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FIGURE 15.1 A wreath is laid in memoriam to victims of the Washington Navy Yard shooting. (credit: modification of work by D. Myles Cullen, US Department of Defense)

INTRODUCTION

CHAPTER OUTLINE 15.1 What Are Psychological Disorders? 15.2 Diagnosing and Classifying Psychological Disorders 15.3 Perspectives on Psychological Disorders 15.4 Anxiety Disorders 15.5 Obsessive-Compulsive and Related Disorders 15.6 Posttraumatic Stress Disorder 15.7 Mood and Related Disorders 15.8 Schizophrenia 15.9 Dissociative Disorders 15.10 Disorders in Childhood 15.11 Personality Disorders

On Monday, September 16, 2013, a gunman killed 12 people as the workday began at the Washington Navy Yard in Washington, DC. Aaron Alexis, 34, had a troubled history: he thought that he was being controlled by radio waves. He called the police to complain about voices in his head and being under surveillance by “shadowy forces” (Thomas, Levine, Date, & Cloherty, 2013). While Alexis’s actions cannot be excused, it is clear that he had some form of mental illness. Mental illness is not necessarily a cause of violence; it is far more likely that the mentally ill will be victims rather than perpetrators of violence (Stuart, 2003). If, however, Alexis had received the help he needed, this tragedy might have been averted.

15Psychological Disorders

15.1 What Are Psychological Disorders? LEARNING OBJECTIVES By the end of this section, you will be able to:

• Understand the problems inherent in defining the concept of psychological disorder • Describe what is meant by harmful dysfunction • Identify the formal criteria that thoughts, feelings, and behaviors must meet to be considered abnormal and,

thus, symptomatic of a psychological disorder

According to the American Psychiatric Association, a psychological disorder, or mental disorder, is “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities” (2013). Psychopathology is the study of psychological disorders, including their symptoms, etiology (i.e., their causes), and treatment. The term psychopathology can also refer to the manifestation of a psychological disorder. Although consensus can be difficult, it is extremely important for mental health professionals to agree on what kinds of thoughts, feelings, and behaviors are truly abnormal in the sense that they genuinely indicate the presence of psychopathology. Certain patterns of behavior and inner experience can easily be labeled as abnormal and clearly signify some kind of psychological disturbance. The person who washes their hands 40 times per day and the person who claims to hear the voices of demons exhibit behaviors and inner experiences that most would regard as abnormal: beliefs and behaviors that suggest the existence of a psychological disorder. But, consider the nervousness a young man feels when talking to an attractive person or the loneliness and longing for home a first-year student experiences during her first semester of college—these feelings may not be regularly present, but they fall in the range of normal. So, what kinds of thoughts, feelings, and behaviors represent a true psychological disorder? Psychologists work to distinguish psychological disorders from inner experiences and behaviors that are merely situational, idiosyncratic, or unconventional.

Mental health issues are often incorrectly viewed as less important than physical illnesses, and sometimes people are blamed or otherwise stigmatized for their condition. People with mental illnesses did not choose or create their illness, and cannot simply manage it through positive thinking or other attitudinal changes. Diagnosis, treatment, and support are all necessary, and all must be considered with respect and sensitivity to the extremely challenging nature of mental illness. While not everyone experiencing difficulty has a psychological disorder, mental health is critical to our ability to function in our relationships, education, and work. It is important that people talk with qualified professionals if they are having persistent feelings or experiences in line with the descriptions below; the discussion may or may not lead to a diagnosis, but as with physical illnesses, one has a better chance at success if they raise the issues with doctors or other experts.

