Chapter 14

 Basic Concepts of Psychological Disorders

L EARNING O BJECTIVE Q UESTION LOQ 14-1
 How should we draw the line between normality and disorder?

Most of us would agree that someone who is depressed and stays mostly in bed for 3 months
has a psychological disorder. But what about a grieving father who can’t resume his usual
social activities 3 months after his child has died? Where do we draw the line between
understandable grief and clinical depression? Between a fear and a phobia? Between
normality and abnormality? In their search for answers, theorists and clinicians ask:

 How should we define psychological disorders?

 How should we understand disorders? How do underlying biological factors
contribute? How do troubling environments influence our well-being? And how do
these effects of nature and nurture interact?
 How should we classify psychological disorders? And can we do so in a way that
allows us to help people without stigmatizing or labeling them?
 Are those with psychological disorders at risk of harming themselves or others?
 What do we know about rates of psychological disorders? How many people have
them? Who is vulnerable, and when?

“Who in the rainbow can draw the line where the violet tint ends and the orange tint begins?
Distinctly we see the difference of the colors, but where exactly does the one first blendingly
enter into the other? So with sanity and insanity.”
—Herman Melville, Billy Budd, Sailor, 1924

A psychological disorder is a syndrome (a collection of symptoms) marked by a “clinically

significant disturbance in an individual’s cognition, emotion regulation, or behavior”
(American Psychiatric Association, 2013). Such thoughts, emotions, or behaviors
are dysfunctional or maladaptive—they interfere with normal day-to-day life. Believing your
home must be thoroughly cleaned every weekend is not a disorder. But if cleaning rituals
interfere with work and leisure, they may be signs of a disorder. Occasional sad moods that
persist and become disabling may likewise signal a psychological disorder.

Distress often accompanies such dysfunction. Kelly, Greta, and Stuart were all distressed by
their thoughts, emotions, or behaviors.

Over time, definitions of what makes for a “significant disturbance” have varied. In 1973, the
American Psychiatric Association voted that “homosexuality” should no longer be classified
as a psychological disorder. The organization made this change because more and more of its
members viewed same-sex attraction as a natural biological predisposition and not a
psychological problem. Such is the power of shifting societal beliefs. In the twenty-first
century, controversies swirl over other new or altered diagnoses in the most recent edition of
psychiatry’s manual for describing disorders (Conway et al., 2019; Widiger et al., 2019).

Understanding Psychological Disorders

LOQ 14-2
 How do the medical model and the biopsychosocial approach influence our
understanding of psychological disorders?

The way we view a problem influences how we try to solve it. In earlier times, people often
thought that strange behaviors were evidence of strange forces—the movements of the stars,
godlike powers, or evil spirits—at work. Had you lived during the Middle Ages, you might
have said, “The devil made me do it.” To drive out demons, people considered “mad” were
sometimes caged or given “therapies” such as genital mutilation, beatings, removal of teeth
or lengths of intestines, or transfusions of animal blood (Farina, 1982).

Reformers, such as Philippe Pinel (1745–1826) in France, opposed such brutal treatments.
Madness is not demonic possession, Pinel insisted, but a sickness of the mind caused by severe
stress and inhumane conditions. He argued that curing the illness requires moral
treatment, including boosting patients’ spirits by unchaining them and talking with them. He and
others worked to replace brutality with gentleness, isolation with activity, and filth with clean air
and sunshine.

In some places, cruel treatments for mental illness—including chaining people to beds or
confining them in spaces with wild animals—linger even today. The World Health Organization
launched a reform that aims to transform hospitals “into patient-friendly and humane places with
minimum restraints” (WHO, 2014b).

The Medical Model

A medical breakthrough around 1900 prompted further reforms. Researchers discovered that
syphilis, a sexually transmitted infection, invades the brain and distorts the mind. This discovery
triggered an eager search for physical causes of other mental disorders, and for treatments that
would cure them. Hospitals replaced asylums, and the medical model of mental disorders was
born. Under its influence we still speak of the mental health movement. A mental illness (also
called a psychopathology) needs to be diagnosed on the basis of its symptoms. It needs to
be treated through therapy, which may include treatment in a psychiatric hospital. The medical
perspective has been energized by recent discoveries that many genes together influence the
brain and biochemistry abnormalities that contribute to all major disorders (Smoller, 2019). A
growing number of clinical psychologists now work in medical hospitals, where they collaborate
with physicians to determine how the mind and body operate together.

The Biopsychosocial Approach

To call psychological disorders “sicknesses” tilts research heavily toward the influence of
biology. But as in so many other areas, biological, psychological, and social-cultural
influences together weave our lived experiences. As individuals, we differ in how much we
experience and how we cope with stressors. Cultures also differ in the sources of stress and
in their traditional ways of coping. We are physically embodied and socially embedded.

Two disorders—major depressive disorder and schizophrenia—occur worldwide. Other

disorders tend to be associated with specific cultures. In Latin America, some
experience susto—severe anxiety or panic in response to an emotional trauma or fear of
black magic. In Japanese culture, people may experience taijin kyofusho—social anxiety
about physical appearance, a readiness to blush, and a fear of eye contact. The eating
disorders anorexia nervosa and bulimia nervosa occur mostly in food-abundant Western
cultures. Such disorders may share an underlying dynamic (such as anxiety) while differing
in the symptoms (an eating problem or a specific fear) manifested in a particular culture.
Even disordered aggression may have varying explanations in different cultures. In
Malaysia, amok describes a sudden outburst of violent behavior (as in the English phrase
“run amok”).

The biopsychosocial approach emphasizes that mind and body are inseparable (FIGURE
14.1). Negative emotions can trigger physical problems and vice versa. The biopsychosocial
approach gave rise to the vulnerability-stress model,1 which assumes that individual
dispositions combine with environmental stressors to influence psychological disorder
(Monroe & Simons, 1991; Zuckerman, 1999). Research on epigenetics supports the
vulnerability-stress model by showing how our DNA and our environment interact. A gene
may be expressed in one environment, but not in another. For some, that will be the
difference between developing a disorder or not.

In biology, classification creates order. To classify an animal as a “mammal” says a great

deal—that it is likely to be warm-blooded, has hair or fur, and produces milk to feed its
young. In psychiatry and psychology, too, classification aims to order and describe
symptoms. To classify a person’s disorder as “schizophrenia” suggests that the person talks
incoherently, has bizarre beliefs, shows either little emotion or inappropriate emotion, or is
socially withdrawn. “Schizophrenia” is a quick way of describing a complex disorder.

Moreover, diagnostic classification gives more than a thumbnail sketch of a disorder. In

psychiatry and psychology, classification also aims to predict a disorder’s future
course, suggest appropriate treatment, and prompt research into its causes. To study a
disorder, we must first name and describe it.

In many countries, the most common tool for describing disorders is the American
Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, now in its
fifth edition ( DSM-5). Physicians and mental health workers use the detailed DSM-5 to
guide diagnoses and treatment. For example, someone who meets all of the criteria
in TABLE 14.1 may be diagnosed with insomnia disorder. Other disorders, such as
posttraumatic stress disorder and major depressive disorder, require people to meet only a
certain number of criteria to be diagnosed. The DSM-5 includes diagnostic codes from the
World Health Organization’s International Classification of Diseases (ICD), which makes it
easy to track worldwide trends in psychological disorders.
In real-world tests (field trials) assessing the DSM-5 categories’ reliability, some diagnoses
fared well and others fared poorly (Freedman et al., 2013). Clinician agreement on
adult posttraumatic stress disorder and childhood autism spectrum disorder, for example,
was near 70 percent. (If one psychiatrist or psychologist diagnosed someone with one of
these disorders, there was a 70 percent chance that another mental health worker would
independently give the same diagnosis.) But for antisocial personality
disorder and generalized anxiety disorder, agreement was closer to 20 percent.

A book of case illustrations accompanying a previous DSM edition provided several examples
for this chapter.

Critics have long faulted the DSM for casting too wide a net, and for bringing “almost any
kind of behavior within the compass of psychiatry” (Eysenck et al., 1983). Some now worry
that the DSM-5’s even wider net will extend the pathologizing of everyday life. For example,
the DSM classifies severe grief following the death of a loved one as a possible depressive
disorder. Critics suggest that such grief could instead simply be considered a normal reaction
to tragic life events.

A newer classification approach that builds upon the DSM is the U.S. National Institute of
Mental Health’s Research Domain Criteria (RDoC) project (Insel et al., 2010; NIMH, 2017).
The RDoC framework organizes disorders according to behaviors and brain activity and
studies them with “the power of [today’s] genetics, neuroscience, and behavioral science”
(Insel & Lieberman, 2013).

Other critics of classification register a more basic complaint—that diagnostic labels can be
subjective, or even value judgments masquerading as science. Once we label a person, we
view that person differently. Labels can change reality by putting us on alert for evidence
that confirms our view. If we hear that a new co-worker is mean-spirited, we may treat them
suspiciously. They may in turn react to us as a mean-spirited person would. Ditto if we’re led
to believe that someone is smart. Teachers who were told certain students were “gifted” then
acted in ways that brought out the behaviors they expected (Snyder, 1984). Labels can be
self-fulfilling, and, if negative, they can be stigmatizing.

In one study, people watched recorded interviews. If told the interviewees were job
applicants, the viewers perceived them as normal (Langer & Abelson, 1974; Langer &
Imber, 1980). Other viewers who were told they were watching cancer or psychiatric patients
perceived the same interviewees as “different from most people.” Therapists who thought
they were watching an interview of a psychiatric patient perceived him as “frightened of his
own aggressive impulses,” a “passive, dependent type,” and so forth. People tend to
stigmatize those with psychological disorders, but activism, education, and contact between
people with psychological disorders and those without reduce this stigma (Corrigan et al.,
2012, 2014).

Modern movies have offered realistic depictions of psychological disorders and disordered
behavior. The superhero character of Tony Stark in the Iron Man and Avengers movies has a
backstory of posttraumatic stress disorder. Black Swan (2010) dramatized a lead character
suffering a delusional disorder. A Single Man (2009) depicted depression.

Labels also have power outside the laboratory. Getting a job or finding a place to rent can be
a challenge for people recently released from a psychiatric hospital. Label someone as
“mentally ill” and people may fear them as potentially violent. That reaction is fading as
people come to better understand psychological disorders. Public figures have helped foster
this understanding by speaking openly about their own struggles with disorders such as
anxiety, depression, and substance abuse—and how beneficial it was to seek help, receive a
diagnosis, and get better through treatment.

“My sister suffers from a bipolar disorder and my nephew from schizoaffective disorder
[includes symptoms of both schizophrenia and a depressive disorder or a bipolar disorder]. There
has, in fact, been a lot of depression and alcoholism in my family and, traditionally, no one ever
spoke about it. It just wasn’t done. The stigma is toxic.”
—Actress Glenn Close, “Mental Illness: The Stigma of Silence,” 2009

So, labels matter. Yet despite their risks, diagnostic labels have benefits. They help mental
health professionals communicate about their cases and study the causes and treatments of
disorders. Clients are often relieved to learn that their suffering has a name, and that they are
not alone in experiencing their symptoms.

Risk of Harm to Self and Others

People with psychological disorders are more likely to harm themselves than are people
without such disorders. Are they also more likely to harm others?

Each year some 160,000 Americans are among the drug, alcohol, or suicide “deaths of
despair” (Case & Deaton, 2020). Have you ever, in a moment of despair, considered suicide?
If so, you have much company. Among the many who entertain the thought, each year some
800,000 despairing people worldwide will complete the act, electing a permanent solution
to what might have been a temporary problem (WHO, 2018c). Someone will likely die by
suicide in the 40-odd seconds it takes you to read this paragraph. For those who have been
anxious, the risk of suicide is tripled, and for those who have been depressed, the risk is
quintupled (Bostwick & Pankratz, 2000; Kanwar et al., 2013). Yet people seldom elect
suicide while in the depths of depression, when energy and initiative are lacking. The risk
increases when they begin to rebound and become capable of following through (Chu et al.,
2016).

“But life, being weary of these worldly bars, Never lacks power to dismiss itself.”
—William Shakespeare, Julius Caesar, 1599

Comparing the suicide rates of different groups, researchers have found

  national differences: Russia has double the suicide rate of the United States, which has
double that of Spain (WHO, 2018c). Within Europe, Lithuanians have been seven times
more likely to die by suicide than Greeks.
 racial differences: Within the United States, Whites and Native Americans die by suicide
roughly twice as often as Blacks, Hispanics, and Asians (Curtin & Hedegaard, 2019). The
rate among Indigenous Canadians is triple that of other Canadians (Kumar & Tjepkema,
2019).
 gender differences: Women and girls are much more likely than men to consider or
attempt suicide. But worldwide, men are twice as likely to actually die by suicide (ONS,
2019; Ritchie et al., 2019b; WHO, 2018c). The methods men use, such as firing a bullet
into the head, are more lethal.
 trait differences: Suicidal thoughts increase when perfectionist people feel driven to
reach a goal or standard—to become thin or straight or rich—and find it unattainable
(Chatard & Selimbegović, 2011; Smith et al., 2018).
 age differences and trends: In late adulthood, rates increase worldwide, with the highest
rate among those over age 70 (Ritchie et al., 2019a).
 other group differences: Suicide rates have been much higher among the rich, the
nonreligious, and the unmarried (Chen et al., 2020; Norko et al., 2017; VanderWeele et
al., 2016, 2017). Gay, transgender, and gender-nonconforming youth facing an
unsupportive environment, including family or peer rejection, are also at increased risk of
attempting suicide (Goldfried, 2001; Haas et al., 2011; Hatzenbuehler, 2011; Testa et al.,
2017). One in four transgender adults has attempted suicide, a very high rate that doubles
among First Nations people (Adams & Vincent, 2019).
 year-by-year differences: In most countries, suicides have been increasing (Richie et al.,
2020). For example, between 2009 and 2019, U.S. high school students’ suicide rate
increased by 62 percent (CDC, 2019f; SAMHSA, 2019).

Social suggestion may trigger suicidal thinking and behavior. One analysis of 17 million Twitter
users’ data showed that sharing suicidal thoughts had a ripple effect, spreading suicidal thinking
through one’s social network (Cero & Witte, 2020). Following highly publicized suicides and
TV programs featuring suicide, rates of suicide sometimes increase (Niederkrotenthaler et al.,
2019). So do fatal auto and private airplane “accidents.” One 6-year study tracked suicide cases
among all 1.2 million people who lived in metropolitan Stockholm during the 1990s (Hedström
et al., 2008). Men became 3.5 times more likely to take their life if exposed to a co-worker’s
suicide.

Suicide is not usually an act of hostility or revenge. People—especially older adults—may

choose death as an alternative to current or future suffering, a way to switch off unendurable pain
and relieve a perceived burden on family members. Suicidal urges typically arise when people
feel like they don’t belong or are a burden to others, when they feel trapped by a seemingly
inescapable situation, or when they feel incapable of experiencing joy (Chu et al., 2018; Ducasse
et al., 2018; Taylor et al., 2011). The COVID-19 pandemic brought widespread unemployment
and social isolation, and a tripling of suicidal thinking (CDC, 2020d).
“People desire death when two fundamental needs are frustrated to the point of extinction: The
need to belong with or connect to others, and the need to feel effective with or to influence
others.”
—Thomas Joiner (2006, p. 47)

In hindsight, families and friends may recall signs they believe should have forewarned them—
verbal hints, giving possessions away, a sudden mood change, or withdrawal and preoccupation
with death (Bagge et al., 2017). To judge from surveys of 84,850 people across 17 nations, about
9 percent of people at some point in their lives contemplate suicide. About 3 in 10 of those who
think about it will actually attempt suicide; of those, fewer than 1 in 20 will die by suicide (Han
et al., 2016; Nock et al., 2008; WHO, 2020a). In one study that followed people for up to 25
years after a first suicide attempt, some 5 percent eventually died by suicide (Bostwick et al.,
2016).

As one research team summarized, suicide is hard to predict: “The vast majority of people who
possess a specific risk factor [for suicide] will never engage in suicidal behavior” (Franklin et al.,
2017, p. 217). But researchers continue to try to solve the suicide puzzle. Using an app that
harvests phone data, investigative teams have gained clues to suicide risk by studying teen
volunteers’ tone of voice, language, photos, music choice, sleep disturbances, and angry words in
text messages (Glenn et al., 2020; Servick, 2019). Some researchers are seeking to identify how
our genes predict suicide risk (Goldman, 2020; Kendler et al., 2020b). Other research teams are
developing suicide-predicting AI (artificial intelligence) algorithms using psychological
assessments, health records, or social media posts (Ribeiro et al., 2019; Simon et al.,
2018; Walsh et al., 2017).

About 47,000 Americans a year die by suicide—half using guns (CDC, 2019c). (Poison and drug
overdoses account for about 80 percent of suicide attempts, but only 14 percent of suicide
fatalities.) States with high gun ownership are states with high suicide rates, even after
controlling for poverty and urbanization (Siegel & Rothman, 2016). After Missouri repealed its
tough handgun law, its suicide rate went up 15 percent; when Connecticut enacted such a law, its
suicide rate dropped 16 percent (Crifasi et al., 2015). Thus, although U.S. gun owners often keep
a gun to feel safer, having a gun in the home makes one less safe, because it
substantially increases the odds of a family member dying by suicide or homicide (Kposowa et
al., 2016; VPC, 2015; Vyse, 2016).

How can we be helpful to someone who is talking suicide—who says, for example, “I wish I
could just end it all” or “I hate my life; I can’t go on”? If people write such things online, you
can anonymously contact various social media safety teams (including on Facebook, Twitter,
Instagram, YouTube, and Snapchat). If a classmate, friend, or family member talks about
suicide, you can

1. listen, empathize, and offer hope;

2. connect the person with their campus counseling center; with (in the United States) the
National Suicide Prevention Lifeline (1-800-273-8255[TALK]) or Crisis Text Line (by
texting HOME to 741741); or with support services in other countries (such
as CrisisServicesCanada.ca); and
 3. protect someone who appears at immediate risk by seeking help from a doctor, the
nearest hospital emergency room, or 911. Better to share a secret than to attend a funeral.
Remain connected—online or in-person—until the person gets the help they need.

Nonsuicidal Self-Injury

Self-harm takes many forms. Some people—mostly adolescents and females—engage

in nonsuicidal self-injury (NSSI) (Mercado et al., 2017) (FIGURE 14.2). They may, for
example, cut or burn their skin, hit themselves, or insert objects under their nails or skin.

Those who engage in NSSI often have experienced bullying, harassment, or stress (A. Miller et
al., 2019; van Geel et al., 2015). They are generally less able to tolerate and regulate emotional
distress (Hamza et al., 2015). And they are often both self-critical and impulsive (Beauchaine et
al., 2019; Cha et al., 2016).

NSSI is often self-reinforcing (Hooley & Franklin, 2018; Selby et al., 2019). People who engage
in NSSI may

 find relief from intense negative thoughts through the distraction of pain.
 attract attention and possibly get help.
 relieve guilt by punishing themselves.
 get others to change their negative behavior (bullying, criticism).
 fit in with a peer group.

Does NSSI lead to suicide? Usually not. Those who engage in NSSI are typically suicide
gesturers, not suicide attempters (Evans & Simms, 2019; Nock & Kessler, 2006). Nevertheless,
NSSI is a risk factor for suicidal thoughts and future suicide attempts, especially when coexisting
with a bipolar disorder (Geulayov et al., 2019). If people do not find help, their nonsuicidal
behavior may escalate to suicidal thoughts and, finally, to suicide attempts.

Does Disorder Equal Danger?

LOQ 14-5
 Do psychological disorders predict violent behavior?

September 16, 2013, started like any other Monday at the Navy Yard in Washington, DC, with
people arriving early to begin work. Then government contractor Aaron Alexis entered the
building and began shooting. An hour later, 13 people were dead—including Alexis, who had a
history of mental illness and had earlier written that an “ultra low frequency attack is what I’ve
been subject to for the last three months. And to be perfectly honest, that is what has driven me
to this.”

This mass shooting, like many others, reinforced public perceptions that people with
psychological disorders pose a threat (Barry et al., 2013; Jorm et al., 2012). “People with mental
illness are getting guns and committing these mass shootings,” said U.S. Speaker of the
House Paul Ryan (2015). In one survey, 84 percent of Americans agreed that “increased
government spending on mental health screening and treatment” would be a “somewhat” or
“very” effective “approach to preventing mass shootings at schools” (Newport, 2012). In the
aftermath of the 2018 Parkland, Florida, school massacre, U.S. President Donald Trump
proposed opening more mental hospitals that could house would-be mass murderers: “When you
have some person like this, you can bring them into a mental institution.”

Can clinicians indeed predict who is likely to do harm? No. Most violent criminals are not
mentally ill, and most mentally ill people are not violent (Leshner, 2019; Verdolini et al.,
2018). Moreover, clinical prediction of violence is unreliable. The few people with disorders
who commit violent acts tend to be either those, like the Navy Yard shooter, who experience
threatening delusions and hallucinated voices that command them to act, or those who abuse
substances (Douglas et al., 2009; Elbogen et al., 2016; Fazel et al., 2009, 2010).

People with disorders are more likely to be victims than perpetrators of violence (Buchanan
et al., 2019). According to the U.S. Surgeon General’s Office (1999, p. 7), “there is very
little risk of violence or harm to a stranger from casual contact with an individual who has a
mental disorder.” Better predictors of violence are alcohol or drug use, previous violence,
gun availability, and—as in the case of the repeatedly head-injured and ultimately homicidal
National Football League player Aaron Hernandez—brain damage (Belson, 2017). Mass-
killing shooters have one more thing in common: They are mostly young males.

Rates of Psychological Disorders

LOQ 14-6
 How many people have, or have had, a psychological disorder? What are some of the risk
factors?

Who is most vulnerable to psychological disorders? At what times of life? To answer such
questions, many countries have conducted lengthy, structured interviews with their citizens.
After asking hundreds of questions that probed for symptoms—“Has there ever been a period
of two weeks or more when you felt like you wanted to die?”—researchers have estimated
the current, prior-year, and lifetime prevalence of various disorders.

How many people have a psychological disorder? “Mental and addictive disorders affected
more than 1 billion people globally in 2016,” reported a major worldwide study (Rehm &
Shield, 2019). In the United States, 47 million adults—19 percent—experienced a mental
illness within the last year (SAMHSA, 2018)

Do rates of psychological disorder vary by place? A World Health Organization study—

based on 90-minute interviews with thousands of people who were representative of their
country’s population—estimated the number of prior-year mental disorders in 28 countries
(Kessler et al., 2009). Cultures vary, and as FIGURE 14.3 illustrates, the lowest rate of
reported mental disorders was in Nigeria; the highest rate was in the United States.
Moreover, immigrants to the United States from Mexico, Africa, and Asia averaged better
mental health than their U.S.-born counterparts with the same ethnic heritage (Breslau et
al., 2007; Maldonado-Molina et al., 2011). For example, compared with Mexican Americans
born in the United States, Mexican Americans who have recently immigrated are less at risk
of mental disorder—a phenomenon known as the immigrant paradox (Salas-Wright et al.,
2018).

