing factors may have occurred to you. Scott has schizophrenia, a disorder that often strikes in late adolescence or early adulthood. Also, as Scott’s case illustrates, it is not especially unusual for someone who develops schizophrenia to develop in a seemingly normal manner before suddenly becoming ill. These cases, which describe real people, give some indication of just how profoundly lives can be derailed because of mental disorders. It is hard to read about difficulties such as these without feeling compassion for the people who are struggling. Still, in addition to compassion, clinicians and researchers who want to help people like Monique and Scott must have other attributes and skills. If we are to understand mental disorders, we must learn to ask the kinds of questions that will enable us to help the patients and families who have mental disorders. These questions are at the very heart of a research-based approach that looks to use scientific inquiry and careful observation to understand abnormal psychology. Asking questions is an important aspect of being a psychologist. Psychology is a fascinating field, and abnormal psychology is one of the most interesting areas of psychology (although we are undoubtedly biased). Psychologists are trained to ask questions and to conduct research. Though not all people who are trained in abnormal psychology (this field is sometimes called psychopathology) conduct research, they still rely heavily on their scientific skills and ability both to ask questions and to put information together in coherent and logical ways. For example, when a clinician first sees a new client or patient, he or she asks many questions to try and understand the issues or problems related to that person. The clinician will also rely on current research to choose the most effective treatment. The best treatments of 20, 10, or even 5 years ago are not invariably the best treatments of today. Knowledge accumulates and advances are made—and research is the engine that drives all of these developments. In this chapter, we outline the field of abnormal psychology and the varied training and activities of the people who work within its demands. First we describe the ways in which abnormal behavior is defined and classified so that researchers and mental health professionals can communicate with each other about the people they see. Some of the issues here are probably more complex and

controversial than you might expect. We also outline basic information about the extent of behavioral abnormalities in the population at large. The second part of this chapter is devoted to research. We make every effort to convey to you how abnormal behavior is studied. Research is at the heart of progress and knowledge in abnormal psychology. The more you know and understand about how research is conducted, the more educated and aware you will be about what research findings do and do not mean.

What Do We Mean by Abnormality? 1.1 Explain how we define abnormality and classify mental disorders. It may come as a surprise to you that there is still no universal agreement about what is meant by abnormality or disorder. This is not to say we do not have definitions; we do. However, a truly satisfactory definition will probably always remain elusive (Lilienfeld et al., 2013; Stein et al., 2010).

Indicators of Abnormality Why does the definition of a mental disorder present so many challenges? A major problem is that there is no one behavior that makes someone abnormal. However, there are some clear elements or indicators of abnormality (Lilienfeld et al., 2013; Stein et al., 2010). No single indicator is sufficient in and of itself to define or determine abnormality. Nonetheless, the more that someone has difficulties in the following areas, the more likely he or she is to have some form of mental disorder: 1. Subjective distress: If people suffer or experience psychological pain we are inclined to consider this as indicative of abnormality. People with depression clearly report being distressed, as do people with anxiety disorders. But what of the patient who is manic and whose mood is one of elation? He or she may not be experiencing any distress. In fact, many such patients dislike taking medications because they do not want to lose their manic “highs.” You may have a test tomorrow and be exceedingly worried. But we would hardly label your subjective distress abnormal. Although subjective distress is an element of abnormality in many cases, it is neither a sufficient condition (all that is needed) nor even a necessary condition (a feature that all cases of abnormality must show) for us to consider something as abnormal. 2. Maladaptiveness: Maladaptive behavior is often an indicator of abnormality. The person with anorexia may restrict her intake of food to the point where she

28  Chapter 1 becomes so emaciated that she needs to be hospitalized. The person with depression may withdraw from friends and family and may be unable to work for weeks or months. Maladaptive behavior interferes with our well-being and with our ability to enjoy our work and our relationships. But not all disorders involve maladaptive behavior. Consider the con artist and the contract killer, both of whom have antisocial personality disorder. The first may be able glibly to talk people out of their life savings, the second to take someone’s life in return for payment. Is this behavior maladaptive? Not for them, because it is the way in which they make their respective livings. We consider them abnormal, however, because their behavior is maladaptive for and toward society. 3. Statistical deviancy: The word abnormal literally means “away from the normal.” But simply considering statistically rare behavior to be abnormal does not provide us with a solution to our problem of defining abnormality. Genius is statistically rare, as is perfect pitch. However, we do not consider people with such uncommon talents to be abnormal in any way. Also, just because something is statistically common doesn’t make it normal. The common cold is certainly very common, but it is regarded as an illness nonetheless. On the other hand, intellectual disability (which is statistically rare and represents a deviation from normal) is considered to reflect abnormality. This tells us that in defining abnormality we make value judgments. If something is statistically rare and undesirable (as is severely diminished intellectual functioning), we are more likely to consider it abnormal than something that is statistically rare and highly desirable (such as genius) or something that is undesirable but statistically common (such as rudeness).

As with most accomplished athletes, Venus and Serena Williams’ physical ability is abnormal in a literal and statistical sense. Their behavior, however, would not be labeled as being abnormal by psychologists. Why not?

