Defining Disorder

A psychological disorder is an ongoing dysfunctional pattern of thought, emotion, and behavior that causes significant distress, and that is considered deviant in that person’s culture or society (Butcher, Mineka, & Hooley, 2007). Psychological disorders have much in common with other medical disorders. They are out of the patient’s control, they may in some cases be treated by drugs, and their treatment is often covered by medical insurance. Like medical problems, psychological disorders have both biological (nature) as well as environmental (nurture) influences. These causal influences are reflected in the bio-psycho-social model of illness (Engel, 1977).

The bio-psycho-social model of illness is a way of understanding disorder that assumes that disorder is caused by biological, psychological, and social factors (Figure 8.1 “The Bio-Psycho-Social Model”). The biological component of the bio-psycho-social model refers to the influences on disorder that come from the functioning of the individual’s body. Particularly important are genetic characteristics that make some people more vulnerable to a disorder than others and the influence of neurotransmitters. The psychological component of the bio-psycho-social model refers to the influences that come from the individual, such as patterns of negative thinking and stress responses. The social component of the bio-psycho-social model refers to the influences on disorder due to social and cultural factors such as socioeconomic status, homelessness, abuse, and discrimination.

To consider one example, the psychological disorder of schizophrenia has a biological cause because it is known that there are patterns of genes that make a person vulnerable to the disorder (Gejman, Sanders, & Duan, 2010). But whether or not the person with a biological vulnerability experiences the disorder depends in large part on psychological factors such as how the individual responds to the stress he experiences, as well as social factors such as whether or not he is exposed to stressful environments in adolescence and whether or not he has support from people who care about him (Sawa & Snyder, 2002; Walker, Kestler, Bollini, & Hochman, 2004). Similarly, mood and anxiety disorders are caused in part by genetic factors such as hormones and neurotransmitters, in part by the individual’s particular thought patterns, and in part by the ways that other people in the social environment treat the person with the disorder. We will use the bio-psycho-social model as a framework for considering the causes and treatments of disorder.

Although they share many characteristics with them, psychological disorders are nevertheless different from medical conditions in important ways. For one, diagnosis of psychological disorders can be more difficult. Although a medical doctor can see cancer in the lungs using an MRI scan or see blocked arteries in the heart using cardiac catheterization, there is no corresponding test for psychological disorder. Current research is beginning to provide more evidence about the role of brain structures in psychological disorder, but for now the brains of people with severe mental disturbances often look identical to those of people without such disturbances.

Because there are no clear biological diagnoses, psychological disorders are instead diagnosed on the basis of clinical observations of the behaviors that the individual engages in. These observations find that emotional states and behaviors operate on a continuum, ranging from more “normal” and “accepted” to more “deviant,” “abnormal,” and “unaccepted.” The behaviors that are associated with disorder are in many cases the same behaviors we that engage in our “normal” everyday life. Washing one’s hands is a normal healthy activity, but it can be overdone by those with an obsessive-compulsive disorder (OCD). It is not unusual to worry about and try to improve one’s body image, but Robert’s struggle with his personal appearance, as discussed at the beginning of this chapter, was clearly unusual, unhealthy, and distressing to him.

Whether a given behavior is considered a psychological disorder is determined not only by whether a behavior is unusual (e.g., whether it is “mild” anxiety versus “extreme” anxiety) but also by whether a behavior is maladaptive—that is, the extent to which it causes distress (e.g., pain and suffering) and dysfunction (impairment in one or more important areas of functioning) to the individual (American Psychiatric Association, 2000)¹. An intense fear of spiders, for example, would not be considered a psychological disorder unless it has a significant negative impact on the sufferer’s life, for instance by causing him or her to be unable to step outside the house. The focus on distress and dysfunction means that behaviors that are simply unusual (such as some political, religious, or sexual practices) are not classified as disorders.

Put your psychology hat on for a moment and consider the behaviors of the people listed in Table 8.2 “Diagnosing Disorder”. For each, indicate whether you think the behavior is or is not a psychological disorder. If you’re not sure, what other information would you need to know to be more certain of your diagnosis?