What increases vulnerability to mental disorders? As TABLE 14.3 indicates, there are

various risk and protective factors for mental disorders. One predictor—poverty—crosses
ethnic and gender lines. The incidence of serious psychological disorders is 2.5 times higher
among those below the poverty line (CDC, 2014). This poverty-disorder correlation raises
further questions: Does poverty cause disorders? Or do disorders cause poverty? The
answer varies with the disorder. Schizophrenia understandably leads to poverty. Yet poverty
can beget suffering that increases the risk of certain disorders. A recession-related financial,
job, or housing loss may produce lingering depression and anxiety (Forbes & Krueger, 2019).

In one natural experiment investigating the poverty-pathology link, researchers tracked rates
of behavior problems in North Carolina Native American children as economic development
enabled a dramatic poverty rate reduction for part of their community. When the study
began, children of poverty exhibited more deviant and aggressive behaviors. After 4 years,
children whose families had moved above the poverty line exhibited a 40 percent decrease in
behavior problems. But children whose families remained in poverty or were never in
poverty exhibited no change (Costello et al., 2003).

At what times of life do disorders strike? About half of people with a disorder experience
their first symptoms by the mid-teens, and three-quarters do so by the mid-twenties (Kessler
et al., 2007; Robins & Regier, 1991). Among the earliest to appear are the symptoms of
antisocial personality disorder (median age 8) and of phobias (median age 10). Alcohol use
disorder, obsessive-compulsive disorder, bipolar disorders, and schizophrenia symptoms
appear at a median age near 20. Major depressive disorder often hits somewhat later, at a
median age of 25.

 Anxiety-Related Disorders

Anxiety is part of life. Speaking in front of a class, peering down from a ladder, or waiting to
learn the results of a final exam can make any of us feel nervous. Anxiety may even cause us
to avoid talking or making eye contact—“shyness,” we call it. Fortunately for most of us, our
uneasiness is not intense and persistent. Some, however, are especially prone to fear the
unknown and notice and remember perceived threats (Gorka et al., 2017; Mitte, 2008). When
the brain’s danger-detection system becomes hyperactive, we are at greater risk for
an anxiety disorder, and for three other disorders that involve anxiety: obsessive-compulsive
disorder (OCD), posttraumatic stress disorder (PTSD), and the somatic symptom disorders.2

Anxiety Disorders
LOQ 14-7
 How do generalized anxiety disorder, panic disorder, and specific phobias differ?
The anxiety disorders are marked by distressing, persistent anxiety or by dysfunctional anxiety-
reducing behaviors. For example, people with social anxiety disorder become extremely anxious
in social settings where others might judge them, such as parties, class presentations, or even
eating in public. One student experienced palpitations, tremors, blushing, and sweating when
giving a presentation, taking an exam, or meeting an authority figure, fearing he would
embarrass himself. By staying home he avoided the anxious feelings. But it was maladaptive:
Avoiding others prevented him from learning to cope and left him feeling lonely (Leichsenring
& Leweke, 2017).

Let’s take a closer look at three anxiety disorders:

 generalized anxiety disorder, in which a person is, for no obvious reason, continually tense and
uneasy;
 panic disorder, in which a person experiences panic attacks—sudden episodes of intense dread
—and fears the next attack; and
 specific phobias, in which a person is intensely and irrationally afraid of something.

Generalized Anxiety Disorder

For two years, Tom, a 27-year-old electrician, was bothered by dizziness, sweating palms, and
irregular heartbeat. He felt on edge and sometimes found himself shaking. Tom mostly hid his
symptoms from his family and co-workers. But he allowed himself few other social contacts, and
occasionally he had to leave work. Neither his family doctor nor a neurologist could find any
physical problem.

Tom’s unfocused, out-of-control, agitated feelings suggest generalized anxiety disorder, which

is marked by excessive and uncontrollable worry that persists for six months or more. People
with this condition (two-thirds are women) worry continually, and they are often jittery, on edge,
and sleep-deprived (McLean & Anderson, 2009). Concentration suffers as everyday worries
demand continual attention. Their autonomic nervous system arousal may leak out through
furrowed brows, twitching eyelids, trembling, perspiration, or fidgeting.

Those affected usually cannot identify, relieve, or avoid their anxiety. To use Sigmund Freud’s
term, the anxiety is free-floating (not linked to a specific stressor or threat). Generalized anxiety
disorder and depression often go hand in hand. But even without depression, generalized anxiety
disorder tends to be disabling. Moreover, it may lead to physical problems, such as high blood
pressure.

Panic Disorder

Some people experience intense anxiety that escalates into a terrifying panic attack—a minutes-
long episode of intense fear that something horrible is about to happen. Irregular heartbeat, chest
pains, shortness of breath, choking, trembling, or dizziness may accompany the panic. One
woman recalled suddenly feeling

hot and as though I couldn’t breathe. My heart was racing and I started to sweat and tremble and I
was sure I was going to faint. Then my fingers started to feel numb and tingly and things seemed
unreal. It was so bad I wondered if I was dying and asked my husband to take me to the emergency
room. By the time we got there (about 10 minutes) the worst of the attack was over and I just felt
washed out (Greist et al., 1986).
For the 3 percent of people with panic disorder, panic attacks are recurrent. These anxiety
tornados strike suddenly, wreak havoc, and disappear, but are not forgotten. Ironically, worries
about anxiety—perhaps fearing another panic attack, or fearing anxiety-related symptoms in
public—can amplify anxiety symptoms (Olatunji & Wolitzky-Taylor, 2009). After several panic
attacks, people may come to fear the fear itself. This may trigger agoraphobia—fear or
avoidance of public situations from which escape might be difficult. People with agoraphobia
may avoid being outside the home, in a crowd, or in an elevator.

Smokers have at least a doubled risk of panic disorder and greater symptoms when they do have
an attack (Knuts et al., 2010; Zvolensky & Bernstein, 2005). Because nicotine is a stimulant,
lighting up doesn’t lighten us up.

Charles Darwin began suffering from panic disorder at age 28, after spending 5 years sailing the
world. He moved to the country, avoided social gatherings, and traveled only in his wife’s
company. But the relative seclusion did free him to elaborate his evolutionary theory. “Even ill
health,” he reflected, “has saved me from the distraction of society and its amusements” (quoted
in Ma, 1997).

Specific Phobias

We all live with some fears. But people with specific phobias are consumed by a persistent,
irrational fear and avoidance of some object, activity, or situation—for example, animals,
insects, heights, blood, or closed spaces (FIGURE 14.4). Many people avoid the triggers,
such as high places, that arouse their fear. Marilyn, an otherwise healthy and happy 28-year-
old, so feared thunderstorms that she felt anxious as soon as a weather forecaster mentioned
possible storms later in the week. If her husband was away and a storm was forecast, she
often stayed with a close relative. During a storm, she hid from windows and buried her head
to avoid seeing the lightning.

Obsessive-Compulsive and Related Disorders

LOQ 14-8
 What is OCD?

As with the anxiety disorders, we can see aspects of our own behavior in obsessive-
compulsive disorder (OCD). Obsessive thoughts are unwanted and seemingly
unending. Compulsive behaviors are responses to those thoughts.

We all are at times obsessed with thoughts, and we may behave compulsively. Have you
ever felt a bit anxious about how your living space will appear to others and found yourself
compulsively cleaning one last time before your guests arrived? Or, perhaps worried about
an upcoming exam, you caught yourself lining up your study materials “just so” before
studying? Our everyday lives are full of little rehearsals and fussy behaviors. They cross the
fine line between normality and disorder only when they persistently interfere with
everyday living and cause distress. Checking that you locked the door is normal; checking 10
times is not. (TABLE 14.4 offers more examples.) At some time during their lives, often
during their late teens or early adulthood, about 2 percent of people cross that line from
normal preoccupations and fussy behaviors to debilitating disorder (Kessler et al., 2012).
Although people know their anxiety-fueled obsessive thoughts are irrational, the thoughts
can become so haunting, and the compulsive rituals so intensely time-consuming, that
effective functioning—including school success—becomes nearly impossible (Pérez-Vigil et
al., 2018).

OCD is more common among teens and young adults than among older people (Samuels &
Nestadt, 1997). A 40-year follow-up study of 144 Swedes diagnosed with the disorder found
that, for most, the obsessions and compulsions had gradually lessened, though only 1 in 5
had completely recovered (Skoog & Skoog, 1999).

Some people experience other OCD-related disorders, such as hoarding disorder (cluttering

their space with acquired possessions they can’t part with), body dysmorphic
disorder (preoccupation with perceived body defects; repeatedly checking their appearance
in the mirror), trichotillomania (hair pulling disorder), or excoriation (skin-
picking) disorder. Many people have some clutter in their living space or feel sensitive about
their appearance. But for these common behaviors and feelings to be considered an OCD-
related disorder, they would need to occur frequently and disrupt people’s lives—their social
life, work, or daily functioning.

Posttraumatic Stress Disorder (PTSD)

LOQ 14-9
 What is PTSD?

While serving overseas, one soldier, Jesse, saw the killing “of children and women. It was
just horrible for anyone to experience.” Back home, he suffered “real bad flashbacks”
(Welch, 2005).

Jesse is not alone. In one study of 104,000 veterans returning from Iraq and Afghanistan, 25
percent were diagnosed with a psychological disorder (Seal et al., 2007). The most frequent
diagnosis was posttraumatic stress disorder (PTSD). Survivors of terror, torture, rape,
earthquakes, and refugee displacement have also exhibited PTSD (Charlson et al.,
2016; Westermeyer, 2018). The hallmark symptoms are recurring vivid, distressing
memories and nightmares. PTSD also often entails laser-focused attention on possible
threats, social withdrawal, jumpy anxiety, and trouble sleeping (Fried et al., 2018; Lazarov et
al., 2019; Malaktaris & Lynn, 2019).

Many of us will experience a traumatic event. And many people will display survivor
resiliency—by recovering after severe stress (Galatzer-Levy et al., 2018). Although
philosopher Friedrich Nietzsche’s (1889/1990) idea that “what does not kill me makes me
stronger” is not true for all, about half of trauma victims report posttraumatic growth (X. Wu
et al., 2019). Sometimes, tears become triumphs.

Why do some 5 to 10 percent of people develop PTSD after a traumatic event while others
do not (Bonanno et al., 2011)? One factor is the amount of emotional distress: The higher the
distress (such as the level of physical torture suffered by prisoners of war), the greater the
risk for posttraumatic symptoms (King et al., 2015; Ozer et al., 2003). Among U.S. soldiers
in Iraq and Afghanistan, those experiencing both high-combat intensity and self-blaming
catastrophic thinking were especially vulnerable to PTSD (Seligman et al., 2019). Among
survivors of the 9/11 terrorist attack on New York’s World Trade Center, the rates of
subsequent PTSD diagnoses for those who had been inside were double the rates of those
who had been outside (Bonanno et al., 2006).

What else influences PTSD development? Individual differences in memory processing

matter. On a novel laboratory memory task, those who experienced PTSD following a Paris
terror attack exhibited more difficulty inhibiting unwanted memories than did those not
experiencing PTSD after the trauma (Mary et al., 2020).

Systemic racism, sexism, and inequality also increase the risk of experiencing PTSD after
traumas. One study found that African Americans and Puerto Ricans who experienced
moderate to frequent trauma, such as being threatened with a weapon or assaulted, also faced
higher than average risk of experiencing PTSD (Pahl et al., 2020). Other studies show that 1
in 4 U.S. college women experience sexual assault, and a dramatically higher than average
risk of PTSD (AAU, 2020; Dworkin et al., 2017).

Some psychologists believe that PTSD has been overdiagnosed (Dobbs, 2009; McNally,
2003). Too often, say critics, PTSD gets stretched to include normal stress-related bad
memories and dreams. And some well-intentioned procedures—such as “debriefing” people
by asking them to revisit the experience and vent their emotions—may worsen normal stress
reactions (Bonanno et al., 2010; Wakefield & Spitzer, 2002).

Somatic Symptom and Related Disorders

LOQ 14-10
 What is a somatic symptom disorder?

Among the common problems bringing people into doctors’ offices are “medically
unexplained illnesses” (Johnson, 2008). Ellen becomes dizzy and nauseated shortly before
she expects her husband home. Neither her primary care physician nor a neurologist can
identify a physical cause. They suspect her symptoms have an unconscious psychological
origin, possibly triggered by her feelings about her husband. Ellen has a somatic symptom
disorder (formerly known as somatoform disorder).

We have all experienced inexplicable physical symptoms under stress. Being told the
problem is “all in your head” gives no comfort. Although the symptoms may be
psychological in origin, they are genuinely felt. One person may have a variety of complaints
—vomiting, dizziness, blurred vision, difficulty swallowing. Another may experience severe
and prolonged pain. Such symptoms become a disorder when they are associated with
significant distress and impaired functioning.

Cultural context has a big effect on people’s physical complaints and how they explain them
(Kirmayer & Sartorius, 2007). In China, anxiety disorders are the most common
psychological disorder (Huang et al., 2019). Yet psychological explanations of anxiety and
depression are socially less acceptable there than in many Western countries, so people less
often express the emotional aspects of distress. The Chinese appear more sensitive to—and
more willing to report—the physical symptoms of their distress (Ryder et al., 2008).

Somatic symptom and related disorders send people not to a psychologist or psychiatrist but
to a physician. This is especially true of those who experience illness anxiety
disorder (previously called hypochondriasis). People with this relatively common disorder
interpret normal sensations (a stomach cramp today, a headache tomorrow) as symptoms of a
dreaded disease. No amount of reassurance by any physician convinces the patient that the
trivial symptoms do not reflect a serious illness. So, the patient moves on to another
physician—seeking and receiving more medical attention, but failing to confront the
disorder’s psychological roots. Other patients with illness anxiety disorder cope with their
fears by avoiding medical care.

Understanding Anxiety-Related Disorders

LOQ 14-11
 How do conditioning, cognition, and biology contribute to the feelings and thoughts that
mark anxiety-related disorders?

Anxiety is a feeling. It is also a cognition—a doubt-laden self-appraisal. How do these

anxious feelings and thoughts arise? Most psychologists attribute them to conditioning,
cognition, and biology.

Conditioning

Through classical conditioning, our fear responses can become linked with formerly neutral
objects and events. To understand the link between learning and anxiety, researchers have given
lab rats unpredictable electric shocks (Schwartz, 1984). The rats, like assault victims who report
feeling anxious when returning to the scene of the crime, then become uneasy in their lab
environment.

Likewise, anxious or traumatized people learn to associate their anxiety with certain cues (Bar-
Haim et al., 2007; Duits et al., 2015). In one survey, 58 percent of those with social anxiety
disorder said their disorder began after a traumatic event (Öst & Hugdahl, 1981). Anxiety or an
anxiety-related disorder is more likely to develop when bad events happen unpredictably and
uncontrollably (Field, 2006; Mineka & Oehlberg, 2008). Even a single painful and frightening
event may trigger a full-blown phobia, thanks to classical conditioning’s stimulus
generalization and operant conditioning’s reinforcement.
Stimulus generalization occurs when a person experiences a fear-provoking event and later
develops a fear of similar events. My [DM’s] car was once struck by a driver who missed a stop
sign. For months afterward, I felt a twinge of unease when any car approached from a side street.

Reinforcement helps maintain learned fears and anxieties. Anything that enables us to avoid or
escape a feared situation can reinforce maladaptive behaviors. Fearing a panic attack, we may
decide not to leave the house. Reinforced by feeling calmer, we are likely to repeat that behavior
(Antony et al., 1992). So, too, with compulsive behaviors. If washing our hands relieves our
feelings of anxiety, we may wash our hands again when those feelings return.

Cognition

Conditioning influences our feelings of anxiety, but so do our thoughts, memories,

interpretations, and expectations. We learn some fears by observing others. Nearly all
monkeys raised in the wild fear snakes, but lab-raised monkeys do not. Surely, most wild
monkeys do not actually suffer snake bites. Do they learn their fear through observation? To
find out, Susan Mineka (1985, 2002) experimented with six monkeys raised in the wild (all
strongly fearful of snakes) and their lab-raised offspring (virtually none of which feared
snakes). After repeatedly observing their parents or peers refusing to reach for food in the
presence of a snake, the younger monkeys developed a similar strong fear of snakes that
persisted when retested 3 months later. We humans similarly learn fears by observing others
(Helsen et al., 2011; Olsson et al., 2007).

Although it pays to be alert to dangers, anxiety is often a response to self-produced fake

news. One study that followed people with anxiety disorder found that more than 9 in 10
worries proved groundless (LaFreniere & Newman, 2020). Such people tend to
be hypervigilant. They more often interpret stimuli as threatening (Everaert et al., 2018). A
pounding heart signals a heart attack; a lone spider indicates an infestation; an everyday
disagreement with a friend spells a doomed relationship. And they more
readily remember threatening events (Van Bockstaele et al., 2014). Anxiety is especially
common when people cannot switch off such intrusive thoughts and feel helpless (Franklin
& Foa, 2011).

Biology

Conditioning and cognition can’t explain all aspects of anxiety disorders, OCD, and PTSD. Our
biology also plays a role.

G ENES

Among monkeys, fearfulness runs in families. A monkey reacts more strongly to stress if its
close biological relatives have sensitive, high-strung temperaments (Suomi, 1986). So, too, with
people. Although twins in general are not at higher risk for disorders, if one identical twin has an
anxiety disorder, the other is also at risk (Polderman et al., 2015). Even when raised separately,
identical twins may develop similar specific phobias (Carey, 1990; Eckert et al., 1981). One pair
of separated identical twins independently became so afraid of water that each would wade into
the ocean backward and only up to her knees. Another pair of twins with OCD rarely left their
house, took hours-long showers, used five bottles of disinfecting rubbing alcohol daily, and,
tragically, died together in an apparent suicide pact (Schmidt, 2018).

Given the genetic contribution to anxiety disorders, researchers are sleuthing the culprit genes.
Among their findings are gene variations associated with typical anxiety disorder symptoms or
specific disorders such as OCD (Purves et al., 2020; Smoller, 2020).

Some genes influence anxiety disorders by regulating brain levels of neurotransmitters. These
include serotonin, which influences sleep, mood, and attending to threats, and glutamate, which
heightens activity in the brain’s alarm centers (Pergamin-Hight et al., 2012; Welch et al., 2007).

So genes matter. Some of us have genes that make us like orchids—fragile, yet capable of beauty
under favorable circumstances. Others of us are like dandelions—hardy, and able to thrive in
varied circumstances (Ellis & Boyce, 2008; Pluess & Belsky, 2013).

But experience affects gene expression. A history of wartime trauma or child abuse can leave
long-term epigenetic marks. These molecular tags attach to our chromosomes and turn certain
genes on or off. Thus, experiences such as abuse can increase the likelihood that a genetic
vulnerability to a disorder such as PTSD will be expressed (Mehta et al., 2013; Zannas et al.,
2015).

T HE B RAIN

Our experiences change our brain, paving new pathways. Traumatic fear-learning
experiences can leave tracks in the brain, creating fear circuits within the amygdala (Etkin &
Wager, 2007; Herringa et al., 2013; Kolassa & Elbert, 2007). These fear pathways create
easy inroads for more fear experiences (Armony et al., 1998). Some antidepressant drugs
dampen this fear-circuit activity and associated obsessive-compulsive behaviors.

Generalized anxiety disorder, panic attacks, specific phobias, OCD, and PTSD express
themselves biologically as overarousal of brain areas involved in impulse control and
habitual behaviors. These disorders reflect the brain’s danger-detection system gone
hyperactive—producing anxiety when little danger exists. In OCD, for example, when the
brain detects that something is amiss, it seems to generate a mental hiccup of repeating
thoughts (obsessions) or actions (compulsions) (Gehring et al., 2000). Brain scans reveal
elevated activity in specific brain areas during behaviors such as compulsive hand washing,
checking, organizing, or hoarding (Insel, 2010; Mataix-Cols et al., 2004, 2005). The anterior
cingulate cortex, a brain region that monitors our actions and checks for errors, is often
especially hyperactive (Maltby et al., 2005) (FIGURE 14.5). Scientists are even identifying
specific brain cells that contribute to anxiety in the hope of helping people control it
(Jimenez et al., 2018).
N ATURAL S ELECTION

We seem biologically prepared to fear the threats our ancestors faced. Our specific phobias
focus on specific fears such as spiders and snakes, enclosed spaces and heights, storms and
darkness. Those who did not fear these threats were less likely to survive and leave
descendants. Nine-month-old infants attend more to sounds signaling ancient threats (hisses,
thunder) than they do to sounds representing modern threats (a bomb exploding, breaking
glass) (Erlich et al., 2013). It is easy to condition and hard to extinguish fears of such
“evolutionarily relevant” stimuli (Coelho & Purkis, 2009; Davey, 1995; Öhman, 2009).
Some of our modern fears (such as of flying) can also have an evolutionary explanation (a
biological predisposition to fear confinement and heights).

Just as our specific phobias focus on dangers our ancestors faced, our compulsive acts
typically exaggerate behaviors that helped them survive. Grooming had survival value. Gone
wild, it becomes compulsive hair pulling. Washing up becomes ritual hand washing. And
checking territorial boundaries becomes checking and rechecking already locked doors
(Rapoport, 1989).

 Depressive Disorders and Bipolar Disorders

LOQ 14-12
 How do depressive disorders and bipolar disorders differ?

In the past year, have you at some time “felt so depressed that it was difficult to function”? If
so, you were not alone. In one national survey, 31 percent of American college students
answered Yes (ACHA, 2009). You may feel deeply discouraged about the future, dissatisfied
with your life, or socially isolated. You may lack the energy to get things done, to see people,
or even to force yourself out of bed. You may be unable to concentrate, eat, or sleep
normally. You might even wonder if you would be better off dead. Perhaps academic success
came easily to you before, but now you find that disappointing grades jeopardize your goals
(Levine et al., 2020). Maybe loneliness, discrimination, or a romantic breakup has plunged
you into despair. And perhaps low self-esteem increases your brooding, worsening your self-
torment or leading you to “doomscroll” through depressing news (NPR, 2020; Orth et al.,
2016). Comparing yourself to seemingly happy, successful others on social media, you
mistakenly think it’s just you feeling this way (Jordan et al., 2011). Most of us will have
some direct or indirect experience with depression. Misery has more company than most
suppose.

As anxiety is a response to the threat of future loss, depression is often a response to past and
current stress. To feel bad in reaction to profoundly sad events is to be in touch with reality.
In such times, depression is like a car’s low-fuel light—a signal to stop and take appropriate
measures. As one book title reminds us, there are “good reasons for bad feelings.” People
with major depressive disorder, however, experience hopelessness and lethargy lasting
several weeks or months. Those with bipolar disorders (formerly called manic-depressive
disorder) alternate between depression and overexcited hyperactivity.

“My life had come to a sudden stop. I was able to breathe, to eat, to drink, to sleep. I could not,
indeed, help doing so; but there was no real life in me.”
—Leo Tolstoy, My Confession, 1887

Biologically speaking, life’s purpose is survival and reproduction, not happiness. Coughing,
vomiting, and various sorts of pain protect our body from dangerous toxins and stimuli.
Depression similarly protects us, sending us into a sort of psychic hibernation. It slows us
down, prompting us, when losing a relationship or blocked from a goal, to conserve energy
(Beck & Bredemeier, 2016; Gershon et al., 2016). When we grind temporarily to a halt and
reassess our life, as depressed people do, we can redirect our energy in more promising ways
(Watkins, 2008). There is sense to suffering.

