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Flirt/SuperStock
Introduction to Abnormal Psychology
Chapter Objectives
After reading this chapter, you should be able to:
• Define abnormal behavior.
• Discuss the history of mental illness.
• Identify the major theorists and theoretical orientations in psychology.
• Discuss the DSM–5.
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Section 1.1 How Do We Define Abnormal Behavior?
CHAPTER 1
1.1 How Do We Define Abnormal Behavior?
One of the things we have discovered over the years is that if one were to poll a random
sample of average people, most would say that they know abnormal behavior when they
see it. They might assess at-a-glance someone’s behavior as strange, odd, or sick, and they
would quickly give you the reasons for their assessment. Let us look at an example of
potentially odd behavior that will illustrate this.
You are walking in your neighborhood on a gorgeous summer afternoon, listening to your
favorite songs on your iPod or smartphone. Suddenly, without warning, a man runs out
from behind the bushes across the street. This wouldn’t normally catch your attention, but
what really catches your eye is that this man has no clothes on. He is running frantically
while trying to cover himself with his hands, all the while looking behind him. Before you
know it, the man disappears around the corner. Was the man’s behavior abnormal? Do
you think this man is likely to present a danger to himself or, more importantly, to other
people? This is one of the goals that practicing psychologists have: to ascertain whether an
individual’s behavior is abnormal or not, and to ascertain whether their behavior presents
a danger to the individual or to others.
Does Abnormal Behavior Automatically Mean Psychopathology?
Psychopathology refers to the study of the causes and development of psychiatric disorders. Many in the mental health professions (psychologists, social workers, counselors,
and psychiatrists, to name a few) agree that it is extremely difficult to arrive at a universal
definition of abnormal behavior (Maddux & Winstead, 2007). They agree in general about
what the term means, but they often use different perspectives to actually define it. Three
perspectives commonly used by psychologists are the statistical frequency perspective
(behavior is abnormal according to the statistics), the social norms perspective (behavior
is abnormal according to the standards set by society), and the maladaptive perspective
(behavior is abnormal because it interferes with the individual’s ability to function on a
daily basis). Each perspective has its own usefulness and limitations, as discussed in the
following sections.
The Statistical Frequency Perspective
The statistical frequency perspective labels behavior as abnormal if the behaviors only
exist (or are exhibited) by the minority of the population. A few presumptions here need
to be examined. First, this perspective presumes that the general population’s behavior is
considered to be normal. However, what is considered normal today wasn’t necessarily
considered normal a hundred years ago, and what’s normal in New York City might not
be considered all that normal in New Delhi. For example, consider the following routine: Someone wakes up, eats breakfast, goes to work, has lunch, goes home, eats dinner,
spends some time with family, watches television, and then goes to bed. This is a routine
that many working adults in the United States follow on a daily basis. Therefore, the general population would consider this to be normal behavior.
So what would you then make of the following: Instead of going to work every day and
following the previously outlined routine, an individual goes to the beach at 8 a.m. and
lies on a blanket until the sun sets, each and every day? Or what about this possibility:
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Section 1.1 How Do We Define Abnormal Behavior?
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A man goes to the beach with a blanket and a guitar, sits on the boardwalk, strums away
while singing folk songs, and has a sign asking for handouts as he has lost his job due
to a bad economy. Is this considered normal behavior based on current standards in the
United States? Or is this behavior crossing over to abnormal behavior?
What about the man we described earlier who ran naked from behind bushes? Do people
usually run through the streets naked anywhere in the United States? And if the statistical
perspective tells us that this is extremely uncommon behavior, does that automatically
mean that the individual must be pathological?
The Social Norms Perspective
The social norms perspective states that behavior is abnormal if it deviates greatly from
accepted social standards, values, or norms. Norms are spoken and unspoken rules for
proper conduct. These are established by a society over time and are subject to changes
over time. Two types of norms used to assess whether behavior is abnormal are legal
norms and psychological norms. Legal norms tend to dictate how an individual should
behave in the realm of his civic surroundings and with regard to his friends and neighbors. In other words, this is a mandatory rule of social behavior that is established by
the state. If someone is labeled a criminal, his behavior violates legal norms as determined by that society. For example, the naked running man described earlier may be
demonstrating abnormal behavior based on legal norms, since he could be arrested for
indecent exposure.
Psychological norms are also
determined by society, but are
codified in the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition, published by
the American Psychiatric Association. Behaviors, thoughts, and
emotions are considered to be
abnormal if they violate the
norms set out by psychologists.
For example, Michael Jackson
was surely one of the most famous
individuals in the world. However, he demonstrated unusual,
perhaps odd, and maybe even
© Olaf Selchow/dpa/Corbis
abnormal behaviors at times.
Is this normal behavior? Michael Jackson would commonly
cover his children’s faces and many considered this behavior to He often wore surgical masks
when he was out in public. Perbe abnormal.
haps more unusual was how he
dressed his children when they went out. He would often cover his children’s faces or
heads with blankets, Halloween-style masks, burqas, or disguises. Is this behavior abnormal? Most likely it is to the everyday individual. However, what if Jackson were germphobic, afraid of catching any kind of pathogen or cold? What if he had a compromised
immune system and therefore needed to keep his face covered? Perhaps he covered his
children’s faces to protect them against kidnappers, since he was an instantly recognizable
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Section 1.1 How Do We Define Abnormal Behavior?
CHAPTER 1
and very wealthy pop star. Do these latter explanations now make his behaviors more
rational and therefore not abnormal? The psychological norms perspective would involve
using diagnostic criteria in the DSM–5 to determine if the pattern of such behaviors is
likely to point to a mental disorder.
The Maladaptive Perspective
Finally, the maladaptive perspective views behavior as abnormal if it interferes with the
individual’s ability to function in life or in society. By this we mean the ability to work,
take care of oneself, and have normal social interactions. Do you think the naked running
man is able to function in everyday life? Can we even make these kinds of judgments
without knowing much about him? If nothing else, we can say that this naked individual
appears to be somewhat unusual. However, is his behavior abnormal or indicative of
mental illness? Let’s look at another example.
There is a woman in your neighborhood that you see often. She works a regular 9-to-5
job, but you notice that it takes her a while to leave for work. You have noticed that she
engages in some rather “unusual” yet regular routines before she finally heads off. She
locks her door then returns at least four more times to make sure it’s locked. You also
notice that it takes her a long time to leave the house. She goes back inside at least five or
six times, disappears for a few minutes, and then returns outside. When she finally gets
in her car, she drives off, then she returns a few minutes later to ensure the garage door is
closed. You also notice that when she finally leaves for good, the time is 10 a.m. Based on
the maladaptive perspective, this woman’s behaviors interfere with her everyday life. She
is able to function, but her daily rituals make her late for work every day. She has extreme
difficulty leaving the house until she is absolutely certain that all the doors are locked and
that her gas oven and range are turned off (we will discuss behaviors like this in more
detail when we discuss obsessive-compulsive and related disorders).
Other Considerations
Let us consider several other factors that we use to classify abnormal behavior. First, is
the individual’s behavior causing danger to him/herself or to other people? Often this is
not the case. The idea that individuals who have a mental illness are dangerous or violent
people like Jeffrey Dahmer or Charles Manson is simply not true. Most individuals with
a mental illness are not dangerous, and of those who are, most are more likely to pose a
threat to themselves than to others.
Another consideration is whether the individual’s behavior is causing him or her distress.
Not all abnormal behavior causes stress to the individual. In many cases, the individual’s
family or loved ones are more distressed than the individual themselves. This makes it especially important for the family to be involved in as many aspects of treatment as possible.
Finally, we must consider factors such as the duration, the age of onset, and the intensity
of the behavior(s). By duration, we mean the length of time the troublesome behaviors
have existed. By age of onset, we mean the age at which the troublesome behaviors first
become noticeable. This is especially important, since some mental illnesses cannot be
diagnosed until an individual has reached a certain age, or cannot be diagnosed once an
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Section 1.1 How Do We Define Abnormal Behavior?
CHAPTER 1
individual has passed a certain age. By intensity, we mean how extreme the behaviors in
question are. So, where does our naked running man fit? Let us see if more information
about him helps to clear up the picture. This man is a sophomore at a major university in
the United States. He is a psychology major and has made the Dean’s List, a status granted
only to the best students. When you looked more closely at the man, you saw that he was
only wearing sneakers, which let him run faster. The sneakers had the university’s logo on
the sides. Is this enough to make a determination?
Psychologists often have to make judgments based on what they see on the surface or in
an individual’s overt behaviors. These are behaviors that are open and detectable by whoever observes them (Reber & Reber, 2001, p. 500). In other words, these are behaviors that
we can see on the surface and therefore measure. Let’s look at some other facts about the
naked running man. He was running because he was “discovered.” He was discovered by
the house’s owners who saw him skinny-dipping in their pool. He also had a camcorder
set up recording his escapades. Does this help?
Now do you think this man’s behavior is abnormal based on the aforementioned perspectives? Is skinny-dipping in someone else’s pool statistically frequent? Does it conform to
social norms? Do you think it interferes with the man’s ability to function at his university? Does the man’s skinny-dipping in a stranger’s pool present a danger to him or to
others? Perhaps a bit more information would help. The man was skinny-dipping and
recording his feat because he was pledging a fraternity at his university. This was part of
a “hazing” ritual. The man had to prove he performed his escapade and therefore filmed
it. As you learn more about the man, you discover
that he is extremely reserved, painfully shy, and
generally withdrawn in many social situations.
Perhaps he is just what David Weeks and Jamie
James (1995) call an eccentric. Eccentrics have odd
or unusual habits but do not have a mental illness.
Weeks and James published a work called Eccentrics: A Study of Sanity and Strangeness, in which
they examined eccentrics throughout history.
They concluded that the eccentrics’ thought patterns are not disrupted and their behavior doesn’t
typically cause them distress; in fact, most eccentrics may take pleasure in being an “original.”
Perhaps you yourself have some odd or unusual
habits, or perhaps you know someone who does.
Albert Einstein could be classified as an eccentric.
