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WHAT IS MENTAL DISORDER? Distinguishing “normal” from “abnormal” is no simple task. Three classic symptoms suggest severe mental disorder: hallucinations, delusions, and extreme affective disturbances. Hallucinations are false sensory experiences, such as hearing nonexistent voices. Delusions are extreme disorders of thinking that involve persistent false beliefs. If you think you are the President of the United States (and you are not), you have a symptom of psychopathology.
Similarly, those whose affect (emotion) is, for no apparent reason, depressed, anxious, or manic???or those who seems to have no emotional response at all???have yet other signs of mental disorder. Beyond such signs of distress, the experts do not always agree, however. What is abnormal and what is not becomes a judgment call, a judgment made more difficult because no sharp boundary separates normal from abnormal thought and behavior. The medical model takes a “disease” view, while psychology sees mental disorder as an interaction of biological, cognitive, social, and other environmental factors.
Evolving Concepts of Mental Disorder In the ancient world, people assumed that supernatural powers were everywhere, accounting for good fortune, disease, and disaster???even for the rise and fall of nations. In about 400 BC, the Greek physician Hippocrates may have taken humanity’s first step toward a scientific view of mental disturbance when he declared that abnormal behavior has physical causes. He taught his disciples to interpret the symptoms of psychopathology as an imbalance among four body fluids called “humors”: blood, phlegm (mucus), black bile, and yellow bile.
Those with an excess of black bile, for example, were inclined to melancholy or depression, while those who had an abundance of blood were sanguine, or warmhearted. With this revolutionary idea, Hippocrates incorporated mental disorder into medicine, and his view influenced educated people in the Western world until the end of the Roman Empire. Then, in the Middle Ages, superstition eclipsed the Hippocratic model of mental disorder. Under the influence of the Church, physicians and clergy reverted to the old ways of explaining abnormality in terms of demons and witchcraft.
Even today some people hold the ancient ideas about spirit possession, witchcraft, and mental disturbance. THE MEDICAL MODEL In the latter part of the 18th century, the “illness” view that originated with Hippocrates reemerged with the rise of science. The resulting medical model held that mental disorders are diseases of the mind that, like ordinary physical diseases, have objective causes and require specific treatments. The new view of mental illness brought sweeping reforms that were implemented in “asylums” for the “insane. In this supportive atmosphere, many patients actually improved ???even thrived???on rest, contemplation, and simple but useful work. Modern psychologists think that the medical model has its own weaknesses. They point out that the assumption of “illness” leads to a doctor-knows-best approach in which the therapist takes all the responsibility for diagnosing the illness and prescribing treatment. The patient becomes a passive recipient of medication and advice, rather than an active treatment participant learning how to manage his or her thoughts and behaviors.
PSYCHOLOGICAL MODELS What do psychologists have to offer in place of the medical model? The psychological alternative gives equal footing to cognitive, environmental, and biological explanations. Like the medical model, this psychological perspective emerged most clearly at the end of the 18th century, helped along by the flamboyant work of Franz Anton Mesmer (1734???1815). Mesmer believed (incorrectly) that many disorders were caused by disruptions in the flow of a mysterious force that he called animal magnetism.
He unveiled several new techniques to study animal magnetism, including one originally called mesmerism, which we now call hypnosis. Sigmund Freud experimented with hypnosis. These experiments eventually led to Freud’s revolutionary idea that psychopathology arises from pressures originating in the unconscious mind. Eventually Freud abandoned hypnosis, replacing it with his “talking cure,” which he claimed to be a more effective system for revealing unconscious conflicts and for treating psychological disorders.
These days, most clinical psychologists have now turned to two other psychological perspectives: behaviorism and cognitive psychology???both of which have a solid base in scientific research. The Cognitive???Behavioral Approach A new understanding of psychopathology combines what were once the two warring camps of cognitive psychology and behaviorism. In brief, cognitive psychology looks inward, emphasizing mental processes. while behaviorism looks outward, emphasizing the influence of the environment.
