Social Psychology

A. Factors in Mental Disorders

Causes of Abnormal Behavior girls and God-fearing adults (L. Shapiro, 1992). In the 1960s,
one major cause of mental disorders was thought to be envi-
Explanations for the causes of mental disorders have ronmental factors, such as stressful events. In the 1990s came
changed dramatically through the centuries. In the Mid- advances in studying genetic factors as well as new methods
dle Ages, mental disorders were thought to be the result to study the structures and functions of living brains (p. 70).
of demons or devils who inhabited individuals and made As a result, current researchers and clinicians believe that
them do strange and horrible things. In the 1600s, men- mental disorders, such as that of Dennis Rader, result from a
tal disorders were thought to involve witches, who were number of factors, which include biological, cognitive-emotional-
believed to speak to the devil. is was the case in Salem, behavioral, and environmental influences (Hersen & omas, 2006).
Massachusetts, in 1692, where, in a short span of four months, 14
women and 5 men were hanged as witches on the testimony of young

Biological Factors Cognitive-Emotional-Behavioral & Environmental Factors

Biological influences include genetic or inherited factors and vari- Because biological factors themselves do not always explain why
ous neurological factors that influence how the brain functions. people develop mental disorders, psychologists point to various
Genetic factors. As an infant, Joan would cry, show great cognitive-emotional-behavioral factors that interact with and con-
fear, and try to avoid new or novel objects or situations. Because tribute to developing mental disorders.
Joan showed great fear as an infant, researchers concluded that her Cognitive-emotional-behavioral and

fearfulness was primarily due to genetic factors (Kagan, 2003a). environmental factors that contribute to the

Genetic factors that contribute to the development of mental disor- development of mental disorders include

ders are unlearned or inherited tendencies that influence how a person deficits in cognitive processes, such as hav-

thinks, behaves, and feels. ing unusual thoughts and beliefs; deficits in

Genetic factors operate by affecting the developing brain and/ processing emotional stimuli, such as under-

or the neurotransmitters that the brain uses for communication. or overreacting to emotional situations;

Researchers estimate that genetic factors contribute from 30% to behavioral problems, such as lacking social

60% to the development of mental disorders, such as depression, skills; and environmental challenges, such

schizophrenia, and anxiety disorders (Rutter & Silberg, 2002). as dealing with stressful situations. Unusual thoughts, emotions,
Neurological factors. Joan, who had started life as a fearful For example, Dennis Rader was behaviors, or events contribute
infant, had developed a serious mental disorder called a social to developing mental disorders.
a shy and polite child who preferred
phobia (p. 518) by the time she was 20. Researchers believed that to spend time alone. As a boy, he recalls watching his grandparents
one reason she developed a social phobia was that her brain’s emo- strangle chickens at their farm, and by the time he reached high
tional detector, called the amygdala (p. 362), was overactive and school, he was strangling cats and dogs. Rader’s hobby during child-
too o en identified stimuli as threatening hood was looking at pictures of women in bondage. By his teens, he
when they were only new or novel. In fantasized about tying up, controlling, and torturing women. He was
fact, when researchers measured the becoming increasingly bothered by murderous impulses but did not
activity (fMRI) of Joan’s amygdala, know how to tell anyone about it (Ortiz, 2005; Singular, 2006). Rader’s
they found that her amygdala overre- many maladaptive thoughts, emotions, and behaviors interacted with
acted when she looked at new or novel his biological factors and resulted in his serious mental disorder.
faces, something that did not happen Environmental factors. In some cases, traumatic events, such as
Amygdala- in the amygdalas of individuals who did being in a war, having a serious car accident, watching some hor-
emotions not have social phobias (C. E. Schwartz et rible event (a dog attacking and killing a child), or being brutally

Very fearful adults al., 2003). In a related study, individuals mugged, assaulted, or raped, can result in a long-lasting emotional Photo Credit: right, © Colin Anderson/Brand X/Corbis
had more activity in who had developed social phobias, like disorder called posttraumatic stress disorder, or PTSD. As we dis-
Joan, showed far more amygdala activity cussed earlier (p. 491), a person with PTSD may relive the terrible
the amygdala. when looking at angry, fearful, or disgusted event through memories and nightmares and have serious emotional

faces than did individuals without social phobias (Luan et al., problems that o en require professional help (Resick et al., 2008).
2006). e studies illustrate neurological factors, such as having Experiencing PTSD is an example of how traumatic environmental
an overactive brain structure that contributes to the development factors can contribute to developing a serious mental disorder.
of a mental disorder by causing a person to see the world in a Many factors. e answer to why Joan developed a social pho-
biased or distorted way and to see threats when none really exist. bia, or Dennis Rader became a serial killer, or a family member,
Although these studies show that biological factors—genetic friend, or relative developed a mental disorder involves a number
and neurological—can contribute to the development of mental of factors—genetic, neurological, cognitive-emotional-behavioral,
disorders, not everyone with an overactive amygdala develops a and environmental. As several or more of these factors interact, the
mental disorder. is means that other factors are also involved result in some cases can be the development of one of the mental
in the development of mental disorders. disorders that we’ll discuss in this and the next module.

510 M O D U L E 2 2 A S S E S S M E N T & A N X I E T Y D I S O R D E R S

Definitions of Abnormal Behavior

Is Mr. In some cases, such as Dennis Rader’s murder and mutilation of 10 individuals, we
have no doubt that he demonstrated an extremely abnormal behavior pattern. In
Thompson other cases, such as Kate Premo’s phobia of flying, we would probably say that most
abnormal? of her life appears to be normal except for a small piece—fear of flying in air-
planes—that is abnormal. In still other cases, such as that of 54-year-old Richard
ompson (right photo), it is less clear what is abnormal behavior.
e City of San Diego evicted ompson and all his belongings from his home. His belongings
included shirts, pants, dozens of shoes, several Bibles, a cooler, a tool chest, lawn chairs, a barbecue grill,
tin plates, bird cages, two pet rats, and his self-fashioned bed. For the previous nine months, ompson
had lived happily and without any problems in a downtown storm drain (sewer). Because the city does
not allow people to live in storm drains, however, ompson was evicted from his underground storm-
drain home and forbidden to return. Although ompson later lived in several care centers and mental
hospitals, he much preferred the privacy and comfort of the sewer (Grimaldi, 1986).
There are three different ways to decide whether Richard Thompson’s behavior—living in the Is it abnormal to live in a storm
sewer—was abnormal. drain if you don’t bother anyone?

Photo Credits: top and bottom center, © San Diego Union Tribune/ZUMA Press; bottom left, © PhotoDisc, Inc.; bottom right, © Kelly Redinger/Design Pics/Corbis Statistical Frequency Deviation from Social Norms Maladaptive Behavior

Although ompson caused no problems Thompson’s behavior—preferring to e major problem with the first two definitions
to others except to violate a city law against live in a sewer—could also be consid- of abnormal behavior—statistical frequency and
living in a storm drain, his preferred liv- ered abnormal based on social norms. deviation from social norms—is that they don’t
ing style could be considered abnormal The social norms approach says that say whether a particular behavior is psychologi-

according to statistical frequency. a behavior is considered abnormal if it cally damaging or maladaptive.

The statistical frequency approach says deviates greatly from accepted social The maladaptive behavior approach defines a

that a behavior may be considered standards, values, or norms. behavior as psychologically damaging or abnormal if it

abnormal if it occurs rarely or Thompson’s decision to live by interferes with the individual’s ability to function in his

infrequently in relation to the himself in a storm drain greatly de- or her personal life or in society.

behaviors of the general viates from society’s norms about For example, being terrified of flying, hear-

population. where people should live. However, a ing voices that dictate dangerous acts, feeling

By this definition, definition of abnormality based solely compelled to wash one’s hands for hours on end,
ompson’s living in a on deviations from social norms runs starving oneself to the point of death (anorexia
storm drain would be into problems when social norms nervosa), and Dennis Rader’s committing serial
According to considered very abnor- change with time. For murders would all be considered maladaptive
statistical mal since, out of over example, 25 years and, in that sense, abnormal.
frequency, 300 million people in ago, very few males However, Thompson’s seemingly successful
living in a the United States, only wore earrings, while adaptation to living in a sewer may not be mal-
a very few prefer his today many males adaptive for him and certainly has no adverse
monastery is
abnormal.

kind of home. This illustrates that even consider earrings consequences to society.
though statistical frequency is a relative- very fashion- Most useful. Of the three definitions dis-
ly precise measure, it is not a very useful able. Similarly, cussed here, mental
measure of abnormality. By this criterion, 40 years ago, a health professionals
getting a Ph.D., being president, living in woman who pre- find that the most use-
a monastery, and selling a million records According to ferred to be very ful definition of abnor-
are abnormal, although some of these be- social norms, thin was consid- mal behaviors is the one
haviors would be considered very desir- living in a storm ered to be ill and based on the maladap-
able by most people. In fact, Guinness drain is abnormal. in need of medi- tive definition—that is,

World Records (2009) lists thousands of cal help. Today, our society pressures whether a behavior or
people who have performed some statis- women to be thin like the fashion behavior pattern inter-
tically abnormal behaviors and are very models in the media. feres with a person’s
proud of them. We would not consider us, defining abnormality on the According to the ability to function nor-
any of these individuals to necessarily basis of social norms can be risky, as maladaptive definition, mally in society (Sue et
have mental disorders. social norms may, and do, change behavior is abnormal al., 2010).
As all these examples demonstrate, the over time. The definition of abnor-
if it interferes with a However, you’ll see
person’s functioning.

statistical frequency definition of abnor- mality most used by mental health that deciding whether behavior is truly maladap-
mality has very limited usefulness. professionals is the next one. tive is not always so easy.

A . F A C T O R S I N M E N T A L D I S O R D E R S 511

B. Assessing Mental Disorders

Definition of Assessment

How do In some cases, it’s relatively easy to identify her car by the edge of the lake, strapped her two children into their
what’s wrong with a person. For example, car seats, shut the windows and doors, got out of the car, walked to
you find out it’s clear that Dennis Rader was a serial the rear, and pushed the car into the lake. She covered her ears so
what’s wrong? killer and that Kate Premo has an intense she couldn’t hear the splash. e car disappeared under the water.
and irrational fear of flying. But in other e two little boys, strapped into their seats, drowned.
cases, it’s more difficult to identify exactly what the Susan’s confession stunned the nation as everyone asked,
person’s motivation and mental problem are. Take “How could she have killed her own children?” “What’s
the tragic case of Susan Smith. wrong with Susan?” To answer these questions, mental health
Susan Smith appeared on the “Today” show, professionals evaluated Susan’s mental health with a proce-
crying for the return of her two little boys (right dure called the clinical assessment (J. M. Wood et al., 2002).
photo), Michael, 3 years old, and Alex, 14 months A clinical assessment involves a systematic evaluation of an

old, who, she said, had been kidnapped. She begged Susan first said her individual’s various psychological, biological, and social factors, as
the kidnapper to feed them, care for them, and sons were kidnapped well as identifying past and present problems, stressors, and other
please, please, return them. And then, nine days but later confessed that cognitive or behavioral symptoms.
later, a er a rigorous investigation turned up doubts she had drowned them.
A clinical assessment is the first step in figuring out
about the kidnapping story, the police questioned Susan again. Not which past or current problems may have contributed to Susan
only did she change her story, but she made the teary confession killing her own children (Begley, 1998b). We’ll discuss how a
that she had killed her two children. She said that she had parked clinical assessment is done.

Three Methods of Assessment
A er Susan’s arrest, mental health professionals did clinical assessments to try to discover what terrible forces
How was pushed her over the edge. Depending on their training, mental health professionals use one or more of three

Susan evaluated? major techniques—neurological exams, clinical interviews, and psychological tests—to do clinical
assessments.

Neurological Tests Clinical Interviews Psychological Tests

We can assume that Susan was As part of her clinical assessment, several psychiatrists As part of her assessment, psycholo-
given a number of neurological spent many hours interviewing Susan. is method is gists may have given Susan a number
tests to check for possible brain called a clinical interview (Hersen & omas, 2007). of personality tests (pp. 450, 474). Photo Credits: top, © Time & Life Pictures/Getty Images; bottom center, © AP Images/Tim Kimzey
damage or malfunction. ese The clinical interview is one method of gathering informa-
Personality tests include two different
tests might include evaluating tion about a person’s past and current behaviors, beliefs, atti- kinds of tests: objective tests (self-report
questionnaires), such as the MMPI, which
reflexes, brain structures (MRI tudes, emotions, and problems. Some clinical interviews are consist of specific statements or ques-
tions to which the person responds with
scans), and brain functions unstructured, which means they have no set specific answers, and projective tests,
such as the Rorschach inkblot test, which
(fMRI scans—p. 70). questions; others are structured, which have no set answers but consist of ambig-
uous stimuli that a person interprets or
Neurological exams are part means they follow a standard format of makes up a story about.

of a clinical assessment because asking a similar set of questions. As we also discussed in Modules
19 and 20, personality tests help
a variety of abnormal psycho- During the clinical interview, clinicians evaluate a person’s traits,
logical symp- Susan would have been asked about attitudes, emotions, and beliefs.
toms may the history of her current problems,
be caused such as when they started and what Purpose. A major goal of doing
by tumors, other events accompanied them. e What are a clinical assessment is to decide
diseases, or focus of the interview would have Susan’s past which mental health disorder best
infections of the been on Susan’s current problem, and current accounts for a client’s symptoms.
Did killing her children, especially on the psychological For example, based on her symptoms,
Susan have problems? Susan was described as having a
brain. neurological mood disorder, which you’ll see
Neurological problems? details of the symptoms that led up to next is one of many possible mental
the killing. e clinical interview is perhaps the primary health problems.
tests are used to
distinguish physical or organic technique used to assess abnormal behavior (Durand &
causes (tumors) from psycho- Barlow, 2006).
logical ones (strange beliefs) Based on 15 hours of interviews, Dr. Seymour Halleck
(Zillmer et al., 2008). Susan was testified that Susan was scarred by her father’s suicide
reported to have no neurological and her stepfather sexually abusing her, which led to
problems. periods of depression, her current problem (Towle, 1995).

512 M O D U L E 2 2 A S S E S S M E N T & A N X I E T Y D I S O R D E R S

C. Diagnosing Mental Disorders

Real-Life Assessment
In criminal trials that involve questions of mental health, the defense and prosecution usually hire their own
What can a psychiatrists or psychologists because they are looking for different problems or symptoms. In Susan’s case,

clinical assessment at least two psychiatrists did clinical assessments to answer a number of questions: What are her current
tell us? symptoms? What past events and situations caused these symptoms? What role did her symptoms play in the
killing of her children?

Her Past Her Present

During clinical interviews, the psychiatrist The psychiatrist found that Susan’s present problems included
found that when Susan was 8 years old, her becoming depressed a er being rejected by her current boyfriend.
father shot himself. When she was 13, psy- She confessed to being so lonely in the months before the killings
chologists wanted to admit her to a hospital that she had multiple sexual encounters: with her stepfather, who
to treat her depression, but her mother and had molested her as a teenager; with her estranged husband,
stepfather refused to cooperate. Later, when whom she was divorcing; with her current boyfriend, who later
Susan was 15, her stepfather sexually molest- wrote a good-bye letter; and with her boyfriend’s father. In addi-
ed her, but her mother refused to press charg- tion, Susan was drinking heavily during this period.
es. When she was in high school, she had Dr. Halleck testified that Susan suffered from severe depres-
periods of depression and attempted suicide. Susan’s clinical sion, drinking, and an adjustment disorder that caused her to have
assessment revealed a
However, she did well academically, was an disturbed person. She is a heightened emotional reaction to stress (D. Morgan, 1995).
honor student and a member of the math being led away to serve a In just 2½ hours, the jury decided that Susan Smith was guilty
club, and was voted the “friendliest female”
life sentence. of murder. She was led from the courthouse (upper le photo) to

in the class of 1989. She married David in 1991, but one serve a life sentence.
year a er the birth of their second son, their marriage fell As a result of her clinical assessment, Susan was diagnosed as having a
apart and they filed for divorce (Bragg, 1995). mood disorder and was treated in prison with antidepressants.
Dr. Seymour Halleck testified that Susan was scarred A clinical assessment is a method of identifying a client’s symptoms,
by her father’s suicide, her stepfather’s sexual abuse, which are used to make a diagnosis. Making a diagnosis requires match-
and her periods of depression, which contributed to her ing the symptoms to a particular disorder, which involves using the DSM-
current difficulties (Towle, 1995). IV-TR.

DSM-IV-TR ose who knew Susan tried to diagnose gave only general descriptions of mental problems because it was based on
the problem that led to her tragic crime.
How Sigmund Freud’s general concepts of psychoses (severe mental disorders,

many mental “Maybe Susan was just plain crazy.” such as schizophrenia) and neuroses (less severe forms of psychological

disorders? “Maybe she was too depressed to know conflict, such as anxiety). Using only general descriptions caused disagree-
what she was doing.” “Maybe she had ments in diagnosing problems. The DSM-III (1980) dropped Freudian
bad genes.” “Maybe something bad happened to her as a child.” terminology and instead listed specific symptoms and criteria for mental
Using a more rigorous method, mental health profession- disorders. However, these criteria were based primarily on clinical opin-
als conduct clinical assessments to identify symptoms, which ions, not research, so disagreements continued. A major improvement in
are then used to make a clinical diagnosis. the current DSM-IV-TR is that it establishes criteria and symptoms for
A clinical diagnosis is a process of matching an individual’s spe- mental disorders based more on research findings than on clinical opin-

cific symptoms to those that define a particular mental disorder. ions (L. A. Clark et al., 1995). When the next DSM comes out, likely in
Making a clinical diagnosis was very difficult prior to the 2012, mental health experts predict that
it will use new findings from genetics Number of Disorders
1950s because there was no uniform code or diagnostic system.
Photo Credit: © AP Images/Ruth Fremson However, since 1952, the American Psychiatric Association and neuroscience to better identify the DSM-I 106
(APA) has been developing a uniform diagnostic system, whose underlying causes of mental disorders
most recent version is known as the Diagnostic and Statistical (First, 2007; M. C. Miller, 2007).
Manual of Mental Disorders-IV-Text Revision, abbreviated as Interestingly, the first Diagnostic and DSM-II 182
DSM-IV-TR (American Psychiatric Association, 2000).
Statistical Manual of Mental Disorders DSM-III 265
The Diagnostic and Statistical Manual of Mental Disorders-IV-
(1952) described about 100 mental dis- 297
Text Revision, or DSM-IV-TR, describes a uniform system for assess- orders, as compared to almost 300 in the DSM-IV-TR

ing specific symptoms and matching them to almost 300 different most recent DSM-IV-TR (right figure).

mental disorders. We’ll use the cases of Dennis Rader (serial killer), Susan Smith (mur-

With each revision of the DSM, there have been improvements derer), and Kate Premo (phobia of flying) to show how mental health
in diagnosing mental disorders. For example, the DSM-II (1968) professionals use the DSM-IV-TR to make a diagnosis.

C . D I A G N O S I N G M E N T A L D I S O R D E R S 513

C. Diagnosing Mental Disorders

Nine Major Problems: Axis I

How do In making a clinical diagnosis, a mental health In diagnosing major depression, the DSM-
professional first assesses the client’s specific IV-TR distinguishes between early (before age
we make a symptoms and then matches these symptoms 21) and late onset depression—Susan would
diagnosis? to those described in the DSM-IV-TR. The be early, and between mild and severe
DSM-IV-TR has five major dimensions, called depression, as judged by how many epi-
axes, which serve as guidelines for making decisions about symp- sodes of depression she had and whether
toms. We’ll first describe Axis I and show how it can be used to she showed a decreased capacity to func-
diagnose the very different problems of Susan Smith and Kate tion normally, such as the inability to work
Premo. ( e numbered items below and on the opposite page are or care for children. Susan’s ability to hold
based on the Diagnostic and Statistical Manual of Mental Disorders- Diagnosis: a job and care for her children suggests mild
IV-Text Revision [2000], American Psychiatric Association.) Mood disorder depression. This example shows how the

Axis I: Nine Major Clinical Syndromes guidelines of Axis I are used to arrive at one of nine major clinical
syndromes—in this case, major depression.
Photo Credits: top, © AP Images/Tim Kimzey; right, © Elizabeth Roll
Axis I contains lists of symptoms and criteria about the onset, sever- 6. Anxiety disorders. Figure/Text Credit: Syndrome titles from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright © 1994 American Psychiatric Association.
ity, and duration of these symptoms. In turn these lists of symptoms ese disorders are characterized by physiological signs of anxi-
are used to make a clinical diagnosis of the following nine major
clinical syndromes. ety (for example, palpitations) and subjective feelings of tension,
apprehension, or fear. Anxiety may be acute and focused (pho-
1. Disorders usually first diagnosed in infancy, childhood, bias) or continual and diffuse (generalized anxiety disorder). An
or adolescence. example of an anxiety disorder is that of Kate Premo.

is category includes disorders that arise before adolescence, such Kate Premo: Diagnosis—Specific Phobia
as attention-deficit disorders, autism, mental retardation, enuresis,
and stuttering (discussed in Modules 1, 2, and 13). Kate Premo’s symptoms include having an
intense fear of flying, knowing that her fear is
2. Organic mental disorders. irrational and that she can’t control it, going
ese disorders are temporary or permanent dysfunctions of brain out of her way to avoid flying, and making res-
ervations that she later cancels. Kate’s symp-
tissue caused by diseases or chemicals, such as delirium, dementia toms most closely match the DSM-IV-TR’s list
(Alzheimer’s—p. 50), and amnesia (p. 265). of symptoms for an anxiety disorder called a
specific phobia. e DSM-IV-TR’s symptoms Diagnosis:
3. Substance-related disorders. for a specific phobia match those of Premo— Specific phobia
This category refers to the maladaptive use of drugs and alcohol. experiencing intense and irrational fear when
Mere consumption and recreational use of such substances are not (aviophobia)
disorders. is category requires an abnormal pattern of use, as with
alcohol abuse and cocaine dependence (pp. 188–189). exposed to a feared situation (flying) and having to avoid that situ-
ation at all costs, which interferes with part of her normal activities
4. Schizophrenia and other psychotic disorders. (going to meetings).
e schizophrenias are characterized by psychotic symptoms (for
7. Somatoform disorders.
example, grossly disorganized behavior, delusions, and hallucina- ese disorders are dominated by somatic symptoms that resem-
tions) and by over six months of behavioral deterioration. is cate-
gory, which also includes delusional disorder and schizoaffective ble physical illnesses. ese symptoms cannot be accounted for by
disorder, will be discussed in Module 23. organic damage. ere must also be strong evidence that these
symptoms are produced by psychological factors or conflicts. is
5. Mood disorders. category, which includes somatization and conversion disorders
e cardinal feature is emotional disturbance. Patients may or may and hypochondriasis, will be discussed in this module.

not have psychotic symptoms. These disorders, including major 8. Dissociative disorders.
depression, bipolar disorder, dysthymic disorder, and cyclothymic ese disorders all feature a sudden, temporary alteration or dys-
disorder, are discussed in Module 23. Susan Smith is an example of a
person with a mood disorder. function of memory, consciousness, identity, and behavior, as in
dissociative amnesia and multiple personality disorder (discussed
Susan Smith: Diagnosis—Mood Disorder in Module 23).
From childhood on, Susan’s symptoms include being depressed,
attempting suicide, seeking sexual alliances to escape loneliness, 9. Sexual and gender-identity disorders.
drinking heavily, and having feelings of low self-esteem and hope- ere are three types of disorders in this category: gender-identity
lessness, all of which match the DSM-IV-TR’s list of symptoms for a
mood disorder. In Susan’s case, the specific mood disorder most disorders (discomfort with identity as male or female), paraphilias
closely matches major depressive disorder but without serious (preference for unusual acts to achieve sexual arousal), and sexual
thought disorders and delusions. dysfunctions (impairments in sexual functioning) (discussed in
Module 15).

514 M O D U L E 2 2 A S S E S S M E N T & A N X I E T Y D I S O R D E R S

Other Problems and Disorders: Axes II, III, IV, V Usefulness of DSM-IV-TR
e figure below shows the steps in mak-
We have explained how Axis I is used to make clinical diagnoses of such mental disor-
ders as major depression (mood disorder) and specific phobias (fear of flying). Now, we’ll ing a clinical diagnosis. Mental health
briefly describe how the other four axes are used in diagnosing problems. professionals begin by using three differ-
ent methods to identify a client’s symp-
Axis II: Personality Disorders toms, a process called clinical assess-
ment. Next, the client’s symptoms are
is axis refers to disorders that involve patterns of personality traits that are long-stand- matched to the five axes in the DSM-IV-
ing, maladaptive, and inflexible and involve impaired functioning or subjective distress. TR to arrive at a diagnosis of each client’s
Examples include borderline, schizoid, and antisocial personality disorders. Personality particular mental disorder.
disorders will be discussed in Module 23. An example of a personality disorder is that
of Rader. 1. Clinical interviews
2. Psychological tests
Dennis Rader: Diagnosis—Antisocial Personality Disorder 3. Neurological tests

Dennis Rader’s symptoms include torturing and killing 10 individuals, Clinical assessment:
feeling no guilt or remorse, and exhibiting this behavior over a consid- identify symptoms
erable period of time. Rader’s symptoms may indicate a combination
Photo Credit: © Jeff Tuttle/AFP/Getty Images of mental disorders, but here we’ll focus on only one from the DSM- DSM-IV-TR:
Figure/Text Credit: Syndrome titles from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright © 1994 American Psychiatric Association. IV-TR, a personality disorder. According to the DSM-IV-TR, the Use symptoms to
essential features of an antisocial personality disorder are strange diagnose mental disorder
inner experiences that differ greatly from the expectations of one’s
culture, that lead to significant impairment in personal, occupa- For mental health professionals, there
tional, or social functioning, and that form a pattern of disregard are three advantages of using the DSM-
Diagnosis: Antisocial for, and violation of, the rights of others. is list of symptoms IV-TR’s uniform system to diagnose and
personality disorder from the DSM-IV-TR matches those of Rader. classify mental disorders (Widiger &
Clark, 2000).
Axis III: Personality Disorders
First, mental health professionals use
is axis refers to physical disorders or conditions, such as diabetes, arthritis, and hemo- the classification system to communi-
philia, that have an influence on someone’s mental disorder. cate with one another and discuss their
clients’ problems.
Axis IV: Psychosocial and Environmental Problems
Second, researchers use the classi-
is axis refers to psychosocial and environmental problems that may affect the diagno- fication system to study and explain
sis, treatment, and prognosis of mental disorders in Axes I and II. A psychosocial or envi- mental disorders.
ronmental problem may be a negative life event (experiencing a traumatic event), an
environmental difficulty or deficiency, a familial or other interpersonal stress, an inade- ird, therapists use the classification
quacy of social support or personal resources, or another problem that describes the con- system to design their treatment pro-
text in which a person’s difficulties have developed (PTSD was discussed on p. 491). gram so as to best fit a particular client’s
problem.
Axis V: Global Assessment of Functioning Scale
Although using the DSM-IV-TR sys-
is axis is used to rate the overall psychological, social, and occupational functioning of tem to diagnose mental problems has
the individual on a scale from 1 (severe danger of hurting self) to 100 (superior function- advantages, it also has a number of po-
ing in all activities). tential problems. For example, mental
health professionals do not always agree
Using all five axes. Mental health professionals use all five axes to make a clinical on whether a client fits a particular di-
diagnosis. For example, in the case of Dennis Rader, his unusual sexual symptoms may agnosis. In addition, there may be social,
match those of a sexual disorder in Axis I. His other maladaptive symptoms match those political, and labeling problems, which
of an antisocial personality disorder in Axis II. Rader apparently had no related medi- we’ll discuss next.
cal conditions listed in Axis III. Rader was a loner with poor self-esteem and struggled
with his schoolwork, which match some of the psychological, social, and environmental
factors listed in Axis IV. Amazingly, Rader functioned well enough to hold a job and
go unnoticed in his neighborhood, which would be used to rate his general function-
ing listed in Axis V. As you can see, each of the five axes in the DSM-IV-TR focuses on
a different factor that contributes to making an overall clinical diagnosis of a person’s
mental health.

