Chapter 12

Psychological Factors Researchers generally agree on the two major psychological contributions to anxiety disorders:

1. Faulty cognitive processes People with anxiety disorders generally have habits of thinking, or cognitive processes, that make them prone to fear. These faulty cognitions, in turn, make them hypervigilant—meaning they constantly scan their environment for signs of danger, and ignore signs of safety. In addition, they tend to magnify uncertain information, ordinary threats and failures, and to be hypersensitive to others' opinions of them (Helbig-Lang et al., 2015; Oglesby et al., 2016; Wild & Clark, 2015). 2. Maladaptive learning In contrast to this cognitive explanation, learning theorists suggest that anxiety disorders result from inadvertent and improper conditioning (Duits et al., 2015; Kunze et al., 2015; van Meurs et al., 2014). As we discovered in Chapter 6, during classical conditioning, if a neutral stimulus (NS), such as a harmless spider, becomes paired with an unconditioned stimulus (US), such as a sudden, frightening noise, it becomes a conditioned stimulus (CS) that elicits a conditioned emotional response (CER)—in this case, fear. To make matters worse, the person generally begins to avoid spiders in order to reduce anxiety (an operant conditioning process known as negative reinforcement), which may lead to a spider phobia

Classifying Schizophrenia For many years, researchers divided schizophrenia into five subtypes: paranoid, catatonic, disorganized, undifferentiated, and residual. Critics suggested that this system does not differentiate in terms of prognosis, cause, or response to treatment and that the undifferentiated type was merely a catchall for cases that are difficult to diagnose.. For these reasons, researchers have proposed an alternative classification system:

1.Positive schizophrenia symptoms are additions to or exaggerations of normal functions. Delusions and hallucinations are examples of positive symptoms. (In this case, and as -discussed in Chapter 6, "positive" means that "something is added," above and beyond normal levels.) 2.Negative schizophrenia symptoms include the loss or absence of normal functions. Impaired attention, limited or toneless speech, flat or blunted affect, and social withdrawal are all classic negative symptoms of schizophrenia. (Recall again that "negative" is not the same as unpleasant or bad. It means that "something is taken away," and in this case daily functioning is "taken away" because it's so far below normal levels.) Positive symptoms are more common when schizophrenia develops rapidly, whereas negative symptoms are more often found in slow-developing schizophrenia. Positive symptoms are associated with better adjustment before the onset and a better prognosis for recovery.

People with agoraphobia restrict their normal activities because they fear having a panic attack in crowded, enclosed, or wide-open places where they would be unable to receive help in an emergency. In severe cases, people with agoraphobia may refuse to leave the safety of their homes.

A specific phobia is a fear of a specific object or situation, such as needles, rats, spiders, or heights. Claustrophobia (fear of closed spaces) and acrophobia (fear of heights) are the specific phobias most often treated by therapists. People with specific phobias generally recognize that their fears are excessive and unreasonable, but they are unable to control their anxiety and will go to great lengths to avoid the feared stimulus.

learned helplessness theory

According to the________ theory (Seligman, 1975, 2007), depression occurs when people (and other animals) become resigned to the idea that they are helpless to escape from a painful situation because of a history of repeated failures. For humans, learned helplessness may be particularly likely to trigger depression if the person attributes failure to causes that are internal ("my own weakness"), stable ("this weakness is long-standing and unchanging"), and global ("this weakness is a problem in lots of settings")

Describing Anxiety Disorders In this section, we discuss three anxiety disorders: generalized anxiety disorder (GAD), panic disorder, and phobias

Although we cover these disorders separately, their symptoms often overlap and they often occur together pg. 338

Brain damage and professional sports

As discussed in Chapter 7, Junior Seau, who played in the NFL for 20 years, committed suicide with a gunshot wound to his chest in 2012 at the age of 43. Later studies concluded that he suffered from chronic traumatic encephalopathy (CTE), a form of concussion-related brain damage that has been found in numerous NFL players.

Sociocultural Factors

As expected, there are numerous sociocultural factors that contribute to anxiety. For example, research shows that children who are psychologically abused—including bullying, severe insults, overwhelming demands and isolation—are at greater risk for developing GAD and social anxiety disorder. Research on cultural factors notes the sharp rise in anxiety disorders in the past 50 years, particularly in Western industrialized countries. Can you see how our fast-paced lives—along with our increased mobility, decreased job security, and decreased family support—might contribute to anxiety? Unlike the dangers early humans faced in our evolutionary history, today's threats are less identifiable and less immediate. This may in turn lead some people to become hypervigilant and predisposed to anxiety disorders. Further support for sociocultural influences on anxiety disorders is our recognition that they can have dramatically different forms in other cultures. For example, in a collectivist twist on anxiety, some Japanese experience a type of social phobia called taijin kyofusho (TKS), a morbid dread of doing something to embarrass others. This disorder is quite different from the Western version of social phobia, which centers on a fear of criticism and self-embarrassment.

Do People with Schizophrenia Have Multiple Personalities?

As shown in this cartoon and in popular movies and television shows, schizophrenia is commonly confused with multiple personality disorder (now known as dissociative identity disorder, p. 353). This widespread error persists in part because of confusing terminology. Literally translated, schizophrenia means "split mind," referring to a split from reality that shows itself in disturbed perceptions, language, thought, emotions, and/or behavior. In contrast, dissociative identity disorder (DID) refers to the condition in which two or more distinct personalities exist within the same person at different times. People with schizophrenia have only one personality. Why does this matter? Confusing schizophrenia with multiple personalities is not only technically incorrect, it also trivializes the devastating effects of both disorders, which may include severe anxiety, social isolation, unemployment, homelessness, substance abuse, clinical depression, and even suicide

Other research points to imbalances of neurotransmitters, including GABA, serotonin, norepinephrine, and dopamine, as possible causes of mood disorders (Artigas, 2015; Fakhoury, 2015; Yin et al., 2016). And both depressive disorders and bipolar disorders are sometimes treated with antidepressants, which affect the amount or functioning of these same neurotransmitters. Surprisingly, one small, recent study found that psilocybin, a hallucinogen from "magic" mushrooms, can help reduce the symptoms of depression (Mithoefer et al., 2016). Perhaps even more surprising, researchers have found that people who regularly ate fast food and commercially produced baked goods (such as croissants and doughnuts) were 51% more likely to develop depression later on (Sánchez-Villegas et al., 2011). Can you see how this may be the result of the chemicals in such foods leading to physiological changes in the brain and body?

