Psychological Disorders

CHAPTER 13: Psychological Disorders
13.1 Defining Psychological Disorders

The term "psychological disorder" evokes the notion of abnormal psychological functioning. It is important to recognize that behaviors may be considered abnormal without being indicative of a psychological disorder. For instance, dressing up for events like Halloween or supporting a team with eccentric outfits (e.g., wearing a wig and painting oneself green) may be viewed as unusual but do not inherently signify a psychological disorder. While these actions deviate from statistical norms, they do not cause significant internal distress or impair an individual's daily functioning. During the COVID-19 pandemic, it was noted that anxiety and depression levels have significantly risen, indicating that an increase in emotional distress or unusual behaviors in response to widespread societal stressors does not always align neatly with psychopathologies requiring a formal diagnosis.

Definition of Psychological Disorder

According to the American Psychiatric Association (APA) (2013), a psychological disorder is defined in the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5) as a "clinically significant disturbance in an individual's cognition, emotion regulation, or behavior." This disturbance is typically associated with significant distress (e.g., intense suffering, emotional pain) or disability (e.g., impairment in social, occupational, or other important activities, such as an inability to maintain relationships or employment). This definition underscores that psychological disorders, or mental disorders, are frameworks used by mental health professionals and countries to understand specific patterns of symptoms that frequently appear together, guiding diagnosis and treatment planning.

Psychopathology and Related Terms

The term "psychopathology" refers both to the scientific study of psychological disorders (their nature, causes, and development) and to the disorders themselves (e.g., a person exhibiting psychopathology). Related concepts include:

  • Abnormal Psychology: The specific field focusing on the scientific study of psychological disorders, including their presentation, etiology, maintenance, and prognosis.

  • Clinical Psychology: Concentrates on the assessment, diagnosis, treatment, and prevention of psychological disorders, often applying research findings to clinical practice.

To qualify as a psychological disorder, a syndrome must not be:

  1. An expectable and culturally sanctioned response to common stressors and losses (e.g., the profound grief and sadness experienced after losing a loved one, which is a natural human reaction rather than a disorder).

  2. A culturally approved response to events (such as trance states or spiritual visions in certain religious practices, which are valued within their cultural context and not indicative of psychopathology).

  3. Simple deviance from social norms (e.g., being a non-conformist or adopting an unconventional lifestyle. The contextual aspect is crucial; behavior must be evaluated within its cultural and individual context).

Continuum of Responses

When considering psychological disorders, a useful conceptualization is a continuum of cognitive, emotional, and behavioral responses that range from normal, healthy adaptation to severely disordered functioning. For example, during the transition to college life, students experience a spectrum of responses, ranging from normal adaptational behaviors (e.g., transient stress, homesickness) to more severe psychological disturbances (e.g., debilitating anxiety, major depressive episodes).

13.2 Assessing Psychological Disorders

The DSM-5 provides explicit diagnostic criteria, allowing mental health practitioners to determine appropriate diagnoses based on observable symptoms and reported experiences. Diagnoses are the initial step in understanding a client's pain, guiding treatment selection, and facilitating communication among professionals. Clinical assessments generally proceed through a clinical interview, where information is systematically collected about the client's current mental state, presenting problems, life circumstances, and relevant history. The clinician may use both open-ended questions (allowing the client to elaborate freely) and structured interviews (following a predetermined set of questions for consistency).

Clinical Interviews and Self-Report Measures

  • Clinical Interviews: These involve a dynamic interaction where clinicians explore client concerns, gather narrative accounts of symptoms, observe client behaviors, and note any discrepancies between reported symptoms and non-verbal behavioral cues. A mental status examination is often incorporated to assess appearance, mood, affect, speech, thought processes, and cognitive function.

  • Self-Report Measures: Standardized assessments like the Minnesota Multiphasic Personality Inventory (MMPI-3), Beck Depression Inventory (BDI-II), or State-Trait Anxiety Inventory (STAI) involve fixed questions which clients answer, often using rating scales, to reveal their symptomatology. These instruments have varying lengths, provide quantitative data on symptom severity, and can also help assess suitability for certain high-risk professions by evaluating personality traits or psychological vulnerabilities.

