Abnormal. Psychology CHAPTER OUTLINE LEARNING OBJECTIVES INTRODUCTION WHAT DOES ABNORMAL MEAN?

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1 Abormal 15 Psychology CHAPTER OUTLINE LEARNING OBJECTIVES INTRODUCTION WHAT DOES ABNORMAL MEAN? WHAT CAUSES ABNORMAL BEHAVIOUR? Biology ad geetics Psychodyamics ad the paret child relatioship Attachmet ad security Leared behaviour Distorted thikig Itegrative models DISORDERS SYMPTOMS AND CAUSES Schizophreia a livig ightmare Mood disorders depressio Axiety disorders whe fear takes over Eatig disorders bulimia ad aorexia Substace use disorders abuse ad depedece Persoality disorders a way of beig FINAL THOUGHTS SUMMARY REVISION QUESTIONS FURTHER READING

2 By the ed of this chapter you should appreciate that: Learig Objectives abormal psychology (or psychopathology) deals with sets of behaviours or symptoms that produce a fuctioal impairmet i people s lives; psychological disorders (e.g. schizophreia) have bee documeted across time ad culture; throughout history, the causes of abormal behaviour have bee costrued from a umber of differet perspectives; biological/geetic models focus o brai defects, biochemical imbalaces ad geetic predispositios as causes of psychopathology; Freudia, cotemporary psychodyamic ad attachmet models focus o the effects of early paret child experieces; behavioural models focus o the learig experieces that result i psychopathology; cogitive models focus o the effect of distorted thought processes; the diathesis stress perspective suggests that the factors idetified by each of the other models may work i accordace with oe aother; the developmetal psychopathology perspective provides a framework for uderstadig how psychopathology develops from childhood to adulthood; these perspectives ca help us uderstad the umerous disorders documeted i classificatio systems such as the DSM-IV ad the ICD-10; there are several major forms of psychopathology, icludig schizophreia, mood disorders, substace abuse, eatig disorders ad persoality disorders. INTRODUCTION Abormal psychology is the study of metal disorders (also called metal illess, psychological disorders or psychopathology) what they look like (symptoms), why they occur (etiology), how they are maitaied, ad what effect they have o people s lives. Metal disorders are surprisigly commo. For example, a study coducted by the World Health Orgaizatio examied the prevalece, or frequecy, of metal disorders i people visitig medical doctors i primary care settigs i 14 coutries. As figure 15.1 shows, the study revealed that 24 per cet of these people had diagosable metal disorders ad aother 10 per cet had severe symptoms of metal disorders (Üstü & Sartorious, 1995).

3 316 Abormal Psychology % of patiets Curret metal disorder Subthreshold disorder Symptomatic Well % of populatio Number of disorders 3 or more Figure 15.1 Rates of curret metal disorder i patiets presetig to primary care facilities across the world. Source: Adapted from Üstü ad Sartorius (1995). Psychopathology ca happe to ayoe ad affects may people aroud them there is o age, race or group that is immue. Furthermore, may people experiece more tha oe disorder at the same time (see figure 15.2). Figure 15.2 Comorbidity i lifetime rates of metal disorders. Comorbidity is the occurrece of two or more disorders at the same time. Of the 48 per cet of people reportig lifetime history of disorder i this study, over half reported two or more simultaeous disorders. These data come from a survey i the US, but similar rates of comorbidity have bee foud i coutries aroud the world. Source: Kessler et al. (1994). The frequecy ad widespread sufferig caused by metal disorders makes our uderstadig of them critical. WHAT DOES ABNORMAL MEAN? Defiig abormality is deceptively difficult. Whe asked to describe abormal behaviour, people typically say that it occurs ifrequetly, is odd or strage, is characterized by sufferig, or is dagerous. All of these are reasoable aswers for some types of abormal behaviour, but oe of them is sufficiet i itself, ad makig them all ecessary results i too strict a defiitio. Oe parsimoious ad practical way to defie abormal behaviour is to ask whether the behaviour causes impairmet i the perso s life. The more a behaviour gets i the way of impairmet extet to which a behaviour or set of behaviours gets i the way successful fuctioig i a importat domai of life of successful fuctioig i a importat domai of the idividual s life (icludig the psychological, iterpersoal ad achievemet/performace domais), the more likely it is to be cosidered a sig of abormality. Whe several such behaviours or symptoms occur together, they may costitute a psychological disorder. Psychological disorders are formally defied i widely used classificatio systems, or osologies: the Iteratioal Classificatio of Diseases 10th editio (ICD-10; World Health Orgaizatio, 1992) ad the Diagostic ad Statistical Maual of Metal Disorders 4th editio (DSM-IV; APA, 1994). Although they differ from oe aother i format, these two systems cover the same disorders ad defie them i a similar maer. Importatly, both the ICD-10 ad the DSM-IV require that the level of impairmet a perso is experiecig be take ito accout whe decidig whether they meet criteria for ay metal disorder. For example, the DSM-IV diagostic criteria for depressio specify that: The symptoms cause cliically sigificat distress or impairmet i social, occupatioal, or other importat areas of fuctioig (p. 327). The ICD-10 descriptio of depressio also states: The extet of ordiary social ad work activities is ofte a useful geeral guide to the likely degree of severity of the episode (p. 121). Fially, it is importat to be sesitive to how cotextual factors affect judgemets about abormality, so as ot to over- or uderpathologize groups or idividuals. Such factors iclude ethicity ad culture, geder, age ad socio-political values. For example, homosexuality was oce listed as a disorder i the DSM, but, as socio-political values chaged to become somewhat more liberal ad acceptig, it was deleted. WHAT CAUSES ABNORMAL BEHAVIOUR? With a basis for uderstadig how to defie abormal behaviour, we ca focus o its causes. Abormal behaviour is costrued from a umber of differet perspectives. Each of the followig models tells us somethig about differet aspects of a multi-faceted group of metal disorders.

4 What Causes Abormal Behaviour? 317 BIOLOGY AND GENETICS Biological ad geetic models assert that metal disorders are diseases, ad symptoms of metal disorders are caused by factors such as brai defects (abor- biochemical imbalace complex eurotrasmitter dysregulatio process ivol- the brai), biochemical imbalmalities i the structures of vig the various eurotrasmitters i aces (complex dysregulatio the brai processes ivolvig various eurotrasmitters) ad geetic predispositios (risk for psychopathology carried via our geetic predispositio likelihood of geetic material). showig coditio or characteristic By ad large, the evidece for brai defects ad carried by geetic material biochemical imbalaces as causes of metal disorders is correlatioal, which meas that, although we kow that such biological problems occur amog people with metal disorders, we do t kow whether they actually cause the disorder. Because the brai is a fairly malleable orga, our behaviour ad experieces ca also affect our brai fuctioig, suggestig that the associatio betwee biology ad abormal behaviour may be reciprocal rather tha uidirectioal. Geetic models of metal disorder suggest that psychopathology is iherited from parets, ad there is certaily evidece for the familial trasmissio of may disorders. For example, familial trasmissio geetic trasmissio of disorders moozygotic (idetical) twis should be more likely tha dizygotic (frateral) twis to have the same disorder because they share 100 per cet of their geetic material, whereas dizygotic twis share oly 50 per cet. For may disorders, this is exactly what research shows. But give that moozygotic twis share 100 per cet of their geetic material, you might expect them to have the same disorders 100 per cet of the time. But i fact they have the same disorders oly about 50 per cet of the time. These fidigs have led researchers to coclude that, rather tha beig determiistic, geetics cotributes about 50 per cet of the risk for metal illess. Such fidigs show that it does t make sese to questio whether metal illess is a fuctio of ature or urture. Istead we eed to focus o how the two iteract. PSYCHODYNAMICS AND THE PARENT CHILD RELATIONSHIP Freud emphasized the role of the early paret child relatioship i the developmet of metal illess. Accordig to Freud, to the extet that the child did ot successfully egotiate the psychosexual stages (see chapter 14), metal illess would develop. But Freud did t focus o what actually occurred i the paret child relatioship (e.g. whether parets were actually poor caretakers). Istead, his focus was o the ucoscious iteral desires ad motivatios of the child (e.g. sexual ad aggressive impulses) ad how the child egotiated them as s/he progressed through the early relatioship with the child s parets. For example, if a adult male foud himself uable to deal with authority figures, this might be iterpreted as uresolved aggressive impulses towards his father. Whether his father behaved as a harsh authority figure or ot would be cosidered less relevat. So, accordig to Freud, metal illess is due to itrapsychic (i.e. withi the mid) coflict. This meas a perso may have very little isight ito the true causes of their symptoms, as these are thought to be occurrig at a ucoscious level of processig. May of Freud s ideas have goe usupported by research, but a umber of them have prove to be fairly accurate. For example, there is ample evidece that people experiece ad process thigs at a o-coscious level (see Weste, 1998; also chapter 14) ad that early iterpersoal experieces affect later outcomes. I fact, this latter hypothesis became cetral to cotemporary psychodyamic models of abormal behaviour. Cotemporary psychodyamic models (e.g., Kohut, 1977; Kerberg, 1976; Mitchell, 1988) also suggest that the early paret child relatioship is the origial source of metal illess, ad that what goes o i the mid of the child (ad the adult) is importat. But these models differ from Freud s i that they focus more o iterpersoal relatioships tha o itrapsychic coflict. These later models suggest that the early relatioship betwee the child ad the primary caregiver is crucial to the developmet of the self-cocept, cocepts of others, ad the quality of relatioships throughout life. The idea is that this early caregiver child relatioship is iteralized by childre, so that they lear about themselves ad others from the maer i which the caregiver treats them. Accordig to this framework, the ature of this iteralized relatioship ad its resultig impact o the sese of self ad the sese of others is what ca create vulerability to psychological problems. ATTACHMENT AND SECURITY The attachmet model of psychopathology, developed by Bowlby (1969; 1973; 1980; see also chapter 9) resembles the cotemporary psychodyamic models i that it also emphasizes the early paret child relatioship ad how the resultig models of self ad others guide developmet. But rather tha beig iterested i people s perceptios of their early experiece, Bowlby was iterested i the actual characteristics of the relatioship. He relied o observatioal studies of parets ad childre to build his theory, rather tha o retrospective reports of adults. The theory therefore has a strog empirical foudatio. Attachmet theory suggests that whe paretal behaviour fails to make childre feel safe, secure, ad able to tur to ad trust the paret i times of eed, the childre will be uable to regulate their emotios ad eeds adaptively ad will develop egative, isecure views of themselves ad others. This would put childre at risk for developig psychological disorders. Research supports this hypothesis, as isecure childre ad adults show more psychopathology tha secure childre ad adults (see Dozier, Stovall & Albus, 1999; Greeberg, 1999).

