Psychological Disorders and Therapies 10 Pamela Hamilton/The Image Bank/Getty Images Focus Questions By the end of the chapter, you should be able to answer the following questions: ሁሁ ሁሁ ሁሁ ሁሁ ሁሁ ሁሁ ሁሁ ሁሁ ሁሁ ሁሁ What are some examples of culturally linked psychological disorders? What are the principal models used to understand psychological disorders? What are symptoms of the main anxiety disorders? What are the most common manifestations of impulse-control and conduct disorders? What are the principle major affective disorders? What are the most common substance-related and addictive disorders? What are dissociative disorders? What are the main sex- and gender-related disorders? What are the identifying characteristics of different personality disorders? What are the main approaches to therapies for psychological disorders? © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution.  Chapter Outline Chapter Outline 10.1 Models of Psychological Disorders Cultural and Historical Views of Psychological Disorders Some Definitions Current Models of Psychological Disorders American Psychiatric Association Classifications of Mental Disorders The Most Common Psychological Disorders 10.2 Anxiety Disorders Panic Disorder Generalized Anxiety Disorder Phobic Disorders 10.3 Disruptive, Impulse-Control, and Conduct Disorders Intermittent Explosive Disorder Oppositional Defiant Behavior Conduct Disorder Other Impulse-Control Disorders 10.4 Depressive, Bipolar, and Related Disorders Major Depressive Disorder Persistent Depressive Disorder Bipolar Disorder 10.5 Substance-Related and Addictive Disorders Substance Use Disorders Behavioral Addictions 10.6 Other DSM-5 Disorders Obsessive-Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Neurodevelopmental Disorders Dissociative Disorders Schizophrenia Spectrum and other Psychotic Disorders Sexual Disorders Somatic Symptoms and Related Disorders Personality Disorders 10.7 Therapies Medical Therapy Psychodynamic Therapy Cognitive-Behavioral Therapies Humanistic Therapy The Effectiveness of Therapies “But I don’t want to go among mad people,” Alice remarked. “Oh, you can’t help that,” said the Cat. “We’re all mad here. I’m mad. You’re mad.” “How do you know I’m mad?” said Alice. “You must be,” said the Cat, “or you wouldn’t have come here.” Lewis Carroll, Alice’s Adventures in Wonderland How, indeed, can we recognize madness (which, incidentally, is not a term commonly used in psychology; mental disorder, psychological disorder, or emotional disorder is more common). Does the cat know that Alice is mad simply because she has come where there are mad people? And is madness contagious? Is Alice justified in wanting to avoid mad people? Should we, like Alice, be cautious? © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Models of Psychological Disorders Section 10.1 10.1 Models of Psychological Disorders In Tim Burton’s movie of Alice in Wonderland, madness takes weird and unexpected forms. “You used to be much more . . . ‘muchier,’” the Mad Hatter says to Alice. “You’ve lost your muchness.” In Wonderland, it seems you simply need to have enough “muchness” to guarantee that you will not be mad. Cultural and Historical Views of Psychological Disorders Wonderland is not the only place that has its own special forms of what was then referred to as madness (this term, like the word insanity, is no longer used when referring to psychological disorders). Many cultures and historical periods have had their own forms of psychological disorders, too. Recognizing and understanding their various manifestations can shed light on our own culture- and era-specific disorders. Eighteenth-century Europe, for example, was swept by a wave of hysterical disorders. Their common symptoms were paralysis, deafness, blindness, and other physical incapacities. Hysteria is no longer used as a term for psychological disorders, having been replaced by the label conversion disorders. A disorder specific to the 19th century is Pibloktoq, an ethnic psychosis observed by Admiral Peary among Eskimo women (Ross, Schroeder, & Ness, 2013). Ethnic psychoses are psychological disorders limited mainly to one or a few ethnic or cultural groups. The primary symptoms displayed by people with Pibloktoq included a short period of intense mania during which victims ran about in extreme excitement, singing, shouting, and tearing off their clothes—which is not entirely sensible in Arctic regions. Subsequently, victims might weep, lose consciousness, or fall asleep and later awaken apparently normal. Windigo (witigo or wihtigo) is another pre-20th-century ethnic psychosis found among native North American tribes—mainly the Canadian Ojibway and Chippewa tribes—where victims were “bewitched” and turned into cannibals (Waldram, 2004). The condition appeared with warning signals such as nausea, vomiting, and increased anxiety. Many people suffering from these initial symptoms were afraid they would kill and eat a friend and might even ask to be killed themselves before they became completely mad. A relatively rare, culture-bound disorder is the condition called amok (whence comes our expression “to run amok”), most prevalent in Malaysia, the Philippines, and Southeast Asia. Victims are suddenly possessed by overpowering aggressive and violent urges and run about destroying property and trying to kill anyone in sight. The condition sometimes lasts until the victims manage to kill themselves, knock themselves senseless, or drop into a coma. Amnesia covering the period of being amok is common. In the research literature, amok is often described as the condition underlying mass murder (Hagan, Podlogar, & Joiner, 2015). A disorder that affects Latinos in Mexico, South America, and elsewhere is susto (the word means “fright” in Spanish). It appears when an intensely frightening (traumatic) episode convinces victims (mainly women) that their soul has left their body. Symptoms may include nervousness, insomnia, despondency, muscle tics, and diarrhea. In an effort to reunite the soul with the body, treatment for susto may involve recourse to curanderos/as—native practitioners of healing arts (Hoskins & Padron, 2018). © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Section 10.1 Models of Psychological Disorders Susto appears to be closely related to nervios (literally, “nerves” in Spanish), another Latin American disorder. It has many of the same symptoms as susto and is also more prevalent among women. Nervios, however, is a broader term that describes a condition linked with more general, ongoing stress rather than with a single intensely frightening or traumatic event (Hofmann & Doan, 2018). iStock/Thinkstock Photofusion/Universal Image Group Editorial/Getty Images ሁሁ Different forms of psychological disorders are often culture and era specific. This man suffers from what he suspects is brain fag, a West African disorder that follows prolonged periods of intense study and results in insomnia, difficulty concentrating, and depression. The woman is bulimic—an uncommon disorder outside North America and Western Europe. Of special interest to students is a condition called brain fag, which, thankfully for North American students, is found almost exclusively in West Africa. It is triggered by prolonged periods of intense study resulting in difficulty concentrating, insomnia, anxiety, and depression (Ebigbo, Elekwacchi, & Nweze, 2017). We too in North America and Western Europe have our own forms of psychological disorders, the most obvious of which are anorexia nervosa and bulimia. As we saw in Chapter 7, these disorders are rare in many other parts of the world. Not surprisingly, many ancient human cultures attributed madness to the work of gods or to possession by evil spirits. Windigo and susto are two examples. Witches were often thought to be responsible. As a result, in 1484, Pope Innocent VIII issued a papal bull (edict) exhorting all clergy to search constantly for witches. Two well-intentioned monks subsequently compiled a manual documenting the existence of witches and explaining how they might be hunted. They described the various signs that could be used to prove that a suspect was a witch. Most important among these were the red marks sometimes left by the devil’s claw on the witch’s © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Models of Psychological Disorders Section 10.1 skin, and the fact that witches do not sink when bound and tossed into water. In addition, this “divinely inspired” manual described the many methods of torture that might be used to convince the devil that a confession would be in order. Those found guilty of being witches were generally executed publicly. By around 1700, an estimated 40,000 to 100,000 witches had been executed in Europe and North America (Levack, 2015). Some Definitions Mental disorders are defined as patterns of behavior or thought that are unusual and unexpected and that are associated with significant distress and/or impairment in normal functioning. The expression psychological disorder has the same meaning as mental disorder: While the two are used interchangeably, the expression psychological disorder has fewer negative connotations than does mental disorder: It is more neutral. Insanity is a legal term, defined by law and determined by a court in consultation with mental health experts. Hence, it is a legal issue that might determine whether a convicted person is responsible for a crime. Individuals found not guilty by reason of insanity are frequently provided with treatment rather than punishment. The term insanity is seldom used in medicine and psychology, although it has been retained by the courts. The terms abnormality, mental illness, personality disorders, psychological disorders, emotional disorders, mental disorders, or other more specific descriptions are preferred. Current Models of Psychological Disorders How we look at and define psychological disorders depends greatly on the models we use. In one sense, models are guides or ways of looking at things. Models tell us what to look for when we’re trying to understand, explain, and define what we mean by psychological disorders. Among the various models used for this purpose are the statistical, the medical/biological, the cognitive-behavioral, the psychodynamic, the biopsychosocial, and the humanistic. The Statistical Model One way of determining whether a behavior is abnormal is in relation to its prevalence in the general population. According to this model, those whose behaviors or personality traits violate social norms, and are therefore demonstrably different from the majority, are abnormal in a statistical sense. Significant departure from normality with respect to emotional functioning, social behavior, perception, and so on may be directly related to mental health. Deviance is evident in behaviors and characteristics that have low frequency. To be afraid of red dirt is deviant because most people are not afraid of red dirt. But if you live where everybody knows red dirt is toxic, not being afraid of it might be abnormal (Figure 10.1). The statistical model is useful in that it provides an objective method for identifying abnormal behavior. For example, intellectual disabilities (also called intellectual development disorder or mental retardation) are defined as a significant departure from average intellectual and adaptive functioning. Thus, these disabilities are often defined in specific measurement terms (for example, a measured IQ below 70–75), coupled with significant limitations in adaptive behaviors. Similarly, disorders such as autism spectrum disorder and specific learning disabilities are defined in terms of behaviors that are not age-appropriate in a statistical sense. Specific learning disabilities are disorders that involve learning difficulties related © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Section 10.1 Models of Psychological Disorders to problems in using basic language or in understanding mathematical calculations. These disabilities are distinct from general mental retardation or other emotional disturbances. (Autism spectrum disorder is explained later in this