FUNDAMENTALS OF

PSYCHOLOGICAL
DISORDERS

Alexis Bridley and Lee W. Da n Jr.

Washington State University
Fundamentals of Psychological Disorders

Alexis Bridley and Lee W. Daffin Jr.

Washington State University
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TABLE OF CONTENTS
Licensing

Part I. Setting the Stage

1: What is Abnormal Psychology?
1.1: Understanding Abnormal Behavior
1.2: Classifying Mental Disorders
1.3: The Stigma of Mental Illness
1.4: The History of Mental Illness
1.5: Research Methods in Psychopathology
1.6: Mental Health Professionals, Societies, and Journals
2: Models of Abnormal Psychology
2.1: Uni- vs. Multi-Dimensional Models of Abnormality
2.2: The Biological Model
2.3: Psychological Perspectives
2.4: The Sociocultural Model
3: Clinical Assessment, Diagnosis, and Treatment
3.1: Clinical Assessment of Abnormal Behavior
3.2: Diagnosing and Classifying Abnormal Behavior
3.3: Treatment of Mental Disorders – An Overview

Part II. Mental Disorders – Block 1

4: Mood Disorders
4.1: Clinical Presentation – Depressive Disorders
4.2: Clinical Presentation – Bipolar and Related Disorders
4.3: Mood Disorders - Epidemiology
4.4: Mood Disorders - Comorbidity
4.5: Mood Disorders - Etiology
4.6: Mood Disorders - Treatment
5: Trauma- and Stressor-Related Disorders
5.1: Trauma- and Stressor-Related Disorders - Stressors
5.2: Trauma- and Stressor-Related Disorders - Clinical Presentation
5.3: Trauma- and Stressor-Related Disorders - Epidemiology
5.4: Trauma- and Stressor-Related Disorders - Comorbidity
5.5: Trauma- and Stressor-Related Disorders - Etiology
5.6: Trauma- and Stressor-Related Disorders - Treatment
6: Dissociative Disorders
6.1: Dissociative Disorders - Clinical Presentation
6.2: Dissociative Disorders - Epidemiology
6.3: Dissociative Disorders - Comorbidity
6.4: Dissociative Disorders - Etiology
6.5: Dissociative Disorders - Treatment

Part III. Mental Disorders – Block 2

7: Anxiety Disorders
7.1: Anxiety Disorders - Clinical Presentation

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 7.2: Anxiety Disorders - Epidemiology
7.3: Anxiety Disorders - Comorbidity
7.4: Anxiety Disorders - Etiology
7.5: Anxiety Disorders - Treatment
8: Somatic Symptom and Related Disorders
8.1: Somatic Symptom and Related Disorders - Clinical Presentation
8.2: Somatic Symptom and Related Disorders - Epidemiology
8.3: Somatic Symptom and Related Disorders - Comorbidity
8.4: Somatic Symptom and Related Disorders - Etiology
8.5: Somatic Symptom and Related Disorders - Treatment
8.6: Somatic Symptom and Related Disorders - Psychological Factors Affecting Other Medical Conditions
9: Obsessive-Compulsive and Related Disorders
9.1: Obsessive-Compulsive and Related Disorders - Clinical Presentation
9.2: Obsessive-Compulsive and Related Disorders - Epidemiology
9.3: Obsessive-Compulsive and Related Disorders - Comorbidity
9.4: Obsessive-Compulsive and Related Disorders - Etiology
9.5: Obsessive-Compulsive and Related Disorders - Treatment

Part IV. Mental Disorders – Block 3

10: Feeding and Eating Disorders
10.1: Feeding and Eating Disorders - Clinical Presentation
10.2: Feeding and Eating Disorders - Epidemiology
10.3: Feeding and Eating Disorders - Comorbidity
10.4: Feeding and Eating Disorders - Etiology
10.5: Feeding and Eating Disorders - Treatment
11: Substance-Related and Addictive Disorders
11.1: Substance-Related and Addictive Disorders - Clinical Presentation
11.2: Substance-Related and Addictive Disorders - Epidemiology
11.3: Substance-Related and Addictive Disorders - Comorbidity
11.4: Substance-Related and Addictive Disorders - Etiology
11.5: Substance-Related and Addictive Disorders - Treatment

Part V. Mental Disorders – Block 4

12: Schizophrenia Spectrum and Other Psychotic Disorders
12.1: Schizophrenia Spectrum and Other Psychotic Disorders - Clinical Presentation
12.2: Schizophrenia Spectrum and Other Psychotic Disorders - Epidemiology
12.3: Schizophrenia Spectrum and Other Psychotic Disorders - Comorbidity
12.4: Schizophrenia Spectrum and Other Psychotic Disorders - Etiology
12.5: Schizophrenia Spectrum and Other Psychotic Disorders - Treatment
13: Personality Disorders
13.1: Personality Disorders - Clinical Presentation
13.2: Personality Disorders - Epidemiology
13.3: Personality Disorders - Comorbidity
13.4: Personality Disorders - Etiology
13.5: Personality Disorders - Treatment

Part VI. Mental Disorders – Block 5

14: Neurocognitive Disorders
14.1: Neurocognitive Disorders - Clinical Presentation

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 14.2: Neurocognitive Disorders - Epidemiology
14.3: Neurocognitive Disorders - Etiology
14.4: Neurocognitive Disorders - Treatment
15: Contemporary Issues in Psychopathology
15.1: Legal Issues Related to Mental Illness
15.2: Patient’s Rights
15.3: The Therapist-Client Relationship

Index

Glossary
Detailed Licensing

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Licensing
A detailed breakdown of this resource's licensing can be found in Back Matter/Detailed Licensing.

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 SECTION OVERVIEW

Part I. Setting the Stage

1: What is Abnormal Psychology?
1.1: Understanding Abnormal Behavior
1.2: Classifying Mental Disorders
1.3: The Stigma of Mental Illness
1.4: The History of Mental Illness
1.5: Research Methods in Psychopathology
1.6: Mental Health Professionals, Societies, and Journals

2: Models of Abnormal Psychology

2.1: Uni- vs. Multi-Dimensional Models of Abnormality
2.2: The Biological Model
2.3: Psychological Perspectives
2.4: The Sociocultural Model

3: Clinical Assessment, Diagnosis, and Treatment

3.1: Clinical Assessment of Abnormal Behavior
3.2: Diagnosing and Classifying Abnormal Behavior
3.3: Treatment of Mental Disorders – An Overview

This page titled Part I. Setting the Stage is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Alexis Bridley
and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available
upon request.

1
 CHAPTER OVERVIEW

1: What is Abnormal Psychology?

 Learning Objectives
Explain what it means to display abnormal behavior.
Clarify how mental health professionals classify mental disorders.
Describe the effect of stigma on those who have a mental illness.
Outline the history of mental illness.
Describe the research methods used to study abnormal behavior and mental illness.
Identify types of mental health professionals, societies they may join, and journals they can publish their work in.

Cassie is an 18-year-old female from suburban Seattle, WA. She was a successful student in high school, graduating valedictorian
and obtaining a National Merit Scholarship for her performance on the PSAT during her junior year. She was accepted to a
university on the opposite side of the state, where she received additional scholarships giving her a free ride for her entire
undergraduate education. Excited to start this new chapter in her life, Cassie’s parents begin the 5-hour commute to Pullman, where
they will leave their only daughter for the first time in her life.
The semester begins as it always does in mid to late August. Cassie meets the challenge with enthusiasm and does well in her
classes for the first few weeks of the semester, as expected. Sometime around Week 6, her friends notice she is despondent,
detached, and falling behind in her work. After being asked about her condition, she replies that she is “just a bit homesick,” and
her friends accept this answer as it is a typical response to leaving home and starting college for many students. A month later, her
condition has not improved but worsened. She now regularly shirks her responsibilities around her apartment, in her classes, and on
her job. Cassie does not hang out with friends like she did when she first arrived for college and stays in bed most of the day.
Concerned, Cassie’s friends contact Health and Wellness for help.
Cassie’s story, though hypothetical, is true of many Freshmen leaving home for the first time to earn a higher education, whether in
rural Washington state or urban areas such as Chicago and Dallas. Most students recover from this depression and go on to be
functional members of their collegiate environment and accomplished scholars. Some students learn to cope on their own while
others seek assistance from their university’s health and wellness center or from friends who have already been through the same
ordeal. These are normal reactions. However, in cases like Cassie’s, the path to recovery is not as clear. Instead of learning how to
cope, their depression increases until it reaches clinical levels and becomes an impediment to success in multiple domains of life
such as home, work, school, and social circles.
In Module 1, we will explore what it means to display abnormal behavior, what mental disorders are, and the way society views
mental illness today and how it has been regarded throughout history. Then we will review research methods used by psychologists
in general and how they are adapted to study abnormal behavior/mental disorders. We will conclude with an overview of what
mental health professionals do.
1.1: Understanding Abnormal Behavior
1.2: Classifying Mental Disorders
1.3: The Stigma of Mental Illness
1.4: The History of Mental Illness
1.5: Research Methods in Psychopathology
1.6: Mental Health Professionals, Societies, and Journals

This page titled 1: What is Abnormal Psychology? is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
Alexis Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit
history is available upon request.

1
1.1: Understanding Abnormal Behavior
 Learning Objectives
Describe the disease model and its impact on the field of psychology throughout history.
Describe positive psychology.
Define abnormal behavior.
Explain the concept of dysfunction as it relates to mental illness.
Explain the concept of distress as it relates to mental illness.
Explain the concept of deviance as it relates to mental illness.
Explain the concept of dangerousness as it relates to mental illness.
Define culture and social norms.
Clarify the cost of mental illness on society.
Define abnormal psychology, psychopathology, and mental disorders.

Understanding Abnormal Behavior

To understand what abnormal behavior is, we first have to understand what normal behavior is. Normal really is in the eye of the
beholder, and most psychologists have found it easier to explain what is wrong with people then what is right. How so?
Psychology worked with the disease model for over 60 years, from about the late 1800s into the middle part of the 20th century.
The focus was simple – curing mental disorders – and included such pioneers as Freud, Adler, Klein, Jung, and Erickson. These
names are synonymous with the psychoanalytical school of thought. In the 1930s, behaviorism, under B.F. Skinner, presented a
new view of human behavior. Simply, human behavior could be modified if the correct combination of reinforcements and
punishments were used. This viewpoint espoused the dominant worldview of the time – mechanism – which presented the world as
a great machine explained through the principles of physics and chemistry. In it, human beings serve as smaller machines in the
larger machine of the universe.
Moving into the mid to late 1900s, we developed a more scientific investigation of mental illness, which allowed us to examine the
roles of both nature and nurture and to develop drug and psychological treatments to “make miserable people less miserable.”
Though this was an improvement, there were three consequences as pointed out by Martin Seligman in his 2008 TED Talk entitled,
“The new era of positive psychology.” These are:
“The first was moral; that psychologists and psychiatrists became victimologists, pathologizers; that our view of human nature
was that if you were in trouble, bricks fell on you. And we forgot that people made choices and decisions. We forgot
responsibility. That was the first cost.”
“The second cost was that we forgot about you people. We forgot about improving normal lives. We forgot about a mission to
make relatively untroubled people happier, more fulfilled, more productive. And “genius,” “high-talent,” became a dirty word.
No one works on that.”
“And the third problem about the disease model is, in our rush to do something about people in trouble, in our rush to do
something about repairing damage, it never occurred to us to develop interventions to make people happier — positive
interventions.”
Starting in the 1960s, figures such as Abraham Maslow and Carl Rogers sought to overcome the limitations of psychoanalysis and
behaviorism by establishing a “third force” psychology, also known as humanistic psychology. As Maslow said,
“The science of psychology has been far more successful on the negative than on the positive side; it has revealed to us much about
man’s shortcomings, his illnesses, his sins, but little about his potentialities, his virtues, his achievable aspirations, or his full
psychological height. It is as if psychology had voluntarily restricted itself to only half its rightful jurisdiction, and that the darker,
meaner half.” (Maslow, 1954, p. 354).
Humanistic psychology instead addressed the full range of human functioning and focused on personal fulfillment, valuing feelings
over intellect, hedonism, a belief in human perfectibility, emphasis on the present, self-disclosure, self-actualization, positive
regard, client centered therapy, and the hierarchy of needs. Again, these topics were in stark contrast to much of the work being
done in the field of psychology up to and at this time.

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In 1996, Martin Seligman became the president of the American Psychological Association (APA) and called for a positive
psychology or one that had a more positive conception of human potential and nature. Building on Maslow and Roger’s work, he
ushered in the scientific study of such topics as happiness, love, hope, optimism, life satisfaction, goal setting, leisure, and
subjective well-being. Though positive and humanistic psychology have similarities, their methodology was much different. While
humanistic psychology generally relied on qualitative methods, positive psychology utilizes a quantitative approach and aims to
help people make the most out of life’s setbacks, relate well to others, find fulfillment in creativity, and find lasting meaning and
satisfaction (https://www.positivepsychologyinstitute.com.au/what-is-positive-psychology).
So, to understand what normal behavior is, do we look to positive psychology for an indication, or do we first define abnormal
behavior and then reverse engineer a definition of what normal is? Our preceding discussion gave suggestions about what normal
behavior is, but could the darker elements of our personality also make up what is normal to some extent? Possibly. The one truth is
that no matter what behavior we display, if taken to the extreme, it can become disordered – whether trying to control others
through social influence or helping people in an altruistic fashion. As such, we can consider abnormal behavior to be a
combination of personal distress, psychological dysfunction, deviance from social norms, dangerousness to self and others, and
costliness to society.

How Do We Determine What Abnormal Behavior Is?

In the previous section we showed that what we might consider normal behavior is difficult to define. Equally challenging is
understanding what abnormal behavior is, which may be surprising to you. A publication which you will become intimately
familiar with throughout this book, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders
5th edition, Text Revision (DSM-5-TR; 2022), states that, “Although no definition can capture all aspects of the range of disorders
contained in DSM-5″ (pg. 13) certain aspects are required. These include:
Dysfunction – Includes “clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that
reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (pg. 14).
Abnormal behavior, therefore, has the capacity to make well-being difficult to obtain and can be assessed by looking at an
individual’s current performance and comparing it to what is expected in general or how the person has performed in the past.
As such, a good employee who suddenly demonstrates poor performance may be experiencing an environmental demand
leading to stress and ineffective coping mechanisms. Once the demand resolves itself, the person’s performance should return to
normal according to this principle.
Distress – When the person experiences a disabling condition “in social, occupational, or other important activities” (pg. 14).
Distress can take the form of psychological or physical pain, or both concurrently. Alone though, distress is not sufficient
enough to describe behavior as abnormal. Why is that? The loss of a loved one would cause even the most “normally”
functioning individual pain. An athlete who experiences a career-ending injury would display distress as well. Suffering is part
of life and cannot be avoided. And some people who exhibit abnormal behavior are generally positive while doing so.
Deviance – Closer examination of the word abnormal indicates a move away from what is normal, or the mean (i.e., what
would be considered average and in this case in relation to behavior), and so is behavior that infrequently occurs (sort of an
outlier in our data). Our culture, or the totality of socially transmitted behaviors, customs, values, technology, attitudes, beliefs,
art, and other products that are particular to a group, determines what is normal. Thus, a person is said to be deviant when he or
she fails to follow the stated and unstated rules of society, called social norms. Social norms change over time due to shifts in
accepted values and expectations. For instance, homosexuality was taboo in the U.S. just a few decades ago, but today, it is
generally accepted. Likewise, PDAs, or public displays of affection, do not cause a second look by most people unlike the past
when these outward expressions of love were restricted to the privacy of one’s own house or bedroom. In the U.S., crying is
generally seen as a weakness for males. However, if the behavior occurs in the context of a tragedy such as the Vegas mass
shooting on October 1, 2017, in which 58 people were killed and about 500 were wounded while attending the Route 91
Harvest Festival, then it is appropriate and understandable. Finally, consider that statistically deviant behavior is not necessarily
negative. Genius is an example of behavior that is not the norm.
Though not part of the DSM conceptualization of what abnormal behavior is, many clinicians add dangerousness to this list when
behavior represents a threat to the safety of the person or others. It is important to note that having a mental disorder does not imply
a person is automatically dangerous. The depressed or anxious individual is often no more a threat than someone who is not
depressed, and as Hiday and Burns (2010) showed, dangerousness is more the exception than the rule. Still, mental health
professionals have a duty to report to law enforcement when a mentally disordered individual expresses intent to harm another
person or themselves. It is important to point out that people seen as dangerous are also not automatically mentally ill.

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The Costs of Mental Illness
This leads us to wonder what the cost of mental illness is to society. The National Alliance on Mental Illness (NAMI) states that
mental illness affects a person’s life which then ripples out to the family, community, and world. For instance, people with serious
mental illness are at increased risk for diabetes, cancer, and cardiometabolic disease while 18% of those with a mental illness also
have a substance use disorder. Within the family, an estimated 8.4 million Americans provide care to an adult with an emotional or
mental illness with caregivers spending about 32 hours a week providing unpaid care. At the community level 21% of the homeless
also have a serious mental illness while 70% of youth in the juvenile justice system have at least one mental health condition. And
finally, depression is a leading cause of disability worldwide and depression and anxiety disorders cost the global economy $1
trillion each year in lost productivity (Source: NAMI, The Ripple Effect of Mental Illness infographic;
https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers).
In terms of worldwide impact, data from 2010 estimates $2.5 trillion in global costs, with $1.7 trillion being indirect costs (i.e.,
invisible costs “associated with income losses due to mortality, disability, and care seeking, including lost production due to work
absence or early retirement”) and the remainder being direct (i.e., visible costs to include “medication, physician visits,
psychotherapy sessions, hospitalization,” etc.). It is now projected that mental illness costs will be around $16 trillion by 2030. The
authors add, “It should be noted that these calculations did not include costs associated with mental disorders from outside the
healthcare system, such as legal costs caused by illicit drug abuse” (Trautmann, Rehm, & Wittchen, 2016). The costs for mental
illness have also been found to be greater than the combined costs of somatic diseases such as cancer, diabetes, and respiratory
disorders (Whiteford et al., 2013).
Christensen et al. (2020) did a review of 143 cost-of-illness studies that covered 48 countries and several types of mental illness.
Their results showed that mental disorders are a substantial economic burden for societies and that certain groups of mental
disorders are more costly than others. At the higher cost end were developmental disorders to include autism spectrum disorders
followed by schizophrenia and intellectual disabilities. They write, “However, it is important to note that while disorders such as
mood, neurotic and substance use disorders were less costly according to societal cost per patient, these disorders are much more
prevalent and thus would contribute substantially to the total national cost in a country.” And much like Trautmann, Rehm, &
Wittchen (2016) other studies show that indirect costs are higher than direct costs (Jin & Mosweu, 2017; Chong et al., 2016).

Defining Key Terms

Our discussion so far has concerned what normal and abnormal behavior is. We saw that the study of normal behavior falls under
the providence of positive psychology. Similarly, the scientific study of abnormal behavior, with the intent to be able to predict
reliably, explain, diagnose, identify the causes of, and treat maladaptive behavior, is what we refer to as abnormal psychology.
Abnormal behavior can become pathological and has led to the scientific study of psychological disorders, or psychopathology.
From our previous discussion we can fashion the following definition of a psychological or mental disorder: mental disorders are
characterized by psychological dysfunction, which causes physical and/or psychological distress or impaired functioning, and is not
an expected behavior according to societal or cultural standards.

Key Takeaways
You should have learned the following in this section:
Abnormal behavior is a combination of personal distress, psychological dysfunction, deviance from social norms,
dangerousness to self and others, and costliness to society.
Abnormal psychology is the scientific study of abnormal behavior, with the intent to be able to predict reliably, explain,
diagnose, identify the causes of, and treat maladaptive behavior.
The study of psychological disorders is called psychopathology.
Mental disorders are characterized by psychological dysfunction, which causes physical and/or psychological distress or
impaired functioning, and is not an expected behavior according to societal or cultural standards

 Review Questions
1. What is the disease model and what problems existed with it? What was to overcome its limitations?
2. Can we adequately define normal behavior? What about abnormal behavior?
3. What aspects are part of the American Psychiatric Association’s definition of abnormal behavior?
4. How costly is mental illness?

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 5. What is abnormal psychology?
6. What is psychopathology?
7. How do we define mental disorders?

This page titled 1.1: Understanding Abnormal Behavior is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated
by Alexis Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit
history is available upon request.

1.1.4 https://socialsci.libretexts.org/@go/page/161399
1.2: Classifying Mental Disorders
 Learning Objectives
Define and exemplify classification.
Define nomenclature.
Define epidemiology.
Define the presenting problem and clinical description.
Differentiate prevalence, incidence, and any subtypes.
Define comorbidity.
Define etiology.
Define course.
Define prognosis.
Define treatment.

Classification
Classification is not a foreign concept and as a student you have likely taken at least one biology class that discussed the taxonomic
classification system of Kingdom, Phylum, Class, Order, Family, Genus, and Species revolutionized by Swedish botanist, Carl
Linnaeus. You probably even learned a witty mnemonic such as ‘King Phillip, Come Out For Goodness Sake’ to keep the order
straight. The Library of Congress uses classification to organize and arrange their book collections and includes such categories as
B – Philosophy, Psychology, and Religion; H – Social Sciences; N – Fine Arts; Q – Science; R – Medicine; and T – Technology.
Simply, classification is how we organize or categorize things. The second author’s wife has been known to color-code her Blu
Ray collection by genre, movie title, and release date. It is useful for us to do the same with abnormal behavior, and classification
provides us with a nomenclature, or naming system, to structure our understanding of mental disorders in a meaningful way. Of
course, we want to learn as much as we can about a given disorder so we can understand its cause, predict its future occurrence,
and develop ways to treat it.

Determining Occurrence of a Disorder

Epidemiology is the scientific study of the frequency and causes of diseases and other health-related states in specific populations
such as a school, neighborhood, a city, country, and the world. Psychiatric or mental health epidemiology refers to the
occurrence of mental disorders in a population. In mental health facilities, we say that a patient presents with a specific problem, or
the presenting problem, and we give a clinical description of it, which includes information about the thoughts, feelings, and
behaviors that constitute that mental disorder. We also seek to gain information about the occurrence of the disorder, its cause,
course, and treatment possibilities.
Occurrence can be investigated in several ways. First, prevalence is the percentage of people in a population that has a mental
disorder or can be viewed as the number of cases divided by the total number of people in the sample. For instance, if 20 people out
of 100 have bipolar disorder, then the prevalence rate is 20%. Prevalence can be measured in several ways:
Point prevalence indicates the proportion of a population that has the characteristic at a specific point in time. In other words, it
is the number of active cases.
Period prevalence indicates the proportion of a population that has the characteristic at any point during a given period of time,
typically the past year.
Lifetime prevalence indicates the proportion of a population that has had the characteristic at any time during their lives.
According to a 2020 infographic by the National Alliance on Mental Illness (NAMI), for U.S. adults, 1 in 5 experienced a mental
illness, 1 in 20 had a serious mental illness, 1 in 15 experienced both a substance use disorder and mental disorder, and over 12
million had serious thoughts of suicide (2020 Mental Health By the Numbers: US Adults infographic). In terms of adolescents aged
12-17, in 2020 1 in 6 experienced a major depressive episode, 3 million had serious thoughts of suicide, and there was a 31%
increase in mental health-related emergency department visits. Among U.S. young adults aged 18-25, 1 in 3 experienced a mental
illness, 1 in 10 had a serious mental illness, and 3.8 had serious thoughts of suicide (2020 Mental Health By the Numbers: Youth
and Young Adults infographic). These numbers would represent period prevalence rates during the pandemic, and for the year

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2020. In the, You are Not Alone infographic, NAMI reported the following 12-month prevalence rates for U.S. Adults: 19% having
an anxiety disorder, 8% having depression, 4% having PTSD, 3% having bipolar disorder, and 1% having schizophrenia.
Source: https://www.nami.org/mhstats
Incidence indicates the number of new cases in a population over a specific period. This measure is usually lower since it does not
include existing cases as prevalence does. If you wish to know the number of new cases of social phobia during the past year
(going from say Aug 21, 2015 to Aug 20, 2016), you would only count cases that began during this time and ignore cases before
the start date, even if people are currently afflicted with the mental disorder. Incidence is often studied by medical and public health
officials so that causes can be identified, and future cases prevented.
Finally, comorbidity describes when two or more mental disorders are occurring at the same time and in the same person. The
National Comorbidity Survey Replication (NCS-R) study conducted by the National Institute of Mental Health (NIMH) and
published in the June 6, 2005 issue of the Archives of General Psychiatry, sought to discover trends in prevalence, impairment, and
service use during the 1990s. The first study, conducted from 1980 to 1985, surveyed 20,000 people from five different
geographical regions in the U.S. A second study followed from 1990-1992 and was called the National Comorbidity Survey (NCS).
The third study, the NCS-R, used a new nationally representative sample of the U.S. population, and found that 45% of those with
one mental disorder met the diagnostic criteria for two or more disorders. The authors also found that the severity of mental illness,
in terms of disability, is strongly related to comorbidity, and that substance use disorders often result from disorders such as anxiety
and bipolar disorders. The implications of this are significant as services to treat substance abuse and mental disorders are often
separate, despite the disorders appearing together.

Other Key Factors Related to Mental Disorders

The etiology is the cause of the disorder. There may be social, biological, or psychological explanations for the disorder which
need to be understood to identify the appropriate treatment. Likewise, the effectiveness of a treatment may give some hint at the
cause of the mental disorder. More on this in Module 2.
The course of the disorder is its particular pattern. A disorder may be acute, meaning that it lasts a short time, or chronic, meaning
it persists for a long time. It can also be classified as time-limited, meaning that recovery will occur after some time regardless of
whether any treatment occurs.
Prognosis is the anticipated course the mental disorder will take. A key factor in determining the course is age, with some
disorders presenting differently in childhood than adulthood.
Finally, we will discuss several treatment strategies in this book in relation to specific disorders, and in a general fashion in Module
3. Treatment is any procedure intended to modify abnormal behavior into normal behavior. The person suffering from the mental
disorder seeks the assistance of a trained professional to provide some degree of relief over a series of therapy sessions. The trained
mental health professional may prescribe medication or utilize psychotherapy to bring about this change. Treatment may be sought
from the primary care provider, in an outpatient facility, or through inpatient care or hospitalization at a mental hospital or
psychiatric unit of a general hospital. According to NAMI, the average delay between symptom onset and treatment is 11 years
with 45% of adults with mental illness, 66% of adults with serious mental illness, and 51% of youth with a mental health condition
seeking treatment in a given year. They also report that 50% of white, 49% of lesbian/gay and bisexual, 43% of mixed/multiracial,
34% of Hispanic or Latinx, 33% of black, and 23% of Asian adults with a mental health diagnosis received treatment or counseling
in the past year (Source: Mental Health Care Matters infographic, https://www.nami.org/mhstats).

Key Takeaways
You should have learned the following in this section:
Classification, or how we organize or categorize things, provides us with a nomenclature, or naming system, to structure our
understanding of mental disorders in a meaningful way.
Epidemiology is the scientific study of the frequency and causes of diseases and other health-related states in specific
populations.
Prevalence is the percentage of people in a population that has a mental disorder or can be viewed as the number of cases
divided by the total number of people in the sample.
Incidence indicates the number of new cases in a population over a specific period.
Comorbidity describes when two or more mental disorders are occurring at the same time and in the same person.

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 The etiology is the cause of a disorder while the course is its particular pattern and can be acute, chronic, or time-limited.
Prognosis is the anticipated course the mental disorder will take.

 Review Questions
1. What is the importance of classification for the study of mental disorders?
2. What information does a clinical description include?
3. In what ways is occurrence investigated?
4. What is the etiology of a mental illness?
5. What is the relationship of course and prognosis to one another?
6. What is treatment and who seeks it?

This page titled 1.2: Classifying Mental Disorders is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
Alexis Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit
history is available upon request.

1.2.3 https://socialsci.libretexts.org/@go/page/161400
1.3: The Stigma of Mental Illness
 Learning Objectives
Clarify the importance of social cognition theory in understanding why people do not seek care.
Define categories and schemas.
Define stereotypes and heuristics.
Describe social identity theory and its consequences.
Differentiate between prejudice and discrimination.
Contrast implicit and explicit attitudes.
Explain the concept of stigma and its three forms.
Define courtesy stigma.
Describe what the literature shows about stigma.

In the previous section, we discussed the fact that care can be sought out in a variety of ways. The problem is that many people
who need care never seek it out. Why is that? We already know that society dictates what is considered abnormal behavior through
culture and social norms, and you can likely think of a few implications of that. But to fully understand society’s role in why people
do not seek care, we need to determine the psychological processes underlying this phenomenon in the individual.
Social cognition is the process through which we collect information from the world around us and then interpret it. The collection
process occurs through what we know as sensation – or detecting physical energy emitted or reflected by physical objects.
Detection occurs courtesy of our eyes, ears, nose, skin and mouth; or via vision, hearing, smell, touch, and taste, respectfully. Once
collected, the information is relayed to the brain through the neural impulse where it is processed and interpreted, or meaning is
added to this raw sensory data which we call perception.
One way meaning is added is by taking the information we just detected and using it to assign people to categories, or groups. For
each category, we have a schema, or a set of beliefs and expectations about a group of people, believed to apply to all members of
the group, and based on experience. You might think of them as organized ways of making sense of experience. So, it is during our
initial interaction with someone that we collect information about them, assign the person to a category for which we have a
schema, and then use that to affect how we interact with them. First impressions, called the primacy effect, are important because
even if we obtain new information that should override an incorrect initial assessment, the initial impression is unlikely to change.
We call this the perseverance effect, or belief perseverance.
Stereotypes are special types of schemas that are very simplistic, very strongly held, and not based on firsthand experience. They
are heuristics, or mental shortcuts, that allow us to assess this collected information very quickly. One piece of information, such
as skin color, can be used to assign the person to a schema for which we have a stereotype. This can affect how we think or feel
about the person and behave toward them. Again, human beings tend to imply things about an individual solely due to a
distinguishing feature and disregard anything inconsistent with the stereotype.
Social identity theory (Tajfel, 1982; Turner, 1987) states that people categorize their social world into meaningfully simplistic
representations of groups of people. These representations are then organized as prototypes, or “fuzzy sets of a relatively limited
number of category-defining features that not only define one category but serve to distinguish it from other categories” (Foddy
and Hogg, as cited in Foddy et al., 1999). We construct in-groups and out-groups and categorize the self as an in-group member.
The self is assimilated into the salient in-group prototype, which indicates what cognitions, affect, and behavior we may exhibit.
Stereotyping, out-group homogeneity, in-group/out-group bias, normative behavior, and conformity are all based on self-
categorization.
How so? Out-group homogeneity occurs when we see all members of an outside group as the same. This leads to a tendency to
show favoritism to, and exclude or hold a negative view of, members outside of, one’s immediate group, called the in-group/out-
group bias. The negative view or set of beliefs about a group of people is what we call prejudice, and this can result in acting in a
way that is negative against a group of people, called discrimination. It should be noted that a person can be prejudicial without
being discriminatory since most people do not act on their attitudes toward others due to social norms against such behavior.
Likewise, a person or institution can be discriminatory without being prejudicial. For example, when a company requires that an
applicant have a certain education level or be able to lift 80 pounds as part of typical job responsibilities. Individuals without a
degree or ability to lift will be removed from consideration for the job, but this discriminatory act does not mean that the company

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has negative views of people without degrees or the inability to lift heavy weight. You might even hold a negative view of a
specific group of people and not be aware of it. An attitude we are unaware of is called an implicit attitude, which stands in contrast
to explicit attitudes, which are the views within our conscious awareness.
We have spent quite a lot of space and time understanding how people gather information about the world and people around them,
process this information, use it to make snap judgements about others, form groups for which stereotypes may exist, and then
potentially hold negative views of this group and behave negatively toward them as a result. Just one piece of information can be
used to set this series of mental events into motion. Outside of skin color, the label associated with having a mental disorder can be
used. Stereotypes about people with a mental disorder can quickly and easily transform into prejudice when people in a society
determine the schema to be correct and form negative emotions and evaluations of this group (Eagly & Chaiken, 1993). This, in
turn, can lead to discriminatory practices such as an employer refusing to hire, a landlord refusing to rent an apartment, or avoiding
a romantic relationship, all due to the person having a mental illness.
Overlapping with prejudice and discrimination in terms of how people with mental disorders are treated is stigma, or when
negative stereotyping, labeling, rejection, and loss of status occur. Stigma takes on three forms as described below:
Public stigma – When members of a society endorse negative stereotypes of people with a mental disorder and discriminate
against them. They might avoid them altogether, resulting in social isolation. An example is when an employer intentionally
does not hire a person because their mental illness is discovered.
Label avoidance –To avoid being labeled as “crazy” or “nuts” people needing care may avoid seeking it altogether or stop care
once started. Due to these labels, funding for mental health services could be restricted and instead, physical health services
funded.
Self-stigma – When people with mental illnesses internalize the negative stereotypes and prejudice, and in turn, discriminate
against themselves. They may experience shame, reduced self-esteem, hopelessness, low self-efficacy, and a reduction in
coping mechanisms. An obvious consequence of these potential outcomes is the why try effect, or the person saying ‘Why
should I try and get that job? I am not worthy of it’ (Corrigan, Larson, & Rusch, 2009; Corrigan, et al., 2016).
Another form of stigma that is worth noting is that of courtesy stigma or when stigma affects people associated with a person who
has a mental disorder. Karnieli-Miller et al. (2013) found that families of the afflicted were often blamed, rejected, or devalued
when others learned that a family member had a serious mental illness (SMI). Due to this, they felt hurt and betrayed, and an
important source of social support during a difficult time had disappeared, resulting in greater levels of stress. To cope, some
families concealed their relative’s illness, and some parents struggled to decide whether it was their place to disclose their child’s
condition. Others fought with the issue of confronting the stigma through attempts at education versus just ignoring it due to not
having enough energy or desiring to maintain personal boundaries. There was also a need to understand the responses of others and
to attribute it to a lack of knowledge, experience, and/or media coverage. In some cases, the reappraisal allowed family members to
feel compassion for others rather than feeling put down or blamed. The authors concluded that each family “develops its own
coping strategies which vary according to its personal experiences, values, and extent of other commitments” and that “coping
strategies families employ change over-time.”
Other effects of stigma include experiencing work-related discrimination resulting in higher levels of self-stigma and stress (Rusch
et al., 2014), higher rates of suicide especially when treatment is not available (Rusch, Zlati, Black, and Thornicroft, 2014; Rihmer
& Kiss, 2002), and a decreased likelihood of future help-seeking intention (Lally et al., 2013). The results of the latter study also
showed that personal contact with someone with a history of mental illness led to a decreased likelihood of seeking help. This is
important because 48% of the university sample stated that they needed help for an emotional or mental health issue during the past
year but did not seek help. Similar results have been reported in other studies (Eisenberg, Downs, Golberstein, & Zivin, 2009). It is
also important to point out that social distance, a result of stigma, has also been shown to increase throughout the life span,
suggesting that anti-stigma campaigns should focus on older people primarily (Schomerus, et al., 2015).
One potentially disturbing trend is that mental health professionals have been shown to hold negative attitudes toward the people
they serve. Hansson et al. (2011) found that staff members at an outpatient clinic in the southern part of Sweden held the most
negative attitudes about whether an employer would accept an applicant for work, willingness to date a person who had been
hospitalized, and hiring a patient to care for children. Attitudes were stronger when staff treated patients with a psychosis or in
inpatient settings. In a similar study,
Martensson, Jacobsson, and Engstrom (2014) found that staff had more positive attitudes towards persons with mental illness if
their knowledge of such disorders was less stigmatized; their workplaces were in the county council where they were more likely to

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encounter patients who recover and return to normal life in society, rather than in municipalities where patients have long-term and
recurrent mental illness; and they have or had one close friend with mental health issues.
To help deal with stigma in the mental health community, Papish et al. (2013) investigated the effect of a one-time contact-based
educational intervention compared to a four-week mandatory psychiatry course on the stigma of mental illness among medical
students at the University of Calgary. The curriculum included two methods requiring contact with people diagnosed with a mental
disorder: patient presentations, or two one-hour oral presentations in which patients shared their story of having a mental illness,
and “clinical correlations” in which a psychiatrist mentored students while they interacted with patients in either inpatient or
outpatient settings. Results showed that medical students held a stigma towards mental illness and that comprehensive medical
education reduced this stigma. As the authors stated, “These results suggest that it is possible to create an environment in which
medical student attitudes towards mental illness can be shifted in a positive direction.” That said, the level of stigma was still
higher for mental illness than it was for the stigmatized physical illness, type 2 diabetes mellitus.
What might happen if mental illness is presented as a treatable condition? McGinty, Goldman, Pescosolido, and Barry (2015) found
that portraying schizophrenia, depression, and heroin addiction as untreated and symptomatic increased negative public attitudes
towards people with these conditions. Conversely, when the same people were portrayed as successfully treated, the desire for
social distance was reduced, there was less willingness to discriminate against them, and belief in treatment effectiveness increased
among the public.
Self-stigma has also been shown to affect self-esteem, which then affects hope, which then affects the quality of life among people
with severe mental illness. As such, hope should play a central role in recovery (Mashiach-Eizenberg et al., 2013). Narrative
Enhancement and Cognitive Therapy (NECT) is an intervention designed to reduce internalized stigma and targets both hope and
self-esteem (Yanos et al., 2011). The intervention replaces stigmatizing myths with facts about illness and recovery, which leads to
hopefulness and higher levels of self-esteem in clients. This may then reduce susceptibility to internalized stigma.
Stigma leads to health inequities (Hatzenbuehler, Phelan, & Link, 2013), prompting calls for stigma change. Targeting stigma
involves two different agendas: The services agenda attempts to remove stigma so people can seek mental health services, and the
rights agenda tries to replace discrimination that “robs people of rightful opportunities with affirming attitudes and behavior”
(Corrigan, 2016). The former is successful when there is evidence that people with mental illness are seeking services more or
becoming better engaged. The latter is successful when there is an increase in the number of people with mental illnesses in the
workforce who are receiving reasonable accommodations. The federal government has tackled this issue with landmark legislation
such as the Patient Protection and Affordable Care Act of 2010, Mental Health Parity and Addiction Equity Act of 2008, and the
Americans with Disabilities Act of 1990. However, protections are not uniform across all subgroups due to “1) explicit language
about inclusion and exclusion criteria in the statute or implementation rule, 2) vague statutory language that yields variation in the
interpretation about which groups qualify for protection, and 3) incentives created by the legislation that affect specific groups
differently” (Cummings, Lucas, and Druss, 2013). More on this in Module 15.

Key Takeaways
You should have learned the following in this section:
Stigma is when negative stereotyping, labeling, rejection, and loss of status occur and take the form of public or self-stigma,
and label avoidance.

 Review Questions
1. How does social cognition help us to understand why stigmatization occurs?
2. Define stigma and describe its three forms. What is courtesy stigma?
3. What are the effects of stigma on the afflicted?
4. Is stigmatization prevalent in the mental health community? If so, what can be done about it?
5. How can we reduce stigmatization?

This page titled 1.3: The Stigma of Mental Illness is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
Alexis Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit
history is available upon request.

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1.4: The History of Mental Illness
 Learning Objectives
Describe prehistoric and ancient beliefs about mental illness.
Describe Greco-Roman thought on mental illness.
Describe thoughts on mental illness during the Middle Ages.
Describe thoughts on mental illness during the Renaissance.
Describe thoughts on mental illness during the 18th and 19th centuries.
Describe thoughts on mental illness during the 20th and 21st centuries.
Describe the status of mental illness today.
Outline the use of psychoactive drugs throughout time and their impact.
Clarify the importance of managed health care for the treatment of mental illness.
Define and clarify the importance of multicultural psychology.
State the issue surrounding prescription rights for psychologists.
Explain the importance of prevention science.

As we have seen so far, what is considered abnormal behavior is often dictated by the culture/society a person lives in, and
unfortunately, the past has not treated the afflicted very well. In this section, we will examine how past societies viewed and dealt
with mental illness.

Prehistoric and Ancient Beliefs

Prehistoric cultures often held a supernatural view of abnormal behavior and saw it as the work of evil spirits, demons, gods, or
witches who took control of the person. This form of demonic possession often occurred when the person engaged in behavior
contrary to the religious teachings of the time. Treatment by cave dwellers included a technique called trephination, in which a
stone instrument known as a trephine was used to remove part of the skull, creating an opening. Through it, the evil spirits could
escape, thereby ending the person’s mental affliction and returning them to normal behavior. Early Greek, Hebrew, Egyptian, and
Chinese cultures used a treatment method called exorcism in which evil spirts were cast out through prayer, magic, flogging,
starvation, having the person ingest horrible tasting drinks, or noisemaking.

Greco-Roman Thought
Rejecting the idea of demonic possession, Greek physician Hippocrates (460-377 B.C.) said that mental disorders were akin to
physical ailments and had natural causes. Specifically, they arose from brain pathology, or head trauma/brain dysfunction or
disease, and were also affected by heredity. Hippocrates classified mental disorders into three main categories – melancholia,
mania, and phrenitis (brain fever) – and gave detailed clinical descriptions of each. He also described four main fluids or humors
that directed normal brain functioning and personality – blood which arose in the heart, black bile arising in the spleen, yellow bile
or choler from the liver, and phlegm from the brain. Mental disorders occurred when the humors were in a state of imbalance such
as an excess of yellow bile causing frenzy and too much black bile causing melancholia or depression. Hippocrates believed mental
illnesses could be treated as any other disorder and focused on the underlying pathology.
Also noteworthy was the Greek philosopher Plato (429-347 B.C.), who said that the mentally ill were not responsible for their
actions and should not be punished. It was the responsibility of the community and their families to care for them. The Greek
physician Galen (A.D. 129-199) said mental disorders had either physical or psychological causes, including fear, shock,
alcoholism, head injuries, adolescence, and changes in menstruation.
In Rome, physician Asclepiades (124-40 BC) and philosopher Cicero (106-43 BC) rejected Hippocrates’ idea of the four humors
and instead stated that melancholy arises from grief, fear, and rage; not excess black bile. Roman physicians treated mental
disorders with massage or warm baths, the hope being that their patients would be as comfortable as they could be. They practiced
the concept of contrariis contrarius, meaning opposite by opposite, and introduced contrasting stimuli to bring about balance in the
physical and mental domains. An example would be consuming a cold drink while in a warm bath.

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The Middle Ages – 500 AD to 1500 AD
The progress made during the time of the Greeks and Romans was quickly reversed during the Middle Ages with the increase in
power of the Church and the fall of the Roman Empire. Mental illness was yet again explained as possession by the Devil and
methods such as exorcism, flogging, prayer, the touching of relics, chanting, visiting holy sites, and holy water were used to rid the
person of demonic influence. In extreme cases, the afflicted were exposed to confinement, beatings, and even execution. Scientific
and medical explanations, such as those proposed by Hippocrates, were discarded.
Group hysteria, or mass madness, was also seen when large numbers of people displayed similar symptoms and false beliefs. This
included the belief that one was possessed by wolves or other animals and imitated their behavior, called lycanthropy, and a mania
in which large numbers of people had an uncontrollable desire to dance and jump, called tarantism. The latter was believed to
have been caused by the bite of the wolf spider, now called the tarantula, and spread quickly from Italy to Germany and other parts
of Europe where it was called Saint Vitus’s dance.
Perhaps the return to supernatural explanations during the Middle Ages makes sense given events of the time. The black death
(bubonic plague) killed up to a third, or according to other estimates almost half, of the population. Famine, war, social oppression,
and pestilence were also factors. The constant presence of death led to an epidemic of depression and fear. Near the end of the
Middle Ages, mystical explanations for mental illness began to lose favor, and government officials regained some of their lost
power over nonreligious activities. Science and medicine were again called upon to explain psychopathology.

The Renaissance – 14th to 16th centuries

The most noteworthy development in the realm of philosophy during the Renaissance was the rise of humanism, or the worldview
that emphasizes human welfare and the uniqueness of the individual. This perspective helped continue the decline of supernatural
views of mental illness. In the mid to late 1500s, German physician Johann Weyer (1515-1588) published his book, On the Deceits
of the Demons, that rebutted the Church’s witch-hunting handbook, the Malleus Maleficarum, and argued that many accused of
being witches and subsequently imprisoned, tortured, and/or burned at the stake, were mentally disturbed and not possessed by
demons or the Devil himself. He believed that like the body, the mind was susceptible to illness. Not surprisingly, the book was
vehemently protested and banned by the Church. It should be noted that these types of acts occurred not only in Europe, but also in
the United States. The most famous example, the Salem Witch Trials of 1692, resulted in more than 200 people accused of
practicing witchcraft and 20 deaths.
The number of asylums, or places of refuge for the mentally ill where they could receive care, began to rise during the 16th century
as the government realized there were far too many people afflicted with mental illness to be left in private homes. Hospitals and
monasteries were converted into asylums. Though the intent was benign in the beginning, as the facilities overcrowded, the patients
came to be treated more like animals than people. In 1547, the Bethlem Hospital opened in London with the sole purpose of
confining those with mental disorders. Patients were chained up, placed on public display, and often heard crying out in pain. The
asylum became a tourist attraction, with sightseers paying a penny to view the more violent patients, and soon was called “Bedlam”
by local people; a term that today means “a state of uproar and confusion” (https://www.merriam-webster.com/dictionary/bedlam).

Reform Movement – 18th to 19th centuries

The rise of the moral treatment movement occurred in Europe in the late 18th century and then in the United States in the early
19th century. The earliest proponent was Francis Pinel (1745-1826), the superintendent of la Bicetre, a hospital for mentally ill men
in Paris. Pinel stressed respectful treatment and moral guidance for the mentally ill while considering their individual, social, and
occupational needs. Arguing that the mentally ill were sick people, Pinel ordered that chains be removed, outside exercise be
allowed, sunny and well-ventilated rooms replace dungeons, and patients be extended kindness and support. This approach led to
considerable improvement for many of the patients, so much so, that several were released.
Following Pinel’s lead, William Tuke (1732-1822), a Quaker tea merchant, established a pleasant rural estate called the York
Retreat. The Quakers believed that all people should be accepted for who they are and treated kindly. At the retreat, patients could
work, rest, talk out their problems, and pray (Raad & Makari, 2010). The work of Tuke and others led to the passage of the Country
Asylums Act of 1845, which required that every county provide asylum to the mentally ill. This sentiment extended to English
colonies such as Canada, India, Australia, and the West Indies as word of the maltreatment of patients at a facility in Kingston,
Jamaica spread, leading to an audit of colonial facilities and their policies.
Reform in the United States started with the figure largely considered to be the father of American psychiatry, Benjamin Rush
(1745-1813). Rush advocated for the humane treatment of the mentally ill, showing them respect, and even giving them small gifts

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from time to time. Despite this, his practice included treatments such as bloodletting and purgatives, the invention of the
“tranquilizing chair,” and reliance on astrology, showing that even he could not escape from the beliefs of the time.
Due to the rise of the moral treatment movement in both Europe and the United States, asylums became habitable places where
those afflicted with mental illness could recover. Regrettably, its success was responsible for its decline. The number of mental
hospitals greatly increased, leading to staffing shortages and a lack of funds to support them. Though treating patients humanely
was a noble endeavor, it did not work for some patients and other treatments were needed, though they had not been developed yet.
Staff recognized that the approach worked best when the facility had 200 or fewer patients, but waves of immigrants arriving in the
U.S. after the Civil War overwhelmed the facilities, and patient counts soared to 1,000 or more. Prejudice against the new arrivals
led to discriminatory practices in which immigrants were not afforded the same moral treatments as native citizens, even when the
resources were available to treat them.
The moral treatment movement also fell due to the rise of the mental hygiene movement, which focused on the physical well-
being of patients. Its leading proponent in the United States was Dorothea Dix (1802-1887), a New Englander who observed the
deplorable conditions suffered by the mentally ill while teaching Sunday school to female prisoners. Over the next 40 years, from
1841 to 1881, she motivated people and state legislators to do something about this injustice and raised millions of dollars to build
over 30 more appropriate mental hospitals and improve others. Her efforts even extended beyond the U.S. to Canada and Scotland.
Finally, in 1908 Clifford Beers (1876-1943) published his book, A Mind that Found Itself, in which he described his struggle with
bipolar disorder and the “cruel and inhumane treatment people with mental illnesses received. He witnessed and experienced
horrific abuse at the hands of his caretakers. At one point during his institutionalization, he was placed in a straitjacket for 21
consecutive nights” (https://www.mhanational.org/our-history). His story aroused sympathy from the public and led him to found
the National Committee for Mental Hygiene, known today as Mental Health America, which provides education about mental
illness and the need to treat these people with dignity. Today, MHA has over 200 affiliates in 41 states and employs 6,500 affiliate
staff and over 10,000 volunteers.
“In the early 1950s, Mental Health America issued a call to asylums across the country for their discarded chains and shackles. On
April 13, 1953, at the McShane Bell Foundry in Baltimore, Md., Mental Health America melted down these inhumane bindings
and recast them into a sign of hope: the Mental Health Bell.
Now the symbol of Mental Health America, the 300-pound Bell serves as a powerful reminder that the invisible chains of
misunderstanding and discrimination continue to bind people with mental illnesses. Today, the Mental Health Bell rings out hope
for improving mental health and achieving victory over mental illnesses.”
For more information on MHA, please visit: https://www.mhanational.org/

20th – 21st Centuries

The decline of the moral treatment approach in the late 19th century led to the rise of two competing perspectives – the biological
or somatogenic perspective and the psychological or psychogenic perspective.
1.4.6.1.Biological or Somatogenic Perspective. Recall that Greek physicians Hippocrates and Galen said that mental disorders
were akin to physical disorders and had natural causes. Though the idea fell into oblivion for several centuries, it re-emerged in the
late 19th century for two reasons. First, German psychiatrist Emil Kraepelin (1856-1926) discovered that symptoms occurred
regularly in clusters, which he called syndromes. These syndromes represented a unique mental disorder with a distinct cause,
course, and prognosis. In 1883 he published his textbook, Compendium der Psychiatrie (Textbook of Psychiatry), and described a
system for classifying mental disorders that became the basis of the American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders (DSM) that is currently in its 5th edition Text Revision (published in 2022).
Secondly, in 1825, the behavioral and cognitive symptoms of advanced syphilis were identified to include a belief that everyone is
plotting against you or that you are God (a delusion of grandeur), and were termed general paresis by French physician A.L.J.
Bayle. In 1897, Viennese psychiatrist Richard von Krafft-Ebbing injected patients suffering from general paresis with matter from
syphilis spores and noted that none of the patients developed symptoms of syphilis, indicating they must have been previously
exposed and were now immune. This led to the conclusion that syphilis was the cause of the general paresis. In 1906, August von
Wassermann developed a blood test for syphilis, and in 1917 a cure was found. Julius von Wagner-Jauregg noticed that patients
with general paresis who contracted malaria recovered from their symptoms. To test this hypothesis, he injected nine patients with
blood from a soldier afflicted with malaria. Three of the patients fully recovered while three others showed great improvement in

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their paretic symptoms. The high fever caused by malaria burned out the syphilis bacteria. Hospitals in the United States began
incorporating this new cure for paresis into their treatment approach by 1925.
Also noteworthy was the work of American psychiatrist John P. Grey. Appointed as superintendent of the Utica State Hospital in
New York, Grey asserted that insanity always had a physical cause. As such, the mentally ill should be seen as physically ill and
treated with rest, proper room temperature and ventilation, and a nutritive diet.
The 1930s also saw the use of electric shock as a treatment method, which was stumbled upon accidentally by Benjamin Franklin
while experimenting with electricity in the early 18th century. He noticed that after suffering a severe shock his memories had
changed, and in published work, he suggested physicians study electric shock as a treatment for melancholia.
1.4.6.2. Psychological or Psychogenic Perspective. The psychological or psychogenic perspective states that emotional or
psychological factors are the cause of mental disorders and represented a challenge to the biological perspective. This perspective
had a long history but did not gain favor until the work of Viennese physician Franz Anton Mesmer (1734-1815). Influenced
heavily by Newton’s theory of gravity, he believed that the planets also affected the human body through the force of animal
magnetism and that all people had a universal magnetic fluid that determined how healthy they were. He demonstrated the
usefulness of his approach when he cured Franzl Oesterline, a 27-year-old woman suffering from what he described as a convulsive
malady. Mesmer used a magnet to disrupt the gravitational tides that were affecting his patient and produced a sensation of the
magnetic fluid draining from her body. This procedure removed the illness from her body and provided a near-instantaneous
recovery. In reality, the patient was placed in a trancelike state which made her highly suggestible. With other patients, Mesmer
would have them sit in a darkened room filled with soothing music, into which he would enter dressed in a colorful robe and pass
from person to person touching the afflicted area of their body with his hand or a rod/wand. He successfully cured deafness,
paralysis, loss of bodily feeling, convulsions, menstrual difficulties, and blindness.
His approach gained him celebrity status as he demonstrated it at the courts of English nobility. However, the medical community
was hardly impressed. A royal commission was formed to investigate his technique but could not find any proof for his theory of
animal magnetism. Though he was able to cure patients when they touched his “magnetized” tree, the result was the same when
“non-magnetized” trees were touched. As such, Mesmer was deemed a charlatan and forced to leave Paris. His technique was
called mesmerism, better known today as hypnosis.
The psychological perspective gained popularity after two physicians practicing in the city of Nancy in France discovered that they
could induce the symptoms of hysteria in perfectly healthy patients through hypnosis and then remove the symptoms in the same
way. The work of Hippolyte-Marie Bernheim (1840-1919) and Ambroise-Auguste Liebault (1823-1904) came to be part of what
was called the Nancy School and showed that hysteria was nothing more than a form of self-hypnosis. In Paris, this view was
challenged by Jean Charcot (1825-1893), who stated that hysteria was caused by degenerative brain changes, reflecting the
biological perspective. He was proven wrong and eventually turned to their way of thinking.
The use of hypnosis to treat hysteria was also carried out by fellow Frenchman Pierre Janet (1859-1947), and student of Charcot,
who believed that hysteria had psychological, not biological causes. Namely, these included unconscious forces, fixed ideas, and
memory impairments. In Vienna, Josef Breuer (1842-1925) induced hypnosis and had patients speak freely about past events that
upset them. Upon waking, he discovered that patients sometimes were free of their symptoms of hysteria. Success was even greater
when patients not only recalled forgotten memories but also relived them emotionally. He called this the cathartic method, and our
use of the word catharsis today indicates a purging or release, in this case, of pent-up emotion.
By the end of the 19th century, it had become evident that mental disorders were caused by a combination of biological and
psychological factors, and the investigation of how they develop began. Sigmund Freud’s development of psychoanalysis followed
on the heels of the work of Bruner, and others who came before him.

Current Views/Trends
1.4.7.1. Mental illness today. An article published by the Harvard Medical School in March 2014 called “The Prevalence and
Treatment of Mental Illness Today” presented the results of the National Comorbidity Study Replication of 2001-2003, which
included a sample of more than 9,000 adults. The results showed that nearly 46% of the participants had a psychiatric disorder at
some time in their lives. The most commonly reported disorders were:
Major depression – 17%
Alcohol abuse – 13%
Social anxiety disorder – 12%

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 Conduct disorder – 9.5%
Also of interest was that women were more likely to have had anxiety and mood disorders while men showed higher rates of
impulse control disorders. Comorbid anxiety and mood disorders were common, and 28% reported having more than one co-
occurring disorder (Kessler, Berglund, et al., 2005; Kessler, Chiu, et al., 2005; Kessler, Demler, et al., 2005).
About 80% of the sample reported seeking treatment for their disorder, but with as much as a 10-year gap after symptoms first
appeared. Women were more likely than men to seek help while whites were more likely than African and Hispanic Americans
(Wang, Berglund, et al., 2005; Wang, Lane, et al., 2005). Care was sought primarily from family doctors, nurses, and other general
practitioners (23%), followed by social workers and psychologists (16%), psychiatrists (12%), counselors or spiritual advisers
(8%), and complementary and alternative medicine providers (CAMs; 7%).
In terms of the quality of the care, the article states:
Most of this treatment was inadequate, at least by the standards applied in the survey. The researchers defined minimum adequacy
as a suitable medication at a suitable dose for two months, along with at least four visits to a physician; or else eight visits to any
licensed mental health professional. By that definition, only 33% of people with a psychiatric disorder were treated adequately, and
only 13% of those who saw general medical practitioners.
In comparison to the original study conducted from 1991-1992, the use of mental health services has increased over 50% during
this decade. This may be attributed to treatment becoming more widespread and increased attempts to educate the public about
mental illness. Stigma, discussed in Section 1.3, has reduced over time, diagnosis is more effective, community outreach programs
have increased, and most importantly, general practitioners have been more willing to prescribe psychoactive medications which
themselves are more readily available now. The article concludes, “Survey researchers also suggest that we need more outreach and
voluntary screening, more education about mental illness for the public and physicians, and more effort to treat substance abuse
and impulse control disorders.” We will explore several of these issues in the remainder of this section, including the use of
psychiatric drugs and deinstitutionalization, managed health care, private psychotherapy, positive psychology and prevention
science, multicultural psychology, and prescription rights for psychologists.
1.4.7.2. Use of psychiatric drugs and deinstitutionalization. Beginning in the 1950s, psychiatric or psychotropic drugs were used
for the treatment of mental illness and made an immediate impact. Though drugs alone cannot cure mental illness, they can
improve symptoms and increase the effectiveness of treatments such as psychotherapy. Classes of psychiatric drugs include anti-
depressants used to treat depression and anxiety, mood-stabilizing medications to treat bipolar disorder, anti-psychotic drugs to
treat schizophrenia, and anti-anxiety drugs to treat generalized anxiety disorder or panic disorder
Frank (2006) found that by 1996, psychotropic drugs were used in 77% of mental health cases and spending on these drugs grew
from $2.8 billion in 1987 to about $18 billion in 2001 (Coffey et al., 2000; Mark et al., 2005), representing over a sixfold increase.
The largest classes of psychotropic drugs are anti-psychotics and anti-depressants, followed closely by anti-anxiety medications.
Frank, Conti, and Goldman (2005) point out, “The expansion of insurance coverage for prescription drugs, the introduction and
diffusion of managed behavioral health care techniques, and the conduct of the pharmaceutical industry in promoting their products
all have influenced how psychotropic drugs are used and how much is spent on them.” Is it possible then that we are
overprescribing these mediations? Davey (2014) provides ten reasons why this may be so, including leading suffers from believing
that recovery is in their hands but instead in the hands of their doctors; increased risk of relapse; drug companies causing the
“medicalization of perfectly normal emotional processes, such as bereavement” to ensure their survival; side effects; and a failure
to change the way the person thinks or the socioeconomic environments that may be the cause of the disorder. For more on this
article, please see: https://www.psychologytoday.com/blog/why-we-worry/201401/overprescribing-drugs-treat-mental-health-
problems. Smith (2012) echoed similar sentiments in an article on inappropriate prescribing. He cites the approval of Prozac by the
Food and Drug Administration (FDA) in 1987 as when the issue began and the overmedication/overdiagnosis of children with
ADHD as a more recent example.
A result of the use of psychiatric drugs was deinstitutionalization, or the release of patients from mental health facilities. This
shifted resources from inpatient to outpatient care and placed the spotlight back on the biological or somatogenic perspective.
When people with severe mental illness do need inpatient care, it is typically in the form of short-term hospitalization.
1.4.7.3. Managed health care.Managed health care is a term used to describe a type of health insurance in which the insurance
company determines the cost of services, possible providers, and the number of visits a subscriber can have within a year. This is
regulated through contracts with providers and medical facilities. The plans pay the providers directly, so subscribers do not have to
pay out-of-pocket or complete claim forms, though most require co-pays paid directly to the provider at the time of service. Exactly

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how much the plan costs depends on how flexible the subscriber wants it to be; the more flexibility, the higher the cost. Managed
health care takes three forms:
Health Maintenance Organizations (HMO) – Typically only pay for care within the network. The subscriber chooses a primary
care physician (PCP) who coordinates most of their care. The PCP refers the subscriber to specialists or other health care
providers as is necessary. This is the most restrictive option.
Preferred Provider Organizations (PPO) – Usually pay more if the subscriber obtains care within the network, but if care
outside the network is sought, they cover part of the cost.
Point of Service (POS) – These plans provide the most flexibility and allow the subscriber to choose between an HMO or a PPO
each time care is needed.
Regarding the treatment needed for mental illness, managed care programs regulate the pre-approval of treatment via referrals from
the PCP, determine which mental health providers can be seen, and oversee which conditions can be treated and what type of
treatment can be delivered. This system was developed in the 1980s to combat the rising cost of mental health care and took
responsibility away from single practitioners or small groups who could charge what they felt was appropriate. The actual impact
of managed care on mental health services is still questionable at best.
1.4.7.4. Multicultural psychology. As our society becomes increasingly diverse, medical practitioners and psychologists alike
must take into account the patient’s gender, age, race, ethnicity, socioeconomic (SES) status, and culture and how these factors
shape the individual’s thoughts, feelings, and behaviors. Additionally, we need to understand how the various groups, whether
defined by race, culture, or gender, differ from one another. This approach is called multicultural psychology.
In August 2002, the American Psychological Association’s (APA) Council of Representatives put forth six guidelines based on the
understanding that “race and ethnicity can impact psychological practice and interventions at all levels” and the need for respect
and inclusiveness. They further state, “psychologists are in a position to provide leadership as agents of prosocial change,
advocacy, and social justice, thereby promoting societal understanding, affirmation, and appreciation of multiculturalism against
the damaging effects of individual, institutional, and societal racism, prejudice, and all forms of oppression based on stereotyping
and discrimination.” The guidelines from the 2002 document are as follows:
“Guideline #1: Psychologists are encouraged to recognize that, as cultural beings, they may hold attitudes and beliefs that can
detrimentally influence their perceptions of and interactions with individuals who are ethnically and racially different from
themselves.
Guideline #2: Psychologists are encouraged to recognize the importance of multicultural sensitivity/responsiveness, knowledge,
and understanding about ethnically and racially different individuals.
Guideline #3: As educators, psychologists are encouraged to employ the constructs of multiculturalism and diversity in
psychological education.
Guideline #4: Culturally sensitive psychological researchers are encouraged to recognize the importance of conducting culture–
centered and ethical psychological research among persons from ethnic, linguistic, and racial minority backgrounds.
Guideline #5: Psychologists strive to apply culturally-appropriate skills in clinical and other applied psychological practices.
Guideline #6: Psychologists are encouraged to use organizational change processes to support culturally informed
organizational (policy) development and practices.”
Source: apa.org/pi/oema/resources/policy/multicultural-guidelines.aspx
This type of sensitivity training is vital because bias based on ethnicity, race, and culture has been found in the diagnosis and
treatment of autism (Harrison et al., 2017; Burkett, 2015), borderline personality disorder (Jani et al., 2016), and schizophrenia
(Neighbors et al., 2003; Minsky et al., 2003). Despite these findings, Schwartz and Blankenship (2014) state, “It should also be
noted that although clear evidence supports a longstanding trend in differential diagnoses according to consumer race, this trend
does not imply that one race (e.g., African Americans) actually demonstrate more severe symptoms or higher prevalence rates of
psychosis compared with other races (e.g., Euro-Americans). Because clinicians are the diagnosticians and misinterpretation, bias
or other factors may play a role in this trend caution should be used when making inferences about actual rates of psychosis among
ethnic minority persons.” Additionally, white middle-class help seekers were offered appointments with psychotherapists almost
three times as often as their black working-class counterparts. Women were offered an appointment time in their preferred time
range more than men were, though average appointment offer rates were similar between genders (Kugelmass, 2016). These
findings collectively show that though we are becoming more culturally sensitive, we have a lot more work to do.

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1.4.7.5. Prescription rights for psychologists. To reduce inappropriate prescribing as described in 1.4.7.2, it has been proposed to
allow appropriately trained psychologists the right to prescribe. Psychologists are more likely to utilize both therapy and
medication, and so can make the best choice for their patient. The right has already been granted in New Mexico, Louisiana, Guam,
the military, the Indian Health Services, and the U.S. Public Health Services. Measures in other states “have been opposed by the
American Medical Association and American Psychiatric Association over concerns that inadequate training of psychologists could
jeopardize patient safety. Supporters of prescriptive authority for psychologists are quick to point out that there is no evidence to
support these concerns” (Smith, 2012).
1.4.7.6. Prevention science. As a society, we used to wait for a mental or physical health issue to emerge, then scramble to treat it.
More recently, medicine and science has taken a prevention stance, identifying the factors that cause specific mental health issues
and implementing interventions to stop them from happening, or at least minimize their deleterious effects. Our focus has shifted
from individuals to the population. Mental health promotion programs have been instituted with success in schools (Shoshani &
Steinmetz, 2014; Weare & Nind, 2011; Berkowitz & Beer, 2007), in the workplace (Czabała, Charzyńska, & Mroziak, B., 2011),
with undergraduate and graduate students (Conley et al., 2017; Bettis et al., 2016), in relation to bullying (Bradshaw, 2015), and
with the elderly (Forsman et al., 2011). Many researchers believe it is the ideal time to move from knowledge to action and to
expand public mental health initiatives (Wahlbeck, 2015). The growth of positive psychology in the late 1990s has further
propelled this movement forward. For more on positive psychology, please see Section 1.1.1.

Key Takeaways
You should have learned the following in this section:
Some of the earliest views of mental illness saw it as the work of evil spirts, demons, gods, or witches who took control of the
person, and in the Middle Ages it was seen as possession by the Devil and methods such as exorcism, flogging, prayer, the
touching of relics, chanting, visiting holy sites, and holy water were used to rid the person of demonic influence.
During the Renaissance, humanism was on the rise which emphasized human welfare and the uniqueness of the individual and
led to an increase in the number of asylums as places of refuge for the mentally ill.
The 18th to 19th centuries saw the rise of the moral treatment movement followed by the mental hygiene movement.
The psychological or psychogenic perspective states that emotional or psychological factors are the cause of mental disorders
and represented a challenge to the biological perspective which said that mental disorders were akin to physical disorders and
had natural causes.
Psychiatric or psychotropic drugs used to treat mental illness became popular beginning in the 1950s and led to
deinstitutionalization or a shift from inpatient to outpatient care.

 Review Questions
1. How has mental illness been viewed across time?
2. Contrast the moral treatment and mental hygiene movements.
3. Contrast the biological or somatogenic perspective with that of the psychological or psychogenic perspective.
4. Discuss contemporary trends in relation to the use of drugs to treat mental illness, deinstitutionalization, managed health
care, multicultural psychology, prescription rights for psychologists, and prevention science.

This page titled 1.4: The History of Mental Illness is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
Alexis Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit
history is available upon request.

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1.5: Research Methods in Psychopathology
 Learning Objectives
Define the scientific method.
Outline and describe the steps of the scientific method, defining all key terms.
Identify and clarify the importance of the three cardinal features of science.
List the five main research methods used in psychology.
Describe observational research, listing its advantages and disadvantages.
Describe case study research, listing its advantages and disadvantages.
Describe survey research, listing its advantages and disadvantages.
Describe correlational research, listing its advantages and disadvantages.
Describe experimental research, listing its advantages and disadvantages.
State the utility and need for multimethod research.

The Scientific Method

Psychology is the “scientific study of behavior and mental processes.” We will spend quite a lot of time on the behavior and mental
processes part throughout this book and in relation to mental disorders. Still, before we proceed, it is prudent to further elaborate on
what makes psychology scientific. It is safe to say that most people outside of our discipline or a sister science would be surprised
to learn that psychology utilizes the scientific method at all. That may be even truer of clinical psychology, especially in light of the
plethora of self-help books found at any bookstore. But yes, the treatment methods used by mental health professionals are based
on empirical research and the scientific method.
As a starting point, we should expand on what the scientific method is.
The scientific method is a systematic method for gathering knowledge about the world around us.
The keyword here is systematic, meaning there is a set way to use it. What is that way? Well, depending on what source you look
at, it can include a varying number of steps. I like to use the following:
Table 1.1: The Steps of the Scientific Method
Step Name Description

To study the world around us, you have to

wonder about it. This inquisitive nature is the
hallmark of critical thinking —our ability to
0 Ask questions and be willing to wonder. assess claims made by others and make
objective judgments that are independent of
emotion and anecdote and based on hard
evidence —and a requirement to be a scientist.
Through our wonderment about the world
around us and why events occur as they do, we
begin to ask questions that require further
investigation to arrive at an answer. This
investigation usually starts with a literature
Generate a research question or identify a
1 review, or when we conduct a literature search
problem to investigate.
through our university library or a search
engine such as Google Scholar to see what
questions have been investigated already and
what answers have been found, so that we can
identify gaps or holes in this body of work.

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 Step Name Description

We now attempt to formulate an explanation of

why the event occurs as it does. This
systematic explanation of a phenomenon is a
Attempt to explain the phenomena we wish to
2 theory and our specific, testable prediction is
study.
the hypothesis. We will know if our theory is
correct because we have formulated a
hypothesis that we can now test.
It goes without saying that if we cannot test our
hypothesis, then we cannot show whether our
prediction is correct or not. Our plan of action
of how we will go about testing the hypothesis
3 Test the hypothesis.
is called our research design. In the planning
stage, we will select the appropriate research
method to answer our question/test our
hypothesis.
With our research study done, we now examine
the data to see if the pattern we predicted
exists. We need to see if a cause and effect
statement can be made, assuming our method
allows for this inference. More on this in
Section 2.3. For now, it is essential to know
that statistics have two forms. First, there are
descriptive statistics which provide a means
of summarizing or describing data and
presenting the data in a usable form. You likely
4 Interpret the results.
have heard of mean or average, median, and
mode. Along with standard deviation and
variance, these are ways to describe our data.
Second, there are inferential statistics that
allow for the analysis of two or more sets of
numerical data to determine the statistical
significance of the results. Significance is an
indication of how confident we are that our
results are due to our manipulation or design
and not chance.
We need to interpret our results accurately and
not overstate our findings. To do this, we need
to be aware of our biases and avoid emotional
reasoning so that they do not cloud our
5 Draw conclusions carefully. judgment. How so? In our effort to stop a child
from engaging in self-injurious behavior that
could cause substantial harm or even death, we
might overstate the success of our treatment
method.
Once we have decided on whether our
hypothesis was correct or not, we need to share
this information with others so that they might
comment critically on our methodology,
Communicate our findings to the broader statistical analyses, and conclusions. Sharing
6
scientific community. also allows for replication or repeating the
study to confirm its results. Communication
occurs via scientific journals, conferences, or
newsletters released by many of the
organizations mentioned in Module 1.6.

Science has at its root three cardinal features that we will see play out time and time again throughout this book. They are:

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 1. Observation – To know about the world around us, we have to be able to see it firsthand. When a mental disorder afflicts an
individual, we can see it through their overt behavior. An individual with depression may withdraw from activities he/she
enjoys, those with social anxiety disorder will avoid social situations, people with schizophrenia may express concern over
being watched by the government, and individuals with dependent personality disorder may leave major decisions to trusted
companions. In these examples and numerous others, the behaviors that lead us to a diagnosis of a specific disorder can easily
be observed by the clinician, the patient, and/or family and friends.
2. Experimentation – To be able to make causal or cause and effect statements, we must isolate variables. We must manipulate one
variable and see the effect of doing so on another variable. Let’s say we want to know if a new treatment for bipolar disorder is
as effective as existing treatments, or more importantly, better. We could design a study with three groups of bipolar patients.
One group would receive no treatment and serve as a control group. A second group would receive an existing and proven
treatment and would also be considered a control group. Finally, the third group would receive the new treatment and be the
experimental group. What we are manipulating is what treatment the groups get – no treatment, the older treatment, and the
newer treatment. The first two groups serve as controls since we already know what to expect from their results. There should
be no change in bipolar disorder symptoms in the no-treatment group, a general reduction in symptoms for the older treatment
group, and the same or better performance for the newer treatment group. As long as patients in the newer treatment group do
not perform worse than their older treatment counterparts, we can say the new drug is a success. You might wonder why we
would get excited about the performance of the new drug being the same as the old drug. Does it really offer any added benefit?
In terms of a reduction of symptoms, maybe not, but it could cost less money than the older drug and that would be of value to
patients.
3. Measurement – How do we know that the new drug has worked? Simply, we can measure the person’s bipolar disorder
symptoms before any treatment was implemented, and then again once the treatment has run its course. This pre-post test
design is typical in drug studies.

Research Methods
Step 3 called on the scientist to test his or her hypothesis. Psychology as a discipline uses five main research designs. They are:
1.5.2.1. Naturalistic and laboratory observation. In terms of naturalistic observation, the scientist studies human or animal
behavior in its natural environment, which could include the home, school, or a forest. The researcher counts, measures, and rates
behavior in a systematic way and, at times, uses multiple judges to ensure accuracy in how the behavior is being measured. The
advantage of this method is that you see behavior as it happens, and the experimenter does not taint the data. The disadvantage is
that it could take a long time for the behavior to occur, and if the researcher is detected, then this may influence the behavior of
those being observed.
Laboratory observation involves observing people or animals in a laboratory setting. The researcher might want to know more
about parent-child interactions, and so, brings a mother and her child into the lab to engage in preplanned tasks such as playing
with toys, eating a meal, or the mother leaving the room for a short time. The advantage of this method over the naturalistic method
is that the experimenter can use sophisticated equipment to record the session and examine it later. The problem is that since the
subjects know the experimenter is watching them, their behavior could become artificial. Clinical observation is a commonly
employed research method to study psychopathology; we will talk about it more throughout this book.
1.5.2.2. Case studies. Psychology can also utilize a detailed description of one person or a small group based on careful
observation. This was the approach the founder of psychoanalysis, Sigmund Freud, took to develop his theories. The advantage of
this method is that you arrive at a detailed description of the investigated behavior, but the disadvantage is that the findings may be
unrepresentative of the larger population, and thus, lacking generalizability. Again, bear in mind that you are studying one person
or a tiny group. Can you possibly make conclusions about all people from just one person, or even five or ten? The other issue is
that the case study is subject to researcher bias in terms of what is included in the final narrative and what is left out. Despite these
limitations, case studies can lead us to novel ideas about the cause of abnormal behavior and help us to study unusual conditions
that occur too infrequently to analyze with large sample sizes and in a systematic way.
1.5.2.3. Surveys/Self-Report data. This is a questionnaire consisting of at least one scale with some questions used to assess a
psychological construct of interest such as parenting style, depression, locus of control, or sensation-seeking behavior. It may be
administered by paper and pencil or computer. Surveys allow for the collection of large amounts of data quickly, but the actual
survey could be tedious for the participant and social desirability, when a participant answers questions dishonestly so that they
are seen in a more favorable light, could be an issue. For instance, if you are asking high school students about their sexual activity,

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they may not give genuine answers for fear that their parents will find out. You could alternatively gather this information via an
interview in a structured or unstructured fashion.
1.5.2.4. Correlational research. This research method examines the relationship between two variables or two groups of variables.
A numerical measure of the strength of this relationship is derived, called the correlation coefficient. It can range from -1.00, a
perfect inverse relationship in which one variable goes up as the other goes down, to 0 indicating no relationship at all, to +1.00 or
a perfect relationship in which as one variable goes up or down so does the other. In terms of a negative correlation, we might say
that as a parent becomes more rigid, controlling, and cold, the attachment of the child to parent goes down. In contrast, as a parent
becomes warmer, more loving, and provides structure, the child becomes more attached. The advantage of correlational research is
that you can correlate anything. The disadvantage is that you can correlate anything, including variables that do not have any
relationship with one another. Yes, this is both an advantage and a disadvantage. For instance, we might correlate instances of
making peanut butter and jelly sandwiches with someone we are attracted to sitting near us at lunch. Are the two related? Not
likely, unless you make a really good PB&J, but then the person is probably only interested in you for food and not companionship.
The main issue here is that correlation does not allow you to make a causal statement.
A special form of correlational research is the epidemiological study in which the prevalence and incidence of a disorder in a
specific population are measured (See Section 1.2 for definitions).
1.5.2.5. Experiments. This is a controlled test of a hypothesis in which a researcher manipulates one variable and measures its
effect on another variable. The manipulated variable is called the independent variable (IV), and the one that is measured is called
the dependent variable (DV). In the example under Experimentation in Section 1.5.1, the treatment for bipolar disorder was the
IV, while the actual intensity or number of symptoms serve as the DV. A common feature of experiments is a control group that
does not receive the treatment or is not manipulated and an experimental group that does receive the treatment or manipulation. If
the experiment includes random assignment, participants have an equal chance of being placed in the control or experimental
group. The control group allows the researcher (or teacher) to make a comparison to the experimental group and make a causal
statement possible, and stronger. In our experiment, the new treatment should show a marked reduction in the intensity of bipolar
symptoms compared to the group receiving no treatment, and perform either at the same level as, or better than, the older treatment.
This would be the initial hypothesis made before starting the experiment.
In a drug study, to ensure the participants’ expectations do not affect the final results by giving the researcher what he/she is
looking for (in our example, symptoms improve whether the participant is receiving treatment or not), we might use what is called
a placebo, or a sugar pill made to look exactly like the pill given to the experimental group. This way, participants all are given
something, but cannot figure out what exactly it is. You might say this keeps them honest and allows the results to speak for
themselves.
Finally, the study of mental illness does not always afford us a large sample of participants to study, so we have to focus on one
individual using a single-subject experimental design. This differs from a case study in the sheer number of strategies available to
reduce potential confounding variables, or variables not originally part of the research design but contribute to the results in a
meaningful way. One type of single-subject experimental design is the reversal or ABAB design. Kuttler, Myles, and Carson
(1998) used social stories to reduce tantrum behavior in two social environments in a 12-year old student diagnosed with autism,
Fragile-X syndrome, and intermittent explosive disorder. Using an ABAB design, they found that precursors to tantrum behavior
decreased when the social stories were available (B) and increased when the intervention was withdrawn (A). A more recent study
(Balakrishnan & Alias, 2017) also established the utility of social stories as a social learning tool for children with autism spectrum
disorder (ASD) using an ABAB design. During the baseline phase (A), the four student participants were observed, and data
recorded on an observation form. During the treatment phase (B), they listened to the social story and data was recorded in the
same manner. Upon completion of the first B, the students returned to A, which was followed one more time by B and the reading
of the social story. Once the second treatment phase ended, the participation was monitored again to obtain the outcome. All
students showed improvement during the treatment phases in terms of the number of positive peer interactions, but the number of
interactions reduced in the absence of social stories. From this, the researchers concluded that the social story led to the increase in
positive peer interactions of children with ASD.
1.5.2.6. Multi-method research. As you have seen above, no single method alone is perfect. All have strengths and limitations. As
such, for the psychologist to provide the most precise picture of what is affecting behavior or mental processes, several of these
approaches are typically employed at different stages of the research study. This is called multi-method research.

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Key Takeaways
You should have learned the following in this section:
The scientific method is a systematic method for gathering knowledge about the world around us.
A systematic explanation of a phenomenon is a theory and our specific, testable prediction is the hypothesis.
Replication is when we repeat the study to confirm its results.
Psychology’s five main research designs are observation, case studies, surveys, correlation, and experimentation.
No single research method alone is perfect – all have strengths and limitations.

 Review Questions
1. What is the scientific method and what steps make it up?
2. Differentiate theory and hypothesis.
3. What are the three cardinal features of science and how do they relate to the study of mental disorders?
4. What are the five main research designs used by psychologists? Define each and then state its strengths and limitations.
5. What is the advantage of multi-method research?

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1.6: Mental Health Professionals, Societies, and Journals
 Learning Objectives
Identify and describe the various types of mental health professionals.
Clarify what it means to communicate findings.
Identify professional societies in clinical psychology.
Identify publications in clinical psychology.

Types of Professionals
There are many types of mental health professionals that people may seek out for assistance. They include:
Table 1.2: Types of Mental Health Professionals
Name Degree Required Function/Training Can they prescribe medications?