5 318 Abormal Psychology Research close-up 1 Recocilig the roles of geetics ad the eviromet i risk for major depressio The research issue As you have read i this chapter, geetic ad evirometal models make very differet assumptios about the causes of depressio. Kedler et al. (1995) coducted a study i a effort to determie the extet to which geetic ad evirometal factors cotribute to depressio. I their study, Kedler ad his colleagues examied two importat questios: (1) do geetic factors ad stressful life evets make uique cotributios to risk for depressio i wome? ad (2) do geetic factors ad stressful life evets iteract to create risk for depressio? I particular, the researchers wodered whether the associatio betwee stressful life evets ad risk for depressio would be greater amog people at high geetic risk compared to people at low geetic risk. Desig ad procedure To examie these questios, Keder ad colleagues studied four groups of wome: (1) wome with a depressed moozygotic (MZ) twi, (2) wome with a depressed dizygotic (DZ) twi, (3) wome with a o-depressed MZ twi, ad (4) wome with a o-depressed DZ twi. Wome with a depressed MZ twi are at the highest geetic risk for depressio, ad wome with a o-depressed MZ twi are at the lowest geetic risk for depressio. For each woma, they assessed whether the perso i questio had experieced a depressive episode i ay give moth over the course of approximately oe year, ad they recorded whether ay severe life evets occurred durig each moth over this oe year time period. Results ad implicatios Both stressful life evets ad geetic factors made uique cotributios to depressio. Regardless of geetic risk, stressful life evets were associated with depressio, ad regardless of life stress, geetic risk was associated with depressio. However, the impact of stressful life evets o risk for depressio was greater amog wome at high geetic risk tha it was for wome at low geetic risk (see figure 15.3). Iterestigly, the stressful life evets that were foud to be most strogly associated with depressio were maily iterpersoal i ature (death of a close relative, serious marital problems, divorce/break-up, ad assault), highlightig the importace of relatioship factors i risk for depressio. Probability of oset High Low Abset Preset Stressful life evets MZ without depressio DZ without depressio DZ with depressio MZ with depressio Figure 15.3 Risk of oset of major depressio as a fuctio of geetic risk ad stressful life evets. Source: Kedler et al. (1995). The fidigs suggest that both geetic risk ad stressful life evets are importat factors i uderstadig wome s risk for depressio. Moreover, cosistet with a diathesis-stress model (see p. 319), wome at high geetic risk who experiece a stressful life evet i the iterpersoal domai of their lives are at greatest risk of all. Therefore, to uderstad risk for depressio amog wome best, we must cosider both geetic factors ad evirometal factors. Kedler, K.S., Kessler, R.C., Walters, E.E. et al., 1995, Stressful life evets, geetic liability, ad oset of a episode of major depressio i wome, America Joural of Psychiatry, 152,

6 What Causes Abormal Behaviour? 319 LEARNED BEHAVIOUR Behavioural models suggest that all behaviour, abormal icluded, is a product of learig maily learig by associatio (see chapter 4). For example, accordig to the classical coditioig model of learig (e.g. Pavlov, 1928), if a ma experieces chest pais which result i axiety while shoppig i a departmet store, he may develop a fear of departmet stores ad begi to avoid them because he associates them with axiety. There is othig iheretly frighteig about departmet stores, but this ma fears them because of the associatio that he has formed with his earlier axiety about havig a possible heart attack. Here is aother example which istead uses the operat model of learig (e.g. Skier, 1953): if a youg ormal weight woma begis to lose weight ad her frieds ad family praise her for doig so, she may cotiue to lose weight, eve if it meas starvig herself. Her restricted eatig behaviour will cotiue because she ow associates a reductio i her diet with the praise ad acceptace of others. There is a third type of learig that does ot rely o persoal experieces to establish associatios. I observatioal learig, behaviour is leared simply by watchig someoe else do somethig ad observig what happes to them (Badura, 1969). For example, a youg boy may lear to be aggressive after watchig his peers act aggressively. Each of these learig models was built o a solid foudatio of empirical research, ad there is a great deal of evidece that each of the three learig processes plays a importat role i abormal behaviour. DISTORTED THINKING Cogitive models of abormal behaviour focus o the way people thik about themselves, others ad the world (e.g. Beck et al., 1979). Distorted cogitive processes such as selectively attedig to some iformatio ad igorig other iformatio, exaggeratig egative feeligs, expectig the worst, or makig iaccurate attributios about evets (see chapters 14 ad 17) have bee show to play a importat role i various types of psychological disorders. For example, suppose a woma has a bad day at work. If she says to herself, Oh well, tomorrow will be better, she will probably feel fie. But if she says to herself, Oh, I m just a horrible perso with o future (i.e. if she exaggerates her egative feeligs), she may become depressed. Or suppose a youg ma loses at a game of cards. If he thiks, I sure had bad luck with the cards today, he will feel fie. But if he thiks, My rotte frieds purposely cheated me! he may become hostile ad aggressive. INTEGRATIVE MODELS The models of abormal behaviour described above are quite differet from oe aother, ad each is more or less well suited to particular disorders. As most disorders are quite complex, o sigle model ca provide a full explaatio of their oset ad course over time. Istead, each model ca help us to uderstad a differet aspect of each disorder. This is where itegrative models are useful. You may have oticed that oly some of the models above explicitly focus o childhood factors that may cotribute to the developmet of abormal behaviour, whereas the others oly do so at a implicit level. For example, behavioural models suggest that abormal behaviour is the product of earlier learig experieces, but they do t elaborate o exactly what those experieces are. By cotrast, developmetal psychopathology provides a more rigorous framework for uderstadig how psychopathology develops from childhood to adulthood. It is also likely that metal illess results oly whe particular combiatios of factors are preset. This otio is at the heart of the diathesis stress model. The diathesis stress model developmetal psychopathology a perspective suggestig that risk for psychopathology depeds o success at egotiatig ad masterig importat developmetal tasks diathesis stress model suggests that some people possess a edurig vulerability factor (diathesis), which, whe coupled with a proximal stressor, results i psychological symptoms The diathesis stress model of metal illess (figure 15.4) suggests that some people possess a edurig vulerability factor (a diathesis) which, whe coupled with a proximal (recet) stressor, results i psychological disorder. Neither the diathesis or the stressor aloe is eough to lead to symptoms both must be preset. Diatheses ad stressors ca be defied broadly. For example, a geetic or biological predispositio to metal illess might be the diathesis, ad a troubled paret child relatioship could be the stressor; or a dysfuctioal patter of thikig about the world ca be the diathesis, ad a major life evet the stressor. Stress? Figure 15.4 Yes No Yes Disorder? Yes Disorder? No Diathesis? No Disorder? No Disorder? No The diathesis stress model of psychopathology. Accordig to this model, psychopathology is most likely to result whe a perso with a diathesis (vulerability) experieces a stressor. This model helps us to uderstad why oly some people with vulerabilities, such as a geetic predispositio, develop psychopathology.

7 320 Abormal Psychology As you read through the followig sectios o the various disorders, you might wat to cosider how a diathesis stress process could describe how each comes about. Developmetal psychopathology Accordig to this model, psychopathology is best uderstood usig a lifespa developmet approach. It cosiders how the egotiatio ad attaimet of earlier developmetal tasks affects people s capacities to maage later tasks (e.g. Cicchetti, Rogosch & Toth, 1994). I other words, people may travel dow oe of may paths; their success or failure at various juctures alog the way determies the subsequet path that they follow. So earlier deficits i fuctioig may leave us uprepared to successfully egotiate subsequet related situatios, puttig us at eve greater risk for psychopathology. For example, a youg girl who is harshly ad chroically criticized by her parets may develop low self-esteem ad the expectatio that people will ot like her, which puts her at risk of becomig depressed. She may the have difficulty makig frieds i school because she is afraid of rejectio. She may feel loely ad udesirable, her withdrawal leadig to actual rejectio by her peers, cotiuig her risk for depressio. But if this youg girl has a teacher who treats her with warmth ad care ad helps her lear how to make frieds, her risk for depressio might be reduced. This is because she is acquirig importat skills that have the potetial to chage the course of her subsequet developmet. DISORDERS SYMPTOMS AND CAUSES For each disorder we will look at its symptoms ad the course it takes. The we will cosider its causes, both biological/geetic ad psychosocial, ad the factors that affect its course. Prevalece rates (i.e. the cross-sectioal proportio of occurreces of the disorder i the populatio) for various disorders are show i figure SCHIZOPHRENIA A LIVING NIGHTMARE Images of schizophreia are easy to cojure a dishevelled perso, aloe, talkig to himself or yellig at someoe else that oly he seems to see. This is a frighteig image, for the symptoms it portrays are extremely odd ad discocertig. Ideed, schizophreia ca be a frighteig disorder to deal with, ot oly for those ivolved with schizophreic people, but for the sufferers themselves. Schizophreia is a severe metal disorder, experieced by may sufferers as a livig ightmare, a fact highlighted by the high rate of suicide amog schizophreics (Caldwell & Gottesma, 1992; see table 15.1). As you read this sectio, try to imagie what it might feel like to experiece some of the thigs schizophreic people experiece. For example, may schizophreic people hear voices. Have you ever heard someoe call your ame, oly to fid there was % of populatio Schizophreia Eatig disorders Figure 15.5 Bipolar disorder o oe there? How did that feel? Rather discocertig, most likely. Now magify your feeligs about 100 times ad you may start to sese how the schizophreic perso feels. Schizophreia is characterized by psychosis, or a break with reality. People who are Obsessivecompulsive disorders Phobias Persoality disorders Symptoms Major depressio Substace abuse/depedece Lifetime prevalece rates for psychological disorders. These rates are from studies coducted i the US (Kessler et al., 1994), but cross-atioal studies idicate similar rates of disorders i other coutries such as Switzerlad, Germay ad Puerto Rico. Source: Kessler et al. (1994). Table 15.1 Suicide: a serious metal health ad public health problem Facts about suicide Suicide occurs across the world, but rates vary by culture Self-iflicted ijuries, icludig suicide, were the 12th leadig cause of death i the world i 1998 I all cultures, me are more likely tha wome are to complete suicide Rates of suicide i childre ad adolescets are o the rise People with metal disorders, especially depressio, substace use disorders, schizophreia, ad borderlie persoality disorder, are at high risk for suicide Risk factors for suicide Past history of attempted suicide Talkig about committig suicide A clear pla to commit suicide Available meas (e.g. firearms, drugs) Depressio Substace abuse Hopelessess Impulsivity Stressful life evets Lack of social support Sayig goodbye to people Givig away persoal items psychosis a break with reality, characteristic of schizophreia

