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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 associated 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.
A psychological disorder, or problematic abnormal behavior, is a psychological dysfunction that is associated with distress or impairment in functioning and a response that is not typical or culturally expected (see Figure 1.1). These three criteria may seem obvious, but they were not easily arrived at and it is worth a moment to explore what they mean.
The criteria defining a psychological disorder.
Psychological dysfunction refers to a breakdown in cognitive, emotional, or behavioral functioning. For example, if you are out on a date, it should be fun. But if you experience severe fear all evening, even though there is nothing to be afraid of, and the fear happens on every date, your emotions are not functioning properly. However, if your friends agree that the person who asked you out is unpredictable and dangerous in some way, it would not be dysfunctional to be fearful.
A dysfunction was clearly present for Judy. But many people experience a mild version of this reaction (feeling queasy at the sight of blood) without meeting the criteria for the disorder. Drawing the line between normal and abnormal dysfunction is often difficult. For this reason, these problems are often considered to be on a continuum rather than either present or absent (McNally, 2011; Widiger & Crego, 2013). This, too, is a reason why just having a dysfunction is not enough to meet the criteria for a psychological disorder.
That the behavior must be associated with distress to be classified as a disorder seems clear: The criterion is satisfied if the individual is extremely upset. We can certainly say that Judy was distressed. But remember, by itself this criterion does not define problematic abnormal behavior. It is often normal to be distressed—for example, if someone close to you dies. Suffering and distress are part of life. Furthermore, for some disorders, by definition, suffering and distress are absent. Consider the person who feels elated and acts impulsively as part of a manic episode. As you will see in Chapter 6, one of the major difficulties with this problem is that some people enjoy the manic state so much they are reluctant to receive treatment for it. Thus, defining psychological disorder by distress alone doesn’t work.
The concept of impairment is useful, although not entirely satisfactory. For example, many people consider themselves shy or lazy. This doesn’t mean they’re abnormal. But if you are so shy that you find it impossible to interact with people even though you would like to have friends, your social functioning is impaired.
Judy was clearly impaired by her phobia, but many people with less severe reactions are not impaired. This difference again illustrates the important point that most psychological disorders are extreme expressions of otherwise normal emotions, behaviors, and cognitive processes.
The criterion that the response be atypical or not culturally expected is also insufficient to determine if a disorder is present by itself. At times, something is considered abnormal because 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, but this obviously isn’t a definition of disorder. Many people’s behavior is far from average, but we call them talented or eccentric, not disordered. For example, it’s not normal to wear a dress made out of meat, but when Lady Gaga wore this to an awards show, it only enhanced her celebrity. 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 violating social norms. This definition is useful in considering 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 5). An example is provided by Robert Sapolsky (2002), a neuroscientist who worked closely with the Masai tribe in East Africa. One day, Sapolsky’s Masai friend Rhoda asked him to bring his jeep to the village where a woman had been acting aggressively and hearing voices. The woman had killed a goat with her own hands. Sapolsky and several Masai were able to subdue her and transport her to a health center. Realizing 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 didshe 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 anyone needs to know about cross-cultural psychiatry.“But she hears voices at the wrong time.” (p. 138)
A social standard of normal can be misused, however. Consider 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. Although such behavior clearly violates social norms, it should not alone be cause for commitment.
Jerome Wakefield (1999, 2009) uses the shorthand definition of harmful dysfunction. A related concept 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 Diagnostic and Statistical Manual (American Psychiatric Association, 2013), which contains the current listing of criteria for psychological disorders (Stein et al., 2010).
Psychopathology is the scientific study of psychological disorders. Within this field are clinical 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. Counseling psychologists tend to study and treat adjustment and vocational issues encountered by relatively healthy individuals, and clinical psychologists usually concentrate on more severe psychological disorders. Psychologists with other specialty training, such as experimental and social psychologists, investigate the basic determinants of behavior but do not assess or treat psychological disorders.