He picked up and smoked discarded cigarette
butts off the street in order to circumvent his doctor’s ban on buying tobacco for his pipe. He also
would use his sailboat on windless days because
he enjoyed a challenge. Oscar Wilde, the famous
novelist, was another famous eccentric. While
studying at Oxford University, Wilde would walk
through the streets with a lobster on a leash, in
addition to engaging in other odd behaviors.
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AP Photo
Eccentrics exhibit odd or unusual habits,
yet do not have a mental illness. Albert
Einstein may be considered an eccentric or
an “original” for displaying peculiar habits.
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Section 1.2 A History of Abnormal Behavior Theories
CHAPTER 1
1.2 A History of Abnormal Behavior Theories
Imagine this: It is a few thousand years ago, and your friend is planning to attend a
regularly occurring event that he is eagerly anticipating. Your friend talks about looking
forward to the occasion, as it is a form of socialization for him. The government sanctions the event and supports it as a way of pleasing its citizens and giving back to them.
Your friend then mentions that he would like you to come along to see how exciting
the event is. You arrive and see that the arena contains at least 80,000 screaming people.
You naturally wonder why everyone is yelling and why they seem so excited. All of the
people are standing. You even see a “royal box” where dignitaries are sitting. At the end
of the event your friend asks you, “Well, what did you think?” You reply that you have
never seen anything like it and love what you saw. You then ask when you can attend
the next performance.
Does any of this seem unusual
or abnormal? What if you now
knew that you were in ancient
Rome attending gladiator fights
and seeing prisoners being torn
to pieces by lions? These events
were considered to be a normal
form of entertainment in ancient
Rome, but if we tried to stage
such an event in the United
States in 2014, you can imagine
the consequences and outrage.
Thus, what constitutes abnormal behavior is partially depen© Heritage Images/Corbis
dent on society’s definitions
of what is normal, which can In ancient Roman times, attending gladiator fights was a
change over the course of time. common form of entertainment.
Humans have demonstrated
abnormal behavior for at least, by this author’s account, a few thousand years. The gladiator fights were not considered unusual in their time, but they are now considered to be
unusual and, by many, repulsive.
Ancient Times
The earliest explanations for mental illness seem to have been that the afflicted were possessed by evil spirits or demons (an idea that some people still believe today). Skulls dating back to 6500 BCE have been discovered with holes bored into them (see Figure 1.1),
which are an indication of trepanning (also known as trephination). The belief seems to
have been that the holes would allow the evil spirits to leave the “possessed” person. In
later medieval societies exorcisms were performed, usually by a priest. This was a noninvasive way to drive the evil spirits out from the possessed individual. These became more
common in the 1600s. Exorcisms, although rare, are still performed today.
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CHAPTER 1
Section 1.2 A History of Abnormal Behavior Theories
Figure 1.1: Trepanning
Trephine
Hole made
by trepanning
Skull
Note the holes bored into the skull.
The first physiology-based explanations for mental illness were provided in ancient
Greece by Hippocrates (460–377 BCE), the father of modern medicine. Hippocrates
viewed abnormal behavior—and physical illnesses in general—as having internal causes.
Specifically, he believed that the body contained four fluids, or humors (yellow bile, black
bile, blood, and phlegm), that must be kept in adequate balance to maintain health (it
must be noted that the theory was wrong about the cause of diseases). His prescriptions
for the ill included rest, proper diet, sobriety, and exercise, strategies that are still recommended today. Hippocrates also believed that if you took care of your body, your mind
would stay well.
Two Important Mental Health Reformers: 1700s–1800s
Philippe Pinel (1745–1826) was one of the early reformers in the proper treatment of individuals with mental illnesses. Pinel, a Frenchman, advocated that they be treated with
sympathy, compassion, and empathy and not with beatings and torture. Dorothea Dix
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Section 1.2 A History of Abnormal Behavior Theories
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(1802–1887) helped to establish many state mental
hospitals in the United States during her nationwide campaign to reform treatments of the mentally ill. She was directly responsible for laws that
aimed to reform treatment of this population.
Psychoanalytic Theory: 1890s–1930s
While trephination dates back thousands of years,
the history of abnormal psychology realistically
dates back to 1895, when Sigmund Freud (1856–
1939), in collaboration with Josef Breuer (1842–
1925), published his first book, Studies in Hysteria.
(The first book Freud wrote alone was The Interpretation of Dreams, published in 1900.) Sigmund
Freud was initially a researcher who studied the
reproductive systems of eels. In 1885, just before
he got married, he obtained a grant to go to Paris
Everett Collection to see the famous neurologist Jean Martin Charcot
(1825–1893). Charcot specialized in the study of
Published in 1895, Studies in Hysteria by
Sigmund Freud and Josef Breuer marks the hysteria and susceptibility to hypnosis. From
history of abnormal psychology.
his time with Charcot, Freud realized the power
that the mind could have over the body, and he
returned from Paris determined to make a name for himself in the field of hypnosis. After
experimenting with hypnosis on his patients, Freud abandoned this form of treatment as
it proved ineffective for many of them. He favored
treatment where the patient talked through his or
her problems, which he termed psychoanalysis.
Josef Breuer, a Viennese physician, treated patients
who suffered from hysteria. Breuer’s patients told
him that they had physical illnesses. However,
after examination, he discovered that they had
no physical symptoms. Breuer discovered that in
some cases his patients’ symptoms eased or disappeared once they discussed the past with him
in a safe environment without censure and while
under hypnosis. Breuer and Freud discussed their
ideas, and Freud expanded on them and created
psychoanalytic theory, thus leading to an entire
movement that is still popular today. Freud’s
basic tenet was as follows: that unconscious processes, motives, and urges are at the core of all of
our behaviors and difficulties.
How did Freud view abnormal behavior? Freud
saw adult human behavior as resulting from a
combination of the components of what he termed
the psyche, which consisted of three parts: the id,
the ego, and the superego (see Figure 1.2). The id
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iStockphoto/Thinkstock
Josef Breuer discovered many of his
patients claimed to have a physical illness,
yet all symptoms disappeared once the
patients discussed their ailments in a safe
environment and were under hypnosis.
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CHAPTER 1
Section 1.2 A History of Abnormal Behavior Theories
is the primitive part of the personality that houses our unconscious desires, wishes, and
basic innate drives such as sex and aggression. If these drives are not satisfied, or if the
unconscious desires come into consciousness, anxiety can result. The id is the only piece of
the psyche that is present at birth. The ego, which is partially conscious and is the second
part of the psyche, does its best to control the id by trying to “convince” it to delay gratification until a reasonable solution to the drive reduction is found. The id does not listen, as it
needs to be satisfied immediately regardless of the consequences. The ego develops when
a child is between 1½ and 3 years old. Eventually the superego, the final part of the psyche,
develops when a child is between 3 and 6 years old and enables the individual to feel guilt
and have a conscience. The superego is also partially conscious, and it helps the ego to
control the id’s desires. Even if the id’s urges are controlled by the ego and the superego, its
desires still exist, driving behavior. Because these desires are so strong, they cause anxiety
if they are unmet. According to psychoanalytic theory, this can lead to abnormal behavior.
Figure 1.2: A schematic illustration of the personality
Conscious
Preconscious
Ego
Superego
Unconscious
Id
Freud compared personality to an iceberg. A very small part is conscious, a somewhat larger part is
preconscious (available to conscious awareness with some mental effort), and the largest part of
personality is unconscious (unavailable to the individual without massive psychoanalytic effort).
From: Steven Schwartz and James Johnson, Psychopathology of childhood: A clinical-experimental
approach, p. 13, Pergamon Press, 1985. Reprinted by permission.
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Section 1.2 A History of Abnormal Behavior Theories
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Freud and his followers also
looked at abnormal behavior in
other ways. For example, Freud
saw depression as anger turned
inward. He maintained that we
all have self-destructive tendencies, but that they usually remain
repressed. Repression is an ego
defense mechanism that operates unconsciously. Repression
keeps certain ideas, impulses,
and memories from reaching
consciousness. If these ideas were
Kablonk/SuperStock to surface, they would produce
anxiety and guilt, among other
According to Freud, depression was a result of unrepressed
feelings. However, when indianger trapped inside rather than expressed outwardly.
viduals are unable to express
their anger appropriately and turn it inward as a form of self-punishment, this can lead
to depression.
Behaviorism: 1910s–1940s
Freud’s explanations for abnormal behavior varied somewhat according to an individual’s diagnosis; however, the explanations of two American psychologists, John B. Watson
(1878–1958) and B. F. Skinner (1904–1990), stayed the same regardless of the individual or
the diagnosis. These two posited that something in the environment is always reinforcing
an individual’s aberrant behavior(s). In other words, the causal factors are outside of the
individual. Behaviorists believe that only observable and scientifically measurable behaviors are worth studying and investigating. Some behaviorists go to more of an extreme,
stating that only physiological responses matter; consciousness and any mental states are
not worth examining as they do not exist. (They have often been called radical behaviorists.)
Let’s consider an example: A child is often disruptive in class, screaming and throwing
objects. That child is usually sent to the principal’s office for subsequent punishment. It
turns out that the child loves the attention he gets when he is removed from class, as he
has no friends and is also ignored at home by his father. His acting out is reinforced by the
attention he gets in the classroom and by getting sent to the principal’s office. Perhaps you
can think of some celebrities whose behaviors are reinforced by environmental actions
(gaining more attention and notoriety). Effective treatment, therefore, always relies on
the manipulation of the environment in order to change the individual’s behavior. In the
case of someone suffering from depression, for example, Skinner would try to discover
what environmental factors were sustaining the depressive symptoms and then help the
patient to eliminate those reinforcers, with little to no emphasis on the person’s thoughts,
unconscious desires, and so on.