8 Disorders Symptoms ad Causes 321 psychotic thik ad behave i ways that have little to do with reality, showig sigificat impairmet i just about every importat domai of fuctioig perceptio, thought, laguage, memory, emotio ad behaviour. People with schizophreia may exhibit ay of these symptoms: paraoid delusios elaborate set of beliefs, commoly experieced by schizophreics, characterized by sigificat distrust of others ad feeligs of persecutio Perceivig thigs that are ot there these halluciatios are usually auditory (e.g. hearig voices), but visual ad tactile halluciatios (e.g. seeig God or the devil, or feelig that isects are crawlig uder your ski) also occur relatively frequetly. Believig thigs that are ot true paraoid delusios are particularly commo. A schizophreic woma may believe that the govermet is plottig agaist her or that alies pla to kill her. Everythig will be iterpreted i the cotext of the delusio, eve thigs that are meat to help, so medicatio will be see as poiso. Delusios of gradeur are also commo: a schizophreic perso may believe that he is someoe famous, such as Elvis or Jesus Christ, ad may isist o behavig like ad beig treated as that perso. Usig odd or bizarre laguage, such as idiosycratic meaigs for commo words or made-up words (eologisms) that oly have meaig to them. They may also go off o tagets whe they speak. Disturbaces i affect flat affect ca result i a lack of facial expressios ad emotioless, mootoe speech, while iappropriate affect is characterized by laughig whe othig fuy has happeed, cryig whe othig sad has happeed or gettig agry whe othig upsettig has happeed. Behavioural disturbaces i four importat areas: 1. odd maerisms, such as repetitive movemets or behaviours ad odd facial expressios (e.g. grimaces); 2. a sigificat lack of motivatio, called avolitio; 3. difficulty takig care of themselves, icludig basic life skills such as payig bills, shoppig, ad dressig; ad 4. poor social skills, beig socially withdraw, ad havig disturbed relatioships with others (the ature of iterpersoal relatioships plays a key role i the course of the disorder). positive symptoms i schizophreia, symptoms that idicate the presece of somethig uusual, such as halluciatios, delusios, odd speech ad iappropriate affect egative symptoms i schizophreia, symptoms that idicate the absece of somethig ormal, such as good social skills, appropriate affect, motivatio ad life skills The symptoms of schizophreia are grouped ito two categories: positive ad egative symptoms. Positive symptoms idicate the presece of somethig uusual (such as halluciatios, delusios, odd speech ad iappropriate affect) ad egative symptoms idicate the absece of somethig ormal (such as good social skills, appropriate affect, motivatio ad life skills). The course of schizophreia Schizophreia is a chroic disorder. Although some people have brief episodes of schizophreic-like behaviour (called brief reactive psychoses), most people with schizophreia suffer from symptoms for their etire lives. Oe commo course of schizophreia is a period of egative symptoms ad odd behaviour durig which the perso s fuctioig slowly deteriorates (the prodromal phase), followed by a first break the first episode of positive symptoms. Some people experiece a episode of positive symptoms with a few warig sigs beforehad. The maifestatio of symptoms ca also take a umber of differet forms. For example, some people may be delusioal but still be able to take basic care of themselves, carry o a coversatio ad succeed i school ad work, whereas others may be completely debilitated by the disorder. Schizophreia typically has its oset i late adolescece or early adulthood. Although it ca start i childhood, this is quite rare. Sufferers do t ecessarily deteriorate over time, but they do have relapses ito episodes of positive symptoms. Causes of schizophreia ad factors affectig its course 1 Geetic ad biological factors These accout for our iitial vulerability to schizophreia, although exactly how they do so is uclear. What is clear is that schizophreia teds to be iherited. For example, moozygotic twis have the highest cocordace rates for schizophreia (Gottesma, 1991), meaig that they are more likely to both have schizophreia if oe of them has it, compared to people who share less geetic material (such as dizygotic twis or sibligs). Iterestigly, schizophreics Pioeer cocordace rates the extet to which people show the same disorders Emil Kraepeli ( ), a Germa psychiatrist ad oe of the foudig fathers of moder psychiatry, made three primary cotributios to the field of metal illess. First, Kraepeli believed that metal illess was caused by biological factors. His work i this area helped defie the field of biological psychiatry ad research ow supports a strog biological basis for some of the disorders i which Kraepeli was most iterested (e.g. schizophreia ad bipolar disorder). Secod, Kraepeli laid the foudatio for moder classificatio systems used to diagose metal disorders, which use patters of symptoms rather tha ay oe symptom i isolatio. This led to his third cotributio, which was the classificatio of ad distictio betwee schizophreia ad bipolar disorder.

9 322 Abormal Psychology ad their close family members show some similar types of europsychological fuctioig, eve if these family members do ot suffer from the illess itself. This suggests that it may be the biological risk factors for schizophreia that are iherited from family members, rather tha the disorder itself (Cao et al., 1994). Adoptio studies also support the otio of geetic trasmissio of vulerability to schizophreia. Childre bor to a schizophreic paret ad adopted away to a o-schizophreic paret are more likely to have schizophreia, compared to childre bor to a o-schizophreic paret (Kety et al., 1994). However, oe study has show that adopted-away childre with a geetic predispositio to schizophreia are more likely to become schizophreic if they are also raised i a disturbed family eviromet. This supports a diathesis stress model of schizophreia (Tieari et al., 1987). Several biological problems may cause schizophreia, as various forms of brai dysfuctio occur amog sufferers, icludig elarged vetricles, reduced blood flow to frotal brai regios ad a excess of dopamie (Adrease et al., 1992; Davis et al., 1991; Flaum et al., 1995). But we do t kow for sure whether these problems are a cause or a cosequece of the disorder. A curret debate focuses o the eurodegeerative hypothesis (that schizophreia leads to progressively deterioratig brai fuctioig) versus the eurodevelopmetal hypothesis (that brai deficits are preset at birth, ifluece the oset of schizophreia ad remai fairly stable). Research supports the eurodevelopmetal hypothesis, but there is also evidece that the brais of some schizophreic people show greater deterioratio over time tha would otherwise be expected. 2 Psychosocial factors A early hypothesis of the schizophreogeic mother suggested that iadequate paretig causes schizophreia (e.g. Arieti, 1955). There is absolutely psychosocial factors psychological, o evidece of this, or that evirometal ad social factors that ay psychosocial factors cause may play a role i psychopathology schizophreia. The evidece overwhelmigly poits to geetic ad biological factors as providig the iitial vulerability. But there is evidece, cosistet with a diathesis stress model, that psychological ad social factors ifluece the course of schizophreia, such as the timig of oset ad the likelihood of relapse. The most well researched psychosocial predictor of the expressed emotio (EE) specific set course of schizophreia is a of feeligs ad behaviours directed pheomeo called expressed at people with schizophreia by their emotio (EE). This does t family members refer to the level of emotio the sufferer expresses, as the ame implies, but to a specific set of feeligs ad behaviours directed at people with schizophreia by their family members. A family that is high i EE teds to be critical ad resetful of their schizophreic relative ad may be overprotective or over-ivolved i his life (Brow et al., 1962). A family that is low i EE teds to be more carig ad acceptig, ad less emeshed i the sufferer s life. % relapsig i 9 12 moths Schizophreia Figure 15.6 Depressio High EE Bipolar disorder Low EE Alcoholism Expressed emotio ad relapse. Across may disorders, people who have family members who are high o EE are more likely to relapse tha are people who have family members who are low o EE. Source: Adapted from Butzlaff & Hooley (1998); O Farrell et al. (1998). The level of EE i the family plays a importat role i what happes to the schizophreic perso. Schizophreic people who have families that are high i EE are more likely to suffer a relapse of symptoms (figure 15.6). This associatio betwee EE ad relapse is also true for a umber of other disorders. Carig for a schizophreic family member is a stressful, tirig udertakig, which ca, i itself, lead to high EE behaviours. Fortuately, psycho-educatioal programmes ca help families ad their schizophreic relatives lear better ways of commuicatig. These programmes, i cojuctio with appropriate medicatio for the sufferer, ca lower relapse rates (e.g. Leff et al., 1982; McFarlae et al., 1995). MOOD DISORDERS DEPRESSION Although mood disorders have some symptoms i commo, they are very differet i terms of their prevalece ad causes. Major depressive disorder, also called uipolar depressio, is oe of the most commo of these disorders, whereas bipolar disorder (also kow as maic-depressio), like schizophreia, is less prevalet. Both disorders ofte result i severe impairmet. Figure 15.7 shows that depressio results i as much impairmet as commo physical health problems, if ot more. Symptoms of major depressive disorder The primary symptom of major depressive disorder is, ot surprisigly, a depressed or sad mood. Almost everyoe experieces a sad mood some time i their life, but major depressive disorder goes much further tha simply feelig sad. Other symptoms iclude: Losig iterest or pleasure i thigs that you usually ejoy a experiece called ahedoia.