Definition of a Psychological Disorder

Perhaps the simplest approach to conceptualizing psychological disorders is to label behaviors, thoughts, and inner experiences that are atypical, distressful, dysfunctional, and sometimes even dangerous, as signs of a disorder. For example, if you ask a classmate for a date and you are rejected, you probably would feel a little dejected. Such feelings would be normal. If you felt extremely depressed—so much so that you lost interest in activities, had difficulty eating or sleeping, felt utterly worthless, and contemplated suicide—your feelings would be atypical, would deviate from the norm, and could signify the presence of a psychological disorder. Just because something is atypical, however, does not necessarily mean it is disordered.

For example, only about 4% of people in the United States have red hair, so red hair is considered an atypical characteristic (Figure 15.2), but it is not considered disordered, it’s just unusual. And it is less unusual in Scotland, where approximately 13% of the population has red hair (“DNA Project Aims,” 2012). As you will learn, some disorders, although not exactly typical, are far from atypical, and the rates in which they appear in the population are surprisingly high.

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FIGURE 15.2 Red hair is considered unusual, but not abnormal. (a) Isla Fischer, (b) Prince Harry, and (c) Marcia Cross are three natural redheads. (credit a: modification of work by Richard Goldschmidt; credit b: modification of work by Glyn Lowe; credit c: modification of work by Kirk Weaver)

If we can agree that merely being atypical is an insufficient criterion for a having a psychological disorder, is it reasonable to consider behavior or inner experiences that differ from widely expected cultural values or expectations as disordered? Using this criterion, a person who walks around a subway platform wearing a heavy winter coat in July while screaming obscenities at strangers may be considered as exhibiting symptoms of a psychological disorder. Their actions and clothes violate socially accepted rules governing appropriate dress and behavior; these characteristics are atypical.

Cultural Expectations

Violating cultural expectations is not, in and of itself, a satisfactory means of identifying the presence of a psychological disorder. Since behavior varies from one culture to another, what may be expected and considered appropriate in one culture may not be viewed as such in other cultures. For example, returning a stranger’s smile is expected in the United States because a pervasive social norm dictates that we reciprocate friendly gestures. A person who refuses to acknowledge such gestures might be considered socially awkward—perhaps even disordered—for violating this expectation. However, such expectations are not universally shared. Cultural expectations in Japan involve showing reserve, restraint, and a concern for maintaining privacy around strangers. Japanese people are generally unresponsive to smiles from strangers (Patterson et al., 2007). Eye contact provides another example. In the United States and Europe, eye contact with others typically signifies honesty and attention. However, most Latin-American, Asian, and African cultures interpret direct eye contact as rude, confrontational, and aggressive (Pazain, 2010). Thus, someone who makes eye contact with you could be considered appropriate and respectful or brazen and offensive, depending on your culture (Figure 15.3).

FIGURE 15.3 Eye contact is one of many social gestures that vary from culture to culture. (credit: Joi Ito)

Hallucinations (seeing or hearing things that are not physically present) in Western societies is a violation of

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cultural expectations, and a person who reports such inner experiences is readily labeled as psychologically disordered. In other cultures, visions that, for example, pertain to future events may be regarded as normal experiences that are positively valued (Bourguignon, 1970). Finally, it is important to recognize that cultural norms change over time: what might be considered typical in a society at one time may no longer be viewed this way later, similar to how fashion trends from one era may elicit quizzical looks decades later—imagine how a headband, legwarmers, and the big hair of the 1980s would go over on your campus today.

The Myth of Mental Illness In the 1950s and 1960s, the concept of mental illness was widely criticized. One of the major criticisms focused on the notion that mental illness was a “myth that justifies psychiatric intervention in socially disapproved behavior” (Wakefield, 1992). Thomas Szasz (1960), a noted psychiatrist, was perhaps the biggest proponent of this view. Szasz argued that the notion of mental illness was invented by society (and the mental health establishment) to stigmatize and subjugate people whose behavior violates accepted social and legal norms. Indeed, Szasz suggested that what appear to be symptoms of mental illness are more appropriately characterized as “problems in living” (Szasz, 1960).