A trained clinical psychologist would have checked off “need more information” for each of the examples in Table 8.2 “Diagnosing Disorder” because although the behaviors may seem unusual, there is no clear evidence that they are distressing or dysfunctional for the person. Talking to ourselves out loud is unusual and can be a symptom of schizophrenia, but just because we do it once in a while does not mean that there is anything wrong with us. It is natural to be depressed, particularly in the long winter nights, but how severe should this depression be, and how long should it last? If the negative feelings last for an extended time and begin to lead the person to miss work or classes, then they may become symptoms of a mood disorder. It is normal to worry about things, but when does worry turn into a debilitating anxiety disorder? And what about thoughts that seem to be irrational, such as being able to “speak the language of angels”? Are they indicators of a severe psychological disorder, or part of a normal religious experience? Again, the answer lies in the extent to which they are (or are not) interfering with the individual’s functioning in society.

Another difficulty in diagnosing psychological disorders is that they frequently occur together. For instance, people diagnosed with anxiety disorders also often have mood disorders (Hunt, Slade, & Andrews, 2004), and people diagnosed with one personality disorder frequently suffer from other personality disorders as well. Comorbidity occurs when people who suffer from one disorder also suffer at the same time from other disorders. Because many psychological disorders are comorbid, most severe mental disorders are concentrated in a small group of people (about 6% of the population) who have more than three of them (Kessler, Chiu, Demler, & Walters, 2005).

Diagnosing Disorder: The DSM

Psychologists have developed criteria that help them determine whether behavior should be considered a psychological disorder and which of the many disorders particular behaviors indicate. These criteria are laid out in a 1,000-page manual known as the Diagnostic and Statistical Manual of Mental Disorders (DSM), a document that provides a common language and standard criteria for the classification of mental disorders (American Psychiatric Association, 2000)¹. The DSM is used by therapists, researchers, drug companies, health insurance companies, and policymakers in the United States to determine what services are appropriately provided for treating patients with given symptoms.

The first edition of the DSM was published in 1952 on the basis of census data and psychiatric hospital statistics. Since then, the DSM has been revised five times. The last major revision was the fourth edition (DSM-IV), published in 1994, and an update of that document was produced in 2000 (DSM-IV-TR). The fifth edition (DSM-V) is currently undergoing review, planning, and preparation and is scheduled to be published in 2013. The DSM-IV-TR was designed in conjunction with the World Health Organization’s 10th version of the International Classification of Diseases (ICD-10), which is used as a guide for mental disorders in Europe and other parts of the world.

As you can see in Figure 8.7, the DSM organizes the diagnosis of disorder according to five dimensions (or axes) relating to different aspects of disorder or disability. The axes are important to remember when we think about psychological disorder, because they make it clear not only that there are different types of disorder, but that those disorders have a variety of different causes. Axis I includes the most usual clinical disorders, including mood disordersand anxiety disorders; Axis II includes the less severe but long-lasting personality disorders as well as mental retardation; Axis III and Axis IV relate to physical symptoms and social-cultural factors, respectively. The axes remind us that when making a diagnosis we must look at the complete picture, including biological, personal, and social-cultural factors.

The DSM does not attempt to specify the exact symptoms that are required for a diagnosis. Rather, the DSM uses categories, and patients whose symptoms are similar to the description of the category are said to have that disorder. The DSM frequently uses qualifiers to indicate different levels of severity within a category. For instance, the disorder of mental retardation can be classified as mild, moderate, or severe.

Each revision of the DSM takes into consideration new knowledge as well as changes in cultural norms about disorder. Homosexuality, for example, was listed as a mental disorder in the DSM until 1973, when it was removed in response to advocacy by politically active gay rights groups and changing social norms. The current version of the DSM lists about 400 disorders. Some of the major categories are shown in Table 8.3 “Categories of Psychological Disorders Based on the “, and you may go to http://en.wikipedia.org/wiki/DSM-IV_Codes_(alphabetical) and browse the complete list.

Although the DSM has been criticized regarding the nature of its categorization system (and it is frequently revised to attempt to address these criticisms), for the fact that it tends to classify more behaviors as disorders with every revision (even “academic problems” are now listed as a potential psychological disorder), and for the fact that it is primarily focused on Western illness, it is nevertheless a comprehensive, practical, and necessary tool that provides a common language to describe disorder. Most U.S. insurance companies will not pay for therapy unless the patient has a DSM diagnosis. The DSM approach allows a systematic assessment of the patient, taking into account the mental disorder in question, the patient’s medical condition, psychological and cultural factors, and the way the patient functions in everyday life.

