Introduction to Psychological Science: Integrating Behavioral, Neuroscience and Evolutionary Perspectives - William J. Ray 2021
✵ 14.1 Explain how psychological disorders are classified and diagnosed.
✵ 14.2 Describe the various types of anxiety, obsessive-compulsive, and mood disorders.
✵ 14.3 Discuss the dissociative disorders of depersonalization, dissociative amnesia, and dissociative identity disorder.
✵ 14.4 Describe the main features and causes of schizophrenia.
✵ 14.5 Discuss the basic characteristics of personality disorders.
✵ 14.6 Discuss the neurodevelopmental disorders that begin early in a child’s life.
The book A Beautiful Mind describes the life and experiences of John Nash (Nasar, 1998). The book tells a powerful story and was made into a major Hollywood film that won the Academy Award for Best Picture of 2001. John Nash was a remarkable figure, who received a PhD in mathematics from Princeton University and taught at both the Massachusetts Institute of Technology (MIT) and Princeton. In 1994, Nash won the Nobel Prize in economics for his work on game theory.
From what you just read, you probably assume that John Nash had a very productive career. However, there was another aspect to John Nash’s life that caused considerable distress to him and puzzlement to others. One day he walked into a room full of others in his university department and held up a copy of The New York Times . He said to no one in particular that the story in the upper-left corner contained an encrypted message that had been put there by inhabitants of another galaxy and that he knew how to decode it (Nasar, 1998, p. 16). He was 30 years old at the time.
In the film, John Nash is contacted by the United States Department of Defense to help decipher codes sent by enemy nations. The defense department asks him to search patterns of Soviet plots placed in American magazines and newspapers. You see a large number of magazines and papers with notations. As you watch the film, everything seems reasonable, for indeed during the Cold War era after World War II many in the American government felt that there was a Soviet plot to overthrow the United States government. It is only later that you realize that the story is being told from John Nash’s perspective. What you discover is that you are seeing the world as John Nash saw it and it is not reality. John Nash created a world that did not exist.
After Nash won the Nobel Prize in 1994, there were times when he was productive, but there were also times where he had disordered thoughts, mumbled to himself without thought of those around him, and experienced delusions of situations that did not exist. He felt there were individuals around him who put him in danger. He even wrote letters to officials in the United States government to suggest that these individuals were setting up alternative governments. John Nash suffered from a serious mental illness called schizophrenia.
As you have moved through the chapters in this book, one theme has been apparent and that is the manner in which we are in close connection with our environment including friends and others. An important part of our relationship with our environment is our ability to reflect on ourselves and our world. In this way, a layer of thought can be injected between the person and the environment. This allows for expectation and even imagination to play a role in human behavior and experience.
We can imagine our lives with very different outcomes. For example, you can tell yourself you are wonderful or you are stupid. Whatever you say internally, there is no one there to dispute it. One positive aspect of this is that your inner world allows you to plan future actions and reflect on past ones. A negative aspect of this is that it can also be experienced as distress when your internal thoughts reflect such states as anxiety or hopelessness. This chapter begins with a discussion of psychological disorders and then looks at several major forms of mental disorder: anxiety, obsessive-compulsive disorder, mood disorders, dissociative disorders, schizophrenia, and neurodevelopmental disorders.
It should be noted that psychological disorders are referred to by a number of different terms depending on the historical tradition. These include the terms abnormal psychology, mental disorders, mental illness, and psychopathology. Psychopathology is the most common term used in neuroscience research. In legal considerations, the term insanity is often used. Of course, there is slang in which people are referred to as crazy or nuts. Additionally, some individuals self-diagnose or make an emotional statement such as, “I am so schizo” or “I am so OCD.” As you will see, there are technical definitions of mental disorders presented in this chapter that have specified criteria. Before presenting these, let’s consider some of the general characteristics of psychopathology.
What is psychopathology? Although there is no one single definition of what represents abnormal processes in general, four ideas have been critical, as shown in Table 14-1. One important characteristic of psychological disorders is the lack of control over one’s experience. This can also be described as a loss of freedom or an inability to consider alternative ways of thinking, feeling, or doing. Some individuals show this loss mainly in terms of emotional processes. Others show the loss in terms of cognitive processes, such as the experiences of John Nash.
Table 14-1 Key personal components of psychopathology.
Four Key Personal Components of Psychopathology
1. Loss of freedom and ability to consider alternatives
2. Loss of honest personal contact
3. Loss of one’s connections with one’s self and ability to live in a productive manner
4. Personal distress
Another common theme seen in psychopathology is the loss of honest personal contact. Individuals with depression or schizophrenia often find it difficult to experience social interactions as experienced by other people. Just having a simple conversation or talking to clerks in stores may seem impossible. Mental illness not only affects individuals’ interpersonal relationships with others but also their relationship with themselves, their intrapersonal relationship. When individuals with schizophrenia or depression talk to themselves, they often think negative thoughts about who they are and what will happen to them in the future.
Additionally, in most cases, the experience of a mental disorder results in personal distress. Not being able to get out of bed, or feeling that a voice in your head is telling you that you are evil, or worrying that even a rice cake or an apple will make you fat all represent different degrees of distress. Distress represents one important aspect of psychological disorders also referred to as psychopathology. In fact, for most disorders, distress is the key ingredient.
Thus, we can consider four important personal components in psychopathology: first, a loss of freedom or ability to consider alternatives; second, a loss of honest personal contact; third, a loss of one’s connection with one’s self and ability to live in a productive manner; and fourth, personal distress. In many psychological disorders, personal distress for a period of time is one of the criteria required for a diagnosis to be made. There is also a more global component in which the person’s behavior and experiences are considered to be different from cultural and statistical norms.
The National Institute of Mental Health (NIMH) estimates that at least 20.6% of adults in America experience a diagnosable mental disorder during a given year (see Figure 14-1). This would be more than 51.5 million people over the age of 18 who experienced a mental disorder in 2019 (https://www.nimh.nih.gov/health/statistics/mental-illness.shtml).
Figure 14-1 Mental illness differs in terms of gender, age, and race among US adults. More females than males experience mental illness. Those aged 50 and older experience less mental illness. Native Americans show the most mental illness often in relation to disorders of substance abuse.
With mental illness being so common, you might think that we as humans would have a complete understanding of the factors involved. However, this is not the case. We are not even sure how to refer to individuals with mental disorders. Are they abnormal? Depending on the reference group one uses, one can be normal or abnormal. Many famous artists such as the Impressionists in France had their work initially rejected because it did not fit into the standards of what was considered good art at the time. However, today we appreciate that these artists showed us another way of viewing the world. Likewise, many movies and edgy YouTube videos today would be rejected as not representing mainstream values at a previous time. Further, what would be acceptable in one culture might be seen as completely “crazy” in another. However, many individuals with mental illness experience stigma.
Stigma and Mental Disorders
Experiencing a mental illness does not mean that one has to live a limited life. Individuals like John Nash not only have had a productive career but have enjoyed successful personal relationships. However, many children, adolescents, and young adults with a mental illness report being told they could never perform in a high-level profession or have the types of relationships that others have.
There is often a stigma experienced by those with a mental disorder. Historically, stigma has been defined as a mark of disgrace associated with a particular person. In psychological terms, stigma involves negative attitudes and beliefs that cause the general public to avoid others including those with a mental illness. Throughout the world, those with mental illness experience stigma. In many cultures, they are seen as different. When they are thus stigmatized, they are no longer treated as an individual person, but only as part of a group that is different. It becomes an “us versus them” way of thinking.
Part of the stigma comes from inaccurate information concerning those with mental illness. For example, many people think that anyone with a mental illness is violent. In 2012, there was a killing of 20 children and 6 teachers at the Sandy Hook Elementary School in Newtown, Connecticut. Immediately, it was suggested that the killer had a mental illness. Officials of the National Rifle Association immediately claimed that this could not have been done by a sane person. The same was true with the Parkland Florida shooting in 2018 in which 17 people were killed. People have talked about “red flag” laws and placing more individuals in institutions. However, the data do not support a strong relationship between mental disorders and violence.
The MacArthur Foundation followed hospitalized individuals with mental illness after their release from the hospital and found that only 2% to 3% of these individuals were involved with violence with a gun. As a general rule, individuals with mental illness do not show more violence than that seen in the general population. There are, however, particular disorders such as psychopathy associated with serial killers in which individuals are violent. Also, substance abuse can increase violence in some individuals. With these exceptions, having a mental illness does not increase violence toward others.
Stigma can be seen on a number of levels. If a society believes that mental illness is the fault of the person—and that the person can change himself or herself by willpower—then it is less likely to spend the money necessary to set up clinics and train professionals. Society may also be less likely to set up school-based programs to help adolescents with bullying or suicide. As well, companies may not be willing to include mental health treatment in their insurance coverage, or they may place limits on benefits for treatment of these disorders.
As a society, Americans show a number of different values when considering individuals with mental illness. On the one hand, we may want to help those who experience distress. Many communities, for example, have developed programs for the homeless, especially those with mental disorders. On the other hand, we may feel it is their own responsibility to take care of themselves.
In the United States, attitudes are moving toward less stigma. In 1996, for example, 54% of the US population viewed depression as related to neurobiological causes. During the next 10 years, this increased to 67%. With a better understanding of mental disorders, it is possible to have a more compassionate as well as intellectual understanding of those with mental disorders.
The modern study of psychopathology is generally dated to the late 1700s. As with the move toward experimentation and empiricism in physics and chemistry, the study of psychopathology initially began with careful description. There was also a shift away from external mechanisms such as possession by spirits toward an explanation in terms of natural processes. With this shift came a differentiation between patients in mental hospitals who experienced mental disorders from those who were just misfits in their society. Marquis de Sade, who wrote novels of a sexual nature, was released by the director of a mental hospital in Paris during this period with the statement, “… is not mad. His only madness is vice” (Pires, 2008, p. 430).
The difference between vice and madness is one of many dichotomies that has plagued the study of psychopathology over the centuries and continues to this day as larger intellectual and societal questions. For example, should we consider drug addiction as a pleasure-seeking mechanism that is being overused and under someone’s control? If so, we would not consider it a disorder, but only the result of lack of will on the part of an individual. It was only at the end of the 20th century that addictions such as alcoholism were officially viewed by the US Federal Government as a physiological disorder rather than a problem of will. This allowed it to be treated in Veterans Administration Hospitals. As you have learned throughout this book, it is important to move beyond simple dichotomies such as “is it mind or body that produces the disorder.” It is also important to realize that psychological disorders can be understood on a variety of levels ranging from cultural influences to genetic ones.
One of the major contributions of the 20th century toward understanding psychopathology was the creation of a reliable diagnosis and classification system. This system in the United States, referred to as the Diagnostic and Statistical Manual of Mental Disorders (DSM), made it easier for different mental health workers to label a disorder in the same way. For example, generalized anxiety disorder (GAD) was described in terms of “Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).” In this way, the particular symptoms of the disorder were specified as well as the requirement that these symptoms had existed for at least 6 months. The next requirement was that “The person finds it difficult to control the worry.”
The experience of anxiety and worry was further differentiated in terms of specific symptoms. These include:
1. restlessness or feeling keyed up or on edge
2. being easily fatigued
3. difficulty concentrating or mind going blank
5. muscle tension
6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
To be diagnosed with GAD, the person would have to experience at least three of the six symptoms. Further, the anxiety must be experienced as distressing by the person and cannot be the result of another disorder or drug use. By the end of the 20th century, mental health facilities in the United States used the DSM system to diagnose and classify mental disorders.
At the end of the 20th century and the beginning of the 21st century, neuroscience techniques such as brain imaging and genetic analysis had been developed and were available in the research and clinical community. For many in the field, this suggests that there will be another level of analysis from which to understand psychopathology. These techniques will not only allow one to note the particular symptoms present as seen with DSM, but it will also be possible to ask how the brain is involved in the disorder.
Currently, the United States National Institute of Mental Health (NIMH) is asking whether multiple levels (from genomics and neural circuits to behavior and self-reports) can also be used to help in the diagnosis of psychopathology (Clark, Cuthbert, Lewis-Fernández, Narrow, & Reed, 2017; Cuthbert & Insel, 2013; Hyman, 2010; Miller & Rockstroh, 2017). This approach is referred to as Research Domain Criteria (RDoC) (https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc/index.shtml).
Other researchers have sought to determine the genetic components involved in particular disorders. We have discovered in children that attention deficit hyperactivity disorder (ADHD) is heritable, but that aggressive and disruptive conduct is not. The critical question is the manner in which genes and behavior are related. A variety of genetic studies suggest that genetic factors account for about 82% of the variance in schizophrenia, suggesting that environmental factors are less critical in the development of schizophrenia (Rutter, 2006). Further, adopted children from families with schizophrenia show a similar rate to those raised with their natural families, also suggesting rearing factors per se are not related to its development.
In terms of depression, genetic studies suggest that depression is equally influenced by genetic and environmental factors (Rutter, 2006). In one set of studies, monkeys with a genetic risk for depression were raised by either a highly responsive or less-responsive foster mother (Suomi, 1999). In this situation, it was the mothers that determined the outcome, with more-responsive foster mothers having less-depressed infants.
Creating a System to Understand Mental Disorders
As science progressed in the 1800s, there was an attempt to bring a classification system to psychological disorders. For example, Emil Kraepelin (1856—1926) who was a student of Wilhelm Wundt’s began to study symptoms of mental illness. It was his ability to observe and describe the symptoms his patients presented that helped to establish Kraepelin’s success. In particular, he was able to describe a set of symptoms that go together. Today, we refer to a collection of symptoms that occur together and have a particular course of development over time as a syndrome. By describing disorders in terms of patterns of symptoms, Kraepelin set the stage for diagnostic systems in both the United States and Europe.
As noted, the current diagnostic system used in the United States and some other countries is the Diagnostic and Statistical Manual of Mental Disorders. This is commonly referred to as DSM followed by a number to denote which edition it is. The initial DSM was released in 1952. DSM-5 was released in 2013. In Europe, psychological disorders are included with medical disorders in International Classification of Diseases, which is referred to as ICD. ICD 11 was released in 2018 and takes effect in 2022. Although similar, there are some differences between DSM and ICD.
One advantage of the DSM system is that it helps to improve the reliability of diagnosis. That is, since mental health workers from different locations use the same criteria for making a diagnosis, the agreement between professionals is higher. Another advantage is that DSM helps interviewers know which questions to ask and ensures that relevant information is not left out. Thus, there is emphasis on reliability of diagnosis such that mental health professionals in one location would diagnose the same individual in the same manner as professionals in another location. As part of this emphasis, there has been a push for observable characteristics that would define a specific disorder. Such characteristics as depressed mood over the day, diminished interest in activities, weight loss, insomnia, fatigue, feelings of worthlessness, difficulty thinking, and thoughts of suicide would be considered in the diagnosis of depression.
The DSM approach also helps to make a decision concerning which disorder is present. What if an individual appears with rapid speech, saying grandiose things, and talking about that they need to protect themselves? You might ask yourself if this person was experiencing a psychosis, or a manic episode? However, if you were to discover this person was using a drug that makes them high such as an amphetamine, then you would know it was drug-related. Neither schizophrenia nor bi polar disorder would be the appropriate diagnosis.
In the development of DSM-5, a variety of questions were asked. One of these is how do we define a mental disorder? One answer that was given was that a mental disorder contains five features (Stein et al., 2010). These are:
A. A behavioral or psychological syndrome or pattern that occurs in an individual
B. That reflects an underlying psychobiological dysfunction
C. The consequences of which are clinically significant distress (for example, a painful symptom) or disability (that is, impairment in one or more important areas of functioning)
D. Must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals)
E. That is not primarily a result of social deviance or conflicts with society
As you read these, you may note that from the DSM-5 standpoint, a mental disorder is more than a difference in cultural traditions or experience. It is also more than our common human experiences in terms of grief over a loved one or day-to-day anxiety or loneliness. A mental disorder is a pattern of symptoms that are distressing and keep the individual from engaging in his or her full functioning in life. A mental disorder also reflects underlying differences in physiological and psychological functioning. This is another way of saying that the brain is involved in all mental disorders. Finally, each disorder described in DSM is defined as a discrete disorder. Table 14-2 shows the major disorder categories in DSM. Currently, DSM plays an important role in our society since it are used in psychological, medical, and legal settings. As you see, legal definitions of psychological disorders are different than that found in DSM. This is described in the box: The World Is Your Laboratory: Legal Understanding of Mental Illness.
Table 14-2 Major DSM-5 disorder categories.
Conditions that begin in childhood such as autism spectrum disorder or attention-deficit/ hyperactivity disorder (ADHD).