As we've seen with the previous disorders, genetic research indicates that both depressive and bipolar disorders may be inherited (Antypa et al., 2016; Jacobs et al., 2015; Pandolfo et al., 2015). In contrast, research that takes an evolutionary perspective suggests that moderate depression may be a normal and healthy adaptive response to a very real loss, such as the death of a loved one, which helps us conserve energy and to step back and reassess our goals (Beck & Bredemeier, 2016; Neumann & Walter, 2015). And clinical, severe depression may just be an extreme version of this generally adaptive response.

Seven psychological perspectives

As you can see in this diagram, the seven major perspectives differ in their various explanations for the general causes of psychological disorders, but there is still considerable overlap.

Identifying and Explaining Psychological Disorders

As you can see, it's difficult to distinguish normal from abnormal behavior, and psychologists have struggled to create a precise definition

Common Myths About Suicide

Because of the shame and secrecy surrounding suicide, there are many misconceptions and stereotypes. Can you correctly identify which of the following is true or false? 1.People who talk about suicide are less likely to actually commit it. 2.Suicide usually takes place with little or no warning. 3.Suicidal people are fully intent on dying. 4.Children of parents who attempt suicide are at greater risk of committing suicide. 5.Suicidal people remain so forever. 6.Men are more likely than women to actually kill themselves by suicide. 7.When a suicidal person has been severely depressed, and seems to be "snapping out of it," the danger of suicide decreases substantially. 8.Only depressed people commit suicide. 9.Thinking about suicide is rare. 10.Asking a depressed person about suicide will push him or her over the edge, and cause a suicidal act that might not otherwise have occurred. Now, compare your responses to the experts' answers and explanations: 1. and 2.False Up to three-quarters of those who take their own lives talk about it, and give warnings about their intentions beforehand. They may say, "If something happens to me, I want you to ...," or "Life just isn't worth living." They also provide behavioral clues, such as giving away valued possessions, withdrawing from family and friends, and losing interest in favorite activities. 3. False Only about 3% to 5% of suicidal people truly intend to die. Most are just unsure about how to go on living. Unfortunately, they can't see their problems objectively enough to recognize alternative courses of action. They often gamble with death, arranging it so that fate or others will save them. However, once the suicidal crisis passes, they're generally grateful to be alive. 4.True Children of parents who attempt or commit suicide are at much greater risk of following in their footsteps. As Schneidman (1969) puts it, "The person who commits suicide puts his psychological skeleton in the survivor's emotional closet" (p. 225). 5. False People who want to kill themselves are usually suicidal only for a limited period. 6. True Although women are much more likely to attempt suicide, men are far more likely to actually commit it. This is true because men generally use more effective and lethal methods, such as guns instead of pills. 7. False When people are first coming out of a depression, they are at greater risk because they now have the energy to actually commit suicide. 8.False Suicide rates are highest among people with major depressive disorders. However, suicide is also the leading cause of premature death in people who suffer from schizophrenia, and a major cause of death in people with anxiety disorders, and alcohol and other substance-related disorders. Furthermore, poor physical health, serious illness, loneliness, unemployment, and even natural disasters may push some people over the edge. Interestingly, people who work in careers that have great pressure for perfectionism—doctors, lawyers, architects, those in leadership roles—also are at elevated risk for p perfectionism-related suicide. 9. False Estimates from various studies are that 40% to 80% of the general public has thought about committing suicide at least once in their lives. 10. False Because society often considers suicide a terrible, shameful act, asking directly about it can give the person permission to talk. In fact, not asking is more likely to lead to further isolation and depression.

In addition to these and other psychological theories, several social factors may also contribute to the mood disorders. Perhaps most surprising is the finding that high Internet and cell phone use (see the photo) are linked with mental health problems, such as depression and anxiety (Panova & Lleras, 2016). This is particularly true when they're used to avoid negative experiences or feelings. However, no link was found if you're using them merely to escape boredom.

Before going on, please keep in mind that suicide is a major danger associated with both depressive disorder and bipolar disorder. Unfortunately, there are many suicide myths and misunderstandings (see Table 12.3) and many people who suffer with these disorders are so disturbed they lose contact with reality and may fail to recognize the danger signs or to seek help

Explaining Schizophrenia Because schizophrenia comes in many different forms, it probably has multiple biological and psychosocial bases. Let's look at biological contributions first.

Biological Factors Most biological explanations of schizophrenia focus on genetics, neurotransmitters, and brain abnormalities: Genetics Current research indicates that the risk for schizophrenia increases with genetic similarity. This means that people who share more genes with a person who has schizophrenia are more likely to develop the disorder (Figure 12.9). Neurotransmitters According to the dopamine hypothesis, overactivity of certain dopamine neurons in the brain causes some forms of schizophrenia This hypothesis is based on two observations. First, administering amphetamines increases the amount of dopamine and can produce (or worsen) some symptoms of schizophrenia, especially in people with a genetic predisposition to the disorder. Second, drugs that reduce dopamine activity in the brain reduce or eliminate some symptoms of schizophrenia. Brain abnormalities A third area of research in schizophrenia explores links to abnormalities in brain function and structure. Researchers have found larger cerebral ventricles (fluid-filled spaces in the brain) and right hemisphere dysfunction in some people with schizophrenia. Also, some people with chronic schizophrenia have a lower level of activity in specific areas of the brain

Emotion

Changes in emotion usually occur in people with schizophrenia. In some cases, emotions are exaggerated and fluctuate rapidly. At other times, they become blunted. Some people with schizophrenia have flattened affect—almost no emotional response of any kind.

