Understanding Abnormal Behavior

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Biological Dimension Genetics, Brain Anatomy, Biochemical Imbalances, Central Nervous System Functioning, Autonomic Nervous System Reactivity, etc.

Sociocultural Dimension Race, Gender, Sexual Orientation, Religion, Socioeconomic Status, Ethnicity, Culture, etc.

MENTAL DISORDER

Psychological Dimension Personality, Cognition, Emotions, Learning, Stress-Coping, SelfEsteem, Self-Efficacy, Values, Developmental History, etc.

Social Dimension Family, Relationships, Social Support, Belonging, Love, Marital Status, Community, etc.

Multipath Model of Mental Disorders The multipath model describes how four major dimensions—biological, psychological, social, and sociocultural—contribute to the development of mental disorders. It operates under several assumptions: • No one theoretical perspective is adequate to explain the complexity of the human condition and the development of mental disorders. • There are multiple pathways and causes to any single disorder. It is a statistical rarity to find a disorder due to only one cause. • Not all dimensions contribute equally to a disorder. • It is guided by the state of research and scientific findings as to the relative merits of a proposed cause. • The multipath model is an integrative and interactive one. It acknowledges that factors may combine in complex and reciprocal ways so that people exposed to the same factors may not develop the same disorder and that different individuals exposed to different factors may develop a similar mental disorder.

Understanding Abnormal Behavior David Sue Western Washington University Derald Wing Sue Teachers College, Columbia University Stanley Sue University of California—Davis

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b r ief con t en t s

Features xv Preface xvi About the Authors xxiii

1 Abnormal Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2 Models of Abnormal Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 3 Assessment and Classification of Abnormal Behavior . . . . . 66 4 The Scientific Method in Abnormal Psychology . . . . . . . . . . . . 93 5 Anxiety Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 6 Dissociative Disorders and Somatoform Disorders. . . . . . . . 149 7 Stress Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 8 Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 9 Substance-Related Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 10 Sexual and Gender Identity Disorders . . . . . . . . . . . . . . . . . . . . . 264 11 Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303 12 Suicide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333 13 Schizophrenia: Diagnosis, Etiology, and Treatment . . . . . . . 359 14 Cognitive Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390 15 Disorders of Childhood and Adolescence. . . . . . . . . . . . . . . . . . 412 16 Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443 17 Legal and Ethical Issues in Abnormal Psychology . . . . . . . . . 474 Glossary G-1 References R-1 Credits C-1 Name Index I-1 Subject Index I-13

iii

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con t en t s

Features xv Preface xvi About the Authors

1

xxiii

Abnormal Behavior

2

The Concerns of Abnormal Psychology Describing Abnormal Behavior Explaining Abnormal Behavior Predicting Abnormal Behavior Controlling Abnormal Behavior

3

Reversion to Supernatural Explanations (the Middle Ages) 17 The Rise of Humanism (the Renaissance) 19 The Reform Movement (Eighteenth and Nineteenth Centuries) 20

7

Causes: Early Viewpoints

3 4 4 5

Determining Abnormality Distress 8 Deviance 8 Dysfunction 8 Dangerousness 9

Contemporary Trends in Abnormal Psychology

The Frequency and Burden of Mental Disorders

12

Stereotypes About the Mentally Disturbed

14

The Drug Revolution in Psychiatry 23 The Push by Psychologists for Prescription Privileges 24 The Development of Managed Health Care 24 An Increased Appreciation for Research 25 The Influence of Multicultural Psychology 26 CRITICAL THINKING: I Have It, Too: The Medical Student Syndrome 28

Historical Perspectives on Abnormal Behavior

16

Implications

Contextual and Cultural Limitations in Defining Abnormal Behavior

9

CONTROVERSY: Is Mental Illness a Myth and a

Political Construction?

12

Prehistoric and Ancient Beliefs 16 Naturalistic Explanations (Greco-Roman Thought) 16

2

21

The Biological Viewpoint 21 The Psychological Viewpoint 22

Summary

28

29

Models of Abnormal Behavior One-Dimensional Models of Mental Disorders

32

Using Models to Describe Psychopathology 33

A Multipath Model of Mental Disorders

34

Dimension One: Biological Factors

36

The Human Brain 37 Biochemical Theories 38 Genetic Explanations 40 Biology-Based Treatment Techniques 41 Multipath Implications of Biological Explanations 43

23

30 Dimension Two: Psychological Factors

44

Psychodynamic Models 44 Behavioral Models 47 Cognitive Models 51 Humanistic and Existential Models 53 Multipath Implications of Psychological Explanations 55

Dimension Three: Social Factors

56

Social Relational Models 56

v

vi

C O NT E N T S

CONTROVERSY: Problems in Using Racial and Ethnic

Family, Couples, and Group Perspectives 56 Social-Relational Treatment Approaches 57 Criticisms of Social-Relational Models 57

Dimension Four: Sociocultural Factors

58

Gender Factors 58 Socioeconomic Class 59 Race/Ethnicity: Multicultural Models of Psychopathology 59

3

Implications Summary

64

65

Assessment and Classification of Abnormal Behavior Reliability and Validity

67

The Classification of Abnormal Behavior

The Assessment of Abnormal Behavior

68

Diagnostic and Statistical Manual of Mental Disorders (DSM) 83 DSM-IV-TR Mental Disorders 85 Evaluation of DSM Classification System 85 Objections to Classification and Labeling 90

Observations 68 Interviews 69 Psychological Tests and Inventories 71 CONTROVERSY: Should the Rorschach Be Used in

Making Assessments? 74 Neurological Tests 80 The Ethics of Assessment 81 CRITICAL THINKING: Can We Accurately Assess the Status of Members of Different Cultural Groups? 82

4

Group References 60 Criticisms of the Multicultural Model 61 CRITICAL THINKING: Applying the Models of Psychopathology 62

Implications Summary

CRITICAL THINKING: Attacks on Scientific Integrity

96 97

Characteristics of Clinical Research 97 CONTROVERSY: Repressed Memories: Issues and Questions 99

Experiments

100

The Experimental Group 101 The Control Group 101 The Placebo Group 102 Additional Concerns in Clinical Research 102

Correlations

92

CRITICAL THINKING: Researcher Allegiance:

A “Wild Card” in Comparative Research 105

Analogue Studies

106

Field Studies

107

Single-Participant Studies

108

The Case Study 108 The Single-Participant Experiment 109

Biological Research Strategies The Human Genome Project 110

110

93

Genetic Linkage Studies 110 The Endophenotype Concept 110 Other Concepts in Biological Research 111

Epidemiological and Other Forms of Research

112

Ethical Issues in Research

113

Implications Summary

103

83

91

The Scientific Method in Abnormal Psychology The Scientific Method in Clinical Research

66

114

115

vii

C ONT ENT S

5

Anxiety Disorders Understanding Anxiety Disorders from a Multipath Perspective

117 119

Biological Dimension 119 Psychological Dimension 122 Social and Sociocultural Dimensions 123

Phobias

124

Social Phobias 125 Specific Phobias 127 Etiology of Phobias 128 CONTROVERSY: Fear or Disgust? 129 Treatment of Phobias 131

Panic Disorder and Agoraphobia

133

Panic Disorder 133 Agoraphobia 134 Etiology of Panic Disorder and Agoraphobia 134 Treatment of Panic Disorder 136 CRITICAL THINKING: Panic Disorder Treatment: Should We Focus on Internal Control? 138

Generalized Anxiety Disorder

138

Etiology of Generalized Anxiety Disorder 139 Treatment of Generalized Anxiety Disorder 140

Obsessive-Compulsive Disorder

141

Implications

Obsessions 142 Compulsions 142

6

Etiology of Obsessive-Compulsive Disorder 143 Treatment of Obsessive-Compulsive Disorder 146 Summary

147

147

Dissociative Disorders and Somatoform Disorders Dissociative Disorders

150

Somatoform Disorders Somatization Disorder 164 Conversion Disorder 164

CRITICAL THINKING: Factitious Disorder and Factitious

Order by Proxy 165 Pain Disorder 167 Hypochondriasis 167 Body Dysmorphic Disorder 168 Etiology of Somatoform Disorders 169 Treatment of Somatoform Disorders 172

Dissociative Amnesia 150 Dissociative Fugue 153 Depersonalization Disorder 153 Dissociative Identity Disorder (Multiple-Personality Disorder) 154 CRITICAL THINKING: Culture and Somatoform and Dissociative Disorders 156 Etiology of Dissociative Disorders 157 CONTROVERSY: “Suspect” Techniques Used to Treat Dissociative Identity Disorder 160 Treatment of Dissociative Disorders 161

Implications Summary

162

149

173

174

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7

CO N T E N T S

Stress Disorders Acute and Posttraumatic Stress Disorders

175 176

Diagnosis of Acute and Posttraumatic Stress Disorders 176

Etiology of Acute and Posttraumatic Stress Disorders

177

Biological Dimension 178 Psychological Dimension 179 Social Dimension 180 Sociocultural Dimension 180

Treatment of Acute and Posttraumatic Stress Disorders

Etiology of Psychophysiological Disorders

181

CRITICAL THINKING: The Hmong Sudden Death

Syndrome 183 Characteristics of Psychophysiological Disorders 183 Coronary Heart Disease 183 Hypertension 184

Treatment of Psychophysiological Disorders

Implications Summary

199

200

201

Diagnosing Personality Disorders

203

Disorders Characterized by Odd or Eccentric Behaviors

205

CONTROVERSY: Impulse Control Disorders

Implications Summary

210

Antisocial Personality Disorder 210 Borderline Personality Disorder 212 Histrionic Personality Disorder 215 Narcissistic Personality Disorder 216