chapter.) Figure 10.1: The statistical model of abnormality ሁሁ According to this model, being significantly different from other people is abnormal. Note that the definition of abnormality indicated by the purple shading at either end of the normal curve is imprecise and arbitrary. In other words, what is meant by being “significantly different from normality” is often vague. The Great Average abnormality normality abnormality Medical/Biological Models Medicine deals with physical (organic) malfunctions that are due to injury, infection, chemical imbalances, genetics, or other causes, and that can often be treated surgically or chemically. The medical view of psychological malfunction is analogous: It views psychological abnormality as a disease or illness caused by internal factors (infection, system malfunction, or genetic causes) and amenable to the same sorts of treatment that might be employed for organic malfunctions. The finding of high heritability of disorders such as bipolar disorders and schizophrenia suggests that, at least for some manifestations of these diseases, there may often be an underlying genetic cause. For example, there is evidence that as much as 60 percent of the risk of acquiring schizophrenia, and 40 percent of the risk of developing a serious depression, is due to identifiable genetic variations (van Os, 2014). Similarly, neuropsychological research provides a great deal of evidence that an overactive amygdala may be associated with a higher risk of depression (Daftary, Van Enkevort, Kulikova, Legacy, & Brown, 2019). And genomics research (research on the contributions of genes) has discovered a variety of links between genome (genetic complement) and different disorders (see, for example, Zavos et al., 2014). The most obvious advantage of the medical models is that they encourage the search for specific organic causes of various disorders and suggest means of dealing with them. They look not only at genes as a possible cause, but also at neurological functioning and especially at the © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Models of Psychological Disorders Section 10.1 role that various neurotransmitters play. The development of highly effective drug therapies for disorders such as depression is related directly to information that neuroscience provides about the role of neurotransmitters in areas of the brain involved in emotion. Cognitive-Behavioral Models The principal difference between medical models of abnormality and the cognitive-behavioral models lies in their explanations of causes. Whereas medical models ascribe abnormality to internal causes such as disease, injury, or chemical imbalances, cognitive-behavioral models claim that abnormal behavior is learned, just as is any other behavior. Cognitive-behavioral models are often based on conditioning theories or on the notion that psychological disorders involve cognitive problems such as might result from distortions of reality. Whereas medical models lead to treatments designed to eliminate the causes of malfunctioning, behavioral models concentrate instead on “unlearning” unacceptable behavior, and learning (or relearning) more normal forms of behavior. Related therapies sometimes use behavioral learning principles such as those involved in conditioning and may be directed toward altering subjects’ perceptions of the world and of themselves—in other words, toward changing cognitions. Psychodynamic Models As we saw in Chapter 9, the psychodynamic model describes how our basic libidinal urges (id) are continually being impeded by our immediate circumstances as well as by the fact that society does not permit unbridled expression of sexuality or aggression (superego). The result of this conflict is anxiety that we (ego) try to reduce in various ways, including using defense mechanisms. Peter Dazeley/Getty Images ሁሁ Cognitive-behavioral models of mental disorders suggest that abnormal behaviors and beliefs are learned and are sometimes apparent in the individual’s distortions of reality. Eating disorders such as anorexia provide examples of learned behaviors (the desirability of emulating culturally approved models of thinness) and of cognitive distortions of reality— evident in this young woman’s distorted perceptions of her body. If the anxiety is sufficiently severe, or if there is an overreliance on defense mechanisms, the result may be psychological disorders of various kinds. Also, if the individual stays stuck in a developmental stage or regresses to an earlier stage, development is said to be abnormal. Biopsychosocial Model The biopsychosocial model, first proposed by George Engel (1980), incorporates important elements of most of the preceding models. This model views psychological disorders as a combined function of biological, psychological, and social/cultural factors. As such, it includes elements of medical/biological, cognitive-behavioral, and psychodynamic approaches. The biopsychosocial model is especially concerned with trying to understand how biological influences (for example, genetics, infections, hormones, nutrition, toxins), psychological factors (stress and anxiety, problems of self-control, negative thoughts), and social/cultural pressures (career demands, religious constraints) interact to affect the individual’s physical © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Models of Psychological Disorders Section 10.1 and psychological health. The model maintains that wellness and illness are seldom a function of only one of these factors but result instead from their combined influences. Humanistic Models Humanistic models are not especially concerned with psychological disorders as these are defined by the American Psychiatric Association. As we saw in Chapter 9, humanistic psychologists such as Maslow were most concerned with healthy development— with self-­actualization. Humanistic models developed as a response to behaviorism and to Freud’s psychodynamic theory. Humanists felt that Freud’s theory exaggerated the negative aspects of human personality and that behaviorism presented an unrealistically mechanistic view. In contrast with psychodynamic and behaviorist approaches, humanistic models underline the importance of personal choice and the responsibility everyone has for self-improvement. Accordingly, therapeutic models associated with the humanistic model seek to accentuate and promote the positive aspects of human existence. Their focus is on enhancing the positive rather than eliminating the negative. Which Model? These various models show the complexity of this part of the human puzzle. It is not possible to say that one of the models is correct and the others not. Nor is it possible to state categorically that one is more useful than the others. Each leads to a different view of psychological disorders and to different forms of intervention or treatment. The statistical model is useful in providing a relatively objective means of identifying bizarre, unconventional behavior, although its value in increasing our understanding of abnormal behavior or our ability to deal with it is clearly limited. It says nothing about causes or possible interventions. Medical/biological models are valuable in providing methods for identifying and describing malfunctions, and often suggest very specific treatments for them, as is clear in the widespread use of medications that are often highly effective treatments for a variety of psychological disorders. The principal contribution of the cognitive-behavioral models has been the development of systematic learning-based and social-cognitive therapies that have proven very useful in many situations. Psychodynamic approaches, despite their historical influence, tend to be imprecise and speculative but continue to be widely used in psychiatry, especially in Europe (European Federation for Psychoanalytical Psychotherapy, 2019). The biopsychosocial approach presents the advantage of combining different models and thus considering a variety of factors that might be involved in psychological disorders. However, it presents no clear and simple way of understanding how the various factors interact and how the contribution of each might vary for different individuals and in different circumstances. © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Section 10.1 Models of Psychological Disorders Humanistic models are less concerned with psychological disorders than with psychological well-being. Their advantage is that they emphasize the positive and suggest ways of enhancing the joy of living. The various models of psychological disorders are summarized in Table 10.1. Table 10.1: Models of psychological disorders Model What therapist looks for Therapeutic approach Objective of therapy Statistical Uncommon behavior in a statistical sense Depends on the nature of the rare behavior Normalize Unresolved conflicts, anxiety, depression Psychoanalysis Achieve insight Any of a combination of therapies depending on the most important contributing factors and the effectiveness and availability of therapeutic options Restoration or maintenance of normal physical and psychological health and wellness Person-centered therapies; growth groups Positive growth; enhanced personal relationships; self-actualization Medical/ biological Psychodynamic Cognitivebehavioral Biopsychosocial Humanistic System malfunction; problems with organic, systemic, or genetic bases Inappropriate, learned behaviors; irrational or inappropriate beliefs about self or others Interactions among factors that are biological (genetics, hormones, and other physical characteristics), psychological (thoughts and emotions), and social/ cultural (ethnicity, culture, social group membership) Impediments to growth, happiness, and self-actualization Drug therapy, surgery, electroconvulsive shock therapy Cure disorder; control symptoms Cognitive-behavioral therapies (such as behavior modification, rational emotive behavior therapy, and dialectic behavior therapy) Change behavior; modify understanding; foster development of coping skills American Psychiatric Association Classifications of Mental Disorders Most of the difficult concepts in psychology cannot easily be defined in a single sentence or paragraph. This text requires many thousands of words to define psychology and lay out the pieces of the human puzzle that have been gathered so far. Still, as we saw earlier, psychological disorders can be defined in one sentence: In general, a psychological (or mental) disorder is a pattern of behavior or thought that is not reasonable or easily understood and that is associated with “clinically significant” distress or impairment in coping with the environment. © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Section 10.1 Models of Psychological Disorders This definition is implicit in the descriptions and classifications of mental disorders provided in the Diagnostic and Statistical Manual of the American Psychiatric Association, the most recent revision of which is known as DSM-5. There, each of the many different disorders is defined separately, mainly in terms of the nature, onset, and implications of characteristic symptoms. DSM-5 presents classifications of mental disorders in terms of major and minor categories, and is used extensively in psychiatric diagnosis. iStock/Thinkstock It describes 18 separate major categories ሁሁ Different models of psychological disorders of disorders. Earlier revisions have often provide different explanations and different added new disorders or removed older distreatments. Most agree that psychological orders. For example, Internet gaming disordisorders involve problems in coping with the der and eating disorders such as anorexia, world and, as in the case of the man shown here, bulimia, and binge eating disorder were significant distress and unhappiness. absent in the first manuals. Homosexuality, once included as a disorder, no longer is. In addition, labels for different disorders often change. What was formerly gender identity disorder is now gender dysphoria, hysteria is conversion disorder, and manic depression is bipolar disorder. One of the important criteria