Diagnosis or Overdiagnosis? ADHD, Autistic Disorder, and Asperger’s Disorder

Two common critiques of the DSM are that the categorization system leaves quite a bit of ambiguity in diagnosis and that it covers such a wide variety of behaviors. Let’s take a closer look at three common disorders—attention-deficit/hyperactivity disorder (ADHD), autistic disorder, and Asperger’s disorder—that have recently raised controversy because they are being diagnosed significantly more frequently than they were in the past.

Generalized Anxiety Disorder

Consider the following, in which “Chase” describes her feelings of a persistent and exaggerated sense of anxiety, even when there is little or nothing in her life to provoke it:

Chase is probably suffering from a generalized anxiety disorder (GAD), a psychological disorder diagnosed in situations in which a person has been excessively worrying about money, health, work, family life, or relationships for at least 6 months, even though he or she knows that the concerns are exaggerated, and when the anxiety causes significant distress and dysfunction.

In addition to their feelings of anxiety, people who suffer from GAD may also experience a variety of physical symptoms, including irritability, sleep troubles, difficulty concentrating, muscle aches, trembling, perspiration, and hot flashes. The sufferer cannot deal with what is causing the anxiety, nor avoid it, because there is no clear cause for anxiety. In fact, the sufferer frequently knows, at least cognitively, that there is really nothing to worry about.

About 10 million Americans suffer from GAD, and about two thirds are women (Kessler, Chiu, Demler, & Walters, 2005; Robins & Regier, 1991). Generalized anxiety disorder is most likely to develop between the ages of 7 and 40 years, but its influence may in some cases lessen with age (Rubio & Lopez-Ibor, 2007).

Panic Disorder

Ceejay is experiencing panic disorder, a psychological disorder characterized by sudden attacks of anxiety and terror that have led to significant behavioral changes in the person’s life. Symptoms of a panic attack include shortness of breath, heart palpitations, trembling, dizziness, choking sensations, nausea, and an intense feeling of dread or impending doom. Panic attacks can often be mistaken for heart attacks or other serious physical illnesses, and they may lead the person experiencing them to go to a hospital emergency room. Panic attacks may last as little as one or as much as 20 minutes, but they often peak and subside within about 10 minutes.

Sufferers are often anxious because they fear that they will have another attack. They focus their attention on the thoughts and images of their fears, becoming excessively sensitive to cues that signal the possibility of threat (MacLeod, Rutherford, Campbell, Ebsworthy, & Holker, 2002). They may also become unsure of the source of their arousal, misattributing it to situations that are not actually the cause. As a result, they may begin to avoid places where attacks have occurred in the past, such as driving, using an elevator, or being in public places. Panic disorder affects about 3% of the American population in a given year.

Phobias

A phobia (from the Greek word phobos, which means “fear”) is a specific fear of a certain object, situation, or activity. The fear experience can range from a sense of unease to a full-blown panic attack. Most people learn to live with their phobias, but for others the fear can be so debilitating that they go to extremes to avoid the fearful situation. A sufferer of arachnophobia (fear of spiders), for example, may refuse to enter a room until it has been checked thoroughly for spiders, or may refuse to vacation in the countryside because spiders may be there. Phobias are characterized by their specificity and their irrationality. A person with acrophobia (a fear of height) could fearlessly sail around the world on a sailboat with no concerns yet refuse to go out onto the balcony on the fifth floor of a building.

A common phobia is social phobia, extreme shyness around people or discomfort in social situations. Social phobia may be specific to a certain event, such as speaking in public or using a public restroom, or it can be a more generalized anxiety toward almost all people outside of close family and friends. People with social phobia will often experience physical symptoms in public, such as sweating profusely, blushing, stuttering, nausea, and dizziness. They are convinced that everybody around them notices these symptoms as they are occurring. Women are somewhat more likely than men to suffer from social phobia.

The most incapacitating phobia is agoraphobia, defined as anxiety about being in places or situations from which escape might be difficult or embarrassing, or in which help may not be available (American Psychiatric Association, 2000)¹. Typical places that provoke the panic attacks are parking lots; crowded streets or shops; and bridges, tunnels, or expressways. People (mostly women) who suffer from agoraphobia may have great difficulty leaving their homes and interacting with other people.

Phobias affect about 9% of American adults, and they are about twice as prevalent in women as in men (Fredrikson, Annas, Fischer, & Wik, 1996; Kessler, Meron-Ruscio, Shear, & Wittchen, 2009). In most cases phobias first appear in childhood and adolescence, and usually persist into adulthood. Table 8.4 “The Most Common Phobias” presents a list of the common phobias that are diagnosed by psychologists.