217

Avoidant Personality Disorder 217 Dependent Personality Disorder 218 Obsessive-Compulsive Personality Disorder 219

Multipath Analysis of One Personality Disorder: Antisocial Personality Disorder Biological Dimension 221

Psychological Dimension 224 Social Dimension 225 Sociocultural Dimension 226

Treatment of Antisocial Personality Disorder 227

Paranoid Personality Disorder 205 CRITICAL THINKING: Is There Gender Bias in Diagnosing Mental Disorders? 207 Schizoid Personality Disorder 208 Schizotypal Personality Disorder 208

Disorders Characterized by Anxious or Fearful Behaviors

197

Relaxation Training 197 Biofeedback 198 Cognitive-Behavioral Interventions 198

Personality Disorders

Disorders Characterized by Dramatic, Emotional, or Erratic Behaviors

192

Biological Dimension 192 Psychological Dimension 194 Social Dimension 196 Sociocultural Dimension 196

Physical Stress Disorders: Psychophysiological Disorders 182

8

Migraine, Tension, and Cluster Headaches 186 Asthma 188 Stress and the Immune System 190 CONTROVERSY: Can Laughter or Humor Influence the Course of a Disease? 191

221

230

231

228

ix

CONT ENT S

9

Substance-Related Disorders Substance-Use Disorders

235

Depressants or Sedatives 236 Stimulants 241 Hallucinogens 244

Etiology of Substance-Use Disorders

246

Biological Dimension 247 Psychological Dimension 249 CONTROVERSY: Is Drug Addiction a Disease? 250 Social Dimension 252 CRITICAL THINKING: Is Drug Use an Indicator of Disturbance? 253 Sociocultural Dimension 254

10

232 Intervention and Treatment of Substance-Use Disorders Pharmacological Approach 255 Cognitive and Behavioral Approaches 257 Self-Help Groups 258 CONTROVERSY: Controlled Drinking

Implications Summary

265

CONTROVERSY: Is Compulsive Sexual Behavior

262

262

270

Sexual Desire Disorders 271 Sexual Arousal Disorders 273 Orgasmic Disorders 275 Sexual Pain Disorders 275

Etiology of Sexual Dysfunctions

276

288

Rape

296

Implications Summary

280

Biological Interventions 280 Psychological Treatment Approaches 282

Homosexuality

283

Aging, Sexual Activity, and Sexual Dysfunctions

284

Gender Identity Disorder

286

Etiology of Gender Identity Disorder 287 Treatment of Gender Identity Disorder 288 Is GID a Valid Psychiatric Diagnosis? 288

Paraphilias

Effects of Rape 298 Etiology of Rape 299 Treatment for Rapists 299 CRITICAL THINKING: Why Do Men Rape Women? 300

Biological Dimension 278 Psychological Dimension 278 Social Dimension 279 Sociocultural Dimension 279

Treatment of Sexual Dysfunctions

264

Paraphilias Involving Nonhuman Objects 290 Paraphilias Involving Nonconsenting Persons 291 Paraphilias Involving Pain or Humiliation 293 Etiology and Treatment of Paraphilias 294

an Addiction? 267 The Study of Human Sexuality 268 The Sexual Response Cycle 268

Sexual Dysfunctions

259

Multimodal Treatment 259 Prevention Programs 260 Effectiveness of Treatment 261

Sexual and Gender Identity Disorders What Is “Normal” Sexual Behavior?

255

301

301

x

CO N TE N T S

11

Mood Disorders

303

Unipolar Depression

304

Symptoms of Unipolar Depression 304 Diagnosis and Classification of Depressive Disorders 307 CONTROVERSY: When Is One Depressed? 308 Prevalence of Unipolar Depression 309

Bipolar Disorders

Etiology of Unipolar Depression

310

Biological Dimension 310 Psychological Dimension 313 Social Dimension 317 Sociocultural Dimension 319

Treatment for Unipolar Depression

322

Biomedical Treatments for Depressive Disorders 323 CRITICAL THINKING: Should We Increasingly Turn to Drugs in the Treatment of Depression? 324

12

Suicide 335

CRITICAL THINKING: Why Do People Kill

Themselves? 336 Facts About Suicide 337

A Multipath Perspective of Suicide

343

Biological Dimension 343 Psychological Dimension 344 Social Dimension 345 Sociocultural Dimension 346

Victims of Suicide

347

Children and Adolescents 347 Elderly People 349

Preventing Suicide

350

Clues to Suicidal Intent 351 Crisis Intervention 351 Suicide Prevention Centers 353

The Right to Suicide: Moral, Ethical, and Legal Issues CONTROVERSY: Do People Have a Right to Die?

Summary

327

Symptoms and Characteristics of Bipolar Disorders 327 Classification of Bipolar Disorders 328 Prevalence of Bipolar Disorders 329 Comparison Between Depressive and Bipolar Disorders 329

Etiology of Bipolar Disorders

329

Treatment for Bipolar Disorders

330

Implications Summary

331

332

333

Correlates of Suicide

Implications

Psychotherapy and Behavioral Treatments for Depressive Disorders 324

357

358

354 356

xi

CONT ENT S

13

Schizophrenia: Diagnosis, Etiology, and Treatment The Symptoms of Schizophrenia

359

361

Positive Symptoms 361 CONTROVERSY: Should We Challenge Delusions and Hallucinations? 364 Negative Symptoms 366 Cognitive Symptoms 367 Cultural Issues 367

Types of Schizophrenia

368

Paranoid Schizophrenia 369 Disorganized Schizophrenia 369 Catatonic Schizophrenia 369 Undifferentiated and Residual Schizophrenia 370 Psychotic Disorders That Were Once Considered Schizophrenia 371 Other Psychotic Disorders 371 CONTROVERSY: Delusional Parasitosis or Physical Disease? 373

The Course of Schizophrenia

The Treatment of Schizophrenia CONTROVERSY: Balancing Prevention and Harm

373

Long-Term Outcome Studies 374

Etiology of Schizophrenia

374

Biological Dimension 375 Psychological Dimension 378 Social Dimension 379 Sociocultural Dimension 381

14

Implications Summary

389

389

390

The Assessment of Brain Damage

392

Types of Cognitive Disorders

393

Dementia 393 Delirium 394 Amnestic Disorders 395 Traumatic Brain Injury 396 Aging and Disorders Associated with Aging 398 Alzheimer’s Disease 400

385

Psychosocial Therapy 385 Interventions Focusing on Family Communication and Education 388

Cognitive Disorders

Etiology of Cognitive Disorders

383

Antipsychotic Medication 383

Cerebral Tumors 406 Epilepsy 406 Use of Psychoactive Substances 408

Treatment/Prevention Considerations 395

Medication 408 Cognitive and Behavioral Approaches 409 Lifestyle Changes 409 Environmental Interventions and Caregiver Support 410

CRITICAL THINKING: Moderators and Mediators:

Implications

What Causes What? 402 Other Diseases and Infections of the Brain 404

Summary

410

411

408

xii

15

CO N T E N T S

Disorders of Childhood and Adolescence CONTROVERSY: Are We Overmedicating Children?

Pervasive Developmental Disorders

412

414

414

Autistic Disorder 415 Other Pervasive Developmental Disorders 417 Etiology 419 Prognosis 421 Treatment 421

Attention Deficit/Hyperactivity Disorders and Disruptive Behavior Disorders

422

Attention Deficit/Hyperactivity Disorders 422 Oppositional Defiant Disorder 426 Conduct Disorders 427 CRITICAL THINKING: School Violence: A Sign of

the Times? 429

Elimination Disorders

431

Enuresis 431 CRITICAL THINKING: Child Abuse

432

434

Etiology 434 Treatment 435

16

Implications Summary

442

442

Eating Disorders Eating Disorders

443 444

Anorexia Nervosa 446 CRITICAL THINKING: Anorexia’s Web 448 Bulimia Nervosa 449 Binge-Eating Disorders 451 Eating Disorder Not Otherwise Specified 453

Etiology of Eating Disorders

Treating Anorexia Nervosa 464

Treating Bulimia Nervosa 466 Treating Binge-Eating Disorder 466

Obesity

467

Etiology of Obesity

469

Biological Dimension 469

454

Biological Dimension 454 Psychological Dimension 455 Social Dimension 456 Sociocultural Dimension 457 CRITICAL THINKING: Is Our Society Creating Eating Disorders? 462

Treatment of Eating Disorders

435

Diagnosing Mental Retardation 436 Etiology of Mental Retardation 437 Programs for People with Mental Retardation 440

Encopresis 433

Learning Disorders

Mental Retardation

CONTROVERSY: Are the BMI Index Standards

Appropriate? 470 Psychological Dimension 470 Social Dimension 471 Sociocultural Dimension 471

Treatments for Obesity Implications

464

Summary

472

472

471

C ONT ENT S

17

Legal and Ethical Issues in Abnormal Psychology Criminal Commitment

xiii 474

478

The Insanity Defense 478 Competency to Stand Trial 481

Civil Commitment

482

Criteria for Commitment 483 Procedures in Civil Commitment 484

Rights of Mental Patients

485

CRITICAL THINKING: Predicting Dangerousness: The Case

of Serial Killers and Mass Murderers 486 Right to Treatment 486 Right to Refuse Treatment 488 CONTROVERSY: Court-Ordered Assisted Treatment:

