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CHAPTER OUTLINE
LEARNING OBJECTIVES
INTRODUCTION
WHAT DOES ‘ABNORMAL’ MEAN?
WHAT CAUSES ABNORMAL BEHAVIOUR?
Biology and genetics
Psychodynamics and the parent–child relationship
Attachment and security
Learned behaviour
Distorted thinking
Integrative models
DISORDERS – SYMPTOMS AND CAUSES
Schizophrenia – a living nightmare
Mood disorders – depression
Anxiety disorders – when fear takes over
Eating disorders – bulimia and anorexia
Substance use disorders – abuse and dependence
Personality disorders – a way of being
FINAL THOUGHTS
SUMMARY
REVISION QUESTIONS
FURTHER READING
Abnormal
Psychology 15
Learning Objectives
By the end of this chapter you should appreciate that:
n abnormal psychology (or psychopathology) deals with sets of behaviours or symptoms that produce a functional impairment in people’s lives;
n psychological disorders (e.g. schizophrenia) have been documented across time and culture;
n throughout history, the causes of abnormal behaviour have been construed from a number of different perspectives;
n biological/genetic models focus on brain defects, biochemical imbalances and genetic predispositions as causes of psychopathology;
n Freudian, contemporary psychodynamic and attachment models focus on the effects of early parent–child experiences;
n behavioural models focus on the learning experiences that result in psychopathology;
n cognitive models focus on the effect of distorted thought processes;
n the diathesis–stress perspective suggests that the factors identified by each of the other models may work in accordance with one another;
n the developmental psychopathology perspective provides a framework for understanding how psychopathology develops from childhood to adulthood;
n these perspectives can help us understand the numerous disorders documented in classification systems such as the DSM-IV and the ICD-10;
n there are several major forms of psychopathology, including schizophrenia, mood disorders, substance abuse, eating disorders and personality disorders.
Abnormal psychology is the study of mental dis- orders (also called mental illness, psychological disorders or psychopathology) – what they look like (symptoms), why they occur (etiology), how they are maintained, and what effect they have on people’s lives. Mental disorders are surprisingly common. For example, a study conducted by the World Health
Organization examined the prevalence, or frequency, of mental disorders in people visiting medical doctors in primary care settings in 14 countries. As figure 15.1 shows, the study revealed that 24 per cent of these people had diagnosable mental disorders and another 10 per cent had severe symptoms of mental disorders (Üstün & Sartorious, 1995).
INTRODUCTION
What Causes Abnormal Behaviour? 317317
BIOLOGY AND GENETICS
Biological and genetic models assert that mental disorders are dis- eases, and symptoms of mental disorders are caused by factors such as brain defects (abnor- malities in the structures of the brain), biochemical imbal- ances (complex dysregulation processes involving various neurotransmitters) and genetic predispositions (risk for psycho- pathology carried via our genetic material). By and large, the evid- ence for brain defects and biochemical imbalances as causes of mental disorders is correlational, which means that, although we know that such biological problems occur among people with mental disorders, we don’t know whether they actually cause the disorder. Because the brain is a fairly malle- able organ, our behaviour and experiences can also affect our brain functioning, suggesting that the association between biology and abnormal behaviour may be reciprocal rather than unidirectional. Genetic models of mental disorder suggest that psychopatho- logy is inherited from parents, and there is certainly evidence for the familial transmission of many disorders. For example, monozygotic (identical) twins should be more likely than dizygotic (fraternal) twins to have the same disorder because they share 100 per cent of their genetic material, whereas dizygotic twins share only 50 per cent. For many disorders, this is exactly what research shows. But given that monozygotic twins share 100 per cent of their genetic material, you might expect them to have the same dis- orders 100 per cent of the time. But in fact they have the same disorders only about 50 per cent of the time. These findings have led researchers to conclude that, rather than being deterministic, genetics contributes about 50 per cent of the risk for mental ill- ness. Such findings show that it doesn’t make sense to question whether mental illness is a function of nature or nurture. Instead we need to focus on how the two interact.
PSYCHODYNAMICS AND THE PARENT–CHILD
RELATIONSHIP
Freud emphasized the role of the early parent–child relationship in the development of mental illness. According to Freud, to the extent that the child did not successfully negotiate the psycho- sexual stages (see chapter 14), mental illness would develop. But Freud didn’t focus on what actually occurred in the parent– child relationship (e.g. whether parents were actually poor care- takers). Instead, his focus was on the unconscious internal desires and motivations of the child (e.g. sexual and aggressive impulses)
and how the child negotiated them as s/he progressed through the early relationship with the child’s parents. For example, if an adult male found himself unable to deal with authority figures, this might be interpreted as unresolved aggressive impulses to- wards his father. Whether his father behaved as a harsh authority figure or not would be considered less relevant. So, according to Freud, mental illness is due to intrapsychic (i.e. within the mind) conflict. This means a person may have very little insight into the ‘true’ causes of their symptoms, as these are thought to be occurring at an unconscious level of processing. Many of Freud’s ideas have gone unsupported by research, but a number of them have proven to be fairly accurate. For example, there is ample evidence that people experience and process things at a non-conscious level (see Westen, 1998; also chapter 14) and that early interpersonal experiences affect later outcomes. In fact, this latter hypothesis became central to contemporary psycho- dynamic models of abnormal behaviour. Contemporary psychodynamic models (e.g., Kohut, 1977; Kernberg, 1976; Mitchell, 1988) also suggest that the early parent–child relationship is the original source of mental illness, and that what goes on in the mind of the child (and the adult) is important. But these models differ from Freud’s in that they focus more on interpersonal relationships than on intrapsychic conflict. These later models suggest that the early relationship between the child and the primary caregiver is crucial to the development of the self-concept, concepts of others, and the quality of relationships throughout life. The idea is that this early caregiver–child rela- tionship is internalized by children, so that they learn about them- selves and others from the manner in which the caregiver treats them. According to this framework, the nature of this internal- ized relationship and its resulting impact on the sense of self and the sense of others is what can create vulnerability to psycholo- gical problems.