Conditions in which individuals show hallucinations, delusions, disordered thought, and flat affect.
Bipolar and Related Disorders
Conditions in which individuals show changes in mood, such as alternations between mania and depression or periods of mania.
Conditions such as depression in which the person feels sad, empty, and without energy to accomplish tasks.
Conditions in which anxiety, worry, or fear are present such as generalized anxiety disorder or phobias.
Obsessive-compulsive and Related Disorders
Conditions in which a person has recurrent thoughts and the desire to engage in certain behaviors.
Trauma and Stressor Related Disorders
Conditions that involve exposure to traumatic events such as posttraumatic stress disorder (PTSD).
Conditions that show changes in experiences related to one’s self, such as not experiencing one’s self as real or dissociative identity disorder (previously called multiple personality disorder).
Somatic Symptom and Related Disorders
Conditions that focus on one’s bodily experiences such as excessive concern about bodily sensations or imagining that one or another person has a medical condition they do not have.
Feeding and Eating Disorders
Conditions involving eating too much or too little to maintain optimal health along with psychological concerns about weight such as anorexia nervosa and bulimia nervosa.
Conditions such as bed-wetting that involve urinary and fecal processes.
Conditions that involve problems with normal sleep-wake cycles such as insomnia or narcolepsy.
Conditions that involve problems with arousal or ability to perform sexually.
Conditions in which there is a difference in one’s experienced gender and the one assigned at birth.
Disruptive, Impulse-Control, and Conduct Disorder
Conditions involving children and adolescents that breaks norms of society such as conduct disorder or stealing.
Substance Related and Addictive Disorders
Conditions that involve addiction to various drugs such alcohol or drug addiction.
Conditions involving a decline in cognitive and other abilities such as Alzheimer’s disease.
Conditions involving problems in one’s relationship with others, such as borderline personality disorder or antisocial disorder.
Conditions related to sexuality such as voyeurism or fetishism.
Although each disorder described in DSM-5 is presented as a discrete disorder, it is possible for an individual to show characteristics of more than one disorder. Technically, when an individual is seen to have more than one disorder at the same time, the disorders are referred to as comorbid. In the National Comorbidity Survey, a large number of individuals with one disorder were found to have one or more additional diagnoses (Kessler et al., 2005). For example, individuals with generalized anxiety disorder will often also show symptoms of depression. Further, these two disorders have overlapping genetic and environmental risk factors (Kendler et al.,, 2012). The number of diagnoses found in the National Comorbidity Survey was associated with the severity of the symptoms. This has suggested to researchers that there exists a general underlying vulnerability to psychopathology that may be independent of the particular symptoms expressed (Pittenger & Etkin, 2008; Lahey, Krueger, Rathouz, Waldman, & Zald, 2017; Marshall, 2020; Smith et al., 2020).
The World Is Your Laboratory: Legal Understanding of Mental Illness
It is important to understand that mental health professionals and the legal system see psychopathology from very different perspectives. In fact, the legal system often uses the word insanity rather than the term psychopathology. Think for a second—what are courts and juries required to do? They determine if a person is innocent or guilty. In doing this they determine if a person is responsible for an action. Often, they further ask if a person performed an action of his or her own free will. The basic idea in the legal system is that it would be unfair to hold someone responsible and punish them for an action that was beyond their control. For example, courts would treat a situation in which someone who was driving had a heart attack and hit another car differently than if a person purposely hit another car. The same is true if mental disorders are involved. This has come to be known as the insanity defense.
The American system of justice in relation to insanity was initially influenced by an event that happened in England some 150 years ago. An individual named Daniel M’Naghten (pronounced McNaughton) believed that he was being persecuted by one of the political parties of England, the Tory party. In response to this belief, M’Naghten planned to kill the British Prime Minister, Sir Robert Peel. However, he ended up attacking and killing the prime minister’s secretary rather than the prime minister himself. When M’Naghten was tried for the crime, medical experts said he was psychotic. Today, he would be described as someone with paranoid schizophrenia. The court found M’Naghten not guilty by reason of insanity. There was some concern about the verdict on the part of the public, which resulted in a more formal definition of mental insanity. Mental insanity could be used as a defense only if
at the time of the committing of the act, the party accused was labouring under such a defect of reason, from a disease of the mind, as not to know the nature and quality of the act he was doing; or, if he did know it, that he did not know he was doing what was wrong.
(Queen v. M’Naghten, 8 Eng. Rep. 718 )
This came to be known as the M’Naghten rule.
In the United States a number of variations based on capacity and knowledge have been applied in determining sanity. In the 1880s, the State of Alabama found an individual not guilty by reason of insanity because mental illness made the person unable to control himself even though he knew the difference between right and wrong. This came to be known as the volitional test. In the 1950s, a decision based on an 1871 New Hampshire ruling became known as the Durham rule. The basic idea is that an individual is not “criminally responsible if his unlawful act is the product of a mental disease or defect.”
The insanity defense was changed drastically by an event on March 30, 1981. On that day in Washington, DC, John Hinckley tried to kill the President of the United States, Ronald Reagan. John Hinckley wanted to have a relationship with an actress named Jodie Foster. Hinckley believed that if he acted like one of the characters in one of her movies, she would notice him and be impressed. He wrote a letter to her a few hours before he shot the president saying, “I would abandon this idea of getting Reagan in a second if I could only win your heart and live out the rest of my life with you…” He further said “I am doing all of this for your sake! By sacrificing my freedom and possibly my life, I hope to change your mind about me…” At his trial, John Hinckley was found not guilty by reason of insanity. This upset the American public and resulted in four changes to the law.
✵ 1. Twelve states changed the insanity plea to guilty but mentally ill.
✵ 2. Some states abolished the insanity defense.
✵ 3. Expert witness testimony was limited in terms of ability to express an opinion.
✵ 4. Burden of proof was increased to require clear and convincing evidence.
Additional legal information concerning this case can be found at http://law2.umkc.edu/faculty/projects/ftrials/hinckley/hinckleytrial.html
At present there is no one rule that determines legal sanity in all 50 states. The insanity defense is largely misunderstood by the lay public. It is often said that someone got off by pleading insanity. Actually, the loss of freedom is generally greater in these cases since the person is usually placed in a facility for the criminally insane for an indefinite period of time. Being convicted for a crime on the other hand carries with it a sentence for a specified period of time. The actual number of insanity pleas is much smaller than public perception and few of these individuals are set free without going to a mental hospital or other facility.
Thought Question: How has the concept of “not guilty by reason of insanity” changed in the US over the last 150 years? What is the rule that determines legal sanity in your state? Should there be one rule that determines legal sanity in all 50 US states as well as at the Federal level?
If psychopathology is part of our human makeup, then we expect to see similar manifestations of it worldwide. One classic study in this regard was performed by Jane Murphy of Harvard University (Murphy, 1976). It dates from the 1970s when mental illness was seen to be related to learning and the social construction of norms. In fact, some suggested that mental illness was just a myth developed by Western societies.
This perspective suggests that neither the individual nor his acts are abnormal in an objective sense. It depends on the situation. What would be seen as mental illness in a Western industrial culture might be very different than what was seen in a less-developed rural culture. That is to say, mental illness in this perspective was viewed as a social construction of the society. The alternative to this perspective is more similar to that we saw with human processes, such as emotionality, in which humans throughout the world show similar expression of the basic emotions.
If mental illness is part of our human history, as evolutionary psychologists would suggest, then we would expect to find similar manifestations across a variety of cultures. Dr. Murphy first studied two geographically separate and distinct non-Western groups, the Inuits of northwest Alaska and the Yorubas of rural tropical Nigeria. Although many researchers of that time would have expected to find that the conceptions of normality and abnormality were very different in the two cultures, this is not what she found.
What she found was that these cultures were well acquainted with processes in which a person was said to be “out of their mind.” This included doing strange things as well as hearing voices. Dr. Murphy concluded that processes of disturbed thought and behavior similar to schizophrenia is found in most cultures and that most cultures have a distinct name in their language for these processes. Additionally, she reported that these cultures had a variety of words for what traditionally is referred to as neurosis, although today we would refer to these as affective disorders such as anxiety and depression. Affective disorders include feeling anxious, tense, fearful of being with others, as well as being troubled and not able to sleep. One Eskimo term was translated as worrying too much until it makes the person sick.
Overall, it appears that most cultures have a word for what has been called psychosis such as schizophrenia, what has been called affective disorders such as anxiety and depression, and what has been called being sane. What is also interesting is that many cultures also have words for describing people who are out of their mind but not crazy. These would include witch doctors, shamans, and artists. Volition appears to be an important distinction for this concept.
To add evidence to her argument that psychopathology is indeed part of our human nature, Murphy also reviewed a large variety of studies conducted by others that looked at how common mental illness was in different cultures. The suggestion here is that if its prevalence is similar in cultures across the world then it is more likely to be part of the human condition rather than culturally derived. Overall, this research established mental illness was not a created concept by a given culture but rather part of the human condition in both its recognition and its prevalence. This set the stage for a development that came to be known as evolutionary psychopathology or Darwinian psychiatry.
Thinking about Psychopathology from an Evolutionary Perspective
An evolutionary perspective on psychopathology goes beyond the traditional psychological considerations. For example, we could ask how long in terms of our human history has a particular psychopathology existed. Let’s take schizophrenia as an example. A World Health Organization (WHO) study examined the presence of schizophrenia in a number of countries with very different racial and cultural backgrounds (Sartorius et al., 1986). If schizophrenia was largely related to the society or family in which you lived, then we would expect to see different rates and manifestations of the disorder in different cultures.
What these authors found was that despite the different cultural and racial backgrounds surveyed, the experience of schizophrenia was remarkably similar across countries. Likewise, the risk of developing schizophrenia was similar in terms of total population presence—about 1%. Further, the disorder had a similar time course in its occurrence with its characteristics first being seen in young adults. If you put these facts together, it was possible to suggest that schizophrenia is not directly related to environmental factors such as culture or family patterns. Because it develops at a similar age and follows a similar pattern across cultures, this suggests a genetic component to the disorder.
The next question that might be asked is how long has schizophrenia existed? Because it is found throughout the world in strikingly similar ways, this suggests that it existed before humans migrated out of Africa. The genes related to schizophrenia were carried by early humans who migrated from Africa and thus its presence is equally likely throughout the world. Given these estimates as to the history of the disorder, one might ask why does schizophrenia continue to exist? We know that individuals with schizophrenia tend to have fewer children than individuals without the disorder. Thus, we might assume that schizophrenia would have disappeared over evolutionary time in that it reduces reproductive success and has a genetic component. However, this is not the case.
This creates a mystery for evolutionary psychologists to solve. In order to answer this question, we can draw on many of the considerations seen in relation to human health and disease. Perhaps, in the same way that sickle cell anemia is associated with a protection against malaria, schizophrenia protects the person from another disorder. Or, perhaps like the reaction of rats to stress, which results in depression-like symptoms, the symptoms seen in schizophrenia are the result of a long chain of stressful events in which the organism breaks down in its ability to function. Psychopathology could even go in a more positive direction and be associated with creative and nontraditional views of the world. For example, there are a variety of accounts that have noted greater creativity in families of individuals with schizophrenia. Thus, the genetic components associated with creativity and intelligence may also make the individual with a variant form susceptible to schizophrenia.
Overall, the evolutionary perspective helps us ask questions such as what function a disorder might serve, as well as how it came about. In the same way that pain can be seen as a warning system in the body to protect from tissue damage, anxiety may have evolved to protect the person from other types of potential threats. For example, many of the outward expressions of social anxiety parallel what is seen in dominance interactions in primates. Submissive monkeys avoid contact with most dominant ones as do individuals experiencing social anxiety.
Developmentally, there is some suggestion that the excessive scanning of the environment seen in some individuals with generalized anxiety disorder is associated with being required as children to prematurely play a responsible parental role for others. That is, if your mother was disorganized when you were a child, you may have needed to watch out for your own needs and maybe even those of younger siblings and your mother. The evolutionary perspective can also help us to think about solutions to how psychopathology should be classified and treated.
1. One way to define psychopathology is to consider its four important personal components. What are these four components?
2. What are four advantages of having a classification system, like DSM, to define psychological disorders?
3. There is often a stigma experienced by those with a mental disorder. What are three examples of this stigmatizing? What can be done to reduce stigmatizing?
4. What does the term comorbid refer to?
5. The modern study of psychopathology is generally dated to the late 1700s. What major changes have occurred in our understanding of psychopathology since that time?
6. Is psychopathology universal? List three pieces of evidence in support of this position.
7. What new kinds of questions does taking an evolutionary perspective allow us to ask in gaining a better understanding of psychopathology?
Common Disorders Involving Emotions or Moods
Our emotions and moods influence our behaviors and experiences. Most of the time they are consistent with our environmental conditions. We hear bad news and feel sad. Something startles us and we feel afraid. We win an award and feel happy. These tend to be short-term events. However, other times the feelings may persist without environmental conditions that would support them. When the experience of anxiety or depression persists without such external stimuli, then these conditions can be classified as psychological disorders. In this section, we will describe such conditions.
Anxiety is to be afraid of what might happen. What if I don’t do well when I give a presentation to a room full of important people? Will I get the job I want? What if a snake bites me when I am in the woods? What if the plane I am on crashes? What if I get germs on my hands when I go into a public restroom? What if others do not like me?
Anxiety is about the future, whereas fear typically has a stimulus in the present. With fear, we see a snake and become apprehensive. We look down from a tall building and feel unease. With anxiety, there is often no stimulus in front of us. With anxiety, the stimulus is in our mind. However, our cognitive and emotional consideration of a negative possibility does not make it any less real. Our body, mind, and emotions experience our ideas as real possibilities. We show the same autonomic nervous systems responses such as a higher heart rate as described in the chapter on stress. In anxiety, we increase the probability in our mind that an undesirable event will happen. Performers such as Ariana Grande and the British performer Adele have spoken openly about their experience with anxiety.
What we do know is that fear and anxiety involve high-level as well as more primitive brain processes. Cognitively, we can make ourselves feel more anxious by thinking of all the terrible things that can happen in a given situation. We get on an airplane feeling somewhat anxious. We then hear a sound from the engine that we interpret to be a problem. This, in turn, results in our being even more vigilant and listening for every sound. The plane begins to move down the runway, and we tell ourselves it is not going to make it. This allows for emotional reactions that our body normally keeps in check to increase and we feel anxious.
Limbic system processes, as you learned about in the coverage of stress, can also respond to stimuli on their own. For example, our amygdala can respond to an angry face in a manner that begins an autonomic nervous system reaction. From an evolutionary perspective, to be fearful in the presence of dangerous situations would be adaptive. However, extreme anxiety can hurt our performance. Thus, anxiety can both help us and hurt us, depending on the situation and the extent of the anxiety. One scientific aspect of this is the question of where these anxieties and fears come from. From research, we know that certain phobias run in families, suggesting a genetic component. However, not everyone has exactly the same fears, suggesting that fears can be learned during development.
The development of anxiety and fear follows a trajectory that is part of the human condition. Children and adolescents show similar profiles of anxiety and fear across cultures; however, cultures that favor inhibition, compliance, and obedience also show increased levels of fear (Ollendick, Yang, King, Dong, & Akande, 1996). Fears are traditionally seen in relation to immediate experiences. Young children during their first year of life, usually about 9 months, will react to strangers. After that, they will react to separation. Infants of other species also show distress vocalizations when separated from their mothers. Human infants also begin to display distress to specific stimuli, such as insects or flying bees, or animals. By adolescence, the fear turns to anxiety in that the object of concern is not present. Social anxiety about a future situation is common among adolescents. The normal expression of fear and anxiety only becomes pathological when it interferes with the child’s or adolescent’s ability to function or causes distress.
A number of epidemiology studies have shown that 2.5% to 5% of children and adolescents meet criteria for anxiety disorders at any one time (see Rapee, Schniering, & Hudson, 2009, for an overview). The earliest anxiety disorder to develop is separation anxiety disorder. The next is specific phobias, which begin in early to middle childhood. Next comes social phobia, which begins in early to middle adolescence. Panic disorder appears in early adulthood. Given the nature of adolescence, anxiety disorders at this time have an influence on popularity and social competence. They are also associated with victimization.
Although fear and anxiety are often studied together, research suggests that different brain areas are involved. Specifically, the areas involved in anxiety are not those directly responsible for the expression of fear. Rather, anxiety is related to the areas of the brain that regulate the fear system. These include the prefrontal cortex (PFC), the amygdala, and the hippocampus. These are systems involved in cognitions, emotional reactivity, and memory—all important components in the social and cognitive aspects of anxiety. These systems are also seen in humans to be the ones involved in increased vigilance and attention to threat (Robinson et al., 2014).
