ABNORMAL PSYCHOLOGY

experts would agree are part of the disorder are

CHAPTER 1: Abnormal Behavior in Historical present (called a prototype).
Context

Understanding Psychopathology
The Science of Psychopathology
Psychological disorder- a psychological
dysfunction within an individual associated with Psychopathology is the scientific study of
distress or impairment in functioning and a psychological disorders.
response that is not typical or culturally
expected. ●​ Clinical psychologists and counseling
psychologists receive the Ph.D., doctor of
Phobia- a psychological disorder characterized philosophy, degree (or sometimes an Ed.D.,
by marked and persistent fear of an object or doctor of education, or Psy.D., doctor of
situation. psychology) and follow a course of
graduate-level study lasting approximately 5
Three Criteria of Psychological Disorder: years, which prepares them to conduct
research into the causes and treatment of
➔​ Psychological Dysfunction: refers to a psychological disorders and to diagnose,
breakdown in cognitive, emotional, or assess, and treat these disorders.
behavioral functioning. ●​ Psychiatrists first earn an M.D. degree in
➔​ Distress or Impairment: The criterion is medical school and then specialize in
satisfied if the individual is extremely upset. psychiatry during residency training that
By itself, this criterion does not define lasts 3 to 4 years. Psychiatrists also
problematic abnormal behavior. investigate the nature and causes of
➔​ Atypical or Not Culturally Expected: psychological disorders, often from a
Important but also insufficient to determine biological point of view; make diagnoses;
if a disorder is present by itself. At times, and offer treatments.
something is considered abnormal because it ●​ Psychiatric social workers typically earn a
occurs infrequently; it deviates from the master’s degree in social work as they
average. The greater the deviation, the more develop expertise in collecting information
abnormal it is. Another view is that your relevant to the social and family situation of
behavior is disordered if you are violating ●​ Psychiatric nurses have advanced degrees,
social norms, even if a number of people are such as a master’s or even a Ph.D., and
sympathetic to your point of view. specialize in the care and treatment of
patients with psychological disorders,
An Accepted Definition
usually in hospitals as part of a treatment
The most widely accepted definition used in DSM-5 team.
describes behavioral, psychological, or biological ●​ Marriage and family therapists and
dysfunctions that are unexpected in their cultural mental health counselors typically spend 1
context and associated with present distress and to 2 years earning a master’s degree and are
impairment in functioning, or increased risk of employed to provide clinical services by
suffering, death, pain, or impairment. hospitals or clinics, usually under the
supervision of a doctoral-level clinician.
The best we may be able to do is to consider how the
apparent disease or disorder matches a “typical”
profile of a disorder when most or all symptoms that
ABNORMAL PSYCHOLOGY
The Scientist- Practitioner ○​ Episodic course: the individual is
likely to recover within a few
●​ Many mental health professionals take a months only to suffer a recur rence
scientific approach to their clinical work. of the disorder at a later time.
●​ Mental health practitio ners may function as ○​ Time-limited course: the disorder
scientist-practitioners in one or more of will improve without treatment in a
three ways: relatively short period with little or
1.​ They may keep up with the latest no risk of recurrence.
scientific developments in their field ●​ Closely related to differences in course of
and therefore use the most current disorders are differences in onset:
diagnostic and treatment procedures. ○​ Acute onset, meaning that they
2.​ Scientist-practitioners evaluate their begin suddenly
own assessments or treatment ○​ Insidious onset: others develop
procedures to see whether they gradually over an extended period.
work. ●​ Prognosis: The anticipated course of a
3.​ Scientist-practitioners might disorder. “The prognosis is good” means
conduct research, often in clinics or recovery; “ The prognosis is guarded”
hospitals, that produces new means the outcome is not good.
information about disorders or their
treatment, thus becoming immune to Developmental Psychology- the study of changes
the fads that plague our field, often in behavior over time.
at the expense of patients and their
families. Development Psychopathology- the study of
changes in abnormal behavior.
Clinical Description
Life-span developmental psychopathology- Study
●​ In hospitals and clinics, we often say that a of abnormal behavior across the entire age span.
patient “presents” with a specific problem or
set of problems or we discuss the presenting
problem.
●​ Clinical description represents the unique Causation, Treatment, and Etiology Outcomes
combination of behav iors, thoughts, and
Etiology: the study of origins, has to do with why a
feelings that make up a specific disorder.
disorder begins (what causes it) and includes
●​ Prevalence: How many people in the
biological, psychological, and social dimensions.
population as a whole have the disorder?
●​ Incidence: Statistics on how many new Treatment: is often important to the study of
cases occur during a given period, such as a psychological disorders. If a new drug or
year psychosocial treatment is successful in treating a
●​ Sex ratio is the percentage of males and disorder, it may give us some hints about the nature
females have the disorder—and the typical of the disorder and its causes.
age of onset, which often differs from one
disorder to another.
●​ Most disorders follow a somewhat
individual pattern, or course.
○​ Chronic course: they tend to last a
long time, sometimes a lifetime.
ABNORMAL PSYCHOLOGY
Historical Conceptions of Abnormal Behavior fluids might be a possible cause of mental disorders.
This influential theory inspired the word lunatic,
The Supernatural Tradition which is derived from the Latin word luna, mean ing
“moon.”
●​ Deviant behavior has been considered a
reflection of the battle between good and The Biological Tradition
evil.
●​ Important to the biological tradition are a
Demons and Witches: During the last quarter of man, Hippocrates; a disease, syphilis; and
the 14th century, religious and lay authorities the early consequences of believing that
supported these popular superstitions, and society as psychological disorders are biologically
a whole began to believe more strongly in the caused.
existence and power of demons and witches.
Treatments included exorcism, in which various Hippocrates and Galen: Hippocrates and his
religious rituals were performed in an effort to rid associates left a body of work called the Hippocratic
the victim of evil spirits. Corpus, written between 450 and 350 b.c., in which
they suggested that psychological disorders could be
Stress and Melancholy: This period reflected the treated like any other disease. They did not limit
enlightened view that insanity was a natural their search for the causes of psychopathology to the
phenomenon, caused by mental or emotional stress, general area of “disease,” because they believed that
and that it was curable. Mental depression and psychological disorders might also be caused by
anxiety were recognized as illnesses, although brain pathology or head trauma and could be
symptoms such as despair and lethargy were often influenced by heredity (genetics). One of the more
identified by the church with the sin of acedia, or interesting and influential legacies of the
sloth. Common treatments were rest, sleep, and a Hippocratic-Galenic approach is the humoral theory
healthy and happy environment. Other treatments of disorders. Hippocrates assumed that normal brain
included baths, ointments, and various potions. functioning was related to four bodily fluids or
humors: blood(heart), black bile(spleen), yellow
Treatments for Possession: Possession is not bile(liver), and phlegm(brain). The humoral theory
always connected with sin but may be seen as was, perhaps, the first example of associating
involuntary and the possessed individual as psychological disorders with a “chemical
blameless. Furthermore, exorcisms at least have the imbalance.”
virtue of being relatively painless.
The 19th Century: Advanced syphilis, caused by
Mass Hysteria: Another fascinating phenomenon is bacteria infecting the brain, produces severe
characterized by large-scale outbreaks of bizarre behavioral and cognitive symptoms such as
behavior. delusions and bizarre behaviors, resembling
psychosis but with a rapidly fatal course called
Modern Mass Hysteria: Mass hysteria may simply
general paresis. This condition was identified in
demonstrate the phenomenon of emotion contagion,
1825 and later linked to syphilis through advances
in which the experience of an emotion seems to
like Pasteur’s germ theory in the 1870s. Physicians
spread to those around us. If one person identifies a
discovered that inducing malaria, which caused high
“cause” of the problem, others will probably assume
fevers, sometimes cured general paresis by killing
that their own reactions have the same source (this
the syphilis bacteria, a practice later replaced by the
shared response is mob psychology).
discovery of penicillin as an effective cure. This
The Moon and the Stars: Paracelsus speculated breakthrough showed that some mental illnesses
that the gravitational effects of the moon on bodily could have biological causes and be curable,
ABNORMAL PSYCHOLOGY
inspiring hope for similar findings in other believed mental disorders were caused by unknown
psychological disorders. John P. Grey, a prominent brain pathologies and thus considered incurable,
19th-century American psychiatrist, argued that leading to a focus on hospitalization rather than
insanity always had physical causes and promoted treatment. Around the turn of the century, some
treating patients as physically ill, improving hospital nurses reported clinical success in treating mental
conditions but also leading to large, impersonal patients but were discouraged from pursuing cures to
institutions. By the late 19th century, concerns about avoid raising false hopes. During this time, attention
the size and impersonality of mental hospitals led to shifted to diagnosis, legal issues regarding patient
calls for downsizing. Nearly a century later, responsibility, and studying brain pathology. Emil
deinstitutionalization released many patients into Kraepelin, a key figure in modern psychiatry, made
communities, but also contributed to increased lasting contributions by classifying psychological
homelessness among the chronically mentally ill. disorders based on symptoms, age of onset, and
course, laying the groundwork for modern diagnosis.
The Development of Biological Treatments: By the end of the 1800s, a scientific and humane
Renewed interest in the biological origins of approach to mental illness was emerging, but active
psychological disorders led to major advances in treatment was often neglected despite some effective
understanding and treating mental illness, including methods being available.
the development of physical interventions like
electric shock and brain surgery in the 1930s. Some The Psychological Tradition
treatments, such as insulin shock therapy, were
discovered accidentally when insulin-induced Moral Therapy: Its basic tenets included treating
convulsions occasionally led to mental health institutionalized patients as normally as possible in a
recovery, though this method was abandoned due to setting that encouraged and reinforced normal social
its dangers. The accidental discovery by Benjamin interaction, thus providing them with many
Franklin that mild electric shocks could induce opportuni ties for appropriate social and
convulsions and temporary amnesia inspired further interpersonal contact.
exploration, eventually leading to electroconvulsive
therapy, which is still used in a modified form today. Asylum Reform and the Decline of Moral
In the 1950s, the first effective drugs for severe Therapy: After the mid-19th century, humane
psychotic disorders, such as neuroleptics and treatment declined because of a convergence of
benzodiazepines, were systematically developed, factors. (1) it was widely recognized that moral
providing relief from symptoms like hallucinations, therapy worked best when the number of patients in
delusions, and agitation for some patients. However, an institution was 200 or fewer, allowing for a great
enthusiasm for new drug therapies has often been deal of individual attention; (2) the mental hygiene
followed by disappointment as side effects and movement being crusaded by Dorothea Dix
limited effectiveness became apparent, as seen with campaigned endlessly for reform in the treatment of
bromides and later neuroleptics. Despite drawbacks, insanity. Her efforts led to a substantial increase in
the success of these biological treatments revitalized the number of mental patients.
research into the biological causes of psychological
The psychological tradition lay dormant for a time,
disorders and spurred the search for new
only to reemerge in several different schools of
medications. This ongoing search has significantly
thought in the 20th century:
advanced the field, although the precise mechanisms
of some treatments, like electroconvulsive therapy, Psychoanalysis: based on Sigmund Freud’s
remain poorly understood. elaborate theory of the structure of the mind
and the role of unconscious processes in
Consequences of the Biological Tradition: In the
determining behavior.
late 19th century, John P. Grey and his colleagues
ABNORMAL PSYCHOLOGY
Behaviorism: associated with John B. Ego develops early in life to help us act realistically,
Watson, Ivan Pavlov, and B. F. Skinner, balancing the id’s demands with the constraints of
which focuses on how learning and adap the real world by using logical and rational thinking
tation affect the development of known as the secondary process.
psychopathology.
Superego represents our internalized moral
Psychoanalytic Theory standards and conscience, aiming to suppress the id’s
dangerous impulses and enforce ethical behavior.
After returning from France, Freud collaborated with The ego mediates conflicts between the id and
Josef Breuer, who used hypnosis to help patients superego, managing their opposing demands while
describe their problems in detail, leading to considering reality; successful mediation allows
emotional relief but little conscious understanding of healthy functioning, while failure can lead to
the root causes. Breuer and Freud observed that psychological disorders. These internal struggles,
much of the material discussed under hypnosis was called intrapsychic conflicts, often involve
inaccessible to the patient’s conscious mind, leading unconscious processes, as Freud believed the id and
them to identify the existence and influence of the superego operate largely outside of conscious
unconscious mind on psychological disorders. They awareness. The ego, which is the conscious part of
also discovered that recalling and reliving the mind, is relatively small compared to the vast
unconscious emotional trauma could be therapeutic, unconscious forces driving much of our behavior.
a process called catharsis, and that deeper insight
into these emotions was beneficial for recovery. The
famous case of Anna O. demonstrated that
discussing and tracing symptoms under hypnosis
could eliminate them one by one, supporting the idea
that unconscious memories drive psychological
symptoms. Freud expanded these clinical
observations into the psychoanalytic model,
proposing a comprehensive theory of personality
development, psychological conflict, and mental
illness. Although Freud’s psychoanalytic theory has
evolved and much remains unproven, its core
ideas—such as the structure of the mind, defense
mechanisms, and stages of psychosexual Defense Mechanisms
development—have had a lasting impact on
●​ Denial: Refuses to acknowledge some
psychology. The collaboration between Freud and
aspect of objective reality or subjective
Breuer thus marked a turning point in understanding
experience that is apparent to others
and treating psychological disorders, emphasizing
●​ Displacement: Transfers a feeling about, or
the importance of unconscious processes and
a response to, an object that causes
emotional insight.
discomfort onto another, usually
The Structure of the Mind: Freud proposed that less-threatening, object or person
the mind consists of three major parts: ●​ Projection: Falsely attributes own
unacceptable feelings, impulses, or thoughts
Id is the source of our primal sexual and aggressive to another individual or object
drives, operating on the pleasure principle to seek ●​ Rationalization: Conceals the true
immediate gratification through irrational and motivations for actions, thoughts, or feelings
emotional thinking called the primary process.
ABNORMAL PSYCHOLOGY
through elaborate reassuring or self serving from unconscious conflicts, resulting
but incorrect explanations anxiety, and ego defense mechanisms.
●​ Reaction formation: Substitutes behavior,
thoughts, or feelings that are the direct Later Developments in Psychoanalytic Thought:
opposite of unacceptable ones Freud’s original psychoanalytic theories have been
●​ Repression: Blocks disturbing wishes, significantly modified and expanded by his students
thoughts, or experiences from conscious and followers, who either focused on specific
awareness components or took the ideas in new directions5.
●​ Sublimation: Directs potentially Anna Freud advanced ego psychology by
maladaptive feelings or impulses into emphasizing how the ego’s defensive reactions
socially acceptable behavior shape behavior and how deficiencies in ego function
can lead to abnormal behavior. Heinz Kohut
Psychosexual Stages of Development developed self-psychology, centering on the
formation of self-concept and the attributes
●​ Freud proposed that infancy and early necessary for psychological health or vulnerability to
childhood involve psychosexual neurosis. Object relations theory, another influential
stages—oral, anal, phallic, latency, and branch, examines how children internalize images
genital—that shape personality and and values of important people (objects), and how
behavior. these introjected relationships shape identity and
●​ Each stage focuses on gratifying basic needs internal conflict. Carl Jung and Alfred Adler, both
and physical pleasure, such as the oral originally close to Freud, broke away to form their
stage's emphasis on feeding and oral own schools: Jung highlighted the collective
stimulation. unconscious and enduring personality traits, while
●​ Fixation at any stage, due to inadequate Adler focused on the inferiority complex and the
gratification or strong impressions, can drive toward self-actualization, both viewing human
influence adult personality traits (e.g., oral nature more positively than Freud. Other theorists,
fixation linked to dependency or such as Erik Erikson, emphasized psychosocial
rebelliousness). development across the lifespan, detailing the crises
●​ The phallic stage (ages 3–6) involves early and conflicts at each stage of life. Collectively, these
genital self-stimulation and the Oedipus developments have broadened psychoanalytic theory
complex, where boys experience to include relational, developmental, and cultural
unconscious sexual desires for their mothers perspectives, moving beyond Freud’s original focus
and rivalry with their fathers, accompanied on internal drives.
by castration anxiety.
●​ Successful resolution of the Oedipus Psychoanalytic Psychotherapy: Psychoanalytic
complex leads to healthy heterosexual psychotherapy employs techniques such as free
relationships and balanced feelings toward association and dream analysis to uncover
parents. unconscious mental processes and conflicts by
●​ The Electra complex, the female helping patients access repressed emotions and gain
counterpart, involves penis envy and desire insight. Free association encourages patients to
to possess the father, resolving through speak freely without censorship, revealing
developing heterosexual relationships and emotionally charged material, while dream analysis
maternal desires; this theory is controversial interprets dreams as symbolic expressions of
and lacks empirical support. unconscious conflicts. The therapeutic relationship
●​ Freud believed that all nonpsychotic plays a crucial role, with phenomena like
psychological disorders (neuroses) stem transference—where patients project childhood
feelings onto the therapist—and
ABNORMAL PSYCHOLOGY
countertransference—where therapists project their areas of functioning, if only we had the freedom to
own feelings onto patients—being central to the grow.
process. Classical psychoanalysis typically involves
frequent sessions over several years, focusing on Abraham Maslow postulated a hierarchy of needs,
analyzing and resolving unconscious conflicts to beginning with our most basic physical needs for
restructure the personality rather than merely food and sex and ranging upward to our needs for
alleviating symptoms. However, due to its high cost self actualization, love, and self-esteem. Social
and limited evidence of effectiveness, classical needs such as friendship fall somewhere between.
psychoanalysis is rarely practiced today. Instead, Maslow hypothesized that we cannot progress up the
modern psychodynamic psychotherapy retains the hierarchy until we have satisfied the needs at lower
emphasis on unconscious conflicts but adopts a more levels.
flexible, interpersonal approach that is shorter in
duration and highlights emotional expression, Carl Rogers originated client centered therapy, later
behavioral patterns, and the therapeutic relationship. known as person-centered therapy. In this approach,
Unlike classical analysis, psychodynamic the therapist takes a passive role, making as few
psychotherapy primarily aims to relieve interpretations as possible. The point is to give the
psychological suffering rather than completely individual a chance to develop during the course of
reconstruct personality, making it more practical and therapy, unfettered by threats to the self.
accessible for contemporary patients. Characteristics
Unconditional positive regard, the complete
of psychodynamic psychotherapy include:
and almost unqualified acceptance of most
1.​ a focus on affect and the expression of of the client’s feelings and actions, is critical
patients’ emotions; to the human istic approach.
2.​ an exploration of patients’ attempts to avoid
Empathy is the sympathetic understanding
topics or engage in activities that hinder the
of the individual’s particular view of the
progress of therapy;
world.
3.​ the identification of patterns in patients’
actions, thoughts, feelings, experiences, and
rela tionships;
4.​ an emphasis on past experiences; The Behavioral Model
5.​ a focus on patients’ interpersonal
experiences; -​ also known as the cognitive-behavioral
6.​ an emphasis on the ther apeutic relationship; model or social learning model, brought the
7.​ an exploration of patients’ wishes, dreams, systematic development of a more scientific
or fantasies. approach to psychological aspects of
8.​ it is significantly briefer than classical psychopathology.
psychoanalysis.
9.​ psychodynamic therapists deemphasize the Pavlov and Classical Conditioning: Ivan Pavlov, a
goal of personality reconstruction, focusing Russian physiologist, discovered classical
instead on relieving the suffering associated conditioning by observing that dogs could learn to
with psychological disorders. associate a neutral stimulus, like the sound of a bell
or footsteps, with food, eventually salivating in
Humanistic Theory response to the neutral stimulus alone. This process
involves pairing a neutral stimulus with an
Self-actualizing- The underlying assumption is that unconditioned stimulus (UCS) that naturally elicits
all of us could reach our highest potential, in all an unconditioned response (UCR), so that the neutral
stimulus becomes a conditioned stimulus (CS)
ABNORMAL PSYCHOLOGY
producing a conditioned response (CR). Classical responses. Wolpe’s method involved creating a
conditioning explains how associations are formed hierarchy of fears, teaching relaxation, and then
not only in animals but also in humans, as seen in pairing relaxation with incremental exposure, even
cancer patients who may feel nauseous at the sight using imagination when real-life exposure wasn’t
of hospital staff or equipment due to previous possible. This approach, which he called behavior
associations with chemotherapy. This learned therapy, proved highly effective for phobias and
response can generalize to similar stimuli, a anxiety, and was one of the first systematic
phenomenon called stimulus generalization, and can applications of behavioral science to
be eliminated through extinction if the conditioned psychopathology. Although Wolpe’s exact
stimulus is repeatedly presented without the procedures are less common today, systematic
unconditioned stimulus. desensitization paved the way for modern
exposure-based therapies that can eliminate severe
Watson and the rise of Behaviorism: John B. phobias, sometimes in a single day.
Watson is recognized as the founder of behaviorism,
a school of psychology that emphasized the study of
observable behavior and rejected introspection or the
analysis of internal mental states. Influenced by B. F. Skinner and Operant Conditioning: B.F.
Pavlov, Watson argued that psychology should be as Skinner was a pioneering behavioral scientist who
scientific as physiology, focusing on the prediction developed the theory of operant conditioning,
and control of behavior through objective which explains how behavior is shaped by its
experimentation. His most famous experiment, the consequences—reinforcement increases the
"Little Albert" study, demonstrated that emotional likelihood of a behavior, while punishment decreases
responses like fear could be conditioned in children it. Unlike Pavlov’s classical conditioning, Skinner’s
by associating a neutral object with a frightening operant conditioning focuses on voluntary behaviors
stimulus, and that these fears could generalize to that operate on the environment, and he
similar objects. Mary Cover Jones, a student of demonstrated these principles through experiments
Watson’s, later showed that conditioned fears could with animals in the “Skinner Box,” where behaviors
also be unlearned through gradual exposure, laying could be systematically reinforced or punished.
the groundwork for behavioral therapies. Although Skinner introduced the concept of reinforcement
some of Watson’s methods would be considered schedules and emphasized that positive
unethical today, his work revolutionized psychology reinforcement is more effective for developing new
by establishing behaviorism as a dominant behaviors than punishment, which he considered
perspective and influencing both research and relatively ineffective in the long run. He also applied
practical applications in fields such as education and his ideas broadly, discussing their implications for
advertising. society in works like Walden Two and Beyond
Freedom and Dignity, and argued that psychology
The Beginnings of Behavior Therapy: The should focus on observable, measurable behavior
significance of Mary Cover Jones’s early work on rather than introspection or unobservable mental
unlearning fear was largely overlooked until the late states. Skinner’s work laid the foundation for
1940s and 1950s, when Joseph Wolpe, dissatisfied modern behavior therapy and continues to influence
with psychoanalytic approaches, turned to fields such as education, clinical psychology, and
behavioral psychology for better treatments. organizational management.
Drawing on Pavlov’s principles, Wolpe developed
systematic desensitization, a behavioral therapy
where individuals are gradually exposed to feared
objects or situations while practicing relaxation
techniques, helping them extinguish their fear
ABNORMAL PSYCHOLOGY
CHAPTER 2: An Integrative Approach to
Psychopathology The Nature of Genes: The first 22 pairs of
chromosomes provide programs or directions for the
Multidimensional Integrative Approach to development of the body and brain, and the last pair,
Psychopathology: called the sex chromosomes, determines an
●​ Biological dimensions include causal factors individual’s sex. A dominant gene strongly
from the fields of genetics and neuroscience. influences a particular trait. A recessive gene, by
●​ Psychological dimensions include causal contrast, must be paired with another (recessive)
factors from behavioral and cognitive gene to determine a trait. Quantitative genetics
processes, including learned helplessness, basically sums up all the tiny effects across many
social learning, prepared learning, and even genes without necessarily telling us which genes are
unconscious processes. responsible for which effects.
●​ Emotional influences contribute in a variety
of ways to psychopathology, as do social New Developments in the Study of Genes and
and interpersonal influences. Behavior: Genetic research indicates that
●​ Developmental influences figure in any approximately half of enduring personality traits and
discussion of the causes of psychological cognitive abilities are influenced by genetics, with
disorders. heritability estimates ranging from 30% to 62% for
traits like memory or shyness. Long-term studies
One-Dimensional versus Multidimensional show genetic factors stabilize adult cognitive
Models abilities, while environmental factors drive changes,
To say that psychopathology is caused by a physical and adverse events like childhood chaos can
abnormality or by conditioning is to accept a linear override genetic influences. Psychological disorders
or one-dimensional model, which attempts to trace involve genetic contributions, but these account for
the origins of behavior to a single cause. less than half the risk, as seen in identical twins,
where schizophrenia concordance is under 50%.
Multiple genes with small effects likely contribute to
these disorders, aided by advances in gene mapping
and molecular genetics to identify genetic clusters.
Ultimately, genetic vulnerabilities interact with
environmental triggers, which can activate or
amplify specific genes tied to psychological
outcomes.

