Atypical Behaviour - Lumen Learning

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Glossary

Agoraphobia - anxiety disorder characterised by intense fear, anxiety, and avoidance of situations in which it might be difficult to escape if one experiences symptoms of a panic attack

Anxiety Disorder - characterised by excessive and persistent fear and anxiety, and by related disturbances in behaviour

Atypical - describes behaviours or feelings that deviate from the norm

Bipolar and Related Disorders - group of mood disorders in which mania is the defining feature

Bipolar Disorder - mood disorder characterized by mood states that vacillate between depression and mania

Body Dysmorphic Disorder - involves excessive preoccupation with an imagined defect in physical appearance

Catatonic Behaviour - decreased reactivity to the environment; includes posturing and catatonic stupor

Comorbidity - co-occurrence of two disorders in the same individual

Delusion - belief that is contrary to reality and is firmly held, despite contradictory evidence

Depersonalization/Derealization Disorder - dissociative disorder in which people feel detached from the self (depersonalization), and the world feels artificial and unreal (derealization)

Depressive Disorder - one of a group of mood disorders in which depression is the defining feature

Diagnosis - determination of which disorder a set of symptoms represents

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition - authoritative index of mental disorders and the criteria for their diagnosis; published by the American Psychiatric Association (APA)

Diathesis-Stress Model - suggests that people with a predisposition for a disorder (a diathesis) are more likely to develop the disorder when faced with stress; model of psychopathology; theory in which certain predispositions or vulnerability factors influence one's reaction to stress

Disorganised/Abnormal Motor Behaviour - highly unusual behaviours and movements (such as child-like behaviours), repeated and purposeless movements, and displaying odd facial expressions and gestures

Disorganised Thinking - disjointed and incoherent thought processes, usually detected by what a person says

Dissociative Amnesia - dissociative disorder characterized by an inability to recall important personal information, usually following an extremely stressful or traumatic experience

Dissociative Disorders - group of DSM-5 disorders in which the primary feature is that a person becomes dissociated, or split off, from his or her core sense of self, resulting in disturbances in identity and memory

Dissociative Fugue - symptoms of dissociative amnesia in which a person suddenly wanders away from one's home and experiences confusion about his or her identity

Dissociative Identity Disorder - dissociative disorder (formerly known as multiple personality disorder) in which a person exhibits two or more distinct, well-defined personalities or identities and experiences memory gaps for the time during which another identity emerged

Dopamine Hypothesis - theory of schizophrenia that proposes than an overabundance of dopamine or dopamine receptors is responsible for the onset and maintenance of schizophrenia

Etiology (or Aetiology) - cause or causes of a psychological disorder

Flashbacks - psychological state lasting from a few seconds to several days, during which one relives a traumatic event and behaves as though the event were occurring at that moment

Flight of Ideas - symptom of mania that involves an abruptly switching in conversation from one topic to another

Generalised Anxiety Disorder - characterised by a continuous state of excessive, uncontrollable, and pointless worry and apprehension

Grandiose Delusion - characterised by beliefs that one holds special power, unique knowledge, or is extremely important

Hallucination - perceptual experience that occurs in the absence of external stimulation, such as the auditory hallucinations (hearing voices) common to schizophrenia

Hoarding Disorder - characterised by persistent difficulty in parting with possessions, regardless of their actual value or usefulness

Hopelessness Theory - cognitive theory of depression proposing that a style of thinking that perceives negative life events as having stable and global causes leads to a sense of hopelessness and then to depression

International Classification of Diseases - authoritative index of mental and physical diseases, including infectious diseases, and the criteria for their diagnosis; published by the World Health Organisation (WHO)

Locus Coeruleus - area of the brainstem that contains norepinephrine, a neurotransmitter that triggers the body's fight-or-flight response; has been implicated in panic disorder

Major Depressive Disorder - commonly referred to as "depression" or "major depression," characterised by sadness or loss of pleasure in usual activities, as well as other symptoms

Mania - state of extreme elation and agitation

Manic Episode - period in which an individual experiences mania, characterized by extremely cheerful and euphoric mood, excessive talkativeness, irritability, increased activity levels, and other symptoms

Mood Disorders - one of a group of disorders characterised by severe disturbances in mood and emotions; the categories of mood disorders listed in the DSM-V are bipolar and related disorders and depressive disorders

Negative Symptom - characterised by decreases and absences in certain normal behaviours, emotions, or drives, such as an expressionless face, lack of motivation to engage in activities, reduced speech, lack of social engagement, and inability to experience pleasure

Obsessive-Compulsive and Related Disorders - groups of overlapping disorders listed in the DSM-5 that involves intrusive, unpleasant thoughts and/or repetitive behaviours

Obsessive-Compulsive Disorder - characterised by the tendency to experience intrusive and unwanted thoughts and urges (obsession) and/or the need to engage in repetitive behaviours or mental acts (compulsions) in response to the unwanted thoughts and urges

Orbitofrontal Cortex - area of the frontal lobe involved in learning and decision-making

Panic Attack - period of extreme fear or discomfort that develops abruptly; symptoms of panic attacks are both physiological and psychological

Panic Disorder - anxiety disorder characterised by unexpected panic attacks, along with at least one month of worry about panic attacks or self-defeating behaviour related to the attacks

Paranoid Delusion - characterised by beliefs that others are out to harm them

Peripartum Onset - subtype of depression that applies to women who experience an episode of major depression either during pregnancy or in the four weeks following childbirth

Persistent Depressive Disorder - depressive disorder characterised by a chronically sad and melancholy mood

Post Traumatic Stress Disorder (PTSD) - experiencing a profoundly traumatic event lead to a constellation of symptoms that include intrusive and distressing memories of the event, avoidance of stimuli connected to the event, negative emotional states, feelings to detachment from others, irritability, proneness toward outbursts, hypervigilance, and a tendency to startle easily; these symptoms must occur for at least one month

Prodromal Symptom - in schizophrenia, one of the early minor symptoms of psychosis

Psychological Disorder - condition characterised by abnormal thoughts, feelings, and behaviours

Psychopathology - study of psychological disorders, including their symptoms, causes, and treatment; manifestation of a psychological disorder

Rumination - in depression, tendency to repetitively and passively dwell on one's depression symptoms, their meanings, and their consequences

Safety Behaviour - mental and behaviour acts designed to reduce anxiety in social situations by reducing the chance of negative social outcomes; common in social anxiety disorder

Schizophrenia - severe disorder characterised by major disturbances in thought, perception, emotion, and behaviour with symptoms that include hallucinations, delusions, disorganised thinking and behaviour, and negative symptoms

Seasonal Pattern - subtype of depression in which a person experiences the symptoms of major depressive disorder only during a particular time of year

Social Anxiety Disorder - characterised by extreme and persistent fear or anxiety and avoidance of social situations in which one could potentially be evaluated negatively by others

Somatic Delusion - belief that something highly unusual is happening to one's body or internal organs

Specific Phobia - anxiety disorder characterised by excessive, distressing, and persistent fear or anxiety about a specific object or situation

Suicidal Ideation - thoughts of death by suicide, thinking about or planning suicide, or making a suicide attempt

Suicide - death caused by intentional, self-directed injurious behaviour

Supernatural - describes a force beyond scientific understanding

Ventricle - one of the fluid-filled cavities within the brain

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Why It Matters: Psychological Disorders

Mental Health Myths

Myth: Mental health problems don't affect me

Fact: Mental health problems are actually very common. In 2014, about:

one in five American adults experienced a mental health issue

one in ten young people experienced a period of major depression

one in twenty five Americans lived with a serious mental illness, such as schizophrenia, bipolar disorder, or major depression

Suicide is the 10th leading cause of death in the United States. It accounts for the loss of more than 41,000 American lives each year, more than double the number of lives lost to homicide.

Myth: Children don't experience mental health problems

Fact: Even very young children may show early warning signs of mental health concerns. These mental health problems are often clinically diagnosable, and can be a product of the interaction of biological, psychological, and social factors.

Half of all mental health disorders show first signs before a person turns 14 years old, and three-quarters of mental health disorders begin before age 24.

Unfortunately, less than 20% of children and adolescents with diagnosable mental health problems receive the treatment they need. Early mental health support can help a child before problems interfere with other developmental needs.

Myth: People with mental health problems are violent and unpredictable

Fact: The vast majority of people with mental health problems are no more likely to be violent than anyone else. Most people with mental health issues are not violent and only 3%-5% of violent acts can be attributed to individuals living with a serious mental issue. In fact, people with severe mental illnesses are over 10 times more likely to be victims of violent crime than the general population. You probably know someone with a mental health problem and don't even realise it, because many people with mental health problems are highly active and productive members of our communities.

Myth: People with mental health needs, even those who are managing their mental illness, cannot tolerate the stress of holding down a job

Fact: People with mental health problems are just as productive as other employees. Employers who hire people with mental health problems report good attendance and punctuality as well as motivation, good work, and job tenure on par with or greater than other employees.

When employees with mental health problems receive effective treatment, it can result in:

lower total medical costs

increased productivity

lower absenteeism

decreased disability costs

Myth: Personality weakness or character flaws cause mental health problems. People with mental health problems can snap out of it if they try hard enough.

Fact: Mental health problems have nothing to do with being lazy or weak and many people need help to get better. Many factors contribute to mental health problems, including:

biological factors, such as genes, physical illness, injury, or brain chemistry

life experiences, such as trauma or a history of abuse

family history of mental problems

People with mental health problems can get better and many recover completely.

Myth: There is no hope for people with mental health problems. Once a friend or family member develops mental health problems, they will never recover

Fact: Studies show that people with mental health problems get better and many recover completely. Recovery refers to the process in which people are able to live, work, learn, and participate fully in their communities. There are more treatments, services, and community support systems than ever before, and they work

Myth: Therapy and self-help are a waste of time. Why bother when you can just take a pill?

Fact: Treatment for mental health problems varies depending on the individual and could include medication, therapy, or both. Many individuals work with a support system during the healing and recovery process

Myth: I can't do anything for a person with a mental health problem

Fact: Friends and loved ones can make a big difference. Only 44% of adults with diagnosable mental health problems and less than 20% of children and adolescents receive needed treatment. Friends and family can be important influences to help someone get the treatment and services they need by:

reaching out and letting them know you are available to help

helping them access mental health services

learning and sharing the facts about mental health, especially if you hear something that isn't true

treating them with respect, just as you would anyone else

refusing to define them by their diagnosis or using labels such as "crazy"

Myth: Prevention doesn't work. It is impossible to prevent mental illnesses

Fact: Prevention of mental, emotional, and behavioural disorders focuses on addressing known risk factors such as exposure to trauma that can affect the chances that children, youth, and young adults will develop mental health problems. Promoting the social-emotional well-being of children and youth leads to:

higher overall productivity

better educational outcomes

lower crime rates

stronger economies

lower health care costs

improved quality of life

increased lifespan

improved family life

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What are Psychological Disorders?

A psychological disorder is a condition characterised by abnormal thoughts, feelings, and behaviours. Psychopathology is the study of psychological disorders, including their symptoms, etiology (i.e., their causes), and treatment. The term psychopathology can also refer to the manifestation of a psychological disorder. Although consensus can be difficult, it is extremely, important for mental health professionals to agree on what kinds of thoughts, feelings, and behaviours are truly abnormal in the sense that they genuinely indicate the presence of psychopathology. Certain patterns of behaviour and inner experience can easily be labelled as abnormal and clearly signify some kind of psychological disturbance. The person who washes his hands 40 times per day and the person who claims to hear the voices of demons exhibit behaviours and inner experiences that most would regard as abnormal: beliefs and behaviours that suggest the existence of a psychological disorder. But, consider the nervousness a person may feel when talking to an attractive love interest or the loneliness and longing for home a freshman may experience during their first semester of college - these feelings may not be regularly present, but they fall in the range of normal. Sp, what kind of thoughts, feelings, and behaviours represent a true psychological disorder? Psychologists work to distinguish psychological disorders from inner experiences and behaviours that are merely situational, idiosyncratic, or unconventional.

Definition of a Psychological Disorder

Perhaps the simplest approach to conceptualising psychological disorders is to label behaviours, thoughts, and inner experiences that are atypical, distressful, dysfunctional, and sometimes even dangerous, as signs of a disorder. For example, if you ask a classmate for a date and you are rejected, you probably would feel a little dejected. Such feelings would be normal. If you felt extremely depressed - so much so that you lost interest in activities, had difficulty eating or sleeping, felt utterly worthless, and contemplated suicide - your feelings would be atypical, would deviate from the norm, and could signify the presence of a psychological disorder. Just because something is atypical, however, does not necessarily mean it is disordered.

For example, only about 4% of people in the United States have red hair, so red hair is considered an atypical characteristic, but it is not considered disordered, it's just unusual. And it is less unusual in Scotland, where approximately 13% of the population has red hair ("DNA Project Aims," 2012). As you will learn, some disorders, although not exactly typical, are far from atypical, and the rates in which they appear in the population are surprisingly high.