10 Disorders Symptoms ad Causes 323 Level of impairmet Depressio Hypertesio Diabetes Arthritis Back pai Figure 15.7 Level of impairmet caused by depressio i compariso to physical disorders. Notice that depressio is as impairig or more impairig tha may commo health problems. The impairmet scale should be iterpreted with regard to the relative impairmet across disorders, rather tha absolute impairmet of each disorder. Source: Adapted from Üstü ad Sartorius (1995). Chages i appetite some fid othig appealig ad have to force themselves to eat, resultig i sigificat weight loss, while others wat to eat more ad gai a lot of weight. Chages i sleep habits depressed people may be uable to sleep or wat to sleep all the time. A very low level of eergy, extreme fatigue ad poor cocetratio. Depressed people have o motivatio to do aythig, ofte fid themselves uable to get out of bed ad uable to complete school or work assigmets. They may move through their lives very slowly, feelig that eve simple activities require too much eergy. Feelig very badly about themselves low self-esteem, feelig worthless ad blamig themselves for all that has goe wrog i their lives ad the world. Depressed people ted to feel hopeless about the future ad do t believe they will ever feel better. Major depressive disorder has egative cosequeces ot oly for how people feel about themselves ad their future, but also for their relatioships. Durig a depressive episode people ted to withdraw socially, feel isecure i relatioships, elicit rejectio from others ad experiece high levels of iterpersoal coflict ad stress. Romatic, family ad peer relatioships all suffer. Give their level of sufferig, impairmet ad hopelessess, it is hardly surprisig that depressio is oe of the biggest risk factors for suicide, with aroud 15 per cet of depressed people committig suicide (Clark & Goebel-Fabbri, 1999). The course of the disorder Figure 15.8 A depressed perso will ted to withdraw socially, feel isecure, elicit rejectio from others ad experiece high levels of iterpersoal coflict ad stress. Major depressive disorder follows a recurret course. Although some people have isolated episodes, most experiece multiple episodes of depressio that may become more severe over time (e.g. Lewisoh, Zeiss & Duca, 1989). Mild forms of depressio with just a few symptoms rather tha full-blow major depressive disorder ca predict the oset of more serious depressio later o (e.g. Pie et al., 1999). Although depressio was oce thought to be a disorder of adulthood, we ow kow that it affects people of all ages, icludig childre (figure 15.9). I fact, the age of oset of major % of populatio Figure 15.9 Obsessivecompulsive disorders Phobias Attetio deficit hyperactivity disorder Geeralized axiety disorder Depressio Separatio axiety Childre experiece psychological disorders too. These rates are from studies i the US. Cross-atioal studies idicate that rates may differ somewhat i differet coutries because of differig cultural values that result i differet defiitios of abormality ad differet symptom expressio. However, childre i all cultures suffer from various psychological disorders.

11 324 Abormal Psychology depressive disorder is decreasig, ad the rates of major depressive disorder i childhood ad adolescece are icreasig rapidly. Early oset predicts a worse course of depressio over time (e.g. Lewisoh et al., 1994), so depressio i childhood ad adolescece is a serious problem that ca lead to ogoig difficulties throughout life. Causes of major depressive disorder ad factors affectig its course 1 Geetic ad biological factors Like schizophreia, major depressive disorder ca be geetically trasmitted (e.g. McGuffi et al., 1996). As for biological factors, the curret view is that o sigle eurotrasmitter is associated with major depressive disorder. Istead, it most likely ivolves dysregulatio of the etire eurotrasmitter system (Siever & Davis, 1991). Ideed, it may be the balace of various eurotrasmitters that regulate mood. Major depressive disorder may also ivolve euroedocrie dysfuctio. Depressed people ted to have elevated cortisol levels (e.g. Halbreich, Asis & Shidledecker, 1985). Cortisol is ivolved i regulatig the body s reactio to stress ad becomes elevated uder stress. This suggests that, physiologically, depressed people may be i a state of chroic stress ad they are perhaps more reactive to stress tha are o-depressed people (e.g. Gold, Goodwi & Chrousos, 1988). As we see i the ext sectio, stress plays a importat role i vulerability to major depressive disorder. 2 Psychosocial factors Ulike schizophreia, which almost certaily has a geetic ad/or biological trigger, major depressive disorder ca be caused by either geetic/biological or psychosocial factors. Oe of the primary psychosocial factors is life stress, icludig sigificat egative life evets ad chroically stressful circumstaces (e.g. Brow & Harris, 1989). Of course, may people experiece stressful situatios, but they do t all become depressed, suggestig that a diathesis stress process might be occurrig. Specifically, it may be the particular way we perceive ad thik about life stressors that leads to depressio. Cosistet with a cogitive model of psychopathology, people who thik about life evets i a pessimistic, dysfuctioal way are more likely to get depressed tha people who thik about life evets i a optimistic way (e.g. Metalsky, Halberstadt & Abramso, 1987). Beck (1967; Beck et al., 1979) describes pessimistic cogitive distortios dysfuctioal ways ways of thikig about ourselves, the world ad the of thikig about the self, the world, other people ad the future that ca future as cogitive distortios. make people vulerable to depressio Examples are viewig thigs ad other egative emotios i a black ad white maer, focusig o ad exaggeratig egative aspects ad miimizig our positive qualities. Whe people egage i cogitive distortios, like those below, to explai their life circumstaces, they put themselves at risk for experiecig egative moods like depressio: All or othig thikig I m a total loser! Overgeeralizatio I m always goig to be a total loser! Catastrophizig I m so bad at my job that I m sure to fail, the I ll get fired, I ll be totally humiliated, obody will ever hire me agai, ad I ll be depressed forever! Persoalizatio It s all my fault that my sister s boyfried broke up with her if I had t bee so eedy of her attetio, she would have spet more time with him ad they would have stayed together! Emotioal reasoig I feel like a icompetet fool, therefore I must be oe! Similarly, Seligma ad colleagues (e.g. Abramso, Seligma & Teasdale, 1978) suggest that people who are vulerable to depressio ted to offer iteral, global ad stable causal explaatios for egative evets (see also chapter 14). For example, if a date goes badly, reactios might iclude: It s all because of me (iteral); I always do the wrog thig (global); ad I ll ever have a proper boyfried (stable). Negative iterpersoal circumstaces are particularly likely to play a role i depressio. Marital, family ad peer relatios are ofte troubled, ad iterpersoal forms of stress such as relatioships edig, coflicts ad lack of supportive relatioships are cosistetly associated with depressio (see Beach & Ficham, 1998; Davila, 2000; Hamme, 1991). Iterpersoal models of depressio highlight how the disorder ca be both a cause ad a cosequece of iterpersoal problems. For example, Coye (1976) suggested that depressed people egage i behaviours that elicit rejectio from others, ad this rejectio leads to further depressio. Similarly, Hamme (1991) proposed that depressed people geerate iterpersoal stress i their lives, which the makes them more depressed. It s possible that, for some people, depressio has its roots i childhood experieces (Cicchetti et al., 1994). A isecure attachmet i childhood may set the stage for depressio by puttig childre at a disadvatage i four importat areas: 1. Low self-esteem puts them at risk for a pessimistic way of viewig themselves ad the world. 2. Iability to successfully regulate their egative emotios leaves them uable to fed off feeligs of depressio. 3. Never havig leared to cope well with stress, they may employ iappropriate strategies (such as keepig problems hidde or rumiatig o them). 4. Negative views of others ad leared dysfuctioal ways of iteractig with others (e.g. excessive depedece o, or complete avoidace, of others) puts them at risk for depressio through the egative effect it has o their iterpersoal relatioships. Symptoms of bipolar disorder I bipolar disorder, depressio alterates with periods of maia, which is virtually the polar opposite of depressio. Durig a

12 Disorders Symptoms ad Causes 325 Research close-up 2 Idetifyig eural correlates of vulerability to psychopathology The research issue Affective eurosciece is a rapidly growig field i psychology that has the potetial to help us uderstad how brai fuctioig is related to risk for emotioal disorders. By usig brai imagig techiques (e.g. Positro Emissio Tomography, PET; Fuctioal Magetic Resoace Imagig, fmri) researchers may be able to idetify areas of the brai that are associated with differet emotios ad motivatioal states. Liotti ad his colleagues (2002) attempted to do just that i order to determie whether there are ay disease markers i brai fuctioig for uipolar depressio. Specifically, they were iterested ot just i whether depressio was associated with certai aspects of brai fuctioig, but whether there are brai chages that may play a causal role i the oset of uipolar depressio. Desig ad procedure I order to test their questio, Liotti et al. compared three groups of participats: remitted depressed idividuals people who were diagosed with major depressive disorder, but who were o loger symptomatic; curretly depressed idividuals people diagosed with major depressive disorder; ad healthy comparisos people with o persoal or family history of depressio or ay other psychiatric disorder. Each participat uderwet PET scas durig (1) a restig state ad (2) a sad-mood iductio i which he or she thought about persoal evets that iduced sadess. The the researchers compared chages i brai fuctioig from the restig state to the sad state i the three groups. Results ad implicatios Comparisos of brai fuctioig chages across the three groups resulted i two importat fidigs: 1. Of most importace, the brai fuctioig of the curretly depressed was very similar to that of the remitted groups, but they were both differet from the healthy comparisos. Therefore, whe remitted depressed people (who are ot curretly depressed) are made to feel sad, their brais fuctio more like those of people who are curretly depressed tha like those of people who are ot curretly depressed. So these commo aspects of brai fuctioig may be markers of risk for uipolar depressio. Of course, this research desig does ot tell us for sure whether the observed chages are a marker of vulerability to depressio or a reflectio of brai chages that follow from havig the disorder. 2. Some aspects of chages i brai fuctioig were similar across all three groups. This suggests that some types of brai fuctioig may reflect processes that are commo to mood regulatio amog all people. I coclusio, the results of this study provide itriguig evidece that there may be eural markers of risk for psychopathology. You ca be certai that this will be a excitig area of research for future geeratios. Liotti, M., Mayberg, H.S., McGiis, S., Braa, S.L., & Jerabek, P., 2002, Umaskig disease-specific cerebral blood flow abormalities: Mood challege i patiets with remitted uipolar depressio, America Joural of Psychiatry, 159, maic period, people feel euphoric or elated. Ad just as major depressio is t the same as simply feelig sad, maia is ot the same as simply feelig happy. Maia is characterized by these symptoms: A excessively euphoric mood typically associated with a sese of gradiosity. Maic people feel ubelievably good about themselves, to the extet that they ofte believe they ca do aythig. Ad they frequetly try to! Egagig i may more activities tha usual. This icrease i activity ofte becomes excessive to the poit of beig dagerous. For example, maic people may go o shoppig sprees, sped amouts of moey that go well beyod their meas, ad icur eormous levels of debt. They may take