The Interaction of Genes and the Environment

Genetic Contributions to Psychopathology

Genes are long molecules of deoxyribonucleic acid

(DNA) located within the cell nucleus at various
locations on chromosomes.
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The Diathesis-Stress Model: posits that genetic or difficulty managing conflict. These inherited traits
vulnerabilities (diatheses) interact with may also influence partner choice, leading to
environmental stressors to trigger psychological repeated relationship difficulties. Ultimately, the
disorders, as seen in cases like inheriting a model highlights that both genetic and
blood-injury phobia or alcoholism susceptibility. A environmental factors interact dynamically, with
landmark study by Caspi et al. (2003) found genes partly shaping the environments individuals
individuals with two short alleles (SS) of the 5-HTT encounter, which in turn affects psychological and
gene faced doubled depression risk after childhood behavioral outcomes
maltreatment, while those with long alleles (LL)
were unaffected by early stress but could still
develop depression from recent stressors. Epigenetics and the Nongenomic “Inheritance” of
Subsequent research, such as Kilpatrick et al. (2007), Behavior
showed similar gene-environment interactions for Recent research suggests genetic influences on
PTSD, where high-risk individuals with SS alleles behavior and psychological disorders may be
and low social support faced 4.5x higher risk after overemphasized, as environmental
trauma. Another Caspi et al. (2002) study linked factors—particularly early life experiences—can
specific genes to violent behavior in adults only if override or reshape genetic predispositions. Studies
they were maltreated as children, highlighting how in mice and monkeys show that nurturing
genetic predispositions require environmental environments (e.g., calm maternal care) can reduce
activation. While these findings require replication stress reactivity across generations through
and involve complex gene networks, they robustly epigenetic changes, altering gene expression without
illustrate the necessity of gene-environment modifying DNA itself. Similarly, humans with
interplay in disorders like depression, PTSD, and genetic vulnerabilities (e.g., to schizophrenia) often
antisocial behavior. avoid disorders in stable, supportive environments,
while chaotic early experiences can disrupt
neuroendocrine function and increase disorder risk.
Even identical twins, sharing identical genes and
environments, exhibited distinct personalities,
highlighting the unpredictable interplay of genes and
life events. Ultimately, psychological outcomes arise
from dynamic gene-environment interactions, where
early nurturing can mitigate genetic risks and
environmental stressors can activate or silence
genetic vulnerabilities.
The Gene–Environment Correlation Model: also
known as the reciprocal gene–environment model,
suggests that genetic traits can influence the
Neuroscience and its Contributions to
environments people experience, often by shaping
Psychopathology
behaviors that lead individuals to seek out or create
certain situations. For example, some people may be
The Central Nervous System
genetically predisposed to seek out challenging
-​ processes all information received from our
relationships or circumstances that increase their risk
sense organs and reacts as necessary. It sorts
for depression. This model has also been applied to
out what is relevant from what isn’t; checks
divorce rates, where individuals with a family
the memory banks to determine why the
history of divorce, especially among identical twins,
information is relevant; and implements the
are much more likely to divorce themselves, likely
right reaction.
due to inherited personality traits such as impulsivity
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Spinal cord- part of the central nervous system, but
its primary function is to facilitate the sending of
messages to and from the brain, which is the other
major component of the central nervous system
(CNS) and the most complex organ in the body.
The brain uses an average of 140 billion nerve cells,
called neurons, to control our thoughts and action.
Neurons transmit information throughout the
nervous system.
The typical neuron contains a central cell
body with two kinds of branches: Dendrites:
have numerous receptors that receive
messages in the form of chemical impulses
from other nerve cells, which are converted
into electrical impulses.
Axon: transmits these impulses to other
neurons. Any one nerve cell may have
multiple connections to other neurons
(called synapses).

Neuron: the fundamental unit of the nervous system,

specialized for transmitting information throughout
the brain and body via electrical and chemical
signals.
Action potential: an electrical impulse that travels
along the axon of a neuron, transmitting information
within the neuron.
Terminal button: the end of the axon where
neurotransmitters are stored and released to
communicate with other neurons.
Synaptic cleft: the small gap between the terminal
button of one neuron and the dendrite of another,
across which neurotransmitters travel.
Neurotransmitters: chemical messengers released
from the axon terminals that transmit impulses
across the synaptic cleft to the receptors on another
neuron.
Vesicles: are small sacs in the terminal buttons that
store neurotransmitters before they are released into
the synaptic cleft8.
Dendrites: branch-like extensions from the neuron’s
cell body that receive signals from other neurons
Glia (glial cells) are supportive cells in the nervous
system that outnumber neurons and play active roles
in modulating neural activity and neurotransmitter
function.
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Central nervous system (CNS) is composed of the
brain and spinal cord and is responsible for
processing and screening information relevant to the
current situation.
Major neurotransmitters relevant to psychopathology
include norepinephrine, serotonin, dopamine,
gamma-aminobutyric acid (GABA), and glutamate,
each of which can have excitatory or inhibitory
effects on neural activity.

The Structure of the Brain

Brain stem:lower, ancient part of the brain that
connects the brain to the spinal cord and is
responsible for essential automatic functions such as
breathing, sleeping, heart rate, and coordinated
movement.
Hindbrain: is the lowest part of the brain stem and
contains the medulla, pons, and cerebellum; it
regulates automatic activities like breathing,
heartbeat, and digestion.
Medulla: is a structure in the hindbrain that controls
involuntary functions such as breathing, heart rate,
and blood pressure.
Pons: is part of the hindbrain that relays signals
from the forebrain to the cerebellum and is involved
in sleep, respiration, and facial sensations.
Cerebellum: is located in the hindbrain and is
responsible for motor coordination and balance;
abnormalities here may be linked to autism.
Midbrain: is a part of the brain stem that coordinates
movement with sensory input and contains parts of
the reticular activating system, which regulates
arousal and tension, including wakefulness and
sleep.
Reticular Activating System: is a network within the
midbrain that influences arousal and alertness.
Thalamus: is located at the top of the brain stem and
acts as a relay station, regulating behavior and
emotion and connecting the forebrain with lower
brain areas.
Hypothalamus: is also at the top of the brain stem,
broadly involved in regulating behavior and
emotion, and maintaining homeostasis.
Forebrain: is the more advanced, recently evolved
part of the brain, central to complex cognitive
activities, sensory processing, and associative
functions.
ABNORMAL PSYCHOLOGY
Limbic system: is a group of structures at the base of Sensory neurons: relay information from sensory
the forebrain, including the hippocampus, cingulate receptors (like those in the skin, ears, and nose) to
gyrus, septum, and amygdala; it regulates emotions, the central nervous system, allowing us to perceive
learning, impulse control, and basic drives such as and respond to external stimuli.
sex, aggression, hunger, and thirst. Autonomic nervous system: is another division of
Basal ganglia: are structures at the base of the the peripheral nervous system that regulates
forebrain, including the caudate nucleus, that help involuntary functions, including the cardiovascular
control motor activity and are implicated in system and endocrine system, as well as digestion
movement disorders and conditions like and body temperature.
obsessive-compulsive disorder. Sympathetic nervous system: is a branch of the
Cerebral cortex: is the largest part of the forebrain, autonomic nervous system that mobilizes the body
containing over 80% of the brain’s neurons, and is during stress or danger, increasing heart rate,
responsible for higher cognitive functions such as respiration, and stimulating the adrenal glands for a
reasoning, planning, and creating; it is divided into “fight or flight” response.
two hemispheres. Parasympathetic nervous system: balances the
Left hemisphere of the cerebral cortex is sympathetic system by calming the body after stress,
mainly responsible for verbal and cognitive normalizing arousal, and facilitating digestion and
processes, energy storage.
Right hemisphere is more involved in Endocrine system: consists of glands that produce
perceiving the environment and creating hormones, which are chemical messengers released
images. into the bloodstream to regulate bodily functions
Each hemisphere of the cerebral cortex is divided such as metabolism, growth, and stress response.
into four lobes: Hormones: chemical messengers produced by
Temporal lobe (recognizing sights endocrine glands, including adrenaline from the
and sounds, long-term memory) adrenal glands, thyroxine from the thyroid gland,
Parietal lobe (sensation of touch, and sex hormones like estrogen and testosterone
body positioning), from the gonadal glands.
Occipital lobe (visual processing) Pituitary gland: known as the master gland because
Frontal lobe (higher cognitive it produces regulatory hormones that control other
functions, planning, reasoning, endocrine glands.
social behavior). Hypothalamic-pituitary-adrenocortical (HPA) axis:
Prefrontal cortex is the front part of the frontal lobe, a system involving the hypothalamus, pituitary
responsible for synthesizing information, gland, and adrenal glands, which regulates stress
decision-making, and enabling social behavior. responses and is implicated in psychological
disorders such as depression.
Telomeres: protective structures at the ends of
chromosomes that can be affected by stress and are
The Peripheral Nervous System linked to vulnerability to disorders like depression.
Somatic Nervous System: is a part of the peripheral
nervous system responsible for voluntary control of Implications for Psychopathology
body movements via skeletal muscles, as well as Psychological disorders generally involve a mix of
transmitting sensory information from the emotional, behavioral, and cognitive symptoms, and
environment to the CNS. are rarely caused by specific, localized brain lesions;
Motor neurons: in the somatic nervous system carry instead, such lesions more often lead to motor or
signals from the brain and spinal cord to skeletal sensory deficits managed by neurologists. Recent
muscles, enabling voluntary movements such as research in psychopathology focuses on how general
walking, talking, or grasping objects. brain function and biologically driven personality
ABNORMAL PSYCHOLOGY
traits, influenced by neurotransmitter patterns, may 4.​ Mechanisms of treatment: Psychological
increase vulnerability to certain disorders, such as therapies (e.g., CBT) often produce
impulsivity linked to low serotonin and high "top-down" brain changes (cortex
dopamine. Brain imaging studies of influencing emotional centers), while drugs
obsessive-compulsive disorder (OCD) have found work "bottom-up" (subcortical areas
increased activity in the orbital surface of the frontal affecting cognition), highlighting distinct
lobe, cingulate gyrus, and caudate nucleus, which pathways for symptom relief.​
are interconnected and rich in serotonin pathways.
However, damage or abnormal activity in these areas 5.​ Precision medicine: Brain imaging can
is not always specific to OCD and may relate to predict treatment response (e.g.,
broader negative emotional states or be a result of amygdala-prefrontal connectivity for CBT
the disorder rather than its cause. Therefore, while efficacy), paving the way for personalized
there is evidence for biological contributions to approaches that match patients to optimal
psychopathology, neuroscientists caution against therapies based on their neural profiles.
drawing simple causal links from brain activity
alone, emphasizing the need for further research and
a focus on brain circuitry rather than isolated
regions. The Physiology and Purpose of Fear

●​ Fear activates the cardiovascular system,

Psychosocial Influences on Brain Structure and
causing blood vessels to constrict, raising
Function
blood pressure, and redirecting blood from
1.​ Treatment insights and causality: While the skin and extremities to vital organs and
treatments for psychological disorders like skeletal muscles needed for emergency
OCD provide clues about causes, action.
successfully targeting symptoms (e.g., ●​ Physical signs of fear, such as turning pale
through medication or therapy) does not and trembling, result from reduced blood
confirm the root cause, as maintaining flow to the skin and shivering or
factors often differ from initiating factors.​ piloerection, which help conserve heat.
●​ Breathing becomes faster and deeper during
2.​ Biological and psychological fear, providing more oxygen to the blood
interventions: Treatments such as and brain, which enhances alertness and
neurosurgery (for severe OCD) or cognitive processing.
serotonin-enhancing drugs address ●​ The liver releases more glucose into the
biological mechanisms, but psychological bloodstream, supplying extra energy to
therapies like cognitive-behavioral therapy crucial muscles and organs, including the
(CBT) can directly normalize brain circuits, brain.
as seen in OCD and depression.​ ●​ Pupils dilate for improved vision, hearing
becomes sharper, and digestive activity is
3.​ Placebo effects and brain function: suspended, leading to dry mouth and a
Placebos induce measurable brain changes reduced urge to eat.
through psychological factors like ●​ Fear can also cause hot-and-cold spells, and
expectation, activating regions such as the in the short term, may trigger the urge to
anterior cingulate cortex, demonstrating how urinate, defecate, or vomit as the body
mental processes directly influence prepares for concentrated action.
neurochemistry and pain perception.​ ●​ The fight-or-flight response is an adaptive
evolutionary mechanism that increased
ABNORMAL PSYCHOLOGY
survival by preparing our ancestors to
respond rapidly and effectively to threats,
passing these traits to future generations.

Anger and Your Heart

●​ Sustained anger and hostility significantly

increase the risk of developing heart disease,
even more than some traditional risk factors
like smoking or high cholesterol.
●​ Frequent or intense anger impairs blood
vessel function, making it harder for vessels
to dilate and increasing the risk of heart
attacks and strokes.
●​ The negative cardiovascular effects of anger
are distinct from those of other negative
emotions such as anxiety or sadness, which
do not cause the same blood vessel
dysfunction.
●​ Even recalling past anger can decrease
heart-pumping efficiency and trigger
dangerous heart rhythm disturbances,
especially in people with existing heart
disease.
●​ Chronic anger may promote inflammation
and contribute to clogged arteries, further
raising heart disease risk.
●​ Adopting a forgiving attitude and practicing
compassion can neutralize the harmful
cardiovascular effects of anger, as shown by
reduced blood pressure and heart rate during
forgiveness.
●​ Scientific evidence supports that managing
anger through psychological strategies and
positive relationships is crucial for
protecting cardiovascular health
ABNORMAL PSYCHOLOGY
CHAPTER 5: Anxiety, Trauma- and Stressor -​ sudden overwhelming reaction if you
Related, and Obsessive-Compulsive and Related experience the alarm response of fear when
Disorders there is nothing to be afraid of—that is, if
you have a false alarm.

The Complexity of Anxiety Disorders Panic Attack- defined as an abrupt experience of

intense fear or acute discomfort, accompanied by
➢​ Anxiety physical symptoms that usually include heart
-​ is an emotion implicated so heavily across palpitations, chest pain, shortness of breath, and,
the full range of psychopathology. possibly, dizziness.
-​ a negative mood state characterized by
bodily symptoms of physical tension and by
apprehension about the future. Diagnostic Criteria for Panic Attack
-​ can be a subjective sense of unease, a set of An abrupt surge of intense fear or intense discomfort
behaviors (looking worried and anxious or that reaches a peak within minutes, and during
fidgeting), or a physiological response which time four (or more) of the following
originating in the brain and reflected in symptoms occur:
elevated heart rate and muscle tension. 1.​ Palpitations, pounding heart, or accelerated
Anxiety is good for us, at least in moderate amounts. heart rate
●​ Social, physical, and intellectual 2.​ Sweating
performances are driven and enhanced by 3.​ Trembling or shaking
anxiety. 4.​ Sensations of shortness of breath or
smothering
Howard Liddell (1949) first proposed this idea when 5.​ Feeling of choking
he called anxiety the “shadow of intelligence.” 6.​ Chest pain or discomfort
●​ The human ability to plan in some detail for 7.​ Nausea or abdominal distress
the future was connected to that gnawing 8.​ Feeling dizzy, unsteady, lightheaded, or faint
feel ing that things could go wrong and we 9.​ Chills or heat sensations
had better be prepared for them. 10.​ Paresthesias (numbness or tingling
sensations)
➢​ Fear 11.​ Derealization (feelings of unreality) or
-​ an immediate alarm reaction to danger. depersonalization (being detached from
-​ protects us by activating a massive response oneself)
from the autonomic nervous system 12.​ Fear of losing control or going crazy
(increased heart rate and blood pressure, for 13.​ Fear of dying
example), along with our subjective sense of
terror, motivates us to escape (flee) or,
possibly, to attack (fight) (flight or fight Causes of Anxiety and Related Disorders
response).
-​ an immediate emotional reaction to current ➢​ Biological Contributions
danger characterized by strong escapist ●​ Increasing evidence shows that we inherit a
action tendencies and, often, a surge in the tendency to be tense, uptight, and anxious.
sympathetic branch of the autonomic ●​ The tendency to panic also seems to run in
nervous system. families and probably has a genetic
component.
➢​ Panic ●​ A genetic vulnerability does not cause
anxiety and/or panic directly.
ABNORMAL PSYCHOLOGY
●​ Anxiety is also associated with specific Danger signals in response to something we
brain circuits and neurotransmitter systems: see that might be threatening descend from
○​ Depleted levels of the cortex to the septal–hippocampal system.
gamma-aminobutyric acid -​ also receives a big boost from the amygdala.
(GABA), part of the GABA When the BIS is activated by signals that
benzodiazepine system, are arise from the brain stem or descend from
associated with increased anxiety, the cortex, we tend to freeze, experience
although the relationship is not quite anxiety, and apprehensively evaluate the
so direct. situation to confirm that danger is present.
○​ The role of the
corticotropin-releasing factor Fight/flight system (FFS)- This circuit originates in
(CRF) system as central to the the brain stem and travels through several midbrain
expression of anxiety (and structures, including the amygdala, the ventromedial
depression) and the groups of genes nucleus of the hypothalamus, and the central gray
that increase the likelihood that this matter.
system will be turned on. -​ When stimulated in animals, this circuit
○​ CRF activates the produces an immediate alarm-and-escape
hypothalamic–pituitary–adrenocort response that looks very much like panic in
ical (HPA) axis, which is part of the humans.
CRF system, and this CRF system -​ activated partly by deficiencies in serotonin.
has wide-ranging effects on areas of
the brain implicated in anxiety, ➢​ Psychological Contributions
including the emotional brain (the ●​ A general “sense of uncontrollability” may
limbic system), particularly the develop early as a function of upbringing
hippocampus and the amygdala; the and other disruptive or traumatic
locus coeruleus in the brain stem; environmental factors.
the prefrontal cortex; and the ●​ The actions of parents in early childhood
dopaminergic neurotransmitter seem to do a lot to foster this sense of
system. control or uncontrollability. Responsive
○​ The area of the brain most often parenting teach children that they have
associated with anxiety is the limbic control over their environment and their
system which acts as a mediator responses have an effect on their parents and
between the brain stem and the their environment. Overprotective and
cortex. overintrusive parenting create a situation in
Behavioral Inhibition System (BIS)- Jeffrey Gray which children never learn how to cope with
identified a brain circuit in the limbic system of adversity when it comes along.
animals that seems heavily involved in anxiety and ●​ Another feature among patients with panic is
may be relevant to humans. the general tendency to respond fearfully to
-​ This circuit leads from the septal and anxiety symptoms (anxiety sensitivity).
hippocampal area in the limbic system to the
frontal cortex. (The septal–hippocampal ➢​ Social Contributions
system is activated by CRF and ●​ Stressful life events trigger our biological
serotonergic- and noradrenergic mediated and psychological vulnerabilities to anxiety.
pathways originating in the brain stem.) ●​ The particular way we react to stress seems
-​ activated by signals from the brain stem of to run in families.
unexpected events, such as major changes in
body functioning that might signal danger.
ABNORMAL PSYCHOLOGY
●​ The presence of any anxiety disorder was
An Integrated Model uniquely and significantly associated with
thyroid disease, respiratory disease,
gastrointestinal disease, arthritis, migraine
headaches, and allergic conditions.
●​ Panic attacks often co-occur with certain
medical conditions, particularly cardio,
respiratory, gastrointestinal, and vestibular
(inner ear) disorders, even though the
majority of these patients would not meet
criteria for panic disorder.