  • Projective Tests: Techniques such as the Thematic Apperception Test (TAT), where clients create stories around ambiguous pictures, and the Rorschach Inkblot Test, where clients interpret abstract inkblots, invite clients to respond to ambiguous stimuli. The premise is that their responses reveal subconscious thoughts, feelings, conflicts, and underlying personality characteristics. However, their validity, reliability, and interpretability have been questioned extensively in empirical research, making them less favored by evidence-based practitioners.

13.3 Using the DSM-5

The DSM-5 is a critical tool for diagnosing psychological disorders, organizing them into categories and providing detailed criteria for each disorder based on clusters of observable symptoms. The DSM has undergone several revisions since its inception in 1952 (DSM-I), reflecting evolving scientific understanding. Significant changes, such as those in the DSM-III (1980), emphasized empirical symptom classification and moved away from broad theoretical backgrounds (e.g., psychodynamic only) to an atheoretical, descriptive approach. The DSM-5 includes 20 categories of disorders and represents an effort to incorporate dimensional approaches where appropriate, recognizing that many disorders exist on a spectrum. It also includes significant acknowledgment of culture-specific syndromes (e.g., ataque de nervios from Latin American cultures, characterized by symptoms like uncontrollable crying, trembling, and dissociation; shenjing shuairuo from Chinese culture, involving symptoms like fatigue, dizziness, and somatic complaints).

Cultural Context

Cultural context is crucial to understanding the prevalence, expression, and interpretation of psychological disorders. For instance, conditions like bulimia nervosa are more widespread in cultures with strong Western influences that promote specific body ideals. The DSM-5 emphasizes the applicability of diagnostic categories to diverse cultural settings, complementing diagnostic considerations with cultural elements such as a "Cultural Formulation Interview" to assess how cultural factors influence a client's experience of symptoms, past help-seeking, and potential social supports.

13.4 Benefits and Costs of Diagnostic Labels

Diagnostic labels, while essential for clinical practice, have various implications:

Benefits

  1. Enhanced Treatment: Clear and standardized labels allow providers to develop and utilize evidence-based, disorder-specific treatment strategies adapted to specific disorders, ensuring more targeted and effective interventions.

  2. Research Facilitation: Specific diagnoses provide a common language for researchers, enabling the establishment of prevalence rates, identification of risk factors, investigation of biological underpinnings, and improvement of resource allocations for specific populations.

  3. Client Relief: Receiving a diagnosis can bring significant relief to individuals, providing an explanation for their confusing and distressing symptoms. Labels can alleviate self-blame, validate their experiences, and encourage individuals to pursue appropriate treatment, knowing they are not alone.

Costs

  1. Stigma: Diagnostic labels can reinforce negative stereotypes, leading to significant societal stigma. This can result in discrimination in employment, housing, and social interactions, as well as self-doubt and societal ostracization for individuals with mental illness. The label can overshadow the person.

  2. Misdiagnosis: Labels may foster a rigid view of disorders, leading to oversimplification or overlooking the unique complexities of an individual's presentation. This rigidity can overshadow the potential for recovery or lead to misdiagnosis when symptoms overlap with other conditions, potentially misdirecting treatment.

  3. Inducing Despair: Some patients may internalize their diagnosis, believing it defines their identity in an immutable or helpless way. This can lead to a sense of hopelessness, reduced motivation for recovery, and a self-fulfilling prophecy where the individual limits their own potential based on the label.

To combat stigma, the use of "person-first" language (e.g., "a person with schizophrenia" instead of "a schizophrenic") is advocated to highlight the individual over the disorder, emphasizing their humanity and potential beyond their diagnosis.

13.5 The Diathesis-Stress Model of Psychological Disorders

The diathesis-stress model underscores that psychological disorders arise from the interplay and combination of genetic or biological predispositions (diatheses) and environmental or psychological stressors. Both factors typically need to converge and interact for a disorder to manifest. A diathesis creates a vulnerability, and then a stressor acts as a trigger. Situational factors, early life experiences (e.g., childhood trauma), and individual cognitive patterns (e.g., negative attributional styles) can significantly contribute to this interplay, modulating how diatheses are expressed under stress.