Normally, the amygdala shows lower firing rates of neurons than other areas. With threat, this silence is broken. With increased neural activity, its connections with other threat networks are activated (Möhler, 2012). Thus, activation of the amygdala and its networks is associated with feeling anxious. The amygdala is also involved in the formation and storage of fear memories and fear conditioning.
One of the major neurotransmitters involved in anxiety is gamma-aminobutyric acid (GABA) (see Kalueff & Nutt, 2007; Millan, 2003; Möhler, 2012, for overviews). GABA is the major inhibitory neurotransmitter in the brain. Although GABA is involved in a variety of processes, it is thought to play a major role in anxiety. The basic idea is that individuals with anxiety have reduced GABA activity, which in turn results in less inhibition of the brain structures, such as the amygdala, that are involved in threat responses. That is, with reduced GABA activity, the amygdala becomes more active and the person experiences increased anxiety. It should also be noted that GABA receptors are densely located in the PFC, the amygdala, and the hippocampus.
One way to reduce anxiety is to use medications that contain benzodiazepines, for example, Valium. These are common drugs used in the treatment of anxiety disorders. One way benzodiazepines work is to influence the GABA system. Specifically, benzodiazepines reduce the amount of serotonin available to the brain. Animal models of anxiety have shown increased GABA activity in the amygdala and a reduction of fear with the introduction of serotonin in the hippocampus and amygdala. There are also developmental processes that influence GABA activity. An adult rat that was nurtured and licked as an infant will have greater expression of GABA activity in the amygdala with fewer signs of fearfulness and stress responses (Fries, Moragues, Caldji, Hellhammer, & Meaney, 2004).
In reviewing studies with both humans and other animals, Gross and Hen (2004) suggested that anxiety should be seen as a developmental problem involving both environmental and genetic factors. From twin studies, it is apparent that the genetic contribution to anxiety is moderate (30%—40%). Genetic studies of individuals with anxiety disorders show the highest concordance for monozygotic (MZ) versus dizygotic (DZ) twin pairs as would be expected if there were a genetic component. Family interviews also suggest the presence of GAD in first-degree relatives. Other anxiety disorders show higher genetic contribution. Panic disorder was associated with a heritability of 48% (Hettema, Neale, & Kendler, 2001). Similar heritability numbers were found for specific phobias, such as animal (47%), blood injury (59%), and situational (46%). Social phobia was found to be 51%. Overall, this strongly suggests genetic contributions to the development of certain anxiety disorders.
Generalized anxiety disorder (GAD) is characterized by excessive anxiety and worry. Its diagnosis in a clinical setting requires that anxiety and worry have been present for more than 6 months. GAD is one of the most commonly diagnosed mental disorders in the United States. It is more commonly seen in women than men. With GAD, there are both physiological and psychological symptoms. The physiological symptoms may include problems sleeping, muscle tension, and feeling fatigued. In fact, one of the more consistent physiological patterns seen in GAD is high muscle tension. The psychological symptoms may include feeling on edge, irritability, and difficulty in concentration as well as decision making (Bishop & Gagne, 2018).
Worry is an important component of GAD. In terms of frequency, those with GAD also report that they worry a larger percentage of each day and tend to have a larger set of domains such as family, money, and friends that they worry about than those without GAD. Those with GAD also reported that they worry about minor things (100%) versus those with other types of anxiety disorders (50%) (Barlow, 2002). Not only do individuals with GAD worry, but they also find it difficult to control their worry. Bodily symptoms such as feeling on edge and muscle tension also accompany the worry.
Social Anxiety Disorder (SAD)
Most of us can think of a time that we were concerned about meeting someone or giving a talk in front of a group. Perhaps I will say the wrong thing. Perhaps others will think I am foolish. Perhaps I will spill my food on my shirt when I am eating. These are all common reactions and are part of our human condition. However, when these feelings are severe and last for more than 6 months, it would be considered a social anxiety disorder (SAD). Previously, social anxiety disorder was referred to as social phobia.
Social anxiety disorder is characterized by marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Those with social anxiety are often concerned that they will humiliate or embarrass themselves. Approximately 8% of US citizens will experience a social anxiety disorder during their lifetime (Kessler et al., 2010). It is more common in women than men. The disorder is also associated with later mood disorders and substance abuse.
Theoretically, it has been suggested that individuals with social anxiety process their world differently from those without the disorder. Specifically, they process social situations with evolutionarily older alarm systems such as the amygdala, whereas non-anxious individuals process the same situations with newer cognitive—analytic processes using the prefrontal cortex (PFC). It has also been suggested that social anxiety can be seen as part of the larger dominance and submission system seen across other primate species (Öhman, 1986, 2009; Öhman & Mineka, 2001). This view is supported by research revealing that individuals with social anxiety show enhanced amygdala activation to images of hostile faces. Further, the degree of amygdala activity is positively correlated with the severity of social anxiety, but not with general anxiety (Phan, Fitzgerald, Nathan, & Tancer, 2006).
A panic disorder is an anxiety disorder that comes quickly and carries with it an intense feeling of apprehension, anxiety, or fear (see Craske et al., 2010; Fava & Morton, 2009, for overviews). It happens without an actual situation that would suggest danger. Physiological symptoms can include shortness of breath, trembling, heart palpitations, dizziness, faintness, and hot or cold flashes. The person can also experience the world as if it were not real and can be concerned about dying. The symptoms usually peak within the first 10 minutes of the attack. The experience of one’s heart pounding (97%) and dizziness (96%) are reported by almost all individuals who experience panic attacks.
A panic attack is a frequent cause of individuals going to a hospital emergency room. The person may think there are heart problems since the symptoms can include a pounding heart, chest pains, feeling dizzy, nausea, shaking, chills, fear of dying, and a number of other bodily sensations. There is some suggestion that panic is more common during periods of stress. Although many individuals experience an episode of panic-like symptoms at some point in their lives, it is necessary for these symptoms to be recurrent and followed by a month of concern or change in lifestyle to be diagnosed with a panic disorder.
Once individuals experience a panic attack, they often become concerned about having another attack. They may also try to change their behavior as a way to prevent panic attacks. For example, some individuals will not exercise or do other tasks that would raise their heart rates. Although presented as a separate anxiety disorder, panic attacks can occur within the context of any of the other anxiety disorders. It is often comorbid with the fear of being in public, referred to as agoraphobia. Lifetime prevalence rates are 4.7% for panic disorder (Kessler et al., 2006). The common age of onset for panic disorder is from 21 to 23 years of age, although children and adolescents may experience panic attacks along with other anxiety disorders. Studies have shown that twice as many women as men have panic disorder.
On a brain level, it is suggested that panic and anxiety involve different areas of the brain (Graeff & Del-Ben, 2008). Anxiety is integrated in the forebrain, whereas panic is organized in the midbrain, especially the basal ganglia and limbic structures. Decreased gray matter in individuals with panic disorder has also been reported in these areas (Lai, 2011). The idea of different areas for anxiety and panic is consistent with the suggestion that there are two defense systems in the brain (Gray & McNaughton, 2000; McNaughton & Corr, 2004). The basic model suggests that fear and anxiety are involved in different approach-and-avoidance systems that utilize distinct brain networks.
Agoraphobia is the condition in which a person experiences fear or anxiety when in public. These situations can involve public transportation, open spaces such as parking lots or marketplaces, or places with a large number of individuals such as theaters or shops, as well as being in a crowd or just being outside the home. One characteristic of agoraphobia is that the person is concerned that escape from the situation would be difficult. In some individuals, panic disorder and agoraphobia go together and in others they do not. Age of onset in both agoraphobia and panic disorder is about 21 to 23 years of age. Agoraphobia is seen more frequently in women than men. Some studies have shown that negative experiences in childhood, such as the death of a parent, are associated with both agoraphobia and panic disorder. With DSM—5, agoraphobia is considered a separate disorder, although it may occur with any other disorder, especially the anxiety disorders.
A specific phobia is an anxiety disorder in which an individual experiences fear or anxiety to a particular situation or object. Common phobias are fear of snakes, spiders, flying, heights, blood, injections, and the dark. Although almost all individuals have experiences such as driving in bad weather in which they feel concern from time to time, these fears tend not to be long-lasting or result in major changes in lifestyle. To be diagnosed with a specific phobia, the individual must actively avoid the condition or object, and the fear or anxiety must have lasted for 6 months or more. Further, the fear or anxiety causes distress and is out of proportion to the actual danger posed by the situation.
Obsessive-Compulsive and Related Disorders
Some individuals hoard their possessions even if they are of no value. Others are always thinking about their body and particular flaws they believe they have. Still others pick at their skin or pull their hair. Other individuals refuse to step on sidewalk cracks, often wash their hands to prevent germs, or experience unwelcome thoughts coming into their minds. In DSM-5, these conditions are referred to as obsessive-compulsive and related disorders.
Obsessive-Compulsive Disorder (OCD)
Have you ever been concerned about walking under a ladder or felt you needed to do a ritual before you played a sport? Do you have specific numbers you play in a lottery? Most of us have superstitions. However, when the thoughts and behaviors become extreme in producing distress and last for a period of time, they can be a part of obsessive-compulsive disorder. Obsessive-compulsive disorder (OCD) is characterized by repetitive thoughts and feelings usually followed by behaviors in response to them (Hirschtritt, Bloch, & Mathews, 2017). The thoughts are usually perceived as unpleasant and not wanted.
A distinction is made between obsessions and compulsions. Obsessions are generally unwelcome thoughts that come into our heads. Will I get sick from using a public toilet? I feel I want to hit that person. Did I put my campfire out? I am thinking of touching another person sexually. That picture frame is crooked. In studies examining these thoughts in patients with OCD, they involve a limited number of categories. The main categories are avoiding contamination, aggressive impulses, sexual content, somatic concerns, religious concerns, and the need for order.
Obsessions can also be defined in terms of how they are experienced by the person (Abramowitz & Jacoby, 2013). The two classes are autogenous obsessions and reactive obsessions. Autogenous obsessions are thoughts or images that come into a person’s mind. They are generally expressed as distressing and may appear without any stimulus in the environment. Some examples would include urges to perform unacceptable acts of an aggressive, sexual, or immoral nature. Reactive obsessions, on the other hand, are evoked by an actual environmental situation. These types of obsessions could result from seeing a dirty bathroom, having a stranger touch you, or seeing a crooked picture. This type of obsession may lead to an action such as making the crooked picture straight.
Compulsions are the behaviors that individuals use to respond to their distressing thoughts. Overall, these behaviors are performed in order to reduce anxiety, gain control, or resist unwanted thoughts. Some behaviors, like cleaning or placing objects in order, reflect a desire to respond to the obsessions. Other compulsions, such as hand washing, are more avoidant in nature for fear of what one might say, do, or experience in a particular situation.
Often individuals with OCD will constantly check to see if they performed a particular behavior such as turning off the stove or unplugging an iron. Interestingly, individuals with OCD may be aware that their thoughts and actions may seem bizarre to others, but they cannot dismiss the thoughts or the need to perform the action. For example, one person checked his window locks every 30 minutes even though each time he found them locked.
Traditionally, compulsions have been seen as a mechanism for reducing the anxiety or distress caused by the obsession. Not being allowed to engage in these behaviors results in distress and anxiety. More than 90% of those with OCD show both obsessions and behavioral rituals. OCD has an adulthood prevalence of 2% to 3% and a child and adolescence prevalence of 1% to 2%. Approximately 40% of those with childhood OCD report continuing symptoms into adulthood. There is not a gender difference in rates.
There is clearly a parallel between the themes found in OCD and concerns expressed by those without the disorder. Most individuals naturally avoid contamination or express concern when they experience unusual bodily sensations. On a societal level, there are often rituals concerned with health and success in the world. Tribal cultures would perform rituals to dispel evil spirits or bring in the good ones. Most modern societies have a variety of rituals including not walking under a ladder, not stepping on sidewalk cracks, or not partaking in other behaviors as ways of avoiding bad luck. Sports teams also have rituals for how to prepare for an important game. Not performing any of these rituals may result in a feeling of anxiety for many individuals.
1. What is anxiety? What is fear? In what ways are they similar? In what ways are they different?
2. What are the defining characteristics of the following anxiety disorders:
a. Generalized anxiety disorder (GAD)?
b. Social anxiety disorder (SAD)?
c. Panic disorder?
e. Specific phobia?
3. What evidence can you cite that anxiety disorders have a genetic component?
4. In obsessive-compulsive disorder (OCD), what are obsessions? What are compulsions? What are some examples of each?
Emotional experiences and moods are an important part of our world. Sometimes we feel happy; other times we feel sad. We have all experienced ourselves as having different moods. Our thoughts are often consistent with our moods as when we feel sad and think we are not doing things well. Likewise our behaviors match our moods. To want to stay in bed in the morning or not to want to be with others is often the outcome of feeling blue. Other times we go in the opposite direction and feel full of energy. Our thoughts when we are in a positive mood influence what activities we can engage in or what accomplishments we can achieve. Behaviorally, we tend to seek social interactions and start new projects.
Neither positive nor negative moods as most of us experience them interfere with our daily life or separate us from ourselves or others. However, the mood disorders discussed in this chapter do. Not only do these disorders separate us; they also last for a long time and, in some cases, are experienced throughout one’s life. The Russian writer Leo Tolstoy who wrote the novel War and Peace wrote, “The truth was that life is meaningless. I had as it were lived, lived, and walked, walked, till I had come to a precipice and saw clearly that there was nothing ahead of me but destruction” (Tolstoy, 1882, p. 402). Tolstoy experienced depression, which influenced his artistic life (Anargyros-Klinger, 2002).
Both depression and mania have been described for more than 2,000 years. The ancient Greek writers Hippocrates, Aretaeus, and Galen each described a condition they referred to as melancholia, which today we call depression. Melancholia was described in terms of despondency, dissatisfaction with life, problems sleeping, restlessness, irritability, difficulties in decision-making, and a desire to die. Mania, on the other hand, was described in terms of euphoria, excitement, cheerfulness, grandiosity, and at times anger. There was also a realization that mania and melancholia could exist in the same person.
Characteristics and Symptoms of Major Depressive Disorder (MDD)
When depression is severe, it is referred to as major depressive disorder (MDD). With major depressive disorder, a person feels sad and empty and may display an irritable mood. These feelings may include hopelessness and be experienced over a number of days. The person may seeing himself or herself as worthless in a world with little support. If asked to remember their past, unlike healthy individuals, individuals with depression tend to remember more negative than positive events (Dillon & Pizzagalli, 2018). Body experiences, such as difficulty sleeping and eating, are also common.
Those who experience depression describe both psychological and physical symptoms. They feel sad much of the time and may even be close to tears for no apparent reason. If you talk with these individuals, they will tell you that they feel worthless. Not only will you notice their negative affect, but you may also notice a lack of any positive affect. They may even say that they just do not feel like being involved in activities or being with others. They may also think of dying. In terms of physical symptoms, you might notice that the person has had weight changes. They will also describe problems with sleeping almost every night. They will report a loss of energy and feeling tired. This loss of energy may also be associated with an inability to concentrate. MDD is seen when the majority of these symptoms last for at least two weeks.
Depression has been related to a variety of physiological, psychological, economic, family, and social components. In 2018, the World Health Organization (WHO) has ranked depression as the leading cause of disability worldwide with women being affected by depression more than men (https://www.who.int/news-room/fact-sheets/detail/depression). It is also estimated to be one of the most economically costly mental disorders worldwide. MDD has been shown to take individuals out of their normal roles or jobs for a number of lost days equal to that due to medical disorders. In fact, MDD is second only to chronic back or neck pain in terms of disability days lost. Part of this is related to the fact that only one-third of those with depression seek help in the first year of onset. The median delay for seeking treatment among those who did not seek treatment in the first year was five years. Even with treatment, the chance of another episode of depression is high. Most patients experience a recurrence within five years (see Boland & Keller, 2009, for an overview). Historical figures such as President Abraham Lincoln have described their own experiences of mood disorders (Shenk, 2005). “I am now the most miserable man living,” Lincoln wrote when he was a state senator to his friend John T. Stuart in 1841. “If what I feel were equally distributed to the whole human family, there would not be one cheerful face on the earth.”
A number of performers have spoken of their personal struggles with depression. Brian Wilson of The Beach Boys said that he would go for long periods without being able to do anything. The actor and singer Ashley Judd describes herself as depressed and isolated. The singer Sheryl Crow has also documented her own experiences of depression and said there were periods she thought about suicide every day. For completeness, it should be noted that many performers and artists have consulted with mental health professionals and reflect this experience in their statements. However, some information presented on the Internet may be just the person saying, “That sounds like me, so I must have this or that disorder,” which may not be the case.
