h a p t e r O u t l i n e

understanding psychopathology What Is a Psychological Disorder? The Science of Psychopathology Historical Conceptions of Abnormal Behavior

the Supernatural tradition Demons and Witches Stress and Melancholy Treatments for Possession Mass Hysteria Modern Mass Hysteria The Moon and the Stars Comments

the Biological tradition Hippocrates and Galen The 19th Century The Development of Biological Treatments Consequences of the Biological Tradition

the psychological tradition Moral Therapy Asylum Reform and the Decline of Moral

Therapy Psychoanalytic Theory Humanistic Theory The Behavioral Model

the present: the Scientific Method and an integrative approach

1 Abnormal Behavior in Historical Context

Je rr

y C

oo ke

/S ci

en ce

S ou

rc e

50443_ch01_ptg01_hr_002-031.indd 2 28/09/16 2:43 PM

Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203

Understanding PsychoPathology 3

student learning outcomes*

• Explain why psychology is a science with the primary objectives of describing, understanding, predicting, and controlling behavior and mental processes (APA SLO 1.1b) (see textbook pages 4–7, 25–27)

• Use basic psychological terminology, concepts, and theories in psychology to explain behavior and mental processes (APA SLO 1.1a) (see textbook pages 3–6, 9–14, 16–21, 23–27)

• Summarize important aspects of history of psychology, including key figures, central concerns, methods used, and theoretical conflicts (APA SLO 1.2c) (see textbook pages 9–27)

• Identify key characteristics of major content domains in psychology (e.g., cognition and learning, developmental, biological, and sociocultural) (APA SLO 1.2a) (see textbook pages 4–6, 13–21, 25–27)

• See APA SLO 1.1b listed above • Incorporate several appropriate levels of complexity

(e.g., cellular, individual, group/system, society/cultural) to explain behavior (APA SLO 2.1c) (see textbook pages 8–9, 12–16, 18–27)

Describe key concepts, principles, and overarching themes in psychology

Develop a working knowledge of the content domains of psychology

Use scientific reasoning to interpret behavior

Understanding Psychopathology Today you may have gotten out of bed, had breakfast, gone to class, studied, and, at the end of the day, enjoyed the company of your friends before dropping off to sleep. It probably did not occur to you that many physically healthy people are not able to do some or any of these things. What they have in common is a psychological disorder, a psychological dysfunction within an individual asso- ciated with distress or impairment in functioning and a response that is not typical or culturally expected. Before examining exactly what this means, let’s look at one individual’s situation.

Judy, a 16-year-old, was referred to our anxiety disorders clinic after increasing episodes of fainting. About 2 years earlier, in Judy’s first biology class, the teacher had shown a movie of a frog dissection to illustrate various points about anatomy.

This was a particularly graphic film, with vivid images of blood, tissue, and muscle. About halfway through, Judy felt a bit lightheaded and left the room. But the images did not

Judy… The Girl Who Fainted at the Sight of Blood

leave her. She continued to be bothered by them and occa- sionally felt slightly queasy. She began to avoid situations in which she might see blood or injury. She stopped looking at magazines that might have gory pictures. She found it difficult to look at raw meat, or even Band-Aids, because they brought the feared images to mind. Eventually, anything her friends or parents said that evoked an image of blood or injury caused Judy to feel lightheaded. It got so bad that if one of her friends exclaimed, “Cut it out!” she felt faint.

Beginning about 6 months before her visit to the clinic, Judy actually fainted when she unavoidably encountered something bloody. Her family physician could find nothing wrong with her, nor could several other physicians. By the time she was referred to our clinic, she was fainting 5 to 10 times a week, often in class. Clearly, this was problematic for her and disruptive in school; each time Judy fainted, the other students flocked around her, trying to help, and class was interrupted. Because no one could find anything wrong with her, the principal finally concluded that she was being manipulative and suspended her from school, even though she was an honor student.

* Portions of this chapter cover learning outcomes suggested by the American Psychological Association (2013) in their guidelines for the undergraduate psychology major. Chapter coverage of these outcomes is identified above by APA Goal and APA Suggested Learning Outcome (SLO).

(Continued next page)

50443_ch01_ptg01_hr_002-031.indd 3 28/09/16 2:43 PM

Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203

4 CHAPTER 1 abnormal behavior in h istor ical context

What Is a Psychological Disorder? Keeping in mind the real-life problems faced by Judy, let’s look more closely at the definition of psychological disorder: or prob- lematic abnormal behavior: It is a psychological dysfunction within an individual that is associated with distress or impair- ment in functioning and a response that is not typical or culturally expected (see E Figure 1.1). On the surface, these three criteria may seem obvious, but they were not easily arrived at and it is worth a moment to explore what they mean. You will see, impor- tantly, that no one criterion has yet been developed that fully defines a psychological disorder.

Psychological dysfunction Psychological dysfunction refers to a breakdown in cognitive, emo- tional, or behavioral functioning. For example, if you are out on a date, it should be fun. But if you experience severe fear all evening and just want to go home, even though there is nothing to be afraid of, and the severe fear happens on every date, your emotions are not functioning properly. However, if all your friends agree that the person who asked you out is unpredictable and dangerous in some way, then it would not be dysfunctional for you to be fearful and avoid the date.