C . D I A G N O S I N G M E N T A L D I S O R D E R S 515

C. Diagnosing Mental Disorders

Potential Problems with Using the DSM-IV-TR
It’s not uncommon to hear people use labels, such as “Jim’s really anxious,” “Mary Ann is compulsive,” or “Vicki is
Is labeling schizophrenic.” Although the goal of the DSM-IV-TR is to give mental disorders particular diagnostic labels, once a

a problem? person is labeled, the label itself may generate a negative stereotype. In turn, the negative stereotype results in negative
social and political effects, such as biasing how others perceive and respond to the labeled person (Greatley, 2004).

Labeling Mental Disorders Social and Political Implications
Diagnostic labels can change how a person is perceived and thus
David Oaks, a sophomore at Harvard University, was having have political and social implications. For instance, in the 1970s, gays
such fearful emotional experiences that he was examined by a protested that homosexuality should not be included in the DSM-I
psychiatrist. Although David believed that he was having a and II as a mental disorder. When studies found that homosexuals
mystical experience, the psychiatrist were no more or less mentally healthy than heterosexuals, homosex-
interpreted and labeled David’s fearful uality as a mental disorder was eliminated from the DSM-III.
experiences as indicating a kind of
short-term schizophrenic disorder In the 1980s, women protested the DSM label of self-
(Japenga, 1994). This mental health defeating personality disorder because the label applied
professional made a clinical diagnosis primarily to women who were said to make destructive life
that resulted in giving a label to choices, such as staying in abusive relationships (Japenga,
David’s problem. 1994). is label was dropped from the DSM-IV because
Labeling refers to identifying and nam- it suggested that women were choosing bad relationships,
which wasn’t true (P. Caplan, 1994).
ing differences among individuals. The
Despite these advances, labeling continues to be a serious
label, which places individuals into spe- problem. For instance, 68% of Americans don’t want someone with a
mental illness marrying into their family and 58% don’t want people
cific categories, may have either positive Some labels with mental illness at their workplace (J. K. Martin et al., 2000). Also,
or negative associations. (anxious, depressed) even though mental illness does not increase the chance of someone
being violent, many Americans still believe that people with mental
At first David felt relieved to know have negative illness tend to behave in violent ways (Elbogen & Johnson, 2009).
that his problem had a diagnosis or stereotypes.
Japan has a special problem with labels: Mental disorder labels
label. Later he realized that his new label was changing his life have very negative connotations, which discourages Japanese from
for the worse. People no longer responded to him as David- seeking professional help for mental disorders. One result is that,
the-college-sophomore but as David-with-schizophrenic- compared to the United States, Japan has a very high rate of suicide.
disorder.
As David’s case shows, the advantage of diagnostic labels at’s because one risk for suicide is depression, a label the Japanese
is their ability to summarize and communicate a whole lot of avoid and thus they do not get timely treatment. In comparison, in
information in a single word or phrase. But, the disadvantage the United States, the label of depression is widely accepted, so peo-
is that if the label has negative associations—for example, ple are more likely to be treated, even by doctors in general practice
mentally ill, retarded, schizo—the very label may elicit nega- (Menchetti et al., 2009).
tive or undesirable responses. For this reason, mental health
professionals advise that we not respond to people with men- ese examples illustrate the social and political implications of
tal disorders by their labels and instead respond to the person labeling individuals with mental disorders.
behind the label (Albee & Joffe, 2004).

Frequency of Mental Disorders
Although labels are a fact of life, researchers and clinicians try to What was surprising was that 59% of those with a mental disorder
apply the DSM labels as fairly as possible. Researchers interviewed had neither asked for nor received any professional treatment. is
a national sample of 9,282 noninsti- study also found that about 50% of all life-
tutionalized civilians aged 18 and Percentage Who Will Have a time mental disorders begin by age 14 and
older and diagnosed their problems Mental Disorder in Their Lifetime 75% begin by age 24.

using the DSM’s diagnostic system. Any disorder 32% 51% Researchers concluded that about one in
As the graph at the right shows, two people will develop a mental disorder
based on those surveyed, 51% of Anxiety disorders sometime in their life, most individuals with
people will develop at least one dis- a mental disorder do not seek treatment, and
order during their lifetime (Kessler Mood disorders 28% there is a need to understand how to best

et al., 2005). e most common men- 15% Alcohol use disorders treat mental disorders in youth.
tal disorder was anxiety, followed by Next, we’ll examine the symptoms and
mood disorders and substance abuse, 9% Drug use disorders treatment of specific disorders, beginning

especially problems with alcohol. with anxiety.

516 M O D U L E 2 2 A S S E S S M E N T & A N X I E T Y D I S O R D E R S

D. Anxiety Disorders

e most common mental disorder reported by adults in Anxiety Disorders
How common the United States is any kind of anxiety disorder (right
Any anxiety disorder 29%
is anxiety? graph) (Kessler et al., 2005). We have already discussed
two serious anxiety problems, panic disorder (p. 481) and 13% Social phobia
11% Specific phobia
posttraumatic stress disorder (PTSD) (p. 491). Here we’ll review panic disorder 8% Posttraumatic stress disorder
and PTSD, as well as discuss other common forms of anxiety: generalized anxiety 5% Generalized anxiety
disorder, three kinds of phobias, and obsessive-compulsive disorder. 5% Agoraphobia

Generalized Anxiety Disorder
During his initial therapy interview, Fred was sweating,
fidgeting in his chair, and repeatedly asking for water to quench 4% Panic disorder
a never-ending thirst. From all indications, Fred was visibly dis- 3% Obsessive-compulsive disorder
tressed and extremely nervous. At first, Fred spoke only of his
dizziness and problems with sleeping. However, it soon became Panic Disorder
clear that he had nearly always felt tense. He admitted to a long
history of difficulties in interacting with others, difficulties One a ernoon, Luisa (pictured below), a 23-year-old college student, was
that led to his being fired from two jobs. He constantly wor- walking on campus and she suddenly felt her heart rate rapidly accelerate,
ried about all kinds of possible disasters that might happen to her throat tighten up, and her arms and legs tremble. She became so nau-
him (Davison & Neale, 1990). Fred’s symptoms showed that seous she almost vomited. Luisa felt she had no control over what was
he was suffering from generalized anxiety disorder.
happening. en, weeks later, while at the movies, she had another
Generalized anxiety disorder (GAD) is characterized by episode during which she experienced dizziness, chest pain,
excessive or unrealistic worry about almost everything or shortness of breath, and weakness in her legs and feet. She
feeling that something bad is about to happen. These anxious feared she was having a heart attack and might die, but a er a
feelings occur on a majority of days for a period of at least six series of tests, her doctors found no medical problem. Luisa’s
months (American Psychiatric Association, 2000). symptoms indicate that she had a panic disorder.
Panic disorder is characterized by recurrent and unexpect-

About 5% of adults are reported to have GAD, ed panic attacks (described below). The person becomes so

but almost twice as many adult women (6.6%) report Anxiety can be worried about having another panic attack that this intense wor-
treated with drugs
GAD as do men (3.6%) (Halbreich, 2003). and psychotherapy. rying interferes with normal psychological functioning (American
Symptoms Psychiatric Association, 2000).

Like Luisa, about 4% of adults in the United States suf-
Generalized anxiety disorder includes both psychological and fer from panic disorder, and women are two to three times more likely
physical symptoms. Psychological symptoms include being to report it than are men (Halbreich, 2003). People who suffer from
irritable, having difficulty concentrating, and being unable to panic disorder have an increased risk of alcohol and other drug abuse,
control one’s worry, which is out of proportion to the actual an increased incidence of suicide, decreased social functioning, and less
event. Constant worrying causes significant distress or marital happiness. About half suffer from depression (Smits et al., 2006).
impaired functioning in social, occupational, and other areas.
Physical symptoms include restlessness, fatigue, sweating, Symptoms

flushing, pounding heart, insomnia, headaches, and muscle Luisa’s symptoms on campus and at the movies indicate that she was
tension or aches (American Psychiatric Association, 2000). having a panic attack, which may occur in several different anxiety dis-
orders but is the essential feature of panic disorder.
Treatment A panic attack is a period of intense fear or discomfort in which four or

Generalized anxiety disorder is commonly treated with psycho- more of the following symptoms are present: pounding heart, sweating, trem-
therapy (see Module 24), with or without drugs. e drugs most bling, shortness of breath, feelings of choking, chest pain, nausea, feeling dizzy,
frequently prescribed are tranquilizers such as alprazolam and and fear of losing control or dying (American Psychiatric Association, 2000).
diazepam, which belong to a group known as the benzodiaz-
epines (ben-zoh-die-AS-ah-peens). One of the limitations of these Treatment

drugs is that at high doses they are addicting and interfere with Panic disorders are usually treated with drugs—benzodiazepines, anti-
the ability to remember newly learned information (Arkowitz & depressants (Prozac-like drugs, which are selective serotonin reuptake
Lilienfeld, 2007a; Rupprecht et al., 2009). Antidepressant drugs inhibitors, or SSRIs)—and/or psychotherapy. Research indicates psy-
are also used to treat GAD and have fewer side effects and a chotherapy is at least as effective as drug therapy and drug therapy
lower risk of addiction (Holmes & Newman, 2006). alone increases the risk of clients relapsing a er treatment ends (Smits
Researchers found that about 40–50% of clients treated et al., 2006). Researchers found that, one year a er treatment with a
for generalized anxiety disorder with either psychotherapy combination of psychotherapy and drugs, about 30–50% of clients were
(cognitive-behavioral) or drugs (tranquilizers) were free of symptom-free (Page, 2002).
symptoms six months to one year later (Arntz, 2003; Holmes Another kind of anxiety disorder that is relatively common involves
& Newman, 2006). different kinds of phobias.

D . A N X I E T Y D I S O R D E R S 517

D. Anxiety Disorders

Phobias

When common fears of seeing blood, spiders, or Reseachers report that because many individuals with phobias
Can fear mice, having injections, meeting new people, trace their onset to specific traumatic events, phobias are learned
go wild? speaking in public, f lying, or being in small through conditioning or observing a person showing fear of some-
places turn into very intense fears, they are called thing. Research also points to genetic and environmental causes of
phobias (over 500 phobias are listed on www.phobialist.com). phobias. us, different pathways may lead to people developing
A phobia (FOE-bee-ah) is an anxiety disorder characterized by phobias (Rowa et al., 2006).
an intense and irrational fear that is out of all proportion to the Common Phobias We discussed fear of blood and injections

possible danger of the object or situation. Because of this intense Social phobia 13% earlier (pp. 201, 493). Here we’ll discuss three
fear, which is accompanied by increased physiological arousal, a Specific phobia 11% common phobias—social phobias, specific
person goes to great lengths to avoid the feared event. If the phobias, and agoraphobia (graph at left)
feared event cannot be avoided, the person feels intense anxiety. 5% Agoraphobia (Durand & Barlow, 2006).

Social Phobias Specific Phobias Agoraphobia Photo Credit: center, © Elizabeth Roll
Figure/Text Credit: (bottom) Bar graphs data on phobias from “Panic and Phobia” by W. W. Eaton, A. Dryman & M. M. Weissman, 1991. In L. N. Robins & D. A. Regier
Why didn’t Billy speak up in class? Why couldn’t Kate get on a plane? Why couldn’t Rose leave her house? (Eds.), Psychiatric Disorders in America: The Epidemiological Catchment Area Study. Free Press.
In junior high school, In the beginning of this module, we told Fear trapped Rose in her house for years. If she
Billy never, never thought about going outside to do her shopping,
spoke up in class or you about Kate Premo pain raced through her arms and chest. She grew
answered any ques- (photo at le ), whose hot and perspired. Her heart beat rapidly and her
tions. The school traumatic childhood legs felt like rubber. She said that thinking about
counselor said that and adult experiences leaving her house caused stark terror, sometimes
Billy would be sick with flying turned lasting for days.
to his stomach the into a phobia of f ly- is 39-year-old
whole day if he ing, which is called a mother of two is
specific phobia. one of millions
knew that he was going to be called Specific phobias, formerly called simple of Americans
on. Billy began to hide out in the phobias, are characterized by marked and suffering from
restrooms to avoid going to class. persistent fears that are unreasonable and an intense fear
Billy’s fear of speaking up in class is triggered by anticipation of, or exposure to, a of being in pub-
an example of a social phobia specific object or situation (flying, heights, lic places, which
(Durand & Barlow, 2010). spiders, seeing blood) (American Psychiatric is called agora-
Association, 2000).
Social phobias are characterized by
irrational, marked, and continuous fear phobia (Los An-
of performing in social situations. The geles Times, October 19, 1980).
individuals fear that they will humiliate Specific Phobias Agoraphobia is characterized by anxiety about being in
or embarrass themselves (American
Psychiatric Association, 2000). Bugs, snakes, etc. 23% places or situations from which escape might be difficult
Heights 22%
or embarrassing (graph above) if a panic attack or panic-

Social Phobias Water 13% like symptoms (sudden
8% Speaking in public
Closed places 10% dizziness or onset of di- Agoraphobia

Source: Eaton et al., 1991 arrhea) were to occur Public transport 13%
(American Psychiatric
5% Speaking to strangers Among the more common specific Association, 2000). 8% Tunnels
4% Eating in public phobias seen in clinical practice (graph or bridges
above) are fear of animals (zoophobia), Agoraphobia arises
Source: Eaton et al., 1991 fear of heights (acrophobia), fear of con- out of an underlying Crowds 7%
finement (claustrophobia), fear of injury
As a fearful social situation ap- or blood, and fear of flying (Durand & Source: Eaton et al., 1991
proaches (graph above), anxiety Barlow, 2006).
builds up and may result in con- fear of either having
siderable bodily distress, such as The content and occurrence of spe- a full-blown panic attack or having a sudden and
nausea, sweating, and other signs cific phobias vary with culture. For unexpected onset of paniclike symptoms.
of heightened physiological arous- example, fears of spirits or ghosts are A er any of these phobias are established, they
al. Although a person with a social present in many cultures but become are extremely persistent and may continue for years
phobia realizes that the fear is ex- specific phobias only if the fear turns if not treated (M. E. Coles & Horng, 2006). We’ll dis-
cessive or irrational, he or she may excessive and irrational (American Psy- cuss drug and psychological treatments for phobias
not know how to deal with it, other chiatric Association, 2000). later in this module—in the Application section.
than by avoiding the situation. Next, we’ll look at another form of anxiety
that can be very difficult to deal with—obsessive-
compulsive disorder.

518 M O D U L E 2 2 A S S E S S M E N T & A N X I E T Y D I S O R D E R S

Obsessive-Compulsive Disorder Posttraumatic
Shirley was an outgoing, popular high-school student with average Stress Disorder
Why grades. Her one problem was that she was late for school almost every
Mark was driving home from work when
was Shirley day. Before she could leave the house in the morning, she had to be sure a huge truck unexpectedly lost control
always late? she was clean, so she needed to take a shower that lasted a full 2 hours. and rammed his car from behind. Mark
A er her shower, she spent a long time dressing because, for each thing had no way to escape the traumatic acci-
she did, such as putting on her stockings, underclothes, skirt, and blouse, she had to repeat dent. ough he needed hospital treat-
the act precisely 17 times. When asked about her washing and counting, she ment, he was lucky to walk away alive.
said she knew it was crazy but she just had to do it and couldn’t explain why However, since the accident Mark has
(Rapoport, 1988). Shirley’s symptoms would be diagnosed as indicative of become so fearful of driving that he
an anxiety problem called obsessive-compulsive disorder. works from home now. He still experi-
An obsessive-compulsive disorder consists of obsessions, which are persistent, ences troublesome, recurring memories
of the event and frequently has terrifying
recurring irrational thoughts, impulses, or images that a person is unable to control and nightmares about being in a car accident.
Mark’s symptoms would be diagnosed as
that interfere with normal functioning, and compulsions, which are irresistible impulses indicative of an anxiety problem called
posttraumatic stress disorder.
to perform over and over some senseless behavior or ritual (hand washing, checking
Posttraumatic stress disorder, or PTSD,
things, counting, putting things in order) (American Psychiatric Association, 2000). is a disabling condition that results from per-
sonally experiencing an event that involves
Obsessive-compulsive disorder, or OCD, was once considered relatively Repeating an actual or threatened death or serious injury
rare, but now it is known to affect about 3% of adults in the United States act 17 times is or from witnessing or hearing of such an
(Riggs & Foa, 2006). We’ll discuss OCD’s symptoms and treatments. a sign of OCD. event happening to a family member or close
friend. People suffering from PTSD experi-
Symptoms ence a number of psychological symptoms,
including recurring and disturbing memories,
Shirley’s symptoms included both obsession—need to be very clean and careful about dress- terrible nightmares, and intense fear and
ing—and compulsions—need to take 2-hour showers and to perform each act of dressing anxiety (APA, 2000).
precisely 17 times. Some individuals have obsessions (irrational, recurring thoughts) without
compulsions. Because compulsions are usually very time-consuming, they o en take an ese horrible memories and feelings
hour or more to complete each day. of fear keep stress levels high and result
in a range of psychosomatic symptoms,
Common compulsions involve cleaning, checking, and counting; the less common including sleep problems, pounding
include buying, hoarding, and putting things in order. For example, individuals obsessed heart, and stomach problems (Marshall
with being contaminated reduce their anxiety by washing their hands until their skin is raw, et al., 2006; Schnurr et al., 2002).
while those obsessed with leaving a door unlocked may be driven to check the lock every
few minutes (American Psychiatric Association, 2000). ese kinds of obsessive-compulsive Treatment. Treatment may involve
behaviors interfere with normal functioning and make holding a job or engaging in social drugs, but some form of cognitive-
interactions difficult. OCD can be a chronic problem that requires treatment with drugs, behavioral therapy (p. 568) is more
psychotherapy, or some combination (Riggs & Foa, 2006). effective in the long term (Bolton et al.,
2004). Cognitive-behavioral therapy
Treatment provides emotional support so victims
can begin the healing process, helps to
Shirley’s compulsive behaviors are thought to be one way that she slowly eliminate the horrible memories
reduces or avoids anxiety. Currently, about half of patients with OCD by bringing out the details of the experi-
report improvement a er being treated with drugs or exposure ther- ence, and gradually replaces the feeling
apy (Franklin et al., 2002). of fear with a sense of courage (Harvey
Exposure therapy involves gradually exposing the person to the actual et al., 2003; Resick et al., 2008).

Photo Credit: right, © Chip Simons/Science Faction/Corbis anxiety-producing situations or objects that he or she is attempting to avoid Next, we’ll discuss how people can
create real physical symptoms that
and continuing the exposure treatments until the anxiety decreases. interfere with normal functioning.

For example, a client like Shirley with OCD could be exposed over D . A N X I E T Y D I S O R D E R S 519
and over to her fearful objects (dirt or dirty things) until such expo-
sures elicit little or no anxiety. Exposure therapy may involve 15 two-
hour sessions over the course of a month. However, Shirley refused to
try exposure therapy and instead was given antidepressant drugs.
Clients like Shirley, who cannot tolerate or are not motivated to
undergo exposure therapy, may be given antidepressant drugs. A er
taking an antidepressant for about three weeks, Shirley’s urges to
wash and count faded sufficiently that she could try exposure therapy
Treatment for (Rapoport, 1988). However, about one-third of clients with OCD are
OCD is psycho- not helped by antidepressants (Riggs & Foa, 2006).
therapy and/or anti-
depressant drugs. A new, last resort treatment for OCD is deep brain stimulation

(p. 61) (DeNoon, 2009b; Talan, 2009).
Next, we’ll describe how a threatening event can lead to posttraumatic stress disorder.

E. Somatoform Disorders

Definition and Examples Mass Hysteria

Imagine someone whose whole life centers around physical symptoms, some that As more than 500 students from various schools
are imagined and others that appear real, such as developing paralysis in one’s began to give a choir and orchestra concert, they
legs. is intense focus on imagined, painful, or uncomfortable physical symp- suddenly began to complain of headaches, dizzi-
toms is characteristic of individuals with somatoform disorders. ness, weakness, abdominal pain, and nausea. ese
symptoms spread rapidly until about half the stu-
Somatoform (so-MA-tuh-form) disorders are marked by a pattern of recurring, multi- dents developed one or more of the symptoms. Stu-
ple, and significant bodily (somatic) symptoms that extend over several years. The bodily dents who became ill were most often those who
symptoms (pain, vomiting, paralysis, blindness) are not under voluntary control, have no saw someone near them become ill. Students from
known physical causes, and are believed to be caused by psychological factors (American one school, particularly girls in the soprano sec-
Psychiatric Association, 2000). tion, experienced the highest rate of symptoms.
Younger members reported more symptoms than
Although not easily diagnosed, somatoform disorders are among the most older ones, and girls (51%) reported more symp-
common health problems seen in general medical practice (Wise & Birket-Smith, toms than boys (41%). At first, someone thought
2002). e DSM-IV-TR lists seven kinds of somatoform disorders. We’ll discuss that a gas line had broken, but no one in the audi-
two of the more common forms—somatization and conversion disorders. ence developed any symptoms. ere was no rup-
tured gas line. The students’ symptoms resulted
Somatization Disorder from mass hysteria (Small et al., 1991).

One kind of somatoform disorder, which was Mass hysteria is a condition experienced by a group
historically called hysteria, is now called somati- of people who, through suggestion, observation, or other
zation disorder and is relatively rare (2.7% of the population). psychological processes, develop similar fears, delu-
Somatization disorder begins before age 30, lasts several sions, abnormal behaviors, or physical symptoms.

years, and is characterized by multiple symptoms—including pain, In this case, several of the most popular and vis-
ible girls complained of feeling dizzy and nauseous
gastrointestinal, sexual, and neurological symptoms—that have (they had been standing for hours). Soon, other stu-
dents were complaining about having similar physi-
no physical causes but are triggered by psychological problems cal symptoms until over 200 students eventually
developed these same symptoms. A similar case of
or distress (American Psychiatric Association, 2000). mass hysteria was reported in a group of teenage girls
in Vietnam, 50 of whom were hospitalized due to
A psychologically distressed This disorder is especially common among sudden fainting a er watching one girl collapse and
individual may have painful women (P. Fink et al., 2004). ose who have soma- be carried away by medical personnel (IANS, 2006).
physical symptoms that have tization disorder use health services frequently and
have twice the annual medical care costs of people Individuals who are emotionally aroused in a group
no physical causes. may experience similar physical symptoms.

without somatization disorder (Barsky et al., 2005). Many people with somatiza- In the Middle Ages, hysteria was attributed to
tion disorder are raised in emotionally cold and unsupportive family environ- possession by evil spirits or the devil. Today, mass
ments and are o en victims of emotional or physical abuse (R. J. Brown et al., hysteria is known to involve members of a group
2005). Somatization disorders may be a means of coping with a stressful situation who experience and share emotional arousal or
or obtaining attention (Durand & Barlow, 2010). excitement, which spreads through the group and
results in its members developing real physical
Conversion Disorder symptoms with no known physical causes (Barlow Photo Credit: left, © Marvin Mattelson
Some people report serious physical problems, such as blindness, that have no physi- & Durand, 2009). Mass hysteria is another example
cal causes and are examples of conversion disorder, a type of somatoform disorder. of somatoform disorders.

A conversion disorder refers to changing anxiety or emotional distress into real physi- After the Concept Review, we’ll discuss how
cal, motor, sensory, or neurological symptoms (headaches, nausea, dizziness, loss of sen- symptoms of mental disorders can vary among
cultures, as we examine a disorder that seems to be
sation, paralysis) for which no physical or organic cause can be identified (American unique to Asian cultures, especially Japan.

Psychiatric Association, 2000).
Usually the symptoms of a conversion disorder are associated with psycho-

logical factors, such as depression, concerns about health, or the occurrence of
a stressful situation. Recent research examining the brains of people with medi-
cally unexplainable paralysis has shown that when patients try to move their
paralyzed limbs, the emotional areas of the brain are activated inappropriately
and may inhibit the functioning of the motor cortex, leaving the patients unable
to move their paralyzed limbs (Kinetz, 2006). e development of such physical
symptoms gets the person attention, removes the person from threatening or anx-
iety-producing situations, and thus reinforces the occurrence and maintenance
of the symptoms involved in the conversion disorder (Durand & Barlow, 2010).
Researchers found that in some cultures, bodily complaints (somatoform disor-
ders) are used instead of emotional complaints to express psychological problems
(Lewis-Fernandez et al., 2005).

e same kind of painful or uncomfortable physical symptoms observed in
somatoform disorders are observed in individuals suffering from mass hysteria.

520 M O D U L E 2 2 A S S E S S M E N T & A N X I E T Y D I S O R D E R S

Concept Review

1. A prolonged or recurring problem that seriously interferes with 6. There are several kinds of anxiety disorders.
the ability of an individual to live a satisfying personal life and An anxiety disorder that is characterized by
function in society is called a . excessive and/or unrealistic worry or feelings of
general apprehension about events or activities,
2. Mental disorders arise from the interaction of a number of when those feelings occur on a majority of days
factors. Biological factors include inherited behavioral tendencies,
which are called (a) factors. for a period of at least six months, is called
(a) disorder. An anxiety dis-
These factors contribute from 30% to 60% to order marked by the presence of recurrent and unexpected panic
the development of mental disorders. Biological
factors also include the overreaction of brain attacks, plus continued worry about having another panic attack,
when such worry interferes with psychological functioning, is
structures to certain stimuli, which are called called a (b) disorder. Suppose a person has a
(b) factors. Other factors
that contribute to the development of mental period of intense fear or discomfort during which four or more
of the following symptoms are present: pounding heart, sweating,
disorders, such as deficits or problems in thinking, processing trembling, shortness of breath, feelings of choking, chest pain,
emotional stimuli, and social skills, are called (c)
factors. Being in or seeing a traumatic event, which is called an nausea, feeling dizzy, and fear of losing control or dying. That
person is experiencing a (c) .
(d) factor, can contribute to developing a mental
disorder such as PTSD.
7. An anxiety disorder characterized by an intense
and irrational fear and heightened physiological
3. There are three definitions of abnormality. A behavior that arousal that is out of all proportion to the danger
occurs infrequently in the general population is abnor-
mal according to the (a) definition. elicited by the object or situation is called a
(a) , of which there are several
A behavior that deviates greatly from accepted kinds. Unreasonable, marked, and persistent fears
social norms is abnormal according to the
Photo Credits: (#2) © Colin Anderson/Brand X/Corbis; (#3) © San Diego Union Tribune/ZUMA Press; (#4) © AP Images/Tim Kimzey (b) definition. Behavior that that are triggered by anticipation of, or exposure
to, a specific object or situation are called a
interferes with the individual’s ability to function (b) . An anxiety that comes from being in places
as a person or in society is abnormal according
to the (c) definition, which is or situations from which escape might be difficult or embarrass-
ing if a panic attack or paniclike symptoms were to occur is called
used by most mental health professionals. (c) . Irrational, marked, and continuous fear of

4. When performed by a mental health professional, a systematic performing in social situations and feeling humiliated or embar-
evaluation of an individual’s various psychological, biological,
and social factors that may be contributing to his or her problem rassed is called a (d) .

is called a clinical (a) . A mental 8. A disorder that consists of persistent, recurring irra-
health professional who determines whether an tional thoughts, impulses, or images that a person is
individual’s specific problem meets or matches the unable to control and irresistible impulses to perform
standard symptoms that define a particular mental over and over some senseless behavior or ritual is called
disorder is doing a clinical (b) . (a) disorder. A nondrug treatment for
One of the primary techniques used to gather an this disorder, which consists of gradually exposing the
enormous amount of information about a person’s person to the real anxiety-producing situations or
past behavior, attitudes, and emotions and details of current prob- objects that he or she is attempting to avoid, is called
lems is the clinical (c) . (b) therapy.