13 326 Abormal Psychology off o a trip i their car, drivig recklessly ad leavig resposibilities behid. They may egage i frequet sexual idiscretios, puttig themselves at risk for sexually trasmitted diseases, pregacy ad relatioship coflict. A decreased eed for sleep eve stayig awake for days at a time. High distractibility ad poor cocetratio as the mid races with a millio thoughts. Speakig very quickly others ca barely get a word i durig coversatios. The course of the disorder The most commo oset for bipolar disorder is i early adulthood, but, like major depressive disorder, it ca occur earlier. Bipolar disorder is a lifelog, recurret disorder that ca take a variable course. Although some people regularly alterate betwee maia ad depressio, the umber of episodes, their timig ad their order ca vary widely. Bipolar disorder ca be seriously debilitatig, but with appropriate medicatio may sufferers live highly productive, ormal lives betwee episodes. Causes of bipolar disorder ad factors affectig its course 1 Geetic ad biological factors There is eve more evidece of geetic trasmissio for bipolar disorder tha for major depressive disorder (Gersho, 1995). There is also evidece of dysfuctio of various eurotrasmitters, icludig serotoi, dopamie ad orepiephrie, although it may ot be the levels of eurotrasmitters themselves that are problematic, but the patter of euroal firig. Sodium ios are critical i proper euroal firig (see chapter 1), ad lithium, which is used to treat bipolar disorder, is chemically similar to sodium, so lithium may work by regulatig dysfuctioal euroal firig (e.g. Goodwi & Jamiso, 1990). Pioeer Kay Redfield Jamiso (1946 ), Professor of Psychiatry at Johs Hopkis Uiversity School of Medicie, is a awardwiig psychologist ad expert i the field of bipolar disorder, a coditio from which she suffers. With Frederick K. Goodwi, she wrote oe of the classic texts o bipolar disorder, Maic-depressive Illess. Her autobiography, A Uquiet Mid, has made a lastig impact because of the cadid ad carig maer i which she describes life with bipolar disorder. She has also produced three televisio programmes about bipolar disorder. Jamiso has served o the first Natioal Advisory Coucil for Huma Geome Research, ad is cliical director for the Daa Cosortium o the Geetic Basis of Maic-Depressive Illess. 2 Psychosocial factors Like schizophreia, there is o evidece that psychosocial factors are the iitial cause of bipolar disorder. But they do ifluece the course of the disorder. Stressful life evets, particularly those that disrupt social ad biological regularities (e.g. birth of a child, chage i work hours, travel), may lead to relapse (see Johso & Roberts, 1995). Negative social relatios may also lead to relapse. I particular, sufferers with high EE families are more likely to relapse (Miklowitz et al., 1988; see figure 15.6). ANXIETY DISORDERS WHEN FEAR TAKES OVER Axiety is a set of symptoms: emotioal (e.g. fear, worry) physical (e.g. shortess of breath, heart poudig, sweatig, upset stomach) cogitive (e.g. fear of dyig, losig cotrol, goig crazy). Whe someoe experieces this cluster of symptoms, it is ofte called a paic attack. Like depressed mood, axiety is a commo experiece almost everyoe has felt some level of axiety i their lives. I may circumstaces, it is a ormal adaptive experiece, physiologically preparig our bodies to respod whe we sese dager. Our autoomic ervous system (see chapter 3) gets us ready for fight or flight ad the, whe the dager has passed, calms us back dow agai so that we ca go back to ormal fuctioig. So how do we differetiate ormal fear from a axiety disorder? I additio to the level of impairmet caused by the axiety, a disorder ofte ivolves fear ad axiety i respose to somethig that is ot iheretly frighteig or dagerous. For example, it is ormal to feel axiety i respose to poisoous sakes, but it less ormal to feel axiety i respose to pictures of sakes. Axiety disorders have four thigs i commo: 1. each is defied by a specific target of fear (the thig the perso is afraid of); 2. axiety or paic attacks are experieced i respose to the target of fear; 3. the target of fear is avoided by the sufferer; ad 4. axiety disorders ted to be chroic they ted to persist rather tha come i episodes. Symptoms ad course of axiety disorders 1 Specific phobias The most commo ad straightforward of the axiety disorders are specific phobias fear ad avoidace of a particular object or situatio (e.g. dogs, heights, flyig). This axiety may be very circumscribed, occurrig oly i respose to the target of fear, ad may result i impairmet i oly a very specific domai. For example, someoe who is afraid of flyig may lead a very ormal, productive life but simply is t able to fly. This may impair their work if they are expected to travel for busiess, or

14 Disorders Symptoms ad Causes 327 Pioeer David Barlow (1942 ), Professor of Psychology ad Director of the Ceter for Axiety ad Related Disorders at Bosto Uiversity, is a expert o the ature ad treatmet of axiety ad related disorders (e.g. sexual dysfuctio). I his classic text, Axiety ad its Disorders, he describes the predomiat cogitive-behavioural approach to uderstadig axiety disorders. He has developed a series of empirically supported cogitive-behavioural treatmets for various axiety disorders ad is particularly well kow for his paic cotrol treatmet. of egative evaluatio ad rejectio by others ad will attempt to avoid it at all costs. Social phobia rages from relatively mild (e.g. fearig ad avoidig public speakig oly) to extremely pervasive (e.g. fearig ad avoidig all social iteractio except with family members). 3 Paic disorder Paic disorder ca also be quite debil- agoraphobia fear of situatios i which escape would be difficult or help is ot itatig, especially whe it is available should paic or axiety occur coupled with agoraphobia. Literally fear of the marketplace, agoraphobia is ofte thought of as fear of leavig the house. More accurately, it is fear of situatios i which escape would be difficult or there would be o oe to help should paic occur. Paic disorder begis with sudde paic attacks that occur out of the blue. The disorder develops whe people worry about havig aother paic attack ad subsequetly begi to avoid places ad situatios they associate with it. For example, if you had a paic attack while drivig, you might avoid drivig agai. Whe someoe avoids so may places ad situatios that they are fially uable to leave their home, they are said to have agoraphobia. 4 Obsessive-compulsive disorder You wo t be surprised to fid that obsessivecompulsive disorder (OCD) is characterized by obsessios (uwated, persistet, itrusive, repetitive thoughts) ad compulsios (ritualistic, repetitive behaviours). obsessios uwated, persistet, itrusive, repetitive thoughts compulsios ritualistic, repetitive behaviours that a perso feels compelled to egage i Whe someoe with OCD experieces obsessios, such as fear of cotamiatio, axiety is geerated. To reduce this axiety, she might egage i compulsios, such as repetitive had-washig. The compulsios reduce axiety briefly, but the obsessios soo retur, ad the sufferer becomes caught i a vicious cycle. Sometimes OCD is fairly circumscribed, but ofte it begis to domiate people s lives, causig sigificat impairmet. Typical obsessios ivolve religio, cotamiatio, fear of hurtig someoe, fear of losig somethig importat, ad fear of sayig or doig somethig iappropriate or dagerous. Typical compulsios are had-washig, checkig, coutig ad hoardig. Figure A specific phobia will ivolve fear ad avoidace of a particular object or situatio. their relatioships if, for example, they ca t take a vacatio with their parter. But it wo t usually affect other areas of their life. 2 Social phobia Social phobia teds to be more impairig because it ofte results i sigificat social isolatio. You might thik that people with social phobia are afraid of people or of social situatios but this is t the case. They are actually afraid 5 Post-traumatic stress disorder Experiecig a traumatic evet ca lead to post-traumatic stress disorder (PTSD). It was first documeted amog war veteras who had bee exposed to wartime atrocities, but we ow kow that it ca occur i respose to may types of evet, icludig atural disasters, accidets, rape ad physical abuse. Ad it is t just the victim who is vulerable to the disorder. Someoe who observes severe physical abuse, for example, is also at risk. PTSD has a paradoxical set of symptoms. The target of fear is the trauma itself, which creates tremedous axiety, so the sufferer will desperately try to avoid aythig associated with the trauma. They may eve lose their memory for the evet. O the