ATTACHMENT AND SECURITY
The attachment model of psychopathology, developed by Bowlby (1969; 1973; 1980; see also chapter 9) resembles the con- temporary psychodynamic models in that it also emphasizes the early parent–child relationship and how the resulting models of self and others guide development. But rather than being inter- ested in people’s perceptions of their early experience, Bowlby was interested in the actual characteristics of the relationship. He relied on observational studies of parents and children to build his theory, rather than on retrospective reports of adults. The theory therefore has a strong empirical foundation. Attachment theory suggests that when parental behaviour fails to make children feel safe, secure, and able to turn to and trust the parent in times of need, then children will be unable to regulate their emotions and needs adaptively and will develop negative, ‘insecure’ views of themselves and others. This would put chil- dren at risk for developing psychological disorders. Research sup- ports this hypothesis, as ‘insecure’ children and adults show more psychopathology than ‘secure’ children and adults (see Dozier, Stovall & Albus, 1999; Greenberg, 1999).
biochemical imbalance complex neuro- transmitter dysregulation process invol- ving the various neurotransmitters in the brain
genetic predisposition likelihood of showing condition or characteristic carried by genetic material
familial transmission genetic transmis- sion of disorders
318318 Abnormal Psychology
Reconciling the roles of genetics and the
environment in risk for major depression
The research issue
As you have read in this chapter, genetic and environmental models make very different assumptions about the causes of depression. Kendler et al. (1995) conducted a study in an effort to determine the extent to which genetic and environmental factors contribute to depression. In their study, Kendler and his colleagues examined two important questions: (1) do genetic factors and stressful life events make unique contributions to risk for depression in women? and (2) do genetic factors and stressful life events interact to create risk for depression? In particular, the researchers wondered whether the association between stressful life events and risk for depression would be greater among people at high genetic risk compared to people at low genetic risk.
Design and procedure
To examine these questions, Kender and colleagues studied four groups of women: (1) women with a depressed monozy- gotic (MZ) twin, (2) women with a depressed dizygotic (DZ) twin, (3) women with a non-depressed MZ twin, and (4) women with a non-depressed DZ twin. Women with a depressed MZ twin are at the highest genetic risk for depression, and women with a non-depressed MZ twin are at the lowest genetic risk for depression. For each woman, they assessed whether the person in question had experienced a depressive episode in any given month over the course of approximately one year, and they recorded whether any severe life events occurred during each month over this one year time period.
Results and implications
Both stressful life events and genetic factors made unique contributions to depression. Regardless of genetic risk, stress- ful life events were associated with depression, and regardless of life stress, genetic risk was associated with depression.
n However, the impact of stressful life events on risk for depression was greater among women at high genetic risk than it was for women at low genetic risk (see figure 15.3). n Interestingly, the stressful life events that were found to be most strongly associated with depression were mainly interpersonal in nature (death of a close relative, serious marital problems, divorce/break-up, and assault), high- lighting the importance of relationship factors in risk for depression.
The findings suggest that both genetic risk and stressful life events are important factors in understanding women’s risk for depression. Moreover, consistent with a diathesis-stress model (see p. 319), women at high genetic risk who experi- ence a stressful life event in the interpersonal domain of their lives are at greatest risk of all. Therefore, to understand risk for depression among women best, we must consider both genetic factors and environmental factors.
Kendler, K.S., Kessler, R.C., Walters, E.E. et al., 1995, ‘Stressful life events, genetic liability, and onset of an episode of major depression in women’, American Journal of Psychiatry , 152, 833–42.
Resear ch close-up 1 Research close-up 1
MZ without depression DZ without depression DZ with depression MZ with depression
High
Low Absent Stressful life events
Present
Probability of onset^ Figure 15. Risk of onset of major depression as a function of genetic risk and stressful life events. Source: Kendler et al. (1995).
320320 Abnormal Psychology
As you read through the following sections on the various dis- orders, you might want to consider how a diathesis–stress process could describe how each comes about.
Developmental psychopathology
According to this model, psychopathology is best understood using a lifespan development approach. It considers how the negotiation and attainment of earlier developmental tasks affects people’s capacities to manage later tasks (e.g. Cicchetti, Rogosch & Toth, 1994). In other words, people may travel down one of many paths; their success or failure at various junctures along the way deter- mines the subsequent path that they follow. So earlier deficits in functioning may leave us unprepared to successfully negotiate subsequent related situations, putting us at even greater risk for psychopathology. For example, a young girl who is harshly and chronically criticized by her parents may develop low self-esteem and the expectation that people will not like her, which puts her at risk of becoming depressed. She may then have difficulty making friends in school because she is afraid of rejection. She may feel lonely and undesirable, her withdrawal leading to actual rejection by her peers, continuing her risk for depression. But if this young girl has a teacher who treats her with warmth and care and helps her learn how to make friends, her risk for depression might be reduced. This is because she is acquiring important skills that have the potential to change the course of her subsequent development.
For each disorder we will look at its symptoms and the course it takes. Then we will consider its causes, both biological/genetic and psychosocial, and the factors that affect its course. Prevalence rates (i.e. the cross-sectional proportion of occurrences of the disorder in the population) for various disorders are shown in figure 15.5.
SCHIZOPHRENIA – A LIVING NIGHTMARE
Images of schizophrenia are easy to conjure – a dishevelled person, alone, talking to himself or yelling at someone else that only he seems to see. This is a frightening image, for the symptoms it por- trays are extremely odd and disconcerting. Indeed, schizophrenia can be a frightening disorder to deal with, not only for those involved with schizophrenic people, but for the sufferers themselves. Schizophrenia is a severe mental disorder, experienced by many sufferers as a living nightmare, a fact highlighted by the high rate of suicide among schizophrenics (Caldwell & Gottesman, 1992; see table 15.1). As you read this section, try to imagine what it might feel like to experience some of the things schizophrenic people experi- ence. For example, many schizophrenic people hear voices. Have you ever heard someone call your name, only to find there was
DISORDERS – SYMPTOMS AND CAUSES
no one there? How did that feel? Rather disconcerting, most likely. Now magnify your feelings about 100 times and you may start to sense how the schizophrenic person feels.