5. The manual that describes the symptoms for almost 300 different 9. When something happens to a group of
mental disorders is called the (a) . The manual’s people so that all share the same fears or
primary goal is to provide mental health professionals with a delusions or develop similar physical
means of (b) mental disor- symptoms, it is called (a) .
ders and (c) that informa- Number of Disorders There is a disorder that involves a pattern

tion in a systematic and uniform way. The DSM-I 106 of recurring, multiple, and significant bodily

DSM-IV-TR has five major dimensions, called DSM-II 182 complaints that have no known physical causes. This is called

(d) , that serve as guidelines DSM-III 265 (b) disorder, and one of its more common forms

for making decisions about symptoms. DSM-IV-TR 297 is somatization disorder.

Answers: 1. mental disorder; 2. (a) genetic, (b) neurological, (c) cognitive-emotional-behavioral, (d) environmental; 3. (a) statistical frequency,
(b) social norms, (c) maladaptive behavior; 4. (a) assessment, (b) diagnosis, (c) interview; 5. (a) Diagnostic and Statistical Manual of Mental
Disorders-IV-TR, (b) diagnosing, (c) communicating, (d) axes; 6. (a) generalized anxiety, (b) panic, (c) panic attack; 7. (a) phobia, (b) specific
phobia, (c) agoraphobia, (d) social phobia; 8. (a) obsessive-compulsive, (b) exposure; 9. (a) mass hysteria, (b) somatoform

C O N C E P T R E V I E W 521

F. Cultural Diversity: An Asian Disorder

Taijin Kyofusho, or TKS Social Customs
Anxiety is a worldwide concern and is the second most com-
Can a mon mental disorder in the United States and several Asian In Japan, individuals are expected to know
culture create nations, notably Japan. e symptoms of one kind of anxiety the needs and thoughts of others by reading
the emotional expressions of faces rather
a disorder? disorder, somatoform disorder, occur in very similar form in than asking direct questions, which is con-
many cultures around the world (Lewis-Fernandez et al., 2005). sidered rude social behavior. In contrast,
However, it’s also true that the unique cultural values of some countries, such as Japan, Westerners may ask direct questions to clar-
can result in the development of a unique anxiety order not found in Western cultures, ify some point and o en use direct eye con-
such as the United States. tact to show interest. Individuals in Japan
If you had a social phobia in the United States, it would usually mean that you who make too much eye contact or ask too
had a great fear or were greatly embarrassed about behaving or performing in social direct questions are likely to be viewed as
situations, such as making a public speech. But if you had a social phobia in several insensitive to others, unpleasantly bold, or
Asian cultures, especially Japan and somewhat in Korea, it might mean that you aggressive. In fact, Japanese children are
had a very different kind of fear or embarrassment, called taijin kyofusho, or TKS taught to fix their gaze at the level of the neck
(Tarumi et al., 2004). of people they are talking to. This Japanese
social custom that emphasizes not making
In Japan, the fear eye contact, blushing, or having trembling
of offending others (by hands or offensive body odors during social
staring) is considered a interactions results in about 20% of Japanese
kind of social phobia. teenagers and young adults developing the
intense, irrational fear called TKS. is social
Taijin kyofusho (tai-jin kyo-foo-show), or TKS, is a kind of social phobia characterized by a phobia is so common in Japan that there are
special clinics devoted only to treating TKS.
terrible fear of offending others through awkward social or physical behavior, such as staring,
e Japanese TKS clinics are comparable in
blushing, giving off an offensive odor, having an unpleasant facial expression, or having trembling popularity to the numerous weight-loss clin-
ics found in the United States. Interestingly,
hands (Dinnel et al., 2002). TKS is a kind of social phobia that doesn’t
occur in Western cultures (Dinnel et al., 2002;
Although many Westerners are also concerned or embarrassed about offending oth- Tarumi et al., 2004).
ers through staring, having offensive body odors, or blushing, TKS is different in that
it is an intense, irrational, morbid fear—in other words, a true phobia. In desperately Cultural differences. Although people in
trying to avoid TKS symptoms, Asians may try to avoid social interactions altogether. many cultures report anxiety about behaving
e Japanese word taijin-kyofu literally means “fear of interpersonal relations.” or performing in public, the particular fears
Occurrence. e graph below shows that TKS is the third most common psychi- that they report may depend on their own cul-
atric disorder treated in Japanese college students (Kirmayer, 1991). TKS is more com- ture’s values. For example, TKS is unique to
mon in males than in females, with a ratio of about 5:4. Most patients have a primary Asian cultures and unknown in Western cul-
symptom, which has changed during the past 40 years. Initially, fear of blushing was tures. Japanese who are especially at risk for
the primary symptom, but it has been replaced by developing TKS are those who score low on
Percentage of Students fear of making eye contact or staring (Yamashita, independence and high on interdependence,
two traits found in traditional Japanese cul-
Psychosomatic 24% 1993). In comparison, making eye contact is very tural values (Dinnel et al., 2002). Clinicians Photo Credits: left, © David Young Wolff/PhotoEdit; right, © PhotoDisc, Inc.
disorders common in Western cultures; if you do not make emphasize the importance of taking cul-
tural values, influences, and differences into
Depressive 20% eye contact in social interactions, you may be account when diagnosing behaviors across
reactions judged as shy or lacking in social skills. cultures (Fernando, 2002).

TKS 19% TKS begins around adolescence, when inter- In Japan,
it is very
personal interactions play a big role in one’s life. important
TKS is rarely seen a er the late twenties because, by then, individuals have learned the to know
proper social behaviors. TKS seems to develop from certain cultural influences that and show
are unique to Japan. the proper
Cultural values. e Japanese culture places great emphasis on the appropriate
way to conduct oneself in public, which means a person should avoid making direct public
eye contact, staring, blushing, having trembling hands, or giving off offensive odors. behaviors.
To emphasize the importance of avoiding these improper behaviors, mothers o en
use threats of abandonment, ridicule, and embarrassment as punishment. rough Next, we’ll discuss a very serious problem
this process of socialization, the child is made aware of the importance of avoid- in the U.S. culture: school shootings.
ing improper public behaviors, which result in a loss of face and reflect badly on the
person’s family and social group. us, from early on, Japanese children are strongly
encouraged to live up to certain cultural expectations about avoiding improper
public behaviors, especially staring and blushing, which are considered to be rude
and disgraceful.

522 M O D U L E 2 2 A S S E S S M E N T & A N X I E T Y D I S O R D E R S

G. Research Focus: School Shootings

What Drove Teens to Kill Fellow Students and Teachers?

What is Sometimes researchers are The diagnosis of conduct disorder seems to apply to Kipland
their problem? faced with answering Kinkel, age 15, who was charged with firing 50 rounds from a
tragic questions, such as
why teenagers took guns semiautomatic rifle into the school cafeteria, killing 2 students
and injuring 22. ose who knew him said that Kinkel had a
to schools and shot and killed at least 500 and violent temper and a history of behavioral problems, which
wounded another 1,000. Everyone wonders what included killing his cat by putting a firecracker in its mouth,
turns these teens into killers. In some cases, but blowing up a dead cow, stoning cars from a highway over-
not all, these adolescents might be diagnosed pass, and making bombs (Witkin et al., 1998). In trying
with conduct disorder. to answer the question “Why did these adolescents shoot
Conduct disorder refers to a repetitive and persis- their fellow students and teachers?” mental health profes-
Adolescent school
tent pattern of behaving that has been going on for at shooters may have sionals have primarily used the case study approach.
least a year and that violates the established social rules conduct disorder. A case study is an in-depth analysis of the thoughts, feelings,
or the rights of others. Problems may include aggressive
beliefs, experiences, behaviors, and problems of a single individual.

behaviors such as threatening to harm people, abusing or killing animals, We’ll give brief case studies of two school shooters and then exam-

destroying property, being deceitful, or stealing. ine some factors that put a student at risk for becoming a shooter.

Case Studies Risks Shared by Adolescent School Shooters

e first school shooting that received national attention Although there are differences among school shooters, researchers have iden-
occurred in Moses Lake, Washington, on February 2, tified a number of risk factors that these boys shared (FBI, 2001; Langman,
1996. On that date, Barry Loukaitis, 14, fired on his alge- 2009; R. Lee, 2005; Pollack, 2007; Robertz, 2007; Verlinden et al., 2000).
bra class, killing three and wounding one. He said that he O Most of the boys (shooters) showed uncontrolled anger and depres-
wanted to get back at a popular boy who had teased him. sion, blaming others for problems and threatening violence. Most had poor
Loukaitis shot that boy dead. Since then, school shoot- coping skills, discipline problems at school or home, access to weapons, and
ings have continued at an alarming rate. Across the a history of drug use.
world, there have been at least 50 adolescents, mostly O Half of the boys had been given little parental supervision, had
boys, who took guns to their schools, fired hundreds of troubled family relationships, and perceived themselves as receiving little
shots, killed at least 500 teachers and students, and support from their families. Most of the boys had recently experienced the
wounded about 1,000 more (IANSA, 2007). breakup of a relationship, a stressful event, or loss of status.
One such shooter is 23-year-old college student Seung- O Most of the boys were generally isolated and rejected by their peers
Hui Cho (below photo), who in 2007 killed 32 people and in school. Most had poor social skills and felt picked on, bullied, and per-
wounded 25 others on the Virginia Tech campus, making secuted and made friends who were also antisocial. e most commonly
it the deadliest school shooting in history. Cho was born stated motives for shootings were to mete out justice to peers or adults who
in South Korea and immigrated to the United States when the teenage shooters believed had wronged them and to obtain status or
he was 8 years old. As a child, he was relentlessly teased importance among their peers. Most teenage shooters gave warning signs of
and bullied for being shy and speaking with a strong their violent intentions that were not taken seriously.
accent. Consequently, he was isolated and developed Neurological factors. Although coming from a broken home, being
anger toward his more “privileged” bullied, and dealing with various life stressors are risk factors for adoles-
peers. He came to view himself as an cents committing violent acts, another important risk factor is inside an
avenger against those who humili- adolescent’s brain. Everyone gets angry and has felt
ated him (White and affluent). He rage and the desire to get revenge, but most of us are
wanted to get even with the “rich able to control these violent impulses. is control
brats” who had trust funds and involves the prefrontal cortex (p. 411), which has
Photo Credit: © AP Images/Virginia State Police drove Mercedes. In a disturbing executive functions, such as planning, making
message on the day of his shooting, decisions, and controlling strong emotional and
he stated to the privileged, “You violent impulses that arise from a very primitive
have never felt a single ounce of part of the brain called the limbic system (p. 411) prefrontal limbic
pain in your whole lives.” At the (right figure). e prefrontal cortex in the ado- cortex system
Seung-Hui Cho
committed the
deadliest school end of his killing spree, Cho took lescent brain is still immature and may not reach
shooting in history. his own life (Gibbs, 2007; Schute, complete maturity until the early twenties. For this reason, adolescents are
2007; E. omas, 2007). especially at risk for committing all kinds of impulsive and violent behav-
However, very, very few students who are picked on iors and, in extreme cases, even school shootings (Luna, 2006).
and bullied commit violent acts, such as shooting teach- Gathering data about what motivates school shooters is an example of using
ers and students. We’ll examine some of the factors that the case study method. Next, we turn to explaining several ways of treating
put students as risk for committing violent acts. two relatively common anxiety disorders—social and specific phobias.

G . R E S E A R C H F O C U S : S C H O O L S H O O T I N G S 523

H. Application: Treating Phobias

Specific Phobia: Flying Kate is undergoing exposure flying, crashing, heights, being in small enclosed
therapy for fear of flying. spaces, or not having control of the situation (Van
At the beginning of this module, we told you about Gerwen et al., 1997).
Kate Premo (right photo), who developed a phobia of
flying. In some cases, people don’t remember what Most phobias do not disappear without some
caused their phobias, but Premo remembers exactly treatment, and on the few occasions that Premo was
when her phobia began. Her fear began as a child forced to fly, she dosed herself with so much alco-
when she was on a very turbulent and stressful flight. hol and tranquilizers that she was groggy for days.
Her fear was further intensified by her memories of Finally, she joined a weekend seminar that helps peo-
the terrorist bombing of Pan Am flight 103, which ple overcome their fears of flying (M. Miller, 2003).
killed several of her fellow students. A er that inci- Treatment for phobias can involve psychotherapy or
dent, her fear of flying turned into a real phobia that drugs, or some combination of them. We’ll discuss
kept her from flying to visit friends and family. An psychotherapy and drug treatment, beginning with
estimated 9% of American adults have a phobia of fly- cognitive-behavioral and exposure therapy.
ing called aviophobia, which may include fear of

Cognitive-Behavioral Therapy Exposure Therapy
For treating phobias, cognitive-behavioral therapy is o en combined with
Kate’s phobia of f lying involves fearful and irrational exposure therapy. e most difficult part of Kate’s phobia treatment is expo-
thoughts, which in turn cause increased physiological sure therapy, when she must actually confront her most feared situation.
arousal. She can learn to reduce her irrational and fear- Exposure therapy consists of gradually exposing the person to the real anxiety-
ful thoughts and reduce her arousal through cognitive-
behavioral therapy (Singer & Dobson, 2006). producing situations or objects that he or she is attempting to avoid and continuing

Cognitive-behavioral therapy involves using a combination exposure treatments until the anxiety decreases.
of two methods: changing negative, unhealthy, or distorted
e first part of Kate’s treatment involved cognitive-behavioral therapy,
thoughts and beliefs by substituting positive, healthy, and real- in which she learned how to control her irrational thoughts and acquire
some basic relaxation techniques. e second part of her treatment involves
istic ones; and changing limiting or disruptive behaviors by exposure therapy, in which she is required to fly on a regularly scheduled
airline, meaning that she will be exposed to her most feared situation. To
learning and practicing new skills to improve functioning. help Kate deal with her fear of flying, Captain Michael Freebairn (photo
Thoughts. Cognitive-behavioral therapy is useful below) sat next to Kate. Each time Kate tensed or looked fearful, the cap-
tain reassured Kate that all was normal and then reminded her to begin
in helping Kate control her fearful thoughts and elimi- relaxation exercises (breathing and relax-
nate dangerous beliefs about flying. For example, Kate ing muscles), to use pleasant images, and
had learned to fear various noises during flight, which to substitute positive, healthy thoughts
she believed indicated trouble. To change these fear- for negative, fearful ones. When the plane
ful thoughts, an airplane pilot explained the various landed, Kate was all smiles (le photo) a er
noises, such as the thumps meant the landing gear was realizing that exposure therapy had signifi-
retracting a er takeoff or being put down for landing. cantly reduced her fear or phobia of flying.
Thus, when Kate has a fearful thought, for example, Programs that treat specific phobias,
“ at noise must mean trouble,” she immediately stops such as fear of flying, o en use some com-
herself and substitutes a realistic thought, “ at’s just bination of cognitive-behavioral and expo-
the landing gear.” Kate smiles after successfully sure therapy, which significantly reduces Photo Credits: top and bottom, © Elizabeth Roll
flying without feeling fear in the majority of clients (R. A. Fried-
Behaviors. Because Kate automatically gets ner- intense fear. man, 2006; M. Miller, 2003).
vous and fearful when just thinking about flying, she
is instructed to do breathing, relaxation, and imagery Clients not helped by cognitive-behavioral or exposure therapy may be
exercises that will help her calm down. Deep and rhyth- given drug therapy (see next page) or they may try virtual reality therapy.
mic breathing is an effective calming exercise because it Virtual reality therapy. Although clients never leave the ground, they
distracts Kate from her fears and focuses her attention sit in real airplane seats that vibrate to the sound of airplane engines. Cli-
on a pleasant activity. Relaxing and tensing groups of ents wear head-mounted displays that surround them with 3-D experiences
muscles are also calming and help to decrease physi- of “taking off ” and “flying.” Everything appears so real that clients who
ological arousal. Finally, imagery exercises are calming have a fear of flying begin to sweat and their hearts pound just as on real
because focusing on pleasant images is a very powerful flights. Virtual reality therapy is a kind of exposure therapy, and it can be
way of using her mind to control (relax) her body’s fight- combined with relaxation exercises and thought substitution and be used
flight response. to treat a variety of specific phobias, including fear of flying (Rothbaum et
al., 2006).
Cognitive-behavioral methods have proved effective
in treating a variety of phobias (Singer & Dobson, 2006).
Sometimes cognitive-behavioral therapy is combined
with another kind of therapy, called exposure therapy.

524 M O D U L E 2 2 A S S E S S M E N T & A N X I E T Y D I S O R D E R S

Social Phobia: Public Speaking Drug Treatment of Phobias
Just as specific phobias can be success- Imagine being told to walk
When does a fully treated with psychotherapy, so How into a room and meet a
fear become too can social phobias, such as public
effective group of strangers while

a phobia? speaking. Almost everyone is some- are drugs? you are stark naked. For
what anxious about getting up and most of us, this idea would
speaking in public. For a fear to become a full-blown phobia, cause such embarrassment, fear, and anxiety
however, the fear must be intense, irrational, and out of all that we would absolutely refuse. is imagined
proportion to the object or situation. For example, individuals situation is similar to the terrible negative emo-
with social phobias have such intense, excessive, and irrational tions that individuals with social phobia feel
fears of doing something humiliating or embarrassing that when they must initiate a conversation, meet
they will go to almost any lengths to avoid speaking in public. strangers, or give a public presentation. As we
ere are a number of very effective nondrug programs for have discussed, social phobias can be treated
treating social phobias (fear of speaking, performing, or act- with cognitive-behavioral and exposure ther-
ing in public). ese programs combine cognitive-behavioral apy. However, some individuals with social
Drug therapy for
and exposure therapies and usually include the following four phobia do not choose to or are too fearful to phobias involves
components (M. E. Coles & Horng, 2006). complete a therapy program that includes expo- tranquilizers or
sure to the feared situation. Instead, these indi- antidepressants.
1 Explain. Clinicians explain to the person that, since the
fears involved in social phobias are usually learned, there are viduals may choose drug therapy, which may involve tranquilizers
(benzodiazepines) or the increasingly prescribed antidepressants
also methods to unlearn or extinguish such fears. e person (Blanco et al., 2003; M. E. Coles & Horng, 2006).
is told how both thoughts and physiological arousal can
exaggerate the phobic feelings and make the person go to any e graphs below show the results of a double-blind study in which
individuals with social phobia were given either a placebo or an anti-
lengths to avoid the feared situation. depressant, in this case sertraline
Average Score on Fear Scale: (Zoloft). After 20 weeks of treat-
2 Learn and substitute. Clinicians Drug reduced fear more ment, individuals given antidepres-
found that some individuals needed to than placebo sants showed a significant clinical
learn new social skills (initiating a reduction in scores on both anxiety
conversation, writing a speech) so that Placebo 16

they would function better in social Drug 13 and fear tests, which means they
situations. In addition, individuals were were able to function relatively well
told to record their thoughts immedi- Average Score on Fear Scale: in social situations (Van Amerin-
ately after thinking about being in a Drug reduced avoidance more gen et al., 2001). Although 34% of

than placebo

feared situation. Then they were Placebo 16 those on antidepressants showed
shown how to substitute positive a significant decrease in social
and healthy thoughts for negative Drug 13 anxiety, a remarkable 18% of those
Treating social and fearful ones. given placebos (sugar pills) showed
phobias involves four a similar decrease. This means that the significant decrease in the
3 Expose. Clinicians first used
components.

imaginary exposure, during which a person imagines being social fears of almost one out of five individuals resulted from purely
psychological factors, such as a client’s expectations and beliefs (“ e
in the situation that elicits the fears. For example, some indi- pill is powerful medicine and will reduce my fear”).
viduals imagined presenting material to their co-workers,
making a classroom presentation, or initiating a conversation Although drug treatments are effective in reducing social phobias,
there are two potential problems. First, about 50–75% of individuals
with the opposite sex. A er imaginary exposure, clinicians relapse when drugs are discontinued, which means that their original
used real (in vivo) exposure, in which the person gives his or
her speech in front of a group of people or initiates conversa- intense social phobic symptoms return. Second, long-term maintenance
on drugs can result in tolerance and increases in dosage, which, in turn,
tions with strangers. can result in serious side effects, such as loss of memory (S. M. Stahl,
2000, 2002). Compared to drug treatment of phobias, psychotherapy
4 Practice. Clinicians asked subjects to practice home- programs have the advantages of no problems with tolerance and no
work assignments. For instance, individuals were asked to
imagine themselves in feared situations and then to elimi- unwanted physical side effects.
nate negative thoughts by substituting positive ones. In addi- Which treatment to choose? Whether a client chooses psycho-
tion, individuals were instructed to gradually expose therapy or drug treatment for phobias depends to a large extent on
themselves to making longer and longer public presentations each individual client’s preference. That’s because drug treatment
or having conversations with the opposite sex. (tranquilizers or antidepressants) and cognitive-behavioral or expo-
Researchers report that programs similar to the one above sure therapy are about equally effective in the treatment of different
resulted in reduced social fears in about 56% of those who phobias, including specific phobias, social phobias, and agoraphobia
completed the program (Lincoln et al., 2003). (Liebowitz et al., 1999).

H . A P P L I C A T I O N : T R E A T I N G P H O B I A S 525

Summary Test

A. Factors in Mental Disorders C. Diagnosing Mental Disorders

1. A prolonged or recurring problem that seri- 6. When mental health professionals
ously interferes with an individual’s ability to determine whether an individual’s spe-
live a satisfying personal life and function in cific problem meets or matches the stan-
society is a . This definition dard symptoms that define a particular
takes into account genetic, behavioral, cogni- mental disorder, they are making a
tive, and environmental factors, all of which (a) . In trying to reach
may contribute to a mental disorder. an agreement on the clinical diagnosis,
mental health professionals use a set of
2. Mental disorders arise from the interaction of a number of guidelines, developed by the American Psychiatric Association,
factors. Biological factors include inherited behavioral tendencies,
which are called (a) factors. These factors con- called the (b) , which is abbreviated as
DSM-IV-TR.
tribute from 30% to 60% to the development of mental disorders.
Biological factors also include the overreaction of brain structures 7. The DSM-IV-TR is a set of guidelines that uses five different
to certain stimuli, which are called (b) factors. dimensions or (a) to diagnose mental disorders.
Other factors that contribute to the development of mental disor- The advantage of the DSM-IV-TR is that it helps mental health
ders, such as deficits or problems in thinking, processing emo- professionals communicate their findings, conduct research, and
tional stimuli, and social skills, are called (c) plan for treatment. One disadvantage of using the DSM-IV-TR to
factors. Being in or seeing a traumatic event, which is called an make a diagnosis is that it places people into specific categories
(d) factor, can contribute to developing a mental that may have bad associations; this problem is called
disorder such as PTSD. (b) .

3. If a behavior is considered abnormal because it occurs infre- D. Anxiety Disorders
quently in the general population, we are using a definition based
on (a) frequency. If a behavior is considered
abnormal because it deviates greatly from what’s acceptable, we 8. A mental disorder that is marked by excessive
and/or unrealistic worry or feelings of general
are using a definition based on (b) . If a behavior apprehension about events or activities, when those
is considered abnormal because it interferes with an individual’s
ability to function as a person or in society, we are using a feelings occur on a majority of days for a period
of at least six months, is called .
definition based on (c) behavior. This anxiety disorder is treated with some form of

B. Assessing Mental Disorders psychotherapy and/or drugs known as benzodiazepines. Photo Credits: (#1) © San Diego Union Tribune/ZUMA Press; (#4) © AP Images/Ruth Fremson

4. A systematic evaluation of an individual’s 9. One mental disorder is characterized by recurring and unex-
pected panic attacks and continued worry about having another
various psychological, biological, and social panic attack; such worry interferes with psychological function-
factors that may be contributing to his or her ing. This problem is called a disorder.
problem is called a (a) . The
primary method used in clinical assessments is 10. Suppose you experience a period of intense fear or discomfort
in which four or more of the following symptoms are present:
to get information about a person’s background, pounding heart, sweating, trembling, shortness of breath, feelings
current behavior, attitudes, and emotions and
also details of present problems through a of choking, chest pain, nausea, feeling dizzy, and fear of losing
control or dying. You are having a (a) . Panic
(b) . A complete clinical assess- disorders are treated with a combination of benzodiazepines or
ment usually includes three major methods:
(c) , , and antidepressants and (b) .

. 11. Another anxiety disorder characterized by increased physio-

5. Assessing mental disorders may be difficult because logical arousal and an intense, excessive, and irrational fear that is
(a) vary in intensity and complexity. The out of all proportion to the danger elicited by the object or situa-
assessment must take into account past and present problems tion is called a .
and current stressors. The accurate assessment of symptoms is
important because it has significant implications for the kind of 12. The DSM-IV-TR divides phobias into three categories. Those
(b) that the client will be given. that are triggered by common objects, situations, or animals (such
as snakes or heights) are called (a) phobias.

526 M O D U L E 2 2 A S S E S S M E N T & A N X I E T Y D I S O R D E R S

Those that are brought on by having to perform in social situa- G. Research Focus: School Shootings
tions and expecting to be humiliated and embarrassed are called
(b) phobias. Those that are characterized by 16. A method of investigation that involves an in-
fear of being in public places from which it may be difficult or depth analysis of the thoughts, feelings, beliefs,
embarrassing to escape if panic symptoms occur are called experiences, behaviors, or problems of a single
(c) . Once established, phobias are extremely individual is called a (a) .
persistent and may require treatment. This method was used to decide if teenage
school shooters had repetitive and persistent
patterns of behavior that had been going on
13. Persistent, recurring irrational thoughts that a person is for at least a year and involved threats or
unable to control and that interfere with normal functioning are
called (a) . Irresistible impulses to perform some physical harm to people or animals, destruc-
tion of property, being deceitful, or stealing. These symptoms
ritual over and over, even though the ritual serves no rational pur- define a mental disorder that is called (b) .
pose, are called (b) . A disorder that consists of
both of these behaviors and that interferes with normal functioning
is called (c) . The most effective nondrug treat-
ment for obsessive-compulsive disorder is (d) H. Application: Treating Phobias

therapy. 17. There are several different treatments for

phobias. A nondrug treatment combines changing
negative, unhealthy, or distorted thoughts and
E. Somatoform Disorders beliefs by substituting positive, healthy, and realistic

14. The appearance of real physical symp- ones and learning new skills to improve function-
ing; this treatment is called (a)
toms and bodily complaints that are not therapy. Another therapy that gradually exposes
under voluntary control, have no known
physical causes, extend over several years, the person to the real anxiety-producing situa-
tions or objects that he or she has been avoiding
and are believed to be caused by psychological is called (b) therapy. Individuals who are
factors is characteristic of (a)
disorders. The DSM-IV-TR lists seven kinds unwilling or too fearful to be exposed to fearful situations or
objects may choose drug therapy.
of somatoform disorders. The occurrence of
multiple symptoms—including pain, gastro-
intestinal, sexual, and neurological symptoms—that have no phys- 18. Social and specific phobias have been successfully treated
with tranquilizers called (a) . Although these
ical causes but are triggered by psychological problems or distress drugs are effective, they have two problems: When individuals stop
is referred to as (b) disorder; a disorder charac-
terized by unexplained and significant physical symptoms or taking these drugs, the original fearful symptoms may return,
which is called (b) ; and, if individuals are main-
deficits that affect voluntary motor or sensory functions and tained on drugs for some length of time, they may develop toler-
that suggest a real neurological or medical problem is called a
(c) disorder. A recent survey reported that ance, which means they will have to take larger doses, which in
turn may cause side effects such as loss of (c) .
somatoform disorders occur worldwide, although their symptoms Researchers found that drug therapy was about equally effective
may differ across cultures.
as cognitive-behavioral or exposure therapy in reducing both
social and specific phobias, including agoraphobia.
F. Cultural Diversity: An Asian Disorder
Answers: 1. mental disorder; 2. (a) genetic, (b) neurological, (c) cognitive-
15. A social phobia found in Percentage of Students emotional-behavioral, (d) environmental; 3. (a) statistical frequency,
Asia, especially Japan, that is (b) social norms, (c) maladaptive behavior; 4. (a) clinical assessment,
characterized by morbid fear (b) clinical interview, (c) clinical interview, psychological tests, neurological
of making eye-to-eye contact, Psychosomatic 24% tests; 5. (a) symptoms, (b) treatment; 6. (a) clinical diagnosis, (b) Diagnos-
disorders tic and Statistical Manual of Mental Disorders-IV-TR; 7. (a) axes,
Photo Credit: (#14) © Marvin Mattelson (b) labeling; 8. generalized anxiety; 9. panic; 10. (a) panic attack,
blushing, giving off an offensive Depressive 20% (b) psychotherapy; 11. phobia; 12. (a) specific, (b) social, (c) agoraphobia;
odor, having an unpleasant or reactions 13. (a) obsessions, (b) compulsions, (c) obsessive-compulsive disorder,
(d) exposure; 14. (a) somatoform, (b) somatization, (c) conversion;
tense facial expression, or hav- TKS 19% 15. taijin kyofusho, or TKS; 16. (a) case study, (b) conduct disorder;
17. (a) cognitive-behavioral, (b) exposure; 18. (a) benzodiazepines,
ing trembling hands is called (b) relapse, (c) memory
. This phobia appears to result from Asian cul-
tural and social influences that stress the importance of showing
proper behavior in public.