Obsessive-Compulsive Disorders

Although he is best known his perfect shots on the field, the soccer star David Beckham also suffers from Obsessive-Compulsive Disorder (OCD). As he describes it,

David Beckham’s experience with obsessive behavior is not unusual. We all get a little obsessive at times. We may continuously replay a favorite song in our heads, worry about getting the right outfit for an upcoming party, or find ourselves analyzing a series of numbers that seem to have a certain pattern. And our everyday compulsions can be useful. Going back inside the house once more to be sure that we really did turn off the sink faucet or checking the mirror a couple of times to be sure that our hair is combed are not necessarily bad ideas.

Obsessive-compulsive disorder (OCD) is a psychological disorder that is diagnosed when an individual continuously experiences distressing or frightening thoughts, and engages inobsessions (repetitive thoughts) or compulsions (repetitive behaviors) in an attempt to calm these thoughts. OCD is diagnosed when the obsessive thoughts are so disturbing and the compulsive behaviors are so time consuming that they cause distress and significant dysfunction in a person’s everyday life. Washing your hands once or even twice to make sure that they are clean is normal; washing them 20 times is not. Keeping your fridge neat is a good idea; spending hours a day on it is not. The sufferers know that these rituals are senseless, but they cannot bring themselves to stop them, in part because the relief that they feel after they perform them acts as a reinforcer, making the behavior more likely to occur again.

Sufferers of OCD may avoid certain places that trigger the obsessive thoughts, or use alcohol or drugs to try to calm themselves down. OCD has a low prevalence rate (about 1% of the population in a given year) in relation to other anxiety disorders, and usually develops in adolescence or early adulthood (Horwath & Weissman, 2000; Samuels & Nestadt, 1997). The course of OCD varies from person to person. Symptoms can come and go, decrease, or worsen over time.

Posttraumatic Stress Disorder (PTSD)

People who have survived a terrible ordeal, such as combat, torture, sexual assault, imprisonment, abuse, natural disasters, or the death of someone close to them may develop posttraumatic stress disorder (PTSD). The anxiety may begin months or even years after the event. People with PTSD experience high levels of anxiety along with reexperiencing the trauma (flashbacks), and a strong desire to avoid any reminders of the event. They may lose interest in things they used to enjoy; startle easily; have difficulty feeling affection; and may experience terror, rage, depression, or insomnia. The symptoms may be felt especially when approaching the area where the event took place or when the anniversary of that event is near.

PTSD affects about 5 million Americans, including victims of the 9/11 terrorist attacks, the wars in Afghanistan and Iraq, and Hurricane Katrina. Sixteen percent of Iraq war veterans, for example, reported experiencing symptoms of PTSD (Hoge & Castro, 2006). PTSD is a frequent outcome of childhood or adult sexual abuse, a disorder that has its own Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis. Women are more likely to develop PTSD than men (Davidson, 2000).

Risk factors for PTSD include the degree of the trauma’s severity, the lack of family and community support, and additional life stressors (Brewin, Andrews, & Valentine, 2000). Many people with PTSD also suffer from another mental disorder, particularly depression, other anxiety disorders, and substance abuse (Brady, Back, & Coffey, 2004).

Dissociative Disorders: Losing the Self to Avoid Anxiety

People who experience anxiety are haunted by their memories and experiences, and although they desperately wish to get past them, they normally cannot. In some cases, however, such as with Jeffrey Ingram, people who become overwhelmed by stress experience an altered state of consciousness in which they become detached from the reality of what is happening to them. A dissociative disorder is a condition that involves disruptions or breakdowns of memory, awareness, and identity. The dissociation is used as a defense against the trauma.

Explaining Anxiety and Dissociation Disorders

Both nature and nurture contribute to the development of anxiety disorders. In terms of our evolutionary experiences, humans have evolved to fear dangerous situations. Those of us who had a healthy fear of the dark, of storms, of high places, of closed spaces, and of spiders and snakes were more likely to survive and have descendants. Our evolutionary experience can account for some modern fears as well. A fear of elevators may be a modern version of our fear of closed spaces, while a fear of flying may be related to a fear of heights.

Also supporting the role of biology, anxiety disorders, including PTSD, are heritable (Hettema, Neale, & Kendler, 2001), and molecular genetics studies have found a variety of genes that are important in the expression of such disorders (Smoller et al., 2008; Thoeringer et al., 2009). Neuroimaging studies have found that anxiety disorders are linked to areas of the brain that are associated with emotion, blood pressure and heart rate, decision making, and action monitoring (Brown & McNiff, 2009; Damsa, Kosel, & Moussally, 2009). People who experience PTSD also have a somewhat smaller hippocampus in comparison with those who do not, and this difference leads them to have a very strong sensitivity to traumatic events (Gilbertson et al., 2002).