4. Violation of the standards of society: All cultures have rules. Some of these are formalized as laws. Others form the norms and moral standards that we are taught to follow. Although many social rules are arbitrary to some extent, when people fail to follow the conventional social and moral rules of their cultural group, we may consider their behavior abnormal. For example, driving a car or watching television would be considered highly abnormal for the Amish of Pennsylvania. However, both of these activities reflect normal everyday behavior for most other Pennsylvania residents. Of course, much depends on the magnitude of the violation and on how commonly the rule is violated by others. As illustrated in the preceding example, a behavior is most likely to be viewed as abnormal when it violates the standards of society and is statistically deviant or rare. In contrast, most of us have parked illegally at some point. This failure to follow the rules is so statistically common that we tend not to think of it as abnormal. Yet when a mother drowns her children there is instant recognition that this is abnormal behavior. 5. Social discomfort: Not all rules are explicit. And not all rules bother us when they are violated. Nonetheless, when someone violates an implicit or unwritten social rule, those around him or her may experience a sense of discomfort or unease. Imagine that you are sitting in an almost empty bus. There are rows of unoccupied seats. Then someone comes in and sits down right next to you. How do you feel? Is the person’s behavior abnormal? Why? The person is not breaking any formal rule. He or she has paid for a ticket and is permitted to sit anywhere he or she likes. But your sense of social discomfort (“Why did this person sit right next to me when there are so many empty seats available?”) will probably incline you to think that this is an example of abnormal behavior. In other words, social discomfort is another potential way that we can recognize abnormality. But again, much depends on circumstances. If the person who gets on the bus is someone you know well, it might be more unusual if he or she did not join you. 6. Irrationality and unpredictability: As we have already noted, we expect people to behave in certain ways. Although a little unconventionality may add some spice to life, there is a point at which we are likely to consider a given unorthodox behavior abnormal. If a person sitting next to you suddenly began to scream and yell obscenities at nothing, you would probably regard that behavior as abnormal. It would be unpredictable, and it would make no sense to you. The disordered speech and the disorganized behavior of patients with schizophrenia are often irrational. Such behaviors are also a hallmark of the manic phases of bipolar disorder. Perhaps the most important factor, however, is our

Abnormal Psychology: Overview and Research Approaches  29

evaluation of whether the person can control his or her behavior. Few of us would consider a roommate who began to recite speeches from King Lear to be abnormal if we knew that he was playing Lear in the next campus Shakespeare production—or even if he was a dramatic person given to extravagant outbursts. On the other hand, if we discovered our roommate lying on the floor, flailing wildly, and reciting Shakespeare, we might consider calling for assistance if this was entirely out of character and we knew of no reason why he should be behaving in such a manner.

poisonous snakes as pets) not immediately regarded as mentally ill? Just because we may be a danger to ourselves or to others does not mean we are mentally ill. Conversely, we cannot assume that someone diagnosed with a mental disorder must be dangerous. Although people with mental illness do commit serious crimes, serious crimes are also committed every day by people who have no signs of mental disorder. Indeed, research suggests that in people with mental illness, dangerousness is more the exception than the rule (Corrigan & Watson, 2005).

7. Dangerousness: It seems quite reasonable to think that someone who is a danger to him- or herself or to another person must be psychologically abnormal. Indeed, therapists are required to hospitalize suicidal clients or contact the police (as well as the person who is the target of the threat) if they have a client who makes an explicit threat to harm another person. But, as with all of the other elements of abnormality, if we rely only on dangerousness as our sole feature of abnormality, we will run into problems. Is a soldier in combat mentally ill? What about someone who is an extremely bad driver? Both of these people may be a danger to others. Yet we would not consider them to be mentally ill. Why not? And why is someone who engages in extreme sports or who has a dangerous hobby (such as free diving, race car driving, or keeping

One final point bears repeating. Decisions about abnormal behavior always involve social judgments and are based on the values and expectations of society at large. This means that culture plays a role in determining what is and is not abnormal. In addition, because society is constantly shifting and becoming more or less tolerant of certain behaviors, what is considered abnormal or deviant in one decade may not be considered abnormal or deviant a decade or two later. At one time, homosexuality was classified as a mental disorder. But this is no longer the case (it was removed from the formal classification system in 1974). A generation ago, pierced noses and navels were regarded as highly deviant and prompted questions about a person’s mental health. Now, however, such adornments are commonplace and attract little attention. What other behaviors can you think of that are now considered normal but were regarded as deviant in the past?

Tattoos, which were once regarded as highly deviant, are now quite commonplace and considered fashionable by many.

How important is dangerousness to the definition of mental illness? If we are a risk to ourselves or to others, does this mean we are mentally ill?

As you think about these issues, consider the person described in the World Around Us box. He is certainly an unusual human being. But is his behavior abnormal? Do you think everyone will agree about this?

30  Chapter 1

The World Around Us Extreme Generosity or Pathological Behavior? Zell Kravinsky was a brilliant student who grew up in a workingclass neighborhood in Philadelphia. He won prizes at school, and at the age of 12, he began investing in the stock market. Despite his abilities, his Russian immigrant parents were, in the words of a family friend, “steadfast in denying him any praise.” Kravinsky eventually completed two Ph.D. degrees and indulged his growing interest in real estate. By the time he was 45 years old, he was married with children. His assets amounted to almost $45 million. Although Kravinsky had a talent for making money, he found it difficult to spend it. He drove an old car, did not give his children pocket money, and lived with his family in a modest home. As his fortune grew, however, he began to talk to his friends about his plans to give all of his assets to charity. His philanthropy began in earnest when he and his wife gave two gifts, totaling $6.2 million, to the Centers for Disease Control Foundation. They also donated an apartment building to a school for the disabled in Philadelphia. The following year the Kravinskys gave real estate gifts worth approximately $30 million to Ohio State University. Kravinsky’s motivation for his donations was to help others. According to one of his friends, “He gave away the money because he had it and there were people who needed it. But it changed his way of looking at himself. He decided the purpose of his life was to give away things.” After he had put some money aside in trust for his wife and his children, Kravinsky’s personal assets were reduced to a house (on which he had a substantial mortgage), two minivans, and around $80,000 in stocks and cash. He had essentially given away his entire fortune. Kravinsky’s donations did not end when his financial assets became depleted. He began to be preoccupied with the idea of nondirected organ donations, in which an altruistic person gives an organ to a total stranger. When he learned that he could live quite normally with only one kidney, Kravinsky decided that the personal costs of giving away one of his kidneys were minimal compared to the benefits received by the kidney recipient. His wife, however, did not share his view. Although she had consented to bequeathing substantial sums of money to worthwhile charities, when it came to her husband offering his kidney, she could not support him. For Kravinsky, however, the burden of refusing to help alleviate the suffering of someone in need was almost unbearable, even if it meant sacrificing his very own organs. He called the Albert Einstein Medical Center and spoke to a transplant coordinator. He met with a surgeon and then with a psychiatrist. Kravinsky told the psychiatrist that his wife did not support his desire to donate one of his kidneys. When the psychiatrist told him that he was doing something he did not have to do, Kravinsky’s response was that he did need to make this sacrifice: “You’re missing the whole point. It’s as much a necessity as food, water, and air.”