Coercion or Caring? 489

Deinstitutionalization

490

The Therapist-Client Relationship

492

Confidentiality and Privileged Communication 492 The Duty-to-Warn Principle 493 Sexual Relationships with Clients 494 Glossary G-1 References R-1 Credits C-1 Name Index I-1 Subject Index I-13

Cultural Competence and the Mental Health Profession Implications Summary

496

496

494

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Feat ur es

Critical Thinking

Controversy

I Have It, Too: The Medical Student Syndrome, 28 Applying the Models of Psychopathology, 62 Can We Accurately Assess the Status of Members of Different Cultural Groups? 82 Attacks on Scientific Integrity, 97 Researcher Allegiance: A “Wild Card” in Comparative Research, 105 Panic Disorder Treatment: Should We Focus on Internal Control? 138 Culture and Somatoform and Dissociative Disorders, 156 Factitious Disorder and Factitious Disorder by Proxy, 165 The Hmong Sudden Death Syndrome, 183 Is There Gender Bias in Diagnosing Mental Disorders? 207 Is Drug Use an Indicator of Disturbance? 253 Why Do Men Rape Women? 300 Should We Increasingly Turn to Drugs in the Treatment of Depression? 324 Why Do People Kill Themselves? 336 Moderators and Mediators: What Causes What? 402 School Violence: A Sign of the Times? 429 Child Abuse, 432 Anorexia’s Web, 448 Is Our Society Creating Eating Disorders? 462 Predicting Dangerousness: The Case of Serial Killers and Mass Murderers, 486

Is Mental Illness a Myth and a Political Construction? 12 Problems in Using Racial and Ethnic Group References, 60 Should the Rorschach Be Used in Making Assessments? 74 Repressed Memories: Issues and Questions, 99 Fear or Disgust? 129 “Suspect” Techniques Used to Treat Dissociative Identity Disorder, 160 Can Laughter or Humor Influence the Course of a Disease? 191 Impulse Control Disorders, 228 Is Drug Addiction a Disease? 250 Controlled Drinking, 259 Is Compulsive Sexual Behavior an Addiction? 267 When Is One Depressed? 308 Do People Have a Right to Die? 356 Should We Challenge Delusions and Hallucinations? 364 Delusional Parasitosis or Physical Disease? 373 Balancing Prevention and Harm, 385 Are We Overmedicating Children? 414 Are the BMI Index Standards Appropriate? 470 Court-Ordered Assisted Treatment: Coercion or Caring? 489

Disorder Charts Anxiety Disorders, 119 Dissociative Disorders, 151 Somatoform Disorders, 163 Personality Disorders, 206 Substance-Related Disorders, 235 Sexual Dysfunctions, 272 Paraphilias, 289 Mood Disorders, 305 Schizophrenia, 368 Cognitive Disorders, 391 Pervasive Developmental Disorders, 418 Attention Deficit and Disruptive Behavior Disorders, 423 Learning Disorders, 435 Mental Retardation, 436 Eating Disorders, 445

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p r efa ce

A

bnormal behaviors both fascinate and are of concern to scientists and the general public. Why people exhibit abnormal behaviors, how they express their disturbances, and how such behaviors can be prevented and treated are questions that continue to intrigue us. We now know that all human beings are touched in one way or another by mental disturbance in their lives, either directly through their own struggles to deal with mental disorders or indirectly through affected friends or relatives. Over the years, major research discoveries in genetics, neurobiology, and psychology have made unprecedented contributions to our understanding of abnormal behaviors. This is clearly evident in the Human Genome Project, where scientists have mapped the location of all genes in the human nucleus. The hope among mental health professionals is that the “map of life” will allow for increased understanding of mental disorders and their subsequent treatments. In addition to this tremendous biological breakthrough, we also know that psychological forms of intervention are effective in treating abnormal behaviors. The move to identify empirically supported treatments has taken the profession by storm. Finally, research has revealed the great cultural variations in abnormal behaviors and what other cultures consider effective treatments. In the Ninth Edition of our book, we examine all of these areas. In writing and revising this book, we have sought to engage students in the exciting process of understanding abnormal behavior and the ways that mental health professionals study and attempt to treat it. In pursuing this goal, we have been guided by three major objectives: • To provide students with scholarship of the highest quality, • To offer an evenhanded treatment of abnormal psychology as both a scientific and a clinical endeavor, giving students the opportunity to explore topics thoroughly and responsibly, and • To make our book inviting and stimulating to a wide range of students. In each edition, we have strived to achieve these objectives, working with comments from many students and instructors and our own work in teaching, research, and practice. The Ninth Edition, we believe, builds on the achievements of previous editions and surpasses them.

Our Approach

x vi

We take an eclectic, multicultural approach to the field, drawing on important contributions from various disciplines and theoretical stances. The text covers the major categories of disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), but it is not a mechanistic reiteration of DSM. We believe that different combinations of life experiences and constitutional factors influence behavioral disorders, and we project this view throughout the text. These combinations of factors are demonstrated in our multipath model, which is a way of looking at the causes of disorders new to the Ninth Edition. There are several elements to our multipath model. First, the contributors to mental disorders are divided into four dimensions: biological, psychological, social, and sociocultural. Second, factors in the four dimensions can interact and influence each other in any direction. Third,

PR EFA CE

different combinations within the four dimensions may cause abnormal behaviors. For instance, assume that a person has severe depression. That depression may be caused primarily by a single factor (e.g., death of a loved one) or by an interaction of factors at different dimensions (e.g., caused by child abuse occurring in early life and stressors in adulthood). Thus, a disorder such as depression may be caused by different factors and different combination of factors. Fourth, many disorders appear to be heterogeneous in nature. Therefore, there may be different types or versions of a disorder (a spectrum of the disorder). Finally, different disorders may be caused by similar factors. For example, anxiety as well as depression may be caused by child abuse and interpersonal stress. In fact, anxiety and depression often occur concurrently in people. Sociocultural factors, including cultural norms, values, and expectations, are given special attention. Because we are convinced that cross-cultural comparisons of abnormal behavior and treatment methods can greatly enhance our understanding of disorders, cultural and gender phenomena are emphasized. Indeed, Understanding Abnormal Behavior was the first textbook on abnormal psychology to integrate and emphasize the role of multicultural factors, and although many texts have since followed our lead, the Ninth Edition continues to provide the most extensive coverage and integration of multicultural models, explanations, and concepts available. Not only do we discuss how changing demographics have increased the importance of multicultural psychology, but we also introduce multicultural models of psychopathology in the opening chapters. As with other models of psychopathology (such as psychoanalytic, cognitive, behavioral, biological), we address multicultural issues throughout the text whenever research findings and theoretical formulations allow. For example, cultural factors as they affect assessment, classification, and treatment of various mental disorders are presented to students. Such an approach adds richness to our understanding of mental disorders. As psychologists (and professors), we know that learning is enhanced whenever material is presented in a lively and engaging manner. We achieve these qualities in part by providing case vignettes and clients’ descriptions of their experiences to complement and illustrate research-based explanations. Our goal is to encourage students to think critically rather than merely assimilate a collection of facts and theories. As a result, we hope that students will develop an appreciation of the study of abnormal behavior.

Special Features The Ninth Edition includes a number of new features as well as features that were popularized in earlier editions and, in some cases, have been revised and enhanced. These features are aimed at aiding students in organizing and integrating the material in each chapter. • As previously noted, our new multipath model provides a framework through which students can understand mental disorders. The model is introduced in Chapter 2 and applied throughout the book. • New and updated Critical Thinking boxes provide factual evidence and thoughtprovoking questions that raise key issues in research, examine widely held assumptions about abnormal behavior, or challenge the student’s own understanding of the text material. • New Controversy boxes deal with controversial issues with wide implications for our society. These boxes stimulate critical thinking, evoke alternative views, provoke discussion, and draw students into issues that help them better explore the wider meaning of abnormal behavior in our society. • New and updated Myth and Reality discussions challenge the many myths and false beliefs that have surrounded the field of abnormal behavior and also helps students realize that beliefs, some of which may appear to be “common sense,” must be checked against scientific facts and knowledge.

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• New Did You Know? margin boxes found throughout the book provide fascinating, at-a-glance research-based tidbits for students. • New Implications sections end each chapter, synthesizing the multipath model implications of the chapter material. • Chapter outlines and Focus Questions, appearing in the first pages of every chapter, provide a framework and stimulate active learning—with questions in mind, students begin thinking about the concepts they are about to explore within the chapter. • Integrated chapter Summaries keyed to the Focus Questions provide students with a concise recap of the chapter’s most important concepts and with tentative answers to the chapter opener’s Focus Questions. • New and updated case studies and examples make issues of mental health and mental disorders “come to life” for students and instructors. Many of the cases are taken from actual clinical files, and all are clearly designated within the text’s design. • Streamlined disorder charts provide snapshots of disorders in an easy-to-read format. • Key terms are highlighted in the text and appear in the margins.