If we can agree that merely being atypical is an insufficient criterion for having a psychological disorder, is it reasonable to consider behaviour or inner experiences that differ from widely expected cultural values or expectations as disordered? Using this criterion, a woman who walks around a subway platform wearing a heavy winter coat in July while screaming obscenities at strangers may be considered as exhibiting symptoms of a psychological disorder. Her actions and clothes violate socially accepted rules governing appropriate dress and behaviour, these characteristics are atypical.

Cultural Expectations

Violating cultural expectations is not, in and of itself, a satisfactory means of identifying the presence of a psychological disorder. Since behaviour varies from one culture to another, what may be expected and considered appropriate in one culture may not be viewed as such in other cultures. For example, returning a stranger's smile is expected in the United Kingdom because a pervasive social norm dictates that we reciprocate friendly gestures. A person who refuses to acknowledge such gestures might be considered socially awkward - perhaps even disordered - for violating this expectation. However, such expectations are not universally shared. Cultural expectations in Japan involve showing reserve, restraint, and a concern for maintaining privacy around strangers. Japanese people are generally unresponsive to smiles from strangers (Patterson et al., 2007). Eye contact provides another example. In the United States and Europe, eye contact with others typically signifies honesty and attention. However, most Latin-American, Asian, and African cultures interpret direct eye contact as rude, confrontational, and aggressive (Pazain, 2010). Thus, someone who makes eye contact with you could be considered appropriate and respectful or brazen and offensive, depending on your culture.

Hallucinations (seeing or hearing things that are not physically present) in Western societies is a violation of cultural expectations, and a person who reports such inner experiences is readily labelled as psychologically disordered. In other cultures, visions that, for example, pertain to future events may be regarded as normal experiences that are positively valued (Bourguignon, 1970). Finally, it is important to recognise that cultural norms change over time: what might be considered typical in a society at one time may no longer be viewed this way later, similar to how fashion trends from one era may elicit quizzical looks decades later - imagine how legwarmers or the big hair of the 1980s would go over on your campus today.

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Diagnosing and Classifying Psychological Disorders

A first step in the study of psychological disorders is carefully and systematically discerning significant signs and symptoms. How do mental health professionals ascertain whether or not a person's inner states and behaviours truly represent a psychological disorder? Arriving at a proper diagnosis - that is, appropriately identifying and labelling a set of defined symptoms - is absolutely crucial. This process enables professionals to use a common language with others in the field and aids in communication about the disorder with the patient, colleagues and the public. A proper diagnosis is an essential element to guide proper and successful treatment. For these reasons, classification systems that organise psychological disorders systematically are necessary,

International Classification of Diseases

The ICD is widely recognised and was published by the World Health Organisation (WHO). The ICD was developed in Europe shortly after World War II and has been revised several times. Although the ICD is used for clinical purposes, this tool is also used to examine the general health of populations and to monitor the prevalence of diseases and other health problems internationally (WHO, 2013). The ICD is in its 10th edition (ICD-10); however, efforts are now underway to develop a new edition (ICD-11) that, in conjunction with the changes in the American DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), will help harmonise the two classification systems as much as possible (APA, 2013).

A study that compared the use of the two classification systems found that worldwide the ICD is more frequently used for clinical diagnosis, whereas the DSM is more valued for research (Mezzich, 2002). Most research findings concerning the etiology and treatment of psychological disorders are based on criteria set forth in the DSM (Oltmanns & Castonguay, 2013). The DSM also includes more explicit disorder criteria, along with an extensive and helpful explanatory text (Regier et al., 2012). The DSM is the classification system of choice among U.S. mental health professionals, and this module is based on the DSM paradigm.

Compassionate View of Psychological Disorders

As these disorders are outlines, please bear two things in mind. First, remember that psychological disorders represent extremes of inner experience and behaviour. If, while reading about these disorders, you feel that these descriptions begin to personally characterise you, do not worry - this moment of enlightenment probably means nothing more than you are normal. Each of us experiences episodes of sadness, anxiety, and preoccupation with certain thoughts - times when we do not quite feel ourselves. These episodes should not be considered problematic unless the accompanying thoughts and behaviours become extreme and have disruptive effect on one's life.

Second, understand that people with psychological disorders are far more than just embodiments of their disorders. We do not use terms such as schizophrenics, depressives, or phobics because they are labels that objectify people who suffer from these conditions, thus promoting biased and disparaging assumptions about them. It is important to remember that a psychological disorder is not what a person is; it is something that a person has - through no fault of their own. As is the case with cancer or diabetes, those with psychological disorders suffer debilitating, often painful conditions that are not of their own choosing. These individuals deserve to be viewed and treated with compassion, understanding, and dignity.

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Perspectives on Psychological Disorders

Supernatural Perspectives of Psychological Disorders

For centuries, psychological disorders were viewed from a supernatural perspective: attributed to a force beyond scientific understanding. Those afflicted were thought to be practitioners of black magic or possessed by spirits (Maher & Maher, 1985). For example, convents throughout Europe in the 16th and 17th centuries reported hundreds of nuns falling into a state of frenzy in which the afflicted foamed at the mouth, screamed and convulsed, sexually propositioned priests, and confessed to having carnal relations with devils, or Christ. Although, today, these cases would suggest serious mental illness; at the time, these events were routinely explained as possession by devilish forces (Waller, 2009a). Similarly, grievous fits by young girls are believed to have precipitated the witch panic in New England late in the 17th century (Demos, 1983). Such beliefs in supernatural causes of mental illness are still help in some societies today; for example, beliefs that supernatural forces cause mental illness are common in some cultures in modern-day Nigeria (Aghukwa, 2012).

Dig Deeper: Dancing Mania

Between the 11th and 17th centuries, a curious epidemic swept across Western Europe. Groups of people would suddenly begin to dance with wild abandon. This compulsion to dance - referred to as dancing mania - sometimes gripped thousands of people at a time. Historical accounts indicate that those afflicted would sometimes dance with bruised and bloody feet for days or weeks, screaming of terrible visions and begging priests and monks to save their souls (Waller, 2009b). What caused dancing mania is not known, but several explanations have been proposed, including spider venom and ergot poisoning ("Dancing Mania," 2011).

Historian John Waller (2009a, 2009b) has provided a comprehensive and convincing explanation of dancing mania that suggests the phenomenon was attributable to a combination of three factors: psychological distress, social contagion, and belief in supernatural forces. Waller argued that various disasters of the time (such as famine, plagues, and floods) produced high levels of psychological distress that could increase the likelihood of succumbing to an involuntary trance state. Waller indicated that anthropological studies and accounts of possession rituals show that people are more likely to enter a trance state if they expect it to happen, and that entranced individuals behave in a ritualistic manner, their thoughts and behaviour shaped by the spiritual beliefs of their culture. Thus, during periods of extreme physical and mental distress, all it took were a few people - believing themselves to have been afflicted with a dancing curse - to slip into a spontaneous trance and then act out the part of one who is cursed by dancing for days on end.

Biological Perspectives of Psychological Disorders

The biological perspective views psychological disorders as linked to biological phenomena, such as genetic factors, chemical imbalances, and brain abnormalities; it has gained considerable attention and acceptance in recent decades (Wyatt & Midkiff, 2006). Evidence from many sources indicates that most psychological disorders have a genetic compnent; in fact, there is little dispute that some disorders are largely due to genetic factors.

Findings have led many of today's researchers to search for specific genes and genetic mutations that contribute to mental disorders. Also, sophisticated neural imaging technology in recent decades has revealed how abnormalities in brain structure and function might be directly involved in many disorders, and advances in our understanding of neurotransmitters and hormones have yielded insights into their possible connections. The biological perspective is currently thriving in the study of psychological disorders.

Diathesis-Stress Model of Psychological Disorders

Despite advances in understanding the biological basis of psychological disorders, the psychosocial perspective is still very important. This perspective emphasises the importance of learning, stress, faulty, and self-defeating thinking patterns, and environmental factors. Perhaps the best way to think about psychological disorders, then, is to view them as originating from a combination of biological and psychological processes. Many develop not from a single cause, but from a delicate fusion between partly biological and partly psychosocial factors.

The diathesis-stress model (Zuckerman, 1999) integrates biological and psychosocial factors to predict the likelihood of a disorder. This diathesis-stress model suggests that people with an underlying predisposition for a disorder (i.e., a diathesis) are more likely than others to develop a disorder when faced with adverse environmental or psychological events (i.e., stress), such as childhood maltreatment, negative life events, trauma, and so on. A diathesis is not always a biological vulnerability to an illness; some diathesis may be psychological (e.g., a tendency to think about life events in a pessimistic, self-defeating way).

The key assumption of the diathesis-stress model is that both factors, diathesis and stress, are necessary in the development of a disorder. Different models explore the relationship between the two factors: the level of stress needed to produce the disorder is inversely proportional to the level of diathesis.

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Phobias and Social Anxiety Disorder

Everybody experiences anxiety from time to time. Although anxiety is closely related to fear, the two states possess important differences. Fear involves an instantaneous reaction to an imminent threat, whereas anxiety involves apprehension, avoidance, and cautiousness regarding a potential threat, danger, or other negative event (Craske, 1999). While anxiety is unpleasant to most people, it is important to our health, safety, and well-being. Anxiety motivates us to take actions - such as preparing for exams, watching our weight, showing up to work on time - that enables us to avert potential future problems. Anxiety also motivates us to avoid certain things - such as running up debts and engaging in illegal activities - that could lead us to future trouble. Most individuals' level and duration of anxiety approximates the magnitude of the potential threat they face. For example, suppose a student went to the U.S. as a "Dreamer" (someone whose parents didn't lawfully immigrate) is concerned about the possibility of being unable to continue in the university program or of losing access to academic financial aid, due to changes and litigation around the Deferred Action for Childhood Arrivals (DACA) program. This person likely would experience anxiety of greater intensity and duration than would a 21-year-old junior who entered college as a birthright citizen. Some people experience anxiety that is excessive, persistent, and greatly out of proportion to the actual threat; if one's anxiety has a disruptive influence on one's life, this is a strong indicator that the individual is experiencing an anxiety disorder.

Anxiety disorders are characterised by excessive and persistent fear and anxiety, and by related disturbances in behaviour (APA, 2013). Although anxiety is universally experienced, anxiety disorders cause considerable distress. As a group, anxiety disorders are common: approximately 25%-30% of the U.S. population meets the criteria for at least one anxiety disorder during their lifetime (Kessler et al., 2005). Also, these disorders appear to be much more common in women than they are in men; within a 12-month period, around 23% of women and 14% of men will experience at least one anxiety disorder (National Comorbidity Survey, 2007). Anxiety disorders are the most frequently occurring class of mental disorders and are often comorbid with each other and with other mental disorders (Kessler, Ruscio, Shear, & Wittchen, 2009).

Specific Phobia

Phobia is a Greek word that means fear. A person diagnosed with a specific phobia (formerly known as a simple phobia) experiences excessive, distressing, and persistent fear or anxiety about a specific object or situation (such as animals, enclosed spaces, elevators, or flying) (APA, 2013). Even though people realise their level of fear and anxiety in relation to the phobic stimulus is irrational, some people with a specific phobia may go to great lengths to avoid the phobic stimulus (the object or situation that triggers the fear and anxiety). Typically, a man with a phobia of lying might refuse to accept a job that requires frequent air travel, thus negatively affecting his career. Clinicians who have worked with people who have specific phobias have encountered many kinds of phobias, for example:

acrophobia - heights

aerophobia - flying

arachnophobia - spiders

claustrophobia - enclosed spaces

cynophobia - dogs

hematophobia - blood

odhidiophobia - snakes

taphophobia - being buried alive

trypanophobia - injections

xenophobia - strangers

Specific phobias are common; in the United States, around 12.5% of the population will meet the criteria for a specific phobia at some point in their lifetime (Kessler et al., 2005). One type of phobia, agoraphobia, is listed in the DSM-5 as a separate anxiety disorder. Agoraphobia, which literally means "fear of the marketplace," is characterised by intense fear, anxiety, and avoidance of situations in which it might be difficult to escape or receive help if one experiences symptoms of a panic attack. These situations include public transportation, open spaces (parking lots), enclosed spaces (stores), crowds, or being outside the home alone (APA, 2013). About 1.4% of Americans experience agoraphobia in their lifetime (Kessler et al., 2005).

Acquisition of Phobias Through Learning

Many theories suggest that phobias develop through learning. Rachman (1977) proposed that phobias can be acquired through three major learning pathways. The first pathway is through classical conditioning. As you may recall, classical conditioning is a form of learning in which a previously neutral stimulus is paired with an unconditioned stimulus (UCS) that reflexively elicits an unconditioned response (UCR), eliciting the same response through its association with the unconditioned stimulus. The response is called a conditioned response (CR). For example, a child who has been bitten by a dog may come to fear dogs because of her past association with pain. In this case, the dog bite is the UCS and the fear it elicits is the UCR. Because a dog was associated with the bite, any dog may come to serve as a conditioned stimulus, thereby eliciting fear; the fear the child experiences around dogs, then, becomes a CR.