Today, major depressive disorder (MDD) is one of the most commonly diagnosed mental disorders among adults and is estimated to be found in about 13 million adult Americans during the preceding 12 months (see Kessler & Wang, 2009). There is a gender difference in that over the course of a lifetime, about one in four females and one in ten males experience a major depressive episode (Rutter, 2006; see also Ryba & Hopko, 2012). Genetic studies suggest that depression is equally influenced by environmental and genetic factors (Rutter, 2006).
There is a difference between factors related to initial episodes and later episodes of depression. Research suggests that the initial episode of depression has a strong environmental component, whereas later episodes are thought to be related to internal physiological changes (Kendler, Thornton, & Gardner, 2000). Thus, major life stress such as loss of a close relationship is highly associated with the development of depression. Individuals with depression are 2.5 to 10 times more likely to have experienced a recent major life event than nondepressive individuals (see Slavich, O’Donovan, Epel, & Kemeny, 2010, for an overview).
From a variety of studies, chronic severe depression has been shown to be familial (Otte et al., 2016 Peterson & Weissman, 2011). Offspring of individuals with MDD have a threefold to fivefold increased risk of developing MDD themselves. From longitudinal studies over three generations, individuals initially show elevated anxiety disorders before puberty, which then become MDD in mid to late adolescence. Further, familial MDD tends to have an earlier onset and to be more severe, more recurrent, and less responsive to treatment than is nonfamilial MDD.
Types and Characteristics of Bipolar Disorder
Bipolar disorder was previously referred to as manic-depressive disorder. Changes in mood are an important aspect of bipolar disorders. These include the intense sense of well-being along with high energy seen in mania and its opposite seen in depression. Changes in cognition and perception also accompany these states. In mania, thoughts seem to flow easily, and many individuals find themselves very productive during mania. Perceptions and sensations may also be heightened. However, mania can also increase a feeling of pressure with racing thoughts and ideas that do not make sense. Sometimes, this includes a feeling of “I can do anything” and the sense that nothing will not work out. Individuals in a manic state may buy expensive items they cannot afford, place large bets, and engage in all types of risky sexual behavior. It is as if there is nothing to worry about.
Terri Cheney, an attorney who has represented such performers as Michael Jackson and Quincy Jones, described her experiences of bipolar disorder in her book Manic (Cheney, 2008).
The mania came in four-day spurts. Four days of not eating, not sleeping, barely sitting in one place for more than a few minutes at a time. Four days of constant shopping…
And four days of indiscriminate, nonstop talking: first to everyone I knew on the West Coast, then to anyone still awake on the East Coast, then to Santa Fe itself, whoever would listen. The truth was, I didn’t just need to talk. I was afraid to be alone.
The depressive episodes show the opposite picture with the person experiencing a bleak outlook, low energy in a world of black-and-white, and a wish to do little. Kay Jamison received her PhD in clinical psychology from UCLA and is a professor of psychiatry at Johns Hopkins University. She has written significant books describing the scientific and clinical aspects of bipolar disorders (for example, Goodwin & Jamison, 2007) as well as her own experiences in An Unquiet Mind (Jamison, 1996). She describes the depressive aspect of bipolar disorder as follows:
Every day I awoke deeply tired, a feeling as foreign to my natural self as being bored or indifferent to life. Those were next. Then a gray, bleak preoccupation with death, dying, decaying, that everything was born but to die, best to die now and save the pain while waiting.
One characteristic experienced in both mania and depression by many individuals is a sense of irritability. Today we call these alternating periods of depression and mania bipolar disorder. This is in contrast to unipolar depression, which is the experience of depression without mania.
DSM—5 classifies bipolar disorder in terms of the manic and the depressive symptoms. Bipolar I disorder requires the presence of one or more manic episodes. Bipolar I does not require any depressive symptoms for the diagnosis. In fact, some individuals with bipolar disorder never report depression (see Johnson, Cuellar, & Miller, 2009, for an overview). However, the majority of individuals with bipolar disorder do experience depression during their lifetime. Bipolar II disorder, on the other hand, requires an episode of a major depressive disorder along with a hypomanic episode. A hypomanic episode is similar to mania but shorter in duration and less severe. Further, an individual with bipolar II disorder cannot have had a full manic episode.
Research over the past 40 years suggests a genetic predisposition for bipolar disorder (see Craddock & Sklar, 2009; Goodwin & Jamison, 2007; Harrison, Geddes, & Tunbridge, 2018). For bipolar disorders, heritability is about 5% to 10% for first-degree relatives and 40% to 70% for monozygotic (MZ) twins compared with only 14% for fraternal twins. That is to say, a first-degree relative of someone with bipolar disorder has approximately ten times the risk of having the disorder compared with a random person. This is much higher than first-degree relatives of a person with depression, which is about three times higher. Further, relatives of individuals with MDD do not appear to be at risk for mania, whereas relatives of those with bipolar disorder are at risk for depression.
The term suicide has been dated to 1642 in a work Religio Medici written by Sir Thomas Browne. It comes from the Latin meaning to kill oneself. Suicidal behaviors can be seen as existing on a continuum ranging from thinking about suicide to attempting suicide to an act that leads to death. However, some individuals think often about suicide—referred to as suicidal ideation—without actually attempting to harm themselves.
Suicidal ideation begins at about the time of puberty (Nock et al., 2013). Having a plan for committing suicide is associated with attempting suicide for the adolescent age group. Beginning at about puberty, suicide ideation begins to increase. Actual suicide plans and attempts increase somewhat, too, but with significantly less frequency than ideation.
Mental illness has a strong connection with suicide (see Goldsmith, 2001, for an overview). Of those suicide attempts that lead to death, it is estimated that 90% of adults and 67% of youth would meet diagnostic criteria for a mental disorder. The most common disorders associated with suicide are depression, bipolar disorder, substance use disorders, personality disorders, and schizophrenia, in that order. In bipolar and personality disorders, suicide is often associated with impulsiveness. With schizophrenia, it is more associated with active manifestation of the disorder. The rate of suicide among those with psychological disorders is highest in the three months following hospitalization (Chung et al., 2017).
To put suicide in perspective, more people die annually from suicide than from homicide and even war. In 2016, there were 793,000 people from around the world who died from suicide (https://www.who.int/gho/mental_health/suicide_rates/en/). This represents a one-year prevalence rate of approximately 11 people per 100,000. This makes suicide the 13th leading cause of death worldwide. It becomes the second leading cause of death among those 15 to 29 years of age. In all age groups, worldwide suicide rates increase with age (see Figure 14-2). This graph also shows that males commit suicide more often than females.
Figure 14-2 Suicide rates worldwide in terms of gender and age.
One theory related to suicide is the interpersonal-psychological theory of suicide (IPTS) (Joiner, 2005). This theory suggests there are two important components for an individual to engage in suicidal behaviors. The first is a suicidal desire to die. According to the theory, part of this is the sense that the person experiences herself as a burden to others and the feeling that she is isolated from others and not important to them. The second important component is the capability to act to commit suicide. This is also associated with a lowered fear of death. Studies based on this theory have shown that factors such as feeling to be a burden is associated with greater suicidal ideation as well as attempts.
As shown in Figure 14-3, there are cultural differences in the rate of suicide. Hungary has the highest national suicide rate in the world, followed by Finland and Austria. Their rates are 66, 43, and 42 per 100,000 compared with 11.3 in the United States. Countries with low rates of suicide such as Mexico tend to be predominantly Catholic or Muslim, have strong family ties, and have a younger population. There are also psychological differences related to suicide worldwide. In the United States and Europe, suicide is associated with depression and alcohol use disorder, whereas in Asia, impulsiveness plays an important role. There are also cultural differences in gender ratios. The rate is more similar in Asia but higher for males in Chile and Puerto Rico. Further, the suicide rate of Caucasians is approximately twice that observed in other races.
Figure 14-3 Map of suicide rates worldwide per 100,000 people for 2016.
In the United States, the suicide rate is about in the middle of all countries (Miller, Azrael, & Barber, 2012). According to the Centers for Disease Control and Prevention (CDC) the US rate increased from 29,199 deaths in 1996 to 47,173 in 2017 (https://www.cdc.gov/nchs/data/hestat/suicide/rates_1999_2017.htm). Among adults aged 18 or older in 2019, 4.8% (or 12 million people) thought seriously about trying to kill themselves in 2019. Further, 1.4% (or 3.5 million people) made a suicide plan (Substance Abuse and Mental Health Services Administration, 2020). In the United States, firearm-related suicide for those under 15 is some 11 times higher. A strong risk factor for attempting suicide is the presence of a mental illness or substance use disorder. During the COVID-19 pandemic in 2020, suicidal ideation increased along with mental health problems especially among younger adults (https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm).
Worldwide, religion plays a protective role in preventing suicide. However, in a recent meta-analysis, the protective aspect of religion was stronger in some cultures than others (Wu, Wang, & Jia, 2015). The authors of this meta-analysis suggest that culturally end of life is understood differently in countries of Africa and South America as compared to India and Vietnam. Overall, Eastern cultures have historically viewed suicide as an act of nobility and selflessness, whereas Western values have typically associated it with shame and cowardice. Religious practices in all cultures have a strong social support aspect that have been associated with less stress and depression.
Although females attempt suicide more often than males, males are three to four times more likely to die because the methods they use are more lethal (see Miller et al., 2012, for an overview). For example, men are more likely to use firearms or hanging as opposed to drug overdose. Among men, firearms account for about 62% of all suicide deaths in the United States.
In older adults, mental disorders are often comorbid with physical disorders. However, a physical disorder alone is not highly associated with suicide. In older adults, hopelessness along with depression was associated with suicidal ideation. Suicide attempts among the US military is highest in those units who had another person attempt suicide during the previous year (Ursano et al., 2017).
College Students and Suicide
Each year, hundreds of thousands of new students begin their undergraduate education at colleges around the United States. For most, their lifestyle changes in many ways. They often meet people who are different from those with whom they went to high school. Competition increases. Those who made perfect grades or were editors of their school newspapers discover that they are no longer unique. Most students find themselves working harder. Some believe that they are the only ones who feel stressed and are working constantly. For a number of these students, every setback is experienced as an extreme failure. Social comparisons leave them feeling inadequate. Some think of suicide.
In response to concern over suicide, many colleges and universities are setting up programs to help identify and treat those at risk. Collecting data from mental health centers at more than 140 colleges and universities around the US gives us a picture of who is seeking help. Data from more than 80,000 students who went to their local mental health center for all types of distress in 2018 shows that anxiety and depression are the two most common presenting problems. More than 30% of all students in this sample have considered suicide (see Figure 14-4).
Figure 14-4 Seriously considered attempting suicide from students who visit campus mental health centers (how many times).
Suicide-prevention programs seek to reduce the factors that increase the risk for suicidal thoughts and behaviors. These programs seek to work on at least four levels: the individual, the individual’s relationships, the community, and the society. Suicide prevention began in the United States in the 1950s and has continued through to the present day. Many communities have hotlines for people to call 24 hours a day. There has also been a national focus on groups that are at higher risk for suicide including Native Americans and members of the armed forces and veterans. Friends and relatives of individuals who show signs described in Table 14-3 should help them find a mental health professional or suicide-prevention center in their community. Interestingly, those who tried to commit suicide but did not succeed tend to feel relieved. This makes it possible for those individuals to receive help.
Table 14-3 The warning signs of suicide.
Talking about wanting to die
Looking for a way to kill oneself
Talking about feeling hopeless or having no purpose
Talking about feeling trapped or being in unbearable pain
Talking about being a burden to others
Increasing the use of alcohol or drugs
Acting anxious, agitated, or reckless
Sleeping too little or too much
Withdrawing or feeling isolated
Showing rage or talking about seeking revenge
Displaying extreme mood swings
Follow-up studies of suicide-prevention programs suggest they are effective. One such study examined youth prevention programs across 46 states and 12 tribal communities in the US (Garraza, Walrath, Goldston, Reid, & McKeon, 2015). These programs included education and mental health awareness, screening activities, gatekeeper training events, improved community partnerships and linkages to services, programs for suicide survivors, and crisis hotlines. Some 57,000 youth aged 16 to 23 years were involved in the suicide-prevention programs. These individuals were compared with some 84,000 youth who were not involved in these prevention programs. In the year following the program, there were 4.9 fewer suicide attempts per 1,000 youth in the treatment group compared to the control group. This suggests that thousands of suicide attempts can be averted by such prevention programs.
1. What is the impact of depression from a number of perspectives:
a. Worldwide prevalence?
b. Lifetime prevalence?
c. Gender prevalence?
d. Costs to economy, society, family, and individual?
e. Other psychological disorders?
2. Changes in mood are an important aspect of bipolar disorders. How would you describe these changes in each of the different types of bipolar disorder?
3. What evidence can you cite on whether there is a scientific basis for the association between creativity and bipolar disorder?
4. In what ways are different types of mental illness related to suicide?
5. How do the following factors influence the rate of suicide:
6. What are the four levels that suicide-prevention programs work on?
Most of us have had the experience of sitting in a lecture and realizing that we have not been listening for a period of time. Most of us also have had the experience of driving down a highway and all of a sudden realizing that 30 minutes has passed with no awareness of what we had been doing. Sometimes while watching a movie, people become so absorbed in the film that they forget they are in a theater. These are common experiences of dissociation, or spacing out, shared by most people. Overall, this is the situation in which there is a disruption in our normal ability to integrate information from our sensory and psychological processes such as memory and awareness.
The term dissociation (désaggregation in French) was introduced by Pierre Janet in 1889 to describe symptoms such as repetitive behaviors triggered by distressful memory, presentation of different incongruous personality characteristics (for example, shy, flirtatious) after a triggering event, and limb paralysis under hypnosis. Janet saw these as representing amnesic processes (memory loss from shock or trauma) where patients “forgot” the ability to receive external stimulation, their own personality, and the ability to move limbs. The common thread in these experiences according to Janet was a traumatic event. That is, a traumatic event or talk of a traumatic event preceded the dissociative experiences. For Janet, dissociation resulted from a weak ego that could not tolerate the overwhelming trauma. Freud, on the other hand, saw dissociation resulting from a strong ego that sought to wall off the experience of trauma as something separate and not part of the self.
Many researchers see dissociation as a normal experience to a difficult situation. In times of stress, it is a mechanism that protects the individual and allows her to survive (see Steinberg & Schnall, 2000, for an overview). In one study using a community sample of 1,055 individuals from Winnipeg, Canada, it was suggested that more than 25% of the individuals reported dissociative experiences, and some 5% showed symptoms consistent with a clinical diagnosis (Ross, Joshi, & Currie, 1990). Overall, Ross and colleagues concluded that dissociative experiences are common in the general population; do not differ in terms of socioeconomic status, gender, education, or religion of the respondent; and are reported less by older respondents.
In order to better understand dissociative experiences as seen in normal populations, Lukens and Ray (1995) interviewed college students who scored high on a common measure of dissociation. These young adults reported a variety of dissociative experiences. Three of these are presented here:
✵ One person reported that she would walk through town and the next moment she would “wake up” standing in line at a store’s cash register with unfamiliar store items in her hands. She also reported feeling embarrassed at having no explanation for her actions.
✵ Another individual reported, “While I was sitting in my room, I zoned out, and then as a third person or camera, I watched myself, my body, leave the room to visit a friend. I then returned to my room whereupon I snapped out of it. An hour had passed.”
✵ Another person said, “I have episodes where I see everything differently, everything starts blending… things look more fluid. I snap out of it on purpose because it is a disturbing experience. I can’t tell what is real and what is not.”
Other studies of college students suggest that slightly over 11% of those 31,905 students studied would qualify for a dissociative disorder (Kate, Hopwood, & Jamieson, 2020). Dissociative experiences can last for a few minutes or hours but reoccur. They can also last for a longer period of time. Some of these experiences are severe and represent significant disruptions in the organization of identity, memory, perception, or consciousness (see Maldonado & Spiegel, 2015; Spiegel et al., 2013, for overviews). More pathological symptoms of dissociation are often connected with trauma and experiences greatly beyond the individual’s control.