Avoiding Ethnocentrism Most research on psychological disorders originates and is conducted primarily in Western cultures. Do you see how such a restricted sampling can limit our understanding of these disorders? And how this limited view could lead to an ethnocentric view—a view that one's own culture is "correct?" Fortunately, cross-cultural researchers have devised ways to overcome these difficulties has found several culture-general symptoms that are useful in diagnosing disorders across cultures (

Culture-General Symptoms of Mental Health Difficulties Nervous 2. Trouble sleeping 3. Low spirits Weak all over 2 Personal worries 3. Restless Feel apart, alone 2. Can't get along 3. Hot all over Worry all the time 2. Can't do anything worthwhile 3. Nothing turns out right

Classifying Psychological Disorders In addition to identifying and explaining abnormal behavior, we need to classify those behaviors into specific categories. Why? Without a clear, reliable system for classifying the wide range of psychological disorders, scientific research on them would be almost impossible, and communication among mental health professionals would be seriously impaired

Diagnostic and Statistical Manual of Mental Disorders (DSM) Fortunately, mental health specialists share a uniform classification system, the ___________. This manual has been updated and revised several times, and the latest, fifth edition, was published in 2013 Each revision of the DSM has expanded the list of disorders and changed the descriptions and categories to reflect the latest in scientific research

Behavior

Disturbances in behavior may take the form of unusual actions that have special meaning to the sufferer. For example, one patient massaged his head repeatedly to "clear it" of unwanted thoughts. People with schizophrenia also may become cataleptic and assume a nearly immobile stance for an extended period.

Obsessive-Compulsive Disorder (OCD)

Do you occasionally worry about whether or not you locked your doors and sometimes feel compelled to run back and check? Most people do. However, people with obsessive compulsive disorder (OCD) experience persistent, unwanted, fearful thoughts (obsessions) and/or irresistible urges to perform repetitive and/or ritualized behaviors (compulsions) to help relieve the anxiety created by the obsession. In adults, women are affected at a slightly higher rate than men, whereas men are more commonly affected in childhood (American Psychiatric Association, 2013). Common examples of obsessions are fear of germs, fear of being hurt or of hurting others, and troubling religious or sexual thoughts. Examples of compulsions are repeatedly checking, counting, cleaning, washing all or specific body parts, or putting things in a certain order. As mentioned before, everyone worries and sometimes double-checks, but people with OCD have these thoughts and do these rituals for at least an hour or more each day, often longer Imagine what it would be like to worry so obsessively about germs that you compulsively wash your hands hundreds of times a day, until they are raw and bleeding. Most sufferers of OCD realize that their actions are senseless. But when they try to stop the behavior, they experience mounting anxiety, which is relieved only by giving in to the compulsions. Given that numerous biological and psychological factors contribute to OCD, it is most often treated with a combination of drugs and cognitive-behavior therapy

What causes abnormal behavior? Historically, evil spirits and witchcraft have been blamed. Stone Age people, for example, believed that abnormal behavior stemmed from demonic possession; the "therapy" was to bore a hole in the skull so the evil spirit could escape, a process we call trephining.

During the European Middle Ages, abnormal behavior was sometimes treated with exorcism, which was a religious or spiritual practice designed to evict the demons by making the troubled person's body inhospitable through lengthy prayers, fasting, and beatings. During the later Renaissance period (14th to the 17th century), many believed that some individuals chose to consort with the Devil. These supposed witches were often tortured, imprisoned for life, or executed

Witchcraft or mental illness?

During the European Renaissance, some people, who may have been suffering from mental disorders, were accused of witchcraft and tortured or hung.

Culture and Psychological Disorders Individuals from different cultures experience psychological disorders in a variety of ways. For example, the reported incidence of schizophrenia varies in different cultures around the world. It is unclear whether these differences result from actual differences in prevalence of the disorder or from differences in definition, diagnosis, or reporting. The symptoms of schizophrenia also vary across cultures (Barnow & Balkir, 2013; Burns, 2013), as do the particular stressors that may trigger its onset

Finally, despite the advanced treatment facilities and methods in industrialized nations, the prognosis for people with schizophrenia is sometimes better in nonindustrialized societies. The reason may be that the core symptoms of schizophrenia (poor rapport with others, incoherent speech, and so on) make it more difficult to survive in highly industrialized countries. In addition, in most industrialized nations families and other support groups are less likely to feel responsible for relatives and friends who have schizophrenia. On the other hand, some countries, such as Indonesia, still shackle and confine their mentally ill in filthy cells without basic human rights

Language and Thought

For people with schizophrenia, words lose their usual meanings and associations, logic is impaired, and thoughts are disorganized and bizarre. When language and thought disturbances are mild, the individual jumps from topic to topic. With more severe disturbances, the person jumbles phrases and words together (into a "word salad") or creates artificial words. The most common—and frightening—thought disturbance experienced by people with schizophrenia is lack of contact with reality (psychosis).

anxiety disorder

Have you ever faced a very important exam, job interview, or first date and broken out in a cold sweat, felt your heart pounding, and had trouble breathing? If so, you have some understanding of anxiety. But when the experiences and symptoms of fear and anxiety become disabling (uncontrollable and disrupting), mental health professionals may diagnose an _______. Fortunately, anxiety disorders are among the easiest to treat and offer some of the best chances for recovery

A personal account of DID

Herschel Walker, Pro Bowl NFL football player, Olympic bobsledder, and business and family man, now suggests that none of the people who played these roles were really he. They were his "alters," or alternate personalities. He has been diagnosed with the controversial diagnosis of dissociative identity disorder (DID). Although some have suggested that the disorder helped him succeed as a professional athlete, it played havoc with his personal life. He's now in treatment and has written a book, Breaking Free, hoping to change the public's image of DID.

Depressive versus bipolar disorders

If depressive disorders and bipolar disorders were depicted on a graph, they might look something like this. Remember that only in bipolar disorders do people experience manic episodes.

Among the Chippewa, Cree, and Montagnais-Naskapi Indians in Canada, there is a disorder called windigo—or wiitiko—psychosis, characterized by delusions and cannibalistic impulses. Believing they have been possessed by the spirit of a windigo, a cannibal giant with a heart and entrails of ice, victims become severely depressed (Faddiman, 1997). As the malady begins, the individual typically experiences loss of appetite, diarrhea, vomiting, and insomnia, and he or she may see people turning into beavers and other edible animals. In later stages, the victim becomes obsessed with cannibalistic thoughts and may even attack and kill loved ones in order to devour their flesh

If you were a therapist, how would you treat this disorder? Does it fit neatly into any category of psychological disorders that we've just discussed? We began this chapter by discussing the complexities and problems with defining, identifying, and classifying abnormal behavior. Before we close, we need to add two additional confounding factors: gender and culture. In this section, we explore a few of the many ways in which men and women differ in their experience of abnormal behavior. We also look at cultural variations in abnormal behavior.

