500 words discussion ABNORMAL PSYCHOLOGY

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In this conversation, here are the two opposing views that you will need to consider to the best of your collective ability by the end of the week:

NOTE: While it is easy to take a position and argue why you believe that position to be true, I challenge you to engage in higher order thinking: Consider the opposing viewpoints and address the following questions:

A. What does each position believe? Why--what is the evidence being used for their arguments? Evaluate the quality of the evidence from a scholarly perspective.
B. Can you identify one or more logical points or pieces of information in each perspective even though you may not agree with that perspective completely?
C. What additional information would be helpful to know to evaluate each perspective more effectively?
D. What is a potential 3rd or 4th perspective that should be considered in this controversy? There are likely many other perspectives besides these two.

The 1st two perspectives we are considering:

1. Ausubel's argument that mental illness is real.
2. Szasz's argument that mental illness is a myth.




EXAMPLE, SAMPLE OF HOW THIS SHOULD LOOK LIKE:

Abnormal Psychology

According to Getzfeld and Schwartz (2014), “psychopathology refers to the study of the causes and development of psychiatric disorders,” but researchers agree that it is difficult to come to a precise definition of abnormal behavior (ch. 1.1).

My definition of psychopathology based on my current understanding of the topic is that it is the study, diagnosis, and treatment of different disorders and mental illnesses. However, I believe that the definition of abnormal psychology is going to be different for every individual based on their upbringing, behavior, thoughts, emotions, and other factors. I think that there are many influences that help to determine what defines abnormal psychology, such as cognitive ability, behavior, genetics, family dynamics, neurobiology, emotions, thoughts, and processes such as modeling, schema development, or associative learning. I think it is also important to keep in mind that what one perceives as abnormal, another might perceive as normal.

I feel that there are a few early theories which go along with my definition. One major theoretical historical perspective that relates to my definition and ideas about what defines abnormal psychology is Cognitive-Behaviorism of the 1950s-1970s, specifically Albert Bandura’s Social Learning Theory. According to Bandura, we learn by observing and copying the behaviors of others, which he termed as modeling (Getzfeld & Schwartz, 2014). Another major theory that I feel influenced my thoughts is Beck’s cognitive perspective theory, which explains that our development of depression starts from the tendency to develop negative schemas about the world and the self during childhood and adolescence (Getzfeld & Schwartz, 2014). A third theoretical perspective that I feel matches part of my definition is the Diathesis-Stress Model, which explains that both biology and environmental stressors influence our behavior by turning genes on or off (Getzfeld & Schwartz, 2014). Whether or not we have a genetic predisposition to having a certain disorder is not the problem entirely; the way in which the environment affects us determines if the diathesis is turned on or off and if we become more or less likely to experience and express genetic disorders.

Szasz versus Ausubel

In 1960, Thomas Szasz developed the notion that there is no such thing as mental illness as it is not a thing, but rather a theoretical concept. He compared the theory of mental illness to ideas such as witchcraft, deities, and microorganisms which have been thought of as the causes of a number of events throughout history. Szasz was quick to differentiate between diseases of the brain and disorders of the mind, explaining that diseases of the brain cannot accurately define all behavior and thinking. He believed that the mind could not be sick as the brain or other parts of the body could be physiologically sick. He explained that beliefs, behaviors, and emotions could not be recognized as symptoms for diseases of the central nervous system. According to Szasz, we organize our knowledge and thoughts in a way that we correspond mental symptoms with physical ones. He goes on to explain that “the concept of illness, whether bodily or mental, implies deviation from some clearly defined norm,” and that it is either the individual or other people around the individual who decide that there has been a deviation (Szasz, 1960, pg. 114, col. 2, para. 2). Szasz notes that people believe that good mental health is the absence of mental illness, and that making the right choices and proper conduct in one’s life secures mental health. However, he argues that it is really the other way around; it is the making of good choices and proper conduct that other people regard as good mental health. (Szasz, 1960)