A dysfunction was present for Judy: She fainted at the sight of blood. But many people experience a mild version of this reaction (feeling queasy at the sight of blood) without meeting the criteria

for the disorder, so knowing where to draw the line between normal and abnormal dysfunction is often difficult. For this rea- son, these problems are often considered to be on a continuum or a dimension rather than to be categories that are either present or absent (McNally, 2011; Stein, Phillips, Bolton, Fulford, Sadler, & Kendler, 2010; Widiger & Crego, 2013). This, too, is a reason why just having a dysfunction is not enough to meet the criteria for a psychological disorder.

distress or impairment That the behavior must be associated with distress to be classi- fied as a disorder adds an important component and seems clear: The criterion is satisfied if the individual is extremely upset. We can certainly say that Judy was distressed and even suffered with her phobia. But remember, by itself this criterion does not define problematic abnormal behavior. It is often quite normal to be dis- tressed—for example, if someone close to you dies. The human condition is such that suffering and distress are very much part of life. This is not likely to change. Furthermore, for some disorders, by definition, suffering and distress are absent. Consider the per- son who feels extremely elated and may act impulsively as part of a manic episode. As you will see in Chapter 7, one of the major difficulties with this problem is that some people enjoy the manic state so much they are reluctant to begin treatment or stay long in

Judy was suffering from what we now call blood– injection– injury phobia. Her reaction was quite severe, thereby meeting the criteria for phobia, a psychological disorder character- ized by marked and persistent fear of an object or situation. But many people have similar reactions that are not as severe when they receive an injection or see someone who is injured, whether blood is visible or not. For people who react as severely as Judy, this phobia can be disabling. They may avoid certain careers, such as medicine or nursing, and, if they are so afraid of needles and injections that they avoid them even when they need them, they put their health at risk. •

E FIgUre 1.1 The criteria defining a psychological disorder.

Psychological disorder

Psychological dysfunction

Distress or impairment

Atypical response

Distress and suffering are a natural part of life and do not in them- selves constitute a psychological disorder.

E ni

gm a/

A la

m y

S to

ck P

ho to

50443_ch01_ptg01_hr_002-031.indd 4 28/09/16 2:43 PM

Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203

Understanding PsychoPathology 5

treatment. Thus, defining psychological disorder by distress alone doesn’t work, although the concept of distress contributes to a good definition.

The concept of impairment is useful, although not entirely satisfactory. For example, many people consider themselves shy or lazy. This doesn’t mean that they’re abnormal. But if you are so shy that you find it impossible to date or even interact with people and you make every attempt to avoid interactions even though you would like to have friends, then your social functioning is impaired.

Judy was clearly impaired by her phobia, but many people with similar, less severe reactions are not impaired. This difference again illustrates the important point that most psychological disorders are simply extreme expressions of otherwise normal emotions, behaviors, and cognitive processes.

atypical or not culturally expected Finally, the criterion that the response be atypical or not culturally expected is important but also insufficient to determine if a disorder is present by itself. At times, something is considered abnormal because it occurs infrequently; it deviates from the average. The greater the deviation, the more abnormal it is. You might say that someone is abnormally short or abnormally tall, meaning that the person’s height deviates substantially from average, but this obviously isn’t a definition of disorder. Many people are far from the average in their behavior, but few would be considered disordered. We might call them talented or eccen- tric. Many artists, movie stars, and athletes fall in this category. For example, it’s not normal to wear a dress made entirely out of meat, but when Lady Gaga wore this to an awards show, it only enhanced her celebrity. The late novelist J. D. Salinger, who wrote The Catcher in the Rye, retreated to a small town in New Hampshire and refused to see any outsiders for years, but he continued to write. Some male rock singers wear heavy makeup on stage. These people are well paid and seem to enjoy their careers. In most cases, the more productive you are in the eyes of society, the more eccentricities society will tolerate. Therefore, “deviating from the average” doesn’t work well as a definition for problematic abnormal behavior.

Another view is that your behavior is disordered if you are vio- lating social norms, even if a number of people are sympathetic to your point of view. This definition is useful in considering impor- tant cultural differences in psychological disorders. For example, to enter a trance state and believe you are possessed reflects a psychological disorder in most Western cultures but not in many other societies, where the behavior is accepted and expected (see Chapter 6). (A cultural perspective is an important point of refer- ence throughout this book.) An informative example of this view is provided by Robert Sapolsky (2002), the prominent neuroscientist who, during his studies, worked closely with the Masai people in East Africa. One day, Sapolsky’s Masai friend Rhoda asked him to bring his vehicle as quickly as possible to the Masai village where a woman had been acting aggressively and had been hearing voices. The woman had actually killed a goat with her own hands. Sapolsky and several Masai were able to subdue her and transport her to a local health center. Realizing that this was an opportunity to learn

more of the Masai’s view of psychological disorders, Sapolsky had the following discussion:

“So, Rhoda,” I began laconically, “what do you suppose was wrong with that woman?”

She looked at me as if I was mad. “She is crazy.” “But how can you tell?” “She’s crazy. Can’t you just see from how she acts?” “But how do you decide that she is crazy? What did

she do?” “She killed that goat.” “Oh,” I said with anthropological detachment, “but

Masai kill goats all the time.” She looked at me as if I were an idiot. “Only the men

kill goats,” she said. “Well, how else do you know that she is crazy?” “She hears voices.” Again, I made a pain of myself. “Oh, but the Masai

hear voices sometimes.” (At ceremonies before long cattle drives, the Masai trance-dance and claim to hear voices.) And in one sentence, Rhoda summed up half of what any- one needs to know about cross-cultural psychiatry.

“But she hears voices at the wrong time.” (p. 138)

We accept extreme behaviors by entertainers, such as Lady Gaga, that would not be tolerated in other members of our society.

S te

ve G

ra ni

tz /G

et ty

Im ag

es

50443_ch01_ptg01_hr_002-031.indd 5 28/09/16 2:43 PM

Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203

6 CHAPTER 1 abnormal behavior in h istor ical context

a rating of 4 would indicate continual and severe symptoms (Beesdo-Baum, et al., 2012; LeBeau, Bogels, Moller, & Craske, 2015; LeBeau et al., 2012). These concepts are described more fully in Chapter 3, where the diagnosis of psychological disor- ders is discussed.