Even mild sadness helps people process and recall faces more accurately (Hills et al., 2011).
They also tend to pay more attention to details, think more critically (with less gullibility),
and make better decisions (Forgas, 2009, 2013, 2017). Bad moods can serve useful purposes.
But sometimes depression becomes seriously maladaptive. How do we recognize the fine
line between a blue mood and a disorder?

“If someone offered you a pill that would make you permanently happy, you would be well
advised to run fast and run far. Emotion is a compass that tells us what to do, and a compass that
is perpetually stuck on NORTH is worthless.”
—Daniel Gilbert, “The Science of Happiness,” 2006
Major Depressive Disorder

Joy, contentment, sadness, and despair are different points on a continuum—points at which
any of us may be found at any given moment. The difference between a blue mood after bad
news and major depressive disorder is like the difference between breathlessness after a
hard run and chronic breathing problems (TABLE 14.5).

Depression is the number-one reason people seek mental health services. Indeed, the
World Health Organization declared depression “the leading cause of disability worldwide”
(WHO, 2017a). In one survey conducted in 21 countries, 4.6 percent of people interviewed
were experiencing moderate or severe depression, as have 1 in 10 U.S. adults at some point
during the prior year (Hasin et al., 2018; Thornicroft et al., 2017). U.S. depression levels rose
dramatically during the COVID-19 pandemic. Younger adults, women, people of color, and
those who were unemployed were hardest hit (Czeisler et al., 2020; Fitzpatrick et al.,
2020; Twenge & Joiner, 2020b). At least 1 in 5 health care professionals—feeling socially
isolated, overworked, and stressed from caring for people dying from the COVID-19 virus—
reported symptoms of depression (Pappa et al., 2020; Rossi et al., 2020).
“Depression is a silent, slow motion tsunami of dark breaking over me. I can’t swim away from
it.”
—Effy Redman, “Waiting for Depression to Lift,” 2017

Some people believe that depression has a seasonal pattern, returning each winter. Canadians
aged 12 to 24 in one large study, for example, reported feeling worse about themselves and
experiencing more trouble falling or staying asleep during the winter (Lukmanji et al., 2020).
Antidepressant prescriptions follow this same seasonal pattern (Lansdall-Welfare et al., 2019).
Although the DSM-5 recognizes a seasonal pattern in major depressive disorder and bipolar
disorders, some researchers challenge the presumption of widespread “seasonal affective
disorder.” They report from national data sets that people in northerly or cloudier places
do not experience more wintertime depression (Øverland et al., 2020; Traffanstedt et al., 2016).
So, is seasonal affective disorder a myth? Stay tuned.

Bipolar Disorders

Our genes dispose some of us, more than others, to respond emotionally to good and bad
events (Whisman et al., 2014). People with a bipolar disorder bounce from one emotional
extreme to the other (often week to week, rather than day to day or moment to moment). For
people with bipolar I disorder, when a depressive episode ends, a euphoric, overly talkative,
and excessively optimistic state called mania follows. But before long, the elated mood
either returns to normal or plunges again into depression, sometimes with back-and-
forth bipolar cycling. Those with bipolar II disorder move between depression and a
milder hypomania.

If depression is living in slow motion, mania is fast forward. During the manic phase, people
with bipolar disorders typically have less need for sleep. They show fewer sexual inhibitions.
Their positive emotions persist abnormally (Gruber et al., 2019; Stanton et al., 2019). Their
speech is loud, flighty, and hard to interrupt. They find advice irritating. Yet they need
protection from their own poor judgment, which may lead to reckless spending or unsafe sex.
Thinking fast feels good, but it also increases risk-taking (Chandler & Pronin, 2012; Pronin,
2013).

Genes associated with creativity increase the likelihood of a bipolar disorder, and risk factors
for developing a bipolar disorder predict greater creativity (Taylor, 2017). George Frideric
Handel (1685–1759), who may have suffered from a mild form of bipolar disorder,
composed his nearly 3-hour-long Messiah during 3 weeks of intense, creative energy in 1742
(Keynes, 1980). Bipolar disorders strike more often among those who rely on emotional
expression and vivid imagery, such as poets and artists, and less often among those who rely
on precision and logic, such as architects and journalists (Jamison, 1993, 1995; Kaufman &
Baer, 2002; Ludwig, 1995). Indeed, one analysis of over a million individuals showed that
the only psychiatric condition linked to working in a creative profession was a bipolar
disorder (Kyaga et al., 2013).
Bipolar disorders are much less common than major depressive disorder, but they are often more
dysfunctional. Unlike major depressive disorder, for which women are at highest risk, bipolar
disorders afflict as many men as women. The diagnosis has risen among adolescents, whose
mood swings may vary from raging to bubbly. In the decade between 1994 and 2003, bipolar
diagnoses in Americans under age 20 showed an astonishing 40-fold increase—from an
estimated 20,000 to 800,000 (Carey, 2007; Flora & Bobby, 2008; Moreno et al., 2007). The new
DSM-5 classifications have, however, begun to reduce the number of child and adolescent
bipolar diagnoses: Some of those who are persistently irritable and who have frequent and
recurring behavior outbursts are now instead diagnosed with disruptive mood dysregulation
disorder (Faheem et al., 2017).

Understanding Depressive Disorders and Bipolar Disorders

LOQ 14-13
 How can the biological and social-cognitive perspectives help us understand depressive
disorders and bipolar disorders?

Today’s psychologists continue to investigate why people have major depressive disorder
and bipolar disorders, and to design more effective ways to treat and prevent these disorders.
Here, we focus on major depressive disorder. Any theory of depression must explain the
following (Lewinsohn et al., 1985, 1998, 2003):

 Behaviors and thoughts change with depression. People trapped in a depressed

mood become inactive and feel alone, empty, and without a meaningful future.
Depression may be triggered by a sad or stressful event, but people with depression
may feel a heavy sadness even when nothing bad happens. They also more often
recall and expect negative happenings (my team will lose, my grades will fall, my
love will fail) (Zetsche et al., 2019).
 Depression is widespread, with women everywhere at greater risk. Worldwide, 350
million people have major depressive disorder and 60 million people have a bipolar
disorder (WHO, 2017a). Globally, women’s risk for major depressive disorder is
roughly double men’s (Kuehner, 2017; see also FIGURE 14.6). The depression
gender gap fits a bigger pattern: Women are generally more vulnerable to disorders
involving internal states, such as depression, anxiety, and inhibited sexual desire.
Women also experience more situations that increase their risk for depression, such as
receiving less pay for equal work, juggling multiple roles, and caring for children and
elderly family members (Freeman & Freeman, 2013). Men’s disorders tend to be
more external—alcohol use disorder, and disorders related to antisocial conduct and
lack of impulse control. Women often get sadder than men do; men often get madder
than women do.
 Most major depressive episodes end on their own. Therapy often speeds recovery.
But even without professional help, most people recover from depression. Some do so
without future depression and with “optimal well-being” (Rottenberg et al., 2019).
The black cloud of depression comes and, after sustained struggle, it often goes. But
for about half of these people, the depression returns (Curry et al., 2011; Klein &
Kotov, 2016). For some 20 percent, the condition will be chronic (Klein, 2010). An
 enduring recovery is more likely if: The first episode strikes later in life, there were
no previous episodes, the person experiences minimal physical or psychological
stress, and there is ample social support (Fuller-Thomson et al., 2016).
 Work and relationship stresses often precede depression. About 1 person in 4
diagnosed with depression has been brought down by a significant loss or trauma,
such as a loved one’s death, a ruptured marriage, a physical assault, or a lost job
(Kendler et al., 2008; Monroe & Reid, 2009; Orth et al., 2009; Wakefield et al.,
2007). Moving to a new culture also increases risk for depression, especially among
younger people who have not yet formed their identities (Zhang et al., 2013). And
childhood abuse doubles a person’s risk of adult depression (Nelson et al., 2017).
 Compared with generations past, depression strikes earlier and more often, with the
highest rates among older teens and young adults (Cross-National Collaborative
Group, 1992; Kessler et al., 2010; Olfson et al., 2015).

The Biological Perspective

Depression is a whole-body disorder. It involves genetic predispositions, brain connectivity

issues, and biochemical imbalances, as well as negative thoughts and a gloomy mood.

G ENES AND D EPRESSION

Major depressive disorder and bipolar disorders run in families. The risk of being diagnosed with
one of these disorders increases if your parent or sibling has the disorder (Sullivan et al.,
2000; Weissman et al., 2016). If one identical twin is diagnosed with major depressive disorder,
the chances are about 1 in 2 that at some time the other twin will be, too. If one identical twin has
a bipolar disorder, the chances of a similar diagnosis for the co-twin are even higher—7 in 10—
even for twins raised apart (DiLalla et al., 1996).

Summarizing the major twin studies, two research teams independently estimated the heritability
—the extent to which individual differences are attributable to genes—of major depressive
disorder at 40 percent (Kendler et al., 2018; Polderman et al., 2015; see also FIGURE 14.7). But
nurture matters, too. A Swedish national study examined children who had a biological parent
with depression. Among families in which at least one child was home-raised and another
adopted into a different family, those raised in the adoptive homes “had a significantly reduced
risk for major depression” (Kendler et al., 2020a).

Emotions are “postcards from our genes” (Plotkin, 1994). To tease out the genes that put people
at risk for depression, researchers may use linkage analysis. First, geneticists find families in
which the disorder appears across several generations. Next, the researchers look for differences
in DNA from affected and unaffected family members. Linkage analysis points them to a
chromosome neighborhood; “A house-to-house search is then needed to find the culprit gene”
(Plomin & McGuffin, 2003). But depression is a complex condition. Many genes work together,
producing a mosaic of small effects that interact with other factors to put some people at greater
risk. Nevertheless, researchers are identifying culprit gene variations in depressive and bipolar
disorders that may open the door to more effective drug therapy (Halldorsdottir et al.,
2019; Stahl et al., 2019).
B RAIN S TRUCTURE AND A CTIVITY

Nearly 100 studies have identified brain abnormalities linked with depression (Gray et al.,
2020). Scanning devices offer a window into the brain’s activity during depressed and manic
states in those with bipolar disorder. During depression, brain activity slows; during mania, it
increases (FIGURE 14.8). Depression can cause the brain’s reward centers to become less
active (Pizzagalli et al., 2019). The left frontal lobe and an adjacent brain reward center
become more active during positive emotions (Davidson et al., 2002; Heller et al.,
2009; Robinson et al., 2012).

At least two neurotransmitter systems are at work during the periods of brain inactivity and
hyperactivity that accompany major depressive disorder and bipolar
disorders. Norepinephrine, which increases arousal and boosts mood, is scarce during depression
and overabundant during mania. Drugs that decrease mania reduce norepinephrine.

Serotonin is also scarce or inactive during depression (Carver et al., 2008). Drugs that relieve
depression tend to increase serotonin or norepinephrine supplies by blocking either their reuptake
(as Prozac, Zoloft, and Paxil do with serotonin) or their chemical breakdown. Repetitive physical
exercise, such as jogging, reduces depression in part because it increases serotonin (Airan et al.,
2007; Harvey et al., 2018; Ilardi, 2009). To get away from a bad mood, some people have used
their own two feet.

N UTRITIONAL E FFECTS

What’s good for the heart is also good for the brain and mind. People who eat a heart-healthy
“Mediterranean diet” (heavy on vegetables, fish, whole grains, and olive oil) have a
comparatively low risk of developing heart disease, stroke, late-life cognitive decline, and
depression—all of which are associated with inflammation in the body (Kaplan et al.,
2015; Psaltopoulou et al., 2013; Rechenberg, 2016). Excessive alcohol use also correlates with
depression, partly because depression can increase alcohol use but mostly because alcohol
misuse leads to depression (Fergusson et al., 2009).

The Social-Cognitive Perspective

Biological influences contribute to depression, but in the nature–nurture dance, our life
experiences also play a part. Diet, drugs, stress, and other environmental influences lay down
epigenetic marks, those molecular genetic tags that can turn certain genes on or off. Animal
studies suggest that long-lasting epigenetic influences may play a role in depression (Nestler,
2011).

Thinking matters, too. The social-cognitive perspective explores how people’s assumptions

and expectations influence what they perceive. Many depressed people have intensely
negative views of themselves, their situation, and their future (Nieto et al., 2020). Norman, a
Canadian university professor, recalled his depression this way:
I [despaired] of ever being human again. I honestly felt subhuman, lower than the lowest vermin.
Furthermore, I … could not understand why anyone would want to associate with me, let alone love
me…. I was positive that I was a fraud and a phony and that I didn’t deserve my Ph.D.… I didn’t
deserve the research grants I had been awarded; I couldn’t understand how I had written books and
journal articles…. I must have conned a lot of people. (Endler, 1982, pp. 45–49)
Expecting the worst, depressed people magnify bad experiences and minimize good ones
(Wenze et al., 2012). Their self-defeating beliefs and negative explanatory style feed their
depression.
N EGATIVE T HOUGHTS , N EGATIVE M OODS , AND G ENDER

Do you agree or disagree that you “at least occasionally feel overwhelmed by all I have to do”?
In a survey, 38 percent of women and 17 percent of men entering U.S. colleges and universities
agreed (Pryor et al., 2006). Relationship stresses also affect teen girls more than boys (Hamilton
et al., 2015). Why are women nearly twice as vulnerable as men to depression, and twice as
likely to take antidepressant drugs (Pratt et al., 2017)?

Susan Nolen-Hoeksema (2003) related women’s higher risk of depression to what she described
as their tendency to ruminate or overthink. Staying focused on a problem—thanks to the
continuous activation of an attention-sustaining frontal lobe area—can be adaptive (Altamirano
et al., 2010; Andrews & Thomson, 2009a,b). But relentless, self-focused rumination can distract
us, increase negative emotions, and disrupt daily activities (Johnson et al., 2016; Leary,
2018; Yang et al., 2017). We can even ruminate about our excessive rumination—by thinking
too much about how we’re thinking about something too much.

Comparisons can also feed misery. Lonely Lori scrolls through her social media feed and
sees Maria having a blast at a party, Angelique enjoying a family vacation, and Amira
looking super in a swimsuit. In response, Lori broods: “My life is terrible.”

But why do life’s unavoidable failures lead only some people to become depressed? The
answer lies partly in their explanatory style—who or what they blame for their failures.
Think of how you might feel if you failed a test. If you can blame someone else (“What an
unfair test!”), you are more likely to feel angry. If you blame yourself, you probably will feel
stupid and depressed.

Depression-prone people respond to bad events in an especially self-focused, self-blaming

way (LeMoult & Gotlib, 2019). As FIGURE 14.9 illustrates, they explain bad events in
terms that are stable, global, and internal.

Self-defeating beliefs may arise from learned helplessness, the hopelessness and passive

resignation that humans and other animals learn when they experience uncontrollable
painful events (Maier & Seligman, 2016). Pessimistic, overgeneralized, self-blaming
attributions may create a depressing sense of hopelessness (Abramson et al., 1989; Groß et
al., 2017). As researcher Martin Seligman has noted, “A recipe for severe depression is
preexisting pessimism encountering failure” (1991, p. 78). What, then, might we expect of
new college students who exhibit a pessimistic explanatory style? Lauren Alloy and her
colleagues (1999) monitored several hundred students every 6 weeks for 2.5 years. Among
those identified as having a pessimistic thinking style, 17 percent had a first episode of
major depression, as did only 1 percent of those who began college with an optimistic
thinking style.

Critics note a chicken-and-egg problem nesting in the social-cognitive explanation of

depression. Which comes first? The pessimistic explanatory style, or the depressed mood?
The negative explanations coincide with a depressed mood, and they are indicators of
depression. But do negative thoughts cause depression, any more than a speedometer’s
reading causes a car’s speed? Temporarily putting people in a bad or sad mood does make
their memories, judgments, and expectations more pessimistic—a phenomenon that memory
researchers call state-dependent memory.

Cultural forces may also nudge people toward or away from depression. Why is depression
so common among young Westerners? Seligman (1991, 1995) has pointed to the rise of
individualism and the decline of commitment to religion and family. In non-Western
cultures, where close-knit relationships and cooperation are the norm, major depressive
disorder is less common and less tied to self-blame for failure (De Vaus et al., 2018; Ferrari
et al., 2013). In Japan, for example, depressed people instead tend to report feeling shame
over letting others down (Draguns, 1990).

D EPRESSION ’ S V ICIOUS C YCLE

Depression is both a cause and an effect of stressful experiences that disrupt our sense of
who we are and why we matter. Such disruptions can lead to brooding, which is rich soil for
growing negative feelings. And that negativity—being withdrawn, self-focused, and
complaining—can by itself cause others to reject us (Furr & Funder, 1998; Gotlib &
Hammen, 1992). Indeed, people deep in depression are at high risk for divorce, job loss, and
other stressful life events. Weary of the person’s fatigue, hopeless attitude, and negativity, a
spouse may threaten to leave, or a boss may begin to question the person’s competence.
Rejection and depression feed each other. Misery may love another’s company, but company
does not love another’s misery.

We can now assemble the pieces of the depression puzzle (FIGURE 14.10): (1) Stressful
experiences interpreted through (2) a brooding, negative explanatory style create (3) a
hopeless, depressed state that (4) hampers the way the person thinks and acts. These thoughts
and actions, in turn, fuel (1) further stressful experiences such as rejection. Depression is a
snake that bites its own tail.

It is a cycle we can all recognize. When we feel down, we think negatively and remember
bad experiences. Britain’s Prime Minister Winston Churchill called depression a “black dog”
that periodically hounded him. U.S. President Abraham Lincoln was so withdrawn and
brooding as a young man that his friends feared he might take his own life (Kline, 1974). As
their lives remind us, “depression” can be an anagram for “I pressed on.” Many people
struggle through depression and regain their capacity to love, to work, and to succeed.

“Like nearly one in 10 Americans—and like many of you—I live with an insidious, chronic
disease. Depression is a malfunction in the instrument we use to determine reality. The brain
experiences a chemical imbalance and wraps a narrative around it.

At the bottom of my recent depression, I did a plus and minus. The plus side, as you’d imagine,
was short. The minus side included the most frightful clichés: ‘You are a burden to your friends.’
‘You have no future.’ ‘No one would miss you.’

The scary thing is that these things felt completely true when I wrote them. At that moment,
realism seemed to require hopelessness.

But then you reach your breaking point—and do not break. With patience and the right medicine,
the fog in your brain begins to thin. If you are lucky, as I was, you encounter doctors and nurses
who know parts of your mind better than you do. There are friends who run into the burning
building of your life to rescue you, and acquaintances who become friends.

Over time, you begin to see hints and glimmers of a larger world outside the prison of your
sadness. The conscious mind takes hold of some shred of beauty or love. And then more shreds,
until you begin to think maybe, just maybe, there is something better on the far side of despair.”
—Washington Post columnist Michael Gerson, 2019

 Schizophrenia

During their most severe periods, people with schizophrenia live in a private inner world,
preoccupied with the strange ideas and images that haunt them. The word itself means
“split” (schizo) “mind” (phrenia). It refers not to a multiple identity split but rather to the mind’s
split from reality, as shown in disturbed perceptions and beliefs, disorganized speech, and
diminished, inappropriate emotions (and actions). Schizophrenia is the chief example of
a psychotic disorder.

As you can imagine, these characteristics profoundly disrupt relationships and work. Given a
supportive environment and medication, over 40 percent of people with schizophrenia will have
periods of a year or more of normal life experience (Jobe & Harrow, 2010). But only 1 in 7
experience a full and enduring recovery (Jääskeläinen et al., 2013).

Symptoms of Schizophrenia
LOQ 14-14
 What patterns of perceiving, thinking, and feeling characterize schizophrenia?

Schizophrenia comes in varied forms. People with schizophrenia display symptoms that
are positive (inappropriate behaviors are present) or negative (appropriate behaviors are absent).
Those with positive symptoms may experience disturbed perceptions, talk in disorganized and
deluded ways, or exhibit inappropriate laughter, tears, or rage. Those with negative symptoms
may exhibit an absence of emotion in their voices, expressionless faces, or mute and rigid bodies.

Disturbed Perceptions and Beliefs

People with schizophrenia sometimes hallucinate—they see, hear, feel, taste, or smell things
that exist only in their minds. Most often, the hallucinations are voices, which sometimes
make insulting remarks or give orders. The voices may tell the person that they are bad or
that they must set fire to their living space. Imagine your own reaction if a dream broke into
your waking consciousness, making it hard to separate your experience from your
imagination. When the unreal seems real, the resulting perceptions are at best bizarre, at
worst terrifying.

 “Now consider this: The regulator that funnels certain information to you and filters out
other information suddenly shuts off. Immediately, every sight, every sound, every smell coming
at you carries equal weight; every thought, feeling, memory, and idea presents itself to you with
an equally strong and demanding intensity.”
—Elyn R. Saks, The Center Cannot Hold, 2007

Hallucinations are false perceptions. People with schizophrenia also have disorganized,

fragmented thinking, often distorted by false beliefs called delusions. If they
have paranoid delusions, they may believe they are being threatened or pursued.

One cause of disorganized thinking may be a breakdown in selective attention. Normally, we

have a remarkable capacity for giving our undivided attention to one set of sensory stimuli
while filtering out others. People with schizophrenia are easily distracted by tiny unrelated
stimuli, such as the grooves on a brick or the tones in a voice. This selective-attention
difficulty is but one of dozens of cognitive differences associated with schizophrenia
(Reichenberg & Harvey, 2007).

Disorganized Speech

Maxine, a young woman with schizophrenia, believed she was Mary Poppins. Communicating
with Maxine was difficult because her thoughts spilled out in no logical order. Her
biographer, Susan Sheehan (1982, p. 25), observed her saying aloud to no one in particular,
“This morning, when I was at Hillside [Hospital], I was making a movie. I was surrounded by
movie stars…. I’m Mary Poppins. Is this room painted blue to get me upset? My grandmother
died four weeks after my eighteenth birthday.”

Jumbled ideas may make no sense even within sentences, forming what is known as word
salad. One young man begged for “a little more allegro in the treatment,” and suggested that
“liberationary movement with a view to the widening of the horizon” will “ergo extort some wit
in lectures.”
Diminished and Inappropriate Emotions

The expressed emotions of schizophrenia are often utterly inappropriate, split off from reality
(Kring & Caponigro, 2010). Maxine laughed after recalling her grandmother’s death. On other
occasions, she cried when others laughed, or became angry for no apparent reason. Others with
schizophrenia lapse into an emotionless flat affect state of no apparent feeling.

Most also have an impaired theory of mind—they have difficulty reading other peoples’ facial
expressions and states of mind (Bora & Pantelis, 2016). Unable to understand others’ mental
states, those with schizophrenia struggle to feel sympathy and compassion (Bonfils et al., 2016).
These emotional deficiencies occur early in the illness and have a genetic basis (Bora & Pantelis,
2013). Motor behavior may also be inappropriate and disruptive. Those with schizophrenia may
experience catatonia, characterized by motor behaviors ranging from a physical stupor
(remaining motionless for hours), to senseless, compulsive actions (such as continually rocking
or rubbing an arm), to severe and dangerous agitation.