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Section 1.2 A History of Abnormal Behavior Theories
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Cognitive Behaviorism: 1950s–1970s
Cognitive behaviorism is a psychotherapeutic method that alters distorted attitudes by
identifying and replacing negative and inaccurate thoughts, which will therefore lead to
behavioral changes. Albert Ellis (1913–2007) took a somewhat unique approach to defining and treating abnormal behavior. He believed that we get depressed and develop other
mental illnesses because of our faulty thinking. For example, Ellis says that some people
set themselves up to fail because of “musterbation.” This means that you create a series
of mental “musts” that are virtually impossible to satisfy, such as “I must always do well
in all of my performances and always win the praise and approval of others. If not, I’m
a failure.” This is an unrealistic expectation, and when it’s not met, the individual gets
depressed and anxious or develops other problems. Ellis defined an ABC model that
refers to the three components of how we experience and interpret events in either a faulty
or a healthy manner. In this model, A is the activating event or adversity, B is the belief
that follows, and C is the consequence. For example, let’s look at a man who receives a
negative work evaluation (this is the A, activating event or adversity). He then believes
that he is a failure (the B, or belief). The end result (or C, consequence) is that the man now
feels anxious and depressed. Ellis created Rational Emotive Behavior Therapy (REBT) to treat
people with problems resulting from such faulty thinking. It works by helping patients
to replace their irrational responses to events
(the B or belief) with a more healthy and rational interpretation (such as, in the case of the poor
job review, “I tried my best” or “I’m still learning
and will get better.”) REBT works well with anxiety disorders and some mood disorders (such as
some depressive disorders); it does not work well
with lower-functioning individuals or with those
who are not very verbal (or verbally astute).
Albert Bandura (b. 1925) created social learning
theory, also known as modeling. Bandura postulated that we could learn by observing the behavior of others—whether in real life, on television,
or in the movies—and then copying, or modeling, those behaviors. Modeling is a very powerful form of learning. How did you learn to read,
ride a bicycle, or use a computer? Likely through
modeling! Therefore, abnormal behavior is easy
to explain from a modeling perspective. The individual sees a model demonstrate a behavior and
either get rewarded for it or not, or get punished
for it. If the model is rewarded for the behavior,
the observer may think, “Hmm, he got rewarded,
maybe I should do the same.” Then the observer
copies what she sees and demonstrates the behavior. Of course this seems (and is, to a degree) rather
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Hemera/Thinkstock
Bandura’s theory of modeling posits
that we learn behavior by observing the
behavior of others. The child pictured
here is learning how to ride a bicycle by
modeling the behaviors of his father.
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Section 1.2 A History of Abnormal Behavior Theories
CHAPTER 1
simplistic, but, in addition to biological factors, this might help to explain why certain
behaviors run in families. For example, if an individual was abused as a child, he or she is
more likely to be an abuser as an adult.
Aaron Beck (b. 1921) developed the cognitive perspective theory to examine the causes
of unipolar depression, known just as depression to most people; this depression has
one “pole” or dysfunctional mood state. These individuals have no history of mania and
revert to a normal mood state when the depression lifts. Bipolar disorder has two poles
and two dysfunctional mood states—a manic state and depression. The cognitive perspective attributes abnormal behavior to faulty thinking—that is, to seeing life’s events in
a negative fashion. Having these negative thoughts will lead to negative behavior, which
can lead to developing unipolar depression. According to Beck, depression develops in
childhood and adolescence because of what he calls negative schemas, or the tendency to
see the world pessimistically or negatively. A schema is defined as the fundamental way
in which people process information, typically about themselves (Gonca & Savasir, 2001).
Individuals acquire these negative schemas for a variety of reasons: for example, the death
of a parent, repeated social rejection of peers, or one tragedy after another. These schemas
are activated whenever the individual experiences a new situation that is similar to the
conditions in which the negative schemas were learned. Beck also notes that these individuals are prone to misinterpreting reality. Thus, they think irrationally and may believe
that they are responsible for all of their family’s ills, that they are totally worthless, and so
on. They may end up seeing themselves as hopeless and their chances of future success as
limited or nonexistent.
These negative schemas and their accompanying cognitive distortions support the negative triad. Beck explained this in the following fashion: First, the person maintains a negative view of him- or herself (“Everything I touch is ruined.”). The person also maintains
a negative view of the environment (“No one could possibly get along with these roommates.”). Finally, the person has a negative view of the future and sees things as hopeless
(“No matter what I do, things will always turn out bad for me, so it is really hopeless to
even try.”). Individuals who follow this triad set themselves up for failure and most likely
depression by adopting these schemas. If they experience stress or disappointment, the
likelihood of becoming depressed increases. In effect, the individual’s negative thoughts
lead to negative behaviors (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979).
Martin Seligman (b. 1942), a professor of psychology at the University of Pennsylvania
(where Beck also taught), was inspired by Beck’s work and developed a theory of learned
helplessness as it applies to depression. Again, keep in mind that even though we are
specifically discussing depression, these theories can explain other mental illnesses, but
not all. Seligman sees individuals developing depression, or perhaps anxiety disorders,
because they see themselves as helpless to control the reinforcers in their environment,
and therefore the environment itself; they cannot make positive changes in their lives. If
individuals are consistently experiencing bad incidents (for example, they might say that
they are having a bad month), Seligman would say that eventually the individuals will
resign themselves to the negativity as “fate.” Avoidance and escape behaviors then disappear and individuals see themselves as helpless to escape, prisoners of their environments
and of their situations. Seligman and his colleagues later revised this theory and renamed
it the reformulated helplessness theory.
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Section 1.2 A History of Abnormal Behavior Theories
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The initial theory had two major
problems. First, the original theory does not distinguish between
cases in which outcomes are
uncontrollable for all people
(called universal helplessness) and
cases in which they are uncontrollable only for some people
(called personal helplessness). Second, the theory does not explain
when helplessness is general
and when it is specific, or when
it is chronic and when it is acute.
The reformulation was based on
SuperStock a revised concept of attribution
According to the reformulated helplessness theory, some
theory (Abramson, Seligman,
individuals develop depression or anxiety because they see
& Teasdale, 1987; Taube-Schiff
themselves as prisoners of fate, unable to control their negative
& Lau, 2008). According to this
situations or environment.
revision, once people perceive
that they lack control over outcomes, they attribute their helplessness to a cause. This cause
can be stable or unstable, global or specific, and internal or external.
Humanism: 1950s
Carl Rogers (1902–1987) created the client- or person-centered approach. Rogers believed
in the innate goodness of all people, and in the ability of all people to grow and to lead
constructive lives. Rogers theorized that dysfunction begins in infancy. Children who receive
unconditional positive regard—when one person
is completely accepting toward another person—
from their parents early in life will grow up to
become constructive and productive adults, even
though they will have flaws. They will realize
that they and their contributions are valued even
with these flaws. In Rogerian therapy, clients
attempt to look at themselves as being valuable
worthwhile human beings. Those who have low
self-esteem may be seen as being incongruent, or
experiencing a mismatch between their idealized
self-image and their true self-image. When this
occurs anxiety and other issues result, and it is
the therapist’s job, first, to be a model of congruence and empathize with the client. Then, the
therapist will help the individual become conRubberBall/SuperStock
gruent and to effectively feel better about him- or Children who receive unconditional
herself.
positive regard from their parents early in
For a summary of all of the main theories and theorists in psychology’s history, see Table 1.1.
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life will grow up to become constructive
and productive adults, even though they
will have flaws.
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Section 1.2 A History of Abnormal Behavior Theories
CHAPTER 1
Table 1.1: The main theories and theorists in psychology’s history
Psychologist
Theory
Explanation
Sigmund Freud
(1856–1939)
Psychoanalytic Theory
Individuals develop neuroses because of their
unresolved conflicts (repressed id impulses surfacing
and overwhelming the ego and superego) and
because of problems occurring during childhood.
Albert Bandura
(1925–)
Social Learning Theory
(Modeling)
Individuals learn based on what they observe others
(models) do in the world.
Albert Ellis
(1913–2007)
Rational Emotive
Behavior Therapy
Individuals develop disorders because of faulty
thinking.
Aaron Beck
(1921–)
Cognitive Perspective
Individuals develop depression in childhood and
adolescence because of the tendency to see the
world negatively.
Martin Seligman
(1942–)
Theory of Learned
Helplessness
Individuals develop disorders because they see
themselves as helpless to control the environment
around them. They therefore “give up” trying to
change their situation and “grin and bear it.”
Carl Rogers
(1902–1987)
Humanism
Dysfunction begins in infancy. Children who receive
unconditional positive regard—when one person is
completely accepting toward another person—from
their parents early in life will grow up to become
constructive and productive adults, even though they
will have flaws.
The Diathesis-Stress Model
Next we will look at a model that straddles the two categories of cognitive and biological
theories. The diathesis-stress model contends that behaviors are a product of both genetics
(biology) and environmental stressors. This is an interactionist model, which means that it
views abnormal behavior as originating from a combination of genetic predisposition(s)
(the diathesis) set off, or “turned on” (like a light switch), by environmental stressors
(Holmes & Rahe, 1967).
We can examine this more closely by using an example. Many psychologists accept that
schizophrenia runs in families and, therefore, that it has a genetic component. However,
this does not guarantee that individuals born into a family with a history of mental illness
will have the disorder; it just means that they are more vulnerable to developing it, or perhaps another mental illness. They are essentially born with this gene “switched off,” and
stress from the environment may or may not eventually “turn on” the gene. For example,
let’s look at a young adult with a genetic predisposition for schizophrenia who uses illicit
substances such as marijuana and heroin. Soon after the drugs’ effects have worn off, she
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Section 1.2 A History of Abnormal Behavior Theories
Universal Images Group/SuperStock
In the diathesis-stress model, stressors like the pressure to
perform and the tendency to binge drink in college can trigger
the genetic predisposition to become an alcoholic.
CHAPTER 1
begins to demonstrate schizophrenic behaviors and thoughts.
This demonstrates how the
environment (the stress) turns
on the diathesis (the genetic predisposition). If this individual
has strong support systems, the
diathesis is less likely to trigger
the switch, and the illness is less
likely to be expressed. This is a
useful theory for the following
reason: It removes some of the
responsibility from individuals
for contracting their illnesses.
