13.1 Psychological Disorders and Abnormal Behavior

psychological disorders

What’s Normal, What’s Not

A year-and-a-half earlier, Ross had been diagnosed with bipolar disorder, a condition marked by dramatic mood swings. We all have our ups and downs—periods of feeling happy, sad, anxious, or irritable—but the emotional roller coaster of bipolar disorder is something quite different. We will explore bipolar disorder in greater detail later in the chapter, but first let’s familiarize ourselves with the broader focus of this chapter: psychological disorders.

Looks Can Be Deceiving Ross Szabo appears happy in his senior class photo, but beneath his smile is profound pain and suffering. This was the year Ross began to have persistent thoughts of death and suicide that nearly drove him to take his own life.

Martin Fella/Fella Studios

A psychological disorder is a set of behavioral, emotional, and cognitive symptoms that are significantly distressing and disabling in terms of social functioning, work endeavors, and other aspects of life. These symptoms are not the result of religious or spiritual experiences; nor are they mere departures from cultural norms. And although stressors can trigger symptoms of psychological disorders, these conditions primarily result from disturbances in psychological, biological, and developmental processes (American Psychiatric Association [APA], 2013).

The academic field devoted to the study of psychological disorders is generally referred to as abnormal psychology. Researchers and scholars in abnormal psychology typically have backgrounds in clinical psychology, or psychiatry if they obtained medical degrees.

Ross, in His Own Words

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Psychologists and other mental health professionals determine if a behavior is abnormal using a variety of criteria (TABLE 13.1). Perhaps the most straightforward criterion is typicality (or lack thereof). An atypical behavior is rarely seen, or infrequent. The profound sadness Ross experienced is relatively rare. Most people experience sadness, even deep sadness at times, but suicidal thoughts are unusual. Although the typicality criterion is useful, it is not enough to confirm the existence of a psychological disorder. A child prodigy who learns to play the piano like a virtuoso by the age of 5 is atypical, but his rare talent does not indicate a psychological disorder.

Deviant, But Not Disordered Occupy Wall Street protesters camp out in Lower Manhattan’s Zuccotti Park in the autumn of 2011. Setting up a tent and sleeping in a city park are behaviors that challenge social norms—you might even call such behaviors deviant. Yet in this case deviance is not necessarily linked to a psychological disorder.

Seth Wenig/AP Photo

We should also consider maladaptive behaviors, or actions that run counter to one’s best interests. The degree of risk associated with these maladaptive behaviors (both to oneself and others) is often used by professionals to determine if a person needs to be admitted to a hospital. In Chapter 14, you can see how Dr. Dan Foster used this criterion in deciding whether to seek hospital care for a client with schizophrenia. We should point out, however, that maladaptive behavior is not always a sign of abnormality. People without disorders exhibit maladaptive behaviors all the time. Just think of the child who occasionally has a tantrum, or the adult who drowns his sorrows in alcohol one night.

To arrive at a more definitive determination of abnormal behavior, mental health professionals typically rely on three criteria (in addition to typicality): dysfunction, distress, and deviance, or the “3 Ds” (APA, 2013; Wakefield, 1992).

The first D, dysfunction, indicates the degree to which a behavior interferes with daily life and relationships. Ross’s depression sometimes rendered him unable to get out of bed; this type of behavior certainly has the potential to interfere with daily life. But dysfunction alone does not confirm the presence of a psychological disorder. If you stay up all night to meet a deadline, you might experience temporary dysfunction in memory and attention, but that doesn’t mean you have a disorder.

The second D is personal distress. Feeling regularly upset or uncomfortable because of unwanted behaviors or emotions is another feature of abnormality, and it’s not always evident from the outside. Prior to his suicide attempt, Ross appeared to be happy and healthy, but inside he was suffering. There are times, however, when distress does not accompany a disorder. When Ross experienced the euphoric highs of bipolar disorder, he may not have been distressed at all. People with psychological disorders do not always have the insight to recognize that a problem exists.

The third D is deviance, or the degree to which a behavior is considered to be outside the standards or rules of a society. Behaving in a way that does not conform to social expectations might be indicative of a psychological disorder. Individuals who are euphoric might talk too loudly in a library or church where people are expected to be quiet, or become so disinhibited that they walk around naked in a public place. Once again, the presence of this sole criterion does not necessarily indicate a psychological disorder. Political protesters, for example, may deliberately break social norms to make a statement. Many participants in Occupy Wall Street chose to set up camp and sleep in public places normally used by others just passing through. Their behavior was deviant but not necessarily suggestive of a psychological disorder.

We should note that conceptions of abnormality and definitions of psychological disorders have changed during the course of history. Homosexuality was once considered a psychological disorder, but this notion was overturned in the 1970s and 1980s by psychiatrists and other mental health professionals (Silverstein, 2009), in part because cultural norms had changed. Always remember that the definition or meaning of “abnormal” is relative to place and time.

Given how psychologists define abnormal behavior, understand that anyone can have experiences similar to the symptoms of psychological disorders. This is because there is a continuum for many behaviors and feelings: Those at one end are generally considered normal, and those at the other end abnormal. Ross’s profound sadness would likely fall at the abnormal end of the continuum, whereas a teary farewell to a close friend who is moving away would be at the normal end.