Trained to make diagnoses and

Clinical Psychologist Ph.D. can provide individual and group Only in select states
therapy

Trained to make diagnoses and

can provide individual and group
School Psychologist Masters or Ph.D. No
therapy but also works with
school staff

Deals with adjustment issues

Counseling Psychologist Ph.D. primarily and less with mental No
illness

Trained to make diagnoses and

can provide individual and group
Clinical Social Worker M.S.W. or Ph.D. therapy and is involved in No
advocacy and case management.
Usually in hospital settings.

Has specialized training in the

Psychiatrist M.D. diagnosis and treatment of mental Yes
disorders

Has specialized treatment in the

Psychiatric Nurse Practitioner M.S.N. care and treatment of psychiatric Yes
patients

Trained to assist individuals

suffering from physical or
Occupational Therapist B.S. No
psychological handicaps and help
them acquire needed resources

Trained in pastoral education and

can make diagnoses and can
Pastoral Counselor Clergy No
provide individual and group
therapy

Trained in alcohol and drug abuse

Drug Abuse and/or Alcohol and can make diagnoses and can
B.S. or higher No
Counselor provide individual and group
therapy

Specialized training in the

Child/Adolescent Psychiatrist M.D. or Ph.D. diagnosis and treatment of mental Yes
illness in children

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 Name Degree Required Function/Training Can they prescribe medications?

Specialized training in marital and

family therapy; Can make
Marital and Family Therapist Masters No
diagnoses and can provide
individual and group therapy

For more information on types of mental health professionals, please visit:

https://www.mhanational.org/types-mental-health-professionals

Professional Societies and Journals

One of the functions of science is to communicate findings. Testing hypotheses, developing sound methodology, accurately
analyzing data, and drawing sound conclusions are important, but you must tell others what you have done too. This is
accomplished by joining professional societies and submitting articles to peer-reviewed journals. Below are some of the
organizations and journals relevant to applied behavior analysis.
1.6.2.1. Professional Societies
Society of Clinical Psychology – Division 12 of the American Psychological Association
Website – https://div12.org/
Mission Statement – “The mission of the Society of Clinical Psychology is to represent the field of Clinical Psychology
through encouragement and support of the integration of clinical psychological science and practice in education, research,
application, advocacy and public policy, attending to the importance of diversity.”
Publications – Clinical Psychology: Science and Practice and the newsletter Clinical Psychology: Science and
Practice(quarterly)
Other Information – Members and student affiliates may join one of eight sections such as clinical emergencies and crises,
clinical psychology of women, assessment psychology, and clinical geropsychology
Society of Clinical Child and Adolescent Psychology – Division 53 of the American Psychological Association
Website – www.clinicalchildpsychology.org/
Mission Statement – “Our mission is to serve children, adolescents and families with the best possible clinical care based on
psychological science. SCCAP strives to integrate scientific and professional aspects of clinical child and adolescent
psychology, in that it promotes scientific inquiry, training, and clinical practice related to serving children and their
families.”
Publication – Journal of Clinical Child and Adolescent Psychology
American Academy of Clinical Psychology
Website – https://www.aacpsy.org/
Mission Statement – The American Academy of Clinical Psychology seeks to “recognize and promote advanced
competence within Professional Psychology,” “provide a professional community that encourages communication between
and among Members and Fellows of the Academy,” “provide opportunities for advanced education in Professional
Psychology,” and “expand awareness and availability of AACP Members and Fellows to the public through promotion and
education.”
Publication – Bulletin of the American Academy of Clinical Psychology (newsletter)
The Society for a Science of Clinical Psychology (SSCP)
Website – http://www.sscpweb.org/
Mission Statement – “The Society for a Science of Clinical Psychology (SSCP) was established in 1966. Its purpose is to
affirm and continue to promote the integration of the scientist and the practitioner in training, research, and applied
endeavors. Its members represent a diversity of interests and theoretical orientations across clinical psychology. The
common bond of the membership is a commitment to empirical research and the ideal that scientific principles should play a
role in training, practice, and establishing public policy for health and mental health concerns. SSCP has organizational
affiliations with both the American Psychological Association (Section III of Division 12) and the Association for
Psychological Science.”

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 Other Information – Offers ten awards ranging from early career award, outstanding mentor award, outstanding student
teacher award, and outstanding student clinician award.
American Society of Clinical Hypnosis
Website – http://www.asch.net/
Mission Statement – “To provide and encourage education programs to further, in every ethical way, the knowledge,
understanding, and application of hypnosis in health care; to encourage research and scientific publication in the field of
hypnosis; to promote the further recognition and acceptance of hypnosis as an important tool in clinical health care and
focus for scientific research; to cooperate with other professional societies that share mutual goals, ethics and interests; and
to provide a professional community for those clinicians and researchers who use hypnosis in their work.”
Publication – American Journal of Clinical Hypnosis
Other Information – Offers certification in clinical hypnosis
1.6.2.2. Professional Journals
Clinical Psychology: Science and Practice
Website – onlinelibrary.wiley.com/journal/10.1111/(ISSN)1468-2850
Published by – American Psychological Association, Division 12
Description – “Clinical Psychology: Science and Practice presents cutting-edge developments in the science and practice of
clinical psychology and related mental health fields by publishing scholarly articles, primarily involving narrative and
systematic reviews as well as meta-analyses related to assessment, intervention, and service delivery.”
Journal of Clinical Child and Adolescent Psychology
Website – www.clinicalchildpsychology.org/JCCAP
Published by – American Psychological Association, Division 53
Description – “It publishes original contributions on the following topics: (a) the development and evaluation of assessment
and intervention techniques for use with clinical child and adolescent populations; (b) the development and maintenance of
clinical child and adolescent problems; (c) cross-cultural and socio-demographic issues that have a clear bearing on clinical
child and adolescent psychology in terms of theory, research, or practice; and (d) training and professional practice in
clinical child and adolescent psychology, as well as child advocacy.”
American Journal of Clinical Hypnosis
Website – http://www.asch.net/Public/AmericanJournalofClinicalHypnosis.aspx
Published by – American Society of Clinical Hypnosis
Description – “The Journal publishes original scientific articles and clinical case reports on hypnosis, as well as reviews of
related books and abstracts of the current hypnosis literature.”

Key Takeaways
You should have learned the following in this section:
Mental health professionals take on many different forms with different degree requirements, training, and the ability to
prescribe mediations.
Telling others what we have done is achieved by joining professional societies and submitting articles to peer-reviewed
journals.

 Review Questions
1. Provide a general overview of the types of mental professionals and the degree, training, and ability to prescribe
medications that they have.
2. Briefly outline professional societies and journals related to clinical psychology and related disciplines.

Module Recap
In Module 1, we undertook a relatively lengthy discussion of what abnormal behavior is by first looking at what normal behavior
is. What emerged was a general set of guidelines focused on mental illness as causing dysfunction, distress, deviance, and at times,
being dangerous for the afflicted and others around him/her. Then we classified mental disorders in terms of their occurrence,

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cause, course, prognosis, and treatment. We acknowledged that mental illness is stigmatized in our society and provided a basis for
why this occurs and what to do about it. This involved a discussion of the history of mental illness and current views and trends.
Psychology is the scientific study of behavior and mental processes. The word scientific is key as psychology adheres to the
strictest aspects of the scientific method and uses five main research designs in its investigation of mental disorders – observation,
case study, surveys, correlational research, and experiments. Various mental health professionals use these designs, and societies
and journals provide additional means to communicate findings or to be good consumers of psychological inquiry.
It is with this foundation in mind that we move to examine models of abnormality in Module 2.

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 CHAPTER OVERVIEW

2: Models of Abnormal Psychology

 Learning Objectives
Differentiate uni- and multi-dimensional models of abnormality.
Describe how the biological model explains mental illness.
Describe how psychological perspectives explain mental illness.
Describe how the sociocultural model explains mental illness.

In Module 2, we will discuss three models of abnormal behavior to include the biological, psychological, and sociocultural models.
Each is unique in its own right and no single model can account for all aspects of abnormality. Hence, we advocate for a multi-
dimensional and not a uni-dimensional model.
2.1: Uni- vs. Multi-Dimensional Models of Abnormality
2.2: The Biological Model
2.3: Psychological Perspectives
2.4: The Sociocultural Model

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1
2.1: Uni- vs. Multi-Dimensional Models of Abnormality
 Learning Objectives
Define the uni-dimensional model.
Explain the need for a multi-dimensional model of abnormality.
Define model.
List and describe the models of abnormality.

Uni-Dimensional
To effectively treat a mental disorder, we must understand its cause. This could be a single factor such as a chemical imbalance in
the brain, relationship with a parent, socioeconomic status (SES), a fearful event encountered during middle childhood, or the way
in which the individual copes with life’s stressors. This single factor explanation is called a uni-dimensional model. The problem
with this approach is that mental disorders are not typically caused by a solitary factor, but multiple causes. Admittedly, single
factors do emerge during a person’s life, but as they arise, the factors become part of the individual. In time, the cause of the
person’s psychopathology is due to all these individual factors.

Multi-Dimensional
So, it is better to subscribe to a multi-dimensional model that integrates multiple causes of psychopathology and affirms that each
cause comes to affect other causes over time. Uni-dimensional models alone are too simplistic to explain the etiology of mental
disorders fully.
Before introducing the current main models, it is crucial to understand what a model is. In a general sense, a model is defined as a
representation or imitation of an object (dictionary.com). For mental health professionals, models help us to understand mental
illness since diseases such as depression cannot be touched or experienced firsthand. To be considered distinct from other
conditions, a mental illness must have its own set of symptoms. But as you will see, the individual does not have to present with the
entire range of symptoms. For example, to be diagnosed with separation anxiety disorder, you must present with three of eight
symptoms for criteria A whereas for a major depressive episode as part of Bipolar II disorder, you have to display five (or more)
symptoms for criteria A. There will be some variability in terms of what symptoms are displayed, but in general, all people with a
specific psychopathology have symptoms from that group.
We can also ask the patient probing questions, seek information from family members, examine medical records, and in time,
organize and process all this information to better understand the person’s condition and potential causes. Models aid us with doing
all of this. Still, we must remember that the model is a starting point for the researcher, and due to this, it determines what causes
might be investigated at the exclusion of other causes. Often, proponents of a given model find themselves in disagreement with
proponents of other models. All forget that there is no individual model that completely explains human behavior, or in this case,
abnormal behavior, and so each model contributes in its own way. Here are the models we will examine in this module:
Biological – includes genetics, chemical imbalances in the brain, the functioning of the nervous system, etc.
Psychological – includes learning, personality, stress, cognition, self-efficacy, and early life experiences. We will examine
several perspectives that make up the psychological model to include psychodynamic, behavioral, cognitive, and humanistic-
existential.
Sociocultural – includes factors such as one’s gender, religious orientation, race, ethnicity, and culture.

Key Takeaways
You should have learned the following in this section:
The uni-dimensional model proposes a single factor as the cause of psychopathology while the multi-dimensional model
integrates multiple causes of psychopathology and affirms that each cause comes to affect other causes over time.
There is no individual model that completely explains human behavior and so each model contributes in its own way.

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  Review Questions
1. What is the problem with a uni-dimensional model of psychopathology?
2. Discuss the concept of a model and identify those important to understanding psychopathology.

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2.2: The Biological Model
 Learning Objectives
Describe how communication in the nervous system occurs.
List the parts of the nervous system.
Describe the structure of the neuron and all key parts.
Outline how neural transmission occurs.
Identify and define important neurotransmitters.
List the major structures of the brain.
Clarify how specific areas of the brain are involved in mental illness.
Describe the role of genes in mental illness.
Describe the role of hormonal imbalances in mental illness.
Describe the role of bacterial and viral infections in mental illness.
Describe commonly used treatments for mental illness.
Evaluate the usefulness of the biological model.

Proponents of the biological model view mental illness as being a result of a malfunction in the body to include issues with brain
anatomy or chemistry. As such, we will need to establish a foundation for how communication in the nervous system occurs, what
the parts of the nervous system are, what a neuron is and its structure, how neural transmission occurs, and what the parts of the
brain are. All while doing this, we will identify areas of concern for psychologists focused on the treatment of mental disorders.

Brain Structure and Chemistry

2.2.1.1. Communication in the nervous system. To truly understand brain structure and chemistry, it is a good idea to understand
how communication occurs within the nervous system. See Figure 2.1 below. Simply:
1. Receptor cells in each of the five sensory systems detect energy.
2. This information is passed to the nervous system due to the process of transduction and through sensory or afferent neurons,
which are part of the peripheral nervous system.
3. The information is received by brain structures (central nervous system) and perception occurs.
4. Once the information has been interpreted, commands are sent out, telling the body how to respond (Step E), also via the
peripheral nervous system.
Figure 2.1. Communication in the Nervous System

Please note that we will not cover this process in full, but just the parts relevant to our topic of psychopathology.
2.2.1.2. The nervous system. The nervous system consists of two main parts – the central and peripheral nervous systems. The
central nervous system(CNS) is the control center for the nervous system, which receives, processes, interprets, and stores
incoming sensory information. It consists of the brain and spinal cord. The peripheral nervous system consists of everything
outside the brain and spinal cord. It handles the CNS’s input and output and divides into the somatic and autonomic nervous
systems. The somatic nervous system allows for voluntary movement by controlling the skeletal muscles and carries sensory

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information to the CNS. The autonomic nervous system regulates the functioning of blood vessels, glands, and internal organs
such as the bladder, stomach, and heart. It consists of sympathetic and parasympathetic nervous systems. The sympathetic nervous
system is involved when a person is intensely aroused. It provides the strength to fight back or to flee (fight-or-flight instinct).
Eventually, the response brought about by the sympathetic nervous system must end. The parasympathetic nervous system calms
the body.
Figure 2.2. The Structure of the Nervous System

2.2.1.3. The neuron. The fundamental unit of the nervous system is the neuron, or nerve cell (See Figure 2.3). It has several
structures in common with all cells in the body. The nucleus is the control center of the neuron, and the soma is the cell body. In
terms of distinctive structures, these focus on the ability of a neuron to send and receive information. The axon sends
signals/information to neighboring neurons while the dendrites, which resemble little trees, receive information from neighboring
neurons. Note the plural form of dendrite and the singular form of axon; there are many dendrites but only one axon. Also of
importance to the neuron is the myelin sheath or the white, fatty covering which: 1) provides insulation so that signals from
adjacent neurons do not affect one another and, 2) increases the speed at which signals are transmitted. The axon terminals are the
end of the axon where the electrical impulse becomes a chemical message and passes to an adjacent neuron.
Though not neurons, glial cells play an important part in helping the nervous system to be the efficient machine that it is. Glial cells
are support cells in the nervous system that serve five main functions:
1. They act as a glue and hold the neuron in place.
2. They form the myelin sheath.
3. They provide nourishment for the cell.
4. They remove waste products.
5. They protect the neuron from harmful substances.
Finally, nerves are a group of axons bundled together like wires in an electrical cable.
Figure 2.3. The Structure of the Neuron

2.2.1.4. Neural transmission. Transducers or receptor cells in the major organs of our five sensory systems – vision (the eyes),
hearing (the ears), smell (the nose), touch (the skin), and taste (the tongue) – convert the physical energy that they detect or sense
and send it to the brain via the neural impulse. How so? See Figure 2.4 below. We will cover this process in three parts.
Part 1. The Axon and Neural Impulse

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The neural impulse proceeds across the following steps:
Step 1 – Neurons waiting to fire are said to be in resting potential and polarized, or having a negative charge inside the neuron
and a positive charge outside.
Step 2 – If adequately stimulated, the neuron experiences an action potential and becomes depolarized. When this occurs,
voltage-gated ion channels open, allowing positively charged sodium ions (Na+) to enter. This shifts the polarity to positive on
the inside and negative outside. Note that ions are charged particles found both inside and outside the neuron.
Step 3 – Once the action potential passes from one segment of the axon to the next, the previous segment begins to repolarize.
This occurs because the Na channels close and potassium (K) channels open. K+ has a positive charge, so the neuron becomes
negative again on the inside and positive on the outside.
Step 4 – After the neuron fires, it will not fire again no matter how much stimulation it receives. This is called the absolute
refractory period. Think of it as the neuron ABSOLUTELY will not fire, no matter what.
Step 5 – After a short time, the neuron can fire again, but needs greater than normal levels of stimulation to do so. This is called
the relative refractory period.
Step 6 – Please note that this process is cyclical. We started at resting potential in Step 1 and end at resting potential in Step 6.
Part 2. The Action Potential
Let’s look at the electrical portion of the process in another way and add some detail.
Figure 2.4. The Action Potential

Recall that a neuron is usually at resting potential and polarized. The charge inside is -70mV at rest.
If it receives sufficient stimulation, causing the polarity inside the neuron to rise from -70 mV to -55mV (threshold of
excitation), the neuron will fire or send an electrical impulse down the length of the axon (the action potential or
depolarization). It should be noted that it either hits -55mV and fires, or it does not fire at all. This is the all-or-nothing
principle. The threshold must be reached.
Once the electrical impulse has passed from one segment of the axon to the next, the neuron begins the process of resetting
called repolarization.
During repolarization the neuron will not fire no matter how much stimulation it receives. This is called the absolute refractory
period.
The neuron next moves into a relative refractory period, meaning it can fire but needs higher than normal levels of stimulation.
Notice how the line has dropped below -70mV. Hence, to reach -55mV and fire, it will need more than the normal gain of
+15mV (-70 to -55 mV).
And then we return to resting potential, as you saw in Figure 2.4
Part 3. The Synapse
The electrical portion of the neural impulse is just the start. The actual code passes from one neuron to another in a chemical form
called a neurotransmitter. The point where this occurs is called the synapse. The synapse consists of three parts – the axon of the
sending neuron, the space in between called the synaptic space, gap, or cleft, and the dendrite of the receiving neuron. Once the
electrical impulse reaches the end of the axon, called the axon terminal, it stimulates synaptic vesicles or neurotransmitter sacs to
release the neurotransmitter. Neurotransmitters will only bind to their specific receptor sites, much like a key will only fit into the
lock it was designed for. You might say neurotransmitters are part of a lock-and-key system. What happens to the neurotransmitters
that do not bind to a receptor site? They might go through reuptake, which is the process of the presynaptic neuron taking up
excess neurotransmitters in the synaptic space for future use or enzymatic degradation when enzymes destroy excess
neurotransmitters in the synaptic space.

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2.2.1.5. Neurotransmitters. What exactly are some of the neurotransmitters which are so critical for neural transmission, and are
essential to our discussion of psychopathology?
Dopamine – controls voluntary movements and is associated with the reward mechanism in the brain
Serotonin – regulates pain, sleep cycle, and digestion; leads to a stable mood, so low levels lead to depression
Endorphins – involved in reducing pain and making the person calm and happy
Norepinephrine – increases the heart rate and blood pressure and regulates mood
GABA – blocks the signals of excitatory neurotransmitters responsible for anxiety and panic
Glutamate – associated with learning and memory
The critical thing to understand here is that there is a belief in the realm of mental health that chemical imbalances are responsible
for many mental disorders. Chief among these are neurotransmitter imbalances. For instance, people with Seasonal Affective
Disorder (SAD) have difficulty regulating serotonin. More on this throughout the book as we discuss each disorder.
2.2.1.6. The brain. The central nervous system consists of the brain and spinal cord; the former we will discuss briefly and in
terms of key structures which include:
Medulla – regulates breathing, heart rate, and blood pressure
Pons – acts as a bridge connecting the cerebellum and medulla and helps to transfer messages between different parts of the
brain and spinal cord
Reticular formation – responsible for alertness and attention
Cerebellum – involved in our sense of balance and for coordinating the body’s muscles so that movement is smooth and
precise. Involved in the learning of certain kinds of simple responses and acquired reflexes.
Thalamus – the major sensory relay center for all senses except smell
Hypothalamus – involved in drives associated with the survival of both the individual and the species. It regulates temperature
by triggering sweating or shivering and controls the complex operations of the autonomic nervous system
Amygdala – responsible for evaluating sensory information and quickly determining its emotional importance
Hippocampus – our “gateway” to memory. Allows us to form spatial memories so that we can accurately navigate through our
environment and helps us to form new memories about facts and events
The cerebrum has four distinct regions in each cerebral hemisphere. First, the frontal lobe contains the motor cortex, which
issues orders to the muscles of the body that produce voluntary movement. The frontal lobe is also involved in emotion and in
the ability to make plans, think creatively, and take initiative. The parietal lobe contains the somatosensory cortex and receives
information about pressure, pain, touch, and temperature from sense receptors in the skin, muscles, joints, internal organs, and
taste buds. The occipital lobe contains the visual cortex for receiving and processing visual information. Finally, the temporal
lobe is involved in memory, perception, and emotion. It contains the auditory cortex which processes sound.
Of course, this is not an exhaustive list of structures found in the brain but gives you a pretty good idea of function and which
structure is responsible for it. What is important to mental health professionals is some disorders involve specific areas of the brain.
For instance, Parkinson’s disease is a brain disorder that results in a gradual loss of muscle control and arises when cells in the
substantia nigra, a long nucleus considered to be part of the basal ganglia, stop making dopamine. As these cells die, the brain
fails to receive messages about when and how to move. In the case of depression, low levels of serotonin are responsible, at least
partially. New evidence suggests “nerve cell connections, nerve cell growth, and the functioning of nerve circuits have a major
impact on depression… and areas that play a significant role in depression are the amygdala, the thalamus, and the hippocampus.”
Also, individuals with borderline personality disorder have been shown to have structural and functional changes in brain areas
associated with impulse control and emotional regulation, while imaging studies reveal differences in the frontal cortex and
subcortical structures for those suffering from OCD.
Check out the following from Harvard Health for more on depression and the brain as a cause:
https://www.health.harvard.edu/mind-and-mood/what-causes-depression

Genes, Hormonal Imbalances, and Viral Infections

2.2.2.1. Genetic issues and explanations. DNA, or deoxyribonucleic acid, is our heredity material. It exists in the nucleus of each
cell, packaged in threadlike structures known as chromosomes, for which we have 23 pairs or 46 total. Twenty-two of the pairs are
the same in both sexes, but the 23rd pair is called the sex chromosome and differs between males and females. Males have X and Y
chromosomes while females have two Xs. According to the Genetics Home Reference website as part of NIH’s National Library of
Medicine, a gene is “the basic physical and functional unit of heredity” (https://ghr.nlm.nih.gov/primer/basics/gene). They act as

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the instructions to make proteins, and it is estimated by the Human Genome Project that we have between 20,000 and 25,000
genes. We all have two copies of each gene, one inherited from our mother and one from our father.
Recent research has discovered that autism, ADHD, bipolar disorder, major depression, and schizophrenia all share genetic roots.
They “were more likely to have suspect genetic variation at the same four chromosomal sites. These included risk versions of two
genes that regulate the flow of calcium into cells.” Likewise, twin and family studies have shown that people with first-degree
relatives suffering from OCD are at higher risk to develop the disorder themselves. The same is true of borderline personality
disorder.
WebMD adds, “Experts believe many mental illnesses are linked to abnormalities in many genes rather than just one or a few and
that how these genes interact with the environment is unique for every person (even identical twins). That is why a person inherits a
susceptibility to a mental illness and doesn’t necessarily develop the illness. Mental illness itself occurs from the interaction of
multiple genes and other factors–such as stress, abuse, or a traumatic event–which can influence, or trigger, an illness in a person
who has an inherited susceptibility to it” (https://www.webmd.com/mental-health/mental-health-causes-mental-illness#1).
For more on the role of genes in the development of mental illness, check out this article from Psychology Today:
https://www.psychologytoday.com/blog/saving-normal/201604/what-you-need-know-about-the-genetics-mental-disorders
2.2.2.2. Hormonal imbalances. The body has two coordinating and integrating systems, the nervous system and the endocrine
system. The main difference between these two systems is the speed with which they act. The nervous system moves quickly with
nerve impulses moving in a few hundredths of a second. The endocrine system moves slowly with hormones, released by
endocrine glands, taking seconds, or even minutes, to reach their target. Hormones are important to psychologists because they
manage the nervous system and body tissues at certain stages of development and activate behaviors such as alertness or sleepiness,
sexual behavior, concentration, aggressiveness, reaction to stress, and a desire for companionship. The pituitary gland is the
“master gland” which regulates other endocrine glands. It influences blood pressure, thirst, contractions of the uterus during
childbirth, milk production, sexual behavior and interest, body growth, the amount of water in the body’s cells, and other functions
as well. The pineal gland helps regulate the sleep-wake cycle while the thyroid gland regulates the body’s energy levels by
controlling metabolism and the basal metabolic rate (BMR). It regulates the body’s rate of metabolism and so how energetic people
are.
Of importance to mental health professionals are the adrenal glands, located on top of the kidneys, and which release cortisol to
help the body deal with stress. Elevated levels of this hormone can lead to several problems, including increased weight gain,
interference with learning and memory, reduced bone density, high cholesterol, and an increased risk of depression. Similarly, the
overproduction of the hormone melatonin can lead to SAD.
For more on the link between cortisol and depression, check out this article:
https://www.psychologytoday.com/blog/the-athletes-way/201301/cortisol-why-the-stress-hormone-is-public-enemy-no-1
2.2.2.3. Bacterial and viral infections. Infections can cause brain damage and lead to the development of mental illness or
exacerbate existing symptoms. For instance, evidence suggests that contracting strep throat, “an infection in the throat and tonsils
caused by bacteria called group A Streptococcus” (for more on strep throat, please visit https://www.cdc.gov/groupastrep/diseases-
public/strep-throat.html), can lead to the development of OCD, Tourette’s syndrome, and tic disorder in children (Mell, Davis, &
Owens, 2005; Giedd et al., 2000; Allen et al., 1995; https://www.mayoclinic.org/diseases-conditions/flu/symptoms-causes/syc-
20351719), have also been linked to schizophrenia (Brown et al., 2004; McGrath and Castle, 1995; McGrath et al., 1994;
O’callaghan et al., 1991) though more recent research suggests this evidence is weak at best (Selten & Termorshuizen, 2017; Ebert
& Kotler, 2005).

Treatments
2.2.3.1. Psychopharmacology and psychotropic drugs. One option to treat severe mental illness is psychotropic medications.
These medications fall under five major categories.
Antidepressants are used to treat depression, but also anxiety, insomnia, and pain. The most common types of antidepressants are
SSRIs or selective serotonin reuptake inhibitors and include Citalopram, Paroxetine, and Fluoxetine (Prozac). Possible side effects
include weight gain, sleepiness, nausea and vomiting, panic attacks, or thoughts about suicide or dying.
Anti-anxiety medications help with the symptoms of anxiety and include benzodiazepines such as Clonazepam, Alprazolam, and
Lorazepam. “Anti-anxiety medications such as benzodiazepines are effective in relieving anxiety and take effect more quickly than

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the antidepressant medications (or buspirone) often prescribed for anxiety. However, people can build up a tolerance to
benzodiazepines if they are taken over a long period of time and may need higher and higher doses to get the same effect.” Side
effects include drowsiness, dizziness, nausea, difficulty urinating, and irregular heartbeat, to name a few.
Stimulants increase one’s alertness and attention and are frequently used to treat ADHD. They include Lisdexamfetamine, the
combination of dextroamphetamine and amphetamine, and Methylphenidate. Stimulants are generally effective and produce a
calming effect. Possible side effects include loss of appetite, headache, motor or verbal tics, and personality changes such as
appearing emotionless.
Antipsychotics are used to treat psychosis or “conditions that affect the mind, and in which there has been some loss of contact with
reality, often including delusions (false, fixed beliefs) or hallucinations (hearing or seeing things that are not really there).” They
can be used to treat eating disorders, severe depression, PTSD, OCD, ADHD, and Generalized Anxiety Disorder. Common
antipsychotics include Chlorpromazine, Perphenazine, Quetiapine, and Lurasidone. Side effects include nausea, vomiting, blurred
vision, weight gain, restlessness, tremors, and rigidity.
Mood stabilizers are used to treat bipolar disorder and, at times, depression, schizoaffective disorder, and disorders of impulse
control. A common example is Lithium; side effects include loss of coordination, hallucinations, seizures, and frequent urination.
For more information on psychotropic medications, please visit:
https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml
The use of these drugs has been generally beneficial to patients. Most report that their symptoms decline, leading them to feel
better and improve their functioning. Also, long-term hospitalizations are less likely to occur as a result, though the medications do
not benefit the individual in terms of improved living skills.
2.2.3.2. Electroconvulsive therapy. According to Mental Health America, “Electroconvulsive therapy (ECT) is a procedure in
which a brief application of electric stimulus is used to produce a generalized seizure.” Patients are placed on a padded bed and
administered a muscle relaxant to avoid injury during the seizures. Annually, approximately 100,000 undergo ECT to treat
conditions such as severe depression, acute mania, suicidality, and some forms of schizophrenia. The procedure is still the most
controversial available to mental health professionals due to “its effectiveness vs. the side effects, the objectivity of ECT experts,
and the recent increase in ECT as a quick and easy solution, instead of long-term psychotherapy or hospitalization”
(https://www.mhanational.org/ect). Its popularity has declined since the 1960s and 1970s.
2.2.3.3. Psychosurgery. Another option to treat mental disorders is to perform brain surgeries. In the past, we have conducted
trephination and lobotomies, neither of which are used today. Today’s techniques are much more sophisticated and have been used
to treat schizophrenia, depression, and some personality and anxiety disorders. However, critics cite obvious ethical issues with
conducting such surgeries as well as scientific issues.
For more on psychosurgery, check out this article from Psychology Today:
https://www.psychologytoday.com/articles/199203/psychosurgery

Evaluation of the Model

The biological model is generally well respected today but suffers a few key issues. First, consider the list of side effects given for
psychotropic medications. You might make the case that some of the side effects are worse than the condition they are treating.
Second, the viewpoint that all human behavior is explainable in biological terms, and therefore when issues arise, they can be
treated using biological methods, overlooks factors that are not fundamentally biological. More on that over the next two sections.

Key Takeaways
You should have learned the following in this section:
Proponents of the biological model view mental illness as being a result of a malfunction in the body to include issues with
brain anatomy or chemistry.
Neurotransmitter imbalances and problems with brain structures/areas can result in mental disorders.
Many disorders have genetic roots, are a result of hormonal imbalances, or caused by viral infections such as strep.
Treatments related to the biological model include drugs, ECT, and psychosurgery.

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  Review Questions
1. Briefly outline how communication in the nervous system occurs.
2. What happens at the synapse during neural transmission? Why is this important to a discussion of psychopathology?
3. How is the anatomy of the brain important to a discussion of psychopathology?
4. What is the effect of genes, hormones, and viruses on the development of mental disorders?
5. What treatments are available to clinicians courtesy of the biological model of psychopathology?
6. What are some issues facing the biological model?

This page titled 2.2: The Biological Model is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Alexis
Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is
available upon request.

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2.3: Psychological Perspectives
 Learning Objectives
Describe the psychodynamic theory.
Outline the structure of personality and how it develops over time.
Describe ways to deal with anxiety.
Clarify what psychodynamic techniques are used.
Evaluate the usefulness of psychodynamic theory.
Describe learning.
Outline respondent conditioning and the work of Pavlov and Watson.
Outline operant conditioning and the work of Thorndike and Skinner.
Outline observational learning/social-learning theory and the work of Bandura.
Evaluate the usefulness of the behavioral model.
Define the cognitive model.
Exemplify the effect of schemas on creating abnormal behavior.
Exemplify the effect of attributions on creating abnormal behavior.
Exemplify the effect of maladaptive cognitions on creating abnormal behavior.
List and describe cognitive therapies.
Evaluate the usefulness of the cognitive model.
Describe the humanistic perspective.
Describe the existential perspective.
Evaluate the usefulness of humanistic and existential perspectives.

Psychodynamic Theory
In 1895, the book, Studies on Hysteria, was published by Josef Breuer (1842-1925) and Sigmund Freud (1856-1939), and marked
the birth of psychoanalysis, though Freud did not use this actual term until a year later. The book published several case studies,
including that of Anna O., born February 27, 1859 in Vienna to Jewish parents Siegmund and Recha Pappenheim, strict Orthodox
adherents who were considered millionaires at the time. Bertha, known in published case studies as Anna O., was expected to
complete the formal education typical of upper-middle-class girls, which included foreign language, religion, horseback riding,
needlepoint, and piano. She felt confined and suffocated in this life and took to a fantasy world she called her “private theater.”
Anna also developed hysteria, including symptoms such as memory loss, paralysis, disturbed eye movements, reduced speech,
nausea, and mental deterioration. Her symptoms appeared as she cared for her dying father, and her mother called on Breuer to
diagnosis her condition (note that Freud never actually treated her). Hypnosis was used at first and relieved her symptoms, as it had
done for many patients (See Module 1). Breuer made daily visits and allowed her to share stories from her private theater, which
she came to call “talking cure” or “chimney sweeping.” Many of the stories she shared were actually thoughts or events she found
troubling and reliving them helped to relieve or eliminate the symptoms. Breuer’s wife, Mathilde, became jealous of her husband’s
relationship with the young girl, leading Breuer to terminate treatment in June of 1882 before Anna had fully recovered. She
relapsed and was admitted to Bellevue Sanatorium on July 1, eventually being released in October of the same year. With time,
Anna O. did recover from her hysteria and went on to become a prominent member of the Jewish Community, involving herself in
social work, volunteering at soup kitchens, and becoming ‘House Mother’ at an orphanage for Jewish girls in 1895. Bertha (Anna
O.) became involved in the German Feminist movement, and in 1904 founded the League of Jewish Women. She published many
short stories; a play called Women’s Rights, in which she criticized the economic and sexual exploitation of women; and wrote a
book in 1900 called The Jewish Problem in Galicia, in which she blamed the poverty of the Jews of Eastern Europe on their lack of
education. In 1935, Bertha was diagnosed with a tumor, and in 1936, she was summoned by the Gestapo to explain anti-Hitler
statements she had allegedly made. She died shortly after this interrogation on May 28, 1936. Freud considered the talking cure of
Anna O. to be the origin of psychoanalytic therapy and what would come to be called the cathartic method.
For more on Anna O., please see:
https://www.psychologytoday.com/blog/freuds-patients-serial/201201/bertha-pappenheim-1859-1936

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2.3.1.1. The structure of personality. Freud’s psychoanalysis was unique in the history of psychology because it did not arise
within universities as most major schools of thought did; rather, it emerged from medicine and psychiatry to address
psychopathology and examine the unconscious. Freud believed that consciousness had three levels – 1) consciousness which was
the seat of our awareness, 2) preconscious that included all of our sensations, thoughts, memories, and feelings, and 3) the
unconscious, which was not available to us. The contents of the unconscious could move from the unconscious to preconscious,
but to do so, it had to pass a Gate Keeper. Content that was turned away was said to be repressed.
According to Freud, our personality has three parts – the id, superego, and ego, and from these our behavior arises. First, the id is
the impulsive part that expresses our sexual and aggressive instincts. It is present at birth, completely unconscious, and operates on
the pleasure principle, resulting in selfishly seeking immediate gratification of our needs no matter what the cost. The second part
of personality emerges after birth with early formative experiences and is called the ego. The ego attempts to mediate the desires of
the id against the demands of reality, and eventually, the moral limitations or guidelines of the superego. It operates on the reality
principle, or an awareness of the need to adjust behavior, to meet the demands of our environment. The last part of the personality
to develop is the superego, which represents society’s expectations, moral standards, rules, and represents our conscience. It leads
us to adopt our parent’s values as we come to realize that many of the id’s impulses are unacceptable. Still, we violate these values
at times and experience feelings of guilt. The superego is partly conscious but mostly unconscious, and part of it becomes our
conscience. The three parts of personality generally work together well and compromise, leading to a healthy personality, but if the
conflict is not resolved, intrapsychic conflicts can arise and lead to mental disorders.
Personality develops over five distinct stages in which the libido focuses on different parts of the body. First, libido is the psychic
energy that drives a person to pleasurable thoughts and behaviors. Our life instincts, or Eros, are manifested through it and are the
creative forces that sustain life. They include hunger, thirst, self-preservation, and sex. In contrast, Thanatos, our death instinct, is
either directed inward as in the case of suicide and masochism or outward via hatred and aggression. Both types of instincts are
sources of stimulation in the body and create a state of tension that is unpleasant, thereby motivating us to reduce them. Consider
hunger, and the associated rumbling of our stomach, fatigue, lack of energy, etc., that motivates us to find and eat food. If we are
angry at someone, we may engage in physical or relational aggression to alleviate this stimulation.
2.3.1.2. The development of personality. Freud’s psychosexual stages of personality development are listed below. Please note
that a person may become fixated at any stage, meaning they become stuck, thereby affecting later development and possibly
leading to abnormal functioning, or psychopathology.
1. Oral Stage – Beginning at birth and lasting to 24 months, the libido is focused on the mouth. Sexual tension is relieved by
sucking and swallowing at first, and then later by chewing and biting as baby teeth come in. Fixation is linked to a lack of
confidence, argumentativeness, and sarcasm.
2. Anal Stage – Lasting from 2-3 years, the libido is focused on the anus as toilet training occurs. If parents are too lenient,
children may become messy or unorganized. If parents are too strict, children may become obstinate, stingy, or orderly.
3. Phallic Stage – Occurring from about age 3 to 5-6 years, the libido is focused on the genitals, and children develop an
attachment to the parent of the opposite sex and are jealous of the same-sex parent. The Oedipus complex develops in boys and
results in the son falling in love with his mother while fearing that his father will find out and castrate him. Meanwhile, girls fall
in love with the father and fear that their mother will find out, called the Electra complex. A fixation at this stage may result in
low self-esteem, feelings of worthlessness, and shyness.
4. Latency Stage – From 6-12 years of age, children lose interest in sexual behavior, so boys play with boys and girls with girls.
Neither sex pays much attention to the opposite sex.
5. Genital Stage – Beginning at puberty, sexual impulses reawaken and unfulfilled desires from infancy and childhood can be
satisfied during lovemaking.
2.3.1.3. Dealing with anxiety. The ego has a challenging job to fulfill, balancing both the will of the id and the superego, and the
overwhelming anxiety and panic this creates. Ego-defense mechanisms are in place to protect us from this pain but are considered
maladaptive if they are misused and become our primary way of dealing with stress. They protect us from anxiety and operate
unconsciously by distorting reality. Defense mechanisms include the following:
Repression – When unacceptable ideas, wishes, desires, or memories are blocked from consciousness such as forgetting a
horrific car accident that you caused. Eventually, though, it must be dealt with, or the repressed memory can cause problems
later in life.
Reaction formation – When an impulse is repressed and then expressed by its opposite. For example, you are angry with your
boss but cannot lash out at him, so you are super friendly instead. Another example is having lustful thoughts about a coworker

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 than you cannot express because you are married, so you are extremely hateful to this person.
Displacement – When we satisfy an impulse with a different object because focusing on the primary object may get us in
trouble. A classic example is taking out your frustration with your boss on your wife and/or kids when you get home. If you
lash out at your boss, you could be fired. The substitute target is less dangerous than the primary target.
Projection – When we attribute threatening desires or unacceptable motives to others. An example is when we do not have the
skills necessary to complete a task, but we blame the other members of our group for being incompetent and unreliable.
Sublimation – When we find a socially acceptable way to express a desire. If we are stressed out or upset, we may go to the
gym and box or lift weights. A person who desires to cut things may become a surgeon.
Denial – Sometimes, life is so hard that all we can do is deny how bad it is. An example is denying a diagnosis of lung cancer
given by your doctor.
Identification – When we find someone who has found a socially acceptable way to satisfy their unconscious wishes and
desires, and we model that behavior.
Regression – When we move from a mature behavior to one that is infantile. If your significant other is nagging you, you might
regress by putting your hands over your ears and saying, “La la la la la la la la…”
Rationalization – When we offer well-thought-out reasons for why we did what we did, but these are not the real reason.
Students sometimes rationalize not doing well in a class by stating that they really are not interested in the subject or saying the
instructor writes impossible-to-pass tests.
Intellectualization – When we avoid emotion by focusing on the intellectual aspects of a situation such as ignoring the sadness
we are feeling after the death of our mother by focusing on planning the funeral.
For more on defense mechanisms, please visit:
https://www.psychologytoday.com/blog/fulfillment-any-age/201110/the-essential-guide-defense-mechanisms
2.3.1.4. Psychodynamic techniques. Freud used three primary assessment techniques—free association, transference, and dream
analysis—as part of psychoanalysis, or psychoanalytic therapy, to understand the personalities of his patients and expose repressed
material. First, free association involves the patient describing whatever comes to mind during the session. The patient continues
but always reaches a point when he/she cannot or will not proceed any further. The patient might change the subject, stop talking,
or lose his/her train of thought. Freud said this resistance revealed where issues persisted.
Second, transference is the process through which patients transfer attitudes he/she held during childhood to the therapist. They
may be positive and include friendly, affectionate feelings, or negative, and include hostile and angry feelings. The goal of therapy
is to wean patients from their childlike dependency on the therapist.
Finally, Freud used dream analysis to understand a person’s innermost wishes. The content of dreams includes the person’s actual
retelling of the dreams, called manifest content, and the hidden or symbolic meaning called latent content. In terms of the latter,
some symbols are linked to the person specifically, while others are common to all people.
2.3.1.5. Evaluating psychodynamic theory. Freud’s psychodynamic theory made a lasting impact on the field of psychology but
also has been criticized heavily. First, Freud made most of his observations in an unsystematic, uncontrolled way, and he relied on
the case study method. Second, the participants in his studies were not representative of the broader population. Despite Freud’s
generalization, his theory was based on only a few patients. Third, he relied solely on the reports of his patients and sought no
observer reports. Fourth, it is difficult to empirically study psychodynamic principles since most operate unconsciously. This begs
the question of how we can really know that they exist. Finally, psychoanalytic treatment is expensive and time consuming, and
since Freud’s time, drug therapies have become more popular and successful. Still, Sigmund Freud developed useful therapeutic
tools for clinicians and raised awareness about the role the unconscious plays in both normal and abnormal behavior.

The Behavioral Model

2.3.2.1. What is learning? The behavioral model concerns the cognitive process of learning, which is any relatively permanent
change in behavior due to experience and practice. Learning has two main forms – associative learning and observational learning.
First, associative learning is the linking together of information sensed from our environment. Conditioning, or a type of
associative learning, occurs when two separate events become connected. There are two forms: classical conditioning, or linking
together two types of stimuli, and operant conditioning, or linking together a response with its consequence. Second, observational
learning occurs when we learn by observing the world around us.
We should also note the existence of non-associative learning or when there is no linking of information or observing the actions of
others around you. Types include habituation, or when we simply stop responding to repetitive and harmless stimuli in our

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environment such as a fan running in your laptop as you work on a paper, and sensitization, or when our reactions are increased
due to a strong stimulus, such as an individual who experienced a mugging and now panics when someone walks up behind
him/her on the street.
Behaviorism is the school of thought associated with learning that began in 1913 with the publication of John B. Watson’s article,
“Psychology as the Behaviorist Views It,” in the journal Psychological Review (Watson, 1913). Watson believed that the subject
matter of psychology was to be observable behavior, and to that end, psychology should focus on the prediction and control of
behavior. Behaviorism was dominant from 1913 to 1990 before being absorbed into mainstream psychology. It went through three
major stages – behaviorism proper under Watson and lasting from 1913-1930 (discussed as classical/respondent conditioning),
neobehaviorism under Skinner and lasting from 1930-1960 (discussed as operant conditioning), and sociobehaviorism under
Bandura and Rotter and lasting from 1960-1990 (discussed as social learning theory).
2.3.2.2. Respondent conditioning. You have likely heard about Pavlov and his dogs, but what you may not know is that this was a
discovery made accidentally. Ivan Petrovich Pavlov (1906, 1927, 1928), a Russian physiologist, was interested in studying
digestive processes in dogs in response to being fed meat powder. What he discovered was the dogs would salivate even before the
meat powder was presented. They would salivate at the sound of a bell, footsteps in the hall, a tuning fork, or the presence of a lab
assistant. Pavlov realized some stimuli automatically elicited responses (such as salivating to meat powder) and other stimuli had to
be paired with these automatic associations for the animal or person to respond to it (such as salivating to a bell). Armed with this
stunning revelation, Pavlov spent the rest of his career investigating the learning phenomenon.
The important thing to understand is that not all behaviors occur due to reinforcement and punishment as operant conditioning says.
In the case of respondent conditioning, stimuli exert complete and automatic control over some behaviors. We see this in the case
of reflexes. When a doctor strikes your knee with that little hammer, your leg extends out automatically. Another example is how a
baby will root for a food source if the mother’s breast is placed near their mouth. And if a nipple is placed in their mouth, they will
also automatically suck via the sucking reflex. Humans have several of these reflexes, though not as many as other animals due to
our more complicated nervous system.
Respondent conditioning (also called classical or Pavlovian conditioning) occurs when we link a previously neutral stimulus with
a stimulus that is unlearned or inborn, called an unconditioned stimulus. In respondent conditioning, learning happens in three
phases: preconditioning, conditioning, and postconditioning. See Figure 2.5 for an overview of Pavlov’s classic experiment.
Preconditioning. Notice that preconditioning has both an A and a B panel. All this stage of learning signifies is that some learning
is already present. There is no need to learn it again, as in the case of primary reinforcers and punishers in operant conditioning. In
Panel A, food makes a dog salivate. This response does not need to be learned and shows the relationship between an
unconditioned stimulus (UCS) yielding an unconditioned response (UCR). Unconditioned means unlearned. In Panel B, we see that
a neutral stimulus (NS) produces no response. Dogs do not enter the world knowing to respond to the ringing of a bell (which it
hears).
Conditioning. Conditioning is when learning occurs. By pairing a neutral stimulus and unconditioned stimulus (bell and food,
respectively), the dog will learn that the bell ringing (NS) signals food coming (UCS) and salivate (UCR). The pairing must occur
more than once so that needless pairings are not learned such as someone farting right before your food comes out and now you
salivate whenever someone farts (…at least for a while. Eventually the fact that no food comes will extinguish this reaction but
still, it will be weird for a bit).
Figure 2.5. Pavlov’s Classic Experiment

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Postconditioning. Postconditioning, or after learning has occurred, establishes a new and not naturally occurring relationship of a
conditioned stimulus (CS; previously the NS) and conditioned response (CR; the same response). So the dog now reliably salivates
at the sound of the bell because he expects that food will follow, and it does.
Watson and Rayner (1920) conducted one of the most famous studies in psychology. Essentially, they wanted to explore “the
possibility of conditioning various types of emotional response(s).” The researchers ran a series of trials in which they exposed a 9-
month-old child, known as Little Albert, to a white rat. Little Albert made no response outside of curiosity (NS–NR not shown).
Panel A of Figure 2.6 shows the naturally occurring response to the stimulus of a loud sound. On later trials, the rat was presented
(NS) and followed closely by a loud sound (UCS; Panel B). After several conditioning trials, the child responded with fear to the
mere presence of the white rat (Panel C).
Figure 2.6. Learning to Fear

As fears can be learned, so too they can be unlearned. Considered the follow-up to Watson and Rayner (1920), Jones (1924; Figure
2.7) wanted to see if a child who learned to be afraid of white rabbits (Panel B) could be conditioned to become unafraid of them.
Simply, she placed the child in one end of a room and then brought in the rabbit. The rabbit was far enough away so as not to cause
distress. Then, Jones gave the child some pleasant food (i.e., something sweet such as cookies [Panel C]; remember the response to
the food is unlearned, i.e., Panel A). The procedure in Panel C continued with the rabbit being brought a bit closer each time until,
eventually, the child did not respond with distress to the rabbit (Panel D).
Figure 2.7. Unlearning Fears

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This process is called counterconditioning, or the reversal of previous learning.
Another respondent conditioning way to unlearn a fear is called flooding or exposing the person to the maximum level of stimulus
and as nothing aversive occurs, the link between CS and UCS producing the CR of fear should break, leaving the person unafraid.
That is the idea, at least. So, if you were afraid of clowns, you would be thrown into a room full of clowns. Hmm….
Finally, respondent conditioning has several properties:
Respondent Generalization – When many similar CSs or a broad range of CSs elicit the same CR. An example is the sound of
a whistle eliciting salivation much the same as a ringing bell, both detected via audition.
Respondent Discrimination – When a single CS or a narrow range of CSs elicits a CR, i.e., teaching the dog to respond to a
specific bell and ignore the whistle. The whistle would not be followed by food, eventually leading to….
Respondent Extinction – When the CS is no longer paired with the UCS. The sound of a school bell ringing (new CS that was
generalized) is not followed by food (UCS), and so eventually, the dog stops salivating (the CR).
Spontaneous Recovery – When the CS elicits the CR after extinction has occurred. Eventually, the school bell will ring,
making the dog salivate. If no food comes, the behavior will not continue. If food appears, the salivation response will be re-
established.
2.3.2.3. Operant conditioning. Influential on the development of Skinner’s operant conditioning, Thorndike (1905) proposed the
law of effect or the idea that if our behavior produces a favorable consequence, in the future when the same stimulus is present, we
will be more likely to make the response again, expecting the same favorable consequence. Likewise, if our action leads to
dissatisfaction, then we will not repeat the same behavior in the future. He developed the law of effect thanks to his work with a
puzzle box. Cats were food deprived the night before the experimental procedure was to occur. The next morning, researchers
placed a hungry cat in the puzzle box and set a small amount of food outside the box, just close enough to be smelled. The cat
could escape the box and reach the food by manipulating a series of levers. Once free, the cat was allowed to eat some food before
being promptly returned to the box. With each subsequent escape and re-insertion into the box, the cat became faster at correctly
manipulating the levers. This scenario demonstrates trial and error learning or making a response repeatedly if it leads to success.
Thorndike also said that stimulus and responses were connected by the organism, and this led to learning. This approach to learning
was called connectionism.
Operant conditioning is a type of associate learning which focuses on consequences that follow a response or behavior that we
make (anything we do or say) and whether it makes a behavior more or less likely to occur. This should sound much like what you
just read about in terms of Thorndike’s work. Skinner talked about contingencies or when one thing occurs due to another. Think
of it as an If-Then statement. If I do X, then Y will happen. For operant conditioning, this means that if I make a behavior, then a
specific consequence will follow. The events (response and consequence) are linked in time.
What form do these consequences take? There are two main ways they can present themselves.
Reinforcement – Due to the consequence, a behavior/response is strengthened and more likely to occur in the future.
Punishment – Due to the consequence, a behavior/response is weakened and less likely to occur in the future.
Reinforcement and punishment can occur as two types – positive and negative. These words have no affective connotation to them,
meaning they do not imply good or bad. Positive means that you are giving something – good or bad. Negative means that
something is being taken away – good or bad. Check out the figure below for how these contingencies are arranged.
Figure 2.8. Contingencies in Operant Conditioning

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Let’s go through each:
Positive Punishment (PP) – If something bad or aversive is given or added, then the behavior is less likely to occur in the
future. If you talk back to your mother and she slaps your mouth, this is a PP. Your response of talking back led to the
consequence of the aversive slap being given to your face. Ouch!!!
Positive Reinforcement (PR) – If something good is given or added, then the behavior is more likely to occur in the future. If
you study hard and receive an A on your exam, you will be more likely to study hard in the future. Similarly, your parents may
give you money for your stellar performance. Cha Ching!!!
Negative Reinforcement (NR) – This is a tough one for students to comprehend because the terms seem counterintuitive, even
though we experience NR all the time. NR is when something bad or aversive is taken away or subtracted due to your actions,
making it that you will be more likely to make the same behavior in the future when the same stimulus presents itself. For
instance, what do you do if you have a headache? If you take Tylenol and the pain goes away, you will likely take Tylenol in the
future when you have a headache. NR can either result in current escape behavior or future avoidance behavior. What does this
mean? Escape occurs when we are presently experiencing an aversive event and want it to end. We make a behavior and if the
aversive event, like the headache, goes away, we will repeat the taking of Tylenol in the future. This future action is an
avoidance event. We might start to feel a headache coming on and run to take Tylenol right away. By doing so, we have
removed the possibility of the aversive event occurring, and this behavior demonstrates that learning has occurred.
Negative Punishment (NP) – This is when something good is taken away or subtracted, making a behavior less likely in the
future. If you are late to class and your professor deducts 5 points from your final grade (the points are something good and the
loss is negative), you will hopefully be on time in all subsequent classes.
The type of reinforcer or punisher we use is crucial. Some are naturally occurring, while others need to be learned. We describe
these as primary and secondary reinforcers and punishers. Primary refers to reinforcers and punishers that have their effect without
having to be learned. Food, water, temperature, and sex, for instance, are primary reinforcers, while extreme cold or hot or a punch
on the arm are inherently punishing. A story will illustrate the latter. When I was about eight years old, I would walk up the street
in my neighborhood, saying, “I’m Chicken Little and you can’t hurt me.” Most ignored me, but some gave me the attention I was
seeking, a positive reinforcer. So I kept doing it and doing it until one day, another kid grew tired of hearing about my other identity
and punched me in the face. The pain was enough that I never walked up and down the street echoing my identity crisis for all to
hear. This was a positive punisher that did not have to be learned, and definitely not one of my finer moments in life.
Secondary or conditioned reinforcers and punishers are not inherently reinforcing or punishing but must be learned. An example
was the attention I received for saying I was Chicken Little. Over time I learned that attention was good. Other examples of
secondary reinforcers include praise, a smile, getting money for working or earning good grades, stickers on a board, points, getting
to go out dancing, and getting out of an exam if you are doing well in a class. Examples of secondary punishers include a ticket for
speeding, losing television or video game privileges, ridicule, or a fee for paying your rent or credit card bill late. Really, the sky is
the limit with reinforcers in particular.
In operant conditioning, the rule for determining when and how often we will reinforce the desired behavior is called the
reinforcement schedule. Reinforcement can either occur continuously meaning every time the desired behavior is made the
subject will receive some reinforcer, or intermittently/partially meaning reinforcement does not occur with every behavior. Our
focus will be on partial/intermittent reinforcement.
Figure 2.9. Key Components of Reinforcement Schedules

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Figure 2.9 shows that that are two main components that make up a reinforcement schedule – when you will reinforce and what is
being reinforced. In the case of when, it will be either fixed or at a set rate, or variable and at a rate that changes. In terms of what is
being reinforced, we will either reinforce responses or time. These two components pair up as follows:
Fixed Ratio schedule (FR) – With this schedule, we reinforce some set number of responses. For instance, every twenty
problems (fixed) a student gets correct (ratio), the teacher gives him an extra credit point. A specific behavior is being
reinforced – getting problems correct. Note that if we reinforce each occurrence of the behavior, the definition of continuous
reinforcement, we could also describe this as an FR1 schedule. The number indicates how many responses have to be made, and
in this case, it is one.
Variable Ratio schedule (VR) – We might decide to reinforce some varying number of responses, such as if the teacher gives
him an extra credit point after finishing between 40 and 50 correct problems. This approach is useful if the student is learning
the material and does not need regular reinforcement. Also, since the schedule changes, the student will keep responding in the
absence of reinforcement.
Fixed Interval schedule (FI) – With a FI schedule, you will reinforce after some set amount of time. Let’s say a company
wanted to hire someone to sell their product. To attract someone, they could offer to pay them $10 an hour 40 hours a week and
give this money every two weeks. Crazy idea, but it could work. Saying the person will be paid every indicates fixed, and two
weeks is time or interval. So, FI.
Variable Interval schedule (VI) – Finally, you could reinforce someone at some changing amount of time. Maybe they receive
payment on Friday one week, then three weeks later on Monday, then two days later on Wednesday, then eight days later on
Thursday, etc. This could work, right? Not for a job, but maybe we could say we are reinforced on a VI schedule if we are.
Finally, four properties of operant conditioning – extinction, spontaneous recovery, stimulus generalization, and stimulus
discrimination – are important. These are the same four discussed under respondent conditioning. First, extinction is when
something that we do, say, think/feel has not been reinforced for some time. As you might expect, the behavior will begin to
weaken and eventually stop when this occurs. Does extinction happen as soon as the anticipated reinforcer is removed? The answer
is yes and no, depending on whether we are talking about continuous or partial reinforcement. With which type of schedule would
you expect a person to stop responding to immediately if reinforcement is not there? Continuous or partial?
The answer is continuous. If a person is used to receiving reinforcement every time they perform a particular behavior, and then
suddenly no reinforcer is delivered, he or she will cease the response immediately. Obviously then, with partial, a response
continues being made for a while. Why is this? The person may think the schedule has simply changed. ‘Maybe I am not paid
weekly now. Maybe it changed to biweekly and I missed the email.’ Due to this endurance, we say that intermittent or partial
reinforcement shows resistance to extinction, meaning the behavior does weaken, but gradually.
As you might expect, if reinforcement occurs after extinction has started, the behavior will re-emerge. Consider your parents for a
minute. To stop some undesirable behavior you made in the past, they likely took away some privilege. I bet the bad behavior
ended too. But did you ever go to your grandparent’s house and grandma or grandpa—or worse, BOTH—took pity on you and let
you play your video games (or something equivalent)? I know my grandmother used to. What happened to that bad behavior that
had disappeared? Did it start again and your parents could not figure out why?
Additionally, you might have wondered if the person or animal will try to make the response again in the future even though it
stopped being reinforced in the past. The answer is yes, and one of two outcomes is possible. First, the response is made, and
nothing happens. In this case, extinction continues. Second, the response is made, and a reinforcer is delivered. The response re-
emerges. Consider a rat trained to push a lever to receive a food pellet. If we stop providing the food pellets, in time, the rat will

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stop pushing the lever. If the rat pushes the lever again sometime in the future and food is delivered, the behavior spontaneously
recovers. Hence, this phenomenon is called spontaneous recovery.
2.3.2.4. Observational learning. There are times when we learn by simply watching others. This is called observational learning
and is contrasted with enactive learning, which is learning by doing. There is no firsthand experience by the learner in
observational learning, unlike enactive. As you can learn desirable behaviors such as watching how your father bags groceries at
the grocery store (I did this and still bag the same way today), you can learn undesirable ones too. If your parents resort to alcohol
consumption to deal with stressors life presents, then you also might do the same. The critical part is what happens to the person
modeling the behavior. If my father seems genuinely happy and pleased with himself after bagging groceries his way, then I will be
more likely to adopt this behavior. If my mother or father consumes alcohol to feel better when things are tough, and it works, then
I might do the same. On the other hand, if we see a sibling constantly getting in trouble with the law, then we may not model this
behavior due to the negative consequences.
Albert Bandura conducted pivotal research on observational learning, and you likely already know all about it. Check out Figure
2.10 to see if you do. In Bandura’s experiment, children were first brought into a room to watch a video of an adult playing nicely
or aggressively with a Bobo doll, which provided a model. Next, the children are placed in a room with several toys in it. The room
contains a highly prized toy, but they are told they cannot play with it. All other toys are allowed, including a Bobo doll. Children
who watched the aggressive model behaved aggressively with the Bobo doll while those who saw the gentle model, played nice.
Both groups were frustrated when deprived of the coveted toy.
Figure 2.10. Bandura’s Classic Experiment

According to Bandura, all behaviors are learned by observing others, and we model our actions after theirs, so undesirable
behaviors can be altered or relearned in the same way. Modeling techniques change behavior by having subjects observe a model
in a situation that usually causes them some anxiety. By seeing the model interact nicely with the fear evoking stimulus, their fear
should subside. This form of behavior therapy is widely used in clinical, business, and classroom situations. In the classroom, we
might use modeling to demonstrate to a student how to do a math problem. In fact, in many college classrooms, this is exactly what
the instructor does. In the business setting, a model or trainer demonstrates how to use a computer program or run a register for a
new employee.
However, keep in mind that we do not model everything we see. Why? First, we cannot pay attention to everything going on
around us. We are more likely to model behaviors by someone who commands our attention. Second, we must remember what a
model does to imitate it. If a behavior is not memorable, it will not be imitated. We must try to convert what we see into action. If
we are not motivated to perform an observed behavior, we probably will not show what we have learned.
2.3.2.5. Evaluating the behavioral model. Within the context of psychopathology, the behavioral perspective is useful because
explains maladaptive behavior in terms of learning gone awry. The good thing is that what is learned can be unlearned or relearned
through behavior modification, the process of changing behavior. To begin, an applied behavior analyst identifies a target
behavior, or behavior to be changed, defines it, works with the client to develop goals, conducts a functional assessment to
understand what the undesirable behavior is, what causes it, and what maintains it. With this knowledge, a plan is developed and
consists of numerous strategies to act on one or all these elements – antecedent, behavior, and/or consequence. The strategies arise
from all three learning models. In terms of operant conditioning, strategies include antecedent manipulations, prompts, punishment

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procedures, differential reinforcement, habit reversal, shaping, and programming. Flooding and desensitization are typical
respondent conditioning procedures used with phobias, and modeling arises from social learning theory and observational learning.
Watson and Skinner defined behavior as what we do or say, but later behaviorists added what we think or feel. In terms of the latter,
cognitive behavior modification procedures arose after the 1960s and with the rise of cognitive psychology. This led to a cognitive-
behavioral perspective that combines concepts from the behavioral and cognitive models, the latter discussed in the next section.
Critics of the behavioral perspective point out that it oversimplifies behavior and often ignores inner determinants of behavior.
Behaviorism has also been accused of being mechanistic and seeing people as machines. This criticism would be true of
behaviorism’s first two stages, though sociobehaviorism steered away from this proposition and even fought against any
mechanistic leanings of behaviorists.
The greatest strength or appeal of the behavioral model is that its tenets are easily tested in the laboratory, unlike those of the
psychodynamic model. Also, many treatment techniques have been developed and proven to be effective over the years. For
example, desensitization (Wolpe, 1997) teaches clients to respond calmly to fear-producing stimuli. It begins with the individual
learning a relaxation technique such as diaphragmatic breathing. Next, a fear hierarchy, or list of feared objects and situations, is
constructed in which the individual moves from least to most feared. Finally, the individual either imagines (systematic) or
experiences in real life (in-vivo) each object or scenario from the hierarchy and uses the relaxation technique while doing so. This
represents the individual pairings of a feared object or situation and relaxation. So, if there are 10 objects/situations in the list, the
client will experience ten such pairings and eventually be able to face each without fear. Outside of phobias, desensitization has
been shown to be effective in the treatment of Obsessive-Compulsive Disorder symptoms (Hakimian and Souza, 2016) and
limitedly with the treatment of depression when co-morbid with OCD (Masoumeh and Lancy, 2016).

The Cognitive Model

2.3.3.1. What is it? As noted earlier, the idea of people being machines, called mechanism, was a key feature of behaviorism and
other schools of thought in psychology until about the 1960s or 1970s. In fact, behaviorism said psychology was to be the study of
observable behavior. Any reference to cognitive processes was dismissed as this was not overt, but covert according to Watson and
later Skinner. Of course, removing cognition from the study of psychology ignored an important part of what makes us human and
separates us from the rest of the animal kingdom. Fortunately, the work of George Miller, Albert Ellis, Aaron Beck, and Ulrich
Neisser demonstrated the importance of cognitive abilities in understanding thoughts, behaviors, and emotions, and in the case of
psychopathology, show that people can create their problems by how they come to interpret events experienced in the world around
them. How so?
2.3.3.2. Schemas and cognitive errors. First, consider the topic of social cognition or the process of collecting and assessing
information about others. So what do we do with this information? Once collected or sensed (sensation is the cognitive process of
detecting the physical energy given off or emitted by physical objects), the information is sent to the brain through the neural
impulse. Once in the brain, it is processed and interpreted. This is where assessing information about others comes in and involves
the cognitive process of perception, or adding meaning to raw sensory data. We take the information just detected and use it to
assign people to categories, or groups. For each category, we have a schema, or a set of beliefs and expectations about a group of
people, presumed to apply to all members of the group, and based on experience.
Can our schemas lead us astray or be false? Consider where students sit in a class. It is generally understood that the students who
sit in the front of the class are the overachievers and want to earn an A in the class. Those who sit in the back of the room are
underachievers who don’t care. Right? Where do you sit in class, if you are on a physical campus and not an online student? Is this
correct? What about other students in the class that you know? What if you found out that a friend who sits in the front row is a C
student but sits there because he cannot see the screen or board, even with corrective lenses? What about your friend or
acquaintance in the back? This person is an A student but does not like being right under the nose of the professor, especially if
he/she tends to spit when lecturing. The person in the back could also be shy and prefer sitting there so that s/he does not need to
chat with others as much. Or, they are easily distracted and sits in the back so that all stimuli are in front of him/her. Again, your
schema about front row and back row students is incorrect and causes you to make certain assumptions about these individuals.
This might even affect how you interact with them. Would you want notes from the student in the front or back of the class?
2.3.3.3. Attributions and cognitive errors. Second, consider the very interesting social psychology topic attribution theory, or
the idea that people are motivated to explain their own and other people’s behavior by attributing causes of that behavior to
personal reasons or dispositional factors that are in the person themselves or linked to some trait they have; or situational factors
that are linked to something outside the person. Like schemas, the attributions we make can lead us astray. How so? The

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fundamental attribution error occurs when we automatically assume a dispositional reason for another person’s actions and
ignore situational factors. In other words, we assume the person who cut us off is an idiot (dispositional) and do not consider that
maybe someone in the car is severely injured and this person is rushing them to the hospital (situational). Then there is the self-
serving bias, which is when we attribute our success to our own efforts (dispositional) and our failures to external causes
(situational). Our attribution in these two cases is in error, but still, it comes to affect how we see the world and our subjective well-
being.
2.3.3.4. Maladaptive cognitions. Irrational thought patterns can be the basis of psychopathology. Throughout this book, we will
discuss several treatment strategies used to change unwanted, maladaptive cognitions, whether they are present as an excess such as
with paranoia, suicidal ideation, or feelings of worthlessness; or as a deficit such as with self-confidence and self-efficacy. More
specifically, cognitive distortions/maladaptive cognitions can take the following forms:
Overgeneralizing – You see a larger pattern of negatives based on one event.
Mind Reading – Assuming others know what you are thinking without any evidence.
What if? – Asking yourself ‘what if something happens,’ without being satisfied by any of the answers.
Blaming – You focus on someone else as the source of your negative feelings and do not take any responsibility for changing
yourself.
Personalizing – Blaming yourself for adverse events rather than seeing the role that others play.
Inability to disconfirm – Ignoring any evidence that may contradict your maladaptive cognition.
Regret orientation – Focusing on what you could have done better in the past rather than on improving now.
Dichotomous thinking – Viewing people or events in all-or-nothing terms.
2.3.3.5. Cognitive therapies. According to the National Alliance on Mental Illness (NAMI), cognitive behavioral therapy
“focuses on exploring relationships among a person’s thoughts, feelings and behaviors. During CBT a therapist will actively work
with a person to uncover unhealthy patterns of thought and how they may be causing self-destructive behaviors and beliefs.” CBT
attempts to identify negative or false beliefs and restructure them. They add, “Oftentimes someone being treated with CBT will
have homework in between sessions where they practice replacing negative thoughts with more realistic thoughts based on prior
experiences or record their negative thoughts in a journal.” For more on CBT, visit: https://www.nami.org/About-Mental-
Illness/Treatments/Psychotherapy. Some commonly used strategies include cognitive restructuring, cognitive coping skills training,
and acceptance techniques.
First, you can use cognitive restructuring, also called rational restructuring, in which maladaptive cognitions are replaced with
more adaptive ones. To do this, the client must be aware of the distressing thoughts, when they occur, and their effect on them.
Next, help the client stop thinking these thoughts and replace them with more rational ones. It’s a simple strategy, but an important
one. Psychology Today published a great article on January 21, 2013, which described four ways to change your thinking through
cognitive restructuring. Briefly, these included:
1. Notice when you are having a maladaptive cognition, such as making “negative predictions.” Figure out what is the worst thing
that could happen and what alternative outcomes are possible.
2. Track the accuracy of the thought. If you believe focusing on a problem generates a solution, then write down each time you
ruminate and the result. You can generate a percentage of times you ruminated to the number of successful problem-solving
strategies you generated.
3. Behaviorally test your thought. Try figuring out if you genuinely do not have time to go to the gym by recording what you do
each day and then look at open times of the day. Add them up and see if making some minor, or major, adjustments to your
schedule will free an hour to get in some valuable exercise.
4. Examine the evidence both for and against your thought. If you do not believe you do anything right, list evidence of when you
did not do something right and then evidence of when you did. Then write a few balanced statements such as the one the article
suggests, “I’ve made some mistakes that I feel embarrassed about, but a lot of the time, I make good choices.”
The article also suggested a few non-cognitive restructuring techniques, including mindfulness meditation and self-compassion. For
more on these, visit: https://www.psychologytoday.com/blog/in-practice/201301/cognitive-restructuring
The second major CBT strategy is called cognitive coping skills training. This strategy teaches social skills, communication,
assertiveness through direct instruction, role playing, and modeling. For social skills training, identify the appropriate social
behavior such as making eye contact, saying no to a request, or starting up a conversation with a stranger and determine whether
the client is inhibited from making this behavior due to anxiety. For communication, decide if the problem is related to speaking,
listening, or both and then develop a plan for use in various interpersonal situations. Finally, assertiveness training aids the client in

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protecting their rights and obtaining what they want from others. Those who are not assertive are often overly passive and never get
what they want or are unreasonably aggressive and only get what they want. Treatment starts with determining situations in which
assertiveness is lacking and developing a hierarchy of assertiveness opportunities. Least difficult situations are handled first,
followed by more difficult situations, all while rehearsing and mastering all the situations present in the hierarchy. For more on
these techniques, visit http://cogbtherapy.com/cognitive-behavioral-therapy-exercises/.
Finally, acceptance techniques help reduce a client’s worry and anxiety. Life involves a degree of uncertainty, and at times we
must accept this. Techniques might include weighing the pros and cons of fighting uncertainty or change. The disadvantages should
outweigh the advantages and help you to end the struggle and accept what is unknown. Chances are you are already accepting the
unknown in some areas of life and identifying these can help you to see why it is helpful in these areas, and how you can apply this
in more difficult areas. Finally, does uncertainty always lead to a negative end? We may think so, but a review of the evidence for
and against this statement will show that it does not and reduce how threatening it seems.
2.3.3.6. Evaluating the cognitive model. The cognitive model made up for an apparent deficit in the behavioral model –
overlooking the role cognitive processes play in our thoughts, feelings, and behaviors. Right before his death, Skinner (1990)
reminded psychologists that the only thing we can truly know and study was the observable. Cognitive processes cannot be
empirically and reliably measured and should be ignored. Is there merit to this view? Social desirability states that sometimes
participants do not tell us the truth about what they are thinking, feeling, or doing (or have done) because they do not want us to
think less of them or to judge them harshly if they are outside the social norm. In other words, they present themselves in a
favorable light. If this is true, how can we know anything about controversial matters? The person’s true intentions or thoughts and
feelings are not readily available to us, or are covert, and do not make for useful empirical data. Still, cognitive-behavioral therapies
have proven their efficacy for the treatment of OCD (McKay et al., 2015), perinatal depression (Sockol, 2015), insomnia (de Bruin
et al., 2015), bulimia nervosa (Poulsen et al., 2014), hypochondriasis (Olatunji et al., 2014), and social anxiety disorder
(Leichsenring et al., 2014) to name a few. Other examples will be discussed throughout this book.

The Humanistic and Existential Perspectives

2.3.4.1. The humanistic perspective. The humanistic perspective, or third force psychology (psychoanalysis and behaviorism
being the other two forces), emerged in the 1960s and 1970s as an alternative viewpoint to the largely deterministic view of
personality espoused by psychoanalysis and the view of humans as machines advocated by behaviorism. Key features of the
perspective include a belief in human perfectibility, personal fulfillment, valuing self-disclosure, placing feelings over intellect, an
emphasis on the present, and hedonism. Its key figures were Abraham Maslow, who proposed the hierarchy of needs, and Carl
Rogers, who we will focus on here.
Rogers said that all people want to have positive regard from significant others in their life. When the individual is accepted as they
are, they receive unconditional positive regard and become a fully functioning person. They are open to experience, live every
moment to the fullest, are creative, accepts responsibility for their decisions, do not derive their sense of self from others, strive to
maximize their potential, and are self-actualized. Their family and friends may disapprove of some of their actions but overall,
respect and love them. They then realize their worth as a person but also that they are not perfect. Of course, most people do not
experience this but instead are made to feel that they can only be loved and respected if they meet certain standards, called
conditions of worth. Hence, they experience conditional positive regard. Their self-concept becomes distorted, now seen as having
worth only when these significant others approve, leading to a disharmonious state and psychopathology. Individuals in this
situation are unsure of what they feel, value, or need leading to dysfunction and the need for therapy. Rogers stated that the
humanistic therapist should be warm, understanding, supportive, respectful, and accepting of his/her clients. This approach came to
be called client-centered therapy.
2.3.4.2. The existential perspective. This approach stresses the need for people to re-create themselves continually and be self-
aware, acknowledges that anxiety is a normal part of life, focuses on free will and self-determination, emphasizes that each person
has a unique identity known only through relationships and the search for meaning, and finally, that we develop to our maximum
potential. Abnormal behavior arises when we avoid making choices, do not take responsibility, and fail to actualize our full
potential. Existential therapy is used to treat substance abuse, “excessive anxiety, apathy, alienation, nihilism, avoidance, shame,
addiction, despair, depression, guilt, anger, rage, resentment, embitterment, purposelessness, psychosis, and violence. They also
focus on life-enhancing experiences like relationships, love, caring, commitment, courage, creativity, power, will, presence,
spirituality, individuation, self-actualization, authenticity, acceptance, transcendence, and awe.” For more information, please visit:
https://www.psychologytoday.com/therapy-types/existential-therapy

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2.3.4.3. Evaluating the humanistic and existential perspectives. The biggest criticism of these models is that the concepts are
abstract and fuzzy and so very difficult to research. Rogers did try to investigate his propositions scientifically, but most other
humanistic-existential psychologists rejected the use of the scientific method. They also have not developed much in the way of
theory, and the perspectives tend to work best with people suffering from adjustment issues and not as well with severe mental
illness. The perspectives do offer hope to people suffering tragedy by asserting that we control our destiny and can make our own
choices.

Key Takeaways
You should have learned the following in this section:
According to Freud, consciousness had three levels (consciousness, preconscious, and the unconscious), personality had three
parts (the id, ego, and superego), personality developed over five stages (oral, anal, phallic, latency, and genital), there are ten
defense mechanisms to protect the ego such as repression and sublimation, and finally three assessment techniques (free
association, transference, and dream analysis) could be used to understand the personalities of his patients and expose repressed
material.
The behavioral model concerns the cognitive process of learning, which is any relatively permanent change in behavior due to
experience and practice and has two main forms – associative learning to include classical and operant conditioning and
observational learning.
Respondent conditioning (also called classical or Pavlovian conditioning) occurs when we link a previously neutral stimulus
with a stimulus that is unlearned or inborn, called an unconditioned stimulus.
Operant conditioning is a type of associate learning which focuses on consequences that follow a response or behavior that we
make (anything we do, say, or think/feel) and whether it makes a behavior more or less likely to occur.
Observational learning is learning by watching others and modeling techniques change behavior by having subjects observe a
model in a situation that usually causes them some anxiety.
The cognitive model focuses on schemas, cognitive errors, attributions, and maladaptive cognitions and offers strategies such as
CBT, cognitive restructuring, cognitive coping skills training, and acceptance.
The humanistic perspective focuses on positive regard, conditions of worth, and the fully functioning person while the
existential perspective stresses the need for people to re-create themselves continually and be self-aware, acknowledges that
anxiety is a normal part of life, focuses on free will and self-determination, emphasizes that each person has a unique identity
known only through relationships and the search for meaning, and finally, that we develop to our maximum potential.

 Review Questions
1. What are the three parts of personality according to Freud?
2. What are the five psychosexual stages according to Freud?
3. List and define the ten defense mechanisms proposed by Freud.
4. What are the three assessment techniques used by Freud?
5. What is learning and what forms does it take?
6. Describe respondent conditioning.
7. Describe operant conditioning.
8. Describe observational learning and modeling.
9. How does the cognitive model approach psychopathology?
10. How does the humanistic perspective approach psychopathology?
11. How does the existential perspective approach psychopathology?

This page titled 2.3: Psychological Perspectives is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Alexis
Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is
available upon request.

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2.4: The Sociocultural Model
 Learning Objectives
Describe the sociocultural model.
Clarify how socioeconomic factors affect mental illness.
Clarify how gender factors affect mental illness.
Clarify how environmental factors affect mental illness.
Clarify how multicultural factors affect mental illness.
Evaluate the sociocultural model.

Outside of biological and psychological factors on mental illness, race, ethnicity, gender, religious orientation, socioeconomic
status, sexual orientation, etc. also play a role, and this is the basis of the sociocultural model. How so? We will explore a few of
these factors in this section.

Socioeconomic Factors
Low socioeconomic status has been linked to higher rates of mental and physical illness (Ng, Muntaner, Chung, & Eaton, 2014)
due to persistent concern over unemployment or under-employment, low wages, lack of health insurance, no savings, and the
inability to put food on the table, which then leads to feeling hopeless, helpless, and dependency on others. This situation places
considerable stress on an individual and can lead to higher rates of anxiety disorders and depression. Borderline personality
disorder has also been found to be higher in people in low-income brackets (Tomko et al., 2012) and group differences for
personality disorders have been found between African and European Americans (Ryder, Sunohara, and Kirmayer, 2015).

Gender Factors
Gender plays an important, though at times, unclear role in mental illness. Gender is not a cause of mental illness, though differing
demands placed on males and females by society and their culture can influence the development and course of a disorder.
Consider the following:
Rates of eating disorders are higher among women than men, though both genders are affected. In the case of men, muscle
dysphoria is of concern and is characterized by extreme concern over being more muscular.
OCD has an earlier age of onset in girls than boys, with most people being diagnosed by age 19.
Females are at higher risk for developing an anxiety disorder than men.
ADHD is more common in males than females, though females are more likely to have inattention issues.
Boys are more likely to be diagnosed with Autism Spectrum Disorder.
Depression occurs with greater frequency in women than men.
Women are more likely to develop PTSD compared to men.
Rates of SAD (Seasonal Affective Disorder) are four times greater in women than men. Interestingly, younger adults are more
likely to develop SAD than older adults.
Consider this…
In relation to men: “While mental illnesses affect both men and women, the prevalence of mental illnesses in men is often lower
than women. Men with mental illnesses are also less likely to have received mental health treatment than women in the past year.
However, men are more likely to die by suicide than women, according to the Centers for Disease Control and Prevention.
Recognizing the signs that you or someone you love may have a mental disorder is the first step toward getting treatment. The
earlier that treatment begins, the more effective it can be.”
https://www.nimh.nih.gov/health/topics/men-and-mental-health/index.shtml
In relation to women: “Some disorders are more common in women such as depression and anxiety. There are also certain types of
disorders that are unique to women. For example, some women may experience symptoms of mental disorders at times of hormone
change, such as perinatal depression, premenstrual dysphoric disorder, and perimenopause-related depression. When it comes to
other mental disorders such as schizophrenia and bipolar disorder, research has not found differences in the rates at which men and
women experience these illnesses. But women may experience these illnesses differently – certain symptoms may be more
common in women than in men, and the course of the illness can be affected by the sex of the individual. Researchers are only now

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beginning to tease apart the various biological and psychosocial factors that may impact the mental health of both women and
men.”
https://www.nimh.nih.gov/health/topics/women-and-mental-health/index.shtml

Environmental Factors
Environmental factors also play a role in the development of mental illness. How so?
In the case of borderline personality disorder, many people report experiencing traumatic life events such as abandonment,
abuse, unstable relationships or hostility, and adversity during childhood.
Cigarette smoking, alcohol use, and drug use during pregnancy are risk factors for ADHD.
Divorce or the death of a spouse can lead to anxiety disorders.
Trauma, stress, and other extreme stressors are predictive of depression.
Malnutrition before birth, exposure to viruses, and other psychosocial factors are potential causes of schizophrenia.
SAD occurs with greater frequency for those living far north or south from the equator (Melrose, 2015). Horowitz (2008) found
that rates of SAD are just 1% for those living in Florida while 9% of Alaskans are diagnosed with the disorder.
Source: https://www.nimh.nih.gov/health/topics/index.shtml

Multicultural Factors
Racial, ethnic, and cultural factors are also relevant to understanding the development and course of mental illness. Multicultural
psychologists assert that both normal behavior and abnormal behavior need to be understood in the context of the individual’s
unique culture and the group’s value system. Racial and ethnic minorities must contend with prejudice, discrimination, racism,
economic hardships, etc. as part of their daily life and this can lead to disordered behavior (Lo & Cheng, 2014; Jones, Cross, &
DeFour, 2007; Satcher, 2001), though some research suggests that ethnic identity can buffer against these stressors and protect
mental health (Mossakowski, 2003). To address this unique factor, culture-sensitive therapies have been developed and include
increasing the therapist’s awareness of cultural values, hardships, stressors, and/or prejudices faced by their client; the identification
of suppressed anger and pain; and raising the client’s self-worth (Prochaska & Norcross, 2013). These therapies have proven
efficacy for the treatment of depression (Kalibatseva & Leong, 2014) and schizophrenia (Naeem et al., 2015).