In one study of individuals who had been subject to torture, all of the individuals who had been tortured showed signs of post-traumatic stress disorder (PTSD) but varied in terms of their level of dissociation (Ray et al., 2006). This suggests that dissociation is a separate process from PTSD, which was discussed in the chapter on stress and health. Additionally, the number of dissociative experiences in these individuals directly and positively correlated with magnetoencephalography (MEG) activity in the left frontal cortex and negatively correlated with MEG activity in the right frontal cortex. This suggests that brain changes associated with not experiencing the overwhelming nature of torture become permanent and result in a disruption of networks involved in integrating emotional experience with the language features and executive control associated with the left hemisphere.
Pathological dissociative symptoms are generally experienced as involuntary disruption of the normal integration of consciousness, memory, identity, or perception. These can range from not having a sense of who one is or not remembering large parts of one’s past to having no memory of one’s personal history or to experiencing a lack of a developmental self. DSM—5 describes three major dissociative disorders. These are depersonalization—derealization disorder, dissociative amnesia, and dissociative identity disorder (DID).
Depersonalization is the perception of not experiencing the reality of one’s self. This experience can include feeling detached or observing one’s self as if you were an outside observer. Derealization, on the other hand, is the experience that the external world is not solid. One’s world is experienced with a sense of detachment or as if in a fog or a dream, or in other ways distorted or unreal. Immediately following an automobile accident, for example, many individuals report feeling as if the world and what is occurring is not real. Unlike psychotic experiences, reality testing is still available to individuals experiencing depersonalization-derealization disorder. It is estimated that at least 50% of all adults in the United States have experienced depersonalization—derealization symptoms sometime in their life (APA, 2013).
Depersonalization and derealization are seen as normal responses to many types of acute stress. However, when they cause distress or impairment in important areas of one’s life, they qualify as a DSM disorder. The lifetime prevalence for the disorder is approximately 2%, and there are no gender differences.
Let’s look at one case study (Simeon et al., 1997). This case study describes a 43-year-old woman who was living with her mother and working at a clerical job. She reports a trauma history of her mother fondling her and frequently giving her enemas until the time she was 10 years old. From the earliest times, this person reports having depersonalization experiences. She explains them this way: “It is as if the real me is taken out and put on a shelf or stored somewhere inside of me. Whatever makes me me is not there. It is like an opaque curtain… like going through the motions and having to exert discipline to keep the unit together.” Each year, she experiences several such depersonalization episodes.
The main diagnostic element of dissociative amnesia is an inability to recall important autobiographical information. Dissociative fugue, which was listed as a separate disorder in DSM-IV, now falls under the diagnosis of dissociative amnesia in DSM-5. Dissociative fugue is a sudden, unexpected travel away from one’s home or place of work with an inability to recall one’s past.
Memory loss in terms of dissociative amnesia appears to be of a particular first-person nature rather than a global memory disorder. In fact, interacting with these individuals would seem like nothing out of the ordinary until they are asked about personal history. At that point, they are unable to remember any of their historical experiences. However, our memory of events is different than our memory of how to do things, such as riding a bike. This type of memory referred to as procedural memory is not lost nor is the ability to create new long-term memories. Dissociative amnesia may last for a few days to years. Unlike the other dissociative disorders, dissociative amnesia occurs most often when someone is in his or her 30s or 40s. Twelve-month prevalence is estimated to be about 1.8% with a 2.6-to-1 female-to-male ratio (APA, 2013).
One case of dissociative amnesia reported in the media concerned Michael Boatwright. Michael Boatwright was taken to the emergency room of the Desert Regional Medical Center in Palm Springs, California. He had been found unconscious in his motel room. When he awoke in the hospital, he said his name was Johan Ek and he only spoke Swedish. He had with him five tennis rackets, two cell phones, a duffel bag filled with casual athletic clothes, some money, photos, and identification cards. Each of the cards—including a passport, a US Department of Veterans Affairs (VA) card, and a social security card—said he was Michael Boatwright. When asked by a translator about the identification cards, the man reported that he was Johan and did not know Michael. The hospital determined it would be unsafe to release this person without any memory who only spoke Swedish. He remained in a nursing facility for a few weeks to evaluate his condition. He had nightmares almost every night. During this time hospital personnel sought to determine his past through his ID cards. They discovered that he recently flew in from China where he had taught English and was a graphic designer for the previous four years. Before that, he had worked in Japan for ten years. The hospital staff also found that he did live in Sweden when he was younger. Through contacts in these countries, they were able to obtain some pictures of him with others. He reported that although he did not recognize the pictures, they gave him a sense of comfort and security. The hospital staff also sought to determine whether he showed any signs of faking, which he did not. He was diagnosed with dissociative amnesia (based on Pelham, 2013).
Dissociative Identity Disorder
Dissociative identity disorder (DID) has received considerable attention from the media and popular press with such films as the Three Faces of Eve released in 1957 and the book Sybil released in 1973. Previously referred to as multiple personality disorder, there is a large amount of misinformation concerning its existence. Most television and film depictions of DID are not true to life and there is evidence that the book Sybil was more storytelling than an accurate picture of a person with a dissociative disorder.
Current views suggest that DID is less the case of a person having multiple personalities than it is a developmental disorder where one consistent sense of self does not occur. That is, the person does not experience his or her thoughts, feelings, or actions in terms of a well-developed “I” or sense of self. Rather, the person experiences different “personalities” at different times. DID is seen as a complex disorder related to the experience of trauma occurring before the age of 5 or 6. This is the time at which a sense of self is in development.
Epidemiological studies suggest the prevalence of DID to be from 1% to 3% with slightly more males than females showing the disorder (see Vermetten, Schmahl, Lindner, Loewenstein, & Bremner, 2006, for an overview). Although the prevalence is similar in males and females, the manner of presentation is different (American Psychiatric Association, 2013). Females with DID are more likely to be seen in adult clinical settings. Males, on the other hand, tend to deny their symptoms and trauma history. However, the symptoms can be seen following children experiencing combat conditions or acts of physical or sexual assault. Cultural differences are also seen. In developing countries or rural communities, the fragmented identities can become part of religious or other experiences. For example, possessions by gods or spirits are described in a number of cultures.
In DSM-5, an important feature of dissociative identity disorder is the presence of two or more distinct personality states or an experience of possession. The experience or the expression of these distinct personality states can be influenced by a number of factors. These factors include the person’s psychological state such as his or her current experience of stress, ability to cope, internal conflicts, as well as cultural factors.
Disruptions in memory are also an important part of DID. These memory problems can appear in three different ways. First, the person may not remember significant parts of his or her life such as what occurred from 12 to 14 years of age or an event that would be considered significantly important to most people. Second, the person may not remember how to perform an act or well-learned skills such as driving or using a computer. And third, there may be discovery of the evidence of actions that the person does not remember doing. For example, individuals may find notes written in their handwriting that they do not remember writing or clothes in their closet they do not remember buying. These disruptions may occur without any significant psychologically stressful event taking place.
Schizophrenia is one of the most debilitating of the mental disorders. It affects one’s ability to express oneself clearly, to have close social relationships, and to express and experience positive emotions (see Andreasen, 2001 Walker, Kestler, Bollini, & Hochman, 2004 for reviews). Some individuals with schizophrenia also hear voices, see images not seen by others, or believe that others wish to harm or control them. It affects about 1% of the population. It is seen throughout the world with similar symptoms regardless of culture or geographical location. In general, the onset of schizophrenia occurs in the late teens or early twenties. It also more often affects males than females.
The course of schizophrenia generally first becomes evident in adolescence or young adulthood (see Tandon, Nasrallah, & Keshavan, 2009, for an overview). The course of the disorder is shown in Figure 14-5. The initial phase is referred to as the premorbid phase. During this phase, only subtle or nonspecific problems with cognition, motor, or social functioning can be detected. These are accompanied by poor academic achievement and social functioning. This is followed by a prodromal phase in which initial positive symptoms along with declining functioning can be seen. From prospective studies, this phase can last from a few months to years with the mean duration being about five years. The next phase is the psychotic phase, where the positive psychotic symptoms are apparent. For most individuals, this phase occurs between 15 and 45 years of age with the onset being about five years earlier in males than females. This phase is marked by repeated episodes of psychosis with remission in between. The greatest decline in functioning is generally seen during the first five years after the initial episode. This phase is followed by a stable phase characterized by fewer positive symptoms and an increase in negative ones. Stable cognitive and social deficits also characterize this phase. The actual course of the disorder varies greatly across individuals.
Figure 14-5 Phases in the development of schizophrenia.
Schizophrenia is part of a broad category of disorders referred to as schizophrenia spectrum and other psychotic disorders. Psychotic disorders involve a loss of being in touch with reality and are characterized by abnormal thinking and sensory processes. Individuals with a psychotic disorder may show delusions, hallucinations, disorganized thinking and speech, abnormal motor behaviors, and negative symptoms. People who do not have schizophrenia may show psychotic symptoms for a brief period of time or for a longer duration. They may also show delusions, affective problems outside the normal range, or simply seem odd to those around them. Psychotic symptoms not part of schizophrenia can be induced through drugs, lack of sleep, and other medical conditions. Also, it should be noted that although the term schizophrenia comes from the Greek meaning to split the mind, it is a very different disorder from dissociation disorders, such as dissociative identity disorder.
Individuals with schizophrenia can display problems in terms of cognitive processes, emotional processes, and motor processes. Cognitive problems can be seen as a disorganization of thinking and behavior. In listening to a person with schizophrenia, you may note a speech style that, although detailed, does not seem to have a coherent focus and does seem to constantly change themes. Technically, these are referred to as circumstantiality and tangentiality. In more severe cases, the speech is actually incoherent and contains a stream of words that are unrelated to one another, which is referred to as word salad.
Mood symptoms include impairments in affective experience and expression. Depression is a common experience with schizophrenia along with thoughts of suicide. A number of individuals with schizophrenia hear voices that tell them to kill themselves. Ken Steele wrote about his experiences with schizophrenia in his book The Day the Voices Stopped. Ken Steele’s voices told him “Hang yourself. The world will be better off. You’re no good, no good at all” (Steele & Berman, 2001). Motor symptoms can range from repetitive behaviors such as rocking to total stiffness or lack of change in posture referred to as catatonia.
Different individuals with schizophrenia may show very different symptoms. For example, some individuals may hear voices but never see a visual hallucination. Others show a still different presentation of symptoms. This has led some researchers to conclude that there exist a variety of similar disorders that are currently described by the term schizophrenia. This would suggest that schizophrenia is not a single disorder but a number of related disorders that are described by the name schizophrenia.
The symptoms of schizophrenia are not constantly present. There are examples of individuals with schizophrenia who are able to finish college and maintain jobs, even high-level jobs. Elyn R. Saks, who you will meet in the next chapter is a professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California’s law school. She describes her experiences with schizophrenia in a memoir, The Center Cannot Hold: My Journey Through Madness. Thus, individuals with schizophrenia may show periods in which they are able to function in terms of external realities. Symptoms for some people tend to appear in times of change or stress.
Positive and Negative Symptoms
Based on initial descriptions used by Hughlings Jackson in the 1800s, schizophrenia symptoms are referred to as positive or negative (Jackson, 1932). The more familiar positive symptoms are hallucinations, delusions, disorganized thinking, and disorganized behavior. The more familiar negative symptoms include lack of affect in situations that call for it, poor motivation, and social withdrawal. Jackson saw positive symptoms as reflecting a lack of high cortical control over more primitive brain processes. Negative symptoms, on the other hand, were the result of loss of function—what today we would refer to as a dysfunctional network of the brain. It should be noted that positive or negative are not evaluative terms when applied to symptoms of schizophrenia. Instead, they indicate either the presence of something unusual such as hearing voices or seeing hallucinations, which would be positive symptoms, or the lack of a normal human process, such as poor motivation or social withdrawal, which would be negative symptoms.
Hallucinations are sensory experiences that can involve any of the senses, although auditory hallucinations are the ones most commonly reported by individuals with schizophrenia. Ken Steele, while listening to music on the radio, heard it tell him to kill himself. Richard McLean in his book Recovered not Cured: A Journey through Schizophrenia reported that he picked up a phone to hear voices tell him that they were following his every move (McLean, 2003). These auditory hallucinations were experienced as coming from outside the person. Other individuals experience the voices or thoughts as coming from within their head. Individuals with schizophrenia report that they may hear voices throughout the day and on more than one day.
Delusions are beliefs without support for their occurrence and that are at odds with the individual’s current environment. One hospitalized patient believed that the Central Intelligence Agency (CIA) had cameras in the drawer pulls of her dresser. John Hinckley, who tried to kill President Ronald Reagan, believed that Jodie Foster, the actress, would be impressed by this event. Another patient believed that God spoke to her when the dogs outside her house barked.
The most common delusions can be organized into categories. The first is persecution. This is the belief that other people or groups such as the CIA are plotting against the individual. John Nash wrote letters to the US government describing attempts of others to take over the world. The second category is grandeur. This is the belief that one is really a very famous person. The individual with schizophrenia may tell everyone that he is Jesus or some other famous figure. The third delusion is control. For example, the delusion is that someone or some entity such as aliens can put thoughts into one’s mind. A related delusion is that others can hear or understand your thoughts without being told what they are. Finally, one common delusion is that one is special and that God or important individuals are speaking directly to the person.
Negative symptoms seen in schizophrenia tend to be more constant and stable than positive symptoms. Several studies have linked negative symptoms with a poorer prognosis (see Foussias & Remington, 2010, for a review). Whereas it is usually the positive symptoms that result in a diagnosis of schizophrenia, it is the negative symptoms that tend to persist over time. Many individuals with schizophrenia have little interest in doing simple day-to-day activities such as taking a bath or shopping for food. This lack of will or volition is technically referred to as avolition. Individuals with schizophrenia also show a lack of interest in talking with others or answering questions with more than a one-or two-word answer. This is referred to as alogia. They also show a flattening of affect or difficulty expressing emotion. Another symptom is referred to as anhedonia or the inability to experience pleasure. One interesting finding is that those with schizophrenia do not experience visual illusions in the same way as others. This is described in the box: Applying Psychological Science: Charlie Chaplin Illusion.
Applying Psychological Science: Charlie Chaplin Illusion
One surprising finding is that those with schizophrenia tend to respond to visual illusions differently than individuals without schizophrenia. This has included the Rubin vase and Schroeder stairs illusions (see Figure 14-6 and Figure 14-7). In one study, those with schizophrenia showed more reversals in the Rubin’s vase and saw the Schroeder stairs from underneath rather than from above (Keil, Elbert, Rockstroh, & Ray, 1998). Another example of differential brain processing in individuals with schizophrenia is the Charlie Chaplin illusion. If healthy individuals look at a mask of Charlie Chaplin as it rotates, they will see the reverse side of the mask not as hollow but as convex. That is, even though the mask from behind should appear to go in, those without schizophrenia see it pop out as you would with a normal face. A video of the rotating mask can be seen online (http://www.richardgregory.org/experiments/). As you can see in the video, as the mask turns, an individual initially sees the hollow mask, but this changes into a normal face. Individuals with schizophrenia do not see the illusion and view the reverse side of the mask as hollow.
Figure 14-6 Rubin vase.
Figure 14-7 Schroeder stairs.
The Charlie Chaplin illusion has been studied with fMRI (Dima et al., 2009). What these researchers found was that individuals with schizophrenia and those without schizophrenia showed different types of connectivity in the brain. Specifically, individuals without schizophrenia showed more top-down processing when perceiving the illusion. This suggests that part of the illusion is the sensory expectation of how a face should appear. Thus, in individuals without schizophrenia, the brain creates the face as it should appear and not hollow as it actually is. Individuals with schizophrenia, on the other hand, show weakened top-down processes and stronger bottom-up processes. As a result, they see the sensory stimuli as they are without expectation. Overall, this is consistent with other research that suggests that individuals with schizophrenia lack the top-down expectations necessary to predict future events (for example, Allen et al., 2008).
Thought Question: After reading this feature, how do you respond to the statement that the individual with a psychological disorder sees the “real” visual stimulus, whereas the “normal” individual sees “something that is not really there” based on expectations?
Factors in the Development of Schizophrenia
Schizophrenia typically is first noted during the transition from late adolescence to adulthood. However, theories related to its development generally see its onset at this time as the manifestation of a process that may have begun before the individual was born (see Uhlhaas, 2011, for an overview). In a review of birth cohort studies in which individuals are followed from birth, there is evidence to suggest that children who later develop schizophrenia show different profiles from those who do not (Welham, Isohanni, Jones, & McGrath, 2009). These data from seven different countries show subtle deficits in terms of behavioral disturbances, intellectual and language deficits, and early motor delays.