  • Examples of diathesis: Genetic vulnerability to a particular disorder (e.g., a family history of depression), previous trauma leading to altered brain structure or function, certain personality traits (e.g., neuroticism), or cognitive styles (e.g., learned helplessness, perfectionism) that increase susceptibility.

  • Examples of stressors: Major life events (e.g., divorce, job loss, death of a loved one), chronic environmental stressors (e.g., poverty, discrimination, abusive relationships), or acute traumatic experiences (e.g., assault, accident).

13.6 Specific Phobias and Social Anxiety Disorder

Anxiety disorders are among the most prevalent psychological disorders, characterized by persistent, excessive anxiety and fear. This anxiety is disproportionate to the actual threat and significantly interferes with daily functioning.

Specific Phobias

Specific phobias involve an excessive, persistent, and irrational fear of particular objects or situations (stimuli), leading to immediate anxiety and consistent avoidance behavior. It's crucial to distinguish between normal fear and a phobia; normal fears are transient, context-dependent, and proportionate to the actual threat, whereas phobic fears are disproportionate to the actual danger. Common types include: animal type (e.g., spiders, snakes), natural environment type (e.g., heights, storms, water), blood-injection-injury type (e.g., needles, seeing blood), and situational type (e.g., enclosed spaces, flying). The lifetime prevalence in the U.S. is approximately 13 percent, and women are diagnosed more frequently than men.

Social Anxiety Disorder

Social anxiety disorder (also known as social phobia) reflects persistent and irrational fears of social scrutiny, negative evaluation, and embarrassment in social situations. This often leads to intense distress and avoidance of social interactions or performance situations where the individual might be judged. Examples include public speaking, eating in public, meeting new people, or using public restrooms. Individuals struggle with self-perception, often catastrophizing potential social mishaps, and experience heightened anticipatory anxiety related to social interactions. The lifetime prevalence of social anxiety disorder is also around 13 percent.

13.7 Panic Disorder and Agoraphobia

Panic disorder is marked by recurrent, unexpected panic attacks and a persistent fear of experiencing future episodes, leading to significant changes in behavior (e.g., avoidance). Panic attacks are abrupt surges of intense fear or discomfort that reach a peak within minutes, often accompanied by a range of distressing physical and cognitive symptoms. The biological and psychological ramifications of panic attacks often lead to agoraphobia, wherein individuals develop a fear of situations where escape might be difficult or embarrassing, or where help might not be available during a panic attack. Panic disorder occurs in about 5 percent of women and 2 percent of men in the U.S.

Symptoms of Panic Attacks

Characteristics of a panic attack include intense physical symptoms such as labored breathing (shortness of breath, hyperventilation), heart palpitations or a pounding heart, chest pain, dizziness, trembling, sweating, nausea, and derealization (feelings of unreality). Cognitively, individuals experience a sense of impending doom, a fear of losing control, or fear of dying. The intense fear of future panic attacks frequently results in anticipatory anxiety and avoidance of certain scenarios (e.g., crowded places, public transport), creating a cycle of dependency on "safe" spaces or people, severely limiting an individual's freedom.

13.8 Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is characterized by pervasive, excessive, and uncontrollable worry that is difficult to turn off and affects multiple aspects of life, such as work, family, finances, and health. This worry is often chronic, occurring on most days for at least six months, and is not tied to a specific, immediate threat. The prevalence rate in the U.S. is about 6 percent. Individuals often grapple with restlessness, feeling on edge, difficulty concentrating (mind going blank), irritability, disrupt sleep (difficulty falling or staying asleep), and bodily symptoms like persistent muscle tension and fatigue. GAD is distinct from other anxiety disorders in its continuous and unfocused nature, unlike specific phobias or panic disorder that are typically triggered by specific stimuli or situations.