Onset and Development of Schizophrenia

LOQ 14-15
 How do chronic schizophrenia and acute schizophrenia differ?

An estimated 20 million people worldwide—about 1 in 270—have schizophrenia (WHO,

2019b). This disorder knows no national boundaries and typically strikes as young people are
maturing into adulthood. Men tend to be diagnosed more often than women, and to be struck
earlier and with more severity (Aleman et al., 2003; Eranti et al., 2013; Picchioni & Murray,
2007).

When schizophrenia is a slow-developing process, called chronic schizophrenia, recovery is

doubtful (Harrison et al., 2001; Jääskeläinen et al., 2013). This was the case with Maxine, whose
schizophrenia took a slow course, emerging from a long history of social inadequacy and poor
school performance (MacCabe et al., 2008). Although people with both chronic and acute
schizophrenia can exhibit positive or negative symptoms, social withdrawal—a negative
symptom—is often found among those with chronic schizophrenia (Kirkpatrick et al., 2006).
Men more often exhibit negative symptoms and chronic schizophrenia (Räsänen et al., 2000).

When previously well-adjusted people develop schizophrenia rapidly following particular life
stresses, this is called acute schizophrenia, and recovery is much more likely. They more often
have positive symptoms that respond to drug therapy (Fenton & McGlashan,
1991, 1994; Fowles, 1992).

Understanding Schizophrenia

Schizophrenia is one of the most heavily researched psychological disorders. Most studies now
link it with abnormal brain tissue and genetic predispositions. Schizophrenia is a disease of the
brain manifested in symptoms of the mind.

Brain Abnormalities
LOQ 14-16
 What brain abnormalities are associated with schizophrenia?

Might chemical imbalances in the brain explain schizophrenia? Scientists have long known that
strange behavior can have strange chemical causes. Have you ever heard the saying “as mad as a
hatter”? That phrase is often thought to refer to the psychological deterioration of British
hatmakers whose brains, it was later discovered, were slowly poisoned by the mercury-laden felt
material (Smith, 1983). Could schizophrenia symptoms have a similar biochemical key?
Scientists are searching for blood proteins that might predict schizophrenia onset (Chan et al.,
2015). And they are tracking the mechanisms by which chemicals produce hallucinations and
other symptoms.

D OPAMINE O VERACTIVITY

One possible answer emerged when researchers examined schizophrenia patients’ brains after
death. They found an excess number of dopamine receptors, including a sixfold excess for the
dopamine receptor D4 (Seeman et al., 1993; Wong et al., 1986). The resulting hyper-responsive
dopamine system may intensify brain signals in schizophrenia, creating positive symptoms such
as hallucinations and paranoia (Maia & Frank, 2017). Drugs that block dopamine receptors often
lessen these symptoms. Drugs that increase dopamine levels, such as nicotine, amphetamines,
and cocaine, sometimes intensify them (Basu & Basu, 2015; Farnia et al., 2014).

A BNORMAL B RAIN A CTIVITY AND A NATOMY

Abnormal brain activity and brain structures accompany schizophrenia. Some people
diagnosed with schizophrenia have abnormally low brain activity in the brain’s frontal lobes,
which help us reason, plan, and solve problems (Morey et al., 2005; Pettegrew et al.,
1993; Resnick, 1992). The brain waves that reflect synchronized neural firing in the frontal
lobes decline noticeably (Spencer et al., 2004; Symond et al., 2005).

One study took PET scans of brain activity while people with schizophrenia were hallucinating
(Silbersweig et al., 1995). When participants heard a voice or saw something, their brain became
vigorously active in several core regions. One was the thalamus, the structure that filters
incoming sensory signals and transmits them to the brain’s cortex. Another PET scan study of
people with paranoia found increased activity in the amygdala, a fear-processing center (Epstein
et al., 1998).

Many studies have also found enlarged ventricles—fluid-filled brain cavities—and a

corresponding shrinkage and thinning of cerebral tissue (Goldman et al., 2009; van Haren et al.,
2016). People often inherit these brain differences. If one affected identical twin shows brain
abnormalities, the odds are at least 1 in 2 that the other twin’s brain will have them (van Haren et
al., 2012). Some studies have even found these abnormalities in people who later developed the
disorder (Karlsgodt et al., 2010). The greater the brain shrinkage, the more severe the thought
disorder (Collinson et al., 2003; Nelson et al., 1998; Shenton, 1992).
Smaller-than-normal areas may include the cortex, the hippocampus, and the corpus callosum
connecting the brain’s two hemispheres (Arnone et al., 2008; Bois et al., 2016). Often, the
thalamus is also smaller than normal, which may explain why filtering sensory input and
focusing attention can be difficult for people with schizophrenia (Andreasen et al., 1994; Ellison-
Wright et al., 2008). Schizophrenia also tends to involve a loss of neural connections across the
brain network (Bohlken et al., 2016; Kambeitz et al., 2016). The bottom line: Schizophrenia
involves not one isolated brain abnormality but problems with several brain regions and their
interconnections (Andreasen, 1997, 2001; Arnedo et al., 2015).

Prenatal Environment and Risk

LOQ 14-17
 What prenatal events are associated with increased risk of developing schizophrenia?

What causes these brain abnormalities in people with schizophrenia? Some scientists point to
prenatal development or delivery (Fatemi & Folsom, 2009; Walker et al., 2010). Risk factors
include low birth weight, maternal diabetes, older paternal age, and oxygen deprivation during
delivery (King et al., 2010). Famine may also increase risks. People conceived during the peak of
World War II’s Dutch famine and during the famine of 1959 to 1961 in eastern China later
developed schizophrenia at twice the normal rate (St. Clair et al., 2005; Susser et al., 1996). And
extreme maternal stress may be a culprit: A study of 200,000 Israeli mothers showed that
exposure to terror attacks during pregnancy doubled their children’s risk of schizophrenia (Y.
Weinstein et al., 2018).

Let’s consider another possible culprit. Might a midpregnancy viral infection impair fetal brain
development (Brown & Patterson, 2011)? To test this fetal-virus idea, scientists have asked these
questions:

 Are people at increased risk of schizophrenia if their country experienced a flu epidemic during
the middle of their fetal development? The repeated answer has been Yes (Mednick et al.,
1994; Murray et al., 1992; Wright et al., 1995).
 Are people born in densely populated areas, where viral diseases spread more readily, at
greater risk for schizophrenia? The answer, confirmed in a study of 1.75 million Danes, has again
been Yes (Jablensky, 1999; Mortensen, 1999).
 Are people born during the winter and spring months—those who were in utero during the
fall-winter flu season—also at increased risk? The answer is again Yes (Fox, 2010; Schwartz,
2011; Torrey & Miller, 2002; Torrey et al., 1997).
 In the Southern Hemisphere, where the seasons are the reverse of the Northern Hemisphere,
are the months of above-average pre-schizophrenia births similarly reversed? Again, the
answer has been Yes. In Australia, people born between August and October are at greater risk.
But people born in the Northern Hemisphere who later moved to Australia still have a greater
risk if they were born between January and March (McGrath et al., 1995; McGrath & Welham,
1999).
 Are mothers who report being sick with influenza during pregnancy more likely to bear
children who develop schizophrenia? In one study of nearly 8000 women, the answer
was Yes. The schizophrenia risk increased from the customary 1 percent to about 2 percent—but
only when infections occurred during the second trimester (Brown et al., 2000). Maternal
 influenza infection during pregnancy affects brain development in monkeys as well (Short et al.,
2010).
 Does blood drawn from pregnant women whose offspring develop schizophrenia show higher-
than-normal levels of antibodies that suggest a viral infection? In several studies, the answer
has again been Yes (Brown et al., 2004; Buka et al., 2001; Canetta et al., 2014).

These converging lines of evidence suggest that fetal-virus infections contribute to the
development of schizophrenia. They also strengthen the World Health Organization’s
(2012b) recommendation that pregnant women be given highest priority for the seasonal flu
vaccine.

Genetic Influences
LOQ 14-18
 How do genes influence schizophrenia?

Fetal-virus infections may increase the odds that a child will develop schizophrenia. But
many women get the flu during their second trimester of pregnancy, and only 2 percent of
them bear children who develop schizophrenia. Why are only some children at risk? Might
some people be more genetically vulnerable to schizophrenia? Yes. The roughly 1-in-270
lifetime odds of any one person being diagnosed with schizophrenia become about 1 in 10
among those who have a sibling or parent with the disorder. If the affected sibling is an
identical twin, the odds increase to nearly 1 in 2 (FIGURE 14.11). Those odds are
unchanged even when the twins are reared apart (Plomin et al., 1997). (Only about a dozen
such cases are on record.)

Remember, though, that identical twins share more than their genes. They also share a
prenatal environment. About two-thirds also share a placenta and the blood it supplies; the
other third have separate placentas. Shared placentas matter. If the co-twin of an identical
twin with schizophrenia shared the placenta, the chances of developing the disorder are 6 in
10. If the identical twins had separate placentas, the co-twin’s chances of developing
schizophrenia drop to 1 in 10 (Davis et al., 1995; Davis & Phelps, 1995; Phelps et al., 1997).
Twins who share a placenta are more likely to share the same prenatal viruses. So perhaps
shared germs as well as shared genes produce identical twin similarities (FIGURE 14.12).

Adoption studies help untangle genetic and environmental influences. Children adopted by
someone who develops schizophrenia do not “catch” the disorder. Rather, adopted children
have a higher risk if a biological parent has schizophrenia (Gottesman, 1991). Genes indeed
matter.

The search is on for specific genes that, in some combination, predispose schizophrenia-
inducing brain abnormalities. In the largest genetic studies of schizophrenia, scientists
analyze worldwide data from the genomes of tens of thousands of people with and without
schizophrenia (Lam et al., 2019; Pardiñas et al., 2018). One analysis found 176 genome
locations linked with this disorder, some affecting dopamine and other neurotransmitters.
Another study of more than 100,000 people identified 413 schizophrenia-associated genes
(Huckins et al., 2019).

Although genes matter, the genetic formula is not as straightforward as the inheritance of eye
color. Schizophrenia is influenced by (no surprise by now) many genes, each with small
effects (Binder, 2019; Weinberger, 2019). As we have seen in so many different contexts,
nature and nurture interact. Recall that epigenetic factors influence whether genes will be
expressed. Like hot water activating a tea bag, environmental factors such as viral infections,
nutritional deprivation, and maternal or severe life stress can “turn on” the genes that put
some of us at higher risk for schizophrenia. Identical twins’ differing histories in the womb
and beyond explain why they may show differing gene expressions (Dempster et al.,
2013; Walker et al., 2010). Our heredity and our life experiences work together. Neither
hand claps alone.

Thanks to our expanding understanding of genetic and brain influences on maladies such as
schizophrenia, the general public increasingly recognizes the potency of biological factors in
psychiatric disorders (Pescosolido et al., 2010).

Few of us can relate to the strange thoughts, perceptions, and behaviors of schizophrenia.
Sometimes our thoughts jump around, but we rarely talk nonsensically. Occasionally we feel
unjustly suspicious of someone, but we do not believe the world is plotting against us. Often
our perceptions err, but rarely do we see or hear things that are not there. We feel regret
after laughing at someone’s misfortune, but we rarely giggle in response to our own bad
news. At times we just want to be alone, but we do not retreat into fantasy worlds.
However, millions of people worldwide do talk strangely, suffer delusions, hear nonexistent
voices, see things that are not there, laugh or cry at inappropriate times, or withdraw into
private imaginary worlds. The quest to solve the cruel puzzle of schizophrenia therefore
continues, more vigorously than ever.

 Dissociative, Personality, and Eating Disorders

Dissociative Disorders
LOQ 14-19
 What are dissociative disorders, and why are they controversial?

Among the most bewildering disorders are the rare dissociative disorders, in which a person’s
conscious awareness dissociates (separates) from painful memories, thoughts, and feelings. The
result may be a dissociative fugue state, a sudden loss of memory or change in identity, often in
response to an overwhelmingly stressful situation (Harrison et al., 2017). Such was the case for
one Vietnam War veteran who was haunted by his comrades’ deaths, and who had left his World
Trade Center office shortly before the 9/11 terrorist attack. Later, he disappeared. Six months
later, when he was discovered in a Chicago homeless shelter, he reported no memory of his
identity or family (Stone, 2006).

Dissociative Identity Disorder

Dissociation itself is not so rare. Any one of us may have a fleeting sense of being unreal, of
being separated from our body, of watching ourselves as if in a movie. A massive dissociation of
self from ordinary consciousness occurs in dissociative identity disorder (DID), in which two
or more distinct identities—each with its own voice and mannerisms—seem to control a person’s
behavior. Thus, the person may be prim and proper one moment, loud and flirtatious the next.
Typically, the original identity denies any awareness of the other(s).

U NDERSTANDING D ISSOCIATIVE I DENTITY D ISORDER

Skeptics question DID. They find it suspicious that the disorder has such a short and
localized history. Between 1930 and 1960, the number of North American DID diagnoses
averaged 2 per decade. By the 1980s, when the Diagnostic and Statistical Manual of Mental
Disorders (DSM) contained the first formal code for this disorder, the number had exploded
to more than 20,000 (McHugh, 1995). The average number of displayed identities also
mushroomed—from 3 to 12 per patient (Goff & Simms, 1993). And although diagnoses have
been increasing in countries where DID has been publicized, the disorder is much less
prevalent outside North America (Lilienfeld, 2017).

Are clinicians who discover multiple identities merely triggering role playing by fantasy-
prone people in a particular social context (Giesbrecht et al., 2008, 2010; Lynn et al.,
2014; Merskey, 1992)? After all, clients do not enter therapy saying, “Allow me to introduce
myselves.” Rather, charge the critics, some therapists go fishing for multiple identities:
“Have you ever felt like another part of you does things you can’t control?” “Does this part
of you have a name?” “Can I talk to the angry part of you?” Once clients permit a therapist to
talk, by name, “to the part of you that says those angry things,” they begin acting out the
fantasy. Like actors who lose themselves in their roles, vulnerable patients may “become”
the parts they are acting out. The result may be the experience of another self. Or perhaps
dissociative identities are simply a more extreme version of the varied “selves” we normally
present—a goofy self around our friends, a subdued self around our employer?

“Pretense may become reality.”

—Chinese proverb

Despite some hoaxes, other researchers and clinicians believe DID is a real disorder. They
cite findings of distinct body and brain states associated with differing identities (Putnam,
1991). Abnormal brain anatomy and activity can also accompany DID. Brain scans show
shrinkage in areas that aid memory and detection of threat (Vermetten et al., 2006).
Heightened activity appears in brain areas linked with the control and inhibition of traumatic
memories (Elzinga et al., 2007).

Both the psychodynamic and learning perspectives have interpreted DID symptoms as ways
of coping with anxiety. Some psychodynamic theorists see them as defenses against the
anxiety caused by unacceptable impulses. In this view, a second identity enables the
discharge of forbidden impulses. Learning theorists see dissociative disorders as behaviors
reinforced by anxiety reduction.
“Though this be madness, yet there is method in ’t.”
—William Shakespeare, Hamlet, 1600

Some clinicians include dissociative disorders under the umbrella of posttraumatic stress
disorder as a natural, protective response to traumatic experiences during childhood (Brand
et al., 2016; Spiegel, 2008). Many people being treated for DID recall being physically,
sexually, or emotionally abused as children (Gleaves, 1996; Lilienfeld et al., 1999). Critics
wonder, however, whether vivid imagination or therapist suggestion contributed to such
recollections (Kihlstrom, 2005). So the scientific debate continues.

Personality Disorders
LOQ 14-20
 What are the three clusters of personality disorders? What behaviors and brain activity
characterize antisocial personality disorder?

The inflexible and enduring behavior patterns of personality disorders interfere with social
functioning. These 10 disorders in DSM-5 tend to form three clusters, characterized by

 anxiety, such as a fearful sensitivity to rejection that predisposes the

withdrawn avoidant personality disorder.
 eccentric or odd behaviors, such as those prompted by the magical thinking
of schizotypal personality disorder.
 dramatic or impulsive behaviors, such as the unstable, attention-getting borderline
personality disorder, the self-focused and self-inflating narcissistic personality
disorder, and—what we next discuss as an in-depth example—the callous, and often
dangerous, antisocial personality disorder.

Antisocial Personality Disorder

People with antisocial personality disorder, usually male, can display symptoms by age 8.

Their lack of conscience becomes plain before age 15, as they begin to lie, steal, fight, or display
unrestrained sexual behavior (Cale & Lilienfeld, 2002). Not all children with these traits become
antisocial adults, and for many males, antisocial behavior often subsides after adolescence
(Moffitt, 2018). (Note that antisocial means socially harmful and remorseless, not merely
unsociable.) Those who do develop the disorder—about half—will generally act in violent or
otherwise criminal ways, be unable to keep a job, and behave irresponsibly toward family
members (Farrington, 1991).

But criminality is not an essential component of antisocial behavior (Skeem & Cooke, 2010).
And many criminals do not exhibit antisocial personality disorder; rather, they show
responsible concern for their friends and family members. In contrast with most criminals,
people with antisocial personality disorder (sometimes called sociopaths or psychopaths) are
more socially deficient. They often exhibit less emotional intelligence—the ability to
understand, manage, and perceive emotions (Ermer et al., 2012b; Gillespie et al., 2019).
Antisocial personalities behave impulsively, and then feel and fear little (Fowles & Dindo,
2009). Their impulsivity can have horrific consequences, including homicide (Camp et al.,
2013; Fox & DeLisi, 2019). Consider the case of Tommy Lynn Sells. He said he killed his
first victim when he was 15. He felt little regret then or later. During his years of crime, he
brutally murdered at least 17 women, men, and children. “I am hatred,” Sells told one
interviewer while on death row (ABC, 2014). “When you look at me, you look at hate.”

U NDERSTANDING A NTISOCIAL P ERSONALITY D ISORDER

Antisocial personality disorder is woven of both biological and psychological strands. Twin
and adoption studies reveal that biological relatives of people with antisocial and
unemotional tendencies are at increased risk for antisocial behavior (Frisell et al.,
2012; Kendler et al., 2015a). No single gene codes for a complex behavior such as crime.
But genes that predispose lower mental ability and self-control predict a higher crime risk
(Wertz et al., 2018).

As with other disorders, geneticists have also identified specific genes that are more common
in those with antisocial personality disorder (Gunter et al., 2010; Tielbeek et al., 2017). The
genes that put people at risk for antisocial behavior also increase the risk for substance use
disorder (Dick, 2007). Disorders often do appear together—for example, depressive
disorders and anxiety disorders (Jacobson & Newman, 2017; Plana-Ripoll et al., 2019).
People diagnosed with one disorder are at higher risk for being diagnosed with another.
Such comorbidity results from overlapping genes that predispose different disorders
(Brainstorm Consortium, 2018; Gandal et al., 2018).

Genetic influences, often in combination with negative environmental factors such as

childhood abuse, family instability, or poverty, help wire the brain (Dodge, 2009). This
gene–environment combination also occurs in chimpanzees, which, like humans, vary in
antisocial (mean/bold/disinhibited) tendencies (Latzman et al., 2017). In people with
antisocial criminal tendencies, the emotion-controlling amygdala is smaller (Pardini et al.,
2014).

The genetic vulnerability of people with antisocial tendencies appears as low arousal in
response to threats. Awaiting events that most people would find unnerving, such as electric
shocks or loud noises, they show little autonomic nervous system arousal (Hare, 1975; Ling
et al., 2019). Long-term studies show that their stress hormone levels were lower than
average as teens, before they had ever committed a crime (FIGURE 14.13). And those who
were slow to develop conditioned fears at age 3 were also more likely to commit a crime
later in life (Gao et al., 2010). Likewise, preschool boys who later become aggressive or
antisocial adolescents tend to be impulsive, uninhibited, unconcerned with social rewards,
and low in anxiety (Caspi et al., 1996; Tremblay et al., 1994).

Traits such as fearlessness and dominance can be adaptive. If channeled in more productive
directions, fearlessness may lead to athletic stardom, adventurism, or courageous heroism
(Costello et al., 2018; Patton et al., 2018). Indeed, 42 American presidents exhibited higher
than usual fearlessness and dominance (Lilienfeld et al., 2012, 2016). Patient S. M., a 49-
year-old woman with amygdala damage, showed fearlessness and impulsivity but also
heroism: She gave a man in need her only coat and scarf, and donated her hair to the Locks
of Love charity after befriending a child with cancer (Lilienfeld et al., 2017). Lacking a sense
of social responsibility, however, the same disposition may produce a cool con artist or killer
(Lykken, 1995).

With antisocial behavior—as with so much else—nature and nurture interact. Once again, the
biopsychosocial perspective helps us understand the whole story. To further investigate the
neural basis of antisocial personality disorder, neuroscientists are exploring the antisocial
brain (Brazil & Buades-Rotger, 2020). Shown emotionally evocative photographs, such as a
man holding a knife to a woman’s throat, criminals with antisocial personality disorder
display blunted heart rate and perspiration responses, and less activity in brain areas that
typically respond to emotional stimuli (Harenski et al., 2010; Kiehl & Buckholtz, 2010).
They also have a larger and hyperreactive dopamine reward system, which predisposes their
impulsive drive to do something rewarding despite the consequences (Buckholtz et al.,
2010; Glenn et al., 2010).

One study compared PET scans of 41 murderers’ brains with those from people of similar
age and sex. The murderers’ frontal lobes, an area that helps control impulses, displayed
reduced activity (Raine, 1999, 2005; FIGURE 14.14). The reduced activation was especially
apparent in those who murdered impulsively. Researchers later found that violent repeat
offenders had 11 percent less frontal lobe tissue than normal (Raine et al., 2000). This helps
explain another finding: People with antisocial personality disorder fall far below normal in
aspects of thinking such as planning, organization, and inhibition, which are all frontal lobe
functions (Morgan & Lilienfeld, 2000). Such data remind us: Everything psychological is
also biological.

Eating Disorders
LOQ 14-21
 What are the three main eating disorders, and how do biological, psychological, and
social-cultural influences make people more vulnerable to them?

Our bodies are naturally disposed to maintain a steady weight, including storing energy for
times when food becomes unavailable. But sometimes psychological influences overwhelm
biological wisdom. This becomes painfully clear in three eating disorders:

 In anorexia nervosa, people—often female adolescents—starve themselves.