Evaluation of the Model

The sociocultural model has contributed significantly to our understanding of the nuances of mental illness diagnosis, prognosis,
course, and treatment for other races, cultures, genders, ethnicities. In Module 3, we will discuss diagnosing and classifying
abnormal behavior from the perspective of the DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, 5th edition,
Text-Revision). Important here is that specific culture- and gender-related diagnostic issues are discussed for each disorder,
demonstrating increased awareness of the impact of these factors. Still, the sociocultural model suffers from unclear findings and
not allowing for the establishment of causal relationships, reliance on more qualitative data gathered from case studies and
ethnographic analyses (one such example is Zafra, 2016), and an inability to make predictions about abnormal behavior for
individuals.

Key Takeaways
You should have learned the following in this section:
The sociocultural model asserts that race, ethnicity, gender, religious orientation, socioeconomic status, sexual orientation all
play a role in the development and treatment of mental illness.

 Review Questions
1. How do socioeconomic, gender, environmental, and multicultural factors affect mental illness and its treatment?
2. How effective is the sociocultural model at explaining psychopathology and its treatment?

Module Recap
In Module 2, we first distinguished uni- and multi-dimensional models of abnormality and made a case that the latter was better to
subscribe to. We then discussed biological, psychological, and sociocultural models of abnormality. In terms of the biological

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model, neurotransmitters, brain structures, hormones, genes, and viral infections were identified as potential causes of mental
illness and three treatment options were given. In terms of psychological perspectives, Freud’s psychodynamic theory; the learning-
related research of Watson, Skinner, and Bandura and Rotter; the cognitive model; and the humanistic and existential perspectives
were discussed. Finally, the sociocultural model indicated the role of socioeconomic, gender, environmental, and multicultural
factors on abnormal behavior.

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available upon request.

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 CHAPTER OVERVIEW

3: Clinical Assessment, Diagnosis, and Treatment

 Learning Objectives
Describe clinical assessment and methods used in it.
Clarify how mental health professionals diagnose mental disorders in a standardized way.
Discuss reasons to seek treatment and the importance of psychotherapy.

Module 3 covers the issues of clinical assessment, diagnosis, and treatment. We will define assessment and then describe key issues
such as reliability, validity, standardization, and specific methods that are used. In terms of clinical diagnosis, we will discuss the
two main classification systems used around the world – the DSM-5-TR and ICD-11. Finally, we discuss the reasons why people
may seek treatment and what to expect when doing so.
3.1: Clinical Assessment of Abnormal Behavior
3.2: Diagnosing and Classifying Abnormal Behavior
3.3: Treatment of Mental Disorders – An Overview

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edit history is available upon request.

1
3.1: Clinical Assessment of Abnormal Behavior
 Learning Objectives
Define clinical assessment.
Clarify why clinical assessment is an ongoing process.
Define and exemplify reliability.
Define and exemplify validity.
Define standardization.
List and describe seven methods of assessment.

What is Clinical Assessment?

For a mental health professional to be able to effectively help treat a client and know that the treatment selected worked (or is
working), they first must engage in the clinical assessment of the client, or collecting information and drawing conclusions
through the use of observation, psychological tests, neurological tests, and interviews to determine the person’s problem and the
presenting symptoms. This collection of information involves learning about the client’s skills, abilities, personality characteristics,
cognitive and emotional functioning, the social context in terms of environmental stressors that are faced, and cultural factors
particular to them such as their language or ethnicity. Clinical assessment is not just conducted at the beginning of the process of
seeking help but throughout the process. Why is that?
Consider this. First, we need to determine if a treatment is even needed. By having a clear accounting of the person’s symptoms
and how they affect daily functioning, we can decide to what extent the individual is adversely affected. Assuming a treatment is
needed, our second reason to engage in clinical assessment will be to determine what treatment will work best. As you will see later
in this module, there are numerous approaches to treatment. These include Behavior Therapy, Cognitive and Cognitive-Behavioral
Therapy (CBT), Humanistic-Experiential Therapies, Psychodynamic Therapies, Couples and Family Therapy, and biological
treatments (psychopharmacology). Of course, for any mental disorder, some of the aforementioned therapies will have greater
efficacy than others. Even if several can work well, it does not mean a particular therapy will work well for that specific client.
Assessment can help figure this out. Finally, we need to know if the treatment we employed worked. This will involve measuring
before any treatment is used and then measuring the behavior while the treatment is in place. We will even want to measure after
the treatment ends to make sure symptoms of the disorder do not return. Knowing what the person’s baselines are for different
aspects of psychological functioning will help us to see when improvement occurs.
In recap, obtaining the baselines happens in the beginning, implementing the treatment plan that is agreed upon happens more so in
the middle, and then making sure the treatment produces the desired outcome occurs at the end. It should be clear from this
discussion that clinical assessment is an ongoing process.

Key Concepts in Assessment

The assessment process involves three critical concepts – reliability, validity, and standardization. These three are important to
science in general. First, we want the assessment to be reliable or consistent. Outside of clinical assessment, when our car has an
issue and we take it to the mechanic, we want to make sure that what one mechanic says is wrong with our car is the same as what
another says, or even two others. If not, the measurement tools they use to assess cars are flawed. The same is true of a patient who
is suffering from a mental disorder. If one mental health professional says the person suffers from major depressive disorder and
another says the issue is borderline personality disorder, then there is an issue with the assessment tool being used. Ensuring that
two different raters are consistent in their assessment of patients is called interrater reliability. Another type of reliability occurs
when a person takes a test one day, and then the same test on another day. We would expect the person’s answers to be consistent,
which is called test-retest reliability. For example, let’s say the person takes the MMPI on Tuesday and then the same test on
Friday. Unless something miraculous or tragic happened over the two days in between tests, the scores on the MMPI should be
nearly identical to one another. What does identical mean? The score at test and the score at retest are correlated with one another.
If the test is reliable, the correlation should be very high (remember, a correlation goes from -1.00 to +1.00, and positive means as
one score goes up, so does the other, so the correlation for the two tests should be high on the positive side).
In addition to reliability, we want to make sure the test measures what it says it measures. This is called validity. Let’s say a new
test is developed to measure symptoms of depression. It is compared against an existing and proven test, such as the Beck

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Depression Inventory (BDI). If the new test measures depression, then the scores on it should be highly comparable to the ones
obtained by the BDI. This is called concurrent or descriptive validity. We might even ask if an assessment tool looks valid. If we
answer yes, then it has face validity, though it should be noted that this is not based on any statistical or evidence-based method of
assessing validity. An example would be a personality test that asks about how people behave in certain situations. Therefore, it
seems to measure personality, or we have an overall feeling that it measures what we expect it to measure.
Predictive validity is when a tool accurately predicts what will happen in the future. Let’s say we want to tell if a high school
student will do well in college. We might create a national exam to test needed skills and call it something like the Scholastic
Aptitude Test (SAT). We would have high school students take it by their senior year and then wait until they are in college for a
few years and see how they are doing. If they did well on the SAT, we would expect that at that point, they should be doing well in
college. If so, then the SAT accurately predicts college success. The same would be true of a test such as the Graduate Record
Exam (GRE) and its ability to predict graduate school performance.
Finally, we want to make sure that the experience one patient has when taking a test or being assessed is the same as another patient
taking the test the same day or on a different day, and with either the same tester or another tester. This is accomplished with the
use of clearly laid out rules, norms, and/or procedures, and is called standardization. Equally important is that mental health
professionals interpret the results of the testing in the same way, or otherwise, it will be unclear what the meaning of a specific
score is.

Methods of Assessment
So how do we assess patients in our care? We will discuss observation, psychological tests, neurological tests, the clinical
interview, and a few others in this section.
3.1.3.1. Observation. In Section 1.5.2.1 we talked about two types of observation – naturalistic, or observing the person or animal
in their environment, and laboratory, or observing the organism in a more controlled or artificial setting where the experimenter
can use sophisticated equipment and videotape the session to examine it later. One-way mirrors can also be used. A limitation of
this method is that the process of recording a behavior causes the behavior to change, called reactivity. Have you ever noticed
someone staring at you while you sat and ate your lunch? If you have, what did you do? Did you change your behavior? Did you
become self-conscious? Likely yes, and this is an example of reactivity. Another issue is that the behavior made in one situation
may not be made in other situations, such as your significant other only acting out at the football game and not at home. This form
of validity is called cross-sectional validity. We also need our raters to observe and record behavior in the same way or to have
high inter-rater reliability.
3.1.3.2. The clinical interview. A clinical interview is a face-to-face encounter between a mental health professional and a patient
in which the former observes the latter and gathers data about the person’s behavior, attitudes, current situation, personality, and life
history. The interview may be unstructured in which open-ended questions are asked, structured in which a specific set of
questions according to an interview schedule are asked, or semi-structured, in which there is a pre-set list of questions, but
clinicians can follow up on specific issues that catch their attention. A mental status examination is used to organize the
information collected during the interview and systematically evaluates the patient through a series of questions assessing
appearance and behavior. The latter includes grooming and body posture, thought processes and content to include disorganized
speech or thought and false beliefs, mood and affect such that whether the person feels hopeless or elated, intellectual functioning
to include speech and memory, and awareness of surroundings to include where the person is and what the day and time are. The
exam covers areas not normally part of the interview and allows the mental health professional to determine which areas need to be
examined further. The limitation of the interview is that it lacks reliability, especially in the case of the unstructured interview.
3.1.3.3. Psychological tests and inventories. Psychological tests assess the client’s personality, social skills, cognitive abilities,
emotions, behavioral responses, or interests. They can be administered either individually or to groups in paper or oral fashion.
Projective tests consist of simple ambiguous stimuli that can elicit an unlimited number of responses. They include the Rorschach
or inkblot test and the Thematic Apperception Test which asks the individual to write a complete story about each of 20 cards
shown to them and give details about what led up to the scene depicted, what the characters are thinking, what they are doing, and
what the outcome will be. From the response, the clinician gains perspective on the patient’s worries, needs, emotions, conflicts,
and the individual always connects with one of the people on the card. Another projective test is the sentence completion test and
asks individuals to finish an incomplete sentence. Examples include ‘My mother…’ or ‘I hope…’
Personality inventories ask clients to state whether each item in a long list of statements applies to them, and could ask about
feelings, behaviors, or beliefs. Examples include the MMPI or Minnesota Multiphasic Personality Inventory and the NEO-PI-R,

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which is a concise measure of the five major domains of personality – Neuroticism, Extroversion, Openness, Agreeableness, and
Conscientiousness. Six facets define each of the five domains, and the measure assesses emotional, interpersonal, experimental,
attitudinal, and motivational styles (Costa & McCrae, 1992). These inventories have the advantage of being easy to administer by
either a professional or the individual taking it, are standardized, objectively scored, and can be completed electronically or by
hand. That said, personality cannot be directly assessed, and so you do not ever completely know the individual.
3.1.3.4. Neurological tests. Neurological tests are used to diagnose cognitive impairments caused by brain damage due to tumors,
infections, or head injuries; or changes in brain activity. Positron Emission Tomography or PET is used to study the brain’s
chemistry. It begins by injecting the patient with a radionuclide that collects in the brain and then having them lie on a scanning
table while a ring-shaped machine is positioned over their head. Images are produced that yield information about the functioning
of the brain. Magnetic Resonance Imaging or MRI provides 3D images of the brain or other body structures using magnetic fields
and computers. It can detect brain and spinal cord tumors or nervous system disorders such as multiple sclerosis. Finally, computed
tomography or the CT scan involves taking X-rays of the brain at different angles and is used to diagnose brain damage caused by
head injuries or brain tumors.
3.1.3.5. Physical examination. Many mental health professionals recommend the patient see their family physician for a physical
examination, which is much like a check-up. Why is that? Some organic conditions, such as hyperthyroidism or hormonal
irregularities, manifest behavioral symptoms that are like mental disorders. Ruling out such conditions can save costly therapy or
surgery.
3.1.3.6. Behavioral assessment. Within the realm of behavior modification and applied behavior analysis, we talk about what is
called behavioral assessment, which is the measurement of a target behavior. The target behavior is whatever behavior we want
to change, and it can be in excess and needing to be reduced, or in a deficit state and needing to be increased. During the behavioral
assessment we learn about the ABCs of behavior in which Antecedents are the environmental events or stimuli that trigger a
behavior; Behaviors are what the person does, says, thinks/feels; and Consequences are the outcome of a behavior that either
encourages it to be made again in the future or discourages its future occurrence. Though we might try to change another person’s
behavior using behavior modification, we can also change our own behavior, which is called self-modification. The person does
their own measuring and recording of the ABCs, which is called self-monitoring. In the context of psychopathology, behavior
modification can be useful in treating phobias, reducing habit disorders, and ridding the person of maladaptive cognitions.
3.1.3.7. Intelligence tests. Intelligence testing determines the patient’s level of cognitive functioning and consists of a series of
tasks asking the patient to use both verbal and nonverbal skills. An example is the Stanford-Binet Intelligence test, which assesses
fluid reasoning, knowledge, quantitative reasoning, visual-spatial processing, and working memory. Intelligence tests have been
criticized for not predicting future behaviors such as achievement and reflecting social or cultural factors/biases and not actual
intelligence. Also, can we really assess intelligence through one dimension, or are there multiple dimensions?

Key Takeaways
You should have learned the following in this section:
Clinical assessment is the collecting of information and drawing conclusions through the use of observation, psychological
tests, neurological tests, and interviews.
Reliability refers to consistency in measurement and can take the form of interrater and test-retest reliability.
Validity is when we ensure the test measures what it says it measures and takes the forms of concurrent or descriptive, face, and
predictive validity.
Standardization is all the clearly laid out rules, norms, and/or procedures to ensure the experience each participant has is the
same.
Patients are assessed through observation, psychological tests, neurological tests, and the clinical interview, all with their own
strengths and limitations.

 Review Questions
1. What does it mean that clinical assessment is an ongoing process?
2. Define and exemplify reliability, validity, and standardization.
3. For each assessment method, define it and then state its strengths and limitations.

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This page titled 3.1: Clinical Assessment of Abnormal Behavior is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or
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3.2: Diagnosing and Classifying Abnormal Behavior
 Learning Objectives
Explain what it means to make a clinical diagnosis.
Define syndrome.
Clarify and exemplify what a classification system does.
Identify the two most used classification systems.
Outline the history of the DSM.
Identify and explain the elements of a diagnosis.
Outline the major disorder categories of the DSM-5-TR.
Describe the ICD-11.
Clarify why the DSM-5-TR and ICD-11 need to be harmonized.

Clinical Diagnosis and Classification Systems

Before starting any type of treatment, the client/patient must be clearly diagnosed with a mental disorder. Clinical diagnosis is the
process of using assessment data to determine if the pattern of symptoms the person presents with is consistent with the diagnostic
criteria for a specific mental disorder outlined in an established classification system such as the DSM-5-TR or ICD-11 (both will
be described shortly). Any diagnosis should have clinical utility, meaning it aids the mental health professional in determining
prognosis, the treatment plan, and possible outcomes of treatment (APA, 2022). Receiving a diagnosis does not necessarily mean
the person requires treatment. This decision is made based upon how severe the symptoms are, level of distress caused by the
symptoms, symptom salience such as expressing suicidal ideation, risks and benefits of treatment, disability, and other factors
(APA, 2022). Likewise, a patient may not meet the full criteria for a diagnosis but demonstrate a clear need for treatment or care,
nonetheless. As stated in the DSM, “The fact that some individuals do not show all symptoms indicative of a diagnosis should not
be used to justify limiting their access to appropriate care” (APA, 2022).
Symptoms that cluster together regularly are called a syndrome. If they also follow the same, predictable course, we say that they
are characteristic of a specific disorder. Classification systems provide mental health professionals with an agreed-upon list of
disorders falling into distinct categories for which there are clear descriptions and criteria for making a diagnosis. Distinct is the
keyword here. People suffering from delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal
motor behavior, and/or negative symptoms are different from people presenting with a primary clinical deficit in cognitive
functioning that is not developmental but acquired (i.e., they have shown a decline in cognitive functioning over time). The former
suffers from a schizophrenia spectrum disorder while the latter suffers from a neurocognitive disorder (NCD). The latter can be
further distinguished from neurodevelopmental disorders which manifest early in development and involve developmental deficits
that cause impairments in social, personal, academic, or occupational functioning (APA, 2022). These three disorder groups or
categories can be clearly distinguished from one another. Classification systems also permit the gathering of statistics to determine
incidence and prevalence rates and conform to the requirements of insurance companies for the payment of claims.
The most widely used classification system in the United States is the Diagnostic and Statistical Manual of Mental Disorders
(DSM) which is a “medical classification of disorders and as such serves as a historically determined cognitive schema imposed on
clinical and scientific information to increase its comprehensibility and utility. The classification of disorders (the way in which
disorders are grouped) provides a high-level organization for the manual” (APA, 2022, pg. 11). The DSM is currently in its 5th
edition Text-Revision (DSM-5-TR) and is produced by the American Psychiatric Association (APA, 2022). Alternatively, the
World Health Organization (WHO) publishes the International Statistical Classification of Diseases and Related Health Problems
(ICD) currently in its 11th edition. We will begin by discussing the DSM and then move to the ICD.

The DSM Classification System

3.2.2.1.A brief history of the DSM. The DSM-5 was published in 2013 and took the place of the DSM IV-TR (TR means Text
Revision; published in 2000). In March 2022, a Text-Revision was published for the DSM-5, making it the DSM-5-TR.
The history of the DSM goes back to 1952 when the American Psychiatric Association published the first edition of the DSM
which was “…the first official manual of mental disorders to contain a glossary of descriptions of the diagnostic categories” (APA,
2022, p. 5). The DSM evolved through four major editions after World War II into a diagnostic classification system to be used by

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psychiatrists and physicians, but also other mental health professionals. The Herculean task of revising the DSM began in 1999
when the APA embarked upon an evaluation of the strengths and weaknesses of the DSM in coordination with the World Health
Organization (WHO) Division of Mental Health, the World Psychiatric Association, and the National Institute of Mental Health
(NIMH). This collaboration resulted in the publication of a monograph in 2002 called A Research Agenda for DSM-V. From 2003
to 2008, the APA, WHO, NIMH, the National Institute on Drug Abuse (NIDA), and the National Institute on Alcoholism and
Alcohol Abuse (NIAAA) convened 13 international DSM-5 research planning conferences “to review the world literature in
specific diagnostic areas to prepare for revisions in developing both DSM-5 and the International Classification of Disease, 11th
Revision (ICD-11)” (APA, 2022, pg. 6).
After the naming of a DSM-5 Task Force Chair and Vice-Chair in 2006, task force members were selected and approved by 2007,
and workgroup members were approved in 2008. An intensive 6-year process of “conducting literature reviews and secondary
analyses, publishing research reports in scientific journals, developing draft diagnostic criteria, posting preliminary drafts on the
DSM-5 website for public comment, presenting preliminary findings at professional meetings, performing field trials, and
revisiting criteria and text” was undertaken (APA, 2022, pg. 7). The process involved physicians, psychologists, social workers,
epidemiologists, neuroscientists, nurses, counselors, and statisticians, all who aided in the development and testing of DSM-5 while
individuals with mental disorders, families of those with a mental disorder, consumer groups, lawyers, and advocacy groups
provided feedback on the mental disorders contained in the book. Additionally, disorders with low clinical utility and weak validity
were considered for deletion while “Conditions for Future Study” were placed in Section 3 and “contingent on the amount of
empirical evidence generated on the proposed diagnosis, diagnostic reliability or validity, presence of clear clinical need, and
potential benefit in advancing research” (APA, 2022, pg. 7).
3.2.2.2. The DSM-5 text revision process. In the spring 2019, APA started work on the Text-Revision for the DSM-5. This
involved more than 200 experts who were asked to conduct literature reviews of the past 10 years and to review the text to identify
any material that was out-of-date. Experts were divided into 20 disorder review groups, each with its own section editor. Four
cross-cutting review groups to include Culture, Sex and Gender, Suicide, and Forensic, reviewed each chapter and focused on
material involving their specific expertise. The text was also reviewed by an Ethnoracial Equity and Inclusion work group whose
task was to “ensure appropriate attention to risk factors such as racism and discrimination and the use of nonstigmatizing language”
(APA, 2022, pg. 11).
As such, the DSM-5-TR “is committed to the use of language that challenges the view that races are discrete and natural entities”
(APA, 2022, pg. 18). Some of changes include:
Use of racialized instead of racial to indicate the socially constructed nature of race
Ethnoracial is used to denote U.S. Census categories such as Hispanic, African American, or White
Latinx is used in place of Latino or Latina to promote gender-inclusive terminology
The term Caucasian is omitted since it is “based on obsolete and erroneous views about the geographic origin of a prototypical
pan-European ethnicity” (pg. 18)
To avoid perpetuating social hierarchies, the terms minority and non-White are avoided since they describe social groups in
relation to a racialized “majority”
The terms cultural contexts and cultural backgrounds are preferred to culture which is only used to refer to a “heterogeneity of
cultural views and practices within societies” (pg. 18)
The inclusion of data on specific ethnoracial groups only when “existing research documented reliable estimates based on
representative samples.” This led to limited inclusion of data on Native Americans since data from nonrepresentative samples
may be misleading.
The use of gender differences or “women and men” or “boys and girls” since much of the information on the expressions of
mental disorders in women and men is based on self-identified gender.
Inclusion of a new section for each diagnosis providing information about suicidal thoughts or behavior associated with that
diagnosis.
3.2.2.3. Elements of a diagnosis. The DSM-5-TR states that the following make up the key elements of a diagnosis (APA, 2022):
Diagnostic Criteria and Descriptors – Diagnostic criteria are the guidelines for making a diagnosis and should be informed by
clinical judgment. When the full criteria are met, mental health professionals can add severity and course specifiers to indicate
the patient’s current presentation. If the full criteria are not met, designators such as “other specified” or “unspecified” can be
used. If applicable, an indication of severity (mild, moderate, severe, or extreme), descriptive features, and course (type of

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 remission – partial or full – or recurrent) can be provided with the diagnosis. The final diagnosis is based on the clinical
interview, text descriptions, criteria, and clinical judgment.
Subtypes and Specifiers – Subtypes denote “mutually exclusive and jointly exhaustive phenomenological subgroupings within a
diagnosis” (APA, 2022, pg. 22). For example, non-rapid eye movement (NREM) sleep arousal disorders can have either a
sleepwalking or sleep terror type. Enuresis is nocturnal-only, diurnal-only, or both. Specifiers are not mutually exclusive or
jointly exhaustive and so more than one specifier can be given. For instance, binge eating disorder has remission and severity
specifiers. Somatic symptom disorder has a specifier for severity, if with predominant pain, and/or if persistent. Again, the
fundamental distinction between subtypes and specifiers is that there can be only one subtype but multiple specifiers. As the
DSM-5-TR says, “Specifiers and subtypes provide an opportunity to define a more homogeneous subgrouping of individuals
with the disorder who share certain features… and to convey information that is relevant to the management of the individual’s
disorder” (pg. 22).
Principle Diagnosis – A principal diagnosis is used when more than one diagnosis is given for an individual. It is the reason for
the admission in an inpatient setting or the basis for a visit resulting in ambulatory care medical services in outpatient settings.
The principal diagnosis is generally the focus of attention or treatment.
Provisional Diagnosis – If not enough information is available for a mental health professional to make a definitive diagnosis,
but there is a strong presumption that the full criteria will be met with additional information or time, then the provisional
specifier can be used.
3.2.2.4. DSM-5 disorder categories. The DSM-5 includes the following categories of disorders:
Table 3.1. DSM-5 Classification System of Mental Disorders
Disorder Category Short Description Module

A group of conditions that arise in the

developmental period and include intellectual
Neurodevelopmental disorders disability, communication disorders, autism Not covered
spectrum disorder, specific learning disorder,
motor disorders, and ADHD

Disorders characterized by one or more of the

following: delusions, hallucinations,
Schizophrenia Spectrum disorganized thinking and speech, 12
disorganized motor behavior, and negative
symptoms

Characterized by mania or hypomania and

Bipolar and Related possibly depressed mood; includes Bipolar I 4
and II and cyclothymic disorder

Characterized by sad, empty, or irritable mood,

as well as somatic and cognitive changes that
affect functioning; includes major depressive,
Depressive 4
persistent depressive disorder, mood
dysregulation disorder, and premenstrual
dysphoric disorder

Characterized by excessive fear and anxiety

and related behavioral disturbances; Includes
Anxiety phobias, separation anxiety, panic disorder, 7
generalized anxiety disorder, social anxiety
disorder, agoraphobia

Characterized by obsessions and compulsions

and includes OCD, hoarding, body
Obsessive-Compulsive 9
dysmorphic disorder, trichotillomania, and
excoriation

Characterized by exposure to a traumatic or

stressful event; PTSD, acute stress disorder,
Trauma- and Stressor- Related 5
adjustment disorders, and prolonged grief
disorder

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 Characterized by a disruption or discontinuity
in memory, identity, emotion, perception, body
representation, consciousness, motor control,
Dissociative 6
or behavior; dissociative identity disorder,
dissociative amnesia, and
depersonalization/derealization disorder

Characterized by prominent somatic

symptoms and/or illness anxiety associated
Somatic Symptom with significant distress and impairment; 8
includes illness anxiety disorder, somatic
symptom disorder, and conversion disorder

Characterized by a persistent disturbance of

eating or eating-related behavior to include
bingeing and purging; Includes pica,
Feeding and Eating 10
rumination disorder, avoidant/restrictive food
intake disorder, anorexia, bulimia, and binge-
eating disorder

Characterized by the inappropriate elimination

of urine or feces; usually first diagnosed in
Elimination Not covered
childhood or adolescence; Includes enuresis
and encopresis

Characterized by sleep-wake complaints about

the quality, timing, and amount of sleep;
includes insomnia, sleep terrors, narcolepsy,
Sleep-Wake Not covered
sleep apnea, hypersomnolence disorder,
restless leg syndrome, and circadian-rhythm
sleep-wake disorders

Characterized by sexual difficulties and

include premature or delayed ejaculation,
Sexual Dysfunctions Not covered
female orgasmic disorder, and erectile disorder
(to name a few)

Characterized by distress associated with the

incongruity between one’s experienced or
Gender Dysphoria Not covered
expressed gender and the gender assigned at
birth

Characterized by problems in the self-control

of emotions and behavior and involve the
violation of the rights of others and cause the
individual to violate societal norms; includes
Disruptive, Impulse-Control, Conduct Not covered
oppositional defiant disorder, antisocial
personality disorder, kleptomania, intermittent
explosive disorder, conduct disorder, and
pyromania

Characterized by the continued use of a

Substance-Related and Addictive substance despite significant problems related 11
to its use

Characterized by a decline in cognitive

functioning over time and the NCD has not
been present since birth or early in life;
Neurocognitive 14
Includes delirium, major and mild
neurocognitive disorder, and Alzheimer’s
disease

3.2.4 https://socialsci.libretexts.org/@go/page/161412
 Characterized by a pattern of stable traits
which are inflexible, pervasive, and leads to
distress or impairment; Includes paranoid,
Personality 13
schizoid, borderline, obsessive-compulsive,
narcissistic, histrionic, dependent, schizotypal,
antisocial, and avoidant personality disorder

Characterized by recurrent and intense sexual

fantasies that can cause harm to the individual
Paraphilic or others; includes exhibitionism, voyeurism, Not covered
sexual sadism, sexual masochism, pedophilic,
and fetishistic disorders

The ICD-11
In 1893, the International Statistical Institute adopted the International List of Causes of Death which was the first international
classification edition. The World Health Organization was entrusted with the development of the ICD in 1948 and published the 6th
version (ICD-6). The ICD-11 went into effect January 1, 2022, though it was adopted in May 2019. The WHO states:
ICD serves a broad range of uses globally and provides critical knowledge on the extent, causes and consequences of human
disease and death worldwide via data that is reported and coded with the ICD. Clinical terms coded with ICD are the main basis for
health recording and statistics on disease in primary, secondary and tertiary care, as well as on cause of death certificates. These
data and statistics support payment systems, service planning, administration of quality and safety, and health services research.
Diagnostic guidance linked to categories of ICD also standardizes data collection and enables large scale research.
As a classification system, it “allows the systematic recording, analysis, interpretation and comparison of mortality and morbidity
data collected in different countries or regions and at different times.” As well, it “ensures semantic interoperability and reusability
of recorded data for the different use cases beyond mere health statistics, including decision support, resource allocation,
reimbursement, guidelines and more.”
Source: www.who.int/classifications/icd/en/
The ICD lists many types of diseases and disorders to include Chapter 06: Mental, Behavioral, or Neurodevelopmental Disorders.
The list of mental disorders is broken down as follows:
Neurodevelopmental disorders
Schizophrenia or other primary psychotic disorders
Catatonia
Mood disorders
Anxiety or fear-related disorders
Obsessive-compulsive or related disorders
Disorders specifically associated with stress
Dissociative disorders
Feeding or eating disorders
Elimination disorders
Disorders of bodily distress or bodily experience
Disorders due to substance use or addictive behaviours
Impulse control disorders
Disruptive behaviour or dissocial disorders
Personality disorders and related traits
Paraphilic disorders
Factitious disorders
Neurocognitive disorders
Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium
It should be noted that Sleep-Wake Disorders are listed in Chapter 07.
To access Chapter 06 of the ICD-11, please visit the following:

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https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f334423054

Harmonization of DSM-5-TR and ICD-11

According to the DSM-5-TR, there is an effort to harmonize the two classification systems: 1) for a more accurate collection of
national health statistics and design of clinical trials aimed at developing new treatments, 2) to increase the ability to replicate
scientific findings across national boundaries, and 3) to rectify the issue of DSM-IV and ICD-10 diagnoses not agreeing (APA,
2022, pg. 13). Complete harmonization of the DSM-5 diagnostic criteria with the ICD-11 disorder definitions has not occurred due
to differences in timing. The DSM-5 developmental effort was several years ahead of the ICD-11 revision process. Despite this,
some improvement in harmonization did occur as many ICD-11 working group members had participated in the development of
the DSM-5 diagnostic criteria and all ICD-11 work groups were given instructions to review the DSM-5 criteria sets and make
them as similar as possible (unless there was a legitimate reason not to). This has led to the ICD and DSM being closer than at any
time since DSM-II and ICD-8 (APA, 2022).

Key Takeaways
You should have learned the following in this section:
Clinical diagnosis is the process of using assessment data to determine if the pattern of symptoms the person presents with is
consistent with the diagnostic criteria for a specific mental disorder outlined in an established classification system such as the
DSM-5-TR or ICD-11.
Classification systems provide mental health professionals with an agreed-upon list of disorders falling into distinct categories
for which there are clear descriptions and criteria for making a diagnosis.
Elements of a diagnosis in the DSM include the diagnostic criteria and descriptors, subtypes and specifiers, the principle
diagnosis, and a provisional diagnosis.

 Review Questions
1. What is clinical diagnosis?
2. What is a classification system and what are the two main ones used today?
3. Outline the diagnostic categories used in the DSM-5-TR.

This page titled 3.2: Diagnosing and Classifying Abnormal Behavior is shared under a CC BY-NC-SA 4.0 license and was authored, remixed,
and/or curated by Alexis Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a
detailed edit history is available upon request.

3.2.6 https://socialsci.libretexts.org/@go/page/161412
3.3: Treatment of Mental Disorders – An Overview
 Learning Objectives
Clarify reasons why an individual may need to seek treatment.
Critique myths about psychotherapy.

Seeking Treatment
3.3.1.1. Who seeks treatment? Would you describe the people who seek treatment as being on the brink, crazy, or desperate? Or
can the ordinary Joe in need of advice seek out mental health counseling? The answer is that anyone can. David Sack, M.D. (2013)
writes in the article 5 Signs Its Time to Seek Therapy, published in Psychology Today, that “most people can benefit from therapy at
least some point in their lives,” and though the signs you need to seek help are obvious at times, we often try “to sustain [our] busy
life until it sets in that life has become unmanageable.” So, when should we seek help? First, if we feel sad, angry, or not like
ourselves. We might be withdrawing from friends and families or sleeping more or less than we usually do. Second, if we are
abusing drugs, alcohol, food, or sex to deal with life’s problems. In this case, our coping skills may need some work. Third, in
instances when we have lost a loved one or something else important to us, whether due to death or divorce, the grief may be too
much to process. Fourth, a traumatic event may have occurred, such as abuse, a crime, an accident, chronic illness, or rape. Finally,
if you have stopped doing the things you enjoy the most. Sack (2013) says, “If you decide that therapy is worth a try, it doesn’t
mean you’re in for a lifetime of head shrinking.” A 2001 study in the Journal of Counseling Psychology found that most people
feel better within seven to 10 visits. In another study, published in 2006 in the Journal of Consulting and Clinical Psychology, 88%
of therapy-goers reported improvements after just one session.”
For more on this article, please visit:
https://www.psychologytoday.com/blog/where-science-meets-the-steps/201303/5-signs-its-time-seek-therapy
3.3.1.2. When friends, family, and self-healing are not enough. If you are experiencing any of the aforementioned issues, you
should seek help. Instead of facing the potential stigma of talking to a mental health professional, many people think that talking
through their problems with friends or family is just as good. Though you will ultimately need these people to see you through your
recovery, they do not have the training and years of experience that a psychologist or similar professional has. “Psychologists can
recognize behavior or thought patterns objectively, more so than those closest to you who may have stopped noticing — or maybe
never noticed. A psychologist might offer remarks or observations similar to those in your existing relationships, but their help may
be more effective due to their timing, focus, or your trust in their neutral stance” (www.apa.org/helpcenter/psychotherapy-
myths.aspx). You also should not wait to recover on your own. It is not a failure to admit you need help, and there could be a
biological issue that makes it almost impossible to heal yourself.
3.3.1.3. What exactly is psychotherapy? According to the APA, in psychotherapy “psychologists apply scientifically validated
procedures to help people develop healthier, more effective habits.” Several different approaches can be utilized to include
behavior, cognitive and cognitive-behavior, humanistic-experiential, psychodynamic, couples and family, and biological treatments.
3.3.1.4. The client-therapist relationship. What is the ideal client-therapist relationship? APA says, “Psychotherapy is a
collaborative treatment based on the relationship between an individual and a psychologist. Grounded in dialogue, it provides a
supportive environment that allows you to talk openly with someone who’s objective, neutral and nonjudgmental. You and your
psychologist will work together to identify and change the thought and behavior patterns that are keeping you from feeling your
best.” It’s not just about solving the problem you saw the therapist for, but also about learning new skills to help you cope better in
the future when faced with the same or similar environmental stressors.
So how do you find a psychotherapist? Several strategies may prove fruitful. You could ask family and friends, your primary care
physician (PCP), look online, consult an area community mental health center, your local university’s psychology department, state
psychological association, or use APA’s Psychologist Locator Service (locator.apa.org/?
_ga=2.160567293.1305482682.1516057794-1001575750.1501611950). Once you find a list of psychologists or other practitioners,
choose the right one for you by determining if you plan on attending alone or with family, what you wish to get out of your time
with a psychotherapist, how much your insurance company pays for and if you have to pay out of pocket how much you can afford,
when you can attend sessions, and how far you are willing to travel to see the mental health professional. Once you have done this,
make your first appointment.

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But what should you bring? APA suggests, “to make the most of your time, make a list of the points you want to cover in your first
session and what you want to work on in psychotherapy. Be prepared to share information about what’s bringing you to the
psychologist. Even a vague idea of what you want to accomplish can help you and your psychologist proceed efficiently and
effectively.” Additionally, they suggest taking report cards, a list of medications, information on the reasons for a referral, a
notebook, a calendar to schedule future visits if needed, and a form of payment. What you take depends on the reason for the visit.
In terms of what you should expect, you and your therapist will work to develop a full history which could take several visits. From
this, a treatment plan will be developed. “This collaborative goal-setting is important, because both of you need to be invested in
achieving your goals. Your psychologist may write down the goals and read them back to you, so you’re both clear about what
you’ll be working on. Some psychologists even create a treatment contract that lays out the purpose of treatment, its expected
duration and goals, with both the individual’s and psychologist’s responsibilities outlined.”
After the initial visit, the mental health professional may conduct tests to further understand your condition but will continue
talking through the issue. He/she may even suggest involving others, especially in cases of relationship issues. Resilience is a skill
that will be taught so that you can better handle future situations.
3.3.1.5. Does it work? APA writes, “Reviews of these studies show that about 75 percent of people who enter psychotherapy show
some benefit. Other reviews have found that the average person who engages in psychotherapy is better off by the end of treatment
than 80 percent of those who don’t receive treatment at all.” Treatment works due to finding evidence-based treatment that is
specific for the person’s problem; the expertise of the therapist; and the characteristics, values, culture, preferences, and personality
of the client.
3.3.1.6. How do you know you are finished? “How long psychotherapy takes depends on several factors: the type of problem or
disorder, the patient’s characteristics and history, the patient’s goals, what’s going on in the patient’s life outside psychotherapy and
how fast the patient is able to make progress.” It is important to note that psychotherapy is not a lifelong commitment, and it is a
joint decision of client and therapist as to when it ends. Once over, expect to have a periodic check-up with your therapist. This
might be weeks or even months after your last session. If you need to see him/her sooner, schedule an appointment. APA calls this
a “mental health tune up” or a “booster session.”
For more on psychotherapy, please see the very interesting APA article on this matter:
www.apa.org/helpcenter/understanding-psychotherapy.aspx

Key Takeaways
You should have learned the following in this section:
Anyone can seek treatment and we all can benefit from it at some point in our lives.
Psychotherapy is when psychologists apply scientifically validated procedures to help a person feel better and develop healthy
habits.

 Review Questions
1. When should you seek help?
2. Why should you seek professional help over the advice dispensed by family and friends?
3. How do you find a therapist and what should you bring to your appointment?
4. Does psychotherapy work?

Module Recap
That’s it. With the conclusion of Module 3, you now have the necessary foundation to understand each of the groups of disorders
we discuss beginning in Module 4 and through Module 14.
In Module 3 we reviewed clinical assessment, diagnosis, and treatment. In terms of assessment, we covered key concepts such as
reliability, validity, and standardization; and discussed methods of assessment such as observation, the clinical interview,
psychological tests, personality inventories, neurological tests, the physical examination, behavioral assessment, and intelligence
tests. In terms of diagnosis, we discussed the classification systems of the DSM-5-TR and ICD-11. For treatment, we discussed the
reasons why someone may seek treatment, self-treatment, psychotherapy, the client-centered relationship, and how well
psychotherapy works.

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This page titled 3.3: Treatment of Mental Disorders – An Overview is shared under a CC BY-NC-SA 4.0 license and was authored, remixed,
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 SECTION OVERVIEW

Part II. Mental Disorders – Block 1

4: Mood Disorders
4.1: Clinical Presentation – Depressive Disorders
4.2: Clinical Presentation – Bipolar and Related Disorders
4.3: Mood Disorders - Epidemiology
4.4: Mood Disorders - Comorbidity
4.5: Mood Disorders - Etiology
4.6: Mood Disorders - Treatment

5: Trauma- and Stressor-Related Disorders

5.1: Trauma- and Stressor-Related Disorders - Stressors
5.2: Trauma- and Stressor-Related Disorders - Clinical Presentation
5.3: Trauma- and Stressor-Related Disorders - Epidemiology
5.4: Trauma- and Stressor-Related Disorders - Comorbidity
5.5: Trauma- and Stressor-Related Disorders - Etiology
5.6: Trauma- and Stressor-Related Disorders - Treatment

6: Dissociative Disorders
6.1: Dissociative Disorders - Clinical Presentation
6.2: Dissociative Disorders - Epidemiology
6.3: Dissociative Disorders - Comorbidity
6.4: Dissociative Disorders - Etiology
6.5: Dissociative Disorders - Treatment

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history is available upon request.

1
 CHAPTER OVERVIEW

4: Mood Disorders
 Learning Objectives
Describe how depressive disorders present.
Describe how bipolar and related disorders present.
Describe the epidemiology of mood disorders.
Describe comorbidity in relation to mood disorders.
Describe the etiology of mood disorders.
Describe treatment options for mood disorders.

In Module 4, we will discuss matters related to mood disorders to include their clinical presentation, epidemiology, comorbidity,
etiology, and treatment options. Our discussion will cover major depressive disorder, persistent depressive disorder (formerly
Dysthymia), bipolar I disorder, bipolar II disorder, and cyclothymic disorder. We will also cover major depressive, manic, and
hypomanic episodes. Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an overview of the various models
to explain psychopathology (Module 2), and descriptions of several therapies (Module 3). Note that this module will cover two
chapters from the DSM 5-TR; namely, Bipolar and Related Disorders and Depressive Disorders.
4.1: Clinical Presentation – Depressive Disorders
4.2: Clinical Presentation – Bipolar and Related Disorders
4.3: Mood Disorders - Epidemiology
4.4: Mood Disorders - Comorbidity
4.5: Mood Disorders - Etiology
4.6: Mood Disorders - Treatment

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Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon
request.

1
4.1: Clinical Presentation – Depressive Disorders
 Learning Objectives
Distinguish the two distinct groups of mood disorders.
Identify and describe the two types of depressive disorders.
Classify symptoms of depression.
Describe premenstrual dysphoric disorder.

Distinguishing Mood Disorders

Within mood disorders are two distinct groups—individuals with depressive disorders and individuals with bipolar disorders. The
key difference between the two mood disorder groups is episodes of mania/hypomania. More specifically, in bipolar I disorder,
the individual experiences a manic episode that “may have been preceded by and may be followed by hypomanic or major
depressive episodes” (APA, 2022, pg. 139) whereas for bipolar II disorder, the individual has experienced in the past or is currently
experiencing a hypomanic episode and has experienced in the past or is currently experiencing a major depressive episode. In
contrast, individuals presenting with a depressive disorder have never experienced a manic or hypomanic episode.

Types of Depressive Disorders

The two most common types of depressive disorders are major depressive disorder (MDD) and persistent depressive disorder
(PDD). Persistent depressive disorder, which in the DSM-5 now includes the diagnostic categories of dysthymia and chronic
major depression, is a continuous and chronic form of depression. While the symptoms of PDD are very similar to MDD, they are
usually less acute, as symptoms tend to ebb and flow over a long period (i.e., more than two years). Major depressive disorder, on
the other hand, has discrete episodes lasting at least two weeks in which there are substantial changes in affect, cognition, and
neurovegetative functions (APA, 2022, pg. 177).
It should be noted that after a careful review of the literature, premenstrual dysphoric disorder, was moved from “Criteria Sets
and Axes Provided for Future Study” in the DSM-IV to Section II of DSM-5 as the disorder was confirmed as a “specific and
treatment-responsive form of depressive disorder that begins sometime following ovulation and remits within a few days of menses
and has a marked impact on functioning” (APA, 2022, pg. 177).
The DSM-5 also added a new diagnosis, disruptive mood dysregulation disorder (DMDD), for children up to 12 years of age, to
deal with the potential for overdiagnosis and treatment of bipolar disorder in children, both in the United States and internationally.
Children with DMDD present with persistent irritability and frequent episodes of extreme behavioral dyscontrol and so develop
unipolar, not bipolar, depressive disorders or anxiety disorders as they move into adolescence and adulthood.
For a discussion of DMDD, please visit our sister book, Behavioral Disorders of Childhood:
https://opentext.wsu.edu/behavioral-disorders-childhood/

Symptoms Associated with Depressive Disorders

When making a diagnosis of depression, there are a wide range of symptoms that may be present. These symptoms can generally
be grouped into four categories: mood, behavioral, cognitive, and physical symptoms.
4.1.3.1. Mood. While clinical depression can vary in its presentation among individuals, most, if not all individuals with depression
will report significant mood disturbances such as a depressed mood for most of the day and/or feelings of anhedonia, which is the
loss of interest in previously interesting activities.
4.1.3.2. Behavioral. Behavioral issues such as decreased physical activity and reduced productivity—both at home and work—are
often observed in individuals with depression. This is typically where a disruption in daily functioning occurs as individuals with
depressive disorders are unable to maintain their social interactions and employment responsibilities.
4.1.3.3. Cognitive. It should not come as a surprise that there is a serious disruption in cognitions as individuals with depressive
disorders typically hold a negative view of themselves and the world around them. They are quick to blame themselves when
things go wrong, and rarely take credit when they experience positive achievements. Individuals with depressive disorders often
feel worthless, which creates a negative feedback loop by reinforcing their overall depressed mood. They also report difficulty
concentrating on tasks, as they are easily distracted from outside stimuli. This assertion is supported by research that has found

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individuals with depression perform worse than those without depression on tasks of memory, attention, and reasoning (Chen et al.,
2013). Finally, thoughts of suicide and self-harm do occasionally occur in those with depressive disorders (Note – this will be
discussed in more detail in Section 4.3).
4.1.3.4. Physical. Changes in sleep patterns are common in those experiencing depression with reports of both hypersomnia and
insomnia. Hypersomnia, or excessive sleeping, often impacts an individual’s daily functioning as they spend the majority of their
time sleeping as opposed to participating in daily activities (i.e., meeting up with friends or getting to work on time). Reports of
insomnia are also frequent and can occur at various points throughout the night to include difficulty falling asleep, staying asleep,
or waking too early with the inability to fall back asleep before having to wake for the day. Although it is unclear whether
symptoms of fatigue or loss of energy are related to insomnia issues, the fact that those experiencing hypersomnia also report
symptoms of fatigue suggests that these symptoms are a component of the disorder rather than a secondary symptom of sleep
disturbance.
Additional physical symptoms, such as a change in weight or eating behaviors, are also observed. Some individuals who are
experiencing depression report a lack of appetite, often forcing themselves to eat something during the day. On the contrary, others
overeat, often seeking “comfort foods,” such as those high in carbohydrates. Due to these changes in eating behaviors, there may be
associated changes in weight.
Finally, psychomotor agitation or retardation, which is the purposeless or slowed physical movement of the body (i.e., pacing
around a room, tapping toes, restlessness, etc.) is also reported in individuals with depressive disorders.

Diagnostic Criteria and Features for Depressive Disorders

4.1.4.1. Major depressive disorder (MDD). According to the DSM-5-TR (APA, 2022), to meet the criteria for a diagnosis of
major depressive disorder, an individual must experience at least five symptoms across the four categories discussed above, and at
least one of the symptoms is either 1) a depressed mood most of the day, almost every day, or 2) loss of interest or pleasure in all,
or most, activities, most of the day, almost every day. These symptoms must be present for at least two weeks and cause clinically
significant distress or impairment in important areas of functioning such as social and occupational. The DSM-5 cautions that
responses to a significant loss (such as the death of a loved one, financial ruin, and discovery of a serious medical illness or
disability), can lead to many of the symptoms described above (i.e., intense sadness, rumination about the loss, insomnia, etc.) but
this may be the normal response to such a loss. Though the individual’s response resembles a major depressive episode, clinical
judgment should be utilized in making any diagnosis and be based on the clinician’s understanding of the individual’s personal
history and cultural norms related to how members should express distress in the context of loss.
4.1.4.2. Persistent depressive disorder (PDD). For a diagnosis of persistent depressive disorder, an individual must experience a
depressed mood for most of the day, for more days than not, for at least two years. (APA, 2022). This feeling of a depressed mood
is also accompanied by two or more additional symptoms, to include changes in appetite, insomnia or hypersomnia, low energy or
fatigue, low self-esteem, feelings of hopelessness, and poor concentration or difficulty with decision making. The symptoms taken
together cause clinically significant distress or impairment in important areas of functioning such as social and occupational and
these impacts can be as great as or greater than MDD. The individual may experience a temporary relief of symptoms; however, the
individual will not be without symptoms for more than two months during this two-year period.
Making Sense of the Disorders
In relation to depressive disorders, note the following:
Diagnosis MDD …… if symptoms have been experienced for at least two weeks and can be regarded as severe
Diagnosis PDD … if the symptoms have been experienced for at least two years and are not severe
4.1.4.3. Premenstrual dysphoric disorder. In terms of premenstrual dysphoric disorder, the DSM-5-TR states in the majority of
menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, being improving with a few
days after menses begins, and disappear or become negligible in the week postmenses. Individuals diagnosed with premenstrual
dysphoric disorder must have one or more of the following: increased mood swings, irritability or anger, depressed mood, or
anxiety/tension. Additionally, they must have one or more of the following to reach a total of five symptoms: anhedonia, difficulty
concentrating, lethargy, changes in appetite, hypersomnia or insomnia, feelings of being overwhelmed or out of control, and/or
experience breast tenderness or swelling. The symptoms lead to issues at work or school (i.e., decreased productivity and
efficiency), within relationships (i.e., discord in the intimate partner relationship or with children, friends, or other family
members), and with usual social activities (i.e., avoidance of the activities).

4.1.2 https://socialsci.libretexts.org/@go/page/161365
Key Takeaways
You should have learned the following in this section:
Mood disorder fall into one of two groups – depressive or bipolar disorders – with the key distinction between the two being
episodes of mania/hypomania.
Symptoms of depression fall into one of four categories – mood, behavioral, cognitive, and physical.
Persistent Depressive Disorder shares symptoms with Major Depressive Disorder though they are usually not as severe and ebb
and flow over a period of at least two years.
Premenstrual dysphoric disorder presents as mood lability, irritability, dysphoria, and anxiety symptoms occurring often during
the premenstrual phase of the cycle and remit around the beginning of menses or shortly thereafter.

 Review Questions
1. What are the different categories of mood disorder symptoms? Identify the symptoms within each category.
2. What are the key differences in a major depression and a persistent depressive disorder diagnosis?
3. What is premenstrual dysphoric disorder?

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curated by Alexis Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed
edit history is available upon request.

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4.2: Clinical Presentation – Bipolar and Related Disorders
 Learning Objectives
Distinguish the forms bipolar disorder takes.
Contrast a manic episode with a hypomanic episode.
Define cyclothymic disorder.

Distinguishing Bipolar I and II Disorders

According to the DSM-5-TR (APA, 2022), there are two types of bipolar disorder- bipolar I and bipolar II. A diagnosis of bipolar I
disorder is made when there is at least one manic episode. This manic episode can be preceded by and/or followed by a hypomanic
or major depressive episode, however, diagnostic criteria for a manic episode is the only criteria that needs to be met for a bipolar I
diagnosis. A diagnosis of bipolar II Disorder is made when there is a current or history of a hypomanic episode and a current or
past major depressive episode. Descriptions of both manic and hypomanic episodes follow below.
Making Sense of the Disorders
In relation to bipoloar I and II disorders, note the following:
Diagnosis bipolar I disorder …. if an individual has ever experienced a manic episode
Diagnosis bipolar II disorder … if the criteria has only been met for a hypomanic episode

Manic and Hypomanic Episodes

4.2.2.1. Manic episode. The key feature of a manic episode is a specific period in which an individual reports abnormal,
persistent, or expansive irritable mood for nearly all day, every day, for at least one week (APA, 2022). Additionally, the individual
will display increased activity or energy during this same time. With regards to mood, an individual in a manic episode will appear
excessively happy, often engaging haphazardly in sexual or interpersonal interactions. They also display rapid shifts in mood, also
known as mood lability, ranging from happy, neutral, to irritable. At least three of the symptoms described below (four if the mood
is only irritable) must be present and represent a noticeable change in the individual’s typical behavior.
Inflated self-esteem or grandiosity (Criterion B1) is present during a manic episode. Occasionally these inflated self-esteem levels
can appear delusional. For example, individuals may believe they are friends with a celebrity, do not need to abide by laws, or even
perceive themselves as God. They also engage in multiple overlapping new projects (Criteria B6 and 7), often initiated with no
prior knowledge about the topic, and engaged in at unusual hours of the day.
Despite the increased activity level, individuals experiencing a manic episode also require a decreased need for sleep (Criterion
B2), sleeping as little as a few hours a night yet still feeling rested. Reduced need for sleep may also be a precursor to a manic
episode, suggesting that a manic episode is to begin imminently. It is not uncommon for those experiencing a manic episode to be
more talkative than usual. It can be difficult to follow their conversation due to the quick pace of their talking, as well as tangential
storytelling. Additionally, they can be difficult to interrupt in conversation, often disregarding the reciprocal nature of
communication (Criterion B3). If the individual is more irritable than expansive, speech can become hostile and they engage in
tirades, particularly if they are interrupted or not allowed to engage in an activity they are seeking out (APA, 2022).
Based on their speech pattern, it should not be a surprise that racing thoughts and flights of ideas (Criterion B4) also present during
manic episodes. Because of these rapid thoughts, speech may become disorganized or incoherent. Finally, individuals experiencing
a manic episode are distractable (Criterion B5).
4.2.2.2. Hypomanic episode. As mentioned above, for a bipolar II diagnosis, an individual must report symptoms consistent with a
major depressive episode and at least one hypomanic episode. An individual with bipolar II disorder must not have a history of a
manic episode—if there is a history of mania, the diagnosis will be diagnosed with bipolar I. A hypomanic episode is like a manic
episode in that the individual will experience abnormally and persistently elevated, expansive, or irritable mood and energy levels,
however, the behaviors are not as extreme as in mania. Additionally, behaviors consistent with a hypomanic episode must be
present for at least four days, compared to the one week in a manic episode.
Making Sense of the Disorders
Take note of the following in relation to manic and hypomanic episodes:

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 A manic episode is severe enough to cause impairments in social or occupational functioning and can lead to hospitalization to
prevent harm to self or others.
A hypomanic episode is NOT severe enough to cause such impairments or hospitalization.

Cyclothymic Disorder
Notably, there is a subclass of individuals who experience numerous periods with hypomanic symptoms that do not meet the
criteria for a hypomanic episode and mild depressive symptoms (i.e., do not fully meet criteria for a major depressive episode).
These individuals are diagnosed with cyclothymic disorder (APA, 2022). Presentation of these symptoms occur for two or more
years and are typically interrupted by periods of normal mood not lasting more than two months at a time. The symptoms cause
clinically significant distress or impairment in important areas of functioning, such as social and occupational. While only a small
percentage of the population develops cyclothymic disorder, it can eventually progress into bipolar I or bipolar II disorder (Zeschel
et al., 2015).

Key Takeaways
You should have learned the following in this section:
An individual is diagnosed with bipolar I disorder if they have ever experienced a manic episode and are diagnosed with bipolar
II disorder if the criteria has only been met for a hypomanic episode.
A manic episode is characterized by a specific period in which an individual reports abnormal, persistent, or expansive irritable
mood for nearly all day, every day, for at least one week.
A hypomanic episode is characterized by abnormally and persistently elevated, expansive, or irritable mood and energy levels,
though not as extreme as in mania, and must be present for at least four days. It is also not severe enough to cause impairments
or hospitalization.
Cyclothymic disorder includes periods of hypomanic and mild depressive symptoms without meeting the criteria for a
depressive episode which lasts two or more years and is interrupted by periods of normal moods.

 Review Questions
1. What is the difference between bipolar I and II disorder?
2. What are the key diagnostic differences between a hypomanic and manic episode?
3. What is cyclothymic disorder?

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platform; a detailed edit history is available upon request.

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4.3: Mood Disorders - Epidemiology
 Learning Objectives
Describe the epidemiology of depressive disorders.
Describe the epidemiology of bipolar disorders.
Describe the epidemiology of suicidality.

Depressive Disorders
According to the DSM-5-TR (APA, 2022), the 12-month prevalence rate for major depressive disorder is approximately 7% within
the United States. Recall that DSM-5 persistent depressive disorder is a blend of DSM-IV dysthymic disorder and chronic major
depressive disorder. The prevalence rate for DSM-IV dysthymic disorder is much lower than MDD, with a 0.5% rate among adults
in the United States, while DSM-IV chronic major depressive disorder is 1.5%.
As well, individuals in the 18- to 29- year-old age bracket report the highest rates of MDD than any other age group. Women
experience about twofold higher rates than men of MDD, especially between menarche and menopause (APA, 2022). The
estimated lifetime prevalence for major depressive disorder in women is 21.3% compared to 12.7% in men (Nolen-Hoeksema,
2001). Regrading DSM-IV dysthymic disorder and chronic major depressive disorder, the prevalence among women is 1.5 and 2
times greater than the prevalence for men for each of these diagnoses, respectively (APA, 2022).

Bipolar Disorders
The 12-month prevalence of bipolar I disorder in the United States is 1.5% and did not differ statistically between men and women.
In contrast, bipolar II disorder has a prevalence rate of 0.8% in the United States and 0.3% internationally (APA, 2022) and some
clinical samples suggest it is more common in women, with approximately 80-90% of individuals with rapid-cycling episodes
being women (Bauer & Pfenning, 2005). Childbirth may be a specific trigger for a hypomanic episode, occurring in 10-20% of
women in nonclinical settings and most often in the early postpartum period.

Suicidality
Individuals with a depressive disorder have a 17-fold increased risk for suicide over the age- and sex-adjusted general population
rate. Features associated with an increased risk for death by suicide include anhedonia, living alone, being single, disconnecting
socially, having access to a firearm, early life adversity, sleep disturbance, feelings of hopelessness, and problems with decision
making. Women attempt suicide at a higher rate though men are more likely to complete suicide. Finally, the premenstrual phase is
considered a risk period for suicide by some (APA, 2022).
In terms of bipolar disorders, the lifetime risk of suicide is estimated to be 20- to 30- fold greater than in the general population and
5-6% of individuals with bipolar disorder die by suicide. Like depressive disorders, women attempt suicide at a higher rate though
lethal suicide is more common in men with bipolar disorder. About 1/3 of individuals with bipolar II disorder report a lifetime
history of suicide attempt, which is similar in bipolar I disorder, though lethality of attempts is higher in individuals with bipolar II
(APA, 2022).

Key Takeaways
You should have learned the following in this section:
Major depressive disorder is experienced by about 7% of the population in the United States, afflicting young adults and women
the most.
Bipolar I disorder afflicts 1.5% and bipolar II disorder afflicts 0.8% of the U.S. population with bipolar II affecting women
more than men and no gender difference being apparent for bipolar I.
Individuals with a depressive disorder have a 17-fold increased risk for suicide while the lifetime risk of suicide for an
individual with a bipolar disorder is estimated to be 20- to 30- fold greater than in the general population and 5-6% of
individuals with bipolar disorder die by suicide.

4.3.1 https://socialsci.libretexts.org/@go/page/161367
  Review Questions
1. What are the prevalence rates of the mood disorders?
2. What gender differences exist in the rate of occurrence of mood disorders?
3. How do depressive and bipolar disorders compare in terms of suicidality (attempts and lethality)?

This page titled 4.3: Mood Disorders - Epidemiology is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
Alexis Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit
history is available upon request.

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4.4: Mood Disorders - Comorbidity
 Learning Objectives
Describe the comorbidity of depressive disorders.
Describe the comorbidity of bipolar disorders.

Depressive Disorders
Studies exploring depression symptoms among the general population show a substantial pattern of comorbidity between
depression and other mental disorders, particularly substance use disorders (Kessler, Berglund, et al., 2003). Nearly three-fourths of
participants with lifetime MDD in a large-scale research study also met the criteria for at least one other DSM disorder (Kessler,
Berglund, et al., 2003). MDD has been found to co-occur with substance-related disorders, panic disorder, generalized anxiety
disorder, PTSD, OCD, anorexia, bulimia, and borderline personality disorder. Gender differences do exist within comorbidities
such that women report comorbid anxiety disorders, bulimia, and somatoform disorders while men report comorbid alcohol and
substance abuse. In contrast, those with PDD are at higher risk for psychiatric comorbidity in general and for anxiety disorders,
substance use disorders, and personality disorders in particular (APA, 2022).
Given the extent of comorbidity among individuals with MDD, researchers have tried to identify which disorder precipitated the
other. The majority of studies found that most depression cases occur secondary to another mental health disorder, meaning that the
onset of depression is a direct result of the onset of another disorder (Gotlib & Hammen, 2009).

Bipolar Disorders
Those with bipolar I disorder typically have a history of three or more mental disorders. The most frequent comorbid disorders
include anxiety disorders, alcohol use disorder, other substance use disorder, and ADHD, along with borderline, schizotypal, and
antisocial personality disorder.
Bipolar II disorder is more often than not associated with one or more comorbid mental disorders, with anxiety disorders being the
most common (38% with social anxiety, 36% with specific phobia, and 30% having generalized anxiety). As with bipolar I,
substance use disorders are common with alcohol use (42%) leading the way, followed by cannabis use (20%). Premenstrual
syndrome and premenstrual dysphoric disorder are common in women with bipolar II disorder especially (APA, 2022).
Finally, cyclothymic disorder has been found to be comorbid with substance-related disorders and sleep disorders.

Key Takeaways
You should have learned the following in this section:
Depressive disorders have a high comorbidity with substance use disorders, anxiety disorders, and some personality disorders.
Bipolar disorders have a high comorbidity with anxiety disorders and substance abuse disorders while cyclothymic disorder is
comorbid with substance-related disorders and sleep disorders.

 Review Questions
1. What are common comorbidities for the depressive disorders?
2. What are common comorbidities for bipolar disorders?

This page titled 4.4: Mood Disorders - Comorbidity is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
Alexis Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit
history is available upon request.

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4.5: Mood Disorders - Etiology
 Learning Objectives
Describe the biological causes of mood disorders.
Describe the cognitive causes of mood disorders.
Describe the behavioral causes of mood disorders.
Describe the sociocultural causes of mood disorders.

Biological
Research throughout the years continues to provide evidence that depressive disorders have some biological cause. While it does
not explain every depressive case, it is safe to say that some individuals may at least have a predisposition to developing a
depressive disorder. Among the biological factors are genetic factors, biochemical factors, and brain structure.
4.5.1.1. Genetics. Like with any disorder, researchers often explore the prevalence rate of depressive disorders among family
members to determine if there is some genetic component, whether it be a direct link or a predisposition. If there is a genetic
predisposition to developing depressive disorders, one would expect a higher rate of depression within families than that of the
general population. Research supports this with regards to depressive disorders as there is nearly a 30% increase in relatives
diagnosed with depression compared to 10% of the general population (Levinson & Nichols, 2014). Similarly, there is an elevated
prevalence among first-degree relatives for both Bipolar I and Bipolar II disorders as well.
Another way to study the genetic component of a disorder is via twin studies. One would expect identical twins to have a higher
rate of the disorder as opposed to fraternal twins, as identical twins share the same genetic make-up, whereas fraternal twins only
share roughly 50%, similar to that of siblings. A large-scale study found that if one identical twin was diagnosed with depression,
there was a 46% chance their identical twin was diagnosed with depression. In contrast, the rate of a depression diagnosis in
fraternal twins was only 20%. Despite the fraternal twin rate still being higher than that of a first-degree relative, this study
provided enough evidence that there is a strong genetic link in the development of depression (McGuffin et al., 1996).
More recently, scientists have been studying depression at a molecular level, exploring possibilities of gene abnormalities as a
cause for developing a depressive disorder. While much of the research is speculation due to sampling issues and low power, there
is some evidence that depression may be tied to the 5-HTT gene on chromosome 17, as this is responsible for the activity of
serotonin (Jansen et al., 2016).
Bipolar disorders share a similar genetic predisposition to that of major depressive disorder. Twin studies within bipolar disorder
yielded concordance rates for identical twins at as high as 72%, yet the range for fraternal twins, siblings, and other close relatives
ranged from 5-15%. It is important to note that both percentages are significantly higher than that of the general population,
suggesting a strong genetic component within bipolar disorder (Edvardsen et al., 2008). The DSM-5-TR more recently reports
heritability estimates around 90% in some twin studies and the risk of bipolar disorder being around 1% in the general population
compared to 5-10% in a first-degree relative (APA, 2022).
4.5.1.2. Biochemical. As you will read in the treatment section, there is strong evidence of a biochemical deficit in depression and
bipolar disorders. More specifically, low activity levels of norepinephrine and serotonin, have long been documented as
contributing factors to developing depressive disorders. This relationship was discovered accidentally in the 1950s when MAOIs
were given to tuberculosis patients, and miraculously, their depressive moods were also improved. Soon thereafter, medical
providers found that medications used to treat high blood pressure by causing a reduction in norepinephrine also caused depression
in their patients (Ayd, 1956).
While these initial findings were premature in the identification of how neurotransmitters affected the development of depressive
features, they did provide insight as to what neurotransmitters were involved in this system. Researchers are still trying to
determine exact pathways; however, it does appear that both norepinephrine and serotonin are involved in the development of
symptoms, whether it be between the interaction between them, or their interaction on other neurotransmitters (Ding et al., 2014).
Due to the close nature of depression and bipolar disorder, researchers initially believed that both norepinephrine and serotonin
were implicated in the development of bipolar disorder; however, the idea was that there was a drastic increase in serotonin during
mania episodes. Unfortunately, research supports the opposite. It is believed that low levels of serotonin and high levels of

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norepinephrine may explain mania episodes (Soreff & McInnes, 2014). Despite these findings, additional research within this area
is needed to conclusively determine what is responsible for the manic episodes within bipolar disorder.
4.5.1.3. Endocrine system. As you may know, the endocrine system is a collection of glands responsible for regulating hormones,
metabolism, growth and development, sleep, and mood, among other things. Some research has implicated hormones, particularly
cortisol, a hormone released as a stress response, in the development of depression (Owens et al., 2014). Additionally, melatonin,
a hormone released when it is dark outside to assist with the transition to sleep, may also be related to depressive symptoms,
particularly during the winter months.
4.5.1.4. Brain anatomy. Seeing as neurotransmitters have been implicated in the development of depressive disorders, it should
not be a surprise that various brain structures have also been identified as contributors to mood disorders. While exact anatomy and
pathways are yet to be determined, research studies implicate the prefrontal cortex, the hippocampus, and the amygdala. More
specifically, drastic changes in blood flow throughout the prefrontal cortex have been linked with depressive symptoms. Similarly,
a smaller hippocampus, and consequently, fewer neurons, has also been linked to depressive symptoms. Finally, heightened activity
and blood flow in the amygdala, the brain area responsible for our fight or flight response, is also consistently found in individuals
with depressive symptoms.
Abnormalities in several brain structures have also been identified in individuals with bipolar disorder; however, what or why these
structures are abnormal has yet to be determined. Researchers continue to focus on areas of the basal ganglia and cerebellum,
which appear to be much smaller in individuals with bipolar disorder compared to the general public. Additionally, there appears to
be a decrease in brain activity in regions associated with regulating emotions, as well as an increase in brain activity among
structures related to emotional responsiveness (Houenou et al., 2011). Additional research is still needed to determine precisely
how each of these brain structures may be implicated in the development of bipolar disorder.

Cognitive
The cognitive model, arguably the most conclusive model with regards to depressive disorders, focuses on the negative thoughts
and perceptions of an individual. One theory often equated with the cognitive model of depression is learned helplessness. Coined
by Martin Seligman (1975), learned helplessness was developed based on his laboratory experiment involving dogs. In this study,
Seligman restrained dogs in an apparatus and routinely shocked them regardless of their behavior. The following day, the dogs
were placed in a similar apparatus; however, this time they were not restrained and there was a small barrier placed between the
“shock” floor and the “safe” floor. What Seligman observed was that despite the opportunity to escape the shock, the dogs flurried
for a bit, and then ultimately laid down and whimpered while being shocked.
Based on this study, Seligman concluded that the animals essentially learned that they were unable to avoid the shock the day prior,
and therefore, learned that they were helpless in preventing the shocks. When they were placed in a similar environment but had
the opportunity to escape the shock, their learned helplessness carried over, and they continued to believe they were unable to
escape the shock.
This study has been linked to humans through research on attributional style (Nolen-Hoeksema, Girgus & Seligman, 1992). There
are two types of attributional styles—positive and negative. A negative attributional style focuses on the internal, stable, and global
influence of daily lives, whereas a positive attributional style focuses on the external, unstable, and specific influence of the
environment. Research has found that individuals with a negative attributional style are more likely to experience depression. This
is likely due to their negative interpretation of daily events. For example, if something bad were to happen to them, they would
conclude that it is their fault (internal), bad things always happen to them (stable), and bad things happen all day to them.
Unfortunately, this maladaptive thinking style often takes over an individual’s daily view, thus making them more vulnerable to
depression.
In addition to attributional style, Aaron Beck also attributed negative thinking as a precursor to depressive disorders (Beck, 2002,
1991, 1967). Often viewed as the grandfather of Cognitive-Behavioral Therapy, Beck went on to coin the terms—maladaptive
attitudes, cognitive triad, errors in thinking, and automatic thoughts—all of which combine to explain the cognitive model of
depressive disorders.
Maladaptive attitudes, or negative attitudes about oneself, others, and the world around them are often present in those with
depressive symptoms. These attitudes are inaccurate and often global. For example, “If I fail my exam, the world will know I’m
stupid.” Will the entire world really know you failed your exam? Not likely. Because you fail the exam, are you stupid? No.
Individuals with depressive symptoms often develop these maladaptive attitudes regarding everything in their life, indirectly

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isolating themselves from others. The cognitive triad also plays into the maladaptive attitudes in that the individual interprets these
negative thoughts about their experiences, themselves, and their futures.
Cognitive distortions, also known as errors in thinking, are a key component in Beck’s cognitive theory. Beck identified 15 errors
in thinking that are most common in individuals with depression (see the end of the module). Among the most common are
catastrophizing, jumping to conclusions, and overgeneralization. I always like to use my dad (first author’s dad) as an example for
overgeneralization. Whenever we go to the grocery store, he always comments about how whatever line he chooses, at every store,
it is always the slowest line. Does this happen every time he is at the store? I’m doubtful, but his error in thinking leads to him
believing this is true.
Finally, automatic thoughts, or the constant stream of negative thoughts, also leads to symptoms of depression as individuals
begin to feel as though they are inadequate or helpless in a given situation. While some cognitions are manipulated and interpreted
negatively, Beck stated that there is another set of negative thoughts that occur automatically. Research studies have continually
supported Beck’s maladaptive thoughts, attitudes, and errors in thinking as fundamental issues in those with depressive disorders
(Lai et al., 2014; Possel & Black, 2014). Furthermore, as you will see in the treatment section (Section 4.5), cognitive strategies are
among the most effective forms of treatment for depressive disorders.

Behavioral
The behavioral model explains depression as a result of a change in the number of rewards and punishments one receives
throughout their life. This change can come from work, intimate relationships, family, or even the environment in general. Among
the most influential in the field of depression is Peter Lewinsohn. He stated depression occurred in most people due to reduced
positive rewards in their life. Because they were not positively rewarded, their constructive behaviors occurred more infrequently
until they stop engaging in the behavior completely (Lewinsohn et al., 1990; 1984). An example of this is a student who keeps
receiving bad grades on their exam despite studying for hours. Over time, the individual will reduce the amount of time they are
studying, thus continuing to earn poor grades.

Sociocultural
In the sociocultural theory, the role of family and one’s social environment play a substantial role in the development of depressive
disorders. There are two sociocultural views: the family-social perspective and the multi-cultural perspective.
4.5.4.1. Family-social perspective. Similar to that of the behavioral theory, the family-social perspective of depression suggests
that depression is related to the unavailability of social support. This is often supported by research studies that show separated and
divorced individuals are three times more likely to experience depressive symptoms than those that are married or even widowed
(Schultz, 2007). While many factors lead a couple to separate or end their marriage, some relationships end due to a spouse’s
mental health issues, particularly depressive symptoms. Depressive symptoms have been positively related to increased
interpersonal conflicts, reduced communication, and intimacy issues, all of which are often reported in causal factors leading to a
divorce (Najman et al., 2014).
The family-social perspective can also be viewed oppositely, with stress and marital discord leading to increased rates of
depression in one or both spouses (Nezlek et al., 2000). While some research indicates that having children provides a positive
influence in one’s life, it can also lead to stress both within the individual, as well as between partners due to division of work and
discipline differences. Studies have shown that women who had three or more young children, and also lacked a close confidante
and outside employment, were more likely than other mothers to become depressed (Brown, 2002).
4.5.4.2. Multi-cultural perspective. While depression is experienced across the entire world, one’s cultural background may
influence what symptoms of depression are presented. Common depressive symptoms such as feeling sad, lack of energy,
anhedonia, difficulty concentrating, and thoughts of suicide are a hallmark in most societies; other symptoms may be more specific
to one’s nationality. More specifically, individuals from non-Western countries (China and other Asian countries) often focus on the
physical symptoms of depression—tiredness, weakness, sleep issues—and less of an emphasis on the cognitive symptoms.
Within the United States, many researchers have explored potential differences across ethnic or racial groups in both rates of
depression, as well as presenting symptoms of those diagnosed with depression. These studies continually fail to identify any
significant differences between ethnic and racial groups; however, one major study has identified a difference in the rate of
recurrence of depression in Hispanic and African Americans (Gonzalez et al., 2010). While the exact reason for this is unclear,
researchers propose a lack of treatment opportunities as a possible explanation. According to Gonzalez and colleagues (2010),
approximately 54% of depressed white Americans seek out treatment, compared to the 34% and 40% Hispanic and African

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Americans, respectively. The fact that there is a large discrepancy in the use of treatment between white Americans and minority
Americans suggests that these individuals are not receiving the effective treatment necessary to resolve the disorder, thus leaving
them more vulnerable for repeated depressive episodes.
4.5.4.3. Gender differences. As previously discussed, there is a significant difference between gender and rates of depression, with
women twice as likely to experience an episode of depression than men (Schuch et al., 2014). There are a few speculations as to
why there is such an imbalance in the rate of depression across genders.
The first theory, artifact theory, suggests that the difference between genders is due to clinician or diagnostic systems being more
sensitive to diagnosing women with depression than men. While women are often thought to be more “emotional,” easily
expressing their feelings and more willing to discuss their symptoms with clinicians and physicians, men often withhold their
symptoms or will present with more traditionally “masculine” symptoms of anger or aggression. While this theory is a possible
explanation for the gender differences in the rate of depression, research has failed to support this theory, suggesting that men and
women are equally likely to seek out treatment and discuss their depressive symptoms (McSweeney, 2004; Rieker & Bird, 2005).
The second theory, hormone theory, suggests that variations in hormone levels trigger depression in women more than men
(Graziottin & Serafini, 2009). While there is biological evidence supporting the changes in hormone levels during various phases of
the menstrual cycle and their impact on women’s ability to integrate and process emotional information, research fails to support
this theory as the reason for higher rates of depression in women (Whiffen & Demidenko, 2006).
The third theory, life stress theory, suggests that women are more likely to experience chronic stressors than men, thus accounting
for their higher rate of depression (Astbury, 2010). Women face increased risk for poverty, lower employment opportunities,
discrimination, and poorer quality of housing than men, all of which are strong predictors of depressive symptoms (Garcia-Toro et
al., 2013).
The fourth theory, gender roles theory, suggests that social and or psychological factors related to traditional gender roles also
influence the rate of depression in women. For example, men are often encouraged to develop personal autonomy, seek out
activities that interest them, and display achievement-oriented goals; women are encouraged to empathize and care for others, often
fostering an interdependent functioning, which may cause women to value the opinion of others more highly than their male
counterparts do.
The final theory, rumination theory, suggests that women are more likely than men to ruminate, or intently focus, on their
depressive symptoms, thus making them more vulnerable to developing depression at a clinical level (Nolen-Hoeksema, 2012).
Several studies have supported this theory and shown that rumination of negative thoughts is positively related to an increase in
depression symptoms (Hankin, 2009).
While many theories try to explain the gender discrepancy in depressive episodes, no single theory has produced enough evidence
to fully explain why women experience depression more than men. Due to the lack of evidence, gender differences in depression
remains one of the most researched topics within the subject of depression, while simultaneously being the least understood
phenomena within clinical psychology.

Key Takeaways
You should have learned the following in this section:
In terms of biological explanations for depressive disorders, there is evidence that rates of depression are higher among
identical twins (the same is true for bipolar disorders), that the 5-HTT gene on chromosome 17 may be involved in depressive
disorders, that norepinephrine and serotonin affect depressive (both being low) and bipolar disorders (low serotonin and high
norepinephrine), the hormones cortisol and melatonin affect depression, and several brain structures are implicated in
depression (prefrontal cortex, hippocampus, and amygdala) and bipolar disorder (basal ganglia and cerebellum).
In terms of cognitive explanations, learned helplessness, attributional style, and maladaptive attitudes to include the cognitive
triad, errors in thinking, and automatic thoughts, help to explain depressive disorders.
Behavioral explanations center on changes in the rewards and punishments received throughout life.
Sociocultural explanations include the family-social perspective and multi-cultural perspective.
Women are twice as likely to experience depression and this could be due to women being more likely to be diagnosed than
men (called the artifact theory), variations in hormone levels in women (hormone theory), women being more likely to
experience chronic stressors (life stress theory), the fostering of an interdependent functioning in women (gender roles theory),
and that women are more likely to intently focus on their symptoms (rumination theory).

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  Review Questions
1. How do twin studies explain the biological causes of mood disorders?
2. What brain structures are implicated in the development of mood disorders? Discuss their role.
3. What is learned helplessness? How has this concept been used to study the development and maintenance of mood
disorders?
4. What is the cognitive triad?
5. What are common cognitive distortions observed in individuals with mood disorders?
6. What are the identified theories that are used to explain the gender differences in mood disorder development?

This page titled 4.5: Mood Disorders - Etiology is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Alexis
Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is
available upon request.

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4.6: Mood Disorders - Treatment
 Learning Objectives
Describe treatment options for depressive disorders.
Describe treatment options for bipolar disorders.
Determine the efficacy of treatment options for depressive disorders.
Determine the efficacy of treatment options for bipolar disorders.