David Ausubel contradicted Szasz’s position about mental illness in 1961, and explained that personality disorder is a disease. Ausubel argued that although diseases of the brain cannot define personality disorder, brain pathology can at least explain some psychological disorders due to neurological damage, injury, or other impairments. He also explained that symptoms do not have to be entirely physical to explain a disease of the body, or entirely mental to explain a disease of the mind; rather the evaluation of all symptoms both physical and mental depends on several factors such as subjective judgement, emotions, societal/cultural norms, and the involvement of the observer. According to Ausubel, abnormal behavior is influenced by both the mind and the body, and to deem mental illness as merely a mythical fragment of guilt or lack of moral judgement constructed by social norms would be foolish. Ausubel explains that immoral behavior and mental illness can be distinguished from one another, and to lump the two together and invalidate mental illness as a disease would be just as dangerous as medical doctors stepping away from clinical medicine. (Ausubel, 1961)

Although I do not agree with either position completely, there are some points from each that I can agree with. I agree with Szasz that diseases of the brain cannot accurately explain all disorders of the mind, as only the body can be physically sick, and not the mind. Although the mind cannot be physically sick, I do not agree with Szasz that mental illness is a myth. Although symptoms may not always be physical, the symptoms are still there, which I feel is the direction that Ausubel was moving towards. I agree with Ausubel that both physical and mental symptoms should be considered in the context of all other factors, both internal and external. Some additional information that I feel would be helpful in evaluating each perspective more effectively would be to research other theorists who adopted the ideas of Szasz and Ausubel and offered their own perspectives on the paradigm.

A third perspective can be offered by Sigmund Freud, who believed that adult human behavior was controlled by the psyche, which was made up of the id, ego, and superego. He believed that the id is the unconscious part of our personality that is present at birth and cradles our desires, while controlling our innate drives such as sex and aggression. The superego deals with morals, guilt, and understanding right from wrong based on social and cultural norms, and is partially a conscious part of the mind. Finally, the ego mediates conflict between the id and superego, controlled in part by the conscious thoughts coming from within the superego. Freud believed that if the three areas of the psyche were not in balance, then we would repress ideas, impulses, and memories from reaching the fully conscious part of the mind. Freud believed that if someone was unable to deal with these ideas or if they were to come to consciousness, the result would be neurosis, anxiety, and depression which could manifest as abnormal behavior. (Lecci, 2015; Getzfeld & Schwartz, 2014)

I cannot agree with most of Freud’s work, because I believe he placed too much emphasis on sexual drive and aggression for a number of his theories within the psychodynamic/psychoanalytic model of psychology. However, I can partially agree with the notion that unconscious processes of the mind do play a role in our behavior, and I do agree that we repress issues as a self-defense mechanism. Although, I do not believe that not being able to deal with repressed ideas would necessarily result in neurosis, anxiety, or depression, and I doubt that it can accurately define abnormal behavior.

References

Ausubel, D. P. (1961). Personality disorder is disease. American Psychologist, 16(2), 69-74. doi:10.1037/h0042627

Getzfeld, Andrew R. & Shwartz, S. (2014). Abnormal Psychology: DSM-5. San Diego, CA: Bridgepoint Education Inc. Retrieved from https://content.ashford.edu (Links to an external site.)Links to an external site.

Lecci, L. (2015). Personality. San Diego, CA: Bridgepoint Education, Inc. Retrieved from https://content.ashford.edu (Links to an external site.)Links to an external site.

Szasz, Thomas S. (1960). The Myth of Mental Illness. American Psychologist, 15, 113-118. doi:10.1037/h0046535. Retrieved from http://homepage.westmont.edu/bsmith/documents/Szasz.pdf (Links to an external site.)Links to an external site.

