Chapter 16.pdf

chapter

Psychological Disorders

THEME:

Judgments of normality are

relative, but psychological

disorders clearly exist and

need to be classi ed,

explained, and treated.

Key Questions

How is normality de ned, and what are

the major psychological disorders?

How do delusional disorders differ from

other psychotic disorders?

What is a personality disorder?

What forms does schizophrenia take?

What causes it?

What problems result when a person

suffers high levels of anxiety?

What are mood disorders? What causes

depression?

How do psychologists explain anxiety-

based disorders?

Why do people commit suicide? Can

suicide be prevented?

What are the general characteristics

of psychotic disorders?

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Preview

Beware the Helicopters

Some 7 percent of the population has an anxiety-related

disorder.

One of every eight school-age children is seriously

maladjusted.

From 10 to 20 percent or more of all adults suffer a

major depression in their lifetime.

Each year in North America, more than 2 million people

are admitted to hospitals for psychiatric treatment.

“The helicopters. Oh no, not the helicopters. Have come

to tear the feathers out of my frontal lobes. Help me,

nurse, help me, can’t you hear them? Gotta get back into

my body to save it. . . . The doctor is thinking I would

make good glue.”

These are the words of Carol North, a psychiatrist who

survived schizophrenia. In addition to being plagued by

hallucinated helicopters, Carol heard voices that said, “Be

good,” “Do bad,” “Stand up,” “Sit down,” “Collide with

the other world,” “Do you want a cigar?” (North, 1987).

Carol North’s painful journey into the shadows of mad-

ness left her incapacitated for nearly 20 years. Her case is

but one hint of the magnitude of mental health problems.

Here are the facts on psychological disorders:

What does it mean to be “crazy”? A hundred years

ago, doctors and nonprofessionals alike used terms such

as “crazy,” “insane,” “cracked,” and “lunatic” quite freely.

The “insane” were thought of as bizarre and de nitely

different from the rest of us. Today, our understanding

of psychological disorders is more sophisticated. To draw

the line between normal and abnormal, we must weigh

some complex issues. We’ll explore some of them in this

chapter, as well as an array of psychological problems.

Of every 100 persons, one will become so severely dis-

turbed as to require hospitalization at some point in his

or her lifetime.

Some 3 to 6 percent of the aged suffer from organic

psychoses.

Normality—What Is Normal?

But couldn’t a person be seriously disturbed without feeling discom-

fort? Yes. Psychopathology doesn’t always cause personal anguish.

A person suffering from mania might feel elated and “on top of

the world.” Also, a lack of discomfort may reveal a problem. For

example, if you showed no signs of grief after the death of a close

friend, we might suspect psychopathology. In practice, subjective

discomfort explains most instances in which people voluntarily

seek professional help.

Some psychologists use statistics to de ne normality more ob-

jectively. Statistical abnormality refers to scoring very high or

low on some dimension, such as intelligence, anxiety, or depres-

sion. Anxiety, for example, is a feature of several psychological

disorders. To measure it, we could create a test to learn how many

people show low, medium, or high levels of anxiety. Usually, the

results of such tests will form a normal (bell-shaped) curve. ( Normal

in this case refers only to the shape of the curve.) Notice that most

people score near the middle of a normal curve; very few have

extremely high and low scores (

Deciding if a person’s behavior is abnormal is harder than it might

seem. The conservative, church-going housewife down the street

might be agrantly psychotic and a lethal danger to her children.

The reclusive eccentric who hangs out at the park could be the san-

est person in town. Let’s begin our discussion with some basic fac-

tors that affect judgments of normality. “That guy is really wacko.

His porch lights are dimming.” “Yeah, the butter’s sliding off his

waf e. I think he’s ready to go postal.” Informally, it’s tempting to

make snap judgments about mental health. However, to seriously

classify people as psychologically unhealthy raises complex and

age-old issues. The scienti c study of mental, emotional, and be-

havioral disorders is known as psychopathology. The term also

refers to mental disorders themselves, such as schizophrenia or de-

pression, and to behavior patterns that make people unhappy and

impair their personal growth (Butcher, Mineka, & Hooley, 2004).

De ning abnormality can be tricky. We might begin by saying

that psychopathology is characterized by subjective discomfort

(private feelings of pain, unhappiness, or emotional distress) like

Carol North endured.