Is Zell Kravinsky’s behavior abnormal, or is he a man with profound moral conviction and courage?

Three months later, Kravinsky left his home in the early hours of the morning, drove to the hospital, and donated his right kidney. He informed his wife after the surgery was over. In spite of the turmoil that his kidney donation created within his family, Kravinsky’s mind turned back to philanthropy almost immediately. “I lay there in the hospital, and I thought about all my other good organs. When I do something good, I feel that I can do more. I burn to do more. It’s a heady feeling.” By the time he was discharged, he was wondering about giving away his one remaining kidney. After the operation, Kravinsky experienced a loss of direction. He had come to view his life as a continuing donation. However, now that his financial assets and his kidney were gone, what could he provide to the less fortunate? Sometimes he imagines offering his entire body for donation. “My organs could save several people if I gave my whole body away.” He acknowledges that he feels unable to hurt his family through the sacrifice of his life. Several years after the kidney donation, Kravinsky still remains committed to giving away as much as possible. However, his actions have caused a tremendous strain in his marriage. In an effort to maintain a harmonious relationship with his wife, he is now involved in real estate and has bought his family a larger home. (Taken from I. Parker, 2004.) Is Zell Kravinsky a courageous man of profound moral commitment? Or is his behavior abnormal and indicative of a mental disorder? Explain how you reached the conclusion you did.

Abnormal Psychology: Overview and Research Approaches  31

DSM-5  Thinking Critically about DSM-5 What Is the DSM and Why Was It Revised? The Diagnostic and Statistical Manual of Mental Disorders (DSM)

think about mental disorders. The revision process for DSM-5

provides all the information necessary (descriptions, lists of

had the goals of maintaining continuity with the previous edition

symptoms) to diagnose mental disorders. As such, it provides

(DSM-IV) as well as being guided by new research findings. But

clinicians with specific diagnostic criteria for each disorder. This

another guiding principle was that no constraints should be

creates a common language so that a specific diagnosis means

placed on the level of change that could be made. If this strikes

the same thing to one clinician as it does to another. In addition,

you as a little contradictory, you are correct. Striking the right bal-

providing descriptive information about the type and number of

ance between change and continuity presented considerable

symptoms needed for each diagnosis helps ensure diagnostic

challenges. It also created a great deal of controversy. As part of

accuracy and consistency (reliability). The DSM is also impor-

the revision process, experts in specific disorders were invited to

tant for research. If patients could not be diagnosed reliably, it

join special DSM-5 work groups and make specific recommenda-

would be impossible to compare different treatments for

tions for change. In some cases, the debates were so heated that

patients with similar conditions. Although the DSM does not

people resigned from their work groups! Now that DSM-5 is here,

include information about treatment, clinicians need to have an

not everyone is happy with some of the changes that have been

accurate diagnosis in order to select the most appropriate treat-

made. On the other hand, many of the revisions that have been

ment for their patients.

made make a lot of sense. In the chapters that follow we highlight

Since DSM-I was first published in 1952, the DSM has been

key changes in DSM-5. We also try to help you think critically

revised from time to time. Revisions are important because they

about the reasons behind the specific modifications that were

allow new scientific developments to be incorporated into how we

proposed and understand why they were accepted.

The DSM-5 and the Definition of Mental Disorder In the United States, the accepted standard for defining various types of mental disorders is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. This manual, commonly referred to as the DSM, is revised and updated from time to time. The current version, called DSM-5, was published in 2013. It is 947 pages long and contains a total of 541 diagnostic categories (Blashfield et al., 2014). This recent revision of the DSM has been the topic of much debate and controversy. In the Thinking Critically about DSM-5 box we explain more about the DSM and discuss why a revision was necessary. Although the DSM is widely used, it is not the only psychiatric classification system. The International Classification of Diseases (called ICD-10 because it is now in its 10th revision) is produced by the World Health Organization (WHO). Chapter V of this document covers mental and behavioral disorders (WHO, 2015b). Although the ICD-10 has much in common with DSM-5, it also many differences, with similar disorders having different

names, for example. The ICD-10 is used in many countries outside the United States and ICD-11 is currently in development. Within DSM-5, a mental disorder is defined as a syndrome that is present in an individual and that involves clinically significant disturbance in behavior, emotion regulation, or cognitive functioning. These disturbances are thought to reflect a dysfunction in biological, psychological, or developmental processes that are necessary for mental functioning. DSM-5 also recognizes that mental disorders are usually associated with significant distress or disability in key areas of functioning such as social, occupational, or other activities. Predictable or culturally approved responses to common stressors or losses (such as death of a loved one) are excluded. It is also important that this dysfunctional pattern of behavior not stem from social deviance or conflicts that the person has with society as a whole. This new DSM-5 definition of mental illness was based on input from various DSM-5 work groups as well as other sources (Broome & Bortolotti, 2010; First & Wakefield, 2010; Stein et al., 2010). Although this definition will still not satisfy everyone, it brings us even closer to a good working

32  Chapter 1 description. Keep in mind that any definition of abnormality or mental disorder must be somewhat arbitrary. Rather than thinking of the DSM as a finished product, it should always be regarded as a work in progress, with regular updates and modifications to be expected. Although earlier versions of the DSM used Roman numerals to refer to each specific edition (e.g., DSM-IV), Arabic numerals are now being used instead of Roman numerals (5 versus V) to facilitate updating (e.g., DSM-5.1, DSM-5.2) in the future.

in review • How can statistically rare behaviors be considered abnormal? • What characteristics help us recognize abnormality?