The second pathway of phobia acquisition is through vicarious learning, such as modelling. For example, a child who observes his cousin react fearfully to spiders may later express the same fears, even though spiders have never presented any danger to him. This phenomenon has been observed in both humans and nonhuman primates (Olsson & Phelps, 2007). A study of laboratory-reared monkeys readily acquired a fear of snakes after observing wild-reared monkeys react fearfully to snakes (Mineka & Cook, 1993).

The third pathway is through verbal transmission of information. For example, a child whose parents, siblings, friends, and classmates constantly tell her ow disgusting and dangerous snakes are may come to acquire a fear of snakes.

Interestingly, people are more likely to develop phobias of things that do not represent much actual danger to themselves, such as animals and heights, and are less likely to develop phobias towards things that present legitimate danger in contemporary society, such as motorcycles and weapons (Ohman & Mineka, 2001). Why might this be so? One theory suggests that the human brain is evolutionarily predisposed to more readily associate certain objects or situations with fear (Seligman, 1971). This theory argues that throughout our evolutionary history, our ancestors associated certain stimuli (e.g. snakes, spiders, heights, and thunder) with potential danger. As time progressed, the mind has become adapted to more readily develop fears of these things than of others. Experimental evidence has consistently demonstrated that conditioned fears develop more readily to fear-relevant stimuli (images of snakes and spiders) than to fear-irrelevant stimuli (images of flowers and berries) (Ohman & Mineka, 2001). Such prepared learning has also been shown to occur in monkeys. In one study (Cook & Mineka, 1989), monkeys watched videotapes of model monkeys reacting fearfully to either fear-relevant stimuli (toy snakes or a toy crocodile) or fear-irrelevant stimuli (flowers or a toy rabbit). The observer monkeys developed fears of the fear-relevant stimuli but not the fear-irrelevant stimuli.

Social Anxiety Disorder

Social anxiety disorder (formerly called social phobia) is characterised by extreme and persistent fear or anxiety and avoidance of social situations in which the person could potentially be evaluated negatively by others (APA, 2013). As with specific phobias, social anxiety disorder is common in the United States; a little over 12% of all Americans experience social anxiety disorders during their lifetime (Kessler et al., 2005).

The heart of the fear and anxiety in social anxiety disorder is the person''s concern that he may act in a humiliating or embarrassing way, such as appearing foolish, showing symptoms of anxiety (blushing), or doing or saying something that might lead to rejection (such as offending others). The kinds of social situations in which individuals with social anxiety disorder usually have problems include public speaking, having a conversation, meeting strangers, eating in restaurants, and, in some cases, using public restrooms. Although many people become anxious in social situations like public speaking, the fear, anxiety, and avoidance experienced in social anxiety disorder are highly distressing and lead to serious impairments in life. Adults with this disorder are more likely to experience lower educational attainment and lower earnings (Katzelnick et al., 2001), perform more poorly at work and are more likely to be unemployed (Moitra, Beard, Weisberg, & Keller, 2011), and report greater dissatisfaction with their family lives, friends, leisure activities, and income (Stein & Kean, 2000).

When people with social anxiety disorder are unable to avoid situations that provoke anxiety, they typically perform safety behaviours: mental or behavioural acts that reduce anxiety in social situations by reducing the chance of negative social outcomes. Safety behaviours include avoiding eye contact, rehearsing sentences before speaking, talking only briefly, and not talking about oneself (Alden & Bieling, 1998). Other examples of safety behaviour include the following (Marker, 2013):

assuming roles in social situations that minimise interaction with others (e.g., taking pictures, setting up equipment, or helping prepare food)

asking people many questions to keep the focus off of oneself

selecting a position to avoid scrutiny or contact with others (sitting in the back of the room)

wearing blank, neutral clothes to avoid drawing attention to oneself

avoiding substances or activities that might cause anxiety symptoms (such as caffeine, warm clothing, and physical exercise)

Although these behaviours are intended to prevent the person with social anxiety disorder from doing something awkward that might draw criticism, these actions usually exacerbate the problem because they do not allow the individual to disconfirm his negative beliefs, often eliciting rejection and other negative reactions from others (Alden & Bieling, 1998).

People with social anxiety disorder may resort to self-medication, such as drinking alcohol, as a means to avert the anxiety symptoms they experience in social situations (Battista & Kocovski, 2010). The use of alcohol when faced with such situations may become negatively reinforcing: encouraging individuals with social anxiety disorder to turn to the substance whenever they experience anxiety symptoms. The tendency to use alcohol as a coping mechanism for social anxiety, however, can come with a hefty price tag: a number of large scale studies have reported a high rate of comorbidity between social anxiety disorder and alcohol use disorder (Morris, Stewart, & Ham, 2005).

As with specific phobias, it is highly probable that the fears inherent to social anxiety disorder can develop through conditioning experiences. For example, a child who is subjected to early unpleasant social experiences (e.g. bullying at school) may develop negative social images of herself that become activated later in anxiety-provoking situations (Hackmann, Clark, & McManus, 2000). Indeed, one study reported that 92% of a sample of adults with social anxiety disorder reported a history of severe teasing in childhood, compared to only 35% of a sample of adults with panic disorder (McCabe, Antony, Summerfeldt, Liss, & Swinson, 2003).

One of the most well-established risk factors for developing social anxiety disorder is behavioural inhibition (Clauss & Blackford, 2012). Behavioural inhibition is thought to be an inherited trait, and it is characterised by a consistent tendency to show fear and restraint when presented with unfamiliar people or situations (Kagan, Reznich, & Snidman, 1988). Behavioural inhibition is displayed very early in life; behavioural inhibited toddlers and children respond with great caution and restraint in unfamiliar situations, and they are often timid, fearful, and shy around unfamiliar people (Fox, Henderson, Marshall, Nichols, & Ghera, 2005). A recent statistical review of studies demonstrated that behavioural inhibition was associated with more than a sevenfold increase in the risk of development of social anxiety disorder, demonstrating that behavioural inhibition is a major risk factor for the disorder (Clauss & Blackford, 2012).

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Panic and Generalised Anxiety Disorder

Panic Disorder

Imagine that you are at the mall one day with you friends and - suddenly and inexplicably - you begin sweating and trembling, your heart starts pounding, you have trouble breathing, and you start to feel dizzy and nauseous. This episode lasts for 10 minutes and is terrifying because you start to think that you are going to die. When you visit your doctor the following morning and describe what happened, she tells you that you have experienced a panic attack. If you experience another one of these episodes two weeks later and worry for a month or more that similar episodes will occur in the future, it is likely that you have developed panic disorder.

People with panic disorder experience recurrent (more than one) and unexpected panic attacks, along with at least one month of persistent concern about additional panic attacks, worry over the consequences of the attacks, or self-defeating changes in behaviour related to the attacks (e.g., avoidance of exercise or unfamiliar situations) (APA, 2013). As is the case with other anxiety disorders, the panic attacks cannot result from the physiological effects of drugs and other substances, a medical condition, or another mental disorder. A panic attack is defined as a period of extreme fear or discomfort that develops abruptly and reaches a peak within 10 minutes.

Panic attack symptoms (APA, 2013) include:

feeling dizzy, unsteady, lightheaded

chest pain, palpitations and/or accelerated heart rate

shortness of breath

nausea or abdominal distress

sweating

trembling

feelings of faintness

fear of losing control

Sometimes panic attacks are expected, occurring in response to specific environmental triggers (such as being in a tunnel); other times, these episodes are unexpected and emerge randomly (such as when relaxing). According to the DSM-5, the person must experience unexpected panic attacks to qualify for a diagnosis of panic disorder.

Experiencing a panic attack is often terrifying. Rather than recognising the symptoms of a panic attack merely as signs of intense anxiety, individuals with panic disorder often misinterpret them as a sign that something is intensely wrong internally (thinking, for example, that the pounding heart represents an impending heart attack). Panic attacks can occasionally precipitate trips to the emergency room because several symptoms of panic attacks are, in fact, similar to those associated with heart problems (e.g., palpitations, racing pulse, and a pounding sensation in the chest) (Root, 2000). Unsurprisingly, those with panic disorder fear future attacks and may become preoccupied with modifying their behaviour in an effort to avoid future panic attacks. For this reason, panic disorder is often characterised as fear of fear (Goldstein & Chambless, 1978).

Panic attacks themselves are not mental disorders. Indeed, around 23% of Americans experience isolated panic attacks in their lives without meeting the criteria for panic disorder (Kessler et al., 2006, indicating that panic attacks are fairly common. Panic disorder is, of course, much less common, afflicting 4.7% of Americans during their lifetime (Kessler et al., 2005). Many people with panic disorder develop agoraphobia, which is marked by fear and avoidance of situations in which escape might be difficult or help might not be available if one were to develop symptoms of a panic attack. People with panic disorder often experience a comorbid disorder, such as other anxiety disorders or major depressive disorder (APA, 2013).

Researchers are not entirely sure what causes panic disorder. Children are at higher risk of developing panic disorder if their parents have the disorder (Biederman et al., 2001), and family and twin studies indicate that the heritability of panic disorder is around 43% (Hettema, Neale, & Kendler, 2001). The exact genes and gene functions involved in this disorder, however, are not well-understood (APA, 2013). Neurobiological theories of panic disorder suggest that a region of the brain called the locus coeruleus may play a role in this disorder. Located in the brainstem, the locus coeruleus is the brain's major source of norepinephrine, a neurotransmitter that triggers the body's fight-or-flight response. Activation of the locus coeruleus is associated with anxiety and fear, and research with nonhuman primates has shown that stimulating the locus coeruleus either electrically or through drugs produces panic-like symptoms (Charney et al., 1990). Such findings have led to the theory that panic disorder may be caused by abnormal norepinephrine activity in the locus coeruleus (Bremner, Krystal, Southwick, & Charney, 1996).

Conditioning theories of panic disorder propose that panic attacks are classical conditional responses to subtle bodily sensations resembling those normally occurring when one is anxious or frightened (Bouton Mineka, & Barlow, 2001). For example, consider a child who has asthma. An acute asthma attack produces sensations, such as shortness of breath, coughing, and chest tightness, that typically elicit fear and anxiety. Later, when the child experiences subtle symptoms that resemble the frightening symptoms of earlier asthma attacks (such as shortness of breath after climbing stairs), he may become anxious, fearful, and then experience a panic attack. In this situation, the subtle symptoms would represent a conditioned stimulus, and the panic attack would be a conditioned response. The finding that panic disorder is nearly three times as frequent among people with asthma as it is among people with asthma (Weiser, 2007) supports the possibility that panic disorder has the potential to develop through classical conditioning.

Cognitive factors may play an integral part in panic disorder. Generally, cognitive theories (Clark, 1996) argue that those with panic disorder are prone to interpret ordinary bodily sensations catastrophically, and these fearful interpretations set the stage for panic attacks. For example, a person might detect bodily changes that are routinely triggered by innocuous events such as getting up from a seated position (dizziness), exercising (increased heart rate, shortness of breath), or drinking a large cup of coffee (increased heart rate, trembling). The individual interprets these subtle bodily changes catastrophically ("Maybe I'm having a heart attack!"). Such interpretations create fear and anxiety, which trigger additional physical symptoms; subsequently, the person experiences a panic attack. Support of this contention rests with findings that people with more severe catastrophic thoughts about sensations have more frequent and severe panic attacks, and among those with panic disorder, reducing catastrophic cognitions about their sensations is as effective as medication in reducing panic attacks (Good & Hinton, 2009).

Generalised Anxiety Disorder

Alex was always worried about many things. He worried that his children would drown when they played at the beach. Each time he left the house, he worried that an electrical short circuit would start a fire in his home. He worried that his wife would lose her job at the prestigious law firm. He worried that his daughter's minor staph infection could turn into a massive life-threatening condition. These and other worries constantly weighed heavily on Alex's mind, so much so that they made it difficult for him to make decisions and often left him feeling tense, irritable, and worn out. One night, Alex's wife was to drive their son home from a soccer game. However, his wife stayed after the game and talked with some of the other parents, resulting in her arriving home 45 minutes late. Alex had tried to call her cell phone three or four times, but he could not get through because the soccer field did not have a signal. Extremely worried, Alex eventually called the police, convinced that his wife and son had not arrived home because they had been in a terrible car accident.

Alex suffers from generalised anxiety disorder: a relatively continuous state of excessive, uncontrollable, and pointless worry and apprehension. People with generalised anxiety disorder often worry about routine, everyday things, even though their concerns are unjustified. For example, an individual may worry about her health and finances, the health of family members, the safety of her children, or minor matters (e.g., being late for an appointment) without having any legitimate reason for doing so (APA, 2013), A diagnosis of generalised anxiety disorder requires that the diffuse of worrying and apprehension characteristic of this disorder - what Sigmund Freud referred to as free-floating anxiety - is not part of another disorder, occurs more days than not for at least six months, and is accompanied by any three of the following symptoms: restlessness, difficulty concentrating, being easily fatigued, muscle tension, irritability, and sleep difficulties.