S U M M A R Y T E S T 527

Critical Thinking

Why Women Marry
Killers behind Bars

I n 2004, Scott Peterson was
convicted of murdering his
wife and unborn child. With-

in an hour of being on Death

Row, he received a marriage

proposal from a woman he

didn’t even know. As if this

proposal wasn’t bizarre

enough, on Scott’s first day

at San Quentin State Prison,

the warden’s office received

QUESTIONS calls from over 30 women A woman fell in love with a convicted and jailed killer.
desperate to make contact
1How would clini-
cians decide if with the convicted killer, many of kept by inmate after the marriage
women who fall in
love with killers have them believing they were in love ceremony. The marriage ceremony
a mental disorder?
with Peterson. will be conducted in the visiting
2 Do women who
almost instantly About a decade earlier, Doreen area with the glass separating the
fall in love with pris-
oners they have never Lioy, a 41-year-old woman, fell in couple being married” (“Inmate
met have obsessive-
compulsive disorder? love with satanic serial killer Rich- marriages,” 2007).

3 According to ard Ramirez, who was convicted of According to Sheila Isenberg, au-
the three defini-
tions of abnormal torturing, sexually abusing, and thor of Women Who Marry Men
behavior, is Doreen
Lioy abnormal? murdering 13 people. Lioy described Who Kill, women who pursue inti-

4 According to her attraction to Ramirez beginning mate relationships with killers are
Freud’s psycho-
dynamic theory of immediately upon seeing his mug usually attractive, intelligent, and
personality, why is
it difficult to explain shot on TV: “I saw something in his very well accomplished. Isenberg
why women fall in
love with and marry eyes. Something that captivated me” also says most of these women have
killers?
(Warrick, 1996, E-1). Lioy began come from loveless homes and have

sending Ramirez letters and visiting been abused by men earlier in their

him behind bars, and soon after lives. Gilda Carle, a relationship ad- 5 Which of the five
axes in the DSM-
they married at the prison, even viser, explains that these women are IV-TR best describes
the problems these
though Ramirez would eventually attracted to the “bad boy syndrome” women share?

be executed. Lioy speaks about her and they feel special when the man 6 What are the
advantages and
complete devotion to her new hus- who has hurt and killed others treats disadvantages of
labeling these wom-
band: “Because of my love for Rich- them with love, kindness, and re- en’s problems?

ard, I have given up my family, spect. In fact, the most repugnant ANSWERS
TO CRITICAL
home, employment, and friends” murderers receive the most attention THINKING
QUESTIONS
(Warrick, 1996, E-1). from women.

There is such a demand for prison- Women in love with convicted kill-

er romance that matchmaking web- ers find the danger, excitement, and

sites, such as prisonpenpals.com, drama of prison romance more

offer thousands of ads from inmates arousing than the routine and pre-

who want to find love outside of their dictability of romance outside prison. Photo Credit: © GN/RCS Reuters

cellblocks. Marriages in prisons are Having an intimate relationship with

common enough for each prison to a man behind bars also makes the re-

have its own set of regulations for in- lationship exceptionally safe. (Adapt-

mate marriages. Some of the rules ed from Fimrite & Taylor, 2005; “In-

for one California prison include: mate marriages,” 2007; Warrick,

“No property will be exchanged and 1996, 1997; Wiltenburg, 2003)

528 M O D U L E 2 2 A S S E S S M E N T & A N X I E T Y D I S O R D E R S

Links to Learning

Key Terms/Key People Learning Activities

agoraphobia, 518 generalized anxiety PowerStudy for Introduction PowerStudy 4.5™
antidepressant drugs, 519 disorder, 517 to Psychology 4.5
assessment, 512
aviophobia, 509 genetic factors, 510 Try out PowerStudy’s SuperModule for Assessment & Anxiety Disorders! In
Axis I: Nine major clinical insanity, 509 addition to the quizzes, learning activities, interactive Summary Test, key
labeling, 516 terms, module outline and abstract, and extended list of correlated websites
syndromes, 514 maladaptive behavior, 511 provided for all modules, the DVD’s SuperModule for Assessment & Anxiety
Axis II: Personality maladaptive behavior Disorders features:
t 4FMG QBDFE
GVMMZ OBSSBUFE MFBSOJOH XJUI B NVMUJUVEF PG BOJNBUJPOT
disorders, 515 approach, 511 t 7JEFPT BCPVU UPQJDT JODMVEJOH QBOJD EJTPSEFS
PCTFTTJWF DPNQVMTJWF
Axis III: General medical mass hysteria, 520 disorder, and virtual reality therapy.
mental disorder, 509 t *OUFSBDUJWF WFSTJPOT PG TUVEZ SFTPVSDFT
JODMVEJOH UIF 4VNNBSZ 5FTU PO
conditions, 515 neurological tests, 512 pages 526–527 and the critical thinking questions for the article on page 528.
Axis IV: Psychosocial obsessive-compulsive
CengageNOW!
and environmental disorder, or OCD, 519 www.cengage.com/login
problems, 515 panic attack, 517 Want to maximize your online study time? Take this easy-
Axis V: Global assessment panic disorder, 517 to-use study system’s diagnostic pre-test and it will create a personalized study
of functioning scale, 515 personality tests, 512 plan for you. e plan will help you identify the topics you need to understand
case study, 523 phobia, 509, 518 better and direct you to relevant companion online resources that are specific
clinical assessment, 512 posttraumatic stress to this book, speeding up your review of the module.
clinical diagnosis, 513
clinical interviews, 512 disorder, 519 Introduction to Psychology Book Companion Website
cognitive-behavioral psychological tests, 512 www.cengage.com/psychology/plotnik
therapy, 524 school shootings, 523 Visit this book’s companion website for more resources to help you
cognitive-emotional- social and political study, including learning objectives, additional quizzes, flash cards, updated
behavioral and environ- links to useful websites, and a pronunciation glossary.
mental factors, 510 implications of
conduct disorder, 523 labeling, 516 Study Guide and WebTutor
conversion disorder, 520 social customs, 522 Work through the corresponding module in your Study
definitions of abnormal social norms approach, 511 Guide for tips on how to study effectively and for help learning the material
behavior, 511 social phobia, 518 covered in the book. WebTutor (an online Study Tool accessed through your
deviation from social social phobia: public eResources account) provides an interactive version of the Study Guide.
norms, 511 speaking, 525
Diagnostic and Statistical somatization disorder, 520
Manual of Mental somatoform disorders, 520
Disorders, 513 specific phobia, 518
drug treatment of statistical frequency
phobias, 525 approach, 511
exposure therapy, 519, 524 taijin kyofusho, or TKS, 522
frequency of mental virtual reality therapy, 524
disorders, 516

Suggested Answers to Critical Thinking 4. According to Freud’s psychodynamic theory of personality,
women who fall in love with and marry killers are influenced by
1. Clinicians would use a clinical assessment (neurological and psycho- unconscious forces, wishes, and repressed desires, which are
logical/personality tests and interviews) to identify symptoms and then difficult to examine and understand because they are uncon-
match symptoms to the mental disorders listed in the DSM-IV-TR. scious and not easily revealed or brought to the surface.

2. These women may have obsessions, which are persistent, irrational 5. To identify potential problems of women who fall in love with kill-
thoughts, but there is no indication that the obsessions cause marked ers, clinicians might use Axis II, which focuses on long-standing
anxiety or that the women engage in compulsions, which are irresist- personality traits that are maladaptive or impair functioning.
ible, senseless behaviors or rituals.
6. One advantage of labeling these women’s problem is that it
3. A woman who falls in love with a convicted killer after seeing his mug may help decide which therapy is best. One disadvantage is that
shot and pursues him even though he will never be able to leave pris- giving women a label may bias how others perceive and respond
on is certainly abnormal in terms of statistical frequency, in terms of to her.
deviation from social norms, and in terms of engaging in maladaptive
behavior (giving up family, home, work, friends). L I N K S T O L E A R N I N G 529

Mood Disorders

23 & Schizophrenia
MODULE
532 Summary Test 550
Photo Credit: © AP Images/Vincent Yu535Critical Thinking552
A. Mood Disorders 536
B. Electroconvulsive Therapy 538 What Is a Psychopath? 553
C. Personality Disorders 543 Links to Learning
D. Schizophrenia 544
Concept Review 546 PowerStudy 4.5™
E. Dissociative Disorders 547 Complete Module
F. Cultural Diversity: Interpreting Symptoms 548
G. Research Focus: Exercise Versus Drugs
H. Application: Dealing with Mild Depression

530

Introduction

Mood Disorder Chuck Elliot (photo below) was check- Schizophrenia When Michael McCabe was 18 years old, Marsha,
ing out the exhibits at an electronics his mother, thought that he was just about over his
Why do convention in Las Vegas when suddenly Why was rebellious phase. She was looking forward to
his thoughts he hearing

speed up? his mind seemed to go wild and spin at voices? relaxing and enjoying herself. But then Michael
twice its regular speed. His words could said that he was hearing voices. At first Marsha
not keep up with his thoughts, thought that Michael’s voices came from his smoking marijuana. But
and he was talking in what the voices persisted for two weeks, and Marsha checked Michael into a
sounded like some strange private drug treatment center. He left the center after 30 days and
code, almost like rapid fire seemed no better off than he had been before. Several days later, Mar-
“dot, dot, dot.” Then he sha found Michael in her parents’ home, a couple of miles down the
stripped off all his clothes road from her own house. Michael was sitting on the floor, his head
and ran stark naked back, holding his throat and making grunting sounds like an animal.
through the gambling Marsha got really scared and called the police, but before they arrived,
casino of the Hilton Michael ran off.
Hotel. The police were Michael spent time with his grandparents, who finally called Marsha
called, and Chuck was taken and said that they couldn’t take his strange behavior anymore. Once
to a mental hospital. A er his again Marsha called the police. Just as Michael (photo below) tried
symptoms were reviewed, to run away, the police caught him and took him to the community
Chuck was diagnosed with psychiatric hospital.
what was then called manic Marsha received a call from
Chuck Elliot’s mind spins depression. a psychiatrist at the hospital,
and whirls out of control. He who explained that Michael
was diagnosed with having At one time, Chuck had a had been diagnosed as hav-
very successful career. A er
bipolar I disorder.

taking postgraduate courses, he obtained a doctor of educa- ing schizophrenia, a serious
tion degree (Ed.D.). He started and ran his own video pro- mental disorder that includes
duction business while also designing computer software. hearing voices and having
But since that first strange episode at the computer electron- disoriented thinking. A few
ics convention, Chuck has been hospitalized about twice a days later, Michael escaped
year when his mind races and spins wildly out of control in from the hospital. He was later
what are called manic episodes. He usually takes medication, returned by police, put into
but because the drug slows him down more than he likes, he leather restraints, and given
stops taking his medication every so o en. Without medica- antipsychotic drugs that would
tion, his energy may come back with such force that it blasts also calm him down. Michael
him into superactive days and sleepless nights, and he o en remained in the hospital and Michael McCabe, 18 years old, began
ends up in a psychiatric hospital. was treated with drugs for about hearing voices and was diagnosed with
His last regular job ended when he was in the middle of a month, with little success.
having schizophrenia.

another manic attack. He was going on 100 hours without Just about the time Marsha was at her wits’ end about what to do
sleep when he went out to his car, grabbed a bunch of maga- next, Michael was put on a new antipsychotic drug, clozapine. A er
zines, books, fruits, and vegetables, and piled them all on the about a month on the new drug, Michael improved enough to be dis-
desk in his office. When his boss came by and found a desk charged back into Marsha’s care (C. Brooks, 1994, 1995a).
piled high with junk and Chuck sitting there with his mind In this module, we’ll explain what schizophrenia is, describe the
spinning, the boss fired him on the spot (C. Brooks, 1994). drugs Michael was given, and report how his treatment is working.
Since that time, despite his very good academic, computer,
and business qualifications, he has not been able to hold a What’s Coming
Photo Credits: both, © Robert Gauthier steady job.
More recently, Chuck married a woman he had been We’ll discuss several different mental disorders and their treatments.
dating for only ten days. She understands Chuck very well We’ll explain mood disorders and their treatments, including the treat-
because she too is manic-depressive and has similar mental ment of last resort for depression, electroconvulsive shock therapy.
health problems. She hopes that they can care for each other. We’ll also examine several personality disorders and different kinds of
She says, “Chuck is the most brilliant man I have ever met. I schizophrenia, along with old and new antipsychotic drugs. We’ll end
am so lucky” (C. Brooks, 1994, p. 4). with a group of strange and unusual disorders, one of which is multiple
In this module, we’ll explain Chuck’s illness, his treatment, personality disorder.
and how he is dealing with his problem.
We’ll begin with Chuck Elliot’s problem, which is an example of one
kind of mood disorder.

I N T R O D U C T I O N 531

A. Mood Disorders

Kinds of Mood Disorders

How bad Depression is not choosy; it happens to about 6 million blues that most of us feel as having a paper cut on our finger.
Americans a year. Major depression is one example of en major depression is more like having to undergo open-
is it? a mood disorder.
heart surgery. It’s some of the worst news that you can get.
A mood disorder is a prolonged and disturbed emotional The DSM-IV-TR lists ten different mood disorders, but

state that affects almost all of a person’s thoughts, feelings, and behaviors. we’ll focus on the symptoms of three of the more common
forms: major depressive disorder, bipolar I disorder, and
Most of us have experienced a continuum of moods, with depression dysthymic disorder.
on one end and elation on the other. However, think of the depression or

Major Depression Bipolar I Disorder Dysthymic Disorder
Another mood disorder that is less
Popular singer-songwriter Sheryl Crow (photo below) Unlike Sheryl Crow, serious than major depression is
says that she has battled major depression most of her life. who has a major called dysthymic (dis-THY-mick)
Major depressive disorder is marked by at least two depressive disor- disorder.
der, Chuck Elliot
weeks of continually being in a bad mood, having no interest (right photo) fluc- Dysthymic disorder is character-
tuates between two ized by being chronically but not con-
in anything, and getting no pleasure from activities. In addition, extreme moods of tinuously depressed for a period of two
depression and years. While depressed, a person expe-
a person must have at least four of the following symptoms: mania; he has riences at least two of the following
what is called bipolar I disorder. symptoms: poor appetite, insomnia,
problems with eating, sleeping, thinking, fatigue, low self-esteem, poor concen-
Bipolar I disorder is marked by fluc- tration, and feelings of hopelessness
concentrating, or making decisions, tuations between episodes of depression (American Psychiatric Association,
and mania. A manic episode goes on for 2000).
lacking energy, thinking about sui- at least a week, during which a person is
unusually euphoric, cheerful, and high Individuals with dysthymic
cide, and feeling worthless or and has at least three of the following disorder, which affects about
symptoms: has great self-esteem, has 6% of the population, are o en
guilty (American Psychiatric little need for sleep, speaks rapidly and described as “down in the dumps.”
frequently, has racing thoughts, is easily Some of these individuals become
Association, 2000). distracted, and pursues pleasurable accustomed to such feelings and
activities (American Psychiatric describe themselves as “always
Sheryl Crow says that she Association, 2000). being this way.”
had been on a world tour with
Michael Jackson, singing in About 1.3% of the population Besides these three mood
front of 70,000 screaming suffer from bipolar I disorder, and disorders, we have also discussed
fans. When the tour ended, she was back in her lonely 1.6% suffer from only manic episodes another mood disorder, sea-
apartment with the anxiety of having to get a record (Rush, 2003). sonal affective disorder, or SAD
contract. All this stress triggered her first bout of depres- (p. 159). People with SAD become
sion, which resulted in her lying in bed, hardly able to Chuck Elliot has the typical pat- depressed as a result of a decrease
move, going unshowered, stringy-haired, and ordering tern of bipolar I disorder. As shown in the number of sunny days,
take-out for seven straight months (Hirshey, 2003). Like in the graph below, Elliot may have such as occurs in fall and winter
Crow, about 16% periods of being normal, which may months, and they recover with the
Major Depressive Disorder of U.S. adults turn into extreme manic episodes arrival of summer.
followed by periods of extreme
Manic reported at least depression. Next, we’ll examine some of the Photo Credits: left, © Evan Agostini/Getty Images; center, © Robert Gauthier
one lifetime common causes of mood disorders.
episode of major
depression,
Normal with women

Depressed outnumbering
men by a ratio
Time (years) of 2 to 1 ( ase,

2006).
To help understand mood disorders, look at the
graph above, which shows three general mood states.
e top bar shows a manic episode or period of incred- Bipolar I Disorder
ible energy and euphoria that we’ll discuss later. e Manic
middle bar shows a normal period when a person’s
moods and emotions do not interfere with normal psy-
chological functioning. However, like what happened Normal

to Crow, some event may cause a person to go from a
normal period to a period of depression (bottom bar).
Individuals may fluctuate between a normal period and Depressed

a bout of severe depression. Time (years)

532 M O D U L E 2 3 M O O D D I S O R D E R S & S C H I Z O P H R E N I A

Causes of Mood Disorders What chemical imbalance in her brain and that depres-
caused sion ran in families (partly inherited or genetic)
Sheryl Crow says that she has had a lifetime battle with Crow’s because her father suffered from similar mood
mood disorders and, contrary to popular myths, when depression? problems (Hirshey, 2003). Let’s see if she’s right.
depressed she cannot make great music or work much at
anything. Crow thought her depression was due to some

Biological Factors Psychosocial Factors

Using recently developed techniques for studying the living brain and In addition to biological factors, an individual may be at
information from mapping the genetic code (Human Genome Project— risk for depression because of psychosocial factors.
p. 68), researchers have been actively studying biological factors involved in Psychosocial factors, such as personality traits, cognitive

mood disorders. styles, social supports, and the ability to deal with stressors,

Biological factors underlying depression are genetic, neurological, chemical, and interact with predisposing biological factors to put one at risk

physiological components that may predispose or put someone at risk for developing for developing a mood disorder.

a mood disorder. Stressful life events. Sheryl Crow says that her

Genetic factors. Sheryl Crow was right about depression having a period of depression was triggered by the overwhelming
genetic component. Research studies comparing depression rates of iden- stress of seeing a fantastic world tour end with her liv-
tical twins with those of fraternal twins, who share only 50% of their ing in a lonely apartment, having to wait on tables while
genes, find that 40–60% of each individual’s susceptibility to depression is struggling to get a record contact. Researchers found that
explained by genetics (Canli, 2008). Researchers believe there is no single stressful life events are strongly related to the onset of
gene but rather a combination of genes that produces a risk, or predisposi- mood disorders such as depression (Kendler et al., 2004).
tion, for developing a mood disorder (B. Bower, 2009b; Levinson, 2009). One Negative cognitive style. There is considerable
theory states that defects in specific genes affect our sensitivity to stress, research to support Aaron Beck’s (1991) idea that depres-
which can result in depression (D. R. Weinberger, 2005). Genes play a role sion may result from one’s perceiving the world in a nega-
in developing a mood disorder because genes are involved in regulating tive way, which in turn leads to feeling depressed. We’ll
the brain’s neurotransmitter or chemical system used for communication discuss Beck’s theory later in the Application, but just
(Canli, 2008). note here that having a negative cognitive style or nega-
Neurological factors. Sheryl Crow was also right about depression tive way of thinking and perceiving can put one at risk
involving a chemical imbalance in her brain. A group of neurotransmit- for developing a mood disorder
ters, called the monoamines (serotonin, norepinephrine, and dopamine), such as depression.
are known to be involved in mood problems. Abnormal levels of certain Personality factors. Indi-
neurotransmitters can interfere with the functioning of the brain’s com- Certain
munication networks and, in turn, put individuals at risk for developing viduals who are especially personality
mood disorders. More recently, researchers discovered that continued stress sensitive to and overreact to factors increase
causes the brain and the body’s stress management machinery (p. 485) to go negative events (rejections, criti- risk for mood
into overdrive, which in turn alters hormonal and neurotransmitter levels cisms) with feelings of fear, anxi- disorders.
Photo Credits: top, © Evan Agostini/Getty Images; right, © Imagesource/Photolibrary ety, guilt, sadness, and anger are at
and can trigger depression ( ase, 2009). risk for developing a mood disorder
Brain scans. Researchers took computerized photos of the structure (D. N. Klein et al., 2002). Researchers also found that
and function of living brains and compared brains of depressed patients individuals who make their self-worth primarily depen-
with those of individuals with normal moods. Researchers reported that a dent on what others say or think have a kind of socially
brain area called the anterior cingulate cortex (figure below) was overactive dependent personality, which puts them at risk for
in very depressed patients. When the anterior cingulate cortex is overac- becoming seriously depressed when facing the end of a
tive, it allows negative emotions to overwhelm thinking and mood. ese close personal relationship or friendship. Some individu-
same researchers cured two-thirds of a group als have a need for control, which puts them at risk for
of very depressed patients who had not depression when they encounter uncontrollable stress
benefitted from years of psychotherapy, (Mazure et al., 2000).
drugs, or electroconvulsive therapy Depressed mothers. Research shows that a depressed
(p. 535) by electrically stimulating mother significantly increases her child’s susceptibility
the brain, which led to reduced to depression, even if the child is adopted and shares no
activity in the anterior cingulate genes with the mother. Also, when depressed mothers
cortex (Mayberg, 2006; May- receive successful treatment, their depressed children
berg et al., 2005). This and other experience mood improvement without receiving therapy
research examining the brains of themselves (B. Bower, 2008c; Tully et al., 2008).
depressed patients suggest that faulty e above psychosocial factors interact with underly-
The anterior cingulate cortex is brain structure or function contrib- ing biological factors to increase one’s risk of developing
overactive in very depressed patients, utes to the onset and/or maintenance a mood disorder ( ase, 2006).
of mood disorders ( ase, 2009). Next, we discuss the treatment for depression.
which allows negative emotions to
overwhelm thoughts and mood.

A . M O O D D I S O R D E R S 533

A. Mood Disorders

Treatment of Mood Disorders
Because the causes of depression include both biological and psychosocial factors, the treatment for depression,
What’s the depending upon the diagnosis and severity, may include psychotherapy, antidepressant drugs, or both. We’ll dis-
treatment? cuss the effectiveness of drugs and psychotherapy.

Major Depression and Dysthymic Disorder Bipolar I Disorder

A er months of depression, Sheryl Crow’s mother finally persuaded her (with Unlike Sheryl Crow’s problem, which is major depres-
threats of coming to haul her baby out of bed) to get professional treatment, sive disorder, Chuck Elliot has bipolar I disorder,
which involved both psychotherapy and antidepressant drugs. which means he cycles between episodes of depression
Antidepressant drugs act by increasing the levels of a specific and mania. For example, one of Elliot’s manic epi-

group of neurotransmitters (monoamines—serotonin, norepinephrine, sodes lasted four days, during which he was in almost

and dopamine) that are involved in the regulation of emotions and constant motion and did not sleep. Several times,

moods. when he lost control, he screamed at

Selective serotonin reuptake inhibitors—SSRIs. About his wife and ripped the blinds from
80% of prescribed antidepressant drugs, such as Prozac and the windows. His wife called the
Zoloft, belong to a group of drugs called SSRIs (selective police, who handcuffed Elliot (right
Treatment serotonin reuptake inhibitors) (Noonan & Cowley, 2002). e photo) and drove him to a psychi-
often requires SSRIs work primarily by raising the level of the neurotransmit- atric hospital for drug treatment.
professional ter serotonin. Common side effects include nausea, insomnia, Treatment. In the past, the drug

help.

sedation, and sexual problems (decreased libido, erectile dysfunction) (Gitlin, of choice to treat bipolar I disorder
2009; Khawam et al., 2006). Antidepressants have recently become the most was a mood stabilizer called lithium
commonly prescribed medication in the United States, used by 10% of the pop- (LITH-ee-um). Although still used
Bipolar I
ulation (Olfson & Marcus, 2009). today as the drug of choice, lithium is treated with
Effectiveness of antidepressants. When depressed patients use an anti- is o en combined with other drugs, lithium and other
depressant, which may take up to 8 weeks to work, symptoms for only one- including antipsychotics and anti-
drugs.

third of the patients will go away (comparable to the recovery rate for a placebo) depressants, which offer a more effective long-term
(Berenson, 2006). e challenge for physicians prescribing antidepressants is treatment program (C. F. Newman, 2006).
that for any given individual, some antidepressants work better than others, Lithium is thought to prevent manic episodes
but no one antidepressant has been found to be more effective for everyone. by preventing neurons from being overstimulated
O en, patients must try a second or third antidepressant until they find one (Lenox & Hahn, 2000). When Elliot takes medication,
that works well and has minimal side effects (Arkowitz & Lilienfeld, 2007b). he functions well enough that he has enrolled in law
Psychotherapy. Researchers compared patients who had received antide- school and is working toward his degree. e problem
pressant drugs, psychotherapy, or a combination of drugs and psychotherapy arises when Elliot doesn’t take lithium. When patients
to treat major depression. For patients with less severe with bipolar I disorder stop taking lithium (and com-
depression, psychotherapy was as effective as anti- bined drugs), about 50% experience a manic episode
depressant drugs. For patients with more severe (P. E. Keck & McElroy, 2003). In terms of effective- Photo Credits: left, © Evan Agostini/Getty Images; right, © Robert Gauthier
depression, a combination of antidepressant drugs ness, 50% of bipolar patients are greatly helped with
(SSRIs) and psychotherapy was more effective than a combined drug program (lithium plus other drugs),
either treatment alone (Hollon et al., 2002). 30% are partially helped, and 20% get little or no help
Relapse. When patients who had recovered were (F. K. Goodwin, 2003).
followed for 18 months, the results were discourag- Mania. Lithium has been found to be effective in
ing because, within that time, 70% of the patients had treating individuals with mania—that is, the manic
relapsed, which means they became depressed again Antidepressants episodes without the depression (F. K. Goodwin,
and required additional treatment. Of those who main- and psychotherapy 2003). Because lithium prevents mania, patients may
tained their recovery and were doing well, 30% had are about equally stop taking it to experience the euphoria they miss, as
been treated with psychotherapy, 20% with antidepres- Elliot did several times.
effective.

sant drugs, and 20% with placebos. us, patients treated with psychotherapy Relapse. For both major depression and bipolar
were somewhat less likely to relapse than those treated with drugs or placebos I disorder, 10–30% of patients receive no help from
(Shea et al., 1992). Psychotherapy may take longer to begin working, but its current drugs and 30–70% initially improve but later
strength is in reducing the likelihood of relapse (Charney, 2009). relapse. Researchers are constantly searching for new
Because 70% of patients treated for depression relapse within 18 months and ways to treat mood disorders and prevent relapse.
82% relapse during the first five years, clinicians concluded that major depression For individuals with major depression who are not
is a long-term or chronic disorder that may require further treatments during helped by drugs, there is something called the treatment
the patient’s lifetime (Moran, 2004; Vos et al., 2004). of last resort.