Dissociative Disorders

If you've ever been daydreaming while driving home from your college campus, and then could not remember making one single turn, you may have experienced a normal form of dissociation, meaning a mild disconnection from your immediate surroundings. The most dramatic extremes of this type of detachment are the dissociative disorders, characterized by a sudden break (dissociation) in conscious awareness, self-identity, and/or memory. Note that this is a disconnection or detachment from immediate surroundings, or from physical or emotional experience. It is very different from the loss of contact with reality seen in psychosis (Figure 12.13). There are several forms of dissociative disorders, including dissociative amnesia and dissociative identity disorder (DID). However, all are characterized by a splitting apart (a dis-association) of significant aspects of experience from memory or consciousness.

Psychosocial Factors

In contrast to the biological factors, psychosocial explanations of depression focus on environmental stressors, disturbances in the person's interpersonal relationships or self-concept, and any history of abuse or assault. The psychoanalytic explanation sees depression as the result of anger turned inward, or as the aftermath of experiencing a real or imagined loss, which is internalized as guilt, shame, self-hatred, and ultimately self-blame. The cognitive perspective explains depression as caused, at least in part, by negative thinking patterns, including a tendency to ruminate, or obsess, about problems (Arora et al., 2015; Yoon et al., 2014). The humanistic school says that depression results when a person demands perfection of him or herself or when positive growth is blocked

Gender Strategies for Managing Depression

In order to prevent or reduce depression, women may benefit from learning better stress reduction and problem-focused coping strategies (Chapter 3). On the other hand, if it's true that men more often express their depression through impulsive, acting-out behaviors, then rewarding deliberate, planned behaviors over unintentional, spur-of-the moment ones may be helpful for treating some forms of male depression (Eaton et al., 2012).

Keep in mind that abnormal behavior, like intelligence and creativity, is not composed of two discrete categories—"normal and "abnormal."

Instead, mental health lies along a continuum, with people being unusually healthy at one end and extremely disturbed at the other

Phobias

Just as most of us have experienced feelings of panic, we may also share a common fear of spiders, sharks, or snakes. However, people who suffer from phobias experience a persistent, intense, irrational fear, and avoidance of a specific object, activity, or situation. Their fears are so disabling that they significantly interfere with their daily life. Although the person recognizes that the level of fear is irrational, the experience is still one of overwhelming anxiety, and a full-blown panic attack may follow. The fifth edition of the DSM divides phobias into separate categories: agoraphobia, specific phobias, and social anxiety disorder (social phobia)

In addition, Nishimoto found several culture-bound symptoms, which are unique to different groups and generally only appear in one population. For example, Vietnamese and Chinese respondents report "fullness in head," Mexican respondents note "problems with [their] memory," and Anglo-American respondents report "shortness of breath" and "headaches." Apparently, people learn to express their problems in ways that are acceptable to others in the same culture ( This division between culture-general and culture-bound symptoms also helps us better understand depression. Certain symptoms of depression (such as intense sadness, poor concentration, and low energy) seem to exist across all cultures (Walsh & Cross, 2013; World Health Organization, 2011). But there is evidence of some culture-bound symptoms. For example, feelings of guilt are found more often in North America and Europe than in other parts of the world. And in China, somatization (the conversion of depression into bodily complaints) occurs more frequently than it does in other parts of the world

Just as there are culture-bound symptoms, researchers also have found culture-bound disorders (Figure 12.16). The earlier example of windigo psychosis, a disorder limited to a few groups of Canadian Indians, illustrates just such a case. Interestingly, the distinctions between many of the previously culture-bound and cultural-general symptoms and disorders may be disappearing as a result of globalization

The Media, Myths, and Mental Illness

Many Americans were shocked and deeply saddened on June 17, 2015, when 21-year-old Dylann Roof shot and killed nine people who were attending a church prayer service in Charleston, South Carolina. Roof later confessed to the crime, saying that he murdered the Black church members because he wanted to ignite a race war. Following the shootings, the news media focused on issues of race and gun control. However, many also expressed the view that mental illness was a motivating factor and a common thread in mass shootings (Gonyea & Montanaro, 2015; Lysiak, 2015). Can you see how this type of intensive media coverage increases the myths, misconceptions, and exaggerated fears of mental illness? To make matters worse, the media seldom, if ever, mentions the fact that people with mental illness are more often self-destructive, or the victims of violence—rather than the perpetrators

Borderline Personality Disorder (BPD)

Mary's troubles first began in adolescence. She began to miss curfew, was frequently truant, and her grades declined sharply. Mary later became promiscuous and prostituted herself several times to get drug money .... She also quickly fell in love and overly idealized new friends. But when they quickly (and inevitably) disappointed her, she would angrily cast them aside.... Mary's problems, coupled with a preoccupation with inflicting pain on herself (by cutting and burning) and persistent thoughts of suicide, eventually led to her admittance to a psychiatric hospital at age 26 Mary's experiences are all classic symptoms of borderline personality disorder (BPD). The core features of this disorder include a pervasive pattern of instability in emotions, relationships, and self-image, along with impulsive and self-destructive behaviors, such as truancy, promiscuity, drinking, gambling, and eating sprees. In addition, people with BPD may attempt suicide and sometimes engage in self-mutilating ("cutting") Those with BPD also tend to see themselves and everyone else in absolute terms—as either perfect or worthless. Constantly seeking reassurance from others, they may quickly erupt in anger at the slightest sign of disapproval. As you might expect, this disorder is typically marked by a long history of broken friendships, divorces, and lost jobs. In short, people with this disorder appear to have a deep well of intense loneliness and a chronic fear of abandonment. Unfortunately, given their troublesome personality traits, friends, lovers, and even family members and therapists often do "abandon" them—thus creating a tragic self-fulfilling prophecy. Sadly, this disorder is among the most commonly diagnosed and functionally disabling of all psychological disorders. Originally, the term implied that the person was on the borderline between neurosis and schizophrenia, but the modern conceptualization no longer has this connotation. The good news is that BPD can be reliably diagnosed and it does respond to professional intervention—particularly in young people What causes BPD? Some research points to environmental factors, such as a childhood history of neglect, emotional deprivation, and/or physical, sexual, or emotional abuse. From a biological perspective, BPD also tends to run in families, and some data suggest that it is a result of impaired functioning of the brain's frontal lobes and limbic system, areas that control impulsive behaviors. For example, research using neuroimaging reveals that people with BPD show more activity in parts of the brain associated with the experience of negative emotions, coupled with less activity in parts of the brain that help suppress negative emotion (Ruocco et al., 2013). As in almost all other psychological disorders, most researchers agree that BPD results from an interaction of biopsychosocial factors

Panic Disorder

Most of us have experienced feelings of intense panic, such as after narrowly missing a potentially fatal traffic collision. However, people with panic disorder endure repeated, sudden onsets of extreme terror and inexplicable panic attacks. Symptoms include severe heart palpitations, trembling, dizziness, difficulty breathing, and feelings of impending doom. The reactions are so intense that many sufferers believe they are having a heart attack. Panic disorder is diagnosed when several apparently spontaneous panic attacks lead to a persistent concern about future attacks. A common complication of panic disorder is agoraphobia, discussed in the next section.