Whether the genetic predisposition to anxiety becomes expressed as a disorder depends on environmental factors. People who were abused in childhood are more likely to be anxious than those who had normal childhoods, even with the same genetic disposition to anxiety sensitivity (Stein, Schork, & Gelernter, 2008). And the most severe anxiety and dissociative disorders, such as PTSD, are usually triggered by the experience of a major stressful event. One problem is that modern life creates a lot of anxiety. Although our life expectancy and quality of life have improved over the past 50 years, the same period has also created a sharp increase in anxiety levels (Twenge, 2006). These changes suggest that most anxiety disorders stem from perceived, rather than actual, threats to our well-being.

Anxieties are also learned through classical and operant conditioning. Just as rats that are shocked in their cages develop a chronic anxiety toward their laboratory environment (which has become a conditioned stimulus for fear), rape victims may feel anxiety when passing by the scene of the crime, and victims of PTSD may react to memories or reminders of the stressful event. Classical conditioning may also be accompanied by stimulus generalization. A single dog bite can lead to generalized fear of all dogs; a panic attack that follows an embarrassing moment in one place may be generalized to a fear of all public places. People’s responses to their anxieties are often reinforced. Behaviors become compulsive because they provide relief from the torment of anxious thoughts. Similarly, leaving or avoiding fear-inducing stimuli leads to feelings of calmness or relief, which reinforces phobic behavior.

In contrast to the anxiety disorders, the causes of the dissociative orders are less clear, which is part of the reason that there is disagreement about their existence. Unlike most psychological orders, there is little evidence of a genetic predisposition; they seem to be almost entirely environmentally determined. Severe emotional trauma during childhood, such as physical or sexual abuse, coupled with a strong stressor, is typically cited as the underlying cause (Alpher, 1992; Cardeña & Gleaves, 2007). Kihlstrom, Glisky, and Angiulo (1994) suggest that people with personalities that lead them to fantasize and become intensely absorbed in their own personal experiences are more susceptible to developing dissociative disorders under stress. Dissociative disorders can in many cases be successfully treated, usually by psychotherapy (Lilienfeld & Lynn, 2003).

Dysthymia and Major Depressive Disorder

The level of depression observed in people with mood disorders varies widely. People who experience depression for many years, such that it becomes to seem normal and part of their everyday life, and who feel that they are rarely or never happy, will likely be diagnosed with a mood disorder. If the depression is mild but long-lasting, they will be diagnosed with dysthymia, a condition characterized by mild, but chronic, depressive symptoms that last for at least 2 years.

If the depression continues and becomes even more severe, the diagnosis may become that of major depressive disorder. Major depressive disorder (clinical depression) is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem and by loss of interest or pleasure in normally enjoyable activities. Those who suffer from major depressive disorder feel an intense sadness, despair, and loss of interest in pursuits that once gave them pleasure. These negative feelings profoundly limit the individual’s day-to-day functioning and ability to maintain and develop interests in life (Fairchild & Scogin, 2008).

About 21 million American adults suffer from a major depressive disorder in any given year; this is approximately 7% of the American population. Major depressive disorder occurs about twice as often in women as it does in men (Kessler, Chiu, Demler, & Walters, 2005; Kessler et al., 2003). In some cases clinically depressed people lose contact with reality and may receive a diagnosis of major depressive episode with psychotic features. In these cases the depression includes delusions and hallucinations.

Bipolar Disorder

While dysthymia and major depressive disorder are characterized by overwhelming negative moods, bipolar disorder is a psychological disorder characterized by swings in mood from overly “high” to sad and hopeless, and back again, with periods of near-normal mood in between. Bipolar disorder is diagnosed in cases such as Juliana’s, where experiences with depression are followed by a more normal period and then a period of mania or euphoria in which the person feels particularly awake, alive, excited, and involved in everyday activities but is also impulsive, agitated, and distracted. Without treatment, it is likely that Juliana would cycle back into depression and then eventually into mania again, with the likelihood that she would harm herself or others in the process.