About 5.7% of the U.S. population will develop symptoms of generalised anxiety disorder during their lifetime (Kessler et al., 2005), and females are 2 times as likely as males to experience the disorder (APA, 2013). Generalised anxiety disorder is highly comorbid with mood disorders and other anxiety disorders (Noyes, 2001), and it tends to be chronic. Also, generalised anxiety disorder appears to increase the risk of heart attacks and strokes, especially in people with pre-existing heart conditions (Martens et al., 2010).

Although there have been few investigations aimed at determining the heritability of generalised anxiety disorder, a summary of available family and twin studies suggests that genetic factors play a modest role in the disorder (Hettema et al., 2001). Cognitive theories of generalised anxiety disorder suggest that worry represents a mental strategy to avoid more powerful negative emotions (Aikins & Craske, 2001), perhaps stemming from earlier unpleasant or traumatic experiences. Indeed, one longitudinal study found that childhood maltreatment was strongly related to the development of this disorder during adulthood (Moffitt et al., 2007); worrying might distract people from remember painful childhood experiences.

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Obsessive-Compulsive and Related Disorders

Obsessive-compulsive and related disorders are a group of overlapping disorders that generally involve intrusive, unpleasant thoughts and repetitive behaviours. Many of us experience unwanted thoughts from time to time (e.g., craving double cheeseburgers when dieting), and many of us engage in repetitive behaviours on occasion (e.g., pacing when nervous). However, obsessive-compulsive and related disorders elevate the unwanted thoughts and repetitive behaviours to a status so intense that these cognitions and activities disrupt daily life. Included in this category are obsessive-compulsive disorder (OCD), body dysmorphic disorder, and hoarding disorder.

Obsessive-Compulsive Disorders

People with obsessive-compulsive disorder (OCD) experience thoughts and urges that are intrusive and unwanted (obsessions) and/or the need to engage in repetitive behaviours or mental acts (compulsions). A person with this disorder might, for example, spend hours each day washing his hands or constantly checking and rechecking to make sure that a stove, faucet, or light has been turned off.

Obsessions are more than just unwanted thoughts that seem to randomly jump into our head from time to time, such as recalling an insensitive remark a coworker made recently, and they are more significant than day-to-day worries we might have, such as justifiable concerns about being laid off from a job. Rather, obsessions are characterised as persistent, unintentional, and unwanted thoughts and urges that are highly intrusive, unpleasant, and distressing (APA, 2013). Common obsessions include concerns about germs and contamination, doubts ("Did I turn off the water?"), order and symmetry ("I need all the spoons in the tray arranged a certain way"), and urges that are aggressive or lustful. Usually, the person knows that such thoughts and urges are irrational and thus tries to suppress or ignore them, but has an extremely difficult time doing so. These obsessive symptoms sometimes overlap, such that someone might have both contamination and aggressive obsessions (Abramowitz & Siqueland, 2013).

Compulsions are repetitive and ritualistic acts that are typically carried out primarily as a means to minimise the distress that obsessions trigger or to reduce the likelihood of a feared event (APA, 2013). Compulsions often include such behaviours as repeated and extensive hand washing, cleaning, checking (e.g., that a door is locked), and ordering (e.g., lining up the pencils in a particular way), and they also include such mental acts as counting, praying, or reciting something to oneself. Compulsions characteristic of OCD are not performed out of pleasure, nor are they connected in a realistic way to the source of the distress or feared event. Approximately 2.3% of the U.S. population will experience OCD in their lifetime (Ruscio, Stein, Chiu, & Kessler, 2010) and, if left untreated, OCD tends to be a chronic condition creating lifelong interpersonal and psychological problems (Norberg, Calamari, Cohen, & Riemann, 2008).

Body Dysmorphic Disorder

An individual with body dysmorphic disorder is preoccupied with a perceived flaw in her physical appearance that is other people (APA, 2013). These perceived physical defects cause the person to think they are unattractive, ugly, hideous, or deformed. These preoccupations can focus on any bodily area, but they typically involve the skin, face, or hair. The preoccupation with imagined physical flaws drives the person to engage in repetitive and ritualistic behavioural and mental acts, such as constantly looking in the mirror, trying to hide the offending body part, comparisons with others, and, in some extreme cases, cosmetic surgery (Phillips, 2005). An estimated 2.4% of the adults in the U.S. meet the criteria for body dysmorphic disorder, with slightly higher rates in women than in men (APA, 2013).

Hoarding Disorder

Although hoarding was traditionally considered to be a symptom of OCD, considerable evidence suggests that hoarding represents an entirely different disorder (Mataix-Cols et al., 2010). People with hoarding disorder cannot bear to part with personal possessions, regardless of how valueless or useless these possessions are. As a result, these individuals accumulate excessive amounts of usually worthless items that clutter their living areas. Often, the quantity of cluttered items is so excessive that the person is unable to use their kitchen or sleep in their bed. People who suffer from this disorder have great difficulty parting with items because they believe the items might be of some later use, or because they form a sentimental attachment to the items (APA, 2013). Importantly, a diagnosis of hoarding disorder is made only if the hoarding is not caused by another medical condition and if the hoarding is not a symptom of another disorder (e.g., schizophrenia) (APA, 2013).

Causes of OCD

The results of family and twin studies suggest that OCD has a moderate genetic component. The disorder is five times more frequent in the first-degree relatives of people with OCD than in people without the disorder (Nestadt et al., 2000). Additionally, the concordance rate of OCD among identical twins is around 57%; however, the concordance rate for fraternal twins is 22% (Bolton, Rijsdijk, O'Connor, Perrin, & Eley, 2007). Studies have implicated about two dozen potential genes that may be involved in OCD; these genes regulate the function of three neurotransmitters: serotonin, dopamine, and glutamate (Pauls, 2010). Many of these studies included small sample sizes and have yet to be replicated. Thus, additional research needs to be done in this area.

A brain region that is believed to play a critical role in OCD is the orbitofrontal cortex (Kopell & Greenberg, 2008), an area of the frontal lobe involved in learning and decision-making (Rushworth, Noonan, Boorman, Walton, & Behrens, 2011). In people with OCD, the orbitofrontal cortex becomes especially hyperactive when they are provoked with tasks in which, for example, they are asked to look at a photo of a toilet or of pictures hanging crookedly on a wall (Simon, Kaufmann, Musch, Kischkel, & Kathmann, 2010). The orbitofrontal cortex is part of a series of brain regions that, collectively, is called the OCD circuit; this circuit consists of several interconnected regions that influence the perceived emotional value of stimuli and the selection of both behavioural and cognitive responses (Graybiel & Rauch, 2000). As with the orbitofrontal cortex, other regions of the OCD circuit show heightened activity during symptom provocation (Rotge et al., 2008), which suggests that abnormalities in these regions may produce the symptoms of OCD (Saxena, Bota, & Brody, 2001). Consistent with this explanation, people with OCD show a substantially higher degree of connectivity of the orbitofrontal cortex and other regions of the OCD circuit than do those without OCD (Beucke et al., 2013).

The findings discussed above were based on imaging studies, and they highlight the potential importance of brain dysfunction in OCD. However, one important limitation of these findings is the inability to explain differences in obsessions and compulsions. Another limitation is that the correlation relationship between neurological abnormalities and OCD symptoms cannot imply causation (Abramowitz & Siqueland, 2013).

Connect the Concepts: Conditioning and OCD

The symptoms of OCD have been theorised to be learned responses, acquired and sustained as the result of a combination of two forms of learning: classical conditioning and operant conditioning (Mowrer, 1960; Steinmetz, Tracy, & Green, 2001). Specifically, the acquisition of OCD may occur as the result of classical conditioning, whereby a neutral stimulus becomes associated with an unconditioned stimulus that provokes anxiety and distress. When an individual has acquired this associated, subsequent encounters with the neutral stimulus trigger anxiety, including obsessive thoughts; the anxiety and obsessive thoughts (which are now a conditioned response) may persist until she identifies some strategy to relieve it. Relief may take the form of a ritualistic behaviour or mental activity that, when enacted repeatedly, reduces the anxiety. Such efforts to relieve anxiety constitute an example of negative reinforcement (a form of operant conditioning). Recall from the chapter on learning that negative reinforcement involves the strengthening of behaviour through its ability to remove something unpleasant or aversive. Hence, compulsive acts observed in OCD may be sustained because they are negatively reinforcing, in the sense that they reduce anxiety triggered by a conditioned stimulus.

Suppose an individual with OCD experiences obsessive thoughts about germs, contamination, and disease whenever they encounter a doorknob. What might have constituted a viable unconditioned stimulus? Also, what would constitute the conditioned stimulus, unconditioned response, and conditioned response? What kinds of compulsive behaviours might we expect, and how do they reinforce themselves? What is decreased? Additionally, and from the standpoint of learning theory, how might the symptoms of OCD be treated successfully?

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Post-Traumatic Stress Disorder (PTSD)

Extremely stressful or traumatic events, such as combat, natural disasters, and terrorist attacks, place the people who experience them at an increased risk for developing psychological disorders such as post-traumatic stress disorder (PTSD). Throughout much of the 20th century, this disorder was called shell shock and combat neurosis because its symptoms were observed in soldiers who had engaged in wartime combat. By the late 1970s it had become clear that women who had experienced sexual traumas (e.g., rape, domestic battery, and incest) often experienced the same set of symptoms as did soldiers (Herman, 1997). The term post-traumatic stress disorder was developed given that these symptoms could happen to anyone who experienced psychological trauma.

A Broader Definition of PTSD

PTSD was listed among the anxiety disorders in previous DSM editions. In DSM-5, it is now listed among a group called Trauma-and-Stressor-Related Disorders. For a person to be diagnosed with PTSD, she must be exposed to, witness, or experience the details of a traumatic experience (e.g., a first responder), one that involves "actual or threatened death, serious injury, or sexual violence" (APA, 2013, p. 271). These experiences can include such events as combat, threatened or actual physical attack, sexual assault, natural disasters, terrorist attacks, and automobile accidents. This criterion makes PTSD the only disorder listed in the DSM in which a cause (extreme trauma) is explicitly specified.

Symptoms of PTSD include intrusive and distressing memories of the event, flashbacks (states that can last from a few seconds to several days, during which the individual relives the event and behaves as if the event were occurring at that moment [APA, 2013]), avoidance of stimuli connected to the event, persistently negative emotional states (e.g., fear, anger, guilt, and shame), feelings of detachment from others, irritability, proneness toward outbursts, and an exaggerated startle response (jumpiness). For PTSD to be diagnosed, these symptoms must occur for at least one month.

Risk Factors of PTSD

Of course, not everyone who experiences a traumatic event will go on to develop PTSD; several factors strongly predict the development of PTSD: traumatic experience, greater trauma severity, lack of immediate social support, and more subsequent life stress (Brewin, Andrews, & Valentine, 2000). Traumatic events that involve harm by others (e.g., combat, rape, and sexual molestation) carry greater risk than do other traumas (e.g., natural disasters) (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Women are more likely to have been traumatized because of sexual trauma, childhood heglect, and childhood physical abuse. Men are more likely to have been traumatized by natural disaster, life-threatening accident, and physical violence, either witnessed or directed at them. Adolescent boys are more likely to experience accident, physical assault, and witness death/injury; adolescent girls are more likely to experience rape/sexual assault, intimate partner violence, or unexpected death or injury of a loved one. Assaultive violence and witnessing trauma to others is more prevalent among non-whites when compared to whites. African American males are more likely to be exposed to and victims of violence than males of other races (Kilpatrick, Badour, & Resnick, 2017).

Factors that increase the risk of PTSD include female gender, low socioeconomic status, low intelligence, personal history of mental disorders, history of childhood adversity (abuse or other trauma during childhood), and family history of mental disorders (Brewin et al., 2000). Personality characteristics such as neuroticism and somatization (the tendency to experience physical symptoms when one encounters stress) have been shown to elevate the risk of PTSD (Bramsen, Dirkzwager, & van der Ploeg, 2000). People who experience childhood adversity and/or traumatic experiences during adulthood are at significantly higher risk of developing PTSD if they possess one or two short versions of a gene that regulates the neurotransmitter serotonin (Xie et al., 2009). This suggests a possible diathesis-stress interpretation of PTSD: its development is influenced by the interaction of psychosocial and biological factors.