For a final challenge, take the problem of defining a psycho- logical disorder a step further and consider this: What if Judy passed out so often that after a while neither her classmates nor her teachers even noticed because she regained consciousness quickly? Furthermore, what if Judy continued to get good grades? Would fainting all the time at the mere thought of blood be a dis- order? Would it be impairing? Dysfunctional? Distressing? What do you think?

The Science of Psychopathology Psychopathology is the scientific study of psychological disorders. Within this field are specially trained professionals, including clin- ical and counseling psychologists, psychiatrists, psychiatric social workers, and psychiatric nurses, as well as marriage and family therapists and mental health counselors. Clinical psychologists and counseling psychologists receive the Ph.D., doctor of philosophy, degree (or sometimes an Ed.D., doctor of education, or Psy.D., doctor of psychology) and follow a course of graduate-level study lasting approximately 5 years, which prepares them to conduct research into the causes and treatment of psychological disorders and to diagnose, assess, and treat these disorders. Although there is a great deal of overlap, counseling psychologists tend to study and treat adjustment and vocational issues encountered by rela- tively healthy individuals, and clinical psychologists usually con- centrate on more severe psychological disorders. Also, programs in professional schools of psychology, where the degree is often a Psy.D., focus on clinical training and de-emphasize or elimi- nate research training. In contrast, Ph.D. programs in universities integrate clinical and research training. Psychologists with other specialty training, such as experimental and social psychologists, concentrate on investigating the basic determinants of behavior but do not assess or treat psychological disorders.

A social standard of normal has been misused, however. Con- sider, for example, the practice of committing political dissidents to mental institutions because they protest the policies of their government, which was common in Iraq before the fall of Saddam Hussein and now occurs in Iran. Although such dissident behav- ior clearly violated social norms, it should not alone be cause for commitment.

Jerome Wakefield (1999, 2009), in a thoughtful analysis of the matter, uses the shorthand definition of harmful dysfunction. A related concept that is also useful is to determine whether the behavior is out of the individual’s control (something the person doesn’t want to do) (Widiger & Crego, 2013; Widiger & Sankis, 2000). Variants of these approaches are most often used in current diagnostic practice, as outlined in the fifth edition of the Diag- nostic and Statistical Manual (American Psychiatric Association, 2013), which contains the current listing of criteria for psycho- logical disorders (Stein et al., 2010). These approaches guide our thinking in this book.

an accepted definition In conclusion, it is difficult to define what constitutes a psycholog- ical disorder (Lilienfeld & Marino, 1995, 1999)—and the debate continues (Blashfield, Keeley, Flanagan, & Miles, 2014; McNally, 2011; Stein et al., 2010; Spitzer, 1999; Wakefield, 2003, 2009; Zachar & Kendler, 2014). The most widely accepted definition used in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) describes behavioral, psychological, or biological dysfunctions that are unexpected in their cultural context and associated with present distress and impairment in functioning, or increased risk of suffering, death, pain, or impairment. This definition can be useful across cultures and subcultures if we pay careful atten- tion to what is functional or dysfunctional (or out of control) in a given society. But it is never easy to decide what represents dysfunction, and some scholars have argued persuasively that the health professions will never be able to satisfactorily define disease or disorder (see, for example, Lilienfeld & Marino, 1995, 1999; McNally, 2011; Stein et al., 2010; Zachar & Kendler, 2014). The best we may be able to do is to consider how the apparent disease or disorder matches a “typical” profile of a disorder—for example, major depression or schizophrenia—when most or all symptoms that experts would agree are part of the disorder are present. We call this typical profile a prototype, and, as described in Chapter 3, the diagnostic criteria from DSM-5 found through- out this book are all prototypes. This means that the patient may have only some features or symptoms of the disorder (a mini- mum number) and still meet criteria for the disorder because his or her set of symptoms is close to the prototype. But one of the differences between DSM-5 and its predecessor, DSM-IV, is the addition of dimensional estimates of the severity of spe- cific disorders in DSM-5 (American Psychiatric Association, 2013; Regier, Narrow, Kuhl, & Kupfer, 2009; Helzer, Wittchen, Krueger, & Kraemer, 2008). Thus, for the anxiety disorders, for example, the intensity and frequency of anxiety within a given disorder such as panic disorder is rated on a 0 to 4 scale where a rating of 1 would indicate mild or occasional symptoms and

Some religious behaviors may seem unusual to us but are culturally or individually appropriate.

ak e1

15 0/

Fo to

lia L

LC

50443_ch01_ptg01_hr_002-031.indd 6 28/09/16 2:43 PM

Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203

Understanding PsychoPathology 7

see whether they work. They are accountable not only to their patients but also to the government agencies and insurance companies that pay for the treatments, so they must demon- strate clearly whether their treatments are effective or not. Third, scientist-practitioners might conduct research, often in clinics or hospitals, that produces new information about disorders or their treatment, thus becoming immune to the fads that plague our field, often at the expense of patients and their families. For example, new “miracle cures” for psy- chological disorders that are reported several times a year in popular media would not be used by a scientist-practitioner if there were no sound scientific data showing that they work. Such data flow from research that attempts three basic things: to describe psychological disorders, to determine their causes, and to treat them (see E Figure 1.3). These three categories compose an organizational structure that recurs throughout this book and that is formally evident in the discussions of specific disorders beginning in Chapter 5. A general overview of them now will give you a clearer perspective on our efforts to understand abnormality.

clinical description In hospitals and clinics, we often say that a patient “presents” with a specific problem or set of problems or we discuss the presenting problem. Presents is a traditional shorthand way of indicating why the person came to the clinic. Describing Judy’s presenting problem is the first step in determining her clinical description, which represents the unique combination of behav- iors, thoughts, and feelings that make up a specific disorder. The word clinical refers both to the types of problems or disorders that you would find in a clinic or hospital and to the activities connected with assessment and treatment. Throughout this text are excerpts from many more individual cases, most of them from our personal files.