15 328 Abormal Psychology other had, people with PTSD might be plagued with uwated ad itrusive thoughts about the evet, such as flashbacks ad ightmares. Sufferers also ted to become psychologically umb. Their emotios shut dow, ad they ca t derive pleasure from thigs or eve evisio the future. But agai, paradoxically, they may also experiece symptoms of hyper-arousal. They are usually hyper-vigilat to their eviromet, they startle easily, ca t sleep or cocetrate, ad are irritable ad easily agered. This complex set of symptoms makes PTSD is a very debilitatig disorder. 6 Geeralized axiety disorder I some ways, geeralized axiety disorder is the simplest, ad i other ways the most complex, axiety disorder. It is characterized by a exteded period say, six moths or more of chroic, ucotrollable worry about umerous thigs. This souds simple. Sufferers sped their lives worried ad tese all the time, they are easily irritated, ad they have trouble sleepig ad cocetratig. O the other had, it is t etirely clear what people are attemptig to avoid ad what fuctio their worry serves. Some theorists have suggested that people with this disorder fear that they will ot be able to cotrol their lives or themselves, ad worry is a way to exert cotrol (Borkovec, 1985). It does t work, of course, but sufferers may feel completely out of cotrol if they stop worryig. They may have o other copig strategies to rely o. Causes of axiety disorders ad factors affectig their course 1 Geetic ad biological factors The extet of heritability varies across disorders. For example, paic disorder shows relatively high rates of heritability, whereas geeralized axiety disorder shows lower rates (e.g. Hettema et al., 2001; Kedler et al., 1992). There is also evidece that people who are proe to axiety disorders are bor with somethig called behavioural ihibitio (see Kaga behavioural ihibitio shyess, quietess, fearfuless, social avoidace, ad & Sidma, 1991). Childre high levels of physiological arousal ad who are behaviourally ihibited are shy, quiet, fearful, stress reactivity i youg childre socially avoidat ad have high levels of physiological arousal (i.e. they are aroused easily ad are very reactive to stimulatio ad stress). These childre are more likely to develop a axiety disorder (e.g. Hirschfeld et al., 1992). Regardig biological factors, there a umber of pathways i the limbic system that are hypothesized to produce various types of axiety reactios (e.g. Gray, 1982). I additio, people with axiety disorders show low levels of the eurotrasmitter gamma amiobutyric acid (GABA). This is a cetral ervous system ihibitor that works to lower physiological arousal ad keep us calm ad relaxed. Low levels of GABA ca therefore lead to icreased euroal firig, which may i tur lead to high levels of physiological arousal ad, cosequetly, axiety. Although some forms of biological dysfuctio may be associated with axiety i geeral, each axiety disorder may also have uique biological causes. For example, some research idicates there is a specific brai circuit that, whe over-activated (e.g. i times of stress), results i repetitive patters characteristic of OCD (e.g. Rapoport, 1989). Research also suggests that vulerability to paic disorder may be the result of a biological sesitivity to physical sesatios (e.g., Klei, 1993). Our bodies may have a alarm system that is hypersesitive to certai sesatios (e.g. lack of oxyge). Whe the alarm souds, we may experiece a paic attack. This is a iterestig model, but it does t idicate how exactly this process leads to paic disorder (i.e. how fear ad avoidace of paic attacks develop). 2 Psychosocial factors Cogitive, behavioural ad life stress factors all affect risk for axiety disorders. I fact, stress is, by defiitio, the cause of PTSD. Whe fear is geerated by life experieces, be they actual experieces, thigs we see or eve thigs we are told about, this ca serve as a powerful coditioig experiece. But, like depressio, the way we view a frighteig evet affects whether it results i a axiety disorder. Axiety is associated with viewig the world as dagerous ad ucotrollable ad viewig the self as helpless (e.g. Beck & Emery, 1985). The developmet of paic disorder is a good example of how various causal factors may iteract. Imagie you are biologically sesitive to physiological chages i your body. Suppose oe day you suddely feel short of breath for o idetifiable reaso. You assume the shortess of breath meas somethig terrible is about to happe ( I m goig to die!, I m goig to lose cotrol of myself! ), ad so you experiece more axiety, likely resultig i a full-blow paic attack. Because this frighteig evet is made eve more so by your catastrophic iterpretatio, you develop a fear of the paic attack (Clark, 1986; see also figure 15.11). If the paic attack occurs while you are drivig, you might also develop a fear of drivig ad begi to avoid it. This avoidace is reiforced, because it reduces the likelihood of further paic attacks. Icreased axiety (e.g. axious, heart racig, short of breath, sweatig) Figure Paic attack (e.g. axious, heart racig, short of breath, sweatig occurs out of the blue) Misattributio of symptoms ( I m goig to die! I m goig to go crazy! ) Cogitive model of paic disorder. Accordig to this model, people develop paic disorder after misiterpretig a set of physical symptoms, such as poudig heart or shortess of breath. The misiterpretatio serves to make them more axious ad icrease the likelihood of a paic attack. This results i a vicious cycle of physical symptoms, misiterpretatio ad paic attacks.

16 Disorders Symptoms ad Causes 329 EATING DISORDERS BULIMIA AND ANOREXIA Eatig disorders have attracted a great deal of attetio i recet years, particularly i uiversity settigs where they ted to be promiet. Yet despite greater public awareess, certai miscoceptios still exist. For example, may people thik eatig disorders are brought about by vaity. This could t be further from the truth. Rather tha beig vai, people with eatig disorders struggle with issues about who they are, what they are worth, whether they will be able to take care of themselves ad how to egotiate relatioships. Eatig disorders are complex ad difficult to overcome. There are curretly two eatig disorders icluded i the ICD-10 ad DSM-IV bulimia ervosa ad aorexia ervosa. Although they differ i importat ways, they have four thigs i commo: 1. a distorted body image (iaccurate assessmet about shape ad weight); 2. a itese fear of beig fat; 3. a sese of self that revolves aroud the idividual s body ad weight; ad 4. eatig that is regulated by psychological rather tha physiological processes, although the form of eatig regulatio is quite differet for the two disorders. Symptoms People with bulimia ted to be of ormal weight ad are sometimes eve overweight. Bulimia ervosa is characterized by recurret episodes of bige eatig ad purgig. Durig a bige, bulimic people cosume a eormous umber of calories i a brief period of time ad feel a overwhelmig loss of cotrol as they are doig so. The bige is the followed by purgig behaviour usually vomitig, takig laxatives, takig diuretics or usig eemas, ad sometimes fastig or excessive exercise. Other symptoms may iclude: somewhat chaotic lives; a tedecy to be impulsive, emotioally labile, sesitive to rejectio ad i eed of attetio; depressio ad/or substace abuse. Aorexia ervosa is characterized by a refusal to maitai ormal body weight. People with aorexia restrict their food itake through diet ad typically egage i excessive exercise. Their weight ofte becomes so low that their bodies stop fuctioig ormally (e.g. females stop mestruatig), ad they ofte appear emaciated. Aorexics also ted to: be perfectioist, rule-boud ad hard-workig; have a strog eed to please others, but ever feel special themselves; be high-achievers, but also feel ucertai of their capacity to be idepedet. Figure People with aorexia ervosa refuse to maitai ormal body weight; they restrict their food itake ad ted to egage i excessive exercise. Some people with aorexia also egage i bigig ad purgig ad have other features of their persoalities ad lives i commo with bulimics. The course of eatig disorders Both bulimia ad aorexia typically begi i adolescece ad ca become chroic. For example, about oe third of people with aorexia will have a lifelog disorder. Both aorexia ad bulimia pose sigificat health risks. This is particularly true for aorexia, i which almost 5 per cet of people die from malutritio ad other related complicatios. Causes of eatig disorders ad factors affectig their course 1 Geetic ad biological factors Research supports geetic trasmissio, but some suggest that it may ot be the disorder itself that is iherited. They believe that a set of persoality traits such as obsessiveess, rigidity, emotioal restrait i the case of aorexia ad impulsivity ad emotioal istability i the case of bulimia might icrease the likelihood of poor copig. The eatig disorder is see as a maladaptive way of copig with stress (e.g. Strober, 1995). Biological models focus o dysfuctio i the hypothalamus (the part of the brai related to eatig behaviour; see chapter 5)