In his 1961 book, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, Szasz expressed his disdain for the concept of mental illness and for the field of psychiatry in general (Oliver, 2006). The basis for Szasz’s attack was his contention that detectable abnormalities in bodily structures and functions (e.g., infections and organ damage or dysfunction) represent the defining features of genuine illness or disease, and because symptoms of purported mental illness are not accompanied by such detectable abnormalities, so-called psychological disorders are not disorders at all. Szasz (1961/2010) proclaimed that “disease or illness can only affect the body; hence, there can be no mental illness” (p. 267).

Today, we recognize the extreme level of psychological suffering experienced by people with psychological disorders: the painful thoughts and feelings they experience, the disordered behavior they demonstrate, and the levels of distress and impairment they exhibit. This makes it very difficult to deny the reality of mental illness.

However controversial Szasz’s views and those of his supporters might have been, they have influenced the mental health community and society in several ways. First, lay people, politicians, and professionals now often refer to mental illness as mental health “problems,” implicitly acknowledging the “problems in living” perspective Szasz described (Buchanan-Barker & Barker, 2009). Also influential was Szasz’s view of sexual orientation. Szasz was perhaps the first psychiatrist to openly challenge the idea that same-sex attraction represented a form of mental illness or disease (Szasz, 1965), which helped pave the way for the social and civil rights that gay and lesbian people now have (Barker, 2010). His work also inspired legal changes that protect the rights of people in psychiatric institutions and allow such individuals a greater degree of influence and responsibility over their lives (Buchanan-Barker & Barker, 2009).

Harmful Dysfunction

If none of the criterion discussed so far is adequate by itself to define the presence of a psychological disorder, how can a disorder be conceptualized? Many efforts have been made to identify the specific dimensions of psychological disorders, yet none is entirely satisfactory. No universal definition of psychological disorder exists that can apply to all situations in which a disorder is thought to be present (Zachar & Kendler, 2007). However, one of the more influential conceptualizations was proposed by Wakefield (1992), who defined psychological disorder as a harmful dysfunction. Wakefield argued that natural internal mechanisms—that is, psychological processes honed by evolution, such as cognition, perception, and learning—have important functions, such as enabling us to experience the world the way others do and to engage in rational thought, problem solving, and communication. For example, learning allows us to associate a fear with a potential

DIG DEEPER

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danger in such a way that the intensity of fear is roughly equal to the degree of actual danger. Dysfunction occurs when an internal mechanism breaks down and can no longer perform its normal function. But, the presence of a dysfunction by itself does not determine a disorder. The dysfunction must be harmful in that it leads to negative consequences for the individual or for others, as judged by the standards of the individual’s culture. The harm may include significant internal anguish (e.g., high levels of anxiety or depression) or problems in day-to-day living (e.g., in one’s social or work life).

To illustrate, Janet has an extreme fear of spiders. Janet’s fear might be considered a dysfunction in that it signals that the internal mechanism of learning is not working correctly (i.e., a faulty process prevents Janet from appropriately associating the magnitude of fear with the actual threat posed by spiders). Janet’s fear of spiders has a significant negative influence on daily life: she avoids all situations in which she suspects spiders to be present (e.g., the basement or a friend’s home), and she quit her job last month because she saw a spider in the restroom at work and is now unemployed. According to the harmful dysfunction model, Janet’s condition would signify a disorder because (a) there is a dysfunction in an internal mechanism, and (b) the dysfunction has resulted in harmful consequences. Similar to how the symptoms of physical illness reflect dysfunctions in biological processes, the symptoms of psychological disorders presumably reflect dysfunctions in mental processes. The internal mechanism component of this model is especially appealing because it implies that disorders may occur through a breakdown of biological functions that govern various psychological processes, thus supporting contemporary neurobiological models of psychological disorders (Fabrega, 2007).