Anorexia often begins as an attempt to lose weight, but the dieting becomes a habit
(Steinglass et al., 2018). Regardless of their actual weight, the self-starved person
feels fat, fears being fat, and focuses obsessively on losing weight, sometimes
exercising excessively.
 In bulimia nervosa, a cycle of repeated episodes of binge eating alternates with
behaviors to compensate, such as vomiting, laxative use, fasting, or excessive
exercise (Wonderlich et al., 2007). Unlike anorexia, bulimia is marked by weight
 fluctuations within or above normal ranges, making the disorder easier to hide.
Bulimia may also be triggered by a weight-loss diet that is broken by gorging on
forbidden foods. People with this disorder—mostly women in their late teens or early
twenties (but also some men)—eat in spurts, sometimes influenced by negative
emotion or by friends who are bingeing (Crandall, 1988; Haedt-Matt & Keel, 2011).
Preoccupied with food (craving sweet and high-fat foods), and fearful of becoming
overweight, binge-purge eaters experience bouts of depression, guilt, and anxiety
during and following binges (Hinz & Williamson, 1987; Johnson et al., 2002).
 Those with binge-eating disorder engage in significant bouts of bingeing, followed
by remorse. But they do not purge, fast, or exercise excessively.

 At some point during their lifetime, about 2.6 million Americans (.8 percent) meet DSM-
5-defined criteria for anorexia, 2.6 million for bulimia, and 2.7 million for binge-eating
disorder (Udo & Grilo, 2019). All three disorders can be deadly. They harm the body and
mind, resulting in shorter life expectancy and greater risk of suicide and nonsuicidal self-
injury (Cucchi et al., 2016; Fichter & Quadflieg, 2016; Mandelli et al., 2019).

 Understanding Eating Disorders

 Eating disorders are not (as some have speculated) a telltale sign of childhood sexual
abuse (Smolak & Murnen, 2002; Stice, 2002). The family environment may influence
eating disorders in other ways, however. For example, families of those with anorexia
tend to be competitive, high achieving, and protective (Ahrén et al., 2013; Berg et al.,
2014; Yates, 1989, 1990).

 Eating disorders share some commonalities with anxiety disorders (Schaumberg et al.,
2021). Those with eating disorders often have low body satisfaction, set perfectionist
standards, and ruminate about falling short of expectations and how others perceive
them (Farstad et al., 2016; Smith et al., 2018; S. Wang et al., 2019). Some of these
factors also predict teen boys’ pursuit of unrealistic muscularity (Karazsia et al.,
2017; Ricciardelli & McCabe, 2004).

 Heredity also matters. Identical twins share these disorders more often than do
fraternal twins—to an extent indicating 50 to 60 percent heritability for anorexia
(Yilmaz et al., 2015). Scientists are searching for culprit genes. The largest study
identified gene differences by comparing the genomes of nearly 17,000 anorexia
patients with 56,000 others who did not have the disorder (Watson et al., 2019).

 But eating disorders also have cultural and gender components. Ideal shapes vary
across culture and time. In countries with high poverty rates, plump may mean
prosperity and thin may signal poverty or illness (Knickmeyer, 2001; Swami et al.,
2010). Not so in wealthy Western cultures. In one analysis of 222 studies, the rise in
eating disorders in the last half of the twentieth century coincided with a dramatic
decline in Western women’s body image (Feingold & Mazzella, 1998).
  Today’s weight-obsessed culture—a culture that says “fat is bad” in countless ways—
motivates millions of women to diet constantly, and invites eating binges by
pressuring women to live in a constant state of semistarvation. One former model
recalled walking into a meeting with her agent, starving and with her organs failing
due to anorexia (Carroll, 2013). Her agent’s greeting: “Whatever you are doing, keep
doing it.” Women who view real and doctored images of unnaturally thin models and
celebrities often feel ashamed, depressed, and dissatisfied with their own bodies—the
very attitudes that predispose eating disorders (Bould et al., 2018; Tiggeman &
Miller, 2010). Even ultrathin models do not reflect the impossible standard of the
original Barbie doll, who had, when adjusted to a height of 5 feet 7 inches, a 32–16–
29 figure (in centimeters, 82–41–73) (Norton et al., 1996).

 Most people diagnosed with an eating disorder do improve. In one 22-year study, 2 in
3 women with anorexia nervosa or bulimia nervosa had recovered (Eddy et al., 2017).
Prevention is also possible. Interactive programs that teach teen girls to accept their
bodies have reduced the risk of eating disorders (Beintner et al., 2012; Melioli et al.,
2016; Vocks et al., 2010). By combating cultural learning, those at risk may instead
live long and healthy lives.

  R ETRIEVE I T

 Neurodevelopmental Disorders

Our thoughts and behaviors change as we grow older. For people with neurodevelopmental
disorders, these typical changes are disrupted in childhood because of unusual features of
the central nervous system.

Intellectual Disability
LOQ 14-22
 What is an intellectual disability?

Intellectual disability is apparent before age 18, often with a known physical cause. Down
syndrome, for example, is a disorder of varying intellectual and physical severity caused by an
extra copy of chromosome 21 in the person’s genetic makeup. To be diagnosed with an
intellectual disability, a person must meet two criteria:

1. An intelligence test score indicating performance that is in the lowest 3 percent of the general
population, or about 70 or below (Schalock et al., 2010).
2. Difficulty adapting to the normal demands of independent living, as expressed in three areas, or
skills: conceptual (language, reading, and concepts of money, time, and number); social
(interpersonal skills, being socially responsible, following basic rules and laws, avoiding being
victimized); and practical (health and personal care, occupational skill, and travel).
In mild forms, intellectual disability, like normal intelligence, results from a combination of
genetic and environmental factors (Reichenberg et al., 2016).

Autism Spectrum Disorder

LOQ 14-23
 What is autism spectrum disorder?

Autism spectrum disorder (ASD) is a cognitive and social-emotional disorder that is

marked by social deficiencies and repetitive behaviors. Once believed to affect 1 in 2500
children (and referred to simply as autism), ASD is now diagnosed in 1 in 38 children in
South Korea, 1 in 54 in the United States, 1 in 62 in Canada, and 1 in 166 in Germany (CDC,
2020e; Chiarotti & Venerosi, 2020). The increase in ASD diagnoses has been offset by a
decrease in the number of children with a “cognitive disability” or “learning disability,”
which suggests a relabeling of children’s disorders (Gernsbacher et al., 2005; Grinker,
2007; Shattuck, 2006).

The underlying source of ASD’s symptoms seems to be poor communication among brain
regions that normally work together to let us take another’s viewpoint. From age 2 months
on, children normally spend more and more time looking into others’ eyes; those who later
develop ASD do so less and less (Baron-Cohen, 2017; Wang et al., 2020). Researchers are
debating whether autistic people have an impaired theory of mind (Gernsbacher & Yergeau,
2019; Matthews & Goldberg, 2018; Velikonja et al., 2019). Mind reading that most of us
find intuitive (Is that face conveying a smile or a sneer?) is often difficult for those with
ASD. They have difficulty inferring how others think differently than they do (Deschrijver &
Palmer, 2020). For example, they may not appreciate that playmates and parents view things
differently, or understand that their teachers know more than they do (Boucher et al.,
2012; Frith & Frith, 2001; Knutsen et al., 2015).

Partly for such reasons, a national survey of parents and school staff reported that 46 percent
of adolescents with ASD had suffered the taunts and torments of bullying—about four times
the 11 percent rate for other children (Sterzing et al., 2012). Children with ASD do make
friends, but their peers often find such relationships emotionally unsatisfying (Mendelson et
al., 2016). This helps explain why people with ASD have a quadrupled risk of experiencing
depression in their lifetime (Hudson et al., 2019).

“I’m autistic, which means everyone around me has a disorder that makes them … creepily stare
into my eyeballs.”
—Facebook.com/autisticnotweird, 2020

ASD has differing levels of severity. Some (those diagnosed with what used to be
called Asperger syndrome) generally function at a high level. They have normal intelligence,
often accompanied by exceptional skill or talent in a specific area. But those with ASD may
lack the motivation and ability to interact and communicate socially, and they tend to
become distracted by irrelevant stimuli (Clements et al., 2018; Remington et al., 2009).
Those at the spectrum’s more severe end struggle to use language.
“Autism makes my life difficult, but it also makes my life beautiful. When everything is more
intense, then the everyday, the mundane, the typical, the normal—those things become
outstanding.”
—Erin McKinney, “The Best Way I Can Describe What It’s Like to Have Autism,” 2015

ASD gets diagnosed in four boys for every girl (CDC, 2020e). Psychologist Simon Baron-
Cohen (2010) believes this is because boys, more often than girls, are “systemizers.” They
tend to understand things according to rules or laws, as in mathematical and mechanical
systems. Girls, he contends, are more often predisposed to be “empathizers.” They tend to
excel at reading facial expressions, predicting what others will feel, and knowing what to do
in social situations. Whether male or female, those with ASD are systemizers who have more
difficulty reading facial expressions, intuitively knowing what others feel, and understanding
how to have smooth social interactions (Greenberg et al., 2018; Velikonja et al., 2019).
People working in STEM (science, technology, engineering, or mathematics) careers are also
somewhat more likely than others to exhibit some ASD-like traits (Ruzich et al., 2015).

Biological factors contribute to ASD (J. Zhou et al., 2019). Prenatal environment matters,
especially when altered by maternal infection, psychiatric drug use, or stress hormones (NIH,
2013; Wang, 2014). Genes also matter. One five-nation study of 2 million individuals found the
heritability of ASD was near 80 percent (Bai et al., 2019). If one identical twin is diagnosed with
ASD, the chances are near 9 in 10 that the co-twin will be as well, though such twins often differ
in symptom severity (Castelbaum et al., 2020). No one “autism gene” accounts for the disorder.
Rather, many genes—with more than 400 identified so far—appear to contribute (Krishnan et al.,
2016; Yuen et al., 2016). Random genetic mutations in sperm cells may also play a role. As men
age, these mutations become more frequent, which helps explain why a man over age 40 has a
much higher risk of fathering a child with ASD than does a man under age 30 (Wu et al., 2017).

Researchers are also sleuthing ASD’s telltale signs in the brain’s structure. Several studies have
revealed “underconnectivity”—fewer-than-normal fiber tracts connecting the front of the brain to
the back (Picci et al., 2016). With underconnectivity, there is less of the whole-brain synchrony
that, for example, integrates visual and emotional information. In children as young as 3 months,
EEG-recorded brain activity can foretell ASD (Bosl et al., 2018).

Biology’s role in ASD also appears in the brain’s functioning. People without ASD often yawn
after seeing others yawn. And as they view and imitate another’s smiling or frowning, they feel
something of what the other is feeling. Not so among those with ASD, who are less imitative and
show less activity in brain areas involved in mirroring others’ actions (Edwards, 2014; Yang &
Hoffman, 2015). When people with ASD watch another person’s hand movements, for example,
their brain displays less-than-normal mirroring activity (Oberman & Ramachandran,
2007; Théoret et al., 2005). Scientists are exploring and debating this idea that the brains of
people with ASD have “broken mirrors” (Gallese et al., 2011; Schulte-Rüther et al., 2016). And
they are exploring whether treatment with oxytocin, the hormone that promotes social bonding,
might improve social understanding in those with ASD (Gordon et al., 2013; Lange &
McDougle, 2013).
What does not contribute to ASD? Childhood vaccinations, which—despite a fraudulent 1998
study claiming otherwise—have no relationship to the disorder (Taylor et al., 2014). In fact, in
one recent study following nearly 700,000 Danish children, those receiving the
measles/mumps/rubella vaccine were actually slightly less likely to later be among the 6517
children diagnosed with ASD (Hviid et al., 2019).

Attention-Deficit/Hyperactivity Disorder

For children who experience the challenging symptoms of attention-deficit/hyperactivity

disorder (ADHD), diagnosis and treatment can help (Kupfer, 2012; Maciejewski et al., 2016).
The DSM has broadened the diagnostic criteria for this disorder, prompting critics to wonder
whether the criteria are now too broad (Frances, 2013). Shall we say such a child is hyperactive
—or energetic? Impulsive—or spontaneous? Excessively talkative—or excited? One 10-year
study in Sweden found children’s attentional behaviors unchanging, while national ADHD
diagnoses increased fivefold (Rydell et al., 2018). (See Thinking Critically About: ADHD—
Normal High Energy or Disordered Behavior?)
Chapter 15
Kay Redfield Jamison is both an award-winning clinical psychologist and a world expert on
the emotional extremes of bipolar disorders. She knows her subject firsthand, as she recalled
in An Unquiet Mind:
For as long as I can remember, I was frighteningly, although often wonderfully, beholden to moods.
Intensely emotional as a child, mercurial as a young girl, first severely depressed as an adolescent,
and then unrelentingly caught up in the cycles of manic-depressive illness [now known as bipolar I
disorder] by the time I began my professional life, I became, both by necessity and intellectual
inclination, a student of moods. (1995, pp. 4–5)
Jamison’s life was blessed with times of intense sensitivity and passionate energy. But like
her father’s, it was also sometimes plagued by reckless spending, racing conversation, and
sleeplessness, alternating with swings into “the blackest caves of the mind.”

Then, “in the midst of utter confusion,” she made a life-changing decision. Risking
professional embarrassment, she made an appointment with a therapist, a psychiatrist she
would visit weekly for years to come:
He kept me alive a thousand times over. He saw me through madness, despair, wonderful and terrible
love affairs, disillusionments and triumphs, recurrences of illness, an almost fatal suicide attempt, the
death of a man I greatly loved, and the enormous pleasures and aggravations of my professional
life…. He was very tough, as well as very kind, and even though he understood more than anyone
how much I felt I was losing—in energy, vivacity, and originality—by taking medication, he never
[lost] sight of the overall perspective of how costly, damaging, and life threatening my illness was….
Although I went to him to be treated for an illness, he taught me … the total beholdenness of brain to
mind and mind to brain. (pp. 87–88)
Actor Kerry Washington and singer Katy Perry have also shared openly about the benefits of
psychotherapy. “I’ve been going to therapy for about five years,” Perry says, “and I think it
has really helped my mental health incredibly” (Chen, 2017). Catherine, Duchess of
Cambridge (a.k.a. Kate Middleton), has worked on reducing the stigma surrounding mental
illness and therapy: “We need to help young people and their parents understand that it’s not
a sign of weakness to ask for help” (Holmes, 2015).

This chapter explores some of the healing options available to therapists and the people who
seek their help. We begin by exploring and evaluating psychotherapies, and then focus
on biomedical therapies and preventing disorders.

The long history of treating psychological disorders has included a bewildering mix of harsh
and gentle methods. Would-be healers have cut holes in people’s heads and restrained, bled,
or “beat the devil” out of them. But they also have given warm baths and massages and
placed people in sunny, serene environments. They have given them drugs. And they have
talked with them about childhood experiences, current feelings, and maladaptive thoughts
and behaviors. Reformers Philippe Pinel (1745–1826) and Dorothea Dix (1802–1887)
pushed for gentler, more humane treatments and for constructing psychiatric hospitals. Their
efforts largely paid off. Since the 1950s, the introduction of effective drug therapies and
community-based treatment programs has emptied most of those hospitals. Unfortunately,
this deinstitutionalization has also contributed to increased homelessness and incarceration.

Modern Western therapies can be classified into two main categories.

 In psychotherapy, a trained therapist uses psychological techniques to help someone

overcome difficulties and achieve personal growth. The therapist may explore a client’s
early relationships, encourage the client to adopt new ways of thinking, or coach the
client in replacing old behaviors with new ones.
 Biomedical therapy offers medication or other biological treatments. For example, a
person with severe depression may receive antidepressants, electroconvulsive shock
therapy (ECT), or deep brain stimulation.

Today, 1 in 5 Americans receives some form of outpatient mental health therapy (Olfson et al.,
2019). The care provider’s training and expertise, and the disorder itself, influence the choice of
treatment. Psychotherapy and medication are often combined. Kay Redfield Jamison received
psychotherapy in her meetings with her psychiatrist, and she took medications to control her wild
mood swings.

Let’s look first at some influential psychotherapy options for those treated with “talk therapies.”
Each is built on one or more of psychology’s major theories: psychodynamic, humanistic,
behavioral, and cognitive. Most of these techniques can be used one-on-one or in groups, in
person or online. Some therapists combine techniques. Indeed, many psychotherapists describe
their approach as eclectic, using a blend of therapies.
Psychoanalysis and Psychodynamic Therapies
LOQ 15-2
 What are the goals and techniques of psychoanalysis, and how have they been adapted in
psychodynamic therapy?

The first major psychological therapy was Sigmund Freud’s psychoanalysis. Although few

clinicians today practice therapy as Freud did, his work deserves discussion. It helped form the
foundation for treating psychological disorders, and it continues to influence modern therapists
working from the psychodynamic perspective.

The Goals of Psychoanalysis

Freud believed that in therapy, people could achieve healthier, less anxious living by releasing
the energy they had previously devoted to id-ego-superego conflicts (Chapter 13). Freud
assumed that we do not fully know ourselves. He believed that there are threatening things
we repress—things we do not want to know, so we disavow or deny them. Psychoanalysis was
Freud’s method of helping people to bring these repressed feelings into conscious awareness. By
helping them reclaim their unconscious thoughts and feelings, and by giving them insight into
the origins of their disorders, the therapist (analyst) could help them reduce growth-impeding
inner conflicts.
The Techniques of Psychoanalysis

Psychoanalytic theory emphasizes the power of childhood experiences to mold the adult. Thus,
psychoanalysis is historical reconstruction. It aims to unearth the past in the hope of loosening its
bonds on the present. After discarding hypnosis as an unreliable excavator, Freud turned to free
association.

Imagine yourself as a patient using free association. You begin by relaxing, perhaps by lying on
a couch. The psychoanalyst, who sits out of your line of vision, asks you to say aloud whatever
comes to mind. At one moment, you’re relating a childhood memory. At another, you’re
describing a dream or recent experience. It sounds easy, but soon you notice how often you edit
your thoughts as you speak. You pause for a second before uttering an embarrassing thought.
You omit what seems trivial, irrelevant, or shameful. Sometimes your mind goes blank or you
clutch up, unable to remember important details. You may joke or change the subject to
something less threatening.

To the analyst, these mental blocks indicate resistance. They hint that anxiety lurks and you
are defending against sensitive material. The analyst will note your resistance and then
provide insight into its meaning. If offered at the right moment, this interpretation—of, say,
your reluctance to call or message your mother—may illuminate the underlying wishes,
feelings, and conflicts you are avoiding. The analyst may also offer an explanation of how
this resistance fits with other pieces of your psychological puzzle, including those based on
analysis of your dream content.

Over many such sessions, your relationship patterns surface in your interaction with your
analyst. You may find yourself experiencing strong positive or negative feelings for this
confidant. The analyst may suggest you are transferring feelings, such as dependency or
mingled love and anger, that you experienced in earlier relationships with family members or
other important people. By exposing such feelings, you may gain insight into your current
relationships.

Relatively few North American therapists now offer traditional psychoanalysis. Much of its
underlying theory is not supported by scientific research. Analysts’ interpretations cannot be
proven or disproven. And psychoanalysis takes considerable time and money, often years of
several expensive sessions per week. Some of these problems have been addressed in the
modern psychodynamic perspective that has evolved from psychoanalysis.

Psychodynamic Therapy

Although influenced by Freud’s ideas, psychodynamic therapists don’t talk much about id-ego-

superego conflicts. Instead, they try to help people understand their current symptoms by
focusing on important relationships and events, including childhood experiences and the
therapist-client relationship. “We can have loving feelings and hateful feelings toward the same
person,” observed psychodynamic therapist Jonathan Shedler (2009), and “we can desire
something and also fear it.” Client-therapist meetings occur once or twice a week (rather than
several times weekly), and often for only a few weeks or months. Rather than lying on a couch,
out of the therapist’s line of vision, clients meet with their therapist face-to-face (in person or
online) and gain perspective by exploring defended-against thoughts and feelings. And in
contrast to Freud’s prescribing cocaine to his depressed patients (!), today’s psychodynamic
therapy patients sometimes take antidepressant drugs that have been researched, tested, and
deemed safe for use (Driessen et al., 2020).

Therapist David Shapiro (1999, p. 8) illustrated this with the case of a young man who had told
women he loved them when he knew that he didn’t. The client’s explanation: They expected it,
so he said it. But later, with his wife, who wished he would say that he loved her, he found
himself unable—“I don’t know why, but I can’t.”

 Therapist: Do you mean, then, that if you could, you would like to?
 Patient: Well, I don’t know…. Maybe I can’t say it because I’m not sure it’s true. Maybe
I don’t love her.

Further interactions revealed that the client could not express real love because it would feel
“mushy” and “soft” and therefore unmanly. He was “in conflict with himself, and … cut off from
the nature of that conflict.” Shapiro noted that with such patients, who are estranged from
themselves, therapists using psychodynamic techniques “are in a position to introduce them to
themselves. We can restore their awareness of their own wishes and feelings, and their
awareness, as well, of their reactions against those wishes and feelings.”
Humanistic Therapies
LOQ 15-3
 What are the basic themes of humanistic therapy? What are the goals and techniques of
Rogers’ person-centered approach?

The humanistic perspective (Chapter 13) emphasizes people’s innate potential for self-

fulfillment. Not surprisingly, humanistic therapies attempt to reduce the inner conflicts that
interfere with natural development and growth. To achieve this goal, humanistic therapists
try to help clients discover new insights. Indeed, because they share this goal, the
psychodynamic and humanistic therapies are often referred to as insight therapies. But
humanistic therapies differ from psychodynamic therapies in many ways, including their
focus on

 growth. Humanistic therapists focus not on illness, but on helping people grow in

self-awareness and self-acceptance. Thus, they call those in therapy “persons” or
“clients” rather than “patients” (a change many other therapists have adopted).
 the present. The path to growth is not uncovering hidden causes, but taking
immediate responsibility for one’s feelings and actions. The present and future are
more important than the past. Therapy thus focuses on exploring feelings as they
occur, rather than on achieving insight into the childhood origins of those feelings.
 the conscious mind. Conscious thoughts are more important than unconscious
thoughts.
All these themes are present in the widely used person-centered therapy, a humanistic
technique that Carl Rogers (1902–1987) developed. In this nondirective therapy, the client
leads the discussion. The therapist listens, without judging or interpreting, and refrains from
directing the client toward certain insights.

Believing that most people possess the resources for growth, Rogers (1961, 1980)

encouraged therapists to foster that growth by exhibiting acceptance, genuineness, and
empathy. By being accepting, therapists may help clients feel freer and more open to change.
By being genuine, therapists hope to encourage clients to express their true feelings. By
being empathic, therapists try to sense and reflect their clients’ feelings, helping them
experience a deeper self-understanding and self-acceptance (Hill & Nakayama, 2000).
As Rogers (1980) explained:
Hearing has consequences. When I truly hear a person and the meanings that are important to him at
that moment, hearing not simply his words, but him, and when I let him know that I have heard his
own private personal meanings, many things happen. There is first of all a grateful look. He feels
released. He wants to tell me more about his world. He surges forth in a new sense of freedom. He
becomes more open to the process of change.