Figure 16.1). A person who de-

viates from the average by being anxious all the time (high anxi-

ety) might be abnormal. So, too, might a person who never feels

anxiety.

●

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Psychological Disorders

533

DISCOVERING PSYCHOLOGY

Crazy for a Day

Performing a mildly abnormal behavior is a good way to get a

sense of how social norms de ne “normality” in daily life. Here’s

your assignment: Do something strange in public and observe

how people react to you. (Please don’t do anything dangerous,

harmful, or offensive—and don’t get arrested!) Here are some de-

viant behaviors that other students have staged:

Sit in the dining area of a fast-food restaurant and loudly carry

on a conversation with an imaginary companion.

Stand in a busy hallway on campus and adopt a Kung Fu

stance. Remain in that position for 10 minutes.

Walk around campus on a sunny day while wearing a raincoat

and carrying an open umbrella. Keep the umbrella over your

head when you are inside buildings.

Stick one nger in your nose and another in your ear. Walk

through a busy shopping mall.

Cover your head with aluminum foil for a day.

Does the idea of performing any of these actions make you

uncomfortable? If so, you may not need to do anything more to

appreciate how powerfully social norms constrain our actions. As

we have noted, social nonconformity is just one facet of abnormal

behavior. Nevertheless, actions that are regarded as “strange”

within a particular culture are often the rst sign to others that a

person has a problem.

Then statistical abnormality tells us nothing about the meaning of

deviations from the norm? Right. It is as statistically “abnormal”

(unusual) for a person to score above 145 on an IQ test as it is to

score below 55. However, only the lower score is regarded as “ab-

normal” or undesirable (Wake eld, 1992). In the same sense, it is

unusual for a person to speak four languages or to win an event at

the Olympics, but these are desirable, if rare, accomplishments.

Statistical de nitions also can’t tell us where to draw the line be-

tween normality and abnormality. To take a new example, we

could obtain the average frequency of sexual intercourse for per-

sons of a particular age, sex, sexual orientation, and marital status.

Clearly, a person who feels driven to have sex dozens of times a

day has a problem. But as we move back toward the norm we face

the problem of drawing lines. How often does a normal behavior

have to occur before it becomes abnormal? As you can see, statisti-

cal boundary lines tend to be somewhat arbitrary (Comer, 2005).

Atypical behavior or nonconformity may underlie some disor-

ders. Social nonconformity refers to disobeying public standards

for acceptable conduct. Extreme nonconformity can lead to de-

structive or self-destructive behavior. (Think, for instance, of a

drug abuser or a prostitute.) However, we must be careful to sepa-

rate unhealthy nonconformity from creative lifestyles. Many ec-

centric “characters” are charming and emotionally stable. Note,

too, that strictly following social norms is no guarantee of mental

health. In some cases, psychopathology involves rigid confor-

mity. (See “Crazy for a Day.”)

Social nonconformity does not automatically indicate psychopathology.

Abnormal?

Psychopathology The scienti c study of mental, emotional,

and behavioral disorders; also, abnormal or maladaptive

behavior.

Statistical abnormality Abnormality de ned on the basis of

an extreme score on some dimension, such as IQ or anxiety.

Social nonconformity Failure to conform to societal norms or

the usual minimum standards for social conduct.

Extremely low

Low

Moderate

High

Extremely high

Characteristic level of anxiety

● Figure 16.1 The number of people displaying a personal characteristic

may help de ne what is statistically abnormal.

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534

CHAPTER 16

CRITICAL THINKING

The Politics of Madness

The year is 1840. You are a slave who has tried repeatedly to escape

from a cruel and abusive master. An expert is consulted about your

“abnormal” behavior. His conclusion? You are suffering from “drap-

etomania,” a mental “disorder” that causes slaves to run away

(Wake eld, 1992). Your “cure”? The expert will cut off your toes.

As this example suggests, psychiatric terms are easily abused.