Bipolar disorder is an often chronic and lifelong condition that may begin in childhood. Although the normal pattern involves swings from high to low, in some cases the person may experience both highs and lows at the same time. Determining whether a person has bipolar disorder is difficult due to the frequent presence of comorbidity with both depression and anxiety disorders. Bipolar disorder is more likely to be diagnosed when it is initially observed at an early age, when the frequency of depressive episodes is high, and when there is a sudden onset of the symptoms (Bowden, 2001).

Explaining Mood Disorders

Mood disorders are known to be at least in part genetic, because they are heritable. (Berrettini, 2006; Merikangas et al., 2002). Neurotransmitters also play an important role in mood disorders. Serotonin, dopamine, and norepinephrine are all known to influence mood (Sher & Mann, 2003), and drugs that influence the actions of these chemicals are often used to treat mood disorders.

The brains of those with mood disorders may in some cases show structural differences from those without them. Videbech and Ravnkilde (2004) found that the hippocampus was smaller in depressed subjects than in normal subjects, and this may be the result of reduced neurogenesis (the process of generating new neurons) in depressed people (Warner-Schmidt & Duman, 2006). Antidepressant drugs may alleviate depression in part by increasing neurogenesis (Duman & Monteggia, 2006).

But psychological and social determinants are also important in creating mood disorders and depression. In terms of psychological characteristics, mood states are influenced in large part by our cognitions. Negative thoughts about ourselves and our relationships to others create negative moods, and a goal of cognitive therapy for mood disorders is to attempt to change people’s cognitions to be more positive. Negative moods also create negative behaviors toward others, such as acting sad, slouching, and avoiding others, which may lead those others to respond negatively to the person, for instance by isolating that person, which then creates even more depression (Figure 8.13 “Cycle of Depression”). You can see how it might become difficult for people to break out of this “cycle of depression.”

Weissman et al. (1996) found that rates of depression varied greatly among countries, with the highest rates in European and American countries and the lowest rates in Asian countries. These differences seem to be due to discrepancies between individual feelings and cultural expectations about what one should feel. People from European and American cultures report that it is important to experience emotions such as happiness and excitement, whereas the Chinese report that it is more important to be stable and calm. Because Americans may feel that they are not happy or excited but that they are supposed to be, this may increase their depression (Tsai, Knutson, & Fung, 2006).

Symptoms of Schizophrenia

Schizophrenia is accompanied by a variety of symptoms, but not all patients have all of them (Lindenmayer & Khan, 2006). As you can see in Table 8.5 “Positive, Negative, and Cognitive Symptoms of Schizophrenia”, the symptoms are divided into positive symptoms, negative symptoms, and cognitive symptoms (American Psychiatric Association, 2008; National Institute of Mental Health, 2010)². Positive symptoms refer to the presence of abnormal behaviors or experiences (such as hallucinations) that are not observed in normal people, whereas negative symptoms (such as lack of affect and an inability to socialize with others) refer to the loss or deterioration of thoughts and behaviors that are typical of normal functioning. Finally, cognitive symptoms are the changes in cognitive processes that accompany schizophrenia (Skrabalo, 2000). Because the patient has lost contact with reality, we say that he or she is experiencing psychosis, which is a psychological condition characterized by a loss of contact with reality.

People with schizophrenia almost always suffer from hallucinations—imaginary sensations that occur in the absence of a real stimulus or which are gross distortions of a real stimulus. Auditory hallucinations are the most common and are reported by approximately three quarters of patients (Nicolson, Mayberg, Pennell, & Nemeroff, 2006). Schizophrenic patients frequently report hearing imaginary voices that curse them, comment on their behavior, order them to do things, or warn them of danger (National Institute of Mental Health, 2009). Visual hallucinations are less common and frequently involve seeing God or the devil (De Sousa, 2007).

Schizophrenic people also commonly experience delusions, which are false beliefs not commonly shared by others within one’s culture, and maintained even though they are obviously out of touch with reality. People with delusions of grandeur believe that they are important, famous, or powerful. They often become convinced that they are someone else, such as the president or God, or that they have some special talent or ability. Some claim to have been assigned to a special covert mission (Buchanan & Carpenter, 2005). People with delusions of persecution believe that a person or group seeks to harm them. They may think that people are able to read their minds and control their thoughts (Maher, 2001). If a person suffers from delusions of persecution, there is a good chance that he or she will become violent, and this violence is typically directed at family members (Buchanan & Carpenter, 2005).