Symptoms
Schizophrenia is character- ized by psychosis , or a break with reality. People who are
% of population
Substance abuse/dependence
30 25 20 15 10 5 0
Major depression Personality disorders
Phobias Obsessive-
compulsive disorders
SchizophreniaEating disordersBipolar disorder
Figure 15. Lifetime prevalence rates for psychological disorders. These rates are from studies conducted in the US (Kessler et al., 1994), but cross-national studies indicate similar rates of dis- orders in other countries such as Switzerland, Germany and Puerto Rico. Source: Kessler et al. (1994).
Table 15.1 Suicide: a serious mental health and public health problem
Facts about suicide Risk factors for suicide
n Suicide occurs across the world, but rates vary by culture n Self-inflicted injuries, including suicide, were the 12th leading cause of death in the world in 1998 n In all cultures, men are more likely than women are to complete suicide n Rates of suicide in children and adolescents are on the rise n People with mental disorders, especially depression, substance use disorders, schizophrenia, and borderline personality disorder, are at high risk for suicide
n Past history of attempted suicide n Talking about committing suicide n A clear plan to commit suicide n Available means (e.g. firearms, drugs) n Depression n Substance abuse n Hopelessness n Impulsivity n Stressful life events n Lack of social support n Saying goodbye to people n Giving away personal items
psychosis a break with reality, charac- teristic of schizophrenia
Disorders – Symptoms and Causes 321321
psychotic think and behave in ways that have little to do with reality, showing significant impairment in just about every im- portant domain of functioning – perception, thought, language, memory, emotion and behaviour. People with schizophrenia may exhibit any of these symptoms:
n Perceiving things that are not there – these hallucinations are usually auditory (e.g. hearing voices), but visual and tactile hallucinations (e.g. seeing God or the devil, or feel- ing that insects are crawling under your skin) also occur relatively frequently. n Believing things that are not true – paranoid delusions are particularly common. A schizophrenic woman may believe that the government is plot- ting against her or that aliens plan to kill her. Everything will be interpreted in the context of the delusion, even things that are meant to help, so medication will be seen as poison. Delusions of grandeur are also common: a schizophrenic person may believe that he is someone famous, such as Elvis or Jesus Christ, and may insist on behaving like and being treated as that person. n Using odd or bizarre language, such as idiosyncratic mean- ings for common words or made-up words (neologisms) that only have meaning to them. They may also go off on tangents when they speak. n Disturbances in affect – flat affect can result in a lack of facial expressions and emotionless, monotone speech, while in- appropriate affect is characterized by laughing when nothing funny has happened, crying when nothing sad has happened or getting angry when nothing upsetting has happened. n Behavioural disturbances in four important areas:
- odd mannerisms, such as repetitive movements or behaviours and odd facial expressions (e.g. grimaces);
- a significant lack of motivation, called avolition;
- difficulty taking care of themselves, including basic life skills such as paying bills, shopping, and dressing; and
- poor social skills, being socially withdrawn, and having disturbed relationships with others (the nature of inter- personal relationships plays a key role in the course of the disorder).
The symptoms of schizo- phrenia are grouped into two categories: positive and negat- ive symptoms. Positive symp- toms indicate the presence of something unusual (such as hallucinations, delusions, odd speech and inappropriate affect) and negative symptoms indicate the absence of some- thing normal (such as good social skills, appropriate affect, motivation and life skills).
The course of schizophrenia
Schizophrenia is a chronic disorder. Although some people have brief episodes of schizophrenic-like behaviour (called brief re- active psychoses), most people with schizophrenia suffer from symptoms for their entire lives. One common course of schizophrenia is a period of negat- ive symptoms and odd behaviour during which the person’s functioning slowly deteriorates (the prodromal phase), followed by a ‘first break’ – the first episode of positive symptoms. Some people experience an episode of positive symptoms with a few warning signs beforehand. The manifestation of symptoms can also take a number of different forms. For example, some people may be delusional but still be able to take basic care of themselves, carry on a conversation and succeed in school and work, whereas others may be completely debilitated by the disorder. Schizophrenia typically has its onset in late adolescence or early adulthood. Although it can start in childhood, this is quite rare. Sufferers don’t necessarily deteriorate over time, but they do have relapses into episodes of positive symptoms.
Causes of schizophrenia and factors affecting its course
1 Genetic and biological factors These account for our initial vulnerability to schizophrenia, although exactly how they do so is unclear. What is clear is that schizophrenia tends to be inherited. For example, monozygotic twins have the highest concordance rates for schizophrenia (Gottesman, 1991), meaning that they are more likely to both have schizophrenia if one of them has it, com- pared to people who share less genetic material (such as dizygotic twins or siblings). Interestingly, schizophrenics
paranoid delusions elaborate set of beliefs, commonly experienced by schizophrenics, characterized by signi- ficant distrust of others and feelings of persecution
positive symptoms in schizophrenia, symptoms that indicate the presence of something unusual, such as hallucina- tions, delusions, odd speech and inap- propriate affect
negative symptoms in schizophrenia, symptoms that indicate the absence of something normal, such as good social skills, appropriate affect, motivation and life skills
concordance rates the extent to which people show the same disorders
Pioneer
Emil Kraepelin (1856–1926), a German psychiatrist and one of the founding fathers of modern psychiatry, made three primary contributions to the field of mental illness. First, Kraepelin believed that mental illness was caused by biological factors. His work in this area helped define the field of biological psychiatry and research now supports a strong biological basis for some of the disorders in which Kraepelin was most interested (e.g. schizophrenia and bipolar disorder). Second, Kraepelin laid the foundation for modern classification systems used to diagnose mental dis- orders, which use patterns of symptoms rather than any one symptom in isolation. This led to his third contribu- tion, which was the classification of and distinction between schizophrenia and bipolar disorder.
Disorders – Symptoms and Causes 323323
n Changes in appetite – some find nothing appealing and have to force themselves to eat, resulting in significant weight loss, while others want to eat more and gain a lot of weight. n Changes in sleep habits – depressed people may be unable to sleep or want to sleep all the time. n A very low level of energy, extreme fatigue and poor con- centration. Depressed people have no motivation to do anything, often find themselves unable to get out of bed and unable to complete school or work assignments. They may move through their lives very slowly, feeling that even simple activities require too much energy. n Feeling very badly about themselves – low self-esteem, feel- ing worthless and blaming themselves for all that has gone wrong in their lives and the world. Depressed people tend to feel hopeless about the future and don’t believe they will ever feel better.