The current research literature suggests that schizophrenia is a disorder that begins early in life. This has led some researchers to suggest that we consider schizophrenia as a neurodevelopmental disorder (Insel, 2010). A variety of negative events can happen to a fetus, including infections and malnutrition. It has been shown, for example, that vitamin D deficiency during pregnancy can be seen as a risk for developing schizophrenia (see McGrath, Burne, Féron, Mackay-Sim, & Eyles, 2010, for a review). Likewise, maternal infection is now regarded as a potential risk factor for schizophrenia (see Brown & Patterson, 2011, for an overview).
Overall, the theory that the development of schizophrenia involves events experienced during pregnancy is referred to as the neurodevelopmental hypothesis. The basic idea is that during the time the fetus is in utero an insult happens that influences the changes to the brain that later take place during adolescence.
We know that adolescence is a time of great reorganization of cortical networks. What can be described about the reorganization of brain processes during adolescence in relation to schizophrenia? Gogtay, Vyas, Testa, Wood, and Pantelis (2011) reviewed two longitudinal studies with this question in mind. The first data set is composed of individuals who developed schizophrenia before puberty and has been studied at the National Institute of Mental Health (NIMH). The second data set is from Melbourne, Australia, and includes adolescents who are ultra-high risk for schizophrenia. Imaging studies showed larger ventricles and greater gray matter loss in the parietal and frontal areas in children who developed schizophrenia before puberty as compared with those who developed schizophrenia in adulthood. The data set from Australia showed that those adolescents who developed schizophrenia showed greater gray matter loss especially in the prefrontal cortex (PFC) as compared with those who did not develop the disorder.
Environmental factors can also play a role in the development of schizophrenia (see van Os, Kenis, & Rutten, 2010, for an overview). The basic idea is that environmental factors can influence the developing social brain and lead to the development of schizophrenia in those at risk. Such factors as early life adversity, growing up in an urban environment, and cannabis use have been associated with the development of schizophrenia. Being part of an ethnic group is not associated with schizophrenia per se if the ethnic group lives together, but if one is a minority in a larger ethnic group, then there is an association. Also, if one moves from an urban environment to a rural one, then the chance of having schizophrenia goes down. Overall, greater amounts of stress are associated with greater chances of developing schizophrenia. However, environmental factors continue to reflect an interaction with genetic influences and are not a sole condition in themselves for developing schizophrenia (Sariaslan et al., 2016).
Genetic Factors in Schizophrenia
Since schizophrenia tends to run in families and is seen throughout the world, it is assumed to have a genetic component. As can be seen in Figure 14-8, schizophrenia has a strong genetic component. The more similar the genes between two individuals, one of whom has schizophrenia, the more likely the other person will also develop its characteristics. That is, if you are an identical twin (MZ) and your twin has schizophrenia, you have a 48% chance of experiencing schizophrenia. If you are a fraternal twin, the risk drops to 18%. If one of your first-degree relatives, such as a parent or sibling, had schizophrenia, you would have a 9% risk. The risk would be even lower (4%) if you had a grandparent or aunt or uncle with schizophrenia. However, the genetic underpinnings of schizophrenia are not simple. It is clearly not the result of a single gene as with some other neurological disorders such as Huntington’s disease.
Figure 14-8 Risk for schizophrenia increases with genetic relatedness.
Source: Gottesman (1991).
Research suggests that the number of genetic variants seen in individuals with schizophrenia is very large. There may be 1,000 different genes contributing to the disorder, which also include rare genetic variants (Cannon, 2015; Keller, 2018; Walker, Shapiro, Esterberg, & Trotman, 2010; Wray & Visscher, 2010). These genes may act in an additive or interactive manner to produce the disorder. That is to say, there may be a variety of genetic combinations that are associated with schizophrenia. For example, heritable traits such as white matter connections and the thickness of gray matter in the brain are reduced in individuals with schizophrenia. Those with schizophrenia show both fewer connections that link different parts of the brain and a reduction of dendrite connections at the level of the neuron. Adolescence and early adulthood bring extensive elimination of synapses in regions of the cerebral cortex, such as the prefrontal cortex. An impairment of this process takes place in those with schizophrenia.
Brain Changes Seen in Schizophrenia
Exactly when brain changes take place in those with schizophrenia is an important question. In order to better understand the role of timing in terms of brain structure, John Gilmore and his colleagues (2010) performed imaging studies before and after birth. These researchers used ultrasound scans prior to birth and magnetic resonance imaging (MRI) scans after birth while the babies slept. They compared children whose mothers had schizophrenia with a matched control group whose mothers did not have the disorder. Using ultrasound prior to birth, they found no differences between the two groups. After birth, males whose mothers had schizophrenia showed more gray matter in the brain, increased cerebrospinal fluid, and larger ventricles. Female infants did not show any differences. This suggests that at least the genetic setup for schizophrenia in males can be seen early in life.
Neuroimaging studies of those with schizophrenia have included both structural and functional approaches (see Giraldo-Chica, Rogers, Damon, Landman, &Woodward, 2018; Karlsgodt et al., 2010; Shenton & Turetsky, 2011, for overviews). Structural approaches have focused on gray matter and white matter differences as well as the size of the ventricles (Cannon, 2015; Thompson et al., 2001). In a variety of reviews, both general and specific reductions in gray matter have been reported for individuals with schizophrenia. Specifically, reductions have been in the temporal cortex, especially the hippocampus, the frontal lobe, and the parietal lobe. Additionally, the striatum part of the basal ganglia has been shown to be reduced (Shenton et al., 2001). Gray matter reductions have also been seen in cases when one identical twin has schizophrenia and the other does not.
What might be at the heart of this gray matter reduction? One possibility is that the neurons actually die. However, a number of studies suggest this is not the case. What has been found is that the neurons in the brains of individuals with schizophrenia are more densely packed. This suggests that the substance found between neurons, neuropil, was reduced, resulting in a greater density of neurons. Further, gray matter abnormalities have been shown to be partly hereditary and also related to trauma during pregnancy (see Karlsgodt et al., 2010, for an overview). Those individuals with schizophrenia show a reduction of gray matter over a five-year period (Thompson et al., 2001). Figure 14-9 shows the differences in gray matter between individuals with schizophrenia and normal controls.
Figure 14-9 Annual loss of gray matter in those with schizophrenia.
White matter changes have also been observed in individuals with schizophrenia. One study compared 114 individuals with schizophrenia with 138 matched controls in terms of white matter (White et al., 2011). Using a brain-imaging technique—diffusion tensor imaging (DTI)—sensitive to white matter, individuals with chronic schizophrenia, individuals with first episode schizophrenia, and matched controls were compared. Measures of white matter were lower for individuals with chronic schizophrenia in the four lobes of the brain but not in the cerebellum or brain stem. Individuals experiencing their first episode of schizophrenia did not show significant differences from controls, which suggests that white matter reduction is part of the progression of the disorder over time.
There are four ventricles in the brain (see Figure 14-10). These ventricles contain cerebrospinal fluid. From a number of studies, it has been shown that individuals with schizophrenia have larger ventricles (see Vita, de Peri, Silenzi, & Dieci, 2006, for a meta-analysis). Since the walls of the ventricles are not rigid, it is assumed that larger ventricles result from a decrease in volume in other areas of the brain. Some of the other areas that have been shown to be smaller in individuals with schizophrenia are the frontotemporal cortices, the anterior cingulate cortex (ACC), and the right insular cortex. One question is whether this reduction could be related to the medications that individuals with schizophrenia take. To answer this question, one study examined individuals with first episode schizophrenia and compared their brain structure with that of matched healthy controls (Rais et al., 2012). These researchers found brain volume loss in the individuals with schizophrenia. This suggests that the brain volume loss is present when symptoms begin. They found reduced volume in the temporal and insular cortex. Brain-imaging studies have shown a larger ventricle in an MZ twin who had schizophrenia and a smaller one in the twin who did not.
Figure 14-10 Location of ventricles in the brain.
In summary, gray matter and white matter changes along with differences in ventricles have been found in schizophrenia in a large number of studies. In addition to these changes in the brains of individuals with schizophrenia, researchers have sought to study cortical networks in schizophrenia.
Myths and Misconceptions: Those Who Have Hallucinations Have Serious Mental Disorders
If someone were to tell you that he hears voices or sees people you do not see, you might think that he had a serious mental disorder such as psychosis or schizophrenia. While that may be true, it is also the case that just hearing voices or having visual hallucinations is not always the result of a serious mental disorder. In fact, visual hallucinations can be produced by the medication that some people with Parkinson’s disease take. Further, people who have lost some of their vision may have visual hallucinations. This is a condition referred to as Charles Bonnet syndrome. Overall, those who take Parkinson’s medication or have Charles Bonnet syndrome know that what they are seeing is not actual reality.
What about hearing voices? It is now increasingly recognized that many individuals in the general population hear voices in the absence of distress or psychiatric disorder (Hill & Lindon, 2013). One survey found that 10% to 15% of the people in the United States reported either visual or auditory hallucinations (Tien, 1991). Of all the people who hear voices, only a small percentage seek help and would be diagnosed with a serious mental disorder.
Albert Powers and his colleagues at Yale University sought to study those who claim to hear voices but would not be diagnosed with a psychological disorder (Powers, Kelley, & Corlett, 2017). To do this, they studied self-identified psychics. They compared the psychics with three other groups of individuals. These were (1) people with a serious mental disorder who hear voices; (2) people without a serious mental disorder who hear voices (psychics); (3) those with a serious mental disorder who do not hear voices; and (4) those without a serious mental disorder and do not hear voices. These individuals were given a number of questionnaires designed to measure psychological symptoms, delusions, and agreement with religious beliefs. In terms of hearing voices, these researchers found the hallucinatory experiences of psychic voice-hearers to be very similar to those of patients who were diagnosed with a mental disorder. Further, they found that this sample of non-help-seeking voice hearers were able to control the onset and offset of their voices and that they were less distressed by their voice-hearing experiences. Those with a serious mental disorder had much more negative voice-hearing experiences.
How should we understand hallucinations in those without a serious mental disorder? The first conclusion is that hallucinations use similar brain networks as those involved in vision and hearing. Thus, hallucinations are not totally different from normal vision and hearing and use the same circuits. The second conclusion is that hallucinations in non-clinical populations tend to be more positive and more under the control of the individual. And third, hallucinations in non-clinical populations may offer a way to understand the components that underlie more serious disorders (Baumeister, Sedgwick, Howes, & Peters, 2017). Although visual and auditory hallucinations can be a part of serious mental disorders, they can also exist in other situations. Oliver Sacks describes one of these individuals in a TED Talk (https://www.ted.com/talks/oliver_sacks_what_hallucination_reveals_about_our_minds).
Thought Question: Clearly, we can no longer say that just because a person has visual or auditory hallucinations, he or she has a mental disorder. What does processing the world “normally” mean? What might be the value of processing the world “differently”?
1. In what ways are dissociative disorders similar to the types of dissociative experiences common to most people? In what ways are they different?
2. What are the defining characteristics of the following dissociative disorders:
b. Dissociative amnesia?
c. Dissociative identity disorder (DID)?
3. How are the four stages of the course of schizophrenia defined, and when do they typically occur? Is the course the same for each individual? If not, how does it differ?
4. The symptoms of schizophrenia are characterized as positive symptoms and negative symptoms.
a. What is the definition of each symptom type?
b. What are primary examples of each type?
c. What role does each type play in the course of schizophrenia?
5. Schizophrenia typically is first noted during the transition from late adolescence to adulthood, but current research suggests that the disorder begins early in life. What evidence points to this characterization?
6. What evidence can you cite that schizophrenia has a genetic component?
7. What structural brain changes in white matter and gray matter are characteristic of those with schizophrenia?
Personality Disorders and Personality
Am I completely selfish? Is that what all this is about? I must be because the one thing that scares me more than living, more than death, is surviving another suicide attempt. Then I would have to face up to my actions. Then I would have to try and mend the relationships that my selfishness has destroyed. So why do it? Why do I have such strong suicidal urges? Why have I had these urges all these years? Why does it seem to bear no relation to what is actually going on in my life? Why won’t the God damn shrinks tell me that one? Have I got too much of the suicidal gene in my DNA? Are there too many suicidal chemicals in my brain? Can’t they give me a pill that deals with that? They can’t can they? They send me to therapy with three different people and not one of them has been able to touch on just why. Why a kid from the country village of Wymondley grew up from catching newts and making camps to slashing his wrists and taking overdoses. Surely there is something in between those two events that has made me this way?… But no one can help me and I have always been meant to kill myself, so that’s what will have to happen. It is my unwritten destiny. It gets to the point where I feel that I really have to do it. It is not even a choice anymore. I must obey.
You might ask how I can do it to my family. How I can do this to the girl I love. Well, the guilt I feel about my plans to die is just as strong as my urge to carry them out. It is as if someone else, the other me, made those plans for me. When Ashley comes home from work I usually put that other me aside and I am there for her, but sometimes he stays like a great dark cloud smothering my thoughts. Living for the sake of someone else is not easy. I wish that I wanted to live for myself, but I probably never will.
(From Westwood, 2007, p. 5)
As you read the self-report from Stephen Westwood above, you probably had a number of reactions. You might have thought of others you know who react in similar ways. You might have thought about how you would react and what upsets you. You might have wondered why some people seem to be so dramatic in everything they do. Some people will tell you that they cut themselves or burn themselves when they experience psychological pain. Steven Westwood tells you that all he thinks about is suicide. However, he also tells you that he can have a relationship with a girlfriend. People who have these types of relationships with themselves and others are described in terms of personality disorders.
What Is a Personality Disorder?
The basic definition of a personality disorder is that it represents an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture (APA, 2013, p. 645). Further, the pattern is inflexible, stable, and generally begins in adolescence, and leads to distress or impairment. The characteristics of these disorders are especially apparent when these individuals find themselves in situations that are beyond their ability to cope. DSM-5 identifies ten personality disorders that form separate categories. These ten disorders can be organized into three clusters, which are presented in Table 14-4.
Table 14-4 Three clusters of personality disorder.
Odd or eccentric disorders
Pervasive distrust and suspiciousness of others; sees others as having malevolent intentions
Detachment from social relationships and restriction of the expression of emotions in interpersonal settings.
Discomfort with close relationships; Cognitive and perceptual distortions and eccentricities of behavior
Dramatic, emotional, or erratic disorders
Disregard for and violation of the rights of others
Instability of interpersonal relationships and impulsivity
Excessive emotionality and attention seeking
Grandiosity, need for admiration, and lack of empathy
Anxious or fearful disorders
Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation
Need to be taken care of, clinging behaviors, and fear of separation
Preoccupation with orderliness, perfectionism, and control at the expense of flexibility, openness, and efficiency
Note: Prevalence based on APA (2013) and Lenzenweger et al. (2007).
The first cluster is referred to as Cluster A and includes odd or eccentric disorders. These include schizoid personality disorder, paranoid personality disorder, and schizotypal personality disorder. Individuals with these disorders typically feel uncomfortable or suspicious of others or restrict their relationships. Schizoid personality disorder is characterized by a pervasive pattern of detachment from social relationships and a restricted range of emotional expression. Paranoid personality disorder is characterized by a pervasive distrust and suspiciousness of others. Schizotypal personality disorder is characterized by odd beliefs and behaviors.
The second cluster is referred to as Cluster B and includes dramatic, emotional, or erratic disorders. These include antisocial personality disorder, borderline personality disorder (BPD), histrionic personality disorder, and narcissistic personality disorder. Individuals with these disorders show a wide diversity of patterns of social and emotional interactions with others. Antisocial personality disorder is characterized by a disregard for the other person. BPD is characterized by instability in relationships. Histrionic personality disorder is characterized by excessive emotional responding and the seeking of attention. Narcissistic personality disorder is characterized by grandiosity in terms of one’s abilities and a lack of empathy.
The third cluster is referred to as Cluster C and includes anxious or fearful disorders. These include avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. Avoidant personality disorder is characterized by a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Dependent personality disorder is characterized by an excessive need to be taken care of, including clinging behavior. Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness, perfectionism, and interpersonal control.
In a number of community samples, personality disorders are found in 9% to 13% of the population (see Lawton, Shields, & Oltmanns, 2011; Lenzenweger, 2008; Tyrer, Reed, & Crawford, 2015 for overviews). This suggests that one in ten people suffers from a personality disorder. Overall, similar numbers of males and females are seen in each personality disorder. The only exception is antisocial personality disorder, which is seen more frequently in men.
In terms of the three clusters, Cluster A shows a prevalence of 5.7%, Cluster B shows a prevalence of 1.5%, and Cluster C shows a prevalence of 6% in a community sample (Lenzenweger, Lane, Loranger, & Kessler, 2007), although prevalence rates vary by a few percent in different studies. Estimates from World Health Organization (WHO) surveys of 13 countries suggest a worldwide prevalence of about 6.1% for having any one personality disorder and 3.6% for Cluster A, 1.5% for Cluster B, and 2.7% for Cluster C (Huang et al., 2009).