Triple Vulnerability Theory

Suicide
●​ 20% of patients with panic disorder had
1.​ Generalized Biological Vulnerability. We
attempted suicide.
can see that a tendency to be uptight or
●​ The risk of someone with panic disorder
high-strung might be inherited; but not
attempting suicide is comparable to that of
sufficient to produce anxiety itself.
individuals with major depression.
2.​ Generalized Psychological Vulnerability.
●​ The Weissman study suggests that having
You might grow up believing the world is
any anxiety or related disorder, not just
dangerous and out of control and you might
panic disorder, uniquely increases the
not be able to cope when things go wrong
chances of having thoughts about suicide
based on your early experiences.
(suicidal ideation) or making suicidal
3.​ Specific Psychological Vulnerability. You
attempts but the relationship is strongest
learn from early experience, such as being
with panic disorder and posttraumatic stress
taught by your parents, that some situations
disorder.
or objects are fraught with danger (even if
they really aren’t).

ANXIETY DISORDERS

❖​ Generalized Anxiety Disorder

Comorbidity of Anxiety and Related Disorders

-​ DSM-5 criteria specify that at least 6 months

Comorbidity- co-occurrence of two or more
of excessive anxiety and worry
disorders in a single individual.
(apprehensive expectation) must be ongoing
more days than not. Furthermore, it must be
By far the most common additional
difficult to turn off or control the worry
diagnosis for all anxiety disorders was major
process.
depression, which occurred in 50% of the cases over
-​ Characterized by muscle tension, mental
the course of the patient’s life, probably due to the
agitation, susceptibility to fatigue (probably
shared vulnerabilities between depression and
the result of chronic excessive muscle
anxiety disorders in addition to the disorder-specific
tension), some irritability, and difficulty
vulnerability.
sleeping. Focusing one’s attention is
difficult, as the mind quickly switches from
Comorbidity with Physical Disorders
crisis to crisis.
ABNORMAL PSYCHOLOGY
-​ People with GAD mostly worry about D. The anxiety, worry or physical symptoms cause
minor, everyday life events, a characteristic clinically significant distress or impairment in social,
that distinguishes GAD from other anxiety occupational, or other important areas of
disorders. functioning.
E. The disturbance is not due to the direct
In generalized anxiety disorder (GAD), anxiety physiological effects of a substance (e.g., a drug of
focuses on minor, everyday events and not on one abuse, a medication) or a general medical condition
major worry or concern. (e.g., hyperthyroidism).
F. The disturbance is not better explained by another
Statistics mental disorder (e.g., anxiety or worry about having
●​ 3.1% of the population meets criteria for panic attacks in panic disorder, negative evaluation
GAD during a given 1-year period and 5.7% in social anxiety disorder).
at some point during their lifetime.
●​ Twice as many individuals with GAD are Causes
female than male in epidemiological studies. ●​ What seems to be inherited is the tendency
●​ Some people with GAD report onset in to become anxious rather than GAD itself.
early adulthood, usually in response to a life ●​ Heritability has been found for a particular
stressor. trait (anxiety sensitivity)
●​ GAD is chronic. One study found only an -​ tendency to become
8% probability of becoming symptom-free distressed in response to
after 2 years of follow-up. arousal related sensations,
arising from beliefs that
Diagnostic Criteria for Generalized Anxiety these anxiety-related
Disorder sensations have harmful
A.​ Excessive anxiety and worry (apprehensive consequences.
expectation), occur ring more days than not ●​ Individuals with GAD do not respond as
for at least 6 months about a number of strongly to stressors as individuals with
events or activities (such as work or school anxiety disorders in which panic is more
performance). prominent:
B.​ The individual finds it difficult to control the ○​ less responsiveness on most
worry. physiological measures, such as
C.​ The anxiety and worry are associated with at heart rate, blood pressure, skin
least three (or more) of the following six conductance, and respiration rate
symptoms (with at least some symp toms ○​ low cardiac vagal tone (the vagus
present for more days than not for the past 6 nerve is the largest parasympathetic
months) [Note: Only one item is required in nerve innervating the heart and
children]: decreasing its activity)
1.​ Restlessness or feeling keyed up or ○​ autonomic inflexibility, because the
on edge heart is less responsive to certain
2.​ Being easily fatigued tasks
3.​ Difficulty concentrating or mind
going blank ●​ People with GAD have been called
4.​ Irritability autonomic restrictors.
5.​ Muscle tension ●​ People with GAD are chronically tense.
6.​ Sleep disturbance (difficulty falling ●​ Individuals with GAD are highly sensitive
or staying asleep or restless, to threat in general, particularly to a threat
unsatisfying sleep) that has personal relevance.
ABNORMAL PSYCHOLOGY
about additional panic attacks or their
consequences (e.g., losing control, having a
Treatment heart attack, “going crazy”), or (b) A
●​ Benzodiazepines are most often prescribed significant maladaptive change in behavior
for generalized anxiety, at least in the short related to the attacks (e.g., behaviors
term. designed to avoid having panic attacks, such
●​ Psychological treatments(CBT) are more as avoidance of exercise or unfamiliar
effective in the long term. situations).
C.​ The disturbance is not attributable to the
physiological effects of a substance (e.g., a
drug of abuse, a medication) or another
medical condition (e.g., hyperthyroidism,
cardiopulmonary disorders).
D.​ The disturbance is not better explained by
another mental disorder (e.g., the panic
attacks do not occur only in response to
feared social situations, as in social anxiety
disorder).

❖​ Agoraphobia- fear and avoidance of

situations in which a person feels unsafe or
unable to escape to get home or to a hospital
in the event of a developing panic,
panic-like symptoms, or other physical
symptoms, such as loss of bladder control.
-​ People develop agoraphobia because they
never know when these symptoms might
occur.
-​ coined in 1871 by Karl Westphal, a German
physician, and, in the original Greek, refers
to fear of the marketplace.

Diagnostic Criteria for Agoraphobia

A.​ Marked fear or anxiety about two or more of
the following five situations: Public
transportation, open spaces, enclosed places,
❖​ Panic Disorder and Agoraphobia
standing in line or being in a crowd, being
-​ individuals experience severe, unexpected
outside the home alone.
panic attacks; they may think they’re dying
B.​ The individual fears or avoids these
or otherwise losing control.
situations due to thoughts that escape might
be difficult or help might not be available in
Diagnostic Criteria for Panic Disorder
the event of developing panic-like
A.​ Recurrent unexpected panic attacks are
symptoms or other inca pacitating or
present.
embarrassing symptoms (e.g., fear of falling
B.​ At least one of the attacks has been followed
in the elderly, fear of incontinence).
by 1 month or more of one or both of the
C.​ The agoraphobic situations almost always
following: (a) Persistent concern or worry
provoke fear or anxiety.
ABNORMAL PSYCHOLOGY
D.​ The agoraphobic situations are actively -​ avoidance of internal
avoided, require the presence of a physical sensations.
companion, or are endured with intense fear Statistics
or anxiety. ●​ PD is fairly common.
E.​ The fear or anxiety is out of proportion to ●​ Approximately 2.7% of the population meet
the actual danger posed by the agoraphobic criteria for PD during a given 1-year period,
situations, and to the sociocultural context. and 4.7% met them at some point during
F.​ The fear, anxiety or avoidance is persistent, their lives, two-thirds of them women.
typically lasting for 6 months or more. ●​ Onset of panic disorder usually occurs in
G.​ The fear, anxiety or avoidance causes early adult life— from midteens through
clinically significant dis tress or impairment about 40 years of age. The median age of
in social, occupational or other important onset is between 20 and 24.
areas of functioning.
H.​ If another medical condition (e.g.,
inflammatory bowel disease, Parkinson’s Cultural Influences
disease) is present, the fear, anxiety or ➢​ Latin America:
avoidance is clearly excessive. Susto- characterized by sweating, increased
I.​ The fear, anxiety or avoidance is not better heart rate, and insomnia but not by reports
explained by the symptoms of another of anxiety or fear, even though a severe
mental disorder, e.g., the symptoms are not fright is the cause.
confined to specific phobia, situational type; Ataques de nervios- anxiety-related,
do not involve only social situations (as in culturally defined syndrome promi nent
social anxiety disorder) and are not related among Hispanic Americans, particularly
exclusively to obsessions (as in those from the Caribbean.
obsessive-compulsive disorder), perceived
deficits or flaws in physical appearance (as
in body dysmorphic disorder), reminders of
traumatic events (as in posttraumatic stress Nocturnal Panic
disorder), or fear of separation (as in Sleep apnea- an interruption of breathing
separation anxiety disorder). during sleep that may feel like suffocation.
Sleep terrors- Often children awaken
Clinical Description imagining that something is chasing them
●​ To meet criteria for panic disorder, a person around the room.
must experience an unexpected panic attack Isolated sleep paralysis- occurs during the
and develop substantial anxiety over the transitional state between sleep and waking,
possibility of having another attack or about when a person is either falling asleep or
the implications of the attack or its waking up, but mostly when waking up.
consequences. -​ During this period, the individual is
●​ An individual who has not had a panic unable to move and experiences a
attack for years may still have strong surge of terror that resembles a
agoraphobic avoidance. Agoraphobic panic attack; occasionally, there are
avoidance is simply one way of coping with also vivid hallucinations.
unexpected panic attacks.
●​ Most patients with panic disorder and Causes
agoraphobic avoidance also display another ●​ Strong evidence indicates that agoraphobia
cluster of avoidant behaviors that we call often develops after a person has unexpected
interoceptive avoidance panic attacks (or panic-like sensations), but
ABNORMAL PSYCHOLOGY
whether agoraphobia develops and how focused on the next panic attack. For some people,
severe it becomes seem to be socially and agoraphobia develops in the absence of panic
culturally determined. attacks or panic-like symptoms.
●​ Some people are also more likely than
others to have an emergency alarm reaction ❖​ Specific Phobia
(unexpected panic attack) when confronted -​ an irrational fear of a specific object or
with stress-producing events. situation that markedly interferes with an
●​ Cues become associated with a number of individual’s ability to function.
different internal and external stimuli Major characteristic:
through a learning process called learned ●​ Marked fear and anxiety about a specific
alarms. object or situation.
●​ Panic disorder and agoraphobia evolve from ●​ Recognition that their fear and anxiety were
psychodynamic causes suggested that early out of proportion to any actual danger.
object loss and/or separation anxiety might ●​ Going to considerable lengths to avoid
predispose someone to develop the situations in which their phobic response
condition as an adult. might occur.

Diagnostic Criteria for Specific Phobia

A.​ Marked fear or anxiety about a specific
object or situation (e.g., f lying, heights,
animals, receiving an injection, seeing
blood).
B.​ The phobic object or situation almost always
provokes im mediate fear or anxiety. Note:
In children, the anxiety may be expressed by
crying, tantrums, freezing, or clinging.
C.​ The phobic object or situation is actively
avoided or endured with intense fear or
anxiety.
D.​ The fear or anxiety is out of proportion to
the actual danger posed by the specific
object or situation, and to the sociocul tural
context.
Treatment
E.​ The fear, anxiety or avoidance is persistent,
●​ Benzodiazepines, selective-serotonin
typically lasting for 6 months or more.
reuptake inhibitors (SSRIs), and
F.​ The fear, anxiety or avoidance causes
serotonin-norepinephrine reuptake
clinically significant dis tress or impairment
inhibitors (SNRIs)
in social, occupational or other important
●​ Panic control treatment (PCT)-
areas of functioning.
concentrates on exposing patients with panic
G.​ The disturbance is not better explained by
disorder to the cluster of interoceptive
the symptoms of another mental disorder,
(physical) sensations that remind them of
including fear, anxiety and avoid ance of:
their panic attacks.
situations associated with panic-like
symptoms or other incapacitating symptoms
In panic disorder, which may or may not be
(as in agoraphobia); objects or situations
accompanied by agoraphobia (a fear and avoidance
related to obsessions (as in OCD); reminders
of situations considered to be “unsafe”), anxiety is
of traumatic events (as in PTSD); separation
ABNORMAL PSYCHOLOGY
from home or attachment figures (as in a drop in blood pressure and a tendency to
separation anxiety disorder); or social faint.
situations (as in social anxiety disorder) -​ develops over the possibility of having this
response.
Four major subtypes of specific phobia: -​ average age of onset for this phobia is
●​ Blood–injection–injury type approximately 9 years.
●​ Situational type (planes, elevators, or -​ runs in families more strongly than any
enclosed places) phobic disorder we know.
●​ Natural environment type (heights, storms,
and water) 2.​ Situational Phobia
●​ Animal type -​ characterized by fear of public
●​ “Other” (phobias that do not fit any of the transportation or enclosed places.
four major subtypes) Claustrophobia, a fear of small enclosed
places.
-​ tends to emerge from midteens to
mid-20s.
-​ people with situational phobia
never experience panic attacks
outside the context of their phobic
object or situation.

3.​ Natural Environment Phobia

-​ fears of situations or events occurring in
nature.
-​ Many of these situations have some danger
associated with them and, therefore, mild to
moderate fear can be adaptive.
-​ have a peak age of onset of about 7 years.
-​ persistent (lasting at least 6 months) and to
interfere substantially with the person’s
functioning.

4.​ Animal Phobia

-​ Fears of animals and insects.
-​ Fear experienced by people with animal
phobias is different from an ordinary mild
revulsion.
-​ Age of onset peaks around 7 years.

Statistics
●​ Specific fears occur in a majority of people.
●​ Fears of snakes and heights rank near the
top.
1.​ Blood–Injection–Injury Phobia ●​ Even though phobias may interfere with an
-​ people with this phobia inherit a strong individual’s functioning, only the most
vasovagal response to blood, injury, or the severe cases come for treatment, because
possibility of an injection, all of which cause
ABNORMAL PSYCHOLOGY
more mildly affected people tend to work hearing about a frightening event is
around their phobias. sufficient for some individuals).
●​ The median age of onset for specific phobia 2.​ Fear is more likely to develop if we
is 7 years of age, the youngest of any are “prepared”; that is, we seem to
anxiety disorder except separation anxiety carry an inherited tendency to fear
disorder. situations that have always been
●​ The prevalence of specific phobias varies dangerous to the human race.
from one culture to another. 3.​ We also have to be susceptible to
○​ Pa-leng- A variant of phobia in developing anxiety about the
Chinese cultures; sometimes frigo possibility that the event will
phobia or “fear of the cold.” happen again.

Treatment
●​ Almost everyone agrees that specific
phobias require structured and consistent
exposure-based exercises.
●​ For separation anxiety, parents are often
included to help structure the exercises and
also to address parental reaction to
childhood anxiety.
●​ In cases of blood– injection–injury phobia,
where fainting is a real possibility, grad
uated exposure-based exercises must be
done in specific ways.

In specific phobia, the fear is focused on a

particular object or situation.
Causes
●​ Phobias acquired by direct experience- ❖​ Separation Anxiety Disorder
where real danger or pain results in an alarm -​ characterized by children’s unrealistic and
response (a true alarm). This is one way of persistent worry that something will happen
developing a phobia, and there are at least to their parents or other important people in
three others: their life or that something will happen to
●​ Panic attack- experiencing a false alarm in the children themselves that will separate
a specific situation them from their parents.
●​ Vicarious experience- observing someone -​ the act of separating from the parent or
else experiencing severe fear attachment figure provokes anxiety and fear;
●​ Under the right conditions, being told about 4.1% of children have separation anxiety at
danger. a severe enough level to meet criteria for a
●​ Information transmission- Sometimes just disorder.
being warned repeatedly about a potential -​ In some cases, the onset is in adulthood
danger is sufficient for someone to develop a rather than carrying over from childhood.
phobia. The focus of anxiety in adults is the same:
In summary, several things have to occur for a that harm may befall loved ones during
person to develop a phobia: separation.
1.​ A traumatic conditioning
experience often plays a role (even
ABNORMAL PSYCHOLOGY
❖​ Social Anxiety Disorder (Social Phobia) F.​ The fear, anxiety or avoidance is persistent,
-​ more than exaggerated shyness. typically lasting for 6 months or more.
-​ experienced marked fear or anxiety focused G.​ The fear, anxiety or avoidance causes
on one or more social or performance clinically significant dis tress or impairment
situations. in social, occupational or other important
-​ Individuals with just performance anxiety, areas of functioning.
which is a subtype of SAD, usually have no H.​ The fear, anxiety or avoidance is not
difficulty with social interaction, but when attributable to the effects of a substance
they must do something specific in front of (e.g., a drug of abuse, a medication) or
people, anxiety takes over and they focus on another medical condition.
the possibility that they will embarrass I.​ The fear, anxiety or avoidance is not better
themselves. explained by the symptoms of another
mental disorder, such as panic disorder (e.g.,
Statistics anxiety about having a panic attack) or
-​ SAD second only to specific phobia as the separation anxiety disorder (e.g., fear of
most prevalent anxiety disorder. being away from home or a close relative).
J.​ If another medical condition (e.g., stuttering,
Diagnostic Criteria for Social Anxiety Disorder Parkinson’s dis ease, obesity, disfigurement
(Social Phobia) from burns or injury) is present, the fear,
A.​ Marked fear or anxiety about one or more anxiety or avoidance is clearly unrelated or
social situations in which the person is is excessive.
exposed to possible scrutiny by others.
Examples include social interactions (e.g., Specify if: Performance only: If the fear is restricted
having a conversation; meeting unfamiliar to speaking or performing in public.
people), being observed (e.g., eating or
drinking), or performing in front of others Causes
(e.g., giving a speech). ●​ Mogg and colleagues (2004) showed that
Note: In children, the anxiety must socially anxious individuals more quickly
occur in peer set tings and not just in recognized angry faces than “normals,”
interactions with adults. whereas “normals” remembered the
B.​ The individual fears that he or she will act in accepting expressions.
a way, or show anxiety symptoms, that will ●​ We inherited a tendency from our ancestors
be negatively evaluated (i.e., will be to fear angry faces probably to avoid hostile,
humiliating, embarrassing, lead to rejection, angry, domineering people who might attack
or offend others). or kill them.
C.​ The social situations almost always provoke ●​ A model of the etiology of SAD would look
fear or anxiety. somewhat like models of panic disorder and
Note: in children, the fear or anxiety specific phobia. Three pathways to SAD are
may be expressed by crying, possible:
tantrums, freezing, clinging, 1.​ Someone could inherit a generalized
shrinking, or failing to speak in biological vulnerability to develop anxiety, a
social situations. biological tendency to be socially inhibited,
D.​ The social situations are avoided or endured or both.
with intense fear or anxiety. 2.​ When under stress, someone might have an
E.​ The fear or anxiety is out of proportion to unexpected panic attack in a social situation
the actual threat posed by the social that would become associated (conditioned)
situation, and to the sociocultural context. to social cues.
ABNORMAL PSYCHOLOGY
3.​ Someone might experience a real social ❖​ Selective Mutism
trauma resulting in a true alarm. Anxiety -​ a rare childhood disorder characterized by a
would then develop (be conditioned) in the lack of speech in one or more settings in
same or similar social situations. which speaking is socially expected.
-​ seems clearly driven by social anxiety, since
the failure to speak is not because of a lack
of knowledge of speech or any physical
difficulties, nor is it due to another disorder
in which speaking is rare or can be impaired
such as autism spectrum disorder.
-​ Treatment employs many of the same
cognitive behavioral principles used
successfully to treat social anxiety in
children but with a greater emphasis on
speech.