Major depressive disorder has negative consequences not only for how people feel about themselves and their future, but also for their relationships. During a depressive episode people tend to withdraw socially, feel insecure in relationships, elicit rejection from others and experience high levels of interpersonal conflict and stress. Romantic, family and peer relationships all suffer. Given their level of suffering, impairment and hopelessness, it is hardly surprising that depression is one of the biggest risk factors for suicide, with around 15 per cent of depressed people committing suicide (Clark & Goebel-Fabbri, 1999).
The course of the disorder
Major depressive disorder follows a recurrent course. Although some people have isolated episodes, most experience multiple episodes of depression that may become more severe over time (e.g. Lewinsohn, Zeiss & Duncan, 1989). Mild forms of depres-
sion with just a few symptoms rather than full-blown major depressive disorder can predict the onset of more serious depres- sion later on (e.g. Pine et al., 1999). Although depression was once thought to be a disorder of adulthood, we now know that it affects people of all ages, including children (figure 15.9). In fact, the age of onset of major
Figure 15. A depressed person will tend to withdraw socially, feel insecure, elicit rejection from others and experience high levels of inter- personal conflict and stress.
% of population
10 8 6 4 2 0
Separation anxiety
GeneralizedDepression anxiety disorder
Phobias
Attention deficit
hyperactivity disorder
Obsessive-
compulsive disorders
Figure 15. Children experience psychological disorders too. These rates are from studies in the US. Cross-national studies indicate that rates may differ somewhat in different countries because of dif- fering cultural values that result in different definitions of abnor- mality and different symptom expression. However, children in all cultures suffer from various psychological disorders.
Level of impairment
DepressionHypertension Diabetes Arthritis Back pain
Figure 15. Level of impairment caused by depression in comparison to physical disorders. Notice that depression is as impairing or more impairing than many common health problems. The impair- ment scale should be interpreted with regard to the relative impairment across disorders, rather than absolute impairment of each disorder. Source: Adapted from Üstün and Sartorius (1995).
324324 Abnormal Psychology
depressive disorder is decreasing, and the rates of major depres- sive disorder in childhood and adolescence are increasing rapidly. Early onset predicts a worse course of depression over time (e.g. Lewinsohn et al., 1994), so depression in childhood and adoles- cence is a serious problem that can lead to ongoing difficulties throughout life.
Causes of major depressive disorder and factors affecting its course
1 Genetic and biological factors Like schizophrenia, major depressive disorder can be genetically transmitted (e.g. McGuffin et al., 1996). As for biological factors, the current view is that no single neurotransmitter is associated with major depressive disorder. Instead, it most likely involves dysregulation of the entire neuro- transmitter system (Siever & Davis, 1991). Indeed, it may be the balance of various neurotransmitters that regulate mood. Major depressive disorder may also involve neuroendocrine dysfunction. Depressed people tend to have elevated cortisol levels (e.g. Halbreich, Asnis & Shindledecker, 1985). Cortisol is involved in regulating the body’s reaction to stress and becomes elevated under stress. This suggests that, physiologically, depressed people may be in a state of chronic stress and they are perhaps more reactive to stress than are non-depressed people (e.g. Gold, Goodwin & Chrousos, 1988). As we see in the next section, stress plays an important role in vulnerability to major depressive disorder.
2 Psychosocial factors Unlike schizophrenia, which almost certainly has a genetic and/or biological trigger, major depressive disorder can be caused by either genetic/biological or psycho- social factors. One of the primary psychosocial factors is life stress, including significant negative life events and chronically stressful circum- stances (e.g. Brown & Harris, 1989). Of course, many people ex- perience stressful situations, but they don’t all become depressed, suggesting that a diathesis–stress process might be occurring. Specifically, it may be the particular way we perceive and think about life stressors that leads to depression. Consistent with a cognitive model of psychopathology, people who think about life events in a pessimistic, dysfunctional way are more likely to get depressed than people who think about life events in an optimistic way (e.g. Metalsky, Halberstadt & Abramson, 1987). Beck (1967; Beck et al.,
- describes pessimistic ways of thinking about our- selves, the world and the future as cognitive distortions. Examples are viewing things in a black and white manner, focusing on and exaggerating negative aspects and minimiz- ing our positive qualities. When people engage in cognitive distor- tions, like those below, to explain their life circumstances, they put themselves at risk for experiencing negative moods like depression:
n All or nothing thinking – ‘I’m a total loser!’ n Overgeneralization – ‘I’m always going to be a total loser!’ n Catastrophizing – ‘I’m so bad at my job that I’m sure to fail, then I’ll get fired, I’ll be totally humiliated, nobody will ever hire me again, and I’ll be depressed forever!’ n Personalization – ‘It’s all my fault that my sister’s boyfriend broke up with her – if I hadn’t been so needy of her atten- tion, she would have spent more time with him and they would have stayed together!’ n Emotional reasoning – ‘I feel like an incompetent fool, therefore I must be one!’
Similarly, Seligman and colleagues (e.g. Abramson, Seligman & Teasdale, 1978) suggest that people who are vulnerable to depres- sion tend to offer internal, global and stable causal explanations for negative events (see also chapter 14). For example, if a date goes badly, reactions might include:
n It’s all because of me (internal); n I always do the wrong thing (global); and n I’ll never have a proper boyfriend (stable).
Negative interpersonal circumstances are particularly likely to play a role in depression. Marital, family and peer relations are often troubled, and interpersonal forms of stress – such as rela- tionships ending, conflicts and lack of supportive relationships – are consistently associated with depression (see Beach & Fincham, 1998; Davila, 2000; Hammen, 1991). Interpersonal models of depression highlight how the disorder can be both a cause and a consequence of interpersonal problems. For example, Coyne (1976) suggested that depressed people engage in behaviours that elicit rejection from others, and this rejection leads to further depression. Similarly, Hammen (1991) proposed that depressed people generate interpersonal stress in their lives, which then makes them more depressed. It’s pos- sible that, for some people, depression has its roots in childhood experiences (Cicchetti et al., 1994). An insecure attachment in childhood may set the stage for depression by putting children at a disadvantage in four important areas:
- Low self-esteem puts them at risk for a pessimistic way of viewing themselves and the world.