Classification and Diagnosis 1.2 Describe the advantages and disadvantages of classification. If defining abnormality is so contentious and so difficult, why do we try to do it? One simple reason is that most sciences rely on classification (e.g., the periodic table in chemistry and the classification of living organisms into kingdoms, phyla, classes, and so on in biology). At the most fundamental level, classification systems provide us with a nomenclature (a naming system). This gives clinicians and researchers both a common language and shorthand terms for complex clinical conditions. Without having a common set of terms to describe specific clinical conditions, clinicians would have to talk at length about each patient individually to provide an overview of the patient’s problems. But if there is a shared understanding of what the term “schizophrenia” means, for example, communication across professional boundaries is simplified and facilitated. Another advantage of classification systems is that they enable us to structure information in a more helpful manner. Classification systems shape the way information is organized. For example, most classification systems typically place diagnoses that are thought to be related in some way close together. In DSM-5, the section on anxiety disorders includes disorders (such as panic disorder, specific phobia, and agoraphobia) that share the common features of fear and anxiety. Organizing information within a classification system also allows us to study the different disorders that we classify and therefore to learn new things. In other words, classification facilitates research, which gives us more information and facilitates greater understanding, not only about what causes various disorders but also how they might best be treated. For example, thinking back to the cases you read about, Monique has alcohol and drug use disorders, and Scott has schizophrenia. Knowing what disorder each of them has is clearly very helpful, because Scott’s treatment would be very different from Monique’s.

A final effect of classification system usage is somewhat more mundane. As others have pointed out, the classification of mental disorders has social and political implications (see Keeley et al., 2015; Kirk & Kutchins, 1992). Simply put, defining the domain of what is considered to be pathological establishes the range of problems that the mental health profession can address. As a consequence, on a purely pragmatic level, it furthermore delineates which types of psychological difficulties warrant insurance reimbursement and the extent of such reimbursement.

What Are the Disadvantages of Classification? Of course, a number of potential disadvantages are associated with the use of a discrete classification system. Classification, by its very nature, provides information in a shorthand form. However, using any form of shorthand inevitably leads to a loss of information. If we know the specific history, personality traits, idiosyncrasies, and familial relations of a person with a particular type of disorder (e.g., from reading a case summary), we naturally have much more information than if we were simply told the individual’s diagnosis (e.g., schizophrenia). In other words, as we simplify through classification, we inevitably lose an array of personal details about the actual person who has the disorder. Moreover, although things are improving, there can still be some stigma (disgrace) associated with having a psychiatric diagnosis. Stigma, of course, is hardly the fault of the diagnostic system itself. But even today, people are generally far more comfortable disclosing that they have a physical illness such as diabetes than they are admitting to any mental disorder. This is in part due to the fear (real or imagined) that speaking candidly about having a psychological disorder will result in unwanted social or occupational consequences or frank discrimination. Be honest. Have you ever described someone as “nuts,” “crazy,” or “a psycho”? Now think of the hurt that people with mental disorders experience when they hear such words. In one study, 96 percent of patients with schizophrenia reported that stigma was a routine part of their lives (Jenkins & Carpenter-Song, 2008). In spite of the large amount of information that is now available about mental health issues, the level of knowledge about mental illness (sometimes referred to as mental health literacy) is often very poor (Thornicroft et al., 2007). Stigma is a deterrent to seeking treatment for mental health problems. This is especially true for younger people, for men, and for ethnic minorities (Clement et al., 2015). Stigma is also a disproportionately greater deterrent to treatment seeking for two other groups: military personnel and (ironically) mental health professionals. Would you have predicted this? Why do you think this is the case? Related to stigma is the problem of stereotyping. Stereotypes are automatic beliefs concerning other people that

Abnormal Psychology: Overview and Research Approaches  33

we unavoidably learn as a result of growing up in a particular culture (e.g., people who wear glasses are more intelligent; New Yorkers are rude). Because we may have heard about certain behaviors that can accompany mental disorders, we may automatically and incorrectly infer that these behaviors will also be present in any person we meet who has a psychiatric diagnosis. Negative stereotypes about psychiatric patients are also perpetuated in movies. If you have ever seen a horror movie you know that a common dominant theme involves the homicidal maniac. And an analysis of 55 horror films made between 2000 and 2012 has shown that it is people with psychosis who are most often portrayed as murderers (Goodwin, 2014). Stereotyping is also reflected in the comment “People like you don’t go back to work” in the case example of James McNulty.

James McNulty I have lived with bipolar disorder for more than 35 years—all of my adult life. The first 15 years were relatively conventional, at least on the surface. I graduated from an Ivy League university, started my own business, and began a career in local politics. I was married, the father of two sons. I experienced mood swings during these years, and as I got older the swings worsened. Eventually, I became so ill that I was unable to work, my marriage ended, I lost my business, and I became homeless. At this point I had my most powerful experience with stigma. I was 38 years old. I had recently been discharged after a psychiatric hospitalization for a suicide attempt, I had no place to live, my savings were exhausted, and my only possession was a 4-year-old car. I contacted the mental health authorities in the state where I then lived and asked for assistance in dealing with my mental illness. I was told that to qualify for assistance I would need to sell my car and spend down the proceeds. I asked how I was supposed to get to work when I recovered enough to find a job. I was told, “Don’t worry about going back to work. People like you don’t go back to work.” (McNulty, 2004)

Finally, stigma can be perpetuated by the problem of labeling. A person’s self-concept may be directly affected by being given a diagnosis of schizophrenia, depression, or some other form of mental illness. How might you react if you were told something like this? Furthermore, once a group of symptoms is given a name and identified by means of a diagnosis, this diagnostic label can be hard to shake even if the person later makes a full recovery. It is important to keep in mind, however, that diagnostic classification systems do not classify people. Rather, they classify the disorders that people have. And stigma may be less a consequence of the diagnostic label than a result of the disturbed behavior that got the person the diagnosis in the first place. In some situations, a diagnosis may even reduce stigma because it provides at least a partial explanation for a person’s otherwise inexplicable behavior (Ruscio, 2004). Nonetheless, when we note that someone has an illness, we should take care not to define him or her by that illness.