A major shift in psychological thinking in recent years sees these two traditions as opposite sides of the same coin. The behavioral perspective tells us that abnormal behaviors can be acquired in the same fashion as healthy behaviors ??? through behavioral learning. This view focuses on our behavior and the environmental conditions, such as rewards and punishments, that maintain it. The cognitive perspective, the other half of the new cognitive???behavioral view, suggests that we must also consider how people perceive or think about themselves and their relations with other people.
Among the important cognitive variables are these: whether people believe they have control over events in their lives (an internal or external locus of control), how they cope with threat and stress, and whether they attribute behavior to situational or personal factors. The cognitive???behavioral approach, then, combines both the cognitive and behavioral perspectives. From this view, a fear of public speaking can be understood as a product of both behavioral and cognitive learning. Thus, the complete picture of the problem involves factors both inside and outside the person.
The Biopsychology of Madness Although most psychologists reject the medical model, they do not deny the influence of biology on thought and behavior. Modern biopsychology assumes that mental disturbances involve the biology of the brain or nervous system in some way, and this view is taking an increasingly prominent position. Many links between psychological disorders and specific brain abnormalities have been revealed by brain scanning techniques, such as PET scans and MRI. Such work has, for example, linked certain cases of violence with brain tumors located in the amygdala, a part of the limbic system associated with aggressive behavior.
Psychology also recognizes that drug therapies alleviate certain symptoms of psychological disorders An Interactionist View Psychologists today increasingly view psychopathology as the product of an interaction among biological, behavioral, and cognitive factors (Cowan, 1988). For example, a genetic predisposition may make a person vulnerable to depression by affecting neurotransmitter levels or hormone levels. At the same time, psychological or social stressors, such as the loss of a love or certain learned grief behaviors, may be required for the disorder to develop fully. Indicators of Abnormality ???Distress.
Does the individual show unusual or prolonged levels of unease or anxiety? ???Irrationality. Does the person act or talk in ways that are irrational or incomprehensible to others? A woman who converses with her long-dead sister, whose voice she hears in her head, is behaving irrationally. Likewise, behavior or emotional responses that are inappropriate to the situation, such as laughing at the scene of a tragedy, show irrational loss of contact with one’s social environment. ???Unpredictability. Does the individual behave erratically and inconsistently at different times or from one situation to another, as if experiencing a loss of control?
For example, a child who suddenly smashes a fragile toy with his fist for no apparent reason is behaving unpredictably. Similarly, a manager who treats employees compassionately one day and abusively the next is acting unpredictably. ???Unconventionality and undesirable behavior. Does the person behave in ways that are statistically rare and violate social norms of what is legally or morally acceptable or desirable? Being merely “unusual” is not a sign of abnormality. ???Observer discomfort. Does the person create discomfort in others by making them feel threatened or distressed?
Bullying behavior is abnormal on this count. So is the behavior of a stranger who sits down beside you in a restaurant and questions you loudly. ???Maladaptiveness. Does the person act in ways that interfere with his or her well-being or the needs of society? We can see this, for example, in someone who drinks so heavily that she or he cannot hold down a job or drive a car without endangering others. Is the presence of just one indicator enough to demonstrate abnormality? Clinicians are more confident in labeling behavior as “abnormal” when two or more of the six indicators are present.
The more extreme and prevalent the indicators are, the more confident psychologists can be about identifying an abnormal condition. In all, a bewildering 300-plus varieties of psychopathology are described in the Diagnostic and Statistical Manual of Mental Disorders (4th edition), known by clinicians and researchers as the DSM-IV (“DSM-four”), used by mental health professionals of all backgrounds to describe and diagnose psychopathology. HOW ARE MENTAL DISORDERS CLASSIFIED? What is the organizing pattern employed by the DSM-IV?