Support for Sufferers of PTSD

Research has shown that social support following a traumatic event can reduce the likelihood of PTSD (Ozer, Best, Lipsey, & Weiss, 2003). Social support is often defined as the comfort, advice, and assistance received from relatives, friends, and neighbors. Social support can help individuals cope during difficult times by allowing them to discuss feelings and experiences and providing a sense of being loved and appreciated. A study of 1,377 American Legionnaires who had served in the Vietnam War found that those who perceived less social support when they came home were more likely to develop PTSD than were those who perceived greater support. In addition, those who became involved in the community were less likely to develop PTSD, and they were more likely to experience a remission of PTSD than were those who were less involved (Koenen, Stellman, Stellman, & Sommer, 2003).

Learning and Development of PTSD

PTSD learning models suggest that some symptoms are developed and maintained through classical conditioning. The traumatic event may act as an unconditioned stimulus that elicits an unconditional response characterized by extreme fear and anxiety. Cognitive, emotional, physiological, and environmental cues accompanying or related to the event are conditioned stimuli. These traumatic responses evoke conditioned responses (extreme fear and anxiety) similar to those caused by the event itself (Nader, 2001). A person who was in the vicinity of the Twin Towers during 9/11 terrorist attacks and who developed PTSD may display excessive hypervigilance and distress when planes fly overhead; this behavior constitutes a conditioned response to the traumatic reminder (conditioned stimulus of the sight and sound of an airplane). Differences in how conditionable individuals are help to explain differences in the development and maintenance of PTSD symptoms (Pittman, 1988). Conditioning studies demonstrate facilitated acquisition of conditioned responses and delayed extinction of conditioned responses in people with PTSD (Orr et al., 2000).

Cognitive factors are important in the development and maintenance of PTSD. One model suggests that two key processes are crucial: disturbances in memory for the event, and negative appraisals of the trauma and its aftermath (Ehlers & Clark, 2000). According to this theory, some people who experience traumas do not form coherent memories of the trauma; memories of the traumatic event are poorly encoded and, thus, are fragmented, disorganized, and lacking in detail. Therefore, these individuals are unable to remember the event in a way that gives it meaning and context. A rape victim who cannot coherently remember the event may remember only bits and pieces (e.g., the attacker repeatedly telling her she is stupid); because she was unable to develop a fully integrated memory, the fragmentary memory tends to stand out. Although unable to retrieve a complete memory of the event, she may be haunted by intrusive fragments involuntarily triggered by stimuli associated with the event (e.g., memories of the attacker's comments when encountering a person who resembles the attacker). This interpretation fits previously discussed material concerning PTSD and conditioning. The model also proposes that negative appraisals of the event ("I deserved to be raped because I'm stupid") may lead to dysfunctional behavioral strategies (e.., avoiding social activities where men are likely to be present) that maintain PTSD symptoms by preventing both a change in the nature of the memory and a change in the problematic appraisals.

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Introduction to Mood Disorders

Mood disorders are those in which the person experiences severe disturbances in mood and emotion. They include depressive disorders and bipolar and related disorders. Depressive disorders include major depressive disorder, which is characterized by episodes of profound sadness and loss of interest or pleasure in usual activities and other associated features, and persistent depressive disorder, which marked by a chronic state of sadness. Bipolar disorder is characterized by mood states that vacillate between sadness and euphoria; a diagnosis of bipolar disorder requires experiencing at least one manic episode, which is defined as a period of extreme euphoria, irritability, and increased activity.

Mood disorders appear to have a genetic component, with genetic factors playing a more prominent role in bipolar disorder than in depression. Both biological and psychological factors are important in the development of depression. People who suffer from mental health problems, especially mood disorders, are at heightened risk for suicide.

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Major Depressive Disorder

Mood disorders are characterised by severe disturbances in mood and emotions - most often depression, but also mania and elation (Rothschild, 1999). All of us experience fluctuations in our moods and emotional states, and often these fluctuations are caused by events in our lives. We become elated if our favourite team wins the World Series and dejected if a romantic relationship ends or if we lose our job. At times, we feel fantastic or miserable for no clear reason. People with mood disorders also experience mood fluctuations, but their fluctuations are extreme, distort their outlook on life, and impair their ability to function.

The DSM-V lists two general categories of mood disorders. Depressive disorders are a group of disorders in which depression is the main feature. Depression is a vague term that, in everyday language, refers to an intense and persistent sadness. Depression is a heterogeneous mood state - it consists of a broad spectrum of symptoms that range in severity. Depressed people feel sad, discouraged, and hopeless. These individuals lose interest in activities once enjoyed, often experience a decrease in drives such as hunger and sex, and frequently doubt personal worth. Depressive disorders vary by degree, but this module highlights the most well-known: major depressive disorder (sometimes called unipolar depression).

Bipolar and related disorders are a group of disorders in which mania is the defining feature. Mania is a state of extreme elation and agitation. When people experience mania, they may become extremely talkative, behave recklessly, or attempt to take on many tasks simultaneously. The most recognised of these disorders is bipolar disorder.

What is Major Depressive Disorder?

According to the DSM-V, the defining symptoms of major depressive disorder include "depressed mood most of the day, nearly every day" (feeling sad, empty, hopeless, or appearing tearful to others), and loss of interest and pleasure in usual activities (APA, 2013). In addition to feeling overwhelmingly sad most of each day, people with depression will no longer show interest or enjoyment in activities that previously were gratifying, such as hobbies, sports, sex, social events, time spent with family, and so on. Friends and family members may notice that the person has completely abandoned previously enjoyed hobbies; for example, an avid tennis player who develops major depressive disorder no longer plays tennis (Rothschild, 1999).

To receive a diagnosis of major depressive disorder, one must experience a total of five symptoms for at least a two-week period; these symptoms must cause significant distress or impair normal functioning, and they must not be caused by substances or a medical condition. At least one of the two symptoms mentioned above must be present, plus any combination of the following symptoms (APA, 2013):

significant weight loss (when not dieting) or weight gain and/or significant decrease or increase in appetite

difficulty falling asleep or sleeping too much

psychomotor agitation (the person noticeably fidgety and jittery, demonstrated by behaviours like the inability to sit, pacing, hand-wringing, pulling or rubbing of the skin, clothing, or other objects) or psychomotor retardation (the person talks and moves slowly, for example, talking softly, very little, or in a monotone)

fatigue or loss of energy

feelings of worthlessness or guilt

difficulty concentrating and indecisiveness

suicidal ideation: thoughts of death (not just fear of dying), thinking about or planning suicide, or making an actual suicide attempt

Major depressive disorder is considered episodic: its symptoms are typically present at their full magnitude for a certain period of time and then gradually abate. Approximately 50%-60% of people who experience an episode of major depressive disorder will have a second episode at some point in the future; those who have had two episodes have a 70% chance of having a third episode, and those who have had three episodes have a 90% chance of having a fourth episode (Rothschild, 1999). Although the episodes can last for months, a majority of people diagnosed with this condition (around 70%) recover within a year. However, a substantial number do not recover; around 12% show serious signs of impairment associated with major depressive disorder after 5 years (Boland & Keller, 2009). In the long-term, many who do recover will still shown minor symptoms that fluctuation in their severity (Judd, 2012).

Results of Major Depressive Disorder

Major depressive disorder is a serious and incapacitating condition that can have a devastating effect on the quality of one's life. The person suffering from this disorder lives a profoundly miserable existence that often results in unavailability for work or education, abandonment of promising careers, and lost wages; occasionally, the condition requires hospitalisation. The majority of those with major depressive disorder report having faced some kind of discrimination and many report that having received such treatment has stopped them from initiating close relationships, applying for jobs for which they are qualified, and applying for education or training (Lasalvia et al., 2013). Major depressive disorder also takes a toll on health. Depression is a risk factor for the development of heart disease in healthy patients, as well as adverse cardiovascular outcomes in patients with preexisting heart disease (Whooley, 2006).

Risk Factors for Major Depressive Disorder

Major depressive disorder is often referred to as the common cold of psychiatric disorders. Around 6.6% of the U.S. population experiences major depressive disorder each year; 16.9% will experience the disorder during their lifetime (Kessler & Wang, 2009). It is more common among women than among men, affecting approximately 20% of women and 13% of men at some point in their life (National Comorbidity Survey, 2007). The greater risk among women is not accounted for by a tendency to report symptoms or to seek help more readily, suggesting that gender differences in the rates of major depressive disorder may reflect biological and gender-related environmental experiences (Kessler, 2003).

Lifetime rates of major depressive disorder tend to be highest in North and South America, Europe, and Australia; they are considerably lower in Asian countries (Hasin, Fenton, & Weissman, 2011). The rates of major depressive disorder are higher among younger age cohorts than among older cohorts, perhaps because people in younger age cohorts are more willing to admit depression (Kessler & Wang, 2009).

A number of risk factors are associated with major depressive disorder: unemployment (including homemakers); earning less than $20,000 per year; living in urban areas; or being separated, divorced or widowed (Hasin et al., 2011). Comorbid disorders include anxiety disorders and substance abuse disorders (Kessler & Wang, 2009).

Subtypes of Depression

The DSM-V lists several different subtypes of depression. These subtypes - what the DSM-V refer to as specifiers - are not specific disorders; rather, they are labels used to indicate specific patterns of symptoms or to specify certain periods of time in which symptoms may be present. One subtype, seasonal pattern, applies to situations in which a person experiences the symptoms of major depressive disorder only during a particular time of year (e.g., fall or winter). In everyday language, people often refer to this subtype as the winter blues.

Another subtype, peripartum onset (commonly referred to as postpartum depression), applies to women who experience major depression during pregnancy or in the four weeks following the birth of their child (APA, 2013). These women often feel very anxious and may even have panic attacks. They may feel guilty, agitated, and be weepy. They may not want to hold or care for their newborn, even in cases in which the pregnancy was desired and intended. In extreme cases, the women may have feelings of wanting to harm her child or herself. In a horrific illustration, a woman named Andrea Yates, who suffered from extreme peripartum-onset depression (as well as other mental illnesses), drowned her five children in a bathtub (Roche, 2002). Most women with peripartum-onset depression do not physically harm their children, but most do have difficulty being adequate caregivers (Fields, 2010). A surprisingly high number of women who experience symptoms of peripartum-onset depression. A study of 100,000 women who had recently given birth found that 14% screened positive for peripartum-onset depression, and that nearly 20% reported having thoughts of wanting to harm themselves (Wisner et al., 2013).

People with persistent depressive disorder (previously known as dysthymia) experience depressed moods most of the dat nearly every day for at least two years, as well as at least two other symptoms of major depressive disorder. People with persistent depressive disorder are chronically sad and melancholy, but do not meet all the criteria for major depression. However, episodes of full-blown major depressive disorder can occur during persistent depressive disorder (APA, 2013).

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Bipolar Disorder

A person with bipolar disorder (commonly known as manic depression) often experiences mood states that vacillate between depression and mania; that is, the person's mood is said to alternate from one emotional extreme to the other (in contrast to unipolar, which indicates a persistently sad mood).

To be diagnosed with bipolar disorder, a person must have experienced a manic episode at least once in his life; although major depressive episodes are common in bipolar disorder, they are not required for a diagnosis (APA, 2013). According to the DSM-5, a manic episode is characterized as a "distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy lasting at least one week," that lasts most of the time each day (APA, 2013, p.124). During a manic episode, some experience a mood that is almost euphoric and become excessively talkative, sometimes spontaneously starting conversations with strangers; others become excessively irritable and complain or make hostile comments. The person may talk loudly and rapidly, exhibiting flight of ideas, abruptly switching from one topic to another. These individuals are easily distracted, which can make a conversation very difficult. They may exhibit grandiosity, in which they experience inflated but unjustified self-esteem and self-confidence. For example, they might quit a job in order to "strike it rich" in the stock market, despite lacking the knowledge, experience, and capital for such an endeavor. They may take on several tasks at the same time (e.g., several time-consuming projects at work) and yet show little, if any, need for sleep; some may go for days without sleep. Patients may also recklessly engage in pleasurable activities that could have harmful consequences. including spending sprees, reckless driving, making foolish investments, excessive gambling, or engaging in sexual encounters with strangers (APA, 2013).

During a manic episode,individuals usually feel as though they are not ill and do not need treatment. However, the reckless behaviors that often accompany these episodes - which can be antisocial, illegal, or physically threatening to others - may require involuntary hospitalization (APA, 2013). Some patients with bipolar disorder will experience a rapid-cycling subtype, which is characterized by at least four manic episodes (or some combination of at least four manic and major depressive episodes) within one year.

Risk Factors for Bipolar Disorder

Bipolar disorder is considerably less frequent than major depressive disorder. In the United States, 1 out of every 167 people meets the criteria for bipolar disorder each year, and 1 out of 100 meet the criteria within the lifetime (Merikangas et al., 2011). The rates are higher in men than in women, and about half of those with this disorder report onset before the age of 25 (Merikangas et al., 2011). Around 90% of those with bipolar disorder have a comorbid disorder, most often an anxiety disorder or a substance abuse problem. Unfortunately, close to half of the people suffering from bipolar disorder do not receive treatment (Merikangas & Tohen, 2011). Suicide rates are extremely high among those with bipolar disorder: around 36% of individuals with this disorder attempt suicide at least once in their lifetime (Novick, Swartz, & Frank, 2010), and between 15-19% complete suicide (Newman, 2004).