17 330 Abormal Psychology ad o serotoi dysregulatio (e.g. Wolfe, Metzger & Jimerso, 1997; see Ferguso & Pigott, 2000). There is presetly o evidece that these dysfuctios actually cause eatig disorders, but they may affect their course. 2 Psychosocial factors Oe of the primary sets of psychosocial factors i the developmet ad course of eatig disorders are social pressures ad cultural forces. I cultures where thiess is the ideal of beauty, eatig disorders are most prevalet. There are expectatios of thiess everywhere i the media, i the family, ad i society at large. Adolescets, particularly youg wome, ofte iteralize these expectatios, ad their etire sese of self-worth may become depedet o beig thi. Furthermore, they are usually socially reiforced for beig thi. Thik how ofte you have heard someoe say, or have eve said yourself, Oh, you ve lost weight you look great! For vulerable youg people, a seemigly beig commet like this reiforces the belief that they must be thi i order to be worthy of attetio. But if everyoe i a culture that values thiess grows up facig the same pressures, why do some develop eatig disorders ad some ot? Apart from possible geetic or biological vulerabilities, the way people thik about themselves ad the world may make them vulerable. Cogitive distortios such as, If I eat oe cookie, I will be a fat, horrible perso or Beig thi will make all the problems i my life go away, may icrease vulerability to eatig disorders (e.g. Butow, Beumot & Touyz, 1993). People who come from certai types of families may also be more vulerable to particular types of eatig disorders (Bruch, 1978; Miuchi, Rosma & Baker, 1978). For example, aorexia is thought to develop whe families are very cocered about exteral appearaces ad prefer to maitai a impressio of harmoy at the expese of ope commuicatio ad emotioal expressio. These families ted to be emeshed (family members are uaware of or uable to maitai persoal boudaries), overprotective, rigid ad coflict-avoidat. Aorexia might be a rebellio or a assertio of idepedece ad autoomy, or it may serve to mask the real problems i the family. Other risk factors iclude families who diet, or parets who are critical of their child s weight or appearace (e.g. Pike & Rodi, 1991). A recet perspective, which fits with family ad geetic/persoality models, suggests that eatig disorders are the product of maladaptive emotio regulatio processes (e.g. Wiser & Telch, 1999). So food is used to help regulate emotios (typically egative oes) whe the perso has ot developed more adaptive strategies. Attachmet theorists take a similar positio, suggestig that people with certai forms of isecure attachmet (e.g. avoidat) may distract themselves from upsettig, attachmetrelated cocers (e.g. fear of itimacy, low self-worth) by focusig o food ad weight (Cole-Detke & Kobak 1996). Everyday Psychology Eatig disorders As discussed i chapter 5, obesity is oe of the so-called diseases of affluece that beset may cotemporary Wester societies. But moder developed societies also maifest a rage of disorders at the other ed of the weight spectrum, kow as eatig disorders (i.e. aorexia ervosa ad bulimia ervosa). These disorders appear to develop as outward sigs of ier emotioal or psychological distress or problems. For the sufferer, they seem to be a way of copig with difficulties i their life. Eatig, or ot eatig, ca be used to block out paiful feeligs. Without appropriate help ad treatmet, eatig problems may persist throughout the sufferer s life. Ayoe ca develop a eatig disorder regardless of age, race, geder or backgroud, but youg wome seem to be most vulerable, particularly betwee the ages of 15 ad 25. This may well relate to the chages ad challeges occurrig i youg wome s lives at aroud this period of persoal developmet. Biological research suggests that geetic make-up may make someoe more or less likely to develop a eatig disorder. Withi the psychosocial domai, a key perso or people (for example, parets or relatives) may adversely ifluece other family members through their attitudes to food. Or someoe might focus o food ad eatig as a way of copig with the stresses of high academic expectatios or other forms of social ad/or family pressure. Traumatic evets ca also trigger aorexia or bulimia ervosa. These evets may be especially promiet durig the teeage ad youg adulthood periods, such as the death of a paret or other close relative, beig bullied or abused at school or at home, upheaval i the family eviromet (such as divorce) or cocers over sexuality. Eatig disorders are complex illesses with critical psychological elemets requirig treatmet as well as the physical aspects (such as the disturbed eatig patter ad its biological cosequeces). A regular eatig patter, icludig a balaced diet, is eeded to restore balaced utritio. Ad helpig someoe to come to terms with the fudametal emotioal issues uderlyig their eatig disorder will eable them to cope i their future lives with persoal difficulties i a way that is ot harmful to them. Striegel-Moore, R.H., Seeley, J.R., & Lewisoh, P.M., 2003, Psychosocial adjustmet i youg adulthood of wome who experieced a eatig disorder durig adolescece, Joural of the America Academy of Child ad Adolescet Psychiatry, 42,

18 Disorders Symptoms ad Causes 331 SUBSTANCE USE DISORDERS ABUSE AND DEPENDENCE Regardless of what people may experiece as positive effects of drugs ad alcohol, they both have egative effects o our health ad ability to fuctio, especially whe used repeatedly. This recurret use may result i a substace use disorder. Symptoms There are two substace use disorders abuse ad depedece. Substace abuse is defied etirely o the criterio of impairmet. If someoe s repeated use of a substace causes sigificat impairmet i eve oe area of life, he ca be described as a substace abuser. Commo impairmets iclude: failure to fulfil major role obligatios e.g. costatly late to or abset from work; recurret use i dagerous situatios e.g. while drivig; frequet substace-related legal problems e.g. arrests for disorderly coduct; ad social ad iterpersoal problems e.g. coflict with parter or other family members. Substace depedece is idicated by physical or psychological depedece or addictio. Physical depedece icludes: tolerace the eed for icreased amouts of the substace or dimiished effect with same amout; ad withdrawal the experiece of physical symptoms whe the substace is stopped, or turig to aother substace to relieve or avoid those symptoms. Psychological depedece is idicated by: takig substaces i larger amouts or over loger periods of time tha iteded; a persistet desire to use or usuccessful efforts to cut dow or cotrol use; spedig a great deal of time tryig to obtai, use or recover from the substace; givig up importat activities; ad cotiued use, despite kowledge of a problem that is exacerbated by the substace. The course of substace use disorders Substace abuse ad depedece ca be chroic, progressive, degeerative problems with severe egative outcomes. But the course they take varies, depedig o the substace beig used. Alcoholism i particular ca have tragic outcomes, icludig health problems, iterpersoal problems ad early death. People who use substaces frequetly will ofte use more tha oe kid of substace. Substace disorders ca begi at ay age ad are becomig more prevalet, particularly amog adolescets. Although Figure Substace use disorders are becomig more prevalet, particularly amog adolescets. most adult substace abusers bega usig i adolescece, most adolescets who try drugs do t progress to severe abuse. So experimetatio does t ecessarily lead to lifelog addictio or adverse cosequeces. Some people with substace use disorders show remissio, especially late i life, but relapse is frequet, particularly i respose to high-risk situatios, such as egative emotioal states, social pressure ad iterpersoal coflict. Ufortuately, because of the high relapse rates, few people fully recover from substace disorders. Causes of substace use disorders ad factors affectig their course 1 Geetic ad biological factors Most research ito substace abuse ivolves alcohol, as alcohol is legal ad very widely available. So evidece of geetic trasmissio comes primarily from alcoholism research. This research supports the role of heredity, particularly amog me (e.g. Goodwi, 1979). Cosistet with a biological approach, substace use disorders are cosidered by some to be diseases (e.g. Jelliek, 1960). Some theorists have suggested that alcoholics may be biologically sesitive to alcohol, which may lead to progressive ad irreversible alcoholism (e.g. Pollock, 1992). The body s ability to metabolize alcohol is aother possible explaatio. The liver produces a ezyme called aldehyde dehydrogease, which breaks dow alcohol i the body. If alcohol is t broke dow, it ca build up ad lead to illess. I some groups of East Asias, this ezyme is abset or reduced a possible reaso for the relatively lower rates of alcoholism i these groups (e.g. Higuchi et al., 1992). We kow very little about other biological causes of substace abuse, but researchers cotiue to study the effects of eurotrasmitter fuctioig, brai-wave fuctioig ad biological sesitivities to substaces i order to elucidate relevat mechaisms ad relatioships.

19 332 Abormal Psychology 2 Psychosocial factors Numerous psychosocial factors have bee implicated i the oset ad course of substace problems. Reiforcemet certaily plays a importat role. Cosistet with the tesio-reductio hypothesis, cotiued substace use is tesio-reductio hypothesis the reiforced because substaces otio that people use substaces i ofte lead to positive feeligs order to reduce tesio ad egative ad help people escape egative feeligs through use of affect these substaces (Coger, 1956). Substace users are said to egage i self-medicatio, usig substaces to help relieve tesio or temporarily elimiate feeligs of axiety or depressio. People also lear to use substaces through observatio. Those whose families or peers use substaces are at high risk for substace use disorders (e.g. Jessor & Jessor, 1975). Leared associatios also affect the course of substace use. If someoe comes to associate particular people, places or circumstaces with substace use, they are more likely to use the substace i similar circumstaces (Collis & Marlatt, 1981). That is why people who get treatmet for substace problems ofte relapse whe they retur to their former eviromet ad social group. Cogitive factors also play a role i the developmet ad course of substace problems, at least i the case of alcoholism. People who expect positive results from usig alcohol (e.g. they thik it will make them feel good or improve their social stadig) are more likely to use it ad to develop alcohol problems (Marlatt, 1987; Smith, 1980). I additio, people who fall prey to the abstiece abstiece violatio effect a more violatio effect are more likely severe relapse resultig from a mior to relapse tha are others violatio of substace use abstiece (Marlatt, 1978). This effect (e.g. oe forbidde drik leadig to occurs whe a mior relapse more) (a violatio of abstiece) leads to guilt, which the leads to a more severe relapse. So if a abstiet alcoholic has oe drik, she may feel guilty ad decide that, havig already failed at abstiece, she may as well drik more. She eds up havig a fullblow relapse istead of a mometary oe. The otio of a addictive persoality has bee suggested. This is a cotroversial topic. So far, there is o evidece for its existece, but research does idicate that some aspects of persoality may cotribute to substace problems. A disihibited persoality style that icludes impulsivity ad atisocial traits may be the best persoality predictor of substace problems (e.g. Shedler & Block, 1990). Cosistet with the tesio-reductio hypothesis discussed earlier, it is also possible that substace problems are maskig some other form of psychopathology. But the research o this topic is mixed ad suggests that problems such as depressio are as likely to follow from substace problems as they are to precede them (e.g. Schuckit, 1994). There are also broader evirometal factors that may cotribute to substace abuse, such as the extet to which substace use is codoed by a particular culture (e.g. Westermeyer, 1999; Yeug & Greewald, 1992). For example, groups whose religious values prohibit or limit the use of alcohol (e.g. Muslims, Mormos, Orthodox Jews) show relatively low rates of alcoholism. Perhaps the best way to approach substace use disorders is from a multiple risk factor perspective, which suggests that the more risk factors someoe experieces, the more likely he is to develop a problem (e.g. Bry, McKeo & Padia, 1982). I additio to the risk factors already discussed, may others for substace abuse have bee idetified, icludig low socio-ecoomic status, family dysfuctio, peer rejectio, behaviour problems, academic failure ad availability of substaces. Of course, because of the ature of the research i this field, some of these factors may be cosequeces of substace abuse istead of (or as well as) beig risk factors. PERSONALITY DISORDERS A WAY OF BEING So far, the disorders we have described have traditioally bee cosidered sydromes, which like physical illesses are ot part of people s basic character structure. Whe treated appropriately, these sydromes usually remit ad people retur to ormal fuctioig, at least for a while. But persoality disorders are differet. They are disorders of people s basic character structure so there is o ormal fuctioig to retur to. The persoality disorders themselves are people s ormal way of fuctioig, ad appropriate treatmet meas learig etirely ew ways of beig. Symptoms All persoality disorders have a umber of thigs i commo. They are: logstadig i.e. begi at a relatively early age; chroic i.e. cotiue over time; ad pervasive i.e. occur across most cotexts. The thoughts, feeligs ad behaviours that characterize persoality disorders are: iflexible i.e. they are applied rigidly ad resistat to chage; ad maladaptive i.e. they do t result i what the perso hopes for. People with persoality disorders usually do t realize they have them. They experiece themselves as ormal ad ofte feel that the people they iteract with are the oes with the problems. The primary persoality disorders ad their key traits, as described i the DSM-IV (APA, 1994) are: Cluster A the odd ad eccetric cluster Paraoid suspicious, distrustful, makes hostile attributios Schizoid iterpersoally ad emotioally cut off, uresposive to others, a loer