Myth: Psychological disorders are a sign of personal weakness. Fact: Like all other illnesses, psychological disorders are a function of many factors, such as exposure to stress, genetic predispositions, a host of personal and sociocultural experiences, and family background. Mentally disturbed individuals can't be blamed for their illness any more than we blame people who develop cancer or other illnesses.

Myth: A mentally ill person is only suited for low-level jobs and never fully recovers. Fact: Once again, like all other illnesses, psychological disorders are complex, and their symptoms, severity, and prognoses differ for each individual. With therapy, the vast majority of those who are diagnosed as mentally ill eventually improve and lead normal, productive lives. Moreover, the extreme symptoms of some psychological disorders are generally only temporary. For example, U.S. President Abraham Lincoln, British Prime Minister Winston Churchill, scientist Isaac Newton, and other high achieving people all suffered from serious psychological disorders at various times throughout their careers.

Common Myths About Mental Illness Myth: Mentally ill people are often dangerous and unpredictable. Fact: Only a few disorders, such as some psychotic and antisocial personality disorders, are associated with violence. The stereotype that connects mental illness and violence persists because of prejudice, selective media attention, and negative portrayals in movies and on television.

Myth: People with psychological disorders act in bizarre ways and are very different from normal people Fact: This is true for only a small minority of individuals and during a relatively brief portion of their lives. In fact, sometimes even mental health professionals find it difficult to distinguish normal from abnormal behaviors without formal screening.

Managing OCD

OCD, including soccer star David Beckham, actors Megan Fox (pictured here) and Leonardo DiCaprio, and singer/actor Justin Timberlake. Fortunately, people can learn to manage the symptoms of OCD, through therapy and/or medication, and lead highly productive and fulfilling lives.

social anxiety disorder (formerly called social phobia)

People with ______________are irrationally fearful of embarrassing themselves in social situations. Fear of public speaking and of eating in public are the two most common social phobias. The fear of public scrutiny and potential humiliation may become so pervasive that normal life is disrupted. People with this disorder are also four times more likely to abuse alcohol

Symptoms of Schizophrenia Schizophrenia is a group of disorders characterized by a disturbance in one or more of the following areas: perception, language, thought, affect (emotions), and/or behavior.

Perception The senses of people with schizophrenia may be either enhanced or blunted. The filtering and selection processes that allow most people to concentrate on whatever they choose are impaired, and sensory stimulation is jumbled and distorted. People with schizophrenia may experience hallucinations—false, imaginary sensory perceptions that occur without external stimuli. Auditory hallucinations (hearing voices and sounds) is one of the most commonly noted and reported symptoms of schizophrenia. On rare occasions, people with schizophrenia hurt others in response to their distorted perceptions. But a person with schizophrenia is more likely to be self-destructive and suicidal than violent toward others.

In addition, the DSM has been criticized for a potential cultural bias. It does provide a culture-specific section and a glossary of culture-bound syndromes, such as amok(Indonesia), genital retraction syndrome (Asia), and windigo psychosis (Canadian Indians), which we discuss later in this chapter. However, the overall classification still reflects a Western European and U.S. perspective

Perhaps the most troubling criticism of the DSM is its possible overreliance on the medical model and the way it may unfairly label people. Consider the classic (and controversial) study conducted by David Rosenhan (1973) in which he and seven colleagues presented themselves at several hospital admissions offices complaining of hearing voices (a classic symptom of schizophrenia). Aside from making this single false complaint and providing false names and occupations, the researchers answered all questions truthfully. Not surprisingly, given their reported symptom, they were all diagnosed with psychological disorders and admitted to the hospital. Once there, the "patients" stopped reporting any symptoms and behaved as they normally would, yet none were ever recognized by hospital staff as phony. Be aware that all eight of these pseudo-patients were eventually released, after an average stay of 19 days. However, all but one were assigned a label on their permanent medical record of "schizophrenia in remission.

As the Renaissance ended, special mental hospitals called asylums began to appear in Europe. Initially designed to provide quiet retreats from the world and to protect society, the asylums unfortunately became overcrowded, inhumane prisons Improvement came in 1792, when Philippe Pinel, a French physician, was placed in charge of a Parisian asylum. Believing that inmates' behavior was caused by underlying physical illness, he insisted that they be unshackled and removed from their dark, unheated cells. Many inmates improved so dramatically that they could be released.

Pinel's actions reflect the ideals of the modern medical model, which assumes that diseases (including mental illness) have physical causes that can be diagnosed, treated, and possibly cured and prevented. This medical model is the foundation of the branch of medicine, known as psychiatry, that deals with the diagnosis, treatment, and prevention of mental disorders. In contrast, psychologists believe that focusing on "mental illness" overlooks important social and cultural factors, as well as our own personal thoughts, feelings, and actions that contribute to psychological disorders. Therefore, we take a multifaceted approach to explaining abnormal behavior, as shown in

Biological Factors -

Recent research suggests that structural brain changes may contribute to depressive and bipolar disorders. For example, some professional athletes are at greater risk of developing such disorders as they age, possibly due to brain damage caused by repeated concussions (Bajwa et al., 2016; Broshek et al., 2015; Yang et al., 2015). Unfortunately, research on former professional football players has found that 41% show cognitive problems and 24% show clinical depression, which may result from neurological changes caused by concussions (Hart et al., 2013). Their brain scans also revealed changes in blood flow within the brain and abnormalities in various parts of the brain. Sadly, these changes may contribute to serious depression and increased risk of suicide