The American Psychiatric Association (APA) Definition

Many of the features of the harmful dysfunction model are incorporated in a formal definition of psychological disorder developed by the American Psychiatric Association (APA). According to the APA (2013), a psychological disorder is a condition that is said to consist of the following:

• There are significant disturbances in thoughts, feelings, and behaviors. A person must experience inner states (e.g., thoughts and/or feelings) and exhibit behaviors that are clearly disturbed—that is, unusual, but in a negative, self-defeating way. Often, such disturbances are troubling to those around the individual who experiences them. For example, an individual who is uncontrollably preoccupied by thoughts of germs spends hours each day bathing, has inner experiences, and displays behaviors that most would consider atypical and negative (disturbed) and that would likely be troubling to family members.

• The disturbances reflect some kind of biological, psychological, or developmental dysfunction. Disturbed patterns of inner experiences and behaviors should reflect some flaw (dysfunction) in the internal biological, psychological, and developmental mechanisms that lead to normal, healthy psychological functioning. For example, the hallucinations observed in schizophrenia could be a sign of brain abnormalities.

• The disturbances lead to significant distress or disability in one’s life. A person’s inner experiences and behaviors are considered to reflect a psychological disorder if they cause the person considerable distress, or greatly impair their ability to function as a normal individual (often referred to as functional impairment, or occupational and social impairment). As an illustration, a person’s fear of social situations might be so distressing that it causes the person to avoid all social situations (e.g., preventing that person from being able to attend class or apply for a job).

• The disturbances do not reflect expected or culturally approved responses to certain events. Disturbances in thoughts, feelings, and behaviors must be socially unacceptable responses to certain events that often happen in life. For example, it is perfectly natural (and expected) that a person would experience great sadness and might wish to be left alone following the death of a close family member. Because such reactions are in some ways culturally expected, the individual would not be assumed to signify a mental disorder.

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Some believe that there is no essential criterion or set of criteria that can definitively distinguish all cases of disorder from nondisorder (Lilienfeld & Marino, 1999). In truth, no single approach to defining a psychological disorder is adequate by itself, nor is there universal agreement on where the boundary is between disordered and not disordered. From time to time we all experience anxiety, unwanted thoughts, and moments of sadness; our behavior at other times may not make much sense to ourselves or to others. These inner experiences and behaviors can vary in their intensity, but are only considered disordered when they are highly disturbing to us and/or others, suggest a dysfunction in normal mental functioning, and are associated with significant distress or disability in social or occupational activities.

15.2 Diagnosing and Classifying Psychological Disorders LEARNING OBJECTIVES By the end of this section, you will be able to:

• Explain why classification systems are necessary in the study of psychopathology • Describe the basic features of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) • Discuss changes in the DSM over time, including criticisms of the current edition • Identify which disorders are generally the most common

A first step in the study of psychological disorders is carefully and systematically discerning significant signs and symptoms. How do mental health professionals ascertain whether or not a person’s inner states and behaviors truly represent a psychological disorder? Arriving at a proper diagnosis—that is, appropriately identifying and labeling a set of defined symptoms—is absolutely crucial. This process enables professionals to use a common language with others in the field and aids in communication about the disorder with the patient, colleagues and the public. A proper diagnosis is an essential element to guide proper and successful treatment. For these reasons, classification systems that organize psychological disorders systematically are necessary.

The Diagnostic and Statistical Manual of Mental Disorders (DSM)

Although a number of classification systems have been developed over time, the one that is used by most mental health professionals in the United States is the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association (2013). (Note that the American Psychiatric Association differs from the American Psychological Association; both are abbreviated APA.) The first edition of the DSM, published in 1952, classified psychological disorders according to a format developed by the U.S. Army during World War II (Clegg, 2012). In the years since, the DSM has undergone numerous revisions and editions. The most recent edition, published in 2013, is the DSM-5 (APA, 2013). The DSM-5 includes many categories of disorders (e.g., anxiety disorders, depressive disorders, and dissociative disorders). Each disorder is described in detail, including an overview of the disorder (diagnostic features), specific symptoms required for diagnosis (diagnostic criteria), prevalence information (what percent of the population is thought to be afflicted with the disorder), and risk factors associated with the disorder. Figure 15.4 shows lifetime prevalence rates—the percentage of people in a population who develop a disorder in their lifetime—of various psychological disorders among U.S. adults. These data were based on a national sample of 9,282 U.S. residents (National Comorbidity Survey, 2007).