Respectful and appropriate language should instead be used. At one time, it was quite common for mental health professionals to describe a given patient as “a schizophrenic” or “a manic-depressive.” Now, however, it is widely acknowledged that it is more accurate (not to mention more considerate) to use what is called person-first language and say, “a person with schizophrenia,” or “a person with bipolar disorder.” Simply put, the person is not the diagnosis.

How Can We Reduce Prejudicial Attitudes Toward People Who Are Mentally Ill? Negative reactions to people with mental illness are common and may be a fairly widespread phenomenon throughout the world. Using focus groups, Arthur and colleagues (2010) asked community residents in Jamaica about the concept of stigma. Some participants came from rural communities, others from more urban areas. Regardless of their gender, level of education, or where they lived, most participants described highly prejudicial attitudes toward those with mental illnesses. One middle-class male participant said, “We treat them as in a sense second class citizens, we stay far away from them, ostracize them, we just treat them bad” (see Arthur et al., 2010, p. 263). Fear of people who are mentally ill was also commonly expressed. A rural-dwelling middle-class man described a specific situation in the following way, “There is a mad lady on the

Are attitudes toward people who are mentally ill in Jamaica more benign than they are in more industrialized countries?

34  Chapter 1 road named […]. Even the police are afraid of her because she throws stones at them. She is very, very terrible” (p. 261). Moreover, even when more kindly attitudes were expressed, fear was still a common response. One person put it simply, “You are fearful even though you may be sympathetic” (p. 262). In short, the results of this study suggest that stereotyping, labeling, and stigma toward people with mental illness are not restricted to industrialized countries. Although we might wish that it were otherwise, prejudicial attitudes are common. This highlights the need for anti-stigma campaigns. For a long time, it was thought that educating people that mental illnesses were “real” brain disorders might be the solution. Sadly, however, this does not seem to be the case. Although there have been impressive increases in the proportion of people who now understand that mental disorders have neurobiological causes, this increased awareness has not resulted in decreases in stigma. In one study, Pescosolido and colleagues (2010) asked people in the community to read a vignette (brief description) about a person who showed symptoms of mental illness. Some people read a vignette about a person who had schizophrenia. Others read a vignette about someone with clinical depression or alcohol dependence. Importantly, no diagnostic labels were used to describe these people. The vignettes simply provided descriptive information. Nonetheless, the majority of the people who were surveyed in this study expressed an unwillingness to work with the person described in the vignette. They also did not want to have to socialize with them and did not want them to marry into their family. Moreover, the level of rejection that was shown was just as high as it was in a similar survey that was done 10 years earlier. Over that same 10-year period, however, many more people embraced a neurobiological understanding about the causes of mental illness. So what this study tells us is that just because people understand that mental illness is caused by problems in the brain doesn’t mean that they are any less prejudiced toward those with mental illness. This is a disappointing conclusion for everyone who hoped that more scientific research into the biology of mental illness would lead to the elimination of stigma. Stigma does seem to be reduced by having more contact with people in the stigmatized group (Corrigan et al., 2014; Couture & Penn, 2003). However, there may be barriers to this. Simply imagining interacting with a person who has a mental disorder can lead to distress and also to unpleasant physical reactions. In an interesting study, Graves and colleagues (2005) asked college students enrolled in a psychology course to imagine interacting with a person whose image was shown to them on a slide. As the slide was being presented, subjects were given some scripted biographical information that described the person. In some scripts, the target person was described as having been diagnosed with schizophrenia, although it was also mentioned that he or she

was “doing much better now.” In other trials, the biographical description made no mention of any mental illness when the person on the slide was being described. Students who took part in the study reported more distress and had more muscle tension in their brows when they imagined interacting with a person with schizophrenia than when they imagined interacting with a person who did not have schizophrenia. Heart rate changes also suggested they were experiencing the imagined interactions with the patients as being more unpleasant than the interactions with the nonpatients. Finally, research participants who had more psychophysiological reactivity to the slides of the patients reported higher levels of stigma toward these patients. These findings suggest that people may tend to avoid those with mental illness because the psychophysiological arousal these encounters create is experienced as unpleasant.

in review • What is stigma? How common is it? • What challenges are involved in reducing stigma toward people with mental illness?