People suffering from schizophrenia also often suffer from the positive symptom of derailment—the shifting from one subject to another, without following any one line of thought to conclusion—and may exhibit grossly disorganized behavior including inappropriate sexual behavior, peculiar appearance and dress, unusual agitation (e.g., shouting and swearing), strange body movements, and awkward facial expressions. It is also common for schizophrenia sufferers to experience inappropriate affect. For example, a patient may laugh uncontrollably when hearing sad news. Movement disorders typically appear as agitated movements, such as repeating a certain motion again and again, but can in some cases include catatonia, a state in which a person does not move and is unresponsive to others (Janno, Holi, Tuisku, & Wahlbeck, 2004; Rosebush & Mazurek, 2010).

Negative symptoms of schizophrenia include social withdrawal, poor hygiene and grooming, poor problem-solving abilities, and a distorted sense of time (Skrabalo, 2000). Patients often suffer from flat affect, which means that they express almost no emotional response (e.g., they speak in a monotone and have a blank facial expression) even though they may report feeling emotions (Kring, 1999). Another negative symptom is the tendency toward incoherent language, for instance, to repeat the speech of others (“echo speech”). Some schizophrenics experience motor disturbances, ranging from complete catatonia and apparent obliviousness to their environment to random and frenzied motor activity during which they become hyperactive and incoherent (Kirkpatrick & Tek, 2005).

Not all schizophrenic patients exhibit negative symptoms, but those who do also tend to have the poorest outcomes (Fenton & McGlashan, 1994). Negative symptoms are predictors of deteriorated functioning in everyday life and often make it impossible for sufferers to work or to care for themselves.

Cognitive symptoms of schizophrenia are typically difficult for outsiders to recognize but make it extremely difficult for the sufferer to lead a normal life. These symptoms include difficulty comprehending information and using it to make decisions (the lack of executive control), difficulty maintaining focus and attention, and problems with working memory (the ability to use information immediately after it is learned).

Explaining Schizophrenia

There is no single cause of schizophrenia. Rather, a variety of biological and environmental risk factors interact in a complex way to increase the likelihood that someone might develop schizophrenia (Walker, Kestler, Bollini, & Hochman, 2004).

Studies in molecular genetics have not yet identified the particular genes responsible for schizophrenia, but it is evident from research using family, twin, and adoption studies that genetics are important (Walker & Tessner, 2008). As you can see in Figure 8.15 “Genetic Disposition to Develop Schizophrenia”, the likelihood of developing schizophrenia increases dramatically if a close relative also has the disease.

Neuroimaging studies have found some differences in brain structure between schizophrenic and normal patients. In some people with schizophrenia, the cerebral ventricles (fluid-filled spaces in the brain) are enlarged (Suddath, Christison, Torrey, Casanova, & Weinberger, 1990). People with schizophrenia also frequently show an overall loss of neurons in the cerebral cortex, and some show less activity in the frontal and temporal lobes, which are the areas of the brain involved in language, attention, and memory. This would explain the deterioration of functioning in language and thought processing that is commonly experienced by schizophrenic patients (Galderisi et al., 2008).

Many researchers believe that schizophrenia is caused in part by excess dopamine, and this theory is supported by the fact that most of the drugs useful in treating schizophrenia inhibit dopamine activity in the brain (Javitt & Laruelle, 2006). Levels of serotonin may also play a part (Inayama et al., 1996). But recent evidence suggests that the role of neurotransmitters in schizophrenia is more complicated than was once believed. It also remains unclear whether observed differences in the neurotransmitter systems of people with schizophrenia cause the disease, or if they are the result of the disease itself or its treatment (Csernansky & Grace, 1998).

A genetic predisposition to developing schizophrenia does not always develop into the actual disorder. Even if a person has an identical twin with schizophrenia, he still has less than a 50% chance of getting it himself, and over 60% of all schizophrenic people have no first- or second-degree relatives with schizophrenia (Gottesman & Erlenmeyer-Kimling, 2001; Riley & Kendler, 2005). This suggests that there are important environmental causes as well.

One hypothesis is that schizophrenia is caused in part by disruptions to normal brain development in infancy that may be caused by poverty, malnutrition, and disease (Brown et al., 2004; Murray & Bramon, 2005; Susser et al., 1996; Waddington, Lane, Larkin, O’Callaghan, 1999). Stress also increases the likelihood that a person will develop schizophrenic symptoms; onset and relapse of schizophrenia typically occur during periods of increased stress (Walker, Mittal, & Tessner, 2008). However, it may be that people who develop schizophrenia are more vulnerable to stress than others and not necessarily that they experience more stress than others (Walker, Mittal, & Tessner, 2008). Many homeless people are likely to be suffering from undiagnosed schizophrenia.