for most DSM-5 categories of psychological disorder is that the condition present significant distress or impairment in important areas of functioning. DSM-5 classifications are summarized in Table 10.2. Table 10.2: Major categories of mental disorders according to the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association Psychological disorder Examples Neurodevelopmental disorders Intellectual disability; autism spectrum disorder; attention-deficit/hyperactivity disorder (ADHD) Bipolar and related disorders Bipolar disorder Schizophrenia spectrum and other psychotic disorders Depressive disorders Anxiety disorders Obsessive-compulsive and related disorders Schizoaffective disorder; delusional disorder Major depressive disorder; persistent depressive disorder Panic attack; agoraphobia; specific phobia Hoarding disorder; trichotillomania (hair-pulling disorder) © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. (continued) Section 10.1 Models of Psychological Disorders Table 10.2: Major categories of mental disorders according to the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association (continued) Psychological disorder Examples Trauma and stressor-related disorders Posttraumatic stress disorder (PTSD); adjustment disorders Somatic symptom and related disorders Hypochondriasis; illness anxiety disorder Dissociative disorders Feeding and eating disorders Elimination disorders Sleep-wake disorders Sexual dysfunctions Gender dysphoria Disruptive, impulse-control, and conduct disorders Substance-related and addictive disorders Neurocognitive disorders Paraphilic disorders Personality disorders Dissociative amnesia; dissociative identity disorder Anorexia; bulimia; binge eating disorder Diagnosed in early childhood; for example, enuresis (bed wetting) Various forms of apnea; REM sleep behavior disorder; restless leg syndrome Hypoactive sexual desire; erectile disorder; genitopelvic pain/penetration disorder Gender incongruence Kleptomania; pyromania; oppositional defiant disorder; antisocial personality disorder Substance use disorder; alcohol use disorder; gambling disorder; tobacco use disorder Delirium; mild to severe dementia Pedophilia; other unusual sexual interests that lead to the use of force or cause distress, injury, or death Antisocial or paranoid personality disorder DSM-5 presents well-defined criteria for diagnosing disorders. Clinicians do not need to rely on their interpretation of what is meant by a classification; they need only determine whether certain symptoms are present and apply relatively definite rules for making the diagnosis. Diagnosis of mental disorders is often aided by reference to the four Ds: deviance, dysfunction, distress, and danger. Sometimes a fifth “D,” duration, is added. Simply put, deviance refers to the extent to which the presenting symptoms deviate from normal thoughts, behaviors, or emotions. Dysfunction relates to the degree to which the problem interferes with activities of daily life. Distress has to do with the severity of the individual's negative emotional reaction to the presumed disorder. Danger concerns the consequences of the disorder both for the individual and for others. Duration relates to the frequency and persistence of symptoms. Use of this four- or five-item checklist is helpful in separating more minor problems from serious disorders that require treatment. © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Section 10.1 Models of Psychological Disorders The Most Common Psychological Disorders A survey of psychological disorders in the United States reveals that the most commonly diagnosed categories of disorders are anxiety disorders, followed by impulse-control disorders, mood disorders, and substance use disorders (National Alliance on Mental Illness, 2019a; Kessler et al., 2005). When nicotine dependence is included among substance use disorders, it becomes the most frequently diagnosed disorder (Health Research Funding Organization, 2019a). Figures 10.2 and 10.3 are based on 2005 data and are presented for illustrative purposes. More current statistics are not readily available for the adult U.S. population. However, current surveys of mental health among youth reveal similar findings (Mental Health America, 2019a). Thus, 11.01 percent of youth (ages 12–17) report having experienced at least one major depressive episode during the past year, and 5.13 percent report dependence or abuse of illicit drugs or alcohol. Figure 10.2: Common psychological disorders ሁሁ The four most commonly diagnosed psychological disorders in the United States, based on a Percentage lifetime prevalence estimates sample of 9,282 English-speaking participants over age 18. 50 45 40 35 30 25 20 15 10 5 0 Anxiety disorders Impulse-control disorders Mood disorders Substance use disorders Any disorder Source: Based on data from Kessler, R. C., Patricia, P., Demler, O., Jin, R., Merikangas, K. R. & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–602. Of these disorders, anxiety and impulse-control disorders appear earliest, at a median age of 11 years; substance use disorders, at age 20; and mood disorders are the latest to appear, at a median age of 30 (Kessler et al., 2005) (Figure 10.3). The following sections deal with each of these five groupings of the most common psychological disorders: anxiety disorders; impulse-control disorders (now grouped in DSM-5 as disruptive, impulse-control, and conduct disorders), mood disorders (now included in separate groupings labeled bipolar and related disorders, and depressive disorders), substance use disorders (now included in a grouping of substance-related and addictive disorders), and a grouping of other DSM-5 disorders. © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Section 10.2 Anxiety Disorders Figure 10.3: Age of onset for psychological disorders ሁሁ Median age of onset for the four most commonly diagnosed psychological disorders in the United States. Median age of onset 35 30 25 20 15 10 5 0 Anxiety disorders Impulse-control disorders Mood disorders Substance use disorders Any disorder Source: Based on data from Kessler, R. C., Patricia, P., Demler, O., Jin, R., Merikangas, K. R. & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–602. 10.2 Anxiety Disorders A variety of disorders, initially labeled neuroses by Freud, are characterized by anxiety. Neuroses were defined as disorders characterized by high anxiety and insecurity leading to the excessive use of one or more defense mechanisms. The term neurosis is no longer used in diagnosis of psychological disorders. Anxiety is among the most devastating and the most baffling of human emotions. It can range from mild trepidation to acute terror and can occur in response to a variety of situations, or sometimes without any apparent provocation. In many cases it is both natural and normal; but sometimes it is maladaptive and irrational. It is the basis of several psychological disorders. Almost one in three people meet the criteria for diagnosis of an anxiety disorder at some point in their lives. Median age of onset is surprisingly young, at age 11 years—meaning that half of those diagnosed with an anxiety disorder will be diagnosed before that age. Panic Disorder A relatively common anxiety disorder involves recurring episodes of intense fear and anxiety, often accompanied by physical symptoms such as shortness of breath and heart palpitations. These panic attacks occur for no apparent reason. Victims often feel they might be having a heart attack or that they are in danger of fainting or even dying. In some individuals, they occur only once or twice. Those who suffer from recurrent and persistent panic attacks are diagnosed as suffering from panic disorder. It is not uncommon for patients suffering from other psychological disorders to also suffer from panic attacks (National Institute of Mental Health, 2018). © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Anxiety Disorders Section 10.2 Panic attacks are relatively common, affecting an estimated 2.4 million U.S. adults per year, more than two thirds of whom are women (MedTV, 2019). Among well-known people who have reportedly suffered panic attacks are Sigmund Freud, Kim Basinger, Tom Cruise, Donny Osmond, Princess Diana, Johnny Depp, and many others (Merrill, 2019). Generalized Anxiety Disorder Generalized anxiety disorder is marked by general rather than episodic sensations of anxiety in the absence of specific situations or objects that might be associated with anxiety reactions. The hallmark of this disorder is worry. Individuals suffering from generalized anxiety, sometimes termed free-floating anxiety, are predominantly tense, nervous, and fearful, and cannot associate their anxiety with anything specific. Although generalized anxiety is not marked by the terror and sensation of impending doom that is the hallmark of a panic attack, those suffering from it go through their days with an exaggerated sense of concern and apprehension and a sometimes crippling inability to relax. Generalized anxiety disorder is often a debilitating disease that is present in slightly more than 3 percent of the U.S. population (Anxiety and Depression Association of America, 2018). It appears to be clearly linked to increased susceptibility to a variety of physical diseases including autoimmune disorders such as rheumatoid arthritis, lupus, celiac disease, and many others (Watad et al., 2017). It is also highly predictive of other anxiety disorders as well as of substance use disorders (Asher & Aderka, 2018; Osland, Arnold, & Pringsheim, 2018). Phobic Disorders Phobias are intense, irrational fears, recognized by the person as unreasonable, and often leading to avoidance of certain situations. These disorders are typically chronic (meaning long-lasting or recurring) and can be distinguished in terms of the objects or situations that bring them about. Agoraphobia Literally, agoraphobia means fear of open or public places. It manifests itself as severe anxiety related to places or situations from which departure or return home may be difficult, and often leads to avoidance of such places. Subjects may experience anxiety at the thought of leaving home, or when traveling alone, being apart from friends, or being in strange places. Agoraphobia is often associated with serious personal distress. In extreme cases, subjects may become completely house-bound for prolonged periods. The prevalence of agoraphobia is uncertain, although some estimates suggest that nearly 5 percent of the U.S. population may have the disorder at some point in their lifetime (Right Diagnosis, 2019). Many people who experience panic attacks later develop agoraphobia. The disorder is seen more frequently in women than in men and most often begins in adolescence or early adulthood, although it may occur considerably later. (Figure 10.4 shows a hierarchy of some of the most common anxiety disorders.) © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Section 10.2 Anxiety Disorders Figure 10.4: An anxiety continuum ሁሁ Anxiety can range from very mild states of worry and vague or specific fears to increasingly serious and sometimes highly distressful or even debilitating psychological disorders. Mild Mild worry Mild fears Generalized anxiety Social anxiety Specific phobias Agoraphobia Panic Severe Terror Social Anxiety Disorder Social anxiety disorder involves fear of social situations—that is, fear of situations in which the individual is exposed to judgment of others. Its most common manifestations include the avoidance of social situations and of public behaviors such as speaking formally to a group. Fear of using public washrooms, eating in public, appearing at certain social gatherings, and writing or performing in public are other manifestations of social phobia. Social phobias often lead the individual to adopt a lifestyle and occupational role that don’t demand a great deal of social contact, thus permitting adequate adjustment and functioning. As a result, relatively few people seek clinical help for this disorder. © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Section 10.2 Anxiety Disorders Specific Phobias Specific