Trauma and Stressor- Related Disorders

DSM-5 consolidates a group of formerly disparate
disorders that all develop after a relatively stressful
life event, often an extremely stressful or traumatic
Treatment life event.
●​ Clark and colleagues (2006) evaluated a
cognitive therapy program that emphasized ❖​ Posttraumatic Stress Disorder (PTSD)
real-life experiences during therapy to -​ describes the setting event for PTSD as
disprove automatic perceptions of danger. exposure to a traumatic event during which
●​ A treatment specifically targets the different an individual experiences or witnesses death
factors that are maintaining the disorder. or threatened death, actual or threatened
One important reason why SAD is serious injury, or actual or threatened sexual
maintained in the presence of repeated violation.
exposure to social cues is because -​ Afterward, victims reexperience the event
individuals with SAD engage in a variety of through memories and nightmares. When
avoidance and safety behaviors to reduce the memories occur suddenly, accompanied by
risk of rejection and, more generally, prevent strong emotion, and the victims find
patients from critically evaluating their themselves reliving the event, they are
catastrophic beliefs about how embarrassed having a flashback.
and foolish they will look if they attempt to -​ Victims often display a characteristic
interact with somebody. restriction or numbing of emotional
responsiveness, which may be disruptive to
Social anxiety disorder is a fear of being around interpersonal relationships.
others, particularly in situations that call for some ●​ They are sometimes unable to
kind of “performance” in front of other people. remember certain aspects of the
event.
●​ They often display a characteristic
restriction or numbing of emotional
responsiveness, which may be
ABNORMAL PSYCHOLOGY
disruptive to interpersonal B.​ Presence of one (or more) of the following
relationships. intrusion symptoms associated with the
●​ They are sometimes unable to traumatic event(s), beginning after the
remember certain aspects of the traumatic event(s) occurred:
event. 1.​ Recurrent, involuntary and intrusive
●​ They display “reckless or distressing memories of the
self-destructive behavior”. traumatic event(s). Note: In young
●​ The diagnosis of PTSD cannot be children, repetitive play may occur
made until at least one month after in which themes or aspects of the
the occurrence of the traumatic traumatic event(s) are expressed.
event. 2.​ Recurrent distressing dreams in
●​ In PTSD with delayed onset, which the content and/or affect of
individuals show few or no the dream are related to the
symptoms immediately or for traumatic event(s).
months after a trauma, but at least 6 Note: In children, there may
months later, and perhaps years be frightening dreams
afterward, develop full-blown without recognizable
PTSD. content.
3.​ Dissociative reactions (e.g.,
Diagnostic Criteria for Posttraumatic Stress flashbacks) in which the individual
Disorder feels or acts as if the traumatic
A.​ Exposure to actual or threatened death, event(s) were recurring. (Such
serious injury, or sexual violence in one (or reactions occur on a continuum,
more) of the following ways: with the most extreme expression
1.​ Directly experiencing the traumatic being a complete loss of awareness
event(s). of present surroundings.)
2.​ Witnessing, in person, the event(s) Note: In young children,
as they occurred to others. trauma specific reenactment
3.​ Learning that the event(s) occurred may occur in play.
to a close relative or close friend. In 4.​ Intense or prolonged psychological
cases of actual or threatened death distress at exposure to internal or
of a family member or friend, the external cues that symbolize or
event(s) must have been violent or resemble an aspect of the traumatic
accidental. event(s).
4.​ Experiencing repeated or extreme 5.​ Marked physiological reactions to
exposure to aversive details of the internal or external cues that
traumatic event(s) (e.g., first symbolize or resemble an aspect of
responders collecting human the traumatic event(s).
remains; police officers repeatedly C.​ Persistent avoidance of stimuli associated
exposed to details of child abuse). with the traumatic event(s), beginning after
Note: Criterion A4 does not the traumatic event(s) occurred, as
apply to exposure through evidenced by one or both of the following:
electronic media, television, 1.​ Avoidance of or efforts to avoid
movies, or pictures, unless distressing memories, thoughts,
this exposure is work feelings, or conversations about or
related. closely associated with the traumatic
event(s).
ABNORMAL PSYCHOLOGY
2.​ Avoidance of or efforts to avoid 1.​ Irritable behavior and angry
external reminders (people, places, outbursts (with little or no
conversations, activities, objects, provocation) typically expressed as
situations) that arouse distressing verbal or physical aggression toward
memories, thoughts, or feelings people or objects.
about or closely associated with the 2.​ Reckless or self-destructive
traumatic event(s). behavior.
D.​ Negative alterations in cognitions and mood 3.​ Hypervigilance.
associated with the traumatic event(s), 4.​ Exaggerated startle response.
beginning or worsening after the traumatic 5.​ Problems with concentration
event(s) occurred, as evidenced by two (or F.​ Sleep disturbance (e.g., difficulty falling or
more) of the following: staying asleep or restless sleep).Duration of
1.​ Inability to remember an important the disturbance (Criteria B, C, D and E) is
aspect of the traumatic event(s) more than one month.
(typically due to dissociative G.​ The disturbance causes clinically significant
amnesia and not to other factors distress or impairment in social,
such as head injury, alcohol, or occupational, or other important areas of
drugs). functioning.
2.​ Persistent and exaggerated negative H.​ The disturbance is not attributable to the
beliefs or expectations about physiological effects of a substance (e.g.,
oneself, others, or the world (e.g., “I medication, alcohol) or another medical
am bad,” “no one can be trusted,” condition.
“the world is completely
dangerous,” “My whole nervous Specify if: With delayed expression: If the full
system is permanently ruined”). diagnostic criteria are not met until at least 6 months
3.​ Persistent distorted cognitions about after the event (although it is understood that onset
the cause or consequences of the and expression of some symptoms may be
traumatic event(s) that lead the immediate).
individual to blame himself/herself Specify whether: With Dissociative Symptoms: The
or others. individual’s symptoms meet the criteria for
4.​ Persistent negative emotional state posttraumatic stress disorder, and in addition, in
(e.g., fear, horror, anger, guilt, or response to the stressor, the individual experiences
shame). persistent or recurrent symptoms of either
5.​ Markedly diminished interest or depersonalization or derealization.
participation in significant activities.
6.​ Feelings of detachment or Acute stress disorder- is similar to PTSD,
estrangement from others. occurring within the first month after the trauma, but
7.​ Persistent inability to experience the different name emphasizes the severe reaction
positive emotions (e.g., inability to that some people have immediately.
experience happiness, satisfaction,
or loving feelings). Statistics
E.​ Marked alterations in arousal and reactivity ●​ Determine the onset of PTSD by simply
associated with the traumatic event(s), observing victims of a trauma and seeing
beginning or worsening after the traumatic how many are suffering from PTSD.
event(s) occurred, as evidenced by two (or ●​ Since a diagnosis of PTSD predicts suicidal
more) of the following: attempts independently of any other
ABNORMAL PSYCHOLOGY
problem, such as alcohol abuse, every case ●​ Cognitive therapy to correct negative
should be taken very seriously. assumptions about the trauma—such as
blaming oneself in some way, feeling guilty,
Causes or both—is another part of treatment.
●​ PTSD is the one disorder for which we ●​ D-Cycloserine (DCS) appears to have a
know the cause at least in terms of the fairly narrow thera peutic window and may
precipitating event: Someone personally not only augment extinction learning, but
experiences a trauma and develops a may also enhance a process called fear
disorder. memory reconsolidation
●​ The greater the vulnerability, the more likely -​ the process when fear
to develop PTSD. memory is reactivated and
●​ Higher intelligence predicted decreased stored back into long-term
exposure to these types of traumatic events. memory again.
Personality and other characteristics, some
of them at least partially heritable, may ❖​ Adjustment Disorder
predispose people to the experience of -​ anxious or depressive reactions to life stress
trauma by making it likely that they will be that are generally milder than one would see
in (risky) situations where trauma is likely to in acute stress disorder or PTSD but are
occur. nevertheless impairing in terms of
●​ PTSD involves a number of neurobiological interfering with work or school
systems, particularly elevated or restricted performance, interpersonal relationships, or
corticotropin-releasing factor (CRF), which other areas of living.
indicates heightened activity in the HPA -​ The stressful events themselves would not
axis. be considered traumatic, but it is clear that
the individual is nevertheless unable to cope
Treatment with the demands of the situation and some
●​ Most clinicians agree that victims of PTSD intervention is typically required.
should face the original trauma, process the -​ If the symptoms persist for more than six
intense emotions, and develop effective months after the removal of the stress or its
coping procedures in order to overcome the consequences, the adjustment disorder
debilitating effects of the disorder. would be considered “chronic.”
Catharsis- reliving emotional -​ Presumably it describes individuals with the
trauma to relieve emotional biological and psychological vulnerabilities
suffering. that are associated with trait anxiety that
Imaginal exposure- the content of flares up when confronting stressful events,
the trauma and the emotions although not to the extent that it would meet
associated with it are worked criteria for another more serious disorder.
through systematically.
●​ At present, the most common strategy to Adjustment disorder is the development of anxiety
achieve this purpose with adolescents or or depression in response to stressful, but not
adults is to work with the victim to develop traumatic, life events.
a narrative of the traumatic experience and
to expose the patients for an extended period ❖​ Attachment Disorders
of time to the image (prolonged exposure -​ disturbed and developmental ly
therapy) that is then reviewed extensively in inappropriate behaviors in children,
treatment. emerging before five years of age, in which
the child is unable or unwilling to form
ABNORMAL PSYCHOLOGY
normal attachment relationships with 2.​ The individual attempts to ignore or
caregiving adults. suppress such thoughts, impulses, or
-​ These seriously maladaptive patterns are due images, or to neutralize them with
to inadequate or abusive child-rear ing some other thought or action
practices. Compulsions are defined by 1 and 2:
-​ In DSM-5, two separate disorders are 1.​ Repetitive behaviors (e.g.,
described: handwashing, ordering, checking) or
Reactive attachment disorder- the mental acts (e.g., praying, counting,
child will very seldom seek out a repeating words silently) that the
caregiver for protection, support, individual feels driven to perform in
and nurturance and will seldom response to an obsession, or
respond to offers from caregivers to according to rules that must be
provide this kind of care. applied rigidly
2.​ The behaviors or mental acts are
Disinhibited social engagement aimed at preventing or reducing
disorder- a pattern of behavior in distress or preventing some dreaded
which the child shows no inhibitions event or situ ation; however, these
whatsoever to approaching adults. behaviors or mental acts either are
not connected in a realistic way with
Obsessive-Compulsive and Related Disorders what they are designed to neutralize
DSM-5 brings together several disorders that share a or prevent or are clearly excessive
number of characteristics, such as driven repetitive B.​ The obsessions or compulsions are
behaviors and some other symptoms, and a similar time-consuming (e.g., take more than 1 hour
course and treatment response. per day), or cause clinically significant
distress or impairment in social,
❖​ Obsessive-Compulsive Disorder(OCD) occupational or other important areas of
-​ the dangerous event is a thought, image, or functioning.
impulse that the client attempts to avoid. C.​ The disturbance is not due to the direct
Obsessions- intrusive and mostly physiological effects of a substance (e.g., a
nonsensical thoughts, images, or urges that drug of abuse, a medication) or another
the individual tries to resist or eliminate. medical condition.
Compulsions- thoughts or actions used to D.​ The disturbance is not better explained by
suppress the obsessions and provide relief. the symptoms of another mental disorder
(e.g., excessive worries, as in generalized
Diagnostic Criteria for Obsessive-Compulsive anxiety disorder, or preoccupation with
Disorder appearance, as in body dysmorphic
A.​ Presence of obsessions, compulsions or disorder).
both:
Obsessions are defined by 1 and 2: Specify if:
1.​ Recurrent and persistent thoughts, With good or fair insight: the individual
urges, or images that are recognizes that obsessive compulsive
experienced, at some time during disorder beliefs are definitely or probably
the disturbance, as intrusive and not true or that they may or may not be true.
inappropriate and that in most With poor insight: The individual thinks
individuals cause marked anxiety or obsessive-compulsive disorder beliefs are
distress probably true.
ABNORMAL PSYCHOLOGY
With absent insight/delusional: the person is biological and psychological precursors as
completely convinced that anxiety in general.
obsessive-compulsive disorder beliefs are Thought- action fusion- When
true. clients with OCD equate thoughts
Specify if: Tic-related: The individual has a current with the specific actions or activity
or past history of a tic disorder. represented by the thoughts.

Types of Obsessions and Compulsions

Tic Disorder and OCD
-​ characterized by involuntary movement
(sudden jerking of limbs, for example). Treatment
Tourette’s Disorder- More complex tics ●​ The most effective drug seem to be those
with involuntary vocalizations. that specifically inhibit the reuptake of
●​ Observations among one small group of serotonin, such as clomipramine or the
children presenting with OCD and tics SSRIs, which benefit up to 60% of patients
suggest that these problems occurred after a with OCD, with no particular advantage to
bout of strep throat (pediatric autoimmune one drug over another. Relapse often occurs
disorder associated with streptococcal when the drug is discontinued, however.
infection, or “PANDAS”). ●​ Exposure and Ritual Prevention (ERP)- a
●​ OCD has a ratio of female to male that is process whereby the rituals are actively
nearly 1:1. prevented and the patient is systematically
Characteristics and gradually exposed to the feared thoughts
●​ The tendency to develop anxiety over or situations.
having additional compulsive thoughts, ●​ Psychosurgery is one of the more radical
however, may have the same generalized treatments for OCD. “Psychosurgery” is a
ABNORMAL PSYCHOLOGY
misnomer that refers to neurosurgery for a clomipramine (Anafranil) and fluvoxamine
psychological disorder. (Luvox); 2)exposure and response
prevention, a type of CBT.
❖​ Body Dysmorphic Disorder
-​ some relatively normal-looking people think Diagnostic Criteria for Body Dysmorphic
they are so ugly they refuse to inter act with Disorder
others or otherwise function normally for A.​ Preoccupation with one or more defects or
fear that people will laugh at their ugliness. flaws in physical appearance that are not
-​ at its center is a preoccupation with some observable or appear slight to others.
imagined defect in appearance by someone B.​ At some point during the course of the
who actu ally looks reasonably normal. disorder, the individual has performed
-​ Has been referred to as “imagined ugliness.” repetitive behaviors (e.g., mirror checking,
-​ was considered a somatoform disorder exces sive grooming, skin picking,
because its central feature is a psychological reassurance seeking) or mental acts (e.g.,
preoccupation with somatic (physical) comparing his or her appearance with that of
issues. But increasing evidence indicated it others) in response to the appearance
was more closely related to OCD. concerns.
-​ People with BDD complain of persistent, C.​ The preoccupation causes clinically
intrusive, and horrible thoughts about their significant distress or impairment in social,
appearance, and they engage in such occupational, or other important areas of
compulsive behaviors as repeatedly looking functioning.
in mirrors to check their physical features. D.​ The appearance preoccupation is not better
-​ previously known as dysmorphophobia explained by concerns with body fat or
(literally, fear of ugliness), was thought to weight in an individual whose symptoms
represent a psychotic delusional state meet diagnostic criteria for an eating
because the affected individuals were unable disorder.
to realize, even for a fleeting moment, that
their ideas were irrational. Specify if:
-​ BDD and OCD also have approximately the With good or fair insight: The individual recognizes
same age of onset and run the same course. that the body dysmorphic disorder beliefs are
-​ The prevalence of BDD is hard to estimate definitely or probably not true or that they may or
because by its very nature it tends to be kept may not be true.
secret. With poor insight: The individual thinks that the
-​ BDD is seen equally in men and women. body dysmorphic disorder beliefs are probably true.
-​ Age of onset ranges from early adolescence With absent insight/delusional beliefs: the individual
through the 20s, peaking at the age of is completely convinced that the body dysmorphic
16–17. disorder beliefs are true.
-​ Individuals with BDD react to what they With muscle dysmorphia: The individual is
think is a horrible or grotesque feature. preoccupied with the idea that his or her body build
Thus, the psychopathology lies in their is too small or insufficiently muscular. This specifier
reacting to a “deformity” that others cannot is used even if the individual is preoccupied with
perceive. Social and cultural determinants of other body areas, which is often the case.
beauty and body image largely define what
is “deformed.” In body dysmorphic disorder (BDD), a person who
-​ There are only two treatments for BDD with looks normal is obsessively preoccupied with some
any evidence of effectiveness: 1) drugs that imagined defect in appearance (imagined ugliness).
block the re-uptake of serotonin, like
ABNORMAL PSYCHOLOGY

Other Obsessive-Compulsive and Related

Disorders

❖​ Hoarding Disorder
-​ The three major characteristics of this
problem are excessive acquisition of things,
difficulty discarding anything, and living
with excessive clutter under conditions best
characterized as gross disorganization.
-​ Hoarding behavior can begin early in life
and get worse with each passing decade.
-​ Cognitive and emotional abnormalities
associated with hoarding alluded to above
include extraordinarily strong emotional
attachment to possessions, an exaggerated
desire for control over possessions, and
marked deficits in deciding when a
possession is worth keeping or not (all
possessions are believed to be equally
valuable).
-​ CBT is a promising treatment for hoarding
disorder. These treatments developed at our
clinic teach people to assign different values
to objects and to reduce anxiety about
throwing away items that are somewhat less
valued.

❖​ Trichotillomania (Hair Pulling Disorder)

and Excoriation (Skin Picking Disorder)
Prior to DSM-5, both disorders were classified
under impulse control disorders, but it has been
established that these disorders often co-occur with
obsessive-compulsive disorder and body dysmorphic
disorder, as well as with each other.
Trichotillomania- the urge to pull out one’s
own hair from anywhere on the body,
including the scalp, eyebrows, and arms.
-​ This behavior results in noticeable
hair loss, distress, and significant
social impairments.

Excoriation- (skin picking disorder) is

characterized, as the label implies, by
repetitive and compulsive picking of the
skin, leading to tissue damage.
ABNORMAL PSYCHOLOGY
CHAPTER 6: Somatic Symptom and Related Severe: Two or more of the symptoms specified in
Disorders and Dissociative Disorders Criterion B are fulfilled, plus there are multiple
somatic complaints (or one very severe somatic
Somatic Symptom and Related Disorders symptom).
Soma means body, and the problems preoccupying
these people seem, initially, to be physical disorders. Somatic symptom disorder is characterized by a
focus on one or more physical symptoms
❖​ Somatic Symptom Disorder accompanied by marked distress focused on the
-​ Was previously called Briquet’s syndrome symptom that is disproportionate to the nature or
after Pierre Briquet. severity of the physical symptoms.
-​ the important factor in this condition is not
whether the physical symptom, in this case ❖​ Illness Anxiety Disorder
pain, has a clear medical cause or not, but (Hypochondriasis)
rather that psychological or behavioral -​ physical symptoms are either not
factors, particularly anxiety, and distress, are experienced at the present time or are very
compounding the severity and impairment mild, but severe anxiety is focused on the
associated with the physical symptoms. possibility of having or developing a serious
disease.
Diagnostic Criteria for Somatic Symptom -​ the concern is primarily with the idea of
Disorder being sick instead of the physi cal symptom
A.​ One or more somatic symptoms that are itself. And the threat seems so real that
distressing and/or result in significant reassurance from physicians does not seem
disruption of daily life. to help.
B.​ Excessive thoughts, feelings, and behaviors -​ the individual is preoccupied with bodily
related to the somatic symptoms or symptoms, misinterpreting them as
associated health concerns as manifested by indicative of illness or disease. Almost any
at least one of the following: physical sensation may become the basis for
1.​ Disproportionate and persistent concern.
thoughts about the serious ness of -​ has a late age of onset, possibly because
one’s symptoms. more physical health problems occur with
2.​ High level of health-related anxiety. aging.
3.​ Excessive time and energy devoted
to these symptoms or health Disease conviction- individuals mistakenly believe
concerns. they have a disease.
C.​ Although any one symptom may not be
continuously present, the state of being Diagnostic Criteria for Illness Anxiety Disorder
symptomatic is persistent (typically more A.​ Preoccupation with fears of having or
than 6 months). acquiring a serious illness.
B.​ Somatic symptoms are not present or, if
Specify if: With predominant pain (previously pain present, are only mild in intensity. If another
disorder): This specifier is for individuals whose medical condition is present or there is a
somatic complaints predominantly involve pain. high risk for developing a medical condition
Specify current severity: (e.g., strong family history is present), the
Mild: Only one of the symptoms in Criterion B is preoccupation is clearly excessive or
fulfilled. disproportionate.
Moderate: Two or more of the symptoms specified
in Criterion B are fulfilled.
ABNORMAL PSYCHOLOGY
C.​ There is a high level of anxiety about health, ●​ Hyper responsivity might combine with a
and the individual is easily alarmed about tendency to view negative life events as
personal health status. unpredictable and uncontrollable and,
D.​ The individual performs excessive therefore, to be guarded against at all times.
health-related behaviors (e.g., repeatedly ●​ Some individuals who develop SSD or IAD
checks his or her body for signs of illness) have learned from family members to focus
or exhibits maladaptive avoidance (e.g., their anxiety on specific physical conditions
avoids doctors’ appointments and hospitals). and illness.
e. Illness preoccupation has been present for ●​ Three other factors may contribute to this
at least 6 months, but the specific illness that etiological process:
is feared may change over that period of 1.​ these disorders seem to develop in
time. the context of a stressful life event
E.​ The illness-related preoccupation is not 2.​ people who develop these disorders
better explained by another mental disorder, tend to have had a disproportionate
such as somatic symptom disorder, incidence of disease in their family
generalized anxiety disorder, or when they were children
obsessive-compulsive disorder. 3.​ an important social and
Specify whether: interpersonal influence may be
Care-seeking type: Medical care, involved.
including physician visits or Treatment
undergo ing tests and procedures, is ●​ Explanatory therapy- in which the clinician
frequently used. went over the source and origins of their
Care-avoidant type: Medical care is symptoms in some detail.
rarely used. ●​ CBT focused on identifying and challenging
illness-related misinterpretations of physical
sensations and on showing patients how to
create “symptoms” by focusing attention on
certain body areas. Bringing on their own
symptoms persuaded many patients that
such events were under their control.
Patients were also coached to seek less
reassurance regarding their concerns.