It is not their fault, not a character flaw; it is just the fact that
they were born with this genetic
predisposition.
Biological Models: 1950s–Present
The field of psychology reached a major milestone in the early 1950s when Henry Laborit
(1914–1955) introduced a drug, Thorazine (generically known as chlorpromazine). This
medication was initially used to tranquilize surgical patients, but Laborit noticed that it
also managed to calm patients without putting them to sleep. Since patients with schizophrenia often exhibit perpetual agitated behavior, Laborit proposed using the drug to treat
schizophrenic disorders. Many psychiatrists thought that his idea had no merit and stood
by the practices of using electroshock therapy or psychotherapy to treat serious mental illnesses. However, a fellow surgeon
informed his brother-in-law, the
psychiatrist Pierre Deniker, about
this possible use of Thorazine.
Deniker became interested and
ordered some to try on his most
agitated, uncontrollable patients.
The results stunned Deniker and
his colleagues, as patients who
needed to be restrained or who
were uncommunicative were
now open to communication and
could be left unsupervised. The
field of psychopharmacology
(the study of the effect of drugs
on the mind and behavior) was
Peter Sickles/SuperStock
unofficially born, and the nature Research in the early 1950s revealed that drugs commonly
of mental illness treatment was used during medical procedures could also be used to treat
changed forever.
mental illness.
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Section 1.2 A History of Abnormal Behavior Theories
CHAPTER 1
How do these psychotropic medications generally work? They increase or decrease levels
of various neurotransmitters, brain chemicals that are presumed to be either at subnormal
or supernormal levels in an individual with a mental illness (see Table 1.2 for a list of common neurotransmitters). Most frequently, psychotropic medications are used to increase
levels of the neurotransmitters serotonin and norepinephrine, which have been implicated
in a variety of mental illnesses. For example, serotonin deficiencies have been implicated
in depression as well as in bulimia nervosa, and high dopamine levels have been tied
to schizophrenia. We’ll discuss these associations in more detail in Chapters 6, 7, and 8,
respectively.
Table 1.2: Some common neurotransmitters
Acetylcholine (ACH): Triggers muscle contractions; involved with muscle movement, memory, anger,
and aggression.
Dopamine: Involved with muscle movement, mood, motivation, and reward-seeking behavior; also
involved with Parkinson’s disease; hypothesized to be involved with schizophrenia and bipolar disorder.
Gamma-Amino Butyric Acid (GABA): Involved with movement and anxiety; involved with anxiety
disorders (too little causes anxiety) and seizure disorder.
Glutamate: Involved with memory and learning; hypothesized to be involved with schizophrenia and
some substance-related disorders.
Norepinephrine: Involved with stress, alertness, arousal, and reward-seeking behavior; hypothesized
to be involved with anxiety and mood disorders.
Serotonin: Regulates mood, sex drive, appetite, body temperature, and sleep; involved with
depression, eating disorders; may be involved with schizophrenia, bipolar disorder, and anxiety
disorders.
The advent of psychotropic medications also led to some other changes in treatment for
the mentally ill. For example, some of these individuals could now be released from inpatient units and be treated on an outpatient basis, freeing up facility beds and allowing the
patients to lead more normal lives.
Today, a number of mental illnesses are treated with a combination of talk therapy and
medications. Medications work well (for some) in alleviating the symptoms of some mental illnesses, but they do not eliminate all of the concerns that bring someone in for treatment. They also can produce side effects, some of which are quite significant, and some
classes of medications have addictive potential. Therefore, medications should not be
viewed as panaceas or be used as the sole treatment for a mentally ill person; nevertheless, they should be used when advisable in conjunction with therapy.
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Section 1.3 The DSM–5
CHAPTER 1
Highlight: Do I Have a Mental Illness?
Have you ever felt sad or lonely and sat down in front of the television with a pint of ice cream
to make yourself feel better? Did you feel like throwing up afterwards? Does this mean that you
have bulimia nervosa? Does it mean you are depressed? If you are like many students, you may be
tempted to self-diagnose your own behaviors as you learn about the disorders that will be described
in the remainder of this book.
It may be that you are neither bulimic nor depressed, but you may have another condition: medical
student syndrome (sometimes called medical school syndrome), wherein medical students often begin
to believe that they are suffering from the disease they are studying. Consider that everyone overeats
at some point in their lives, and everyone has days, perhaps many in a row, where they feel blue or
depressed. We are all human and, like all humans, we have good days and bad days, and the bad days
may sometimes include behaviors that could be mistaken for mental illness symptoms. However, rest
assured that the diagnostic criteria in the DSM–5 (American Psychiatric Association [APA], 2013) require,
in most instances, a duration of several months to at least two years before any diagnosis can be made.
If your behaviors are brief and occur only occasionally, you are probably acting “normally” and have little
to worry about. You will learn more about symptoms and diagnosis of disorders in later chapters. If after
reading more, you still think you may be suffering from mental illness, by all means, we encourage you
to seek help. (One resource is the National Alliance on Mental Illness: http://www.nami.org/).
1.3 The DSM–5
The classification system to which psychologists and other helping professionals refer
when making diagnoses concerning mental health issues is the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM–5; APA, 2013). This manual has always been
published by the American Psychiatric Association (APA) and covers all defined mental
illnesses in both children and adults that were known at the time of publication. The book
lists symptoms and signs that can help categorize the various illnesses. Symptoms are the
patient’s subjective description of the complaints that they may have, while signs are generally objective observations made by the diagnostician, either from an interview or some
type of test that is given to the patient.
The Evolution of the DSM
The DSM was first published in 1952 and has undergone several revisions since that time.
The sole purpose of the DSM was to classify and provide a descriptive explanation for all
known mental disorders. The first version was 132 pages long, listed 106 disorders, and
offered concise descriptions of major psychiatric diagnoses. This inventory was an important advancement in the field of psychology and led to greater reliability of mental illness
diagnoses because all researchers began to use the same criteria. The second edition was
published in 1968 and included 182 disorders, yet it was quite similar to the DSM–I. Both
the DSM–I and DSM–II emphasized the psychodynamic (Freudian) perspective, yet the
DSM–II included sociological and biological knowledge about each disorder as well.
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Section 1.3 The DSM–5
CHAPTER 1
The third edition of the DSM was published in 1980 and was 494 pages long—quite a bit
longer than the first edition. This edition included many important changes. For example, it addressed the fact that the first two editions neglected extraneous factors, such as
medical conditions, environmental concerns, and life stressors, that may play a part in
the development of mental illnesses. The DSM–III, unlike the DSM–I and DSM–II, was
based on scientific evidence. Its reliability was improved with the addition of explicit
diagnostic criteria. In short, the third edition acknowledged that many disorders do not
have a single cause but are triggered by the cumulative effect of multiple factors (Mayes
& Horwitz, 2005).
The third edition also introduced a new multiaxial system where disorders were evaluated on five different axes. Many of the disorders that are listed in the DSM–III have
a high level of co-occurrence with other disorders. This is called co-morbidity (Fowler,
O’Donohue & Lilienfeld, 2007). However, the idea of co-morbidity may not be accurate
according to Drake and Wallach (2007) who feel that, rather than distinct conditions,
many disorders could be a variation of a single underlying disorder.
Because of some inconsistencies in the criteria of some disorders, the APA issued a revision of the DSM–III in 1987 and named it the DSM–III–R. This edition increased the coverage of psychopathologies. The next major revision of the DSM took place in 1994 with
the publication of the DSM–IV, which had 943 pages and covered 373 different diagnoses
(APA, 2000). Additional revisions were published in 2000 that included some corrections
and updates to the content; this was called the DSM–IV–TR (Text Revision). The latest
major revision is called the DSM-5 (APA, 2013). Table 1.3 summarizes the DSM series up
to and including the DSM-IV-TR. To give you an idea how diagnostic criteria appear in
the DSM–5, refer to Table 1.4, which shows the diagnostic criteria for bulimia nervosa.
Highlight: Removing Disorders From the DSM
Did you know that until the DSM–III was published in 1980, homosexuality was considered to be a
mental illness/mental disorder? The DSM task force decided to eliminate homosexuality in December
1973; this took place with the seventh printing of the DSM–II (1974). Technically, however, homosexuality was not completely removed (i.e., not mentioned at all) until the DSM–III was published. Also,
did you know that Asperger’s syndrome (a pervasive developmental disorder that is a higher functioning form of autism) has now been reclassified as an Autism Spectrum Disorder? If nothing else, these
changes show how our views of what constitutes mental illness, how it is defined, and what each
diagnosis entails, have changed over the years. What are your views on this?
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CHAPTER 1
Section 1.3 The DSM–5
Table 1.3: Summary of the DSM series from DSM-I through DSM-IV-TR
Version
Year Published
Length/# of Diagnoses
Description/Changes
DSM–I
1952
132 pages/106
diagnoses
Concise descriptions of major
psychiatric diagnoses
DSM–II
1968
136 pages/182
diagnoses
Increased attention given to problems
of children and adolescents with
addition of Behavior Disorders of
Childhood-Adolescence
DSM–III
1980
494 pages/265
diagnoses
Addressed the role of extraneous
factors, such as medical conditions
and life stressors, that may play a role
in mental illness; introduced the new
multiaxial system
DSM–III–R
1987
567 pages/ 292
diagnoses
Increased coverage of
psychopathologies
DSM–IV
1994
943 pages/373
diagnoses
Included new clinically significant
criteria in almost half the categories
DSM–IV–TR
2000
943 pages/373
diagnoses
Some information updated
Source: Adapted from Andreasen and Black (2006).
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Section 1.3 The DSM–5
CHAPTER 1
Table 1.4: How the DSM–5 summary table appears for bulimia nervosa
DSM–5 Diagnostic Criteria for Bulimia Nervosa (307.51)
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the
following:
1. Eating, in a discrete period of time (e.g., within any 2 hour period), an amount of food that
is definitely larger than most people would eat during a similar period of time under similar
circumstances.
2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop
eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as selfinduced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a
week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Specify if:
In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of
the criteria have been met for a sustained period of time.