New and Updated Coverage of the Ninth Edition Our foremost objective in preparing this edition was to update thoroughly and present the latest trends in research and clinical thinking. This has led to updated coverage of dozens of topics throughout the text, including the following: • The growing ethnic and cultural diversity in the United States and its implications for mental health research, theory, and practice. • Expanded and balanced coverage of the biological perspective and the latest research strategies and findings on genetic factors in mental disorders. • Integrated coverage of the growing prevalence of psychoactive drug use in U.S. society. • New developments concerning the implications of managed health care on mental health services and the use of evidence-based treatments. • Research findings concerning the rates of each mental disorder and the prevalence of disorders according to gender, ethnicity, and age. • Updated suicide coverage. • Coverage of date rape and reasons for why men rape. • Expanded coverage on eating disorders and obesity. • Expanded coverage of learning disorders. • Identification of psychotherapies and treatments that are likely to increase or decrease in use in the future. • Ethical and legal issues raised by recent cases involving insanity pleas, courtroom testimony by psychologists, and assisted suicide. • Integrated coverage of culture-specific therapeutic strategies for treating African American, Asian American, Latino American, and Native American clients. The design of the book has been revamped to present the content in the clearest, most accessible way. As in the previous edition, the Ninth Edition contains an abundance of tables, illustrations, figures, and photographs that graphically show research data, illustrate comparisons and contrasts, and enhance the understanding of concepts or controversies in the field. In addition to updating the book’s coverage, its look, and its special features, we have maintained a streamlined organization of the book, as described next.

P REFA C E

Organization of the Text To make covering the book’s contents over the course of a quarter or semester more manageable, the text is seventeen chapters long, in keeping with feedback from users of the book. Long-time users of our text will immediately notice that we continue to offer features that have been helpful, that we continue to have a chapter on eating disorders (Chapter 16), and that we provide coverage of mental retardation in the chapter on childhood disorders (Chapter 15). In addition, all of the chapters have been thoroughly revised and updated with an eye toward balancing research findings with clinical implications. Chapters 1 through 4 provide a context for viewing abnormal behavior and treatment by introducing students to definitions of abnormal behavior and historical perspectives (Chapter 1), the key theoretical perspectives used to explain deviant behavior (Chapter 2), methods of assessment and classification (Chapter 3), and the research process involved in the study of abnormal behavior (Chapter 4). Especially noteworthy is our new multipath model discussion found in Chapter 2. The bulk of the text, Chapters 5 through 16, presents the major disorders covered in DSM-IV-TR. In each chapter, disorders are viewed through a multipath perspective that focuses on symptoms, etiology, and treatment. Our disorders charts include not only the definitions of disorders but also their prevalence, onset, and course, so, at a glance, students are able to gain an important overview of the disorders. Highlights of the coverage in this part of the book include an entire chapter devoted to suicide (Chapter 12), which was deemed important because of its increasing visibility in the mental health professions and our society. In addition, major contemporary issues involving the right to die, assisted suicide, and our aging population have thrust it into the public limelight as well. This chapter presents information on the reasons for suicide and also on its moral, legal, and ethical implications. Chapter 16 still provides thorough coverage of eating disorders and now includes an expanded discussion of obesity and its possible inclusion in DSM-V. Research now links eating disorders to situational factors, biological proclivity, and other interlocking mental disorders. The fact that the majority of those who suffer from eating disorders are women is also a powerful statement of how the images society portrays to them may result in unhealthy behaviors. Chapter 17 concludes the book with a look at the legal and ethical issues in psychopathology, including topics such as the insanity defense, patients’ rights, confidentiality, and mental health practices in general. In our earlier edition, a separate chapter was devoted to therapy, but we have chosen to discuss treatment approaches in each of the chapters on disorders instead, allowing students closure in covering particular disorders. The therapeutic intervention chapter from previous editions is still available online for those instructors who would like to use it. The text is therefore manageable for a one-semester class. While research findings and knowledge in the field of psychopathology have grown considerably, we have tried to provide the most important and significant developments in the field without sacrificing the scholarly and comprehensive nature of the book.

Ancillaries This text is supported by a rich set of supplementary materials designed to enhance the teaching and learning experience. Several new components make use of new instructional technologies.

For Instructors • Instructor’s Resource Manual: The Instructor’s Resource Manual includes an extended chapter outline, learning objectives, discussion topics, classroom exercises, handouts, and list of supplementary readings and multimedia resources.

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The Instructor’s Resource Manual is available on the instructor Web site, www .cengage.com/psychology/sue, and is also available in print. Please consult your sales representative for further details. Test Bank: The Test Bank is a static test bank in Word that contains 100 multiple-choice and three essay questions (with sample answers) per chapter. Each question is labeled with the corresponding text page reference as well as the type of question being asked for easier test creation. The Test Bank is available on the Diploma Testing CD-ROM and in print. Please consult your sales representative for further details. Diploma Testing CD-ROM: The Diploma Testing CD-ROM—powered by Diploma—is a flexible testing program that allows instructors to create, edit, customize, and deliver multiple types of tests via print, network server, or the Web on either the MAC or WIN platform. It contains 100 multiple-choice and three essay questions (with sample answers) per chapter. Each question is labeled with the corresponding text page reference as well as the type of question being asked for easier test creation. New! PowerLecture with JoinIn: This one-stop digital library and presentation tool includes preassembled Microsoft® PowerPoint® lecture slides that highlight the major topics in abnormal psychology. In addition to a full Instructor’s Resource Manual and Test Bank, PowerLecture also includes JoinIn™ Student Response System, offering instant assessment and better student results. With JoinIn, instructors can perform on-the-spot assessments and gauge students’ understanding of a particular concept or question, while students receive immediate feedback on how well they understand concepts covered in the text and where they need to improve. PowerLecture also houses all of your media resources in one place, including an image library with graphics from the book itself, video clips, and more. Instructor Web site: Instructors can access a variety of resources at any time via www.cengage.com/psychology/sue. The instructor’s Web site includes the complete Instructor’s Resource Manual, presentation materials, video guides, and more. New! CengageNOW with Cengage Learning eBook: CengageNOW™ is an online teaching and learning resource that gives you more control in less time and delivers better outcomes—NOW. CengageNOW offers all of your teaching and learning resources in one intuitive program organized around the essential activities you perform for class—lecturing, creating assignments, grading, quizzing, and tracking student progress and performance. CengageNOW provides students access to an integrated eBook, as well as interactive tutorials, videos, animations, and more that help students get the most out of your course. WebTutor on Blackboard and WebCT: Jumpstart your course with customizable, rich, text-specific content within your Course Management System. Whether you want to Web-enable your class or put an entire course online, WebTutor™ delivers. WebTutor offers a wide array of resources, including media assets, quizzing, weblinks, and more! Visit webtutor.cengage.com to learn more. Abnormal Psych in Film DVD/VHS: The Abnormal Psych in Film® DVD/VHS is a hybrid product that contains clips from popular films such as The Deer Hunter and Apollo 13 that illustrate key concepts in abnormal psychology, as well as thought-provoking footage from documentaries and client interviews. Each clip is accompanied by overviews and discussion questions to help bring the study of abnormal psychology alive for students.

For Students • Study Guide: The Study Guide, available on the student Web site and in print, provides a complete review of the chapter with chapter outlines, learning objectives, fill-in-the-blank review of key terms, and multiple-choice questions.

P REFA C E

Answers to test questions include an explanation for both the correct answer and incorrect answers. • Student Companion Site: This text-specific Web site contains additional study aids, including quizzes, online study guide, interactive Critical Thinking exercises, and multimedia tutorials—all designed to help students improve their grades while learning more about abnormal psychology. All Web resources may be accessed by logging onto the Web site at www.cengage.com/psychology/sue. • Passkeys: Passkeys for protected assets are available with every new copy of the text. Students who have bought a used textbook can purchase access to the student Web site separately. • New! CengageNOW with Cengage Learning eBook: CengageNOW™ is an easyto-use online resource that helps students study in less time to get the grade they want—NOW. A diagnostic study tool featuring the Cengage Learning eBook and Personalized Study, CengageNOW gives students access to valuable text-specific resources that help them focus on just what they don’t know and learn more in less time to get a better grade. If the textbook does not include an access code card, students can go to www.ichapters.com to get CengageNOW with Cengage Learning eBook. • Case Studies in Abnormal Psychology: Case Studies in Abnormal Psychology, by Clark Clipson, California School of Professional Psychology, and Jocelyn Steer, San Diego Family Institute, contains sixteen studies and can be shrink-wrapped with the text at a discounted package price. Each case represents a major psychological disorder. After a detailed history of each case, critical-thinking questions prompt students to formulate hypotheses and interpretations based on the client’s symptoms, family and medical background, and relevant information. The case proceeds with sections on assessment, case conceptualization, diagnosis, and treatment outlook, and is concluded by a final set of discussion questions. • Abnormal Psychology in Context: Voices and Perspectives: Abnormal Psychology in Context: Voices and Perspectives is a supplementary text, written by David Sattler, College of Charleston; Virginia Shabatay, Palomar College; and Geoffrey Kramer, Grand Valley State University, that features forty cases and can be shrink-wrapped with the text at a discounted package price. This unique collection contains first-person accounts and narratives written by individuals who live with a psychological disorder and by therapists, relatives, and others who have direct experience with someone suffering from a disorder. These vivid and engaging narratives are accompanied by critical-thinking questions and a psychological concept guide that indicates which key terms and concepts are covered in each reading.