It groups nearly all recognized forms of psychopathology into categories, according to mental and behavioral symptoms, such as anxiety, depression, sexual problems, and substance abuse. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-IV, was published in 1994 by the American Psychiatric Association. Then, in 2000, that volume was given a midedition update, the DSM-IV-TR (TR means Text Revision). It offers practitioners a common and concise language for the description of mental disorders. It also contains criteria for diagnosing each of the more than 300 disorders it covers. Even though the manual was developed primarily by psychiatrists, its terminology has been adopted by clinicians of all stripes, including psychiatrists, psychologists, and social workers. In addition, most health insurance companies use DSM-IV standards in determining what treatments they will pay for???a fact that gives this manual enormous economic influence. The fourth edition of the DSM has brought with it some big changes. For example, it has banished the term neurosis from the official language of psychiatry. . In the DSM-IV, the term neurosis has been replaced by the term disorder A neurosis is now referred to as a neurotic disorder.
In contrast, a psychotic disorder or psychosis was previously thought to differ from neurosis in both the quality and severity of symptoms. A condition was designated as psychotic if it involved profound disturbances in perception, rational thinking or affect (emotion). Using previous editions of the DSM, a clinician would have been more likely to diagnose severe depression, for example, as “psychotic. ” In the DSM-IV, the term “psychotic” is restricted mainly to a loss of contact with reality, as is found in the schizophrenic disorders. Mood Disorders Emotionality is a normal part of our ability to interpret and adapt to our world.
However, when moods careen out of control, soaring to extreme elation or plunging to deep depression, the diagnosis will probably be one of the mood disorders. BIPOLAR DISORDER Wide swings of mood, unexplained by events in a person’s life, signify a form of mood disturbance, often called manic???depressive disorder. The DSM-IV calls it bipolar disorder. The alternating periods of mania (excessive elation or manic excitement) and the profound sadness of depression represent the two “poles. ” During the manic phase, the individual becomes euphoric, energetic, hyperactive, talkative, and emotionally wound tight like a spring.
Biologically speaking, however, these two forms of depression differ: We know this because the antidepressant drugs that work well on unipolar depression are not usually effective for bipolar disorder. A genetic component in bipolar disorder is well established, although the exact genes involved have not been pinpointed. While only 1 % of the general population has bipolar attacks, having an identical twin afflicted with the problem inflates one’s chances to about 70% UNIPOLAR DEPRESSION If you fail an important examination, lose a job, or lose a love, it is normal to feel depressed.
If a close friend dies, it is also normal to feel depressed. But if you remain depressed for weeks or months, long after the depressing event has passed, then you may have the clinically significant depressive disorder called unipolar depression, the commonest of all major mental disturbances. Incidence Psychologist Martin Seligman has called depression the “common cold” of psychological problems because nearly everyone has suffered it at some time. In the United States, depression accounts for the majority of all mental hospital admissions, but it is still believed to be under-diagnosed and undertreated.
Countless people in the throes of depression may feel worthless, lack appetite, withdraw from friends and family, have difficulty sleeping, lose their jobs, and become agitated or lethargic. In severe cases, they may also have psychotic distortions of reality. Most worrisome of all, suicide claims one in 50 depression sufferers. Cross-cultural studies indicate that depression is the single most prevalent form of disability around the globe, although the incidence of major depression varies widely throughout the world.
Causes of Depression Some cases of unipolar depression, however, almost certainly have a genetic predisposition. Severe bouts with depression often run in families. Further indication of a biological basis for depression comes from the favorable response that many depressed patients have to drugs that affect the brain’s neurotransmitters norepinephrine, serotonin, and dopamine. A special form of unipolar depression seems to be related to sunlight deprivation. It appears most frequently during the long, dark winter months among people who live in high latitudes.