- Inability to successfully regulate their negative emotions leaves them unable to fend off feelings of depression.
- Never having learned to cope well with stress, they may employ inappropriate strategies (such as keeping problems hidden or ruminating on them).
- Negative views of others and learned dysfunctional ways of interacting with others (e.g. excessive dependence on, or complete avoidance, of others) puts them at risk for depres- sion through the negative effect it has on their interper- sonal relationships.
Symptoms of bipolar disorder
In bipolar disorder, depression alternates with periods of mania, which is virtually the polar opposite of depression. During a
cognitive distortions dysfunctional ways of thinking about the self, the world, other people and the future that can make people vulnerable to depression and other negative emotions
326326 Abnormal Psychology
off on a trip in their car, driving recklessly and leaving responsibilities behind. They may engage in frequent sex- ual indiscretions, putting themselves at risk for sexually transmitted diseases, pregnancy and relationship conflict. n A decreased need for sleep – even staying awake for days at a time. n High distractibility and poor concentration as the mind races with a million thoughts. n Speaking very quickly – others can barely get a word in dur- ing conversations.
The course of the disorder
The most common onset for bipolar disorder is in early adult- hood, but, like major depressive disorder, it can occur earlier. Bipolar disorder is a lifelong, recurrent disorder that can take a variable course. Although some people regularly alternate between mania and depression, the number of episodes, their timing and their order can vary widely. Bipolar disorder can be seriously debilitating, but with appro- priate medication many sufferers live highly productive, normal lives between episodes.
Causes of bipolar disorder and factors affecting its course
1 Genetic and biological factors There is even more evid- ence of genetic transmission for bipolar disorder than for major depressive disorder (Gershon, 1995). There is also evidence of dysfunction of various neurotrans- mitters, including serotonin, dopamine and norepinephrine, although it may not be the levels of neurotransmitters themselves that are problematic, but the pattern of neuronal firing. Sodium ions are critical in proper neuronal firing (see chapter 1), and lithium, which is used to treat bipolar disorder, is chemically sim- ilar to sodium, so lithium may work by regulating dysfunctional neuronal firing (e.g. Goodwin & Jamison, 1990).
2 Psychosocial factors Like schizophrenia, there is no evid- ence that psychosocial factors are the initial cause of bipolar dis- order. But they do influence the course of the disorder. Stressful life events, particularly those that disrupt social and biological regularities (e.g. birth of a child, change in work hours, travel), may lead to relapse (see Johnson & Roberts, 1995). Negative social relations may also lead to relapse. In particular, sufferers with high EE families are more likely to relapse (Miklowitz et al., 1988; see figure 15.6).
ANXIETY DISORDERS – WHEN
FEAR TAKES OVER
Anxiety is a set of symptoms:
n emotional (e.g. fear, worry) n physical (e.g. shortness of breath, heart pounding, sweat- ing, upset stomach) n cognitive (e.g. fear of dying, losing control, going crazy).
When someone experiences this cluster of symptoms, it is often called a panic attack. Like depressed mood, anxiety is a common experience – almost everyone has felt some level of anxiety in their lives. In many cir- cumstances, it is a normal adaptive experience, physiologically preparing our bodies to respond when we sense danger. Our autonomic nervous system (see chapter 3) gets us ready for fight or flight and then, when the danger has passed, calms us back down again so that we can go back to normal functioning. So how do we differentiate ‘normal’ fear from an anxiety dis- order? In addition to the level of impairment caused by the anxiety, a disorder often involves fear and anxiety in response to some- thing that is not inherently frightening or dangerous. For example, it is normal to feel anxiety in response to poisonous snakes, but it less normal to feel anxiety in response to pictures of snakes. Anxiety disorders have four things in common:
- each is defined by a specific target of fear (the thing the per- son is afraid of);
- anxiety or panic attacks are experienced in response to the target of fear;
- the target of fear is avoided by the sufferer; and
- anxiety disorders tend to be chronic – they tend to persist rather than come in episodes.
Symptoms and course of anxiety disorders
1 Specific phobias The most common and straightforward of the anxiety disorders are specific phobias – fear and avoidance of a particular object or situation (e.g. dogs, heights, flying). This anxiety may be very circumscribed, occurring only in response to the target of fear, and may result in impairment in only a very specific domain. For example, someone who is afraid of flying may lead a very normal, productive life but simply isn’t able to fly. This may impair their work if they are expected to travel for business, or
Pioneer
Kay Redfield Jamison (1946– ), Professor of Psychiatry at Johns Hopkins University School of Medicine, is an award- winning psychologist and expert in the field of bipolar dis- order, a condition from which she suffers. With Frederick K. Goodwin, she wrote one of the classic texts on bipolar disorder, Manic-depressive Illness. Her autobiography, An Unquiet Mind , has made a lasting impact because of the can- did and caring manner in which she describes life with bipolar disorder. She has also produced three television programmes about bipolar disorder. Jamison has served on the first National Advisory Council for Human Genome Research, and is clinical director for the Dana Consortium on the Genetic Basis of Manic-Depressive Illness.
Disorders – Symptoms and Causes 327327
their relationships if, for example, they can’t take a vacation with their partner. But it won’t usually affect other areas of their life.
2 Social phobia Social phobia tends to be more impairing because it often results in significant social isolation. You might think that people with social phobia are afraid of people or of social situations – but this isn’t the case. They are actually afraid
of negative evaluation and rejection by others and will attempt to avoid it at all costs. Social phobia ranges from relatively mild (e.g. fearing and avoiding public speaking only) to extremely pervasive (e.g. fearing and avoiding all social interaction except with family members).
3 Panic disorder Panic dis- order can also be quite debil- itating, especially when it is coupled with agoraphobia. Literally ‘fear of the market- place’, agoraphobia is often thought of as fear of leaving the house. More accurately, it is fear of situations in which escape would be difficult or there would be no one to help should panic occur. Panic disorder begins with sudden panic attacks that occur out of the blue. The disorder develops when people worry about hav- ing another panic attack and subsequently begin to avoid places and situations they associate with it. For example, if you had a panic attack while driving, you might avoid driving again. When someone avoids so many places and situations that they are finally unable to leave their home, they are said to have agoraphobia.