Clearly, one important function of the clinical description is to specify what makes the disorder different from normal behav- ior or from other disorders. Statistical data may also be relevant.

For example, how many people in the population as a whole have the disorder? This figure is called the prevalence of the dis- order. Statistics on how many new cases occur during a given period, such as a year, represent the incidence of the disorder. Other statistics include the sex ratio—that is, what percentage of males and females have the disorder—and the typical age of onset, which often differs from one disorder to another.

Psychiatrists first earn an M.D. degree in medical school and then specialize in psychiatry during residency training that lasts 3 to 4 years. Psychiatrists also investigate the nature and causes of psychological disorders, often from a biological point of view; make diagnoses; and offer treatments. Many psychiatrists emphasize drugs or other biological treatments, although most use psychosocial treatments as well.

Psychiatric social workers typically earn a master’s degree in social work as they develop expertise in collecting information relevant to the social and family situation of the individual with a psychological disorder. Social workers also treat disorders, often concentrating on family problems associated with them. Psychi- atric nurses have advanced degrees, such as a master’s or even a Ph.D., and specialize in the care and treatment of patients with psychological disorders, usually in hospitals as part of a treat- ment team.

Finally, marriage and family therapists and mental health counselors typically spend 1 to 2 years earning a master’s degree and are employed to provide clinical services by hospitals or clin- ics, usually under the supervision of a doctoral-level clinician.

the scientist-Practitioner The most important development in the recent history of psy- chopathology is the adoption of scientific methods to learn more about the nature of psychological disorders, their causes, and their treatment. Many mental health professionals take a scientific approach to their clinical work and therefore are called scientist-practitioners (Barlow, Hayes, & Nelson, 1984; Hayes, Barlow, & Nelson-Gray, 1999). Mental health practitio- ners may function as scientist-practitioners in one or more of three ways (see E Figure 1.2). First, they may keep up with the latest scientific developments in their field and therefore use the most current diagnostic and treatment procedures. In this sense, they are consumers of the science of psychopathology to the advantage of their patients. Second, scientist-practitioners evaluate their own assessments or treatment procedures to

E FIgUre 1.2 Functioning as a scientist-practitioner.

Consumer of science • Enhancing the practice

Evaluator of science • Determining the effectiveness of the practice

Creator of science • Conducting research that leads to new procedures useful in practice

Mental health

professional

Ke vi

n Pe

te rs

on /P

ho to

di sc

/G et

ty Im

ag es

E FIgUre 1.3 Three major categories make up the study and discussion of psychological disorders.

Studying psychological

disorders

Focus

Clinical description

Causation (etiology)

Treatment and outcome

50443_ch01_ptg01_hr_002-031.indd 7 28/09/16 2:43 PM

Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203

8 CHAPTER 1 abnormal behavior in h istor ical context

disorders is so important to this field, we devote an entire chapter (Chapter 2) to it.

Treatment, also, is often important to the study of psy- chological disorders. If a new drug or psychosocial treatment is successful in treating a disorder, it may give us some hints about the nature of the disorder and its causes. For example, if a drug with a specific known effect within the nervous system alleviates a certain psychological disorder, we know that some- thing in that part of the nervous system might either be causing the disorder or helping maintain it. Similarly, if a psychologi- cal treatment designed to help clients regain a sense of control over their lives is effective with a certain disorder, a diminished sense of control may be an important psychological component of the disorder itself.

As you will see in the next chapter, psychopathology is rarely simple. This is because the effect does not necessarily imply the cause. To use a common example, you might take an aspirin to relieve a tension headache you developed during a grueling day of taking exams. If you then feel better, that does not mean that the headache was caused by a lack of aspirin. Nevertheless, many people seek treatment for psychological disorders, and treatment can provide interesting hints about the nature of the disorder.

In addition to having different symptoms, age of onset, and possibly a different sex ratio and prevalence, most disorders follow a somewhat individual pattern, or course. For example, some disorders, such as schizophrenia (see Chapter 13), follow a chronic course, meaning that they tend to last a long time, sometimes a lifetime. Other disorders, like mood disorders (see Chapter 7), follow an episodic course, in that the individual is likely to recover within a few months only to suffer a recur- rence of the disorder at a later time. This pattern may repeat throughout a person’s life. Still other disorders may have a time-limited course, meaning the disorder will improve without treatment in a relatively short period with little or no risk of recurrence.

Closely related to differences in course of disorders are dif- ferences in onset. Some disorders have an acute onset, mean- ing that they begin suddenly; others develop gradually over an extended period, which is sometimes called an insidious onset. It is important to know the typical course of a disorder so that we can know what to expect in the future and how best to deal with the problem. This is an important part of the clini- cal description. For example, if someone is suffering from a mild disorder with acute onset that we know is time limited, we might advise the individual not to bother with expensive treatment because the problem will be over soon enough, like a common cold. If the disorder is likely to last a long time (become chronic), however, the individual might want to seek treatment and take other appropriate steps. The anticipated course of a disorder is called the prognosis. So we might say, “the prognosis is good,” meaning the individual will probably recover, or “the prognosis is guarded,” meaning the probable outcome doesn’t look good.

The patient’s age may be an important part of the clini- cal description. A specific psychological disorder occurring in childhood may present differently from the same disorder in adulthood or old age. Children experiencing severe anxiety and panic often assume that they are physically ill because they have difficulty understanding that there is nothing phys- ically wrong. Because their thoughts and feelings are differ- ent from those experienced by adults with anxiety and panic, children are often misdiagnosed and treated for a medical disorder.