Acknowledgments We continue to appreciate the critical feedback received from reviewers and colleagues. The following individuals helped us prepare the Ninth Edition by sharing with us valuable insights, opinions, and recommendations. Julia C. Babcock, University of Houston Betty Clark, University of Mary-Hardin Irvin Cohen, Hawaii Pacific University & Kapiolani Community College Lorry Cology, Owens Community College Bonnie J. Ekstrom, Bemidji State University Greg A. R. Febbraro, Drake University Kate Flory, University of South Carolina David M. Fresco, Kent State University

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Jerry L. Fryrear, University of Houston, Clear Lake Michele Galietta, John Jay College of Criminal Justice Christina Gordon, Fox Valley Technical College George-Harold Jennings, Drew University Robert Hoff, Mercyhurst College Kim L. Krinsky, Georgia Perimeter College Brian E. Lozano, Virginia Polytechnic Institute and State University Jan Mohlman, Rutgers University Sherry Davis Molock, George Washington University Rebecca L. Motley, University of Toledo Gilbert R. Parra, University of Memphis Kimberly Renk, University of Central Florida Mark Richardson, Boston University Alan Roberts, Indiana University Daniel L. Segal, University of Colorado at Colorado Springs Tom Schoeneman, Lewis & Clark College Michael D. Spiegler, Providence College Ma. Teresa G. Tuason, University of North Florida Theresa A. Wadkins, University of Nebraska, Kearney Susan Brooks Watson, Hawaii Pacific University Fred Whitford, Montana State University We also wish to acknowledge the continuing support and high quality of work done by Shannon LeMay-Finn and Laura Hildebrand, Development Editors; Henry Cheek, Associate Editor; Jane Potter, Senior Sponsoring Editor; Aileen Mason and Bob Greiner, Senior Project Editors; and Laura Collins, Editorial Assistant. We also thank text designer Susan Gilday, art editor Laura Brown, photo researcher Marcy Kagan, copy editor Elaine Lauble Kehoe, proofreader Mary Kanable, and indexer Leoni McVey. D. S. D. W. S. S. S.

a bout t he aut h or s

David Sue is Professor Emeritus of Psychology at Western Washington University, where he is an associate of the Center for Cross-Cultural Research. He has served as the Director of both the Psychology Counseling Clinic and the Mental Health Counseling Program. He and his wife recently completed the book Counseling and Psychotherapy in a Diverse Society. He received his Ph.D. in Clinical Psychology from Washington State University. His research interests revolve around multicultural issues in individual and group counseling. He and his wife are proud grandparents of two grandsons (twins).

Derald Wing Sue is Professor of Psychology and Education in the Department of Counseling and Clinical Psychology at Teachers College, Columbia University. He has written extensively in the field of counseling psychology and multicultural counseling/therapy and is author of a best-selling book, Counseling the Culturally Diverse: Theory and Practice. Dr. Sue has served as president of the Society of Counseling Psychology and the Society for the Psychological Study of Ethnic Minority Issues. He received his doctorate from the University of Oregon and is married and the father of two children. Friends describe him as addicted to exercise and the Internet.

Stanley Sue is University Distinguished Professor of Psychology and Asian American Studies at the University of California, Davis. He received his B.S. from the University of Oregon and Ph.D. from UCLA. He was Assistant and Associate Professor of Psychology at the University of Washington (1971–1981) and Professor of Psychology at UCLA (1981–1996). His research interests lie in the areas of clinical-community psychology and ethnicity and mental health. His hobbies include working on computers, which has resulted in an addiction to the Internet, and jogging with his wife.

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Abnormal Behavior

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chapter outline The Concerns of Abnormal Psychology

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Determining Abnormality

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Contextual and Cultural Limitations in Defining Abnormal Behavior

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The Frequency and Burden of Mental Disorders

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Stereotypes About the Mentally Disturbed

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Historical Perspectives on Abnormal Behavior

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Causes: Early Viewpoints

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Contemporary Trends in Abnormal Psychology

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IMP LIC AT IONS

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n April 16, 2007, college student Seung Hui Cho used two semiautomatic handguns on the Virginia Tech campus to kill twenty-seven students and five faculty members, wound twenty-five others, and commit suicide with a shot to his head. The incident was the deadliest mass shooting in modern U.S. history and left many grief-stricken, horrified, and baffled at Cho’s actions. To the public, the mass killings immediately brought to mind the 1999 Columbine High School massacre in which Eric Harris and Dylan Klebold killed twelve students and one teacher before committing suicide. The Virginia Tech rampage began in the early morning hours, when Cho shot a female student and male resident assistant in a dormitory. Approximately two hours later, he went to Norris Hall, where classes were in session, and chained shut the building doors to prevent easy escape. There he fired some 174 rounds, killing and wounding many students and professors as he moved from classroom to classroom. While the second attack lasted only nine minutes, to those trapped in the building, it must have seemed like an eternity. Chaos ensued as students fled for their lives. Some jumped from second-story windows to escape, and others attempted to barricade the classroom doors. There were multiple reports of heroic actions by professors and students to save others, but it often resulted in their own deaths (summarized from the Virginia Tech Review Panel, August 2007).

CONTROVERSY Is Mental

Illness a Myth and a Political Construction?

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CRITICAL THINKING I Have It, Too: The Medical Student Syndrome 28

2

In an attempt to make sense out of an apparently “senseless” act, many questions were asked. What could have motivated Cho to carry out such a heinous deed and take so many innocent lives? Why did he commit suicide? Was he deranged, a psychopathic killer, or high on drugs? Were there warning signs that he was homicidal or suicidal? Did he suffer from a mental disorder? Would therapy or medication have helped him? Did his race, culture, and immigration status play any role in his actions?

FOCUSQUESTIONS

1 What is abnormal psychology? 2 What criteria are used to determine normal or abnormal behaviors?

3 How do context and cultural differences affect definitions of abnormality?

4 How common are mental disorders?

1 6 How have explanations of abnormal behavior changed over time?

7 What were early viewpoints on the causes of mental disorders?

8 What are some contemporary trends in abnormal psychology?

5 What are some common misconceptions about the mentally disturbed?

These questions are extremely difficult to answer for a number of reasons. First, we do not know enough about the causes of abnormal behavior and especially mental disorders to arrive at a definitive answer. It appears that psychopathology, or abnormal behavior, is not the result of any singular cause but an interaction of many factors. Most mental disorders have multiple contributors, a fact that we discuss in the next chapter. Second, Cho is no longer alive so that we could ascertain his state of mind. As a result, we must rely on secondary sources such as health or school records, observations by peers, family, and acquaintances, and any other available data (suicide notes, essays, pictures, and media communications) to construct a portrait of his state of mind. Sad to say, the Virginia Tech massacre illustrates how complex the study of abnormal psychology becomes in real life. In a sense, the purpose of this book, Understanding Abnormal Behavior, is to help you answer such questions. To do so, however, requires us first to examine some basic aspects of the study of abnormal behavior, including some of its history and emerging changes in the field. Periodically, we use the Cho case to illustrate the many complex interacting mental health issues in the field.

SEUNG HUI CHO PHOTO SENT TO NBC ON DAY OF THE MASSACRE Was Cho mentally disturbed? At college, he became known as the “question mark kid” because he would only put down a question mark for his name. He would not respond when greeted, sat for hours in his dorm room staring out the window, and referred to an imaginary girlfriend by the name of “Jelly,” a supermodel who lived in outer space. At one time, he informed a roommate that he was vacationing with Vladimir Putin, the president of Russia.

The Concerns of Abnormal Psychology Abnormal psychology is the scientific study whose objectives are to describe, explain, predict, and control behaviors that are considered strange or unusual. Its subject matter ranges from the bizarre and spectacular to the more commonplace—from the violent homicides, suicides, and “perverted” sexual acts that are widely reported by the news media to such unsensational (but more prevalent) behaviors as depression, ulcers, and anxiety about examinations.

Describing Abnormal Behavior The description of a particular case of abnormal behavior must be based on systematic observations by an attentive professional. These observations, usually paired with the results of the person’s psychological history, become the raw material for a psychodiagnosis, an attempt to describe, assess, and systematically draw inferences about an individual’s psychological disorder.

a term clinical psychologists use as a synonym for abnormal behavior

psychopathology

abnormal psychology

the scientific study whose objectives are to describe, explain, predict, and control behaviors that are considered strange or unusual an attempt to describe, assess, and systematically draw inferences about an individual’s psychological disorder

psychodiagnosis

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For example, Cho was taken to a mental health agency in Virginia, where a psychiatric evaluation was undertaken. Because we have limited access to these records, the precise nature of the therapist’s observations is tentative. Usually, however, mental status exams are conducted by mental health professionals to ascertain the degree to which clients are in contact with reality, whether they suffer from hallucinations or delusions, and whether they are potentially dangerous. Based on clinical observations, analysis of his history, and possibly psychological testing, the therapist concluded that Cho was of “imminent danger to self or others,” “mentally ill,” and in need of hospitalization. The precise psychiatric diagnosis is unknown because of confidentiality laws. Unfortunately, instead of commitment to a mental institution, a court magistrate ordered only outpatient treatment. As we now know, Cho never complied with the order to seek therapy.

Explaining Abnormal Behavior

Did You Know?

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ho’s behavior motivated his mother to seek help from churches in northern Virginia. One Presbyterian congregation felt that Cho was afflicted by a demonic power and needed spiritual deliverance. Others speculated that Cho was the epitome of evil. Although claiming that he was possessed by supernatural forces might appear far-fetched, such explanations of bizarre behavior were once common.