534 M O D U L E 2 3 M O O D D I S O R D E R S & S C H I Z O P H R E N I A

B. Electroconvulsive Therapy

Definition and Usage Effectiveness of ECT
Because the use of shock as therapy has Because antidepressants had not worked, the
What’s it o en been portrayed incorrectly in the Why is ECT patient we just described agreed to ECT. e rea-
like to get media, it helps to see the treatment from considered the son ECT is the last resort for treating depression

ECT? the eyes of an actual patient. last resort? is that ECT produces major brain seizures and
“. . . As far as manic-depressive tales may cause varying degrees of memory loss. How-
go, my stories are typical. My illness went undiagnosed for a ever, even as a treatment of last resort, ECT is effective in reducing
decade, a period of euphoric highs and desperate lows high- depressive symptoms in about 70–90% of patients (Husain et al., 2004).
lighted by $25,000 For example, the graph below shows the results for eight out of nine seri-
shopping sprees, ously depressed patients who had received no help from antidepressants.
impetuous trips to A er a series of ECT treatments, they showed a dramatic reduction in
Tokyo, Paris, and depressive symptoms and remained symptom-free a er one year (Paul et
Milan, drug and al., 1981). However, the average
alcohol binges. . . . relapse rate after ECT treatment 14
exceeds 50%, which means patients 12 ECT
Photo Credits: top, © Photo Researchers, Inc.; bottom, © Canadian Press/PhototakeAfter seeing eight treatment
Daily depression rating
psychiatrists, I fi- may need antidepressant therapy 10

Electrodes on this patient’s forehead will nally received a following ECT treatment or addi- 8
carry electricity through the brain and diagnosis of bipo- tional ECT treatments for depres-
cause a major seizure. lar disorder on my sion (Nemeroff, 2007). Researchers 6 Post-ECT
32nd birthday. Over are not sure how ECT works but
4 Pre-
ECT
the next year and a half, I was treated unsuccessfully with suggest it changes brain chemistry
more than 30 medications. My suburban New Jersey up- and restores a normal balance to 2 101 2345
neurotransmitters (Salzman, 2008). Week
bringing, my achievements as a film major at Wesleyan, and
a thriving career in public relations couldn’t help me. . . . As a Modern ECT. Unlike patients who received ECT in the movie One
last resort, I’m admitted to the hospital for ECT, electrocon- Flew Over the Cuckoo’s Nest, there is no evidence that modern ECT pro-
vulsive therapy, more commonly known as electroshock. . . . cedures cause brain damage or turn people into “vegetables” (Ende et al.,
e doctor presses a button. Electric current shoots through 2000). Modifications to modern ECT, including the proper placement of
my brain for an instant, causing a grand-mal seizure for 20 electrodes on the scalp and reduced levels of electric current, have less-
seconds. . . . I wake up 30 minutes later and think I’m in a ened the risk for complications (Nemeroff, 2007; Sackeim et al., 2000).
hotel room in Acapulco. My head feels as if I’ve just downed Memory loss. A side effect of ECT is memory loss, which ranges from
a frozen margarita too quickly. . . . After four treatments, a loss of memory for events experienced during the weeks of treatment to
there is marked improvement. No more egregious highs or events both before and a er treatment. Following ECT treatment, there
lows. But there are huge gaps in my memory. I avoid friends is a gradual improvement in memory functions, and for most patients,
and neighbors because I don’t know their names anymore. I memory returns to normal levels. However, some patients complain of
can’t remember the books I’ve read or the movies I’ve seen. long-term memory problems (Gitlin, 2009; Sackeim & Stern, 1997).
I have trouble recalling simple vocabulary. I forget phone Mental health experts cautiously endorse ECT as a treatment of last
numbers. . . . But I continue treatment because I’m getting resort for severe depression (Glass, 2001; K. G. Rasmussen, 2003). Now
better. . . . On the one-year anniversary of my first electro- we’ll briefly discuss another last resort treatment.
shock treatment, I’m clearheaded and even-keeled. I call my New treatment. For patients with treatment-resistant depression, a new
doctor to announce my ‘new and improved’ status. . . . Two treatment option is transcranial magnetic stimulation (shown below).
and a half years later, I still miss ECT. But medication keeps Transcranial magnetic stimulation (TMS) is a noninvasive technique that

my illness in check, and I’m more sane than I’ve ever been” activates neurons by sending pulses of magnetic energy into the brain.

(Behrman, 1999, p. 67). Research shows that depressed patients who did not
is patient received electroconvulsive therapy (ECT). benefit from various medications experienced signifi-
Electroconvulsive therapy, or ECT, involves placing elec- cant improvement in symptoms a er 40 minutes

trodes on the skull and administering a mild electric current that of TMS daily for four weeks (O’Reardon

passes through the brain and causes a seizure. Usual treatment et al., 2007). Although side effects, such

consists of a series of 10 to 12 ECT sessions, at the rate of about as headache, light-headedness, and

three per week. scalp discomfort, may occur, advan-

Usage. Because antidepressants fail to decrease depres- tages of TMS over ECT are that it is
sion in up to 40% of patients, many of these patients choose unlikely to cause seizures and does
to undergo ECT, a last resort option to treat their severe not require anesthesia (Baldauf, 2009;
depression. In the United States, ECT is currently used for George, 2009).
100,000 patients per year (Gitlin, 2009; Newsweek, 2006; Next, we’ll discuss a disorder
Westly, 2008). shared by many serial killers.

B . E L E C T R O C O N V U L S I V E T H E R A P Y 535

C. Personality Disorders

Definition and Types Borderline Personality Disorder
We have all heard the expression “Don’t judge a book by its People who have borderline
What are serial cover.” at advice proved absolutely true when we heard What does personality disorder have
killers like? what their friends and neighbors said about the following it mean to be intense, unpredictable

individuals. borderline? emotional outbursts and
His boss said David Berkowitz was “quiet and reserved and kept pretty much to lack impulse control, which
himself. at’s the way he was here, nice—a quiet, shy fellow.” Berkowitz, known causes them to express inappropriate anger and
as “Son of Sam,” was convicted of killing six people. engage in very dangerous behaviors.
A neighbor of Westley Allan Dodd said that he “seemed so harmless, such an About 75% of patients with borderline person-
all-around, basic good citizen.” Dodd was executed for kidnapping, raping, and ality disorder hurt themselves through cutting,
murdering three small boys. burning, or other forms of self-mutilation, and
A neighbor said John Esposito “was such a quiet, caring person. He was a very another 10% eventually commit suicide. Patients
nice person.” Esposito was charged with kidnapping a young girl and keeping her with borderline personality are so emotionally
in an underground bunker for 16 days. erratic that they are capable of expressing pro-
A friend said Jeffrey Dahmer “didn’t have much to say, found love and intense rage almost simultaneously.
was quiet, like the average Joe.” Dahmer confessed to kill- Such emotional vola-
ing and dismembering 15 people (Time, July 12, 1993, tility makes it difficult
p. 18). for them to maintain
Notice how friends and neighbors judged all these stable interpersonal
cold-blooded killers to be “quiet” and “nice” and even relationships. ey are
“caring” individuals. However, while these individuals terrified of losing the
appeared very ordinary in public appearance and behav- people most close to
ior, each was hiding a deep-seated, serious, and dangerous them, yet they rage-
personality disorder (Hickey, 2006). fully attack these same
A personality disorder consists of inflexible, long-standing, people, only to later
Why do friends describe maladaptive traits that cause significantly impaired functioning show sweetness and
serial killers, such as or great distress in one’s personal and social life (American affection toward them
Dahmer, as quiet, Psychiatric Association, 2000). (APA, 2000; Cloud,
nice, and caring?

Personality disorders are found in about 9% of the adult population in the 2009). 75% of people with Photo Credits: left, © Alan Fredrickson/Reuters/Corbis; right, © Angela Hampton Picture Library/Alamy
United States, affecting men and women equally, although gender may influence We’ll discuss the borderline personality
which personality disorder a person develops (Kluger, 2003). Of the ten differ- disorder hurt themselves.
causes and treatment
ent personality disorders described in DSM-IV-TR, here are seven of the more of borderline personality disorder.
common types. Causes. Borderline personality disorder
O Paranoid personality disorder is a pattern of distrust and suspiciousness and perceiving appears to have both environmental and genetic

others as having evil motives (0.5–2.5% of population). causes. Experiencing trauma during childhood,

O Schizotypal personality disorder is characterized by an acute discomfort in close rela- such as being abused or prohibited from express-

tionships, distortions in thinking, and eccentric behavior (3–5% of population). ing negative emotions, places individuals at risk

O Histrionic personality disorder is characterized by excessive emotionality and attention for this condition. Brain scan studies have shown

seeking (2% of population). that the amygdala (emotional center of the brain)

O Obsessive-compulsive personality disorder is an intense interest in being orderly, in these patients is overactive, while the brain areas

achieving perfection, and having control (4% of population). responsible for controlling emotional responses are

O Dependent personality disorder refers to a pattern of being submissive and clingy underactive. is helps explain why these patients

because of an excessive need to be taken care of (2% of population). lack emotional regulation. Though no specific

O Borderline personality disorder is a pattern of instability in personal relationships, self- genes have been identified, we know that the major

image, and emotions, as well as impulsive behavior (2% of population). symptoms of this condition, such as impulsivity

O Antisocial personality disorder refers to a pattern of disregarding or violating the rights and aggression, are highly heritable (J. E. Brody,

of others without feeling guilt or remorse (3% of population, predominantly males) 2009; Cloud, 2009; Meyer-Lindenberg, 2009).
Treatment. The most effective treatment
(American Psychiatric Association, 2000).

Individuals with personality disorders o en have the following characteristics: for this condition is dialectical behavior therapy,
troubled childhoods, childhood problems that continue into adulthood, maladap- a type of cognitive-behavioral therapy, which helps

tive or poor personal relationships, and abnormal behaviors that are at the extreme patients identify thoughts, beliefs, and assumptions that

end of the behavioral continuum. eir difficulties arise from a combination of make their life challenging and teaches them different

genetic, psychological, social, and environmental factors (Vargha-Khadem, 2000). ways to think and react (Linehan, 1993). Typically,
We’ll focus on two particular personality disorders, the borderline personality intense, long-term therapy is required, as well as
and antisocial personality, because they are mentioned most o en by the media. medication.

536 M O D U L E 2 3 M O O D D I S O R D E R S & S C H I Z O P H R E N I A

Antisocial Personality Disorder
e “nice,” “quiet” killers we described would probably be diagnosed as having antisocial
What are people personality disorder or some combination of personality disorders. Between 50% and 80%
with antisocial of prisoners meet the criteria for a diagnosis of antisocial personality disorder (Ogloff,
2006). But, not all people diagnosed with antisocial personality disorder are alike, and
personality

disorder like? the diagnostic symptoms vary along a continuum. At one end of the continuum are the
chronic delinquents, bullies, and lawbreakers; at the other end are the serial killers.
Delinquent. An example of someone on the delinquent end of the continuum is Tom, who always seemed to
be in trouble. As a child, he would steal items (silverware) from home and sell or swap them for things he wanted.
As a teenager, he skipped classes in school, set deserted buildings on fire, forged his father’s name on checks, stole
cars, and was finally sent to a federal institution. A er Tom served his time, he continued to break the law, and by
the age of 21, he had been arrested and imprisoned 50 to 60 times (Spitzer et al., 1994).
Serial killer. At the other end of the psychopathic continuum is serial killer Jeffrey Dahmer, who would pick up Jeffrey Dahmer
was diagnosed as
young gay men, bring them home, drug them, strangle them, have sex with their corpses, and then, in some cases, eat having an antisocial
their flesh. As Dahmer said in an interview, “I could completely control a person—a person that I found physically attrac-
tive, and keep them with me as long as possible, even if it meant just keep a part of them” (Gleick et al., 1994, p. 129). personality
disorder.
We’ll discuss the causes and treatment of antisocial personality disorder.

Causes Treatment

Antisocial personality disorder involves complex psychosocial and bio- Psychotherapy has not proved very effective in treating peo-
logical factors (Moffitt, 2005). ple with antisocial personality disorder because these indi-
Psychosocial factors. Researchers have found that aggressive and viduals are guiltless, mistrusting, irresponsible, and
antisocial children whom parents find almost impossible to control are at practiced liars, who fail to see that many of their behaviors
risk for developing an antisocial personality (Morey, 1997). Also, research are antisocial and maladaptive. As a result, psychotherapists
shows that children who experience physical or sexual abuse are at an have a very difficult time changing their behavior (Bateman
increased risk of developing antisocial personality disorder (D. Black, & Fonagy, 2000).
2006). However, since many abused children do not develop an antiso- Because of the
cial personality, it is difficult to determine how much childhood abuse relative ineffective- Drug that Increases Serotonin

contributes to the development of antisocial personality disorder. ness of psychother- 45

Biological factors. Researchers suggest that the early appearance apy, clinicians have 35
tried various drugs
Photo Credit: top, © Alan Fredrickson/Reuters/Corbisof serious behavioral problems, such as having temper tantrums, bul-that raise levels of
Aggression scorelying other children, torturing animals, and habitually lying, indicates25

that underlying biological factors, both genetic and neurological, may serotonin in the 15
predispose or place a child at risk for developing antisocial personality brain. Researchers
disorder (Pinker, 2008). believe that some
5

Evidence for genetic factors comes from twin and adoption studies that abnormality in the
show that genetic factors contribute 30–50% to the development of antiso- brain’s serotonin
system may under- Baseline 2 Weeks 4 8

cial personality disorder ( apar & McGuffin, 1993). Evidence for neuro-
logical factors comes from individuals with brain damage and from MRI lie the impulsive
studies on the brains of individuals with antisocial personality disorder. and aggressive behaviors observed in personality disorders
For example, researchers found that early brain damage to the pre- (D. Black, 2006). As shown in the graph above, patients who
frontal cortex (shown below) resulted in two children who did not learn took a serotonin-increasing drug (sertraline) reported sig-
normal social and moral behaviors and showed no empathy, remorse, or nificant decreases in their aggressive behaviors across eight
guilt as adults. In addition, MRI scans (p. 70) indicated weeks of treatment. However, researchers caution that
Prefrontal that individuals diagnosed with antisocial personal- aggressive behaviors may return once patients stop taking
cortex

ity disorder had 11% fewer brain cells in their these serotonin-increasing drugs (Coccaro & Kavoussi, 1997).
prefrontal cortex (A. Raine et al., 2000). Since Other research shows that the use of antipsychotic medica-
the prefrontal cortex is known to be involved in tion (p. 541) can decrease impulsivity, hostility, aggressive-
important executive functions, such as making ness, and rage in patients with antisocial personality disorder
decisions and planning, researchers suggest that (C. Walker et al., 2003).
damage to or maldevelopment of the prefrontal Even though there are some treatment successes, research-
cortex predisposes or increases the risk of an individual developing anti- ers caution that for 69% of the patients, antisocial personality
social personality disorder. Researchers believe that biological factors disorder is an ongoing, relatively stable, long-term problem
can predispose individuals to act in certain ways but that the interaction that needs continual treatment (G. Parker, 2000).
between biological and psychosocial factors results in the development Next, we’ll examine one of the most tragic mental
and onset of personality disorders (A. B. Morgan & Lilienfeld, 2000). disorders—schizophrenia.

C . P E R S O N A L I T Y D I S O R D E R S 537

D. Schizophrenia

Definition and Types Symptoms
At the beginning of this module, we described 18-year-old Michael
What if McCabe (photo below), who said that his mind began to weaken Schizophrenia is a serious mental dis-
you lose touch during the summer of 1992. “I totally hit this point in my life where order that lasts for at least six months
and includes at least two of the follow-
with reality? I was so high on life, it was amazing. I had this sense of indepen- ing symptoms:
dence. I was 18 and turning into an adult. Next thing I knew I got
this feeling that people were trying to take things from me. Not my soul, but physical things 1 Disorders of thought.
from me. I couldn’t sleep because they [his mother and sister] were planning to do something ese are characterized by incoherent
to me. I think there was a higher power inside the thought patterns, formation of new
7-Eleven that was helping me out the whole time, just words (called neologisms), inability to
bringing me back to a strong mental state” (C. Brooks, stick to one topic, and irrational beliefs
1994, p. 9). Michael was diagnosed as having schizo- or delusions. For example, Michael
phrenia (skit-suh-FREE-nee-ah). believed that his mother and sister
Schizophrenia is a serious mental disorder that lasts for were plotting against him.

at least six months and includes at least two of the following 2 Disorders of attention.
ese include difficulties in concentra-
symptoms: delusions, hallucinations, disorganized speech, tion and in focusing on a single chain
of events. For instance, one patient
disorganized behavior, and decreased emotional expression. said that he could not concentrate on
television because he couldn’t watch
These symptoms interfere with personal or social functioning and listen at the same time.

(American Psychiatric Association, 2000). 3 Disorders of perception.
ese include strange bodily sensations
Michael has a number of these symptoms, including and hallucinations.
delusions (higher power inside the 7-Eleven), halluci-
Michael McCabe had many of the nations (hearing voices), and disorganized behavior. Hallucinations are sensory experi-
symptoms described on the right. Schizophrenia affects about 0.2–2% of the adult popula- ences without any stimulation from the

tion, or about 4.5 million people (equal numbers of men and women) in the United States environment.
(American Psychiatric Association, 2000). About 70% of schizophrenics report

Subcategories of Schizophrenia hearing voices that sound real and talk
Michael’s case illustrates some of the symptoms that occur in schizophrenia. In fact, no two either to them (steal brain cells) or
patients have exactly the same set of symptoms, which are described in the list on the right. about them (mostly negative things,
like “You have a cancer”) ( raenhardt,
e DSM-IV-TR describes five subcategories of schizophrenia, each of which is characterized 2006). Research using brain imaging
by different symptoms. We’ll briefly describe three of the more common schizophrenia shows that when schizophrenics hal-
subcategories. lucinate people, their visual cortex
becomes active, and when they hallu-
Paranoid schizophrenia is characterized by auditory hallucinations or delusions, such as thoughts cinate voices, their auditory cortex is
of being persecuted by others or thoughts of grandeur. activated (Begley, 2008c).

Disorganized schizophrenia is marked by bizarre ideas, often about one’s body (bones melting), 4 Motor disorders.
confused speech, childish behavior (giggling for no apparent reason, making faces at people), great
These include making strange facial
emotional swings (fits of laughing or crying), and often extreme neglect of personal appearance and expressions, being extremely active, or
(the opposite) remaining immobile for
hygiene. long periods of time.
Catatonic schizophrenia is characterized by periods of wild excitement or periods of rigid, pro-
5 Emotional (affective) disorders.
longed immobility; sometimes the person assumes the same frozen posture for hours on end. ese may include having little or no
Differentiating between types of schizophrenia can be difficult because some symptoms, emotional responsiveness or having
emotional responses that are inappro-
such as disordered thought processes and delusions, are shared by all types. priate to the situation—for example,
laughing when told of the death of a
Chances of Recovery close friend. Photo Credit: © Robert Gauthier
Chances of recovery are dependent upon a number of factors, which have been grouped
under two major types of schizophrenia (Crow, 1985). The cause of these schizophrenia
symptoms involves biological, neuro-
Type I schizophrenia includes having positive symptoms, such as hallucinations and delusions, logical, and environmental factors.
which are a distortion of normal functions. In addition, this group has no intellectual impairment, good

reaction to medication, and thus a good chance of recovery.
Type II schizophrenia includes having negative symptoms, such as dulled emotions and little incli-

nation to speak, which are a loss of normal functions. In addition, this group has intellectual impair-

ment, poor reaction to medication, and thus a poor chance of recovery.
According to this classification system, the best predictor of recovery for a person with

schizophrenia is his or her symptoms: ose with positive symptoms have a good chance of
recovery, while those with negative symptoms have a poor chance (Dyck et al., 2000).

Next, we’ll describe the major symptoms of schizophrenia.

538 M O D U L E 2 3 M O O D D I S O R D E R S & S C H I Z O P H R E N I A

Biological Causes
When Michael was in the hospital, his disorder. In comparison, if one brother or sister (sibling or fraternal
What caused mother, Marsha (photo below), began twin) has schizophrenia, there is only about a 10–17% chance that the
Michael’s going to a support group to get help and other will develop the disorder (Gottesman, 2001). Because genetic fac-

problems? find out about schizophrenia. At one meet- tors are involved in developing schizophrenia, researchers are searching
ing, Marsha said, “I haven’t been doing for the location of specific genes involved in schizophrenia; such genes
very well with this, to be per- are called genetic markers (Levinson, 2003).
fectly honest. How in the hell A genetic marker refers to an identifiable gene or number of genes or a

were we dealt this hand?” specific segment of a chromosome that is directly linked to some behavioral,
(C.Brooks, 1994, p. 8). physiological, or neurological trait or disease.

e psychiatrist who led Researchers have reported many genetic markers for schizophrenia,
Marsha’s group answered but none proved valid because none could be repeated or replicated by
that about 1 in 100 people other laboratories. Researchers now believe that schizophrenia depends
get schizophrenia but the on a combination of genes and that no one gene by itself has a strong
odds increase to 1 in 10 if genetic influence (ISC, 2009; T. Walsh et al., 2008).
Marsha tries to help her son, it’s already in the family. If a Breakthroughs. There have been several reports of major break-
Michael, who has schizophrenia. person inherits a predispo-
throughs in identifying genetic markers for schizophrenia. For instance,
sition for schizophrenia, any number of things—such as drugs, researchers found evidence of a slight excess of a protein in the prefrontal
a death in the family, growing-up problems—can trigger its cortex of people with schizophrenia, resulting from a variation in a gene
onset (C. Brooks, 1994). e psychiatrist was pointing out three they believe may explain common symptoms of the disorder (Law &
major factors—biological, neurological, and environmental— Weinberger, 2006). Also, researchers found that a disruption in a particu-
that interact in the development of schizophrenia. We’ll begin lar gene makes new neurons that are supposed to reach the hippocampus,
with biological factors, specifically genetic causes. an area of the brain important for memory and emotional processing, go
elsewhere, causing a burst of abnormal brain activity, which may explain
Genetic Predisposition schizophrenia symptoms (H. Song, 2007). Other researchers
In 1930, the birth of four found a gene linked to negative symptoms of schizophrenia
identical baby girls (quadru- (p. 541), which suggests that researchers should seek genes
plets) was a rare occurrence responsible for specific symptoms (Fanous et al., 2005). Taken
(1 in 16 million) and received together, recent genetic studies plus earlier studies on identical
great publicity. By the time twins indicate that schizophrenia has a genetic factor.
the girls reached high school,
all four were labeled “differ- Infections

ent.’’ ey sometimes broke All four of these identical quadruplets Another biological factor that may contribute to the devel-
light bulbs, tore buttons off developed schizophrenia. opment of schizophrenia is infections. For instance, preg-
their clothes, complained of nant women who get the flu have been found to be more
bones slipping out of place, and had periods of great confusion. likely to give birth to children who will develop schizophrenia. Also,
By young adulthood, all four girls, who are called the Genain some childhood infections, such as the mumps virus, have been associ-
quadruplets and share nearly 100% of their genes, were diag- ated with an increased risk of later developing schizophrenia symp-
nosed with schizophrenia (Mirsky & Quinn, 1988). e finding toms. Researchers believe that some infections directly affect the brain,
that all four Genain quadruplets (above photo) developed whereas others trigger immune reactions that interfere with normal
Photo Credits: top, © Robert Gauthier; center, Courtesy of Edna Morlok schizophrenia indicates that increased genetic similarity is brain development (Dalman et al., 2008; Wenner, 2008a).
associated with increased risk for developing schizophrenia and However, biological factors alone cannot completely explain why
suggests that a person inherits a predisposition for developing individuals develop schizophrenia. As we’ll discuss, environmental
the disorder. Support for a genetic predisposition also comes factors must interact with biological factors (Mueser et al., 2006).
from twin studies.

Genetic Markers Risk of Developing Schizophrenia

Because researchers knew that schizophrenia might Identical twins 48%–83%
have a genetic factor, they compared rates of schizo- (100% of genes in common) 45%
phrenia in identical twins, who share nearly 100%
of their genes, with rates in fraternal twins and sib- Offspring of two schizophrenic parents
lings (brothers and sisters), who share only 50% of (50% of genes from each parent)
their genes. e right graph shows the risk of devel-
oping schizophrenia for individuals who share dif- Fraternal twins (50% 17%
ferent percentages of genes and thus have different of genes in common)
degrees of genetic similarity. Notice that if one
identical twin has schizophrenia, there is a 48–83% Siblings 10% (50% of genes in common)
chance that the other twin will also develop the
1%–2% General population
(0% of genes in common)

D . S C H I Z O P H R E N I A 539

D. Schizophrenia

Neurological Causes Environmental Causes
New techniques for studying the structures and functions of the If biological or neurological
Is the living brain (MRI and f MRI—p. 70) reveal major differences Can stress factors explained why peo-
brain between brains of schizophrenics and brains of mentally healthy act as a ple develop schizophrenia,

different? individuals. We’ll discuss two reliable differences—larger ventricles trigger? then the risk for developing
and decreased activity in the prefrontal cortex. schizophrenia in identical
twins would be almost 100% rather than 48–
Ventricle Size 83%. Because biological and neurological fac-

Normal: Most us of don’t realize that our brains have four fluid-filled tors alone cannot explain the development of
Lateral ventricles cavities called ventricles (le figure). e fluid in these cavi- schizophrenia, research-
ties helps to cushion the brain against blows and also serves
as a reservoir of nutrients and hormones for the brain. One ers look at the influence
of environmental fac-
reliable finding is that in up to 80% of the brains of schizo- tors, such as the inci-
phrenics, the ventricles are larger than normal (Niznikie-
Fluid-filled ventricles wicz et al., 2003). Using brain scans (MRIs), researchers dence of stressful events
in normal brains studied 15 pairs of identical twins; one was diagnosed with and how individuals

schizophrenia, while the other was mentally healthy (nor- cope. For example, Photo Credits: top left, Courtesy of Drs. E. Fuller Torrey & Daniel R. Weinberger, NIMH, Neuroscience Center, Washington D.C.; top right, © Robert Gauthier
when Michael McCabe
mal). The brains of twins with schizophrenia had larger (right photo) was 18,
Schizophrenia: ventricles than the brains of the mentally healthy twins (le he began to develop
Lateral ventricles figures) (Suddath et al., 1990). However, not all brains of symptoms of schizo- Stressful events may
phrenia. The onset of have led to his onset
people with schizophrenia have larger ventricles or an over-
all decrease in brain size. Also, the enlarged ventricles in of schizophrenia.

some schizophrenics may remain the same over the course these symptoms oc-
of their illness, while the size of ventricles may change over curred a er the death of his father and during
Increased size of time for others (DeLisi et al., 2004). Researchers conclude the potentially stressful period of adolescence.
fluid-filled ventricles in that some people with schizophrenia have abnormally large Stressful events, such as hostile parents,
brains of schizophrenics

ventricles, which results in a reduction in brain size and in turn may contribute to the poor social relationships, the death of a parent
or loved one, and career or personal problems,
development of schizophrenia (I. C. Wright et al., 2000). can contribute to the development and onset

Frontal Lobe: Prefrontal Cortex of schizophrenia. This relationship between

Another brain structure involved in many executive functions, such as reasoning, stress and the onset of schizophrenia is called
planning, remembering, paying attention, and making decisions, is the prefrontal the diathesis stress theory (S. R. Jones & Ferny-
cortex (figure below). Researchers report that in pairs of identical twins where one hough, 2007).
twin has schizophrenia and the other does not, the brain of the twin with schizophre- The diathesis (die-ATH-uh-sis) stress theory of

nia was characterized by significantly less activation of the prefrontal cortex schizophrenia says that some people have a genetic

(F. E. Torrey et al., 1994). is decreased prefrontal lobe activity is consistent with the predisposition (a diathesis) that interacts with life

deficits in many executive functions observed in schizophrenics, stressors to result in the onset and development of

such as disorganized thinking, irrational beliefs, and lack schizophrenia.

of concentration (Niznikiewicz et al., 2003). The diathesis stress theory assumes that
Other researchers report that in the brains of people biological or neurological factors have initially
with schizophrenia, the frontal and temporal lobes are produced a predisposition for schizophrenia.
smaller because there are fewer brain cells (neurons— If a person already has a predisposition for
p. 50) and fewer connections (axons—p. 50) among schizophrenia, then being faced with stressful
neurons (K. Davis, 2003; Pantelis et al., 2003). Fewer environmental factors can increase the risk
neurons with fewer connections cause deficits in Prefrontal and vulnerability for developing schizophrenia
transmitting information, which in turn may underlie cortex as well as trigger the onset of schizophrenia

problems in executive functions, such as disorganized symptoms (S. R. Jones & Fernyhough, 2007).
thinking and reasoning, which are major symptoms of us, the diathesis stress theory says that bio-
patients diagnosed with schizophrenia (Holden, 2003). logical and neurological factors first create a
ese studies point to neurological factors, such as abnormal brain structures and predisposition, such as overreacting to stressful
functions, that researchers believe underlie and contribute to the development of situations, that then makes a person vulnerable
schizophrenia and make it so difficult to treat (Holden, 2003). or at risk for developing schizophrenia.
Besides genetic and neurological factors, there are also environmental factors Now we’ll examine the drugs used to treat
involved in developing schizophrenia. schizophrenia.