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The Biological Basis of Mood Disorders

Mood disorders have been shown to have a strong genetic and biological basis. Relatives of those with major depressive disorder have double the risk of developing major depressive disorder, whereas relatives of patients with bipolar disorder have over nine times the risk (Merikangas et al., 2011). The rate of concordance for major depressive disorder is higher among identical twins than fraternal twins (50% vs. 38%, respectively), as is that of bipolar disorder (67% vs. 16%, respectively), suggesting that genetic factors play a stronger role in bipolar disorder than major depressive disorder (Merikangas et al., 2011). People with mood disorders often have imbalances in certain neurotransmitters, particularly norepinephrine and serotonin (Thase, 2009). These neurotransmitters are important regulators of the bodily functions that are disrupted in mood disorders, including appetite, sex drive, sleep, arousal, and mood. Medications that are used to treat major depressive disorder typically boost serotonin and norepinephrine activity, whereas lithium - used in the treatment of bipolar disorder - blocks norepinephrine activity at the synapses.

Depression is linked to abnormal activity in several regions of the brain (Fitzgerald, Laird, Maller, & Daskalakis, 2008) including those important in assessing the emotional significance of stimuli and experiencing emotions (amygdala), and in regulating and controlling emotions (like prefrontal cortex, or PFC) (LeMoult, Castonguay, Joormann, & McAleavey, 2013). Depressed individuals show elevated amygdala activity (Drevets, Bogers, & Raichle, 2002), especially when presented with negative emotional stimuli, such as photos of sad faces (Surguladze et al., 2005). Interestingly, heightened amygdala activation to negative emotional stimuli among depressed persons occurs even when stimuli are presented outside of conscious awareness (Victor, Furey, Fromm, Ohman, & Drevets, 2010), and it persists even after the negative emotional stimuli are no longer present (Siegle, Thompson, Carter, Steinhauer, & Thase, 2007). Additionally, depressed individuals exhibit less activation in the prefrontal, particularly on the left side (Davidson, Pizzagalli, & Nitschke, 2009). Because the PFC can dampen amydgala activation, thereby enabling one to suppress negative emotions (Phan et al., 2005), decreased activation in certain regions of the PFC may inhibit its ability to override negative emotions that might then lead to more negative mood states (Davidson et al., 2009). These findings suggest that depressed persons are more prone to react to emotionally negative stimuli, yet have greater difficulty controlling these reactions.

Since the 1950s, researchers have noted that depressed individuals have abnormal levels of cortisol, a stress hormone released into the blood by the neuroendocrine system during times of stress (Mackin & Young, 2004). When cortisol is released, the body initiates a fight-or-flight response in reaction to a threat or danger. Many people with depression show elevated cortisol levels (Holsboer & Ising, 2010), especially those reporting a history of early life trauma such as the loss of a parent or abuse during childhood (Baes, Tofoli, Martins, & Juruena, 2012). Such findings raise the question of whether high cortisol levels are a cause or a consequence of depression. High levels of cortisol are a risk factor for future depression (Halligan, Herbert, Goodyer, & Murray, 2007), and cortisol activates activity in the amygdala while deactivating activity in the PFC (McEwen, 2005) - both brain disturbances are connected to depression. Thus, high cortisol levels may have a causal effect on depression, as well as on its brain function abnormalities (van Praag, 2005). Also, because stress results in increased cortisol release (Michaud, Matheson, Kelly, & Anisman, 2008), it is equally reasonable to assume that stress may precipitate depression.

Diathesis-Stress Model and Major Depressive Disorders

Indeed, it has long been believed that stressful life events can trigger depression, and research has consistently supported this conclusion (Mazure, 1998). Stressful life events include significant losses, such as death of a loved one, divorce or separation, and serious health and money problems; life events such as these often precede the onset of depressive episodes (Brown & Harris, 1989). In particular, exit events - instances in which an important person departs (e.g., a death, divorce, or separation, or a family member leaving home) - often occur prior to an episode (Paykel, 2003). Exit events are especially likely to trigger depression if these happenings occur in a way that humiliates or devalues the individual. For example, people who experience the breakup of a relationship initiated by the other person develop major depressive disorder at a rate more than 2 times that of people who experience the death of a loved one (Kendler, Hettema, Butera, Gardner, & Prescott, 2003).

Likewise, individuals who are exposed to traumatic stress during childhood - such as separation from a parent, family turmoil, and maltreatment (physical or sexual abuse) - are at a heightened risk of developing depression at any point in their lives (Kessler, 1997). A recent review of 16 studies involving over 23,000 subjects concluded that those who experience childhood maltreatment are more than 2 times as likely to develop recurring and persistent depression (Nanni, Uher, & Danese, 2012).

Of course, not everyone who experiences stressful life events or childhood adversities succumbs to depression - indeed, most do not. Clearly, a diathesis-stress interpretation of major depressive disorder, in which certain predispositions or vulnerability factors influence one's reaction to stress, would seem logical. If so, what might such predispositions be? A study by Caspi and others (2003) suggests that an alteration in a specific gene that regulates serotonin (the 5-HTTLPR gene) might be one culprit. These investigators found that people who experienced several stressful life events were significantly more likely to experience episodes of major depression if they carried one or two short versions of the 5-HTTLPR gene were unlikely to experience an episode, however, if they had experienced few or no stressful life events. Numerous studies have replicated these findings, including studies of people who experienced maltreatment during childhood (Goodman & Brand, 2009). In a recent investigation conducted in the United Kingdom (Brown & Harris, 2013), researchers found that childhood maltreatment before age 9 elevated the risk of chronic adult depression (a depression episode lasting for at least 12 months) among those individuals having one (LS) or two (SS) short versions of the 5-HTTLPR gene. Childhood maltreatment did not increase the risk for chronic depression for those have two long (LL) versions of this gene. Thus, genetic vulnerability may be one mechanism through which stress potentially leads to depression.

Cognitive Theories of Depression

Cognitive theories of depression take the view that depression is triggered by negative thoughts, interpretations, self-evaluations, and expectations (Joormann, 2009). These diathesis-stress models propose that depression is triggered by a "cognitive vulnerability" (negative and maladaptive thinking) and by precipitating stressful life events (Gotlib & Joormann, 2010). Perhaps the most well-known cognitive theory of depression was developed in the 1960s by psychiatrist Aaron Beck, based on clinical observations and supported by research (Beck, 2008). Beck theorized that depression-prone people possess depressive schemas, or mental predispositions to think about most things in a negative way (Beck, 1976). Depressive schemas contain themes of loss, failure, rejection, worthlessness, and inadequacy, and may develop early in childhood in response to adverse experiences, then remain dormant until they are activated by stressful or negative life events. Depressive schemas prompt dysfunctional and pessimistic thoughts about the self, the world, and the future. Beck believed that this dysfunctional style of thinking is maintained by cognitive biases, or errors in how we process information about ourselves, which lead us to focus on negative aspects of experiences, interpret things negatively, and block positive memories (Beck, 2008). A person whose depressive schema consists of a theme of rejection might be overly attentive to social cues of rejection (more likely to notice another's frown), and he might interpret this cue as a sign of rejection and automatically remember past incidents of rejection. Longitudinal studies have supported Beck's theory, in showing that a preexisting tendency to engage in this negative, self-defeating style of thinking - when combined with life stress - over time predicts the onset of depression (Dozois & Beck, 2008). Cognitive therapies for depression aimed at changing a depressed person's negative thinking, were developed as an expansion of this theory (Beck, 1976).

Another cognitive theory of depression, hopelessness theory, postulates that a particular style of negative thinking leads to a sense of hopelessness, which then leads to depression (Abramson, Metalsky, & Alloy, 1989). According to this theory, hopelessness is an expectation that unpleasant outcomes will occur or that desired outcomes will not occur, and there is nothing one can do to prevent such outcomes. A key assumption of this theory is that hopelessness stems from a tendency to perceive negative life events as having stable ("it's never going to change") and global ("it's going to affect my whole life") causes, in contrast to unstable ("it's fixable") and specific ("it applies only to this particular situation") causes, especially if these negative life events occur in important life realms, such as relationships, academic achievement, and the like. Suppose a student who wishes to go to law school does poorly on an admissions test. If the student infers negative life events as having stable and global causes, she may believe that her poor performance has a stable and global cause ("I lack intelligence, and it's going to prevent me from ever finding a meaningful career"), as opposed to an unstable and specific cause ("I was sick the day of the exam, so my low score was a fluke"). Hopelessness theory predicts that people who exhibit this cognitive style in response to undesirable life events will view such events as having negative implications for their future and self-worth, thereby increasing the likelihood of hopelessness - the primary cause of depression (Abramson et al., 1989). One study testing hopelessness theory measured the tendency to make negative inferences for bad life effects in participants who were experiencing uncontrollable stressors. Over the ensuring six months, those with scores reflecting high cognitive vulnerability were 7 times more likely to develop depression compared to those with lower scores (Kleim, Gonzalo, & Ehlers, 2011).

A third cognitive theory of depression focuses on how people's thoughts about their distressed moods - depressed symptoms in particular - can increase the risk and duration of depression. This theory, which focuses on rumination in the development of depression, was first described in the late 1980s to explain the higher rates of depression in women than in men (Nolen-Hoeksema, 1987). Rumination is the repetitive and passive focus on the fact that one is depressed and dwelling on depressed symptoms, rather than distracting one's self from the symptoms or attempting to address them in an active, problem-solving manner (Nolen-Hoeksema, 1991). When people ruminate, they have thoughts such as "Why am I so unmotivated? I just can't get going. I'm never going to get my work done feeling this way" (Nolen-Hoeksema & Hilt, 2009, p. 393). Women are more likely than men to ruminate when they are sad or depressed (Butler & Nolen-Hoeksema, 1994), and the tendency to ruminate is associated with increases in depression symptoms (Nolen-Hoeksema, Larson, & Grayson, 1999), heightened risk of major depressive episodes (Abela & Hankin, 2011), and chornicity of such epsiodes (Robinson & Alloy, 2003).

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Suicide

For some people with mood disorders, the extreme emotional pain they experience becomes unendurable. Overwhelmed by hopelessness, devastated by incapacitating feelings of worthlessness, and burdened with the inability to adequately cope with such feelings, they may consider suicide to be a reasonable way out. Suicide, defined by the CDC as "death caused by self-directed injurious behavior with any intent to die as the result of the behavior" (CDC, 2013a), in a sense represents an outcome of several things going wrong all at the same time (Crosby, Ortega, & Melanson, 2011). Not only must the person be biologically or psychologically vulnerable, but he must also have the means to perform the suicidal act, and he must lack the necessary protective factors (e.g., social support from friends and family, religion, coping skills, and problem-solving skills) that provide comfort and enable one to cope during times of crisis or great psychological pain (Berman, 2009). Suicide is not listed as a disorder in the DSM-5; however, suffering from a mental disorder - especially a mood disorder - poses the greatest risk for suicide. Around 90% of those who complete suicides have a diagnosis of at least one mental disorder, with mood disorders being the most frequent (Fleischman, Bertolote, Belfer, & Beautrais, 2005). In face, the association between major depressive disorder and suicide is so strong that one of the criteria for the disorder is thoughts of suicide, as discussed above (APA, 2013). Suicide rares can be difficult to interpret because some deaths that appear to be accidental may in fact be acts of suicide (e.g., automobile crash). Nevertheless, investigations into U.S. suicide rates have uncovered these facts:

suicide was the 10th leading cause of death for all ages in 2010 (CDC, 2012)

there were 38,364 suicides in 2012 in the United States - an average of 105 each day (CDC, 2012)

suicide among males is 4 times higher than among females and accounts for 79% of all suicides; firearms are the most commonly used methods for suicide for males, whereas poisoning is the most commonly used method for females (CDC, 2012)

from 1991 to 2003, suicide rates were consistently higher among those 65 years and older. Since 2001, however, suicide rates among those ages 25-64 have risen consistently, and since 2006, suicide rates among middle-aged Americans has prompted concern in some quarters that baby boomers (individuals born between 1946-1964) who face economic worry and easy access to prescription medication may be particularly vulnerable to suicide (Parker-Pope, 2013)

the highest rates of suicide within the United States are among American Indians/Alaskan natives and Non-Hispanic Whites (CDC, 2013b)

suicide rares vary across the United States, with the highest rates consistently found in the mountain states of the west (Alaska, Montana, Nevada, Wyoming, Colorado, and Idaho) (Berman, 2009).

Contrary to popular belief, suicide rates peak during the springtime (April and May), not during the holiday season or winter. In fact, suicide rates are generally lowest during the winter months (Postolache et al., 2010).