phobias include the variety of other specific fears that are not agoraphobic or social. Some of the most common phobias are listed in Figure 10.5. The criteria for a phobia are simply that the fear be irrational, be completely out of proportion to the potential danger of the feared object or situation, and not be shared by a significant number of other people, and that it have been present for at least 6 months. Human phobias tend to be limited to a handful of common situations—or the anticipation of these situations—most of which imply some sort of danger. Thus, although few people have furniture or vegetable phobias, a much larger number are afraid of open spaces, heights, closed spaces, insects, snakes, and darkness. Figure 10.5: A selection of phobias ሁሁ Most phobias make some sort of evolutionary sense. Snake and spider phobias are relatively common; fear of the moon or of Brussels sprouts, not so much. Specific phobias Feared object or situation Acrophobia Heights Algophobia Pain Mysophobia Germs Hydrophobia Water Claustrophobia Being enclosed Agoraphobia Open places Anthropophobia People Thanatophobia Death Ochlophobia Crowds Monophobia Being alone Zoophobia Animals Nyctophobia Darkness, night Arachnophobia Spiders Ophidiophobia Snakes Photo Source: Sergey Karlov/iStock/Thinkstock (snake); Elena Garber/iStock/Thinkstock (spider) © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Disruptive, Impulse-Control, and Conduct Disorders Section 10.3 10.3 Disruptive, Impulse-Control, and Conduct Disorders In this category, DSM-5 includes intermittent explosive disorder, oppositional defiant disorder, conduct disorder, and disorders such as pyromania and kleptomania. Impulse-control disorders and conduct disorders, which are primarily childhood disorders, occur almost as frequently as anxiety disorders—in approximately one in four people. They manifest at about the same age (median age of 11; see Figure 10.3). Impulse-control disorders are marked by failure to resist an impulse to engage in a behavior that is harmful either to the person or to others. They are marked by highly impulsive behaviors characterized by lack of emotional and behavioral control. Note that high impulsivity is also characteristic of a variety of other psychological disorders including substance use disorders, attention-deficit/ hyperactivity disorder, conduct disorder, and, frequently, schizophrenia and mood disorders. Symptoms often include a range of aggressive behaviors. Intermittent Explosive Disorder Intermittent explosive disorder is marked by the repeated failure to resist aggressive impulses. Children diagnosed with this disorder have typically engaged in a number of excessively violent acts against people or property, or both. As adults, they are at higher risk of aggression toward others (Steakley-Freeman, Lee, McCloskey, & Coccaro, 2018) and, not infrequently, in their romantic relationships (O’Leary, Tintle, & Bromet, 2014). They may also be more prone to episodes of uncontrolled fury such as might be evident in road rage and are more susceptible to episodes of self-harm (Jenkins, McCloskey, Kulper, Berman, & Coccaro, 2015). Oppositional Defiant Behavior Another aggression-based impulse-control disorder is oppositional defiant disorder. It is characterized by a pattern of hostile, disobedient, defiant behavior toward authority figures. DSM-5 describes three main symptoms of oppositional defiant disorder: a characteristically angry, easily irritated mood; argumentative and defiant behavior; and vindictiveness. The disorder is sometimes apparent in children given to violent temper tantrums and persistent negative moods. Bullying, stealing, and vandalism are other possible symptoms. Oppositional defiant behavior is often linked with conduct disorder (Wiesner et al., 2014). Peter Dazeley/Photographer's Choice/Getty Images ሁሁ Oppositional defiant disorder is more common among boys than girls. It is marked by characteristically argumentative, defiant, and even hostile behavior, and is often associated with conduct disorder. © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Depressive, Bipolar, and Related Disorders Section 10.4 Conduct Disorder Conduct disorder is a disorder that begins in late childhood and often becomes more severe in adolescence. A related disorder more typical of adults is antisocial personality disorder, which is also included in the DSM-5 category of disruptive, impulse-control, and conduct disorders. Conduct disorder is far more common among boys than girls, affecting between 6 and 16 percent of boys and between 2 and 9 percent of girls (Mental Health America, 2019b). The disorder is marked by a persistent pattern of behaviors that violate the rights of others or that are socially inappropriate for the child’s age. Children with a conduct disorder are often described as callous and selfish. They typically relate poorly with others and don’t display a normal sense of guilt. They are frequently the school bullies, given to threatening, fighting, abusing animals, breaking rules, and vandalism. Other Impulse-Control Disorders There are several other impulse-control disorders, most of which are relatively uncommon. They include the following: • Kleptomania: an irresistible urge to steal things even when they are not needed or particularly valuable • Pyromania: a compulsion to set fires for personal pleasure and gratification • Trichotillomania: the recurrent pulling out of one’s hair, resulting in noticeable hair loss and considerable tension if the individual tries to resist 10.4 Depressive, Bipolar, and Related Disorders In the DSM-5 revision, what were formerly grouped as mood disorders are now two distinct classifications: bipolar and related disorders and depressive disorders. The main feature of these disorders is that they involve a significant disturbance in mood, typically expressed as depression or inappropriate euphoria (mania). Depressive disorders include major depressive disorder and persistent depressive disorder. Major Depressive Disorder Depressive disorders are the most common of all mood disorders, affecting an estimated 9.1 percent of the adult U.S. population in a given year (Centers for Disease Control and Prevention, 2015b). Current surveys indicate that women are more likely than men to experience major depression with highest frequencies being found among middle-aged women (45 to 64 years). Depression is also more frequent among the unemployed and the uneducated (Ariasde la Torre, Vilagut, Martin, Molina, & Alonso, 2018). © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Depressive, Bipolar, and Related Disorders AE Pictures Inc./DigitalVision/Getty Images ሁሁ Depressive disorders are the most common of all mood disorders, affecting nearly 1 in 10 U.S. adults each year. Although depression is somewhat more frequent among women and among those who are unemployed, it is found in all circumstances of life, including, as shown here, even the most advantageous social and economic conditions. Section 10.4 Major depressive disorder is characterized by a collection of symptoms including apathy, listlessness, despair, loss of appetite, sleep disturbances, unwavering pessimism, and thoughts of suicide (although not all these symptoms need be present in every case). Some people have a single major depressive disorder event in their lifetime, although it is more common to have several episodes. DSM-5 criteria for major depressive disorder stipulate that there be at least one major depressive episode. A depressive episode is defined as a period of at least 2 weeks during which the individual suffers from a depressed mood and/or loss of interest and pleasure in normal life activities. The depressed mood typically characterizes most of every day. A clear relationship appears to exist between suicide and depression. In fact, more than 90 percent of people who commit suicide suffer from depression or some other psychological disorder (Sarhan et al., 2019). Persistent Depressive Disorder Whereas a major depressive episode lasts at least 2 weeks, persistent depressive disorder (formerly labeled dysthymic disorder or dysthymia) describes a chronically depressed mood that lasts at least 2 years and that is characteristic of most days during that period. Except for its longer duration, persistent depressive disorder is marked by much the same symptoms as a major depressive episode, but of lesser severity. In effect, it is a lower-grade, chronic, longterm depression. DSM-5 also identifies several other forms of depression that vary in terms of their duration, intensity, or precipitating causes. For example, postpartum depression describes serious depression following birth. It affects some 10 to 15 percent of new mothers and is thought to be related to physical and hormonal changes following childbirth, as well as to stressors associated with adjusting to major changes in life circumstances. Interestingly, after the earthquake and tsunami in Japan in 2011, incidence of postpartum depression in the tsunami zone increased dramatically (Nishigori et al., 2014). Psychotic depression describes a persistent depression that is associated with, or triggered by, some other form of psychosis such as delusions (for example, overwhelming feelings of worthlessness or failure), hallucinations (persistent hearing of voices or visual hallucinations), or some other serious break with reality. As many as one quarter of patients admitted to hospitals for treatment of depression are diagnosed as having psychotic depression (Depression Health Center, 2019). © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Substance-Related and Addictive Disorders Section 10.5 Bipolar Disorder Bipolar disorder, previously labeled manic depression and also known as bipolar affective disorder, is approximately half as common as major depressive disorder, affecting an estimated 2.8 percent of the U.S. adult population (Harvard Medical School, 2007). DSM-5 presents diagnostic criteria for two types of bipolar disorder, bipolar I disorder and bipolar II disorder. Both are marked by recurring episodes of depression. The major difference between the two is that bipolar I is characterized by periods of intense mania alternating with depression. Mania contrasts sharply with periods of depression. It is characterized by periods of extreme and intense activity, irrepressible good humor, grandiose plans and involvements, and overwhelming displays of energy and joie-de-vivre. In contrast, bipolar II disorder is diagnosed when the individual has not had a full-blown manic episode but experiences, instead, milder forms of elation and perhaps hyperactivity (termed hypomania). In states of hypomania, the person tends to be highly energetic and supremely confident. In both forms of bipolar disorder, the attacks are cyclical. That is, mania (or hypomania) is followed by depression, which may then be followed by another period of mania, and so on. More frequently, subjects experience a single episode of mania or hypomania and one of depression, not necessarily in that order, and may then be free of both for long periods—sometimes even decades. Family and twin studies provide strong evidence of a genetic basis for bipolar disorder, where the heritability coefficient has been estimated at over 50 percent (Song et al., 2018). In this context, heritability coefficient means the extent to which the variability in a characteristic is due to genetics. 