540 M O D U L E 2 3 M O O D D I S O R D E R S & S C H I Z O P H R E N I A

Treatment ability to express thoughts, and decreased initiative to engage in goal-
directed behaviors (American Psychiatric Association, 2000).
How is A er Michael (right photo) was
taken to the psychiatric hospital,
Michael his symptoms were assessed and Like most individuals diagnosed with schizophrenia,
treated? he was diagnosed with schizo- Michael had both positive symptoms, such as delusions that
phrenia. Schizophrenia symp- people were going to steal from him, and negative symptoms,
toms are commonly divided into positive and such as loss of emotional expression. To reduce these symptoms,
negative symptoms. he was given haloperidol, which is an example of an antipsychotic
or neuroleptic (meaning “taking hold of the nerves”) drug.
Positive symptoms of schizophrenia reflect a dis- Michael was
given a neuro- Neuroleptic drugs, also called antipsychotic drugs, are used to
tortion of normal functions: distorted thinking results in leptic drug to treat treat serious mental disorders, such as schizophrenia, by changing the
delusions; distorted perceptions result in hallucinations; his schizophrenia.
and distorted language results in disorganized speech. levels of neurotransmitters in the brain.

Negative symptoms of schizophrenia reflect a decrease in or loss of There are two kinds of neuroleptic drugs: typical and
normal functions: decreased range and intensity of emotions, decreased atypical.

Typical Neuroleptics Atypical Neuroleptics

Typical Typical neuroleptics In Michael’s case and for about 20% of all schizophrenics, typical Atypical
neuroleptics: were discovered in neuroleptic drugs (phenothiazines, such as haloperidol or ora- neuroleptics:
the 1950s and were zine) have little or no effect on their symptoms. Many of these decrease dopamine
decrease the first effective patients are being helped by newer atypical neuroleptic drugs. & serotonin
dopamine medical treatment
Atypical neuroleptic drugs (clozapine, risperidone) lower levels of

for schizophrenia. dopamine and also lower levels of other neurotransmitters, especially

Typical neuroleptic drugs primarily reduce serotonin. These drugs primarily reduce positive symptoms, may reduce negative symptoms, and

levels of the neurotransmitter dopamine. These prevent relapse (Downar & Kapur, 2008).

drugs mainly reduce positive symptoms and have e first atypical neuroleptic, clozapine, was approved for use in schizophrenia in

little effect on negative symptoms. Because typi- 1990. Since then, atypical neuroleptics have proven effective in decreasing symptoms of
cal neuroleptics reduce levels of dopamine, schizophrenia, especially in patients who were not helped by typical
their action supports the dopamine theory neuroleptics (W. Carpenter, 2003).
of schizophrenia (Downar & Kapur, 2008). Michael, for example, showed little improvement with typical
The dopamine theory says that in schizophre- neuroleptics (haloperidol). However, the atypical neuroleptic
nia, the dopamine neurotransmitter system is clozapine reduced his positive symptoms to the point
somehow overactive and gives rise to a wide that he was allowed to leave the psychiatric hospi-
range of symptoms. tal and return home. A year later, Michael was still

e dopamine theory focuses on neurons taking clozapine and was making slow progress in
in a group of brain structures called the overcoming his symptoms, such as paranoia.
basal ganglia (figure below). Typical neu- On most days, Michael comes home from group
roleptics block dopamine usage in the basal therapy and job-training classes, puts on a Bob Mar-
ganglia, which reduces commu- ley record, and sits and listens, afraid to do much
nication among these neurons basal ganglia else. As Michael explains, “I can’t go out and Atypical neuroleptics helped Michael
and in turn reduces some of skate or do anything because I’m afraid I’m (shown with his mother and sister)
the symptoms of schizo- going to have a paranoia attack” (C. Brooks, reduce his symptoms.

phrenia. However, because 1995b, p. D-3). His mother and sister provide Michael with financial and social
20% of people with schizo- support but wish Michael would take greater initiative to improve his own life.
phrenia are not helped by Michael, as well as others with schizophrenia, face a daily struggle to overcome
typical neuroleptics and their symptoms, which points to the need for continued social support and
because recent findings psychotherapy (Bustillo et al., 2001).
Photo Credits: both, © Robert Gauthier point to the involvement of Current treatment. For many years, compared to typical neuroleptics, atypi-
several nondopamine neu- cal neuroleptics were the preferred treatment because they were reported to be at
rotransmitters (serotonin and least as effective in reducing positive symptoms, more effective in reducing nega-
glutamate), the dopamine the- tive symptoms, and helpful for patients who showed no improvement with typical
ory will need revision to include neuroleptics (S. Burton, 2006; J. M. Davis et al., 2003). More recently, a large, carefully
other neurotransmitter systems. conducted study compared the cognitive effects of the two types of neuroleptics and
Using typical neuroleptics to treat schizo- found that, contrary to previous research outcomes, typical and atypical neuroleptics
phrenia is being challenged by newer drugs, were about equally effective in boosting cognitive skills (R. S. E. Keefe et al., 2007).
called atypical neuroleptics. Next, we’ll discuss the serious side effects of typical and atypical neuroleptics.

D . S C H I Z O P H R E N I A 541

D. Schizophrenia

Evaluation of Neuroleptic Drugs
e major advantage of neuroleptic drugs is that they effectively reduce positive
What are symptoms so that many patients can regain some degree of normal function- Typical: Atypical:
the side ing. However, neuroleptics also have two potentially serious disadvantages: decrease decrease
dopamine dopamine &
effects? ey may produce undesirable side effects, and they may decrease but not serotonin
prevent relapse or return of the original symptoms of schizophrenia.

Typical Neuroleptics Atypical Neuroleptics

Side effects. One group of typical neuroleptics, Side effects. One advantage of atypical neuroleptics is they cause tardive dys-
called the phenothiazines (pheen-no-THIGH-ah- kinesia in only about 5% of patients, compared to 1–29% of patients given typical
zeens), is widely prescribed to treat schizophrenia. neuroleptics (Caroff et al., 2002). However, atypical neuroleptics can cause side
Phenothiazines can produce unwanted motor move- effects, the most serious being increased levels of cholesterol and glucose or blood
ments, which is a side effect called tardive dyskinesia sugar, weight gain, and onset or worsening of diabetes (S. Burton, 2006; Dolder,
(Dolder, 2008). 2008). us, typical and atypical neuroleptics may produce serious side effects.
Tardive dyskinesia (TAR-div dis-cah-KNEE-zee-ah) Effectiveness and relapse. From the 1950s through the middle of the 1990s,

involves the appearance of slow, involuntary, and uncon- the drugs of choice for treating schizophrenia were typical neuroleptics. Begin-
trollable rhythmic movements and rapid twitching of the ning in the late 1990s and continuing to the present, there has been a general
mouth and lips, as well as unusual movements of the limbs. switch to atypical neuroleptics. at’s because, compared to typical neurolep-
This condition is associated with the tics, atypical neuroleptics have generally proved to
continued use of typical neuroleptics. Risks of Developing Tardive Dyskinesia be as effective in reducing positive symptoms, more

As shown in the right graph, the 3 months 16% effective in reducing negative symptoms, less likely to
risk for developing tardive dyskine- cause tardive dyskinesia, and more effective in prevent-
sia increases with use: After three 3–12 months 29% ing relapse, the recurrence of schizophrenia symptoms

months, 16% developed this side 1–10 years 30% (S. Burton, 2006; J. M. Davis et al., 2003). However, some
effect; a er ten years, 40% developed research found that the use of typical and atypical drugs
it (Sweet et al., 1995). About 30% of More than 10 years 40% led to about equal improvement in patients with schizo-
patients with tardive dyskinesia will phrenia and similar rates of movement-related side
experience a reduction in symptoms if they are taken effects, such as tardive dyskinesia (J. A. Lieberman, 2005). Due to these incon-
off typical neuroleptics, but the remaining 70% may sistencies, clinicians must carefully consider which type of drug to prescribe to
continue to have the problem when the drug therapy their patients.
is stopped (Roy-Byrne & Fann, 1997). Conclusions. Two strange, recurring findings in the treatment of mental dis-
Effectiveness. Researchers have completed orders are that the same drug may help one patient but not another, and for some
several long-term follow-up studies on patients who patients drugs cause no improvement at all. One reason drugs don’t always work
were treated for schizophrenia with typical neuro- is that mental disorders, like schizophrenia, may have different causes (genetic,
leptics. ey found that, 2 to 12 years a er treatment, neurological, environmental) that may require a combination of different drugs
about 20–30% of patients showed a good outcome, and/or psychotherapy. Another reason drugs don’t always work is that each per-
which means they needed no fur- son’s nervous system functions differently and has a different level of neurotrans-
ther treatment and had no relapse; mitters (Niznikiewicz et al., 2003). is explains why the same drug may
about 40–60% continued to suffer cause various types and severities of side effects for different people.
some behavior impairment and Researchers find that, for the majority of patients, schizophrenia
relapse, although their symptoms is a chronic or life-long problem with a high risk for relapse. us, in
reached a plateau in about 5 years addition to drug treatment, patients need psychotherapy and social
and did not worsen a er that; and support to improve their social interactions, work at an acceptable job,
about 20% were not helped by these and maintain their quality of life (Lauriello, 2007; Mueser et al., 2006).
drugs. New direction. Because some patients with schizophrenia either do
Unwanted motor
Relapse. e basic problem with movements (lip smacking)
taking patients off typical neuro- are a side effect of typical not benefit from typical or atypical neuroleptics or experience intoler-
leptics is that they may relapse. For neuroleptics but less so able side effects, researchers have been working to create a new drug that
with atypical neuroleptics. targets a different neurotransmitter called glutamate. Glutamate may be

example, after an average of about just as important as dopamine and serotonin in schizophrenia because
one year, 60% of patients taken off a typical neuro- it is associated with perception, memory, emotion, and concentration. Scientists
leptic experienced a relapse, as compared to a relapse think drugs that target glutamate will provide patients with another treatment
rate of 34% for those who were maintained on an option that promises to be effective and have limited side effects (Berenson, 2008;
atypical neuroleptic (Csernansky et al., 2002). Downar & Kapur, 2008; Goff, 2008; S. F. Locke, 2008).
Next, we’ll learn about the side effects and effec- After the Concept Review, we’ll discuss a disorder that has a very strange
tiveness of the newer atypical neuroleptics. symptom—the person does not know who he or she is.

542 M O D U L E 2 3 M O O D D I S O R D E R S & S C H I Z O P H R E N I A

Concept Review

1. A prolonged emotional state that affects almost all of a person’s 8. Certain psychoactive drugs act by increas-
thoughts and behaviors is called a disorder. ing levels of a specific group of neurotransmit-
ters (monoamines, such as serotonin) that
2. The most common form of are believed to be involved in the regulation
mood disorder is marked by at
least two weeks of daily being in a of emotions and moods. These are called
(a) drugs. A mood stabilizer that is used to treat
Normal bad mood, having no interest in

anything, and getting no pleasure bipolar I disorder is called (b) , and it’s often
combined with antidepressants and antipsychotics.
from activities and having at least
Time (years) four of these additional symptoms: 9. A person who has inflexible, long-standing,
maladaptive traits that cause significantly
problems with weight or appetite, insomnia, fatigue, difficulty impaired functioning or great distress in his
thinking, and feeling worthless and guilty. This problem is called or her personal and social life is said to have
disorder. a (a) disorder. Examples
of this disorder include a pattern of distrust
3. Another depressive disorder is characterized by being chroni- and suspiciousness and perceiving others
cally depressed for many but not all days over a period of two as having evil motives, which is called a
years and having two of the following symptoms: poor appetite, (b) personality disorder; a
insomnia, fatigue, low self-esteem, and feelings of hopelessness. pattern of being submissive and clingy because of an excessive
This problem is called disorder. need to be taken care of, which is called a (c)
personality disorder; and a pattern of disregarding or violating the
4. Another mood disorder is rights of others without feeling guilt or remorse, which is called an
characterized by a fluctuation (d) personality disorder.
between a depressive episode
and a manic episode that lasts Normal

about a week, during which a 10. A serious mental disturbance that lasts
person is unusually euphoric,
cheerful, or high, speaks rapidly, Time (years) for at least six months and that includes at

feels great self-esteem, and needs little sleep. This problem is least two of the following persistent symp-
toms—delusions, hallucinations, disorga-
called disorder. nized speech, grossly disorganized behavior,

5. Underlying genetic, neurological, chemical, or physiological and decreased emotional expression—is
components may predispose a person to developing a mood disor- called (a) . There are sub-
der. Together, these components are called categories of this disorder: the one charac-
terized by auditory hallucinations or delusions, such as thoughts
factors.

6. Factors such as dealing with stres- of being persecuted by others or thoughts of grandeur, is called
(b) schizophrenia.
sors and stressful life events are
believed to interact with predispos-
Photo Credits: (#9) © Alan Fredrickson/ Reuters/Corbis; (#10) © Robert Gauthiering biological factors and contribute 11. Drugs that are used to treat schizophrenia and act primarily
to reduce levels of dopamine are called (a)
Daily depression ratingto the development, onset, anddrugs. Drugs that are used
maintenance of mood disorders. These
are called factors. to treat schizophrenia and : :
reduce levels of dopamine decrease decrease
7. One treatment for major depres- 14 and levels of serotonin are dopamine dopamine &
serotonin

sion involves placing electrodes on 12 ECT called (b)
the skull and administering a mild treatment drugs, which are generally more effective than (c)

electric current that passes through 10 drugs. The theory that, in schizophrenia, the dopamine neuro-

the brain and causes a seizure. Usual 8 transmitter system is somehow overactive and gives rise to

treatment consists of a series of 10 to 6 Post-ECT many of the symptoms observed in schizophrenics is called the

12 such sessions, at the rate of about 4 Pre- (d) theory, which is supported by the actions
ECT

three per week. This treatment is 2 of (e) drugs but not by the actions of
101 2345

called . Week (f) drugs.

Answers: 1. mood; 2. major depressive; 3. dysthymic; 4. bipolar I; 5. biological; 6. psychosocial; 7. electroconvulsive therapy, or ECT; 8. (a) anti-
depressant, (b) lithium; 9. (a) personality, (b) paranoid, (c) dependent, (d) antisocial; 10. (a) schizophrenia, (b) paranoid; 11. (a) typical neuroleptic,
(b) atypical neuroleptic, (c) typical neuroleptic, (d) dopamine, (e) typical neuroleptic, (f) atypical neuroleptic

C O N C E P T R E V I E W 543

E. Dissociative Disorders

Definition

What if You have probably had the dissociative experience so extreme that your own
experience of being so self splits, breaks down, or disappears.
you became absorbed in a fantasy, A dissociative disorder is characterized by a per-
someone else? thought, or memory that, son having a disruption, split, or breakdown in his or
for a short period of time, her normal integrated self, consciousness, memory,
you cut yourself off from the real world. How- or sense of identity. This disorder is relatively rare
ever, if someone calls your name, you quickly and unusual (American Psychiatric Association,
return and explain, “I’m sorry, I wasn’t paying 2000).
attention. I was off in my own world.” is is an We’ll discuss three of the five more common
example of a normal “break from reality,” or dis- dissociative disorders listed in the DSM-IV-
sociative experience, which may occur when you TR. ese are dissociative amnesia, dissociative
are self-absorbed, hypnotized, or fantasizing (Berlin & What if you had a split or
Koch, 2009; Kihlstrom et al., 1994). Now imagine a breakdown in your self? fugue, and dissociative identity disorder (formerly
called multiple personality disorder).

Dissociative Amnesia Dissociative Fugue

Mark is brought into the hospital emergency room by police. He A 40-year-old man wanders the streets of Denver with $8 in his
looks exhausted and is badly sunburned. When questioned, he pocket. He asks people to help him figure out who he is and where
gives the wrong date, answering September 27th instead of Octo- he lives. He feels lost, alone, anxious, and desperate to learn his
ber 1st. He has trouble answering specific questions about what identity. He appears on news shows pleading for help: “If anybody
happened to him. With much probing, he gradually remembers recognizes me, knows who I am, please let somebody know”
going sailing with friends on about September 25th and hitting (Ingram, 2006). A er his parents and fiancée
bad weather. He cannot recall anything else; he doesn’t know what see him on television, they contact the police, Who am I?
happened to his friends or the sailboat, how he got to shore, where informing them that the man’s name is Jeffrey What’s my name?

I can’t remember he has been, or where he is now. Each time Ingram and that he lives in Seattle. Upon
anything about the he is told that it is really October 1st and he reuniting with his fiancée and family, Jeffrey
is in a hospital, he looks very surprised fails to recognize their faces. He also can-
past month. (Spitzer et al., 1994). Mark is suffering from not recall anything about his past (Wood-

dissociative amnesia. ward, 2006). Jeffrey Ingram had experienced
Dissociative amnesia is character- dissociative fugue.

ized by the inability to recall important Dissociative fugue is a disturbance marked

personal information or events and is by suddenly and unexpectedly traveling away

usually associated with stressful or trau- from one’s home or place of work and being

matic events. The importance or extent unable to recall one’s past. The person may not

of the information forgotten is too great remember his or her identity or may be confused about his or her new

to be explained by normal forgetfulness assumed identity (American Psychiatric Association, 2000).

(American Psychiatric Association, Before clinicians diagnosed Jeffrey as suffering from dissociative

2000). fugue, they ruled out drugs, medications, and head injuries. His Photo Credit: right, © AP Images/The Denver Post/Karl Gehring

In Mark’s case, you might think fiancée explained that Jeffrey had been on his way to Canada to visit
his forgetfulness was due to a blow his friend’s wife, who was dying of cancer. She believes the stress of
to the head suffered on the sail- seeing his friend’s wife dying led him to an amnesia state. Jeffrey’s
boat in rough seas. However, doctors found no evidence of head history is especially fascinating because he had experienced a simi-
injury or neural problems. To recall the events between Septem- lar dissociative fugue in 1995, when he disappeared during a trip
ber 25th and October 1st, Mark was given a drug (sodium amytal) to the grocery store and wasn’t found until 9 months later. And,
that helps people relax and recall events that may be blocked by Jeffrey recently went missing for a third time! This time, he was
stressful experiences. While under the effect of the drug, Mark quickly identified because he had gotten a tattoo on his arm that
recalled a big storm that washed his companions overboard but gave his name and state ID number. Jeffrey is now considering his
spared him because he had tied himself to the boat. us, Mark options to always have GPS technology with him so his family can
did suffer from dissociative amnesia, which was triggered by the quickly find him if he should go missing again (Alexander, 2007).
stressful event of seeing his friends washed overboard (Spitzer As Jeffrey’s case illustrates, the onset of dissociative fugue is related
et al., 1994). In dissociative amnesia, the length of memory loss to stressful life events. Usually, fugue states end quite suddenly, and
varies from days to weeks to years and is o en associated with a the individual recalls most or all of his or her identity and past.
series of stressful events (Eich et al., 1997). In other cases, a person’s self splits into two or more “true” selves
As we’ll see next, a person may even forget who he or she is. or identities, which is called dissociative identity disorder.

544 M O D U L E 2 3 M O O D D I S O R D E R S & S C H I Z O P H R E N I A

Dissociative Identity Disorder

e idea that one individual could possess two or more “different persons” who may or may not know one another and
Is it who may appear at different times to say and do different things describes one of the more remarkable and controver-
really true? sial mental disorders (Eich et al., 1997). Previously this disorder was called multiple personality disorder, but now it’s

called dissociative identity disorder. We’ll discuss a real case of dissociative identity disorder and its possible causes.

Definition Occurrence and Causes

Herschel Walker is recognized for being an NFL leg- e worldwide occurrence of dissociative identity disorder was very
end, Heisman Trophy winner, track star, Olympic rare before 1970, with only 36 cases reported. However, an “epi-
competitor, and successful businessman. You demic” occurred in the 1970s and 1980s, with estimates ranging
would think Herschel would feel as though he was from 300 to 2,000 cases (Spanos, 1994). Reasons for the upsurge
on top of the world. On the contrary, Herschel felt include incorrect diagnosis, renewed professional interest, the
that his life was out of his control. He had diffi- trendiness of the disorder, and therapists’ (unknowing) encour-
culty managing his anger, he struggled to feel con- agement of patients to play the roles. Whatever the reasons, the
nected to people, and he experienced unexplained vast majority (70–80%) of mental health professionals are
periods of memory loss. skeptical about the upsurge in occurrence of dissociative
Herschel’s wife of 16 years (now divorced) identity disorder (Lilienfeld et al., 1999). e patients most
also noticed several oddities about him. For Football legend Herschel o en diagnosed with dissociative identity disorder (DID)
instance, she described him as having many Walker is diagnosed with are females, who outnumber males by 8 to 1. In addition,
different sides, such as the side with an inter- dissociative identity patients with DID usually have a history of other mental
est in the Marines, the side interested in bal- disorders.
let, the side interested in the FBI, and the side disorder, formerly called
multiple personality disorder. Explanations. ere are two opposing explanations for

interested in sports. She even noticed that he would occasionally DID. One is that DID results from the severe trauma of childhood
speak in different voices and show uniquely different physical abuse, which causes a mental splitting or dissociation of identities
mannerisms. as one way to defend against or
A er Herschel got the courage to seek professional help to cope with the terrible trauma.
understand what had been happening to him, his therapist diag- A second explanation is that
nosed him as suffering from a very rare and complex disorder DID has become commonplace
called dissociative identity disorder. because of cultural factors, such
Dissociative identity disorder (formerly called multiple personality as DID becoming a legitimate
disorder) is the presence of two or more distinct identities or personality way for people to express their
states, each with its own pattern of perceiving, thinking about, and frustrations or to manipulate or
relating to the world. Different personality states may take control of the gain personal rewards (Lilien-
individual’s thoughts and behaviors at different times (American feld et al., 1999). ese opposing
Psychiatric Association, 2000). explanations reflect the current

Photo Credits: top, © Kabik/Retna Ltd./Corbis; bottom, © Ron Nickel/Photolibrary As a boy, Herschel was severely teased and bullied for being an controversy about why so many
overweight child who had a severe stutter. His therapist explains patients have been diagnosed
that Herschel developed his alter personalities to help him over- with DID. Dissociative identity disorder is said
come the abuse by his peers as well as other major challenges he to have two very different causes.
Researchers have found bio-
faced later in life. logical evidence to support the existence of dissociative identity
Herschel identifies about a dozen alter personalities, includ- disorder. For instance, they found that the brains of patients with
ing “ e Hero,” who came out in public appearances, and “ e the condition generate multiple distinct patterns of seeing, thinking,
Warrior,” who was in charge of playing football and coping with and behaving. eir physiological arousal patterns (e.g., heartbeat,
the physical pain that came with it. Herschel’s therapist describes brain wave activity) are distinctively different depending on which
meeting the alter personalities in therapy by saying, “ ey will alter is present (Reinders et al., 2006).
come out and say, I am so-and-so. I’m here to tell you Herschel is Treatment. Patients diagnosed with DID may also have prob-
not doing too good. . . . When he finishes, it would just disappear lems with depression, anxiety, interpersonal relationships, and sub-
back in him, and Herschel comes out” (Mungadze, 2008). stance abuse. As a result, treatment for DID involves helping patients
As in Herschel’s case, the personalities are usually quite dif- with these related problems as well as helping them integrate their
ferent and complex, and the original personality is seldom aware various personalities into one unified self, which may take years. For
of the others. A er nearly ten years of psychotherapy, Herschel example, a er two years of treatment, patients diagnosed with DID
managed to obtain great insight about his condition and says who showed the greatest improvement were those who showed the
he is doing much better now (H. Walker, 2008; Woodruff et greatest ability to integrate and resolve the differences of their sepa-
al., 2008). rate selves and see themselves as a person with a single self. Clini-
How common is dissociative identity disorder, and what cians concluded that treatment for DID is a long-term process that
causes it? usually involves some form of psychotherapy (Chu et al., 2005).

E . D I S S O C I A T I V E D I S O R D E R S 545

F. Cultural Diversity: Interpreting Symptoms

Spirit Possession

How does Imagine being a clinician and where spirit possession is part of their culture and
interviewing a 26-year-old female about 45% of married women over 15 years of age
the world view client who reports the following report spirit possession (Boddy, 1988). Although in
mental disorders? sy mptoms: “Somet i mes a the United States symptoms of spirit possession would
spirit takes complete control probably be interpreted as delusional and abnormal, in
of my body and mind and makes me do things and say Northern Sudan spirit possession is interpreted as a
things that I don’t always remember. e spirit is very normal behavior and an expression of the women’s
powerful and I never know when it will take control. e culture. To deal with possible cultural differences, the
spirit first appeared when I was 16 and has been with me DSM-IV-TR now includes an appendix that describes
ever since.” how to diagnose symptoms within the context of a per-
As a clinician, you would of course conduct a much son’s culture (American Psychiatric Association, 2000).
more in-depth clinical interview and administer a Spirit possession is an example of how cultural
number of psychological tests. But on the basis of these About 45% of the women factors determine whether symptoms are interpreted
symptoms alone, would you say that she has delusions in Northern Sudan report as normal or abnormal. Researchers are also finding
and hallucinations and possibly schizophrenia or that spirit possession, which that cultural factors and gender influence the occur-
she has multiple identities and possibly dissociative rence of certain other kinds of mental disorders.
is part of their culture.

identity disorder? In this case, both diagnoses would be incorrect. We’ll examine how culture and gender influence the occurrence of
is female client comes from a small village in Northern Sudan, mental disorders.

Culture-Specific Mental Disorders Gender Differences in Mental Disorders
Mental illness is present across all cultures; however, cultures
o en differ in what they consider to be normal and abnormal. Many mental disorders in the United States, such as bipolar I disor-
der and personality disorders, are reported about equally by women
ere are some mental disorders that are unique to a culture and and men (Kluger, 2003; C. F. Newman, 2006). However, as shown in
are best understood within the context of a particular culture. the graph below, disorders such as major depression and dysthymic
disorders are reported significantly more frequently by women than
ey are collectively referred to as culture-specific disorders. by men in the United States as well as in many other countries
A culture-specific disorder is a pattern of mental illness or abnor- around the world (Kessler, 2003; ase, 2006).

mal behavior that is unique to an ethnic or cultural population and does

not match the Western classifications of mental disorders (APA, 2007).