13.9 Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) features intrusive, unwanted, and recurrent thoughts, urges, or images (obsessions) that cause marked anxiety or distress, coupled with repetitive mental acts (e.g., praying, counting) or behaviors (e.g., handwashing, checking, ordering) that the individual feels driven to perform in response to an obsession or according to rigid rules (compulsions). These compulsions are aimed at reducing the anxiety generated by the obsessions or preventing some dreaded event, but they are often not realistically connected to what they are designed to neutralize. Up to 2 percent of the U.S. population is affected, with symptoms typically beginning in childhood or early adulthood.

Characteristics of OCD

Symptoms vary widely but commonly include fears of contamination (leading to excessive cleaning rituals), doubts about having locked doors or turned off appliances (leading to repetitive checking behaviors), a need for symmetry or exactness, or aggressive/sexual intrusive thoughts. These rituals are time-consuming, causing notable discomfort and emotional turmoil when disrupted, and lead to substantial impairments in daily functioning, social interactions, and occupational performance due to their compulsive and often pervasive nature.

13.10 Trauma- and Stressor-Related Disorders

Triggered by exposure to actual or threatened death, serious injury, or sexual violence, trauma- and stressor-related disorders include acute stress disorder (ASD) and posttraumatic stress disorder (PTSD). ASD has similar symptoms to PTSD but lasts for a shorter period, from 3 days to 1 month following the trauma. If symptoms persist beyond one month, a diagnosis of PTSD may be made. PTSD affects approximately 7 percent of the U.S. population. It is characterized by four main symptom clusters: 1) Intrusion symptoms (e.g., recurrent, intrusive memories; nightmares; flashbacks); 2) Avoidance of reminders (e.g., thoughts, feelings, places, people); 3) Negative alterations in cognitions and mood (e.g., distorted beliefs about oneself or the world, persistent negative emotional states, anhedonia); and 4) Alterations in arousal and reactivity (e.g., irritability, hypervigilance, exaggerated startle response, difficulty concentrating or sleeping). Trauma exposure does not guarantee PTSD, as only a fraction of individuals who experience trauma develop the disorder, influenced by factors like resilience, social support, and the nature of the trauma.

13.11 What Causes Anxiety-Related Disorders?

Anxiety-related disorders arise from a complex interaction of genetic predispositions, reflecting inherited vulnerabilities, alongside environmental triggers and learning experiences. Biological risk factors include genetic elements that influence neurotransmitter systems (e.g., dysregulation of GABA, serotonin, or norepinephrine), as well as structural and functional abnormalities in brain regions involved in fear and emotional processing, such as the amygdala and prefrontal cortex. Psychological maltreatment (e.g., emotional abuse, neglect) and behavioral experiences (e.g., classical conditioning of fear, observational learning) serve to introduce and maintain risks across multiple anxiety disorders, emphasizing the necessity of multi-faceted treatment approaches that address both biological and psychological factors.

13.12 Major Depressive Disorder

Mental health professionals consider major depressive disorder (MDD) when a person experiences five or more specific symptoms for at least two weeks, including either marked depressed mood (e.g., sadness, emptiness, hopelessness) or loss of interest or pleasure (anhedonia) in nearly all activities. Other common accompanying symptoms include significant weight changes or appetite disturbance, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, diminished ability to think or concentrate, and recurrent thoughts of death or suicide. The lifetime prevalence ranges from 7-25%, varying between men and women, with women being diagnosed more frequently. Studies indicate that ruminative thought patterns (repetitively dwelling on negative thoughts, problems, and feelings) significantly exacerbate depressive symptoms, particularly among women, contributing to the longer duration and higher incidence of depression.

13.13 Bipolar Disorder

Bipolar disorder is characterized by distinct periods of abnormally and persistently elevated, expansive, or irritable mood (manic episodes) alternating with major depressive episodes. There are different types, with Bipolar I Disorder involving at least one manic episode, and Bipolar II Disorder involving hypomanic episodes (less severe mania) and major depressive episodes. The lifetime prevalence is approximately 4 percent in the U.S. During manic episodes, individuals display lofty goals, grandiosity (inflated self-esteem), decreased need for sleep, rapid or racing thoughts, increased talkativeness, impulsivity, and scant regard for consequences, often leading to risky behaviors (e.g., excessive spending, reckless driving, promiscuity). The disorder can involve significant cognitive and emotional extremes which severely interfere with functioning across all life domains, thus demonstrating the necessity for early diagnosis and effective treatment strategies, including mood stabilizers.