Aptly named, seasonal affective disorder, or SAD, is related to levels of the light-sensitive hormone melatonin, which regulates our internal biological clocks. The cognitive approach to depression points out that negative thinking styles are learned and modifiable. This implies that, if you work on changing the way you think, perhaps blaming yourself less and focusing more on constructive plans for doing better, you can ultimately change your feelings and your performance. Who Becomes Depressed?
Clinicians have noted that depression rates are higher for women than for men. Th e response styles of men and women once they begin to experience negative moods may account for the difference. In this view; when women experience sadness, they tend to think about the possible causes and implications of their feelings. In contrast, men attempt to distract themselves from depressed feelings, either by shifting their attention to something else or by engaging in a physical activity that will take their minds off their mood.
This model suggests that the more ruminative response of women ??? characterized by a tendency to concentrate on problems???increases women’s vulnerability to depression. According to Martin Seligman, depression is between 10 and 20 times as common as it was 50 years ago. At midcentury, most casualties of depression were middle-aged women, but now it has become a teenage problem???still more prevalent in females than in males. Currently, the average age of individuals diagnosed with depression in the United States is between 14 and 15 years.
Seligman, who has studied depression extensively, blames this increase in occurrence and decrease in age to three factors: (1) an out-of-control individualism and self-centeredness that focuses on individual success and failure, rather than group accomplishments; (2) the self-esteem movement, which has taught a generation of schoolchildren that they should feel good about themselves, irrespective of their efforts and achievements; and (3) a culture of victimology, which reflexively points the finger of blame at someone or something else.
Anxiety Disorders Everyone, of course, has experienced anxiety or fear in threatening or dangerous situations. But pathological anxiety is far more severe than the normal anxiety associated with life’s challenges. It is also relatively common???even more common than depression. PANIC DISORDER The distinguishing feature of panic disorder is a feeling of panic that has no connection with present events (Barlow, 2001). The feeling is one of’ “free-floating anxiety. ” Attacks usually last for only a few minutes and then subside (McNally, 1994).
Because of the unexpected nature of these “hit-and-run” attacks, anticipatory anxiety often develops as an added complication. The dread of the next attack and of being helpless and suddenly out of control can lead a person to avoid public places, yet fear being left alone. Cognitive???behavioral theorists view panic attacks as conditioned responses to physical sensations that may have initially been learned during a period of stress. Biologically, we have evidence of a genetic influence in panic disorder.
However, the brain mechanism responsible for this condition lies in the limbic system ??? especially in the amygdala, which appears abnormal on PET scans of many patients. Overstimulation of these circuits can produce lasting physical changes that make the individual more susceptible to anxiety attacks in the future. To complicate matters, many victims of panic disorder have additional symptoms of agoraphobia. This condition involves panic that develops when they find themselves in situations from which they cannot easily escape, such as crowded public places or open spaces.
Fortunately, the treatment outlook is good, Medical therapy involves antianxiety drugs to relieve the panic attacks. Purely psychological treatment is also effective: Studies have shown that cognitive???behavioral therapy may equal or outperform drug therapy in combating panic attacks. PHOBIC DISORDERS In contrast with panic disorder, phobia, or phobic disorder, involves a persistent and irrational fear of a specific object, activity, or situation ??? a response all out of proportion to the circumstances. Phobias are relatively common. Studies suggest that 12. 5 % of Americans suffer from some form of phobia at some point in their lives. Among the most common phobic disorders are social phobias, irrational fears of normal social situations such as interacting with others or appearing in front of a group. Phobic responses to heights (acrophobia), snakes (ophidiophobia), and closed-in spaces (claustrophobia) are also common. What causes phobias? Martin Seligman contends that humans are biologically disposed to learn some kinds of fears more easily than others. This preparedness hypothesis suggests that we carry an innate tendency, acquired through natural selection, to respond quickly and automatically to stimuli that posed a survival threat to our ancestors.