Cross-cultural research has identified numerous culture- Major Depression and Dysthymic Disorder

specific disorders, a few of which are described below (Gaw, 2001). Women 67%
O Latah involves the inability to stop copy- Men
ing or imitating others’ behaviors, such as
movements and speech. Individuals with 33%

this disorder are susceptible to doing
things they wouldn’t typically do, such as Some clinicians attribute the higher per-
using intense profanity. Latah is found in centage of women reporting depression to
Malaysian and Indonesian cultures. cultural differences in gender roles. For
O Bibloqtoq involves an intense urge to example, the stereotypical gender role for
leave one’s home, tear off one’s clothes, and men is to be independent and assertive
Some mental expose oneself to the freezing cold weather. and to take control, which tends to reduce
disorders are It is found in Greenland, Alaska, and the levels of stress. In comparison, the ste-
unique to specific Canadian Arctic. reotypical gender role for women is to be
ethnic or cultural dependent, passive, and emotionally sensi-
populations. O Susto involves insomnia, depression,

and anxiety and is o en brought on by fear. It is found among tive, which reinforces women’s feelings of
the people of the Andean highlands and is believed to develop being dependent, not having control, and
Compared with men,
twice as many women
from contact with witches and the evil eye. being helpless, and increases levels of stress report problems with
O Koro involves the fear and sensation of one’s penis retract- and puts women at greater risk for develop-
ing into the body and the belief that one will die as a result. is ing depression (Durand & Barlow, 2006). depression.

syndrome is found in Malaysian cultures. Some researchers suggest that biological (hormonal changes) and
ese examples show the importance of cultural factors in psychosocial (concerns over having and raising children) factors may
mental disorders. Cultural factors influence not only the occur- also contribute to women’s higher rate of depression (NIMH, 2005).
rence of disorders but also the rates of occurrence in males Next, we’ll look at a very simple yet effective treatment for
and females. depression.

546 M O D U L E 2 3 M O O D D I S O R D E R S & S C H I Z O P H R E N I A

G. Research Focus: Exercise Versus Drugs

Choices of Therapy for Depression at least four of the following symptoms: problems with eating,

What would you think if you were in the
Can exercise middle of feeling very depressed and sleeping, thinking, concentrating, or making decisions,

help? someone recommended running three lacking energy, thinking about suicide, and feeling worth-

times a week as a good treatment? It less or guilty (American Psychiatric Association, 2000).

seems hard to believe that something as simple as exercising We have already discussed how psychotherapy,
could be as effective as antidepressants. Remember that antidepressants, and a combination of the two have
major depression is not how you feel from having a bad day proven effective in treating major depression (Goode,
or doing poorly on an exam. Major depression must meet 2003). Now researchers are asking if regular exercise
the following definition. can also be effective in treating major depression.
is Research Focus shows how scientists used
Major depressive disorder is marked by at least two weeks of Can depressed people the experimental approach to answer a question that
get help from walking? potentially has very practical or applied benefits.
continually being in a bad mood, having no interest in anything, and
getting no pleasure from activities. In addition, a person must have

Exercise Experiment: Seven Rules

Method and Results Rule 7: Analyze. Researchers found that about 60% of patients in
the exercise group had greatly improved, compared with 66% of sub-
You may remember that there are seven rules for doing an exper- jects taking antidepressants and 69% of those who combined exer-
iment (pp. 36–37). We’ll review these seven rules by showing how cise and antidepressants. Although these percentages look different,
researchers followed them in their study (Babyak et al., 2000). statistical analysis indicated that the three treatments were equally
Rule 1: Ask. Every experiment asks a specific question that effective. is means that exercise alone was as effective in reducing
is changed into a hypothesis or educated guess. In this study, depression as were antidepressants or the combination, which supports
the hypothesis is that exercise will be as effective a treatment for the researchers’ original hypothesis.
major depression as are antidepressants.
Rule 2: Identify. Researchers identify the Relapse
treatment, which is called the independent
variable because researchers Antidepressants: We discussed how, a er treat-
are able to control or admin- independent ment for a mental disorder, a Relapse Rate after Treatment
ister it to the subjects. Here, variable
certain percentage of patients Antidepressants 38%
relapse or again return to hav-
the independent variable has three levels of treat- ing symptoms. Of the 60–69% Combination
ments: the first level is 30 minutes of exercise 31%
of patients in each of the three
Exercise: (stationary bike or walking/jogging) three times treatment groups who showed 8% Exercise
independent a week; the second level is taking
antidepressants (Zolo ); and the significant improvement (few
variable third level is a combination of if any depressive symptoms), some patients had relapsed during the

exercising and taking antidepressants. 6-month period following treatment. Researchers reported (above
graph) that 38% of patients who had received antidepressants had
Next, researchers identify the behavior(s), relapsed and 31% of patients who had received both exercise and anti-
called the dependent variable, which depends
on the treatment, and measure its effectiveness. In Scale to depressants had relapsed. However, only 8% of patients relapsed who
measure were in the exercise-only treatment.
this study, the dependent variable is a scale (Ham- depression:
Photo Credits: top and left, © PhotoLink/PhotoDisc, Inc. ilton rating scale for depression) that measures dependent Conclusions
increases or decreases in subjects’ depression. variable Researchers found that a er 4 months of treatment for depression,
patients in all three treatment groups showed improvement. However,
Rule 3: Choose. Researchers choose subjects, who in this study when patients were retested 6 months later, those who had received
are 156 adult volunteers (50 years or older) who have been diag- exercise only showed less relapse. Researchers suggest that exercise
nosed with major depression (according to the above definition). helps patients develop a sense of personal mastery and positive self-
Rule 4: Assign. e chosen patients are randomly assigned regard, which helps patients get over being depressed and decreases
to groups, which means that each of the 156 patients has an equal the risk of future relapse (Babyak et al., 2000). Other research found
chance of being assigned to one of the three treatment groups. that depressed patients who exercised 30 minutes, three to five times
Rule 5: Manipulate. Researchers administer or manipulate a week, reported a 50% reduction in symptoms of depression a er
the three levels of the treatment by giving one level of treatment 12 weeks (Dunn et al., 2005). Also, researchers found that exercise
to each of the three groups of patients. has an immediate positive effect on mood that lasts for as long as
Rule 6: Measure. A er 4 months of treatments, research- 12 hours (Sibold, 2009). As a treatment for depression, exercise is
ers use the depression scale to measure how effective each one effective and inexpensive and has no unwanted side effects.
of the three levels of treatment was in decreasing the patients’
depression. Next, we’ll discuss several ways to overcome mild depression.

G . R E S E A R C H F O C U S : E X E R C I S E V E R S U S D R U G S 547

H. Application: Dealing with Mild Depression

Mild Versus Major Depression Beck’s Theory of Depression
ere is a big difference between mild and major depression. Janice thinks that her
How does Earlier, we discussed singer Sheryl Crow, who experienced How much depression is caused by

depression major depressive disorder. Symptoms of major depressive dis- do thoughts outside forces, such as
differ? order include being in a bad mood for at least two weeks, hav- matter? academic pressures, fi-
ing no interest in anything, and getting no pleasure from nancial concerns, per-
activities. Additionally, to be diagnosed with major depression, a person must have at sonal difficulties, and family pressures. ere is
least two of the following problems: difficulty in sleeping, eating, thinking, and mak- no question that stressful events or negative sit-
ing decisions or having no energy and feeling continually fatigued. Compared with uations can depress Janice’s mood. However,
the symptoms of major depressive disorder, the symptoms of mild depression are another factor that Janice may not be aware of
milder and generally have less impact on a person’s function- and that may contribute to her depression is a
ing. For example, take the case of Janice, who has what is particular pattern of thinking, which is de-
o en called the sophomore blues. scribed by Aaron Beck’s (1991) cognitive theory
“At first I was excited about going off to college and of depression.
being on my own,” explains Janice. “But now I feel Beck’s cognitive theory of depression says that

worn out from the constant pressure to study, get good when we are feeling down, automatic negative

grades, and scrape up enough bucks to pay my rent. I’ve thoughts that we rarely notice occur continually

lost interest in classes, I have trouble concentrating, throughout the day. These negative thoughts distort

I’m doing poorly on exams, and I’m thinking about how we perceive and interpret the world and thus

changing my major—again. And to make everything influence our behaviors and feelings, which in turn

even more depressing, my boyfriend just broke up contribute to our feeling depressed.

with me. I sit around wondering what went wrong Often these automatic negative thoughts
or what I did or why he broke it off. What did I do are centered on personal inadequacies, such as
There is a big difference that was so bad? My friends are tired of my moping thinking one is a failure, is not liked, or never
between the symptoms of around and complaining, and I know they are starting gets anything done. Beck has identified a num-
major and mild depression. to avoid me. Yeah, everyone says that I should just get ber of specific negative, maladaptive thoughts
that he believes contribute to developing anxi-
over him and get on with my life. But exactly what do I do to get out of my funk?” ety and depression. For example, thinking “I’m
Continuum. Some researchers have argued that the kind of depression reported a failure” a er doing poorly on one test is an ex-
by college students is related to general distress and does not represent any of the par-
ticular symptoms and feelings found in major depression (J. C. Coyne, 1994). However, ample of overgeneralization—that is, making a
other researchers find that depression is best thought of as a continuum. At one end blanket judgment about yourself based on a sin-
of the continuum is mild depression, such as that experienced by many college stu- gle incident. inking “People always criticize
dents, which is basically similar in quality but just a milder form of major depression, me” is an example of selective attention—that
which is at the other end of the continuum (Flett et al., 1997). is, focusing on one detail so much that you do
College students. Although many college students experience mild depres- not notice other positive events, such as being
sion, a considerable number also suffer from more severe forms of depression. For complimented. Beck believes that maladaptive
instance, a national survey found that 40% of college students have reported feeling thought patterns cause a distorted view of one-
“so depressed it’s difficult to function,” and another 10% reported they had “seriously self and one’s world, which in turn may lead
considered suicide.” In fact, more than 5% of students reported they had actually to various emotional
attempted suicide, which is the second leading cause of death among college stu- problems, such as
dents, compared to its ranking as the ninth leading cause of death in the general depression. Thus, Increased risk
population (ACHA, 2007; NAMH, 2008). ese statistics are devastating but perhaps one of the things for depression

not surprising when you consider that college students are experiencing almost all that Janice must
the major stressors of adulthood, including coping with a new environment, dealing work on to get out of her
with academic pressures, trying to establish intimate personal relationships, experi- depressed state is to
encing financial difficulties, and trying to achieve some independence from parents identify and change 1. Academic
and family (Pennebaker et al., 1990). her negative, mal- pressures
Vulnerability. ere are three major factors that increase an individual’s vulner- adaptive thoughts.
2. Financial concerns

ability or risk for developing mild depression. e first factor is being a young adult We’ll discuss how 3. Family pressures

who is facing new, challenging, and threatening situations and feelings. e second negative thoughts 4. Negative thought
factor is having a high number of negative life events. Since college students experi- and two other fac-
patterns

ence both of these factors, they are at high risk for developing mild depression, which tors maintain depres-
may lead to major depression later in life. e third factor involves an individual’s sion, as well as ways to
pattern of thinking, which is the basis for Beck’s theory of depression. change them.

548 M O D U L E 2 3 M O O D D I S O R D E R S & S C H I Z O P H R E N I A

Overcoming Mild Depression

Once we get “down in the dumps,” we are likely to stay there for some time unless we work at changing cer-
What can one do? tain thoughts and behaviors, such as improving social skills, increasing social support, and eliminating

negative thoughts. We’ll describe several ways to “get out of the dumps” and overcome mild depression.

Improving Social Skills Eliminating Negative Thoughts

Problem. In some cases, a person may feel mildly depressed Problem. According to Beck’s theory of depression, a depressed person
because he or she has poor social skills, which lead to prob- thinks negative, maladaptive thoughts, which in turn cause the person
lems in having good social interactions. to pay attention to, perceive, and remember primarily negative and
For example, researchers found that depressing situations, events, and conversations (A. T. Beck, 1991). us,
depressed teenagers and college students besides improving social skills and increasing social support, depressed
may be overly dependent, competi- individuals also need to stop the
tive, aggressive, or mistrustful, which automatic negative thought pattern
in turn caused problems in developing that maintains depression. After identifying
and maintaining close social relation- negative thoughts . . .
Researchers found that depressed
ships (M. K. Reed, 1994). If part of being individuals have a tendency to select
depressed involves poor social skills, a and remember unhappy, critical, . . . substitute
person can learn new ways of interact- or depressing thoughts, events, or
ing with friends. remarks, remember fewer good positive thoughts

Poor social skills Program. As with every behavioral things than bad things, and take
can increase
chances of feeling change program, the first step is to a more pessimistic view of life (Corey, 2005). Although discussed later
monitor our social interactions to notice (pp. 574–575), here’s a brief description of a program for changing negative
depressed. what we are doing wrong, such as com- thought patterns.

plaining too much and irritating our friends. Once we’re Program. The first step is to monitor the occurrence of negative,
aware of our bad habits, such as being negative, not asking depressive thoughts. e second step is to eliminate depressive thoughts
questions or showing interest, and not being sympathetic, we by substituting positive ones. This second step is difficult because it
can begin to take positive steps. at means making a real requires considerable effort to stop thinking negative thoughts (“I really
effort to stop complaining and to show more interest in our am a failure”) and substitute positive ones (“I’ve got a lot going for me”).
friends’ activities and to be more sensitive to their feelings. With practice, we can break the negative thought pattern by stopping
By proceeding in gradual steps, we can learn to improve our negative thoughts and substituting positive ones. ese kind of “talk”
social skills and get more rewards from social interactions, programs can help a person overcome mild depression and enjoy life
which in turn will make us feel better and help us get over more (Freeman et al., 2004). One reason “talk” programs can help as
our mild depression (Hokanson & Butler, 1992). much as antidepressants is that “talk” programs and antidepressants
Problem. Researchers find that individuals o en become produce strikingly similar changes in the brain.
and remain mildly depressed because
they do not give themselves credit for Power of Positive Thinking

any success (however small), make every Everyone has heard about the power of positive thinking, and now
situation (however small) into a bad or researchers have found a concrete example. It began with the interesting
unpleasant experience, and constantly and reliable finding that psychotherapy (“talk” therapy) can o en reduce
blame themselves for every failure, depressive symptoms as much as antidepressants can (Rupke et al., 2006).
which makes them more depressed and Wondering why psychotherapy was as powerful as drugs, researchers took
thus elicits more negative reactions from brain scans (pp. 70–71) of patients diagnosed with depression before and
friends (Nurius & Berlin, 1994). a er 12 weeks of treatment with either psychotherapy or antidepressants.
Program. e first step in increasing e result was that both treatments, psychotherapy and antidepressants,
our self-esteem is to become aware of decreased depression. But the surprising finding was that both psycho-
self-blame by monitoring our thoughts Learning to take therapy and antidepressants produced similar changes in the brain, one of
credit for our
actions can help
and noticing all the times we blame our- overcome which was to decrease the abnormally high activity
selves for things, no matter how small. of the prefrontal cortex (right figure) (A. L. Brody
Once we become aware of self-blame, feelings of mild et al., 2001).
depression.

we can substitute thoughts of our past Several studies have now reported similar
or recent accomplishments, no matter how small. By substi- results: Talk therapy can and does alter brain
tuting thoughts of accomplishment and focusing on recent functioning (Roffman et al., 2005). This
successes, we will gradually improve our self-esteem. As means that the next time you are down in the
our self-esteem improves, we will slowly get a more positive dumps, try the power of positive thinking to Prefrontal
attitude, which increases the social support of our friends change your brain functioning. You may be cortex

(Granvold, 1994). pleasantly surprised by the happy results.

H . A P P L I C A T I O N : D E A L I N G W I T H M I L D D E P R E S S I O N 549

Summary Test

A. Mood Disorders B. Electroconvulsive Therapy

1. A disturbed emotional state that affects almost all of 7. If antidepressant drugs fail to 14
a person’s thoughts and behaviors is treat major depression, the treat-
called a disorder. ment of last resort involves placing Daily depression rating 12 ECT
electrodes on the skull and admin- treatment
istering a mild electric current that
passes through the brain and causes 10
a seizure. This treatment is called
2. One mood disorder is marked by (a) therapy. A 8
potentially serious side effect of this
being in a daily bad mood, having 6 Post-ECT

no interest in anything, getting no 4 Pre-
ECT

pleasure from activities, and having 2
at least four of the following symp- 101 2345
Week

toms: problems with weight, appetite, treatment is impairment or deficits in (b) ,
sleep, fatigue, thinking, or making decisions and having suicidal
thoughts. This is called (a) disorder, which is which usually affects events experienced during the weeks of
treatment as well as events before and after treatment. However,
the most common form of mood disorder. Another mood disorder following ECT treatment, there is a gradual improvement in
is characterized by being chronically depressed for many but
not all days over a long period of time and having two of the memory functions.

following symptoms: problems with appetite and sleep, fatigue, C. Personality Disorders
low self-esteem, and feelings of hopelessness. This is called
(b) disorder.
8. A disorder that involves inflexible, long-
standing, maladaptive traits that cause signifi-
3. A mood episode that is characterized by a distinct period, cantly impaired functioning or great distress
lasting at least a week, during which a person is unusually
euphoric, cheerful, or high and has at least three of the in one’s personal and social life is called a
(a) disorder. Ten of these
following symptoms—has great self-esteem, needs little sleep, disorders are listed in the DSM-IV-TR, includ-
speaks rapidly and frequently, experiences racing thoughts,
is easily distracted—is called a (a) episode. ing: a pattern of being submissive and clingy
because of an excessive need to be taken care of,
A disorder characterized by periods of fluctuation between which is called a (b) disorder, and a pattern of
episodes of depression and mania is called (b)
disorder. disregarding or violating the rights of others without feeling guilt
or remorse, which is called an (c) disorder.
There is evidence that personality disorders develop from an
4. Underlying genetic, neurological, or physiological compo- interaction of (d) and factors.
nents may predispose a person to developing a mood disorder.
These components are called (a) factors.
Factors such as dealing with stressors and stressful life events 9. Evidence that genetic factors influence personality disorders
comes from studies on , which show that genetic
are believed to interact with predisposing biological influences factors contribute 30–50% to the development of these personality
and contribute to the development, onset, and maintenance of
mood disorders. These are called (b) factors. disorders.

5. Some drugs increase levels of neurotransmitters (serotonin, D. Schizophrenia
norepinephrine, dopamine) called (a) . These
drugs, which are involved in the regulation of emotions and
moods, such as major depression, are called (b) 10. Schizophrenia is a serious mental dis- NEUROLEPTICS
turbance that lasts for at least six months
and may take up to 8 weeks before they begin to work. The and includes at least two of the following Typical: Atypical: Photo Credit: (#8) © Alan Fredrickson/Reuters/Corbis
newer and more popular antidepressants (Prozac) are called persistent symptoms: delusions, halluci- decrease decrease
dopamine dopamine &
serotonin
(c) , or SSRIs, and are not more effective
but have fewer unwanted (d) than older nations, disorganized speech, grossly
disorganized behavior, and decreased emotional expression. These
antidepressants. symptoms interfere with personal or social .

6. A mood stabilizer used to treat bipolar I disorder is called 11. The DSM-IV-TR lists five subcategories of schizophrenia,
(a) , and it’s often combined with antidepres- which include the following three. A category characterized by
sants and antipsychotics. This drug is also used to treat bizarre ideas, confused speech, childish behavior, great emotional
euphoric periods without depression; this disorder is called swings, and often extreme neglect of personal appearance and
(b) . hygiene is called (a) schizophrenia. Another

550 M O D U L E 2 3 M O O D D I S O R D E R S & S C H I Z O P H R E N I A

form marked by periods of wild excitement or periods of rigid, F. Cultural Diversity: Interpreting Symptoms
prolonged immobility is called (b) schizophre-
nia. A third form characterized by thoughts of being persecuted or 18. Spirit possession is one example of how cultural fac-
thoughts of grandeur is called (c) schizophrenia. tors determine whether symptoms are interpreted as
(a) or . An
12. Researchers have searched for an identifiable gene or a specif- example of how cultural factors may increase
ic segment of a chromosome that is directly linked to developing the risk for development of mood disorders
schizophrenia. This genetic link is called a . can be traced to the differences in assigned
(b) roles: Males are expected to
13. Two kinds of neuroleptic drugs are used to treat schizophrenia be independent and in control, and females are
symptoms by changing levels of neurotransmitters in the brain. expected to be dependent and not have control.
Drugs that act primarily to reduce levels of the neurotransmitter
dopamine are called (a) neuroleptics. An exam-
ple is the phenothiazines. Drugs that lower levels of dopamine but, G. Research Focus: Exercise Versus Drugs
more important, also reduce levels of other neurotransmitters,
especially serotonin, are called (b) neuroleptics. 19. After three different treatments, including
exercise only, researchers found that at least 60%
These drugs are generally more effective in reducing schizophrenia of patients diagnosed with (a)
symptoms and better at preventing (c) .
showed significant improvement. Another finding
was that when patients were retested 6 months
14. One side effect of the continued use of phenothiazines is the later, those who had received exercise only
appearance of slow, involuntary, and uncontrollable rhythmic move-
ments and rapid twitching of the mouth and lips, as well as unusual showed significantly less (b) .
Researchers suggest that (c) helps patients
movements of the limbs. This side effect is called . develop a sense of personal mastery and positive self-regard,

15. One theory of schizophrenia says that it develops when the which helps prevent relapse.
(a) neurotransmitter is overactive. Another
related theory says that some people have a genetic predisposition,
called a (b) , that interacts with life stressors to H. Application: Dealing with Mild Depression
result in the onset and development of schizophrenia.
20. Beck’s cognitive theory of depression says
that when we are depressed, we have automatically
occurring (a) , which center
E. Dissociative Disorders around being personally inadequate. In turn, these

16. A dissociative disorder is characterized by negative thoughts (b) how we
a (a) in a person’s normally perceive and interpret the world and thus influence
integrated functions of memory, identity, or our behaviors and feelings. There are effective programs for
perception of the environment. The DSM-IV- developing better social skills and eliminating negative thoughts.
Photo Credits: (#19) © PhotoLink/PhotoDisc, Inc.; (#16) © Ron Nickel/Photolibrary TR lists five types of dissociative disorder, Psychotherapy and antidepressant drugs both reduced depression
which include the following three. If a person is and both produced similar changes in how the (c)
unable to recall important personal information or events, usually functions.
in connection with a stressful or traumatic event, and the infor-
mation forgotten is too important or lengthy to be explained by
normal forgetfulness, it is called (b) . If a person
suddenly and unexpectedly travels away from home or place of
work and is unable to recall the past and may assume a new identi- Answers: 1. mood; 2. (a) major depressive, (b) dysthymic; 3. (a) manic,
ty, it is called (c) . If a person experiences the (b) bipolar I; 4. (a) biological, (b) psychosocial; 5. (a) monoamines,
presence of two or more distinct identities or personality states, (b) antidepressants, (c) selective serotonin reuptake inhibitors, (d) side
each with its own pattern of perceiving, thinking about, and relat- effects; 6. (a) lithium, (b) mania; 7. (a) electroconvulsive, (b) memory;
ing to the world, it is called (d) disorder. 8. (a) personality, (b) dependent, (c) antisocial, (d) biological, psycho-
logical; 9. twins; 10. functioning; 11. (a) disorganized, (b) catatonic,
17. One theory says that dissociative identity disorder (DID) (c) paranoid; 12. genetic marker; 13. (a) typical, (b) atypical, (c) relapse;
develops as a way to cope with the severe trauma of childhood 14. tardive dyskinesia; 15. (a) dopamine, (b) diathesis; 16. (a) disruption,
(a) . A second explanation is that DID has split, breakdown, (b) dissociative amnesia, (c) dissociative fugue, (d) disso-
become a culturally approved way for people to express their ciative identity; 17. (a) physical or sexual abuse, (b) frustrations, fears;
(b) or to control others or gain personal rewards. 18. (a) normal, abnormal, (b) gender; 19. (a) major depression, (b) relapse,
(c) exercise; 20. (a) negative thoughts, (b) bias or distort, (c) brain

S U M M A R Y T E S T 551

Critical Thinking

What Is
a Psychopath?

QUESTIONS Jeffrey Dahmer would behaviors, such as eating and sex, as 5 How would a
pick up young gay men, well as emotional behaviors, such as psychopath do on
1According to the bring them home, drug fear, anger, and aggression. Also, a lie detector test?
three definitions them, strangle them, have some psychopaths have a disruption
of abnormal behavior sex with their corpses, in the communication between the 6 What is it called
(p. 511), are Dahmer and then, in some cases, hippocampus and the prefrontal when someone
and Rader abnormal? eat their flesh. cortex, which is believed to contrib- has inherited a gene
ute to their lack of control, inability for psychopathic
2What objective Dennis Rader would to regulate aggression, and insensi- behaviors but devel-
test can be used break into people’s homes, tivity to cues that predict they will ops those behaviors
to best assess for tie them up, strangle them, and get caught and punished. Interest- only if he or she has a
these psychopathic eventually murder them. His murder ingly, psychopaths also have lower stressful childhood?
personality traits? method earned him the name “BTK autonomic arousal and consequently
killer,” which stands for Bind, Tor- experience less distress when exposed ANSWERS
3Which trait theory ture, and Kill. to threats. TO CRITICAL
can explain how THINKING
an individual can dis- Dahmer and Rader share much in The life histories of psychopaths QUESTIONS
play such drastically common. They are superficially often include a chaotic upbringing,
inconsistent behaviors? charming, unemotional, impulsive, lack of parental attention, parental
and self-centered. They are patho- substance abuse, and child abuse.
4 What part of the logical liars who constantly manipu- These life experiences may interact
limbic system late others. Also, both men com- with biological or neurological fac-
explains how psycho- pletely lack remorse, guilt, and tors linked to psychopathic behav-
paths can be so cold empathy. Finally, they have low self- iors. For instance, children may have
and fearless? esteem, a strong desire to be in con- genes for psychopathic behaviors
trol, and a lifelong sense of loneli- that get activated only under stress;
ness. Dahmer, for example, felt so if they are raised in a nurturing envi-
lonely that he admitted to killing ronment, they may very well develop
people for company. Together, the into well-behaved, moral adults. In
above characteristics define a other words, at least for some chil-
psychopath. dren, the consequences of having a
stressful childhood can be deadly.
What may seem surprising is that (Adapted from B. Bower, 2006b,
psychopaths can love their parents, 2008e; Crenson, 2005; C. Goldberg,
spouses, and children but have great 2003; Hickey, 2006; Larsson et al.,
difficulty loving the rest of the 2006; Lilienfeld & Arkowitz, 2007;
world. Rader, for instance, was a Martens, 2002; A. Raine et al., 2004;
loving husband and father. Yet, he Wilgoren, 2005; Yang et al., 2005b)
seemed completely devoid of hu-
manity as he plainly recounted the
details of how he murdered his many
victims.