Depressive Disorders
Given that Major Depressive Disorder is among the most frequent and debilitating psychiatric disorders, it should not be surprising
that the research on this disorder is quite extensive. Among its treatment options, the most efficacious ones include antidepressant
medications, Cognitive-Behavioral Therapy (CBT; Beck et al., 1979), Behavioral Activation (BA; Jacobson et al., 2001), and
Interpersonal Therapy (IPT; Klerman et al., 1984). Although CBT is the most widely known and used treatment for Major
Depressive Disorder, there is minimal evidence to support one treatment modality over the other; treatment is generally dictated by
therapist competence, availability, and patient preference (Craighhead & Dunlop, 2014).
4.6.1.1. Psychopharmacology – Antidepressant medications. Antidepressants are often the most common first-line attempt at
treatment for MDD for a few reasons. Oftentimes an individual will present with symptoms to their primary caregiver (a medical
doctor) who will prescribe them some line of antidepressant medication. Medication is often seen as an “easier” treatment for
depression as the individual can take the medication at their home, rather than attending weekly therapy sessions; however, this
also leaves room for adherence issues as a large percentage of individuals fail to take prescription medication as indicated by their
physician. Given the biological functions of neurotransmitters and their involvement in maintaining depressive symptoms, it makes
sense that this is an effective type of treatment.
Within antidepressant medications, there are a few different classes, each categorized by their structural or functional relationships.
It should be noted that no specific antidepressant medication class or medication have been proven to be more effective in treating
MDD than others (APA, 2010). In fact, many patients may try several different types of antidepressant medications until they find
one that is effective, with minimal side effects.
4.6.1.2. Psychopharmacology – Selective serotonin reuptake inhibitors(SSRIs). SSRIs are among the most common
medications used to treat depression due to their relatively benign side effects. Additionally, the required dose to reach therapeutic
levels is low compared to the other medication options. Possible side effects from SSRIs include but are not limited to nausea,
insomnia, and reduced sex drive.
SSRIs improve depression symptoms by blocking the reuptake of norepinephrine and/or serotonin in presynaptic neurons, thus
allowing more of these neurotransmitters to be available for postsynaptic neurons. While this is the general mechanism through
which all SSRI’s work, there are minor biological differences among different types of medications within the SSRI family. These
small differences are beneficial to patients in that there are a few treatment options to maximize medication benefits and minimize
side effects.
4.6.1.3. Psychopharmacology – Tricyclic antidepressants. Although originally developed to treat schizophrenia, tricyclic
antidepressants were adapted to treat depression after failing to manage symptoms of schizophrenia (Kuhn, 1958). The term
tricyclic came from the molecular shape of the structure: three rings.
Tricyclic antidepressants are like SSRIs in that they work by affecting brain chemistry, altering the number of neurotransmitters
available for neurons. More specifically, they block the absorption or reuptake of serotonin and norepinephrine, thus increasing
their availability for postsynaptic neurons. While effective, tricyclic antidepressants have been increasingly replaced by SSRIs due
to their reduced side effects. However, tricyclic antidepressants have been shown to be more effective in treating depressive
symptoms in individuals who have not been able to achieve symptom reduction via other pharmacological approaches.
While the majority of the side effects are minimal – dry mouth, blurry vision, constipation, others can be serious such as sexual
dysfunction, tachycardia, cognitive and/or memory impairment. Due to the potential impact on the heart, tricyclic antidepressants
should not be used in cardiac patients as they may exacerbate cardiac arrhythmias (Roose & Spatz, 1999).
4.6.1.4. Psychopharmacology – Monoamine oxidase inhibitors (MAOIs). The use of MAOIs as a treatment for depression
began serendipitously as patients in the early 1950s reported reduced depression symptoms while on the medication to treat

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tuberculosis. Research studies confirmed that MAOIs were effective in treating depression in adults outside the treatment of
tuberculosis. Although still prescribed, they are not typically first-line medications due to their safety concerns with hypertensive
crises. Because of this, individuals on MAOIs have strict diet restrictions to reduce their risk of hypertensive crises (Shulman,
Herrman & Walker, 2013).
How do MAOIs work? In basic terms, monoamine oxidase is released in the brain to remove excess neurotransmitters
norepinephrine, serotonin, and dopamine. MAOIs essentially prevent the monoamine oxidase (hence the name monoamine oxidase
inhibitors) from removing these neurotransmitters, thus resulting in an increase in these brain chemicals (Shulman, Herman &
Walker, 2013). As previously discussed, norepinephrine, serotonin, and dopamine are all involved in the biological mechanisms of
maintaining depressive symptoms.
While these drugs are effective, they come with serious side effects. In addition to the hypertensive episodes, they can also cause
nausea, headaches, drowsiness, involuntary muscle jerks, reduced sexual desire, weight gain, etc. (APA, 2010). Despite these side
effects, studies have shown that individuals prescribed MAOIs for depression have a treatment response rate of 50-70% (Krishnan,
2007). Overall, despite their effectiveness, MAOIs are likely the best treatment for late-stage, treatment-resistant depression
patients who have exhausted other treatment options (Krishnan, 2007).
It should be noted that occasionally, antipsychotic medications are used for individuals with MDD; however, these are limited to
individuals presenting with psychotic features.
4.6.1.5. Psychotherapy – Cognitive behavioral therapy (CBT). CBT was founded by Aaron Beck in the 1960s and is a widely
practiced therapeutic tool used to treat depression (and other disorders as well). The basics of CBT involve what Beck called the
cognitive triangle— cognitions (thoughts), behaviors, and emotions. Beck believed that these three components are
interconnected, and therefore, affect one another. It is believed that CBT can improve emotions in depressed patients by changing
both cognitions (thoughts) and behaviors, which in return enhances mood. Common cognitive interventions with CBT include
thought monitoring and recording, identifying cognitive errors, examining evidence supporting/negating cognitions, and creating
rational alternatives to maladaptive thought patterns. Behavioral interventions of CBT include activity planning, pleasant event
scheduling, task assignments, and coping-skills training.
CBT generally follows four phases of treatment:
Phase 1: Increasing pleasurable activities. Similar to behavioral activation (see below), the clinician encourages the patient to
identify and engage in activities that are pleasurable to the individual. The clinician can help the patient to select the activity, as
well as help them plan when they will engage in that activity.
Phase 2: Challenging automatic thoughts. During this stage, the clinician provides psychoeducation about the negative
automatic thoughts that can maintain depressive symptoms. The patient will learn to identify these thoughts on their own during
the week and maintain a thought journal of these cognitions to review with the clinician in session.
Phase 3: Identifying negative thoughts. Once the individual is consistently able to identify these negative thoughts on a daily
basis, the clinician can help the patient identify how these thoughts are maintaining their depressive symptoms. It is at this point
that the patient begins to have direct insight as to how their cognitions contribute to their disorder.
Phase 4: Changing thoughts. The final stage of treatment involves challenging the negative thoughts the patient has been
identifying in the last two phases of treatment and replacing them with positive thoughts.
4.6.1.6. Psychotherapy – Behavioral activation (BA). BA is similar to the behavioral component of CBT in that the goal of
treatment is to alleviate depression and prevent future relapse by changing an individual’s behavior. Founded by Ferster (1973), as
well as Lewinsohn and colleagues (Lewinsohn, 1974; Lewinsohn, Biglan, & Zeiss, 1976), the goal of BA is to increase the
frequency of behaviors so that individuals have opportunities to experience greater contact with sources of reward in their lives. To
do this, the clinician assists the patient by developing a list of pleasurable activities that they can engage in outside of treatment
(i.e., going for a walk, going shopping, having dinner with a friend). Additionally, the clinician assists the patient in identifying
their negative behaviors—crying, sleeping in, avoiding friends—and monitoring them so that they do not impact the outcome of
their pleasurable activities. Finally, the clinician works with the patient on effective social skills. By minimizing negative behaviors
and maximizing pleasurable activities, the individual will receive more positive reward and reinforcement from others and their
environment, thus improving their overall mood.
4.6.1.7. Psychotherapy – Interpersonal therapy (IPT). IPT was developed by Klerman, Weissman, and colleagues in the 1970s
as a treatment arm for a pharmacotherapy study of depression (Weissman, 1995). The treatment was created based on data from
post-World War II individuals who expressed a substantial impact on their psychosocial life events. Klerman and colleagues

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noticed a significant relationship between the development of depression and complicated bereavement, role disputes, role
transitions, and interpersonal deficits in these individuals (Weissman, 1995). The idea behind IPT is that depressive episodes
compromise interpersonal functioning, which makes it difficult to manage stressful life events. The basic mechanism of IPT is to
establish effective strategies to manage interpersonal issues, which in return, will ameliorate depressive symptoms.
There are two main principles of IPT. First, depression is a common medical illness with a complex and multi-determined etiology.
Since depression is a medical illness, it is also treatable and not the patient’s fault. Second, depression is connected to a current or
recent life event. The goal of IPT is to identify the interpersonal problem that is related to the depressive symptoms and solve this
crisis so the patient can improve their life situation while relieving depressive symptoms.
4.6.1.8. Multimodal treatment. While both pharmacological and psychological treatment alone is very effective in treating
depression, a combination of the two treatments may offer additional benefits, particularly in the maintenance of wellness.
Additionally, multimodal treatment options may be helpful for individuals who have not achieved wellness in a single modality.
Multimodal treatments can be offered in three different ways: concurrently, sequentially, or within a stepped manner (McGorry et
al., 2010). With a stepped manner treatment, pharmacological therapy is often used initially to treat depressive symptoms. Once the
patient reports some relief in symptoms, the psychosocial treatment is added to address the remaining symptoms. While all three
methods are effective in managing depressive symptoms, matching patients to their treatment preferences may produce better
outcomes than clinician-driven treatment decisions.

Bipolar Disorder
4.6.2.1. Psychopharmacology. Unlike treatment for MDD, there is some controversy regarding effective treatment of bipolar
disorder. One suggestion is to treat bipolar disorder aggressively with mood stabilizers such as Lithium or Depakote as these
medications do not induce pharmacological mania/hypomania. These mood stabilizers are occasionally combined with
antidepressants later in treatment only if absolutely necessary (Ghaemi, Hsu, Soldani & Goodwin, 2003). Research has shown that
mood stabilizers are less potent in treating depressive symptoms, and therefore, the combination approach is believed to help
manage both the manic and depressive episodes (Nivoli et al., 2011).
The other treatment option is to forgo the mood stabilizer and treat symptoms with newer antidepressants early in treatment.
Unfortunately, large scale research studies have not shown great support for this method (Gijsman, Geddes, Rendell, Nolen, &
Goodwin, 2004; Moller, Grunze & Broich, 2006). Antidepressants often trigger a manic or hypomanic episode in bipolar patients.
Because of this, the first-line treatment option for bipolar disorder is mood stabilizers, particularly Lithium.
4.6.2.2. Psychological treatment. Although psychopharmacology is the first and most widely used treatment for bipolar disorders,
occasionally psychological interventions are also paired with medication as psychotherapy alone is not a sufficient treatment
option. Majority of psychological interventions are aimed at medication adherence, as many bipolar patients stop taking their mood
stabilizers when they “feel better” (Advokat et al., 2014). Social skills training and problem-solving skills are also helpful
techniques to address in the therapeutic setting as individuals with bipolar disorder often struggle in this area.

Outcome of Treatment
4.6.3.1. Depressive treatment. As we have discussed, major depressive disorder has a variety of treatment options, all found to be
efficacious. However, research suggests that while psychopharmacological interventions are more effective in rapidly reducing
symptoms, psychotherapy, or even a combined treatment approach, are more effective in establishing long-term relief of symptoms.
Rates of relapse for major depressive disorder are often associated with individuals whose onset was at a younger age (particularly
adolescents), those who have already experienced multiple major depressive episodes, and those with more severe symptomology,
especially those presenting with severe suicidal ideation and psychotic features (APA, 2022).
4.6.3.2. Bipolar treatment. Lithium and other mood stabilizers are very effective in managing symptoms of patients with bipolar
disorder. Unfortunately, it is the adherence to the medication regimen that is often the issue with these patients. Bipolar patients
often desire the euphoric highs that are associated with manic and hypomanic episodes, leading them to forgo their medication. A
combination of psychopharmacology and psychotherapy aimed at increasing the rate of adherence to medical treatment may be the
most effective treatment option for bipolar I and II disorder.

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Key Takeaways
You should have learned the following in this section:
Treatment of depressive disorders include psychopharmacological options such as anti-depressant mediations, SSRIs, tricyclic
antidepressants, and MAOIs and/or psychotherapy options to include CBT, behavioral activation (BA), and interpersonal
therapy (IPT). A combination of the two main approaches often works best, especially in relation to maintenance of wellness.
Treatment of bipolar disorder involves mood stabilizers such as Lithium and psychological interventions with the goal of
medication adherence, as well as social skills training and problem-solving skills.
Regarding depression, psychopharmacological interventions are more effective in rapidly reducing symptoms, while
psychotherapy, or even a combined treatment approach, is more effective in establishing long-term relief of symptoms.
A combination of psychopharmacology and psychotherapy aimed at increasing the rate of adherence to medical treatment may
be the most effective treatment option for bipolar I and II disorder.

 Review Questions
1. Discuss the effectiveness of the different pharmacological treatments for mood disorders.
2. What are the four phases of CBT? How do they address symptoms of mood disorder?
3. What is ITP and what are its main treatment strategies?
4. What are the effective treatment options for bipolar disorder?

Module Recap
That concludes our discussion of mood disorders. You should now have a good understanding of the two major types of mood
disorders – depressive and bipolar disorders. Be sure you are clear on what makes them different from one another in terms of their
clinical presentation, epidemiology, comorbidity, and etiology. This will help you with understanding treatment options and their
efficacy.

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 CHAPTER OVERVIEW

5: Trauma- and Stressor-Related Disorders

 Learning Objectives
Define and identify common stressors.
Describe how trauma- and stressor-related disorders present.
Describe the epidemiology of trauma- and stressor-related disorders.
Describe comorbidity in relation to trauma- and stressor-related disorders.
Describe the etiology of trauma- and stressor-related disorders.
Describe treatment options for trauma- and stressor-related disorders.

In Module 5, we will discuss matters related to trauma- and stressor-related disorders to include their clinical presentation,
epidemiology, comorbidity, etiology, and treatment options. Our discussion will consist of PTSD, acute stress disorder, adjustment
disorder, and prolonged grief disorder. Prior to discussing these clinical disorders, we will explain what stressors are, as well as
identify common stressors that may lead to a trauma- or stressor-related disorder. Be sure you refer Modules 1-3 for explanations of
key terms (Module 1), an overview of models to explain psychopathology (Module 2), and descriptions of various therapies
(Module 3).
5.1: Trauma- and Stressor-Related Disorders - Stressors
5.2: Trauma- and Stressor-Related Disorders - Clinical Presentation
5.3: Trauma- and Stressor-Related Disorders - Epidemiology
5.4: Trauma- and Stressor-Related Disorders - Comorbidity
5.5: Trauma- and Stressor-Related Disorders - Etiology
5.6: Trauma- and Stressor-Related Disorders - Treatment

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1
5.1: Trauma- and Stressor-Related Disorders - Stressors
 Learning Objectives
Define stressor.
Identify and describe common stressors.

Before we dive into clinical presentations of four of the trauma and stress-related disorders, let’s discuss common events that
precipitate a stress-related diagnosis. A stress disorder occurs when an individual has difficulty coping with or adjusting to a recent
stressor. Stressors can be any event—either witnessed firsthand, experienced personally, or experienced by a close family member
—that increases physical or psychological demands on an individual. These events are significant enough that they pose a threat,
whether real or imagined, to the individual. While many people experience similar stressors throughout their lives, only a small
percentage of individuals experience significant maladjustment to the event that psychological intervention is warranted.
Among the most studied triggers for trauma-related disorders are combat and physical/sexual assault. Symptoms of combat-related
trauma date back to World War I when soldiers would return home with “shell shock” (Figley, 1978). Unfortunately, it was not until
after the Vietnam War that significant progress was made in both identifying and treating war-related psychological difficulties
(Roy-Byrne et al., 2004). With the more recent wars in Iraq and Afghanistan, attention was again focused on posttraumatic stress
disorder (PTSD) symptoms due to the large number of service members returning from deployments and reporting significant
trauma symptoms.
Physical assault, and more specifically sexual assault, is another commonly studied traumatic event. Rape, or forced sexual
intercourse or other sexual act committed without an individual’s consent, occurs in one out of every five women and one in every
71 men (Black et al., 2011). Unfortunately, this statistic likely underestimates the actual number of cases that occur due to the
reluctance of many individuals to report their sexual assault. Of the reported cases, it is estimated that nearly 81% of female and
35% of male rape victims report both acute stress disorder and posttraumatic stress disorder symptoms (Black et al., 2011).
Now that we have discussed a little about some of the most commonly studied traumatic events, we will now examine the clinical
presentation of posttraumatic stress disorder, acute stress disorder, adjustment disorder, and prolonged grief disorder.

Key Takeaways
You should have learned the following in this section:
A stressor is any event that increases physical or psychological demands on an individual.
It does not have to be personally experienced but can be witnessed or occur to a close family member or friend to have the same
effect.
Only a small percentage of people experience significant maladjustment due to these events.
The most studied triggers for trauma-related disorders include physical/sexual assault and combat.

 Review Questions
1. Given an example of a stressor you have experienced in your own life.
2. Why are the triggers of physical/sexual assault and combat more likely to lead to a trauma-related disorder?

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detailed edit history is available upon request.

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5.2: Trauma- and Stressor-Related Disorders - Clinical Presentation
 Learning Objectives
Describe how PTSD presents.
Describe how acute stress disorder presents.
Describe how adjustment disorder presents.
Describe how prolonged grief disorder presents.

Posttraumatic Stress Disorder

Posttraumatic stress disorder, or more commonly known as PTSD, is identified by the development of physiological,
psychological, and emotional symptoms following exposure to a traumatic event. Individuals must have been exposed to a situation
where actual or threatened death, sexual violence, or serious injury occurred. Examples of these situations include but are not
limited to witnessing a traumatic event as it occurred to someone else; learning about a traumatic event that occurred to a family
member or close friend; directly experiencing a traumatic event; or being exposed to repeated events where one experiences an
aversive event (e.g., victims of child abuse/neglect, ER physicians in trauma centers, etc.).
It is important to understand that while the presentation of these symptoms varies among individuals, to meet the criteria for a
diagnosis of PTSD, individuals need to report symptoms among the four different categories of symptoms.
5.2.1.1. Category 1: Recurrent experiences. The first category involves recurrent experiences of the traumatic event, which can
occur via dissociative reactions such as flashbacks; recurrent, involuntary, and intrusive distressing memories; or even recurrent
distressing dreams (APA, 2022, pgs. 301-2). These recurrent experiences must be specific to the traumatic event or the moments
immediately following to meet the criteria for PTSD. Regardless of the method, the recurrent experiences can last several seconds
or extend for several days. They are often initiated by physical sensations similar to those experienced during the traumatic events
or environmental triggers such as a specific location. Because of these triggers, individuals with PTSD are known to avoid stimuli
(i.e., activities, objects, people, etc.) associated with the traumatic event. One or more of the intrusion symptoms must be present.
5.2.1.2. Category 2: Avoidance of stimuli. The second category involves avoidance of stimuli related to the traumatic event and
either one or both of the following must be present. First, individuals with PTSD may be observed trying to avoid the distressing
thoughts, memories, and/or feelings related to the memories of the traumatic event. Second, they may prevent these memories from
occurring by avoiding physical stimuli such as locations, individuals, activities, or even specific situations that trigger the memory
of the traumatic event.
5.2.1.3. Category 3: Negative alterations in cognition or mood. The third category experienced by individuals with PTSD is
negativealterations in cognition or mood and at least two of the symptoms described below must be present. This is often reported
as difficulty remembering an important aspect of the traumatic event. It should be noted that this amnesia is not due to a head
injury, loss of consciousness, or substances, but rather, due to the traumatic nature of the event. The impaired memory may also
lead individuals to have false beliefs about the causes of the traumatic event, often blaming themselves or others. An overall
persistent negative state, including a generalized negative belief about oneself or others is also reported by those with PTSD.
Similar to those with depression, individuals with PTSD may report a reduced interest in participating in previously enjoyable
activities, as well as the desire to engage with others socially. They also report not being able to experience positive emotions.
5.2.1.4. Category 4: Alterations in arousal and reactivity. The fourth and final category is alterations in arousal and reactivity
and at least two of the symptoms described below must be present. Because of the negative mood and increased irritability,
individuals with PTSD may be quick-tempered and act out aggressively, both verbally and physically. While these aggressive
responses may be provoked, they are also sometimes unprovoked. It is believed these behaviors occur due to the heightened
sensitivity to potential threats, especially if the threat is similar to their traumatic event. More specifically, individuals with PTSD
have a heightened startle response and easily jump or respond to unexpected noises just as a telephone ringing or a car backfiring.
They also experience significant sleep disturbances, with difficulty falling asleep, as well as staying asleep due to nightmares;
engage in reckless or self-destructive behavior, and have problems concentrating.
Although somewhat obvious, these symptoms likely cause significant distress in social, occupational, and other (i.e., romantic,
personal) areas of functioning. Duration of symptoms is also important, as PTSD cannot be diagnosed unless symptoms have been

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present for at least one month. If symptoms have not been present for a month, the individual may meet criteria for acute stress
disorder (see below).

Acute Stress Disorder

Acute stress disorder is very similar to PTSD except for the fact that symptoms must be present from 3 days to 1 month following
exposure to one or more traumatic events. If the symptoms are present after one month, the individual would then meet the criteria
for PTSD. Additionally, if symptoms present immediately following the traumatic event but resolve by day 3, an individual would
not meet the criteria for acute stress disorder.
Symptoms of acute stress disorder follow that of PTSD with a few exceptions. PTSD requires symptoms within each of the four
categories discussed above; however, acute stress disorder requires that the individual experience nine symptoms across five
different categories (intrusion symptoms, negative mood, dissociative symptoms, avoidance symptoms, and arousal symptoms;
note that in total, there are 14 symptoms across these five categories). For example, an individual may experience several arousal
and reactivity symptoms such as sleep issues, concentration issues, and hypervigilance, but does not experience issues regarding
negative mood. Regardless of the category of the symptoms, so long as nine symptoms are present and the symptoms cause
significant distress or impairment in social, occupational, and other functioning, an individual will meet the criteria for acute stress
disorder.
Making Sense of the Disorders
In relation to trauma- and stressor-related disorders, note the following:
Diagnosis PTSD …… if symptoms have been experienced for at least one month
Diagnosis acute stress disorder … if symptoms have been experienced for 3 days to one month
5.2.3. Adjustment Disorder
Adjustment disorder is the least intense of the three disorders discussed so far in this module. An adjustment disorder occurs
following an identifiable stressor that happened within the past 3 months. This stressor can be a single event (loss of job, death of a
family member) or a series of multiple stressors (cancer treatment, divorce/child custody issues).
Unlike PTSD and acute stress disorder, adjustment disorder does not have a set of specific symptoms an individual must meet for
diagnosis. Rather, whatever symptoms the individual is experiencing must be related to the stressor and must be significant enough
to impair social, occupational, or other important areas of functioning and causes marked distress “…that is out of proportion to the
severity or intensity of the stressor” (APA, 2022, pg. 319).
It should be noted that there are modifiers associated with adjustment disorder. Due to the variety of behavioral and emotional
symptoms that can be present with an adjustment disorder, clinicians are expected to classify a patient’s adjustment disorder as one
of the following: with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with
mixed disturbance of emotions and conduct, or unspecified if the behaviors do not meet criteria for one of the aforementioned
categories. Based on the individual’s presenting symptoms, the clinician will determine which category best classifies the patient’s
condition. These modifiers are also important when choosing treatment options for patients.

Prolonged Grief Disorder

The DSM-5 included a condition for further study called persistent complex bereavement disorder. In 2018, a proposal was
submitted to include this category in the main text of the manual and after careful review of the literature and approval of the
criteria, it was accepted in the second half of 2019 and added as a new diagnostic entity called prolonged grief disorder. Prolonged
grief disorder is defined as an intense yearning/longing and/or preoccupation with thoughts or memories of the deceased who died
at least 12 months ago. The individual will present with at least three symptoms to include feeling as though part of oneself has
died, disbelief about the death, emotional numbness, feeling that life is meaningless, intense loneliness, problems engaging with
friends or pursuing interests, intense emotional pain, and avoiding reminders that the person has died.
Individuals with prolonged grief disorder often hold maladaptive cognitions about the self, feel guilt about the death, and hold
negative views about life goals and expectancy. Harmful health behaviors due to decreased self-care and concern are also reported.
They may also experience hallucinations about the deceased, feel bitter an angry be restless, blame others for the death, and see a
reduction in the quantity and quality of sleep (APA, 2022).

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Key Takeaways
You should have learned the following in this section:
In terms of stress disorders, symptoms lasting over 3 days but not exceeding one month, would be classified as acute stress
disorder while those lasting over a month are typical of PTSD.
If symptoms begin after a traumatic event but resolve themselves within three days, the individual does not meet the criteria for
a stress disorder.
Symptoms of PTSD fall into four different categories for which an individual must have at least one symptom in each category
to receive a diagnosis. These categories include recurrent experiences, avoidance of stimuli, negative alterations in cognition or
mood, and alterations in arousal and reactivity.
To receive a diagnosis of acute stress disorder an individual must experience nine symptoms across five different categories
(intrusion symptoms, negative mood, dissociative symptoms, avoidance symptoms, and arousal symptoms).
Adjustment disorder is the last intense of the three disorders and does not have a specific set of symptoms of which an
individual has to have some number. Whatever symptoms the person presents with, they must cause significant impairment in
areas of functioning such as social or occupational, and several modifiers are associated with the disorder.
Prolonged grief disorder is a new diagnostic entity in the DSM-5-TR and is defined as an intense yearning/longing and/or
preoccupation with thoughts or memories of the deceased who died at least 12 months ago.

 Review Questions
1. What is the difference in diagnostic criteria for PTSD, Acute Stress Disorder, and Adjustment Disorder?
2. What are the four categories of symptoms for PTSD? How do these symptoms present in Acute Stress Disorder and
Adjustment Disorder?
3. What is prolonged grief disorder?

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5.3: Trauma- and Stressor-Related Disorders - Epidemiology
 Learning Objectives
Describe the epidemiology of PTSD.
Describe the epidemiology of acute stress disorder.
Describe the epidemiology of adjustment disorders.
Describe the epidemiology of prolonged grief disorder.

PTSD
The national lifetime prevalence rate for PTSD using DSM-IV criteria is 6.8% for U.S. adults and 5.0% to 8.1% for U.S.
adolescents. There are currently no definitive, comprehensive population-based data using DSM-5 though studies are beginning to
emerge (APA, 2022). It should not come as a surprise that the rates of PTSD are higher among veterans and others who work in
fields with high traumatic experiences (i.e., firefighters, police, EMTs, emergency room providers). In fact, PTSD rates for combat
veterans are estimated to be as high as 30% (NcNally, 2012). Between one-third and one-half of all PTSD cases consist of rape
survivors, military combat and captivity, and ethnically or politically motivated genocide (APA, 2022).
Concerning gender, PTSD is more prevalent among females (8% to 11%) than males (4.1% to 5.4%), likely due to their higher
occurrence of exposure to traumatic experiences such as childhood sexual abuse, rape, domestic abuse, and other forms of
interpersonal violence. Women also experience PTSD for a longer duration. (APA, 2022). Gender differences are not found in
populations where both males and females are exposed to significant stressors suggesting that both genders are equally predisposed
to developing PTSD. Prevalence rates vary slightly across cultural groups, which may reflect differences in exposure to traumatic
events. More specifically, prevalence rates of PTSD are highest for African Americans, followed by Latinx Americans and
European Americans, and lowest for Asian Americans (Hinton & Lewis-Fernandez, 2011). According to the DSM-5-TR, there are
higher rates of PTSD among Latinx, African-Americans, and American Indians compared to whites, and likely due to exposure to
past adversity and racism and discrimination (APA, 2022).

Acute Stress Disorder

The prevalence rate for acute stress disorder varies across the country and by traumatic event. Accurate prevalence rates for acute
stress disorder are difficult to determine as patients must seek treatment within 30 days of the traumatic event. Despite that, it is
estimated that anywhere between 7-30% of individuals experiencing a traumatic event will develop acute stress disorder (National
Center for PTSD). While acute stress disorder is not a good predictor of who will develop PTSD, approximately 50% of those with
acute stress disorder do eventually develop PTSD (Bryant, 2010; Bryant, Friedman, Speigel, Ursano, & Strain, 2010).
As with PTSD, acute stress disorder is more common in females than males; however, unlike PTSD, there may be some
neurobiological differences in the stress response, gender differences in the emotional and cognitive processing of trauma, and
sociocultural factors that contribute to females developing acute stress disorder more often than males (APA, 2022). With that said,
the increased exposure to traumatic events among females may also be a strong reason why women are more likely to develop
acute stress disorder.

Adjustment Disorder
Adjustment disorders are relatively common as they describe individuals who are having difficulty adjusting to life after a
significant stressor. In psychiatric hospitals in the U.S., Australia, Canada, and Israel, adjustment disorders accounted for roughly
50% of the admissions in the 1990s. It is estimated that anywhere from 5-20% of individuals in outpatient mental health treatment
facilities have an adjustment disorder as their principal diagnosis. Adjustment disorder has been found to be higher in women than
men (APA, 2022).

Prolonged Grief Disorder

As this is a new disorder, the prevalence of DSM-5 prolonged grief disorder is currently unknown. Using a different definition of
the disorder a meta-analysis of studies across four continents suggests a pooled prevalence of 9.8%. It should be noted that these
studies could only be loosely compared with one another making the reported prevalence rate questionable.

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Key Takeaways
You should have learned the following in this section:
Regarding PTSD, rates are highest among people who are likely to be exposed to high traumatic events, women, and minorities.
As for acute stress disorder, prevalence rates are hard to determine since patients must seek medical treatment within 30 days,
but females are more likely to develop the disorder.
Adjustment disorders are relatively common since they occur in individuals having trouble adjusting to a significant stressor,
though women tend to receive a diagnosis more than men.

 Review Questions
1. Compare and contrast the prevalence rates among the trauma and stress-related disorders.
2. What do we know about the prevalence rate for prolonged grief disorder and why?

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5.4: Trauma- and Stressor-Related Disorders - Comorbidity
 Learning Objectives
Describe the comorbidity of PTSD.
Describe the comorbidity of acute stress disorder.
Describe the comorbidity of adjustment disorder.
Describe the comorbidity of prolonged grief disorder.

PTSD
Given the traumatic nature of the disorder, it should not be surprising that there is a high comorbidity rate between PTSD and other
psychological disorders. Individuals with PTSD are more likely than those without PTSD to report clinically significant levels of
depressive, bipolar, anxiety, or substance abuse-related symptoms (APA, 2022). There is also a strong relationship between PTSD
and major neurocognitive disorders, which may be due to the overlapping symptoms between these disorders (Neurocognitive
Disorders will be covered in Module 14).

Acute Stress Disorder

Because 30 days after the traumatic event, acute stress disorder becomes PTSD (or the symptoms remit), the comorbidity of acute
stress disorder with other psychological disorders has not been studied. While acute stress disorder and PTSD cannot be comorbid
disorders, several studies have explored the relationship between the disorders to identify individuals most at risk for developing
PTSD. The literature indicates roughly 80% of motor vehicle accident survivors, as well as assault victims, who met the criteria for
acute stress disorder went on to develop PTSD (Brewin, Andrews, Rose, & Kirk, 1999; Bryant & Harvey, 1998; Harvey & Bryant,
1998). While some researchers indicated acute stress disorder is a good predictor of PTSD, others argue further research between
the two and confounding variables should be explored to establish more consistent findings.

Adjustment Disorder
Unlike most of the disorders we have reviewed thus far, adjustment disorders have a high comorbidity rate with various other
medical conditions (APA, 2022). Often following a critical or terminal medical diagnosis, an individual will meet the criteria for
adjustment disorder as they process the news about their health and the impact their new medical diagnosis will have on their life.
Other psychological disorders are also diagnosed with adjustment disorder; however, symptoms of adjustment disorder must be met
independently of the other psychological condition. For example, an individual with adjustment disorder with depressive mood
must not meet the criteria for a major depressive episode; otherwise, the diagnosis of MDD should be made over adjustment
disorder. As the DSM-5-TR says, “adjustment disorders are common accompaniments of medical illness and may be the major
psychological response to a medical condition” (APA, 2022).

Prolonged Grief Disorder

Prolonged grief disorder is commonly comorbid with MDD, PTSD if the death occurred in violent or accidental circumstances,
substance use disorders, and separation anxiety disorder.

Key Takeaways
You should have learned the following in this section:
PTSD has a high comorbidity rate with psychological and neurocognitive disorders while this rate is hard to establish with acute
stress disorder since it becomes PTSD after 30 days.
Adjustment disorder has a high comorbidity rate with other medical conditions as people process news about their health and
what the impact of a new medical diagnosis will be on their life.
Prolonged grief disorder has a high comorbidity with PTSD, MDD, separation anxiety disorder, and substance use disorders.

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  Review Questions
1. What are the most common comorbidities among trauma and stress-related disorders?
2. Why is it hard to establish comorbidities for acute stress disorder?

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5.5: Trauma- and Stressor-Related Disorders - Etiology
 Learning Objectives
Describe the biological causes of trauma- and stressor-related disorders.
Describe the cognitive causes of trauma- and stressor-related disorders.
Describe the social causes of trauma- and stressor-related disorders.
Describe the sociocultural causes of trauma- and stressor-related disorders.

Biological
HPA axis. One theory for the development of trauma and stress-related disorders is the over-involvement of the hypothalamic-
pituitary-adrenal (HPA) axis. The HPA axis is involved in the fear-producing response, and some speculate that dysfunction
within this axis is to blame for the development of trauma symptoms. Within the brain, the amygdala serves as the integrative
system that inherently elicits the physiological response to a traumatic/stressful environmental situation. The amygdala sends this
response to the HPA axis to prepare the body for “fight or flight.” The HPA axis then releases hormones—epinephrine and
cortisol—to help the body to prepare to respond to a dangerous situation (Stahl & Wise, 2008). While epinephrine is known to
cause physiological symptoms such as increased blood pressure, increased heart rate, increased alertness, and increased muscle
tension, to name a few, cortisol is responsible for returning the body to homeostasis once the dangerous situation is resolved.
Researchers have studied the amygdala and HPA axis in individuals with PTSD, and have identified heightened amygdala
reactivity in stressful situations, as well as excessive responsiveness to stimuli that is related to one’s specific traumatic event
(Sherin & Nemeroff, 2011). Additionally, studies have indicated that individuals with PTSD also show a diminished fear
extinction, suggesting an overall higher level of stress during non-stressful times. These findings may explain why individuals with
PTSD experience an increased startle response and exaggerated sensitivity to stimuli associated with their trauma (Schmidt,
Kaltwasser, & Wotjak, 2013).

Cognitive
Preexisting conditions of depression or anxiety may predispose an individual to develop PTSD or other stress disorders. One theory
is that these individuals may ruminate or over-analyze the traumatic event, thus bringing more attention to the traumatic event and
leading to the development of stress-related symptoms. Furthermore, negative cognitive styles or maladjusted thoughts about
themselves and the environment may also contribute to PTSD symptoms. For example, individuals who identify life events as “out
of their control” report more severe stress symptoms than those who feel as though they have some control over their lives
(Catanesi et al., 2013).

Social
While this may hold for many psychological disorders, social and family support have been identified as protective factors for
individuals prone to develop PTSD. More specifically, rape victims who are loved and cared for by their friends and family
members as opposed to being judged for their actions before the rape, report fewer trauma symptoms and faster psychological
improvement (Street et al., 2011).

Sociocultural
As was mentioned previously, different ethnicities report different prevalence rates of PTSD. While this may be due to increased
exposure to traumatic events, there is some evidence to suggest that cultural groups also interpret traumatic events differently, and
therefore, may be more vulnerable to the disorder. Hispanic Americans have routinely been identified as a cultural group that
experiences a higher rate of PTSD. Studies ranging from combat-related PTSD to on-duty police officer stress, as well as stress
from a natural disaster, all identify Hispanic Americans as the cultural group experiencing the most traumatic symptoms
(Kaczkurkin et al., 2016; Perilla et al., 2002; Pole et al., 2001).
Women also report a higher incidence of PTSD symptoms than men. Some possible explanations for this discrepancy are stigmas
related to seeking psychological treatment, as well as a greater risk of exposure to traumatic events that are associated with PTSD
(Kubiak, 2006). Studies exploring rates of PTSD symptoms for military and police veterans have failed to report a significant

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gender difference in the diagnosis rate of PTSD suggesting that there is not a difference in the rate of occurrence of PTSD in males
and females in these settings (Maguen, Luxton, Skopp, & Madden, 2012).

Key Takeaways
You should have learned the following in this section:
In terms of causes for trauma- and stressor-related disorders, an over-involvement of the hypothalamic-pituitary-adrenal (HPA)
axis has been cited as a biological cause, with rumination and negative coping styles or maladjusted thoughts emerging as
cognitive causes.
Culture may lead to different interpretations of traumatic events thus causing higher rates among Hispanic Americans.
Social and family support have been found to be protective factors for individuals most likely to develop PTSD.

 Review Questions
1. Discuss the four etiological models of the trauma- and stressor-related disorders. Which model best explains the
maintenance of trauma/stress symptoms? Which identifies protective factors for the individual?

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detailed edit history is available upon request.

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5.6: Trauma- and Stressor-Related Disorders - Treatment
 Learning Objectives
Describe the treatment approach of the psychological debriefing.
Describe the treatment approach of exposure therapy.
Describe the treatment approach of CBT.
Describe the treatment approach of Eye Movement Desensitization and Reprocessing (EMDR).
Describe the use of psychopharmacological treatment.

Psychological Debriefing
One way to negate the potential development of PTSD symptoms is thorough psychological debriefing. Psychological debriefing
is considered a type of crisis intervention that requires individuals who have recently experienced a traumatic event to discuss or
process their thoughts and feelings related to the traumatic event, typically within 72 hours of the event (Kinchin, 2007). While
there are a few different methods to a psychological debriefing, they all follow the same general format:
1. Identifying the facts (what happened?)
2. Evaluating the individual’s thoughts and emotional reaction to the events leading up to the event, during the event, and then
immediately following
3. Normalizing the individual’s reaction to the event
4. Discussing how to cope with these thoughts and feelings, as well as creating a designated social support system (Kinchin,
2007).
Throughout the last few decades, there has been a debate on the effectiveness of psychological debriefing. Those within the field
argue that psychological debriefing is not a means to cure or prevent PTSD, but rather, psychological debriefing is a means to assist
individuals with a faster recovery time posttraumatic event (Kinchin, 2007). Research across a variety of traumatic events (i.e.,
natural disasters, burns, war) routinely suggests that psychological debriefing is not helpful in either the reduction of posttraumatic
symptoms nor the recovery time of those with PTSD (Tuckey & Scott, 2014). One theory is these early interventions may
encourage patients to ruminate on their symptoms or the event itself, thus maintaining PTSD symptoms (McNally, 2004). In efforts
to combat these negative findings of psychological debriefing, there has been a large movement to provide more structure and
training for professionals employing psychological debriefing, thus ensuring that those who are providing treatment are properly
trained to do so.

Exposure Therapy
While exposure therapy is predominately used in anxiety disorders, it has also shown great success in treating PTSD-related
symptoms as it helps individuals extinguish fears associated with the traumatic event. There are several different types of exposure
techniques—imaginal, in vivo, and flooding are among the most common types (Cahill, Rothbaum, Resick, & Follette, 2009).
In imaginal exposure, the individual mentally re-creates specific details of the traumatic event. The patient is then asked to
repeatedly discuss the event in increasing detail, providing more information regarding their thoughts and feelings at each step of
the event. During in vivo exposure, the individual is reminded of the traumatic event through the use of videos, images, or other
tangible objects related to the traumatic event that induces a heightened arousal response. While the patient is re-experiencing
cognitions, emotions, and physiological symptoms related to the traumatic experience, they are encouraged to utilize positive
coping strategies, such as relaxation techniques, to reduce their overall level of anxiety.
Imaginal exposure and in vivo exposure are generally done in a gradual process, with imaginal exposure beginning with fewer
details of the event, and slowly gaining information over time. In vivo starts with images or videos that elicit lower levels of
anxiety, and then the patient slowly works their way up a fear hierarchy, until they are able to be exposed to the most distressing
images. Another type of exposure therapy, flooding, involves disregard for the fear hierarchy, presenting the most distressing
memories or images at the beginning of treatment. While some argue that this is a more effective method, it is also the most
distressing and places patients at risk for dropping out of treatment (Resick, Monson, & Rizvi, 2008).

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Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy, as discussed in the mood disorders chapter, has been proven to be an effective form of treatment for
trauma/stress-related disorders. It is believed that this type of treatment is effective in reducing trauma-related symptoms due to its
ability to identify and challenge the negative cognitions surrounding the traumatic event, and replace them with positive, more
adaptive cognitions (Foa et al., 2005).
Trauma-focused cognitive-behavioral therapy (TF-CBT) is an adaptation of CBT that utilizes both CBT techniques and trauma-
sensitive principles to address the trauma-related symptoms. According to the Child Welfare Information Gateway (CWIG; 2012),
TF-CBT can be summarized via the acronym PRACTICE:
P: Psycho-education about the traumatic event. This includes discussion about the event itself, as well as typical emotional
and/or behavioral responses to the event.
R: Relaxation Training. Teaching the patient how to engage in various types of relaxation techniques such as deep breathing
and progressive muscle relaxation.
A: Affect. Discussing ways for the patient to effectively express their emotions/fearsrelated to the traumatic event.
C: Correcting negative or maladaptive thoughts.
T: Trauma Narrative. This involves having the patient relive the traumatic event (verbally or written), including as many
specific details as possible.
I: In vivo exposure (see above).
C: Co-joint family session. This provides the patient with strong social support and a sense of security. It also allows family
members to learn about the treatment so that they are able to assist the patient if necessary.
E: Enhancing Security. Patients are encouraged to practice the coping strategies they learn in TF-CBT to prepare for when they
experience these triggers out in the real world, as well as any future challenges that may come their way.

Eye Movement Desensitization and Reprocessing (EMDR)

In the late 1980s, psychologist Francine Shapiro found that by focusing her eyes on the waving leaves during her daily walk, her
troubling thoughts resolved on their own. From this observation, she concluded that lateral eye movements facilitate the cognitive
processing of traumatic thoughts (Shapiro, 1989).
While EMDR has evolved somewhat since Shapiro’s first claims, the basic components of EMDR consist of lateral eye movement
induced by the therapist moving their index finger back and forth, approximately 35 cm from the client’s face, as well as
components of cognitive-behavioral therapy and exposure therapy. The following 8-step approach is the standard treatment
approach of EMDR (Shapiro & Maxfield, 2002):
1. Patient History and Treatment Planning – Identify trauma symptoms and potential barriers to treatment.
2. Preparation – Psychoeducation of trauma and treatment.
3. Assessment – Careful and detailed evaluation of the traumatic event. Patient identifies images, cognitions, and emotions related
to the traumatic event, as well as trauma-related physiological symptoms.
4. Desensitization and Reprocessing – Holding the trauma image, cognition, and emotion in mind, while simultaneously
assessing their physiological symptoms, the patient must track the clinician’s finger movement for approximately 20 seconds.
At this time, the patient must “blank it out” and let go of the memory.
5. Installation of Positive Cognitions – Once the negative image, cognition, and emotions are reduced, the patient must hold onto
a positive image or thought while again tracking the clinician’s finger movement for approximately 20 seconds.
6. Body Scan – Patient must identify any lingering bodily sensations while again tracking the clinician’s fingers for a third time to
discard any remaining trauma symptoms.
7. Closure – Patient is provided with positive coping strategies and relaxation techniques to assist with any recurrent cognitions or
emotions related to the traumatic experience.
8. Reevaluation – Clinician assesses if treatment goals were met. If not, schedules another treatment session and identifies
remaining symptoms.
As you can see from above, only steps 4-6 are specific to EMDR; the remaining treatment is essentially a combination of exposure
therapy and cognitive-behavioral techniques. Because of the high overlap between treatment techniques, there have been quite a
few studies comparing the treatment efficacy of EMDR to TF-CBT and exposure therapy. While research initially failed to identify
a superior treatment, often citing EMDR and TF-CBT as equally efficacious in treating PTSD symptoms (Seidler & Wagner, 2006),
more recent studies have found that EMDR may be superior to that of TF-CBT, particularly in psycho-oncology patients

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(Capezzani et al., 2013; Chen, Zang, Hu & Liang, 2015). While meta-analytic studies continue to debate which treatment is the
most effective in treating PTSD symptoms, the World Health Organization’s (2013) publication on the Guidelines for the
Management of Conditions Specifically Related to Stress, identified TF-CBT and EMDR as the only recommended treatment for
individuals with PTSD.
The National Institute for Health and Care Excellence (NICE) says to consider EMDR for adults with a diagnosis of PTSD and
who presented between 1 and 3 months after a non-combat related trauma if the person shows a preference for EMDR and to offer
it to adults with a diagnosis of PTSD who have presented more than three months after a non-combat related trauma. They state
that EMDR for adults should (cited directly from their website):
be based on a validated manual
typically be provided over 8 to 12 sessions, but more if clinically indicated, for example if they have experienced multiple
traumas
be delivered by trained practitioners with ongoing supervision
be delivered in a phased manner and include psychoeducation about reactions to trauma; managing distressing memories and
situations; identifying and treating target memories (often visual images); and promoting alternative positive beliefs about the
self
use repeated in-session bilateral stimulation (normally with eye movements but use other methods, including taps and tones, if
preferred or more appropriate, such as for people who are visually impaired) for specific target memories until the memories are
no longer distressing
include the teaching of self-calming techniques and techniques for managing flashbacks, for use within and between sessions.
For more on NICE’s PTSD guidance (2018) as it relates to EMDR, please see Sections 1.6.18 to 1.6.20:
https://www.nice.org.uk/guidance/ng116/chapter/Recommendations

Psychopharmacological Treatment
While psychopharmacological interventions have been shown to provide some relief, particularly to veterans with PTSD, most
clinicians agree that resolution of symptoms cannot be accomplished without implementing exposure and/or cognitive techniques
that target the physiological and maladjusted thoughts maintaining the trauma symptoms. With that said, clinicians agree that
psychopharmacology interventions are an effective second line of treatment, particularly when psychotherapy alone does not
produce relief from symptoms.
Among the most common types of medications used to treat PTSD symptoms are selective serotonin reuptake inhibitors (SSRIs;
Bernardy & Friedman, 2015). As previously discussed in the depression chapter, SSRIs work by increasing the amount of serotonin
available to neurotransmitters. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are also
recommended as second-line treatments. Their effectiveness is most often observed in individuals who report co-occurring major
depressive disorder symptoms, as well as those who do not respond to SSRIs (Forbes et al., 2010). Unfortunately, due to the
effective CBT and EMDR treatment options, research on psychopharmacological interventions has been limited. Future studies
exploring other medication options are needed to determine if there are alternative medication options for stress/trauma disorder
patients.

Key Takeaways
You should have learned the following in this section:
Several treatment approaches are available to clinicians to alleviate the symptoms of trauma- and stressor-related disorders.
The first approach, psychological debriefing, has individuals who have recently experienced a traumatic event discuss or
process their thoughts related to the event and within 72 hours.
Another approach is to expose the individual to a fear hierarchy and then have them use positive coping strategies such as
relaxation techniques to reduce their anxiety or to toss the fear hierarchy out and have the person experience the most
distressing memories or images at the beginning of treatment.
The third approach is Cognitive Behavioral Therapy (CBT) and attempts to identify and challenge the negative cognitions
surrounding the traumatic event and replace them with positive, more adaptive cognitions.
The fourth approach, called EMDR, involves an 8-step approach and the tracking of a clinician’s fingers which induces lateral
eye movements and aids with the cognitive processing of traumatic thoughts.

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 Finally, when psychotherapy does not produce relief from symptoms, psychopharmacology interventions are an effective
second line of treatment and may include SSRIs, TCAs, and MAOIs.

 Review Questions
1. Identify the different treatment options for trauma and stress-related disorders. Which treatment options are most effective?
Which are least effective?

Module Recap
In Module 5, we discussed trauma- and stressor-related disorders to include PTSD, acute stress disorder, adjustment disorder, and
prolonged stress disorder. We defined what stressors were and then explained how these disorders present. In addition, we clarified
the epidemiology, comorbidity, and etiology of each disorder. Finally, we discussed potential treatment options for trauma- and
stressor-related disorders. Our discussion in Module 6 moves to dissociative disorders.

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 CHAPTER OVERVIEW

6: Dissociative Disorders
 Learning Objectives
Describe how dissociative disorders present.
Describe the epidemiology of dissociative disorders.
Describe comorbidity in relation to dissociative disorders.
Describe the etiology of dissociative disorders.
Describe treatment options for dissociative disorders.

In Module 6, we will discuss matters related to dissociative disorders to include their clinical presentation, epidemiology,
comorbidity, etiology, and treatment options. Our discussion will consist of dissociative identity disorder, dissociative amnesia, and
depersonalization/ derealization. Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an overview of models
to explain psychopathology (Module 2), and descriptions of the various therapies (Module 3).
6.1: Dissociative Disorders - Clinical Presentation
6.2: Dissociative Disorders - Epidemiology
6.3: Dissociative Disorders - Comorbidity
6.4: Dissociative Disorders - Etiology
6.5: Dissociative Disorders - Treatment

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1
6.1: Dissociative Disorders - Clinical Presentation
 Learning Objectives
Describe dissociative disorders.
Describe how dissociative identity disorder presents.
Describe how dissociative amnesia presents.
Describe how depersonalization/derealization presents.

Dissociative disorders are a group of disorders characterized by symptoms of disruption and/or discontinuity in consciousness,
memory, identity, emotion, body representation, perception, motor control, and behavior (APA, 2022). These symptoms are likely
to appear following a significant stressor or years of ongoing stress (i.e., abuse; Maldonadao & Spiegel, 2014). Occasionally, one
may experience temporary dissociative symptoms due to lack of sleep or ingestion of a substance; however, these would not
qualify as a dissociative disorder due to the lack of impairment in functioning. Furthermore, individuals who suffer from acute
stress disorder and PTSD often experience dissociative symptoms, such as amnesia, numbing, flashbacks, and
depersonalization/derealization. However, because of the identifiable stressor (and lack of additional symptoms listed below), they
meet diagnostic criteria for a stress disorder as opposed to a dissociative disorder.
There are three main types of dissociative disorders: dissociative identity disorder, dissociative amnesia, and
depersonalization/derealization disorder.

Dissociative Identity Disorder (DID)

The key diagnostic criteria for dissociative identity disorder is the presence of two or more distinct personality states or an
experience of possession (Criteria A). How overt or covert the personality states are depends on psychological motivation, stress
level, cultural context, emotional resilience, and internal conflicts and dynamics (APA, 2022), and severe or prolonged stress may
result in sustained periods of identify confusion/alteration. Those presenting as being possessed by spirits or demons and for a
small proportion of non-possession-form cases, the alternate identifies are readily observable. Generally, though, the identities in
non-possession-form dissociative identity disorder are not overtly displayed or only subtly displayed and when they are, it is just in
a minority of individuals and manifests as different names, hairstyles, handwritings, wardrobes, accents, etc. If the alternate
identities are not observable, their presence is identified through sudden alterations or discontinuities in the individual’s sense of
self and sense of agency, as well as recurrent dissociative amnesias (see the second criteria below; APA, 2022).
The second main diagnostic criteria (Criteria B) for dissociative identity disorder is that there must be a gap in the recall of events,
information, or trauma due to the switching of personalities. These gaps are more excessive than typical forgetting one may
experience due to a lack of attention. The dissociative amnesia presents as gaps in autobiographical memory, lapses in memory of
well-learned skills or recent events, and discovering possessions for which there is no recollection of ever owning, and can involve
everyday events and not just events that are stressful or traumatic.
It should be noted that most possession states occurring around the world are part of broadly accepted cultural or religious practice
and should not be diagnosed as dissociative identity disorder (Criteria D). The possession-form identities in dissociative identity
disorder manifest most often as a spirit or supernatural being taking control and the individual speaking or acting in a distinctly
different way. These identities present recurrently, are involuntary and unwanted, and cause significant distress or impairment
(Criteria C). Impairment varies in adults from minimal (i.e., high functioning professionals) to profound. For those minimally
affected, marital, family, relational, and parenting functions are more likely to be impaired by symptoms of dissociative identity
disorder rather than their occupational and professional life.
While personalities can present at any time, there is generally a dominant or primary personality that is present most of the time.
From there, an individual may have several subpersonalities. Although it is hard to identify how many subpersonalities an
individual may have at one time, it is believed that there are on average 15 subpersonalities for women and 8 for men (APA, 2000).
The switching or shifting between personalities varies among individuals and can range from merely appearing to fall asleep, to
very dramatic, involving excessive bodily movements, though for most, the change is subtle and may occur with only subtle
changes in overt presentation. When sudden and unexpected, switching is generally precipitated by a significant stressor, as the
subpersonality best equipped to handle the current stressor will present. The relationship between subpersonalities varies between
individuals, with some individuals reporting knowledge of other subpersonalities while others have a one-way amnesic relationship

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with subpersonalities, meaning they are not aware of other personalities (Barlow & Chu, 2014). These individuals will experience
episodes of “amnesia” when the primary personality is not present.

Dissociative Amnesia
Dissociative amnesia is identified by the inability to recall important autobiographical information, usually of a traumatic or
stressful nature. It often consists of selective amnesia for a specific event or events or generalized amnesia for identity and life
history. This type of amnesia is different from what one would consider permanent amnesia in that the information was
successfully stored in memory but cannot be freely recollected. It is conceptualized as possibly being a reversible memory retrieval
deficit. Additionally, individuals experiencing permanent amnesia often have a neurobiological cause, whereas dissociative
amnesia does not (APA, 2022).
There are a few types of amnesia within dissociative amnesia. Localized amnesia, the most common type, is the inability to recall
events during a specific period. The length of time within a localized amnesia episode can vary—it can be as short as the time
immediately surrounding a traumatic event, to months or years, should the traumatic event occur that long (as commonly seen in
abuse and combat situations). Selective amnesia is, in a sense, a component of localized amnesia in that the individual can recall
some, but not all, of the details during a specific period. For example, a soldier may experience dissociative amnesia during the
time they were deployed, yet still have some memories of positive experiences such as celebrating Thanksgiving or Christmas
dinner with the members of their unit. Systematized amnesia occurs when an individual fails to recall a specific category of
information such as not recalling a specific room in their childhood home.
Conversely, some individuals experience generalized dissociative amnesia in which they have a complete loss of memory for
most or all of their life history, including their own identity, previous knowledge about the world, and/or well-learned skills.
Individuals who experience this amnesia experience deficits in both semantic and procedural knowledge. This means that
individuals have no common knowledge of (i.e., cannot identify letters, colors, numbers) nor can they engage in learned skills (i.e.,
typing shoes, driving car). While generalized dissociative amnesia is extremely rare, it is also extremely frightening. The onset is
acute, and the individual is often found wandering in a state of disorientation. Many times, these individuals are brought into
emergency rooms by law enforcement following a dangerous situation such as an individual wandering on a busy road.
The distress and impairment suffered by those with dissociative amnesia resulting from childhood/adolescent traumatization varies.
Some are chronically impaired in their ability to form and sustain satisfactory attachments while others are highly successful in
their occupation due to compulsive overwork. And finally, a substantial subgroup of those afflicted by generalized dissociative
amnesia develop a highly impairing, chronic autobiographical memory deficit that is not ameliorated by relearning their life
history, resulting in poor overall functioning in most life domains (APA, 2022).

Depersonalization/Derealization Disorder
Depersonalization/derealization disorder is categorized by recurrent episodes of depersonalization and/or derealization.
Depersonalization can be defined as a feeling of unreality or detachment from oneself. Individuals describe this feeling as an out-
of-body experience where you are an observer of your thoughts, feelings, and physical being. Furthermore, some patients report
feeling as though they lack speech or motor control, thus feeling at times like a robot. Distortions of one’s physical body have also
been reported, with various body parts appearing enlarged or shrunken. Emotionally, one may feel detached from their feelings,
lacking the ability to feel emotions despite knowing they have them.
Symptoms of derealization include feelings of unreality or detachment from the world—whether it be individuals, objects, or their
surroundings. For example, an individual may feel as though they are unfamiliar with their surroundings, even though they are in a
place they have been to many times before. Feeling emotionally disconnected from close friends or family members whom they
have strong feelings for is another common symptom experienced during derealization episodes. Sensory changes have also been
reported, such as feeling as though your environment is distorted, blurry, or even artificial. Distortions of time, distance, and
size/shape of objects may also occur.
These episodes can last anywhere from a few hours to days, weeks, or even months. The onset is generally sudden, and like the
other dissociative disorders, is often triggered by intense stress or trauma. Many individuals describe feeling like they are “crazy”
or “going crazy” and fear they have irreversible brain damage. They experience an altered sense of time and may be obsessed about
whether they really exist.
As one can imagine, depersonalization/derealization disorder can cause significant emotional distress, as well as impairment in
one’s daily functioning. The disorder is associated with major morbidity and impairment occurs in both interpersonal and

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occupational spheres due to “…the hypoemotionality with others, subjective difficulty in focusing and retaining information, and a
general sense of disconnectedness form life” (APA, 2022).

Key Takeaways
You should have learned the following in this section:
Dissociative disorders are characterized by disruption in consciousness, memory, identity, emotion, perception, motor control,
or behavior. They include dissociative identity disorder, dissociative amnesia, and depersonalization/derealization disorder.
Dissociative identity disorder is the presence of two or more distinct personality states or an experience of possession.
Dissociative amnesia is characterized by the inability to recall important autobiographical information, whether during a
specific period (localized) or one’s entire life (generalized).
Depersonalization/derealization disorder includes a feeling of unreality or detachment from oneself (depersonalization) and
feelings of unreality or detachment from the world (derealization).

 Review Questions
1. Identify the diagnostic criteria for each of the three dissociative disorders. How are they similar? How are they different?
2. What are the types of amnesia within dissociative amnesia?
3. What is the difference between depersonalization and derealization?

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6.2: Dissociative Disorders - Epidemiology
 Learning Objectives
Describe the epidemiology of dissociative disorders.

Dissociative disorders were once believed to be extremely rare; however, more recent research suggests that they may be more
present in the general population than once thought. Estimates for the prevalence of dissociative identity disorder in U.S. adults is
1.5%, with women predominating in adult clinical settings. Symptom profiles, clinical history, and childhood trauma history show
few gender differences though women have higher rates of somatization. Research shows that dissociative amnesia occurs in
approximately 1.8% of the U.S. population. It is estimated that about one-half of all adults have experienced at least one episode of
depersonalization/derealization during their life, however, symptomatology that meets full criteria for the disorder is markedly less
common than these transient symptoms. A one-month prevalence of about 1-2% was reported in the United Kingodm (APA, 2022).
The onset of dissociative disorders is generally late adolescence to early adulthood, with the exception of dissociative identity
disorder. Due to the high comorbidity between childhood abuse and dissociative identity disorder, it is believed that symptoms
begin in early childhood following the repeated exposure to abuse; however, the full onset of the disorder is not observed (or
noticed by others) until adolescence (Sar et al., 2014).

Key Takeaways
You should have learned the following in this section:
Dissociative identity disorder has a prevalence of 1.5% and dissociative amnesia occurs in approximately 1.8% of the U.S.
population.
Estimates for depersonalization/derealization disorder are unknown, though it is believed that about half of all adults have
experienced at least one episode during their life (i.e. transient symptoms and not full criteria).

 Review Questions
1. What are the prevalence rates for dissociative disorders? What are some identified barriers in determining prevalence rates
of these disorders?

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6.3: Dissociative Disorders - Comorbidity
 Learning Objectives
Describe the comorbidity of dissociative disorders.

Given that a traumatic experience often precipitates dissociative disorders, it should not be surprising that there is a high
comorbidity between most dissociative disorders and PTSD (comorbidity of depersonalization/derealization disorder with PTSD is
low). Similarly, depressive disorders are also commonly found in combination with dissociative disorders, likely due to the impact
the disorders have on social and emotional functioning. In individuals with dissociative amnesia, a wide range of emotions related
to their inability to recall memories during the episode often present once the amnesia episode is in remission (APA, 2022). These
emotions frequently contribute to the development of a depressive episode.
There has been some evidence of comorbid somatic symptom disorder and conversion disorder, particularly for those who
experience dissociative amnesia. Furthermore, dependent, obsessive-compulsive, avoidant, and borderline personality
traits/disorders are comorbid and for dissociative identity disorder and dissociative amnesia there is evidence of comorbid
substance-related and feeding and eating disorders. Anxiety disorders are common for depersonalization/derealization disorder, and
often individuals concurrently have unipolar depressive disorder.

Key Takeaways
You should have learned the following in this section:
Many dissociative disorders have been found to have a high comorbidity with PTSD and depressive disorders.
Somatic symptom and conversion disorders, as well as some personality disorders, have also been found to be comorbid.

 Review Questions
1. What are the common comorbid diagnoses for individuals with dissociative disorders?

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6.4: Dissociative Disorders - Etiology
 Learning Objectives
Describe the biological causes of dissociative disorders.
Describe the cognitive causes of dissociative disorders.
Describe the sociocultural causes of dissociative disorders.
Describe the psychodynamic causes of dissociative disorders.

Biological
While studies on the involvement of genetic underpinnings need additional research, there is some suggestion that heritability rates
for dissociation rage from 50-60% (Pieper, Out, Bakermans-Kranenburg, Van Ijzendoorn, 2011). However, it is suggested that the
combination of genetic and environmental factors may play a larger role in the development of dissociative disorders than genetics
alone (Pieper, Out, Bakermans-Kranenburg, Van Ijzendoorn, 2011).

Cognitive
One proposed cognitive theory of dissociative disorders, particularly dissociative amnesia, is a memory retrieval deficit. More
specifically, Kopelman (2000) theorizes that the combination of psychological stress and various other biopsychosocial
predispositions affects the frontal lobes executive system’s ability to retrieve autobiographical memories (Picard et al., 2013).
Neuroimaging studies have supported this theory by showing deficits to several prefrontal regions, which is one area responsible
for memory retrieval (Picard et al., 2013). Despite these findings, there is still some debate over which specific brain regions within
the executive system are responsible for the retrieval difficulties, as research studies have reported mixed findings.
Specific to dissociative identity disorder, neuroimaging studies have shown differences in hippocampus activation between
subpersonalities (Tsai, Condie, Wu & Chang, 1999). As you may recall, the hippocampus is responsible for storing information
from short-term to long-term memory. It is hypothesized that this brain region is responsible for the generation of dissociative
states and amnesia (Staniloiu & Markowitsch, 2010).

Sociocultural
The sociocultural model of dissociative disorders has been primarily influenced by Lilienfeld and colleagues (1999) who argue that
the influence of mass media and its publications of dissociative disorders, provide a model for individuals to not only learn about
dissociative disorders but also engage in similar dissociative behaviors. This theory has been supported by the significant increase
in dissociative identity disorder cases after the publication of Sybil, a documentation of a woman’s 16 subpersonalities (Goff &
Simms, 1993).
These mass media productions are not just suggestive to patients. It has been suggested that mass media also influences the way
clinicians gather information regarding dissociative symptoms of patients. For example, therapists may unconsciously use
questions or techniques in session that evoke dissociative types of problems in their patient following exposure to a media source
discussing dissociative disorders.

Psychodynamic
The psychodynamic theory of dissociative disorders assumes that dissociative disorders are caused by an individual’s repressed
thoughts and feelings related to an unpleasant or traumatic event (Richardson, 1998). In blocking these thoughts and feelings, the
individual is subconsciously protecting himself from painful memories.
While a single incidence of repression may explain dissociative amnesia, psychodynamic theorists believe that dissociative identity
disorder results from repeated exposure to traumatic experiences, such as childhood abuse, neglect, or abandonment (Dalenberg et
al., 2012). According to the psychodynamic perspective, children who experience repeated traumatic events such as physical abuse
or parental neglect lack the support and resources to cope with these experiences. To escape from their current situation, children
develop different personalities to essentially flee the dangerous situation they are in. While there is limited scientific evidence to
support this theory, the nature of severe childhood psychological trauma is consistent with this theory, as individuals with
dissociative identity disorder have the highest rate of childhood psychological trauma compared to all other psychiatric disorders
(Sar, 2011).

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Key Takeaways
You should have learned the following in this section:
Though there is some evidence for a genetic component to dissociative disorders, a combination of genes and environment are
thought to play a larger role.
A cognitive explanation assumes a memory retrieval deficit, particularly related to dissociative amnesia, and differential
hippocampus activation between subpersonalities in dissociative identity disorder.
Mass media is also purported to have caused a rise in dissociative disorders due to the attention it gives these disorders in its
publications and movies such as Sybil.
Finally, repressed thoughts and feelings are thought to be the cause of dissociative disorders in the psychodynamic theory.

 Review Questions
1. How do the biological, cognitive, sociocultural, and psychodynamic perspectives differ in their explanation of the
development of dissociative disorders?

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6.5: Dissociative Disorders - Treatment
 Learning Objectives
Clarify why treatment for dissociative disorders is limited.
Describe treatment options for dissociative identity disorder.
Describe treatment options for dissociative amnesia.
Describe treatment options for depersonalization/derealization disorder.

Treatment for dissociative disorders is limited for a few reasons. First, with respect to dissociative amnesia, many individuals
recover on their own without any intervention. Occasionally treatment is sought out after recovery due to the traumatic nature of
memory loss. Second, the rarity of these disorders has offered limited opportunities for research on both the development and
effectiveness of treatment methods. Due to the differences between dissociative disorders, treatment options will be discussed
specific to each disorder.

Dissociative Identity Disorder

The ultimate treatment goal for dissociative identity disorder is the integration of subpersonalities to the point of final fusion (Chu
et al., 2011). Integration refers to the ongoing process of merging subpersonalities into one personality. Psychoeducation is
paramount for integration, as the individual must understand their disorder, as well as acknowledge their subpersonalities. As
mentioned above, many individuals have a one-way amnesic relationship with the subpersonalities, meaning they are not aware of
one another. Therefore, the clinician must first make the individual aware of the various subpersonalities that present across
different situations.
Achieving integration requires several steps. First, the clinician needs to build a relationship and strong rapport with the primary
personality. From there, the clinician can begin to encourage communication and coordination between the subpersonalities
gradually. Making the subpersonalities aware of one another, as well as addressing their conflicts, is an essential component of the
integration of subpersonalities, and the core of dissociative identity disorder treatment (Chu et al., 2011).
Once the individual is aware of their personalities, treatment can continue with the goal of fusion. Fusion occurs when two or more
alternate identities join (Chu et al., 2011). When this happens, there is a complete loss of separateness. Depending on the number of
subpersonalities, this process can take quite a while. Once all subpersonalities are fused and the individual identifies themselves as
one unified self, it is believed the patient has reached final fusion.
It should be noted that final fusion is difficult to obtain. As you can imagine, some patients do not find final fusion a desirable
outcome, particularly those with harrowing histories; chronic, severe stressors; advanced age; and comorbid medical and
psychiatric disorders, to name a few. For individuals where final fusion is not the treatment goal, the clinician may work toward
resolution or sufficient integration and coordination of subpersonalities that allows the individual to function independently (Chu et
al., 2011). Unfortunately, individuals that do not achieve final fusion are at greater risk for relapse of symptoms, particularly those
with whose dissociative identity disorder appears to stem from traumatic experiences.
Once an individual reaches final fusion, ongoing treatment is essential to maintain this status. In general, treatment focuses on
social and positive coping skills. These skills are particularly helpful for individuals with a history of traumatic events, as it can
help them process these events, as well as help prevent future relapses.

Dissociative Amnesia
As previously mentioned, many individuals regain memory without the need for treatment; however, there is a small population
that does require additional treatment. While there is no evidenced-based treatment for dissociative amnesia, both hypnosis and
phasic therapy have been shown to produce some positive effects in patients with dissociative amnesia.
6.5.2.1. Hypnosis. One theory of dissociative amnesia is that it is a form of self-hypnosis and that individuals hypnotize themselves
to forget information or events that are unpleasant (Dell, 2010). Because of this theory, one type of treatment that has routinely
been implemented for individuals with dissociative amnesia is hypnosis. Through hypnosis, the clinician can help the individual
contain, modulate, and reduce the intensity of the amnesia symptoms, thus allowing them to process the traumatic or unpleasant
events underlying the amnesia episode (Maldonadao & Spiegel, 2014). To do this, the clinician will encourage the patient to think
of memories just before the amnesic episode as though it was the present time. The clinician will then slowly walk them through

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the events during the amnesic period to reorient the individual to experience these events. This technique is essentially a way to
encourage a controlled recall of dissociated memories, something that is particularly helpful when the memories include traumatic
experiences (Maldonadao & Spiegel, 2014).
Another form of “hypnosis” is the use of barbiturates, also known as “truth serums,” to help relax the individual and free their
inhibitions. Although not always effective, the theory is that these drugs reduce the anxiety surrounding the unpleasant events
enough to allow the individual to recall and process these memories in a safe environment (Ahern et al., 2000).

Depersonalization/Derealization Disorder
Depersonalization/derealization disorder symptoms generally occur for an extensive period before the individual seeks out
treatment. Because of this, there is some evidence to support that the diagnosis alone is effective in reducing symptom intensity, as
it also relieves the individual’s anxiety surrounding the baffling nature of the symptoms (Medford, Sierra, Baker, & David, 2005).
Due to the high comorbidity of depersonalization/derealization disorder with anxiety and depression, the goal of treatment is often
alleviating these secondary mental health symptoms related to the depersonalization/derealization symptoms. While there has been
some evidence to suggest treatment with an SSRI is effective in improving mood, the evidence for a combined treatment method of
psychopharmacological and psychological treatment is even more compelling (Medford, Sierra, Baker, & David, 2005). The
psychological treatment of preference is cognitive-behavioral therapy as it addresses the negative attributions and appraisals
contributing to the depersonalization/derealization symptoms (Medford, Sierra, Baker, & David, 2005). By challenging these
catastrophic attributions in response to stressful situations, the individual can reduce overall anxiety levels, which consequently
reduces depersonalization/ derealization symptoms.

Key Takeaways
You should have learned the following in this section:
Treatment for dissociative identity disorder involves the integration of subpersonalities to the point of final fusion and takes
several steps to achieve.
For some patients, this is not possible as they do not find final fusion to be a desirable outcome.
Instead, the clinician will work to achieve resolution or sufficient integration and coordination of the subpersonalities to allow
the person to function independently.
For dissociative amnesia, hypnosis and phasic therapy are used, as well as barbiturates known as “truth serums.”
Finally, diagnosis alone is sometimes enough to reduce the intensity of symptoms related to depersonalization/derealization
disorder and due to the high comorbidity with anxiety and depression, alleviation of these secondary symptoms is often the goal
of treatment.

 Review Questions
1. What is the treatment goal for dissociative identity disorder? How is it achieved?
2. What are the treatment options for dissociative amnesia and depersonalization/depersonalization disorder?

Module Recap
In this module, we discussed the dissociative disorders of Dissociative Identity Disorder, Dissociative Amnesia, and
Depersonalization/Derealization Disorder in terms of their clinical presentation, epidemiology, comorbidity, etiology, and treatment
approaches.

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 SECTION OVERVIEW

Part III. Mental Disorders – Block 2

7: Anxiety Disorders
7.1: Anxiety Disorders - Clinical Presentation
7.2: Anxiety Disorders - Epidemiology
7.3: Anxiety Disorders - Comorbidity
7.4: Anxiety Disorders - Etiology
7.5: Anxiety Disorders - Treatment

8: Somatic Symptom and Related Disorders

8.1: Somatic Symptom and Related Disorders - Clinical Presentation
8.2: Somatic Symptom and Related Disorders - Epidemiology
8.3: Somatic Symptom and Related Disorders - Comorbidity
8.4: Somatic Symptom and Related Disorders - Etiology
8.5: Somatic Symptom and Related Disorders - Treatment
8.6: Somatic Symptom and Related Disorders - Psychological Factors Affecting Other Medical Conditions

9: Obsessive-Compulsive and Related Disorders

9.1: Obsessive-Compulsive and Related Disorders - Clinical Presentation
9.2: Obsessive-Compulsive and Related Disorders - Epidemiology
9.3: Obsessive-Compulsive and Related Disorders - Comorbidity
9.4: Obsessive-Compulsive and Related Disorders - Etiology
9.5: Obsessive-Compulsive and Related Disorders - Treatment

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1
 CHAPTER OVERVIEW

7: Anxiety Disorders
 Learning Objectives
Describe how anxiety disorders present.
Describe the epidemiology of anxiety disorders.
Describe comorbidity in relation to anxiety disorders.
Describe the etiology of anxiety disorders.
Describe treatment options for anxiety disorders.

In Module 7, we will discuss matters related to anxiety disorders to include their clinical presentation, epidemiology, comorbidity,
etiology, and treatment options. Our discussion will include generalized anxiety disorder, specific phobia, agoraphobia, social
anxiety disorder, and panic disorder. Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an overview of the
various models to explain psychopathology (Module 2), and descriptions of the various therapies (Module 3).
7.1: Anxiety Disorders - Clinical Presentation
7.2: Anxiety Disorders - Epidemiology
7.3: Anxiety Disorders - Comorbidity
7.4: Anxiety Disorders - Etiology
7.5: Anxiety Disorders - Treatment

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1
7.1: Anxiety Disorders - Clinical Presentation
 Learning Objectives
Describe how generalized anxiety disorder presents.
Describe how specific phobia presents.
Describe how agoraphobia presents.
Describe how social anxiety disorder presents.
Describe how panic disorder presents.

The hallmark symptoms of anxiety-related disorders are excessive fear and anxiety and related behavioral disturbances. How do we
distinguish fear from anxiety? The DSM says that fear is an emotional response to a real or perceived imminent threat which leads
to “…surges of autonomic arousal necessary for flight or flight, thoughts of immediate danger, and escape behaviors.” Anxiety, on
the other hand, is the anticipation of a future threat leading to, “…muscle tension and vigilance in preparation for future danger and
cautious or avoidant behaviors” (APA, 2022, pg. 215). The anxiety disorders differ from one another in the types of objects or
situations that lead to fear, anxiety, or avoidance behavior. We will cover generalized anxiety disorder, specific phobia,
agoraphobia, social anxiety disorder, and panic disorder.

Generalized Anxiety Disorder

Generalized anxiety disorder is characterized by an underlying excessive anxiety and worry related to a wide range of events or
activities and lasting for more days than not for at least six months. While many individuals experience some degree of worry
throughout the day, individuals with generalized anxiety disorder experience worry of greater intensity and for longer periods than
the average person (APA, 2022). Additionally, they are often unable to control their worry through various coping strategies, which
directly interferes with their ability to engage in daily social and occupational tasks. To receive a diagnosis of generalized anxiety
disorder, three or more of the following somatic symptoms must be present in adults as well: restlessness, fatigue, difficultly
concentrating, irritability, muscle tension, and problems sleeping (APA, 2022; Gelenberg, 2000).

Specific Phobia
Specific phobia is distinguished by fear or anxiety specific to an object or a situation. While the amount of fear or anxiety related
to the specific object or situation varies among individuals, it also varies related to the proximity of the object or situation. When
individuals are face-to-face with their specific phobia, immediate fear is present, and the phobic object or situation is actively
avoided or endured. It should also be noted that these fears are excessive and irrational, often severely impacting one’s daily
functioning. The fear, anxiety, or avoidance is persistent, lasting at least six months (APA, 2022).
Individuals can experience multiple specific phobias at the same time. In fact, nearly 75% of individuals with a specific phobia
report fear of more than one object and the average individual fears three or more objects or situations (APA, 2022). When making
a diagnosis of specific phobia, it is important to identify the stimulus. Among the most diagnosed specific phobias are animals,
natural environment (height, storms, water), blood-injection-injury (needles, invasive medical procedures), or situational (airplanes,
elevators, enclosed places). In terms of gender differences, women predominantly experience animal, natural environment, and
situational specific phobias while blood-injection-injury phobia is experienced by both men and women equally (APA, 2022).

Agoraphobia
Agoraphobia is defined as intense fear or anxiety triggered by two or more of the following: using public transportation such as
planes, trains, ships, buses; being in large, open spaces such as parking lots or on bridges; being in enclosed spaces like stores or
movie theaters; being in a crowd or standing in line; or being outside of the home alone. The individual fears or avoids these
situations because they believe something terrible may occur and due to concern over not being able to escape or help not being
available (APA, 2022). Active avoidance of the situations occurs and can be behavioral such as changing daily routines or using
delivery to avoid entering a restaurant or cognitive such as using distraction to bear with an agoraphobic situation. The avoidance
can result in the person being homebound. The fear or anxiety is out of proportion to the actual danger they pose and has been
present for at least six months.

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Social Anxiety Disorder
For social anxiety disorder, the anxiety or fear relates to social situations, particularly those in which an individual can be
evaluated by others. More specifically, the individual is worried that they will be judged negatively and viewed as stupid, anxious,
crazy, boring, or unlikeable, to name a few. Some individuals report feeling concerned that their anxiety symptoms will be obvious
to others via blushing, stuttering, sweating, trembling, etc. These fears severely limit an individual’s behavior in social settings and
have occurred for six months or more.
To explain social anxiety in greater detail, let’s review the story of Mary. Mary reported the onset of her social anxiety disorder in
early elementary school when teachers would call on students to read parts of their textbook aloud. Mary stated that she was fearful
of making mistakes while reading and to alleviate this anxiety, she would read several sections ahead of the class to prepare for her
turn to read aloud. Despite her preparedness, one day in 5th grade, Mary was called to read, and she stumbled on a few words.
While none of her classmates realized her mistake, Mary was extremely embarrassed and reported higher levels of anxiety during
future read aloud moments in school. In fact, when she was called upon, Mary stated she would completely freeze up and not talk
at all. After a few moments of not speaking, her teacher would skip Mary and ask another student to read her section. It took
several years and a very supportive teacher for Mary to begin reading aloud in class again.
Like Mary, individuals with social anxiety disorder report that all or nearly all social situations provoke this intense fear. Some
individuals even report significant anticipatory fear days or weeks before a social event is to occur. This anticipatory fear often
leads to avoidance of social events in some individuals; others will attend social events with a marked fear of possible threats.
Because of these fears, there is a significant impact on one’s social and occupational functioning.
It is important to note that the cognitive interpretation of these social events is often excessive and out of proportion to the actual
risk of being negatively evaluated. As we saw in Mary’s case, when she stumbled upon her words while reading to the class, none
of her peers even noticed her mistake. Situations in which individuals experience anxiety toward a real threat, such as bullying or
ostracizing, would not be diagnosed with social anxiety disorder as the negative evaluation and threat are real.

Panic Disorder
Panic disorder consists of a series of recurrent, unexpected panic attacks coupled with the fear of future panic attacks. A panic
attack is defined as a sudden or abrupt surge of fear or impending doom along with at least four physical or cognitive symptoms.
Physical symptoms include heart palpitations, sweating, trembling or shaking, shortness of breath, feeling as though they are being
choked, chest pain, nausea, dizziness, chills or heat sensations, and numbness/tingling. Cognitive symptoms may consist of feelings
of derealization (feelings of unreality) or depersonalization (feelings of being detached from oneself), the fear of losing control or
‘going crazy,’ or the fear of dying (APA, 2022). While symptoms generally peak within a few minutes, it seems much longer for
the individual experiencing the panic attack.
There are two key components to panic disorder—the attacks are unexpected, meaning there is nothing that triggers them, and they
are recurrent, meaning they occur multiple times. Because these panic attacks occur frequently and are primarily “out of the blue,”
they cause significant worry or anxiety in the individual as they are unsure of when the next attack will happen. In contrast to
unexpected there are also expected panic attacks, or those that have an obvious trigger. The DSM-5-TR states that presence of
expected panic attacks does not rule out the diagnosis of panic disorder as about half of individuals diagnosed with the disorder in
the United States and Europe have both types of attacks (APA, 2022).
In some individuals, significant behavioral changes such as fear of leaving their home or attending large events occur as the
individual is fearful an attack will happen in one of these situations, causing embarrassment. Additionally, individuals report worry
that others will think they are “going crazy” or losing control if they were to observe an individual experiencing a panic attack.
Occasionally, an additional diagnosis of agoraphobia is given to an individual with panic disorder if their behaviors meet diagnostic
criteria for this disorder as well.
The frequency and intensity of these panic attacks vary widely among individuals. Some people report panic attacks occurring once
a week for months on end, others report more frequent attacks multiple times a day, but then experience weeks or months without
any attacks. The intensity of symptoms also varies among individuals, with some patients experiencing four or more symptoms
(full-symptom) or less than four (limited-symptom. Furthermore, individuals report variability within their panic attack symptoms,
with some panic attacks presenting with more symptoms than others. To be diagnosed with panic disorder, the individual must
present with more than one unexpected full-symptom panic attack (APA, 2022).

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Key Takeaways
You should have learned the following in this section:
All anxiety disorders share the hallmark symptoms of excessive fear or worry related to behavioral disturbances.
Generalized anxiety disorder is characterized by an underlying excessive worry related to a wide range of events or activities
and an inability to control their worry through coping strategies.
Specific phobia is characterized by fear or anxiety specific to an object or a situation and individuals can experience fear of
more than one object.
Agoraphobia is characterized by intense fear related to situations in which the individual is in public situations where escape
may be difficult and help may not be able to come.
Social anxiety disorder is characterized by fear or anxiety related to social situations, especially when evaluation by others is
possible.
Panic disorder is characterized by a series of recurrent, unexpected panic attacks coupled with the fear of future panic attacks.