Historically, some have been applied to culturally disapproved be-

haviors that are not really disorders. One of our personal favorites

is the diagnosis of “anarchia,” a form of insanity that leads one to

seek a more democratic society (Brown, 1990b). All of the follow-

ing were also once considered disorders: childhood masturbation,

lack of vaginal orgasm, self-defeating personality (applied mainly

to women), homosexuality, and nymphomania (a woman with a

healthy sexual appetite) (Wake eld, 1992). Even today, race, gen-

der, and social class continue to affect the diagnosis of various dis-

orders (Nathan & Langenbucher, 1999; Poland & Caplan, 2004).

Gender is probably the most common source of bias in judging

normality because standards tend to be based on males (Nolen-

Hoeksema, 2004; Widiger, 2005). According to psychologist Paula

Caplan (1995) and others, women are penalized both for con-

forming to female stereotypes and for ignoring them. If a woman

is independent, aggressive, and unemotional, she may be consid-

ered “unhealthy.” Yet at the same time, a woman who is vain,

emotional, irrational, and dependent on others (all “feminine”

traits in our culture) may be classi ed as a histrionic or dependent

personality (Bornstein, 1996). Indeed, a majority of persons classi-

ed as having dependent personality disorder are women. In view

of this, Paula Caplan asks, why isn’t there a category called

“delusional dominating personality disorder” for obnoxious men

(Caplan, 1995)?

The differences we have reviewed illustrate the subtle in uence

that culture can have on perceptions of disorder and normality. Be

cautious before you leap to conclusions about the mental health

of others ( DSM-IV-TR, 2000). (They might be doing an assignment

for their psychology class!)

A young woman ties a thick rubber cord around her ankles,

screams hysterically, and jumps head rst off a bridge. Thirty years

ago, the woman’s behavior might have seemed completely crazy.

Today, it is a routine form of entertainment. Before any behavior

can be de ned as abnormal, we must consider the situational con-

text (social situation, behavioral setting, or general circumstances)

in which it occurs. Is it normal to stand outside and water a lawn

with a hose? It depends on whether it is raining. Is it abnormal for

a grown man to remove his pants and expose himself to another

man or woman in a place of business? It depends on whether the

other person is a bank clerk or a doctor!

Almost any imaginable behavior can be considered normal in

some contexts. In mid-October 1972, an airplane carrying a rugby

team crashed in the snow-capped Andes of South America. In-

credibly, 16 of the 45 people onboard survived 73 days in deep

snow and subfreezing temperatures. They were forced to use ex-

tremely grim measures to do so—they ate the bodies of those who

died in the crash.

As implied by our earlier discussion of social norms, culture is

one of the most in uential contexts in which any behavior is

judged. In some cultures it is considered normal to defecate or

urinate in public or to appear naked in public. In our culture such

behaviors would be considered unusual or abnormal. In Muslim

cultures, women who remain completely housebound are consid-

ered normal or even virtuous. In Western cultures they might

be diagnosed as suffering from a disorder called agoraphobia

(Fabrega, 2004). (Agoraphobia is described later in this chapter.)

Thus, cultural relativity (the idea that judgments are made rela-

tive to the values of one’s culture) can affect the diagnosis of psy-

chological disorders. (See “The Politics of Madness.”) Still, all cul-

tures classify people as abnormal if they fail to communicate with

others or are consistently unpredictable in their actions.

Core Features of Disordered Behavior

If abnormality is so hard to de ne, how are judgments of psychopathol-

ogy made? It’s clear that all of the standards we have discussed are

relative. However, abnormal behavior does have two core features.

First, it is maladaptive. Rather than helping people cope success-

fully, abnormal behavior makes it more dif cult for them to meet

the demands of day-to-day life. Second, people suffering from

psychological disorders lose the ability to control their thoughts,

behaviors, or feelings adequately. For example, gambling is not a

problem if people bet for entertainment and can maintain self-

control. However, compulsive gambling is a sign of psychopa-

thology. The voices that Carol North kept hearing are a prime ex-

ample of what it means to lose control of one’s thoughts. In the

most extreme cases, people become a danger to themselves or

others, which is clearly maladaptive (Hansell & Damour, 2004).

Various levels of functioning—from superior to severely dis-

turbed—are described in ■ Table 16.1. Note that the bottom of

the scale reads, “Persistent danger of hurting self or others.” Obvi-

ously, behavior at that level is maladaptive and involves a serious

loss of control.