We call the study of changes in behavior over time develop- mental psychology, and we refer to the study of changes in abnor- mal behavior as developmental psychopathology. When you think of developmental psychology, you probably picture researchers studying the behavior of children. We change throughout our lives, however, and so researchers also study development in adolescents, adults, and older adults. Study of abnormal behav- ior across the entire age span is referred to as life-span develop- mental psychopathology. The field is relatively new but expanding rapidly.

causation, treatment, and etiology outcomes Etiology, or the study of origins, has to do with why a disorder begins (what causes it) and includes biological, psychological, and social dimensions. Because the etiology of psychological

Children experience panic and anxiety differently from adults, so their reactions may be mistaken for symptoms of physical illness.

© H

un g

C hu

ng C

hi h

/S hu

tt er

st oc

k. co

m

50443_ch01_ptg01_hr_002-031.indd 8 28/09/16 2:43 PM

Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203

the sUPernatUral tradit ion 9

The Supernatural Tradition For much of our recorded history, deviant behavior has been considered a reflection of the battle between good and evil. When confronted with unexplainable, irrational behavior and by suffering and upheaval, people have perceived evil. In fact, in the Great Persian

In the past, textbooks emphasized treatment approaches in a general sense, with little attention to the disorder being treated. For example, a mental health professional might be thoroughly trained in a single theoretical approach, such as psychoanalysis or behavior therapy (both described later in the chapter), and then use that approach on every disorder. More recently, as our science has advanced, we have developed spe- cific effective treatments that do not always adhere neatly to one theoretical approach or another but that have grown out of a deeper understanding of the disorder in question. For this reason, there are no separate chapters in this book on such types of treatment approaches as psychodynamic, cognitive behavioral, or humanistic. Rather, the latest and most effec- tive drug and psychosocial treatments (nonmedical treatments that focus on psychological, social, and cultural factors) are described in the context of specific disorders in keeping with our integrative multidimensional perspective.

We now survey many early attempts to describe and treat abnormal behavior and to comprehend its causes, which will give you a better perspective on current approaches. In Chapter 2, we examine exciting contemporary views of causation and treatment. In Chapter 3, we discuss efforts to describe, or classify, abnormal behavior. In Chapter 4, we review research methods—our systematic efforts to discover the truths underlying description, cause, and treatment that allow us to function as scientist-practitioners. In Chapters 5 through 15, we examine specific disorders; our discussion is organized in each case in the now familiar triad of description, cause, and treatment. Finally, in Chapter 16 we examine legal, professional, and ethical issues relevant to psychological dis- orders and their treatment today. With that overview in mind, let us turn to the past.

Historical Conceptions of Abnormal Behavior For thousands of years, humans have tried to explain and con- trol problematic behavior. But our efforts always derive from the theories or models of behavior popular at the time. The purpose of these models is to explain why someone is “acting like that.” Three major models that have guided us date back to the beginnings of civilization.

Humans have always supposed that agents outside our bodies and environment influence our behavior, think- ing, and emotions. These agents—which might be divini- ties, demons, spirits, or other phenomena such as magnetic fields or the moon or the stars—are the driving forces behind the supernatural model. In addition, since the era of ancient Greece, the mind has often been called the soul or the psyche and considered separate from the body. Although many have thought that the mind can influence the body and, in turn, the body can influence the mind, most philosophers looked for causes of abnormal behavior in one or the other. This split gave rise to two traditions of thought about abnormal behav- ior, summarized as the biological model and the psychological model. These three models—the supernatural, the biological, and the psychological—are very old but continue to be used today.

Part A Write the letter for any or all of the following definitions of abnormality in the blanks: (a) societal norm violation, (b) impairment in functioning, (c) dysfunction, and (d) distress.

1. Miguel recently began feeling sad and lonely. Although still able to function at work and fulfill other responsi- bilities, he finds himself feeling down much of the time and he worries about what is happening to him. Which of the definitions of abnormality apply to Miguel’s situation? _____________

2. Three weeks ago, Jane, a 35-year-old business executive, stopped showering, refused to leave her apartment, and started watching television talk shows. Threats of being fired have failed to bring Jane back to reality, and she continues to spend her days staring blankly at the television screen. Which of the definitions seems to describe Jane’s behavior? ______________

Part B Match the following words that are used in clinical descriptions with their corresponding examples: (a) presenting problem, (b) prevalence, (c) incidence, (d) prognosis, (e) course, and (f) etiology.

3. Maria should recover quickly with no intervention necessary. Without treatment, John will deteriorate rapidly. ________________

4. Three new cases of bulimia have been reported in this county during the past month and only one in the next county. ______________

5. Elizabeth visited the campus mental health center because of her increasing feelings of guilt and anxiety. _________________

6. Biological, psychological, and social influences all contribute to a variety of disorders. ______________

7. The pattern a disorder follows can be chronic, time- limited, or episodic. _________

8. How many people in the population as a whole suffer from obsessive-compulsive disorder? ____________

Concept Check 1.1

50443_ch01_ptg01_hr_002-031.indd 9 28/09/16 2:43 PM

Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203

10 CHAPTER 1 abnormal behavior in h istor ical context

Empire from 900 to 600 b.c., all physical and mental disorders were considered the work of the devil (Millon, 2004). Barbara Tuchman, a noted historian, chronicled the second half of the 14th century, a particularly difficult time for humanity, in A Distant Mirror (1978). She ably captures the conflicting tides of opinion on the origins and treatment of insanity during that bleak and tumultuous period.

Demons and Witches One strong current of opinion put the causes and treatment of psychological disorders squarely in the realm of the supernatu- ral. During the last quarter of the 14th century, religious and lay authorities supported these popular superstitions, and society as a whole began to believe more strongly in the existence and power of demons and witches. The Catholic Church had split, and a sec- ond center, complete with a pope, emerged in the south of France to compete with Rome. In reaction to this schism, the Roman Church fought back against the evil in the world that it believed must have been behind this heresy.