This explains why we develop phobias for snakes and lightning much more easily that we develop fears for automobiles and electrical outlets???objects that have posed a danger only in recent times. OBSESSIVE-COMPULSIVE DISORDER Obsessive???compulsive disorder, is a condition characterized by patterns of persistent, unwanted thoughts and behaviors. Obsessive???compulsive disorder (OCD) affects about 2. 5% of Americans at some point during their lives. The obsession component of OCD consists of thoughts, images, or impulses that recur or persist despite a person’s efforts to suppress them.
For example, a person with an obsessive fear of germs may avoid using bathrooms outside his or her home or refuse to shake hands with strangers. Compulsions, the other half of obsessive???compulsive disorder, are repetitive, purposeful acts performed according to certain private “rules,” in response to an obsession. Victims feel that their compulsive behavior will reduce the tension associated with their obsessions. Typical compulsions include irresistible urges to clean, to check that lights or appliances have been turned off, and to count objects or possessions. The tendency for OCD to run in families suggests a genetic link.
Another hint comes from the finding that many people with OCD also display tics, unwanted involuntary movements, such as exaggerated eye blinks. Curiously, certain drugs that are commonly prescribed for depression can alleviate both the obsessions and the compulsive rituals. Evidence that learning plays a role can be seen in the results of behavioral therapy which is effective in reducing compulsive actions. The behavioral strategy for treating compulsive hand-washing, for example, calls for a form of extinction, in which the therapist soils the patient’s hands and prevents him or her from washing them for progressively longer periods.
Indeed, behavioral therapy can produce changes that show up in PET scans of OCD sufferers’ brains. Somatoform Disorders “Soma” means body. Thus, we use the term somatoform disorders for psychological problems appearing in the form of bodily symptoms or physical complaints, such as weakness or excessive worry about disease. Because these symptoms have no apparent biological cause, clinicians call them psychogenic: The cause originates in the mind. CONVERSION DISORDER Paralysis, weakness, or loss of sensation??? with no discernible physical ause???distinguishes conversion disorder (formerly called “hysterical neurosis”). Patients with this diagnosis may, for example, be blind, deaf, unable to walk, or insensitive to touch in part of their bodies. Yet they have no organic disease that shows up on neurological examinations, laboratory tests, or X-rays. In conversion disorder, the problem really is “all in the mind. ” Some cases of conversion disorder are now thought to be physical stress responses. For unknown reasons, the problem has declined in industrialized countries, but it still occurs frequently in economically undeveloped regions, such as China.
HYPOCHONDRIASIS “Hypochondriacs” worry about getting sick. Every ache and pain signals a disease. Because of their exaggerated concern about illness, patients with hypochondriasis often bounce from physician to physician until they find one who will listen to their complaints and prescribe some sort of treatment ??? often tranquilizers or placebos. Naturally, these individuals represent easy marks for health fads and scams. They also find their way to the fringes of the medical community, where they may buy extensive treatment packages from disreputable practitioners.
Dissociative Disorders The common denominator for all the dissociative disorders is “fragmentation” of the personality ??? a sense that parts of the personality have detached (dissociated) from others, Among the dissociative disorders, we find some of the most fascinating forms of mental pathology, including dissociative fugue, depersonalization disorder, and the controversial dissociative identity disorder (formerly called “multiple personality”), made famous by the fictional Dr. Jekyll and Mr. Hyde. Their underlying causes remain unclear. Dissociative Fugue
Persons with dissociative fugue not only lose their memory and sense of identity, but they abruptly flee their homes, families, and jobs. Some appear disoriented and perplexed. Others may travel to distant locations and take up new lives, appearing unconcerned about the unremembered past. Usually the fugue state lasts only hours or days, followed by complete and rapid recovery. Heavy alcohol use may predispose a person to dissociative fugue. This suggests that it may involve some brain impairment???although no certain cause has been established.