Personality Disorders and Typical Personality Traits
Not only do the ten separate personality disorders show considerable overlap with other mental disorders, they also show considerable overlap with traits found in typical personality patterns (see Bagby & Widiger, 2018; Costa & Widiger, 2002; Krueger & Markon, 2014; Samuel & Widiger, 2008; South, Oltmanns, & Krueger, 2011, for overviews). In one study, measures of typical personality functioning and pathological personality functioning showed a shared dimensional structure (Samuel, Simms, Clark, Livesley, & Widiger, 2010). That is to say, personality characteristics reflected in personality disorders can be seen as an extreme version of typical personality characteristics.
Initially, the studies concerning typical personality factors and personality disorders were conducted separately. In the development of DSM, scales were conducted and analyzed in terms of the symptoms of personality disorder. These separate studies have found a five-factor structure of personality disorder characteristics (see DeYoung, Carey, Krueger, & Ross, 2016 for an overview). These five factors emphasize the opposite poles of typical personality dimensions. These factors have been labeled detachment, negative affectivity, antagonism, disinhibition, and psychoticism. Detachment, for example, can be seen as the extreme and opposite version of extraversion.
Thus, there can be both healthy and maladaptive personality styles. An individual can be extraverted in a healthy manner by seeking relationships with others and developing warm and meaningful relationships. He can also enjoy large parties and feel fulfilled by meeting new people. This could also occur in a maladaptive manner in which the individual has a need to always be with others and to value himself only when in a relationship. An individual can also be introverted in a healthy way by valuing his inner experiences such as writing poetry or enjoying walks alone or with a friend. One could also be introverted in a maladaptive manner by avoiding or distrusting others and living a life without meaningful contact with others and one’s self.
Antisocial Personality Disorder
The diagnostic criteria in DSM—5 for antisocial personality disorder describe a person who shows a pattern of disregard for the rights of others. A person with this disorder must be 18 years old, and the personality style should have been present since 15 years of age. Before age 15, the person should meet criteria for a conduct disorder. Child conduct disorder includes aggression toward animals or people, destruction of property, deception or stealing, and serious rule violations. Three specific characteristics should also currently be present for a diagnosis of antisocial personality disorder. These characteristics include (1) a failure to observe social norms that can result in legal arrest, (2) a deceitfulness including lying to and using others, (3) a failure to plan ahead, (4) an irritability and aggressiveness that lead to physical fights, (5) a reckless disregard for the safety of others, (6) an irresponsibility, such as a failure to pay debts or perform duties at work, and (7) a lack of remorse when another person is hurt.
The prevalence rate for antisocial personality disorder is about 3%, with more males than females having the disorder. Those with antisocial disorder also show a high comorbidity (80%) with the use of drugs (see Patrick, 2007, for an overview). However, the opposite is not the case. That is, those who use drugs do not necessarily have an antisocial personality disorder. The prevalence of antisocial personality disorder also tends to be higher in correctional and forensic settings. In prisons, the base rates have been recorded between 50% and 80% of the population (Hare, 2003). Often those who are mandated by the courts for treatment of sexual offences would qualify for an antisocial personality disorder.
Borderline Personality Disorder (BPD)
Borderline personality disorder (BPD) is characterized by an instability in mood, interpersonal relationships, and a sense of self (see Bradley, Conklin, & Westen, 2007, for an overview). These three factors interact with one another in such a manner that the person with BPD experiences a changing world without a solid sense of self. At one point, the person may feel rejected and abandoned due to a misinterpretation of an event and lash out in anger. At other times, they may see another person as perfect and form an intense relationship only to have that go to its opposite without warning. The movie Fatal Attraction released in 1987 and the 2015—2019 TV series Crazy Ex-Girlfriend show this type of intense relationship seen in people with BPD.
In her book Borderline Traits, Arlene Roberson describes the experiences of a person with BPD: “I go from feeling panicked and angry to feeling depressed and hurt to feeling anxious” (Roberson, 2010). It continues: “I have to react to this pain by lashing out at everything and everyone around me.” This lashing out includes not only angry outbursts at others but also self-mutilating behaviors and suicide attempts. It is estimated that 75% of those with BPD engage in self-injurious behavior. Two common behaviors are to cut or burn themselves. Some say that the external pain from burning or cutting gives them an experience that they are alive compared with feeling that they do not exist. For those with BPD, feelings of emptiness and boredom are common as well as feelings of being special or having exceptional talents. Table 14-5 shows some of the common functions of self-injurious behavior as reported by female inpatients.
Table 14-5 Functions of self-injurious behavior.
Source: Shearer, Peters, Quaytman, and Wadman (1988).
Self-harm is closely related to attempts to regulate one’s emotions. One review of the literature suggests three aspects of this relationship (Klonsky, 2007). The first aspect is that acute negative affect precedes self-injury. The second aspect is that after self-injury, individuals report relief. The third aspect is that individuals engage in self-injury as a means to reduce their experience of negative affect. Although many studies involve self-report, similar findings were seen in research studies performed in the lab.
Although self-harm is different from suicide, successful suicide is estimated to be about 9% in clinical samples with BPD. Also, suicide threats or gestures are estimated to occur in 90% of clinical samples with BPD (Gunderson & Ridolfi, 2001). Their view of self and others is sometimes described in terms of splitting or having things be all good or all bad without the nuance most individuals experience in their relationships. Thus, people with BPD have a sense of self that is fluid and can change quickly.
The conceptualization of BPD has been greatly influenced by the work of Kernberg (1984, 1995), who viewed these individuals as using immature ways of dealing with impulses and emotions. Historically, the term borderline, as the name implies, denoted individuals who were neither neurotic nor psychotic. Although not out of touch with reality, when under stress, these individuals can become disorganized in their view of self and others. On the other hand, their experiences go beyond those seen in anxiety or depression where the tendency is to withdraw when experiencing psychological distress.
One term that has been used to describe individuals with BPD is fearful preoccupation (Levy, 2005). This reflects an intense need for attention and closeness on the one hand and a deep fear of rejection and abandonment on the other. Thus, these individuals want to be close but become fearful and then angry when they experience closeness. Anger is also seen whenever individuals perceive they are being rejected.
Although genetic factors may play a role in terms of the trait of impulsivity, environmental factors play an important role. About 70% of these individuals report some type of physical, emotional, or sexual abuse. Overall, there is evidence to suggest that the development of BPD is related to heightened risk from chaotic family life, increased stress experienced by the parents, and disruptive communications between the caregiver and the child.
The disorder is also related to attachment (see Levy, 2005, for an overview). In general, individuals with BPD show an insecure pattern of attachment. Only some 6% to 8% show secure attachment patterns. Studies that used dimensional measures of BPD show an inverse relationship between secure attachment and BPD. Further, studies that have looked at early loss or separation in children found that it occurred in 37% to 64% of individuals with BPD.
The diagnostic criteria in DSM—5 for BPD describe a person who shows a pattern of instability and impulsivity in social relationships and his or her self-image. This personality style should begin in early adulthood. Five specific characteristics should also be present. These characteristics include (1) a frantic effort to avoid abandonment, whether real or imagined; (2) a pattern of unstable and intense interpersonal relationships characterized by alternating idealization and devaluation; (3) an unstable self-image and sense of self; (4) impulsivity in areas that can be damaging such as sexual relations, substance abuse, reckless driving, and binge eating; (5) recurrent suicidal behaviors or self-mutilating behaviors; (6) emotional instability lasting only a few hours; (7) chronic feelings of emptiness; (8) inappropriate anger and ability to control anger; and (9) short-term stress-related dissociative experiences or paranoid ideation. The current DSM—5 criteria for BPD can be met in a variety of ways. Given the nine criteria, there are at least 150 different ways that a person can receive the diagnosis based on various combinations of the criteria. This suggests that the instability of the self and its functioning can be manifested in a number of ways.
One way the instability manifests for society is that individuals with BPD are high consumers of emergency room services, crisis lines, and referrals from health professionals to mental health services (see Bradley et al., 2007). It is estimated that individuals with BPD represent 20% of inpatients and 10% of outpatients in mental health clinics. Prevalence rates in community samples are about 1.6%, as found in the National Comorbidity Survey Replication (Lenzenweger et al., 2007).
1. What is the basic definition of a personality disorder?
2. DSM-5 has organized personality disorders into three clusters—A, B, and C. What are the defining characteristics that run through the personality disorders in each cluster? What is an example of a disorder in each cluster?
3. What is the relationship between the five-factor model of personality you read about in the chapter on personality and what you have read in this chapter on personality disorders?
4. What are the three defining characteristics of borderline personality disorder (BPD)?
5. What role do self-mutilating behaviors and suicide attempts play in individuals with BPD?
6. What environmental factors play a role in the development of BPD?
Neurodevelopmental disorders are those disorders that begin early in a child’s life. These can include problems in the development of language, as well as cognitive, emotional, and motor problems. Two of these disorders are autism spectrum disorder and attention deficit hyperactivity disorder (ADHD).
Autism Spectrum Disorder (ASD)
Autism was initially described by Leo Kanner (1943) as an innate disorder in which children do not show normal development in emotional contact with others. Autism spectrum disorder (ASD) has achieved a significant place in clinical and research programs. Individuals with autism spectrum disorder (ASD) have difficulty in three separate areas. The first is social interactions. Children with autism do not connect with other children or adults in the manner that other children do. They do not look others in the eye or may appear to ignore others while being more interested in other aspects of their environment. The second area is communication. The communication patterns of those with autism spectrum disorder do not usually show the give-and-take of most conversations. The third area is behavioral processes. Individuals with autism spectrum disorder often engage in the same behavior in a repetitive manner (Baron-Cohen & Belmonte, 2005; Kamio, Tobimatsu, & Fukui, 2011). About 30% of children with ASD may also show additional complications such as seizure disorders, intellectual disabilities of various kinds, and gastrointestinal problems.
DSM—5 uses ASD as the new single disorder “umbrella” term for what were previously separate disorders—autistic disorder, Asperger’s disorder, and a general pervasive developmental disorder—to be evaluated and specified on a continuum (spectrum). In DSM-5, the term Asperger’s syndrome, which had been added to the DSM in 1994, is no longer used. Historically, Asperger’s disorder was the diagnostic term for a milder form of autism in which developmental language delays may not be present. Also, compared with many others with autism, individuals identified with Asperger’s are high-functioning in social processes, and show average to above average cognitive skills. General pervasive developmental disorder was characterized in DSM—IV as a disorder in which the full criteria for autism were not met, and the individuals exhibited a much lower level of functioning.
Some researchers suggest that autism spectrum disorder offers us a way to study brain development that takes a non-normal route (Wicker & Gomot, 2011), and acknowledges a sharp gradation of functioning level among those with the disorder. ICD-11 combined autism spectrum disorder and Asperger’s syndrome as a single disorder. Those with the Asperger’s side of autism spectrum disorder report that they do not see the world as others do.
An example of a person who would have been diagnosed with Asperger’s syndrome is Temple Grandin. Temple Grandin described her experiences of being a person who experienced an autism spectrum disorder (Grandin, 2009, 2010). She described how at age 2 and a half she did not speak and performed actions in a repetitive manner. She was also very sensitive to certain sounds and would respond to these by rocking or staring at sand dribbling through her fingers. Later as a child, she had no understanding of how people relate to one another. She would watch others, trying to understand how she should behave.
Figure 14-11 Temple Grandin has experienced a special relationship with animals. Source: Associated Press.
Temple Grandin became very productive. She received her PhD and is a professor of animal sciences at Colorado State University. She has consulted with many companies concerning how to design environments that treat livestock in a humane manner. She, herself, describes individuals with autism as specialized thinkers (Grandin, 2009). For her, they are specialized in one of three types of thinking. The first is visual thinking, which allows one to view the world and even words in terms of images. The second is pattern thinking, in which the thinking is in terms of patterns such as those seen in music and mathematics. The third is word and fact thinking, in which the individual displays an ability to know a large number of facts such as baseball scores or the names of films and who their stars were. More formal research articles have also shown that hypersensitivity to sensory information along with strong logical reasoning ability may be at the basis of talent seen in individuals with autism spectrum disorder (Baron-Cohen, Ashwin, Ashwin, Tavassoli, & Chakrabarti, 2009). An exception to sensory sensitivity is found with odors. Children with autism spectrum disorder show little reaction to strong unpleasant odors such as sour milk or rotten fish (Rozenkrantz et al., 2015).
Causes of Autism Spectrum Disorder
Autism was initially thought to be largely influenced by environmental factors. In the 1960s and 1970s, individuals with autism were considered to have a form of psychosis similar to childhood schizophrenia. Consistent with the historical view at that time, environmental factors such as bad parenting were suggested to be a cause of the disorder. Often, the mother was seen as the cause of the disorder. Another study suggested that measles, mumps, and rubella (MMR) vaccinations produced changes in the infant that led to autism. Not only has this been shown to be false; it was discovered that the original research was fraudulent. Today parenting or social factors are seen to play little role at all with genetic factors being more important.
Autism has been shown to have a strong genetic component (see Dawson et al., 2009, for an overview). Concordance rates from numerous studies of twins in terms of autism show a range from 69% to 95% for monozygotic (MZ) twins and 0% to 24% for dizygotic (DZ) twins. Also, relatives of those with autism show higher rates of autism-like symptoms. The farther a relative is from the person with autism, the fewer symptoms that are seen. This suggests that autism involves a genetic pathway involving a number of genes in a complex manner. In fact, hundreds of genetic differences have been associated with autism but each of these represents a small percentage of cases (see Klin, Shultz, & Jones, 2015, for an overview).
There is also some suggestion that autism spectrum disorder shares common genetic processes with schizophrenia (Chisholm, Lin, Abu-Akel, & Wood, 2015). There is also a connection with attention deficit hyperactivity disorder (ADHD) (Lord & Bishop, 2015). A large-scale study of more than 10,000 twin pairs in Sweden reported that an MZ twin with autism spectrum disorder had a 44% chance of also being diagnosed with ADHD, whereas a DZ twin had only a 15% chance (Lichtenstein, Carlstrom, Råstam, Gillberg, & Anckarsäter, 2010).
In addition, genetic factors show a complex relationship involving environmental factors such as the age of the mother (see Waterhouse, 2012, for an overview). Younger mothers have the lowest risk for having children with ASD, and older mothers have the highest risk. There is also some suggestion that the mother’s health during pregnancy is associated with ASD, although the exact factors remain ambiguous. Fathers more than 50 years of age have four times the risk of having a child with autism. Whether this is related to the older males having a different quality of sperm is not known.
Brain Contributions to Autism Spectrum Disorder
In terms of the brain, it is suggested that ASD reflects dysfunction in areas associated with the social brain (see Minshew & Williams, 2007, for an overview). Briefly, these are the amygdala, specific areas of the frontal lobes, and areas of the temporal lobe. Further, those with autism were shown to have less activity in the mirror neuron system when viewing emotional expressions of faces (Dapretto et al., 2006). In those with autism, there was a negative correlation between cortical activity during this task and the severity of symptoms in the social domain. Another characteristic of autism is the desire to have a stable set of routines, which results in problems shifting attention.
Adolescents with ASD show fewer whole-brain connections than a control group (Moseley et al., 2015). This was particularly true in networks involved in visual processing and the default network. However, those with ASD show more connections between the primary sensory areas and subcortical areas such as the thalamus and basal ganglia (Cerliani et al., 2015). This can help to explain why those with ASD focus more on sensory stimuli rather than social processes.
Attention Deficit Hyperactivity Disorder (ADHD)
Attention deficit hyperactivity disorder (ADHD) is a disorder of childhood that tends to develop before the age of 12 and is seen worldwide (Hinshaw, 2018). Although the conceptualization of ADHD has changed over the years, it currently includes two major dimensions (see Adler, Spencer, & Wilens, 2015; Frick & Nigg, 2012, for overviews). The first dimension is inattention. Children and adults with inattention problems tend to exhibit these in a cognitive realm such as letting their mind wander or not paying attention. As shown with the inattention diagnostic criteria, these individuals may have difficulty paying close attention to details or focusing on activities such as schoolwork or lectures, appear disorganized, be unwilling to engage in activities that require mental effort, and be easily distracted. Individuals with this type of ADHD may also show learning problems.