People increasingly turned to magic and sorcery to solve their problems. During these turbulent times, the bizarre behavior of people afflicted with psychological disorders was seen as the work of the devil and witches. It followed that individuals possessed by evil spirits were probably responsible for any misfortune experi- enced by people in the local community, which inspired drastic action against the possessed. Treatments included exorcism, in which various religious rituals were performed in an effort to rid the victim of evil spirits. Other approaches included shaving the pattern of a cross in the hair of the victim’s head and securing suf- ferers to a wall near the front of a church so that they might benefit from hearing Mass.

The conviction that sorcery and witches are causes of madness and other evils continued into the 15th century, and evil contin- ued to be blamed for unexplainable behavior, even after the found- ing of the United States, as evidenced by the Salem, Massachusetts, witch trials in the late 17th century, which resulted in the hanging deaths of 20 women.

Stress and Melancholy An equally strong opinion, even during this period, reflected the enlightened view that insanity was a natural phenomenon, caused by mental or emotional stress, and that it was curable (Alexander & Selesnick, 1966; Maher & Maher, 1985a). Mental depression and anxiety were recognized as illnesses (Kemp, 1990; Schoeneman, 1977), although symptoms such as despair and lethargy were often identified by the church with the sin of acedia, or sloth (Tuchman, 1978). Common treatments were rest, sleep, and a healthy and happy environment. Other treatments included baths, ointments, and various potions. Indeed, during the 14th and 15th centuries, people with insanity, along with those with physical deformities or disabilities, were often moved from house to house in medieval villages as neighbors took turns caring for them. We now know that this medieval practice of keeping people who have psycho- logical disturbances in their own community is beneficial (see Chapter 13). We return to this subject when we discuss biological and psychological models later in this chapter.

During the Middle Ages, individuals with psychological disorders were sometimes thought to be possessed by evil spirits and exorcisms were attempted through rituals.

D E

A P

IC TU

R E

L IB

R A

R Y

/G et

ty Im

ag es

In the 14th century, one of the chief advisers to the king of France, a bishop and philosopher named Nicholas Oresme, also suggested that the disease of melancholy (depression) was the source of some bizarre behavior, rather than demons. Oresme pointed out that much of the evidence for the existence of sorcery and witchcraft, particularly among those considered insane, was obtained from people who were tortured and who, quite under- standably, confessed to anything.

These conflicting crosscurrents of natural and supernatural explanations for mental disorders are represented more or less strongly in various historical works, depending on the sources consulted by historians. Some assumed that demonic influences were the predominant explanations of abnormal behavior during the Middle Ages (for example, Zilboorg & Henry, 1941); others believed that the supernatural had little or no influence. As we see in the handling of the severe psychological disorder experienced by late-14th-century King Charles VI of France, both influences were strong, sometimes alternating in the treatment of the same case.

50443_ch01_ptg01_hr_002-031.indd 10 28/09/16 2:44 PM

Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203

the sUPernatUral tradit ion 11

Treatments for Possession With a perceived connection between evil deeds and sin on the one hand and psychological disorders on the other, it is logical to conclude that the sufferer is largely responsible for the disor- der, which might well be a punishment for evil deeds. Does this sound familiar? The acquired immune deficiency syndrome (AIDS) epidemic was associated with a similar belief among some people, particularly in the late 1980s and early 1990s. Because the human immunodeficiency virus (HIV) is, in Western societies, most prevalent among individuals with homosexual orientation, many people believed it was a divine punishment for what they considered immoral behavior. This view became less common as the AIDS virus spread to other segments of the population, yet it persists.

Possession, however, is not always connected with sin but may be seen as involuntary and the possessed individual as blameless. Furthermore, exorcisms at least have the virtue of being relatively painless. Interestingly, they sometimes work, as do other forms of faith healing, for reasons we explore in subsequent chapters. But what if they did not? In the Middle Ages, if exorcism failed, some authorities thought that steps were necessary to make the body uninhabitable by evil spirits, and many people were subjected to confinement, beatings, and other forms of torture (Kemp, 1990).

Somewhere along the way, a creative “therapist” decided that hanging people over a pit full of poisonous snakes might scare the evil spirits right out of their bodies (to say nothing of terrifying the people themselves). Strangely, this approach sometimes worked; that is, the most disturbed, oddly behaving individuals would suddenly come to their senses and experi- ence relief from their symptoms, if only temporarily. Naturally, this was reinforcing to the therapist, so snake pits were built in many institutions. Many other treatments based on the hypoth- esized therapeutic element of shock were developed, including dunkings in ice-cold water.

Mass Hysteria Another fascinating phenomenon is characterized by large-scale outbreaks of bizarre behavior. To this day, these episodes puzzle historians and mental health practitioners. During the Middle Ages, they lent support to the notion of possession by the devil. In Europe, whole groups of people were simultaneously com- pelled to run out in the streets, dance, shout, rave, and jump

In the summer of 1392, King Charles VI of France was under a great deal of stress, partly because of the divi- sion of the Catholic Church. As he rode with his army to the province of Brittany, a nearby aide dropped his lance with a loud clatter and the king, thinking he was under attack, turned on his own army, killing several prominent knights before being subdued from behind. The army immediately marched back to Paris. The King’s lieutenants and advisers concluded that he was mad.

During the following years, at his worst the King hid in a corner of his castle believing he was made of glass or roamed the corridors howling like a wolf. At other times, he couldn’t remember who or what he was. He became fearful and enraged whenever he saw his own royal coat of arms and would try to destroy it if it was brought near him.

The people of Paris were devastated by their leader’s apparent madness. Some thought it reflected God’s anger, because the King failed to take up arms to end the schism in the Catholic Church; others thought it was God’s warning against taking up arms; and still others thought it was divine punishment for heavy taxes (a conclusion some people might make today). But most thought the King’s mad- ness was caused by sorcery, a belief strengthened by a great drought that dried up the ponds and rivers, causing cattle to die of thirst. Merchants claimed their worst losses in 20 years.