 Review Questions
1. What is the difference between fear and anxiety?
2. What are the key differences between generalized anxiety disorder and agoraphobia?
3. Individuals with social anxiety disorder will experience both physical and cognitive symptoms, particularly when presented
with social interactions. What are these symptoms?
4. What are the common types of specific phobias?
5. What are the physical and cognitive symptoms observed during panic disorder?
6. What are the key components of panic disorder?

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7.2: Anxiety Disorders - Epidemiology
 Learning Objectives
Describe the epidemiology of generalized anxiety disorder.
Describe the epidemiology of specific phobia.
Describe the epidemiology of agoraphobia.
Describe the epidemiology of social anxiety disorder.
Describe the epidemiology of panic disorder.

Generalized Anxiety Disorder

The 12-month prevalence for generalized anxiety disorder is estimated to be 2.9% of the adult general population of the United
States while the mean 12-month prevalence around the world is 1.3% (with a range of 0.2% to 4.3%). The disorder occurs more
frequently in women and adolescent girls, those of European descent, and those living in high-income countries (APA, 2022).

Specific Phobia
The prevalence rate for specific phobia is 8-12% in the United States and about 6% in European countries. There is a 2:1 ratio of
females to males diagnosed with specific phobia. Prevalence rates are lower in older individuals and those from Asia, Africa, and
Latin America.

Agoraphobia
The prevalence rate of agoraphobia worldwide for adolescents and adults is 1% to 1.7%. As with other anxiety disorders, women
are twice as likely to be diagnosed with it. Older adults in the United States (aged 65 and up) have a 12-month prevalence of 0.4%
and for older adults aged 55 and up in Europe and North America, the prevalence is 0.5%.

Social Anxiety Disorder

The overall prevalence rate of social anxiety disorder is significantly higher in the United States than in other countries, with an
estimated 7% of the U.S. population diagnosed with social anxiety disorder, compared to 0.5% to 2.0% worldwide (median
prevalence in Europe is 2.3%). A decrease in the diagnosis of social anxiety disorder among older individuals, aged 65 years and
older, has been found. Regarding gender, there is a higher diagnosis rate in females than males. This gender discrepancy is greater
among adolescents and young adults. Finally, non-Hispanic whites in the United States have a higher prevalence rate than Asian,
Latinx, African American, and Caribbean Black descent (APA, 2022).

Panic Disorder
The 12-month prevalence for panic disorder in the general population is estimated at around 2-3% in adults and adolescents across
the United States and several European countries. Higher rates of panic disorder are found in American Indians and non-Latinx
whites. Females are more commonly diagnosed than males with a 2:1 diagnosis rate. Prevalence declines from about 1.2% in adults
older than 55 to 0.7% in adults aged 64 and up.

Key Takeaways
You should have learned the following in this section:
Prevalence rates for anxiety disorders range from 1.0% for agoraphobia up to 12% for specific phobia.
For most anxiety disorders, females are twice as likely to be diagnosed.

 Review Questions
1. Create a table of the prevalence rates across the various anxiety related disorders. What are the differences between the
disorders?
2. How do prevalence rates vary as a function of gender, race, nationality, and age?

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This page titled 7.2: Anxiety Disorders - Epidemiology is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by
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7.3: Anxiety Disorders - Comorbidity
 Learning Objectives
Describe the comorbidity of generalized anxiety disorder.
Describe the comorbidity of specific phobia.
Describe the comorbidity of agoraphobia.
Describe the comorbidity of social anxiety disorder.
Describe the comorbidity of panic disorder.

Generalized anxiety disorder

There is a high comorbidity between generalized anxiety disorder and the other anxiety-related disorders, as well as unipolar
depressive disorders. Comorbidity with substance use, neurodevelopmental, neurocognitive, psychotic, and conduct disorders is
less common for those afflicted with generalized anxiety disorder. Generalized anxiety disorder is associated with higher levels of
suicidal ideation and behavior and psychological autopsy studies reveal it is the most frequent anxiety disorder diagnosed in
suicides (APA, 2022).

Specific phobia
Other anxiety disorders, depressive and bipolar disorders, substance-related disorders, and somatic symptom disorder are typically
comorbid with specific phobia. Additionally, personality disorders, in particular dependent personality disorder, are comorbid.
Specific phobia is associated with the transition from suicidal ideation to attempt (APA, 2022).

Agoraphobia
As with other anxiety disorders, common comorbid mental disorders include other anxiety disorders and depressive disorders.
Agoraphobia is also comorbid with PTSD and alcohol use disorder. For those with comorbid major depressive disorder, the
agoraphobia is more treatment-resistant compared to those with agoraphobia alone. About 15% of patients diagnosed with
agoraphobia report suicidal thoughts or behavior (APA, 2022).

Social Anxiety Disorder

Among the most common comorbid diagnoses with a social anxiety disorder are other anxiety-related disorders, major depressive
disorder, and substance-related disorders. The high comorbidity rate among anxiety-related disorders and substance-related
disorders is likely connected to the efforts of self-medicating to deal with social fears. For example, an individual with social
anxiety disorder may consume more alcohol in social settings in efforts to alleviate the anxiety of the social situation. The
comorbidity with major depressive disorder may be due to the chronic social isolation associated with social anxiety disorder.
Comorbidity has also been found with body dysmorphic disorder and avoidant personality disorder.

Panic disorder
Panic disorder rarely occurs in isolation, as 80% of individuals report symptoms of other anxiety disorders, major depressive
disorder, bipolar I and bipolar II disorder, and possibly mild alcohol use disorder. Some individuals diagnosed with panic disorder
also develop a substance-related disorder, likely as an attempt to treat their anxiety with alcohol or other substances. About 25% of
patients report suicidal thoughts and the disorder may increase the risk for future suicidal behaviors but not deaths. (APA, 2022).
Unlike some of the other anxiety disorders, there is a high comorbidity with general medical symptoms. More specifically,
individuals with panic disorder are more likely to report somatic symptoms such as dizziness, cardiac arrhythmias, COPD, asthma,
irritable bowel syndrome, and hyperthyroidism (APA, 2022). The relationship between panic symptoms and these conditions is
unclear.

Key Takeaways
You should have learned the following in this section:
Many anxiety disorders are comorbid with one another.
Other common comorbid disorders include depressive disorders and substance-related disorders.

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 Agoraphobia has a high comorbidity with PTSD and panic disorder with general medical symptoms.
Most anxiety disorders are associated with suicidal thoughts and behaviors, but not always deaths.

 Review Questions
1. What other disorders commonly occur with specific anxiety related disorders and why?
2. What anxiety-related disorder has a high comorbidity with medical symptoms?
3. What is the relationship of the disorders with suicidal ideation and attempts/behaviors? Be specific.

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7.4: Anxiety Disorders - Etiology
 Learning Objectives
Describe the biological causes of anxiety disorders.
Describe the psychological causes of anxiety disorders.
Describe the sociocultural causes of anxiety disorders.

Biological
7.4.1.1. Biological – Genetic influences. While genetics have been known to contribute to the presentation of anxiety symptoms,
the interaction between genetics and stressful environmental influences appears to account for more anxiety disorders than genetics
alone (Bienvenu, Davydow, & Kendler, 2011). The quest to identify specific genes that may predispose individuals to develop
anxiety disorders has led researchers to the serotonin transporter gene (5-HTTLPR). Mutation of the 5-HTTLPR gene is related to a
reduction in serotonin activity and an increase in anxiety-related personality traits (Munafo, Brown, & Hairiri, 2008).
7.4.1.2. Biological – Neurobiological structures. Researchers have identified several brain structures and pathways that are likely
responsible for anxiety responses. Among those structures is the amygdala, the area of the brain that is responsible for storing
memories related to emotional events (Gorman, Kent, Sullivan, & Coplan, 2000). When presented with a fearful situation, the
amygdala initiates a reaction to ready the body for a response. First, the amygdala triggers the hypothalamic-pituitary-adrenal
(HPA) axis to prepare for immediate action— either to fight or flight. The second pathway is activated by the feared stimulus itself,
by sending a sensory signal to the hippocampus and prefrontal cortex, to determine if the threat is real or imagined. If it is
determined that no threat is present, the amygdala sends a calming response to the HPA axis, thus reducing the level of fear. If a
threat is present, the amygdala is activated, producing a fear response.
Specific to panic disorder is the implication of the locus coeruleus, the brain structure that serves as an “on-off” switch for
norepinephrine neurotransmitters. It is believed that increased activation of the locus coeruleus results in panic-like symptoms;
therefore, individuals with panic disorder may have a hyperactive locus coeruleus, leaving them more susceptible to experience
more intense and frequent physiological arousal than the general public (Gorman, Kent, Sullivan, & Coplan, 2000). This theory is
supported by studies in which individuals experienced increased panic symptoms following the injection of norepinephrine
(Bourin, Malinge, & Guitton, 1995).
Unfortunately, norepinephrine and the locus coeruleus fail to fully explain the development of panic disorder, as treatment would
be much easier if only norepinephrine was implicated. Therefore, researchers argue that a more complex neuropathway is likely
responsible for the development of panic disorder. More specifically, the corticostriatal-thalamocortical (CSTC)circuit, also
known as the fear-specific circuit, is theorized as a major contributor to panic symptoms (Gutman, Gorman, & Hirsch, 2004).
When an individual is presented with a frightening object or situation, the amygdala is activated, sending a fear response to the
anterior cingulate cortex and the orbitofrontal cortex. Additional projection from the amygdala to the hypothalamus activates
endocrinologic responses to fear, releasing adrenaline and cortisol to help prepare the body to fight or flight (Gutman, Gorman, &
Hirsch, 2004). This complex pathway supports the theory that panic disorder is mediated by several neuroanatomical structures and
their associated neurotransmitters.

Psychological
7.4.2.1. Psychological – Cognitive. The cognitive perspective on the development of anxiety related disorders centers around
dysfunctional thought patterns. As seen in depression, maladaptive assumptions are routinely observed in individuals with
anxiety-related disorders, as they often engage in interpreting events as dangerous or overreacting to potentially stressful events,
which contributes to an overall heightened anxiety level. These negative appraisals, in combination with a biological
predisposition to anxiety, likely contribute to the development of anxiety symptoms (Gallagher et al., 2013).
Sensitivity to physiological arousal not only contributes to anxiety disorders in general, but also for panic disorder where
individuals experience various physiological sensations and misinterpret them as catastrophic. One explanation for this theory is
that individuals with panic disorder are more susceptible to more frequent and intensive physiological symptoms than the general
public (Nillni, Rohan, & Zvolensky, 2012). Others argue that these individuals have had more trauma-related experiences in the
past, and therefore, are quick to misevaluate their symptoms as a potential threat. This misevaluation of symptoms as impending

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disaster likely maintain symptoms as the cognitive misinterpretations to physiological arousal creates a negative feedback loop,
leading to more physiological changes.
Social anxiety is also primarily explained by cognitive theorists. Individuals with social anxiety disorder tend to hold unattainable
or extremely high social beliefs and expectations. Furthermore, they often engage in preconceived maladaptive assumptions that
they will behave incompetently in social situations and that their behaviors will lead to terrible consequences. Because of these
beliefs, they anticipate social disasters will occur and, therefore, avoid social encounters (or limit them to close friends/family
members) in efforts to prevent the disaster (Moscovitch et al., 2013). Unfortunately, these cognitive appraisals are not only isolated
to before and during the event. Individuals with social anxiety disorder will also evaluate the social event after it has taken place,
often obsessively reviewing the details. This overestimation of social performance negatively reinforces future avoidance of social
situations.
7.4.2.2. Psychological – Behavioral. The behavioral explanation for the development of anxiety disorders is mainly reserved for
phobias—both specific and social phobia. More precisely, behavioral theorists focus on respondent conditioning – when two
events that occur close together become strongly associated with one another, despite their lack of causal relationship (see Module
2 for an explanation of respondent conditioning). Watson and Rayner’s (1920) infamous Little Albert experiment is an example of
how respondent conditioning can be used to induce fear through associations. In this study, Little Albert developed a fear of white
rats by pairing a white rat with a loud sound. This experiment, although lacking ethical standards, was groundbreaking in the
development of learned behaviors. Over time, researchers have been able to replicate these findings (in more ethically sound ways)
to provide further evidence of the role of respondent conditioning in the development of phobias.
7.4.2.3. Psychological – Modeling is another behavioral explanation of the development of specific and social phobias. In
modeling, an individual acquires a fear though observation and imitation (Bandura & Rosenthal, 1966). For example, when a
young child observes their parent display irrational fear of an animal, the child may then begin to display similar behavior.
Similarly, seeing another individual being ridiculed in a social setting may increase the chances of developing social anxiety, as the
individual may become fearful that they would experience a similar situation in the future. It is speculated that the maintenance of
these phobias is due to the avoidance of the feared item or social setting, thus preventing the individual from learning that the
object or situation is not something that should be feared.
While modeling and respondent conditioning largely explain the development of phobias, there is some speculation that the
accumulation of many these learned fears will develop into generalized anxiety disorder. Through stimulus generalization, or the
tendency for the conditioned stimulus to evoke similar responses to other stimuli, a fear of one stimulus (such as the dog) may
become generalized to other items (such as all animals). As these fears begin to grow, a more generalized anxiety will present, as
opposed to a specific phobia.

Sociocultural
Seeing how prominent the biological and psychological constructs are in explaining the development of anxiety-related disorders,
we also need to review the social constructs that contribute and maintain anxiety disorders. While characteristics such as living in
poverty, experiencing significant daily stressors, and increased exposure to traumatic events are all identified as significant
contributors to anxiety disorders, additional sociocultural influences such as gender and discrimination have also received
considerable attention, mainly due to the epidemiological nature of the disorder.
Gender has largely been researched within anxiety disorders due to the consistent discrepancy in the diagnosis rate between men
and women. As previously discussed, women are routinely diagnosed with anxiety disorders more often than men, a trend that is
observed throughout the entire lifespan. One potential explanation for this discrepancy is the influence of social pressures on
women. Women are more susceptible to experience traumatic experiences throughout their life, which may contribute to anxious
appraisals of future events. Furthermore, women are more likely to use emotion-focused coping, which is less effective in
reducing distress than problem-focused coping (McLean & Anderson, 2009). These factors may increase levels of stress
hormones within women that leave them susceptible to develop symptoms of anxiety. Therefore, it appears a combination of
genetic, environmental, and social factors may explain why women tend to be diagnosed more often with anxiety-related disorders.
Exposure to discrimination and prejudice, particularly relevant to ethnic minorities and other marginalized groups, can also impact
an individual’s anxiety level. Discrimination and prejudice contribute to negative interactions, which is directly related to negative
affect and an overall decline in mental health (Gibbons et al., 2014). The repeated exposure to discrimination and prejudice over
time can lead to fear responses in individuals, along with subsequent avoidance of social situations in efforts to protect themselves
emotionally.

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Key Takeaways
You should have learned the following in this section:
Biological causes of anxiety disorders include the serotonin transporter gene (5-HTTLPR); brain structures to include the
amygdala, hippocampus, and prefrontal cortex; and the locus coeruleus and corticostriatal-thalamocortical (CSTC) circuit in
relation to panic disorder.
Psychological causes of anxiety disorders include maladaptive assumptions, the linking of events through respondent
conditioning, modeling, and stimulus generalization as it relates to generalized anxiety disorder.
Sociocultural causes of anxiety disorders include social pressures leading to a higher rate of diagnosis for women and
discrimination and prejudice which affects ethnic minorities and other marginalized groups.

 Review Questions
1. Discuss the biological etiology of panic disorders. What brain structures and neurotransmitters are involved?
2. How does the cognitive model explain the development and maintenance of anxiety related disorders?
3. What is the difference between emotion-focused and problem-focused coping strategies? How do these two coping
strategies explain differences in anxiety related disorders?
4. What are the effects of prejudice and discrimination on the development of anxiety disorders?

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Alexis Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit
history is available upon request.

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7.5: Anxiety Disorders - Treatment
 Learning Objectives
Describe treatment options for generalized anxiety disorder.
Describe treatment options for specific phobia.
Describe treatment options for agoraphobia.
Describe treatment options for social anxiety disorder.
Describe treatment options for panic disorder.

Generalized Anxiety Disorder

7.5.1.1. Psychopharmacology. Benzodiazepines, a class of sedative-hypnotic drugs that will be discussed in more detail in the
substance abuse module, originally replaced barbiturates as the leading anti-anxiety medication due to their less addictive nature,
yet equally effective ability to calm individuals at low dosages. Unfortunately, as more research was done on benzodiazepines,
serious side effects, as well as physical dependence of benzodiazepines at large dosages, has routinely been documented (NIMH,
2013). Due to these negative effects, selective serotonin-reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake
inhibitors (SNRIs) are generally considered to be first-line medication options for those with generalized anxiety disorder. Findings
indicate a 30-50% positive response rate to these psychopharmacological interventions (Reinhold & Rickels, 2015). Unfortunately,
none of these medications continue to provide any benefit once they are stopped; therefore, other effective treatment options such
as CBT, relaxation training, and biofeedback are often encouraged before the use of pharmacological interventions.
7.5.1.2. Rational-Emotive therapy. Albert Ellis developed rational emotive therapy in the mid-1950s as one of the first forms of
cognitive-behavioral therapy. Ellis proposed that individuals were not aware of the effect their negative thoughts had on their
behaviors and various relationships, and thus, established a treatment to address these thoughts and provide relief to those suffering
from anxiety and depression. The goal of rational emotive therapy is to identify irrational, self-defeating assumptions, challenge the
rationality of those assumptions, and to replace them with new, more productive thoughts and feelings. By identifying and
replacing these assumptions, the individual will experience relief of generalized anxiety disorder symptoms (Ellis, 2014).
7.5.1.3. Cognitive Behavioral Therapy (CBT). CBT is discussed in detail in the Mood Disorder Module; however, it is also
among the most effective treatment options for a variety of anxiety disorders, including generalized anxiety disorder. Findings
suggest 60 percent of individuals report a significant reduction/elimination in anxious thoughts one-year post treatment (Hanrahan,
Field, Jones, & Davy, 2013). The fundamental goal of CBT is a combination of cognitive and behavioral strategies aimed to
identify and restructure maladaptive thoughts while also providing opportunities to utilize these more effective thought patterns
through exposure-based experiences. Through repetition, the individual will be able to identify and replace anxious thoughts
outside of therapy sessions, ultimately reducing their overall anxiety levels (Borkovec, & Ruscio, 2001).
7.5.1.4. Biofeedback. Biofeedback provides a visual representation of a patient’s physiological arousal. To achieve this feedback, a
patient is connected to a computer that provides continuous information on their physiological states. There are several ways a
patient can connect to the computer. Among the most common is electromyography (EMG). EMG measures the amount of muscle
activity currently experienced by the individual. An electrode is placed on a patient’s skin just above a major muscle group, usually
the forearm or the forehead. Other common areas of measurement are electroencephalography (EEG), which measures the
neurofeedback or brain activity; heart rate variability (HRV), which measures autonomic activity such as heart rate or blood
pressure; and galvanic skin response (GSR) which measures sweat.
Once the patient is connected to the biofeedback machine, the clinician can walk the patient through a series of relaxation scripts or
techniques as the computer simultaneously measures the changes in muscle tension. The theory behind biofeedback is that in
providing a patient with a visual representation of changes in their physiological state, they become more skilled at voluntarily
reducing their physiological arousal, and thus, their overall sense of anxiety or stress. While research has identified only a modest
effect of biofeedback on anxiety levels, patients do report a positive experience with the treatment due to the visual feedback of
their physiological arousal (Brambrink, 2004).

Specific Phobias
7.5.2.1. Exposure treatments. While there are many treatment options for specific phobias, research routinely supports the
behavioral techniques as the most effective treatment strategies. Seeing as the behavioral theory suggests phobias develop via

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respondent conditioning, the treatment approach revolves around breaking the maladaptive association between the object and fear.
This is generally accomplished through exposure treatments. As the name implies, the individual is exposed to their feared
stimuli. This can be done in several different approaches: systematic desensitization, flooding, and modeling.
Systematic desensitization is an exposure technique that utilizes relaxation strategies to help calm the individual as they are
presented with the fearful object. The notion behind this technique is that both fear and relaxation cannot exist at the same time;
therefore, the individual learns how to replace their fearful reaction with a calm, relaxing reaction.
To begin, the patient, with assistance from the clinician, will identify a fear hierarchy, or a list of feared objects/situations ordered
from least fearful to most fearful. After teaching several different types of relaxation techniques, the clinician will present items
from the fear hierarchy, starting from the least fearful object/subject, while the patient practices using the learned relaxation
techniques. The presentation of the feared object/situation can be in person—in vivo exposure—or it can be imagined—imaginal
exposure. Imaginal exposure tends to be less intensive than in vivo exposure; however, it is less effective than in vivo exposure in
eliminating the phobia. Depending on the phobia, in vivo exposure may not be an option, such as with a fear of a tornado. Once the
patient can effectively employ relaxation techniques to reduce their anxiety to a manageable level, the clinician will slowly move
up the fear hierarchy until the individual does not experience excessive fear of all objects on the list.
Flooding is another exposure technique in which the clinician does not utilize a fear hierarchy, but rather repeatedly exposes the
individual to their most feared object or situation. Similar to systematic desensitization, flooding can be done in either in vivo or
imaginal exposure. Clearly, this technique is more intensive than systematic or gradual exposure to feared objects. Because of this,
patients are at a greater likelihood of dropping out of treatment, thus not successfully overcoming their phobias.
Modeling is another common technique used to treat phobias (Kelly, Barker, Field, Wilson, & Reynolds, 2010). In this technique,
the clinician approaches the feared object/subject while the patient observes. As the name implies, the clinician models appropriate
behaviors when exposed to the feared stimulus, showing that the phobia is irrational. After modeling several times, the clinician
encourages the patient to confront the feared stimulus with the clinician, and then ultimately, without the clinician.

Agoraphobia
Similar to the treatment approaches for specific phobias, exposure-based techniques are among the most effective treatment options
for individuals with agoraphobia. However, unlike the high success rate in specific phobias, exposure treatment for agoraphobia
has been less effective in providing complete relief from the disorder. The success rate may be impacted by the high comorbidity
rate of agoraphobia and panic disorder. Because of the additional presentation of panic symptoms, exposure treatments alone are
not the most effective in eliminating symptoms as residual panic symptoms often remain (Craske & Barlow, 2014). Therefore, the
best treatment approach for those with agoraphobia and panic disorder is a combination of exposure and CBT techniques (see panic
disorder treatment).
For individuals with agoraphobia without panic symptoms, the use of group therapy in combination with individual exposure
therapy has been identified as a successful treatment option. The group therapy format allows the individual to engage in exposure-
based field trips to various community locations, while also maintaining a sense of support and security from a group of individuals
whom they know. Research indicates that this type of treatment provides improvement for nearly 60 to 80 percent of patients with
agoraphobia; however, there is a relatively high rate of partial relapse, suggesting that long-term treatment or booster sessions
should continue for several years at minimum (Craske & Barlow, 2014).

Social Anxiety Disorder

7.5.4.1. Exposure. A hallmark treatment approach for all anxiety disorders is exposure. Specific to social anxiety disorder, the
individual is encouraged to engage in social situations where they are likely to experience increased anxiety. Initially, the clinician
will role-play various social situations with the patient so they can practice social interactions in a safe, controlled environment
(Rodebaugh, Holaway, & Heimberg, 2004). As the patient becomes habituated to the interaction with the clinician, the clinician
and patient may venture outside of the treatment room and engage in social situations with random strangers at various locations
such as fast-food restaurants, local stores, libraries, etc. The patient is encouraged to continue with these exposures outside of
treatment to help reduce anxiety related to social situations.
7.5.4.2. Social skills training. This treatment is specific to social anxiety disorder as it focuses on the patient’s skill deficits or
inadequate social interactions that contribute to their negative social experiences and anxiety. During a session, the clinician may
use a combination of skills such as modeling, corrective feedback, and positive reinforcement to provide feedback and
encouragement to the patient regarding their behavioral interactions (Rodebaugh, Holaway, & Heimberg, 2004). By incorporating

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the clinician’s feedback into their social repertoire, the patient can engage in positive social behaviors outside of the treatment room
and improve their overall social interactions while reducing ongoing social anxiety.
7.5.4.3. Cognitive restructuring. While exposure and social skills training are suitable treatment options, research routinely
supports the need to incorporate cognitive restructuring as an additive component in treatment to provide substantial symptom
reduction. Like cognitive restructuring previously discussed in the Mood Disorder module, the clinician will work with the
therapist to identify negative, automatic thoughts that contribute to the distress in social situations. The clinician can then help the
patient establish new, positive thoughts to replace these negative thoughts. Research indicates that implementing cognitive
restructuring techniques before, during, and after exposure sessions enhances the overall effects of treatment of social anxiety
disorder (Heimberg & Becker, 2002).

Panic Disorder
7.5.5.1. Cognitive Behavioral Therapy(CBT). CBT is the most effective treatment option for individuals with panic disorder as
the focus is on correcting misinterpretations of bodily sensations (Craske & Barlow, 2014). Nearly 80 percent of people with panic
disorder report complete remission of symptoms after mastering the following five components of CBT for panic disorder (Craske
& Barlow, 2014).
Psychoeducation. Treatment begins by educating the patient on the nature of panic disorder, the underlying causes of panic
disorder, as well as the mechanisms that maintain the disorder such as the physical, cognitive, and behavioral response systems
(Craske & Barlow, 2014). This part of treatment is fundamental in correcting any myths or misconceptions about panic symptoms,
as they often contribute to the exacerbation of panic symptoms.
Self-monitoring. Self-monitoring, or the act of self-observation, is essential to the CBT treatment process for panic disorder. In
this part of treatment, the individual is taught to identify the physiological cues immediately leading up to and during a panic
attack. Then, the patient is encouraged to recognize and document the thoughts and behaviors associated with these physiological
symptoms. By bringing awareness to the symptoms, as well as the relationship between physical arousal and cognitive-behavioral
responses, the patient learns the fundamental processes with which they can manage their panic symptoms (Craske & Barlow,
2014).
Relaxation training. Similar to that in exposure-based treatment for phobias, prior to engaging in exposure training, the individual
must learn relaxation techniques to apply during onset of panic attacks. Though breathing training was once included as the
relaxation training technique of choice for panic disorder more recent research has failed to support this technique as effective in
the use of panic disorder due to the high incidence of hyperventilation during panic attacks (Schmidt et al., 2000). Findings suggest
that breathing retraining is more commonly misused as a safety behavior or means for avoiding physical symptoms as opposed to
an effective physiological response to stress (Craske & Barlow, 2014).
Progressive muscle relaxation. To replace the breathing retraining, Craske & Barlow (2014) suggest progressive muscle
relaxation (PMR). In PMR, the patient learns to tense and relax various large muscle groups throughout the body. The patient is
encouraged to start at either the head or the feet, and gradually work their way through the entire body, holding the tension for
roughly 10 seconds before relaxing. The theory behind PMR is that in tensing the muscles for a prolonged period, the individual
exhausts those muscles, forcing them (and eventually) the entire body to engage in relaxation (McCallie, Blum, & Hood, 2006).
Cognitive restructuring. Cognitive restructuring, or the ability to recognize cognitive errors and replace them with alternate, more
appropriate thoughts, is likely the most powerful part of CBT treatment for panic disorder, aside from the exposure part. As noted
previously, cognitive restructuring involves identifying the role of thoughts in generating and maintaining emotions. The clinician
encourages the patient to view these thoughts as “hypotheses” as opposed to fact, which allows the beliefs to be questioned and
challenged. This is where the detailed recordings produced by self-monitoring are helpful. By discussing what the patient has
recorded for the relationship between physiological arousal and thoughts/behaviors, the clinician can help the patient restructure the
maladaptive thought processes to more positive thought processes, which in return, helps to reduce fear and anxiety.
Exposure. As discussed in detail in the specific phobia section, the patient is next encouraged to engage in a variety of exposure
techniques such as in vivo exposure and interoceptive exposure, while also incorporating the cognitive restructuring and relaxation
techniques previously learned to reduce and eliminate ongoing distress. Interoceptive exposure involves inducing panic-specific
symptoms to the individual repeatedly for a prolonged period, so that maladaptive thoughts about the sensations can be
disconfirmed and conditional anxiety responses are extinguished (Craske & Barlow, 2014). Some examples of these exposure
techniques include spinning a patient repeatedly in a chair to induce dizziness and breathing in a paper bag to cause
hyperventilation. These treatment approaches can be presented gradually; however, the patient must endure the physiological

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sensations for at least 30 seconds to 1 minute to ensure adequate time for applying cognitive strategies to misappraisal of cognitive
symptoms (Craske & Barlow, 2014).
Interoceptive exposure is continued both in and outside of treatment until panic symptoms remit. Over time, the habituation of fear
within an exposure session ultimately leads to habituation across treatment and long-term remission of panic symptoms (Foa &
McNally, 1996). Occasionally, panic symptoms will return in individuals who report complete remission of panic disorder. Follow-
up booster sessions reviewing the steps above are generally effective in eliminating symptoms again.
7.5.5.2. Pharmacological interventions. According to Craske & Barlow (2014), nearly half of patients with panic disorder present
to psychotherapy already on medication, likely prescribed by their primary care physician. Some researchers argue that anti-anxiety
medications impede the progress of CBT treatment as the individual is not able to fully experience the physiological sensations
during exposure sessions, thus limiting their ability to modify maladaptive thoughts and maintaining the panic symptoms. Results
from large clinical trials suggest no advantage during or immediately after treatment of combining CBT and medication (Craske &
Barlow, 2014). Additionally, when the medication was discontinued post-treatment, the CBT+ medication groups fared worse than
the CBT treatment-only groups, thus supporting the theory that immersion in interoceptive exposure is limited due to the use of
medication. Therefore, it is suggested that medications be reserved for those who do not respond to CBT therapy alone (Kampman,
Keijers, Hoogduin & Hendriks, 2002).

Key Takeaways
You should have learned the following in this section:
Treatment options for generalized anxiety disorder include benzodiazepines, rational-emotive therapy, CBT, and biofeedback.
Treatment options for specific phobias include exposure treatments such as systematic desensitization, flooding, and modeling.
Treatment options for agoraphobia include exposure and CBT techniques.
Treatment options for social anxiety disorder include exposure treatment, social skills training, and cognitive restructuring.
Treatment options for panic disorder include CBT, psychoeducation, self-monitoring, relaxation training, cognitive
restructuring, exposure, and pharmacological interventions.

 Review Questions
1. Discuss the types of exposure treatments for individuals with anxiety disorders? Which are most effective? What have been
some concerns with exposure treatment?
2. What is biofeedback? How is biofeedback used to treat anxiety related disorders?
3. What are the concerns with using pharmacological interventions in the treatment of anxiety disorders? Is there a time when
it is helpful to use this treatment method?

Module Recap
Module 7, the first module of Unit 3, covered the topic of anxiety disorders. This discussion included generalized anxiety disorder,
specific phobias, agoraphobia, social anxiety disorder, and panic disorder. As with other modules in this book, we discussed the
clinical presentation, epidemiology, comorbidity, and etiology of the anxiety disorders. Treatment options included biological,
psychological, and sociocultural options. In Module 8, we will discuss somatic symptom and related disorders.

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 CHAPTER OVERVIEW

8: Somatic Symptom and Related Disorders

 Learning Objectives
Describe how somatic symptom disorders present.
Describe the epidemiology of somatic symptom disorders.
Describe comorbidity in relation to somatic symptom disorders.
Describe the etiology of somatic symptom disorders.
Describe treatment options for somatic symptom disorders.
Describe psychological factors affecting other medical conditions in terms of their clinical presentation, diagnostic criteria,
common types of psychophysiological disorders, and treatment.

In Module 8, we will discuss matters related to somatic symptom disorders to include the clinical presentation, epidemiology,
comorbidity, etiology, and treatment options for somatic symptom disorder, illness anxiety disorder, functional neurological
symptom (conversion) disorder , and factitious disorder. We also will discuss psychological factors affecting other medication
conditions in relation to their clinical presentation, diagnostic criteria, common types of psychophysiological disorders, and
treatment. Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an overview of the various models to explain
psychopathology (Module 2), and descriptions of therapies (Module 3).
8.1: Somatic Symptom and Related Disorders - Clinical Presentation
8.2: Somatic Symptom and Related Disorders - Epidemiology
8.3: Somatic Symptom and Related Disorders - Comorbidity
8.4: Somatic Symptom and Related Disorders - Etiology
8.5: Somatic Symptom and Related Disorders - Treatment
8.6: Somatic Symptom and Related Disorders - Psychological Factors Affecting Other Medical Conditions

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1
8.1: Somatic Symptom and Related Disorders - Clinical Presentation
 Learning Objectives
Describe somatic symptom and related disorders.
Describe how somatic symptom disorder presents.
Describe how illness anxiety disorder presents.
Describe how functional neurological symptom (conversion) disorder presents.
Describe how factitious disorder presents.

Psychological disorders that feature somatic symptoms are often challenging to diagnose due to the internalizing nature of the
disorder, meaning there is no real way for a clinician to measure the somatic symptom. Furthermore, the somatic symptoms could
take on many forms. For example, the individual may be faking the physical symptoms, imagining the symptoms, exaggerating the
symptoms, or they could be real and triggered by external factors such as stress or other psychological disorders. The symptoms
also may be part of a real medical illness or disorder, and therefore, the symptoms should be treated medicinally.
All the disorders within this chapter share a common feature: there is a presence of somatic symptoms and/or illness anxiety
associated with significant distress or impairment. Oftentimes, individuals with a somatic disorder will present to their primary care
physician with their physical complaints. Occasionally, they will be referred to clinical psychologists after an extensive medical
evaluation concludes that a medical diagnosis cannot explain their current symptoms. As you will see, despite their similarities,
there are key features that distinguish the disorders in this class from one another.

Somatic Symptom Disorder

Individuals with somatic symptom disorder often present with multiple somatic symptoms at one time. These symptoms are
significant enough to impact their daily functioning, such as preventing them from attending school, work, or family obligations.
The symptoms can be localized (i.e., in one spot) or diffused (i.e., entire body), and can be specific or nonspecific (e.g., fatigue).
Individuals with somatic symptom disorder often report excessive thoughts, feelings, or behaviors surrounding their somatic
symptoms (APA, 2022). For example, individuals with somatic symptom disorder may spend an excessive amount of time or
energy evaluating their symptoms, as well as the potential seriousness of their symptoms. A lack of medical explanation is not
needed for a diagnosis of somatic symptom disorder, as it is assumed that the individual’s suffering is authentic. Somatic symptom
disorder is often diagnosed when another medical condition is present, as these two diagnoses are not mutually exclusive.
Somatic symptom disorder patients generally present with significant worry about their illness. Their interpretation of symptoms is
often viewed as threatening, harmful, or troublesome (APA, 2022). Because of their negative appraisals, they fear that their medical
status is more serious than it typically is, and high levels of distress are often reported. Oftentimes these patients will “shop” at
different physician offices to confirm the seriousness of their symptoms.

Illness Anxiety Disorder

Illness anxiety disorder, previously known as hypochondriasis, involves an excessive preoccupation with having or acquiring a
serious medical illness. The key distinction between illness anxiety disorder and somatic symptom disorder is that an individual
with illness anxiety disorder does not typically present with any somatic symptoms. Occasionally an individual will present with a
somatic symptom; however, the intensity of the symptom is mild and does not drive the anxiety. Acquiring a serious illness drives
concerns and they will even avoid visiting a sick relative or friend for fear of jeopardizing their own health.
Individuals with illness anxiety disorder generally are cleared medically; however, some individuals are diagnosed with a medical
illness. In this case, their anxiety surrounding the severity of their disorder is excessive or disproportionate to their actual medical
diagnosis. While an individual’s concern for an illness may be due to a physical sign or sensation, most individual’s concerns are
derived not from a physical complaint, but their actual anxiety related to a suspected medical disorder. This excessive worry often
expands to general anxiety regarding one’s health and disease. Unfortunately, this anxiety does not decrease even after reassurance
from a medical provider or negative test results, even when provided by multiple physicians and diagnostic tests.
As one can imagine, the preoccupation and anxiety associated with attaining a medical illness severely impacts daily functioning.
The individual will often spend copious amounts of time scanning and analyzing their body for “clues” of potential ailments.
Additionally, an excessive amount of time is often spent on internet searches related to symptoms and rare illnesses. Illness

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becomes a central feature of the person’s identity and self-image. Although extreme, some cases of invalidism have been reported
due to illness anxiety disorder (APA, 2022).
Making Sense of the Disorders
In relation to somatic symptom and related disorders, note the following:
For somatic symptom disorder …… the patient presents with multiple somatic symptoms at one time that are significant
enough to impact their daily functioning
For illness anxiety disorder … the patient does not typically present with any somatic symptoms but if they do, the symptoms
are just mild in intensity

Functional Neurological Symptom Disorder (Conversion Disorder)

Functional neurological symptom (conversion) disorder occurs when an individual presents with one or more symptoms of
altered voluntary motor or sensory function (APA, 2022). Common motor symptoms include weakness or paralysis, abnormal
movements (e.g., tremors), and gait abnormalities (i.e., limping). Sensory symptoms include altered, reduced, or absent skin
sensation, vision, or hearing. Less commonly seen are epileptic seizures and episodes of unresponsiveness resembling fainting or
coma (Marshall et al., 2013). The disorder was called “conversion disorder” in prior versions of the DSM and in the psychiatric
literature. As noted, “The term “conversion” originated in psychoanalytic theory, which proposes that unconscious psychic conflict
is “converted” into physical symptoms” (APA, 2022).
The most challenging aspect of functional neurological symptom disorder is the complex relationship with a medical evaluation.
While a diagnosis of conversion disorder requires that the symptoms not be explained by a neurological disease, just because a
medical provider fails to provide evidence that it is not a specific medical disorder is not sufficient. Therefore, there must be
evidence of an incompatibility of the medical disorder and the symptoms. For example, an individual experiencing a seizure would
require a normal simultaneous electroencephalogram (EEG), indicating that there is not epileptic activity during what was
previously thought of as an epileptic seizure.

Factitious Disorder
Factitious disorder differs from the three previously discussed somatic disorders in that there is deliberate falsification of medical
or psychological symptoms imposed on oneself or on another, with the overall intention of deception. While a medical condition
may be present, the severity of impairment related to the medical condition is more excessive due to the individual’s need to
deceive those around them. Even more alarming is that this disorder is not only observed in the individual leading the deception—
it can also be present in another individual, often a child or an individual with a compromised mental status who is not aware of the
deception behind their illness.
Some examples of factitious disorder behaviors include, but are not limited to, altering a urine or blood test, falsifying medical
records, ingesting a substance that would indicate abnormal laboratory results, physically injuring oneself, and inducing illness by
injecting or ingesting a harmful substance. Although most individuals with factitious disorder seek treatment from health care
professionals, some choose to mislead community members either in person or online about the illness or injury (APA, 2022).
While it is unclear why an individual would want to fake their own (or someone else’s) physical illness, there is some evidence
suggesting that factors such as depression, lack of parental support during childhood, or an excessive need for social support may
contribute to this disorder (McDermott, Leamon, Feldman, & Scott, 2012; Ozden & Canat, 1999; Feldman & Feldman, 1995).
Individuals with factitious disorder are at risk for experiencing psychological distress or functional impairment causing harm to
themselves and others such as family, friends, heath care professionals, and faith leaders. The DSM-5-TR states, “Whereas some
aspects of factitious disorders might represent criminal behavior, such criminal behavior and mental illness are not mutually
exclusive” (APA, 2022, pg. 368).

Key Takeaways
You should have learned the following in this section:
Somatic symptom disorder is characterized by the presence of multiple somatic symptoms, whether localized or diffused and
specific or nonspecific, at one time which impact daily functioning.
Illness anxiety disorder is characterized by concern over having or acquiring a serious illness, and not the actual presence of
somatic symptoms. Individuals spend a great deal of time scanning and analyzing their body for “clues” of potential ailments.

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 Functional neurological symptom disorder is characterized by one or more symptoms of voluntary motor or sensory function.
Factitious disorder is characterized by deliberate falsification of medical or psychological symptoms of oneself or another, with
the overall intention of deception.

 Review Questions
1. What are some commonly shared features of somatic disorders?
2. Which somatic disorder usually accompanies a medical diagnosis?
3. What are the key distinctions between illness anxiety disorder and somatic symptom disorder?
4. What are the key differences between factitious disorder and the other somatic disorders?

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8.2: Somatic Symptom and Related Disorders - Epidemiology
 Learning Objectives
Describe the epidemiology of somatic disorders.

The prevalence rates for somatic disorders are often difficult to determine; however, overall estimates of somatic symptom disorder
are around 4-6%. There is a trend that females report more somatic symptoms than males; thus, more females are diagnosed with
somatic symptom disorder than males (APA, 2022).
Seeing as illness anxiety disorder is a newer diagnosis (replacing hypochondriasis), prevalence rates are largely based on the
previous disorder. Previous findings suggest that illness anxiety disorder occurs in 1.3% to 10% of the general population and is
equal among males and females.
Prevalence rates of factitious disorder are largely unknown, likely due to the use of deception in individuals diagnosed with the
disorder. Additionally, health care professionals infrequently record the diagnosis, even in recognized cases (APA, 2022).
And like the other somatic symptom disorders, the prevalence of functional neurological symptom disorder is unknown, even
though transient functional neurological symptoms are common. In the United States and northern Europe, research shows that the
incidence of individual persistent functional neurological symptoms to be around 4-12 of every 100,000 annually (APA, 2022).

Key Takeaways
You should have learned the following in this section:
Though prevalence rates for somatic symptom disorders are hard to determine, it is believed that between 1 and 10% of the
population suffer from one of these disorders.
Females are more like to be diagnosed with somatic symptom disorder and are as likely as males to be diagnosed with illness
anxiety disorder.

 Review Questions
1. Create a table of the prevalence rates across the various somatic disorders. What are the differences between the disorders?
2. What gender differences are evident in the disorders, if any?

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8.3: Somatic Symptom and Related Disorders - Comorbidity
 Learning Objectives
Describe the comorbidity of somatic disorders.

Given that half of psychiatric patients also have an additional medical disorder, 35% have an undiagnosed medical condition, and
approximately 20% reported medical problems caused their mental condition, it should not come as a surprise that somatic
disorders, in general, have high comorbidity with other psychological disorders (Felker, Yazel, & Short, 1996). More specifically,
anxiety and depressive disorders are among the most commonly co-diagnosed disorders for somatic disorders. While there is not a
lot of information regarding specific comorbidities among somatic symptom and related disorders, there is some evidence to
suggest that those with illness anxiety disorder are at risk of developing OCD and personality disorders. Similarly, personality
disorders are more common in individuals with functional neurological symptom disorder than the general public. Somatic
symptom disorder is also comorbid with PTSD and OCD. (APA, 2022). No comorbidity information is given for factitious
disorder.
There is also high comorbidity between somatic disorders and other physical disorders classified as central sensitivity syndromes
(CSSs), due to their common central sensitization symptoms, yet medically unexplained symptoms (McGeary, Harzell, McGeary, &
Gatchel, 2016). Disorders included in this group are fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome.
Comorbidity rates are estimated at 60% for these functional syndromes and somatic pain disorder (Egloff et al., 2014).

Key Takeaways
You should have learned the following in this section:
Anxiety and depression have a high comorbidity with somatic symptom and related disorders.
Functional neurological symptom disorder and illness anxiety disorder frequently occur with personality disorders.
PTSD and OCD are comorbid with somatic symptom disorder.
Central sensitivity syndrome also has high comorbidity with somatic disorders.

 Review Questions
1. In general, what other disorders often occur with somatic disorders?
2. Which disorder do we not know anything about?

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8.4: Somatic Symptom and Related Disorders - Etiology
 Learning Objectives
Describe the psychodynamic causes of somatic disorders.
Describe the cognitive causes of somatic disorders.
Describe the behavioral causes of somatic disorders.
Describe the sociocultural causes of somatic disorders.

Psychodynamic
Psychodynamic theory suggests that somatic symptoms present as a response against unconscious emotional issues. Two factors
initiate and maintain somatic symptoms: primary gain and secondary gain. Primary gains produce internal motivators, whereas
secondary gains produce external motivators (Jones, Carmel & Ball, 2008). When you relate this to somatic disorders, the primary
gain, according to psychodynamic theorists, provides protection from the anxiety or emotional symptoms and/or conflicts. This
need for protection is expressed via a physical symptom such as pain, headache, etc. The secondary gain, the external experiences
from the physical symptoms that maintain these physical symptoms, can range from attention and sympathy to missed work,
obtaining financial assistance, or psychiatric disability, to name a few.

Cognitive
Cognitive theorists often believe that somatic disorders are a result of negative beliefs or exaggerated fears of physiological
sensations. Individuals with somatic related disorders may have a heightened sensitivity to bodily sensations. This sensitivity,
combined with their maladaptive thought patterns, may lead individuals to overanalyze and interpret their physiological symptoms
in a negative light.
For example, an individual with a headache may catastrophize the symptoms and believe that their headache is the direct result of a
brain tumor, as opposed to stress or other inoculate reasons. When their medical provider does not confirm this diagnosis, the
individual may then catastrophize even further, believing they have an extremely rare disorder that requires an evaluation from a
specialist.

Behavioral
Keeping true with the behavioral approach to psychological disorders, behaviorists propose that somatic disorders are developed
and maintained by reinforcers. More specifically, individuals experiencing significant somatic symptoms are often rewarded by
gaining attention from other people (Witthoft & Hiller, 2010). These rewards may also extend to more significant factors, such as
receiving disability payments.
While the behavioral theory of somatic disorders appears to be like the psychodynamic theory of secondary gains, there is a clear
distinction between the two – behaviorists view these gains as the primary reason for the development and maintenance of the
disorder, whereas psychodynamic theorists view these gains as secondary, only after the underlying conflicts create the disorder.

Sociocultural
There are a couple of different ways that sociocultural factors contribute to somatic related disorders. First, there is the social factor
of familial influence that likely plays a significant role in the attention to somatic symptoms. Individuals with somatic symptom
disorder are more likely to have a family member or close friend who is overly attentive to their somatic symptoms or report high
anxiety related to their health (Watt, O’Connor, Stewart, Moon, & Terry, 2008; Schulte, Petermann, & Noeker, 2010).
Culturally, Western countries express less of a focus on somatic complaints compared to those in the Eastern part of the world. This
may be explained by the different evaluations of the relationship between mind and body. For example, Westerners tend to have a
view that psychological symptoms sometimes influence somatic symptoms, whereas Easterners focus more heavily on the mind-
body relationship and how psychological and somatic symptoms interact with one another. These different cultural beliefs are
routinely seen in research where Asian populations are more likely to report the physical symptoms related to stress than the
cognitive or emotional problems that many in the United States report (Sue & Sue, 2016).

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Key Takeaways
You should have learned the following in this section:
Psychodynamic causes of somatic disorders include primary and secondary gains.
Cognitive causes of somatic disorders include negative beliefs or exaggerated fears of physiological sensations.
Behavioral causes of somatic disorders include reinforcers such as attention gained from others or receiving disability.
Sociocultural causes of somatic disorders include familial influence and culture.

 Review Questions
1. How does catastrophizing contribute to the development and maintenance of somatic disorders?
2. How do somatic disorders develop according to behavioral theorists? Does this theory also explain how the symptoms are
maintained? Explain.
3. What does the sociocultural model suggest regarding somatic disorders across cultures?

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detailed edit history is available upon request.

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8.5: Somatic Symptom and Related Disorders - Treatment
 Learning Objectives
Describe treatment options for somatic disorders.

Treatment for these disorders is often difficult as individuals see their problems as completely medical, and therefore, do not think
psychological intervention is necessary (Lahmann, Henningsen, & Noll-Hussong, 2010). Once an individual does not find relief
from their symptoms after meeting with several different physicians, they often do willingly engage in psychotherapy,
psychopharmacology, or both (Raj et al., 2014).
Among the most effective treatment approaches is the biopsychosocial model of treatment. This approach considers the various
biological, psychological, and social factors that influence the illness and presenting symptoms (Gatchel et al., 2007). This
treatment is often achieved through a multidisciplinary approach where the symptoms are managed by many providers, usually
including a physician, psychiatrist, and psychologist. The interdisciplinary approach involves a higher level of care as the multiple
disciplines interact with one another and identify a treatment goal (Gatchel et al., 2007). This approach, although more difficult to
find, particularly in more rural settings, is presumed to be more effective due to the integration of health care providers and their
ability to work together to treat the patient uniformly.

Psychotherapy
8.5.1.1. Psychodynamic. Interpersonal psychotherapy, a type of psychodynamic therapy, has been found to be efficacious in
treating somatic disorders. Interpersonal psychotherapy focuses on the relationship between self-experience and the unconscious,
and how these factors contribute to body dysfunction. This type of treatment has been shown to reduce anxiety, depression, and
improve the overall quality of life immediately following treatment; however, effects appear to diminish over time (Abass et al.,
2014; Steinert et al., 2015).
8.5.1.2. CBT. Traditional cognitive-behavioral therapies (CBT) have been employed to address the cognitive attributions and
maladaptive coping strategies that are responsible for the development and maintenance of the disorder. The most common
misattribution for these disorders is catastrophic thinking, or the rumination about worst-case scenario outcomes. Additionally,
goals of CBT treatment are the acceptance of the medical condition, addressing avoidance behaviors, and mediating expectations of
treatment (Gatchel et al., 2014).
8.5.1.3. Behavioral. Behavioral therapies have also been shown to effectively manage complex chronic somatic symptoms,
particularly pain. The behavioral approach involves bringing attention to physiological symptoms, the individual’s attribution to
those symptoms, and the subsequent anxiety produced by the negative attributions (Looper & Kirmayer, 2002).

Psychopharmacology
Psychopharmacological interventions are rarely used due to possible side effects and unknown efficacy. Given that these
individuals already have a heightened reaction to their physiological symptoms, there is a high likelihood that the side effects of
medication would produce more harm than help. With that said, psychopharmacological interventions may be helpful for those
individuals who have comorbid psychological disorders such as depression or anxiety, which may negatively impact their ability to
engage in psychotherapy (McGeary, Harzell, McGeary, & Gatchel, 2016).

Key Takeaways
You should have learned the following in this section:
The biopsychosocial model of treatment is one of the most effective for somatic disorders as it considers the various biological,
psychological, and social factors that influence the illness and presenting symptoms and includes a multidisciplinary approach.
Psychotherapy options include interpersonal psychotherapy, CBT, and behavioral.
Psychopharmacological interventions are rarely used for somatic disorders due to the side effects of the medication producing
more harm than good. When used, they deal with comorbid disorders such as depression or anxiety.

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  Review Questions
1. Discuss the difference between multidisciplinary and interdisciplinary approaches to treatment of somatic disorders.
2. What is the biopsychosocial model for treatment of somatic disorders? What are the three main components of this
treatment?
3. Are there any treatments that are not effective in treating somatic disorders? If so, why?

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platform; a detailed edit history is available upon request.

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8.6: Somatic Symptom and Related Disorders - Psychological Factors Affecting
Other Medical Conditions
 Learning Objectives
Describe how psychological factors affecting other medical conditions presents.
List and describe the most common types of psychophysiological disorders.
Describe treatment options for psychological factors affecting other medical conditions.

Although previously known as psychosomatic disorders, the DSM-5-TR has identified physical illnesses that are caused or
exacerbated by biopsychosocial factors as psychological factors affecting other medical conditions. This disorder is different than
all the previously mentioned somatic related disorders as the primary focus of the disorder is not the mental disorder, but rather the
physical disorder. Psychological or behavioral factors adversely affect the medical condition by, “…influencing its course or
treatment, by constituting an additional well-established health risk factor, or by influencing the underlying pathophysiology to
precipitate or exacerbate symptoms or to necessitate medical attention” (APA, 2022, pg. 365). It is believed that a lack of positive
coping strategies, psychological distress, or maladaptive health behaviors exacerbate these physical symptoms (McGeary, Harzell,
McGeary, & Gatchel, 2016).

Psychophysiological Disorders
The most common types of psychophysiological disorders are headaches (migraines and tension), gastrointestinal (ulcer and
irritable bowel), insomnia, and cardiovascular-related disorders (coronary heart disease and hypertension). We will briefly review
these disorders and discuss the associated psychological features believed to exacerbate symptoms.
8.6.1.1. Headaches. Among the most common types of headaches are migraines and tension headaches (Williamson, 1981).
Migraine headaches are often more severe and are explained by a throbbing pain localized to one side of the head, frequently
accompanied by nausea, vomiting, sensitivity to light, and vertigo. It is believed that migraines are caused by the blood vessels in
the brain narrowing, thus reducing the blood flow to various parts of the brain, followed by the same vessels later expanding, thus
rapidly changing the blood flow. It is estimated that 23 million people in the U.S. alone suffer from migraines (Williamson, Barker,
Veron-Guidry, 1994).
Tension headaches are often described as a dull, constant ache localized to one part of the head or neck; however, it can co-occur in
multiple places at one time. Unlike migraines, nausea, vomiting, and sensitivity to light do not often occur with tension headaches.
Tension headaches, as well as migraines, are believed to be primarily caused by stress as they are in response to sustained muscle
contraction that is often exhibited by those under extreme stress or emotion (Williamson, Barker, Veron-Guidry, 1994). In efforts to
reduce the frequency and intensity of both migraines and tension headaches, individuals have found relief in relaxation techniques,
as well as the use of biofeedback training to help encourage the relaxation of muscles.
8.6.1.2. Gastrointestinal. Among the two most common types of gastrointestinal psychophysiological disorders are ulcers and
irritable bowel syndrome (IBS). Ulcers, or painful sores in the stomach lining, occur when mucus from digestive juices are
reduced, allowing digestive acids to burn a hole into the stomach lining. Among the most common type of ulcers are peptic ulcers,
which are caused by the bacteria H. pylori (Sung, Kuipers, El-Serag, 2009). While there is evidence to support the involvement of
stress in the development of dyspeptic symptoms, the evidence linking stress and peptic ulcers is slowly growing. (Purdy, 2013).
Researchers believe that while H. pylori must be present for a peptic ulcer to develop, increased stress levels may impact the
amount of digestive acid present in the stomach lining, thus increasing the frequency and intensity of symptoms (Sung, Kuipers,
El-Serag, 2009).
IBS is a chronic, functional disorder of the gastrointestinal tract. Common symptoms of IBS include abdominal pain and extreme
bowel habits (diarrhea or constipation). It affects up to a quarter of the population and is responsible for nearly half of all referrals
to gastroenterologists (Sandler, 1990).
Because IBS is a functional disorder, there are no known structural, chemical, or physiological abnormalities responsible for the
symptoms. However, there is conclusive evidence that IBS symptoms are related to psychological distress, particularly in those
with anxiety or depression. Although more research is needed to pinpoint the timing between the onset of IBS and psychological
disorders, preliminary evidence suggests that psychological distress is present before IBS symptoms. Therefore, IBS may be best
explained as a somatic expression of associated psychological problems (Sykes, Blanchard, Lackner, Keefer, & Krasner, 2003).

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8.6.1.3. Insomnia. Insomnia, the difficulty falling or staying asleep, occurs in more than one-third of the U.S. population, with
approximately 10% of patients reporting chronic insomnia (Perlis & Gehrman, 2013). While exact pathways of chronic
psychophysiological insomnia are unclear, there is evidence of some biopsychosocial factors that may predispose an individual to
develop insomnia such as anxiety, depression, and overactive arousal systems (Trauer et al., 2015). Part of the difficulty with
insomnia is the fact that these psychological symptoms can impact one’s ability to fall asleep; however, we also know that lack of
adequate sleep also predisposes individuals to increased psychological distress. Due to this cyclic nature of psychological distress
and insomnia, intervention for both sleep issues as well as psychological issues is vital to managing symptoms.
8.6.1.4. Cardiovascular. Heart disease has been the leading cause of death in the United States for the past several decades. Costs
related to disability, medical procedures, and societal burdens are estimated to be $444 billion a year (Purdy, 2013). With this large
financial burden, there have been considerable efforts to identify risk and protective factors in predicting cardiovascular mortality.
Researchers have identified that depression is a predictor of early-onset coronary heart disease (Ketterer, Knysk, Khanal, &
Hudson, 2006). More specifically, there is a five-fold increase of depression in those with coronary heart disease than the general
population (Ketterer, Knysk, Khanal, & Hudson, 2006). Additionally, anxiety and anger have also been identified as an early
predictor of cardiac events, suggesting psychological interventions aimed at reducing anxiety and establishing positive coping
strategies for anger management may be effective in reducing future cardiac events (Ketterer, Knysk, Khanal, & Hudson, 2006).
8.6.1.5. Hypertension. Also called or chronically elevated blood pressure, is also found to be affected by psychological factors.
More specifically, constant stress, anxiety, and depression have all been found to impact the likelihood of a cardiac event due to
their impact on vasoconstriction (Purdy, 2013). Elevated inflammatory markers such as C-reactive protein, which is indicative of
plaque instability, has been found in chronically depressed individuals, thus predisposing them to potential heart attacks (Ketterer,
Knysk, Khanal, & Hudson, 2006).

Treatments for Psychological Factors Affecting Other Medical Conditions

As more information regarding contributing factors to psychophysiological disorders is discovered, more psychological treatment
approaches have been developed and applied to these medical problems. The most common types of treatments include relaxation
training, biofeedback, hypnosis, traditional CBT treatments, group therapy, as well as a combination of the previous treatments.
8.6.2.1. Relaxation training. Relaxation training essentially teaches individuals how to relax their muscles on command. While
relaxation is used in combination with other psychological interventions to reduce anxiety (as seen in PTSD and various anxiety
disorders), it has also been shown to be effective in treating physical symptoms such as headaches, chronic pain, as well as pain
related to specific causes (e.g., injection sites, side effects of medications; McKenna et al., 2015).
8.6.2.2. Biofeedback. Biofeedback is a unique psychological treatment in which an individual is connected to a machine (usually a
computer) that allows for continuous monitoring of involuntary physiological reactions. Measurements that can be obtained are
heart rate, galvanic skin response, respiration, muscle tension, and body temperature, to name a few.
There are a few different ways in which biofeedback can be administered. The first is clinician-led. The clinician will actively
guide the patient through a relaxation monologue, encouraging the patient to relax muscles associated near the pain region (or
within the entire body). While going through the monologue, the clinician is provided with real-time feedback about the patient’s
physiological response. Research studies have routinely supported the use of biofeedback, particularly for those with pain and
headaches that have not been responsive to pharmacological interventions (McKenna et al., 2015).
Another option of biofeedback is through computer programs developed by psychologists. The most common, a program called
Wild Devine (now Unyte) is an integrative relaxation program that encourages the use of breathing techniques while
simultaneously measuring the patient’s physiological responses. This type of programming is especially helpful for younger
patients as there are various “games” the child can play that requires the awareness and control of their thoughts, feelings, and
emotions.
8.6.2.3. Hypnosis. Hypnosis, which some argue is just an extreme sense of relaxation, has been effective in reducing pain and
managing anxiety symptoms associated with medical procedures (Lang et al., 2000). Through extensive training, an individual can
learn to engage in self-hypnosis or obtain recorded hypnosis monologues to assist with the management of physiological symptoms
outside of hypnosis sessions. While additional research is still needed within the field of hypnosis, studies have indicated that
hypnosis is effective in not only treating chronic pain, but also assists with a reduction in anxiety, improved sleep, and improved
overall quality of life (Jensen et al., 2006).

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8.6.2.4. Group Therapy. Group therapy is another effective treatment option for individuals with psychological distress related to
physical disorders. These groups not only aim to reduce the negative emotions associated with chronic illnesses, but they also
provide support from other group members that are experiencing the same physical and psychological symptoms. These groups are
typically CBT based and utilize cognitive and behavioral strategies in a group setting to encourage acceptance of disease while also
addressing maladaptive coping strategies.

Key Takeaways
You should have learned the following in this section:
Psychological factors affecting other medical conditions has as its primary focus the physical disorder, and not the mental
disorder.
The most common types of psychophysiological disorders include headaches to include migraines and tension, gastrointestinal
to include ulcers and IBS, insomnia, coronary heart disease, and hypertension.
Common treatments for these other medical conditions include relaxation training, biofeedback, hypnosis, traditional CBT
treatments, and group therapy.

 Review Questions
1. What are the most common types of psychophysiological disorders?
2. Discuss the differences between the different types of headaches.
3. What is the difference between ulcers and irritable bowel syndrome?
4. What are the identified predictors to coronary heart disease and other cardiac events?
5. What are the most effective treatment options for psychophysiological disorders?

Module Recap
In Module 8, we discussed somatic disorders in terms of their clinical presentation, epidemiology, comorbidity, etiology, and
treatment options. Somatic disorders included somatic symptom disorder, illness anxiety disorder, functional neurological symptom
(conversion) disorder , and factitious disorder. We also discussed psychological factors affecting other medication conditions in
relation to their clinical presentation, common types of psychophysiological disorders, and treatment.

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 CHAPTER OVERVIEW

9: Obsessive-Compulsive and Related Disorders

 Learning Objectives
Describe how obsessive-compulsive disorders present.
Describe the epidemiology of obsessive-compulsive disorders.
Describe comorbidity in relation to obsessive-compulsive disorders.
Describe the etiology of obsessive-compulsive disorders.
Describe treatment options for obsessive-compulsive disorders.

In Module 9, we will discuss matters related to obsessive-compulsive and related disorders to include their clinical presentation,
epidemiology, comorbidity, etiology, and treatment options. Our discussion will include obsessive compulsive disorder (OCD),
body dysmorphic disorder (BDD), and hoarding. Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an
overview of the various models to explain psychopathology (Module 2), and descriptions of the therapies (Module 3).
9.1: Obsessive-Compulsive and Related Disorders - Clinical Presentation
9.2: Obsessive-Compulsive and Related Disorders - Epidemiology
9.3: Obsessive-Compulsive and Related Disorders - Comorbidity
9.4: Obsessive-Compulsive and Related Disorders - Etiology
9.5: Obsessive-Compulsive and Related Disorders - Treatment

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1
9.1: Obsessive-Compulsive and Related Disorders - Clinical Presentation
 Learning Objectives
Describe how obsessive compulsive disorder presents.
Describe how body dysmorphic disorder presents.
Describe how hoarding disorder presents.

Obsessive-Compulsive Disorder
Obsessive-compulsive disorder, more commonly known as OCD, requires the presence of obsessions, compulsions, or both.
Obsessions are defined as repetitive and persistent thoughts, urges, or images. These obsessions are intrusive, time-consuming (i.e.,
take more than an hour a day), and unwanted, often causing significant distress or impairment in an individual’s daily functioning.
Common obsessions are contamination (dirt on self or objects), errors of uncertainty regarding daily behaviors (locking the door,
turning off appliances), thoughts of physical harm or violence, and orderliness, to name a few (Cisler, Adams, et al., 2011; Yadin &
Foa, 2009). Often the individual will try to ignore these thoughts, urges, or images. When they are unable to ignore them, the
individual will engage in compulsory behaviors to gain temporary relief from the distress or anxiety.
Compulsions are time-consuming, repetitive behaviors or mental acts that an individual performs in response to an obsession.
Common examples of compulsions are checking (e.g., repeatedly checking if the stove is turned off even though the first four-times
they checked it was), counting (e.g., flicking the lights off and on exactly five times), hand washing, symmetry, fears of harm to
self or others, or repeating specific words (APA, 2022). These compulsive behaviors essentially alleviate the anxiety associated
with the obsessive thoughts. For example, an individual may feel as though their hands are dirty after using utensils at a restaurant.
They may obsess over this thought for some time, impacting their ability to interact with others or complete a specific task. This
obsession will ultimately lead to the individual performing a compulsion where they will wash their hands with extremely hot
water to rid all the germs, or even wash their hands a specified number of times if they also have a counting compulsion. At this
point, the individual’s anxiety should be temporarily relieved.
These obsessions and compulsions are more excessive than the typical “cleanliness” as they consume a large part of the
individual’s day. Additionally, they cause significant impairment in one’s daily functioning. Given the example above, an
individual with a fear of contamination may refuse to eat at restaurants, or they may bring their utensils from home. The frequency
and severity of the obsessions and compulsions varies by patient, with some having mild to moderate symptoms and only spending
1-3 hours a day obsessing or engaging in compulsive behaviors, while other patients present with severe symptoms and have nearly
constant intrusive thoughts or compulsions that can become incapacitating (APA, 2022).

Body Dysmorphic Disorder

Body dysmorphic disorder is another obsessive disorder; however, the focus of the obsessions is with perceived defects or flaws
in one’s physical appearance. A key feature of these obsessions is that they are not observable or appear slight to others. An
individual who has a congenital facial defect or a burn victim who is concerned about their scars are not examples of an individual
with body dysmorphic disorder. The obsessions related to one’s appearance can run the spectrum from feeling “unattractive” to
“looking hideous.” While any part of the body can be a concern for an individual with body dysmorphic disorder, the most
commonly reported areas are skin (acne, wrinkles, skin color), hair (particularly thinning or excessive body hair), and nose (size or
shape; APA, 2022). Interestingly, the disorder can occur by proxy meaning the individual is not concerned with their own defects
but those of another person, often a spouse or partner but at times, a parent, child, sibling, or stranger.
Due to the distressing nature of the obsessions regarding one’s body, individuals with body dysmorphic disorder also engage in
compulsive behaviors that take up a considerable amount of time in their day. For example, they may repeatedly compare their
body to other people’s bodies in the general public; frequently look at themselves in the mirror; engage in excessive grooming,
which includes using make-up to modify their appearance. Some individuals with body dysmorphic disorder will go as far as
having numerous plastic surgeries in attempts to obtain their “perfect” appearance.
While most of us are guilty of engaging in some of these behaviors, to meet criteria for body dysmorphic disorder, one must spend
a considerable amount of time preoccupied with their appearance (i.e., on average 3-8 hours a day), as well as display significant
impairment in social, occupational, or other areas of functioning. Some individuals excessively tan, change their clothes repeatedly,
or compulsively shop such as for beauty products. Camouflaging perceived defects is a common behavior and could involve

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applying makeup, adjusting a hat or one’s clothes, or covering the forehead or eyes with one’s hair, all to hide or cover the
perceived defect or problem area (APA, 2022).
As the DSM-5-TR notes, body dysmorphic disorder has been associated with, “abnormalities in emotion recognition, attention, and
executive function, as well as information-processing biases and inaccuracies in interpretation of information and social situations”
(APA, 2022, pg. 273). These individuals tend to express a bias for negative and threatening interpretations of facial expressions and
situations that would be classified as ambiguous, for instance.
9.1.2.1. Muscle dysmorphia. While muscle dysmorphia is not a formal diagnosis, it is a common type of BDD, particularly within
the male population. Muscle dysmorphia refers to the belief that one’s body is too small or lacks the appropriate amount of muscle
definition (Ahmed, Cook, Genen & Schwartz, 2014). While the severity of BDD between individuals with and without muscle
dysmorphia appears to be the same, some studies have found higher use of substance abuse (i.e., steroid use), poorer quality of life,
and increased reports of suicide attempts in those with muscle dysmorphia (Pope, Pope, Menard, Fay Olivardia, & Philips, 2005).
The DSM-5-TR instructs clinicians to specify if body dysmorphic disorder occurs with muscle dysmorphia.
9.1.2.2. Insight specifiers. Those diagnosed with body dysmorphic disorder vary in the degree of insight they have about the
accuracy of their body dysmorphic disorder beliefs, ranging from good to absent/delusional. On average, insight is poor and at least
one-third of those diagnosed with the disorder display absent/delusional insight. Mental health professionals would indicate the
degree of insight regarding body dysmorphic disorder beliefs using with good or fair insight, with poor insight, or with absent
insight/delusional beliefs. See page 272 of the DSM-5-TR for more information. Note that the insight specifier is used with OCD
and hoarding disorders as well.

Hoarding Disorder
In hoarding disorder, the key feature is the persistent over-accumulation of possessions (APA, 2022). While we all obtain items
throughout life, individuals with hoarding disorder continue to accumulate items without discarding possessions, regardless of their
value or sentiment. This lack of discarding occurs over a long period and is not explained by a recent significant stressor (e.g., lost
house in fire, so now keeps everything). For example, last week’s newspaper would likely have no relevance to you or possibly any
historical value, but those with hoarding disorder would keep this newspaper despite the lack of value or sentiment.
The most commonly hoarded items are newspapers, magazines, clothes, bags, books, mail, and paperwork (APA, 2022). While
these items may be stored in attics and garages, individuals with a hoarding disorder also have these items cluttering their living
space, sometimes to the extent that they are unable to utilize their furniture because it is covered in stuff. Cognitive factors
contributing to the need to hold onto these non-sentimental items are fear of losing valuable information and fear of being wasteful.
When asked to “clean out” their house or get rid of these items, individuals with hoarding disorder experience significant distress.
Individuals with hoarding disorder display indecisiveness, avoidance, procrastination, perfectionism, difficulty planning and
organizing tasks, and are easily distractible.
One’s hoarding behaviors also impacts their daily functioning and causes impairment in social and occupational functioning. It can
lead to low quality of life and in extreme cases, place the individual at risk for figure, falling, poor sanitation, and other health risks.
Family relationships are often strained and conflict with neighbors and local authorities is common (APA, 2022).

Key Takeaways
You should have learned the following in this section:
As part of OCD, obsessions are repetitive and persistent thoughts, urges, or images while compulsions are repetitive behaviors
or mental acts that an individual performs in response to an obsession.
Body dysmorphic disorder is characterized by obsessions over perceived defects or flaws in one’s physical appearance.
Muscle dysmorphia refers to the belief that one’s body is too small or lacks the appropriate amount of muscle definition and is a
type of body dysmorphic disorder common to men.
Hoarding disorder is characterized by accumulating items without discarding possessions, regardless of their value or sentiment.

 Review Questions
1. Define obsessions and compulsions. Provide a list of examples of each thought/behavior.
2. What is body dysmorphic disorder? Give examples of characteristics that would not be consistent with a body dysmorphic
disorder diagnosis.

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 3. Many of us save items throughout our lifetime that remind us of specific events. How is this different from hoarding?

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9.2: Obsessive-Compulsive and Related Disorders - Epidemiology
 Learning Objectives
Describe the epidemiology of OCD.
Describe the epidemiology of body dysmorphic disorder.
Describe the epidemiology of hoarding disorder.

OCD
The prevalence rate for OCD is approximately 1.2% both in the U.S. and worldwide (APA, 2022). Women are diagnosed with
OCD more often than males; however, in childhood, boys are diagnosed more frequently than girls (APA, 2022). With respect to
gender and symptoms, females are more likely to be diagnosed with cleaning related obsessions and compulsions. In contrast,
males are more likely to display symptoms related to forbidden thoughts and symmetry (APA, 2022). The DSM-5-TR reports that
the mean age of onset of OCD is 19.5 years with a quarter of cases starting by 14 years of age. Additionally, males have an earlier
age of onset (5-15 yrs.) compared to females (20-24 yrs.; Rasmussen & Eisen, 1990).

Body Dysmorphic Disorder

The point prevalence rate for body dysmorphic disorder among U.S. adults is 2.4% while outside the U.S., the point prevalence is
1.7% to 2.9%. Gender-based prevalence rates indicate that women are more likely to be diagnosed with body dysmorphic disorder
than men, though muscle dysmorphia is diagnosed more frequently in men. Additionally, women are more likely to be preoccupied
with weight, breasts, buttocks, legs, hips, and excessive body or facial hair while men have preoccupations with their genitals, body
build, and thinning hair (APA, 2022).

Hoarding Disorder
While national studies on the prevalence rate of hoarding within the U.S. and internationally are not available, community surveys
estimate clinically significant hoarding as occurring in 1.5% to 6.0% of the population (APA, 2022; Gilliam & Tolin, 2010).
Clinical samples are more highly represented by females than males and older individuals (over the age of 65 years) are three times
more likely to be diagnosed with hoarding disorder than younger adults.

Key Takeaways
You should have learned the following in this section:
The prevalence rate for OCD is about 1.2% while body dysmorphic disorder is 2.4% and hoarding is estimated at 1.5% to 6%.
In terms of gender, females are more likely to be diagnosed with the three disorders, though in terms of body dysmorphic
disorder, males receive the muscle dysmorphia specifier more than females.
Gender differences are also present for symptom presentation in OCD and the area of the body focused on in body dysmorphic
disorder.

 Review Questions
1. What are the key gender differences related to OCD and body dysmorphic disorder?
2. How do the prevalence rate of the three disorders compare?

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9.3: Obsessive-Compulsive and Related Disorders - Comorbidity
 Learning Objectives
Describe the comorbidity of OCD.
Describe the comorbidity of body dysmorphic disorder.
Describe the comorbidity of hoarding disorder.

OCD
There is a high comorbidity between OCD and other anxiety disorders. Nearly 76% of individuals with OCD will be diagnosed
with another anxiety disorder, most commonly panic disorder, social anxiety disorder, generalized anxiety disorder, or a specific
phobia. Additionally, due to the nature of OCD and its symptoms, nearly 41% of those with OCD will also be diagnosed with a
depressive or bipolar disorder (APA, 2022).
There is a high comorbidity between OCD and tic disorder, particularly in males with an onset of OCD in childhood. Children
presenting with early-onset OCD typically have a different presentation of symptoms than traditional OCD. Research has also
indicated a strong triad of OCD, tic disorder, and ADHD in children. Due to this psychological disorder triad, it is believed there is
a neurobiological mechanism at fault for the development and maintenance of the disorders.
It should be noted that there are several disorders—schizophrenia, bipolar disorder, eating disorders, body dysmorphic disorder,
and Tourette’s disorder – that OCD is much more common in. Therefore, clinicians who have a patient diagnosed with one of the
disorders should also routinely assess patients for OCD (APA, 2022).
Finally, OCD has a mean rate of lifetime suicide attempts of 14.2%, a mean rate of lifetime suicidal ideation of 44.1%, and a mean
rate of current suicidal ideation of 25.9%. Severity of OCD, the symptom dimension of unacceptable thoughts, a history of
suicidality, and severity of comorbid depressive and anxiety symptoms are predictors of greater suicide risk (APA, 2022).

Body Dysmorphic Disorder

Major depressive disorder is the most common comorbid psychological disorder with body dysmorphic disorder and typically
occurs after the onset of body dysmorphic disorder. Additionally, there are some reports of social anxiety disorder, OCD, and
substance-related disorders (likely related to muscle enhancement; APA, 2022). Those with body dysmorphic disorder are four
times more likely to have experienced suicidal thoughts and 2.6 times more likely to have made suicide attempts compared to
healthy control subjects and those diagnosed with eating disorders, OCD, or any anxiety disorder.

Hoarding Disorder
Of those diagnosed with hoarding disorder, about 75% have a comorbid mood or anxiety disorder with major depressive disorder,
social anxiety disorder, and generalized anxiety disorder being the most common comorbid conditions. Additionally, nearly 20%
also meet the criteria for OCD (APA, 2022).

Key Takeaways
You should have learned the following in this section:
OCD is shown to have a high comorbidity with anxiety and depressive disorders as well as tic disorder and ADHD in children.
Body dysmorphic disorder has a high comorbidity with major depressive disorder.
Hoarding disorder has a high comorbidity with mood and anxiety disorders.

 Review Questions
1. What are the most common comorbidities for OCD? Be specific.
2. This section discussed the OCD triad in children. What two other disorders complete this triad?
3. Which disorder is body dysmorphic disorder most comorbid with?
4. What can we say about comorbidities with hoarding disorder?

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9.4: Obsessive-Compulsive and Related Disorders - Etiology
 Learning Objectives
Describe the biological causes of obsessive-compulsive disorders.
Describe the cognitive causes of obsessive-compulsive disorders.
Describe the behavioral causes of obsessive-compulsive disorders.

Biological
There are a few biological explanations for obsessive-compulsive related disorders, including hereditary transmission,
neurotransmitter deficits, and abnormal functioning in brain structures.
9.4.1.1. Hereditary transmission. With regards to heritability studies, twin studies routinely support the role of genetics in the
development of obsessive-compulsive behaviors, as monozygotic twins have a substantially greater concordance rate (80-87%)
than dizygotic twins (47-50%; Carey & Gottesman, 1981; van Grootheest, Cath, Beekman, & Boomsma, 2005). Additionally, first
degree relatives of patients diagnosed with OCD are at a 5-fold increase to develop OCD at some point throughout their lifespan
(Nestadt, et al., 2000).
Interestingly, a study conducted by Nestadt and colleagues (2000) exploring the familial role in the development of obsessive-
compulsive disorder found that family members of individuals with OCD had higher rates of both obsessions and compulsions than
control families; however, the familial relationship with regards to obsessions were stronger than that of compulsions suggesting
that there is a stronger heritability association for obsessions than compulsions.
This study also found a relationship between age of onset of OCD symptoms and family heritability. Individuals who experienced
an earlier age of onset, particularly before age 17, were found to have more first-degree relatives diagnosed with OCD. In fact, after
the age of 17, there was no relationship between family diagnoses, suggesting those who develop OCD at an older age may have a
different diagnostic origin (Nestadt, et al., 2000).
Initial studies exploring genetic factors for BDD and hoarding also indicate a hereditary influence; however, environmental factors
appear to play a more significant role in the development of these disorders than that of OCD (Ahmed, et al., 2014; Lervolino et al.,
2009).
9.4.1.2. Neurotransmitters. Neurotransmitters, particularly serotonin, have been identified as a contributing factor to obsessive
and compulsive behaviors. This discovery was made accidentally, when individuals with depression and comorbid OCD were
given antidepressant medications clomipramine and fluoxetine—both of which increase levels of serotonin—to mediate symptoms
of depression. Not only did these patients report a significant reduction in their depressive symptoms, but also a substantial
improvement in their OCD symptoms (Bokor & Anderson, 2014). Antidepressant medications that do not affect serotonin levels
are not effective in managing obsessive and compulsive symptoms, thus offering additional support for deficits of serotonin levels
as an explanation of obsessive and compulsive behaviors (Sinopoli, Burton, Kronenberg, & Arnold, 2017; Bokor & Anderson,
2014). More recently, there has been some research implicating the involvement of additional neurotransmitters—glutamate,
GABA, and dopamine—in the development and maintenance of OCD, although future studies are still needed to draw definitive
conclusions (Marinova, Chuang, & Fineberg, 2017).
9.4.1.3. Brain structures. Seeing as neurotransmitters have direct involvement in the development of obsessive-compulsive
behaviors, it’s only logical that brain structures that house these neurotransmitters also likely play a role in symptom development.
Neuroimaging studies implicate the brain structures and circuits in the frontal lobe, more specifically, the orbitofrontal cortex,
which is located just above each eye (Marsh et al., 2014). This brain region is responsible for mediating strong emotional responses
and converts them into behavioral responses. Once the orbitofrontal cortex receives sensory/emotional information via sensory
inputs, it transmits this information through impulses. These impulses are then passed on to the caudate nuclei, which filters
through the many impulses received, passing along only the strongest impulses to the thalamus. Once the impulses reach the
thalamus, the individual essentially reassesses the emotional response and decides whether to act (Beucke et al., 2013). It is
believed that individuals with obsessive compulsive behaviors experience overactivity of the orbitofrontal cortex and a lack of
filtering in the caudate nuclei, thus causing too many impulses to transfer to the thalamus (Endrass et al., 2011). Further support for
this theory has been shown when individuals with OCD experience brain damage to the orbitofrontal cortex or caudate nuclei and
experience remission of OCD symptoms (Hofer et al., 2013).

