CONCEPT I: Defining Psychological Disorders

Abnormal behavior can be defined in many ways. A statistical criterion specifies that abnormality is any substantial deviation from the average. A social norms criterion defines abnormal behavior as that which differs significantly from the norms of society. Another definition suggests that abnormality can be defined by comparing behavior to an absolute standard of mental health. All these definitions have advantages and disadvantages, and none is sufficient in itself. In fact, the more criteria that can be applied, the less confident we become of our diagnosis. Thus, mental health can be best viewed as a continuum, with extremes at the normal and abnormal ends, and with an ambiguous area in between.

CONCEPT II: Perspectives on Psychological Disorders

Several theories have been proposed to account for abnormal behavior; each applies to different cases and each suggests different causes and cures.

The biological perspective likens psychological disorder to physical illness: Symptoms are used to diagnose the underlying "mental illness," which results from a physical problem. The medical discovery that the madness associated with general paresis, the deterioration of mental and physical processes as the result of a syphilis infection, was the result of a venereal disease caused by microorganisms provided strong support for the biological perspective. Now, biological researchers are trying to understand the brain chemistries of mentally disturbed people to try to understand the causes of mental illness.

Many mental-health professionals emphasize the role of psychological factors in the development of psychological disorders, and several perspectives stress explanations consistent with this view.

The psychoanalytic perspective, developed by Freud, holds that unresolved sexual conflicts in early childhood or conflicts between the id, ego, and superego set the stage for psychological disorders later in life. When the ego becomes too weak, abnormal behavior results. Psychoanalysis, a deep probing of people's thoughts and feelings, attempts to give patients insight into their unconscious conflicts and thereby make them healthier. The psychoanalytic perspective, like the biological model, views symptoms as being produced by underlying disorders.

The learning perspective differs sharply from the biological and psychoanalytic models because it proposes that psychological disturbances arise from learning abnormal responses. Treatment usually consists of trying to extinguish the maladaptive behavior and teach more normal methods of living.

The cognitive approach suggests that, in addition to the influence of the learned behaviors, the interpretations a person places on an event are significant determinants of how he or she will respond to that event. Cognitive therapies emphasize changing negative cognitions so as to allow the person to break free of maladaptive behaviors.

Two other perspectives are also proposed: Both consider the social world in which a disturbed person lives. The interpersonal or family-systems perspective suggests that the source of a psychological disturbance may not be entirely within the person: The relationships the person has with others may also be a cause of maladaptive behavior. The sociocultural perspective looks for the source of psychological disturbances in the society in which a person lives. It suggests that conditions such as overcrowding and poverty may produce undesirable behavior. The poor are also less prepared to cope with severe stress, and research shows that mental illness is higher among the poor.

None of these theories provides perfect answers, but each contributes a different perspective for the study of psychological disturbances. The diathesis-stress model attempts to combine some elements from several models. It argues that a person's genetic makeup creates a diathesis, or predisposition, toward a certain mental disorder which may develop if certain environmental conditions are met.

CONCEPT III: Classifying Psychological Disorders

In diagnosing a mental disorder, therapists classify it according to its syndrome, a set of symptoms which tend to occur together. Classification gives mental health professionals a shorthand means of communicating, it helps suggest effective treatments, it encourages the pooling of research data, and it aids in making predictions. The standard classification system is DSM III-R (Diagnostic and Statistical Manual of Mental Disorders, third edition, revised). According to this manual, patients are evaluated on five axes that help clinicians determine the most effective treatment strategies. Axis I lists clinical syndromes; Axis II refers to maladaptive personality traits; Axis III evaluates the patient's physical illness; Axis IV assesses the stress in the patient's life; Axis V measures the highest level of functioning the patient has experienced in the previous year.

Some people criticize classification systems, arguing that they ignore relevant individual differences and lead professionals to see patients according to their diagnosis rather than their actual behavior. However, most classifications are quite reliable, and potential problems with validity do not override their usefulness.

CONCEPT IV: Anxiety Disorders

The anxiety disorders are characterized by emotional distress caused by feelings of vulnerability, apprehension, or fear.

The anxiety disorders include panic disorder, phobic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. Panic disorder involves attacks of inexplicable, intense fear, and it occurs in about 1 percent of both men and women. Often panic disorder is accompanied by agoraphobia, an intense fear of being in a place from which one cannot escape without embarrassment. Panic disorder is sometimes accompanied by depression, and tends to run in families.