Like dissociative amnesia, fugue occurs more often in those under prolonged high stress, especially in times of war and other calamities. DEPERSONALIZATION DISORDER Yet another form of dissociation involves a sensation that mind and body have separated. Patients with depersonalization disorder commonly report “out-of-body experiences” or feelings of being external observers of their own bodies. Usually the sensation passes quickly, although it can recur. Investigators have attributed the disorder to hallucinations and to natural changes in the brain that occur during shock.
DISSOCIATIVE IDENTITY DISORDER Robert Louis Stevenson’s famous story of Dr. Jekyll and Mr. Hyde has become a misleading stereotype of dissociative identity disorder. In reality, most cases of dissociative identity disorder occur in women, and most display more than two identities. Unlike the homicidal Mr. Hyde, rarely do they pose a danger to others. Once thought to be rare, some specialists now believe that dissociative identity disorder has always been common, but hidden or misdiagnosed. It usually first appears in childhood, and its victims frequently report having been sexually abused.
The formation of multiple identities or selves may be a form of defense by the dominant self to protect itself from terrifying events. In some cases, dozens of characters emerge to help the person deal with a difficult life situation. These alternate personalities, each with its own consciousness, emerge suddenly usually under stress. What lies behind this mysterious disturbance? Psychodynamic theories explain it as a fracturing of the ego, as a result of ego defense mechanisms that do not allow energy from conflicts and traumas to escape from the unconscious mind.
Cognitive theories see it as a form of role-playing or mood-state dependency, a form of memory bias in which events experienced in a given mood are more easily recalled when the individual is again in that mood state. Eating Disorders ANOREXIA NERVOSA The condition called anorexia (persistent lack of appetite) may develop as a consequence of certain physical diseases or conditions, such as shock, nausea, or allergic reactions. However, when loss of appetite that endangers an individual’s health stems from emotional or psychological causes, the syndrome is called anorexia nervosa (“nervous anorexia”).
What causes anorexia nervosa? A strong hint comes from the finding that most anorectic persons are young white females from middle-class American homes. They typically have backgrounds of good behavior and academic success, but they starve themselves, hoping to become acceptably thin and attractive. A victim of anorexia typically holds a distorted body image, believing herself to be unattractively fat, and rejects others’ reassurances that she is not overweight.
In an effort to lose imagined “excess” weight, the anorectic victim rigidly suppresses her appetite, feeling rewarded for such self-control when she does lose pounds and inches???but never feeling quite thin enough. BULIMIA In the “binge-and-purge” syndrome known as bulimia, the sufferer overeats (binges) and then attempts to lose weight (purges) by means of self-induced vomiting, laxative use, or fasting. Those who suffer from bulimia usually keep their disorder inconspicuous and may even be supported in their behavior patterns by peers and by competitive norms in their academic, social, and athletic lives.
Cognitive explanations for eating disorders analyze how the individual sees herself and thinks about food, eating, and weight. Accordingly, many successful treatments of eating disorders employ strategies that alter self-perception and boost feelings of self-efficacy. Schizophrenic Disorders Literally, the word schizophrenia means “split or broken mind. ” In psychological terms, schizophrenia is a severe form of psychopathology in which personality seems to disintegrate and perception is distorted. Schizophrenia is the disorder we usually mean when we refer to “madness,” “psychosis,” or “insanity. In schizophrenia, emotions may become blunted, thoughts turn bizarre, and language takes strange twists. Memory may also become fragmented. Between two and three million living Americans have suffered from this tragic mental disorder. For as yet unknown reasons, the first occurrence of schizophrenia typically occurs for men before they are 25 and for women between 25 and 45 years of age. For years, schizophrenia has consistently been the primary diagnosis for about 40 % of all patient admissions to public mental hospitals ??? far out of proportion to all other possible categories of mental illness.