4 Obsessive-compulsive disorder You won’t be sur- prised to find that obsessive- compulsive disorder (OCD) is characterized by obsessions (unwanted, persistent, intru- sive, repetitive thoughts) and compulsions (ritualistic, repeti- tive behaviours). When someone with OCD experiences obsessions, such as fear of contamination, anxiety is generated. To reduce this anxiety, she might engage in compulsions, such as repetitive hand-washing. The compulsions reduce anxiety briefly, but the obsessions soon return, and the sufferer becomes caught in a vicious cycle. Sometimes OCD is fairly circumscribed, but often it begins to dominate people’s lives, causing significant impairment. Typical obsessions involve religion, contamination, fear of hurting some- one, fear of losing something important, and fear of saying or doing something inappropriate or dangerous. Typical compul- sions are hand-washing, checking, counting and hoarding.
5 Post-traumatic stress disorder Experiencing a traumatic event can lead to post-traumatic stress disorder (PTSD). It was first documented among war veterans who had been exposed to wartime atrocities, but we now know that it can occur in response to many types of event, including natural disasters, acci- dents, rape and physical abuse. And it isn’t just the victim who is vulnerable to the disorder. Someone who observes severe phy- sical abuse, for example, is also at risk. PTSD has a paradoxical set of symptoms. The target of fear is the trauma itself, which creates tremendous anxiety, so the suf- ferer will desperately try to avoid anything associated with the trauma. They may even lose their memory for the event. On the
Figure 15. A specific phobia will involve fear and avoidance of a particular object or situation.
obsessions unwanted, persistent, intrus- ive, repetitive thoughts
compulsions ritualistic, repetitive beha- viours that a person feels compelled to engage in
Pioneer
David Barlow (1942– ), Professor of Psychology and Director of the Center for Anxiety and Related Disorders at Boston University, is an expert on the nature and treat- ment of anxiety and related disorders (e.g. sexual dys- function). In his classic text, Anxiety and its Disorders , he describes the predominant cognitive-behavioural approach to understanding anxiety disorders. He has developed a series of empirically supported cognitive-behavioural treat- ments for various anxiety disorders and is particularly well known for his panic control treatment.
agoraphobia fear of situations in which escape would be difficult or help is not available should panic or anxiety occur
Disorders – Symptoms and Causes 329329
EATING DISORDERS – BULIMIA
AND ANOREXIA
Eating disorders have attracted a great deal of attention in recent years, particularly in university settings where they tend to be prominent. Yet despite greater public awareness, certain miscon- ceptions still exist. For example, many people think eating dis- orders are brought about by vanity. This couldn’t be further from the truth. Rather than being vain, people with eating disorders struggle with issues about who they are, what they are worth, whether they will be able to take care of themselves and how to negotiate relationships. Eating disorders are complex and difficult to overcome. There are currently two eating disorders included in the ICD- and DSM-IV – bulimia nervosa and anorexia nervosa. Although they differ in important ways, they have four things in common:
- a distorted body image (inaccurate assessment about shape and weight);
- an intense fear of being fat;
- a sense of self that revolves around the individual’s body and weight; and
- eating that is regulated by psychological rather than phy- siological processes, although the form of eating regulation is quite different for the two disorders.
Symptoms
People with bulimia tend to be of normal weight and are some- times even overweight. Bulimia nervosa is characterized by recurrent episodes of binge eating and purging. During a binge, bulimic people consume an enormous number of calories in a brief period of time and feel an overwhelming loss of control as they are doing so. The binge is then followed by purging behaviour – usually vomiting, taking laxatives, taking diuretics or using enemas, and sometimes fasting or excessive exercise. Other symptoms may include:
n somewhat chaotic lives; n a tendency to be impulsive, emotionally labile, sensitive to rejection and in need of attention; n depression and/or substance abuse.
Anorexia nervosa is characterized by a refusal to maintain normal body weight. People with anorexia restrict their food intake through diet and typically engage in excessive exercise. Their weight often becomes so low that their bodies stop func- tioning normally (e.g. females stop menstruating), and they often appear emaciated. Anorexics also tend to:
n be perfectionist, rule-bound and hard-working; n have a strong need to please others, but never feel special themselves; n be high-achievers, but also feel uncertain of their capacity to be independent.
Some people with anorexia also engage in binging and purging and have other features of their personalities and lives in com- mon with bulimics.
The course of eating disorders
Both bulimia and anorexia typically begin in adolescence and can become chronic. For example, about one third of people with anorexia will have a lifelong disorder. Both anorexia and bulimia pose significant health risks. This is particularly true for anorexia, in which almost 5 per cent of people die from malnutrition and other related complications.
Causes of eating disorders and factors affecting their course
1 Genetic and biological factors Research supports genetic transmission, but some suggest that it may not be the disorder itself that is inherited. They believe that a set of personality traits
- such as obsessiveness, rigidity, emotional restraint in the case of anorexia and impulsivity and emotional instability in the case of bulimia – might increase the likelihood of poor coping. The eat- ing disorder is seen as a maladaptive way of coping with stress (e.g. Strober, 1995). Biological models focus on dysfunction in the hypothalamus (the part of the brain related to eating behaviour; see chapter 5)
Figure 15. People with anorexia nervosa refuse to maintain normal body weight; they restrict their food intake and tend to engage in excessive exercise.
330330 Abnormal Psychology
and on serotonin dysregulation (e.g. Wolfe, Metzger & Jimerson, 1997; see Ferguson & Pigott, 2000). There is presently no evid- ence that these dysfunctions actually cause eating disorders, but they may affect their course.