In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria
have been met for a sustained period of time.
Specify current severity:
The minimum level of severity is based on the frequency of inappropriate compensatory behaviors
(see below). The level of severity may be increased to reflect other symptoms and the degree of
functional disability.
Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week.
Moderate: An average of 4–7 episodes of inappropriate compensatory behaviors per week.
Severe: An average of 8–13 episodes of inappropriate compensatory behaviors per week.
Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.
Source: American Psychiatric Association (APA, 2013, p. 345)
How Do We Use the DSM–5?
The DSM–5 describes mental disorders and their symptoms and gives statistics and gender breakdowns for each disorder. This common diagnostic and classification system provides a way for mental health professionals to communicate with each other about specific disorders. The DSM–5 gives psychologists and other helping professionals a common
communication system, where mental disorders and diagnostic criteria remain the same
regardless of specialty area. Communicating a diagnosis about a patient to another mental
health professional in a succinct manner is important in trying to get the patient the help
that he/she needs (Blashfield & Burgess, 2007). Using a standardized method of diagnosis
leads to a better understanding of disorders and, as a consequence, better treatment.
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Section 1.3 The DSM–5
CHAPTER 1
There must be a high degree of reliability when a standardized classification system is
used. Reliability refers to the consistency of the diagnostic system. Interrater reliability
means that a test will have the same or similar results when used by different people.
The validity of a classification system, that is, the measurement or accuracy of the information in the diagnostic categories, is also clearly important. In other words, does the test
measure or predict what it is supposed to? If it does, then we can say that the assessment
technique is valid. For example, does an intelligence test really measure intelligence? It
may measure “book smarts” but not “street smarts,” which is a type of intelligence.
The number of disorders now listed in the DSM–5 may make it easier to diagnose more
individuals as having disorders. Although this results in several more types of mental
illnesses, they are more distinct from each other now than they were several years ago.
Nevertheless, the problem remains: How do you diagnose someone who meets only
three of the four required symptoms of a disorder? For example, someone who is anxious also commonly suffers from depression. That means that this particular individual
will now have two different diagnostic labels—not just a single one that may encompass
both aspects of the individual’s disorder.
The Medical Model
All mental illnesses described in the DSM–5 are seen as having similar symptoms in
common within each diagnostic category and subcategory. For example, all individuals
suffering from bulimia nervosa will demonstrate binging behaviors as well as recurrent
inappropriate compensatory behaviors (self-induced vomiting, abuse of laxatives, fasting,
and so on). The mental illnesses listed in the DSM–5 are seen as being similar to physical
diseases (i.e., all influenzas have the same general symptoms, all bronchial pneumonias
have similar symptoms), hence the term medical model. In addition there is thought to be
a physiological basis or cause for the individual’s problem(s). Those who endorse the
medical model consider symptoms to be visible signs of the physical disorder. Therefore
if symptoms are grouped together and classified into a disorder such as bulimia nervosa,
the true cause can eventually be discovered and appropriate physical treatment administered. The behaviors that one demonstrates (hallucinations, depressed mood, fear of
heights, and so on) are considered to be symptoms of a mental illness. The symptoms
are clustered together to define various mental illnesses. Therefore, when psychologists
attempt to diagnose a new patient, they will look at symptoms and see into which DSM–5
category the symptoms fit. This is critical because it allows the helping professions to have
a common language in which to communicate.
We would like to conclude with this thought: Many students, when they first encounter the DSM–5, have the following reaction, “Well, where does this book tell me how to
treat this complicated disorder?” The DSM–5 does not include treatment information; it
is only, as its title states, a diagnostic manual that describes the disorders. Psychologists
and others in the helping professions learn how to treat mental illnesses by direct practice,
classwork, and, of course, studying and reading. We will discuss how to treat the most
commonly presented mental illnesses in the remainder of this book.
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Chapter Summary
CHAPTER 1
Chapter Summary
How Do We Define Abnormal Behavior?
•
•
•
The statistical frequency perspective labels behavior as abnormal if it occurs
rarely in relation to the behavior of the general population.
The social norms perspective considers behavior to be abnormal if the behavior
deviates greatly from accepted social standards, values, or norms.
The maladaptive perspective views behavior as abnormal if it interferes with the
individual’s ability to function in life or in society.
A History of Abnormal Behavior Theories
•
•
•
•
•
•
•
•
•
During ancient times, mental illness was explained as the presence of “evil spirits” within the body of the ill person. One method for treating mental illness was
trepanning, in which a small instrument was used to bore holes in the skull to
allow the evil spirits to leave the “possessed” person.
Hippocrates noted a connection between abnormal behavior and internal, physiological causes.
Sigmund Freud and Josef Breuer noticed that some of their patients presented
physiological symptoms while having no physiological problems. Freud realized
that one way to help these individuals was via psychoanalysis, or talk therapy.
Freud’s theory includes the ideas of repression and the psyche, which consists of
the id, ego, and superego; this theory emphasizes the importance of examining
people’s unconscious minds.
B. F. Skinner and John Watson believed that abnormal behavior was environmentally caused, as an individual’s behavior was reinforced in the environment,
therefore making it more likely to recur.
Albert Ellis, Albert Bandura, Aaron Beck, and Martin Seligman believed that
a person’s thoughts (irrational, maladaptive, or otherwise) lead to, or cause, a
person’s aberrant or abnormal behaviors. Bandura believed that a person learns
abnormal behaviors by watching others perform them, and then the individual
reproduces (or “models”) what he or she sees.
Carl Rogers believed that all humans are innately good and that problems arise
when an individual is incongruent, that is, experiencing a mismatch between
their idealized self-image and their true self-image.
The diathesis-stress model posits that abnormal behavior originates from a combination of genetic factors (the diathesis) triggered or “turned on” (like a light
switch) by environmental stressors.
Biological models view mental illness as having biological origins, specifically
neurotransmitter levels being too low or too high. Medications are often used to
treat mental illnesses in this model.
The DSM–5
•
•
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The DSM–5 describes mental disorders, their signs and symptoms, and gives
statistics and gender breakdowns for each disorder.
The medical model views all mental illnesses described in the DSM–5 as having
similar symptoms in common within each diagnostic category and subcategory.
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Key Terms
CHAPTER 1
Critical Thinking Questions
1. What criteria would you use to determine whether someone’s behavior is abnormal or not?
2. Discuss whether social norms should be used to determine/diagnose mental
illness.
3. Behaviorists like Skinner focus on the present, not on the past or on a person’s
upbringing. How successful would this approach be in psychotherapy, and why?
4. Which of the theories mentioned in this chapter do you think best explains the
origins of mental illness? Why?
5. What are your views on Rogers’s concept of innate goodness? Do you think
people are innately good or bad?
6. What are the pros and cons of using medications to treat mental illnesses?
Key Terms
ABC model A model of three components
of how we experience and interpret events:
A, the activating event or adversity; B, the
belief that follows; and C, the consequence.
age of onset The age at which the troublesome behaviors first become noticeable.
behaviorists Psychologists who believe
that only observable and scientifically
measurable behaviors are worth studying
and investigating.
bipolar disorder A disorder with two
poles and two dysfunctional mood states—
a manic state and a depressed state.
cognitive behaviorism A psychotherapeutic method that alters distorted attitudes
by identifying and replacing negative and
inaccurate thoughts, which will therefore
lead to behavioral changes.
cognitive perspective theory Aaron
Beck’s theory that abnormal behavior is
caused by faulty thinking such as viewing
life events in a negative fashion.
diathesis-stress model A model that
contends behaviors are a product of both
genetics (biology) and environmental
stressors.
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duration The length of time the troublesome behaviors have existed for a patient.
eccentric Individuals who have odd or
unusual habits but do not have a mental
illness.
ego A partially conscious part of the
psyche (which develops when an infant is
between 1½ and 3 years old) that seeks to
control the id by “convincing” it to delay
gratification until a reasonable solution to
the drive reduction is found.
id The primitive part of the personality,
present from birth, that houses our unconscious desires, wishes, and our basic innate
drives such as sex and aggression.
intensity How extreme the behaviors in
question are.
learned helplessness Seligman’s theory
that individuals develop depression
or anxiety disorders because they see
themselves as helpless to control their
environments.
legal norms Rules for behavior based on
society’s laws.
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Key Terms
maladaptive perspective Behavior is
deemed abnormal if it interferes with the
individual’s ability to function.
medical student syndrome Syndrome
where medical students begin to believe
they are suffering from the disease they are
studying.
modeling The idea that we can learn by
observing the behavior of others.
negative schema A view of the world that
is negative or pessimistic. Beck believed
this to be the cause of depression.
neurotransmitters Brain chemicals; they
are presumed to be at subnormal or supernormal levels in individuals with mental
disorders.
norms Spoken and unspoken rules for
proper conduct that are established by a
society over time and of course are subject
to changes over time.
overt behaviors Behaviors that are on the
surface or clearly visible to others.
psyche In Freudian theory, this consists
of three parts: the id, the ego, and the
superego.
psychoanalytic theory The set of concepts
that state individuals develop neuroses
because of their unresolved conflicts,
repressed id impulses surfacing and
overwhelming the ego and superego, and
problems that occurred during childhood.
psychological norms Rules for behavior
as codified in the DSM–5.
psychopathology The study of the causes
and development of psychiatric disorders.
CHAPTER 1
reformulated helplessness theory
Revised version of the helplessness theory
that differentiates between universal and
personal helplessness, as well as between
helplessness that is general or specific.
repression An ego defense mechanism
that operates unconsciously to keep certain
ideas, impulses, and memories from reaching consciousness.
social norms perspective Behavior is
deemed abnormal according to the standards set by society
statistical frequency perspective Behavior is deemed abnormal because it occurs
rarely or in only a small minority of the
population.
superego The final part of the psyche; it
develops when a child is between 3 and
6 years old and enables the individual
to feel guilt and have a conscience. The
superego is partially conscious and helps
the ego to control the id’s desires.
trepanning A process in which a small
instrument is used to bore holes into
the skull; the purpose may have been
to release evil spirits from an afflicted
person.
unconditional positive regard When one
person is completely accepting toward
another person. Carl Rogers believed that
people who receive unconditional positive regard from their parents early in life
will grow up to become constructive and
productive adults.
unipolar depression Known just as
depression to most people; this depression has one “pole” or dysfunctional
mood state.
psychopharmacology The study of the
treatment of mental illnesses with drugs
and medication.