Most sobering, about one-third of all schizophrenic patients will never fully recover, even with the best therapy available. MAJOR TYPES OF SCHIZOPHRENIA Many investigators consider schizophrenia a constellation of separate disorders. Here are the five most common: ???Disorganized type represents everyone’s image of mental illness, featuring incoherent speech, hallucinations, delusions, and bizarre behavior. A patient who talks to imaginary people most likely has this diagnosis. ???Catatonic type, involving a spectrum of motor dysfunctions, appears in two forms.
Persons with the more common catatonic stupor may remain motionless for hours???even days???sometimes holding rigid, statue-like postures. In the other form, called catatonic excitement, patients become agitated and hyperactive. ???Paranoid type features delusions and hallucinations, but no catatonic symptoms and none of the incoherence of disorganized schizophrenia. The delusions found in paranoid schizophrenia are typically less well-organized???more illogical???than those of the patient with a purely delusional disorder. Undifferentiated type serves as a catchall category for schizophrenic symptoms that do not clearly meet the requirements for any of the other categories above. ???Residual type is the diagnosis for individuals who have suffered from a schizophrenic episode in the past but currently have no major symptoms such as hallucinations or delusional thinking. Instead, their thinking is mildly disturbed, or their emotional lives are impoverished. The diagnosis of residual type may indicate that the disease is entering remission, or becoming dormant. Many investigators now merely divide the schizophrenias into “positive” and “negative” types.
Positive schizophrenia involves active symptoms, such as delusions and hallucinations, while negative schizophrenia is distinguished by deficits, such as social withdrawal and poverty of thought processes. Patient responses to drug therapy support this division: Those with positive schizophrenia usually respond to antipsychotic drugs, while those with negative schizophrenia do not. POSSIBLE CAUSES OF SCHIZOPHRENIA an emerging consensus among psychiatrists and psychologists views schizophrenia as fundamentally a brain disorder???or a group of disorders.
Support for this brain-disorder view comes from many quarters. As we have noted, the antipsychotic drugs (sometimes called major tranquilizers) ???which interfere with the brain’s dopamine receptors ??? can suppress the symptoms of positive schizophrenia. On the other hand, drugs that stimulate dopamine production (e. g. , the amphetamines) can actually produce schizophrenic symptoms. As we found with the mood disorders, the closer one’s relationship to a person with schizophrenia, the greater one’s chances of developing it.
This conclusion comes from impressive studies of identical twins reared apart and from adoption studies of children having schizophrenic blood relatives. While only about 1 % of us in the general population become schizophrenic, the child of a schizophrenic parent incurs a risk about 14 times higher. The worst case would be to have an identical twin who has developed the condition. In that event, the other twin’s chances of becoming schizophrenic jump to nearly 50%. As with the mood disorders, genetics does not tell the whole story of schizophrenia.
We can see the effect of the environment, for example, in the fact that 90% of the relatives of schizophrenic patients do not have schizophrenia. Even in identical twins who share exactly the same genes, the concordance rate for schizophrenia is only about 50%. That is, in half the cases in which schizophrenia strikes identical twins, it leaves one twin untouched. Apparently, schizophrenia requires a biological predisposition plus some unknown environmental agent to “turn on” the hereditary tendency. This agent could be a chemical toxin, stress, or some factor we have not yet dreamed of.
This broader perspective is often called the diathesis???stress hypothesis. It says that biological factors may place the individual at risk, but environmental stressors transform this potential into an actual schizophrenic disorder. Thus, schizophrenia can be seen as a stress response. Personality Disorders A way of life characterized by distrust, lack of feelings for others, attention seeking, hypersensitivity, submissiveness, perfectionism, impulsivity, unstable relationships, or a pathological need for admiration suggests one of the personality disorders.
These conditions involve a chronic, pervasive, inflexible, and maladaptive pattern of thinking, emotion, social relationships, or impulse control. Ten types of personality disorder are recognized in the DSM-IV. Here we will consider two of the better known: narcissistic personality disorder and antisocial personality disorder. People with a narcissistic personality disorder have a grandiose sense of self-importance, a preoccupation with fantasies of success or power, and a need for constant attention or admiration.