Some of the fascinating charac-
teristics and behaviors of psycho-
paths may be explained by biologi-
cal and neurological factors. For
example, some psychopaths have
abnormalities in their limbic system,
which is responsible for motivational

552 M O D U L E 2 3 M O O D D I S O R D E R S & S C H I Z O P H R E N I A

Links to Learning

Key Terms/Key People Learning Activities

antidepressant drugs, 534 genetic marker, 539 PowerStudy for Introduction PowerStudy 4.5™
antisocial personality, 536 hallucinations, 538 to Psychology 4.5
atypical neuroleptics, 541 histrionic personality, 536
Beck’s cognitive theory of improving social skills, 549 Try out PowerStudy’s SuperModule for Mood Disorders & Schizophrenia! In
lithium, 534 addition to the quizzes and learning activities, interactive Summary Test, key
depression, 548 major depressive terms, module outline and abstract, and extended list of correlated websites
biological factors and provided for all modules, the DVD’s SuperModule for Mood Disorders &
disorder, 532, 547 Schizophrenia offers features including:
depression, 533 major depression, t 4FMG QBDFE
GVMMZ OBSSBUFE MFBSOJOH XJUI B NVMUJUVEF PG BOJNBUJPOT
biological causes of t 7JEFPT BCPVU UPQJDT JODMVEJOH NBKPS EFQSFTTJPO
CJQPMBS EJTPSEFS

treatment, 534 personality disorders, and schizophrenia
schizophrenia, 539 mania, 534 t *OUFSBDUJWF WFSTJPOT PG TUVEZ SFTPVSDFT
JODMVEJOH UIF 4VNNBSZ 5FTU PO
bipolar I disorder, 532 mood disorder, 532 pages 550–551 and the critical thinking questions for the article on page 552
bipolar I, treatment, 534 negative cognitive style, 533
borderline personality negative symptoms of CengageNOW!
www.cengage.com/login
disorder, 536 schizophrenia, 541 Want to maximize your online study time? Take this easy-
brain scans, 533 neuroleptic drugs, 541 to-use study system’s diagnostic pre-test and it will create a personalized study
catatonic neurological causes of plan for you. e plan will help you identify the topics you need to understand
better and direct you to relevant companion online resources that are specific
schizophrenia, 538 schizophrenia, 540 to this book, speeding up your review of the module.
culture-specific neurological factors, 533
obsessive-compulsive Introduction to Psychology Book Companion Website
disorders, 546 www.cengage.com/psychology/plotnik
dependent personality, 536 personality, 536 Visit this book’s companion website for more resources to help you
depressed mothers, 533 paranoid personality, 536 study, including learning objectives, additional quizzes, flash cards, updated
dialectical behavior paranoid links to useful websites, and a pronunciation glossary.

therapy, 536 schizophrenia, 538 Study Guide and WebTutor
diathesis stress theory, 540 personality disorder, 536 Work through the corresponding module in your Study
disorganized personality factors, 533 Guide for tips on how to study effectively and for help learning the material
positive symptoms of covered in the book. WebTutor (an online Study Tool accessed through your
schizophrenia, 538 eResources account) provides an interactive version of the Study Guide.
dissociative amnesia, 544 schizophrenia, 541
dissociative disorder, 544 power of positive
dissociative fugue, 544
dissociative identity thinking, 549
psychosocial factors, 533
disorder, 545 schizophrenia, 538
dopamine theory, 541 schizotypal personality, 536
dysthymic disorder, 532 selective serotonin
electroconvulsive therapy,
reuptake inhibitors, 534
ECT, 535 spirit possession, 546
electroconvulsive therapy, stressful life events, 533
tardive dyskinesia, 542
effectiveness, 535 transcranial magnetic
eliminating negative
stimulation, 535
thoughts, 549 Type I schizophrenia, 538
environmental causes of Type II schizophrenia, 538
typical neuroleptics, 541
schizophrenia, 540
exercise versus drugs, 547
genetic factors, 533

Suggested Answers to Critical Thinking (happy) or negative (fearful, threatening) emotional significance for
our survival. Damage to the amygdala explains how psychopaths
1. Dahmer and Rader’s behaviors are abnormal in terms of statistical can completely lack empathy and not learn to fear and avoid dan-
frequency, deviation from social norms, and being maladaptive. gerous situations, such as cues that predict they will get caught.
5. A lie detector test (pp. 370–371) measures involuntary physiological
2. The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) (p. 474) responses and is based on the theory that a person who lies will
is an objective personality test that assesses a range of personality feel guilt or fear, which will result in an increase in the galvanic skin
traits, including anger, truthfulness, self-esteem, friendliness, and response and other physiological responses. Because psychopaths
seriously deviant behaviors. do not feel guilt or fear and do not sweat easily due to lower auto-
nomic arousal, they should pass a lie detector test with flying colors.
3. The person-situation interaction (p. 464) explains how a person’s 6. Having biological or neurological factors for psychopathic behaviors
behavior results from an interaction between his or her traits and produces a predisposition (p. 540) for psychopathic behaviors, which
the effects of being in a particular situation. It explains how psycho- increases the risk or vulnerability of developing such behaviors.
paths, such as Dahmer and Rader, can be loving people with their
families but cold-blooded, heartless serial killers in the community. L I N K S T O L E A R N I N G 553

4. The amygdala (pp. 80, 362) is the structure located in the limbic sys-
tem that is responsible for evaluating whether stimuli have positive

24 Therapies
MODULE

Photo Credit: © Daniel Lai/Getty Images
A. Historical Background 556 H. Application: 574
B. Questions about Psychotherapy 558 Cognitive-Behavioral Techniques
C. Insight Therapies 560 Summary Test 576
D. Behavior Therapy
Concept Review 566 Critical Thinking 578
E. Review: Evaluation of Approaches
F. Cultural Diversity: Different Healer 569 Can Virtual Reality Be More than Fun & Games?
G. Research Focus: EMDR—New Therapy 570 Links to Learning 579

554 572
573 PowerStudy 4.5™

Complete Module

PowerStudy 4.5™ Introduction

Module 9
F. Research Focus: Conditioning Little Albert

Beginning of Psychoanalysis Beginning of Behavior Therapy
It is the late 1800s, and we are listening It was the early 1900s when John Watson, an
Why couldn’t to a young, intelligent woman named Why was up-and-coming behaviorist, showed 9-month-

she drink a Anna O. She explains that she was per- Albert afraid of old Albert a number of objects to see if any

glass of water? fectly healthy until she was 21 years a white rat? caused fear. Little Albert looked at a white rat,
old, when she began to experience rabbit, dog, monkey, several masks, pieces of
strange physical symptoms. She developed a terrible squint wool, and burning newspapers without showing the slightest sign
that blurred her vision, a gagging feeling when she tried to of fear.
drink a glass of water, and a paralysis in her right arm that Later, when Albert was about 11 months old, Watson retested
would spread down her body. These symptoms occurred at Albert. This time, as Albert sat on a mattress, Watson suddenly
about the time her father developed a serious illness and she took a white rat out of a basket and showed it to Albert. At the very
felt the need to care for him by spending endless hours at his moment Albert touched the animal,
bedside. When her symptoms persisted, she another experimenter standing
consulted her doctor, Joseph Breuer. behind Albert struck a steel bar
Dr. Breuer takes up Anna’s story and with a hammer. e sudden loud noise
explains that, during some of her visits, she made Albert jump violently and fall
would sit in a trancelike state and talk forward into the mattress. Five more
uninhibitedly of her past experiences. times Watson showed Albert the white
One time Anna related a childhood This white rat caused rat and each time a loud sound rang out from
incident in which she had watched her no fear until . . . behind. Finally, Watson showed Albert the

governess’s dog drink out of a glass. rat but there was no loud sound. e instant the rat appeared, Albert
e experience was disgusting to her began to cry and turn away from the rat. From this demonstration,
because she disliked both the govern- Watson concluded that he had shown, for the first time, that an emo-
ess and the dog. At the time of the tional reaction—in this case, fear—could be
incident, Anna had shown no emo- conditioned to any stimulus (Watson &
tional reaction. But as she retold her Rayner, 1920).
Photo Credits: left, Sigmund Freud Copyrights/Sulloway/Mary Evans Picture Gallery; top center, © PhotoDisc, Inc. story, she let out strong emotional reac- The case of Little Albert could be
tions that had been locked inside. A er considered the starting point for a very
releasing these pent-up emotional feel- different kind of psychotherapy, known
ings, she was once again able to drink a as behavior therapy. Behavior therapists
glass of water without gagging. believe that emotional problems may arise
Breuer explains that sometimes hyp- through conditioning and thus may be
nosis helped Anna recall painful past treated—or unconditioned—by using other
Her right arm experiences. She told of sitting by her principles of learning.
became paralyzed father’s sickbed, falling asleep, and hav- The cases of Little Albert and Anna O. . . . Little Albert was
with no physical or ing a horrifying dream in which a snake classically conditioned.
neurological cause. illustrate two very different assumptions

attacked him. She could not reach out about how psychotherapy works. According
and stop the snake because her arm had fallen asleep from to behavior therapy, emotional problems are learned and thus can be
hanging over the chair. As Anna relived her powerful guilt unlearned through conditioning techniques. According to psycho-
feelings of not being able to protect her father, the paraly- analysis, emotional problems arise from unconscious fears, which can
sis of her right arm disappeared. Breuer describes how, each be uncovered and revealed only with special techniques. We’ll discuss
time Anna recalled a past traumatic experience, a physical these two assumptions along with those of several other therapies as
symptom associated with that trauma would vanish. Breuer well as whether different therapies produce different results.
would o en discuss Anna’s case with his friend and colleague,
Sigmund Freud. What’s Coming
Dr. Freud interpreted Anna’s symptoms as being caused by
strong, primitive forces, probably related to unconscious sex- In this module we’ll discuss the history of psychotherapy and how cur-
ual desires (Breuer & Freud, 1895/1955). e case of Anna O. rent therapists are trained. We’ll explain Freud’s psychoanalysis and
is important because it played a role in the development of how those who disagreed with Freud developed their own kinds of
Freud’s system of psychoanalysis, which was the start of what therapies. We’ll discuss three of the more popular forms of psychother-
we currently call psychotherapy. apy: behavior therapy, cognitive therapy, and humanistic therapy.
Just as psychoanalysis had its beginning with Anna O., Finally, we’ll answer one of the most interesting questions: Do therapies
another very different kind of therapy had its beginning with differ in their effectiveness?
Little Albert.
Let’s begin with how psychotherapy came about and how it has
developed into a multibillion-dollar business.

I N T R O D U C T I O N 555

A. Historical Background

Definition Psychotherapy has three basic characteristics: verbal interaction between
therapist and client(s); the development of a supportive relationship in which a
Today, there are over 400 different forms of psychotherapy, client can bring up and discuss traumatic or bothersome experiences that may
some of them tested and some based purely on personal beliefs. have led to current problems; and analysis of the client’s experiences and/or
For example, some states do not require the licensing of thera- suggested ways for the client to deal with or overcome his or her problems.
pists; almost anyone can hang out a sign and go into practice
(M. T. Singer & Lalich, 1997). The remaining states require We’ll discuss the major changes in treating mental disorders,
licensing and training of therapists. There are about a dozen including early inhumane treatments, the breakthrough in the use of
tested psychotherapies that may differ in assumptions and drugs, and community mental health centers.
methods but generally share the following three characteristics.

Early Treatments Reform Movement
From 1400 to 1700, people who today In the 1800s, a Boston schoolteacher named
Why did would be diagnosed as schizophrenics What did Dorothea Dix (right photo below) began to visit Photo Credits: center left, National Library of Medicine, #A-13392; top right, Photo by Ken Smith of painting in Harrisburg State Hospital/LLR Collection; bottom left,
hospitals sell were considered insane and called National Library of Medicine, # A-13394
she change? the jails and poorhouses where most of the
tickets? lunatics. ey were primarily confined mental patients in the United States were kept.
to asylums or hospitals for the men- Dix publicized the terrible living conditions and the lack of reason-
tally ill, where the treatment was o en inhumane and cruel. able treatment of mental patients. Her work was
For example, patients were treated by being placed in a hood part of the reform movement that emphasized
and straitjacket, chained to a cell wall, swung moral therapy.
back and forth until they were quieted, Moral therapy, which was popular in the early 1800s,

strapped into a chair (right drawing), locked was the belief that mental patients could be helped to

in handcuffs, hosed down with water until function better by providing humane treatment in a

they were exhausted, or twirled until they relaxed and decent environment.

passed out. During the reform movement, pleasant mental
In the late 1700s, Dr. Benjamin Rush, hospitals were built in rural settings so that moral
who is considered the father of American therapy could be used to treat patients. However, Dorothea Dix
psychiatry, developed the “tranquilizing these mental hospitals soon became overcrowded, began the humane
chair” (bottom drawing). A patient was Early treatment the public lost interest, funds became tight, and treatment of the
strapped into this chair and remained was to be strapped
mentally ill.
to a chair.
treatment became scarce.
until he or she seemed calmed down. By the late 1800s, the belief that moral therapy would cure mental
Dr. Rush believed that mental disorders were caused by too disorders was abandoned. Mental hospitals began to resemble human
much blood in the brain. To cure this problem, he attempted snake pits, in which hundreds of mental patients, in various states of
to treat patients by withdrawing huge amounts of blood, as dress or undress, milled about in a large room while acting out their
much as six quarts over a period of months. Dr. Rush also symptoms with little or no supervision. Treatment went backward, and
tried to cure patients with fright, such as once again patients were put into straitjackets, handcuffs, and various
putting them into coffins and convinc- restraining devices (Routh, 1994).
ing them they were about to die. Despite By the early 1900s, Sigmund Freud had devel-
these strange and inhumane treatments, oped psychoanalysis, the first psychotherapy.
Dr. Rush encouraged his staff to treat Psychoanalysis eventually spread from Europe to
patients with kindness and under- the United States and reached its peak of popu-
standing (Davison & Neale, 1994). larity in the 1950s. However, psychoanalysis was
In the 1700s, some hospitals even more effective in treating less serious mental
sold tickets to the general public. disorders (neuroses) than in treating the serious
People came to see the locked-up mental disorders (psychoses) that kept people in
“wild beasts” and to laugh at the mental hospitals.
tragic and pathetic behaviors of Thus, the wretched conditions and inhumane
individuals with severe men- treatment of patients with serious mental disor-
tal disorders. However, in the Freud ders persisted until the early 1950s. By then, more
Early treatment was to sit late 1700s and early 1800s, a few developed first than half a million patients were locked away.
in a “tranquilizing chair.” doctors began to make reforms psychotherapy.

by removing the patients’ chains, forbidding physical punish- But in the mid-1950s, two events dramatically
changed the treatment of mental patients: one was the discovery of
ment, and using a more psychological approach to treat mental antipsychotic drugs, and the other was the development of community
disorders (J. C. Harris, 2003). mental health centers.

556 M O D U L E 2 4 T H E R A P I E S

Phenothiazines and Deinstitutionalization Community Mental Health Centers
e discovery of drugs for treating mental disorders ere is a need for treatment of
What was o en occurs by chance. Such was the case in the 1950s Where can mental disorders in the home-

the first as a French surgeon, Henri Laborit, searched for a they go for less, county prisoners, those

breakthrough? drug that would calm down patients before surgery treatment? released from mental hospitals,
without causing unconsciousness. He happened to try as well as about 26% of Ameri-
a new drug on a woman about to have surgery and who was also schizophrenic. cans who experience a mental disorder in the course
To the doctor’s great surprise, the drug not only calmed the woman down but of a year (NIMH, 2008b). Some of these individuals
also decreased her schizophrenic symptoms. is is how the drug, chlorpro- may have less serious mental disorders that require
mazine, was discovered to be a treatment for schizophrenia. Chlorpromazine professional help but not hospitalization. One way to
(klor-PRO-ma-zeen) belongs to a group of drugs called phenothiazines. provide professional help to individuals with less seri-
Phenothiazines (fee-no-THIGH-ah-zeens), which were discovered in the early 1950s, ous mental disorders is through community mental

block or reduce the effects of the neurotransmitter dopamine and reduce schizophrenic health centers.

symptoms, such as delusions and hallucinations. Community mental health

After 200 years of often cruel and inhumane treatments for mental dis- centers offer low-cost or free
orders, chlorpromazine was the first drug shown to be effective in reducing
severe mental symptoms, such as delusions and hallucinations. For this rea- mental health care to members
son, the discovery of chlorpromazine is considered the first revolution in the
drug treatment of mental disorders. Earlier we discussed the phenothiazines, of the surrounding com-
now called typical neuroleptics, as well as the newer discovery of atypical neu-
roleptics (p. 541), which are used in the treatment of schizophrenia. munity, especially the

In 1954, one of the phenothiazines, chlorpromazine (trade name: ora- underprivileged. The
zine), reached the United States and had two huge effects. First, it stimulated
research on neurotransmitters and on the development of new drugs to treat services may include
mental disorders. Second, chlorpromazine reduced severe mental symp-
toms such as delusions and hallucinations to the point that patients could psychotherapy, support
function well enough to be released from mental hospitals, a policy called
deinstitutionalization. groups, and telephone

Deinstitutionalization refers to the release of mental patients from mental hospi- crisis counseling.

Just as the 1950s
saw the introduc-
tion of a new drug
treatment for mental
disorders (phenothi- Therapist is treating a
tals and their return to the community to develop more independent and fulfilling lives. azines), the 1960s saw client in a community mental
the growing avail- health center, which helps those
In 1950, before the discovery of phenothiazines, there were 550,000 ability of new treat- who need care but can’t afford it.

patients in mental hospitals in the United States. A er the use of phenothi- ment facilities, community mental health centers.
azines and deinstitutionalization, the number of patients in mental hospitals e goal of these centers as well as other outpatient
had dropped to about 150,000 in 1970 and to about 80,000 in 2000 (Mander- centers is to provide treatment for the poor and those
scheid & Sonnenschein, 1992). However, deinstitutionalization has created a who have no other forms of treatment for their men-
related problem. tal health problems. ese kinds of mental health cen-
Homeless. The goal of deinstitutionalization, which is to get patients ters provide briefer forms of therapy that are needed
back into the community, has been only partly realized. Some former men- in emergencies and focus on the early detection and
tal patients do live in well-run prevention of psychological problems. To meet these
Photo Credits: left, © AP Images/Rusty Kennedy; right, © Mira/Alamy halfway houses (F. R. Lipton et al., ambitious goals required an enormous increase in
2000). However, recent investiga- the number of mental health personnel (Burns, 2004;
tions have found that some half- J. Rosenberg, 2006).
way houses are poorly maintained, In the 1960s, psychiatrists provided the majority
use untrained staff, and provide of psychological services, which consisted of mainly
little or no treatment for the resi- psychoanalysis and served individuals in the middle
dents. e major problems are lack and upper social classes who were not very seriously
of funding and poor supervision disturbed. Because of the limited number of psy-
of halfway houses. chiatrists, community mental health centers turned
About 25–80% of the homeless have some Because there are not enough to clinical psychologists and social workers to pro-
degree of mental problems.

good halfway houses, many dein- vide the new mental health services. This demand
stitutionalized patients end up on the streets and homeless. e result is that increased the number of clinical and counseling
about 25–80% of today’s homeless individuals have serious mental disorders psychologists and social workers and stimulated the
and receive little or no treatment (Hartwell, 2003; USCM, 2007). To provide development of new therapy approaches (Garfield &
mental health treatment for the homeless as well as those released from hos- Bergin, 1994).
pitals or too poor to pay for services, there is another place to receive help— Before discussing specific psychotherapies, we’ll
community mental health centers. answer four general questions about psychotherapy.

A . H I S T O R I C A L B A C K G R O U N D 557

B. Questions about Psychotherapy

What do I If you or a family member, friend, relative, or acquaintance has a mental health problem, there are at least four
need to know? questions that you might ask about seeking professional help or psychotherapy: Do I need professional help? Are
there different kinds of therapists? What are the different approaches? How effective is psychotherapy? We’ll
answer each question in turn.

Do I Need Professional Help? Are There Different Kinds of Therapists?
Each year, more than 30 million Americans need help We’ll discuss three of the more common kinds of therapists: psychiatrists,
in dealing with a variety of mental disorders (NIMH, clinical psychologists, and counseling psychologists, each of whom receives a
2009a). For example, a person may feel overwhelmed by different kind of training in psychotherapy techniques. Together, they provide
a sense of sadness, depression, or helplessness so that he psychotherapy to 3% of the U.S. population each year (Weissman et al., 2006).
or she cannot form a meaningful relationship. A person Psychiatrists go to medical school, receive an MD degree, and then take a psychi-

may worry or expect such terrible things to happen that atric residency, which involves additional training in pharmacology, neurology,

he or she cannot concentrate or carry out everyday psychopathology, and psychotherapeutic techniques.

activities. A person may become so Psychiatrists usually prescribe drugs to treat mental health disorders.
dependent on drugs that he or she Since the 1990s, psychiatrists have been providing less psychotherapy and
has difficulty functioning in per- instead focusing primarily on biological factors. Currently, less than 30% of
sonal, social, or professional situa- psychiatrist office visits involve psychotherapy (Westly, 2008).
tions. If these problems begin to
Clinical psychologists go to graduate school in clinical psychology and earn a

interfere with daily functioning doctorate degree (PhD, Psy, or EdD). This training, which includes one year of work in

in social, personal, business, an applied clinical setting, usually requires five to six years of work after obtaining a

academic, or professional college degree.

interactions and activities, Clinical psychologists focus on psychosocial and environmental factors
then a person may need help and use psychotherapy to treat mental health disorders. ey generally can-
Each year, about not prescribe drugs. However,
30 million Americans
need help in dealing with from a mental health profes- in a trial program, clinical CooruEndsDelianngdpcsoyucnhsoelolignigstehxapseraiePnhcDe., PsyD,
sional (APA, 2009a). psychologists were trained Clinical psychologist has a PhD, PsyD,
mental disorders. in prescribing drugs for a
One reason individuals variety of mental disor-
do not seek professional help ders. Evaluators of this
involves the social stigma program concluded that,
attached to having a mental with proper training,
disorder. For example, in an College
degree or EdD and clinical experience.
earlier module, we discussed
how well-known singer- clinical psychologists can haaPvnsdeycphsyiacthriisattrhicasreasnidMenDcy.
songwriter Sheryl Crow suf- provide high-quality drug
fered from major depression treatment for their patients (Dittmann,
for several years before being 2003). Since then, New Mexico and Louisiana
persuaded by her mother to seek professional help passed laws that allow psychologists with advanced medical
(p. 532). Although still present, the stigma of having a training to prescribe medications for patients with mental disorders.
mental disorder is decreasing as people recognize the Several other states may soon pass similar legislation giving psychologists
need for professional treatment (Alonso et al., 2009; the right to prescribe medication (Munsey, 2008a, 2008b). For political and
Golberstein et al., 2008). financial reasons, psychiatrists oppose laws that allow specially trained
Another reason individuals do not seek professional psychologists to prescribe drugs (Munsey, 2006; R. J. Sternberg, 2003c).
help is that they don’t realize they need it. In an earlier
Counseling psychologists go to graduate school in psychology or education

module, we discussed the case of Michael McCabe, who and earn a doctorate degree (PhD, PsyD, or EdD). This training, which includes work

heard voices and believed people were going to steal in a counseling setting, usually requires about four to six years after obtaining a

things from him (schizophrenia); and in another case, bachelor’s degree.

Chuck Elliot went sleepless for four nights and had trou- Counseling psychologists receive training similar to that of clinical psy- Photo Credit: right, © PhotoDisc, Inc.
ble controlling his behavior (bipolar I disorder) (p. 531). chologists but with less emphasis on research and more emphasis on coun-
Although both of these individuals needed professional seling in real-world settings. Counseling psychologists, who function in
treatment, neither wanted or asked for it. us, in some settings such as schools, industry, and private practice, generally deal more
cases, individuals with serious mental disorders may not with problems of living than with the mental disorders that are treated by
be able to decide what is best, and their friends or family clinical psychologists.
may need to help them get professional help. In addition, other mental health professionals, such as clinical social
Currently, there are a number of different kinds of workers and psychiatric nurses, provide mental health services.
mental health professionals who may provide a drug or
Just as there are different kinds of therapists, there are also different kinds
nondrug treatment program or some combination. of therapeutic approaches from which to choose.

558 M O D U L E 2 4 T H E R A P I E S

What Are the Different Approaches? How Effective Is Psychotherapy?
If you were to seek professional help for a mental problem, you could choose Sometimes when we have a problem, we might say,
from a number of different therapeutic approaches: Some use primarily psycho- “I’ll just wait, and maybe the problem will go away by
therapy, some use primarily drugs, and others use a combination of psycho- itself.” is kind of remark raises a major question: Is
therapy and drugs. ese different therapies can be divided into three groups: psychotherapy more effective than just waiting for
insight therapy, cognitive-behavioral therapy, and medical therapy. problems to go away? To answer this question and
determine the effectiveness of psychotherapy,
With insight therapy, the therapist and client talk about the client’s symptoms and researchers have used a complex statistical procedure
called meta-analysis.
problems with the goal of reaching or identifying the cause of the problem. Once the cli-
Meta-analysis is a powerful statistical procedure that
ent has an insight into the cause of the problem, possible solutions can be discussed

with the therapist.

e classic example of insight therapy is psychoanalysis, whose goal is to help compares the results of dozens or hundreds of studies to

clients get insights into their problems. But because psychoanalysis requires determine the effectiveness of some variable or treatment

hundreds of sessions, it is very costly; and because it is no more effective than examined in these studies.

other, briefer therapies, its popularity has significantly decreased since the Researchers have done meta-analysis on more than
1950s. e next kind of therapy, called cognitive-behavioral therapy, combines 1,500 studies that examined the effects of psycho-
some features of insight therapy with a much more directive approach. therapy on a variety of problems, such as depression,
Cognitive-behavioral therapy anxiety disorders, family problems, eating disorders,
Here’s my
problem . . . involves the application of principles and headaches (Butler et al., 2006; L. Luborsky et al.,
of learning that were discussed in 2002; P. E. Nathan et al., 2000). We’ll discuss three of

Modules 9 and 10. The therapist the major findings:

focuses on the client’s problem, O Ps yc hot he r a p y Mood Disorder

identifies specific thoughts and was effective in relieving

behaviors that need to be changed, a wide variety of psycho- Anxiety Disorder
logical and behavioral Relationship Problem
and provides techniques based on symptoms in compari-

learning principles to make desired

changes. son with control groups Eating Disorder

Unlike psychoanalysis, which who were on a waiting
focuses on insight and gives little list to receive therapy or
direction for change, cognitive- who received no system- Substance Use
behavioral therapy focuses on Disorder
There are several kinds of drug and changing specific undesirable or
nondrug therapies for mental disorders. atic treatment. Psychotherapy has proved
O ere was little or effective for a wide variety
problematic thoughts and behaviors. is approach combines techniques and
ideas from cognitive therapy (p. 565) and behavior therapy (p. 566). Cognitive- no significant difference of mental disorders.
in effectiveness among
behavioral therapy is an example of the most popular approach, which is used the approaches used by different therapies. In other
by 25–33% of therapists and is called the eclectic approach (Norcross, 2005). words, the same psychological or behavioral symp-
The eclectic (e-KLEK-tik) approach involves combining and using techniques and toms were, in most cases, treated effectively with dif-

ideas from many different therapeutic approaches. ferent approaches.

For example, a therapist using an eclectic approach might combine some O The vast majority of patients (75%) showed
of the nondirective techniques from psychoanalysis with more directive measurable improvement by the end of six months of
techniques from cognitive-behavioral therapy. Unlike insight and cognitive- once-a-week psychotherapy sessions (24 sessions).
behavioral approaches, which focus on psychosocial factors, the next kind of us, based on data from thousands of patients,
therapy focuses on changing biological factors. psychotherapy has proved effective in treating many
mental and behavioral problems, and the greatest
Medical therapy involves the use of various psychoactive drugs to treat mental disor-

Photo Credit: bottom, © S. Wanke/PhotoDisc, Inc. ders by changing biological factors, such as the levels of neurotransmitters in the brain. improvement occurs in a relatively brief time (13 to

In Modules 22 and 23, we discussed medical therapies and how various psy- 18 sessions) (M. J. Lambert et al., 2004). However,
choactive drugs are used to treat a wide variety of the amount of improvement varies across patients
mental disorders, including anxiety, mood disor- (G. S. Brown et al., 2005; Sotsky et al., 2006).
ders, and schizophrenia. Unlike medical therapies, Although many different therapies have been
in which drugs may have undesirable physical side shown to be about equally effective, we’ll discuss
effects, no undesirable side effects are associated why some therapeutic approaches are preferred for
with psychotherapy. In this module, we’ll focus on certain problems and why some clients may prefer
several psychotherapies, specifically insight and one approach over another (Chambless & Ollendick,
cognitive-behavioral approaches. A number of different 2001; O’Donahue & Fisher, 2009).
drugs (neuroleptics, anti-
With so many different therapeutic approaches, depressants) may be used We’ll begin with one of the oldest and best-
is one kind of psychotherapy more effective than to treat more serious known therapy approaches—Freud ’s system of
another? mental disorders. psychoanalysis.

B . Q U E S T I O N S A B O U T P S Y C H O T H E R A P Y 559