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Cognitive
Cognitive theorists believe that OCD behaviors occur due to an individual’s distorted thinking and negative cognitive biases. More
specifically, individuals with OCD are more likely to overestimate the probability of harm, loss of control, or uncertainty in their
life, thus leading them to over-interpret potential negative outcomes of events. Additionally, some research has indicated that those
with OCD also experience disconfirmation bias, which causes the individual to seek out evidence of their failure to perform the
ritual or compensatory behavior correctly (Sue, Sue, Sue, & Sue, 2017). Finally, individuals with OCD often report the inability to
trust themselves and their instincts, and therefore, feel the need to repeat the compulsive behavior multiple times to ensure it is
done correctly. These cognitive biases are supported throughout research studies that repeatedly find individuals with OCD
experience more intrusive thoughts than those without OCD (Jacob, Larson, & Storch, 2014).
We have shown that individuals with OCD experience cognitive biases and that these biases contribute to the obsessive and
compulsive behaviors, but why do these cognitive biases occur so often? Everyone has times when they have repetitive or intrusive
thoughts such as: “Did I shut the oven off after cooking dinner?” or “Did I remember to lock the door before I left home?”
Fortunately, most individuals are able to either concede to their thoughts once, or even forgo acknowledging their thoughts after
they confidently talk themselves through their actions, ensuring that the behavior in question was or was not completed.
Unfortunately, individuals with OCD are unable to neutralize these thoughts without performing a ritual as a way to put themselves
at ease. As you will see in more detail in the behavioral section below, the behaviors (compulsions) used to neutralize the thoughts
(obsessions) provide temporary relief to the individual. As the individual is continually exposed to the obsession and repeatedly
engages in the compulsive behaviors to neutralize their anxiety, the behavior is repeatedly reinforced, thus becoming a compulsion.
This theory is supported by studies where individuals with OCD report using more neutralizing strategies and report significant
reductions in anxiety after employing these neutralizing techniques (Jacob, Larson, & Storch, 2014; Salkovskis et al., 2003).

Behavioral
The behavioral explanation of obsessive compulsive-related disorders focuses on compulsions rather than obsessions. Behaviorists
believe that these compulsions begin with and are maintained through operant conditioning. How so? Well, an individual with
OCD may experience negative thoughts or anxieties related to an unpleasant event (obsession; the event is a stimulus). These
thoughts/anxieties cause significant distress to the individual, and therefore, they seek out some behavior (compulsion; the
response) to alleviate these threats (i.e., escape behavior associated with negative reinforcement). This provides temporary relief to
the individual, thus reinforcing the compulsive behaviors used to lessen the threat. Over time, the compulsive behaviors are
reinforced due to the repeated exposure of the obsession and the temporary relief that comes with engaging in these compulsive
behaviors (escape behavior).
Strong support for this theory is the fact that the behavioral treatment option for OCD- exposure and response prevention, is among
the most effective treatments for these disorders. As you will read below, this treatment essentially breaks the patient’s operant
conditioning associated with the obsessions and compulsions by preventing the individual from engaging in the compulsive
behavior until anxiety is reduced.

Key Takeaways
You should have learned the following in this section:
Biological causes of obsessive-compulsive disorders include hereditary transmission, neurotransmitter deficits particularly in
relation to serotonin, and abnormal functioning in brain structures.
Cognitive causes of obsessive-compulsive disorders include distorted thinking such as overestimating the probability of harm,
loss of control, or uncertainty in their life, and negative cognitive biases such as disconfirmation bias.
Behavioral causes of obsessive-compulsive disorders include operant conditioning.

 Review Questions
1. What are the biological implications regarding the etiology of OCD and related disorders? What brain structures have been
linked to these disorders?
2. Discuss identified cognitive biases that are related to the development and maintenance of OCD and related disorders?
3. The behavioral model discusses how respondent conditioning may explain the development and maintenance of these
disorders. What type of reinforcement is at work and how?

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9.5: Obsessive-Compulsive and Related Disorders - Treatment
 Learning Objectives
Describe treatment options for OCD.
Describe treatment options for body dysmorphic disorder.
Describe treatment options for hoarding disorder.

OCD
9.5.1.1. Exposure and Response Prevention (ERP). Treatment of OCD has come a long way in recent years. Among the most
effective treatment options is exposure and response prevention (March, Frances, Kahn, & Carpenter, 1997). First developed by
psychiatrist Victor Meyer (1966), as you might infer from the name, individuals are repeatedly exposed to their obsession, thus
causing anxiety/fears, while simultaneously prevented from engaging in their compulsive behaviors. Exposure sessions are often
done in vivo (in real life), via videos, or even imaginary, depending on the type of obsession. For example, a fear that one’s house
would burn down if their compulsion was not carried out would obviously be done via imaginary exposure, as it would not be
ethical to have a person burn their house down.
Prior to beginning the exposure and response prevention exercises, the clinician must teach the patient relaxation techniques for
them to engage in during the distress of being exposed to the obsession. Once relaxation techniques are taught, the clinician and
patient will develop a hierarchy of obsessions. Treatment will start at those with the lowest amount of distress to ensure the patient
has success with treatment, as well as preventing withdrawal of treatment.
Within the hierarchy of obsessions, the individual is also gradually exposed to their obsession. For example, an individual obsessed
with germs, may first watch a person sneeze on the computer in session. Once anxiety is managed and compulsions refrain at this
level of exposure, the individual would move on to being present in the same room as a sick individual, to eventually shaking hands
with someone obviously sick, each time preventing them from engaging in their compulsive behavior. Once this level of their
hierarchy was managed, they would move on to the next obsession and so forth until the entire list was complete.
Treatment outcome for exposure and response prevention is very effective in treating individuals with OCD. In fact, some studies
suggest up to an 86% response rate when treatment is completed (Foa et al., 2005). Combination treatments such as ERP with
family counseling (utilizing CBT techniques) may increase this response rate even higher (Bolleau, 2011; Krebs & Heyman, 2015).
Like most OCD related treatments, the largest barrier to treatment is getting patients to commit to treatment, as the repeated
exposures and prevention of compulsive behaviors can be extremely distressing to patients.
9.5.1.2. Psychopharmacology. There has been minimal support for the treatment of OCD with medication alone. This is likely due
to the temporary resolution of symptoms during medication use. Among the most effective medications are those that inhibit the
reuptake of serotonin, clomipramine and SSRIs. Reportedly, up to 60% of patients show improvement in symptoms while taking
these medications; however, symptoms are quick to return when medications are discontinued (Dougherty, Rauch, & Jenike, 2002).
While there has been some promise in a combined treatment option of exposure and response prevention and SSRIs, these findings
were not superior to exposure and response prevention alone, suggesting that the inclusion of medication in treatment does not
provide an added benefit (Foa et al., 2005).

Body Dysmorphic Disorder

Seeing as though there are strong similarities between OCD and body dysmorphic disorder, it should not come as a surprise that the
only two effective treatments for body dysmorphic disorder are those that are effective in OCD. Exposure and response prevention
has been successful in treating symptoms of body dysmorphic disorder, as patients are repeatedly exposed to their body
imperfections/obsessions and prevented from engaging in compulsions used to reduce their anxiety. (Veale, Gournay, et al., 1996;
Wilhelm, Otto, Lohr, & Deckersbach, 1999). The other treatment option, psychopharmacology, has also been shown to reduce
symptoms in patients with body dysmorphic disorder. Similar to OCD, medications such as clomipramine and SSRIs are generally
prescribed. While these are effective in reducing body dysmorphic disorder symptoms, once medication is discontinued, symptoms
resume nearly immediately suggesting this is not an effective long-term treatment option for those with body dysmorphic disorder.
Treatment of body dysmorphic disorder appears to be difficult, with one study finding that only 9% of participants had full
remission at a 1-year follow-up, and 21% reported partial remission (Phillips, Pagano, Menard & Stout, 2006). A more recent

9.5.1 https://socialsci.libretexts.org/@go/page/161397
finding reported more promising findings, with 76% of participants reporting full remission over 8 years (Bjornsson, Dyck, et al.,
2011).
9.5.2.1. Plastic surgery and medical treatments. Many individuals with body dysmorphic disorder seek out plastic surgery to
attempt to correct their deficits. Phillips and colleagues (2001) evaluated treatments of patients with body dysmorphic disorder and
found that 76.4% of the patients reported some form of plastic surgery or medical treatment, with dermatology treatment the most
reported (45%) followed by plastic surgery (23%). The problem with this type of treatment is that the individual is rarely satisfied
with the outcome of the procedure, thus leading them to seek out additional surgeries on the same defect (Phillips et al., 2001).
Therefore, it is important that medical professionals thoroughly screen patients for psychological distress before completing any
medical treatment.

Hoarding Disorder
Recent research has concluded that unlike OCD, many individuals with hoarding disorder do not experience intrusive thoughts, nor
do they experience urges to perform rituals. Because of this difference, treatment for hoarding disorder has moved away from
exposure and response prevention, and more toward a traditional cognitive-behavioral approach.
Frost and Hartl (1996) believed that individuals with hoarding disorder engage in complex decision-making processes,
overanalyzing the value and worth of possessions, thus leading to hoarding the object as opposed to discarding it. Therefore, in
addition to having the individual engage in exposure treatment, an added component of cognitive restructuring and motivational
interviewing are added to address the complex-decision making that is involved in maintaining unnecessary possessions. By
discussing motives for keeping items, as well as fears that may be associated with discarding items, clinicians can assist patients in
their cognitive processes to ultimately determine the item’s actual worth (Williams & Viscusi, 2016). Unfortunately, due to the
distressing nature of having to discard their possessions, many individuals in treatment for hoarding disorder prematurely end
treatment, thus never reaching remission of symptoms (Mancebo, Eisen, Sibrava, Dyck, & Rasmussen, 2011).

Key Takeaways
You should have learned the following in this section:
Treatment options for OCD include exposure and response prevention, as well as SSRIs though the drug does not provide an
added benefit in treatment.
Treatment options for body dysmorphic disorder include exposure and response prevention and drugs clomipramine and SSRIs.
Treatment options for hoarding disorder include exposure treatment, cognitive restructuring, and motivational interviewing.

 Review Questions
1. Discuss the various types of treatments for OCD. Which treatment option has the best outcome?
2. What are the different components of Exposure and Response Prevention? How do they work together to reduce OCD
symptoms?
3. What are the most effective treatment approaches for body dysmorphic disorder?
4. According to Frost and Hartl (1996) what are the main components that contribute to the maintenance of hoarding
disorder?

Module Recap
As in all modules past, we have discussed the clinical presentation, epidemiology, comorbidity, etiology, and treatment options for
a specific class of disorders – obsessive compulsive and related disorders.

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 SECTION OVERVIEW

Part IV. Mental Disorders – Block 3

10: Feeding and Eating Disorders
10.1: Feeding and Eating Disorders - Clinical Presentation
10.2: Feeding and Eating Disorders - Epidemiology
10.3: Feeding and Eating Disorders - Comorbidity
10.4: Feeding and Eating Disorders - Etiology
10.5: Feeding and Eating Disorders - Treatment

11: Substance-Related and Addictive Disorders

11.1: Substance-Related and Addictive Disorders - Clinical Presentation
11.2: Substance-Related and Addictive Disorders - Epidemiology
11.3: Substance-Related and Addictive Disorders - Comorbidity
11.4: Substance-Related and Addictive Disorders - Etiology
11.5: Substance-Related and Addictive Disorders - Treatment

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1
 CHAPTER OVERVIEW

10: Feeding and Eating Disorders

 Learning Objectives
Describe how feeding and eating disorders present.
Describe the epidemiology of feeding and eating disorders.
Describe comorbidity in relation to feeding and eating disorders.
Describe the etiology of feeding and eating disorders.
Describe treatment options for feeding and eating disorders.

In Module 10, we will discuss matters related to feeding and eating disorders to include their clinical presentation, epidemiology,
comorbidity, etiology, and treatment options. Our discussion will include anorexia nervosa, bulimia nervosa, and binge eating
disorder. Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an overview of the various models to explain
psychopathology (Module 2), and descriptions of the therapies (Module 3).
10.1: Feeding and Eating Disorders - Clinical Presentation
10.2: Feeding and Eating Disorders - Epidemiology
10.3: Feeding and Eating Disorders - Comorbidity
10.4: Feeding and Eating Disorders - Etiology
10.5: Feeding and Eating Disorders - Treatment

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1
10.1: Feeding and Eating Disorders - Clinical Presentation
 Learning Objectives
Describe how anorexia nervosa presents.
Describe how bulimia nervosa presents.
Describe how binge-eating disorder (BED) presents.

Feeding and eating disorders are “…characterized by a persistent disturbance of eating or eating-related behavior that results in the
altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning” (APA, 2022,
pg. 371). They are very serious, yet relatively common mental health disorders, particularly in Western society, where there is a
heavy emphasis on thinness and physical appearance. In fact, 13% of adolescents will be diagnosed with at least one eating
disorder by their 20th birthday (Stice, Marti, & Rohde, 2013). Furthermore, a large number of adolescents will engage in
significant disordered eating behaviors just below the clinical threshold (Culbert, Burt, McGue, Iacono & Klump, 2009). While
there is no exact cause for eating disorders, the combination of biological, psychological, and sociocultural factors has been
identified as major contributors in both the development and maintenance of eating disorders.
Within the DSM 5-TR (APA, 2022), six disorders are classified under the Feeding and Eating Disorders chapter: pica, rumination
disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder. In this book, we
will cover the latter three whose diagnostic criteria are mutually exclusive, meaning that only one of these diagnoses can be
assigned at any given time due to substantial differences in their clinical course, outcome, and treatment needs, despite a number of
common psychological and behavioral features.
For more on eating disorders in general, please visit the National Eating Disorders Association website below:
www.nationaleatingdisorders.org/what-are-eating-disorders
10.1.1. Anorexia Nervosa
Anorexia nervosa involves the restriction of energy intake, which leads to significantly low body weight relative to the individual’s
age, sex, and development. This restriction is often secondary to an intense fear of gaining weight or becoming fat, despite the
individual’s low body weight. Altered perception of self and an over-evaluation of one’s body weight and shape contribute to this
disturbance of body size.
Typical warning signs and symptoms are divided into two different categories: emotional/behavioral and physical. Some emotional
and behavioral symptoms include dramatic weight loss; preoccupation with food, weight, calories, etc.; frequent comments about
feeling “fat;” eating a restricted range of foods; making excuses to avoid mealtimes; and not eating in public. Physical changes may
include dizziness, difficulty concentrating, feeling cold, sleep problems, thinning hair/hair loss, and muscle weakness, to name a
few. When the individual loses weight, they view this as an impressive achievement and a sign of extraordinary discipline, while
weight gain is seen as an unacceptable failure of self-control (APA, 2022).
The onset of the disorder typically begins with mild dietary restrictions such as eliminating carbs or specific fatty foods. As weight
loss is achieved, the dietary restrictions progress to more severe, e.g., under 500 calories/day. Symptoms present in adolescence or
young adulthood and rarely before puberty or after age 40. The onset of the disorder typically is preceded by a stressful life event
such as leaving home for college.
For more on anorexia nervosa, please visit the National Eating Disorders Association website below:
www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia

Bulimia Nervosa
Unlike anorexia nervosa where there is solely restriction of food, bulimia nervosa involves a pattern of recurrent binge eating
behaviors. Binge eating can be defined as a discrete period of time where the amount of food consumed is significantly more than
most people would eat during a similar time period. Individuals with bulimia nervosa often report a sense of lack of control over-
eating during these binge-eating episodes. While not always the case, these binge-eating episodes are followed by a feeling of
disgust with oneself, which leads to a compensatory behavior to rid the body of the excessive calories. These compensatory
behaviors include vomiting, use of laxatives, fasting (or severe restriction), diuretics or other medications, or excessive exercise.

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This cycle of binge eating and compensatory behaviors occurs on average, at least once a week for three months (National Eating
Disorder Association website; APA, 2022).
It is important to note that while there are periods of severe calorie restriction like anorexia, the two disorders cannot be diagnosed
simultaneously. Therefore, it is important to determine if an individual engages in a binge-eating episode—if they do, they do not
meet the criteria for anorexia nervosa.
Signs and symptoms of bulimia nervosa are similar to anorexia nervosa. These symptoms include but are not limited to hiding food
wrappers or containers after a bingeing episode, feeling uncomfortable eating in public, developing food rituals, limited diet,
disappearing to the bathroom after eating a meal, and drinking excessive amounts of water or non-caloric beverages. Additional
physical changes include weight fluctuations both up and down, difficulty concentrating, dizziness, sleep disturbance, and possible
dental problems due to purging post binge eating episode.
Making Sense of the Disorders
Though anorexia and bulimia share some common features, they differ as follows:
Diagnosis anorexia …… if severe calorie restriction occurs alone
Diagnosis bulimia … if severe calorie restriction occurs AND there is a binge-eating episode
Symptoms of bulimia nervosa typically present later in development – adolescence or early adulthood. Like anorexia nervosa,
bulimia nervosa initially presents with mild restrictive dietary behaviors; however, episodes of binge eating interrupt the dietary
restriction, causing bodyweight to rise around normal levels. In response to weight gain, patients engage in compensatory behaviors
or purging episodes to reduce body weight. This cycle of restriction, binge eating, and calorie reduction often occurs for years
before seeking help.
Additionally, those with bulimia are often ashamed of their eating problems and attempt to hide the symptoms. The binge eating
occurs in secrecy or as inconspicuously as possible. Common antecedents of binge eating include negative affect; interpersonal
stressors; dietary restraint; boredom; and negative feelings linked to body weight, shape, and food.
For more on bulimia nervosa, please visit the National Eating Disorders Association website below:
www.nationaleatingdisorders.org/learn/by-eating-disorder/bulimia

Binge-Eating Disorder (BED)

Binge-eating disorder is similar to bulimia nervosa in that it involves recurrent binge eating episodes along with feelings of lack of
control during the binge-eating episode. The binge-eating episodes are associated with at least three of the following: eating
quicker than usual, eating until uncomfortably full, eating large amounts even if not hungry, eating alone, and feeling disgust with
oneself or being depressed. Despite the feelings of shame and guilt post-binge, individuals with BED will not engage in vomiting,
excessive exercise, or other compensatory behaviors. These binge eating episodes occur on average, at least once a week for 3
months.
Because these binge-eating episodes occur without compensatory behaviors, individuals with BED are at risk for obesity and
related health disorders. Individuals with BED report feelings of embarrassment at the quantity of food consumed, and thus will
often refuse to eat in public. Due to the restriction of eating around others, individuals with BED often engage in secret binge
eating episodes in private, followed by discrete disposal of wrappers and containers.
Making Sense of the Disorders
Though bulimia and BED are similar, they differ as follows:
Diagnosis BED …… if binge eating occurs alone
Diagnosis bulimia … if binge eating occurs AND there are compensatory behaviors to prevent weight gain
While much is still being researched about binge-eating disorder, current research indicates that the onset of BED is adolescence to
early adulthood but can begin later in life. Those who seek treatment tend to be older than those with either bulimia or anorexia.
Binge eating has been found to be common in adolescent and college-age samples and for all, is associated with social role
adjustment issues, impaired health-related quality of life and life satisfaction, and increased medical morbidity and mortality (APA,
2022).
For more on binge eating disorder, please visit the National Eating Disorders Association website below:

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www.nationaleatingdisorders.org/learn/by-eating-disorder/bed

Key Takeaways
You should have learned the following in this section:
Anorexia nervosa involves the restriction of food, which leads to significantly low body weight relative to the individual’s age,
sex, and development, and an intense fear of gaining weight or becoming fat.
Bulimia nervosa is characterized by a pattern of recurrent binge eating behaviors followed by compensatory behaviors.
Binge-eating disorder is characterized by recurrent binge eating episodes along with a feeling of lack of control but no
compensatory behavior to rid the body of the calories.

 Review Questions
1. What does mutually exclusive mean? What does it mean with respect to eating disorders?
2. What are the key differences in diagnostic criteria for anorexia, bulimia, and binge eating disorder?
3. Define compensatory behavior. What disorder is this found in?

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platform; a detailed edit history is available upon request.

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10.2: Feeding and Eating Disorders - Epidemiology
 Learning Objectives
Describe the epidemiology of anorexia nervosa.
Describe the epidemiology of bulimia nervosa.
Describe the epidemiology of binge eating disorder.

Anorexia Nervosa
According to the National Eating Disorder Alliance (NEDA) website, at any point in time more women (0.3-0.4%) than men
(0.1%) will be diagnosed with anorexia. Anorexia nervosa is most prevalent in postindustrialized, high-income countries such as
the United States, Australia, New Zealand, Japan, and many European countries. In the U.S., prevalence is lower among Latinx and
non-Latinx Black Americans than non-Latinx Whites (APA, 2022).

Bulimia Nervosa
According to the NEDA website, at any point in time, 1.0% of women and 0.1% of men will meet the diagnostic criteria for
bulimia nervosa. A study by Stice and Bohon (2012) found that between 1.1% and 4.6% of females and 0.1% to 0.5% of males will
develop bulimia and that subthreshold bulimia occurs in 2.0% to 5.4% of adolescent females. The DSM reports that the 12-month
prevalence ranges from 0.14% to 0.3% with higher rates in females and high-income countries. Rates are similar across ethnoracial
groups across the U.S. (APA, 2022).

Binge Eating Disorder

Hudson et al. (2007) reports that BED is three times more common than anorexia and bulimia and is more common than breast
cancer, HIV, and schizophrenia. It has also been found that between 0.2% and 3.5% of females and 0.9% and 2.0% of males will
develop binge eating disorder with subthreshold binge eating disorder occurring in 1.6% of adolescent females (Stice & Bohon,
2012). The DSM reports a 12-month prevalence of 0.44% to 1.2% with rates 2-3 times higher in women, similar rates across
ethnoracial groups in the United States and between most high-income industrialized countries (APA, 2022).
For more on statistics and research related to feeding and eating disorders, please visit the National Eating Disorders Association
website below:
www.nationaleatingdisorders.org/statistics-research-eating-disorders

Key Takeaways
You should have learned the following in this section:
BED is three times more common than anorexia and bulimia.
All feeding and eating disorders are more common in women and high-income, industrialized countries.
Only anorexia shows differences across ethnoracial groups in the United States.

 Review Questions
1. Which feeding and eating disorder is most common?
2. What gender differences occur with regards to the eating disorders?
3. Are there any other noteworthy similarities or differences in the prevalence rates of the three disorders?

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10.3: Feeding and Eating Disorders - Comorbidity
 Learning Objectives
Describe the comorbidity of anorexia nervosa.
Describe the comorbidity of bulimia nervosa.
Describe the comorbidity of BED.

Anorexia Nervosa
Anorexia is rarely a single diagnosis. High rates of bipolar, depressive, and anxiety disorders are common among individuals with
anorexia nervosa. Obsessive-compulsive disorder is more often seen in those with the restricting type of anorexia nervosa, whereas
alcohol use disorder and other substance use disorders are more commonly seen in those with anorexia who engage in binge-
eating/purging behaviors. Unfortunately, there is also a high rate of suicidality, with rates reported to be 18 times greater than in an
age- and gender-matched comparison group. It is also estimated that between 9% and 25% of individuals with anorexia have
attempted suicide (APA, 2022).

Bulimia Nervosa
The majority of individuals diagnosed with bulimia nervosa also present with at least one other mental disorder. Similar to anorexia
nervosa, there is a high frequency of depressive symptoms (i.e., low self-esteem), as well as bipolar and depressive disorders.
While some experience mood fluctuations because of their eating pattern (occurring at the same time or following the development
of bulimia), some individuals will identify mood symptoms prior to the onset of bulimia nervosa (APA, 2022).
Anxiety, particularly social anxiety, is often present in those with bulimia nervosa. However, most mood and anxiety symptoms
resolve once an effective treatment of bulimia is established. Substance use disorder, and in particular alcohol use disorder, is also
prevalent in those with bulimia, with about a 30% prevalence among those with bulimia. The substance abuse begins as a
compensatory behavior (e.g., stimulant use is used to control appetite and weight) and over time, as the eating disorder progresses,
so does the substance abuse. There is also a percentage of individuals with bulimia nervosa who display personality features that
meet the criteria for at least one personality disorder, most often borderline personality disorder. Finally, about one-quarter to one-
third of individuals with bulimia have had suicidal ideation and a comparable amount have attempted suicide.

BED
Research shows that BED shares similar comorbidities with anorexia nervosa and bulimia nervosa. Common comorbidities include
major depressive disorder and alcohol use disorder. About 25% of those with BED have shown suicidal ideation (APA, 2022).

Key Takeaways
You should have learned the following in this section:
Anorexia has a high comorbidity with bipolar, depressive, and anxiety disorders. OCD and alcohol use disorder are also
comorbid but depend on the type of anorexia (restricting or binge-eating/purging).
Bulimia has a high comorbidity with bipolar disorder, depressive symptoms and disorders, social anxiety, and substance use
disorder.
BED is highly comorbid with MDD and alcohol use disorder.
There is a high rate of suicidal ideation with all three disorders.

 Review Questions
1. Discuss the comorbidity rates among the three main eating disorders.

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10.4: Feeding and Eating Disorders - Etiology
 Learning Objectives
Describe the biological causes of feeding and eating disorders.
Describe the cognitive causes of feeding and eating disorders.
Describe the sociocultural causes of feeding and eating disorders.
Describe how personality traits are the cause of feeding and eating disorders.

What causes eating disorders? While researchers have yet to identify a specific cause of eating disorders, the most compelling
argument to date is that eating disorders are multidimensional disorders. This means many contributing factors lead to the
development of an eating disorder. While there is likely a genetic predisposition, there are also environmental, or external factors,
such as family dynamics and cultural influences that impact their presentation. Research supporting these influences is well
documented for anorexia nervosa and bulimia nervosa; however, seeing as BED has only just recently been established as a formal
diagnosis, research on the evolvement of BED is ongoing.

Biological
There is some evidence of a genetic predisposition for eating disorders, with relatives of those diagnosed with an eating disorder
being up to six times more likely than other individuals to be diagnosed also. Twin concordance studies also support the gene
theory. If an identical twin is diagnosed with anorexia, there is a 70% percent chance the other twin will develop anorexia in their
lifetime. The concordance rate for fraternal twins (who share less genes) is 20%. While not as strong for bulimia, identical twins
still display a 23% concordance rate, compared to the 9% rate for fraternal twins.
In addition to hereditary causes, disruption in the neuroendocrine system is common in those with eating disorders (Culbert,
Racine, & Klump, 2015). Unfortunately, it’s difficult for researchers to determine if these disruptions caused the disorder or have
been caused by the disorder, as manipulation of eating patterns is known to trigger changes in hormone production. With that said,
researchers have explored the hypothalamus as a potential contributing factor. The hypothalamus is responsible for regulating
body functions, particularly hunger and thirst (Fetissov & Mequid, 2010). Within the hypothalamus, the lateral hypothalamus is
responsible for initiating hunger cues that cause the organism to eat, whereas the ventromedial hypothalamus is responsible for
sending signals of satiation, telling the organism to stop eating. Clearly, a disruption in either of these structures could explain why
an individual may not take in enough calories or experience periods of overeating.

Cognitive
Some argue that eating disorders are, in fact, a variant of obsessive-compulsive disorder (OCD). The obsession with body shape
and weight—the hallmark of an eating disorder—is likely a driving factor in anorexia nervosa. Distorted thought patterns and an
over-evaluation of body size likely contribute to this obsession and one’s desire for thinness. Research has identified high levels of
impulsivity, particularly in those with binge eating episodes, suggesting a temporary lack of control is responsible for these
episodes. Post binge-eating episode, many individuals report feelings of disgust or even thoughts of failure. These strong cognitive
factors are indicative as to why cognitive-behavioral therapy is the preferred treatment for eating disorders.

Sociocultural
Eating disorders are overwhelmingly found in Western countries where there is a heavy emphasis on thinness—a core feature of
eating disorders. It is also found in countries where food is in abundance, as in places of deprivation, round figures are viewed as
more desirable (Polivy & Herman, 2002). While eating disorders were once thought of as disorders of higher SES, recent research
suggests that as our country becomes more homogenized, the more universal eating disorders become.
10.4.3.1. Media. One commonly discussed contributor to eating disorders is the media. The idealization of thin models and
actresses sends the message to young women (and adolescents) that to be popular and attractive, you must be thin. These images
are not isolated to magazines, but are also seen in television shows, movies, commercials, and large advertisements on billboards
and hanging in store windows. With the emergence of social media (e.g., Facebook, Snapchat, Instagram), exposure to media
images and celebrities is even easier. Couple this with the ability to alter images to make individuals even thinner, it is no wonder
many young people become dissatisfied with their body (Polivy & Herman, 2004).

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10.4.3.2. Ethnicity. While eating disorders are not solely a “white woman” disorder, there are significant discrepancies when it
comes to race, especially for anorexia nervosa. Why is this? Research indicates that black men prefer heavier women than do white
men (Greenberg & Laporte, 1996). Given this preference, it should not be surprising that black women and children have larger
ideal physiques than their white peers (Polivy & Herman, 2000). Since black women are less driven to thinness, black women
would appear to be less likely to develop anorexia; however, findings suggest this is not the case. Caldwell and colleagues (1997)
found that high-income black women were equally as dissatisfied as high-income white women with their physique, suggesting
body image issues may be more closely related to SES than that of race. The race discrepancies are also less significant in BED,
where the prominent feature of the eating disorder is not thinness (Polivy & Herman, 2002).
10.4.3.3. Gender. Males account for only a small percentage of eating disorders. While it is unclear as to why there is such a
discrepancy, it is likely somewhat related to cultural desires of women being “thin” and men being “muscular” or “strong.”
Of men diagnosed with an eating disorder, the overwhelming percentage of them identified a job or sport as the primary reason for
their eating behaviors (Strother, Lemberg, Stanford, & Turberville, 2012). Jockeys, distance runners, wrestlers, and bodybuilders
are some of the professions identified as most restrictive regarding body weight.
There is some speculation that males are not diagnosed as frequently as women due to the stigma attached to eating disorders.
Eating disorders have routinely been characterized as a “white, adolescent female” problem. Due to this bias, young men may not
seek help for their eating disorder in efforts to prevent labeling (Raevuoni, Keski-Rahkonen & Hoek, 2014).
10.4.3.4. Family. Family influences are one of the strongest external contributors to maintaining eating disorders. Often family
members are praised for their slenderness. Think about the last time you saw a family member or close friend- how often have you
said, “You look great!” or commented on their appearance in some way? The odds are likely high. While the intent of the family
member is not to maintain maladaptive eating behaviors by praising the physical appearance of someone struggling with an eating
disorder, they are indirectly perpetuating the disorder.
While family involvement can help maintain the disorder, it can also contribute to the development of an eating disorder. Families
that emphasize thinness or place a large emphasis on physical appearance are more likely to have a child diagnosed with an eating
disorder (Zerbe, 2008). In fact, mothers with eating disorders are more likely to have children who develop a feeding/eating
disorder than mothers without eating disorders (Whelan & Cooper, 2000). Additional family characteristics that are common
among patients receiving treatment for eating disorders are enmeshed, intrusive, critical, hostile, or overly concerned with
parenting (Polivy & Herman, 2002). While there has been some correlation between these family dynamics and eating disorders,
they are not evident in all families of people with eating disorders.

Personality
There are many personality characteristics that are common in individuals with eating disorders. While it is unknown if these
characteristics are inherent in the individual’s personality or a product of personal experiences, the thought is eating disorders
develop due to the combination of the two.
10.4.4.1. Perfectionism. It should come as no surprise that perfectionism, or the belief that one must be perfect, is a contributing
factor to disorders related to eating, weight, and body shape (particularly anorexia nervosa). While an exact mechanism is
unknown, it is believed that perfectionism magnifies normal body imperfections, leading an individual to go to extreme (i.e.,
restrictive) behaviors to remedy the flaw (Hewitt, Flett & Ediger, 1995).
10.4.4.2. Self-Esteem. Self-esteem, or one’s belief in their worth or ability, has routinely been identified as a moderator of many
psychological disorders, and eating disorders are no exception. Low self-esteem not only contributes to the development of an
eating disorder but is also likely involved in the maintenance of the disorder. One theory, the transdiagnostic model of eating
disorders, suggests that overall low self-esteem increases the risk for over-evaluation of body, which in turn, leads to negative
eating behaviors that could lead to an eating disorder (Fairburn, Cooper & Shafran, 2003).

Key Takeaways
You should have learned the following in this section:
Biological causes of eating disorders include a genetic predisposition and disruption in the neuroendocrine system.
Cognitive causes of eating disorders include distorted thought patterns and an over-evaluation of body size.
Sociocultural causes of eating disorders include the idealization of thin models and actresses by the media, SES, gender, and
family involvement.

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 The personality trait of perfectionism and low self-esteem are contributing factors to disorders related to eating, weight, and
body shape.

 Review Questions
1. Define multidimensional disorders?
2. What evidence is there to suggest eating disorders are biologically driven?
3. According to the cognitive theory, eating disorders may be a variant of what other disorder?
4. Discuss the four sociocultural subgroups that explains development of eating disorders.
5. What are the two personality traits most commonly used to describe behaviors associated with eating disorders?

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curated by Alexis Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed
edit history is available upon request.

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10.5: Feeding and Eating Disorders - Treatment
 Learning Objectives
Describe treatment options for anorexia nervosa.
Describe treatment options for bulimia nervosa.
Describe treatment options for binge eating disorder.
Discuss the outcome of treatment for feeding and eating disorders.

Anorexia Nervosa
The immediate goal for the treatment of anorexia nervosa is weight gain and recovery from malnourishment. This is often
established via an intensive outpatient program, or if needed, through an inpatient hospitalization program where caloric intake can
be managed and controlled. Both the inpatient and outpatient programs use a combination of therapies and support to help restore
proper eating habits. Of the most common (and successful) treatments are Cognitive-Behavioral Therapy (CBT) and Family-Based
Therapy (FBT).
10.5.1.1. CBT. Because anorexia nervosa requires changes to both eating behaviors as well as thought patterns, CBT strategies
have been very effective in producing lasting changes to those suffering from anorexia nervosa. Some of the behavioral strategies
include recording eating behaviors—hunger pains, quality and quantity of food—and emotional behaviors—feelings related to the
food. In addition to these behavioral strategies, it is also important to address the maladaptive thought patterns associated with their
negative body image and desire to control their physical characteristics. Changing the fear related to gaining weight is essential in
recovery.
10.5.1.2. Family based therapy (FBT). FBT is also an effective treatment approach, often used as a component of individual CBT,
especially for children and adolescents with the disorder. FBT has been shown to elicit 50-60% of weight restoration in one year, as
well as weight maintenance 2-4 years post-treatment (Campbell & Peebles, 2014; LeGrange, Lock, Accurso, Agras, Darcy,
Forsberg, et al, 2014). Additionally, FBT has been shown to improve rapid weight gain, produce fewer hospitalizations, and is
more cost-effective than other types of therapies with family involvement (Agras, Lock, Brandt, Bryson, Dodge, Halmi, et al.,
2014).
FBT typically involves 16-18 sessions which are divided into 3 phases: (1) Parents take charge of weight restoration, (2) client’s
gradual control of overeating, and (3) addressing developmental issues including fostering autonomy from parents (Chen, et al.,
2016). While FBT has shown to be effective in treating adolescents with anorexia nervosa, the application for older eating patients
(i.e., college-aged students and above) is still undetermined. As with adolescents, the goal for a family-based treatment program
should center around helping the patient separate their feelings and needs from that of their family.

Bulimia Nervosa
Just as anorexia nervosa treatment initially focuses on weight gain, the first goal of bulimia nervosa treatment is to eliminate binge
eating episodes and compensatory behaviors. The aim is to replace both negative behaviors with positive eating habits. One of the
most effective ways to establish this is through Cognitive Behavioral Therapy (CBT).
10.5.2.1. CBT. Similar to anorexia nervosa, individuals with bulimia nervosa are expected to keep a journal of their eating habits;
however, with bulimia nervosa, it is also important that the journal include changes in sensations of hunger and fullness, as well as
other feelings surrounding their eating patterns in efforts to identify triggers to their binging episodes (Agras, Fitzsimmons-Craft &
Wilfley, 2017). Once these triggers are identified, psychologists will utilize specific behavioral or cognitive techniques to prevent
the individual from engaging in binge episodes or compensatory behaviors.
One method for modifying behaviors is through Exposure and Response Prevention. As previously discussed in the OCD chapter,
this treatment is very effective in helping individuals stop performing their compulsive behaviors by literally preventing them from
engaging in the action, while simultaneously using relaxation strategies to reduce anxiety associated with not engaging in the
negative behavior. Therefore, to prevent an individual from purging post-binge episodes, the individual would be encouraged to
partake in an activity that directly competes with their ability to purge, e.g., write their thoughts and feelings in a journal at the
kitchen table. Research has indicated that this treatment is particularly helpful for individuals suffering from comorbid anxiety
disorders (particularly OCD; Agras, Fitzsimmons-Craft & Wilfley, 2017).

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In addition to changing behaviors, it is also important to change the maladaptive thoughts toward food, eating, weight, and shape.
Negative thoughts such as “I am fat” and “I can’t stop eating when I start” can be modified into more appropriate thoughts such as
“My body is healthy” or “I can control my eating habits.” By replacing these negative thoughts with more appropriate, positive
thought patterns, individuals begin to control their feelings, which in return, can help them manage their behaviors.
10.5.2.2. Interpersonal Psychotherapy (IPT). IPT has also been established as an effective treatment for those with bulimia
nervosa, particularly if an individual has not been successful with CBT treatment. The goal of IPT is to improve interpersonal
functioning in those with eating disorders. Originally a treatment for depression, IPT-E was adapted to address the social isolation
and self-esteem problems that contribute to the maintenance of negative eating behaviors.
IPT-E has 3 phases typically covered in weekly sessions over 4-5 months. Phase One consists of engaging the patient in treatment
and providing psychoeducation about their disease and the treatment program. This phase also includes identifying interpersonal
problems that are maintaining the disease.
Phase Two is the main treatment component. In this phase, the primary focus is on problem-solving interpersonal issues. The most
common types of interpersonal issues are lack of intimacy and interpersonal deficits, interpersonal role disputes, role transitions,
grief, and life goals. Once the main interpersonal problem is identified, the clinician supports the patient in their pursuit to identify
ways to change. A key component of IPT-E is the supportive role of the clinician, as opposed to the teaching role in other
treatments. The idea is that by having the patient make changes, they can better understand their problems, and as a result, make
more profound changes (Murphy, Straebler, Basden, Cooper, & Fairburn, 2012).
Phase Three is the final stage. The goals of this phase are to ensure that the changes made in Phase two are maintained. To achieve
this, treatment sessions are spaced out, allowing patients more time to engage in their changed behavior. Additionally, relapse
prevention (i.e., problem-solving ways not to relapse) is also discussed to ensure long term results. In doing this, the patient
reviews the progress they have made throughout treatment, as well as identifying potential interpersonal issues that may arise, and
how their treatment can be adapted to address those issues.
Support for IPT-E is limited; however, two extensive studies suggest that IPT-E is effective in treating bulimia nervosa, and
possibly BED. While treatment is initially slower than CBT, it is equally effective in long-term follow-up and maintenance of
disorder (Fairburn, Marcus, & Wilson, 1993).

Binge Eating Disorder

Given the similar presentations of BED and bulimia nervosa, it should not be surprising that the most effective treatments for BED
are similar to that of bulimia nervosa. CBT, along with antidepressant medications, are among the most effective in treating BED.
Interpersonal therapy, as well as dialectical behavioral therapy, have also been effective in reducing binge-eating episodes;
however, they have not been effective in weight loss (Guerdjikova, Mori, Casuto, & McElroy, 2017). Goals of treatment are, of
course, to eliminate binge eating episodes, as well as reduce body weight as most individuals with BED are overweight. Seeing as
BED has only recently been established as a separate eating disorder, treatment research specific to this disorder is expected to
grow.
10.5.3.1. Antidepressant medications. Given the high comorbidity between eating disorders and depressive symptoms,
antidepressants have been a primary method of treatment for years. While they have been shown to improve depressive symptoms,
which may help individuals make gains in their eating disorder treatment, research has not supported antidepressants as an effective
treatment strategy for treating the eating disorder itself.

Outcome of Treatment
Now that we have discussed treatments for eating disorders, how effective are they? Research has indicated favorable prognostic
features for anorexia nervosa are early age of onset and a short history of the disorder. Conversely, unfavorable features are a long
history of symptoms prior to treatment, severe weight loss, and binge eating and vomiting. The mortality rate over the first 10 years
from presentation is about 10%. Most of these deaths are from medical complications due to the disorder or suicide.
Unfortunately, research has not identified any consistent predictors of positive outcomes for bulimia nervosa. However, there is
some speculation that individuals with childhood obesity, low self-esteem, and those with a personality disorder have worse
treatment outcomes. While treatment outcome for BED is still in its infancy, initial findings suggest that remission rates of BED are
much higher than that for anorexia nervosa and bulimia nervosa.

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Key Takeaways
You should have learned the following in this section:
Treatment options for anorexia nervosa include CBT and FBT.
Treatment options for bulimia nervosa include CBT, exposure and response prevention, and the three phases of interpersonal
psychotherapy.
Treatment options for BED include the taking of antidepressants to manage depressive symptoms, CBT, and interpersonal
therapy.

 Review Questions
1. What is the initial (main) goal of treatment for anorexia?
2. What are the three phases of family-based treatment?
3. What is the goal for interpersonal psychotherapy? Discuss the three phases of IPT.
4. What is the overall treatment effectiveness of eating disorders?

Module Recap
Module 10 covered eating disorders in terms of their clinical presentation, epidemiology, comorbidity, etiology, and treatment
options. In Module 11, we will discuss substance-related and addictive disorders, which will conclude this part.

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 CHAPTER OVERVIEW

11: Substance-Related and Addictive Disorders

 Learning Objectives
Describe how substance-related and addictive disorders present.
Describe the epidemiology of substance-related and addictive disorders.
Describe comorbidity in relation to substance-related and addictive disorders.
Describe the etiology of substance-related and addictive disorders.
Describe treatment options for substance-related and addictive disorders.

Module 11 will cover matters related to substance-related and addictive disorders to include their clinical presentation,
epidemiology, comorbidity, etiology, and treatment options. Our discussion will include substance intoxication, substance use
disorder, and substance withdrawal. We also list substances people can become addicted to. Be sure you refer to Modules 1-3 for
explanations of key terms (Module 1), an overview of the various models to explain psychopathology (Module 2), and descriptions
of the therapies (Module 3).
11.1: Substance-Related and Addictive Disorders - Clinical Presentation
11.2: Substance-Related and Addictive Disorders - Epidemiology
11.3: Substance-Related and Addictive Disorders - Comorbidity
11.4: Substance-Related and Addictive Disorders - Etiology
11.5: Substance-Related and Addictive Disorders - Treatment

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1
11.1: Substance-Related and Addictive Disorders - Clinical Presentation
 Learning Objectives
Define substances and substance abuse.
Describe properties of substance abuse.
Describe how substance use disorder presents.
Describe how substance intoxication presents.
Describe how substance withdrawal presents.
Define depressants and describe types.
Define stimulants and describe types.
Define hallucinogens/cannabis/combination and describe types.

Defining Terms and Adding Context

Substance-related and addictive disorders are among the most prevalent psychological disorders, with roughly 100 million people
in the United States reporting the use of an illegal substance sometime throughout their life (SAMHSA, 2014). It is worth noting
that the DSM-5 shifted terminology from drug addiction to substance use disorder, “…to describe the wide range of the disorder,
from a mild form to a severe state of chronically relapsing, compulsive pattern of drug taking.” The DSM-5 acknowledges that
many clinicians will use the term drug addiction to describe more severe presentations, but it is omitted from the DSM-5 due to
“…its uncertain definition and its potentially negative connotation” (APA, 2022, pg. 543).
What are substances? Substances are any ingested materials that cause temporary cognitive, behavioral, or physiological
symptoms within the individual. The DSM uses 10 classes of substances: alcohol, caffeine, cannabis, hallucinogens, inhalants,
opioids, sedatives, stimulants, tobacco, and other (or unknown).
Repeated use of these substances or frequent substance intoxication can develop into a long-term problem known as substance
abuse. Abuse occurs when an individual consumes the substance for an extended period or must ingest large amounts of the
substance to get the same effect a substance provided previously. The need to continually increase the amount of ingested substance
is known as tolerance. As tolerance builds, additional physical and psychological symptoms present, often causing significant
disturbances in an individual’s personal and professional life. Individuals with substance abuse often spend a significant amount of
time engaging in activities that revolve around their substance use, thus spending less time in recreational activities that once
consumed their time.
Sometimes, there is a desire to reduce or abstain from substance use; however, cravings and withdrawal symptoms often prohibit
this from occurring. Common withdrawal symptoms include, but are not limited to, cramps, anxiety attacks, sweating, nausea,
tremors, and hallucinations. Depending on the substance and the tolerance level, most withdrawal symptoms last anywhere from a
few days to a week. For those with extensive substance abuse or abuse of multiple substances, withdrawal should be closely
monitored in a hospital setting to avoid severe consequences such as seizures, stroke, or even death.
According to the DSM-5-TR (APA, 2022), the substance-related disorders are divided into two groups: substance use disorders and
substance-induced disorders which include substance intoxication and substance withdrawal. While there are some subtle
differences in symptoms, particularly psychological, physical, and behavioral symptoms, the general diagnostic criteria for
substance use disorder, substance intoxication, and substance withdrawal remains the same across substances. These criteria are
reviewed below, with more specific details of psychological, physical, and behavioral symptoms in the Section 11.1.5.: Types of
Substances Abused.

Substance Use Disorder

The essential feature of substance use disorder, is a “…cluster of cognitive, behavioral, and physiological symptoms indicating
that the individual continues using the substance despite significant substance-related problems” (APA, 2022, pg. 544) and can be
diagnosed for all ten substance classes except for caffeine. Distress or impairment can be described as any of the following:
inability to complete or lack of participation in work, school or home activities; increased time spent on activities obtaining, using,
or recovering from substance use; impairment in social or interpersonal relationships; use of a substance in a potentially hazardous
situation; psychological problems due to recurrent substance abuse; craving the substance; an increase in the amount of substance
used over time (i.e., tolerance); difficulty reducing the amount of substance used despite a desire to reduce/stop using; and/or

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withdrawal symptoms (APA, 2022). While the number of these symptoms may vary among individuals, only two symptoms are
required for a diagnosis of substance use disorder.

Substance Intoxication
For a diagnosis of substance intoxication, the individual must have recently ingested a substanc. Immediately following the
ingestion of this substance, significant behavioral and/or psychological change is observed. In addition, physical and physiological
symptoms present as a direct result of the substance ingested. As stated above, these behavioral, physical, and physiological
symptoms are dependent on the type of substance that is ingested and, therefore, discussed in more detail within each substance
category (i.e., depressants, stimulants, hallucinogens/cannabis/combination). This said, the most common changes involve
disturbances of perception, wakefulness, attention, thinking, psychomotor behavior, interpersonal behavior, and judgment (APA,
2022).

Substance Withdrawal
Finally, substance withdrawal is diagnosed when there is cessation or reduction of a substance that has been used for a long
period of time. Individuals undergoing substance withdrawal will experience physiological and psychological symptoms within a
few hours after cessation/reduction. These symptoms cause significant distress or impairment in daily functioning (APA, 2022). As
with substance intoxication, physiological and psychological symptoms during substance withdrawal are often specific to the
substance abused and are discussed in more detail within each substance category later in the module.

Types of Substances Abused

For our purposes, the most abused substances will be divided into three categories based on how they impact one’s physiological
state: depressants, stimulants, and hallucinogens/cannabis/combination.
11.1.5.1. Depressants. Depressants include alcohol, sedative-hypnotic drugs, and opioids are known to have an inhibiting effect on
one’s central nervous system; therefore, they are often used to alleviate tension and stress. Unfortunately, when used in large
amounts, they can also impair an individual’s judgment and motor activity.
While alcohol is one of the only legal (over-the-counter) substances we will discuss, it is also the most commonly consumed
substance. According to the 2015 National Survey on Drug Use and Health, approximately 70% of individuals drank an alcoholic
beverage in the last year, and nearly 56% of individuals drank an alcoholic beverage in the past month (SAMHSA, 2015). While
the legal age of consumption in the United States is 21, approximately 78% of teens report that they drank alcohol at some point in
their life (SAMHSA, 2013).
Despite the legal age of consumption, many college-aged students engage in binge or heavy drinking. In fact, 45% of college-aged
students report engaging in binge drinking, with 14% binge drinking at least 5 days per month (SAMHSA, 2013). In addition to
these high levels of alcohol consumption, students also engage in other behaviors such as skipping meals, which can impact the rate
of alcohol intoxication and place them at risk for dehydration, blacking out, and developing alcohol-induced seizures (Piazza-
Gardner & Barry, 2013).
The “active” substance of alcohol, ethyl alcohol, is a chemical that is absorbed quickly into the blood via the lining of the stomach
and intestine. Once in the bloodstream, ethyl alcohol travels to the central nervous system (i.e., brain and spinal cord) and produces
depressive symptoms such as impaired reaction time, disorientation, and slurred speech. These symptoms are produced due to the
ethyl alcohol binding to GABA receptors, thus preventing GABA from providing inhibitory messages and allowing the individual
to relax (Filip et al., 2015).
The effect of ethyl alcohol in moderation allows for an individual to relax, engage more readily in conversation, and in general,
produce a confident and happy personality. However, when consumption is increased or excessive, the central nervous system is
unable to metabolize the ethyl alcohol adequately, and adverse effects begin to present. Symptoms such as blurred vision, difficulty
walking, slurred speech, slowed reaction time, and sometimes, aggressive behaviors are observed.
The extent to which these symptoms present are directly related to the concentration of ethyl alcohol within the body, as well as the
individual’s ability to metabolize the ethyl alcohol. There are a lot of factors that contribute to how quickly one’s body can
metabolize ethyl alcohol. Food, gender, body weight, and medications are among the most common factors that affect alcohol
absorption (NIAAA,1997). More specifically, recent consumption of food, particularly those high in fat and carbohydrates, slow
the absorption rate of ethyl alcohol, thus reducing its effects. Regarding gender, women absorb and metabolize alcohol differently
than men, likely due to the smaller amount of body water and the lower activity of an alcohol metabolizing enzyme in the stomach.

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Another factor related to gender is weight—with individuals with more body mass metabolizing the alcohol at a slower rate than
those who weigh less. Finally, various medications, both over the counter and prescription, can impact the liver’s ability to
metabolize alcohol, thus affecting the severity of symptoms that present (NIAAA, 1997).
Sedative-Hypnotic drugs, more commonly known as anxiolytic drugs, have a calming and relaxing effect on individuals. When
used at a clinically appropriate dosage, they can have a sedative effect, thus making them a suitable drug for treating anxiety-
related disorders. In the early 1900s, barbiturates were introduced as the main sedative and hypnotic drug; however, due to their
addictive nature, as well as respiratory distress when consumed in large amounts, they have been largely replaced by
benzodiazepines which are considered a safer alternative as they have less addictive qualities (Filip et al., 2014).
Commonly prescribed benzodiazepines— Xanax, Ativan, and Valium—have a similar effect to alcohol as they too bind to the
GABA receptors and increase GABA activity (Filip et al., 2014). This increase in GABA produces a sedative and calming effect.
Benzodiazepines can be prescribed for both temporary relief (pre-flight or before surgery) or long-term use (generalized anxiety
disorder). While they do not produce respiratory distress in large dosages like barbiturates, they can cause intoxication and
addictive behaviors due to their effects on tolerance.
Opioids are naturally occurring, derived from the sap of the opium poppy. In the early 1800s, morphine was isolated from opium
by German chemist Friedrich Wilhelm Adam Serturner. Due to its analgesic effect, it was named after the Greek god of dreams,
Morpheus (Brownstein, 1993). Its popularity grew during the American Civil War as it was the primary medication given to
soldiers with battle injuries. Unfortunately, this is also when the addictive nature of the medication was discovered, as many
soldiers developed “Soldier’s Disease” as a response to tolerance of the drug (Casey, 1978).
In an effort to alleviate the addictive nature of morphine, heroin was synthesized by the German chemical company Bayer in 1898
and was offered in a cough suppressant (Yes, Bayer promoted heroin). For years, heroin remained in cough suppressants as well as
other pain reducers until it was discovered that heroin was more addictive than morphine. In 1917, Congress stated that all drugs
derived from opium were addictive, thus banning the use of opioids in over-the-counter medications.
Opioids are unique in that they provide both euphoria and drowsiness. Tolerance to these drugs builds quickly, thus resulting in an
increased need of the medication to produce desired effects. This rapid tolerance is also likely responsible for opioids’ highly
addictive nature. Opioid withdrawal symptoms can range from restlessness, muscle pain, fatigue, anxiety, and insomnia.
Unfortunately, these withdrawal symptoms, as well as intense cravings for the drug, can persist for several months, with some
reports up to years. Because of the intensity and longevity of these withdrawal symptoms, many individuals struggle to remain
abstinent, and accidental overdoses are common (CDC, 2013).
The rise of abuse and misuse of opioid products in the early-to-mid 2000s is a direct result of the increased number of opioid
prescription medications containing oxycodone and hydrocodone (Jayawant & Balkrishnana, 2005). The 2015 report estimated 12.5
million Americans had abused prescription narcotic pain relievers in the past year (SAMHSA, 2016). In an effort to reduce such
abuse, the FDA developed programs to educate prescribers about the risks of misuse and abuse of opioid medications.
11.1.5.2. Stimulants. The two most common types of stimulants abused are cocaine and amphetamines. Unlike depressants that
reduce the activity of the central nervous system, stimulants have the opposite effect, increasing the activity in the central nervous
system. Physiological changes that occur with stimulants are increased blood pressure, heart rate, pressured thinking/speaking, and
rapid, often jerky behaviors. Because of these symptoms, stimulants are commonly used for their feelings of euphoria, to reduce
appetite, and prevent sleep.
Similar to opioids, cocaine is extracted from a South American plant—the coca plant—and produces feelings of energy and
euphoria. It is the most potent natural stimulant known to date (Acosta et al., 2011). Low doses can produce feelings of excitement,
talkativeness, and euphoria; however, as the amount of ingested cocaine increases, physiological changes such as rapid breathing,
increased blood pressure, and excessive arousal can be observed. The psychological and physiological effects of cocaine are due to
an increase of dopamine, norepinephrine, and serotonin in various brain structures (Hart & Ksir, 2014; Haile, 2012).
One key feature of cocaine use is the rapid high of cocaine intoxication, followed by the quick depletion, or crashing, as the drug
diminishes within the body. During the euphoric intoxication, individuals will experience poor muscle coordination, grandiosity,
compulsive behavior, aggression, and possible hallucinations and delusions (Haile, 2012). Conversely, as the drug leaves the
system, the individual will experience adverse effects such as headaches, dizziness, and fainting (Acosta et al., 2011). These
negative feelings often produce a negative feedback loop, encouraging individuals to ingest more cocaine to alleviate the negative
symptoms. This also increases the chance of accidental overdose.

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Cocaine is unique in that it can be ingested in various ways. While cocaine was initially snorted via the nasal cavity, individuals
found that if the drug was smoked or injected, its effects were more potent and longer-lasting (Haile, 2012). The most common way
cocaine is currently ingested is via freebasing, which involves heating cocaine with ammonia to extract the cocaine base. This
method produces a form of cocaine that is almost 100% pure. Due to its low melting point, freebased cocaine is easy to smoke via a
glass pipe. Inhaled cocaine is absorbed into the bloodstream and brain within 10-15 seconds suggesting its effects are felt almost
immediately (Addiction Centers of America).
Crack is a derivative of cocaine that is formed by combining cocaine with water and another substance (commonly baking soda) to
create a solid structure that is then broken into smaller pieces. Because of this process, it requires very little cocaine to make crack,
thus making it a more affordable drug. Coined for the crackling sound that is produced when it is smoked, it is also highly
addictive, likely due to the fast-acting nature of the drug. While the effects of cocaine peak in 20-30 minutes and last for about 1-2
hours, the effects of crack peak in 3-5 minutes and last only for up to 60 minutes (Addiction Centers of America).
Amphetamines are manufactured in a laboratory setting. Currently, the most common amphetamines are prescription medications
such as Ritalin, Adderall, and Dexedrine (prescribed for sleep disorders). These medications produce an increase in energy and
alertness and reduce appetite when taken at clinical levels. However, when consumed at larger dosages, they can produce
intoxication similar to psychosis, including violent behaviors. Due to the increased energy levels and appetite suppressant qualities,
these medications are often abused by students studying for exams, athletes needing extra energy, and individuals seeking weight
loss (Haile, 2012). Biologically, similar to cocaine, amphetamines affect the central nervous system by increasing the amount of
dopamine, norepinephrine, and serotonin in the brain (Haile, 2012).
Methamphetamine, a derivative of amphetamine, is often abused due to its low cost and feelings of euphoria and confidence;
however, it can have serious health consequences such as heart and lung damage (Hauer, 2010). Most commonly used
intravenously or nasally, methamphetamine can also be eaten or heated to a temperature in which it can be smoked. The most
notable effects of methamphetamine use are the drastic physical changes to one’s appearance, including significant teeth damage
and facial lesions (Rusyniak, 2011).
While we are sure you are well aware of how caffeine is consumed, you may be surprised to learn that in addition to coffee, energy
drinks, and soft drinks, caffeine can also be found in chocolate and tea. Because of the vast use of caffeine, it is the most widely
consumed substance in the world, with approximately 90% of Americans consuming some form of caffeine each day (Fulgoni,
Keast, & Lieberman, 2015). While caffeine is often consumed in moderate dosages, caffeine intoxication and withdrawal can
occur. In fact, an increase in caffeine intoxication and withdrawal have been observed with the simultaneous popularity of energy
drinks. Common energy drinks such as Monster and RedBull have nearly double the amount of caffeine of tea and coke (Bigard,
2010). While adults commonly consume these drinks, a startling 30% of middle and high schoolers also report regular consumption
of energy drinks to assist with academic and athletic responsibilities (Terry-McElrath, O’Malley, & Johnston, 2014). The rapid
increase in caffeinated beverages has led to a rise in ER visits due to the intoxication effects (SAMHSA, 2013).
11.1.5.3. Hallucinogens/Cannabis/Combination. The final category includes both hallucinogens and cannabis- both of which
produce sensory changes after ingestion. While hallucinogens are known for their ability to produce more severe delusions and
hallucinations, cannabis also has the capability of producing delusions or hallucinations; however, this typically occurs only when
large amounts of cannabis are ingested. More commonly, cannabis has been known to have stimulant and depressive effects, thus
classifying itself in a group of its own due to the many different effects of the substance.
Hallucinogens come from natural sources and have been involved in cultural and religious ceremonies for thousands of years.
Synthetic forms of hallucinogens have also been created—most common of which are PCP, Ketamine, LSD, and Ecstasy. In
general, hallucinogens produce powerful changes in sensory perception. Depending on the type of drug ingested, effects can range
from hallucinations, changes in color perception, or distortion of objects. Additionally, some individuals report enhanced auditory,
as well as changes in physical perception such as tingling or numbness of limbs and interchanging hot and cold sensations (Weaver
& Schnoll, 2008). Interestingly, the effect of hallucinogens can vary both between individuals, as well as within the same
individual. This means that the same amount of the same drug may produce a positive experience one time, but a negative
experience the next time.
Overall, hallucinogens do not have addictive qualities; however, individuals can build a tolerance, thus needing larger quantities to
produce similar effects (Wu, Ringwalt, Weiss, & Blazer, 2009). Furthermore, there is some evidence that long-term use of these
drugs results in psychosis, mood, or anxiety disorders due to the neurobiological changes after using hallucinogens (Weaver &
Schnoll, 2008).

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Similar to hallucinogens and a few other substances, cannabis is also derived from a natural plant—the hemp plant. While the
most powerful of hemp plants is hashish, the most commonly known type of cannabis, marijuana, is a mixture of hemp leaves,
buds, and the tops of plants (SAMHSA, 2014). Many external factors impact the potency of cannabis, such as the climate it was
grown in, the method of preparation, and the duration of storage. Of the active chemicals within cannabis, tetrahydrocannabinol
(THC) appears to be the single component that determines the potent nature of the drug. Various strains of marijuana have varying
amounts of THC; hashish contains a high concentration of THC, while marijuana has a small concentration.
THC binds to cannabinoid receptors in the brain, which produces psychoactive effects. These effects vary depending on both an
individual’s body chemistry, as well as various strains and concentrations of THC. Most commonly, people report feelings of calm
and peace, relaxation, increased hunger, and pain relief. Occasionally, negative symptoms such as increased anxiety or paranoia,
dizziness, and increased heart rate also occur. In rare cases, individuals develop psychotic symptoms or schizophrenia following
cannabis use (Donoghue et al., 2014).
While nearly 20 million Americans report regular use of marijuana, only 10% of these individuals will develop a dependence on
the drug (SAMHSA, 2013). Of particular concern is the number of adolescents engaging in cannabis use. One in eight 8th graders,
one in four 10th graders, and one in three 12th graders reported use of marijuana in the past year (American Academy of Child and
Adolescent Psychiatry, 2013). Individuals who begin cannabis abuse during adolescence are at an increased risk of developing
cognitive effects from the drug due to the critical period of brain development during adolescence (Gruber, Sagar, Dahlgren,
Racine, & Lukas, 2012). Increased discussion about the effects of marijuana use, as well as psychoeducation about substance abuse
in general, is important in preventing marijuana use during adolescence.
It is not uncommon for substance abusers to consume more than one type of substance at a time. This combination of substance
use can have dangerous results depending on the interactions between substances. For example, if multiple depressant drugs (i.e.,
alcohol, benzodiazepines, and/or opiates) are consumed at one time, an individual is at risk for severe respiratory distress or even
death due to the compounding depressive effects on the central nervous system. Additionally, when an individual is under the
influence of one substance, judgment may be impaired, and ingestion of a larger amount of another drug may lead to an accidental
overdose. Finally, the use of one drug to counteract the effects of another drug—taking a depressant to combat the effects of a
stimulant—is equally as dangerous as the body is unable to regulate homeostasis.

Key Takeaways
You should have learned the following in this section:
An individual is diagnosed with substance use disorder, substance intoxication, or substance withdrawal specific to the
substance or substances being ingested though the symptoms remain generally the same across substances.
Substance use disorder occurs when a person experiences significant impairment or distress for 12 months due to the use of a
substance.
Substance intoxication occurs when a person has recently ingested a substance leading to significant behavioral and/or
psychological changes.
Substance withdrawal occurs when there is a cessation or reduction of a substance that has been used for a long period of time.
Depressants include alcohol, sedative-hypnotic drugs, and opioids.
Stimulants include cocaine and amphetamines, but caffeine as well.
Hallucinogens come from natural sources and produce powerful changes in sensory perception.
Cannabis is also derived from a natural plant and produces psychoactive effects.
Many drugs are taken by users in combination which can have dangerous results depending on the interactions between the
substances.

 Review Questions
1. What is a substance?
2. What is the difference between substance intoxication and substance abuse?
3. What is the difference between tolerance and withdrawal?
4. Create a table listing the three types of substances abused, as well as the specific substances within each category.
5. What are the common factors that affect alcohol absorption?
6. What are the effects of sedative-hypnotic drugs?
7. What receptors are responsible for increasing activity in alcohol and benzodiazepines?

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 8. What is responsible for the addictive nature of opioids?
9. Which neurotransmitters are implicated in cocaine use?
10. What are the different ways cocaine can be ingested?
11. List the common types of amphetamines.

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11.2: Substance-Related and Addictive Disorders - Epidemiology
 Learning Objectives
Describe the epidemiology of depressants.
Describe the epidemiology of stimulants.
Describe the epidemiology of hallucinogens.

It has been estimated that nearly 9% of teens and adults in the United States have a substance abuse disorder (SAMHSA, 2014).
Asian/Pacific Islanders, Hispanics, and African Americans are less likely to develop a lifetime substance abuse disorder compared
to non-Hispanic white individuals (Grant et al., 2016). Native Americans have the highest rate of substance abuse at nearly 22
percent (NSDUH, 2013). Additional demographic variables also suggest that overall substance abuse is greater in men than
women, younger versus older individuals, unmarried/divorced individuals than married, and in those with an education level of a
high school degree or lower (Grant et al., 2016). With regards to specific types of substances, the highest prevalence rates of
substances abused are cannabis, opioids, and cocaine, respectively (Grant et al., 2016).

Depressants
Concerning depressant substances, men outnumber women in alcohol abuse 2 to 1 (Johnston et al., 2014). Ethnically, Native
Americans have highest rate of alcoholism, followed by White, Hispanic, African, and Asian Americans. With regards to opioid
use, roughly 1% of the population has this disorder, with 80% of those being addicted to pain-reliever opioids such as oxycodone or
morphine; the remaining 20% are heroin (SAMHSA, 2014).

Stimulants
Nearly 1.1% of all high school seniors have used cocaine within the past month (Johnston et al., 2014). Due to the high cost of
cocaine, it is more commonly found in suburban neighborhoods where consumers have the financial means to purchase the drugs.
Methamphetamine is used by men and women equally. It is popular among biker gangs, rural America, and urban gay
communities, as well as in clubs and all-night dance parties (aka raves; Hopfer, 2011).
A growing concern is the abuse of stimulant medication among college students as 17% of college students reported abusing
stimulant medications. Greek organization membership, academic performance, and other substance use were the most highly
correlated variables related to stimulant medication abuse.

Hallucinogens
Up to 14% of the general population have used LSD or another hallucinogen. Nearly 20 million adults and adolescents report
current use of marijuana. Men report more than women. Sixty-five percent of individuals report their first drug of use was
marijuana—labeling it as a gateway drug to other illicit substances (APA, 2022). Due to the increased research and positive effects
of medicinal marijuana, the movement to legalize recreational marijuana has gained momentum, particularly in the Pacific
Northwest of the United States.

Key Takeaways
You should have learned the following in this section:
More men and Native Americans are addicted to depressants.
Cocaine is more prevalent in suburban neighborhoods due to its cost and methamphetamine is used equally by men and women.
Hallucinogens are used by up to 14% of the general population.

 Review Questions
1. Identify the gender and ethnicity differences of substance abuse across the three substance categories.
2. Are these substances abused by other unique groups of people?

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11.3: Substance-Related and Addictive Disorders - Comorbidity
 Learning Objectives
Describe the comorbidity of substance-related and addictive disorders.

Substance abuse, in general, has a high comorbidity within itself (meaning abuse of multiple different substances), as well as with
other mental health disorders. Researchers believe that substance abuse disorders are often secondary to another mental health
disorder, as the substance abuse develops as a means to “self-medicate” the underlying psychological disorder. In fact, several large
surveys identified alcohol and drug dependence to be twice as more likely in individuals with anxiety, affective, and psychotic
disorders than the general public (Hartz et al., 2014). While it is difficult to identify exact estimates of the relationship between
substance abuse and serious mental health disorders, the consensus among researchers is that there is a strong relationship between
substance abuse and mood, anxiety, PTSD, and personality disorders (Grant et al., 2016).

Key Takeaways
You should have learned the following in this section:
Substance abuse has a high comorbidity within itself and with mental health disorders such as mood, anxiety, PTSD, and
personality disorders.

 Review Questions
With what other conditions are substance-related and addictive disorders highly comorbid?

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11.4: Substance-Related and Addictive Disorders - Etiology
 Learning Objectives
Describe the biological causes of substance-related and addictive disorders.
Describe the cognitive causes of substance-related and addictive disorders.
Describe the behavioral causes of substance-related and addictive disorders.
Describe the sociocultural causes of substance-related and addictive disorders.

Biological
11.4.1.1. Genetics. Similar to other mental health disorders, substance abuse is genetically influenced. With that said, it is different
than other mental health disorders in that if the individual is not exposed to the substance, they will not develop substance abuse.
Heritability of alcohol abuse is among the most well studied substances, likely because it is the only legal substance (except
cannabis in some states). Twin studies have indicated a range of 50-60% heritability risk for alcohol disorder (Kendler et al., 1997).
Studies exploring the heritability of other substance abuse, particularly drug use, suggests there may be a stronger heritability link
than previously thought (Jang, Livesley, & Vernon, 1995). Twin studies indicate that the genetic component of drug abuse is
stronger than drug use in general, meaning that genetic factors are more significant for abuse of a substance over nonproblematic
use (Tsuang et al., 1996). Merikangas and colleagues (1998) found an 8-fold increased risk for developing a substance abuse
disorder across a wide range of substances.
Unique to substance abuse is the fact that both genetic and familial influence are both at play. What does this mean? Well,
biologically, the individual may be genetically predisposed to substance abuse; additionally, the individual may also be at risk due
to their familial environment where their parents or siblings are also engaging in substance abuse. Individuals whose parents abuse
substances may have a greater opportunity to ingest substances, thus promoting drug-seeking behaviors. Furthermore, families with
a history of substance abuse may have a more accepting attitude of drug use than families with no history of substance abuse
(Leventhal & Schmitz, 2006).
11.4.1.2. Neurobiological. A longstanding belief about how drug abuse begins and is maintained is the brain reward system. A
reward can be defined as any event that increases the likelihood of a response and has a pleasurable effect. Most of the research on
the brain reward system has focused on the mesocorticolimbic dopamine system, as it appears this area is the primary reward
system of most substances that are abused. As research has evolved in the field of substance abuse, five additional
neurotransmitters have also been implicated in the reinforcing effect of addiction: dopamine, opioid peptides, GABA, serotonin,
and endocannabinoids. More specifically, dopamine is less involved in opioid, alcohol, and cannabis. Alcohol and benzodiazepines
lower the production of GABA, while cocaine and amphetamines decrease dopamine. Cannabis has been shown to reduce the
production of endocannabinoids.

Cognitive
Cognitive theorists have focused on the beliefs regarding the anticipated effects of substance use. Defined as the expectancy effect,
drug-seeking behavior is presumably motivated by the desire to attain a particular outcome by ingesting a substance. The
expectancy effect can be defined in both positive and negative forms. Positive expectations are thought to increase drug-seeking
behavior, while negative experiences would decrease substance use (Oei & Morawska, 2004). Several studies have examined the
expectancy effect on the use of alcohol. Those with alcohol abuse reported expectations of tension reduction, enhanced sexual
experiences, and improved social pleasure (Brown, 1985). Additionally, observing positive experiences, both in person and through
television or social media, also shapes our drug use expectancies.
While some studies have explored the impact of negative expectancy to eliminate substance abuse, research has failed to
continually support this theory, suggesting that positive experiences and expectations are a more powerful motivator of substance
abuse than the negative experiences (Jones, Corbin, Fromme, 2001).

Behavioral
Operant conditioning has been implicated in the role of developing substance use disorders. As you may remember, operant
conditioning refers to the increase or decrease of a behavior, due to reinforcement or punishment. Since we are talking about

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increasing substance use, behavioral theorists suggest that substance abuse is positively and negatively reinforced due to the effects
of a substance.
Positive reinforcement occurs when substance use is increased due to the positive or pleasurable experiences of the substance.
More specifically, the rewarding effect or pleasurable experiences while under the influence of various substances directly impacts
the likelihood that the individual will use the substance again. Studies of substance use on animals routinely support this theory as
animals will work to receive injections of various drugs (Wise & Koob, 2013).
Negative reinforcement, or the increase of a given behavior due to the removal of a negative effect, also plays a role in substance
abuse in two different ways. First, many people ingest a substance as an escape from their unpleasant life—whether it be physical
pain, stress, or anxiety, to name a few. Therefore, the substance temporarily provides relief from a negative environment, thus
reinforcing future substance abuse (Wise & Koob, 2013). Secondly, negative reinforcement is involved in symptoms of withdrawal.
As previously mentioned, withdrawal from a substance often produces significant negative symptoms such as nausea, vomiting,
uncontrollable shaking, etc. To eliminate these symptoms, an individual will consume more of the substance, thus again escaping
the negative symptoms and enjoying the “highs” of the substance.

Sociocultural
Arguably, one of the strongest influences of substance abuse is the impact of one’s friends and the immediate environment. Peer
attitudes, perception of others’ drug use, pressure from peers to use substances, and beliefs about substance use are among the
strongest predictors of drug use patterns (Leventhal & Schmitz, 2006). This is particularly concerning during adolescence when
patterns of substance use typically begin.
Additionally, research continually supports a strong relationship between second-generation substance abusers (Wilens et al.,
2014). The increased possibility of family members’ substance abuse is likely related to both a genetic predisposition, as well as the
accepting attitude of the familial environment (Chung et al., 2014). Not only does a child have early exposure to these substances if
their parent has a substance abuse problem, but they are also less likely to have parental supervision, which may impact their
decision related to substance use (Wagner et al., 2010). One potential protective factor against substance use is religiosity. More
specifically, families that promote religiosity may reduce substance use by promoting negative experiences (Galen & Rogers,
2004).
Another sociocultural view on substance abuse is stressful life events, particularly those related to financial stability. Prevalence
rates of substance abuse are higher among poorer people (SAMHSA, 2014). Furthermore, additional stressors such as childhood
abuse and trauma, negative work environments, as well as discrimination are also believed to contribute to the development of a
substance use disorder (Hurd, Varner, Caldwell, & Zimmerman, 2014; McCabe, Wilsnack, West, & Boyd, 2010; Unger et al.,
2014).

Key Takeaways
You should have learned the following in this section:
Biological causes of substance-related and addictive disorders include the brain reward system and a genetic predisposition,
though if the individual is not exposed to the substance they will not develop the substance abuse.
Cognitive causes of substance-related and addictive disorders include the expectancy effect, and research provides stronger
support for positive expectancy over negative expectancy.
Behavioral causes of substance-related and addictive disorders include positive and negative reinforcement.
Sociocultural causes of substance-related and addictive disorders include friends and the immediate environment.

 Review Questions
1. Discuss the brain reward system. What neurobiological regions are implicated within this system?
2. Define the expectancy effect. How does this explain the development and maintenance of substance abuse?
3. Discuss operant conditioning in the context of substance abuse. What are the reinforcers?
4. How does the sociocultural model explain substance abuse?

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11.5: Substance-Related and Addictive Disorders - Treatment
 Learning Objectives
Describe biological treatment options for substance-related and addictive disorders.
Describe behavioral treatment options for substance-related and addictive disorders.
Describe cognitive-behavioral treatment options for substance-related and addictive disorders.
Describe sociocultural treatment options for substance-related and addictive disorders.

Given the large number of the population affected by substance abuse, it is not surprising that there are many different approaches
to treat substance use disorder. Overall, treatments for substance-related disorders are only mildly effective, likely due in large part
to the addictive qualities in many of these substances (Belendiuk & Riggs, 2014).

Biological
11.5.1.1. Detoxification. Detoxification refers to the medical supervision of withdrawal from a specified drug. While most
detoxification programs are inpatient for increased monitoring, some programs allow for outpatient detoxification, particularly if
the addiction is not as severe. There are two main theories of detoxification—gradually decreasing the amount of the substance
until the individual is off the drug completely, or eliminating the substance entirely while providing additional medications to
manage withdrawal symptoms (Bisaga et al., 2015). Unfortunately, relapse rates are high for those engaging in detoxification
programs, particularly if they lack any follow-up psychological treatment.
11.5.1.2. Agonist drugs. As researchers continue to learn more about both the mechanisms of substances commonly abused, as
well as the mechanisms in which the body processes these substances, alternative medications are created to essentially replace the
drug in which the individual is dependent on. These agonist drugs provide the individual with a “safe” drug that has a similar
chemical make-up to the addicted drug. One common example of this is methadone, an opiate agonist that is often used in the
reduction of heroin use (Schwartz, Brooner, Montoya, Currens, & Hayes, 2010). Unfortunately, because methadone reacts to the
same neurotransmitter receptors as heroin, the individual essentially replaces their addiction to heroin with an addiction to
methadone. While this is not ideal, methadone treatment is highly regulated under safe medical supervision. Furthermore, it is
taken by mouth, thus eliminating the potential adverse effects of unsterilized needles in heroin use. While some argue that
methadone maintenance programs are not an effective treatment because it simply replaces one drug for another, others claim that
the combination of methadone with education and psychotherapy can successfully help individuals off both illicit drugs and
methadone medications (Jhanjee, 2014).
11.5.1.3. Antagonist drugs. Unlike agonist drugs, antagonist drugs block or change the effects of the addictive drug. The most
commonly prescribed antagonist drugs are Disulfiram and Naloxone. Disulfiram is often given to individuals trying to abstain from
alcohol as it produces significant negative effects (i.e., nausea, vomiting, increased heart rate, and dizziness) when coupled with
alcohol consumption. While this can be an effective treatment to eliminate alcohol use, the individual must be motivated to take the
medication as prescribed (Diclemente et al., 2008).
Similar to Disulfiram, Naloxone is used for individuals with opioid abuse. Naloxone acts by binding to endorphin receptors, thus
preventing the opioids from having the intended euphoric effect. In theory, this treatment appears promising, but it is extremely
dangerous as it can send the individual into immediate, severe withdrawal symptoms (Alter, 2014). This type of treatment requires
appropriate medical supervision to ensure the safety of the patient.

Behavioral
11.5.2.1. Aversion therapy. Based on respondent conditioning principles, aversion therapy is a form of treatment for substance
abuse that pairs the stimulus with some type of negative or aversive stimulus. For example, an individual may be given a shock
every time they think about or attempt to drink alcohol. By pairing this aversive stimulus to the abused substance, the individual
will begin to independently pair the substance with an aversive thought, thus reducing their craving/desire for the substance. Some
view the use of agonist and antagonist drugs as a form of aversion therapy as these medications utilize the same treatment strategy
as traditional aversion therapy.
11.5.2.2. Contingency management. Contingency management is a treatment approach that emphasizes operant conditioning—
increasing sobriety and adherence to treatment programs through rewards. Originally developed to increase adherence to

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medication and reinforce opiate abstinence in methadone patients, contingency management has been adapted to increase
abstinence in many different substance abuse treatment programs. In general, patients are “rewarded” with vouchers or prizes in
exchange for abstinence from substance use (Hartzler, Lash, & Roll, 2012). These vouchers allow individuals to gain incentives
specific to their interests, thus increasing the chances of abstinence. Common vouchers include movie tickets, sports equipment, or
even cash (Mignon, 2014).
Contingency management has been proven to be effective in treating various types of substance abuse, particularly alcohol and
cocaine (Lewis & Petry, 2005). Not only has it been effective in reducing substance use in addicts, but it has also been effective in
increasing the amount of time patients remain in treatment as well as compliance with the treatment program (Mignon, 2014).
Despite its success, dissemination of this type of treatment has been rare. To rectify this, the federal government has provided
financial resources through SAMHSA for the development, implementation, and evaluation of contingency management as a
treatment to reduce alcohol and drug use (Mignon, 2014).

Cognitive-Behavioral
11.5.3.1. Relapse prevention training. Relapse prevention training is essentially what it sounds like—identifying potentially high-
risk situations for relapse and then learning behavioral skills and cognitive interventions to prevent the occurrence of a relapse.
Early in treatment, the clinician guides the patient to identify any interpersonal, intrapersonal, environmental, and physiological
risks for relapse. Once these triggers are identified, the clinician works with the patient on cognitive and behavioral strategies such
as learning effective coping strategies, enhancing self-efficacy, and encouraging mastery of outcomes. Additionally,
psychoeducation about how substance abuse is maintained, as well as identifying maladaptive thoughts and learning cognitive
restructuring techniques, helps the patient make informed choices during high-risk situations. Finally, role-playing these high-risk
situations in session allows patients to become comfortable engaging in these effective coping strategies that enhance their self-
efficacy and ultimately reducing the chances of a relapse. Research for relapse prevention training appears to be somewhat
effective for individuals with substance-related disorders (Marlatt & Donovan, 2005).