They have problems in interpersonal relationships, feel entitled to favors without obligations, exploit others selfishly, and have difficulty understanding how others feel. Antisocial personality disorder is marked by a long-standing pattern of irresponsible or harmful behavior that indicates a lack of conscience and a diminished sense of responsibility to others. Chronic lying, stealing, and fighting are common signs. People with antisocial personality disorder may not experience shame or any other sort of intense emotion.
Violations of social norms begin early in their lives ??? disrupting class, getting into fights, and running away from home. Individuals who show a criminal pattern of antisocial personality disorder, such as committing murders and other serious crimes, are popularly referred to as “psychopaths” or “sociopaths. ” Although carriers of the antisocial type of personality disorder can be found among street criminals and con artists, they are also well represented among successful politicians and businesspeople who put career, money, and power above everything and everyone.
Adjustment Disorders and Other Conditions Although the large majority of everyday psychological problems involve making choices and dealing with confusion, frustration, and loss, the DSM-IV gives these problems short shrift under adjustment disorders and under the awkwardly named “other conditions that may be a focus of clinical attention. ” Together, these categories represent a catch basin for relatively mild problems that do not fit well under other headings.
Consequently, the largest group of people suffering from mental problems may fit these headings ??? even though the DSM-JV devotes disproportionately little space to them. WHAT ARE THE CONSEQUENCES OF LABELING PEOPLE? Ideally, an accurate diagnosis leads to an effective treatment program for the afflicted individual. Sometimes, however, labels create confusion and hurt. They can turn people into stereotypes, masking their personal characteristics and the unique circumstances that contribute to their disorders. And, if that is not enough, labels can provoke prejudices and social rejection.
Diagnostic Labels Can Compound the Problem Labeling a person as mentally disturbed can have both serious and long-lasting consequences, aside from the mental disturbance itself. People may suffer a broken leg or an attack of appendicitis, but when they recover, the diagnosis moves into the past. Not so with mental disorders. A label of “depression” or “mania” or “schizophrenia” can be a stigma that follows a person forever. The diagnostic label may also become part of a cycle of neglect resulting from the inferior status accorded people with mental disorders.
This, of course, lowers self-esteem and reinforces disordered behavior. Thus, society extracts costly penalties from those who deviate from its norms, and in the process it perpetuates the problem of mental disorder. We must keep in mind, therefore, that the goal of diagnosis is not simply to fit a person into a diagnostic box. Instead, a diagnosis should initiate a process that leads to a greater understanding of a person and to the development of a plan to help. A diagnosis should be a beginning, not an end. The Cultural Context of Mental Disorder
Many psychologists advocate an ecological model that takes the individual’s external world into account. In this model, abnormality is viewed as an interaction between individuals and the social and cultural context. Disorder results from a mismatch between a person’s behavior and the needs of the situation. If you are a private investigator, for example, it might pay to have a slightly suspicious, or “paranoid,” complexion to your personality, but if you are a nurse, this same characteristic might be called “deviant. In support of an ecological model, studies show that culture influences both the prevalence of mental disorders and the symptoms that disturbed people display. Psychiatry, too, is beginning to note the effects of culture on psychopathology. The DSM-IV. in fact, has a section devoted to culture-specific disorders. According to psychiatrists Arthur Kleinman and Alex Cohen, psychiatry has clung too long to three persistent myths: ???The myth that mental disorders have a similar prevalence in all cultures. The myth that biology creates mental disorder, while culture merely shapes the way a person experiences it. ???The myth that culture-specific disorders occur only in exotic places, rather than here at home. The incidence of specific mental disorders also varies among cultures. Abundant evidence shows that, while schizophrenia, for example, can be found everywhere, American clinicians use the diagnosis far more frequently than their counterparts in other countries. In the United States we apply the