A phobia is an extreme and irrational fear focused on a particular object. Social phobias involve a fear of doing something in public that could be embarrassing; simple phobias involve the fear of nonsocial things, such as enclosed places. About 13 percent of the population experiences phobias. Phobics know their fears are unreasonable, yet they are unable to control them. Freudians explain phobias as the result of a defense mechanism to protect the ego from the too-powerful id. Learning theories see phobias as the result of conditioning, and some evidence suggests we are innately prepared to develop certain phobias. Observational learning may also play a role.

Generalized anxiety is a state of persistent apprehension without good cause, often accompanied by tension. The psychoanalytic view is that generalized anxiety disorder results from the ego's fear that the id impulses will be punished, a condition Freud called "free-floating anxiety." The cognitive perspective suggests this disorder is the result of one's inability to control negative life events.

An obsession is a recurring, irrational thought that intrudes continuously, even though the person tries to avoid thinking about it. A compulsion is an uncontrollable, repetitive behavior such as excessive handwashing. Although obsessions and compulsions often occur together, they each occur separately as well. The psychoanalytic view sees these disorders as the result of ego defenses. The learning view suggests compulsions are reinforced by reducing anxiety, but cannot account for obsessions. The biological perspective views these disorders as the result of brain abnormalities and points out that they have an inherited component.

Posttraumatic stress disorder (PTSD) is a state of anxiety and depression that follows severe trauma, like warfare, rape, or natural disaster, and may appear long after the distressing event is over and last for years. Symptoms include tension, insomnia, trouble concentrating, a feeling of remoteness, and flashbacks. The major determinant of who experiences PTSD is how severe the trauma was.

CONCEPT V: Somatoform Disorders

Somatoform disorder involves the symptoms of a physical dysfunction, even though the ailment has no organic cause. Hypochondriasis is characterized by the irrational belief that the person has contracted a serious illness, even though no corresponding symptoms are present. Even when medical examination reveals no physical impairments, the hypochondriac typically does not believe the favorable diagnosis.

A conversion disorder usually involves the real loss of some body function following a traumatic event. The conversion disorder arises to protect the person from being forced to confront a high-anxiety situation. Freud argued that conversion disorders are defenses against forbidden impulses. Learning theorists see them as leading to rewards by reducing anxiety. Family-systems theorists see them as serving a useful role in a family by helping other family members function.

CONCEPT VI: Dissociative Disorders

The dissociative disorders involve the splitting of the personality into component parts so that memory or identity is disrupted. Psychogenic amnesia, the forgetting of past experiences, involves the dissociation of present memories from certain memories of the past. In a psychogenic fugue state, people leave their identity and take up a new life, having entirely forgotten their past.

Multiple personality disorder is the dissociation of the mind into several "people," each with different characteristics. These personalities tend to form three clusters: those who are demure, shy, and withdrawn; those who are aggressive and promiscuous; and those who are level or rational. Often the personality who goes for help does not know about the other personalities but is troubled by memory lapses or unexplained events. Multiple personality usually begins in childhood, often as the result of severe sexual abuse.

CONCEPT VII: Mood Disorders

Mood disorders involve intense moods which last for longer than normal periods of time. There are two major categories: depressive disorders and bipolar disorders.

Major depression is characterized by one or more episodes of deep sadness and despair which last all day long for two or more weeks. Symptoms include: loss of energy, slowing down of behavior, agitation, difficulty thinking, eating disturbances, problems in sleeping, an exaggerated sense of worthlessness, and recurring thoughts of death and suicide. Depressive episodes typically last 3 to 6 months, and relapses occur in about 50 percent of the cases. Dysthymia is like major depression except it endures for years at a time with only short remissions.

Nearly 30,000 deaths are recorded as suicides each year in this country, and the actual number is much higher, perhaps 100,000. Suicide is the second most common cause of death for the fifteen to twenty-four age group in this country. Three times more men kill themselves than women, but three times more women than men attempt suicide. Many of the common myths about suicide are not true.

Different theories have attempted to explain depression in a variety of ways. The psychoanalytic approach suggests that depression is the result of self-loathing due to the rage one feels when abandoned by a loved one. Another view suggests that depression is the result of the loss of something valuable by a person whose needs in infancy were not met.

Lewinsohn, a learning theorist, proposes that depression occurs because a person is no longer receiving any pleasurable reinforcement from life. Beck, a cognitive theorist, believes that depressed people make errors in their thinking, which leads them to put a consistently negative interpretation on nearly everything.