2 Psychosocial factors One of the primary sets of psychosocial factors in the development and course of eating disorders are social pressures and cultural forces. In cultures where thinness is the ideal of beauty, eating dis- orders are most prevalent. There are expectations of thinness everywhere – in the media, in the family, and in society at large. Adolescents, particularly young women, often internalize these expectations, and their entire sense of self-worth may become dependent on being thin. Furthermore, they are usually socially reinforced for being thin. Think how often you have heard some- one say, or have even said yourself, ‘Oh, you’ve lost weight – you look great!’ For vulnerable young people, a seemingly benign comment like this reinforces the belief that they must be thin in order to be worthy of attention. But if everyone in a culture that values thinness grows up fac- ing the same pressures, why do some develop eating disorders and some not? Apart from possible genetic or biological vulner- abilities, the way people think about themselves and the world may make them vulnerable. Cognitive distortions such as, ‘If I eat one cookie, I will be a fat, horrible person’ or ‘Being thin will
make all the problems in my life go away,’ may increase vulner- ability to eating disorders (e.g. Butow, Beumont & Touyz, 1993). People who come from certain types of families may also be more vulnerable to particular types of eating disorders (Bruch, 1978; Minuchin, Rosman & Baker, 1978). For example, anorexia is thought to develop when families are very concerned about external appearances and prefer to maintain an impression of har- mony at the expense of open communication and emotional expression. These families tend to be enmeshed (family members are unaware of or unable to maintain personal boundaries), over- protective, rigid and conflict-avoidant. Anorexia might be a rebel- lion or an assertion of independence and autonomy, or it may serve to mask the real problems in the family. Other risk factors include families who diet, or parents who are critical of their child’s weight or appearance (e.g. Pike & Rodin, 1991). A recent perspective, which fits with family and genetic/per- sonality models, suggests that eating disorders are the product of maladaptive emotion regulation processes (e.g. Wiser & Telch, 1999). So food is used to help regulate emotions (typically negat- ive ones) when the person has not developed more adaptive strategies. Attachment theorists take a similar position, suggest- ing that people with certain forms of insecure attachment (e.g. avoidant) may distract themselves from upsetting, attachment- related concerns (e.g. fear of intimacy, low self-worth) by focus- ing on food and weight (Cole-Detke & Kobak 1996).
Eating disorders
As discussed in chapter 5, obesity is one of the so-called ‘diseases of affluence’ that beset many contemporary Western societies. But modern developed societies also manifest a range of disorders at the other end of the weight spectrum, known as eating disorders (i.e. anorexia nervosa and bulimia nervosa). These disorders appear to develop as outward signs of inner emotional or psychological distress or problems. For the sufferer, they seem to be a way of coping with difficulties in their life. Eating, or not eating, can be used to block out painful feelings. Without appropriate help and treatment, eat- ing problems may persist throughout the sufferer’s life. Anyone can develop an eating disorder regardless of age, race, gender or background, but young women seem to be most vulnerable, particularly between the ages of 15 and 25. This may well relate to the changes and challenges occurring in young women’s lives at around this period of personal development. Biological research suggests that genetic make-up may make someone more or less likely to develop an eating disorder. Within the psychosocial domain, a key person or people (for example, parents or relatives) may adversely influence other family members through their attitudes to food. Or someone might focus on food and eating as a way of coping with the stresses of high academic expectations or other forms of social and/or family pressure. Traumatic events can also trigger anorexia or bulimia nervosa. These events may be especially prominent during the teenage and young adulthood periods, such as the death of a parent or other close relative, being bullied or abused at school or at home, upheaval in the family environment (such as divorce) or concerns over sexuality. Eating disorders are complex illnesses with critical psychological elements requiring treatment as well as the physical aspects (such as the disturbed eating pattern and its biological consequences). A regular eating pattern, including a bal- anced diet, is needed to restore balanced nutrition. And helping someone to come to terms with the fundamental emotional issues underlying their eating disorder will enable them to cope in their future lives with personal difficulties in a way that is not harmful to them.
Striegel-Moore, R.H., Seeley, J.R., & Lewinsohn, P.M., 2003, ‘Psychosocial adjustment in young adulthood of women who experienced an eating disorder during adolescence’, Journal of the American Academy of Child and Adolescent Psychiatry , 42, 587–93.
Ever yday Psychology Everyday Psychology
332332 Abnormal Psychology
2 Psychosocial factors Numerous psychosocial factors have been implicated in the onset and course of substance problems. Reinforcement certainly plays an important role. Consistent with the tension-reduction hypothesis , continued substance use is reinforced because substances often lead to positive feelings and help people escape negat- ive feelings through use of these substances (Conger, 1956). Substance users are said to engage in ‘self-medication’, using substances to help relieve tension or temporarily eliminate feelings of anxiety or depression. People also learn to use substances through observation. Those whose families or peers use substances are at high risk for sub- stance use disorders (e.g. Jessor & Jessor, 1975). Learned associ- ations also affect the course of substance use. If someone comes to associate particular people, places or circumstances with sub- stance use, they are more likely to use the substance in similar circumstances (Collins & Marlatt, 1981). That is why people who get treatment for substance problems often relapse when they return to their former environment and social group. Cognitive factors also play a role in the development and course of substance problems, at least in the case of alcoholism. People who expect positive results from using alcohol (e.g. they think it will make them feel good or improve their social stand- ing) are more likely to use it and to develop alcohol problems (Marlatt, 1987; Smith, 1980). In addition, people who fall prey to the abstinence violation effect are more likely to relapse than are others (Marlatt, 1978). This effect occurs when a minor relapse (a violation of abstinence) leads to guilt, which then leads to a more severe relapse. So if an abstinent alcoholic has one drink, she may feel guilty and decide that, having already failed at abstinence, she may as well drink more. She ends up having a full- blown relapse instead of a momentary one. The notion of an ‘addictive’ personality has been suggested. This is a controversial topic. So far, there is no evidence for its existence, but research does indicate that some aspects of person- ality may contribute to substance problems. A disinhibited per- sonality style that includes impulsivity and antisocial traits may be the best personality predictor of substance problems (e.g. Shedler & Block, 1990). Consistent with the tension-reduction hypothesis discussed earlier, it is also possible that substance problems are masking some other form of psychopathology. But the research on this topic is mixed and suggests that problems such as depression are as likely to follow from substance prob- lems as they are to precede them (e.g. Schuckit, 1994). There are also broader environmental factors that may contribute to substance abuse, such as the extent to which sub- stance use is condoned by a particular culture (e.g. Westermeyer, 1999; Yeung & Greenwald, 1992). For example, groups whose religious values prohibit or limit the use of alcohol (e.g.