Biological Factors

Some researchers believe phobias reflect an evolutionary predisposition to fear things that were dangerous to our ancestors (Gilbert, 2014; Mineka & Oehlberg, 2008; New & German, 2015). Unfortunately, many who suffer from panic disorder seem genetically predisposed toward an overreaction of the autonomic nervous system. Stress and arousal also seem to play a role in panic attacks, and drugs such as caffeine or nicotine and even hyperventilation can trigger an attack, all suggesting a biochemical disturbance. In addition, recent research shows that disturbed sleep is linked to both anxiety disorders and chronic depression

Anxiety disorders and the biopsychosocial model

The biopsychosocial model takes into account the wide variety of factors than can contribute to anxiety disorders.

dissociative identity disorder (DID)

The most controversial, and least common, dissociative disorder is dissociative identity disorder (DID)—previously known as multiple personality disorder (MPD). An individual with this disorder has at least two separate and distinct personalities (or identities) in the same individual (Figure 12.14). Each personality has unique memories, behaviors, and social relationships. Transition from one personality to another occurs suddenly, and is often triggered by psychological stress . Typically, there is a "core" personality, who has no knowledge or awareness of the alternate personalities, but is often aware of lost memories and lost periods of time. The disorder is diagnosed about equally among men and women DID is a controversial diagnosis. Some experts suggest that many cases are faked or result from false memories and/or an unconscious need to please a therapist

schizophrenia

This description is taken from the true case history of a patient who suffers from schizophrenia. As shown in this example and discussed in this section, people with schizophrenia have major disturbances in perception (seeing or hearing things that others don't), language (bizarre words and meanings), thought (impaired logic), emotion (exaggerated or blunted), and/or behavior (peculiar movements and social withdrawal). In addition, some may have serious problems caring for themselves, relating to others, and holding a job. The DSM-5 places schizophrenia within the category of "schizophrenic spectrum and other psychotic disorders." Recall that psychosis refers to a serious loss of contact with reality. In extreme cases, the illness is so severe that it's considered a psychosis and treatment may require institutional or custodial care. Schizophrenia is one of the most widespread and devastating psychological disorders. Approximately 1% of people in any given adult population will develop it in their lifetime, and approximately half of all people who are admitted to mental hospitals are diagnosed with this disorder. Schizophrenia usually emerges between the late teens and the mid-30s and only rarely prior to adolescence or after age 45. It seems to be equally prevalent in men and women, but it's generally more severe and strikes earlier in men Many people confuse schizophrenia with dissociative identity disorder, which is sometimes referred to as split or multiple personality disorder (see the following Real World Psychology). Schizophrenia means "split mind," but when Eugen Bleuler coined the term in 1911, he was referring to the fragmenting of thought processes and emotions, not of personalities (Neale et al., 1983). As we discuss later in this chapter, dissociative identity disorder is popularly referred to as having a "split personality"—the rare and controversial condition of having more than one distinct personality.

Gender Differences When you picture someone suffering from depression, anxiety, alcoholism, or antisocial personality disorder, what is the gender of each person? Most people tend to visualize a woman for the first two and a man for the last two. There is some truth to these stereotypes. Research has found many gender differences in the prevalence rates of various psychological disorders. Let's start with the well-established fact that around the world, the rate of severe depression for women is about double that for men. Why is there such a striking gender difference? Certain risk factors for depression (such as genetic predisposition, marital problems, pain, and medical illness) are common to both men and women. However, poverty is a well-known contributor to many psychological disorders, and women are far more likely than men to fall into the lowest socioeconomic groups. Women also experience more wage disparity and discrimination in the work force, sexual trauma, partner abuse, and chronic stress in their daily lives, which are all well-known contributing factors in depression

To examine different expectations about depression as a function of gender, researchers in one study asked participants to read a story about a fictitious person (Kate in one version, Jack in the other). The story was exactly the same in both conditions and included the following information: "For the past two weeks, Kate/Jack has been feeling really down. S/he wakes up in the morning with a flat, heavy feeling that sticks with her/him all day. S/he isn't enjoying things the way s/he normally would. S/he finds it hard to concentrate on anything." Although all participants read the same story, those who read about Kate rated her symptoms as more distressing, deserving of sympathy, and difficult to treat (Swami et al., 2012). Research also suggests that some gender differences in depression may relate to the way women and men tend to internalize or externalize their emotions. Using structured interview techniques, researchers found that women ruminate more frequently than men, which means they are more likely to focus repetitively on their internal negative emotions and problems rather than engage in more external problem-solving strategies. In contrast, men tend to be more disinhibited and more likely to externalize their emotions and problems. Can you see how these gender differences in depression may result from misapplied gender roles? The most common symptoms of stereotypical depression, such as crying, low energy, dejected facial expressions, and withdrawal from social activities, are more socially acceptable for women than for men. In contrast, men in Western societies are typically socialized to suppress their emotions and to show their distress by acting out (being aggressive), acting impulsively (driving recklessly and committing petty crimes), and/or engaging in substance abuse. Given these differences in socialization and behaviors, combined with the fact that gender differences in depression are more pronounced in cultures with traditional gender roles, male depression may "simply" be expressed in less stereotypical ways, and therefore be underdiagnosed Understanding the importance of genetic predispositions, external environmental factors (like poverty), and cognitive factors (like internalizing versus externalizing emotions and problems) may help mental health professionals better understand individual and gender-related differences in depression.

Understanding and Evaluating the DSM

To understand a disorder, we must first name and describe it. The DSM identifies and describes the symptoms of approximately 400 disorders, which are grouped into 22 categories Note that we focus on only the first 7 in this chapter. Also, keep in mind that people may be diagnosed with more than one disorder at a time, a condition referred to as comorbidity.

Classification and diagnosis of psychological disorders are essential to scientific study. Without a system such as the DSM, we could not effectively identify and diagnose the wide variety of disorders, predict their future courses, or suggest appropriate treatment. Moreover, the DSM facilitates communication among professionals and patients, and serves as a valuable educational tool.

Unfortunately, the DSM does have limitations and potential problems. For example, critics suggest that it may be casting too wide a net and overdiagnosing. Given that insurance companies compensate physicians and psychologists only if each client is assigned a specific DSM code number, can you see how compilers of the DSM may be encouraged to add more diagnoses?