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11
iStockphoto/Thinkstock
Neurodevelopmental Disorders
Chapter Objectives
After reading this chapter you should be able to:
• Explain how developmental psychology contributes to our understanding of psychological disorders among children and adolescents.
• Describe the main psychological disorders first observed in childhood and adolescence.
• Explain the effects of a childhood disorder on other family members.
• Describe how childhood and adolescent disorders can be treated.
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Section 11.1 Understanding Developmental Psychopathology
CHAPTER 11
11.1 Understanding Developmental Psychopathology
It is stressful for any family when one member has a psychological disorder; it is especially stressful when the affected person is a child. Children are constantly changing.
Unfortunately, because of disease, genetics, or traumatic experiences (to name just three
possible factors), some children find the road to adulthood full of obstacles. Unless they
are helped, such children are at risk for psychological disorders. In addition to the at-risk
children, their parent(s) and/or caregivers are also at risk. In order to gain a better picture
of children’s issues, and those of their caregivers, we will examine the members of the
University Hospital Parent Support Group. This group was organized by psychologist
Stuart Berg. Its members are parents of children under treatment for psychological disorders. See the case study below to be introduced to this group.
Case Study: Support Group, Part 1
Parent Support Group Transcript
DR. BERG: My name is Stuart Berg. I am a clinical psychologist working here at University Hospital.
I want to welcome each of you to this first support group meeting. I know some of you, and I will
look forward to meeting and working with all of you in the weeks to come. The goal of this support
group is to help you help your children and yourselves. You are all here because you have a child in
treatment and because you indicated an interest in mutual support. Although these meetings will
be unstructured, they do have a goal—to help you cope with a child who has a psychological disorder. Some of the issues we discuss will be practical: how to access government assistance programs,
how to find a baby-sitter, how to get your child to the dentist. Because some parents whose children
develop psychological disorders feel guilty and ashamed, as if they were the cause of their child’s
problems, we will also try to educate ourselves about what causes psychological disorders in children
and what we can do about them. Because this is our first meeting, I thought it might be a good idea
to go around and have each of you introduce yourself to the others. Let’s begin on my left.
JOHN CHENEY: My name is John Cheney. I am a doctor, a radiologist, in this hospital. My son, Eddie,
has autism. He is 8. I have no other children. I just couldn’t handle any more.
INGRID CHENEY: I am Ingrid Cheney, John’s wife. I do not work. My life is looking after Eddie.
PASQUALE ARMANTI: My name is Pasquale Armanti. I am a builder here in town. In fact, my company
built this hospital. My wife, Francesca, couldn’t have children. We adopted Paolo when he was a baby.
My life hasn’t been the same since. He has been in trouble since he could walk and nothing—
FRANCESCA ARMANTI (interrupting her husband): You are always picking on him. You never wanted
Paolo. You always rejected him. Even when he was little, you spanked him—
PASQUALE ARMANTI (interrupting his wife): Lighten up! Listen to yourself. Who are you kidding?
Paolo is out of control. He needs discipline.
DR. BERG: Perhaps we should get back to this later. Let’s move on.
KAREN BEASLEY: I’m Karen. Karen Beasley. I’m 19 years old. I’m here on my own because my boyfriend
Eric left us a few months ago. It’s just me and Michelle now. Michelle is 4, and she won’t talk. She
won’t hug me or let me hug her. She just stays in her room. Sometimes she watches TV; (continued)
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Section 11.1 Understanding Developmental Psychopathology
CHAPTER 11
Case Study (continued)
other times she just cries. Sometimes she hurts herself by banging her head against the wall. But even
when she is hurting herself, she won’t let me comfort her. I don’t have a job. I never finished high
school. Lately I’ve become fat. I’m dieting, but it doesn’t help. I’ve been running, and even that doesn’t
work. That’s me—a fat girl with no money, no boyfriend, and a kid who won’t talk.
CELIA BEROFSKY (to Karen): How did you get into this mess? A baby at 15, abandoned at 19. And what
makes you think you are fat? You’re nothing but skin and bones.
KAREN BEASLEY: I am? But I feel fat.
DR. BERG (addressing Celia): Perhaps you can introduce yourself?
CELIA BEROFSKY: I am Celia Berofsky, and this is my husband, Michael.
MICHAEL BEROFSKY: Hi.
CELIA BEROFSKY: My son Gordon won’t go to school. When we force him to go, he won’t talk to anyone. I know this is just a phase that he will grow out of. Michael thinks so too. Our psychologist suggested that we come to this group, but I don’t think we will be members long.
DR. BERG: Thanks, everyone, that was good. Perhaps one of you could start off the discussion by telling us about your experiences and the problems you are encountering. Everyone should feel free to
ask questions. Now, who wants to start?
PASQUALE ARMANTI: I’ll start. I am used to talking about Paolo. According to the psychologists at
school and Dr. Gale, our private psychologist, Paolo has attention-deficit hyperactivity disorder. But
this is not his only diagnosis. For a long time, they told me he had an oppositional defiant disorder,
and he also supposedly has a conduct disorder. Once they suspected Tourette’s disorder. I wonder if
anyone knows what is wrong with Paolo. Maybe he’s just a difficult kid.
Diagnosing psychological disorders in childhood is not easy because behavior that is
appropriate to one developmental stage may not be appropriate to another. For example,
wetting the bed is considered normal in many 1-year-olds but not in a 10-year-old. To
understand whether a child’s behavior is “abnormal,” we need to know what behaviors are
“normal” for children at different stages of development. Studying abnormal behavior in
its developmental context is the goal of the specialty area of clinical psychology known as
developmental psychopathology (refer to Chapter 1 for a definition of psychopathology).
The goal of those working in this field is to identify, as early in life as possible, the
risk factors for psychological disorders, and much of their work focuses on childhood
temperament.
Temperament and Behavior
All children display a characteristic temperament (Chess & Alexander, 1995; Strelau, 1998).
Easy children have regular patterns of elimination, eating, and sleeping. They adapt readily
to new environments, and, even when they are distressed, their emotional reactions are
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CHAPTER 11
usually mild. Slow-to-warm-up
children take longer to adapt to
new situations than easy children, but they eventually adjust.
Like easy children, their emotional reactions are mild. Difficult
children are another matter. They
are slow to adapt to new situations, and they have intense,
usually negative, emotional
reactions (such as tantrums).
Difficult children are at risk to
develop psychological disorders
© Getty Images/Jupiterimages/Photos.com/Thinkstock later in childhood and as adults
There are three types of temperament in children: easy, slow(Chess & Alexander, 1995). They
to-warm-up, and difficult.
are particularly prone to develop
“acting out” or externalizing
disorders, which involve behaviors that annoy or threaten others (Achenbach & McConaughy, 1996). Of course, not all difficult children develop psychological disorders, nor do
all easy and slow-to-warm-up children avoid them. Some members of the latter groups
will develop internalizing disorders, such as depression and anxiety, in which symptoms
are directed inward. Whether children develop a psychological disorder depends on the
fit between their temperaments and their environments (Chess & Alexander, 1999).
Elimination Disorders 1
Despite their different emphases, researchers of all theoretical orientations agree that elimination disorders are most likely to occur when toilet training is harsh or inconsistent,
especially when a child is resistant. “Difficult children,” especially those with conduct disorders, have a particularly hard time with toilet training (Foreman & Thambirajah, 1996).
Children who do not toilet train successfully by the usual age (or developmental level, if
they have an intellectual disability) are diagnosed as having enuresis (poor control of urination), encopresis (poor control of defecation), or, in rare cases, both. Enuresis typically
occurs at night (nocturnal enuresis), but it can occur during the day (diurnal enuresis).
Children must be at least 5 years old to be diagnosed with enuresis. About 10% of children
between the ages of 5 and 16 are bed-wetters, but as the child ages the problem becomes
less common (Friman, 2008). More recent data note the prevalence as between 5 to 10%
among 5-year-olds, 3 to 5% among 10-year-olds, and 1% among children 15 years of age
and older (APA, 2013). Encopresis is diagnosed when a child is older than 4 years, or
developmentally equivalent to 4 years old, and affects about 1% of 5-year-olds (American
Psychiatric Association, 2013). It is often the cause of chronic constipation that is unrelated
to medical or functional causes (Issenman et al., 1999; van Dijk et al., 2007). Elimination
disorders occur more often in boys than in girls and seem to run in families (APA, 2013).
Although this implicates biology in their etiology, elimination disorders are also linked to
stressful life situations such as a parent’s death (Johnson et al., 2006). Behavioral therapy
1. Note that in the DSM-5 elimination disorders are not in the Neurodevelopmental Disorders chapter, but appear in their own chapter: Elimination Disorders.
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Section 11.2 Disruptive, Impulse-Control, Conduct, and Attention Disorders
CHAPTER 11
is usually successful for enuresis and may help encopresis. It is frequently supplemented
with cognitive therapy and antidepressants (Friman, 2008).
11.2 Disruptive, Impulse-Control, Conduct,
and Attention Disorders
Conduct Disorder
Many children have mild temper tantrums and can be argumentative. While this sort
of behavior rarely presents a serious interpersonal problem, children who commit violent acts of aggression, such as hitting, biting, and kicking, may develop a conduct disorder. Learning the difference between aggression, which harms others, and assertiveness,
which is necessary for effective functioning in society, is an important part of growing up.
(As you can see in Part 1, Paolo Armanti had considerable difficulty learning to make this
distinction. See your e-book for Part 2 of the Parent Support Group case study.)