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1 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. get81325_01_c01.indd 1 12/5/13 3:59 PM 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: get81325_01_c01.indd 2 12/5/13 3:59 PM Section 1.1 How Do We Define Abnormal Behavior? CHAPTER 1 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 get81325_01_c01.indd 3 12/5/13 3:59 PM 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 get81325_01_c01.indd 4 12/5/13 3:59 PM 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. get81325_01_c01.indd 5 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. 12/5/13 3:59 PM 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. get81325_01_c01.indd 6 12/5/13 3:59 PM 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 get81325_01_c01.indd 7 12/5/13 3:59 PM Section 1.2 A History of Abnormal Behavior Theories CHAPTER 1 (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 get81325_01_c01.indd 8 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. 12/5/13 3:59 PM 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. get81325_01_c01.indd 9 12/5/13 3:59 PM Section 1.2 A History of Abnormal Behavior Theories CHAPTER 1 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. get81325_01_c01.indd 10 12/5/13 4:00 PM Section 1.2 A History of Abnormal Behavior Theories CHAPTER 1 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 get81325_01_c01.indd 11 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. 12/5/13 4:00 PM 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. get81325_01_c01.indd 12 12/5/13 4:00 PM Section 1.2 A History of Abnormal Behavior Theories CHAPTER 1 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. get81325_01_c01.indd 13 life will grow up to become constructive and productive adults, even though they will have flaws. 12/5/13 4:00 PM 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 get81325_01_c01.indd 14 12/5/13 4:00 PM 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. get81325_01_c01.indd 15 12/5/13 4:00 PM 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. get81325_01_c01.indd 16 12/5/13 4:00 PM 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. get81325_01_c01.indd 17 12/5/13 4:00 PM 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? get81325_01_c01.indd 18 12/5/13 4:00 PM 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). get81325_01_c01.indd 19 12/5/13 4:00 PM 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. get81325_01_c01.indd 20 12/5/13 4:00 PM 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. get81325_01_c01.indd 21 12/5/13 4:00 PM 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 • • get81325_01_c01.indd 22 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. 12/5/13 4:00 PM 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. get81325_01_c01.indd 23 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. 12/5/13 4:00 PM 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. get81325_01_c01.indd 24 12/5/13 4:00 PM 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. get81325_11_c11.indd 289 12/10/13 10:28 AM 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) get81325_11_c11.indd 290 12/10/13 10:28 AM 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 get81325_11_c11.indd 291 12/10/13 10:28 AM Section 11.1 Understanding Developmental Psychopathology 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. get81325_11_c11.indd 292 12/10/13 10:28 AM 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 get81325_11_c11.indd 293 12/10/13 10:28 AM Section 11.2 Disruptive, Impulse-Control, Conduct, and Attention Disorders CHAPTER 11 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. get81325_11_c11.indd 294 12/10/13 10:28 AM Section 11.2 Disruptive, Impulse-Control, Conduct, and Attention Disorders 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. get81325_11_c11.indd 295 12/10/13 10:28 AM Section 11.2 Disruptive, Impulse-Control, Conduct, and Attention Disorders © 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.) get81325_11_c11.indd 296 12/10/13 10:28 AM 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. get81325_11_c11.indd 297 12/10/13 10:28 AM 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. get81325_11_c11.indd 298 12/10/13 10:28 AM 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. get81325_11_c11.indd 299 12/10/13 10:28 AM 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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ABNORMAL PSYCHOLOGY
Psychopathology can be defined as the study of causes and development of mental disorders. In
my own opinion psychopathology can be defined as the study of causes, development stages,
symptoms and treatment of mental disorders including manifestation of certain behaviors which
are indicative of the presence of a mental distress. However, arriving at a common definition of
abnormal behavior has over time proved difficult, because different people view different
behaviors differently. And for this reason what one person perceives abnormal, may be totally
different in the eyes of another person. Definition of abnormal psychology is dependent on human
behavior, emotion, thoughts and even the environment in which different individuals are brought
up in, (Prilleltensky, 780).
Based on the existing theories of abnormal psychology factors such as cognitive ability, associative
learning, social norms, ...


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