What to Do If You Think Someone Is Suicidal If you have a friend or loved one with serious depression, it may feel like you're walking through a minefield when you're attempting to comfort and help them. What do the experts suggest? What NOT to Do: Don't ignore the warning signs. (See again the Test Yourself) Depression, like cancer or heart disease, is a critical, life-threatening brain disease. Knowing the signs of suicide risk can increase your confidence in how and when to intervene (Ramchand et al., 2016). Don't equate suicide with "selfishness." Just as we wouldn't say a drug addict and/or diabetic died because he or she lacked courage and were being selfish, we need to recognize the courage and strength of the chronically and deeply depressed who struggle each day NOT to die. Don't be afraid to discuss suicide. In a calm voice, ask the person a direct question, such as, "Are you thinking of hurting yourself?" Many people fear the topic of suicide because they think they might put that idea into the other person's head. As mentioned before, the reality is that virtually every adult knows what suicide is, and many have even considered it for themselves. Furthermore, people who are told "you can't be seriously considering suicide" often feel even more alone, become less likely to share their true feelings, and more likely to actually attempt it. Don't abandon the person after the suicidal crisis has seemingly passed. Depression and suicidal thoughts don't magically disappear. For many, the fight against depression is a painful, lifelong struggle, and your friend or loved one needs your ongoing support.

What To Do: Stay with the person. Encourage him or her to talk to you rather than to withdraw. Show the person that you care, but do not give false reassurances that "everything will be okay." If you feel like you can't handle the crisis by yourself, share your suspicions with parents, friends, or others who can help in a suicidal crisis. To save a life, you may have to betray a secret when someone confides in you. Be Rogerian. As mentioned in Chapters 11 and 13, Carl Rogers' four important qualities of communication (empathy, unconditional positive regard, genuineness, and active listening) are probably the best, and safest, approach for any situation—including talking with a depressed, suicidal person. Find help fast! If a friend or loved one mentions suicide, or if you believe he or she is considering it, get professional help fast! Most cities have walk-in centers that provide emergency counseling. Also, consider calling the police for emergency intervention, and/or the person's family, a therapist, the toll-free 7/24 hotline 1-800-SUICIDE, or 1-800-273-TALK. Famous victims of suicide Even people who enjoy enormous fame and financial success may be at risk for suicide, including well-known actors, comedians, and musicians, like Robin Williams (pictured here) and Kurt Cobain. Sadly, there are also tragic victims of suicide in other fields, such as professional athletes, like Olympic medalist Jeret Peterson, or football player Junior Seau; and influential writers or artists like Virginia Woolf, Ernest Hemingway, and Vincent van Gogh. On a slightly more positive note, research shows that one of the best ways to reduce suicides—although not depression—is to pass laws that limit access to handguns. Compared to states without such laws, those with background checks have a 53% lower gun suicide rate, those with mandated gun locks have a 68% lower gun suicide rate, and those with restrictions on open carry have a 42% lower gun suicide rate. Similarly, the longer the waiting period to buy a gun, the lower the gun suicide rate

Creativity and Bipolar Disorder

What do you picture when you think of a creative genius? Thanks to movies, television, and novels, many people share the stereotypical image of an eccentric inventor or deranged artist, like the lead ballerina in the film Black Swan. Is there an actual link between creativity and psychological disorders? Researchers interested in this question collected data from more than 1 million people, including their specific professions, whether they had ever been diagnosed and treated for a psychological disorder, and if so what type (Kyaga et al., 2012). Kyaga and his colleagues found that individuals in generally creative professions (scientific or artistic) were no more likely to suffer from investigated psychiatric disorders than those in other professions. However, bipolar disorder was significantly more common in artists and scientists, and particularly in authors. What do you think? How would you explain this intriguing association between certain creative professions and bipolar disorder? Does the manic phase of bipolar disorder increase the energy levels of artists, scientists, and authors, giving them greater access to creative ideas than they would otherwise have? Or does it interfere with their overall output? Can you see how variables like choice of occupation might confound these results (Patra & Balhara, 2012)? As you'll discover later in this chapter, there is a strong genetic component in bipolar disorders. And, just as you are much more likely to enter a profession similar to that of your parents because of familiarity, access, and modeling, children of artists, scientists, and authors are more likely to choose similar professions—thus possibly explaining the link between creativity and mental illness. If you find these questions fascinating and the lack of answers frustrating, you may be the perfect candidate for a career as a research psychologist. Recall from Chapter 1 that the scientific method is circular and never-ending—but guaranteed to excite!

The Dangers and Stigma of Mental Illness

What do you think about the Rosenhan study? Do you see how it demonstrates the inherent dangers and "stickiness" of all forms of labels? This particular study has been criticized, but few doubt that the stigma, prejudice, and discrimination surrounding mental illness often create lifetime career and social barriers for those who are already struggling with the psychological disorder itself. Furthermore, despite the U.S. surgeon general's 2010 landmark mental health report identifying stigma as a public health concern, it still exists. Sadly, stigmatizing mental illness discourages individuals from seeking help when they need it, and deters the public from wanting to pay for it—which can lead to devastating, even life-threatening consequences

Personality Disorders

What would happen if the characteristics of a personality were so inflexible and maladaptive that they significantly impaired someone's ability to function? This is what occurs with personality disorders Several types of personality disorders are included in this category in the fifth edition of the DSM, but here we will focus on antisocial personality disorder (ASPD) and borderline personality disorder (BPD)

Coping with Anxiety Disorders

What would you do if you were a promising new professional basketball player expected to fly all over the country with your team but suffered from an intense fear of flying? This is just one of the many challenges facing NBA rookie player Royce White, who speaks openly about his illness and personal experiences, hoping to boost public awareness of psychological illness. Although twice as many women as men are diagnosed with anxiety disorders, men like White also suffer from this widespread disease. In fact, anxiety disorders are among the most frequently occurring psychological disorders in the general population

People with bipolar disorders, however, rebound to the opposite state, known as mania, which is characterized by unreasonable elation and hyperactivity During a manic episode, individuals often feel unusually "high" and optimistic, and experience unrealistically high self-esteem and grandiose beliefs about their abilities and powers. While mania feels good at first, it has serious and often dangerous side effects, such as becoming aggressive, and engaging in reckless behaviors, including inappropriate sexual activity, gambling away savings, giving away valuable possessions or going on wild spending sprees. In addition, they are often hyperactive and may not sleep for days at a time without becoming apparently fatigued. Thinking is faster than normal and can change abruptly to new topics, showing "rapid flight of ideas." Speech is also rapid ("pressured speech"), making it difficult for others to get a word in edgewise. A manic episode may last a few days or a few months, and it generally ends abruptly. The ensuing depressive episode generally lasts three times as long as the mania The lifetime risk for bipolar disorder is low—between 0.5 and 1.6%—but it can be one of the most debilitating and lethal disorders. Due in part to the impulsivity associated with this disorder, the suicide rate is between 10 and 20% among sufferers (Depp et al., 2016; Ketter & Miller, 2015). Before going on, let's explore the link between bipolar disorder and creativity