Naturally, the King was given the best care available at the time. The most famous healer in the land was a 92-year-old physician whose treatment program included moving the King to one of his residences in the country where the air was thought to be the cleanest in the land. The physician prescribed rest, relaxation, and recreation. After some time, the King seemed to recover. The physi- cian recommended that the King not be burdened with the responsibilities of running the kingdom, claiming that if he had few worries or irritations, his mind would gradually strengthen and further improve.

Unfortunately, the physician died and the insanity of King Charles VI returned more seriously than before. This time, however, he came under the influence of the conflicting crosscurrent of supernatural causation. “An unkempt evil- eyed charlatan and pseudo-mystic named Arnaut Guilhem was allowed to treat Charles on his claim of possessing a book given by God to Adam by means of which man could overcome all affliction resulting from original sin” (Tuchman, 1978, p. 514). Guilhem insisted that the King’s malady was caused by sorcery, but his treatments failed to bring about a cure.

A variety of remedies and rituals of all kinds were tried, but none worked. High-ranking officials and doctors of the university called for the “sorcerers” to be discovered and punished. “On one occasion, two Augustinian friars, after getting no results from magic incantations and a liquid made

Charles VI… The Mad King from powdered pearls, proposed to cut incisions in the King’s head. When this was not allowed by the King’s council, the friars accused those who opposed their recommendation of sorcery” (Tuchman, 1978, p. 514). Even the King himself, during his lucid moments, came to believe that the source of madness was evil and sor- cery. “In the name of Jesus Christ,” he cried, weeping in his agony, “if there is any one of you who is an accom- plice to this evil I suffer, I beg him to torture me no longer but let me die!” (Tuchman, 1978, p. 515). •

50443_ch01_ptg01_hr_002-031.indd 11 28/09/16 2:44 PM

Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203

12 CHAPTER 1 abnormal behavior in h istor ical context

to spread to those around us (Hatfield, Cacioppo, & Rapson, 1994; Ntika, Sakellariou, Kefalas, & Stamatpoulou, 2014; Wang, 2006). If someone nearby becomes frightened or sad, chances are that, for the moment, you also will feel fear or sadness. When this kind of experience escalates into full-blown panic, whole communities are affected (Barlow, 2002). People are also suggestible when they are in states of high emotion. Therefore, if one person identifies a “cause” of the problem, others will probably assume that their own reactions have the same source. In popular language, this shared response is sometimes referred to as mob psychology. Until recently, it was assumed that victims had to be in contact with each other for the contagion to occur, as were the girls described above in the adjacent classrooms. But lately there are document- ed cases of emotion contagion occurring across social networks, raising the possibility that episodes of mass hysteria may increase (Bartholomew, Wessely, & Rubin, 2012; Dimon, 2013)

The Moon and the Stars Paracelsus, a Swiss physician who lived from 1493 to 1541, rejected notions of possession by the devil, suggesting instead that the movements of the moon and stars had profound effects on people’s psychological functioning. Echoing similar thinking in ancient Greece, Paracelsus speculated that the gravitational effects of the moon on bodily fluids might be a possible cause of mental disorders (Rotton & Kelly, 1985). This influential theory inspired the word lunatic, which is derived from the Latin word luna, mean- ing “moon.” You might hear some of your friends explain some- thing crazy they did one night by saying, “It must have been the full moon.” The belief that heavenly bodies affect human behavior still exists, although there is no scientific evidence to support it (Raison, Klein, & Steckler, 1999; Rotton & Kelly, 1985). Despite much ridicule, millions of people around the world are convinced that their behavior is influenced by the stages of the moon or the positions of the stars. This belief is most noticeable today in followers of astrology, who hold that their behavior and the major events in their lives can be predicted by their day-to-day relation- ship to the position of the planets. No serious evidence has ever confirmed such a connection, however.

Comments The supernatural tradition in psychopathology is alive and well, although it is relegated, for the most part, to small religious sects in this country and to primitive cultures elsewhere. Members of organized religions in most parts of the world look to psychology and medical science for help with major psychological disorders; in fact, the Roman Catholic Church requires that all health- care resources be exhausted before spiritual solutions such as exorcism can be considered. Nonetheless, miraculous cures are sometimes achieved by exorcism, magic potions and rituals, and other methods that seem to have little connection with modern science. It is fascinating to explore them when they do occur, and we return to this topic in subsequent chapters. But such cases are relatively rare, and almost no one would advocate supernatural treatment for severe psychological disorders except, perhaps, as a last resort.

around in patterns as if they were at a particularly wild party late at night (still called a rave today, but with music). This behavior was known by several names, including Saint Vitus’s Dance and tarantism. It is most interesting that many people behaved in this strange way at once. In an attempt to explain the inexplicable, several reasons were offered in addition to possession. One rea- sonable guess was reaction to insect bites. Another possibility was what we now call mass hysteria (Veith, 1965). Consider the following example.

Modern Mass Hysteria One Friday afternoon, an alarm sounded over the public address system of a community hospital, calling all physicians to the emer- gency room immediately. Arriving from a local school in a fleet of ambulances were 17 students and 4 teachers who reported dizzi- ness, headache, nausea, and stomach pains. Some were vomiting; most were hyperventilating.

All the students and teachers had been in four classrooms, two on each side of the hallway. The incident began when a 14-year-old girl reported a funny smell that seemed to be com- ing from a vent. She fell to the floor, crying and complaining that her stomach hurt and her eyes stung. Soon, many of the students and most of the teachers in the four adjoining class- rooms, who could see and hear what was happening, experi- enced similar symptoms. Of 86 susceptible people (82 students and 4 teachers in the four classrooms), 21 patients (17 students and 4 teachers) experienced symptoms severe enough to be evaluated at the hospital. Inspection of the school building by public health authorities revealed no apparent cause for the reac- tions, and physical examinations by teams of physicians revealed no physical abnormalities. All the patients were sent home and quickly recovered (Rockney & Lemke, 1992).