Risk Factors for Suicide

Suicidal risk is especially high among people with substance abuse problems. Individuals with alcohol dependence are at 10 times greater risk for suicide than the general population (Wilcox, Connor, & Caine, 2004). The risk of suicidal behavior is especially high among those who have made a prior suicide attempt. Among those who attempt suicide, 16% make another attempt within a year and over 21% make another attempt within four years (Owens, Horrocks, & House, 2002). Suicidal individuals may be at high risk for terminating their life if they have a lethal means in which to act, such as a firearm in the home (Brent & Bridge, 2003). Withdrawal from social relationships, feeling as though one is a burden to others, and engaging in reckless and risk-taking behaviors may be precursors to suicidal behavior (Berman, 2009). A sense of entrapment or feeling unable to escape one's miserable feelings or external circumstances (e.g., an abusive relationship with no perceived way out) predicts suicidal behavior (O'Connor, Smyth, Ferguson, Ryan, & Williams, 2013). Tragically, reports of suicides among adolescents following instances of cyberbullying have emerged in recent years.In one widely-publicized case a few years ago, Phoebe Prince, a 15-year-old Massachusetts high school student. committed suicide following incessant harassment and taunting from her classmates via texting and Facebook (McCabe, 2010).

Suicides can have a contagious effect on people. For example, another's suicide, especially that of a family member, heightens one's risk of suicide (Agerbo, Nordentoft,& Mortensen, 2002). Additionally, widely-publicized suicides tend to trigger copycat suicides in some individuals. One study examining suicide statistics in the United States from 1947-1967 found that the rates of suicide skyrocketed for the first month after a suicide story was printed on the front page of the New York Times (Phillips, 1974). Austrian researchers found a significant increase in the number of suicides by firearms in the three weeks following extensive reports in Austria's largest newspaper of a celebrity suicide by gun (Etzersdorfer, Voracek, & Sonneck, 2004). A review of 42 studies concluded that media coverage of celebrity suicides is more than 14 times more likely to trigger copycat suicides than is coverage of non-celebrity suicides (Stack, 2000). This review also demonstrated that the medium of coverage is important televised stories are considerably less likely to prompt a surge in suicides than are newspaper stories. Research suggests that a trend appears to be emerging whereby people use online social media to leave suicide notes, although it is not clear to what extent suicide notes on such media might induce copycat suicides (Ruder, Hatch, Ampanozi, Thali, & Fischer, 2011). Nevertheless, it is reasonable to conjecture that suicide notes left by individuals on social media may influence the decisions of other vulnerable people who encounter them (Luxton, June, & Fairall, 2012).

One possible contributing factor in suicide is brain chemistry. Contemporary neurological research shows that disturbances in the functioning of serotonin are linked to suicidal behavior (Pompili et al., 2010). Low levels of serotonin predict future suicide attempts and suicide completions, and low levels have been observed post-mortem among suicide victims (Mann, 2003). Serotonin dysfunction, as noted earlier, is also known to play an important role in depression; low levels of serotonin have also been linked to aggression and impulsivity (Stanley et al., 2000). The combination of these three characteristics constitutes a potential formula for suicide - especially violent suicide. A classic study conducted during the 1970s found that patients with major depressive disorder who had very low levels of serotonin attempted suicide more frequently and more violently than did patients with higher levels (Asberg, Thoren, Traskman, Bertilsson, & Ringberger, 1976; Mann, 2003).

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Introduction to Schizophrenia and Dissociative Disorders

Schizophrenia is a severe disorder characterized by a complete breakdown in one's ability to function in life; it often requires hospitalization. People with schizophrenia experience hallucinations and delusions, and they have extreme difficulty regulating their emotions and behavior. Thinking is incoherent and disorganized, behavior is extremely bizarre, emotions are flat, and motivation to engage in most basic life activities is lacking.

Schizophrenia is not to be confused with multiple personality disorder, which is technically termed dissociative identity disorder. The main characteristic of dissociative disorders is that people become dissociated from their sense of self, resulting in memory and identity disturbances. Dissociative disorders listed in the DSM-5 include dissociative amnesia, depersonaliation/derealization disorder, and dissociative identity disorder. A person with dissociative amnesia is unable to recall important personal information, often after a stressful or traumatic experience. In this section, you'll learn about the differences between schizophrenia and these disorders.

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Schizophrenia

Schizophrenia is a devastating psychological disorder that is characterised by major disturbances in thought, perception, emotion, and behaviour. About 1% of the population experiences schizophrenia in their lifetime, and usually the disorder is first diagnosed during early adulthood (early to mid-20s). Most people with schizophrenia experiences significant difficulties in many day-to-day activities, such as holding a job, paying bills, caring for one-self (grooming and hygiene), and maintaining relationships with others. Frequent hospitalisations are more often the rule rather than the exception with schizophrenia. Even when they receive the best treatments available, many with schizophrenia will continue to experience serious social and occupational impairment throughout their lives.

What is schizophrenia? First, schizophrenia is not a condition involving a split personality; that is, schizophrenia is not the same thing as dissociative identity disorder (better known as multiple personality disorder). These disorders are sometimes confused because the word schizophrenia first coined by the Swiss psychiatrist Eugen Bleuler in 1911, derives from Greek words that refer to a "splitting" (schizo) of psychic functions (phrene) (Green, 2001).

Schizophrenia is considered a psychotic disorder, or one in which the person's thoughts, perceptions, and behaviours are impaired to the point where she is not able to function normally in life. In informal terms, one who suffers from a psychotic disorder (that is, has a psychosis) is disconnected from the world in which most of us live.

Symptoms of Schizophrenia

The main symptoms of schizophrenia include hallucinations, delusions, disorganised thinking, disordered or abnormal motor behaviour and negative symptoms (APA, 2013). A hallucination is a perceptual experience that occurs in the absence of external stimulation. Auditory hallucinations (hearing voices) occur in roughly two-thirds of patients with schizophrenia and are by far the most common form of hallucination (Andreasen, 1987). The voices may be familiar or unfamiliar, they may have a conversation or argue, or the voices may provide a running commentary on the person's behaviour (Tsuang, Farone, & Green, 1999).

Less common are visual hallucinations (seeing things that are not there) and olfactory hallucinations (smelling odours that are not actually present).

Delusions are beliefs that are contrary to reality and are firmly held even in the face of contradictory evidence. Many of us hold beliefs that some would consider odd, but a delusion is easily identified because it is clearly absurd. A person with schizophrenia may believe that his mother is plotting with the FBI to poison his coffee, or that his neighbour is an enemy spy who wants to kill him. These kinds of delusions are known as paranoid delusions, which involve the (false) belief that other people or agencies are plotting to harm the person. People with schizophrenia also may hold grandiose delusions, beliefs that one holds special power, unique knowledge, or is extremely important. For example, the person who claims to be Jesus Christ, or who claims to have knowledge going back 5,000 years, or who claims to be a great philosopher is experiencing grandiose delusions. Other delusions include the belief that one's thoughts are being removed (thought withdrawal) or thoughts have been placed inside one's head (thought insertion). Another type of delusion is somatic delusion, which is the belief that something highly abnormal is happening to one's body (e.g., that one's kidneys are being eaten by cockroaches).

Disorganised thinking refers to disjointed and incoherent thought processes - usually detected by what a person says. The person might ramble, exhibit loose associations (jump from topic to topic), or talk in a way that is so disorganised and incomprehensible that it seems as though the person is randomly combining words. Disorganised thinking is also exhibited by blatantly illogical remarks (e.g., "Fenway Park is in Boston. I live in Boston. Therefore, I live at Fenway Park.") and by tangentiality: responding to others' statements or questions by remarks that are either barely related or unrelated to what was said or asked. For example, if a person diagnosed with schizophrenia is asked if she is interested in receiving special job training, she might state that she once rode on a train somewhere. To a person with schizophrenia, the tangential (slightly related) connection between jobs training and riding a train are sufficient enough to cause such a response.

Disorganised or abnormal motor behaviour refers to unusual behaviours and movements becoming unusually active, exhibiting silly child-like behaviours (giggling and self-absorbed smiling), engaging in repeated and purposeless movements, or displaying odd facial expressions and gestures. In some cases, the person will exhibit catatonic behaviours, which show decreased reactivity to the environment, such as posturing, in which the person maintains a rigid and bizarre posture for long periods of time, or catatonic stupor, a complete lack of movement and verbal behaviour.

Schizophrenia has positive and negative symptoms. Positive symptoms of schizophrenia are symptoms of commission, meaning they are something that individuals do or think. Examples include the hallucinations, delusions, and bizarre or disorganised behaviour described above. Negative symptoms are those that reflect noticeable decreases and absences in certain behaviours, emotions, or drives (Green, 2001). A person who exhibits diminished emotional expression shows no emotion in his facial expressions, speech, or movements, even when such expressions are normal or expected (also known as flat effect). Avolition is characterised by a lack of motivation to engage in self-initiated and meaningful activity, including the most basic of tasks, such as bathing and grooming. Alogia refers to reduced speech output; in simple terms, patients do not say much. Another negative symptom is asociality, or social withdrawal and lack of interest in engaging in social interactions with others. A final negative symptom, anhedonia, refers to an inability to experience pleasure. One who exhibits anhedonia expresses little interest in what most people consider to be pleasurable activities, such as hobbies, reaction, or sexual activity.

Causes of Schizophrenia

There is considerable evidence suggesting that schizophrenia has a genetic basis. The risk of developing schizophrenia is nearly 6 times greater if one has a parent with schizophrenia than if one does not (Goldstein, Buka, Seidman, & Tsuang, 2010). Additionally, one's risk of developing schizophrenia increases as genetic relatedness to family members diagnosed with schizophrenia increases (Gottesman, 2001).

Genes

When considering the role of genetics in schizophrenia, as in any disorder, conclusions based on family and twin studies are subject to criticism. This is because family members who are closely related (such as siblings) are more likely to share similar environments than are family members who are less closely related (such as cousins); further, identical twins may be more likely to be treated similarly by others than might fraternal twins. Thus, family and twin studies cannot completely rule out the possible effects of shared environments and experiences. Such problems can be corrected by using adoption studies, in which children are separated from their parents at an early age. One of the first adoption studies of schizophrenia conducted by Heston (1966) followed 97 adoptees, including 47 who were born to mothers with schizophrenia, over a 36-year period. Five of the 47 adoptees (11%) whose mothers had schizophrenia, compared to none of the 50 control adoptees. Other adoption studies have consistently reported that for adoptees who are later diagnosed with schizophrenia, their biological relatives have a higher risk of schizophrenia than do adoptive relatives (Shih, Belmonte, & Zandi, 2004).

Another adoption studies have supported the hypothesis that genetic factors contribute to schizophrenia, they have also demonstrated hat the disorder most likely arises from a combination of genetic and environmental factors, rather than just genes themselves. For example, investigators in one study examined the rates of schizophrenia among 303 adoptees (Tienari et al., 2004). A total of 145 of the adoptees had biological mothers with schizophrenia; these adoptees constituted the high genetic risk group. The other 158 adoptees had mothers with no psychiatric history; these adoptees composed the low genetic risk group. The researchers managed to determine whether the adoptees' families were either healthy or disturbed. For example, the adoptees were considered to be raised in disturbed family environment if the family exhibited a lot of criticism, conflict, and a lack of problem-solving skills. The findings revealed that adoptees whose mothers had schizophrenia (high genetic risk) and who had been raised in a disturbed family environment were much more likely to develop schizophrenia or another psychotic disorder (36.8%) than were adoptees whose biological mothers had schizophrenia but who had been raised in a healthy environment (5.8%), or than adoptees with a low genetic who were raised in either a disturbed (5.3%) or healthy (4.8%) environment. Because the adoptees who were at high genetic risk were likely to develop schizophrenia only if they were raised in a disturbed home environment, this study supports a diathesis-stress interpretation of schizophrenia - both genetic vulnerability and environmental stress are necessary for schizophrenia to develop, genes alone do not show the complete picture.

Neurotransmitters

If we accept that schizophrenia is at least partly genetic in origin, as it seems to be, it makes sense that the next step should be to identify biological abnormalities commonly found in people with the disorder. Perhaps not surprisingly, a number of neurobiological factors have indeed been found to be related to schizophrenia. One such factor that has received considerable attention for many years is the neurotransmitter dopamine. Interest in the role of dopamine in schizophrenia was stimulated by two sets of findings: drugs that increase dopamine levels can produced schizophrenia-like symptoms, and medications that block dopamine activity reduce the symptoms (Howed & Kapur, 2009). The dopamine hypothesis of schizophrenia proposed that an overabundance of dopamine or too many dopamine receptors are responsible for the onset and maintenance of schizophrenia (Snyder, 1976). More recent work in this area suggests that abnormalities in dopamine vary by brain region and thus contribute to symptoms in unique ways. In general, this research has suggested than an overabundance of dopamine in the limbic system may be responsible for some symptoms, such as hallucinations and delusions, whereas low levels of dopamine in the prefrontal cortex might be responsible primarily for the negative symptoms (avolition, alogia, asociality, and anhedonia) (Davis, Khan, Ko, & Davidson, 1991). In recent years, serotonin has received attention, and newer antipsychotic medications used to treat the disorder work by blocking serotonin receptors (Baumeister & Hawkins, 2004).