To explain abnormal behavior, the psychologist must identify its causes and determine how they led to the described behavior. This information, in turn, bears heavily on how a program of treatment is chosen. One popular explanation of Cho’s behavior was that he was high on drugs. An autopsy, however, revealed no evidence of alcohol or drugs present in his system. Nevertheless, Cho’s background suggests many other possible causes for his rampage: • As a child, Cho was described by family members as mute, cold, and shy. His mother speculated that he was “autistic,” a condition associated with social isolation, delayed speech, and repetitive behavior and believed to have a strong constitutional component. Some relatives say that he was different from birth and suggest that his problem was biological in nature. • Cho was often the subject of teasing and cruel taunts by classmates, probably because of his unusual behaviors. He was often bullied, called names, mocked, and told to “go back to China.” Although he seldom showed anger, rumors abounded that he kept a “hit list” of students he wanted to kill. Could such malicious actions from peers account for his homicidal and suicidal actions? • Cho was a twenty-three-year-old South Korean citizen with U.S. permanent resident status in Virginia. He immigrated to this country at age eight with his parents and sister. Some believe he never adequately adjusted to his new life in the United States and encountered culture conflicts. He felt isolated, alone, and alienated from others. Unable or unwilling to make connections with people, Cho had difficulty distinguishing between fantasy and reality. • Cho came from a very poor background and lived in a three-room basement with his family in Korea. His father was a self-employed secondhand bookstore owner who made little money and moved his family to the United States to improve their financial state. Cho appeared very self-conscious about being poor and resented “rich kids,” materialism, and hedonism. His writings and video recordings sent to NBC News contained extremely hostile statements toward those “with money.” In these snippets of Cho’s life, it is clear that many explanations for his rampage could be offered. There was something biologically wrong with him from birth; he could not tolerate the merciless teasing and bullying; his alienation from a new culture created social isolation and resentment; and his poverty made him envious and angry toward more affluent students. Depending on your viewpoint, some explanations may appear more valid than others. As we will see in the next chapter, no one explanation is sufficient to explain the complexity of the human condition; normal and abnormal behaviors result from a combination of factors.

Predicting Abnormal Behavior If a therapist can correctly identify the source of a client’s difficulty, he or she should be able to predict the kinds of problems the client will face during therapy and the symptoms the client will display. Many believe that there was sufficient evidence to predict that Cho was likely to take the lives of others and his own based on a number of reported events:

The Concerns of Abnormal Psychology

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INTERVENING THROUGH THERAPY Group therapy is a widely used form of treatment for many problems, especially those involving interpersonal relationships. In this group session, participants are learning to develop new and adaptive social skills in coping with social problems rather than relying on alcohol or drugs to escape the stresses of life.

• Cho was involved in three stalking incidents on the Virginia Tech campus. All three involved female students in whom he developed brief but intense interest. His contacts were made through instant messaging on his computer. He sent them annoying messages, made an uninvited appearance at one student’s dorm room, and left graffiti on her bulletin board. Cho was warned by campus police to cease his unwarranted contacts with them. He apparently acceded to their warnings. • Several professors reported that Cho was menacing, had a mean streak, and that his writings were often intimidating, obscene, and violent. His writings, they contend, “dripped with anger,” were graphic and disturbing, and possessed macabre violence. One professor became so fearful for her own safety and that of others that she reported Cho to the student affairs office, the dean’s office, and campus police. Each unit responded that nothing could be done if Cho made no overt threats against others. In light of these reports, why was Cho allowed to stay on campus? Why was he allowed to purchase firearms despite having a diagnosed mental condition? Why did mental health professionals not intervene more quickly? There appear to be several reasons. First, civil commitment, or involuntary hospitalization/confinement, represents an extreme decision that has major implications for an individual’s civil liberties. Our legal system operates under the assumption that people are innocent until proven guilty. Locking someone up before they commit a dangerous act potentially violates a person’s civil rights. Second, although this particular therapist proved to be correct in declaring Cho dangerous, clinicians are notoriously inaccurate in predicting dangerousness. Research shows that mental health professionals do a poor job of predicting future violence; they tend to greatly overpredict it (Buchanan, 1997).

Controlling Abnormal Behavior Abnormal behavior may be controlled through therapy, which is a program of systematic intervention whose purpose is to modify a client’s behavioral, affective (emotional), and/or cognitive state. For example, many therapists wonder whether Cho could have been helped and the mass killings prevented if he had been forced into treatment. Allowing Cho an opportunity to get in touch with and to vent his anger would reduce his chances of doing harm to others. Some mental health professionals might also recommend family therapy or social skills training. Some might even recommend hospitalization, which unfortunately was recommended but not done.

a program of systematic intervention whose purpose is to modify a client’s behavioral, affective (emotional), and/or cognitive state

therapy

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TA B L E

1.1

THE MENTAL HEALTH PROFESSIONS Clinical Psychology

Clinical psychology is the professional field concerned with the study, assessment, treatment, and prevention of abnormal behavior in disturbed individuals. A clinical psychologist must hold a Ph.D. degree from a university or a Psy.D. (doctor of psychology) degree, a more practitioner-oriented degree granted by several institutions. Their training includes course work in psychopathology, personality, diagnosis, psychological testing, psychotherapy, and human physiology. Apart from these and other course requirements, there are two additional requirements for the Ph.D. degree: students are required to complete a doctoral dissertation and usually a one-year internship. Clinical psychologists work in a variety of settings, but most commonly they provide therapy to clients in hospitals and clinics and in private practice. Some choose to work in academic settings in which they can concentrate on teaching and research. Other clinical psychologists are hired by government or private organizations to do research.

Counseling Psychology

To a great extent, a description of clinical psychology applies to counseling psychology as well. The academic and internship requirements are similar, but the emphasis differs. Whereas clinical psychologists are trained to work specifically with a disturbed client population, counseling psychologists are usually more immediately concerned with the study of life problems in relatively normal people. Furthermore, counseling psychologists are more likely to be found in educational settings than in hospitals and clinics.

Marriage and Family Counseling

A specialty in marriage and family counseling has recently emerged, with its own professional organizations, journals, and state licensing requirements. Marriage and family counselors have varied professional backgrounds, but their training usually includes a master’s degree in counseling and many hours of supervised clinical experience.

Mental Health Counseling

As of this writing, mental health counselors are recognized and licensed for clinical/counseling practice in 49 states. They work in a variety of settings, receive intensive training in personal, emotional, vocational, and human development, and have their own professional association. Mental health counselors must meet many hours of supervised clinical experience and possess master’s degrees in counseling.

Psychiatry

Psychiatrists hold M.D. degrees. Their education includes the four years of medical school required for that degree, along with an additional three or four years of training in psychiatry. Of all the specialists involved in mental health care, only psychiatrists can prescribe drugs in the treatment of mental disorders.

Psychoanalysis

Psychoanalysis has been associated with medicine and psychiatry because its founder, Sigmund Freud, and his major disciples were physicians. But Freud was quite adamant in stating that one need not be medically trained to be a good psychoanalyst. Nevertheless, most psychoanalysts hold either an M.D. or a Ph.D. degree. In addition, psychoanalysts receive intensive training in the theory and practice of psychoanalysis at an institute devoted to the field. This training includes the individual’s own analysis by an experienced analyst.

Psychiatric Social Work

Those entering psychiatric social work are trained in a school of social work, usually in a two-year graduate program leading to a master’s degree. Included in this program is a one-year internship in a social-service agency, sometimes a mental health center. Some social workers go on to earn the D.S.W. (doctor of social work) degree. Traditionally, psychiatric social workers work in family counseling services or community agencies, where they specialize in intake (assessment and screening of clients), take psychiatric histories, and deal with other agencies.

School Psychology

School psychology is the field of study concerned with the processes of cognitive and emotional development of students in educational settings. Thus it focuses on the processes of learning, remembering, and thinking and on human development as it applies to the educational process. A school psychologist may hold either a master’s or a doctoral degree. They are often employed by school districts to help with assessment and testing and with the treatment of learning difficulties.

Determining Abnormality

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Those who see Cho’s condition as caused by a chemical imbalance might rely on a primarily biological means of intervention and prescribe medication, such as antipsychotic drugs. As we shall shortly see, the treatment for abnormal behavior generally follows from its explanation. Just as there are many ways to explain abnormal behaviors, there are many proposed ways of conducting therapy and an equal number of professional helpers offering their services. Along with the demand for mental health treatment, the numbers and types of qualified helping professionals have grown. In the past, mental health services were controlled primarily by psychiatrists, psychologists, and psychiatric social workers. The list of acceptable (licensed) providers in different fields has expanded rapidly. Table 1.1 lists the qualifications, training, and workplace settings of various mental health professionals. As you can see, students desiring to enter practice can choose from a variety of professional careers.