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FIGURE 15.4 The graph shows the breakdown of psychological disorders, comparing the percentage prevalence among adult males and adult females in the United States. Because the data is from 2007, the categories shown here are from the DSM-IV, which has been supplanted by the DSM-5. Most categories remain the same; however, alcohol abuse now falls under a broader Alcohol Use Disorder category.

The DSM-5 also provides information about comorbidity; the co-occurrence of two disorders. For example, the DSM-5 mentions that 41% of people with obsessive-compulsive disorder (OCD) also meet the diagnostic criteria for major depressive disorder (Figure 15.5). Problematic substance use is highly comorbid with other mental illnesses; 6 out of 10 people who have a substance use disorder also suffer from another form of mental illness (National Institute on Drug Abuse [NIDA], 2007).

FIGURE 15.5 Obsessive-compulsive disorder and major depressive disorder frequently occur in the same person.

Comorbidity As you’ve learned in the text, comorbidity refers to situations in which an individual suffers from more than one disorder, and often the symptoms of each can interact in negative ways. Co-occurrence and comorbidity of psychological disorders are quite common, and some of the most pervasive comorbidities involve substance use disorders that co-occur with psychological disorders. Indeed, some estimates suggest that around a quarter of

CONNECT THE CONCEPTS

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people who suffer from the most severe cases of mental illness exhibit substance use disorder as well. Conversely, around 10 percent of individuals seeking treatment for substance use disorder have serious mental illnesses. Observations such as these have important implications for treatment options that are available. When people with a mental illness are also habitual drug users, their symptoms can be exacerbated and resistant to treatment. Furthermore, it is not always clear whether the symptoms are due to drug use, the mental illness, or a combination of the two. Therefore, it is recommended that behavior is observed in situations in which the individual has ceased using drugs and is no longer experiencing withdrawal from the drug in order to make the most accurate diagnosis (NIDA, 2018).

Obviously, substance use disorders are not the only possible comorbidities. In fact, some of the most common psychological disorders tend to co-occur. For instance, more than half of individuals who have a primary diagnosis of depressive disorder are estimated to exhibit some sort of anxiety disorder. The reverse is also true for those diagnosed with a primary diagnosis of an anxiety disorder. Further, anxiety disorders and major depression have a high rate of comorbidity with several other psychological disorders (Al-Asadi, Klein, & Meyer, 2015).

The DSM has changed considerably in the half-century since it was originally published. The first two editions of the DSM, for example, listed homosexuality as a disorder; however, in 1973, the APA voted to remove it from the manual (Silverstein, 2009). While the DSM-III did not list homosexuality as a disorder, it introduced a new diagnosis, ego-dystonic homosexuality, which emphasized same-sex arousal that the patient viewed as interfering with desired heterosexual relationships and causing distress for the individual. This new diagnosis was considered by many as a compromise to appease those who viewed homosexuality as a mental illness. Other professionals questioned how appropriate it was to have a separate diagnosis that described the content of an individual’s distress. In 1986, the diagnosis was removed from the DSM-III-R (Herek, 2012). Additionally, beginning with the DSM-III in 1980, mental disorders have been described in much greater detail, and the number of diagnosable conditions has grown steadily, as has the size of the manual itself. DSM-I included 106 diagnoses and was 130 total pages, whereas DSM-III included more than 2 times as many diagnoses (265) and was nearly seven times its size (886 total pages) (Mayes & Horowitz, 2005). Although DSM-5 is longer than DSM-IV, the volume includes only 237 disorders, a decrease from the 297 disorders that were listed in DSM-IV. The latest edition, DSM-5, includes revisions in the organization and naming of categories and in the diagnostic criteria for various disorders (Regier, Kuhl, & Kupfer, 2012), while emphasizing careful consideration of the importance of gender and cultural difference in the expression of various symptoms (Fisher, 2010).