Muslims, Mormons, Orthodox Jews) show relatively low rates of alcoholism. Perhaps the best way to approach substance use disorders is from a multiple risk factor perspective, which suggests that the more risk factors someone experiences, the more likely he is to develop a problem (e.g. Bry, McKeon & Pandina, 1982). In addi- tion to the risk factors already discussed, many others for sub- stance abuse have been identified, including low socio-economic status, family dysfunction, peer rejection, behaviour problems, academic failure and availability of substances. Of course, because of the nature of the research in this field, some of these factors may be consequences of substance abuse instead of (or as well as) being risk factors.
PERSONALITY DISORDERS –
A WAY OF BEING
So far, the disorders we have described have traditionally been considered syndromes, which – like physical illnesses – are not part of people’s basic character structure. When treated appro- priately, these syndromes usually remit and people return to normal functioning, at least for a while. But personality disorders are different. They are disorders of people’s basic character structure – so there is no ‘normal func- tioning’ to return to. The personality disorders themselves are people’s ‘normal’ way of functioning, and appropriate treatment means learning entirely new ways of being.
Symptoms
All personality disorders have a number of things in common. They are:
n longstanding – i.e. begin at a relatively early age; n chronic – i.e. continue over time; and n pervasive – i.e. occur across most contexts.
The thoughts, feelings and behaviours that characterize personal- ity disorders are:
n inflexible – i.e. they are applied rigidly and resistant to change; and n maladaptive – i.e. they don’t result in what the person hopes for.
People with personality disorders usually don’t realize they have them. They experience themselves as normal and often feel that the people they interact with are the ones with the problems. The primary personality disorders and their key traits, as described in the DSM-IV (APA, 1994) are:
Cluster A – the odd and eccentric cluster Paranoid – suspicious, distrustful, makes hostile attributions Schizoid – interpersonally and emotionally cut off, unrespons- ive to others, a ‘loner’
abstinence violation effect a more severe relapse resulting from a minor violation of substance use abstinence (e.g. one forbidden drink leading to more)
tension-reduction hypothesis the notion that people use substances in order to reduce tension and negative affect
Disorders – Symptoms and Causes 333333
Schizotypal – odd thoughts, behaviours, experiences; poor interpersonal functioning
Cluster B – the dramatic and erratic cluster Histrionic – dramatic, wants attention, emotionally shallow Narcissistic – inflated sense of self-importance, entitled, low empathy, hidden vulnerability Antisocial – behaviours that disregard laws, norms, rights of others; lacking in empathy Borderline – instability in thoughts, feelings, behaviour and sense of self
Cluster C – the fearful and avoidant cluster Obsessive-compulsive – rigid, controlled, perfectionistic Avoidant – fears negative evaluation, rejection and abandonment Dependent – submissive, dependent on others for self-esteem, fears abandonment
As you can see, this organization of the personality disorders puts them into clusters. These clusters are thought to reflect disorders with common traits. Although the disorders within each cluster do show commonalities, it is also the case the there are high levels of comorbidity among disorders across clusters. Borderline personality disorder and antisocial personality dis- order (similar to what is often called psychopathy) have received more attention than the others, as they tend to have some of the most negative consequences, including suicide and violence.
Causes of personality disorders and factors affecting their course
1 Genetic and biological factors There is evidence of modest genetic transmission for some personality disorders, especially antisocial personality disorder, although environmental factors also play an important role (e.g. Cadoret et al., 1995). There is also evidence that children are born with different temperaments, which may serve as vulnerability factors. For example, inhibition – which predisposes children towards shyness and anxiety – may put them at risk for personality disorders char- acterized by those traits. Disinhibited children are outgoing, talk- ative, impulsive and have low levels of physiological arousal. These children may be at risk for personality disorders characterized by impulsivity, erratic or aggressive behaviour, or lack of empathy. Biological factors are also being explored as causes of some personality disorders, such as antisocial personality disorder. For example, research suggests that people with antisocial personal- ity traits show low levels of physiological arousal, which may account for their ability to engage in behaviours that normally cause people to feel anxious (e.g. Raine, Venables & Williams, 1990).
2 Psychosocial factors Cognitive, psychodynamic and attach- ment theorists all suggest that negative early experiences in the family put people at risk for developing personality disorders. The assumption is that this happens, at least in part, through the cognitions that people develop. Early experiences with people who fail to validate a child’s self-worth may be internalized and result in a deep-seated set of severely rigid and dysfunctional thoughts about the self, others and the world, which then translate into rigid behavioural pat- terns. For example, if parents are not available to help a child cope with stress but are critical or abusive instead, the child will learn that she can’t rely on her parents, even though she may desperately want to. She may learn to hide her feelings, to expect that she will be criticized and rejected by others, and so to avoid close interpersonal relationships, even if she secretly yearns for them. If this pattern continues to develop and becomes rigid as the child grow up, she may eventually develop an avoidant personality disorder. Research is beginning to suggest that temperamental and psy- chosocial factors interact. Kochanska (1995) found that children of different temperaments show more adaptive moral development in response to different qualities of the parent–child relationship. For example, fearful children respond better to gentle discipline, whereas non-fearful children respond better when they are securely attached to a parent. This suggests that the closer the parenting style matches the needs associated with that particular children’s temperament, the more adaptive their children will become. When a mismatch occurs, children may develop com- pensatory coping strategies, possibly leading to the rigid patterns that are associated with personality disorders.
Pioneer
Marsha Linehan (1943– ), Professor of Psychology and Director of the Behavioral Research and Therapy Clinics at the University of Washington, is best known for her con- tributions to the understanding and treatment of suicidal behaviour and borderline personality disorder. Linehan proposed that borderline personality disorder can be best understood from a biopsychosocial approach, which bases the disorder in the interaction of an underlying biological dysfunction and an invalidating, non-accepting family environment. Linehan developed dialectical behaviour therapy (DBT) as a treatment for borderline personality disorder and suicidal behaviour. DBT is an empirically supported treatment, which combines traditional Western approaches with Eastern Zen approaches.