Illness anxiety disorder is a condition in which

individuals believe they are seriously ill and become
Causes anxious over this possibility, even though they are
●​ Faulty interpretation of physical signs and not experiencing any notable physical symptoms at
sensations as evidence of physical illness is the time.
central, so almost everyone agrees that these
disorders are basically disorders of cognition ❖​ Psychological Factors Affecting Medical
or perception with strong emotional Condition
contributions. -​ The essential feature of this disorder is the
●​ The Stroop test has confirmed that presence of a diagnosed medical condition
participants with these disorders show that is adversely affected (increased in
enhanced perceptual sensitivity to illness frequency or severity) by one or more
cues. psychological or behavioral factors.
ABNORMAL PSYCHOLOGY
-​ These behavioral or psychological factors
would have a direct influence on the course In conversion disorder, there is physical
or perhaps the treatment of the medical malfunctioning, such as paralysis, without any
condition. apparent physical problems.

Closely related Disorders

❖​ Conversion Disorder (Functional Distinguishing among conversion reactions,
Neurological Symptom Disorder) medically explained symptoms, and outright
-​ generally have to do with physical mal malingering (faking) is sometimes difficult.
functioning, such as paralysis, blindness, or
difficulty speaking (aphonia), without any ❖​ Factitious Disorder
physical or organic pathology to account for -​ fall somewhere between malingering and
the malfunction. conver sion disorders.
-​ symptoms suggest that some kind of -​ The symptoms are under voluntary control,
neurological disease is affecting as with malingering, but there is no obvious
sensory–motor systems, although conversion reason for voluntarily producing the
symptoms can mimic the full range of symptoms except, possibly, to assume the
physical malfunctioning. sick role and receive increased attention.
-​ Other symptoms may include total mutism
and the loss of the sense of touch, seizures
(psychogenic non-epileptic seizures), globus
hystericus (the sensation of a lump in the Factitious Disorder Imposed on Another
throat). (Munchausen Syndrome by Proxy)
Conversion- popularized by Freud, who believed the -​ When an individual deliberately makes
anxiety resulting from unconscious conflicts someone else sick.
somehow was “converted” into physical symptoms -​ The offending parent may resort to extreme
to find expression. tactics to create the appearance of illness in
Functional- refers to a symptom without an organic the child.
cause.
Diagnostic Criteria for Factitious Disorders
Diagnostic Criteria for Conversion Disorder A.​ Falsification of physical or psychological
(Functional Neurological Symptom Disorder) signs or symptoms, or induction of injury or
A.​ One or more symptoms of altered voluntary disease, associated with identified deception.
motor or sensory function. B.​ The individual presents himself or herself to
B.​ Clinical findings provide evidence of others as ill, impaired or injured.
incompatibility between the symptom and C.​ The deceptive behavior is evident even in
recognized neurological or medical the absence of obvious external rewards.
conditions. D.​ The behavior is not better accounted for by
C.​ The symptom or deficit is not better another mental disorder such as delusional
explained by another medical or mental belief system or acute psychosis.
disorder.
D.​ The symptom or deficit causes clinically Specify if:
significant distress or impairment in social, Single episode
occupational, or other important areas of Recurrent episodes: Two or more events of
functioning or warrants medical evaluation. falsification of illness and/ or induction of injury.
ABNORMAL PSYCHOLOGY

●​ Prior experience with real physical

In factitious disorder, the person’s symptoms are problems, usually among other family
feigned and under voluntary control, as with members, tends to influence the later choice
malingering, but for no apparent reason. of specific con version symptoms; that is,
patients tend to adopt symptoms with which
Unconscious Mental Processes they are familiar.
Unconscious cognitive processes is most seen in ●​ Biological contributory factors seem to be
conversion disorders and related conditions. less important than the overriding influence
of interpersonal factors.
Statistics
●​ Conversion disorders are relatively rare in Treatment
mental health settings, but only because ●​ A principal strategy in treating conversion
people who seek help for this condition are disorder is to identify and attend to the
more likely to consult neurologists or other traumatic or stressful life event, if it is still
specialists. present (either in real life or in memory).
●​ Conversion disorders are found primarily in ●​ The therapist must also work hard to reduce
women and typically develop during any reinforcing or supportive consequences
adolescence or slightly thereafter. of the conversion symptoms (secondary
●​ tends to occur in less educated, lower gain).
socioeconomic groups where knowledge
about disease and medical illness is not well
developed. Dissociative Disorders

Causes Depersonalization- your perception alters so that

Freud described four basic processes in the you temporarily lose the sense of your own reality.
development of conversion disorder: Derealization- your sense of the reality of the
1.​ the individual experiences a external world is lost.
traumatic event— in Freud’s view,
an unacceptable, unconscious ❖​ Depersonalization-Derealization
conflict. Disorder
2.​ because the conflict and the -​ When feelings of unreality are so severe
resulting anxiety are unacceptable, and frightening that they dominate an
the person represses the conflict, individual’s life and prevent normal
making it unconscious. functioning.
3.​ the anxiety continues to increase -​ Mean age of onset was 16 years
and threatens to emerge into -​ The course tended to be chronic.
consciousness, and the person -​ All patients were substantially impaired.
“converts” it into physical -​ Anxiety, mood, and personality disorders are
symptoms, thereby relieving the also commonly found in these individuals.
pressure of having to deal directly
with the conflict (primary gain) Dissociative disorders are characterized by
4.​ the individual receives greatly alterations in perceptions: a sense of detachment
increased attention and sympathy from one’s own self, from the world, or from
from loved ones and may also be memories.
allowed to avoid a difficult situation
or task (secondary gain).
ABNORMAL PSYCHOLOGY
Diagnostic Criteria for Depersonalization- -​ Fugue states usually end rather abruptly, and
Derealization Disorder the individual returns home, recalling most,
A.​ The presence of persistent or recurrent if not all, of what happened
experiences of deper sonalization,
derealization, or both: Diagnostic Criteria for Dissociative Amnesia
Depersonalization: Experiences of A.​ An inability to recall important
unreality, detachment, or being an autobiographical information, usually of a
outside observer with respect to traumatic or stressful nature, that is
one’s thoughts, feelings, sensations, inconsistent with ordinary forgetting.
body or actions (e.g., perceptual Note: Dissociative amnesia most
alterations, distorted sense of time, often consists of localized or
unreal or absent self, emotional selective amnesia for a specific
and/or physical numbing). event or events; or generalized
Derealization: Experiences of amnesia for identity and life history.
unreality or detachment with respect B.​ The symptoms cause clinically significant
to surroundings (e.g., individuals or distress or impair ment in social,
objects are experi enced as unreal, occupational, or other important areas of
dreamlike, foggy, lifeless, or functioning.
visually distorted). C.​ The disturbance is not attributable to the
B.​ During the depersonalization or physiological effects of a substance (e.g.,
derealization experience, real ity testing alcohol or other drug of abuse, a medication)
remains intact. or a neurological or other medical condition
C.​ The symptoms cause clinically significant (e.g., partial com plex seizures, transient
distress or impair ment in social, global amnesia, sequelae of a closed head
occupational, or other important areas of injury/traumatic brain injury, or other
functioning. neurological condition).
D.​ The disturbance is not attributable to the D.​ The disturbance is not better explained by
physiological effects of a substance (e.g., a dissociative identity disorder, posttraumatic
drug of abuse, medication) or another stress disorder, acute stress disorder, somatic
medical condition (e.g., seizures). symptom disorder, or major or mild
E.​ The disturbance is not better explained by neurocognitive disorder.
another mental disorder, such as
schizophrenia or panic disorder. Specify if: With dissociative fugue: Apparently
purposeful travel or bewildered wandering that is
In depersonalization-derealization disorder, in associated with amnesia for identity or for other
which the individual’s sense of personal reality is important autobiographical information.
temporarily lost (depersonalization), as is the reality
of the external world (derealization). Generalized Amnesia
-​ People who are unable to remember
❖​ Dissociative Amnesia anything, including who they are.
-​ Perhaps the easiest to understand of the -​ May be lifelong or may extend from a
severe dissociative disorders. period in the more recent past, such as 6
-​ seldom appears before adolescence and months or a year previously.
usually occurs in adulthood. Localized or Selective Amnesia
-​ Once dissociative disorders do appear, -​ a failure to recall specific events, usually
however, they may continue well into old traumatic, that occur during a specific
age. period.
ABNORMAL PSYCHOLOGY
Dissociative Fugue B.​ Recurrent gaps in the recall of everyday
-​ a subtype of dissociative amnesia, memory events, important personal information,
loss is combined with an unexpected trip (or and/or traumatic events that are incon sistent
trips). with ordinary forgetting.
Dissociative Trance C.​ The symptoms cause clinically significant
-​ When the state is undesirable and distress or impair ment in social,
considered pathological by members of the occupational, or other important areas of
culture, particularly if the trance involves a functioning.
perception of being possessed by an evil D.​ The disturbance is not a normal part of a
spirit or another person. broadly accepted cul tural or religious
practice.
Note: In children, the symptoms are
❖​ Dissociative Identity Disorder not attributable to imaginary
-​ People with DID may adopt as many as 100 playmates or other fantasy play.
new identities, all simultaneously coexisting, E.​ The symptoms are not attributable to the
although the average number is closer to 15. physiological effects of a substance (e.g.,
-​ In many cases, only a few characteristics blackouts or chaotic behavior during alco
are distinct, because the identities are only hol intoxication) or another medical
partially independent, so it is not true that condition (e.g., complex partial seizures).
there are “multiple” complete personalities.
-​ include amnesia, as in dissociative amnesia. Statistics
In DID, however, identity has also ●​ Of people with DID, the ratio of females to
fragmented. males is as high as 9:1 in accumulated cases.
-​ The person who becomes the patient and ●​ The onset is almost always in childhood,
asks for treatment is usually a “host” often as young as 4 years of age, although it
identity. is usually approximately 7 years after the
-​ Host personalities usually attempt to hold appearance of symptoms before the disorder
various fragments of identity together but is identified.
end up being overwhelmed. ●​ A large percentage of DID patients have
Alters- the shorthand term for the different identities simultaneous psy chological disorders that
or personalities in DID. may include anxiety, substance abuse,
Switch- transition from one personality to another. depression, and personality disorders.

Diagnostic Criteria for Dissociative Identity Causes

Disorder ●​ There is a wide-ranging agreement that DID
A.​ Disruption of identity characterized by two is rooted in a natural tendency to escape or
or more distinct personality states, which “dissociate” from the unremitting negative
may be described in some cultures as an affect associated with severe abuse.
experience of possession. The disruption of ●​ Dissociative amnesia and fugue states are
marked discontinuity in sense of self and clearly reactions to severe life stress. But the
sense of agency, accompanied by related life stress or trauma is in the present rather
alterations in affect, behavior, than the past.
consciousness, memory, perception, ●​ One perspective suggests that DID is an
cognition, and/or sensory-motor functioning. extreme subtype of PTSD, with a much
These signs and symptoms may be observed greater emphasis on the process of
by others or reported by the individual. dissociation than on symptoms of anxiety,
although both are present in each disorder.
ABNORMAL PSYCHOLOGY
●​ The fundamental goal is to identify cues or
Suggestibility triggers that provoke memories of trauma,
-​ a personality trait distributed normally dissoci ation, or both, and to neutralize
across the population, much like weight and them. More important, the patient must
height. Some people are more suggestible confront and relive the early trauma and
than others; some are relatively immune to gain control over the horrible events, at least
suggest ibility; and the majority fall in the as they recur in the patient’s mind.
midrange. ●​ To instill this sense of control, the therapist
●​ According to the autohypnotic model, must skillfully, and slowly, help the patient
people who are suggest ible may be able to visualize and relive aspects of the trauma
use dissociation as a defense against extreme until it is simply a terrible memory instead
trauma. of a current event.
●​ Hypnosis is often used to access
Biological Contributions unconscious memories and bring various
●​ Patients with dissociative experiences who alters into awareness.
have seizure disorders are clearly different ●​ It is possible that reemerging memories of
from those who do not. The seizure patients trauma may trigger further dissociation.
develop dissociative symptoms in adulthood ●​ Trust is important to any therapeutic
that are not associated with trauma, in clear relationship, but it is essential in the
con trast to DID patients without seizure treatment of DID. Occasionally, medication
disorders. is combined with therapy, but there is little
●​ Head injury and resulting brain damage indication that it helps much.
may induce amnesia or other types of
dissociative experience. But these conditions In the extreme, new identities, or alters, may be
are usually easily diagnosed because they formed, as in dissociative identity disorder (DID).
are generalized and irrevers ible and are
associated with an identifiable head trauma.

Real Memories and False

●​ Studies suggest that individuals pre senting
with dissociation, and particularly DID, may
have expe rienced severe trauma, such as
sexual abuse, early in their lives but that
they have dissociated themselves from this
experience and “repressed” the memory.