The definition of mental health is not the same for all groups of people. As the biopsychosocial model reminds us, we must consider culture and other social influences when trying to understand concepts like “normal” and “abnormal.” Some disorders and symptoms are unique to particular cultures. Koro, for example, is an episode of intense anxiety observed mainly in Southeast Asia, although similar conditions have been documented in China. The main feature of koro is the unrealistic and intense fear that sexual organs will be pulled into the body, perhaps resulting in death (APA, 2013; Roy et al., 2011). A man with koro might be exceedingly anxious about the idea of his penis disappearing into his abdomen, whereas a woman might fear that her nipples will be pulled into her chest. Another example is susto, most evident in Latino populations (Donlan & Lee, 2010). Someone with susto reacts to a frightening situation with the belief that her soul has left her body, which ultimately results in illness and sadness (APA, 2013).

We know some disorders are specific to certain cultures because researchers have studied the frequency and variation of these conditions across cultures. Susto and koro, for example, are found only in some cultures; however, schizophrenia (discussed later in the chapter) is evident across all cultures and throughout the world, suggesting it is a universal disorder.

Let’s review what we have learned. Psychologists use three main criteria to identify abnormality—dysfunction, distress, and deviance. The 3 Ds are useful, but be mindful of their limitations. The same could be said of other mental health concepts (normal, abnormal, and so forth), because their meanings may vary over time, across cultures, and even within the same culture.

THINK again

The Insanity Plea

Perhaps you have heard the term “insanity” used in a legal context. “The defendant got off on an insanity plea,” or “The defense failed to demonstrate insanity.” What do these mean? Insanity is a legal determination of the degree to which a person is responsible for his criminal behaviors. Those deemed legally insane are thought to have little or no control over or understanding of their behaviors at the time they committed their crimes. Therefore, they are offered psychological treatment rather than criminal punishment, such as imprisonment or the death penalty. In America, 46 states offer a form of the insanity defense; only Idaho, Kansas, Montana, and Utah do not (Lilienfeld & Arkowitz, 2011). Many people believe that the insanity defense is frequently used, when in fact it is utilized in about 1% of cases. Of those cases, just 10–25% of insanity defenses are successful (Torry & Billick, 2010). Among those who avoided prison after entering an insanity plea was John Hinckley Jr., the man who attempted to assassinate President Ronald Reagan in 1981. The insanity plea did not work so well for serial murderer Jeffrey Dahmer, however; in 1992 he was sentenced to 15 life terms for the horrific murders of 15 young men (PBS, 2013).

Insanity? In the summer of 2012, James Holmes walked into a movie theater in Aurora, Colorado, and opened fire on the audience, killing 12 people. Holmes’s attorneys entered a plea of insanity; they claim he committed the murders in a psychotic state (Ingold, 2013, September 30).

AP Photo/The Denver Post, Andy Cross, Pool

THE INSANITY PLEA DID NOT WORK SO WELL FOR SERIAL MURDERER JEFFREY DAHMER.

Do you believe individuals whom the courts judge to be insane are still responsible for their actions? Knowing that a handful of states do not allow the insanity defense, what argument might you use to convince their legislatures to allow it?

Now that we have explored the meaning of abnormality, let’s find out more about the experience of having a psychological disorder—and the negative judgments that sometimes accompany it.

Watching his classmates laugh about people with psychological disorders, Ross bore witness to the stigma attached to mental illness. Stigma is a negative attitude or opinion about groups of individuals based on certain traits or characteristics they have. It can lead to discrimination and stereotypes, and negative characterizations in general (Corrigan, 2005). Surely, you have heard people equate psychological disorders with violence and aggression, or perhaps you have seen TV shows portraying people with mental illness as wild and aggressive. Reality check: People with psychological disorders are usually not violent. Other factors, such as lower socioeconomic status, male gender, and substance abuse, may be better predictors of violence (Stuart, 2003). The criterion of being a danger to oneself and others does determine the necessity of treatment, but given the degree of violence in our society, it is actually atypical of people with serious psychological disorders, and more commonly associated with substance abuse (Arkowitz & Lilienfeld, 2011; Fazel, Gulati, Linsell, Geddes, & Grann, 2009).

Hollywood Stereotypes Anthony Hopkins (right) plays the role of serial killer Hannibal Lecter in the 1991 film The Silence of the Lambs. Characters like “Hannibal the Cannibal” tend to perpetuate stereotypes about people with psychological disorders, most of whom are not violent (Arkowitz & Lilienfeld, 2011; Fazel et al., 2009).

Orion/The Kobal Collection

Stigma can have devastating repercussions. It may lower self-esteem, impair social functioning, and interfere with people getting much needed treatment. Research suggests that many individuals do not seek mental health services because of the stigma associated with psychological disorders and their treatment (Corrigan, 2005).

What can we do to combat stigma? One suggestion is to use “people-first language”; that is, refer to the individual affected by the disorder (She has been diagnosed with schizophrenia), not define the person by her disorder (She is schizophrenic; American Psychological Association [APA], 2010c). We should also be cautious about using terms such as “crazy” and “insane.” While these words are used to describe people on a daily basis, they are inappropriate, derogatory, and sure indicators of stigma.

Thus far, our discussion has focused on overarching concepts like abnormal behavior and stigma, which have relevance for all psychological disorders. Now it’s time to shift to a discussion of more practical matters. How do psychologists and psychiatrists go about identifying and classifying disorders?