20 Disorders Symptoms ad Causes 333 Schizotypal odd thoughts, behaviours, experieces; poor iterpersoal fuctioig Cluster B the dramatic ad erratic cluster Histrioic dramatic, wats attetio, emotioally shallow Narcissistic iflated sese of self-importace, etitled, low empathy, hidde vulerability Atisocial behaviours that disregard laws, orms, rights of others; lackig i empathy Borderlie istability i thoughts, feeligs, behaviour ad sese of self Cluster C the fearful ad avoidat cluster Obsessive-compulsive rigid, cotrolled, perfectioistic Avoidat fears egative evaluatio, rejectio ad abadomet Depedet submissive, depedet o others for self-esteem, fears abadomet As you ca see, this orgaizatio of the persoality disorders puts them ito clusters. These clusters are thought to reflect disorders with commo traits. Although the disorders withi each cluster do show commoalities, it is also the case the there are high levels of comorbidity amog disorders across clusters. Borderlie persoality disorder ad atisocial persoality disorder (similar to what is ofte called psychopathy) have received more attetio tha the others, as they ted to have some of the most egative cosequeces, icludig suicide ad violece. Causes of persoality disorders ad factors affectig their course 1 Geetic ad biological factors There is evidece of modest geetic trasmissio for some persoality disorders, especially atisocial persoality disorder, although evirometal factors also play a importat role (e.g. Cadoret et al., 1995). There is also evidece that childre are bor with differet temperamets, which may serve as vulerability factors. For example, ihibitio which predisposes childre towards shyess ad axiety may put them at risk for persoality disorders characterized by those traits. Disihibited childre are outgoig, talkative, impulsive ad have low levels of physiological arousal. These childre may be at risk for persoality disorders characterized by impulsivity, erratic or aggressive behaviour, or lack of empathy. Biological factors are also beig explored as causes of some persoality disorders, such as atisocial persoality disorder. For example, research suggests that people with atisocial persoality traits show low levels of physiological arousal, which may accout for their ability to egage i behaviours that ormally cause people to feel axious (e.g. Raie, Veables & Williams, 1990). 2 Psychosocial factors Cogitive, psychodyamic ad attachmet theorists all suggest that egative early experieces i the family put people at risk for developig persoality disorders. The assumptio is that this happes, at least i part, through the cogitios that people develop. Early experieces with people who fail to validate a child s self-worth may be iteralized ad result i a deep-seated set of severely rigid ad dysfuctioal thoughts about the self, others ad the world, which the traslate ito rigid behavioural patters. For example, if parets are ot available to help a child cope with stress but are critical or abusive istead, the child will lear that she ca t rely o her parets, eve though she may desperately wat to. She may lear to hide her feeligs, to expect that she will be criticized ad rejected by others, ad so to avoid close iterpersoal relatioships, eve if she secretly years for them. If this patter cotiues to develop ad becomes rigid as the child grow up, she may evetually develop a avoidat persoality disorder. Research is begiig to suggest that temperametal ad psychosocial factors iteract. Kochaska (1995) foud that childre of differet temperamets show more adaptive moral developmet i respose to differet qualities of the paret child relatioship. For example, fearful childre respod better to getle disciplie, whereas o-fearful childre respod better whe they are securely attached to a paret. This suggests that the closer the paretig style matches the eeds associated with that particular childre s temperamet, the more adaptive their childre will become. Whe a mismatch occurs, childre may develop compesatory copig strategies, possibly leadig to the rigid patters that are associated with persoality disorders. Pioeer Marsha Lieha (1943 ), Professor of Psychology ad Director of the Behavioral Research ad Therapy Cliics at the Uiversity of Washigto, is best kow for her cotributios to the uderstadig ad treatmet of suicidal behaviour ad borderlie persoality disorder. Lieha proposed that borderlie persoality disorder ca be best uderstood from a biopsychosocial approach, which bases the disorder i the iteractio of a uderlyig biological dysfuctio ad a ivalidatig, o-acceptig family eviromet. Lieha developed dialectical behaviour therapy (DBT) as a treatmet for borderlie persoality disorder ad suicidal behaviour. DBT is a empirically supported treatmet, which combies traditioal Wester approaches with Easter Ze approaches.

21 334 Abormal Psychology FINAL THOUGHTS I this chapter you read about some of the major psychological disorders schizophreia, mood disorders, axiety disorders, eatig disorders, substace use disorders ad persoality disorders. Although these disorders (ad their various subtypes) are amog the most prevalet ad impairig i the field of psychopathology, they by o meas exhaust the umber of psychological disorders that have bee documeted. Our goal has bee to help you uderstad what these disorders look like, how they progress, ad what causes them, highlightig potetial biological ad psychosocial causes. I additio to gettig a sese of what we kow about these disorders, it should be clear that there is still a lot that we do ot kow. That is part of what makes the study of abormal psychology so itriguig. There is so much left to lear, particularly with regard to how our biology ad our eviromets iteract to cause ad affect psychological problems. As research o abormal behaviour progresses, we ca expect ot oly to better uderstad curret disorders ad their causes, but also to discover ew oes. Summary The field of abormal psychology, or psychopathology, deals with sets of behaviours, or symptoms, that result i impairmet i people s lives. These sets of symptoms costitute psychological disorders or metal illess. Although the defiitio of abormal behaviour is sesitive to a umber of cotextual factors, psychological disorders (e.g. schizophreia) have bee documeted across time ad culture. Throughout history, the causes of abormal behaviour have bee costrued from a umber of differet perspectives, each of which tells us somethig uique about differet aspects of psychological disorders. Biological/geetic models focus o brai defects, biochemical imbalaces ad geetic predispositios as causes of psychopathology. I cotrast, Freudia, cotemporary psychodyamic ad attachmet models focus o the effects of early paret child experieces. Behavioural models focus o the learig experieces that result i psychopathology, whereas cogitive models focus o the effect of distorted thought processes. Other perspectives itegrate various models. The diathesis stress perspective suggests that the factors idetified by each of the other models may work i accordace with oe aother, so that psychopathology oly results whe certai combiatios of factors (e.g. geetic, evirometal) are preset. Similarly, the developmetal psychopathology perspective provides a framework for uderstadig how psychopathology develops from childhood to adulthood. These perspectives ca help us uderstad the umerous disorders documeted i osologies such as the DSM-IV ad the ICD-10.

22 Revisio Questios 335 REVISION QUESTIONS 1. Do metal disorders reflect brai dysfuctio ad geetic abormalities? If so, does this mea that biological itervetios (e.g. drugs) would ecessarily be the treatmet of choice? 2. There are several models of abormal behaviour. Discuss the extet to which they ca be itegrated. I particular, do psychodyamic models share ay commo groud with behavioural ad cogitive models? 3. Do you thik that the origis of metal disorders i adulthood ca be foud i childhood? What should we look for i childhood as precursors of adult abormal behaviour? 4. Imagie you had the power to create a huma beig with a metal disorder. What disorder would you give them so that they were: (a) maximally dysfuctioal; (b) miimally dysfuctioal; (c) had the best chace of recoverig from the disorder? Discuss why you made the choices that you did. 5. A fried hears that you are studyig abormal psychology ad comes to ask you about some experieces she or he has had, watig to kow if they are sigs of metal disorder. What would you do? What would you tell him or her? 6. Why are some disorders more commo tha others? What might be some of the cultural, societal, ad biological reasos ivolved? 7. What kids of thigs do the differet disorders discussed i this chapter have i commo? 8. Does it make sese to thik about these disorders as exemplifyig differet categories of disorder? Or are there uderlyig problems that characterize all of these disorders? FURTHER READING Clarki, J.F., & Lezeweger, M.F. (1996). Major Theories of Persoality Disorder. New York: Guilford Press. A historical overview of may of the most promiet theories of persoality disorders. Hamme, C. (1997). Depressio. Hove: Psychology Press/Lawrece Erlbaum ad Associates. Research-based iformatio o causes ad treatmets of depressio from various theoretical viewpoits. Jamiso, K.R. (1996). A Uquiet Mid. New York: Radom House. The author s persoal accout of her battle with bipolar disorder. Leoard, K.E., & Blae, H. (1999). Psychological Theories of Drikig ad Alcoholism. 2d ed. New York: Guilford Press. Recet reviews of all of the major psychological ad geetic/biological theories of alcoholism. Nasar, S. (1988). A Beautiful Mid. New York: Simo & Schuster. Biography of Joh Forbes Nash, Jr, a mathematical geius whose career was cut short by schizophreia ad who miraculously recovered ad was hooured with a Nobel Prize. Rachma, S. (1998). Axiety. Hove: Psychology Press/Lawrece Erlbaum ad Associates. Psychological approaches to the coceptualizatio ad treatmet of axiety disorders, drawig o recet empirical work. Zuckerma, M. (1999). Vulerability to Psychopathology: A Biosocial Model. Washigto, DC: America Psychological Associatio. Describes how psychopathology ca be uderstood from a diathesis stress perspective, emphasizig iteractios betwee biology/geetics, persoality ad stressful life evets. Cotributig authors: Joae Davila & Frak D. Ficham