The second dimension is hyperactivity and impulsivity. Children with hyperactivity and impulsivity tend to show these symptoms in a behavioral or motor realm. As shown in the hyperactivity and impulsivity diagnostic criteria, these individuals may have difficulty waiting their turn, waiting to respond, keeping still, and remaining in their seat. Children with this type of ADHD may also show conduct problems. There is some suggestion that hyperactivity problems may lessen as a child grows older, whereas attentional problems may increase, resulting in increasing difficulty with schoolwork. It is also possible that individuals with ADHD show characteristics of both inattention and hyperactivity.
ADHD is reported to be the most common emotional—behavioral disorder treated in youth (see Wilens, Biederman, & Spencer, 2002, for an overview). Epidemiological studies suggest a prevalence rate of 4% to 5% of children in the United States, New Zealand, Australia, Germany, and Brazil. Of those with ADHD, some 20% to 30% have the inattentive subtype, less than 15% have the hyperactive-impulsive subtype, and 50% to 75% have a combination of both. Although long-term studies show different rates, it is assumed that more than 50% of the children with ADHD will show continued ADHD into adolescence. A smaller proportion will show ADHD symptoms in adulthood.
Adults with ADHD show more symptoms related to inattention as compared with hyperactivity and impulsivity (Kessler et al., 2010). Specifically, almost half (45.7%) of the individuals studied who had childhood ADHD continued to meet full DSM—IV criteria for current adult ADHD, with 94.9% of these cases having attention deficit disorder and 34.6% hyperactivity disorder. According to the Centers for Disease Control and Prevention (CDC), boys are more likely (13.2%) than girls (5.6%) to be diagnosed with ADHD (www.cdc.gov/ncbddd/adhd/data.html).
1. Individuals with autism spectrum disorder (ASD) have difficulty in three separate areas. What are those areas and what specific types of difficulty do these individuals encounter in each area?
2. Some researchers suggest that autism spectrum disorder (ASD) offers us a way to study brain development that takes a non-normal route. Temple Grandin, who is on the spectrum, describes individuals with ASD as specialized thinkers. Give a brief description of the three types of thinking she describes.
3. What are the primary genetic, environmental, and neurological factors related to autism spectrum disorder (ASD)?
4. Describe the two (2) primary dimensions of attention deficit hyperactivity disorder (ADHD) and give an example of each.
Learning Objective 1: Explain how psychological disorders are classified and diagnosed.
We can consider four important personal components in psychopathology: first, a loss of freedom or ability to consider alternatives; second, a loss of honest personal contact; third, a loss of one’s connection with one’s self and ability to live in a productive manner; and fourth, personal distress. In many psychological disorders, personal distress for a period of time is one of the criteria required for a diagnosis to be made. There is also a more global component in which the person’s behavior and experiences are considered to be different from cultural and statistical norms.
Stigma involves negative attitudes and beliefs that cause the general public to avoid others including those with a mental illness. Throughout the world, those with mental illness experience stigma. In many cultures, they are seen as different. When they are thus stigmatized, these individuals are no longer treated as an individual person, but only as part of a group that is different.
One of the major contributions of the 20th century toward understanding psychopathology was the creation of a reliable diagnosis and classification system. This system in the United States, referred to as Diagnostic and Statistical Manual of Mental Disorders (DSM), made it easier for different mental health workers to label a disorder in the same way. For example, generalized anxiety disorder (GAD) was described in terms of “Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).”
Neuroscience techniques such as brain imaging and genetic analysis have been developed and are available in the research and clinical community. These techniques not only allow one to note the particular symptoms present as seen with DSM, but also to ask how the brain is involved in the disorder. Researchers have sought to determine the genetic components involved in particular disorders. We have discovered in children that ADHD (attention deficit hyperactivity disorder) is heritable, but that aggressive and disruptive conduct is not. A variety of genetic studies suggest that genetic factors account for about 82% of the variance in schizophrenia, suggesting that environmental factors are less critical in the development of schizophrenia.
We refer to a collection of symptoms that occur together and have a particular course of development over time as a syndrome. By describing disorders in terms of patterns of symptoms, Emil Kraepelin set the stage for diagnostic systems in both the United States and Europe.
A mental disorder contains five features: (a) a behavioral or psychological syndrome or pattern that occurs in an individual; (b) reflects an underlying psychobiological dysfunction; (c) the consequences are clinically significant distress; (d) must not be merely an expectable response to common stressors and losses or a culturally sanctioned response to a particular event; (e) is not primarily a result of social deviance or conflicts with society.
Research established mental illness was not a created concept by a given culture but rather part of the human condition in both its recognition and its prevalence. This set the stage for a development that came to be known as evolutionary psychopathology or Darwinian psychiatry.
Learning Objective 2: Describe the various types of anxiety, obsessive-compulsive, and mood disorders.
Anxiety is to be afraid of what might happen. Anxiety is about the future, whereas fear typically has a stimulus in the present. Generalized anxiety disorder (GAD) is characterized by excessive anxiety and worry. Its diagnosis in a clinical setting requires that anxiety and worry have been present for more than 6 months. GAD is one of the most commonly diagnosed mental disorders in the United States. It is more commonly seen in women than men. Social anxiety disorder is characterized by marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. A panic disorder is an anxiety disorder that comes quickly and carries with it an intense feeling of apprehension, anxiety, or fear.
A panic attack is a frequent cause of individuals going to a hospital emergency room. Agoraphobia is the condition in which a person experiences fear or anxiety when in public. A specific phobia is an anxiety disorder in which an individual experiences fear or anxiety to a particular situation or object. Common phobias are fear of snakes, spiders, flying, heights, blood, injections, and the dark.
Obsessive-compulsive disorder (OCD) is characterized by repetitive thoughts and feelings usually followed by behaviors in response to them. The thoughts are usually perceived as unpleasant and not wanted. A distinction is made between obsessions and compulsions. Obsessions are generally unwelcome thoughts that come into our heads. Compulsions are the behaviors that individuals use to respond to their distressing thoughts. Overall, these behaviors are performed in order to reduce anxiety, gain control, or resist unwanted thoughts. Other compulsions, such as hand washing, are more avoidant in nature for fear of what one might say, do, or experience in a particular situation.
When depression is severe, it is referred to as major depressive disorder (MDD). With major depressive disorder, a person feels sad and empty and may display an irritable mood. These feelings may include hopelessness and be experienced over a number of days. Body experiences, such as difficulty sleeping and eating, are also common.
Bipolar disorder was previously referred to as manic-depressive disorder. Changes in mood are an important aspect of bipolar disorders. These include the intense sense of well-being along with high energy seen in mania and its opposite seen in depression. Changes in cognition and perception also accompany these states. In mania, thoughts seem to flow easily, and many individuals find themselves very productive during mania. The depressive episodes show the opposite picture with the person experiencing a bleak outlook, low energy in a world of black-and-white, and a wish to do little.
Mental illness has a strong connection with suicide (see Goldsmith, 2001, for an overview). Of those suicide attempts that lead to death, it is estimated that 90% of adults and 67% of youth would meet diagnostic criteria for a mental disorder. The most common disorders associated with suicide are depression, bipolar disorder, substance use disorders, personality disorders, and schizophrenia, in that order. In bipolar and personality disorders, suicide is often associated with impulsiveness. With schizophrenia, it is more associated with active manifestation of the disorder. The rate of suicide among those with psychological disorders is highest in the three months following hospitalization.
Learning Objective 3: Discuss the dissociative disorders of depersonalization, dissociative amnesia, and dissociative identity disorder.
Dissociate disorders involve problems with memory. The dissociative experiences can last for a few minutes or hours but reoccur. They can also last for a longer period of time. Some of these experiences are severe and represent significant disruptions in the organization of identity, memory, perception, or consciousness. More pathological symptoms of dissociation are often connected with trauma and experiences greatly beyond the individual’s control. The main types include depersonalization—derealization disorder, dissociative amnesia, and dissociative identity disorder.
Learning Objective 4: Describe the main features and causes of schizophrenia.
Schizophrenia is part of a broad category of disorders referred to as schizophrenia spectrum and other psychotic disorders. Psychotic disorders involve a loss of being in touch with reality and are characterized by abnormal thinking and sensory processes. Individuals with a psychotic disorder may show delusions, hallucinations, disorganized thinking and speech, abnormal motor behaviors, and negative symptoms.
The course of schizophrenia generally first becomes evident in adolescence or young adulthood. The initial phase is referred to as the premorbid phase. This is followed by a prodromal phase in which initial positive symptoms along with declining functioning can be seen. The next phase is the psychotic phase, where the positive psychotic symptoms are apparent. For most individuals, this phase occurs between 15 and 45 years of age with the onset being about five years earlier in males than females. This phase is marked by repeated episodes of psychosis with remission in between. The greatest decline in functioning is generally seen during the first five years after the initial episode. This phase is followed by a stable phase characterized by fewer positive symptoms and an increase in negative ones. Stable cognitive and social deficits also characterize this phase. The actual course of the disorder varies greatly across individuals.
The current research literature suggests that schizophrenia is a disorder that begins early in life. This has led some researchers to suggest that we consider schizophrenia as a neurodevelopmental disorder. A variety of negative events can happen to a fetus, including infections and malnutrition. It has been shown, for example, that vitamin D deficiency and maternal infection during pregnancy can be seen as a risk for developing schizophrenia.
Environmental factors can also play a role in the development of schizophrenia. The basic idea is that environmental factors can influence the developing social brain and lead to the development of schizophrenia in those at risk. Greater amounts of stress are associated with greater chances of developing schizophrenia. Since schizophrenia tends to run in families and is seen throughout the world, it is assumed to have a genetic component. The risk of developing schizophrenia is much higher if someone else in your family also has the disorder.
Learning Objective 5: Discuss the basic characteristics of personality disorders.
The basic definition of a personality disorder is that it represents an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. Further, the pattern is inflexible, stable, and generally begins in adolescence, and leads to distress or impairment. The characteristics of these disorders are especially apparent when these individuals find themselves in situations that are beyond their ability to cope. DSM-5 identifies ten personality disorders that form separate categories.
These ten disorders can be organized into three clusters. The first cluster is referred to as Cluster A and includes odd or eccentric disorders. These include schizoid personality disorder, paranoid personality disorder, and schizotypal personality disorder. The second cluster is referred to as Cluster B and includes dramatic, emotional, or erratic disorders. These include antisocial personality disorder, borderline personality disorder (BPD), histrionic personality disorder, and narcissistic personality disorder. The third cluster is referred to as Cluster C and includes anxious or fearful disorders. These include avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder.
The diagnostic criteria in DSM—5 for antisocial personality disorder describe a person who shows a pattern of disregard for the rights of others. A person with this disorder must be 18 years old, and the personality style should have been present since 15 years of age. Before age 15, the person should meet criteria for a conduct disorder. Child conduct disorder includes aggression toward animals or people, destruction of property, deception or stealing, and serious rule violations.
Individuals who display signs of psychopathy show emotional detachment with a lack of empathy for the experiences of others (see Patrick, 2010, for an overview). They also show impulsive behavior and a callousness concerning their actions. These patterns are stable and difficult to change. Although individuals with this condition take a real toll on society, there is also a fascination by many with these individuals.
Borderline personality disorder (BPD) is characterized by an instability in mood, interpersonal relationships, and a sense of self. These three factors interact with one another in such a manner that the person with BPD experiences a changing world without a solid sense of self.
Learning Objective 6: Discuss the neurodevelopmental disorders that begin early in a child’s life.
Neurodevelopmental disorders are those disorders that begin early in a child’s life. These can include problems in the development of language and cognitive, emotional, and motor problems. Two of these disorders are autism spectrum disorder and attention deficit hyper-activity disorder (ADHD).
Individuals with autism spectrum disorder (ASD) have difficulty in three separate areas. The first is social interactions. Children with autism do not connect with other children or adults in the manner that other children do. They do not look others in the eye or may appear to ignore others while being more interested in other aspects of their environment. The second area is communication. The communication patterns of those with autism spectrum disorder do not usually show the give-and-take of most conversations. The third area is behavioral processes. Individuals with autism spectrum disorder often display stereotypical behaviors and the desire to engage in the same behavior in a repetitive manner.
Attention deficit hyperactivity disorder (ADHD) is a disorder of childhood that tends to develop before the age of 12. Although the conceptualization of ADHD has changed over the years, it currently includes two major dimensions. The first dimension is inattention. The second dimension is hyperactivity and impulsivity. There is some suggestion that hyper-activity problems may lessen as a child grows older whereas, attentional problems may increase, resulting in increasing difficulty with schoolwork. It is also possible that individuals with ADHD show characteristics of both inattention and hyperactivity.
1. What is the contribution of each of these to our understanding of psychopathology today:
a. The move toward experimentation and empiricism in science?
b. The move beyond simple dichotomies in terms of causes?
c. The development of the Diagnostic and Statistical Manual of Mental Disorders (DSM)?
d. The use of neuroscience techniques?
e. The use of genetic studies?
2. How are anxiety and fear related? When is our experience of anxiety and fear a normal part of the human condition? What turns it into a psychopathology?
3. What are the functions of obsessions and compulsions in obsessive-compulsive disorder (OCD)? How are they different from similar concerns and behaviors in individuals who do not have OCD?
4. Mental illness has a strong connection with suicide. This is especially true of depression and bipolar disorder. With what you’ve learned in this chapter, design a suicide-prevention program that targets a specific population of individuals with depression or bipolar disorder.
a. What cultural, gender, and age factors would you consider?
b. How would your program focus on the following levels: the individual, the individual’s relationships, the community, and the society?
5. “In times of stress, [dissociation] is a mechanism that protects the individual and allows her to survive.” Considering all of the dissociative disorders, how do they protect the individual? What are they protecting her from? What are some of the costs of that protection?
6. This chapter states that “individuals with schizophrenia have a variety of different symptoms and show an inconsistent picture of the disorder. This has led some to suggest that there is not a single schizophrenia disorder but rather a variety of syndromes.” What do you think: Is schizophrenia one disorder? What evidence would you cite to support your position?
7. Are the prevalence rates and patterns the same for the three clusters of personality disorders? If not, how are they different? What are the prevalence rates and patterns specifically for antisocial personality disorder and borderline personality disorder (BPD)?
8. Historically, the term borderline, as the name implies, denoted individuals who were neither neurotic nor psychotic. From what you have read in this chapter, what additional meanings do you think the term borderline implies about that personality disorder?
9. What is the significance of “spectrum” in the term autism spectrum disorders? Why did DSM—5 group previously separate disorders under this one characterization? How does it help us better understand the disorders in terms of causes, diagnostic criteria, and treatments? What are the disadvantages of grouping the disorders as a spectrum?
10. Describe the typical course of attention deficit hyperactivity disorder (ADHD) and presentation of symptoms across different age groups and ADHD subtypes.
For Further Reading
✵ Jamison, Kay (2006). An Unquiet Mind. New York: Random House.
✵ Lowe, J. (2017). Mental, Lithium, Love, and Losing My Mind. New York: Blue Rider Press.
✵ McLean, R. (2003). Recovered, Not Cured: A Journey through Schizophrenia. Australia: Allen Unwin.
✵ Mukherjee, S. (2016). Runs in the family: New findings about schizophrenia rekindle old questions about genes and identity. The New Yorker (March 28).
✵ Nasar, S. (1998). A Beautiful Mind. New York: Simon & Schuster.
✵ Sacks, Oliver (2012). Hallucinations. New York: Alfred Knopf.
✵ Saks, Elyn (2007). The Center Cannot Hold: My Journey Through Madness. New York: Hyperion.
✵ Steele, K., & Berman, C. (2001). The Day the Voices Stopped. New York: Basic Books.
✵ Torrey, E. (1997). Out of the Shadows: Confronting America’s Mental Illness Crisis. New York: Wiley.
✵ NIMH mental health statistics—https://www.nimh.nih.gov/health/statistics/mental-illness.shtml
✵ WHO and depression—https://www.who.int/news-room/fact-sheets/detail/depression
✵ Charlie Chaplin—www.richardgregory.org/experiments.
✵ Oliver Sacks—https://www.ted.com/talks/oliver_sacks_what_hallucination_reveals_about_our_minds
✵ CDC ADHD—www.cdc.gov/ncbddd/adhd/data.html
Key Terms and Concepts
antisocial personality disorder
attention deficit hyperactivity disorder (ADHD)
autism spectrum disorder (ASD)
borderline personality disorder (BPD)
dissociative identity disorder (DID)
generalized anxiety disorder (GAD)
major depressive disorder (MDD)
obsessive-compulsive and related disorders
obsessive-compulsive disorder (OCD)
pathological dissociative symptoms
schizophrenia schizophrenia spectrum and other psychotic disorders
social anxiety disorder (SAD)