13.14 Suicide

Annually, over 800,000 individuals die by suicide globally, making it a leading cause of death worldwide. The strongest and most consistent predictors of suicide include the presence of mental disorders, notably mood disorders (e.g., major depressive disorder, bipolar disorder), and a history of previous suicide attempts. Other significant risk factors include access to lethal means, chronic physical pain or illness, recent interpersonal loss, social isolation, and exposure to suicidal behavior in others. Societal stigma surrounding mental illness and suicide exacerbates the risks by deterring individuals from seeking help, necessitating keen awareness, open communication, and strategic interventions (e.g., crisis hotlines, means restriction, public education) to mitigate risks and promote prevention.

13.15 What Causes Mood-Related Disorders?

Major depressive and bipolar disorders arise from interlinked biological, psychological, and social factors, forming a complex etiological model. Genetic predispositions play significant roles in vulnerability, with heritability estimates ranging from 37-50% for MDD and 60-80% for bipolar disorder, indicating a substantial inherited component. Neurotransmitters such as serotonin, dopamine, and norepinephrine are intricately implicated in these disorders; imbalances or dysregulation in their synthesis, release, reuptake, or receptor sensitivity influence mood regulation, energy levels, and emotional responses (e.g., low serotonin is often associated with depression; dopamine dysregulation with mania). Chronic exposure to stressors in adverse environments (e.g., poverty, childhood adversity, chronic interpersonal conflict), along with cognitive factors (e.g., negative cognitive triad, learned helplessness), further contributes to the prevalence and severity of mood-related disorders.

13.16 Symptoms and Prevalence of Schizophrenia

Schizophrenia manifests through a range of severe cognitive, emotional, and behavioral symptoms, typically categorized into positive, negative, and cognitive symptoms. Positive symptoms reflect an excess or distortion of normal functions, such as delusions (firmly held false beliefs, e.g., persecutory, grandiose, referential) and hallucinations (sensory experiences without external stimuli, most commonly auditory, but also visual, tactile, or olfactory). Negative symptoms reflect a diminution or absence of normal functions, including emotional dysregulation (e.g., flat affect, apathy), alogia (poverty of speech), avolition (lack of motivation), and anhedonia (inability to experience pleasure). Cognitive impairments involve deficits in executive functions, working memory, and attention. With a lifetime prevalence of approximately 0.5% worldwide, schizophrenia typically arises in late adolescence or early adulthood, carrying profound implications for quality of life, daily functioning, education, and employment across the lifespan.

13.17 Brain Bases of Schizophrenia

The dopamine hypothesis posits that dysregulation and dysfunction in dopamine systems underlie many symptoms of schizophrenia. Specifically, an excess of dopamine activity in the mesolimbic pathway is thought to contribute to positive symptoms (e.g., hallucinations, delusions), while a deficit of dopamine in the mesocortical pathway is linked to negative and cognitive symptoms. Furthermore, structural abnormalities in various brain regions associated with emotion, cognition, and sensory processing contribute to the complexity of this disorder. Studies often reveal enlarged ventricles, reduced gray matter volume (particularly in the frontal and temporal lobes), and abnormal neural connectivity. These neurobiological findings necessitate a comprehensive understanding of both genetic and environmental contributions to the disorder.

13.18 What Causes Schizophrenia?

Schizophrenia's etiology is multifaceted, involving a complex interplay of genetic susceptibility, neurodevelopmental abnormalities, and environmental factors. Genetic factors play a significant role, as evidenced by twin and adoption studies showing substantial concordance rates (e.g., 48% for identical twins, 17% for fraternal twins). This suggests multiple genes, not a single one, contribute to vulnerability. Prenatal exposure to infections (e.g., influenza, rubella), birth complications (e.g., oxygen deprivation, premature birth), and maternal malnutrition can impact fetal brain development and increase risk. Significant psychosocial stressors (e.g., urbanicity, cannabis use in adolescence, family environments with high expressed emotion) are believed to act as triggers or exacerbating factors, particularly for individuals already genetically predisposed, impacting neural development and functioning and leading to the disorder's onset.