Determining Abnormality Implicit in our discussion so far is the one overriding concern of abnormal psychology: abnormal behavior itself. But what exactly is abnormal behavior, and how do psychologists define a mental disorder? The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000a), the most widely used classification system of mental disorders, defines abnormal behavior as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. (American Psychiatric Association, 2000a, p. xxxi)

This definition is quite broad and raises many questions. First, when is a syndrome or group of behaviors significant enough to have meaning? From early descriptions of Cho in elementary school, his behavioral patterns were noticed but not considered significant (that is, not associated with pathology). He was a good student in math and English, quiet in classes, but not disliked or feared by classmates. Some teachers would even view him as a model example of compliant and appropriate classroom behavior. It was only much later that Cho’s withdrawn behaviors became pronounced. Second, what constitutes “present distress” and “painful symptoms”? We have limited access to psychiatric records, but there is little evidence that Cho was anxious or depressed. Some say that the fact that he took his own life indicates that he was depressed. However, as we will see in a later chapter, the relationship of suicide to depression is a mixed one. Certainly, however, we can speculate that his intense anger might be distressful to him. Yet is it possible to have a mental disorder without any subjective discomfort (unhappiness, distress, anxiety, and so forth)? For example, people who commit antisocial acts such as rape, murder, or robbery may not feel remorseful; rather, they may be quite contented with their acts. Third, what criteria do we use in ascertaining an “increased risk of suffering death, pain, disability,” and loss of freedom? Again, it is obvious to us that Cho met this criterion firmly because he killed himself. But Cho’s action was an extreme one, far outside normative standards. How would this last criterion apply to someone with, for example, a phobia? One could certainly make a strong case that “loss of freedom” applied; a person with a phobia about crossing bridges would be severely restricted in travel. Yet if people have only a mild phobia of snakes and seldom place themselves in an environment with them, there would be minimal restrictions on their lives. Despite problems in defining abnormal behavior, practitioners tend to agree that it represents behavior that departs from some norm and that harms the affected individual or others. Nearly all definitions of abnormal behavior use some form of statistical

abnormal behavior a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom

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average to gauge deviations from normative standards. Four major means of judging psychopathology include distress, deviance (bizarreness), dysfunction (inefficiency in behavioral, affective, and/or cognitive domains), and dangerousness.

Distress

Did You Know?

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uring the Victorian era, women wore six to eight layers to conceal their bodies from the neck down. Exposing an ankle was roughly equivalent to going topless at the beach today. Taboos against publicly recognizing sexuality dictated that words avoid any sexual connotation. Victorians said “limb” instead of “leg” because the word leg was considered erotic. Even pianos and tables were said to have limbs. People who did not adhere to these codes of conduct were considered immoral.

Most people who seek the help of therapists are suffering physical or psychological distress. Many physical reactions stem from a strong psychological component; among them are disorders such as asthma, hypertension, and ulcers, as well as physical symptoms such as fatigue, nausea, pain, and heart palpitations. Distress can also be manifested in extreme or prolonged emotional reactions, of which anxiety and depression are the most prevalent and common. Of course, it is normal for a person to feel depressed after suffering a loss or a disappointment. But if the reaction is so intense, exaggerated, and prolonged that it interferes with the person’s capacity to function adequately, it is likely to be considered abnormal.

Deviance Deviance is most closely related to using a statistical average. Statistical criteria equate normality with those behaviors that occur most frequently in the population. Abnormality is therefore defined in terms of those behaviors that occur least frequently. Bizarre or unusual behavior is an abnormal deviation from an accepted standard of behavior (such as an antisocial act) or a false perception of reality (such as a hallucination or delusion). This criterion can be extremely subjective; it depends on the individual being diagnosed, on the diagnostician, and on the particular cultural context. Certain sexual behaviors, delinquency, and homicide are examples of acts that our society considers abnormal. But social norms are far from static, and behavioral standards cannot be considered absolute. Changes in our attitudes toward human sexuality provide a prime example. Many American magazines and films now openly exhibit the naked human body, and topless and bottomless nightclub entertainment is hardly newsworthy. Various sex acts are explicitly portrayed in NC-17-rated movies, and women are freer to question traditional sex roles and to act more assertively in initiating sex. Such changes in behavior make it difficult to subscribe to absolute standards of normality. Nevertheless, some behaviors can usually be judged abnormal in most situations. Among these are severe disorientation, hallucinations, and delusions. Disorientation is confusion with regard to identity, place, or time. People who are disoriented may not know who they are, where they are, or what historical era they are living in. Hallucinations are false impressions—either pleasant or unpleasant—that involve the senses. People who have hallucinations may hear, feel, or see things that are not really there, such as voices accusing them of vile deeds, insects crawling on their bodies, or monstrous apparitions. Delusions are false beliefs steadfastly held by the individual despite contradictory objective evidence. A delusion of grandeur is a belief that one is an exalted personage, such as Jesus Christ or Joan of Arc; a delusion of persecution is a belief that one is controlled by others or is the victim of a conspiracy.

Dysfunction SOCIETAL NORMS AND DEVIANCE Societal norms often affect our definitions of normality and abnormality. When social norms begin to change, standards used to judge behaviors or roles also shift. Here we see four male nurses in an overwhelmingly female occupation. In the past, being a male nurse would have brought on stereotypes about their masculinity. Role reversals in employment, hobbies, sports, and other activities are becoming more acceptable over time.

In everyday life, people are expected to fulfill various roles—as students or teachers; as workers and caretakers; as parents, lovers, and marital partners. Emotional problems sometimes interfere with the performance of these roles, and the resulting role dysfunction may be used as an indicator of abnormality. Thus one way to assess dysfunction is to compare an individual’s performance with the requirements of a role. Another related way to assess dysfunction is to compare an individual’s performance with his or her potential. For example,

Contextual and Cultural Limitations in Defining Abnormal Behavior

an individual with an IQ score of 150 who is failing in school can be labeled inefficient. (The label underachiever is often hung on students who possess high intelligence but obtain poor grades in school.) Similarly, a productive worker who suddenly becomes unproductive may be experiencing emotional stress. The major weakness of this approach is that it is difficult to accurately assess potential. How do we know whether a person is performing at his or her peak? To answer such questions, psychologists, educators, and the business sector have relied heavily on testing. Tests of specific abilities and intelligence are attempts to assess potential and to predict performance in schools or jobs.

Dangerousness Predicting the dangerousness of clients to themselves and others has become an inescapable part of clinical practice (Haggard-Grann, 2007). Ever since the California Supreme Court ruled in 1976 (Tarasoff v. Regents of the University of California, 1976) that therapists have a responsibility to assess dangerousness of clients (to themselves and others) and to protect the intended victim, psychologists have attempted to devise risk-assessment procedures and to ascertain what actions a therapist must take to comply with “a duty to protect.” Certainly, the case of Cho represents a graphic example of the need for mental health professionals to accurately assess violence risk. Yet, as we shall see in a later chapter, this is a tall order. Despite the fear of violence in persons suffering from a mental disorder, it is a statistical rarity (Corrigan & Watson, 2005). Further, predicting dangerousness is not easy, and there is no clear-cut criterion correlated with it. One of the strongest risk factors, for example, is previous violent behavior (such as suicide attempts and physical assaults). Yet, as we know, Cho evidenced neither of these in his history.

Contextual and Cultural Limitations in Defining Abnormal Behavior Nearly all criteria used to define abnormality use a statistical deviation from some normative standard. Doing so, however, presents many problems. One problem mentioned previously is that statistical criteria are static and fail to take into account differences in place, time, and community standards. Another is that statistical criteria do not provide any basis for distinguishing between desirable and undesirable deviations from the norm. An IQ score of 100 is considered normal or average. But what constitutes an abnormal deviation from this average? More important, is abnormality defined in only one direction or in both? An IQ score of 55 is considered abnormal by most people, but should people with IQ scores of 145 or higher also be considered abnormal? How does one evaluate such personality traits as assertiveness and dependence in terms of statistical criteria? Two other central problems also arise. First, people who strike out in new directions—artistically, politically, or intellectually—may be seen as candidates for psychotherapy simply because they do not conform to normative behavior. Second, statistical criteria may “define” quite widely distributed but undesirable characteristics, such as anxiety, as normal. Many psychological tests and much diagnosis and classification of behavior disorders are based in part on statistical criteria. Perhaps one of the strongest criticisms of abnormality definitions comes from the multicultural perspective. If deviations from the majority are considered abnormal, then many ethnic and racial minorities who show strong subcultural differences from the majority must be classified as abnormal. When we use a statistical definition, the dominant or most influential group generally determines what constitutes normality and abnormality. Multiculturalists contend that all behaviors, whether normal or abnormal, originate from a cultural context. Psychologists are increasingly recognizing that this is an inescapable conclusion and that culture plays a major role in our understanding of human behavior. But what is culture? There are many definitions of “culture.” For our purposes, culture is “shared learned behavior which is transmitted from one generation to another for purposes of individual and societal growth, adjustment, and adaptation: culture is represented externally as artifacts, roles, and

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DETERMINING WHAT’S ABNORMAL By most people’s standards, the fullbody tattoos of these three men would probably be considered unusual at best and bizarre at worst. Yet despite the way their bodies appear, these three openly and proudly display them at the National Tattoo Convention. Such individuals may be very “normal” and functional in their work and personal lives. This leads to an important question: What constitutes abnormal behavior and how do we recognize it?

institutions, and it is represented internally as values, beliefs, attitudes, epistemology, consciousness and biological functioning” (Marsella, 1988, pp. 8–9). Three important points should be emphasized: 1. Culture is not synonymous with race or ethnic group. Jewish, Polish, Irish, and Italian Americans represent diverse ethnic groups whose individual members may share a common racial classification. Yet their cultural contexts may differ substantially from one another. Likewise, an Irish American and an Italian American, despite their different ethnic heritages, may share the same cultural context. 2. Every society or group that shares and transmits behaviors to its members possesses a culture. European Americans, African Americans, Latino/Hispanic Americans, Asian Americans/Pacific Islanders, Native Americans, and other social groups within the United States have cultures. A strong argument can be made that hearing impaired or deaf people also possess a culture (Olkin, 1999) and that “signing” represents a language. 3. Culture is a powerful determinant of worldviews (Sue & Sue, 2008a). It affects how we define normal and abnormal behaviors and how we treat disorders encountered by members of that culture. Even racial or ethnic groups that possess many similarities may have quite different cultural constellations.