Treatment
●​ Individuals who experience dissociative
amnesia or a fugue state usually get better
on their own and remember what they have
for gotten. The episodes are so clearly
related to current life stress that prevention
of future episodes usually involves
therapeutic resolution of the distressing
situations and increasing the strength of
personal coping mechanisms.
ABNORMAL PSYCHOLOGY
CHAPTER 7: Mood Disorders and Suicide Criteria for Major Depressive Episode
A.​ Five (or more) of the following symptoms
Mood disorders- characterized by gross deviations have been present during the same 2-week
in mood. period and represent a change from previous
-​ The fundamental experiences of depression functioning; at least one of the symptoms is
and mania contribute, either singly or either (1) depressed mood or (2) loss of
together, to all the mood disorders. interest or pleasure.
Note: Do not include
Mood disorders are among the most common symptoms that are clearly
psychological dis orders, and the risk of developing due to a general medical
them is increasing worldwide, particularly in condition or
younger people. mood-incongruent delusions
or hallucinations.
1.​ Depressed mood most of the day,
❖​ Major Depressive Episode nearly every day, as indi cated by
-​ most commonly diagnosed and most severe either subjective report (e.g., feels
depression. sad or empty) or observation made
-​ DSM-5 criteria describes it as an extremely by others (e.g., appears tearful).
depressed mood state that lasts at least 2 Note: in children and
weeks and includes cognitive symptoms adolescents can be irritable
(such as feelings of worthlessness and mood.
indecisiveness) and disturbed physical 2.​ Markedly diminished interest or
functions (such as altered sleeping patterns, pleasure in all, or almost all,
significant changes in appetite and weight, activities most of the day, nearly
or a notable loss of energy) to the point that every day (as indicated by either
even the slightest activ ity or movement subjective account or observation
requires an overwhelming effort. made by others).
-​ The episode is typically accompanied by a 3.​ Significant weight loss when not
general loss of interest in things and an dieting or weight gain (e.g., a
inability to experience any pleasure from change of more than 5% of body
life. weight in a month), or decrease or
-​ Evidence suggests that the most central increase in appetite nearly every
indicators of a full major depressive episode day.
are the physical changes (somatic or Note: in children, consider
vegetative symptoms), along with the failure to make expected
behavioral and emotional “shutdown,” as weight gains.
reflected by low behavioral activation. 4.​ Insomnia or hypersomnia nearly
-​ Anhedonia (loss of energy and inability to every day.
engage in pleasurable activities or have any 5.​ Psychomotor agitation or retardation
“fun”) is more characteristic of these severe nearly every day (observable by
episodes of depression. This reflects that others, not merely subjective
these episodes represent a state of low feelings of restlessness or being
positive affect and not just high negative slowed down).
affect. 6.​ Fatigue or loss of energy nearly
every day.
7.​ Feelings of worthlessness or
excessive or inappropriate guilt
ABNORMAL PSYCHOLOGY
(which may be delusional) nearly With atypical features
every day (not merely self reproach With mood-congruent psychotic features
or guilt about being sick). With mood-incongruent psychotic features
8.​ Diminished ability to think or With catatonia
concentrate, or indecisive ness, With peripartum onset
nearly every day (either by With seasonal pattern (recurrent episode
subjective account or as observed by only)
others). In partial remission, in full remission
9.​ Recurrent thoughts of death (not just
fear of dying), recur rent suicidal ❖​ Mania
ideation without a specific plan, or a -​ abnormally exaggerated elation, joy, or
suicide attempt or a specific plan for euphoria.
committing suicide. -​ individuals find extreme pleasure in every
B.​ The symptoms cause clinically significant activity
distress or impair ment in social, -​ They become extraordinarily active
occupational, or other important areas of (hyperactive), require little sleep, and may
functioning. develop grandiose plans, believing they can
C.​ The symptoms are not due to the direct accomplish anything they desire.
physiological effects of a substance (e.g., a -​ “persistently increased goal-directed activity
drug of abuse, a medication) or a general or energy”
medical condition (e.g., hypothyroidism). -​ Speech is typically rapid and may become
incoherent, because the individual is
Diagnostic Criteria for Major Depressive attempting to express so many exciting ideas
Disorder at once (flight of ideas).
A.​ At least one major depressive episode. -​ manic episode require a duration of only 1
B.​ The occurrence of the major depressive week, less if the episode is severe enough to
episode is not better explained by require hospitalization.
schizoaffective disorder, schizophrenia, -​ duration of an untreated manic episode is
schizo phreniform disorder, delusional typically 3 to 4 months.
disorder, or other specified and unspecified
schizophrenia spectrum and other psychotic Hypomanic Episode
disorders. -​ a less severe version of a manic episode that
C.​ There has never been a manic episode or does not cause marked impairment in social
hypomanic episode. or occupational functioning and need last
Note: This exclusion does not apply only 4 days rather than a full week.
if all of the manic-like or -​ (Hypo means “below”; thus the episode is
hypomanic-like episodes are below the level of a manic episode.)
substance-induced or are attribut -​ not in itself necessarily problematic, but its
able to the direct physiological presence does contribute to the definition of
effects of another medical condition. several mood disorders.
Specify the clinical status and/or features of the The Structure of Mood Disorders
current or most recent major depressive episode: ❖​ Unipolar Mood Disorder
Single episode or recurrent episode -​ Individuals who experience either
Mild, moderate, severe depression or mania
With anxious distress -​ their mood remains at one “pole” of the
With mixed features usual depression–mania continuum.
With melancholic features
ABNORMAL PSYCHOLOGY
lasting at least 1 week and present most of
An individual who suffers from episodes of the day, nearly every day (or any duration if
depression only is said to have a unipolar disorder. hospitalization is necessary).
B.​ During the period of mood disturbance and
❖​ Bipolar Mood Disorder increased energy or activity, three (or more)
-​ Someone who alternates between depression of the following symptoms (four if the mood
and mania is only irritable) are present to a significant
-​ Mood traveling from one “pole” of the degree and represent a noticeable change
depression–elation continuum to the other from usual behavior:
and back again. 1.​ Inflated self-esteem or grandiosity
2.​ Decreased need for sleep (e.g., feels
An individual who alternates between depression rested after only 3 hours of sleep)
and mania has a bipolar disorder. The key 3.​ More talkative than usual or
identifying feature of bipolar disorders is an pressure to keep talking
alternation of manic episodes and major depressive 4.​ Flight of ideas or subjective
episodes. experience that thoughts are racing
5.​ Distractibility (i.e., attention too
❖​ Mixed Features easily drawn to unimportant or
-​ An individual can experience manic irrelevant external stimuli), as
symptoms but feel somewhat depressed or reported or observed
anxious at the same time, or be depressed 6.​ Increase in goal-directed activity
with a few symptoms of mania. (either socially, at work or school, or
-​ requires specifying whether a predominantly sexually) or psychomotor agitation
manic or predominantly depressive episode (e.g., purposeless non-goal-directed
is present and then noting if enough activity)
symptoms of the opposite polarity are 7.​ Excessive involvement in activities
present to meet the mixed features criteria. that have a high potential for painful
consequences (e.g., engaging in
●​ It is important to determine the course or unrestrained buying sprees, sexual
temporal pattern ing of the depressive or indiscretions, or foolish business
manic episodes. For example, do they tend investments)
to recur? If they do, does the patient recover C.​ The mood disturbance is sufficiently severe
fully for at least two months between to cause marked impairment in social or
episodes (full remission) or only partially occupational functioning or to necessitate
recover retaining some depressive symptoms hospitalization to prevent harm to self or
(partial remission)? others, or there are psychotic features.
●​ The importance of temporal course D.​ The episode is not attributable to the
(patterns of recurrence and remittance) physiological effects of a substance (e.g., a
makes the goals of treating mood disorders drug of abuse, a medication, other treatment)
somewhat different from those for other or to another general medical condition.
psychological disorders.
Note: A full manic episode that emerges during
Criteria for Manic Episode antidepressant treatment (e.g., medication,
A.​ A distinct period of abnormally and electroconvulsive therapy) but persists at a fully
persistently elevated, expansive, or irritable syndromal level beyond the physiological effect of
mood and abnormally and persistently that treatment is sufficient evidence of a manic
increased goal-directed activity or energy, episode and, therefore, a bipolar I diagnosis.
ABNORMAL PSYCHOLOGY
❖​ Persistent Depressive Disorder C.​ During the 2-year period (1 year for children
(Dysthymia) or adolescents) of the disturbance, the
-​ shares many of the symptoms of major person has never been without the symptoms
depressive disorder but differs in its course. in criteria A and B for more than 2 months
-​ defined as depressed mood that continues at at a time.
least 2 years, during which the patient can D.​ Criteria for major depressive disorder may
not be symptom free for more than 2 months be continuously present for 2 years.
at a time even though they may not E.​ There has never been a manic episode or a
experience all of the symptoms of a major hypomanic episode, and criteria have never
depressive episode. been met for cyclothymic disorder.
-​ identifies patients who were formerly F.​ The disturbance is not better explained by a
diagnosed with dysthymic disorder and persistent schizoaffective disorder,
other depressive dis orders schizophrenia, delusional disorder, or other
-​ differs from a major depressive disorder in specified or unspecified schizophrenia
the number of symptoms required, but spectrum and other psychotic disorder.
mostly it is in the chronicity. G.​ The symptoms are not attributable to the
-​ considered more severe, since patients with physiological effects of a substance (e.g., a
persistent depression present with higher drug of abuse, a medication) or another
rates of comorbidity with other mental medical condition (e.g., hypothyroidism).
disorders, are less responsive to treatment, H.​ The symptoms cause clinically significant
and show a slower rate of improvement over distress or impairment in social,
time. occupational, or other important areas of
-​ 22% of people suffering from persistent functioning.
depression with fewer symptoms (specified
as “with pure dysthymic syndrome”) Specify if:
eventually experienced a major depressive Current severity: Mild, moderate, severe
episode. With anxious distress
With mixed features
Diagnostic Criteria for Persistent Depressive With melancholic features
Disorder (Dysthymia) With atypical features
A.​ Depressed mood for most of the day, for With mood-congruent psychotic features
more days than not, as indicated by either With mood-incongruent psychotic features
subjective account or observation by others, With peripartum onset
for at least 2 years. Early onset: If onset is before age 21 years
Note: In children and adolescents, Late onset: If onset is at age 21 years or
mood can be irritable and duration older
must be at least 1 year. Specify (for most recent 2 years of dysthymic
B.​ Presence, while depressed, of two (or more) disorder):
of the following: With pure dysthymic syndrome: if full
1.​ Poor appetite or overeating criteria for a major depressive episode have
2.​ Insomnia or hypersomnia not been met in at least the preceding 2
3.​ Low energy or fatigue years
4.​ Low self-esteem With persistent major depressive episode: if
5.​ Poor concentration or difficulty full criteria for a major depressive episode
making decisions have been met throughout the preceding
6.​ Feelings of hopelessness 2-year period
ABNORMAL PSYCHOLOGY
With intermittent major depressive episodes, 2.​ Anxious distress specifier. The presence
with current episode: if full criteria for a and severity of accompanying anxiety,
major depressive episode are currently met, whether in the form of comorbid anxiety
but there have been periods of at least 8 disorders (anxiety symptoms meeting the
weeks in at least the preceding 2 years with full criteria for an anxiety disorder) or
symptoms below the threshold for a full anxiety symptoms that do not meet all the
major depressive episode criteria for disorders.
With intermittent major depressive episodes, 3.​ Mixed features specifier. Predominantly
without current episode: if full criteria for a depressive episodes that have several (at
major depressive episode are not currently least three) symptoms of mania as described
met, but there has been one or more major above would meet this specifier.
depressive episodes in at least the preceding 4.​ Melancholic features specifier. This
2 years In full remission, in partial remission specifier applies only if the full criteria for a
major depressive episode have been met,
In Persistent Depressive Disorder (dysthymia), the whether in the context of a persistent
symptoms are often some what milder but remain depressive disorder or not.
relatively unchanged over long periods. 5.​ Catatonic features specifier. This specifier
can be applied to major depressive episodes
Double depression- individuals suffer from both in the context of a persistent depressive
major depressive episodes and persistent depression order or not, and even to manic episodes,
with fewer symptoms. although it is rare. This serious condition
-​ Typically, a few depressive symptoms involves an absence of movement (a
develop first, perhaps at an early age, and stuporous state) or catalepsy (a patient’s
then one or more major depressive episodes arms or legs remain in any position in which
occur later only to revert to the underlying they are placed).
pattern of depression once the major 6.​ Atypical features specifier. This specifier
depressive episode has run its course. applies to both depressive episodes, whether
in the context of persistent depressive
disorder or not. Individuals with this
Additional Defining Criteria for Depressive specifier consistently oversleep and overeat
Disorders during their depression and therefore gain
weight, leading to a higher incidence of
In addition to rating severity of the episode as mild, diabetes.
moderate, or severe, clinicians use eight basic 7.​ Peripartum onset specifier. Peri means
specifiers to describe depressive disorders. These “surrounding,” in this case the period of
are: time just before and just after the birth. This
1.​ Psychotic features specifiers. Some specifier can apply to both major depressive
individuals in the midst of a major and manic episodes.
depressive (or manic) episode may 8.​ Seasonal pattern specifier. This temporal
experience psychotic symptoms, specifically specifier applies to recurrent major
hallucinations (seeing or hearing things that depressive disorder (and also to bipolar dis
aren’t there) and delusions (strongly held but orders). It accompanies episodes that occur
inaccurate beliefs); auditory hallucinations during certain seasons.
(hearing voices), delusions of grandeur Seasonal Affective Disorder
(believing, for example, they are (SAD)- These episodes must have
supernatural or supremely gifted) occurred for at least two years with
no evidence of nonseasonal major
ABNORMAL PSYCHOLOGY
depressive episodes occurring its MDD, but remains the most
during that period of time. severely depressed after 10 years.
-​ Emerging evidence suggests ●​ The nonchronic major depressive
that SAD may be related to disorder group evidences the most
daily and seasonal changes recovery (on average).
in the production of
melatonin, a hormone
secreted by the pineal gland. From Grief to Depression

Some of these specifiers apply only to

major depressive disorder. Others
apply to both major depressive
disorder and persistent depressive
disorder. Each is described briefly
below.
Onset and Duration
●​ Risk for developing major
depression begins to rise in a
steady (linear) fashion in early
teens.
●​ The length of depressive
episodes is vari able, with
some lasting as little as 2
weeks; in more severe cases,
an episode might last for
several years, with the typical
duration of the first episode
being 2 to 9 months if
untreated.
●​ Patients with PDD with less
severe depressive symptoms
(dysthymia) were more likely
to attempt suicide than a
comparison group with
(nonpersistent) episodes of
major depressive disorder
during a 5-year period.
●​ Those who have had persistent
depressive disorder, as many
as 79% have also had a major
depressive episode at some
point in their lives.
●​ The group with PDD, on the
average, stays depressed.
●​ The double depression group
starts off more severe, recovers from
ABNORMAL PSYCHOLOGY
Integrated grief- The acute grief most of us would tearful, or increased sensitivity to
feel eventually evolves into acknowledging the rejection).
finality of death and its consequences and the 2.​ Marked irritability or anger or
individual adjusts to the loss. increased interpersonal conflicts.
-​ often recurs at significant anniversaries, 3.​ Marked depressed mood, feelings of
such as the birthday of the loved one, hopelessness, or self-deprecating
holidays, and other meaningful occasions, thoughts.
including the anniversary of the death. 4.​ Marked anxiety, tension, and/or
-​ This is all a very normal and positive feelings of being keyed up or on
reaction edge.
C.​ One (or more) of the following symptoms
●​ After 6 months to a year or so, the chance must additionally be present, to reach a total
of recovering from severe grief without of five symptoms when combined with
treatment is considerably reduced, and for symptoms from Criterion B above:
approxi mately 7% of bereaved individuals, 1.​ Decreased interest in usual activities
a normal process becomes a disorder. (e.g., work, school, friends,
hobbies).
Complicated grief- At this stage, suicidal thoughts 2.​ Subjective difficulty in
increase substantially and focus mostly on joining concentration.
the beloved deceased 3.​ Lethargy, easy fatigability, or
-​ The ability to imagine events in the future is marked lack of energy.
generally impaired, since it is difficult to 4.​ Marked change in appetite;
think of a future with out the deceased. overeating; or specific food
cravings.
Other Depressive Disorders 5.​ Hypersomnia or insomnia.
6.​ A sense of being overwhelmed or
❖​ Premenstrual Dysphoric Disorder out of control.
(PMDD) 7.​ Physical symptoms such as breast
-​ a combination of physical symptoms, tenderness or swelling, joint or
severe mood swings, and anxiety are muscle pain, a sensation of
associated with incapacitation during this “bloating,” or weight gain.
period of time. Note: The symptoms in
Criteria A–C must have
been met for most menstrual
Diagnostic Criteria for Premenstrual Dysphoric cycles that occurred in the
Disorder preceding year.
A.​ In the majority of menstrual cycles, at least D.​ The symptoms are associated with clinically
five symptoms must be present in the final significant distress or interference with
week before the onset of menses, start to work, school, usual social activities, or
improve within a few days after the onset of relationships with others (e.g., avoidance of
menses, and become minimal or absent in social activities; decreased productivity and
the week postmenses. efficiency at work, school, or home).
B.​ One (or more) of the following symptoms E.​ The disturbance is not merely an
must be present: exacerbation of the symptoms of another
1.​ Marked affective lability (e.g., mood disorder, such as major depressive disorder,
swings; feeling suddenly sad or panic disorder, persistent depressive disorder
(dysthymia), or a personality disorder
ABNORMAL PSYCHOLOGY
(although it may co-occur with any of these more consecutive months without all of the
disorders). symptoms in Criteria A–D.
F.​ Criterion A should be confirmed by F.​ Criteria A and D are present in at least two
prospective daily ratings during at least two of three settings (i.e., at home, at school,
symptomatic cycles. with peers) and are severe in at least one of
Note: The diagnosis may be made these.
provisionally prior to this G.​ The diagnosis should not be made for the
confirmation. first time before age 6 years or after age 18
G.​ The symptoms are not attributable to the years.
physiological effects of a substance (e.g., a H.​ By history or observation, the age at onset of
drug of abuse, a medication) or another Criteria A–E is before 10 years.
medical condition (e.g., hypothyroidism). I.​ There has never been a distinct period
lasting more than 1 day during which the
❖​ Disruptive Mood Dysregulation Disorder full symptom criteria, except duration, for a
(DMDD) manic or hypomanic episode have been met.
-​ include children with chronic irritability, Note: Developmentally appropriate
anger, aggression, hyperarousal, and mood elevation, such as occurs in
frequent temper tantrums that are not limited the context of a highly positive
to an occasional episode (as might be the event or its anticipation, should not
case if the child were cycling into a manic be considered as a symptom of
episode, since irritability sometimes mania or hypomania.
accompanies discrete manic episodes). J.​ The behaviors do not occur exclusively
-​ Adults with a history of disruptive mood during an episode of major depressive
dysregulation dis order are at increased risk disorder and are not better explained by
for developing mood and anxiety disorders another mental disorder (e.g., autism
as well as many other adverse health spectrum disorder, post traumatic stress
outcomes. disorder, separation anxiety disorder,
persistent depressive disorder [dysthymia]).
Diagnostic Criteria for Disruptive Mood K.​ The symptoms are not attributable to the
Dysregulation Disorder physiological effects of a substance or to
A.​ Severe recurrent temper outburst manifested another medical or neurological condition.
verbally (e.g., verbal rages) and/or
behaviorally (e.g., physical aggression ❖​ Bipolar Disorders
toward people or property) that are grossly -​ A key identifying feature is the tendency of
out of proportion in intensity or duration to manic episodes to alternate with major
the situation or provocation. depressive episodes in an unending
B.​ The temper outbursts are inconsistent with roller-coaster ride from the peaks of elation
developmental level. to the depths of despair.
C.​ The temper outbursts occur, on average,
three or more times per week. Bipolar I disorder- major depressive episodes
D.​ The mood between temper outbursts is alternate with full manic episode.
persistently irritable or angry most of the Bipolar II disorder- are the same, except the
day, nearly every day, and is observable by individual experiences a hypomanic episodes rather
others (e.g., parents, teachers, peers). than full manic episodes.
E.​ Criteria A–D have been present for 12 or
more months. Throughout that time, the
individual has not had a period last ing 3 or
ABNORMAL PSYCHOLOGY
Diagnostic Criteria for Bipolar II Disorder
A.​ Criteria have been met for at least one Cyclothymic disorder- A milder but more chronic
hypomanic episode and at least one major version of bipolar disorder.
depressive episode. Criteria for a hypomanic -​ a chronic alternation of mood elevation and
episode are identical to those for a manic depression that does not reach the severity
episode, with the following distinctions: of manic or major depressive episodes.
1) Minimum dura tion is 4 days; -​ Individuals tend to be in one mood state or
2) Although the episode represents a definite the other for years with relatively few
change in functioning, it is not severe periods of neutral (or euthymic) mood.
enough to cause marked social or -​ This pattern must last for at least 2 years (1
occupational impairment or hospitalization; year for children and adolescents) to meet
3) There are no psychotic features. criteria for the disorder.
B.​ There has never been a manic episode.
C.​ The occurrence of the hypomanic episode(s) Additional Defining Criteria for Bipolar
and major depressive episode(s) is not better Disorders
explained by schizoaffective disorder, ●​ Catatonic features specifier applies mostly
schizophrenia, schizophreniform disorder, to major depressive episodes, though rarely
delusional disorder, or other specified or may apply to a manic episode.
unspecified schizophrenia spectrum and ●​ Psychotic features specifier may apply to
other psychotic disorder. manic episodes, during which it is common
D.​ The symptoms of depression or the to have delusions of grandeur.
unpredictability caused by frequent ●​ Anxious distress specifier is also present in
alternation between periods of depression bipolar disorders, as it is in depressive
and hypomania causes clinically significant disorders.
distress or impairment in social, ●​ Mixed features specifier is meant to
occupational, or other important areas of describe the major depressive or manic
functioning. episode that has some symptoms from the
Specify current or most recent episode: opposite polarity
Hypomanic: If currently (or most recently) ●​ Seasonal pattern specifier may also apply
in a hypomanic episode to bipolar disorders.
Depressed: If currently (or most recently) in
a major depressive episode Rapid-cycling specifier- one specifier that is unique
Specify if: to bipolar I and II disorders.
With anxious distress -​ An individual with BPD who experiences at
With mixed features least four manic or depressive episodes
With rapid cycling within a year.
With mood-congruent psychotic features -​ Approximately 20% to 50% of bipolar
With mood-incongruent psychotic features patients experience rapid cycling.
With catatonia
With peripartum onset Rapid switching or Rapid mood switching- direct
With seasonal pattern transition from one mood state to another happens; is
Specify course if full criteria for a mood episode are a particularly treatment-resistant form of the
not currently met: disorder.
In full remission, in partial remission Ultra-rapid cycle lengths- only last for days to
Specify severity if full criteria for a mood episode weeks
are currently met: Ultra-ultra-rapid cycling- cases where cycle lengths
Mild, moderate, severe are less than 24 hours.
ABNORMAL PSYCHOLOGY
●​ The overall prevalence of major depressive
Onset and Duration disorder for individuals over 65 is about half
●​ Average age of onset for bipolar I disorder that of the general population.
is from 15 to 18 ●​ Bipolar disorder seems to occur at about the
●​ Average age of onset for bipolar II disorder same rate (1%) in childhood and
is from 19 and 22. adolescence as in adults.
●​ About 1/3 of the cases of bipolar disorder
begin in adolescence, and the onset is often An Integrative Theory
preceded by minor oscillations in mood or
mild cyclothymic mood swings.
●​ Between 10% and 25% of peo ple with
bipolar II disorder will progress to full
bipolar I disorder.
●​ It is relatively rare for someone to develop
bipolar disorder after the age of 40.
●​ Bipolar disorder is associated with a high
risk of suicide attempts and suicide death,
the latter being associated with male sex and
having a first-degree relative who
committed suicide.
●​ In typical cases, cyclothymia is chronic and
lifelong. In about 1/3 - 1/2 of patients,
cyclothymic mood swings develop into
full-blown bipolar disorder.

Prevalence of Mood Disorders

●​ The prevalence rates for the combination of
per sistent depressive disorder and chronic
major depression are approximately 3.5%, Treatment of Mood Disorders
both for lifetime and in the past year. ●​ Antidepressants: Four basic types of
●​ For BPD, the estimates are 1% life time antidepressant medications are used to treat
prevalence and 0.8% during the past year. depressive disorders: selective-serotonin
●​ Studies indicate that women are twice as reuptake inhibitors (SSRIs), mixed
likely to have mood disorders as men, but reuptake inhibitors, tricyclic
the imbalance in prevalence between males antidepressants, and monoamine oxidase
and females is accounted for solely by major (MAO) inhibitors.
depressive disorder and persistent depressive ●​ Lithium: It is also often effective in
disorder (dysthymia). preventing and treating manic episodes.
Therefore, it is most often referred to as a
Prevalence in Children, Adolescents, and Older mood-stabilizing drug.
Adults ●​ Electroconvulsive Therapy: Electric shock
●​ The general conclusion is that depressive is administered directly through the brain for
disorders occur less often in prepubertal less than a second, producing a seizure and a
children than in adults but rise dramatically series of brief convulsions that usually lasts
in adolescence. for several minutes.
ABNORMAL PSYCHOLOGY
●​ Transcranial Magnetic Stimulation ●​ Nock and Kessler (2006) distinguish
(TMS): It works by placing a magnetic coil “attempters” (self-injurers with the intent to
over the individual’s head to generate a die) from
precisely localized electromagnetic pulse. “gesturers” (self-injurers who intend not to
Anesthesia is not required, and side effects die but to influence or manipulate somebody
are usually limited to headaches. or communicate a cry for help).
●​ Cognitive-Behavioral Therapy: Clients are ●​ Although males commit suicide more often
taught to exam ine carefully their thought than females in most of the world, females
processes while they are depressed and to attempt suicide at least 3 times as often.
recognize “depressive” errors in thinking. ●​ Between 16% and 30% of adolescents who
●​ Interpersonal Psychotherapy (IPT)- think about killing themselves actually
Focuses on resolving problems in existing attempt it.
relationships and learn ing to form important
new interpersonal relationships. Causes
●​ Prevention: The Institute of Medicine
(IOM) delineated three types of programs: ●​ Past Conceptions: Emile Durkheim
Universal programs, which are (1951) defined a number of suicide types,
applied to everyone; based on the social or cultural conditions in
Selected interventions, which target which they occurred.
individuals at risk for depression “formalized” suicides that were
because of factors such as divorce, approved of (ie. hara-kiri in Japan).
family alcoholism, and so on; and Durkheim referred to this as
Indicated interventions, in which the altruistic suicide. Durkheim also
individual is already showing mild recognized the loss of social
symptoms of depression. supports as an important
●​ Maintenance treatment: to prevent relapse provocation for suicide; he called
or recurrence over the long term. this egoistic suicide.
Anomic suicides are the result of
marked disruptions, such as the
sudden loss of a high-prestige job.
Suicide (Anomie is feeling lost and
●​ Around the world, suicide causes more confused.)
deaths per year than homicide or HIV/AIDS. fatalistic suicides result from a loss
●​ Regardless of age, in every country around of control over one’s own destiny.
the world except China, males are 4 times
more likely to commit suicide than females.
●​ In addition to completed suicides, three
other important indices of suicidal behavior
are:
suicidal ideation (thinking seriously
about suicide)
suicidal plans (the formulation of a
specific method for killing oneself)
suicidal attempts (the person
survives)
ABNORMAL PSYCHOLOGY
Risk Factors Treatment
Edward Shneidman pioneered the study of risk ●​ Cha, Najmi, Park, Finn, and Nock (2010)
factors for suicide. have developed measures of implicit
Psychological autopsy- The psychological profile (unconscious) cognition, adapted from the
of the person who committed suicide is labs of cognitive psychology, to assess
reconstructed through extensive interviews with implicit suicidal ideation.
friends and family members who are likely to know ●​ The clinician must assess for
what the individual was thinking and doing in the (1) suicidal desire (ideation,
period before death. hopelessness, burdensomeness,
feeling trapped);
●​ Family History: If individuals have an (2) suicidal capability (past
early onset of their mood disorder, as well as attempts, high anxiety and/or rage,
aggressive or impulsive traits, then their available means);
families are at a greater risk for suicidal (3) suicidal intent (available plan,
behavior. expressed intent to die, preparatory
●​ Neurobiology: It is possible then that low behavior)
levels of serotonin may contribute to If all three conditions are present, immediate action
creating a vulnerability to act impulsively. is required.
This may include killing oneself, which is ●​ Suicide prevention programs for the elderly
sometimes an impulsive act. tend to focus on decreasing risk factors (e.g.,
●​ Existing Psychological Disorders and treating depression) rather than shoring up
Other Psychological Risk Factors: More protective factors like familial support, and
than 80% of people who kill themselves could be improved by greater involvement
suffer from a psycho logical disorder, of individuals’ social networks.
usually mood, substance use, or impulse ●​ Empirical research indicates that
control disorders. cognitive-behavioral inter ventions can be
●​ Stressful Life Events: Given preexisting efficacious in decreasing suicide risk.
vulnerabilities—including psychological
disorders, traits of impulsiveness, and lack Suicide is often associated with mood disorders but
of social support—a stressful event can can occur in their absence or in the presence of
often put a person over the edge. other disorders.