13.19 Psychological Disorders and the Law

Legal frameworks govern how psychological disorders intersect with criminal responsibility and the necessity for civil commitment. Key concepts include the "insanity defense," which argues that a person should not be held criminally responsible for an act due to a mental disease or defect that prevented them from knowing the nature or wrongfulness of their actions (e.g., M'Naghten Rule) or from controlling their behavior. Another concept is "competency to stand trial," which involves assessing whether a defendant has a factual and rational understanding of the legal proceedings against them and can assist in their own defense. Understanding the nuances of when individuals can be held accountable for actions versus when they require involuntary treatment for mental health concerns through civil commitment (which allows for the detention and treatment of individuals who pose a danger to themselves or others due or are gravely disabled due to mental illness) is critical to informing public policy and societal attitudes towards mental illness, balancing individual rights with public safety.

13.20 Autism Spectrum Disorder

Autism Spectrum Disorder (ASD) is a developmental disorder encompassing persistent deficits in social interaction, social communication, and restricted, repetitive patterns of behavior, interests, or activities. The noted prevalence is between 1-2% in the U.S. The diagnosis is typically made in early childhood, often around age 2-3, and the "spectrum" reflects a wide variety of symptom severity and functioning levels, from individuals requiring substantial support to those who are highly independent. Deficits in social interaction include challenges with nonverbal communication (e.g., eye contact, facial expressions), developing and maintaining relationships, and social-emotional reciprocity (e.g., sharing interests, emotions). Communication challenges can involve delays in language development, repetitive use of language (e.g., echolalia), or difficulty understanding nuances. Restricted patterns of behavior manifest as highly fixated, abnormal interests, repetitive motor movements (e.g., hand-flapping), insistence on sameness, and unusual responses to sensory input (e.g., hyper- or hypo-reactivity to sensory stimuli). Genetic factors and biological dysfunctions (e.g., differences in brain structure and connectivity) substantively contribute to the disorder's manifestations.

13.21 Attention-Deficit/Hyperactivity Disorder (ADHD)

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder frequently diagnosed in children, with symptoms persisting into adulthood for a significant portion of affected individuals. The disorder is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. Inattentive symptoms include difficulty maintaining focus on tasks, being easily distracted, not listening when spoken to directly, and poor organization. Hyperactivity-impulsivity symptoms involve fidgeting, excessive talking, difficulty waiting turn, and interrupting others. It reflects underlying challenges in executive functions, particularly in attention shifting, inhibitory control, and working memory, often linked to dysregulation in the prefrontal cortex and dopamine pathways. Research demonstrates significant genetic influence, with heritability estimates ranging from 70-80%. Stimulant medications are commonly prescribed and have been shown to be effective interventions for managing core symptoms, despite ongoing debates over diagnosis prevalence, potential overdiagnosis, and long-term treatment effects and strategies.

13.22 Dissociative Identity Disorder (DID)

Dissociative Identity Disorder (DID), formerly known as Multiple Personality Disorder, is a controversial and complex disorder featuring the existence of two or more distinct personality states (often referred to as "alters" or identities) within a single individual. Each identity may have its own distinct patterns of perceiving, relating to, and thinking about the environment and self, frequently exhibiting different memories, behaviors, and emotional responses. The disorder is marked by recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events, beyond normal forgetfulness. The rapid increase in diagnoses following the publication of "Sybil" in the 1970s, alongside cultural influences, media portrayal, and certain therapeutic practices (e.g., encouraging the recovery of suppressed memories), has raised questions about the validity and understanding of DID. While the prevailing view is that it is a response to severe, prolonged childhood trauma (trauma model), some theories suggest it may be iatrogenically induced or influenced by socio-cognitive factors (sociocognitive model) in suggestible individuals, leading to a high degree of skepticism and debate within the psychiatric community. It remains one of the most enigmatic and least understood psychological disorders.