cultural universality

the assumption that a fixed set of mental disorders exists whose obvious manifestations cut across cultures the belief that lifestyles, cultural values, and worldviews affect the expression and determination of deviant behavior

cultural relativism

These three points give rise to a major problem: one group’s definition of mental illness may not be shared by another. This contradicts the traditional view of abnormal psychology, which is based on cultural universality—the assumption that a fixed set of mental disorders exists whose obvious manifestations cut across cultures (Kim & Berry, 1993; McGoldrick, Giordano, & Garcia-Preto, 2005). This psychiatric tradition dates back to Emil Kraepelin (discussed later in this chapter), who believed that depression, sociopathic behavior, and especially schizophrenia were universal disorders that appeared in all cultures and societies. Early research supported the belief that these disorders occurred worldwide, had similar processes, and were more similar than dissimilar (Howard, 1992). From this flowed the belief that a disorder such as depression is similar in origin, process, and manifestation in all societies, such as Asia, Africa, and Latin America. As a result, no modifications in diagnosis and treatment need be made; western concepts of normality and abnormality can be considered universal and equally applicable across cultures. In contrast to the traditional view of cultural universality has been cultural relativism, the belief that lifestyles, cultural values, and worldviews affect the expression and determination of deviant behavior. This concept arose from the anthropological

Contextual and Cultural Limitations in Defining Abnormal Behavior

CULTURAL RELATIVISM Cultural differences often lead to misunderstandings and misinterpretations. In a society that values technological conveniences and clothing that comes from the runways of modern fashion, the lifestyles and cultural values of others may be perceived as strange. The Amish, for example, continue to rely on traditional modes of transportation (horse and buggy). And women in both the Amish and Islamic cultures wear simple, concealing clothing; in their circumstances, dressing in any other way would be considered deviant. Swimsuits and revealing clothes are not allowed in sunbathing or swimming.

tradition and emphasized the importance of culture and diversity in the manifestation of abnormal symptoms. For example, a body of research supports the conclusion that acting-out behaviors (aggressive acts, antisocial behaviors, and so forth) associated with mental disorders are much higher in the United States than in Asia and that even Asian Americans in the United States are less likely to express symptoms via acting out (Asian American Federation of New York, 2003; Sue & Sue, 2008a; Yang & WonPat-Borja, 2007). Researchers have proposed that Asian cultural values (restraint of feelings, emphasis on self-control, and need for subtlety in approaching problems) all contribute to this restraint. Proponents of cultural relativism also point out that cultures vary in what they consider to be normal or abnormal behavior. In some societies and cultural groups, hallucinating (having false sensory impressions) is considered normal in specific situations. Yet in the United States, hallucinating is generally perceived to be a manifestation of a disorder. Which view is correct? Should the criteria used to determine normality and abnormality be based on cultural universality or cultural relativism? Few mental health professionals today embrace the extreme of either position, although most gravitate toward one or the other. Proponents of cultural universality focus on the disorder and minimize cultural factors, and proponents of cultural relativism focus on the culture and on how the disorder is manifested within it. Both views have validity. It is naive to believe that no disorders cut across different cultures and share universal characteristics. For example, even though hallucinating may be viewed as normal in some cultures, proponents of cultural universality argue that it still represents a breakdown in biological-cognitive processes. Likewise, it is equally naive to believe that mental disorders and how they are manifested are unaffected by cultural values and lifestyle characteristics of a society (APA, 2000a). A third point to consider is that some common disorders, such as depression, are manifested similarly in different cultures. A more fruitful approach to studying multicultural criteria of abnormality is to explore two questions: • What is universal in human behavior that is also relevant to understanding psychopathology? • What is the relationship between cultural norms, values, and attitudes and the incidence and manifestation of behavior disorders? These are important questions that we hope you will ask as we continue our journey into the field of abnormal psychology. In Chapter 2, we try to address these questions by presenting a multipath model that takes into consideration biological, psychological, social, and sociocultural dimensions in understanding the complexity of the human condition.

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controversy

Is Mental Illness a Myth and a Political Construction?

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n my opinion, mental illness is a myth. People we label “mentally ill” are not sick, and involuntary mental hospitalization is not treatment. It is punishment. . . . The fact that mental illness designates a deviation from an ethical rule of conduct, and that such rules vary widely, explains why upper-middle-class psychiatrists can so easily find evidence of “mental illness” in lower-class individuals; and why so many prominent persons in the past fifty years or so have been diagnosed by their enemies as suffering from some types of insanity. Barry Goldwater was called a paranoid schizophrenic . . . Woodrow Wilson a neurotic . . . Jesus Christ, according to two psychiatrists . . . was a born degenerate with a fixed delusion system. (Szasz, 1970, pp. 167–168)

In a radical departure from conventional beliefs, psychiatrist Thomas Szasz (1987) has asserted that mental illness is a myth, a fictional creation by society used to control and change people. According to Szasz, people may suffer from “problems in living,” not from “mental illness.” His argument stems from three beliefs: 1. that abnormal behavior is so labeled because it is different, not necessarily because it is a reflection of “illness” 2. that unusual belief systems are not necessarily wrong 3. that abnormal behavior is frequently a reflection of something wrong with society rather than with the individual

According to Szasz, individuals are labeled “mentally ill” because their behaviors violate the social order and their beliefs challenge the prevailing wisdom of the times. Szasz finds the concept of mental illness to be dangerous and a form of social control used by those in power. Hitler branded Jews as abnormal. Political dissidents in many countries, including both China and the former Soviet Union, have often been cast as mentally ill. And the history of slavery indicates that African Americans who tried to escape their white masters were often labeled as suffering from drapetomania, defined as a sickness that makes the person desire freedom. Few mental health professionals would take the extreme position advocated by Szasz, but his arguments highlight an important area of concern. Those who diagnose behavior as abnormal must be sensitive to individual value systems, societal norms and values, and potential sociopolitical ramifications. For Further Consideration 1. What do you think of Szasz’s position? 2. Can you think of examples in which psychiatric diagnosis may reflect differences in culture or political beliefs?

The Frequency and Burden of Mental Disorders

the percentage of people in a population who suffer from a disorder at a given point in time

prevalence

lifetime prevalence the total proportion of people in the population who have ever had a disorder in their lives incidence the onset or occurrence of a given disorder over some period of time

A student once asked one of the authors, “How crazy is this nation?” This question, put in somewhat more scientific terms, has occupied psychologists for some time. Psychiatric epidemiology provides insights into factors that contribute to the occurrence of specific mental disorders. To address this question, some terms need to be clarified. The prevalence of a disorder indicates the percentage of people in a population who suffer from a disorder at a given point in time; lifetime prevalence refers to the total proportion of people in the population who have ever had a disorder in their lives. Incidence refers to the onset or occurrence of a given disorder over some period of time. From this information, we can find out how frequently or infrequently various disturbances occur in the population. We can also consider how the prevalence of disorders varies by ethnicity, gender, and age and whether current mental health practices are sufficient and effective. Two of the most recent, thorough, and comprehensive studies of the incidence of mental disorders in the U.S. adult population (eighteen years and older) were conducted by the National Institute of Mental Health (NIMH, 1985) and the National Comorbidity Survey Replication Study (NCS-R; Kessler, Berglund, et al., 2005; Kessler, Chiu, et al., 2005). The NIMH epidemiological study included a large sample of approximately 20,000 persons, while the NCS-R interviewed 9,282 people in their homes. Both used categories in the Diagnostic and Statistical Manual of the American Psychiatric Association in the construction of the research instruments. In the NCS-R study, lifetime prevalence rates for the following were found: anxiety disorders, 28.8 percent; mood disorders, 20.8 percent; impulse-control disorders, 24.8 percent; and substance use disorders, 14.6 percent. Lifetime prevalence rates across all four mental disorders were 46.4 percent.

The Frequency and Burden of Mental Disorders

Percent of group

In the NIMH study, researchers found that although men and women are equally likely to suffer from mental disorders, they differ in the kinds of disorders they experience. For example, alcohol abuse or dependence occurs in 24 percent of men but in only 4 percent of women; drug abuse is more likely to occur in men; and depression and anxiety are more likely to occur in women. Age was also an important factor. Alcoholism and depression are most prominent in the twenty-five- to forty-four-year-old age group; drug dependence in the eighteen- to twenty-four-year-old age group; and cognitive impairment in people age sixty-five and older. Phobias, however, were equally represented at all ages. Studies on even the young (children and adolescents) suggest that nearly 17 percent suffer from a serious disorder (Kessler et al., 1994; Regier et al., 1993). Figure 1.1 summarizes the rates of psychiatric disorders in various demographic categories. The cost and burden of mental disorders to our nation are indeed a major source of concern. The recognition of this problem was the impetus for Mental Health: A Report of the Surgeon General (U.S. Surgeon General, 1999) and Achieving the Promise: Transforming Mental Health Care in America (President’s New Freedom Commission on Mental Health, 2003), two comprehensive reports on the state of mental health in our nation. Their conclusions were very troubling: (1) at least 30 percent of the nation’s adults suffer from a diagnosable mental disorder; (2) 20 percent of children show signs of a diagnosable disorder in the course of a year; and (3) by the year 2020, neuropsychiatric disorders in children will increase by 50 percent and become one of the five most common forms of disability. To indicate the profound impact mental disorders have on

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LONG-TERM EFFECTS OF TRAUMA The September 11, 2001, terrorist attacks that destroyed the World Trade Center in lower Manhattan killed thousands and traumatized a nation. What are the mental health consequences of extreme disasters? How are these effects measured?

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