Culture and Abnormality 1.3 Explain how culture affects what is considered abnormal and describe two different culturespecific disorders. Just as we must consider changing societal values and expectations in defining abnormality, so too must we consider differences across cultures. In fact, this is explicitly acknowledged in the DSM-5 definition of disorder. Within a given culture, many shared beliefs and behaviors exist that are widely accepted and that may constitute one or more customary practices. For instance, many people in Christian countries believe that the number 13 is unlucky. The origins of this may be linked to the Last Supper, at which 13 people were present. Many of us try to be especially cautious on Friday the 13th. Some hotels and apartment buildings avoid having a 13th floor altogether. Similarly, there is frequently no bed numbered 13 in hospital wards. The Japanese, in contrast, are not worried about the number 13. Rather, they attempt to avoid the number 4. This is because in Japanese the sound of the word for “four” is similar to the sound of the word for “death” (see Tseng, 2001, pp. 105–106). There is also considerable variation in the way different cultures describe psychological distress. For example, there is no word for “depressed” in the languages of certain Native Americans, Alaska Natives, and Southeast Asian cultures (Manson, 1995). Of course, this does not mean that members from such cultural groups do not experience clinically significant depression. As the accompanying case illustrates,

Abnormal Psychology: Overview and Research Approaches  35 coats are ragged; they’re thinner. They just wander aimlessly; even the ewes don’t seem to care about the little ones.” Physical examination and laboratory tests are normal. Mr. GH continues to take two tablets of acetaminophen daily for mild arthritic pain. Although he describes himself as a “recovering alcoholic,” Mr. GH reports not having consumed alcohol during the last 23 years. He denies any prior episodes of depression or other psychiatric problems. (Manson, 1995, p. 488)

There is no word for “depressed” in the languages of certain Native American tribes. Members of these communities tend to describe their symptoms of depression in physical rather than emotional terms.

however, the way some disorders present themselves may depend on culturally sanctioned ways of articulating distress.

Depression in a Native American Elder JGH is a 71-year-old member of a Southwestern tribe who has been brought to a local Indian Health Service hospital by one of his granddaughters and is seen in the general medical outpatient clinic for multiple complaints. Most of Mr. GH’s complaints involve nonlocalized pain. When asked to point to where he hurts, Mr. GH indicates his chest, then his abdomen, his knees, and finally moves his hands “all over.” Barely whispering, he mentions a phrase in his native language that translates as “whole body sickness.” His granddaughter notes that he “has not been himself” recently. Specifically, Mr. GH, during the past 3 or 4 months, has stopped attending or participating in many events previously important to him and central to his role in a large extended family and clan. He is reluctant to discuss this change in behavior as well as his feelings. When questioned more directly, Mr. GH acknowledges that he has had difficulty falling asleep, sleeps intermittently through the night, and almost always awakens at dawn’s first light. He admits that he has not felt like eating in recent months but denies weight loss, although his clothes hang loosely in many folds. Trouble concentrating and remembering are eventually disclosed as well. Asked why he has not participated in family and clan events in the last several months, Mr. GH describes himself as “too tired and full of pain” and “afraid of disappointing people.” Further pressing by the clinician is met with silence. Suddenly the patient states, “You know, my sheep haven’t been doing well lately. Their

As is apparent in the case of JGH, culture can shape the clinical presentation of disorders like depression, which are present across cultures around the world (see Draguns & Tanaka-Matsumi, 2003). In China, for instance, individuals with depression frequently focus on physical concerns (fatigue, dizziness, headaches) rather than verbalizing their feelings of melancholy or hopelessness (Kleinman, 1986; Parker et al., 2001). This focus on physical pain rather than emotional pain is also noteworthy in Mr. GH’s case. Despite progressively increasing cultural awareness, we still know relatively little concerning cultural interpretation and expression of abnormal psychology (Arrindell, 2003). The vast majority of the psychiatric literature originates from Euro-American countries—that is, Western Europe, North America, and Australia/New Zealand (Patel & Kim, 2007; Patel & Sumathipala, 2001). To exacerbate this underrepresentation, research published in languages other than English tends to be disregarded (Draguns, 2001). Prejudice toward people with mental illness seems to be found worldwide. However, some types of psychopathology appear to be highly culture specific: They are found only in certain areas of the world and seem to be highly linked to culturally bound concerns. A case in point is taijin kyofusho. This syndrome, which is an anxiety disorder, is quite prevalent in Japan. It involves a marked fear that one’s body, body parts, or body functions may offend, embarrass, or otherwise make others feel uncomfortable. Often, people with this disorder are afraid of blushing or upsetting others by their gaze, facial expression, or body odor (Levine & Gaw, 1995).

Some disorders are highly culture specific. For example, taijin kyofusho is a disorder that is prevalent in Japan. It is characterized by the fear that one may upset others by one’s gaze, facial expression, or body odor.

36  Chapter 1 Another culturally rooted expression of distress, found in people of Latino descent, especially those from the Caribbean, is ataque de nervios or an “attack of nerves” (Lizardi et al., 2009; Lopez & Guarnaccia, 2005). This is a clinical syndrome that does not seem to correspond to any specific diagnosis within the DSM. The symptoms of an ataque de nervios, which is often triggered by a stressful event such as divorce or bereavement, include crying, trembling, and uncontrollable screaming. There is also a sense of being out of control. Sometimes the person may become physically or verbally aggressive. Alternately, the person may faint or experience a seizure-like fit. Once the ataque is over, the person may promptly resume his or her normal manner, with little or no memory of the incident. As noted earlier, abnormal behavior is behavior that deviates from the norms of the society in which the person lives. Experiences such as hearing the voice of a dead relative might be regarded as normative in one culture (e.g., in many Native American tribes) yet abnormal in another cultural milieu. Nonetheless, certain unconventional actions and behaviors are almost universally considered to be the product of mental disorder. Many years ago, the anthropologist Jane Murphy (1976) studied abnormal behavior in the Yoruba of Africa and the Yupik-speaking Eskimos living on an island in the Bering Sea. Both societies had words that were used to denote abnormality or “craziness.” In addition, the clusters of behaviors that were considered to reflect abnormality in these cultures were behaviors that most of us would also regard as abnormal. These included hearing voices, laughing at nothing, defecating in public, drinking urine, and believing things that no one else believes. Why do you think these behaviors are universally considered to be abnormal?

in review • In what ways can culture shape the clinical presentation of mental disorders? • Are the same disorders always found worldwide, regardless of culture?