Some believe that establishing new diagnoses might overpathologize the human condition by turning common human problems into mental illnesses (The Associated Press, 2013). Indeed, the finding that nearly half of all Americans will meet the criteria for a DSM disorder at some point in their life (Kessler et al., 2005) likely fuels much of this skepticism. The DSM-5 is also criticized on the grounds that its diagnostic criteria have been loosened, thereby threatening to “turn our current diagnostic inflation into diagnostic hyperinflation” (Frances, 2012, para. 22). For example, DSM-IV specified that the symptoms of major depressive disorder must not be attributable to normal bereavement (loss of a loved one). The DSM-5, however, has removed this bereavement exclusion, essentially meaning that grief and sadness after a loved one’s death can constitute major depressive disorder.

The International Classification of Diseases

A second classification system, the International Classification of Diseases (ICD), is also widely recognized. Published by the World Health Organization (WHO), the ICD was developed in Europe shortly after World War II and, like the DSM, has been revised several times. The categories of psychological disorders in both the DSM and ICD are similar, as are the criteria for specific disorders; however, some differences exist. Although the ICD is used for clinical purposes, this tool is also used to examine the general health of populations and to monitor the prevalence of diseases and other health problems internationally (WHO, 2013). The ICD is in its 10th

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edition (ICD-10); however, efforts are now underway to develop a new edition (ICD-11) that, in conjunction with the changes in DSM-5, will help harmonize the two classification systems as much as possible (APA, 2013).

A study that compared the use of the two classification systems found that worldwide the ICD is more frequently used for clinical diagnosis, whereas the DSM is more valued for research (Mezzich, 2002). Most research findings concerning the etiology and treatment of psychological disorders are based on criteria set forth in the DSM (Oltmanns & Castonguay, 2013). The DSM also includes more explicit disorder criteria, along with an extensive and helpful explanatory text (Regier et al., 2012). The DSM is the classification system of choice among U.S. mental health professionals, and this chapter is based on the DSM paradigm.

The Compassionate View of Psychological Disorders

As these disorders are outlined, please bear two things in mind. First, remember that psychological disorders represent extremes of inner experience and behavior. If, while reading about these disorders, you feel that these descriptions begin to personally characterize you, do not worry—this moment of enlightenment probably means nothing more than you have had a range of experiences and emotions. Each of us experiences episodes of sadness, anxiety, and preoccupation with certain thoughts—times when we do not quite feel ourselves. These episodes should not be considered problematic unless the accompanying thoughts and behaviors become extreme and have a disruptive effect on one’s life. Second, understand that people with psychological disorders are far more than just embodiments of their disorders. We do not use terms such as schizophrenics, depressives, or phobics because they are labels that objectify people who have these conditions, thus promoting biased and disparaging assumptions about them. It is important to remember that a psychological disorder is not what a person is; it is something that a person has—through no fault of their own. As is the case with cancer or diabetes, those with psychological disorders suffer debilitating, often painful conditions that are not of their own choosing. These individuals deserve to be viewed and treated with compassion, understanding, and dignity.

15.3 Perspectives on Psychological Disorders LEARNING OBJECTIVES By the end of this section, you will be able to:

• Discuss supernatural perspectives on the origin of psychological disorders, in their historical context • Describe modern biological and psychological perspectives on the origin of psychological disorders • Identify which disorders generally show the highest degree of heritability • Describe the diathesis-stress model and its importance to the study of psychopathology

Scientists, mental health professionals, and cultural healers may adopt different perspective