10.5 Substance-Related and Addictive Disorders DSM-5 describes two kinds of substance-related disorders: substance use disorders, defined in terms of the abuse of or dependence on drugs such as alcohol or narcotics; and substanceinduced disorders, such as might be brought about by medication or by withdrawal from substance use. Substance Use Disorders Substance use disorders in DSM-5 no longer distinguish between substance dependence and substance abuse. Dependence is defined mainly in terms of drug tolerance and withdrawal symptoms. Drug tolerance refers to the fact that, with increasing use, many drugs have diminishing effects. As we saw in Chapter 2, most abused drugs are effective precisely because they increase the release of dopamine and other neurotransmitters associated with pleasure and reinforcement or block their reuptake. As a result, the brain produces less of the affected neurotransmitter as it becomes increasingly dependent on external sources. Hence, tolerance increases and the individual needs to use more of the drug to obtain the same effect. © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Substance-Related and Addictive Disorders Section 10.5 Withdrawal, the physiological and psychological effects of stopping drug use, results from a sudden reduction in stimulation of those areas of the brain associated with pleasure and typically leads to feelings of dysphoria—feelings of profound unhappiness and distress (the opposite of euphoria). Withdrawal symptoms vary depending on the drug, its manner of ingestion, and the individual. It is often marked by depression and anxiety, as well as by a strong craving, this being the hallmark of addiction. Sudden and complete withdrawal from alcohol use following dependence can be fatal. DSM-5 includes descriptions and diagnostic criteria for nine different kinds of substance use disorders based on the substances used: alcohol, cannabis (marijuana), hallucinogens, inhalants, opioids (heroin, for example), sedatives and hypnotics (for example, valium), stimulants (such as cocaine and methamphetamines), tobacco, and other or unknown substances. A 10th substance, caffeine, is included in the list but does not qualify for a diagnosis of substance use disorder. Diagnosis of a substance use disorder is based on the presence of 11 criteria, including the person’s apparent inability to control use, significant distress and social impairment as a result of substance use, related high-risk behaviors, and symptoms of increasing tolerance and withdrawal symptoms. The severity of the substance use disorder is assessed based on the number of criteria that are met. Nearly half (47.8 percent) of twelfth-grade students have tried one or more drugs during their lifetime, although only half that number (24 percent) describe themselves as current users (those who have used the drug in the past 30 days). Nicotine and alcohol continue to be the most widely used drugs (National Institute on Drug Abuse, 2019). Drugs are typically classified in terms of their effects rather than their composition. There are narcotics such as morphine, fentanyl, and opium, addictive drugs that produce sensations of well-being; sedatives, such as anti-anxiety drugs and barbiturates; stimulants, such as the amphetamines and cocaine; and hallucinogens, such as LSD, ecstasy, and Rohypnol. Marijuana is also ordinarily classified as a hallucinogenic drug, although its effects are seldom as dramatic as those of LSD or ecstasy (see Table 10.3). Figure 10.6 presents drug-use data for eighth, tenth, and twelfth graders based on surveys spanning the years 1991 through 2018. During those years, there were reductions in the lifetime use of all classes of drugs except for marijuana, which is no longer illegal in many jurisdictions, and vaping, which was not an option in 2018. There have been especially noticeable declines in alcohol and cigarette usage in those decades (Johnston et al., 2019). A 2017 survey of college-age adults found that marijuana use among college students is lower than among their noncollege peers (below 6 percent daily use compared with 13.2 percent for noncollege participants). Nicotine use is also significantly lower among college students (2.0 percent compared with 14.4 percent); however, alcohol use is somewhat higher (62 percent compared with 56 percent; National Institute on Drug Abuse, 2018). © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Section 10.5 Substance-Related and Addictive Disorders Figure 10.6: Drug use among U.S. high school students ሁሁ Trends in lifetime prevalence of drug use for U.S. high school students, 1991–2018, based on surveys of eighth, tenth, and twelfth grade students. 1.1 0.6 Heroin 4.6 2.6 Cocaine 1991 2018 Hallucinogens 6.1 4.1 Tranquilizers 5.5 5.4 Inhalants 6.6 Amphetamines 7.7 Any illicit drug other than marijuana 17.0 12.9 19.1 14.2 Cigarettes 53.5 16.1 22.7 29.7 Marijuana Vaping 33.4 Alcohol 80.1 41.2 0 10 20 30 40 50 60 70 80 90 100 Percentage who have ever used the drug Source: Based on Johnston, L. D., Miech, R. A., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick, M. E. (2019). Monitoring the Future national survey results on drug use 1975-2018: Overview, key findings on adolescent drug use. Ann Arbor, MI: Institute for Social Research, University of Michigan. Retrieved April 9, 2019, from http://www.monitoringthefuture.org//pubs /monographs/mtf-overview2018.pdf © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Section 10.5 Substance-Related and Addictive Disorders Table 10.3: Symptoms of drug use and their effects on the nervous system Effects on nervous system Drug Early symptoms Long-term symptoms Narcotics (opium, morphine, heroin, codeine, methadone, fentanyl) Medicinal breath Traces of white powder around nostrils (heroin is sometimes inhaled) Red or raw nostrils Needle marks or scars on arms Long sleeves (or other clothing) at inappropriate times Physical evidence may include cough syrup bottles, syringes, cotton swabs, and spoon or cap for heating heroin Loss of appetite Constipation Death from overdosing is possible and increasingly frequent with fentanyl (which is many times more potent than morphine or heroine) Bind to painkilling sites to dull sensation of pain; block reuptake of neurotransmitters such as dopamine Mimic endorphins (cause sensations of pleasure and well-being) With chronic use, the brain may stop producing endorphins so that user develops tolerance and craves more drugs to feel good Withdrawal symptoms when discontinued Possible convulsions Activate GABA receptors (which are inhibitory and cause drowsiness) GHB increases dopamine levels in the brain (associated with sense of well-being) Sedatives (barbiturates, tranquilizers, alcohol, Rohypnol and GHB [the “date-rape” drugs]) Stimulants (cocaine, crack, amphetamines, caffeine, nicotine) Symptoms of alcohol consumption with or without odor: Poor coordination and speech Drowsiness Loss of interest in activity Excessive activity Irascibility Argumentativeness Nervousness Pupil dilation Dry mouth and nose with bad breath Chapped, dry lips Scratching or rubbing of nose Long periods without sleep Loss of appetite Loss of appetite Possible hallucinations and psychotic reactions Caffeine and amphetamines promote release of noradrenaline (causes excitement and wakefulness) Cocaine and crack promote release of dopamine and inhibit its reuptake (causes sense of euphoria); leads to tolerance and addiction © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. (continued) Section 10.5 Substance-Related and Addictive Disorders Table 10.3: Symptoms of drug use and their effects on the nervous system (continued) Drug Early symptoms Long-term symptoms Effects on nervous system Hallucinogens (marijuana LSD, PCP, mescaline, psilocybin) Odor on breath and clothing Animated behavior or its opposite Bizarre behavior Panic Disorientation None definite for marijuana Possible contribution to psychoses and possible recurrence of experiences later Stimulate serotonin activity Interfere with noradrenaline activity (produces hallucinations) Inhalants (glue, paint thinner, aerosol sprays, solvents, other combustibles) Odor of glue, solvent, or related substance Redness and watering of eyes Appearance of alcoholic intoxication Physical evidence of plastic bags, rags, aerosol glue, or solvent containers Disorientation Brain damage Long-term use can break down myelin, leading to muscle spasms, tremors, and other physical problems Behavioral Addictions For the first time in any revision of its diagnostic manual, the American Psychiatric Association has included behavioral (rather than simply substance) addictions: gambling disorder and Internet gaming disorder. The addition of behavioral addictions has been somewhat controversial, although neurological evidence suggests that the same reward systems in the brain are activated by abused substances and by gambling (Peterson & Forlano, 2017). Gambling disorder is marked by an overwhelming and persistent urge to gamble where gambling becomes a constant preoccupation and need that cannot easily be discontinued. Criteria for diagnosis require that the problematic gambling behavior lead to significant impairment or distress, that it have been ongoing for at least 12 months, and that it be marked by at least four of nine listed criteria. These criteria include the need to gamble increasing amounts to achieve the same satisfaction and excitement; gambling in response to feelings of guilt, anxiety, or depression; lying to conceal the activity or associated losses; inability to stop gambling in spite of efforts to do so; and loss of employment or relationships as a result of the behavior. There is evidence that gambling disorder may be associated with a variety of other psychiatric disorders (Hellberg, Russell, & Robinson, 2018). Some forms of cognitive-behavioral therapy have been shown to be effective for reducing or eliminating gambling disorder (ChalletBouju, Bruneau, Victorri-Vigneau, & Grall-Bronnec, 2017). © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Other DSM-5 Disorders Section 10.6 Internet gaming disorder is defined as the persistent and recurring use of the Internet to play games, either alone or with other players, where the activity leads to significant impairment and distress. Internet gaming disorder is marked by an overriding, all-consuming preoccupation with Internet or computer-based games. Diagnosis of Internet gaming disorders is difficult, given that many children and adults spend many hours playing these games without experiencing a ClarkandCompany/E+/Getty Images high degree of preoccupation or of withሁሁ A relatively new DSM-5 disorder is Internet drawal symptoms when prevented from gaming disorder. Its roots may begin very early. playing. Some researchers suggests that, at least in this respect, Internet gaming is quite different from Internet gambling (or other forms of gambling) (see, for example, Bae, Han, Jung, Nam, & Renshaw, 2017). 10.6 Other DSM-5 Disorders The four groupings of psychological disorders we’ve considered so far—anxiety disorders; disruptive, impulse-control, and conduct disorders; depressive, bipolar, and related disorders; and substance-related and addictive disorders—are the four most commonly diagnosed in the United States. DSM-5 lists a total of 18 separate categories of mental disorders. Some of the others are summarized in the sections that follow. Obsessive-Compulsive and Related Disorders Obsessive-compulsive disorder (OCD) is defined by the presence of recurring thoughts or impulses that appear irrational to the person having them (obsessions) and/or behaviors that are not perceived as the result of the individual’s wishes but give rise to intense urges to engage in them, and that result in anxiety when they are resisted (compulsions). Thus, a compulsion is a behavior and an obsession is a thought. Both obsessions and compulsions are perceived as incompatible with the individual’s nature, but neither can easily be resisted. The most common obsessions revolve around cleanliness and might include fear of germs and of dirt, and fear of thinking evil thoughts. They also sometimes take the form of repetitive thoughts of violence, accompanied by considerable fear of engaging in some highly undesirable behavior. Alternatively, obsessions may be marked by perpetual indecision and doubting that can be severe enough to prevent the person from reaching any decision. Compulsions typically involve a strong impulse to engage in some senseless and meaningless act constantly (for example, checking drawers and locks or touching certain objects repeatedly). They are often centered on washing and cleansing rituals. Evidence suggests that about 1.2 percent of the adult U.S. population can be classified as having obsessive-compulsive disorder. The disorder is approximately three times more common among females than