I have often noticed that the more deeply I hear the meanings of the person, the more there is that
happens. Almost always, when a person realizes he has been deeply heard, his eyes moisten. I think
in some real sense he is weeping for joy. It is as though he were saying, “Thank God, somebody
heard me. Someone knows what it’s like to be me.” (p. 10)

“We have two ears and one mouth that we may listen the more and talk the less.”
—Zeno, 335–263 B . C . E ., Diogenes Laertius

To Rogers, “hearing” was active listening. The therapist echoes, restates, and seeks

clarification of what the client expresses (verbally or nonverbally). The therapist also
acknowledges those expressed feelings. Active listening is now an accepted part of
counseling practices in many schools, colleges, and clinics. Counselors listen attentively.
They interrupt only to restate and confirm feelings, to accept what was said, or to check their
understanding of something. In the following brief excerpt, note how Rogers tried to provide
a psychological mirror that would help the client see himself more clearly (Meador &
Rogers, 1984, p. 167):

 Rogers:  Feeling that now, hm? That you’re just no good to yourself, no good to
anybody. Never will be any good to anybody. Just that you’re completely worthless,
huh?—Those really are lousy feelings. Just feel that you’re no good at all, hm?
 Client: Yeah. (Muttering in low, discouraged voice) That’s what this guy I went to
town with just the other day told me.
 Rogers:  This guy that you went to town with really told you that you were no good?
Is that what you’re saying? Did I get that right?
 Client: M-hm.
 Rogers:  I guess the meaning of that if I get it right is that here’s somebody that meant
something to you and what does he think of you? Why, he’s told you that he thinks
 you’re no good at all. And that just really knocks the props out from under
you. (Client weeps quietly.) It just brings the tears. (Silence of 20 seconds)
 Client: (Rather defiantly) I don’t care though.
 Rogers:  You tell yourself you don’t care at all, but somehow I guess some part of you
cares because some part of you weeps over it.

Can a therapist be a perfect mirror, without selecting and interpreting what is reflected?
Rogers conceded that no one can be totally nondirective. Nevertheless, he said, the
therapist’s most important contribution is to accept and understand the client. Given a
nonjudgmental, grace-filled environment that provides unconditional positive
regard, people may accept even their worst traits and feel valued and whole.

How can we improve communication in our own relationships by listening more actively?
Three Rogers-inspired hints may help:

1. Paraphrase. Check your understanding by summarizing the person’s words out loud,

in your own words.
2. Invite clarification. “What might be an example of that?” may encourage the person
to say more.
3. Reflect feelings. “It sounds frustrating” might mirror what you’re sensing from the
person’s body language and intensity.

Behavior Therapies
LOQ 15-4
 How does the basic assumption of behavior therapy differ from the assumptions of
psychodynamic and humanistic therapies? What classical conditioning techniques are
used in exposure therapies and aversive conditioning?

The insight therapies assume that self-awareness and psychological well-being go hand in
hand. For example, psychodynamic therapists expect people’s problems to diminish as they
gain insight into their unresolved and unconscious tensions. And humanistic therapists
expect problems to diminish as people get in touch with their feelings. Behavior
therapists, however, doubt the healing power of self-awareness. Rather than delving deeply
below the surface looking for inner causes, behavior therapists assume that problem
behaviors are the problems. (You can become aware of why you are highly anxious during
exams and still be anxious.) If specific phobias, sexual dysfunctions, or other maladaptive
symptoms are learned behaviors, why not replace them with new, constructive behaviors?

Classical Conditioning Techniques

One cluster of behavior therapies derives from principles developed in Ivan Pavlov’s early
twentieth-century conditioning experiments (Chapter 7). As Pavlov and others showed, we
learn various behaviors and emotions through classical conditioning. If a dog attacks us, we
may thereafter have a conditioned fear response when other dogs approach. (Our fear
generalizes, and all dogs become conditioned stimuli.)
Could maladaptive symptoms be examples of conditioned responses? If so, might
reconditioning be a solution? Learning theorist O. H. Mowrer thought so. He developed a
successful conditioning therapy for chronic bed-wetting, using a liquid-sensitive pad
connected to an alarm. If the sleeping child wets the bed pad, moisture triggers the alarm,
waking the child. After several trials, the child associates bladder relaxation with waking. In
three out of four cases, the treatment has been effective and the success has boosted the
child’s self-image (Christophersen & Edwards, 1992; Houts et al., 1994).

Can we unlearn fear responses, such as to public speaking or flying, through new
conditioning? Many people have. An example: The fear of riding in an elevator is often a
learned aversion to being in a confined space. Counterconditioning, such as with exposure
therapy, pairs the trigger stimulus (in this case, the enclosed space of the elevator) with a
new response (relaxation) that is incompatible with fear.
E XPOSURE T HERAPIES

Picture this scene: Behavioral psychologist Mary Cover Jones is working with 3-year-old
Peter, who is petrified of rabbits and other furry objects. To rid Peter of his fear, Jones plans
to associate the fear-evoking rabbit with the pleasurable, relaxed response associated with
eating. As Peter begins his midafternoon snack, she introduces a caged rabbit on the other
side of the huge room. Peter, eagerly munching away on his crackers and drinking his milk,
hardly notices. On succeeding days, she gradually moves the rabbit closer and closer. Within
two months, Peter is holding the rabbit in his lap, even stroking it while he eats. Moreover,
his fear of other furry objects subsides as well, having been countered, or replaced, by a
relaxed state that cannot coexist with fear (Fisher, 1984; Jones, 1924).

Unfortunately for many who might have been helped by Jones’ counterconditioning
procedures, her story of Peter and the rabbit didn’t become well-known when it was reported
in 1924. It was more than 30 years before psychiatrist Joseph Wolpe (1958; Wolpe & Plaud,
1997) refined Jones’ counterconditioning technique into the exposure therapies used today.
These therapies, in a variety of ways, try to change people’s reactions by repeatedly exposing
them to stimuli that trigger unwanted reactions. We all experience this process in everyday
life. A person moving to a new apartment may be annoyed by nearby loud traffic noise, but
only for a while. With repeated exposure, the person adapts. So, too, with people who have
fear reactions to specific events, such as people with PTSD (Thompson-Hollands et al.,
2018). Exposed repeatedly to the situation that once petrified them, they can learn to react
less anxiously (Holder et al., 2020). Exposure therapy is neither pleasant nor easy, so it helps
to have supportive family and friends (Meis et al., 2019).

One exposure therapy widely used to treat specific phobias is systematic

desensitization. You cannot simultaneously be anxious and relaxed. Therefore, if you can
repeatedly relax when facing anxiety-provoking stimuli, you can gradually eliminate your
anxiety. The trick is to proceed gradually. If you fear public speaking, a behavior therapist
might first help you construct an anxiety hierarchy—a kind of ladder of speaking situations
that trigger increasing levels of anxiety. Yours might range from mildly anxiety-provoking
situations (perhaps speaking up in a small group of friends) to panic-provoking situations
(having to address a large audience).

Next, the therapist would train you in progressive relaxation. You would learn to release
tension in one muscle group after another, until you achieve a comfortable, complete state of
relaxation. Then the therapist might ask you to imagine, with your eyes closed, a mildly
anxiety-arousing situation: You are having coffee with a group of friends and are trying to
decide whether to speak up. If imagining the scene causes you to feel any anxiety, you are
told to signal by raising your finger. Seeing the signal, the therapist will instruct you to
switch off the mental image and go back to deep relaxation. This imagined scene is
repeatedly paired with relaxation until you feel no trace of anxiety.

The therapist will then move to the next item in your anxiety hierarchy, again using
relaxation techniques to desensitize you to each imagined situation. After several sessions,
you move to actual situations and practice what you had only imagined before, beginning
with relatively easy tasks and gradually moving to more anxiety-filled ones. Conquering
your anxiety in an actual situation, not just in your imagination, will increase your self-
confidence (Foa & Kozak, 1986; Williams, 1987). Eventually, you may even become a
confident public speaker. Often people fear not just a situation, such as public speaking, but
also being incapacitated by their own fear response. As their fear subsides, so also does their
fear of the fear.

“The only thing we have to fear is fear itself.”

—U.S. President Franklin D. Roosevelt, First Inaugural Address, 1933

If anxiety-arousing situations (such as flying, heights, particular animals, and public

speaking) are too expensive, difficult, or embarrassing to re-create, the therapist may
recommend virtual reality exposure therapy. Imagine donning a head-mounted display
unit that projects a lifelike three-dimensional virtual world tailored to your particular fear
(FIGURE 15.1). If you fear flying, for example, you could peer out of a simulated plane,
feel the engine’s vibrations, and hear it roar as the plane taxis down the runway and takes off.
If you fear social interactions, you could experience simulated stressful situations, such as
entering a roomful of people. In controlled studies, people treated with virtual reality
exposure therapy have experienced relief from real-life fear and social anxiety (Anderson et
al., 2017; Freeman et al., 2018; Minns et al., 2019).
A VERSIVE C ONDITIONING

Exposure therapy helps you learn what you should do; it enables a more relaxed, positive
response to an upsetting harmless stimulus. Aversive conditioning helps you learn what
you should not do; it creates a negative (aversive) response to a harmful stimulus (such as
alcohol). The aversive conditioning procedure is simple: It associates the unwanted behavior
with unpleasant feelings. To treat compulsive nail biting, the therapist may suggest painting
the fingernails with a nasty-tasting nail polish (Baskind, 1997). To treat alcohol use disorder,
the therapist may offer the client appealing drinks laced with a drug that produces severe
nausea. If that therapy links alcohol with violent nausea, the person’s reaction to alcohol may
change from positive to negative (FIGURE 15.2).

Taste aversion learning has been a successful alternative to killing predators in some animal
protection programs (Dingfelder, 2010; Garcia & Gustavson, 1997). After being sickened by
eating a tainted sheep, wolves may later avoid sheep. Does aversive conditioning also transform
humans’ reactions to alcohol? In the short run it may. In one classic study, 685 hospital patients
with alcohol use disorder completed an aversion therapy program (Wiens & Menustik, 1983).
Over the next year, they returned for several booster treatments that paired alcohol with sickness.
At the end of that year, 63 percent were not drinking alcohol. But after three years, only 33
percent were alcohol free.

In therapy, as in research, cognition influences conditioning. People know that outside the
therapist’s office they can drink without fear of nausea. This ability to discriminate between the
therapy situation and all others can limit aversive conditioning’s effectiveness. Thus, therapists
often combine aversive conditioning with other treatments.

Operant Conditioning Techniques

LOQ 15-5
 What is the main premise of behavior therapy based on operant conditioning principles,
and what are the views of its proponents and critics?

If you have learned to swim, you learned how to hold your breath with your head under water,
how to pull your body through the water, and perhaps even how to dive safely. Operant
conditioning shaped your swimming. You were reinforced for safe, effective behaviors. And you
were naturally punished, as when you swallowed water, for improper swimming behaviors.

Consequences strongly influence our voluntary behaviors. Knowing this basic principle of
operant conditioning, behavior therapists can apply behavior modification. They reinforce
desirable behaviors, and they fail to reinforce—or sometimes punish—undesirable behaviors.

Using operant conditioning to solve specific behavior problems has raised hopes for some
seemingly hopeless cases. Children with intellectual disabilities have been taught to care for
themselves. Socially withdrawn children with autism spectrum disorder (ASD) have learned to
interact. People with schizophrenia have been helped to behave more rationally. In such cases,
therapists use positive reinforcers to shape behavior. In a step-by-step manner, they reward
closer and closer approximations of the desired behavior.

In extreme cases, treatment must be intensive. One study worked with 19 withdrawn,
uncommunicative 3-year-olds with ASD. For two years, 40 hours each week, the children’s
parents attempted to shape their behavior (Lovaas, 1987). They positively reinforced desired
behaviors and ignored or punished aggressive and self-abusive behaviors. The combination
worked wonders for some children. By first grade, 9 of the 19 were functioning successfully in
school and exhibiting normal intelligence. In a control group of 40 comparable children not
undergoing this effortful treatment, only one showed similar improvement. Later studies focused
on positive reinforcement—which turned out to be the effective aspect of this early intensive
behavioral intervention (Reichow, 2012).

Rewards used to modify behavior vary. For some people, the reinforcing power of attention or
praise is sufficient. Others require concrete rewards, such as food. In institutional settings,
therapists may create a token economy. When people display a desired behavior, such as getting
out of bed, washing, dressing, eating, talking meaningfully, cleaning their rooms, or playing
cooperatively, they receive a token or plastic coin. Later, they can exchange a number of these
tokens for rewards, such as candy, TV time, day trips, or better living quarters. Token economies
have been used successfully in group homes, classrooms, and correctional institutions, and
among people with various disabilities (Matson & Boisjoli, 2009).

Behavior modification critics express two concerns:

 How durable are the behaviors? Will people become so dependent on extrinsic rewards that the
desired behaviors will stop when the reinforcers stop? Behavior modification advocates believe
the behaviors will endure if therapists wean people from the tokens by shifting them toward
other, real-life rewards, such as social approval. As people become more socially competent, the
intrinsic satisfaction of social interaction may sustain the behaviors.
 Is it right for one human to control another’s behavior? Those who set up token economies
deprive people of something they desire and decide which behaviors to reinforce. To critics, this
whole process feels too authoritarian. Advocates reply that control already exists: People’s
destructive behavior patterns are being maintained and perpetuated by natural reinforcers and
punishers in their environments. Isn’t using positive rewards to reinforce adaptive behavior more
humane than institutionalizing or punishing people? Advocates also argue that the right to
effective treatment and an improved life justifies temporary deprivation.

Cognitive Therapies
LOQ 15-6
 What are the goals and techniques of the cognitive therapies and of cognitive-behavioral
therapy?

People with specific fears and problem behaviors may respond to behavior therapy. But how
might behavior therapists modify the wide assortment of behaviors that accompany
depressive disorders? Or treat people with generalized anxiety disorder, where unfocused
anxiety doesn’t lend itself to a neat list of anxiety-triggering situations? The cognitive
revolution that has profoundly changed other areas of psychology since the 1960s has
influenced therapy as well.

“You have power over your mind.”

—Marcus Aurelius (121–180 C . E .), Meditations

The cognitive therapies assume that our thinking colors our feelings (FIGURE 15.3).

Between an event and our response lies the mind. Anxiety, for example, can arise from an
“attention bias to threat” (MacLeod & Clarke, 2015). Self-blaming and overgeneralized
explanations of bad events feed depression. If depressed, we may interpret a suggestion as
criticism, disagreement as dislike, praise as flattery, friendliness as pity. Dwelling on such
thoughts sustains negative thinking. Cognitive therapies help people change their mind with
new, more constructive ways of perceiving and interpreting events (I. Schmidt et al., 2019).

Beck’s Therapy for Depression

In the late 1960s, a woman left a party early. Things had not gone well. She felt disconnected
from the other partygoers and assumed no one liked her. A few days later, she visited
cognitive therapist Aaron Beck. Rather than go down the traditional path to her childhood,
Beck challenged her thinking. After she then listed a dozen people who did like her, Beck
realized that challenging people’s automatic negative thoughts could be therapeutic. And
thus was born his cognitive therapy (Spiegel, 2015).

“Life does not consist mainly, or even largely, of facts and happenings. It consists mainly of the
storm of thoughts that are forever blowing through one’s mind.”
—Author and humorist Mark Twain

Depressed people, Beck found, often reported dreams with negative themes of loss, rejection,
and abandonment. These themes extended into their waking thoughts, and even into therapy,
as clients recalled and rehearsed their failings and worst impulses (Kelly, 2000). Beck and
his colleagues (1979) used cognitive therapy to reverse clients’ negativity about themselves,
their situations, and their futures. With this technique, gentle questioning seeks to reveal
irrational thinking, and then to persuade people to remove the dark glasses through which
they view life (Beck et al., 1979, pp. 145–146):

 Client: I agree with the descriptions of me but I guess I don’t agree that the way I
think makes me depressed.
 Beck: How do you understand it?
 Client: I get depressed when things go wrong. Like when I fail a test.
 Beck: How can failing a test make you depressed?
 Client: Well, if I fail I’ll never get into law school.
 Beck: So failing the test means a lot to you. But if failing a test could drive people
into clinical depression, wouldn’t you expect everyone who failed the test to have a
depression? … Did everyone who failed get depressed enough to require treatment?
 Client: No, but it depends on how important the test was to the person.
 Beck: Right, and who decides the importance?
 Client: I do.
 Beck: And so, what we have to examine is your way of viewing the test (or the way
that you think about the test) and how it affects your chances of getting into law
school. Do you agree?
 Client: Right.
 Beck: Do you agree that the way you interpret the results of the test will affect you?
You might feel depressed, you might have trouble sleeping, not feel like eating, and
you might even wonder if you should drop out of the course.
  Client: I have been thinking that I wasn’t going to make it. Yes, I agree.
 Beck: Now what did failing mean?
 Client: (tearful) That I couldn’t get into law school.
 Beck: And what does that mean to you?
 Client: That I’m just not smart enough.
 Beck: Anything else?
 Client: That I can never be happy.
 Beck: And how do these thoughts make you feel?
 Client: Very unhappy.
 Beck: So it is the meaning of failing a test that makes you very unhappy. In fact,
believing that you can never be happy is a powerful factor in producing unhappiness.
So, you get yourself into a trap—by definition, failure to get into law school equals “I
can never be happy.”

We often think in words. Therefore, getting people to change what they say to
themselves is an effective way to change their thinking. Perhaps you can identify with
the anxious students who, before an exam, make matters worse with self-defeating
thoughts: “This exam’s going to be impossible. All these other students are so
confident. I didn’t study hard enough. I’ll probably forget everything.” Psychologists
call this sort of relentless, overgeneralized, self-blaming behavior catastrophizing.
To change such negative self-talk, cognitive therapists have offered stress inoculation
training: teaching people to restructure their thinking in stressful situations (Meichenbaum,
1977, 1985). Sometimes it may be enough simply to say more positive things to yourself:
“Relax. The exam may be hard, but it will be hard for everyone else, too. I studied harder
than most people. Besides, I don’t need a perfect score to get a good grade.” After learning
to “talk back” to negative thoughts, depression-prone children, teens, and college students
have shown a greatly reduced rate of future depression (Reivich et al., 2013; Seligman et al.,
2009). Ditto for anxiety (Krueze et al., 2018). To a large extent, it is the thought that counts.
It’s not just depressed people who can benefit from positive self-talk. We all talk to
ourselves (thinking “I wish I hadn’t said that,” for example, can protect us from repeating
the blunder). The findings of nearly three dozen sport psychology studies show that self-talk
interventions can even enhance the learning of athletic skills (Hatzigeorgiadis et al., 2011).
Novice basketball players may be trained to think “focus” and “follow through,” swimmers
to think “high elbow,” and tennis players to think “look at the ball.” People anxious about
public speaking have grown in confidence if asked to recall a speaking success, and then
asked this: “Explain WHY you were able to achieve such a successful performance” (Zunick
et al., 2015).

Cognitive-Behavioral Therapy

“The trouble with most therapy,” said therapist Albert Ellis (1913–2007), “is that it helps you
to feel better. But you don’t get better. You have to back it up with action, action,
action.” Cognitive-behavioral therapy (CBT) takes a combined approach to treating
depressive and other disorders. This widely practiced integrative therapy aims to alter not
only the way people think but also the way they act. Like other cognitive therapies, CBT
seeks to make people aware of their irrational negative thinking and to replace it with new
ways of thinking. And like other behavior therapies, it trains people to practice the more
positive approach in everyday settings.

Anxiety, depressive, and bipolar disorders share a common problem: unhealthy emotion
regulation (Aldao & Nolen-Hoeksema, 2010; Szkodny et al., 2014). An effective CBT
program for these emotional disorders trains people both to replace their
catastrophizing thinking with more realistic appraisals and, as homework, to
practice behaviors that are incompatible with their problem (Kazantzis et al., 2010; Moses &
Barlow, 2006). A person might keep a log of daily situations associated with negative and
positive emotions, and engage more in activities that lead to feeling good. Those who fear
social situations might learn to restrain the negative thoughts surrounding their social anxiety
and practice approaching people.

CBT effectively treats people with obsessive-compulsive and related disorders (Öst et al.,
2015; Tolin et al., 2019). In one classic study, people learned to prevent their compulsive
behaviors by relabeling their obsessive thoughts (Schwartz et al., 1996). Feeling the urge to
wash their hands again, they would tell themselves, “I’m having a compulsive urge.” They
would explain to themselves that the hand-washing urge was a result of their brain’s
abnormal activity, which they had previously viewed in PET scans. Then, instead of giving
in, they would spend 15 minutes in an enjoyable, alternative behavior—practicing an
instrument, taking a walk, gardening. This helped “unstick” the brain by shifting attention
and engaging other brain areas. For two or three months, the weekly therapy sessions
continued, with relabeling and refocusing practice at home. By the study’s end, most
participants’ symptoms had diminished, and their PET scans revealed normalized brain
activity. Many other studies confirm CBT’s effectiveness for treating other disorders, such as
PTSD and alcohol or other substance use disorders (Lewis et al., 2020; Magill et al., 2020).

A newer CBT variation, dialectical behavior therapy (DBT), helps change harmful and even
suicidal behavior patterns (Bohus et al., 2020; McCauley et al., 2018). Dialectical means
“opposing,” and this therapy attempts to make peace between two opposing forces—
acceptance and change. Therapists create an accepting and encouraging environment, helping
clients feel they have an ally who will offer them constructive feedback and guidance. In
individual sessions, clients learn new ways of thinking that help them tolerate distress and
regulate their emotions. They also receive training in social skills and in mindfulness
meditation, which helps alleviate depression (Wielgosz et al., 2019). Group training sessions
offer additional opportunities to practice new skills in a social context, with further practice
as homework.

Group Therapy
Except for traditional psychoanalysis, most therapies may also occur in small groups. Group
therapy does not provide the same degree of therapist involvement with each client.
However, it offers other benefits:

 It saves therapists’ time and clients’ money and often is no less effective than
individual therapy (Burlingame et al., 2016).
 It offers a social laboratory for exploring social behaviors and developing social
skills. Therapists frequently suggest group therapy for people experiencing frequent
conflicts or whose behavior distresses others. The therapist guides people’s
interactions as they discuss issues and try out new behaviors.
 It enables people to see that others share their problems. It can be a relief to
discover that others have experienced similar stressors, troublesome feelings, and
behaviors (Rahman et al., 2019).
 It provides feedback as clients try out new ways of behaving. Hearing that you look
or sound poised, even though you feel anxious and self-conscious, can be very
reassuring.

Family Therapy

One special type of group interaction, family therapy, assumes that no person is an island.

We live and grow in relation to others, especially our family. We struggle to differentiate
ourselves from our families, but we also need to connect with them emotionally. These two
opposing tendencies can create stress for both the individual and the family.

Family therapists view families as systems, in which each person’s actions trigger reactions
from others. A child’s rebellion, for example, affects and is affected by other family tensions.
Therapists are often successful in helping family members identify their roles within the
family’s social system, improve communication, and discover new ways of preventing or
resolving conflicts (Hazelrigg et al., 1987; Shadish et al., 1993).

Self-Help Groups

More than 100 million Americans have belonged to religious, special-interest, or support
groups that meet regularly—with 9 in 10 reporting that group members “support each other
emotionally” (Gallup, 1994). Self-help groups often provide support to people who struggle
to find it elsewhere (Dingle et al., 2021). One analysis of more than 14,000 self-help groups
reported that most focus on stigmatized, hard-to-discuss problems (Davison et al., 2000).