Sociocultural
11.5.4.1. Self-help. In 1935, two men suffering from alcohol abuse met and discussed their treatment options. Slowly, the group
grew, and by 1946, this group was known as Alcoholics Anonymous (AA). The two founders, along with other early members,
developed the Twelve Step Traditions to help guide members in spiritual and character development. Due to the popularity of the
treatment program, other programs such as Narcotics Anonymous and Cocaine Anonymous, adopted and adapted the Twelve Steps
for their respective substance abuse. Similarly, Al-Anon and Alateen are two support groups that offer support for families and
teenagers of individuals struggling with alcohol abuse.
The overarching goal of AA is abstinence from alcohol. To achieve this, the participants are encouraged to “take one day at a
time.” In using the 12 steps, participants are emboldened to admit that they have a disease, that they are powerless over this disease,
and that their disease is more powerful than any person. Therefore, participants turn their addiction over to God and ask for help to
right their wrongs and remove their negative character defects and shortcomings. The final steps include identifying and making
amends to those who they have wronged during their alcohol abuse.
While studies examining the effectiveness of AA programs are inconclusive, AA’s membership indicates that 27% of its members
have been sober less than one year, 24% have been sober 1-5 years, 13% have been sober 5-10 years, 14% have been sober 10-20
years, and more than 22% have been sober over 20 years (Alcoholics Anonymous, 2014). Some argue that this type of treatment is
most effective for those who are willing and able to abstain from alcohol as opposed to those who can control their drinking to
moderate levels.
11.5.4.2. Residential treatment centers. Another type of treatment similar to self-help is residential treatment programs. In this
placement, individuals are completely removed from their environment and live, work, and socialize within a drug-free community
while also attending regular individual, group, and family therapy. The types of treatment used within a residential program varies
from program to program, with most focusing on cognitive-behavioral and behavioral techniques. Several also incorporate 12-step
programs into treatment, as many patients transition from a residential treatment center to a 12-step program post discharge. As one
would expect, the residential treatment goal is abstinence, and any evidence of substance abuse during the program is grounds for
immediate termination.
Studies examining the effectiveness of residential treatment centers suggest that these programs are useful in treating a variety of
substance abuse disorders; however, many of these programs are very costly, thus limiting the availability of this treatment to the

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general public (Bender, 2004; Galanter, 2014). Additionally, many individuals are not able to completely remove themselves from
their daily responsibilities for several weeks to months, particularly those with families. Therefore, while this treatment option is
very effective, it is also not an option for most individuals struggling with substance abuse.
11.5.4.3. Community reinforcement. The goal for community reinforcement treatment is for patients to abstain from substance
use by replacing the positive reinforcements of the substance with that of sobriety. This is done through several different techniques
such as motivational interviewing, learning adaptive coping strategies, and encouraging family support (Mignon, 2014).
Essentially, the community around the patient reinforces the positive choices of abstaining from substance use.
Community reinforcement has been found to be effective in both an inpatient and outpatient setting (Meyers & Squires, 2001). It is
believed that the intrinsic motivation and the effective coping skills, in combination with the support of an individual’s immediate
community (friends and family) is responsible for the long-term positive treatment effects of community reinforcement.

Key Takeaways
You should have learned the following in this section:
Biological treatment options for substance-related and addictive disorders include detoxification programs, agonist drugs, and
antagonist drugs.
Behavioral treatment options for substance-related and addictive disorders include aversion therapy and contingency
management.
Cognitive-behavioral treatment options for substance-related and addictive disorders include relapse prevention training.
Sociocultural treatment options for substance-related and addictive disorders include Alcoholics Anonymous, residential
treatment centers, and community reinforcement.

 Review Questions
1. Discuss the differences between agonist and antagonist drugs. Give examples of both.
2. What are the two behavioral treatments discussed in this module? Discuss their effectiveness.
3. What are the main components of the 12-step programs? How effective are they in substance abuse treatment?

Module Recap
And that concludes Part IV of the book and Block 3 of mental disorders. In this module, we discussed substance-related and
addictive disorders to include substance use disorder, substance intoxication, and substance withdrawal. Substances include
depressants, sedative-hypnotic drugs, opioids, stimulants, and hallucinogens. As in past modules, we discussed the clinical
presentation, epidemiology, comorbidity, and etiology of the disorders. We then also discussed the biological, behavioral,
cognitive-behavioral, and sociocultural treatment approaches.

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 SECTION OVERVIEW

Part V. Mental Disorders – Block 4

12: Schizophrenia Spectrum and Other Psychotic Disorders
12.1: Schizophrenia Spectrum and Other Psychotic Disorders - Clinical Presentation
12.2: Schizophrenia Spectrum and Other Psychotic Disorders - Epidemiology
12.3: Schizophrenia Spectrum and Other Psychotic Disorders - Comorbidity
12.4: Schizophrenia Spectrum and Other Psychotic Disorders - Etiology
12.5: Schizophrenia Spectrum and Other Psychotic Disorders - Treatment

13: Personality Disorders

13.1: Personality Disorders - Clinical Presentation
13.2: Personality Disorders - Epidemiology
13.3: Personality Disorders - Comorbidity
13.4: Personality Disorders - Etiology
13.5: Personality Disorders - Treatment

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 CHAPTER OVERVIEW

12: Schizophrenia Spectrum and Other Psychotic Disorders

Describe how schizophrenia spectrum disorders present.
Describe the epidemiology of schizophrenia spectrum disorders.
Describe comorbidity in relation to schizophrenia spectrum disorders.
Describe the etiology of schizophrenia spectrum disorders.
Describe treatment options for schizophrenia spectrum disorders.

In Module 12, we will discuss matters related to schizophrenia spectrum disorders to include their clinical presentation,
epidemiology, comorbidity, etiology, and treatment options. Our discussion will consist of schizophrenia, schizophreniform
disorder, schizoaffective disorder, and delusional disorder. Be sure you refer Modules 1-3 for explanations of key terms (Module
1), an overview of the various models to explain psychopathology (Module 2), and descriptions of the therapies (Module 3).
12.1: Schizophrenia Spectrum and Other Psychotic Disorders - Clinical Presentation
12.2: Schizophrenia Spectrum and Other Psychotic Disorders - Epidemiology
12.3: Schizophrenia Spectrum and Other Psychotic Disorders - Comorbidity
12.4: Schizophrenia Spectrum and Other Psychotic Disorders - Etiology
12.5: Schizophrenia Spectrum and Other Psychotic Disorders - Treatment

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12.1: Schizophrenia Spectrum and Other Psychotic Disorders - Clinical Presentation
 Learning Objectives
List and describe distinguishing features that make up the clinical presentation of schizophrenia spectrum disorders.
Describe how schizophrenia presents.
Describe how schizophreniform disorder presents.
Describe how schizoaffective disorder presents.
Describe how delusional disorder presents.

The Clinical Presentation of Schizophrenia Spectrum Disorders

The schizophrenia spectrum and other psychotic disorders are defined by one of the following main symptoms: delusions,
hallucinations, disorganized thinking (speech), disorganized or abnormal motor behavior, and negative symptoms. Individuals
diagnosed with a schizophrenia spectrum disorder experience psychosis, which is defined as a loss of contact with reality.
Psychosis episodes make it difficult for individuals to perceive and respond to environmental stimuli, causing a significant
disturbance in everyday functioning. While there are a vast number of symptoms displayed in schizophrenia spectrum disorders,
presentation of symptoms varies greatly among individuals, as there are rarely two cases similar in presentation, triggers, course, or
responsiveness to treatment.
12.1.1.1. Delusions. Delusions are “fixed beliefs that are not amenable to change in light of conflicting evidence” (APA, 2022, pp.
101). This means that despite evidence contradicting one’s thoughts, the individual is unable to distinguish their thoughts from
reality. The inability to identify thoughts as delusional is likely likely due to a lack of insight. There are a wide range of delusions
that are seen in the schizophrenia related disorders to include:
Delusions of grandeur– belief they have exceptional abilities, wealth, or fame; belief they are God or other religious saviors
Delusions of control– belief that others control their thoughts/feelings/actions
Delusions of thought broadcasting– belief that one’s thoughts are transparent and everyone knows what they are thinking
Delusions of persecution– belief they are going to be harmed, harassed, plotted or discriminated against by either an individual
or an institution; it is the most common delusion (Arango & Carpenter, 2010)
Delusions of reference– belief that specific gestures, comments, or even larger environmental cues are directed directly to them
Delusions of thought withdrawal– belief that one’s thoughts have been removed by another source
It is believed that the presentation of the delusion is primarily related to the social, emotional, educational, and cultural background
of the individual (Arango & Carpenter, 2010). For example, an individual with schizophrenia who comes from a highly religious
family is more likely to experience religious delusions (delusions of grandeur) than another type of delusion.
12.1.1.2. Hallucinations. Hallucinations are “perception-like experiences that occur without an external stimulus” (APA, 2022,
pg. 102). They can occur in any of the five senses: hearing (auditory hallucinations), seeing (visual hallucinations), smelling
(olfactory hallucinations), touching (tactile hallucinations), and tasting (gustatory hallucinations). Additionally, they can occur in a
single modality or present across a combination of modalities (e.g., having auditory and visual hallucinations). For the most part,
individuals recognize that their hallucinations are not real and attempt to engage in normal behavior while simultaneously
combating ongoing hallucinations.
According to various research studies, nearly half of all patients with schizophrenia report auditory hallucinations, 15% report
visual hallucinations, and 5% report tactile hallucinations (DeLeon, Cuesta, & Peralta, 1993). Among the most common types of
auditory hallucinations are voices talking to the patient or various voices talking to one another. Generally, these hallucinations are
not attributable to any one person that the individual knows. They are usually clear, objective, and definite (Arango & Carpenter,
2010). Additionally, the auditory hallucinations can be pleasurable, providing comfort to the patient; however, in other individuals,
the auditory hallucinations can be unsettling as they produce commands or malicious intent.
12.1.1.3. Disorganized thinking (Speech). Among the most common cognitive impairments displayed in patients with
schizophrenia are disorganized thoughts, communication, and speech. More specifically, thoughts and speech patterns may appear
to be circumstantial or tangential. For example, patients may give unnecessary details in response to a question before they finally
produce the desired response. While the question is eventually answered in circumstantial speech patterns, in tangential speech
patterns the patient never reaches the point. Another common cognitive symptom is speech incoherence or word salad, where

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speech is “nearly incomprehensible and resembles receptive aphasia in its linguistic disorganization” (APA, 2022, pg. 102).
Derailment, or the illogical connection in a chain of thoughts, is another common type of disorganized thinking. Although not
always, derailment is often seen in illogicality, or the tendency to provide bizarre explanations for things.
These types of distorted thought patterns are often related to concrete thinking. That is, the individual is focused on one aspect of a
concept or thing and neglects all other aspects. This type of thinking makes treatment difficult as individuals lack insight into their
illness and symptoms.
12.1.1.4. Disorganized/abnormal motor behavior. These symptoms manifest as childlike “silliness” to unpredictable agitation.
Catatonic behavior, the decreased or complete lack of reactivity to the environment, is among the most commonly seen grossly
disorganized motor behavior in schizophrenia. There runs a range of catatonic behaviors from negativism (resistance to
instruction); mutism or stupor (complete lack of verbal and motor responses); rigidity (maintaining a rigid or upright posture while
resisting efforts to be moved); or posturing (holding odd, awkward postures for long periods). There is one type of catatonic
behavior, catatonic excitement, where the individual experiences hyperactivity of motor behavior, in a seemingly excited or
delirious way. Other features include repeated stereotyped movements, staring, grimacing, and the echoing of speech (APA, 2022,
pg. 102).
12.1.1.5. Negative symptoms. Up until this point, all the symptoms can be categorized as positive symptoms, or symptoms that
are an over-exaggeration of normal brain processes; these symptoms are also new to the individual. The final diagnostic criterion is
negative symptoms, which are defined as the inability or decreased ability to initiate actions, speech, express emotion, or feel
pleasure (Barch, 2013). Negative symptoms often present before positive symptoms and remain once positive symptoms remit.
Because of their prevalence through the course of the disorder, they are also more indicative of prognosis, with more negative
symptoms suggesting a poorer prognosis. The poorer prognosis may be explained by the lack of effectiveness antipsychotic
medications have in addressing negative symptoms (Kirkpatrick, Fenton, Carpenter, & Marder, 2006). There are six main types of
negative symptoms seen in patients with schizophrenia. Such symptoms include:
Diminished emotional expression – Reduction in emotional expression; reduced display of emotional expression
Alogia – Poverty of speech or speech content
Anhedonia – Inability to experience pleasure
Asociality – Lack of interest in social relationships
Avolition – Lack of motivation for goal-directed behavior

Schizophrenia
As stated above, the hallmark symptoms of schizophrenia include the presentation of at least two of the following during a one
month period: delusions, hallucinations, disorganized speech, disorganized/abnormal behavior, or negative symptoms. These
symptoms create significant impairment in an individual’s ability to engage in normal daily functioning such as work, school,
relationships with others, or self-care, and continuous signs of the disturbance persist for at least 6 months. It should be noted that
the presentation of schizophrenia varies significantly among individuals, as it is a heterogeneous clinical syndrome (APA, 2022).
While the presence of symptoms must persist for a minimum of 6 months to meet the criteria for a schizophrenia diagnosis, it is not
uncommon to have prodromal symptoms that precede the active phase of the disorder and residual symptoms that follow it. These
prodromal and residual symptoms are “subthreshold” forms of psychotic symptoms that do not cause significant impairment in
functioning, with the exception of negative symptoms (Lieberman et al., 2001). Due to the severity of psychotic symptoms, mood
disorder symptoms are also common among individuals with schizophrenia; however, these mood symptoms are distinct from a
mood disorder diagnosis in that psychotic features will exist beyond the remission of depressive symptoms.

Schizophreniform Disorder
Schizophreniform disorder is similar to schizophrenia, except for the length of presentation of symptoms. Schizophreniform
disorder is considered an “intermediate” disorder between schizophrenia and brief psychotic disorder as the symptoms are present
for at least one month but not longer than six months. Schizophrenia symptoms must be present for at least six months and a brief
psychotic disorder is diagnosed when symptoms are present for less than one month. Approximately two-thirds of individuals who
are initially diagnosed with schizophreniform disorder will have symptoms that last longer than six months, at which time their
diagnosis is changed to schizophrenia (APA, 2022).
Another key distinguishing feature of schizophreniform disorder is the lack of criteria related to impaired functioning. While many
individuals with schizophreniform disorder do display impaired functioning, it is not essential for diagnosis. Finally, any major

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mood episodes—either depressive or manic— that are present concurrently with the psychotic features must only be present for a
short time, otherwise a diagnosis of schizoaffective disorder may be more appropriate (APA, 2022).
Making Sense of the Disorders
In relation to schizophrenia spectrum and other psychotic disorders, note the following:
Diagnosis brief psychotic disorder …… if symptoms have been present for less than one month
Diagnosis schizophreniform disorder …… if symptoms have been present for at least one month but not longer than six months
Diagnosis schizophrenia … if the symptoms have been present for at least six months

Schizoaffective Disorder
Schizoaffective disorder is characterized by the psychotic symptoms included in schizophrenia and a concurrent uninterrupted
period of a major mood episode—either a major depressive or manic episode. It should be noted that because the loss of interest in
pleasurable activities is a common symptom of schizophrenia, to meet the criteria for a depressive episode within schizoaffective
disorder, the individual must present with a pervasive depressed mood (APA, 2022). While schizophrenia and schizophreniform
disorder do not have a significant mood component, schizoaffective disorder requires the presence of a depressive or manic episode
for the majority, if not the total duration of the disorder. While psychotic symptoms are sometimes present in depressive episodes,
they often remit once the depressive episode is resolved. For individuals with schizoaffective disorder, psychotic symptoms should
continue for at least two weeks in the absence of a major mood disorder (APA, 2022). This is the key distinguishing feature
between schizoaffective disorder and major depressive disorder with psychotic features.

Delusional Disorder
As suggestive of its title, delusional disorder requires the presence of at least one delusion that lasts for at least one month in
duration. It is important to note that if an individual experiences hallucinations, disorganized speech, disorganized or catatonic
behavior, or negative symptoms—in addition to delusions—they should not be diagnosed with delusional disorder as their
symptoms are more aligned with a schizophrenia diagnosis. Unlike most other schizophrenia-related disorders, daily functioning is
not overly impacted due to the delusions. Additionally, if symptoms of depressive or manic episodes present during delusions, they
are typically brief compared to the duration of the delusions.
The DSM-V-TR (APA, 2022) has identified five main subtypes of delusional disorder to better categorize the symptoms of the
individual’s disorder. When making a diagnosis of delusional disorder, one of the following modifiers (in addition to mixed
presentation) is included. Erotomanic delusion occurs when an individual reports a delusion of another person being in love with
them. Generally speaking, the individual whom the convictions are about is of higher status, such as a celebrity. Grandiose
delusion involves the conviction of having great talent or insight. Occasionally, patients will report they have made an important
discovery that benefits the general public. Grandiose delusions may also take on religious affiliation, as people believe they are
prophets or even God. Jealous delusion revolves around the conviction that one’s spouse or partner is/has been unfaithful. While
many individuals may have this suspicion at some point in their relationship, a jealous delusion is much more extensive and
generally based on incorrect inferences that lack evidence. Persecutory delusion involves the individual believing that they are
being conspired against, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in pursuit of their
long-term goals (APA, 2022). Of all subtypes of delusional disorder, those experiencing persecutory delusions are the most at risk
of becoming aggressive or hostile, likely due to the persecutory nature of their distorted beliefs. Finally, somatic delusion involves
delusions regarding bodily functions or sensations. While these delusions can vary significantly, the most common beliefs are that
the individual emits a foul odor despite attempts to rectify the smell; there is an infestation of insects on the skin; or that they have
an internal parasite (APA, 2022). If no one delusion predominates, the mixed type specifier is used and if the dominant delusional
belief cannot be clearly determined, use the unspecified type specifier. A separate specifier is used when the content of the
delusions are deemed bizarre or implausible, not understandable, and not derived from ordinary life experience.

Key Takeaways
You should have learned the following in this section:
Schizophrenia spectrum disorders are characterized by delusions, hallucinations, disorganized thinking (speech), disorganized
or abnormal motor behavior, and negative symptoms.
Delusions are beliefs that do not change even when conflicting evidence is presented and can be of grandeur, control, thought
broadcasting, persecution, reference, and thought withdrawal.

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 Hallucinations occur in any sense modality and most individuals recognize that they are not real.
Disorganized thinking, abnormal motor behavior, catatonic behavior, and negative symptoms such as affective flattening,
alogia, anhedonia, asociality, and avolition are also common to schizophrenia spectrum disorders.
Schizophrenia is characterized by delusions, hallucinations, disorganized speech, disorganized/abnormal behavior, or negative
symptoms lasting six months.
Schizophreniform disorder is considered an “intermediate” disorder between schizophrenia and brief psychotic disorder as the
symptoms are present for at least one month but not longer than six months.
Schizoaffective disorder is characterized by the psychotic symptoms included in schizophrenia and a concurrent uninterrupted
period of a major mood episode—either a depressive or manic episode.
Delusional disorder requires the presence of at least one delusion that lasts for at least one month in duration to include
erotomanic, grandiose, jealous, persecutory, and somatic.

 Review Questions
1. What are the four positive symptoms identified in a schizophrenia diagnosis? Define and identify their difference.
2. What is meant by negative symptoms? What are the negative symptoms observed in schizophrenia related disorders?
3. Identify diagnostic differences between schizophrenia, schizophreniform, schizoaffective, and delusional disorders.

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12.2: Schizophrenia Spectrum and Other Psychotic Disorders - Epidemiology
 Learning Objectives
Describe the epidemiology of schizophrenia spectrum disorders.

Schizophrenia occurs in approximately 0.3%-0.7% of the general population (APA, 2022). There is some discrepancy in rates of
diagnosis between genders; these differences appear to be related to the emphasis of various symptoms. For example, men typically
present with more negative symptoms, whereas women present with more affect-laden symptoms. Despite gender differences in the
presentation of symptoms, there appears to be an equal risk for both genders to develop the disorder.
Schizophrenia typically occurs between late teens and mid-30s, with the onset of the disorder slightly earlier for males than females
(APA, 2022). Earlier onset of the disorder is generally predictive of a worse overall prognosis. Onset of symptoms is typically
gradual, with initial symptoms presenting similarly to depressive disorders; however, some individuals will present with an abrupt
presentation of the disorder. Negative symptoms appear to be more predictive of prognosis than other symptoms. This may be due
to negative symptoms being the most persistent, and therefore, most difficult to treat. Overall, an estimated 13.5% of individuals
diagnosed with schizophrenia meet recovery criteria, according to one meta-analysis of 50 studies of individuals with broadly
defined schizophrenia (APA, 2022).
Schizoaffective disorder, schizophreniform disorder, and delusional disorder prevalence rates are all significantly less than that of
schizophrenia, occurring in 0.2% to 0.3% of the general population. While schizoaffective disorder is diagnosed more in females
than males (similar to schizophrenia but using the less stringent DSM-IV criteria), schizophreniform and delusional disorder appear
to be diagnosed equally between genders (APA, 2022).

Key Takeaways
You should have learned the following in this section:
Less than 1% of the general population is diagnosed with schizophrenia and 13.5% of these people fully recovery from the
disorder.
Both genders have an equal risk of developing schizophrenia while men typically display more negative symptoms while
women present with more affect-laden symptoms.
Schizoaffective disorder, schizophreniform disorder, and delusional disorder have prevalence rates between 0.2 to 0.3%.

 Review Questions
1. Discuss the different prevalence rates across the schizophrenia related disorders. Are there differences among the disorders?
Between genders?
2. Are there differences in prevalence rates depending on symptom presentations? If so, what?

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12.3: Schizophrenia Spectrum and Other Psychotic Disorders - Comorbidity
 Learning Objectives
Describe the comorbidity of schizophrenia spectrum disorders.

There is a high comorbidity between schizophrenia and substance abuse disorder and there is some evidence to suggest that the use
of various substances (particularly marijuana) may place an individual at an increased risk of developing schizophrenia if the
genetic predisposition is also present (see diathesis-stress model below; Corcoran et al., 2003). Additionally, there appears to be
comorbidity with anxiety-related disorders, specifically panic disorder, and obsessive-compulsive disorder, among individuals with
schizophrenia than compared to the general public. Schizotypal or paranoid personality disorder sometimes precede the onset of
schizophrenia. About 5-6% of individuals diagnosed with schizophrenia die by suicide, about 20% have attempted suicide on at
least one occasion, and many more have significant suicidal ideation.
It should also be noted that individuals diagnosed with a schizophrenia-related disorder are also at an increased risk for associated
medical conditions such as weight gain, diabetes, metabolic syndrome, and cardiovascular and pulmonary disease (APA, 2022).
This predisposition to various medical conditions is likely related to medications and poor lifestyle choices, and also place
individuals at risk for a reduced life expectancy.
Schizoaffective disorder is comorbid with substance use disorders and anxiety disorders. Metabolic syndrome occurs at a higher
rate than for the general population as well.
Cormorbidity information is not given for delusional disorder or schizophreniform disorder.

Key Takeaways
You should have learned the following in this section:
Schizophrenia has a high comorbidity with substance abuse disorders, anxiety-related disorders, OCD, and some medical
conditions.
Schizoaffective disorder is comorbid with substance use disorders, anxiety disorder, and metabolic syndrome.

 Review Questions
1. What comorbidities exist between schizophrenia spectrum and other psychotic disorders?

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12.4: Schizophrenia Spectrum and Other Psychotic Disorders - Etiology
 Learning Objectives
Describe the biological causes of schizophrenia spectrum disorders.
Describe the psychological causes of schizophrenia spectrum disorders.
Describe the sociocultural causes of schizophrenia spectrum disorders.

Biological
12.4.1.1. Genetic/Family studies. Twin and family studies consistently support the biological theory. More specifically, if one
identical twin develops schizophrenia, there is a 48% chance that the other will also develop the disorder within their lifetime
(Coon & Mitter, 2007). This percentage drops to 17% in fraternal twins. Similarly, family studies have also found similarities in
brain abnormalities among individuals with schizophrenia and their relatives; the more similarities, the higher the likelihood that
the family member also developed schizophrenia (Scognamiglio & Houenou, 2014).
12.4.1.2. Neurobiological. There is consistent and reliable evidence of a neurobiological component in the transmission of
schizophrenia. More specifically, neuroimaging studies have found a significant reduction in overall and specific brain region
volumes, as well as tissue density of individuals with schizophrenia compared to healthy controls (Brugger, & Howes, 2017).
Additionally, there has been evidence of ventricle enlargement as well as volume reductions in the medial temporal lobe. As you
may recall, structures such as the amygdala (involved in emotion regulation), the hippocampus (involved in memory), as well as
the neocortical surface of the temporal lobes (processing of auditory information) are all structures within the medial temporal lobe
(Kurtz, 2015). Additional studies also indicate a reduction in the orbitofrontal regions of the brain, a part of the frontal lobe that is
responsible for response inhibition (Kurtz, 2015).
12.4.1.3. Stress cascade. The stress-vulnerability model suggests that individuals have a genetic or biological predisposition to
develop the disorder; however, symptoms will not present unless there is a stressful precipitating factor that elicits the onset of the
disorder. Researchers have identified the HPA axis and its consequential neurological effects as the likely responsible
neurobiological component responsible for this stress cascade.
The HPA axis is one of the main neurobiological structures that mediate stress. It involves the regulation of three chemical
messengers (corticotropin-releasing hormone [CRH], adrenocorticotropic hormone [ACTH], and glucocorticoids) as they respond
to a stressful situation (Corcoran et al., 2003). Glucocorticoids, more commonly referred to as cortisol, is the final neurotransmitter
released which is responsible for the physiological change that accompanies stress to prepare the body to “fight” or “flight.”
It is hypothesized that in combination with abnormal brain structures, persistently increased levels of glucocorticoids in brain
structures may be the key to the onset of psychosis in prodromal patients (Corcoran et al., 2003). More specifically, stress exposure
(and increased glucocorticoids) affects the neurotransmitter system and exacerbates psychotic symptoms due to changes in
dopamine activity (Walker & Diforio, 1997). While research continues to explore the relationship between stress and onset of the
disorder, evidence for the implication of stress and symptom relapse is strong. More specifically, schizophrenia patients experience
more stressful life events leading up to a relapse of symptoms. Similarly, it is hypothesized that the worsening or exacerbation of
symptoms is also a source of stress as they interfere with daily functioning (Walker & Diforio, 1997). This stress alone may be
enough to initiate the onset of a relapse.

Psychological
12.4.2.1. Cognitive. The cognitive model utilizes some of the aspects of the diathesis-stress model in that it proposes that
premorbid neurocognitive impairment places individuals at risk for aversive work/academic/interpersonal experiences. These
experiences, in turn, lead to dysfunctional beliefs and cognitive appraisals, ultimately leading to maladaptive behaviors such as
delusions/hallucinations (Beck & Rector, 2005). Beck proposed the following diathesis-stress model for how schizophrenia
develops (Fee Figure 12.1).
Figure 12.1. Diathesis-Stress Model of the Development of Schizophrenia

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 Adapted from Beck & Rector, 2005, pg. 580
Based on this theory, an underlying neurocognitive impairment (as discussed above) makes an individual more vulnerable to
experience aversive life events such as homelessness, conflict within the family, etc. Individuals with schizophrenia are more likely
to evaluate these aversive life events with a dysfunctional attitude and maladaptive cognitive distortions. The combination of the
aversive events and negative interpretations produces a stress response in the individual, thus igniting hyperactivation of the HPA
axis. According to Beck and Rector (2005), it is the culmination of these events leads to the development of schizophrenia.

Sociocultural
12.4.3.1. Expressed emotion. Research regarding supportive family environments suggests that families high in expressed
emotion, meaning families that have high hostile, critical, or overinvolved family members, are predictors of relapse (Bebbington
& Kuipers, 2011). In fact, individuals who return post-hospitalization to families with high criticism and emotional involvement are
twice as likely to relapse compared to those who return to families with low expressed emotion (Corcoran et al., 2003). Several
meta-analyses have concluded that family atmosphere is causally related to relapse in patients with schizophrenia, and that these
outcomes can be improved when the family environment is improved (Bebbington & Kuipers, 2011). Therefore, one major
treatment goal in families of patients with schizophrenia is to reduce expressed emotion within family interactions.
12.4.3.2. Family dysfunction. Even for families with low levels of expressed emotion, there is often an increase in family stress
due to the secondary effects of schizophrenia. Having a family member with schizophrenia increases the likelihood of a disruptive
family environment due to managing the patient’s symptoms and ensuring their safety while they are home (Friedrich et al., 2015).
Because of the severity of symptoms, families with a loved one diagnosed with schizophrenia often report more conflict in the
home as well as more difficulty communicating with one another (Kurtz, 2015).

Key Takeaways
You should have learned the following in this section:
Biological causes of schizophrenia spectrum and other psychotic disorders include genetics, several brain structures, and the
HPA axis.
Psychological causes of schizophrenia spectrum disorders include the diathesis-stress model.
Sociocultural causes of schizophrenia spectrum disorders include families high in expressed emotion and family dysfunction.

 Review Questions
1. What evidence is there to support a biological model with respect to explaining the development and maintenance of the
schizophrenia spectrum and other psychotic disorders?
2. Discuss the stress-vulnerability model with respect to schizophrenia spectrum and other psychotic disorders.
3. How does the sociocultural model explain the maintenance (and relapse) of schizophrenia related symptoms?

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12.5: Schizophrenia Spectrum and Other Psychotic Disorders - Treatment
 Learning Objectives
Describe psychopharmacological treatment options for schizophrenia spectrum and other psychotic disorders.
Describe psychological treatment options for schizophrenia spectrum and other psychotic disorders.
Describe family interventions for schizophrenia spectrum and other psychotic disorders.

While a combination of psychopharmacological, psychological, and family interventions is the most effective treatment in
managing schizophrenia symptoms, rarely do these treatments restore a patient to premorbid levels of functioning (Kurtz, 2015;
Penn et al., 2004). Although more recent advancements in treatment for schizophrenia appear promising, the disease itself is still
viewed as one that requires lifelong treatment and care.
12.5.1. Psychopharmacological
Among the first antipsychotic medications used for the treatment of schizophrenia was Thorazine. Developed as a derivative of
antihistamines, Thorazine was the first line of treatment that produced a calming effect on even the most severely agitated patients
and allowed for the organization of thoughts. Despite their effectiveness in managing psychotic symptoms, conventional
antipsychotics (such as Thorazine and Chlorpromazine) also produced significant side effects similar to that of neurological
disorders. Therefore, psychotic symptoms were replaced with muscle tremors, involuntary movements, and muscle rigidity.
Additionally, these conventional antipsychotics also produced tardive dyskinesia in patients, which included involuntary
movements isolated to the tongue, mouth, and face (Tenback et al., 2006). While only 10% of patients reported the development of
tardive dyskinesia, this percentage increased the longer patients were on the medication, as well as the higher the dose (Achalia,
Chaturvedi, Desai, Rao, & Prakash, 2014). In efforts to avoid these symptoms, clinicians have been cognizant of not exceeding the
clinically effective dose of conventional antipsychotic medications. If the management of psychotic symptoms cannot be resolved
at this level, alternative medications are often added to produce a synergistic effect (Roh et al., 2014).
Due to the harsh side effects of conventional antipsychotic drugs, newer, arguably more effective second-generation or atypical
antipsychotic drugs have been developed. The atypical antipsychotic drugs appear to act on both dopamine and serotonin receptors,
as opposed to only dopamine receptors in the conventional antipsychotics. Because of this, common medications such as clozapine
(Clozaril), risperidone (Risperdal), and aripiprazole (Abilify), appear to be more effective in managing both positive and negative
symptoms. While there continues to be a risk of developing side effects such as tardive dyskinesia, recent studies suggest it is much
lower than that of the conventional antipsychotics (Leucht, Heres, Kissling, & Davis, 2011). Thus, due to their effectiveness and
minimal side effects, atypical antipsychotic medications are typically the first line of treatment for schizophrenia (Barnes &
Marder, 2011).
It should be noted that because of the harsh side effects of antipsychotic medications in general, many individuals, nearly one half
to three-quarters of patients, discontinue the use of antipsychotic drugs (Leucht, Heres, Kissling, & Davis, 2011). Because of this, it
is also important to incorporate psychological interventions along with psychopharmacological treatment to both address
medication adherence, as well as provide additional support for symptom management.
12.5.2. Psychological Interventions
12.5.2.1.Cognitive Behavioral Therapy (CBT). As discussed in previous chapters, the goal of treatment is to identify the negative
biases and attributions that influence an individual’s interpretations of events and the subsequent consequences of these thoughts
and behaviors. For schizophrenia, CBT focuses on the maladaptive emotional and behavioral responses to psychotic experiences,
which is directly related to distress and disability. Therefore, the goal of CBT is not on symptom reduction, but rather to improve
the interpretations and understandings of these symptoms (and experiences) which will reduce associated distress (Kurtz, 2015).
Common features of CBT for schizophrenia patients include psychoeducation about their disease and the course of their symptoms
(i.e., ways to identify coming and going of delusions/hallucinations), challenging and replacing the negative thoughts/behaviors
associated with their delusions/hallucinations to more positive thoughts/behaviors, and finally, learning positive coping strategies to
deal with their unpleasant symptoms (Veiga-Martinez, Perez-Alvarez, & Garcia-Montes, 2008).
Findings from studies exploring CBT as a supportive treatment have been promising. One study conducted by Aaron Beck (the
founder of CBT) and colleagues (Grant, Huh, Perivoliotis, Stolar, & Beck, 2011) found that recovery-oriented CBT produced a
marked improvement in overall functioning as well as symptom reduction in patients diagnosed with schizophrenia. This study
suggests that by focusing on targeted goals such as independent living, securing employment, and improving social relationships,

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patients were able to slowly move closer to these targeted goals. By also including a variety of CBT strategies such as role-playing,
scheduling community outings, and addressing negative cognitions, individuals were also able to address cognitive and social skill
deficits.
12.5.3. Family Interventions
The diathesis-stress model of schizophrenia has primarily influenced family interventions. As previously discussed, the emergence
of the disorder and exacerbation of symptoms is likely related to environmental stressors and psychological factors. While the
degree in which environmental stress stimulates an exacerbation of symptoms varies among individuals, there is significant
evidence to conclude that stress does impact illness presentation (Haddock & Spaulding, 2011). Therefore, the overall goal of
family interventions is to reduce the stress on the individual that is likely to elicit the onset of symptoms.
Unlike many other psychological interventions, there is not a specific outline for family-based interventions related to
schizophrenia. However, the majority of programs include the following components: psychoeducation, problem-solving skills, and
cognitive-behavioral therapy.
Psychoeducation is important for both the patient and family members as it is reported that more than half of those recovering from
a psychotic episode reside with their family (Haddock & Spaulding, 2011). Therefore, educating families on the course of the
illness, as well as ways to recognize onset of psychotic symptoms, is important to ensure optimal recovery.
Problem-solving is a crucial component in the family intervention model. Seeing as family conflict can increase stress within the
home, which in return can lead to worsening of psychotic symptoms, family members benefit from learning effective methods of
problem-solving to address family conflicts. Additionally, teaching positive coping strategies for dealing with the symptoms of
mental illness and its direct effect on the family environment may also alleviate some friction within the home
The third component, CBT, is similar to that described above. The goal of family-based CBT is to reduce negativity among family
member interactions, as well as help family members adjust to living with someone with psychotic symptoms. These three
components within the family intervention program have been shown to reduce re-hospitalization rates, as well as slow the
worsening of schizophrenia-related symptoms (Pitschel-Walz, Leucht, Baumi, Kissling, & Engel, 2001).
12.5.3.1.Social skills training. Given the poor interpersonal functioning among individuals with schizophrenia, social skills
training is another type of treatment commonly suggested to improve psychosocial functioning. Research has indicated that poor
interpersonal skills not only predate the onset of the disorder but also remain significant even with the management of symptoms
via antipsychotic medications. Impaired ability to interact with individuals in a social, occupational, or recreational setting is
related to poorer psychological adjustment (Bellack, Morrison, Wixted, & Mueser, 1990). This can lead to greater isolation and
reduced social support among individuals with schizophrenia. As previously discussed, social support has been identified as a
protective factor of symptom exacerbation, as it buffers psychosocial stressors that are often responsible for the exacerbation of
symptoms. Learning how to interact with others appropriately (e.g., establish eye contact, engage in reciprocal conversations, etc.)
through role-play in a group therapy setting is one effective way to teach positive social skills.
12.5.3.2.Inpatient Hospitalizations. More commonly viewed as community-based treatments, inpatient hospitalization programs
are essential in stabilizing patients in psychotic episodes. Generally speaking, patients will be treated on an outpatient basis;
however, there are times when their symptoms exceed the needs of an outpatient service. Short-term hospitalizations are used to
modify antipsychotic medications and implement additional psychological treatments so that a patient can safely return to their
home. These hospitalizations generally last for a few weeks as opposed to a long-term treatment option that would last months or
years (Craig & Power, 2010).
In addition to short-term hospitalizations, there are also partial hospitalizations where an individual enrolls in a full-day program
but returns home for the evening. These programs provide individuals with intensive therapy, organized activities, and group
therapy programs that enhance social skills training. Research supports the use of partial hospitalizations as individuals enrolled in
these programs tend to do better than those who enter outpatient care (Bales et al., 2014).

Key Takeaways
You should have learned the following in this section:
Psychopharmacological treatment options for schizophrenia spectrum disorders include antipsychotic drugs such as Thorazine,
Chlorpromazine, Clozaril, Risperdal, and Abilify.

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 Psychological treatment options for schizophrenia spectrum disorders include CBT, the goal of which is to improve the
interpretations and understandings of symptoms (and experiences) which will reduce associated distress.
Family interventions for schizophrenia spectrum disorders include psychoeducation, problem-solving skills, cognitive-
behavioral therapy (CBT), social skills training, and inpatient/partial hospitalizations.

 Review Questions
1. Define tardive dyskinesia.
2. What pharmacological interventions have been effective in managing schizophrenia related disorder symptoms?
3. What is the main goal of family interventions? How is this achieved?

Module Recap
In our first module of Part V – Block 4, we discussed the schizophrenia spectrum and other psychotic disorders to include
schizophrenia, schizophreniform disorder, schizoaffective disorder, and delusional disorder. We started by describing their common
features, such as delusions, hallucinations, disorganized thinking, disorganized/abnormal motor behavior, and negative symptoms.
This led to a discussion of the epidemiology, comorbidity, etiology, and treatment options for the disorders.

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 CHAPTER OVERVIEW

13: Personality Disorders

 Learning Objectives
Describe how personality disorders present.
Describe the epidemiology of personality disorders.
Describe comorbidity in relation to personality disorders.
Describe the etiology of personality disorders.
Describe treatment options for personality disorders.

In Module 13, we will cover matters related to personality disorders to include their clinical presentation, epidemiology,
comorbidity, etiology, and treatment options. Our discussion will include Cluster A disorders of paranoid, schizoid, and
schizotypal; Cluster B disorders of antisocial, borderline, histrionic, and narcissistic; and Cluster C personality disorders of
avoidant, dependent, and obsessive-compulsive. Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an
overview of the various models to explain psychopathology (Module 2), and descriptions of the therapies (Module 3).
13.1: Personality Disorders - Clinical Presentation
13.2: Personality Disorders - Epidemiology
13.3: Personality Disorders - Comorbidity
13.4: Personality Disorders - Etiology
13.5: Personality Disorders - Treatment

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available upon request.

1
13.1: Personality Disorders - Clinical Presentation
 Learning Objectives
Define personality trait.
Define personality disorder.
List the defining features of personality disorders.
Describe the three clusters.
Describe how paranoid personality disorder presents.
Describe how schizoid personality disorder presents.
Describe how schizotypal personality disorder presents.
Describe how antisocial personality disorder presents.
Describe how borderline personality disorder presents.
Describe how histrionic personality disorder presents.
Describe how narcissistic personality disorder presents.
Describe how avoidant personality disorder presents.
Describe how dependent personality disorder presents.
Describe how obsessive-compulsive personality disorder presents.

Overview of Personality Disorders

According to the DSM-5-TR, personality traits are “…enduring patterns of perceiving, relating to, and thinking about the
environment and oneself that are exhibited in a wide range of social and personality contexts while a personality disorder “…is an
enduring pattern of inner experience and behavior that deviates markedly from the norms and expectations of the individual’s
culture, is pervasive and inflexible, and has an onset in adolescence or early adulthood, is stable over time, and leads to distress or
impairment” (APA, 2022, pg. 733). Personality disorders have four defining features, which include distorted thinking patterns,
problematic emotional responses, over- or under-regulated impulse control, and interpersonal difficulties. While these four core
features are universal among all ten personality disorders, the DSM-5-TR divides the personality disorders into three different
clusters based on symptom similarities.
Cluster A is described as the odd or eccentric cluster and consists of paranoid, schizoid, and schizotypal personality disorders. The
common feature between these three disorders is social awkwardness and social withdrawal. Often these behaviors are similar to
those seen in schizophrenia; however, they tend to be not as extensive or impactful on daily functioning as seen in schizophrenia. In
fact, there is a strong relationship between Cluster A personality disorders among individuals who have a relative diagnosed with
schizophrenia (Chemerinksi & Siever, 2011).
Cluster B is the dramatic, emotional, or erratic cluster and consists of antisocial, borderline, histrionic, and narcissistic personality
disorders. Individuals with these personality disorders often experience problems with impulse control and emotional regulation.
Due to the dramatic, emotional, and erratic nature of these disorders, it is nearly impossible for individuals to establish healthy
relationships with others.
And finally, Cluster C is the anxious or fearful cluster and consists of avoidant, dependent, and obsessive-compulsive personality
disorders. As you read through the descriptions of the disorders, you will see an overlap with symptoms from the anxiety and
depressive disorders. Cluster C disorders have the most treatment options of all the personality disorders, likely because the
overlapping anxiety and depressive disorders have well-established treatment options.
To meet the criteria for any personality disorder, the individual must display the pattern of behaviors in adulthood. Children cannot
be diagnosed with a personality disorder. Some children may present with similar symptoms, such as poor peer relationships, odd
or eccentric behaviors, or peculiar thoughts and language; however, a formal personality disorder diagnosis cannot be made until
the age of 18. The DSM-5-TR reports that median prevalence across several countries is 3.6% for Cluster A disorders, 4.5% for
Cluster B, 2.8% for Cluster C, and 10.5% for any personality disorder.
It is also noted that the clustering approach used in the DSM has not been consistently validated and has some serious limitations.
As written, “An alternative to the categorical approach is the dimensional perspective that personality disorders represent
maladaptive variants of personality traits that merge imperceptibly into normality and into one another” (APA, 2022, pg. 734).
Interested readers should consult Section III of the DSM (beginning on page 881) for a full description of the dimensional model

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for personality disorders and an alternative model for personality disorders that utilizes a hybrid dimensional-categorical model
approach.

Cluster A
13.1.2.1. Paranoid personality disorder. Paranoid personality disorder is characterized by a marked distrust or suspicion of
others. Individuals interpret and believe that other’s motives and interactions are intended to harm them, and therefore, they are
skeptical about establishing close relationships outside of family members—although, at times, even family members’ actions are
also believed to be malevolent (APA, 2022). Individuals with paranoid personality disorder often feel as though they have been
deeply and irreversibly hurt by others even though they lack evidence to support that these others intended to or did hurt them.
Because of these persistent suspicions, they will doubt relationships that show true loyalty or trustworthiness. Compliments are
misinterpreted and they may view an offer of help as a criticism that they are not doing a good enough job on their own.
Individuals with paranoid personality disorder are also hesitant to share any personal information or confide in others as they fear
the information will be used against them. Additionally, benign remarks or events are often viewed as demeaning or threatening.
For example, if an individual with paranoid personality disorder was accidentally bumped into at the store, they would interpret this
action as intentional, with the purpose of causing them injury. Because of this, individuals with paranoid personality disorder are
quick to hold grudges and unwilling to forgive insults or injuries- whether intentional or not. They are known to quickly and
angrily counterattack, either verbally or physically, in situations where they feel they were insulted (APA, 2022).
13.1.2.2. Schizoid personality disorder. Individuals with schizoid personality disorder display a persistent pattern of avoidance
of social relationships, along with a limited range of emotional expression in interpersonal settings (APA, 2022). Similar to those
with paranoid personality disorder, individuals with schizoid personality disorder do not have many close relationships; however,
unlike paranoid personality disorder, this lack of connection is not due to suspicious feelings, but rather, the lack of desire to
engage with others and the preference to engage in solitary behaviors. Individuals with schizoid personality disorder are often
viewed as “loners” and prefer activities where they do not have to engage with others (APA, 2022). Established relationships rarely
extend outside that of the family as they make no effort to start or maintain friendships. This lack of establishing social
relationships also extends to sexual behaviors, as these individuals report a lack of interest in engaging in sexual experiences with
others.
Regarding the limited range of emotion, individuals with schizoid personality disorder are often indifferent to criticisms or praises
of others and appear not to be affected by what others think of them. Individuals will rarely show any feelings or expressions of
emotion and are often described as having a “bland” exterior (APA, 2022). In fact, individuals with schizoid personality disorder
rarely reciprocate facial expressions or gestures typically displayed in normal conversations such as smiles or nods. Because of this
lack of emotion, there is a limited need for attention or acceptance.
13.1.2.3. Schizotypal personality disorder. Schizotypal personality disorder is characterized by a range of impairment in social
and interpersonal relationships due to discomfort in relationships, along with odd cognitive or perceptual distortions and eccentric
behaviors (APA, 2022). Similar to those with schizoid personality disorder, individuals also seek isolation and have few, if any
established relationships outside of family members.
One of the most prominent features of schizotypal personality disorder is ideas of reference, or the belief that unrelated events
pertain to them in a particular and unusual way. Ideas of reference also lead to superstitious behaviors or preoccupation with
paranormal activities that are not generally accepted in their culture (APA, 2022). The perception of special or magical powers,
such as the ability to mind-read or control other’s thoughts, has also been documented in individuals with schizotypal personality
disorder. Similar to schizophrenia, unusual perceptual experiences such as auditory hallucinations, as well as unusual speech
patterns of derailment or incoherence, are also present.
Like the other personality disorders within cluster A, there is a component of paranoia or suspiciousness of other’s motives.
Additionally, individuals with schizotypal personality disorder display inappropriate or restricted affect, thus impacting their ability
to appropriately interact with others in a social context. Significant social anxiety is often also present in social situations,
particularly in those involving unfamiliar people. The combination of limited affect and social anxiety contributes to their inability
to establish and maintain personal relationships; most individuals with schizotypal personality disorder prefer to keep to themselves
to reduce this anxiety.

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Cluster B
13.1.3.1. Antisocial personality disorder. The essential feature of antisocial personality disorder is the persistent pattern of
disregard for, and violation of, the rights of others. This pattern of behavior begins in late childhood or early adolescence and
continues throughout adulthood. While this behavior presents before age 15, the individual cannot be diagnosed with antisocial
personality disorder until the age of 18. Prior to age 18, the individual would be diagnosed with conduct disorder. Although not
discussed in this book as it is a disorder of childhood, conduct disorder involves a repetitive and persistent pattern of behaviors that
violate the rights of others or major age-appropriate norms. Common behaviors of individuals with conduct disorder that go on to
develop antisocial personality disorder are aggression toward people or animals, destruction of property, deceitfulness or theft, or
serious violation of rules (APA, 2022).
While commonly referred to as “psychopaths” or “sociopaths,” individuals with antisocial personality disorder fail to conform to
social norms. This also includes legal rules as individuals with antisocial personality disorder are often repeatedly arrested for
property destruction, harassing/assaulting others, or stealing (APA, 2022). Deceitfulness is another hallmark symptom of antisocial
personality disorder as individuals often lie repeatedly, generally to gain profit or pleasure. There is also a pattern of impulsivity—
decisions made in the moment without forethought of personal consequences or consideration for others (Lang et al., 2015). This
impulsivity also contributes to their inability to hold jobs as they are more likely to impulsively quit their jobs (Hengartner et al.,
2014). Employment instability, along with impulsivity, also impacts their ability to manage finances; it is not uncommon to see
individuals with antisocial personality disorder with large debts that they are unable to pay (Derefinko & Widiger, 2016).
While also likely related to impulsivity, individuals with antisocial personality disorder tend to be extremely irritable and
aggressive, repeatedly getting into fights. The marked disregard for their safety, as well as the safety of others, is also observed in
reckless behavior such as speeding, driving under the influence, and engaging in sexual and substance abuse behavior that may put
themselves at risk (APA, 2022).
Of course, the most known and devastating symptom of antisocial personality disorder is the lack of remorse for the consequences
of their actions, regardless of how severe they may be. Individuals often rationalize their actions as the fault of the victim, minimize
the harmfulness of the consequences of their behaviors, or display indifference (APA, 2022). Overall, individuals with antisocial
personality disorder have limited personal relationships due to their selfish desire and lack of moral conscience.
13.1.3.2. Borderline personality disorder. Individuals with borderline personality disorder display a pervasive pattern of
instability in interpersonal relationships, self-image, and affect (APA, 2022). The combination of these symptoms causes significant
impairment in establishing and maintaining personal relationships. They will often go to great lengths to avoid real or imagined
abandonment. Fears related to abandonment can lead to inappropriate anger as they often interpret the abandonment as a reflection
of their own behavior. It is not uncommon to experience intense fluctuations in mood, often observed as volatile interactions with
family and friends (Herpertz & Bertsch, 2014). Those with borderline personality disorder may be friendly one day and hostile the
next.
To prevent abandonment, individuals with borderline personality disorder will often exhibit impulsive behaviors such as self-harm
and suicidal behavior. In fact, individuals with borderline personality disorder engage in more suicide attempts, and completion of
suicide is higher among these individuals than the general public (Linehan et al., 2015). Other impulsive behaviors, such as non-
suicidal self-injury (cutting) and sexual promiscuity, are frequently seen within this population, typically occurring during high-
stress periods (Sansone & Sansone, 2012). They often have chronic feelings of emptiness along with painful feelings of aloneness.
Occasionally, hallucinations and delusions are present, particularly of a paranoid nature; however, these symptoms are often
transient and recognized as unacceptable by the individual (Sieswerda & Arntz, 2007).
13.1.3.3. Histrionic personality disorder. Histrionic personality disorder is the first personality disorder that addresses
pervasive and excessive emotionality and attention-seeking. These individuals are usually uncomfortable in social settings unless
they are the center of attention. To help gain attention, the individual is often vivacious and dramatic, using physical gestures and
mannerisms along with grandiose language. These behaviors are initially very charming to their audience; however, they begin to
wear due to the constant need for attention to be on them. If the theatrical nature does not gain the attention they desire, they may
go to great lengths to draw attention, such as using a fictitious story or creating a dramatic scene.
To ensure they gain the attention they desire, individuals with histrionic personality disorder frequently dress and engage in
sexually seductive or provocative ways. These sexually charged behaviors are not only directed at those in which they have a
sexual or romantic interest but to the general public as well (APA, 2022). They often spend a significant amount of time on their
physical appearance to gain the attention they desire.

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Individuals with histrionic personality disorder are easily suggestible. Their opinions and feelings are influenced by not only their
friends but also by current fads (APA, 2022). They also tend to exaggerate relationships, considering casual acquaintanceships as
more intimate than they are.
13.1.3.4. Narcissistic personality disorder. Like histrionic personality disorder, narcissistic personality disorder also centers
around the individual; however, with narcissistic personality disorder, individuals display a pattern of grandiosity along with a lack
of empathy for others (APA, 2022). The grandiose sense of self leads to an overvaluation of their abilities and accomplishments.
They often come across as boastful and pretentious, repeatedly proclaiming their superior achievements. These proclamations may
also be fantasized to enhance their success or power. Oftentimes they identify themselves as “special” and will only interact with
others of high status.
Given the grandiose sense of self, it is not surprising that individuals with narcissistic personality disorder need excessive
admiration from others. While it appears that their self-esteem is hugely inflated, it is very fragile and dependent on how others
perceive them (APA, 2022). Because of this, they may constantly seek out compliments and expect favorable treatment from
others. When this sense of entitlement is not upheld, they can become irritated or angry that their needs are not met.
A lack of empathy is also displayed in individuals with narcissistic personality disorder as they often struggle to (or choose not to)
recognize the desires or needs of others. This lack of empathy also leads to exploitation of interpersonal relationships, as they are
unable to understand other’s feelings (Marcoux et al., 2014). They often become envious of others who achieve greater success or
possessions than them. Conversely, they believe everyone should be envious of their achievements, regardless of how small they
may be.

Cluster C
13.1.4.1. Avoidant personality disorder. Individuals with avoidant personality disorder display a pervasive pattern of social
inhibition due to feelings of inadequacy and increased sensitivity to negative evaluations (APA, 2022). The fear of being rejected
drives their reluctance to engage in social situations so that they may prevent others from evaluating them negatively. This fear
extends so far that it prevents individuals from maintaining employment due to their intense fear of negative evaluation or
rejection.
Socially, they have very few if any friends, despite their desire to establish social relationships. They actively avoid social
situations in which they can develop new friendships out of the fear of being disliked or ridiculed. Similarly, they are cautious of
new activities or relationships as they often exaggerate the potential negative consequences and embarrassment that may occur; this
is likely a result of their ongoing preoccupation with being criticized or rejected by others. Within intimate relationships, their fear
of being shamed or ridiculed leads to restraint, and they view themselves as socially inept (APA, 2022).
Making Sense of the Disorders
As you read the clinical description of avoidant personality disorder, did you think it sounded a lot like social anxiety disorder? You
likely did as there is a great deal of overlap between the two disorders. So, how do they differ if they are to be regarded as separate
diagnostic categories in the DSM? This difference is linked to self-concept. How so?
In social anxiety disorder the negative self-concept is unstable and less pervasive and entrenched.
In avoidant personality disorder, the negative self-concept is more stable as an enduring and pervasive pattern, typical of
personality traits.
Additionally, avoidant personality disorder frequently occurs in the absence of social anxiety disorder and some separate risk
factors have been identified for the two.
13.1.4.2. Dependent personality disorder. Dependent personality disorder is characterized by pervasive and excessive need to
be taken care of by others (APA, 2022). This intense need leads to submissive and clinging behaviors as they fear they will be
abandoned or separated from their parent, spouse, or another person with whom they are in a dependent relationship. They are so
dependent on this other individual that they cannot make even the smallest decisions without first consulting with them and gaining
their approval or reassurance. They often allow others to assume complete responsibility for their life, making decisions in nearly
all aspects of their lives. Rarely will they challenge these decisions as their fear of losing this relationship greatly outweighs their
desire to express their own opinion. Should the relationship end, the individual experiences significant feelings of helplessness and
quickly seeks out another relationship to replace the old one (APA, 2022).

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When they are on their own, individuals with dependent personality disorder express difficulty initiating and engaging in tasks on
their own. They lack self-confidence and feel helpless when they are left to care for themselves or engage in tasks on their own. So
that they do not have to engage in tasks alone, individuals will go to great lengths to seek out support of others, often volunteering
for unpleasant tasks if it means they will get the reassurance they need (APA, 2022).
13.1.4.3. Obsessive-compulsive personality disorder (OCPD). OCPD is defined by an individual’s preoccupation with
orderliness, perfectionism, and ability to control situations that they lose flexibility, openness, and efficiency in everyday life (APA,
2022). One’s preoccupation with details, rules, lists, order, organization, or schedules overshadows the larger picture of the task or
activity. In fact, the need to complete the task or activity is significantly impacted by the individual’s self-imposed high standards
and need to complete the task perfectly, that the task often does not get completed. The desire to complete the task perfectly often
causes the individual to spend an excessive amount of time on the task, occasionally repeating it until it is to their standard. Due to
repetition and attention to fine detail, the individual often does not have time to engage in leisure activities or engage in social
relationships. Despite the excessive amount of time spent on activities or tasks, individuals with OCPD will not seek help from
others, as they are convinced that the others are incompetent and will not complete the task up to their standard.
Personally, individuals with OCD are rigid and stubborn, particularly with their morals, ethics, and values. Not only do they hold
these standards for themselves, but they also expect others to have similarly high standards, thus causing significant disruption to
their social interactions. The rigid and stubborn behaviors are also seen in their financial status, as they are known to live
significantly below their means to prepare financially for a potential catastrophe (APA, 2022). Similarly, they may have difficulty
discarding worn-out or worthless items, despite their lack of sentimental value.
Though on the surface it may appear that OCPD and OCD are one and the same, there is a distinct difference as the personality
disorder lacks definitive obsessions and compulsions (APA, 2022). In fact, most individuals with OCD do not have a pattern of
behavior that meets criteria for this personality disorder.

Key Takeaways
You should have learned the following in this section:
Personality disorders share the features of distorted thinking patterns, problematic emotional responses, over- or under-
regulated impulse control, and interpersonal difficulties and divide into three clusters.
Cluster A personality disorders are described as the odd/eccentric cluster and share as the common feature social awkwardness
and social withdrawal. It consists of paranoid, schizoid, and schizotypal personality disorders.
Cluster B personality disorders are described as the dramatic, emotional, or erratic cluster and consists of antisocial, borderline,
histrionic, and narcissistic personality disorders.
Cluster C is the anxious/fearful cluster and consists of avoidant, dependent, and obsessive-compulsive personality disorders.
Paranoid personality disorder is characterized by a marked distrust or suspicion of others.
Schizoid personality disorder is characterized by a persistent pattern of avoidance of social relationships, along with a limited
range of emotion among social relationships.
Schizotypal personality disorder is characterized by a range of impairment in social and interpersonal relationships due to
discomfort in relationships, along with odd cognitive or perceptual distortions and eccentric behaviors.
Antisocial personality disorder is characterized by a persistent pattern of disregard for, and violation of, the rights of others.
They show no remorse for their behavior
Borderline personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image,
and affect.
Histrionic personality disorder is characterized by pervasive and excessive emotionality and attention-seeking.
Narcissistic personality disorder is characterized by a pattern of grandiosity along with a lack of empathy for others.
Avoidant personality disorder is characterized by a pervasive pattern of social anxiety due to feelings of inadequacy and
increased sensitivity to negative evaluations.
Dependent personality disorder is characterized by pervasive and excessive need to be taken care of by others.
OCPD is characterized by an individual’s preoccupation with orderliness, perfectionism, and the ability to control situations that
they lose flexibility, openness, and efficiency in everyday life.

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  Review Questions
1. What are personality traits and how do they lead to personality disorders?
2. What are the three clusters? How are disorders grouped into these three clusters? Discuss the differences in symptom
presentation between the three personality clusters.
3. Create a chart identifying each of the disorders among the three clusters. Be sure to include personality characteristics of
each disorder. It is important to find characteristics unique to each personality disorder to aid in their identification.

This page titled 13.1: Personality Disorders - Clinical Presentation is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or
curated by Alexis Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed
edit history is available upon request.

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13.2: Personality Disorders - Epidemiology
 Learning Objectives
Describe the epidemiology of Cluster A personality disorders.
Describe the epidemiology of Cluster B personality disorders.
Describe the epidemiology of Cluster C personality disorders.

Cluster A
Disorders within Cluster A have a prevalence rate of around 2-5%. More specifically, according to Part II of the National
Comorbidity Survey Replication, the estimated prevalence of paranoid personality disorder was 2.3%, schizoid personality disorder
was 4.9%, and schizotypal personality disorder was 3.3%. Schizotypal personality disorder has been found to be more common in
men while research on schizoid personality disorder leans to no gender difference in prevalence. As for paranoid personality
disorder, it appears to be more common in men though the National Epidemiologic Survey on Alcohol and Related conditions
found it to be more common in women (APA, 2022).

Cluster B
Using Part II of the National Comorbidity Survey Replication, it was found that for Cluster B personality disorders prevalence rates
were: 0.6% for antisocial, 1.4% for borderline, 0.0% for histrionic, and 0.0% for narcissistic. It should be noted that the prevalence
of histrionic personality disorder was 1.8% and narcissistic was 6.2% in the National Epidemiologic Survey on Alcohol and
Related Conditions.
As for sex-and gender-related differences, antisocial personality disorder is three times more common in men and they present with
irritability/aggression and reckless disregard for the safety of others more often than women. Borderline personality disorder is
more common among women in clinical samples while community samples show no difference in prevalence, likely due to the
tendency of women to seek help leading them to clinical settings. Histrionic personality disorder is more predominant in females in
clinical settings, though some studies using structured assessments point to no difference in prevalence rates across the genders.
Narcissistic personality disorder occurs more in men than women.

Cluster C
Using Part II of the National Comorbidity Survey Replication, it was found that for Cluster C personality disorders prevalence rates
were: 5.2% for avoidant, 0.6% for dependent, and 2.4% for OCPD. Women are more likely to be diagnosed with avoidant and
dependent personality disorders while OCPD appears to be equally prevalent in women and men.
For expanded information on the prevalence of the various personality disorders from the DSM-5-TR, please see Table 13. 1 below.

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Key Takeaways
You should have learned the following in this section:
Prevalence rates of Cluster A personality disorders range from 2% to 5% with schizotypal being more common in men and
there being no difference in schizoid and conflicting evidence for paranoid.
Prevalence rates of Cluster B personality disorders range from 0.0% to 1.4% and antisocial and narcissistic are more common in
men with borderline and histrionic being more common in women, in general.
Prevalence rates of Cluster C personality disorders range from 0.6% to 5.2% with women being more likely to be diagnosed
with avoidant and dependent personality disorders and OCPD appearing to be equally prevalent in women and men.

 Review Questions
1. What is the difference in prevalence rates across the three clusters? Are there any trends among gender?
2. Identify the most commonly occurring personality disorder. Which is the least common?

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13.3: Personality Disorders - Comorbidity
 Learning Objectives
Describe the comorbidity of personality disorders.

Among the most common comorbid diagnoses with personality disorders are mood disorders, anxiety disorders, and substance
abuse disorders (Lenzenweger, Lane, Loranger, & Kessler, 2007). A large meta-analysis exploring the data on the comorbidity of
major depressive disorder and personality disorders indicated a high diagnosis of major depressive disorder, bipolar disorder, and
dysthymia (Friborg, Martinsen, Martinussen, Kaiser, Overgard, & Rosenvinge, 2014). Further exploration of major depressive
disorder suggested the lowest rate of diagnosis in Cluster A disorders, higher rate in Cluster B disorders, and the highest rate in
Cluster C disorders. While the relationship between bipolar disorder and personality disorders has not been consistently clear, the
most recent findings report a high comorbidity between Cluster B personality disorders, with the exception of OCPD (which is in
Cluster C), which had the highest comorbidity rate than any other personality disorder. Overall analysis of dysthymia suggested
that it is the most diagnosed depressive disorder among all personality disorders.
A more detailed analysis exploring the prevalence rates of the four main anxiety disorders (generalized anxiety disorder, specific
phobia, social phobia, and panic disorder) among individuals with various personality disorders found a clear relationship specific
to personality disorders and anxiety disorders (Skodol, Geier, Grant, & Hasin, 2014). More specifically, individuals diagnosed with
borderline and schizotypal personality disorders were found to have an additional diagnosis of one of the four main anxiety
disorders. Individuals with narcissistic personality disorder were more likely to be diagnosed with generalized anxiety disorder and
panic disorder; schizoid and avoidant personality disorders reported significant rates of generalized anxiety disorder; avoidant
personality disorder had a higher diagnosis rate of social phobia. Substance use disorders occur less frequently across the ten
personality disorders but are most common in individuals diagnosed with antisocial, borderline, and schizotypal personality
disorders (Grant et al., 2015). Schizotypal personality disorder is also comorbid with brief psychotic disorder, schizophreniform
disorder, delusional disorder, and schizophrenia while borderline is additionally comorbid with eating disorders, PTSD, and ADHD
(APA, 2022).

Key Takeaways
You should have learned the following in this section:
Mood disorders, anxiety disorders, and substance abuse disorders have a high comorbidity with personality disorders.
Substance abuse disorders occur less frequently across the ten personality disorders but when they do, are comorbid with
antisocial, borderline, and schizotypal personality disorders.

 Review Questions
1. With what other disorders are personality disorders comorbid?

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13.4: Personality Disorders - Etiology
 Learning Objectives
Describe the biological causes of personality disorders.
Describe the psychological causes of personality disorders.
Describe the social causes of personality disorders.

Research regarding the development of personality disorders is limited compared to that of other mental health disorders. The
following is a general overview of contributing factors to personality disorders. While there is some research lending itself to
specific causes of specific personality disorders, the overall contribution of biological, psychological, and social factors will be
reviewed.

Biological
Research across the personality disorders suggests some underlying biological or genetic component; however, identification of
specific mechanisms have not been identified in most disorders, except for those below. Because of this lack of concrete evidence,
researchers argue that it is difficult to determine what role genetics plays into the development of these disorders compared to that
of environmental influences. Therefore, while there is likely a biological predisposition to personality disorders, exact causes
cannot be determined at this time.
Research on the development of schizotypal personality disorder has identified similar biological causes to that of schizophrenia—
high activity of dopamine and enlarged brain ventricles (Lener et al., 2015). Similar differences in neuroanatomy may explain the
high similarity of behaviors in both schizophrenia and schizotypal personality disorder.
Surprisingly, antisocial personality disorder and borderline personality disorder also have similar neurological changes. More
specifically, individuals with both disorders reportedly show deficits in serotonin activity (Thompson, Ramos, & Willett, 2014).
These low levels of serotonin activity in combination with deficient functioning of the frontal lobes—particularly the prefrontal
cortex which is used in planning, self-control, and decision making—as well as an overly reactive amygdala, may explain the
impulsive and aggressive nature of both antisocial and borderline personality disorder (Stone, 2014).

Psychological
Psychodynamic, cognitive, and behavioral theories are among the most common psychological models used to explain the
development of personality disorders. Although much is still speculation, the following are general etiological views with regards
to each specific theory.
13.4.2.1. Psychodynamic. The psychodynamic theory places a large emphasis on negative early childhood experiences and how
these experiences impact an individual’s inability to establish healthy relationships in adulthood. More specifically, individuals
with personality disorders report higher levels of childhood stress, such as living in impoverished environments, exposure to
domestic violence, and experiencing repeated maltreatment (Kumari et al., 2014). Additionally, high levels of childhood neglect
and parental rejection are also observed in personality disorder patients, with early parental loss and rejection leading to fears of
abandonment throughout an individual’s life (Newnham & Janca, 2014; Roepke & Varter, 2014; Caligor & Clarkin, 2010).
Psychodynamic theorists believe that maltreatment in early childhood has the potential to negatively affect an individual’s sense of
self and their perception of others, leading to the development of a personality disorder. For example, an individual who was
neglected as a young child and deprived of love may report a lack of trust in others as an adult, a characteristic of antisocial
personality disorder (Meloy & Yakeley, 2010). Difficulty trusting others or beliefs that they are unable to be loved may also impact
one’s ability or desire to establish social relationships, as seen in many personality disorders, particularly schizoid. Because of these
early childhood deficits, individuals may also overcompensate in their relationships to convince themselves that they are worthy of
love and affection (Celani, 2014). Conversely, individuals may respond to their early childhood experiences by becoming
emotionally distant, using relationships as a sense of power and destructiveness.
13.4.2.2. Cognitive. While psychodynamic theory emphasizes early childhood experiences, cognitive theorists focus on the
maladaptive thought patterns and cognitive distortions displayed by those with personality disorders. Overall deficiencies in
thinking can lead individuals with personality disorders to develop inaccurate perceptions of others (Beck, 2015). These
dysfunctional beliefs likely originate from the interaction between a biological predisposition and undesirable environmental

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experiences. Maladaptive thought patterns and strategies are strengthened during aversive life events as a protective mechanism
and ultimately come together to form patterns of behavior displayed in personality disorders (Beck, 2015).
Cognitive distortions such as dichotomous thinking, also known as all-or-nothing thinking, are observed in several personality
disorders. More specifically, dichotomous thinking explains rigidity and perfectionism in OCPD, and the lack of self-sufficiency
among individuals with dependent and borderline personality disorders (Weishaar & Beck, 2006). Discounting the positive also
explains the underlying mechanisms for avoidant personality disorder (Weishaar & Beck, 2006). For example, individuals who
have been routinely criticized or rejected during childhood may have difficulty accepting positive feedback from others, expecting
only to receive rejection and harsh criticism. In fact, they may employ these misattributions to positive feedback to support their
ongoing theory that they are constantly rejected and criticized by others.
13.4.2.3. Behavioral. Behavioral theorists apply three major theories to explain the development of personality disorders:
modeling, reinforcement, and lack of social skills. In modeling, an individual learns maladaptive social patterns and behaviors by
directly observing family members engaging in similar behaviors (Gaynor & Baird, 2007). While we cannot discredit the biological
component of the familial influence, research does support an additive modeling or imitating component to the development of
personality disorders, especially antisocial personality disorder (APA, 2022).
Reinforcement, or rewarding of maladaptive behaviors is also observed in the development of many personality disorders. Parents
may unintentionally reward aggressive behaviors by giving in to a child’s desires to cease the situation or prevent escalation of
behaviors. When this is done repeatedly over time, children (and later as adults) continue with these maladaptive behaviors as they
are effective in gaining their needs and wants. On the other side, there is some speculation that excessive reinforcement or praise
during childhood may contribute to the grandiose sense of self observed in individuals with narcissistic personality disorder
(Millon, 2011).
Finally, failure to develop normal social skills may explain the development of some personality disorders, such as avoidant
personality disorder (Kantor, 2010).

Social
13.4.3.1. Family dysfunction. High levels of psychological and social dysfunction within families have also been identified as
contributing factors to the development of personality disorders. High levels of poverty, unemployment, family separation, and
witnessing domestic violence are routinely observed in individuals diagnosed with personality disorders (Paris, 1996). While
formalized research has yet to explore the relationship between SES and personality disorders fully, correlational studies suggest a
link between poverty, unemployment, and poor academic achievement with increased levels of personality disorder diagnoses
(Alwin, 2006).
13.4.3.2. Childhood maltreatment. Childhood maltreatment is among the most influential argument for the development of
personality disorders in adulthood. Individuals with personality disorders often struggle with a sense of self and the ability to relate
to others—something that is generally developed during the first four to six years of a child’s life, and it is affected by the
emotional environment in which that child was raised. This sense of self is the mechanism in which individuals view themselves
within their social context, while also informing attitudes and expectations of others. A child who experiences significant
maltreatment, whether it be through neglect or physical, emotional, or sexual abuse, is at-risk for an underdeveloped or absent
sense of self. Due to the lack of affection, discipline, or autonomy during childhood, these individuals are unable to engage in
appropriate relationships as adults as seen across the spectrum of personality disorders.
Another way childhood maltreatment contributes to personality disorders is through the emotional bonds or attachments
developed with primary caregivers. John Bowlby thoroughly researched the relationship between attachment and emotional
development as he explored the need for affection in Harlow monkeys (Bowlby, 1998). Based on Bowlby’s research, four
attachment styles have been identified: secure, anxious, ambivalent, and disorganized. While securely attached children
generally do not develop personality disorders, those with anxious, ambivalent, and disorganized attachment are at an increased
risk of developing various disorders. More specifically, those with an anxious attachment are at-risk for developing internalizing
disorders, ambivalent are at-risk for developing externalizing disorders, and disorganized are at-risk for dissociative symptoms and
personality-related disorders (Alwin, 2006).

Key Takeaways
You should have learned the following in this section:

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 Biological causes of personality disorders have not been identified in most disorders, the exception being schizotypal which has
similar biological causes as schizophrenia and antisocial and borderline personality disorders which have similar neurological
changes.
Psychological causes of personality disorders include negative early childhood experiences; maladaptive thought patterns and
cognitive distortions; and modeling, reinforcement, and lack of social skills.
Social causes of personality disorders include high levels of psychological and social dysfunction within families and
maltreatment.

 Review Questions
1. What personality disorders are most explained by the biological model?
2. How does the psychodynamic model explain the development of personality disorders?
3. What cognitive distortions are most discussed with respect to personality disorders?
4. What are the three behavioral theories used to explain the development of personality disorders?
5. Discuss the roll of attachment and how theorists have used it to explain the development of personality disorders.

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13.5: Personality Disorders - Treatment
 Learning Objectives
Describe treatment options for personality disorders.

Cluster A
Individuals with personality disorders within Cluster A often do not seek out treatment as they do not identify themselves as
someone who needs help (Millon, 2011). Of those that do seek treatment, the majority do not enter it willingly. Furthermore, due to
the nature of these disorders, individuals in treatment often struggle to trust the clinician as they are suspicious of the clinician’s
intentions (paranoid and schizotypal personality disorder) or are emotionally distant from the clinician as they do not have a desire
to engage in treatment due to lack of overall emotion (schizoid personality disorder; Kellett & Hardy, 2014, Colli, Tanzilli,
Dimaggio, & Lingiardi, 2014). Because of this, treatment is known to move very slowly, with many patients dropping out before
any resolution of symptoms.
When patients are enrolled in treatment, cognitive-behavioral strategies are most commonly used with the primary intention of
reducing anxiety-related symptoms. Additionally, attempts at cognitive restructuring—both identifying and changing maladaptive
thought patterns—are also helpful in addressing the misinterpretations of other’s words and actions, particularly for individuals
with paranoid personality disorder (Kellett & Hardy, 2014). Schizoid personality disorder patients may engage in CBT techniques
to help experience more positive emotions and more satisfying social experiences, whereas the goal of CBT for schizotypal
personality disorder is to evaluate unusual thoughts or perceptions objectively and to ignore the inappropriate thoughts (Beck &
Weishaar, 2011). Finally, behavioral techniques such as social-skills training may also be implemented to address ongoing
interpersonal problems displayed in the disorders.

Cluster B
13.5.2.1. Antisocial personality disorder. Treatment options for antisocial personality disorder are limited and generally not
effective (Black, 2015). Like Cluster A disorders, many individuals are forced to participate in treatment, thus impacting their
ability to engage in and continue with treatment. Cognitive therapists have attempted to address the lack of morality and encourage
patients to think about the needs of others (Beck & Weishaar, 2011).
13.5.2.2. Borderline personality disorder. Borderline personality disorder is the one personality disorder with an effective
treatment option—Dialectical Behavioral Therapy (DBT). DBT is a form of cognitive-behavioral therapy developed by Marsha
Linehan (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). There are four main goals of DBT: reduce suicidal behavior,
reduce therapy interfering behavior, improve quality of life, and reduce post-traumatic stress symptoms.
Within DBT, five main treatment components collectively help to reduce harmful behaviors (i.e., self-mutilation and suicidal
behaviors) and replace them with practical, life-enhancing behaviors (Gonidakis, 2014). The first component is skills training.
Generally performed in a group therapy setting, individuals engage in mindfulness, distress tolerance, interpersonal effectiveness,
and emotion regulation. Second, individuals focus on enhancing motivation and applying skills learned in the previous component
to specific challenges and events in their everyday life. The third, and often the most distinctive aspect of DBT, is the use of
telephone and in vivo coaching for DBT patients from the DBT clinical team. It is not uncommon for patients to have the cell
phone number of their clinician for 24/7 availability of in-the-moment support. The fourth component, case management, consists
of allowing the patient to become their own “case manager” and effectively use the learned DBT techniques to problem-solve
ongoing issues. Within this component, the clinician will only intervene when absolutely necessary. Finally, the consultation team,
is a service for the clinicians providing the DBT treatment. Due to the high demands of borderline personality disorder patients, the
consultation team offers support to the providers in their work to ensure they remain motivated and competent in DBT principles to
provide the best treatment possible.
Support for the effectiveness of DBT in borderline personality disorder patients has been implicated in several randomized control
trials (Harned, Korslund, & Linehan, 2014; Neacsiu, Eberle, Kramer, Wisemeann, & Linehan, 2014). More specifically, DBT has
shown to significantly reduce suicidality and self-harm behaviors in those with borderline personality disorders. Additionally, the
drop-out rates for treatment are extremely low, suggesting that patients value the treatment components and find them useful in
managing symptoms.

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13.5.2.3. Histrionic personality disorder. Individuals with histrionic personality disorder are more likely to seek out treatment
than other personality disorder patients. Unfortunately, due to the nature of the disorder, they are very difficult patients to treat as
they are quick to employ their demands and seductiveness within the treatment setting. The overall goal for the treatment of
histrionic personality disorder is to help the patient identify their dependency and become more self-reliant. Cognitive therapists
utilize techniques to help patients change their helpless beliefs and improve problem-solving skills (Beck & Weishaar, 2011).
13.5.2.4. Narcissistic personality disorder. Of all the personality disorders, narcissistic personality disorder is among the most
difficult to treat (with maybe the exception of antisocial personality disorder). Most individuals with narcissistic personality
disorder only seek out treatment for those disorders secondary to their personality disorder, such as depression (APA, 2022). The
focus of treatment is to address the grandiose, self-centered thinking, while also trying to teach patients how to empathize with
others (Beck & Weishaar, 2014).

Cluster C
While many individuals within avoidant and OCPD personality disorders seek out treatment to address their anxiety or depressive
symptoms, it is often difficult to keep them in treatment due to distrust or fear of rejection from the clinician. Treatment goals for
avoidant personality disorder are similar to that of social anxiety disorder. CBT techniques, such as identifying and challenging
distressing thoughts, have been effective in reducing anxiety-related symptoms (Weishaar & Beck, 2006). Specific to OCPD,
cognitive techniques aimed at changing dichotomous thinking, perfectionism, and chronic worrying help manage symptoms of
OCPD. Behavioral treatments such as gradual exposure to various social settings, along with a combination of social skills training,
have been shown to improve individuals’ confidence prior to engaging in social outings when treating avoidant personality disorder
(Herbert, 2007). Antianxiety and antidepressant medications commonly used to treat anxiety disorders have also been used with
minimal efficacy; furthermore, symptoms resume as soon as the medication is discontinued.
Unlike other personality disorders where individuals are skeptical of the clinician, individuals with dependent personality disorder
try to place obligations of their treatment on the clinician. Therefore, one of the main treatment goals for dependent personality
disorder patients is to teach them to accept responsibility for themselves, both in and outside of treatment (Colli, Tanzilli,
Dimaggio, & Lingiardi, 2014). Cognitive strategies such as challenging and changing thoughts on helplessness and inability to care
for oneself have been minimally effective in establishing independence. Additionally, behavioral techniques such as assertiveness
training have also shown some promise in teaching individuals how to express themselves within a relationship. Some argue that
family or couples therapy would be particularly helpful for those with dependent personality disorder due to the relationship
between the patient and another person being the primary issue; however, research on this treatment method has not yielded
consistently positive results (Nichols, 2013).

Key Takeaways
You should have learned the following in this section:
Individuals with a Cluster A personality disorder do not often seek treatment and when they do, struggle to trust the clinician
(paranoid and schizotypal) or are emotionally distant from the clinician (schizoid). When in treatment, cognitive restructuring
and cognitive behavioral strategies are used.
In terms of Cluster B, treatment options for antisocial are limited and generally not effective, borderline responds well to
dialectical behavioral therapy (DBT), histrionic patients seek out help but are difficult to work with, and finally narcissistic are
the most difficult to treat.
For Cluster C, cognitive techniques aid with OCPD while gradual exposure to various social settings and social skills training
help with avoidant. Clinicians use cognitive strategies to challenge thoughts on helplessness in patients with dependent
personality disorder.

 Review Questions
1. What is the process in Dialectical Behavioral Therapy (DBT)? What does the treatment entail? What disorders are treated
with DBT?
2. Given the difference in personality characteristics between the three clusters, how are the suggested treatment options
different between cluster A, B, and C?

Module Recap

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Module 13 covered three clusters of personality disorders: Cluster A, which includes paranoid, schizoid, and schizotypal; Cluster
B, which includes antisocial, borderline, histrionic, and narcissistic; and Cluster C which includes avoidant, dependent, and
obsessive-compulsive. We also covered the clinical description, epidemiology, comorbidity, etiology, and treatment of personality
disorders.