males (National Institute of Mental Health, 2017). © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Other DSM-5 Disorders Section 10.6 Hoarding disorder is now classified under the grouping of obsessive-compulsive and related disorders. Hoarding disorder is characterized by an overpowering inability to part with possessions, no matter their value. Some people hoard animals—as in the case of the man who had more than 100 cats in his home (Gerson, 2010). Others simply allow all their possessions and acquisitions to continue to accumulate in their dwellings. In some cases, even objects they have identified and bagged as garbage are kept indefinitely. Compulsive shopping is sometimes linked with hoarding disorder (Faraci, Perdighe, Del Monte, & Saliani, 2018). Also, hoarding disorder is frequently associated with higher anxiety and higher scores on neuroticism scales (Hezel & Hooley, 2014). Trauma- and Stressor-Related Disorders Psychological disorders that appear following exposure to an extremely traumatic event— such as war, rape, or a horrendous accident—sometimes take the form of posttraumatic stress disorder (PTSD) (U.S. Department of Veterans Affairs, 2019). Symptoms may include flashbacks or nightmares during which the individual reexperiences the event. PTSD is often marked by sleep disturbances, anger and aggression, numbing and avoidance, hypervigilance, and significant impairment in social functioning. Many veterans who meet the criteria for PTSD also have alcohol-related disorders. Norman, Haller, Hamblen, Southwick, and Pietrzak (2018) examined the prevalence of the co-occurrence (termed comorbidity) of alcohol use disorder (AUD) and PTSD in a large sample of U.S. military veterans. They found that among veterans with probable AUD, 20.3 percent qualified for probable PTSD. Veterans with both PTSD and AUD were far more likely to also suffer from major depression (36.8 percent versus 2.3 percent). They were also more likely to have attempted suicide (46.0 percent versus 4.1 percent). Estimates of the prevalence of PTSD vary widely. One study that looked at the results of 19 different investigations that had attempted to determine the prevalence of PTSD among veterans returning from Iraq found estimates ranging from a low of 1.4 percent to an astounding 31 percent (Sundin, Fear, Iversen, Rona, & Wessely, 2010). A national U.S. survey estimates that some 7.8 percent of the population between ages 15 and 54 meets the criteria for PTSD during their lifetime (5 percent of men and 10.4 percent of women). Incidence rates among military veterans are considerably higher at 13.8 percent among Gulf War veterans (Gradus, 2018). According to DSM-5, a diagnosis of PTSD requires that there have been exposure to a traumatic event meeting specific criteria. Among these are exposure to death or the possibility thereof, or actual or threatened serious injury or sexual violence. The trauma needs to have been experienced directly by the individual or witnessed firsthand. Diagnostic criteria also include the recurrence of the traumatic experience (for example, in nightmares or flashbacks or other forms of reminders) and associated alterations in mood and in reactivity (for example, exaggerated startle responses, hypervigilance, sleep disturbances, uncharacteristically aggressive behavior). Also, the symptoms must persist for at least 1 month and must not be related to other causes such as illness or substance use. Neurodevelopmental Disorders Among neurodevelopmental disorders described in DSM-5 are autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD), and intellectual disability (formerly called mental retardation). © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Other DSM-5 Disorders Section 10.6 Autism spectrum disorder is marked by significant impairment in social interaction and communication skills that becomes evident very early in the developmental period (usually in the first 2 years). It is also often characterized by highly limited interests and repetitive patterns of behavior. What parents are most likely to notice first is that the child has difficulty interacting socially, often not developing speech, not making eye contact, and perhaps even avoiding physical contact. Repetitive and stereotypical behaviors such as twirling or hand flapping and persistent preoccupation with a specific toy or other object are also common early symptoms. DSM-5 uses the descriptor spectrum to underline that the symptoms of autism span a very wide range of skills and behaviors and can be accompanied by disabilities that are very mild or, in some cases, extremely severe. The causes of autism spectrum disorder are uncertain but are thought to involve both genetic and environmental factors. Treatments often include a combination of behavioral and medical therapies. ADHD was previously described as an impulse-control disorder. In fact, one of its identifying symptoms is often high impulsivity, but it can also be diagnosed in the absence of high impulsivity or hyperactivity if the person manifests specific deficits in attention. That is, although ADHD is often marked by excessive activity for the child’s age, persistent inattention that is maladaptive, and high impulsivity, not all children diagnosed with ADHD manifest all symptoms. Nor is diagnosis easy, given that similar symptoms can be associated with a variety of other problems including learning disabilities, anxiety, and depression. Also complicating diagnosis is the fact that boisterous, highly active, and seemingly impulsive behavior is characteristic of many normal children and especially of boys. DSM-5 now recognizes that ADHD can appear later than originally thought. Diagnosis of ADHD among adults requires slightly different criteria than among younger children. Among children younger than 16 years, at least six of nine different symptoms of inattention must be present. These symptoms include behaviors such as failing to pay attention, careless mistakes, inability to follow instructions, problems in organizing activities, frequent loss of personal objects, and high distractibility. In addition, certain symptoms of hyperactivity and impulsivity might also be present. Depending on the pattern of symptoms, children may be described as showing combined presentation (both impulsive and hyperactive), predominantly inattentive presentation (mainly symptoms of inattention), or predominantly hyperactive-impulsive (insufficient symptoms of inattention but meeting the criteria for hyperactivity and impulsivity). Some research indicates that as many as 60 percent of all children diagnosed with ADHD also meet the criteria for oppositional defiant disorder or conduct disorder (Hudec & Mikami, 2018). Adolescents who were diagnosed with ADHD as children are more likely to display oppositional defiant disorder as adults. They are also more likely to fail or drop out of school and to abuse drugs and alcohol (Dunne, Hearn, Rose, & Latimer, 2014). ADHD is the most frequently diagnosed childhood psychological disorder. In fact, some observers think it is grossly overdiagnosed (see, for example, Merten, Cwik, Margraf, & Schneider, 2017). Overdiagnosis may sometimes be the result of parents and teachers wanting explanations for child misbehaviors and of pharmaceutical companies wanting to sell medication. Another reason for overdiagnosis may be as simple as the fact that many young boys are still relatively immature when they start kindergarten. As a result, their behaviors are marked by higher levels of activity and lower impulse control than is characteristic of older children. © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Other DSM-5 Disorders Section 10.6 Following a study of some 12,000 kindergarten children, Elder (2010) reports that the youngest children were 60 percent more likely to be diagnosed as having ADHD. By his estimates, as many as one million children in the United States may be wrongly diagnosed. That some of the causes of ADHD are genetic seems clear. One line of evidence is the fact that only about 10 to 20 percent of cases are female. In addition, genomic researchers have now identified genetic markers closely related to ADHD (Bidwell et al., 2017). The most common treatment for ADHD involves stimulant drugs such as dextroamphetamine (Dexedrine) and methylphenidate (Ritalin). Instead of acting as stimulants, these drugs have a paradoxical effect on children. That is, they appear to sedate rather than stimulate. Dissociative Disorders Fuse/Corbis/Getty Images ሁሁ ADHD is marked by different combinations of excessive activity, persistent inattention, and high impulsivity. It is the most frequently diagnosed childhood disorder, and is far more common among boys than among girls. Many observers suspect it might be grossly overdiagnosed. Three principal dissociative disorders are described in DSM-5. They are called dissociative because they involve the splitting or separating of aspects of personality and functioning. Dissociative symptoms are sometimes seen in patients with PTSD. Dissociative Amnesia Disorder Dissociative amnesia disorder is defined by a sudden and temporary loss of memory not attributable to any organic cause. Typically the memory loss is for some unusually stressful or traumatic event. Some instances of dissociative amnesia involve loss of memory for violent outbursts or suicide attempts. Dissociative amnesia may take different forms, distinguishable in terms of the type of material that cannot be remembered and the time period covered by the amnesia. In localized amnesia, the individual is unable to recall anything for a period following some event such as a car accident. In systematized amnesia, some events may be recalled during the circumscribed period, but many others will have been completely forgotten. Generalized amnesia, highly unusual in practice although common as a literary and motion picture subject, involves the sudden inability to recall any detail of one’s previous life. Interestingly, ability to speak, intellectual skills, and motor skills are retained. Continuous amnesia, also very rare, involves loss of memory from a specific time onward (up to and including the present). Continuous amnesia differs from generalized amnesia in that the individual retains memory of events prior to the onset of amnesia but cannot remember events that have just occurred. © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Other DSM-5 Disorders Section 10.6 One manifestation of dissociative amnesia, dissociative fugue, involves unplanned travel or wandering, and sometimes assuming a new identity. People suffering from a fugue state undergo an episode during which they have forgotten who they are but are unaware of having been anyone else. During this time, they may leave their homes and even establish very different lives somewhere else. Both onset and recovery are usually rapid, but the individual may then be left with a feeling of disorientation and confusion. Dissociative Identity Disorder The dissociative aspects of amnesia are obvious: It is as though parts of the individual’s personality and memory become separated from one another, some parts remaining temporarily inaccessible to (dissociated from) the individual. Dissociative identity disorder, previously called multiple personality disorder, involves a more complex type of dissociation in which individuals are from time to time dominated by distinctly different, complex, highly integrated personalities. Typically, domination by one personality is complete and does not involve any memory of other personalities, although it sometimes does. Shifts from one personality to another may be sudden and dramatic. AbleStock.com/Thinkstock ሁሁ Multiple personality, a popular fiction theme, is a rare condition now labeled dissociative identity disorder. In a few classic cases, distinct personalities manifest themselves almost as clearly as this doctored photo indicates. The Three Faces of Eve (Thigpen & Cleckley, 1954) presents a classic illustration of dissociative identity disorder. “Eve White,” who had been in psychotherapy for some time following complaints of severe headaches and blackouts, was