The main DSM–5 diagnostic criteria for conduct disorder also apply to antisocial personality disorder. The main difference between the two disorders is age. In theory, an adult
may be given the diagnosis of conduct disorder, but in practice, antisocial personality disorder is used for individuals over age 18, whereas conduct disorder is applied to people
under 18. The DSM–5 distinguishes three conduct disorder subtypes: childhood-onset
(before age 10), adolescent-onset (for those who are older than age 10 when the characteristic behaviors first appear), and unspecified onset, when criteria are met to diagnose
conduct disorder (but it is unclear if the onset of the first symptom was before or after
age 10). Three severity specifiers may also be applied: mild (behavior causes little harm),
moderate (stealing, but little violence), and severe (when the person displays many criterion behaviors and causes considerable harm to others).
In community settings, conduct disorder is more common among boys (14.1%) than
girls (3.8%), but the ratio is more equal in clinical settings (Costello et al., 2003). Higher
estimates may include children who live in threatening, high-crime neighborhoods and
engage in aggressive antisocial behavior as part of gangs. For most such children, antisocial behavior may not be a sign of a psychological disorder but simply a way of life.
There is consistent evidence that there is a genetic basis for conduct disorder (Dick et al.,
2002; Goldstein, Prescott, & Kendler, 2001; Slutske et al., 1997). Precisely what is inherited that causes conduct disorder remains unclear though. One theory is that people with
conduct disorder are chronically underaroused. To make up for this, they are always
seeking excitement. When their environment lacks socially acceptable opportunities for
excitement, they may turn to antisocial behaviors (Sarasalo, Bergman, & Toth, 1996; Frick
et al., 2003).
Although genetics may predispose children to conduct disorders, it is not the whole story.
The concordance rate for conduct disorders among identical twins is less than 1 (perfect), so environment must also play a role. One place to look for the environment’s influence is in faulty family relationships. Consistently, studies have focused on parent-child
relationships, conflict and hostility within the family, and marital problems between parents as causes of conduct disorder (Phrase, 2003; Biederman et al., 2001). However, these
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troublesome family interactions could just as easily be the result of having a child with a
conduct disorder as the cause of the child’s disorder.
In addition to family dynamics, some theorists attribute conduct disorders to drug abuse
and social factors such as poverty and exposure to community violence and aggressive
and criminal peers and models (Hibbs & Jensen, 2005; Hill & Maughan, 2001). Still, others emphasize how extra parental and teacher attention can reinforce antisocial behavior
(Dadds, 1997). Of course, parental neglect, exposure to antisocial models, and the reinforcement of antisocial behavior are not mutually exclusive. Many children experience all
three (Dadds, 1997; Moore & Arthur, 1983). Whatever the cause or causes of conduct disorders, the outlook is poor for those whose disorder is first diagnosed in childhood (Lahey,
2008; Dadds, 1997; Moffitt, 1993; Vitelli, 1997). Many such children go on to be diagnosed
with antisocial personality disorder (Salekin, 2006; Searight et al., 2001). Many have high
rates of marital instability, poor
work histories, and a tendency
toward substance abuse (Colman et al., 2009). The relationship between age of onset and
prognosis is similar for both
sexes, although females are less
likely than males to develop
antisocial personality disorder
as adults (Zoccolillo, 1993).
Children with conduct disorders
may also have specific learning
disorders such as a specific learning disorder with impairment in
Hemera/Thinkstock reading, often called dyslexia
(APA, 2013; Waldie & Spreen,
Learning disorders may be a direct cause of conduct disorder.
1993). More than one-third of
Children who fail at school experience a sense of humiliation
boys and one-half of girls with
and act out as a response.
conduct disorder also display
attention-deficit/hyperactivity disorder (Waschbusch, 2002). It is possible that these specific learning disorders may be one of the causes of conduct disorders. Specifically, children
who continuously fail at school feel humiliated because other children ridicule them. To
win respect and ease the pain of repeated failure, such children may act out. While trying
to control this disorderly behavior, teachers may actually reinforce it by giving disruptive
children extra attention. Eventually, antisocial behavior becomes a well-rewarded habit.
Although this hypothesis is plausible, keep in mind that it is based on a correlation between
conduct and specific learning disorders. It is equally possible that the causal mechanism
goes the other way around. Conduct disorders may cause specific learning disorders, perhaps by interfering with study time. It is also possible that conduct and learning disorders
both result from the same cause. For example, both may result from distractibility—the
main symptom of attention-deficit/hyperactivity disorder.
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CHAPTER 11
Attention-Deficit/Hyperactivity Disorder (ADHD)
Attention-deficit/hyperactivity disorder (ADHD) is a psychological disorder that typically begins in childhood. It is now found in the “Neurodevelopmental Disorders” chapter
of the DSM-5. It is characterized by long spells of inattention, hyperactivity, and/or impulsivity. It can be difficult to properly diagnose and assess (Rapport et al., 2008). The notion
for the disorder originated with the work of Alfred Strauss and his colleagues (see Strauss
& Kephart, 1955). Their goal was to identify childhood behaviors that could be used to
diagnose brain damage in ambiguous cases (when there were no clear-cut signs of neurological impairment). Because children with brain damage were often very active, they
argued that hyperactivity (a term they did not define) is a sign that a child is brain damaged.
To get around the problem that hyperactive children did not show any hard signs of brain
damage, the concept of minimal brain damage (or dysfunction) was introduced (Strother,
1973). These children were said to be hyperactive, impulsive, distractible, and emotionally
unstable. They had short attention spans, perceptual-motor deficits, poor coordination, and
learning disorders.
Despite the many attempts to refine them, the DSM–5 diagnostic criteria still have problems. Clinicians do not know how much fidgeting is “excessive” for children at different
stages of development. Moreover, children behave differently depending on the context.
Some children have attentional problems at school, whereas at home they sit and watch
television for hours. Because norms are unavailable for many attentional behaviors and
because behavior depends on context, parents, teachers, and clinicians often fail to agree
about which children suffer from ADHD (Rapport et al., 2008; Lahey, Pelham, Stein, et
al., 1998).
ADHD is more common among boys (4.7%) than girls (1.1%; Costello et al., 2003). This
may reflect a genuine sex difference or a social bias. That is, girls may not be diagnosed
with ADHD because they rarely cause the discipline problems that lead to teacher intervention. Although the gender difference in ADHD prevalence may provide clues to its etiology, until recently many studies included only boys (Rutter, Caspi, & Moffitt, 2003). The
DSM–IV (American Psychiatric Association, 1994) field trials established that the inclusion of a ‘’predominantly inattentive’’ (IN) subtype might identify substantially more girls
affected by ADHD (Lahey et al., 1994).
Because ADHD counts as a disability, it qualifies children for special treatment under the
Americans With Disabilities Act (1990, 2008). Parents may actually want their children to
be diagnosed with ADHD if this means they will receive special services.
Lead poisoning, brain damage, birth defects, food additives, and too much sugar in the diet
have all been blamed at one time for “causing” ADHD, but none of these supposed causes
has found strong empirical support (Barabasz & Barabasz, 1996; Barkley, 1996). There is
evidence that the problem runs in families though. Children whose parents have ADHD
are more likely to develop it (APA, 1994, 2000, 2013). Among monozygotic twins, when
one twin is diagnosed with ADHD, the other is more likely to receive the same diagnosis
than if he or she were a dizygotic twin (Eaves, Silberg, Maes, et al., 1993; Sherman, McGue,
& Iacono, 1997). Although these data suggest that inheritance contributes to ADHD, even
for identical twins the concordance rate is less than 1. In other words, genetics produces
a disposition to ADHD, but environmental factors also play a role. Most research efforts
have gone into treatment, specifically the use of stimulant drugs to control the symptoms
of ADHD.
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© Ralf-Finn Hestoft/Corbis
Ritalin is a common stimulant prescribed to
children with ADHD. After receiving a small
dosage, children begin to calm down and
focus their attention.
CHAPTER 11
The most commonly used stimulants are methylphenidate (Ritalin), pemoline (Cylert), dextroamphetamine (Dexedrine), and a mixture of several
amphetamines (Adderall). Stimulants can have
dramatic effects. After only a few tablets, children
who are constantly on the go calm down and
focus their attention. Because stimulants produce
a dramatic calming effect in children with ADHD,
some writers have argued that a “paradoxical”
calming response to stimulant drugs is diagnostic all by itself. In other words, if stimulant drugs
lead to less hyperactivity and distractibility, then
the child probably has ADHD. In reality, the
response of people with ADHD is not paradoxical; it is not even unusual. Stimulants improve
everyone’s ability to concentrate (Connor, 2006;
Virani et al., 2009). However, despite its effects
on attention and behavior, it is not clear if methylphenidate improves academic achievement
(Hechtman & Greenfield, 2003; Wells et al., 2000).
It does decrease the core symptoms of ADHD and
makes children more manageable (Frick & Morris, 2004; Livingston, 1997).
A drawback to the use of stimulants is the likelihood of unpleasant side effects, although for most
they are not severe (Pliszka, 2007; Virani et al., 2009). These include sleeplessness, irritability, loss of appetite, and growth retardation. Cylert can also cause liver damage. Taking
drugs may also affect a child’s self-concept. Children may learn to “externalize” responsibility for their behavior (“I can’t control myself, so I must take medicine”). Externalizing
responsibility could make children less responsive to learning self-control (Lambert et al.,
2001; Block, 1997; Garber, Spizman, & Garber, 1997). Skepticism about stimulant treatment
has almost as long a history as stimulant treatment itself (Biederman et al., 2005) In practice, the appropriate treatment for ADHD is not an either-or choice. Many ADHD children
receive a combination of stimulants, cognitive therapy, and behavioral therapy, as well as
various forms of special education (Daly et al., 2007).
Behavioral therapy has been well researched and appears to be quite effective in treating ADHD, especially when combined with stimulants (Rapport et al., 2008; Hoza et al.,
2008). Typically, behavioral therapy will focus on training teachers and parents to reward
attention and self-control in the child or pupil; this is often done while using a token
economy system. Research has also revealed that combined stimulant and behavior modification treatment will eventually lead to lower levels of medication required (Hoza et al.,
2008). In sum, research indicates that stimulants, either alone or with behavior modification therapy, are the most effective treatment approaches for ADHD. (See your e-book for
Part 3 of the Parent Support Group case study.)