In practice, deciding that a person needs help usually occurs

when the person does something (hits a person, hallucinates, stares

into space, collects rolls of toilet paper, and so forth) that annoys

or gains the attention of a person in a position of power in the per-

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535

TABLE 16.1

Levels of Functioning

SCALE

LEVEL OF FUNCTIONING

EXAMPLES

100

Superior functioning in a wide range of activities.

Life’s problems never seem to get out of hand.

No symptoms.

Person is sought by others because of his or her many

positive qualities.

Absent or minimal symptoms, functioning well in all areas, no more than

Has mild anxiety before exams, occasional arguments

everyday problems.

with family members.

If symptoms are present, they are brief and common reactions to stressors.

Has dif culty concentrating after family arguments,

No more than slight impairment in relationships, work, or school.

is falling behind in schoolwork.

Some mild symptoms, or some dif culty with relationships, work, or

Mood is depressed and has mild insomnia. Has been

school.

truant at school and has stolen things at home.

Moderate symptoms or moderate problems with relationships, work,

Emotions are blunted, speech evasive, occasional

or school.

panic attacks, no friends, unable to keep a job.

Serious symptoms or any serious impairments in relationships, work,

Person has suicidal thoughts, engages in obsessional

or school.

rituals, shoplifts, has no friends, is unable to keep a job.

Some impairment in grasp of reality or in communication, plus major

Speech is illogical, obscure, or irrelevant. Person is

impairments in work or school relationships, judgment, thinking

depressed and avoids friends, neglects family, and is

or mood

unable to work

Behavior is considerably affected by delusions or hallucinations; or,

Person is sometimes incoherent; acts grossly

person is seriously impaired in communication or judgment;

inappropriately; is preoccupied with suicide; stays in

or, is unable to function in almost all areas.

bed all day; has no job, home, or friends.

Some danger of hurting self or others; or, occasionally fails to

Person makes tentative suicide attempts, is frequently

maintain minimal personal hygiene; or, communication is

violent and manically excited, smears own feces,

grossly impaired.

is either incoherent or mute.

Persistent danger of severely hurting self or others; or, persistent

Repeatedly violent, maintains almost no personal

inability to maintain minimal personal hygiene; or, serious suicidal acts.

hygiene, has made potentially lethal suicide attempts.

Adapted from Global Assessment of Functioning Scale, DSM-IV, 1994.

An Overview of Psychological Disorders

People suffering from psychotic disorders have “retreated from

reality.” That is, they suffer from hallucinations and delusions

and they are socially withdrawn. Psychotic disorders are severely

disabling and often lead to hospitalization. Typically, psychotic

patients cannot control their thoughts and actions. For example,

a college student who became psychotic told his father, “It’s the

strangest thing. I hear voices, hundreds of them, telling me that

everyone wants me dead. It’s like all the radios of the world blar-

ing all the stations at once, and it doesn’t stop. It jams my brain.”

(Weisburd, 1990). Psychotic symptoms occur in schizophrenia,

delusional disorders, and some mood disorders. Also, psychosis

son’s life (an employer, teacher, parent, spouse, or the person

himself or herself). That person then does something about it. (A

police of cer may be called, the person may be urged to see a psy-

chologist, a relative may start commitment proceedings, or the

person may voluntarily seek help.)

Classifying Mental Disorders—

Problems by the Book

Psychological problems are classi ed by using the Diagnostic and

Statistical Manual of Mental Disorders ( DSM-IV-TR, 2000). The DSM

helps psychologists correctly identify mental disorders and select

the best therapies to treat them (First & Pincus, 2002).

A mental disorder is a signi cant impairment in psychologi-

cal functioning. If you were to glance through DSM-IV-TR, you

would see many disorders described, including those in ■ Table

16.3 (on page 539). It’s impossible here to discuss all of these prob-

lems. Major disorders are listed in the table so you can see the

types of problems found in the DSM. (You don’t need to memo-

rize all of them.) The descriptions that follow will give you an

overview of some selected problems.

Maladaptive behavior Behavior that makes it dif cult to adapt

to the environment and meet the demands of day-to-day life.

Mental disorder A signi cant impairment in psychological

functioning.

Psychotic disorder A severe mental disorder characterized by

a retreat from reality, by hallucinations and delusions, and by

social withdrawal.

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