Is Suicide Contagious?
●​ Suicides are often romanticized in the
media.
●​ Media accounts often describe in detail the
methods used in the suicide, thereby
providing a guide to potential victims.
●​ Little is reported about the paralysis, brain
damage, and other tragic consequences of
the incomplete or failed suicide or about
how suicide is almost always associated
with a severe psychological disorder.
ABNORMAL PSYCHOLOGY
CHAPTER 8: Eating and Sleep–Wake Disorders Medical Consequences
●​ Salivary gland enlargement caused by
Major Types of Eating Disorders repeated vomiting, which gives the face a
-​ The chief characteristic of these related chubby appearance.
disorders is an overwhelming, ●​ Repeated vomiting also may erode the
all-encompassing drive to be thin. dental enamel on the inner surface of the
front teeth as well as tear the esophagus.
❖​ Bulimia nervosa ●​ Continued vomiting may upset the chemical
-​ out-of control eating episodes, or binges, are balance of bodily fluids, including sodium
followed by self-induced vomiting, and potassium levels(called electrolyte
excessive use of laxatives, or other attempts imbalance; can result in serious medical
to purge (get rid of) the food. complications if unattended, includ ing
-​ one of the most common psychological cardiac arrhythmia (disrupted heartbeat),
disorders on college campuses. seizures, and renal (kidney) failure, all of
-​ eating a larger amount of food—typically, which can be fatal).
more junk food than fruits and ●​ Intestinal problems resulting from laxative
vegetables—than most people would eat abuse are also potentially serious; they can
under similar circumstances. include severe constipation or permanent
-​ Just as important as the amount of food colon damage.
eaten is that the eating is experienced as out ●​ Some individuals with bulimia have marked
of control. calluses on their fingers or the backs of their
-​ the individual attempts to compensate for hands caused by the friction of contact with
the binge eating and potential weight gain, the teeth and throat when repeatedly sticking
almost always by purging techniques: their fingers down their throat to stimulate
●​ self-induced vomiting immediately the gag reflex.
after eating
●​ using laxatives (drugs that relieve Associated Psychological disorders
constipation) and diuretics (drugs An individual with bulimia usually presents with
that result in loss of fluids through additional psychological disorders, particularly
greatly increased frequency of anxiety and mood disorders.
urination).
●​ Some people use both methods ●​ 80.6% of individuals with bulimia had an
●​ Some attempt to compensate in anxiety disorder at some point during their
other ways lives.
●​ Some exercise excessively ●​ 66% of adolescents with bulimia presented
(although rigorous exercising is with a co-occurring anxiety disorder when
more usually a characteristic of interviewed.
anorexia nervosa) ●​ Mood disorders, particularly depression,
-​ BM was subtyped in DSM-IV-TR into: also commonly co-occur with bulimia, with
●​ purging type (e.g., vomiting, about 20% of bulimic patients meeting
laxatives, or diuretics) criteria for a mood disorder when
●​ nonpurging type (e.g., exercise interviewed.
and/or fasting) ●​ 36.8% of individuals with bulimia and 27%
-​ One of the more important additions to the of individuals with anorexia were also
DSM-IV criteria in 1994 was the substance abusers when interviewed, with
specification of a psychological even higher lifetime rates of substance
characteristic. abuse.
ABNORMAL PSYCHOLOGY
Statistics -​ They are so successful at losing weight that
●​ The overwhelming majority (90% to 95%) they put their lives in considerable danger.
of individuals with bulimia are women. -​ People with anorexia are proud of both their
●​ Males with bulimia have a slightly later age diets and their extraordinary control.
of onset, and a large minority are -​ Less common than bulimia, but there is a
predominantly gay males or bisexual. great deal of overlap.
-​ Many individuals with bulimia have a
history of anorexia; that is, they once used
Diagnostic Criteria for Bulimia Nervosa fasting to reduce their body weight below
A.​ Recurrent episodes of binge eating. An desirable levels
episode of binge eating is characterized by -​ People with anorexia have an intense fear of
both of the following: obesity and relentlessly pursue thinness.
1.​ Eating, in a discrete period of time -​ DSM-5 specifies two subtypes of anorexia
(e.g., within any 2-hour period), an nervosa:
amount of food that is definitely ●​ Restricting type: individuals diet to
larger than most people would eat limit calorie intake;
during a similar period of time and ●​ Binge eating–purging type: they
under similar circumstances rely on purging. Unlike individuals
2.​ A sense of lack of control over with bulimia, binge-eating–purging
eating during the episode (e.g., a anorexics binge on relatively small
feeling that one cannot stop eating amounts of food and purge more
or control what or how much one is consistently, in some cases each
eating) time they eat.
B.​ Recurrent inappropriate compensatory -​ Individuals with anorexia are never satisfied
behavior in order to prevent weight gain, with their weight loss. Staying the same
such as self-induced vomiting; misuse of weight from one day to the next or gaining
laxatives, diuretics, or other medications; any weight is likely to cause intense panic,
fasting; or excessive exercise. anxiety, and depression.
C.​ The binge eating and inappropriate -​ Another key criterion is a marked
compensatory behaviors both occur, on disturbance in body image.
average, at least once a week for 3 months. -​ Individuals with anorexia seldom seek
D.​ Self-evaluation is unduly influenced by treatment on their own. Usually pressure
body shape and weight. from somebody in the family leads to the
E.​ The disturbance does not occur exclusively initial visit.
during episodes of anorexia nervosa. -​ Up to 20% die as a result of their disorder,
with slightly more than 5% dying within 10
years.

❖​ Anorexia nervosa Medical Consequences

-​ the person eats only minimal amounts of ●​ One common medical complication of
food or exercises vigorously to offset food anorexia nervosa is cessation of
intake so body weight sometimes drops menstruation (amenorrhea), which also
dangerously. occurs relatively often in bulimia( dropped
-​ literally means a “nervous loss of as a criterion in DSM-5)
appetite”—an incorrect definition because ●​ Other medical signs and symp toms of
appetite often remains healthy. anorexia include dry skin, brittle hair or
ABNORMAL PSYCHOLOGY
nails, and sensitivity to or intolerance of binge eating or purging behavior (i.e., self-induced
cold temperatures. vomiting or the misuse of laxatives, diuretics, or
●​ Lanugo (downy hair on the limbs and enemas). This subtype describes presentations in
cheeks) which weight loss is accomplished primarily through
●​ Cardiovascular problems, such as dieting, fasting, and/or excessive exercise.
chronically low blood pressure and heart Binge-eating/purging type: During the past 3
rate months, the individual has engaged in recurrent
episodes of binge eating or purging behavior (i.e.,
self-induced vomiting or the misuse of laxatives,
Associated Psychological Disorders diuretics, or enemas)
●​ Anxiety disorders and mood disorders are
often present in individuals with anorexia, ❖​ Binge-eating disorder
with rates of depression occurring at some -​ Individuals may binge repeatedly and find it
point during their lives in as many as 71% of distressing, but they do not attempt to purge
cases. the food.
●​ One anxiety disorder that seems to co-occur -​ Evidence that supports its elevation to
often with anorexia is obsessive-compulsive disorder status includes somewhat different
disorder (OCD). patterns of heritability compared with other
●​ In anorexia, unpleasant thoughts are focused eating disorders, as well as a greater likeli
on gaining weight, and individuals engage in hood of occurring in males and a later age of
a variety of behaviors, some of them onset.
ritualistic, to rid themselves of such -​ There is also a greater likelihood of
thoughts. remission and a better response to treatment
in BED compared with other eating
Diagnostic Criteria for Anorexia Nervosa disorders.
A.​ Restriction of energy intake relative to -​ Individuals who meet preliminary criteria
requirements, leading to a significantly low for BED are often found in weight-control
body weight in the context of age, sex, programs.
developmental trajectory, and physical -​ The general consensus is that about 20% of
health. Significantly low weight is defined obese individuals in weight-loss programs
as a weight that is less than minimally engage in binge eating, with the number
normal or, for children and adolescents, less rising to approximately 50% among
than that minimally expected. candidates for bariatric surgery (surgery to
B.​ Intense fear of gaining weight or of correct severe or morbid obesity).
becoming fat, or persistent behavior that -​ About half of individuals with BED try
interferes with weight gain, even though at a dieting before binge ing, and half start with
significantly low weight. bingeing and then attempt to diet; those who
C.​ Disturbance in the way in which one’s body begin bingeing first become more severely
weight or shape is experienced, undue affected by BED and are more likely to have
influence of body weight or shape on self additional disorders.
evaluation, or persistent lack of recognition
of the seriousness of the current low body
weight.
Diagnostic Criteria for Binge-Eating Disorder
Specify type: A.​ Recurrent episodes of binge eating. An
Restricting type: During the past 3 months, the episode of binge eating is characterized by
individual has not engaged in recurrent episodes of both of the following:
ABNORMAL PSYCHOLOGY
1.​ Eating, in a discrete period of time Causes of Eating Disorders
(e.g., within any 2-hour period), an
amount of food that is definitely Social Dimensions: The cultural imperative for
larger than what most people would thinness directly results in dieting, the first
eat in a similar period of time under dangerous step down the slippery slope to anorexia
similar circumstances. and bulimia. Distortions of body image in some
2.​ A sense of lack of control over males can also have tragic consequences. Men with
eating during the episode (e.g., a “reverse anorexia nervosa” reported they were
feeling that one cannot stop eating extremely concerned about looking small, even
or control what or how much one is though they were muscular.
eating).
B.​ The binge-eating episodes are associated Dietary Restraint: If cultural pressures to
with three (or more) of the following: be thin are as important as they seem to be
1.​ Eating much more rapidly than in triggering eating disorders, then such
normal. disorders would be expected to occur where
2.​ Eating until feeling uncomfortably these pressures are particularly severe. Thus,
full. dieting is one factor that can contribute to
3.​ Eating large amounts of food when eating disorders, and, along with
not feeling physically hungry. dissatisfaction with one’s body, is a primary
4.​ Eating alone because of feeling risk factor for later eating disorders.
embarrassed by how much one is
eating. Family influences: Whatever the
5.​ Feeling disgusted with oneself, preexisting relationships, after the onset of
depressed, or very guilty afterward. an eating disorder, particularly anorexia,
C.​ Marked distress regarding binge eating is family relationships can deteriorate quickly.
present.
D.​ The binge eating occurs, on average, at least Biological Dimensions: Studies suggest that
once a week for 3 months. relatives of patients with eating disorders are 4 to 5
E.​ The binge eating is not associated with the times more likely than the gen eral population to
recurrent use of inappropriate compensatory develop eating disorders themselves, with the risks
behavior as in bulimia nervosa and does not for female relatives of patients with anorexia higher.
occur exclusively during the course of There is no clear agreement on just what is inherited.
bulimia nervosa or anorexia nervosa. Hsu and Steiger speculate that nonspecific
personality traits such as emotional instability and,
Cross-Cultural Considerations: Anorexia and perhaps, poor impulse control might be inherited. In
bulimia are relatively homogeneous, and other words, a person might inherit a tendency to be
both—particularly bulimia—were overwhelmingly emotionally responsive to stressful life events and,
associated with Western cultures until recently. In as one con sequence, might eat impulsively in an
addition, the frequency and pattern of occurrence attempt to relieve stress and anxiety. Biological
among minority Western cultures differed somewhat processes are quite active in the regulation of eat ing
in the past, but those differences seem to be and thus of eating disorders, and substantial
diminishing. evidence points to the hypothalamus as playing an
important role. Low levels of serotonergic activity,
Developmental Considerations: Because the the system most often associated with eating
overwhelming majority of cases begin in disorders, are associated with impulsivity generally
adolescence, it is clear that anorexia and bulimia are and binge eating specifically.
strongly related to development.
ABNORMAL PSYCHOLOGY
Psychological Dimensions: Perfectionism alone,
however, is only weakly associated with the
development of an eating disorder, because
individuals must consider themselves overweight
and manifest low self-esteem before the trait of
perfec tionism makes a contribution. But when
perfectionism is directed to distorted perception of
body image, a powerful engine to drive eating
disorder behavior is in place. Specific distortions in
perception of body shape change often, depending
on day-to-day experience. At least a subgroup of
these patients has difficulty tolerating any negative
emotion (mood intolerance) and may binge or
engage in other behaviors, such as self-induced
vomiting or intense exercise, in an attempt to
regulate their mood (reduce their anxiety or distress
by doing something they think will help them avoid
being fat).

An Integrative Model
●​ Individuals with eating disor ders may have Treatment of Eating Disorders
some of the same biological vulnerabilities Drug Treatments: here is some evidence that drugs
(such as being highly responsive to stressful may be useful for some people with bulimia,
life events) as individuals with anxiety particularly during the bingeing and purging cycle.
disorders. The drugs generally considered the most effective
●​ Social and cultural pressures to be thin for bulimia are the same antidepressant medica tions
motivate significant restriction of eating, proven effective for mood disorders and anxiety
usually through severe dieting. disorders. A more recent review (meta-analysis)
●​ An emphasis in families on looks and suggested that selective serotonin reuptake inhibitors
achievement, and perfectionistic tendencies, are helpful in the treat ment of bulimia.
may help establish strong attitudes about the
overrid ing importance of physical Psychological Treatments: Short-term
appearance to popularity and success, cognitive-behavioral treatments target problem
attitudes reinforced in peer groups. These eating behavior and associated attitudes about the
attitudes result in an exaggerated focus on overriding importance and significance of body
body shape and weight. weight and shape, and these strategies became the
●​ There is the question of why a small treatment of choice for bulimia. The essential
minority of individuals with eating dis components of cognitive behavioral therapy (CBT)
orders can control their intake through directed at causal factors common to all eating
dietary restraint, result ing in alarming disorders are targeted in an integrated way. Thus, the
weight loss (anorexia), whereas the majority principal focus of this protocol is on the distorted
are unsuccessful at losing weight and evaluation of body shape and weight, and
compensate in a cycle of binge ing and maladaptive attempts to control weight in the form
purging. of strict dieting, possibly accompanied by binge
eating, and methods to compensate for overeating
such as purging, laxative misuse, etc.
​
ABNORMAL PSYCHOLOGY
Obesity energy-dense diet is the larg est single
-​ is not considered an official disorder in the contributor to the obesity epidemic.
DSM, but is thought to be one of the most ●​ Genes influence the number of fat cells an
danger ous epidemics confronting public individual has, the likelihood of fat storage,
health authorities around the world today. saiety, and, most likely, activity levels.
●​ The more overweight someone is at a given Generally, genes are thought to account for
height, the greater the risks to health. These about 30% of the equa tion in causation of
risks are widespread and involve greatly obesity, with a “toxic environment” to turn
increased prevalence of cardiovascular on these genes.
disease, dia betes, hypertension, stroke, ●​ Physiological processes, particularly
gallbladder disease, respiratory disease, hormonal regulation of appe tite, play a
muscular skeletal problems, and large role in the initiation and maintenance
hormone-related cancers. of eating and vary considerably from
●​ People with obesity do not necessarily eat individual to individual.
more or exercise less than their lean coun ●​ Psychological processes of emotional
terparts. Although the tendency to overeat regulation (for example, eating to try to
and exercise too little unquestionably has a cheer yourself up when you’re feeling
genetic component, the excessive eating at down), impulse control, attitudes and
the core of the problem is the reason that motivation toward eating, and
obesity could be considered a disorder of responsiveness to the consequences of
eating. eating are also important.