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Section 11.3 Tourette’s
CHAPTER 11
11.3 Tourette’s
Tourette’s disorder is characterized by strange utterances (swearing, barking) and multiple motor tics (sudden repetitive but irregular movements). The DSM–5 also includes
other tic disorders (chronic motor or vocal tic disorders, provisional tic disorder) that have
some, but not all, of the symptoms of Tourette’s disorder. Unlike those for many psychiatric diagnoses, the criteria for Tourette’s disorder have hardly changed from Tourette’s
original description. The criteria include vocal and motor tics that are generally chronic
(although tic-free periods can occur).
Like most childhood disorders, Tourette’s disorder occurs more often in boys than in girls
(Shapiro et al., 1998; APA, 2013). It begins with facial tics, usually blinking or sniffing.
In serious cases, it progresses to neck and shoulder jerking, head banging, arm flinging,
and other peculiar movements. Sometimes, the tics are self-destructive (head banging,
for instance). Odd verbalizations are always part of the disorder. People with Tourette’s
may sniff, bark, or, in some cases, shout obscenities (a symptom known as coprolalia; APA,
2013). As already noted, tics come and go, and old ones are replaced by new ones (Shapiro,
Shapiro, Young, & Feinberg, 1998).
People with Tourette’s disorder can consciously inhibit their tics for brief periods, although
this requires considerable effort. Because they can inhibit their symptoms at least part of
the time and because their tics disappear during sleep, people with Tourette’s were long
considered to have a psychological disorder (Shapiro, Shapiro, Bruun, & Sweet, 1978).
Symptoms such as coprolalia were explained as either displaced aggression or the expression of poorly “defended” id impulses. Psychotherapy designed to uncover the unconscious conflicts causing Tourette’s disorder did not meet with much success (Shapiro et
al., 1998), and attention shifted to the neurochemistry of the illness (Murray, 1997). The
discovery that small doses of Haldol (haloperidol), a dopamine-suppressing drug used
to treat schizophrenia, suppresses Tourette’s symptoms in many people has led to the
hypothesis that those with Tourette’s may have an excess of dopamine (Murray, 1997).
Further evidence for this hypothesis comes from the finding that drugs that increase
dopamine levels, such as L-dopa (which is used in the treatment of Parkinson’s disease),
tend to increase the severity of tics.
An important finding is that Tourette’s disorder seems to be a genetically transmitted
dominant trait (Barr & Sandor, 1998). This is why people with Tourette’s disorder often
have relatives who also have tic disorders (Hebebrand, Klug, Fimmers, & Seuchter, 1997).
They also have a high frequency of relatives with obsessive-compulsive disorder and
ADHD, and many people with Tourette’s disorder have these other disorders too (Scahill
& Leckman, 2005). Several writers have remarked on the substantial similarities between
people with Tourette’s disorder and people who stutter (Abwender, Trinidad, Jones, et al.,
1998; Pauls, Leckman, & Cohen, 1993). Both have facial tics and odd grimaces, particularly when they are in emotionally arousing situations, and both may be helped by Haldol (haloperidol), Risperdal (risperidone), and Geodon (ziprasidone; Virani et al., 2009).
Coprolalia, surely the most peculiar symptom of Tourette’s disorder, has also been noted
among patients with aphasia and schizophrenia (Lenneberg, 1967). It has been noted that
stress makes it, and the other symptoms of Tourette’s disorder, worse. In other words,
Tourette’s disorder, like practically all other psychological disorders, has both a geneticphysiological and a psychological component.
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Section 11.4 Separation Anxiety Disorder
CHAPTER 11
Estimates approximate that Tourette’s disorder occurs in 10 to 80 children out of 10,000
(Scahill & Leckman, 2005). More recent estimates range from 3 to 8 per 1,000 children
(APA, 2013). There is some evidence, however, that the syndrome may be underdiagnosed
(Mason, Banerjee, Eapen, et al., 1998). Every time a television show or magazine article
discusses Tourette’s, many people with Tourette’s symptoms consult their doctors. Some
of these people say that they have suffered from the symptoms all of their lives without
knowing that their condition had a name.
Haldol (haloperidol) remains the most common treatment for Tourette’s syndrome. Unfortunately, people often discontinue treatment because of Haldol’s side effects, which, ironically, include a movement disorder similar to Parkinson’s. Other side effects include tardive
dyskinesia (involuntary movements of the tongue, face, mouth, or jaw), and grogginess,
blurred vision, and dry mouth (Kane & Marder, 2005). For those who need treatment in
addition to drugs (or who reject drugs because of their side effects), behavior therapy and
cognitive-behavior therapy have been used to help people relax and to deal with the interpersonal and social problems caused by having a tic disorder (Cook & Blacher, 2007).
11.4 Separation Anxiety Disorder2
At home, playing computer games, 10-year-old Gordon Berofsky seems to be a normal
boy, but he has significant problems. He will not attend school, and when he does, he will
not talk to his school-bus driver, the other children, or his teachers. Gordon has been seen
by two psychologists and a psychiatrist and has received several diagnoses, as his mother
relates in Part 4 of the Support Group case study. (See your e-book for Part 4.)
Diagnosis and Etiology
Note the importance of taking developmental level into account. It is normal for young
children to be more uneasy about separation than older children. It is unclear whether
there is a relationship between separation anxiety disorder in children and the development of panic disorders in adolescence and adults, but studies have shown a poor prognosis; many children who have separation anxiety go on to develop adult anxiety disorders
(Biederman et al., 2007).
As school is children’s primary social venue, it is not surprising that the school context is
a significant source of distress for children and adolescents with social anxiety disorder
(Essau, Conradt, & Petermann, 1999; Strauss & Last, 1993). It seems to occur equally often
in boys and girls and is most likely to occur at transition points—entry to elementary school
or at the beginning of junior or senior high school. Children who refuse to go to school need
not have difficulty with schoolwork. Some may fear evaluation; others fear mixing with
new children and may suffer from a social phobia or avoidant personality disorder. Some
school refusers may fear bullying or ridicule. However, for children like Gordon, the term
school phobia is misleading. It is not the fear of school that motivates Gordon to stay home;
it is the fear of separation from his mother. Gordon’s physical symptoms are an excuse to
2. Separation anxiety disorder appears in the “Anxiety Disorders” chapter of the DSM-5. Because this is the most common anxiety
disorder in children who are younger than 12 years old (APA, 2013), we include it in this chapter.
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Section 11.5 Autism Spectrum Disorder
CHAPTER 11
avoid school. Children like Gordon are different from truants,
who skip school without their
parents’ knowledge to do something they like better, such as go
to the beach or a ball game (Lee
& Miltenberger, 1996). Gordon
skips school to stay home, and
his parents know all about it.
There are many possible causes
for separation anxiety. In some
cases, a child may have actually
experienced separation from his
Westend61/SuperStock
or her parents through death Children suffering from separation anxiety experience severe
or, more often, divorce. In other distress at the thought of separating from home or close
cases, separation anxiety may family members. Younger children typically encounter a mild
arise from overprotectiveness. uneasiness about separation or attending school, yet if the
Parents who worry excessively symptoms occur to a greater degree, they may be diagnosed
about harm coming to their with early-onset separation anxiety disorder.
child once the child is outside
of their immediate purview communicate their anxiety to their child, who learns to fear
separation. Children are likelier to have an anxiety disorder if a parent has one (Beidel &
Turner, 1997; Lieb et al., 2000).
Staying home is reinforcing because it not only reduces anxiety but also offers secondary
rewards, such as maternal attention. Refusal to go to school and separation anxiety disorder make a dangerous combination. Children who show both signs may develop other
anxiety disorders (Bruckl et al., 2006).
(Before we begin to discuss autism spectrum disorder, see your e-book for more of the
Support Group case study.)
11.5 Autism Spectrum Disorder
Autism spectrum disorder is the most serious psychopathological condition occurring in
childhood. It is marked by poor interpersonal relationships and communication skills, and
repetitive/stereotyped behavior. At one time, this disorder was referred to as childhood
schizophrenia, but it is now clear that it is different from schizophrenia. It is not associated
with hallucinations or delusions, and the children do not develop schizophrenia when they
grow up. Previously classified in the DSM-IV-TR as pervasive developmental disorders,
autism spectrum disorder now constitutes a separate category of psychological disorder in
the DSM-5. Autism disorder is now classified on a spectrum, ranging from some impairment to severe impairment.
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Section 11.5 Autism Spectrum Disorder
© Robin Nelson/ZUMA Press/Corbis
Autistic disorder is characterized by poor social interactions,
impaired communication, and odd motor behaviors. Parents
notice unusual behavior before age 3 and often report their
child’s lack of responsiveness.
CHAPTER 11
One important note: Not every
child with autism spectrum disorder (also referred to as autism
throughout the remainder of the
chapter) has an intellectual disability. Percentages of children
with autism and an intellectual
disability have been estimated
as ranging from 25% to 80%;
one researcher claimed that
this prevalence is overstated
(Edelson, 2006). The association
between intellectual disabilities
and autism is not because they
usually have common causes,
but because the presence of both
makes it more likely that both
will be diagnosed (Skuse, 2007).
John and Ingrid Cheney were both 27 years old when Eddie was born. Neither John nor
Ingrid knows of any mental illness in their families, although Ingrid’s brother had a developmental language disorder as a child. As you can see from Part 5 of the Parent Support Group case study, Eddie’s problems became apparent early in life, and his behavior
reflects almost all of the diagnostic criteria for autism spectrum disorder, which are summarized in Table 11.1.
Table 11.1: DSM-5 Diagnostic Criteria for Autism Spectrum Disorder (299.00) (F84.0)
A. Persistent deficits in social communication and social interaction across multiple contexts, as
manifested by the following, currently or by history (Examples are illustrative, not exhaustive; see
text):
1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach
and failure or normal back-and-forth conversation; to reduced sharing of interests, emotions, or
affect; to failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for ex...
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