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, 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. Psychiatric nurses have advanced degrees and specialize in the care and treatment of patients with psychological disorders, usually in hospitals as part of a 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 clinics.
The most important recent development in psychopathology is the adoption of scientific methods to learn more about psychological disorders, their causes, and 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 practitioners function as scientist-practitioners in three ways (see Figure 1.2). First, they keep up with the latest developments in their field and use the most current diagnostic and treatment procedures. In this sense, they are consumers of the science of psychopathology. Second, they evaluate their own assessments or treatment procedures to see whether they work. They are accountable not only to their patients but also to government agencies and insurance companies that pay for the treatments, so they must demonstrate whether their treatments are effective. Third, scientist-practitioners conduct research that produces new information about disorders or their treatment. Such research attempts three basic things: to describe psychological disorders, to determine their causes, and to treat them (see Figure 1.3). These three categories compose an organizational structure that recurs throughout this book. A general overview of them will give you a clearer perspective on our efforts to understand abnormality.
Functioning as a scientist-practitioner.
Kevin Peterson/Photodisc/Getty ImagesFigure 1.3
Three major categories make up the study and discussion of psychological disorders.
In hospitals and clinics, we often say that a patient “presents” with a specific problem or we discuss the presenting problem. Describing Judy’s presenting problem is the first step in determining her clinical description, the unique combination of behaviors, thoughts, and feelings that make up a specific disorder. The word clinical refers both to the types of disorders you would find in a clinic or hospital and to the activities connected with assessment and treatment.
An important function of the clinical description is to specify what makes the disorder different from normal behavior 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 disorder. 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—what percentage of males and females has the disorder—and the typical age of onset.
In addition, most disorders follow a particular pattern, or course. For example, some disorders, such as schizophrenia (see Chapter 12), follow a chronic course, meaning they tend to last a long time. Other disorders, like mood disorders (see Chapter 6), follow an episodic course, in that the individual is likely to recover within a few months only to suffer a recurrence of the disorder. Still other disorders may have a time-limited course, meaning they 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 differences in onset. Some disorders have an acute onset, meaning 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 we can know what to expect and how best to deal with the problem. 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. If the disorder is likely to last a long time (become chronic) however, the individual might want to seek treatment. The anticipated course of a disorder is called the prognosis.
The patient’s age may be an important part of the clinical description. A psychological disorder occurring in childhood may present differently from the same disorder in adulthood or old age. For example, children experiencing severe anxiety often assume they are physically ill. Because their thoughts and feelings are different from those experienced by adults with anxiety, children are often misdiagnosed and treated for a medical disorder.
We call the study of changes in behavior over time developmental psychology and we refer to the study of changes in abnormal behavior as developmental psychopathology. Because we change throughout our lives, researchers study development in children, adolescents, and adults. Study of abnormal behavior across the entire age span is referred to as life-span developmental psychopathology.
Etiology, or the study of origins, has to do with why a disorder begins and includes biological, psychological, and social dimensions. Chapter 2 is devoted to this key aspect of abnormal psychology.
Children experience anxiety differently from adults, so their reactions may be mistaken for symptoms of physical illness.
Hung Chung Chih/ Shutterstock.com
Treatment is also important to the study of psychological 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 specific disorder, we know that something in that part of the nervous system might either be causing the disorder or helping maintain it. As you will see in the next chapter, psychopathology is rarely simple because the effect does not necessarily imply the cause. For example, you might take an aspirin to relieve a headache. If you then feel better, that does not mean the headache was caused by a lack of aspirin. Nevertheless, many people seek treatment for psychological disorders, and treatment can provide hints about the nature of the disorder.
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 trained in a single theoretical approach, such as psychoanalysis or behavior therapy, and then use that approach on every disorder. More recently, we have developed specific 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 effective treatments 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. In Chapter 2, we examine 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 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13, we examine specific disorders. Finally, in Chapter 14 we examine legal, professional, and ethical issues relevant to psychological disorders and their treatment. With that overview in mind, let us turn to the past.
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