Another social factor that has been found to be important in schizophrenia is the degree to which one or more of the patient’s relatives is highly critical or highly emotional in their attitude toward the patient. Hooley and Hiller (1998) found that schizophrenic patients who ended a stay in a hospital and returned to a family with high expressed emotion were three times more likely to relapse than patients who returned to a family with low expressed emotion. It may be that the families with high expressed emotion are a source of stress to the patient.

Borderline Personality Disorder

Borderline personality disorder (BPD) is a psychological disorder characterized by a prolonged disturbance of personality accompanied by mood swings, unstable personal relationships, identity problems, threats of self-destructive behavior, fears of abandonment, and impulsivity. BPD is widely diagnosed—up to 20% of psychiatric patients are given the diagnosis, and it may occur in up to 2% of the general population (Hyman, 2002). About three quarters of diagnosed cases of BDP are women.

People with BPD fear being abandoned by others. They often show a clinging dependency on the other person and engage in manipulation to try to maintain the relationship. They become angry if the other person limits the relationship, but also deny that they care about the person. As a defense against fear of abandonment, borderline people are compulsively social. But their behaviors, including their intense anger, demands, and suspiciousness, repel people.

People with BPD often deal with stress by engaging in self-destructive behaviors, for instance by being sexually promiscuous, getting into fights, binge eating and purging, engaging in self-mutilation or drug abuse, and threatening suicide. These behaviors are designed to call forth a “saving” response from the other person. People with BPD are a continuing burden for police, hospitals, and therapists. Borderline individuals also show disturbance in their concepts of identity: They are uncertain about self-image, gender identity, values, loyalties, and goals. They may have chronic feelings of emptiness or boredom and be unable to tolerate being alone.

BPD has both genetic as well as environmental roots. In terms of genetics, research has found that those with BPD frequently have neurotransmitter imbalances (Zweig-Frank et al., 2006), and the disorder is heritable (Minzenberg, Poole, & Vinogradov, 2008). In terms of environment, many theories about the causes of BPD focus on a disturbed early relationship between the child and his or her parents. Some theories focus on the development of attachment in early childhood, while others point to parents who fail to provide adequate attention to the child’s feelings. Others focus on parental abuse (both sexual and physical) in adolescence, as well as on divorce, alcoholism, and other stressors (Lobbestael & Arntz, 2009). The dangers of BPD are greater when they are associated with childhood sexual abuse, early age of onset, substance abuse, and aggressive behaviors. The problems are amplified when the diagnosis is comorbid (as it often is) with other disorders, such as substance abuse disorder, major depressive disorder, and posttraumatic stress disorder (PTSD; Skodol et al., 2002).

Antisocial Personality Disorder (APD)

In contrast to borderline personality disorder, which involves primarily feelings of inadequacy and a fear of abandonment, antisocial personality disorder (APD) is characterized by a disregard of the rights of others, and a tendency to violate those rights without being concerned about doing so. APD is a pervasive pattern of violation of the rights of others that begins in childhood or early adolescence and continues into adulthood. APD is about three times more likely to be diagnosed in men than in women. To be diagnosed with APD the person must be 18 years of age or older and have a documented history of conduct disorder before the age of 15. People having antisocial personality disorder are sometimes referred to as “sociopaths” or “psychopaths.”

People with APD feel little distress for the pain they cause others. They lie, engage in violence against animals and people, and frequently have drug and alcohol abuse problems. They are egocentric and frequently impulsive, for instance suddenly changing jobs or relationships. People with APD soon end up with a criminal record and often spend time incarcerated. The intensity of antisocial symptoms tends to peak during the 20s and then may decrease over time.

Biological and environmental factors are both implicated in the development of antisocial personality disorder (Rhee & Waldman, 2002). Twin and adoption studies suggest a genetic predisposition (Rhee & Waldman, 2002), and biological abnormalities include low autonomic activity during stress, biochemical imbalances, right hemisphere abnormalities, and reduced gray matter in the frontal lobes (Lyons-Ruth et al., 2007; Raine, Lencz, Bihrle, LaCasse, & Colletti, 2000). Environmental factors include neglectful and abusive parenting styles, such as the use of harsh and inconsistent discipline and inappropriate modeling (Huesmann & Kirwil, 2007).