How Common Are Mental Disorders? 1.4 Distinguish between incidence and prevalence and identify the most common and prevalent mental disorders. How many and what sort of people have diagnosable psychological disorders today? This is a significant question for a number of reasons. First, such information is essential when planning and establishing mental health services. Mental health planners require a precise understanding of

the nature and extent of the psychological difficulties within a given area, state, or country because they are responsible for determining how resources such as funding of research projects or services provided by community mental health centers may be most effectively allocated. It would obviously be imprudent to have a treatment center filled with clinicians skilled in the treatment of anorexia nervosa (a very severe but relatively rare clinical problem) if there were few clinicians skilled in treating anxiety or depression, which are much more prevalent disorders. Second, estimates of the frequency of mental disorders in different groups of people may provide valuable clues as to the causes of these disorders. For example, data from the United Kingdom have shown that schizophrenia is about three times more likely to develop in ethnic minorities than in the white population (Kirkbridge et al., 2006). Rates of schizophrenia in southeast London are also high relative to other parts of the country. This is prompting researchers to explore why this might be. Possible factors may be social class and neighborhood deprivation, as well as diet or exposure to infections or environmental contaminants.

Prevalence and Incidence Before we can further discuss the impact of mental disorders upon society, we must clarify the way in which psychological problems are counted. Epidemiology is the study of the distribution of diseases, disorders, or healthrelated behaviors in a given population. Mental health epidemiology is the study of the distribution of mental disorders. A key component of an epidemiological survey is determining the frequencies of mental disorders. There are several ways of doing this. The term prevalence refers to the number of active cases in a population during any given period of time. Prevalence figures are typically expressed as percentages (i.e., the percentage of the population that has the disorder). Furthermore, there are several different types of prevalence estimates that can be made. Point prevalence refers to the estimated proportion of actual, active cases of a disorder in a given population at a given point in time. For example, if we were to conduct a study and count the number of people who have major depressive disorder (i.e., clinical depression) on January 1 of next year, this would provide us with a point prevalence estimate of active cases of depression. A person who experienced depression during the months of November and December but who managed to recover by January 1 would not be included in our point prevalence calculation. The same is true of someone whose depression did not begin until January 2. If, on the other hand, we wanted to calculate a 1-year prevalence figure, we would count everyone who experienced depression at any point in time throughout the entire

Abnormal Psychology: Overview and Research Approaches  37

year. As you might imagine, this prevalence figure would be higher than the point prevalence figure because it would cover a much longer time. It would moreover include those people who had recovered before the point prevalence assessment as well as those whose disorders did not begin until after the point prevalence estimate was made. Finally, we may also wish to obtain an estimate of the number of people who have had a particular disorder at any time in their lives (even if they are now recovered). This would provide us with a lifetime prevalence estimate. Because they extend over an entire lifetime and include both currently ill and recovered individuals, lifetime prevalence estimates tend to be higher than other kinds of prevalence estimates. An additional term with which you should be familiar is incidence. This refers to the number of new cases that occur over a given period of time (typically 1 year). Incidence figures tend to be lower than prevalence figures because they exclude preexisting cases. In other words, if we were assessing the 1-year incidence of schizophrenia, we would not count people whose schizophrenia began before our given starting date (even if they were still ill) because they are not “new” cases of schizophrenia. On the other hand, someone who was quite well previously but then developed schizophrenia during our 1-year window would be included in our incidence estimate.

Prevalence Estimates for Mental Disorders Now that you have an understanding of some basic terms, let’s turn to the 1-year prevalence rates for several important disorders. The most comprehensive source of prevalence estimates for adults in the United States diagnosed with mental disorders is the National Comorbidity Survey Replication (NCS-R). It sampled the entire adult American population using a number of sophisticated methodological strategies (Kessler et al., 2004; Kessler, Berglund, Borges, et al., 2005; Kessler & Merikangas, 2004). Table 1.1 shows 1-year and lifetime prevalence estimates of the DSM-IV mental disorders assessed from the NCS-R study.

Table 1.1  Prevalence of Mental Disorders in Adults in the United States 1-Year (%)

Lifetime (%)

Any anxiety disorder

18.1

28.8

Any mood disorder

 9.5

20.8

Any substance-abuse disorder

 3.8

14.6

Any disorder

26.2

46.4

SOURCES: Based on Kessler, R. C., Berglund, P., Borges, G., Nock, M., & Wang, P. S. (2005a). Trends in suicide ideation, plans, gestures, and attempts in the United States. JAMA, 293(20), 2487–95.; Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005c). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch. Gen. Psychiatry, 62, 617–27.

Because DSM-5 is so new, no comprehensive lifetime prevalence data using this revised version of the DSM are yet available. However, the lifetime prevalence of having any DSM-IV disorder is 46.4 percent. This means that almost half of the Americans who were questioned had been affected by mental illness at some point in their lives (Kessler, Berglund, Demler, et al., 2005). Although this figure may seem high, it may actually be an underestimate, as the NCS-R study did not assess for eating disorders, schizophrenia, or autism, for example. Neither did it include measures of most personality disorders. As you can see from Table 1.1, the most prevalent category of psychological disorders is anxiety disorders. The most common individual disorders are major depressive disorder, alcohol abuse, and specific phobias (e.g., fear of small animals, insects, flying, heights). Social phobias (e.g., fear of public speaking) are similarly very common (see Table 1.2).

Table 1.2  Most Common Individual Mental Disorders in the United States Disorder

1-Year Prevalence (%)

Lifetime Prevalence (%)

Major depressive disorder

6.7

16.6

Alcohol abuse

3.1

13.2

Specific phobia

8.7

12.5

Social phobia

6.8

12.1

Conduct disorder

1.0

 9.5

SOURCES: Based on Kessler, R. C., Berglund, P., Borges, G., Nock, M., & Wang, P. S. (2005a). Trends in suicide ideation, plans, gestures, and attempts in the United States. JAMA, 293(20), 2487–95.; Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005c). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch. Gen. Psychiatry, 62, 617–27.