Seligman, another learning theorist, suggests that depression is a learned response of inactivity which arises when a person feels he has no control over what happens to him. The severity and duration of depression depend upon a person's attributional style-whether the cause of helplessness is attributed to an external cause or to some trait the individual identifies as responsible for the helplessness. For example, people who attribute undesirable outcomes to temporary external causes feel dejected but don't blame themselves and their chances for recovery are good. People who attribute bad outcomes to personal inadequacies feel guilt and self-blame along with the depression. People who attribute bad outcomes to personal shortcomings and see these as enduring traits will probably experience the severest depressions. Some research, however, suggests that depressed people not only see their circumstances as negative; their circumstances are negative. Thus, it seems more accurate to view mood and attributional style as interacting with each other. Perhaps negative attributions contribute to depression, as does the tendency to cast oneself in a negative light and the tendency to assume negative events will have severe consequences. Another piece of data which fits such a cognitive interpretation is that men tend to respond to depression with physical activity whereas women ruminate on their problems: Perhaps this explains why twice as many women as men are depressed.

Studies comparing identical twins to fraternal twins and studies investigating rates of depression in adopted infants demonstrate the presence of a genetic tendency toward depression. Other biological theories have proposed that depression arises from disruptions in the amount of neurotransmitters such as serotonin or norepinephrine. Support for these biological views comes from the fact that certain drugs which alter brain chemistry also alter mood, and can sometimes lift depression, although the mechanism by which they work is currently unknown.

The family, or systems, approach specifies that depression results from disturbed interactions among family members. Research supporting this view shows that people do have more negative reactions to depressed people than to those who are not depressed. Depressed people have also been found to have more negative conversation styles, smile less, and are less animated and pleasant. These negative responses are usually met by negative reactions, which causes depression to deepen.

Because the roots of depression are many and complex, a combination of perspectives helps us understand this disorder.

In 5 to 10 percent of depressions, mania is also involved, resulting in a syndrome called manic-depression, which affects about 1 percent of the population. Mania is a state of exaggerated elation characterized by irritability, hyperactivity, decreased need for sleep, constant talkativeness, flight of ideas, distractibility, inflated self-esteem, and reckless behavior. Mild manic episodes produce a feeling of power and competence, but more severe forms produce severe impairments. Manic-depressive disorder appears to differ from unipolar depression in that it starts earlier in life, runs more in families, and responds favorably to the drug lithium carbonate. Cyclothymia is a chronic but milder form of manic-depressive disorder. Manic-depression has been linked to two defective genes on chromosome eleven, and a biological explanation is strongly implicated.

Seasonal mood disorders take two forms, the more common wintertime depression, and summertime depression. Typically, people who experience depression in the winter oversleep, overeat, and gain weight; people with summer depressions have trouble sleeping, lose their appetites, and lose weight. Wintertime depression may be triggered by shortened daylength and use of artificial sunlight sometimes helps improve symptoms as does travel to a more southern location. Summertime depression may be triggered by heat. These disorders may bear some similarity to seasonal changes seen in other animals, for example, hibernation.

CONCEPT VIII: Schizophrenia

Schizophrenia, a severe mental disorder which affects about 1 percent of the population, accounts for about half of all people committed to mental hospitals. Schizophrenia is usually characterized by a deterioration of behavior which results in an active phase, which may improve to a residual phase, only to be followed by more active phase-residual phase cycles. Symptoms include: disturbances in thought content, including delusions (irrational beliefs); disturbance in thought as evidenced by disjointed and impoverished speech; of perception; of emotion; in the sense of self; in volition (ability to act); in interpersonal relationships; and in motor behavior, as exemplified by the catatonic stupor, in which the person remains in one position for hours. Most schizophrenics exhibit a split between various ideas and emotions. Often, their language indicates the inappropriate shifting from one thought to the next as they ramble through meaningless and unrelated phrases. Schizophrenics also have a distorted view of reality: They see, feel, and hear things that have no existence in reality. They may also display bizarre and inappropriate behaviors. Sometimes, when in a catatonic stupor, the schizophrenic displays no behavior at all, just remaining motionless for long periods of time. There is a tendency to be withdrawn into an inner world and to avoid social interaction.