Mass hysteria may simply demonstrate the phenomenon of emotion contagion, in which the experience of an emotion seems

In hydrotherapy, patients were shocked back to their senses by appli- cations of ice-cold water.

Source: U.S. National Library of Medicine

50443_ch01_ptg01_hr_002-031.indd 12 28/09/16 2:44 PM

Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203

the b iological tradit ion 13

humoral theory of disorders. Hippocrates assumed that normal brain functioning was related to four bodily fluids or humors: blood, black bile, yellow bile, and phlegm. Blood came from the heart, black bile from the spleen, phlegm from the brain, and choler or yellow bile from the liver. Physicians believed that dis- ease resulted from too much or too little of one of the humors; for example, too much black bile was thought to cause melan- cholia (depression). In fact, the term melancholer, which means “black bile,” is still used today in its derivative form melancholy to refer to aspects of depression. The humoral theory was, perhaps, the first example of associating psychological disorders with a “chemical imbalance,” an approach that is widespread today.

The four humors were related to the Greeks’ conception of the four basic qualities: heat, dryness, moisture, and cold. Each humor was associated with one of these qualities. Terms derived from the four humors are still sometimes applied to personality traits. For example, sanguine (literal meaning “red, like blood”) describes someone who is ruddy in complexion, presumably from copious blood flowing through the body, and cheerful and optimistic, although insomnia and delirium were thought to be caused by excessive blood in the brain. Melancholic means depres- sive (depression was thought to be caused by black bile flooding the brain). A phlegmatic personality (from the humor phlegm) indicates apathy and sluggishness but can also mean being calm under stress. A choleric person (from yellow bile or choler) is hot tempered (Maher & Maher, 1985a).

Excesses of one or more humors were treated by regulating the environment to increase or decrease heat, dryness, moisture, or cold, depending on which humor was out of balance. One reason King Charles VI’s physician moved him to the less stressful coun- tryside was to restore the balance in his humors (Kemp, 1990). In addition to rest, good nutrition, and exercise, two treatments were developed. In one, bleeding or bloodletting, a carefully measured

amount of blood was removed from the body, often with leeches. The other was to induce vomiting; indeed, in a well-known treatise on depression published in 1621, Anatomy of Melancholy, Robert Burton recommended eating tobacco and a half-boiled cabbage to induce vomiting (Burton, 1621/1977). If Judy had lived 300 years ago, she might have been diagnosed with an illness, a brain disorder, or some other physical problem, perhaps related to excessive humors, and been given the proper medical treatments of the day: bed rest, a healthful diet, exercise, and other ministrations as indicated.

In ancient China and throughout Asia, a similar idea existed. But rather than “humors,” the Chinese focused on the move- ment of air or “wind” throughout the body. Unexplained mental disorders were caused by blockages of wind or the presence of cold, dark wind (yin) as opposed to warm, life- sustaining wind (yang). Treatment involved restoring proper flow of wind through vari- ous methods, including acupuncture.

The Biological Tradition Physical causes of mental disorders have been sought since early in history. Important to the biological tradition are a man, Hippocrates; a disease, syphilis; and the early consequences of believing that psychological disorders are biologically caused.

Hippocrates and galen The Greek physician Hippocrates (460–377 b.c.) is considered to be the father of modern Western medicine. He and his asso- ciates left a body of work called the Hippocratic Corpus, writ- ten between 450 and 350 b.c. (Maher & Maher, 1985a), in which they suggested that psychological disorders could be treated like any other disease. They did not limit their search for the causes of psychopathology to the general area of “dis- ease,” because they believed that psychological disorders might also be caused by brain pathology or head trauma and could be influenced by heredity (genetics). These are remarkably astute deductions for the time, and they have been supported in recent years. Hippocrates considered the brain to be the seat of wisdom, consciousness, intelligence, and emotion. Therefore, disorders involving these functions would logically be located in the brain. Hippocrates also recognized the importance of psychological and interpersonal contributions to psychopathology, such as the sometimes-negative effects of family stress; on some occasions, he removed patients from their families.

The Roman physician Galen (approximately a.d. 129–198) later adopted the ideas of Hippocrates and his associates and developed them further, creating a powerful and influential school of thought within the biological tradition that extended well into the 19th century. One of the more interesting and influential legacies of the Hippocratic-Galenic approach is the

Emotions are contagious and can escalate into mass hysteria.

A P

Im ag

es /H

at em

M ou

ss a

50443_ch01_ptg01_hr_002-031.indd 13 28/09/16 2:44 PM

Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203

14 CHAPTER 1 abnormal behavior in h istor ical context

syphilis Behavioral and cognitive symptoms of what we now know as advanced syphilis, a sexually transmitted disease caused by a bac- terial microorganism entering the brain, include believing that everyone is plotting against you (delusion of persecution) or that you are God (delusion of grandeur), as well as other bizarre behav- iors. Although these symptoms are similar to those of psychosis— psychological disorders characterized in part by beliefs that are not based in reality (delusions), perceptions that are not based in reality (hallucinations), or both—researchers recognized that a subgroup of apparently psychotic patients deteriorated steadily, becoming paralyzed and dying within 5 years of onset. This course of events contrasted with that of most psychotic patients, who remained fairly stable. In 1825, the condition was designated a disease, general paresis, because it had consistent symptoms (pre- sentation) and a consistent course that resulted in death. The rela- tionship between general paresis and syphilis was only gradually established. Louis Pasteur’s germ theory of disease, developed in about 1870, facilitated the identification of the specific bacterial microorganism that caused syphilis.