When depression is unipolar, and the depressive episode ends, the person generally returns to a normal emotional level

depressive disorders

are so deeply sad and discouraged that they often have trouble sleeping, are likely to lose (or gain) significant weight, and may feel so fatigued that they cannot go to work or school or even comb their hair and brush their teeth (see the cartoon). Seriously depressed individuals also have trouble concentrating, making decisions, and being social. In addition, they often have difficulty recognizing their common "thinking errors," such as tunnel vision , which involves focusing on only certain aspects of a situation (usually the negative parts) and ignoring other interpretations or alternatives. Do you see how this type of depressed thinking would deepen depression and possibly even lead to suicide

Subcategories of Mental Disorders

check pg 335.

Generalized Anxiety Disorder (GAD)

experience persistent, uncontrollable, and free-floating, nonspecified anxiety. The fears and anxiety are referred to as "free-floating" because they're unrelated to any specific threat—thus the term "generalized" anxiety disorder. Sadly, the fears and anxieties of GAD are generally chronic and uncontrollable and last at least six months (Louie & Roberts, 2015; Szkodny & Newman, 2014). Because of persistent muscle tension and autonomic fear reactions, people with this disorder may develop headaches, heart palpitations, dizziness, and insomnia, making it even harder to cope with normal daily activities. The disorder affects twice as many women as men (Horwath & Gould, 2011).

Delusions

false or irrational beliefs that are maintained despite clear evidence to the contrary, are also common in people with schizophrenia (see the cartoon). We all experience exaggerated thoughts from time to time, such as thinking a friend is trying to avoid us, but the delusions of schizophrenia are much more extreme. For example, if someone falsely believed that the postman who routinely delivered mail to his house every afternoon was a co-conspirator in a plot to kill him, it would likely qualify as a delusion of persecution or paranoia. In delusions of grandeur, people believe that they are someone very important, perhaps Jesus Christ or the Queen of England. In delusions of control, the person believes his or her thoughts or actions are being controlled by outside and/or alien forces— "the CIA is controlling my thoughts."

abnormal behavior (or psychopathology)

mental health professionals generally agree that _____________ can be identified as patterns of behaviors, thoughts, or emotions considered pathological (diseased or disordered) for one or more of these four reasons: deviance, dysfunction, distress, and/or danger

Culture-bound disorders Some disorders are fading as remote areas become more Westernized, whereas other disorders (such as anorexia nervosa) are spreading as other countries adopt Western values. As you can see, culture has a strong affect on psychological disorders. Studying the similarities and differences across cultures can lead to better diagnosis and understanding. It also helps all of us avoid, or at least minimize, our ethnocentrism. Before closing this chapter, we want to caution you that although it's tempting to use the information you've gained to diagnose yourself or others, only professionals are adequately trained to do so. If you're concerned about your own mental health or that of others, be sure to contact these professionals. In addition, the following PositivePsych explains how resilience offers an interesting, positive approach to mental health.

pg. 159

neurosis In previous editions of the DSM, the term neurosis reflected Freud's belief that all neurotic conditions arise from unconscious conflicts Now, conditions that were previously grouped under the heading neurosis have been formally studied and redistributed as separate categories.

psychosis Unlike neurosis, the term psychosis is still listed in the current edition of the DSM because it remains useful for distinguishing the most severe psychological disorders, such as schizophrenia.

Antisocial Personality Disorder (ASPD)

sometimes called psychopaths or sociopaths—are typically egocentric and exhibit a lack of conscience, remorse, or empathy for others. They're also manipulative, deceitful, and willing to use others for personal gain. These behaviors typically begin in childhood or early adolescence and continue through adulthood. They also lie so far outside the ethical and legal standards of society that many consider ASPD the most serious of all psychological disorders. Unlike people with anxiety, mood disorders, and schizophrenia, those with this diagnosis feel little personal distress (and may not be motivated to change). Yet their maladaptive traits generally bring considerable harm and suffering to others (Cummings, 2015; Jones, 2016; Paris, 2015). Although serial killers are often seen as classic examples of people with ASPD, most people who have this disorder generally harm others in less dramatic ways—for example, as ruthless business people and crooked politicians. Unlike most other adults, individuals with ASPD act impulsively, without giving thought to the consequences. They are usually poised when confronted with their destructive behavior, and feel contempt for anyone they are able to manipulate. In addition, they typically change jobs and relationships suddenly, and often have a history of truancy from school or of being expelled for destructive behavior. People with antisocial personalities can be charming and persuasive, and they often have remarkably good insight into the needs and weaknesses of other people. Twin and adoption studies suggest a possible genetic predisposition to ASPD. Researchers also have found abnormally low autonomic activity during stress, right hemisphere abnormalities, reduced gray matter in the frontal lobes, and biochemical disturbances For example, MRI brain scans of criminals currently in prison for violent crimes, such as rape, murder, or attempted murder, and showing little empathy and remorse for their crimes, reveal reduced gray matter volume in the prefrontal cortex (Gregory et al., 2012). (Recall from Chapter 2 that this is the area of the brain responsible for emotions, such as fear, empathy, and/or guilt.) Evidence also exists for environmental or psychological causes. People with antisocial personality disorder often come from homes characterized by severely abusive parenting styles, emotional deprivation, harsh and inconsistent disciplinary practices, residential mobility, and antisocial parental behavior. Still other studies show a strong interaction between both heredity and environment

According to the diathesis-stress model of schizophrenia

stress plays an essential role in triggering schizophrenic episodes in people with an inherited predisposition (or diathesis) toward the disease. In line with this model, children who experience severe trauma before age 16 are three times more likely than other people to develop schizophrenia. People who experience stressful living environments, including poverty, unemployment, and crowding, are also at increased risk (Brown & Lau, 2016; Kirkbride et al., 2014; Sweeney et al., 2015). How should we evaluate the different theories about the causes of schizophrenia? Like virtually all psychological disorders, nature and nurture interact. Most scientists believe schizophrenia is probably the result of a combination of known and unknown interacting factors