Schizophrenia is organized into subtypes which include the disorganized, or hebephrenic, type; the catatonic type; the paranoid type; and the undifferentiated type. A newer classification divides schizophrenics into three categories: those with positive or active symptoms; those with negative or passive symptoms; and those with mixed symptoms. It seems likely that different subtypes might well have different causes.

Different theories propose various explanations of the cause of schizophrenia. Biological approaches have suggested that schizophrenia may result from a genetic predisposition (schizophrenia is positively correlated with similarity of genetic makeup), too much dopamine in the brain (drugs that block dopamine absorption sometimes reduce schizophrenic symptoms), unusually sensitive dopamine receptors in critical areas, or too many dopamine receptors in critical brain locations. Some research suggests that there are two common types of schizophrenia, the "active" type (characterized by hallucinations and thought disorders and linked to dopamine activity) and the "passive" type (characterized by withdrawal and not linked to dopamine). This passive type might be linked to structural damage in the brain.

Family, or systems, theorists believe that schizophrenia is related to inappropriate family functioning. Families high in expressed emotion, which involves an emotionally charged atmosphere high in hostility and criticism, tend to be linked with higher relapse rates of schizophrenic family members. Another area of research shows that the "schismatic family" may encourage schizophrenia by setting up a situation in which parental strife divides the family. In the "skewed family," strife is avoided by total submission of the one spouse to the other, and schizophrenia may result from the uncertainty and confusion. Another possible cause may be abnormal interpersonal communications: The child receives two contradictory messages and never learns to make sense out of the situation.

Schizophrenia is more common in lower than in higher socioeconomic classes; the sociocultural theorists believe this is the result of environmental stress, genetic predisposition, or overanxious diagnosis. There is also the fact that a schizophrenic's inability to cope with the demands of a good job contributes to low economic status.

The diathesis-stress model integrates the diathesis (biological predisposition) and the stress (environmental and learned aspects) to account for schizophrenia, and suggests both factors are necessary for the disorder to be manifested.

CONCEPT IX: Personality Disorders

Personality disorders are deep-seated patterns of maladaptive behaviors that cause distress to others. Unlike the anxiety disorders, the personality disorders produce little or no guilt or anxiety.

Antisocial personalities, or sociopaths, are people who follow their impulses without guilt and without considering the consequences of their behaviors for others. About 4 percent of American men and 1 percent of women have this disorder, which is usually apparent by age 15 and is characterized by impulsiveness; disregard for the truth; aggression; irresponsibility in family, occupational, and financial obligations; and incapacity for normal friendship or love. Psychoanalytic theorists explain sociopathy as the result of rejecting parents and the corresponding failure to develop a conscience. Learning theorists suggest that the sociopath receives reinforcement when he or she commits sociopathic acts. The view is supported by the fact that antisocial people tend to have antisocial fathers to model. Biological theorists suggest such a person may suffer from autonomic underarousal, and commit crimes to get a thrill.

People with narcissistic personality disorder have an overblown sense of their own importance, yet have very fragile self-esteem. Borderline personality disorder is characterized by instability in self-image, interpersonal relations, and mood. These people are very erratic in their behavior, which is characterized by extreme highs and lows.

CONCEPT X: Psychoactive Substance Use Disorders

The addictive disorders involve centering one's life around the use of psychoactive drugs. Alcohol is the most commonly abused in our society. Alcohol dependence involves pathological and compulsive use of alcohol and physical need for the drug. Dependence involves the development of a tolerance (it takes more and more alcohol to get drunk) and the presence of withdrawal symptoms when consumption is temporarily halted. Alcohol abusers are people who are not alcoholics but who have a drinking problem. About 13 percent of Americans will at some point in their lives have a problem with alcohol. Although presently alcoholism affects mostly men, it is increasing in women and teenagers. Alcoholism takes a serious toll on the alcoholic's health and on the productivity of our society, costing our economy as much as $120 billion per year in lost productivity and increased health care. About 85 percent of alcoholics receive no treatment.

The psychoanalytic perspective suggests that alcoholism results from conflict over oral gratification in infancy. Furthermore, these theorists suggest that alcoholism may be a means of coping with low self-esteem. Learning theorists argue that drinking provides the alcoholic with rewards, especially the reduction of stress that results from intoxication. This tension-reduction function may be the result of the body's compensating for a reduction of the neurotransmitter endorphin which normally reduces pain and elevates mood. There is also evidence of a genetic link in alcoholism. Since no single theory or therapy seems satisfactory, treatment is often based on a combination of several different approaches.