Many self-help groups use a 12-step program modeled on that of Alcoholics Anonymous
(AA), the grandparent of support groups. Such a program asks members to admit their
powerlessness, to seek help from a higher power and from one another, and (the twelfth step)
to take the message to others in need of it (Galanter, 2016). Studies of 12-step programs such
as AA have found that they help reduce alcohol use disorder at rates comparable to other
treatment interventions (Ferri et al., 2006; Moos & Moos, 2005). An 8-year, $27 million
investigation found that AA participants reduced their drinking sharply, as did those assigned
to CBT or an alternative therapy (Project Match, 1997). The more meetings AA members
attend, the greater their alcohol abstinence (Moos & Moos, 2006). Those whose personal
stories include a “redemptive narrative”—who see something good as having come from
their struggles—more often sustain sobriety (Dunlop & Tracy, 2013).
With more than 2 million members in 180 countries, AA is said to be “the largest organization
on Earth that nobody wanted to join” (Finlay, 2000).

In an individualist age, with more and more people living alone or feeling isolated, the
popularity of support groups—for the addicted, the bereaved, the divorced, or simply those
seeking fellowship and growth—may reflect a longing for community and connectedness.

 Evaluating Psychotherapies

Many people have great confidence in psychotherapy’s effectiveness. “Seek counseling” or

“Ask your mate to find a therapist,” advice columnists often urge. Before 1950, psychiatrists
were the primary providers of mental health care. Today’s providers include clinical and
counseling psychologists; clinical social workers; pastoral, marital, abuse, and school
counselors; and psychiatric nurses. With such an enormous outlay of time as well as money
and effort, it is important to ask: Are the millions of people worldwide justified in placing
their hopes in psychotherapy?
Is Psychotherapy Effective?
LOQ 15-8
 Does psychotherapy work? How can we know?

The question, though simply put, is not simply answered. If an infection quickly clears, we
may assume an antibiotic has been effective. But how can we assess psychotherapy’s
effectiveness? By how we feel about our progress? By how our therapist feels about it? By
how our friends and family feel about it? By how our behavior has changed?

Client Perceptions

If client testimonials were the only measuring stick, we could strongly affirm psychotherapy’s
effectiveness. Consider the 2900 Consumer Reports readers who related their experiences with
mental health professionals (Consumer Reports, 1995; Kotkin et al., 1996; Seligman, 1995).
How many were at least “fairly well satisfied”? Almost 90 percent (as was Kay Redfield
Jamison, as we saw at this chapter’s beginning). Among those who recalled feeling fair or very
poor when beginning therapy, 9 in 10 now were feeling very good, good, or at least so-
so. Worldwide, most people report benefiting from psychotherapy (Stein et al., 2020). We have
clients’ word for it—and who should know better?

We should not dismiss these testimonials. But critics note reasons for skepticism:

 People often enter therapy in crisis. When, with the normal ebb and flow of events, the
crisis passes, people may attribute their improvement to the therapy. Depressed people
often get better no matter what they do.
  Clients believe that treatment will be effective. The placebo effect is the healing power of
positive expectations.
 Clients generally speak kindly of their therapists. Even if the problems remain, clients
“work hard to find something positive to say. The therapist had been very understanding,
the client had gained a new perspective, he learned to communicate better, his mind was
eased, anything at all so as not to have to say treatment was a failure” (Zilbergeld, 1983,
p. 117).

Clients want to believe the therapy was worth the effort. If you invested time and money in
something, wouldn’t you be motivated to find something positive about it? Clinician
Perceptions

If clinician perceptions were proof of therapy’s effectiveness, we would have even more reason
to celebrate. Case studies of successful treatment abound. The problem is that clients enter
psychotherapy focused on their unhappiness and leave it focused on their well-being. Therapists
treasure compliments from those clients saying good-bye or later expressing their gratitude. But
they hear little from clients who experience only temporary relief and seek out new therapists for
their recurring problems. Thus, therapists are most aware of the failures of other therapists. With
the same recurring anxieties, depression, or marital difficulty, the same person may be a
“success” story in several therapists’ files. Moreover, therapists, like the rest of us, are vulnerable
to cognitive errors. Confirmation bias can lead them to unconsciously seek evidence that
confirms their beliefs and to ignore contradictory evidence, and illusory correlations can lead
them to perceive associations that don’t really exist (Lilienfeld et al., 2015b).

Outcome Research

How, then, can we objectively measure the effectiveness of psychotherapy?

What outcomes can we expect—what types of people and problems are helped, and by what
type of psychotherapy?

In search of answers, psychologists have turned to the well-traveled path of controlled

research. Similar research in the 1800s transformed the field of medicine when skeptical
physicians began to realize that many patients were dying despite receiving then-mainstream
treatments (such as bloodletting), and many others were getting better on their own. Sorting
fact from superstition required observing patients and recording outcomes with and without a
particular treatment. Typhoid fever patients, for example, often improved after being bled,
convincing most physicians that the treatment worked. Then came the shock. A control
group was given mere bed rest, and after 5 weeks of fever, 70 percent improved, showing
that the bloodletting was worthless (Thomas, 1992).

A similar shock—and a spirited debate—followed the summary of 24 studies of

psychotherapy outcomes (Eysenck, 1952). Two-thirds of people who received psychotherapy
for disorders not involving hallucinations or delusions improved markedly. To this day, no
one disputes that optimistic estimate. But there was a catch: Similar improvement occurred
among people who were untreated, such as those on treatment waiting lists. With or without
psychotherapy, roughly two-thirds improved noticeably. Time was a great healer.
Later research revealed shortcomings in the summary’s analyses and methods. The sample
was small—only 24 outcome studies in 1952, compared with thousands available today. The
best of these are randomized clinical trials, in which researchers randomly assign people on
a waiting list to therapy or to no therapy. Later, they evaluate everyone and compare
outcomes, using tests and assessments done by others who don’t know whether therapy was
given.

A glimpse of psychotherapy’s overall effectiveness can then be provided by means of

a meta-analysis, a statistical procedure that combines the conclusions of a large number of
different studies. Simply said, a meta-analysis summarizes lots of studies’ results. Therapists
welcomed the first meta-analysis of some 475 psychotherapy outcome studies (Smith et al.,
1980). It showed that the average therapy client ends up better off than 80 percent of the
untreated individuals on waiting lists (FIGURE 15.4). Psychologist Mary Lee Smith and her
colleagues summed it up: “Psychotherapy benefits people of all ages as reliably as schooling
educates them, medicine cures them, or business turns a profit” (p. 183).

Dozens of subsequent summaries have now examined psychotherapy’s effectiveness. Their

verdict echoes earlier results: Those not undergoing therapy often improve, but those
undergoing therapy are more likely to improve—and to improve more quickly and with less
risk of relapse (Eckshtain et al., 2019; Weisz et al., 2017). (One qualification: Compared
with studies that find no therapy benefit, those that do find a positive therapy effect are more
likely to get published [Driessen et al., 2015].) After therapy, many people exhibit improved
insight and emotional awareness, with a more patient, outgoing personality (Høglend &
Hagtvet, 2019; Roberts et al., 2017). Some people with depression or anxiety also experience
sudden symptom reductions between their treatment sessions (Aderka et al., 2012).
Those sudden gains bode well for long-term improvement (Shalom & Aderka, 2020).

Psychotherapy also can be cost-effective. Studies show that when people seek psychological
treatment, their search for other medical treatment drops substantially—by 16 percent in one
digest of 91 studies (Chiles et al., 1999). Substance abuse and other psychological disorders
exert a staggering cost on society, including crime, accidents, and lost work. By one
estimate, the opioid epidemic cost the United States more than $1 trillion between 2001 and
2017 (Altarum, 2018). Given such costs, psychotherapy is a good investment, much like
investing time and money in healthy foods and exercise (Johnson et al., 2019). Both reduce
long-term costs. Boosting employees’ psychological well-being can lower medical costs,
improve work efficiency, and diminish absenteeism. It’s no wonder that U.S. health insurers
and the National Health Service in Britain have increasingly funded therapy (Hockenberry et
al., 2019; NHS, 2020).

But note that the claim—that psychotherapy, on average, is somewhat effective—refers to

no one therapy in particular. It is like reassuring lung-cancer patients that “on average,”
medical treatment of health problems is effective. What people want to know is whether
a particular treatment is effective for their specific problem.
Which Psychotherapies Work Best?
LOQ 15-9
  Are some psychotherapies more effective than others for specific disorders?

The early statistical summaries and surveys did not find that any one type of psychotherapy
is generally better than others (Smith & Glass, 1977; Smith et al., 1980). Later studies have
similarly found that clients can benefit from psychotherapy regardless of their clinicians’
experience, training, supervision, and licensing (Cuijpers, 2017; Kivlighan et al.,
2015; Wampold et al., 2017). A Consumer Reports survey found the same result (Seligman,
1995). Were clients treated by a psychiatrist, psychologist, or social worker? Were they seen
in a group or individual context? Did the therapist have extensive or relatively limited
training and experience? It didn’t matter.

So, was Alice in Wonderland’s dodo bird right: “Everyone has won and all must have
prizes”? Not quite. One general finding emerges from the studies: The more specific the
problem, the greater the hope that psychotherapy might solve it (Singer, 1981; Westen &
Morrison, 2001). Those who experience panic or specific phobias, who are unassertive, or
who are frustrated by sexual performance problems can hope for improvement. Those with
less-focused problems, such as depression and anxiety, usually benefit in the short term but
often relapse later.

Nevertheless, some forms of therapy do get prizes for effectively

treating particular problems:

 Cognitive and cognitive-behavioral therapies—primarily anxiety, posttraumatic

stress disorder, insomnia, and depression (Qaseem et al., 2016; Scaini et al.,
2016; Tolin, 2010).
 Behavioral conditioning therapies—behavior problems such as bed-wetting, specific
phobias, compulsions, marital difficulties, and sexual dysfunctions (Baker et al.,
2008; Hunsley & DiGiulio, 2002; Shadish & Baldwin, 2005).
 Psychodynamic therapy—depression and anxiety (Driessen et al., 2010; Leichsenring
& Rabung, 2008; Shedler, 2010). Some analyses suggest that psychodynamic therapy
and cognitive-behavioral therapy are equally effective in reducing depression
(Driessen et al., 2017; Steinert et al., 2017).
 Nondirective (person-centered) counseling—mild to moderate depression (Cuijpers
et al., 2012).

“Different sores have different salves.”

—English proverb

The tendency of many disordered states of mind to return to healthy, combined with the
placebo effect (the healing power of mere belief in a treatment), creates fertile soil for
pseudotherapies. No prizes—and no scientific support—go to certain alternative therapies
(Arkowitz & Lilienfeld, 2006; Lilienfeld et al., 2015a). We would all be wise to avoid
therapies that propose to manipulate invisible “energy fields,” therapies that re-enact the
supposed trauma of a client’s birth, and therapies that use touch to “facilitate”
communication with noncommunicative people.

Like some medical treatments, some psychological treatments are not only ineffective but
also harmful. The American Psychiatric Association, the Canadian Psychological
Association, and the British Psychological Society have warned against conversion therapies
that purport to change people’s gender identity or sexual orientation. These therapies aim to
“repair … something that is not a mental illness and therefore does not require therapy,”
declared American Psychological Association president Barry Anton (2015). Indeed,
conversion therapy entails “a significant risk of harm” (APA, 2018; Turban et al., 2020).
Such evidence has led to many conversion therapy bans, especially for minors. Other
initiatives—the Scared Straight program designed to tame teenage violence, the police-
promoted D.A.R.E. anti-drug effort, numerous weight-reduction programs, and several
pedophile rehabilitation efforts—have also been found ineffective or harmful (Walton &
Wilson, 2018).

The evaluation question—which therapies get prizes and which do not?—lies at the heart of
what some call psychology’s civil war. To what extent should science guide both clinical
practice and insurers’ willingness to pay for psychotherapy? On one side are research
psychologists using scientific methods to extend the list of well-defined and validated
therapies for various disorders. They decry clinicians who seem to “give more weight to their
personal experience than to science” (Baker et al., 2008). On the other side are some
nonscientist therapists who view their practice more as an art, arguing that people are too
complex and psychotherapy is too intuitive to describe in a manual or test in an experiment.

Between these two factions stand the science-oriented clinicians calling for evidence-based
practice, which has been endorsed by the American Psychological Association (APA) and
others (APA, 2006; Holmes et al., 2018; Sakaluk et al., 2019; FIGURE 15.5). After rigorous
evaluation, clinicians apply therapies suited to their own skills and their clients’ unique
situations. Some are using technology, too. By analyzing many pieces of clients’
information, computer programs can help clinicians offer personalized therapeutic solutions
(Ewbank et al., 2019; Webb et al., 2020). Increasingly, insurer and government support for
mental health services require evidence-based practice.

 Why have studies found little correlation between therapists’ training and experience
and clients’ outcomes? One answer seems to be that all psychotherapies offer three
basic benefits (Cuijpers et al., 2019; Frank, 1982; Wampold, 2007): Hope for
discouraged people People seeking therapy typically feel anxious, depressed, self-
disapproving, and incapable of turning things around. What any psychotherapy offers
is the expectation that, with commitment from the therapy seeker, things can and will
get better. This belief, apart from any therapy technique, may improve morale, create
feelings of self-efficacy, and diminish symptoms (Corrigan, 2014; Meyerhoff &
Rohan, 2016).
  A new perspective Every psychotherapy offers people a plausible explanation of their
symptoms. Armed with a believable fresh perspective, they may approach life with a
new attitude, open to making changes in their behaviors and their views of
themselves.
 An empathic, trusting, caring relationship No matter what technique they use,
effective therapists are empathic. They seek to understand the client’s experience.
They communicate care and concern, and they earn trust through respectful listening
and guidance (Ovenstad et al., 2020). These qualities were clear in recorded therapy
sessions from 36 recognized master therapists (Goldfried et al., 1998). Some took a
cognitive-behavioral approach. Others used psychodynamic principles. Although the
master therapists used different approaches, they showed some
striking similarities. They helped clients evaluate themselves, link one aspect of their
life with another, and gain insight into their interactions with others. The emotional
bond between therapist and client—the therapeutic alliance—helps explain why
empathic, caring therapists are especially effective (Flückiger et al., 2020). Whether
experienced in Canada or Cambodia, a strong therapeutic alliance fosters
psychological health (Falkenström et al., 2019; Gold, 2019). It may even save lives.
In one analysis of a dozen studies, a strong therapeutic alliance predicted less frequent
suicidal thoughts, self-harming behaviors, and suicide attempts (Dunster-Page et al.,
2017).

These three common elements—hope, a fresh perspective, and an empathic, caring

relationship—help us understand why paraprofessionals (briefly trained caregivers) can
assist many troubled people so effectively (Bryan & Arkowitz, 2015; Christensen &
Jacobson, 1994). They are also part of what the growing numbers of in-person and online
self-help and support groups offer their members. And they are part of what traditional
healers have offered (Jackson, 1992). Healers everywhere—special people to whom others
disclose their suffering, whether psychiatrists or shamans—have listened to understand and
to empathize, reassure, advise, console, interpret, or explain (Torrey, 1986). Such qualities
may explain why people who feel supported by close relationships—who enjoy the
fellowship and friendship of caring people—have been less likely to seek therapy (Frank,
1982; O’Connor & Brown, 1984).
To recap, people who seek help usually improve. So do many of those who do not, which is
a tribute to our human resourcefulness and our capacity to care for one another.
Nevertheless, though the therapist’s orientation and experience appear not to matter much,
people who receive some psychotherapy usually improve more than those who do not.
People with clear-cut, specific problems tend to improve the most.

Human Diversity and Psychotherapy

LOQ 15-11
 What personal factors influence the therapist-client relationship?

All psychotherapies offer hope. Nearly all psychotherapists attempt to enhance their clients’
sensitivity, openness, personal responsibility, and sense of purpose (Jensen & Bergin, 1988).
But in matters of culture, values, and personal identity, psychotherapists differ from one
another and may differ from their clients (Delaney et al., 2007; Kelly, 1990).

These differences can create a mismatch—for example, when a therapist from one culture
interacts with a client from another. In North America, Europe, and Australia, most
psychotherapists reflect their culture’s individualism, which often gives priority to personal
desires and identity. Clients with a collectivist perspective, as with many from Asian
cultures, may be more mindful of social and family responsibilities, harmony, and group
goals. These clients may have trouble relating to therapists who ask them to think only of
their own well-being (Markus & Kitayama, 1991). In one experiment, Asian American
clients matched with counselors who shared their cultural values (rather than mismatched
with those who did not) perceived more counselor empathy and felt a stronger alliance with
the counselor (Kim et al., 2005).

Client-therapist mismatches may also stem from other personal differences. Highly religious
people may prefer and benefit from religiously similar therapists who share their values and
beliefs (Masters, 2010; Pearce et al., 2015). Likewise, therapists’ attitudes toward people
who identify as lesbian, gay, bisexual, transgender, or questioning/queer (LGBTQ) can affect
the client-therapist relationship. Transgender people, for example, may understandably seek
out therapists who affirm them (Bettergarcia & Israel, 2018).

Cultural differences help explain some groups’ reluctance to use mental health services.
People living in “cultures of honor” prize being strong and tough. They may feel that seeking
mental health care is an admission of weakness rather than an opportunity for growth (Brown
et al., 2014). Refugees, despite having frequently endured trauma and discrimination, tend to
avoid seeking mental health services due to distrust, poverty, and language barriers (Byrow
et al., 2020). And some cultural groups tend to be both reluctant to seek therapy and quick to
leave it (Chen et al., 2009; Sue et al., 2009).

The bottom line: By building their cultural competence—understanding and respecting

different cultural groups’ values, beliefs, and traditions—therapists can better serve their
clients (Soto et al., 2018).
Seeking Psychotherapy
LOQ 15-12
 When should a person seek therapy, and what should people look for when selecting a
therapist?

Life for everyone is marked by a mix of serenity and stress, blessing and bereavement, good
moods and bad. So, when should we seek a mental health professional’s help? The APA
offers these common trouble signals:

 Feelings of hopelessness
 Deep and lasting depression
 Self-destructive behavior, such as substance abuse and self-injury
 Disruptive fears
  Sudden mood shifts
 Thoughts of suicide
 Compulsive rituals, such as lock checking
 Sexual difficulties
 Hearing voices or seeing things that others don’t experience

In looking for a therapist, you may want to have a preliminary consultation with two or three.
Meeting with more than one therapist gives you more opportunities to find someone with
whom you feel comfortable. College and university health centers are generally good starting
points; you may be able to access qualified therapists and some free services by browsing the
health service’s web page or visiting in person. You may also get a referral from a physician
or walk-in clinic. If you have insurance coverage, your provider may supply a listing of
participating therapists.

Many people also use the internet to search for therapists, and many receive help online or
via one of the more than 10,000 mental health apps (Kocsis, 2018; Levin et al.,
2018; Nielssen et al., 2019). Therapist-guided, online and app-based therapy can help reduce
depression, social anxiety disorder, and panic disorder (Niles et al., 2021). Being able to
meet with an online therapist has helped people who—because of their location, income, or
embarrassment—may struggle to attend in-person sessions (Dadds et al., 2019; Markowitz et
al., 2021). Such online therapy also offered a useful alternative solution when it was unsafe
to attend in-person therapy sessions during the COVID-19 pandemic.

“Being physically present with a client does not appear essential to generating therapeutic
outcomes.”
—Psychologist Ashley Batastini and colleagues (2020)

During your in-person or online meetings, you can describe your problem and learn each
therapist’s treatment approach. You can ask questions about the therapist’s values,
credentials (TABLE 15.3), and fees. And you can assess your own feelings about each
therapist. The emotional bond between therapist and client is perhaps the most important
factor in effective therapy.

The APA recognizes the importance of a strong therapeutic alliance, and it welcomes diverse
therapists who can relate well to diverse clients. It accredits programs that provide training in
cultural sensitivity (for example, differing values, communication styles, and language) and
that recruit underrepresented cultural groups.
Ethical Principles in Psychotherapy
LOQ 15-13
 What ethical principles guide psychotherapy?

Psychotherapists use different approaches to help reduce their clients’ suffering. But before
psychotherapists begin their treatment, they must follow their country’s ethical principles
and code of conduct (APA, 2017).
According to the American Psychological Association, your therapist should follow these
principles:

 Seek to benefit you and do you no harm

 Establish a feeling of trust and a defined role as your therapist, as well as be of service
to the therapeutic community
 Be honest, truthful, and accurate
 Be fair and promote justice for you and others, helping everyone to have access to the
benefits of therapy
 Respect the dignity and worth of you and others, recognizing the right to privacy,
confidentiality, and self-determination

The Biomedical Therapies and Preventing Psychological Disorders

Psychotherapy is one way to treat psychological disorders. The other is biomedical

therapy. Biomedical treatments can change the brain’s chemistry with drugs; affect its
circuitry with electrical stimulation, magnetic impulses, or psychosurgery; or influence its
responses with lifestyle changes.

Are you surprised to find lifestyle changes in this list? We find it convenient to talk of
separate psychological and biological influences, but everything psychological is also
biological. Thus, our lifestyle—exercise, nutrition, relationships, recreation, relaxation,
religious or spiritual engagement, and service to others—affects our mental health (Bennie et
al., 2020; Walsh, 2011). (See Thinking Critically About: Therapeutic Lifestyle Change.)
Every thought and feeling depends on the functioning brain. Every creative idea, every
moment of joy or anger, every experience of depression emerges from the electrochemical
activity of the living brain. Anxiety disorders, obsessive-compulsive and related disorders,
posttraumatic stress disorder, depressive disorders, bipolar disorders, and schizophrenia are
all biological events. Some psychologists consider even psychotherapy to be a biological
treatment, because changing the way we think and behave is a brain-changing experience
(Kandel, 2013). When psychotherapy relieves behaviors associated with obsessive-
compulsive disorder or schizophrenia, PET scans reveal a calmer brain (Habel et al.,
2010; Schwartz et al., 1996). As we have seen over and over, a human being is an integrated
biopsychosocial system.

By far the most widely used biomedical treatments today are the drug therapies. Most drugs
for anxiety and depression are prescribed by primary care providers, followed by
psychiatrists and, in some U.S. states, psychologists.

Since the 1950s, discoveries in psychopharmacology have revolutionized the treatment of

people with severe disorders, liberating hundreds of thousands from hospital confinement.
Thanks to drug therapies and community mental health programs, today’s resident
population of psychiatric hospitals has dropped to a small fraction of what it once was. For
some who are unable to care for themselves, however, release from hospitals has meant
homelessness, not liberation.

Almost any new treatment, including drug therapy, is greeted by an initial wave of
enthusiasm as many people apparently improve. But that enthusiasm often diminishes on
closer examination. To evaluate any new drug’s effectiveness, researchers also need to know
the following:

 How many people recover without treatment, and how quickly?

 Is recovery due to the drug or to the placebo effect? When patients or mental health
workers expect positive results, they may see what they expect, not what really
happens. Even mere exposure to advertising about a drug’s supposed effectiveness
can increase its effect (Kamenica et al., 2013).

 To control for these influences, drug researchers give half the patients the drug, and the
other half a similar-appearing placebo. Because neither the staff nor the patients know
who gets which, this is called a double-blind procedure. The good news: In double-blind
studies, several types of drugs effectively treat psychological disorders.