Although lifetime (and 12-month) rates of mental disorders appear to be quite high, it is important to remember that, in some cases, the duration of the disorder may be relatively brief (e.g., depression that lasts for a few weeks after the breakup of a romantic relationship). Furthermore, many people who meet criteria for a given disorder will not be seriously affected by it. For instance, in the NCS-R study, almost half (48 percent) of the people diagnosed with a specific phobia had disorders that were rated as mild in severity, and only 22 percent of phobias were regarded as severe (Kessler, Chiu, et al., 2005). Meeting diagnostic criteria for a particular disorder and being seriously impaired by that disorder are not necessarily synonymous. In the NCS-R data, 12-month rates of serious mental illness are estimated to be 5.8 percent for adults and 8.0 percent among adolescents (Kessler et al., 2012). One problem with the NCS-R data is that they are now well over a decade old. Fortunately, another survey, called the National Survey on Drug Use and Health (NSDUH), is conducted every year. Although this survey does not include information about specific disorders, it can be used to provide the most recent information. As you can see from Figure 1.1, the most up-to-date estimates show that

38  Chapter 1

Figure 1.1  Prevalence of Serious Mental Illness Among U.S. Adults (2012) Rates of severe mental illness are higher in women, people ages 26 to 49, and some minority groups. (Data courtesy of SAMHSA)

Prevalence of Serious Mental Illness Among U.S. Adults (2012) 9

8.5

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4.9

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the 1-year prevalence of serious mental illness (excluding substance use disorders) in adults in the United States is 4.1 percent overall. This is not too far from the 5.8 percent rate reported in the NCS-R (which did include substance use disorders). You can also see from the figure that rates of serious mental illness are higher in some groups than in others. A final finding from the NCS-R study concerns the widespread occurrence of comorbidity among diagnosed disorders (Kessler, Chiu, et al., 2005). Comorbidity is the term used to describe the presence of two or more disorders in the same person. Comorbidity is especially high in people who have severe forms of mental disorders. In the NCS-R study, half of the individuals with a disorder rated as serious on a scale of severity (mild, moderate, and serious) had two or more additional disorders. An illustration of this would be a person who drinks excessively and who is simultaneously depressed and suffering from an anxiety disorder. In contrast, only 7 percent of the people who had a mild form of a disorder also had two or more other diagnosable conditions. What this indicates is that comorbidity is much more likely to occur in people who have the most serious forms of mental disorders. When the condition is mild, comorbidity is the exception rather than the rule.

Disorders do not always occur in isolation. A person who abuses alcohol may also be depressed or pathologically anxious. This is an example of comorbidity.

Abnormal Psychology: Overview and Research Approaches  39

The Global Burden of Disease

Treatment

Mental and substance use disorders are often disabling conditions. Worldwide, they account for over 7 percent of the global burden of disease. This is more than the burden of disease caused by HIV/AIDS, tuberculosis, diabetes, or transportation injuries. Because they are so common, anxiety disorders, depressive disorders, and substance use disorders together account for 184 million disability adjusted years of life (DALYs), where one DALY can be thought of as the loss of 1 year of otherwise “healthy” life. The disorder that results in the biggest global burden is depression, which accounts for more than 40 percent of the DALYs (see Figure 1.2). In terms of lost economic output caused by people with mental disorders being temporarily or permanently unable to work, estimates are that, worldwide, mental disorders will cost 16 trillion U.S. dollars (about 25 percent of global GDP in 2010) during the next 20 years. This is a staggering figure. It also does not include the costs of treatment or the personal (emotional) costs that living with a mental disorder can cause for the person and his or her family (Whiteford et al., 2013). All of this points to the need to find better ways to provide mental health services, especially in developing countries. In war-torn or resourceconstrained environments, however, this presents numerous challenges.

Although they may not be available to everyone, many treatments for psychological disorders exist. These include medications as well as different forms of psychotherapy. Each chapter of this book that covers specific disorders also includes a section describing how those disorders are treated. In addition, in Chapter 16 we discuss different approaches to treatment more broadly and describe different types of therapy in detail. However, it is important to emphasize that not all people with psychological disorders receive treatment. In some cases, people deny or minimize their suffering. Others try to cope on their own and may manage to recover without ever seeking aid from a mental health professional. As we noted earlier, stigma is a factor that makes some people especially reluctant to seek help (Clement et al., 2015). Even when they recognize that they have a problem, it is typical for individuals to wait a long time before deciding to seek help. Half of individuals with depression delay seeking treatment for more than 6 to 8 years. For anxiety disorders, the delay ranges from 9 to 23 years (Wang, Berglund, et al., 2005)! When people with mental disorders do seek help, they are often treated by their family physician rather than by a mental health specialist (Wang, Berglund, et al., 2005). It is also the case that the vast majority of mental health treatment

Figure 1.2  The Burden of Mental Illness for Different Disorders Across the Lifespan Disability adjusted life years (DALYs) for various mental and substance use disorders are shown according to age. DALYs represent the total (worldwide) number of otherwise healthy years of life that are lost or profoundly impacted because of the disorder. Depression causes the greatest total disability. This is because depression is a relatively common disorder. (Adapted from Whiteford et al., 2013. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet, 382, 1580.)

8000 7000 Depressive disorders Anxiety disorders Schizophrenia Bipolar disorder Eating disorders Childhood behavioral disorders Pervasive developmental disorders Idiopathic intellectual disability Alcohol use disorders Drug use disorders Other mental disorders

5000 4000 3000 2000 1000

10 9 –1 15 4 –1 20 9 –2 25 4 –2 30 9 –3 35 4 –3 40 9 –4 45 4 –4 50 9 –5 55 4 –5 60 9 –6 65 4 –6 70 9 –7 75 4 –7 9 ≥8 0

4

5–