Brain Anatomy

Brain imaging studies reveal that people with schizophrenia have enlarged ventricles, the cavities within the brain that contain cerebral spinal fluid (Green, 2001). This finding is important because larger than normal ventricles suggests that various brain regions are reduced in size, thus implying that schizophrenia is associated with a loss of brain tissue. In addition, many people with schizophrenia display a reduction in grey matter (cell bodies of neurons) in the frontal lobes (Lawrie & Abukmeil, 1998), and many show less frontal lobe activity when performing cognitive tasks (Buchsbaum et al., 1990). The frontal lobes are important in a variety of complex cognitive functions, such as planning and executing behaviour, attention, speech, movement, and problem solving. Hence, abnormalities in this region provide merit in explaining why people with schizophrenia experience deficits in these areas.

Events During Pregnancy

Why do people with schizophrenia have these brain abnormalities? A number of environmental factors that could impact normal brain development might be at fault. High rates of obstetric complications in the births of children who later developed schizophrenia have been reported (Cannon, Jones, & Murray, 2002). In addition, people are at an increased risk for developing schizophrenia if their mother who exposed to influenza during the first trimester of pregnancy (Brown et al., 2004). Research has also suggested that a mother's emotional stress during pregnancy may increase the risk of schizophrenia in offspring. One study reported that the risk of schizophrenia is elevated substantially in offspring whose mothers experienced the death of a relative during the first trimester of pregnancy (Khashan et al., 2008).

Marijuana

Another variable that is linked to schizophrenia is marijuana use. Although a number of reports have shown that individuals with schizophrenia are more likely to use marijuana than are individuals without schizophrenia (Thornicroft, 1990), such investigations cannot determine if marijuana use leads to schizophrenia, or vice versa. However, a number of longitudinal studies have suggested that marijuana use is, in fact, a risk factor for schizophrenia. A classic investigation of over 45,000 Swedish conscripts who were followed up after 15 years found that those individuals who had reported using marijuana at least once by the time of conscription were more than 2 times as likely to develop schizophrenia during the ensuring 15 years than those who reported never using marijuana; those who had indicated using marijuana 50 or more times were 6 times as likely to develop schizophrenia (Andreasson, Allbeck, Engstrom, & Rydberg, 1987). More recently, a review of 35 longitudinal studies found a substantially increased risk of schizophrenia and other psychotic disorders in people who had used marijuana, with the greatest risk in the most frequent users (Moore et al., 2007). Other work has found that marijuana use is associated with an onset of psychotic disorders at an earlier age (Large, Sharma, Compton, Slade, & Nielssen, 2011). Overall, the available evidence seems to indicate that marijuana use plays a casual role in the development of schizophrenia, although it is important to point out that marijuana use it not an essential or sufficient risk factor as not all people with schizophrenia have used marijuana and the majority of marijuana users do not develop schizophrenia (Casadio, Fernandes, Murray, & Di Forti, 2011). One plausible interpretation of the data is that early marijuana use may disrupt normal brain development during important early maturation periods in adolescence (Trezza, Cuomo, & Vanderschuren, 2008). Thus, early marijuana use may set the stage for the development of schizophrenia and other psychotic disorders, especially among individuals with an established vulnerability (Casadio et al., 2011).

Schizophrenia: Early Warning Signs

Early detection and treatment of conditions such as heart disease and cancer have improved survival rates and quality of life for people who suffer from these conditions. A new approach involves identifying people who show minor symptoms of psychosis, such as unusual thought content, paranoia, odd communication, delusions, problems at school or work, and a decline in social functioning - which are coined prodromal symptoms - and following these individuals over time to determine which of them develop a psychotic disorder and which factors best predict such a disorder. A number of factors have been identified that predict a greater likelihood that prodromal individuals will develop a psychotic disorder: genetic risk (a family history of psychosis), recent deterioration in functioning, high levels of unusual thought content, high levels of suspicion or paranoia, poor social functioning, and a history of substance abuse (Fusar-Poli et al., 2013). Further research will enable a more accurate prediction of those at greatest risk for developing schizophrenia and thus to whom early intervention efforts should be directed.

Forensic Psychology

In August 2013, 17-year-old Cody Metzker-Madsen attacked 5-year-old Dominic Elkins on his foster parents' property. Believing that he was fighting goblins and that Dominic was the goblin commander, Metzker-Madsen beat Dominic with a brick and then held him face down in a creek. Dr Alan Goldstein, a clinical and forensic psychologist, testified that Metzker-Madsen believed that the goblins he saw were real and was not aware that it was Dominic at the time. He was found not guilty by reason of insanity and was not held legally responsible for Dominic's death (Nelson, 2014). Cody was also found to be a danger to himself or others. He will be held in a psychiatric facility until he is judged to be no longer dangerous. This does not mean that he "got away with" anything. In fact, according to the American Psychiatric Association, individuals who are found not guilty by reason of insanity are often confined to psychiatric hospitals for as long or longer than they would have spent in prison for a conviction.

Most people with mental illness are not violent. Only 3-5% of violent acts are committed by individuals diagnosed with severe mental illness, whereas individuals with severe mental illnesses are more than ten times as likely to be victims of crime (MentalHealth.gov, 2017). The psychologists who work with individuals such as Metzker-Madsen are part of the subdiscipline of forensic psychology. Forensic psychologists are involved in psychological assessment and treatment of individuals involved with the legal system. They use their knowledge of human behaviour and mental illness to assist the judicial and legal system in making decisions in cases involving such issues as personal injury suits, workers' compensation, competency to stand trial, and pleas of not guilty by reason of insanity.

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Dissociative Disorders

Dissociative disorders are characterized by an individual becoming split off, or dissociated, from her core sense of self. Memory and identity become disturbed; these disturbances have a psychological rather than physical cause. Dissociative disorders listed in the DSM-5 include dissociative amnesia, depersonalization/derealization disorder, and dissociative identity disorder.

Dissociative Amnesia

Amnesia refers to the partial or total forgetting of some experience or event. An individual with dissociative amnesia is unable to recall important personal information, usually following an extremely stressful or traumatic experience such as combat, natural disasters, or being the victim of violence. The memory impairments are not caused by ordinary forgetting. Some individuals with dissociative amnesia will also experience dissociative fugue (from the word "to flee" in French), whereby they suddenly wander away from their home, experience confusion about their identity, and sometimes even adopt a new identity (Cardena & Gleaves, 2006). Most fugue episodes last only a few hours or days, but some can last longer. One study of residents in communities in upstate New York reported that about 1.8% experienced dissociative amnesia in the previous year (Johnson, Cohen, Kasen, & Brook, 2006).

Some have questioned the validity of dissociated amnesia (Pope, Hudson, Bodkin, & Oliva, 1998); it has even been characterized as a "piece of psychiatric folklore devoid of convincing empirical support" (McNally, 2003, p. 275). Notably, scientific publications regarding dissociative amnesia rose during the 1980s and reached a peak in the mid-1990s, followed by an equally sharp decline by 2003; in face, only 13 cases of individuals with dissociative amnesia worldwide could be found in the literature that same year (Pope, Barry, Bodkin, & Hudson, 2006). Further, no description of individuals showing dissociative amnesia following a trauma exists in any fictional or nonfictional work prior to 1800 (Pope, Poliakoff, Parker, Boynes, & Hudson, 2006). However, a study of 82 individuals who enrolled for treatment at a psychiatric outpatient hospital found that nearly 10% met the criteria for dissociative amnesia, perhaps suggesting that the condition is underdiagnosed, especially in psychiatric populations (Foote, Smolin, Kaplan, Legatt, & Lipschitz, 2006).

Depersonalization/Derealization Disorder

Depersonalization/derealization disorder is characterized by recurring episodes of depersonalization, or derealization, or both. Depersonalization is defined as feelings of "unreality or detachment from, or unfamiliarity with, one's whole self or from aspects of the self" (APA, 2013, p. 302). Individuals who experience depersonalization might believe their thoughts and feelings are not their own; they may feel robotic as though they lack control over their movements and speech; they may experience a distorted sense of time and, in extreme cases, they may sense an "out-of-body" experience in which they see themselves from the vantage point of another person. Derealization is conceptualized as a sense of "unreality or detachment from, or unfamiliarity with, the world, be it individuals, inanimate objects, or all surroundings" (APA, 2013, p. 303). A person who experiences derealization might feel as though he is in a fog or a dream, or that the surrounding world is somehow artificial and unreal. Individuals with depersonalization/derealization disorder often have difficulty describing their symptoms and may think they are going crazy (APA, 2013).

Dissociative Identity Disorder

By far, the most well-known dissociative disorder is dissociative identity disorder (formerly called multiple personality disorder). People with dissociative identity disorder exhibit two or more separate personalities or identities, each well-defined and distinct from one another. They also experience memory gaps for the time during which another identity is in charge (e.g., one might find unfamiliar items in her shopping bags or among her possessions), and in some cases may report hearing voices, such as a child's voice or the sound of somebody crying (APA, 2013). The study of upstate New York residents mentioned above (Johnson et al., 2006) reported that 1.5% of the sample experienced symptoms consistent with dissociative identity disorder in the previous year.

Dissociative identity disorder (DID) is highly controversial. Some believe that people fake symptoms to avoid the consequences of illegal actions (e.g., "I am not responsible for shoplifting because it was my other personality") In fact, it has been demonstrated that people are generally skilled at adopting the role of a person with different personalities when they believe it might be advantageous to do so. As an example, Kenneth Bianchi was an infamous serial killer who, along with his cousin, murdered over a dozen females around Los Angeles in the late 1970s. Eventually, he and his cousin were apprehended. At Bianchi's trial, he pled not guilty by reason of insanity, presenting himself as though he had DID and claiming that a different personality ("Steve Walker") committed the murders. When these claims were scrutinized, he admitted faking the symptoms and was found guilty (Schwartz, 1981).

A second reason DID is controversial is because rates of the disorder suddenly skyrocketed in the 1980s. More cases of DID were identified during the five years prior to 1986 than in the preceding two centuries (Putnam, Guroff, Silberman, Barban, & Post, 1986). Although this increase may be due to the development of more sophisticated diagnostic techniques, it is also possible that the popularization of DID - helped in part by Sybil, a popular 1970s book (and later film) about a woman with 16 personalities - may have prompted clinicians to overdiagnose the disorder (Piper & Merskey, 2004). Casting further scrutiny on the existence of multiple personalities or identities is the recent suggestion that the story of Sybil was largely fabricated, and the idea for the book might have been exaggerated (Nathan, 2011).

Despite its controversial nature, DID is clearly a legitimate and serious disorder, and although some people may fake symptoms, others suffer their entire lives with it. People with this disorder tend to report a history of childhood trauma, some cases having been corroborated through medical or legal records (Cardena & Gleaves, 2006). Research by Ross et al. (1990) suggests that in one study about 95% of people with DID were physically and/or sexually abused as children. Of course, not all reports of childhood abuse can be expected to be valid or accurate. However, there is strong evidence that traumatic experiences can cause people to experience states of dissociation, suggesting that dissociative states - including the adoption of multiple personalities - may serve as a psychologically important coping mechanism for threat and danger (Dalenberg et al., 2012).

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Introduction to Personality Disorders

Individuals with personality disorders exhibit a personality style that is inflexible, causes distress and impairment, and creates problems for themselves and others. The DSM-5 recognizes 10 personality disorders, organized into three clusters. The disorders in Cluster A include those characterized by a personality style that is odd and eccentric. These include paranoid, schizoid, and schizotypal disorders. Cluster B includes personality disorders characterized chiefly by a personality style that is impulsive, dramatic, highly emotional, and erratic (antisocial, histrionic, narcissistic, borderline), and those in Cluster C are characterized by a nervous and fearful personality style.

Two Cluster B personality disorders. borderline personality disorder and antisocial personality disorder, are especially problematic. People with borderline personality disorder show marked instability in mood, behavior, and self-image, as well as impulsivity. They cannot stand to be alone, are unpredictable, have a history of stormy relationships, and frequently display intense and inappropriate anger. Genetic factors and adverse childhood experiences (e.g., sexual abuse) appear to be important in its development. People with antisocial personality display a lack of regard for the rights of others; they are impulsive, deceitful, irresponsible, and unburdened by any sense of guilt. Genetic factors and socialization both appear to be important in the origin of antisocial personality disorder. Research has also shown that those with this disorder do not experience emotions the way most other people do.

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Personality Disorders

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Borderline Personality Disorder

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Antisocial Personality Disorder

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Introduction to Childhood Disorders

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ADHD

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Autism

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Review: Classifying Psychological Disorders