 Antipsychotic Drugs

 An accidental discovery launched a treatment revolution for people with psychosis. The

discovery: Certain drugs, used for other medical purposes, calmed the hallucinations or
delusions that are part of these patients’ split from reality. First-generation antipsychotic
drugs, such as chlorpromazine (sold as Thorazine), dampened responsiveness to
irrelevant stimuli. Thus, they provided the most help to patients experiencing positive
(actively inappropriate) symptoms of schizophrenia, such as auditory hallucinations and
paranoia (Leucht et al., 2018). (Antipsychotic drugs are less effective in changing
negative symptoms, such as apathy and withdrawal.)

 The molecules of most conventional antipsychotic drugs are similar enough to molecules
of the neurotransmitter dopamine to occupy its receptor sites and block its activity. This
finding reinforces the idea that an overactive dopamine system contributes to
schizophrenia.
 Perhaps you can guess an occasional side effect of L-dopa, a drug that raises dopamine
levels for Parkinson’s patients: hallucinations.

 Antipsychotics also have powerful side effects. Some produce sluggishness, tremors, and
twitches similar to those of Parkinson’s disease (Kaplan & Saddock, 1989). Long-term
use of antipsychotics can produce tardive dyskinesia, with involuntary movements of the
facial muscles (such as grimacing), tongue, and limbs. Many of the newer-generation
antipsychotics, such as risperidone (Risperdal) and olanzapine (Zyprexa), have fewer of
these effects (Furukawa et al., 2015). These drugs may, however, increase the risk of
obesity and diabetes (Buchanan et al., 2010; Tiihonen et al., 2009). To identify doses that
reduce symptoms with fewer side effects, researchers have combed through data for more
than 20 antipsychotic medications (Leucht et al., 2020).
 Antipsychotics, combined with life-skills programs and family support, have given new
hope to many people with schizophrenia (Goff et al., 2017; Guo, 2010). Computer
programs now help clinicians identify which people with schizophrenia will benefit from
specific antipsychotic medications (B. Lee et al., 2018; Yu et al., 2018b). Hundreds of
thousands of patients have returned to work and to near-normal lives (Leucht et al.,
2003). Elyn Saks (2007), a University of Southern California law professor, knows what
it means to live with schizophrenia. Thanks to her treatment, which combines an
antipsychotic drug and psychotherapy, she noted, “Now I’m mostly well. I’m mostly
thinking clearly. I do have episodes, but it’s not like I’m struggling all of the time to stay
on the right side of the line.”

 Antianxiety Drugs

 Like alcohol, antianxiety drugs, such as Xanax and Ativan, depress central nervous

system activity (and so should not be used in combination with alcohol). Some
antianxiety drugs have been successfully used in combination with psychological therapy
to enhance exposure therapy’s extinction of learned fears and to help relieve the
symptoms of posttraumatic stress disorder and obsessive-compulsive disorder (Davis,
2005; Kushner et al., 2007).

 Some critics fear that antianxiety drugs may reduce symptoms without resolving
underlying problems, especially when used as an ongoing treatment. “Popping a Xanax”
at the first sign of tension can create a learned response: The immediate relief reinforces a
person’s tendency to take drugs when anxious. Antianxiety drugs can also be addictive.
Regular users who stop taking these drugs may experience increased anxiety, insomnia,
and other withdrawal symptoms.

 Antidepressant Drugs

 The antidepressant drugs were named for their ability to lift people up from a state
of depression, and this was their main use until recently. These drugs are now also
increasingly used to treat anxiety disorders, obsessive-compulsive and related
disorders, and posttraumatic stress disorder (Beaulieu et al., 2019; Merz et al.,
2019; Slee et al., 2019). Many work by increasing the availability of
neurotransmitters, such as norepinephrine or serotonin, which elevate arousal and
mood and are scarce when a person experiences feelings of depression or anxiety. The
most commonly prescribed drugs in this group, including Prozac and its cousins
Zoloft and Paxil, work by blocking the normal reuptake process (FIGURE 15.6).
Given their use in treating disorders other than depressive ones—from anxiety to
strokes—these drugs are most often called SSRIs (selective serotonin reuptake
inhibitors) rather than antidepressants (Kramer, 2011).

 Some of the older antidepressant drugs work by blocking the reabsorption or breakdown
of both norepinephrine and serotonin. Though effective, these dual-action drugs have
potential side effects, such as dry mouth, weight gain, hypertension, or dizzy spells
(Anderson, 2000; Mulrow, 1999). Administering them by means of a patch, which
 bypasses the intestines and liver, helps reduce such side effects (Bodkin & Amsterdam,
2002).

 But be advised: Patients with depression who begin taking antidepressants do not wake
up the next morning singing “It’s a beautiful day!” SSRIs begin to influence
neurotransmission within hours, but their full psychological effect may take 4 weeks (and
may involve a side effect of diminished sexual desire). One possible reason for the delay
is that increased serotonin promotes new synapses plus neurogenesis—the birth of new
brain cells—perhaps reversing stress-induced loss of neurons (Launay et al., 2011).

 For those at risk of suicide, researchers are also exploring the possibility of quicker-
acting antidepressants. One is ketamine—an anesthetic that is also sometimes used as a
risky, psychedelic party drug—which blocks hyperactive receptors for glutamate, a
neurotransmitter. Ketamine can provide relief from depression in as little as an hour
(Domany et al., 2019; Phillips et al., 2019; V. Popova et al., 2019). But the relief often
dissipates in a week, which raises questions about the risks of repeated use (Schatzberg,
2019; Zimmermann et al., 2020). Given that ketamine acts as an opioid, one skeptic
wonders if ketamine clinics are “nothing more than modern opium dens” (George, 2018).
But others note that ketamine stimulates new synapses, aiding long-lasting change
(Beyeler, 2019). Some drug companies are hoping to develop ketamine-like, fast-acting
drugs with fewer side effects (Kirby, 2015). Researchers are also exploring therapeutic
benefits of microdosing psychedelic drugs such as psilocybin (Reiff et al.,
2020; Vollenweider & Preller, 2020).

 Antidepressant drugs are not the only way to give the body a lift. Aerobic exercise often
calms people who feel anxious and energizes those who feel depressed. Regular physical
activity boosts teen mental health (Beauchamp et al., 2018). And for adults worldwide,
three or more weekly exercise hours predicts a lower risk of future depression (Choi et
al., 2019; Schuch et al., 2018).

 Cognitive therapy, by helping people reverse their habitual negative thinking style, can
boost drug-aided relief from depression and reduce posttreatment relapses (Amick et al.,
2015). Some clinicians attack depression from both below and above. They use
antidepressant drugs to work, bottom-up, on the emotion-related limbic system. And they
use cognitive-behavioral therapy to work, top-down, to change frontal lobe activity and
thinking (Guidi & Fava, 2021).

 Researchers generally agree that people with depression often improve after a month on
antidepressant drugs. But after allowing for natural recovery and the placebo effect, how
big is the drug effect? The effect is consistent but, critics argue, not very big (Cipriani et
al., 2018; Kirsch, 2010). In double-blind clinical trials, placebos produced improvement
comparable to about 75 percent of the active drug’s effect. For those with severe
depression, there is less of a placebo effect and the added drug benefit is somewhat
greater (Fournier et al., 2010; Kirsch et al., 2008; Olfson & Marcus, 2009). Given the
negative side effects of antidepressant drugs, some clinicians advise beginning with
psychotherapy before introducing antidepressants (Strayhorn, 2019; Svaldi et al., 2019).
 “If [drugs] are to be used at all,” notes Irving Kirsch (2016), “it should be as a last
resort.” The point to remember: If you’re concerned about your mental health, consult
with a mental health professional to determine the best treatment for you.

    To play the role of a clinical researcher exploring these questions, engage
online with the activity How Would You Know How Well Antidepressants Work?

 Mood-Stabilizing Medications

 In addition to antipsychotic, antianxiety, and antidepressant drugs, psychiatrists

have mood-stabilizing drugs in their arsenal. One of them, Depakote, was originally used
to treat epilepsy. It was also found effective in controlling the manic episodes associated
with bipolar disorders. Another, the simple salt lithium, effectively levels the emotional
highs and lows of bipolar disorders.

 In the 1940s, Australian physician John Cade discovered that lithium calmed guinea pigs.
Wondering if it might do the same for humans, he first tried it himself (to confirm its
safety), and then on 10 people with mania—all of whom improved dramatically (W.
Brown, 2019). About 7 in 10 people with bipolar disorders benefit from a long-term daily
dose of this cheap salt, which helps prevent or ease manic episodes and, to a lesser extent,
lifts depression (Solomon et al., 1995). Kay Redfield Jamison (1995) described the effect:
 Lithium prevents my seductive but disastrous highs, diminishes my depressions, clears out
the wool and webbing from my disordered thinking, slows me down, gentles me out, keeps
me from ruining my career and relationships, keeps me out of a hospital, alive, and makes
psychotherapy possible. (pp. 88–89)
 Taking lithium also correlates with a lower risk of suicide among people with bipolar
disorders—about one-sixth the risk of those not taking lithium (Oquendo et al., 2011).
Naturally occurring lithium in drinking water has also correlated with lower suicide rates
(across 18 Japanese cities and towns) and lower crime rates (across 27 Texas counties)
(Ohgami et al., 2009; Schrauzer & Shrestha, 1990, 2010; Terao et al., 2010). Lithium
works.

  R ETRIEVE I T
Brain Stimulation
LOQ 15-16
 How are brain stimulation and psychosurgery used in treating specific disorders?

Electroconvulsive Therapy

Another biomedical treatment, electroconvulsive therapy (ECT), manipulates the brain by

shocking it. When ECT was first introduced in 1938, the wide-awake patient was strapped to a
table and jolted with electricity to the brain. The procedure, which produced convulsions and
brief unconsciousness, gained a barbaric image. Although that image lingers, today’s ECT is
much kinder and gentler, and no longer “convulsive.” The patient receives a general anesthetic
and a muscle relaxant (to prevent bodily convulsions). A psychiatrist then delivers a brief
electrical pulse, sometimes only to the brain’s right side, which triggers a 30- to 60-second brain
seizure (McCall et al., 2017). Within 30 minutes, the patient awakens and remembers nothing of
the treatment or of the preceding hours.

Study after study confirms that ECT can effectively treat severe depression in “treatment-
resistant” patients who have not responded to drug therapy (Fink, 2009; Giacobbe et al.,
2018; Ross et al., 2018). After three such sessions each week for 2–4 weeks, 70 percent or more
of those receiving today’s ECT improve markedly, without discernible brain damage or
increased dementia risk (Osler et al., 2018). ECT also reduces suicidal thoughts and has been
credited with saving many from suicide (Kellner et al., 2006). A Journal of the American
Medical Association editorial concluded that “the results of ECT in treating severe depression
are among the most positive treatment effects in all of medicine” (Glass, 2001).
The medical use of electricity is an ancient practice. Physicians treated the Roman Emperor
Claudius (10 B . C . E .–54 C . E .) for headaches by pressing electric eels to his temples. Today, about
17 people per 100,000—people whose depression has not responded to other treatments—have
received ECT (Lesage et al., 2016).

How does ECT relieve severe depression—and, in other studies, mania (Elias et al., 2021)? After
more than 70 years, no one knows for sure. One patient likened ECT to the smallpox vaccine,
which was saving lives before we knew how it worked. Perhaps the brief electric current calms
neural centers where overactivity produces depression. Some research indicates that ECT
stimulates neurogenesis (new neurons) and new synaptic connections (Joshi et al.,
2016; Rotheneichner et al., 2014; Wang et al., 2017b).

No matter how impressive the results, the idea of electrically shocking a person’s brain still
strikes many as barbaric, especially given our ignorance about why ECT works. Moreover, the
mood boost may not last long. Many ECT-treated patients eventually relapse back into
depression, although relapses are somewhat fewer for those who also receive antidepressant
drugs or who do aerobic exercise (Rosenquist et al., 2016; Salehi et al., 2016). The bottom
line: In the minds of many psychiatrists and patients, ECT is a lesser evil than severe
depression’s anguish and risk of suicide. After ECT, psychiatrist Rebecca Barchas
(2021) reported “regaining my joie de vivre, my high level of motivation, and my ability to make
decisions.”

Alternative Neurostimulation Therapies

Three other neural stimulation techniques—mild cranial electrical stimulation, magnetic

stimulation, and deep brain stimulation—also aim to treat the depressed brain (FIGURE
15.7).
T RANSCRANIAL E LECTRICAL S TIMULATION

In contrast to ECT, which produces a brain seizure with about 800 milliamps of
electricity, transcranial direct current stimulation (tDCS) administers a weak 1- to 2-milliamp
current to the scalp. Skeptics argue that such a current is too weak to penetrate the brain
(Underwood, 2016). But research suggests that tDCS is a modestly effective treatment for
depression (Razza et al., 2020).
M AGNETIC S TIMULATION

Depressed moods also sometimes improve when a painless procedure called transcranial

magnetic stimulation (TMS) is performed on wide-awake patients in sessions over several
weeks. Repeated pulses surging through a magnetic coil held close to the skull can stimulate or
suppress activity in areas of the cortex. Like tDCS (and unlike ECT), the TMS procedure
produces no memory loss or other serious side effects, aside from possible headaches.

Results are mixed. Some studies have found that, for 30 to 40 percent of people with depression,
TMS works, although it is less effective than ECT (Carmi et al., 2019; Mutz et al., 2019). TMS
also reduces some schizophrenia symptoms, such as social apathy and memory loss (Osoegawa
et al., 2018; Xiu et al., 2020). How it works is unclear. One possible explanation is that the
stimulation energizes the brain’s left frontal lobe, which is relatively inactive during depression
(Helmuth, 2001). Repeated stimulation may cause nerve cells to form new functioning circuits
through the process of long-term potentiation. Another possible explanation is a placebo effect:
People benefit when, after being given a credible explanation, they believe TMS will work
(Geers et al., 2019; Yesavage et al., 2018).
D EEP B RAIN S TIMULATION

Other patients whose depression has resisted both drugs and ECT have benefited from an
experimental treatment pinpointing a neural hub that bridges the thinking frontal lobes to the
limbic system (Becker et al., 2016; Brunoni et al., 2017; Ryder & Holtzheimer, 2016). This
area, which is overactive in the brain of a depressed or temporarily sad person, typically
calms when treated by ECT or antidepressants. To experimentally activate neurons that
inhibit this negative activity, neuroscientist Helen Mayberg drew upon deep brain
stimulation (DBS) technology, sometimes used to treat Parkinson’s tremors. Since 2003, she
and her colleagues have used DBS to treat some 200 depressed patients with implanted
electrodes in a brain area that functions as the neural “sadness center” (Lozano & Mayberg,
2015). For some patients, DBS produces large and enduring reductions in depression
(Crowell et al., 2019; Kisely et al., 2018). “The bottom line,” notes Mayberg, “is that if you
get better, you stay better” (Carey, 2019).
Psychosurgery

Because its effects are irreversible, psychosurgery is the most drastic and least-used
biomedical intervention for changing behavior. In the 1930s, Portuguese physician Egas
Moniz developed what would become the best-known psychosurgical operation:
the lobotomy. Moniz found that cutting the nerves connecting the frontal lobes with the
inner brain’s emotion-controlling centers calmed uncontrollably emotional and violent
patients. In what would later become, in others’ hands, a crude but quick and easy procedure,
a neurosurgeon would shock the patient into a coma, hammer an icepick-like instrument
through the top of each eye socket into the brain, and then wiggle it to sever connections
running up to the frontal lobes. Between 1936 and 1954, tens of thousands of people with
mental illness were “lobotomized” (Valenstein, 1986).
Although the intention was simply to disconnect emotion from thought, the effect was often
more drastic. A lobotomy usually decreased misery or tension, but it also produced a
permanently lethargic, immature, uncreative person. During the 1950s, after some 35,000
people had been lobotomized in the United States alone, calming drugs became available and
psychosurgery became scorned, as in the saying sometimes attributed to satirist Dorothy
Parker: “I’d rather have a bottle in front of me than a frontal lobotomy.”

Today, lobotomies are history. More precise, microscale psychosurgery is sometimes used in
extreme cases. For example, if a patient suffers uncontrollable seizures, surgeons can
deactivate the specific nerve clusters that cause or transmit the convulsions. MRI-guided
precision surgery is also occasionally done to cut the circuits involved in severe major
depressive disorder and obsessive-compulsive disorder (Carey, 2009, 2011; M. Kim et al.,
2018; Sachdev & Sachdev, 1997). Because these procedures are irreversible, neurosurgeons
perform them only as a last resort. Psychotherapies and biomedical therapies tend to locate
the cause of psychological disorders within the person. We infer that people who act cruelly
must be cruel and that people who act “crazy” must be “sick.” We attach labels to such
people, thereby distinguishing them from “normal” folks. It follows, then, that we try to treat
“abnormal” people by giving them insight into their problems, by changing their thinking, by
helping them gain control with drugs.

There is an alternative viewpoint: We could interpret many psychological disorders as

understandable responses to a disturbing and stressful world. According to this view, it is not
just the person who needs treatment. Rather, as the soaring mental health problems during
the COVID-19 pandemic illustrated, it’s also the person’s social context. It is better to
prevent problems by reforming an unhealthy situation and developing people’s coping
competencies than waiting for and treating problems.

Preventive Mental Health

A story about the rescue of a drowning person from a rushing river illustrates this viewpoint:
Having successfully administered first aid to the victim, the rescuer spots another struggling
person and pulls that person out, too. After a half-dozen repetitions, the rescuer suddenly turns
and starts running away while the river sweeps yet another floundering person into view. “Aren’t
you going to rescue that person?” asks a bystander. “No way,” the rescuer replies. “I’m going
upstream to find out what’s pushing all these people in.”

Preventive mental health is upstream work. It seeks to prevent psychological casualties by

identifying and alleviating the conditions that cause them. As George Albee (1986, 2006)
pointed out, there is abundant evidence that poverty, lack of meaningful work, constant criticism,
unemployment, and discrimination undermine people’s sense of competence, personal control,
and self-esteem. Such stresses increase their risk of depression, alcohol use disorder, and suicide.
To prevent psychological casualties we should, Albee contended, support programs that work to
improve these demoralizing situations.
Psychotherapies and biomedical therapies tend to locate the cause of psychological
disorders within the person. We infer that people who act cruelly must be cruel and that
people who act “crazy” must be “sick.” We attach labels to such people, thereby
distinguishing them from “normal” folks. It follows, then, that we try to treat “abnormal”
people by giving them insight into their problems, by changing their thinking, by helping
them gain control with drugs.

There is an alternative viewpoint: We could interpret many psychological disorders as

understandable responses to a disturbing and stressful world. According to this view, it is not
just the person who needs treatment. Rather, as the soaring mental health problems during
the COVID-19 pandemic illustrated, it’s also the person’s social context. It is better to
prevent problems by reforming an unhealthy situation and developing people’s coping
competencies than waiting for and treating problems.

Preventive Mental Health

A story about the rescue of a drowning person from a rushing river illustrates this viewpoint:
Having successfully administered first aid to the victim, the rescuer spots another struggling
person and pulls that person out, too. After a half-dozen repetitions, the rescuer suddenly turns
and starts running away while the river sweeps yet another floundering person into view. “Aren’t
you going to rescue that person?” asks a bystander. “No way,” the rescuer replies. “I’m going
upstream to find out what’s pushing all these people in.”

Preventive mental health is upstream work. It seeks to prevent psychological casualties by

identifying and alleviating the conditions that cause them. As George Albee (1986, 2006)
pointed out, there is abundant evidence that poverty, lack of meaningful work, constant criticism,
unemployment, and discrimination undermine people’s sense of competence, personal control,
and self-esteem. Such stresses increase their risk of depression, alcohol use disorder, and suicide.
To prevent psychological casualties we should, Albee contended, support programs that work to
improve these demoralizing situations.

Preventing psychological problems means empowering those who have learned an attitude of
helplessness, and changing environments that breed loneliness, suicidal thinking, and excessive
alcohol and drug use. It means teaching children how to manage their emotions, get along with
others, and keep up with academic demands (Godwin, 2020). It means harnessing positive
psychology interventions to enhance human flourishing. One intervention taught adolescents that
personality isn’t fixed—people can change—and reduced their chances of future depression by
40 percent (Miu & Yeager, 2015). This result is no fluke: Preventive therapies have consistently
reduced the risk for depression (Breedvelt et al., 2018).

In short, “everything aimed at improving the human condition, at making life more fulfilling and
meaningful, may be considered part of primary prevention of mental or emotional disturbance”
(Kessler & Albee, 1975, p. 557). Prevention can sometimes provide a double payoff. People with
a strong sense of life’s meaning are more engaging socially (Stillman et al., 2011). By
strengthening people’s sense of meaning in life, we may also lessen their loneliness as they
become more engaging companions.
Among the upstream prevention workers are community psychologists. Mindful of how people
interact with their environment, they focus on creating environments that support psychological
health. Through their research and social action, community psychologists aim to empower
people and to enhance their competence, health, and well-being.

“Mental disorders arise from physical ones, and likewise physical disorders arise from mental
ones.”
—The Mahabharata, 200 B . C . E .

Building Resilience

Preventive mental health includes efforts to build individuals’ resilience.

Faced with extreme suffering or trauma, some people experience lasting harm, some experience
stable resilience, and some actually experience growth (Myers, 2019). In the aftermath of the
September 11 terror attacks, many New Yorkers exhibited resilience. This was especially true for
those who enjoyed supportive close relationships and who had not recently experienced other
stressful events (Bonanno et al., 2007). More than 9 in 10 New Yorkers, although stunned and
grief-stricken by 9/11, did not have a dysfunctional stress reaction. Among those who did, the
stress symptoms were mostly gone by the following January (Person et al., 2006). Even most
combat-stressed veterans, most political rebels who have survived torture, and most people with
spinal cord injuries do not later exhibit posttraumatic stress disorder (Bonanno et al.,
2012; Mineka & Zinbarg, 1996).
 Let the globe, if nothing else, say this is true:
 That even as we grieved, we grew
 That even as we hurt, we hoped
 That even as we tired, we tried

—Poet Amanda Gorman, “The Hill We Climb” (U.S. Presidential inaugural poem, 2021)

Struggling with challenging crises can lead to posttraumatic growth. Many cancer survivors
have reported a greater appreciation for life, more meaningful relationships, increased personal
strength, changed priorities, and a richer spiritual life (Tedeschi & Calhoun, 2004). Out of even
our worst experiences, some good can come, especially when we can imagine new possibilities
(Mangelsdorf et al., 2019; Roepke, 2015). As with positive experiences, suffering can beget new
sensitivity and strength.

If you just finished reading this book, your introduction to psychological science is
completed. Our tour of psychological science has taught us much—and you, too?—about our
moods and memories, about the reach of our unconscious, about how we flourish and
struggle, about how we perceive our physical and social worlds, and about how our biology
and culture shape us. As your guides on this tour, we hope that you have shared our
fascination, grown in your understanding and compassion, and sharpened your critical
thinking. And we hope you enjoyed the ride.

With every good wish in your life journey ahead.