a quiet, demure, soft-spoken woman. The therapist had no reason to suspect a multiple personality until one day: As if seized by sudden pain, she put both hands to her head. After a tense moment of silence, both hands dropped. There was a quick, reckless smile, and, in a bright voice that sparkled, she said, “Hi, there, Doc!” The demure and constrained posture of Eve White had melted into buoyant repose. (p. 137) The “new” woman had no doubt that she was “Eve Black.” Later, “Jane” emerged as a third personality. Dissociative amnesia disorder and dissociative identity disorder can be distinguished principally in terms of the repeated shifts of personality that occur in dissociative identity disorder but not in dissociative amnesia disorder. In addition, the two or more personalities that alternately dominate the individual diagnosed as having a dissociative identity disorder are complete personalities with well-integrated identities. © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Other DSM-5 Disorders Section 10.6 There is sometimes confusion between schizophrenia and “dissociative” or “multiple” identities, but the two are quite different. None of the schizophrenias involve dual (or triple) personalities in the sense of well-integrated, apparently normal, but separate manifestations of identity. In addition, the schizophrenias typically involve serious problems of perceptual or cognitive distortion. Among well-known people who have spoken about their experiences with dissociative identity disorder are actress and comedian Roseanne Barr and retired football player Hershel Walker. Actress Marilyn Monroe is reported to have had the disorder, along with her grandparents and her mother (Health Research Funding Organization, 2019b). Depersonalization/Derealization Disorder Those with depersonalization disorder often feel as though they are in a dreamlike state and perhaps as though their body does not belong to them. It is a disorder characterized by feelings of unreality. Adam Duritz, frontman for the rock group Counting Crows, says of his depersonalization disorder, “[It] makes the world seem like it’s not real, as if things aren’t taking place. It’s hard to explain, but you feel untethered” (Duritz, 2008, para. 11). The disorder is uncommon and often disappears on its own. Schizophrenia Spectrum and Other Psychotic Disorders This grouping includes a variety of disorders characterized by psychotic symptoms such as hallucinations—perceptions of experiences without corresponding external stimuli together with a compelling feeling that these are real—and delusions—false beliefs or opinions. These disorders are severe, debilitating conditions. They include several distinct disorders, each distinguishable by its symptoms. Thus, DSM-5 provides diagnostic criteria for a variety of disorders, including schizotypal (personality) disorder, brief psychotic disorder, schizoaffective disorder, substance/ medication-induced psychotic disorder, and delusional disorder. Schizophrenia Grunnitus Studio/Science Source/Getty Images ሁሁ Schizophrenia and related psychotic disorders are severe, debilitating conditions often marked by hallucinations and delusions. Catatonia, evident in the rigid, immobile postures that sometimes, as in the case of this patient, last for a dangerously long time, may be characteristic of a variety of serious psychotic disorders. Among the most severe of psychological disorders, schizophrenia is characterized by emotional, cognitive, and perceptual confusion and a consequent breakdown of effective contact with others and with reality. Symptoms may include delusions of grandeur and feelings of persecution, which often go hand in hand. Schizophrenics with symptoms of paranoia typically suffer from delusions that they are someone of extreme importance, believing, for example, that they are some historical figure such as Napoleon or Jesus Christ. At the same time, they are © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Other DSM-5 Disorders Section 10.6 overwhelmed by the conviction that someone or something is after them—that they are being persecuted because they are important, because they know something that someone else wants, or simply because the historical figure they know themselves to be was persecuted. Such individuals may spend a lifetime running from their imaginary persecutors, gathering evidence that they are being persecuted, sometimes hearing voices belonging to their enemies and hallucinating their presence. In severe cases, subjects may seek to retaliate or defend themselves and can become extremely dangerous. Sirhan B. Sirhan, assassin of Robert F. Kennedy, was diagnosed by defense experts as a paranoid schizophrenic who believed himself to be the savior of his people. In DSM-5, catatonia is diagnosed as a condition associated with other disorders such as schizophrenia, PTSD, or bipolar disorder, rather than as a separate psychological disorder. It is marked by rigid, immobile (catatonic) postures frequently adopted by patients, sometimes for hours. Typically, immobility is absolute during a catatonic stupor. Patients sometimes have no bowel or bladder control and must be fed intravenously. The rigidity may be so complete that saliva runs unchecked down their chins because they don’t even swallow. Patients with catatonia often alternate between periods of immobility and periods of intense physical activity accompanied by a great deal of excitement. Changes from one state to the other are sometimes violent and dramatic. Periods of intense activity may be accompanied by aggressive and dangerous behavior. If precautions are not taken, catatonic patients sometimes hurt themselves as a result of prolonged immobilization and hampered blood circulation as well as muscular strain, or as a result of doing themselves violence and injury while in a frenzy of catatonic excitement. Causes Various schizophrenic spectrum and other psychotic disorders appear to be related to malfunctions in the metabolic processes involved in the essential transformations that occur among synaptic neurotransmitters such as dopamine, serotonin, glutamate, and epinephrine (see Chapter 2; Foley, 2019). The effectiveness of many psychotherapeutic drugs appears to result from their effects on neurotransmitters, providing added evidence that these are implicated in some psychological disorders. In addition, research with animals has shown that stressful environmental events may adversely affect essential metabolic processes in the brain. Genomic research provides strong evidence that schizophrenia has a genetic component. Hilker and associates (2018) report on a large Danish study (31,524 twin pairs) that looked at incidence of schizophrenia among monozygotic and dizygotic twins. Their estimate is that the contribution of genetics to schizophrenia is approximately 79 percent. This finding is consistent with the belief that neurotransmitters are implicated in this psychological disorder. Sexual Disorders Three of the 18 DSM-5 categories of psychological disorders are sex related: those having to do with gender dysphoria (gender identity problems); those relating to unusual objects of sexual gratification and unusual modes of sexual expression (the paraphilias); and those relating to sexual dysfunction. © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Other DSM-5 Disorders Section 10.6 Gender Dysphoria Disorder The term dysphoria is derived from a Greek word meaning “unhappiness or dissatisfaction with one’s life.” Gender dysphoria disorder refers to a conflict between anatomical sex (male or female, genetically) and gender identity. Gender identity refers to the subjective feelings individuals have concerning their sexuality. In the absence of gender identity problems, anatomical males and females feel that they are male or female. Cisgender is the term used to describe those who identify with their anatomical sex. A gender identity disorder would be evident in a strong feeling of discomfort with one’s anatomical sex and persistent feelings that one is or should be the other sex, a condition to which the label transgender applies. DSM-5 emphasizes that whether gender dysphoria is a psychological disorder is not implicit in the fact of being transgender but is dependent on the degree of distress, if any, that the individual experiences. That is, being transgender is not always pathological. Gender identity disorders are sometimes confused with transvestism, which is included as a paraphilia in DSM-5. Transvestism refers to the act of cross-dressing for sexual gratification (dressing in clothing that is culturally recognized as appropriate for the other sex). Gender identity disorders sometimes lead individuals to undergo sex-change procedures, which typically include both surgery and hormone treatment—as did Chastity Bono, daughter (now son, Chaz) of Sonny Bono and Cher (Carmichael, 2017), and Bruce Jenner, former decathlon Olympic winner (now Caitlyn Jenner). Paraphilias Kevin Mazur/WireImage/Getty Images ሁሁ Gender dysphoria disorder is apparent in the individual’s strong feeling of discomfort with his or her anatomical sex, sometimes leading to sex-change surgery and related hormonal treatments—as in the case of Caitlyn Jenner (formerly Bruce Jenner), shown here. It should not be confused with transvestism, now classified as a paraphilia and evident in the act of cross-dressing. Paraphilias include a variety of sexual deviations (from para, meaning “deviation,” and philia, meaning “attraction or love”). Among these are the fetishes, involving sexual attraction to nonliving objects such as women’s undergarments, shoes, hats, and walnuts. Fetishism occurs primarily in males. Paraphilias eventually replace the person’s desire for intimacy with another person. Among the paraphilias are several other behaviors undertaken for sexual gratification. These include exhibitionism (flashing of private parts); fetishism (sexual arousal related to a physical object or situation); frotteurism (rubbing against a nonconsenting person); masochism and sadism (giving or receiving pain, respectively); transvestic fetishism (cross-dressing); and voyeurism (spying on people engaged in intimate behaviors). Pedophilia is a condition involving the use of prepubertal children as sexual partners or objects. Pedophilia is predominantly heterosexual rather than homosexual. It is the most commonly seen paraphilia in clinical practice. In a study of 1,310 Finnish adult males, Santtila © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Other DSM-5 Disorders Section 10.6 and associates (2015) found that 0.2 percent reported sexual interest in children under 12. In particular, the use of children in pornographic books, films, and websites has increased dramatically with the proliferation of electronic media (Carr, 2017). Reliable statistics on the prevalence of paraphilias are lacking, but it is known that they occur much more frequently in men than in women. One study found that 13.4 percent of adult male psychiatric inpatients admitted to having one or more paraphilias—most commonly voyeurism and exhibitionism (Marsh et al., 2010). Diagnoses of paraphilias is not always clear. Because of the risk of inaccurate diagnosis (false positives), especially in legal situations involving sex offenders, diagnosis is often controversial (King, Wylie, Brank, & Heilbrun, 2014). Sexual Dysfunctions The sexual dysfunctions include impediments to the enjoyment of normal sexual activity. Their principal psychological consequence is one of distress that may vary in severity depending on the individual concerned. Among sexual dysfunctions are delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, genitopelvic pain/penetration disorder, male hypoactive sexual desire disorder, premature early ejaculation, and substance/medication-induced sexual dysfunction. Somatic Symptoms and Related Disorders Another grouping of disorders included in DSM-5 are the somatic symptoms and related disorders. These include a variety of conditions whereby the patient reports symptoms suggestive of some medical problem but where no such problem can be found. People with somatic