Disordered Eating Patterns in Cases of Obesity Treatment

There are two forms of maladaptive eating patterns
in people who are obese: ●​ The treatment of obesity is only moderately
1.​ binge eating successful at the individual level, with
2.​ night eating syndrome- occurs in between somewhat greater long-term evidence for
6% and 16% of obese individuals seeking effectiveness in children compared to adults.
weight-loss treatment but in as many as 55% ●​ Treatment is usually organized in a series of
of those with extreme obesity seeking steps from least intrusive to most intrusive
bariatric surgery depending on the extent of obesity:
-​ Individuals with NES consume a ○​ The first step is a self directed
third or more of their daily intake weight-loss program in individuals
after their evening meal and get out who buy a popular diet book (most
of bed at least once during the night usual result is that some individuals
to have a high-calorie snack. In the may lose some weight in the short
morning, however, they are not term but almost always regain that
hungry and do not usually eat weight).
breakfast. ○​ The next step is commercial
self-help program and stand a better
Causes chance at achieving some success.
●​ Henderson and Brownell point out that However, up to 80% of individuals,
obesity epidemic is clearly related to the even if they are initially successful,
spread of modernization. That is, the are not successful in the long run.
promotion of an inactive, sedentary lifestyle ○​ The most successful programs are
and the consumption of a high-fat, professionally directed behavior
modification programs.
ABNORMAL PSYCHOLOGY
○​ For those individuals who have and being monitored on a number of
become more dangerously obese, measures, including respiration and
very-low-calorie diets and possibly oxygen desaturation (a measure of
drugs, combined with behavior airflow); leg movements; brain
modification programs, are wave activity, measured by an
recommended. electroencephalogram; eye
○​ Bariatric surgery- surgical approach movements, measured by an
to extreme obesity. electrooculogram; muscle
movements, measured by an
electromyogram; and heart activity,
Sleep–Wake Disorders: The Major Dyssomnias measured by an electrocardiogram.
●​ Actigraph- One alternative to the
An Overview of Sleep–Wake Disorders comprehensive assessment of sleep is to use
●​ Moral treatment, used in the 19th century for a wristwatch-size device.
people with severe mental illness, included -​ records the number of arm
encouraging patients to get adequate movements, and the data can be
amounts of sleep as part of therapy. downloaded into a computer to
●​ The limbic system, involved in anxiety, is determine the length and quality of
also involved with dream sleep or rapid eye sleep.
movement (REM) sleep. This mutual
neurobiological connection suggests that ❖​ Insomnia Disorder
anxiety and sleep may be interrelated in -​ one of the most common sleep–wake
important ways, although the exact nature of disorders.
the relationship is still unknown. -​ Difficulty falling asleep at bedtime,
●​ Sleep abnormalities are preceding signs of problems staying asleep throughout the
serious clinical depression, which may night, or sleep that does not result in the
suggest that sleep problems can help predict person feeling rested even after normal
who is at risk for later mood disorders. amounts of sleep.
●​ Sleep–wake disorders are divided into two -​ Microsleeps last several seconds or longer.
major categories: -​ Fatal Familial Insomnia (a degenerative
○​ Dyssomnias involve difficulties in brain disorder), total lack of sleep eventually
getting enough sleep, problems with leads to death.
sleeping when you want to , and -​ People are considered to have insomnia if
complaints about the quality of they have trouble falling asleep at night
sleep, such as not feeling refreshed (difficulty initiating sleep), if they wake up
even though you have slept the frequently or too early and can’t go back to
whole night. sleep (difficulty maintaining sleep), or even
○​ Parasomnias are characterized by if they sleep a reasonable number of hours
abnormal behavioral or but are still not rested the next day
physiological events that occur (nonrestorative sleep).
during sleep, such as nightmares and -​ Sleep problems were not related to other
sleepwalking. medical or psychiatric problems (primary
●​ Polysomnographic (PSG) evaluation- insomnia).
clearest and most comprehensive picture of
your sleep habits. Statistics
-​ The patient spends one or more
nights sleeping in a sleep laboratory
ABNORMAL PSYCHOLOGY
●​ Approximately one third of the population ●​ People with insomnia may have unrealistic
reports some symptoms of insomnia during expectations about how much sleep they
any given year. need and about how disruptive disturbed
●​ Total sleep time often decreases with sleep will be.
depression, substance use disorders, anxiety ●​ It is generally accepted that people suffering
disorders, and neurocognitive disorder due from sleep problems associate the bedroom
to Alzheimer’s disease. and bed with the frustration and anxiety that
●​ Alcohol is often used to initiate sleep . In go with insomnia.
small amounts, it helps make people drowsy,
but it also interrupts ongoing sleep. An Integrative Model
Interrupted sleep causes anxiety, which often ●​ An integrative view of sleep disorders
leads to repeated alcohol use and an includes several assumptions:
obviously vicious cycle. ○​ Both biological and psychological
●​ Women more often report problems factors are present in most cases.
initiating sleep, which may be related to ○​ These multiple factors are
hormonal differences or to differential reciprocally related.
reporting of sleep problems, with women
generally more negatively affected by poor ●​ People may be biologically vulnerable to
sleep than men. disturbed sleep. This vulnerability differs
●​ Approximately one in five young children from person to person and can range from
experiences insomnia. mild to more severe disturbances
●​ The percentage of individuals who complain (predisposing conditions)
of sleep problems increases as they become ●​ Biological vulnerability may, in turn,
older adults. interact with sleep stress, which includes a
number of events that can negatively affect
Causes sleep.
●​ Insomnia accompanies many medical and
psychological disorders, including pain and
physical discomfort, physical inactivity
during the day, and respiratory problems.
●​ Some people who can’t fall asleep at night
may have a delayed temperature rhythm:
Their body temperature doesn’t drop, and
they don’t become drowsy until later at
night.
●​ Other factors that can interfere with sleeping
are drug use and a variety of environmental
influences such as changes in light, noise, or
temperature.
●​ Other sleep disorders, such as sleep apnea (a
disorder that involves obstructed nighttime
breathing) or periodic limb movement
disorder (excessive jerky leg movements),
can cause interrupted sleep and may seem
similar to insomnia.
●​ Various psychological stresses can also
disrupt your sleep.
ABNORMAL PSYCHOLOGY
Persistent: Symptoms last 3 months or longer
Diagnostic Criteria for Insomnia Disorder Recurrent: Two (or more) episodes within the space
A.​ A predominant complaint of dissatisfaction of 1 year
with sleep quantity or quality associated
with one or more of the following ❖​ Hypersomnolence Disorders
symptoms: -​ involve sleeping too much (hyper means “in
1.​ Difficulty initiating sleep. (In great amount” or “abnormal excess”). Many
children, this may manifest as people who sleep all night find themselves
difficulty initiating sleep without falling asleep several times the next day.
caregiver intervention.) -​ The DSM-5 diagnostic criteria include not
2.​ Difficulty maintaining sleep, only excessive sleepiness but also the
characterized by frequent subjective impression of this problem.
awakenings or problems returning to -​ People with hypersomnolence sleep through
sleep after awakenings. the night and appear rested upon awakening
(In children, this may manifest as but still complain of being excessively tired
difficulty returning to sleep without throughout the day.
caregiver intervention.) -​ Sleep apnea- People with this problem have
3.​ Early-morning awakening with difficulty breathing at night. They often
inability to return to sleep. snore loudly, pause between breaths, and
B.​ The sleep disturbance causes clinically wake in the morning with a dry mouth and
significant distress in social, occupational, headache.
educational, academic, behavioral, or other -​ In identifying hypersomnolence, the
important areas of functioning. clinician needs to rule out insomnia, sleep
C.​ The sleep difficulty occurs at least 3 nights apnea, or other reasons for sleepiness during
per week. the day.
D.​ The sleep difficulty is present for at least 3
months. Diagnostic Criteria for Hypersomnolence
E.​ The sleep difficulty occurs despite adequate Disorder
opportunity for sleep. A.​ Self-reported excessive sleepiness
F.​ The insomnia is not better explained by and (hypersomnolence) despite a main sleep
does not occur exclusively during the course period lasting at least 7 hours, with at least
of another sleep–wake disorder (e.g., one of the following symptoms:
narcolepsy, breathing-related sleep disorder, 1.​ Recurrent periods of sleep or lapses
a circadian rhythm sleep–wake disorder, a into sleep within the same day.
parasomnia). 2.​ A prolonged main sleep episode of
G.​ The insomnia is not attributable to the more than 9 hours per day that is
physiological effects of a substance (e.g., a non-restorative (i.e., unrefreshing).
drug abuse, a medication). 3.​ Difficulty being fully awake after
H.​ Coexisting mental disorders and medical abrupt awakening.
conditions do not adequately explain the B.​ The hypersomnolence occurs at least three
predominant complaint of insomnia. times per week, for at least 3 months.
C.​ The hypersomnolence is accompanied by
Specify if: significant distress or impairment in
Episodic: Symptoms last at least 1 month but less cognitive, social, occupational, or other
than 3 months important areas of functioning.
D.​ The hypersomnolence is not better explained
by and does not occur exclusively during the
ABNORMAL PSYCHOLOGY
course of another sleep disorder (e.g., (NREM) stages that typically precede REM
narcolepsy, breathing-related sleep disorder, sleep, people with narcolepsy periodically
a circadian rhythm sleep–wake disorder, a progress right to this dream-sleep stage
parasomnia). almost directly from the state of being
E.​ The hypersomnolence is not attributable to awake.
the physiological effects of a substance (e.g., -​ Two other characteristics distinguish people
a drug abuse, a medication). who have narcolepsy:
F.​ Coexisting mental and medical disorders do -​ Paralysis (a brief period after
not adequately explain the predominance awakening when they can’t move or
complaint of hypersomnolence. speak that is often frightening to
those who go through it)
Specify if: -​ Hypnagogic hallucinations (vivid
Acute: Duration of less than 1 month and often terrifying experiences that
Subacute: Duration of 1–3 months begin at the start of sleep and are
Persistent: Duration of more than 3 months said to be unbelievably realistic
Specify current severity: because they include not only visual
Specify severity based on degree of aspects but also touch, hearing, and
difficulty maintaining daytime alertness as even the sensation of body
manifested by the occurrence of multiple movement)
attacks of irresistible sleepiness within any -​ is relatively rare, occurring in 0.03% to
given day occurring, for example, while 0.16% of the population, with the numbers
sedentary, driving, visiting with friends, or approximately equal among males and
working. females.
Mild: Difficulty maintaining daytime -​ Previous research suggests that narcolepsy is
alertness 1–2 days/week associated with a cluster of genes on
Moderate: Difficulty maintaining daytime chromosome 6, and it may be an autosomal
alertness 3–4 days/week recessive trait. It appears that there is a
Severe: Difficulty maintaining daytime significant loss of a certain type of nerve cell
alertness 5–7 days/week (hypocretin neurons) in those with
narcolepsy.
❖​ Narcolepsy
-​ In addition to daytime sleepiness, some Diagnostic Criteria for Narcolepsy
people with narcolepsy experience A.​ Recurrent periods of irrepressible need to
cataplexy sleep, lapsing into sleep, or napping
-​ a sudden loss of muscle tone. occurring within the same day. These must
-​ occurs while the person is awake have been occurring at least three times per
and can range from slight weakness week over the past 3 months.
in the facial muscles to complete B.​ The presence of at least one of the
physical collapse. following:
-​ lasts from several seconds to several 1.​ Episodes of cataplexy defined as
minutes; it is usually preceded by either (a) or (b), occurring at least a
strong emotion such as anger or few times per month:
happiness. a.​ In individuals with long
-​ appears to result from a sudden standing disease, brief
onset of REM sleep. (seconds to minutes)
-​ Instead of falling asleep normally and going episodes of sudden bilateral
through the four non rapid eye movement loss of muscle tone with
ABNORMAL PSYCHOLOGY
maintained consciousness, Breathing-Related Sleep Disorders
precipitated by laughter or -​ People whose breathing is interrupted during
joking. their sleep often experience numerous brief
b.​ In children or in individuals arousals throughout the night and do not feel
within 6 months of onset, rested even after 8 or 9 hours asleep.
spontaneous grimaces or -​ Breathing is constricted a great deal and
jaw-opening episodes with may be labored (hypoventilation) or, in the
tongue thrusting or a global extreme, there may be short periods (10 to
hypotonia, without any 30 seconds) when they stop breathing
obvious emotional triggers. altogether, called sleep apnea.
2.​ Hypocretin deficiency, as measured
using cerebrospinal fluid (CSF) There are three types of apnea, each with different
hypocretin-1 immunoreactivity causes, day time complaints, and treatment:
values (less than or equal to one ➔​ Obstructive sleep apnea hypopnea
third of values obtained in healthy syndrome occurs when airflow stops despite
subjects tested using the same assay continued activity by the respiratory system
or less than or equal to 110 pg/ml). -​ In some people, the airway is too
Low CSF levels of hypocretin-1 narrow; in others, some abnormality
must not be observed in the context or damage interferes with the
of acute brain injury, inflammation ongoing effort to breathe.
or infection. -​ Obstructive sleep apnea is most
3.​ Nocturnal sleep polysomnography common in males and is thought to
showing rapid eye movement occur in approximately 20% of the
(REM) sleep latency less than or population.
equal to 15 minutes, or a multiple
sleep latency test showing a mean Diagnostic Criteria for Obstructive Sleep Apnea
sleep latency less than or equal to 8 Hypopnea
minutes and two or more sleep onset A.​ Either (1) or (2):
REM periods. 1.​ Evidence by polysomnography of at
least five obstructive apneas or
Specify current severity: hypopneas per hour of sleep and
Mild: Infrequent cataplexy (less than once either of the following sleep
per week), need for naps only once or twice symptoms:
per day, and less disturbed nocturnal sleep a.​ Nocturnal breathing
Moderate: Cataplexy once daily or every disturbances: snoring,
few days, disturbed nocturnal sleep, and snorting/ gasping or
need for multiple naps daily breathing pauses during
Severe: Drug-resistant cataplexy with sleep.
multiple attacks daily, nearly constant b.​ Daytime sleepiness, fatigue,
sleepiness, and disturbed nocturnal sleep or unrefreshing sleep
(i.e., movements, insomnia, and vivid despite sufficient
dreaming) opportunities to sleep that is
not better explained by
another mental disorder
(including a sleep disorder)
and is not attributable to
another medical condition.
ABNORMAL PSYCHOLOGY
2.​ Evidence by polysomnography of
15 or more obstructive apneas Diagnostic Criteria for Sleep-Related
and/or hypopneas per hour of sleep Hypoventilation
regardless of accompanying A.​ Polysomnography demonstrates episodes of
symptoms. decreased respiration associated with
elevated CO2 levels.
Specify current severity: (Note: In the absence of objective
Mild: Apnea hypopnea index is less than 15 measurement of CO2 , persistent low levels
Moderate: Apnea hypopnea index is 15–30 of hemoglobin oxygen saturation
Severe: Apnea hypopnea index is greater than 30 unassociated with apneic/hypopneic events
may indicate hypoventilation.)
➔​ Central sleep apnea, involves the complete B.​ The disorder is not better explained by
cessation of respiratory activity for brief another current sleep disorder.
periods and is often associated with certain Specify current severity:
central nervous system disorders, such as Severity is graded according to the degree of
cerebral vascular disease, head trauma, and hypoxemia and hypercarbia present during sleep and
degenerative disorders. evidence of end organ impairment due to these
-​ those with central sleep apnea wake abnormalities (e.g., right-sided heart failure). The
up frequently during the night but presence of blood gas abnormalities during
they tend not to report excessive wakefulness is an indicator of greater severity.
daytime sleepiness and often are not
aware of having a serious breathing Circadian Rhythm Sleep Disorder
problem. -​ This disorder is characterized by disturbed
sleep (either insomnia or excessive
Diagnostic Criteria for Central Sleep Apnea sleepiness during the day) brought on by the
A.​ Evidence by polysomnography of five or brain’s inability to synchronize its sleep
more central apneas per hour of sleep. patterns with the current patterns of day and
B.​ The disorder is not better explained by night.
another current sleep disorder. -​ Our brains have a mechanism that keeps us
in sync with the outside world. Our
Specify current severity: biological clock is in the suprachiasmatic
Severity of central sleep apnea is graded according nucleus in the hypothalamus. Connected to
to the frequency of the breathing disturbances as the supra chiasmatic nucleus is a pathway
well as the extent of associated oxygen desaturation that comes from our eyes. The light we see
and sleep fragmentation that occur as a consequence in the morning and the decreasing light at
of repetitive respiratory disturbances. night signal the brain to reset the biological
clock each day. Unfortunately, some people
have trouble sleeping when they want to
➔​ Sleep-related hypoventilation is a decrease because of problems with their circadian
in airflow without a complete pause in rhythms.
breathing. This tends to cause an increase in -​ There are several types of circadian rhythm
carbon dioxide (CO2) levels, because sleep disorders:
insufficient air is exchanged with the ●​ Jet lag type is caused by rapidly
environment. crossing multiple time zones.
●​ Shift work type sleep problems are
associated with work schedules.
ABNORMAL PSYCHOLOGY
●​ Delayed sleep phase type where Environmental Treatments: One general principle
sleep is delayed or there is a later for treating circadian rhythm disorders is that phase
than normal bedtime. delays (moving bedtime later) are easier than phase
●​ Advanced sleep phase type of advances (moving bedtime earlier). In other words,
circadian rhythm disorder are “early it is easier to stay up several hours later than usual
to bed and early to rise.” than to force yourself to go to sleep several hours
●​ Irregular sleep wake type people earlier.
who experience highly varied sleep
cycles Psychological Treatments: Relaxation treatments
●​ Non-24-hour sleep–wake type e.g., reduce the physical tension that seems to prevent
sleeping on a 25- or 26-hour cycle some people from falling asleep at night. Cognitive
with later and later bedtimes treatment may also focus on worries about sleep
ultimately going throughout the day itself, such as by helping patients to change their
assumptions that they can’t function well on little
sleep, which can trigger anxiety that disrupts falling
Diagnostic Criteria for Circadian Rhythm asleep.
Sleep–Wake Disorders
A.​ A persistent or recurrent pattern of sleep
disruption that is primarily due to an Preventing Sleep Disorders
alteration of the circadian system or to a
misalignment between the endogenous Sleep hygiene: These changes in lifestyle can be
circadian rhythm and the sleep–wake relatively simple to follow and can help avoid
schedule required by an individual’s problems such as insomnia for some people. Some
physical environment or social or sleep hygiene recommendations rely on allowing the
professional schedule. brain’s normal drive for sleep to take over, replacing
B.​ The sleep disruption leads to excessive the restrictions we place on our activities that
sleepiness or insomnia, or both. interfere with sleep. Avoiding the use of caffeine and
C.​ The sleep disturbance causes clinically nicotine—which are both stimulants—can also help
significant distress or impairment in social, prevent problems such as nighttime awakening.
occupational, and other important areas of
functioning.
Specify if: Good Sleep Habits
Episodic: Symptoms last at least 1 month but less
than 3 months · Establish a set bedtime routine.
Persistent: Symptoms last 3 months or longer
Recurrent: Two or more episodes occur within the · Develop a regular bedtime and a regular time to
space of 1 year awaken.

Treatment of Sleep Disorders · Eliminate all foods and drinks that contain
caffeine 6 hours before bedtime.
Medical Treatments: People who complain of
· Limit any use of alcohol or tobacco.
insomnia to a medical professional are likely
prescribed one of several benzodiazepine or related
· Try drinking milk before bedtime.
medications, which include short-acting drugs such
as triazolam (Halcion), zaleplon (Sonata), and · Eat a balanced diet, limiting fat.
zolpidem (Ambien) and long-acting drugs such as
flurazepam (Dalmane).
ABNORMAL PSYCHOLOGY
· Go to bed only when sleepy and get out of bed if signs of autonomic arousal, such as
you are unable to fall asleep or back to sleep mydriasis, tachycardia, rapid
after 15 minutes. breathing, and sweating, during each
episode. There is relative
· Do not exercise or participate in vigorous unresponsiveness to efforts of others
activities in the hours before bedtime. to comfort the person during the
episode.
· Do include a weekly program of exercise during
the day. B. No or little (e.g., only a single-visual-scene)
dream imagery is recalled.
· Restrict activities in bed to those that help
induce sleep. C. Amnesia for the episodes is present.

· Reduce noise and light in the bedroom. D. The episodes cause clinically significant
distress or impairment in social, occupational, or
· Increase exposure to natural and bright light other important areas of functioning.
during the day.
E. The disturbance is not attributable to the
· Avoid extreme temperature changes in the physiological effects of a substance (e.g., a drug
bedroom (that is, too hot or too cold). of abuse, a medication).
Parasomnias and Their Treatment F. Coexisting mental and medical disorders do not
explain the episodes of sleepwalking or sleep
Parasomnias are not problems with sleep itself
terrors.
but abnormal events that occur either during
sleep or during that twilight time between
sleeping and waking.
DSM-5 identifies a number of different
Diagnostic Criteria for Non-Rapid Eye parasomnias:
Movement Sleep Arousal Disorders
Nightmares (or nightmare disorder) occur
A. Recurrent episodes of incomplete awakening during REM or dream sleep. About 10% to
from sleep usually occurring during the first 50% of children and about 9% to 30% of
third of the major sleep episode, accompanied adults experience them regularly. According
by either one of the following: to DSM-5 criteria, these experiences must
be so distressful that they impair a person’s
1. Sleepwalking: Repeated episodes
ability to carry on normal activities (such as
of rising from bed during sleep and
making a person too anxious to try to sleep
walking about. While sleepwalking,
at night).
the person has a blank, staring face;
is relatively unresponsive to the
efforts of others to communicate
with him or her; and can be Diagnostic Criteria for Nightmare Disorder
awakened only with great difficulty.
A. Repeated occurrences of extended, extremely
2. Sleep terrors: Recurrent episodes of dysphoric, and well-remembered dreams that
abrupt terror arousals from sleep, usually involve efforts to avoid threats to
usually beginning with a panicky survival, security, or physical integrity and that
scream. There is intense fear and
ABNORMAL PSYCHOLOGY
generally occur during the second half of the Sleepwalking is primarily a problem during
major sleep episode. childhood, affecting more than 10% of
school-aged children. Sleepwalking episodes
B. On awakening from the dysphoric dreams, the have been associated with violent behavior,
person rapidly becomes oriented and alert. including homicide and suicide.

C. The sleep disturbance causes clinically One approach to reducing chronic sleep terrors is the
significant distress or impairment in social, use of scheduled awakenings.
occupational, or other important areas of
functioning. Nocturnal eating syndrome- when individuals rise
from their beds and eat while they are still asleep.
D. The nightmare symptoms are not attributable to Different than the night eating syndrome; may be
the physiological effects of a substance (e.g., a more frequent than previously thought; it was found
drug of abuse, a medication). in almost 6% of individuals in one study who were
referred because of insomnia complaints.
E. Coexisting mental and medical disorders do not
adequately explain the predominant complaint of Sexsomnia- acting out sexual behaviors such as
dysphoric dreams. masturbation and sexual intercourse with no memory
of the event. This rare problem can cause
Specify current severity: relationship problems and, in extreme cases, legal
problems when cases occur without consent or with
Severity can be rated by the frequency with
minors.
which the nightmares occur:

Mild: Less than one episode per week on

average Diagnostic Criteria for Rapid Eye Movement
Sleep Behavior Disorder
Moderate: One or more episodes per week but
less than nightly A. Repeated episodes of arousal during sleep
associated with vocalization and/or complex
Severe: Episodes nightly
motor behaviors.

B. These behaviors arise during rapid eye

Disorder of arousal includes a number of motor movement (REM) sleep and therefore usually
movements and behaviors during NREM sleep such occur greater than 90 minutes after sleep onset,
as sleepwalking, sleep terrors, and incomplete are more frequent during the later portions of the
awakening: sleep period and uncommonly occur during
daytime naps.
Sleep terrors, which most commonly afflict
children, usually begin with a piercing C. Upon awakening from these episodes, the
scream. individual is completely awake, alert, and not
confused or disoriented.
- appear to resemble
nightmares—the child cries and D. Either of the following:
appears frightened—but they occur
1. REM sleep without atonia on
during NREM sleep and therefore
polysomnographic recording.
are not caused by frightening
dreams.
ABNORMAL PSYCHOLOGY
2. A history suggestive of REM sleep
behavior disorder and an established
synucleinopathy diagnosis (e.g.,
Parkinson’s disease, multiple system
atrophy).

E. The behaviors cause clinically significant

distress or impairment in social, occupational, or
other important areas of functioning (which may
include injury to self or the bed partner).

F. The disturbance is not attributable to the

physiological effects of a substance (e.g., a drug
of abuse, a medication) or another medical
condition.

G. Coexisting mental and medical disorders do not

explain the episodes.