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 SECTION OVERVIEW

Part VI. Mental Disorders – Block 5

14: Neurocognitive Disorders
14.1: Neurocognitive Disorders - Clinical Presentation
14.2: Neurocognitive Disorders - Epidemiology
14.3: Neurocognitive Disorders - Etiology
14.4: Neurocognitive Disorders - Treatment

15: Contemporary Issues in Psychopathology

15.1: Legal Issues Related to Mental Illness
15.2: Patient’s Rights
15.3: The Therapist-Client Relationship

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1
 CHAPTER OVERVIEW

14: Neurocognitive Disorders

 Learning Objectives
Describe how neurocognitive disorders present.
Describe the epidemiology of neurocognitive disorders.
Describe the etiology of neurocognitive disorders.
Describe treatment options for neurocognitive disorders.

In Module 14, we will cover matters related to neurocognitive disorders (NCDs) to include their clinical presentation,
epidemiology, etiology, and treatment options. Our discussion will include delirium, major neurocognitive disorder, and mild
neurocognitive disorder. We also discuss nine subtypes to include: Alzheimer’s disease, traumatic brain injury (TBI), vascular
disorder, substance/medication induced, dementia with Lewy bodies, frontotemporal NCD, Parkinson’s disease, Huntington’s
disease, and HIV infection. Be sure you refer Modules 1-3 for explanations of key terms (Module 1), an overview of the various
models to explain psychopathology (Module 2), and descriptions of the therapies (Module 3).
14.1: Neurocognitive Disorders - Clinical Presentation
14.2: Neurocognitive Disorders - Epidemiology
14.3: Neurocognitive Disorders - Etiology
14.4: Neurocognitive Disorders - Treatment

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1
14.1: Neurocognitive Disorders - Clinical Presentation
 Learning Objectives
Describe how delirium presents.
Describe how major neurocognitive disorder presents.
Describe how mild neurocognitive disorder presents.

Unlike many of the disorders we have discussed thus far, neurocognitive disorders often result from disease processes or medical
conditions. Therefore, it is important that individuals presenting with these symptoms complete a medical assessment to better
determine the etiology behind the disorder.
There are three main categories of neurocognitive disorders—delirium, major neurocognitive disorder, and mild neurocognitive
disorder. Within major and minor neurocognitive disorders are several subtypes due to the etiology of the disorder. For this book,
we will review diagnostic criteria for both major and minor neurocognitive disorders, followed by a brief description of the various
disease subtypes in the etiology section.
It is important to note as well that the criteria for the various NCDs are based on defined cognitive domains. These include the
following, with a brief explanation of what it is:
1. Complex attention – Sustained, divided, or selective attention and processing speed
2. Executive function – planning, decision-making, overriding habits, mental flexibility, and responding to feedback/error
correction
3. Learning and memory – includes cued recall, immediate or long-term memory, and implicit learning
4. Language – Includes expressive language and receptive language
5. Perceptual-motor – Includes any abilities related to visual perception, gnosis, perceptual-motor praxis, or visuo-constructional
6. Social cognition – Includes recognition of emotions and theory of mind

Delirium
Delirium is characterized by a notable disturbance in attention along with reduced awareness of the environment. The disturbance
develops over a short period of time, representing a change from baseline attention and awareness, and fluctuates in severity during
the day. There is also a disturbance in cognitive performance that is significantly altered from one’s usual behavior. Disturbances in
attention are often manifested as difficulty sustaining, shifting, or focusing attention. Additionally, an individual experiencing an
episode of delirium will have a disruption in cognition, including confusion of where they are. Disorganized thinking, incoherent
speech, and hallucinations and delusions may also be observed during periods of delirium.
Delirium is associated with increased functional decline and risk of being placed in an institution. That said, most people with
delirium recover fully with or without treatment, especially if not elderly, but if undetected or the underlying cause is untreated, it
may progress to stupor, coma, seizures, or death (APA, 2022).

Major Neurocognitive Disorder

Individuals with major neurocognitive disorder show a significant decline in both overall cognitive functioning (see the previously
listed six domains) as well as the ability to independently meet the demands of daily living such as paying bills, taking medications,
or caring for oneself (APA, 2022). While it is not necessary, it is helpful to have documentation of the cognitive decline via
neuropsychological testing within a controlled, standardized testing environment. Information from close family members or
caregivers is also important in documenting the decline and impairment in areas of functioning.
Within the umbrella of major neurocognitive disorder is dementia, a striking decline in cognition and self-help skills due to a
neurocognitive disorder. The DSM-5-TR (APA, 2022) refrained from using this term in diagnostic categories as it is often used to
describe the natural decline in degenerative dementias that affect older adults; whereas neurocognitive disorder is the preferred
term used to describe conditions affecting younger individuals such as impairment due to traumatic brain injuries or other medical
conditions. Therefore, while dementia is accurate in describing those experiencing major neurocognitive disorder due to age, it is
not reflective of those experiencing neurocognitive issues secondary to an injury or illness.

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Mild Neurocognitive Disorder
Individuals with mild neurocognitive disorder demonstrate a modest decline in one of the listed cognitive domains. The decline in
functioning is not as extensive as that seen in major neurocognitive disorder, and the individual does not experience difficulty
independently engaging in daily activities. However, they may require assistance or extra time to complete these tasks, particularly
if the cognitive decline continues to progress.
It should be noted that the primary difference between major and mild neurocognitive disorder is the severity of the decline and
independent functioning. Some argue that the two are earlier and later stages of the same disease process (Blaze, 2013).
Conversely, individuals can go from major to mild neurocognitive disorder following recovery from a stroke or traumatic brain
injury (Petersen, 2011). The DSM-5-TR describes major and mild NCD as existing on a spectrum of cognitive and functional
impairment (APA, 2022, pg. 685).

Key Takeaways
You should have learned the following in this section:
The criteria for the various NCDs are based on the cognitive domains of complex attention, executive function, learning and
memory, language, perceptual-motor, and social cognition.
Delirium is characterized by a notable disturbance in attention or awareness and cognitive performance that is significantly
altered from one’s usual behavior.
Major neurocognitive disorder is characterized by a significant decline in both overall cognitive functioning as well as the
ability to independently meet the demands of daily living.
Mild neurocognitive disorder is characterized by a modest decline in one of the listed cognitive areas with no interference in
one’s ability to complete daily activities.

 Review Questions
1. What are the six cognitive domains the diagnostic criteria for NCDs are based on?
2. Define delirium. How does this differ from mild and major neurocognitive disorders?
3. What are the main differences between mild and major neurocognitive disorders?

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detailed edit history is available upon request.

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14.2: Neurocognitive Disorders - Epidemiology
 Learning Objectives
Describe the epidemiology of neurocognitive disorders.

Delirium
The prevalence of delirium in the general community is relatively low at 1% to 2% based on data from the United States and
Finland. For older individuals presenting to North American emergency departments, the rate is 8% to 17%. Prevalence rates for
those admitted to the hospital range from 18% to 35%. For those in nursing homes or post-acute care settings prevalence is 20 to
22% and 88% for individuals with terminal illnesses at the end of life. Prevalence rates are lower for younger African Americans
compared to White individuals of similar age.

Major and Mild NCD

Major and mild neurocognitive disorder prevalence rates vary widely depending on the etiological nature of the disorder and
overall prevalence estimates are generally only available for older populations. Internationally, dementia occurs in 1-2% of
individuals at age 65, and up to 30% of individuals by age 85. The female gender is associated with higher prevalence of dementia
overall. Estimates for mild NCD among older individuals range from 2% to 10% at age 65 and 5% to 25% at age 85. In the U.S.,
incidence is highest in African Americans followed by American Indians/Alaska Natives, Latinx, Pacific Islanders, non-Latinx
Whites, and Asian Americans.

Major and Mild NCD Subtypes

Alzheimer’s disease, the most commonly diagnosed neurocognitive disorder, is observed in nearly 5.5 million Americans
(Alzheimer’s Association, 2017a), with 11% of those aged 65 and older and 32% older than 85 having dementia due to Alzheimer’s
disease. It should also be noted that somewhere between 60-90% of dementias are attributable to Alzheimer’s disease, depending
on the setting and diagnostic criteria. In terms of ethnoracial background in the U.S. the highest prevalence rates have been found
among African Americans and Latinx of Caribbean origin (APA, 2022).
Over 2.87 million traumatic brain injuries (TBIs) happen each year within the United States, with men being 40% more likely to
experience a TBI compared with women. The most common causes of TBI, in order of occurrence, are falls followed by collision
with a moving or stationary object, automobile accidents, and assaults. It has also become increasingly recognized that concussion
in sport causes mild TBI (APA, 2022).

Key Takeaways
You should have learned the following in this section:
As individuals age, the rate of occurrence of delirium and dementia increases dramatically.
Estimates for mild NCD among older individuals range from 2% to 10% at age 65 and 5% to 25% at age 85.
As for Alzheimer’s disease, prevalence rates are 11% of those aged 65 and older and 32% of those older than 85.
Men are more likely to experience a TBI than women.

 Review Questions
1. What is the rate of occurrence of the neurocognitive disorders?

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14.3: Neurocognitive Disorders - Etiology
 Learning Objectives
Define degenerative.
Describe the symptoms and causes of Alzheimer’s disease.
Describe the symptoms and causes of traumatic brain injury (TBI).
Describe the symptoms and causes of vascular disorders.
Describe the symptoms and causes of substance/medication-induced major or mild NCD .
Describe the symptoms and causes of dementia with Lewy bodies.
Describe the symptoms and causes of frontotemporal NCD.
Describe the symptoms and causes of Parkinson’s disease.
Describe the symptoms and causes of Huntington’s disease.
Describe the symptoms and causes of HIV infection.

Neurocognitive disorders occur due to a wide variety of medical conditions or injury to the brain. Therefore, this section will focus
on a brief description of the nine different etiologies of neurocognitive disorders per the DSM-5-TR (APA, 2022). As you will see,
most of these neurocognitive disorders are both degenerative, meaning the symptoms and cognitive deficits become worse over
time, as well as related to a medical condition or disease.
Per the DSM-5-TR (APA, 2022), an individual will meet diagnostic criteria for either mild or major neurocognitive disorder as
listed above. In order to specify the type of neurocognitive disorder, additional diagnostic criteria specific to one of the following
subtypes must be met.

Alzheimer’s Disease
Alzheimer’s disease is the most prevalent neurodegenerative disorder. While the primary symptom of Alzheimer’s disease is the
gradual progression of impairment in cognition, it is also important to identify concrete evidence of cognitive decline. This can be
done in one of two ways: via genetic testing of the individual or a documented family history of the disease, or, through clear
evidence of cognitive decline over time by repeated standardized neuropsychological evaluations (APA, 2022). It is crucial to
identify these markers in making the diagnosis of Alzheimer’s disease as some individuals present with memory impairment but
eventually show a reversal of symptoms; this is not the case for individuals with Alzheimer’s disease.
14.3.1.1. Causes of Alzheimer’s disease. Autopsies of individuals diagnosed with Alzheimer’s disease identify two abnormal
brain structures— beta-amyloid plaques and neurofibrillary tangles— both of which are responsible for neuron death,
inflammation, and loss of cellular connections (Lazarov, Mattson, Peterson, Pimplika, & van Praag, 2010). It is believed that beta-
amyloid plaques, large bundles of plaque that develop between neurons, appear before the development of dementia symptoms. As
these plaque bundles increase in size and number, cognitive symptoms and impaired daily functioning become evident to close
family members. Neurofibrillary tangles are believed to appear after the onset of dementia symptoms and are found inside of cells,
affecting the protein that helps transport nutrients in healthy cells. Both beta-amyloid plaques and neurofibrillary tangles impact the
health of neurons within the hippocampus, amygdala, and the cerebral cortex, areas associated with memory and cognition (Spires-
Jones & Hyman, 2014).
Researchers have identified additional genetic and environmental influences in the development of Alzheimer’s disorder.
Genetically, the apolipoprotein E (ApoE) gene that helps to eliminate beta-amyloid by-products from the brain, has been
implicated in the development of Alzheimer’s disorder. One of the three variants of this gene, the e4 allele, appears to reduce the
production of ApoE, thus increasing the number of beta-amyloid plaques within the brain. However, not all individuals with the e4
allele develop Alzheimer’s disease; therefore, this explanation may better explain a vulnerability to Alzheimer’s disease as opposed
to the cause of the disease.
Various brain regions have also been implicated in the development of Alzheimer’s disease. More specifically, neurons shrinking or
dying within the hypothalamus, thalamus, and the locus ceruleus have been linked to declining cognition (Selkoe, 2011, 1992).
Acetylcholine-secreting neurons within the basal forebrain also appear to shrink or die, contributing to Alzheimer’s disease
symptoms (Hsu et al., 2015).

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Environmental toxins such as high levels of zinc and lead may also contribute to the development of Alzheimer’s disease. More
precisely, zinc has been linked to the clumping of beta-amyloid proteins throughout the brain. Although lead has largely been
phased out of environmental toxins due to negative health consequences, current elderly individuals were exposed to these toxic
levels of lead in gasoline and paint as young children. There is some speculation that lead and other pollutants may impact
cognitive functioning in older adults (Richardson et al., 2014).
14.3.1.2. Onset of Alzheimer’s disease. Alzheimer’s disease is defined by the onset of symptoms. Early-onset Alzheimer’s disease
occurs before the age of 65. While only a small percentage of individuals experience early onset of the disease, those that do
experience early disease progression appear to have a more genetically influenced condition and a higher rate of family members
with the disease.
Late-onset Alzheimer’s disease occurs after the age of 65 and has less of a familial influence. This onset appears to occur due to a
combination of biological, environmental, and lifestyle factors (Chin-Chan, Navarro-Yepes, & Quintanilla-Vega, 2015). Nearly
30% of individuals within this class of diagnosis have the ApoE gene that fails to eliminate the beta-amyloid proteins from various
brain structures. It is believed that the combination of the presence of this gene along with environmental toxins and lifestyle
choices (i.e., more stress) impact the development of Alzheimer’s disease.

Traumatic Brain Injury (TBI)

TBIs occur when an individual experiences significant trauma or damage to the head. Neurocognitive disorder due to TBI is
diagnosed when persistent cognitive impairment is observed immediately following the head injury, along with one or more of the
following symptoms: loss of consciousness, posttraumatic amnesia, disorientation and confusion, or neurological impairment
(APA, 2022).
The presentation of symptoms varies among individuals and depends largely on the location of the injury and the intensity of the
trauma. Furthermore, the effects of a TBI can be temporary or permanent. Symptoms generally range from headaches,
disorientation, confusion, irritability, fatigue, poor concentration, and emotional and behavioral changes. More severe injuries can
result in more significant neurological symptoms such as seizures, paralysis, and visual disturbances.
Major or mild NCD due to TBI may be comorbid with specified or unspecified depressive, anxiety, or personality disorders and
PTSD. Rates of suicidal ideation are as high as 10% with rates of suicide attempt hovering around 0.8% to 1.7% (APA, 2022).
The most common type of TBI is a concussion. A concussion occurs when there is a significant blow to the head, followed by
changes in brain functioning. It often causes immediate disorientation or loss of consciousness, along with headaches, dizziness,
nausea, and sensitivity to light (Alla, Sullivan, & McCrory, 2012). While symptoms of a concussion are usually temporary, there
can be more permanent damage due to repeated concussions, particularly if they are close in time. The media has brought
considerable attention to this with the recent discussions of chronic traumatic encephalopathy (CTE) which is a progressive,
degenerative condition due to repeated head trauma. CTEs are most commonly seen in athletes (i.e., football players) and military
personnel (Baugh et al., 2012). In addition to the neurological symptoms, psychological symptoms such as depression and poor
impulse control have been observed in individuals with CTE. These individuals also appear to be at greater risk for the
development of dementia (McKee et al., 2013).

Vascular Disorders
Neurocognitive disorders due to vascular disorders can occur from a one-time event such as a stroke or ongoing subtle disruptions
of blood flow within the brain (APA, 2022). The occurrence of these vascular disorders general begins with atherosclerosis, or the
clogging of arteries due to a build-up of plaque. The plaque builds up over time, eventually causing the artery to narrow, thus
reducing the amount of blood able to pass through to other parts of the body. When these arteries within the brain become entirely
obstructed, a stroke occurs. The lack of blood flow during a stroke results in the death of neurons and loss of brain function. There
are two types of strokes—a hemorrhagic stroke that occurs when a blood vessel bursts within the brain and an ischemic stroke,
which is when a blood clot blocks the blood flow in an artery within the brain (American Stroke Association, 2017).
While strokes can occur at any age, the majority of strokes occur after age 65 (Hall, Levant, & DeFrances, 2012). A wide range of
cognitive, behavioral, and emotional changes occur following a stroke. Symptoms are generally dependent on the location of the
stroke within the brain as well as the extensiveness of damage to those brain regions (Poels et al., 2012). For example, strokes that
occur on the left side of the brain tend to cause problems with speech and language, as well as physical movement on the right side
of the body; whereas strokes that occur on the right side of the brain tend to cause problems with impulsivity and impaired
judgement, short-term memory loss, and physical movement on the left side of the body (Hedna et al., 2013).

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After Alzheimer’s disease, vascular disease is the second most common cause of NCD and population prevalence estimates are
0.98% for those between the ages of 71-79 years, 4.09% for individuals aged 80-89 years, and 6.19% for those aged 90 years and
up. Within three months of a stroke, 20%-30% of people are diagnosed with dementia. Finally, stroke is more common in men up
to age 65 and after that, it shifts to women. Vascular disease is frequently comorbid with major or mild NCD due to Alzheimer’s
disease and depression.

Substance/Medication-Induced Major or Mild NCD

Significant cognitive changes occur due to repetitive drug and alcohol abuse. Delirium can be observed in individuals with extreme
substance intoxication, withdrawal, or even when multiple substances have been used within a close period (APA, 2022). While
delirium symptoms are often transient during these states, mild neurocognitive impairment due to heavy substance abuse may
remain until a significant period of abstinence is observed (Stavro, Pelletier, & Potvin, 2013).

Dementia with Lewy Bodies

Symptoms associated with neurocognitive disorder due to Lewy bodies include significant fluctuations in attention and alertness;
recurrent visual hallucinations; impaired mobility; and sleep disturbances such as rapid eye movement sleep behavior disorder
(APA, 2022). While the trajectory of the illness develops more rapidly than Alzheimer’s disease, the survival period is similar in
that most individuals do not survive longer than eight years post-diagnosis (Lewy Body Dementia Association, 2017).
Lewy bodies are irregular brain cells that result from the buildup of abnormal proteins in the nuclei of neurons. These brain cells
deplete the cortex of acetylcholine, which causes the behavioral and cognitive symptoms observed in both dementia with Lewy
bodies and Parkinson’s disease. The motor symptoms seen in both these disorders occur from the depletion of dopamine by the
Lewy body nerve cells that accumulate in the brain stem.

Major or Mild Frontotemporal NCD

Frontotemporal NCD causes “progressive development of behavioral and personality change and/or language impairment” (APA,
2022, pg. 696). For the behavioral variant, individuals display at least three of the following: behavioral disinhibition, apathy or
inertia, loss of sympathy or empathy, preservative or compulsive behavior, or hyperorality and dietary changes. For the language
variant, they show prominent decline in language ability (i.e., speech production, word finding, object naming, grammar, or word
comprehension). There is relative sparing of learning and memory and perceptual-motor functioning. Individuals with
frontotemporal NCD commonly present in their 50s though the age of onset has a range of age 20 to 80 years. The median survival
is 6-11 years after symptom onset and 3-4 years after diagnosis (APA, 2022).

Parkinson’s Disease
The awareness of Parkinson’s disease has increased in recent years due in large part to Michael J. Fox’s early diagnosis in 1991. It
affects approximately 630,000 individuals (Kowal, Dall, Chakrabarti, Storm, & Jain, 2013). While many are aware of the tremors
of hands, arms, legs, and face, the other three main symptoms of Parkinson’s disease are rigidity of the limbs and trunk; slowness
in initiating movement; and drooping posture or impaired balance and coordination (National Institute of Neurological Disorders
and Stroke, 2017). These motor symptoms are generally present at least one year prior to the beginning of cognitive decline,
although severity and progression of symptoms vary significantly from person to person.
Onset of Parkinson’s disease is typically from age 50 to 89 years. Mild NCD develops early in the course of Parkinson’s disease
while Major NCD does not occur until individuals are much older. The prevalence of Parkinson’s disease in the U.S. increases with
age and is more common in men than women. The disease is comorbid with Alzheimer’s disease and cerebrovascular disease.
Depression, psychosis, REM sleep behavior disorder, apathy, and motor symptoms can make functional impairment worse (APA,
2022).

Huntington’s Disease
Huntington’s disease is a rare genetic disorder that involves involuntary movement, progressive dementia, and emotional
instability. Due to the degenerative nature of the disorder, there is a shortened life-expectancy as death typically occurs 15-20 years
post-onset of symptoms (Clabough, 2013). Although symptoms can present at any time, the average age of symptom presentation
is during middle adulthood (between ages 35 and 45 years; APA, 2022). Symptoms generally begin with neurocognitive decline,
particularly in executive function, along with changes in mood and personality. As symptoms progress, more physical symptoms
present, such as facial grimaces, difficulty speaking, and repetitive movements. Because there is no treatment for Huntington’s

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disease, the severity of the cognitive and physical impairments ultimately leads to complete dependency and the need for full-time
care. Suicide is among the leading causes of death in Huntington’s disease (APA, 2022).

HIV Infection
Not many people are aware that cognitive impairment is sometimes the first symptom of untreated HIV. While symptoms vary
among individuals, slower mental processing, impaired executive function, problems with more demanding attentional tasks, and
difficulty learning new information are among the most common early signs (APA, 2022). When HIV becomes active in the brain,
significant alterations of mental processes occur, thus leading to a diagnosis of neurocognitive disorder due to HIV infection.
Significant impairment can also occur due to HIV-infection related inflammation throughout the central nervous system.
Fortunately, antiretroviral therapies used in treating HIV have been effective in reducing and preventing the onset of severe
cognitive impairments; however, HIV-related brain changes still occur in nearly half of all patients on antiretroviral medication.
There is hope that once antiretroviral therapies can cross the blood-brain barrier in the central nervous system, there will be a
significant improvement in the prevalence of HIV-related neurocognitive disorder (Vassallo et al., 2014).

Key Takeaways
You should have learned the following in this section:
Most neurocognitive disorders are degenerative meaning they become worse over time.
Alzheimer’s disease is characterized by the gradual progression of impairment in cognition as well as the presence of beta-
amyloid plaques and neurofibrillary tangles.
TBIs occur when an individual experiences significant trauma or damage to the head with the most common type being a
concussion.
Vascular disorders generally begin with atherosclerosis which leads to a stroke.
Significant cognitive changes occur due to repetitive drug and alcohol abuse such as delirium.
Dementia with Lewy bodies is characterized by significant fluctuations in attention and alertness; recurrent visual
hallucinations; impaired mobility; and sleep disturbance.
Frontotemporal NCD causes progressive declines in language or behavior due to the degeneration in the frontal and temporal
lobes of the brain.
Parkinson’s disease is characterized by tremors of hands, arms, legs, or face; rigidity of the limbs and trunk; slowness in
initiating movement; and drooping posture or impaired balance and coordination.
Huntington’s disease involves involuntary movement, progressive dementia, and emotional instability.
HIV infection begins with slower mental processing, impaired executive function, problems with more demanding attentional
tasks, and difficulty learning new information.

 Review Questions
1. Define degenerative. What disorders discussed in this module are considered degenerative?
2. Identify the biological causes of Alzheimer’s disease.
3. What is a TBI?
4. How do vascular disorders occur?
5. What are Lewy bodies? How does dementia with Lewy bodies differ from Alzheimer’s disease?
6. What are the main symptoms of Parkinson’s disease? Huntington’s disease?

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14.4: Neurocognitive Disorders - Treatment
 Learning Objectives
Describe treatment options for neurocognitive disorders.

Treatment options for those with neurocognitive disorders are minimal at best, with most attempting to treat secondary symptoms
as opposed to the neurocognitive disorder itself. Furthermore, the degenerative nature of these disorders also makes it difficult to
treat, as many diseases will progress regardless of the treatment options.

Pharmacological
Pharmacological interventions, and more specifically medications designed to target acetylcholine and glutamate, have been the
most effective treatment options in alleviating symptoms and reducing the speed of cognitive decline within individuals diagnosed
with Alzheimer’s disease. Specific medications such as donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne), and
memantine (Namenda) are among the most commonly prescribed (Alzheimer’s Association, 2017a). Due to possible negative side
effects of the medications, these drugs are prescribed to individuals in the early or middle stages of Alzheimer’s as opposed to
those with advanced disease. Researchers have also explored treatment options aimed at preventing the build-up of beta-amyloid
and neurofibrillary tangles; however, this research is still in its infancy (Alzheimer’s Association, 2017a)
Parkinson’s disease has also found success in pharmacological treatment options. The medication levodopa increases dopamine
availability, which provides relief of both physical and cognitive symptoms. Unfortunately, there are also significant side effects
such as hallucinations and psychotic symptoms; therefore, the medication is often only used when the benefits outweigh the
negatives of the potential risks (Poletti & Bonuccelli, 2013).

Psychological
Among the most effective psychological treatment options for individuals with neurocognitive disorders are the use of cognitive
and behavioral strategies. More specifically, engaging in various cognitive activities such as computer-based cognitive stimulation
programs, reading books, and following the news, have been identified as effective strategies in preventing or delaying the onset of
Alzheimer’s disease (Szalavits, 2013; Wilson, Segawa, Boyle, & Bennett, 2012).
Engaging in social skills and self-care training are additional behavioral strategies used to help improve functioning in individuals
with neurocognitive deficits. For example, by breaking down complex tasks into smaller, more attainable goals, as well as
simplifying the environment (i.e., labeling location of items, removing clutter), individuals can successfully engage in more
independent living activities.

Support for Caregivers

Supporting caregivers is an important treatment option to include as the emotional and physical toll on caring for an individual with
a neurocognitive disorder is often underestimated. According to the Alzheimer’s Association (2017b), nearly 90% of all individuals
with Alzheimer’s disease are cared for by a relative. The emotional and physical demands on caring for a family member who
continues to decline cognitively and physically can lead to increased anger and depression in a caregiver (Kang et al. 2014). It is
important that medical providers routinely assess caregivers’ psychosocial functioning, and encourage caregivers to participate in
caregiver support groups, or individual psychotherapy to address their own emotional needs.

Key Takeaways
You should have learned the following in this section:
Pharmacological interventions for Alzheimer’s disease target the neurotransmitters acetylcholine and glutamate and newer
research is focused on the build-up of beta-amyloid and neurofibrillary tangles.
Psychological treatments include cognitive and behavioral strategies such as playing board games, reading books, or social
skills training.
Caregivers need to join support groups to help them manage their own anger and depression, especially since 90% of such
caregivers are relatives of the afflicted.

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  Review Questions
1. Review the listed treatment options for neurocognitive disorders. What are the main goals of these treatments?

Module Recap
Our discussion in Module 14 turned to neurocognitive disorders to include the categories of delirium, major neurocognitive
disorder, and Mild neurocognitive disorder. We also discussed the subtypes of Alzheimer’s disease, traumatic brain injury (TBI),
vascular disorder, substance/medication induced, dementia with Lewy bodies, frontotemporal NCD, Parkinson’s disease,
Huntington’s disease, and HIV infection. The clinical description, epidemiology, etiology, and treatment options for neurocognitive
disorders were discussed.

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 CHAPTER OVERVIEW

15: Contemporary Issues in Psychopathology

 Learning Objectives
Describe how clinical psychology interacts with law.
Describe issues related to civil commitment.
Describe issues related to criminal commitment.
Outline patient’s rights.
Clarify concerns related to the therapist-client relationship.

In our final module, we will tackle the issue of how clinical psychology interacts with law. Our discussion will include topics
related to civil and criminal commitment, patient’s rights, and the patient-therapist relationship. We end on an interesting note and
discuss whether gaming can be addictive. Enjoy.
15.1: Legal Issues Related to Mental Illness
15.2: Patient’s Rights
15.3: The Therapist-Client Relationship

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1
15.1: Legal Issues Related to Mental Illness
 Learning Objectives
Define forensic psychology/psychiatry.
Describe potential roles a forensic psychologist might have.
Define civil commitment.
Identify criteria for civil commitment.
Describe dangerousness.
Outline procedures in civil commitment.
Define criminal commitment.
Define NGRI.
Describe pivotal rules/acts/etc. in relation to the concept of insanity.
Define GBMI.
Clarify what it means to be competent to stand trial.

Forensic Psychology/Psychiatry
According to the American Psychological Association, forensic psychology/psychiatry is when clinical psychology is applied to
the legal arena in terms of assessment, treatment, and evaluation. Forensic psychology can also include the application of research
from other subfields in psychology to include cognitive and social psychology. Training includes law and forensic psychology, and
solid clinical skills are a must. According to APA, a forensic psychologist might “perform such tasks as threat assessment for
schools, child custody evaluations, competency evaluations of criminal defendants and of the elderly, counseling services to
victims of crime, death notification procedures, screening and selection of law enforcement applicants, the assessment of post-
traumatic stress disorder and the delivery and evaluation of intervention and treatment programs for juvenile and adult offenders.”
A key issue investigated by forensic psychologists includes mens rea or the insanity plea. We will discuss this shortly.
To learn more about forensic psychology, or to investigate the article mentioned above, please visit:
www.apa.org/ed/precollege/psn/2013/09/forensic-psychology.aspx

Civil Commitment
15.1.2.1. What is civil commitment? When individuals with mental illness behave in erratic or potentially dangerous ways, to
either themselves or others, then something must be done. The responsibility to act falls on the government through what is called
parens patriae or “father of the country” or “country as parent.” Action, in this case, involves involuntary commitment in a hospital
or mental health facility and is done to protect the individual and express concern over their well-being, much like a parent would
do for their child. An individual can voluntarily admit themselves to a mental health facility, and upon doing so, staff will
determine whether treatment and extended stay are needed.
15.1.2.2. Criteria for civil commitment. Though states vary in the criteria used to establish the need for civil commitment, some
requirements are common across states. First, the individual must present a clear danger to either themselves or others. Second, the
individual demonstrates that they are unable to care for themself or make decisions about whether treatment or hospitalization is
necessary. Finally, the individual believes they are about to lose control, and so, needs treatment or care in a mental health facility.
15.1.2.3. Assessment of “dangerousness.” Dangerousness can best be defined as the person’s capacity or likelihood of harming
themselves or others. Most people believe that those who are mentally ill are more dangerous than those free of mental illness,
especially when espousing self-reported conservatism and RWA (Right-Wing Authoritarianism; Gonzales, Chan, and Yanos, 2017;
DeLuca and Yanos, 2015) or after tragic events such as a mass shooting (Metzl & MacLeish, 2015). The media plays a role in this,
and as McGinty et al. (2014) found, 70% of news coverage of serious mental illness (SMI) and gun violence over a 16-year period
(1997 to 2012) focused on extreme events and described specific shootings by persons with SMI. The authors wrote, “Even in
thematic news coverage focused on describing the general problem of SMI and gun violence, the majority of news stories did not
mention that most people with SMI are not violent or that we lack tools capable of accurately identifying persons with SMI who are
at heightened risk of committing future violence.” They concluded that media coverage of persons with SMI as violent might
contribute to negative public attitudes.

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Rozel & Mulvey (2017) showed that mental illness is a weak risk factor for violence though this is not to say that the mentally ill
do not commit violent acts. The authors write, “…it has been documented repeatedly that people who report diagnosable levels of
psychiatric symptoms also report more involvement in acts of violence toward others than the general population reports.”
Approximately 4% of criminal violence can be attributed to the mentally ill (Metzl & MacLeish, 2015), while those with mental
illness are three times more likely to be targets and not perpetrators of violence (Choe et al., 2008).
Regardless of this, we do attempt to identify the level of dangerousness a person may exhibit or have the potential to exhibit. How
easy is it to make this prediction? As you might think, it can be very difficult. First, the definition of dangerousness is vague. It
implies physical harm, but what about psychological abuse or the destruction of property? Second, past criminal activity is a good
predictor of future dangerousness but is often not admissible in court. Third, context is critical; in some situations, the person is
perfectly fine, but in other circumstances, like having to wait in line at your local Department of Motor Vehicles, the person
experiences considerable frustration and eventually anger or rage.
15.1.2.4. Procedures in civil commitment. The process for civil commitment does vary somewhat state-to-state, but some
procedures are held in common. First, a family member, mental health professional, or primary care practitioner, may request that
the court order an examination of an individual. If the judge agrees, two professionals, such as a mental health professional or
physician, are appointed to examine the person in terms of their ability for self-care, need for treatment, psychological condition,
and likelihood to inflict harm on self or others. Next, a formal hearing gives the examiners a chance to testify as to what they
found. Testimonials may also be provided by family and friends, or by the individual him/herself. Once testimonies conclude, the
judge renders judgment about whether confinement is necessary and, if so, for how long. Typical confinements last from 6 months
to 1 year, but an indefinite period can be specified too. In the latter case, the individual has periodic reviews and assessments. In
emergencies, the process stated above can be skipped and short-term commitment made, especially if the person is an imminent
threat to themself or others.
Before we move on, consider for a minute that a person who is accused of a crime is innocent until proven guilty, has a trial, and if
found guilty beyond a reasonable doubt (or almost complete certainty) is only then incarcerated. This is not true for the mentally ill,
who may be committed to a facility without ever having committed a crime or having a trial, but simply because they were judged
as having the potential to do so (or was seen as dangerous). This potential means that there must be “clear and convincing” proof,
which the U.S. Supreme Court defines as 75% certainty. The standard to commit is much different for those accused of criminal
acts and those who are mentally ill.

Criminal Commitment
When people are accused of crimes but found to be mentally unstable, they are usually sent to a mental health institution for
treatment. This is called criminal commitment. Individuals may plead not guilty by reason of insanity (NGRI) or as it is also
called, the insanity plea. When a defendant pleads NGRI they are acknowledging their guilt for the crime (actus rea) but wish to
be seen as not guilty since they were mentally ill at the time (mens rea).
The origins of the modern definition of insanity go back to Daniel M’Naghten in 1843 England. He murdered the secretary to
British Prime Minister, Robert Peel, during an attempted assassination of the Prime Minister. He was found to be not guilty due to
delusions of persecution, which outraged the public and led to calls for a more precise definition of insanity. The M’Naghten rule
states that having a mental disorder at the time of a crime does not mean the person was insane. The individual also had to be
unable to know right from wrong or comprehend the act as wrong. But how do you know what the person’s level of awareness was
when the crime was committed?
Dissatisfaction with the M’Haghten rule led some state and federal courts in the U.S. to adopt instead the irresistible impulse test
(1887), which focused on the inability of a person to control their behaviors. The issue with this rule is in distinguishing when a
person is unable to maintain control rather than choosing not to exert control over their behavior. This meant there were two
choices in the U.S. in terms of how insanity was defined – the M’Haghten rule and the irresistible impulse test. A third test
emerged in 1954 from the Durham v. United States case, though it was short-lived. The Durham test, or products test, stated that
a person was not criminally responsible if their crime was a product of a mental illness or defect. It offered some degree of
flexibility for the courts but was viewed as too flexible. Since almost anything can cause something else, the term product is too
vague.
In 1962, the American Law Institute (ALI) offered a compromise to the three precepts in use at the time. The American Law
Institute standard stated that people are not criminally responsible for their actions if, at the time of their crime, they had a mental
disorder or defect that did not allow them to distinguish right from wrong and to obey the law. Though this became the standard, it

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also became controversial when defense attorneys used it as the basis to have John Hinckley, accused of attempting to assassinate
President Ronald Regan, found not guilty by reason of insanity in 1982.
Public uproar led the American Psychiatric Association to reiterate the stance of the M’Naghten test and assert people were only
insane if they did not know right from wrong when they committed their crime. The Federal Insanity Defense Reform ACT
(IDRA) of 1984 “was the first comprehensive federal legislation governing the insanity defense and the disposition of individuals
suffering from a mental disease or defect who are involved in the criminal justice system.” The ACT included the following
provisions:
significantly modified the standard for insanity previously applied in the federal courts
placed the burden of proof on the defendant to establish the defense by clear and convincing evidence
limited the scope of expert testimony on ultimate legal issues
eliminated the defense of diminished capacity, created a special verdict of “not guilty only by reason of insanity,” which triggers
a commitment proceeding
provided for federal commitment of persons who become insane after having been found guilty or while serving a federal
prison sentence.
Source: https://www.justice.gov/usam/criminal-resource-manual-634-insanity-defense-reform-act-1984
This is the current standard in all federal courts and about half of all state courts, with Idaho, Kansas, Montana, and Utah choosing
to get rid of the insanity plea altogether.
For more on the insanity plea, please visit:
https://www.npr.org/sections/health-shots/2016/08/05/487909967/with-no-insanity-defense-seriously-ill-people-end-up-in-prison
Another possibility is for the jury to deliver a verdict of guilty but mentally ill (GBMI), effectively acknowledging that the person
did have a mental disorder when committing a crime, but the illness was not responsible for the crime itself. The jurors can then
convict the accused and suggest they receive treatment. Though this looks like an excellent alternative, jurors are often confused by
it (Melville & Naimark, 2002), NGRI verdicts have not been reduced, and all prisoners have access to mental health care anyway.
Hence it differs from a guilty verdict in name only (Slovenko, 2011; 2009).
A final concept critical to this discussion is whether the defendant is competent to stand trial and refers to the accused’s mental
state at the time of psychiatric examination after arrest and before going to trial. To be deemed competent, federal law dictates that
the defendant must have a rational and factual understanding of the proceedings and be able to rationally consult with counsel when
presenting their defense (Mossman et al., 2007; Fitch, 2007). This condition guarantees criminal and civil rights and ensures the
accused understands what is going on during the trial and can aid in their defense. If they are not fit or competent, then they can be
hospitalized until their mental state improves.

Key Takeaways
You should have learned the following in this section:
Forensic psychology is when clinical psychology is applied to the legal arena in terms of assessment, treatment, and evaluation,
though it can include research from other subfields to include cognitive and social psychology.
Civil commitment occurs when a person acts in potentially dangerous ways to themselves or others and can be initiated by the
person or the government.
Dangerousness is defined as the person’s capacity of harming themselves or others and implies physical harm but not
necessarily psychological abuse or the destruction of property.
Criminal commitment occurs when a person is accused of a crime but found to be mentally unstable.
Several rules or tests have been attempted to determine if a person is responsible for their actions at the time a crime was
committed. These include the M’Naghten rule, irresistible impulse test, Durham test, and the American Law Institute standard.

 Review Questions
1. Describe the subfield of forensic psychology.
2. What is civil commitment and what criteria is used when establishing its need?
3. What does the concept of dangerousness mean?
4. What is criminal commitment?

15.1.3 https://socialsci.libretexts.org/@go/page/161500
 5. Outline the various rules/tests used to determine if someone is responsible for their actions at the time of a crime.
6. Contrast the insanity plea with the concept of being competent to stand trial.

This page titled 15.1: Legal Issues Related to Mental Illness is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or
curated by Alexis Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed
edit history is available upon request.

15.1.4 https://socialsci.libretexts.org/@go/page/161500
15.2: Patient’s Rights
 Learning Objectives
Describe rights patients with mental illness have and identify key court cases.

The following are several rights that patients with mental illness have. They include:
Right to Treatment – In the 1966 case of Rouse v. Cameron, the D.C. District court said that the right to treatment is a
constitutional right, and failure to provide resources cannot be justified due to insufficient resources. In the 1972 case of Wyatt
v. Stickney, a federal court ruled that the state of Alabama was constitutionally obligated to provide all people who were
committed to institutions with adequate treatment and had to offer more therapists, privacy, exercise, social interactions, and
better living conditions for patients. In the case of O’Connor v. Donaldson (1975), the court ruled that patient’s cases had to be
reviewed periodically to see if they could be released. As well, if they are not a danger and are able to survive on their own or
with help from family or friends, that they be released.
Right to Refuse Treatment – As patients have the right to request treatment, they too have the right to refuse treatment such as
biological treatment, psychotropic medications (Riggins v. Nevada, 1992), and electroconvulsive therapy.
Right to Less Restrictive Treatment – In Dixon v. Weinberger (1975), a U.S. District Court ruled that individuals have a right
to receive treatment in facilities less restrictive than mental institutions. The only patients who can be committed to hospitals
are those unable to care for themselves.
Right to Live in a Community – The 1974 U.S. District Court case, Staff v. Miller, ruled that state mental hospital patients had
a right to live in adult homes in their communities.

Key Takeaways
You should have learned the following in this section:
Patients with a mental illness have a right to treatment, to refuse treatment, to have less restrictive treatment, and to live in a
community.

 Review Questions
1. What rights do patients with mental illness have and what court cases were pivotal to their establishment?

This page titled 15.2: Patient’s Rights is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Alexis Bridley
and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available
upon request.

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15.3: The Therapist-Client Relationship
 Learning Objectives
Describe three concerns related to the therapist-client relationship.

Three concerns are of paramount importance in terms of the therapist-client relationship. These include the following:
Confidentiality – As you might have learned in your introductory psychology course, confidentiality guarantees that
information about you is not disseminated without your consent. This applies to students participating in research studies as
well as patients seeing a therapist.
Privileged communication – Confidentiality is an ethical principle while privileged communication is a legal one, and states
that confidential communications cannot be disseminated without the patient’s permission. There are a few exceptions to this
which include the client being younger than 16, when they are a dependent elderly person and a victim of a crime, or when the
patient is a danger to him or herself or others, to name a few.
Duty to Warn – In the 1976 Tarasoff v. the Board of Regents of the University of California ruling, the California Supreme
Court said that a patient’s right to confidentiality ends when there is a danger to the public, and that if a therapist determines
that such a danger exists, they are obligated to warn the potential victim. Tatiana Tarasoff, a student at UC, was stabbed to death
by graduate student, Prosenjit Poddar in 1969, when she rejected his romantic overtures, and despite warnings by Poddar’s
therapist that he was an imminent threat. The case highlights the fact that therapists have a legal and ethical obligation to their
clients but, at the same time, a legal obligation to society. How exactly should they balance these competing obligations,
especially when they are vague? The 1980 case of Thompson v. County of Alameda ruled that a therapist does not have a duty to
warn if the threat is nonspecific.

Key Takeaways
You should have learned the following in this section:
There are three concerns which are important where the therapist-client relationship is concerned – confidentiality, privileged
communication, and the duty to warn.

 Review Questions
1. What are the three concerns related to the therapist-client relationship? Describe each and state any relevant court rulings
relevant to them.

Check This Out

Can you play video games so much, that it becomes addictive? Does this mean that it is a diagnosable mental illness to be listed in
the DSM 5-TR? Currently, the disorder is only listed in the DSM 5-TR as a condition for further study and is called internet
gaming disorder. It is thought to include symptoms such as:
Preoccupation with Internet games
Withdrawal symptoms when not playing Internet games
The person has tried to stop or curb playing Internet games, but has failed to do so
The need to spend increasing amounts of time engage in Internet gaming
A person has had continued overuse of Internet games even with the knowledge of how much they impact a person’s life
The person uses Internet games to relieve anxiety or guilt or to escape
Loss of interests in previous hobbies and entertainment except for internet gaming
Interestingly, the DSM-5-TR says the mean prevalence of 12-month Internet gaming disorder is approximately 4.7% across
multiple countries and is similar in Asian and Western countries. It is more common in males than females. It is comorbid with
major depressive disorder, OCD, and ADHD.
And, the ICD now includes gaming disorder in its 11th edition.
For more on this “disorder,” check out the following articles:

15.3.1 https://socialsci.libretexts.org/@go/page/161502
 Psychology Today – https://www.psychologytoday.com/us/blog/here-there-and-everywhere/201407/internet-gaming-disorder-
in-dsm-5
The Cognitive Psychology of Internet Gaming Disorder (2014 article in Clinical Psychology Review) –
www.sciencedirect.com/science/article/pii/S0272735814000658
CNN – https://www.cnn.com/2017/12/27/health/video-game-disorder-who/index.html
Huffington Post – https://www.huffingtonpost.com/christopher-j-ferguson/the-muddled-science-of-internet-gaming-
disorder_b_9405478.html
WHO – www.who.int/features/qa/gaming-disorder/en/
What do you think?
Module Recap
And that’s it. Our final module explored some concepts that transcend any one mental disorder but affect people with mental illness
in general. This included civil and criminal commitment and issues such as NGRI or the insanity plea, what makes someone
dangerous and what we should do about it, and determining competency to stand trial. We then moved to patient rights, such as the
right to treatment and, conversely, the right to refuse treatment. Finally, we ended by discussing the patient-therapist relationship
and specifically, when the patient’s right to confidentiality and privileged communication ends, and the therapist has a moral and
legal obligation to warn. We hope you find these topics interesting and explore the issues further through the links that were
provided and peer-reviewed articles that were cited.

This page titled 15.3: The Therapist-Client Relationship is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated
by Alexis Bridley and Lee W. Daffin Jr. via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit
history is available upon request.

15.3.2 https://socialsci.libretexts.org/@go/page/161502
Index
S
scientific method
1.5: Research Methods in Psychopathology
Glossary
Abnormal behavior – behavior that Amygdala – The part of the brain begin to feel as though they are
involves a combination of personal responsible for evaluating sensory inadequate or helpless in a given situation
distress, psychological dysfunction, information and quickly determining its Autonomic nervous system - Regulates
deviance from social norms, emotional importance functioning of blood vessels, glands, and
dangerousness to self and others, and Anal Stage – Lasting from 2-3 years, the internal organs such as the bladder,
costliness to society libido is focused on the anus as toilet stomach, and heart; It consists of
Abnormal psychology – The scientific training occurs sympathetic and parasympathetic nervous
study of abnormal behavior, with the Anhedonia - Inability to experience systems
intent to be able to reliably predict, pleasure Avoidant personality disorder - Display
explain, diagnose, identify the causes of, a pervasive pattern of social anxiety due
Anorexia Nervosa – An eating disorder
and treat maladaptive behavior to feelings of inadequacy and increased
characterized by the restriction of energy
sensitivity to negative evaluations
Absolute refractory period - After the intake relative to requirements, leading to
neuron fires it will not fire again no a significantly low body weight in the Avolition - Lack of motivation of goal-
matter how much stimulation it receives context of age, sex, developmental directed behavior
Acceptance techniques – A cognitive trajectory, and physical health; intense Axon - Sends signals/information to
therapy used to reduce a client’s worry fear of gaining weight or of becoming fat, neighboring neurons
and anxiety or persistent behavior that interferes with
weight gain, despite significantly low Axon terminals - The end of the axon
Action potential – When the neuron weight; and disturbance in the way in where the electrical impulse becomes a
depolarizes and fires which one’s body weight or shape is chemical message and is passed to an
Acute stress disorder - Though very experienced, undue influence of body adjacent neuron
similar to PTSD, symptoms must be weight or shape on self-evaluation, or Behavior modification - The process of
present from 3 days to 1 month following persistent lack of recognition of the changing behavior
exposure to one or more traumatic events seriousness of the current low body
Behavioral assessment - The
weight
Adjustment disorder - Occurs following measurement of a target behavior
an identifiable stressor within the past 3 Antecedents - The environmental events
Behaviors - What the person does, says,
months; stressor can be a single event or stimuli that trigger a behavior
thinks/feels
(loss of job) or a series of multiple Antisocial personality disorder –
stressors (marital discord that ends in a Binge-Eating Disorder (BED) – An
Characterized by the persistent pattern of
divorce); there is not a set of specific eating disorder characterized by recurrent
disregard for, and violation of, the rights
symptoms an individual must meet for episodes of binge eating associated with:
of others
diagnosis, rather, the symptoms must be significant distress regarding binge eating
significant enough that they impair social, Apathy - General lack of interest behaviors; binge eating occurring, on
occupational, or other important areas of Asociality - Lack of interest in social average, at least once a week for 3
functioning relationships months; and binge eating behaviors are
not associated with compensatory
Adrenal glands - Located on top of the Asylums - Places of refuge for the behaviors such as that in bulimia nervosa
kidneys, and which release cortisol to mentally ill where they could receive care
help the body deal with stress Biological Model – Includes genetics,
Attribution theory - The idea that people chemical imbalances in the brain, the
Affective flattening - Reduction in are motivated to explain their own and functioning of the nervous system, etc.
emotional expression; reduced display of other people’s behavior by attributing
emotional expression causes of that behavior to personal Bipolar Disorder I – A mood disorder
reasons or dispositional factors that are in characterized by a least one manic
Agoraphobia - When a person
the person themselves or linked to some episode and the symptoms are not
experiences fear specific to leaving their
trait they have; or situational factors that explained by a personality disorder
home and traveling to public places
are linked to something outside the Bipolar Disorder II – A mood disorder
All-or-nothing principle – The neuron person characterized by having at least one
either hits -55mV and fires or it does not hypomanic episode and at least one major
Automatic thoughts - The constant
Alogia - Poverty of speech or speech stream of negative thoughts, also leads to depressive episode, never having had a
content symptoms of depression as individuals manic episode, and the symptoms are not
better explained by a personality disorder;
Symptoms cause clinically significant Client-centered therapy - Stated that the Confounding variables - Variables not
distress or impairment in daily humanistic therapist should be warm, originally part of the research design but
functioning understanding, supportive, respectful, and contribute to the results in a meaningful
Body Dysmorphic Disorder (BDD) - is accepting of his/her clients way
an obsessive disorder, the focus of the Clinical assessment – The collecting of Consciousness – According to Freud, the
obsessions being on perceived defects or information and drawing conclusions level of personality that is the seat of our
flaws in the person’s physical appearance through the use of observation, awareness
psychological tests, neurological tests,
Borderline personality disorder - Consequences - The outcome of a
and interviews to determine what the
Display a pervasive pattern of instability behavior that either encourages it to be
client’s problem is and what symptoms
in interpersonal relationships, self-image, made again in the future or discourages
he/she is presenting with
affect, and instability its future occurrence
Bulimia Nervosa – An eating disorder Clinical description - Includes Contingencies - When one thing occurs
characterized by recurrent episodes of information about the thoughts, feelings, due to another
binge eating, recurrent compensatory and behaviors that constitute that mental
disorder Control group – The group in an
behaviors to prevent weight gain, and the
experiment that does not receive the
over-evaluation of shape and weight; the Clinical diagnosis - The process of using
treatment or is not manipulated
binge eating and compensatory behaviors assessment data to determine if the
both occur, on average, at least once a pattern of symptoms the person presents Conversion Disorder – A somatic
week for 3 months and these behaviors do with is consistent with the diagnostic symptom and related disorders
not occur exclusively during an episode criteria for a specific mental disorder set characterized by at least one voluntary
of anorexia nervosa forth in an established classification motor or sensory dysfunction, lack of
system such as the DSM-5 or ICD-10 medical compatibility between symptom
Catatonic behavior - The decrease or and neurological/medical condition,
even lack of reactivity to the environment Clinical interview - A face-to-face symptom(s) not better explained by
Central nervous system (CNS) - The encounter between a mental health another medical or mental disorder, and
control center for the nervous system professional and a patient in which the causes clinically significant distress or
which receives, processes, interprets, and former observes the latter and gathers impairment in daily functioning
stores incoming sensory information data about the person’s behavior,
attitudes, current situation, personality, Cortisol - A hormone released as a stress
Cerebellum – The part of the brain and life history response
involved in our sense of balance and for
Cognitive coping skills training - Counterconditioning - The reversal of
coordinating the body’s muscles so that
Teaches social skills, communication, and previous learning
movement is smooth and precise;
Involved in the learning of certain kinds assertiveness through direct instruction, Courtesy stigma - When stigma affects
of simple responses and acquired reflexes role playing, and modeling people associated with the person with a
Cognitive restructuring - Also called mental disorder
Chronic traumatic encephalopathy
rational restructuring, in which Course – The particular pattern a
(CTE) - A progressive, degenerative
maladaptive cognitions are replaced with disorder displays
condition due to repeated head trauma
more adaptive ones
Civil commitment - When individuals Criminal commitment - When people
with a mental illness behave in erratic or Comorbidity - When two or more mental are accused of crimes but found to be
potentially dangerous ways, it is disorders are occurring at the same time mentally unstable, they are usually sent to
responsibility of the government to place and in the same person a mental health institution for treatment
the individual in involuntary commitment Compulsions - Repetitive behaviors or Critical thinking - Our ability to assess
in a hospital or mental health facility to mental acts that an individual performs in claims made by others and make
protect the individual response to an obsession objective judgments that are independent
Classification - The way in which we Concussion - Occurs when there is a of emotion and anecdote and based on
organize or categorize things significant blow to the head, followed by hard evidence, and required to be a
changes in brain functioning scientist
Classification systems -Provide mental
health professionals with an agreed upon Conditioning - A type of associative Cross-sectional validity – When a
list of disorders falling in distinct learning, occurs which two events are behavior made in one environment
categories for which there are clear linked happens in other environments as well
descriptions and criteria for making a Culture - The totality of socially
diagnosis transmitted behaviors, customs, values,
technology, attitudes, beliefs, art, and Depressant substances - Such as associated with the reward mechanism in
other products that are particular to a alcohol, sedative-hypnotic drugs, and the brain
group, and determines what is normal opioids, are known to have a depressing, Dream analysis – In psychoanalytic
Culture-sensitive therapies – A or inhibiting effect on one’s central theory, is an attempt to understand a
sociocultural therapies that include nervous system; therefore, they are often person’s inner most wishes as expressed
increasing the therapist’s awareness of used to alleviate tension and stress in their dreams
cultural values, hardships, stressors, Derealization - Include feelings of
Dysfunction – Includes “clinically
and/or prejudices faced by their client; the unreality or detachment from the world—
significant disturbance in an individual’s
identification of suppressed anger and whether it be individuals, objects, or their
cognition, emotion regulation, or
pain; and raising the client’s self-worth surroundings
behavior that reflects a dysfunction in the
Cyclothymic disorder – A mood Descriptive statistics – Statistics which psychological, biological, or
disorder characterized by hypomanic provide a means of summarizing or developmental processes underlying
symptoms and mild depressive symptoms describing data, and presenting the data in mental functioning” (APA, 2013)
(i.e. do not fully meet criteria for a a usable form Ego – According to Freud, the part of
depressive episode) Deviance - A move away from what is personality that attempts to mediate the
Dangerousness - When behavior normal, or the mean, and so is behavior desires of the id against the demands of
represents a threat to the safety of the that occurs infrequently reality, and eventually the moral
person or others limitations or guidelines of the superego
Displacement – When we satisfy an
Degenerative - Meaning the symptoms impulse with a different object because Ego-defense mechanisms – According to
and cognitive deficits become worse focusing on the primary object may get us Freud, they protect us from the pain
overtime in trouble created by balancing both the will of the
Deinstitutionalization - The release of Dissociative disorders - A group of id and the superego, but are considered
patients from mental health facilities disorders categorized by symptoms of maladaptive if they are misused and
disruption in consciousness, memory, become our primary way of dealing with
Delirium - Characterized by a significant stress
disturbance in attention or awareness and identify, emotion, perception, motor
cognitive performance that is control, or behavior Enactive learning - Learning by doing
significantly altered from one’s usual Dissociative Amnesia Disorder - Endorphins – Neurotransmitters
behavior Dissociative disorder identified by the involved in reducing pain and making the
inability to recall important person calm and happy
Dementia - A major decline in cognition
autobiographical information
and self-help skills due to a Eros - Our life instincts which are
neurocognitive disorder Dissociative fugue - Considered to be the manifested through the libido and are the
Dendrites - Receives information from most extreme type of dissociative creative forces that sustain life
neighboring neurons and look like little amnesia where not only does an Erotomanic delusion - Occurs when an
trees individual forget personal information, individual reports a delusion of another
but they also flee to a different location person being in love with them
Denial – Sometimes life is so hard all we
Dissociative Identity Disorder –
can do is deny how bad it is Enzymatic degradation - When
Dissociative disorder characterized by the
Dependent personality disorder - enzymes are used to destroy excess
presence of two or more distinct
Characterized by pervasive and excessive neurotransmitters in the synaptic space
personality states which causes
need to be taken care of by others discontinuity of self; difficulty recalling Epidemiological study - A special from
Dependent variable (DV) – In an everyday events, personal information, or of correlational research in which the
experiment, the variable that is measured traumatic events due to lapse of memory; prevalence and incidence of a disorder in
and causes significant distress or a specific population are measured
Depersonalization - Defined as a feeling
impairment in daily functioning Epidemiology - The scientific study of
of unreality or detachment from oneself
Distress – When a person experiences a the frequency and causes of diseases and
Depolarized – When ion gated channels other health-related states in specific
disabling condition that can affect social,
open allowing positively charged Sodium populations such as a school,
occupational, or other domains of life and
ions to enter; This shifts the polarity to neighborhood, a city, country, and the
takes psychological and/or physical pain
positive on the inside and negative world
outside Dopamine – Neurotransmitter which
controls voluntary movements and is Etiology - The cause of the disorder
Existential perspective - This approach Frontotemporal Lobar Degeneration memories so that we can accurately
stresses the need for people to continually (FTLD) - Causes progressive declines in navigate through our environment and
re-create themselves and be self-aware, language or behavior due to the helps us to form new memories about
acknowledges that anxiety is a normal degeneration in the frontal and temporal facts and events
part of life, focuses on free will and self- lobes of the brain; symptoms include Histrionic personality disorder -
determination, emphasizes that each significant changes in behavior and/or Addresses the pervasive and excessive
person has a unique identity known only language need for emotion and attention from
through relationships and the search for Fundamental attribution error - Occurs others; these individuals are often
meaning, and finally, that we develop to when we automatically assume a uncomfortable in social settings unless
our maximum potential dispositional reason for another person’s they are the center of attention
Exorcism – A procedure in which evil actions and ignore situational factor
Hoarding – Focused on the persistent
spirts were cast out through prayer,
GABA – Neurotransmitter responsible over-accumulation of possessions
magic, flogging, starvation, having the
for blocking the signals of excitatory Hypertension - -Chronically elevated
person ingest horrible tasting drinks, or
neurotransmitters responsible for anxiety blood pressure
noise-making
and panic
Experimental group – In an experiment, Hypomanic episode - Persistently
Gaps - Holes in the literature of a given
the group that receives the treatment or elevated, expansive, or irritable mood;
area
manipulation May present as persistent increased
Generalizability – Begin able to apply activity or energy; Symptoms last at least
Extinction - When something that we do,
your findings for the sample to the 4 consecutive days and present most of
say, think/feel has not been reinforced for
population the day, nearly every day; Includes at
some time
Generalized amnesia – A type of least three of the following: inflated self-
Factitious disorder - Commonly referred dissociative amnesia in which the person esteem or grandiosity, decreased need for
to as Munchausen syndrome, is has a complete loss of memory of their sleep, more talkative or pressured speech,
characterized by intentional falsification entire life history, including their own flight of ideas, distractibility, increase in
of medical or psychological symptoms of identity goal-directed activity or psychomotor
oneself or another, with the overall agitation, or excessive involvement in
intention of deception Generalized anxiety disorder - The activities that have a high potential for
most common anxiety disorder painful consequences
Fixed Interval schedule (FI) – With a FI characterized by a global and persistent
schedule, you will reinforce after some feeling of anxiety Hypothalamic-pituitary-adrenal (HPA)
set amount of time axis - Involved in the fear producing
Genital Stage – Beginning at puberty, response and may be involved in the
Fixed Ratio schedule (FR) – With this
sexual impulses reawaken and unfulfilled development of trauma symptoms
schedule, we reinforce some set number
desires from infancy and childhood can
of responses Hypothalamus – The part of the brain
be satisfied during lovemaking
involved in drives associated with the
Flooding - Exposing the person to the Glial cells - The support cells in the survival of both the individual and the
maximum level of stimulus and as nervous system that serve five main species; It regulates temperature by
nothing aversive occurs, the link between functions: as a glue and hold the neuron triggering sweating or shivering, and
CS and UCS producing the CR of fear in place, form the myelin sheath, provide controls the complex operations of the
should break, leaving the person unafraid nourishment for the cell, remove waste autonomic nervous system
Forensic psychology/psychiatry - When products, and protect the neuron from
clinical psychology is applied to legal harmful substances Hypothesis – A specific, testable
arena in terms of assessment, treatment, prediction
Glutamate – Neurotransmitter associated
and evaluation Humanism - The worldview that
with learning and memory
emphasizes human welfare and the
Free association – In psychoanalytic Grandiose delusion - Involves the uniqueness of the individual
theory, this technique involves the patient conviction of having a great talent or
describing whatever comes to mind insight Id – According to Freud, is the impulsive
during the session part of personality that expresses our
Habituation - When we simply stop sexual and aggressive instincts
Frontal lobe – Part of the cerebrum that responding to repetitive and harmless
contains the motor cortex which issues stimuli in our environment Ideas of reference - The belief that
orders to the muscles of the body that unrelated events pertain to them in a
produce voluntary movement Hippocampus - Our “gateway” to particular and unusual way
memory; Allows us to form spatial
Identification – This is when we find favorable consequence, in the future directed activity or psychomotor
someone who has found a socially when the same stimulus is present, we agitation, or excessive involvement in
acceptable way to satisfy their will be more likely to make the response activities that have a high potential for
unconscious wishes and desires and we again, expecting the same favorable painful consequences
model that behavior consequence Manifest content - The person’s actual
Illness anxiety disorder - Previously Learning - Any relatively permanent retelling of the dream
known as hypochondriasis, involves the change in behavior due to experience
Mass madness – or Group hysteria;
excessive preoccupation with having or
Libido - The psychic energy that drives a When large numbers of people display
acquiring a serious medical illness
person to pleasurable thoughts and similar symptoms and false beliefs; a
Incidence - The number of new cases in a behaviors term used during the Middle Ages
population over a specific period of time Lifetime prevalence - Indicates the Medulla – The part of the brain that
Independent variable (IV) – In an proportion of a population that has had regulates breathing, heart rate, and blood
experiment, the variable that is the characteristic at any time during their pressure
manipulated lives
Melatonin - A hormone released when it
Inferential statistics – Statistics which Literature review - When we conduct a is dark outside to assist with the transition
allow for the analysis of two or more sets literature search through our university to sleep
of numerical data library or a search engine such as Google Mental disorders - Characterized by
Insomnia - The difficult falling or Scholar to see what questions have been psychological dysfunction which causes
staying asleep investigated already and what answers physical and/or psychological distress or
have been found impaired functioning and is not an
Intellectualization- When we avoid
emotion by focusing on intellectual Localized amnesia - The most common expected behavior according to societal or
aspects of a situation type of dissociative amnesia, is the cultural standards
inability to recall events during a specific Mental health epidemiology - Refers to
Intelligence tests - Used to determine the period of time the occurrence of mental disorders in a
patient’s level of cognitive functioning
Major Depressive Disorder – A mood population
and consists of a series of tasks asking the
disorder characterized by depressed mood
patient to use both verbal and nonverbal Mental hygiene movement - An idea
most of the day or decreased interest or
skills arising in the late 18th century to the
pleasure in all or most activities most of
Ions - Charged particles found both early 19th century with the fall of the
the day, along with insomnia or
inside and outside the neuron moral treatment movement, it focused on
hypersomnia, fatigue, feelings of
the physical well-being of patients
Irritable bowel syndrome (IBS) - A worthlessness, or difficulty concentrating
to name a few symptoms; symptoms Mental status examination - Used to
chronic, functional disorder of the
occur during a two week period organize the information collected during
gastrointestinal tract including symptoms
the clinical interview and systematically
such as abdominal pain and extreme Major neurocognitive disorder – evaluates the patient through a series of
bowel habits (diarrhea and/or Individuals with the disorder show questions assessing appearance and
constipation) significant decline in both overall behavior to include grooming and body
Jealous delusion - Revolves around the cognitive functioning as well as the posture, thought processes and content to
conviction that one’s spouse or partner ability to independently meet the include disorganized speech or thought
is/has been unfaithful demands of daily living such as paying and false beliefs, mood and affect such
bills, taking medications, or caring for that whether the person feels hopeless or
Laboratory observation - A research
oneself elated, intellectual functioning to include
method in which the scientist observes
people or animals in a laboratory setting Manic episode - Persistent elevated, speech and memory, and awareness of
expansive, or irritable mood. May present surroundings to include where the person
Latency Stage – From 6-12 years of age,
as persistent increased goal-directed is and what the day and time are
children lose interest in sexual behavior
activity or energy; Symptoms last at least
and boys play with boys and girls with Migraine headaches - Headaches
1 week and present most of the day,
girls explained by a throbbing pain localized to
nearly every day; includes three of the
one side of the head and often
Latent content - The hidden or symbolic following: inflated self-esteem or
accompanied by nausea, vomiting,
meaning of a dream grandiosity, decreased need for sleep,
sensitivity to light, and vertigo
Law of effect (Thorndike, 1905) - The more talkative or pressured speech, flight
of ideas, distractibility, increase in goal- Model - A representation or imitation of
idea that if our behavior produces a
an object
Modeling - Techniques used to change Nerves - A group of axons bundled Paranoid personality disorder -
behavior by having subjects observe a together like wires in an electrical cable Characterized by a marked distrust or
model in a situation that usually causes Neurological tests - Used to diagnose suspicion of others
them some anxiety cognitive impairments caused by brain Parasympathetic nervous system – The
Moral treatment movement – An idea damage due to tumors, infections, or head part of the autonomic nervous system that
arising in Europe in the late 18th century injury; or changes in brain activity calms the body after sympathetic nervous
and then in the United States in the early system arousal
Neuron - The fundamental unit of the
19th century, it stressed affording the
nervous system Parietal lobe – The part of the cerebrum
mentally ill respect, moral guidance, and
Neurotransmitter – When the actual that contains the somatosensory cortex
humane treatment, all while considering
code passes from one neuron to another in and receives information about pressure,
their individual, social, and occupational
a chemical form pain, touch, and temperature from sense
needs
receptors in the skin, muscles, joints,
Myelin sheath - The white, fatty Nomenclature – A naming system internal organs, and taste buds
covering which: 1) provides insulation so Norepinephrine – Neurotransmitter Peripheral nervous system - Consists of
that signals from adjacent neurons do not which increases the heart rate and blood everything outside the brain and spinal
affect one another and, 2) increases the pressure and regulates mood cord; It handles the CNS’s input and
speed at which signals are transmitted output and divides into the somatic and
Nucleus - The control center of the body
Multicultural psychology – The area of autonomic nervous systems
Observation – Observing others either
psychology which attempts to understand
naturalistically or in a controlled Period prevalence - Indicates the
how the various groups, whether defined
environment proportion of a population that has the
by race, culture, or gender, differ from
characteristic at any point during a given
one another Observational learning - When we learn
period of time, typically the past year
by observing the world around us
Multi-dimensional model – An Persecutory delusion - Involves the
explanation for mental illness that Obsessions - Repetitive and persistent
individual believing that they are being
integrates multiple causes of thoughts, urges, or images
conspired against, spied on, followed,
psychopathology and affirms that each Obsessive compulsive disorder - More poisoned or drugged, maliciously
cause comes to affect other causes over commonly known as OCD, the disorder maligned, harassed, or obstructed in
time requires the presence of both obsessions pursuit of their long-term goals
Narcissistic personality disorder - and compulsions
Persistent Depressive Disorder – A
Individuals display a pattern of Obsessive-Compulsive personality mood disorder characterized by poor
grandiosity along with a lack of empathy disorder - Defined by an individual’s appetite or overeating, insomnia or
for others preoccupation with orderliness, hypersomnia, low self-esteem, low
Naturalistic observation - A research perfectionism, and ability to control energy, and feelings of hopelessness
method in which the scientist studies situations that they lose flexibility, lasting most of the day, for more days
human or animal behavior in its natural openness, and efficiency in everyday life than not, for at least 2 years
environment which could include the Operant conditioning - A type of Personality disorders - Have four
home, school, or a forest associate learning which focuses on defining features which include distorted
Negative Punishment (NP) – This is consequences that follow a response or thinking patterns, problematic emotional
when something good is taken away or behavior that we make (anything we do, responses, over- or under- regulated
subtracted making a behavior less likely say, or think/feel) and whether it makes a impulse control, and interpersonal
in the future behavior more or less likely to occur difficulties
Negative Reinforcement (NR) – This is Oral Stage – Beginning at birth and Personality inventories - Ask clients to
when something bad or aversive is taken lasting to 24 months, the libido is focused state whether each item in a long list of
away or subtracted due to your actions, on the mouth and sexual tension is statements applies to them, and could ask
making it that you will be more likely to relieved by sucking and swallowing at about feelings, behaviors, or beliefs
make the same behavior in the future first, and then later by chewing and biting
Personality traits - Enduring patterns of
when the same stimuli presents itself as baby teeth come in
perceiving, relating to, and thinking about
Negative symptoms – The inability or Panic disorder - When an individual the environment and oneself that are
decreased ability to initiate actions, experiences recurrent panic attacks exhibited in a wide range of social and
speech, expressed emotion, or to feel consisting of physical and cognitive personality contexts
pleasure symptoms
Phallic Stage – Occurring from about age our sensations, thoughts, memories, and Psychosis - A loss of contact with reality
3 to 5-6 years, the libido is focused on the feelings Public stigma – When members of a
genitals and children develop an Presenting problem – The issue the society endorse negative stereotypes of
attachment to the parent of the opposite person displays people with a mental disorder and
sex and are jealous of the same sex parent discriminate against them
Prevalence - The percentage of people in
Pineal gland - Helps regulate the sleep-
a population that has a mental disorder or Punishment – Due to the consequence, a
wake cycle
can be viewed as the number of cases per behavior/response is less likely to occur
Pituitary gland - The “master gland” some number of people in the future
which regulates other endocrine glands; It Prevention – When we identify the Random assignment – When
influences blood pressure, thirst, factors that cause specific mental health participants have an equal chance of
contractions of the uterus during issues and implement interventions to being placed in the control or
childbirth, milk production, sexual stop them from happening, or at least experimental group
behavior and interest, body growth, the minimize their deleterious effects
amount of water in the body’s cells, and Rape - Forced sexual intercourse or other
other functions as well Prognosis - The anticipated course the sexual act committed without an
mental disorder will take individual’s consent
Placebo - Or a sugar pill made to look
exactly like the pill given to the Projection – When we attribute Rationalization – When we offer well
experimental group threatening desires or unacceptable thought out reasons for why we did what
motives to others we did but in reality these are not the real
Point prevalence - Indicates the reason
proportion of a population that has the Projective tests – A psychological test
characteristic at a specific point in time which consists of simple ambiguous Reaction formation – When an impulse
stimuli that can elicit an unlimited is repressed and then expressed by its
Polarized – When the neuron has a number of responses opposite
negative charge inside and a positive
charge outside Psychoanalysis - Psychoanalytic therapy Reactivity – When the observed changes
used to understand the personality of a behavior due to realizing they are being
Pons – The part of the brain that acts as a
therapist’s patient and to expose repressed observed
bridge connecting the cerebellum and
material Receptor sites – Locations where
medulla and helps to transfer messages
between different parts of the brain and Psychological debriefing - A type of neurotransmitters bind to
spinal cord crisis intervention that requires
Reinforcement – Due to the
individuals who have recently
Posttraumatic stress disorder - More consequence, a behavior/response is more
experienced a traumatic event to discuss
commonly known as PTSD, is identified likely to occur in the future
or process their thoughts and feelings
by the development of physiological, related to the traumatic event, typically Reinforcement schedule - The rule for
psychological, and emotional symptoms within 72 hours of the event determining when and how often we will
following exposure to a traumatic even reinforce a desired behavior
Psychological model – includes learning,
Positive psychology – The position in Relative refractory period - After a
personality, stress, cognition, self-
psychology that holds a more positive short period of time, the neuron can fire
efficacy, and early life experiences and
conception of human potential and nature again, but needs greater than normal
how they affect mental illness
Positive Punishment (PP) – If something levels of stimulation to do so
Psychological or psychogenic
bad or aversive is given or added, then the perspective - States that emotional or Regression – When we move from a
behavior is less likely to occur in the psychological factors are the cause of mature behavior to one that is infantile in
future mental disorders and represented a nature
Positive Reinforcement (PR) – If challenge to the biological perspective Reliable – When our assessment is
something good is given or added, then Psychological tests - Used to assess the consistent
the behavior is more likely to occur in the client’s personality, social skills, Replication - Repeating a study to
future cognitive abilities, emotions, behavioral confirm its results
Positive symptoms - Symptoms that are responses, or interests and can be
Repolarization – When the Na channels
an over-exaggeration of normal brain administered either individually or to
close and Potassium channels open; K has
processes groups in paper or oral fashion
a positive charge and so the neuron
Preconscious – According to Freud, the Psychopathology - The scientific study becomes negative again on the inside and
level of personality that includes all of of psychological disorders positive on the outside, or polarizes
Repression – When unacceptable ideas, major mood episode—either a depressive Single-subject experimental design –
wishes, desires, or memories are blocked or manic episode When we have to focus on one individual
from consciousness Schizoid personality disorder - Displays in a study
Research design - Our plan of action of a persistent pattern of avoidance from Social anxiety disorder - Occurs when
how we will go about testing the social relationships along with a limited an individual experiences anxiety related
hypothesis range of emotion among social to social or performance situations, where
relationships there is the possibility that they will be
Resistance – According to
evaluated negatively
psychoanalytic theory, is the point during Schizophrenia – A mental disorder that
free association that the patient cannot or includes the presentation of at least two of Social cognition - The process of
will not proceed any further the following for at least one month: collecting and assessing information
Respondent conditioning (also called delusions, hallucinations, disorganized about others
classical or Pavlovian conditioning) - speech, disorganized/abnormal behavior, Social desirability - When a participant
Occurs when we link a previously neutral or negative symptom answers questions dishonestly so that
stimulus with a stimulus that is unlearned Schizophreniform Disorder – A mental he/she is seen in a more favorable light
or inborn disorder characterized by at least two of
Social norms - The stated and unstated
the following: delusions, hallucinations,
Respondent Discrimination – When the rules of society
disorganized speech,
CR is elicited by a single CS or a narrow Sociocultural Model – includes factors
disorganized/abnormal behavior, and/or
range of CSs such as one’s gender, religious
negative symptoms
Respondent Extinction – When the CS orientation, race, ethnicity, and culture
is no longer paired with the UCS Schizotypal personality disorder - that affect mental illness
Characterized by a range of impairment
Respondent Generalization – When a in social and interpersonal relationships Soma - The cell body
number of similar CSs or a broad range of due to discomfort in relationships, along Somatic delusion - Involves delusions
CSs elicit the same CR with odd cognitive and/or perceptual regarding bodily functions or sensations
Resting potential – When the neuron is distortions and eccentric behaviors
Somatic nervous system - Allows for
waiting to fire Scientific method - A systematic method voluntary movement by controlling the
Reticular formation – The part of the for gathering knowledge about the world skeletal muscles and carries sensory
brain responsible for alertness and around us information to the CNS
attention Sedative-Hypnotic drugs - More Somatic Symptom Disorder – A somatic
Reuptake reuptake - The process of the commonly known as anxiolytic drugs, symptom or related disorder characterized
presynaptic neuron taking up excess these drugs have a calming and relaxing by disproportionate and persistent
neurotransmitters in the synaptic space effect on individuals thoughts of the seriousness of the
for future use Selective amnesia - Is in a sense, a symptom, high levels of anxiety about the
Reversal or ABAB design – A study in component of localized amnesia in that symptom, and/or excessive time/energy
which the control is followed by the the individual can recall some, but not all, spent focused on the symptom
treatment, and then a return to control and of the details during a specific time period Specific phobia - Observed when an
second administration of the treatment Self-monitoring – When the person does individual experiences anxiety related to a
condition; builds replication in to the their own measuring and recording of the specific object or subject
design ABCs Spontaneous recovery – When the CS
Schema - A set of beliefs and Self-serving bias - When we attribute our elicits the CR after extinction has
expectations about a group of people, success to our own efforts (dispositional) occurred
presumed to apply to all members of the and our failures to outside causes Standardization – When we use clearly
group, and based on experience (situational) laid out rules, norms, and/or procedures
Self-stigma – When people with mental Sensitization - When our reactions are in the process of assessing client’s
illnesses internalize the negative increased due to a strong stimulus Statistical significance - An indication of
stereotypes and prejudice, and in turn, how confident we are that our results are
Serotonin – Neurotransmitter which
discriminate against themselves due to our manipulation or design and not
controls pain, sleep cycle, and digestion;
Schizoaffective disorder - Characterized leads to a stable mood and so low levels chance
by the psychotic symptoms included in leads to depression Stigma - When negative stereotyping,
criteria A of schizophrenia and a labeling, rejection, and loss of status
concurrent uninterrupted period of a
occur Substances - Any ingested materials that Threshold of excitation - -55mV or the
Stressors - Any event- either witnessed cause temporary cognitive, behavioral, amount of depolarization that must occur
firsthand, experienced personally or and/or physiological symptoms within the for a neuron to fire; It rises from -70mV
experienced by a close family member- individual to -55mV
that increases physical or psychological Superego - According to Freud, the part Thyroid gland – The endocrine gland
demands on an individual of personality which represents society’s which regulates the body’s rate of
expectations, moral standards, rules, and metabolism and so how energetic people
Sublimation – When we find a socially
represents our conscience are.
acceptable way to express a desire
Substance abuse - Occurs when an Sympathetic nervous system - Involved Tolerance - The need to continually
individual consumes the substance for an when a person is intensely aroused; It increase the amount of ingested substance
extended period of time, or has to ingest provides the strength to fight back or to Transference – In psychoanalytic theory,
large amounts of the substance to get the flee (fight-or-flight instinct) this technique involves patients
same effect a substance provided Synapse - The point where the code transfering to the therapist attitudes
previously passes from one neuron to another; he/she held during childhood
Consists of three parts – the axon of the
Substance Intoxication – A substance Trauma-focused cognitive-behavioral
sending neuron; the space in between
use disorder characterized by recent therapy (TF-CBT) - An adaptation of
called the synaptic space, gap, or cleft;
ingestion of substance, significant CBT, that utilizes both CBT techniques,
and the dendrite of the receiving neuron
behavioral or psychological changes as well as trauma sensitive principles to
immediately following the ingestion of Syndrome - Symptoms occurred address the trauma related symptoms
substance, physical and physiological regularly in clusters Treatment - Any procedure intended to
symptoms develop after ingestion of Target behavior - Whatever behavior we modify abnormal behavior into normal
substance, and changes in behavior not want to change and it can be in excess or behavior
attributable to a medical condition or needing to be reduced, or in a deficit state
other psychological disorder Trephination - In which a stone
and needing to be increased instrument known as a trephine was used
Substance Use Disorder – A substance Tension headaches - Often described as a to remove part of the skull, creating an
use disorder diagnosed when the dull, constant ache that is localized to one opening
individual presents with at least two part of the head/neck; however, it can co-
criteria to include: substance is consumed Trial and error learning - Making a
occur in multiple places at one time
in larger amounts over time, desire or response repeatedly if it leads to success
inability to reduce quantity of substance Thalamus – The major sensory relay Ulcers - Or painful sores in the stomach
use, cravings for substance use, use of the center for all senses but smell lining, occur when mucus from digestive
substance in potentially hazardous Thanatos - Our death instinct which is juices are reduced, thus allowing
situations, tolerance of substance use, and either directed inward as in the case of digestive acids to burn a hole into the
withdrawal, to name a few (11 total suicide and masochism or outward via stomach lining
criteria) hatred and aggression
Unconscious – According to Freud, the
Substance Withdrawal - A substance Thematic Apperception Test – A level of personality not available to us
use disorder characterized by cessation or projective test which asks the individual Uni-dimensional model – A single factor
reduction in substance that has been to write a complete story about each of 20 explanation for mental illness
previously used for a long or heavy cards shown to them and give details
period of time, physiological and/or about what led up to the scene depicted, Validity – When the test measures what it
psychological symptoms within a few what the characters are thinking, what says it measures
hours after cessation/reduction, they are doing, and what the outcome will Variable Interval schedule (VI) –
physiological and/or psychological be Reinforcing at some changing amount of
symptoms cause significant distress or time
Theory – A systematic explanation of a
impairment in functioning, and symptoms
phenomenon Variable Ratio schedule (VR) –
not attributable to a medical condition or
other psychological disorder Reinforcing some varying number of
responses
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