symptoms are often anxious about their health. They genuinely believe they are physically ill. Personality Disorders Personality disorders—sometimes called character disorders—are evident in behaviors that are socially inappropriate, inflexible, and often antisocial. These behaviors typically become apparent during childhood or adolescence and are manifested as relatively stable, although sometimes highly maladaptive, personality characteristics. Unlike those with more serious psychological disorders, persons suffering from personality disorders usually continue to function in society. Often, too, they experience little anxiety over their behaviors since they are ordinarily unaware of their maladaptive nature. Most are unlikely to seek help on their own. Many individuals diagnosed with other forms of psychological disorder have a long-standing history of personality disorders. People characterized by one or more of the dark traits (Machiavellianism, narcissism, and psychopathy—discussed in Chapter 9) may manifest many of the symptoms associated with personality disorders but at a sub-clinical level (Southard & Zeigler-Hill, 2016). The personality disorders identified in DSM-5 are the following: • Paranoid personality disorder is marked by a profound, long-term, and unjustified conviction that other people are hostile, dangerous, and out to get them. It often leads to social isolation. © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Other DSM-5 Disorders Section 10.6 • Schizoid personality disorder is characterized by disinterest in social relationships and a limited range of emotional reaction. It is sometimes evident in emotional coldness and a solitary lifestyle. • Histrionic personality disorder, primarily a female disorder, is evident in excessive emotionality, attention seeking, and inappropriate flirtatiousness. People with histrionic personalities typically want to be the center of attention and are often egocentric and self-indulgent. • Narcissistic personality disorder, primarily a male disorder, is evident in excessive selflove. Narcissus, of the Greek legend, loved Mienny/E+/Getty Images himself above all else. Extreme arrogance, ሁሁ Histrionic personality disorder is cavalier disregard for social convention primarily a female disorder marked by and the rights of others, supreme confiexcessive emotionality and attention dence, and selfish exploitation of others seeking. Most naturally outgoing, are the principal characteristics of the nar- bubbling, emotional people such as this cissistic personality. Not surprisingly, such woman are not victims of histrionic individuals appear only rarely in clinics. personality disorder. In fact, many of • Antisocial personality disorder involves us who assume we are mainly “normal” a pattern of pervasive disregard for, and display mild symptoms of many different violation of, the rights of others. Compersonality disorders. mon characteristics might include lack of remorse for actions that hurt others, lack of empathy, cruelty to animals, poor and abusive relationships, and frequent problems with the law. • Borderline personality disorder is evident in fluctuating and unpredictable moods that are often extreme. Those with borderline personality disorder tend to alternate between idealizing and devaluing, and they often have unstable and chaotic interpersonal relationships. • Schizotypal personality disorder is marked by a need for social isolation and by what are often very different convictions and beliefs, and sometimes odd or eccentric dress and behavior. • Avoidant personality disorder is characterized by an extreme and pervasive pattern of social inhibition evident in feelings of inadequacy and avoidance of social interaction. • Dependent personality disorder describes a chronic and long-term condition characterized by excessive dependence on others for physical and emotional needs. • Obsessive-compulsive personality disorder (OCPD) is different from obsessive-compulsive disorder (OCD), described earlier. Whereas OCD is marked by recurring obsessions (thoughts that will not go away) and compulsions (behaviors that must be carried out repeatedly), OCPD is a personality disorder. It is marked by a chronic and persistent maladaptive pattern of interacting with other people and with the environment. Among its manifestations are excessive preoccupation with orderliness, perfectionism, and details, and a need to control all aspects of the environment. © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Other DSM-5 Disorders Section 10.6 There is a danger, when reading quick descriptions of disorders, of recognizing clusters of symptoms among people we know and to wonder whether they might have this or that disorder. For example, we all know people who are neat and orderly, but the fact is that probably none of them would come close to satisfying the criteria for obsessive-compulsive personality disorder. Nor are all people who are shy candidates for a diagnosis of avoidant personality disorder. For all personality disorders, diagnosis is made only based on specific combinations of persistent, prolonged, and/or chronic beliefs and behaviors—hence the importance of the four-D (or five-D) checklist described earlier: distress, dysfunction, deviance, danger, and duration. There is a danger, too, of assuming that mental disorders are as universal as conditions such as appendicitis, hunger, and measles. But, as we saw earlier, there have historically been some highly culture- and era-specific mental illnesses—for example, windigo, amok, susto, brain fag, and, in Western European and North American cultures, a range of eating disorders. We might also assume that attitudes toward mental disorders and their treatment are common through most of the world. We would be mistaken. (See Views from Other Cultures: Mental Disorders and Culture-Related Stigma.) Views from Other Cultures: Mental Disorders and CultureRelated Stigma In Western cultures, we tend to think of mental disorders as statistically rare and unexpected ways of thinking, feeling, and behaving that cause affected individuals significant distress and that are associated with impairment in day-to-day functioning. We believe these conditions have one or more causes that might include chemical imbalances, physiological/neurological problems, excessively stressful life circumstances, or perhaps one or more traumatic experiences. Our rational, biomedically based explanations have reduced much of the stigma that once surrounded mental illness. The current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) categorizes mental disorders and organizes them according to their symptoms. But our Western conceptions of mental disorders, and our careful classifications and prescribed treatments, are not universally applicable. fotomem/iStock/Getty Images Plus ሁሁ Western European and North American societies treat their assortment of mental disorders with a combination of chemicals, psychiatric therapies, counselling, and dietary and physical regimens. In other cultures, various alternative methods and remedies are utilized. In many societies, mental disorders are manifested in different ways, and their treatments do not resemble ours. For example, in some cultural groups, people believe their emotional problems are caused by witchcraft or by evil spirits. Instead of going to doctors for antianxiety, antidepression, or antipsychotic medication, they obtain brews, herbs, and potions from a local, traditional healer; instead of calling a psychiatrist, they consult shamans, prophets, priests, and witch doctors. (continued on next page) © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Section 10.7 Therapies Views from Other Cultures: Mental Disorders and CultureRelated Stigma (continued) Attitudes toward mental disorders also vary from culture to culture. In some American indigenous tribes, for example, mental illness is not stigmatized as it often is in other societies (Abdullah & Brown, 2011). In contrast, in many Asian cultures, mental illness is often seen as a shameful reflection on the family (Tran, 2018). In Muslim countries, as well, mental disorders tend to be highly stigmatized and hidden (Ali, Nanji, & Brown, 2017). Even within mainstream American culture, different subgroups tend to react differently to the diagnosis and treatment of mental disorders. For example, one study found that African Americans tended to express frustration with the system’s emphasis on chemical treatment of mental illness; in contrast, European Americans accepted medical treatment as effective and necessary. Latino participants in this study discounted official clinical diagnoses, considering them socially damaging. They preferred to attribute the disorder to “nervios”—simply a case of nerves (Carpenter-Song et al., 2010). To Think About 1. Reflect on your attitudes toward mental disorders. Do you find them rational? Empathetic? Accepting? 2. How aligned are they with dominant attitudes in your social group? 10.7 Therapies Basically, there are four broad approaches to treating psychological disorders. In many instances, these reflect the therapist’s basic model, as summarized in Table 10.1. Thus, if the therapist views the disorder as being the result of a system malfunction (medical/biological model), drug therapy, electroconvulsive shock therapy, or, more rarely, surgery will be the therapies of choice. If the therapist views disorders as resulting from psychic conflicts (psychodynamic model), some form of psychoanalysis may be used. If the therapist thinks the disorder is learned or results from inappropriate cognitions (cognitive-behavioral model), one of several cognitive-behavioral therapies may be employed. If the therapist believes disorders result from the interaction of biological, psychological, and social influences (biopsychosocial model), a combination of approaches is likely to be used. And if the therapist is concerned primarily with the person’s growth, development, happiness, and self-actualization (humanistic model), a highly person-centered, humanistic approach is most likely. However clear this might seem in theory, the fact is that this handful of models has yielded hundreds of different therapies. Most therapists use a variety of them in dealing with psychological disorders. Only rarely are the nonmedical approaches used without also using some form of drug therapy (for example, antidepressants, sedatives, antipsychotic drugs). Medical Therapy Science has provided practitioners with chemicals and surgical procedures that can sometimes arrest a disease or rectify a condition before its more extreme results appear. Syphilis, for example, can, if unchecked, lead to neurological impairment and the manifestation © 2020 Zovio Inc. All rights reserved. Not for resale or redistribution. Section 10.7 Therapies of various psychological disorders. Simple and highly effective treatment with penicillin or related drugs in the early stages of the disease prevents the appearance of psychological disorders. Similarly, thyroid problems, insulin issues, and a variety of metabolic and glandular difficulties that can lead to physical and mental complications can be controlled chemically. Drug Therapy Mild anti-anxiety drugs (Valium®, Librium®, Xanax®, Ativan®) are useful for phobias, panic disorders, PTSD, and so on. As we saw in Chapter 2, they have a sedating effect on brain activity. Drugs known as antidepressants (Celexa®, Lexapro®, Prozac®) are widely used in the treatment of depression. Most become effective only after several weeks or even months of treatment. They work well for about a third of patients with major depression. Antipsychotic drugs (Haldol®, Navane®, Thorazine®) are used extensively to treat schizophrenia. Lithium and other drugs are used widely for bipolar disorder. Disulfiram (Antabuse) is sometimes used to treat alcohol addiction. iStock/Thinkstock WIN-Initiative/Neleman/WINInitiative/Getty Images ሁሁ Treatment of psychological disorders has changed dramatically with drug therapy. Calming medications can now accomplish what required a straitjacket on...
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